Reoperative Aesthetic and Reconstructive Plastic Surgery [2 ed.] 1576261808, 9781626239906, 9781626236134, 9781576261804

Table of contents :
Frontmatter.pdf (p.1-24)
Chapter 1 What Is Reoperative Plastic Surgery.pdf (p.25-60)
Chapter 2 The Patient.pdf (p.61-80)
Chapter 3 Psychological Considerations in Reoperative Plastic Surgery Patients.pdf (p.81-102)
Chapter 4 The Surgeon.pdf (p.103-112)
Chapter 5 Common Secondary Complications.pdf (p.113-138)
Chapter 6 Scars and Scar Revision.pdf (p.139-172)
Chapter 7 Reoperation for Donor Site Complications.pdf (p.173-200)
Chapter 8 Repeated Tissue Expansion.pdf (p.201-220)
Chapter 9 Failed and Failing Free Flaps.pdf (p.221-242)
Chapter 10 Milestones in the Evolution of Face-Lift Techniques.pdf (p.243-282)
Chapter 11 Reoperative Rhytidectomy.pdf (p.283-334)
Chapter 12 Reoperative Forehead Lift.pdf (p.335-358)
Chapter 13 Use of Endoscopy in Reoperative Brow-Lifting.pdf (p.359-372)
Chapter 14 Adjunctive Surgical Procedures to Improve the Face-Lift Result.pdf (p.373-402)
Chapter 15 Adjunctive Procedures to Improve the Results in Facial Aesthetic Surgery.pdf (p.403-428)
Chapter 16 Revisional Fat Grafting of the Cheek and Lower Eyelid.pdf (p.429-466)
Chapter 17 Reoperative Blepharoplasty.pdf (p.467-506)
Chapter 18 Reoperative Lower Lid Blepharoplasty.pdf (p.507-538)
Chapter 19 Secondary Ptosis Correction.pdf (p.539-570)
Chapter 20 Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery.pdf (p.571-620)
Chapter 21 Secondary Rhinoplasty.pdf (p.621-730)
Chapter 22 Reoperative Surgery for Nasal Reconstruction.pdf (p.731-784)
Chapter 23 Staged Sequential Procedures for Ear Reconstruction.pdf (p.785-826)
Chapter 24 Surgery for Recurrent Cutaneous Malignancies of the Head and Neck.pdf (p.827-854)
Chapter 25 Reoperative Issues Following Flap Reconstruction in the Head.pdf (p.855-884)
Chapter 26 Secondary Procedures in Facial Reanimation.pdf (p.885-906)
Chapter 27 Primary Care and Secondary Reconstruction of the Burned Face and Neck.pdf (p.907-928)
Chapter 28 Reoperative Facial Fracture Repair.pdf (p.929-1038)
Chapter 29 Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity.pdf (p.1039-1078)
Chapter 30 Secondary Cleft Palate Surgery.pdf (p.1079-1138)
Chapter 31 Reoperative Craniomaxillofacial Surgery With Emphasis on Alloplastic Failure.pdf (p.1139-1164)
Chapter 32 Reoperative Craniomaxillofacial Surgery.pdf (p.1165-1220)
Chapter 33 Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy.pdf (p.1221-1286)
Chapter 34 Reoperative Surgery Following Breast Augmentation.pdf (p.1287-1342)
Chapter 35 Reoperation Following Implant Breast Reconstruction.pdf (p.1343-1390)
Chapter 36 Finishing Touches After Breast Reconstruction With Pedicled Flaps.pdf (p.1391-1436)
Chapter 37 Reoperation Following Free Flap Breast Reconstruction.pdf (p.1437-1506)
Chapter 38 Imaging Considerations in Plastic Surgery of the Breast.pdf (p.1507-1536)
Chapter 39 Local Recurrence After Mastectomy and Breast Reconstruction.pdf (p.1537-1550)
Chapter 40 Reoperative Surgery of the Chest Wall.pdf (p.1551-1624)
Chapter 41 Reoperative Liposuction.pdf (p.1625-1660)
Chapter 42 Reoperation After Liposuction and Body Contour Surgery.pdf (p.1661-1726)
Chapter 43 Staging, Reoperation, and Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient.pdf (p.1727-1766)
Chapter 44 Reoperative Surgery of the Abdominal Wall.pdf (p.1767-1850)
Chapter 45 Treatment of Recurrent Pressure Sores.pdf (p.1851-1886)
Chapter 46 Reoperative Hand Surgery.pdf (p.1887-1964)
Chapter 47 Secondary Surgery Following Digit Replantation.pdf (p.1965-1988)
Chapter 48 Reoperative Surgery After Excision and Grafting of Upper Extremity Burns.pdf (p.1989-2010)
Chapter 49 Reoperative Peripheral Nerve Surgery.pdf (p.2011-2034)
Chapter 50 Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction.pdf (p.2035-2084)
Chapter 51 In Closing.pdf (p.2085-2090)
Credits.pdf (p.2091-2092)
Answer Key to Review Questions.pdf (p.2093-2094)
Index.pdf (p.2095-2122)

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AESTHETIC

&

RECONSTRUCTIVE PLASTIC SURGERY

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SECOND EDITION

AESTHETIC

&

RECONSTRUCTIVE PLASTIC SURGERY EDITOR

JAMES C. GROTTING, MD Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham; Private Practice, Grotting Plastic Surgery, Birmingham, Alabama

ILLUSTRATED BY

Jennifer N. Gentry, MA, CMI

2007

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

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

© 2007 Thieme Medical Publishers, Inc. Thieme Publishers New York 333 Seventh Avenue, New York, NY 10001 USA +1 800 782 3488, [email protected] Thieme Publishers Stuttgart Rüdigerstrasse 14, 70469 Stuttgart, Germany +49 [0]711 8931 421, [email protected] Thieme Publishers Delhi A-12, Second Floor, Sector-2, Noida-201301 Uttar Pradesh, India +91 120 45 566 00, [email protected] Thieme Publishers Rio de Janeiro, Thieme Publicações Ltda. Edifício Rodolpho de Paoli, 25º andar Av. Nilo Peçanha, 50 – Sala 2508 Rio de Janeiro 20020-906, Brasil +55 21 3172 2297 eISBN 978-1-62623-990-6

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

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Contributors Ali Al-Attar, MD, PhD Resident, Department of Plastic Surgery, Georgetown University Hospital, Washington, DC

Elisabeth K. Beahm, MD Associate Professor, Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas

Al S. Aly, MD Private Practice, Iowa City Plastic Surgery, Coralville, Iowa

John Bostwick III, MD† Former Professor and Chairman, Division of Plastic, Reconstructive, and Maxillofacial Surgery, Emory University School of Medicine, Atlanta, Georgia

Adel Hussein Amr, MB, BCh, MSc Assistant Lecturer in Plastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Ain Shams University, Cairo, Egypt

Dean E. Burget, Jr., MD Staff Surgeon/Private Practice, Department of Plastic Surgery, Jennersville Regional Hospital, West Grove, Pennsylvania

Carl C. Askren, MD Assistant Clinical Professor, Department of Surgery, Plastic Surgery Section, University of California– San Francisco/Fresno, Fresno, California

Gary C. Burget, MD Associate Clinical Professor, Section of Plastic and Reconstructive Surgery, University of Chicago, Chicago, Illinois

Alexander W. Baker, BA Research Assistant, Department of Psychiatry, Center for Weight and Eating Disorders, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

Joseph F. Capella, MD Department of Plastic Surgery, Hackensack University Medical Center, Hackensack; Private Practice, Capella Plastic Surgery, Ramsey, New Jersey

Tracy M. Baker, MD Instructor in Surgery, Department of Surgery, Division of Plastic Surgery, University of Miami; Attending Surgeon, Baker Plastic Surgery, Miami, Florida

Grant W. Carlson, MD Wadley R. Glenn Professor of Surgery, Department of Surgery, Emory University, Atlanta, Georgia

Ricardo Baroudi, MD James H. Carraway, MD

São Paulo, Brazil

Professor and Chairman, Division of Plastic Surgery, Eastern Virginia Medical School, Norfolk, Virginia

Bruce S. Bauer, MD, FAAP Chief, Division of Plastic Surgery, Children’s Memorial Hospital; Professor of Surgery, Division of Plastic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois

Kristoffer Ning Chang, MD Associate Clinical Professor of Surgery, Department of Surgery, University of California–San Francisco, San Francisco, California

†Deceased.

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Contributors

Simon H. Chin, MD Former Chief Resident, Section of Plastic Surgery, Yale School of Medicine, New Haven, Connecticut; Hand Fellow, Department of Orthopaedics, University of Washington, Seattle, Washington Mark A. Codner, MD Clinical Assistant Professor, Department of Plastic and Reconstructive Surgery, Emory University; Paces Plastic Surgery, Atlanta, Georgia

Alvin B. Cohn, MD Aesthetic and Breast Fellow, Grotting Plastic Surgery, Birmingham, Alabama

Loren H. Engrav, MD Professor, Department of Surgery/Plastic Surgery, University of Washington, Seattle, Washington

R. Jobe Fix, MD Professor, Department of Surgery, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, Alabama

Leonard T. Furlow, Jr., MD Clinical Professor, Department of Plastic Surgery, University of Florida College of Medicine, Gainesville, Florida

G. Mabel Gamboa-Bobadilla, MD Sydney R. Coleman, MD Department of Plastic and Reconstructive Surgery, New York University School of Medicine, New York, New York

Associate Professor, Section of Plastic and Reconstructive Surgery, Medical College of Georgia, Augusta, Georgia

Paul M. Gardner, MD Associate, South Florida Plastic Surgery, Naples, Florida

Grady B. Core, MD President, Core and Associates, Birmingham, Alabama

Paulo da Paula, MD Former Visiting Fellow, Division of Plastic and Reconstructive Surgery, The Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania Jorge I. de la Torre, MD Associate Professor and Residency Director, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, Alabama A. Lee Dellon, MD Director, Dellon Institutes for Peripheral Nerve Surgery, Baltimore, Maryland Stamatia V. Destounis, MD Clinical Associate Professor, Department of Radiology, University of Rochester; Radiologist, Elizabeth Wende Breast Clinic, Rochester, New York

Jacob Gerzenshtein, MD Staff Plastic Surgeon, Department of Surgery, Division of Plastic Surgery, Mercy Hospital, Janesville, Wisconsin

Robert M. Goldwyn, MD Clinical Professor of Surgery, Harvard Medical School, Boston, Massachusetts

James C. Grotting, MD Clinical Professor, Division of Plastic Surgery, University of Alabama at Birmingham; Private Practice, Grotting Plastic Surgery, Birmingham, Alabama

M. Keith Hanna, MD Paces Plastic Surgery, Atlanta, Georgia

Jeffrey M. Hartog, MD, DMD Medical Director, Bougainvillea Clinique, Winter Park, Florida

Paul S. Howard, MD William R. Dougherty, MD Associate Professor of Surgery, Department of Plastic Surgery, Vanderbilt University Medical Center, Vanderbilt School of Medicine, Nashville, Tennessee

Associate Clinical Professor of Plastic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama

Kenneth B. Hughes, MD Ivica Ducic, MD, PhD Associate Professor, Department of Plastic Surgery, Georgetown University Hospital, Washington, DC

Section of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas

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Contributors

Alison L. Infield, BA Research Assistant, Department of Psychiatry, Center for Weight and Eating Disorders, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

Victoria R. Masear, MD

Ian T. Jackson, MD, MD(G)(Hon), DSc(Hon), FRCS, FRCS(G)(Hon), FRACS(Hon) Director, Institute for Craniofacial and Reconstructive Surgery; Division of Plastic Surgery, Providence Hospital, Southfield, Michigan

Clinton D. McCord, Jr., MD

Glyn E. Jones, MD, FRCS(Ed), FCS(SA) Associate Professor, Department of Plastic Surgery, Emory Clinic, Atlanta, Georgia

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Clinical Assistant Professor, Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama

Associate Clinical Professor, Department of Plastic Surgery, Emory University, Atlanta, Georgia

Wyndell H. Merritt, MD Clinical Professor, Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia

James R. Miller, MD Matthew B. Klein, MD Assistant Professor, Burn Center and Division of Plastic Surgery, University of Washington, Seattle, Washington

Gary S. Kopf, MD Professor of Surgery, Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut W. Thomas Lawrence, MPH, MD Professor and Chief, Section of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas

Assistant Clinical Professor, Department of Plastic Surgery, Albany Medical College; Chief, Division of Plastic Surgery, Albany Memorial Hospital, Albany, New York

Joseph M. Mlakar, MD Director, Burn Center, and Chief of Surgery, St. Joseph’s Hospital, Fort Wayne, Indiana

Foad Nahai, MD Plastic Surgeon, Paces Plastic Surgery, Atlanta, Georgia

Tanya M. Oswald, MD Bradley K. Lewis, MD Medical Director, Emergency Department/Urgent Care Medicine, After Hours Medical, Salt Lake City, Utah

Microsurgery Fellow, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi

Omer Refik Ozerdem, MD William C. Lineaweaver, MD Professor, Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi Ernest K. Manders, MD Professor of Surgery, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania Paul N. Manson, MD Professor, Department of Surgery, Johns Hopkins Hospital; Professor, Department of Surgery, University of Maryland Shock Trauma Unit, Baltimore, Maryland

Cosmetic Surgery and Breast Reconstruction Fellow, Department of Plastic and Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Associate Professor, Department of Plastic, Reconstructive, and Aesthetic Surgery, Baskent University, Ankara, Turkey

Silvio Podda, MD Craniofacial Fellow, Department of Plastic and Reconstructive Surgery, Miami Children’s Hospital, Miami, Florida

Julian J. Pribaz, MD Program Director, Harvard Plastic Surgery; Professor of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts

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Contributors

Brunno Ristow, MD Private Practice, California Pacific Medical Center; Chief Emeritus of Plastic Surgery, Presbyterian Medical Center, San Francisco, California Rod J. Rohrich, MD Professor and Chairman, Crystal Charity Ball Distinguished Chair in Plastic Surgery, Betty and Warren Woodward Chair in Plastic and Reconstructive Surgery, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas

Eva Rubin, MD Clinical Director, Breast Imaging, Department of Radiology, Montgomery Radiology Associates, Montgomery, Alabama

David B. Sarwer, PhD Associate Professor of Psychology, Departments of Psychiatry and Surgery, Center for Human Appearance, Center for Weight and Eating Disorders, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania R. Bruce Shack, MD

Stephanie A. Stover, MD Associate, Nashville Plastic Surgery, Nashville, Tennessee

James M. Stuzin, MD Assistant Professor of Surgery (Plastic), Voluntary, University of Miami School of Medicine, Miami, Florida

Helena O.B. Taylor, MD, PhD Resident, Harvard Plastic Surgery, Boston, Massachusetts

Sumeet S. Teotia, MD Private Practice, Charlotte Plastic Surgery, Charlotte; Clinical Assistant Professor, Division of Plastic and Reconstructive Surgery and Surgery of the Hand, University of North Carolina, Chapel Hill, North Carolina

Luis O.Vásconez, MD Professor and Chief, Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, Alabama

Fausto Viterbo, MD, PhD Professor and Chief, Department of Plastic and Reconstructive Surgery, São Paulo State University/UNESP, Botucatu, São Paulo, Brazil

Professor and Chairman, Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee

Robert L. Walton, MD

Jack H. Sheen, MD

Clinical Professor, Department of Surgery, Section of Plastic Surgery, University of Chicago, Chicago, Illinois

Santa Barbara, California

Anne G. Warren, BA Randy Sherman, MD The Audrey Skirball Kenis Professor and Chair, Department of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, California

Doris Duke Clinical Research Fellow, Department of Surgery (Plastic), Harvard Medical School, Boston, Massachusetts

S. Anthony Wolfe, MD Sumner A. Slavin, MD Associate Clinical Professor of Surgery, Department of Surgery (Plastic), Harvard Medical School; Chief, Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Richard S. Stahl, MD, MBA Vice President, Ambulatory Services Division, Yale– New Haven Hospital; Clinical Professor, Department of Surgery, Yale University, New Haven, Connecticut

Chief, Department of Plastic and Reconstructive Surgery, Miami Children’s Hospital, Miami, Florida

G. Jackie Yee, MD Attending Plastic Surgeon, Baker Plastic Surgery, Miami, Florida

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To Ann, Jimmy, and Ben and To my mother, Shirley Grotting Lindemann, and my father, John K. Grotting, MD (1915-1968), who would have been awed by the tremendous advances in his beloved specialty of plastic surgery, yet reassured to know that kind and compassionate care of patients remains its foundation.

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Preface

to the Second Edition

T

he specialty of plastic surgery has long served as an incubator for surgeons with creativity and imagination . Ours is a discipline that continues to evolve , fueled by innovation and an ongoing desire to refine and improve our results. We are privi- leged to be plastic surgeons at a time when we have so much to offer our patients . In the 12 years since the publication of the first edition of Reoperative Aesthetic & Reconstructive Plastic Surgery , the world has witnessed the introduction of numerous medical and technologic advances that have given us the tools to accomplish the previously unimaginable . From face transplantation to tissue engineering , plastic surgeons have been at the forefront of surgical innovation. The nature of what we do demands open, fertile minds that dare—to “see,” to dream, and to implement solutions for seemingly intractable problems. No area of plastic surgery demands more creativity , ingenuity , and problem solving skill than that of reoperative plas- tic surgery. It is gratifying to note that reoperative surgery , a subject that was little discussed when the first edition was published , is now increasingly a familiar theme in scien- tific publications , meeting panels, and program topics. The first edition advanced the concept of reoperative plastic surgery , providing a foundation for ongoing dis- cussion . Now, after another decade of experience and directed thought about this subject , we have crafted a second edition to continue the conversation and to ex- amine lessons learned and new options currently available. It contains the latest in- formation on this topic. Regrettably , the topic of reoperative surgery does not always receive the attention it deserves . Even experienced surgeons are sometimes reluctant to share lessons learned from errors, unsatisfactory results, or complications . Yet it is exactly that information that is most valuable to surgeons who have not yet encountered the same conditions but may face them with the very next patient they see. The goal of this book is to put this elusive knowledge at your fingertips. It is for this very rea- son that the book has become a favorite among young plastic surgeons preparing for their oral board examinations as well as experienced practitioners seeking in- sight into difficult cases or contemplating recertification Although many basic plastic surgery principles remain solidly entrenched in these freshly inked pages , there is much that is new. Anatomy has not changed —but our understanding of anatomic relationships has evolved, enabling us to develop new procedures and to refine and improve old ones. xi

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Preface to the Second Edition

As with the first edition, the book consists of two volumes comprising seven parts arranged by anatomic region. All chapters have been revised, and there are 11 totally new chapters that address topics such as endoscopic treatment of secondary brow ptosis, staged procedures and reoperations following massive-weight-loss surgery, secondary fat grafting, correction of postlipoplasty deformities, reoperative head and neck reconstruction, reoperative lower lid blepharoplasty, and psycholog - ical considerations for the reoperative patient. I am joined by a group of expert contributors who have shared their experience in reoperative situations to guide you, the reader, toward proven approaches, prevent - ing strategic errors , and providing a ready resource for consultation . Authors from the first edition have carefully updated their material , adding new cases, deleting concepts or procedures that they have abandoned , and providing insight into tech- nical nuances that maximize and enhance long-term corrections . New contributors have addressed topics that were underrepresented previously and those that are new to this edition. It is helpful to remember that these new procedures are not neces- sarily immune to the need for secondary surgery. Throughout these pages, the emphasis is on surgical judgment and the clinical problem-solving process that is critical to the successful execution of any reoperative procedure. Many new features and hundreds of photographs, medical illustrations, and clinical cases have been added to enhance the educational experience . To improve the aesthetic appearance and facilitate understanding of the various oper- ative sequences , the majority of illustrations and cases are now in color . The book is filled with tips and tricks and surgical nuances to assist surgeons with developing the finesse necessary to avoid complications in the pursuit of excellence . Each chap- ter now includes multiple-choice board review questions , annotated references, key points, and improved illustrated operative technique. Two DVDs with operative video complement the book. It is likely that these volumes will be consulted in bits and pieces—a few paragraphs , a chapter , or a section at a time . However , I recommend that these chapters be read early: “The Patient,” “The Surgeon,” and “What Is Reoperative Surgery ?” These will set the stage for the information that follows and help you gain perspec- tive on the special problems associated with the reoperative patient before you are confronted with a difficult patient who is frightened , angry, or critically ill. It is hoped that the information contained within these pages will prompt you to pay closer attention to your own outcomes with secondary surgery and provide in- sight into the techniques that have proven effective . Reoperative surgery is a chal- lenging yet wonderfully rewarding endeavor . We hone our skills and sensibilities by becoming expert in solving these interesting and complex problems . The ultimate reward is enhanced results and improved outcomes for our patients, and an oppor- tunity to advance the art and science of our specialty. James C. Grotting

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Preface

to the First Edition

R

eoperative plastic surgery assumes many guises in a plastic surgeon’s practice . Although complications and salvage situations immediately come to mind when we think of reoperative surgery, the scope is far broader. It is the staged procedure care - fully planned to preserve blood supply or the finishing touch that transforms a good result into a superlative one. Perhaps it represents a surgical intervention to treat the recurrence of disease or the continued biologic changes of aging. It may be the creative solution for improving an unsatisfactory result— the nemesis of all surgeons . Whatever the definition , much of our practice is reoperative in nature. The thread of commonality uniting all reoperative surgery is that the plastic sur- geon finds himself confronting tissue plans biologically altered by the effects of wound healing. This challenge often demands more innovative solutions and greater skill than the initial surgical intervention ; it is more right brained than left, more creative than analytic. Much like a chess game, strategic planning is the crit- ical element defining a successful outcome. When faced with any difficult problem, we typically turn to the literature and to the masters who have preceded us to guide our way. In secondary surgery the an - swers we seek are more elusive . Despite the complex nature of these procedures , their artful execution and pitfalls have received scant attention in the literature . Thus we often approach these secondary cases with surgical plans derived from our own personal and anecdotal experience only to find ourselves adrift without a nautical chart or compass. This book is in response to the need for a source of information to which to turn when confronted with secondary problems—a synthesis if you will. Similar to the travel clubs so popular in plastic surgery that have long been a rich source of shared experience and verbal problem solving, this book culls the wisdom and clinical advice from a national and international group of expert contributors. It is an attempt to draw on the cumulative experience of master surgeons to increase our chances of obtaining a favorable result. It would serve us well to have a road map— to know in advance that a brilliantly conceived plan may already have been clinically applied with an unfortunate outcome because of unanticipated tissue failure and to know that an alternative surgical approach would provide a safer, more ef - fective solution . We have focused on those clinical conditions in which previous surgery has resulted in significant tissue changes and in which secondary correction requires an approach that differs from the primary plan. By analyzing reoperative conditions, we seek to better understand the mechanisms by which they occur, thus developing a strategy for avoiding problems and promoting favorable outxiii

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Preface to the First Edition

comes. We also attempt to capture the surgical artistry and vision that enable experienced surgeons to produce unparalleled results. The contributors to this book were carefully selected for their technical skill, their innovative approach to problem solving, and their extensive experience in a particular area. These chapters represent each author’s personal approach to specific sur - gical conundrums . A virtual gold mine of untapped information is contained within their results , taking the reader through the critical planning process essen- tial to achieving superior results. The perspective of each chapter is dictated by its unique subject matter . Some chapters address primarily complications . Others dis- cuss staged procedures , whereas others examine a mix of problems and planned re- visions. Some chapters focus on one clinical case and use it as a springboard to dis- cuss a wide range of problems , whereas others contain numerous case examples to highlight individual anatomic challenges. The scope of this book is both aesthetic and reconstructive; the distinction becomes blurred in the reoperative setting.The 47 chapters are divided into seven sections starting with the reoperative environment and basic issues of scarring, tissue movement and transplantation and then proceeding anatomically to investigate specific reoperative problems of the head and neck, breast, chest wall, trunk and extremities . To make the reading process as smooth as possible , text and illustrations are in close proximity to each other. Hundreds of patient examples and operative sequences have been described and illustrated in color to assist the reader in under- standing the nuances of various operative approaches. One of the primary criticisms levied against any contributor work is the unevenness and overlapping of material from one chapter to another. A concentrated ef - fort was made to obviate this problem by providing a basic format and structure to shape the authors ’ presentations and by investing enormous time and effort writ- ing my own chapters and editing others to ensure a consistent approach . Notwith- standing these guiding principles , the contributors had the freedom to vary the format when the topic so dictated . In addition , to facilitate the learning process, some overlap still remains when the information is integral to the understanding of a problem or a clinical description . Every attempt was made , however , to retain the author ’s personality and distinctive style . The wit and individual style displayed by each contributor permit the reader a rare insight into the creative spirit that guides the scalpel. As the writing process draws to a close, my initial enthusiasm and vitality begin to resurface . I trust that this legacy will be worth the sacrifices and the stolen mo- ments from family and practice. My desire is that the reader and patients will be the bene ficiaries of this first attempt to harvest the collective wisdom from those who have risen to the challenge of reoperative surgery. James C. Grotting

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Acknowledgments

T

his book represents the combined contributions of many of the world ’s most gifted surgeons who have generously shared their experience and wisdom with colleagues in the United States and abroad. They have done so unselfishly, stealing time away from their families and their practices to translate their thoughts into the written word. I am indebted to them for their participation in this endeavor and their encouragement throughout. Their positive feedback about how this writing experience has contributed to their professional growth has been a prime motiva - tor for me throughout the writing and editing process . Hopefully this writing as - signment has challenged them to think about reoperative surgery in new ways that may not have been evident to them before they were invited to put pen to paper (or fingers to keyboard). I am also grateful to readers of the first edition who have provided an ongoing stream of insightful suggestions for improving the organiza- tion and content of these volumes. I am deeply indebted to a team of publishing professionals whose concentrated efforts have nurtured this edition of Reoperative Aesthetic & Reconstructive Plastic Surgery from concept to reality . As before , it has been the relentless and determined en - ergy of Karen Berger and her outstanding team at Quality Medical Publishing who have pushed this project along, with careful thought given to every detail that makes a book like this enjoyable and readable. Who but Karen would be willing to grind out paragraph after paragraph with me in the solitude of her office at 1:30 AM on a Sunday morning in July after working for 30 straight hours with minimal rest ! I would like to speci fically thank and acknowledge the other members of the QMP family here. Suzanne Wake field, Director of Editing , played an enormous role as project manager , editing the entire manuscript along with Becky Sweeney and Donna Rothenberg . Michelle Berger , Editor , oversaw the organization and pro - cessing of the project and Amy Debrecht, Assistant Editor, checked in each chap- ter and each figure to ensure accuracy and completeness . Reproduction of images , graphics , and medical illustrations is really what constitutes the beauty of a textbook like this one. Amanda Behr, Director of Medical Illustration , and Jennifer Gentry served as the tremendously talented medical illustrators whose work is seen through - out the book. Brett Stone, Graphics Technician , handled all the color correction and coordinated the electronic files of images while Sandy Hanley scanned all of the images to be used from the first edition. Carolyn Reich, Director of Manufacturing and Production, oversaw all layout and page proof production, coordinated the cover of the book, and supervised the printing and manufacturing of the book. Layout artists Susan Trail and Elaine Kitsis, sized all the images, typeset the manu xv

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Acknowledgments

scripts, and created the visually attractive appearance of each page. Throughout the process, Andrew Berger has been tremendously supportive, running me back and forth to the Spirit of St. Louis airport and crafting plans for the marketing and sales of the book. On the home front, I could not have completed this project without the staff of Grotting Plastic Surgery in Birmingham. My dedicated office team has played a vital role every step of the way. Nanette Rasberry, Office Manager, coordinated the communication and transfer of all materials between our office and QMP. Martha Garrison, Clinical Coordinator, and Jennifer Tatum, RN, spent countless hours contacting patients for postoperative follow-up and handled the processing of digital images for many of the chapters. Their personal attention to detail is apparent throughout the book.Vicki Goldstein, Patient Care Coordinator, managed my surgical and travel schedules to allow for the necessary trips back and forth to St. Louis to complete the project. Dr. Al Cohn, our 2006-2007 plastic surgery fellow, has been invaluable as a chapter contributor, question writer, and final proof editor for much of the book. Each of these individuals has given of their time and talent to help this book reach its full potential.

I would like to acknowledge the exceptional talent of William Hook , who painted the work that adorns the cover of this book and is pictured above. When Ann and I first saw this painting, we knew immediately that we wanted it to hang in our per - sonal collection . To us, it is a metaphor for Reoperative Aesthetic & Reconstructive Plas- tic Surgery. If one envisions the challenge of reoperations in our specialty as a little like being “lost in the woods,” then perhaps this book can be “ the clear path ” out — at least that is our hope ! With luck , great results and grateful patients will await us Over the Hill! Finally, I want to thank my beautiful and loving wife, Ann, and my sons, Jimmy and Ben, for their unwavering support and encouragement during the writing of this book, which they have come to accept as our constant companion over the past several years. So many late nights and absent weekends have stolen my attention away from those whom I so dearly love. Yet, even as I write these words, I know that they are proud of the critical supportive role they have played in helping me to create a work that hopefully will provide a lasting contribution to plastic surgery .

Contents VOLUME I Part I

THE REOPERATIVE ENVIRONMENT 1 What Is Reoperative Plastic Surgery? 3 James C. Grotting

2 The Patient 35 James C. Grotting

3 Psychological Considerations in Reoperative Plastic Surgery Patients 55 David B. Sarwer,Alexander W. Baker, and Alison L. Infield

4 The Surgeon 77 Robert M. Goldwyn

Part II

SCARS, TISSUE MOVEMENT, AND TRANSPLANTATION 5 Common Secondary Complications 89 James C. Grotting

6 Scars and Scar Revision 113 Kenneth B. Hughes and W. Thomas Lawrence

7 Reoperation for Donor Site Complications 147 James C. Grotting and Grady B. Core

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8 Repeated Tissue Expansion 175 Ernest K. Manders and Paulo da Paula

9 Failed and Failing Free Flaps 195 William C. Lineaweaver, Stephanie A. Stover, and Jacob Gerzenshtein

Part III

REOPERATIVE SURGERY HEAD AND NECK

OF THE

Facial Rejuvenation 10 Milestones in the Evolution of Face-Lift Techniques 219 Brunno Ristow

11 Reoperative Rhytidectomy 257 James C. Grotting and James M. Stuzin

12 Reoperative Forehead Lift 309 Brunno Ristow

13 Use of Endoscopy in Reoperative Brow-Lifting 333 Jorge I. de la Torre and Luis O.Vásconez

14 Adjunctive Surgical Procedures to Improve the Face-Lift Result 347 G. Mabel Gamboa-Bobadilla, Omer Refik Ozerdem, and Luis O.Vásconez

15 Adjunctive Procedures to Improve the Results in Facial Aesthetic Surgery 377 Tracy M. Baker and G. Jackie Yee

16 Revisional Fat Grafting of the Cheek and Lower Eyelid 403 Sydney R. Coleman

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Surgery of the Eyes, Nose, and Ears 17 Reoperative Blepharoplasty 441 James H. Carraway, James R. Miller, and Bradley K. Lewis

18 Reoperative Lower Lid Blepharoplasty 481 Mark A. Codner and M. Keith Hanna

19 Secondary Ptosis Correction 513 James H. Carraway, James R. Miller, and Bradley K. Lewis

20 Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery 545 Clinton D. McCord, Jr., and Foad Nahai

21 Secondary Rhinoplasty 595 Rod J. Rohrich, Jack H. Sheen, and Sumeet S.Teotia

22 Reoperative Surgery for Nasal Reconstruction 705 Gary C. Burget, Dean E. Burget, Jr., Elisabeth K. Beahm, and Robert L.Walton

23 Staged Sequential Procedures for Ear Reconstruction 759 Bruce S. Bauer

Head and Neck Reconstruction 24 Surgery for Recurrent Cutaneous Malignancies of the Head and Neck 801 Grant W. Carlson

25 Reoperative Issues Following Flap Reconstruction in the Head 829 Julian J. Pribaz and Helena O.B.Taylor

26 Secondary Procedures in Facial Reanimation 859 Fausto Viterbo and Adel Hussein Amr

27 Primary Care and Secondary Reconstruction of the Burned Face and Neck 881 Loren H. Engrav and Matthew B. Klein

28 Reoperative Facial Fracture Repair 903 Paul N. Manson

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VOLUME II Craniomaxillofacial Surgery 29 Secondary Corrections for Cleft Lip and Cleft Lip Nasal Deformity 1013 Ian T. Jackson

30 Secondary Cleft Palate Surgery 1053 Leonard T. Furlow, Jr.

31 Reoperative Craniomaxillofacial Surgery With Emphasis on Alloplastic Failure 1113 S.Anthony Wolfe, Paul S. Howard, Silvio Podda, and Jeffrey M. Hartog

32 Reoperative Craniomaxillofacial Surgery 1139 Ian T. Jackson

Part IV

REOPERATIVE SURGERY OF THE BREAST AND CHEST WALL 33 Reoperative Breast Surgery After Reduction Mammaplasty and Mastopexy 1197 James C. Grotting and Carl C.Askren

34 Reoperative Surgery Following Breast Augmentation 1261 James C. Grotting, Paul M. Gardner, and Alvin B. Cohn

35 Reoperation Following Implant Breast Reconstruction 1317 James C. Grotting

36 Finishing Touches After Breast Reconstruction With Pedicled Flaps 1365 Glyn E. Jones and John Bostwick III

37 Reoperation Following Free Flap Breast Reconstruction 1411 James C. Grotting

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38 Imaging Considerations in Plastic Surgery of the Breast 1481 Eva Rubin and Stamatia V. Destounis

39 Local Recurrence After Mastectomy and Breast Reconstruction 1511 Sumner A. Slavin and Anne G.Warren

40 Reoperative Surgery of the Chest Wall 1525 Richard S. Stahl, Gary S. Kopf, and Simon H. Chin

Part V

REOPERATIVE SURGERY

OF THE

TRUNK

41 Reoperative Liposuction 1601 Kristoffer Ning Chang

42 Reoperation After Liposuction and Body Contour Surgery 1635 Ricardo Baroudi

43 Staging, Reoperation, and Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient 1701 Al S.Aly and Joseph F. Capella

44 Reoperative Surgery of the Abdominal Wall 1741 Grady B. Core and James C. Grotting

45 Treatment of Recurrent Pressure Sores 1825 R. Jobe Fix

Part VI

REOPERATIVE SURGERY OF THE EXTREMITIES 46 Reoperative Hand Surgery 1863 Wyndell H. Merritt and Victoria R. Masear

47 Secondary Surgery Following Digit Replantation 1939 William C. Lineaweaver and Tanya M. Oswald

48 Reoperative Surgery After Excision and Grafting of Upper Extremity Burns 1963 William R. Dougherty, Joseph M. Mlakar, and R. Bruce Shack

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49 Reoperative Peripheral Nerve Surgery 1985 Ivica Ducic,A. Lee Dellon, and Ali Al-Attar

50 Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction 2009 Randy Sherman

Part VII

IN CLOSING 51 In Closing 2061 James C. Grotting

Credits C1 Answer Key to Review Questions A1 Index I1

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AESTHETIC

&

RECONSTRUCTIVE PLASTIC SURGERY

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Part I THE REOPERATIVE ENVIRONMENT

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Chapter 1 What Is Reoperative Plastic Surgery? James C. Grotting

But no perfection is so absolute, that some impurity doth not pollute. William Shakespeare

Reasons for Reoperation Planned reoperation Less than satisfactory outcome Refinements or touch-ups

Recurrence of disease Continued biologic processes Complications

R

eoperative plastic surgery defies clear-cut definition. The full spectrum of aesthetic and reconstructive challenges is represented. Although complications naturally come to mind when one thinks of reoperative surgery, in actuality much more is involved. The finishing touches after a breast reconstruction, correction of a dorsal irregularity after primary rhinoplasty, evacuation of a hematoma after a face lift, salvage of a failing free flap, or reoperation for a recurrent sagging jowl 10 years after primary rhytidectomy represent the diversity encountered in these demanding and challenging surgical interventions. Secondary surgery includes planned steps in a staged procedure and aesthetic refinements necessary to perfect the result of a previously successful operation. All of these situations may mandate reoperation.

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The many circumstances potentially requiring reoperation appear to be significantly different; however, closer examination reveals common elements. Whether treating patients with complications or those in whom revisions or staged procedures are necessary, the plastic surgeon deals with tissue planes that have been subjected to the biologic effects of wound healing.The scalpel alters intrinsic anatomic relationships, isolates and compartmentalizes zones of perfusion, and produces injury that results in scars. Guiding principles for the reoperative surgeon are difficult to uncover in the medical literature. In terms of complications and unsatisfactory results, there is a natural tendency for surgeons not to report their misadventures or shortcomings even though great ingenuity was required to solve a particular problem or salvage a result. In addition, as surgeons mature in their profession, they may precipitate fewer of their own patients’ needs for reoperation but will likely continue to address problems created by others. Ideally, this is the natural history of self-education by experience. Nevertheless, no surgeon ever becomes exempt from facing unanticipated reoperative situations in his or her own patients. As is often stated, surgeons who boast that they never have any complications are either lying or have stopped operating! However, the principles of reoperative surgery are communicated among us frequently in “curbside consultations,” late night telephone calls, or conversations in surgeons’ lounges. They have become part of the orally transmitted surgical lore rather than the recorded word. An experienced senior surgeon may have a wealth of knowledge regarding techniques for handling problem conditions, yet may be reluctant to commit that knowledge to the written word.

THE SPECTRUM OF REOPERATIVE SURGERY PLANNED REOPERATION Many plastic surgery procedures include second and third operations as part of the overall reconstructive plan. Breast reconstruction by tissue expansion followed by the insertion of a permanent prosthesis and inframammary fold adjustment is one such plan that deliberately involves multiple procedures. Although secondary procedures may be brief in duration and may even be performed with the patient under local anesthesia on an outpatient basis, the proper execution of the procedure is often absolutely critical to the overall success of the result. For example, the division and inset of a transferred pedicle flap represents a planned reoperation. One might ask oneself,“Should the pedicle be divided at this time or should this wait a bit longer? Should the pedicle be completely divided, or should it be divided in stages? Can the flap be thinned and refined now or should yet another reoperation be planned?” These important considerations must be addressed before what otherwise may seem to be a very simple secondary procedure can be performed.

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This 16-year-old girl was brought in by her parents for surgical correction of Poland’s syndrome.

Before surgery she had been using the external prosthesis shown (right).

The reconstructive plan was to place a tissue expander in the subcutaneous plane to create an adequate space for a future free transverse rectus abdominis muscle (TRAM) flap. The expansion was carried out over a 3-month period.

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The surgical plan for the free TRAM flap is outlined. This flap was chosen because of the desire for permanent breast reconstruction and the requirement for adequate volume replacement, including the tail of the breast area.

Three months after the free TRAM flap procedure, the patient has a stable reconstruction. The skin island monitor is visible at the lateral edge of the inframammary incision used to insert the flap.

The patient returned 10 years later after having married, becoming a registered nurse , and having two children . She desired further corrections to equalize the size and shape of her breasts.

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A staged revision was planned. In the first stage the skin island monitor from the free TRAM was excised, deepithelialized, and transplanted as a dermal fat graft to augment the still deficient tail of the breast area.

A small periareolar mastopexy was performed on the slightly ptotic left side to diminish the distance the right nipple would have to be moved inferiorly.

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Additional autogenous fat grafting was done to supplement the tail of the breast area. The immediate intraoperative result is shown.

A considerable challenge was to further move the right nipple inferiorly. This was done by creating an “inchworm” flap to increase nipple size and move the native nipple inferiorly. A small graft taken from the opposite areola was placed on the donor site.

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The reconstruction was completed with areolar tattooing 3 months after the right nipple transposition. This sequence of planned and staged reconstructive procedures illustrates the essence of reoperative plastic surgery. Each stage needed to be carefully planned and executed so as not to sacrifice valuable native tissue, and further, not to overstress the tissues to avoid complications. Obviously, a reconstruction carried out over 12 years requires an optimistic and understanding patient as well as carefully considered plastic surgery execution. The components of success include a clear plan of the primary procedure and the reoperation, good technical execution, and a wellinformed patient.

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LESS THAN SATISFACTORY OUTCOME An outcome that does not achieve all of the goals for the procedure is a frequent reason for reoperation, particularly early in a surgeon’s career. Ideally, with experience surgeons are able to achieve the anticipated outcome the first time around in a greater percentage of cases. However, no surgeon is able to “hit it just right” 100% of the time. It is a commonly accepted observation that reoperation rates go up following national plastic surgery meetings. Returning surgeons may elect to try out a newly acquired technique before they are equipped with the judgment that comes with experience.Therefore part of every preoperative consultation should be the careful discussion of what will be done if either the patient or the surgeon is not satisfied with the result. In some cases a revision of this type will be entirely elective and left to the patient’s discretion. In other situations, such as recurrent airway obstruction following septoplasty, the patient may be compelled to undergo reoperation to correct functional problems.

This 17-year-old woman is an example of a patient with persistent problems following a primary procedure . She was involved in an automobile accident in which she sustained a through -and-through laceration of the left eyelid and brow. The initial repair included the placement of a small postauricular graft to replace what was perceived as the tissue deficit. Postoperatively the persistent deformity —the inability to fully close the left eye—was apparent . The revision included the wide re-creation of the initial defect and release of the skin from the underlying orbic- ularis oculi muscle. A second postauricular graft placed as an aesthetic unit allowed complete eye closure.

REFINEMENTS

OR

TOUCH-UPS

A reoperative procedure to refine a previous surgery is usually purely elective and the outcome satisfying for both surgeon and patient . However , surgical touchups can be tremendously challenging for the surgeon in attempting to devise ways to shape the tissues , improve aesthetic form , and achieve a more natural appearance . It is not uncommon to encounter patients who will continually pressure the plastic

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surgeon for multiple additional improvements, particularly if a third-party payor is covering the cost. Of course, currently, these repeated refinements are more difficult to justify to insurance carriers. Therefore patients may temper their demands for further improvements if they must bear the cost.

A 41-year-old woman who had lost 120 pounds following gastric bypass surgery presented for correction of ptotic atrophic breasts.

The surgical plan was to perform an augmentation mastopexy through a vertical approach using saline implants in the subpectoral position. The superiorly based parenchymal flap was folded beneath the upper pole.

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The 8-day result and the 2-month photo demonstrate bottoming out of the implants, particularly on the right side.

The reoperative refinement (left) required internal capsulorrhaphy of both breasts to resupport the implant. This revision was carried out in the office with the patient under local anesthesia, at minimal expense. The 6-month postoperative result is shown (right).

RECURRENCE

OF

DISEASE

When a disease process leads to a primary surgery, it can also be involved in creating the necessity for reoperation. Recurrent scarring or keloid formation is one example. The recurrence of a cancer is one of the more prevalent reasons for reoperation. In the past the only treatment alternatives for locally recurrent cutaneous malignancies involving critical structures were radiation and chemotherapy. Improvements in immediate flap reconstruction now allow a more aggressive surgical approach to the excision of these aggressive, recurrent tumors.

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Treatment of recurrent aggressive skin cancers may require orbital exenteration and subsequent major reconstructive procedures. This 64-year-old woman presented with the third recurrence of a basal cell carcinoma in the right temporal and lateral canthal area. A CT scan showed invasion into the orbit involving the extraocular muscles. A much more aggressive surgical plan was mandatory.

Orbital exenteration was performed through a bicoronal approach with frontal craniectomy . A template of the planned skin resection was used to design a rectus abdominis musculocutaneous flap to fill the defect.

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CONTINUED BIOLOGIC PROCESSES Aging is the best example of this cause for reoperative surgery. Frequently, patients who present for this reason have had previous satisfactory outcomes from their surgery but some years later request additional correction to offset the effects of aging. The recurrence of breast ptosis following an initial mastopexy with a satisfactory outcome is such an instance. Reoperating under these circumstances involves special considerations and pitfalls. Patients are most able to accept the need for reoperation in this circumstance if they have been well counseled regarding the natural aging process in advance of the primary procedure.

Radiation produces tissue effects that are destructive and progressive over many years. This 32-year-old woman presented 2 years after undergoing a left modified radical mastectomy and immediate conventional TRAM flap reconstruction of her left breast. A decision was made to irradiate her breast and chest wall as adjunctive treatment for her breast cancer. The TRAM flap became fibrotic, contracted, and painful at 2 years after radiotherapy.

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The reconstructive plan required introduction of healthy vascularized tissue, since it was not possible to expand this mass with a tissue expander or implant alone. A large latissimus dorsi musculocutaneous flap was mobilized to cover the deepithelialized and debrided TRAM flap, which was left as a central “autogenous” implant. The inframammary fold was significantly lowered and a further reduction was accomplished on the right side.

With the addition of a small implant secondarily to lower the inframammary fold and nipple reconstruction, a stable reconstruction was achieved 2 years postoperatively.

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COMPLICATIONS Although all operations carry the risk of complications, only some of these problems require operative management. Complications, of course, have significant ramifications for both the patient and the surgeon. In many cases, such as an expanding hematoma or failing microsurgical anastomosis, there is an urgent need to act expeditiously. The reoperative surgeon may not have the luxury of time to consult with colleagues, review published journal articles and books, or return to the cadaver laboratory to practice. He or she must quickly formulate the reoperative plan and execute it immediately.

Hematoma is a complication common in all fields of surgery. When it occurs following an aesthetic procedure such as a breast augmentation, its consequences extend beyond the local tissue affects. This healthy 34-year-old woman presented for elective breast augmentation. Three days postoperatively she suddenly experienced pain, swelling, and a bluish discoloration of her left breast after physical exertion. Prompt reexploration and evacuation of the hematoma ultimately resulted in a satisfactory outcome.

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Complications, of course, can manifest early or late in the postoperative period. They may involve only the anatomic areas operated on (for example, wound dehiscence, skin graft loss) or they may be generalized (for example, systemic sepsis, pulmonary failure). Complications are frequently precipitated by technical errors but also result from tissue failure or host factors. In any event, treatment must balance the cause of the complication against the risk of compounding the problem by any additional intervention. For example, the surgical plan for treating a hematoma is well known: it must be drained. But, determining the underlying cause is the more important issue. Did the hematoma stem from a small bleeding vessel now harmlessly thrombosed or did it result from a ruptured microaneurysm because a critical microsurgical anastomosis was made to recipient vessels damaged by previous radiation? Clearly these two “simple” hematomas require dramatically different reoperative plans even though the clinical presentation appears similar.

THE REOPERATIVE PLAN Surgery is a combination of planning and execution. With reoperative surgery the surgeon is challenged in both arenas, because the decision-making process and the handling of tissues become more complex. Reoperative plastic surgery demands careful clinical analysis and judgment. Previously altered tissues leave scant room for error. How will the circulation to the tissues be affected after reelevation? Will skin elasticity be diminished? Will tissue transposition or rotation be possible without undue tension? What does this patient expect the surgery to achieve and will it be possible to satisfy him? All of these elements must be factored into the planning process. Furthermore, it is crucial that the surgeon consider all potential problems that could lead to failure, since the incidence of complications at this stage is higher than that with primary surgery. The reoperative surgeon must assess the degree of anatomic distortion, nature and consistency of the scar, scope and condition of the involved anatomic area, and availability of healthy surrounding tissue.The reoperative plan will emerge from the synthesis of all of these factors. The physician-patient relationship also has an impact on what will be done and how soon. The same reoperative condition in two different patients might be treated in vastly different ways, depending on the wound maturation process, associated medical problems, and patient expectations. With secondary surgery the reoperative plan assumes special importance. Whether this surgical intervention is dictated by an untoward result or is part of a staged procedure or refinement, the goals are to correct the problem or defect, avoid recurrence of problems, and prevent the creation of new complications.Therefore the surgical plan must be carefully formulated to address all of the issues that might impact the outcome.

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Dr. Luis Vásconez teaches residents, “If plan A did not work, do not make plan B the same as plan A.” Creativity rather than rote duplication of previous surgical efforts is essential to success. This is especially true if the reoperative surgeon is not the same surgeon who implemented plan A. Reoperative surgeons must avoid the mistake of believing that their own skills are so superior that they will not fall into the same traps. Poor technique may not have been at fault. Many times it is not a poorly trained surgeon but a poorly prepared surgeon who is the root of the problem. Although occasionally choice of a surgical technique can doom a procedure, more often than not it is the surgical plan that was deficient.

HOW REOPERATIVE SURGERY DIFFERS FROM PRIMARY SURGERY GOALS Of necessity, the goals of reoperative surgery are more limited and focused than those for primary surgery. The limitations of technology and tissue tolerance carry their own restrictions. When multiple procedures are required, the surgeon must help the patient to understand why total correction cannot be achieved in a single operation. False hopes need to be dispelled to avoid further disappointment in a patient who may already be frustrated by previous surgical misadventures or shortcomings.

SCARRING1 Reoperative surgery is almost always performed through or around previous incisions. Prior scars may dictate a surgical approach that is less than optimal for ideal exposure. Reduction of overall scarring or preservation of circulation and innervation may mandate such a trade-off. When scarred tissue is incised, it often has a greater tendency to retract, making secondary closure difficult or impossible without undue tension. This principle is particularly true when burned skin is incised; in this situation the surgeon must be prepared to transfer new tissue to the operative site or to use skin grafts for wound closure.These differences in the tissue must be anticipated so that the surgeon is not forced into intraoperative crisis management.

Chapter 1 What Is Reoperative Plastic Surgery?

Residual deformities are common following the primary treatment of burns by excision and skin grafting. In this patient, severe burn scar contracture of the neck resulted despite primary excision and grafting.

Release of the contracture caused an enormous defect, which was treated with a sheet graft. Ultimately, satisfactory contour and release of the secondary burn scar deformities were obtained using Z-plasties for the webs and placing additional sheet grafts. A surgical incision sets into motion a series of physiologic and biochemical events that affect wound healing.1,2 This process culminates in the formation of scar. The visible scar at the skin surface represents only the most superficial edge of a sheet of collagen scar that extends into all tissue interfaces created by dissection and elevation during surgery.The injury produced by surgery results in some degree of tissue destruction as a result of direct injury and secondary atrophy. Delicate tissues such as fat and endothelium are particularly vulnerable. As neutrophils and macrophages initiate wound healing, cellular debris is carried away and replaced by collagen. With time, the initial proliferative phase is followed by a maturation phase, with softening and thinning of the scar (see p. 27). As this process occurs, previously elevated tissues may thin, resulting in a slightly atrophic area.

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This interesting 58-year-old patient presented with near-lifelong scarring that had resulted from a childhood infection. She had been treated at the Mayo Clinic 50 years earlier. She brought in this photo (top) following multiple debridements and skin grafting for what appeared to be actinomycosis.The disease process had left her with severe scarring and contracture of the submandibular area on the right side, extending along the preauricular area and temporal hairline.

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Careful excision of the scar and mobilization of nearby normal skin allowed improvement via a cervicofacial rotation flap and direct closure of the neck defect. A SMAS face lift was done on both sides, as well as upper and lower blepharoplasties.

The final result is shown 1 year postoperatively.

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Random pattern of subcutaneous plexus

Divided fasciocutaneous perforators

Divided musculocutaneous perforators

Previously elevated flap replaced in bed

Preservation of subcutaneous plexus as only source of blood supply

No ingrowth from either the previously divided musculocutaneous or fasciocutaneous perforators

Previously undermined skin will usually have a radically altered blood supply. Fasciocutaneous or musculocutaneous perforators may have been divided, converting the skin perfusion pattern to a large random subdermal network. An ill-planned incision for a secondary procedure might precipitate ischemic strangulation of an isolated perfusion zone. Similarly, if the reoperative plan includes the use of an axial flap, the surgeon must be certain that the axial vessel was not sacrificed previously. This situation is particularly problematic in the case of elevation of a fasciocutaneous flap in an area of previous undermining. As a result of a diminished blood supply, previously elevated or incised tissue may be less tolerant of tension and more vulnerable to disruption or infection.

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ALTERED ANATOMIC RELATIONSHIPS

Preoperative view shows unsupported lower lip

Postoperative view after resuspension of chin soft tissue

The scalpel also alters anatomic relationships. Once supporting structures are divided, scar contracture, gravitational pull, and settling of tissues may result in gross distortion of formerly closely related structures. For instance, multiple intraoral procedures were performed in this patient to treat a nonunion of a mandibular fracture. Reoperation resulted in intraoral scarring, ptosis of the soft tissues, and disinsertion of the supporting musculature of the chin and lower lip. The soft tissues and muscles were reelevated and secured with permanent sutures fastened to drill holes in the mandible just beneath the tooth roots.The tissues were then supported with an external compression garment for 4 weeks. This correction resulted in the satisfactory restoration of the anatomic relationship between the chin musculature, lower lip, and jaw. The patient demonstrates considerably less lip strain following secondary reconstruction.

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ALTERED TISSUE CHARACTERISTICS Plastic surgeons are keenly aware that previously operated tissues respond less predictably than normal tissues. Surgery inevitably creates scarring, and scarring alters the quality of normal tissue. Any surgeon who has redissected the tip cartilages of the nose in a secondary rhinoplasty patient is acutely aware of how the tissues change as the result of the primary surgery: there is a loss of the normal delicate supporting structures around the cartilage as well as a softening of the cartilage itself. The same changes occur in skin, muscle, bone, and fat to a greater or lesser extent.When skin has been previously undermined, it loses some of its pliability, elasticity, and ability to hold moisture. The skin simply does not move as well. If the surgeon fails to consider the altered state of the tissues when formulating his plan for secondary surgery, he may be faced with intraoperative surprises that he is illequipped to handle. Another factor contributing to altered tissue characteristics is denervation. This process is most destructive in muscle but also affects fat and skin. Surgeons will usually cautiously avoid damaging motor nerves but will often sacrifice small sensory branches indiscriminately. Loss of the sympathetic innervation to the skin affects the delicate vasomotor responses of the sweat glands and capillary beds and can induce thinning, dryness, and loss of pliability. More controversial is the effect of denervation on wound healing, which has been the subject of many studies conducted in both experimental animals and humans. To some degree these changes also occur in locally denervated tissue. Reinnervation may occur in nonanatomic patterns. Therefore, in reoperations involving tissues that were previously manipulated surgically, reinjury of small nerve twigs with resultant additional atrophy and scarring is to be anticipated. The effect may be subtle, or it may be quite marked.

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This 57-year-old patient was treated with conventional abdominoplasty and liposuction. In the right photo one can see the effects of denervation on the infraumbilical area. The patient used a heating pad to treat swelling and developed a partial-thickness burn that gradually healed with local care.

Unbelievably, following an additional revision of the scar, the patient placed an ice bag on her lower abdomen and developed frostbite! Clearly, the effects of denervation can lead to a hazardous alteration of tissue characteristics.

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ASYMMETRY Except in the case of midline scars, surgery almost always produces some degree of asymmetry. Many reoperative procedures are aimed at addressing persistent or recurrent noticeable asymmetry. The asymmetry may be the result of malaligned or misplaced scars, inadequate insetting or shaping of transferred tissue, or denervation and atrophy. The asymmetry may be static or dynamic, as in the case of facial paralysis. Consideration of asymmetries must be factored into the planning of any secondary operation to prevent unsatisfactory aesthetic results and patient disappointment.

This 57-year-old woman had a previous upper and lower lid blepharoplasty and desired additional periorbital improvement. Preoperatively she had upper eyelid asymmetry with more fat removal on the right than on the left. Following endoscopic brow lift (right) the upper eyelid asymmetry is unmasked and is considerably worse, even though no surgery was performed on the upper eyelid. The patient was unaware of the asymmetry preoperatively but became exceedingly unhappy with her appearance postoperatively. This case illustrates the importance of careful review of preoperative photographs so that asymmetry can be discussed with the patient preoperatively to avoid an unhappy outcome.

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WOUND HEALING CONSIDERATIONS IN REOPERATIVE SURGERY Reoperation implies incision or dissection through tissue that is in some phase of wound healing. Depending on the time elapsed between the primary surgery and the reoperation, one might encounter tissue in stages ranging from dense hemorrhagic scar to filmy, almost normal tissue planes.

A knowledge of the events associated with the normal sequence of wound healing is helpful to understand the types of tissue that might be encountered during reoperation; how the need for reoperation may be precipitated by a failure of wound healing; if possible, when best to plan secondary surgery; and special considerations for reapproximating the wound.

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INFLAMMATORY PHASE The early events of wound healing consist primarily of coagulation and inflammation. Platelet aggregation is stimulated by the exposure of platelets to collagen and the subsequent release of adenosine 5-diphosphate (ADP), which in turn causes the aggregation of additional platelets. Fatty acids from injured cells also contribute to the stimulation of platelet aggregation. Both intrinsic and extrinsic coagulation cascades ensue, resulting in the production of a fibrin scaffolding. Activated aggregated platelets release locally active growth factors. The complement cascade then follows, causing increased capillary permeability.This permeability, which allows fluid and cells to migrate passively into the extravascular space, is an important part of the inflammatory response. The sympathetic nervous system mediates an initial period of vasoconstriction followed by vasodilation through the action of histamine, prostaglandins, and serotonin. Complement factor C5a is one of the most important chemotactic agents for the extravasation of neutrophils, macrophages, and lymphocytes. Neutrophils enter the wound within hours after injury.They release lysosomes, which in turn increase capillary permeability and contribute to the phagocytosis of tissue particles and bacterial remnants. Macrophages become activated by cytokines and also participate in the cleanup process. Macrophages gradually predominate over the neutrophil population in the inflammatory response and become the essential cellular element of wound healing. By 72 hours after injury the basal layer of the skin at the wound margins begins to thicken. Fibroblasts begin to accumulate and proliferate.

LYTIC PHASE During days 2 through 14 following wounding a lytic phase occurs.3 This phase is the result of the action of lytic enzymes plus the release of lysosomes from leukocytes, which soften the surrounding ground substance. In addition, fibroblast and endothelial buds initiate fibrinolysis. The wound develops a central zone of hypoxia surrounded by a zone of hyperoxia and vasodilation. Neutrophils are sensitive to the low PO2 in the wound center and to the acidic environment, which cause them to disintegrate and release lysosomes. The collagenase from the lysosomes helps to dissolve the collagen at the wound edges.

FIBROPROLIFERATIVE PHASE The lytic phase is followed by a phase of active cellular proliferation during which angiogenesis and epithelialization occur. The events associated with the active proliferative phase are the appearance of various substrates required for wound healing, including proteoglycans and glycosaminoglycans, which seem to have a structural and regulatory role in the wound healing process.4 The level of hydroxyproline also becomes elevated to five to six times the baseline value.

Chapter 1 What Is Reoperative Plastic Surgery?

Capillary budding occurs along breaks in the basement membrane; each solid sprout then develops a lumen as the endothelial cells migrate to and surround it. Certain angiogenic factors appear to control this process, including acidic fibroblast growth factor (a-FGF), basic fibroblast growth factor (b-FGF), and angiotensin. These new capillaries convey oxygen and substrate , eventually linking up with each other and bridging the approximated wound. If the wound is left open, the capil- laries form the delicate pink structure of what is referred to as granulation tissue. Granulation tissue will readily accept a skin graft, because the capillaries link directly with those in the graft. Epithelialization first occurs at the wound. Cells begin to elongate and migrate within the first 24 hours after injury. By 72 hours, increased mitotic activity is ev - ident in the basal layer . When the advancing cells from both sides of the wound meet , differentiation into a mature , layered structure of skin begins to occur. How- ever, the rete pegs of mature skin do not develop in areas where the basement membrane has been lost.

COLLAGEN FORMATION Central to the wound healing process is the formation of collagen. Platelet growth factors such as platelet-derived growth factor (PDGF) and transforming growth factor-beta (TGF-beta) stimulate the differentiation of pluripotential perivascular mesenchymal cells. Some of these cells evolve into collagen-producing fibroblasts and others become myofibroblasts, the cells responsible for wound contraction. En - dothelial cells promote this response by inducing fibrinolysis ahead of these mi- grating mesenchymal cells. Several different forms of molecular collagen exist. The most common, type I, is widely distributed through bone, tendon, skin, dentin, ligaments, fascia, arteries, and the uterus. Skin is also relatively high in type III collagen. Types II, III, and IV are found in cartilage , arteries , and basement membrane . In the proliferative phase of wound healing , early collagen synthesis results in small , less -well organized fi- brils rather than mature collagen bundles. These fibrils cross-link in the first 4 to 6 weeks following injury to obtain the strength and organization of mature colla- gen. However , scar collagen remains relatively irregular , with thinner collagen fas- cicles. This pattern is thought to be related to the types of glycoproteins present in the ground substance. Normal skin contains both type I and type III collagen in a ratio of approximately 4:1. However, in hypertrophic or immature scars, the relative amount of type III collagen may rise to 50% of the total.

MATURATION PHASE The final phase of wound healing is the maturation phase; this phase overlaps the proliferative phase.3 During maturation, the immature collagen fibrils increase their degree of cross-linking and therefore increase the tensile strength of the wound.

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Similarly, the cellularity of the wound and collagen solubility diminish.The wound achieves 25% of its ultimate strength by 24 days after injury. Fifty percent is achieved by 50 days, with maximal strength attained by approximately 1 year. However, even when fully mature, the scar will have only approximately 80% of the normal tensile strength of unwounded skin. By 2 to 3 months after wounding, collagen deposition is gradually overtaken by collagen degradation, resulting in extensive remodeling of the scar. This remodeling process is continuous for approximately 1 year.

IMPLICATIONS

FOR THE

REOPERATIVE SURGEON

If a fresh wound must be opened between 24 and 48 hours after injury, a fibrin seal between the cut surfaces is encountered. The surrounding tissues are edematous and thickened from the cellular proliferative response. Collagenolysis at the epithelial edge of the wound weakens the connective tissue, which means that sutures may pull through more easily with considerably less tension than normal. Reopening a wound during the first 3 to 4 days after injury is generally easy and does not require reincision but simply blunt dissection. However, after this period, the effects of the intense angiogenesis and neovascularization are noted on dissection. The dilated venules and capillary buds will freely bleed. During the lytic phase (days 2 through 14), the wound is at its weakest as a result of the lysosomal activity at the wound margin. Surgeons have long recognized that problems such as abdominal dehiscence and the development of an orocutaneous or intestinal fistula are most likely to appear around day 7 following injury. However, this weak state can persist for as long as 3 weeks. When reclosing such a wound, one must be aware that this zone of weakness is present at the wound margins. In regions where the tissues are thick and heavy, such as the abdomen, sutures must be placed outside this zone at least 1.5 cm from the wound margin to achieve satisfactory tensile strength to maintain the integrity of the closure. In the face, the sutures may be within 1 cm of the skin edge. It is also important to keep in mind that when a 7-day-old wound is reopened and then reclosed, this action does not convert the wound to the state it was in during the first 24 hours of wound healing. All of the cellular populations that were called forth are still present, and the biochemical events that took place have not been reversed.Therefore continued healing proceeds directly at what appears to be an accelerated pace. The increased collagen synthesis present in the wound during the proliferative and maturation phases can work to the surgeon’s advantage.With these processes active at several times the normal rate, wound healing will advance directly and completely in a shorter period of time than after primary wounding, when the inflammatory phase must occur to incite the proliferative phase. It is for this reason that a delayed primary closure appears to result in accelerated healing,

Chapter 1 What Is Reoperative Plastic Surgery?

especially if the wound itself is not reexcised during the debridement process. Wounds closed in this way are ultimately no weaker than those closed primarily. Reoperation during the proliferative stage of wound healing can be treacherous. First, the tissues are noncompliant and weak because the collagen at the wound margin is immature . Therefore attempting to place sutures in tissues of this type can result in a failure of firm healing . For example , attempts to close an orocutaneous fistula or to resuture a flap intraorally may result in wound breakdown because the sutures simply will not hold. Second, opening a wound during the proliferative phase can result in profuse bleeding . Attempts to coagulate bleeding points will re- sult in further injury and increased tissue destruction. Wounds that are allowed to heal on their own are greatly aided by the presence of myofibroblasts at the wound margin. These specialized cells will persist in wounds for up to 2 months. By forming intercellular attachments, myofibroblasts, which have properties similar to those of smooth muscle, create a line of contraction around the edges of the wound. This process can result in a bandlike effect, especially in scars that cross flexion creases. For this reason, scars of this type may need to be excised to allow the surrounding skin to return to its normal position before a closure method is designed that might result in an improved scar. In terms of bleeding and dense adhesions, the worst time to reoperate on a patient is early in the maturation phase of wound healing, between 20 and 60 days after injury. Reentering the abdomen during that time will usually reveal dense, bloody ad - hesions, and inadvertent enterotomy can occur easily. After 90 days, collagen re- modeling and maturation have progressed to the point at which adhesions are largely absent. Similarly, by this time the skin and subcutaneous tissues have be- come soft and more pliable. Reoperation can thus be much more easily and safely accomplished. High collagenase activity at the margins of a scar or keloid has been used to advantage during scar revision surgery . It is postulated that if a thin rim of previous scar is left, the resultant scar may be thinner and of higher quality than if no previous scar is left.5 More often , however , the presence of this previous tissue injury is detri- mental to healing following secondary surgery. Finally , the principles of good surgical technique assume a much more important role in reoperative surgery . The plastic surgeon becomes an exceptionally good judge of tissue tolerances by look and feel. The differences in tissue are explainable on the basis of the orderly events of wound healing . When wound healing is inhib - ited by such factors as poor nutrition , chronic disease , drugs , or radiation , then fur - ther alteration of tissue quality is likely to be encountered (see Chapter 5). Gentle tissue handling, sharp dissection, limited use of cautery, preservation of vascularity, and careful reapposition of tissues without tension often can make the difference between success and failure in reoperative surgery.

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References —With Key Annotated References 1. Broughton G II, Rohrich RJ. Wounds and scars. Select Read Plast Surg 10:7, 2005. This publication discusses the phases, factors, and adjuncts of wound healing, including wound care, closure, and dressings. A section on hypertrophic scars and keloids includes treatments both nonsurgical and surgical.The volume includes a section on exotic wounds. 2. Glat P, Longaker M. Wound healing. In Grabb WC, Smith JW, Aston SJ, et al, eds. Grabb and Smith’s Plastic Surgery, Philadelphia: Lippincott-Raven, 1997. This book explains the fundamental principles of plastic surgery and microsurgery and describes specific aesthetic and reconstructive surgical procedures for various anatomic regions. 3. McQuarrie DG. The pathophysiology of wound healing and its relationship to reoperative surgery. In McQuarrie DG, Humphrey EW, eds. Reoperative General Surgery. St Louis: Mosby, 1992. This text covers all reoperations performed by general surgeons. Anesthetic concerns, reoperative vascular surgery, reoperation after minimally invasive surgery, reoperations after severe, acute trauma, and reoperation for necrotizing soft tissue infections are included.This text also includes advice for using various diagnostic tools and nonoperative solutions. 4. Hopkinson I. The extracellular matrix in wound healing: An introduction to the series in wounds: A compendium of clinical research and practice. J Wound Heal 4:88-91, 1992. 5. Peacock EE Jr, Van Winkle W Jr. Wound repair. Philadelphia: WB Saunders, 1976.

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REVIEW QUESTIONS 1. The spectrum of reoperative surgery includes all of the following except: a. Planned reoperation b. Liposuction c. Improving a less than satisfactory outcome d. Refinements or touchups e. Treatment of complications 2. The reoperative surgeon must assess: a. The degree of anatomic distortion b. The nature and consistency of the scar c. The scope and condition of the involved anatomic area d. The availability of healthy surrounding tissue e. All of the above 3. Reoperative surgery differs from primary surgery because of all of the following except: a. Scarring b. Asymmetry c. Potential denervation d. The need to obtain informed consent e. Altered tissue characteristics 4. The worst time to reoperate on a patient because of profuse bleeding or dense adhesions is during the: a. Fibroproliferation phase of wound healing b. Lytic phase of wound healing c. Early in the maturation phase of wound healing (20 to 60 days after injury) d. During the first 12 hours postoperatively e. Late in the maturation phase of wound healing (greater than 90 days after injury) 5. The likelihood of success versus failure in reoperative surgery is increased by: a. Gentle tissue handling b. Limited use of cautery c. Preservation of vascularity d. Careful reapposition of tissues free of tension e. All of the above

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Chapter 2 The Patient James C. Grotting

T

he patient is waiting in exam room 5. As I approach the door, I see a folder thick with medical records, radiographs, and CT scans. Reading through these documents, I wonder what kind of person is sitting inside. Will I be able to help him? Can I hope to accomplish something that the previous surgeon had not? Reoperative patients’ surgical history and past interactions with health care professionals set them apart from primary surgery patients and influence how they respond to the prospect of further surgery. As surgeons we have no way of predicting this response. What is predictable, however, is that the patient’s focus will be on the problem that requires reoperation. All that the patient knows is that something is wrong:“It doesn’t look right” or “It doesn’t feel right.” He or she may not know what went wrong or why, but just wants it “fixed.”The patient may desire a lengthy explanation of all the factors contributing to the poor result or may simply want to get on with the surgical correction. Although some patients may appear to be uneducated, unsophisticated, or incapable of fully understanding all of the considerations involved in a staged reconstruction or the factors that can contribute to a less than satisfactory result, it is generally a mistake to assume this is true. A patient usually appreciates all of the information the surgeon can provide, even if there is too much information to fully assimilate or if the patient has crossed the line from active participation to blind trust. It is best to explain things simply but completely. Making the same point several different ways at various times in the consultation enhances the patient’s memory of the concept and avoids misunderstanding.

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THE REOPERATIVE ENVIRONMENT The patient may require reoperation for one of the following reasons: 1. To proceed with a planned second or third stage of a reconstructive plan 2. To treat an early complication, perhaps one that developed before discharge from the hospital or before primary healing has occurred 3. To treat a late complication that detracts from an otherwise good postoperative result 4. To improve an initial result deemed suboptimal by either the surgeon or the patient 5. To address biologic factors such as tumor recurrence or the effects of continued aging, despite a successful initial operation The attitudes and psychological needs of the patient may be quite different in each of these situations. Clearly, the patient requesting a secondary face lift 10 years after a successful rhytidectomy is not likely to have negative feelings about the procedure or toward the surgeon. Conversely, the hostility generated by an angry young male rhinoplasty patient with an overresected nose can intimidate even the most seasoned plastic surgeon. Most patients feel vulnerable when facing reoperative surgery. They may feel that they are dependent on the skills of the plastic surgeon and at the mercy of the health care system.This sense of a loss of control may lead to resignation, anger, and even hostility. Patients are often more fearful about the second operation than they were about the initial surgery and frequently need more reassurance. They fear more pain, further scars, additional complications, and undergoing general anesthesia. Considerable time should be allocated to the care and counseling of the patient with early unresolved problems or complications such as open wounds, immature scars, or infection. A patient with these early problems tends to view his or her doctor with distrust. We have all had patients who consult with us as a second plastic surgeon before their original surgeon has even removed the sutures. The most common reason cited by patients for changing physicians is a perception that their plastic surgeon is uncaring or unavailable to address their concerns. This sentiment is echoed in statements such as, “My doctor did not believe me when I told him I was having a problem,” or “I tried to call her at her office but she wouldn’t return my calls.” The plastic surgeon who hopes that by ignoring the problem it will disappear usually finds it has only been compounded, and, of course, anger can assume a life of its own.1 The patient who feels abandoned may seek the

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solace of an attorney, who will always make plenty of time for the patient to air complaints. Many times I have had the opportunity to see patients who have had procedures by other plastic surgeons on referral from my own patients in the community. More often than not, I have been able to reassure the patients that the concerns they have are very real but can easily be addressed by their treating plastic surgeon. Simply by spending a little time listening, I feel that I have been able to get them back on track with their original plastic surgeon and have not ended up taking them on as patients in my practice. Listening, I feel, is an underrated skill. It is crucial in establishing and maintaining a good doctor-patient relationship.

DEFINING REALISTIC EXPECTATIONS Most patients consulting with a plastic surgeon for the first time have misconceptions about what a plastic surgeon can accomplish. It is astounding how many believe that plastic surgeons can completely remove scars or that various kinds of plastics can be used to miraculously transform the way people look. It is the responsibility of the surgeon to give each patient the opportunity to fully verbalize expectations from an operation. Based on this information, the surgeon must then help to bring the patient’s expectations into line with reality and dispel any misconceptions. Nothing is as effective for convincing a patient that less than perfect results are possible as a failed or poorly executed operation. Patients who are counseled about the possibility of unsatisfactory results and the necessity for reoperation in advance will not be as troubled by complications or by the need for finishing touches as those who thought that their first operation was supposed to be their last! Well-prepared patients will be disappointed but not shocked if reoperation is necessary. The patients may feel “unfortunate” but will also be aware that further treatment will produce better results, and thus they will remain optimistic about the future. Realistic expectations about the outcome of an operation are even more important for patients facing secondary surgery. Because they feel a little wiser now, they may ask more questions, desire more information, and require more details about possible outcomes. Providing best case and worst case scenarios is key to establishing realistic expectations in this group of patients. The surgeon should show photographs of average results, a result considered excellent, and a poor result as well. The surgeon should outline a series of steps or timetables for managing an untoward result or complication should it occur.

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COMMUNICATING WITH THE REOPERATIVE PATIENT Goldwyn2 aptly pointed out that if either the patient or the surgeon knew before an operation that something was going to go wrong, neither would enter into the contract! Unfortunately, it is usually in retrospect that we begin to understand how suboptimal results might have been anticipated and avoided. When surgeons deal with patients facing unanticipated secondary surgery to treat complications or to improve less than optimal results, the following principles merit attention.* Always tell the truth. This maxim is of the utmost importance in dealing with the reoperative patient. One must deal honestly with patients to gain their trust. The sooner the issues are confronted, the healthier the relationship will be. Do not deny reality when deformities exist. The surgeon must acknowledge problems squarely and not dismiss even seemingly minor complaints. If a revision could improve a small deformity, the patient should be advised accordingly and offered a treatment plan. However, unrealistic expectations should not be fostered by stating that you can take an excellent result and make it perfect. If the patient has a legitimate complaint or problem, the surgeon must first acknowledge the deformity, admit that the result is less than hoped for, and begin to outline a plan. Correction of a problem should be planned as soon as possible to ensure patient satisfaction. Although the timing for initiating the reoperative plan may need to be revised based on wound healing considerations, the act of merely determining a timetable will instill confidence and help the patient to understand what to expect. It is human nature to instinctively turn away from an adverse outcome when it is one that we have created ourselves. Conversely, when the problem was created by another surgeon, we tend to be more critical. For our own adverse outcomes the worst mistake one can make is to try to blame the patient. Yes, smoking plays a role in wound healing, but it is not always the sole factor in a complication.The angry patient will only become angrier when attacked by a plastic surgeon who is not willing to take any responsibility for a poor result. On the other hand, some patients may perceive a deformity that simply does not exist. These patients must be allowed to verbalize their complaints, but there is no reason to lend credence to an imagined deformity. One must never be tempted to

*Patients undergoing planned secondary stages or secondary aesthetic surgery years later are discussed elsewhere, since the issues are somewhat different.

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try to correct a condition that cannot possibly be improved. This action will guarantee a dissatisfied patient later on. Demonstrate that you are appropriately concerned about the patient’s problem. Patients merit our attention, respect, and sympathy. The surgeon should plan to spend adequate time listening to the patient’s concerns. Each of the patient’s questions and concerns should be addressed seriously and truthfully. Being a good listener under these circumstances will often relieve the patient of considerable stress and anxiety by allowing verbalization of these feelings. Anger and hostility, if present, will then usually give way to collaboration. Do not ignore pain, as it is often a mechanism by which patients express dissatisfaction.We may feel that a patient who complains of pain well beyond the time frame that we deem appropriate for a particular procedure is merely seeking pain medication or has a low pain threshold. However, it may be the only way that a patient can open the door to a conversation about areas of dissatisfaction.The surgeon must try to reach beyond the subjective pain complaints and elicit these important clues regarding the patient’s perception of the result. In other words, not every patient complaining of chronic pain is malingering or trying to avoid a return to work. Postoperative depression is common and may be unrecognized by the patient and manifested by complaints of pain. Discussing a less than satisfactory outcome with a patient has potential pitfalls, particularly if the patient was not adequately counseled preoperatively. It is important to try to see what the patient sees. Usually he is concentrating on the mirror image to make a determination about persistent deformity. For this reason photographically documenting and discussing preoperative asymmetry in advance is an important part of the consultation. The preoperative photographs can then be reviewed with the patient postoperatively to help him to evaluate the outcome. It is possible to create dissatisfaction by pointing out a minor flaw that the patient does not see at all. I well remember one patient who came for a follow-up visit 1 year after bilateral breast reconstruction. She was absolutely beaming over the result and had been proudly showing herself to other women and potential patients in the community. I made the mistake of pointing out to her that the nipple reconstruction had undergone considerable atrophy, losing more projection than I had anticipated. This was something that she had not noticed and with which she had not been concerned. However, from that day on, the loss of nipple projection became the focus of our discussion every time she came to my office. I do not believe she was ever entirely pleased with the reconstruction again.

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It is often helpful to attempt to evaluate the patient as if you were a casual observer rather than a plastic surgeon: What is the most striking feature of the deformity? It is possible to lose sight of the “big picture” after having performed multiple operations on a patient. Your priorities may not be those of the patient or his or her friends and family. Ask the patient,“What is it about the problem that bothers you the most?” and “If you could have only one thing changed or improved, what would it be?” These types of questions will help you refocus your plan so that it is more in line with the patient’s concerns. Recently I saw a patient with face and neck burns whom I had treated 1 year earlier. He had been undergoing a series of operations with expanded neck flaps to resurface his neck and jawline. His neck and lower face area actually looked quite good, but for the first time I suddenly realized that the most obvious deformity was his badly burned ears. He agreed that this defect had been bothering him, but he did not think anything could be done about it. From that point on, my reconstructive plan addressed the correction of the more obvious deformities.

Certain problems may not be amenable to surgical improvement. The patient may choose to forego surgery rather than have an operation for something that does not bother him. For example, most plastic surgeons when confronted with this patient would immediately focus on the missing right breast. However, this elderly patient had been getting along quite well for many years following a modified radical mastectomy for carcinoma of the breast. In fact, the only problem that she had was the fact that the external prosthesis required for symmetry was large, heavy, and quite uncomfortable in the summertime.Therefore her perception of the problem was that her left breast was simply too large to match her prosthesis. Even af-

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ter a discussion of the options available to her for a reconstruction, the patient did not wish to undergo breast reconstruction but rather she simply preferred a reduction mammaplasty of the large opposite breast. This procedure was done on an outpatient basis and resulted in a much improved quality of life for her.

