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

Table of contents :
Any screen. Any time. Anywhere.
Plastic Surgery
Copyright
Contents
Video Contents
Lecture Video Contents
Preface to the Fifth Edition
List of Editors
List of Contributors
Acknowledgments
Dedication
1
1 Managing the aesthetic surgery patient
Societal interest in cosmetic surgery
The concept of beauty
Increasing societal acceptance of cosmetic surgery
The role of social media
The role of video conferencing
The Aesthetic Society statistics
Surgeon advertising
Patient motivation for cosmetic surgery
The ideal patient
Special patient groups
The male cosmetic surgery patient
The young aesthetic surgery patient
Friends or family as your aesthetic surgery patient
The initial consultation
First contact with the office
Nurse assessment
Surgeon's assessment
Photography
Patient coordinator
After the appointment
Second and subsequent consultations
Saying “no” to a potential patient
When to say “no”
How to say “no”
Saying “yes”: what is involved?
Managing surgical expectations
Managing financial expectations
Informed consent
Preoperative regime for the patient
Anesthesia consultation
Postoperative follow-up
Follow-up consultations
The unsatisfactory outcome
The patient is happy
Both the patient and the surgeon are unhappy
The patient is unhappy but the surgeon is happy
Managing the unhappy patient
Managing a colleague's unhappy patient
Managing your own unhappy patient
Conclusion
References
2
2 Principles of practice management and social media for cosmetic surgery
Identifying your brand: a roadmap to your entire practice
Staffing
Physical space
Digital marketing and website
Design and ease of use
Content
Media: photographs and video
Search engine optimization (SEO)
Reputation management
How to solicit positive reviews
How to handle negative reviews
Social media
Conclusion
References
3
3 Essential elements of patient safety in aesthetic plastic surgery
Introduction
Why do medical errors happen?
The three pillars of patient safety
Pillar 1 Tools and resources: evidence-based medicine/best practices
Pillar 2 Systems and processes
Pillar 3 Culture and communication
Specific patient safety considerations
Cardiovascular and venous thromboembolic considerations
Pulmonary considerations
Hypothermia
Other important patient factors
Telemedicine
Conclusions
References
4
4 Pain management in plastic surgery
Introduction
Opioid epidemic
Opioids
Acetaminophen, nonsteroidal anti-inflammatory drugs, and selective COX-2 inhibitors
Acetaminophen
NSAIDs
COX-2 inhibitors
Adjuvant multimodal medications
Gabapentin
Muscle relaxants
Steroids
Topical anesthetics
Local anesthetics
Tumescent analgesia
Regional anesthesia
Epidural anesthesia
Putting it all together: multimodal analgesia (MMA) regimen
References
5
5 Anatomic blocks of the face and neck
Introduction
Anatomic blocks of the face
Section 1: Infraorbital nerve block
Anatomy
Technique
Area of anesthesia
Section 2: mental and mental plus nerve blocks
Anatomy
Technique
Area of anesthesia
Section 3: Supraorbital/supratrochlear, infratrochlear nerve blocks
Anatomy
Technique
Area of anesthesia
Section 4: zygomaticotemporal nerve, zygomaticofacial nerve, and lacrimal nerve
Anatomy
Technique
Area of anesthesia
Section 5: dorsal nasal nerve
Anatomy
Technique
Area of anesthesia
Section 6: great auricular nerve and lobular nerve
Anatomy
Technique
Area of anesthesia
Section 7: transverse cervical nerves and lesser occipital nerve
Anatomy
Technique
Area of anesthesia
Section 7: V3 and buccal nerve
Anatomy
Technique
Area of anesthesia
Conclusion
References
6
6 Local anesthesia
Introduction
Combining local anesthetic agents with oral analgesics and anxiolytic agents (benzodiazepines)
Current practice
Summary
References
7
7 Non-surgical skin care and rejuvenation
Introduction
Cleansers
Cold cream cleansers
Cleansing milks
Cleansing oils
Micellar water cleansers
Cleansing scrubs
Moisturizers
Improved skin smoothness and softness
Increased skin hydration
Improved optical appearance
Moisturizer ingredients
Petrolatum
Silicone
Ceramides
Natural moisturizing factor
Sodium PCA
Urea and lactic acid
Retinoids
Sunscreens
Summary
References
8-1
8.1 Editors’ perspective: injectables and non-surgical resurfacing techniques
8-2
8.2 Injectables and resurfacing techniques: Soft-tissue fillers
Introduction
The pathophysiology of wrinkles
Historical perspective
Classification of fillers
Autologous fillers
Biologic fillers
Synthetic fillers
Injection technique
Indications and applications
Glabellar lines
Forehead lines
Eyebrows
Tear troughs
Nasolabial folds
Malar augmentation
Marionette lines
Jawline augmentation
Panfacial volumetric augmentation
Facial lipoatrophy
Lips
Perioral and mandibular filling
Chin
Nasal reshaping (off-label)
Scars and deformities
Hand rejuvenation
Use and dosage of hyaluronidase
Contraindications and considerations
Complications and their treatment
Special considerations for energy-based devices and facelift procedures
Conclusion
References
8-3
8.3 Injectables and resurfacing techniques: Botulinum toxin/neurotoxins
Botulinum toxin types
Upper face
Forehead
Anatomy
Treatment goals
Dosing and injection technique
Glabella
Anatomy
Treatment goal
Dosing and injection technique
Periocular region
Anatomy
Treatment goals
Injection technique
Midface
Nose
Anatomy
Treatment goals
Dosing and injection technique
Gingival show
Anatomy
Treatment goals
Dosing and injection technique
Lower face
Masseter muscle prominence
Anatomy
Treatment goal
Dosing and technique
Perioral lines
Anatomy
Treatment goals
Dosing and technique
Chin
Anatomy
Treatment goals
Dosing and injection technique
Depressor anguli oris (DAO)
Anatomy
Treatment goal
Dosing and injection technique
Platysmal bands
Anatomy
Treatment goals
Dosing and injection technique
References
8-4
8.4 Injectables and resurfacing techniques: Lasers in aesthetic surgery
Introduction
Historical perspective
Basic science of resurfacing procedures
Biology of wound healing
Inflammation
Proliferation
Remodeling
Laser–tissue interactions and properties of lasers
Molecular basis of light–tissue interaction
Selective photothermolysis (SPT)
Reaction types
Photothermal
Biostimulation
Cooling
Ablative skin rejuvenation
Non-ablative skin rejuvenation
Fractional resurfacing
Diagnosis and clinical evaluation
Patient selection and treatment
Facial rejuvenation
Full-field ablative lasers
Fractional ablative lasers
Fractional non-ablative lasers
Intense pulsed light
Combination treatments
Improving vessels
Improving pigment
Contraindications
Post-procedure care
Complications
Pigmentary change
Scarring
Infection
Prolonged erythema
Acne
Milia
Disclosures
References
8-5
8.5 Injectables and resurfacing techniques: Chemical peels
Medium-depth trichloroacetic acid (TCA) peels
Pre-peel skin preparation
Jessner’s solution/TCA 35%
Dry ice/TCA 35%
Obagi Blue Peel/Z.O. CDP
Deep chemical peels
Patient evaluation
Preoperative planning
Preparation of the solution
Intraoperative routine
Factors determining the depth of the peel
Judging the depth of the peel
Full-face peel
Aftercare
Variation of peels
Results
Complications
Conclusion
References
8-6
8.6 Minimally invasive multimodal facial rejuvenation
Introduction
Rejuvenation: changing attitudes and new procedures
Techniques
Botox
Fillers
Facial liposculpture
Fat suction
Fat injection
Other procedures
Conclusion
References
9-1
9.1 Editors’ perspective: surgical facial rejuvenation
9-2
9.2 Facial anatomy and aging
Introduction
Regions of the face
Surgical anatomy of the face, layered anatomy, SMAS, facial spaces and retaining ligaments
Layer 1: skin
Layer 2: subcutaneous tissue
Layer 3: musculo-aponeurotic layer
Layer 4
Layer 5
Anatomy over the cavities in the skeleton
Facial spaces
Upper temporal space
Prezygomatic space
Premaxillary space
Premasseter spaces
Middle premasseter space
Buccal space
Retaining ligaments of the face
Facial nerve branches
Aging changes of the face
Skin
Subcutaneous tissue
Muscle aging
Facial spaces and retaining ligaments
Bone changes
Regional changes observed with the aging face temple and forehead
The midcheek
Lower face
Considerations for correcting aging changes of the face based on facial anatomy
Dissection planes
SubSMAS dissection (layer 4)
Level 5
Placement of sutures
Summary
Acknowledgments
References
9-3
9.3 Principles and surgical approaches of facelift
Introduction
Historical perspective
Anatomy and patient presentation
Skin
Facial fat: ptosis, volume loss, and volume gain
Change in facial shape
Superficial musculo-aponeurotic system
Facial muscles
Retaining ligaments
Deep fascia
Bone
Facial nerve
Sensory nerves
Neck anatomy
Patient selection
Anatomic assessment
Surgery
Anesthesia
Local anesthetic infiltration
Surgical technique
Subcutaneous facelift
Facelift incisions
Facelift skin flap dissection
Deep tissue surgery
SMAS plication
Loop sutures (MACS lift)
Supraplatysmal plane facelift
SMASectomy
SMAS flap with skin attached (deep-plane facelift)
Subcutaneous facelift with separate SMAS flap (dual plane facelift)
Subperiosteal facelift
Skin flap closure (Video 9.3.4)
Neck surgery
Choice of procedure
Ancillary techniques
Browlift surgery and blepharoplasty
Volume removal
Volume augmentation
Midface lift
Lip procedures
Dressings and drains
Postoperative care
Early complications
Hematoma
Sensory nerve injury
Motor nerve injury
Skin necrosis
Infection
Sialocele or fistula (submandibular or parotid glands)
Venous thromboembolism
Late complications
Unsatisfactory scars
Alopecia
Ear deformities
Facial distortion and irregularities
Facial analysis, anthropometrics and concepts of facial shape
References
9-4
9.4 Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives
Introduction
Considerations of the facial aging process
Considerations on the centrofacial aging process
Anterior midface
Periorbital area
Perioral area
Skin aging
Patient evaluation
Matching the correct procedure to each deformity
Surgical strategy and technique
The minimal access cranial suspension (MACS) facelift
Preoperative markings
Infiltration
Incision and flap elevation
Suspension sutures
Skin redraping and resection
The Auersvald hemostatic net
Ancillary lifting procedures
Neck lift
Temporal lift/gliding brow lift
Periorbital rejuvenation
Augmentation blepharoplasty
Augmentation upper blepharoplasty
Internal browpexy and temporal lift
Temporal lift
Lower augmentation blepharoplasty
The lower lid augmentation procedure
Resurfacing procedures of the periocular area
Laser resurfacing
Croton oil peel
Dark circles
Perioral rejuvenation
Lip lift
Surgical technique
Volume restoration of the lips
Lip volume loss
Loss of lip definition
Vertical rhytids
Nasolabial fold and marionette grooves
Lip resurfacing procedures
Laser resurfacing
Croton oil peel
Facial volume restoration and skin rejuvenation
Microfat graft lipofilling
Surgical technique
Sharp needle intradermal fat grafting (SNIF)
Surgical technique
Complications of SNIF
Nanofat injection and needling
Clinical indications for nanofat delivery
Surgical technique
Nanofat delivery methods
Fine needle injection
Microneedling
Nanofat mixture
Nanofat cream
Postoperative care and complications
MACS lift/neck lift
Perioral rejuvenation
Microfat grafting
Periorbital rejuvenation
Skin resurfacing
Nanofat delivery
References
9-5
9.5 Facelift: Platysma-SMAS plication
Introduction
Technique (Video 9.5.1 and Video lecture 9.5.1)
Evaluation
Patients and methods
Results
Complications
Discussion
The neck
Conclusion
References
9-6
9.6 Facelift: Lateral SMASectomy facelift
Historical perspective
Senior author’s personal philosophy
Surgical technique
Anesthesia
Incisions
Skin flap elevation
Defatting the neck and jowls
Open submental incision with medial platysma approximation
Lateral SMASectomy including platysma resection
Vectors
Skin closure, temporal and earlobe dog-ears
Postoperative care
Complications
Further reading
9-7
9.7 Facelift: The extended SMAS technique in facial rejuvenation
Introduction
Anatomic considerations
Retaining ligaments
Aesthetic analysis and treatment planning
Descent of facial fat
Volume loss and facial deflation
Radial expansion
Role of skeletal support in formulating a surgical treatment plan
Facial width, bizygomatic diameter and malar volume
Facial length and the relative vertical heights of the lower and middle third of the face
Convexity of the malar region juxtaposed to the concavity of the submalar region
Vertical height of the mandibular ramus and horizontal length of the mandibular body
Aesthetic advantages of formal SMAS elevation in a two-layer dual plane SMAS facelift
Surgical technique: extended SMAS dissection
SMAS elevation
SMAS fixation
Variations in extended SMAS technique to affect a restoration in facial shape
Release
Vectors of fat elevation: facial asymmetry
SMAS fixation
Correction of platysma bands and cervical obliquity
Sequence of SMAS fixation versus platysmaplasty
Incisions
Summary
References
9-8
9.8 High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface
Introduction
Fundamental concepts in rejuvenation of the face
Why use the SMAS?
SMAS and the midface
The “high SMAS” concept
The extended SMAS concept
Lamellar dissection and bidirectional tissue shifts
“Lateral sweep” and the SMAS
Recognizing the components of the aging change of the face and employing logical solutions to improve them
Preoperative planning
Planning the temple incision
Planning the pre-auricular incision
Planning the postauricular incision
Planning the conchomastoid portion of the postauricular incision
Planning the transmastoid portion of the postauricular incision
Planning the occipital portion of the postauricular incision
Preoperative preparations
General
Smoking
Radiofrequency and ultrasonic “skin-shrinking” treatments
Hair color and chemical treatment of hair
Infection prophylaxis
Allocating operating room time
Anesthesia
Preoperative anesthesia medications
Patient monitoring during anesthesia
Method of intra-operative sedation
Surgical technique
Patient positioning, urinary catheter insertion, and patient marking
Patient prepping and draping
Administering local anesthesia
Making incisions
Skin flap elevation
Temple dissection
SMAS dissection
Assessing completeness of SMAS flap dissection
Neck lift
SMAS suspension and proper SMAS vector
SMAS suspension in the narrow face
SMAS suspension when the temporal incision is along the temporal hairline
SMAS suspension with a trifurcated SMAS flap
SMAS suspension when interzygomatic widening is not desired
Trimming and management of the posterior margin of the SMAS flap
Suspension of the lateral SMAS border
Drain placement
Skin flap repositioning and suspension suture placement
Exteriorizing the lobule
Skin flap trimming and closure
Trimming and closure along the conchomastoid/auriculomastoid sulcus
Trimming and closure of the occipital incision
Microgathering of occipital wound-length discrepancy and dog-ear management
Trimming and closure of the temporal incision
Trimming and closure of the pre-auricular incision
Earlobe reconfiguration and reduction
Insetting the lobule
Closure of the submental incision
Dressings
Postoperative care
Summary
Declaration
Acknowledgment and retention of rights
References
9-9
9.9 The lift-and-fill facelift
Introduction
Basic science/disease process
Anatomy
Retaining ligaments of the face
Superficial fat compartments
Deep fat compartments
Blood supply
Chronology of compartmental fat deflation
Danger zones
Patient selection, evaluation and planning
Midface width and facial length evaluation
Facial fullness evaluation
Treatment/surgical technique
Preoperative marking
Filling of fat compartments
Fat grafting sequence
Fat harvesting, preparation and injection technique
Donor site selection
Fat harvesting technique
Fat refinement and purification
Fat injection
Facelift classifications
Skin incisions
Local anesthetic infiltration technique
Selective skin undermining
SMAS and platysma manipulation
Postoperative bruising and swelling reduction
Superficial versus deep-plane dissection
Postoperative care
Outcome, prognosis, complications
Minor complications
Infection
Fat embolism
Hematoma
Seroma
Ischemia
Sensory nerve injury
Motor nerve injury
References
9-10
9.10 Neck rejuvenation
Introduction
Historical perspective
Anatomy and the effect of aging
Effects of aging/disease process
Preoperative assessment
Non-surgical options
Surgical options
Liposuction
Technique for liposuction of the neck
Anterior (submental) incision
Technique for anterior lipectomy and platysmaplasty (Video 9.10.4 )
Direct excision of neck skin and Z-plasty
Management of the submandibular glands
Postoperative care
Complications
References
9-11
9.11 Male facelift
Introduction
Aging of the male face and male facial aesthetics
Recognizing the components of the aging deformity of the face
Treatment strategies in the male patient
The bald man and the man with short hair
Man with shaved head
The “facelift” phobic man
Short scar facelifts in men
Preoperative planning in the male facelift patient
Planning incisions in the male facelift patient
Planning the temple incision
Planning the pre-auricular incision
Planning the perilobular incision
Planning the postauricular incision
Planning the transmastoid portion of the postauricular incision
Planning the occipital incision
Planning the submental incision
Treating the forehead in the male facelift patient
Treating the neck in the male facelift patient
Treating the chin in the male facelift patient
Eyelid surgery in the male facelift patient
Fat grafting in the male facelift patient
Preoperative preparations in the male patient
Anesthesia in the male facelift patient
Surgical technique
SMAS suspension
Drain placement
Pre-auricular beard follicle epilation
Ancillary procedures and alternative strategies in the male patient
Earlobe reduction
Upper lip lift
Nasolabial fold excision
Postoperative care of the male facelift patient
Summary
Case examples
Declaration
Acknowledgment and retention of rights
References
9-12
9.12 Secondary facelift irregularities and the secondary facelift
Introduction
Strategy in treating the secondary facelift patient
Identification and analysis of secondary aging change
Identification and analysis of secondary surgical irregularities
Hairline displacement and disruption
Hair loss
Poorly sited scars
Pre-helical portion of the preauricular incision
Tragal portion of the preauricular incision
Perilobular portion of the facelift incision
Postauricular portion of the facelift incision
Submental incision
Wide scars
Cross-hatched scars
Distortion of tragal anatomy
Distortion of earlobe anatomy
Over-excision of subcutaneous fat
Over-excision of subplatysmal fat
Over-excision of buccal fat
Under-rejuvenated neck
Prominent submandibular glands
Protruding digastric muscles
Residual platysma bands
Treatment of “radiofrequency neck” and “ultrasound neck”
Undertreatment of the SMAS
Uncorrected and undercorrected midface irregularities
Residual jowl
Distortion and abnormal appearances due to inappropriate skin shifts
Compression of the temporal face
Skin deficiencies and “tight look”
Skin slough
Distortion and abnormal appearances due to inappropriate SMAS shifts or SMAS injury
“Smile block”
Unaesthetic facial implants
The unrejuvenated forehead
Unrejuvenated perioral region
Uncorrected facial atrophy
Eyelid skin deficiencies and eyelid malposition
Over-reliance on laser resurfacing
Patient considerations
Technical considerations in secondary facelift
Conclusion
Case studies
Declaration
Acknowledgment
References
9-13
9.13 Perioral rejuvenation, including chin and genioplasty
Perioral anatomy and aesthetics
Chin aesthetics and analysis
Perioral imperfections
Chin deformities and procedure selection
Lip surgical corrections
Direct lip lift (DLL)
Indirect lip lift (ILL)
Resurfacing
Lip augmentation
Autogenous materials
Nonautogenous injectables
Conclusions
References
9-14
9.14 Facial feminization
Introduction
Historical perspective
Anatomy
Diagnosis, indications, pre- and postoperative management
Patient selection criteria
Hormone therapy
Timeline for FGS
General postoperative management
Outcomes, complications and future directions
Outcomes and complications
Medical necessity of FGS
Future directions
Virtual surgical planning in FGS
Upper third and hair
Frontonasal-orbital contouring, hairline restoration and brow lift
Introduction
Anatomic considerations
Preoperative considerations, diagnosis, indications
Surgical techniques, treatments
Approach
Frontal sinus setback and burring
Postoperative care
Outcomes, prognosis, and complications
Middle third
Malar augmentation and zygomatic osteotomies
Introduction
Preoperative considerations, diagnosis, indications
Surgical techniques, treatments
Approach
Malar implants
Zygomatic osteotomies
Autologous fat grafting
Postoperative care
Outcomes, prognosis, and complications
Feminizing rhinoplasty and lip augmentation
Introduction
Preoperative considerations, diagnosis, indications
Surgical techniques
Approach
Dorsal hump reduction
Nasal bone osteotomies
Tip reduction, rotation and deprojection
Lip lift
Postoperative care
Outcomes, prognosis, and complications
Lower third and neck
Mandibular reduction and genioplasty
Introduction
Surgical techniques, treatments
Angle reduction, mandibular body ostectomy and genioplasty
Postoperative care
Outcomes, prognosis, and complications
Chondrolaryngoplasty
Introduction
Anatomic considerations
Surgical techniques, treatments
Chondrolaryngoplasty
Postoperative care
Outcomes, prognosis, and complications
Vocal cord surgery
References
10
10 Editors’ perspective: brow and eye
11
11 Forehead rejuvenation
Introduction
Historical perspective
Anatomy
Galea
Muscle
Sensory nerves
Motor nerves
Patient presentation
Forehead aging
Aesthetics
Patient selection
Surgical techniques
Open coronal approach
Anterior hairline approach
Endoscopic approach
Temple approach
Transpalpebral approach – muscle modification
Lateral brow approach
Cutaneous approaches
Transpalpebral browpexy
Suture suspension browpexy
Postoperative care
Outcomes
Complications
Secondary procedures
References
12
12 Endoscopic brow lift
Introduction
Anatomic considerations
Brow considerations
Patient selection
Surgical technique
Postoperative care
Outcomes, prognosis and complications
Final considerations
Further reading
13
13 Blepharoplasty
Introduction
Historical perspective
Basic science/disease process
Essential and dynamic anatomy
Osteology and periorbita
Lateral retinaculum
Medial orbital vault
Forehead and temporal region
Eyelids
Upper eyelid
Septal extension
Lower eyelid
Retaining ligaments
Blood supply
Innervation: trigeminal nerve and facial nerve
Youthful, beautiful eyes
Etiology of aging
Diagnosis/patient presentation
Evaluation basics
Medical and ophthalmic history
Ocular examination
Visual acuity
External examination
Orbits and malar eminence
Pupils
Extraocular muscles
Globe
Tear film
Photographic documentation
Unintentional deception in eye appearance
Patient selection
Operative planning
Anatomic-directed therapy
Upper eyelid position
Lower eyelid tonicity
Eyelid ptosis or retraction
Globe position and malar prominence
Tear trough deformities
Optimal brow positioning
Treatment/technique (Video 13.1 & Video Lecture 13.1 )
Continuum of aesthetic enhancement
Upper eyelid surgery
Simple skin blepharoplasty
Anchor (or invagination) blepharoplasty
Orbital fat excision
Blepharoptosis
Surgical technique
Lower lid blepharoplasty
Transconjunctival blepharoplasty
Transcutaneous blepharoplasty
Orbital fat
Orbital fat transposition
Plication techniques
Orbital septum plication
Capsulopalpebral fascia plication
Orbicularis suspension
Canthopexy
Midfacelifting
Postoperative care
Complications
Special considerations
Non-surgical enhancement
Male blepharoplasty
Blepharoplasty in people of color
References
14
14 Secondary blepharoplasty
Introduction
Anatomy
Corneal protection
Pathophysiology and anatomical changes of the aging eyelid
Patient evaluation
Medical history
Physical examination
Procedures/techniques
Upper eyelid blepharoplasty
Eyelid malposition
Ptosis
Upper lid retraction
Lower eyelid blepharoplasty
Transcutaneous lower lid blepharoplasty
Transconjunctival lower lid blepharoplasty
Lateral canthal tendon anchoring procedures
Secondary lower lid procedures
Complications in blepharoplasty
Visual loss secondary to hemorrhage
Globe perforation during anesthesia
Damage to the extraocular muscles
Damage to the cornea
Wound dehiscence
Lower eyelid malposition
Upper eyelid malposition
Loss of lashes
Dry eyes
Infection
Incisional scarring
Excessive fat resection
Inappropriate lower lid fat resection
Conclusion
References
15
15 Asian facial cosmetic surgery
Introduction
Asian blepharoplasty
Introduction
Historical perspective
Preoperative consideration and diagnosis
Double-eyelidplasty
Non-incisional method
Incisional method
Ptosis correction
Non-incisional method
Incisional method
Secondary double-eyelidplasty
Height problem
Depth problem
Adhesion problem
Power problem
Volume problem
Four-directional extension
Medial epicanthoplasty
Lateral canthal lengthening
Lower lid lowering
Asian lower blepharoplasty
Aging upper blepharoplasty
Infrabrow lift
Asian rhinoplasty
Introduction
Historical perspective
Recent trends
Diagnosis
Nasal dorsum
Nasal tip
Surgical techniques and treatment
Prerequisites for Asian rhinoplasty (Figs. 15.34 & 15.35)
How to control the nasal tip projection
How to control nasal tip rotation
How to augment the nasal dorsum
Principles in nasal dorsum augmentation
Procedures
Outcomes, prognosis, and complications
Implant deviation
Exposure and infection of alloplastic implant
Capsular contracture
Secondary procedures
Forehead augmentation
Paranasal augmentation
Alar base surgery
Genioplasty
Asian facial bone surgery
Introduction
New perspective for aesthetic facial bone surgeries
Three planes on the face
Coronal plane with facial depth
Axial plane with facial depth
Sagittal plane with facial depth
Historical perspective
Malarplasty
Mandibuloplasty
Orthognathic surgery and anterior segmental ostectomy
Diagnosis and patient indication
Total facial profiles
Prominent mandible
Prominent zygoma
Chin
Dentoalveolar protrusion
Surgical techniques and treatments
Mandibuloplasty (Fig. 15.49)
Malarplasty (Fig. 15.52)
Intraoral infracture technique with incomplete osteotomy
Bicoronal approach
Narrowing genioplasty (Fig. 15.54)
Aesthetic orthognathic surgery
Surgery-first orthognathic approach (Fig. 15.58)
Occlusal plane-altering orthognathic surgery (Fig. 15.60)
Bimaxillary protrusion: anterior segmental setback ostectomy
Combined ASO, orthognathic surgery with facial contouring surgery
Outcomes, prognosis, and complications
Malarplasty
Mandibuloplasty
Asian facelift
Introduction
Historical perspective
Anatomic considerations in Asian facelifts
Preoperative considerations and diagnosis
Surgical techniques and treatment
Extended SMAS facelift (Fig. 15.63)
Incision and skin flap elevation (Fig. 15.64A,B)
SMAS flap elevation (Fig. 15.64C)
SMAS fixation and skin closure (Fig. 15.64D)
Neck lift
Asian male facelift
Outcomes, prognosis, and complications
Conclusion
Acknowledgment
R­ef­er­en­ces
16
16 Facial fat grafting
Introduction
Diagnosis/patient presentation
Patient selection
Surgical technique
Preoperative markings
Patient positioning
Harvesting
Refinement
Infiltration
Postoperative care
Outcomes, prognosis, and complications
Nanofat, platelet-rich plasma, platelet-rich fibrin, and concentrated growth factors
Conclusion
References
17
17 Editors’ perspective: nose
18
18 Nasal analysis and anatomy
Introduction
Nerve supply
Intrinsic and extrinsic nasal musculature
Nasal ligaments
Nasal bones, cartilages, and septum
References
19
19 Open technique rhinoplasty
Introduction
Historical perspective
Basic science/disease process
Diagnosis/patient presentation
Consultation
Nasal history
Nasal examination
Imaging
Expectations
Informed consent
Patient selection
Treatment surgical technique
Anesthesia and preoperative management (Video 19.1 )
Incisions and approach
Component dorsal hump reduction and dorsal reconstitution
The nasal airway
Septal reconstruction
Inferior outfracture/limited submucous resection
Harvesting autologous grafting material
Septal cartilage
Ear cartilage
Costal cartilage
Temporal fascia
The nasal tip
Cephalic trim
Columellar strut graft
Septal extension grafts
Nasal tip suturing techniques
Nasal tip grafting techniques
The alar rims
Alar contour and extended alar contour grafts
Lateral crural strut grafts
The alar–columellar relationship
Percutaneous lateral nasal osteotomies
Closure
Depressor septi nasi muscle release
Shaping the columella
Alar base surgery
Alar flaring
Alar flaring with modification of nostril shape
Correction of specific deformities
Deviated nose with dorsal hump
Systematic analysis
Operative goals
Surgical plan
Outcome
Long, wide nose with a drooping tip and nasal airway obstruction
Systematic analysis
Operative goals
Surgical plan
Outcome
Postoperative care
Dressings and wound care
Medications
Activity restrictions
General instructions
Follow-up
Outcomes, prognosis, complications
Outcomes
Prognosis
Complications
Bleeding
Infection
Prolonged edema
Deformities and deviation
Nasal airway obstruction
Secondary procedures
References
20
20 Closed technique rhinoplasty
Introduction
The anatomy and science necessary for surgical success
Why is rhinoplasty difficult?
Rhinoplasty as a right-brain operation
Equilibrium and balance
The structural nasal layers
Upper cartilaginous vaults
Middle and lower cartilaginous vaults
Dorsum and tip
Patterns of secondary deformity
Four common anatomic traps that predispose to unfavorable results (Table 20.1)
Low radix or low dorsum
Narrow middle vault
Inadequate tip projection
Alar cartilage malposition
The traps in surgical practice
The effect of rhinoplasty on the airway
Traditional concepts and clinical observations
Results of an airway outcome study in 600 patients
Patient selection
Fallacies of planning: two false assumptions that lead to unsatisfactory results
The interview
Differences in primary and secondary candidates
The preoperative examination
Valves
Septum
Turbinates
External nose
Basic nasal aesthetics
Preoperative photographs
Setting goals with the patient
Discussion of potential complications and revisions
Parameters of rhinoplasty planning
Skin thickness and distribution
Tip lobular contour
The balance between nasal base size and bridge height
Why this author still prefers endonasal rhinoplasty
The decision to operate
How to teach yourself rhinoplasty
Surgical technique
Routine order of surgical steps
Skeletonization
Technical details
Dorsal resection
Technical details
Nasal spine–caudal septum
Technical details
Alar cartilage resection
Technical details
Upper lateral cartilages and shortening the nose
Technical details
Septoplasty, spreader graft tunnels
Technical details
Turbinectomy
Graft placement and wound closure
Osteotomy
Technical details
Alar wedge resection
Technical details
Prioritizing the septal graft specimen for augmentation
Augmentation strategy: radix, spreader, and tip grafts
Dorsum and radix
Spreader grafts
Lateral wall and columellar grafts
Tip grafting (Fig. 20.18)
Technical details
Routine postoperative care
Dressings
Selection and use of additional graft donor sites and other augmentation materials
Conchal cartilage
Calvarial bone
Costal cartilage
Alloplastics
Maxillary augmentation
The postoperative course
Variations on the standard
Nasal deviation (Fig. 20.21)
Rhinoplasty in men
Ethnic rhinoplasty
Cleft lip nasal deformity
Older patients
Rhinophyma
The donor site-depleted patient
Problems in the postoperative course
Iatrogenic airway obstruction
Skeletal problems
Soft-tissue problems
Graft problems
Intraoperative and postoperative hemorrhage
Septal perforation
Rhinitis
Circulatory problems
Infection
Septal collapse
Red nose
Obscure complications
The unhappy patient
Identity of the previous surgeon
The decision to re-operate
Secondary rhinoplasty
Why primary and secondary rhinoplasty are the same operation
Deformities caused by prior open rhinoplasty
How to understand our most unhappy patients
References
21
21 Airway issues and the deviated nose
Introduction
Anatomy
Physiology
Temperature regulation and humidification
Particulate filtration
Olfaction
Phonation
Secondary sex organ
Historical perspective
Basic science/disease process
Rhinitis
The septum
The internal nasal valve
The external nasal valve
The turbinates
Diagnosis/patient presentation
History
Physical examination
Rhinomanometry
Radiology
Patient selection
Treatment/surgical technique
Treatment of rhinitis based on sub-type
Infectious rhinitis
Allergic rhinitis
Vasomotor rhinitis
Atrophic rhinitis
Rhinitis medicamentosa
Hypertrophic rhinitis
Correction of deviated nasal bones
Treatment of the deviated septum
Septal tilt
C-shaped anteroposterior deviation
C-shaped cephalocaudal deviation
S-shaped anteroposterior deviation
S-shaped cephalocaudal deviation
Localized deviation
Treatment of the incompetent internal nasal valve
Treatment of the incompetent external nasal valve
Treatment of turbinate disorders
Mechanical procedures
Destructive procedures
Turbinate resection procedures
Postoperative care
Outcomes/prognosis/complications
Secondary procedures
References
22
22 Secondary rhinoplasty
Introduction
Definitions
Why secondaries are difficult
Analysis
Operative techniques
Preparing to be a biological sculptor
The open versus closed approach in secondary rhinoplasty
Anesthesia
Opening the nose and tip deconstruction
Suture techniques and grafts (reconstruction)
Suture techniques: general principles
Grafts: general principles
Common secondary problems
Broad, bulbous, round tip
Collapsed middle third of nose
Collapsed or concave rims (external valves)
Isolated collapse of the lateral external valve
Short nose
Broad nasal base
Nasal dorsum irregularities
Saddle nose deformity
Pollybeak deformity
Airway problems (septoplasty)
Postoperative care
Early bad result
Tape
Fillers
Corticosteroids
Complications and untoward results
Columellar scar
Post-rhinoplasty fibrotic syndrome
The difficult patient
References
23
23 Otoplasty and ear reduction
Introduction
Historical perspective
Basic science/disease process
Diagnosis/patient presentation
Overall size and shape
Upper third
Middle third
Lower third
Asymmetry
Patient selection
Treatment/surgical technique
Standard otoplasty for prominent ears of normal size
Incision (Video 23.1 )
Dissection
Correction (Fig. 23.3)
Endpoint
Closure
Otoplasty for large ears or ears with inadequate helical rim definition
Incision
Dissection
Correction
Closure
Otoplasty for constricted ears
Otoplasty for cryptotia
Otoplasty for Stahl’s ears
Correction of aging, elongated earlobes
Incision
Closure
Correction of earring-related complications
Correction of facelift deformities around the ear
Earlobe deformities
Tragal deformities
Retroauricular deformities
Scars
Postoperative care
Outcomes, prognosis, and complications
Secondary procedures
References
24
24 Hair restoration
Introduction
Historical perspective
Patient selection
Preoperative marking (Fig. 24.1)
Technique4–8
Postoperative care
Case examples
Conclusion and key summary points
References
25-1
25.1 Editors’ perspective: liposuction
25-2
25.2 Liposuction: a comprehensive review of techniques and safety
Introduction
Basic science and anatomic considerations
Classification
Diagnosis, operative indications, and patient selection
Preoperative assessment
Initial evaluation
Physical exam
Patient education and informed consent
Operative considerations
Preoperative marking
Anesthesia and location of operation
Maintaining core body temperature and immediate preoperative care
Patient positioning
Prone/supine
Lateral decubitus positioning
Lidocaine
Epinephrine
Wetting solutions and perioperative fluid management
Tranexamic acid
Current recommendations for perioperative fluid management
Fluid resuscitation
Treatment options
Surgical endpoints
Cannulas and probes
Tip configuration
Cannula diameter
Cannula length
Cannulas utilized in traditional SAL
Cannulas utilized in PAL
VAL
Treatment areas
Arms
Back
Abdomen
Hips/flanks
Buttocks
Thighs
Lateral and posterior thighs
Medial thigh
Anterior thigh
Knees/ankles
Neck
Postoperative care
Complications
Emerging technology
Injection lipolysis
Non-invasive devices
Conclusion
References
25-3
25.3 Correction of liposuction deformities with the SAFE liposuction technique
Introduction
Challenges of repeat liposuction
The dose–response curve
Adjunctive energy modalities
Paradigms for the treatment of fat
Indications and contraindications
Patient evaluation
Preoperative planning and preparation
Surgical technique
Anesthesia
Markings
Patient positioning
Technique
Step 1: Separation
Step 2: Aspiration
Step 3: Fat equalization
Preventing contour deformities
Ancillary procedures
Postoperative care
Results and outcomes
Problems and complications
26
26 Editors’ perspective: abdominal contouring
27
27 Abdominoplasty
Introduction
Historical perspective
Patient selection and screening
Anatomy
Preoperative planning and preparation
Informed consent
Perioperative management
Contraindications to abdominoplasty
Patient positioning and superwet local anesthesia
Nuisances, untoward sequelae, and complications
Infections
Fluid collections
Blood loss and fluid replacement
Hematoma
Venous thromboembolism (VTE)
Nerve entrapment syndromes
Wound ischemia and necrosis
Scars
Pain
Combined procedures: abdominoplasty and breast surgery or intra-abdominal pelvic surgery with concomitant abdominal contour ...
Combining abdominoplasty with anatomically distant procedures, including breast surgery
Significance of operative procedure length
Related considerations in abdominoplasty
Downstaging
Limited abdominoplasties (types II and III in the abdominolipoplasty system of classification and treatment)181–184
Mini-abdominoplasty (type II)
The modified or lower abdominoplasty (type III)
Panniculectomy without umbilical circumscription
Scarring
Umbilicus
Scarred abdomen
Flanks
Reverse abdominoplasty
Secondary abdominoplasty
Bariatric plastic surgery
Males
Fleur-de-lis abdominoplasty
A note on scarring and the umbilicus
The waistline
Mons pubis
High definition
Visceral fat
Functional outcomes of abdominoplasty
Energy devices and non-surgical techniques in relation to an abdominoplasty
360° liposuction and abdominoplasty
Abdominoplasty surgical markings
Abdominoplasty surgical technique
Summary
References
28
28 Lipoabdominoplasty with anatomical definition: a new concept in abdominal aesthetic surgery
Introduction
Principles of the lipoabdominoplasty with anatomical definition
Patient selection
Marking
Upper abdomen
Lower abdomen and pubis
Point A
Surgical technique
Anatomical definition liposuction
Negative areas
Positive areas
Horizontal incision and preservation of Scarpa's fascia
Tunnel construction and diastasis plication
Omphaloplasty
Suture, drainage, therapeutics, and postoperative care
Special cases
Results
Comments
Conclusion
References
29
29 Editors’ perspective: truncal contouring
30
30 Bra-line back lift
Introduction/overview
Treatment goals and planned outcomes
Preoperative planning and preparation
Patient evaluation
Preoperative markings
Patient positioning
Procedural approach
Potential complications and management
Postprocedural care
Outcomes and evidence
Summary
References
31
31 Belt lipectomy
Introduction
Historical perspective
Basic science and disease process
Anatomy
Massive weight loss patients
The 20–30 pounds overweight group
Normal weight patients group
Diagnosis and patient presentation
BMI level at presentation
Fat deposition pattern
The skin/fat envelope
Commonalities of presentation
Patient selection
Lower bodylift type II (Lockwood technique)
Belt lipectomy/central bodylift
Selection criteria
Preoperative evaluation
Treatment/surgical techniques
Rationale for circumferential excisional procedures
Belt lipectomy
Goals
Marking the vertical midline
Horizontal mons pubis marking
Mark from lateral mons to ASIS
Superior horizontal abdominal marks
The posterior vertical midline is marked
The posterior midline extent of resection is marked
The inferior back marks
The superior back marks
Vertical alignment marks
Positioning sequence
Anesthesia and deep vein thrombosis/pulmonary embolism prophylaxis
Surgical technique
Postoperative care
Outcomes/prognosis/complications
Complications
Wound separation
Seromas
Dehiscence
Infection
Tissue necrosis
Deep vein thrombosis and pulmonary embolism
Psychological difficulties
References
32
32 Circumferential approaches to truncal contouring in massive weight loss patients: the lower lipo-bodylift
Introduction
Patient selection and screening
Treatment goals and planned outcomes
Preoperative planning and preparation
Markings
Patient positioning
Procedural approach
Type 1
Types 2 and 3
Anterior preparation
Mons pubis reconstruction
Adjuvant liposuction
Male “love handles”
Potential complications and management
Postoperative care
Outcomes
Maximal point of gluteal projection
Scar appearance
Transition vectors
Conclusions
References
33
33 Circumferential approaches to truncal contouring: autologous buttocks augmentation with purse-string gluteoplasty
Introduction
Patient selection
Surgical technique
Postoperative care
Outcomes and complications
References
34
34 Circumferential approaches to truncal contouring: Lower bodylift with autologous gluteal flaps for augmentation and pre ...
Introduction
Gluteal hypoplasia in the massive weight loss and aesthetic patient
Development of techniques
Aesthetic analysis
BMI and procedural indications
Gluteal flap selection
Clinical anatomy
Operative markings
Operative technique
Complications
Perioperative care and safety
Summary
References
35-1
35.1 Editors’ perspective: buttock augmentations
35-2
35.2 Buttock augmentation with implants
Gluteal aesthetic ideals
Topographical anatomy
Aesthetic analysis
Upper inner gluteal/sacral junction: ideal presacral space shape
Lower inner gluteal fold/leg junction
Lateral mid-buttock/hip contour
Lateral view aesthetics
Diagnosis/patient presentation
Ethnic considerations
Caucasian
Hispanic
African American
Asian
Patient selection
Aesthetic goals
Buttock implants (Video 35.2.1 )
Implant placement and selection
Anatomic planes of dissection for implant placement
Submuscular plane
Intramuscular plane
Subfascial plane
Implant shape selection
Muscle height-to-width ratio
Implant selection
The lateral view
Implant size selection
Intramuscular implant surgical technique
Markings
Preparation
Anesthesia/positioning
Incision design/selection
Skin flap dissection
Muscle dissection
Sizers/implant size
Drains
Implant placement/closure
Subfascial implant surgical technique
Markings
Technique
Drains
Closure
Postoperative care
Activity
Garments
Postoperative pain management
Complications
Wound dehiscence
Implant exposure
Infection
Seroma
Capsular contracture
Neuropraxia
Implant rotation
Implant malposition
Hyperpigmentation/skin discoloration
Skin ulceration
Chronic pain
Secondary procedures
Scar revision
Conclusion
References
Further reading
35-3
35.3 Buttock shaping with fat grafting and liposuction
Expert commentary on gluteal fat grafting
Introduction
Historical perspective
Gluteal aesthetic ideals
Diagnosis/patient presentation
Patient selection
Who is a good candidate for autologous fat grafting of the buttocks?
Aesthetic goals
Fat grafting surgical technique
Pre-surgical markings
Surgical technique
Postoperative care
Activity and follow-up
Outcomes, prognosis, and complications
Complications of grafting
Infection
Seromas
Neuropraxia
Hematologic and metabolic disturbances
Fat embolism
Secondary procedures
Additional augmentation
Expert commentary on gluteal fat grafting* Daniel A. Del Vecchio * Dedicated to D. Ralph Millard, MD
Commentary on patient selection, technique, and safety
What’s in a name?
GFG patient subtypes and preoperative considerations
Bimodal age distribution
The relative result and the absolute result
GFG subtypes
“Skinny” GFG (100% GFG, 0% liposuction)
Obese GFG (80% liposuction, 20% GFG)
The dense, fibrous fat GFG patient
The male GFG patient
Transgender male to female GFG
The staged versus the revision GFG patient
Comorbidities
Author’s current technique
Simultaneous separation and tumescence (SST)
Concluding comments
References
36
36 Upper limb contouring
Introduction
Historical perspective
Basic science/disease process
Diagnosis/patient presentation
Patient selection
Plan formulation
Laboratory work-up
Preoperative visit
Thromboembolic disease prophylaxis
Treatment/surgical technique
Anatomy
Marking
Operative technique (Videos 36.1 & 36.2 , Video Lecture 36.1 )
Postoperative care
Outcomes, prognosis, and complications
Secondary procedures
References
37
37 Medial thigh
Introduction
Anatomy
Patient selection and pre-surgical assessment
Pre-thighplasty liposuction
Surgical considerations
The upper third
The middle third
The lower third
Preoperative markings
Horizontal resection
Vertical resection
Intra-operative approach
Complications
Conclusions
References
38
38 Post-bariatric reconstruction
Obesity
Definition and epidemiology
Methods of weight reduction
Diet and exercise
Pharmacotherapy
Bariatric surgery
Incidence and decision-making for body contouring post-bariatric surgery
Diagnosis/presentation/evaluation
History
Physical examination
Assessment
Patient preoperative counseling and education
Patient selection/timing of surgery
Psychological considerations in post-bariatric body contouring
Patient safety and intraoperative considerations
Surgical techniques by anatomic region
Abdominal contouring
Deformity/patient evaluation
Operative planning and techniques
Variations in abdominal contouring and reconstruction
Complications
Lower bodylift/buttock contouring
Deformity/patient evaluation
Patient selection
Markings
Operative technique (Video 38.1)
Postoperative care
Vertical thigh-lift
Deformity/patient evaluation
Patient selection
Markings
Operative technique (Fig. 38.13)
Postoperative care
Complications
Contouring of the arms, breast, upper trunk, and male chest in the MWL patient
Staging and combination procedures
Complications/secondary procedures
Body contouring centers of excellence
References
39
39 Energy devices in aesthetic surgery
Introduction
Historical perspective
Background
Ultrasound-assisted liposuction
Preoperative preparation
Surgical technique
Optimizing outcomes
Postoperative care
Complications and management
Laser-assisted liposuction
Preoperative preparation
Surgical technique
Postoperative care
Complications and management
Energy-based skin tightening
Historical perspective
Radiofrequency-based skin tightening
Helium plasma-based skin tightening
Patient selection
Summary
References
40
40 Aesthetic genital surgery
Introduction
Male genital aesthetic surgery
Introduction
Measurements
Patient selection/examination
Anatomy
Penile enlargement
Penile lengthening
Outcomes
Girth increase treatment
Fat injections
Foreign body injections
Dermal and dermal fat grafts
Allograft dermal matrix grafts
Reconstruction of penile enlargements
Reversal of V–Y advancement flap
Fat removal
Diffuse foreign body removal
Dermal fat graft and AlloDerm removal
Postoperative care
Outcomes
Penoscrotal web
Scrotum enlargement
Hidden penis
Surgical technique
Outcomes
Female genital aesthetic surgery
Introduction
Anatomy
Labia minora reduction
Surgical technique
Outcomes
Labia majora modeling and reduction
Surgical technique
Mons pubis descent and lipodystrophy
Conclusion
References
Confidence is ClinicalKey

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Front matter

Fifth Edition

Plastic Surgery Aesthetic Volume Two

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

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

Fifth Edition

Plastic Surgery Aesthetic Volume Two Volume Editors

J. Peter Rubin

Alan Matarasso

MD, FACS

MD, FACS

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

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

Editor-in-Chief

Multimedia Editor

Peter C. Neligan

Daniel Z. Liu

MB, FRCS(I), FRCSC, FACS

MD

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

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

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

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

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

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

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

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

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

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

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

17 Skin grafting

206

18 Tissue engineering

220

19 Repair, grafting, and engineering of cartilage

235

20 Repair and grafting of bone

265

21 Repair and grafting of peripheral nerve

295

22 Repair and grafting fat and adipose tissue

309

23 Vascular territories

321

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

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

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

1 Plastic surgery and innovation in medicine

1

2 History of reconstructive and aesthetic surgery

9

Peter C. Neligan

Riccardo F. Mazzola and Isabella C. Mazzola

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

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

32

5 Business principles for plastic surgeons 6 Value-based healthcare

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

Steven F. Morris and G. Ian Taylor

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

37

25 Principles and techniques of microvascular surgery

414

60

26 Tissue expansion and implants

442

27 Principles of radiation therapy

452

8 Pre- and intra-operative imaging for plastic surgery83

28 Lymphedema: pathophysiology and basic science

472

9 Patient safety in plastic surgery

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

490

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

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

7 Digital photography in plastic surgery Daniel Z. Liu

66

Arash Momeni and Lawrence Cai

Jessica Erdmann-Sager and Christopher J. Pannucci

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

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

12 Patient-reported outcomes in plastic surgery

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

94 101 115 135

146

14 Principles of cancer management

153

15 Wound healing

163

16 Scar prevention, treatment, and revision

186

Stav Brown and Babak J. Mehrara

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

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

Stav Brown, Michelle Coriddi, and Babak J. Mehrara

Rei Ogawa

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

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

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

31 Implants and biomaterials

544

32 Transplantation in plastic surgery

555

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

568

34 Robotics in plastic surgery

582

35 Digital technology in plastic surgery

594

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

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

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

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

619

vi

Contents

38 Global plastic surgery

625

9.5 Facelift: Platysma-SMAS plication

203

9.6 Facelift: Lateral SMASectomy facelift

212

9.7 Facelift: The extended SMAS technique in facial rejuvenation

219

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

236

9.9 The lift-and-fill facelift

282

9.10 Neck rejuvenation

301

9.11 Male facelift

319

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

9.12 Secondary facelift irregularities and the secondary facelift

345

4 Pain management in plastic surgery

9.13 Perioral rejuvenation, including chin and genioplasty390

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

39 Gender-affirming surgery

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

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

634

Index652

Daniel C. Baker and Steven M. Levine

James M. Stuzin

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

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

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

1

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

13

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

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

6 Local anesthesia Malcolm D. Paul

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

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

Timothy Marten and Dino Elyassnia

25

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

Timothy Marten and Dino Elyassnia

Ali Totonchi and Bahman Guyuron

33 42

9.14 Facial feminization

404

10 Editors’ perspective: brow and eye

424

11 Forehead rejuvenation

425

12 Endoscopic brow lift

441

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

47 53

Richard Warren

Renato Saltz and Eric W. Anderson

13 Blepharoplasty453 Julius Few Jr., and Marco Ellis

8.2 Injectables and resurfacing techniques: Soft-tissue fillers

54

8.3 Injectables and resurfacing techniques: Botulinum toxin/neurotoxins

73

14 Secondary blepharoplasty

484

15 Asian facial cosmetic surgery

513

16 Facial fat grafting

559

17 Editors’ perspective: nose

567

96

18 Nasal analysis and anatomy

568

8.6 Minimally invasive multimodal facial rejuvenation118

19 Open technique rhinoplasty

581

Kavita Mariwalla

Rawaa Almukhtar and Sabrina G. Fabi

8.4 Injectables and resurfacing techniques: Lasers in aesthetic surgery

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

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

84

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

Luiz S. Toledo

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

20 Closed technique rhinoplasty

607

9.1 Editors’ perspective: surgical facial rejuvenation130

21 Airway issues and the deviated nose

647

9.2 Facial anatomy and aging

22 Secondary rhinoplasty

662

23 Otoplasty and ear reduction

681

24 Hair restoration

690

Alan Matarasso

Bryan Mendelson and Chin-Ho Wong

131

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

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

Mark B. Constantian

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

Alfonso Barrera and Victor Zhu

Contents

vii

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

700

25.2 Liposuction: a comprehensive review of techniques and safety

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

701

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

J. Peter Rubin

Gianfranco Frojo, Jayne Coleman, and Jeffrey Kenkel

1 Management of craniomaxillofacial fractures

25.3 Correction of liposuction deformities with the SAFE liposuction technique

723

26 Editors’ perspective: abdominal contouring

731

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

27 Abdominoplasty732 Alan Matarasso

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

2

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

2 Scalp and forehead reconstruction

39

3 Aesthetic nasal reconstruction

52

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

4 Auricular construction

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

110

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

29 Editors’ perspective: truncal contouring

785

6.1 Computerized surgical planning: introduction 155

30 Bra-line back lift

786

6.2 Three-dimensional virtual planning in orthognathic surgery

157

31 Belt lipectomy

792

6.3 Computerized surgical planning in head and neck reconstruction

173

7 Introduction to post-oncologic reconstruction

188

834

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

190

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

841

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

217

35.1 Editors’ perspective: buttock augmentations

854

10 Local flaps for facial coverage

229

35.2 Buttock augmentation with implants

855

11 Lip reconstruction

256

J. Peter Rubin

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

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

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

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

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

819

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

37 Medial thigh

Samantha G. Maliha and Jeffrey Gusenoff

878 891

38 Post-bariatric reconstruction

898

39 Energy devices in aesthetic surgery

919

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

40 Aesthetic genital surgery Gary J. Alter

Pradip R. Shetye and Srinivas M. Susarla

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

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

Richard A. Hopper

926

Index951

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

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

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

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

14 Secondary facial reconstruction

336

15 Facial paralysis

359

Afaaf Shakir and Lawrence J. Gottlieb

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

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

17 Facial feminization

Luis Capitán, Daniel Simon, and Fermín Capitán-Cañadas

400

viii

Contents

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

442 451

19.2 Rotation advancement cheiloplasty

456

19.3 Extended Mohler repair

488

Philip Kuo-Ting Chen and Lucia Pannuto

808

25.3 Multisutural syndromic synostosis

827

Sameer Shakir and Jesse A. Taylor

Richard A. Hopper and Benjamin B. Massenburg

Section I: Clefts 19.1 Unilateral cleft lip: introduction

Joseph E. Losee and Michael R. Bykowski

25.2 Nonsyndromic craniosynostosis

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

26 Craniofacial microsomia

859

27 Idiopathic progressive hemifacial atrophy

887

28 Robin sequence

902

29 Treacher Collins syndrome

923

21.2 Straight line repair with intravelar veloplasty (IVVP)542

Section III: Pediatrics 30 Congenital melanocytic nevi

935

21.3 Double opposing Z-palatoplasty

549

31 Vascular anomalies

952

21.4 Buccal myomucosal flap palate repair

557

32 Pediatric chest and trunk deformities

974

21.5 The buccal fat pad flap

567

33 Pediatric tumors

988

34 Conjoined twins

1001

Roberto L. Flores

19.4 Anatomic subunit approximation approach to unilateral cleft lip repair

499

20 Repair of bilateral cleft lip

519

21.1 Cleft palate: introduction

538

Raymond W. Tse and David M. Fisher

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

Brian Sommerlad

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

James D. Vargo and Steven R. Buchman

21.6 Oral fistula closure

Mirko S. Gilardino, Sabrina Cugno, and Abdulaziz Alabdulkarim

21.7 Alveolar clefts

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

575 583

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

21.9 Velopharyngeal dysfunction

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

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

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

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

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

618

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

2 Management of lower extremity trauma Hyunsuk Peter Suh

1 52

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

636

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

21.11 Cleft and craniofacial orthognathic surgery

661

Section II: Craniofacial 22 Pediatric facial fractures

3.2 Imaging modalities for diagnosis and treatment of lymphedema 78

708

3.3 Lymphaticovenular bypass

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

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

102

747

3.5 Debulking strategies and procedures: liposuction of leg lymphedema

111

775

3.6 Debulking strategies and procedures: excision 120

24 Craniofacial clefts

25.1 Craniosynostosis: introduction

Christopher R. Forrest and Johanna N. Riesel

92

3.4 Vascularized lymph node transplant

726

James P. Bradley and Henry K. Kawamoto Jr.