THE FAMILY DYNAMIC An operation on a loved one can represent a crisis for the entire family. If the patient undergoes an elective operation against the wishes of family members and then suffers a complication or unsatisfactory result, family relationships can deteriorate precipitously. The patient may feel guilty about the decision to have the procedure, particularly if a family member paid for an aesthetic procedure that produced a less than satisfactory result. The patient may even construe these circumstances as God’s punishment for having defied the family. Financial considerations may come into play. Reoperation may mean more time off from work, loss of income, and additional expense, which may cause stress among family members. Sometimes the surgeon may find that facilitating family communication is more crucial to a patient’s treatment and well-being than the operation itself. It is helpful to have another family member present for the consultation. Many patients will not completely comprehend or remember the doctor’s explanations. Family members can often help to later remind them of issues that were discussed or to explain things that the patient did not understand. Likewise, having another staff member in the examination room is good practice. Another staff member may notice facial expressions or other nonverbal clues that the surgeon might miss that indicate problems in family relationships or a lack of understanding on the part of the patient. Furthermore, a nurse or other staff member can spend additional time with the family answering questions in the surgeon’s absence. In addition, in the event of litigation, the verification by an additional person that certain issues regarding informed consent were fully discussed could make an enormous difference in a courtroom. I have the good fortune to work with office staff who are amazingly intuitive when it comes to forecasting which patients will be “problem” patients. I always make certain that the staff interact with potentially difficult patients. A patient may behave quite differently with members of the office staff when not in the surgeon’s presence. He or she may provide clues that would influence whether or not this individual is considered a good operative candidate. Input from various members of the office staff can also be exceedingly valuable in formulating the final operative plan.

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OUTLINING THE PLAN Trying to make a patient believe that a complication is minor by outlining an overly simple treatment plan sets a potentially dangerous precedent that often leads to further patient dissatisfaction. There is no quicker way to lose the trust and confidence of a patient than to trivialize the problem. The plastic surgeon performing secondary surgery may feel pressured to cut corners because of financial considerations. A patient who has just paid a considerable sum of money for a face lift will be understandably upset when, to have a hematoma drained, he or she must pay an additional fee for the operating room and the anesthesiologist. The surgeon who has not in advance discussed the possibility of additional costs to treat a complication of this sort might be tempted to try to take shortcuts to save the patient or himself this expense. For this reason, it is crucial to establish financial responsibility before a procedure rather than trying to address the issue on a crisis basis. The well-prepared patient has been informed about the range of adverse outcomes and the costs of treating them.The well-prepared surgeon has thought about these issues well in advance and established a plan for treating complications should they arise. In the realm of cosmetic surgery, costs of initial treatment and those related to reoperative problems can profoundly affect the doctor-patient relationship. In fact an unplanned hospitalization following cosmetic surgery can generate huge expenses that may well not be covered by the patient’s own health insurance. This is a fact that is often not recognized nor addressed by either the patient or the treating physician. However, when it occurs it can rapidly lead to a complete breakdown in communication as the responsibility for payment of these expenses becomes a source of contention. Litigation may ensue as patients seek to transfer responsibility for these costs back to the treating plastic surgeon, hospital, or other medical staff. This can occur even in the absence of negligence or below-standard-of-care treatment. By addressing these issues in advance or preparing for them by having a plan in place, the surgeon can mitigate potential problems and reduce the likelihood of an unhappy patient. Insurance to cover unplanned hospitalization following cosmetic surgery is now available to address this issue. For the patient who has had a series of surgical misadventures, the surgeon must ask himself, “What are the factors contributing to these repeated problems?” Many times a problem cannot be solved by further rearrangement of local tissues, and a different course of action must be taken. In this situation, it is difficult for the patient to accept that much of the previous surgery has accomplished nothing and that the new plan may include additional risks. Nevertheless, it is certainly a worse choice to pursue a course that is doomed to further failure.

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THE PATIENT SEARCHING FOR ANOTHER SURGEON The patient needing reoperation usually chooses to remain under the care of the initial operating surgeon. Even if a problem occurs months or years later, most individuals seek recommendations and care from their original doctor. Patients switch surgeons for a variety of reasons. The change may be occasioned by a practical reason, such as a move to a different location. More commonly, the patient loses confidence in his or her surgeon or feels that surgeon is incapable of correcting a problem or treating a complication. The patient may see a second surgeon on the advice of an attorney or occasionally at the request of an insurance company. At other times a plastic surgeon may suggest that the patient obtain a second opinion or consult with a fellow surgeon. In each of these circumstances the role of the second plastic surgeon is different. If you are meeting with the patient at the request of another plastic surgeon, you must clarify whether that surgeon intends to have you assume care of the patient or simply provide assurance to the patient that the original treating surgeon is “on the right track.” The original surgeon should inform the consulting surgeon if he or she intends to cover the cost of the consultation; otherwise, the patient must pay the cost and should be advised as such. The original surgeon should send copies of the patient’s records for review. If these records are not forthcoming, your office should contact the original surgeon’s office to obtain the necessary medical records and information so that an unbiased second opinion can be rendered. If the patient has sought you out directly, then your approach will be ultimately influenced by what the patient wants. However, you must ask yourself, “Do I have skills that the original surgeon does not possess?”“What are the chances of avoiding a further complication or less than optimal result with my plan?” As the second surgeon, you have increased legal risks: it is usually the second surgeon who gets sued rather than the first. Despite this risk, most plastic surgeons are best served by letting their surgical judgment guide them. As a consultant, you must determine the patient’s motivation. Most patients are genuine in seeking to have their problem corrected by a skilled and caring surgeon. Some, however, have no intention of undergoing further surgery and are motivated by the promise of a malpractice settlement or continued disability payments. Certain patients may have a psychological need to remain disabled to maintain the sympathy and attention of family and friends. In any event, your role as a consultant is to guide the patient to an honest and reasonable second opinion. What the patient does with that information is of his or her own choosing.

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SPECIFIC PROBLEMS Human beings are complex, but patients often convey recognizable patterns of behavior. The reoperative surgeon should be alert to these behavior patterns and ad - just his or her approach to the patient accordingly.

THE ANGRY PATIENT As discussed earlier, a certain degree of anger is common in the reoperative patient. This patient is often looking for someone to blame for his or her misfortune , and the surgeon , or in some cases other members of the health care team, are the recipients . Some of the anger may be directed at the spouse or other family mem- bers simply because they are not the ones with the problem. The most effective way to deal with this situation is to allow the patient to vent this anger and verbalize his or her feelings. The surgeon must help the patient to under - stand that anger is a normal reaction. The surgeon and patient can then move on and discuss a course of action . The patient who cannot move beyond the anger phase may benefit from referral to a social worker , psychologist , or skilled member of your office; sometimes an uninvolved nonthreatening third party is effective in helping the patient to deal with this hostility . Eventually , with the establishment of a treatment timetable , the patient redirects energy in a more constructive manner and much of the anger will usually disappear.

THE DISSATISFIED PATIENT Patients facing secondary surgery or reoperation of any type may have justifiable reason for dissatisfaction. The results may indeed be less than optimal. Unrealistic initial expectations and incomplete preoperative preparation may also contribute to patient displeasure . This sense of grievance can be compounded by factors such as monetary considerations, particularly if aesthetic surgery has not been paid for in advance . As the weeks and months following the operation go by and the patient is still making monthly payments , the little things that otherwise might have gone unnoticed or been ignored become a major focus of dissatisfaction ; patients may consider themselves continuing to pay for a deteriorating result ! Occasionally the patient will confront the surgeon and try to negotiate a new contract :“I don’t be- lieve I should have to pay the balance of my bill because my breast lift no longer looks as good as it did.” This situation is most awkward for the plastic surgeon , who must then either press for payment or defer to a new arrangement merely to avoid having to do a secondary correction gratis. By reviewing the preoperative and postoperative photographs with the patient, often the surgeon can help the patient to appreciate improvements that the patient may not recognize . People have short memories regarding certain deformities and often simply forget how much they disliked the way they looked preoperatively . Comparing the photographs may help them to feel good about themselves once

Chapter 2 The Patient

again. Conversely, if only modest improvements are appreciable when the photo - graphs are compared , this observation may fuel the patient’s perception that the expense outweighed the visible benefits of the surgery. Usually a reminder of the preoperative discussion of the various potential outcomes will seem adversarial to the patient and will be counterproductive at this point. Nevertheless, it may be worth mentioning the conversation to a patient who seems to have completely lost memory of the preoperative counseling.

THE PATIENT WITH A PSYCHIATRIC PROBLEM Patients with psychiatric disorders are a potential problem for all plastic surgeons, but particularly in reoperative situations. Patients with certain psychiatric disorders who seek elective aesthetic surgery are often not helped by the surgery and may in fact be harmed. One such disorder has been called body dysmorphic disorder (BDD) (see Chapter 3) in which the patient becomes preoccupied with and grossly exaggerates a slight physical defect.4 The disorder can profoundly affect the patient’s ability to function in a normal capacity. The patient might even imagine a defect when in fact there is none . He or she might become obsessed with hiding the deformity to the point that the patient will not venture outside the home. The patient may go from surgeon to surgeon seeking to have the imagined defect sur- gically treated . Depression can accompany this disorder . The most effective way to screen for BDD is to conduct a careful and thorough patient interview . In this set- ting the plastic surgeon can often pick up clues that will help to identify this type of patient . When questioned about motivations for a particular procedure , the pa - tient may exhibit behaviors that re flect an inappropriate concern about the defor- mity. He or she may be unemployed or unmarried and causally link this situation to the perceived defect rather than to other factors.3 Even though we can all think of patients who might fit this BDD profile, the spe - cific diagnosis of BDD may not be so straightforward 4 (see Chapter 3). Many cos - metic surgery patients do have some degree of preoccupation with appearance is- sues that we might consider minimal or slight. It is quite common during cosmetic surgery consultations to find patients who use close-up mirrors and view them- selves in certain lighting at odd angles to define concerns they have about their fa- cial features. Certainly not all of these deserve a diagnosis of BDD . However , with experience most plastic surgeons can recognize that fine line between appropriate concern and dysfunction. If this disorder is detected, the plastic surgeon might inquire as to whether the patient is currently under the care of a psychiatric professional. If so, the surgeon should ask the patient to be allowed to speak with the psychiatrist regarding any possible surgery . In addition , the surgeon should inquire if the patient is receiving any kind of psychoactive medication ; some types call for special consideration in terms of anesthesia . If such a patient is not under the care of a psychotherapist , an appropriate referral would be prudent before proceeding with any kind of surgery.3

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I recently saw a patient who had been turned down for secondary rhinoplasty by 5 other plastic surgeons. Although she exhibited obvious deformity that could have been improved through surgery, she exhibited clear psychiatric disturbance that made it difficult to develop anything but an antagonistic doctor-patient relationship. She rocked back and forth in her seat, repeating over and over again that she knew that I would refuse to operate on her because of her race, even before I could outline possible surgical approaches for her. She threatened to bring an EEOC action against us, all before allowing us to take photos or even become acquainted with her. She was in need of psychiatric care but would not accept referral. Quite obviously to operate on this patient would be a grave error. Rejection by multiple other plastic surgeons should always raise a red flag.

THE DEPRESSED PATIENT Patients who have not had an optimal result or even those who have had a satisfactory outcome may occasionally experience postoperative depression. They may be inclined to focus on small imperfections of a procedure or on the complication or problem if one has occurred. It is important to recognize this condition early and have the patient seek consultation if getting the patient to “open up and talk” does not seem to help. For hospitalized patients, the unfamiliar environment can also play a role in this phenomenon. Often we are inclined to keep patients in the hospital to be able to keep a close watch on “how the wounds heal .” However , a patient with a prolonged hospitalization who has had complications naturally can become depressed . The patient quickly grows weary of the hospital environment and, as the days wear on, he is likely to feel that he is simply not getting any better, believe that no one cares, and begin to dwell on the complication rather than looking forward to the future . It is neither advisable nor desirable to keep a patient hospitalized until all wounds are completely healed. There are two approaches to this situation . When the patient has a wound that contains necrotic tissue , the patient can be returned to the oper- ating room for debridement and coverage with either a skin graft or a local flap. When the patient has a wound that is simply slow in healing, the patient can be dis- charged and then monitored with close follow -up in the office. Many times visit - ing nurse associations are a tremendous help in providing wound care or even par- enteral therapy in the patient ’s own home . This type of home management certainly is not appropriate for every patient, and one does not want to give the im- pression that the patient is being discharged prematurely . However , many patients will view their impending discharge as a sign that they are getting better . The home environment is often conducive to physical recovery and mental well-being. The patient who has unrealistic expectations regarding the surgery may be at risk for postoperative depression. Although plastic surgery is potentially life changing for some patients, for the vast majority it is not. Those who expect that things will be

Chapter 2 The Patient

entirely different for them after cosmetic surgery set themselves up for profound depression postoperatively once they realize that their world remains much the same as before . Clearly the best way to avoid this outcome is prevention by careful screening for appropriate motivation and by good preoperative counseling . Another type of patient at risk for postoperative depression is the patient whose facial appearance has been dramatically changed. It is quite possible for an individual to feel as if he or she has lost a familiar identity and in a sense feel like a completely different person. This phenomenon is not uncommon in patients who undergo orthognathic surgery, rhinoplasty, and soft tissue contouring procedures. Post - operatively , they actually might not be recognized by their own friends ! A period of readjustment must ensue during which depression can supervene despite a pro- found improvement in appearance . Computer imaging can help patients develop realistic expectations with a sense of how their appearance might change. These issues should be addressed in the preoperative discussion.

THE PATIENT WITH PAIN Most people fear pain.The reoperative patient has already experienced some degree of pain with the primary surgery and will naturally be concerned about how much discomfort can be expected from the next operation. I have had several patients forgo nipple -areola reconstruction following a TRAM fl ap breast reconstruction because of the memory of the abdominal pain following the initial flap harvest and mound construction. Despite my efforts to demonstrate that the breast mound is insensate and that they will experience very little if any pain with nipple-areola reconstruction, they cannot bring themselves to proceed with additional surgery. They are willing to live without the completed reconstruction rather than submit to a second elective operation no matter how “minor” the pain . In these situations , the fear of pain becomes worse than the pain itself and is the dominant factor in in- fluencing whether a patient proceeds with elective reoperation. Some patients develop unusual chronic pain syndromes subsequent to surgery . Not always easily explained , these disorders can occur following procedures as diverse as face lifts and lower extremity liposuction . Fortunately most patients improve with time . One must be cautious about reoperating for pain alone . Often the result of blind exploration is a patient who is no better and sometimes worse. The develop - ment of neuromas because of previous incisions may often explain unresolved pain syndromes (see Chapter 48). Diagnostic nerve blocks can be helpful in patients who demonstrate point tenderness in known cutaneous nerve distributions. The plastic surgeon would be well advised to rule out every other mechanical cause of pain before referral. I prefer to refer patients with recalcitrant pain to a pain clinic where various treatment modalities including group therapy are available. 5 Massage and desensitization training by physical therapists may sometimes improve localized chronic pain . If this fails , however , more sophisticated techniques of pain control may be indicated . Medications such as gabapentin ( Neurontin) or prega- balin (Lyrica) may be of great benefit. The patient in whom pain develops with ob-

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vious secondary gain must also be identified, with careful documentation of the objective signs and symptoms in the medical record.

THE PATIENT WHO HAS HAD MULTIPLE FAILED OPERATIONS Multiple failed procedures lead to anguish for both the patient and surgeon. Each surgeon develops his or her own style for delivering good news and bad news and for maintaining healthy doctor-patient relationships when things get rocky. By be - ing flexible and learning to read patients’ moods and personalities , the surgeon can adapt the approach depending on the circumstances . The key is to always maintain healthy , open communication . It is important to let the patient know that the sur- geon cares greatly about what has happened, and reassure the patient that they will face the future together and that the surgeon can be trusted to provide guidance to- ward the correct course of action. All surgeons must recognize their own limitations.We are limited not only in what we can do technically but also in our abilities to work with every type of patient. At some point a surgeon may realize that he or she has reached the limit of what can safely be accomplished for a patient or the limit of their ability to provide care . It is then the surgeon ’s obligation to refer the patient to another physician who can assume care and responsibility . Those who exceed these limits doom both the result and the doctor -patient relationship . When referring a difficult patient, the surgeon should call the new consultant personally, provide copies of all medical records, and follow up to make certain the patient has been assisted in every way possible to make the transition to a new treating physician a favorable one.

THE TERMINAL CANCER PATIENT Occasionally a plastic surgeon will care for a terminal cancer patient who has had complex reconstructions . It is well to remember that “it is better to give life to years , not just years to life.” 6 Preservation of dignity and hope in the final months of life is essential; the surgeon should do all possible to allow the patient to main- tain a sense of esteem and worth. Patients facing death will go through the well-known stages of adjustment, includ - ing anger. It helps patients to have their physician face the anger with them and to know that the physician will be with them to the end. Sometimes facing a bad sit- uation squarely together can make the bleakest circumstance an experience that both you and your patient will find enriching.

MEDICOLEGAL CONSIDERATIONS The very nature of reoperative plastic surgery increases the odds that a medical malpractice claim may be filed. Claims usually arise from a patient’s response to a disappointing surgical result . Both the initial surgeon and the reoperating surgeon

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are at high risk of liability stemming from various aspects of reoperative patient care. Even though many types of reoperative surgery have no medical or legal re - lationship to previous surgical care , the increased technical dif ficulty of reoperative surgery and the unpredictability of the outcome make the reoperating surgeon a target for malpractice . Patients need to be carefully counseled preoperatively, and these discussions must be meticulously recorded in the medical record along with photographs documenting preoperative appearance and postoperative result.

INFORMED CONSENT All surgeons must be familiar with the elements of informed consent under their own state law. The surgeon is required to provide the patient with a diagnosis, a written and spoken description of the nature of the planned procedure including its risks and bene fits, and an explanation of the consequence of not having the pro - cedure . The process of obtaining informed consent under reoperative circumstances is no different from that for obtaining it with primary surgery. There are very few exceptions to the requirement for obtaining informed consent , particularly in plas- tic surgery in which life-threatening emergencies that would preclude this discus- sion are rare.7

ELEMENTS REQUIRED

FOR INFORMED

CONSENT8

In general, five types of information are required for informed consent. They are: 1. Diagnosis 2. Nature and purpose of the proposed procedure 3. Options for alternative treatments, including those which the treating plastic surgeon may not perform 4. Risks, complications, and possible outcomes 5. Potential results if no treatment is performed Actually , a detailed description of the procedure is not required although it is often a good idea. Some patients request an explanation of the minute details of a pro- cedure and others may not wish to know much of anything, saying,“Don’t tell me what you are going to do, Doctor, just do it.” Although you might avoid address - ing a step-by-step description of the procedure , you must spend time mentioning commonly known risks and complications, for example, a hematoma following a breast augmentation . Other consequences that might occur should be mentioned but generally extremely unlikely risks do not require disclosure. It is always best to err on the side of a more thorough discussion to avoid having to explain later in court why a complication or unfavorable result was never mentioned. A situation in which informed consent may not be required is when the surgeon is aware that the patient has prior adequate knowledge. Also outcomes that are commonly known do not always require discussion. Again, it is always safer to mention risks, especially if they involve death, paralysis, or loss of other vital functions.

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When a patient who has had a complication or less than ideal result presents for an initial consultation, it is common for the patient to begin pointing the finger at the previous surgeon. He is likely to ask questions such as, “Why did things go wrong?” or “Why didn’t Dr. X tell me something like this could happen?” It is im - perative that the reoperative surgeon not indicate by facial expression or direct comment even the slightest hint of dismay , disdain , or negative attitude toward the patient ’s surgical course or the previous surgeon . After all, you were not there, and you probably do not have access to all of the medical records; even if you did , these records would not necessarily reflect all of the factors that contributed to a partic - ular medical or surgical decision . Instead , the surgeon should focus on the present and the future. It is not for the reoperating surgeon to stand in judgment of the pa- tient’s previous treatment or the patient’s previous surgeon.9 If you were the initial surgeon, then the informed consent process for the reoperation is critically important. Extra time should be spent with the patient. Perhaps a family member should be invited to be present. Patients are likely to judge all information that they are given for preoperative counseling for secondary surgery in light of their own personal experience the first time around.They may have lingering misconceptions. Generally, the term minor surgery should be avoided. It should be explained that reoperative surgery sometimes proceeds at a slower pace because of previous scarring and alteration of anatomy. Bleeding can be more common . Under some circumstances , the surgical plan must be altered based on intraopera - tive findings . These eventualities must be fully discussed with the patient. The informed consent discussion should be documented in a handwritten note recorded preoperatively in the patient ’s chart. It is helpful to list all of the steps of the planned procedure and all of the possible risks that were discussed . Sometimes sketching an accompanying drawing in front of the patient clarifies some of the technical aspects of the planned procedure and helps the patient understand when pitfalls may occur. When the patient understands that the informed consent process is required by law, he or she usually will not feel unduly frightened or concerned by the discus - sion. The surgeon should use the experience to strengthen the doctor-patient re- lationship . Elements from the patient ’s previous surgery can be used to indicate your concern for the patient ’s safety and your thoroughness of preparation :“As we discussed before your surgery , Mrs . Johnson , if the flap tissue appears to lose its blood circulation , the best thing to do is to go right back to the operating room, where we have a very good chance of being able to fix it. That’s the reason we’ve been checking on you so often since your surgery.” If you are not the original sur- geon , you should make certain that you have inquired about various aspects of the previous surgery . Was there increased bleeding ? Did the patient have any dif ficulty with general anesthesia ? This information should then be incorporated in the in- formed consent :“As you know, Mrs. Jones, your healing was delayed after your first operation . This could happen again because of the previous radiation therapy.”

Chapter 2 The Patient

If surgical residents are to be involved with the patient’s care, the patient needs to understand the resident’s role in the surgical care team, training credentials, and importance in helping to provide comprehensive surgical care.

MEDICAL RECORD The medical record is the physician ’s written documentation of the nature and progress of the patient’s treatment.10 We are obliged to maintain an adequate med- ical record to assist in communication with other members of the medical commu - nity , especially in a situation in which patients change physicians . The medical record is also a written document of the informed-consent process . It should be timely , precise , and legible . Every patient visit , from the initial consultation until fi- nal discharge , including telephone calls and any other interactions, should be doc- umented. It must be kept confidential and must never be altered . This is not to sug- gest that errors , especially involving spelling and transcription , cannot be corrected , but this must be done in the proper way. A mistake in the medical record is cor- rected by drawing a simple line through it so that it can still be read, followed by the corrected entry nearby and the date and initials of the editing party. Never try to erase or obliterate an error, as this will almost always be an impossible act to defend in court . Never be tempted to remove an old notation and substitute a new one in the medical record , even if you really feel that an honest mistake was made. If ad- ditional entries are to be made in the medical record, it is best to discuss them with your attorney prior to making any changes. The key in this process is to become a good communicator. Some patients learn best by talking; others prefer looking at diagrams and drawings; and still others require a careful reading of a written document to incorporate the information being conveyed. For some patients a more personalized relationship to the plastic surgeon and staff is necessary to fully understand the information being presented. By developing an open and caring bedside manner , all of the pertinent information can be effectively communicated without unduly alarming even the reoperative pa- tient . Above all, the surgeon should be approachable so that patients feel comfort- able asking questions that they may even consider silly or unimportant.

CONCLUSION The theory behind most reconstructive surgery is to take large chunks of muscle , skin, and bone and slap them into the roughly appropriate place, then slowly carve this mess into some sort of shape. It involves long operations , countless smaller ones, a lot of pain, and many, many years. — Lucy Grealy, cancer patient11 This quote is how one patient summed up her lifelong experience with multiple reoperations for a facial tumor. Although it might sound pessimistic , it helps us to recognize that our patients might view the fruits of our labors somewhat differently than we do ! Fortunately , not all reoperative surgery is judged so harshly. However,

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our patients deserve to be honestly informed about what we recommend and the chances for success or failure. They deserve to be intimately involved in the decision-making process. Many of the modes of dissatisfaction or adverse outcome of reoperative plastic surgery result directly from poor patient preparation or communication. All surgeons have patients who experience complications and failures. However, totally separate from the actual aesthetic or reconstructive result of the secondary surgery, the way we deal with our patients who require reoperation can either maximize success or incite failure. Understanding the patient’s viewpoint and where he fits into this complex dynamic will help to make the surgeon and the patient partners in optimizing results.

References —With Key Annotated References 1. Anger GM. The seven deadly sins [book review]. New York Times, 1993. 2. Goldwyn R.The unfavorable result in reoperative plastic surgery. Presented at the Reoperative Aesthetic Plastic Surgery Symposium, Amelia Island, FL, April, 1993. 3. Abrams M. Spotting psychiatric disorders in prospective patients. Aesthetic Plast Surg 17:9, 1993. 4. Sarwer DB. Body dysmorphic disorder. In Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. St Louis: Quality Medical Publishing, 2005. 5. Dobritt DW. The pain clinic: Its organization and application. Perspect Plast Surg 6:101-115, 1992. 6. Moyers BD. Healing and the Mind. New York: Doubleday, 1993. This text explores the healing connection between the mind and the body from a host of angles, including topics such as alternative medical treatments and the role of the mind in illness and recovery. 7. Sprung CL. Informed consent and the critically ill. Perspect Crit Care 1:61-72, 1988. 8. Reisman NR. Discussion of informed consent, record keeping, and documentation. In Goldwyn RM, Cohen MN, eds. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001, pp 35-37. A collection of more than 26 years of clinical research on the complications that can result from various cosmetic surgeries.The text highlights advances in plastic surgery, in areas like bone, skin, and nerve grafts, facial reconstruction, and breast augmentation. Legal issues are also covered. 9. Lee JT, Cole PA. Medicolegal considerations. In Fry D, ed. Reoperative Surgery: Views of a Surgeon and an Attorney in Reoperative Abdominal Surgery. Philadelphia: WB Saunders, 1986. 10. Sullivan WG. Informed consent, record keeping, and documentation. In Goldwyn RM, Cohen MN, eds. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001, pp 29-35. A collection of more than 26 years of clinical research on the complications that can result from various cosmetic surgeries.The text highlights advances in plastic surgery, in areas like bone, skin and nerve grafts, facial reconstruction, and breast augmentation. Legal issues are also covered. 11. Grealy L. Mirrorings:To gaze upon my reconstructed face. Harper’s, Feb 1993, pp 66-75. Cited in Yousif NJ, Larson DL. Evolution of the revolution in head and neck reconstruction. Perspect Plast Surg 7:29-48, 1993. Ms. Grealy presents a first-person account of her lifelong struggle with cancer that appeared in her jaw as a child. She recounts her chemotherapy as a young girl and a series of reconstructive procedures in her adult years, and the surgery involving a tissue expander and a bone graft.

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REVIEW QUESTIONS 1. The most common reason cited by patients for changing physicians postoperatively is: a. A perception that their plastic surgeon is uncaring or unavailable to address their concerns b. Financial issues c. A perception that the physician’s staff is unfriendly and unhelpful d. An inconvenient office visit schedule e. A feeling that their plastic surgeon has a personality disorder 2. If reoperation is necessary, the well-prepared patient: a. Will be disappointed but not shocked if reoperation is necessary b. May feel “unfortunate” c. Is able to remain optimistic about the future d. Is aware that further treatment might produce better results e. All of the above 3. Communicating with the reoperative patient is facilitated by: a. “Stretching” the truth to make a complication understandable to the patient b. Ignoring the deformity to concentrate on the positive c. Attempting to minimize the problem to bolster the patient’s spirits d. Dealing honestly with the patient to gain his or her trust e. Not revealing the timetable for correction so as not to upset the patient 4. Body dysmorphic disorder is: a. A condition in which a patient becomes preoccupied with and grossly exaggerates a slight physical defect b. An obsession with a gross physical deformity c. Usually seen in children d. Overdiagnosed in plastic surgery populations e. Untreatable 5. The elements of informed consent include a discussion of: a. Diagnosis b. The nature and reason for the proposed treatment c. Options for alternative treatments d. Complications and risks e. All of the above

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Chapter 3 Psychological Considerations in Reoperative Plastic Surgery Patients David B. Sarwer, Alexander W. Baker, and Alison L. Infield

Rollin Becker had a mantra he’d use before he saw a patient: “Thank you for allowing me to watch you heal yourself.” Hilmar Moore

A

ccording to the American Society of Plastic Surgeons (ASPS), more than 10. 2 million Americans underwent a cosmetic surgical or minimally invasive procedure in 2005 .1 The vast majority of procedures consisted of minimally invasive, nonsur- gical procedures , which have increased by more than 50% since 2000 .1 These num - bers , although familiar to many plastic surgeons , are often staggering to other med- ical professionals and lay persons who are unaware of the number of Americans who turn to medicine to enhance their physical appearance . The dramatic increase probably reflects an increased acceptance of and desire to improve appearance by medical means , and underscores the premium that is placed on physical appear- ance in contemporary society.2

Several factors have probably contributed to the growth in popularity of cosmetic surgery.2-5 Changes in the medical and surgical communities, including improvements in safety and the proliferation of direct-to-consumer marketing, have increased access to cosmetic surgery.The role of physical appearance in daily social in - teractions is another probable influence . A large body of research suggests that more attractive people are judged more favorably and receive preferential treatment in a wide range of social situations.2,6 Widely watched “reality-based” television pro - grams such as The Swan and Extreme Makeover have helped to champion cosmetic surgery and further perpetuate the media ’s historically unrealistic beauty ideals . These influential factors serve as a backdrop to the significant dissatisfaction that many Americans experience with their physical appearance. Considering all of

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these factors, perhaps the dramatic increase in the popularity of cosmetic surgical and minimally invasive treatments is not surprising. Plastic surgeons and mental health professionals have been interested in the psycho - logical aspects of cosmetic surgery for decades .7,8 Numerous studies have found that patients report increased satisfaction with their appearance , as well as psycho- logical improvements, postoperatively.7,8 Some patients, however, are less satisfied with their postoperative appearance and ultimately undergo revision procedures with the same or another surgeon. Precise statistics on the number of revision pro- cedures performed each year are not available . However , 36% of patients who un- derwent a cosmetic procedure in 2005 were considered to have undergone re- peated procedures .1 Some of these were probably revision procedures. Understanding the psychological characteristics of patients who desire and undergo primary or secondary cosmetic procedures is important for at least two reasons. First, cosmetic procedures are often seen as analogous to psychological interventions; when successful, both result in psychosocial benefits to the patient.3 Second, there may be a subset of patients, particularly patients with certain psychiatric disorders, for whom repeated or revision procedures may not be beneficial. This chapter will provide an overview of the psychological aspects of cosmetic sur - gery . The chapter begins with a review of studies that have investigated the psycho - logical characteristics of individuals who have undergone the most common cos- metic procedures . The chapter then provides an overview of body dysmorphic disorder (BDD), the psychiatric disorder that may be most relevant to cosmetic surgery patients in general, and specifically to patients who seek repeated proce - dures . The chapter concludes with a discussion of the psychological assessment of patients who undergo cosmetic surgery.

PSYCHOLOGICAL ASPECTS OF THE MOST COMMON COSMETIC PROCEDURES RHINOPLASTY Rhinoplasty is the second most popular cosmetic surgical procedure in the United States, with just less than 300,000 performed in 2005.1 The psychological characteristics of patients who undergo rhinoplasty have received as much research attention as the characteristics of people who have undergone any cosmetic procedure. 7 The first clinical reports date back to the 1940s and 1950s.9,10 Psychodynamic or Freudian theory was the dominant theoretical orientation in psychiatry at the time and influenced interpretations of the preoperative motivations and postoperative outcomes of patients . The initial reports , as well as subsequent investigations in the 1960s, suggested that patients were highly psychopathological . The nose was often thought to symbolize the penis , and the desire for rhinoplasty was believed to rep- resent the patient’s unconscious displacement of sexual con flicts onto the nose . 11 ,12 During the 1970 s and 1980 s, a “second generation ” of research in cosmetic surgery emerged and included valid and reliable psychometric measures to assess patients’

Chapter 3 Psychological Considerations in Reoperative Plastic Surgery Patients

psychological characteristics.4,5,7,8 Studies conducted during this era found less preoperative psychopathology,13-16 and several studies reported postoperative improvements in psychosocial status.14-18 Unfortunately, the validity of many of these studies has been called into question because of methodological problems such as small sample sizes and the lack of appropriate control groups.7 More recent studies, several of which addressed previous methodological issues, described less preoperative psychopathology and psychosocial improvement after surgery.19-26 Unfortunately, despite a revision rate estimated at approximately 10%,27 formal investigations have yet to specifically study the psychological characteristics of patients who have undergone revision rhinoplasty. As discussed later in the chapter, evidence suggests that some of these patients may suffer from BDD.

BREAST AUGMENTATION Despite the long-standing debate about the safety and efficacy of breast implants, the number of women in the United States who have undergone breast augmentation has risen by more than 700% in the last decade.1 A fairly extensive literature has investigated the psychological characteristics of patients who have undergone breast augmentation.8 Some studies have described the preoperative psychological characteristics of these women; others have examined the psychological changes that they experience postoperatively. The stereotypical image of a patient who undergoes breast augmentation is a single, European-American woman, in her early twenties, who is interested in breast augmentation as a means of facilitating the development of a romantic relationship. In reality, reports suggest that the average patient is in her late twenties or early thirties, is married, and has children.8 Many of these women report that their primary motivation for surgery is to return their breasts to their former, prechildbirth shape and size. Nevertheless, women who range in age from their late teens to mid-forties and who represent a variety of ethnic backgrounds present for breast augmentation, making it probable that there is no “typical” patient. Although it is difficult to define the average breast augmentation patient, one can identify some differences between women who have breast implants and those who do not. Women who have undergone breast augmentation are more likely to have more lifetime sexual partners, report a greater use of oral contraceptives, be younger at their first pregnancy, and have a history of terminated pregnancies compared with other women.28-31 They have also been found to use alcohol and tobacco more frequently and to have higher rates of divorce.28-32 Many present for surgery with a below-average body weight, leading to the concern that some may experience eating disorders.28-31,33-35 Several reports have described the preoperative body image concerns of patients who undergo breast augmentation.33-38 These reports suggested that women interested in undergoing breast augmentation have greater dissatisfaction with their breasts, greater investment in their overall appearance, and greater concern with

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their appearance in social situations compared with women who are not interested in breast augmentation.33-36 In addition, candidates for breast augmentation were more likely to practice significant behavioral avoidance in response to negative feel - ings about their breasts compared with women who are not interested in surgery .36 Finally , prospective patients more frequently reported being the victims of teasing about their physical appearance and of using psychotherapy than control patients .35 Studies of the more general psychological status of candidates for breast augmen- tation have followed a similar pattern to studies of candidates for patients who un- dergo rhinoplasty.39 Early reports relied on clinical interviews to assess preoperative psychological functioning and found that patients experienced increased symptoms of depression , anxiety , guilt , and low self-esteem .32,34,40-43 Subsequent studies have been more likely to use valid and reliable psychometric measures, and typically found fewer symptoms of psychopathology .37,38 Other studies have examined psychosocial changes postoperatively. Several have re - ported improvements , or at least no change , in self-esteem and depressive symp - toms . However , the most profound psychological effects of breast augmentation may occur in the domain of body image . In one of the largest studies of psychoso - cial outcomes in patients who have undergone breast augmentation , more than 90% of patients reported an improved body image 2 years postoperatively .44 Pa- tient satisfaction and body image improvements , however, may be tempered by a postoperative complication and revision surgery. Up to 25% of women experience a surgical or implant -related complication , most commonly capsular contracture or hardening of the breast .45-52 At least three studies have suggested that the expe- rience of a complication is negatively related to postoperative satisfaction ; women who experienced postoperative complications reported less favorable improvements in self-image and body image .44,45,53 During the last several years , five large epi- demiological studies in the United States and Europe designed to investigate the re- lationship between breast implants and mortality found an unexpected relation - ship between breast implants and suicide . 54 -58 The suicide rate (obtained from patients ’ death records ) was two to three times greater among patients with breast implants compared with either patients who underwent other cosmetic surgical procedures or population estimates. The specific nature of the relationship between breast implants and suicide is unknown . Two hypotheses regarding this relationship , although speculative , have some intuitive appeal . Some women may enter into surgery with unrealistic expectations about the effect that breast augmentation will have on their lives.When these expec - tations are not met, they may become despondent , depressed , and potentially suici - dal . Alternatively , women who experience postoperative complications statistically not associated with breast implants (for example , autoimmune and connective tissue diseases ), and who may require additional surgery , may believe these complications are a consequence of their implants . These women may become depressed as a re- sult of a lack of perceived or real attention from the medical community.

Chapter 3 Psychological Considerations in Reoperative Plastic Surgery Patients

In their study, Jacobsen et al56 found an increased prevalence of preoperative hospitalizations for psychiatric reasons in women with breast implants compared with women who underwent other forms of cosmetic surgery or breast reduction.56 These results suggest that the increased suicide rate among women who have breast implants may reflect some underlying psychopathology rather than a direct relationship to the implants.59,60 As noted previously, women seeking breast augmentation present for surgery with certain preoperative personality characteristics that are associated with an increased risk of suicide. Joiner61 has argued that these and other personality characteristics would actually predict an even higher suicide rate than found in the epidemiologic investigations. He further suggested that postoperative improvements in body image may produce a protective effect from the otherwise increased risk. Clearly, additional prospective epidemiologic and clinical studies of the relationship between breast augmentation and suicide are needed.

LIPOSUCTION More than 320,000 men and women underwent liposuction in 2005, making it the most popular cosmetic surgical procedure .1 Few, if any, studies have speci fi cally investigated the preoperative and postoperative psychological status of patients who underwent liposuction . Clinical reports suggest that there is great deal of public misperception about liposuction . Many patients mistakenly believe that liposuc - tion leads to permanent changes in weight and body shape . Others believe that li- posuction will result in “washboard abs” and perfectly smooth thighs. Unfortu- nately, these “ideal” results may not occur in reality. Between 40 % and 50 % of patients reported weight gain after surgery , and up to 29% claimed that their fat re- turned to the surgical site.62,63 Most patients , however , report satisfaction with their results and maintain a more proportional shape, even if they do gain weight post- operatively.63

ABDOMINOPLASTY Only one study64 has documented the psychosocial changes associated with abdominoplasty . In this study , women reported signi ficant improvements in overall dissatisfaction with their body image and abdomen , and in self-conscious avoidance of body exposure during sexual activity 8 weeks after surgery. Patients did not re - port signi ficant improvements in self -concept or general life satisfaction . These re- sults are consistent with other postoperative studies that suggest that the impact of cosmetic surgery procedures may be limited to specific improvements of discontent with body image, but not necessarily to more general psychosocial functioning . 7,8 The number of men and women who seek abdominoplasty has increased by 115% since 2000.1 This increase may be a result of the rising numbers of individuals with extreme obesity who are now undergoing bariatric surgery (“stomach stapling ”) to achieve weight loss .65 Unfortunately , after the massive weight loss , many patients who undergo bariatric surgery are left with excess folds of skin and fat on the ab-

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domen and other body areas. This redundant skin may contribute to increased dissatisfaction with body image,66 and as a result may lead patients to seek abdominoplasty and other body-contouring procedures. In 2005, more than 20,000 individuals underwent extended abdominoplasty or a lower body lift after massive weight loss; more than 30,000 women underwent breast reduction/breast lifts.1 The high complication rate associated with these body-contouring procedures often necessitates subsequent surgical revision.67 Unfortunately, formal studies of the psychological characteristics of people who seek these body-contouring procedures have yet to appear in the literature.

SURGICAL ANTIAGING PROCEDURES In 2005, 108,955 rhytidectomy and 230,697 blepharoplasty procedures were performed in the United States.1 Similar to the early studies of patients who underwent rhinoplasty and breast augmentation, the first studies of patients who underwent facelift procedures suggested that these patients had considerable psychopathologic characteristics. Patients were often characterized as dependent and depressed; approximately 70% of patients received a preoperative psychiatric diagnosis.68,69 However, the majority of patients reported postoperative improvements in well-being and did not experience postoperative emotional disturbances.68 More recently , the body image concerns of these and other patients undergoing cosmetic surgery have become an area of great interest in the cosmetic surgery lit- erature.3-5,7-8 In one of the first empirical studies investigating the body image con- cerns of patients who undergo cosmetic surgery , nearly half the patients studied sought face-lift and/or blepharoplasty procedures.70 They reported higher levels of dissatisfaction with the feature for which they sought surgery, but they did not re- port increased dissatisfaction with their overall body image .70 Patients who under - went rhytidectomy and /or blepharoplasty have reported greater investment in their appearance as well as greater satisfaction with their overall body image compared with women who sought rhinoplasty .26 Postoperatively , patients reported decreases in dissatisfaction with their body image of the feature that was treated, but no changes in overall body image.71

MINIMALLY INVASIVE ANTIAGING PROCEDURES Minimally invasive antiaging procedures using products such as Botox and Restylane have rapidly become the predominant form of cosmetic medical treatment in the United States.1 These procedures have far surpassed the popularity of the more traditional surgical procedures . Despite their popularity , little is known about the psychological characteristics or body image concerns of the patients who seek these procedures . A German study 72 of 30 patients who received Botox injections for improvement of facial lines examined posttreatment social outcomes and attitudes toward appearance . More than half of the patients reported improvements in their appearance and nearly 50% reported greater confi dence in their appearance . A re- cent study 73 of 178 patients seeking laser skin resurfacing reported that 18% re-

Chapter 3 Psychological Considerations in Reoperative Plastic Surgery Patients

ceived prior treatment for depression. A third study74 evaluated the psychosocial benefits associated with the use of alpha hydroxy acid. Patients noted significant improvements in appearance and satisfaction with relationships after treatment. Patients who undergo these procedures often return for subsequent treatments. Repeated procedures are not technically “revision” procedures. However, they may raise some concern about the possibility of significant body image dissatisfaction or BDD, particularly in the absence of a noticeable physical “deformity.”

BODY DYSMORPHIC DISORDER All of the major psychiatric diagnoses can probably be found within the population of patients who undergo cosmetic and reconstructive surgery.4,5,7,8 However, there is growing evidence that BDD may occur with greater frequency among populations of patients who undergo cosmetic surgery compared with the general population. This disorder may appear with even greater frequency among patients who present for revision procedures. BDD is defined as a preoccupation with an imagined defect in appearance (or if a slight physical defect is present, the person’s concern is exaggerated) that results in significant emotional distress or impairment in functioning for the patient.75 Although not recognized as a formal psychiatric disorder in the United States until 1987,76 descriptions of people with the distinctive symptoms first appeared in the American dermatology and plastic surgery literatures much earlier. Reports in the dermatology literature described patients presenting with a “dermatological nondisease,”77 whereas reports in the plastic surgery literature described “minimal deformity” and “insatiable” patients.78,79 BDD is estimated to occur in 0.5% to 2% of the general population,80,81 and rates of 2.5% to 5% have been reported in university samples.82-85 In cosmetic surgery and dermatology settings, however, the condition appears to be far more common. Studies from several countries have suggested that between 7% and 15% of patients who present to cosmetic surgeons or dermatologists suffer from the disorder.70,86-89 Thus it may be the psychiatric condition that warrants the most attention from plastic surgeons.4,7, 90 The onset of BDD typically occurs in late adolescence and is equally prevalent among men and women.91,92 Although the most common sources of preoccupation are the skin, hair, and nose, any body area may be the focus of concern.91-93 Preoccupation with more than one feature is also common.93 Although the course of BDD tends to be chronic , the features of concern , severity of symptoms , and degree of insight into the disorder may vary over time.92,94 Patients often experience intrusive thoughts about their appearance or “defect .” Although some may recognize the exaggerated nature of these concerns , others may experience poor insight into their condition and hold delusional beliefs.95,96

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Skin picking, mirror checking, camouflaging with cosmetics or clothing, and reassurance seeking are some ways patients with BDD attempt to decrease their distress.94,97-101 Others may engage in avoidance behaviors such as not looking in mirrors or refusing to leave the house. These behaviors may range in severity, but typically involve 1 or more hours a day.98 The emotional distress and ritualistic behaviors often result in significant impairment in social and occupational functioning, and decreased quality of life.101-104 Self-harm and thoughts of suicide are relatively common.92,94,100,103,104 Individuals with BDD frequently seek cosmetic and dermatologic treatments to correct their perceived defect and to lessen their concerns about appearance.92,93,103-105 In two large studies of BDD patients, more than 70% of patients sought and more than 60% received such treatments.93,105 More than 90% of these treatments resulted in either no change or a worsening in BDD symptoms. After treatment, people with BDD often remain focused on the same body feature or become focused on a different feature. Studies suggest that nonpsychiatric treatments are often ineffective at reducing preoccupation with appearance, and in some cases may even exacerbate symptoms.87,92,93 There are even some reports of dissatisfied patients displaying violence, and threatening or taking legal action against their surgeons.106-108 As a result, the presence of BDD is often considered a contraindication for cosmetic procedures.* Psychopharmacologic and cognitive behavioral psychotherapeutic interventions appear to be more effective strategies.112-124

PREOPERATIVE EVALUATION OF A PATIENT UNDERGOING COSMETIC SURGERY Within the past several years, greater attention has been paid to assessing the psychological characteristics of patients who undergo cosmetic surgery.4,109,125,126 In general, three areas should be assessed during the initial consultation: motivations and expectations; body image dissatisfaction and BDD; and general psychiatric status and history. In addition, surgeons (and their staff) should be observant of patients’ behavior in the office. Finally, surgeons should be prepared to provide referrals to mental health professionals when appropriate.

MOTIVATIONS AND EXPECTATIONS Motivations for cosmetic surgery have been categorized as internal (for example, undergoing the surgery to improve one’s appearance, body image, or self-esteem) or external (for example, undergoing the surgery for some secondary gain such as attempting to save a failing marriage).127-130 To assess the nature of the motivations, it may be useful for the surgeon to start the initial consultation by asking why the patient is interested in surgery at this time as opposed to undergoing such a procedure 6 to 12 months ago.

*References 4, 5, 7, 90, 109-111.

Chapter 3 Psychological Considerations in Reoperative Plastic Surgery Patients

Postoperative expectations have been categorized as surgical, psychological, and social in nature.129,131 Surgical expectations address the patient’s specific concerns about the nature of the surgery (for example,“How much will it hurt?” or “How long will I wear bandages?”) as well as the anticipated changes in postoperative appearance. In some cases, patients and surgeons may not agree on the postoperative result. Patients may simply be dissatisfied with a technically satisfactory result or, in more severe cases, they may be suffering from psychopathology that was not detected preoperatively. These patients may be more likely to ask for revision procedures, either from the original or a second surgeon. Additionally, these patients may be likely to threaten or actually file lawsuits, and in the most extreme circumstances, threaten violence or inflict physical harm on their surgeons.107 Psychological expectations include potential improvements in psychological functioning such as anticipated changes in self-esteem after surgery. Social expectations address the potential social benefits of cosmetic surgery. Patients are typically judged by others to be more physically attractive after surgery, but there is no evidence that cosmetic surgery leads to changes in social or romantic behavior. Prospective patients need to be reminded that an improvement in appearance is not likely to result in a change in the social responses of others. In their review of the literature on the psychological aspects of cosmetic surgery, Honigman et al132 found three studies that suggested that unrealistic expectations are associated with lower levels of postoperative satisfaction.40,44,133 In contrast, patients who are internally motivated and who have realistic expectations are more likely to be satisfied with their postoperative result.

DISSATISFACTION WITH BODY IMAGE AND BODY DYSMORPHIC DISORDER Assessing the degree of preoperative dissatisfaction with body image is an essential part of the preoperative consultation. Some dissatisfaction is typical with most patients and probably motivates the pursuit of surgery.* Body image also appears to be the psychological construct most likely to change after cosmetic surgery.44,64,71,85,135 Some patients, however, present for surgery with an intense and frequent preoccupation with their comparatively “normal” appearance. As discussed earlier, the report of extreme dissatisfaction, particularly in the presence of a minimal defect, may suggest the presence of BDD. To assess for BDD, patients should be asked how their feelings about their appearance impact their daily functioning. Patients may have BDD if they have no obvious defect in appearance and report that their concerns about appearance prevent them from maintaining employment or relationships, or from engaging in daily activities most people would perform without a second thought. It is important to remember, however, that the symptoms of BDD fall on a continuum. Severe cases in

*References 36-38, 44, 45, 64-67, 71, 110, 134.

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which individuals are unable to maintain employment or rarely leave their homes can be relatively easy to recognize . In less severe forms of the disorder , individuals are able to work and maintain relationships , but their quality of life suffers dramat- ically. For example, they avoid various social situations or endure them with con- siderable self-consciousness. These patients may be far more diffi cult to identify. Patients may unintentionally reveal the extent of their preoccupation with their appearance in their initial consultation . Some may present the surgeon with numer- ous photographs of models or celebrities who have the feature or features they de- sire. Others may take photographs of themselves and, either through crude pencil drawings or elaborate computer enhancements , attempt to depict the desired changes. Still others may report a history of repeated cosmetic procedures or home - made appearance remedies that they have tried . These behaviors should be consid- ered as possible indicators of BDD. The plastic surgeon may have a difficult time identifying symptoms of BDD in patients who present for revision of an initial procedure or who report being dissatisfied with the results of a previous procedure from another surgeon. Although the surgeon may believe that additional surgery can improve the “objective ” appearance of a feature , it is often the patient ’s “subjective ” perception of that feature that needs additional treatment.The plastic surgeon faces a similar challenge when asked to re- pair a self-inflicted injury (for example , chronic skin picking ), which may be symp- tomatic of BDD. Cosmetic surgeons are clearly aware of the presence of individuals with BDD in their practices.107 When faced with a patient believed to have BDD, 84% of surgeons reported that they had refused to operate on a patient; 64% had scheduled a second consultation; and 50% had referred the patient for a mental health consultation. The vast majority (84%) of surgeons indicated that they had operated on a patient who they believed was an appropriate candidate for surgery , only to realize after the operation that the patient may have had BDD. Of surgeons who had this experience, 82% reported that the patient had a poor outcome with regard to BDD symptoms. Approximately 30% of survey respondents indicated that they had been threatened legally by a patient who they believed had BDD , and approximately 10% reported that in addition to legal threats , they had been threatened physically . This information , coupled with the finding that fewer than 10% of patients with BDD report improvement in their symptoms after nonpsychiatric treatment , sug- gests that BDD is a contraindication to cosmetic surgery.

GENERAL MENTAL HEALTH STATUS AND HISTORY As in any medical consultation, the plastic surgeon should assess a new patient’ s mental health status and history . In addition to assessing the symptoms of BDD , special attention should be paid to disorders with a body image component, such as eating and mood disorders.

Chapter 3 Psychological Considerations in Reoperative Plastic Surgery Patients

Eating Disorders Given the central role of body image in both eating disorders and cosmetic surgery , patients seeking procedures such as liposuction or breast augmentation should be as- sessed for symptoms of anorexia nervosa and bulimia nervosa. To help assess for the presence of these conditions , the height and weight of all patients should be used to calculate body mass index (the patient ’s weight [in kilograms ] divided by their height [in meters] squared). Patients with a BMI of less than 20 kg/m2 should be asked about a history of recent weight fluctuations , ongoing dieting efforts , binge eating , and purg- ing or other compensatory behaviors . Women should be asked about amenorrhea.

Mood Disorders Dissatisfaction with one’s body image also can contribute to a mood disorder . The first step in screening for a mood disorder is to identify irregularities in a patient ’s mood , affect , and overall presentation . If these symptoms suggest a potential mood disorder, then neurovegetative symptoms, including sleep, appetite , and concentra- tion should be assessed. If patients admit to having any of these symptoms , or if their behavior suggests that they may have any of these symptoms , they should be asked about the frequency of crying or irritability , social isolation, feelings of hope- lessness, and the presence of suicidal thoughts. An untreated mood disorder may contribute to the motivation for surgery because patients may believe that they will feel better about themselves if they look better . Underlying mood disorders also may contribute to lower levels of satisfaction with the postoperative results . Many of these patients would probably be better served by psychotherapeutic or psychopharmacologic treatment than by cosmetic surgery. In addition to assessing current mental health status, the treating surgeon should obtain a psychiatric history. This information should be routinely obtained as part of a patient ’s general medical history . If this information is typically collected before the consultation , the patient ’s responses should be reviewed during the initial visit . Some patients are reluctant to candidly report their mental health histories , in part out of fear that previous or ongoing treatment will preclude cosmetic surgery. Ap- proximately 20% of patients who undergo cosmetic surgery report ongoing psychi- atric treatment at the time of cosmetic surgery.136 Many of these patients probably received these medications from their primary care physician and not from a psy - chiatrist . Investigations from other surgical populations suggest that primary care professionals often prescribe subtherapeutic dosages of these medications .137 Thus the surgeon should not assume that a low dosage of an antidepressant medication is appropriately controlling depressive symptoms. Patients with a history of psychopathology who are not currently engaged in mental health treatment may warrant a preoperative mental health consultation to further assess their psychological status and appropriateness for surgery . Patients currently in treatment should be asked if their mental health professional is aware

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of their interest in surgery. Surgeons should contact these professionals to confi rm that the proposed treatment is appropriate at this time. Patients who have not men- tioned their interest in cosmetic surgery to their mental health provider , or who re- fuse to allow the surgeon to contact that professional , should be viewed with cau- tion. Such secretiveness was once commonplace ; however , in today’s environment of greater acceptance of cosmetic surgery, it may reflect a degree of paranoid think - ing suggestive of psychopathology . Some patients who are dissatisfied with their postoperative result have used their preoperative psychiatric history as part of their legal action against the surgeon , arguing that their psychiatric condition prevented them from fully understanding the procedure and its potential outcomes . These occurrences underscore the importance of assessing and documenting the psychi - atric status of all patients undergoing cosmetic surgery.

OBSERVING BEHAVIOR

IN THE

OFFICE

A 30- to 45-minute consultation is a relatively brief period of time to assess a patient ’s psychosocial functioning . Patients typically are on their best behavior during their initial consultation with a plastic surgeon and will often expend a great deal of effort to present themselves as “appropriate” for surgery. Therefore every bit of information obtained either during the consultation , or observed during interac- tions with the nursing or office staff, should be used in making a determination of appropriateness for surgery. Nursing staff and office assistants are in unique positions to gather important information about patients; they often witness different aspects of patients’ behavior during interactions outside of the surgeon’s eyesight. Patients who have difficulty fol - lowing the office routine , as well as patients who frequently cancel or change appointments, ask for appointments outside of office hours, or who do not wish to talk to anyone other than the surgeon , should be reconsidered for surgery . These behaviors often suggest the presence of psychopathology that may interfere with the postoperative outcome . Patients who raise concerns among the staff should , at a minimum , be seen for a second preoperative consultation . If concerns persist , these patients should be referred to a psychologist or psychiatrist for a consultation.

MENTAL HEALTH REFERRALS A trusted psychologist or psychiatrist can be a valuable asset to a successful cosmetic surgery practice . Given the relationship between body image dissatisfaction and cosmetic surgery , a mental health professional with interest or expertise in body image may be the ideal consultant . These professionals often work with other forms of psychopathology that have a body image component , such as eating disorders or BDD . They often are affiliated with major medical centers or can be found in large urban areas. Patients may react to mental health referrals with anger , and some may even refuse to accept the referral. These patients are probably not good candidates for treat-

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ment. Unfortunately, in this current competitive environment, many patients will “doctor shop” until they eventually find a physician who will treat them, thereby not receiving the mental health care they need. Hopefully, some patients will hear the concerns of the surgeon they initially consulted and realize that cosmetic treatment is not appropriate at this time. Therefore the surgeon must treat the referral to the psychologist or psychiatrist like any other referral to a medical professional. This practice often helps to destigmatize the mental health professional in the eyes of the patient and makes the referral more acceptable. It is important to communicate to the patient the reason for the consultation. It may be useful to say:“Undergoing a cosmetic medical treatment is an important decision.You are considering making changes to your appearance that are more or less permanent. These treatments often lead to changes in how you feel about your appearance, some of which may be positive, and others may be less positive. I think it is important that we both are 100% sure that this treatment is right for you at this time.Therefore because I care about your well being, I would like you to see a psychologist (psychiatrist) who often works with us to help us decide if this is the right time for surgery.” Such a statement underscores the importance of the consultation to the patient in a nonthreatening manner and hopefully prevents the patient from responding with anger or hostility. Based either on the information gathered during the initial consultation or after the patient has consulted a mental health professional, surgeons may find themselves in the unusual position of wanting to say “No” to patients who have requested treatment. Training in both the medical and mental health professions teaches professionals both directly and indirectly to help everyone who seeks treatment. Nevertheless, there will be patients who ask for the wrong kind of help. Some will ask for cosmetic surgery when a mental health treatment is more appropriate. Others may ask for a treatment outside of the professional’s area of expertise. Still others may simply rub the professional the wrong way, making an appropriate professional relationship difficult. In these cases, the professional should remember that a cosmetic treatment is elective. Patients can elect to have them; professionals can elect to say “no.” If a medical professional decides to say “no” to a proposed treatment, this should be communicated clearly, with sensitivity, and in person. The conversation should be thoroughly documented in the chart and followed by a letter to the patient. Professionals who do not deal with these issues directly and who avoid these patients can put themselves at greater risk for legal action.

CONCLUSION Over the last several decades there has been a great deal of interest in the psychological characteristics of people who seek cosmetic surgery, as well as their psycho - logical responses postoperatively. These clinical reports and empirical studies can be used to shape our understanding of the psychological considerations of a patient

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seeking revision procedures. These patients have received far less attention in the scientific literature. Dissatisfaction with body image is believed to motivate the patient to pursue cosmetic surgery and probably plays an equally important role in revision procedures. Patients who present with excessive dissatisfaction after an initial procedure (performed by either the same or a different surgeon), as well as patients who acknowledge extreme dissatisfaction related to a minimal deformity, may be suffering from BDD. These individuals are unlikely to benefit from additional surgery and may be more appropriately treated by a mental health professional. These patients also may be most likely to threaten or bring legal action against the surgeon, or less frequently, to threaten or commit acts of violence against the surgeon and the office staff. Appropriately assessing patients’ motivations and expectations for surgery, their degree of dissatisfaction with body image, and their current psychiatric status and history, may help identify patients for whom additional surgery is not appropriate.

References —With Key Annotated References 1. American Society of Plastic Surgeons. 2005 National Plastic Surgery Statistics. Arlington Heights, IL: American Society of Plastic Surgeons, 2006. 2. Sarwer DB, Magee L. Physical appearance and society. In Sarwer DB, Pruzinsky T, Cash TF , et al, eds . Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery : Empirical, Clinical, and Ethical Issues. Philadelphia: Lippincott Williams & Wilkins, 2006, pp 23-36. 3. Cash TF. Body image and cosmetic surgery . In Sarwer DB, Pruzinsky T, Cash TF, et al, eds. Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery : Empirical , Clinical, and Ethical Issues. Philadelphia: Lippincott Williams & Wilkins, 2006, pp 37-59. 4. Sarwer DB, Crerand CE. Body image and cosmetic medical treatments. Body Image 1:99 - 111, 2004. 5. Sarwer DB, Magee L, Crerand CE. Cosmetic surgery and cosmetic medical treatments. In Thompson JK, ed. Handbook of Eating Disorders and Obesity. Hoboken, NJ: John Wiley & Sons, 2004, pp 718-737. 6. Etcoff NL. Survival of the Prettiest: The Science of Beauty. New York: Anchor Books, 1999. 7. Crerand CE, Cash TF, Whitaker LA. Cosmetic surgery of the face. In Sarwer DB, Pruzinsky T, Cash TF , et al, eds . Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Empirical, Clinical, and Ethical Issues. Philadelphia: Lippincott Williams & Wilkins , 2006, pp 233-249. This chapter reviews studies of the psychological characteristics of patients who undergo facial procedures, with particular attention to studies of patients who undergo rhinoplasty, antiaging treatments , and facial skeletal procedures.The relationship between facial procedures and both body dysmorphic dis- order and social anxiety disorder are reviewed. 8. Sarwer DB, Didie ER, Gibbons LM. Cosmetic surgery of the body. In Sarwer DB, Pruzinsky T, Cash TF , et al, eds . Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Empirical, Clinical, and Ethical Issues. Philadelphia: Lippincott Williams & Wilkins, 2006, pp 251-266. This chapter reviews the research on the psychological characteristics of patients before and after undergoing cosmetic procedures of the body.The primary focus is on studies of patients who have under - gone cosmetic breast augmentation , although studies of patients who have undergone liposuction and other body-contouring procedures also are discussed.The chapter concludes with a discussion of eat- ing disorders and muscle dysmorphia (thought to be a subtype of BDD), which are believed to be the most common and relevant psychiatric disorders among persons who undergone these procedures.

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9. Hill G, Silver AG. Psychodynamic and esthetic motivations for plastic surgery. Psychosom Med 12:345-352, 1950. 10. Linn L, Goldman IB. Psychiatric observations concerning rhinoplasty. Psychosom Med 11:307-315, 1949. 11. Book HE. Sexual implications of the nose. Compr Psychiatry 12:450-455, 1971. 12. Gifford S. Cosmetic surgery and personality change: A review and some clinical observations. In Goldwyn RM, ed. The Unfavorable Result in Plastic Surgery: Avoidance and Treat - ment. Boston: Little Brown, 1973, pp 11-33. 13. Hay GG. Psychiatric aspects of cosmetic nasal operations. Br J Psychiatry 116:85-97, 1970. 14. Micheli-Pellegrini V, Manfrida GM. Rhinoplasty and its psychological implications: Applied psychology observations in aesthetic surgery. Aesthetic Plast Surg 3:299-319, 1979 . 15. Robin AA, Copas JB, Jack AB, et al. Reshaping the psyche: The concurrent improvement in appearance and mental state after rhinoplasty. Br J Psychiatry 152:539-543, 1988. 16. Wright MR, Wright WK. A psychological study of patients undergoing cosmetic surgery . Arch Otolaryngol 101:145-151, 1975. 17. Hay GG, Heather BB. Changes in psychometric test results following cosmetic nasal opera - tions. Br J Psychiatry 122:89-90, 1973. 18. Marcus P. Psychological aspects of cosmetic rhinoplasty. Br J Plast Surg 37:313-318, 1984. 19. Borges-Dinis P, Dinis M, Gomes A. Psychosocial consequences of nasal aesthetic and func - tional surgery: A controlled prospective study in an ENT setting. Rhinology 36:32-36, 1998. 20. Dziewulski P, Dujon D, Spyriounis P, et al. A retrospective analysis of the results of 218 con- secutive rhinoplasties. Br J Plast Surg 48:451-454, 1995. 21. Ercolani M, Baldaro B, Rossi N, et al. Five-year follow-up of cosmetic rhinoplasty. J Psycho - som Res 47:283-286, 1999. 22. Ercolani M, Baldaro B, Rossi N, et al. Short-term outcome of rhinoplasty for medical or cos - metic indication. J Psychosom Res 47:277-281, 1999. 23. Goin MK, Rees TD. A prospective study of patients’ psychological reactions to rhinoplasty. Ann Plast Surg 27:210-215, 1991. 24. Hern J, Hamann J, Tostevin, P, et al. Assessing psychological morbidity in patients with nasal deformity using the CORE questionnaire. Clin Otolaryngol 27:359-364, 2002. 25. Hern J, Rowe-Jones J, Hinton A. Nasal deformity and interpersonal problems. Clin Oto - laryngol 28:121-124, 2003. 26. Sarwer DB, Whitaker LA, Wadden TA, et al. Body image dissatisfaction in women seeking rhytidectomy or blepharoplasty. Aesthetic Surg J 17:230-234, 1997. 27. Brinton LA, Brown SL, Colton T, et al. Characteristics of a population of women with breast implants compared with women seeking other types of plastic surgery . Plast Reconstr Surg 105:919-927, 2000. 28. Beale S, Lisper H, Palm B. A psychological study of patients seeking augmentation mammaplasty. Br J Psychiatry 136:133-138, 1980. 29. Cook LS, Daling JR,Voigt LF, et al. Characteristics of women with and without breast aug - mentation. JAMA 277:1612-1617, 1997. 30. Fryzek JP, Weiderpass E, Signorello LB, et al. Characteristics of women with cosmetic breast augmentation surgery compared with breast reduction surgery patients and women in the general population of Sweden. Ann Plast Surg 45:349-356, 2000. 31. Kjoller K, Holmich LR, Fryzek JP, et al. Characteristics of women with cosmetic breast implants compared with women with other types of cosmetic surgery and population-based controls in Denmark. Ann Plast Surg 50:6-12, 2003. 32. Schlebusch L, Levin A. A psychological profile of women selected for augmentation mammaplasty. S Afr Med J 64:481-483, 1983. 33. Baker JL, Kolin IS, Bartlett ES. Psychosexual dynamics of patients undergoing mammary augmentation. Plast Reconstr Surg 53:652-659, 1974. 34. Didie ER, Sarwer DB. Factors that influence the decision to undergo cosmetic breast aug - mentation surgery. J Womens Health 12:241-253, 2003.

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35. Sarwer DB, LaRossa D, Bartlett S, et al. Body image concerns of breast augmentation pa - tients. Plast Reconstr Surg 112:83-90, 2003. 36. Sarwer DB, Bartlett SP, Bucky LP, et al. Bigger is not always better: Body image dissatisfaction in breast reduction and breast augmentation patients. Plast Reconstr Surg 101:1956-1961, 1998. 37. Schlebusch L. Negative bodily experience and prevalence of depression in patients who request augmentation mammaplasty. S Afr Med J 75:323-326, 1989. 38. Shipley RH, O’Donnell JM, Bader KF. Personality characteristics of women seeking breast augmentation. Comparison to small-busted and average-busted controls. Plast Reconstr Surg 60:369-376, 1977. 39. Sarwer DB, Nordmann JE, Herbert JD. Cosmetic breast augmentation surgery: A critical overview. J Womens Health 9:843-856, 2000. 40. Edgerton MT, Meyer E, Jacobson WE. Augmentation mammaplasty. II. Further surgical and psychiatric evaluation. Plast Reconstr Surg 27:279-302, 1961. 41. Napoleon A. The presentation of personalities in plastic surgery. Ann Plast Surg 31:193-208, 1993. 42. Ohlsen L, Ponten B, Hambert G. Augmentation mammaplasty: A surgical and psychiatric evaluation of the results. Ann Plast Surg 2:42-52, 1978. 43. Sihm F, Jagd M, Pers M. Psychological assessment before and after augmentation mamma - plasty. Scand J Plast Surg 12:295-298, 1978. 44. Cash TF, Duel LA, Perkins LL. Women’s psychosocial outcomes of breast augmentation with silicone gel-filled implants: A 2-year prospective study. Plast Reconstr Surg 109:21122121, 2002. 45. Cunningham BL, Lokeh A, Gutowski KA. Saline-filled breast implant safety and efficacy: A multicenter retrospective review. Plast Reconstr Surg 105:2143-2149, 2000. 46. Fryzek JP, Signorello LB, Hakelius L, et al. Local complications and subsequent symptom re - porting among women with cosmetic breast implants. Plast Reconstr Surg 107:214221, 2001. 47. Fryzek JP, Signorello LB, Hakelius L, et al. Self-reported symptoms among cosmetic breast implant and breast reduction surgery. Plast Reconstr Surg 107:206-213, 2001. 48. Gabriel SE, Woods JE, O’Fallon WM, et al. Complications leading to surgery after breast im - plantation. N Engl J Med 336:677-682, 1997. 49. Handel N, Wellisch D, Silverstein MJ, et al. Knowledge, concern and satisfaction among aug - mentation mammaplasty patients. Ann Plast Surg 30:13-22, 1993. 50. Holmich LR, Kjoller K, Fryzek JP, et al. Self-reported diseases and symptoms by rupture status among unselected Danish women with cosmetic silicone breast implants. Plast Reconstr Surg 111:723-732, 2003. 51. Jensen B, Wittrup IH, Friss S, et al. Self-reported symptoms among Danish women follow - ing cosmetic breast implant surgery. Clin Rheumatol 21:35-42, 2002. 52. Kjoller K, Holmich LR, Jacobsen PH, et al. Epidemiological investigation of local complications after cosmetic breast implant surgery in Denmark. Ann Plast Surg 48:229-237, 2002. 53. Fiala TG, Lee WPA, May JW. Augmentation mammoplasty: Results of a patient survey. Ann Plast Surg 30:503-509, 1993. 54. Brinton LA, Lubin JH, Burich MC, et al. Mortality among augmentation mammoplasty pa - tients. Epidemiology 12:321-326, 2001. 55. Brinton LA, Lubin JH, Murray MC, et al. Mortality rates among augmentation mammaplasty patients: An update. Epidemiology 17:162-169, 2006. 56. Jacobsen PH, Holmich LR, McLaughlin JK, et al. Mortality and suicide among Danish women with cosmetic breast implants. Arch Intern Med 164:2450-2455, 2004. 57. Koot VC, Peeters PH, Granath F, et al. Total and cause specific mortality among Swedish women with cosmetic breast implants: A prospective study. BMJ 326:527-528, 2003. 58. Pukkala E, Kulmala I, Hovi SL, et al. Causes of death among Finnish women with cosmetic breast implants, 1971-2001. Ann Plast Surg 51:339-342; discussion 343-344, 2003.

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59. McLaughlin JK, Lipworth L, Tarone RE. Suicide among women with cosmetic breast implants: A review of the epidemiologic evidence. J Long Term Eff Med Implants 13:445-450 , 2003. 60. Sarwer DB. Discussion of Pukkala E, Kulmala I, Hovi SL, et al. Causes of death among Finnish women with cosmetic breast implants, 1971-2001. Ann Plast Surg 51:343344, 2003. 61. Joiner TE. Does breast augmentation confer risk of or protection from suicide? Aesthetic Surg J 23:370-375, 2003. 62. Dillerud E, Haheim LL. Long-term results of blunt suction lipectomy assessed by a patient questionnaire survey. Plast Reconstr Surg 92:35-42, 1993. 63. Rohrich RJ, Broughton G, Horton B, et al. The key to long-term success in liposuction: A guide for plastic surgeons and patients. Plast Reconst Surg 114:1945-1952, 2004. 64. Bolton MA , Pruzinsky T, Cash TF, et al. Measuring outcomes in plastic surgery : Body image and quality of life in abdominoplasty patients. Plast Reconstr Surg 112:619-625, 2003. 65. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA 294:1909-1917, 2005. 66. Sarwer DB, Thompson JK, Cash TF. Body image and obesity in adulthood. Psychiatr Clin North Am 28:69-87, 2005. 67. Rohrich RJ, Kenkel JM. Body contouring after massive weight loss supplement. Plast Recon - str Surg 117(Suppl):S1-S86, 2006. 68. Goin MK, Burgoyne RW, Goin JM, et al. A prospective psychological study of 50 female face-lift patients. Plast Reconstr Surg 65:436-442, 1980. 69. Webb WL Jr, Slaughter R, Meyer E, et al. Mechanisms of psychosocial adjustment in pa - tients seeking “face-lift” operation. Psychosom Med 27:183-192, 1965. 70. Sarwer DB, Wadden TA, Pertschuk MJ, et al. Body image dissatisfaction and body dysmor - phic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg 101:1644-1649, 1998. 71. Sarwer DB, Wadden TA, Whitaker LA. An investigation of changes in body image following cosmetic surgery. Plast Reconstr Surg 109:363-369, 2002. 72. Sommer B, Zschocke I, Bergfeld D, et al. Satisfaction of patients after treatment with botu - linum toxin for dynamic facial lines. Dermatol Surg 29:456-460, 2003. 73. Koch RJ, Newman JP, Safer DL. Psychological predictors of patient satisfaction with laser skin resurfacing. Arch Facial Plast Surg 5:445-446, 2003. 74. Fried RG, Cash TF. Cutaneous and psychosocial benefits of alpha hydroxyl acid use. Percept Mot Skills 86:137-138, 1998. 75. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders , 4th ed text rev. Washington, DC: APA Press, 2000. 76. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders , 3rd ed rev. Washington, DC: APA Press, 1987. 77. Cotterill JA. Dermatological non-disease: A common and potentially fatal disturbance of cu - taneous body image. Br J Dermatol 104:611-619, 1981. 78. Edgerton MT, Jacobson WE, Meyer E. Surgical-psychiatric study of patients seeking plastic (cosmetic ) surgery : Ninety -eight consecutive patients with minimal deformity . Br J Plast Surg 13:136-145, 1960. 79. Knorr NJ, Edgerton MT, Hoopes JE. The “insatiable” cosmetic surgery patient. Plast Recon - str Surg 40:285-289, 1967. 80. Faravelli C, Salvatori S, Galassi F, et al. Epidemiology of somatoform disorders: A community survey in Florence. Soc Psychiatry Psychiatr Epidemiol 32:24-29, 1997. 81. Otto MW, Wilhelm S, Cohen LS, et al. Prevalence of body dysmorphic disorder in a com - munity sample of women. Am J Psychiatry 158:2061-2063, 2001. 82. Bohne A, Keuthen NJ, Wilhelm S, et al. Prevalence of symptoms of body dysmorphic disor - der and its correlates: A cross-cultural comparison. Psychosomatics 43:486-490, 2002. 83. Bohne A, Wilhelm S, Keuthen NJ, et al. Prevalence of body dysmorphic disorder in a Ger - man college student sample. Psychiatry Res 109:101-104, 2002.

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84. Cansever A, Uzun O, Donmez E, et al. The prevalence and clinical features of body dysmor - phic disorder in college students: A study in a Turkish sample. Compr Psychiatry 44:6064, 2003. 85. Sarwer DB, Cash TF, Magee L, et al. Female college students and cosmetic surgery: An inves - tigation of experiences, attitudes, and body image. Plast Reconstr Surg 115:931-938, 2005 . 86. Phillips KA, Dufresne RG, Wilkel C, et al. Rate of body dysmorphic disorder in dermatol - ogy patients. J Am Acad Dermatol 42:436-441, 2000. 87. Dufresne RG, Phillips KA,Vittorio CC, et al. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 27:457-462, 2001. 88. Uzun O, Basoglu C, Akar A, et al. Body dysmorphic disorder in patients with acne. Compr Psychiatry 44:415-419, 2003. 89. Crerand CE, Sarwer DB, Magee L, et al. Rate of body dysmorphic disorder among patients seeking facial cosmetic procedures. Psychiatr Ann 34:958-965, 2004. 90. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery . Plast Reconstr Surg (in press). This article reviews the history of the diagnosis of BDD and the current diagnostic criteria. Etiologic theories, demographic and clinical characteristics, and common psychiatric comorbidities are discussed . Studies on the prevalence of BDD in cosmetic surgery populations are highlighted , and the medical, psychiatric and psychotherapeutic treatments are reviewed. 91. Perugi G, Akiskal HS, Giannotti D, et al. Gender-related differences in body dysmorphic dis - order (dysmorphophobia). J Nerv Ment Dis 185:578-582, 1997. 92. Phillips KA, Diaz S. Gender differences in body dysmorphic disorder. J Nerv Ment Dis 185:570-577, 1997. 93. Phillips KA, Grant JE, Siniscalchi J, et al. Surgical and nonpsychiatric medical treatment of pa - tients with body dysmorphic disorder. Psychosomatics 42:504-510, 2001. 94. Phillips KA, McElroy SL, Keck PE, et al. Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 150:302-308, 1993. 95. Phillips KA, McElroy SL. Insight, overvalued ideation, and delusional thinking in body dysmorphic disorder: Theoretical and treatment implications. J Nerv Ment Dis 181:699-702, 1993. 96. Phillips KA, McElroy SL, Keck PE, et al. A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharmacol Bull 30:179-186, 1994. 97. Koblenzer CS. Psychodermatology of women. Clin Dermatol 15:127-141, 1997. 98. Phillips KA. The Broken Mirror. New York: Oxford University Press, 1996. 99. Phillips KA, Castle DJ. Body dysmorphic disorder. In Castle DJ, Phillips KA, eds. Disorders of Body Image. Hampshire, England: Wrighton Biomedical Publishing, 2002, pp 101-120. 100. Phillips KA, Taub SL. Skin picking as a symptom of body dysmorphic disorder. Psychophar - macol Bull 31:279-288, 1995. 101. Rosen JC, Reiter J, Orosan P. Cognitive-behavioral body image therapy for body dysmorphic disorder. J Consult Clin Psychol 63:263-269, 1995. 102. Phillips KA. Quality of life for patients with body dysmorphic disorder. J Nerv Ment Dis 188:170-175, 2000. 103. Veale D. Outcome of cosmetic surgery and ‘DIY’’ surgery in patients with body dysmorphic disorder. Psychiatr Bull R 24:218-220, 2000. 104. Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder: A survey of fifty cases. Br J Psychiatry 169:196-201, 1996. 105. Crerand CE, Phillips KA, Menard W, et al. Nonpsychiatric medical treatment of body dys - morphic disorder. Psychosomatics 46:549-555, 2005. This study describes the frequency, types, and outcomes of nonpsychiatric treatments sought and re - ceived by individuals with BDD. Such treatment rarely improved body dysmorphic disorder . Thus nonpsychiatric medical treatments do not appear effective in its treatment. 106. Leonardo J. New York’s highest court dismisses BDD case. Plastic Surgery News, July 2001 , pp 1-9.

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107. Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: Results of a survey of American Society for Aesthetic Plastic Surgery members. Aesthetic Surg J 22:531-535, 2002. 108. Yazel L. The serial-surgery murder. Glamour, May, 1999, pp 108-114. 109. Sarwer DB. Psychological considerations in cosmetic surgery. In Goldwyn RM, Cohen NM, eds. The Unfavorable Result in Plastic Surgery. Philadelphia: Lippincott Williams & Wilkins , 2001, pp 14-23. 110. Sarwer DB, Didie ER. Body image in cosmetic surgical and dermatological practice. In Castle DJ, Phillips KA, eds. Disorders of Body Image. Petersfield, UK: Wrightson Biomedical Publishing, 2002, pp 37-53. 111. Sarwer DB, Pertschuk MJ. Cosmetic surgery. In Kornstein SG, Clayton AH, eds. Textbook of Women’s Mental Health. New York: Guilford Publications, 2002, pp 481-496. 112. Hollander E, Allen A, Kwon J, et al. Clomipramine vs desipramine crossover trial in body dys - morphic disorder. Arch Gen Psychiatry 56:1033-1039, 1999. 113. Hollander E, Liebowitz M, Winchel R, et al. Treatment of body-dysmorphic disorder with serotonin reuptake blockers. Am J Psychiatry 146:768-770, 1989. 114. Looper KJ, Kirmayer LJ. Behavioral medicine approaches to somatoform disorders. J Consult Clin Psychol 70:810-827, 2002. 115. Neziroglu FA, Yaryura-Tobias JA. Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic disorder. Behav Ther 24:431-438, 1993. 116. Perugi G, Giannotti D, Di Vaio S, et al. Fluvoxamine in the treatment of the body dysmor - phic disorder (dysmorphophobia). Int Clin Psychopharmacol 11:247-254, 1996. 117. Phillips KA. Body dysmorphic disorder: Clinical aspects and treatment strategies. Bull Menninger Clin 62 4(Suppl 1):A33-A48, 1998. 118. Phillips KA, Dwight MM, McElroy SL. Efficacy and safety of fluvoxamine in body dysmorphic disorder. J Clin Psychiatry 59:165-171, 1998. 119. Phillips KA, Albertini RS, Siniscalchi JM, et al. Effectiveness of pharmacotherapy for body dysmorphic disorder: A chart review study. J Clin Psychiatry 62:721-727, 2001. 120. Phillips KA, Albertini RS, Rasmussen SA. A randomized placebo-controlled trial of fluoxe - tine in body dysmorphic disorder. Arch Gen Psychiatry 59:381-388, 2002. 121. Phillips KA, Najjar F. An open-label study of citalopram in body dysmorphic disorder. J Clin Psychiatry 64:715-720, 2003. 122. Sarwer DB, Gibbons LM, Crerand CE. Treating body dysmorphic disorder with cognitive - behavior therapy. Psychiatr Ann 34:934-941, 2004. 123. Veale D, Gournay K, Dryden W, et al. Body dysmorphic disorder: A cognitive behavioural model and pilot randomised controlled trial. Behav Res Ther 34:717-729, 1996. 124. Wilhelm S, Otto MW, Lohr B, et al. Cognitive behavior group therapy for body dysmorphic disorder: A case series. Behav Res Ther 37:71-75, 1999. 125. Sarwer DB. Psychological assessment of cosmetic surgery patients. In Sarwer DB, Pruzinsky T, Cash TF , et al, eds . Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Empirical, Clinical, and Ethical issues. Philadelphia: Lippincott Williams & Wilkins , 2006, pp 267-283. This chapter discusses the psychological assessment of cosmetic surgery patients from two different perspectives . It begins by discussing the psychological evaluation of these individuals as conducted by the plastic surgeon, with the goal of determining when a preoperative or postoperative referral to a men - tal health professional is appropriate .The second half of the chapter discusses the psychological eval- uation of cosmetic surgery patients as conducted by a mental health professional. 126. Sarwer DB, Pruzinsky T, Cash TF, et al. Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery : Empirical , Clinical , and Ethical Issues . Philadelphia : Lippincott Williams & Wilkins, 2006. 127. Edgerton MT, Knorr NJ. Motivational patterns of patients seeking cosmetic (aesthetic) sur - gery. Plast Reconstr Surg 48:551-557, 1971. 128. Goin JM, Goin MK. Changing the Body: Psychological Effects of Plastic Surgery. Baltimore : Williams & Wilkins, 1981.

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129. Grossbart TA, Sarwer DB. Cosmetic surgery: Surgical tools—psychosocial goals. Semin Cutan Med Surg 18:101-111, 1999. 130. Myer E, Jacobson WE, Edgerton MT, et al. Motivational patterns in patients seeking elective plastic surgery. Psychol Med 22:193-202, 1960. 131. Pruzinsky T. Cosmetic plastic surgery and body image: Critical factors in patient assessment. In Thompson JK, ed. Body Image, Eating Disorders, and Obesity. Washington, DC: American Psychological Association, 1996, pp 109-127. 132. Honigman R, Phillips KA, Castle DJ. A review of psychological outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg 113:1229-1237, 2004. 133. Beale S, Lisper H, Palm B. A psychological study of patients seeking augmentation mammaplasty. Br J Psychol 136:133-138, 1980. 134. Dunofsky M. Psychological characteristics of women who undergo single and multiple cosmetic surgeries. Ann Plast Surg 39:223-228, 1997. 135. Banbury J,Yetman R, Lucas A, et al. Prospective analysis of the outcome of subpectoral breast augmentation: Sensory changes, muscle function, and body image. Plast Reconstr Surg 113:701-707, 2004. 136. Sarwer DB, Zanville HA, LaRossa D, et al. Mental health histories and psychiatric medication usage among persons who sought cosmetic surgery. Plast Reconstr Surg 114:1927-1933, 2004. 137. Sarwer DB, Cohn NI, Gibbons LM, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg 14:1148-1156, 2004.

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REVIEW QUESTIONS 1. Breast augmentation patients, compared with other women, report ______: a. A greater number of previous marriages b. A greater number of terminated pregnancies c. Greater use of alcohol and tobacco d. All of the above 2. According to epidemiologic studies, the rate of suicide among women with breast implants is ______ compared with women in the general population. a. Two to three times greater b. Two to three times less c. Four to five times greater d. No different 3. The rate of body dysmorphic disorder in the general population is thought to be: a. 1% to 2% b. 3% to 4% c. 5% to 6% d. 7% to 8% 4. The best estimates of the rate of body dysmorphic disorder among persons who seek cosmetic surgery or dermatologic treatment is: a. 0% to 10% b. 5% to 15% c. 10% to 20% d. 15% to 25% 5. According to two studies, approximately ______ of persons with BDD report no change or a worsening of their symptoms after a nonpsychiatric treatment. a. 60% b. 70% c. 80% d. 90% 6. During the initial consultation, which of the following areas of psychosocial functioning should be assessed? a. Motivations and expectations b. Body image dissatisfaction c. Psychiatric status and history d. All of the above

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7. During the initial consultation, a patient starts crying when talking about her dissatisfaction with the results of her face-lift procedure performed by a different surgeon 9 months ago. She reports that she is currently taking an antidepressant, 20 mg/day, as prescribed by her primary care physician. The current surgeon should: a. Go ahead and schedule her for surgery, since she is taking an antidepressant. b. Contact the primary care physician to further assess the patient’s depressive symptoms c. Inquire about current or past psychotherapy. d. Not schedule her for surgery. 8. During the initial consultation, a patient reports significant dissatisfaction with a previous rhinoplasty procedure. She reports that she is now “disfigured” and cannot date because of her nose. In the surgeon’s opinion, the initial result is very good, although some slight revisions could be made. The patient denies any current or past psychiatric treatment. The current surgeon should: a. Go ahead and schedule her for surgery, since it is only a slight revision b. Contact the primary care physician to further assess the patient’s functioning c. Consider a psychiatric evaluation before scheduling surgery d. Not schedule her for surgery

Chapter 4 The Surgeon Robert M. Goldwyn

Mistakes, no less benefits, witness to the existence of the art; for what benefited did so because correctly administered. Now where correctness and incorrectness each have a defined limit, surely there must be an art. For absence of art I take to be absence of correctness and incorrectness; but where both are present, art cannot be absent. Hippocrates

F

ew events are as demanding on the surgeon and the patient as when another operation is necessary because something went wrong. The surgeon who is reop- erating or considering doing so will be treating his or her patient, or someone else’s, with differing circumstances and consequences.1-3

WHEN THE PATIENT IS YOUR OWN IF, W HEN, AND HOW TO REOPERATE: E STABLISHING THE PROBLEM In most instances, the problem is evident to both the patient and the surgeon as, for example, with an expanding hematoma, or a fluctuant, infected wound. These in - escapable realities require immediate , unequivocal attention and action . However , with a slightly asymmetrical nipple after breast reduction or a persistent unilateral fullness following rhytidectomy, the patient may be quicker to recognize the prob- lem than the surgeon is. It is axiomatic that anything that concerns the patient should concern the surgeon, who should not deceptively minimize its existence or cavalierly dismiss it. 77

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Not every patient in whom something has gone wrong should have another operation. Not doing anything further is frequently the best treatment, but the decision is harder when the patient is our own, because we may be less objective. If the decision is made not to operate, the patient may believe that the surgeon’s unwillingness is a way of minimizing his or her dissatisfaction and think the surgeon is trying to dodge the problem. In that situation, the surgeon must carefully and unhurriedly explain the benefits of waiting. If the patient does not accept the advice or mistrusts the surgeon’s motives after a thorough discussion, the surgeon would be wise to refer that patient for another opinion. A referral serves not only to obtain advice but also to gain time, avoiding a rush into an ill-advised procedure because of the patient’s anxiety and the desire of the patient and surgeon to rectify the problem quickly. Patients are seldom patient—and surgeons are frequently impatient. If the patient has been told to wait, you must provide structure and not leave that person suspended with ambiguous responses. Saying “We’ll see how it does” carries no reassurance and spawns anxiety. A better alternative would be something like the following: “Your incision has opened, as you already know. It looks as if it is infected, and I will give you antibiotics for 10 days. Every day you should change your dressing at least twice; I will show you how to do it. But I want to see you at least three times a week, and certainly as often as necessary and you desire. I know that with time everything will get better [if true].We’ll see this through together.”That statement lets the patient know that you are not abandoning him or her, that you care, that you also are concerned about the problem. By assuring the patient that you are committed, you have lessened anxiety and increased confidence. A few of my patients who needed additional surgery because of a complication later became my most devoted and enthusiastic patients. Adversity, if managed properly, can be a uniting experience. The worst mistakes a surgeon can make with a patient who has had a complication or an unfavorable result are to trivialize or deny its existence, to become angry at the patient, to be unavailable or shunt the patient to an assistant—a nurse, a secretary, or a resident.1 The primary responsibility belongs to the surgeon who did the operation, with whom the patient has had an implicit if not explicit contract. In the words of President Truman,“The buck stops here.” In this regard, I remember a patient describing her surgeon:“He was always there to get the money, and before the operation his office treated me like royalty. But when I had this happen (separation of the wound after reduction mammaplasty), he was never around. Even the FBI would have had trouble finding him.”

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To emphasize to patients that I am available , I ask them to call me at my office or at home (I give them my number , even though it is listed in the telephone book) whenever they wish. It is surprising how few phone calls I receive. Just the realiza- tion that the surgeon truly cares and is ready to help may be sufficient for the pa- tient if this is combined with frequent, scheduled visits to the office. With a patient who is either dissatisfied with the result and/or requires reoperation , the surgeon should be empathetic . He or she should be willing to say, “I am sorry this happened. I too am frustrated and distressed, but I know that both of us to- gether can bring this to a successful conclusion [if true].” This openness comforts the patient, who realizes you share his or her discomfort, but at the same time that you are in charge , and con fident and competent to solve the problem.

GATHERING SUPPORT After having admitted the existence of the problem and after having outlined a plan , the surgeon must marshal support among those close to the patient : members of the family, perhaps a friend, and definitely the referring physician and/or the family physician. You and the patient need every ally possible. It is not easy to call the physician who has referred the patient and report an unfortunate outcome , but it must be done as quickly as possible before the physician has heard it from the angry patient or an irate family member.

USING A CONSULTANT The proper use of a consultant requires tact and skill. Most patients want to remain with the original physician, but it can comfort the patient as well as the surgeon to have another opinion when warranted. If you are attuned to sense when the patient wishes a consultation, do not make the patient jump through hurdles to obtain one. At the same time, however, the patient should not feel discarded but di - rected to the other physician . I usually dictate a letter in the patient’s presence de- scribing the problem and asking the other physician for advice, which, I state, should be discussed freely with the patient . An occasional patient may declare that he or she does not want to pay for “your mistake .” You must address that statement and try to explain that you did your best , but no physician , no surgeon can control every aspect of treatment . That is why informed consent exists, and it serves as a gentle reminder to the patient that he or she understood that com- plications could occur and that this was so stated in the informed consent. Ideally , a surgeon will see an aggrieved patient for a colleague at no charge to help the unhappy individual and the hard -pressed physician . If you believe , however, that the patient should not be charged for the consultation and that the physician to whom you have referred the patient will likely not forgo a fee, you should in-

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form the patient and the surgeon that you would be willing to pay for the consultation. This does not signify culpability per se; it acknowledges the reality of your having an unhappy patient.Your volunteering to defray the consultation fee shows your empathy, especially with a patient who is financially stressed. As mentioned, if the patient does not want to see a consultant of your choice, make it clear to the pa- tient that he or she is certainly free to select a physician and that you would be happy to forward records and confer with the other surgeon , but only with the pa- tient’s signed permission.

REOPERATING

ON YOUR

OWN PATIENT

When you must perform another procedure because the original operation did not accomplish its goal, the patient is likely to be disappointed , even hostile , but has sufficient confidence in you to let you try again. If you conclude that correcting the problem requires not just your efforts but those of another surgeon , you should not hesitate to inform the patient and urge him or her to see the other surgeon.You both should make the arrangements, with the patient’s knowledge, to combine sur- gical efforts, if required. The following story illustrates how not to behave. A colleague once called me to help with a secondary procedure on his patient. I agreed, but then refused when he said , “She ’ll never know you ’re there , because she’ll be asleep .” I did not want to participate in something that was unfair and unethical . Fortunately , the other plas - tic surgeon reversed field , sent the patient to me , and with full disclosure we both operated on her successfully (a redo reduction mammaplasty). The surgeon who reoperates on a patient already has one strike against him or her . Another strike and the surgeon may be out , since it is a rare patient and a persis- tent surgeon who would make a third attempt, at least on his or her own. In this situation, it is not a question of courage but of common sense. I am not al - luding to a staged procedure about which the patient should have been informed initially as with a difficult breast reconstruction . I am not referring to minor revi- sions. Much different, for example, is the male rhinoplasty patient on whom you have already tried to rectify the problem twice. He should probably not have you as a surgeon a third, or worse, a fourth or fifth time. Better for each of you that another surgeon enter the scene.

LISTEN TO THE PATIENT This instruction is so elemental that it is often neglected. The following case is apt: Ms. B. came because of pain behind her right ear after having had a face lift 3 years previously . When I had last seen her , 1 ⁄ 1 2 years earlier , she had no complaints about her result, which we both thought was completely satisfactory. In taking her history

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on this occasion, I elicited the fact that the pain behind her ear began when her lover , a married man, was diagnosed and hospitalized because of colon cancer . Not surprisingly , as his treatment progressed and he became better , her pain disappeared . Throughout those months , I did see her periodically , more for her psyche than her scar, which was minimal and without evidence of a neuroma.

WHEN PSYCHOTHERAPY IS NEEDED Some patients may complain about a problem that neither you nor an objective observer can detect , as in the patient just cited . However , unlike that patient , some may become extremely depressed, hostile, and threaten to sue if you do not “do some- thing.” With this level of anxiety and acrimony, and even if the problem would eventually benefit by an operation, the help of a therapist, psychologist, or psychi- atrist may be necessary. The challenge is then how to get that patient to go for a consultation. Sometimes the patient adamantly refuses. If so, speaking with the fam - ily or the patient ’s physician to get their help is successful . It is often effective to tell the patient that you know he or she is intelligent enough to realize that medicine and surgery have made many advances and that one would be foolish to ignore anything that could improve the patient’s well-being. For example, you can say that if she or he were having a heart problem during the course of treatment with you, you would need the help of a cardiologist and you know he or she would willingly go. Now you believe that a psychologist or psychiatrist could be beneficial, at least for a consultation . It does not mean that you should tell the patient that years of psychotherapy will be necessary , but certainly a consultation is in order and perhaps some help for a few weeks to “get over the hump .” You can add, if it is true, that you have had other patients who have been helped immeasurably and rather quickly by a psychotherapist.You know one or two therapists with whom you have worked [if true] and with whom you can arrange a consultation . At the same time, you must tell the patient that you still consider yourself his or her plastic surgeon and will want to see him or her regularly until “things get better.” Again, it is impossible to overemphasize that no patient, indeed no human being, wants to feel abandoned, and certainly not after a failed operation by the surgeon he or she has chosen and whom that person still considers to be his or her physician. The plastic surgeon would do well to remember that unlike a family physician, he or she has likely been consulted only once or twice and has had limited interaction with the patient. In an urban area, the paths of the patient and the surgeon may cross only in the office, operating room, or hospital. This relationship is very differ - ent from that between the patient and his or her family physician , whose interac- tion has been longer and deeper. The usual reasons that bring adults to consult a plastic surgeon result in short-term contact and brief treatment, unlike what transpires between patients and their internist. When something goes wrong between a patient and a plastic surgeon, the basis on which to continue what could be a strained relationship is less solid—all the more reason for the surgeon to make himself or herself easily accessible. A tele -

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phone call to the patient at home, for example, in between scheduled visits and not in response to the patient’s call, can do much to ameliorate a difficult situa - tion.

FINANCIAL ASPECTS If the failed operation and the condition that prompted it were of a reconstructive nature, insurance will generally cover the cost of reoperating , including the cost of the hospital stay. An astute and understanding surgeon will not charge the patient more than what the insurance pays. Aside from the question of the surgeon’s fee, the patient with an unsuccessful out - come from an aesthetic operation might have to confront additional hospital costs unless the surgeon has his or her own operating facility and does not charge for its use. I never billed a patient for a revision, but since I operated in a hospital, the patient had to pay those associated costs. Every patient undergoing aesthetic surgery signed a form saying that he or she would be financially responsible for the hospital charges relating to the “improvement” of a result. However, the act of signing the form does not mean that the patient acquiesces calmly to these additional charges. Usually patients resent them , because they believe that the surgeon “should have done it right the first time.” The surgeon is then in the uncomfortable situation of fear- ing that the patient will sue, particularly if reoperation fails. On a few occasions I asked the hospital to reduce or write off the charges, and once, at the patient’s re- quest, I paid those costs when I was convinced that the patient would not sue. Be- fore doing that , it is well to obtain advice from the malpractice insurance carrier and an attorney to avoid the possible allegation that your willingness to pay those expenses was an admission of negligence. The problem of finances becomes more difficult when the patient is another surgeon’s.

WHEN THE PATIENT IS SOMEONE ELSE’S One would hope that the surgeon seeing a colleague ’s patient with a problem would not use the situation to denigrate the other surgeon or to plump his or her own ego. Because all of us who operate are destined to have some failures, rejoic- ing openly or secretly in a colleague’s poor result is puerile and myopic. At the time that this patient is in your office, one of yours may be in his or hers.

IF AND WHEN TO OPERATE As with a patient of your own, the medical-surgical problem should determine the decision of whether to operate . The alternative of not operating may be the best treatment. You should not unconsciously undertake an operation to bolster your

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stature or placate an overwrought patient. The fact that we can operate does not mean that we should.

THE REOPERATING SURGEON AND THE ORIGINAL SURGEON The surgeon who may be reoperating on another plastic surgeon’s patient should focus on the problem without directly or indirectly attacking the original surgeon by an explicit statement or innuendo or by body language such as a raised eyebrow, a sigh, or an “oh, my” shake of the head. When you are not the original surgeon, you should act as does a good relief pitcher in baseball called to do a difficult task; he does not chastise the other pitcher for having loaded the bases. Unfortunately, some plastic surgeons take pleasure in verbally assassinating a col - league. The patient should not be the victim of a personal vendetta. A patient once related that a surgeon whom she had seen in consultation said to her,“I never knew he performed this kind of operation.” It was a rhinoplasty, a sta - ple in his practice and in that of most plastic surgeons . Other wounding remarks that patients have shared with me are: “He is getting too old to operate, I would think ,” or “He just opened his practice . I know eventually he will be excellent , but now he ’s just learning the ropes .” Another gem was : “He ’s a wonderful guy, but in the operating room, he can really be unpredictable.” Those comments make patients feel stupid and exploited, believing that they went to the wrong surgeon. Plastic surgery demands enough of our energy without wasting it in slander. As you obtain the patient’s history, remember that you are hearing the patient’ s version, not the surgeon’s. The two might differ markedly. It is to be hoped that the patient will allow you to communicate with the other surgeon ; if not, you should tell the patient that it is in his or her best interests for you to have as much infor- mation as possible. If a patient still refuses, you must decide whether to terminate the relationship or continue it. Since our primary commitment is to the patient, it is difficult, occasionally impossible, or wrong to refuse to be the patient’s next surgeon. For the patient’ s well-being and perhaps for the other surgeon’s professional well-being, treating the patient may be advisable , even though the patient has restricted your communication . At no time should the second surgeon write or speak with the original surgeon , even if a close friend, unless the patient has given permission . One has no legal or ethical right to breach con fidentiality without speci fic consent. Aside from the le- gal implications, you lose credibility and effectiveness if the patient discovers that communication has occurred without his or her knowledge.

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Although the ideal may be to convince the patient to return to this original surgeon , who may have referred the patient to you , I do not believe it is wise medically or correct ethically to force a patient to return to a physician whom he or she no longer trusts or likes , even though the patient ’s reasons might be unjust and un- founded. Furthermore, you might be the logical person to correct the problem. If the patient does allow communication with the original surgeon, the patient may be suspicious about what you will say. To allay doubt , you can telephone the other physician in the patient ’s presence . To obtain a thorough report and a thoughtful opinion from the other physician and to have documentation for the record, I prefer a letter or email, with a copy to the patient. This open approach does much to reduce the patient’s suspicions, anxiety, and hostility and makes your task easier.

Patient Example A 20-year-old student had a reduction mammaplasty in another state a month before she consulted me. Some of her wounds had dehisced. Every time I saw the pa - tient , I not only dictated a report to her surgeon but on several occasions also called him so that they could speak to each other. She healed without difficulty and told me that as much as she liked me, she wanted to have her breasts “made better” by her first surgeon. Thus an ideal outcome was reached for all concerned. She had no insurance for her visits, and I did not charge her.

FINANCIAL ASPECTS As mentioned , the financial aspects of reoperating on another surgeon ’s patient can be extremely trying . If the original procedure was reconstructive , in most instances , the patient would fortunately be covered by insurance for hospital charges and, hopefully , for the surgeon ’s bill. Again , if the procedure had been aesthetic , the pa - tient will have had to pay the entire cost . If you are the reoperating surgeon , you can theoretically charge whatever you wish , but I would hope that colleagues would be kind to each other and the patient by charging fairly or not at all if, for example, only a minor revision were needed. It is not unusual for a patient to tell you, the reoperating surgeon, that the original surgeon should pay for your charges or the hospital’s. “After all,” they may say, “ I went to him (or her) and he (she) messed up. Now I have to have another opera- tion, and why should I pay for it?” The patient incorrectly views a surgical opera - tion as a commodity , an item to be purchased , repaired , or replaced if necessary. The patient considers his relationship with the surgeon like that of a consumer. No matter how eloquently you, the second surgeon, may dispute that viewpoint, the patient may remain unconvinced and angry.

Chapter 4 The Surgeon

On occasion I have called the first surgeon and said that I would reduce my fee considerably and that it might be advisable for him or her to speak with the patient to come to some agreement, perhaps even returning the patient’s money or a portion of it but this would be entirely between the surgeon and the patient, depending on the legal advice the other surgeon receives. The decision about charging for reoperation can be tempered by a collegial and humanitarian view of medicine and plastic surgery, an attitude not always possible to maintain in today’s turbulent environment. However, if the surgeon considers the medical world a jungle or a marketplace and feels a high level of entitlement, the patient as well as the first surgeon will likely not receive compassion. It is possible, furthermore, that reoperation also will fail; the patient then will hold both surgeons accountable, not only medically but fiscally and legally.

THE PROBLEM SURGEON The “problem surgeon” is not, as one might think, a surgeon who manages problems, but a surgeon who creates them. Unfortunately, a few physicians, among them plastic surgeons, fail to learn from mistakes; they are incapable of introspection. They may undertake a procedure for which they are ill trained. For reasons of money or ego they may subject a patient to an operation that he or she should not have had and the surgeon should never have attempted. All surgeons should keep a list of their complications and attempt to detect a possible pattern.4 If you do this, you have the choice of improving your performance by attending courses or consulting colleagues, or visiting them in their operating room. If you are unwilling or incapable of doing better, for whatever reason, you should drop that procedure from your repertoire. I have yet to meet a surgeon, plastic or otherwise, who does all things equally well. Every surgeon should have enough self-awareness to know whether he or she is in good physical and mental health. A surgeon who is continually overstressed would do well to consult an internist or a therapist, or both. The Biblical advice,“Physician, heal thyself,” is not only relevant but mandatory—if not for yourself, then for your patients.

CONCLUSION Few situations in the professional life of plastic surgeons are as difficult as the circumstances under which they must reoperate, either on their own patient or on someone else’s. In the process, reoperating surgeons, either with their own patient or a colleague’s, may paradoxically forge a relationship stronger than what might have been if the initial procedure had gone well.

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References —With Key Annotated Reference 1. Goldwyn RM. The Patient and the Plastic Surgeon, 2nd ed. Boston: Little Brown, 1991, pp 247-259. 2. Goldwyn, RM. The dissatisfied patient. In Goldwyn RM, Cohen MN, eds. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001, pp 9-13. A collection of more than 26 years of clinical research on the complications that can result from various cosmetic surgeries.The text highlights advances in plastic surgery, in areas like bone, skin and nerve grafts, facial reconstruction, and breast augmentation. Legal issues are also covered. 3. Goldwyn RM. Psychological aspects of plastic surgery: Observations and reflections. In Sarwer DB, Prozinsky T, Cash TF, et al, eds. Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Clinical, Empirical, and Ethical Perspectives. Philadelphia: Lippincott Williams & Wilkins, 2006, pp 13-22. 4. Goldwyn RM. Why we fail. In Goldwyn RM, Cohen MN, eds. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001, pp 1-8.

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Chapter 5 Common Secondary Complications James C. Grotting

One thorn of experience is worth A whole wilderness of warning. James Russell Lowell

Reoperative Problems Hematoma Seroma

Coagulation abnormalities Wound-healing problems

A

number of complications are common to all plastic surgery procedures. Although most are not serious, a small percentage of these can have major aesthetic and functional repercussions. In rare instances, life-threatening complications can occur. To be able to anticipate and prevent such problems, surgeons must be aware of the factors predisposing to these complications. When such complications do occur, prompt and definitive management is imperative. Common complications can be divided into four categories: hematoma, seroma, coagulation abnormalities, and wound-healing problems.

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HEMATOMA A hematoma is a localized mass of extravasated blood that is relatively or completely confined within an organ, tissue, space, or potential space. The blood is usually clotted and may demonstrate various degrees of organization. Other forms of extravasated blood include petechiae, purpura, and ecchymoses. Petechiae are minute hemorrhagic spots usually measuring 2 to 3 mm in diameter. A purpura is a larger extravasation of blood, measuring up to 1 cm. Ecchymoses, purplish patches caused by extravasation of blood into the skin, tend to be blotchy and larger than purpura.

Causes of Hematoma Following Surgical Procedure Technical Reason Failure to recognize and ligate arterial or venous bleeder Predisposition to Perioperative Bleeding Preexisting hemostatic defect Platelet function disorder Coagulopathy Preoperative aspirin or anticoagulant therapy Transfusion-related Hemodilution Hemolytic transfusion reaction; disseminated intravascular coagulation (DIC) Sepsis Endotoxin-induced thrombocytopenia Acute postoperative increase in systemic or local pressure Hypertension on extubation (for example, struggling or coughing that raises intraabdominal, retrobulbar pressures)

Causes of Hematoma Unrelated to Surgical Procedure Blunt trauma Hemostatic defect Platelet function disorder Coagulopathy Medication Tumors Hemorrhage into necrotic tumor Tumor-induced fibrinolysis Thrombocytopenia resulting from bone marrow involvement

Infection Disseminated intravascular coagulation Thrombocytopenia Systemic disease Hypertension Liver disease Atherosclerotic vascular disease Metabolic disorder Malnutrition/scurvy

Chapter 5 Common Secondary Complications

Hematomas can be categorized by etiologic factors as those resulting from surgical procedures and those unrelated to surgical procedures (see the boxes on p. 90).

PATHOPHYSIOLOGY The ultimate fate of a hematoma, left to follow its natural course, depends largely on its size and location and the presence or absence of infection. It may liquefy and be completely absorbed, or it may undergo organization, with replacement by a fibrous scar. After extravasated blood has accumulated, an anaerobic environment gradually forms. Lactate production results, with red and white blood cell lysis occurring because of the increased acidity. The reticuloendothelial system is responsible for the uptake of iron, pigment, and cellular dermis released as a result of the blood cell lysis. An inflammatory reaction ensues, with involvement of white blood cells, macrophages, and fibroblasts. The outcome of a hematoma at this juncture is determined by competition between the processes of absorption and organization. Many small hematomas may be completely absorbed.Thus uptake and transport of the extravasated blood are facilitated by the reticuloendothelial system, with concomitant lymphatic drainage of edematous fluid. This transport is hindered by infection or recurrent bleeding. Hematomas that are not completely absorbed progress to organization, the process wherein a hematoma is replaced by fibrous scar. Platelets and macrophages normally present in the inflammatory reaction stimulate fibroblast proliferation, with subsequent ingrowth of granulation tissue and fibrous scar formation. The most significant recent advance in the understanding of hematoma pathophysiology has been the identification of free radicals. It was formerly presumed that overlying flap necrosis was caused by a pressure effect, resulting in obstruction of dermal flow. However, studies have shown that pressure has a limited role; the most influential mechanism is the direct toxic effect of blood on skin flaps.1 Free radicals tend to form in the anaerobic environment of the hematoma.2 These ions are quite damaging to overlying tissues. Both iron and hemoglobin, vital blood components, are involved in this process. Iron is a catalyst in the reaction of superoxide to hydroxyl, a major step in the formation of free radicals. It also interferes with host defenses. Hemoglobin inhibits polymorphonuclear chemotaxis.3

COMPLICATIONS Complications of hematomas are as varied as the tissues involved. They range from the minor “blip” in the otherwise normal process of wound healing to the major life-threatening compression of vital structures (see the box on p. 92).

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Complications of Hematoma in Plastic Surgery Fibrosis Aesthetic importance Capsule formation around implants Infection Area of cellular debris Interference of host defenses by iron Inhibition of chemotaxis by hemoglobin Wound dehiscence Secondary to tissue necrosis and pressure effect on wound edges Toxic effect caused by free radicals Overlying tissue necrosis Pressure effect on dermal flow (old theory) Toxic effect caused by free radicals

Compression of vital structures Airway Visual axis Nerves Ossification Results from mixing of periosteal cells from locally traumatized bone Most common near long bones and skull Seen with neonatal scalp and pelvic hematomas caused by forceps injury Residual pigmentation Hemosiderin

CLINICAL SIGNIFICANCE The clinical significance of hematoma formation extends to all aspects of plastic surgery practice.These areas are considered individually with particular emphasis on prevention and treatment.

Skin Grafts Any fluid collection that separates a skin graft from its underlying bed impedes diffusion and prevents vascularization. Prevention includes proper patient selection, with particular attention to patients who are taking aspirin or anticoagulant medications and patients with a history of bleeding disorders. Ensuring proper hemostasis, use of drainage, and application of compressive dressings is vital. Treatment requires early recognition, drainage, and reapplication of the skin graft after the predisposing factors are addressed.

Flaps Surgical closures in plastic surgery often involve some type of flap. Hematomas, which are known to cause dehiscence and overlying necrosis, can significantly jeopardize flap survival.1 Prevention requires early detection, evacuation, and irrigation of the hematoma cavity and subsequent arrest of any bleeding points. Drains placed under flaps may be helpful in the prevention of hematoma formation, but they certainly cannot be relied on in every circumstance.

Chapter 5 Common Secondary Complications

Face

Hematoma is the foremost complication of a face lift (occurring in approximately 2% of cases).4-6 It usually takes one of two forms: a small collection of extravasated blood that is first noticed several days postoperatively, when swelling subsides, or an expanding hematoma presenting during the first few postoperative hours. However, expanding face-lift hematomas caused by bleeding from the superficial temporal artery or vein have been reported to occur as late as 8 to 10 days postoperatively.7 We monitor our patients carefully overnight for this complication and use compression dressings only for the first 2 to 3 hours until vital signs are stabilized. A small portion of the postauricular incision may be left open to roll out any collected blood on the first postoperative morning. Prevention calls for consideration of several factors, which helps to keep the incidence of this complication to a minimum (see the box below).8

Factors in Prevention of Face-Lift Hematoma Patient selection (warning signs: bleeding diathesis, hypertension) Laboratory test results: preoperative platelet count, prothrombin time, partial thromboplastin time, bleeding time, platelet aggregation Institution of hypotensive anesthesia Avoidance of postoperative hypertension: 0.1 to 0.3 mg clonidine (Catapres) PO morning of surgery has been recommended3 Use of local anesthesia versus general anesthesia (to avoid postoperative coughing) Maintenance of meticulous hemostasis Postoperative care: head elevation, application of cool packs Insertion of drains Application of compressive dressing Avoidance of strenuous physical activity for several weeks postoperatively

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Treatment of a face-lift hematoma is based on the size and speed of formation.The expanding hematoma is best treated by surgical evacuation and inspection of the entire wound. The bleeding vessel is rarely found. Small hematomas often liquefy 7 to 10 days postoperatively and may be aspirated or drained through small stab incisions. Because of the deleterious effect of hematomas on all tissues, prompt diagnosis and treatment of all hematomas is warranted.

Nasal Septum Nasal septal hematomas occur most frequently as a result of fracture-dislocation or bending of septal cartilage with intact overlying mucosa. These hematomas may be unilateral or bilateral. Postoperative septal hematomas may occur as adrenalin effect wears off postoperatively. They must be drained urgently to prevent secondary complications. The septal hematoma may organize, causing septal thickening and subsequent nasal obstruction. With large hematomas, pressure necrosis of cartilage with absorption may occur, resulting in septal perforation. Loss of the nasal septum can cause collapse of the nasal dorsum, leading to saddle nose deformity. The risk of septal hematomas in nasal surgery can be reduced by the use of Silastic splints and by mattress suturing of the septal mucoperichondral flaps to each other. Treatment involves evacuation via horizontal incisions along the floor of the nose with or without the use of concomitant packing, splint, or mattress sutures.

Ear Auricular hematomas may be secondary to a single blow or repeated blows to the anterior ear. Similar to the nasal septum, postoperative hematomas in the ear may occur as the adrenaline effect subsides. These hematomas may develop in a subperichondral or subcutaneous plane. Treatment of the subcutaneous hematoma involves evacuation and the application of a form-fitting compression dressing. If the hematoma occurs in the deeper subperichondral plane, the avulsed perichondrium over time forms new cartilage, which is held in place by the tight perichondreal envelope. A bulky, disorganized surface results, obliterating the normal convolutions of the ear and causing the so-called cauliflower ear.9 Treatment requires evacuation of the hematomas and the use of a compressive dressing with or without bolster sutures. Late treatment is more difficult and involves the surgical carving of the delicate convolutions of the cartilaginous framework from the illdefined cauliflower ear.

Chapter 5 Common Secondary Complications

Breast

Breast Augmentation The incidence of hematomas following breast augmentation is 1% to 2%.10 These hematomas usually present clinically with pain, swelling, and occasionally fever. It should be kept in mind that breast hematomas often are not palpable, especially when tense, thereby making diagnosis easier to miss. Breast hematomas following augmentation have been implicated as an etiologic factor in capsule formation. Prevention includes ensuring meticulous hemostasis, use of drains, and application of a compression dressing. The classic treatment involves evacuation of the hematoma, hemostasis, and drainage. Aspiration is not recommended (see Chapter 34). We prefer to manage these in the operating room, although sometimes local anesthetic with sedation is adequate. Failure to drain these hematomas may lead to eventual capsular contracture. Breast Reduction Hematomas following breast-reduction surgery may lead to necrosis of either the overlying skin flaps or the nipple-areola complex. Treatment, as with breast augmentation hematomas, requires evacuation, hemostasis, and drain placement.

Eyelid Subcutaneous Hematoma Subcutaneous hematomas following blepharoplasty are essentially an aesthetic problem only and are usually detected after postoperative swelling subsides. Evacuation by aspiration or stab incision is required to avoid the prolonged appearance of a “hump.” Diagnosis in the first several hours after surgery should be managed by teasing open the incision and rolling out the blood collection. Retrobulbar Hematoma With a retrobulbar hematoma there is bleeding posterior to the orbital septum, which could potentially result in blindness. The bleeding is usually caused by vessel injury from a needle or by a transected fat pad. A

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retrobulbar hematoma causes a firm, protruding, and often painful eyeball. Deterioration of vision may occur. Factors important in prevention include proper patient selection, with special attention to the patient’s preoperative medication regimen and preoperative hypertension, use of the bipolar cautery to cauterize fat pads, avoidance of deep injections, and postoperative use of cool compresses with head elevation. There continues to be a debate as to whether local anesthesia offers any advantage over general anesthesia in the prevention of retrobulbar hematomas. The most important factor in the management of retrobulbar hematomas is early recognition. Once a retrobulbar hematoma is diagnosed, all sutures should be removed promptly. The surgeon must open the orbital septum widely and attempt to locate any bleeding points. Performing a lateral canthotomy and administering mannitol intravenously should be considered. Prompt consultation with an ophthalmologist to assist in evaluation and management is prudent and advisable.

Neonatal Pelvis or Scalp Neonatal hematomas are most often caused by the application of forceps at delivery.They occur in the scalp and pelvis, usually secondary to shear stress and/or prolonged pressure.Treatment is conservative; the hematoma is allowed to be absorbed and incorporated into the growing cranium.

SEROMA There appear to be no clear disposing factors to seroma formation. Some researchers have speculated that hypoproteinemia leads to an increased risk. Dissection of large areas with wide undermining is believed to increase the risk of seroma formation.11 Seromas usually develop in wounds with large potential dead space.

PATHOPHYSIOLOGY The pathophysiology of a seroma may be divided into a development phase, inflammatory phase, and organization or resorption phase. The development of a seroma usually begins with the formation of a transudate. Because there are few cellular elements and little cellular debris in the transudate, no true liquefaction phase takes place, like that in the development of hematomas. However, a local inflammatory response often occurs in which protein levels rise, which may lead to further increases in the volume of the transudate. Most seromas resolve by complete resorption, probably because there are few cellular components and thus a low risk of infection. A pseudocapsule occasionally may develop; in this case there is an increased likelihood of fibrosis and scarring.

Chapter 5 Common Secondary Complications

COMPLICATIONS Complications occur less frequently with seromas than with hematomas. Complications include organization (with formation of scar tissue), infection, wound dehiscence, and pseudocapsule formation with chronic drainage. Seromas do not cause necrosis of overlying tissues.

TREATMENT Treatment of seromas is more varied than that for hematomas, because no one modality will succeed in all cases. Some surgeons advocate benign neglect: they believe that with the natural history of seroma resorption, the problem will spontaneously resolve . Aspiration followed by application of a compressive dressing is the most frequently administered treatment . If the seroma fails to resolve after two at- tempts at treatment by aspiration alone, we prefer to insert a dependent passive or active drain after aspiration . If a pseudocapsule forms , excision or curettage of the capsule with or without fibrin glue administration has been advocated. If the seroma becomes infected, administering an antibiotic is useful, because these have been shown to penetrate serous fluid.

CLINICAL SIGNIFICANCE In plastic surgery, seromas are associated most often with latissimus dorsi flap trans - fer, abdominoplasty , and skin grafting . There is a high incidence of seroma in latis- simus dorsi donor sites; patients undergoing the transfer of this flap should be in- formed of this risk preoperatively . Prevention includes the use of drains and compression dressings . Some surgeons advocate deep tissue closure with mattress sutures in vertical layers to subcompartmentalize the dissected area. If a seroma is as- pirated, the needle should be inserted in a dependent location (for example , for a seroma at a right-sided latissimus dorsi flap site, a drain should be placed in the left lateral decubitus position). Seroma following abdominoplasty is common. Again, patients should be informed of the risk of this complication preoperatively . Prevention is effected by insertion of drains and the application of compressive dressings . Persistent seromas are aspirated as needed. Like hematomas , seromas are capable of elevating skin grafts off the un - derlying bed . Interestingly enough , case reports in the literature describe skin grafts vascularizing directly over a seroma.

COAGULATION ABNORMALITIES Coagulation problems lead to unexpected and potentially dangerous complica - tions. Bleeding disorders may be categorized as platelet function disorders and clot- ting factor disorders . These abnormalities may be inherited , acquired , or drug in- duced. To understand coagulation abnormalities, one must be familiar with the various stages of hemostasis and the steps in the coagulation pathway.12, 13

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Hemostasis is commonly initiated by blood vessel or tissue injury. Subendothelial exposure results in platelet adhesion at the injured blood vessel. Platelet membrane lipases are activated, causing the release of thromboxane A2, which potentiates the release of the platelet-aggregating agent adenosine diphosphate (ADP).This release leads to platelet aggregation and formation of a platelet plug at the injury site.

TF VII

VIIa

T XI

XIa

VIIa/TF

IX

IXa

T VIII

VIIIa

IXa/VIIIa

X

Xa

T V

Va

Xa/Va PT

T

Fibrinogen

Fibrin

CLOT FORMATION

The extrinsic pathway of coagulation can be activated by the interaction of tissue factor (TF) and factor VII. The complex factor VIIa/TF activates factor X and sub - sequently leads to the generation of thrombin (T) from prothrombin (PT). It is now known that the VIIa /TF complex also activates factors IX to IXa , thereby serving as the link between the extrinsic and classic intrinsic pathways. The intrinsic pathway of coagulation can be initiated by the activation of factor XII by negatively charged surfaces (the contact phase of coagulation ). In vivo, this step is not essential, since the intrinsic pathway can be activated via the VIIa/TF com- plex, as noted previously, or via thrombin-mediated activation of factor XI to XIa.

Chapter 5 Common Secondary Complications

Both pathways lead to the conversion of prothrombin to thrombin, which converts fibrinogen to fibrin. The hemostatic clot consisting of fibrin polymers is further stabilized by factor XIIIa. Antithrombin III (AT III) is a naturally occurring inhibitor of thrombin and other serine proteases, which act at different stages of the coagulation cascade. It is produced by endothelial cells and helps to regulate clot formation. Heparin is a cofactor for AT III and exerts its anticoagulant effect via AT III. Therefore patients who do not respond to heparin therapy need to be examined for AT III deficiency.

PLATELET DISORDERS Platelet disorders tend to present with bruising and petechiae. They can be divided into quantitative and qualitative defects (see the box below). At preoperative consultation the patient should be queried about bruising and bleeding problems and medication regimens.14 The patient should be asked about any family history of bleeding problems in addition to the patient’s own history of bleeding problems (or lack thereof) during serious surgical procedures. Obtaining a thorough history is crucial to guiding further diagnostic workup. Physical signs of platelet function disorders are the presence of petechiae and ecchymosis. Laboratory investigations should include a complete blood cell count, bleeding time, and liver function tests. In general, bleeding complications are uncommon at platelet counts above 50,000/mm3, and even lower platelet counts can be tolerated in patients with immune thrombocytopenic purpura (ITP). In an otherwise healthy individual, platelet

Platelet Disorders Thrombocytopenic Purpura (Quantitative) Decreased production Hereditary (for example, amegacaryocytosis) Bone marrow suppression (for example, drugs, radiation, chemotherapy) Bone marrow infiltration (for example, leukemia, lymphoma, metastatic carcinoma) Aplastic anemia Decreased survival Immune thrombocytopenic purpura Hypersplenism Disseminated intravascular coagulation Thrombotic thrombocytopenic purpura Nonthrombocytopenic Purpura (Qualitative) Defective platelet function Hereditary (for example, von Willebrand disorder) Acquired (for example, aspirin, NSAIDs, uremia) Vascular disorders Immunologic (for example, vasculitis, Henoch-Schonlein purpura) Nonimmunologic (for example, vitamin C deficiency, steroid)

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counts below 20,000/mm3 are frequently associated with spontaneous bleeding. This condition can be significantly exacerbated by administration of nonsteroidal antiinflammatory drugs (NSAIDs). It is important to recall that aspirin (but not other NSAIDs) interferes with platelet function for the entire lifespan of the platelet (7 days). Platelet transfusions may be indicated in patients with thrombocytopenia or platelet dysfunction.

DISORDERS

OF

CLOTTING FACTORS

Unlike platelet abnormalities, which tend to present with bruising, coagulopathies tend to present with bleeding. A detailed patient history and preoperative laboratory tests may be helpful in defining specific areas of concern regarding factor deficiency. In general, prothrombin time is a measure of the extrinsic clotting pathway’s integrity. Partial thromboplastin time measures the function of the intrinsic clotting pathway. Thrombin time measures the conversion of fibrinogen to fibrin; it is prolonged with fibrinogen deficiency, dysfibrinogenemia, and/or circulating antithrombin. Deficiency of specific clotting factors requires replacement therapy using fresh frozen plasma, cryoprecipitate, or specific factor concentrates. The level and frequency of factor replacement therapy are determined by the type of deficiency and the planned surgical procedure.15,16 This treatment should be coordinated in conjunction with a hematologist. Hemophilia A is an X-linked recessive disorder associated with factor VIII deficiency. Symptomatology ranges from mild to severe bleeding tendency, depending on the level of residual factor VIII. Treatment involves administration of factor VIII concentrate and/or cryoprecipitate. Mild cases can be treated with desmopressin acetate (DDAVP). Hemophilia B (Christmas disease) is an X-linked recessive disorder associated with factor IX deficiency. Treatment includes administration of fresh frozen plasma, cryoprecipitate, or factor IX concentrate. Von Willebrand disease is an autosomal dominant disorder resulting in mild factor VIII deficiency and platelet dysfunction.Treatment requires administration of cryoprecipitate, which provides factor VIII and von Willebrand factor. The vitamin K–dependent factors are factors II,VII, IX, and X. Causes of vitamin K deficiency include dietary deficiency (usually in chronically ill individuals receiving long-term antibiotic therapy, which kills intestinal bacterial flora), malabsorption, chronic biliary tract obstruction, and oral anticoagulant administration. Treatment requires parenteral administration of vitamin K (5 to 15 mg intravenously), which corrects the deficiency within 4 to 6 hours. If active bleeding is occurring, fresh frozen plasma or cryoprecipitate should be administered to relieve the factor deficiency.

Chapter 5 Common Secondary Complications

Liver disease may result in gross malfunction of the coagulation cascade, because all factors except factor VIII are produced in the liver.The platelet count may be concomitantly reduced as a result of hypersplenism. Treatment involves correction of the underlying cause of liver failure and factor replacement therapy. Disseminated intravascular coagulation (DIC) refers to the generalized and uncontrolled activation of the coagulation cascade. Coagulation factors and platelets are consumed and secondary stimulation of fibrinolysis occurs, resulting in prolonged prothrombin time, partial thromboplastin time, and thrombin time, with increased levels of fibrin degradation products and decreased fibrinogen levels. Causes include sepsis, transfusion reactions, metastatic cancer (for example, mucin-producing adenocarcinoma), placental abruption, and eclampsia.The underlying cause must be treated, and adjunctive infusion of fresh frozen plasma and platelets must be performed. Some hematologists advocate administration of heparin. Aggressive replacement of blood loss by red blood cell units without concomitant plasma and platelet transfusion can lead to dilution of clotting factors. The underlying cause must be treated and plasma, cryoprecipitate, and platelets administered. Medications can also interfere with the coagulation process.16 The most common clinically significant drugs that can affect coagulation are heparin, warfarin (Coumadin), and aspirin. Heparin is a potent organic acid with a strong negative charge. It accelerates the inhibiting action of antithrombin III on thrombin. Its half-life is approximately 60 minutes, and it is degraded in the liver and excreted by the kidney. Its anticoagulant efficacy is monitored by evaluation of the partial thromboplastin time. Heparin may be administered intravenously or subcutaneously but not intramuscularly. Its antidote is protamine sulfate administered intravenously (10 mg of protamine sulfate/1000 U heparin). Warfarin, an oral anticoagulant, inhibits the y-carboxylation of vitamin K–dependent factors. Its full therapeutic effect may take 3 to 5 days. Degradation of warfarin occurs in the liver and excretion is achieved via the kidney. Its anticoagulant efficacy is monitored by the evaluation of the prothrombin time.Vitamin K and fresh frozen plasma are effective antidotes. Aspirin inhibits platelet granule release and platelet aggregation by blocking thromboxane A2 production.This effect lasts through the life cycle of the affected platelet; there is no effective antidote except for platelet transfusions. Plastic surgeons commonly encounter patients who are self-treating with over-thecounter herbal medications, vitamins, and plant extracts. Many of these agents have measurable effects on clotting and should be discontinued before any additional surgical procedures are undertaken.17 Some of the more commonly used substances are outlined in the table on pp. 102-104.

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Herbs, Foods, and Spices to be Avoided for at Least Two Weeks Before Any Surgery Substance

Also Known As

Effect

Agrimony

Agrimonia eupatoria, agrimonia, cocklebur

Coagulant effect from vitamin K constituent

Alfalfa

Medicago saliva, Lucerne, purple medick

Anticoagulant effect from coumarin constituents and coagulant effect from vitamin K

Aloe vera gel

May enhance wound healing

Angelica

Angelica archangelica, root of the Holy Ghost

Anticoagulant and antiplatelet effect from coumarin constituents

Anise

Pimpinella anisum, aniseed, sweet cumin

Anticoagulant effect from excessive doses from coumarin constituents

Arnica

Arnica montana, leopard’s bane, wolf ’s bane, mountain tobacco

Anticoagulant effect from coumarin constituents

Asafoetida

Ferula assafoetida, assant, fum, giant fennel, devil’s drug

Anticoagulant effect from coumarin constituents

Aspen

Populi cortex, Populi folium

Antiplatelet effect from salicin constituent

Black cohosh

Cimicifuga racemosa, bugwort, black snakeroot, baneberry

Antiplatelet effect from salicylate constituent

Bogbean

Menyanthes trifoliata, water shamrock, buckbean, marsh trefoil

Bleeding risk from unknown constituent

Boldo

Peumus boldus, boldine

Anticoagulant effect from coumarin constituents

Borage seed oil

Borago officinalis, starflower, bee plant, burage

Anticoagulant effect from gamma linolenic acid and antiplatelet effect

Bromelain

Ananas comosus, bromelin

Anticoagulant effect from enzyme constituents

Capsicum

Capsicum frutescen, African pepper, cayenne pepper, chili pepper

Antiplatelet effect from capsaicinoid constituents

Celery

Apium graveolens, smallage, Apii fructus

Antiplatelet effect from apiogenin (coumarin) constituent

Clove

Syzygium aromaticum, caryophyllus

Antiplatelet effect from eugenol constituent

Danshen

Salvia miltiorrhiza, red sage, salvia root

Anticoagulant effect from protocatechualdehyde 3,4-dihydroxyphenyl-lactic acid constituent

Dong quai

Angelica sinensis, Danggui, Chinese angelica

Anticoagulant and antiplatelet from coumarin constituents

European mistletoe

Viscum album, devil’s fuge, drudenfuss, all-heal

Coagulant effect from lectin constituent

Fenugreek

Trigonella foenum-graecum, bird’s foot, Greek hay

Anticoagulant effect from coumarin constituents

Feverfew

Tanacetum parthenium, bachelor’s button, featherfew, midsummer daisy

Antiplatelet effect from the crude extracts

Fish oils

Omega-3 fatty acids

Antiplatelet effect with prostacyclin synthesis, vasodilation, reduced platelets and adhesiveness, and prolonged bleeding time

Fucus

Fucus vesiculosis, kelp, black tang, bladderwrack, cutweed

Anticoagulant effect which can increase the risk of bleeding

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Chapter 5 Common Secondary Complications

Substance

Also Known As

Effect

Garlic

Allium sativum, nectar of the gods, stinking rose

Inhibition of platelet aggregation and can increase risk of bleeding in excessive doses

Ginger

Zingiber officinale

Anticoagulant effect with increased risk of bleeding

Ginkgo

Ginkgo biloba, maidenhair

Inhibits platelet aggregation and decreases blood viscosity

Ginseng

Panax ginseng, Asian ginseng, Korean red, jintsam

Anticoagulant and antiplatelet effects

Goldenseal

Hydrastis canadensis, eye balm, yellow puccoon

Coagulant effect from berberine constituent

Horsechestnut

Aesculus hippocastanum, escine, Venostat

Anticoagulant effect from aesculin (coumarin) constituent

Horseradish

Armoracia rusticana, pepperroot, mountain radish

Anticoagulant effect from coumarin constituents

Licorice

Glycyrrhiza glabra, sweet root

Antiplatelet effect from coumarin constituent

Meadowsweet

Filipendula ulmaria, bridewort, dropwort

Anticoagulant effect from salicylate constituents

Northern prickly ash

Xanthoxylum americanum, pepper wood, toothache bark

Anticoagulant effect from coumarin constituents

Onion

Allium cepa

Antiplatelet effect from unknown constituents

Papain

Carica papaya

Bleeding risk from unknown constituent

Passionflower

Passiflora incarnate, apricot vine, Maypop

Anticoagulant effect from coumarin constituents

Pau d’Arco

Tabebuia impetiginosa, ipes, taheebo tea, lapacho

Anticoagulant effect from lapachol constituent

Plantain

Plantago major, common plantain, greater plantain

Coagulant effect from vitamin K constituent

Poplar

Populus tacamahacca, balm of Gilead

Antiplatelet effect from salicin constituent

Quassia

Quassia amara, bitterwood

Anticoagulant effect from coumarin constituents

Red clover

Trifolium praetense, trefoil, cow clover, beebread

Anticoagulant effect from coumarin constituents

Roman chamomile

Chamaemelum nobile, English chamomile, whig plant, garden chamomile

Anticoagulant effect from coumarin constituents

Safflower

Carthamus tinctorium, saffron, zaffer

Anticoagulant effect from safflower yellow constituent

Southern prickly ash

Zanthoxylum clava-herculis, sea ash, yellow wood

Anticoagulant effect from coumarin constituents

St. John’s wort

Hypericum perforatum, Klamath weed, goat weed

Photosensitivity, especially when used with Retin-A

Stinging nettle

Urtica dioica, nettle

Anticoagulant effect from vitamin K constituent

Sweet clover

Melilotus officinalis, hay flower, common melilot, sweet Lucerne

Anticoagulant effect from dicumarol constituent

Sweet vernal grass

Anthoxanthum odoratum, spring grass

Anticoagulant effect from coumarin constituent Continued

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Herbs, Foods, and Spices to be Avoided for at Least Two Weeks Before Any Surgery—cont’d Substance

Also Known As

Effect

Tonka bean

Dipteryx odorata, coumarouna, torquin bean Anticoagulant effect from coumarin constituent

Turmeric

Curcuma longa, Indian saffron, turmeric

Anticoagulant effect from coumarin constituent

Vitamin E

Alpha-tocopherol

Inhibits platelet aggregation and adhesion and interferes with vitamin K–dependent clotting factor in large doses

Wild carrot

Daucus carota, Queen Anne’s lace, beesnest plant

Anticoagulant effect from coumarin constituents

Wild lettuce

Lactuca virosa, green endive, lettuce opium Anticoagulant effect from coumarin constituents

Willow bark

Salix alba, white willow, silbereide

Antiplatelet effects from salicylate constituents

Yarrow

Achillea millefolium, wound wort, thousand-leaf

Anticoagulant effect from achilleine constituent

Everyday foods and spices are listed in bold letters.

WOUND-HEALING PROBLEMS Wound healing is necessary for survival. Classic wound healing involves, at its most simplistic level, three phases: (1) inflammation (lag phase), (2) repair (fibroproliferation phase: collagen production and fibroplasia occur), and (3) maturation (consolidation phase).The arrest of healing can occur at any phase (see Chapter 1). For example, the repair phase cannot begin until acute inflammation begins to subside . Many individual factors adversely affect wound healing , and they often present concomitantly18 (see the box on p. 105).

DRUGS Of all interventional drugs used in plastic surgery , steroids have the greatest effect on wound healing . Steroids decrease and in some cases even arrest infl ammatory re- sponse . This action is secondary to macrophage inhibition , with delay in fibrogen- esis and angiogenesis . The macrophage is considered to be the principal cell in the modulation of wound repair . 3 In addition , lysosomal membranes are stabilized , fur- ther contributing to an antiin flammatory effect. Collagen production may be de- creased , because steroids have an inhibitory effect on propyl and lysyl hydroxylase , two important enzymes in collagen production . The most important effect of steroids on collagen is in collagenolysis stimulation . Secondary wound contraction is also inhibited . The clinical effects of steroids on wound healing include atrophy, depigmentation, and an increased tendency toward wound dehiscence. Vitamin A is known to reverse the stabilizing effects of steroids on lysosomal mem - branes . It counteracts steroid -retarded monocytic in flammation and theoretically may reactivate the disease for which the steroids were originally administered. The

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exact mechanism is unknown. Vitamin A is also a necessary cofactor for collagen synthesis and cross-linkage. In the absence of steroids, vitamin A offers no benefit to healing. Vitamin C is a cofactor necessary for collagen synthesis in the intracellular hydroxylation of proline and lysine. Scurvy (vitamin C deficiency) results when fibroblasts remain immature.With a lack of ascorbic acid, fibroblasts revert to inactivated fibrocytes. A buildup of free ribosomes, a decrease in endoplasmic reticulum, and an increase in stored fat occur, which lead to an overall decrease in protein synthesis and a halting in wound repair. In addition, immature granulation tissue forms. New capillaries are defective, leading to hemorrhage in the wound area. Tensile strength in a healed scar will decrease in the absence of vitamin C secondary to decreased collagen synthesis in the face of active ongoing physiologic collagenolysis. The presence of an excessive concentration of vitamin C does not promote supernormal healing. Vitamin E inhibits wound healing, decreasing tensile strength in the collagen produced.This effect may be related to the membrane-stabilizing properties of vitamin E; hence its attractiveness for the treatment of fibromatoses such as those that occur with Peyronie’s disease. It does not reverse the retardation of wound healing caused by steroids. The effects of vitamin E are reversed by vitamin A. The mechanism is unclear. Vitamin E has been found to increase the breaking strength of wounds exposed to preoperative irradiation. Its antioxidant effect neutralizes the lipid peroxidation caused by ionizing radiation, thereby decreasing the production of free radical products via lipid peroxidation known to cause cellular damage.Vitamin E’s therapeutic efficacy and indications remain to be defined.The conviction among the lay public regarding vitamin E is so strong that many apply topical preparations of vitamin E to their scars without consulting their physicians. There seems to be no evidence that this practice improves the quality or the aesthetic appearance of the surgical scars. Patients should be advised of the high incidence of minor adverse reactions (rash or itching) when vitamin E is applied to the skin.

Factors Affecting Wound Healing Drugs: Steroids, vitamin A, vitamin C, vitamin E, trace metals, beta-aminopropionitrile (BAPN), colchicine, chemotherapeutic agents, penicillamine, antiinflammatory medications, nicotine Edema Anemia Local oxygen tension Nutrition

Surgical technique Infection Denervation Hydration Diabetes mellitus Radiation Uremia Inheritable disorders of collagen metabolism

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Trace metals play an important role in wound healing. Zinc is a normal component of many enzyme systems and serves as a cofactor for both collagen production and the enzyme systems responsible for cellular proliferation . However , administration of zinc in the absence of a deficiency has no bene ficial effect . Zinc deficiency re- sults in a reduction in the rate of epithelialization , rate of gain of wound strength, and diminution of collagen strength. Copper is a cofactor that acts extracellularly . It is involved in deamination of lysyl oxidase and the formation of aldehyde groups for intramolecular collagen cross- linking. Magnesium is a cofactor involved in glycosylation when glucosyl or glucosylgalactosyl residues are attached to hydroxylysine . Other vitamins such as riboflavin and thiamine also serve as cofactors in collagen cross-linking. Lathyrogens prevent the formation of aldehyde intermediates in a cross-linking process of collagen formation. The result is reduced strength of collagen bundles. Lathyrism occurs as a result of ingestion of certain varieties of peas (Lathyrus odoratus), commonly known as sweet peas. The active agent of the pea that causes the effect on collagen is beta-aminopropionitrile (BAPN). BAPN inhibits the enzyme systems necessary for intramolecular and intermolecular bonding outside the cell by preventing deamination of lysyl oxidase. Colchicine interferes with the extracellular secretion of collagen precursors, thereby causing a form of “cellular constipation.” Penicillamine inhibits chelation of copper, thereby producing copper deficiency in a concomitant inhibitory effect in collagen cross-linking. Cancer chemotherapeutic agents have been shown to affect almost all phases of wound-healing. Neutropenia prolongs the inflammatory phase. Agents such as cy- clophosphamide inhibit the early vasodilatory phase of inflammation . In addition, chemotherapeutic agents are known to interfere with DNA replication, RNA pro- duction, and protein synthesis. With chemotherapy, proliferation of fi broblasts and secondary wound contraction are decreased. When chemotherapy is begun 10 to 14 days postoperatively , little effect is noted on wound -healing over the long term despite a demonstrable early decrease in wound strength. Nonsteroidal antiinflammatory drugs (for example, aspirin, ibuprofen) have been shown to decrease collagen synthesis even at ordinary therapeutic doses . The effect is dose dependent and mediated through prostaglandins. Nicotine is the principal vasoactive component in the gas phase of cigarette smoke . It is an odorless , colorless , poisonous alkaloid that, when ingested or inhaled , can liberate adrenal catecholamines . In addition, nicotine has a direct cutaneous vaso-

Chapter 5 Common Secondary Complications

constrictive effect. Nicotine impairs wound contraction in animal models from the fourth to the tenth day of wound-healing. From the twelfth to the twentieth days , wounds contract at essentially a normal rate. Therefore cigarette smoking, with its associated nicotine ingestion, is adverse to the early stages of wound healing.

OTHER FACTORS

IN

WOUND HEALING

Mild anemia has little effect on collagen synthesis. Normal physiologic adjustments such as an increased blood circulation rate are able to compensate. However, a hematocrit level of 20% or less will begin to seriously affect oxygen delivery. With edema, the expansion of tissue fluid increases the distance between capillaries and the collagen-synthesizing fibroblasts. This effect may result from increased venous pressure with secondary reduced capillary blood flow.Venous stasis is a pri - mary example. Fibroblasts are known to be oxygen sensitive . Fibroblast replication is potentiated by a PO 2 of 30 to 40 mm Hg , but collagen synthesis requires higher levels . Collagen production and tensile strength are stimulated by hyperoxia. In patients on a nor- mal diet with an adequate vitamin C intake, the rate-limiting cofactor in collagen production is the availability of oxygen to the fibroblasts. Tissue oxygen deficiency is the most common cause of qualitatively inadequate healing. Proper tissue oxygenation requires sufficient inspired PO2 transfer of oxygen by suf ficient hemoglobin for transport and adequate tissue vascularity . Problems in maintaining local oxygen tension accounts for healing problems in such diverse conditions as radiation diabetes, peripheral vascular disease, chronic infection, and pressure sores. There has been a resurgence in the use of hyperbaric oxygen therapy , especially for enhancing healing and treatment of selected problem wounds.19 The most im- portant effects of hyperbaric oxygen therapy for the plastic surgeon are the stimu - lation of leukocyte microbial killing , improvement of fibroblast replication, and in- creased collagen formation and neovascularization in ischemic tissue . Preoperative hyperbaric oxygen therapy induces neovascularization in radionecrotic tissue. Re- fractory osteomyelitis and necrotizing fasciitis appear to respond to adjunctive hy- perbaric oxygen . Crush injury and compartmental syndrome appear to benefit from hyperbaric oxygen therapy through presentation of adenosine 5-triphosphate in cell membranes, which limits edema. Hyperbaric oxygen therapy for burn injury permits shorter hospital stays, reduced number of surgeries , and less fluid replace - ment . When hyperbaric oxygen therapy is instituted postoperatively , skin grafts are reported to take more completely and more rapidly. The same mechanisms may apply to ischemic problem wounds, such as infected extremities in diabetic pa- tients. Hyperbaric oxygen therapy will not cause normal wounds to heal more rap - idly but may under certain circumstances cause problem wounds to heal at a more normal rate.

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Wound infection occurs when the number of pathogenic organisms exceeds the ability of local tissue defenses to combat them. Infection has a detrimental effect on wound healing by decreasing tissue PO 2 , increasing collagen lysis , and perpetuating the continued presence of an inflammatory reaction. Good nutrition is essential for the effective repair of wounds. Since all wound repair requires a certain amount of regeneration, the raw biologic materials must be present at the correct place and time to allow proper tissue synthesis. Lack of protein (kwashiorkor) causes a marked decrease in the tensile strength of the wound as a result of a shortage of both fibroblasts and collagen. Protein depletion also prolongs the inflammatory phase. Although methionine represents only 1% of all of the essential amino acids required in the synthesis of collagen , methionine is an espe - cially critical factor , because it cannot be synthesized by humans . Methionine is the most important source of cysteine. Cysteine, a sulfated amino acid, is not di- rectly involved in collagen synthesis, but since formation of disulfi de bonds is crit- ical to the proper alignment and attachment of peptide chains in the triple -helix structure of tropocollagen , sulfur -containing amino acids ( cysteine, arginine, histi- dine) have an important support role. Much less is known about the role of carbohydrates and fats in the wound-healing process. Glucose is required as an energy source by white blood cells during the inflammatory phase. Fats are essential constituents of cell membranes, but there appears to be no impairment of wound healing associated with fatty acid deficiency . Wound contraction and epithelialization are not affected by denervation. How - ever, denervated skin is prone to ulcerate because of high rates of collagenase activ- ity. Paralyzed patients tend to develop large , progressive skin ulcerations over anes- thetic areas that are often worse than the pressure sores experienced by debilitated patients with intact nervous systems. Poor surgical technique is detrimental to wound healing. The degree of tissue necrosis increases with the severity of the trauma induced by the surgical procedure . Tight sutures cause tension on the incision , resulting in local ischemia . Excessive cauterization and the use of irritative sutures (for example , plain catgut, silk) all prolong the inflammatory phase. These factors, depending on their extent , may re - sult in subsequent wound breakdown in a patient with an otherwise normal intrin- sic repair mechanism. A well-hydrated wound will epithelialize faster than a dry wound. Biologic dressings, grafts, and synthetic occlusive wound coverings hasten epithelial repair and control the proliferation of granulation tissue. Diabetes mellitus has both metabolic and mechanical effects on wound-healing outcome. Metabolic effects include a decrease in collagen synthesis. In addition, there is a defect in leukocyte function, with decreased chemotaxis and phagocytosis, resulting in an increased risk of infection and impaired healing. Mechanical im -

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pairments include microangiopathy and major arterial occlusion. Diabetic neuropathy, a separate category, may also have a deleterious influence on wound heal - ing. Instituting insulin therapy soon after a skin wound occurs in a diabetic patient restores an adequate inflammatory response and enhances collagen synthesis. Uremia has a detrimental effect on wound healing and a particularly negative influence on fibroblast proliferation. Radiation is especially deleterious to wound healing. The effects of radiation at a molecular level result in the death or partial injury of the cell directly or indirectly secondary to the ionization of cell water with liberation of free radicals. Free radicals interact with DNA molecules, which are then damaged. The exact lesion of ionizing radiation remains undefined, but once alterations in nucleotide sequences occur, a change in transcription or defective repair sets the stage for interference with wound healing. The degree of cell damage is determined by the relative importance of the destroyed molecule to the function of the cell, dose of radiation, and ability of the tissue involved to repair itself. The net effect of radiation on wounds includes loss of the ability of cells to replicate. Fibroblasts are particularly sensitive , leading to decreased collagen production and delayed wound contraction . Fibrosis constricts lymphatic vessels and small capillaries, causing increased edema. Obliter - ative endarteritis /endothelial cell swelling leads to luminal narrowing and gradual obliteration of small arterial vessels , resulting in late fibrosis , necrosis, and poor wound healing; and depletion of parenchymal stem cells. Therapy for tissue breakdown secondary to radiation essentially consists of debridement of the necrotic area and the introduction of fresh, well-vascularized tissue with or without adjunctive hyperbaric oxygen therapy. Numerous genetic disorders are known to affect wound healing. Some of the more significant syndromes relevant to plastic surgery include pseudoxanthoma elasticum , cutis hyperelastica (Ehlers-Danlos syndrome ), cutis laxa, Werner ’s syndrome , and progeria. Detailed descriptions of these individual syndromes are beyond the scope of this chapter.

CONCLUSION The cellular mechanisms in the biochemical events discussed are the processes by which common complications occur in plastic surgery as well as in surgery in general. As we learn more about the complex interactions between the patient host, surgical alteration of tissues, and pharmacologic manipulation of cellular events, we can begin to influence outcome on a cellular level and hopefully decrease morbidity. A surgeon aware of pharmacologic and cellular events that predispose to coag - ulation and wound -healing complications is one who is best prepared to prevent these problems . Although the incidence of these complications may never be re- duced to zero, awareness of the contributing etiologic factors is the fi rst step toward minimizing their incidence and severity.

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References —With Key Annotated References 1. Mulliken J. Pathogenesis of skin flap necrosis from an underlying hematoma. Plast Reconstr Surg 63:540-545, 1979. 2. Angel MF, Narayanan K, Swartz WM, et al. The etiologic role of free radicals in hematomainduced flap necrosis. Plast Reconstr Surg 77:795-801, 1986. 3. Diegelmann RF, Cohen IK, Kopler AM. The role of macrophages in wound repair: A review. Plast Reconstr Surg 68:107-113, 1981. 4. Straith R. The study of hematomas in 500 consecutive face lifts. Plast Reconstr Surg 59:694698, 1977. 5. Thompson DP, Ashley FL. Face lift complications: A study of 922 cases performed in a 6-year period. Plast Reconstr Surg 61:40, 1978. 6. Rees T. Expanding hematoma after rhytidectomy. Plast Reconstr Surg 51:149-153, 1973. 7. Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg 10:543, 1983. 8. Baker TM, Baker TJ, Stuzin JM. Browlift and facelift. In Goldwyn RM, Cotten MN, eds. The Unfavorable Result in Plastic Surgery. Philadelphia: JB Lippincott, 2001. 9. Skoog T. The pathogenesis of cauliflower ear. Scand J Plast Surg 9:34-39, 1975. 10. Madden JW, Peacock EE Jr. Studies on the biology of collagen during wound healing: III. Dynamic metabolism of scar collagen and remodeling of clinical wounds. Ann Surg 174:511520, 1971. 11. Coons MS, Folliquet T, Rodriquez C. Prevention of seroma after dissection of musculocutaneous flaps. Am Surg 59:215-218, 1993. 12. Furie B, Furie BC. Molecular and cellular biology of blood coagulation. N Engl J Med 326: 800-806, 1992. 13. Roberts HR, Lozier JN. New perspectives on the coagulation cascade. Hosp Pract 15:97-112, 1992. 14. Goldsmith SM, Leshin B, Owen J. Management of patients taking anticoagulants and platelet inhibitors prior to dermatologic surgery. J Dermatol Surg Oncol 19:578-581, 1993. 15. Todd D, Galbraith D. Management of an orthognathic surgery patient with factor XI deficiency. J Oral Maxillofac Surg 51:417-420, 1993. 16. Weaver DW. Differential diagnosis and management of unexplained bleeding. Surg Clin North Am 73:353-361, 1993. 17. Pribitkin ED, Boger F. Herbal therapy: What every facial plastic surgeon must know. Arch Facial Plast Surg 3:127-132, 2001. 18. Hunt TK. Disorder of wound healing. World J Surg 4:271-277, 1980. 19. Kindwall EP, Gottlieb LJ, Larson DL. Hyperbaric oxygen therapy in plastic surgery: A review article. Plast Reconstr Surg 88:898-906, 1991. The most important effects of hyperbaric oxygen (HBO), for the surgeon, are the stimulation of leukocyte microbial killing, the enhancement of fibroblast replication, and increased collagen formation and neovascularization of ischemic tissue. Preoperative hyperbaric oxygen induces neovascularization in tissue with radionecrosis. Refractory osteomyelitis and necrotizing fasciitis appear to respond to adjunctive hyperbaric oxygen. Crush injury and compartment syndrome appear to benefit through preservation of ATP in cell membranes, which limits edema.The use of hyperbaric oxygen in the treatment of burn injury permits shorter hospital stays, a reduced number of surgeries, and less fluid replacement. Skin grafts and flaps are reported to take more completely and more rapidly.The same mechanisms may apply in ischemic problem wounds such as infected diabetic extremities. Contraindications and side effects are described. Hyperbaric oxygen will not heal normal wounds more rapidly but may, under certain circumstances, induce problem wounds to heal more like normal ones.

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REVIEW QUESTIONS 1. A 47-year-old man develops a hematoma following a face lift. The most likely technical reason for this complication is: a. A platelet function disorder b. Uncontrolled hypertension c. Failure to recognize and control an arterial or venous bleeder d. Preoperative aspirin therapy e. Hemolytic transfusion reaction 2. The single most important factor causing flap necrosis from hematoma occurs as a result of: a. Pressure from obstruction of dermal flow b. Tight suture line closure c. No reflow phenomenon d. Direct toxic effect of free radical formation on skin flap e. Hemoglobin 3. Factors to consider in the prevention of face-lift hematoma include: a. Hypotensive anesthesia b. Meticulous hemostasis c. Avoidance of postoperative hypertension d. Head elevation and application of cool packs e. All of the above 4. The treatment for retrobulbar hematoma is: a. Observation b. Diamox c. Suture removal, opening of orbital septum, and lateral canthotomy d. Ice e. Needle aspiration 5. All of the following medications can affect bleeding except: a. Aspirin b. Warfarin c. Torodol d. Vitamin C e. Vitamin E

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Chapter 6 Scars and Scar Revision Kenneth B. Hughes and W. Thomas Lawrence

Though the wound be healed, yet the scar remains. English proverb

Reoperative Problems Impaired wound healing Scar realignment More complex tissue rearrangements

Nonsurgical scar modifications Abnormal scarring conditions

S

cars are the inevitable result of any surgical procedure . The plastic surgeon ’s goal is to generate a scar that does not impair form or function to any significant degree . Attention to detail and precision in wound creation and closure maximize the oppor- tunity for producing an excellent scar as the primary result. Sometimes, however, a surgeon must close unfavorable wounds resulting from burns, trauma, or oncologic ablations. The resulting scar may be imperfect because of limitations created by the wound itself. In other cases, patient characteristics can contribute to less-satisfactory scarring. Severely injured or very ill patients are often incapable of healing wounds in a precise manner. Chronic problems such as diabetes can also contribute to less-satisfactory healing and scarring. Some patients have a predisposition to hypertrophic scars or keloids that can affect surgical results. When a plastic surgeon is facing a reoperative problem related to scarring,

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the goal is to overcome the limitations in form or function created by the healing of the original wound. He or she must be aware that not all factors that contributed to undesirable scarring can be overcome, and this needs to be considered in any plans for scar revision. Patients must also understand that surgeons are not magicians and cannot make scars disappear. All that can be hoped for is a minimally apparent scar that does not impair function in any way. The scar should be flat and narrow and should match the surrounding skin in color and texture to the best degree possible. It should not generate any tightness or bow-stringing, even with movement. Imperfect scars may have excessive width, prominence, thickness, tightness, or abnormal pigmentation. They may also be atrophic and depressed or have an undesirable orientation. An individual scar may have one or more unfavorable characteristics; both the surgeon and the patient must be aware that not all problems can be corrected. The goal of any revision procedure is to correct the specific characteristics of the individual scar that are less than ideal and amenable to correction. Only a portion of a scar may harbor these characteristics, and in such cases, any intervention should be targeted to only the unsatisfactory portion of the scar. As with many surgical enterprises, the key to improving a surgical result starts with diagnosis of the problem and an understanding of what caused the problem to occur. This requires some knowledge of what is involved in normal wound healing and what problems result from aberrations in the normal process.

WOUND HEALING Ideally, wound healing is a carefully orchestrated process that involves distinct yet intimately related processes: hemostasis, inflammation, cellular proliferation, matrix production, wound contraction, and remodeling. Deviations from the ideal progression of wound-healing events can contribute to less-satisfactory scars. One must ensure that the environment that contributed to less desirable scarring has been modified to the best degree possible before attempting to revise the scar.

HEMOSTASIS Hemostasis occurs as the first response to skin penetration and is initially mediated by the vasoconstriction of blood vessels at the point of injury. The coagulation cascades are subsequently activated, resulting in the formation of fibrin. Factors produced by damaged cells activate platelets that aggregate at the site of injury as well. The combination of fibrin and aggregated platelets along with erythrocytes and other trapped cellular elements make up the clot that plugs damaged blood vessels. The fibrin lattice resulting from this process also serves as the early wound matrix that facilitates progression of wound healing. Platelets release multiple cytokines as

Chapter 6 Scars and Scar Revision

they aggregate, including platelet-derived growth factor (PDGF) and transforming growth factor beta (TGF-beta), and these cytokines also play active roles in orchestrating later cellular processes involved in healing. Derangements in hemostasis or severe trauma that overtax the hemostatic mechanism can lead to an excessive accumulation of blood in wounded tissues. Such collections of blood provide a mechanical barrier to healing and can predispose to infection. They can prolong the inflammatory process, which contributes to edema and imprecise healing. Precise hemostasis is required during any revision surgery to maximize the opportunities for optimal scarring.

INFLAMMATION The inflammatory process is initiated within hours after the wound occurs, resulting in erythema, edema, and heat. Inflammatory mediators such as histamine, prostacyclins, and leukotrienes contribute to vasodilation and the migration of inflammatory cells such as polymorphonuclear (PMN) cells and monocytes to the injury site. These inflammatory cells produce a wide variety of proteinases and reactive oxygen species that aid in the breakdown and phagocytosis of damaged matrix and cells. Macrophages and lymphocytes, in addition, produce cytokines, which, along with the platelet-derived cytokines, have a major influence on the orchestration of the overall healing mechanism.1,2 Derangements in wound healing that lead to undesirable scarring may result from inadequate or excessive inflammation. Inadequate inflammation may be a consequence of poor nutrition, systemic steroid administration, or a multitude of other problems and can generate an inadequate stimulus to scar formation. This can result in an atrophic, excessively wide scar. Prolonged inflammation can result in an excess of inflammatory mediators and cytokines in the wound environment. This can contribute to excessive scar formation, resulting in scar prominence or tightness or prolonged scar erythema. Edema is a significant aspect of the inflammatory response, and significant edema limits skin perfusion and oxygenation. All aspects of healing are impaired in a hypoxic environment, and this can also contribute to a wide and/or depressed scar.

CELLULAR PROLIFERATION After the inflammatory reaction to injury begins to diminish, keratinocytes and mesenchymal cells begin to actively migrate into the wound environment and proliferate. Endothelial cells also migrate and proliferate in the wound environment resulting in new blood vessels that revascularize the damaged area. These processes predominate between 2 and 5 days after injury.

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Significant trauma can damage cells over a large area, limiting the ability of keratinocytes, fibroblasts, and endothelial cells to contribute optimally to the healing process. Limitations in cellular function can also be produced by ischemia resulting either from vascular damage or simply, prolonged edema.This impairment can lead to inadequate scar formation and excessive scar width.