Balazs Mohos and Chieh-Han John Tzou

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

23 Orbital hypertelorism

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

Joon Pio Hong and David H. Song

Rebecca M. Garza and David W. Chang

Håkan Brorson

Hung-Chi Chen and Yueh-Bih Tang

Contents

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

128

5 Reconstructive surgery: lower extremity coverage154 Joon Pio Hong

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

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

6.3 Lower extremity pain: regenerative peripheral nerve interfaces

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

7 Skeletal reconstruction

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

8 Foot reconstruction

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

9.1 Diabetic foot: introduction

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

190 203

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

311 327

12 Reconstruction of the posterior trunk

354

13 Abdominal wall reconstruction

388

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

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

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

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

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

17 Perineal reconstruction

489

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

501

19 Extremity burn reconstruction

538

20 Management of the burned face and neck

561

21 Pediatric burns

589

Ping Song, Hakim Said, and Otway Louie

Raphael C. Lee and Chad M. Teven

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

Sebastian Q. Vrouwe and Lawrence J. Gottlieb

edited by Maurice Y. Nahabedian

265

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



462

Ibrahim Khansa and Jeffrey E. Janis

Volume Five: Breast

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

11 Reconstruction of the chest

16 Pressure sores

228

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

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

452

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

Index610

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

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

15 Reconstruction of acquired vaginal defects

Vinita Puri and Venkateshwaran Narasiman

210

ix

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

1

2 Current status of breast implants

13

3 Primary breast augmentation with implants

28

Patrick Mallucci and Giovanni Bistoni Charles Randquist

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

5 Augmentation mastopexy

69

6 Mastopexy after massive weight loss

83

7 Prevention and management of complications following breast augmentation and mastopexy

92

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

M. Bradley Calobrace and Chester J. Mays

8 Short scar breast reduction

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

102

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

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

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

x

Contents

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

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

174

182

191

15 Management strategies for gynecomastia

200

Michele Ann Manahan

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

207

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

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

234

19 Introduction to prosthetic breast reconstruction239 Maurice Y. Nahabedian

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

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

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

247

265

293

Kiya Movassaghi and Christopher N. Stewart

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

Jin Sup Eom and Hyunho Han

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

413

33 Introduction to autologous reconstruction with alternative free flaps

420

34 Gluteal free flaps for breast reconstruction

424

Pierre Chevray

Maurice Y. Nahabedian

Salih Colakoglu and Gedge D. Rosson

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

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

450

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

461

38 Hybrid breast reconstruction: combining flaps and implants

468

39 Innervation of autologous flaps

475

40 Stacked and conjoined flaps

481

41 Management of complications following autologous breast reconstruction

488

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

Phillip Blondeel and Dries Opsomer

Aldona J. Spiegel and Janak A. Parikh

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

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

371

Adrian McArdle and Joan E. Lipa

Nicholas T. Haddock and Sumeet S. Teotia

280

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

30 Autologous breast reconstruction with the DIEP flap

Arash Momeni, Hani Sbitany, and Suhail K. Kanchwala

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

355

Dennis C. Hammond

31 Autologous breast reconstruction with the free TRAM flap 396

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

29 Breast reconstruction with the latissimus dorsi flap

298

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

43 Secondary procedures following autologous reconstruction516 Jian Farhadi and Vendela Grufman

44 Introduction to oncoplastic breast surgery

526

45 Partial breast reconstruction using reduction and mastopexy techniques

533

Maurice Y. Nahabedian

304

26 Secondary refinement procedures following prosthetic breast reconstruction

317

27 Introduction to autologous breast reconstruction with abdominal free flaps

46 Oncoplastic breast reconstruction: local flap techniques547

336

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

Roy de Vita and Veronica Vietti Michelina

Maurice Y. Nahabedian

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

Albert Losken, Nusaiba F. Baker, and Alexandre Munhoz

Moustapha Hamdi and Claudio Angrigiani

340

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

556

Contents

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

Jaume Masià, Cristhian D. Pomata, and Javier Sanz

567

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

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

590

51 Current options for nipple reconstruction

603

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

Index610

Introduction:  Plastic surgery contributions to hand surgery James Chang

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

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

liii

1

3 Diagnostic imaging of the hand and wrist

70

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

5 Principles of internal fixation

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

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

95 109

123

8 Fractures and dislocations of the wrist and distal radius

173

9 Flexor tendon injuries and reconstruction

193

Jin Bo Tang

10 Extensor tendon injuries

Kai Megerle and Karl-Josef Prommersberger

230

11 Replantation250 Dong Chul Lee and Eugene Park

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

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

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

17 Dupuytren’s disease

384

18 Osteoarthritis in the hand and wrist

411

19 Rheumatologic conditions of the hand and wrist

449

20 Occupational disorders of the hand

491

Section IV: Nerve Disorders 21 Nerve entrapment syndromes

499

22 Peripheral nerve repair and reconstruction

526

23 Brachial plexus injuries: adult and pediatric

552

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

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

24 Tetraplegia585 Carina Reinholdt and Catherine Curtin

25 Tendon transfers

605

26 Nerve transfers

638

27 Free-functioning muscle transfer

665

Section V: Challenging Disorders 28 The ischemic hand

680

29 The spastic hand

704

30 The stiff hand

716

31 The painful hand

735

Neil F. Jones

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

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

147

Steven C. Haase and Kevin C. Chung

356

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

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

7 Hand fractures and joint injuries

Warren C. Hammert and Randy R. Bindra

16 Tumors of the hand

Elisabet Hagert and Donald Lalonde

49

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

337

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

Celine Yeung and Steven J. McCabe

2 Examination of the upper extremity Ryosuke Kakinoki

Section III: Specific Disorders 15 Infections of the hand

Douglas M. Sammer and Kevin C. Chung

Volume Six: Hand and Upper Extremity

xi

Caroline Leclercq, Nathalie Bini, and Charlotte Jaloux



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

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

33 Congenital hand II: Malformations – whole limb

770

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

790

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

Brinkley K. Sandvall and Charles A. Goldfarb

xii

Contents

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

824

36 Congenital hand V: Deformations and dysplasias – variant growth

842

Christianne A. van Nieuwenhoven

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

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

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

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

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

930

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

42 Aesthetic hand surgery

963

43 Hand therapy

983

David Alan Kulber and Meghan C. McCullough

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

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

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

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

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

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

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

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

Volume Two

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

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

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

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

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

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

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

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

Chapter 13: Blepharoplasty

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

13.1: Perioribital rejuvenation Julius Few Jr. and Marco Ellis

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Video Contents

Chapter 15: Asian facial cosmetic surgery

Chapter 38: Post-bariatric reconstruction

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

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

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

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

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

Chapter 5: Secondary treatment of acquired cranio-orbital deformities

Chapter 19: Open technique rhinoplasty

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

19.1: Open technique rhinoplasty Allen L. Van Beek

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

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

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

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

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

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

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

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

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

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

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

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

Chapter 37: Medial thigh

Chapter 16: Surgical management of facial pain, including migraines

37.1: Thighplasty Samantha G. Maliha and Jeffrey Gusenoff

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

Video Contents

Chapter 17: Facial feminization

Chapter 23: Orbital hypertelorism

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

23.1: Box-shift osteotomy Eric Arnaud

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

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

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

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

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

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

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

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

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

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

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

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

Chapter 21.9: Velopharyngeal dysfunction

Chapter 3.3: Lymphaticovenular bypass

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

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

Chapter 21.7: Alveolar clefts

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

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

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

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

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

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

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

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

Chapter 5: Reconstructive surgery: lower extremity coverage

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

5.1: Anterolateral thigh flap harvest Michel Saint-Cyr

Chapter 17: Perineal reconstruction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Video Contents

15.2: Ultrasound-assisted liposuction Charles M. Malata

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

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

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

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

Chapter 25: Management of complications of prosthetic breast reconstruction

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

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

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

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

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

Chapter 31: Autologous breast reconstruction with the free TRAM flap

Chapter 26: Secondary refinement procedures following prosthetic breast reconstruction

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

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

Chapter 35: Autologous breast reconstruction with medial thigh flaps

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

Chapter 34: Gluteal free flaps for breast reconstruction

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

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

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

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

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

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

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

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

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

3.3: Wrist ultrasound Alphonsus K.S. Chong

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

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

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

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

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

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

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

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

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

Video Contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Video Contents

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

Chapter 39: Growth considerations in the pediatric upper extremity

32.1: Pediatric trigger thumb release James Chang

39.1: Epiphyseal transplant harvesting technique Marco Innocenti and Sara Calabrese

Chapter 33: Congenital hand II: Malformations – whole limb

Chapter 41: Upper extremity composite allotransplantation

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

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

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

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

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

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

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

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

Chapter 26: Tissue expansion and implants

Chapter 7: Digital photography in plastic surgery

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

Digital photography in plastic surgery

Chapter 27: Principles of radiation therapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Lecture Video Contents

Chapter 9.2: Facial anatomy and aging

Chapter 11: Forehead rejuvenation

Facial anatomy and aging Bryan Mendelson and Chin-Ho Wong

Forehead rejuvenation Richard Warren

Chapter 9.3: Principles and surgical approaches of facelift

Chapter 12: Endoscopic brow lift

Principles and surgical approaches of facelift Richard J. Warren

Endoscopic brow lifting Renato Saltz and Eric W. Anderson

Chapter 13: Blepharoplasty

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

Blepharoplasty Julius Few Jr. and Marco Ellis

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

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

Chapter 9.5: Facelift: Platysma-SMAS plication

Chapter 15: Asian facial cosmetic surgery

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

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

Chapter 9.6: Facelift: Lateral SMASectomy facelift

Chapter 16: Facial fat grafting

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

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

Chapter 18: Nasal analysis and anatomy

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

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

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

Chapter 19: Open technique rhinoplasty

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

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

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

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

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

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

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

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

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

Chapter 24: Hair restoration

Chapter 9.12: Secondary facelift irregularities and the secondary facelift

Hair restoration Alfonso Barrera and Victor Zhu

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

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

Chapter 9.13: Perioral rejuvenation, including chin and genioplasty

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

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

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

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

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

Lecture Video Contents

Chapter 27: Abdominoplasty Abdominoplasty Alan Matarasso

Volume Three

Chapter 30: Bra-line back lift

Chapter 1: Management of craniomaxillofacial fractures

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

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

Chapter 31: Belt Lipectomy

Chapter 2: Scalp and forehead reconstruction

Belt lipectomy Amitabh Singh and Al S. Aly

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

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

Chapter 3: Aesthetic nasal reconstruction

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

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

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

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

Chapter 35.3: Buttock shaping with fat grafting and liposuction

Aesthetic nasal reconstruction Frederick J. Menick

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

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

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

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

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

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

Chapter 12: Oral cavity, tongue, and mandibular reconstructions

Chapter 36: Upper limb contouring

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

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

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

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

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

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

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Lecture Video Contents

Chapter 19.1: Unilateral cleft lip: introduction

Chapter 12: Reconstruction of the posterior trunk

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lecture Video Contents

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

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

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

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

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

Volume Six Chapter 1: Anatomy and biomechanics of the hand

Chapter 29: Breast reconstruction with the latissimus dorsi flap

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

Breast reconstruction with the latissimus flap Dennis C. Hammond

Chapter 7: Hand fractures and joint injuries

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

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

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

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

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

Chapter 40: Stacked and conjoined flaps

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

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

Chapter 11: Replantation Replantation Dong Chul Lee and Eugene Park

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

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

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

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

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

Chapter 24: Tetraplegia

Chapter 43: Secondary procedures following autologous reconstruction

Tetraplegia Carina Reinholdt and Catherine Curtin

Secondary procedures following autologous reconstruction Jian Farhadi and Vendela Grufman

Chapter 25: Tendon transfers Tendon transfers Neil F. Jones

Chapter 44: Introduction to oncoplastic breast surgery

Chapter 26: Nerve transfers

Introduction to oncoplastic breast surgery Maurice Y. Nahabedian

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

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Lecture Video Contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Multimedia editor

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

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

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

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

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List of Contributors

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

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

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

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

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

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

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

List of Contributors

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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List of Contributors

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

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

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

List of Contributors

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

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

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

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List of Contributors

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

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

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

List of Contributors

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

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

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

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

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List of Contributors

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

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

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

List of Contributors

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

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

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

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

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

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

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

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

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

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List of Contributors

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

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

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

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

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

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

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

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

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

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

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

List of Contributors

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

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

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

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

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

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

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

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

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List of Contributors

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

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

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

List of Contributors

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

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

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

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List of Contributors

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

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

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

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

List of Contributors

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

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

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

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List of Contributors

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

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

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

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

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

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

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

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

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

List of Contributors

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

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

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

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List of Contributors

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

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

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

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

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

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

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

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

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

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

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

List of Contributors

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

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

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

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

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

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

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

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

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

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

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

xlvii

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

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List of Contributors

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

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

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

List of Contributors

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

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

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

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

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

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

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

SYNOPSIS















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

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

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

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

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CHAPTER 1  • Managing the aesthetic surgery patient

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

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

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

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

Societal interest in cosmetic surgery

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

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

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

Top Five Surgical Procedures in 2019

270,670

280,692

146,711

140,381 113,229

LIPOSUCTION

BREAST AUGMENTATION

TUMMY TUCK

EYELID SURGERY

BREAST LIFT

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

Change in Procedure Numbers 1997–2016 280,692

270,670

176,863 159,232

146,711

137,053 140,381 113,229

101,176

19,882 LIPOSUCTION

BREAST AUGMENTATION

TUMMY TUCK 1997

EYELID SURGERY

2019

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

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BREAST LIFT

CHAPTER 1  • Managing the aesthetic surgery patient

4

Table 1.1  Age distribution of plastic surgery patients

17 years and under

19–34 years

35–50 years

51–64 years

65+ years

Surgical procedures

0.90%

20.20%

40.00%

28.70%

10.20%

Non-surgical procedures

0.70%

15.10%

37.10%

32.80%

14.30%

The Aesthetic Society, 2019 data.

Table 1.2  Gender distribution of plastic surgical patients

Female

Male

Number

Percentage

Number

Percentage

Surgical procedures

1,366,914

93.00%

102,838

7.00%

Non-surgical procedures

2,818,219

90.30%

303,221

9.70%

Overall

4,185,133

406,059

The Aesthetic Society, 2019 data.

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

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

  Show

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

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

Patient motivation for cosmetic surgery

5

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

Your online information is poor

Your practice

Another practice

First contact

No reply Unhelpful or impolite response

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

First appointment

Receptionist

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

Surgery

Surgeon

Nurse

Photography Garment fitting

Practice manager

Postoperative appointment(s)

Practice management algorithm.

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

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

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

CHAPTER 1  • Managing the aesthetic surgery patient

6

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

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

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

Top Five Cosmetic Surgeries for Men 2019 32,827

21,407 18,751

LIPOSUCTION

MALE BREAST REDUCTION

EYELID SURGERY

5037

5831

NOSE SURGERY

TUMMY TUCK

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

Special patient groups

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

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

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

Percentage of Patients 18 Years and Under

3571 3329

2588

1777

EAR SURGERY

NOSE SURGERY

1949

BREAST REDUCTION BREAST AUGMENTATION

LIPOSUCTION

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

7

Special patient groups

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

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CHAPTER 1  • Managing the aesthetic surgery patient

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

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

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

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

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

The initial consultation

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

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Continued

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B

Figure 1.6, cont’d

CHAPTER 1  • Managing the aesthetic surgery patient

The initial consultation

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

__________________________________________ Signature

______________ Date

__________________________________________ Print Name

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

Figure 1.7  Example photographic consent form.

______________ Date

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Saying “no” to a potential patient

9

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

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

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

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

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

Figure 1.9  Gorney’s patient selection guide.

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

Saying “no” to a potential patient

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

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CHAPTER 1  • Managing the aesthetic surgery patient

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

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

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

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

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

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

Saying “yes”: what is involved?

Figure 1.10  Example surgery consent form.

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CHAPTER 1  • Managing the aesthetic surgery patient

The unsatisfactory outcome

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

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

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

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

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

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

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

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

The unsatisfactory outcome

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

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Figure 1.12  Example pre-surgery anesthesia evaluation form.

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Figure 1.13  Example discharge advice form.

Continued

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

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

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

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

Access the reference list online at   Elsevier eBooks+

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

Reputation management

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

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17

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

References

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

9.

10. 11. 12. 13. 14.

15. 16. 17. 18.

17.e1

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

 

SECTION I •  Aesthetic Anesthesia Techniques

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

SYNOPSIS

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

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

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

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

The three pillars of patient safety

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

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

Inadequate VTE prophylaxis used (EVIDENCE)

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

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

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

19

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

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

20

SECTION I

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

II

II III

DIAGNOSTIC

THERAPEUTIC

RISK

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

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

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

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

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

21

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

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

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

Algorithm 3.1 Calculate Revised Cardiac Risk Index2

0–2

No symptoms

3+

Active angina or other cardiac symptoms

No further preoperative cardiac evaluation indicated

Preoperative cardiac evaluation for aesthetic procedures requiring general anesthesia.

Referral for medical optimization/cardiac testing

The three pillars of patient safety

23

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

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

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

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

24

SECTION I

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

Algorithm 3.2 General anesthesia and >45 min procedure

No

Yes

Contraindications/patient refuses chemoprophylaxis or already on active anticoagulation

Yes No Calculate Caprini score (Figure 3.3)

3–4

1–2

0

5–6

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

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

7–8

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

9+

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

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

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

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

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

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

References

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

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

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

46. 47.

48.

49. 50.

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

SECTION I  •  Aesthetic Anesthesia Techniques

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

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

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

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

26

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CHAPTER 4  • Pain management in plastic surgery

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

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

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

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

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

Adjuvant multimodal medications

27

COX-2 inhibitors

Muscle relaxants

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

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

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

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

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

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CHAPTER 4  • Pain management in plastic surgery

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

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

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

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

Table 4.1  Local anesthetic dosing recommendations

Anesthetic

Onset

Duration of analgesia

Maximum dose without epinephrine

Maximum dose with epinephrine

Lidocaine

10–20 min

3–8 h

4.5 mg/kg

7 mg/kg

Mepivacaine

10–20 min

3–10 h

5 mg/kg

7 mg/kg

Ropivacaine

15–30 min

5–24 h

3 mg/kg

3.5 mg/kg

Bupivacaine

15–30 min

5–30 h

2.5 mg/kg

3 mg/kg

Epidural anesthesia

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

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

29

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

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

30

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CHAPTER 4  • Pain management in plastic surgery

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

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

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

Table 4.2  Multimodal analgesia (MMA) options

Medication/ technique

Initiation

Dosage

Duration

Contraindications/caution

Epidural

Preoperatively

Per anesthesia acute pain team

3–5 days until patient able to tolerate PO MMA

Caution in patients with preexisting pulmonary disease, hypotension

Local and/or regional block

Pre- or intra-operatively

Attention to local anesthetic maximum dosage

Patient-controlled analgesia

Postoperatively as needed

Start at lowest dose without basal rate

Until patient able to tolerate CLD

Do not combine with epidural

Acetaminophen

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

1000 mg/1000 mg q6 h

Continue 5 days after discharge

Liver disease

Celecoxib

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

400 mg/200 mg TID

Continue 5 days after discharge

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

Gabapentin

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

Continue 5 days after discharge

OSA; caution in patients with renal impairment

Cyclobenzaprine

Postoperatively PRN when patient able to tolerate CLD

5–10 mg TID

Continue 5 days after discharge if initiated inpatient

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

Oxycodone

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

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

Discontinue as soon as able

IV hydromorphone

Postoperatively PRN

0.5–1.0 mg hydromorphone q3h PRN breakthrough pain

Discontinue as soon as able

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

Putting it all together: multimodal analgesia (MMA) regimen

31

Table 4.3  MMA options for common plastic surgery procedures

Breast surgery

Duration

Contraindications/ caution

1000 mg/1000 mg q6 h

Continue 5 days after discharge

Liver disease

Single re-operative dose/postoperatively

400 mg/200 mg TID

Continue 5 days after discharge

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

Gabapentin

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

900 mg/300 mg TID

Continue 5 days after discharge

OSA; caution in patients with renal impairment

Oxycodone

Single re-operative dose/postoperatively PRN

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

Discontinue as soon as able

TAP block

Preoperatively

Attention to local anesthetic maximum dosage

Acetaminophen

Single re-operative dose/ postoperatively

1000 mg/1000 mg q6 h

Continue 5 days after discharge

Liver disease

Celecoxib

Single re-operative dose/postoperatively

400 mg/200 mg TID

Continue 5 days after discharge

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

Gabapentin

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

900 mg/300 mg TID

Continue 5 days after discharge

OSA; caution in patients with renal impairment

Oxycodone

Single re-operative dose/postoperatively PRN

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

Discontinue as soon as able

Tumescent

Klein solution

Intra-operatively

150 cc per side

Oral

Acetaminophen

Single re-operative dose/postoperatively

1000 mg/1000 mg q6 h

Continue 5 days after discharge

Liver disease

Celecoxib

Single re-operative dose/postoperatively

400 mg/ 200 mg TID

Continue 5 days after discharge

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

Oxycodone

Single re-operative dose/postoperatively PRN

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

Discontinue as soon as able

Medication/ technique

Initiation

Dosage

Regional block

PECS I or II block

Preoperatively

Attention to local anesthetic maximum dosage

Oral

Acetaminophen

Single re-operative dose/postoperatively

Celecoxib

Abdominoplasty Regional block Oral

Facelift

Max. safe dose 35 mg/kg

32

SECTION I

CHAPTER 4  • Pain management in plastic surgery

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

Hand surgery

Duration

Contraindications/ caution

1000 mg/1000 mg q6 h

Continue 5 days after discharge

Liver disease

Single re-operative dose/postoperatively

400 mg/200 mg TID

Continue 5 days after discharge

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

Single re-operative dose/postoperatively PRN

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

Discontinue as soon as able

Medication/ technique

Initiation

Dosage

Regional block

Supra- or infraclavicular blocks

Preoperatively

Attention to local anesthetic maximum dosage

Oral

Acetaminophen

Single re-operative dose/postoperatively

Celecoxib

Oxycodone

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

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

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

 

 

SECTION I • Aesthetic Anesthesia Techniques

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

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

Introduction

Anatomic blocks of the face

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

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

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

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CHAPTER 5  • Anatomic blocks of the face and neck

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

Anatomic nerve block

Section in this chapter

Infraorbital nerve

1

Mental nerve Nerve from the mylohyoid (mental plus)

2

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

3

Zygomaticotemporal nerve Zygomaticofacial nerve Lacrimal nerve

4

Dorsal nasal nerve

5

Great auricular nerve Lobular nerve

6

Transverse cervical nerves Lesser occipital nerve

7

Mandibular branch of cranial nerve V (V3) Buccal nerve

8

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

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

Infraorbital nerve

Mental nerve

Greater auricular nerve and lobular nerve

Lacrimal nerve

Nerve from the mylohyoid

Transverse cervical nerve

Lesser occipital nerve

Zygomaticofacial/zygomaticotemporal nerves

Supraorbital/supratrochlear nerves

Buccal nerve

Dorsal nasal nerve

Infratrochlear nerve

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

V3

Anatomic blocks of the face

B

A

C

35

D

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

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

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

Technique

Area of anesthesia

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

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

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CHAPTER 5  • Anatomic blocks of the face and neck

B

A

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

A

B

Mental nerve

Nerve from mylohyoid

C

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

Anatomic blocks of the face

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

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

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

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

37

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

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

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

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

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CHAPTER 5  • Anatomic blocks of the face and neck

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

Section 6: great auricular nerve and lobular nerve Anatomy

A

Zygomaticotemporal nerve

Zygomaticofacial nerve

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

Technique

B

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

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

Area of anesthesia This block anesthetizes the mid-vault, or cartilaginous dorsum, the sidewalls distal to the end of the nasal bones, and the nasal tip. Since injecting local anesthetic directly into the

To successfully block the great auricular nerve, the SCM needs to be identified. A reproducible way to do this is by having the patient turn their head toward the ipsilateral shoulder against the resistance of your hand. This will outline the body of the muscle. Then taking a line dropped down from the external auditory canal to the midportion of this muscle and measuring 6.5 cm, the injector will be able to successfully administer 1–2 cc of local anesthetic to block this nerve.22 While every surgeon is different, 6.5 cm is usually the length of the small finger or the distance from the metacarpal phalangeal joint of the thumb to the tip of the thumb (Fig. 5.6). Alternatively, if only the lobule requires anesthesia, a lobular nerve block can be employed. This is particularly useful in earlobe repair or reduction. To effectively perform this block, 1–2 cc of local anesthetic is infiltrated in a square-shaped area 3.3 cm below the external auditory canal between a line dropped down from the tragus and a second line dropped down from the antitragus.

Area of anesthesia The great auricular nerve supplies the skin over the parotid and angle of the mandible, the lower ear including the lobule, and the skin over the mastoid process.23 This block is especially valuable for earlobe repair and for skin cancer resection and reconstruction of the earlobe, mastoid region, anterior lower cheek, and angle of the mandible.

Section 7: transverse cervical nerves and lesser occipital nerve Anatomy In addition to the great auricular nerve, there are other clinically relevant cervical cutaneous nerves: namely, the

Anatomic blocks of the face

39

Algorithm 5.1 Algorithm for nasal blockade Patient prefers general anesthesia

Patient unfit for general anesthesia

Patient prefers local anesthesia

Nasal blockade

General anesthesia

Tip

Sidewall

Dorsum

Dorsal nasal block

Ala

Columella

Infraorbital block

Medial to medial canthus

Infratrochlear block

Algorithm for nasal blockade. If the patient is amenable for local anesthesia for cosmetic or reconstructive nasal procedures, then nasal blockade can be employed. Based on the specific area of concern, the patient may require a dorsal nasal block, infraorbital block infratrochlear block, or some combination of the three.

transverse cervical nerves and the lesser occipital nerve. The transverse cervical nerves innervate the anterior and lateral neck below the mandible and the lesser occipital nerve innervates the skin posterior to the ear and the middle third of the helix and antihelix of the ear. The transverse cervical arises from the ventral rami of spinal nerves C2 and C3. The lesser occipital nerve arises primarily from C2 but can also have a component of C3. Both nerves become more superficial along the posterior border of the SCM. Similar to the great auricular nerve, these nerves are classically depicted also exiting at Erb’s point. We now know that there are at least seven different branching patterns for the cervical cutaneous nerves as they penetrate the fascia of the posterior border of the SCM.24 These authors found that 50% of the time, the lesser occipital nerve, the great auricular nerve, and the transverse cervical nerves exit independent sites at the level of the posterior border of the SCM.24 The average emergence of each nerve as a ratio of the total length of the SCM was lesser occipital 0.63, great auricular 0.54, and transverse cervical 0.47. The authors did note that the order in which they emerge is highly consistent with the lesser occipital being most cranial and the transverse cervical being most caudal.24

Technique To successfully block the transverse cervical nerves, the SCM needs to be identified. This can be done in a similar way to the description in Section 6 earlier. This will help identify the point at which the great auricular nerve becomes more superficial. The branches of the transverse cervical nerves will be caudal to this point, cephalad to Erb’s point, and superficial at the level of the anterior border of the SCM. It is important to note that these branches will still be deep to the platysma. Thus, to block these branches, 3 cc of local anesthetic is infiltrated in a rectangularshaped distribution at the anterior border of the SCM, deep to the platysma between these landmarks (see Fig. 5.6). Using a similar technique, the lesser occipital can be blocked by creating a similar rectangle along the posterior border of

the SCM, with the caudal border being the point at which the great auricular nerve becomes superficial, as described in Section 6 earlier.

Area of anesthesia The transverse cervical nerve block will give anesthesia to the anterior and lateral neck and some of the cheek while the lesser occipital nerve block will give anesthesia to the skin posterior to the ear and a portion of the middle third of the helix and antihelix. This block is valuable for cosmetic procedures and lasers of the neck. Also, this block is valuable for skin cancer resection and reconstruction of the anterior and lateral neck.

Section 7: V3 and buccal nerve Anatomy The mandibular branch of cranial nerve V, or V3, is the most invasive of the described blocks in this chapter. This nerve gives sensation to a large area of the cheek, the upper preauricular region, and the auriculotemporal hair regions. The V3 nerve travels behind the pterygoid muscles, 1 cm posterior to the pterygoid plate. This is the region of the proposed block. Alternatively, if only the mucous membrane of the cheek, or the commissure of the mouth is required, then a buccal nerve block can be performed.25 The buccal nerve is 1 cm superior to the mandibular third molar at the anterior border of the pterygomandibular raphe.

Technique To successfully block V3, first find the sigmoid notch. This is generally palpable 2.5 cm anterior to the tragus, under the arch. Confirm this position by asking your patient to open their mouth widely. Mark this area and, using a 25 G or 27 G needle, inject a small amount of local anesthetic while

SECTION I

40

CHAPTER 5  • Anatomic blocks of the face and neck

Transverse B cervical nerve

A

Figure 5.6  Location of the great auricular nerve and transverse cervical nerves. (A) Reproducible location of great auricular nerve at Erb’s point, which is 6.5 cm below the external ear at the midpoint of the sternocleidomastoid (SCM) muscle. (B) The branches of the transverse cervical nerves. It is important to note that this injection should be placed at the anterior border of the SCM, deep to the platysma.

Algorithm 5.2 Algorithm for V3 distribution blockade Patient prefers general anesthesia

Patient unfit for general anesthesia

General anesthesia

Patient prefers local anesthesia

V3 distribution blockade Comfortable with V3 block V3 block

Uncomfortable with V3 block V3 block substitutes

Preauricular

Cheek

Mandibular

Auriculotemporal nerve block

Buccal nerve block

Tumescent anesthesia

Algorithm for V3 distribution blockade. If the patient is amenable for local anesthesia for cosmetic or reconstructive procedures in the V3 distribution, then consider a V3 block. If you are uncomfortable with the V3 block, you can use an auricular temporal nerve block, a buccal nerve block, or tumescent anesthesia in the area as an alternative.

hubbing the needle. Next, change to a 22G spinal needle on a 5-cc syringe. Now you must advance the needle straight back until you hit the pterygoid plate. At this point, mark the depth of the needle (usually 4.5 cm). Next, retract the needle almost to the skin and redirect the needle posterior by approximately 1 cm. Stop at the same depth that you had previously marked when hitting the pterygoid plate. Next, aspirate and inject 3–4 cc of local anesthetic. This is an important step; the maxillary vessels are located in this region. Please note, if you do not feel

comfortable with the anatomy or this specific technique, the cheek is amenable to dilute infiltration to offer a similar, albeit superficial, block (Algorithm 5.2). If the commissure requires anesthesia or if the entire lips require anesthesia, then a buccal nerve block performed either alone or in conjunction with an infraorbital and mental nerve block can be performed. The buccal nerve can be blocked with 1–2 cc of local anesthetic just superior to the third molar just anterior to the pterygomandibular raphe.

Conclusion

Area of anesthesia The V3 block will anesthetize the bulk of the cheek and upper preauricular and auricular temporal hair regions. A buccal nerve block will block the mucosal surface of the inside of the cheek as well as the commissure of the mouth and, sometimes, a small area of adjacent skin.25 The buccal block is especially valuable performing intraoral surgery or excising buccal fat pads. In addition, this block will anesthetize the commissure, which can be helpful for skin cancer resection and reconstruction.

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41

Conclusion Regional blocking techniques help keep patients safe and comfortable during both cosmetic and reconstructive procedures. This is especially important when trying to avoid unnecessary costs for aesthetic procedures or if a patient is considered moderate or high risk to undergo general anesthesia. This chapter should serve as both a guide and a reference when blocking the face and, at minimum, make you question whether all cases that you perform in the operating room truly require general anesthesia.

References

References 1. Wilson SC, et al. Trends and drivers of the aesthetic market during a turbulent economy. Plast Reconstr Surg. 2014;133(6):783e–789e. 2. Connelly N, Leonard R. Discomfort associated with regional anesthetic placement in obstetrics: does alkalinization help? Int J Obstet Anesth. 1996;5(2):89–91. 3. Fialkov J, McDougall E. Warmed local anesthetic reduces pain of infiltration. Ann Plast Surg. 1996;36(1):11–13. 4. Shaefer JR, Lee SJ, Anderson NK. A vibration device to control injection discomfort. Compend Contin Educ Dent. 2017;38(6):e5–e8. 5. Clark LE, Mellette JR. Jr. The use of hyaluronidase as an adjunct to surgical procedures. J Dermatol Surg Oncol. 1994;20(12):842–844. 6. McMinn R, Hutchings R, Logan B. Color Atlas of Head and Neck Anatomy. Chicago: Year Book Medical Publishers; 1981:10. 7. Zide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg. 1998;101(3):840–851. 8. Zide BM, Jelks GW, Polack FM. Surgical Anatomy of the Orbit. Philadelphia: Lippincott, Willims and Wilkins, 1986. 9. Haribhakti VV. The dentate adult human mandible: an anatomic basis for surgical decision making. Plast Reconstr Surg. 1996;97(3):536–541. discussion 542. 10. Roberts G, Harris M. Neurapraxia of the mylohyoid nerve and submental analgesia. Br J Oral Surg. 1973;11(2):110–113. 11. Marinho RM, Tennant CJ. Paresthesia of the cutaneous branch of the mylohyoid nerve after removal of a submandibular salivary gland. J Oral Maxillofac Surg. 1997;55(2):170–171. 12. Xie K, et al. Effects of supraorbital foramen variations on the treatment efficacy of radiofrequency therapy for V1 trigeminal neuralgia: a retrospective study. Pain Res Manag. 2020 Article ID: 8142489. 13. Janis JE, et al. The anatomy of the corrugator supercilii muscle: part II. Supraorbital nerve branching patterns. Plast Reconstr Surg. 2008;121(1):233–240.

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14. Christensen KN, et al. Cutaneous depth of the supraorbital nerve: a cadaveric anatomic study with clinical applications to dermatology. Dermatol Surg. 2014;40(12):1342–1348. 15. Kaçar CK, et al. Effects of adding a combined infraorbital and infratrochlear nerve block to general anaesthesia in septorhinoplasty. J Pain Res. 2020;13:2599–2607. 16. Jeong SM, et al. Anatomical consideration of the anterior and lateral cutaneous nerves in the scal. J Korean Med Sci. 2010;25(4):517–522. 17. Totonchi AN, Pashmini Guyuron B. The zygomaticotemporal branch of the trigeminal nerve: an anatomical study. Plast Reconstr Surg. 2005;115(1):273–277. 18. Zide BM, Swift R. Addendum to “How to block and tackle the face”. Plast Reconstr Surg. 1998;101(7):2018. 19. de Freitas CAF, et al. Nonmelanoma skin cancer at critical facial sites: results and strategies of the surgical treatment of 102 patients. J Skin Cancer. 2019:4798510–4798510. 20. Zide BM. Nasal anatomy: the muscles and tip sensation. Aesthetic Plast Surg. 1985;9(3):193–196. 21. Lefkowitz T, et al. Anatomical landmarks to avoid injury to the great auricular nerve during rhytidectomy. Aesthet Surg J. 2013;33(1):19–23. 22. Sharma VS, et al. What is the lobular branch of the great auricular nerve? Anatomical description and significance in rhytidectomy. Plast Reconstr Surg. 2017;139(2):371e–378e. 23. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidectomy. Plast Reconstr Surg. 1980;66(5):675–679. 24. Kim HJ, et al. Emerging patterns of the cervical cutaneous nerves in Asians. Int J Oral Maxillofac Surg. 2002;31(1):53–56. 25. Takezawa KM, Ghabriel M, Townsend G. The course and distribution of the buccal nerve: clinical relevance in dentistry. Aust Dent J. 2018;63(1):66–71.

SECTION I  •  Aesthetic Anesthesia Techniques

6 Local anesthesia Malcolm D. Paul

Introduction The first local anesthetic agent was cocaine, discovered and utilized in the nineteenth century. In 1885 Halsted at Johns Hopkins University first introduced cocaine for nerve blocks. He later became addicted to cocaine through self-experimentation. Either by blocking conduction in peripheral nerves or by preventing excitation of nerve endings, local anesthetics effectively block the receptors for pain. This is achieved by anesthetics reversibly binding to, and inactivating, sodium channels. The depolarization of nerve cell membranes and the propagation of impulses along the course of the nerve occurs by the influx of sodium channels. When depolarization does not occur as well as the loss of the capacity to propagate an impulse, there is a loss of sensation in the area supplied by the nerve.1 The two classes of local anesthetics are amino esters and amino amides (Table 6.1, Fig. 6.1). In plastic surgical procedures, the amide esters, principally lidocaine and bupivacaine, are the most common local anesthetic agents used. The following considerations are important in deciding the dose of local anesthetic to be administered: 1. Patient weight. 2. Was epinephrine added to the local anesthetic agent? 3. Modality of administration: a. Will the local anesthetic agent be administered by a syringe or by an infusion pump utilized in the tumescent technique? b. What volume of tumescent anesthesia is administered? 4. The acidity of the environment that you are injecting into. 5. Whether or not the patient is taking medications (or supplements) that compete with the metabolism of the local anesthetic.

6.

An unintentionally high blood level of local anesthetic results in an excessive concentration at the central nervous and cardiovascular systems. This may lead to a clinical spectrum of toxicity ranging from mild symptoms to cardiac arrest and death. 7. Rate of absorption of local anesthetic into the bloodstream is a primary determinant of systemic toxicity and is influenced by local vascularity and extent of local tissue binding. 8. Presentation and rapidity of onset of local anesthetic toxicity is variable and is dependent on the local anesthetic used and whether the patient is sedated/ anesthetized. 9. Intralipid emulsion is effective at reversing local anesthetic toxicity, although the underlying mechanism is poorly understood. 10. CPR, ACLS, and low-dose epinephrine are the focus of treatment for local anesthetic toxicity-induced cardiovascular collapse. 1 1. Preventative measures (safety checklists, monitoring, appropriate dosing) can help reduce the incidence of local anesthetic toxicity. It follows that one should administer the smallest dose of local anesthetic, administered over the longest time period, achieving maximum anesthesia, and, when desired, maximum vasoconstriction. It has been argued that the maximum dose of lidocaine per kilogram patient weight can be increased when utilizing the “tumescent technique”. However, care must be taken to avoid large volumes of fluid injected at the start of the procedure with a recommended dose of 30 cc of 1% lidocaine plain per 1 L of lactated Ringer’s solution and 1  mg epinephrine/L. Certainly, adding epinephrine to the tumescent formula will decrease the rate of absorption of the lidocaine and, significantly, tumescent fluid is aspirated with the lipoaspirate (Box 6.1, Algorithm 6.1).

Combining local anesthetic agents with oral analgesics and anxiolytic agents (benzodiazepines)

43

Table 6.1  Dosages of local anesthetics

Drug

Onset

Maximum dose (with epinephrine)

Duration (with epinephrine)

Lidocaine

Rapid

4.5 mg/kg (7 mg/kg)

120 min (240 min)

Mepivacaine

Rapid

5 mg/kg (7 mg/kg)

180 min (360 min)

Bupivacaine Ropivacaine Levobupivacaine

Slow Medium Medium

2.5 mg/kg (3 mg/kg) 2–3 mg/kg 2.0 mg/kg or 400 mg in 24 h

4 h (8 h) 3 h (6 h) 4–6 h (8–12 h)

Procaine

Slow

8 mg/kg (10 mg/kg)

45 min (90 min)

Chloroprocaine

Rapid

10 mg/kg (15 mg/kg)

30 min (90 min)

Etidocaine

Rapid

2.5 mg/kg (4 mg/kg)

4 h (8 h)

Prilocaine

Medium

5 mg/kg (7.5 mg/kg)

90 min (360 min)

Tetracaine

Slow

1.5 mg/kg (2.5 mg/kg)

3 h (10 h)

Aromatic lipophilic portion

N

–

Amine – hydrophilic portion

Intermediate chain

O C O C C N

AMINO ESTERS

H O N C C N

AMINO AMIDES

Figure 6.1  Chemical structure of local anesthetics.

Combining local anesthetic agents with oral analgesics and anxiolytic agents (benzodiazepines) The level of anesthesia includes criteria that are designed to insure patient safety. The four levels of anesthesia are: Level 1: Local anesthesia with minimal sedation/anxiolysis: the patient is fully conscious and can respond to verbal commands. Level 2: Moderate sedation: consciousness is reduced, but the patient can respond to verbal commands. Level 3: Deep sedation: the patient can respond to repeated painful stimuli, but he cannot be aroused easily. Level 4: General anesthesia: the patient loses consciousness and cannot be aroused even with painful stimuli. The patient needs assistance with breathing. The muscle function is depressed and heart function may be impaired. The evolution of techniques in performing facial aesthetic procedures under local anesthesia alone (wide-awake approach) or under Level 1 anesthesia followed the sequence below:

BOX 6.1  Signs of lidocaine toxicity 1. Early neurological symptoms: a. Circumoral and/or tongue numbness b. Metallic taste c. Lightheadedness d. Dizziness e. Visual and auditory disturbances (difficulty focusing and tinnitus) f. Disorientation g. Drowsiness 2. Severe respiratory and cardiovascular symptoms: a. Hypotension b. Arrhythmia c. Bradycardia d. Cardiac arrest e. Respiratory arrest 3. Treatment of patients with suspected local anesthetic toxicity: a. The initial step is to stabilize any potential threats to life. b. If one notices the onset of signs and symptoms of local anesthetic toxicity, one should immediately stop the injections and prepare to treat the signs and the symptoms of local anesthetic toxicity. c. The treating physician must ensure adequate oxygenation by mask or by intubation. d. One must pay attention to impending respiratory arrest, significant hypotension, dysrhythmias, and seizures, as these are crucial in the management of a patient who is showing signs and symptoms of lidocaine toxicity. Once other possible causes of these signs and symptoms have been ruled out, management of the specific symptoms can begin.

1.

Lalonde2,3 pioneered the concept of completely anesthetizing skin and soft tissue without the use of any medications other than the careful injection of local anesthetic agents. His technique includes the following recommendations: a. Buffer local anesthetic with sodium bicarbonate. b. Use smaller 27- or 30-gauge needles. c. Immobilize the syringe with two hands and have your thumb ready on the plunger before inserting the needle.

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CHAPTER 6  • Local anesthesia

SECTION I

Algorithm 6.1 Initial management Mild cardiac suppression Cardiac arrest

Emergency call Stop LA injection Secure airway Establish iv line

Antihypotension (ephedrine, adrenaline, etc.) Anti-arrhythmia (atropine, etc.)

Anticonvulsant (benzodiazepine) Lipid emulsion

Lipid emulsion

CPR ACLS (adrenaline)

After circulatory stabilization

Lipid emulsion

Close monitoring until completely awake

Cardiopulmonary bypass

Consider stay in ICU

A

Initial management Mild cardiac suppression Cardiac arrest Lipid emulsion

Lipid emulsion Bolus 1.5 mL/kg iv over 1 min

After circulatory stabilization

Continuous infusion 0.25–0.5 mL/kg/min (~18mL/min) Repeat bolus once or twice for persistent cardiovascular collapse

Continue infusion for at least 10 min after attaining circulatory stability. (Recommended upper limit: approximately 10 mL/kg lipid emulsion over the first 30 min) B

Management of acute local anesthetic toxicity. ACLS, Advanced cardiovascular life support; CPR, cardiopulmo­nary resuscitation; ICU, intensive care unit; iv, intravenous; LA, local anesthetic. ACLS, Advanced cardiovascular life support; CPR, cardiopulmo­nary resuscitation; ICU, intensive care unit; iv, intravenous; LA, local anesthetic. From Sekimoto K, Tobe M, Saito S. Local anesthetic toxicity: acute and chronic management. Acute Med Surg. 2017 Mar 6;4(2):152-160. doi: 10.1002/ams2.265. PMID: 29123854; PMCID: PMC5667269.

d. Use more than one type of sensory noise when inserting needles into the skin. e. Try to insert the needle at 90 degrees. f. Do not inject in the dermis, but in the fat just below it. g. Inject at least 2 mL slowly just under the dermis before moving the needle at all and inject all local anesthetic slowly when you start to advance the needle. h. Never advance sharp needle tips anywhere that is not yet numb. i. Always inject from proximal to distal relative to the nerves. j. Use blunt-tipped cannulas when tumescing large areas. k. Only reinsert needles into skin that is already numb when injecting large areas. l. Always ask patients to tell you every time they feel pain during the whole injection process so that you can score yourself and improve with each injection. m. Always inject too much volume instead of not enough volume to eliminate surgery pain and the need for “top-ups”.

2. 3. 4. 5.

The volume of local anesthetic administered should be within the safe dosage range, regardless of the method of injection. Using a small-diameter cannula in place of a sharp needle can improve the patient experience and decrease the risk of intravascular injections and small hematoma formation. Most facial aesthetic surgeons performing surgery under Level 1 anesthesia embrace a combination of local anesthesia with analgesics and anxiolytic agents. A combination of pre- and intraoperative meds that worked for decades in providing analgesia and anxiolytic effects included an opioid along with a benzodiazepine. This combination was within the guidelines for Level 1 anesthesia. However, dosing a patient with larger and/ or more frequent amounts of these medications can move the case to Level 2 anesthesia, which (depending upon the state) may require that the facility be accredited and there may be the requirement of additional equipment, etc. While adhering to the guidelines in Level 1 anesthesia, the dosage and amount of each of these components was determined by: a. BMI. b. Level of anxiety.

Current practice

6.

7.

c. Tolerance to the individual medications selected, including a history of taking these medications prior to the surgical procedure. d. Allergies including a history of allergic reaction to local anesthetics. Recently, surgeons have switched to non-opioid medications (NSAIDs, GABA analog, and COX-2 inhibitors) to avoid the possibility of creating opioid dependency. However, this is unlikely when opioid medications are only administered for a short period of time unless the patient has a history of prior addiction. Most recently, this author has begun utilizing sublingual sufentanil (DSUVIA, AcelRX Pharmaceuticals, Inc.) in the place of the combination of acetaminophen and oxycodone. DSUVIA (an opioid) produces profound analgesia in 20–30 min, is slowly absorbed by the oral mucosa lasting 3–4 h, does not produce respiratory depression when used as directed, and still permits the anesthesia to be classified as Level 1. This medication is a “game-changer” in allowing the surgeon to perform a variety of facial aesthetic procedures with a single sublingual medication and half the dose of the benzodiazepine selected. In this author’s experience, patients have had no pain sensation for their entire procedure(s) beginning with the injection of the local anesthetic agent and throughout the surgical procedure. If the procedure(s) takes longer than 3-4 h, the medications can be given a second time. As in the use of opioids, the facility where the procedure is performed should have the necessary equipment to support respiratory function as well as a “crash cart”.

Current practice Regardless of the level of anesthesia that is selected, it is important to check off the items listed in the guidelines developed by the American Society of Plastic Surgeons (Box 6.2). Clearly, a majority of patients are good or excellent candidates to have their facial aesthetic procedures performed in a well-equipped outpatient surgery center or office-based facility. Basic equipment includes, but is not limited to: intravenous (IV) sets and IV fluids, a “crash cart”, oxygen tank and mask equipment for supporting respiration, continuous monitoring of pulse oximetry, pulse and blood pressure monitoring, and an electrocardiogram (ECG) on demand or running continuously with the ability to print the readings. Even though the patient will be treated under Level 1 anesthesia, cardiopulmonary problems and local anesthetic toxicity can occur due to the following conditions: 1. Pre-existing cardiovascular disease including arrythmias, which may present as tachycardia and/or premature atrial contractions and premature ventricular contractions. Ischemia may be pre-existing and can become symptomatic during stress and/or the absorption of epinephrine. This occurrence may be related to the rapid absorption of epinephrine from injected soft tissues or from direct intravascular injections. It is important to slowly administer the local anesthetic agent and monitor the pulse. If the pulse becomes rapid or the blood pressure rises quickly, it is important to stop injecting local with epinephrine.

45

BOX 6.2  American Society of Plastic Surgeons Task Force guidelines for Safety in office-based surgery* Patient selection guidelines 1. Perform thorough history and physical examination 2. Order appropriate preoperative testing: a. Age >45 years old: electrocardiogram b. History of cardiac disease: electrocardiogram, possible cardiology referral for clearance c. Complete blood count, metabolic panel as indicated by comorbidities 3. Determine ASA physical status classification: a. ASA physical status 1: normal healthy patient – Ideal candidate for office-based surgery b. ASA physical status 2: patient with mild systemic disease that is well controlled without functional limitations – Ideal candidate for office-based surgery c. ASA physical status 3: patient with severe single-system disease and some functional limitations – Reasonable candidate for office-based surgery, recommend local and sedation techniques . ASA physical status 4: patient with severe systemic disease d that is a constant threat to life – Only with local and sedation techniques

Procedural guidelines 1. Hypothermia: a. Facility should be equipped to adequately monitor and adjust temperature b. Equipment should be available to warm patient c. Intraoperative blood loss: d. If predicted blood loss >500 mL, procedure should only be performed in facility with access to blood and blood components 2. Liposuction: a. Limit lipoaspirate to 6 h. If so, in-hospital observation should be considered 4. Thromboprophylaxis: a. Low risk, (no risk factors, 40 years old, procedure >30 min, general anesthesia) – Pneumatic compression devices c. High risk (>40 years old, >1 risk factor, long procedure, general anesthesia) – Pneumatic compression, consider medical prophylaxis ASA, American Society of Anesthesiologists. *Adapted from the following sources: Iverson RE. Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting. Plast Reconstr Surg. 2002; 110:1337; discussion 1343; Iverson RE, Lynch DJ. Patient safety in office-based surgery facilities: II. Patient selection. Plast Reconstr Surg. 2002; 110:1785; discussion 1791; and Iverson RE, Lynch DJ. Practice advisory on liposuction. Plast Reconstr Surg. 2004; 113:1478; discussion 1491.

46

2. 3.

SECTION I

CHAPTER 6  • Local anesthesia

Respiratory depression can occur from the oral ingestion of opioids combined with benzodiazepines. Narcotic reversal medication such as naloxone should be available. Injecting large volumes of local anesthetic during a short period of time may cause lidocaine toxicity, which can be reversed with lipid emulsion therapy. It appears that diazepam can reverse lidocaine toxicity. Doses of bupivacaine above the recommended dose may cause cardiac toxicity, which may be reversed with lipid emulsion therapy or with the administration of glucose, insulin, and potassium.

Suitable candidates for office-based aesthetic plastic surgical procedures performed under local anesthesia/Level 1 undergo the following protocol: 1. Medical clearance if indicated by the information provided in a complete history and physical examination. 2. Hypertensive patients must be cleared by their primary care MD, internist, or cardiologist. 3. An ECG is required within 6 months of the procedure for any patient with a history of cardiac disease. 4. Patients above age 59 have a screening ECG. 5. Patients are asked to stop smoking at least 2 weeks before their scheduled procedure. 6. Informed consent is obtained. 7. Appropriate skin markings and discussion with the surgeon before the procedure to answer any remaining questions or concerns.

1.

2.

3.

4.

The following protocol is used routinely. Patients bring all meds with them to the surgery center including: • Lorazepam 2 mg • Diazepam 5 mg • Oxycodone with acetaminophen 5:325 for postoperative pain control • Cephalosporin if not allergic (ciprofloxacin or clindamycin can be substituted) • Ondansetron 4 mg oral dissolving tablet (ODT) to prevent nausea • Medrol Dosepak to be initiated before or immediately after surgery. DSUVIA (sufentanil) sublingual tablet, 30 mcg is administered along with 1 mg lorazepam, ondansetron 4 mg ODT, and one antibiotic dose. The Medrol Dosepak may be started as well or delayed until immediately after the procedure. Patients are placed in a comfortable position on the operating table and the following are added: a. Pneumatic compression devices. b. Pulse oximetry fingertip sensor applied. c. ECG/blood pressure and pulse monitors applied. Some patients will still be awake although pain free and may need a second milligram of lorazepam to allow them to relax during the injections and the procedure(s).

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5.

Prior to the incorporation of DSUVIA in the author’s practice, patients would often be uncomfortable with some injections and often would require frequent redosing. DSUVIA will provide profound analgesia for 3–4 h (obese patients metabolize the medication faster and may require a second dose after 3 h). If the procedure will take longer than 3–4 h, a second dose can be given sublingually as indicated. 6. Within 20–30 min of having received DSUVIA and lorazepam, patients are ready for the first injections of local anesthesia. 7. Utilizing three 10-cc syringes containing lidocaine 1% with epinephrine and 1 cc sodium bicarbonate on 27-gauge needles, the planned incision lines are injected along with a block of the greater auricular nerves. 8. Tumescent anesthesia, developed and published by Klein,4 has significantly improved the dissection of facial soft tissues while reducing blood loss and is administered via a liposuction infusion pump (available from several manufacturers). The tumescent fluid is mixed as follows: a. 500 cc of lactated Ringer’s ( if 250-cc bags of lactated Ringer’s are used, divide the doses of the following by half) b. 30 cc of 1% lidocaine plain c. 1 cc epinephrine (for a dilution of 1:500,000) d. 1 g of Tratnexamic acid to improve hemostasis due to its’ antifibrinolytic property. 9. The tumescent fluid is injected before prepping and draping occurs through a 22-gauge spinal needle attached to the infusion tubing. By injecting the tumescent fluid before the patient is prepped and draped, there is adequate time to achieve the full effect of epinephrine, which takes about 26 min (not 7 min, as we always thought). Care is taken to observe the monitors for tachycardia, and/or hypertension related to the absorption of epinephrine. If this occurs, stop the injection and wait for the readings to return to normal. It is rare for the increase in heart rate and blood pressure to not return to normal within a few minutes. Delaying further injections of tumescent fluid is the correct decision. 10. The procedures are performed as planned. It is unusual to have to reinject areas of the face and neck because of the prolonged effect of sublingual sufentanil.

Summary The evolution of the use of local anesthesia along with the availability of impressive analgesics and anxiolytic medications has allowed the safe performance of facial aesthetic procedures in an equipped free-standing surgery center or office-based surgery center while adhering to Level 1 anesthesia criteria. As always, safety is our primary concern and, with the proper training, education, and equipment, the majority of our patients can have their facial aesthetic procedures performed safely while avoiding the risks and the sequelae of general anesthesia.

References

References 1. McLeod I.K., Meyers, A.D. Local anesthetics. Medscape; March 2021. Available: https://emedicine.medscape.com/otolaryngology. 2. Lalonde DH. Wide-awake flexor tendon repair. Plast Reconstr Surg. 2009;123:623–626.

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3. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg. 2013;132(3):675–684. 4. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmetic Surg. 1987;4:263.

 

 

SECTION II • Aesthetic Surgery of the Face

7 Non-surgical skin care and rejuvenation Zoe Diana Draelos

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Introduction Skin care involves several basic hygiene activities that include cleansing and moisturizing. With advancements in the understanding of skin physiology, more effective moisturizers have been developed that contain ingredients designed to improve the appearance and functioning of the skin. These products are known as cosmeceuticals; however, from a regulatory standpoint, there is no such category. Cosmeceuticals are simply cosmetics, usually with a moisturizer base and some added “hero” ingredient that may be called “active” because it imparts some added benefit to the skin. These specialty ingredients are usually vitamins, botanicals, or proteins that are generally recognized as safe and therefore do not require any regulatory oversight. Basic to skin care is an understanding of the different skin types, each with unique skin care cares. There are many classifications for skin type based on the degree of wrinkling, skin color, amount of sebum production, etc. The classification that seems most helpful is the Fitzpatrick skin type classification system based on erythema and tanning reactions to the first sun exposure in early summer (Table 7.1). Based on this skin typing system, recommendations can made for sun protection and appropriate formulations can be selected for cleansing and moisturization. It is interesting to note that there are physiologic differences between the various Fitzpatrick skin types. The differences are summarized in Table 7.2. While the corneocyte surface is the same, there are 20 stratum corneum cell layers in African-American skin as compared with 16 cell layers in Caucasian skin. The desquamation rate for African American skin is 2.5 times that of Caucasian skin, perhaps accounting for the increase in skin ashiness, accompanied by the pigmentation of the desquamating skin scale. However, the stratum corneum lipid content is higher in African Americans than Caucasians, but the ceramide level is lower. As expected, melanophage and mast cell granule size is larger in African-American skin. These unique differences may account for some of the dermatologic issues

observed and can be addressed in customized skin care for the unique needs of all skin types. Despite all of these differences, it is important to note that the number of melanocytes per unit area of skin does not vary across ethnicities. Instead, it is the relative amount of melanin packaged into melanocytes that accounts for the physiologic differences between Caucasian skin and ethnic skin.1 There are pronounced differences in photoaging between the various Fitzpatrick skin types based on the ability to withstand reactive oxygen species generation by photoradiation. Ten percent of the UVB radiation penetrates to the dermis, accounting for sunburn; however, the mean transmission into the dermis by Fitzpatrick type VI skin is 5.7%, compared with 29.4% for Fitzpatrick type I and II skin. Similarly, 50% of the UVA radiation penetrates to the papillary dermis; however, the mean transmission for Fitzpatrick type VI skin is 17.5%, as compared with 55% for Fitzpatrick skin type I and II.2 This difference is due to the basal cell layer functioning as the main site for UV filtration in Fitzpatrick type VI skin while the stratum corneum functions as the site for UV filtration in Fitzpatrick skin types I and II. The basal cell layer removes twice as much UV radiation as the stratum corneum.3 Based on these unique skin needs, we can then better understand how to address cleansing, moisturizing, retinoids, and sun protection for persons of all skin types.

Cleansers Cleansing is perhaps the most profound of all activities undertaken for skin hygiene and beautification. Cleansing is necessary after all surgical procedures to prevent infection and optimize wound healing, but cleansing of the face and other body areas is also undertaken on daily basis by most individuals. Cleansing requires a delicate balance between skin hygiene and stratum corneum barrier damage. The act of cleansing is a complex physical and chemical interaction between water, detergent, and the skin. During cleansing,

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CHAPTER 7  • Non-surgical skin care and rejuvenation

Table 7.1  Fitzpatrick skin type classification system

Skin type

Erythema and tanning reactions to first sun exposure in early summer

I

Always burn, never tan

II

Usually burn, tan less than average (with difficulty)

III

Sometimes mild burn, tan about average

IV

Rarely burn, tan more than average (with ease)

V

Brown-skinned persons

VI

Black-skinned persons

Table 7.2  Skin characteristic comparison

African American

Caucasian

Corneocyte surface area

Same, 900 μm

Same, 900 μm

Stratum corneum cell layers

20 cell layers

16 cell layers

Spontaneous desquamation rate

2.5 times Caucasian

Transepidermal water loss

Same

Stratum corneum lipid content

Higher than Caucasian

Ceramides

Lower than Caucasian

Mast cell granules

Larger than Caucasian

Melanophage size

Larger than Caucasian

Same

micelles are created with external hydrophilic groups surrounding an internal lipophilic pocket. These micelles can surround oily substances, such as sebum, dispersing the oil in water for removal and rinsing.4 Cleansers are based on surfactants and are the primary cause of dry skin. This arises because surfactants cannot distinguish between lipophilic skin soils requiring removal and the lipophilic intercellular lipids required for barrier maintenance. The bipolar structure of skin soils is similar to the fatty acids, cholesterol, and ceramides comprising the lipid bilayers of the stratum corneum.5 Cleanser barrier damage leads to alterations in stratum corneum function and desquamatory failure with increased corneocyte retention. This is the mechanism by which cleansers induce the rough, scaly appearance characteristic of dry skin.6 The cleanser component that causes dry skin is the highcharge density of the carboxyl head group, which promotes strong protein binding. This characteristic insures excellent cleansing and removal of protein soils, but damages the stratum corneum proteins, denatures enzymes, and alters corneocyte water holding of the capability.7 Barrier damage is also influenced by cleanser pH. Soap typically has an alkaline pH of 10–11, producing skin protein swelling and ionization of the lipid bilayers. Thus, synthetic detergents with more

neutral pH of 5–7 minimize barrier damage and are the preferred cleanser.8 There are many different types of cleansers available for purchase with unique compositions and specific skin benefits. The term soap is used loosely to refer to any cleanser; however, this is not correct, as soap denotes a specific chemical entity. Soap is created when a fat interacts with an alkali, resulting in a fatty acid salt with detergent properties.9 Modern commercial soaps are a blend of tallow and nut oil, or the fatty acids derived from these products, in a ratio of 4:1. Altering the ratio modifies the cleansing ability of the formulation. For example, increasing this ratio results in “superfatted” soaps touted for their cleansing “mildness.” It is the excess fatty acid that reduces the ability of the cleanser to remove lipids, thus these products are marketed as “sensitive skin” cleansers. These soaps can be packaged as bars or liquids. The most common cleanser formulations marketed today are composed of synthetic detergents, known as syndets, and possess a lower alkaline pH, resulting in less removal of intercellular lipids. Soaps typically have a pH of 9–10 while syndets are formulated at a pH of 5.5–7, closer to the natural neutral skin pH (Dove Soap, Unilever).10 It is possible to combine both soap and syndet cleansers into a formulation known as a combar, providing better cleansing with less lipid disruption (Dial Bar, Henkel).11 Bar cleansers are the most widely used form of cleanser, with many different types of bar cleansers available, as summarized in Table 7.3. The typical bar cleanser composition is a combination of two surfactants: the soap alkyl carboxylate and the syndet acyl isethionate. Alkyl carboxylate and acyl isethionate are both anionic surfactants, but the carboxylate group is most damaging, binding and denaturing stratum corneum proteins. Liquid cleansers have a composition similar to bar cleansers, except they are poured from a bottle. There are a variety of different cosmeceutical cleansers that are currently available and will be briefly discussed by type.

Cold cream cleansers Cold cream, composed of water, beeswax and mineral oil, uses fats to solubilize lipophilic skin soils.12 Beeswax and mineral oil function as lipid solvents that combine with the detergent action of borax, also known as decahydrate of sodium tetraborate, to cleanse the face.13 The formulation also contains ceresin and carbomer to thicken the cream and fragrance. The cold cream is wiped on with the fingers, wiped off with a tissue, and may be rinsed or left on the face. Cold cream is an excellent facial cleanser and cosmetic remover for patients with dry skin.

Cleansing milks A thinner variant of cleansing cream is cleansing milk, without the more viscous waxes, designed for normal to combination skin. Cleansing milk contains water and lightweight oils, such as olive oil, sunflower oil, jojoba oil, or sesame seed oil, and emollients, such as glycerin, making it less likely to leave a facial residue. The oils are emulsified into the water, making cleansing milks an oil-in-water emulsion providing cleansing by dissolving, as opposed to emulsifying, skin soils. The liquid is dispensed from a bottled and wiped over the face with a cotton pad.14 The cleanser can be wiped off or wiped first,

Moisturizers

Table 7.3  Bar soap formulations

Bar soap type

Formulation details

Superfatted

Increased fat, up to 10%

Castile

Olive oil added as fat

Deodorant/antibacterial

Antibacterial agent added to kill odor causing bacteria, OTC drug, composition regulated by monograph

French milled

Milder formulation with lower pH

Floating

Air introduced into soap by whipping

Oatmeal

Ground oatmeal added, whole oats create a more exfoliating bar while oat powder creates a bar with less exfoliation

Acne

OTC drug, composition regulated by monograph, may contain sulfur, salicylic acid, or benzoyl peroxide

Facial

Smaller bar size

Bath

Larger bar size

Botanical ingredients:aloe vera/chamomile/lavender

Botanical ingredient added to soap, no special skin benefit in a rinse-off product, no special claims possible

Vitamin E

Vitamin E added for marketing purposes, no special skin benefit in a rinse-off product

Cocoa butter

Cocoa butter used as fat

Nut oil/fruit oil

Nut oil or fruit oil used as fat

Transparent/glycerin

Glycerin added, does not reduce barrier damage

Heavy-duty abrasive

Ground pumice used as grit to exfoliate stained skin

Exfoliating

Plant material (nut kernels, dried herbs, fruit pits, etc.) added to physically exfoliate the skin

Soap-free

Contains syndets (synthetic detergents)

Natural

No formulation meaning, consumer marketing appeal

Organic

No formulation meaning, consumer marketing appeal

Handcrafted

Bar molded by hand instead of poured or machine molded, offers no cleansing benefit

49

pad, rubbed, and rinsed away with water. The clear oil will turn milky when water rinsed. Mineral oil, castor oil, jojoba oil, and olive oil are commonly used. Olive oil can be comedogenic; thus the cleansing oil should be thoroughly water rinsed and might require the addition of a detergent for complete removal.

Micellar water cleansers Micellar water cleansers, also known as cleansing waters, contain water and a very mild surfactant representing a dilute cleansing solution. A micelle is a molecular cluster with a hydrophilic and a hydrophobic end, in this case dissolved in a water solution. The hydrophobic end attaches to the skin soils, dissolving the soil in water through the hydrophilic end, and allowing water rinsing to cleanse the face. Several different surfactants can be used, such as cetrimonium bromide, a ­cationic quaternary surfactant also known as a “quat”. Quats are mild surfactants commonly found in hair conditioners that allow the excess conditioner to water rinse down the drain, preventing the hair from appearing greasy. Polysorbate 20 is also used because it is a non-foaming surfactant. Amphoteric surfactants of the type found in baby shampoo can also be used, such as disodium cocoamphodiacetate. The product is stroked on the face with a cotton pad, rubbed to remove skin soils, and rinsed with water. Micellar water is excellent at removing water-soluble cosmetics or facial cleansing in patients with dry, sensitive skin.

Cleansing scrubs Cleansing scrubs are particulate-containing cleansers designed to mechanically exfoliate either the face or body. The cleanser is based on previously discussed detergents in cream form with the addition of aluminum oxide, ground fruit pits, polyethylene beads, or sodium tetraborate decahydrate granules.15 The particles are manually massaged into the skin, dislodging desquamating corneocytes and improving skin visual smoothness and tactile softness. Typically, the scrub is used once weekly; more frequent or aggressive use can cause skin barrier damage and skin sensitivity. Aluminum oxide and ground fruit pits produce the most aggressive exfoliation due to their rough surface contour; however, recently, apricot pit powder has been introduced, producing less skin trauma.

Moisturizers

followed by water rinsing. Cleansing milks are commonly used for the removal of eye cosmetics, since they are non-irritating and do not readily blur vision with an oily residue.

The excellent efficacy of cleansers has led to the need for moisturizers. Moisturizers must fulfill four basic needs in order of consumer importance: make the skin smooth and soft; increase skin hydration; improve appearance; and possibly deliver a cosmeceutical ingredient to the skin surface. A moisturizer that does not deliver on these four attributes cannot be a success in the marketplace.

Cleansing oils

Improved skin smoothness and softness

Cleansing oils are a water-in-oil emulsion primarily used for the removal of facial or eyelid waterproof cosmetics and waterproof sunscreens that cannot be easily removed with soap and water. The oil is spread over the face with a cotton

The most basic consumer need achieved by moisturizer application is smooth and soft skin. All moisturizers in the current marketplace make the skin smooth and soft; however, better formulations are longer lasting. Skin that is smooth and soft

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CHAPTER 7  • Non-surgical skin care and rejuvenation

is an assessment of the organization of the corneocytes on the skin surface. As the intercellular lipids are removed, the edges of the corneocytes fold, thus creating friction when the hand is rubbed across the skin surface. Creating smooth and soft skin utilizes emollients, such as propylene glycol, dimethicone and cetyl alcohol, which are thin oily substances capable of depositing between the desquamating corneocytes temporarily until the next cleansing, at which time they must be reapplied.

Increased skin hydration Moisturizers that are medically relevant must increase skin hydration by retarding water loss from the skin surface, known as transepidermal water loss (TEWL).16 This is accomplished by placing a water-impermeable film over the skin to retard evaporation and by applying substances to the skin surface to attract water. Moisturizers are a misnomer, as they do not moisturize the skin.17 Only through skin barrier repair can TEWL be permanently returned to normal levels. Increased skin hydration is the mechanism by which most cosmeceuticals decrease fine lines of dehydration, especially those around the eye where the skin is thinnest. Retarding TEWL will hydrate this skin temporarily until the moisturizer is removed with cleansing. While wrinkle reduction may appear to be a functional benefit, it is a result of increased skin hydration that will be temporary unless skin barrier repair occurs.