MATRIX PRODUCTION AND SCAR CONTRACTION Beginning about 5 days after injury, the synthesis of collagen and other matrix components, and active wound contraction, result in an increase in wound strength and diminished scar size.These processes are all mediated by cytokines produced by macrophages and other cell types during the earlier healing phases. Cellular damage and vascular impairment limit matrix proliferation and scar contraction, similar to the way in which they limit cellular proliferation. The end result of these limitations is weaker scars that will widen and possibly be atrophic. Excessive wound contraction can produce scars that limit movement, especially when they occur in the vicinity of joints. Semicircular scars are particularly predisposed to problems related to wound contraction. The tissue within the curve is often elevated upward by contractile forces, producing a pincushion effect.The semicircular nature of the wound must be altered in any revision procedure to minimize this problem.

REMODELING During this last phase of tissue repair, which begins approximately 3 weeks after injury, wound remodeling results in increased cross-linking of collagen and improved collagen alignment resulting in greater wound strength.3,4 The greatest percentage of ultimate wound strength is generated during this phase of healing. In addition to active collagen synthesis, appropriate metalloproteinase function is required to modulate the quantity and alignment of scar in a wound. Any derangement in the wound environment that alters cytokine or metalloproteinase function can limit the process of scar remodeling. Depending on the nature of the derangement, collagen and matrix synthesis and wound contraction can be impaired or excessive. Impaired cross-linking and collagen realignment can result in a widened, possibly depressed scar. Alternatively, an imbalance resulting in excessive collagen synthesis can produce an excess of scar.

Chapter 6 Scars and Scar Revision

IMPAIRED WOUND HEALING As suggested, some derangements in healing result from characteristics of the wound environment; other problems derive from characteristics of the patient themselves. There are a variety of conditions, which negatively influence scar formation. Some of these conditions can be eliminated and some cannot. A number of nutritional derangements can negatively impact healing. Protein deficiency results in impairments in capillary formation, fibroblast proliferation, and collagen synthesis. It also contributes to an impairment in immune function, which can increase infection risk.5-8 Vitamin deficiencies can also impair healing. A deficiency in vitamin A impairs epithelialization.Vitamin C deficiency prevents hydroxylation of prolene and lysine and thereby limits collagen cross-link formation.9 A deficiency of zinc, magnesium, or copper can also decrease the tensile strength of the ultimate scar.10 If malnutrition of any sort has contributed to less-satisfactory scarring, correction of the nutritional impairment must precede any surgical intervention if the ultimate quality of the scar is to be improved. Steroids impair almost all aspects of healing and can contribute to the formation of widened, atrophic scars. Chemotherapeutic agents and immunosuppressive drugs also inhibit wound healing and lead to the production of weaker scars.11 If these agents are only required for a limited period, scar revision should be postponed until use of the agents has been discontinued. If steroids cannot be discontinued because of the chronicity of the problem for which they are being used, their inhibitory effects on the healing process can be modulated by the concomitant administration of vitamin A, either topically or systemically. Diabetes is another patient characteristic that can impair healing. Although diabetes cannot be eliminated, its inhibitory effects on the healing process can be minimized through precise blood sugar control.12 Smoking causes local tissue ischemia by stimulating acute vasoconstriction and by contributing to carboxyhemoglobin production, which limits the oxygen-carrying capacity of the blood. In addition, it contributes to deleterious long-term effects on the peripheral vasculature and lungs that limit tissue perfusion. Smoking should be eliminated before scars are revised to maximize the opportunities for optimal healing and limit the likelihood of widened, atrophic scars. In addition to patient characteristics that impair healing, impairments in the quality of tissues locally can lead to impaired healing.The healing process is significantly impaired in radiated tissues as a result of impaired cellular function and relative tissue hypoxia. Impaired circulation resulting from traumatic scarring can also slow healing and contribute to unsatisfactory scars. Hyperbaric oxygen treatment can sometimes improve local circulation and lead to improved healing and scarring.

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SURGICAL PRINCIPLES IN SCAR REVISION Any surgical procedure used for scar revision must incorporate several basic surgical principles that contribute to optimal healing: 1. Gentle handling of tissues to minimally traumatize the structures involved in the revision procedure 2. A tension-free wound closure to minimize stress on healing tissues 3. Incisions made perpendicular to the skin edge to allow for precise tissue reapproximation 4. Incisions ideally oriented within the relaxed skin tension lines (RSTLs) to the degree possible13; note the RSTLs in the illustrations below

Chapter 6 Scars and Scar Revision

Borges13 heightened awareness of the importance of placing scars in the RSTLs. These relaxed skin tension lines are intrinsic to the skin itself and do not correspond fully to wrinkle lines or Langer lines. In cases in which the RSTLs cannot be determined, a circular incision can be made, and the surgeon can look for the formation of an ellipse to determine proper orientation. Antitension lines (ATLs) correspond to lines perpendicular to RSTLs and should be avoided whenever possible. Scars in ATLs are more apparent in that they do not mimic normal skin folds, and they are also more prone to scar hypertrophy.

FUSIFORM EXCISION The simplest procedure used for scar revision is fusiform excision. Fusiform excision typically requires only minimal lengthening of the scar and is best suited to scars that already correspond to RSTLs. Fusiform excision can often be used to modify scars that are excessively wide, depressed, or thick. However, the area excised needs to adhere to a length-to-width ratio of 4:1 to avoid dog-ears. A key to a satisfactory result after fusiform excision is prolonged support of the closure to minimize scar spread. It has been suggested that support for up to 6 months with a permanent buried suture may be necessary to maximally limit scar spread.14 For depressed scars, a modification of the simple fusiform excision can be used. The skin is incised in a fusiform fashion around the scar to the subcutaneous level. The central scar is then deepithelialized, and the peripheral skin edges are advanced over the deepithelialized scar. The deepithelialized scar provides support to the wound edges and prevents recurrent scar depression.

SCAR REALIGNMENT For larger scars that do not correspond to RSTLs, scar realignment may lead to a more aesthetic scar with fewer tendencies to hypertrophy or contraction. Sometimes this can be accomplished by excising a scar and reapproximating tissues in a manner that either approximates the RSTLs or is more curvilinear and less prone to contraction. Borges promoted the use of Z-plasties or W-plasties to improve scar alignment for scars that deviate more severely from the ideal orientation. These techniques are particularly useful at breaking up contracted scars and scars with “pincushioning.” The choice of technique depends on whether scar lengthening is desired.15,16 Alternative methods of realigning scars include geometric scar realignment and YV-plasties.

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Z-PLASTY Limb 1

60

2

Central limb

° 2

1

Limb

A Z-plasty both lengthens and breaks up a linear scar.17 It requires tissue laxity in the plane perpendicular to the scar to allow advancement of the Z-plasty flaps. The Z-plasty is particularly useful in situations where the scar has become somewhat contracted. It is often employed in the following situations18:  ATL scars of eyelids, lips, nasolabial folds, and nonfacial areas that limit tissue mobility  Scars on forehead, temples, cheeks, nose, and chin running at less than 35 degrees to inclination to RSTLs  Semicircular trapdoor scars Several principles apply to Z-plasty design. The central limb of the Z-plasty should always fall over the scar. The flaps should be oriented so that, after transposition, they are oriented close to RSTLs.19 The length of all limbs must be reasonably equal. The inherent elasticity of skin allows for slight discrepancies in limb length, though the discrepancy cannot be significant. The two lateral limb–central limb angles can differ, though similar, if not identical, angles are generally used.20 The degree of scar lengthening increases with the size of the central limb–lateral limb angles, though flap transposition is often difficult when angles exceed 60 degrees. For that reason, a 60-degree angle is often used in that it provides reasonable central limb lengthening needed while avoiding prohibitive tension at closure . A Zplasty with 60-degree angles produces a 75% lengthening of the scar as compared with a 30-degree angle that produces only 25% lengthening .20 In multiple Zplasties, seg- ments should not generally be smaller than 1 cm to provide flaps of reasonable size for transposition. The scar length increase provided by a given Z-plasty or multiple Z-plasties in series can be readily calculated. The original central limb increases in length by a factor of  3.21 The total gain in length increases with the size of the Z-plasty limbs

Chapter 6 Scars and Scar Revision

and is generally greater with one large Z-plasty as opposed to multiple small Z-plasties.17 However, Furnas demonstrated that geometric calculations for gain in length of a Z-plasty on a two-dimensional surface do not precisely predict the gain in scar length in vivo on a three-dimensional surface. The key element in this loss of predicted length was skin tension. Lengthening was always less than that predicted mathematically, ranging from 55% to 84% of the predicted value based on regions of the body and the individuals on which the Z-plasty was performed.

W-PLASTY The W-plasty technique for scar revision is similar to Z-plasty in that it breaks up a straight-line scar into a pattern that is less conspicuous. Unlike the Z-plasty, there is no length gained; therefore there is no release of any contracture. Because the resulting scar is irregular, however, it does provide some increase in scar elasticity and provides fewer tendencies to contract secondarily than with a linear incision. It is most useful when the original scar deviates more severely from the RSTLs. Similar to a fusiform excision, a W-plasty involves the removal of skin. For this reason the method should be avoided if significant tension is present across the wound edges. W-plasty scar revision has been promoted for the following conditions22:  ATL scars of the forehead, eyebrows, temples, cheeks, nose, and chin  Small but broad, depressed scars

There are several principles involved in designing a W-plasty. The base of the tri - angle at each end should be at right angles to the scar. The angles of the flaps should be 55 to 60 degrees. The length of individual segments should practically be be- tween 5 and 7 mm. Limbs should be shorter toward the ends of the Wplasty to prevent formation of dog-ears and limit the length of scars within ATLs. 16

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GEOMETRIC BROKEN-LINE REVISION

Geometric broken-line revision can be used in all of the same situations as a W-plasty to break up the zigzag pattern and presumably make the scar less conspicuous to the eye. It differs from a Z-plasty in that the interdigitated shapes are not all angular. It can be difficult to execute and is not commonly used.

YV-PLASTY Multiple YV-plasties Incision made 1

Flaps advanced 1

2 1

2

1 2 2

A YV-plasty, like a Z-plasty, lengthens the scar to some degree and is useful for the release of contracted scars. The orientation of the resulting scars is different from those after a Z-plasty, which may provide advantages in some clinical situations. In YV-plasties the skin for transposition is not detached from its substratum (in contrast to the Z-plasty) but is displaced by sliding it on its substratum. The tongues of the upper part slide into the stem of the Y and form a V. 23 Tension along a scar can be limited by several transverse Y-shaped incisions situated in parallel.

MORE COMPLEX TISSUE REARRANGEMENTS As mentioned, a basic surgical requirement for ideal scar creation is tension-free wound closure. In most cases, the resolution of edema and some skin stretching allows for minimal tension in secondary revision procedures. In cases in which tension persists, additional tissue needs to be recruited to the area.This can often be ac-

Chapter 6 Scars and Scar Revision

complished through tissue expansion, which increases the volume of skin with similar color and texture characteristics in the area of injury.This will provide the most aesthetic reconstructive result. Alternatively, flaps can be rotated from adjacent areas into the injured area to augment the volume of local tissue.

NONSURGICAL SCAR MODIFICATION For scars that are not exceptionally wide or irregular, nonincisional modalities such as dermabrasion, various laser treatments, and chemical peels can be useful. They generally smooth the contour of the injured area so that fewer shadows are produced by changes in skin or scar contour. The resurfacing stimulated by these procedures often blurs the juncture of scarred and unscarred areas. The primary risks are scarring and skin pigmentation changes:  Pigmentation issues are of particular concern in dark-skinned individuals.  Pigmentation changes and scarring are much more likely when resurfacing is taken into the reticular dermis and are rare, especially in white individuals, when treatment is limited to a more superficial level.  Pigmentation changes may also be more likely in pregnant women and those taking oral contraceptives.

DERMABRASION AND MICRODERMABRASION With dermabrasion, a high-speed abrasive device removes the superficial skin layers like a sander. Skin is generally removed down to the papillary dermis where pinpoint bleeding is encountered to allow for prompt and reliable skin reepithelialization. Harmon et al24 demonstrated an increase in collagen bundle density and size, with a reorientation of collagen fibers parallel to the epidermal surface in scars treated with dermabrasion. These changes may contribute to the beneficial effects noted with treatment. Some have used refrigerants such as fluoroethyl to make the skin firmer before treatment, but these agents may be associated with more pain and increased risks of scarring and pigmentation changes. Alternatively, a tumescent technique can be used to firm tissues in lax areas before treatment. Dermabrasion is a particularly useful technique for modifying acne scars. It does not eliminate the pits entirely but smooths their margins, resulting in less shadowing and scar prominence. Dermabrasion is also a useful technique for smoothing prominent scars. Collins and Farber25 reported favorable results with dermabrasion for postsurgical nasal scars in 1984. Robinson later demonstrated smoother contours after postoperative dermabrasion to full-thickness skin grafts.26,27 Rohrich et al28 have used primary dermabrasion to wounds created during nasal reconstructions, and it is their feeling that this has improved scarring.

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This 32-year-old woman demonstrates a depressed linear scar of the left cheek after excision of a basal cell carcinoma. Secondary correction via multiple Z-plasties was attempted. Scars of this nature are prominent because they tend to reflect light along their edges; they are difficult to conceal with cosmetics.

A W-plasty failed to conceal the scar adequately over its lateral portion; therefore dermabrasion was performed over the area outlined. A rotating dermabrasion wire brush or wheel is used to plane down the area, going deeper where the ridges are most prominent. It is important to feather the borders into the surrounding normal skin. The immediate result shows punctate bleeding and the whitish scar is less visible.

Chapter 6 Scars and Scar Revision

At 3 months postoperatively, the scar is less visible. At this point the area is easily concealed by cosmetics. Microdermabrasion, although probably more commonly used for aesthetic indications, can also be used as a treatment for prominent scarring.25 Histologic benefits of microdermabrasion include fibroblast stimulation and dermal collagen deposition.29,30 This technique uses a stream of fine abrasives, usually aluminum oxide crystals, directed at the skin with a compressed air system.The pressure with which the crystals are projected is adjusted to achieve a mild pink color in treated areas. The operator also controls the depth of treatment with the speed of movement of the handpiece and the number of passes. Once a treatment session is completed, any residual powder may be wiped away. Healing generally occurs over 3 days. This procedure can be performed weekly or biweekly for multiple sessions. Microdermabrasion has the benefits of minimal discomfort, no bleeding or desquamation, and only minimal temporary erythema.31 Complications usually arise secondary to irritation caused by the aluminum oxide crystals and are most commonly seen in the eye.

CO2 LASER The quality of scars can often be improved by treatment of the injured area with a CO2 laser. As with dermabrasion, cells in treated areas are ablated and secondary healing results in a smoother contour to the treated region. The depth of injury is generally modulated to extend to the papillary dermis to allow for relatively rapid healing, though energy levels can be increased to provide a greater depth of injury if desired. Shim et al studied biopsies from scars of 23 patients after laser resurfacing and demonstrated an increase in collagen layer thickness and new collagen formation following treatment.32 Gardner et al33 demonstrated that part of the CO2 resurfacing laser’s acute mechanism of action is because of collagen contraction. Bernstein et al34 treated 30 subjects with mature surgical, traumatic, acne, or varicella scars with either a high-energy, short-pulsed CO2 laser or a continuous-wave CO2 laser with flash-scanner.Twenty of 24 surgical scars demonstrated greater than

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75% improvement, and 100% of scars had greater than 50% improvement by photographic analysis. They also noted that elevated scars improved more dramatically than depressed scars. Similar findings with high-energy, pulsed and scanned CO 2 lasers on atrophic scars resulting from acne, surgery, or trauma were reported by West35 and Nehal et al.36

YAG LASER Wavelength-specific lasers (yttrium-aluminum-garnet and pulsed dye lasers) have been used to selectively ablate blood vessels and thereby limit erythema and facilitate scar flattening and maturation. Abergel et al37 reported flattening and softening in scars in eight patients treated with the YAG laser with 3-year follow-up . They postulated that the treatment produced an inhibition of fibroblast functions. A recent study of 36 patients by Kwon and Kye38 showed that the pulsed YAG laser is an effective and safe treatment option for hypertrophic and depressed scars. Twelve of these patients were treated for hypertrophic scars, 20 for depressed scars, and four for burn scars. Nine of 12 hypertrophic scars, 17 of 20 depressed scars, and two of four burn scars were improved more than 50%.

PULSED DYE LASER Flashlamp-pumped pulsed dye lasers have shown promise in both limiting erythema in scars and flattening them as well.39-41 This modality was also studied in 106 patients (171 anatomic sites) treated within 2 weeks after surgery where fast resolution of scar stiffness and erythema and improvement in quality of scarring was noted.42 However, a recent single-blind, randomized, controlled study in 20 patients with hypertrophic scars showed no improvements in hypertrophic scars following pulsed dye laser therapy.43

FREE ELECTRON LASER The free electron laser is an infrared laser that is broadly tunable. This laser can de - liver nonoverlapping pulses in a preformed pattern using a computer -assisted sur- gical techniques system .44 Previous studies with the free electron laser have demon - strated that wavelengths targeting vibrational modes of extracellular matrix protein cause loss of structural integrity with minimal collateral damage. 45,46 Edwards et al 45 reported that tissue ablation using the free electron laser set at 6 .45 m resulted in less thermal collateral injury than that generated by the CO 2 laser. They also stated that the free electron laser provides better scar reduction in vivo than CO 2 resurfacing lasers and dermabrasion , the classic method for resurfacing scars.

CHEMICAL PEELS Chemical peels can be used to flatten scars in a manner similar to dermabrasion and CO2 laser resurfacing. Chemical peels may be divided into superficial (for epider-

Chapter 6 Scars and Scar Revision

mal injury), medium depth (for superficial dermal injury to the papillary dermis), and deep (for mid-dermal injury to the reticular dermis). Superficial peels can be performed using alpha-hydroxy acids or 15% to 20% trichloroacetic acid. Agents most frequently used to create a medium-depth peel include 35% trichloroacetic acid, a combination of 35% tricarboxylic acid with 70% glycolic acid (Coleman technique), and 35% tricarboxylic acid with Jessner’s solution (Monheit tech - nique).47,48 The deep chemical peel agent includes 50% trichloroacetic acid and the Baker-Gordon formula (3 ml SUP [standard unit of processing] liquid phenol, 2 ml tap water, 8 drops liquid soap, and 3 drops cotton oil). Patients with a history of car- diac, renal, or hepatic disease may not be candidates for phenol peels. Skin preparation for any peel includes vigorous cleansing with an exfoliant to remove oils and debris. The use of acetone may provide more even penetration. For medium depth or deep peels, patients may benefit from administration of mild sedatives and antiinflammatory drugs to alleviate swelling and discomfort. Antiviral and/or antibacterial agents are often used prophylactically for deeper peels. As the depth of peel increases , the therapeutic effects increase , smoothing the skin contour and generating more tightening of dermal collagen . Complications of medium and deep chemical peels include prolonged erythema, infection, scarring, and skin atrophy.49

SOFT TISSUE FILLERS Atrophic depressed scars or pitlike scars such as those resulting from acne can sometimes be improved by the injection of soft tissue filler. One approach is to use a bi - ologic material such as fat. The traditional approach to fat grafting involves the use of a large piece of dermis and fat excised from another anatomic location . More re- cently , micro -fat grafts have been popularized for the correction of subcutaneous defects. W.P. Coleman 50 has described in detail his harvesting and injection tech- nique for lipotransfer. He aspirates fat from an area of fat excess and then uses a cen- trifuge to separate fat cells from other components of the aspirate. He further breaks up the aspirated fat by transferring it between two syringes attached through a bi-Luer-Lok connector .51 The cells are then injected with small syringes into the area to be treated. AlloDerm (LifeCell Corp ., Branchburg , NJ ) is an acellular human dermal collagen matrix that has found utility in a variety of clinical situations for soft tissue augmen- tation. It can be placed within subcutaneous tissues to increase soft tissue bulk and smooth irregular contours that can result from some types of scar. Alternatively, a variety of injectable soft tissue fillers are currently available commer - cially . Bovine collagen , marketed as Zyderm and Zyplast (Inamed Aesthetics , Santa Barbara , CA ), is the injectable agent that has been available the longest . Bovine col- lagen is detected as a foreign substance and is degraded by human collagenases and

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inflammatory cells over several months. Investigations in vivo have demonstrated that bovine collagen is undetectable in the treated dermis 3 months after injection. Therefore bovine collagen must be administered frequently to maintain its clinical results, and it has been occasionally associated with allergic reactions.52,53 Cosmoderm and Cosmoplast (Inamed Aesthetics) are newer soft tissue fillers that include natural human collagen. These fillers are considered to be less immunogenic, and it is speculated that they will degrade more slowly and last longer. Other filling agents such as hyaluronic acid have also been recently approved for human use. Hyaluronic acid is a naturally occurring polysaccharide found in intercellular matrix that serves a primary role in the hydration, lubrication, and stabilization of connective tissue. It has been approved for the treatment of facial rhytids. Olenius54 evaluated 285 facial rhytids treated with hyaluronic acid and found that the degree of correction or aesthetic improvement as rated by the physicians declined from 98% at 2 weeks to 82% at 3 months, 69% at 6 months, and 66% at 1 year. Side effects were infrequent and self-limited. It would be expected that improvement in scar contours created by hyaluronic acid injections would last for similar periods.

ABNORMAL SCARRING CONDITIONS KELOIDS AND HYPERTROPHIC SCARS Hypertrophic scars and keloids develop exclusively in humans. They occur with equal frequency in males and females and occur most commonly in younger people, particularly in the second decade of life. They are differentiated by their gross appearance. Hypertrophic scars are confined to the area of injury, whereas keloids proliferate beyond the boundaries of the original scar.141 Both keloids and hypertrophic scars cause itching, tenderness, and pain and frequently recur after excision. The cause of both keloids and hypertrophic scars is unknown, although both are associated with a prolonged inflammatory response and increased extracellular matrix production.55-58 The anterior chest, shoulders, upper arms, and jawline have a predilection to abnormal scarring. The increased incidence of abnormal scarring in these locations has been attributed to increased skin tension in these areas.The eyelids, genitalia, palms, soles, and mucous membranes are not commonly affected.59-63 There are some differences between the growth characteristics of keloids and hypertrophic scars. Keloids may not appear immediately after injury. Although they are generally evident within 3 months, they can rarely develop years after the original injury. They almost never spontaneously recede. In contrast, hypertrophic scars generally appear within 4 weeks of injury and often regress over time.64 Keloids primarily occur in dark-pigmented individuals who are predisposed toward them.56,64-66

Chapter 6 Scars and Scar Revision

MANAGING ABNORMAL SCARRING It can never be stated with assurance whether an abnormal scar will develop in a specific clinical environment. One can identify wounds and individuals that have a greater likelihood of abnormal scarring, but nothing is 100% predictive. Similarly, no one can guarantee that any treatment regimen will prevent recurrence. Although no treatment is uniformly efficacious, a variety of treatment options are available. Some are more amenable to hypertrophic burn scars or linear incisions, whereas others are more useful for keloids. Generally, less-invasive modalities are preferred if they can produce the desired degree of improvement. Any treatment regimen, including surgery or scar ablation, harbors the risk of exacerbating the abnormal scarring.The risks and benefits of all options available must be considered when developing a treatment plan for a patient with abnormal scarring.

SILICONE SHEETING The application of topical silicone gel sheeting has been used to either limit the development of abnormal scars or treat them once they have occurred. The treatment costs little and morbidity is low, so it is a good first-line treatment for the prevention or treatment of abnormal scars. Several controlled trials have demonstrated the efficacy of silicone gel sheeting for managing hypertrophic scars and keloids.67 Ahn et al68,69 studied the effects of a silicone gel bandage worn for at least 12 hours daily on the resolution of hypertrophic burn scars. They reported increased scar elasticity and diminished volume scar after 1 and 2 months of treatment as compared with controls. Several authors have treated a series of patients with abnormal scars with either silicone sheeting or silicone gel–filled cushion and showed that in the majority of patients scar volume was reduced.70-72 Agarwal et al67 performed punch grafting in 15 patients with vitiligo, using punches varying in diameter from 2 to 3 mm and used silicone gel sheets as a postoperative dressing. Two months after biopsy, no cobblestoning or other untoward effects were evident. The authors cited other advantages of the sheeting, such as providing a sterile atmosphere for the grafts, facilitating periodic observation because of their transparency, and easy removal at follow-up. The mode of action of silicone materials is still unknown. It has been demonstrated that their therapeutic effect is not caused by pressure, a difference in oxygen tension, or temperature.73,74 It may be the occlusive nature of the material itself, which increases the level of hydration of the skin.73,75 Hydration has been proven to modulate the activity of keratinocytes on fibroblasts.76,77 Keratinocytes in a moist milieu down-regulate collagen and glycosaminoglycan synthesis by fibroblasts.75,78 It has been recommended that the silicone material be worn 24 hours a day for at least 3 months to prevent rebound hypertrophy.79

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PRESSURE THERAPY Pressure therapy has been used to manage hypertrophic scars and keloids since the 1970s. It is commonly used to limit the development of hypertrophic burn scars.80-85 It is felt that the pressure exerted should be at least 24 mm Hg to exceed the inherent capillary pressure.86,87 The pressure is believed to cause ischemia, which decreases tissue metabolism and increases collagenase activity within the wound.79 Maintaining this pressure for months to 2 years has been shown clinically to resolve hypertrophic scars permanently.87-89 It is generally recommended that pressure garments be worn 18 to 24 hours a day for at least 4 to 6 months59,88,90-92 to prevent rebound hypertrophy after burn injury .88 Like silicone sheeting , pressure therapy has limited morbidity and is a good first line treatment for abnormal scars . Pressure therapy and silicone sheeting can also be used together. A 60% to 85% reduction in burn scar hypertrophy has been reported with pressure garments, though definitive efficacy has never been demonstrated in a randomized prospective trial.93,94 In one of the few objective studies that has been performed, Chang et al95 prospectively assigned patients in a random fashion to receive either pressure garment therapy or no pressure garment therapy after burn injury; 122 consecutive patients were enrolled in the study . No significant differences were found between the two groups when time to wound maturation was compared. Pressure has also been used as an adjunctive modality to surgery in the treatment of keloids and established hypertrophic scars . Pressure -generating earrings are partic - ularly useful in treating keloids of the earlobe after surgery . Surgery followed by pressure treatment has produced success rates of up to 90% to 100%. 93,96-99

CORTICOSTEROID INJECTIONS There is a broad consensus that injected triamcinolone is frequently efficacious in limiting the firmness and prominence of hypertrophic scars and keloids.26,80,90,100 -104 The mechanism of action is not entirely known , although treatment with intrale- sional steroid agents may increase local collagenase levels and diminish collagen synthesis . Reported response rates vary from 50 % to 100 %, with recurrence rates of 9% to 50%.79 Although more invasive than silicone sheeting , this method can still be employed in the outpatient clinic and has little chance of contributing to scar worsening. For already established abnormal scars and scars which are not amenable or responsive to treatment with pressure and silicone sheeting, corticosteroid injec- tions can be useful. Although a variety of steroids have been applied topically or intralesionally injected for abnormal scars, triamcinolone acetate is probably the most effective and is most commonly used.105,106 Up to 3 ml of 40 mg/ml triamcinolone acetate is injected at

Chapter 6 Scars and Scar Revision

one time. Treatments are spaced at 6-week intervals to minimize the chance of systemic steroid effects. Two or three injections are usually sufficient, although occasionally injections continue for 6 months or more.105,106 Complications of longterm use can include tissue atrophy, depigmentation, and telangiectasia. Various mechanisms of action for corticosteroid injection on scar resolution have been postulated. Steroids affect almost all aspects of the healing process, but when injected into abnormal scars, the primary effect is most likely related to an alteration in the balance between collagen synthesis and breakdown by metalloproteinases.79,91,107-112 Injections may be used alone or as adjuncts to other therapies such as surgery.105 Tang113 showed promising results with a protocol consisting of surgical excision combined with steroid injections intraoperatively, weekly postoperatively for 2 to 5 weeks and then monthly for another 3 to 6 months.

INTERFERON-ALPHA2B Intralesional interferon-alpha2b (IFN-alpha2b) has been used more recently as a treatment modality for keloids and hypertrophic scars. Like steroids, it can be used alone or as an adjunct to surgical treatment. Interferon-alpha2b has been shown to reduce serum TGF-beta concentration, and this may one of the primary actions of interferon-alpha2b on scar remodeling.114 Intralesional interferon-alpha2b alone has been demonstrated to produce a reliable reduction in keloid area with a recurrence rate of 8% to 18.7%.96,115 Tredget et al114 demonstrated that IFN-alpha2b injections three times weekly created a greater degree of improvement in hypertrophic scars than seen in a control group. Berman and Flores116 used IFN-alpha2b in an adjuvant setting for keloids and reported that in lesions excised without postoperative injections, 51.1% recurred, while 18.7% of IFN-alpha2b–treated lesions recurred (p  0.025). They concluded that injection of IFN-alpha2b offers a therapeutic advantage over keloid excision alone.

OTHER INTRALESIONAL AGENTS Interferon-gamma has also been used as an intralesional agent in the treatment of keloids and hypertrophic scars. Granstein et al117 reported that intralesional interferon-gamma produced a mean reduction of 30.4% in scar volume versus 1.1% at the control site. Larrabee et al118 demonstrated 50% reduction in 5 of 10 treated scars after 10 weeks of intralesional interferon-gamma (IFN-gamma) injections. Purported mechanisms of scar resolution with intralesional IFN-gamma include a diminished quantity of thickened collagen bundles in the dermis, a reduced amount of active fibroblasts, and an increased number of inflammatory cells.117

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Intralesional 5-fluorouracil (5-FU) has been used successfully as monotherapy or in combination with intralesional corticosteroids to treat hypertrophic scars and keloids. Fitzpatrick119 reported success with a regimen that included one to three injections of 5-FU per week; this was continued until the scars began to resolve. The frequency of injections was then gradually diminished (weekly to monthly). The combination of 5-FU and Kenalog was felt to be more effective and less painful. 5-FU injections in combination with pulsed dye laser treatments were deemed most effective. Gupta and Kalra120 tested 5-FU injections on 24 patients with keloids of 6 cm or less. One third of these patients showed more than 75% flattening of the keloid. Overall, about half of the patients showed more than 50% flattening of the treated keloid. Side effects included pain and hyperpigmentation in all patients tested. Intralesional bleomycin injections have also proved effective for managing hypertrophic scars.121,122 A small pilot study by España et al123 in 13 patients showed complete or significant flattening (more than 90%) in 12 of 13 hypertrophic scars and keloids after administration of bleomycin using a multiple-puncture method on the skin surface. The authors suggested that further larger studies are needed to confirm these findings. Intralesional verapamil has also been used, both independently and as an adjunct to surgical treatment for keloids and hypertrophic scars. Lawrence124 administered intralesional verapamil (2.5 mg/ml) 7 to 14 days after keloid removal and again, when possible, approximately 1 month after removal. Patients were instructed to wear pressure earrings essentially continuously for a minimum of 6 months after excision. Twenty-two keloids (55%) were cured by this modality, with a minimum follow-up of 6 months.

TOPICAL AGENTS Imiquimod 5% cream is currently approved for treatment of genital and perianal warts, and it has also been used adjunctively in the treatment of keloids. It activates natural killer cells, macrophages, and Langerhans cells and induces the local synthesis and release of cytokines, including IFN-alpha2b, IFN-gamma, TNF-alpha, and interleukins-1, -6, -8, and -12, when topically applied.125 There is a dose-dependent inhibition of human fibroblast collagen production by IFN-alpha and IFN-gamma.126 Kaufman and Berman127 examined the effects of imiquimod 5% cream after surgical excision of 13 keloids from 12 adult patients. Imiquimod 5% cream was applied nightly, beginning the day of surgery and continuing for 8 weeks. At 24 weeks after surgery, no recurrence of keloid growth was noted among any of the patients who completed the study. Local skin reactions included pruritus and infection, though no systemic effects were noted.

Chapter 6 Scars and Scar Revision

Clark128 randomized 30 patients after keloid excision either to receive an IFNalpha2b injection the day of surgery and again 1 week later, or to apply imiquimod 5% cream to the surgical wound daily for 8 weeks. After 6 months, only one recurrence was reported in each group.

SURGERY

FOR

ABNORMAL SCARS

If silicone gel sheeting, pressure garments, and intralesional modalities are not successful, or if the abnormal scar is extensive enough to make a complete response to less-invasive treatment unlikely, surgical excision may be appropriate. Surgical excision alone results in elimination of approximately one third of keloids.105 Surgery alone is more likely to be successful in circumstances in which abnormal scarring developed after prolonged inflammation or extensive trauma. The healing environment after a revision procedure would be quite different, and improved results might reasonably be anticipated. It is important to incorporate the basic surgical principles just discussed for any surgical procedure to revise abnormal scars. Minimizing the use of permanent or slowly dissolving sutures is recommended, because they may promote prolonged inflammation and increased scar production.

This patient underwent facial rejuvenation with an extended SMAS technique. The 6-month postoperative result demonstrates the effect of excessive tension at the earlobe, probably as a result of overexuberant skin excision. The area of hypertrophic scarring is outlined.

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The operative plan involved excision of the hypertrophic scar and the recruitment of skin rotated into the postauricular sulcus. In this manner the dog-ear can be chased into an area of concealment. She is shown immediately after revision surgery. Permanent skin sutures and minimal deep sutures were placed to avoid stimulation of inflammation.

At 3 months her scar is less visible.There is no evidence of hypertrophic scar recurrence. The line of closure is also less visible.

Chapter 6 Scars and Scar Revision

Some surgeons have promoted the use of intramarginal keloid excisions, where a rim of keloid is left to stent the wound and potentially limit the stimulus for recurrent keloid formation. The efficacy of this approach has not been substantiated. Grafting of the excised area, sometimes using dermal and epidermal elements removed from the excised keloid, has also been suggested as a method of closing a wound resulting from keloid excision. Such grafts limit tension on the closed wound and eliminate the need for creating an additional wound in a donor area. In areas where tension is felt to be a contributing factor to abnormal scar development, techniques such as the Z-plasty can also limit the likelihood of recurrence. However, the irregular scar created by this technique may not be desirable in some locations. An alternative approach to the Z-plasty is to use a series of small wave incisions approximately 1 cm in length.These small wave incisions combine to form a smooth wave shape, which approximates a straight line after closure.Tension in the wound is reduced, and the result appears to be an inconspicuous linear scar.129

OTHER ABLATIVE MODALITIES Cryosurgery Cryosurgery as a monotherapy regimen for treating hypertrophic scars and keloids first evolved in 1982.130 The extremely low temperatures generated by the cryoprobe cause vascular damage and blood stasis within the keloid tissue that leads to cell anoxia and death. Hoffmann et al demonstrated complete destruction of the vasculature in the center of a cryosurgically treated area with a gradual transition to normal vascular patency as one moved radially outward from the primary treatment site.131 Shepherd et al130 demonstrated that a solitary cryosurgical session for keloids achieved 80% improvement and a recurrence rate of 33%. Repeated surface/spray cryosurgical sessions have also been demonstrated to produce a beneficial effect on hypertrophic scars and keloids (between 68% and 81% remission), with almost no recurrence (2%).132,133 More recent studies report cryotherapy results in keloid flattening in 51% to 74% of patients after two or more sessions.134-136 Limitations in cryotherapy include the delay of several weeks required for postoperative healing and a side effect of permanent hypopigmentation. Other possible side effects include hyperpigmentation, skin atrophy, and pain.137 Because only a portion of the scar is eliminated, results are often less than ideal.

Lasers Lasers of various types have been used to treat keloids and hypertrophic scars. Purely ablative lasers such as the CO2 lasers generally produce success rates similar to surgery alone.

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More-selective lasers, such as the YAG laser which targets blood vessels, have also been used. In a recent study of 17 patients with keloids, nearly 60% of keloids were flattened following one session of YAG laser treatment. These patients remained free of keloid scarring at 18-month to 5-year follow-up.138 The remaining seven patients required further laser treatment and intralesional corticosteroids to flatten the keloids completely. Recurrence of keloids occurred in three patients who responded to further laser treatment. Improvements in appearance of hypertrophic scars and keloids have been noted in 57% to 83% of cases treated with the pulsed dye laser.139 Further improvements were noted when used in combination with intralesional corticosteroids.139 A recent pilot study has reaffirmed that laser treatment in combination with intralesional corticosteroids is effective in eliminating previously resistant keloids.140

Radiotherapy Radiotherapy has been used both as a primary treatment for keloids and hypertrophic scars and as an adjunctive modality in combination with surgical excision. Response to radiotherapy alone is 10% to 94%, with a keloid recurrence rate of 50% to 100%. Best results have been achieved with 1500 to 2000 rads over five or six sessions in the early postoperative period.142,143 There have been mixed results from radiotherapy after surgical excision of keloids, with significant objective response rates reported in 25% to 100% of patients.144,145 Sclafani et al145 demonstrated improved results in keloid treatment with surgery and adjuvant radiotherapy compared with surgery and corticosteroid injections (12.5% versus 33% relapse at 12 months after treatment) in a prospective randomized trial. This difference did not reach statistical significance, however. Ragoowansi et al146 reviewed 6741 cases of keloids treated adjunctively with radiotherapy after surgical excision, including 4263 keloids in articles published from 1961 onward. Reported recurrence rates at 1 year or more vary from 53% to 2%. These authors found only five cases of possible radiation-induced cancers after keloid treatment despite the large number of patients treated. The crude risk from the published data accessed is at most 1 in 1348.

TIMING OF SCAR REVISION Ideally, scar revisions should be delayed for at least 6 months after a scar is created to allow the normal healing process to approach completion.This interval provides reasonable assurance that any unfavorable characteristic of the scar is not simply related to incomplete healing. With time, many problems spontaneously resolve, especially excessive scar erythema and prominence. Allowing scars to mature before

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considering revision allows the tissues to soften and become more pliable. These more natural tissue characteristics allow more precise surgical manipulations during any revision procedure. Some interventions are probably best carried out before a scar is fully mature. If a scar is becoming hypertrophic, the progression of the process may be limited by the application of pressure or topical silicone or intralesional injections with steroids or other agents. Some promote dermabrasion to relatively immature scars to promote more uniform healing of the scar surface. Some scar problems will clearly not improve with time. Widened, atrophic scars will not become narrower or flatter, no matter what the time interval. Such problems may be addressed whenever the nature of the surrounding tissues allows it.

CONCLUSION Complications related to scarring can result from almost any surgical procedure. When faced with an unattractive or dysfunctional scar, one must first diagnose what the problem is and then develop a hypothesis to explain why the problem might have developed. An assessment must then be made as to whether the problem is amenable to correction, and, if so, a decision must be made regarding which of the many treatment options available for scar revision is most appropriate for the specific clinical situation. Although there are many therapeutic modalities currently available, the future may hold newer and better techniques for modifying scars. Specific agents that directly affect cellular processes involved in healing may allow us to favorably influence scar production. These may include cytokines or antibodies that specifically limit the function of certain cytokines. Tissue engineering and expanded knowledge of genetic modulators of tissue production may allow us to eventually stimulate tissue regeneration instead of scar production. Such techniques could revolutionize wound and scar management.

References —With Key Annotated References 1. Montandon D, D’andiran G, Gabbiani G. The mechanism of wound contraction and epithelialization: Clinical and experimental studies. Clin Plast Surg 4:325-346, 1977. 2. Pollack S.Wound healing: A review. III. Nutritional factors affecting wound healing. J Dermatol Surg Oncol 5:615-619, 1979. 3. Bhanot S, Alex JC. Current applications of platelet gels in facial plastic surgery. Facial Plast Surg 18:27-33, 2002. 4. Gorti G, Ronson S, Koch RJ. Wound healing. Facial Plast Surg Clin North Am 10:119-127, 2002.

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5. Mullen J. Indications and effects of preoperative parenteral nutrition. World J Surg 10:53-63, 1986. 6. Thakral KK, Goodson WH III, Hunt TK. Stimulation of wound blood vessel growth by wound macrophages. J Surg Res 26:430-436, 1979. 7. Peacock E. Wound Repair. Philadelphia: WB Saunders, 1984. 8. Smith KP, Zardiackas LD, Didlake RH. Cortisone, vitamin A, and wound healing:The impor - tance of measuring wound surface area. J Surg Res 40:120-125, 1986. 9. Enquist I, Adamson R. Collagen syntheses and lysis in healing wounds. Minn Med 48:16951698, 1965. 10. Mizumoto T. Effects of the calcium ion on the wound healing process. Hokkaido Igaku Zasshi 61:332-345, 1987. 11. Carrico T, Mehrhof A, Cohen I. Biology of wound healing. Surg Clin North Am 64:721 - 733, 1984. 12. Weringer EJ, Kelso JM, Tamai IY, et al. Effects of insulin on wound healing in diabetic mice . Acta Endocrinol 99:101-108, 1982. 13. Borges AF. Relaxed skin tension lines (RSTL) versus other skin lines. Plast Reconstr Surg 73:144-150, 1984. 14. Elliot D, Mahaffey PJ. The stretched scar: The benefit of prolonged dermal support. Br J Plast Surg 42:74-78, 1989. 15. Borges AF. Elective Incision and Scar Revision. Boston: Little Brown, 1973. 16. Borges AF. Scar analysis and objectives of revision procedures. Clin Plast Surg 4:223-237, 1977. These articles by Borges constitute a thorough review of not only surgical management of problem scars , but also provide in-depth coverage of principles of plasty selection. 17. Furnas DW. The four fundamental functions of the Z-plasty. Arch Surg 96:458-463, 1968. 18. Robinson JB, Friedman RM. Wound healing and closure. Selected Readings in Plastic Surgery, vol 8, no. 1, 1995. 19. Rohrich RJ, Zbar RI. A simplified algorithm for the use of Z-plasty. Plast Reconstr Surg 103:1513-1517, 1999. This article provides an excellent summary of the principles described by Borges, Furnas, and others regarding Z-plasty. 20. McGregor IA. The Z-plasty. Br J Plast Surg 19:82-87, 1966. 21. Stevenson TW. Release of circular constricting scar by Z flaps. Plast Reconstr Surg 1:39, 1946. 22. Rohrich RJ, Robinson JB. Wound healing. Selected Readings in Plastic Surgery, vol 9, no. 3, 1999. 23. Olbrisch RR. Running V-Y plasty. Ann Plast Surg 26:52-56, 1991. 24. Harmon CB, Zelickson BD, Roenigk RK, et al. Dermabrasive scar revision. Immunohisto - chemical and ultrastructural evaluation. Dermatol Surg 21:503-508, 1995. 25. Collins PS, Farber GA. Postsurgical dermabrasion of the nose. J Dermatol Surg Oncol 10:476-477, 1984. 26. Kelly AP. Keloids. Dermatol Clin 6:413-424, 1988. 27. Robinson JK. Improvement of the appearance of full-thickness skin grafts with dermabrasion. Arch Dermatol 123:1340-1345, 1987. 28. Rohrich RJ, Griffin JR, Ansari M, et al. Nasal reconstruction—beyond aesthetic subunits: A 15-year review of 1334 cases. Plast Reconstr Surg 114:1405-1416, 2004. 29. Rubin MG, Greenbaum SS. Histologic effects of aluminum oxide microdermabrasion on fa - cial skin. J Aesthetic Dermatol 1:237-239, 2000. 30. Tan MH, Spencer JM, Pires LM, et al.The evaluation of aluminum oxide crystal microderm - abrasion for photodamage. Dermatol Surg 27:943-949, 2001. 31. Freedman BM, Rueda-Pedraza E, Waddel SP. The epidermal and dermal changes associated with microdermabrasion. Dermatol Surg 127:1031-1033, 2001. 32. Shim E,Tse Y,Velazquez E, et al. Short-pulse carbon dioxide laser resurfacing in the treatment of rhytides and scars: A clinical and histopathological study. Dermatol Surg 24:113 -117, 1998.

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33. Gardner ES, Reinisch L, Stricklin GP, et al. In vitro changes in non-facial human skin follow - ing CO2 laser resurfacing: A comparison study. Lasers Surg Med 19:379-387, 1996. 34. Bernstein LJ, Kauvar AN, Grossman MC, et al. Scar resurfacing with high-energy short - pulsed and flash scanning carbon dioxide lasers. Dermatol Surg 24:101-107, 1998. 35. West TB. Laser resurfacing of atrophic scars. Dermatol Clin 15:449-457, 1997. 36. Nehal KS, Levine V, Ross B, et al. Comparison of high-energy pulsed carbon dioxide laser resurfacing and dermabrasion in the revision of surgical scars. Dermatol Surg 24:647 -650, 1998. 37. Abergel RP, Meeker CA, Lam T, et al. Control of connective tissue metabolism by lasers: Recent developments and future prospects. J Am Acad Dermatol 11:1142-1150, 1984. 38. Kwon SD, Kye YC. Treatment of scars with a pulsed Er:YAG laser. J Cutan Laser Ther 2:27 - 31, 2000. 39. Alster TS. Improvement of erythematous and hypertrophic scars by the 585-nm flashlamp - pulsed dye laser. Ann Plast Surg 32:186-190, 1994. 40. Alster TS, Kurban A, Grove G, et al. Alteration of argon induced scars by the pulsed dye laser . Lasers Surg Med 13:368-373, 1993. 41. Alster TS, Williams C. Treatment of keloid sternotomy scars with 585 nm flashlamppumped pulsed-dye laser. Lancet 345:1198-1200, 1995. 42. McCraw JB, McCraw JA, McMellin A, et al. Prevention of unfavorable scars using early pulse dye laser treatments: A preliminary report. Ann Plast Surg 42:7-14, 1999. 43. Wittenberg GP, Fabian BG, Bogomilsky JL, et al. Prospective single-blind, randomised controlled study to assess the efficacy of the 585-nm flashlamp pumped pulsed dye laser and silicone gel sheeting in hypertrophic scar treatment. Arch Dermatol 135:1049-1055, 1999. 44. Reinisch L, Mendenhall MH, Charous S, et al. Computer-assisted surgical techniques using the Vanderbilt free electron laser. Laryngoscope 104:1323-1329, 1994. 45. Edwards G, Logan R, Copeland M, et al. Tissue ablation by a free-electron laser tuned to the amide II band. Nature 371:416-419, 1994. 46. Ellis DL, Weisberg NK, Chen JS, et al. Free electron laser infrared wavelength specificity for cutaneous contraction. Lasers Surg Med 25:1-7, 1999. 47. Coleman WP, Futrell JM. The glycolic acid trichloroacetic acid peel. J Dermatol Surg On - col 20:76-80, 1994. 48. Monheit GD. The Jessner’s-trichloroacetic acid peel. Dermatol Clin 13:277-283, 1995. 49. Baker TJ, Gordon HL. Chemical face peeling. In Baker G, ed. Surgical Rejuvenation of the Face. St Louis: Mosby, 1986, pp 37-100. 50. Coleman WP III. Lipotransfer. In Elson ML, ed. Evaluation and Treatment of the Aging Face . New York: Springer-Verlag, 1995, p 101. 51. Coleman WP, Lawrence N, Sherman RN, et al. Autologous collagen? Lipocytic dermal aug - mentation: A histopathologic study. J Dermatol Surg Oncol 19:1032-1040, 1993. 52. Robinson JK, Hanke CW. Injectable collagen implant: Histopathologic identification and longevity of correction. J Dermatol Surg Oncol 11:124-130, 1985. 53. Kligman AM, Armstrong RC. Histologic response to intradermal Zyderm and Zyplast (glu - taraldehyde cross-linked) collagen in humans. J Dermatol Surg Oncol 12:351-357, 1986. 54. Olenius M. The first clinical study using a new biodegradable implant for the treatment of lips, wrinkles, and folds. Aesthetic Plast Surg 22:97, 1998. 55. Adzich N. Wound healing: Biologic and clinical features. In Sabiston DC, Lylery HK, eds. Textbook of Surgery and the Biological Basis of Modern Surgical Practices, 15th ed. Philadelphia: WB Saunders, 1997, pp 207-220. 56. Murray JC, Pinnell SR. Keloids and excessive dermal scarring. In Cohen IK, Diegelmann RF, Lindblad WJ, eds.Wound Healing: Biochemical and Clinical Aspects. Philadelphia:WB Saun - ders, 1992. 57. Bettinger DA, Yager D, Diegelmann RF, Cohen IK. The effect of TGF-beta on keloid fi - broblast proliferation and collagen synthesis. Plast Reconstr Surg 98:827-833, 1996. 58. Bayat A, McGrouther DA, Ferguson MW. Skin scarring. Br Med J 326:88-92, 2003.

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59. Ketchum LD. Hypertrophic scars and keloids. Clin Plast Surg 4:301-310, 1977. 60. Alhady SM, Sivanantharajah K. Keloids in various races: A review of 175 cases. Plast Reconstr Surg 44: 564-566, 1969. 61. Buchwald C, Nielsen LH, Rosborg J. Keloids of the external ear. J Otorhinolaryngol Relat Spec 54:108-112, 1992. 62. LeFlore I, Antoine G. A keloid formation on palmar surface of hand. J Natl Med Assoc 83:463-464, 1991. 63. Ford T, Widgerow AD. Umbilical keloid: An early start. Ann Plast Surg 25:214-215, 1990. 64. Peacock EE, Madden JW, Trier WC. Biologic basis for the treatment of keloids and hypertrophic scars. South Med J 63:755-760, 1970. 65. Tredget EE, Nedelec B, Scott PG, Ghahary A. Hypertrophic scars, keloids, and contractures. Surg Clin North Am 77:701-730, 1997. 66. Darzi MA, Chowdri NA, Caul SK, et al. Evaluation of various methods of treating keloids and hypertrophic scars: A 10-year follow-up study. Br J Plast Surg 45:374-379, 1992. 67. Agarwal US, Jain D, Gulati R, et al. Silicone gel sheet dressings for prevention of post-minigraft cobblestoning in vitiligo. Dermatol Surg 25:102-104, 1999. 68. Ahn ST, Monafo WW, Mustoe TA. Topical silicone gel for the prevention and treatment of hypertrophic scars. Arch Surg 126:499-504, 1991. 69. Ahn ST, Monafo WW, Mustoe TA. Topical silicone gel: A new treatment for hypertrophic scars. Surgery 106:781-786, 1989. 70. Berman B, Flores F. Comparison of a silicone gel-filled cushion and silicone gel sheeting for the treatment of hypertrophic or keloid scars. Dermatol Surg 25:484-486, 1999. 71. Gold MH. A controlled clinical trial of topical silicone gel sheeting in the treatment of hypertrophic scars and keloids. J Am Acad Dermatol 30:506-507, 1994. 72. Cruz-Korchin NI. Effectiveness of silicone sheets in the prevention of hypertrophic breast scars. Ann Plast Surg 37:345-348, 1996. 73. Quinn KJ. Silicone gel in scar treatment. Burns Incl Therm Inj 13(Suppl):S33, 1987. 74 Quinn KJ, Evans JH, Courtney JM, et al. Non-pressure treatment of hypertrophic scars. Burns Incl Therm Inj 12:102, 1985. 75. Chang CC, Kuo YF, Chiu HC, et al. Hydration, not silicone, modulates the effects of keratinocytes on fibroblasts. J Surg Res 59:705, 1995. 76. Sawada Y, Sone K. Hydration and occlusion treatment for hypertrophic scars and keloids. Br J Plast Surg 45:599-603, 1992. 77. Sawada Y, Sone K. Treatment of scars and keloids with a cream containing silicone oil. Br J Plast Surg 43:683-688, 1990. 78. Davey RB, Wallis KA, Bowering K. Adhesive contact media—an update on graft fixation and burn scar management. Burns 17:313-319, 1991. 79. Niessen FB, Spauwen PHM, Schalkwijk J, et al. On the nature of hypertrophic scars and keloids: A review. Plast Reconstr Surg 104:1435-1458, 1999. 80. Mustoe TA, Cooter RD, Gold MH, et al for the International Advisory Panel on Scar Management. International clinical recommendations on scar management. Plast Reconstr Surg 110:560-571, 2002. This is an exceptional review article summarizing the panel’s consensus views on the management of problem scars as well as an in-depth review of the literature surrounding some of the more popular and/or efficacious treatments. 81. Fricke NB, Omnell ML, Dutcher KA, et al. Skeletal and dental disturbances in children after facial burns and pressure garment use: A 4-year follow-up. J Burn Care Rehabil 20:239-249, 1999. 82. Ward RS. Pressure therapy for the control of hypertrophic scar formation after burn injury: A history and review. J Burn Care Rehabil 12:257-262, 1991. 83. Tredget EE. Management of the acutely burned upper extremity. Hand Clin 16:187-203, 2000.

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84. Nedelec B, Ghahary A, Scott P, et al. Control of wound contraction: Basic and clinical fea - tures. Hand Clin 16:289-302, 2000. 85. Rayner K. The use of pressure therapy to treat hypertrophic scarring. J Wound Care 9:151 - 153, 2000. 86. Sawada Y. Alterations in pressure under elastic bandages: Experimental and clinical evaluation . J Dermatol. 20:767-772, 1993. 87. Kischer CW, Shetlar MR, Shetlar CL. Alteration of hypertrophic scars induced by mechan - ical pressure. Arch Dermatol 111:60-64, 1975. 88. Page RE, Robertson GA, Pettigrew NM. Microcirculation in hypertrophic burn scars. Burns Incl Therm Inj 10:64-70, 1983. 89. Clark JA, Cheng JC, Leung KS, et al. Mechanical characterisation of human postburn hyper - trophic skin during pressure therapy. J Biomech 20:397-406, 1987. 90. Murray JC. Scars and keloids. Dermatol Clin 11:697-708, 1993. 91. Sherris DA, Larrabee WF Jr, Murakami CS. Management of scar contractures, hypertrophic scars, and keloids. Otolaryngol Clin North Am 28:1057-1068, 1995. 92. Su CW, Alizadeh K, Boddie A, et al. The problem scar. Clin Plast Surg 25:451-465, 1998. 93. Haq M, Haq A. Pressure therapy in treatment of hypertrophic scar, burn contracture and keloid: The Kenyan experience. East Afr Med J 11:785-793, 1990. 94. Rose MP, Deitch EA. The clinical use of a tubular compression bandage, Tubigrip, for burn - scar therapy: A critical analysis. Burns Incl Therm Inj 12:58-64, 1985. 95. Chang P, Laubenthal KN, Lewis RW II, et al. Prospective, randomized study of the effi cacy of pressure garment therapy in patients with burns. J Burn Care Rehabil 16:473-475, 1995. 96. Berman B, Bieley HC. Adjunct therapies to surgical management of keloids. Dermatol Surg 22:126-130, 1996. 97. Brent B. The role of pressure therapy in management of earlobe keloids: Preliminary report of a controlled study. Ann Plast Surg 1:579-581, 1978. 98. Mercer DM, Studd DM. “Oyster splints”: A new compression device for the treatment of keloid scars of the ear. Br J Plast Surg 36:75-78, 1983. 99. Pierce HE. Postsurgical acrylic ear splints for keloids. J Dermatol Surg Oncol 12:583-585, 1986. 100. Urioste S, Arndt KA, Dover JS. Keloids and hypertrophic scars: Review and treatment strate - gies. Semin Cutan Med Surg 18:159-171, 1999. 101. Rockwell WB, Cohen IK, Ehrlich HP. Keloids and hypertrophic scars: A comprehensive re - view. Plast Reconstr Surg 84:827-837, 1989. 102. Alster TS, West TB. Treatment of scars: A review. Ann Plast Surg 39:418-432, 1997. 103. Murray JC. Keloids and hypertrophic scars. Clin Dermatol 12:27-37, 1994. 104. Griffith BH, Monroe CW, McKinney P. A follow-up study on the treatment of keloids with triamcinolone acetonide. Plast Reconstr Surg 46:145-150, 1970. 105. Lawrence WT. In search of the optimal treatment of keloids: Report of a series and a review of the literature. Ann Plast Surg 27:164-178, 1991. 106. Boyadjiev C, Popchristova E, Mazgalova J. Histomorphologic changes in keloids treated with Kenacort. J Trauma 38:299-302, 1995. 107. Alaish SM,Yager DR, Diegelmann RF, et al. Hyaluronic acid metabolism in keloid fibroblasts . J Pediatr Surg 30:949-952, 1995. 108. McCoy BJ, Diegelmann RF, Cohen IK. In vitro inhibition of cell growth, collagen synthesis, and prolyl hydroxylase activity by triamcinolone acetonide. Proc Soc Exp Biol Med 163:216-222, 1980. 109. Kauh YC, Rouda S, Mondragon G, et al. Major suppression of pro-alphal (I) type I collagen gene expression in the dermis after keloid excision and immediate intrawound injection of triamcinolone acetonide. J Am Acad Dermatol 37:586-589, 1997. 110. Lavker RM, Schechter NM. Cutaneous mast cell depletion results from topical cortico - steroid usage. J Immunol 135:2368-2373, 1985.

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111. Gadson PF, Russell JD, Russell SB. Glucocorticoid receptors in human fibroblasts derived from normal dermis and keloid tissue. J Biol Chem 259:11236-11241, 1984. 112. Krusche T, Worret WI. Mechanical properties of keloids in vivo during treatment with intralesional triamcinolone acetonide. Arch Dermatol Res 287:289-293, 1995. 113. Tang YW. Intra- and postoperative steroid injections for keloids and hypertrophic scars. Br J Plast Surg 45:371-373, 1992. 114. Tredget EE, Shankowsky HA, Pannu R, et al. Transforming growth factor-beta in thermally injured patients with hypertrophic scars: Effects of interferon alpha-2b. Plast Reconstr Surg 102:1317-1328; discussion 1329-1330, 1998. 115. Berman B, Duncan MR. Short-term treatment in vivo with human interferon alpha-2b results in a selective and persistent normalization of keloidal fibroblast collagen, glycosaminoglycan, and collagenase production in vitro. J Am Acad Dermatol 21:694-702, 1989. 116. Berman B, Flores F. Recurrence rates of excised keloids treated with postoperative triamcinolone acetonide injections of interferon alfa-2b injections. J Am Acad. Dermatol 37:755757, 1997. 117. Granstein RD, Rook A, Flotte TJ, et al. Controlled trial of intralesional recombinant interferon-gamma in the treatment of keloidal scarring. Arch Dermatol 126:1295-1302, 1990. 118. Larrabee WF Jr, East CA, Jaffe HS, et al. Intralesional interferon gamma treatment for keloids and hypertrophic scars. Arch Otolaryngol Head Neck Surg 116:1159-1162, 1990. 119. Fitzpatrick RE. Treatment of inflamed hypertrophic scars using intralesional 5-FU. Dermatol Surg 5:224-232, 1999. 120. Gupta S, Kalra A. Efficacy and safety of intralesional 5- fluorouracil in the treatment of keloids. Dermatology 204:130-132, 2002. 121. Bodokh I, Brun P. Traitement des chéloïdes par infiltrations de Bléomycine. Ann Dermatol Venereol 123:791-794, 1996. 122. Larouy JC. Traitement des chéloïdes: Trois méthodes. Nouv Dermatol 19:295, 2000. 123. España A, Solano T, Quintanilla E. Bleomycin in the treatment of keloids and hypertrophic scars by multiple needle punctures. Dermatol Surg 27:23-27, 2001. 124. Lawrence WT. Treatment of earlobe keloids with surgery plus adjuvant intralesional verapamil and pressure earrings. Ann Plast Surg 37:167-169, 1996. 125. Berman B, Villa A. Imiquimod 5% cream for keloid management. Dermatol Surg 29:10501051, 2003. 126. Jimenez SA, Freundlich B, Rosenbloom J. Selective inhibition of diploid fibroblast collagen synthesis by interferons. J Clin Invest 74:1112-1116, 1984. 127. Kaufman J, Berman B. Pilot study of the effect of postoperative imiquimod 5% cream on the recurrence rate of excised keloids. J Am Acad Dermatol 47(4 Suppl):S209-S211, 2002. 128. Clark J. Imiquimod vs. interferon: Cream matches injection in terms of eliminating keloid recurrence while showing no adverse events. Dermatol Times Dec 15-16, 2002. 129. Hyakusoku H, Ogawa R. The small-wave incision for long keloids. Plast Reconstr Surg 111:964-965, 2003. 130. Shepherd JP, Dawber RP. The response of keloid scars to cryosurgery. Plast Reconstr Surg 70:677-682, 1982. 131. Hoffmann NE, Bischof JC. Cryosurgery of normal and tumor tissue in the dorsal skin flap chamber: II. Injury response. J Biomech Eng 123:310-316, 2001. 132. Zouboulis CC, Blume U, Buttner P, et al. Outcomes of cryosurgery in keloids and hypertrophic scars: A prospective consecutive trial of case series. Arch Dermatol 129:1146-1151, 1993. 133. Rusciani L, Rossi G, Bono R. Use of cryotherapy in the treatment of keloids. J Dermatol Surg Oncol 19:529-534, 1993. 134. Layton AM,Yip J, Cunliffe WJ. A comparison on intralesional triamcinolone and cryosurgery in the treatment of acne keloids. Br J Dermatol 130:498-501, 1994.

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135. Ciampo E, Iurassich S. Liquid nitrogen cryosurgery in the treatment of acne lesions. Ann Ital Dermatol Clin Sper 51:67, 1997. 136. Ernst K, Hundeiker M. [Results of cryosurgery in 394 patients with hypertrophic scars and keloids] Hautarzt 46:462-466, 1995. 137. Rusciani L, Rossi G, Bono R. Use of cryotherapy in the treatment of keloids. J Dermatol Surg Oncol 19:529-534, 1993. 138. Kumar K, Kapoor BS, Rai P, et al. In-situ irradiation of keloid scars with Nd:YAG laser. J Wound Care 9:213-215, 2000. 139. Goldman M, Fitzpatrick RE. Laser treatment of scars. Dermatol Surg 21:685-687, 1995. 140. Connell PG, Harland CC. Treatment of keloid scars with pulsed dye lasers and intralesional steroid. J Cutan Laser Ther 2:147-150, 2000. 141. Cosman B, Crikelair GF, Ju DM, et al. The surgical treatment of keloids. Plast Reconstr Surg 27:335, 1961. 142. Brown LA Jr, Pierce HE. Keloids: Scar revision. J Dermatol Surg Oncol 12:51-56, 1986. 143. Levy DS, Salter MM, Roth RE. Postoperative irradiation in the prevention of keloids. Am J Roentgenol 127:509-510, 1976. 144. Edsmyr F, Larson LG, Onyango J, et al. Radiotherapy in the treatment of keloids in East Africa. East Afr Med J 50:457-461, 1973. 145. Sclafani AP, Gordon L, Chadha M, et al. Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: A randomised, prospective study and review of the literature. Dermatol Surg 22:569-574, 1996. 146. Ragoowansi R, Cornes PGS, Moss AL, et al.Treatment of keloids by surgical excision and immediate postoperative single-fraction radiotherapy. Plast Reconstr Surg 111:1853-1859, 2003. This is an impressive review article covering virtually all reported cases of radiotherapy-directed scar revision in the last 40 years as well as a historical review of the field.

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REVIEW QUESTIONS 1. Which of the following statements is true of keloids? a. They are seldom present on the anterior chest, shoulders, upper arms, and jaw b. They can frequently spontaneously recede c. They tend to occur in lighter-skinned individuals d. Unlike hypertrophic scars, keloids do not cause itchiness, redness, or pain e. The palms, soles, and mucous membranes are not typically affected 2. Which of the following is not true of the Z-plasty? a. It is suitable for revision of ATL scars of eyelids, lips, nasolabial folds, and nonfacial areas that limit tissue mobility b. The central limb of the Z-plasty should always fall over the scar c. The flaps should be oriented so that after transposition, they are oriented close to RSTLs d. The length of all limbs must be nearly equal e. The original central limb increases in length by a factor of 2 3. Which of the following is important to obtaining a more favorable scar? a. Gentle handling of tissues to minimally traumatize structures in the revision b. Tension-free wound closure to minimize stress on healing tissues c. Incisions are made perpendicular to the skin edge to allow precise reapproximation d. Incisions are ideally oriented within the RSTLs to the degree possible e. All of the above 4. All of the following are true of chemical peels except: a. Chemical peels may be divided into superficial (epidermal injury), medium-depth (superficial dermal injury to the papillary dermis), and deep (mid-dermal injury to the reticular dermis) b. Superficial peels can be performed using alpha hydroxy acids or 15% to 20% trichloroacetic acid c. Antiviral and/or antibacterial agents are never used prophylactically for deeper peels d. Agents most frequently used to create a medium-depth peel include 35% trichloroacetic acid, a combination of 35% tricarboxylic acid with 70% glycolic acid (Coleman technique), and 35% tricarboxylic acid with Jessner’s solution (Monheit technique) e. The deep chemical peel agent includes 50% trichloroacetic acid and the Baker-Gordon formula (3 ml SUP liquid phenol, 2 ml tap water, 8 drops liquid soap, and 3 drops cotton oil)

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5. All of the following are true of wound healing except: a. Inflammatory mediators such as histamine, prostacyclins and leukotrienes contribute to vasoconstriction b. Prolonged inflammation can result in an excess of inflammatory mediators and cytokines in the wound environment c. After the inflammatory reaction to injury begins to diminish, keratinocytes and mesenchymal cells begin to actively migrate into the wound environment and proliferate d. In addition to active collagen synthesis, appropriate metalloproteinase function is required to modulate the quantity and alignment of scar in a wound e. Protein deficiency results in impairments in capillary formation, fibroblast proliferation, and collagen synthesis

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Chapter 7 Reoperation for Donor Site Complications James C. Grotting and Grady B. Core

I think everyone should experience defeat at least one time during their career. You learn from it. Lou Holtz

Reoperative Problems Scarring Contour deformities Hernia

Impaired function Pain Aesthetic deficiencies

D

onor site complications have been a relatively unreported area in comparison with other problems in reconstructive surgery. This is unfortunate, because donor site morbidity should be optimally minimized and the potential complications should be well known to all who undertake reconstructive procedures. Donor site problems can be divided into those that involve nonvascularized tissue and those involving vascularized tissue. When such complications occur, reoperative measures are frequently required.

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NONVASCULARIZED GRAFT COMPLICATIONS SKIN The most common complication of split-thickness skin grafts at the donor site that may require reoperation is deep partial-thickness injury or full-thickness injury resulting from either overzealous harvesting or secondary infection. If the donor site is small and the wound is clean, it can simply be excised and closed primarily; however, this is usually not the case. It is best to wait 2 to 4 weeks before undertaking reoperation, because many of these defects heal with time, with skin regenerating from residual skin appendages. Care should be taken to use a nonadherent dressing during the healing period so that regenerating epithelium is not destroyed during dressing changes. If the area is not healing well within 2 weeks or is obviously a full-thickness injury, the wound should be closed with a thin skin graft from another area or with local flaps. Another donor site complication associated with split-thickness or full-thickness skin grafting that may require reoperative surgery is hypertrophic scarring or keloid formation. In a patient with no previous history of scarring problems, the wound can be excised and reclosed with local injection of triamcinolone around the wound edges. Controversy exists as to whether intralesional versus extralesional excision of keloids reduces their recurrence rate. Although no clearly established benefit of one method over the other has been proved, there is theoretical support for intralesional excision.1 Otherwise, in high-risk patients, nonoperative measures such as steroid injections and topical silicone sheeting2 should be employed initially. In some cases adjunctive irradiation may be useful. Excision and radiation have been shown to reduce the recurrence rate to approximately 2% with no evidence of carcinogenesis over many years.3

BONE Although bone grafts may be harvested from a variety of sites, the most common donor sites are the ilium, the outer table of the calvarium, and rib. Risks of infec - tion or bleeding that may require secondary drainage are common to all bone donor sites. However, each site has specific risks that may call for reoperative inter- vention.

Cranium The major risk to the cranial bone donor site is intracranial bleeding. Fortunately , this event is rare, but the consequences are serious . Neurosurgical consultation and intervention should be obtained immediately . Other secondary complications of cranial bone harvesting are contour deformity and alopecia . The partial-thickness calvarial defect can be filled with bone paste produced by mixing bone shavings with blood. This paste can be smoothed into the defect to prevent a secondary contour deformity . Bone wax application in the donor site should be minimized,

Chapter 7 Reoperation for Donor Site Complications

because this substance creates a physical barrier to the regeneration of the outer table and can cause deformities to be persistent.4 Contour deformities anterior to the hairline are caused by poor donor site selection and can be managed by regrafting the donor site from a more posterior site or by filling the defect with bone dust or an alloplastic material such as methylmethacrylate or hydroxyapatite. Alope - cia can be managed by excision and primary closure if the site is small. If a large area is involved, tissue expansion or scalp flaps may be required.

Rib Rib graft harvesting may be complicated by a hemopneumothorax; in this case, a tube thoracostomy would be indicated. However, if the wound is sealed and the pneumothorax is small and not enlarging, simple aspiration may suffice. Small pneu - mothoraxes can resolve spontaneously , but serial chest radiographs should be ob- tained to confirm resolution. In general, pneumothoraxes affecting less than 20 % of the lung field with a sealed wound do not require tube thoracostomy.5

Ilium Bone grafts of cancellous or cortical bone may be taken from the anterior or posterior ilium.6 The anterior ilium is the more popular donor site. However, approximately three times more cancellous bone can be obtained from the posterior ilium than from the anterior ilium.7 Problems and complications associated with harvesting a bone graft from the posterior ilium are pain, difficulty with ambulation, and possible damage to the superior and medial cluneal nerves . Fortunately , the latter problem is uncommon , as is damage to the sacroiliac joint and the sciatic nerve.6,7 The complications that these two donor sites share are pain, difficulty of ambula- tion, blood loss, and hematoma formation. Patients who have undergone posterior iliac harvesting may have dif ficulty climbing stairs because of the detachment of the gluteus maximus muscle . Some very unusual complications have been reported in association with the posterior iliac crest donor site, such as traumatic arteriovenous fistula and ureteral injury.8 The need for reoperative intervention for these two donor sites is rare. Drainage of a hematoma is the most commonly indicated reoperative procedure associated with the bone graft donor site. Other unfavorable outcomes resulting from harvesting of iliac bone grafts include abdominal herniation, vascular injuries, and fracture of the wing of the iliac bone . Hematoma formation can be minimized with the use of micro fibrillar collagen products such as Avitene.

CARTILAGE The most common sites of cartilage graft harvesting are the septum, ear, and ribs . Complications resulting from septal cartilage harvesting are usually caused by over- harvesting. Loss of tip support, collapse of the nasal dorsum, and permanent septal

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perforation may require reoperation. These complications and their management are addressed in Chapter 21. Fortunately , the harvesting of conchal cartilage is rarely associated with complications . The most common problems are hematoma and asymmetry , but hypertrophic scarring has occurred. Asymmetries must be evaluated individually and treated accordingly. Rib cartilage graft harvesting may be associated with the same complications as noted for rib bone graft harvesting. Secondary intervention would be the same .

VEIN Autogenous tissue for vascular grafts is usually supplied by the superficial veins of the extremities such as the saphenous or cephalic veins. Secondary complications at these donor sites that may require reoperation are seroma, hematoma, or secondary infection , all of which may require incision and drainage . Occasionally , neuromas can form at the incision site, which , if unresponsive to conservative measures , may be an indication for reoperation (see Chapter 49 ). The saphenous nerve, which courses in close proximity to the saphenous vein in the lower leg, is often injured when this vein is harvested.

NERVE Nerve grafts may be harvested from several different areas. The most common sites are the sural region on the posterior lower extremity , the cervical region in the neck, and the forearm. In addition to local wound complications , these nerve graft donor sites share the risk of neuroma formation ; this problem is most common in the extremities. Secondary treatment of neuromas in the extremities initially in- volves conservative measures such as observation and massage for desensitization . Local injection of an ablative solution such as isopropyl alcohol has also been used , but this approach is controversial and rarely offers a permanent cure. Reoperative management consists of localization of the neuroma and, if possible, re - pair of the nerve in continuity with its distal remnant . If this is not possible , second - ary nerve grafting may help to resolve the neuroma . Otherwise , implantation of the proximal nerve into adjacent muscle or bone has been described as a thera - peutic measure . 9,l0 Simply resecting the nerve more proximally has been successful in some cases but is a second -line measure . Treatment of neuromas in the extrem- ities is discussed in detail in Chapter 49.

FAT Donor site complications for fat graft harvesting are quite rare. Usually fat grafts are obtained through liposuction, but at times direct excision may be employed.11 Sec - ondary complications requiring reoperation may consist of hematoma , seroma , and secondary infection , which may call for incision and drainage . Occasionally, contour

Chapter 7 Reoperation for Donor Site Complications

defects may occur, which are an indication for reoperation using secondary liposuc - tion or lipoinjection . However, these defects are very difficult to correct and in some cases may be permanent.

FASCIA AND TENDON Nonvascularized fascial grafts are harvested primarily from the lateral thigh when indicated for uses requiring structural support of the recipient site. Occasionally , however , fascial grafts are also taken in the head and neck area for aesthetic purposes such as rhinoplasty . These grafts are usually from the temporoparietal fascia. Be- yond the grafts mentioned, nonvascularized fascial grafts are unusual. Sources for tendon grafts include the palmaris longus muscle , plantaris muscle , and extensor digitorum longus muscle. The superficialis tendon to the little finger from an injured hand can also be used. Reoperative indications for these donor sites are unusual outside routine local wound complications.

VASCULARIZED FLAPS Although a variety of skin flap classifications have evolved, none is ideal. The simplest system classifies skin flaps according to their blood supply: random cutaneous , fasciocutaneous , and musculocutaneous .12 Regardless of the type of flap used, the donor site morbidity created by raising the flap is usually minimal . All flap compli- cations can be categorized as site specific or non–site specific; the latter includes general wound complications.

RANDOM CUTANEOUS FLAPS The most common complaint concerning cutaneous flaps is that the defect created may be unsightly . To reduce the chances of an unusually unsightly donor site, every effort is made to achieve primary closure. If this is not feasible, the surgeon should consider local flap techniques that facilitate donor site closure , such as advance - ment , rotation , or interpolation flaps .12 If this is not possible , skin grafting must be considered . Flaps such as the deltopectoral flap or the transverse back flap leave large areas of exposed underlying muscle and fascia, which require skin grafting for closure. If the patient requests aesthetic refinement of these donor sites , revisions can be performed with tissue expansion techniques.13,14 Expansion can be per- formed either before flap transfer or at a later date as a secondary procedure to correct the donor site.14,15 Depending on the location of the defect , tissue expan - sion may not always be feasible . The lower extremity , especially below the knee, has been shown to be an area of high risk for complications with tissue expansion tech - niques .16 Other methods for closure of large cutaneous defects include presuturing 17 and more recently the use of a skin-stretching device.18 Both techniques attempt to harness the viscoelastic properties of skin so that primary closure may be obtained without resorting to skin grafting or tissue expansion.19 At present, only a few clin-

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ical cases have been reported , and thus the techniques are unproved . However , the techniques deserve mention based on their theoretical potential and early reported results. Intraoperative expansion has also been advocated for the closure of large skin defects . However , some investigators have demonstrated no bene fit of this technique over standard undermining techniques.20 The surgeon should be aware of situations in which primary closure of a flap donor site by any method is not the best option. For example, for certain facial defects re - sulting from Mohs’ chemosurgery , delayed reconstruction or secondary healing may be the best plan. In some cases the aesthetic results achieved with secondary heal- ing may be superior to those possible with primary closure.21,22

FASCIAL AND FASCIOCUTANEOUS FLAPS The most commonly used free fascial or free fasciocutaneous flaps are the flaps from the radial forearm, scapula, lateral arm, and temporoparietal fascia. Management of donor site deformities after fascial and fasciocutaneous flap harvest is similar to that for skin flaps. Primary closure of the donor site should be performed whenever possible. However, if closure of the defect with local flaps or skin graft - ing is not possible , tissue expansion or stretching techniques can be used. In the text that follows, we address some of the site-specific problems that can occur with these more common donor sites.

Radial Forearm Flap The radial forearm donor site has been the source of the greatest volume of literature on donor site morbidity for virtually any type of flap.15,23-29 The reason is simple: morbidity is high.23-29 The incidence of delayed healing as the result of skin graft failure has been reported to be as high as 50%.15,23 Skin graft failure usually results from the grafts not taking well over the exposed tendons in the forearm. In cases for which direct closure with local flaps is not feasible,23 the flexor carpi radialis tendon that is exposed can be oversewn with neighboring muscle fibers to create a better bed for skin graft adherence.27 In addition, these tendons can be covered with a pronator quadratus muscle flap on which the skin graft is then placed.30,31 A reverse radial forearm fascial flap has been described in which the radial artery is spared and the deep fascia remains in the bed of the donor site, thus making the donor site more easily skin grafted . 32 Tissue expansion techniques for donor site closure , using either preexpansion of the flap or late reconstruction with expansion , have been used with good results , although the morbidity rate for tissue expansion techniques in the upper extremity can be high .13,16 Other site-specific problems that occur with the radial forearm flap donor site include persistent or intermittent swelling; stiffness of the hand, wrist, elbow, or shoul -

Chapter 7 Reoperation for Donor Site Complications

der; reduced grip strength; reduced or abnormal sensation in all or part of the radial nerve distribution; cold intolerance; and fracture of the radius when the flap is raised as an osteocutaneous flap.26,33 Reconstruction of the radial artery has been recommended in the past because of concerns about vascular compromise.28 However, several large series in which the radial forearm flap was transferred without radial artery reconstruction have demonstrated no significant morbidity in this regard.23,34 In addition, a comparative study of the operated arm versus the unoperated arm using noninvasive vascular techniques revealed no statistically significant difference between the two sides, except in early rewarming of the radial side of the hand after cold immersion at 1 minute.34 By 5 minutes the operated side matched the unoperated side in temperature. Arterial reconstruction, therefore, should not be routinely performed but is indicated if distal ischemia is noted intraoperatively. In addition, if the patient has an underlying condition that predisposes to vascular compromise (for example, a vasospastic condition, or atherosclerosis), arterial reconstruction should be considered.

Scapular Flap With the harvest of the scapular or parascapular flap, primary closure of the donor site is possible in most cases. When primary closure is not obtainable, the alternative techniques already mentioned can be used. However, skin grafting is difficult in this area because of shoulder motion. For this reason primary closure is the rule, if at all possible. Dehiscence should be managed with prompt reclosure unless the wound is contaminated or infected. Closure by secondary intention can be achieved with fair results if other techniques are not feasible.

This patient underwent transfer of a complex scapular osteomyocutaneous flap for extensive facial reconstruction. Donor site healing was complicated by dehiscence; the site was allowed to heal by secondary intention. Options for improvement in - clude excision followed by deepithelialized advancement flap vest-over-pants clo- sure and additional autologous fat injection.

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Lateral Arm Flap The lateral arm flap has been well accepted by clinical surgeons because of its low donor site morbidity and its favorable properties as a thin fasciocutaneous flap.35 The need to reoperate because of donor site problems is rare. However, potentially serious site-specific problems include radial nerve injury and fracture of the humerus as a result of overzealous osteotomy when harvesting an osteocutaneous flap.33

Temporoparietal Fascial Flap The temporoparietal fascial flap donor site is the most ideal of all donor sites, because morbidity requiring reoperation is virtually nonexistent in this area. Reoperation is usually only to address minor aesthetic concerns such as alopecia correction or filling in the temporal fossa region with a Silastic or Medpor implant if the temporalis muscle is harvested or injured.36,37

Lower Extremity Fasciocutaneous Flap For fasciocutaneous flaps in the lower extremity, as is true after the harvest of such flaps from other areas on the body, the primary donor site defect consists of an unsightly depression, usually requiring skin grafting for closure. Consequently, there may be areas of exposed tendons where skin graft adherence is poor, thus resulting in secondary defects that consist of chronic open wounds with exposed tendons. Coverage of these tendons by oversewing local muscle tissue should be achieved if at all possible. Tissue expansion techniques in the lower extremity, although feasible, have been fraught with high complication rates consisting of paresthesia or numbness, lymphedema, cellulitis, and extrusion.17 When reoperation for fasciocutaneous donor site defects for aesthetic purposes is considered, tissue expansion is still the best method currently available. Site-specific risk factors in this area are minimal, although one should always keep in mind the location of the superficial peroneal nerve and thus avoid injuring it.

MUSCLE AND MUSCULOCUTANEOUS FLAPS Complications of muscle and musculocutaneous flaps that require reoperation can also be categorized as those that are site specific and those that all sites have in common: hematoma, seroma, wound infection, dehiscence, skin graft loss, and necrotizing fasciitis. Complication rates for musculocutaneous flaps vary greatly. Frequently the compli - cation is in the donor site. For the tensor fascia lata flap, the complication rate is ap- proximately 19%.The overall complication rate for the latissimus dorsi flap is 31 %.38 The inability to close a latissimus dorsi donor site has been treated with a “ reverse” latissimus dorsi musculocutaneous flap.39

Chapter 7 Reoperation for Donor Site Complications

Complications associated with the harvesting of musculocutaneous flaps are possible in any flap, no matter what the site, although some general wound complications are more common in specific sites. For example, the most common complication of the latissimus dorsi donor site is seroma.38 Seromas should be aspirated if large; otherwise, they can be treated with compression. Aspiration of seromas should always be performed with sterile technique. After aspiration, compression should be applied. Brachial plexus injury has been associated with any surgery that requires arm abduction.Therefore this complication is a potential problem with the latissimus dorsi flap, scapular flap, gluteal flap, and TRAM flap, as recently reported.40 Reoperative experience for this problem is limited, and improvement is most likely based on patience and physical therapy. Occasionally, persistent nerve compressions documented by electromyography and nerve conduction velocity testing may require exploration and release. Avoidance of this problem is based on close attention to position, pressure, and padding.

Improper position creating maximum stretch on brachial plexus

The “at risk” position for brachial plexus stretch injury is with the arm extended , abducted, and externally rotated with the neck flexed and rotated. Attention to axillary pressure, no matter what procedure is being performed, is im - portant . However , in our free TRAM flap series , in which upper extremity neu- ropathy occurred in four of 117 cases, it was found that those patients with neu- ropathy most likely had preexisting predisposing conditions .40 Therefore any patient who is about to undergo extensive surgery in this region , whether for harvesting the latissimus dorsi flap or insetting a free TRAM flap and who has a prior history of peripheral nerve problems in the upper extremity should undergo preoperative screening for subclinical peripheral nerve compression . This information must be documented in the medical record.

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Some morbidity is associated with loss of the muscle unit itself. Of course, the function associated with that muscle is lost if the whole muscle is taken or denervated. Fortunately, the redundant muscular system in the body allows the sacrifice of these muscle units with remarkably little morbidity. However, with certain muscle flaps, particularly in elderly patients, this diminished function may be a source of postoperative difficulty. For example, the trapezius muscle is a powerful stabilizer of the medial scapula and shoulder joint. In rare instances, its sacrifice may be associated with shoulder dysfunction from this loss of support.

TRAM Flap The most common causes for the need to reoperate a TRAM flap donor site are skin necrosis of the abdominal flap, hematoma, seroma, wound infection, and dehiscence.38 Less common, but no less formidable, is abdominal wall hernia or eventration. Other rare indications include bowel obstruction and pelvic hematoma. Hartrampf 41 outlined criteria for patient selection to minimize these problems.

After TRAM flap breast reconstruction, this patient complained of intermittent crampy abdominal pain with a weakness in the left lower quadrant of the abdominal wall.

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At the time of the exploratory operation, the patient was found to have not only an abdominal wall hernia but also perforation of the small bowel, with Prolene sutures creating partial obstruction.

After bowel resection, primary anastomosis, and Gore-Tex patch repair of the abdomen, the patient recovered and has been well for 1 year without evidence of recurrence.

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Management of donor site seromas or hematomas should be aggressive, with prompt drainage as soon as the collection is identified. Seromas can be collapsed by placing a suction drain or, if small, with intermittent syringe drainage and compression. If detected early, hematomas should be reexplored and drained, and the bleeding sites should be controlled. The surgeon should be especially aware of the possibility of a “hidden” hematoma, which is characterized by a dropping hemoglobin level and blood volume with no visible collection of blood in the operative sites. A fullness in the groin or pain may be the only physical findings. If clinical and laboratory findings indicate continuing blood loss, the patient should undergo reexploration to detect bleeding in the vicinity of the deep inferior epigastric vessels. Skin necrosis should always be managed conservatively if the wound is dry and free of infection. The edge of the viable skin will demarcate, creating a blackened eschar inferiorly that will eventually slough, leaving a bed of granulation tissue beneath. Early debridement of the nonviable skin is not advised if the skin is not infected, since this may allow the remaining upper abdominal skin flap (which is under tension) to retract, thus causing a much larger defect. Once the flap is well adherent to the abdominal wall and the eschar has begun to separate (usually in 3 to 4 weeks), debridement may be initiated. Topical mafenide (Sulfamylon) cream (applied to the eschar only) will penetrate the eschar and help to protect the necrotic tissue from becoming infected.42-44 If at any time the wound begins to appear infected or “soupy,” debridement should be performed and all nonviable tissue should be removed. Once the wound is clean, it should be allowed to heal by secondary intention rather than by skin grafting, because the contracture of the wound will help the defect to shrink, and in many cases the eventual result will be satisfactory. Scar revisions on small, healed, contracted wounds are much easier than on large skin-grafted areas.

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In this patient with Raynaud’s syndrome, problems with skin flap necrosis occurred immediately postoperatively after bilateral free TRAM breast reconstruction. The exposed mesh was removed, and the wound was allowed to heal by secondary intention.

The patient underwent giant prosthetic reinforcement of the visceral sac using Prolene mesh. Six months after the repair, she shows no evidence of recurrence.

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After wound dehiscence exposed the underlying Gore-Tex prosthesis, this patient required removal of the Gore-Tex patch, thus giving rise to abdominal wall weakness and herniation. A hernia is noted in the right lower quadrant below the arcuate line with eventration of the entire region because of attenuation of the fascia and retraction of rectus abdominis muscle.

The entire area of weakness was excised, and repair was performed using a giant prosthetic reinforcement of the visceral sac (see Chapter 44).

Chapter 7 Reoperation for Donor Site Complications

Six months postoperatively, the patient is without evidence of recurrence. Necrosis of the umbilical stalk should be managed nonoperatively because it will eventually slough. The resultant scar will in many cases serve as an acceptable umbilicus. Reoperation for eventration or hernia should always be performed electively well after the patient has recovered from the initial surgery if no acute problem has resulted from the hernia. Most hernias will occur in the lower abdomen below the arcuate line and result from the loss of anterior abdominal wall support.43-45 Most commonly the fascial repair fails outright, the muscle has been harvested too low or allowed to retract toward the pubis, or the edge of the internal oblique muscle has not been secured in a two-layer fascial closure (see Chapter 37). Closure of this defect by direct methods is difficult. Experience in the closure of abdominal wall ventral hernias has shown that small defects may be repaired primarily with an acceptable recurrence rate if local tissue of sufficient strength can be recruited from the periphery without undue tension. However, for more complicated defects of any significant size (greater than 4 cm), the use of prosthetic material must be considered.

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After conventional bilateral TRAM breast reconstruction, this patient underwent two attempts at mesh correction of abdominal hernias that failed because of recurrent infection. After the mesh was removed for the second time, obvious hernias remained.

Because of repeated failure to restore support with the use of prosthetic material, the decision was made to reconstruct the defect with vascularized muscle and fascia using bilateral rectus femoris musculofascial flaps. These flaps were tunneled through the groin skin, sutured across one another, and approximated to the fascial margin of the hernia.

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Postoperatively stable correction of the hernias was achieved. Although the additional donor site scars and muscle sacrifice are clear disadvantages of this approach, under these uncommon circumstances it is usually best to implement a surgical plan that stands the greatest chance of producing a successful functional result. A variety of materials and techniques have been described for closure of ventral hernias and are discussed further in Chapter 44.The method of Stoppa has demonstrated the lowest recurrence rate when used for repair of recurrent and large ventral hernias.46 True abdominal wall hernias should be repaired in all cases; however, areas of weakness or eventrations should be repaired only at the patient’s request and provided there have been no intervening health problems that would unacceptably elevate the risk of further complications. In cases in which prosthetic material is not an option because of either infection risks or prior problems with prosthetic material, repair of the TRAM flap donor site can be achieved with rectus femoris flaps. This reconstructive option will provide innervated dynamic muscle with a strong fascial component and has been found to provide good support in reported clinical cases.47 However, recurrence rates for autogenous tissue repair using flaps are not well documented because no large series comparing this method to prosthetic repair has been published. In addition, the TRAM flap is usually performed in patients who do not desire additional scarring along the anterior thighs, so this option should really be viewed as a “last resort” approach.

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This 55-year old patient presented 1 year after bilateral mastectomies and radiation therapy to the right chest wall for carcinoma of the right breast and left prophylactic mastectomy.

Six days after undergoing bilateral breast reconstruction with bilateral free TRAM flaps, the patient had a violent coughing episode. She felt a “pop” in her abdomen, which immediately began to swell. Surgical reexploration of the abdominal wound revealed a large hematoma and complete dehiscence of the fascial closure on both sides.

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It was not possible to reclose the fascial defects primarily; therefore a large sheet of Prolene mesh was placed as an onlay. The wound was thoroughly irrigated and drained.

The patient healed uneventfully without infection and is shown symptom free at 4 months.

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Inferior Gluteal Free Flap Experience with the inferior gluteal free flap is limited in most centers, and problems with the donor site have been mostly cosmetic. However, because of its location, this donor site is susceptible to increased tension during hip flexion and sitting. Acute wound dehiscence can be managed with reclosure. However, if excess tension still exists or if the wound has become contaminated or infected, then healing by secondary intention should be allowed. The site can then be revised at a later date.

This course of action was taken to treat the donor site problem of this woman, who had undergone free gluteal breast reconstruction.

Postoperatively, the donor site underwent dehiscence and became contaminated. The wound was allowed to heal by secondary intention. Closure of the dehisced wound, if clean, can be obtained using a posterior thigh flap or a tensor fascia lata flap, as would be done for ischial pressure sores in ambulatory patients.48,49

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OSSEOUS AND OSTEOCUTANEOUS FLAPS The most commonly used osteocutaneous flaps are radial forearm, iliac crest, fibula, and scapula. Complications not specific to a particular osseous and osteocutaneous flap that may require reoperation are the same as those for muscle and musculocutaneous flaps: wound dehiscence, infection, seroma, and hematoma. Principles of management of these problems are also the same. However, there are some osteocutaneous flap donor sites that are not amenable to skin grafting, such as the scapular area. Obviously, any area in which bone is exposed is not amenable to skin grafting. Therefore a secure primary closure of the donor site is important in the management of dehiscence in these regions, and local flaps are required for closure in many cases.15,23 Also, in the presence of infection, the bone should be thoroughly evaluated for osteomyelitis and debrided if necessary.

Radial Forearm Osteocutaneous Flap (Hand) Radial vascular bundle No

Yes

Intramuscular septum

Insertion of pronator teres muscle

(Elbow)

A high incidence of radius fracture is associated with the radial forearm osteocutaneous flap. Bardsley et al25 suggested that such fractures can be minimized by including less than 40% of the diameter of the radius in the flap. In addition , the bone should be beveled at both ends rather than step cut to avoid producing a weak point in the radius that may be susceptible to fracture. If this flap is used, a long arm cast should be applied and maintained for at least 6 weeks postoperatively . When radial fractures occur in this setting , they frequently require open reduction and internal fixation for proper alignment.

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Boyd et al52 compared the radial forearm flap with the deep circumflex iliac artery flap, pointing out the relative advantages and disadvantages . They concluded that these flaps are complementary techniques in oromandibular reconstruction.

Iliac Crest Free Flap First described by Taylor et al,53 the iliac crest osseous flap, or osteocutaneous flap, based on the deep circumflex iliac artery (DCIA), is a flap favored by many surgeons for oromandibular reconstruction . As an osteocutaneous flap, it is quite bulky and lends itself well to the repair of large soft tissue defects , particularly in those pa- tients who must undergo total or subtotal glossectomies as part of composite resec- tion. A secondary flap-thinning procedure is often necessary in a substantial per- centage of patients . A study by Boyd et al 52 pointed out the detriment of this bulk when the flap is used in small composite defects , and it showed that there is a higher incidence of intraoral wound breakdown and bone exposure in DCIA flap recon- structions than with radial forearm osteocutaneous flap reconstructions . The bone shape of the iliac crest is similar to that of a hemimandible, making the iliac crest free flap a good choice for a bone-only flap. The thickness of the bone transferred with this flap makes osteointegrated implants feasible. Forrest et al53 recently re- viewed donor site complications after iliac crest free flap transfer . They found that in the first 6 postoperative weeks , pain is by far the most common complaint . Late complications included anesthesia or paresthesia in the lateral and anterior thigh, contour irregularity , and hernia. The iliac crest donor site is susceptible to abdominal wall herniation.53 Repair of this hernia is indicated. Because of the difficulty in reapproximating the adjacent anatomy , it is recommended that prosthetic mesh or a Gore-Tex patch be used for repair 54 (see Chapter 44 ). In addition , femoral nerve palsies have been reported at this donor site and are likely secondary to the placement of retractors on the femoral nerve at the time of pedicle dissection .6 Because this condition is probably a neurapraxia, there is no indication for reoperation.

Free Fibula Flap Fortunately, complications with the free fibula flap are rare, and reoperative indica - tions are uncommon.55 Potentially, however, distal vascularity could be impaired if the arterial trifurcation is damaged. Other possible problems are damage to the pe- roneal nerve (in its super ficial position adjacent to the neck of the fibula ), ankle in- stability (if too much of the distal fibula is resected —7 cm should remain), valgus deformity in children , and neuroma formation (at the site of the transection of the superficial sensory nerves).56,57 Some investigators have reported a higher incidence of problems on late follow -up and thorough evaluation with gait analysis .56-59 Only 4 of 10 patients in one study were truly asymptomatic , whereas the others exhib- ited abnormal stride characteristics , joint angles , and ground reaction forces as well as altered centers of pressure . Three of these patients demonstrated partial lateral popliteal nerve palsies (one permanent ), and one patient had chronic pain.56 Despite these problems , reoperative indications were not found.

Chapter 7 Reoperation for Donor Site Complications

Scapular Osteocutaneous Flap The scapular osteocutaneous flap is harvested from a very favorable donor site with minimal morbidity.60,61 Reoperative indications are rare beyond problems associated with inability to close the donor site, wound infection, and dehiscence. In general, open wounds at this site should be treated with dressing changes, and they should be allowed to close by secondary intention since skin grafting in this area is difficult because of shoulder motion. Occasionally a pseudobursa can develop that may be chronic; in this case, reexploration and obliteration may be required. The free scapular skin island can be expanded to facilitate wound closure and to enlarge the size of the donor skin island. Most reoperative indications in this situation relate primarily to the complications associated with tissue expansion such as exposure or infection of the periprosthetic space. For donor site complications such as distal scapular bone viability and postoperative shoulder immobility , reoperation is not indicated. These problems can be prevented by careful attention to anatomy in- traoperatively for the former and an appropriate program of physical therapy for the latter. Immobilization of the shoulder for a period of not longer than 1 week usu- ally will not interfere with shoulder mobility and can help to avoid potential wound separation problems in patients undergoing tight donor site closures.62 Shoulder problems may also be exacerbated when portions of the scapula are harvested with either the trapezius, scapula, or serratus anterior flaps. Long-term pain and stiffness may require prolonged physical therapy.To avoid scapular instability af - ter the harvesting of portions of the scapula, the surrounding muscle groups can be attached to the periosteum of the remaining bone with heavy sutures. The teres major muscle will provide good lateral stability . Also, the upper five slips of the ser- ratus anterior muscle must not be detached from the medial border of the scapula or “winging” will occur.

ORGAN TRANSFERS BOWEL Donor site morbidity after the harvest of a free bowel segment for esophageal reconstruction is the same as for bowel resection. These problems include wound in - fection , anastomotic dehiscence , bowel obstruction , peritonitis , fasciitis , hernia for - mation , stricture , fistula formation , and even death . Most reoperative indications for this type of surgery are within the realm of the general surgeon . However , any plastic surgeon who harvests tissue from this area should be trained in abdominal surgery and be capable of dealing with potential complications . Reoperative indi- cations for hernia formation and techniques for repair are discussed in Chapter 44. Signs of early bowel obstruction consist of crampy abdominal pain, abdominal dis- tention , obstipation , and vomiting . An anastomotic dehiscence with subsequent in- traabdominal abscess is the most serious complication associated with free bowel transfer. Symptoms are signs of toxicity , fever, elevated white blood cell count , per- sistent and more localized abdominal tenderness , and persistent ileus . Both small bowel obstruction and intraabdominal abscess should be explored expediently . Ad - hesiolysis with decompression is necessary to treat bowel obstruction, whereas

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drainage is indicated for intraabdominal abscess. Reoperative indications for fasciitis are addressed in Chapter 44. Omentum, another source for intraabdominal flaps, has donor site morbidity similar to that of free bowel transfers: small bowel obstruction, wound dehiscence, or late hernia. However, one form of bowel obstruction unique to omental pedicle flaps is gastric outlet obstruction when the flap is based on the right gastroepiploic artery. This problem may require reexploration and decompression.63

TOE TRANSFER The ability to reconstruct an absent thumb by transfer of a toe has become a common procedure. Three types of transfer are possible: complete great toe transfer, a wraparound flap, and second toe transfer.64 The wraparound flap is designed to leave a greater amount of tissue at the donor site, thus minimizing donor site morbidity.65 Obvious donor site morbidity is seen cosmetically, especially with great toe transfers, and the harvest of the toe can interfere with gait. However, reopera - tion is indicated usually only for morbidity associated with pain or infection . Pain may be caused by hyperkeratotic lesions on the plantar surface resulting from clo- sure with skin grafts. Although it is best to avoid the development of these lesions by performing direct closure of the plantar skin at the initial procedure, the lesions can be managed secondarily by excision and closure either primarily or with local flaps. Ulceration is uncommon and if present is usually associated with poor - quality coverage , which may require reoperation to transfer more durable skin to the donor site. Neuromas in this area are managed similarly to those in the upper extremity with exploratory surgery, repair, grafting , or relocation of the nerves into muscle or bone.9,10 Infection of this donor site requires open drainage with delayed primary closure or closure over drains if bone is exposed. Elevation of the foot and intravenous antibiotics are also indicated.

UNSOLVED PROBLEMS Donor site morbidity will continue to remain difficult to manage until more surgeons are forthcoming in reporting the problems they encounter. Historically sur - geons are reluctant to report what they may consider their own failing, yet by not sharing this information, they may miss an opportunity to realize that their so- called failure is simply a common pitfall inherent in a challenging donor site. They also miss the opportunity to combine their efforts with those of other surgeons to find solutions to these pitfalls. Such has been the case with the recent reporting of brachial plexus injury associated with free fl ap breast reconstruction.49 After our report, we found that surgeons at other major centers were experiencing similar problems . By combining our efforts , we have now arrived at a reasonable plan to help us and others avoid this problem in the future .

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The difficulty in compiling the data for this chapter is testimony to the fact that either we are all such outstanding surgeons that donor site morbidity requiring secondary reoperation is very rare, or we do not report it often.We would hope for the former, but we suspect the latter.

References —With Key Annotated References 1. Peacock EE Jr, Madden JW, Trier WC. Biologic basis for the treatment of keloids and hyper - trophic scars. South Med J 63:755, 1970. 2. Perkins K, Davey RB,Wallis KA. Silicone gel: A new treatment for burn scars and contractures . Burns Int Thermal Injury 9:201, 1983. 3. Borok TL, Brey M, Sinclair I, et al. Role of ionizing radiation for 393 keloids. Int J Radiat On - col Biol Phys 15:865, 1988. 4. Thaller SR, Kim JC, Kawamoto HK. Calvarial bone graft donor site: A histological study in a rabbit model. Ann Plast Surg 23:390, 1989. 5. Scott SM. The pleura and empyema. In Sabiston’s Textbook of Surgery, 14th ed. Philadelphia: WB Saunders, 1991, p 1721. 6. Bick IL. Iliac bone transplantation. J Bone Joint Surg 18:1, 1946. 7. Bloomquist DS, Feldman GR.The posterior ileum as a donor site for maxillofacial bone graft - ing. J Maxillofac Surg 8:16, 1980. 8. Escelas F, Dwald R. Combined traumatic AV fistula and urethral injury: A complication of il - iac bone grafting. J Bone Joint Surg Am 59:270, 1977. 9. Dellon AL, Mackinnon SE.Treatment of the painful neuroma by neuroma resection and mus - cle implantation. Plast Reconstr Surg 77:427, 1986. This classic article by two of the most well-known researchers and clinicians in nerve physiology outlines the treatment of neuromas primarily in the extremities. 10. Mass DP, Ciano MC,Tortosa R, et al.Treatment of painful hand neuromas by their transfer into bone. Plast Reconstr Surg 74:182, 1984. 11. Lewis CM. The current status of autologous fat grafting. Aesthetic Plast Surg 17:109, 1993. One of the earlier papers on autologous fat grafting which set the stage for Dr. Coleman’s excellent work on the subject. 12. Coleman SR. Structural Fat Grafting. St Louis: Quality Medical Publishing, 2004. 13. Weeks PM. General principles of hand surgery. In McCarthy JG, ed. Plastic Surgery, vol 7. Philadelphia: WB Saunders, 1980, p 4297. 14. Daniel RK, Kerrigan CL. Principles and physiology of skin flap surgery. In McCarthy JG, ed . Plastic Surgery, vol 1. Philadelphia: WB Saunders, 1980, p 277. 15. Hallock GG. Refinement of the radial forearm flap donor site using skin expansion. Plast Re - constr Surg 81:21, 1988. 16. Leighton WD, Russel RC, Feller AM, et al. Experimental pre-transfer expansion of free fl ap donor sites. II. Physiology, histology and clinical correlation. Claim 82:76, 1988. 17. Masser MR. The pre-expanded radial free flap. Plast Reconstr Surg 86:295, 1990. 18. Argenta LC, Austad ED. Principles and technique of tissue expansion. In McCarthy JG, ed . Plastic Surgery, vol 1. Philadelphia: WB Saunders, 1990, pp 503-504. 19. Liang MD, Briggs PB, Heckler FR, et al. Presuturing: A new technique for closing large skin defects. Clin Exp Stud 81:694, 1988. 20. Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin stretching device for harnessing of the vis - coelastic properties of skin. Plast Reconstr Surg 92:260, 1993. 21. Hirshowitz B, Kaufman T, Ullman J. Reconstruction of the tip of the nose and ala by load cy - cling of the nasal skin and harnessing of extra skin. Plast Reconstr Surg 77:316, 1986.

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22. Mackay DR, Saggers GC, Kotwal N, et al. Stretching skin: Undermining is more important than intraoperative expansion. Plast Reconstr Surg 86:722, 1990. This interesting paper examines some conventional clinical “wisdom” with the finding summarized in the title. 23. Barton FE Jr, Cottel WI,Walker B.The principle of chemosurgery and delayed primary recon - struction in the management of difficult basal cell carcinomas. Plast Reconstr Surg 68: 746, 1981. 24. Goldwyn RM, Rueckert F. The value of healing by secondary intention for sizeable defects of the face. Arch Surg 112:285, 1977. Too often we fail to recognize how good the results can be with healing by secondary intention. 25. Bardsley AF, Soutar DS, Elliot D, et al. Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 86:287, 1990. 26. Swanson E, Boyd JB, Manktelow RT. The radial forearm flap: Reconstructive applications in donor site defects in 35 consecutive patients. Plast Reconstr Surg 85:258, 1990. This excellent article was one of the early published papers to examine this versatile donor site for free tissue transfer. 27. Swanson E, Boyd JB, Mulholland RS.The radial forearm flap: A biomechanical study of the os - teotomized radius. Plast Reconstr Surg 85:267-272, 1990. 28. Timmons MJ, Missotten FEM, Poole MD, et al. Complications of radial forearm flap donor sites. Br J Plast Surg 39:176-178, 1986. 29. Fenton OM, Roberts JO. Improving the donor site of the radial forearm flap. Br J Plast Surg 38:504, 1985. 30. Jones BM, O’Brien CJ. Acute ischemia of the hand resulting from elevation of a radial fore - arm flap. Br J Plast Surg 38:396, 1985. 31. McGregor AD. The free radial forearm flap: The management of the secondary defect. Br J Plast Surg 40:83, 1987. 32. Dellon AL, Mackinnon SE.The pronator quadratus muscle flap. J Hand Surg Am 9:923, 1984. 33. Kupfer D, Lister G. The pronator quadratus muscle flap: Coverage of the osteotomized radius following elevation of the radial forearm flap. Plast Reconstr Surg 90:1093, 1992. 34. Weinzwerg N, Chen L, Chen ZW. Reverse radial forearm fascial flap with preservation of the radial artery for coverage of the hand. Presented at the Annual Meeting of the American Society of Plastic and Reconstructive Surgery, Washington, DC, Sept 1992. 35. Meland NB, Maki S, Chao EYS, et al.The radial forearm flap: A biomechanical study of donor site morbidity utilizing sheep tibia. Plast Reconstr Surg 90:763, 1992. 36. Meland NB, Core GB, Hoverman VR. The radial forearm flap donor site: Should we vein graft the artery? A comparative study. Plast Reconstr Surg 91:865, 1993. 37. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: Anatomy and clinical applications. Ann Plast Surg 12:489, 1984. 38. Brent B, Upton J, Acland RD, et al. Experience with the temporoparietal fascial free flap. Plast Reconstr Surg 76:177, 1985. Following this paper, new interest was generated in the use of this thin flap for the hand, foot, and face where thin coverage was required. 39. Baker DC, Conley J. Regional muscle transposition for rehabilitation of the paralyzed face . Clin Plast Surg 6:317, 1979. 40. Colen SR, Shaw WW, McCarthy JG. Review of the morbidity of 300 free flap donor sites. Plast Reconstr Surg 76:948, 1986. 41. Maruyama Y, Iwahira Y. Correction of donor site defect with the reverse latissimus flap. Plast Reconstr Surg 80:848, 1987. 42. Core GB, Grotting JC. Peripheral nerve injury associated with the free TRAM flap. Perspect Plast Surg 7:49-57, 1993. 43. Hartrampf CR Jr. Breast reconstruction with a transverse abdominal island flap: A retrospec - tive evaluation of 335 patients. Perspect Plast Surg 1:123, 1987. 44. Waymack J, Pruitt BA Jr. Burn wound care. Adv Surg 23:261, 1990.

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45. Mizgala CL, Hartrampf CR Jr, Bennett GK. Assessment of the abdominal wall post pedicled TRAM flap surgery: Five to seven year follow-up of 150 consecutive patients. Plast Reconstr Surg 93:988-1002, 1994. 46. Bleichrodt RP, Simmermacher RK, Vanderlie B, et al. Expanded PTFE patch vs polypropylene mesh for the repair of contaminated defects of the abdominal wall. Surg Gynecol Obstet 176:18, 1993. 47. Kroll SS, Marchi M. Comparison of strategies for preventing abdominal wall weakness after TRAM flap breast reconstruction. Plast Reconstr Surg 89:1045, 1992. 48. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 113:545, 1989. Although this paper was not widely viewed at the time, it is a classic description of a technique that is now widely used for complex hernias of the abdominal wall. 49. Bostwick J, Hill HL, Nahai E. Repairs in the lower abdomen, groin, or perineum with myocutaneous or omental flaps. Plast Reconstr Surg 63:186, 1979. 50. Conway HC, Griffeth BH. Plastic surgical closure of decubitus ulcers in patients with paraplegia: Based on experience with 1000 cases. Am J Surg 91:946, 1956. 51. Tobin GR, Pompi-Sanders B, Man D, et al. The biceps femoris myocutaneous advancement flap: A useful modification for ischial pressure ulcer reconstruction. Ann Plast Surg 6:396, 1981. 52. Boyd JB, Rosen I, Rotstein L, et al. The iliac crest and radial forearm flap in vascularized oromandibular reconstruction. Am J Surg 159:301, 1990. 53. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Clinical work. Plast Reconstr Surg 64:745, 1979. 54. Forrest C, Boyd B, Manktelow R, et al. The free vascularized iliac crest tissue transfer: Donor site complications associated with 82 cases. Br J Plast Surg 15:89-93, 1992. 55. Lotem M, Maor P, Haimoff H, et al. Lumbar hernia at an iliac bone graft donor site. Clin Orthop Relat Res 80:130, 1971. 56. Geis WP, Salatta JD. Lumbar hernia. In Nyhus LM, Condon RE, eds. Hernia, 3rd ed. Philadelphia: JB Lippincott, 1989, pp 401-415. 57. Hidalgo D. The fibular free flap: A new method of mandible reconstruction. Plast Reconstr Surg 84:71, 1989. 58. Lee EH, Goh JCH, Helm R, et al. Donor site morbidity following resection of the fibula. J Bone Joint Surg Br 72:129-131, 1990. 59. Wiltse LL.Valgus deformity of the ankle: A sequel to acquired or congenital abnormalities of the fibula. J Bone Joint Surg Am 54:595, 1972. 60. Kimura N, Minami A, Takahara M, et al. Donor site morbidity following free vascularized fibular transfer [abstr]. J Reconstr Microsurg 9:467, 1993. 61. Takemoto S, Ikuta Y. Donor site morbidity after vascularized bone graft [abstr]. J Reconstr Microsurg 9:467, 1993. 62. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg 69:601, 1982. 63. Sullivan MJ, Baker SR, Crompton R, et al. Free scapular osteocutaneous flap for mandibular reconstruction. Arch Otolaryngol Head Neck Surg 115:1334, 1989. 64. Robb GL. Free scapular flap reconstruction of the head and neck. Clin Plast Surg 21:45-58, 1994. 65. Arnold PG, Witzke DJ, Irons GB, et al. Use of omental transposition flaps for soft tissue reconstruction. Ann Plast Surg 11:508, 1983. 66. Steichen JB, Weiss APC. Reconstruction of traumatic absence of the thumb by microvascular tissue transfer from the foot. Hand Clin 8:17, 1992. 67. Urbaniak JK. Wrap-around procedure for thumb reconstruction. Hand Clin 1:259, 1985.

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REVIEW QUESTIONS 1. Many donor sites share the following similar potential complications, with the exception of: a. Hematoma b. Carpal tunnel syndrome c. Seroma d. Pain e. Deformity 2. A patient who just underwent harvesting of a rib cartilage graft for ear reconstruction exhibits shortness of breath in the recovery room. The best treatment option is: a. Sedation b. Increased oxygen flow c. Chest radiograph to rule out pneumothorax d. Elevate the head of the bed e. Increase intravenous hydration 3. Reoperative management of a painful neuroma includes: a. Repair of the nerve in continuity with its distal remnant b. Secondary nerve grafting c. Implantation of the proximal nerve into adjacent muscle or bone d. Trimming the nerve back more proximally e. All of the above 4. To prevent brachial plexus injury during any surgery that requires arm abduction, you should: a. Rotate the head to the opposite side b. Place the arm at 100 degrees from the side of the body c. Fully externally rotate the elbow d. Place the forearm in the neutral position (neither pronated nor supinated) e. Flex the neck forward 5. Abdominal skin necrosis after TRAM flap surgery should be managed as follows: a. Aggressive reexcision of eschar and readvancement of the flap b. Hyperbaric oxygen c. Tissue expansion d. Conservative debridement of demarcated eschar e. Immediate vacuum-assisted closure of the wound

Chapter 8 Repeated Tissue Expansion Ernest K. Manders and Paulo da Paula

Nothing in this world can take the place of persistence. Calvin Coolidge

Reoperative Problems Deflation Expander shift/drift Exposure

Inadequate expansion Infection “Stretch-back”

A

Tissue loss Unfavorable geometry Venous congestion

lthough simple in conception and straightforward in application, soft tissue expansion is sometimes attended by complications, as described by Manders et al,1 Antonyshyn et al,2 Neale et al,3 and Elias et al.4 Tissue is seldom lost when complications occur; it is often possible to achieve a satisfactory result despite setbacks such as exposure, infection, deflation, inadequate expansion, unfavorable geometry, and poor planning. In the following case, all of these complications were encountered, presenting a challenge to the surgeon, patient, and her family. Success was ultimately achieved in good measure as the result of thoughtful treatment planning and patience.

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PATIENT EXAMPLE

A 4-year-old girl was brought to the emergency department after a massive scalp avulsion that occurred when her hair was caught in the power-takeoff axle of a tractor. The scalp had been brought with her and was judged suitable for replantation. In the operating room, two arterial repairs were successfully completed. No veins of sufficient caliber could be found to reestablish an adequate outflow despite extensive dissection and searching. The scalp was perfused and the edges were only loosely approximated to allow bleeding. Unfortunately, venous congestion required a return to the operating room the next day. The replanted scalp was removed and used as a donor site for the harvest of split-thickness skin grafts. More than one split-thickness graft was harvested from the avulsed scalp because of the thickness of the skin.

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Two months later, the wounds were well healed and the patient and her family asked for reconstruction. The defect was extensive: there was no hair-bearing scalp on the top of the head. On the right side much of the temporal hairline and the temporal and parietal scalp were absent. On the left side the remaining temporal hairline was somewhat higher. A reconstruction program using soft tissue expansion was planned. Four months after the injury, three soft tissue expanders were placed under the remaining scalp. A 50 cc rectangular expander was placed under the right temporal scalp, a 300 cc round backless expander was placed under the left side of the scalp, and a 500 cc round backless expander was placed under the occipital scalp. The plan was to surround the defect as much as possible and to expand all of the available scalp. Experience has taught that the expander should lie flat when placed under tissues to be expanded. Backless expanders were used because they can be folded when necessary to best fit the pockets dissected. Because the available scalp was limited, expanders with back plates were avoided. Although folds in an envelope are usually troublefree, a folded stiff back might erode through the scalp, leading to exposure.

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Almost 3 months later, the first scalp advancement was performed. The plan was to advance the scalp and place larger expanders. Because the largest area of scalp lay over the occiput, the plan was to preferentially expand the occipital scalp. Two male-pattern baldness differential expanders were inserted under the advanced lateral and posterior scalp.The differentially expanding ends, which would achieve the greatest expansion, were positioned under the occipital scalp as can be seen in the immediate postoperative view.

Three weeks later, on a return visit to the clinic, an exposure of the left expander at the left temple suture line was observed. A small amount of drainage had been noted at home. There was no purulence at the wound margin and she appeared well. A smear of the wound surface was obtained, Gram stained, and examined immediately by the surgeons. There were few polymorphonuclear leukocytes or bacteria seen. The exposure seemed to have occurred quite recently.

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The patient was taken to the operating room for irrigation and debridement. A closed suction drain was placed and the exposure site was closed. Postoperatively she received parenteral and oral antibiotics. Cultures of the expander cavity obtained at the time of the operation grew Streptococcus viridans.

Six weeks later, after several injections had been performed in the clinic, the expanders were expanding visibly. The treatment course to this point had been smooth, but now the child seemed ill. Her mother reported increased irritability, anorexia, and fever. The child appeared somewhat subdued in the clinic. The scalp was slightly tender. Aspiration over the left injection port yielded a turbid fluid that contained abundant polymorphonuclear leukocytes and gram-positive cocci. She was taken to the operating room where thorough irrigation and drainage were carried out. A cephalosporin in saline solution was placed in the expander cavity after deflation of the expander devices. Closed suction drains were inserted and placed to suction. The capsule surrounding the expanders appeared normal except for some fibrin exudate in places. The scalp and adjacent soft tissues showed no sign of cellulitis.To avoid extensive dissection and blood loss at a future date, the decision was made to retain the expanders and simply drain the expander cavity. The patient is shown after open irrigation and closed drainage for the periexpander infection. Postoperatively, the patient received intravenous antibiotics for 4 days, and then oral antibiotics for 10 days. Afterward, the expansion proceeded nicely. Two and a half months later, the progress of expansion suddenly ceased and expander deflation was diagnosed. She was returned to the operating room for the second scalp advancement to take advantage of the progress made and to replace the expanders. A 300 cc backless expander was placed under the forehead skin and two male-pattern baldness expanders were inserted as before, with the differentially expanding ends located over the occiput. Her course was uncomplicated except for some separation of the medial ends of the expanders.

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After 4 months of leisurely expansion during the summer after the injury, or 15 months after the initial injury, there was a noticeable gap between the ends of the expanders in the midline under the occipital scalp. Because the unexpanded area was fixed to the occiput, she was brought to the operating room for a third scalp advancement and placement of an occipital expander to ensure adequate expansion of the scalp.Without expansion of the scalp between the two expanders on either side of the midline, the advancement of the occipital scalp would have been severely limited.

Almost 3 months later, after satisfactory expansion of both the male-pattern baldness expanders and the occipital expander, the patient was admitted for the fourth scalp advancement procedure, this time of the scalp and forehead.

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Because of the large occipital expansion, the occipital scalp could be advanced far forward. The temporal scalp also closed somewhat medially. It was possible to close with almost total removal of the skin graft. Only a small area of skin graft remained at the right anterior hairline. In the photo upper left, the scalp has been incised with expanders in place. Upper right, the scalp and expander cavities are seen before advancement. Lower left, a trial advancement was done before excision of the skin graft over the avulsion defect. The photo lower right shows final advancement of the expanded scalp and the expanded forehead.

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The patient recovered without incident postoperatively. She could style her hair and was very pleased with her appearance. Two years after the injury, the patient had done very well but the scalp had stretched back somewhat, widening the area of skin graft and moving the anterior hairline somewhat more posterior since the advancement 5 months earlier. Therefore soft tissue expanders were placed under the anterior scalp so that the scalp could be advanced again with removal of all forehead skin graft. Because this young girl voiced a great fear of the needles used for percutaneous injection of the expander ports, the expanders that were positioned on either side of the midline were placed with the ports exiting through subcutaneous tunnels that opened behind the ears, making the process of filling the expanders easier. Her early postoperative course was fairly unremarkable. A small amount of drainage was noted from around the tubing at the site where it entered the scalp.

As the expansion proceeded, 1 month later, the soft tissue expander appeared to move somewhat downward under the scalp, and the flange that supported the tubing entry to the envelope actually protruded through the skin entry site, exposing the base of the expander. Expansion was continued until measurements across the dome of the expanders indicated that adequate expansion had been achieved to allow successful advancement. An impetiginous crust developed over the right suture line, and was treated with scrubbing and oral antibiotics. The problem resolved with treatment.

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After another month, at advancement, the expanders were removed and the site of the exposure was debrided. Granulation tissue was present, lining the capsule around the tubing entry site on the right and around the exposure site on the left. A routine culture of this tissue was carried out and organisms were recovered. Despite this infection, advancement of the scalp was possible, removing the widened scar and skin graft and closing the tubing entry sites. Drains were left in place and removed postoperatively. The patient tolerated the procedure well and obtained additional improvement from this final advancement. Her postoperative course was uneventful. She is now able to style her hair almost any way she chooses.

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DISCUSSION This case illustrates the full range of complications that can be encountered during soft tissue expansion. Fortunately, as a surgeon’s expertise grows, difficulties presented here become rarer. However, certain patients, because of the size of the defects, their inability to cooperate, or host factors that make the tissues less wholesome, may experience difficulties. This patient suffered complications of exposure, infection, deflation, and shifting of the expanders. Yet, despite these significant interferences, a successful outcome was obtained. Soft tissue expansion is particularly valuable because tissue viability is seldom threatened by simple elevation. If proper care is taken during the expansion, it is unlikely that tissue will be lost, even if other complications such as those experienced by this patient, do occur. We wish to discuss elements of the management of this patient. At the first admission, this patient underwent surgery in an attempt to reattach the scalp. If this reattachment had been successful, she would have been the youngest reported patient to have successfully undergone scalp replantation in the literature at that time. Unfortunately, we could not find venous tributaries affording adequate venous drainage, even after arterial anastomosis and reperfusion. A previous report documenting the replacement of a portion of scalp and its ultimate survival, and our knowledge of smaller composite replantations (for example, fingertip replantation) prompted us to leave the perfused scalp in place with the hope that if adequate drainage persisted until inosculation occurred, at least some scalp could be saved. The following 12 hours showed that this strategy would not succeed, and the scalp was promptly removed. Despite the failure of replantation, the avulsed scalp remained important for wound closure. Because the scalp is thick, more than one split-thickness skin graft may be obtained from its surface with subsequent satisfactory take. A segment of avulsed scalp may be harvested at least twice to obtain skin to cover the defect. Using this technique, we covered the avulsion defect completely with harvested split-thickness skin grafts that closed the wound successfully. At the second admission, 4 months later, three soft tissue expanders were placed with the goal of expanding the occipital scalp and moving it up, over and across the vertex like a visor advancement. The decision was made to use separate expanders for reasons of convenience, and because we felt it would be difficult to fit one large expander properly. There was also some concern that with the inflation of one large expander, the corners might move forward, thinning the temporal scalp that

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had already been injured, especially on the right side where a large laceration had been repaired at the initial surgery. To avoid local tissue problems, we believed it would be advantageous to be able to control the rate of expansion in each major area of the scalp. In retrospect, it may have been better for this particular patient to carefully outline the remaining scalp and fashion a large single-lumen expander that would have underlain the entire scalp and have expanded it all at the same time. Such a tracing was made for this patient, but it was decided not to fashion an individual expander in view of the above considerations. Using one expander does offer significant advantages because webs of capsule at the site where adjacent expanders touch do not develop; instead there is one smooth surface from one envelope. In this patient such a web was a problem later in the treatment course. At the third admission, 2 months and 1 week later, the first scalp advancement was carried out. She tolerated this surgery well, and the operation was successful. Our goal was to expand the scalp and then advance it, followed by the immediate placement of larger expanders underneath the scalp so that the process could be continued. It was desirable to change the expanders at this point because a more uniform expansion could be obtained with larger expanders. The development of webs between adjacent expanders, which can limit advancement, would be eliminated by the insertion of larger expanders that overlapped. An attempt was made to make the pockets large enough so that the expander bases would not impinge on the suture line. The pocket appeared adequate at the time of closure; however, at the fourth admission 3 weeks later, it was clear that the pocket in the left temple area was probably not wide enough. Although it is possible that this patient may have scratched the area or picked it, it is more likely that the soft tissue expander envelopes pushed into the suture line, leading to exposure. A great deal of thought went into the decision to simply drain the area without removing the soft tissue expander. At this time the scalp was not under tension. The patient was not ill, there were no signs of infection, and only scant evidence of colonization was found. To preserve the large pockets created and with the hopes that reoperation and blood loss could be prevented, the decision was made to retain the expanders after thorough irrigation and drainage of the cavities. The patient was treated with antibiotics for several days in the hospital and then discharged; an oral antibiotic regimen was prescribed. She did well and had begun soft tissue expansion when she returned 6 weeks later not feeling well. Aspiration over the injection port revealed a purulent fluid. The surgeon can obtain aspirate to determine whether infection is present in the expander cavity by simply inserting the needle over the injection port and aspirating some of the fluid.

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This technique is successful even if a remote port is used. Purulent fluid will track along the tubing to the injection port, because the expander is in one cavity. Immediate gram stains should be obtained to determine whether polymorphonuclear leukocytes are present and whether bacteria can be identified. The material can also be sent for culture and antibiotic sensitivity determinations for isolated organisms. At this admission it was decided that an open operation would again be necessary; the same concerns regarding the risk of leaving the expanders in place still existed. Because of minimal tissue signs of inflammation, it was decided to proceed with partial deflation of the expanders and insertion of drains after thorough irrigation. As before, the patient was treated with intravenous antibiotics for several days and oral antibiotics on an outpatient basis. Soft tissue expansion was resumed without difficulty after drain removal. She did very well until 10 weeks later, when it became evident that the expansion, which had been proceeding nicely, was now stalled by expander deflation. At the time of exposure or overt infection of a soft tissue expander, the surgeon is faced with a difficult decision: to remove the expander or not. In most instances we decide to remove the expander and carry out an advancement. At times it will be impossible to effect an advancement. In situations in which the patient appears ill and exhibits systemic signs, or the survival of the tissue is threatened, it may be wiser to simply remove the expanders, drain the cavity widely, and do nothing more. We have even gone so far as to leave the entire expander pocket open for the best drainage possible; this maneuver, however, has never been necessary in the case of a scalp expansion. We recognize that the decision regarding drainage of an expander and continuation of expansion without entire removal of the expanders is controversial. There are precedents in cases of other prostheses, including heart pacemakers, vascular prostheses, metallic apparatus for orthopedic reconstructions, and implants such as Silastic chin implants. On the patient’s sixth admission, this time for replacement of leaking expanders, a significant advancement was achieved despite the leaking that became evident after several weeks. We have removed soft tissue expanders from the scalp, breast, and lower extremities only to discover there were multiple perforations in the envelopes. Obviously, satisfactory expansion can be achieved despite perforations and a presumed slow leak.

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We have treated leaking expanders by aspirating the saline solution external to the envelope and then reinflating the expander. After all available saline solution external to the expander has been aspirated, a second needle is inserted while the first needle remains in place. The second needle enters the injection port and saline solution is injected. As the envelope expands, this action will often force the saline solution into the needle overlying the injection port with bevel down and further aspiration can be carried out. Once the envelope is filled to the appropriate tenseness, both needles are removed. At times when the silicone elastomer envelopes are adjacent to the soft tissue capsule, the perforations are essentially closed and expansion can proceed normally. On the seventh admission, 4 months later, a third expander had to be inserted to elevate the occipital scalp. When soft tissue expanders are overlapped, one of three things may happen. First, at sites where expanders significantly overlap, perhaps one third to one half of their length, there is great impetus for continued overriding because the soft tissues will normally resist expansion. As inflation occurs, expansion tends to become spherical, creating the smallest surface area for a given volume. Therefore it is only natural that as one expander is filled, it slides over or under the adjacent expander. Physics determines that this sequence will happen unless the expander base plates are sewn down or the excursion of expanders is limited by fixation of their tubing or their shape. Second, it is possible for two soft tissue expanders to stay exactly where positioned next to each other, which has been the case in our practice on several occasions. However, there is always a web of capsule that has a triangular cross-section that fills the space between the two adjacent tissue expander domes. This web must be cut transversely to allow the flap to advance, and sometimes it must be entirely excised to allow shaping of a flap. This web is a bit of a nuisance, and when one expander will do the job, that approach is preferred. Third, the soft tissue expanders may drift apart. This scenario occurred in this case and resulted in an unexpanded isthmus of scalp between the two differential scalp expanders. This outcome meant a portion of the occipital scalp with the highest density of hair was not expanded and could not be advanced. To obtain the proper geometry to allow maximal advancement, an occipital expander was placed. Once accomplished, soft tissue expansion proceeded smoothly. After a full expansion of the occipital expander, and once measurements indicated that satisfactory advancement would be possible, the patient was admitted for advancement three months after the third expander was placed. At this time it was possible to advance the large visor of occipital scalp up across the top of the head and forward. The anterior hairline was reconstructed. The advancement proceeded

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with some tension, however. As a result, there was significant stretch-back with widening of the remaining skin graft scar to approximately three times its width present at the conclusion of the advancement procedure 4 months earlier. Stretchback has been observed in a number of situations. The best defense is adequate soft tissue expansion so that a tension-free closure can be accomplished. The degree of widening of the postoperative scar seems to depend somewhat on the individual and is site dependent; for example, sagittal scars always widen more than coronal scars. Because the patient desired elimination of much of the widened scar anteriorly, another expansion was required. Five months later, this young girl was returned to the operating room to insert the expanders. Expansion was performed during the next 2 months. The vertex scalp was then advanced forward to allow successful reconstruction of the anterior hairline. When planning the final advancement procedure, because of the patient’s expressed fear of needles, we elected to use exteriorized ports. It has been our experience that such a fear is seldom a problem and can be usually overcome by simple conditioning. We used to have patients rub the area of the injection port with a small ice cube every day and in the clinic before injection. Now, topical local anesthetic creams serve to anesthetize the area quite effectively and have supplanted the ice cube method in our clinic. In the case of this particular patient, there was clearly an element of secondary gain in her behavior. Many surgeons have had great success using exteriorized ports. Our own experience has been mixed. In this patient the left expander migrated along the course of the tubing and was eventually exposed. We still prefer buried ports when possible, but we recognize the occasional utility of an exteriorized port. This patient had a long and difficult course. The end result is good. Subsequent to the reconstruction reported here, she has grown into a young teenager who has had one more scar revision on an outpatient basis. All has gone well for her, and she and her family have recovered both physically and psychologically. Although soft tissue expansion can be trying, with careful planning, meticulous execution, good judgment, and persistence, remarkable results may be obtained. This case catalogs the difficulties encountered in one patient. Taken singly, each of the complications was by no means unusual. It should be stated, however, that we have never had so many complications in one patient before or since.This patient, therefore, is all the more valuable for study, and we share the history of her treatment course in the hope that the information presented will lead to safer and more successful soft tissue expansion for future patients undergoing soft tissue expansion.

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GENERAL CONSIDERATIONS Soft tissue expansion can be very effective in reconstructing major soft tissue defects. Attention paid to several simple principles will aid the surgeon and the patient in their quest for a successful reconstruction. Perhaps most important for success is recognition of the link between surgeon and patient; the process of expansion will bind them together on what may be a rather lengthy journey that cannot be rushed. The first and foremost principle of tissue expansion is that the process cannot be hurried. The time course of expansion must be governed by the tolerance of the patient, who should never sense pain, and by the appearance of the tissues being expanded. Tissues should not become thinned by the process if enough time is allotted and inflation pressures are kept low. Adequate expansion time is important not only to preserve the integrity and quality of the soft tissues being expanded, but also to permit complete expansion. Expansion should proceed until it affords a flap of dimensions sufficient to allow reconstruction of the defect without tension. Perhaps the most common error in soft tissue expansion is rushing the expansion. This causes discomfort, expander exposure, and, even more common, an imperfect reconstruction resulting from the expanded flap being too small to do the job intended. Planning is crucial to success. The surgeon should begin by determining where the final scars should lie, and then decide where to place the expander—under what tissue and through which incision. Ideally, the incision for expander placement is eliminated by the advancement. The surgeon should attempt to minimize the scar burden for the patient. Often this incision can be located at the edge of the defect. This site poses little risk if the tissue is of good quality. Usually the largest expander possible should be used. Expander size is, of course, limited by the tissue available for expansion, and at times by the geometry of the defect. In general, however, using the largest expander possible works best. Sometimes the patient is best served by the fabrication of a custom expander that can serve in the place of two or more conventional off-the-shelf expanders. The use of one large expander will for the most part eliminate the problems of webs of tissue between adjacent expanders and inadequate expansion caused by the migration of adjacent expanders.

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In addition, the larger the expander and the larger the dimensions of the expanded flap, the greater the flap’s mobility at the time of inset. A word should be added about making the decision to return to the operating room for advancement of the expanded flaps. When does the surgeon know that the time is right? First, the base of the tissue expander is measured by sight, from one edge where it rises above the plane of the unexpanded tissue to the other side. Next, the arc of the expander is measured from side to side with a flexible tape measure. Subtracting the base width from the arc length provides an estimate of the advancement that is possible. By following this measurement in the clinic, the surgeon can know when enough tissue is available to allow a successful expansion.

Croissant expander

The above measurements are not foolproof , however . Expanders that have a round base or rectangular expanders that are nearly square produce hemispheric expan - sions . Hemispheric flaps do not advance well over flat or cylindrical surfaces be- cause the perimeter of the flap is not very elastic. This realization prompted the design of the croissant expander , thus named because the crescent shaped expander enlarges to resemble the French pastry . Using the croissant expander to half sur - round the defect provides a dimensionally matched advance with a minimum of scar and no soft tissue redundancy . Now the conventional croissant design has been advanced with the introduction of the adjustable -base expander shown above (Spe- cialty Surgical Products , Hamilton , MT). This expander can be made long or short , and the angle can be changed between the arms . This design allows each expander to function as a custom expander for the defect to be treated . Four sizes can han- dle any defect . The adjustable design is complemented by an integrated magnetic port for easy detection and confident filling, especially by people performing ex- pansion at home or medical personnel with less experience.

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Deflation is seldom a problem. Leaks are sometimes discovered to the surgeon’s surprise at the time of expander removal. Should a leak occur with concomitant deflation and inability to continue expansion, the expander should simply be replaced, or its tube or remote port may be replaced, depending on the site of the leak. The occurrence of a leak should not be regarded as a catastrophe. The expander can be replaced in a short outpatient procedure with the patient under local anesthesia in all but pediatric patients and the most anxious adult patients. Exposure is most often the consequence of infection. Despite skin preparation, prophylactic antibiotic administration, drainage of the expander cavity, and care appropriate to a given patient, infection is still an occasional problem. In most cases the prudent decision is to remove the expander, allow a period of recovery, and eventually replace the expander. The patient and surgeon should be encouraged by the knowledge that no tissue will be lost and that a fully successful expansion is probably possible after resolution of the infection. Although some surgeons are reluctant to embrace the concept of expansion at home performed by the patient and family members, patients themselves eagerly pursue this option when it is offered. Home expansion saves money and time, makes the patient an active partner in the process of reconstruction, and builds selfesteem. For these reasons home expansion is a valuable part of the process of reconstruction surgery. Patients are uniformly successful in this endeavor and generally appreciative of the responsibility and confidence invested in them. Tissue expansion has come of age. Its utility is widely recognized. With patience and adherence to a few principles, both the patient and the surgeon are well served by this technique.

References —With Key Annotated References 1. Manders EK, Schenden MJ, Hetzler PT, et al. Soft tissue expansion: Concepts and complications. Plast Reconstr Surg 74:493-507, 1984. An early paper in the history of soft tissue expansion describing the design strategies for using the technique and the complications that one sees.The unique advantages of tissue expansion are listed and discussed. Major and minor complications are presented. 2. Antonyshyn O, Gross JS, Mackinnon SE, et al. Complications of soft tissue expansion. Br J Plast Surg 41:239-250, 1988. 3. Neale HW, High RM, Billimire DA, et al. Complications of controlled tissue expansion in the pediatric burn patient. Plast Reconstr Surg 82:840-845, 1988. 4. Elias DL, Baird WL, Zubowicz VN. Applications and complications of tissue expansion in pediatric patients. J Pediatr Surg 26:15-21, 1991. Another in a series of papers over the years documenting the seemingly greater challenge of tissue expansion in the pediatric age group.

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Suggested Readings Manders EK, Au VK, Wong RKM. Scalp expansion for male pattern baldness. Clin Plast Surg 14:469-475, 1987. Tissue expansion can be used for very impressive reconstructions of male-pattern baldness.The only drawback is the temporary deformity, which can largely be disguised with appropriate hats.The advantage of rapid, complete reconstruction with uniform hair distribution in a natural pattern has much to offer. Manders EK, Graham WP III, Schenden MJ, et al. Scalp expansion to eliminate large scalp defects. Ann Plast Surg 12:305-312, 1984. The first paper to describe scalp reconstruction using soft tissue expansion. Serial expansion is described.The effectiveness of reconstructing hairless defects with scalp of uniform hair distribution is well documented. Manders EK, Oaks TE, Au VK, et al. Soft tissue expansion in the lower extremity. Plast Reconstr Surg 81:208, 1987. The experience of tissue expansion in the lower extremity is described.The chance of periexpander infection is 80% if tissue expansion is used in patients with an open wound at or below the knee. Manders EK, Saggers GC, Diaz-Alonzo P, et al. Elongation of peripheral nerve and viscera containing smooth muscle. Clin Plast Surg 14:551-562, 1987. Tissue expansion can elongate tissues other than those of the integument. Peripheral nerve, ureter, and even small bowel can be lengthened through tissue expansion. Intraluminal expansion of viscera containing smooth muscle in their walls results in massive mural hypertrophy that negates any increase in diameter. McCarthy CM, Pusic AL, Disa JJ, et al. Unilateral postoperative chest wall radiotherapy in bilateral tissue expander/implant reconstruction patients: A prospective outcomes analysis. Plast Reconstr Surg 116:1642-1647, 2005. A small prospective study of the natural history of irradiation of the breast reconstructed using tissue expansion with the nonradiated side serving as control. Radiation did increase the incidence and severity of capsular contracture, but the results overall were thought to be acceptable.

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REVIEW QUESTIONS 1. Can an area of soft tissue be expanded more than once, and how soon can a reexpansion, if possible, begin? a. Never reexpand an expanded flap of soft tissue b. You may reexpand beginning about a year after the last advancement surgery c. You may begin in about a month d. You may begin in about a week after an advancement e. You may begin immediately, stressing the line of closure with a tense expansion 2. How do you know when it is time to go to the operating room to perform an advancement? a. The patient tells you he and she is ready b. The patient’s family tells you they are ready c. The referring doctor tells you he/she is ready d. You feel ready e. Measurements reveal that you have the increase in tissue dimensions to allow the intended reconstruction 3. How do you know if there is an infection around an expander? a. The patient feels like he/she “has the flu” b. The area of the expansion is red c. The area of the expansion is tender d. Aspiration over the port returns a turbid fluid e. All of the above 4. How is a periexpander infection treated? a. Treat with expander removal, irrigation, and flap advancement b. Remove the expander and pack open c. Remove the expander, irrigate, and close over drains d. Remove the expander, sterilize it in the autoclave or replace it, irrigate and debride, replace the expander over a drain, and close e. Potentially each of the above could be used depending on the circumstances of the case 5. Can expansion be conducted safely in the patient’s home? a. Yes, with appropriate instruction given to the patient and family b. No, it should be performed by a doctor on every occasion c. No, it should be performed by a nurse in a medical office d. No, it is against the law e. Only if one uses osmotically driven expanders

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Chapter 9 Failed and Failing Free Flaps William C. Lineaweaver, Stephanie A. Stover, and Jacob Gerzenshtein

You do what you can as long as you can, and when you finally can’t, you do the next best thing. You back up, but you don’t give up. Chuck Yeager

Reoperative Problems Detection of flap circulation impairment Nonoperative intervention Operative reexploration

Recognition and management of flap failure Reconstruction after flap failure

A

surgeon’s approach to failing and failed flaps consists of a complex of judg - ments and actions . Recognition of flap circulation problems needs to come as close as possible to the onset of the problem . Treatment should progress quickly through nonoperative maneuvers to operative reexploration and anastomosis revision. A failed flap requires thorough reassessment of reconstructive goals and options.

Microsurgical flap procedures are established reconstructive options for difficult and extensive defects of the head and neck, trunk, extremities, and genitalia.1-4 Microsurgical flaps can be used for such diverse problems as total scalp loss, mastectomy defects, and loss of a critical fingertip. In such areas as mandible reconstruc 195

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tion and thumb reconstruction, microsurgical flaps (for example, fibula reconstruction of the jaw and toe reconstruction of the thumb) clearly show how microsurgery has revolutionized reconstructive strategies from prolonged series of staged procedures to single-stage surgeries that can provide reconstructive units of vascularized tissue with a variety of components.5 Since the 1980s, flap failure rates have been between 2% and 10% in large microsurgery series.6,7 Flap failures, although rare, are always a severe setback for the patient and surgeon and can be limb threatening, deforming, or fatal. Recognition of flap complications preceding flap death can lead to interventions that can result in flap rescue. Effective secondary strategies applied after a flap failure can lead ultimately to satisfactory and functional outcomes for patients where initial microsurgical reconstruction failed.

DETECTION OF FLAP CIRCULATION IMPAIRMENT INTRAOPERATIVE INSPECTION Clearly, the best time to detect and correct a circulatory complication in a microsurgical flap is at the time of the initial procedure. At the completion of the arterial anastomosis, visible pulsations and filling of the pedicle artery, evidence of flap perfusion (visible tissue perfusion, Doppler signals from the flap artery), and pedicle venous return should be systematically confirmed by the surgeon. After completion of the venous anastomosis, the surgeon should confirm recipient vein filling. Sustained dilation of flap pedicle veins should be immediately evaluated for possibilities of recipient vein obstruction. After completion of the vascular anastomoses, flap procedures include flap inset, donor site repair, and sometimes skin grafting. During these steps of the procedure, the flap should be examined periodically for color changes or for loss of Doppler signals. Throughout the initial flap procedure, any evidence of perfusion compromise should lead to careful inspection of the vascular anastomoses and implementation of revision strategies such as the ones discussed later in this chapter.

POSTOPERATIVE MONITORING Dressing, Splinting, and Positioning The first step toward effective postoperative examination is the application of dressings and splints at the conclusion of the flap procedure. Dressings around and on a flap should be minimal.

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In the lateral arm flap to a first web space shown here, the dressing supplies a splint to aid with stability and elevation, and a wide window for flap inspection. Dressings should avoid any possibility of compressing the flap, and the flap should be partially or totally visible for periodic examination. Splints should be applied as necessary for skeletal stability and should be well padded and constructed to avoid flap and pedicle compression. Splints can be effective stabilizers for postoperative extremity positioning. Specific attention should be paid to patient positioning following microsurgical flap procedures.

UPPER EXTREMITY FLAP

LOWER EXTREMITY FLAP

Head: Position of comfort Hand/wrist: Above elbow No circumferential suspension or fixation

Head: Position of comfort Upper extremities: Free Lower extremity: Knee straight, foot above knee

Flap at wrist Flap

Extremities should be comfortably but securely elevated to minimize swelling, but potentially constricting slings or restraints should be avoided.

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HEAD AND NECK FLAP

BREAST FLAP

Head: Elevated No pressure on flap

Head: Elevated; position of comfort Arms: Free Minimal dressings on flap margins without circumferential wrapping

Flap Flap

Patients with flaps to the head and neck or breast can be effectively and comfortably positioned with the head of the bed elevated to produce a reclined sitting posture.

Clinical Examination Some flaps, such as those used for esophageal reconstruction or femoral head revascularization, cannot be examined, but all flaps with at least a partial component on the surface of the body can be clinically evaluated. Even buried flaps can be inspected if they are designed to have an externalized component (the so-called monitoring flap).8,9 Generally, a knowledgeable observer who periodically inspects the flap can reliably detect signs of arterial obstruction (pallor, loss of turgor) and venous obstruction (increasingly brisk capillary return, cyanosis, distension). Clinical detection of a vascular complication is necessarily dependent on secondary changes; thus a vascular complication can be long-standing by the time it is grossly indicated by visible changes in the flap.

Monitoring Many devices have been applied to the task of monitoring flap circulation following a microsurgical procedure. These instruments fall into two general categories : (1) devices for detecting circulatory obstruction by measuring a physiologic pa- rameter, such as temperature, tissue pH, or tissue electrical conductivity, and (2) monitors that directly evaluate arterial circulation, venous circulation, or both. 10

How effective are flap-monitoring devices? Despite an extensive literature on flap monitoring published over several decades, useful data applicable to this question are scarce.

Chapter 9 Failed and Failing Free Flaps

One basic error that limits the assessment of many monitoring systems is the apparent detection of uncomplicated flaps as a measure of monitoring success.11 For example, if a flap monitor applied to a series of 100 flaps gives a signal that all the flaps have uncomplicated circulation, and 95 of the flaps survive, the flap monitor may be reported as having a 95% success rate. The problem is that a monitor should not be evaluated by its performance relative to uncomplicated flaps. Meaningful outcomes of flap monitoring should be based on detection of complicated flaps and, more precisely, the eventual survival of those complicated flaps after operative rescue attempts.12 Complicated microsurgical flaps detected by clinical examination alone are reported to have salvage rates of about 55%.8 Only four monitoring devices have been reported to be associated with higher salvage rates than clinical monitoring: the hand-held Doppler, quantitative fluorimetry, laser Doppler flowmetry, and implantable Doppler probes.

Salvage Rates of Complicated Microsurgical Flaps Author

Cho et al8 (2002) 13

Disa et al (1998) 12

Whitney et al (1992) 14

Goldberg et al (1990) 15

Kind et al (1998)

Monitoring Method

Salvage Rate (%)

Clinical examination

55

Surface Doppler

77

Quantitative fluorimetry

86

Laser Doppler

83

Implantable Doppler

100

Flap

The hand-held Doppler has been used as an easily applied adjunct to clinical examination. It is applied directly to the flap, and an audible signal is obtained. The probe is best suited to monitoring arterial pulsations, but venous flow may also be detectable . Salvage of complicated flaps detected by this method has been reported to be as high as 67% to 77%.13

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Fluorimetry unit

Functional arterial inflow and venous outflow Venous occlusion Arterial occlusion

0

Injection

10

20

30

40 Time

50

60

Flap

With quantitative fluorimetry, a 2-hour injection cycle of fluorescent dye is used to monitor arterial inflow and outflow. A light source is connected to an otoscopeshaped projector-reader, which flashes ultraviolet light onto the flap surface, and then reads subsequent fluorescence, which is related to the amount of fluorescein in tissue. The technique requires a skin component, and it does not work on pigmented skin, freshly applied skin grafts, or muscle. An 86% salvage rate of complicated flaps and toe transplants has been reported using this monitoring method.12

Flap

In laser Doppler flowmetry, laser light is transmitted to a probe on the flap by a fiberoptic cable . The probe detects capillary flow by scatter and wavelength change in the reflected light.The source translates the probe data into an estimated flow ex- pressed numerically . Thus laser Doppler provides a continuous monitor of capillary flow, and signi ficant decreases from baseline readings are associated with flap circu - lation complications . Flap salvage rates using this monitoring method have ranged from 69% to 83%.14

Chapter 9 Failed and Failing Free Flaps

Artery

Vein

Flap

Implantable Doppler probes have been used to directly, audibly, and continuously monitor flow distal to arterial and venous pedicle anastomoses. Monitoring the venous pedicle alone may be a very sensitive early detection strategy; one report describes 100% salvage of complicated flaps using this method. Another advantage of this monitor is that it can be applied to all tissue types as well as to buried flaps.15 All monitoring systems must ultimately be judged by their efficacy in individual practices and sites. Factors including false-positive alarms, cost, and technical limitations of staff can set limitations of application of any monitoring system, and each practicing microsurgeon must make decisions about monitor utilization based on specific needs and conditions. Will there ever be an ideal clinical monitor for flap circulation? Power Doppler imaging systems provide real-time dynamic images of arterial and venous circulation, and the visualization of vessel flow is enhanced by audible signals and estimates of blood flow. Continued refinements and affordability of this technology may make it a real-time, noninvasive window on flap circulation.16

NONOPERATIVE INTERVENTIONS When compromised flap circulation is suspected or identified postoperatively, some specific nonoperative interventions can be undertaken while a decision for operative exploration is finalized.

DRESSING REMOVAL AND PATIENT POSITIONING For a flap with questionable circulation, an initial intervention should be complete removal of all dressings on or around the flap. This maneuver allows complete examination of the flap and removal of any constrictive or compressive dressing elements.

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For extremity flaps, positioning of the flap and extremity should be evaluated at this time. Extremity positioning should follow the rules of “foot above knee” and “hand above elbow” to avoid dependent hands and feet with proximal extremity elevation. Slings and positioning pillows, if used, should be adjusted to avoid extremity or flap compression.

INSET RELEASE Inspection of the flap may reveal tension of the flap inset over the pedicle or a tight skin closure over the pedicle. In some cases, inset suture or skin closure sutures can be released at the bedside and the effect on flap circulation assessed. If no vessels or significant underlying structures are exposed, these areas may often be allowed to heal with dressings. In some cases, an underlying hematoma may also be relieved by partial inset release, and this drainage may restore the flap circulation by relieving compression.

ANTICOAGULATION Anticoagulation medication as an adjunct to microsurgical flap procedures has a long and inconclusive history. Such agents are often used in complicated circumstances, and their actual effects are difficult to determine.17 For a flap with questionable or failing circulation, systemic heparin may be administered in the hope of averting clot development and propagation. Heparin administration is variably used by microsurgeons, with doses ranging from full therapeutic anticoagulation (with frequent bleeding at donor and recipient sites) to fractional doses that may not change the results of clotting studies. When it is used, heparin administration generally continues for 5 to 7 days after initiation. Low-molecularweight dextran may be administered as a volume expander, and there is some evidence that it may function as a fibrinolytic in capillary beds. In adults, lowmolecular-weight dextran is commonly given as an infusion of 25 ml/hr for 3 to 5 days after the flap procedure.

LEECHES Leeches function as a route for evacuation of venous blood in tissue that has arterial inflow but inadequate venous outflow. These creatures have a recognized and efficacious role in complicated replantation cases, but their utility in flaps is very limited.

Chapter 9 Failed and Failing Free Flaps

Leeches remove blood until venous outflow is established between compromised tissue and its bed. In replanted fingers, this venous revascularization can occur as quickly as 3 days, and leeches can be used for this period, as long as the tissue arterial circulation is intact. Leeches drain off sufficient amounts of blood to require transfusion in some cases.18,19 Leech use in large flaps is a questionable undertaking. It is not clear that leeches adequately drain large tissue units, and blood loss could be prohibitive. Leeches only attach to skin, so they are not effective on tissue surfaces with muscle or fresh skin grafts.18 Leeches may be considered in complicated small cutaneous flaps when reoperation seems unfeasible.20 Arterial flow to the tissue must be intact for any hope of success, and the patients should be given systemic antibiotics effective against Aeromonas hydrophila to prevent infection by this leech-borne bacterium.21

OPERATIVE REEXPLORATION TIMING Generally, operative reexploration of a compromised microsurgical flap should be considered as soon as the complication is recognized or strongly suspected. During the initial operation, the pedicle vessels should be reinspected at any time during the procedure if circulation appears unsatisfactory.22 Postoperatively, surgical reevaluation should be prompt. Warm ischemia times of 4 hours for muscle flaps and 6 to 10 hours for skin flaps and toes are generally associated with irreversible tissue damage.23

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EXPOSURE In surgery, the first maneuver in exploring a complicated flap should be recreating the exposure used for the initial vessel anastomoses.This exposure may require partial release of the flap inset, complete reelevation of the flap, or extended incisions.

This 31-year-old man lost his thumb, index, and middle finger in a crush injury. Reconstruction consisted of a great toe transplant to the thumb position. The dorsalis pedis artery to the toe was connected end-to-side to the dorsal radial artery. In the recovery room, arterial occlusion was diagnosed clinically. Reexploration consisted of exposure and inspection of the vascular anastomoses, followed by revision of the end-to-side anastomosis to an end-to-end anastomosis. Healing of the toe transplant was uncomplicated thereafter, and the patient went on to have a functional result. If the complication consists of vessel kinking or compression from a hematoma, pedicle exposure alone may correct the problem. The reinset must be designed to prevent recurrence of the complication. The flap inset can be revised to change the course of the pedicle or eliminate angulation. Local flaps from the margin of the recipient site can be considered, and split-thickness skin grafts can be directly applied to areas of pedicle vessel exposure with satisfactory healing, especially in small areas.24

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After evacuation of a hematoma, any obvious bleeding points should be controlled , either in the flap or in the bed . The recipient and pedicle vessels should be evalu - ated microscopically to detect unsecured branches or other sources of bleeding in these critical structures , and microscopic techniques of either suturing or clip ap- plication should be used to control bleeding points. Drains may be carefully placed beneath the flap. If suction drains are used, they should be positioned so that they are reliably isolated from the area of the vascular pedicle.

REVISION

OF

ANASTOMOSES

Exposure of the pedicle and recipient vessels allows microscopic evaluation of the anastomoses. Thrombosis is usually visibly obvious, but partial anastomotic takedown can be done initially if circumstances are not clear. Once thrombosis is identified, the affected vessel is controlled with microvascular clamps, and the immediate area of the anastomosis is resected. Attempting subtotal revision of an anastomosis after clot removal using the frayed margin of the original vessel repair is often unsatisfactory. Inspection of the resected anastomosis can be useful. Detection of a technical problem (such as a back-wall stitch) can be transiently mortifying for the surgeon but ultimately reassuring since a competent second anastomosis may be the key to rescue . In revising the arterial anastomosis , the surgeon must be certain that the recipient vessel still has satisfactory flow. If flow is poor or absent, a more proximal site on the artery must be explored , or another recipient artery selected . Either of these cir- cumstances may require a vein graft; thus a suitable vein graft donor site should be included in the patient positioning and preparation for surgery . The pedicle artery should be carefully cleaned of all clots by extraction and irrigation . If the recipient and pedicle arteries are satisfactorily dissected and declotted, a second arterial anas- tomosis is then performed. After its completion , the surgeon should be satisfied with its flow and should confirm venous return. Venous anastomotic thrombosis should also be approached by vessel control and resection of the anastomosis. All clot should be carefully removed and flow from the pedicle vein confirmed. If there is no flow from the pedicle vein, the artery should be reinspected and revised as necessary . If the artery is patent , absence of venous flow may indicate infarction of the flap with a no-reflow phenomenon. The recipient vein is then confirmed to be patent by irrigation. If the vein does not irrigate easily, then another vein may need to be used. These eventualities may re - quire vein grafting. When both the recipient and pedicle veins are found to be functional, a second venous anastomosis is performed.

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After revision anastomoses, the surgeon should inspect the flap for satisfactory perfusion and then reinspect the anastomoses for evidence of uncomplicated flow.The inset placement should take into account any swelling of the flap and recipient site tissues, and consider local flaps and skin grafts as necessary. Administration of systemic heparin and dextran, as well as local irrigation with heparin, fibrinolytics, and vasodilators can be considered at any time.

ALTERNATIVE RECIPIENT VESSELS At reexploration, the surgeon may find that the original recipient vessels are unsuitable for another attempt, either because of extensive clotting or progression of some initial damage. Alternative recipient vessels should be promptly considered.

Superficial temporal artery

External carotid artery Facial artery Hypoglossal nerve Lingual artery External jugular vein Cephalic vein

In the head and neck, superficial temporal vessels can be replaced by facial vessels, usually requiring vein grafts if the flap is in the midface or higher. Nonfunctional facial vessels can be replaced by going directly to the external carotid artery and jugular veins.25 If one side of the neck is extensively damaged by scar and radiation, making the major vessel mobilization difficult, recipient vessels from the other side of the neck can be used with submental vein grafts.26 The cephalic vein can also be brought up to the neck as a recipient vessel.27

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External jugular vein Cephalic vein Thoracoacromial artery Internal mammary artery

Thoracodorsal artery

The recipient vessels for the upper chest are used most often for breast reconstruction. The surgeon should be able to utilize thoracodorsal vessels, including serratus branches, internal mammary vessels, and thoracoacromial vessels.22,28 The external jugular vein and the cephalic vein can also be brought to this region.29

Radial artery

Ulnar artery

Dorsal radial artery

In the upper extremity, the surgeon should be able to use digital vessels, deep and superficial arches, and dorsal vessels as necessary for toe transplants and other flaps to the hand. In the forearm, end-to-side anastomoses may be necessary if an initial unsatisfactory recipient site requires use of a single remaining vessel in the arm.

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Peroneal artery

Similarly, in the lower extremity, an initial vessel choice may fail, requiring careful end-to-side anastomosis to a single functioning artery in the leg or to the popliteal artery proximally.30

Anterior tibial artery Posterior tibial artery

Dorsalis pedis artery

Deep inferior epigastric artery and vein Superficial circumflex iliac artery and vein Femoral artery and vein

Saphenous vein

Flaps to the groin and pelvis are rare but critical procedures when undertaken for such problems as extensive defects or penile reconstruction. Recipient sites in this region include the femoral vessels, the deep inferior epigastric vessels, and, with less consistency, the superficial circumflex iliac vessels. The saphenous vein can be turned up to this region, and remote pedicles, such as the thoracodorsal vessels, can be considered with long vein grafts.31

Chapter 9 Failed and Failing Free Flaps

ALTERNATIVE FLAP VESSELS Some flaps have alternative vessels that can be considered for salvage if the initial pedicle vessels cannot be reused. The radial forearm flap can be drained either by veins accompanying the radial artery or by subcutaneous veins. If either system fails, the other system can be explored.32 The rectus muscle flap can be sustained by the superior epigastric vessels if the deep inferior epigastric pedicle cannot be used.33 The superficial inferior epigastric vessels can be used as alternatives if the original pedicle of the deep inferior epigastric perforator flap is compromised.34 The skin paddle of the deep circumflex iliac crest flap can be independently vascularized through the superficial circumflex iliac vessels.35

RECOGNITION AND MANAGEMENT OF FLAP FAILURE NO REFLOW Recognition of a failed flap is an important clinical decision. At reexploration, a flap that has obvious tissue changes and no venous outflow should be declared dead and removed despite patent arterial flow.36 Delays at this point only prolong subsequent complications of infection or fruitless systemic anticoagulation.

DEBRIDEMENT Operative debridement after a failed flap can be an important and sometimes multistaged part of management after flap failure. Most flaps die completely when they fail, but the recipient beds can very rapidly develop significant granulation tissue. The goal of debridement should be careful removal of dead tissue with sparing of any viable tissue. Cultures can be obtained, especially if infection is present in the original lesion or complication.

INTERVAL DRESSINGS AND COVERAGE The defect can initially be managed by debriding dressings, such as saline solution on gauze wet-to-dry dressings. A clean, stable wound can be treated with a vacuum dressing device to minimize dressing changes during any prolonged interval between flap failure and subsequent procedures. Specific wounds may be managed comfortably with allografts for extended periods of time.37

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SALVAGE AFTER A FLAP FAILURE EVALUATION AND RECONSTRUCTIVE GOALS Failure of a microsurgical flap procedure forces the patient and surgeon to reassess the original reconstructive goal and factor in the elements of patient motivation and surgeon confidence. Some reconstructive problems leave little choice but to consider another microsurgical procedure. Large areas of scalp loss, skull-base defects, and defects of the mandible and oropharynx condemn patients to extraordinary morbidity if not satisfactorily reconstructed, and frequently another microsurgical flap is the only alternative.