Improved optical appearance A lesser moisturizer goal is to improve skin appearance, a characteristic known as radiance or luminosity. These attributes are the appreciation of the amount of light reflected by the skin surface back into the eye of the observer, which is directly related to the smoothness of the skin surface. With advancing age, skin melanin, hemoglobin, and collagen distribution become more irregular. Cosmeceutical moisturizers capable of delivering a lightly pigmented film to the skin surface or enhancing light reflection from the skin surface may improve the optical appearance of the skin. Pigments, such as iron oxide, and optically reflective materials, such as mica or fish scale, can be added to moisturizers to create anti-aging appearance benefits. All cosmeceutical moisturizers work through two basic mechanisms of restoring skin water content: occlusion and humectancy.18 Occlusive moisturizers function by placing a water-impermeable barrier over the skin surface, creating an environment conducive to barrier repair. The most occlusive and most physiologic moisturizer is said to be petrolatum; however, its aesthetics are undesirable, accounting for the myriad cosmeceutical moisturizers on the market.19 It reduces TEWL by 99%, allowing enough water vapor to leave the skin for initiation of barrier repair.20,21 Humectants are substances that attract water, acting like sponges on and in the skin. All liquid and cream moisturizers contain humectants to prevent product desiccation, but the humectant may be present in insufficient concentration to have a physiologic function. The dermis possesses glycosaminoglycans, including hyaluronic acid, to function as humectants; however, other cosmeceutical humectants include glycerin, honey, sodium lactate, urea, propylene glycol, sorbitol, pyrrolidone carboxylic acid, gelatin, vitamins, and some proteins.22,23

These topically applied ingredients can draw water from the air, although the moisturizer becomes sticky and unaesthetic when this occurs. Most humectants, of which glycerin is the most effective, draw water from the deeper epidermis and dermis, allowing the skin to feel smoother by filling holes in the stratum corneum through swelling.24 An unopposed humectant will draw water from the skin to the lower-humidity atmosphere; thus a cosmeceutical moisturizer must contain both occlusives and humectants for optimal efficacy.25

Moisturizer ingredients Many ingredients are used to formulate moisturizers. The most commonly used moisturizer constituents are presented next.

Petrolatum Petrolatum is a semisolid mixture of hydrocarbons obtained through the dewaxing of heavy mineral oils. Pure cosmeticgrade petrolatum is practically odorless and tasteless, but has not been synthetically duplicated. Petrolatum is the most effective moisturizing ingredient on the market today, reducing TEWL by 99%. It functions as an occlusive to create an oily barrier through which water cannot pass. Thus, it maintains cutaneous water content until barrier repair can occur. Petrolatum is able to penetrate into the upper layers of the stratum corneum and aid in the restoration of the stratum corneum barrier. Petrolatum impacts all four phases of skin remoisturization: initiation of barrier repair, alteration of surface cutaneous moisture partition coefficient, onset of dermal–epidermal moisture diffusion, and synthesis of intercellular lipids.

Silicone After petrolatum, the most significant cosmetic ingredient to be discovered is silicone. Topical silicone is hypoallergenic, noncomedogenic, and non-acnegenic. It is a remarkable nongreasy moisturizer and skin conditioning agent providing the basis for “oil-free” moisturizers. Silicone acts as a nongreasy, occlusive agent that can have an astringent effect on other oily substances, such as petrolatum. Silicone can also function as an emollient, filling in spaces between desquamating corneocytes, to create the smooth skin surface that patients desire, until the product is removed with rubbing or washing, creating a smooth surface. Dimethicone and cyclomethicone are the two most common derivatives utilized in moisturizer formulations.

Ceramides Endogenous ceramide synthesis is the first step in barrier repair. Nine different ceramides have been identified and synthetically duplicated for inclusion in moisturizer formulations distinguished by their polar head group architecture, as well as by their hydrocarbon chain properties.26 Many cosmeceutical moisturizers use a ceramide cocktail to improve the skin barrier.

Natural moisturizing factor There are a group of substances reported to regulate the moisture content of the stratum corneum, known as natural

Sunscreens

moisturizing factor (NMF). NMF has been synthetically formulated consisting of a mixture of amino acids, derivatives of amino acids, and salts. Cosmeceutical NMF contains amino acids, pyrrolidone carboxylic acid, lactate, urea, ammonia, uric acid, glucosamine, creatinine, citrate, sodium, potassium, calcium, magnesium, phosphate, chlorine, sugar, organic acids and peptides.27 Ten percent of the dry weight of the stratum corneum cells is composed of NMF broken down from filaggrin; however, cosmeceutical formulations attempt to remoisturize the skin through synthetic NMF combinations.

Sodium PCA One ingredient of synthetic NMF is sodium PCA, which is a sodium salt of 2-pyrrolidone-5-carboxylic acid. Synthetic sodium PCA has been shown to be a better moisturizer than glycerol and is found in several cosmeceutical products functioning as a humectant when used in concentrations of 2% or higher.28

Urea and lactic acid Urea and lactic acid are also components of synthetic NMF and can diffuse into the outer stratum corneum, disrupting hydrogen bonding, exposing water-binding sites on the corneocytes, and facilitating increased hydration. This is especially important in callouses, which can be improved by cosmeceutical foot products containing these ingredients to increase stratum corneum pliability in direct proportion to the amount of lactic acid or urea absorbed.29

Retinoids Retinoids are some of the most efficacious anti-aging ingredients in the marketplace today. Topical cosmeceutical retinoids are synthetic vitamin A derivatives, which include retinol (vitamin A alcohol), retinyl esters, retinoic acid (tretinoin), and retinyl palmitate. Retinoids are biologic modifiers producing receptor-specific effects, including regulating growth of epidermal cells and promoting differentiation of cell lines.30,31 They are difficult to topically formulate due to their inherent photo instability and degradation upon exposure to oxygen. Retinol can be oxidized into retinaldehyde, and then into retinoic acid, the biologically active form of vitamin A. Retinol may be also esterified with fatty acids to form retinyl esters. Retinoic acid is oxidized to a less-active metabolite, 4-oxoretinoic acid, or converted to retinoyl glucuronide, whereas retinol is converted to retinyl glucuronide. Retinyl palmitate is the most stable of the vitamin A esters and can be easily incorporated into the oil phase of creams and lotions, due to its lipophilic nature; however, it is not very biologically active.32 Topical activity of retinyl palmitate is thought to occur following cutaneous enzymatic cleavage of the ester bond and subsequent conversion of retinol to retinoic acid. It is this cutaneous conversion of retinol to retinoic acid that is responsible for the biologic activity of some of the new stabilized over-the-counter (OTC) retinol preparations. Unfortunately, only small amounts of retinol can be converted by the skin, accounting for the increased efficacy seen with prescription preparations containing retinoic acid.33

51

Sunscreens Sunscreens are important for skin health and the prevention of cutaneous aging.34 Both UVB (290–320 nm) and UVA (320–400 nm) radiation are damaging to the skin, with UVB inducing sunburn and skin cancer while UVA rays penetrate deeper within the dermis, producing reactive oxygen species, which are damaging to DNA, collagen, and blood vessels.35 UVA radiation induces immunosuppression, also contributing to the formation of skin cancer.36 Thus, sunscreens must protect against both UVA and UVB radiation by including filters to prevent the energy from destroying the skin.37 These filters can be inorganic or organic, depending on their chemical and physical properties, and function by absorbing, reflecting, or diffusing UV radiation. Table 7.4 lists all the sunscreen filters that are approved for use in the US. The US has far fewer approved filters than the rest of the world. Sunscreens are considered over-the-counter drugs and are regulated by the US Food and Drug Administration (FDA). Inorganic filters are so named because they do not undergo a chemical reaction to diffuse UV radiation. They are powders formed from metal oxides, such as titanium dioxide and zinc oxide. They reflect and diffuse UV radiation, but leave a gritty white film on the skin surface, which may not be acceptable to persons with higher Fitzpatrick skin types. This white film is minimized by decreasing the particle size of the metal oxides through grinding. However, the decrease in particle size changes the protective properties of titanium dioxide, shifting the protection range from the longer UVA wavelengths to the UVB wavelengths. The larger particles can also scatter and absorb visible light, which has more recently been associated with photoaging. Zinc oxide

Table 7.4  US-approved sunscreens

Sunscreen filter

Maximum concentration (%)

p-Aminobenzoic acid (PABA)

15

Avobenzone

3

Cinoxate

3

Dioxybenzone

3

Ensulizole (phenylbenzimidazole sulfonic acid)

4

Homosalate

15

Meradimate (menthyl anthranilate)

5

Octinoxate (octyl methoxycinnamate)

7.5

Octisalate (octyl salicylate)

5

Octocrylene

10

Octyl dimethyl PABA

8

Oxybenzone (benzophenone-3)

6

Sulisobenzone

10

Titanium dioxide

25

Trolamine salicylate

12

Zinc oxide

25

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CHAPTER 7  • Non-surgical skin care and rejuvenation

has better absorption in the UVA wavelengths but is not very good at both UVB and UVA absorption when used alone. The combination of zinc oxide and titanium oxide is best. The inorganic sunscreens are frequently coated with dimethicone to decrease the formation of secondary oxygen radicals, which are formed when radiation bounces off the particulate filter. They are considered safe, as they do not penetrate the skin to any significant degree. Organic filters are sunscreen ingredients that absorb UV radiation at wavelengths according to their chemical structure, which is called a chromophore.38 The chromophore consists of electrons in conjugated double bond sequences. A photon of UV energy causes electron transfer to a higherenergy orbit in the molecule. The sunscreen filter that was in a low-energy state is converted into a higher-energy state with the excess energy released as heat.39 Table 7.5 presents the protective wavelength for each of the FDA-approved sunscreen ingredients. Controversy has recently arisen regarding the safety of organic filters, which can be absorbed through the skin and appear in the plasma and urine.40,41 Oxybenzone, a commonly used UVB and UVA filter, can be absorbed transdermally and may be an endocrine disruptor.42 Therefore, sunscreens should only be used when necessary and washed off the skin when no longer outdoors.

Summary This chapter has presented basic skin care concepts in terms of cleansing, moisturizing, retinoid use, and sunscreens. These items are widely available and used multiple times daily by most individuals. Their impact on the skin and skin health is significant.

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Table 7.5  US-approved sunscreen filters based on UV protection wavelength

Sunscreen ingredient

UV protection wavelength UVB (290– 320 nm)

UVA2 (320– 340 nm)

UVA1 (340– 400 nm)

Titanium dioxide

*

*

Zinc oxide

*

*

*

*

*

Inorganic

Organic p-Aminobenzoic acid

*

Avobenzone Cinoxate

*

Dioxybenzone

*

Ensulizole

*

Homosalate

*

Meradimate

*

*

Octinoxate

*

Octisalate

*

Octocrylene

*

Oxybenzone

*

Padimate O

*

Sulisobenzone

*

Trolamine salicylate

*

* *

References

References 1. Szabo G, Gerald AB, Pathak MA, Fitzpatrick TB. Racial differences in the fate of melanosomes in human epidermis. Nature. 1969;222:1081–1082. 2. Kaidbey KH, Agin PP, Sayre RM, Kligman AM. Photoprotection by melanin: a comparison of black and Caucasian skin. J Am Acad Dermatol. 1979;1:249–260. 3. Munavalli GS, Weiss RA, Halder RM. Photoaging and nonablative photorejuvenation in ethnic skin. Dermatol Surg. 2005;31:1250–1260. discussion 1261. 4. Fowler JF, Eichenfield LF, Elias PM, Horowitz P, McLeod RP. The chemistry of skin cleansers: an overview for clinicians. Semin Cutan Med Surg. 2013;32(2 Suppl 2):S25–S27. 5. Slotosch CM, Kampf G, Loffler H. Effects of disinfectants and detergents on skin irritation. Contact Derm. 2007;57(4):235–241. 6. Dykes P. Surfactants and the skin. Int J Cosmet Sci. 1998;20(1):53–61. 7. Slotosch CM, Kampf G, Loffler H. Effects of disinfectants and detergents on skin irritation. Contact Derm. 2007;57(4):235–241. 8. Ananthapadmanabhan KP, Moore DJ, Subramanyan K, Misra M, Meyer F. Cleansing without compromise: the impact of cleansers on the skin barrier and the technology of mild cleansing. Dermatol Ther. 2004;17(Suppl 1):16–25. 9. Willcox MJ, Crichton WP. The soap market. Cosmet Toilet. 1989;104:61–63. 10. Wortzman MS. Evaluation of mild skin cleansers. Dermatol Clin. 1991;9(1):35–44. 11. Johnson AW. Overview: Fundamental skin care – protecting the barrier. Dermatol Ther. 2004;17:1–6. 12. deNavarre MG. Cleansing creams. 2nd edn. In: deNavarre MG, ed. The Chemistry and Manufacture of Cosmetics. Vol III. Wheaton, IL: Allured Publishing Corporation; 1975:251–264. 13. Jass HE. Cold creams. 2nd edn. In: deNaarre MG, ed. The Chemistry and Manufacture of Cosmetics. Vol III. Wheaton, IL: Allured Publishing Corporation; 1975:237–249. 14. Barlage T, Griffiths-Brophy Hasenoehrl EJ. Facial cleansers and cleansing cloths. In: Draelos ZD, ed. Cosmetic Dermatology: Products and Procedures. Chichester: Wiley Blackwell; 2016:103–109. 15. Mills OH, Kligman AM. Evaluation of abrasives in acne therapy. Cutis. 1979;23:704–705. 16. Anderson PC, Dinulos JG. Are the new moisturizers more effective? Curr Opin Pediatr. 2009;21(4):486–490. 17. Draelos ZD. Concepts in skin care maintenance. Cutis. 2005;76(6 Suppl):19–25. 18. Goldner R. Moisturizers: a dermatologist’s perspective. J ToxicolCut & Ocular Toxicol. 1992;11(3):193–197. 19. Friberg SE, Ma Z. Stratum corneum lipids, petrolatum and white oils. Cosmet Toilet. 1993;108:55–59. 20. Grubauer G, Feingold KR, Elias PM. Relationship of epidermal lipogenesis to cutaneous barrier function. J Lip Res. 1987;28:746–752. 21. Ghadially R, Halkier-Sorensen L, Elias PM. Effects of petrolatum on stratum corneum structure and function. J Am Acad Dermatol. 1992;26:387–396. 22. De Groot AC, Weyland JW, Nater JP. Unwanted Effects of Cosmetics and Drugs Used in Dermatology. 3rd edn. Amsterdam: Elsevier; 1994:498–500.

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23. Spencer TS. Dry skin and skin moisturizers. Clinics Dermatol. 1988;6:24–28. 24. Robbins CR, Fernee KM. Some observations on the swelling of human epidermal membrane. J Soc Cosmet Chem. 1983;37:21–34. 25. Idson B. Dry skin: moisturizing and emolliency. Cosmet Toilet. 1992;107:69–78. 26. Garidel P, Fölting B, Schaller I, Kerth A. The microstructure of the stratum corneum lipid barrier: mid-infrared spectroscopic studies of hydrated ceramide: palmitic acid: cholesterol model systems. Biophys Chem. 2010;150(1–3):144–156. 27. Wehr RF, Krochmal L. Considerations in selecting a moisturizer. Cutis. 1987;39:512–515. 28. Wilkinson JB, Moore RJ. Harry’s Cosmeticology. 7th edn. New York: Chemical Publishing;; 1982:62–64. 29. Idson B. Dry skin: moisturizing and emolliency. Cosmet Toilet. 1992;107:69–78. 30. Goodman DS. Vitamin A and retinoids in health and disease. N Engl J Med. 1984;310(16):1023–1031. 31. Noy N. Interactions of retinoids with lipid bilayers and with membranes. In: Livrea MA, Packer L, eds. Retinoids: Progress in Research and Cinical Applications. New York: Marcel Dekker; 1993:17–27. 32. Idson B. Vitamins and the skin. Cosmet Toilet. 1993;108:79–92. 33. Babamiri K, Nassab R. Cosmeceuticals: the evidence behind the retinoids. Aesthetic Surg J. 2010;30(1):74–77. 34. Moyal D, Fourtanier A. Acute and chronic effects of UV on skin. In: Rigel DS, Weiss RA, Lim HW, Dover JS, eds. Photoaging. New York: Marcel Dekker; 2004:15–32. 35. Moyal D, Fourtanier A. Effects of UVA radiation on an established immune response in humans and sunscreen efficacy. Exp Dermatol. 2002;11(Suppl 1):28–32. 36. Peak MJ, Peak JG. Molecular photobiology of UVA. In: Urbach F, Gange RW, eds. The Biological Effects of UVA Radiation. New York: Praeger Publishers; 1986:42–52. 37. Agar NS, Halliday GM, Barnetson RS, et al. The basal layer in human squamous tumors harbors more UVA than UVB fingerprint mutations: a role for UVA in human skin carcinogenesis. Proc Natl Acad Sci USA. 2004;101:4954–4959. 38. Fourtanier A, Moyal D, Seité S. UVA filters in sun-protection products: regulatory and biological aspects. Photochem Photobiol Sci. 2012;11(1):81–89. 39. Fourtanier A, Bernerd F, Bouillon C, Marrot L, Moyal D, Seité S. Protection of skin biological targets by different types of sunscreens. Photodermatol Photoimmunol Photomed. 2006;22:22–32. 40. Matta MK, Florian J, Zusterzeel R, et al. Effect of sunscreen application on plasma concentration of sunscreen active ingredients: a randomized clinical trial. JAMA. 2020;323(3):256–267. 41. Matta MK, Zusterzeel R, Pilli NR, et al. Effect of sunscreen application under maximal use conditions on plasma concentration of sunscreen active ingredients: a randomized clinical trial. JAMA. 2019;321(21):2082–2091. 42. Arya S, Dwivedi AK, Alvarado L, Kupesic-Plavsic S. Exposure of U.S. population to endocrine disruptive chemicals (Parabens, Benzophenone-3, Bisphenol-A and Triclosan) and their associations with female infertility. Environ Pollut. 2020;265(Pt A):114763.

SECTION II  •  Aesthetic Surgery of the Face

8.1

Editors’ perspective: injectables and nonsurgical resurfacing techniques J. Peter Rubin

Our growing armamentarium of non-surgical techniques serves as a useful and important complement to our surgical facial rejuvenation strategies. Notably, non-surgical strategies are often the “gateway” procedure to entering the practice of a plastic surgeon. Moreover, many non-surgical facial rejuvenation methods will be repeated by patients on a regular and recurring basis, thus creating a long-term relationship with the practice. The chapter on facial fillers by Kavita Mariwalla covers state-of-the-art knowledge of characteristics and applications of injectable agents to add volume to the face. While small in volume, the strategic and focused use of fillers can make a dramatic difference in not only treating signs of facial aging but also in improving facial shape. The chapter on injectable botulinum toxin by Rawaa Almukhtar and Sabrina Fabi discusses the pharmacology, pharmacokinetics, and applications of agents to reduce the activity of muscles of facial expression in an artistic manner. Our concepts of the application of neurotoxins are evolving over time, moving from a more basic approach of simply mitigating dynamic or active facial rhytides to making artistic changes in facial shape and expression. Of all the non-surgical rejuvenation methods, the use of neurotoxins is most likely to result in a long-term regular treatment regimen selected by your patients. The reputational benefits to your practice through those long-term recurrent visits are obvious, providing the patient experience is maximized. The use of lasers in aesthetic surgery has grown, along with the evolution and refinement of the technology. The precise control of

wavelength and energy delivery has expanded the applications dramatically and enables the effective treatment of pigmentary changes, skin texture, and hair growth. The chapter by Jonathan Cook, David Turer, Barry DiBernardo, and Jason Pozner skillfully covers the physics and practical applications of lasers in facial rejuvenation. As anticipated, these different non-surgical modalities for non-surgical facial rejuvenation present the opportunity for combination therapy. Chemical peels have become a vital tool in facial rejuvenation, either as an alternative to lasers or as an adjunct. The use of chemical agents for skin resurfacing involves a number of different compounds that can effectively improve skin texture. The chapter on chemical peels by Richard Bensimon and Peter Rullan discusses the indications and applications for these methods. The chapter on multimodal non-surgical facial rejuvenation by Luiz Toledo discusses strategies for combining these different methodologies into an integrated and effective approach that can be individualized for each patient. In the modern area of facial rejuvenation, the understanding of the non-surgical treatment modalities is essential for the aesthetic surgeon. Although non-surgical, the different strategies discussed in this section of the textbook are not without significant risk. The aesthetic surgeon must have a keen awareness of the potential complications of non-surgical strategies and a thorough knowledge of the methods for identifying and managing complications that may occur.

SECTION II  •  Aesthetic Surgery of the Face

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

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

SYNOPSIS

ƒ Soft-tissue fillers provide versatile tools in the correction of facial wrinkles and facial contouring, as well as in the restoration of the volumetric loss associated with aging. ƒ Reversibility is an advantageous property of fillers, allowing adjustments that may be needed due to technical errors or changes in the tissues that occur with aging. ƒ Inexperienced injectors should always opt for rapidly resorbable fillers such as hyaluronic acid (HA). This allows for faster resolution of any technical errors or overinjection. Hyaluronidase can be used to dissolve the filler. ƒ With respect to the treatment of deep folds and tear troughs, it is important to undercorrect these deformities. This results in a more natural appearance and leaves room for further correction in the future if that is desirable. Overcorrection of these areas can result in visible abnormalities. ƒ “Off-label” use of synthetic materials is technically possible but does carry risk, and discretion should be exercised when using products in this manner. Additionally, the patient must be informed. ƒ Patients often forget their preoperative appearance; pre- and post-treatment photography as well as highlighting asymmetries prior to injection are essential. ƒ Complications of dermal fillers can be avoided by the use of proper technique (small aliquots, appropriate depth and quantity of injection, undercorrection, etc.).

Introduction Facial beauty is in the eye of the beholder; however, facial volume gives the face a characteristic youthful shape and can modify the appearance of what is perceived as beautiful. Indeed it is volume that can connote indicators of youth, symmetry, and even gender differentiation by modulating light and shadows as they fall across the face. Unfortunately, with

time soft-tissue descent, ligament laxity, and bone resorption lead to changes in proportion and placement of volume on the face. As a result, there has been historical interest in the use of injected material to modify the contour of skin, underlying soft tissue, and bone. However, effective and safe tools to accomplish such a goal have become available only in recent decades. The plastic surgeon now has access to numerous fillers to soften the stigmata of aging or correct the contour deficits that occur with many disease processes. In order to use these fillers optimally, one must understand the nature of each product. The goal of this chapter is to present the different classes of fillers and the indications and techniques for their use. Particular attention is paid to the correction of the aging face and techniques for specific areas for enhancement.

The pathophysiology of wrinkles Prior to augmenting facial skin, it is important to understand the factors that create the aging face. Aging is a complex process, which is the result of both intrinsic (soft-tissue maturation, skeletal change/atrophy, genetics, and muscular hyperactivity) and extrinsic factors (gravity, solar damage, smoking and weight fluctuation). As a result, the smooth curvy appearance of the face is slowly replaced by sharp angles, fine and deep wrinkles, and abrupt hollows and bulges. The anatomy of facial aging is thoroughly reviewed in other chapters in this volume. With aging, bony changes give rise to a decrease in height and a moderate widening of the facial skeleton. An increased orbital volume, caused in part by an expanding lower orbital rim, results in sunken eyes. This, when combined with an age-related reduction in maxillary height, and nasal resorption leads to a reduced area for the attachment of midfacial soft tissues. The cheeks descend and consequently the nasolabial folds become deeper. The upper lip complex descends (window shade effect), while tear troughs and perioral rhytides appear. If teeth are lost,

Classification of fillers

alveolar height decreases and the chin atrophies. Additionally, the ligamentous attachments of the soft tissues become lax, which further contributes to the appearance of furrows and creases. In the midface, for example, there are seven distinct fat compartments which all change in shape leading to varying aging features. Similarly, we now understand that most major retaining ligaments induce deep facial grooves as the face ages in an inward and downward fashion. Thus, injecting along the line of ligaments can produce projection while injection behind the line of ligaments can create lift. With age, cell division slows. The epidermis thins out, and the epidermal–dermal junction becomes flatter. The integrity of the stratum corneum decreases and the basal cells acquire more atypia. As a result of these changes, water loss through the skin is increased, leading to drier, more fragile skin. The comparative shrinkage of the more rigid stratum corneum over the deeper and less rigid dermis leads to the classical appearance of wrinkles. These skin depressions are more pronounced in sun-exposed regions and areas that are subject to repeated movements such as face, neck, and hands. Subcutaneous fat atrophy leads to easy bruising and less light reflection which optically also ages the face. The dermis becomes thinner and contains fewer elastic and collagen fibers. Sebaceous glands are less numerous and less active, which also contributes to skin dryness. All the above changes lead to a drier, less elastic, more fragile skin that is more susceptible to gravity and thus wrinkling. It is important to discuss with patients that fillers alone may not achieve their desired aesthetic result and combination treatment with lasers and energy-based devices may also be required. In all cases, topical skincare should not be ignored as skin barrier integrity, hydration and maintenance are key to the end result of soft-tissue filling. Of course it is also important to realistically set goals of volumization with fillers. For many patients, filler use will not be enough and they are actually facelift candidates. Similarly, many facelift patients over time may need filler as tissue descent is a chronic, lifelong process. Chronic sun exposure is the most significant environmental factor impacting skin aging. It is responsible for dyschromia, lentigines, telangiectasias, and the loss of the youthful pink hue. Skin texture becomes coarser because the epidermis is thicker in photoaged skin than in normal skin. Overall collagen amount decreases, except in the superficial dermis where there is an area of increased collagen production (grenz zone) representing a chronic inflammatory process known as heliodermatitis. Solar elastosis is pathognomonic of photoaged skin with abundant, degraded, thickened elastic fibers. Lastly, sun exposure contributes to a reduction in ground substance, contributing to deeper folds and wrinkles. Microscopically, all wrinkles appear like thinned breaks in the dermis. Even though the terms wrinkles, folds, creases, furrows, and rhytides are often used interchangeably, specific features can be used to distinguish between different types of rhytides. Fine wrinkles refer to changes in the texture of the skin that involve the superficial aspect of the dermis. Mimetic wrinkles can extend down to the middle level of the dermis (lines) or down to its full thickness (furrows). These are due to the repeated folding of the skin secondary to the contraction of the facial muscles. As a result, they are perpendicular to the direction of these muscles and occur in locations such as the glabella, periorbita, forehead, and lips. Dynamic wrinkles eventually become static, remaining visible even when the underlying muscle is relaxed.

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Folds refer to larger grooves with some level of skin overlap. These are the result of soft-tissue descent secondary to gravity, decreased support, and loss of skin elasticity. Examples include upper eyelid dermatochalasis, nasolabial folds, marionette lines, jowls, and horizontal neck lines. The tear trough is an infraorbital groove that results from soft-tissue tethering along the arcus marginalis between bulging orbital fat above and descending deflated soft tissue below. The importance of being able to classify wrinkles is central to being able to direct treatment.1 Superficial lines that course at the upper level of the dermis are amenable to dermabrasion, chemical peels, and lasers. Mimetic wrinkles respond to muscle inactivation with neuromodulators (Botox, Dysport, Xeomin, Jeuveau, and Daxxify) or myotomy/myectomy but can also be improved with the concomitant use of fillers. Finally, fillers are most useful in the treatment of folds, during their early stages, or as an adjuvant modality to surgery, during their more advanced stages. To help guide the physician’s treatment and their assessment of improvement, several classification systems have appeared over the years. One of these, the Lemperle classification (see Table 8.2.4) is based on wrinkle depth and can be very helpful.

Access the Historical Perspective section online at Elsevier eBooks+

Classification of fillers Soft-tissue fillers are an ideal option for patients seeking facial rejuvenation with minimal downtime. For the young patient not requiring surgery, these materials offer a viable option, while for older patients, surgery can be combined with fillers and other surface treatments to create an optimal result.8,9 Although the number and variety of products available are impressive, the ideal filler has not yet been found.10–12 The definition of an ideal filler may be debatable, but there are certain basic qualities that are agreed upon (Box 8.2.1). Ultimately, even though it is important that worldwide research and development for the ideal soft-tissue filler continues, a balance is needed between embracing new products and ensuring patient safety. In fact, in May 2015, the FDA released a safety communication entitled “Unintentional Injection of Soft Tissue Filler into Blood Vessels in the Face”, which states that: Unintentional injection of soft-tissue fillers into blood vessels in the face can result in rare, but serious side effects … This can cause vision impairment, blindness, stroke and damage and/or death of the skin (necrosis) and underlying facial structures. … certain injection locations where blood vessel blockage have been reported more often. These sites include the skin between the eyebrows and nose (glabella), in and around the nose, forehead, and around the eyes (periorbital region).13 In October 2021 the FDA convened a multidisciplinary panel reviewing the type and incidence of filler complications. They have not issued a final recommendation. The statement also goes on to recommend avoiding the injection of fillers if the level of training and experience is insufficient.13 In order to better understand the properties of each product that is either already available or in the pipeline, fillers can be classified into the following categories:

Historical perspective

Historical perspective The use of an exogenous material to augment soft tissue can be traced back to Neuber in 1893 who used fat transplanted from the arms to correct facial defects.2 Later, with the invention of the syringe, Brunning first injected fat in 1911, but significant resorption and fat necrosis depopularized this technique. It was not until liposuction and the concept of micro fat grafting that the use of lipoaspirate for soft-tissue augmentation successfully resurfaced. Concurrent with the initial efforts to graft fat came attempts to inject other synthetic materials in order to volumize soft tissue.2,3 In 1899, Robert Gersuny first injected Vaseline, while later, Eckstein used paraffin to correct fistulas and hernias and to attain aesthetic soft-tissue augmentation. Serious complications such as granulomatous inflammatory reactions (paraffinomas) and nodule formation, embolization, and migration were reported early on, yet paraffin kept being used for over two decades before it was abandoned. The first reports of the use of silicone date from the end of World War II in Japan when numerous women had their breasts injected with non-medical grade silicone.4 Shortly after, in 1947, Dr. James Barrett Brown first used silicone for the correction of soft-tissue deficits in the US. Concurrently, hard and rubber silicone found use in creating alloplastic implants. Early flawed animal experiments suggested that injectable silicone was safe, and physicians relied heavily on this improper information. The popularity of the technique led to numerous complications such as lump formation, migration, ulceration,

55.e1

and extrusion.5 The illicit injection of non-medical grade silicone continues to this day, even though the US Food and Drug Administration (FDA) took a more active role in criminalizing its use in the 1990s. Today, highly purified medical grade silicone oil (AdatoSil 5000, Silikon 1000) is FDA approved for the treatment of retinal detachment and can be used cautiously off-label for volume augmentation. In 1981, bovine collagen was the first filler approved by the FDA for soft-tissue augmentation; it soon became the gold standard against which all fillers were compared. Its rapid resorption and allergenic nature led to a series of efforts to develop a compound that would not cause allergic reactions and that would last longer. It was not until two decades later that hyaluronic acid (HA) became available for clinical use. HA found multiple medical uses before it was approved in the US as a soft-tissue filler. HA dermal fillers rapidly replaced collagen as the gold standard in cosmetic soft-tissue augmentation. The high demand and success of HA products led to an intense search for products that are similar to HA, which did not cause hypersensitivity reactions, but are longer lasting.7 This in turn led to a number of newer and longer-­lasting products such as poly-l-lactic acid (PLLA: Sculptra, FDA approval in 2004 for HIV-related facial lipoatrophy; Galderma Laboratories, FDA approval in 2009), calcium hydroxylapatite (Radiesse, FDA approval in 2006), and polymethylmethacrylate (PMMA)/polyacrylamide products such as Bellafill (previously Artefill, FDA approval in 2006).6 Today, plastic surgeons have in their armamentarium numerous safe fillers that can produce unprecedented aesthetic results, provided that they are used in an educated/safe manner.

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SECTION II

CHAPTER 8.2  • Injectables and resurfacing techniques: Soft-tissue fillers

BOX 8.2.1  Ideal filler characteristics • • • • • • • • • • •

Non-toxic Biocompatible Long-lasting (if not permanent) Reversible Off-the-shelf Autologous Easy to use Safe Produces positive, natural, discernible change Minimal downtime Level of placement (could be placed through dermis at subcutaneous, intramuscular, or periosteal levels) • Predictable (permanence, bulk, and behavior) • Performs well as a person ages • Not discernible by touch/appearance

  autologous

materials materials   synthetic materials.   biologic

Autologous fillers Autologous materials are derived from the patient’s own tissue.14–17 They therefore come closest to matching the description of the ideal soft-tissue filler in terms of safety. However, they are not as convenient to use since they require a two-step procedure – harvesting of tissue and injection. Toxicity, allergenicity, immunogenicity, carcinogenicity, and teratogenicity are not issues, but there can be problems with donor site scar, infection, migration, inflammatory reactions, loss of persistence, and unreliable reproducibility. Autologous fillers include:   dermis, fascia, cartilage, superficial musculoaponeurotic system (SMAS), breast implant capsule   fat grafts   platelet-rich fibrin matrix (PRFM)   platelet-rich plasma (PRP)   cultured fibroblasts   bone marrow-derived and adipose-derived stem cells. Dermis and cartilage grafts have a long history of use in plastic surgery, and with careful handling and placement, these grafts may have good, long-lasting results. Similarly, fascial grafts from the fascia lata of the thigh, the temporalis, sternocleidomastoid, and the SMAS can be used. In a good recipient bed, fascia is permanent and persists through a combination of creeping replacement by host fibroblasts and continued viability of fascial fibroblasts. Fat grafts as free en bloc transfers of tissue lose at least onehalf of their bulk after transplantation, and frequently develop cysts, calcifications, and necrotic lumps. However, this is not the case with micro fat grafting in which small intact packets of fatty tissue are harvested as atraumatically as possible and injected in tiny amounts along multiple tracts. This keeps the injected fat cells near a blood supply for increased survival and integration. The great advantage of this technique is that the fat that survives is permanent. The disadvantage is the

unpredictability of the survival, the need for a donor site, and the time required to process the fat.14–16,18 Selphyl (Aesthetic Factors, Princeton, NJ) is a patented system that allows the extraction of platelet-rich fibrin matrix (PRFM) from the patient’s own blood.19,20 This novel technology allows processing of blood in the office in a three-step process that takes approximately 20 minutes. The collected PRFM is then injected into the patient’s wrinkles. The collection of a 9 mL blood sample allows the collection of 4 cc of PRFM. The development of collagen and dermal matrix increases over a period of 3 weeks and there is early evidence to suggest long-lasting wrinkle correction (up to 20 months).19-22 Possible applications include correction of nasolabial folds, glabellar lines, and panfacial rejuvenation, as well as acne and other scar treatments. Selphyl has been cleared for use in the US (FDA) and Europe (CE mark). In recent years several companies have come forward with cost- and time-efficient in-office PRP extraction methods. Typically once blood is drawn, the process of spinning and collecting the platelet-rich plasma takes only 10–15 minutes. The quality of the PRP and the quantification of platelet-derived growth factors has not been compared between different systems but what is clear is that the differences between systems lie in the separating gel. Whether specific separating gels present in the blood collection tubes produce a higher grade of PRP has not been studied across brands. LAVIV or Azficel-T (Fibrocell Science, Exton, PA; FDA approval 2011) is approved for the correction of moderate to deep nasolabial folds. LAVIV is an autologous cellular product composed of fibroblasts harvested from postauricular skin.23 The fibroblasts obtained from the skin biopsy are aseptically cultured and expanded until sufficient cells for three consecutive injections are obtained. The treatment sessions are spaced 3–6 weeks apart. Although the mechanism of action of LAVIV is unclear, a two-point improvement in the Lemperle classification scale was achieved in up to 57% of subjects treated. The longevity of this correction beyond 6 months remains to be shown.24

Biologic fillers Biologic materials derived from organic sources (humans, animals, or bacteria) offer the benefits of ready, “off-the-shelf” availability, but can introduce issues of allergenicity, immunogenicity, and transmission of disease.25–29 Biologics provide only a temporary effect and typically do not correct the wrinkles or creases completely. The three major types of biologic tissue fillers are acellular soft-tissue matrix, collagen, and hyaluronic acid (HA) products. Although there are a few classes of materials that fall under the category of biologic fillers, hyaluronic acid filler use is by far the most common globally. Examples of different types that have FDA approval include those listed in Box 8.2.2. AlloDerm (LifeCell, Branchburg, NJ) is an acellular, structurally intact sheet of human dermal graft that was first used clinically in the treatment of full-thickness burns. Processed from prescreened human cadaver skin, the cells responsible for immunogenicity are removed while the matrix structure and biochemical components are left intact. The grafted material then acts as a template for recipient cell repopulation, resulting in soft-tissue regeneration. Some of its cosmetic-related applications include lip augmentation, nasolabial fold correction, glabellar wrinkle softening, and rhinoplasty

Classification of fillers

(dorsum and tip), as well as septal perforation, Frey syndrome, liposuction defect, and scar treatments. Complications include infection, persistent palpability or lumpiness, and variable “take” of the grafted material. Cymetra (LifeCell, Branchburg, NJ) is also a lyophilized acellular collagen matrix derived from human cadaver dermis, but in a particulate form. It is FDA-approved for subcutaneous injection and is used for lips, nasolabial folds, and deep wrinkles. Bovine collagen, marketed as Zyderm and Zyplast (Allergan, Irvine, CA), became available in 1981 and was the first commercially marketed injectable approved by the FDA for soft-tissue augmentation; at the time, it was the standard

against which all other fillers were compared. CosmoDerm and CosmoPlast (Allergan, Irvine, CA) contained human collagen and did not require a pretreatment skin test.30–32 They are no longer available. Hyaluronic acid or HA is an anionic, hydrophilic, nonsulfated glycosaminoglycan common to most living organisms and is a component of synovial fluid and of connective tissues of the skin, cartilage, and bone. In human skin, HA adds bulk and acts as a shock absorber and lubricant. HA, in its unprocessed molecular configuration, has a half-life of two days as it is rapidly degraded and metabolized by the liver.33 The solution to this problem has been to cross-link HAs into more stable compounds with significantly longer degradation times.34 HA, being extremely hydrophilic, maintains its volume by binding water from the interstitial fluids around it. In fact, 1 g of HA can bind an impressive 6 L of water.33 As the HA is progressively degraded by the surrounding tissues, underlying molecules of HA bind more water and therefore maintain the initial filling volume. This process is called “isovolumetric degradation” and it is the reason that HA fillers can maintain a virtually constant fill volume until the product is almost completely degraded.33,35 The significant differences between the HA fillers on the market today include the source of HA, concentration, type and degree of cross-linking, amount of free unmodified HA present, and whether the product is monophasic (cohesive gel) or biphasic (particulate). Another crucial characteristic is the elastic modulus or G′ (pronounced G prime) of a gel, which is a measure of its firmness and resistance to deformation.36 In general, the HA family of dermal fillers is a good choice for novice injectors, treatment-naïve patients, and for patients with moderate aging changes. The rheology of HA fillers is critical to understand as it allows for better selection of a particular HA brand based on the need for flexibility, volume, and support of a particular area of the face. A comparison of commercially available fillers in the US is presented in Fig. 8.2.1.

BOX 8.2.2 FDA-Approved soft-tissue fillers Cymetra

SKINVIVE by Juvederm

AlloDerm

Juvederm Ultra

Dermalogen

Juvederm Ultra Plus

Surgisis

Juvederm Voluma XC

Renuva

Juvederm Volbella XC

Bellafill

Juvederm Vollure

Sculptra

Juvederm Volux

Restylane

Juvederm Volite

Restylane Lyft

Belotero Balance

Restylane Refyne

Radiesse

Restylane Defyne

RHA Redensity

Restylane Kysse

RHA 2

Restylane Contour

RHA 3

Restylane Silk

RHA 4 Revanesse Versa

Restylane Eyelight

57

Source: https://www.fda.gov/medical-devices/aesthetic-cosmetic-devices/dermalfillers-soft-tissue-fillers. Accessed June 1, 2023.

600 Restylane Lyft Restylane-L

Firmness/support (G’)

450

Restylane Silk Juvéderm Voluma

300

Teosyal RHA 4

Juvéderm Vollure

Juvéderm Vollux Restylane Defyne Teosyal RHA 3

Teosyal RHA 1

150

Juvéderm Volbella Revanesse Versa

Restylane Kysse Juvéderm Ultra plus XC

Teosyal RHA 2

Juvéderm Ultra XC Belotero Balance

0

0

150

300

450

600

750

900

1050

1200

Flexibility (x strain) (%)

Figure 8.2.1 US FDA-approved commercially available hyaluronic acid fillers in comparison to each other based on strength (G′) and flexibility.  

Restylane Refyne

1350

1500

58

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CHAPTER 8.2  • Injectables and resurfacing techniques: Soft-tissue fillers

Restylane (Galderma Laboratories, Lausanne, Switzerland) is a NASHA (non-animal stabilized hyaluronic acid) soft-tissue filler that originally received FDA approval in 2003 for use in the correction of facial wrinkles.7,37–45 It is now marketed as a family of products differing in the size of the constituent particles. Brands within this group that differ by viscosity include Restylane Silk, Restylane Kysse, Restylane-L, Restylane Lyft, Restylane Defyne, Restylane Refyne and Restylane Contour. In 2006, Allergan’s Juvéderm series of HA fillers received FDA clearance. Similar to Restylane, Juvéderm also comes in various concentrations and viscosities and its cross-linking technology is termed Hylacross and Vycross. The Vycross range of fillers are homogeneous smooth gels that are used for both lift and lines. The patented Vycross technology incorporates short- and long-chain HA leading to more efficient cross-linking than Juvéderm Ultra, which only has long-chain HA. Addition of the short chains of HA permits more cross-links, more stability, and consequently, a longer lasting filler than the previous generation. This increased cross-linking also produces a more viscose gel, and therefore a greater lift capacity as well.46 Brands in this portfolio include Juvéderm Voluma, Juvéderm Vollure, Juvéderm Volbella, Juvéderm Volux XC, Juvéderm Volite, Juvéderm Ultra Plus XC and Juvéderm Ultra XC (Allergan, Irvine, CA). New to the US market but used globally for many years is Teosyal RHA 4, Teosyal RHA 3, Teosyal RHA 2 and Teosyal Redensity. Produced by Swiss HA product manufacturer Teoxane, all are marketed in the US by Revance Therapeutics Inc. (Nashville, TN) as RHA 4, RHA 3, RHA 2 and RHA Redensity (FDA approval 2019). Belotero Balance (Merz Aesthetics, Greensboro, NC; FDA approval 2011) is another HA filler available in the US. It has unique properties that make it softer (lower G′), longer lasting, and particularly useful for superficial injections of fine lines. Its low viscosity allows it to spread evenly throughout the soft tissues, which makes for a soft, smooth fill.47

Revanesse Versa (Prollenium Medical Technologies Inc., Aurora, ON; FDA approval December 2017) is new to the market and similar to the other HA fillers can be used for lift as well as lines. As discussed above, many of the recent fillers already contain lidocaine, but alternatively, lidocaine (usually 2%) can be mixed with most fillers to obtain analgesia during injection. However, doing this will most probably change the viscosity of the product, as well as certain of its properties. There are still a large number of non-FDA-approved biological fillers, which are available in the rest of the world.48 These are mainly HA-based products, with various sources, processing, and cross-linking (Table 8.2.1).

Synthetic fillers Synthetic materials can offer permanence. Many injectable and surgically implantable synthetic products have been used over the years, and many have been condemned for complications, including granulomas, acute and delayed infections, migration or displacement, and deformities that can result

Table 8.2.2  Synthetic fillers approved by the Food and Drug Administration (FDA) in the United States

FDA-approved synthetic fillers

Type

AdatoSil 5000

Silicone

Silikon 1000

Silicone

Bellafill (Artecoll)

Polymethylmethacrylate (PMMA)

Radiesse

Calcium hydroxyapatite

Sculptra (New-Fill)

Poly-l-lactic acid (PLLA)

Table 8.2.1  Biological fillers not approved by the Food and Drug Administration (FDA) in the United States, but approved elsewhere

Non-FDA-approved biological fillers

Type

Country (approval)

R-fine

Hyaluronic acid

Canada, Europe, Asia

Hyaluderm

Hyaluronic acid

Europe

Revanesse/ReDexis

Hyaluronic acid (cross-linked)

Canada

MacDermol S/MacDermol R

Hyaluronic acid (avian, cross-linked)

Europe

Varioderm

NASHA

Europe

Amalian

NASHA

Europe

Macrolane

NASHA

Europe

Zetaderm/Zetavisc

NASHA

Europe, Canada, Russia

HydraFill

NASHA (cross-linked)

Europe

Esthelis/Fortelis

NASHA (CMP technology cross-linked)

Europe, Canada, Asia

Puragen

NASHA (DXL technology cross-linked)

Europe, Canada

Rolifan/Philoderm/Beautygel/Esthirase/Coilingel

NASHA (cross-linked)

Europe, Canada, Brazil

HyalSkin

NASHA (BDDE cross-linked)

Europe

BDDE, 1,4-Butanediol diglycidyl ether; CMP, cohesive polydensified matrix; DXL, double cross-linked; NASHA, non-animal-stabilized hyaluronic acid.

Injection technique

from complications or removal of the material. It is with these products that the difference between the regulatory process in the US and that in the rest of the world is highlighted. The FDA controls access to the US market and enforces strict “labeling” practices, which means that the manufacturer must spell out the exact applications for which the material has been approved. Synthetic fillers approved by the FDA appear in Table 8.2.2. AdatoSil 5000 (Bausch & Lomb Incorporated, Rochester, NY) and Silikon 1000 (Alcon Research, LLC, Fort Worth, TX) are silicone gels with improved viscosity that have been approved by the FDA for use in treating detached retina. Both can be legally injected off-label for skin augmentation according to the 1997 FDA Modernization Act. However, only FDAapproved highly purified liquid silicone should be considered and injected using a microdroplet technique. Historically, injectable silicone products have tended to harden, migrate, and cause inflammation and skin necrosis.4,49 Those who have achieved success with silicone do so by injecting limited amounts at monthly intervals or longer. While side effects can be difficult to treat, liquid injectable silicone is particularly effective for human immunodeficient virus-associated lipoatrophy. Bellafill (Suneva Medical, San Diego, CA) is a permanent injectable implant consisting of smooth and round microspheres of nonresorbable polymethylmethacrylate (PMMA) which are 30–50 micrometers (20% by volume) suspended in a water-based gel containing 3.5% bovine collagen gel (80% by volume) and 0.3% lidocaine.50–52 After injection, the collagen is resorbed and the round, smooth microspheres are encapsulated by host collagen where they are stabilized and become permanent. Used in Europe for the past decade as Artecoll (Canderm Pharma Inc., Canada), Bellafill was approved by the FDA in October of 2006. Radiesse (Merz Aesthetics, Greensboro, NC) is a mixture of calcium hydroxyapatite (30%) and polysaccharide gel (70%).52–58 The polysaccharide gel is very white, which makes Radiesse inappropriate for use in the dermis. Radiesse is FDAapproved (December 2006) for nasolabial and labiomental crease correction, and since mid-2015 it is also FDA approved as a cosmetic filler for the dorsum of the hand.59 It is reported to last anywhere between 1 and 2 years. Recent use of hyperdilute Radiesse has shown neocollagenesis and is frequently used as a biostimulatory filler. Areas such as the decolleté and neck are now being augmented in this way. Sculptra (Galderma Laboratories, Forth Worth, TX) is a biocompatible, biodegradable material that is composed of PLLA (poly-l-lactic acid), sodium carboxymethylcellulose, and non-pyrogenic mannitol. It must be reconstituted with 5–10 mL of sterile water at least 2 hours prior to injection and does not require a skin test.60,61 Sculptra is hypothesized to induce the production of fibroblasts leading to collagen production. Over time (6–24 months), Sculptra is degraded in the skin to carbon dioxide and water.62,63 Sculptra has been used in surgical products for more than 20 years as a component of dissolvable sutures. It has also been safely used outside the US since 1999 in over 30 countries under the trade name of “New-Fill” for a variety of facial volume and contour deformities. It was approved by the FDA in August of 2004 as the only product for the correction of human immunodeficiency virus (HIV)-associated facial lipoatrophy

59

Table 8.2.3  Synthetic fillers not approved by the Food and Drug Administration (FDA) in the United States, but approved elsewhere

Non-FDA-approved synthetic fillers

Type

Country (approval)

Bioplastique

Silicone

Europe

Aquamid

Polyacrylamide

Europe, 40 other countries

Beautical

Polyacrylamide

Europe

Bio-Alcamid

Polyacrylamide

Europe

Outline

Polyacrylamide

Europe

Evolution

Polyacrylamide

Europe

Formacryl

Polyacrylamide

Russia

Argiform

Polyacrylamide

Russia

Bioformacryl

Polyacrylamide

Ukraine

Amazing Gel

Polyacrylamide

Asia

DermaLive/DermaDeep

Polyacrylamide

France

Metacril

Methylmethacrylate

Brazil

ArteSense

Methylmethacrylate

Europe, Canada, Asia

Rhegecoll

Methylmethacrylate

Pending worldwide

Laresse Dermal Filler

Carboxymethyl cellulose/ polyethylene

Europe

Atléan BTCP

Tricalcium phosphate

Europe

Bioinblue

Polyvinyl alcohol

Europe

Reviderm

DEAE Sephadex

Europe, Canada, Asia

Matridex

DEAE Sephadex

Europe

DEAE, diethylaminoethyl.

and is also approved for cosmetic use in the US (Galderma Laboratories; FDA approval 2009). It is injected subcutaneously in the area of fat loss/volume loss and provides a gradual and significant increase in volume. It is reported to last up to 2 years after three consecutive treatment sessions, approximately 1 month apart. A large number of other synthetic fillers are available in various parts of the world and a few are listed in this chapter48,64 and in Table 8.2.3. It is difficult to comment on the effectiveness and safety of these products because very little evidence to support these products is found in the literature.

Injection technique Before using injectable fillers, anesthesia of the areas to be treated should be considered. Nerve blocks, such as mental,

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infraorbital, and supraorbital/supratrochlear, work well and provide analgesia to large areas of the face. Direct infiltration of the area with lidocaine is another option, but this could lead to distortion of the anatomic structure to be corrected, and thus potentially to over- or undercorrection. The inclusion of epinephrine in the infiltration can potentially decrease bruising.65 Currently almost all fillers contain lidocaine so it is important to ensure that patients do not have a lidocaine allergy prior to use. Additional lidocaine with epinephrine can be admixed with fillers as a way to dilute them, but keep in mind that epinephrine can blanch areas of injection which can mask vascular compromise. The needle used for injection largely depends on the viscosity of the product injected. Less viscous HA products are injected with 30–31 G needles. More viscous HA products can be slowly injected through either a small needle such as a 30 G or a larger 28 G needle with more ease. Radiesse usually requires a 28 G needle, as does Voluma, while Sculptra and Bellafill, which are among the most viscous products injected, require at least a 26 G needle. Injection is usually in an anterograde or retrograde fashion, as the needle is advanced or withdrawn, respectively. Anterograde technique can be helpful in areas where soft fluid filler product ballottes the subcutaneous tissues away to decrease the risk of vascular injection.

The injection technique can vary from simple linear threading and the deposition of a small aliquot to more complex methods such as serial linear threading, radial fanning, cross-hatching, and serial puncture deposition.66 These techniques are used in combination depending on the location to be treated. The linear threading or tunneling technique involves injection either intradermally or into the subcutaneous level (Fig. 8.2.2A). Once the needle is inserted, the product is injected in a retrograde or anterograde fashion. Linear threading is most commonly used to correct wrinkles and furrows. However, when deeper creases are treated, multiple parallel linear threads at different levels have to be used to accomplish the desired volumetric augmentation (Fig. 8.2.2C). Examples of where this technique is commonly used include the glabellar lines, the nasolabial folds, the lips, and the tear trough, among others. Radial fanning is a variation of the linear threading technique (Fig. 8.2.3A). Just before the needle is completely withdrawn from the skin, it is reinserted in a different direction and the product is again injected in a retrograde fashion. This process is repeated multiple times in different directions until adequate correction is accomplished. This approach is particularly useful in malar augmentation, but it is also used

Epidermis

Dermis

Epidermis

Dermis

Subcutaneous tissue A

Subcutaneous tissue Epidermis Muscle Periosteum

Dermis B

C

Subcutaneous tissue

Figure 8.2.2 The (A) linear threading or tunneling, (B) droplet or depot, and (C) parallel linear threading techniques for dermal filler injection.  

Bone

Indications and applications

61

B

A

Figure 8.2.3  (A) Radial fanning and (B) cross-hatching techniques of dermal filler injection.

in the correction of the prejowl sulcus and the nasolabial fold. Cross-hatching is often used in the correction of large surface areas such as the marionette lines/prejowl sulcus or the hollowing of the lower cheek (Fig. 8.2.3B). Two independent radial fanning injections oriented perpendicular to each other constitute also a form of cross-hatching and are commonly used in cheek augmentation. Frequently the needle is inserted deep into the tissue and an aliquot of product is laid down; this is known as the depot or droplet technique (Fig. 8.2.2B). Large volumes deposited in this fashion can lead to palpable nodules and irregularities. Usually small droplets are deposited in a serial fashion; this is known as the serial puncture technique. These aliquots have to be close together to prevent irregularities. If any irregularities appear they can be managed by massaging. This technique is frequently used for tear trough correction and in lip augmentation, but also in the treatment of all other wrinkles and creases. Experienced injectors often use combinations of all of these techniques. Some practitioners recommend the use of blunt-tipped microcannulas. Many authors describe their experience of decreased bruising, especially when using a fanning injection technique.67–69 Microcannulas have gained tremendous popularity in recent years due to a perceived decrease in risk of vascular occlusion. This author cautions against relying on the blunt tip as cannula gauges even at 25 G can pop an inflated balloon.

Knowledge of anatomy is central to injecting anything in the face, whether with a needle or a cannula. It is not clear if cannula use more precisely deposits product and prevents its migration compared to a needle. Use of the instrument to place fillers is ultimately a personal preference of the injector though cannulas are becoming more common as one needs only to introduce the cannula through a single puncture hole to be able to reach several areas for filler.

Indications and applications There are multiple indications for the use of dermal fillers. Below is a list of the most common areas of the aging face usually addressed with injectables. The appropriate types of fillers for each area, as well as some technical nuances for their optimal application, are also described.

Glabellar lines Commonly, the glabellar furrow is successfully treated with neuromodulators. However, for toxin-naïve patients in their sixth decade or in patients with heavy solar damage, these lines are static – typically requiring a combination approach with lasers or with fillers. In addition to static lines, it is important to take note of brow descent that can be seen with the aging process but also with consistent neuromodulator treatment of the frontalis. The “chronic toxin” look appears as

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a flat forehead expression with descent of the brows over time. Thus, the glabellar lines should always be evaluated in combination with assessment of periocular bone and fat loss. This is where filler not only in the glabellar area is important but also the adjacent forehead. Key to the placement of fillers in the glabella is an understanding of the inherent risk. Informed consent for the use of fillers in this area should include the risk of arterial occlusion and its consequences, including blindness and a discussion of the potential for both superficial and deep vascular occlusion. Hyaluronidase should always be on hand in any practice injecting fillers but especially so in this area and a plan should be known to staff in case an event occurs. Prior to injection, photographs are necessary, as is marking of the supratrochlear and supraorbital arteries. Position the patient with their head at a 45° angle for optimal approach. Use of a needle in this area is preferrable to a cannula, as placement is superficial and filler choice should likewise reflect the depth of placement. The exception to this is if the glabellar area is to be volumetrically reflated with dilute low-molecular-weight hyaluronic acid, as detailed by Carruthers and Carruthers.8 This technique employs a depot of filler in the subgaleal vascular safe zone and then massage over the subgaleal glide plane. With the needle in the bevel-up position, the deeper etched component of the glabellar furrow can be treated with hyaluronic acid placed at the dermal–epidermal junction using a serial linear threading fashion in an retrograde motion. Often

filler will appear to extrude from a pore which is normal and if the appropriate filler is chosen, will not create a Tyndall effect. It is not advisable to use a fanning injection technique in this area. Depending on the product used, serial droplets can also be employed. This author prefers Belotero Balance or Redensity for this area in particular. It is important to let patients know that the lidocaine present in the filler may cause transient brow drop for up to an hour after the procedure. When combined with neuromodulators, the effect can last more than 6 months. With a combination technique of filler and toxin, patients will notice an improved more open palpebral aperture and a more relaxed appearance of the glabellar area. A follow-up is always offered at 1 month as some patients may require additional filler for ideal correction. In this author’s practice toxin and filler are not placed in this area on the same day and toxin is used first followed by filler 2 weeks later if indicated.

Forehead lines Changes of the forehead skin texture are usually sun-related whereas age-related changes cause volume loss, descent of the brow and muscular atrophy. Together these can give the near permanent appearance of horizontal forehead lines. While direct injection into the lines delivers a satisfactory result, on occasion a bolus of filler is needed in the forehead concavity to give support. Similar to unintended consequences of chronic

Epidermis

Epidermis

Dermis

Dermis

B

Subcutaneous tissue

Subcutaneous tissue Epidermis

Muscle Dermis

Periosteum A

Bone

C

Subcutaneous tissue

Figure 8.2.4 Injection of dermal filler into the deep tissue/periosteal level (A), more superficial into the subcutaneous tissue (B), and into the most superficial epidermal– dermal junction (C).  

Indications and applications

toxin in the glabella, chronic toxin in the forehead, especially in mature women beyond the sixth decade, can give a plasticized appearance to the forehead skin, which may make the skin appear thin. This requires forehead recontouring rather than injection into superficial lines themselves. For full reflation, PLLA or CaHa is preferred with placement by a cannula in the suprabrow concavity. As with glabellar lines, a combination of neuromodulator (done first) and filler can be ideal. The injection technique in this area is similar to that used for the glabellar lines. If the patient has a very dynamic forehead, then neuromodulators will be very helpful in achieving a better result and increase longevity of the filler. More commonly, low-viscosity fillers are used, and these are placed at the dermal–epidermal junction using a serial droplet or linear threading technique (Fig. 8.2.4C). Reflation should begin at the central forehead and progress laterally. In general, injections into forehead creases are placed superficially and because of this, are painful. Topical numbing preparations cause hyperemia and given the vascularity of the forehead, often create significant bruising. For patients on blood thinners this bruising can leave some hemosiderin deposition on the forehead. To avoid this, numb the forehead in sections using ice packs. Because several injection points are used, needles should be changed every 6 to 7 injections. Fanning technique is discouraged. Caution should be used above the brow area as a heavy hand with fillers can lead to some brow descent. Edema is common for up to 48 hours and patients are encouraged to sleep with their head elevated and to avoid exercise for 48 hours. Bruising can be delayed when injecting in this area but given the vascularity of the forehead, patients are encouraged to call with any bruises that seem out of the ordinary following treatment.

Eyebrows With age, the brow position drops more laterally than medially leading to a flat appearance and loss of projection. It is important to assess the eyebrows according to their three-dimensional shape rather than the shape imparted by the eyebrow hair. The most important part of treating eyebrows with fillers is to remember that not all brows look better with filler. Patients will often inquire about ways to lift the brows non-surgically and while it is possible to gain a 1–2 mm elevation with fillers in this area, it is far from a work around for surgery. Those with brows that have even descent or brows in which the medial supraorbital crease peaks medially are ideal candidates for brow filler. For some patients, the look of “nursing home eyes” has occurred not due to age but rather as a result of aggressive removal of upper eyelid fat resulting in a skeletonized orbital rim. For these patients, filler in the temple for correction is needed, in addition to the brow. This author prefers hyaluronic acid fillers for the eyebrows as HAs provide better structural support and projection. The goal of eyebrow filler is to achieve a larger look in the vertical dimension to the upper lid. However, it is important to define where in the eyebrow area filler is being placed. The smooth contour over the superior orbital room is created by the ROOF (retro-orbicularis oculus fat) pad. Filler above the lateral eyebrow line will worsen the appearance of an orbital hollow. Ideally, filler is placed at the line of the brow at the lateral tail. This also gives the illusion of raising the eyebrows

63

while restoring a more youthful appearance to the upper lid and eyebrow region. Injection in this area must be slow and a bolus technique is not advised. Sandwich the brow between the thumb and first finger and using a 30 G ½-inch needle, begin laterally and plan three longitudinal fills across the brow in a linear fashion moving the needle slowly but constantly with low-pressure flow. Care must be taken to inject small volumes with each pass to prevent emboli and injury to the sensory nerves. The filler is placed at a level that is not mobile. Caution is necessary in the eyebrow region as the supraorbital and supratrochlear nerves/vessels emerge here. It is important to keep the needle in the area where the brow is sandwiched between the fingers. Point the needle tip superior to avoid any tracking to an area like the globe which is adjacent to the orbital rim. For this reason, a canula is not recommended by this author as they are long and can easily track subcutaneously and inadvertently end up in an unintended space. Rarely does one need more than 0.5 cc of filler in the brow itself. Bruising is possible though not common and neither is edema. The goal is not necessarily the appearance of a lid lift but a repositioning of tissue such that light reflection gives the illusion of a wider eye and more projected and contoured eyebrow. When placed in the right plane, filler in this area can last up to 2 years. If planning to use any energy-based devices to create lift, proceed with those first before placing fillers.

Tear troughs The tear trough, or the infraorbital hollow, is a common area for correction. It is important to assess patients properly as many who present with the complaint of looking tired and wanting undereye filler actually require a lower lid blepharoplasty for a prominent and herniated infraorbital fat pad. The tear trough is one component of the infraorbital hollow with the nasojugal fold and the palpebromalar groove comprising the other components. Patients with thick smooth skin,

A

B

Figure 8.2.5  Tear troughs. (A) This 48-year-old woman presented with significant tear troughs that made her appear tired. Perlane was placed at the depth of the periorbital hollow on the bone and on the malar bone to augment cheek projection and minimize the negative vector. A total volume of 1.1 cc was placed per side; it was placed mainly in the periorbital hollow, but a smaller amount was placed on the malar bone to increase cheek projection relative to the globe. (B) The patient is seen 6 months after treatment.