This 40-year-old patient developed chronic osteomyelitis following an open distal tibia fracture. An initial reconstructive attempt consisted of sequestrectomy, excision of his chronic soft tissue wound, and a rectus microsurgical flap based on an endto-side anastomosis to the posterior tibial artery, the patient’s only remaining arterial supply to the foot. On day 5, the flap failed because of venous thrombosis. The flap was debrided with preservation of the posterior tibial artery. The wound was treated with dressings. The patient remained committed to limb salvage. After stabilization of the wound, the patient underwent rotation of his long medial gastrocnemius muscle belly to the fracture site. A skin graft was applied after muscle viability was clear in 3 days. A residual distal wound was covered with a delayed distally based fasciocutaneous rotation flap. The patient had stable coverage and no evidence of infection 2 years after this final reconstructive procedure.

Chapter 9 Failed and Failing Free Flaps

This 28-year-old man suffered a crush injury to his hand with loss of his thumb, three finger metacarpals, exterior tendons, and dorsal skin. Initial reconstruction was attempted using an iliac crest osteocutaneous flap based on the dorsal radial vessels as recipients. This flap failed. The wound was thoroughly debrided and the hand skeleton was stabilized with an external fixator. A latissimus dorsi flap was then successfully transplanted to the radial vessels and covered with a skin graft. Subsequent procedures, including index pollicization, rib grafts to the metacarpals, and two-stage exterior tendon grafting, have resulted in a functional hand. A patient with a failed second toe to fingertip transplantation, however, may choose to live with the original amputation. A patient with a failed microsurgical breast reconstruction may choose an expander/implant reconstruction as an alternative. A patient with a failed muscle flap over a long-standing lower extremity osteomyelitis may wish to consider a below-the-knee amputation and a prosthesis. Consensus between the patient and surgeon is critical at this point, and if a second microsurgical procedure is elected, it should be undertaken with thorough planning.38

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ASSESSMENT

OF

RECIPIENT VESSELS

In head and neck cases, as well as in breast reconstruction, second flap procedures should be planned to use recipient vessels that were not involved in the original procedure. In head and neck cases, this principle suggests using another zone of vessels, such as moving from facial vessels to the external carotid artery and jugular vein; or moving to the other side of the neck entirely and using vein grafts.25,26 In breast reconstruction, entirely new recipient vessels should be chosen.22 In extremities, arteriography should be given very serious consideration for the delineation of any arterial changes subsequent to the failed flap procedure. Recipient site options and vein graft possibilities should then be an explicit part of the operative plan.38

FLAP SELECTION OPTIONS Most flaps exist in pairs, and a second latissimus can be considered for a scalp reconstruction, while a second fibula can be used to rebuild a mandible (when the initial donor site was uncomplicated). Perforator flaps have added several choices for second attempts at breast reconstruction. An initial failure that used the deep inferior epigastric system can be succeeded by a gluteal perforator flap procedure.34 However, a second rectus flap may be a poor choice for a salvage procedure because of the extensive consequent abdominal wall defect. Generally, the flap type should be selected within the limits of acceptable donor site morbidity.

OUTCOMES Several groups have described in detail their management of failures following initial microsurgical flap procedures.

Outcomes After Failed First Flaps Author

Nonmicrosurgical Treatment

Second Flap

Success Rate (%)

54

36

18

89

28 (breast)

27

1

0

12 (head and neck)

70

44

92

3

4

75

42 (head and neck)

25

17

94

59 (extremity)

42

17

88

Failed Flaps

Oliva et al39 (1993) 40

Beahm and Walton (2005)

7 (lower extremity) 41

Wei et al (2001)

Chapter 9 Failed and Failing Free Flaps

Oliva et al39 analyzed 54 patients who suffered flap failure. Of these, 36 patients retreated from the original reconstruction goal and either accepted the original defect, underwent alternative reconstruction, or proceeded to amputation. Eighteen patients chose to try a second microsurgical flap, and 16 (89%) of these operations succeeded. Beahm and Walton40 found that breast reconstruction patients rarely chose a second microsurgical procedure after the failure of a first one. Patients with head and neck lesions and patients with extremity lesions underwent secondary microsurgical procedures in 44% and 57% of cases, respectively, following initial microsurgical failures. Success rates for the second flaps were 92% in the head and neck and 75% in the extremities. Wei et al41 also reported that the majority of their patients with failed flaps do no go on to a second attempt. For those who do, however, second flap success rates were 94% in the head and neck and 88% in the extremities. In general, most patients with failed microsurgical flaps do not proceed to second microsurgical flaps. Those patients who do, however, have success rates comparable to initial microsurgical procedures.

References —With Key Annotated References 1. Swartz W, Banis J. Head and Neck Microsurgery. Baltimore: Williams & Wilkins, 1992. An excellent textbook of microsurgical flaps and reconstructive options for the head and neck. 2. Nahabedian MY, Momen B, Galdino G, et al. Breast reconstruction with the free TRAM or DIEP flap: Patient selection, choice of flap, and outcome. Plast Reconstr Surg 110:466-475; dis - cussion 476-477, 2002. 3. Saint-Cyr M, Goodwin A, Tregaskiss A, et al. Free tissue transfer for reconstruction of the traumatized extremities: Predictors of outcome in 347 cases. Plast Reconstr Surg 116(3 Suppl):107-109, 2005. 4. Mutaf M. A new surgical procedure for phallic reconstruction. Plast Reconstr Surg 105:13611370, 2000. 5. Lineaweaver W. New microsurgical applications. Clin Plast Surg 29:81-102, 2002. 6. Lineaweaver W, Buncke HJ, Whitney TM, et al. Factors associated with microvascular flap fail - ure. Plast Surg Forum 12:252, 1989. 7. Hidalgo D, Disa JJ, Cordeiro P, et al. A review of 716 consecutive free flaps for oncologic sur - gical defects. Plast Reconstr Surg 102:722-732, 1998. 8. Cho BC, Shin DP, Byun JS, et al. Monitoring flap for buried free tissue transfer: Its importance and reliability. Plast Reconstr Surg 110:1249-1258, 2002. 9. Hallock GG. Free flap monitoring using a chimeric sentinel muscle perforator flap. J Recon - str Microsurg 21:351-354, 2005. 10. Buncke HJ, Lineaweaver W, Valauri F, et al. Monitoring. In Buncke HJ, ed. Microsurgery. Philadelphia: Lea & Febiger, 1991, pp 715-721. A detailed atlas of microsurgical flaps and related anatomy. 11. Lineaweaver W. The implantable Doppler probe [letter]. Plast Reconstr Surg 82:1009, 1988.

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12. Whitney T, Lineaweaver W, Billys J, et al. Improved salvage of complicated microvascular trans- plants monitored with quantitative fluorometry. Plast Reconstr Surg 90:105-112, 1992. This article contains a detailed discussion of the analysis of monitor efficacy. 13. Disa J, Cordeiro P, Hidalgo DA. Efficacy of conventional monitoring techniques in free tissue transfer: An 11-year experience in 750 cases. Plast Surg Forum 21:254-255, 1998. 14. Goldberg J, Sepka RS, Perona BP, et al. Laser Doppler blood flow measurement of common cu - taneous donor sites for reconstructive surgery. Plast Reconstr Surg 85:581-586, 1990. 15. Kind G, Buntic RF, Buncke G, et al. The effect of an implantable Doppler probe on the sal - vage of microvascular tissue transplants. Plast Reconstr Surg 101:1268-1273, 1998. 16. Loh N, Ch’en I, Olcott E, et al. Power Doppler imaging in preoperative planning and postop - erative monitoring of muscle flaps. J Clin Ultrasound 25:456-472, 1997. 17. Lineaweaver W,Valauri F. Pharmacology. In Buncke HJ, ed. Microsurgery. Philadelphia: Lea & Febiger, 1991, pp 696-714. 18. Lineaweaver W, O’Hara M, Stridde B, et al. Clinical leech use in a microsurgery unit. Blood Coag Fibrinolysis 2:201-209, 1991. 19. Furnas HJ, Lineaweaver W, Buncke HJ. Blood loss associated with anticoagulation of patients with replanted digits. J Hand Surg 174:226-230, 1992. 20. Amato M, Rodriguez L, Lineaweaver W. Survival of free tissue transfer following internal jugu - lar venous thrombosis. Plast Reconstr Surg 104:1406-1407, 1999. 21. Lineaweaver W, Hill M, Buncke GM, et al. Aeromonas hydrophilas infections following use of medicinal leeches in replantation and flap surgery. Ann Plast Surg 29:238-244, 1992. 22. Temple C, Strom E,Youssef A, et al. Choice of recipient vessels in delayed TRAM reconstruc - tion. Plast Reconstr Surg 115:105-113, 2005. This article is a thorough review of regional vascular anatomy. 23. Picard-Ami L Jr, Thompson JG, Kerrigan CL. Critical ischemia times and survival patterns of experimental pig flaps. Plast Reconstr Surg 86:739-743, 1990. 24. McDonald H, Buncke HJ, Goodstein WA. Split-thickness skin grafts in microvascular surgery . Plast Reconstr Surg 68:731-736, 1981. 25. Takamatsu A, Harashima T, Inoue T. Selection of appropriate recipient vessels in difficult mi - crosurgical head and neck reconstruction. J Reconstr Microsurg 12:499-507, 1996. This article helps the reader distinguish among various recipient vessel systems in free flap transfer to the head and neck. It is critical to make these decisions ahead of time to maximize success in difficult head and neck reconstructions. 26. Lineaweaver W, Hui KC, Kauffman D. Cross-facial vein grafting in complicated flap recon - struction of the head and neck. J Reconstr Microsurg 13:545-549, 1997. 27. Kim KA, Chandrasekhar BS. Cephalic vein in salvage microsurgical reconstruction in the head and neck. Br J Plast Surg 51:2-7, 1998. 28. Beer GM. The thoracoacromial vessels as recipient vessels in microsurgery and supermicrosurgery. Plast Reconstr Surg 115:77-83, 2005. The thoracoacromial vessels are uncommonly used as recipient vessels in free flap transfer .This paper outlines an excellent technique to access these vessels which can be a flap saver when primary recipi- ent vessels are inadequate. 29. Mehrara B, Santoro T, Smith A, et al. Alternative venous outflow vessels in microvascular breast reconstruction. Plast Reconstr Surg 112:448-455, 2003. This well-written article outlines a variety of secondary venous outflow sources which can be used during critical intraoperative problems with reestablishing free flap circulation. 30. Chaivanichsiri P. Influence of recipient vessels on free tissue transplantation of the extremities . Plast Reconstr Surg 104: 970-975, 1999. 31. Oswald TM, Lineaweaver WC, Hui K. Recipient vessels for microsurgical flaps to the groin and pelvis: A review. J Reconstr Microsurg 22:5-14, 2006. 32. Soutar DS, Scheker LR, Tanner NSB, et al. The radial forearm flap: A versatile method for in - tra-oral reconstruction. Br J Plast Surg 36:1-8, 1983. 33. Canales FL, Furnas H, Glafkides M, et al. Microsurgical transfer of the rectus abdominis muscle using the superior epigastric vessels. Ann Plast Surg 24:534-537, 1990.

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Chapter 9 Failed and Failing Free Flaps

34. Gill P, Hunt JP, Guerra A, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 113:1153-1160, 2004. 35. Koshima J, Nanba Y, Tsutsui T, et al. Sequential vascularized iliac bone graft and a superficial circumflex iliac artery perforator flap with a single source vessel. Plast Reconstr Surg 113:101106, 2004. 36. May J, Chait L, O’Brien B, et al. The no-reflow phenomenon in experimental free flaps. Plast Reconstr Surg 61:256-267, 1974. 37. Riccio M, Pangrazi P, Campodonico A, et al. Delayed microsurgical reconstruction of the extremities for complex soft tissue injuries. Microsurgery 25:272-283, 2005. 38. Smith AA, Duncan SFM. Preoperative planning for free tissue transfer. Microsurgery 25:365372, 2005. 39. Oliva A, Lineaweaver W, Buncke HJ, et al. Salvage of wounds following failed tissue transplantation. J Reconstr Microsurg 9:257-263, 1993. This article comprises a detailed analysis of treatment after flap failure. 40. Beahm EK, Walton RL. What is done when free flaps fail? Plast Reconstr Surg 116(3 Suppl):116-118, 2005. The authors review their experience with secondary reconstruction following failed free flaps and present an algorithm for decision-making. 41. Wei F, Demirkin F, Chen H, et al. The outcome of failed flaps in head and neck and extremity reconstruction. Plast Reconstr Surg 108:1154-1160, 2001.

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REVIEW QUESTIONS 1. Which monitoring technique theoretically provides continuous monitoring of flap circulation? a. Clinical examination b. Examination with a hand-held Doppler probe c. Quantitative fluorometry d. Implantable Doppler probes e. None of the above 2. Which bacterium is specifically associated with infection following clinical use of leeches? a. Serratia marcesans b. Haemophilus spp. c. Aeromonas hydrophila d. Vibrio spp. e. Enterococcus spp. 3. Which flap tissue has the lowest tolerance for primary ischemia? a. Skin b. Muscle c. Bone d. Small intestine e. Fascia 4. The superficial inferior epigastric vein may be an alternative venous pedicle for which flap? a. Radial forearm flap b. Latissimus dorsi myocutaneous flap c. Deep circumflex iliac artery bone flap d. Deep inferior epigastric perforator flap e. Gracilis myocutaneous flap 5. Patients with which defects most frequently go on to second microsurgical flaps after failure of a first flap? a. Head and neck b. Upper extremity c. Breast d. Pelvis e. Lower extremity

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Facial Rejuvenation

Chapter 10

Milestones in the Evolution of Face-Lift Techniques Brunno Ristow We are what we practice. Therefore, excellence is not an act but a habit. Aristotle

Breakthroughs in Face-Lift Procedures Excision of the submental fat pad Division of the platysma to sculpt the jaw and neck Progression into the deep facial layers Discovery of the SMAS: Advent of full-thickness facial flaps Suspension of the anterior SMAS to the zygomatic fascia Full-sized SMAS flaps and the reimplementation of thin skin flaps Multidirectional redraping of the SMAS Abandonment of platysmal midline plication

W

ill and Ariel Durant , authors of the monumental 10-volume The Story of Civ- ilization ,1 also later published a complementary book entitled The Lessons of History .2 In the last chapter , provocatively titled “Is Progress Real ?” these brilliant authors make a compelling case that progress cannot be measured by, for instance , “happi - ness .” Our ancestors , they point out, who led simpler lives than ours, were un- doubtedly happier.

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Examining the excellent results of face lifts obtained nearly half a century ago by Sir Harold Gillies, and considering that there have been too many less-favorable results since then, I decided to examine the progress in face-lift surgery in an incisive manner: Has the progress been real, or has it always depended on the particular artistry of a surgeon? Gillies’s results are still quite significant by today’s standards, as demonstrated by the preoperative view and postoperative result above.

Myriad new incisions and techniques have been proposed since that time, yet if we study the most effective vectors of traction in regard to the best obtainable results , aren ’t Sir Harold ’s proposed lines of face -lift incisions almost as modern today as they were in his day? In the twenty -first century , this statement by Gillies and Millard is still true:“Certainly a beautiful woman is worth preserving and should be kept youthful while she is still young enough to enjoy it. The desire to look young is not the prerogative of any one class , and it is not the good fortune of everyone to grow old gracefully. The removal of wrinkles, folds, and fat is justifiable if the pa- tients are chosen with due discrimination.”3

Chapter 10 Milestones in the Evolution of Face-Lift Techniques

Any attempt to evaluate the progress in the development of face lifts will necessarily be colored by my own prismatic experience and view of the events. I want to examine the breaks with established paradigms that redirected our thoughts and techniques to achieve ever more refined aesthetic results. My aim is to highlight cardinal ideas that have been expressed before, as well as new concepts that I believe modify the surgical pathway of facial rejuvenation. My personal involvement with face-lift surgery spans more than 37 years. My earliest instructor in this art was Ivo Pitanguy and, after my arrival in the United States in 1967, I was privileged to study with gifted surgeons such as John Marquis Converse, Thomas D. Rees, Cary Guy, and Blair O. Rogers. I also had the good fortune to have a short but interesting contact with Tord Skoog. With the possible exception of Skoog’s approach in the 1960s, the universally practiced face lift was the “skin face lift.” This particular technique proposed that “the skin flap [be] raised with a very thin layer of fat, almost as in a full-thickness graft. When such a flap is retracted and seen from underneath, it is almost transparent.”4

Although this standard technique of the time delivered a significant number of good results, as shown above, the outcome depended exclusively on a predetermined type of facial structure. It was preferable that the patient seeking a face lift in those days be an old beautiful person, so that she could appear again as a young beautiful person. An unattractive old person would be the recipient of a result that at best qualified as an unattractive young person. How well I remember those days! Submental fat, preparotid fat, and simple excess facial fat were strict contraindications. A warm but evasive “It is best for you to get to your ideal weight before we do your surgery” was a guarantee that the patient would never return. The now well-known and scientifically proven effective treatments for chronic obesity through behavior modification were still a decade away.5

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The fact that the skin lift would make a naturally slim-faced person look more youthful was understandable ; the technique fits the available facial fat into a tighter skin envelope. Sadly, however, it is also true that in a patient with excessive facial fat, the skin lift causes the fat to be compacted into a smaller envelope. The result, of course, is an even rounder face. I recall a patient in my first months of practice in San Francisco . She had traveled from the East , where a notable surgeon had oper - ated on her with little improvement . With the overcon fi dence typical of a new practitioner, I operated on her. When the dressings came off, she looked at her face and said,“I don’t like it.” Worst of all, I had to agree ; with the swelling and the still- present fat, the improvement appeared to be nil. Gillies and Millard made a point of removing fat:“As the facial and neck skin is stretched back, it will be noted that the fat piles up in front and below the ear, fat that has, in fact, been squeezed up from the neck. This must be excised but do not take parotid with it.” 3 This step , however , was only a rudimentary beginning to the precise scissors sculpting of fa- cial and neck fat that is performed routinely today. The skin flap face lift leads to another technical sin. Fear of injury to the branches of the facial nerve led to a most unfortunate technique. I refer to the use of the scis - sors, with tips up, being pushed under the skin to elevate the flap. This approach has much potential to damage the subdermal plexus of the vessels and to cause “ embar- rassment of circulation , thrombosis , and sloughing of the skin.”4 I have therefore condemned it for the past three decades . There is simply no place for this techni- cal assault in the modern face lift. I believe that gentle dissection under direct vision is the preferred technique that can achieve signi ficant improvement and avoid potential disasters . The “ pushing scissors” technique is the very same one that for so long precluded access to crows’- feet, contributed to hair loss, and resulted in contour deformities by causing the death of skin and fat necrosis. Therefore the days of the skin face lift appeared to be numbered . (Curiously , the ability to develop thin flaps later became an important skill that allowed substan - tial SMAS flaps to be raised.) According to George Leonard ’s “mastery curve ,” 6 the first significant elevation in the plateau of knowledge that I experienced at the time occurred with the publication of Millard’s results with the removal of sub- mental fat.

FIRST BREAKTHROUGH: SUBMENTAL FAT PAD OF THE NECK The direct surgical access and removal of the submental fat pad was the major breakthrough offering hope to all patients who have a heavy neck. An early mention of this maneuver was found again in Gillies and Millard: “The patient must give permission for a short, transverse neck incision along the natural crease for the safe and complete removal of the central fat pad.”3 However, it was with the

Chapter 10 Milestones in the Evolution of Face-Lift Techniques

publication of the classic report by Millard et al7 that I realized what was now possible . Examination of the results convinced me that Millard had shared with plastic surgeons a novel approach that has not been surpassed to this day . A submental in- cision that affords direct vision and thus direct gentle dissection of the submental fat pad is paramount to an excellent postoperative neck appearance. Later ,“closed ” li- posuction of the submental fat pad gained favor . Except in young patients , the re - sults have been mixed . The proper amount of subcutaneous fat to be left under the flap in older patients is difficult to preserve. Also, no treatment of platysmal bands or subplatysmal fat is possible . Thus, with the exception of correction of lesser de- formities in young patients , a direct open approach to the neck remains the opti- mal means for producing superior results.

SECOND BREAKTHROUGH: LATERAL EDGES OF THE PLATYSMA The method of elevating the platysma on its lateral border from the deep structures, low cutting of these muscles from lateral to medial, and subsequent lateral superior displacement of this muscle flap over the sternocleidomastoid muscle was first related to me by Friedland,8 who had observed Peterson’s successful manipulations of this muscle . This area has to be approached with reverence and caution , because the 0.7 mm diameter marginal mandibular nerve lies here under tenuous cover. The scissors must be advanced very gently here (especially in secondary face lifts), always by spreading, never by a cutting action. When significant platysmal bands are present, transection of this muscle at the level of the cricoid cartilage remains the preferred technique . Whenever possible — and in most instances it is—I develop a SMAS /platysma sling 9 just below the angle of the mandible and attach it to the occipital region with appropriate tension . This further enhances the jaw -neck contour and adds signi ficant support to the sub- mandibular gland region.

THIRD BREAKTHROUGH: THE SKOOG TECHNIQUE— ADVANCEMENT INTO THE DEEP LAYERS OF THE FACE In October 1975, at the annual meeting of the American Society of Plastic and Reconstructive Surgeons (ASPRS ) in Toronto , I encountered a publication that would cause me to again reexamine face-lift techniques. Fascinated, I looked at the royal blue book that I had just purchased at the exhibits —Tord Skoog ’s book.10 I knew then that I had never seen better results or a more novel approach. I studied this book intensely , word by word (Skoog wrote succinctly ). This remarkable text - book did not go on a shelf in my library —it went into the operating room. Many times in the following months, in a quest for better and higher quality results, I had a nurse hold Skoog’s book open for me for reference so I could make doubly certain that I was operating precisely where he instructed .

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I used the markings for Skoog ’s technique illustrated in his book and transferred them to a patient who was about to undergo surgery . The results achieved a new dimension . Inroads into the deep face and below the platysma became the rule. Skoog ’s deep thrusts into the face, combined with Millard ’s technique of defatting the neck and the advancement of the platysma flaps as advocated by Peterson, gave truly excellent results.

FOURTH BREAKTHROUGH : THICKNESS OF THE FLAPS As recalled earlier, it was the accepted standard to have thin flaps, whether at the neck or face. In 1976 Mitz and Peyronie11 described the nature of the superficial musculoaponeurotic system (SMAS) of the face and correctly predicted its importance in face lifts . In November of the same year , Millard had just presented some excellent postoperative results as a panel member at the Denver ASPRS Sympo - sium . The question period had opened when someone asked the innovative sur- geon, “Why do you place so much tension on such a thin flap, so far from the blood supply [supraauricular and retroauricular key sutures]?” In response , Millard stated emphatically that “the flaps should never be thin !” Connell , in the spring of 1977, explained his technique as follows : “I dissect in front of the tragus until the level of the preparotid fascia and then proceed forward at this level below the super- ficial investing fascia.”12 Thus both Millard and Connell were active early on in im- plementing the concept of full-thickness flaps. Louis Pasteur stated,“Chance favors the prepared mind.” I feared the thin flaps, and the thought-provoking statements of Millard and Connell made an immediate impression on me. The retroauricular flaps were never to be thin again, and the preau - ricular flaps remained thick until the advent of the separate SMAS flaps years later.

Chapter 10 Milestones in the Evolution of Face-Lift Techniques

The dissection progresses gently forward—never pushing, always cutting—directly above the sternocleidomastoid fascia. Over the well-known course of the great auricular nerve,13 the scissors14 advance parallel to its course rather than perpendicularly. It is noteworthy that occasionally the surgeon encounters two branches of the greater auricular nerve.The corollary is that finding one branch is no assurance that it is the only branch; caution in this area is warranted. Utmost care must be used to avoid injury to the lesser occipital nerve, which lies quite superficially. If this nerve is injured, a disturbing neuroma can result. Despite this care, even experienced surgeons, on rare occasions, can injure the lesser occipital nerve. If repair is possible, I believe it should be done. If not, traction on the proximal stump followed by division will let the nerve retract deep into muscle, thus avoiding a superficial neuroma.

FIFTH BREAKTHROUGH: SUSPENSION OF THE ANTERIOR SMAS (ROOF OF BICHAT’S FAT PAD) TO THE FASCIA ABOVE THE ZYGOMATIC ARCH15-17 The relentless pursuit of better results led to my realization that the elevation of the midface in one general direction was effective but did not achieve the best potential result. Standing in front of the mirror with my hands on my midface to simulate the elevation possible with a face lift, I was convinced that the vector of pull should be much more vertical than the current technique allowed. But how could this be done?

Such an angle of elevation could be affected by the suspension of the SMAS through a suture from the roof of Bichat’s fat pocket to the fascia above the zygo - matic arch . The internal surgical shift of tissues as marked on the skin is also shown.

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The effect of suture suspension of the anterior SMAS on the surface anatomy is demonstrated. The results achieved with this type of SMAS suspension were impressive and natural looking: the interlabial curved line was corrected, the jowls practically disappeared, and the labiomandibular fold became flattened.

Preoperative and postoperative views are shown after Connell’s upper face thick flaps (below the SMAS), suspension of the anterior SMAS to the zygomatic arch SMAS, Peterson’s platysma redraping, and Millard’s submental lipectomy.

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Chapter 10 Milestones in the Evolution of Face-Lift Techniques

These two patients show the effectiveness of the elevation of the anterior SMAS to the zygomatic arch by a suture. More impressive are the long-term results, seen 10 years later.

This patient is seen in preoperative and 10-year postoperative views following suspension of the anterior SMAS to the region above the zygomatic arch.

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In this patient the markings show the vector of skin redraping as a 90-degree angle in relation to the nasolabial fold. The nasolabial fold was improved by the vector of pull from the fold.

The SMAS flap followed the accepted design of the times, which began approximately 1 inch below the projection of the zygomatic arch.18 This is generally lower than that performed today. The suspension of the anterior SMAS offered one sig - nificant improvement over Skoog’s suture to the masseteric fascia: it allowed a dif- ferent , more vertical elevation of the perioral structures , enhancing the malar prominence at the same time (see the photo on p. 226). The suspension of the an- terior SMAS to the fascia over the zygomatic arch set a new standard of postoper - ative midface surface anatomy for the new SMAS flap technique to meet (compare the photos on p. 226 with those on p. 246). Although the suture suspension of the anterior SMAS over Bichat ’s fat pocket was performed exclusively for many years without a single nerve injury, I realized that this sterling safety record could be attributed to the clear view of the roof to the suctorial fat pad and the nerves that cross that area , which helped the surgeon avoid catching them in the suture loop. In 1989 Connell 19 proposed the use of an inci- sion over and even above the zygomatic arch projection for the beginning of the SMAS elevation. I realized, as he certainly had, the potential of this modification.

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Chapter 10 Milestones in the Evolution of Face-Lift Techniques

Courtesy F. Barton, MD

The entire anterior face could be elevated with one broadly based, deeply supported, anterior SMAS flap. Dissections accomplished by blunt thumb-pushing over the malar eminence—a bit higher but similar to the direction proposed by Skoog—disclosed that in the perioral region the skin is very firmly attached to the perioral muscles of expression. Both the free muscles and the free ends of the fixed muscles20 contribute significantly to expression and concentrate at the modiolus labii.

Note the perioral and mimetic muscles of expression. Elevation of this entire block of perioral tissues, without undermining the attachments of the muscles of expression from the overlying skin, was incorporated into the technique. A peninsula of skin was preserved over these muscles.

The markings show the peninsula of skin not to be undermined; this protects fine expression secondary to the attachments of the perioral muscles to the overlying skin. An exception to this rule of noninvasion of the peninsular area is the release of the skin over the attachments of the depressor anguli oris muscle to the skin, as demonstrated in the following images.21

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The Stille scissors elevate the skin over the depressor anguli oris muscle and lower portions of the depressor labii inferioris muscle.

The skin is elevated over the lower part of the chin.

Note the extent of the undermining over the chin.

Sub SMAS area Subcutaneous area

The need for a strong and supportive SMAS flap forced surgeons to fashion thin and delicate midface skin flaps similar to the ones abandoned in the mid -1970 s. Great delicacy and gentleness are essential to the modern two-layered SMAS and skin face lifts. Again, the use of scissors that are neither blunt nor sharp 14 is essential for the devel - opment of nearly perfect flaps. There is no doubt that this technique is significantly less forgiving than the Skoog-type techniques. Because the effects of smoking on face-lift flaps are so serious, they merit special mention.22 Nicotine, a powerful vasoconstrictive alkaloid, has been implicated in flap necrosis.23-25 I did not question the effect of nicotine on flaps until some years ago when I asked a smoker—who had a flawless postoperative recuperation from a face lift—if it had been difficult for him to stop smoking. “Not at all, I chewed

Chapter 10 Milestones in the Evolution of Face-Lift Techniques

Nicorette gum the whole time!” was his answer. This statement prompted my review of the issue, and after examining the published data,26 I became convinced that the major culprit in flap necrosis is carboxyhemoglobin (COHb).22 The oxygencarrying capacity of hemoglobin may be diminished between 6% and 20% in a smoker. This represents the amount of hemoglobin tied to carbon monoxide. This COHb molecule is very stable and has a long half-life. Aside from this fact, there are other toxic effects of COHb, such as the poisoning of cytochromes in respiratory enzymes and platelets.22 Nicotine is a short-acting sympathomimetic drug, and a significant number of vessels in a face-lift flap undergo sympathetic denervation.27-30 Therefore, since I made this observation, we prescribe Nicorette for all prospective face-lift patients who smoke, but we forbid smoking. Postoperative oxygen inhalation therapy for the first night is helpful.22-26 The high concentration of oxygen molecules dislodges the remaining carbon monoxide molecules from the hemoglobin. Since we began the practice of this therapy, postoperative vascular impairment of the flap has for practical purposes diminished appreciably.31

THE ROLE OF THE SMAS IN FACIAL REJUVENATION SURGERY The SMAS is a fascinating structure that lends itself to high art, depending on the surgeon’s interest in expressing this potential.The SMAS affects all areas of facial rejuvenation: midface, mouth, malar eminence, neck, labiomandibular fold, and eyes. The SMAS affects the nasolabial fold positively. When the SMAS flap is advanced, the nasolabial fold changes significantly in direction and flattens out. Direct interference with the underlying muscles of the nasolabial fold32,33 by dividing them from the overlying crease through a 3 mm facial incision34 improves its appearance significantly, and results are lasting.

This patient is seen preoperatively and 11⁄ 2 years after a face lift, neck lift, forehead lift, lower blepharoplasties, and division of extensions of muscles to the nasolabial fold.

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Bosse,35 in his keen observations, demonstrated that the SMAS in the midface of primates is still a muscle. In essence, the platysma continues as a muscle over the entire parotid to form a solid sheet with the occipitofrontalis muscle:“This anatomical fact can be observed when a monkey grins by the formation of skin folds that extend from his mouth to his ears.”35

Observe that the SMAS dissection becomes superficial to the zygomaticus major muscle. The green circle represents the area of the retaining ligament that must be divided.

In the malar region the dissection does not have to extend further into the levator labii superioris muscle . Any traction on these muscles elevates the lip and exposes the canine teeth, causing a snarl (left). The elevation of the zygomaticus major mus- cle, possible with the SMAS technique, creates a pleasing result (right ).

OUR PREFERRED ANESTHESIA Since my arrival at the California Pacific Medical Center in San Francisco in 1973, our anesthesiologists have used a technique known as “closed-system” anesthesia. 36 The advantages of this method as opposed to the use of vaporizers are quite impres - sive . Because the great majority of plastic surgery procedures are now performed in private facilities and accredited offices, use of this clean, inexpensive, and precise ap- proach is worth noting. “Closed-circuit” anesthesia was introduced in the 1920s when cyclopropane became available . The gas was extremely expensive (and explosive ), and efforts were made to use it sparingly ; therefore , as with ether , it was used in a closed system . Ni- trous oxide , narcotics , curare , and oxygen became available in the 1940s; they were

Chapter 10 Milestones in the Evolution of Face-Lift Techniques

inexpensive and therefore easy to use in multiliter flows. The risk of explosion was removed and, unfortunately, the technique of closed-circuit anesthesia was forgot - ten. Therefore an entire generation of anesthesiologists has never experienced this superior technique. Harry J. Lowe, MD,37 a chemist as well as an anesthesiologist, took it upon himself in the 1970s to resurrect the closed system.The anesthesiologists at our center were greatly influenced by this remarkable gentleman , and since that time they have been using the closed system for the following reasons:  Oxygen consumption is continuously monitored, allowing rapid detection of malignant hyperthermia. Cardiac output, which is directly related to oxygen consumption, is known.  Anesthetic consumption becomes quantitative, because it is injected directly into the system. Disconnections are immediately evident.  Pregnant operating room personnel (such as physicians, nurses, and physician assistants) are not exposed to any anesthetic gases. (We have worn monitors for several months, and absolutely no gases have been detected.)  Use of only halocarbon (isoflurane) and oxygen allows maximum transport of oxygen to tissues, which is calculated to be equivalent to an additional 400 ml of blood.  There is immediate and precise control of the depth of anesthesia, blood pres - sure, and recovery time.  The closed system is invaluable in rhinoplasty; systolic pressures can be dropped to 80 mm Hg, allowing essentially a dry field, without any untoward effects on the patient. Closed -system anesthesia was taught at the University of Chicago , City of Hope (Los Angeles ), Massachusetts General Hospital , and the University of Alabama , but not widely throughout the country . The basic concepts are simple and can be learned by any anesthesiologist . This method affords several advantages in terms of safety, cost, and legal issues.

CURRENT TECHNIQUE In the past, on occasion I mused that current technique could not get any better , only to be proved wrong in my assumption . At the beginning of this millennium, I again tried to initiate improvements. My goals were to obtain results equivalent to the two-flap midface approach while reducing the risk to the blood supply inher- ent in the two-flap (SMAS and skin) approach.38,39 Some surgeons had not fully adopted the extended two-flap technique , with two vectors in the final midface redraping. The results were good and natural, and I de- cided to explore their approach . Results again were good , but in my opinion the two -flap technique offered longer -lasting outcomes and better perioral rejuvena - tion. I wondered whether a third technique —one that used elements of both of the previously mentioned approaches—would produce safety (a thick flap) with long- lasting, excellent results.

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Beginning in 2003, I started to use the following approach to rejuvenation. First, I establish and mark on the skin the position of the zygomaticus major muscle and the position of the roof of the suctorial fat pad.

The facial skin drawing shows the roof of Bichat’s fat pocket (red circle) and the suture (purple) to the SMAS over the zygomatic arch. Note that the orientation is almost vertical. This is the first elevation of the SMAS.

Second, I establish the most effective position for the suspension on the SMAS and also mark it on the skin. I observed that left and right “ideal” points of SMAS suspensions can vary from side to side in the same patient.

The anteriormost green triangle is the second area of the SMAS to be elevated (note the vertical vector), and the posterior red triangle is the third area to be elevated.

If this advice is ignored, the technique will not work properly. The green triangle (above photo) indicates the point that the surgeon judges to be best for elevation of the SMAS.This anatomic location is always just behind the posterior edge of the zygomaticus major and is usually a few millimeters below the zygomatic arch. If this cardinal rule is not followed, the skin will redrape with difficulty and the result will be compromised. (Higher anchoring triangles will necessitate the elevation of the temporal hair flap at the subcutaneous level to place the SMAS flap under it; not ideal anchoring.) Third, I delineate the degree of subcutaneous and sub-SMAS undermining. The dissection of the thin skin flap must extend to that ideal SMAS flap suspension area, but not beyond. Anterior to this key elevation point (green triangle) (frequently

Chapter 10 Milestones in the Evolution of Face-Lift Techniques

just posterior to the insertion of the zygomaticus major), all the forward dissection is below the SMAS. The dissection of the subcutaneous flap is now limited to the following:  The key suspension in the malar region.  Over the platysma, including the release of the submental and depressor of the lip ligaments.  The sub-SMAS incision starts at the junction of the posterior and middle portion at the lower edge (not above) the zygomatic arch. It descends parallel to the preauricular incision to the angle of the mandible. It descends in front of the sternocleidomastoideus for another inch. If division of the platysma (at the cricoid level) is indicated to reduce bands, now is the ideal time to do it.

The dissection of the sub-SMAS begins with a No. 10 Personna Plus blade, followed by a change to the new Stille-Ristow14 curved scissors. An important technical aspect of these scissors is that the end tips are neither sharp nor blunt. If the points are too sharp, the proper plane can be easily lost. If the points are too blunt , in scarred faces the effort to advance the dissection is too difficult, and the surgeon ’s trapezium/scaphoid joint eventually pays the price.The extent of the sub-SMAS dis- section advances over the lateral aspects of the orbicularis occuli , over and anterior to the zygomaticus muscle , releases the zygomatic and masseteric ligaments, and ends with full view of Bichat’s fat pocket. A suspension suture (3-0 Nylon ) from the spe- cialized and strong SMAS over Bichat ’s fat pocket to the SMAS over the zygomatic arch adds to the rejuvenation. The elevation can be up to 3 cm and the attachment is to the cut edge of the SMAS at the level of the zygomatic arch. The vector is aes- thetically pleasing but has a significant vertical component . Before securing the su- ture, one should observe the best result and then tie the knot. In fact, experience shows that the SMAS only drapes easily in one direction ; that is the correct vector. The second SMAS suspension , with a vertical vector , is now tied to the SMAS above the zygomatic arch . Two additional elevation sutures are placed; the last one has a superoposterior vector and attaches to the supraauricular SMAS . The overall effects on the face are beautiful : the corners of the mouth are raised , jowls flatten out, and malar fat pads again cover the lateral orbital region. The lower eyelids, which appeared short or loose preoperatively , now have extra tissue or at least a normal appearance. Whenever possible, a SMAS sling is affixed to the occipital region9 as well. Sculp - ting by removing excess fat that overlies the platysma follows.

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SYNERGY BETWEEN THE PLATYSMA AND THE SMAS Bilateral elevation of the SMAS flaps has a profound effect on the contour of the neck. Before I had the technical know-how to make full use of the SMAS potential, I performed plication of the platysmal bands in the neck fairly often. The approximation was performed to two different distances: to the thyroid or to the cricoid cartilage. The outcome was quite good, and excellent jaw-neckline angles were obtained.

Observe the good jaw-neck angle obtained by midline approximation of the platysma, but also the subtle restriction of the midface elevation. If you plicate the midline platysmal edges before elevating and securing the SMAS, the upward displacement of the SMAS flaps is severely restricted with results that are detrimental to the midface elevation.

THE NECK In recent years I came to the realization that the neck is more complex than generally recognized. The sequence of events with my surgical approach is as follows: I delineate the submental incision at 2.5 cm, which is approximately 1 cm behind the submental crease. The degree of subcutaneous undermining varies by patient, but it normally extends to the level of either the thyroid cartilage or cricoid cartilage.The attachments to the depressors of the lip and the submental ligament to the skin are released next.The fat overlying the platysma is now removed. A vertical incision opens the platysma between the symphysis of the mentum and the thyroid cartilage. Excess fat, if present, and very rarely some digastric muscle, if indicated, are

Chapter 10 Milestones in the Evolution of Face-Lift Techniques

removed.The platysma between the symphysis of the mentum and the thyroid cartilage is now resutured edge to edge. When performed as described above, the submental platysma will not restrict the midface SMAS in its upward movement. It will, however, accentuate the jaw-neck angle, which is a positive and desirable result. How the SMAS is redraped has a profound effect on the face. Removing excess SMAS from the preauricular area will significantly thin a round face. It is the upward movement of the SMAS that is responsible for returning midface structures to their youthful position. Finally, a word about skin closure. With the technique described earlier, little or no variation is possible in the skin closure of the midface; all was decided at the deeper levels. In the retroauricular/occipital areas, variations of the vector are possible. However, a vector of 90 degrees between the neck and redraping of the skin gives the best results.40 In the temporal area, if the supraauricular incision extends backward over the ear (a common approach I have now abandoned (see the figure on p. 228 in favor of an “at-the-hairline” temporal incision), it will be technically impossible to drape the midface correctly. A gap of tissue will result, and to close it, an inefficient vector of pull will be created. The technique I describe brings so much excess skin to the temporal region that only an at-the-hairline incision will preserve a natural hairline.

An intraoperative image depicting the significant skin advancement of a typical primary face and neck lift dictating the necessity of “at the hairline” suture techniques. More complex approaches to reconstruct the hairline have been described,40 but to achieve the best results, a wide variation of incisional directions is not advised.

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THOUGHTS ON REOPERATION The earlier a surgeon grasps the issues pertinent to facial rejuvenation, the more satisfying his or her professional life will be. Among these issues are preservation of the normal hairline, mastery of flap tension (a principal component of our specialty), and concealment of incisions. Surgeons who early in their careers comprehend these essential elements can often anticipate reoperating on their own satisfied patients. Repeating a well-conceived procedure that was performed years earlier is easy. Beginning 1 or 2 mm behind the original scars will eliminate them, and the subtle shift in the hairline downward will again place incisions and the hairlines precisely at their ideal positions. However, we are also faced with far more difficult problems. Some of the more frequently occurring problems include elevation of the temporal hairline, blunting of the tragus with forward displacement, earlobes that are pulled forward and downward, retroauricular scars that have migrated to the occipital region, displacement of glabrous neck skin in the occipital region into areas normally filled with hair, and removal of soft, delicate hairs in the lower neck.41

ELEVATION

OF THE

TEMPORAL HAIRLINE

During the years when a face lift almost always included a temporal lift, it became imperative that a solution to the problem of hairline displacement be found. The question was: If the scalp is cut posteriorly (temporal incision), inferiorly (to return it to the front of the upper part of the ear), anteriorly, and from underneath (during elevation), could the hair follicles survive? Their only blood supply would be from the stump of the temporal artery by the retrograde flux (see Chapter 12), and the superior base should support adequate venous return as well.40 In essence, the superficial temporal artery is divided just above the ear. The flux in the stump reverses and supplies the temporal flap. The flap is elevated in a subgaleal plane and subsequently lowered in front of the upper aspect of the ear.

Chapter 10 Milestones in the Evolution of Face-Lift Techniques

RATIONALE BEHIND THE TECHNIQUE Numerous anatomic dissections of the temporal region were reviewed. The superficial temporal artery is posterior to the branches of the seventh cranial nerve (see the Terzis dissection in Chapter 12), which makes it possible to leave the temporal artery stump within the flap as well as preserve the branches of the seventh cranial nerve to the forehead. After the temporal flap is elevated, the trajectory of the temporal artery is identified in the flap either by palpation or direct visualization. A needle is passed just anterior to the artery (leaving the seventh cranial nerve branches anterior to the future flap). The galea is divided from the needle to the incision just above the ear. This is a flap with a broad superoanterior base and, lined by the galea, supports the viability of the hair follicles.This composite flap of skin, a layer of subcutaneous hair follicle, and galea is sufficiently healthy to be positioned lower, thus correctly creating a new temporal hairline.

Note the position of the superficial temporal artery and the frontal branch of the facial nerve showing the incision of the galea between these structures. By nature I am averse to risk, but these flaps do survive along with their hair.

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The sequence of lowering a temporal hairline is shown. Where the patency of the superficial temporal artery below the temporal hair cannot be ascertained, this maneuver theoretically is riskier. Although not completely clear to me, the body creates new vessels and enlarges existing ones making this possible (tube flaps come to mind as an example of this neovascularization).27 Where the temporal hair has been lost, the only option is hair transplants; note the excellent result in the hands of competent surgeons with this expertise.

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Courtesy Alfonso Barrera, MD

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Results of hair transplants to the temporal region.

BLUNTING

OF THE

TRAGUS

Here the strategy requires sufficient mobilization of the midface so that enough skin can be redraped over the tragus. The cartilage itself should be cut free from its base to allow it to fold posteriorly, again partially covering the ear canal. A transcutaneous suture is used from the skin of the concha through the posterior skin of the tragus, encompassing the tragus, exiting again, and then tying it over the concha. This ensures healing of the tragus in the correct position. The suture is removed in 5 to 7 days. The pretragal concavity is created by placing a thin, long-term, biodegradable suture 1 cm anterior to the tragal crest. This suture also deflects tension on the tragal cartilage.

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FORWARD-DISPLACED AND LONG EARLOBES Earlobes that are displaced forward or are too long are caused by a failure to master tension and result from too much traction; therefore the repair involves reduction or elimination of tension on the earlobe. The flaps of the midface and neck must be mobilized to rectify this problem.The earlobe is set back by 15 degrees and secured deeply with a long-term biodegradable suture (encompassing the earlobe, occipital fascia, and deep dermis). Frequently the length of the earlobe must be trimmed to obtain a natural contour.

RETROAURICULAR SCAR MIGRATING TO THE OCCIPITAL REGION Again, tension is the original culprit. Mobilization of neck skin is essential for success. The skin is anchored to the retroauricular groove with long-term biodegradable sutures to promote sustained support during the first weeks of healing.

DISPLACEMENT OF GLABROUS NECK SKIN IN THE OCCIPITAL REGION INTO AREAS NORMALLY FILLED WITH HAIR This displacement reflects an error in the original planning and, unfortunately, is difficult to correct. First, a high incision into the hair negates the proper vector to correct the sagging neck. Second, the defect is visible with the hair worn up. Because even extensive mobilization of the scalp yields a minimal downward shift— particularly in this area—complete improvement of this defect continues to be difficult. Our limitations are very disappointing to patients who wish to wear their hair up. The surgeon faces difficult choices; if there is a significant amount of loose skin on the neck, repeating this poor incision can be catastrophic in that the hair below it will be lost. Abandoning the “high scar” and placing the scar properly will leave the patient with two scars. Each patient is evaluated individually, and suggestions for improvements are discussed.

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ABSENCE

OF THE

SOFT, DELICATE HAIR LOW

ON THE

NECK

Incisions should completely avoid this area by going upward for 1.5 or 2 cm in this region.These hairs are attractive and are included in a small flap designed in the original drawing. At the end of the procedure, a recipient area is cut above, and the flap with these soft hairs is fitted into the scalp.34,40 If the original incision has ablated these hairs, there is no possible solution. Skillfully applied tattoos or individual microtransplants of hair may offer some camouflage. Because of the long-term effects of a poor outcome, correct planning in the initial stages is essential. All problems appear to be linked to mistakes in planning the initial procedure.With skilled implementation of the proper strategies for face lifts, difficult reoperative problems can be avoided. Unfortunately, these strategies have not yet been universally adopted.

PROGRESS IN FACE-LIFT TECHNIQUES EXAMPLES OF DIFFERENT FACE-LIFT TECHNIQUES Single Midface Flap (Mid-1970s)

Preoperative and postoperative views after Connell’s upper face thick flaps (below the SMAS), suspension of the anterior SMAS to the zygomatic arch SMAS, Peterson’s platysma redraping, and Millard’s submental lipectomy.

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Two-Layer Flap and Two Distinct Flaps

Preoperative and 2-year postoperative views of a patient who underwent a face lift, forehead lift, upper and lower blepharoplasties, and upper and lower autologous lip augmentation.

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Results of a face and neck lift, forehead lift, and upper and lower blepharoplasties performed in 1992 in a 64-year-old woman. A distinct two-flap (SMAS and skin) technique was used in this patient.

Preoperative and postoperative views demonstrating the results that can be achieved with the application of current face-lift concepts.

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The proper position of the secured upper SMAS flap before skin redraping.

Two distinct layers are seen in midface (SMAS and skin) face and neck lifts, upper and lower blepharoplasties, forehead lift, and perioral dermabrasion.

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Note the appearance of the temporal and preauricular (at the tragal crest) healing 24 days after surgery.

The technique seen here was used in the early 1990s, with two distinct flaps, SMAS and skin, face and neck lifts, autologous tissue lip volume restoration, upper and lower blepharoplasties, and forehead lift.

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TWO-LAYER DISSECTION CLOSED AS A SINGLE LAYER The following five patients demonstrate the current technique.

Postoperative views of this patient demonstrate the current technique (2005 ), which included a face and neck lift , upper and lower blepharoplasties , and autologous tis- sue lip volume restoration.

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This patient is shown before and after undergoing face, neck, and forehead lifts, lower lid blepharoplasties, and autologous lip volume resoration by the current technique. The current technique has produced good results. The greatest difference is in the accurate understanding of the anatomy, which in this technique ultimately overlaps the SMAS, creating a solid fascia-to-fascia healing. What role does artistry play? A large one, I would venture to say. Studying the reason that certain faces are harmonious and beautiful should be a constant endeavor of aesthetic surgeons. How can we measure such an element? What about proposed technical innovations?

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This prematurely aged 45-year-old patient was treated by the current technique, including face and neck lift, upper and lower blepharoplasties, forehead lift, and autologous restoration of lip volume.

The natural results in this patient seen 6 months postoperatively are characteristic of the current technique.

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The benefits of the current technique are also evident in this patient, who had a face and neck lift, upper and lower lid blepharoplasties, and autologous tissue lip volume restoration.

There have been many new techniques with no measurable positive, lasting results. And the role of technologically advanced instruments? To a degree, advances such as capnography and oximetry have provided greater security, which allows us to accept a hopeful older patient and offer her a secure surgical journey. Note the results of a modern face lift in this 85-year-old patient.

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CONCLUSION To return to the questions at the beginning of this chapter, has progress in face lifts been real? If we look at the results of the last 40 years, it is not easy to answer. If we measure progress in face lifts by control of refinements in the surgical outcome, then progress has been real (preservation of hairlines, better surgical outcomes of necks, understanding the role of SMAS as fundamental to natural results, and so on). No longer will well-trained young surgeons be defeated by a round face, as was common in the 1960s. The techniques, thoughts, and advice of many illustrious surgeons are now recorded for us to consider. Excellent surgical technique cannot be inherited. Each of us has to learn it by constantly thinking about the issues. A few distinguished surgeons made significant contributions in the past, and I sincerely believe the impact of their concepts will continue to be felt. According to Will and Ariel Durant,“History is, above all else, the creation and recording of that heritage; progress is its increasing abundance, preservation, transmissions, and use.”2 In face lifts this concept appears valid. Individual progress also depends on the surgeon’s ability to take advantage of innovations but to quickly recognize the false pathways. In this regard, we should be cautious, realizing that in several periods of our civilization, and in aesthetic surgery as well, progress has been adverse; in other words, knowledge has been lost. Familiarization with the concepts devised by visionary surgeons will help future generations maintain and improve the excellence of current results. In retrospect, we have known what is beautiful for 2000 years of Western culture. Fibonacci’s lines of the eyelids, the soft malar prominence of Phidias’s sculptures, and the serenity and corner lip elevations of Leonardo da Vinci’s Mona Lisa are examples known to all. We have also known the deficiencies of face lifts: shifts in hairlines, the flat midface that can result from unilayer techniques, displaced earlobes, and tragal blunting. Understanding the anatomy of aging42,43 and how to technically reverse it brings us ever closer to our ambitions in facial rejuvenation. Aesthetic vision, knowledge of anatomy, and technical skills have been instrumental in arriving at our current level of achievement.

References —With Key Annotated References 1. Durant W, Durant A. The Story of Civilization. New York: Simon & Schuster, 1935 through 1967. 2. Durant W, Durant A. The Lessons of History. New York: Simon & Schuster, 1968. 3. Gillies H, Millard DR. The Principles and Art of Plastic Surgery, vol 2. Boston: Little Brown, 1957, pp 396-397. 4. Rees TD, Wood-Smith D. Cosmetic Facial Surgery. Philadelphia: WB Saunders, 1973, p 162. 5. Zalman A, Sutherland AE,Weiner A. Stay Slim for Good. New York:Walker & Johnson, 1976. 6. Leonard G. Mastery. New York: Penguin Books, 1992, p 14.

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7. Millard DR Jr, Garst WP, Beck RL, et al. Submental and submandibular lipectomy in conjunc - tion with a face lift, in the male or female. Plast Reconstr Surg 49:385-391, 1972. Submental lipectomy through a small, transverse incision, in continuity with submandibular through a male or female lift incision, achieves excellent neck contour with hidden scars. 8. Friedland J. Personal communication re: R. Peterson’s technique on lateral platysma, May 1975. 9. Randall P, Skiles MS. The “SMAS sling”: An additional fixation in facelift surgery. Ann Plast Surg 12:5-9, 1984. 10. Skoog T. Plastic Surgery. Stockholm: Almqvist & Wiksell, 1974. 11. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 58:80-88, 1976. The authors studied anatomic dissections, radiographs, and histologic sections of the superficial mus - culoaponeurotic system (SMAS) in the parotid and cheek areas.They found that the SMAS may be helpful in corrective surgery for facial palsy and during face -lift operations if a retrofascial approach is used. Although this procedure is safe in the parotid area, the surgical cleavage points are very appar- ent anterior to the gland, and with good technique , there should be no injuries to the nerves. 12. Connell B. Rhytidectomy with special emphasis on lower face and neck. American Society of Aesthetic Plastic Surgeons Teaching Course, Los Angeles, March 1977. 13. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidec - tomy. Plast Reconstr Surg 66:675-679, 1980. 14. Stille-Ristow Facelift Scissors. Article No. 101-8454-1. For 20 years, Oscar Ortiz, a naval weapons machinist, has modified scissors for me to my specifica - tions.The tips should be neither blunt nor sharp, but somewhere in between (see this chapter’s text for the reasons).The president of Stille Instruments (Solna, Sweden) visited me and asked whether I had some ideas for his company . I decided to share my concept for the scissors. I gave him one of mine (I had six pairs ). He produced a prototype that I put through extensive testing (using the scissors in pro- cedures on more than 100 faces ). I found that Prototype 1 was superb . Stille produced Prototype 2, and after testing it, I felt that Prototype 1 was superior. I recommended that one, and they decided to produce a model based on Prototype 1 for their line.The production of such an item is immensely com- plex. Numbers have to be assigned, quality control exercised, and so forth . It takes a long time before it reaches the market.This chapter is the first report on these scissors. The Stille -Ristow scissors will be available by the time this book’s is published , bringing another excellent device to the world of plas- tic surgery. 15. Ristow B. Facial rejuvenation. Presented at the Annual Meeting of the Southeastern Society of Plastic Surgery, Boca Raton, June 1986. 16. Ristow B. Midface rejuvenation. Presented at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons, Atlanta, Nov 1987. 17. Ristow B. The suspension of the anterior SMAS to the zygomatic arch [film]. Presented at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons, Atlanta, Nov 1987. 18. Peterson RE, Johnson DL. Facile identification of facial nerve branches. Clin Plast Surg 14:775778, 1987. 19. Connell BE. Personal communication, Jan 1989. 20. Bosse JP. The anatomy of the SMAS. Presented at the Annual Meeting of the Canadian Soci - ety of Aesthetic Plastic Surgery, Quebec, Sept 1990. 21. Pontes R. Witch’s chin correction [film]. Presented at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons, Atlanta, Nov 1987. 22. Goodman LS, Gilman A. The Pharmacological Basis of Therapeutics. New York: Macmillan, 1990. 23. Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg 73:911-915, 1984. 24. Lawrence WT, Murphy RC, Robson MC, et al.The detrimental effect of cigarette smoking on flap survival: An experimental study in the rat. Br J Plast Surg 37:216-219, 1984.

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25. Riefkohl R,Wolfe J, Cox E, et al. Association between cutaneous occlusive vascular disease, skin slough after rhytidectomy, and cigarette smoking. Presented at the Annual Meeting of the American Society of Aesthetic Plastic Surgery, Boston, April 1985. 26. Rudolph R. Problems in Aesthetic Surgery: Biological Causes and Clinical Solutions. St Louis: Mosby, 1986, pp 76-82. 27. Hynes W. The blood vessels in skin tubes and flaps. Br J Plast Surg 3:165, 1950. 28. Jurell G, Norberg K, Palmer B. Surgical denervation of the cutaneous blood vessels. Acta Physiol Scand 74:511-512, 1968. 29. Norberg KA, Palmer B. Effects of noradrenaline and felypressin on cutaneous local blood flow after sympathetic denervation. A study on rats. Scand J Plast Reconstr Surg 6:106-109, 1972. 30. Palmer B. Sympathetic denervation and reinnervation of cutaneous blood vessels following surgery. An experimental study on rats by means of a histochemical fluorescence method. Scand J Plast Reconstr Surg 4:93-99, 1970. 31. Ristow B. Midface rejuvenation. Presented at the Symposium on Surgery of the Aging Face. Plastic Surgery Education Foundation, Laguna Nigel, CA, Jan 1993. 32. Barton E. The SMAS anatomy. Presented at the Symposium on Surgery of the Aging Face. Plastic Surgery Education Foundation, Laguna Nigel, CA, Jan 1993. 33. Pessa JE. The anatomy of the labiomandibular fold: A gross and histological study in fresh cadavers. Presented at the Annual Meeting of the American Society of Aesthetic Plastic Surgeons, Boston, April 1993. 34. Connell B. Personal communication, Santa Ana, CA, 1989. 35. Bosse JP. The anatomy of the SMAS. Presented at the Symposium on Surgery of the Aging Face. Plastic Surgery Education Foundation. Laguna Nigel, CA, Jan 1993. 36. In collaboration with Laurens N. Garlington, MD, Chief Emeritus of the Department of Anesthesia, California Pacific Medical Center, San Francisco, CA. 37. Lowe HJ. The Quantitative Practice of Anesthesia: Use of Closed Circuit. Baltimore: Williams & Wilkins, 1981. 38. Ristow B. Facelift subtleties and highlights.“Primary Face Lift” Panel. Presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, Orlando, 2000. 39. Ristow B. About Face Symposium. American Society of Plastic Surgeons, Plastic Surgery Educational Foundation, American Society for Aesthetic Plastic Surgery, Aesthetic Surgery Educational and Research Foundation, Colorado Springs, CO, 2003. 40. Ristow B. A personal technique for facial rejuvenation. Aesthetic Surg J July-August 20:325, 2000. 41. Peck GC, ed. Complications and Problems in Aesthetic Plastic Surgery. New York: Gower Medical Publishing, 1992. 42. Hester TR, Codner MA, McCord C. Operative techniques in plastic and reconstructive surgery. Mid Face Rejuv 5:167, 1998. 43. Ristow B. Aesthetic Plastic Surgery of the Upper Face. Surgery Technology International. London: Century Press/Grosvenor Press, 1991, pp 325, 327.

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REVIEW QUESTIONS 1. The proper surgical elevation of the SMAS will: a. Have no effect on the jaw-neck angle b. Only slightly improve the nasolabial fold c. Increase the possibility of surgical bleeding d. None of the above e. All of the above 2. Elevation of the SMAS will: a. Recruit tissues under the lower eyelid b. Elevate the corners of the lips c. Have an effect on the modiolus d. Accentuate the jaw-neck angle e. All of the above 3. If a smoker is accepted for surgery, he or she will: a. Have a safer result by the two-layer face lift b. Have a safer result by Skoog’s technique c. Be permitted to smoke only five cigarettes a day d. Be prohibited from chewing Nicorette gum e. All of the above 4. Submental liposuction is best: a. Because it leaves the normal anatomy of the platysma intact b. Because one can gauge exactly how much fat to preserve c. In young patients d. A simple small drain will prevent most swelling e. All of the above 5. For best results, unilayer face-lift techniques may: a. Require internal suspension of the SMAS b. Have a tendency to flatten the midface c. May be further enhanced by small SMAS grafts to the cheeks d. All of the above e. None of the above 6. In a primary face lift in a patient with sufficient hair: a. It is best to place the incision high into the hair b. A high (into the hair) incision is the best vector to correct a saggy neck c. For the first-time face lift, it is fine because the hair can always be lowered later d. One should follow the hairline and then move the incision upward creating a small flap e. All of the above

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7. Division of the platysma is best done: a. At the thyroid cartilage level to accentuate the contour b. At the cricoid cartilage level c. Never, because the platysma will roll up like a window shade d. Never; bands quickly reappear e. All of the above 8. Retroauricular (auricular groove) scars appear to migrate into neck skin. An effective prevention may be to: a. Place the incision high behind the ear so when it migrates, it goes to the groove b. Create no tension and use catgut sutures c. Close the incision with buried long-term biodegradable suture material (such as Monocryl) d. Leaves excess skin there to avoid tension e. All of the above 9. Strong plication of the platysma in the midline of the neck is a good technique: a. When only the neck is being operated on b. When a complete SMAS elevation is planned c. Should never be done d. But rarely achieves anything significant e. All of the above

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Chapter 11 Reoperative Rhytidectomy James C. Grotting and James M. Stuzin

How old would you be if you didn’t know how old you were? Satchel Paige

Reoperative Problems Scars Hair pattern changes Fat irregularities and deficiencies Descended facial or cervical fat Skin laxity

Earlobe deformities Cervical obliquity Platysmal banding Misdirected rhytids Attenuation of deep layer support

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W

ith the ever-increasing popularity of aesthetic surgery, most plastic surgeons encounter patients seeking facial rejuvenation who have already undergone a facial procedure. In many ways, these patients come better prepared for the realities of surgical intervention than those who have never experienced it. On the other hand, reoperative patients present certain challenges that must be anticipated and planned for to optimize outcomes, and that is the subject of the pages that follow. Further, both primary and secondary rhytidectomy patients have early and late complications that must be dealt with, and these will be addressed as well. Ours is a changing paradigm with regard to evaluation and possible treatment options for patients seeking additional rejuvenation. It is likely that patients who present having had surgery in the remote past underwent standard variations on the classic rhytidectomy. However, we are also seeing more patients who may have less than desirable outcomes from the newer procedures, which include limited incision lifts, endoscopic lifts, suture suspension lifts (“thread-lifts”), autologous fat injections, and implant surgery. Over time, we anticipate seeing these patients back who had good improvement with less-invasive procedures, but who now desire more definitive correction. “How long will my face lift last, Doctor?” Almost every patient undergoing facial rejuvenation will ask this question. Of course, there is no one right answer, since so many factors come into play, all of which can affect the longevity of a rhytidectomy. Some patients want to do things at more frequent intervals to maintain a certain look, whereas others may wish to have one procedure done in their entire life and are satisfied with that. The point is that all patients understand that the results of a face lift will not last forever and that they will continue to be affected by aging and gravity.

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Anatomic Considerations James M. Stuzin

Mimetic muscle

Parotidomasseteric fascia

SMAS

SMAS

Buccal fat pad Mimetic muscle (platysma)

Subcutaneous layer Parotidomasseteric fascia

Subcutaneous layer Skin

Plane of facial nerve

The anatomic principle that allows a rhytidectomy to be performed safely is the fact that facial soft tissue is architecturally arranged as a series of concentric layers. This arrangement allows dissection within one anatomic plane to proceed completely separate from the structures lying within another anatomic plane . The layers of the face, from superficial to deep, are the skin; subcutaneous layer; superficial facial fas- cia (superficial musculoaponeurotic system [SMAS]); mimetic muscles; deep facial fascia (parotidomasseteric fascia); and the plane of facial nerve, parotid duct, buccal fat pad, facial artery, and facial vein.

SKIN The outermost layer of the face is the skin. The aging of facial skin is influenced by actinic damage as well as intrinsic genetic factors. Because the skin envelope has been tightened in the primary face-lift procedure , little skin is removed in second- ary rhytidectomy. Skin envelope tightening is not as important a factor in improv - ing the facial contour in the secondary procedure . Similarly , patients with facial rhytids in whom the cervicofacial flaps were rotated in a cephalad direction during the primary procedure are at greater risk for having an abnormal postoperative ap- pearance if the cervicofacial flap is again redraped in a cephalad direction . Before the secondary procedure is performed , these factors must be carefully evaluated to determine the best direction to redrape the facial skin.

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This patient, who was operated on by another surgeon, was dissatisfied with the unnatural facial appearance and the distorted temporal hairline. Because the facial skin has been previously delayed following the primary procedure, the vascular supply to cervicofacial skin is usually healthy at the time of secondary rhytidectomy. For this reason, the risk of skin slough or hypertrophic scarring associated with wide undermining of facial skin secondarily was minimal. This factor is especially relevant when dealing with a patient with a history of cigarette smoking.

SUBCUTANEOUS LAYER Directly deep to the skin lies a variable amount of subcutaneous fat.This fat sits directly above the SMAS and is the anatomic plane of dissection we use in face-lift procedures. The thickness of this layer varies from patient to patient. Most patients undergoing reoperative rhytidectomy have a thinner layer of subcutaneous fat compared with primary rhytidectomy patients, because a variable amount of fat is lost through the trauma of the original procedure. This problem is compounded in a thin patient undergoing secondary rhytidectomy, and it is sometimes difficult to precisely undermine within the scant subcutaneous layer. This clinical situation presents the possible hazard of the dissection being carried inadvertently deep in a sub-SMAS plane; great care is required during dissection. Similarly, it is not uncommon to encounter a fair amount of cicatrix in the subcutaneous layer during undermining; dissection through this fibrous tissue should be performed cautiously to ensure that the proper level of undermining is maintained.

Chapter 11 Reoperative Rhytidectomy

SUPERFICIAL FACIAL FASCIA (SMAS) The superficial musculoaponeurotic system represents a discrete fascial layer that separates the overlying subcutaneous fat from the underlying parotidomasseteric fascia and facial nerve branches. When rhytidectomy is being performed, identification of the SMAS is of paramount importance. As long as the integrity of this layer is maintained, facial nerve injury will not result from the dissection. The SMAS represents an extension of the superficial cervical fascia cephalad into the face.1 This superficial fascia forms a continuous sheath throughout the face and neck, extending into the temporal region, forehead, scalp, malar regions, nose, and upper lip.2 The thickness of the SMAS varies greatly from patient to patient, as well as from one region of the face to another. The superficial facial fascia is thick overlying the parotid gland; it is this anatomic component that many physicians clinically refer to as the SMAS. Superiorly cephalad to the zygomatic arch, this fascial layer is referred to as the temporoparietal fascia (within the temporal region) and galea (within the scalp), both of which are of substantial thickness. As the SMAS is traced medially into the cheek over the masseter muscle and the buccal fat pad, this layer tends to become thinner and less distinct.3 Within the malar region, the SMAS is quite thin, essentially comprising the epimysium of the elevators of the upper lip. Much of the contouring obtained in secondary rhytidectomy involves tightening of the superficial facial fascia, or SMAS, which commonly is lax compared with the tight skin envelope in this type of patient. The SMAS layer in the secondary rhytidectomy patient is thinner than that present in the primary surgical patient; most likely this change results from the loss of subcutaneous fat overlying the SMAS following the original procedure. Some patients will have undergone a SMAS elevation during the primary procedure, which can distort the landmarks during sub-SMAS dissection. Nonetheless, with careful attention to detail during dissection, most secondary rhytidectomy patients will benefit from a formal undermining and tightening of the SMAS layer during the reoperative procedure.

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MIMETIC MUSCULATURE Galea aponeurotica

Occipitofrontalis muscle

Orbicularis oculi muscle Levator labii superioris muscle

Temporalis muscle Nasalis muscle

Zygomaticus minor muscle Zygomaticus major muscle

Facial nerve branches

Levator anguli oris muscle Risorius muscle Orbicularis oris muscle Depressor anguli oris muscle Depressor labii inferioris muscle Mentalis muscle

Masseter muscle Buccinator muscle Platysma muscle

Sternocleidomastoid muscle

Platysma muscle

Deep to the SMAS and intimately associated with it are the mimetic muscles, or muscles of facial expression. Rather than all being situated within the same layer within the facial soft tissue architecture, these muscles are arranged in four anatomic layers that overlap one another.4 The mimetic muscles that might be encountered during rhytidectomy—platysma, orbicularis oculi, zygomaticus major, and zygomaticus minor—are superficially situated in relation to the plane of the facial nerve and thus receive their innervation along their deep surfaces. In contrast, the buccinator, mentalis, and levator anguli oris muscles, which are the most deeply situated mimetic muscles within the facial soft tissue architecture, lie posterior to the plane of the facial nerve and therefore are innervated along their superficial surfaces. The surgical significance of this anatomic relationship is that when SMAS elevation is being performed, as long as the dissection is carried along the superficial surface of the facial muscles, injury to muscular innervation cannot occur. For example, elevation of the SMAS within the malar region will expose fibers of the underlying zygomaticus major and zygomaticus minor muscles, but their innervation will not be injured as long as the integrity of these muscles is not violated.

Chapter 11 Reoperative Rhytidectomy

DEEP FACIAL FASCIA (PAROTIDOMASSETERIC FASCIA) Because the face and neck are contiguous, it makes sense that the fasciae of the neck continue cephalad into the face. Just as the SMAS represents a continuation of the superficial cervical fascia into the face, the corresponding deeper layer of cervical fascia (superficial layer of the deep cervical fascia) continues into the face. This layer has been termed the parotidomasseteric fascia. The relevance of this fascia to facial anatomy is infrequently discussed, but it is extremely important: within the cheek, the facial nerve branches and the parotid duct always lie deep to the parotidomasseteric fascia.5,6

This cadaver dissection (left) following SMAS-platysma elevation within the cheek has exposed the underlying parotid gland, the anterior border of the parotid gland (marked in ink), and the parotidomasseteric fascia (held in forceps).The facial nerve branches within the cheek are always deep to the parotidomasseteric fascia. The cadaver dissection (right) following elevation of the parotidomasseteric fascia has exposed the underlying masseter muscle and the marginal mandibular nerve as it crosses the facial artery and vein. Within the neck, the superficial layer of the deep cervical fascia is found along the superficial surface of the strap muscles. Superior to the hyoid bone, this fascial layer overlies the mylohyoid and can be traced superiorly over the mandibular body.7

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Temporoparietal fascia Skin

Deep temporal fascia

Superficial temporal artery (divided)

Superficial temporal artery (divided)

Frontal branch of facial nerve (divided)

Frontal branch of facial nerve (divided) Parotid gland Zygomatic ligaments

Parotid duct Parotidomasseteric fascia

Buccal fat pad Masseteric cutaneous ligaments

Parotid cutaneous ligaments Facial artery Platysma invested by superficial facial fascia (SMAS)

This deep fascia extends into the face and overlies the parotid gland, at this point becoming the parotid capsule or investing parotid fascia. More anteriorly, the deep facial fascia overlies the masseter muscle and is called the masseteric fascia. Medial to the masseter muscle, the deep facial fascia lines the superficial surface of the buccal fat pad and parotid duct.This fascia extends into the malar region, lying deep to the elevators of the upper lip. An extension of deep facial fascia superior to the zygomatic arch, within the temporal region, has been called the deep temporal fascia.

FACIAL NERVE Facial nerve injury is the most feared complication in rhytidectomy.When the surgeon fully understands the facial anatomy and performs careful anatomic dissection, the chances of facial nerve injury are greatly lessened. The facial nerve is encompassed by the parotid gland in the lateral aspect of the face. Medially it emerges from the parotid gland and traverses the superficial surface of the masseter muscle immediately deep to the parotidomasseteric fascia. Medial to the masseter muscle, the facial nerve overlies the buccal fat pad. The buccal fat pad, parotid duct, facial artery and vein, and facial nerve lie within the same anatomic plane within the cheek. As the facial nerve courses peripherally, it sends branches to the overlying mimetic muscles.

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The frontal branch of the facial nerve is an anomaly. Unlike other nerve branches that lie deep to the deep facial fascia, once the frontal branch crosses the zygomatic arch, it traverses the temporal region along the undersurface of the temporoparietal fascia, invested in subSMAS fat, and then peripherally penetrates this layer to innervate the occipitofrontalis muscle along its deep surface.

Temporoparietal fascia Loose areolar tissue Deep temporal fascia ß Line of fusion Superficial layer Deep layer Temporal fat pad Frontal branch of facial nerve Zygomatic arch SMAS Masseter muscle Parotidomasseteric fascia

Temporalis muscle

Buccal fat

Posterior masseteric fascia

In this illustration, a cross section of the temporal region demonstrates the continuation of the SMAS cephalad to the zygomatic arch where it is called temporoparietal fascia. The temporal region therefore represents one area of the facial anatomy where a complete violation of the SMAS layer can produce direct injury to a motor branch. For a motor branch injury to occur during undermining within the cheek during rhytidectomy, the dissection must penetrate not only the SMAS but also the deep facial fascia. However, because of the more superficial course of the frontal branch in the temporal region, this motor nerve is at risk of injury if just the temporoparietal fascia is violated at this site during dissection.8

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RETAINING LIGAMENTS

Masseter muscle

Zygomatic ligaments Zygomaticus minor muscle Zygomaticus major muscle

Parotid cutaneous ligaments

Masseteric cutaneous ligaments Mandibular cutaneous ligament

Facial soft tissue is supported over bony prominences by a series of retaining ligaments that run from deep, fixed facial structures to the overlying dermis.9 On cadaver dissection there appear to be two types of retaining ligaments. First, there are true osteocutaneous ligaments, which are a series of fibrous bands that run from the periosteum and insert directly into the dermis. The zygomatic and mandibular ligaments are examples of osteocutaneous ligaments. The masseteric cutaneous ligament and the parotid cutaneous ligaments are formed as a condensation between the superficial and deep facial fasciae. Rather than originating from periosteum, these ligaments originate from relatively fixed facial structures such as the parotid gland and the anterior border of the masseter muscle . Attenuation of support from the retaining ligaments is responsible for many of the stigmata that occur in the aging face. Second, there is a system of supporting ligaments formed by coales- cences that occur between the superficial and deep facial fasciae in certain regions of the face (for example , parotid cutaneous ligaments and masseteric cutaneous lig- aments). These fascial connections fixate both superficial and deep facial fasciae to underlying fixed structures , such as the parotid gland and anterior border of the masseter muscle, and support facial soft tissue with fibrous septa that extend into the dermis. The zygomatic ligaments exist as a series of fibrous septa that originate laterally from the periosteum of the malar region where the zygomatic arch joins the body of the zygoma. Similar fibers are observed overlying the malar eminence. A partic - ularly stout ligament is noted to originate along the most medial portion of the zy- goma near the zygomaticomaxillary suture . The zygomatic ligaments extend through the malar pad (McGregor ’s patch) and insert into the overlying malar skin; they fix the malar pad to the underlying zygomatic eminence.

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In this cadaver dissection, the mandibular ligaments are identified in the parasymphyseal region of the mandible just lateral to the chin pad and extend from bone into the overlying skin. The mandibular ligaments tend to be the thickest and most discrete of the retaining ligaments, forming a series of sturdy fibrous bands that securely fixate the parasymphyseal dermis to the underlying mandible. Masseteric cutaneous ligaments support the soft tissues of the medial cheek superiorly over the mandibular body.These ligaments consist of a series of fibrous bands that originate along the entire anterior border of the masseter muscle from the malar region to the mandibular border and extend vertically from the masseter muscle through the platysma and subcutaneous fat to insert into the overlying dermis. These fibers are easily identified in sub-SMAS dissection. Once the SMAS is elevated anterior to the parotid gland, an areolar plane, extending from the anterior border of the parotid gland to the anterior border of the masseter muscle, can be visualized between the superficial and deep facial fasciae. On reaching the anterior border of the masseter muscle, this areolar plane ends as the fibrous septa of the masseteric ligaments are encountered. In summary, there appear to be two systems of retaining ligaments supporting facial soft tissue in a superior position. First, true osteocutaneous ligaments exist, which are fibrous structures running from bone through the facial soft tissue to insert into the overlying dermis. Second, a system of ligamentous support is formed by a coalescence between the superficial and deep facial fasciae, fixating facial skin to underlying structures such as the parotid gland and masseter muscle. Although tending to be finer in appearance than osteocutaneous ligaments, these attachments between superficial and deep fasciae similarly function to support facial soft tissues in normal anatomic position.

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ANATOMIC CHANGES THAT OCCUR WITH AGING Although arranged within anatomic layers, the individual structures composing facial soft tissue relate to one another anatomically to form a cohesive, working structure, producing facial movement while providing resistance to gravitational change. Precise knowledge of the anatomic relationships existing between these layers is useful in understanding the changes that occur in the aging face, allowing the surgeon to formulate a rational approach to correct various deformities during rhytidectomy. The retaining ligaments of the face support the facial soft tissue in normal anatomic location. As stated earlier, two types of ligamentous support exist. As this ligamentous system becomes attenuated with age and dermal elastosis occurs, the stigmata of the aging face develop.

The importance of the zygomatic ligaments lies in their ability to suspend malar soft tissue over the zygomatic eminence. This 26-year-old patient is shown after a full-face chemical peel; she is shown again at 57 years of age. With aging, attenuation of malar support commonly occurs, leading to an inferior migration of malar soft tissue. This soft tissue ptosis occurs adjacent to the line of muscular fixation along the nasolabial fold. It is not that the fold deepens with aging; instead, malar soft tissue lateral to the nasolabial line descends, which accounts for the fold prominence in the aging face.Therefore attempts at diminishing the prominent nasolabial fold should be directed at restoration of malar support and repositioning of malar soft tissue.10,11

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The fibers of the masseteric cutaneous ligament originate along the anterior border of the masseter muscle, extend vertically through the platysma and subcutaneous fat, and insert into the dermis of the cheek. The importance of these fibers lies in their support of the soft tissue of the cheek superiorly above the mandibular border. In our opinion, attenuation of support from masseteric cutaneous ligaments leads to an inferior migration of cheek soft tissue below the mandibular border and is largely responsible for the formation of jowls in elderly patients. Because of the anatomic arrangement existing between the retaining ligaments, if one examines a patient with prominent jowling, it is apparent that the jowl complex has anatomically constant borders. Anteriorly the jowl is bordered by the tethering mandibular ligaments, whereas posteriorly the jowl complex is located along the anterior border of the masseter muscle. Attempts to diminish the prominent jowl should therefore be directed at restoring cheek support and repositioning the soft tissue of the jowl complex superiorly above the mandibular border. Aging is not skin deep; the deep facial soft tissues are also involved. Attenuation of support from retaining ligaments, dermal elastosis, and facial lipodystrophy are the three main factors that must be addressed to reverse the anatomic changes that occur with aging. In general, the dermal aspects of aging are treated through the redraping of the skin flap in rhytidectomy. Lipodystrophy, which commonly occurs in the submental and cervical regions of the face but can also involve the jowls and nasolabial folds, must also be dealt with through the contouring of fat. To address the problems of attenuation of support from the retaining ligaments, some form of deep layer support is mandated, usually involving SMASplatysma contouring.

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PLATYSMA BANDS Similar to the retaining ligaments within the face, retaining ligaments within the neck tightly support the platysma against the deep cervical fascia overlying the floor of the mouth and thyroid cartilage. These fibers exist along the caudal mandibular border, course throughout the fibrous subplatysmal fat that lines the submental triangle, and extend from the hyoid bone and superior aspect of the thyroid cartilage into the overlying platysma. The arrangement of these ligaments accounts for the acute cervicomental angle associated with a youthful appearance.

With aging, attenuation of the cervical support for the platysma occurs, allowing the anterior edges of the platysma muscle to descend inferiorly and causing the platysma bands to become prominent. As the platysma muscle slips from its cervical support and descends inferiorly, cervical obliquity blunts the previously acute cervicomental angle. Muscular hypertrophy with age and shortening of the bowstringed platysma also contribute to platysma band prominence in the aging face. Therefore attempts to correct platysma banding and cervical obliquity must center on restoring the platysma to its normal anatomic location and contour. Any tethering within the platysma that has occurred over time as the result of the platysma muscle residing in a bow-stringed position must also be dealt with through some form of transection myotomy to release and lengthen the muscle.

Chapter 11 Reoperative Rhytidectomy

Early Complications Following Primary and Secondary Rhytidectomy James C. Grotting The face-lift operation, like any other aesthetic procedure, is at risk for early com - plications . The most common of these is hematoma , although skin slough and in- fection can also interfere with recovery . Nerve injuries , both sensory and motor , continue to occur and may lead to serious morbidity if they do not resolve spon- taneously . Other early complications of primary and secondary rhytidectomy are dysphagia and emotional issues. Hematoma following face lift is a signi ficant source of morbidity . Various authors report the incidence among all patients at 1% to 12.9%.12-18 The risk factors for hematoma include hypertension , especially when it is uncontrolled preoperatively ; male sex; bleeding disorders ; and the use of various medications that interfere with coagulation .19,20 Clearly , prevention is paramount in reducing the incidence of post - operative hematoma . Blood pressure control pays the highest dividends in this ef- fort. The incidence of hematoma among patients having facial rejuvenation under local anesthesia with sedation may be a bit lower than those undergoing general anesthesia. However, with either group it is crucial that blood pressure be normal- ized before the start of the procedure. If the patient ’s blood pressure remains greater than 180 systolic or 90 diastolic after initial sedation , we do not proceed until the blood pressure is diminished . Persistent elevation is an indication for referral and workup by the patient ’s primary physician . Clonidine has been recommended as a useful agent for preoperative control of blood pressure at doses of 0.1 to 0.2 mg orally the morning of surgery.17 Men have a higher incidence than women of bleeding during face-lift procedures and more frequently develop postoperative hematomas (between 3.97% and 12.9% of cases).21 The cause of this phenomenon is likely from increased sebaceous glands and more hair follicles, each of which is surrounded by a more extensive capillary network. As a result, the vascularity of the male skin is increased leading to greater sources of blood vessel disruption. In light of this phenomenon, more limited undermining in men as well as a conservative closed approach to the neck can decrease the surface area at risk for postoperative bleeding. We ask our anesthetists to avoid spikes in blood pressure as the patient emerges from general anesthesia, because this is the time of great risk for the development of a hematoma. Drains are useful as a monitoring mechanism for the amount of bleeding, but it is well accepted that they do not prevent hematoma. Head elevation, cool compresses, pain control, and continued sedation are all useful in maintaining the blood pressure at an acceptable level.

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MANAGEMENT

OF

HEMATOMAS

Hematomas following a face-lift procedure can fall into two categories: small ones that can be drained at the bedside without returning to the operating room, and large ones where the cheek and/or neck must be reopened and explored to control the bleeding source.

Bedside Management of Hematomas The key to successful management of hematomas is early detection. When detected early, a hematoma is more likely to be able to be managed without return to the operating room.17 Bedside management is accomplished by removal of enough sutures or staples to be able to remove clots and fresh blood. Preparation for this procedure should include some oral pain medication or sedation if the patient is overly anxious. Blood pressure must be under good control. Thorazine or nitropaste are useful agents for decreasing blood pressure by vasodilation. Towels or “chucks” are spread beneath the patient’s head, and the area is prepared with a solution such as Betadine. A Yankauer suction tip or red Robinson catheter is helpful for evacuating all the clots, and the surgeon can then assess ongoing bleeding. The area is irrigated profusely with saline solution until the return is clear.Then 20 to 30 ml of 0.4% lidocaine with 1:200,000 epinephrine solution are injected under the flap. Compression is held for 5 to 10 minutes, and a supportive circumferential dressing is applied.

Operative Treatment of Hematomas If the hematoma is large and seems to involve both cheeks and the neck, a return to the operating room is indicated. Other factors that should sway the surgeon toward the operating room are:  An uncooperative patient  An overly anxious patient  A large, delayed hematoma  Labile blood pressure  Bilateral hematomas  A compromised airway

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If the patient is having difficulty breathing, immediate removal of sutures and decompression are essential. Since intubation and airway control in the presence of a large hematoma can be exceedingly difficult, I prefer to initially get control of the situation under local anesthesia with a little sedation. Often, very little is needed, because the tissues are often still numb from the initial procedure, and antianxiety and pain medications may already have been given. The surgeon must try to locate the primary source of fresh bleeding and pack that area while evacuating the remainder. With large hematomas, I usually remove the majority of sutures to make absolutely certain that all sources of bleeding have been controlled, because the worst scenario is to think one has control of the bleeding source only to find that the hematoma has recurred after the patient has already left the operating room. Profuse irrigation with saline solution and dilute hydrogen peroxide will usually reveal the bleeding source. Of course, one feels most confident when a single “pumper” is found. When multiple bleeding points are encountered, I prefer to keep the patient in the operating room under observation a bit longer until I am sure no further bleeding is going to occur. Drains should always be replaced and their proper function confirmed.

Four hours after undergoing a face lift, an endoscopic brow lift, and a lower blepharoplasty, this 59-year-old patient developed an obvious hematoma involving both cheek pockets and the neck. Exploration revealed two arterial bleeding points in the neck that were controlled. All regions were washed out and the skin was reclosed.

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The 4-month postoperative result shows near complete resolution of the sequelae of this complication.

Chapter 11 Reoperative Rhytidectomy

SKIN SLOUGH Skin sloughs usually occur as a result of closure under excessive tension. Blood under the flap, tight dressings, flexed neck positioning, smoking, and diabetes are all contributing factors. If an impending tissue necrosis is diagnosed in the early postoperative period by flap cyanosis or lack of capillary refill, sutures should be immediately removed and the skin allowed to retract. As in the case of a released nipple-areola complex, the open wound can be covered with Xeroform and a light dressing for 5 to 7 days, at which time one is often able to reclose the wound with salvage of the skin flap. If available, hyperbaric oxygen treatments once or twice daily for 5 days can be helpful in salvaging underperfused skin flaps. If the skin is clearly demarcating, usually conservative treatment is indicated. The surgeon should make certain that the patient is not continuing to smoke if he or she is a smoker. These patients will require continuous reassurance, because this complication may seriously affect their ability to return to work or other social activities. On the other hand, little wound care is necessary in the eschar phase.When spontaneous separation begins to occur, I debride any nonviable tissue and begin dressing changes. Allowing the wound to contract and heal spontaneously usually gives a result that is a better color and texture match than a skin graft would. Obviously, if flap advancement and reclosure is a possibility, this is the best option. However, usually there is too much tension to accomplish this.

INFECTION Fortunately, infections following face lifts are rare, but they can have devastating consequences.22-24 Prevention is the key. We have all our patients wash their faces themselves at least three times with an antibacterial soap on the morning of surgery. It is difficult to maintain a strict sterile field with facial rejuvenation surgery because of the presence of hair and the oral and nasal cavities within the field, as well as the endotracheal tube or airways and oxygen. Nevertheless, every attempt must be made to avoid contamination, especially when the procedure is prolonged.We have found that soaking braided sutures in Betadine before use has decreased small suture infections, especially in the region of the platysma plication. Also, before closure of the cheek dissection, we meticulously irrigate all open areas with dilute Betadine to wash out any debris, particularly loose fat globules. Infections may arise in undrained hematomas or seromas; these are often seen as collections in dependent portions of the undermined area. An overlying erythema is usually the first sign, but there may be little or no associated pain or fever.

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Drainage is of paramount importance, even more crucial than appropriate antibiotic selection; however, cultures should be obtained to guide antibiotic selection. If the combination of drainage and antibiotic agents fails to rapidly resolve the problem, operative exploration should be considered to rule out an infected foreign body. Cotton used to plug the external auditory meatus has been known to drop into the wound and should be accounted for in the sponge and needle counts. In severe infections of the face, thorough irrigation, debridement of any nonviable tissue, and wide drainage is generally effective, in addition to administration of an appropriate antibiotic. Hospitalization and intravenous antibiotic therapy are rarely needed, but anything less than rapid resolution of the infection should be treated in this manner.

PAROTID FISTULA Parotid injury has become a more common event with face-lift techniques that involve dissection in the sub-SMAS plane. Unfortunately, it is even more likely when the SMAS has been previously elevated as in some secondary face lifts. With any secondary facial procedure the parotid is at greater risk of injury because of altered anatomy and scar.25,26 The gland is at highest risk over its superficial lobe just at the mandibular angle. The superficial fascia can usually be separated from the parotid fascia unless the plane has been previously obliterated surgically. Actually, raising both the superficial fascia and the parotid fascia in continuity is sometimes advantageous when the superficial fascia is thin, because this adds strength for the deep tissue fixation. However, one is dissecting right on top of the glandular lobules of the parotid, which can look very similar to the sub-SMAS fat and is therefore susceptible to injury.This is how most parotid injuries occur.The duct is rarely injured but can be obstructed if the gland is torqued with suture fixation. The key to management is to recognize the injury to the parotid at the moment it occurs so that the plane of dissection is immediately corrected. The injured parotid is simply coagulated with the electrocautery or rarely, oversewn with fine sutures if the injury appears to enter the terminal ductules. The area is drained and compression applied for 48 hours. If there is obvious saliva appearing in the drain, it should be left in place until the output is minimal. Generally, these fistulas are selflimited as long as the duct is not obstructed. Sialography or duct endoscopy has been reported to be helpful in reopening an obstructed duct.26,27 Injuries late in the postoperative period are diagnosed by a swelling and fluid collection over the parotid that on aspiration yields a high amylase titer. Generally, the patient is afebrile. The swelling often increases with eating. It is managed by inserting a closed suction drain, adding a pressure dressing, and administering antibiotic agents. Atropine and glycopyrrolate have been reported to be helpful for their antisialagogue effects.25

Chapter 11 Reoperative Rhytidectomy

NERVE INJURY Any branch of the facial nerve can be injured during a face lift. With the altered anatomy from primary surgery, deeper dissections beneath the SMAS during secondary face lifts risk injury to the facial nerve.28 The frontal branch is the most commonly injured branch followed by the marginal mandibular, and the buccal. Although severed branches do occur, the more typical injury is a result of traction or thermal injury from the use of cautery in close proximity.The vast majority of nerves which are still in continuity recover in time although this can take up to a year or more. Most recover within two weeks to three months.

When frontal branch weakness is noted postoperatively and persists beyond one month, I favor the use of Botox to weaken the normal side if the patient will accept it while the injured side recovers. Often as the Botox wears off, the nerve has recovered on the injured side and symmetric movement is reestablished. If the nerve has not recovered by one year, a more permanent solution is to do ei - ther a direct or endoscopic brow lift on the affected side and on the normal side if indicated . A similar strategy can be used for the marginal mandibular branch with weakening of the depressor anguli oris (check muscle name ) on the normal side with Botox. Resection of this muscle has been reported for perioral rejuvenation and could be considered if the asymmetric smile persists beyond one year . Other solutions are discussed in Chapter 26 . Injuries to the great auricular nerve are usu - ally managed conservatively as often sensation will spontaneously return.

DYSPHAGIA Dysphagia is attributable to the platysmal tightening which is a dramatic change for patients who are accustomed to a loose neck. Diazepam is effective for symptomatic treatment early on, and no surgical intervention is ever indicated as the muscle always relaxes with time.

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EMOTIONAL ISSUES Recovery from a face lift is an emotional roller coaster for some patients. The effects of anesthesia, steroids and other medications, as well as fear regarding eventual appearance can take a serious toll on the emotional well-being of the face-lift patient. Preoperative education can help prepare the patient for “the blues” that frequently accompany the recovery process. A relationship with a clinical psychologist in your community can pay great dividends if intervention seems to be necessary. Other patient issues are discussed in Chapter 3.

AESTHETIC EVALUATION OF THE PATIENT SEEKING A SECONDARY FACE LIFT With better understanding of the aging process, we now know that repeated pulling of skin, especially in a disadvantageous direction, will not restore a youthful appearance, but rather yield an appearance that belies repeated surgery and may be exceedingly difficult to correct.29,30 The “lateral sweep” of the lifted lateral cheek and jowl but uncorrected midface is a classic example of this. Therefore patient evaluation must begin by careful analysis of which features are yielding an aged appearance. The upper third of the face as well as eyelid surgery is discussed elsewhere in this volume and therefore, will not be covered here. (See Chapters 12, 13, 17, 18 and 19.)

Factors to Be Considered in Secondary Facial Rejuvenation Quality and texture of skin Degree of skin relaxation Degree of fat atrophy with residual hollowing Facial asymmetries Depth of nasolabial, labiomental, and nasojugal creasing Ear and earlobe malposition, ptosis, and deformities Tragal definition and position Hairline shifts or hair loss Visibility and quality of previous scars

Other aging features not previously addressed including perioral lines, thinning and lengthening of lips Platysmal banding and laxity Submandibular gland prominence Chin shape and ptosis Contour deformities of the neck resulting from excess fat in neck or jowls, either above or below the platysma Malar flattening Digastric muscle prominence Dentition

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In this patient with sun-damaged skin and facial wrinkling, the wrinkles run in a cephalad direction as the result of a previous face lift. This problem usually becomes more evident with animation and when the patient flexes the neck. It is usually a mistake to immediately conclude that what every patient must have is your definitive face lift, as if whoever did it the first time might be lacking your skill. We all have patients who do not get as long-lasting a result as we would have liked. In fact, some heavy-jowled or “bull-necked” patients should be told in advance that an angular fashion-model type of neck could never be achieved for them. Instead, they may be candidates for an early retightening because of the loss of good skin elasticity.

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This 66-year-old patient has considerable loss of skin elasticity with very loose tissues in the neck and a rounded facial appearance.This type of patient is a likely candidate for an early secondary correction, even as early as 1 year after the primary procedure, because of the likelihood for recurrence of jowling and laxity. She must be informed of this in advance to avoid dissatisfaction and unrealistic expectations. This patient’s operative sequence is shown on pp. 295-297. Further, many patients may be seeing you because they have heard you are not a surgeon who immediately wants to do another face lift on everyone.You now have multiple different approaches available to you, so the first rule is listen to your patient! Then ask,“What is it about your face that is beginning to bother you?” and “Were these features improved after your first face lift?” Starting with questions like these will assist the plastic surgeon in tailoring valuable consultation time toward the patient’s primary concerns rather than discussing all sorts of items that the patient will simply not consider. Nevertheless, the consultation is also an opportunity to help educate the patient about procedures or treatments that will give lasting improvement versus treatment options that he or she may have heard about but for which the patient is not a candidate. Botox and fillers are not going to give a facelift–like result, quite obviously, but some patients are confused about issues such as these. In recent years, much more attention has been paid to the midface as well as volumetric shaping of the face.31,32 These are issues that might not have been addressed during the patient’s initial face lift. Of course, if you performed the original procedure, you have easy access to the records for what was done. If the original surgery was done by someone else, you may not be able to determine exactly what was done the first time around. However, if the assessment reveals an aged midface ap-

Chapter 11 Reoperative Rhytidectomy

pearance, you will need to address this at the time of surgery. Also, the addition of fillers, including autologous fat for volumetric replacement, is more commonly done today than just a few years ago. Therefore it is likely that the patient has not benefited from some of the newer technologic innovations that plastic surgeons now have available to them. Often the quality of the skin has either further deteriorated or has never been treated in a secondary patient. This may be the primary source of concern for the patient, and improvement is more a matter of resurfacing, filling, or skin care, which are fully discussed in Chapter 15.

TECHNICAL APPROACHES FOR A SECONDARY FACE LIFT The approach to secondary rejuvenation flows out of the previous comments on assessment. The plan should encompass correction of as many of the problems listed earlier as is practical, given the desires of the patient and limitations of time, finances, or comorbid conditions. If the patient desires a second facial rejuvenation, then many of the conditions discussed earlier can be addressed through the open approach.

INCISIONS

If the neck has retained a youthful appearance, a postauricular incision can sometimes be avoided, although if the previous scar is already there, little harm is done by reopening it. Certainly, if the position of the previous scar is disadvantageous and visible or if there is a step-off in the posterior hairline, then it should be opened and corrected. It is desirable to try to keep the transverse portion of the postauricular scar at or above the upper third of the ear. I prefer to open the old incision and undermine the skin flaps and then determine how far up I can move the postauricular incision before excising the normal skin above the old incision.

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Anterior incisions should almost always be anterior to the sideburn and posterior to the tragus (at least in women) to avoid further shifting of the sideburn and hairline posteriorly and to reduce the visibility of the tragal scar. The anterior sideburn incision can be designed as a W-plasty and be beveled along the hair follicles to improve the chances that viable hair will grow up through the scar. Alternatively, the vertical portion can be placed inside the hairline, so in some cases, where little skin is removed, the resulting scar will be hidden by the natural hairline.33 The best scars will result from a tension-free closure, so attention must be paid to releasing tension from the earlobe and from the tragus to prevent secondary deformities. The best anchoring point for the skin flap is the root of the helix of the ear and the top of the postauricular incision, if one has been made.

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UNDERMINING THE SKIN Whenever possible, I prefer to limit the undermining to the malar area, the midcheek, the jawline, and lateral neck area. The undermining should be precise and under direct vision or using the knife, the thickness of the skin flap must be kept even. Most patients will require elevation of the malar area, and exposure to this region is necessary. If the neck can be managed with liposuction alone, I leave it closed to avoid hematoma dissecting into this region. Obviously, if heavy, active platysmal bands are present or if one feels compelled to work on the digastric muscles, subplatysmal fat, or submandibular glands, the neck will require undermining through a separate submental incision.

THE SMAS Once the SMAS is exposed, I determine whether it requires separate dissection as a flap or can be simply plicated. If I know that a SMAS flap was previously done or if the patient is elderly or the SMAS is thin, plication is preferable to SMAS undermining. If the SMAS appears substantial and manual distraction of it does not produce the desired result at the nasolabial fold and corner of the mouth, I prefer to do the SMAS elevation and anchoring of the malar fat pad to the malar periosteum.

Incisions for an “extended SMAS dissection” are shown.

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The typical extent of SMAS dissection in the malar region, cheek, and neck is illustrated.To obtain adequate mobility with redraping, the SMAS in the malar region must be freed completely from its zygomatic attachments. To reelevate jowl fat into the cheek usually requires division of both the zygomatic ligaments as well as the upper portion of the masseteric cutaneous ligaments. The SMAS in the cheek below the parotid duct is usually elevated to the anterior border of the masseter muscle; occasionally division of the lower masseteric cutaneous fibers is required. The SMAS in the neck is elevated from the tail of the gland, extending anteriorly within the areolar plane deep to the platysma, until adequate mobility is obtained to allow contouring of the submandibular and submental regions. The key to SMAS elevation is to obtain adequate mobilization that allows reelevation of facial fat without undue tension.

It is often necessary to extend the malar SMAS dissection more peripheral than the subcutaneous dissection to obtain adequate flap mobility of the soft tissues lateral to the nasolabial fold. This portion of the dissection is easily performed by inserting the scissors in the plane between the superficial surface of the elevators of the upper lip, and the overlying subcutaneous fat and bluntly dissecting toward the nasolabial fold. As long as the scissors remain superficial to the elevators of the upper lip, motor nerve injury will be prevented. Usually three or four passes are required to obtain adequate flap mobility.

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In SMAS redraping in the cheek, note that some of the excess SMAS is transposed posterior to the ear to affect contour in the submental and submandibular regions through lateral tension. It is important to secure this flap to the mastoid fascia, which is an immobile structure, rather than to the fascia overlying the sternocleidomastoid muscle, which is a mobile structure. Final closure is shown on the bottom image.

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The excess SMAS, rather than being excised, is rolled on itself, forming a double layer of SMAS thickness. Once the roll has been formed, it is fixated to the periosteum of the zygomatic buttress using permanent sutures. It is essential to obtain a secure intraoperative fixation; fixation is as important as adequate SMAS mobilization.

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The subcutaneous undermining for the malar fat pad elevation proper reaches anteriorly to a vertical line dropped from the lateral canthus and superiorly to the level of the lateral eyebrow. Elevation of the malar fat pad in the vertical vector is obtained with suspension sutures to the superficial temporal fascia in front of the temporal hairline at the level of the lateral brow.

The lateral SMASectomy approach popularized by Dr. Dan Baker takes advantage of the looser SMAS substance in the midcheek region to produce effective elevation of the nasolabial fold and corner of the mouth. This submalar tightening is an excellent way to tighten the loose jowl.

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The weaving suspension sutures popularized by Tonnard and Verpaele are designed to produce a strong vertical vector to the SMAS and work well in patients who have some degree of laxity of the SMAS without undermining.

The malar fat pad suspension suture is shown. A horizontal mattress suture is placed so that greater tension is exerted along the superior margin of the pad to produce a central vector of lift that corrects the central infraorbital hollowing of the midface catenary. Simultaneously, the suture lifts the fat pad apex along a vector perpendicular to the prominent nasolabial fold.

Chapter 11 Reoperative Rhytidectomy

Plication can be done in a variety of ways.Vertical suturing to “stack” the malar or submalar area with fat is particularly effective for jowl correction as described by Little.31 This submalar imbrication can give the illusion of malar augmentation by accentuating the inward curve beneath the malar prominence (the “ogee” curve).

THE NECK Overresection of fat from the neck results in a skeletonization of the cervical area that is very difficult to correct. I know of no way to restore adequate thickness of subcutaneous fat between the platysma and skin other than autologous fat injection. For this reason, I am conservative about fat removal in the neck, whether in a primary or secondary procedure. Subplatysmal fat is removed during secondary procedures only when necessary to try to develop a cervicomental angle which is acceptable in a short heavy neck. Removal of portions of the submandibular gland or the anterior belly of the digastric muscle have been reported to assist in sculpting the neck.34-36 Repairing the platysma using a vest-over-pants technique is also helpful in developing an aesthetic cervicomental angle in a patient whose platysma muscle is quite redundant.

The platysma is exposed along the anterior aspect of the neck.

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After the platysma has been mobilized, the muscle edges are overlapped and the excess muscle is excised. It is important for the resection to be conservative so that the edge-to-edge approximation of the platysma will be performed under tension that is not too great.

Edge-to-edge approximation of the platysma muscle, extending from mentum to the thyroid cartilage, is performed.This long plication greatly enhances the surgeon’s ability to tighten the platysma and to conform the platysma closely against the floor of the mouth and the thyroid cartilage. A better foundation for the redraping of cervical skin is thus produced.

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Following edge-to-edge approximation of the platysma from the mentum to the cricoid cartilage, some form of muscular release is performed. This release consists of a horizontal cut extending from the midline to the anterior border of the sternocleidomastoid muscle. The key to platysma transection is to perform it as low in the neck as possible and just caudal to the last suture that has been placed in muscular plication.

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SKIN REDRAPING

To avoid the lateral sweep appearance of the cheek, the area must be carefully observed as the skin is redraped. Usually, satisfactory elevation of the midface combined with a more vertical vector of the skin redraping will eliminate this appearance of the skin. Sometimes laser resurfacing is helpful to produce some skin retraction and improvement of surface wrinkling. As noted earlier, keeping tension off the earlobe and tragus is essential.This is accomplished by good SMAS support. Deep sutures away from the ear will help keep the stress off the ear and allow it to stay or rotate back to its normal axis. The earlobe should be released and inset free of tension on top of the resupported skin flap. A deep suture from the dermis of the skin flap anchored to the inferior portion of the concha under the earlobe will keep the stress off the earlobe. If there is insufficient skin to cover the tragus, a small flap from the cheek flap superior to the tragus can be rotated back down to cover it without distorting it away from the external auditory canal.

Unusual hypertrophic scarring is seen in this patient following a primary face lift that involved both the preauricular segment and the postauricular sulcus. Correction is possible only by careful excision and flap readvancement, a closure free of tension, and injection of triamcinolone (Kenalog 10 mg/ml), repeated every 4 to 6 weeks as necessary to avoid recurrence.

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PATIENT EXAMPLES Staged Facial Rejuvenation

This 40-year-old patient requested facial improvement but was not ready for a face lift. Her initial treatment was a reduction in lower facial volume using ultrasonic lipocontouring of the jowls and neck area.

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Five years later, she noted laxity through the lower face and neck and requested tightening. An extended SMAS face lift was performed, with considerable improvement along the jawline and malar areas. Her reoperation was made easier by the previous defatting of the lower third of her face; however, increased scarring was encountered in the facial undermining as a result of her previous liposuction. The result is shown 2 years postoperatively.

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This sequence demonstrates the staged procedures in a 67-year-old patient undergoing facial rejuvenation. Analysis of her preoperative appearance reveals a very heavy laxity through the jowls and cervical area. She was counseled preoperatively that an early retightening of the neck would be a strong possibility because of the difficulty in maintaining the tightening.

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Unfortunately, her postoperative course was complicated by a neck hematoma that developed as a solid, fibrous mass as a result of incomplete drainage. Even after 6 months, the fibrous cord failed to soften or dissipate. Under local anesthesia the mass was excised as shown.

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Ultimately, a secondary lift procedure was performed to improve the jawline; several SMAS plication sutures were placed and the skin redraped.The result is shown 1 year after the secondary lift procedure.

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These images show a patient 10 years after a primary face lift with scars as shown. She returned requesting additional improvement and repositioning of the scars.

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The secondary procedure was designed to elevate the postauricular scars up higher behind the ear and restore the gap in the hairline, elevate the midface, and tighten the neck; an endoscopic brow lift was also performed. The postoperative result is shown.

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This patient is seen prior to a revision brow lift, face lift, and laser rejuvenation and 4 years, 5 months postoperatively.

Chapter 11 Reoperative Rhytidectomy

Seven months later the patient underwent a third procedure, including endobrow, face lift, and rhinoplasty.

In this patient, 22 years elapsed from the time of her first facial rejuvenation surgery until she sought additional correction. No previous records were available.The operative plan included additional correction of the lower lids, reelevation of the midface, platysma repair, and fat injection in the nasolabial folds and oral commissures. Additionally, we attempted to restore the tragus back to a more normal appearance.37,38

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The planned new incision is shown in relation to the old scars to attempt to make these less conspicuous.

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A standard SMAS flap is marked just below the zygomatic arch to include the malar fat pad and the lateral platysma. Fixation is to the malar periosteum and to the cut edge of SMAS horizontally and vertically.

The tragal cartilage is transected and a 4-0 nylon suture is used to tie the tragal remnant back to the conchal bowl as depicted above. The covering cheek skin fl ap will then be stented by this tragal retaining suture for one week to prevent it from being outwardly distracted.

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The following case represents a longer term follow-up of a patient undergoing tertiary face-lifting using the techniques described in this chapter.

This 47-year-old woman presented with complaints of continued facial aging and prominent scars following an initial face lift at age 36 and a mini-lift at age 41. The presideburn scars are visible, as is descent of the malar fat pad and minor jowling.

A tertiary face lift that included an extended SMAS technique anchoring the malar fat pad to the malar periosteum was performed, with the result seen at 1 year.

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At 4 years postoperatively, the result remains stable and the scars are improved. No further procedures except skin care have been performed.

CONCLUSION Our concepts of facial rejuvenation are continuously evolving and as this occurs, so will the tools and techniques available to us for reoperative improvements. Aging and surgery can both result in profound volumetric changes that conventional lifting methods cannot always change. Similarly, surface wrinkling is a major problem with our aging population, and correction can be disappointing with the surgical techniques that are currently available. Nevertheless, our goal continues to be to maintain a natural and youthful appearance, taking great care not to leave telltale signs of our interventions.

References —With Key Annotated References 1. Ruess W, Owsley JQ.The anatomy of the skin and fascial layers of the face in aesthetic surgery. Clin Plast Surg 14:677, 1987. 2. Letourneau A, Daniel RK. Superficial musculoaponeurotic system of the nose. Plast Reconstr Surg 82:48, 1988. 3. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 85:29, 1990. 4. Freilinger G, Gruber H, Happak W, et al. Surgical anatomy of the mimic muscle system and the facial nerve: Importance for reconstructive and aesthetic surgery. Plast Reconstr Surg 80: 686, 1987. 5. Peterson RA, Johnston DL. Facile identification of the facial nerve branches. Clin Plast Surg 14:785, 1987. 6. Baker D, Conley J. Avoiding facial nerve injuries in rhytidectomy. Variations and pitfalls. Plast Reconstr Surg 64:781, 1979.

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7. Lemmon M. Superficial fascia rhytidectomy: A restoration of the SMAS with control of the cervicomental angle. Clin Plast Surg 10:449, 1983. 8. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy of the frontal branch of the facial nerve: The significance of the temporal fat pad. Plast Reconstr Surg 83:265, 1989. 9. Furnas D. The retaining ligaments of the cheek. Plast Reconstr Surg 83:11, 1989. 10. Hamra S. The deep plane rhytidectomy. Plast Reconstr Surg 86:53, 1990. 11. Hamra ST. Composite Rhytidectomy. St Louis: Quality Medical Publishing, 1993. 12. Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: A personal 8-year quest. Reviewing 910 patients. Plast Reconstr Surg 113:381; discussion 388, 2004. The authors examined the effect of various parameters (that is, dressings , drains , fibrin glue, and tumescent infiltration with and without epinephrine ) on the rate of hematoma in this large consecu - tive retrospective study . Only the omission of epinephrine signi ficantly decreased the hematoma rate. An incisive critical analysis of their results by the discussant suggests the restoration of normal blood pressure and other factors may be more instrumental in achieving a low complication rate. 13. Matarasso A, Elkwood A, Rankin M, et al. National Plastic Surgery Survey: Face lift techniques and complications. Plast Reconstr Surg 106:1185; discussion 1196, 2000. Trends in the techniques used in rhytidectomy and complication rates and management of complications among American plastic surgeons were surveyed.The conclusions drawn were somewhat chal - lenged by a 15% response rate, which was nonetheless statistically significant.The discussant added conventional wisdom to this ambitious project. 14. Moyer JS, Baker SR. Complications of rhytidectomy. Facial Plast Surg Clin North Am 13:469, 2005. 15. Niamtu J III. Expanding hematoma in face-lift surgery: Literature review, case presentations , and caveats. Dermatol Surg 31(9 Pt 1):1134; discussion 1144, 2005. 16. Kamer FM, Song AU. Hematoma formation in deep plane rhytidectomy. Arch Facial Plast Surg 2:240, 2000. 17. Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas. Plast Recon - str Surg 115:2119; discussion 2123, 2005. The authors describe their technique for management hematomas following face-lift surgery using an emergency “hematoma kit” at the bedside with monitoring with the patient under sedation and anal - gesia. Contraindications are also discussed , such as delayed diagnosis , bilateral hematoma , and airway compromise .With close perioperative monitoring and early diagnosis and treatment, costly return to the operating room can be minimized. 18. Grover R, Jones BM, Waterhouse N. The prevention of hematoma following rhytidectomy: A review of 1078 consecutive facelifts. Br J Plast Surg 54:481, 2001. 19. de la Cruz L, Berenguer B, de la Plaza R. Thromboembolism after face lift because of muta - tion of the prothrombin gene. Plast Reconstr Surg 116:682, 2005. 20. Reinisch JF, Bresnick SD , Walker JW , et al. Deep venous thrombosis and pulmonary embolus after face lift: A study of incidence and prophylaxis. Plast Reconstr Surg 107:1570; discussion 1576, 2001. 21. 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 116:1973; discussion 1986, 2005. This is an excellent, well-written, well-organized, comprehensive retrospective study on the incidence of hematoma in male rhytidectomy patients .The authors have provided an in-depth analysis of the causative factors and recommended therapeutic and preventive measures for management of this most common adverse event, including a very practical table of commonly used medication in the perioper- ative period. 22. Christian MM, Behroozan DS, Moy RL. Delayed infections following full-face CO2 laser resurfacing and occlusive dressing use. Dermatol Surg 26:32-36, 2000. 23. Akers JO, Mascaro JR, Baker SM. Mycobacterium abscessus infection after facelift surgery: A case report. J Oral Maxillofac Surg 58:572; discussion 574, 2000. 24. Jallali N, Lamberty BG. A rare and near fatal complication of rhytidectomy. Plast Reconstr Surg 114:279, 2004.

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25. Feingold RS. Parotid salivary gland fistula following rhytidectomy. Plast Reconstr Surg 101:245, 1998. 26. Barron R, Margulis A, Icekson M, et al. Iatrogenic parotid sialocele following rhytidectomy: Diagnosis and treatment. Plast Reconstr Surg 108:1782; discussion 1785, 2001. Recently there have been more reports of parotid fistulas and pseudocysts associated with SMAS dissection during rhytidectomy.This is a case report of a parotid sialocele associated with Stensen’s duct obstruction and paresis of the mandibular branch of the facial nerve in which the authors used sialography and an endoscopic exam of Stensen’s duct as management tools.The discussion, by Dr. Stuzin, gives helpful guidelines for prevention and management of this distressing complication of facial aesthetic surgery. 27. Lapid O, Kreiger Y, Sagi A. Transdermal scopolamine use for post-rhytidectomy sialocele. Aesthetic Plast Surg 28:24, 2004; Epub May 3, 2004. 28. Daane SP, Owsley JQ. Incidence of cervical branch injury with “marginal mandibular nerve pseudo-paralysis” in patients undergoing face lift. Plast Reconstr Surg 111:2414, 2003. 29. Hamra ST. Correcting the unfavorable outcomes following facelift surgery. Clin Plast Surg 28:621, 2001. 30. Hamra ST. Frequent face lift sequelae: Hollow eyes and the lateral sweep: Cause and repair. Plast Reconstr Surg 102:1658, 1998. 31. Little JW. Applications of the classic dermal fat graft in primary and secondary facial rejuvenation. Plast Reconstr Surg 109:788, 2002. 32. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al. Rejuvenation of the midface by elevating the malar fat pad: Review of technique, cases, and complications. Plast Reconstr Surg 110:1526; discussion 1537, 2002. 33. Brennan HG, Toft KM, Dunham BP, et al. Prevention and correction of temporal hair loss in rhytidectomy. Plast Reconstr Surg 104:2219; discussion 2226, 1999. 34. Connell BF, Shamoun JM. The significance of digastric muscle contouring for the rejuvenation of the submental part of the face. Plast Reconstr Surg 99:1586,1997. 35. Guyuron B, Bokhari F, Thomas T. Secondary rhytidectomy. Plast Reconstr Surg 100:1281, 1997. 36. Guyuron B. Secondary rhytidectomy. Plast Reconstr Surg 114:797, 2004. Sequelae such as malposition of the sideburn, earlobe deformity, hypertrophic scars, loss of tragal definition, uncorrected marionette lines, and neck contour irregularities are often associated with secondary rhytidectomy.The author discusses some of his methods for the prevention and correction of these problems and guidelines for laser skin resurfacing combined with rhytidectomy. 37. Brink RR. Auricular displacement with rhytidectomy. Plast Reconstr Surg 109:408, 2002. 38. Mowlavi A, Meldrum DG,Wilhelmi BJ, et al.The “pixie” ear deformity following face lift surgery revisited. Plast Reconstr Surg 115:1165-1171, 2005.

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REVIEW QUESTIONS 1. The SMAS: a. Is generally thicker in reoperative rhytidectomy b. Is easily elevated in secondary rhytidectomy c. Is a discrete fascial layer that separates the overlying subcutaneous fat from the underlying parotidomasseteric fascia and facial nerve branches d. Is of uniform thickness from the superficial cervical fascia to the superficial temporal fascia e. Is thickest over the malar region 2. All of the following muscles receive their innervation from their deep surfaces except: a. Platysma b. Orbicularis oculi c. Levator anguli oris d. Zygomaticus major e. Zygomaticus minor 3. The risk factors for hematoma include all of the following except: a. Hypertension b. Male sex c. Bleeding disorders d. SMAS undermining e. Aspirin usage 4. Bedside management of hematomas should be avoided in all of the following except: a. Uncooperative patient b. Unilateral postauricular swelling c. Labile blood pressure in a 50-year-old man d. Bilateral hematomas e. Compromised airway 5. The primary management of a parotid fistula is: a. Ductal cannulation b. Parotidectomy c. Atropine d. Drainage e. Sialography

Chapter 12 Reoperative Forehead Lift Brunno Ristow

Our knowledge is the amassed thought and experience of innumerable minds. Ralph Waldo Emerson

Reoperative Problems Scar depression and contour defects Unacceptable hairline scar Residual rhytids Hair loss

Recurrent brow ptosis or asymmetry Paralyzed forehead Elevated hairline

F

orehead lifts have earned an enduring place in the repertoire of surgeons who perform facial rejuvenation procedures.This operation makes an undeniably significant contribution to facial rejuvenation, as demonstrated by the preoperative and postoperative views of three different patients on p. 310. Like upper and lower blepharoplasties, forehead lifts are frequently once in a lifetime operations; reoperation is rarely required. However, secondary procedures are not unheard of. A solid knowledge of the vascular anatomy of the forehead, gentle technical dissection, mastery of tension, and careful strategic planning are key components of any reoperative procedure to ensure consistent, natural results.

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Preoperative and postoperative views are shown following forehead lift and face lift in three patients.

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VASCULAR ANATOMIC CONSIDERATIONS Knowledge of how the blood supply may have been altered by the primary brow lift is of paramount importance in planning a reoperative brow lift procedure. The surgeon must address the following questions to outline a safe and effective secondary operation:  Is the supratrochlear artery intact?  Is the superficial temporal artery intact?  Is the anastomosis between the two arteries intact?

Supraorbital artery Possible site of injury (less frequent)

Supratrochlear artery Possible site of injury

Superficial temporal artery

Ophthalmic artery Site of commonly performed division Lateral nasal artery

Facial artery External carotid artery Internal carotid artery

Common carotid artery After A. von Ristow, MD

The superficial temporal artery has its major anastomoses with the supratrochlear artery and alternative branches to the supraorbital artery. To further mobilize the upper face for either facelift or brow lift, many surgeons divide the superficial temporal artery. The division of this artery at the upper pole of the anterior aspect of the ear does not appear to cause ill effects provided the anastomosis of the superficial temporal artery to the supratrochlear artery on that same side remains intact.1

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The location of this anastomosis between these two arteries is low within the forehead, and even a hairline forehead incision is extremely unlikely to injure the arterial network as shown in this intraoperative view. The tip of the Ragnell scissors points to the superficial temporal artery in its normal low course where it anastomosis with the supratrochlear artery.

To determine the status of these arteries, digital pressure is applied to the superficial temporal artery over the zygomatic bone to occlude this vessel, thus increasing compensatory blood flow within the supratrochlear artery . A portable Doppler flowmeter placed over the course of the supratrochlear artery (above, left) on the upper lateral side of the nose will, within 3 seconds, double its audible sound, attest- ing to the patency of the anastomosis . The probe (above, right) confi rms the position of the superficial temporal artery. One should always consider the possibility that the previous surgeon may have ligated the supratrochlear or supraorbital arteries. In this case, the frequently performed division of the superficial temporal artery would have a deleterious effect on the viability of the hair follicles. In rare circumstances the arterial anastomosis between the super ficial temporal and supratrochlear systems can provide an important alternative blood supply to the brain by retrograde flow. I know of one patient, a 56-year-old man, kept alive by a single unilateral patent sequence of this particular anastomosis . 2 This patient, a smoker and neurologically asymptomatic , had complete occlusion of the left in- ternal carotid artery by progressive arteriosclerotic disease and 80% stenosis of the right internal carotid artery. Since these obstructions progressed over a period of time, the circulation gradually adapted to these changes in the vasculature.

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Chapter 12 Reoperative Forehead Lift

As demonstrated in this angiogram, the blood supply to the brain was maintained by the anastomosis of the left external carotid artery to the left superficial tempo - ral artery . From there the blood flowed to the left supratrochlear artery and then, by retrograde flow, coursed to the ophthalmic artery to irrigate the brain. The large arrow points to the intracerebrally located carotid siphon . This is not a rare finding in patients with bilateral carotid vascular disease. Of course, division of the super - ficial temporal artery on the left side , which is routinely performed in forehead lifts or facelifts , in this case would have had tragic consequences. The implication is clear: when dissecting the corrugator muscles in the glabellar area, one must use extreme caution to avoid injury to the supratrochlear artery and the supraorbital artery. This dissection is best performed with Potts tenotomy scis - sors by gently divulsing and cutting the fibers of the corrugator muscles , preserv- ing intact all arteries, veins, and nerves. The dissection is not difficult, but it must be performed with care. Passing one limb of a mosquito clamp behind the corrugator muscle and then clamping and dividing the muscle is too dangerous ; the supra- trochlear artery could conceivably be cut. If this occurs and the super ficial tempo - ral artery on the same side has been previously ligated , the blood supply to the sen- sitive follicles is seriously jeopardized and eventual thinning or even loss of the hair is not only possible but very likely . My personal understanding of these anatomic interactions in the last few years has been the single most important factor in allow - ing me to plan strategically sound reoperations for forehead lifts.

BASIC TECHNIQUE FOR PRIMARY FOREHEAD LIFT Because many problems requiring reoperation could be prevented if adequate con - sideration had been given to certain factors in the primary procedure , a brief dis- cussion of the basic forehead lift technique is merited . For example , in the primary operation the surgeon may not have addressed anatomic structures such as the cor- rugator and occipitofrontalis muscles , and consequently the patient has had an early recurrence of the preoperative appearance.

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Incision in galea aponeurotica

Bicoronal incision

Regardless of the type of incision employed, I always leave the cuff of galea on the cephalad incisional edge. This cuff helps to create a solid and level postoperative scar. The flap is elevated sharply using a No. 10 Personna Plus blade, and the dissection is extended just above the zygomatic arch and short of the emergence of the neurovascular bundles. From this region forward, the dissection is performed bluntly with a peanut dissector. It is important to preserve orbital retaining structures so that the eyebrow does not raise to an unnatural level. The corrugator muscles are exposed, as is the upper fourth of the nasal bone. A Ragnell scissors is used to elevate the nasal skin for approximately 1 cm in width through the entire length of the nose.3 This maneuver allows the skin of the upper vault to drape upward, which can often make a short nose appear longer and more elegant. This technique also subtly elevates the tip of the nose.

These preoperative and postoperative profile views demonstrate the subtle but noticeable lift of a ptotic nose that was obtained by simply undermining the dorsum during a forehead lift.

Chapter 12 Reoperative Forehead Lift

The Potts tenotomy scissors is now used to divulse the fibers of the corrugator muscles.Veins, large and small arteries, and nerves are always preserved. The cephalad and caudad stumps of the corrugator muscles are excised. The procerus muscle is generally not altered at all. When division of the procerus muscle is considered to alleviate transverse creases of the skin of the upper one third of the nose, a single division is made low to avoid creating any depression contour deformities. Connell’s method4 of dividing the procerus muscle below the skin creases and undermining it from its subcutaneous tissues is an excellent maneuver as well. The occipitofrontalis muscle also merits careful consideration. Leaving the occipitofrontalis muscle intact has distinct advantages; one must remember that the occipitofrontalis muscle elevates the eyebrows, an important facial expression that communicates friendliness and interest. For this reason significant excision of the occipitofrontalis muscle has properly been abandoned.4 Anatomically the occipitofrontalis muscle is actually two muscles, one on the right and one on the left. They begin their diversion from one another at the glabellar level. The occipitofrontalis muscle is separated from the pericranium by a layer of specialized tissues that allow gliding of the forehead skin over the frontal bone. It is my experience that this tissue is the best donor site for harvest of the insulating and bulk-correcting graft in the glabella.

Two different designs of the gliding tissue graft are used.The first is in the shape of an anvil and provides two limbs to surround each set of neurovascular bundles. With the harvest of the autograft, a shallow, inclined V is created in the remaining occipitofrontalis muscle. During lateral animation this V effectively camouflages the transitional zones between muscle and fascia.

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Galeal graft Limb A Limb B Scalp reflected forward

Galea aponeurotica Right supratrochlear neurovascular bundle

Occipitofrontalis muscle

Right supraorbital neurovascular bundle

Procerus muscle

Orbicularis oculi muscle

The second, which is more common, is shaped like a triangle; once harvested, the graft is notched on two sides to create the limbs necessary to encompass the neurovascular bundles. The advantages of the latter design are that (1) the forehead flap, partially devoid of its gliding tissues, heals at a higher level, thus elevating the eyebrows, and (2) the occipitofrontalis muscle remains intact for animation and expression.

The dynamics of the glabella must be understood. The division of the corrugator muscles (and rarely of the procerus muscle) permits the overlying skin to be elevated and smoothed. Of course, this is one of the main objectives of the operation . However , the same amount of skin now covers a much greater area. Without an au- tograft in place to correct the volume deficit caused by the severance and removal of the corrugator muscles, stretching of the skin over a larger area results in a glabel- lar depression, as evident in this patient. Furthermore, without correction by auto - graft , the small stumps of the corrugator muscles may reattach themselves, causing animation of the overlying forehead skin.5

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Limb A of graft

Stumps of corrugator muscle

Limb B of graft

Galea aponeurotica Occipitofrontalis muscle

Left supraorbital neurovascular bundle

Donor site of galeal graft Galeal graft sutured to pericranium Pericranium Galeal cuff Scalp

Thus the use of an autograft of the naturally gliding tissues in the glabella is logical. On rare occasions this graft may include some occipitofrontalis muscle fibers. The extensions of the graft are passed cephalad and caudad to the neurovascular bundles on the right and left. Sometimes, I place the mid-portion of the graft between the procerus muscle and the overlying subcutaneous tissues. However, with 5-0 Monocryl sutures, the graft is always secured around the neurovascular bundles.

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Key sutures placed and excess scalp removed

Undermined to nasal tip

A 10 Fr smooth, fluted, silicone drain is placed (for example, the Jackson-Pratt Hemaduct REF JP-HUR 100), exiting from either the right or left supraauricular scalp. A tension-determining D’Assumpçao clamp is used in five locations: two on the right, one in the center, and two on the left. The clamp is used to mark the galea below the flap and not on the skin above. (The ink is placed on the dorsum of the clamp’s upper arm as opposed to the underside.) A 3.0 clear Monocryl suture secures the flap galea to the cuff galea. The scalp is then redraped with some redundancy (so minimal hair is removed) and closed with 4.0 Prolene. In this fashion a solid fascia-to-fascia closure is ensured.

PATIENT EVALUATION FOR SECONDARY FOREHEAD LIFT Examination of a patient who may benefit from a secondary brow lift can be simple or complex. The most common complaint of the patient seeking reoperation following brow lift is that the result “did not last and I have all the frown lines back.” If the hairline of such a patient is in an acceptable or even low position, the correct technical execution of a bicoronal forehead lift operation will achieve a very pleasing result. If the hairline is already high and the patient is not a smoker, a subcutaneous forehead lift with the incision at the hairline is indicated.

Chapter 12 Reoperative Forehead Lift

SPECIFIC PROBLEMS SCAR DEPRESSION AND CONTOUR DEFECTS

A common complaint of brow lift patients is depression of the scalp at the previous incision sites. To prevent the creation of a postoperative scar depression, the initial incision should advance through the scalp and subcutaneous fat but not through the galea.6 The caudad flap is then elevated with a double-prong nasal hook and dissected free from the underlying galea. The various vessels that overlie the galea can be coagulated easily because they are clearly visible. Electrocautery injury to the cephalad follicles is unlikely because of the distance of the cautery from the cephalad scalp. Approximately 1.5 cm from the scalp’s cephalad incision, the galea is divided. Essentially the entire cephalad incision is bordered by a galea cuff approximately 1.5 cm in width.The follicles in the caudad flap usually incline forward. Consequently, when trimming the excess strip of scalp, the surgeon must angle the knife so that it is parallel with the orientation of the follicles. As a corollary, the cephalad galea will project and be visible under the scalp incision. At the time of wound closure, the caudad cuff of galea will be established.This refinement prevents depressions of the scar because it ensures a solid, deep double layer of galea healed by a strong, inelastic scar, which supports the scalp above. This strategy avoids the occurrence of wide, depressed, or glabrous areas. With time these scars become inconspicuous. If a patient presents with glabrous areas or the depressed contour of scalp suture lines, the surgeon should determine whether the posterior scalp has retained a measurable gliding ability. If so, a significant mobilization of the scalp will provide a tension-free closure, which is essential to the survival of the hair follicles at the incisional line. If at all possible, the galea should be doubled under the incisional line.

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ROLE

OF

FAT INJECTION

Fat transfers, if properly performed, will survive in their new location. However, maintaining the exact contour or volume is not predictable; therefore I use fat grafts only in locations in which precise long-term volume and contour are not of paramount importance. For optimal survival, fat grafts must be placed between two soft surfaces, not between a soft surface and a bone.

This patient underwent a fat graft to the glabella between the corrugator muscle and the dermis. At 8 months postoperatively, the right side of the graft had absorbed partially, whereas the left side of the graft had survived intact, creating a slight projecting bulge. This problem was resolved by repeated injections of 0.5 mg of triamcinolone (Kenalog) into the graft over a period of weeks.

This patient exhibits the same problem: equal fat grafts of identical origin and volume were placed over the malar bones. Two years postoperatively , the survival of the right malar graft remains complete, whereas the graft on the left only partially sur-

Chapter 12 Reoperative Forehead Lift

vived. If these grafts had been placed in the midface below the zygomatic arch, these differences would not be so apparent. Therefore, because of their unpredictable survival, fat grafts are not indicated in the glabellar region.

UNACCEPTABLE HAIRLINE SCAR Problems with an unacceptable hairline scar are inextricably linked to the brow-lift technique employed and may be very difficult to correct if the defect is significant. Before agreeing to attempt a correction, the surgeon must establish if the motility of both cephalad and caudad flaps will allow a tension-free closure. If tension on closure is inevitable, the key suture that bears the tension must be placed inside the hair—never at the hairline closure. Two techniques can be performed to achieve an optimal hairline scar in the forehead. In the first technique the incision follows the contour of each hair and its corresponding follicle, and the cut is extended through the galea. The surgeon can literally see each hair extend down through the entire depth of the subcutaneous tissue. After closure, the hair shafts will emerge at the incision line or minimally (less than 1 mm) behind it.7 In the second technique, which I prefer, the incision is made at an acute angle with the knife inclined very substantially forward, leaving one, two or three follicles of hair in front of the incision. The caudad flap is trimmed so that it follows the same beveled angle. The result is that one or two follicles remain under the thinnest possible epidermal-dermal cover, and these hairs will emerge at the scar or slightly in front of it. These incisions must be closed without tension and with very fine sutures. My preference is 6.0 clear Monocryl.

A closeup view of an incision at the hairline, as described earlier. Note that scars are virtually invisible.

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RESIDUAL RHYTIDS If the primary brow lift did not address the corrugator muscles, the reappearance of frown lines may occur in only a matter of weeks. A judicious approach to the corrugator muscles is indispensable . The patient ’s wishes for retained expression , which is especially important for individuals in certain professions (for example, trial lawyers, clerics, professors, judges, actors, and actresses), must be taken into consideration . Only the corrugator muscles should be divided or excised . Muscles that surround the corrugator muscles must be preserved , otherwise noticeable lat- eral migration of the medial ends of the eyebrows can occur. The statement,“Doc- tor, I don’t ever want to see those lines again!” by a prospective patient should be countered with an explanation that some muscles must be left in place ; otherwise , the eyebrows will diverge . Here the galea autograft also plays an important role by keeping these structures (for example , neurovascular bundles) at their correct posi- tion postoperatively. Recurrence of occipitofrontalis muscle rhytids must be approached with caution. Of course, there are patients with a massive, hypertrophied occipitofrontalis muscle. My preference in this case is to remove lateral strips of 1 cm of occipitofrontalis muscle across the forehead . For this thinning procedure , meticulous care should be exercised to preserve the ascending neurovascular bundles intact . I do not think the occipitofrontalis muscle should ever be completely excised, only thinned , using a curved scissors . Either Stille 8 scissors or Potts tenotomy scissors accomplish this task effectively.

HAIR LOSS Experienced surgeons are likely to have been consulted by at least one patient who has suffered disastrous hair loss at the incision line from either a forehead lift or facelift. I have examined women who had been operated on elsewhere whose hair anterior to the incision was completely lost on both sides. More frequently a patient complains of the hair having “thinned out” after surgery. These problems are diffi - cult to correct . In my opinion three conditions can be responsible for such a dev- astating and complex complication : (1) surgical dissection too super ficial, with sub- sequent injury to the hair follicles and subdermal vascular plexus, (2) excessive tension, and (3) injury to the main arteries nourishing the flap. If the intricacies of the arterial network are completely understood by the operating surgeon, hair loss from vascular injury will be extremely rare. Hair loss may also be caused by failure of the surgeon to observe the different inclinations of the hair shafts and corresponding follicles and to preserve their integrity. For instance , just above the ear , the hair shafts often sharply incline backward , with the emerg- ing hair posterior to the follicles. Approximately 1 inch above that point, the incli - nation is neutral , but then again , above this area , the inclination is usually forward. Clearly, the recommendation is to make the incision parallel the inclinations of the hair shaft. These hair shaft inclination patterns differ from one patient to the next.

Chapter 12 Reoperative Forehead Lift

The correction of problems of hair loss is complex. Hair transplants offer a possible solution , but if the loss is secondary to impaired blood supply , transplanted hair is subject to the same limitations . For hair loss of undetermined origin ( when the arterial network is known to be intact), minoxidil applied twice a day is suggested and appears to have a positive effect because of its vasodilative action. An additional cause of hair loss is the subcutaneous implantation of testosterone pellets in postmenopausal or oophorectomized women. Insufficient estrogen levels , impaired thyroid function , or increased androgen levels of any kind produce hair loss. Particularly devastating hair loss can occur in women who are receiving a com- bined estrogen-testosterone oral medication to increase the libido level. The char- acteristic of this type of hair loss is that it is generalized and not segmental , as in forehead-lifted flaps.

RECURRENT BROW PTOSIS

OR

ASYMMETRY

The recurrence of brow ptosis is probably the most common indication for brow lift reoperation. In such cases, very likely a conservative first operation was performed in which the muscular problems were not addressed, the gliding tissue was not harvested, and therefore the forehead was not secured at a higher elevation. A reoperation in which these issues are addressed should produce a satisfying result. The practice of direct excision of excess forehead skin is controversial at best. I have seen a number of patients dissatisfied with the resulting scar. If such an attempt is made , the excision should be subcutaneous . The surgeon must also consider that the resulting elevation of the brow may not be uniform between the medial and lateral portions of the eyebrow . Theoretically , elevation of the eyebrow , lowering of the hairline, and avoidance of muscle surgery are all advantages of a “direct excision.” The resulting scars can be very disappointing , however , even with the finest closure performed. Specialized publications refer to various formulaic operative procedures that will supposedly secure the eyebrow at a certain elevation postoperatively. I have not used such methods mainly because I believe that multiple unpredictable variables (for example , tissue strength , age , damage from sun ) invalidate these approaches . The general rules for me are to (1) dissect to the orbital rims—no more, no less, (2) use tension - determining clamps (that is, a D’Assumpçao clamp )9 judiciously at the time of clo- sure, and (3) preserve the natural brow-retaining structures to avoid undo elevation. In my opinion, few errors produce as unnatural a look as an overly elevated brow. In terms of brow asymmetry, the patient and the surgeon must remember that asymmetry of the face is not only common but usually present in even the most at- tractive people . A patient whose foremost desire is symmetry should be examined guardedly as perfect symmetry is an unattainable goal . A large degree of asymme - try can be ameliorated by freeing the superior periorbital attachment of the lower eyebrow, but not of the higher eyebrow. The patient must be advised before the op- eration that exact symmetry is impossible to obtain because of variations in tissue.

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PARALYZED FOREHEAD FROM FRONTAL BRANCH INJURY The frontal branch of the seventh cranial nerve is well protected from injury. The nerve is deeply located in the face, emerging from under the parotid gland approximately 0.5 cm in front of the tragus. It ascends deep, crosses the zygomatic bone, literally hugging its arch, and advances deep to the occipitofrontalis muscle between the muscle and its deep fascia. It courses quite anterior to the superficial temporal artery, a fact that is of major importance. With the advent of more extensive procedures, such as dissecting to the zygomatic arch, the potential for injury of the frontal branch of the seventh cranial nerve has become a true possibility. I decided to examine this risk by localizing the nerve on the underside of the flap. On the skin a line was traced starting 0.5 cm in front of the lower aspect of the tragus and superiorly passing 2 cm from the lateral aspect of the eyebrow. With a C-Line Vary-Stim RIII nerve stimulator set at 1⁄ 2 mA, I then probed for this nerve and found the following: 1. The position of the nerve in 20 patients was, for practical purposes, constant and very closely reflected the line marked on the skin. 2. The nerve was mostly single! Probing with the stimulator both cephalad and caudad of the nerve did not elicit further movement of the muscles. 3. The nerve is visible on the underside of the flap as a small, thin, 0.5 mm filament. Its accompanying vessel is also frequently visible. The conclusion is that injury to the frontal branch during forehead lifts is quite possible if precise plane dissection is not followed. With the Daniel forehead elevator I dissect until the I feel the resistance of the attachments of the fascia to the zygomatic arch. Further elevation at the cost of entering the area of the superficial temporal fat pad appears to produce negligible gain and perhaps causes potential loss of this important volumetric anatomic structure.

Superficial temporal artery Zygomatic branches

Frontal (temporal) branch

Injury to the frontal branch is more common during facelifts if deviation from safe planes of dissection occurs. The study of Terzis’ remarkable dissections of the facial nerve is recommended and should orient the surgeon properly.

Buccal branches

Marginal mandibular branch

Chapter 12 Reoperative Forehead Lift

If such paralysis were to occur, however, static support by selective lifting of the skin on the paralyzed side offers the only possibility of improvement. A useful technique in this situation is the segmental subcutaneous lift. In this procedure a hairline incision is made and the dissection is advanced subcutaneously for the necessary distance to effect correction. Dissection does not have to extend to the eyebrow; 2 to 4 cm of dissection may be sufficient to elevate the ptotic eyebrow. The tensiondemarcating D’Assumpçao clamp or one of its variations should be used to judge proper closure.

ELEVATED HAIRLINE Another problem frequently encountered in reoperative forehead surgery concerns the height of the existing hairline. If a secondary coronal incision will leave the hairline at an acceptable elevation (a rare occurrence), one can simply repeat the original incision at the coronal level. Or, if the initial incision was at the hairline, the same approach can simply be repeated.

This intraoperative view shows that a substantial amount of skin can be removed in a patient with a high forehead . The hairline will descend as a result of the gliding ability of the scalp. Thus the forehead height can be greatly reduced. Regrettably, most patients in whom a coronal approach was used the first time, re - sulting in an elevated hairline , desire a brow lift that produces no further elevation of the hairline. The approach for the second procedure must therefore be at the hairline . In my opinion , the dissection of the forehead must then be subcutaneous. The blood supply to the scalp anterior to a coronal incision must come from the supratrochlear , supraorbital , and superficial temporal arteries . A subgaleal hairline approach would divide the cephalad follicles between the old and new incisions from their only blood supply . Although a subgaleal hairline incision (after a previous bicoronal had been performed ) was done a number of times without untoward ef- fects,10 I am concerned about the blood supply to the hair follicles . Hair transplants have gotten excellent results currently and could always be considered. Further, un- dermining of the cephalad scalp and scoring the galea to allow the lowering of the hairline 11 is impossible because the gliding ability of the galea is usually lost.

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SUBCUTANEOUS FOREHEAD LIFT RATIONALE FOR USE AS REOPERATIVE PROCEDURE Subcutaneous forehead lifts appeal to me for the following reasons: 1. The sensory nerves are not divided. 2. The multiple attachments of the occipitofrontalis muscle to the overlying skin are divided, therefore effectively diminishing, if not eliminating, most of the creases. 3. The arterial network remains intact. 4. The corrugator muscle attachments to the overlying skin are effectively interrupted, thereby eliminating the need for total excisions, divisions, or partial excisions of the corrugator muscles. I have observed that results of subcutaneous forehead lifts are long-lasting and that the mild reattachment of the occipitofrontalis and corrugator muscles to the overlying skin does not cause objectionable deep creases. The lines that do reappear are mild and faint and give the forehead a serene, normal appearance. The main contraindication to subcutaneous forehead lifts in my experience is smoking. On occasion, I have operated on smokers, as always using my gentlest technique. One patient lost the few very important temporal hairs I leave in front of the temporal aspect of the incision. Although after 4 months the hair returned, it was not of the same quality. Twice daily application of minoxidil is of value in these instances.12 The second patient had two areas of skin compromise that healed uneventfully but small scars remained. Therefore I avoid performing subcutaneous forehead lifts on smokers, believing the risk to be excessive. Some of the ill effects of smoking can be countered by the use of 100% oxygen and isoflurane intraoperatively in a closed anesthesia system and the supplemental use of oxygen postoperatively for the first night. The mechanism of displacement of carbon monoxide from the hemoglobin molecule is purely by competition between the molecules of oxygen and carbon monoxide. All of our facial rejuvenation patients who smoke receive this extra treatment13 (see Chapter 10).

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TECHNIQUE

In the forehead the occipitofrontalis muscle is in intimate contact with the overlying skin; there is no subcutaneous fat or tissue. In this respect the orbicularis oris and the orbicularis oculi muscles are identical in their relation to the overlying skin.

To effect the delicate dissection between the dermis and occipitofrontalis muscle, I suggest that a larger amount of anesthetic solution with diluted epinephrine be placed at the skin/muscle interface.

The incision is placed just within the hair follicles with a No. 15 Personna Plus blade angled anteriorly independent of the hair shaft inclination. The objective is to leave some viable hair follicles just below the thin caudad flap. These few hairs will thus emerge through the scar.

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Since hair growth continues during the immediate postoperative period, these hairs will make their emergence quite early through the incision line. In blonde patients the scar is even less visible.

Even in brunettes, in whom the hair color contrasts with the light-colored scar, the incision line is difficult to detect.

As dissection proceeds caudally, the skin becomes progressively thicker. Indeed, at the glabellar region the skin is almost 0.5 cm thick.14 Hemostasis is delicately ob- tained using a fine-pointed titanium jewelers’ forceps. All efforts are made to min- imize the handling of the flap.

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Chapter 12 Reoperative Forehead Lift

When the flap is redraped, two key sutures are placed, one on the right and one on the left, each approximately 2 inches from the midline. To ensure that the flap is correctly positioned at the midline , a temporary suture is placed in the center of the flap and tied to the center of the scalp. However, the central flap overlies the cen- ter scalp at this point; the ultimate adjustment of the hairline will be done only once the lateral fixed points (left and right ) have been secured with the proper ten- sion. Only then is the excess caudad central flap tissue trimmed, and even then it must overlap the cephalad flap by 2 mm. A thin Jackson-Pratt drain is used transversely under the flap, exiting eccentrically in the scalp.

POSTOPERATIVE CARE Before the patient awakens in the operating room, a sterile water shampoo is performed, and all incisions are subsequently covered with a layer of bacitracin ointment.The same care to keep sutures free of blood and covered with antibiotic ointment is continued in the recovery room. Patients are allowed to shampoo their hair the day following surgery. They are instructed to continue to apply bacitracin oint - ment over the suture lines for the ensuing 5 days if possible. The application of topical antibiotics exerts a positive influence on scar lines, keeping them moist and free of bacteria.

CAVEATS FOR REOPERATIVE FOREHEAD LIFTS The following principles must be respected and adhered to in reoperative forehead lifts:  Know the arterial status of the patient.  Do not execute “new ” incisions that would leave segments of hair bearing scalp devoid of blood supply in a patient who had a previous coronal incision (for example , a coronal incision more inferior than the previous coronal in- cision, a full-depth hairline incision).  Study the position and the course of the frontal branch of the seventh cranial nerve carefully . Rely on true anatomic dissections to appreciate its variances rather than on conceptualized drawings found in textbooks.  Master the feel of tension on flaps. Tension-demarcating clamps are treacherous to the inexperienced ! However , they are the best tool in the hands of those who have mastered their nuances.  Be gentle with all dissections. Release and reapply all sutures that seem too tight.  Be conscious of and respect hair follicle inclination.  Do not use interlocking, deeply encompassing sutures. They close off the blood supply to the healing edges. The wound may heal, but the hair will be lost.  Do not “compress” scalp on closure in an effort to save hair follicles. This is as big a reason for hair loss as is tension.

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UNSOLVED PROBLEMS Overly resected corrugator muscles, resection of the procerus muscle, overly elevated eyebrows giving a startled look, hairline severely displaced upward, and widened scars because of excessive tension on closure sadly remain unsolved problems. Skillful tattooing with skin-colored pigment offers some help in disguising visible scars.

References —With Key Annotated References 1. Ristow B. Forehead lifts. In Cohen M, ed. Mastery of Surgery—Plastic and Reconstructive Surgery. Boston: Little Brown, 1992. A classic text presenting surgical techniques practiced and perfected by the most respected plastic surgeons in the field. 2. von Ristow A, Bonamigo T, Buriham E, et al. Doencas da Aorta e Seus Ramos: Diagnostico e Tratamento. Sao Paulo: Grafica e Editorial, 1991. 3. Pitanguy I. Aesthetic Plastic Surgery of Head and Body. Berlin: Springer-Verlag, 1981. 4. Connell BE. The forehead lift: Techniques to avoid complications and produce optimal results. Aesthetic Plast Surg 13:217-237, 1989. This discussion of forehead lifting, based on modifications of Vinas, Caviglia, and Cortinas, shares the authors’ methods of patient evaluation, diagnostic details, architectural planning, and surgical concepts for forehead rhytidectomy along with correction of malpositioned and ptotic eyebrows as well as glabellar frown problems. 5. Ristow B.The forehead and the eyebrows. In Vistnes LM, ed. Procedures in Plastic and Reconstructive Surgery—How They Do It. Boston: Little Brown, 1991. 6. Ristow B. Aesthetic plastic surgery of the upper face. In Braverman MH, ed. Surgical Technology International. London: Century Press, 1991. 7. Connell BE. Personal communication, 1990. 8. Stille-Ristow Facelift Scissor Article No. 101-8454-1. 9. D’Assumpçao EA. A new instrument for rhytidoplasty. Br J Plast Surg 23:301, 1970. 10. Connell BF. Personal communications, 1992 and 2005. 11. Marten TJ. Hairline lowering foreheadplasty. Plast Reconstr Surg 103:224-236, 1999. Scientific article on technique for lowering hairline during forehead lift procedure. 12. Hoefflin SM. Instructional course for the American Society for Aesthetic Plastic Surgery, Los Angeles, April 1992. 13. Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 8th ed. New York: Pergamon Press, 1990. 14. Papillon J. Closed circuit surgical demonstration. ISS-Face Congress, Marseille, May 1990.

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REVIEW QUESTIONS 1. In open foreheadplasty, it is important to: a. Close the galea layer tightly so that the follicles have plenty of blood supply b. Close the galea on key points only, sometimes just two sutures c. Preserve hair, compress the hair tightly on the closure d. Not close the galea at all, just the scalp 2. In open foreheadplasty: a. Corrugators can be removed without later postoperative lateral migration of eyebrows b. The ablation of corrugators never leaves any postoperative depressions c. It’s a good idea to place a galeal graft between the neurovascular bundles (to prevent depressions and migrations) d. None of the above 3. Subcutaneous forehead lifts are appealing because: a. No major sensory nerves are divided b. Muscular connections to overlying skin (creases) are divided c. The arterial network essentially remains intact d. All of the above e. a and c only 4. A careful surgical technique was employed but a frontal branch is injured. The best is: a. Be confident that it could not have been cut b. Do nothing; movement of the affected side almost always recuperates completely c. May use some Botox on the normal side d. All of the above e. None of the above 5. The position of the superficial temporal artery in relation to the frontal branch is: a. Always posterior to the branch b. Always anterior to the branch c. Varies considerably from patient to patient d. Right above the frontal branch e. Immediately below the frontal branch 6. In incising the scalp, leaving a cuff of galea will: a. Make it easy to stop bleeding because you see the vessels b. Make it less likely to thermically injure follicles c. Provide a “cuff over pants,” fascia over fascia healing d. Effectively avoid scalp depressions e. All of the above

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Chapter 13 Use of Endoscopy in Reoperative Brow-Lifting Jorge I. de la Torre and Luis O.Vásconez

In the forehead and the eye, the lecture of the mind doth lie. French proverb

Reoperative Problems Elevated hairline Persistent transverse wrinkles Asymmetry

Recurrent brow ptosis Alopecia Depressed scar

T

he current era of forehead rejuvenation has seen the evolution of technical ap - proaches from traditional coronal brow lifts (see Chapter 12) to endoscopic tech- niques.1 Although the coronal (open) technique is effective in elevating the brow, it can result in visible scars, retrodisplacement of the hairline, and alopecia.2 The en- doscopic forehead lift helps to prevent lengthy scars, alopecia, posterior displace - ment of the hairline , and postoperative paresthesia of the forehead . In addition , the length of the procedure and time required for recovery are both shorter .3,4 Advan - tages of the endoscopic approach to reoperative forehead surgery include provid - ing a safe approach to secondary rejuvenation of the forehead , and improving the stigmata of prior traditional coronal brow lift procedures.5

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ANATOMIC CONSIDERATIONS The anatomic layers of the scalp are of particular importance in the endoscopic approach to reoperative forehead surgery. These layers include the skin, subcutaneous tissue, galea, loose areolar tissue, and pericranium. In the frontal area, the galea envelops the frontalis muscle, forming the superficial and deep galea planes. The superficial galea also overlies the procerus and orbicularis oculi muscles. The superficial and deep galea layers fuse with the periosteum inferiorly, approximately 1 cm above the supraorbital rim.6 In the temporal region, the superficial temporal fascia is continuous with the galea aponeurotica, frontalis, and the superficial musculoaponeurotic system (SMAS).7 The periosteum continues as temporal fascia, which divides into superficial and deep layers above the level of supraorbital rim.8 The superficial temporal fat pad is separated from the buccal fat pad by the deep layer of the temporal fascia.9 The deep temporal fat pad is the extension of the buccal fat pad that lies beneath and traverses the zygomatic arch.10 The superficial layer of temporal fascia ends at the zygomatic arch periosteum, whereas the deep layer blends with the parotidomasseteric fascia. The superficial temporal, occipital, and supratrochlear vessels form a network superficial to the galea, and send branches to the deeper layers where they anastomose with the branches of the middle meningeal artery.11,12

The facial nerve and its branches, including the frontotemporal branch, run deep to the SMAS. This branch runs obliquely under the superficial temporal fascia be - tween the tragus and the lateral canthus , 3 to 5 cm from the lateral orbital margin , as shown above .13,14 This nerve is separated from the arch by the deep layer of the deep temporal fascia and can easily be injured during dissection ; care must be taken when releasing the lateral aspect of the periosteum to avoid injury to the frontalis branch. The supratrochlear nerve is 1.7 cm lateral to midline and the supraorbital nerve is 2.7 cm lateral to midline . These nerves provide the sensory innervation of

Chapter 13 Use of Endoscopy in Reoperative Brow-Lifting

the forehead and the scalp region up to the vertex. Ramirez and Robertson15 noted accessory branches of the supraorbital nerve in 10% of cases.

Originating from the galea, the frontalis muscle (green arrow) inserts into the brow skin. This muscle has multiple attachments to the skin; its contraction causes transverse forehead creases. The procerus (yellow arrow) lies in the midline, within the same surgical plane as the frontalis muscle . This muscle originates from the junction of the nasal bones and the upper lateral cartilages , and inserts into the skin. Lateral to the procerus is the corrugator supercilii (blue arrow). This muscle originates from the medial end of the orbit , enters the galea fat pad , runs superiorly and laterally along the deep galea plane, and then inserts into the skin of the supraorbital region above the middle third of the eyebrow.16 The depressor supercilii muscle originates from the superomedial orbital rim , overlying the origin of the corrugator, and in- serts into the dermis of the medial eyebrow. The orbicularis oculi muscle (red arrow ) encircles the eye . The medial head of the orbital portion of this muscle originates from the medial canthus. The orbicularis oculi, corrugator, depressor supercilii, and procerus muscles are de - pressors . The medial head of the orbital orbicularis oculi originates from the me- dial canthus and pulls the medial eyebrow downward, creating vertical frown lines . The transverse head of the corrugator produces vertical frown lines and contributes to oblique lines , whereas the oblique head of the corrugator , depressor supercilii , and medial head of the orbital portion of the orbicularis oculi muscle depress the medial eyebrow and contribute to glabellar oblique lines .

SURGICAL TECHNIQUE Whether it is performed as a primary or reoperative procedure , successful forehead elevation depends on three basic principles. First, there must be adequate release of the periosteum at the supraorbital rim. Second, ablation of the depressor muscles of the brow must be performed . Last , the suspension technique used should be effec- tive, but simple and safe.17

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STANDARD ENDOSCOPIC TECHNIQUE

Subperiosteal undermining is performed between the hairline and supraorbital rims using three small prehairline incisions. Elevation is extended laterally in both directions to the transition zone between the frontal periosteum and the deep temporal fascia. No undermining is performed posterior to the hairline. The endoscopic approach allows adequate visualization within the optical cavity as a result of elevation in the subperiosteal plane. The blunt dissector can be used to free the inferior aspect of the periosteum.

Using a 30-degree wide-angled endoscope for visualization, the periosteum is released at the level of the supraorbital rims, from lateral to the supraorbital nerves to the level of the lateral orbital rim. Release of the lateral periosteum can be performed easily using an endoscopic carpal tunnel scalpel. The right-angle blade allows controlled release to avoid injury to the frontal branch of the facial nerve.

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An endoscopic biopsy forceps can then be used to resect the corrugator and procerus muscles between the supraorbital nerves.

Postoperative forehead suspension is maintained using temporary suture suspension. A staple is placed in each of the closed incision sites and a second staple is placed approximately 5 cm posterior to the hairline over each incision. A 3-0 nylon suture is threaded between each pair of staples and is used to apply tension. The sutures are left in place for 3 to 5 days and then the suture and staples are removed.

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BIPLANAR TECHNIQUE

The biplanar technique uses a limited prehairline incision and subcutaneous undermining of 2 to 4 cm. A beveled incision is placed within the hairline at the border of the denser hair between both temporal regions (left). A hemostat is spread bluntly in the subcutaneous plane for 3 to 4 cm anterior to the hairline incision, leaving the frontalis muscle intact. Three small incisions are made in the frontalis muscle to permit elevation within the subperiosteal plane (right).

After resection of the depressors, the three access ports are closed (left) and the frontalis muscle is plicated at 1 to 1.5 cm intervals (right). The frontalis plication results in extra skin at the hairline that can be resected, allowing the forehead flap to be closed without any tension. No drains or suspension is required with this technique.

Chapter 13 Use of Endoscopy in Reoperative Brow-Lifting

SUBPERIOSTEAL DISSECTION The subperiosteal plane elevation offers safe and reproducible mobilization of the forehead in the patient who has previously undergone either a coronal approach or an endoscopic forehead lift. This technique preserves a robust blood supply to the forehead, regardless of the prior plane of dissection. Plane elevation is straightforward and the reflective properties of the bone periosteum increase the light to enhance visualization with the endoscope.18 Direct visualization of the nerves helps to preserve sensory innervation of the forehead and maximize access to the inferior depressor muscles. For these reasons, subperiosteal dissection is safer than dissection along the subgaleal plane. Once the frontal periosteum is released and the brow depressor muscles are ablated, the elevated forehead should be maintained in position until the periosteum adheres to the frontal bone. The time frame for this process varies in the literature from a few days to several weeks, depending on the author.The objective of the fixation technique is to hold the eyebrow in position, but not pull or distract it. In patients who have had a previous coronal incision, we have not observed a compromise to the scalp between the hairline and the more posterior coronal incision.

ANATOMIC RATIONALE After operative correction, recurrent signs of aging can appear in the forehead. Wrinkles return and the brow drops, giving the patient a tired and/or angry appearance. In addition, prior operative management may result in undesirable sequelae. Secondary correction has three primary objectives: (1) improvement of the vertical and transverse wrinkles, (2) reelevation of the eyebrows, and (3) reduction of signs of prior surgery. The risk of complications is not increased when the endoscopic technique is used as a secondary procedure.

WRINKLES The forehead exhibits horizontal wrinkles as well as vertical wrinkles at the glabellar region, and a transverse crease at the root of the nose. The mimetic muscle activity of the upper face results in two types of facial wrinkles—static and dynamic— that may recur after a coronal brow lift. The flat muscles of the face have no enveloping fascia and can contract portions of the dermis, giving rise to the expressive quality of mimetic musculature. This muscle contraction results in dynamic wrinkles that are no longer present when the muscles relax. With age, progressive loss of elasticity in the dermis and repeated mimetic activity result in permanent alterations or creases in the dermis, the static wrinkles.

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The coronal incision approach involves lifting the forehead skin, thus tightening the dermis and ablating the static wrinkles. Elevation of the entire forehead counters the action of the depressor muscle group and reduces dynamic wrinkles. However, this technique does not offer a lasting result because, with time, laxity in the forehead skin and gravity permit the forehead to become ptotic again. The imbalance in function between the frontalis and depressor muscles recurs, thus both the dynamic and static wrinkles return. Similarly, in patients with upper lid ptosis correction surgery will not only improve the periorbital appearance but will decrease the activity of the frontalis muscle, reducing transverse forehead wrinkling. Ablation of the brow depressor muscles should be an integral part of the reoperative endoscopic forehead lift. Resection of the depressor muscles needs to be conservative enough to avoid a noticeable depression; however, ablation of the muscle mass between the supratrochlear and supraorbital nerves can be more aggressive. This maneuver improves the wrinkles in the glabellar area, and elevates and separates the medial brow, which is particularly important for older patients who often present with inferomedial drooping of the medial brows.

This 74-year-old patient underwent a coronal brow lift 10 years before undergoing an endoscopic forehead lift with midface elevation. The patient is shown 8 months postoperatively.

Chapter 13 Use of Endoscopy in Reoperative Brow-Lifting

Ablating the corrugator muscle is also important because it eliminates the force that counteracts the frontalis muscle over the lateral eyebrow.The resting tension of the frontalis muscle allows elevation of the lateral brow. Despite aggressive ablation of the muscles between the supratrochlear and supraorbital nerves, animation is preserved to ensure a rejuvenated yet natural appearance.19 This 66-year-old woman underwent a coronal brow lift and face lift 7 years before undergoing an endoscopic forehead lift, midface lift, platysmal plication, and nasoplasty. She is shown before and 10 months after surgery.