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minimal laxity and moderate tear troughs are the ideal candidates for HA fillers in this area. It is important not to be singularly focused when volumizing this area as there is significant interplay with the medial cheek. Often reflation of the midface medially is required in addition to correction of the trough. Patients should be photographed with standardized lighting which can highlight the tear trough deformity and lower lid fat prolapse. Like the glabella, injection of the infraorbital hollow is a high-risk injection and informed consent discussions should detail this. Pre-injection icing is key and likely to reduce bruising compared to topical analgesia. Patients are injected in the upright position and planning should include marking the areas of injection while the patient is looking upward. One approach to filling this area is to place hyaluronic acid filler product deep on the bone and periosteum (Fig. 8.2.5). This ensures that the product is not palpable or visible, especially with animation. Various fillers have been used for this purpose, but the most commonly applied are Restylane, Juvéderm, or Belotero. Other long-term fillers such as Radiesse, Sculptra, and Bellafill can have a devastating outcome in the case of visible nodular/granulomatous formation, and should be avoided for this use.53,70–72 Another technique involves using a cannula at one insertion point lateral to the lateral canthus and using a serial linear threading technique to rejuvenate not only the trough but also the lateral orbital rim. Discontinuous aliquots of 0.1 mL are deposited along the length of the infraorbital hollow. This author uses a ½-inch 30 G needle with an insertion point at the upper medial cheek. The needle is pointed toward the medial canthus and using a slow flow injection technique, filler is placed in the SOOF. A bolus of no more than 0.1 cc is placed and milked upwards toward the trough and medially. Similar boluses are placed inferior to the orbital rim and massaged into place. With this technique rarely is more than 0.5 cc of filler needed per side. When compared to a cannula, a needle produces the same results. It is important to note that while many believe a cannula can prevent vascular injection, in this area the prominent infratrochlear vessels adjacent to the nasal bone and the infraorbital nerve in the midpupillary line make this area one that is high risk regardless of tool used. Usually 0.5 cc of filler is used per side, depending on the severity of the tear trough and the desired projection of the malar prominence. Regardless of technique used, the product can be massaged to smoothen its distribution over the bone and the hollow. If swelling and bruising are noticed immediately after filler injection, pressure and cold compresses should be applied. In the case of overcorrection, the product can be massaged down for up to 2–3 weeks. If the overcorrection persists, the HA filler can be partially dissolved with hyaluronidase. If placed in the SOOF (suborbicularis oculi fat), filler does not need to be repeated more than once a year. Indeed patients who return for repeat infraorbital hollow correction at the 6 or 8 month mark usually need to have product dissolved by year 4 or 5 as persistent edema begins to predominate as the filler ages. Post-procedure edema is common and can last up to 3 weeks. Keep in mind that the tear trough is very unforgiving and the Tyndall effect can happen easily, as can bruising. The most severe complications in this area include retrograde embolus into the periorbital vasculature as the filler inadvertently slips behind the orbital septum. Less is more in the tear trough and persistent edema laterally is a sign that too much

Table 8.2.4  The Lemperle nasolabial fold classification

Class

Description

0

No wrinkles

1

Just-perceptible wrinkles

2

Shallow wrinkles

3

Moderately deep wrinkles

4

Deep wrinkles, well-defined edges

5

Very deep wrinkles, redundant folds

filler has been placed and needs to be dissolved. For the tear trough, meticulous injection technique and planning are key to avoiding creation of a “sausage roll” underneath the eye at the conclusion of correction which is why it is also always important to check filler placement with the patient animating at the end of the treatment.

Nasolabial folds The nasolabial folds may be of different shapes, lengths, and depths. In addition, some patients have pre-existing telangiectasia in this area that can be made worse with injections. The gradation system, as described by Dr. Lemperle (Table 8.2.4), is useful in evaluating and discussing goals of correction with patients. For the nasolabial folds in general, it is paramount to assess whether the fold is being contributed to by midface descent. If it is, than filler directly into the folds is a mistake without concomitant correction of the cheek area. The amount of change in the average case should be approximately 50% correction of the depth of the fold (Fig. 8.2.6). Care must be taken not to overfill the fold because this will give patients an odd appearance when they animate or smile. Fillers can be used to soften the broader portion of the fold, which is usually the upper two-thirds down to the lateral oral commissure. Choices here include all types of fillers.39 Keep in mind that anatomy of the vasculature here can vary so it is important to know the depth of placement of product. Most HA fillers can be placed at the level of the mid to deep dermis. With semipermanent or permanent fillers (Radiesse, Sculptra, Bellafill), the product should be placed in the deep subcutaneous tissue (see Fig. 8.2.4C).43,70,73,74 The filler is placed at angles to the fold in order to decrease the risk of intra-arterial facial artery injection. Layering may be performed to enhance longevity (see Fig. 8.2.5B). Also, for very deep folds, more viscous products (Voluma, Vollure, Restylane Lyft, Juvéderm Ultra Plus, RHA 4, Defyne) or permanent/semipermanent products (Radiesse, Sculptra, Bellafill) may be placed deep under less viscous fillers such as Restylane and Juvéderm. This may increase longevity of the correction and give a more polished appearance. If the nasolabial fold has a superficial line etched into it, this can be softened with Restylane Silk or Belotero or RHA 2. As with all repeated injections of HA, the product lasts longer and less volume of product is needed to achieve the same volume and contour change. Taping of the fold after the injection for a few days may help the product bind into place with scar tissue and can prevent the lateral displacement of the product to the nasolabial fold when the patient smiles.

Indications and applications

A

65

B

Figure 8.2.6  Nasolabial folds and marionette lines. (A) This 64-year-old woman presented with perioral lines and significant jowls. However, she was not interested in surgical rejuvenation and wanted just to soften the appearance of her perioral wrinkles and folds. Approximately 0.4 cc of Restylane was used for each nasolabial fold and 0.3 cc to address the marionette lines on each side. (B) The patient is shown 1 month post treatment.

Typically the technique of injecting directly into the nasolabial folds has been retired in favor of harmonious volumization of the midface and lower face together. At the lateral oral commissure, nasolabial folds can be mimicked by natural dimples. It is important not to chase this line and to assess where it is being created from as filler into a perceived fold that dimples with smiling will look fine at rest and unusual in animation if corrected. While the presence of laugh lines are a common patient complaint it is critical to assess the entire midface when attempting correction of this area.

Malar augmentation Malar augmentation can be achieved with most fillers available.75 In the case of semipermanent and permanent fillers, care must be taken for the product to be injected deep in the tissue (see Fig. 8.2.4A). With HA fillers, the product can be applied from the deepest layers to the most superficial (see Fig. 8.2.4A–C). Medium-viscosity (MV) HAs such as Juvéderm and Restylane can be used in this manner applying the product over bone, into deep tissue, and in the dermis. Alternatively, more durable fillers such as high-viscosity (HV) HAs, Radiesse, Sculptra, or Bellafill, can be used deep, with MVHAs placed more superficial to obtain further refinement if necessary. This approach leads to a more durable result. The most appropriate technique for malar augmentation is the radial fanning technique, with entry points first lateral and then inferior to the malar prominence (see Fig. 8.2.5A). Nevertheless, any other technique can probably yield adequate results. Pressure over the augmented area should be avoided over the first week post-treatment. When used appropriately, dermal fillers can replace the use of an implant for malar augmentation. The goal in this area is to reposition light reflection rather than to create the same apple cheek for each patient.

Marionette lines Marionette lines extend from the oral commissure in a downward oblique fashion, giving a sad appearance. Usually there is a volume deficit medially extending to the level of

the jawline, creating what is known as the prejowl sulcus. Therefore, correction of the marionette lines is often combined with correction of the prejowl sulcus. Most fillers available today can be used for correction of the marionette lines. The principles mentioned earlier for other sites apply here too. More permanent viscous fillers are used for deeper correction, with less viscous, finer products for more superficial correction.76 The area to be filled is actually triangular, extending from the marionette line to the lower lateral lip vermilion to the superolateral aspect of the chin (Fig. 8.2.7). Usually a radial fanning technique from two independent injection sites, superior and inferior, can lead to a smooth correction of the area. A layering technique with more viscous hyaluronic acids like RHA 4 leads to excellent results though it is important to massage these aliquots carefully so the patient does not feel as though they have nodules. Because of the location, some filler technology can produce nodules if exposed to transient bacteremia as is the case after dental procedures. For this reason it is important to take a careful history and to tell patients to avoid the dentist for at least 1 month post filler. In this dynamic area, partial to complete correction is possible, but overcorrection can lead to lumps that are visible or felt intraorally under the oral mucosa, as well as a strange appearance upon animation. Semipermanent filler like Radiesse into the prejowl sulcus can achieve excellent results especially when molded over the jawline. This definition can set not only the melolabial lines but also the lips and chin. Bruising is very common in this area. Almost all HA fillers are acceptable to use in this area but depending on the amount of correction needed, the choice should be made based on the product’s ability for anterior projection as the marionette lines often appear as topographic depressions of the lower face.

Jawline augmentation In the areas along the jawline (filling the hollow anterior to the jowl), filler is best placed on the very deep plane on the bone or subcutaneously to allow augmentation of the soft tissues similar to a solid implant (see Fig. 8.2.4A). HVHAs or MVHAs

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2nd needle insertion point

2nd

1st 1st needle insertion point

B

A

1st (0.5” needle)

1st (0.25” needle)

2nd 2nd

3rd

C

Figure 8.2.7  Technique used (A) for malar augmentation, (B) for marionette lines, and (C) for nasolabial folds.

A

B

Figure 8.2.8 Sculptra. (A) Preoperative and (B) 1-year postoperative results after augmentation to the brow, cheeks, and jawline with three sessions of Sculptra (two vials per session) in a 51-year-old female. The dilution of each vial of Sculptra consisted of 7 mL of sterile water and 3 mL of 1% lidocaine with epinephrine.  

Indications and applications

A

Figure 8.2.9  Fat grafts. (A) Preoperative and (B) 1-year postoperative results after micro fat grafting to the temples, cheeks, and jawline, and bilateral upper blepharoplasty in a 50-year-old male.

B

may be used but, of note, only Juvéderm Volux XC has specific FDA clearance for filler in this area (August, 2022). Jawline augmentation is usually combined with marionette/prejowl sulcus correction. HA is placed in the deepest point of the hollow. This will correct most of the deformity. Placement of the material in the deep dermis may be required for complete correction of the jowl deformity. Using the thumb, massaging and molding the filler into place so that it appears congruous with the bony jawline is important.

Panfacial volumetric augmentation With aging, the ovoid soft shape of youth gives way to sharper angles, hollows, and creases. It is not enough to augment one area of the face but rather a need develops to improve overall facial volume in order to achieve harmonious balance of the upper and lower face. Correction of the temporal hollowing, lifting of the brow, filling of the periorbital hollowing, and malar, jawline, and perioral enhancement, can result in a markedly rejuvenated appearance (Figs. 8.2.8 & 8.2.9). This non-surgical facelift can be achieved with HA, Sculptra, or Radiesse injected in the deep tissues, in combination with superficial HA injections to obtain more refinement. Because both Radiesse and Sculptra show a delay in the appearance of the final result and because multiple injections may be required, more viscous HA fillers in the deep tissues may be used instead for an immediate effect and more predictable results. The advantage of using Radiesse and Sculptra is that they last for 1 and 2–3 years, respectively. Alternatively, fat can be used for panfacial volumetric augmentation, with “finer” fillers used to obtain a more superficial correction.

Facial lipoatrophy HVHAs or MVHAs are ideal fillers to soften the appearance of lipoatrophy associated with antiretroviral therapy for HIV. Other options include Sculptra, Radiesse, Bellafill, and fat.77,78

67

The areas that are best treated are the concavities adjacent to the zygomatic–temporal bone and the zygomatic arch (less so the inframalar hollow). In the temple and adjacent to the arch, it is important to place the filler deep within or under the periosteum and take care to inject slowly to be sure of even placement and to minimize bruising. The product is easily massaged, but if the massage is too aggressive the entire effect will be minimized. The idea is not to fill the entire area of atrophy completely but to soften the contours so that the wasting does not appear too severe. In the inframalar hollow, the goal should be to correct one-third to one-half of the hollow. Linear threading or a fanning technique may be used, and a gradual and consistent result can be achieved. Volumes of 0.5–1.5 cc per area may be used, on average. This will vary among individuals, depending on their requested goals. Repeated injections on a 2–4-week basis may help to contour areas that have a large volume deficiency.

Lips Contouring of the lips may be accomplished with several kinds of fillers (Fig. 8.2.10A,B).79,80 When approaching the lips it is important to distinguish lip volume from lip structure but in both scenarios one must keep in mind ethnic variation of lip size and width as well as aesthetic preferences. Hyaluronic acids are ideal for lip rejuvenation as they can be reversed and while it is common to use one filler for both the vermilion border and the body of the lip some practitioners will choose a more structural filler for the lip border and a softer product for the body (e.g., Restylane for the border and Juvéderm Ultra for the tubercles). Most patients have baseline asymmetry to their lips between the sides which should be marked and demonstrated to them prior to injection. If using an intraoral block for anesthesia of the lips it is important to work quickly as analgesia often causes a natural and temporary drop of the upper lip. While it is always encouraged that one use the syringe and needle the

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A

B

Figure 8.2.10  Lips. (A) This 51-year-old woman requested lip augmentation. Restylane was injected into the vermilion border and philtral columns to achieve a narrower appearance. Restylane was injected from the inside of the lip from the vermilion border to the wet–dry junction. (B) She is shown 3 months after injection with good persistence of filler.

filler is FDA approved with, back-filling tuberculin syringes allows for precise placement of filler in this delicate area. Prior to injection, the consultation should focus on whether the patient is seeking restoration of the lip or enhancement and it may be necessary to address the other components of the perioral area at the same time; namely the chin, upper lip lines and skin texture. If the patient has a very active depressor anguli oris muscle the corners of the mouth can become downturned so the addition of low-dose botulinum toxin may be necessary. While it is becoming increasingly popular to use low-dose botulinum toxin for perioral rhytids, this author finds the result in patients beyond the fourth decade to be underwhelming with a greater chance of interruption of phonation compared to enhancement of appearance. Begin injections at the oral commissure and crisp the vermilion lip at the white roll first. Previous teachings focused on retrograde injection but an anterograde pushing forward technique was demonstrated to cause less bruising and pain. A cannula can easily be used in the lip but caution should be exercised when monitoring filler volume as product flows quite readily through a cannula and the back and forth motion in the lip creates significant edema. The philtral columns may also be augmented with filler placed in the mid-dermal level but care must be taken not to lengthen the upper lip. Filler in the philtral column should also always be placed at an angle as the columns are less vertical and more like the Leaning Tower of Pisa. Deposit more filler in the lower two-thirds of the philtral column as to enhance and peak the Glogau–Klein points and create a more natural appearance of the upper lip, especially in mature patients whose philtral columns flatten. Palpation of the tissue as the filler is injected is important. Injection of the lip proper from the wet–dry junction to the vermilion border may also be carried out just deep to the mucosa within the orbicularis oris muscle. If it is placed immediately beneath the mucosa, it will be seen as a blue color. Placement posterior to the wet–dry junction along the wet mucosa may enhance the lip volume as well as the projection. Variation in the placement of the product must be done, depending on the desires of the patient and the starting shape of the lips.

The cupid’s bow becomes wider with age and should be made narrower. The depth of the mental fold increases with age and may require softening. Frequently the upper lip is atrophied above the vermilion border, particularly the lateral aspects, and restoration is done with MVHA placed at the mid-dermal level to improve volume and projection of the upper lip. One should use minimal volume in the upper lip above the vermilion border as any added volume may cause lengthening of the upper lip. Care must also be taken to limit the amount of filler placed in the upper lip skin adjacent to the nasolabial fold because this will result in an awkward animation of the upper lip and nasolabial fold, particularly during smiling, and can give the appearance of a “joker-type” upper lip or create an unusual fold at the lateral edge of the upper lip. Patients with long, thin lips and very broad smiles may get limited results because of tissue tension. Often patients complain that their lips are too thin when they smile. This is a dynamic change and cannot be corrected with fillers or implants. Patients with lips that are tight to the dentition or a class II occlusion should be augmented with conservative volumes, since irregularities of dentition may be reflected in the upper lip appearing too prominent or “duck-like”. Approximate volumes for augmentation of the lips may range from 0.5–1.0 mL per lip. MVHAs should last for a period of 4–6 months; however, when it is repeated, the results may last for 8–12 months. Care must be taken in persons with soft, supple lips that move a lot with animation; these patients may not respond well to HVHAs, and their lips may appear too stiff. When injecting HVHAs, one must avoid the formation of lumps or bumps as they are difficult to massage out of the tissue. If the patient has lip implants, then the filler may be added around the implant. HA fillers can also be combined with other tissue fillers. Less viscous HAs may first be injected along the vermilion border, which provides augmentation of the white roll. Lastly, patients with a history of herpes should be given prophylaxis because the treatment may cause a herpetic outbreak and scarring. Edema can last for up to 72 hours and

Indications and applications

patients should be advised to ice at 10 minute intervals per hour to minimize this. On occasion, touch ups may be needed at 2 weeks after the initial treatment and caution should be exercised to avoid overcorrection. Late-onset nodules have been reported, especially if dental procedures follow lip augmentation in the month prior or following filler placement. There is no evidence of keloid formation in patients of different ethnicities and for patients with autoimmune disorders like scleroderma fillers are not considered a contraindication and can actually diminish disease progression in the oral area.

Perioral and mandibular filling Retrusion of perioral bone and fat and age-related descent of the cutaneous envelope leads to jowl formation, etching, and folding of the marionette lines and a pebbled appearance of the chin. The enlargement of the piriform aperture from recession of the medial edge of the maxilla combined with bony mandible loss contributes to the shortening of the lower face in the older patient. It thus becomes important when addressing the lip that one also assess and augment the framing area around the lips. Fillers that are soft and malleable give the best functional result in the perioral area. Nonpermanent crosslinked fillers are ideal for lip lines while calcium hydroxylapatite works particularly well in the jawline. Lip lines are best injected directly using a superficial filler such as RHA 2 or Belotero. Use of a thin needle (31 G or 32 G) is ideal and massage is critical to avoid beads-on-a-string appearance in this area. Keep in mind that when perioral lines are augmented the vermilion border should be assessed so that the upper lip does not become too full or flattened as to then push down on the lip or create a simian appearance. The contour of the mandibular margin changes over time and prior to filling in this area it is important to understand the neurovascular landmarks at the antigonal notch. Palpate the anterior border of the masseter to understand where the facial artery is so as to avoid it during injection. A high G′ filler is ideal for this injection which is carried out by pinching

A

69

the skin upward and injecting in an anterograde fashion away from the periosteum. The lateral mandibular area is best injected with the physician standing on the side of the correction, however frequent assessment should be done with the patient looking straight ahead to attain symmetry.

Chin As the bony mandible loses definition, so too does the chin fat become atrophic. The pebbled appearance of the chin is easily corrected with low doses of botulinum toxin placed directly into the mentalis whether as a depot into the insertion of the mentalis at the menton or as two injections into the belly of the mentalis which bifurcates. In addition to or in lieu of toxin, filler produces a very nice enhancement for chin retrusion. A high G′ filler or CaHa are successful products to be used in this area. Injections should be placed deep and as a bolus in the center of the mentum between the arches of the mental arteries. Massage is carried about by rocking the chin in the cupped palm of the injector’s hand. Additional amounts of 0.2 to 0.4 mL of HA filler can be injected superior and lateral to the mentum in order to create a continuous arc with filler in the marionette lines.

Nasal reshaping (off-label) Many fillers have been used in the correction of minor nasal deformities (Fig. 8.2.11A,B).56,81 More commonly, HA fillers and calcium hydroxylapatite have been used for non-surgical rhinoplasty. Radiesse, even though it may provide more support than HA fillers, can also become visible if placed in large amounts or too superficially. In general, permanent fillers have a higher risk of becoming visible or palpable. If a permanent filler such as Bellafill is to be used, it is probably preferable to attempt correction with a resorbable filler first. Injection can be by either serial threading or tunneling techniques. The product should be placed in the subcutaneous layer, especially in patients with thin skin, to avoid visibility. Patients with a mild

B

Figure 8.2.11 Nose. (A) This 30-year-old woman had concerns about the irregular appearance of her nasal tip cartilage. Restylane was used to fill in the hollows and shape the tip of her nose. Restylane, 0.4 cc, was used to soften the appearance of the nasal cartilage. The patient had inquired initially about rhinoplasty with tip alteration. She had not had previous surgery, and the nasal tip had not changed other than the irregularity becoming more noticeable with time. The skin at the tip of the nose was very thin, and any slight surgical irregularity may have been noticeable; additionally, the skin may have been compromised by an open rhinoplasty. The new tip contour was achieved under a block with local anesthetic and 0.4 cc of Restylane. (B) She is seen here 5 months after injection.  

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hump, short nose, saddle nose and irregularity of the nasal dorsum at lateral view are all candidates for filler rhinoplasty. As with lips, ethnic considerations should be considered for nasal shape and a careful history of prior procedures in the area is necessary. Typical features of leptorrhine, platyrrhine, and meshorrhine can be changed with filler in the nasal tip and radix so it is important to review this with patients as it can significantly change their appearance post procedure. When using an HA filler in the nose, it is important to use one high in viscoelasticity and low in water-absorbing capacity. Cannula use is well tolerated in this region with an entry point at the pronasale. Regardless of tool used to deploy filler, it should be placed in the radix to the nasal tip to improve nasal length and height. On side angle always assess the radix to glabellar angle to make sure that curvilinear arch is preserved. The injector should be positioned in front of the patient during injection and pushing the cannula to the sellion begin injection in a retrograde fashion continuously to build a column in order to achieve the desired height of the nasal bridge. Pinch the skin of the nose while doing this to prevent filler from lateral spread. A double-layer approach is preferable to depositing excessive amounts of filler in the dorsum, which can create the appearance of a thick nose. Begin by first placing filler deep and follow it by superficial injection in the subdermal layer. Once the height of the nose is achieved, lateral sides of the nasal sidewall should be injected using a needle regardless of what was used to create the original column. Correction of the nasal tip is accomplished with filler placement in the interdomal area. Similarly columella retraction is corrected by placement of 0.2 mL of filler into the subcutaneous columella to improve its projection. While filler use cannot sharpen the angle of the nasal tip, creating a narrower nose can give the optical illusion of a sharpened tip. There are reports of alar skin and nasal tip necrosis with injection of fillers, especially post rhinoplasty. Care should be taken to inject small amounts (100°C) less than 1 ms) can induce cell death.1,4

Biostimulation Biostimulation (also called low-level laser therapy) belongs to the group of photochemical interactions. Most biostimulation studies involve low-power lasers, and this field continues to be a subject of controversy. Home-use devices that use LEDs are now available in a wide range of wavelengths. Typical fluences are in the range of 1–10 J/cm2, and normally there is no acute temperature elevation, or any clinical endpoint.1,4

Cooling Before the addition of surface cooling, fluence thresholds for efficacy and epidermal damage were often close. Visible light technologies, (especially green–yellow light sources such as

IPL (420–1400)

Absorption Coefficient (cm -1)

20,000

1470 nm

2940 nm

1987 nm

5,000 1,000

Oxyhemoglobin Deoxyhemoglobin Melanin Water

100 1 0.1 200

400

700

1,000

5,000

10,000

Wavelength Figure 8.4.2 Absorption curves for hemoglobin, melanin, and water. IPL, intense pulsed light. (Image courtesy of Sciton (Palo Alto, CA), based on absorption spectra data courtesy of Scott Prahl, PhD and Steven L. Jacques, PhD, Oregon Medical Laser Center (omlc.org/spectra).)  

Diagnosis and clinical evaluation

A

89

B

Figure 8.4.3  (A) Pre- and (B) post-KTP (potassium titanium oxide phosphate) laser treatment (8 J/cm2, 20 ms).

IPL, potassium titanium oxide phosphate (KTP) laser, and pulsed dye laser (PDL)) are the wavelength ranges where epidermal damage is most likely. The epidermis is an innocent bystander in cutaneous laser applications where the intended targets, such as hair follicles or blood vessels, are located in the dermis (Fig. 8.4.3).1,4 Beyond visible light sources, surface cooling also has been employed in near- and mid-infrared (NIR and MIR) lasers. With NIR lasers, surface cooling is important because of dermal/epidermal junction-derived epidermal heating. In addition, deep beam penetration may cause significant bulk heating to nearby tissues. With MIR lasers, the chromophore is water. Without surface cooling or a fractional design, water’s ubiquitous nature in the skin causes a laser-induced top-tobottom injury. All techniques are susceptible to operator error and device failure. As physicians rely more heavily on cooling devices, any lack of their proper deployment unveils the dark side of cooling. Fractured sapphire windows, disabled cryogen spray apparatus, and crimped forced air chiller tubes have all contributed to unintended epidermal injury.1,4

Ablative skin rejuvenation Fully ablative lasers include carbon dioxide (CO2) and erbium (Er:YAG), both of which target water as a chromophore. Similar to the concept of chemical peels or dermabrasion, these devices can be used for “full-field” ablation, meaning that 100% of the target area from the epidermis down is treated.

Non-ablative skin rejuvenation The original concept of non-ablative rejuvenation was wrinkle reduction by selective dermal heating.24,25 Deeply penetrating non-fractional mid-IR lasers coupled with surface cooling were designed to “bypass” the epidermis, creating a “slablike” dermal injury. Unfortunately, “CO2-like” results were never replicated because dermal heating was either too deep or too mild. Superficial severe dermal heating was almost

always associated with epidermal damage. It followed that all of these devices “bypassed” the solar elastosis ultimately responsible for most static wrinkles of the face.1,4 The “non-ablative” term has now evolved to include any light-based intervention with “relative” epidermal preservation.26 In addition to wrinkle reduction, new outcome measures include acne scar improvement, telangiectasia resolution, homogenization of pigment, pore size reduction, skin tightening (jowls, neck, and some extrafacial sites), and improved skin tone (Fig. 8.4.4).24–26

Fractional resurfacing Resurfacing with fractional photothermolysis represents a newer class of therapy (see Fig. 8.4.1). Fractional ablative resurfacing creates a column of ablated tissue, while nonablative fractional resurfacing creates a column of desiccated tissue. In a non-ablative fractional injury, the stratum corneum is left largely intact as thousands of microscopic wounds surrounded by viable tissue are made with a variety of laser wavelengths and delivery systems. In both ablative and non-ablative fractional treatments, the untreated tissue provides growth factors, cytokines, and fibroblasts to the treated areas, assisting in faster wound healing when compared to non-fractionated lasers. These islands of viable untreated epidermis and dermis also maintain the skin’s barrier function while speeding re-epithelialization (Fig. 8.4.5).1,27

Diagnosis and clinical evaluation Adequate evaluation and photographic documentation of the patient prior to laser treatment is essential.27–28 This assessment includes consideration of age, medical issues and medications, skin type, the severity of actinic damage, degree of redness, depth and number of rhytides, and the presence of scars. The patient with deep rhytides and excessive facial skin laxity is likely a better candidate for traditional rhytidectomy with or without resurfacing. The patient with moderate

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CHAPTER 8.4  • Injectables and resurfacing techniques: Lasers in aesthetic surgery

A

B

Figure 8.4.4  Acne scar treatment with 1550-nm erbium:glass fractional laser: (A) before; and (B) 6 months after three treatments.

A

B

C

Figure 8.4.5  Fractional resurfacing (2940 nm):(A) immediately before laser treatment; (B) immediately after treatment; and (C) 3 months after laser treatment.

photodamage and medium rhytides may be a more optimal candidate for one of the many types of resurfacing procedures. Some patients may benefit from both procedures because rhytidectomy typically addresses skin quantity and soft-tissue malposition, whereas resurfacing addresses skin quality. It should be noted, however, that great care should be undertaken when both rhytidectomy and resurfacing are performed concurrently. If rhytidectomy is performed, it is recommended to avoid deep resurfacing of the undermined facial skin, as wound healing issues may ensue. An important tool of the evaluation of the patient for a resurfacing procedure is Fitzpatrick’s scale of sun-reactive skin types. This scale describes patients’ reactions to ultraviolet radiation and existing degree of pigmentation. Type I patients always burn and never tan. Type II patients tan only with difficulty and usually burn. Type III patients tan but sometimes burn. Type IV patients rarely burn and tan with ease.

Type V patients tan very easily and very rarely burn. Type VI patients tan very easily and never burn.29 Patients with lighter skin types can expect to undergo laser treatments with minimal concern for abnormal pigment changes, whereas individuals with darker skin are at higher risk for unwanted hyperpigmentation or hypopigmentation.29 An often-ignored rule is that patients tend to revert to their constitutive color after resurfacing (unless it is carried out very deeply). So, although there is a concern that constitutively dark patients might be at risk for temporary dyspigmentation, on a practical level it is the severely photodamaged type II and III patients that present the greatest challenges in moderate-depth resurfacing. This group of patients, once their superficial melanin is removed by the procedure, tend to remain “less tan” after the photodamage is reduced. This can result in conspicuous lines of demarcation between treated and untreated areas. Another helpful classification system is the Glogau30 photodamage

Patient selection and treatment

scale. Type 1 patients have little wrinkling, no keratoses, no scarring, and require no make-up. Type 2 patients have early wrinkling, early actinic changes, minimal scarring, and require a small amount of make-up. Type 3 patients have wrinkles present at rest, moderate actinic keratoses, moderate scarring, and always require make-up. Type 4 patients have severe wrinkling, actinic keratoses, and scarring that even large amounts of make-up does not cover. A thorough medical history and review of systems should be completed in concert with the physical examination, as part of a thorough patient workup. Pre-existing cardiac, hepatic, or renal disease may influence the treatment decision and choice of chemical peel or alternative resurfacing method. The use of exogenous estrogens, oral contraceptives, and other photosensitizing medications has been shown to predispose patients to unpredictable pigment changes.28 Therefore, such agents should be avoided several weeks before and after treatment. For any procedure that includes epidermal compromise, the physician should provide antiviral prophylaxis several days before and after the treatment for those patients with a history of herpes simplex infection. Prophylaxis will help minimize chances of unwanted viral reactivation as the re-epithelialization process occurs. It is also advisable to allow any existing viral-type lesion to heal completely before proceeding with a resurfacing procedure.28 Patient cooperation and compliance with the post-treatment regimen is required to ensure normal wound healing and to avoid complications.28 It is ill-advised to treat patients likely to be noncompliant or unable to avoid sun exposure because of occupation. Men may be less willing to use camouflage make-up in the event of pigmentary disturbances. Patients with a decreased number of epithelial appendages from prior radiation treatment or current isotretinoin (Accutane) use are also poor candidates because healing will proceed more slowly and scarring is more likely. One should wait at least 6 months after stopping isotretinoin to allow sufficient regeneration of epithelial appendages prior to deep full-field ablative resurfacing. For non-ablative treatments, the role of isotretinoin in wound healing is unclear. Most likely, healing will proceed unimpeded, and no special precautions are necessary. Still, treatments during an actual course of isotretinoin should only be undertaken if the benefits outweigh the potential risks.

Patient selection and treatment The optimal approach to the treatment of the aging face depends on selecting the appropriate treatment for the patient’s pathology.

Facial rejuvenation Careful patient selection and a clear understanding of potential complications are important to achieving consistent results. The most common indications for both full-field and fractional laser resurfacing are superficial dyschromias, textural anomalies, superficial-to-deep rhytids, acne scars, and surgical scars. There are several approaches that can be used to achieve a rejuvenated facial appearance, and we review each technology in terms of indications, applications, pre- and post-procedure preparation, and complications.

91

These options are “full-field” ablative laser resurfacing, fractional non-ablative laser resurfacing, fractional ablative resurfacing, IPL, and, finally, combination therapies. It should be emphasized again that the term “full field” refers to the delivery of laser energy across the entire surface of the skin within the treatment area, covering the “full field,” rather than a smaller, “fractional” treatment zone.

Full-field ablative lasers Full-field ablative resurfacing is reserved for patients with the deepest rhytids and is especially well suited to the treatment of deep rhytids in the cheeks and perioral areas. The distinction must be made between wrinkles resulting from skin excess, and deeper furrows within the skin itself. Visible lines caused by relative skin excess (and skin laxity) can only be effectively treated by excising the additional skin, such as during rhytidectomy. In contrast, “etched-in” lines, which arise within the skin itself (most commonly around the mouth and eyes), and mild laxity can be effectively treated with deep full-field ablative laser resurfacing. Options for full-field laser ablation include erbium (Er:YAG) with a wavelength of 2940 nm, and carbon dioxide (CO2) with a wavelength of 10,600 nm. Our preference is to use Er:YAG for full-field ablative resurfacing, as it has an absorption coefficient 10 times greater than the CO2 laser and thereby ablates tissue more efficiently with less residual thermal damage (5–10 μm) (Fig. 8.4.2). There is a linear relationship between fluence (energy density), and the amount of tissue ablated, with 3–4 μm of tissue removed per J/cm2. Multiple passes of Er:YAG can be used to produce deeper tissue removal without additive residual thermal injury. This results in recovery times following deep full-field Er:YAG laser resurfacing of only 7–10 days to full epithelialization, followed by 3–6 weeks of erythema. Superficial and deep resurfacing can be performed with these devices with increasing results and increasing recovery times with deeper treatments. Complications such as hypopigmentation occur less often than with CO2 laser full-field resurfacing. Variable-pulse Er:YAG systems allow for shorter ablative pulses followed by longer subablative pulses to create increasing thermal damage, with a coagulative effect. These devices are typically used to emulate CO2 laser-like results but without the long healing times and tendency for complications such as hypopigmentation.

Fractional ablative lasers The same ablative laser technologies utilized for full-field resurfacing, CO2, and erbium are also available in fractional ablative systems produced by various manufacturers. The fractional application of ablative wavelengths results in fully vaporized channels through the skin, creating holes of various depths depending on fluence (the amount of energy applied per unit surface area). The various devices available differ in terms of system power, spot size, speed, and the amount of peripheral thermal damage created deep to and around the ablated hole. The advantage of all fractional ablative lasers, in comparison to full-field ablation, is shorter healing times and fewer complications. Fractional ablative lasers are capable of delivering

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more significant results than fractional non-ablative lasers, with particular efficacy in creating textural improvement, and mild-to-moderate skin tightening. In our practices, we use fractional ablative erbium primarily for treating postsurgical and acne scars. We find significant improvement in the appearance of scars after three to five treatments, spaced 4–6 weeks apart. Direct comparison between devices is difficult because of differences in power output, spot size, density, and degree of thermal damage; however, similar degrees of injury should produce similar clinical results (Figs. 8.4.6 & 8.4.7).

A

Fractional non-ablative lasers Fractional non-ablative lasers apply the same principle of treating a fraction of the total skin surface, only using non-ablative wavelengths. Instead of vaporizing tissues, these devices create columns of thermal damage, without eliminating the epidermal barrier. These thermal injuries can be thought of as similar to a coagulative effect, in which proteins are denatured but not completely vaporized. Healing of these wounds takes place from adjacent and deep structures and involves remodeling of the treated tissue

B

Figure 8.4.6  Treatment of perioral wrinkles with fractional CO2 laser: (A) before and (B) 6 months after a single treatment.

A

B

Figure 8.4.7 Fractional CO2 resurfacing done sequentially– SMAS facelift followed by fractional CO2 3 months later: (A) before and (B) 6 months after treatment.  

Patient selection and treatment

(rather than filling in a vaporized hole). For this reason, fractional non-ablative treatments have shorter recovery times than their ablative counterparts. By avoiding an open ablative wound, these treatments also have less risk of scarring and hypopigmentation. The indications for fractional non-ablative lasers depend to some extent on the wavelengths of each particular device; however, in general they are well suited for treating minor textural abnormalities, including fine lines and visible pores. There are several non-ablative fractional devices from various manufacturers with wavelengths of 1440 nm, 1470 nm, 1540 nm, and 1550 nm. As with fractional ablative devices, non-ablative fractional lasers differ in power output, spot size, density, and degree of thermal injury; this makes comparisons of clinical efficacy difficult between devices. The newest wavelength to be introduced into the fractional arena is thulium (1927 nm), with devices available by several manufacturers. This non-ablative fractional laser is especially effective at removing superficial pigment, due to its ability to target the dermal–epidermal junction where melanin is concentrated within pigmented lesions. Because the chromophore of thulium is water (and not pigment), there is less melanocyte excitation and therefore less risk of PIH. One final application of fractional laser technology is the hybrid fractional laser, with devices made by Sciton, Inc. (Palo Alto, CA) and Alma (Buffalo Grove, IL). The Alma device, called the Alma Hybrid, creates adjacent pulses of fractional ablative CO2 (10,600 nm) and fractional non-ablative 1570-nm injuries. The Sciton device, called Halo, delivers superficial fractional ablative erbium (2940 nm), followed by deeper fractional non-ablative pulses at 1470 nm, stacking both treatments within the same fractional treatment hole. This combination is quite effective at treating textural abnormalities, visible pores, and fine rhytids.31 It allows for a range of treatment depths and densities and can provide significant treatment effects with minimal healing times. This is the authors’ laser of choice for skin rejuvenation when recovery time is limited.

Intense pulsed light In contrast to the ablative and non-ablative laser technologies previously discussed, which generate a single wavelength of light, IPL devices utilize a high-intensity light

A

source to produce a range of noncoherent light wavelengths. Filters placed between the light source and the skin are configured to optimize heating of specific targets, by filtering out all wavelengths below a certain cutoff. Various devices utilize active cooling in their handpieces to prevent injury to the epidermis. Filters in the range of 515 nm are used to treat pigment with a target chromophore of melanin, and filters in the 560–590 nm are used to treat vascular lesions (such as telangiectasias and rosacea) with a target chromophore of hemoglobin. Given the wide range of wavelengths generated from an IPL device, there are many uses for IPL either alone (as a form of “photorejuvenation”) or in combination with other modalities. In our practices we frequently combine IPL with fractional laser treatments, to enhance clearance of pigment and redness. The newest IPL device on the market is the Sciton HERO (high-energy rapid output). This device combines a high repetition rate (up to 4 Hz) and low pulse width to allow for continuous handpiece movement. The technique of “in-motion” IPL avoids some of the common complications, such as “striping” and uneven energy delivery, providing for very effective treatments over large surface areas.

Combination treatments Although a discussion of non-laser technologies is outside the scope of this chapter, it is worth mentioning that lasers can be combined with non-light-based treatments to create a synergistic effect. Some examples of these treatments are high-intensity focused ultrasound (HIFU) and radiofrequency microneedling.

Improving vessels There are several lasers that can improve vascularity within the skin, either by targeting water or hemoglobin as chromophores. In our aesthetic practices, we employ several different modalities. The first option is hybrid fractional erbium, which if set to depths of 400 μm or more, can be used to obliterate superficial visible capillaries and reduce the appearance of redness. Care must be taken with these settings to avoid dyspigmentation in darker skin types (Fig. 8.4.8).

B

Figure 8.4.8 1550-nm fractional erbium:glass laser for perioral wrinkles: (A) before and (B) 6 months after six treatments.  

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CHAPTER 8.4  • Injectables and resurfacing techniques: Lasers in aesthetic surgery

The second device we use for treating vascularity is IPL. In contrast to hybrid fractional erbium, which targets the vessels by their depth relative to the skin surface, IPL works by targeting oxyhemoglobin within vessels through selective photothermolysis. This device works well for treating a background of red skin but may also be used to treat discrete smaller vessels (0.1–0.5 mm). For patients with fair skin types, we use the 560-nm filter, and in darker patients we use the 590-nm filter to decrease “bystander absorption” by melanin (which could result in dyspigmentation). Another option for treating vascular lesions is the flashlamp-pumped PDL. Working on the principle of selective photothermolysis, PDL creates selective damage to vessels by emitting wavelengths of 585 nm, 595 nm, or 600 nm, targeting oxyhemoglobin. The fluence and spot size of PDL can be varied, and lower fluences can be used to treat macular disorders in children and higher fluences are used to treat adult portwine stains, telangiectasias, and other vascular lesions. The disadvantage of PDL is post-treatment purpura, which lasts 1–2 weeks following treatment. As with IPL, PIH may occur in darker skin type patients, because melanin competes with hemoglobin for laser light absorption. For treating telangiectasias, cherry angiomas, larger vessels (0.1 mm and beyond), and in patients with darker skin types, we prefer the Nd:YAG laser (1064 nm). This wavelength is not as readily absorbed by hemoglobin as the previously discussed wavelengths; however, there is almost no melanin absorption at this wavelength. It is also capable of deeper penetration and therefore better absorption by deeper vessels. Care must be taken to apply the smallest fluence and smallest spot size to achieve vessel closure. Surface cooling is necessary to prevent epidermal blistering and it is important to ensure adequate coupling between the skin surface and any active cooling apparatus. The immediate endpoint in these treatments is either “vanishing” of the vessel, or “darkening,” which signifies coagulation. With this clinical response, vessels will disappear in 7–14 days, although repeat treatments may be necessary to eradicate any arborized tributaries that dilate in response. One final option is the Q-switched KTP laser, which uses a KTP crystal to double the frequency of a beam generated by an Nd:YAG laser, to produce a wavelength of 532 nm. This device is useful in the treatment of facial telangiectasias, with less purpura than Nd:YAG alone. It may also be used to treat leg veins with varying degrees of success. As with the other modalities, repeated treatments may be necessary.

Improving pigment Several devices are effective for treating cutaneous pigment, such as light or dark lentigines and early seborrheic keratoses. There is some overlap between the devices which are effective at treating pigment and those effective at treating vascularity, due to the shared mechanism of selective photothermolysis. The first device is hybrid fractional erbium. This device can be used to clear pigmented lesions by delivering fractional energy to the level of the skin that contains the lesion (the dermoepidermal junction or beyond). The denser the fractional energy delivered to a particular lesion, the greater the post-treatment clearance. The device is designed to calculate fluence (energy per surface area) through measurements

of aesthetic subunits, and it is possible to deliver increased treatment densities to specific lesions: either through multiple targeted passes during a treatment, or by performing a second pass over the areas of interest. As with vessels, IPL is also useful for treating pigment. Depending on the size of the lesions, it is often useful to “spot treat” lentigines with 1–3 IPL pulses, using a spot adapter. For fair skin types we use the 515-nm filter since there is little “bystander” cutaneous melanin chromophore. Darker skin types require increasing the filter, as well as potentially decreasing fluence and raising pulse width. For these patients, this may result in more sessions to achieve lesion clearance. For lentigines that are evolving into seborrheic keratoses, especially if they are exophytic, we use pulsed Er:YAG in small spot treatments. Repeated passes of this laser are performed under local anesthesia, and the resulting eschar is “wiped away” using a moistened gauze pad, until the lesion is gone. Occasionally pinpoint bleeding is observed, but this technique is associated with rapid healing. The newest device that we use for treating cutaneous pigment, including light lentigines and melasma, is fractional thulium (1927 nm). This device targets water as a chromophore, and due to its depth of penetration, it is capable of clearing pigment at (or slightly below) the dermoepidermal junction. This versatile laser can behave as a fractional non-ablative device, or by increasing its energy it can also approach the ablative threshold. Because it does not target melanin, the device has a low risk of causing PIH, even in patients with darker skin types. This is especially useful when treating patients in warm climates, where pigment often coincides with some degree of baseline sun damage and “sun tan.” With this device, we are able to demonstrate effective clearing of light and dark lentigines, as well as melasma, in 1–3 treatments spaced 1 month apart. Patients must be cautioned to avoid the sun, as repeated sun exposure will “bring back” the pigment they worked (and paid) to clear. We also recommend that our sun-exposed and darker skin type patients use medicalgrade skin care if they are prone to melasma, in order to maintain their results.

Contraindications Laser and chemical resurfacing have common contraindications. These include active bacterial, viral, fungal, or herpetic infection; open wounds; history of drugs with photosensitizing potential; pre-existing inflammatory dermatoses; uncooperative patients; patients with unrealistic expectations; and history of abnormal or keloid-type scarring.28

Post-procedure care Postoperative care after full-field laser resurfacing is aimed at providing an ideal environment for moist wound healing. Initially, bland ointment (white petrolatum, Aquaphor, or A&D ointment) is applied to the entire treated area. Patients are instructed to reapply the ointment throughout the day, any time the face feels tight or dry. As the outer layers begin to shed, the patient is allowed to shower and gently wash the face with non-residue soap using fingertips only. After

Disclosures

showering, the face should be patted dry, and a new coating of ointment applied. Patients are instructed not to pick at the face during the recovery period.28 Understanding the process of re-epithelialization and the importance of compliance with the prescribed post-treatment regimen is essential information for every patient. This includes awareness of likely facial edema that may contribute to symptoms such as diplopia. If antiviral therapy is instituted, continue therapy until re-epithelialization is complete. In the early stages of wound healing, re-examine the patient within 48 h and again every several days. Instruct patients to refrain from trans-retinoic acid, sunscreen, or make-up, until the face is healed to the satisfaction of the treating physician.28 After fractional lasers, mild moisturizing lotion is used for the first 3 days, then Cetaphil lotion for the duration of the healing process. Healing takes place over the first few days, with re-epithelialization nearly complete by 48 h post-treatment. Redness typically subsides over the next 3–4 days and gradually disappears over the next 3–4 weeks. Early results have been impressive.

Complications Pigmentary change Pigmentary change is not an uncommon complication, especially with deeper laser treatments. Taking proper precautions (as described earlier) can help prevent undesirable pigmentary changes. Usually, patients with lighter complexions have a lower risk of hyperpigmentation than darker-skinned individuals.

Scarring Scarring remains the most feared complication of facial resurfacing. The contributing factors are still not well understood but typically, outside of infection, the depth of the procedure is the primary risk factor in conventional resurfacing. In the case of fractional lasers, the depths and density of the micro injuries should be conservative enough to avoid bulk heating of the skin. By employing the most appropriate resurfacing procedure for any given patient, the risk of scarring can be decreased. In addition, to further decrease the risk of scarring, the patient should be advised to refrain from touching or picking at the healing skin. Patients with a history of keloids should be approached with caution prior to medium or deep treatments because of their risk of scarring. Weaker superficial treatments that only exfoliate the stratum corneum or superficial epidermis can be used for these high-risk patients.28

Access the reference list online at   Elsevier eBooks+

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Infection Cold sores can be prevented with valganciclovir (1 g PO bid), beginning 1 day prior to treatment, and continuing for 7 days afterwards. Candidiasis can also develop, for which a short course of fluconazole may be used. Cultures may be taken if the diagnosis in in question, and appropriate antibiotics should be administered.28 More recently, atypical mycobacterial infections have been reported after ablative fractional procedures.32 The penetrating nature of fractional approaches may allow these opportunists to thrive. Measures to decrease the risk include thorough cleansing before treatment and avoidance of tap water at the wound site during and immediately after treatment. Physicians should note that the greatest association with infection is pain. If the skin is healing poorly and the patient reports marked pain, an infection is likely. The absence of pain does not remove the possibility of infection but markedly reduces its likelihood.

Prolonged erythema Patients usually do not complain about erythema because it typically subsides within a few weeks, but sometimes erythema can persist for longer than 30–90 days. Prolonged erythema is usually not permanent, and topical hydrocortisone can be used to speed its resolution.28

Acne Some patients develop acne after a facial resurfacing procedure. This usually occurs between days 3 and 9. If it is a true acne occurrence in a patient with a history of acne, then the appropriate oral or topical antibiotic may be started. If severe enough, isotretinoin may be initiated.

Milia Small inclusion cysts, sometimes called milia, can appear in the healing process after a treatment. These usually appear about 2–3 weeks after re-epithelialization and may be aggravated by ointments, owing to occlusion of the sebaceous glands.28

Disclosures Dr. Pozner and Dr. DiBernardo receive discounts from Cynosure, and Dr. DiBernardo is a paid researcher. Dr. Pozner is a paid consultant, speaker, researcher, stockholder, and board member for Scition. Dr. Cook and Dr. Turer do not have a financial interest in any of the products, devices, or drugs mentioned in this manuscript. No funding was received for this chapter.

References

References 1. Alexander JT, Goldman MP, Roberts TL. Facial resurfacing. 2nd edn. In: Mathes J, editor. Plastic Surgery. Vol. 2 Philadelphia: WB Saunders; 2006:339–384. 2. Smith L. Histopathologic characteristics and ultrastructure of aging skin. Cutis. 1989;43:414. 3. Brody HJ. Chemical Peeling and Resurfacing. 2nd edn. St. Louis: Mosby-Yearbooks; 1997:29–38. 4. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983;220:524–527. 5. Ross EV, Swann M, Soon S, et al. Full-face treatments with the 2790-nm erbium:YSGG laser system. J Drugs Dermatol. 2009;8:248–252. 6. Goldman L, Wilson RG, Hornby P, et al. Radiation from a Q-switched ruby laser. Effect of repeated impacts of power output of 10 megawatts on a tattoo of man. J Invest Dermatol. 1965;44:69–71. 7. Goldman L, Rockwell RJ. Laser action at the cellular level. JAMA. 1966;198:641–644. 8. Goldman L, Rockwell Jr RJ. Laser systems and their applications in medicine and biology. Adv Biomed Eng Med Phys. 1968;1:317–382. 9. Schenk P, Ehrenberger K. Effect of CO2 laser on skin lymphatics. An ultrastructural study. Langenbecks Arch Chir. 1980;350:145–150. 10. Baker SS, Muenzler WS, Small RG, et al. Carbon dioxide laser blepharoplasty. Ophthalmology. 1984;91:238–244. 11. Fitzpatrick RE, Goldman MP, Satur NM, et al. Pulsed carbon dioxide laser resurfacing of photo-aged facial skin. Arch Dermatol. 1996;132:395–402. This is a blinded assessment of CO2 laser efficacy

for periorbital and perioral rhytids. CO2 laser was found to be useful in this setting.

12. Manstein D, Herron GS, Sink RK, et al. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med. 2004;34:426–438. A novel method for skin resurfacing is presented.

Microscopic treatment zones are targeted for thermal injury.

13. Geronemus RG. Fractional photothermolysis: current and future applications. Lasers Surg Med. 2006;38:169–176. 14. Mezzana P, Valeriani M. Rejuvenation of the aging face using fractional photothermolysis and intense pulsed light: a new technique. Acta Chir Plast. 2007;49:47–50. 15. Gillitzer R, Goebeler M. Chemokines in cutaneous wound healing. J Leukoc Biol. 2001;69:513–521. 16. Glat PM, Longaker MT. Wound healing. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb and Smith's Plastic Surgery. Philadelphia: Lippincott-Raven; 1997.

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17. Anderson RR. Dermatologic history of the ruby laser: the long story of short pulses. Arch Dermatol. 2003;139:70–74. 18. Welch AJ, van Gemert MJ. Overview of optical and thermal interaction and nomenclature. In: Welch AJ, van Gemert MJ, eds. Optical Thermal Response of Laser-Irradiated Tissue. New York: Plenum; 1995:1–14. 19. Anderson R, Ross E. Laser–tissue interactions. In: Fitzpatrick R, Goldman M, eds. Cosmetic Laser Surgery. St Louis: Mosby; 2000:1–30. 20. Anderson R. Laser–tissue interactions. In: Goldman M, Fitzparick R, eds. Cutaneous Laser Surgery – The Art and Science of Selective Photothermolysis. St Louis: Mosby; 1994:3–5. 21. Ross EV, Sajben FP, Hsia J, et al. Nonablative skin remodeling: selective dermal heating with a mid-infrared laser and contact cooling combination. Lasers Surg Med. 2000;26:186–195. 22. Ross E, Anderson R. Laser tissue interactions. In: Goldman M, ed. Cutaneous and Cosmetic Laser Surgery. Philadelphia: Elsevier; 2006. 23. DiBernardo BE, Reyes J, Chen B. Evaluation of tissue thermal effects from 1064/1320-nm laser-assisted lipolysis and its clinical implications. J Cosmet Laser Ther. 2009;11(2):62–69. https://doi. org/10.1080/14764170902792181. 24. Kelly KM, Nelson JS, Lask GP, et al. Cryogen spray cooling in combination with nonablative laser treatment of facial rhytides. Arch Dermatol. 1999;135:691–694. 25. Lask G, Lee PK, Seyfzadeh M, et al. Nonablative laser treatment of facial rhytides. In: Anderson RR, ed. Lasers in Surgery: Advanced Characterization, Therapeutics, and Systems VII. Vol. 2970. San Jose: Society of Photo-Instrumentation Engineers; 1997:338–349. 26. Sadick NS. Update on non-ablative light therapy for rejuvenation: a review. Lasers Surg Med. 2003;32:120–128. A review of non-ablative skin resurfacing modalities is presented. 27. Cohen SR, Henssler C, Johnston J. Fractional photothermolysis for skin rejuvenation. Plast Reconstr Surg. 2009;124:281–290. 28. Fabbrocini G. Chemical peels. 2015. Online. Available: http:// emedicine.medscape.com/article/1829120-overview. 29. Fitzpatrick RE, Goldman MP, Satur NM, et al. Pulsed carbon dioxide laser resurfacing of photo-aged facial skin. Arch Dermatol. 1996;132:395–402. 30. Glogau RG, Matarasso SL. Chemical peels. Trichloroacetic acid and phenol. Dermatol Clin. 1995;13:263–276. 31. Cohen JL, Ross EV. Combined fractional ablative and nonablative laser resurfacing treatment: a split-face comparative study. J Drugs Dermatol. 2013;12(2):175–178. 32. Palm MD, Butterwick KJ, Goldman MP. Mycobacterium chelonae infection after fractionated carbon dioxide facial resurfacing (presenting as an atypical acneiform eruption). Case report and literature review. Dermatol Surg. 2010;36:1473–1481.

 

SECTION II •  Aesthetic Surgery of the Face

8.5

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

 

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

The process of facial aging can be broken down into three major categories: (1) structural or gravitational changes; (2) correction of deflation or loss of volume; and (3) treatment of wrinkles, texture, and skin quality. The first two categories are very familiar to practitioners and the bulk of clinical and academic activities involve these areas. The treatment of well-established wrinkles and aging textural changes has received much less attention, and since surgeons seem less well equipped to deal with them, it is simply ignored. This is regrettable because even the best performed facelift with “old” skin will still look old. Moreover, we surgeons know that surgery has no effect on perioral rhytids and a facelift can make them more noticeable because of the contrast that is created. Also, aging changes of the skin itself can have greater importance to patients than jowls or loose skin. Why the reluctance to resurfacing? It is our contention that this is mainly due to lack of exposure and especially misconceptions about deep chemical peeling and misinformation that is still seen in professional publications. Our purpose in this chapter is to consider medium-depth trichloroacetic acid (TCA) peels and the deeper, more versatile, croton oil peels. Both authors are experienced deep peelers and PPR, a dermatologist, will share his knowledge with TCA peels. Of note, both authors are in agreement that croton oil peels offer the best solution for deeper, more established wrinkles. Regarding deep chemical peels, the topic will be distilled to its essence and give detailed practical instruction so that practitioners may consider this terrific technique and then be able to provide their patients with a more complete result. The role of facelifting is considered and, especially, the synergy of lipofilling and peeling is discussed as a particularly favorable combination.

Medium-depth trichloroacetic acid (TCA) peels TCA peels are the most commonly used medium-depth chemical peels, and are the most common for dermatology residents

to be trained in. Their popularity over the more effective croton oil is due to three factors. First, it has not been linked to cardiac toxicity and thus does not require cardiac monitoring. Second, it does not require mixing and can be bought in different strengths. Third, it is moderately effective for mild to moderate photoaging, acne scars, skin pre-cancers (actinic keratoses), and other skin conditions. Achieving a medium-depth injury must meet both clinical and histologic criteria, as described below. Some TCA peels are used to treat superficial skin conditions, usually applied as a single agent and in low concentration (%). For example, 10–15% TCA (one coat) is used to treat melasma and acne vulgaris. Many commercial peels with TCA (usually in combination with lactic acid, salicylic acid or even phenol), produced a superficial, or at most, a superficial to medium injury. We will not cover these peels here but focus instead on a true medium-depth TCA peel, where the injury reaches the upper reticular dermis (URD). Medium-depth TCA peels include the augmented 35% TCA peels, where Jessner’s solution (Dr. Gary Monheit1) or carbon dioxide “dry ice” (Dr. Harold Brody2) are used to increase the penetration and depth of TCA. Jessner’s solution (JS) contains 14% salicylic, 14% lactic acid, and 14% resorcinol. Two very similar peels, Obagi’s “Blue Peel” and Z.O.’s “Controlled Depth Peel” (CDP), were both developed by Dr. Zein Obagi.3 In these, a blue/green dye is used to help the peeler find the right depth of injury by using multiple applications of either 20% or 26% TCA, until a desired depth is found. These also contain a propriety emulsifying/surfactant agent to help penetration. Most dermatologists buy TCA from Delasco (Delasco.com, Plano, TX), which uses the weight/volume method to formulate their TCA peels. Brody2 compared the depth of injury from JS or carbon dioxide/dry ice plus 35% TCA (CO2/TCA 35%), using one to three coats, at different times post peels. Three days post peel with JS or CO2 followed by three applications of TCA, the epidermis has full-thickness necrosis, ghost cells with re-epithelization, and mixed dermal infiltrate of neutrophils and lymphocytes. The papillary dermal collagen fibers have been disrupted, and there is edema with increased ground substance extending to

Medium-depth trichloroacetic acid (TCA) peels

the upper reticular dermis. Thirty days post peel with a single application of TCA, there is a hyperplastic epidermis, mean of about 7 cells thick. A thickened papillary dermis is present, and there are increased collagen fibers in the upper reticular dermis. Thirty days post peel by triple application of TCA, there is a very hyperplastic epidermis (about 10 cells thick). A thickened papillary dermis, and many new collagen fibrils and increased ground substance are present in the upper reticular dermis. When compared to the histology of croton oil peels, the biggest difference is the latter’s significant thicker band of neocollagenesis. Recent studies by Dr. Carlos Wambier et al.4 showed the NETosis, or a strong neutrophilic response to phorbol esters, was responsible for this neocollagenesis, rather than simply depth of injury (mid-reticular dermis). The clinical endpoint of these peels varies. With the JS/TCA 35%, the endpoint is an even white frost with some erythema (2+ frost), and without erythema, in the background (3+ frost) (Figs. 8.5.1–8.5.3). With CO2/TCA 35% the endpoint is also an even frost, but it will be accompanied by more edema and erythema afterwards, revealing a deeper injury (Figs. 8.5.4–8.5.6). With the Obagi peels, the endpoint is an even blue edematous color and texture to the skin. The edema is such that when pinching the skin, there is no wrinkling or epidermal sliding. In all of these peels, the skin becomes edematous and red for the first 2 days. The skin dries out, with reddish tones, which then become dark brown. These sheets begin to exfoliate regionally, beginning around day 5 and around the mouth. Healing takes around 7–10 days, revealing a pink re-epithelialized fresh epidermis. Note improvement with CO2/TCA 35%, 30 days later (Fig. 8.5.7).

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author 8likes to administer 1 mg of alprazolam and 10 mg of zolpidem pre peel as oral sedatives.

Jessner’s solution/TCA 35% Degrease the skin after washing it with a foaming cleanser, using isopropyl alcohol and acetone (pre-mixed or separately). Jessner’s is applied multiple times until a light frost is achieved, ensuring that the stratum corneal layer has been weakened. Using a non-woven 2 × 2 gauze, begin applying 35% TCA (in a metal cup), starting along the perimeter of the face like the mandibular skin and hairlines. This lets you assess the permeability and responsiveness of the skin. Then continue onto the midface, beginning in the periorbital skin and then the upper lip. Step back and let the frost develop (helps refrain from overapplying TCA). Observe. Repeat the TCA where the frost has not become confluent. Step back and observe. When satisfied,

Pre-peel skin preparation Use retinoid creams to increase cell turnover (which reduces the risk of post-inflammatory hyperpigmentation [PIH] and leads to faster healing), and to thin the stratum corneum (which enhances peel evenness and penetration). Prescribe antivirals (valacyclovir) for 10 days starting the day before peel; and instruct the home aide on the use of cold-water compresses and possible analgesics. Hydroquinone is useful in patients with risk of PIH. Stop the retinoids 4–7 days before the peel. Another tip is to remove crusts such as actinic keratoses or seborrheic keratoses before starting the peel. The

Figure 8.5.1 2+ frost from J+35% TCA, one coat. (Courtesy of Dr. Jennifer Rullan.)  

Figure 8.5.2  3+ frost from J+35% TCA, multiple coats. (Courtesy of Dr. Jennifer Rullan.)

Figure 8.5.3 2+ frost from J+35% TCA, two coats.  

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CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

apply a very cold washcloth immersed in ice-water. Zimmer Cooler or personal electric fans help. Rarely are more than three layers of TCA needed. Beginner peelers can opt to achieve a less-dense white frost as their endpoint.

Dry ice/TCA 35%

Figure 8.5.4  Dry ice being rubbed prior to applying 35% TCA. (Courtesy of Dr. Jennifer Rullan.)

Figure 8.5.5  Dry ice + 35% TCA; note the edema, day 2. Treated actinic keratoses.

Figure 8.5.7 Thirty days after dry ice and 35% TCA. (Courtesy of Dr. Jennifer Rullan.)  

On the day of the peel, purchase an inexpensive block of dry ice (readily available in supermarkets, adjacent to the ice bags). With a small hammer, cut off a handful-size piece of ice and wrap it with a towel. Prepare a bowl with a 1 : 3 ratio of isopropyl alcohol and acetone (used to dip the dry ice right before every time it is rubbed onto the face). After thoroughly degreasing the skin, begin rubbing the dry ice in a quick rotating movement to cosmetic unit (about 10 strokes) followed by the TCA, using 2–3 strokes to achieve a frosting. Rub the dry ice lighter over bone and harder over acne scars. Use same pain control measures as for Jessner’s/ TCA above.

Figure 8.5.6  Day 3 after dry ice + 35% TCA.

Preoperative planning

Obagi Blue Peel/Z.O. CDP These peels must be purchased as kits. You will also need 30% TCA. Pump the Blue Dye 4 times into a cup, followed by either 4 mL or 30% TCA (generates a 20% peel), or 8 mL of 30% (to generate a 26% peel). Once you stir this mixture, begin the peel using the same technique as the Jessner’s/TCA technique. Achieving the “total blue face” endpoint takes longer than with Jessner’s. Beginner peelers can opt to achieve a lessdense blue frost as their endpoint. Patients find it amusing to see their face turn blue. Use the same pain control measures as for Jessner’s/TCA above. Ice-cold water compresses and over-the-counter (OTC) analgesics, like acetaminophen and ibuprofen, are usually adequate to control post-peel burning, which can last 4–8 hours. These are the most important skin care items needed initially. Once burning subsides, topical agents like Alastin Serum Nectar (Alastin Skincare, Inc., Carlsbad, CA) and Aquaphor (Beiersdorf, Inc., Stamford, CT) are the author’s (PPR) favorite agents. Aquaphor is used once the peeling begins. Alastin is used initially and after the peeling occurs, to help reduce the redness faster. Patients can resume the use of retinoids, hydroquinone, and other agents once the skin is not sensitive (around 2–3 weeks after the peel). Sunscreens with zinc oxide and iron oxide can be used as tolerated, usually 2 weeks post peel. Patients should avoid sweating and possible sunbathing for 3–4 weeks.

Deep chemical peels The history of deep chemical peels is a fascinating one, mainly involving lay peelers using “secret” formulas and shrouded in mystery.5 The first instance of a practical formula came from Thomas Baker, a plastic surgeon from Miami in 1961. This formula, presumably obtained from a lay peeler, was simple and could be easily reproduced. It included four ingredients: liquid phenol, three drops of croton oil, water, and a surgical soap Septisol to act as a surfactant to allow miscibility of the aqueous and oily components.6 The presumption was that the phenol was the peeling agent and it was unclear what the croton oil did. In 1962, Dr. Baker halved the volume of the formula, presumably for convenience, while keeping the three drops of the croton oil unchanged. This change appeared inconsequential, but it elevated the concentration of the croton oil to 2.1% and affected the course of chemical peeling. This formula was published nationally and became the standard for decades.7 This peel worked very well in improving severe wrinkles, but it also caused significant and predictable hypopigmentation. The results were certainly there, but patients developed an unnatural porcelain look that necessitated the permanent use of make-up. Due to this, the Baker peel, as it became known, was reserved for older, light-eyed individuals. It was believed that phenol had an “all-or-none” phenomenon that was out of the surgeon’s control. Phenol also had the reputation of being cardiotoxic, requiring careful timing and strict cardiac monitoring. For these reasons, “phenol peels” carry a negative reputation that persists to this day and has limited their acceptance despite more recent improvements. The crucial step in the development of modern chemical peels came about from the work of Gregory Hetter.8 Hetter,

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a plastic surgeon in Las Vegas, frustrated by his options of resurfacing, took a scientific approach in the hope of better understanding the Baker formula. Hetter experimented by performing a number of peels with different combinations of the ingredients and discovered that phenol alone has little effect. Adding croton oil to the phenol at different concentrations resulted in deeper peels proportional to the concentrations of the croton oil. An analysis of the classic Baker formula showed for the first time that the croton oil concentration was very high at 2.1% – responsible for the results as well as the hypopigmentation. Recognizing that croton oil, not phenol, was the peeling agent, Hetter could now alter the concentration so as to give the clinical result without negatively altering the quality of the skin. An important observation was that the “all-or-none” phenomenon ascribed to phenol was simply that the croton oil concentration was so high that it immediately peeled to the point of hypopigmentation. This may seem a small difference but it is actually a fundamental change that ushered in the modern era of chemical peeling. Being able to choose the croton oil concentration allowed the procedure to be performed superficially or deep and made it applicable to all ages and skin types. An important improvement was that different croton oil concentrations could be used in different areas of the face depending on skin thickness and clinical need. A critical change was that with weaker croton oil concentrations, the application technique became an important factor in determining the depth reached. The entire process is slowed down so that the surgeon can observe the skin changes and stop at the depth deemed appropriate. In this manner, the surgeon is in precise control and the process becomes orderly and predictable.9

Patient evaluation When considering facial rejuvenation, it is important to carefully discuss the patient’s wishes. If correction of jowling and neck deformities are the primary goal, then surgery is indicated. Most patients seeking a facelift have a degree of volume depletion; therefore lipofilling is a consideration. If a patient has pronounced wrinkles, especially around the mouth and eyes, then a facelift would provide incomplete correction, and indeed, a facelift can make their wrinkles look worse by contrast. Keep in mind that a well-performed peel, especially when coupled with lipofilling, may provide greater aesthetic impact than a facelift. If a patient is interested in comprehensive rejuvenation, then all three components can be addressed, usually beginning with a facelift and after about 4 months, proceeding with a peel and lipofilling. The combination of facelift and peeling is not advocated. There are practitioners that peel around the mouth at the time of a facelift. This is certainly feasible, but it may create an imbalance with the rest of the face, and of course, there is always value in treating the entire face.

Preoperative planning On a basic level, a chemical peel is a controlled chemical burn done in the expectation of creating an anatomic change in the dermis via an increased deposition of collagen and elastin. The more advanced the wrinkling and solar damage, the

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deeper the peel must go, while avoiding hypopigmentation and scarring. As this is a true injury, it is followed by a somewhat peculiar recovery for which the patient must be prepared. It is important to note that any technique, be it peeling or laser, that intends to give a real result has a real recovery period. Any modality that touts an easy recovery will also have little result. The immediate post-peel phase is not long and typically not uncomfortable, but it is unusual; therefore the surgeon must be completely honest with the patient. Detailed photographs of the day-by-day recovery are shown to the patient and possibly to a spouse or caregiver. Meeting with a patient who has had a similar peel is valuable, and today with social media there are many examples available to view. The surgeon must set an upbeat and optimistic, although realistic, tone. Patients do well if they are well informed and bring a good attitude. The reward is a dramatic and remarkably stable improvement in skin texture which is not possible with any other modality. The skin is prepared prior to the peel to prevent pigmentary changes such as hyperpigmentation and to have the skin in optimal condition. The main medications are tretinoin and hydroquinone 4%. The effect is to stabilize the epidermis, stimulate the dermis, to increase collagen content and vascularity, and to suppress melanocytes. The preparation begins 4–6 weeks before peeling with tretinoin 0.05% or 0.1% at night and hydroquinone 4% two times daily. The preparation is stopped about 4 days prior to the procedure to allow the epidermis to normalize. Remember to take clinical photographs prior to the preparation to avoid a possible flaky, irritated appearance. There are differences of opinion whether this skin preparation is necessary, but the author’s experience (RHB) has been that there is more erythema if skipped. In darker-skinned individuals, the preparation is all the more important. In fairskinned, light-eyed individuals, the bleaching aspect (hydroquinone) can be omitted.

Preparation of the solution The preparation of the acid solution is a critical step that should be performed by the operating surgeon. The ingredients are the same as in the classic Baker peel: namely, water, phenol, croton oil, and Septisol (but see below). Phenol is a solid crystalline substance that is soluble in water. Standard solutions found in pharmacies and dermatologic suppliers are 88% or 89% phenol. Phenol has a corrosive effect on skin by denaturing the protein and allowing it to pass into the dermis. Croton oil is a natural oil extracted from the seeds of Croton tiglium, a small tree native to India and Southeast Asia. Croton oil is very caustic and will result in a full-thickness ulcer if applied full strength on the skin. When properly diluted and applied, however, croton oil can bring about dramatic results. Septisol is a surgical soap consisting of liquid hexachlorophene, which serves as a surfactant to allow adequate mixing of the aqueous and oil components. Recently, there has been a problem with Septisol in that it has been banned in the US by the FDA due to issues with triclosan, a preservative. This has nothing to do with its use in peeling, but the end result is that it is no longer available. Thankfully, Young Pharmaceuticals

(youngpharm.com, Wetherfield, CT) has formulated an excellent substitute called Novisol. This is also a surfactant, but its action is different and it results in a stable solution that lasts 45 minutes. A problem with Septisol was that the solution separated immediately, possibly resulting in variable concentrations across the applying sponge. Novisol is used in the same volume as Septisol. Due to the stability of the solution, it may appear that the action using Novisol may be a little weaker. The only repercussion of this is that the highest concentration used may be 1.2% rather than 0.8% on deeper wrinkles such as around the mouth (see below). The water used is regular tap water. Preparation of the solution requires careful attention and a systematic approach. The ingredients are arranged is glass bowls in the order they will be added. Various-sized syringes are available, along with a glass or metal funnel and sterile gloves for protection. Once readied, the acids can be stored in opaque glass containers and sealed with phenolic cone – lined, leak-proof caps. (SKS-bottle.com, bottlesandmore.com) These solutions are stable for an extended period of time. Original formulas involved using drops of croton oil. The problem with this is that the volume of a drop is not uniform, leading to variability, and a drop cannot be subdivided, limiting the options. A very practical solution provided by Hetter was to prepare a standard phenol/croton oil solution using larger volumes that would be then further diluted with the other ingredients. The standard or “stock solution” is made by mixing 24 mL of 88% or 89% phenol with 1 mL of croton oil. By using larger volumes of the ingredients, they are easily measured with accuracy using standard syringes and a multitude of concentrations are possible.10 Standard tables are available showing the specific volumes of each ingredient to arrive at the final croton oil concentration. The final phenol concentration in these formulas is 35% (Table 8.5.1). An examination of the standard formulas shows that the volumes of water and Novisol remain constant at 5.5 mL and 0.5 mL respectively. The values that change are the relative volumes of phenol and stock solution (which contains phenol and croton oil). The sum of the volumes of the 88% phenol and stock solution is 4 mL in each of the formulas. Table 8.5.1  Croton oil formula with 35% phenol concentration

Croton oil 0.2%

0.4%

0.8%

1.2%

Water

5.5 mL

5.5 mL

5.5 mL

5.5 mL

Novisol

0.5 mL

0.5 mL

0.5 mL

0.5 mL

USP phenol 88%

3.5 mL

3.0 mL

2.0 mL

1.0 mL

Stock solution containing phenol

0.5 mL

1.0 mL

2.0 mL

3.0 mL

10 mL

10 mL

10 mL

10 mL

And croton oil (see below) Total

0.1% = 1 mL of 0.4% × 1.2 mL phenol + 1.8 mL water 0.05% = 1 mL of 0.2% + 1.2 phenol + 1.8 mL water Stock solution = 24 mL phenol + 1 mL croton oil (0.4 mL croton oil/1 mL stock solution or 4% croton oil) {1/4}X%: 1 mL X% croton oil solution + 1.2 mL phenol + 1.8 mL water

Intraoperative routine

Analyzing Table 8.5.1 further explains how the variable concentrations are arrived at. The stock solution consists of 24 mL of phenol and 1 mL of croton oil. Each mL of stock solution has 0.04 mL of croton oil, making this a 4% croton oil solution. If we examine the formula for 0.8% croton oil, it is made up of 5.5 mL of water, 0.5 mL of Novisol, 2.0 mL of phenol, and 2.0 mL of stock solution. The 2.0 mL of stock solution has 0.08 mL of croton oil (2 × 0.04 mL). Because the total volume of the solution is 10 mL, the final concentration of croton oil is 0.08 mL in 10 mL total volume, or 0.8%. By knowing the content of croton oil in the stock solution and the volume of stock solution in any of the formulas, the final concentration of croton oil can be easily determined. It is very important to remember that the croton oil concentration of stock solution is very high at 4% and should never be applied directly on the skin without further dilution. For a reference, the Baker formula had a croton oil concentration of 2.1%. To make weaker concentrations, one first mixes 0.4% or 0.2% solutions and these are further diluted using the formulas in Table 8.5.1. The final volume is 4 mL, and the final phenol concentration remains at 35%. This formula is very useful because whatever starting concentration is used will be diluted by one-fourth, i.e., 1 mL of X% croton oil solution + 1.2 mL phenol + 1.8 mL water will yield {1/4} X% solution. Since Hetter’s publications in 2000, 35% phenol concentration has become standard, but useful variations are possible. For example, there are darker-skinned individuals who may have less wrinkling and more pigmentary issues. In this instance, a low croton oil concentration formula is chosen and then the relative volume of water and phenol are changed to elevate the phenol concentration to 50% or 60%. For example, to change the phenol concentration to 60% in the 0.1% croton oil, 4 mL formula, the total volume of phenol needed (X) is determined by X/4 mL = 0.6; then X=2.4 mL. The 1 mL of 0.4% croton oil solution brings 0.35 mL phenol (35% phenol solution), this leaves 2.05 mL of phenol lacking. 0.88X = 2.05 mL represents the volume of 88% phenol needed, or 2.33 mL. In the formula, the volume of phenol and the volume of water add up to 3 mL; substituting 2.33 mL of phenol and 0.67 mL of water in the formula results in a 60% phenol solution. Understanding and manipulating the formulas results in enormous variability. More recently, the dermatological supply company Delasco (Delasco.com, Plano, TX) is preparing and selling ready-made croton oil solutions based on a historically older formula which utilizes glycerin as a surfactant. This formula contains phenol and croton oil and is available on a custom basis in any concentration desired. The phenol concentration in these formulas is 50%, typical of solutions prior to Hetter’s. The author (RHB) has used these solutions in the last 6 months in concentrations of 0.8% and 0.4%. From these, I have diluted multiple solutions resulting in all the standard concentrations commonly used, albeit with a 50% phenol concentration. The dilution formula is as follows: 1 mL X% + 1.7 mL phenol + 1.3 mL water = {1/4}X% These formulas work well and are reminiscent of the original Hetter formulas. With the higher phenol concentration, weaker croton oil concentrations are useful on darker skin with more pigmentary issues. The higher phenol concentration

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has not caused any issues nor limited the absorption of the solution. These new formulas give the practitioners another option in their peeling armamentarium.

Intraoperative routine Traditionally, deep chemical peels have been performed under general anesthesia or intravenous sedation due to the intense discomfort of the chemical burn. Following induction, standard sensory blocks are performed with bupivacaine with epinephrine and ketorolac tromethamine 30–60 mg is administered as an adjunct to anesthesia. This is a viable approach which I have used for years and is certainly acceptable. There have been recent developments that have led to an alternative technique. Experience treating pigmented spots on my hand with 50% or 60% phenol demonstrated to me that there is an initial period of stinging lasting 10–15 seconds after which the skin is very anesthetic, even when slowly twirling a needle to the point of bleeding. This is explained by phenol causing a neurolytic effect that reversibly prevents the transmission of nerve impulses. This phenol effect is potentially useful; I began peeling by first applying a pass of 50% or 60% phenol. This was initially stimulating, but it quickly subsided, and the peel could proceed. This technique may do away with the need for sensory blocks, but further experience is needed. My experience has been that this use of phenol leads to a relatively pain-free emergence and a comfortable post-peel course.11 The anesthetic use of phenol is very useful in awake segmental peels. To make 50% phenol, one simply dilutes 10 mL of 88% phenol with 7.5 mL water. Ophthalmic ointment and corneal protection are not used because phenol can dissolve in the ointment or become trapped under a protector, preventing complete flushing out if it becomes necessary. Constant vigilance around the eyes is essential. The fear of cardiac toxicity due to phenol requires careful consideration. Reports of arrhythmias and death have been sporadic and anecdotal. It had been the belief that peels performed under general anesthesia but without blocks led to intense stimulation due to the high concentration of croton oil and this led to the cardiac irritability. The general belief was that with proper local blocks and performing a full-face peel in no less than 45 minutes, there was little danger. A recent experience during a live surgery course was very elucidating. An overzealous novice applied peeling solution over a large portion of the face much too quickly and a multitude of worrisome arrhythmias were seen. The decision was to back off, actively hydrate and do nothing. In 10 minutes, the electrocardiogram (ECG) reverted to normal and remained so. This important episode has led me to conclude that (1) phenol is absorbed and can lead to significant arrhythmias and (2) this is an orderly and predictable process that is related to speed of application. If the peel is not hurried and a fullface peel takes 45 minutes to 1 hour, there is no fear of cardiac irritability. A screening ECG is performed in patients over 65 years old or if there is a history of arrhythmias. The first step is to degrease the skin to allow even absorption of the solutions. Ask the patient not to apply anything on the skin on the morning of the peel. Be specific – mention not

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to apply a moisturizer, as they may not think of it. Acetone is the best agent for degreasing. If regulations in the operating room do not allow acetone, it can be applied in the preoperative area and then degrease again in the operating room with alcohol. The process of peeling is a little stilted, especially for the novice, in the interest of safety. The environment must be quiet and organized, not hectic and hurried. This is especially true around the eyes. Corneal protection and ophthalmic ointments are not used, and extreme care is the sole protection. The head of the bed is elevated to prevent the solution from rolling into the eyes. The applying instrument, be it sponge or cotton-tipped applicator, should never be so wet that it can drip. Never crossing over the eyes with the applying hand is extremely important and should become second nature, not unlike sterile technique. The surgeon’s hand must be dry so as not to apply acid where it is not wanted. The best way to insure this is to clip a surgical towel to the surgeon’s scrub shirt shoulder and draped over the front, always at the ready for wiping the hands. The bottle containing the solution is shaken to evenly mix the ingredients. Both of the formulas discussed will stay well mixed with one shake, but I retain the older habit of shaking the bottle each time I pour out some solution. A small volume of the desired solution is poured into a small glass bowl, and a second bowl is placed over it to prevent escape of the vapors. A small fan held by an assistant helps dissipate these vapors, and the now ubiquitous N-95 masks are useful. A calm, measured demeanor by the surgeon completes the picture. The most common applying material is a 2-inch by 2-inch gauze, preferably synthetic fiber, which is less abrasive. Cotton-tipped applicators are useful for the eyelids and to target individual wrinkles. The splintered wooden end of the applicator or toothpicks are also useful. The gauze is folded twice to decrease the size and have more precision. It is now dipped in the solution and wrung out so that it is moist and not so wet that it could drip. The gauze is set down in a safe place, and the hands are dried with the clipped towel in order to prevent inadvertent application of the acid where it is not wanted. This is particularly important in segmental peels where the error would be obvious. The applying hand should never cross over the eyes. Once the gauze is applied to the skin, the effect is seen in 10–15 seconds depending on how wet the gauze is and the concentration of the croton oil solution. The action of the acid is to coagulate and precipitate the protein of the skin forming a “frost”, which is varying degrees of a white appearance. As more passes are made, the depth of the skin reached is assessed by the degree and quality of the white appearance. With increased depth, the frost becomes progressively more dense, solid, and opaque. On a cellular level, this represents the coagulating action of the acid passing through the epidermis to the papillary dermis (juncture between epidermis and dermis). As the peel passes from the papillary dermis to the upper and mid-reticular dermis, the frosting becomes a dull, flat white. Unlike TCA peels, the action is quick and there is no need to wait a few minutes to see the final effect. Unlike some other peels, this change is irreversible. The only control available to the surgeon is that if the application is too wet, quickly blotting it will diminish the action.

Factors determining the depth of the peel Older peels with a croton oil concentration of 2.1% were problematic because they immediately peeled to a depth resulting in hypopigmentation – there was no control. A key concept of modern peels is that with lower croton oil concentrations, the entire process is slowed down and there is ample opportunity to gauge the depth of peel. In this manner, the application technique, which is wholly under the control of the surgeon, becomes the determining factor of the depth reached. The number of coats applied has a cumulative effect and with a particular concentration, a damp sponge can be rubbed multiple times, variable pressure can be used, or the gauze can be wetter and fewer passes made. The same depth can be reached using different techniques or different concentrations. By the same token, a weak concentration can be repeatedly applied and lead to deep involvement.

Judging the depth of the peel The key to a successful resurfacing is choosing and safely reaching the appropriate endpoint. A superficial peel wounds the epidermis, and although it can improve pigmentation and give a bright look, it does not improve real wrinkles. A medium-depth peel reaches the papillary dermis. Deep peels go to the upper and mid-reticular dermis, and it is this layer that must be reached to have significant improvement of stubborn wrinkles. The recovery is dependent on the depth reached and croton oil peels require more time for re-epithelialization and resolution. Any other modality touting a quicker recovery, such as fractionated laser, will not have a similar result. Typically, in most cases, different depths are reached in different areas of the face depending on skin thickness and clinical need. Peeling deeper than the mid-reticular dermis can lead to hypopigmentation and scarring. During the peel, specific attention must be paid to appearance and quality of the frost as this is the way to judge the depth. The clues to look for are background color, “thickness”, and opacity. A thin, transparent frost with a pinkish background means that acid has traversed through the epidermis into the papillary dermis. There is a quality of translucence that allows visualization of the horizontal vessels of the dermis, resulting in the pink color (Fig. 8.5.8). This may well be the endpoint in some areas. With further application, the acid passes into the reticular dermis and forms a solid, opaque, evenly colored organized frost (Fig. 8.5.9). The action of the acid has destroyed the more superficial dermal vessels and the opacity does not allow visualization of the deeper subdermal plexus, therefore the pink background is not seen. In thicker areas, such as around the mouth, the peel is stopped at this point and the frost is allowed to subside, or “defrost”. If the upper to mid-reticular dermis has been successfully reached, the defrosting takes about 15 minutes, and the skin takes on a reddish-brown overtone (Fig. 8.5.10). This is a very reliable sign and if it is not seen, further peeling may be needed. A gray–white appearance of the frost suggests reaching the lower reticular dermis and is not recommended.

Full-face peel

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A A

B B Figure 8.5.8  Progressive frosting. (A) The patient is sedated and the skin degreased. (B) The first passes are made, and a thin translucent frost appears with a pink background. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

Figure 8.5.9  Progressive frosting. (A) As more passes area are made, the frost becomes more organized and opaque, with a pink background still evident. This denotes reaching the papillary dermis. (B) After more passes in the thicker glabella, and the frost has become thicker, organized, and opaque. The peel has passed into the reticular dermis. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

Another visual cue to assess the depth of peel, especially in thin skin like the eyelids, is epidermal sliding. Epidermal sliding is a phenomenon that occurs when the peel reaches the papillary dermis and the tight bond between the epidermis and dermis is broken, allowing the epidermis to slide as a single sheet. This sliding disappears when the peel goes deeper and the epidermis and dermis bond as a single protein block. The progression from superficial to deep is gradual, orderly, and the visual changes are easily recognizable and predictable. The advantage of the modern peels is that the surgeon has control. This is based on going slow enough to recognize the various stages, stop at the appropriate depth and go no deeper.

Full-face peel The following is a step-by-step description of the author’s (RHB) approach to a full-face peel. The patient is sedated and has received clonidine 0.1 mg p.o. prior. This is based on empirical experience that it helps prevent arrhythmias. Endotracheal gas anesthesia is an option, but it is my preference to avoid it. The head of the bed is slightly elevated to prevent drops from flowing into the eyes. The skin is degreased with acetone and no ophthalmic ointment or corneal protection is used. Sterile surgical gloves offer more protection than

Figure 8.5.10  The red-brown appearance after defrosting is a reliable sign that the reticular dermis has been reached. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

non-sterile ones. A surgical towel is clipped to the shoulder of the scrub shirt and draped over the front. A preliminary pass of 50% phenol is made for the anesthetic effect, starting on the forehead. This is done slowly for a light frost and being vigilant for a change in pulse. Allow the frosting to subside, then proceed with peeling.

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The various solutions have been pre-mixed and placed in clearly labeled bottles. Small glass bowls are available to pour solution into for dipping. Extra gauze and irrigating ophthalmic solution are kept within easy reach in case washing out of the eyes should be needed. The bottle of the solution to be used is gently shaken to evenly mix the ingredients and a small amount is poured into a glass bowl. A 2 × 2 gauze is folded twice, dipped into the bowl and then wrung out until damp but not dripping. A second glass bowl is placed over the first to trap the fumes. The damp gauze is set in a safe place, the hands are wiped on the clipped towel, then the gauze is retrieved for peeling. I start on the perioral area as I usually want to peel to the reticular dermis and then move on to other areas as the mouth defrosts. Starting on the upper lips, a first pass is made, and the skin is examined. I usually use 0.8% concentration or possibly 1.2% with the solutions using Novisol on deeper wrinkles. A light frost appears and as more passes are made, the frost becomes denser and more concentrated. A translucent frost with a pink background means that the papillary dermis has been reached. With more passes, redipping the gauze as necessary, the frost becomes progressively more dense, more opaque, losing the pink background as the upper reticular dermis is reached. As previously mentioned, this is a slow, orderly process and the surgeon can stop at any point if a lesser peel is desired. The skin is stretched to allow even application of the acid between wrinkles. The commissures are also spread and

respond well to deep peeling. The lower lips and chin area are peeled in a similar manner to an opaque solid white frost. The margin of the peel is the inferior border of the mandible and chin (Fig. 8.5.11). The peel can now proceed to the next area while monitoring the defrosting over the next 15–20 minutes, observing for the tan, red-brown overtones. This confirms having reached the upper to mid-reticular dermis. If this color change is not evident or too faint, the area can be repeeled. The next area is the glabella and nose, which have roughly similar thickness as the mouth; the glabella in particular can have deeply etched lines and can be peeled to the reticular dermis. The lower nose does not wrinkle, but “roughness” and deep pores respond well to similarly deep peeling. The skin of the forehead is thicker centrally and thins out superiorly and laterally. Aside from the glabella and transverse lines, the forehead does not have generalized wrinkles. A common approach is to peel centrally with 0.4%, feathering superiorly. The rest of the forehead is peeled with 0.2% to the papillary dermis and peeling lightly in the temporal area as it is delicate and not usually wrinkled (Fig. 8.5.12). The transverse lines and glabella lines can be targeted deeper, as will be discussed later. The peels do not affect hair growth, so peeling should continue to hairline and brows in order to avoid a demarcation. Treating the dynamic lines of the upper face with botulinum toxin 2 weeks prior is recommended to decrease mobility during healing. The face between the eyes and mouth are peeled next. The skin of the posterior face is densely attached and less mobile,

A

B

C

D

Figure 8.5.11 Progressive peeling of the perioral area. (A) Light translucent frost of upper lip as the early passes are made. (B) More passes have been made in the upper lip and the frost is solid and opaque. The lower lip and chin still show a pink background. (C) Both upper and lower lips/chin demonstrate solid, dense frost indicative of reaching the reticular dermis. (D) The commissures do well and can be specifically targeted. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)  

Full-face peel

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Figure 8.5.12  The peel of the forehead is deeper centrally, tapering superiorly and laterally. The glabella is often peeled to the reticular dermis whereas the superior and lateral skin shows a light frost with a pink background, which represents peeling to the papillary dermis. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

Figure 8.5.14  The lower eyelids are peeled with 0.1% croton oil solution to a point of epidermal sliding and an even white frost. The upper lids are peeled with 0.1% solution or possibly 0.05%, depending on the degree of laxity. The peel stops at the tarsal fold unless obvious laxity is seen below the fold. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

Figure 8.5.13  The central face is peeled to the papillary dermis. Deeper wrinkles can be individually targeted. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)

therefore usually less wrinkled. The posterior area is usually peeled with 0.2% to the papillary dermis, with light application in the preauricular area which is delicate (Fig. 8.5.13). Peeling should continue to the sideburn, tragus, and earlobe. The earlobe responds nicely and can be peeled with 0.4%. The anterior face, showing more mobility, is usually more wrinkled. Depending on the individual case, this area is peeled with 0.2% or 0.4% to the papillary dermis or slightly deeper and individual wrinkles can be targeted as necessary. The anterior face can be tricky, because on occasion, there can be deep wrinkles in an area where the skin is not as thick, therefore the patient must be advised that complete correction may not be possible. The peel should extend to about 1 cm below the mandible and the entire corridor of the mandibular border between the mandibular angle to the geniomandibular groove is delicate and rarely wrinkled, therefore it should be peeled lightly. The eyelids are an excellent area for peeling, especially the lower eyelids, because they can show great improvement and

are very predictable. The skin is very thin, but it responds well to a weak solution such as 0.1%. The solution is applied with two cotton-tipped applicators which are dipped into the bottle after it has been shaken. The wet applicators are touched to a gauze or drape to slightly dry them, and then applied to the skin. The peel begins in the lower part of the lid and then proceeds gradually superiorly, approximating the ciliary margin. The relative dampness of the applicators and the number of passes made determine the depth. The cheek is gently pulled down to fully expose the skin and smooth out the wrinkles. With progressive passes, the friction of the application will demonstrate epidermal sliding and the frost will become an even white color. When the cheek is released, the soft tissue moves up and the degree of epidermal sliding can be easily seen. When the epidermis is loose and there is an even white frost, the opposite lid can be addressed. After defrosting, a prominent wrinkle or redundancy may be seen at midheight which can be repeeled, possibly with 0.05% solution (Fig. 8.5.14). Having a detailed photograph present is useful to see the precise location of the wrinkles. Due to the tightness that is created, precipitating an ectropion is always a possibility, so testing the laxity of the lid preoperatively is important. If there is concern about laxity, a preemptive canthopexy or tarsorrhaphy suture can be performed or sequential lighter peels can be done. Patients may experience tightness in the lower lids after peeling, but this responds promptly to upward massage. The skin of the upper lids respond to peeling by shrinking, which looks quite nice and can mimic a blepharoplasty. If laxity is present, peel with 0.1%, and it is usually stopped at the tarsal fold. If there is laxity below the fold, the peel can approximate the lashes. One nuisance of peeling the upper lid is that the eye may swell shut, usually until the next day.

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Figure 8.5.15  Precise deeper peeling of more pronounced wrinkles is possible with a wetter application, then quickly drying as the frost appears. This is repeated until the desired depth is reached. This is an extremely valuable tool in the perioral area. (From Bensimon RH. Croton oil peels. Aesthet Surg J, 2008;28:33–45.)

Beware of the medial upper lid, where there may be “double peeling” from the nose. The peel is then extended onto the neck with a very dilute solution of 0.25% or even weaker. This is done with very light, wispy strokes and a barely moist sponge, leaving a faint frost that is scattered and disorganized. This peel is done only to prevent a line of demarcation and not to improve wrinkles; the neck skin is delicate and lacks the healing potential of the face. Attempting to improve wrinkles is likely to cause hypopigmentation or scarring. A weak TCA peel in the neck is an option and liposuction of the neck with any peeling is not recommended. Likewise, a brow lift, even if performed at a deep level, is to be avoided. At this point, the entire face is inspected to see if any further peeling is needed. Areas where the intention was to reach the mid-reticular dermis are examined for the re-brown color. If not present or faint, they should be repeeled. If there is uneven blending of areas peeled with different concentrations, then a light overpeel with a dilute solution such as 0.1% is needed. This is most common in the midface. Precise peeling of individual deeper rhytids without affecting the surrounding areas is an extremely valuable tool, especially in the perioral area, chin, glabella, and forehead. A wetter cotton-tipped applicator is used to paint the individual line and then quickly drying it as the frost appears. This is repeated until the desired depth is reached (Fig. 8.5.15). This is particularly useful in stubborn radial lines around the mouth and can have a profound effect. Another approach is to saturate a toothpick and “flood” the valley of the wrinkle and leave it in place for a few seconds before drying it. Transverse forehead lines are stubborn, but improvement can be expected from this technique. This is also true for glabella lines, transverse nasal lines, and crow’s feet. Various croton oil concentrations have been recommended in the previous sections, but keep in mind that the concentration of the solution is only one variable, and the surgeon needs to monitor the appearance of the frost at all times and

decide the depth at which to stop. Repeated passes of whatever concentration will have an additive effect and the safety of a weaker concentration is a relative one. The patient should be well hydrated and under cardiac monitoring during a full-face peel. The surgeon should be aware of the pulse rate, and, if it increases, back off until it slows down. Resist the temptation of peeling too fast, especially as experience is gained. A full-face peel should take between 45 minutes and 1 hour. If arrhythmias are seen, stop the peel for some minutes until the rhythm reverts to normal. In all likelihood, treatment will not be necessary.

Aftercare Dealing with the skin after the peel is perhaps the most challenging aspect of deep chemical peels. There is, in essence, an open wound and the aim is to provide a good environment to promote re-epithelialization in the fastest time with the least difficulty for the patient. Keep in mind that to obtain a significant result, there must be an injury into the dermis, and as a result, there is a real recovery. Any other process that has a quick recovery has not adequately injured the dermis and will not give a comparable result. The traditional technique of aftercare, which I used for the first 14 years of my peeling experience, involved using triple antibiotic ointment mixed with lidocaine jelly and constantly applying it to the face. This technique works and is a viable option, but it is messy and gives the patient a dramatic view of the “aftermath” and requires constant touching of the face. Moreover, sensitization to the antibiotics can cause breakouts and rashes. Milia were common and there was the impression that the subsequent erythema was more intense. What follows is my present regimen which I instituted to improve the patient experience and have used successfully for the past 8 years. This is an older technique used by various peelers around the world and was taught to me by Jean-Luc

Aftercare

Vigneron, an accomplished peeler from France. Once the peel is finished and all the frosting has subsided, all the peeled areas are covered with zinc oxide tape. This is the pink tape commonly used by anesthesia providers to secure the endotracheal tube. Petrolatum ointment is applied to the brow and hairline to prevent sticking, and no taping is done to the skin of the upper lid below the tarsal fold (Fig. 8.5.16). Typically, when patients awaken from the peel, they may feel some stinging which is not intense and may or may not necessitate medication. This is not long-lasting, and when discharged in about 1 hour, they are comfortable. Unlike the very difficult recovery from the Baker peel (and ablative lasers), this is usually the last discomfort felt. The tape mask remains in place overnight, at which point the patient returns to the office. The tape mask is removed from inferior to superior without difficulty and without discomfort. The patient should be warned that any discomfort felt is simply some hair caught in the tape. An inconvenience of peeling the upper lid is that it may swell shut the night of the peel or the tape may impede the lid from opening. Vision

Figure 8.5.16  Zinc oxide tape is applied to peeled areas at the end of the peel. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)

A

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is restored the next day when the tape is removed. Displaying the “trophy” of the removed mask to the patient is a common source of amusement (Fig. 8.5.17). The peeled skin is examined and gently cleansed with a saline gauze in order to remove any loose fibrous material. The edge of a tongue depressor can also be used to gently “shave” the skin. The next step is to mix the bismuth subgallate powder with water to create an even, creamy paste with a consistency reminiscent of cake frosting. A small bit of ophthalmic gel can be added to give a more even texture. The paste is applied to all peeled surfaces with a tongue depressor or a mini silicone spatula (available in a kitchen store). A fan-shaped make-up brush works well on the eyelids. The paste is not applied below the tarsal fold. Organic coconut oil is applied to the vermillion and the lightly peeled neck (Fig. 8.5.18). Once the bismuth mask is on, it is allowed to dry and form a crust. The patient is admonished that from this point on, they are to strictly avoid touching the face. Over the next 7–12 days, the skin beneath will re-epitheliaze and shed the crust piecemeal. Again, the patient is advised not to pick at, wash, or touch the face. At about day 7, the patient is seen and a heavy petroleum ointment is applied to any remaining crust and allowed to seep in during that day. On day 8, the patient can shower gently (deflect the full force of the shower with a hand), gently pat dry with clean hands and clean towel, and re-apply the ointment (which is supplied to the patient) on remaining crust. This is repeated daily until the mask is completely shed and the new pink skin is evident (usually 9–12 days) (Figs. 8.5.19 & 8.5.20). This approach with the bismuth has the disadvantage of looking bizarre but the typical reaction has been one of amusement and patients are very tolerant of it. The handsoff approach is appreciated and office visits and worried calls have been significantly cut down in the first 2 weeks. Any questions are easily handled via smart phone photo. The bismuth has proven less reactive than ointment and the post-peel erythema is much less. For any skeptics, bismuth is a heavy metal with many wellknown curative properties and surgeons are surely familiar

Figure 8.5.17  (A) The tape mask is removed the day after the peel. (B) Appearance immediately after tape mask removal. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)

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with it through Xeroform medicated gauze, whose active ingredient is 3% bismuth tribromophenate. Once skin is exposed, a medical quality moisturizer is applied with clean hands and continued for the ensuing weeks. Strict sun avoidance is important for the early periods, and usually a physical sun block can be used on the third week giving the patient increased freedom. The erythema can last 8–12 weeks but is easily covered with make-up or tinted sunblock. To be sure, there are many other techniques to treat resurfaced skin, but the tape–bismuth approach has proven to be effective and practical. Some patients may consider the process too onerous, but in reality, the 2-week early recovery is quite short when considering there is no other treatment equal in quality and longevity. As more practitioners perform these peels, an improved healing technique may come to light.

A

Materials and suppliers

B Figure 8.5.18  (A) Bismuth subgallate paste. (B) Bismuth paste applied to face. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)

A

B

Phenol

Most pharmacies, Delasco

Croton oil

Delasco (Delasco.com)

Novisol

Young Pharmaceuticals (Youngpharm.com)

Bismuth subgallate powder

Delasco, McKesson, Amazon, multiple medical suppliers

5-FU

McKesson, Medline, multiple medical suppliers

Zinc oxide tape (Hy-Tape)

Delasco, McKesson, Amazon, multiple medical suppliers

Glass bottles, phenolic caps

SKS Bottle & Packaging (sks-bottle.com), Bottles and More (bottlesandmore.com)

Glass bowls (Duralex, Pyrex)

Amazon, kitchen supply stores

Silicone spatula

Amazon, kitchen supply stores

C

Figure 8.5.19 Process of healing with bismuth subgallate paste. (A) Day 1. (B) Day 5. (C) Day 7. Note that erythema is more where peel is deeper (glabella), but overall is mild. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)  

Variation of peels

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Variation of peels Partial or segmental peels are a possibility but must be done judiciously so as not to create a mismatch in color. This is particularly true in patients with widespread solar damage, making a full-face peel a better choice. For example, if an isolated peel is performed, the true color of the skin will be brought out and this could be in harsh contrast to surrounding sun-damaged skin. In these situations, a lesser peel may be preferable in order to avoid the need for make-up. Some individuals with

Figure 8.5.20  Healing process for segmental peel. (A) Taping immediately after peel. (B) Day 1, tape removal and application of bismuth subgallate paste. (C) Interim healing. Partial shedding of crust. (D) Appearance after complete shedding of crust. Note that erythema is mild and easily concealable. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)

isolated upper lip lines without extensive sun damage elsewhere can benefit from a peel of the mustache area (Fig. 8.5.21). The eyelids are an excellent area for segmental peeling. Signs of early aging are often seen first around the eyelids in late 30 s to mid-40s. The upper lids exhibit slight redundancy, and the lower lids show crisscrossing, visible wrinkling, and crepiness. These changes are bothersome to patients as they are often the only signs of aging and the myriad of creams and treatments available do little. A simple peel, often performed in the office without anesthesia in 10 minutes, can greatly improve the problem. The thin lid skin, if peeled, within the

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A

B

Figure 8.5.21  Isolated mustache peel. (A) 54 year old women with fine wrinkling of upper lip and large pores. (B) One year after isolated mustache peel.

A

B

Figure 8.5.22  (A) A 44-year-old man with crepiness and slight redundancy of lower lid skin as the main expression of aging. A lower lid blepharoplasty might have further accentuated the rounding of his outer canthi. (B) Result 6 months after peel of lower eyelids. This is an excellent option for this problem. (From Bensimon RH. The technical use of croton oil peels. In Centrofacial rejuvenation, p.323–377. New York: Thieme Publishers, 2018.)

boundary of the orbital rim responds very well and is easy to hide with make-up or glasses. If more result is desired, the peel can be repeated with little expenditure in time or materials. In a real sense, the patient can obtain as smooth a lid as they wish. There is great versatility in these eyelid peels: if a quicker recovery is needed, a lighter peel can be done with the thought of repeating it at a later time. A lower eyelid peel tightens the anterior lamella and tends to soften the early bulging of fat in younger patients. Likewise, the skin of the upper lid reacts by shrinking, giving a bright, natural look without surgery. The combination of a transconjunctival blepharoplasty and a lower lid peel is an excellent choice that gives predictably good results without changing the shape of the eye (Figs. 8.5.22 & 8.5.23). An evolving tactic is to peel the eyelids of young patients when this is the only sign of aging. After some years go by and there is some further deterioration, the peel is repeated, and the skin is brought back to its previous condition. This

is an effective way to keep up with aging. These peels (and any touch-ups) can be done with mild oral sedation and a first pass of 50% phenol. After about 12 seconds of stinging, the skin is numb, and you can proceed to the next lid. Once all areas are anesthetic, the peel can proceed. This preemptive approach can be applied to the whole face as fine wrinkling and the dullness of solar elastosis begins to appear. This may be the situation in younger patients not contemplating any surgery, but also not seeing adequate results from superficial peels, microdermabrasion, etc. In these circumstances, a lighter peel can be done, targeting any problem areas such as the eyelids or lip lines. The recovery will be quicker, but the result will be more profound than with TCA or fractionated laser. Any persistent wrinkle can be easily touched up. This treatment plan is applicable to a large portion of the population, and, if repeated appropriately, will prevent more obvious aging.

Results

Figure 8.5.23  (A) A 48-year-old man with early changes of upper face and overall “rough” appearance. (B) Result after upper blepharoplasty, neuromodulators, skin care, and lower lid peel. Relatively simple procedures have produced considerable impact.

B

A

A

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B

C

Figure 8.5.24  (A) A 45-year-old woman with generalized elastosis and chin wrinkles. (B) One year post peel. The skin looks healthier with bright reflection of light and improvement of chin wrinkles. (C) Six years postoperatively. There is remarkable stability of results. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

Results In its basics, croton oil peels injure the skin to a particular level and elicit an acute inflammatory response that stimulates the deposition of collagen and elastin. Histology of peeled skin shows a significant new layer of collagen in the dermis that is aligned in an orderly way and is remarkably stable for years, even decades. The positive result in patients in their 60 s can be considered permanent. The qualitative improvement of the skin is by means of a true regenerative process that changes the skin anatomy. The skin looks younger because, in a real

sense, younger skin has been created. The haphazard arrangement of epidermal cells is reordered: light penetrates the dermis and is reflected back brightly, replacing the dull, ashen, sallow look of sun damage and elastosis. The generalized qualitative improvement of the skin radiates the luminescence of youth. There is an intangible quality that no surgery can provide. In fact, the results of a well-done facelift without radiant skin is incomplete and still looks old. The longevity of peels is unequalled by any other process and, rather than showing loss of effect, the skin appears to improve with time. Figs. 8.5.24–8.5.32 are representative of the results that can be seen with these deep chemical peels.

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CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

B

C

D

Figure 8.5.25  (A) and (C) A 47-year-old woman with widespread sun damage, elastosis, pigmentary changes, and opaque skin. (B) Four years after croton oil peel. Global improvement in the quality of the skin and even pigmentation area evident. (D) Detail of periorbital area 1 year after peeling. The qualitative improvement consists of softening of the hard lizard-like skin and the natural absorption and reflection of light. (From Bensimon RH. The technical use of croton oil peels. In Centrofacial rejuvenation, p.323–377. New York: Thieme Publishers, 2018.)

Microscopic studies of peeled skin show destruction of actinic keratoses and cancer cells within the dermis before they become clinically evident.12,13 This is to be expected because deep peels go to the depth that these cells are found. The impression of experienced peelers is patients that have been peeled do not develop facial basal cell or squamous cell cancer. Individuals with a previous history of skin cancer show a significant decrease in frequency or even complete eradication. In fact, dermatologic studies have shown that resurfacing techniques are successful in keeping susceptible patients free of non-melanoma skin cancer for the studied 5 years.14 In recent years, there has been increased attention in addressing the loss of volume that is seen in aging. The use of fat transfer or lipofilling is becoming more important not only for replenishing lost volume in the face, but also for the regenerative effect of stem cells and epidermal growth factors. With experience, it has been found that lipofilling and croton oil peels can be done at the same time and are very

synergistic. This is a powerful combination, and there are many instances where this approach may afford a greater aesthetic impact than a facelift. Of course, if all three components of aging are corrected, the result can be very dramatic.

Complications The main complications of croton oil peels are similar to other deep resurfacing procedures. The most feared complication, scarring, has occurred mainly if the patient picked at their face during the healing process or if they inadvertently transferred genital herpes to the face. This infection is more virulent and has resulted in scarring. If healing is delayed longer than 14 days or thickening develops, this is suggestive that the peel has reached the deep reticular dermis and scarring may ensue. The suggested treatment is to apply a fluorinated topical steroid 5 days on

Complications

LA

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RA

RB

LB

Figure 8.5.26  Left, a 59-year-old woman with the classic ashen, sallow look of sun damage, prominent upper lip lines and rough chin skin. Right, 1 year after croton oil peeling. Generalized improvement of skin quality and pigment, along with stark improvement of upper lip lines and elevation of the vermillion. No other modality has equaled these results. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

A

B

Figure 8.5.27  (A) A facelift on this 65-year-old woman without resurfacing would be an aesthetic failure as the prominent lines of the face would be minimally improved and around the mouth and upper face, not at all. (B) One year after croton oil peeling. It could be argued that the peel has provided more global rejuvenation than surgery. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

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A

Figure 8.5.28  (A) This 75-year-old woman demonstrates obvious centrofacial aging in contrast with relatively unaffected posterior face. (B) Results 5 years after facelift and 1 year after croton oil peeling. This demonstrates the power of surgery and subsequent peeling. (Or vice versa.) (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

B

A

B

C

Figure 8.5.29  (A) A 63-year-old woman with structural changes of aging, jowling, neck laxity, mild hollowing of upper lids, and prominent line especially periorally and upper face. (B) One year after facelift and lipofilling. The lack of improvement in the texture distracts from the result and despite the improvements, she still looks “old”. (C) At 18 months after peeling. A natural, comprehensive result as all three components of facial aging (structure, volume, texture) have been addressed. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

and 5 days off with careful monitoring. If a scar develops, a useful treatment is the intralesional injection of 5-fluorouracil (5-FU). 5-FU is a common intravenous chemotherapeutic agent with a long history of use by dermatologists and plastic surgeons. The intralesional injection is considered off-label. The schedule of injection can be as frequent as every 1 or 2 weeks, depending on results. Steroid can be mixed with 5-FU, but it appears that 5-FU alone is more effective without the complications of the steroid.

Particular attention should be paid to the temporal area, preauricular area, the geniomandibular border, and the medial upper lid, as these areas are delicate and could lead to scarring. The region of the mandibular border from angle to chin should not be over-peeled as it is delicate and rarely wrinkled. The medial upper lid may be peeled deep when peeling the nose, therefore special care is advised. Hypopigmentation can result if the peel goes too deep and was the norm with older peels. This is largely

Complications

LA

RA

LB

RB

LC

RC

LD

RD

LE

RE

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Figure 8.5.30  Left, this 61-year-old woman is a classic example of negative skin aging due to sun damage and long-term smoking; her structural changes are mild, therefore a facelift would not be a first choice. She has prominent perioral and periorbital wrinkles, blotchy pigment throughout, and thick, opaque skin. Right, the changes 6 months after peeling alone clearly show the power of this technique. The overall appearance is bright and healthy. She has a look of youth that was not present before. The wrinkles around the mouth and upper face have been nicely eradicated without depigmentation. Note the skin tightening, shrinking of upper lid skin, and shortening of upper lip. The improvement of skin quality of the midface is quite dramatic. (From Bensimon RH. The technical use of croton oil peels. In Centrofacial rejuvenation, p.323–377. New York: Thieme Publishers, 2018.)

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Figure 8.5.31  (A) This 70-year-old woman shows considerable facial wrinkling, but also generalized deflation, which is a prominent feature of her appearance. (B) Result at 14 months after lipofilling and croton oil peeling. This synergistic combination has the potential of providing a greater aesthetic impact than a facelift.

B

A

B

Figure 8.5.32  (A) Early skin thickening or scar. (B) Result after one injection of intralesional 5-FU.

preventable with the modern iteration of these peels as proposed in this chapter. If an individual has very deep wrinkles and tough leathery skin, it may be necessary to peel so deep as to cause hypopigmentation. In general, this hypopigmentation is well worth it and does not have the artificial, porcelain look of the older peels. Careful assessment preoperatively is important because there are patients that have lighter upper lip skin naturally which may become more obvious once the solar damage is improved. Also, it is prudent to point out to the patient if there is hypopigmentation due to previous dermabrasion or carbon dioxide laser treatment. Sun exposure in the early recovery can result in hyperpigmentation, usually in dark-skinned individuals. Strict sun avoidance in the first 2 weeks, along with pretreatment to suppress melanocytes, is important. After the first 2 weeks, most patients can tolerate a physical sun block, resulting in considerably more freedom. Hyperpigmentation can be treated with tretinoin and hydroquinone 4%, but it can look blotchy and linger for a few weeks. A herpetic infection is a constant fear; therefore all patients are treated prophylactically with valacyclovir 500 mg twice a day starting 3 days prior to the peel and continuing for 7 days after. If an outbreak is suspected, the dose of the antiviral is doubled and a topical antiviral such as penciclovir is used.

This is carefully applied with a cotton-tipped applicator so as not to spread the infection. As has been discussed, the potential of spreading genital herpes to the face can be very troubling. All patients must be considered potential carriers, so they need to be warned to wash their hands before touching their face when allowed on day 8. To date, we have seen no herpetic infection since switching to the bismuth paste and a no-touch technique. One of the positive effects of the peels is skin shrinkage. This could potentially precipitate an ectropion, therefore the lower lid should be examined for laxity preoperatively. If present, segmental lighter peeling and a tarsorrhaphy suture are options. If more extensive laxity is seen, a formal canthopexy may be needed. Mild tension in the lower lid is not uncommon and responds well to upward massage. Milia were common when occlusive ointments were used; they are much less frequent with the bismuth mask. Milia can be treated with tretinoin (after 6 weeks) or carefully excised with a fine needle. Erythema lasting more than 12 weeks is possible, but it always subsides completely and has not required treatment as was sometimes needed with ablative CO2 lasers. There has been a notable decrease in erythema since the use of taping and bismuth subgallate paste.

Conclusion

Conclusion The finding that croton oil is the critical peeling ingredient has been pivotal in the evolution of deep chemical peeling. By modulating the croton oil concentration, the process has been slowed, giving the surgeon control of the peel; by using appropriate application technique, the desired clinical result is possible without causing hypopigmentation. By lowering the croton oil concentration, the feared “all-or-none” action in older peels is gone and now surgeons have an excellent option for effective skin resurfacing. Peeling older patients with established wrinkles is an obvious indication for croton oil peels and peeling younger patients incrementally to keep up with aging is an interesting prospect that opens up these peels to a much wider audience. The prevention and potential treatment of non-melanoma skin cancer is an intriguing proposition that deserves more interest and research.

Access the reference list online at   Elsevier eBooks+

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Although laser resurfacing, especially erbium, is a viable alternative, there are cellular differences. Laser resurfacing results in increased collagen but elastin is not elicited. The clinical observation is that erbium laser simply does not improve perioral lines and chin wrinkles like croton oil peels. Lasered skin is thinner and there is a degradation of results after a few years. The surprising stability of results, if not permanence, is a hallmark of croton oil peels. If a practitioner owns a laser and wishes to use it, a croton oil peel can be used in the perioral and periorbital areas where lasers show less results. When discussing laser vs. peels, the very high cost of lasers must be considered. With the insignificant cost of peels, it is my belief that lasers would have to be much better to justify recommending them. One of the main purposes of this chapter is to give readers practical guidance to try these peels before spending large sums on a laser.

References

References 1. Monheit G. The Jessner’s + TCA peel: a medium-depth chemical peel. J Dermatol Surg Oncol. 1989;15(9):945–950. 2. Brody H. Variations and comparisons of medium depth peeling. Dermatol Surg Oncol. 1989;15:953–963. 3. Obagi ZE, Obagi S, Alaiti S, Stevens MB. A TCA-based blue peel: a standardized procedure with depth control. Dermatol Surg. 1999;25(10): 773–780. 4. Justo AS, Lemes BM, Nunes B, Wambier C. Characterization of the activity of croton tiglium oil in Hetter’s very heavy phenol–croton oil chemical peels. Dermatol Surg. 2021;47(7):944–946. 5. Hetter GP. An examination of the phenol-croton oil peel: part II. The lay peelers and their croton oil formulas. Plast Reconstr Surg. 2000;105:240–248. 6. Baker TJ. The abolition of rhitides by chemical means: a preliminary report. J Fla Med Assoc. 1961;48:451–454. 7. Baker TJ. Chemical face peeling and rhytidectomy: a combined approach for facial rejuvenation. Plast Reconstr Surg. 1962;29: 199–207.

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8. Hetter GP. An examination of the phenol-croton oil peel: part I. Dissecting the formula. Plast Reconstr Surg. 2000;105:227–239. 9. Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45. 10. Hetter GP. An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg. 2000;105:1061–1083. 11. Bensimon RH. Technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377. 12. Kaminaka C, Yamamoto Y, Yonei N, et al. Phenol peels as a novel therapeutic approach for actinic keratosis and Bowen disease: prospective pilot trial with assessment of clinical histological and immunohistochemical correlations. J Am Acad Dermatol. 2009;60: 615–625. 13. Kaminaka C, Yamamoto Y, Furukawa F. Nevoid basal cell carcinoma syndrome successfully treated with trichloroacetic acid and phenol peeling. J Dermatol. 2007;34:841–843. 14. Hantash BM, Stewart DB, Cooper ZA, et al.Facial resurfacing for non-melanoma skin cancer prophylaxis. Arch Dermatol. 142:976-982,2006.

 

SECTION II •  Aesthetic Surgery of the Face

8.6 Minimally invasive multimodal facial rejuvenation Luiz S. Toledo

SYNOPSIS

We have been performing “refreshing” techniques for the past 35 years, offering an alternative to the classical facelift for facial rejuvenation. We can start treating some of our patients at an earlier age, and, as well, improve the aspect of faces that have been “over-stretched” by several rhytidoplasties. With these techniques we can improve the facial appearance of patients of all ages, using our technique of superficial syringe liposculpture – SSL – with fine cannulas aspirating fat to recontour the jawline, and injecting fat with fine needles in the nasolabial, malar, and glabellar regions, postponing the first facelift, or complementing our older patients’ facelift. The “refreshing techniques” would not, however, give the same results of rhytidoplasty, neither do we advocate this operation to be abandoned. Refreshing is a combination of gentle facial contouring procedures that can be used alone or as an adjunct to rhytidoplasty, a complement to other techniques.

Introduction In 1992 we organized for the third time in São Paulo a symposium called Recent Advances in Plastic Surgery, RAPS III,1 where we encouraged plastic surgeons to present new ideas and new techniques in all areas of aesthetic surgery. As in the previous two meetings we published the Annals with all the presented papers.2 In our articles, we showed different options to the two accepted facial rejuvenation techniques at the time, blepharoplasty and rhytidoplasty, which were minimally invasive procedures that could enhance the looks of the patient and could be used as an alternative, or in conjunction with the traditional techniques. The role of skin retraction became an important consideration, something that would be explored in the following years, through many new devices and techniques.

Rejuvenation: changing attitudes and new procedures We have to look at facial rejuvenation without the rigid confines taught in the early years of plastic surgery. Instead, we

appreciate the wants of the patient, looking to improve the appearance with minimal morbidity through simpler, faster procedures, as an option to the traditional “cut and stretch” techniques. We can offer smaller procedures under local anesthesia, with no need for hospitalization, a major factor in the patient’s considerations. Rejuvenation could be described as a state of mind and by improving the appearance we can also help to improve the state of mind. “It feels much better to look younger and have less wrinkles, than to carry the burden of an older face all your life,” a patient of mine once said. The interesting point is that the changes do not need to be drastic to provoke a more youthful appearance and elevate the spirit of the “tired“ face. The best compliment to the patient and the surgeon is when friends notice “You look great!“ without perceiving any drastic changes. The worst is when the patient enters a room and it is noticed that “You’ve had something done!“, or worse, “You’ve had plastic surgery!“ Human appearance is the sum of several components. It has been studied for centuries by artists and more recently by psychologists and plastic surgeons. In 1845, in his Essai de Physiognomonie,3 published in Geneva, Rodolphe Töpffer explained what is now considered “The Töpffer law”4: Any configuration that can be interpreted as a human face, badly drawn as it may be, will have, ipso facto, its own expression and individuality (Fig. 8.6.1). Based in his work, almost a hundred years later, in 1937, Vienna psychologist Egon Brunswik5 confirmed our extreme perception to the smallest changes in the physiognomy. In his studies he explains that small variations in the proportions of the human face can affect our judgment of the person’s personality. Our subconscious mind judges people by their appearance, even if consciously we know we should not. The division of the face in thirds of similar proportion, the forehead, the eyebrows to nose tip and nose tip to chin, is considered to be proportions of beauty. A wide forehead is considered a sign of intelligence and a short one, stupidity. Big ears are often taken as a sign of a “dumbo“, a receding chin, or “weak chin“ is equated to indecisiveness, while a big chin will have the opposite judgment,

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Figure 8.6.1  Rodolphe Töpffer’s original illustration of expressive character in the human face. (From Toepffer R. Essai de Physiognomonie. Geneva, 1845.)

no matter what the real qualities are. A woman with thin lips can be thought of as mean and another with full, pout lips, as generous and good. The extreme, the anomalous, usually sticks in our mind and gives us preconceived diagnosis and ideas. Caricaturists distort and exaggerate facial features so as to portray their subject in a few lines. It could be a dangerous profession.6 In France, Charles Philipon was fined 6000 francs for portraying King Louis-Phillipe as a pear in 1831 – the king as an imbecile, although Philipon was not sure which phase of the transformation he was being condemned for (Fig. 8.6.2). It is important to try to balance the facial proportions, to achieve what the patient seeks, which most often is a feeling of similarity with their peers and “normality”. I altered my concept of facial rejuvenation when I became uncomfortable performing facelifts on young, 35–45-yearold patients. First of all, I do not like to place the extensive and permanent scar on “borderline age“ cases, and I do not like to only stretch the skin to accomplish the “younger look“. The stigma of a stretched face, the “what’s happening? look“, although it can be avoided by a good surgeon, can alter the facial expressions and outwardly the personality of the patient. Even a good result will leave marks that cannot be disguised. I still, of course, perform the procedure, when indicated, but I find it is less often, and in patients usually 45 years old and over. Patients in this age group will come to me and ask for rejuvenation, to ”have something done“ to improve their appearance without undergoing rhytidoplasty; we can help with this. Before liposuction, little could be done. The so-called “minilift” of the midface, temporal, or cervical regions still holds the same stigmas of rhytidoplasty. We can use

Figure 8.6.2  Charles Philipon’s caricature of King Louis-Phillipe of France as a pear. (history_docu_photo / Alamy Stock Photo.)

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the blepharoplasty procedure, solving excess skin, muscle, and fat within the orbital region. Blepharoplasty is a wonderful procedure and there is no substitute for it. It solves the eyelid problems thoroughly and leaves inconspicuous scars. In the early 1980s we started using liposuction to improve facial contours. Facial cannulas were thick in those days, 4– 6 mm, and results were, as in all cases of liposuction at that time, limited by the patient’s skin quality and the depth of suction. A patient was considered a good candidate for liposuction if young and with good skin tone. Otherwise, a skin resection was usually recommended to complement the facial sculpting. By the mid 1980s we had started fat grafting of the face and body, and by 1986 we were using 10-cc disposable syringes for facial sculpturing. This facial procedure has become very delicate with much finer cannulas. We use cannulas of 1.5-mm to 3-mm gauge for the face and neck. Anesthesia has improved and we started suctioning and injecting fat as an office procedure under local anesthesia. Office surgery became more frequent. The ease and safety of the procedure, allied with a global financial recession, has drastically cut the number of hospital surgeries. Fat grafting became an accepted alternative after an initial phase of discredit related to high reabsorption rates of the injected fat, due to the mistreatment of the fat cells. We have perfected our technique and have a high rate of patient satisfaction. In the 1990s we started performing endoscopic brow lifts and midface lifts. Although endoscopic procedures use minimal scarring, they are hardly minimally invasive as the dissection of the tissues can be very traumatic. After Botox and fillers were introduced, we could substitute the endoscopic brow lifts and finally start treating younger patients with non-surgical procedures. With Botox we can treat the fine wrinkles that do not disappear with the surgical procedures and with fillers we can improve folds and highlight the angles of the face. The option of deep chemical peels and dermabrasion has limited use in dark-skinned individuals and was responsible for the unpredictable scarring and hyperchromia that has always limited these procedures in certain ethnic populations. Peelings have become gentler. In the 1990s TCA peels experienced a comeback, allied to Retin A and alpha-hydroxy acid (AHA) peels.7 We can now treat both patients of Caucasian origin and darkskinned patients all year round, providing they follow strict recommendations of skin care and the use of sun-blocking agents. The idea of “refreshing“ rejuvenation has become extremely popular and public education has brought to our offices a new kind of patient, those afraid of the drawbacks of the traditional rejuvenation techniques. These patients, instead of waiting for their face to “fall“ at the age of 50, now came to our clinic in their early 30 s, or even late 20 s, looking for maintenance procedures until the facelift age finally arrives. We learned that all these small procedures can also be used in conjunction with rhytido- and blepharoplasty, enhancing their results. Perioral wrinkles, never treated with rhytidoplasty, could now be improved with fat grafting.

Techniques We classify facial rejuvenation procedures as surgical and non-surgical. Usually, the non-surgical options are indicated for younger patients, also older patients who do not want to undergo a surgical procedure, as well as to complement or improve the results of a surgery. Today Botox and fillers have been popularized and I have utilized these options from early on in my practice and have always offered this to my patients regardless of their age. I know some surgeons prefer not to, but I have felt that if we as plastic surgeons do not offer it, other specialties would start entering our field. Also, eventually, when these patients feel they need surgery, they would come to us and there would be an element of continuity.

Botox In the younger patient, we start treatment with Botox when the first wrinkles start to show in the forehead, glabella, and periorbital areas (crow`s feet) (Figs. 8.6.3 & 8.6.4). We also use Botox to elevate the corners of the eyebrows, to reduce platysmal bands in the neck, and lip vertical wrinkles (so-called code bar wrinkles). Botox is a trademarked product (Allergan Aesthetics). There are other botulinum toxins on the market, but we prefer to use the original. I prefer never to inject too much to avoid the “frozen”-look face. I tell my patients to return after a week and if they need a touch up it will be included in the original fee. This way I can control the amount to inject and avoid injecting too much. Patients are informed the treatment will last from 4 to 6 months. I also often administer Botox for bruxism and migraine, with good results.

Fillers When the nasolabial folds start showing we inject hyaluronic acid (HA) fillers. The next step also includes injection of the

Figure 8.6.3  Botox injection on the forehead with eyebrow elevation and glabella.

Figure 8.6.4  Botox injection on the forehead and glabella.

Techniques

malar region when fat here starts to be reabsorbed or displaced by gravity (Figs. 8.6.5 & 8.6.6). This malar injection also enhances the nasolabial area, giving it the support the skin has lost. The glabellar region is next, with a fold or two forming between the eyebrows. I never inject the periorbital area with sharp needles, to avoid any undue complications. We use the sharp needle to perforate the skin, then change to a blunt cannula to administer the injection. Although fillers and fat are not the natural substitute for bone, we can use them to accentuate a weak chin or facial angles, by injecting the zygomatic area, the chin, or the mandible angle (Fig. 8.6.7). Working in the Middle East we saw in our practice some disasters caused by the injection elsewhere of permanent fillers in the face. Some practitioners injected substances that were not approved by the proper health authorities, such as hydrogel. The result was traumatic (Fig. 8.6.8) exceedingly difficult and sometimes impossible to correct. We always advise patients they should only have temporary fillers injected, and to keep the label with the make of the filler. Although many

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patients still ask for a “more permanent filler” we should always discourage them. We only use HA fillers from reputable companies (Chapter 8.2 offers details of approved products). Patients are informed the treatment will last from 4 to 6 months and they should return in due course for a “top up”. If patients want a more lasting result, I offer them fat grafting; one to three procedures should last for up to 2 years. Lip augmentation with fillers is one of the most soughtafter procedures. We avoid injecting the lips as if they were a sausage, instead we recreate the normal lip volumes (Fig. 8.6.9). I always finish the procedure by accentuating the Cupid’s bow and the lower lip border to redefine it.

Facial liposculpture The results we can obtain by only suctioning the excess fat from the submental area and neck can be impressive (Figs. 8.6.10–8.6.12). It is at a time, usually when our patients reach their late 30 s and are looking for more than Botox

Figure 8.6.5  Filler injection to augment chin and mandible angles.

Figure 8.6.6  Filler injection in the zygomatic area and chin.

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Figure 8.6.7  Filler injection to augment chin.

Figure 8.6.8  (Left) Patient with infection and allergic reaction to unknown filler 3 years after injection. (Right) Six months after several treatments, including drainage, local and systemic corticosteroids, and antibiotics.

Figure 8.6.9  Filler injection to augment lips should produce a natural-looking result (right). The author injects in an oval shape in the orbicularis muscle, and finishes with a small amount in the Cupid`s bow.

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123

Figure 8.6.10  Submental and neck syringe liposuction to define the neck and mandible line.

Figure 8.6.11  Before and 12 years after neck syringe liposuction and three fat grafting procedures in the nasolabial folds and periorbital region.

and fillers, that we discuss with them the option of facial liposculp­ture, a combination of aspiration and injection of fat. This is a procedure for patients who do not have excess skin. We start with suction of the jowls and submandibular area, combining suction with injection of fat in the mandible angle and chin, redefining the “lost“ jawline. Fat is aspirated with a 10-mL syringe and 3 mm gauge cannula, decanted, and transferred from one syringe to another. We can use syringes varying from 1 to 3 mL for a more precise injection.

Suction is usually performed once and injection two or three times, following the Fournier principle of “over-inject in time, not in space”. Injection is performed in threads and can be repeated after 35 days. This means, in reality, that a facial liposculpture patient, is ready to return to normal activities the following day if they had only injection, in 2–3 days if they had suction, depending on the amount of fat removed and on patients’ predisposition to bruising. Corrective make-up is useful for clients with a busy schedule. Some patients might not need three fat injections and so do not repeat this

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Figure 8.6.13  (Top) The 5-mm gauge cannula for aspiration and injection of fat. (Bottom) The 1.5-mm two-holed flat-tipped 15-cm long cannula, both are adapted to a 10-mL Luer-Lock syringe.

Figure 8.6.12  Submental and neck syringe liposuction to define the neck and mandible line.

procedure. This procedure is ideal for men and women who cannot stay away from work too long. In 1987 we were using 3-mm gauge cannulas to treat the face and the neck areas. Our results were good, but we felt we could improve them if we went even more superficially, even closer to the skin, using the same principle we were using to provoke skin retraction in the abdominal and femoral regions with superficial syringe liposculpture. In 1990 we developed a 1.5-mm two-holed flat-tipped 15-cm long cannula, to be adapted to a 10-mL Luer-Lock syringe, the same syringe we use for facial suction and injection (Fig. 8.6.13). A similar cannula, 3.7-mm gauge, had been used to treat hydro adenitis, scraping the skin from underneath, removing sweat glands. Our modification works well, especially in patients with flaccid skin of the jowls and submental areas. After fat suction, the cannula is turned, the holes facing the dermis, to scrape the skin, provoking an even, controlled retraction of the area. This refinement of the technique needs to be performed by an experienced plastic surgeon with, naturally, the utmost care and concentration.

Fat suction We have seen sequelae of superficial suction of the face, with unacceptable retracted skin areas around the neck, which are difficult to correct. The difference here lies in the words even,

uniform, and controlled retraction. Retraction occurs only when and where it is indicated. Even using this technique, some patients will still have excess skin, usually diagnosed as a case for resection. We were surprised reoperating these patients, after the local anesthetic infiltration, that when we suctioned, fat would appear in the syringe, and so in many cases we managed to recontour the neck superficially without having to resect skin or muscle (Fig. 8.6.14).

Fat injection To treat the face we aspirate fat with a 10-mL Luer-Lock syringe and a 3-mm gauge cannula. Initially we would centrifuge the syringes filled with aspirated fat and anesthetic fluid for one minute at 1500 rpm. Lately our preferred method to separate the substances is to decant the syringes for 10 minutes. The result is similar. After ejecting the local anesthesia fluid, we transfer the fat to the syringe we will use to inject fat. Fat injection should be made in “threads,” as the cannula is being removed, leaving space between grafts for neovascularization7 (Fig. 8.6.15). Grafts should not be thicker than 3 mm, or a central necrosis of the fat will occur (Fig. 8.6.16). We also use the Fournier “autolipocollagen” technique8 when we need to inject through finer needles to improve subcutaneous dermis in areas like the cleavage wrinkles, or to refine the Cupid`s bow. This technique, published by Fournier in 1991, gained projection recently under a different name, Nanofat. The passage of the fat between two syringes through transfers of smaller gauge will emulsify fat and make it possible to be injected with a 27 G needle. We have used syringe liposculpture (the suction and injection of fat) with success since 19889 (Figs. 8.6.17–8.6.23), always following the principles stipulated by Carpaneda,10 keeping the grafts small, maximum 3-mm thick.

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Figure 8.6.14  Before and after two submental fat suction procedures on a 55-year-old patient, after regular subdermal scraping to retract the skin. Only fat suction and injection. No rhytidoplasty.

“Plumping” of the skin

Fat “threads” should be injected as we remove the cannula

Figure 8.6.15  Fat cells should be injected as the cannula is removed, leaving space for neovascularization.

Viable cells

Central necrosis

Inflammatory tissue

Figure 8.6.16  If the grafted cells are around 1-cm diameter, there will be necrosis in the center of the graft. Around the necrosis is the viable graft, 1.5- to 2-mm thick. Around the graft is the inflammatory tissue, which lasts around 35 days.

Figure 8.6.17  Before and 5 years after three procedures of fat grafting in the malar and nasolabial areas.

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Figure 8.6.18  Before and 1 year after fat grafting of the nasolabial and lips, plus skin treatment with 70% hydroxy acid peels and home exfoliating treatment.

Figure 8.6.19  Patient shown 1 year after rhytidoplasty. Her perioral area was treated with three procedures of fat grafting.

Figure 8.6.20  Before and 1 year after two fat grafting procedures of nasolabial and lips.

Figure 8.6.21  Before and 6 months after fat grafting of the lower eyelids. No blepharoplasty.

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Figure 8.6.22  Before and 1 year after upper blepharoplasty and fat grafting of the lower eyelids.

Figure 8.6.23  Fat grafting of the earlobes rejuvenates the ears and helps with the use of earrings.

Figure 8.6.24  Before and 1 year after three fat grafting procedures in the malar and nasolabial areas.

Other procedures Fat grafting is a good procedure to correct “runner`s face”. Runners tend to lose fat on the face and a simple fat injection can improve the areas and give the patient a healthy younger look (Fig. 8.6.24). In the 1990s I started performing laser skin resurfacing, but again, although the improvement of the skin can be remarkable, it is an overly aggressive procedure, with a long

recovery time, so it is not recommended for every patient (Figs. 8.6.25–8.6.27). Light chemical peels can be combined with daily exfoliation with hydroxy acid creams to improve facial rejuvenation. The peels improve fine wrinkles and old age spots, giving the skin a more youthful and healthy appearance. AHA peels are done fortnightly in the office in conjunction with a line of home care daily creams (Fig. 8.6.28).

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Figure 8.6.25  CO2 laser resurfacing in the periorbital area. It is better to treat the full face to avoid a noticeable difference in the skin quality with the untreated areas.

Figure 8.6.26  Before and 1 week after laser resurfacing of the lower eyelids. Women can hide the redness with make-up.

Figure 8.6.27  Before and 1 year after laser resurfacing of the face. Good improvement in the periorbital area and in the quality of the skin.

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Figure 8.6.28  Before and after upper blepharoplasty on a 72-year-old patient. She had only a lower transconjunctival procedure to remove excess fat. The skin was treated with 30% TCA chemical peel.

Conclusion The safety limits established for facial rejuvenation, in our hands, have changed. Subtle changes can radically alter our perception of a human face. Combining Botox, fillers, suction,

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fat injection, and the use of light chemical peels, the results can be comparable to the results obtained through more extensive surgery, that frequently involves hospitalization and a higher risk and cost. The traditional procedures have not been abandoned by any means, but their indications have been revised according to the development of modern plastic surgery.

References

References 1. Toledo L.S. Facial rejuvenation – the role of skin retraction. Annals of the International Symposium “Recent Advances in Plastic Surgery“. RAPS III, March 14–15, 1992. Estadão, São Paulo, Brazil, pp. 30–37. 2. Toledo L.S. Superficial syringe liposculpture. Annals of the International Symposium “Recent Advances in Plastic Surgery“. RAPS/90, March 3–5, 1990. São Paulo, Brazil, p. 446. 3. Töpffer R. Essai de physiognomonie. Geneva; 1845. 4. Gombrich E.H., Hochberg J., Black M. Arte, percepción y realidad. Barcelona: Ed. Paidós; 1973:42. 5. Brunwick E, Reiter L. Eindrucks Charaktere Schematisierter Gesichter. Zeitschrift Psychol. 1937;142:67–134.

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6. Gombrich E.H., Hochberg J., Black M. Arte, percepción y realidad. Barcelona: Ed. Paidós; 1973:59. 7. Rubin M. Non-phenol chemical peels. Annals of the International Symposium “Recent Advances in Plastic Surgery“. RAPS/90. March 3–5, 1990. São Paulo, Brazil, p. 614. 8. Fournier P. Le Filling dermique au collagène autologue. Liposculpture, ma technique. Paris: Arnette; 1989:269–272. 9. Toledo LS. Syringe liposculpture: a two-year experience. Aesthetic Plast Surg. 1991;15:321–326. 10. Carpaneda CA, Ribeiro MT. Study of the histological alterations and viability of the adipose graft in humans. Aesthetic Plast Surg. 1993;17(1):43–47.

 

 

SECTION II • Aesthetic Surgery of the Face

9.1

Editors’ perspective: surgical facial rejuvenation Alan Matarasso

The publication of these volumes marks the 5th edition of this iconic series. Considering that plastic surgery is a specialty that is less than 100 years old, it is remarkable to note that these books have been in print for the majority of plastic surgery’s existence. The authors of these chapters are like a “Who’s Who” of the giants in plastic surgery, and the table of contents of each series is like a precious time capsule, reflecting the modern-day evolution in the expansion and scope of plastic surgery. From the inclusion of hand surgery and craniofacial surgery in the 1970s and 1980s to plastic surgery, to the nascent field of microsurgery that began in the late 1970s and early 1980s and its ultimate application to every part of the body, each of these textbook editions has incorporated these surgical areas, further underscoring our mantra about being the only surgical specialty not limited to one anatomic region. This series of textbooks has continued to mature with our specialty. In the 1980s and 1990s we saw the introduction and refinement of liposuction to plastic surgery, and a society (Lipoplasty Society) was established and devoted solely to the field of liposuction. Now as this volume of aesthetic surgery indicates, non-surgical injectables, fillers and energy devices herald another major addition to the field of plastic surgery that began at the turn of this century. These non-surgical and minimally invasive procedures have continued to expand at an unparalleled rate. Another relatively new field in plastic surgery is massive weight loss surgery. With the lifesaving explosion in bariatric surgery procedures, plastic surgeons stepped in to help patients complete their weight loss metamorphosis, and thus began the era of bariatric plastic surgery. Moreover, we are now experiencing the integration of the plastic surgeon’s skills that are derived from microsurgery, craniofacial surgery, body contouring surgery, and aesthetic surgery to the increasing population of transgender patients. Proving once again that plastic surgeons are, above all, innovators. We adapt our expertise to serve our patient’s needs.

None of these subspecialties in plastic surgery exists in a vacuum, rather the fundamental principles of all of them cross-pollinate the entire spectrum of plastic surgery. The cornerstone of facial rejuvenation is undoubtably a facelift. Many other related surgical and non-surgical procedures compliment, enhance, or even delay surgery, but there is currently no alternative that has the ability to achieve the same overall outcome of a facelift. Understanding the complex anatomy of the face is essential to understanding the aging process and selecting a tailored approach to each situation. In surgery, mastering a routine is useful. That routine should serve as a flexible template that can be adjusted to the unique goals, nuances and anatomy of each patient, in order to deliver consistent results. Facelift had long been an operation of wide tissue undermining, skin tightening, and defatting. As our understanding of aging and anatomy advanced, surgeons began to treat routinely the SMAS/platysma layers and, more recently, the fat compartments of the face that were deflated with advancing age. We have added adjunctive perioral rejuvenation for aging, elongated, deflated, or downturned lips, as well as resurfacing and treatments that are beneficial to the quality of the skin. Since the last edition of this textbook, the neck has also been parsed out as a separate part of a “full” facelift and is now often selectively treated independently. In selected cases of neck surgery, the deeper anterior neck structures can also be surgically modified to achieve a more sculpted and youthful appearance. What is evident throughout these chapters, is that we now have a firmer grasp on the anatomic etiology of facial aging and how to correct the stigmata it creates. Some of our finest surgeon contributors in the world demonstrate their methods throughout these volumes. From that, it is also clear that there are numerous different ways to reach the end zone.

SECTION II  •  Aesthetic Surgery of the Face

9.2 Facial anatomy and aging Bryan Mendelson and Chin-Ho Wong

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Introduction

Regions of the face

The pathogenesis of facial aging is largely explained on an anatomical basis, particularly the variations in the onset and outcome of aging seen in different individuals. Surgical anatomy is a particular branch of anatomy that focuses on specific surgical objectives. In contrast, traditional anatomy deals with bodily structure from an evolutionary and comparative perspective. Understanding of ambiguous dissection findings is explained by these related aspects. This chapter is on surgical anatomy of the face as it relates to the performance of facelifts. An anatomical approach to surgical rejuvenation of the face provides the way of obtaining a ‘natural’ result that is safe, with minimal morbidity and results that are lasting (Video Lecture 9.2.1). Fundamental to safety when operating in the face is the surgeon having a firm grounding in the principles on which the facial soft tissue layers are constructed.1 Understanding of the facial nerve branches and their relation to the soft tissue layers, retaining ligaments and soft tissue spaces is crucial in predicting the location of the facial nerves. This is most important in addressing the overriding concern when performing surgery, the course and location of the facial nerve branches. The development of facial laxity with aging of the face occurs primarily in the mobile superficial fascia, immediately superficial to the ‘deep plane’ or layer 4 as will be described. A core principle of plastic surgery, as advocated by Pare, is to ‘restore to their place things which are displaced’.2 Many facelift techniques have been utilized using various planes of dissection. Operating in the surgical plane is therefore the logical plane to dissect in facelifts. The surgical anatomy described here is intended for surgeons to enhance their ability and margin of safety when performing deep plane facelift surgery.

The traditional approach to assessing the face is to consider the face in thirds (upper, middle and lower thirds).3 While useful in selecting surgical procedures to address the patient’s concerns, this approach limits conceptualization, as it is not based on the function of the face. From a functional perspective, the face has an anterior aspect and a lateral aspect, which is distinctively different. The anterior face, which is the face proper, is highly evolved for communication, including facial expression. In contrast, the lateral face, which is concealed by hair in most animals including non-human primates, essentially covers the structures involved in mastication.4 A vertical line descending from the lateral orbital rim is the approximate division between the lateral and the anterior face. This corresponds internally with a series of facial retaining ligaments located along this line, which provide the structural basis for the demarcation (Fig. 9.2.1). The mimetic muscles of the face are located within the superficial fascia of the anterior face, predominantly in relation to the eyes and the mouth. This highly mobile area of the face is designed to allow fine movement, which predisposes it to the development of laxity with aging. In contrast, the lateral face is relatively immobile as it passively overlies the structures to do with mastication, which are located in relation to the deep fascia, the temporalis and masseter muscles, with the parotid gland and its duct. The only significant superficial muscle in the lateral face is the platysma in the lower third, which extends up to the level of the oral commissure. The soft tissues of the anterior face should be considered in two parts: (A) the part that overlies the skeleton proper; and (B) the highly specialized sphincters that overlie the bony cavities.5 The soft tissues that overlie the orbital and oral cavities are modified, as the cavities cannot have a deep fascia layer to provide support. An adaption is needed to compensate for

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this absence of usual support from behind. From necessity, the support comes from a system of specialized retaining ligaments attaching to the rim of the bony cavities. The fixation at the transition zones (between areas that overlie the skeleton and the bony cavities) is not apparent in youth, but become increasingly evident with aging.

the five-layered arrangement are most clearly understood by studying the scalp and forehead, whose soft tissues have been ‘distended’, as a consequence of the evolutionary expansion of the underlying cranial vault (necessary to accommodate the highly developed frontal lobe in humans) (Fig. 9.2.2). Layer 4

Surgical anatomy of the face, layered anatomy, SMAS, facial spaces and retaining ligaments Conceptually the facial soft tissues are organized in five concentric layers:1,5 (1) skin; (2) subcutaneous tissue; (3) musculo-aponeurotic layer; (4) loose areola tissue; (5) deep fascia. Significantly, the layers are not uniform across the face. Each layer varies in thickness according to the particular type of contained tissue, in accordance with the specific function of the region. Even the skin, the simplest layer to understand, is not homogeneous. The thickness of its epidermis and dermis varies according to the region of the face. The principles of

Figure 9.2.1  Regions of the face. The mobile anterior face is separated from the relatively fixed lateral face by a vertical line of ligaments (shown in red). The mobile anterior face is functionally adapted for facial expression while the lateral face passively overlies the masticatory structures. The ligaments are (from above): temporal, lateral orbital, zygomatic, masseteric and mandibular ligaments. The prezygomatic space allows a functional separation of the crowded midcheek structures into two separate but overlapping parts. The orbital-related structures, orbicularis oculi and the orbicularis retaining ligament, are superficial, extending into the roof of the prezygomatic space (shaded blue). The perioral part below is deeper (shaded yellow), where it has a skeletal attachment beneath the floor of the prezygomatic space. These deeply attached perioral structures include the zygomatic muscles and the zygomatic ligaments.

Figure 9.2.2  The basic five-layered construct of the facial soft tissues is most readily understood in the scalp. While this same construct continues over the entire face, for functional purposes there are significant regional modifications. Layer 4, the most variable layer, contains soft tissue spaces alternating with retaining ligaments. In addition, the facial nerve branches travel through layer 4, where they remain outside the spaces and then ascend to layer 3 in close relationship with retaining ligaments. (Inset). Showing the facial nerve branches ascend across layer 4 where they are under the protection of a ligament.

Surgical anatomy of the face, layered anatomy, SMAS, facial spaces and retaining ligaments

Layers

1

Dermis

2

Retinacular cutis

3

SMAS

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Dissection level 2a. Subcutaneous, superficial

2b. Subcutaneous, deep 4. sub-SMAS

4

Retaining ligament

5

Periosteum 6. subperiosteal

(the loose areolar tissue) is the layer that allows the superficial fascia (defined as the composite flap of layers 1 through 3) to glide over the deep fascia (layer 5), as noted with facial expression. For example, the frontalis functions independent of the deeper muscle of mastication, the temporalis. The ‘simplified’ anatomy over the scalp gives the basic prototype of layer 4. For the most part, this plane is essentially an avascular gliding plane space. At the boundaries of the scalp across the supraorbital rim and along the superior temporal lines, the scalp of the forehead is firmly anchored by ligamentous attachments to the periosteum. Vital structures, the nerves, vessels and lymphatics, are not in the ‘space’, but are located in close proximity to the retaining ligaments when transitioning in their course from deep to superficial. The principles of construction remain the same in other parts of the face, although with greater complexity. This relates to the evolutionary compaction of the midface structure due to the absence of forward projection of the human mid face (as is present in other species) as well as the prominence of the orbital and oral cavities at the expense of solid bone. This reduces the amount of bony platform available for the attachment of muscles and retaining ligaments. The five soft tissue layers are secured to the facial skeleton by an elaborate system of retaining ligaments that bind the dermis to the skeleton (or deep muscle fascia, where the facial skeleton is covered by the muscles for mastication). The components of this multi-linked fibrous support system pass through all layers (Figs. 9.2.3 & 9.2.4).6 The descriptive terms layer and level are used almost interchangeably, although having a somewhat different connotation. The plane of surgical dissection of a target support layer, such as the SMAS (layer 3), is not within the layer but at a level above (deep subcutaneous level, layer 2) or below (in layer 4), or both (see Fig. 9.2.3). Layers 2 and 4 are the dissection layers and in them the surgical dissection level may be superficial or deep.

Layer 1: skin The epidermis is a cell-rich layer composed mainly of differentiating keratinocytes and a smaller number of

Figure 9.2.3  The multi-link fibrous support system concept, based around retaining ligaments, whose form can be likened to a tree. The ‘trunk’ of the ligament attaches the soft tissues to the periosteum of the facial skeleton or deep muscle fascia. The ligaments pass through all soft tissue layers, fanning out as multiple branches through the SMAS to eventually insert into the dermis. The ligamentous component in the subcutaneous layer is seen as the retinacular cutis. The possible dissection levels are indicated by the horizontal dotted lines.

Figure 9.2.4  The retaining ligaments of the face appear in three morphological forms: true ligaments, septae and areas of adhesion.

pigment-producing melanocytes and antigen-presenting Langerhans cells. A rich vascular plexus is an important component of the dermis. The thickness of the dermis relates to its function and tends to be inversely proportionate to its mobility. The dermis is thinnest in the eyelids and thickest over the forehead and the nasal tip. The thinner the dermis, the more susceptible it is to qualitative deterioration aging changes like wrinkling and creases formation.

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Layer 2: subcutaneous tissue The subcutaneous layer has two components: the subcutaneous fat, which provides volume, and the fibrous retinacular cutis that binds the dermis to the underlying superficial musculo-aponeurotic system (SMAS) of the face.7,8 Of note, the retinacular cutis is the name given to that part of the retaining ligament that passes through the subcutaneous tissues. The amount, proportion and arrangement of each component varies in different regions of the face. In the scalp, the subcutaneous layer has uniform thickness and consistency of fixation to the overlying dermis. In contrast, in the face proper, the subcutaneous layer has significant variations in thickness and attachments. In highly specialized mobile areas, such as the eyelids and lips, the subcutaneous layer is significantly compacted such that fat may appear non-existent. In other areas, such as the nasolabial segment, it is thick.5 In areas with thick subcutaneous tissue, the retinacular cutis lengthens significantly, predisposing its fibers to distention and weakening with aging. Within the subcutaneous tissue, the overall attachment to the overlying dermis is stronger and denser than the attachment to the underlying SMAS. This is a result of the tree-like arrangement of the retinacular cutis fibers (see Fig. 9.2.3), with fewer but thicker fibers deep as its rises through the SMAS then progressively divides into multiple fine microligaments as they reach the dermis. This explains why dissection is easier to perform at the deep subcutaneous level (just on the surface of the underlying SMAS) than more superficially nearer the dermis, as there are fewer retinacular cutis fibers and the subcutaneous fat here does not attach directly to the outer surface of the underlying SMAS. Furthermore, the retinacular cutis fibers are not uniform across the face. They vary in orientation and density according to the anatomy of the underlying deeper structures.7 As will be apparent when the anatomy of the underlying layer 4 is described, at the location of the retaining ligaments, the vertically oriented retinacular cutis fibers are most dense and are the most effective in supporting for the overlying soft tissues and in so doing, forms boundaries that compartmentalize the subcutaneous fat. These areas, such as the so-called McGregor’s patch over the body of the zygoma, often require sharp release to mobilize. In between these retaining ligaments in layer 4 are located the soft tissue spaces of the face, that facilitate the mobility of the superficial fascia over the deep fascia. Where the subcutaneous fat overlies a space, the retinacular fibers are less dense and oriented more horizontally. This has a surgical significance as the tissues tend to separate with relative ease, often with just simple blunt finger dissection (Fig. 9.2.5). The variation in the density and orientation of the retinacular cutis fibers in the subcutaneous fat is the anatomical basis for the ‘superficial subcutaneous fat’ compartments.9–11 Dye injection into the subcutaneous fat results in staining of the fat in discrete compartments. While the relevance of superficial subcutaneous fat compartments remains debated, anatomically, the compartments are defined by their retaining ligaments boundaries.12

Layer 3: musculo-aponeurotic layer The muscles of facial expression are unique and fundamentally different from skeletal muscles beneath the deep fascia

Figure 9.2.5  The effective strength of the retinacular cutis fibers varies in different areas of the face. Overlying the retaining ligaments, the fibers are more vertically orientated, more densely arranged and resist aging changes. Whereas, overlying a space the retinacula fibers are more horizontal and less dense. This structure allows the mobility required for muscle contraction, but the less supported roof over the spaces is prone to laxity with aging.

because of their situation within the superficial fascia and the tissues they move are not bone but the soft tissues of which they are a part. All muscles of facial expression have either all or the majority of their course within layer 3. They are predominantly located over and around the orbital and oral cavities. In the prototype scalp, the occipital-frontalis moves the overlying soft tissue of the forehead, while its undersurface glides over the subgaleal aponeurotic space (layer 4). Layer 3 is continuous over the entire face, although for descriptive purposes, different names are given to certain parts according to the superficial muscle within. It is called the galea over the scalp, the temporoparietal (superficial temporal) fascia over the temple, the orbicularis fascia in the periorbital region, the SMAS over the mid and lower face and platysma in the neck.13 Within layer 3, the facial muscles themselves have a layered configuration, with the broad, flat muscles forming the superficial layer over the anterior aspect of the face. The frontalis covers the upper third, orbicularis oculi the middle third and the platysma the lower third. The muscles of this superficial muscle layer have minimal direct attachment to the bone. They are stabilized indirectly to the skeleton by the vertically oriented retaining ligaments at their periphery, as noted earlier. The frontalis is fixed along the superior temporal line by the superior temporal septum, the orbicularis oculi laterally by the lateral orbital thickening and the orbicularis retaining ligament, and the platysma at its upper border by the lower key masseteric ligament and medially by its mandibular attachment. The deeper muscles in layer 3 have bony origins to provide greater functional control of the sphincters over the bony cavities. Particularly around the mouth, the dynamic aperture of the expansile oral cavity, which has elevators (zygomaticus major and minor, levator labii superioris, levator anguli oris). Levator labii superioris alaeque nasi and depressor muscles (depressor anguli oris, depressor labii inferioris) and mentalis.1 In relation to the orbital cavity, deep muscles are limited to the corrugator supercilii and procerus.

Layer 4 Layer 4 is the plane in which dissection is performed in subSMAS facelifts, aptly named by Hamra as the deep plane.14,15 It is a layer of significant complexity that contains the following structures: (1) soft tissue spaces; (2) retaining ligaments; (3)

Anatomy over the cavities in the skeleton

*

Figure 9.2.6  Topographical anatomy of layer 4 over the lateral face. Spaces (blue), ligaments (red) and areas of important anatomy (stippled). The vertical line of masseteric retaining ligaments demarcates the transition between the stable lateral face and the highly mobile anterior face. The spaces over the zygoma and over the masseter allow for intermediate mobility. The triangular-shaped non-space areas, immediately above and below the arch of the zygoma, contain important anatomy; namely, the temporal and zygomatic branches of the facial nerve respectively, which proceed from lateral into the anterior face. The asterisk indicates the uppermost premasseteric area.

deep part of the intrinsic muscles, where passing from their more definitive superficial soft tissue position to obtain a deeper (level 5) bone attachment; and (4) facial nerve branches, passing from deep to superficial. Functionally, there is a series of soft tissue spaces in layer 4 that allow for movement of the periorbital and perioral muscle of facial expressions (located in the roof of the spaces) independent of the major muscles of mastication, which are beneath the deep fascia floor of the spaces.16 The retaining ligaments of the face are strategically placed within the boundaries between the soft tissue spaces (Fig. 9.2.6). In the lateral face, immediately in front of the ear, extending 25 to 30 mm forward of the ear cartilage to the posterior border of the platysma, is a broad area of ligamentous attachment, described by Furnas as the platysma auricular fascia (PAF).7 As no active facial expression occurs in this region, the dermis, subcutaneous tissue, aponeurotic part of the SMAS and the underlying parotid capsule (layers 1 to 5) are bound together as an area of retaining ligament. Layer 4 is reduced to a fibrous fusion layer, without a soft tissue space, as mobility of the superficial fascia is not required here. Whereas, in the anterior face where there is considerable movement, not only over but also around the bony cavities, the ligaments are significantly compacted and arranged around the rim of the bony cavities. The bone boundaries provide the last position where underlying deep fascia is present for ligamentous attachment. These important ligaments provide support for the mobile shutters of the cavities, the eyelids and lips. Importantly for the surgeon, the retaining ligaments also act as transition points for the facial nerve branches to pass from deep to superficial on their way to innervate their target muscles.

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The soft tissue spaces of the face are in two forms: (1) those described overlying bone, where the spaces allow the overlying superficial fascia to glide freely over the deeper layer 5; and (2) those overlying the bony cavities, such as the preseptal space of the eyelid over the orbit and the vestibule of the oral cavity under the lips and the lower nasolabial segment of the cheek.

Layer 5 Of potential confusion to surgeon anatomists is the definition of deep fascia; a term used to describe the dense connective tissue related to skeletal muscles and organs. It is accepted that the superficial fascia denotes several layers based on the loose connective tissue, layer 2, linking the layer 3 muscle and the skin. According to this way of describing fasciae, the deep fascia is considered to be all the connective tissue deep to the superficial fascia. From this perspective, layer 4 as described, would be considered part of the deep fascia. However, from a surgeon’s perspective of facial anatomy, layer 4 is a well-defined transition layer that functionally separates the superficial fascia from the deep fascia. The deep fascia, the deepest soft tissue layer of the face, has multiple components. It is formed by the periosteum where it overlies bone. Over the lateral face, where the muscle of mastication (temporalis and masseter) overlie the bone, the deep fascia is instead the fascial covering of the muscles, i.e. the deep temporal fascia and masseteric fascia. Over the anterior face there is not a deep fascia layer within the lids and lips, the mobile shutters that overlie the bony cavities. Here, the deep fascia is replaced by a mobile lining from the cavities, the conjunctiva and oral mucosa. The recently described ‘deep fat compartments’ is fat located in layer 5, having more generally been called preperiosteal fat.11,12 In the neck, the corresponding layer is the investing layer of deep cervical fascia, which covers the suprafyoid muscles and splits to form the submandibular space containing the submandibular gland. In contrast to expectation, the investing deep cervical fascia is thin, being almost translucent but tough and quite flexible, consistent with the significant mobility of the neck.

Anatomy over the cavities in the skeleton The general pattern of the five-layered anatomy is modified over the anterior face where the orbital, nasal and oral cavities are present (Fig. 9.2.7). Only the superficial fascia, the outer three-layer composite, continues into the soft tissue overlying the cavities. The SMAS layer within this composite includes the sphincteric orbicularis muscles that extend to the free edge of the soft tissue aperture of the eyelids and the lips. The retaining ligaments, which are such a key feature of the five-layered anatomy, are not present over the cavities. There are functional and anatomical transitions from the relative stability over the fixed areas to the high mobility of the soft tissue shutters over the cavities. In order to support this composite, the retaining ligaments are condensed, being compacted along the bony orbital rim (Fig. 9.2.8). This is the anatomical basis for the periorbital ligament around the orbit, of which the lower lid part is the orbicularis retaining

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Figure 9.2.8  The system of retaining ligaments situated across the temple and around the bony cavities, the orbital and oral, stabilize the soft tissue both over and around the cavities.

Figure 9.2.7  The soft tissue anatomy over the midcheek, showing the arrangement of the spaces (preseptal, prezygomatic and premaxillary) and the related ligaments (orbicularis retaining above and zygomatic and maxillary below).

(orbito-malar) ligament, which stabilizes the orbicularis oculi to the orbital rim periosteum.18–21 Around the oral cavity, the zygomatic ligaments arise from the periphery, being the body and arch of the zygoma and from the deep fascia near the medial edge of the masseter.22 The deeper components of the eyelids and lips are derived from the cavity they cover and are not an extension of the facial soft tissues. In the eyelids, the deeper lid muscles with their related aponeurosis (levator and capsulopalpebral fasciae) and the orbital fat are retained by a fascial system, the septum orbitale. The free edges of the upper and lower eyelids obtain their ligamentous support from the tarsal plates, with their canthal tendon attachments to the medial and lateral orbital rims. In the pretarsal area, the superficial and deep lid structures, the anterior and posterior lamellae, merge. Whereas, in the preseptal part, between the pretarsal area of the lids and the orbital rim, the lamellae remain separated by a soft tissue space, the preseptal space of the lower lid, which allows movement of the preseptal orbicularis over the orbital septum. This space provides the surgeon an atraumatic and bloodless dissection plane to access the lower eyelid and the midcheek further inferiorly. There is not an equivalent space in the upper lids as the preperiosteal fat pad over the superior orbital rim continues down on the surface of the septum orbitale adherent to the fascia on the underside of the orbicularis. The vestibule of the oral cavity overlies a significant extent of the buccal surface of the maxilla and mandible. This part of the skeleton underlying a ‘space’ is unavailable for deep

ligamentous support, as ligaments cannot cross the space of the vestibule. The large area of the perioral soft tissues that overlies the extensive vestibule has compromised support. Along with the extreme mobility of the lips and, particularly, the adjacent cheek with jaw opening, these tissues are particularly susceptible to aging changes. In fact, the indication for a lower facelift is largely to correct aging laxity of this unsupported tissue.

Facial spaces The subSMAS layer 4 is not homogeneous, but varies significantly in the type of content according to the different functional areas. In the lateral face especially, a large component of layer 4 consists of soft tissue ‘spaces’, which allow for mobility. The spaces have defined boundaries that are reinforced in strategically important areas by retaining ligaments.5,22,23 Significantly, these described spaces are actually areas of loose areolar connective tissue that are anatomically ‘potential spaces’. These are easily converted to ‘surgical spaces’ by blunt surgical dissection within the loose connective tissues. Even then, the created surgical space may not necessarily extend all the way to the structural boundaries of the space. By definition these are anatomically ‘safe spaces’, as no vital structures cross within the areolar tissue space, meaning all facial nerve branches are outside these spaces. The mobile roof is the least-supported part of the space, being more prone to developing laxity with aging, compared to the ligament-reinforced boundaries. This differential laxity accounts for much of the characteristic changes that occur with aging. Once a space has been surgically defined to its boundaries, the retaining ligaments in the boundary can then be precisely defined and released under direct vision to achieve the desired mobilization, while the vital structures

Facial spaces

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The upper temporal space provides safe surgical access to the lateral brow and upper midcheek.25,26 The space can be readily opened by blunt dissection to its boundaries. Once identified, the boundaries can then be released by precise dissection. The STS can be released sharply, taking care only to preserve the lateral (deep) branch of the supraorbital nerve, which runs parallel to the septum about 15 mm medial to it.18 The ITS provides a marker to the important anatomy here as the temporal branches of the facial nerve are located parallel to and immediately inferior to this septum. To release the ITS, the ceiling of the space is gently lifted off the deep temporal fascia floor, which three-dimensionalizes the septum in preparation for gentle release at the level of the floor, bearing in mind the frontal branches are located on the underside of the temporoparietal fascia in the ceiling, under the roof of the lower temporal area. Once released, the sentinel vein comes into view. Contrary to what is suggested by its name, the sentinel vein is not necessarily a good ‘sentinel’ to warn the surgeon of the imminent proximity of the temporal branches when dissecting inferiorly from the temple approach. See further discussion in section Facial nerve branches.

Prezygomatic space Figure 9.2.9  Structures around the orbital cavity in level 4. Above is the upper temporal space between the retaining ligaments of the temple; the superior temporal septum (STS) and the inferior temporal septum (ITS), both being extensions of the temporal ligamentous adhesion (TLA). There are no structures in the upper temporal space. The TLA continues medially as the supraorbital ligamentous adhesion (SLA). Below the bilaminar inferior temporal septum is the triangular-shaped lower temporal compartment (stippled), where the temporal branches of the facial nerve (TFN) course immediately inferior to the septum on the underside of the temporoparietal fascia. Also crossing level 4 in this area are the medial and lateral branches of the zygomaticotemporal nerve within the orbicularis retaining ligament, and the sentinel vein. The periorbital septum (PS, green) outside the orbital rim contains two areas of ligamentous thickening, the lateral orbital thickening (LOT) and the lateral brow thickening (LBT). ZFN, Zygomaticofacial nerve.

closely associated with the ligaments are preserved. A brief description of the surgically significant facial soft tissue spaces follows.

Upper temporal space In the temple overlying the temporalis muscle fascia are two compartments that are separated by the obliquely orientated inferior temporal septum (Fig. 9.2.9). The upper compartment is a surgical space while the lower compartment is not a space, but an area containing important anatomy.19 Both compartments are interposed between the superficial temporal fascia (temporoparietal fascia) and the deep temporal fascia (temporalis muscle fascia). Anatomically, the upper compartment is an extension of the forehead anatomy down into the upper temple, while the lower compartment is an upward extension of the upper cheek anatomy into the lower temple.24 The upper temporal space is separated from the forehead by the superior temporal septum (STS) along the superior temporal line, whereas antero-inferiorly, the inferior temporal septum (ITS) separates the upper space from the triangular-shaped lower temporal area that contains important anatomy. These two septae merge anteriorly at the triangular-shaped zone of adhesion called the temporal ligament.18

This triangular-shaped space overlies the body of the zygoma, its floor covering the preperiosteal fat and origins of the zygomatic muscles. The space allows contraction of the orbicularis oculi (pars orbitale) in its roof, independent of the zygomatic muscles under the floor. Contraction of the overlying orbicularis elevates the prezygomatic soft tissue roof. When these tissues have significant laxity the contraction results in significant movement of the skin toward the lateral canthus, forming zygomatic smile lines (below the crow’s feet) (Fig. 9.2.10).19 With aging laxity the resting position of the roof of the space is at a lower level. This results in a greater amplitude of movement on orbicularis contraction, which exaggerates the zygomatic smile lines.

Premaxillary space This quadrangular-shaped space overlies the maxilla, medial to the prezygomatic space. Its floor is formed by the levator labii superioris on which it overlies. The space allows independent movement of the closely related muscles, orbicularis oculi in the roof, and levator labii superioris under the floor (Fig. 9.2.11). Laxity of the roof of the premaxillary space contributes to deepening of the nasolabial fold with aging.

Premasseter spaces The area overlying the lower two-thirds of the masseter, inferior to the parotid gland, is a large area of ‘glide plane’ space, which is analogous to the temporal space in that it overlies the deep fascia of a muscle of mastication (Fig. 9.2.12).22 This gliding soft tissue plane allows wide jaw opening without restriction or distortion of the overlying soft tissues. The roof of the larger, lower premasseter space is formed by the platysma, which continues over the anterior face to the oral commissure. The upper edge of the platysma is stabilized in position by the lower key masseteric ligament, and does not extend higher than this to be in the roof of the adjacent upper space. Laxity in the roof of the lower space, particularly

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Figure 9.2.11  The anatomy and key relations of the prezygomatic and premaxillary spaces and the tear trough ligament. The prezygomatic space overlies the origins of zygomaticus major and minor. The premaxillary space overlies levator labii superioris with the infra-orbital nerve beneath, the angular vein immediately lateral to the space and the angular artery immediately medial. ORL, Orbicularis retaining ligament; TTL, tear trough ligament. Figure 9.2.10  The prezygomatic space overlies the body of the zygoma. The origins of the zygomatic muscles extend under the floor between preperiosteal fat. The roof is formed by the orbicularis oculi lined by the thin suborbicularis oculi fat. The upper ligamentous border, formed by the orbicularis retaining ligament, is not as strong as the zygomatic ligament-reinforced lower border.

anteriorly, where it has a weakened attachment to the anterior masseter and its inferior boundary, contributes to the formation of the jowl.

Middle premasseter space The middle premasseter space is a small rectangular space cephalad to the lower premasseter space (Fig. 9.2.13).27 As in the lower space, the floor of the upper space is formed by the masseter fascia, but the roof is formed here by the SMAS without platysma. The upper space is important in subSMAS facelifts, as it provides an anatomically safe area to dissect, in proximity to the upper and lower buccal branches of the facial nerve. Significantly, the nerves are located immediately outside the space, within its upper and lower membranous boundaries respectively. The parotid duct is closely associated with the upper membranous boundary of the space, where it courses immediately deep to the upper buccal branch of the facial nerve.

Buccal space The buccal space is located in the anterior face above the level of the oral commissure. It is a deep facial space, being like

the submandibular space (which contains the submandibular gland), in that it is deep in the deep fascia (layer 5).28,29 The space and its major content, the buccal fat pad, facilitate movement of the overlying nasolabial segment of the midcheek as well as buffering this area during major jaw opening. With aging and attrition of the boundaries, particularly of the most inferior masseteric ligaments, the platysma becomes less firmly bound to the masseter. This allows the buccal space to enlarge, as a consequence of which, the buccal fat prolapses inferiorly below the level of the oral commissure into the lower face. As the buccal fat then comes to overlie the anterior border of the lower part of the masseter, its volume contributes to increased prominence of the labiomandibular fold and jowl.

Retaining ligaments of the face It is a fundamental concept that the retaining ligaments function to bind all five layers of the facial soft tissues. As a consequence, the ligaments are the anatomical basis for the formation of cutaneous grooves (seen between areas of laxity/ bulges). As an example, the midcheek, where the tear trough– orbicularis retaining ligament complex is the key retaining ligament of the upper midcheek.30 It is located just outside the orbital rim and closely follows the edges of the rim. This retaining ligament system separates the bony cavity (the orbit) from the bony platform of the midcheek skeleton below. This ligament functions to stabilize and secure the soft tissues of

Retaining ligaments of the face

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Figure 9.2.12  The rhomboidal-shaped lower premasseter space overlies the lower half of the masseter. The platysma forming the roof does not extend over the middle space. The posterior border of the space extends to edge of the parotid. The anterior border curves forward inferiorly, reflecting the shape of the lower masseter and is reinforced by the masseteric ligaments near the anterior edge of muscle. The inferior boundary is mobile, mesentery-like and does not contain any ligament. Weakness of the platysma roof at the lower anterior and inferior boundaries contributes to the formation of the jowl, immediately behind the strong mandibular ligament. The buccal space containing the buccal fat is anterior to the key masseteric ligaments. All facial nerve branches course around and outside the spaces. The surgically important mandibular branch, after leaving the parotid, courses under the inferior boundary of the space then rises onto the masseter surface before reaching the mandibular ligament.

the lower eyelid where it transitions from the relative stability over the bone to the mobile area over the orbital cavity. The tear trough ligament is a true osteocutaneous ligament originating from the maxilla and inserting into the dermis of the nasojugal groove, the tear trough, passing through and binding all five soft tissue layers.30 This ligament is the anatomical basis for the tear trough deformity (see Fig. 9.2.11). The tear trough ligament continues laterally as the orbicularis retaining ligament, which is the anatomical basis for the palpebromalar groove. The continuity of the tear trough ligament with the orbicularis retaining ligament explains the observation that, as aging progresses, the tear trough becomes continuous with the palpebromalar groove to form the prominent cutaneous groove, sometimes called a prominent ‘lid–cheek junction’. This demonstrates the key role of the retaining ligaments in the formation of the cutaneous grooves that appear with aging. Figure 9.2.13  The middle space, overlies the anterior masseter, cephalad to the lower space and within the anterior concavity of the parotid. The upper and lower buccal trunks of the facial nerve course immediately outside the space, as does the parotid duct, just within the upper and lower membranous boundaries. The masseteric process of the buccal fat pad, when large, is the only content in this space.

Facial nerve branches The danger zones for facial nerve injury are well described in the literature. However, this is of limited value to the

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Figure 9.2.15  Modular construction of the face showing in layer 4 the ligaments and neurovascular structures passing outward in the interval between spaces.

Figure 9.2.14  Illustration to emphasize the location of the facial nerve branches and their course relative to the spaces and ligaments. The nerves course outside the spaces at all times in the lateral face. As they approach the ligamentous boundary into the mobile anterior face, the facial nerve branches ascend from deep in layer 4 to superficial layer 4, always in close, protective relationship with the retaining ligaments within the boundary. The interconnecting nerve branches between adjacent nerve trunks are located ii immediately sub-SMAS.

surgeon due to the topographical 2D perspective this gives of the expected course of the nerve relative to surface landmarks.31–33 Surgical confidence when approaching the nerve surgically comes from having a 3D understanding of the course of the nerve relative to the layered anatomy as described above and visually identifying the nerves in relation to defined landmarks (Fig. 9.2.14).34 The trunks of the facial nerve, while having some variability in their exact location as they travel to innervate their target muscles of facial expression follow certain anatomical principles. Specifically, nerve branches transition from deep to superficial in close association with retaining ligaments as these provides protection for the vulnerable nerves. The facial nerve branches enter the face at a deep level as they emerge from the parotid gland, then continue in the deep fascia of the lateral face. As they approach the anterior face near the anterior border of the masseter, the branches traverse layer 4, ascending to reach the underside of the mimetic muscles layer (layer 3). It is at these transition points across layer 4 that the nerves are at greatest risk of injury during facelift surgery 27,35,36 (Fig. 9.2.15). Surgical release of these ligaments, performed to obtain the needed mobility, must be performed with extreme care on account of the proximity of the nerves. The temporal and mandibular branches are the most significant in terms of surgical risk because of the lack of cross innervation of their target muscles. The surface marking of the temporal branch of the facial nerve along the Pitanguy line, is from a point 0.5 cm below the tragus to a point 1.5 cm lateral to the supraorbital rim.37–40 It is traditional teaching that once the temporal branches exit the parotid, they immediately travel superficially from the deep fascia and come to lie just deep to the SMAS where they cross the arch of the zygoma. Because of its superficial location, surgical

transection of the SMAS here, so-called high SMAS transection (i.e., at or above the arch), had generally been discouraged. However, it is now apparent that the temporal nerve branches cross the zygomatic arch deeper than previously thought. A histological study confirmed that the temporal branches are in transition from where they exit the parotid inferior to the zygomatic arch, to where they enter the underside of the temporoparietal fascia some 2 cm above the arch.41 They course deep in layer 4, superficial to the periosteum, here protected by a fascial, fatty layer, which is an upward prolongation of the parotid-masseteric fascia, named the parotid-temporal fascia. The temporal branches make their transition to the underside of the temporoparietal fascia (layer 3) between 1.5 cm and 3 cm above the zygomatic arch. From here the nerves remain on the underside of the temporoparietal fascia (layer 3). The transition is always before the nerve reaches the sentinel vein further cephalad. When dissecting from the temporal approach, once the sentinel vein is visualized, the temporal branches are in the lower temporal compartment in a wafer-like layer of fat on the underside of the temporoparietal fascia.18 Accordingly, when approaching from the temple, dissecting in the temporal space (layer 4), the safe plane of dissection is right on the deep temporal fascia floor, as the temporal nerves are located just superficial in level 4 above the level of dissection on the floor. Once the sentinel vein is clearly visualized, the dissection would have passed the temporal nerves. For this reason, the name sentinel nerve is misleading as the vein is supposed to herald the temporal branches. However, when the dissection is from above, logically through the temporal space once the vein is visualized, the dissection has already passed these branches. The zygomatic branch exits the parotid gland deep, inferior to the zygomatic arch and cephalad to the parotid duct. It travels with the transverse facial artery horizontally across the masseter on the masseter fascia, heading toward the major zygomatic retaining ligament (that arises from the lower border of the body of the zygoma), immediately lateral to the origin of zygomaticus major. As the nerve approaches the lateral border of the ligament, it gives off a small vertically oriented motor branch to orbicularis oculi that enters the muscle at its inferolateral corner.42 The main zygomatic nerve continues its course by passing beneath zygomaticus major and then zygomaticus minor, which it supplies from their deep aspect.42–44

Aging changes of the face

The use of precise dissection in this area of important anatomy, using gentle vertical spreading of blunt-tipped scissors, is fundamental to avoiding damage to the zygomatic nerve and the orbicularis motor branch while always staying superficial to zygomaticus major. The upper buccal trunk exits the parotid approximately in line with the parotid duct, but is superficial to it, and continues deep to the parotid–masseteric fascia, within the membranous upper boundary of the upper premasseter space.27 Approaching the anterior edge of the masseter, this branch leaves the masseter fascia floor and continues forward on the inferior aspect of the upper key masseteric ligament (see Fig. 9.2.14). The lower buccal trunk emerges from the parotid lower down, approximately at the level of the earlobe and remains within the masseter fascia floor of the lower premasseter space as it approaches the membranous interval between the premasseter spaces. Similar to the upper buccal branch, upon approaching the anterior masseter, the lower buccal trunk, while now in the interval just outside the space, transitions from deep to gain the underside of the SMAS in close association with the superior aspect of the lower key masseteric ligament. When immediately forward of the ligament on the underside of layer 3, the upper and lower buccal trunks send an interconnecting branch to each other before continuing their course to innervate the mimetic muscles of the anterior face. The upper buccal also sends an interconnecting nerve with the zygomatic trunk, as does the lower buccal branch share an interconnecting branch with the mandibular. This accounts for the overlap in muscle innervation by these nerves. The marginal mandibular nerve exits the anterior-inferior portion of the parotid near the angle of the mandible and remains deep to the platysma, in the investing deep cervical fascia. Its location is variable here, initially being somewhat inferior to the mandibular rim, although it can be located above or as low as 3 cm below the inferior border of the mandible (see Fig. 9.2.14). The nerve swings upwards before the mid body of the mandible and then transversely crosses superficial to the facial vein and artery. It is always located above the lower border of the mandible anterior to the facial artery. It innervates the depressor quadratus labii inferioris and mentalis from their deep surfaces. It may anastomose with the cervical and buccal branches to supply the depressor angularis oris and the cephalic portion of the platysma. It is at risk where fixed by its close association with retaining ligaments, both early in its course, within the PAF around the angle of the mandible, and then well anteriorly close to the mandibular ligament.45–48 Early in its course, the mandibular branch is in relation to the inferior boundary of the premasseter space. When dissecting here it is safer to focus on the underside of the platysma, which, being muscular, has inherent mobility where it overlies the mandible and the submandibular area. It is not necessary to dissect in the immediate vicinity of the mandibular branch, which is deeper with some mobility where it is in relation to the inferior extent of the lower premasseter space; hence, the reported variability of the location in this part of its course. The mandibular branch becomes more at surgical risk once it crosses the rim of the mandible and over the anterior-inferior corner of the masseter in a thin layer of fat, in which it remains until it intimately crosses the facial vein and then the artery, then the short distance between the artery and the mandibular ligament. The danger zone for injury extends from the angle

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of the mandible to its crossing of the facial artery over the area from the body of the mandible to a parallel line 3 cm below. The cervical branch exits the inferior part of the parotid gland slightly anterior to the angle of the mandible deep within the deep fascia. Early in its course the cervical trunk is close to the marginal mandibular nerve. As the nerves runs more distally, the cervical branch continues caudally while the marginal mandibular turns forward and then more cephalically to be located above the lower border of the mandible.49 The cervical trunk continues inferiorly parallel to the anterior border of the sternomastoid, approximately 1 cm anterior to the muscle, within the deep fascia. A series of smaller branches coming off the cervical trunk pass forward initially deep in the deep fascia, transitioning to more superficial at the deep surface of the platysma, sending terminal branches innervating the platysma along the deep surface. Cervical branch injury, either by traction or transection, is not uncommon in facelifts, with an incidence as high as 3%.50 Injury results in paralysis of the lip depressors (depressor angularis oris) of the affected side in patients who have a communicating branch with the marginal mandibular nerve. This injury has been called ‘marginal mandibular nerve pseudo-paralysis’ as it may mimic an injury of the marginal mandibular branch. Cervical branch injury can be distinguished from marginal mandibular nerve injury by the ability of the patient to evert the lower lip, an action of the mentalis that is innervated by the marginal mandibular branch. Fortunately, cervical branch injury has an excellent prognosis with expected full recovery in most patients within 3 weeks to 6 months. The danger point for injury of the cervical branch is at its point of transition from the deep investing fascia to the underside of the platysma.50,51 To mobilize the platysma, subplatysmal dissection may be needed. The platysma should be mobilized 4 cm below the angle of the mandible and bluntly elevated with a Trepsat dissector.52 Unfortunately, there is not yet sufficient detail on the cervical branch to satisfy the creative needs of surgeons. For example, in which part of the course of the cervical branch would it be logical and safe to perform a functional disruption, e.g., cryotherapy, of the cervical branch in order to overcome the clinical problem of recurrence of contractile platysma bands following platysma transection?

Aging changes of the face The youthful face has the general appearance of high rounded fullness, while the aging process is characterized by a look of depletion and sagging, suggestive of tiredness. Changes with aging occur at every level of the facial anatomy, starting with the facial skeleton. Current understanding of the aging process remains largely empirical, given that it is based on the effectiveness of treatments designed to satisfy the requirements of patients for a younger appearance. Historically, stretching of loose facial skin (traditional facelift), removal of apparent tissue excess (traditional blepharoplasty), tightening the dermis and evening the complexion (early phenol peels and CO2 laser resurfacing), and in recent years soft tissue volume augmentation (lipofilling and soft tissue fillers) have all had a positive impact on rejuvenating appearance. The success of each is attributed to having reversed a component of facial aging. Yet, when each of these modalities is continued as the

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sole treatment, to further reverse the aging appearance and contend with ongoing aging, the results tend to be bizarre, leading to the conclusion that multimodal therapy is required to appropriately reverse what must be multiple components of the aging process. An understanding of the changes that occur in the layered anatomy forms the basis for logical treatment. Changes of the skin are readily observable and changes in the skeleton affecting layer 5 can also be observed radiologically. Because the changes within the superficial fascia (layers 2 and 3) are not directly measurable, empiricism has remained prevalent. A correlation of the surface anatomy changes of aging with the anatomy of layers 2, 3 and 4 indicates that bulging occurs over the roof of soft tissue spaces, which stand out in contrast to the absence of bulging of the adjacent cutaneous grooves. The grooves reflect the restriction imposed by the dermal insertions of the retaining ligaments at the boundaries of the spaces. The extent to which the bulging reflects true elongation from primary tissue degeneration and laxity and how much is ‘apparent’ laxity secondary to loss of volume (skeletal and soft tissue) has yet to be defined.

Skin Skin aging is influenced by genetics, environmental exposure, hormonal changes and metabolic processes.53–59 With aging, the supple skin of youth becomes thinned and flattened, with loss of elasticity and architectural regularity. Atrophy of the extracellular matrix is reflected by the decreased number of fibroblasts and decreased levels of collagen (especially Types I and III) and elastin in the dermis. While chronological skin aging and photoaging can be readily distinguished and considered as s separate entities, both share important molecular features: altered signal transduction that promote matrix-metalloproteinase (MMP) expression, decreased procollagen synthesis and connective tissue damage. Oxidative stress is considered of primary importance in driving the aging process, resulting in increased hydrogen peroxide and other reactive oxygen species (ROS) and decreased antioxidant enzymes. These changes result in gene and protein structure alterations. Other environmental factors, notably smoking, accelerate skin aging by between 10 and 20 years. Increased collagenase and decreased skin circulation have been suggested as possible mechanisms. The muscles of facial expression flex the skin in a specific pattern. As the underlying collagen weakens and the skin thins, the dermis loses its capacity to resist the constant force of the muscles and these lines becomes etched in the skin and ultimately, even at rest.

Subcutaneous tissue The fibrous and fat components in the subcutaneous tissue are not uniform but arranged in discrete compartments. Due to the prominence of the subcutaneous fat in particular sites, specific names have been given, such as the malar fat pad and nasolabial fat.60,61 The boundaries of these subcutaneous compartments correspond to the location of the retaining ligaments, which pass superficially to insert into the dermis. In youth, the transition between compartments is smooth and non-discernible. With aging, the appearance changes to a series of convexities over these compartments separated by concavities between. These changes have been attributed to a

number of causes including fat descent, selective atrophy and hypertrophy and attenuation of the retaining ligaments that causes fat compartment malpositioning. It is, however, now apparent that fat descends minimally with aging.62–64 Distinct compartmentalization by the retaining ligaments holds the fat in its relative position.

Muscle aging Skeletal muscles, in general, have been noted to atrophy up to 50% with age.65 This is presumably applicable to the muscle of mastication, such as the temporalis and masseter as a result of decreased demand and deterioration of the dentition with aging. As yet, no specific study on the effect of aging on these muscles has been reported. The mimetic muscle of the face, in contrast to skeletal muscles, may not undergo the same degree of degeneration with aging because of their constant use with facial expression. The orbicularis oculi has been noted to remain histologically unchanged with no loss of muscle fibers, adherence to surrounding tissues or ptosis with aging.66 The upper lip elevators, zygomaticus major and levator labii superioris were also noted to remained unchanged with aging, based on magnetic resonance imaging (MRI) of their length, thickness and volume.67 In contrast, the upper lip orbicularis atrophies with aging, with decreased muscle thickness, smaller muscle fascicles and increase in surrounding epimysium.

Facial spaces and retaining ligaments The multi-linked fibrous support system attenuates with aging, with decreasing strength of the ligaments and increasing laxity. In general, the spaces expand with aging in proportion to the amount of movement. This is greatest with the lower premasseter space from the related mandibular movement and least over the zygoma. Expansion is related to the laxity that develops in the roof of the spaces and to a degree in the ligamentous boundaries, resulting in bulges between areas of relative fixation. Accordingly, the spaces dissect more easily in older patients, and the boundaries widen as the ligaments weaken. In young people, the spaces are more potential than real and do not open so easily with blunt dissection (Fig. 9.2.16). This aging changes of the prezygomatic space, with bulging of its roof, accentuated by its well-supported upper boundary, is the anatomical basis for the clinical entity variously described as malar mounds, bags or malar crescent. The presence of this ‘deformity’ indicates significant laxity, with the treatment directed to tightening the laxity of the roof. Surgically, the prezygomatic space forms an area of surgical reprieve, in contrast to the region inferior to it where there is not a space. Instead, here is an area of surgically important anatomy, in which safely locating zygomaticus major is a key objective. By first dissecting the prezygomatic space, the level of the upper surface of zygomaticus major is readily found, immediately beneath the floor of the space.

Bone changes The facial skeleton changes significantly with aging (Fig. 9.2.17) and this has a profound impact on the appearance of

Bone changes

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Figure 9.2.16  In youth, the spaces are tight glide plane spaces. With aging, and the reduction of tissue tone, the spaces expand, and to a larger degree where facial movement is greater, namely in the lower face where the lower masseteric ligament fence distends the most. The weakened attachment of the platysma to the masseter here allows this corner of the lower premasseter space to expand, contributing to the jowl. The reduction of ligament tone also allows descent of the buccal fat into the labiomandibular fold.

Figure 9.2.17  The arrows indicate the areas of the craniofacial skeleton most susceptible to resorption with aging and the relative degree according to the arrow size.

the face with aging (Fig. 9.2.18).68–80 At birth, the facial skeleton is underdeveloped and rudimentary. This explains why infants and toddlers often transiently have visibly distinct midcheek segments (despite excellent tissue quality), which disappear with the expansion of the midcheek skeleton with growth. Peak skeletal projection is probably attained in early adulthood. Thereafter, while certain areas continue to expand, selective areas of the facial skeleton undergo significant

Figure 9.2.18  Skeletal aging and its consequences. The stippled areas on the skeleton indicate the location where bone is resorbed and the relative amount. On the subjects left side, the stigmata of aging present in the facial soft tissues correspond to the areas of weakened skeletal support as a result of bone resorption.

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resorption. These are predominantly the soft dental bones, the maxilla and mandible, following the eruption of the secondary dentition, which had grown in these bones. The area with the most significant resorption is the midface skeleton, particularly that part contributed by the maxilla, including the pyriform area of the nose and, to a lesser degree, the superomedial and inferolateral aspects of the orbital rim and the prejowl area of the mandible.81,82 The resultant deficiencies in the skeletal foundation have a significant effect on the overlying soft tissues. In the midcheek in particular, retrusion of the maxilla results in increased prominence of the tear trough and the nasolabial folds. The retrusion of the facial skeleton causes the origin of the multi-linked fibrous retaining ligaments to be displaced posteriorly. This pulls the skin inwards, exaggerating the concavity between the areas of relative convexity that develop with aging. This loss of projection with deepening grooves gives the visual impression of tissue descent with aging. In patients who have a congenitally weak, meaning inadequately projecting, skeletal structure, the skeleton may be the primary cause of the manifestations of premature aging. Accordingly, in patients who suffer premature facial aging, a weakness of the relevant part of the underlying skeleton is immediately suspect and should be addressed in order to obtain better aesthetic results.

Regional changes observed with the aging face temple and forehead The skin of the temple differs from that of the forehead, being thinner and less firmly supported to the underlying layers. The loose attachment reflects the underlying temporal space, which is extensive, as well as the nature of the surrounding temporal ligaments. These are unlike other facial ligaments, being septal-like and do not continue through the thin, loose subcutaneous layer 2 over the temple. This explains why deep layer procedures in the temple are not as effective in toning the overlying skin as they are, for example, in the cheek. Corrugator muscle contraction is associated with the emotional states of grief and sadness.83 The transverse head of corrugator supercilii moves the eyebrow medially and produces vertical glabella lines. The oblique head of the corrugator, the depressor supercilii and the medial fibers of the orbicularis oculi act in concert to depress the medial brow and produce oblique glabella frown lines. The procerus, also a brow depressor, causes transverse nasal skin lines. Laterally, the action of the lateral fibers of the orbicularis oculi with the transverse head of the corrugator supercilii promotes lateral brow ptosis. The ptosis of the lateral brow together with, and to a lesser extent, the laxity of the skin with aging produces a pseudoexcess of the upper eyelid skin. Frontalis muscle hypertonicity from lateral brow skin hooding and its reaction to the action of antagonistic muscles (corrugator supercilii, orbicularis oculi and procerus) results in the development of transverse forehead skin lines.84 The medial brow, in contrast, seldom descends with aging and in fact may rise.85–87 The mechanism responsible for this includes the chronic activation of the frontalis muscle. This elevation of the brow/eyelid complex is to relieve visual field obstruction from either hanging excess eyelid

skin or from chronic ptosis from levator system weakness.84 Anatomically, the lateral extent of the frontalis muscle is at approximately the temporal fusion line (STS). Lateral to this, there is not an upward vector to counteract the downward pull of brow depressors and gravity on the lateral brow, which may explain why more descent occurs at the lateral brow.

The midcheek The midcheek is the anterior part of the midface.5 It is triangular in shape, bounded superiorly by the pretarsal part of the lower eyelid, medially by the side of the nose and the nasolabial groove below, and laterally around the lateral cheek where the arch of the zygoma meets the body. A smooth, rounded midcheek is a powerful image of youth and gives a certain freshness to the face. With aging, the three distinct segments of the midcheek become clearly discernible, as they become separated by the three cutaneous grooves of the midcheek: the nasojugal, palpebromalar and midcheek grooves. This “segmentation” of the midcheek has a profound impact on appearance that is responsible for the ‘tired’ look we associate with aging. The three segments of the midcheek reflect its structure, with each segment or module overlying a specific part of the midcheek skeleton (Fig. 9.2.19). The lid–cheek segment overlies the prominence of the inferior orbital rim, the malar segment overlies the body of the zygoma, and the nasolabial segment overlies the maxilla. The skeletal foundation of the midcheek borders the three bony cavities of the anterior face, the orbital, nasal and oral

Figure 9.2.19  The midcheek has three segments, of which the lid–cheek segment (blue) and the malar segment (green) are within the periorbital part. These are adjacent to the nasolabial segment (yellow), which is in the perioral part overlying the vestibule of the oral cavity. The boundaries of the three segments are formed by the three grooves, which interconnect like the italic letter Y. The palpebromalar groove (1) overlies the inferolateral orbital rim. The nasojugal groove (2) overlies the inferomedial orbital rim, then continues into the midcheek groove, or furrow (3).

Considerations for correcting aging changes of the face based on facial anatomy

cavities. Because of the many spaces and, therefore, limited bony support available, there is some intrinsic structural weaknesses of the midcheek. Three factors make the midcheek susceptible to aging changes: (1) the wedge shape of the soft tissue of the midcheek, which is thin above and thicker below; (2) the natural posterior incline of the midcheek skeleton, from the relative prominence of the infra­ orbital rim; and (3) the significant retrusion that occurs with aging as a result of resorption of the maxilla. This is not uniform, as the maxilla recedes more medially and inferiorly.82 With early aging, the retrusion of the maxilla, along with a slight descent of the wedge-shaped cheek soft tissue, results in an appreciable reduction of volume of the upper cheek. The result is that the small amount of orbital fat over the prominent edge of the inferior orbital rim (originally concealed by the volume of the upper cheek) now becomes revealed, especially the underside of the lid fat bulge over the middle part. The visual impression is of a ‘lengthened’ lower lid. At the same time, the increased thickness of the soft tissue mass over the lower cheek tends to conceal the degree of maxillary resorption and gives the profound visual impression that the soft tissue mass has descended into the lower part of the midcheek. Of the three segments of the midcheek, the lower lid segment changes the most dynamically with aging. It has two distinct grooves across its surface that vary in their expression during the aging process, often coexisting. The upper is the infratarsal groove at the junction of the pretarsal and preseptal parts of the eyelid. It defines the lower boundary of the pretarsal bulge. The pretarsal bulge in youth is the visual separation of the lid above and the cheek below. This so-called ‘high lid–cheek junction’ is located well above the infra-orbital rim and is a characteristic of youth. The infratarsal groove location does not change with aging, although its contour usually fades. The lower groove is the lid–cheek junction that relates to the lower edge of the preseptal part of the lid. It is not present in youth and appears with aging and then progressively deepens and descends slightly over time. Its shape, when it first appears, is a gentle “C”-shaped contour, but as it “descends”, particularly in its central portion, its shape changes to a progressively more angulated “V” shape with the medial side being formed by the developing nasojugal groove and the lateral side by the palpebromalar groove. The center of the V, the lowest and deepest part, has the nasojugal groove continuing down the cheek as the midcheek groove that separates the cheek into the malar and nasolabial segments. The reason why this contour demarcation changes, while the skin itself does not descend, is explained by the difference in the tissue layers. The orbicularis retaining ligament is not rigid where it is over the center of the inferior orbital rim in contrast to the medial and lateral ends. Accordingly, distention results in relative sliding between it and layer 3, the orbicularis oculi. As the lid–cheek junction becomes more prominent, it visually takes over from the infratarsal groove and becomes the new separation between the lower eyelid and the cheek. This is the basis for the commonly used, but inaccurate phrase “lengthening of the lid–cheek junction with aging”, which is, in fact the result of a visual shift from the prominence of the infratarsal groove in youth to the lid–cheek junction with age. Correction of the aging of the lid–cheek segment of the midcheek, has gained the colloquial name of ‘blending the lid–cheek junction’.

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Lower face The jowl and the labiomandibular fold in the lower face are not present in youth and develop with aging. With the description of the concept of soft tissue spaces of the face, and specifically the premasseter space, the mechanism for the formation of the jowl can now be understood on an anatomical basis.22 With the onset of aging, laxity develops in the roof of the premasseter space associated with attenuation of the anterior and inferior boundaries. The major retaining ligaments, the key masseteric and the mandibular, in contrast remain relatively strong and at these locations the superficial fascia remains firmly fixed to the underlying deep fascia. Distention of the weaker masseteric ligaments at the anterior border of the lower premasseter space (below the key masseteric ligament) and inferior displacement of the buccal fat (within the buccal space) is the anatomical basis for the development of the labiomandibular fold. The mandibular ligament demarcates the transition from the labiomandibular fold above and medial and the jowl below. The jowl develops as a result of distention of the roof of the lower premasseter space with resultant descent of the tissues below the body of the mandible. The more prominent the jowl, the more apparent will be the cutaneous tethering provided by the mandibular ligament. Accordingly, the anatomical solution to correcting these aging changes is to reduce the inferiorly displaced buccal fat and to tighten laxity in the roof of the premasseter space near the mandibular rim.

Considerations for correcting aging changes of the face based on facial anatomy Dissection planes The subcutaneous plane of dissection (layer 2) is historically the most commonly used plane in facelifts, either in isolation or more commonly with some form of SMAS management from the superficial aspect (Fig. 9.2.20).88–90 A distinction should be drawn between subcutaneous dissection over the lateral face from that over the anterior face. This plane of dissection is intrinsically “safe” as dissection remains superficial to the facial nerve branches at all times, this being the main appeal of the subcutaneous plane of dissection. The subcutaneous dissection can be performed either in the superficial subcutaneous level or deep subcutaneous level. In the former, there is a more uniform density of the retinacular cutis fibers as the multi-linked ligaments branch out before inserting into the dermis. The deep subcutaneous plane of dissection is on the outer surface of the SMAS (layer 3), also called supraSMAS, where fewer ligament fibers and vessels are encountered, although these are thicker and stronger. The deep subcutaneous layer is not uniform in its tenacity; rather, it mirrors the underlying anatomy in layers 3 and 4. Where it overlies the facial spaces it is inherently easier to dissect, while the areas that overlie ligaments are more strongly attached and usually require sharp surgical release. For example, over the malar eminence at McGregor’s patch, where the zygomatic ligaments are

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Figure 9.2.20  Possible levels for dissection and redraping in facelift surgery. Dissection can be performed through any one of three alternative layers, namely subcutaneous (level 2), subSMAS (level 4) and subperiosteal (level 6) for the upper two-thirds of the face. Redraping traction (arrows) is applied either to the skin (level 1), the SMAS (level 3) or the periosteum (level 5).

located, sharp release of the overlying retinacula cutis is usually required. In contrast, in the more mobile lower face over the premasseter space, the subcutaneous layer separates quite readily, usually requiring only blunt finger dissection, especially with the weakening and elongation of the facial structures with aging.

SubSMAS dissection (layer 4) In the scalp, this is the preferred tissue plane for dissection, as the scalp (the composite of layers 1, 2 and 3) readily separates from the underlying periosteum (layer 5) through the avascular areolar tissue with ease and inherent safety. Bruising and swelling is kept to a minimum because of this favorable anatomy. While the anatomical principles remain the same in the face proper, layer 4 is potentially the most dangerous plane to dissect in respect of the facial nerve branches which, having originated from deep in the face, transition through this layer, to innervate the facial muscles in layer 3. However, it should be appreciated that, similar to the situation in the scalp, where dissection performed to raise the flap in layer 4 gives a structurally integrated robust composite flap that can be effectively tightened, subSMAS dissection in the face offers the same advantages and potential benefits.91–93 Dissection can be performed safely in layer 4 by applying understanding of the 3D anatomy of the face described earlier; the key being the facial spaces, which provide safe access through this layer. Because these spaces are “predissected”, once correct access is obtained, the actual dissection is quick, atraumatic and unexpectedly easy. A prime example of this is the lower premasseter space, being the largest and most mobile space. To access the space, subcutaneous dissection is performed to approximately 30 mm anterior to the ear cartilage, through the zone of fixation, the PAF, where the fibrous SMAS is fused to the deep fascia including the parotid capsule.94 Because the objective of the surgery is to correct laxity in the mobile anterior face, the level of dissection used in the lateral face is of secondary importance. A further benefit of leaving the PAF intact is that the strength of this tissue is maintained, to be used for secure suture fixation. Once dissection has proceeded beyond the PAF (indicated by the posterior fibers of the platysma), the

Figure 9.2.21  Surgical entry into the lower premasseter space. As the premasseter space commences immediately forward of the anterior extent of the parotid, the surgical entry is planned to be through this part of layer 3, just forward of the platysma auricular fascia, which includes the parotid capsule. The ideal entry is immediately at the posterior extent of the platysma, as the platysma muscle is in the roof of the space. The posterior edge of the platysma may be more difficult to see with muscle atrophy with aging.

SMAS is then incised to provide direct access into the lower premasseter space (Fig. 9.2.21). The space can then be opened by gentle blunt dissection, to define the boundaries of the space. The premasseter spaces below and the prezygomatic space above form a series of spaces around the anterior face (Figs. 9.2.22 & 9.2.23). The boundaries of the spaces, reinforced by retaining ligaments, are where the important anatomy is located. These ligaments need to be precisely released to eliminate their tethering effect on the superficial soft tissues, which is inherently more difficult in younger patients as the ligaments are denser and stronger. Clear visualization, optimized by lifting the roof of the adjacent opened facial spaces, is beneficial. When blunt-tip scissors are used with repeated gentle, small-­amplitude vertical spreading of the blades, the surrounding fat and areolar tissue tends to separate, revealing the ligaments and the facial nerve branches in relation to

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deep temporal space to the lateral brow, the preseptal space to the lower eyelid, and the prezygomatic and the premaxillary spaces to the midcheek.95

Level 5

Figure 9.2.22  The subSMAS facial spaces are located around the mobile anterior face. In subSMAS facelifts these are ‘safe spaces’ for surgical dissection. The spaces are: 1a, lower premasseter space; 1b, upper premasseter; 2, prezygomatic space; 3, temporal space. The asterisk locates the surgically important (nonspace) area of anatomy overlying the upper masseter, lateral to the main zygomatic ligament, and lateral to zygomaticus major. The zygomatic branch of the facial nerve crosses the masseter fascia here, from the parotid border to continue deep to zygomaticus major.

Subperiosteal ‘lifts’ have the appeal of safety as far as facial nerve risk is concerned as the nerves are superficial to the dissection plane and the remote nerves never cross this plane.96–99 Subperiosteal lifts, however, have inherent limitations. The accumulated aging changes across all five tissue layers are elevated as part of the subperiosteal lift. Overcorrection is required to effect the desired changes of soft tissue shape and especially skin tone, to compensate for the ‘lift-lag’ phenomenon, which is proportionate to the thickness of the soft tissues and amount of laxity. Accordingly, subperiosteal lifting works best in those areas where the layers are more compact, as the lift-lag is minimized. This explains the popularity of subperiosteal brow lifts, as they are most effective. Where the layers are thicker, such as the nasolabial segment of the midcheek, the lift-lag phenomenon significantly limits the improvement that can be achieved. Because of the unyielding nature of the periosteum, extensive undermining beyond the target area is needed or alternatively a ‘periosteal release’ immediately beyond the area requiring the lift to isolate the area to a limited island of periosteum.

Placement of sutures

2

zm * 1b

1a

3

Figure 9.2.23  Intraoperative photograph of the deep plane facelift dissection (right side). The spaces are, from below: 1a, lower premasseter; 1b, upper premasseter; 2, prezygomatic; 3, upper temporal. The spaces on the masseter interconnect, providing for ease of surgical dissection with safety. Note the platysma roof of the lower space and the buccal branch crossing diagonally beneath the fascial floor of the lower premasseter space. *The upper premasseter area of surgically important anatomy between the lower border of the zygoma and the upper premasseter space is not a space. zm indicates zygomaticus major, which take origin off the body of the zygoma. The vertical orientation is surgical, due to the roof of the spaces being elevated by retraction. The lateral aspect of the tented-up muscle is partially concealed by the zygomatic ligament, also on stretch. The motor branch of the zygomatic nerve, also under tension, is seen passing straight up to the orbicularis.

them. With progressive lifting, the ligaments become more certainly defined as they vertically tighten further, at which time they can be safely released, while the nerves, being obliquely oriented, dislodge out of the way, unaffected by the controlled stretching. The subSMAS spaces can be used to safely and atraumatically access various part of the face, the

While adequate surgical release of ligamentous restraint is needed for mobility of areas of laxity medial to strong retaining ligaments, is the definitive surgical fixation achieves the desired effect by maintaining the mobilized soft tissues in their new position. The strength and tenacity of the superficial fascia is not uniform and diminishes with age. The areas where retaining ligaments are located have an inherent ligamentous reinforcement, making them ideal for suture placement (Fig. 9.2.24). It is also the location in which traction gives the most natural appearance, as these are the natural suspension sites of the face. Accordingly, the suture fixation should, in general, be placed where the retaining ligaments are located. Fixation sutures placed in subSMAS surgery function as replacements for the retaining ligaments that have either weakened or have been divided in order to mobilize the composite flap. Accordingly, the replacement sutures should replicate the quality of support provided by the original ligaments as the ‘mobile’ spaces remain. In this respect, braided permanent sutures are advantageous as they stimulate collagen and elastic fiber deposition within the suture, making it structurally similar to a ligament.100 The PAF, the diffuse ligamentous area on the preauricular part of the lateral face, provides an ideal area, both anatomically and physically, to fix the facelift flap, due to its inherent strength.

Summary This chapter has been structured to assist the surgeon reader to develop a conceptual understanding of facial anatomy and how it changes with aging. It is the framework that unifies the increasing amount of detailed anatomical information

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available in the literature. This chapter provides a foundation for understanding deep plane surgery, recognizing that surgeons with considerable experience are aware of more detail that is beyond the limited capacity of this chapter. Other observations may not yet be supported by formal anatomical studies, such as the subplatysma space. This knowledge, once understood, provides the anatomical foundation for the logical selection and application of surgical techniques for rejuvenation of the aging face.

Acknowledgments The authors wish to acknowledge the contribution of the Faculty of the Melbourne Advanced Facial Anatomy Course (MAFAC) for their input into the contents of this chapter. Also, we acknowledge the contribution of the MAFAC Tagliacozzi Research Fellow, Dr. Lennert Minelli, for critical review and anatomical updates. Figure 9.2.24  Concept of surgical fixation of the advanced flap harnessing the benefit of the ligament branching within the composite flap. This incorporates the diffuse ligamentous structural support within the sutured tissue of the flap to provide even and secure flap fixation into its advanced and tightened position.

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References

References 1. Mendelson BC. Facelift anatomy, SMAS, retaining ligaments and facial spaces. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. London: Elsevier Saunders; 2012:53–72. 2. Rohrich RJ, Timberlake AT, Afrooz PN. Revisiting the fundamental operative principles of plastic surgery. Plast Reconstr Surg. 2021;148(5S):117S–120S. 3. Nahai F. Clinical Decision Making in Face Lift and Neck Lift. In the Art of Aesthetic Surgery: Principles and Technique. St Louis: Quality Medical Publishing; 2005:898–926. 4. Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with periosteal fixation. Plast Reconstr Surg. 1992;89(5):822–833. 5. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek; facial layers, spaces, and midcheek segments. Clin Plast Surg. 2008;35:395–404. 6. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3):441–449. A discussion of the concept of facial soft tissue being arranged in concentric layers, and the SMAS as the ‘investing’ layer of the superficial mimetic muscles of the face. The relationship between the deep and superficial fascias is described, with acknowledgement of ‘areola’ planes and areas of dense fibrous attachments, including true osteocutaneous ligaments and other coalescences representing the retaining ligamentous boundaries of the face. Age-associated laxity of the retaining ligament was noted to be a key component of facial aging. 7. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11. 8. Furnas D. The superficial musculoaponeurotic plane and the retaining ligaments of the face. In: Psillakis JM, ed. Deep face-lifting techniques. New York: Thieme Medical Publishers; 1994. 9. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219–2227. 10. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2008;121(5):1804–1809. 11. Rohrich RJ, Pessa JE. The anatomy and clinical implications of perioral submuscular fat. Plast Reconstr Surg. 2009;124(1):266–271. 12. Surek CC, Beut J, Stephens R, Jelks G, Lamb J. Pertinent anatomy and analysis for midface volumizing procedures. Plast Reconstr Surg. 2015;135(5):818e–829e. 13. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58:80. 14. Hamra ST. Deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86:53. 15. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90:1. 16. Muzaffar AR, Mendelson BC, Adams Jr. WP. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002 Sep 1;110(3):873–884. 17. Deleted in proof. 18. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000;105(4):1475–1490. A through description of the retaining ligaments of the temporal and periorbital regions is given. The term ‘ligamentous adhesion’ is introduced to increase the understanding of the system, and there is emphasis on the relations of the temporal branch of the facial nerve and the trigeminal branches to structures visualized in surgery rather than to less useful landmarks, which are not. A discussion of age-related changes to the region complements one of surgical approach with respect to the anatomy described. 19. Mendelson BC, Muzaffar AR, Adams Jr. WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110(3):885–896. discussion 897–911.

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20. Ghavami A, Pessa JE, Janis J, Khosla R, Reece EM, Rohrich RJ. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg. 2008;121(3):994–1001. 21. Yousif NJ, Mendelson BC. Anatomy of the midface. Clin Plast Surg. 1995;22(2):227–240. 22. Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg. 2008;32(2):185–195. Introduces the concept of the ‘premasseter’ space, age-related changes, and utility for safe sub-SMAS dissection. Distinction is made between this space, over the lower part of the masseter, and another space overlying the upper part of the masseter where the neurovascular structures, the accessory lobe of the parotid gland and duct are located. The true shape of the anterior border of the masseter muscle is described, with the border ending antero-inferiorly at the mandibular ligament. This description completes the picture of the retaining ligaments as a continuous border separating the anterior and lateral parts of the face. The relations of the facial nerve branches, particularly that of the lower buccal trunk, to the masseter and its fascia is described. 23. Mendelson BC. Advances in the understanding of the surgical anatomy of the face. In: Eisenmann-Klein M, Neuhann-Lorenz C, eds. Innovations in Plastic and Aesthetic Surgery. New York: Springer Verlag; 2007:141–145. 24. O’Brien JX, Ashton MW, Rozen WM, Ross R, Mendelson BC. New perspectives on the surgical anatomy and nomenclature of the temporal region. Literature Review & Dissection Study. Plast Reconstr Surg. 2013;131:510. 25. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg. 2009;124(6):2118–2126. 26. Wong CH, Mendelson B. Facial soft-tissue spaces and retaining ligaments of the midcheek: defining the premaxillary space. Plast Reconstr Surg. 2013;132(1):49–56. 27. Mendelson BC, Wong CH. Surgical anatomy of the middle premasseter space and its application in sub-SMAS face lift surgery. Plast Reconstr Surg. 2013;132(1):57–64. 28. Kahn JL, Wolfram-Gabel R, Bourjat P. Anatomy and imaging of the deep fat of the face. Clin Anat. 2000;13(5):373–382. 29. Zhang HM, Yan YP, Qi KM, Wang JQ, Liu ZF. Anatomical structure of the buccal fat pad and its clinical adaptations. Plast Reconstr Surg. 2002;109(7):2509–2518. 30. Wong CH, Hsieh MK, Mendelson B. The tear trough ligament: anatomical basis for the tear trough deformity. Plast Reconstr Surg. 2012;129(6):1392–1402. 31. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: anatomic variations and pitfalls. Plast Reconstr Surg. 1979;64:781. 32. Gosain AK. Surgical anatomy of the facial nerve. Clin Plast Surg. 1995;222:241. 33. Seckel BR. Facial danger zones. Avoiding nerve injury in facial plastic surgery. St Louis: Quality Medical; 1994. 34. Owsley JQ, Agrawal CA. Safely navigating around the facial nerve in three- dimensions. Clin Plast Surg. 2008;35:469–477. 35. Ruess W, Owsley JQ. The anatomy of the skin and fascial layers of the face in aesthetic surgery. Clin Plast Surg. 1987;14(4):677–682. 36. Roostaeian J, Rohrich RJ, Stuzin JM. Anatomical considerations to prevent facial nerve injury. Plast Reconstr Surg. 2015;135(5):1318–1327. 37. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in facelifting. Plast Reconstr Surg. 1966;38 352–256. 38. Furnas DW. Landmarks for the trunks and the temporofacial division of the facial nerve. Br J Surg. 1965;52:694–696. 39. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989;83(2):265–271. 40. Agarwal CA, Mendenhall 3rd SD, Foreman KB, Owsley JQ. The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg. 2010;125(2):532–537. 41. Trussler AP, Stephan P, Hatef D, Schaverien M, Meade R, Barton FE. The frontal branch of the facial nerve across the zygomatic

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arch: anatomical relevance of the high-SMAS technique. Plast Reconstr Surg. 2010;125(4):1221–1229. 42. Alghoul M, Bitik O, McBride J, Zins JE. Relationship of the zygomatic facial nerve to the retaining ligaments of the face: the sub-SMAS danger zone. Plast Reconstr Surg. 2013;131:245e–252e. 43. Lowe JB 3rd, Cohen M, Hunter DA, Mackinnon SE. Analysis of the nerve branches to the orbicularis oculi muscle of the lower eyelid in fresh cadavers. Plast Reconstr Surg. 2005;116(6):1743–1749. 44. Ramirez OM, Santamaria R. Spatial orientation of motor innervation of the lower orbicularis oculi muscle. Aesthetic Surg J. 2000;20:107. 45. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg. 1962;29:266. 46. Nelson DW, Gingrass RP. Anatomy of the mandibular branches of the facial nerve. Plast Reconstr Surg. 1979;63:479. 47. Conley J, Baker DC. Paralysis of the mandibular branch of the facial nerve. Plast Reconstr Surg. 1982;70:569. 48. Huettner F, Rueda S, Ozturk CN, Ozturk C, Drake R, Langevin C, Zins J. The relationship of the marginal mandibular nerve to the mandibular osseocutaneous ligament and lesser ligaments of the lower face. Aesthet Surg J. 2015;35:111–120. 49. Ellenbogen R. Pseudo-paralysis of the mandibular branch of the facial nerve after platysmal face-lift operation. Plast Reconstr Surg. 1979;63(3):364–368. 50. Daane SP, Owsley JQ. Incidence of cervical branch injury with "marginal mandibular nerve pseudo-paralysis" in patients undergoing face lift. Plast Reconstr Surg. 2003;111(7):2414–2418. 51. Kwon TK, Choi YH. Asian facelift. Facial Plast Surg Clin North Am. 2021;29(4):471–486. 52. Pelle-Ceravolo M, Angelini Matteo A, Silvi Erminia S. Treatment of anterior neck aging without a submental approach: lateral skin-platysma displacement, a new and proven technique for platysma bands and skin laxity. Plast Reconstr Surg. 2017;139(2):308–321. 53. Montagna W, Carlisle K. Structural changes in the aging skin. Br J Dermatol. 1990;122(suppl. 35):61–70. 54. Wulf HC, Sandby-Moller J, Kobayashi T, Gniadecki R. Skin aging and natural photoprotection. Micron. 2004;35:185–191. 55. Hall G, Phillips TJ. Estrogen and skin: the effects of estrogen, menopause and hormone replacement therapy on the skin. J Am Acad Dermatol. 2005;53:555–568. 56. Sander CS, Chang H, Salzmann S, Müller CS, EkanayakeMudiyanselage S, Elsner P, Thiele JJ. Photoaging is associated with protein oxidation in human skin in vivo. Invest Dermatol. 2002;118(4):618–625. 57. Chung JH, Seo JY, Choi HR, et al. Modulation of skin collagen metabolism in aged and photoaged human skin in vivo. J Invest Dermatol. 2001;117(5):1218–1224. 58. Freiman A, Bird G, Metelitsa AI, Barankin B, Lauzon GJ. Cutaneous effects of smoking. J Cutan Med Surg. 2004;8(6):415–423. 59. Haruko C, Okada HC, Alleyne B, Varghai K, Kinder K, Guyuron B. Facial changes caused by smoking: a comparison between smoking and nonsmoking identical twins. Plast Reconstr Surg. 2013;132:1085. 60. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volumetric analysis of soft-tissue changes in the aging midface using high-resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg. 2005;115(4):1143–1152. discussion 1153–1155. 61. Gosain AK, Amarante MT, Hyde JS, Yousif NJ. A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: implications for facial rejuvenation and facial animation surgery. Plast Reconstr Surg. 1996;98(4):622–636. 62. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120(5):1367–1376. 63. Lambros V. Facial aging: A 54-year, three-dimensional population study. Plast Reconstr Surg. 2020;145(4):921–928. 64. Lambros V, Amos G. Three-dimensional facial averaging: a tool for understanding facial aging. Plast Reconstr Surg. 2016;138(6):980e–982e.

65. Faulkner JA, Larkin LM, Claflin DR, Brooks SV. Age-related changes in the structure and function of the skeletal muscles. Clin Exp Phamacol Physiol. 2007;34:1091–1096. 66. Pottier F, El-Shazly NZ, El-Shazly AE. Aging of orbicularis oculi: anatomophysiologic consideration in upper blepharoplasty. Arch Facial Plast Surg. 2008;10(5):346–349. 67. Penna V, Stark GB, Eisenhardt SU, Bannasch H, Iblher N. The aging lip: a comparative histological analysis of age-related changes in the upper lip complex. Plast Reconstr Surg. 2009;124(2):624–628. 68. Hellman M. Changes in the human face brought about by development. Int J Orthod. 1927;13:475. 69. Todd TW. Thickness of the white male cranium. Anat Rec. 1924;27:245. 70. Lasker GW. The age factor in bodily measurements of adult male and female Mexicans. Hum Biol. 1953;25:50. 71. Garn SM, Rohmann CG, Wagner B, Ascoli W. Continuing bone growth during adult life: a general phenomenon. Am J Phys Anthropol. 1967;26:313. 72. Kahn DM, Shaw Jr. RB. Aging of the bony orbit: a threedimensional computed tomographic study. Aesthet Surg J. 2008;28(3):258–264. 73. Pessa JE, Chen Y. Curve analysis of the aging orbital aperture. Plast Reconstr Surg. 2002;109(2):751–755. 74. Pessa JE, Zadoo VP, Mutimer KL, Haffner C, Yuan C, DeWitt AI, Garza JR. Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging. Plast Reconstr Surg. 1998;102(1):205–212. 75. Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106(2):479–488. 76. Shaw Jr RB, Kahn DM. Aging of the midface bony elements: a three-dimensional computed tomographic study. Plast Reconstr Surg. 2007;119(2):675–681. 77. Mendelson BC, Hartley W, Scott M, McNab A, Granzow JW. Age-related changes of the orbit and midcheek and the implications for facial rejuvenation. Aesthetic Plast Surg. 2007;31(5):419–423. 78. Zadoo VP, Pessa JE. Biological arches and changes to the curvilinear form of the aging maxilla. Plast Reconstr Surg. 2000;106(2):460–466. 79. Pessa JE, Slice DE, Hanz KR, Broadbent Jr TH, Rohrich RJ. Aging and the shape of the mandible. Plast Reconstr Surg. 2008;121(1):196–200. 80. Shaw Jr RB, Katzel EB, Koltz PF, Kahn DM, Girotto JA, Langstein HN. Aging of the mandible and its aesthetic implications. Plast Reconstr Surg. 2010;125(1):332–342. 81. Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and facial aging: nonlinear aspects of youthfulness and skeletal remodeling, and why, perhaps, infants have jowls. Plast Reconstr Surg. 1999;103(2):635–644. 82. Mendelson BC, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36(4):753–760. This review paper consolidated the literature on the areas of the facial skeleton that are prone to resorption with facial aging. This regularly cited paper brought to attention the profound changes of the facial skeleton in aging and the application of the knowledge in surgical and non-surgical approaches in facial rejuvenation. Skeletal augmentation is an important aspect of natural and harmonious facial rejuvenation. 83. Schwartz GE, Fair PL, Mandel MR, Slat P, Mieske M, Klerman GL. Facial electromyography in the assessment of improvement in depression. Psychosom Med. 1978;40:355. 84. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg. 2009 Dec;124(6):2118–2126. 85. Knize DM. Muscles that act on glabella skin: a closer look. Plast Reconstr Surg. 2000;105:350.

References

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92. Wong CH, Mendelson BC. Extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution. Plast Reconstr Surg. 2017;140:273–282. 93. Wong CH, Hsieh MKH, Mendelson BC. Asian facelift with the composite facelift technique. Plast Reconstr Surg. 2022;149(1):59–69. 94. Labbé D, Franco RG, Nicolas J. Platysma suspension and platysmaplasty during neck lift: anatomical study and analysis of 30 cases. Plast Reconstr Surg. 2006;117(6):2001–2007. 95. Wong CH, Mendelson BC. Mid cheek lift utilizing facial soft tissue spaces of the mid cheek. Plast Reconstr Surg. 2015;136(6): 1155–1165. 96. Le Louarn C. The concentric malar lift: malar and lower eyelid rejuvenation. Aesthetic Plast Surg. 2004;28(6):359–372. 97. Sullivan SA, Dailey RA. Endoscopic subperiosteal midface lift: surgical technique with indications and outcomes. Ophthal Plast Reconstr Surg. 2002 Sep;18(5):319–330. 98. Ramirez OM. Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg. 2002;109(1):329–340. 99. Rowe DJ, Guyuron B. Optimizing results in endoscopic forehead rejuvenation. Clin Plast Surg. 2008;35(3):355–360. 100. Huggins RJ, Freeman ME, Kerr JB, Mendelson BC. Histologic and ultrastructural evaluation of sutures used for surgical fixation of the SMAS. Aesthetic Plast Surg. 2007;31(6):719–724.

 

SECTION II •  Aesthetic Surgery of the Face

9.3 Principles and surgical approaches of facelift Richard J. Warren

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SYNOPSIS

ƒ Age-related changes occur in all layers of the face, including skin, superficial fat, superficial musculo-aponeurotic system (SMAS), deep fat, and bone. ƒ Patients presenting for facial rejuvenation surgery are usually middle-aged or older, thus increasing the chance of comorbidities. Risk factors such as hypertension and smoking should be dealt with prior to facelift surgery. ƒ Careful preoperative assessment will provide the surgeon with an aesthetic diagnosis regarding the underlying facial shape, the age-related issues that predominate, and the appropriate surgical procedures for every individual patient. ƒ Almost all facelift techniques begin with a subcutaneous facelift flap. Careful incision placement, tissue handling, and flap repositioning are important in order to avoid the obvious stigmata of facelift surgery. ƒ In its pure form, the subcutaneous, skin-only facelift has a limited effect on the position of heavier deep tissue. ƒ In SMAS plication, a skin flap is created with suture manipulation of the superficial fat and the underlying SMAS/platysma. ƒ In loop suture techniques (minimal access cranial suspension [MACS] lift), a skin flap is created with long suture loops taking multiple bites of superficial fat and platysma – fixed to a single point on the deep temporal fascia. ƒ The supraplatysma plane creates a single flap of skin and superficial fat mobilized and advanced along the same vector. ƒ SMASectomy involves a skin flap plus excision of superficial fat and SMAS from the angle of the mandible to the malar prominence, with direct suture closure of the resulting defect. ƒ A SMAS flap raised with skin attached (deep plane) creates a flap of SMAS/platysma, superficial fat and skin, all mobilized and advanced along the same vector. ƒ A separate SMAS flap (dual plane) creates two flaps, the skin flap and the superficial fat/SMAS/platysma, which are advanced along two different vectors.

ƒ The subperiosteal lift involves dissection against bone, with mobilization and advancement of all soft-tissue elements. ƒ Additional volume augmentation, and in some locations volume reduction, should be considered in all cases of facelift surgery. ƒ Facial aging is usually a pan-facial phenomenon. Therefore, in order to obtain a harmonious result, patients will often benefit from surgery to other components of their face. ƒ The most common complication of facelift surgery is hematoma. This problem should be dealt with promptly.

Introduction Complete facial rejuvenation involves the forehead, periorbital region, cheek, neck, and perioral region. In this chapter, we deal with the middle and lower thirds of the face – the cheek and neck. Terminologies for procedures that address these areas include rhytidectomy, rhytidoplasty, meloplasty, and facialplasty, although in this text, the more common term “facelift” will be used. Facelift surgery was originally conceived as a method of placing traction on the aging face by excising skin in the periphery of the face and closing the resulting defect under tension. Since that simple beginning over 100 years ago, the procedure has evolved to encompass a wide range of techniques which lift, augment, and rearrange facial tissues. Despite the development of many less invasive technologies, nothing can match a facelift in its ability to globally treat the face, returning its basic architecture to a more youthful configuration.

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Anatomy and patient presentation The classic stigmata of the aging face involve multiple changes (Fig. 9.3.1):   Visible changes in skin, including folds, wrinkles, dyschromias, dryness, and thinning.   Folds in the skin and subcutaneous tissue created by chronic muscle contraction: glabellar frown lines, transverse forehead lines, and crow’s feet over the lateral orbital rim.   Deepening folds between adjoining anatomic units: the nasojugular fold (tear trough), nasolabial folds, marionette lines, and submental crease.   Ptosis of soft tissue, particularly in the lower cheek, jowls, and neck.   Loss of volume in the upper two-thirds of the face, which creates hollowing of the temple, the lateral cheek, the central midface and in the upper lip, premaxillary area between the two nasolabial folds. The result is a more skeletal appearance in the temple, the periorbita, and the malar region as well as deepening of the nasolabial folds.   Expansion of volume in the neck and lateral jawline, which leads to the formation of jowls and fullness of the neck. The driving force behind our ability to explain these many changes has been an improved understanding of facial anatomy and how it changes over time. Facial aging occurs in all its layers, from skin down to bone; no tissue

Transverse forehead creases

is spared. The face can be considered a five-layer structure as described in Chapter 9.2: skin, subcutaneous fat, the superficial musculo-aponeurotic system (SMAS) and muscles of facial expression, fascial spaces, and deep fascia (Fig. 9.3.2). Underlying everything is bone, except over the oral cavity. The surgical significance of this concentric layer arrangement is that dissection can be done in the planes between the layers so that anatomical changes in each of the layers can be addressed independently.

Skin Skin is directly adherent to underlying subcutaneous fat via the retinacular cutis system. In certain predictable areas, the skin is tethered to bone or underlying muscle by condensed areas of connective tissue. These can be string-like cutaneous ligaments or ribbon-like septae. Because nerves and vessels often reach the skin adjacent to these vertically running fibrous structures, dissection of skin is more difficult and bloody where the skin is tethered. McGregor’s patch is such an area because of its association with the zygomatic cutaneous ligaments and a perforating branch of the transverse facial artery. Surface changes in facial skin are some of the most obvious signs of aging. Skin aging is both intrinsic and extrinsic. Intrinsic aging is the result of genetically determined apoptosis. The skin becomes thinner; there is a decrease in melanocytes, a reduced number of fibroblasts, and a loss of skin appendages, leading to dryness. In the

Frontalis contraction

Temporal wasting Temporal fat pad atrophy Upper lid sulcus hollowing Crow’s feet Tear trough Midface flattening Cheek descent Nasolabial folds Thinning lips Marionette lines Jowls

Transverse neck folds Platysma bands Vertical neck pleats

Lateral brow ptosis Obicularis contracture Lower lid laxity Obicularis oculi laxity Loss of midface fat Malar fat descent Elongation and volume loss in upper lip Perioral wrinkles Buccal fat pad ptosis Expansion and ptosis of jowl fat Excess preplatysmal and subplatysmal fat Platysma muscle laxity

Figure 9.3.1 The aging face exhibits changes in the skin including superficial wrinkles and deeper folds. There is ptosis of soft tissue, particularly in the cheek, along the jawline and in the neck. There is loss of volume in areas such as the temple, the upper cheek, the midcheek and the premaxilla.  

Historical perspective

Historical perspective Facelift surgery dates from the early part of the 20th century. Its colorful history has been thoroughly reviewed by Stuzin.1 In the past, the history of aesthetic facial surgery has been reported by a number of authors, including Rogers,2,3 Rees and Wood-Smith,4 Gonzalez-Ulloa,5 Rees,6 and Barton.7,8 There is still doubt as to who performed the first facelift, but most sources date it to the first decade of the twentieth century.3,9,10 According to Rogers,3 Hollander11 reported in a chapter entitled “Cosmetic surgery” in Handbuch der Kosmetik that “as a victim of the art of feminine persuasion”, he removed pieces of skin at the margins of the hairline and in the natural aging skinfolds of a woman to freshen up “her wrinkles and drooping cheeks”. In this chapter, Hollander did not date the procedure, but in 1932 he stated that his original procedure had been performed in 1901 for a Polish aristocrat.12 Lexer,10 however, reported in 1931 that he had performed a facelift for an actress in 1906 and that he was unaware of any such operation before that date. Joseph9 reported in 1921 that he had performed an operation in 1912 for correction of aging cheek tissues in a 48-year-old woman. By the time Hollander, Lexer, and Joseph reported their first procedures, a number of other prominent surgeons in Europe, such as Noel, Passot, Morestin, Bourguet, and Lagarde, were busy performing cosmetic surgical procedures. In the United States, Miller and Kolle had large cosmetic surgery practices. Passot13 in 1919 published an illustrated article showing sites of elliptic skin excision of the hairline, the forehead, and the temporal and preauricular areas to tighten the skin and an elliptic excision of skin and fat to reduce submental fat deposits. Bourguet14 reported elliptic skin excisions similar to those of Passot. He was the first to report fat excisions to correct herniated periorbital fat pads (1924)15 and to publish preoperative and postoperative photographs of fat pad excision (1925).16 Noel published a book in 1926,17 La Chirurgie Esthetique: Son Role Social, describing facialplasty, blepharoplasty, forehead lifting, and correction of loose skin of the neck, burns, scars, protruding ears, and laxity of the upper arms. Although her procedures were not aggressive by modern standards, Noel was a true master of that era. Miller18 published the first book in medical history devoted entirely to the subject of cosmetic surgery. Miller was described by Rogers3 as a “quack” on one hand and at the same time, “a surgical visionary years ahead of his academic colleagues … medicine’s first truly cosmetic surgeon.” Miller was a prolific writer. In 1906, he wrote the first article in the medical literature describing an attempt to remove excess skin from the eyelids.19 In 1907, he published the first article with a photograph illustrating lower eyelid incisions,20 and he also published three cosmetic surgery textbooks.18,21,22 Kolle was born in Germany and practiced in New York. His book Plastic and Cosmetic Surgery23 represented the second description of cosmetic surgery in medical history. The book was more than 500 pages in length and contained hundreds of illustrations, including preoperative and postoperative photographs of protruding ears; it took a rather aggressive surgical approach to the correction of excess skin of the eyelids. Bettman24 was the first to publish preoperative and postoperative facelift photographs and to describe a continuous temporal scalp, preauricular, postauricular, and mastoid area incision. With modifications, his incision is essentially that

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used for facialplasty today. Hunt25 published a book, Plastic Surgery of the Head, Face and Neck, that included facelifting and forehead/browlifting operations. All the early facialplasty procedures were limited to skin excision and wound closure without subcutaneous undermining. Bames26 described subcutaneous face and neck undermining, skin redraping, and excision of excess skin. The continuous incision described by Bettman24 and subcutaneous undermining recommended by Bames26 essentially established the basic facelift procedure for the next 40 years. As discussed by Rees,6 a great deal of secrecy surrounded early facelift procedures. Surgeons were reluctant to share their techniques because of professional jealousy and greed. The disdain for “vanity” surgery by both the medical profession and the public restricted most facelift procedures to private offices and small clinics. The extent of surgery in such settings was necessarily limited. Many prominent plastic surgeons in major medical centers were forced to perform their facelifts in small clinics or to hide their cases by misnaming the procedures on the operating schedule. Renowned plastic surgeons after the First and Second World Wars, such as Gillies, Blair, Davis, Pierce, McIndoe, Mowlem, Conway, and others, did a great deal of cosmetic surgery but were reluctant to publish on the subject.6 The conventional facelift operation (skin dissection only) failed to address the effect of aging and the force of gravity on the structures (e.g., muscle, fat, and superficial fascia) deep to the skin. Likewise, the classic skin dissection facialplasty failed to account for the wide variation in facial, jawline, and cervical deformities; in the location of fat deposits; in the asymmetry of anatomic structures; and in the genetically determined deformities, such as microgenia and the obtuse cervicomental angle. Aufricht27 discussed the limitations of the subcutaneous facelift, particularly its failure to correct submental fat deposits and platysma bands. Adamson and colleagues28 discussed correction of the platysma bands in the submental area, and Millard and co-workers29 recommended extensive submental defatting. Pennisi and Capozzi30 and Baker and Gordon31 described suture plication of the deep tissues of the cheek and lateral neck. Tipton32 challenged the deep suture techniques in a study of 33 patients in whom he performed unilateral plication. Two years postoperatively, there was no obvious difference in the two sides of the face. In 1973 Skoog33,34 described a technique of dissection of the superficial fascial layer in the face, in continuity with the platysma muscle in the neck and advancement of the myofascial unit in a cephaloposterior direction. This was the beginning of the modern era in facelifting. Subsequent to Skoog’s innovation, Mitz and Peyronie35 used cadaver dissections to define the superficial musculo-aponeurotic system (SMAS) in the face and noted that tightening of this layer would be beneficial in facialplasty. SMAS-platysma facelifting, wide skin undermining, and extensive fat removal soon gained worldwide popularity. Many surgeons went on to describe different techniques involving SMAS-platysma repositioning.36–44 Lemmon and Hamra and later Barton, modified the Skoog technique focusing on a composite flap of SMAS and skin. In 1989, Furnas,45 described the retaining ligaments of the midface, which led to a better understanding of anatomic areas where facial soft tissue is supported and the involvement of these ligaments in leading to the anatomic changes

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that occur with aging. These ligaments were further defined by others46,47 who thought that loss of the support from the retaining ligament system allowed facial fat to descend inferiorly in the face, deepening the nasolabial fold and forming facial jowls with aging. Knowledge of the retaining ligaments led to modifications in procedures involving ligament release in subSMAS dissection,47–56 Stuzin, Aston, Connell and Owsley all advanced the concept of a separate skin and SMAS flap, with the SMAS used to reposition descended facial fat. Other surgeons, preferring subperiosteal rather than subSMAS dissection to reposition fat, developed procedures whose similar goal is to resuspend descended malar fat to the malar eminences using the subperiosteal plane.57–59

A combination of subperiosteal and subcutaneous lifting has also been described.60 In the neck, Connell and Feldman identified the platysma as a critical component to be modified for adequate rejuvenation of the entire face.38,61 In concert with attempts to reposition facial fat, astute observations were eventually made about the age-related deflation of the human face.62–65 This led to the use of injected fillers and injected fat (lipofilling), championed by Coleman, in order to re-inflate the aging face, either independently or at the same time as facelift surgery. Later, anatomic dissections determined that facial fat is in distinct compartments both in the superficial and deep layers of the face.62,66

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Figure 9.3.2  The face is composed of concentric layers of soft tissue. The most superficial layer is skin and subcutaneous fat – elevated in this image. Next is the superficial musculo-aponeurotic system (SMAS), which is contiguous with the platysma inferiorly and with the superficial temporal fascia (temporoparietal fascia) and galea superiorly. Deep to the superficial fascia is the parotidomasseteric fascia, contiguous with the deep cervical fascia inferiorly and the deep temporal fascia superiorly. © Marco Swanson.

Galea aponeurotica Frontalis Procerus Corrugator supercilii Orbicularis oculi, orbital portion Orbicularis oculi, preseptal portion Orbicularis oculi, pretarsal portion Nasalis Levator labii superioris alaeque nasi Levator labii superioris Auricularis anterior Zygomaticus minor Zygomaticus major Levator anguli oris Masseter Buccinator Depressor septi nasi Risorius Orbicularis oris Depressor anguli oris Depressor labii inferioris Mentalis Platysma

Figure 9.3.3  Muscles of facial expression. The solid lines demonstrate overlying skin creases caused by repeated contraction of the underlying muscles. (Netter illustration from www.netterimages.com.© Elsevier Inc. All rights reserved.)

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dermal matrix, there is fragmentation of the collagen and impairment of fibroblast function.67,68 Thinner skin becomes more susceptible to the repeated contraction of underlying facial muscles, which leads to permanent skin folds in predictable locations (Fig. 9.3.3). Extrinsic forces include sun exposure, cigarette smoke, extreme temperatures, and weight fluctuations. The net result is that aging facial skin becomes weaker, thinner, and dryer. It also loses its ability to recoil, a condition called elastosis. This has surgical implications, because firm tight skin is youthful, and to varying degrees, the tightening of loose facial skin contributes to the surgical result. However, a facelift does not improve the quality or the texture of the skin. Therefore, patients with good-quality skin are likely to enjoy better results from facelift surgery than patients with poor-quality skin. When skin quality is poor, options such as injectable fillers and skin resurfacing may be more appropriate for rejuvenation than facelift surgery. In most cases of facial rejuvenation, medical and surgical therapies can work in concert for a more complete result.

Facial fat: ptosis, volume loss, and volume gain The face is carpeted in a layer of superficial fat immediately deep to the dermis. Between individuals, there is much variability in the thickness of this superficial fat layer. This has surgical implications because heavier patients have thicker, heavier tissues to reposition. With thinner patients, the weight of tissue to be lifted is less, but facial layers are packed closely together, like an onion, increasing the difficulty in surgical separation of the skin from SMAS and SMAS from underlying structures. The malar fat pad is a thickened area of superficial fat overlying the zygomatic body.54 This is a triangular-shaped mass bordered by the nasolabial fold, the infraorbital arch, and a diagonal line across the midcheek. Its apex is over the malar eminence (Fig. 9.3.4). One study looked at fat volume in the cheek and found 56% of the fat superficial to the SMAS and 44% deep to the SMAS and the muscles of facial expression.69 The superficial fat is separated by vertical septae into five distinct compartments: nasolabial, medial cheek, middle cheek, lateral temporoparietal, and the inferior orbital fat (Fig. 9.3.5).66 The two central fat compartments (medial and middle) are the primary components of the malar fat pad. The deep fat is also compartmentalized (Fig. 9.3.6). Current terminology identifies the pyriform space medially, the deep medial fat compartment and the suborbicularis oculi fat (SOOF) – medial and lateral portions.62,70,71 It has been theorized that age-related deflation in the deep fat leads to “pseudoptosis” of the overlying superficial fat and skin – ptosis that is real but caused by a lack of underlying support.62 Using computed tomography (CT) scans over time in the same subjects, a significant loss of fat was observed from both superficial and deep fat compartments, although there is a greater percentage of loss in the deep fat layer.72 This contributes to changes such as the “inverted V deformity” below the infraorbital rim.73 Using sophisticated photographic analysis and facial averaging, Lambros identified significant age-related loss of volume in the premaxillary and perioral zone. The result is

Orbicularis oculi Zygomaticus major

Malar fat pad

Figure 9.3.4  The malar fat pad is a triangular area of thickened superficial fat with its base along the nasolabial fold and its apex over the superolateral malar prominence.

decreased projection of premaxillary soft tissue, an elongated upper lip and deepening of the nasolabial folds.74 In youth, facial fat is tightly packed, creating surface contours which undulate smoothly from convexity to concavity. The malar fat pad creates the principal cosmetic highlight zone in the youthful face. In the aging face, fat is less tightly packed, and facial contours become more abrupt. In areas of tight ligamentous attachment, such as the preparotid area, the anterior jowl border, and the zygomatic ligament insertions, visible depressions develop.63 Surgeons have traditionally viewed superficial cheek fat as a ptotic layer that requires repositioning. In support of this theory, it has been demonstrated that the primary muscles of facial expression in the midcheek (zygomaticus major and minor) do not change in length, while the overlying fat migrates inferiorly.75 Another study, using CT scans, identified age-related inferior migration of the midfacial fat compartments as well as inferior volume shift within the individual compartments.76 In the lower face, the jowl area appears to thicken with age, making the mandible appear wider. Sometimes called radial expansion, this may be caused by fat hypertrophy, or by soft-tissue ptosis within the premasseteric space, a natural

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the neck, the SMAS continues as the superficial cervical fascia, which envelopes the platysma muscle. Clinically, the thickness and strength of the SMAS varies between patients, and by location, being thicker and strongest posteriorly over the parotid and weakest anteriorly.83 During surgical dissection, the SMAS is most tenuous under the malar fat pad where it splits to encompass the zygomaticus major and the orbicularis oculi.53,84 The SMAS has several important surgical implications. Its fibrous attachments to skin allow it to act as a carrier for overlying subcutaneous fat; also it has been shown to be much more resistant to stretch than skin.85 Furthermore, below the zygomatic arch, all branches of the facial nerve are deep to the SMAS. Therefore, dissection superficial to the SMAS is safe. The relationship of the SMAS (superficial fascia of the face) to the deep fascia of the face involves areas of mobility interspersed between areas of attachment. SMAS is tethered to the deep fascia by retaining ligaments over the parotid gland, at the inferior border of the zygomatic body, and along the anterior edge of the masseter (see Chapter 9.2 and later in this chapter). Between these areas of fixation, the SMAS is free to move over the underlying deep fascia. These are the suprazygomatic zone where superficial temporal fascia slides over the deep temporal fascia, the midcheek where SMAS rides over the parotid masseteric fascia (premasseteric space), and the neck where the platysma lies unattached over the underlying strap muscles.

Facial muscles Figure 9.3.5  Superficial facial fat is compartmentalized by vertically running septae. In the midcheek, from medial to lateral, these compartments are the nasolabial, medial, middle, and lateral compartments. The nasolabial and medial compartments make up the malar fat pad.

glide plane”.77–79 Below the mandible, fat distribution in the neck evolves over time with a decrease in fat in the lower third of the neck, but an increase in the upper third, contributing to a more obtuse cervicomental angle.80

Change in facial shape The combination of volume loss in some areas, volume gain in others, and soft-tissue ptosis creates a cascade effect resulting in the loss of natural youthful curves (Fig. 9.3.7). Gradually, the cheek fullness of youth gives way to jowl formation and upper neck fullness associated with age. The face changes from a heart shape to a more rectangular shape, or from an egg sitting on its narrow end to an egg resting on its broad end. This has been called losing the “inverted cone of youth” and has been likened to a reversal of the “Ogee” curve, a natural S-shaped curve seen in architecture.60,81

Superficial musculo-aponeurotic system Immediately deep to the subcutaneous fat is the SMAS, described by Mitz and Peyronie in 1976.35 The SMAS can be thought of as a continuous fascial sheath encompassing the entire face and neck. Superiorly, it continues into the temple as the superficial temporal fascia (temporoparietal fascia) and then into the scalp as the galea aponeurotica.82 Inferiorly, into

The muscles of facial expression are found in two layers: superficial and deep. The superficial muscles are orbicularis oculi, orbicularis oris, zygomaticus major, zygomaticus minor, levator labii superioris, risorius, and depressor anguli oris. These muscles are innervated on their deep surface by branches of the facial nerve (VII). Consequently, surgical dissection on the superficial surface of these muscles will not endanger their innervation. The only facial muscles innervated on their superficial surface are the muscles in the deep layer: mentalis, levator anguli oris and buccinator. The three facial muscles most important to surgeons are orbicularis oculi and platysma – because they are often manipulated during facelift surgery – and zygomaticus major – because it is used as a landmark in certain facelift techniques (see Figure 9.3.3). Most muscles of facial expression take their origins from bone and insert into the dermis, thus allowing for voluntary and involuntary movement of facial soft tissues. Platysma is a purely subcutaneous muscle taking its origin from the fascia of the pectoralis and inserting into soft tissue of the face, with a small bony insertion on the anterior mandible. It is also tethered posteriorly to the sternocleidomastoid (SCM) muscle via the cervical retaining ligaments.86 The platysma interdigitates with the depressor labii inferioris and in some individuals the platysma provides some effect on the depression of the lower lip. The platysma is thickest in the neck and can be visualized when a patient grimaces. As the muscle courses superiorly, crossing the mandibular border, it becomes much thinner. In some individuals the platysma can be found extending well into the midcheek, occasionally approaching the lower fibers of the orbicularis oculi. While most muscles of facial expression do not change appreciably with age, the orbicularis oculi and the platysma

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A

ORL

SCS

ORL SOOF ZM

Nasolabial

Medial

Middle

Lateral

Figure 9.3.5  Superficial facial fat is compartmentalized by vertically running septae. In the midcheek, from medial to lateral, these compartments are the nasolabial, medial, middle, and lateral compartments. The nasolabial and medial compartments make up the malar fat pad.

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Figure 9.3.6  The deep facial fat is compartmentalized by septae. In this cadaveric dissection the levator labii superioris has been removed to expose the deep fat compartments. From medial to lateral, the deep fat compartments are the deep pyriform space, the deep medial fat compartment and the lateral fat compartment. White lines indicate the zygomaticocutaneous ligament and the orbicularis retaining ligament (ORL). Above the ORL are the medial (MS) and lateral (LS) components of the suborbicularis oculi fat. (From Cotofana S, Gotkin RH, Frank K, et al. The functional anatomy of the deep facial fat compartments: a detailed imaging-based investigation. Plast Reconstr Surg. 2018;143(1):53-63.)

undergo age-related changes. Both muscles have a large surface area and are relatively thin – a configuration lending them to potential redundancy if they lose tone or if their deep tissue attachment is attenuated. For example, in some individuals redundancy develops in the lower half of the orbicularis, a condition that is a speculated cause of lower eyelid festoons.87 Some have suggested that it is the loss of support of the orbicularis through attenuation of the orbicularis retaining ligament (orbitomalar ligament) that contributes to deformities of the lower eyelid/cheek junction.73 Similarly, the paired platysma muscles, which are encased by SMAS, appear to gradually fall away from their deep cervical attachment carrying the overlying fat and skin. The net result is a more obtuse cervicomental angle and the development of visible platysma bands at the anterior platysmal border. Another issue common to orbicularis oculi and platysma is that these are the only facial muscles that are undermined during certain surgical procedures, thus imperiling some of their motor innervation. Fortunately, the orbicularis has multiple motor nerve branches providing a

level of collateral innervation.88 There is a less-elaborate innervation to the platysma; two or three cervical branches can be identified just inferior and anterior to the angle of the mandible in the plane between the deep cervical fascia and the undersurface of the platysma. Preservation of these branches is potentially important because the platysma acts as a support structure and also influences lower lip depression, especially in those individuals with a “full dentition” smile.89

Retaining ligaments Facial soft tissue and skin are held in place by retaining ligaments running from underlying fixed bone or fascia, through facial fat, inserting into the dermis.45,46,48 (Fig. 9.3.8). These ligaments influence the way gravity affects the aging face by holding fixed points into position. They also impair the surgeon’s ability to mobilize ptotic soft tissue, thus requiring surgical release. Different authors differentiate between different types of fixation, depending on their density and configuration. As

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Figure 9.3.7  This healthy 75-year-old woman has never undergone facial surgery, has gained 10 pounds, but has aged 50 years. She has lost fat in the periorbital region and middle third of her face, revealing underlying bone. The orbit seems to have enlarged. Overall volume has been lost in the middle third of the face. The soft tissues that remain appear to be ptotic, flattening her cheeks, and widening her jawline. The heart-shaped face of youth has become more rectangular.

Temporalis Upper edge of temporal fat Orbital ligaments Temporal fat pad

Zygomatic ligaments Platysma auricular fascia

Platysma auricular fascia

Zygomaticus major

Masseteric ligaments

Sternocleidomastoid

Cervical retaining ligament

Mandibular ligament

Platysma

Figure 9.3.8 Facial soft tissue is tethered to underlying bone by the orbital, zygomatic and mandibular ligaments. Soft tissue is tethered to underlying deep fascia by the masseteric cutaneous ligaments and by an area of attachment anterior and inferior to the earlobe, known by a number of different terms: platysma auricular ligament (Furnas), platysma auricular ligament (Mendelson), parotid cutaneous ligament (Stuzin), and a distinct area anterior to the earlobe known as Lore’s fascia.  

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a result, retaining structures are referred to by all these terms: zones of adhesion, septa and ligaments.45,46,73 There are two ligament systems, based on the tissue of origin.46 The first are osteocutaneous ligaments, tethering skin to bone: the orbital, zygomatic, and the mandibular ligaments. The orbital ligament is found at the junction of the superior and lateral orbital rims and constitutes the inferior thickening of the temporal crest line zone of fixation (zone of adhesion) (see Chapter 11). The zygomatic ligament is actually a group of ligaments originating from the lower half of the zygomatic body to join the zygomatic arch. The zygomaticus major bony origin is in this location. These ligaments stabilize the overlying malar fat pad, going through this structure to the overlying skin. In this area, a perforating branch of the transverse facial artery courses from deep to superficial, contributing to the clinical bleeding seen when the zygomatic ligaments are released in this area during superficial skin flap dissection (McGregor’s patch). A branch of the zygomaticofacial nerve also accompanies the ligaments in this area, coursing directly from bone to skin, providing sensation to the skin of the malar cheek prominence. As described in Chapter 9.2, the zygomatic ligaments constitute the lower border of the prezygomatic space and must be released if the malar fat pad is to be fully mobilized and elevated. The mandibular ligament is a short but strong structure originating from the parasymphyseal mandible, tethering the overlying skin and contributing to formation of marionette lines. Its release is often necessary to allow tightening of loose skin in the submental region. The second ligament system involves tethering structures not originating from bone, but rather tethering the SMAS to the deep fascia. Along the anterior border of the masseter, the masseteric ligaments extend in a line from the zygoma down to the lower cheek.46 These ligaments support the anterior cheek and are more clinically significant superiorly, where they intermingle with the zygomatic ligaments. The most superior fibers of the obliquely running platysma can be seen terminating in the most superior masseteric ligaments. Over the parotid gland, the superficial fascia is fused with the deep fascia. Continuing inferiorly, the fascia encompassing the platysma is attached to the SCM fascia via the cervical retaining ligaments.86 Where the SMAS is fixed to the parotid, authors have applied different names to the same structure: platysma auricular fasica,90 platysma auricular ligament,45 and parotid cutaneous ligament.46 Deep to this area and attaching the SMAS to the bone of the ear canal is Lore’s fascia.91,92 In this area, the soft tissue is tethered to such a degree that it does not become ptotic with age. The surgical significance of this immobile area is that the so-called “fixed SMAS” can be used to support the surgically mobilized more anterior “mobile SMAS”. A number of facelift techniques depend on this concept (Fig. 9.3.9 ). The importance of retaining ligaments in aging is potentially two-fold. One theory holds that with age, ligaments relax, causing a gravitational shift of overlying superficial fat and skin. In youth, these appear to be firmly adherent to underlying bone and deep fascia, while with age the same soft tissue appears to become ptotic. One area where this has been proposed is along the infraorbital rim, where the orbicularis retaining ligament may relax, leading to the V deformity at the lid–cheek junction.73,93–95 Over the malar highlight area, the ligament relaxation theory suggests that the zygomatic ligaments become attenuated and the malar fad pad becomes

ptotic, causing a migration of fat medially and inferiorly, contributing to the development of the nasolabial fold. The second way that retaining ligaments become an issue with aging is through their tethering effects. The concept of “pseudoptosis” suggests that a loss of facial fat volume leads to ptosis, but the ligaments tether the overlying skin, leading to depressions and grooves in the surface contour of the face. Examples of tethering include the midcheek groove, caused by the zygomatic ligaments; the nasojugular groove, partly caused by the orbicularis retaining ligament (orbitomalar ligament); and the jowl/marionette line, caused by the mandibular ligament.90–92,94

Deep fascia The deep fascial covers the deepest structures in the face, including the masseter muscle and the parotid gland, where it is fused with the parotid capsule; the combined complex is called the parotid masseteric fascia (parotidomasseteric fascia; see Chapter 9.2). When the SMAS is surgically raised anterior to the parotid gland over the premasseteric space, the parotid masseteric fascia can be seen as a thin shiny membrane – an important landmark, because in the cheek (unlike the neck and temple), all branches of the facial nerve are deep to this deep fascial layer. The equivalent layer in the temple is the deep temporal fascia covering the temporalis. The equivalent layer in the neck is the deep cervical fascia that covers the superficial strap muscles and the SCM. The deep fascia covering the SCM is fused to the overlying platysma through the cervical retaining ligaments. If the platysma is to be mobilized in this area, these ligaments need to be released, or the platysma needs to be incised anterior to the ligaments (Video 9.3.1 ).86

Bone The bony skeleton of the face was once thought to be quite stable in volume and shape as the body aged. However, there is ample evidence that atrophy in certain portions of the facial skeleton is a factor in facial aging.96–101 This is reviewed in Chapter 9.2. CT of young and old skulls has shown a retrusion of the infraorbital rim as well as recession of the maxillary face below the infraorbital rim (Fig. 9.3.10).98 This has been confirmed by others who have also demonstrated an enlarging orbital aperture (Fig. 9.3.11).102 Loss of bone has surgical implications because it contributes to an overall loss of volume, and more specifically, to a loss of soft-tissue support in critical areas such as the infraorbital rim. This contributes to development of the tear trough deformity and age-related flattening of the anterior midface. Bone loss can be replaced with solid facial implants and partially replicated with soft-tissue fillers and fat grafting.

Facial nerve The facial nerve exits the stylomastoid foramen, separating into an upper and lower division within the parotid glad. Classically, there are five branches arising and exiting the cover of the superficial lobe of the parotid: temporal, zygomatic, buccal, marginal mandibular, and cervical. There are typically two to three temporal branches; four to five zygomatic

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Figure 9.3.9  Mendelson’s interpretation of soft-tissue attachments (see Chapter 9.2). The fixed posterior soft tissue is held in place by the platysma auricular fascia (large red area). The anterior face is fixed by a vertical column of attachments: orbital ligament, lateral orbital thickening (superficial canthal tendon), zygomatic ligaments, masseteric ligaments, mandibular ligament). In the midcheek, there is some mobility of these ligaments, while there is limited mobility over the platysma auricular fascia. The so-called “fixed SMAS” is that portion attached to the parotid and the posterior border of the platysma. Anterior to this, is the “mobile SMAS”. (Courtesy of Dr. Levent Efe, CMI.)

Figure 9.3.10  Computed tomography of young and old skulls has demonstrated a retrusion of the infraorbital rim. (Courtesy of Pessa JE. An algorithm of facial aging: verification of Lambros's theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106:479.)

Anatomy and patient presentation

Figure 9.3.10  Computed tomography of young and old skulls has demonstrated a retrusion of the infraorbital rim. (Courtesy of Pessa JE. An algorithm of facial aging: verification of Lambros's theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106:479.)

A

B

Figure 9.3.11  Computed tomography scans of (A) a male patient in the younger age group and (B) a male patient in the older age group. The image from the older age group shows significant bony remodeling (arrows) both superomedially and inferolaterally. (Courtesy of Kahn DM, Shaw RB. Aging of the bony orbit: a threedimensional computed tomographic study. Aesthetic Surg J. 2008;28:258.)

branches; three buccal branches; two to three mandibular branches; and two to three cervical branches (Fig. 9.3.12). In fact, there is considerable variation in the anatomy of facial nerve branches. One study identified up to eight

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branches exiting the parotid, with multiple connections between these branches.103–105 All facial nerve branches are found deep to the SMAS/ platysma/superficial temporal fascia. The temporal (frontal) branches exit the parotid superiorly, coursing obliquely across the middle third of the zygomatic arch. Like all other facial nerve branches, the temporal branches start out deep to the deep fascia of the midcheek (parotid masseteric fascia), but unlike all other facial nerve branches in the cheek, they become more superficial. At a point 1.5–3.0  cm superior to the zygomatic arch, the temporal branches transition from deep to superficial, traveling at first on the undersurface and then within the superficial temporal fascia (temporoparietal fascia), staying there until they terminate in the frontalis muscle, upper orbicularis, and corrugator supercilii. The surgical implication is that a SMAS flap can be safely raised from a point just superior to the zygomatic arch providing that surgical dissection does not extend superiorly to the level where the temporal branch transitions more superficially.106 A classic external landmark for the course of the temporal branch is Pitanguy’s line, which is drawn from a point 0.5 cm below the tragus to a point 1.5  cm lateral to the lateral eyebrow.107 Recent studies have found that the temporal branch consists of 2–5 individual branches that do not adhere completely to this landmark. These branches cross the middle third of the zygomatic arch, with an anterior safe zone 2 cm posterior to the lateral orbital rim and a posterior safe zone 1  cm anterior to the acoustic meatus. Once above the zygomatic arch, these branches are consistently found anterior and inferior to the anterior branch of the temporal artery, a palpable landmark in the temple.108 The zygomatic and buccal branches all exit the parotid deep to the parotid masseteric fascia. As they travel anteriorly, they often arborize with each other. Zygomatic branches course parallel to the transverse facial artery and course inferior to the zygomatic retaining ligaments to the undersurface of the muscles that they innervate: zygomaticus major, zygomaticus minor, and orbicularis oculi. Deep to the parotid masseteric fascia, within the premasseteric space, the parotid duct courses anteriorly along an imaginary line from the tragus to the corner of the mouth. Accompanying the duct is normally a buccal branch. Beyond the anterior border of the masseter, a buccal branch can normally be seen crossing the buccal extension of the buccal fat pad (fat pad of Bichat).109 The mandibular branches, normally two in number, exit the parotid within 1 or 2 cm of the mandibular angle deep to the parotidomasseteric fascia. They travel forward 80% of the time superior to the mandibular border and 20% of the time just below the mandibular border.110 Around 23 mm from the gonial angle, they encounter the facial artery and vein, where they become superficial to the deep fascia and turn superiorly, crossing the facial vessels on their superficial side. This is a danger zone for nerve injury when dissection is done deep to the platysma. From there they travel 9 mm superior to the mandibular ligament, innervating the depressors of the lower lip. (Note: at all times the nerve is deep to platysma.)110,111 The cervical branches, 1 or 2 rami, exit the parotid at its inferior border and course anteriorly below the mandibular border. The cervical branches innervate the platysma with the

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Temporal branches

Zygomatic branches Posterior auricular nerve Temporofacial division Cervicofacial division Parotid gland Buccal branches Marginal mandibular branch Cervical branch B

A

Figure 9.3.12  (A) A cadaveric dissection of the facial nerve. The skin has been reflected anteriorly. The superficial musculo-aponeurotic system (SMAS) has been elevated, held with clamps and the cut edge is highlighted with blue dashes. The facial nerve branches emerge from the parotid gland; they are identified by black arrows and are highlighted by blue background. OO, Orbicularis oculi; ZM, zygomaticus major. (B) Diagram of the facial nerve. The facial nerve exits the stylomastoid foramen and normally divides within the parotid gland into a superior and inferior division. Classically, five groups of branches are seen: temporal, zygomatic, buccal, mandibular, and cervical. There is arborization between branches, particularly between the zygomatic and buccal branches. (A from Hashem AM, Couto RA, Duraes EFR, et al. Facelift part i: history, anatomy and clinical assessment. Aesthetic Surg J. 2020;40 (1): 1–18, Figure 1, p. 2.)

point of innervation near the anterior muscle border at the level of the thyroid cartilage.112 There may be connections with the marginal mandibular branch and the transverse cervical nerve.89 Because the buccal and zygomatic branches are multiple and interconnected, there is a reserve capacity in the event of a single branch injury; therefore, permanent injury is uncommon. However, the temporal and marginal mandibular branches enjoy less collateral innervation, making permanent loss more likely if these branches are injured. Also, damage to the cervical branches has been suggested as a cause of “pseudo paralysis” of the lower lip, a phenomenon that has been questioned in recent studies.112,113

Sensory nerves The great auricular nerve, a branch of the cervical plexus, is sensory to the earlobe and lateral portion of the pinna. This nerve wraps around the posterior border of the SCM and courses obliquely across the muscle in a superior direction. The classic landmark for this nerve is McKinney’s point at the midportion of the SCM, 6.5  cm below the external auditory canal114 (Fig. 9.3.13). It runs parallel and about 1 cm posterior to the external jugular vein, which also crosses the SCM roughly along the same vector. The nerve is deep to the superficial fascia,

but the platysma is usually absent over the posterior SCM. Hence, the nerve is at risk of injury during surgical dissection along the posterior border of the SCM because, with lack of fascial cover, it is technically subcutaneous in that location.87,115 The auriculotemporal nerve, a branch of the trigeminal, is sensory to the preauricular skin and the lesser occipital nerve is sensory to the retroauricular scalp. The zygomaticofacial nerve exits through its foramen in the body of the zygoma, piercing the malar fat pad to provide sensation to the skin of the malar prominence; this nerve is often transected when the malar fat pad is surgically mobilized (Fig. 9.3.14).

Neck anatomy From the perspective of rejuvenation surgery, the key anatomic structures in the neck are the skin, the superficial and deep fat compartments, the platysma muscles, the retaining ligaments, the digastric muscles and the submandibular glands. The deep cervical fascia is analogous to the deep fascia of the face. The superficial neck fascia encases the platysma muscle and is analogous to the SMAS in the face. Motor nerves of concern are the mandibular and cervical branches of the facial nerve. The primary sensory nerve of concern is the great auricular nerve. This subject matter is thoroughly reviewed in Chapter 9.8.

Anatomic assessment

6.5cm

McKinney’s point Great auricular nerve External jugular vein

Figure 9.3.13  The great auricular nerve crosses the midportion of the sternocleidomastoid (SCM) at McKinney’s point, which is 6.5 cm inferior to the external auditory canal. It usually travels about 1 cm posterior to the external jugular vein. Anterior to McKinney’s point, the nerve is covered by the superficial cervical fascia and the platysma (SMAS), but at the posterior border of the SCM, the nerve is effectively subcutaneous. The most common point of injury is at the posterior border of the SCM muscle.

Patient selection Like any elective surgical procedure, the patient’s physical and mental status must be appropriate to withstand the rigors of surgery, recovery, and any potential complications. The patient’s expectations must be explored to determine if they are realistic and if they are technically achievable. The quality of surgical result will be affected by many patient-related factors including the facial skeleton, the weight of facial soft tissue, the depth and location of folds, and the quality of the skin. For every patient there are some issues that can be predictably reversed, others attenuated, and some may not be correctable at all. The patient presenting for facial rejuvenation will usually be middle-aged or older, thus increasing the chances of underlying medical problems. In an otherwise apparently healthy individual, specific issues that must be addressed are blood pressure, smoking history, and the use of medications or supplements that can promote surgical bleeding. Incipient hypertension is common in the general population and can promote postoperative hematomas if it is not identified prior to surgery. Hematoma is by far the commonest complication in facelift surgery; therefore, uncontrolled hypertension is a contraindication for surgery, while controlled hypertension is not a contraindication. The labile hypertensive can be the most insidious situation. If patients

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have intermittent hypertension (the white coat syndrome), or they are simply type A individuals who are easily excitable, perioperative treatment with medications such as clonidine should be considered.116,117 Smokers can exhibit delayed wound healing due to microvasoconstriction and abnormal cell function.118 One study reported a 12.5 times greater chance of having skin flap necrosis in a smoking patient compared with a non-smoker.119 Long-term smokers have reduced arteriole function, which may never return to normal. Nevertheless, there are significant short-term effects that can be reversed by abstaining from tobacco use for 2–3 weeks prior to surgery. Tests for the metabolites of nicotine in the blood are available to confirm abstinence from smoking. Commonly used nonsteroidal anti-inflammatory medications (NSAIDs) and the consumption of certain dietary supplements may promote intra-operative and postoperative bleeding based on platelet function inhibition. Patients should avoid these medications for 3 weeks prior to surgery. Female patients in the facelift age group may be on hormone replacement and are therefore at increased risk for developing postoperative deep vein thrombosis (DVT) and a potentially lethal pulmonary embolism. For these patients, in addition to all recognized preventative measures, consideration should be given to stopping hormonal replacement 3 weeks prior to surgery. With respect to the surgical objectives in facelift surgery, patients will typically present with specific concerns about specific areas – often the soft-tissue ptosis in the neck or jowls, or the visible wrinkles and folds in the cheek and neck. Patients are usually unaware of the underlying anatomic changes that are causing the problems they see in the mirror. Nevertheless, it is important to recognize that what the patient can see is the patient’s primary concern. To help focus the discussion, old photographs are useful in determining which aging changes predominate and what features the patient would most like to correct. As with any cosmetic surgery, helping the patient develop realistic expectations is a critical component of preoperative consultation.

Anatomic assessment Before surgery, the entire face should be assessed. This examination is conducted in a well-lit space with the patient sitting vertically in a comfortable position. Examination should be orderly so that nothing is missed. The face is examined with the patient in repose and in animation, thus assessing facial nerve function. The face should be assessed as a whole – looking for the equality of facial thirds, the degree of symmetry, and the overall shape (round, thin, wide).120 Classic tenants of facial shape are reviewed at the completion of this chapter. Facial shape influences the choice of surgical procedure.78 For example, a wide, full face may be more suited to soft-tissue excision rather than overlapping facial fat in the midface. Fat grafting may not be necessary. Conversely, a long, thin face will require the preservation of all soft tissue, overlapping it rather than excising it, and potentially adding additional volume. Preoperative identification of asymmetries is important and should be pointed out to the patient because facelift surgery will make some asymmetries more obvious.

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Ophthalmic nerve V1

Supratrochlear nerve Supraorbital nerve Lacrimal nerve Zygomaticotemporal nerve

Maxillary nerve V2

Infratrochlear nerve External nasal nerve Zygomaticofacial nerve Auriculotemporal nerve Infraorbital nerve Buccal nerve

Mandibular nerve V3 Mental nerve

Figure 9.3.14  Major sensory nerves of the face.

Surgeons should develop an organized way to examine all the zones of the face: forehead, eyelids, cheeks, the perioral area, and the neck. In certain individuals, the appropriate procedure will be a correction of only one of these areas, but more commonly, all or most or the zones should be addressed in order to achieve a harmonious result. Assessment of the forehead and orbital area are discussed in Chapter 11. In the cheeks, the surgeon should assess the shape and prominence of the underlying skeleton, the volume and distribution of facial fat, the degree of soft-tissue atrophy and ptosis, and the relative mobility of the subcutaneous (superficial) fat. Significant hollowing or flattening should be noted, and conversely, any radial expansion (fat deposition) in the jowl and neck should be noted. With the diversity of surgical techniques available, a surgeon should think like a sculptor – considering the face in three dimensions with a view to adding tissue in some areas, removing tissue in other areas, and repositioning tissue to a more youthful location. In the perioral area, the plumpness of the lips should be assessed, and any elongation of the upper lip should be noted. On smiling and at rest, the amount of dental show is observed. In the young face, there is normally some visible incisor show with the mouth in the resting slightly open position. A distance from the columella base to Cupid’s bow exceeding 15 mm may signify an elongated upper lip. The skin should be assessed, its quality noted, along with the

depth of wrinkles and folds, including the nasolabial fold and the marionette lines. The neck is examined in various positions: neutral, flexion, and turning side-to-side. In lateral view, changes in neck contour can be assessed in comparison to the youthful state using photographs as well as a comparison to the ideal neck.121 Classically, the youthful neck should display a distinct inferior mandibular border and a cervicomental angle of approximately 105°. The presence of anterior plastysma bands at rest, called passive bands, are assessed. The patient is asked to contract the platysma by clenching the teeth and grimacing. This will identify active platysma bands and help determine platysma thickness and strength. Also, with palpation, the amount of subcutaneous fat superficial to the platysma can be determined when the plastysma is contracted. The amount of soft tissue deep to the platysma is also estimated. Structures to be assessed are subplatysma fat, the digastric muscles and the submandibular glands, all of which may require modification during neck rejuvenation. In looking ahead to the effect of facelift surgery, manual repositioning of the lower cheek soft tissue is a useful measure to assess the effect on the neck. The ear should be examined with a thought to the potential placement of incisions. Important factors include the size and orientation of the earlobe, the angle of attachment of the tragus, the difference in character of the cheek skin and tragal skin, and the size of the tragus. The density of the hair

Surgery

surrounding the ear, the location of the hairline in the temple, the sideburn, and posterior to the ear all influence incision choice. If the temple hairline to lateral canthal distance is greater than 5 cm the surgical incision should be planned to avoid increasing this distance. Careful assessment of the skin is also important to determine if anything non-surgical is indicated – before, during, or after facelift surgery. Assessment will include skin type, skin quality, skin excess, the depth of folds, the degree of fine wrinkling, and the amount of photoaging. In particular, perioral rhytides should be examined as they are often a significant concern for the patient. Issues with the skin should be pointed out to the patient and options discussed because facelift surgery itself will not improve the texture and quality of the skin – a common misconception. Excellent photographic documentation of the preoperative face is important, and should, at the minimum include frontal, oblique, and profile views. Other useful views include the smile view and the neck in repose, with platysma contracture and with the head flexed down. Changes in the face from facelift surgery may be more subtle than other aesthetic procedures, so a reliable record of the surgical starting point is imperative.

Surgery A facelift is a significant operation. It should be done under excellent conditions, with appropriate medical staff, appropriate equipment, and adequate backup.

Anesthesia Anesthesia can be safely done using intravenous sedation or with varying levels in the spectrum of general anesthesia. An anesthesiologist can decide in consultation with the surgeon what form of anesthesia is preferred for an individual patient. There should be proper intra-operative patient positioning, intra-operative monitoring, intra-operative warming, and intra-operative DVT prophylaxis.

Local anesthetic infiltration Regardless of the systemic anesthesia used, local anesthetic infiltration is a critical component in facelift surgery. Mixtures of Xylocaine and/or bupivacaine are routinely used along with epinephrine to reduce intra-operative bleeding. However, a problem with postoperative rebound bleeding has led some surgeons to operative without vasoconstriction.122 Another popular method of local anesthetic infiltration is the use of tumescence where up to 500 cc of dilute local anesthetic is injected into the face and neck.123 The advantages of this tumescence are a form of hydrodissection and a widespread local anesthetic effect. The addition of tranexamic acid to the infused fluid has gained popularity as has its intravenous systemic administration. Safely used in other surgical specialties, tranexamic acid blocks the conversion of plasminogen to plasmin, thus stabilizing clot. Tranexamic acid has been shown to reduce the time spent accomplishing hemostasis during facelift surgery.124 Also, given intravenously, it has been shown to reduce postoperative swelling and bruising.125

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Surgical technique Historically, surgeons have been guided by the simple fact that people look younger when soft tissue in the cheek is shifted superiorly. Strategically placed volume augmentation can also make people look younger without any soft-tissue elevation at all.126,127 By combining these approaches – adding volume in some areas, repositioning ptotic soft tissue and subtracting volume in other areas, a modern facelift can more accurately restore the contours of youth. The repositioning of ptotic tissue is the principal objective since facelift surgery began. Many methods have been described. The choice of technique depends on the patient’s desires, the aesthetic diagnosis and the surgeon’s comfort level with particular procedures. In this section, the classic subcutaneous facelift will be described followed by a review of the most popular methods used to manipulate the deeper soft tissue of the face. In subsequent chapters, these techniques will be described in detail.

Subcutaneous facelift The first facelift, dating from the early twentieth century, was a simple skin incision at the temporal hairline and anterior to the ear; several authors have claimed this innovation.9–11 This method evolved into a subcutaneous dissection of a large random-pattern skin flap that was shifted in a superior–lateral direction.24,26 This procedure removes excess skin and relies on skin tension to reposition the underlying facial soft tissue against the force of gravity. The advantages of a “skinonly” facelift are its relative simplicity, a rapid postoperative recovery, and the use of a dissection plane that does not risk damage to the facial nerve or other deep structures. The inherent disadvantage of the “skin-only” facelift is that a thin flap placed under tension to support heavy underlying soft tissue will inevitably stretch, leading to a loss of surgical effect. Unfortunately, if a surgeon increases skin tension in a misguided attempt to reposition ptotic deep tissue, several problems arise. The face can be distorted as skin tension flattens facial shape, negating the rounded contours of youth. Tension can cause wrinkles and folds to become oriented abnormally. Incision line tension can cause malposition of the hairline, alopecia, distorted earlobes, widened scars, and possible skin flap necrosis. Despite these issues, an isolated skin lift procedure can be a useful in secondary or tertiary situations where the deep tissues have previously been repositioned and the primary problem is a recurrence of skin laxity.

Facelift incisions The purpose of a facelift incision is twofold. First and most importantly, the incision provides access for surgical manipulation of the deep tissues of the face – the primary goal of most modern facelift techniques. Second, the incision allows facial skin to be repositioned and for excess skin to be removed. The incision is designed to be hidden by hair and by contours of the ear. In the temple area, the incision can be placed in the hair, at the anterior hairline, or a hybrid of the two, with an incision in the hair plus a transverse extension at the base of the sideburn (Fig. 9.3.15). The advantage of the incision in the hair is

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A

C

B

D

E

Figure 9.3.15  (A) The traditional hidden incision in the temple hair is appropriate when the temporal hairline will not be shifted adversely. (B) A temple incision along the hairline is used if a hidden incision will adversely shift the hairline. (C) The distance from the lateral orbital rim to the temporal hairline should not exceed 5 cm. (D) The retrotragal incision follows the edge of the tragus. (E) The pretragal incision is placed in the pretragal sulcus.

that it is hidden, but when the flap is drawn up, the anterior hairline and sideburn will shift, the degree of this depending on skin laxity. If the incision is placed at the anterior hairline, the scar is potentially more visible, but there will be no shift of the hairline. A popular compromise is to place the incision at the base of the sideburn and to place the incision partly at the hairline and partly behind the hairline128 (Fig. 9.3.16). Several factors should be assessed before committing to an incision within the temple hair, including density of the hair and the distance between the lateral orbital rim and the temporal hairline. In youth, this distance is generally less that 4–5 cm, while in older patients, the distance increases.129 If the distance is already excessive, or if the expected movement of the temporal hairline will create a distance over 5 cm, then an incision

in the hair should be avoided. Several alternate solutions have been devised to hide incisions made along the temple hairline, including beveling the incision to encourage growth of hair through the scar and the use of zigzag incisions.130,131 The anterior hairline incision should be meticulously sutured under minimal tension. Anterior to the ear, the incision can be pretragal, or along the tragal edge. The advantage of the tragal edge incision is that it is hidden, but care must be taken to thin the flap covering the tragus in order to simulate a normal tragal appearance. Furthermore, as pointed out by Connell,129,132 the tragus looks like a rectangle, with a top and a bottom, and to preserve a distinct lower border, a short transverse cut at the inferior end of the tragus (the incisura) should be made. Before committing

Surgery

A

B

to a tragal edge incision, the quality of tragal skin and that of facial skin must be compared; if the difference is too great, drawing thick cheek skin onto the tragus may be problematic because the skin covering the tragus will not be anatomically appropriate. Therefore, in certain cases, a pretragal incision is preferred. For example, in men, the pretragal approach may be beneficial if it appears that thick-bearded skin will be drawn up onto the tragus and the surgeon is concerned that removing hair follicles and thinning the flap will not ameliorate the appearance of cheek skin on the tragus. Elsewhere in front of the ear, the superior portion of the incision should follow a curved line along the helix and a slightly straighter curve along the anterior attachment of the earlobe; a long, straight line incision in front of the ear should be avoided (Video 9.3.2 ). Around the earlobe, the incision can be place either in the cleft of earlobe attachment or 1–2 mm distal to the cleft, leaving a cuff of skin along the earlobe. This cuff will ease the process of insetting the earlobe on closure. In the retroauricular sulcus, the incision can be placed directly in the conchal groove as it courses superiorly. Various landmarks have been described to determine how high to carry this incision. These include the level of the external auditory canal, or slightly higher, at the level of the antihelix. A “short scar” facelift incision involves only the temple incision and the preauricular incision, extending into the retroauricular sulcus, but not beyond.133 The advantage is to eliminate an incision into the occipital hairline and the main indication is facial rejuvenation when the neck is not a problem. The main disadvantage is the reduced effect for patients with excess neck skin; attempts to deal with this may result in a gathering of skin in the retroauricular sulcus, creating vertical pleats. Also, access to deep tissues is somewhat limited and there is a tendency to draw the skin flap in a more superior direction, possibly requiring a pre-hairline incision in the temple and possibly causing traction lines and wrinkles to course superiorly.

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Figure 9.3.16  (A) The author’s preferred anterior incision is just behind the hairline in the temple, across the base of the sideburn, follows the contours of the ear and is along the tragal edge. (B) When there is minimal skin shift expected, the posterior extent can be limited to the retroauricular sulcus (“short scar” technique). When more skin shift is expected from the neck, the incision extends across non-hair-bearing skin into the occipital hair. In this example a “lazy S” follows the occipital hairline for 1 cm before entering the occipital hair.

With the standard approach, the incision extends from the retroauricular sulcus across non–hair-bearing skin into the occipital hair. Many variations have been described, ranging from an incision that goes vertically into the scalp134 to an incision that courses inferiorly along the hairline of the neck. Most commonly, surgeons use an incision that is between these two extremes. The principal objective is to take up redundant neck skin while avoiding distortion of the occipital hairline. Commonly a “lazy S” pattern can be used, where the incision follows the occipital hairline for 1–2 cm, before angling more posteriorly into the scalp, as in Fig. 9.16. A rough guide is to use the lazy S approach if 2 cm or more of neck skin is to be removed at the incision line (Video 9.3.3 ).129

Facelift skin flap dissection Either the temple dissection or the postauricular dissection can be done first, depending on surgeon preference. Dissection is usually begun with a scalpel for the first 1–2 cm, at which point most surgeons switch to scissors. In the postauricular area, the flap is firmly attached to the deep cervical fascia. Also, this is the most common location to see skin flap necrosis, so the flap should be raised sharply under direct vision, keeping the dissection against the underlying deep fascia to maintain flap thickness. As the dissection continues inferior to the earlobe level, the surgeon must be cognizant of the great auricular nerve, which is most at risk over the posterior border of the SCM. By keeping the dissection in the subcutaneous plane, the nerve will be protected. In the temple, if the incision has been made along the anterior hairline, dissection begins directly in the subcutaneous plane. If the incision has been made in the hair-bearing scalp of the temple, dissection can be carried out in one of two planes: superficial to the superficial temporal (temporoparietal fascia), which will continue directly into the subcutaneous facelift plane, or between the superficial temporal fascia and the deep temporal fascia. If the deeper approach is used, the dissection

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proceeds quickly against deep fascia, but at the anterior hairline, the dissection plane must transition into the subcutaneous facelift plane. This change of plane results in a narrow ribbon of superficial temporal fascia that will contain the superficial temporal artery and vein and branches of the auriculotemporal nerve. This has been called the “mesotemporalis”, which must be divided, often requiring ligation of the superficial temporal vessels. The argument in favor of the deeper dissection is to protect temporal hair follicles, although vessels and a nerve must be sacrificed (Fig. 9.3.17A). The superficial plane has the reverse attributes: vessels and nerves within the superficial temporal fascia are preserved, but the hair follicles can be injured unless care is taken (see Fig. 9.3.17B). Anterior to the anterior hairline, the subcutaneous plane is developed. This is the “facelift plane” where the dissection normally leaves about 2 mm of fat on the dermis which creates a cobblestone appearance of fat on the underside of the flap. Techniques to keep the flap consistent include direct vision or transillumination. This dissection results in a large random-pattern skin flap, the survival of which will entirely depend on the subdermal plexus. In the upper face, this dissection normally continues anteriorly until the orbicularis oculi is encountered where it encircles the lateral orbital rim. Depending on the type of deep-plane surgery planned, the midcheek dissection may stop short of the malar fat pad, or alternatively, carry on over the fat pad, freeing it from the overlying skin in the temple and cheek. Lower in the cheek, anterior to the ear and overlying the parotid, the skin is tethered to fascia which, as described earlier, has been names different things by different authors, including platysma auricular fascia and the parotid cutaneous ligament. Beyond this zone, subcutaneous dissection proceeds

A

relatively easily. Once the skin flaps anterior and posterior to the ear have been raised, the two dissections are joined. The extent of the facelift flap dissection into the cheek and neck will depend on the type of deep tissue technique being employed. When a submental incision is used for midline platysma plication, it is important to widely mobilize the cervical skin from the underlying platysma in order to allow the cervical skin to be re-draped along a vector opposite to that in which the platysma is being moved. If, on the other hand, there is no submental incision and the neck platysma and neck skin are moved in the same direction, the neck dissection can be more limited (Figs. 9.3.18 & 9.3.19).

Deep tissue surgery As reviewed in Chapter 9.2 the anatomy of facial aging is a complex process involving all layers of the face, from the skin to the bone. Logically, surgical rejuvenation of the aging face should address all or most of these layers. The subcutaneous facelift flap allows for tightening and removal of excess skin but does not address the descent of the thicker and heavier underlying soft tissue. A host of surgical approaches have been described to do this. These are outlined here and in subsequent chapters.

SMAS plication After surgeons learned to raise large random-pattern skin flaps, it became apparent that facial shape could be more effectively changed by using sutures to manipulate the underlying soft tissue.27

B

Figure 9.3.17 (A) Facelift flap has been raised in two different planes, initially deep to the superficial temporal fascia, against the deep temporal fascia (seen as an oval window), with a change of planes near the anterior temporal hairline into the subcutaneous plane. The “mesotemporalis” is a bridge of tissue that develops between these two planes. In order to unify the planes, it has been divided with ligation of the superficial temporal artery. (B) Facelift flap has been raised in a single subcutaneous plane, with dissection directly on the superficial temporal fascia and deep to the hair follicles of the scalp. The purple line outlines the course of the anterior branch of the superficial temporal artery.  

Surgery

Figure 9.3.18  Subcutaneous facelift flap has been raised.

Suture plication creates an in-folding of the superficial fat, drawing fat from the lower face up to the point where the sutures are placed (Fig. 9.3.20). Areas of fixed tissue, such as over the parotid gland, are less movable and can act as an anchoring point, whereas anterior to the parotid, mobile tissues can be easily manipulated.135 Multiple sutures with customized vectors can be used, allowing reshaping of the superficial facial fat. The technique is relatively easy to master; it can be customized for the individual case and can be modified intraoperatively by removing and replacing sutures as necessary. The superficial fat can be shifted in a different direction than the skin, usually along a more vertical vector. When plication sutures are placed properly, there is little or no risk to branches of the facial nerve. Proponents of plication claim long-lasting results without the need for invasive dissection.136 The primary concern with plication is the potential loss of effect if sutures cut through the soft tissue (the “cheese wire” effect). Another concern is that the degree of improvement may be limited by the tethering effect of the retaining ligaments, which in this technique are not released at their deeper extent; they are, however, released at the subcutaneous level during skin flap dissection. When the subcutaneous fat is fragile, suture fixation may fail. Also plication may have a limited effect in patients with very heavy jowls and ptotic tissues in the neck.

Loop sutures (MACS lift) A variation of suture plication is the loop suture method (Fig. 9.3.21), for which the main variant is the MACS lift

165

(minimal access cranial suspension). This procedure, which itself was derived from the “S-lift”, relies on long suture loops that take multiple small bites of soft tissue in a purse-string fashion.137,138 A vertical loop (the “U” suture) and an oblique loop (the “O” suture) are used with some of the tissue bites strategically placed into platysma below the border of the mandible. Superiorly, the sutures are secured to the deep temporal fascia at a point just superior to the zygomatic arch and anterior to the ear. The theoretical explanation for the efficacy of this technique relates to the use of multiple bites of tissue, which the developers of the technique feel creates “microimbrications” of the superficial fat and SMAS.138 Anteriorly, a third suture can be placed to advance the malar fat pad, although the fat pad is not surgically released and its repositioning depends on its own intrinsic mobility. Treatment of the neck can be done with closed liposuction or with an open procedure done through a submental incision, as described in Chapter 9.8. On closure, proponents of this technique recommend a nearly vertical vector for the skin flap, with a short scar incision. This may generate bunching of skin in the temple, which is dealt with by a W-plasty. The advantages with this technique are similar to those of plication, although proponents point to the added benefit of using a firmer point of fixation (deep fascia) and the improved effect of microimbrications. Disadvantages are the same as SMAS plication: potential loss of effect if the sutures pull through, the lack of deep ligament release, and concerns about the effectiveness of sutures holding heavy jowls and ptotic neck tissues against gravity. Lastly, surgeons using this technique must address the tendency for loop sutures to cause fat to bunch up, potentially leaving bulges that can be visible through the skin.

Supraplatysmal plane facelift The supraplatysmal plane facelift (Fig. 9.3.22) involves a deep subcutaneous dissection carried out immediately superficial to the SMAS and platysma. Originally called the “extended supraplatysmal (ESP)” facelift, this procedure raises the skin and superficial fat as a single layer, leaving the SMAS layer untouched.139 The zygomatic ligaments are released as dissection of the superficial facial fat extends over the malar prominence as far forward as the nasolabial folds. The theory behind this technique is the belief that the superficial fat is ptotic, but the underlying SMAS and platysma are not.139 After the flap has been raised, the fat on the underside of the flap can be contoured and sutures can also be placed from this fat to underlying fixation points. This technique provides good mobilization because ligaments are released, and it produces a thick robust flap. Also, with no surgical penetration of the underlying SMAS, there is theoretically no risk to branches of the facial nerve. Concerns about this method are that the flap is unidirectional (the skin and fat move en bloc) and the fact that repositioning the weight of this flap depends primarily on skin tension at the suture line.

SMASectomy The SMASectomy procedure involves excision and direct closure of the SMAS and superficial fat in the midcheek (Fig. 9.3.23). After skin flap elevation, a strip of SMAS and overlying fat, angling obliquely across the cheek, is removed from the lateral malar eminence to the angle of the mandible.140

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Figure 9.3.19  (A,B) Subcutaneous flap dissection with no submental incision. Platysma and skin are being moved in the same direction, superolaterally, thus requiring minimal separation of skin from platysma. (C,D) Subcutaneous flap dissection with submental incision. The paired platysma muscles, when sutured together in the midline, are shifted medially. As the skin is being moved in the opposite direction, a more thorough separation of skin from platysma is required.

A

B

C

D

The resulting defect, usually 2 to 3 cm in width, is sutured directly. The procedure can be done with a conventional facelift incision or a short scar approach. If required, the neck can be treated directly with closed liposuction or with platysma plication done through a submental incision. A primary advantage of this technique is the location of traction, which is close to the ptotic lower facial tissues, such as the jowl, and therefore potentially more effective than a more superiorly placed SMAS flap. The technique allows for skin and SMAS to be moved along different vectors. By suturing two freshly cut edges, fixation may be more secure than plication alone. Compared with doing a separate SMAS flap, the procedure is less time consuming, with less theoretical risk to the facial nerve because there is no deep-plane dissection. Also, the cut edges have not been undermined, potentially making them more viable than undermined SMAS flaps. Proponents feel that fixation is effective because the mobile SMAS is advanced and anchored to the fixed SMAS. Disadvantages include

the possibility of injuring a facial nerve branch (if the SMAS removal is done too deeply) and the lack of any ligamentous release, which may limit the movement of certain tissues such as the malar fat pad.

SMAS flap with skin attached (deep-plane facelift) Tord Skoog in 1974 published his method of raising skin, subcutaneous fat, and the SMAS as a single layer, which created a thick robust flap with excellent blood supply. It also contained a stretch-resistant structure (the SMAS), giving the promise of a long-lasting result.141 In concept, this procedure is like the ESP procedure (above), except that the SMAS is also included in the flap being raised. Because the operation was devised before Furnas described the retaining ligaments, the original Skoog procedure afforded only limited improvement

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in the anterior face. This lack of anterior movement was later found to be due to tethering of the SMAS to the lip elevators: zygomaticus major and minor and levator labii superioris.84 In order to overcome some of these shortcomings, several variations were developed (Barton: high SMAS; Hamra: deep plane; Fig. 9.3.24).53,142–144 The skin is normally raised for only 2–3 cm anterior to the tragus, the SMAS is then incised, and the rest of the dissection is done deep to the SMAS as far as the zygomaticus major muscle from which the SMAS is released. Beyond that, dissection can become more superficial. The skin and subcutaneous fat are left attached to the SMAS, and the entire flap is then advanced and fixated. Advantages of this technique are the robustness and physical strength of the flap, and the requirement for only one plane of dissection. Ligaments can also be released. Certain variations of the technique also allow for repositioning of the malar fat pad.142,144 In the composite technique, the orbicularis oculi muscle and overlying skin were included in the dissection.142,143 The neck is treated as required with an open approach to deal with the platysma and excess fat. Disadvantages of the purely deepplane procedures include the inherent risks of dissecting under the SMAS. Also, these procedures are mostly “monobloc” techniques, where the skin, subcutaneous fat, and SMAS are generally moved in one direction.

Subcutaneous facelift with separate SMAS flap (dual plane facelift) Figure 9.3.20  Subcutaneous flap with SMAS plication.

Figure 9.3.21  Subcutaneous flap with loop sutures (minimal access cranial suspension [MACS] lift).

Surgeons wishing to move the SMAS and subcutaneous fat in a different direction than the skin arrived at the concept of two separate flaps: the random-pattern facelift skin flap and a SMAS flap carrying the superficial fat (Fig. 9.3.25). Once the skin flap has been raised, the dissection plane for the SMAS flap is like the deep-plane dissection. Multiple variations of the SMAS flap component have been described with some dissections beginning above the zygomatic arch (high SMAS), some from below the zygomatic arch (low SMAS) and some in the midcheek. There are also variations in the pattern and extent of lateral platysma mobilization in the neck. In all cases, retaining ligaments are released and the SMAS, in conjunction with the platysma, is repositioned. Terminology has been introduced by different authors depending on their SMAS flap design (extended SMAS: Stuzin; high SMAS: Connell and Marten; FAME: Aston; MAPS Lift: Warren; Extended Vertical: Jacono).47,51,55,145–151 Proponents of this method feel that that moving the skin and subcutaneous soft tissues along different vectors provides more control over the facelift result. Typically, the deep tissue flap is shifted more vertically than the skin flap, which is shifted perpendicular to the nasolabial fold. A second advantage is the ability to reposition deep facial tissues by mobilizing and fixating the SMAS flap internally without the need to rely on skin tension for support. Retaining ligaments are surgically released, resulting in excellent mobilization and advancement of the SMAS and overlying fat. Disadvantages relate to a more time-consuming procedure because two different surgical planes are developed. In addition, these two planes introduce the inherent problems of each: potential damage to deep structure when doing the SMAS flap dissection and potential problems with the skin flap if it is too thinly dissected or if it is placed on too much tension. In a thin patient, both layers can be quite thin, which increases the technical demands placed on the surgeon.

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SMAS/platysma

Superficial fat

ESP dissection

A

Area of skin and subcutaneous fat elevation in extended supraplatysmal plane (ESP)

SMAS/platysma B

Figure 9.3.22  (A,B) Supraplatysmal plane (extended supraplatysmal plane [ESP] lift).

Subperiosteal facelift

Lateral SMASectomy extends from tail of parotid to lateral canthus Resection is at interface of fixed and mobile SMAS. Width of resection determined by SMAS laxity and desired debulking Undermining posterior border of platysma for advancement to mastoid

Figure 9.3.23  Subcutaneous flap with SMAS excision (SMASectomy).

Paul Tessier, in 1979, first presented his concept for a subperiosteal approach using craniofacial principles to elevate facial tissue.57,152 Variations were developed,59,153 but it was not until the introduction of the endoscope that surgeons widely adopted this concept (Fig. 9.3.26 ). As with an endoscopic browlift (see Chapter 11) approaching from the temple, the midface can be dissected in either the subperiosteal58,154 or supraperiosteal plane.155,156 Added exposure can be achieved by including access through a lower eyelid or an intraoral incision. The advantages are a dissection that is deep to all vital structures, a relatively short incision, and harmonious lifting of the midface and lateral brow. There is little or no tension on the skin, thus eliminating problems from excess tension on the skin. Disadvantages include the additional technology and equipment involved, a limited effect in the lower face/neck region, and limited effect on superficial structures, particularly loose skin. The younger patient who requires midface improvement without skin tightening has been proposed as being a good candidate.157

Skin flap closure (Video 9.3.4

)

Regardless of the technique used (excepting a pure subperiosteal approach), skin flap mobilization and closure is an important part of a facelift. Errors made during closure can create some of the most obvious facelift deformities which will denigrate an otherwise well-done procedure. At all times, the

Surgery

Subgaleal dissection Subcutaneous dissection 4cm

169

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

Subcutaneous dissection of neck from mastoid to midline superficial to platysma

Upper lateral corner of SMAS remains attached to skin

Temporal branch, facial nerve

SMAS incision Dissection from beneath SMAS over zygomaticus major thus releasing restraint of investing fascia

Marginal mandibular branch of facial nerve

Figure 9.3.24  SMAS flap with skin attached (deep-plane facelift).

skin should be considered a covering layer, not a structural one. Therefore, skin flap repositioning should be seen as a removal of redundancy rather than a method to hold up ptotic soft tissue. In dual plane techniques, the skin flap is advanced

superolaterally along an oblique vector that is less vertical than the typical vector used for repositioning deep tissues. In other techniques, such as the MACS lift, surgeons employ a nearly vertical vector to the skin flap. In a deep-plane procedure,

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Figure 9.3.25  Subcutaneous facelift with separate SMAS flap (dual plane facelift).

the skin and deep tissues are mobilized together. A popular way to treat the skin flap is to redrape it “where it lies”, which means moving the cheek skin flap obliquely to the position it naturally assumes when the patient is lying in the supine position on an operating table.158 Another common guide is to advance the skin flap toward the temple along a vector that is perpendicular to the nasolabial fold. This is also approximately along the long axis of the zygomaticus major muscle. Determining flap tension is a surgical judgment and a skin flap marking forceps can help to determine where the skin should be incised. The anterior anchor point is immediately adjacent to the helix of the ear at the junction of the hair-bearing scalp. It can be held in place with a half-buried mattress suture to minimize the chance of a visible suture mark (Fig. 9.3.27 ). Posteriorly, the skin flap should be drawn along a vector that roughly parallels the body of the mandible. The second anchor point will be at the superior-most extent of the postauricular sulcus at the point where the incision starts to transition posteriorly. Once again, a half-buried mattress suture can be used. At this point, trimming of the overlapping flap and suturing can be done in the temple and in the occipital region; the order is based on surgeon preference. Then excess skin around the ear is trimmed, with no tension on the closure. If a tragal edge incision is used, the tragal flap is thinned and hair follicles are removed. In the retroauricular sulcus, there is normally little or no skin to be trimmed if the posterior flap has been correctly positioned. Earlobe inset is done last and is designed to angle the lobe 15° posterior to the long access of the ear (Fig. 9.3.28).129,132 Tension on the earlobe can lead to distortions such as the pixie ear deformity and the malpositioned earlobe, both of which are difficult to correct (see Chapter 9.10).

Proper insetting of the earlobe

A

B

Figure 9.3.28  The earlobe should be inset with the long axis of the earlobe (dotted line) about 15° posterior to the long axis of the ear itself. If the earlobe is pulled forward, an unnatural appearance results.

Neck surgery In most patients, an aging-looking neck accompanies an aging face and appropriate rejuvenation involves the correction of both. Anatomic structures in the neck that contribute to aging changes include the skin, subcutaneous fat, platysma muscles, subplatysmal fat, the digastric muscles and the

Surgery

170.e1

Fronto-temporal approach Intraoral approach Submental approach

Figure 9.3.27  Diagram shows typical skin flap redraping along an oblique direction which is slightly less vertical than the vector along which deep tissues are moved. There is considerable variation in this, however. Some techniques involve a more horizontal vector (dual plane extended SMAS) while other techniques utilize a nearly vertical vector (MACS lift).

SOOF

Intraoral incision Subcutaneous dissection Buccal fat

Figure 9.3.26  Subperiosteal facelift. SOOF, Suborbicularis oculi fat.

Surgery

submandibular glands. Basic principles for dealing with these structures are covered here, with a more thorough review presented in Chapter 9.8. A proper physical examination of the neck will help delineate the underlying anatomy and determine what tissues need correction. With the patient vertical, a traction test is done by manually repositioning cheek soft tissue to simulate the effect a facelift could have on the upper neck. Asking the patient to contract the platysma helps determine the thickness of subcutaneous fat as well as the strength and configuration of the platysma muscles. Viewing the patient from the side is helpful in assessing the length of the mandibular body, the degree of chin projection, the nature of the cervicomental angle and the location of the hyoid bone. The skin of the neck is typically thinner and less elastic than facial skin. In younger patients, the only lines present may be transverse, so-called necklace lines, which may be amenable to filler injection. With age, neck skin becomes more lax, often causing vertical wrinkles and pleats. These can be corrected by tightening the skin in a posterior oblique direction. One school of thought is that the platysma and skin are embryologically formed together and should be repositioned together by using a superior/oblique vector.138,159 Conversely, when the skin and platysma are treated separately, they must be surgically separated to allow them to be mobilized in different directions. With age, subcutaneous fat is lost in the lower neck while total fat volume increases in the upper neck. Increased upper neck fat, both superficial and deep to the platysma, contributes to blunting of the cervicomental angle.80 When the presence of subcutaneous fat is the only presenting problem, closed liposuction is a good solution when the skin is young and firm.160 Non-surgical measures such as cryolipolysis or injections of deoxycholic acid can also be used in that setting.161,162 Many surgeons perform closed liposuction in patients with looser neck skin, providing the skin is simultaneously tightened as part of a facelift. An important long-term consideration with all these methods is that submental fat removal can lead to laxity of submental skin later in life (Fig. 9.3.29). In general, the removal of subcutaneous fat should be done conservatively,

leaving a layer of fat on the skin that is thick enough to hide and disguise underlying anatomic undulations. The paired platysma muscles have well-recognized variations in their anatomy. The majority (roughly 75%) of necks exhibit interdigitation of the platysma muscles in the submental region for the first 1–2  cm behind the chin.163,164 The remaining 25% either overlap extensively, or do not overlap at all (Fig. 9.3.30). With age, there is a loss of tethering of the platysma muscles to the deep cervical fascia, analogous to the loss of tethering of the orbicularis oculi along the infraorbital rim. As a result, the anterior platysma borders fall away from the cervical mandibular angle and the sharp angle of youth gives way to the obtuse angle of age. The leading edge of the paired platysma muscles may cause visible bands, but clinical experience has

Figure 9.3.29  This 55-year-old woman had submental liposuction 25 years previously. She presents with excessive skin laxity in the submental region where the liposuction was done.

Mandibular symphysis

Thyroid cartilage

Limited platysma interdigitation

Extensive platysma interdigitation

No platysma interdigitation

Figure 9.3.30 Three types of platysma anatomy: limited interdigitation, 75%; extensive interdigitation, 15%; no interdigitation, 10%.  

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demonstrated that not all visible bands in the anterior neck are muscle; they may be caused by folds of excess loose skin. The distinction between muscle redundancy or loose skin should be determined during preoperative physical examination. Anterior platysma bands are considered either passive (present at rest) or active (only present on animation). To treat anterior passive neck bands caused by the platysma, one option is to treat the platysma and overlying skin as a common layer, as previously mentioned for treatment of loose neck skin. In conjunction with the facial SMAS, the platysma muscles can be drawn in a superior/oblique direction with fixation to firm fascia such as the platysma auricular fascia.92,159 In addition to this action, the anterior platysma muscle can be divided from the posterior approach, usually with a wedge excision to help ensure separation. One modification of this technique is the lateral skin-platysma displacement (LSD) procedure which creates a transposition flap out of anterior platysma that tightens anterior neck skin as the flap is mobilized posteriorly.165 Alternatively, the paired platysma muscles can be treated independently from the overlying skin. The approach to the platysma muscles is through a 2–3 submental incision, either in the submental crease or posterior to it. The muscles can then be drawn medially and approximated in the midline.28,166 Central approximation of the platysma muscles may require removal of interplatysmal fat and fascia. In joining the paired platysma muscles together, some surgeons advocate multiple rows of sutures to aggressively advance the platysma muscles medially; this has been termed the “corset platysmaplasty”.61 The logic in suturing the platysma muscles centrally is that a hammock effect is created to help support the deeper neck tissues and the platysma bands are eliminated by converting two muscles into one. A further maneuver, transecting the platysma inferior to the plication sutures, is necessary to eliminate active bands. In patients with very strong platysma muscles with a short thick neck, it may be necessary to do a complete transection of the muscles. Deep to platysma muscles, the subplatysmal fat has been described in three components: central, medial and lateral.167 The largest portion is the central, which is fibrous fat that fills the space between and overlies the digastrics. On its deep surface it extends to the mylohyoid. Laterally the medial portion becomes less fibrous and terminates as the most lateral portion

A

overlying the submandibular gland (Fig. 9.3.31A,B). This deep fat contributes to blunting of the cervicomental angle. It is easily accessed through the submental approach and can be partially or completely removed under direct vision. Also the anterior digastric muscle bellies may contribute to the appearance of submental fullness and can be surgically thinned. When submandibular glands are visible below the mandibular border or will become so after neck tightening, they can be treated with partial excision.168–170 Conceptually, deep soft tissues in the upper neck, consisting of deep fat, digastric muscles and submandibular glands should be considered as a contiguous soft-tissue mass that adds bulk to the neck. The alteration of any one component may require the alteration of all structures to create a congruent result.171,172 (Fig. 9.3.32). In some patients, when the only concern is the neck, an isolated neck procedure can be done. In that scenario, a submental incision is used for fat removal, platysma plication, or platysma transection plus the manipulation of anatomic structures deep to the platysma.173 Skin laxity can be corrected with an isolated retroauricular incision to redrape the skin. Through

Figure 9.3.32  Subplatysmal structures that affect neck contour. (1) Anterior belly of the digastric muscle, (2) submandibular salivary gland, (3) hyoid, and (4) mylohyoid muscle. Subplatysmal fat (not depicted) is distributed around these structures. (From Auersvald A, Auersvald LA, Uebel CO. Subplatysmal necklift: a retrospective analysis of 504 patients. Aesthet Surg J. 2017;37(1):1–11.)

B

Figure 9.3.31 (A) Subplatysmal fat elevated showing pyramidal shape. (B) Subplatysmal fat reflected revealing the floor of the submental triangle made by the mylohyoid muscle and the lateral boundaries made up by the digastric muscles. (From O’Daniel TG. Understanding deep neck anatomy and its clinical reverence. Clin Plastic Surg. 2018; 45: 447–454.)  

Ancillary techniques

this incision, tightening of the posterior plastysma can also be accomplished. The limitation with isolated neck lifts is often the skin which, when mobilized posteriorly, causes pleating anterior to the ear. This may require extending the incision anterior to the ear, thus approximating a facelift incision. In some older male patients with significant neck tissue laxity, a preferred option may be a direct excision of excess neck skin using a midline incision often broken up with a zigzag pattern or with Z-plasties.174 This minimally invasive technique is easily done with local anesthetic with or without sedation and provides unparalleled access to the platysma and subplatysmal structures. It allows maximal tightening of redundant neck skin. The primary disadvantage of this approach is a midline neck scar.

Choice of procedure With so many different methods described, it is difficult for the novice to choose the appropriate approach for face and neck lift surgery. In subsequent chapters, leading proponents of the techniques described here review their methods in detail. This is a field where personal opinions are strong, and the greatest difference of opinion among facelift surgeons relates to the way they manage the deeper tissue of the face and neck. Some surgeons feel that surgery above the SMAS (SMASectomy, Plication, MACS lift) will suffice, while others feel that dissecting and repositioning the SMAS is imperative for long-lasting results. In the neck, some surgeons feel that any anterior platysma banding warrants open surgery through a submental incision, while others rely completely on posterior–superior platysma traction. Some surgeons feel that visible submandibular glands must be addressed, while others feel it should never be done. In all cases, the objective is the same: an effective procedure with a long-lasting result and a high margin of safety. Over the years, a number of studies have been done attempting to compare different facelift techniques.32,175–183 One study involved four surgeons and two pairs of identical twins. At 10 years, both sets of twins had similar results.183 A systematic review of the world literature over a 60-year period was done looking for reliable data to support the efficacy and safety of one method over another.184 No clear indication could be found that any one facelift technique was superior to any other. As a result of such studies, surgeons are left to use their own judgment based on experience with different procedures in their own hands. Furthermore, the surgical technique for face and neck must be tailored to the individual patient because no one operation will fit every situation. Regardless of technique, there is inevitably some deterioration of the facelift result over time, something that depends on the quality of tissue being manipulated as well as technique being used.181 For example, one paper documented the recurrence of skin laxity and platysma bands in the anterior neck in 50% of patients at 1 year after extensive neck surgery.185 Comparing different face and neck lift techniques has historically been difficult because of the subjective nature of the end product. Recently, there has been progress in the objective assessment of surgical results using patient satisfaction as the metric.186 Looking forward, new technologies show promise in comparing facelift results based on the objective measurement of reduced apparent age as rated by independent reviewers or with artificial intelligence software.187,188

173

Ancillary techniques Browlift surgery and blepharoplasty Facial aging is typically a pan-facial phenomenon, and a comprehensive approach is often required to achieve a harmonious result. For many patients, surgery for the brow (Chapter 11) and the eyelids (Chapter 13) are critical components of a global approach to rejuvenation. Also, a facelift may introduce an indication for lateral brow lifting because of soft-tissue recruitment in the temple region. In this area, when a considerable amount of skin has been mobilized with cheek reposition, skin bunching can occur, and the best option may be to reposition the lateral brow and temple skin.

Volume removal With radial expansion of the lower third of the face and upper neck, many patients require fat removal. Superficial fat in the jowl area can be sculpted under direct vision or with closed small cannula liposuction. Deep fat removal in the cheek involves the buccal fat pad, which can be accessed during a facelift when the dissection plane is deep to the SMAS. The buccal fat pad is found between the buccal and zygomatic branches of the facial nerve. It then can be repositioned or partially removed.189,190 (Video 9.3.5 ). An alternative method is to partially remove the buccal fat through the mouth with an upper buccal sulcus incision.191 In the neck, superficial fat can be removed under direct vision or with closed liposuction. Deep fat in the central neck can be removed under direct vision. In all cases of fat removal in the face or neck, caution is advised because of the potential defects that can be produced when too much fat is removed.

Volume augmentation As volume loss in the face is a critical component of aging, proper rejuvenation should address facial deflation as well as soft-tissue ptosis. Volume can be added to the aging face using synthetic implants (cheek implants, submalar implants, orbital rim implants), injectable synthetic fillers, hydroxyapatite granules, or fat graft. Techniques involved in harvesting, processing, and injection of micro-droplet fat grafts (lipofilling) have undergone technical improvements and as a result, this technology is reproducible and reliable.64,192 For many surgeons fat grafting is now an integral part of facelift.193 There is a high rate of fat graft take after fat injection in the middle third and upper third of the face; in fact, significant over-grafting should be avoided in the periorbital area because of the possibility of visible ridges or lumps. Fat grafting is less reliable around the vascular mobile structures such as the lips. Specific areas that are commonly fat grafted in conjunction with facelift surgery are temples, the periorbita (orbital rim, upper lid sulcus, and the tear trough), the midfacial groove, and the malar prominence.193 The depth of injection can be in the superficial fat layer (superficial to SMAS) or, more commonly, in the deep fat layer against bone. As mentioned earlier, it has been proposed that the deep medial fat compartment may play a unique role in support of soft tissue in the midface, suggesting the benefits of fat grafting these zones.66 Therefore, the suborbicularis fat compartment

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(SOOF) and the deep medial fat compartments are grafted to restore midface volume in the midcheek. Fat injection can be done independently or in combination with facelift surgery. When done in conjunction with facelifting, it is done at the surgeon’s preference, either at the beginning of the procedure before the facelift flap has been raised (this author’s preference) or at the end of the procedure (Video 9.3.6 ).

Midface lift In an attempt to lift the tissue immediately inferior to the infraorbital rim (the midface), an approach through the lower lid was developed.194 This involves a subciliary or a transconjunctival blepharoplasty-type incision followed by a dissection down over the face of the maxilla. This procedure can be done in the subperiosteal plane, which requires an inferior periosteal release, or it can be done in a supraperiosteal plane.195 After mobilization of the cheek mass, the soft tissue is secured superiorly, either laterally along the lateral orbital rim,194 or more vertically with anchoring to the bone of the infraorbital rim.196 Disadvantages have included the learning curve necessary for surgeons to feel comfortable with this approach and a significant incidence of revisions for malposition of the lower eyelid.197 An alternative to the blepharoplasty approach is an endoscopic approach through the temple. This involves an extension of the endoscopic temple dissection along the lateral orbital rim, across the malar prominence, into the midface. The midface soft tissue is then elevated and fixated to the deep temporal fascia with long cable sutures or with specially made fixation devices.198

Lip procedures The aging face often develops changes in the perioral region, but a facelift will not affect this region except for some minor improvement in marionette lines. Common changes include elongation of the upper lip as measured from Cupid’s bow to the base of the columella, a thinning of the vermilion, and the development of perioral rhytides. Elongation of the upper lip is highly variable, but if present, tends to hide the upper teeth when the lips are in a relaxed position. It has been estimated that the ideal distance from Cupid’s bow to the base of the columella is 15 mm.199,200 The upper lip can be shortened by performing a skin excision along the contours of the base of the nose (bullhorn pattern). Skin is excised along with underlying fibrofatty tissue, exposing the orbicularis oculi. After undermining, the skin flap is drawn superiorly, with direct approximation of skin at the nasal base. Disadvantages include a potentially visible scar and a certain degree of relapse (Fig. 9.3.33). Alternatively, a strip of skin can be removed along the vermilion border, advancing the vermilion superiorly. This has the advantage of immediately increasing the apparent width of the vermilion lip, but the disadvantages are that the white roll is eliminated, and a permanent scar will be left along the vermilion border. Women can deal with this by using lipstick, but this is usually a lifelong commitment when the scar is visible. Lip augmentation can be done with many different techniques. Commonly used methods include injectable filler, injected fat, dermal fat graft, acellular dermis, and SMAS grafts. Many different types of human tissue and many synthetic materials have been used to thicken lips. Depending on the technique used, various problems have included

A

B

Figure 9.3.33  (A) Pre- and (B) postoperative photographs of a lip-shortening procedure using a bullhorn-shaped incision along the nostril sill.

resorption and loss of effect, permanently overfilled lips, misshaped lips, immobile lips, and in some cases, tissue necrosis from vascular compr