BROW PTOSIS Although ablation of the muscles is important in correcting dynamic forehead rhytids, forehead elevation addresses static rhytids and brow ptosis. The skin of the inferior half of the forehead is more mobile than that of the superior half. This change in forehead skin mobility is a manifestation of the transition of the deep galea plane from a single-layered to a multilayered plane. When the supraorbital skin is mobilized superiorly, it slides together with its frontalis muscle over the most superficial layers of the deep galea plane. The movement of the skin over the upper forehead is limited because there is tight adherence between the one-layered deep galea plane deep to the frontalis muscle and the periosteum. Therefore at the deep galea transition zone, the inferior, more mobile forehead skin moves in a cranial direction against the upper forehead skin, which is quite adherent to the periosteum. On the surface, this movement can manifest as transverse skin creases, particularly in the cephalad part of the forehead.20

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The frontalis muscle is tethered to the frontal bone over a 2 cm supraorbital band. The deep galea plane of the upper forehead transitions into the firmly fixed deep galea plane of the lower forehead. Because it is tethered, the mobile lower frontalis muscle requires a higher resting tone to produce animated eyebrow elevation. Multiple fibrous septa connecting the frontalis muscle to the dermis results in transverse creases on the forehead skin.Transecting the periosteum and deep galea of the lower forehead frees the frontalis muscle, allowing enhanced brow elevation with a lower resting tone, thus reducing dynamic rhytids. A concomitant ablation of the eyebrow depressor muscles will further reduce the counteracting forces to the frontalis muscle. Effectively restoring the balance between the depressor and elevator muscles will, however, provide physiologic suspension of the brow. This suspension is the result of the resting tone of the frontalis muscle.

HAIRLINE Overelevation using the coronal brow approach can result in posterior displacement of the hairline, thus creating a very long forehead.The use of the standard endoscopic technique will allow correction of recurrent ptosis without exacerbating the high hairline, but it will not offer significant correction of the problem. However, using the biplanar forehead lift will allow the excess forehead height to be decreased. In addition, this technique can provide significant improvement for patients with extremely deep recurrent or residual transverse forehead wrinkles. Freeing the forehead skin over the upper half severs the fibrous septa between the muscle and the dermis, reducing the transverse creases.

This technique requires making a prehairline incision that results in acceptable results for many patients. In addition, plication of the frontalis muscle allows the skin to be redraped and inset without tension, which improves the scar quality, partic - ularly in patients older than 55 years of age. This 64-year-old patient underwent a previous brow elevation and a subsequent endoscopic -assisted biplanar brow lift. Preoperative , postoperative , and long-term follow-up photos are shown. The post- operative photo was taken at 6 months, and the long-term photo was taken more than 1 year after the endoscopic forehead lift was performed.

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BROW ASYMMETRY AND IRREGULARITY A great deal of attention is focused on accurate repositioning and reshaping of the eyebrows, particularly when prior surgery results in asymmetry of the eyebrow location. Mild to moderate cases of asymmetry can be treated using the endoscopic approach. The biplanar technique allows greater control to correction of asymmetry. Plicating the frontalis muscle allows a more accurate correction of the position, shape, and asymmetry of the eyebrows’ shape and location.

This patient underwent an endoscopic brow lift and face lift 8 years before presentation. A secondary endoscopic forehead lift and midface elevation were performed . She is shown 7 months postoperatively. Irregularity of the brow and glabellar region usually results from inconsistent or overaggressive resection of the muscles. Improvement can be achieved with careful and conservative resection. Overresection requires filling the soft tissue defect. This can be performed using various materials. If an SMAS resection and facelift are performed concomitantly , the resected SMAS can be contoured and inserted through the endoscopy port and positioned with a through-and-through suture of fast-absorbing plain gut.

ALOPECIA Alopecia is rare when prehairline incisions and the staple fixation technique are used. Screws that are removed require scarring at the time of both placement and removal. Absorbable screws often result in sterile abscess formation and drainage. Avoiding the use of screw fixation and the need to undermine the posterior scalp will also reduce alopecia. In rare cases, however, the micrograft technique can be used for hair transplantation. If desired, this technique can be performed either at the time of the reoperative endoscopic procedure or later.

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CONCLUSION As the use of endoscopy has expanded, so have the number of technical variations. However, the key elements to successful forehead rejuvenation for all variations include (1) adequate release of the periosteum, (2) ablation of the depressor muscles of the brow, and (3) a simple and reliable suspension technique. The endoscopic forehead lift consistently attenuates transverse forehead wrinkles, reduces the glabellar frown lines, and raises the eyebrows in patients who have had prior aesthetic surgery of the brow, either endoscopically or by a coronal approach. In addition, this technique creates a more open and pleasing expression to the eyes so that the patient looks less tired or angry, avoiding a surprised appearance. Understanding the limitations of standard minimal-access endoscopy is as essential as executing it properly. The use of the biplanar approach expands the indications for endoscopy of the forehead and, with proper patient selection, can yield improved results. This approach is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. Long-term follow-up demonstrates that using endoscopy for reoperative rejuvenation of the upper third of the face yields lasting and predictable results.21

References —With Key Annotated References 1. Vásconez LO, Core GB, Gamboa-Bobadilla M, et al. Endoscopic techniques in coronal brow lifting. Plast Reconstr Surg 94:788-793, 1994. This is one of the seminal descriptions of endoscopy for forehead rejuvenation. Using fresh cadaver heads to demonstrate the feasibility of endoscopic techniques and the clinical experience in 32 patients , the endoscopic approach was established as an effective technique. 2. Gonzáles-Ulloa M. Facial wrinkles-integral elimination. Plast Reconstr Surg 29:659, 1962. 3. Vásconez LO, Core GB, Gamboa-Bobadilla M, et al. Endoscopic techniques in coronal brow lifting. Plast Reconstr Surg 94:788, 1994. 4. Guyuron B. Endoscopic forehead rejuvenation. I. Limitations, flaws, and rewards. Plast Recon - str Surg 117:1121-1133; discussion 1134-1136, 2006. The purpose of this article is to discuss the common features and reasons for suboptimal endoscopic forehead rejuvenation outcomes , and how to avoidance these flaws based on the author ’s experience with 372 procedures. 5. de la Torre JI, Paulsen SM, Decordier B, et al. Ann Plast Surg 54:251-255, 2005. The secondary endoscopic forehead lift is effective in rejuvenating the upper face in the patient who has had a previous coronal forehead lift. It elevates the eyebrows and reduces both transverse and vertical wrinkle, avoiding further displacement of the hairline. It is reliable and safe in this patient pop - ulation. 6. Knize D. Reassessment of the coronal incision and subgaleal dissection for foreheadplasty. Plast Reconstr Surg 102:478-489, 1998. 7. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 58:80-88, 1976. 8. Heinrichs HL, Kaidi A. Subperiosteal face lift: A 200-case, 4-year review. Plast Reconstr Surg 102:843-855, 1998. 9. Guyuron B, Michelow BJ. Refinements in endoscopic forehead rejuvenation. Plast Reconstr Surg 100:154, 1997.

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10. Stuzin JM, Wagstrom L, Kawamato H, Wolfe SA. Anatomy of the frontal branch of the facial nerve: The significance of the temporal fat pad. Plast Reconstr Surg 83:265-271, 1989. 11. Cutting CB, McCarthy JG, Berenstein A. Blood supply of the upper craniofacial skeleton: The search for composite calvarial bone flaps. Plast Reconstr Surg 74:603-610, 1984. 12. Casanova R, Cavalcante D, Grotting JC,Vásconez LO, Psillakis JM. Anatomic basis for vascularized outer-table calvarial bone flaps. Plast Reconstr Surg 78:300-308, 1986. 13. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: The importance of its variations in face lifting. Plast Reconstr Surg 38:352-356, 1966. 14. Ishikawa Y. An anatomical study on the distribution of the temporal branch of the facial nerve. J Craniomaxillofac Surg 18:287-292, 1990. 15. Ramirez OM, Robertson KM. Update in endoscopic rejuvenation. Facial Plast Surg Clin North Am 10:37-51, 2002. 16. Knize D. Muscles that act on glabellar skin: A closer look. Plast Reconstr Surg 105: 350-361, 2000. 17. De Cordier B, de la Torre JI, Al-Hakeem MS, et al. Endoscopic forehead lift: Review of technique, cases, and complications. Plast Reconstr Surg 110:1558-1568, 2002. A large clinical experience demonstrates the significant improvement in the surgical rejuvenation of the upper face using the endoscopic forehead lift.To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. 19. Hamas RS. Endoscopic management of glabellar frown lines. Clin Plast Surg 22:675, 1995. 20. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg 98:1148, 1996. 21. Behmand RA, Guyuron B. Endoscopic forehead rejuvenation. II. Long-term results. Plast Reconstr Surg 117:1137-1143, 2006. This study objectively demonstrates the long-term efficacy of the endoscopic forehead lift. Preoperative and postoperative photographs of 100 patients who underwent endoscopic forehead rejuvenation were evaluated with a mean follow-up of 44 months. Brow position relative to the orbital rim, brow arch form, vertical frown lines, and horizontal frown lines of the forehead were analyzed, with stable results many years after surgery.

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REVIEW QUESTIONS 1. The temporal branch of the facial nerve found between which anatomic layers? a. Galea and periosteum b. Temporalis muscle and superficial layer of the deep temporal fascia c. Temporalis muscle and deep layer of the deep temporal fascia d. Temporoparietal fascia and superficial layer of the deep temporal fascia e. Temporoparietal fascia and subcutaneous tissue 2. Which of the following are considered adequate methods of postoperative fixation after endoscopic forehead lift? a. Suture suspension from absorbable screws b. Suture suspension to deep soft tissue or fascia c. Temporary external fixation d. No fixation e. All of the above 3. Advantages of the subperiosteal dissection do not include: a. Safety b. Creation of optical cavity c. Preservation of the forehead blood supply d. Avoidance of the supratrochlear and supraorbital nerves e. All of the above 4. Which of the following is considered to be a disadvantage of the endoscopic brow lift approach versus the coronal (open) approach? a. Decreased operative length b. Decreased scalp paresthesia c. Need for special equipment d. Decreased incision length e. Increased patient acceptance of procedure 5. Indications for secondary forehead lift do not include: a. Persistent wrinkles b. Recurrent brow ptosis c. Brow asymmetry d. Upper lid ptosis e. Patient’s desire for further aesthetic improvement

Chapter 14 Adjunctive Surgical Procedures to Improve the Face-Lift Result G. Mabel Gamboa-Bobadilla, Omer Refik Ozerdem, and Luis O.Vásconez

We are built to solve problems, to achieve goals, and we find no real satisfaction or happiness in life without obstacles to conquer and goals to achieve. Maxwell Maltz

Reoperative Problems Thinning lips “Sad pleats” deformity Malar fat pad descent

Ptotic chin Aging nose Prominent ears

P

Earlobe deformities Prominent brow furrows

rimary face-lift procedures seek to correct the major signs of aging exhibited in the face and neck. Most approaches provide a rested, more youthful appearance by smoothing facial wrinkles, excising and tightening the skin, removing excess fat and skin, and lifting or restoring key anatomic landmarks . Face-lift patients com- monly request correction of facial wrinkling, double chin, jowls, drooping eyelids and eyebrows , and horizontal forehead and vertical glabellar wrinkles.1 In addition to these obvious common complaints , there are other defects associated with aging that often are not addressed during the primary face lift , such as thinning of the up347

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per lip and mouth, ptotic chin, prominent labiomental folds, thickening of the nasal tip, a hanging columella, and earlobe deformities. Over the years we have found that minor surgical corrections of such problems improve the overall primary result. More recently we have begun to incorporate these refinements or finishing touches as a part of the primary face-lift procedure to having to address these problems secondarily and enhance patient satisfaction.

THINNING AND ELONGATION OF THE UPPER LIP A harmonious facial appearance is determined by a balanced relationship among all the facial features. Thinning of the lips and formation of perioral wrinkles are part of the normal degenerative process; the upper lip lengthens with age, becoming flat and curtainlike as a result of the loss of delineation of the philtral columns and vermilion pout.These signs of aging are often unacceptable to the patient who desires a more youthful appearance.2-5 When analyzing the aging mouth, the aesthetic surgeon encounters three types of abnormalities that are amenable to surgical correction: (1) elongation of the upper lip, resulting in loss of symmetry and convexity, (2) thinning of the vermilion, with loss of shape and commissural drooping, and (3) formation of radial lines from the vermilion extending onto the upper and lower lips. These lines are the result of constant stress imposed on the perioral dermis by continuous intrinsic muscular activity, and they become more pronounced once skin elasticity has been lost. Two major techniques have been described for the correction of the aging lip: local surgery and chemical peel or mechanical dermabrasion (see Chapter 15).

FLEUR-DE-LIS EXCISION AT THE NASAL BASE Excision of the nasal base has limited applications because it leaves a scar at the base of the nose. We restrict its use to patients over 55 years of age in whom the scarring process is less active and who are thus less likely to have scarring problems. In these patients we suggest shortening the upper lip by removing an ellipse of skin at the base of the nose.

The skin next to the base of the nose is meticulously and symmetrically marked in the form of a fleur-de-lis, breaking the line at the base of each nostril to maintain the natural lip-nose intersection. If necessary, the line of excision may extend to the alar bases. The average width of the excision is about 5 mm.

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Following removal of the skin, the underlying orbicularis oris muscle is exposed and tightened form philtrum to philtrum with one or two horizontal mattress sutures of fine nylon. If necessary, the orbicularis oris muscle is reattached to the nasal spine above. This produces a tightening of the muscle at the nasal base and causes the red portion of the lip to pout.

A dog-ear is resected at the center of the lip vertically. In very long lips the horizontal excision is combined with a vertically oriented elliptical excision of 2 to 3 mm along the philtral crests. This additional excision both compensates for the dog-ear resulting from the orbicularis oris plication and restores the natural convexity of the philtral columns.

The result is shown 3 months postoperatively.

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Preoperative and postoperative photos are shown of the patient above, who underwent fleur-de-lis excision of the nose base and excision of the nasolabial folds and the marionette lines.

NARROWING THE NOSTRILS Millard’s alar cinch stitch technique could be used to narrow the wide alar bases.6 This also enhances the length of the columella slightly and changes the direction of the nostrils from transverse to oblique or vertical. In this technique, bilateral alar flaps are elevated at the nostril sills, denuded, and sutured to each other and to the nasal spine through a tunnel at the base of the caudal septum. Ship’s alar base resection modification technique is another method available to narrow the alar sills.7 In this method, rectangular tissues are removed at the alar bases bilaterally and the alar base flaps are advanced to close the defect, narrowing the flaring nostrils.

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EXCISION

OF THE VERMILION

BORDER

Thin, inexpressive, “sad” lips can be corrected by direct excision at the vermilion border. For the upper lip the vermilion is meticulously and symmetrically marked, with two junction points at the philtral crests. The midline of the lip and vermilion border is marked. The new height and form of the lip are designed symmetrically. Between each philtral crest and the midline we recommend that the line of excision be an acute angle. This angle should be marked in a slightly overcorrected position resembling the top point of an M. The midline point marks an acute angle in the midline and touches the vermilion. Positioning the midpoint in this way gives the lip an extra pout and natural contour. Excision along the other acute angles of the M gives a natural, protruding mucocutaneous border, and subsequent scarring will contract the overlying skin without erasing the contour of the lip, thereby preserving a smooth expression that gives a very pleasing result. The lateral lines of excision are curved slightly toward the commissures but do not touch the commissures. The lower line of excision is marked along the white line of the vermilion border. The border of the vermilion is preserved at the midline of the lip to maintain the eversion of the midlobule of the lip. Markings for the lower lip follow the shape of the lip and define the excision that will be necessary. As with the upper excision, to prevent circumferential scar contracture, the lower excision should not meet the commissures.The skin between the actual and future vermilion borders is completely excised. In this patient a 2 mm skin resection was performed.

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The wound must be closed in a meticulous fashion with half-buried horizontal mattress sutures that pass through the dermis of the upper margin vertically and are tied horizontally over the vermilion to prevent cutaneous stitch marks. The sutures are removed on the third postoperative day.

The patient is shown 2 weeks postoperatively.

Chapter 14 Adjunctive Surgical Procedures to Improve the Face-Lift Result

This patient had a very thin upper lip. Three months after upper lip enhancement by direct excision, the appearance of the upper lip is much improved. This procedure is seldom indicated at present since it produces a visible and palpable scar. Besides, good results could be obtained with autogenous (for example, fat) or exogenous (for example, Restylane) filling materials.

VERMILION THINNING For patients in whom the vermilion has thinned as a result of aging and younger patients with congenitally thin vermilion borders, treatment includes VY advancement lip augmentation combined with orbicularis muscle tightening or fat/collagen injection.

VY ADVANCEMENT LIP AUGMENTATION VY advancement lip augmentation was first suggested by Dr. Aldo Piccolo of Rome, Italy.8 This technique involves two isolated VY advancements of the mucosa of the upper lip. The apex of each V is marked at the approximate midpoint between the philtral column and the commissure. The limbs extend at an approximately 45-degree angle from the buccal sulcus to the wet-dry line of the lip. The incision is deepened through the mucosa to expose the orbicularis oris muscle on each side.The philtral columns are left uninvolved. If necessary, the orbicularis muscle may be tightened with a horizontal mattress suture, which is then tacked to the nasal spine. Only 5 to 7 mm of advancement is necessary to obtain a satisfactory result. The central portion of the lip is left undisturbed, thus avoiding the creation of an abnormal pout. The effectiveness of this procedure is based on the clinical observation that any incision along the mucosal border of the lip heals by hypertrophy. Johnson9 advocated applying this clinical prolonged swelling and discomfort as well as the potential of asymmetry if the advancements are unequal.

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LABIOMENTAL FOLDS OR “SAD PLEATS” DEFORMITY “Sad pleats” are furrows that arise from the oral commissure and turn downward, giving the patient a stern or sad look.10 Even with extensive undermining during the face-lift procedure, these furrows in the skin are not always corrected. Several corrective approaches have been suggested, including selective resection of the levator alae nasi muscle and elevation of the malar fat pad.

SELECTIVE RESECTION

OF THE

LEVATOR ALAE NASI MUSCLE

The levator alae nasi muscle is a paired thin muscle that lies deep to the orbicularis oculi muscle superiorly, originates from the maxilla, and inserts into the lateral alae and orbicularis oris muscles. The angular artery and vein coarse medial and superficial to the levator alae nasi muscle, and the infraorbital nerve lies lateral to the levator alae nasi muscle and beneath the levator labii superioris alaeque nasi muscle. Action of the levator alae nasi muscle elevates the alar base, creating a sneer expression. As the alar base is elevated, the nasolabial angle becomes acute and the medial nasolabial fold becomes accentuated. Pessa11 and Pessa and Brown12 stated that levator labii superioris alaeque nasi creates the medial nasolabial fold, whereas the levator labii superioris creates the middle part of the fold. They also reported that the zygomaticus major muscle has little effect on the lateral part of the fold, but does affect the corner of the mouth. Dissection is performed through a subciliary incision, and the skin-muscle flap is elevated.The orbicularis oculi muscle is dissected inferiorly to free it from the orbital rim. The dissection proceeds medially to the groove between the maxilla and nasal bone where the levator alae nasi muscle is located and identified. A 0.5 to 1 cm segment of this muscle is resected. The transconjunctival method, as described by Goldberg,13 is preferred; the origin of the muscle could be found and resected following dissection behind the orbicularis oculi muscle and then at the infraorbital area subperiosteally. This procedure is seldom performed at present, because the same effect can be obtained temporarily with Botox.

MALAR FAT SUSPENSION ADJUVANT TO RHYTIDECTOMY As part of the aging process, the malar fat pad descends and causes deepening of the nasolabial fold. As the malar fat descends, a hollowing effect at the lower portion of the lower lid along the infraorbital rim occurs, forming the so-called nasojugal crease. Descent of this midface fat also contributes to the formation of marionette lines and visible lowering of the corners of the mouth.

Chapter 14 Adjunctive Surgical Procedures to Improve the Face-Lift Result

Surgeons have attempted to reposition this fat using a variety of methods. Our preferred technique is to reposition the malar fat pad by means of suspension sutures.

Suture purchases edge of orbicularis oculi muscle

Orbicularis oculi muscle

Suspensory sutures in SMAS

The area is approached through the prehairline incisions.14 The malar fat pad is covered by the SMAS layer, which forms a continuous sheath through the midface . A subcutaneous dissection over the SMAS allows access to the malar fat pad.

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As shown in the illustration on p. 355 and the cadaver dissections above, two suspension sutures are placed in the SMAS medially and in the malar fat pad laterally; a third suture is placed at the lateral aspect of the orbicularis oculi muscle. The sutures are then anchored above to the zygomatic arch. This maneuver restores the youthful appearance of the face with fullness in the infraorbital area and marked improvement in the nasolabial folds. Elevation of the corners of the mouth and some flattening of the perioral folds are also achieved.

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This 43-year-old woman requested improvement of deep nasolabial folds and a ptotic central face. Malar fat elevation was performed as an adjunct to rhytidectomy. The correction was maintained at 1 year postoperatively.

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Preoperative and postoperative pictures are shown of this patient who had a previous face lift and underwent malar fat elevation and allograft insertion to the dorsum of the nose secondarily.

This intraoperative photo shows malar fat pad lifting that has been employed on the right side. Please note the malar fullness on the right side.

Chapter 14 Adjunctive Surgical Procedures to Improve the Face-Lift Result

PTOTIC CHIN The tip of the chin tends to droop with age. This sagging is exaggerated as the soft tissues droop in edentulous patients, resulting in a lack of anterior support to the midline musculature. Following rhytidectomy and suction-assisted lipectomy with platysma plication, the ptotic chin becomes more obvious. Correction of the jaw line with standard techniques of rhytidectomy may accentuate even a mildly ptotic chin.15 A great number of procedures have been advocated for the correction of the ptotic chin. Most of these techniques attempt to elevate the soft tissues as well as the muscular insertions on the bone through resection of skin and fat. In addition, chin implants inserted at a higher level may be used to camouflage the ptosis and to take up the excess skin. Our preferred method is to elevate the soft tissues or the hanging part of the chin upward over the mandible, thereby enabling the skin to redrape over the elevated tissues.The procedure is performed in conjunction with the face lift without significantly increasing the operative time. Successful results are achieved in patients with mild, moderate, and severe degrees of chin ptosis.

TECHNIQUE After the face lift has been performed, usually in conjunction with submental lipectomy and platysma plication through an added submental incision, we elevate the skin and muscle above the horizontal lateral rami of the mandible and the submental crease and over the symphysis close to the mental crease.

The oral cavity is irrigated with a dilute mixture of povidone-iodine (Betadine), and a puncture wound is made in the mucosa appropriately 1 cm anterior to the labial sulcus. A 3-0 Prolene suture is placed through the intraoral stab wound to exit at the ptotic side on the chin; the surgeon must be careful to include the fixation point on the mandibular periosteum.

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POINTED CHIN TYPE

The needle is then introduced through the same side on the skin and directed back toward the intraoral stab wound. The second limb of the suture loop is placed in a slightly different plane from the first.The suture is then tied with moderate tension under direct vision in order to control the degree of correction.

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SQUARE CHIN TYPE

The technique may be modified, depending on the type of the chin to be corrected. In patients with pointed chins, the U stitch is reinserted exactly at the cutaneous exit point. In patients with square ptotic chins, the suture is redirected intraorally 3 to 4 mm horizontally in the intradermal plane.

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Immediate postoperative correction of the ptotic chin is performed concomitantly with the rhytidectomy. The mucosal insertion is then closed with 4-0 chromic catgut. As the Prolene suture is tied intraorally, a dimple is created in the submental area. Although this feature usually lasts for several months, it has not been a problem in our experience. Many patients notice this dimple, and some consider it an added benefit. Having followed up a good number of these patients over the years, we believe that this technique produces a lasting correction. Only rarely have we had to repeat this maneuver in the same patient.

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This 60-year-old woman is shown 1 year after correction of the ptotic chin as an adjunctive procedure to a face lift.The percutaneous chin stitch is barely noticeable. This percutaneous mentopexy restores facial balance and can be used successfully in both rhytidectomy patients and patients who have an underdeveloped mandible and refuse a chin implant at the time of rhinoplasty.

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AESTHETIC RHINOPLASTY IN THE AGING PATIENT Certain changes in the skin and soft tissue of the nose occur with aging including involution of the sebaceous glands and thinning of the skin. The skin over the tip of the nose in particular can become thinner, thus making the alar cartilages more prominent. The nose lengthens with age, and the tip of the nose tends to droop. The membranous septum may become redundant, requiring correction. Patients requesting face-lift procedures are usually unaware of these changes. Since the results of tip rhinoplasties and small adjunctive techniques in the nose are so gratifying to patients, we will sometimes suggest these procedures. Reassurance is given that the facial appearance will not be dramatically changed nor will the patient have the stigmata of a “nose job.” Subtle adjustments specifically to the tip of the nose bring the facial features into harmony. It is important that the surgeon fit the nose to the face rather than trying to make the nose fit an ideal mold. A classic rhinoplasty should not be performed on these patients because this procedure would dramatically change their appearance, potentially requiring a long period of psychological adjustment. After analyzing our cases, we have found that in most the correction involved a bulbous tip, drooping nasal tip, or minimal nasal hump, which is amenable to rasping without osteotomy. Lifting the nasal tip and refining the nasal lines without changing the basic facial characteristics add much to facial rejuvenation, and when combined with face lift, patients are almost universally pleased with the results. The surgical technique for thinning the bulbous tip of the nose is cephalic resection of the alar cartilage and insertion of a crushed cartilaginous tip graft, since the nasal tip droops following alar cartilage resection.

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This patient underwent face and neck lifting, blepharoplasty and nasoplasty with tip elevation. Her preoperative and postoperative photos are shown.

CORRECTION

OF THE

HANGING COLUMELLA

The hanging columella, which may have been acceptable in youth, becomes much more prominent as the patient ages. Our approach is to resect a sufficient part of the membranous septum to correct the hanging portion. A minimal 2 to 3 mm segment is also resected from the caudal end of the septum, excising a bit more mucosa than cartilage, and the remaining caudal septum is then wedged between the leaves of the membranous septum using horizontal mattress sutures of fine nylon. In addition, a tip graft is often added to maintain elevation of the nasal tip.

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On occasion, the orbicularis oris muscle may be tightened by grasping it on both sides of the anterior nasal spine through the incision in the membranous septum and by reattaching it above the nasal spine.

This patient’s primary concern was her aging face. However, the hanging columella and ptotic nasal tip contributed to her elderly appearance. Rhytidectomy, minimal resection of the caudal end of the septum to correct the hanging columella, and repositioning of the ptotic chin were performed (see p. 363).

PROMINENT EARS As patients age, the prominence of the external ear may become accentuated, and conchae of the ear may become deeper. To set the ears back, making them less prominent, requires only a simple maneuver during the face-lift procedure. As the postauricular incision is closed, the skin overlying the conchae is undermined, the mastoid fascia is exposed posteriorly, and one or two conchae-mastoid sutures of 4-0 clear nylon are placed that, when tightened, effectively set the ears back, thereby enhancing the overall result of the face lift. If the concha is quite deep, we do not hesitate to resect an ellipse of conchae posteriorly. On rare occasions we may perform a complete otoplasty with creation of an antihelix. This simple maneuver has not been discussed elsewhere to our knowledge; we recommend it highly.

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Preoperative and postoperative photos are shown of the patient who underwent cervicofacial lifting and otoplasty. The ear descends with age. This could be improved during the midface lift procedure.We continue the temporal prehairline incision posteriorly at the upper part of the ear and then advance anteriorly to carry on the preauricular incision, creating a triangular peninsula. Excision of this part followed by suturing the upper and lower wound edges during the face-lift procedure elevates the ear.

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This illustration shows tissue excised and vertical traction applied, elevating the ear.

EARLOBE DEFORMITIES The earlobe is an almost universal attribute of beauty throughout the world, exemplified by its decoration with earrings and coloring in countless cultures. With aging the earlobe becomes longer and wrinkled and earlobe ptosis or pseudoptosis may occur.16,17 As it enlarges, it flattens and takes on a rounded configuration, which seems to hang down from the face. Reduction of the earlobe is recommended in patients who show moderate to marked enlargement of the earlobe and is performed in conjunction with the face-lift procedure.

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We prefer a rectangular excision of the redundant earlobe. The edges are approximated in an anteroposterior layer of fine nylon sutures. We do not advocate the use of a triangular resection, since this design creates a pointed earlobe, which is less attractive. This procedure is simple and effective and ameliorates some of the wrinkles. The earlobe regains its natural shape and size. For patients with pierced ears, the ear is repierced and a 1-0 Prolene suture is loosely tied to maintain the opening. Following the earlobe reduction, the incision heals so well that it is hardly noticeable.

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This patient underwent fleur-de-lis excision of the nose base and an earlobe reduction.

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An alternative method to reduce the earlobes consists of a rounded tangential excision outlined at the caudal end of the earlobe that follows the normal curvature. We resect the anteroposterior thickness with a No. 11 blade, and the wound edges are sutured with 6-0 nylon sutures. Once the wound heals, the scar is hardly noticeable. The pixie-ear deformity, which results from the adherence of the earlobe to the skin of the cheek, can be avoided during the face-lift procedure. The postauricular flap is suspended with one suture superiorly and one suture at the concha-mastoid sulcus, leaving the tip of the earlobe free of any sutures. The maximal tension and fixation are thus above the earlobe. The surgeon should avoid hanging the postauricular flap on the earlobe because the earlobe becomes elongated in a tethered position with gravity and wound contraction.

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Edge left unsutured Skin of lateral neck sutured behind ear

If the pixie-ear deformity occurs, it can be corrected by the following procedure. The attached portion of the earlobe is released up to its normal level of attachment. The neck skin is then rotated into the postauricular area, trimmed, and sutured in the postauricular crease. It is best to leave the edge of the released earlobe unsutured, allowing the earlobe to heal with a completely normal shape and virtually without a scar.

Chapter 14 Adjunctive Surgical Procedures to Improve the Face-Lift Result

REDUCING FULLNESS OF THE CHEEK The buccal fat pad is located in the masticatory space and separates the masticatory muscles, so that gliding surfaces of these muscles do not affect each other during mastication.18 In the round face this tissue can be removed partially. Either an external or an intraoral approach may be used as described by Stuzin et al18 and Adamson and Tokso.19 In an external approach, after subcutaneous dissection during the face-lifting procedure, SMAS-masseteric fascia is dissected gently with a hemostat so as not to injure the facial nerve branches, exposing the underlying buccal fat pad in front of the masseter. In an intraoral approach, an incision is made in the upper buccal sulcus, 5 mm above the attached gingiva at the level of the second molar and extended 2 cm posteriorly. Then the fascia of the fat pad is incised and the desired amount of fat is removed. Stuzin et al18 stated that 1 to 2 g of tissue in many cases and 4 to 5 g in severe cases are adequate amounts to be removed.

CONCLUSION The procedures described in this chapter, although simple, require a certain amount of daring, an artistic eye, and an appreciation of the contribution of subtle adjustments to the overall final result. These refinements address deformities not improved by rhytidectomy; such problems call for a direct surgical approach. Potential difficulties can be obviated by the careful selection of patients and the performance of appropriate surgical techniques.

References —With Key Annotated References 1. Barton FE. The SMAS and the nasolabial fold. Plast Reconstr Surg 89:1054-1057, 1992. 2. Baker TJ, Gordon HL. Chemical peeling as a practical method for removing rhytides of the upper lip. Ann Plast Surg 2:209-212, 1979. 3. Cardoso AD, Sperli AE. Rhytidoplasty of the upper lip. In Transactions of the Fifth International Congress of Plastic and Reconstructive Surgery. Melbourne, AU: Butterworth, 1971, pp 1127-1129. 4. Gonzáles-Ulloa M. The aging lip. In Transactions of the Sixth International Congress of Plastic and Reconstructive Surgery. Paris: Masson, 1975, pp 443-446. 5. Pitanguy I, Muller P, Piccolo N, et al. Esthetic surgery of the aging lip. Compendium 8:460463; 465, 1987. 6. Millard DR Jr. The alar cinch in the flat, flaring nose. Plast Reconstr Surg 65:669-672, 1980. 7. Ship AG. Alar base resection for wide flaring nostrils. Br J Plast Reconstr Surg 28:77-79, 1975. 8. Piccolo A. Personal communication, LO Vásconez, 1990. 9. Johnson HA. A simple method for the repair of minor post-operative cleft lip “whistling” deformity. Br J Plast Surg 25:152-154, 1972. 10. Borges AF. Sad pleats. Ann Plast Surg 22:74-75, 1989. 11. Pessa JE. Improving the acute nasolabial angle and medial nasolabial fold by levator alae muscle resection. Ann Plast Surg 29:23-30, 1992.

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12. Pessa JE, Brown F. Independent effect of various facial mimetic muscles on the nasolabial fold. Aesth Plast Surg 16:167-171, 1992. The independent effect of the contraction of various facial mimetic muscles on the nasolabial fold was defined through study of cadaver dissections.The four major lip elevator muscles were identified, and the effect of traction of these muscles on the nasolabial fold was studied.This study identified the levator alae muscle (levator labii superioris alaeque nasi) as the primary facial muscle responsible for creating the medial nasolabial fold.The levator labii superioris muscle was found to define the middle nasolabial fold.These two facial muscles may be significant in the etiology of the prominent nasolabial fold that occurs with aging. 13. Goldberg RA. Transconjunctival orbital fat repositioning: Transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 105:743-748, 2000. 14. Collawn SS,Vásconez LO, Gamboa M, et al. Subcutaneous approach for elevation of the malar fat pad through a prehairline incision. Plast Reconstr Surg 97:836-841, 1996. Vertical suspension of the malar fat pad has been a safe procedure that results in the creation of a more youthful cheek and a lessening of the prominence of the nasolabial folds. 15. de la Torre JI, Martin SA, Al-Hakeem MS, et al. A minimally invasive approach for correction of chin ptosis. Plast Reconstr Surg 113:404-409, 2004. Although ptosis of the tip of the chin is common and can be seen in persons of any age, it is frequently seen in older patients who seek facial rejuvenation.The authors describe a minimally invasive method that can be used to correct chin ptosis.This technique uses a small intraoral incision to place a U-shaped Prolene suture that gathers the soft tissue of the chin and elevates it above the lower border of the mandibular symphysis.A retrospective review of 314 cases performed in conjunction with face lifts between January 1994 and January 2000 was performed to evaluate this technique. 16. Mowlavi A, Meldrum DG, Wilhelmi BJ, et al. Effect of face lift on earlobe ptosis and pseudoptosis. Plast Reconstr Surg 114:988-991, 2004. In this study, the authors evaluated the effects of standard face-lift surgery on earlobe ptosis and pseudoptosis by comparing the preoperative and postoperative earlobe height measurements from lifesize photographs of 44 patients who underwent rhytidectomy performed by the senior author. Earlobe height changes can result from either age-related lobule ptosis (increase in free caudal segment), as previously described, or in patients undergoing rhytidectomy (increase in attached cephalic segment). Therefore ideal lobule distances, along with the effects of aging and rhytidectomy surgery on the lobule, should be discussed with patients seeking a more youthful facial appearance, so that the aging ear may be addressed concurrently with the aging face. 17. Mowlavi A, Meldrum DG, Wilhelmi BJ, et al. Incidence of earlobe ptosis and pseudoptosis in patients seeking facial rejuvenation surgery and effects of aging. Plast Reconstr Surg 113:712717, 2004. 18. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 85:29-37, 1990. The buccal fat pad is an anatomically complex structure that has great importance in facial contour. In properly selected individuals, judicious harvesting of buccal fat can produce dramatic changes in facial appearance by reducing the fullness of the cheek and highlighting the malar eminences. Using fresh cadaver dissection, the anatomy of the buccal fat pad is delineated, and its relationship to the masticatory space, facial nerve, and parotid duct is defined.An intraoral approach for buccal fat harvesting is described based on these anatomic findings. Clinical experience manipulating the buccal fat pad for aesthetic modification of facial contour is illustrated. 19. Adamson JE, Tokso AE. Progress in rhytidectomy by platysma-SMAS rotation and elevation. Plast Reconstr Surg 68:23, 1981.

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REVIEW QUESTIONS 1. The so-called pixie ear deformity: a. Occurs after every face-lift operation b. Is unavoidable because of scar contraction c. Is easily correctible by reopening the ear lobe and resuturing d. Is prevented by leaving the lowest portion of the earlobe unsutured during the face-lift operation e. Is usually prevented and corrected by postoperative massage 2. Which of the following adjunctive procedures, if properly performed, will not enhance the overall result? a. Tip nasoplasty and crushed cartilage added to the lip b. Shortening the long and flat upper lip c. Reducing the enlarged earlobes d. Elevation of the tip of the chin e. CO2 laser treatment to the entire face 3. A patient with a rounded face seeks facial improvement. What will enhance the overall face-lift result? a. Extensive liposuction of the face b. Lipoinjection of the nasolabial folds c. Removal of the buccal fat pads through the face-lift incision d. Asking the patient to lose 10% of her body weight preoperatively e. Prolonged use of a facial compression device

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Chapter 15 Adjunctive Procedures to Improve the Results in Facial Aesthetic Surgery Tracy M. Baker and G. Jackie Yee

Wrinkles should merely indicate where smiles have been. Mark Twain

Reoperative Problems Persistent rhytids Dermal/subdermal augmentation

Pigmentary irregularities Actinic damage

O

ur knowledge of the many changes involved with aging and the improved understanding of the surgical anatomy allows tailoring of the operation to fit specific presenting challenges. No longer is a face lift an operation to simply tighten the skin envelope. Rather, we can now design surgical rejuvenative procedures to be specific to the problem (or problems) at hand. These many approaches are well covered elsewhere in this text. In this chapter we will discuss the more subtle but equally important aspects of aging that lie, for the most part, beyond the reach of the scalpel.We will discuss restoration of the loss in facial volume, eradication of fa-

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cial lines, thickening and reorganization of the skin’s dermal collagen layers, and correction of the aging lip and vermilion complex. The recognition and the treatment modalities to address these many different aspects of aging dramatically improve our results in facial aesthetic surgery. With the growth of our knowledge and these available tools, results today are softer, more natural, and truly more complete. Patients consult us for specific problems of aging. When you hand them a mirror during a consultation, they will take their free hand and physically demonstrate what bothers them. They point, suspend, move, and mechanically reposition various portions of their brow, eyes, face, and neck. A patient generally does not sit across from the surgeon and request a specific procedure. Therefore we have organized this chapter into isolated problems within anatomic regions. We must keep in mind that there are many ways to solve the same problem.These adjunctive procedures are complementary to the surgery and frequently to one another. A nasolabial fold can be improved with a face lift, a fat graft, laser resurfacing, dermabrasion, injection of hyaluronic acid, or even direct excision and many other approaches.The specific treatment or combination of modalities chosen is a decision to be made between the patient and surgeon based on many factors. Many adjunctive procedures by themselves can often provide a satisfactory improvement to postpone a face lift in the early phases of the inevitable aging process. If an individual is first seeing the signs of aging and/or is nearing the time for undergoing surgery, the problem may be camouflaged or temporarily fixed by just filling and replacing volume. In these patients, fillers are excellent for reaching their goals. Inevitably, the problem worsens to such an extent that surgery should be performed to ideally correct the problem or may be the only option to obtain a realistic and believable result. Most patients eventually require a combination of surgical and adjunctive procedures to produce a satisfactory result. A good surgeon is able to assess the limitations of the surgery and adjunctive procedures being discussed in this chapter. Good judgment should always be used when counseling patients in borderline cases where surgical procedures are early options. Open and honest discussion of the potential results and limitations of the procedure being considered is essential so that the patient can take an informed role in the decision-making process.

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ANALYSIS OF FACIAL AGING

This woman shows classic facial aging. No component of the face is immune from the effects of time. These changes are often compounded by other deleterious influences: sun exposure, hormonal alterations, cigarette smoking, extreme weight fluctuations, nutritional factors, and even previous aesthetic surgeries. Complete restoration will require surgery and adjunctive techniques. Bone undergoes resorption, muscle and fascia become atrophic, lax, and malpositioned, and malar and jowl fat pads descend, with the overall facial subcutaneous fat demonstrating substantial loss of volume. Brow ptosis with upper lid skin and fat excess becomes evident. Anchoring and suspension ligaments elongate, allowing soft tissues to delaminate from the underlying skeleton.The fat pads of the lower lid fat herniate and the lower lid tissue thins to expose the orbital rim. The volume of the orbit enlarges, and together with the lower lid tear trough, often reveals a skeletonized appearance. Atrophy and collapse of the soft tissues around the mouth contribute to marionette lines, nasolabial folds, and the loss of full, sharp lip and vermilion border anatomy. Lines of expression around the eyes and perioral wrinkles become marked. The collagen of the dermis becomes thin and disordered and natural elasticity is diminished, while the epidermis becomes thickened and more variably pigmented. Clinically, these skin changes produce a lax, dull, atrophic, blotchy, and irregularly pigmented appearance. Clearly these inevitable changes demand surgical procedures as well as adjunctive techniques to complement surgical success. With that in mind, there are specific nuances with certain modalities that merit separate consideration before we discuss their application by anatomic area.

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AUTOLOGOUS FAT TRANSFER We have long been able to move autologous fat from one site to another. However, until recent advances in our understanding of this procedure, the results were often doomed to failure by resorption of the transferred fat within the first few months. In fact, we often still hear from patients the common belief that fat grafting lasts only a short time. In reality, we are now capable of permanent results that show little short-term resorption. Of course, there is some variability, as will be discussed; however, a good rule of thumb is that the clinical improvements visible at 3 months after autologous fat transfer should remain indefinitely. A few caveats deserve specific mention. Fat is a living cell. It must be respected as such and handled as atraumatically as possible. The suction applied to aspiration syringes needs to be kept as low as possible: a 10 cc syringe with the plunger engaged just far enough to yield fat is ideal. As a general rule, the aspirated material from suction-assisted lipoplasty is a poor choice of material, because the majority of the fat cells will be damaged or ruptured from the high negative pressures generated by the machines. We prefer to harvest the donor material just before transfer to ensure living, fresh fat. Frozen fat is already dead and will generally not provide a long-term correction. Special instrumentation helps to ensure proper survival of the graft. Collection cannulas should keep the fat cell membranes intact and produce tiny pearls or globules no larger than a few millimeters. This ensures maximal surface area contact of the graft with the recipient bed and therefore better graft survival.The collected fat can be centrifuged at very low RPMs or wicked on Telfa strips to separate the associ - ated blood and serum from the minute intact fatty grafts .1 The injection should also be a low pressure system, ideally created with 1 cc tuberculin syringes. The in- jection needles are typically blunt tipped and side injecting to minimize trauma to the recipient bed. Additionally , the internal diameter of the injection needles should be matched to the harvest cannula for proper size and less graft injury . Graft place - ment should be in very small increments (0.05 cc or less) deposited with multiple passes from several access sites. Graft donor sites have minimal bearing on graft survival. Regardless of the donor site chosen, it should be free of previous trauma or surgery and should produce rich golden fat grafts. Thin, watery aspirates from the donor site do not bode well for long-term survival of the graft. Our preference for facial grafting requiring less than 50 cc of harvest is the abdomen or anterior thigh. These sites eliminate the need for patient repositioning and turning and will generally produce an aspirate of satisfactory composition and volume. Assuming all previously discussed components being equal, the biggest factor influ - encing graft survival is the location of the recipient site. Since fat is moved as a

Chapter 15 Adjunctive Procedures to Improve the Results in Facial Aesthetic Surgery

nonvascularized graft, a good analogy is a skin graft.When discussing recipient sites, the best survival is obtained when fat grafts are placed into well-vascularized beds with little or no motion . In the face , the mouth is constantly moving during facial expression, eating and drinking, and conversation. Consequently, the closer to the mouth a graft is placed, generally the poorer is the survival. Fat grafts to the lips and marionette lines have high resorption rates; fat grafts to the nasolabial folds have an intermediate survival rate; and grafts placed in the relatively nonmobile and well- vascularized malar and periorbital regions have the highest survival rate. Grafts placed subcutaneously do not fare as well as grafts placed into muscle or on the sur- face of the periosteum.2 In our practice, the typical patient who undergoes fat grafting has it done concomitantly with a scheduled operative procedure, not as a separate procedure. Al - though fat grafting can be performed with the use of a local anesthetic , the patient and surgeon will be more comfortable with sedation or general anesthesia. Patients who are not undergoing a surgical procedure are generally offered other options . Fat is commonly used as either a pure filler to replace the lost facial volume that is inevitable in the aging process of the malar region or as a pure filler to the isolated depressions commonly seen in the nasolabial fold and tear troughs. Practitioners who are beginning to incorporate fat grafting into their practices will do well to study the concepts presented here in more detail. The reference section contains a wealth of information, and one should ideally spend some time with an expert in fat grafting to gain the experience required to master this powerful tool.3

RESURFACING TOOLS: DERMABRASION , LASERS, AND PEELS With the emergence of laser resurfacing in the 1990s, dermabrasion has increasingly become a lost art. Lasers are modern and computerized and thought by the public to be the final word when applied to nearly any surgery. True, dermabrasion is messy , and there are no standard “settings ” to be taught in a weekend laser course . Rather , the expertise is learned and clinical judgment and technique are more crit- ical. Early generation CO2 lasers were quite effective around the mouth but had ex- ceptionally long erythema phases and too high an incidence of posttreatment hy- popigmentation . The evolution of the Erbium Sciton laser has greatly reduced these side effects .4,5 The paradox is that with the advent of machines that create less tis- sue damage and have shorter healing times and erythema phases , the efficacy has also diminished in eradicating moderate and deep rhytids, particularly in the peri- oral region. Phenol peels remain an excellent means for correcting severe rhytids and pigmentation problems in properly selected patients. However, with the current array of choices for facial resurfacing, phenol peeling has been largely relegated to historical significance.Trichloroacetic acid peels remain a very effective modality for treat - ing superficial wrinkles and pigment problems.6,7

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This 51-year-old woman underwent treatment of her aging face with resurfacing tools for upper lip rhytids and moderate sun damage. She is seen 6 months after treatment with 35% trichloroacetic acid face peel and synchronous upper lip dermabrasion. Dermabrasion in our practice remains the workhorse for moderate to severe perioral rhytids in properly selected patients. Although dermabrasion results in a higher incidence of posttreatment hypopigmentation, it remains our modality of choice in moderate to severe perioral rhytids in Fitzpatrick I, II, and III patients. In such cases Erbium Sciton lasers are gentler on the melanocyte but are significantly less powerful in eradicating lines around the mouth. We use a small electrically powered, motor-driven, hand-held unit. One distinct advantage is the unit’s portability. A surgeon who operates in several facilities may be disappointed by the lack of availability of a laser from place to place.The RPMs are kept low (12,000 to 15,000) for a gradual, even wound. The abrading heads are interchangeable, and finer grits allow the surgeon to progress at a more even and comfortable pace.The depth should be taken no deeper than is required to eradicate the lines. Generally, this is the mid to deep dermis for moderate to severe lines, respectively. Clinically, this is recognized by a pinkish-red color and a rough grainy appearance of the wound. Bleeding is pinpoint and sparse within the superficial dermis and progresses to brisk bleeding on a rougher, redder background as the papillary dermis is approached. Universal precautions should be employed, because the aerosolized particulate matter is capable of transmitting hepatitis and HIV. All resurfaced wounds are occluded with a petroleum-based ointment, regardless of whether they are produced with chemicals, lasers, or dermabraders. Patients who are undergoing facial resurfacing should have prophylaxis against herpes viral outbreak, whether the patient has a history of herpes or not.8,9

Chapter 15 Adjunctive Procedures to Improve the Results in Facial Aesthetic Surgery

Note the pretreatment appearance of this 71-year-old woman with severe perioral rhytids. Her result is seen 8 months after extended perioral dermabrasion to the papillary-reticular junction. Note that dermabrasion, like other resurfacing modalities, is more effective on the upper lip than the chin pad complex. When a laser is chosen for resurfacing, we currently use the Erbium Sciton laser. It is ideal for the more superficial lines around crow’s-feet and lower lids. Because it is a nonmechanical, no-touch instrument, it can be used safely around the eyes. Full-face applications are superb for superficial to moderate rhytids and for pigmentary irregularities from sun damage or aging. However, full-face applications of any agent during rhytidectomy should be discouraged. Staged procedures that separate face lifting from full-face resurfacing will prevent slough from injury to the skin flap’s vital blood supply.10-13

This 53-year-old woman shows aging and sun damage. Her concerns were pigmentation and abnormalities and generalized fine lines. She is shown 3 months after Erbium Sciton laser resurfacing. This treatment delayed her need for rhytidectomy for several years.

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INJECTABLES: BOTULINUM TOXIN AND FILLERS Botulinum toxin type A is a purified neurotoxin complex produced from Clostridium botulinum type A. It blocks neuromuscular transmission by binding to acceptor sites on motor nerve terminals, entering the nerve terminal and inhibiting the release of acetylcholine. This results in localized reduction in muscle contraction and activity. Each vial of Botox Cosmetic (botulinum toxin type A; Allergan, Inc., Irvine, CA) contains 100 units of the neurotoxin, 0.5 mg of human albumin, and 0.9 mg of sodium chloride in a sterile, vacuum-dried form without a preservative. We reconstitute each vial with 2.5 ml of 0.9% sterile saline solution without a preservative. A 30-gauge by 1⁄ 2-inch needle attached to a Terumo non–Luer-Lok tip tuberculin syringe is used for injection. The amount injected for treatment will be discussed in the anatomic discussion. Currently, Botox Cosmetic is FDA approved for treatment of the frown lines between the brows.14 In addition to treatment of the glabellar lines, we will discuss using Botox for other lines on the face. The role of Botox used to inactivate certain muscles of the face to obtain the resultant reciprocal action that is blocked is of great use when rejuvenating and shaping certain aspects of the face. Botox injections last an average of 3 months.We will also address off-label uses, including treatment of the forehead, crow’s-feet of the lateral canthal area, and the perioral region.15 A multitude of fillers ranging from nonpermanent to permanent and autologous to nonautologous are available to correct volume loss in the aging face.The injectable fillers, other than the previously discussed fat, include collagen, hyaluronic acid, lactic acid, calcium hydroxylapatite, and silicone. Our filler of choice is Restylane (Medicis Aesthetics, Scottsdale, AZ), a brand of hyaluronic acid injectable gel. Hyaluronic acid is a glycosaminoglycan that consists of regularly repeating nonsulfated disaccharide units of glucuronic acid and N-acetylglucosamine. Restylane is a nonanimal, terminally heat-sterilized and stabilized hyaluronic acid suspended in physiologic buffer at a pH of 7.0. The concentration is 20 mg/ml, available in differing amounts in prefilled syringes. It is currently indicated for mid to deep dermal implantation for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds.16 The current indication is limited to 1.5 ml per treatment site. It is packaged for single patient use in disposable glass syringes with a Luer-Lok fitting. The sterile needle included in the packaging is a 30-gauge by 1⁄ 2-inch. If the skin is particularly thick or repeated injections are required, the

Chapter 15 Adjunctive Procedures to Improve the Results in Facial Aesthetic Surgery

needle can be changed to a separate sterile needle of the same size.17 Ideally, Restylane is injected into the dermis or immediately subdermal. Per the package insert, the duration is thought to be less when Restylane is injected too deep or intramuscularly, but depth is variable, depending on the area to be treated, such as tear troughs and lips. On average, Restylane injections last 6 months, but the longevity of effects differs among patients, the area injected, and the technique of the injector. Patients may return as soon as 2 months later or more than a year later to be reinjected. It should be discussed with the patient that full correction must be achieved before a return visit for reinjection is considered maintenance. Some of the uses and volumes discussed are off-label uses of Restylane. When Restylane is injected into the dermis, not only does it correct or efface the wrinkles or folds being injected, it can also create increased turgor to the skin, hence increasing the support and ability of the tissue to withstand compressive forces. To obtain this effect, the proper technique is usually a crosshatching or an overlapping pattern. This technique can act as a foundation or form a buttress in certain areas, allowing the skin and surrounding tissues to combat the effects of the weight of aging and sagging structures. An example would be the prejowl area of the labiomental groove (marionette line) that has formed from the weight of the jowl, or the nasolabial fold that has deepened by the weight of the malar unit.18

This 50-year-old woman requested nonsurgical rejuvenation.We performed Restylane injections to the vermilion border, oral commissures, nasolabial folds (Type IIIb), and marionette lines. A total of four syringes of Restylane were used in two separate sessions 6 months apart.

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This 73 -year -old woman had undergone a rhytidectomy and perioral dermabrasion several years earlier. Resurfacing techniques were not an option for this particular patient because she had limited available downtime and was reluctant to undergo surgery because of anesthesia risks and medical issues . Restylane injections to the oral commissures , nasolabial folds (type IIIa ), and marionette lines were performed to rejuvenate the perioral area.

THE BROW AND EYELID REGION People communicate verbally and nonverbally while making eye contact. Aside from color, eyes vary little between individuals. It is the soft tissues surrounding the eyes that impart expression: sadness, joy, surprise, youth, tiredness, and so on. It follows that direct surgical and adjunctive techniques strive to favorably change these soft tissues to impart added youth, softness, and a rested appearance. Upper and lower lid blepharoplasties , either alone or in combination with face and brow procedures, have their shortcomings. Frequently, Botox, fat grafting, and laser resurfacing are used concomitantly to improve the surgical result. Transverse forehead lines can be treated by a multitude of options: brow lift, laser, chemical peel, Botox injection, or dermal fillers. The wrinkles form from the repeated activation of the frontalis muscle, together with the deterioration of the skin’ s inherent structure and support . When the surgeon is assessing the patient for treat - ment of these lines , consideration of the patient ’s expectations and a full examination are critical.This examination includes the resting tone of the forehead musculature , degree of brow ptosis , excess eyelid skin, symmetry , lid ptosis , and other factors. Brow positioning, shaping, and ptosis can be addressed with both brow lift and Botox injections . If signi ficant ptosis of the brow presents as the patient ’s primary complaint, a brow lift is indicated. In these individuals, the wrinkles most likely re- sult from compensatory frontalis muscle activity to raise the ptotic brow or compen - sate for excess upper eyelid skin . If this is not clinically recognized preoperatively or before injection , it will certainly worsen if treated solely by Botox injections.

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Patients who are good candidates for Botox injections alone are those with transverse wrinkles caused by the activity of the frontalis muscle from expression such as openness, surprise or interest or as habit. These patients are good candidates for Botox alone because no significant brow ptosis may be underlying and they are seeking treatment of the lines only.

Note this patient’s face at rest before and after Botox injections (1.5 cc total) to the glabella , forehead , and crow ’s-feet . The patient had some degree of compensa- tory frontalis muscle activation. The results reveal improved shaping of the brow from the slight depression of the medial brows, significant elevation of the lateral brows , and inactivation of the forehead /frontalis . Note the correction of the upper eyelid skin excess. In a borderline patient, a certain extent of brow ptosis can be corrected or camouflaged with Botox injection. This is the patient with minimal brow ptosis, with or without transverse rhytids. A certain amount of brow elevation can be obtained by injecting the brow depressors concurrently with frontalis injections. This not only treats the rhytids, but also gives the illusion of brow elevation, if performed in the correct patient. The depressors of the brow that can be inactivated with Botox, hence yielding elevation, are the procerus, corrugators, and the orbicularis oculi. By injecting these areas in conjunction with the frontalis, the surgeon can effectively treat the transverse furrows and elevate the brow or at least not cause brow ptosis. When performed in a good candidate , a certain amount of shaping can be achieved in these patients. An elegantly shaped feminine brow is arched, with its superior - most aspect at the junction of the lateral two thirds of the brow . This shaping , which can be accomplished in conjunction with the treatment of the wrinkles and brow ptosis, is a much-desired effect for most female patients. Complaints regarding the glabellar area are commonly related to the presence of wrinkles at rest and/or during muscle activity. These wrinkles may be vertical , oblique , or horizontal . If the wrinkles are not present at rest, then the patient most often complains of the concerned , furrowed , frowning , or angry look associated

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with activation of the corrugators and /or procerus muscles . By inactivating these muscles, Botox injection to this area treats the lowering of the eyebrows that the de- pressor muscle groups produce and combats the medialization of the corrugators . Hence the medial brow is elevated , and the brows are lateralized . This desired ef- fect is one that patients perceive as “opening” of the periorbital area. If the rhytids of the glabellar area have been present for quite some time and are deep, Botox injection alone will not be an adequate treatment, and a filler may have to be used in conjunction. We prefer to perform the Botox injection first and allow adequate time (2 weeks) for this to take effect. This allows the skin to respond to the decreased muscle activity and the resultant defect presents itself. The filler of choice can then be precisely injected. Fat grafts in this area are often not precise enough to treat the dermal defect/component for some patients; thus Resty - lane is the filler of choice for augmenting this area. Excision of the muscle groups in this area during brow lift or blepharoplasty, includ - ing the corrugators and procerus , has been successful in treating hyperactive mus - cles . But complete excision of bulky muscles may not be an option , especially if re- moving too much muscle may result in a defect or contour irregularity . Thus partial excision may be indicated , or in the event the muscle does reform and reactivate , Botox may be required to maintain the desired look and the inactivity of the muscle. There are surgical remedies for the crow’s-feet associated with lateral orbicularis function , but these treatments tend to be aggressive and fraught with return of muscle function and thus return of the deformity. We prefer to use either laser resurfacing or Botox injection. At times, we use both . The decision rests largely in the discussion between patient and surgeon . Paralysis of the orbicularis function by Botox injection during the healing and collagen proliferation phase of laser resur- facing may help the longterm result that can be produced with laser treatment. Laser resurfacing to treat crow’s-feet is generally chosen for a patient undergoing a surgical procedure for which he or she intends to invest a few weeks of recovery — blepharoplasty , brow lift, and/or face lift—the logic being that the patient is recu - perating and out of circulation anyway . Women can cover the reepithelialized laser wound with makeup in 10 days. Men who must return to the public eye sooner than the 6 to 8 weeks required for postlaser erythema to resolve may well be bet- ter candidates for Botox injections. Although laser treatment of crow ’s-feet produces a more long -term solution than Botox injection, return of the deformity within the first year or two following laser treatment is not uncommon . The orbicularis muscle continues to function and the lines will, at some point, form again. Costs are generally a wash: 12 to 24 months of Botox treatment will run about the same as periorbital laser resurfacing. The lateral periorbital rhytids that appear lateral to the eye and near the temple respond well to Botox injections. One of the benefits of injecting the lateral aspect of the crow’s-feet, as mentioned previously, is that this can result in elevation of the lat -

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eral eyebrow. The injections to this area inactivate the depressing action of the orbicularis oculi muscle because it is a natural brow depressor in this location. Thus treatment of crow’s-feet and lateral brow ptosis can be accomplished with Botox. Injections to treat the wrinkles inferior to the eye can be fraught with problems. The appearance of “swagging” is from “chasing” the wrinkles from lateral to the eye to inferior to the eye that the patient may ask for and that an inexperienced injector is tempted to perform.This will mimic a malar bag after the Botox has taken effect.

This patient shows a smiling expression before and after Botox injections to the glabella, forehead, and crow’s-feet (1.5 cc total). Note the improvement of the crow’s-feet with expression, but not full correction or inactivation. The tear trough deformity commonly seen in the lower lid is produced by attenuation and weakening of the septum orbitale, which allows the lower lid fat to present as a bulge above the orbital rim together with thinning of the skin, orbicularis mus - cle , and subcutaneous fat along the rim itself . This produces the characteristic tear trough deformity seen with the aging lower lid. Frequently , the appearance of a volumetrically enlarged orbit may also be present. Removal of fat from orbits that already appear to be empty may further exacerbate the appearance of aging. Today there are many techniques that preserve orbital fat, preserve and turn the fat pads over to cover the rim, and even procedures to lift the entire lid/cheek complex . These surgical variants all seek to preserve fat and favorably reposition tissues to cover the tear trough while maintaining a low, youthful orbital volume. An excellent (and simpler) alternative is to perform conservative lower lid fat excision and reestablish lower lid soft tissue cover with fat grafting. Indeed, in patients over 40 years of age and in almost all cases of visible tear trough deformity , fat grafting is used as a routine part of our lower lid blepharoplasty . Fat is trans- ferred as previously described, with a few important variations. The lower lid tear trough is one of the places on the face where one can count on a nearly 100 % “take ” of the fat graft . Fat injections must be exact , with no overcorrection of the depression . The surgeon should stay just on the bone hugging the surface of the periosteum , deep to the orbicularis muscle . Grafts placed intramuscularly or in the subcutaneous plane may be visible.

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This patient had lower lid nasal and central fat pad prominence, with the characteristic tear trough deformity.The patient is shown 6 months after upper and lower lid blepharoplasty with conservative fat excision. She also had fat grafting of the tear troughs and malar complex. The mouth was restored by upper lip laser resurfacing and Restylane injections to the upper lip and type Ia nasolabial folds.

This woman is shown 8 months after lower lid blepharoplasty and fat grafting to the tear troughs. Note the visible bulge of the graft along the right orbital rim in the tear trough . This resulted from too superficial a plane of deposit . Grafts here should be kept deep just on top of the periosteum. Typically, no more than a few tenths of a cubic centimeter is adequate. Overgraft - ing or malposition that is recognized during transfer can be softened by massage both during the procedure and in the immediate postoperative period . Visible grafts that are recognized after they are well established become more problematic . Vig - orous massage , combined with ultrasonic therapy or injection of a very dilute steroid agent, may be helpful. Surgical excision is diffi cult and should be considered a last resort.

Chapter 15 Adjunctive Procedures to Improve the Results in Facial Aesthetic Surgery

Hyaluronic acid may also be used to correct a tear trough.This is a good option for a patient who wants minimal downtime or who has just the beginnings of a tear trough that may not require significant enhancement. Generally, reinjection is required to maintain the correction, but the product tends to last longer in this location than when injected in other areas.Tear trough implants present another choice for permanent correction but have their own subset of issues. The malar area is subject to the changes of aging. Commonly, the tear trough graft is carried out laterally as far as required to soften the rim and reestablish lost volume and obliterate the skeletonization (see p. 390). Similarly, tear trough grafts continue inferiorly and are blended with malar grafting to complete the lower lid/orbital rim/malar complex rejuvenation. Loss and descent of malar fat with aging produces the classic midface deflation. The youthful triangular shape created by the mandibular-malar relationship is replaced by a rectangular aged and deflated appearance. Face lifts and procedures for the “central oval” have blossomed to address the problem of midface descent and volume loss. Most procedures have varying success. Malar grafting has been routinely incorporated into our face-lift regimen for the last 8 years.19

This patient shows the typical findings in facial aging 8 years after a primary rhytidectomy. Note the redescent of the malar and jowl fat pads, producing a de - faulted rectangular appearance . She is shown 9 months after secondary rhytidec- tomy with fat grafting to the malar, marionette, and nasolabial folds. The technique described in this chapter is used. The plane of deposit is as close to the periosteum as possible on the malar complex. The anterior process of the zygomatic bone is followed as far posterolaterally as required. Feathering into the muscle, fascia, and even subcutaneous planes may be required in some presenta-

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tions. The volume of grafting varies greatly and may be as little as 2 to 3 cc and as much as 20 to 25 cc or more per side. Asking patients to bring in photographs of themselves when they were in their twenties or thirties may be helpful in determining the volume and precise location of grafting sites.The surgeon can count on excellent “take” in the malar region because of the reliable vascularity and relatively immobile bed of the site. The malar region is one of the most forgiving, and also the most rewarding. Because injection with autologous material in this area is relatively simple and is long-lasting, the use of cheek implants, with their associated costs and problems, is a second choice. Other fillers such as hyaluronic acids have a place for patients who are not undergoing general anesthesia, but their drawback continues to be their relatively brief effectiveness.

THE PERIORAL REGION The nasolabial fold is perhaps the single most common region pointed out by patients who seek surgical rejuvenation of the aging face. This area is a watershed region of aging. Many factors affect and compound the appearance of the nasolabial folds; thus many treatments serve to improve them. Most face lifts are conceived to improve the nasolabial folds, but in reality, success in this region can frequently be elusive and incomplete. Results of surgery can fall well short of both the surgical plan and patient expectations. Thus the nasolabial fold is an area in which adjunctive techniques can dramatically improve success.

This 64-year-old woman had undergone a rhytidectomy several years earlier. Resur - facing techniques were not an option for this patient , because she had limited down- time available and required a rapid recovery. Restylane was injected into the na - solabial folds (type IIIa ), oral commissures , vermilion border , and marionette lines. Almost every adjunctive treatment in this chapter , excluding botulinum toxin, is a reliable tool for improving the nasolabial fold. The adjunctive method (or methods) chosen will depend on the specifics of the fold, the skill set of the surgeon, and the choices of the patient.

Chapter 15 Adjunctive Procedures to Improve the Results in Facial Aesthetic Surgery

Classification of Nasolabial Folds Type Ia

The fold is a dermal/epidermal rhytid with little or no underlying defect or “valley.” Type Ia folds are limited regionally between the alar crease and just lateral to the oral commissure (see below).

Type Ib

Identical to Type Ia, but extends inferiorly below the oral commissure into the chin pad complex (see p. 394).

Type II

The fold is composed of a visible trough or valley creating a depression without a skin crease of significance. Type II nasolabial folds may have redundant tissue accumulated superolateral to the valley (see p. 394).

Type IIIa

The fold is a combination of type Ia and type II. The defect is a visible, significant valley with a skin crease in its floor limited from the alar crease to the oral commissure (see p. 395).

Type IIIb

The fold is a combination of type Ib and type II. The defect is a visible, significant valley with a skin crease in its floor extending inferiorly into the chin pad complex (see p. 395).

We classify folds into three basic categories to help analyze the problem and to better organize the discussion of treatments. Type Ia patients have nasolabial folds that are little more than creases in the skin, similar to a rhytid. It originates at the alar crease and is limited to at or above the oral commissures. These patients have little or no valley beneath the crease and the defect is relatively two-dimensional.They are ideal for either Restylane injection or resurfacing, because the defect is not substantially volume deficient, and this category of fold will respond poorly to face-lifting techniques. Fat grafting in these individuals may efface the crease, but without a val - ley to fill, the graft may become visible as a tubular fullness beneath the fold. At the completion of the face lift , patients with type Ia folds who are not undergoing resurfacing of any other region are selected for Restylane injection alone. Patients who are having laser treatment or upper lip dermabrasion will be selected for resur-

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facing of the nasolabial fold. Frequently we perform resurfacing followed immediately by detailing with Restylane while the patient is still under anesthesia. Combination approaches on type I nasolabial folds are very powerful.

This 38-year-old woman disliked the aged appearance of her nasolabial folds and perioral region. Resurfacing techniques were not an option for this patient because of her lifestyle, which included daily exposure to the sun and limited downtime. Restylane injections to the vermilion border, oral commissures, nasolabial folds (type Ib) and marionette lines were performed to correct and rejuvenate the perioral area. Injections to the vermilion border defined and reestablished the lip border and corrected her rhytids.

Type II defects are true valleys with no skin crease . There is better success in patients undergoing face lift for these problems, but generally a volume deficit will still ex- ist. These individuals are ideal for fat grafting at the time of face lift. Resurfacing is not applicable here because the problem is beyond the reach of any resurfacing modality. Of course, Restylane is also an option during the initial operation; how- ever, we generally use hyaluronic acid for touch-up improvements at 3 to 6 months in patients who have a persistent fold.

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Type IIIa folds are depressions with an associated overlying skin crease limited to at or above the lateral oral commissure. This patient’s treatment consisted of both extended SMAS face lifting and fat grafting to the underlying valley of the fold.

Type IIIb folds are identical to IIIa in appearance but extend more inferiorly to involve the chin pad complex . This patient was treated with the combined modal- ities of extended SMAS face lift, fat grafting the nasolabial folds and malar region, and second-stage full-face CO2 laser resurfacing. Type IIIa and IIIb patients, like Type Ia and Ib patients, are candidates for a multi - ple-modality treatment plan. Typically these patients will undergo face lifting, fat grafting , and skin resurfacing (see the patient above ), with or without Restylane injections into the dermis of the crease itself. On occasion, if the lip or lower lids are also being resurfaced , the wound can be carried to encompass the skin fold and produce additional improvements. Direct excision of type IIIa and IIIb folds in properly selected patients remains an excellent means of treating these difficult

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problems. This method is generally reserved for severe or refractory folds in male patients or individuals who do not want formal face lifting. Consideration of direct excision should be weighed against the type of scar the patient is likely to form. Because the resultant scar mimics a crease, we are essentially converting a type III nasolabial fold to the more favorable type I fold.

Severe type IIIa and IIIb patients may be well treated by direct excision. Used predominantly in males, excision can be a powerful tool for men who desire correction of the fold without a face lift. This patient underwent upper lid blepharoplasty with direct excision of the nasolabial folds. No face lift was performed. There is no right or wrong method. Each patient presents with a slightly different variation of the nasolabial fold. Likewise, each surgeon develops skills and preferences for those unique problems. Perioral aging can consist of slight superficial wrinkles that originate in the dry vermilion and encroach just across the white roll or may represent extensive perioral wrinkling with profound volume loss and dermal collapse.With proper selection of adjunctive procedures, the surgeon can customize treatment based on the individual patient’s problem. Patients with more superficial upper lip rhytids can be very well treated with the Erbium Sciton laser (see p. 390).This laser is chosen when lower lid and crow’s-feet laser resurfacing is being performed. One tool is easier and the wounds appear and heal similarly. However, as the upper lip lines become deeper and or the chin pad and lower lip becomes involved, dermabrasion becomes the preferred tool. Moderate to severe lines, particularly in the lower lip and chin pad, simply respond better to the dermabrader (see p. 383).

Chapter 15 Adjunctive Procedures to Improve the Results in Facial Aesthetic Surgery

As a rule, no tool completely eliminates perioral lines, particularly inferior to the oral commissures. Dermabrasion results in a higher incidence of postresurfacing hypopigmentation than does the Erbium Sciton laser.Thus the surgeon should take wounds only as deep as they need to go to solve the problem. These issues should be discussed with the patient. As with all resurfacing tools, as the baseline pigment in the skin increases, postresurfacing hypopigmentation increases as well. Thus Fitzpatrick III patients may be better approached with the Erbium laser, accepting slightly less efficacy. If a patient is not a good candidate for resurfacing procedures because of skin type, lifestyle, sun exposure, or the downtime required, fillers should be considered. Certain aspects are especially amenable to correction or rejuvenation with filler. Loss of lip volume occurs with age and is usually perceived more in the upper lip than in the lower lip, especially when the individual is smiling. Additional aspects include loss of the lip border and pout, which leads to the appearance of an elongated philtrum/upper lip and a less pouty appearance of the mouth.

This 38-year-old woman complained of the aged appearance around her mouth. Two syringes of Restylane were injected to correct the wrinkles, soften and fill the nasolabial folds (type IIIb), and reestablish volume to the lips. As mentioned previously, perioral rhytids can be adequately corrected with resurfacing tools, but the added benefit of fillers includes the volume replacement to the lips, reestablishment of the pout, and the appearance of a shortened upper lip/philtrum by volume replacement. Vertical rhytids around the vermilion border can be treated partially and/or completely with fillers. Mild to moderate lines are amenable to treatment by volume replacement or filler placed along the vermilion border.20 The vertical rhytids may be injected if they are deep enough, with care

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taken to not overfill these, since this may result in a ridge instead of a wrinkle.Very severe lines may need to be addressed with resurfacing and a filler.21 Another aspect of perioral facial aging is ptosis of the oral commissures. Ptosis in this area gives the appearance of sadness or anger. Attempts to correct this area with face-lift procedures can be distorting or incomplete. Perioral rhytids will often siphon into the marionette lines, and this, combined with the ptosis of the oral commissure, usually requires multiple corrective techniques.

This 59-year-old woman was bothered by her perioral rhytids, marionette lines, and the downward turn of her mouth. Restylane was injected in the vermilion border, oral commissures, and marionette lines to correct and rejuvenate the perioral area. Injections to the vermilion border reestablished the lip border and partially corrected the rhytids. No injections to the nasolabial folds (Type IIIa) were done.

CONCLUSION For any challenge in facial aesthetic surgery, there are always several ways to proceed.The final decision will be a product of discussion between the patient and the surgeon. It is a pleasure that today we have a multitude of treatment options that can be individualized to meet the goals in a more customized fashion. The adjunctive tools discussed in this chapter can create the subtle finishing touches on surgery that may well be beyond the reach of the scalpel. For each anatomic problem, we have covered several techniques to improve the overall result. In most situations, there is not a right and wrong, but rather a surgeon or patient preference. There are few similarities between this chapter and the original one written for the first edition just 11 years ago. We are excited to think that in just another decade from now, our choices will again be greater and more powerful.

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References —With Key Annotated References 1. Kuran I, Tumerdem B. A new simple method used to prepare fat for injection. Aesthetic Plast Surg 29:18, 2005. In this report, the authors present their 5-year clinical experience with facial fat grafting by isolated and combined procedures using a simple method they developed for fat preparation.This technique includes fat harvesting with syringe aspiration and filtration of the fat aspirate instead of centrifugation. 2. Stuzin JM, Baker TJ, Baker TM. Discussion of Kitzmiller WJ, Visscher M, Page DA, et al. A controlled evaluation of dermabrasion versus CO2 laser resurfacing for the treatment of perioral wrinkles. Plast Reconstr Surg 106:1373, 2000. 3. Stuzin JM, Baker TJ, Baker TM. Expert commentary on Karp RB, Teimourian B. Laser skin resurfacing: The high-energy “peel” of the twenty-first century? Perspect Plast Surg 10:38, 1996. 4. Stuzin JM, Baker TJ, Gordon HL, Baker TM. Invited discussion of Perkins SW, Sklarew EC. Prevention of facial herpetic infections after chemical peel and dermabrasion: New treatment strategies in the prophylaxis of patients undergoing procedures of the perioral area. Plast Reconstr Surg 98:434, 1996. 5. Stuzin JM, Baker TJ, Baker TM, et al. Histologic effects of the high-energy pulsed CO2 laser on photoaged facial skin. Plast Reconstr Surg 99:2036, 1997. To delineate the histologic effects of laser resurfacing at photoaged skin, a protocol was designed to biopsy laser test sites in conjunction with adjacent actinically damaged skin at the time of rhytidectomy. Five patients with photodamaged skin underwent resurfacing of the preauricular region to ex - amine the effect of increasing pulse energy and increasing number of passes on depth of dermal pen- etration.The histologic effects of laser resurfacing are microscopically similar to those of phenol peeling in terms of the amelioration of photodamage .The distinction between these two treatment methods lies in their apparent effect on epidermal melanocytes , which appear to function normally following laser resurfacing. 6. Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg 22:295, 1995. To obtain consistent results, face-lifting should be approached not just as a tightening or lifting proce - dure but also as a reconstructive procedure , reversing the anatomic changes that occur in aging.The abil- ity to bring aesthetic harmony back into the aging face requires the blending of surgical technique, anatomic knowledge, and artistic sensitivity to individualize the surgical approach for a given pa- tient.To obtain surgical rejuvenation while minimizing signs of surgical distortion remains the ulti- mate goal of the authors’ face-lifting procedures. 7. Fitzpatrick RE, Tope WD , Goldman MP, et al. Pulsed carbon laser , trichloroacetic acid , Baker and Gordon phenol, and dermabrasion : A comparative clinical and histologic study of cuta- neous resurfacing in a porcine model. Arch Dermatol 132:469, 1996. 8. Baker TJ. The ablation of rhytides by chemical means: A preliminary report. J Fla Med Assoc 47:451, 1961. 9. Baker TJ, Stuzin JM, Baker TM. Facial Skin Resurfacing. St Louis: Quality Medical Publishing, 1997. 10. Carruthers J, Fagien S, Matarasso SL, Botox Consensus Group. Consensus recommendations on the use of Botulinum toxin type A in facial aesthetics. Plast Reconstr Surg 114 (6 Suppl):1S, 2004. The use of botulinum toxin type A for facial enhancement is the most common cosmetic procedure cur - rently undertaken in the United States. Overall clinical and study experience with botulinum toxin type A treatment for facial enhancement has confirmed that it is effective and safe in both the short and long term . Nevertheless , consistent guidelines representing the consensus of experts for aesthetic treatments of areas other than glabellar lines have not been published.Therefore a panel of experts on the aesthetic uses of Botox Cosmetic was convened to develop consensus guidelines .This publication comprises the recom- mendations of this panel and provides guidelines on general issues, such as the importance of the aesthetic

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11. 12. 13. 14.

15. 16.

17. 18. 19. 20.

21.

evaluation and individualization of treatment, reconstitution and handling of the botulinum toxin type A, procedural considerations, dosing and injection-site variables, and patient selection and counseling. In addition, specific considerations and recommendations are provided by treatment area.The review of each area encompasses the relevant anatomy, specifics on injection locations and techniques, starting doses (total and per injection point), the influence of other variables, such as the patient’s sex, and assessment and retreatment issues. Factors unique to each area are presented, and the discussion of each treatment area concludes with a review of key elements that can increase the likelihood of a successful outcome. Botox Cosmetic (botulinum toxin type A) purified neurotoxin complex (package insert). Irvine, CA: Allergan Inc., Jan 2005. Stuzin JM, Baker TJ, Baker TM. CO2 and erbium:YAG laser resurfacing: Current status and personal perspective. Plast Reconstr Surg 103:588, 1999. Baker TM. Chemicals and lasers for skin resurfacing. Aesthetic Plast Surg J 19:325, 1999. Baker TM. Dermabrasion. Clin Plast Surg 25:81, 1998. Dermabrasion remains an effective and reliable resurfacing option for perioral rhytids, acne scars, traumatic facial scars, and rhinophyma. It is inexpensive, portable, and widely available. It is well taught in most plastic surgical training programs and therefore does not require expensive secondary training courses. Dermabrasion requires no specialized accessory equipment and poses no fire hazard in the operating room. Extensive literature and clinical experience document its efficacy. Proper patient selection and recognition of planing depth are both essential to successful outcome. Despite the recent popularity of the carbon dioxide laser, dermabrasion should remain a fundamental working skill for all plastic surgeons. Guyuron B. The armamentarium to battle the recalcitrant nasolabial fold. Clin Plast Surg 22:253, 1995. Matarasso S, Carruthers J, Jewell M, Restylane Consensus Group. Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane). Plast Reconstr Surg 117(3 Suppl):3S; discussion 35S, 2006. Ergun SS, Cek DI, Baloglu H, et al. Why is lip augmentation with autologous fat injection less effective in the vermilion border? Aesthetic Plast Surg 25:350, 2001. Restylane injectable gel (non-animal stabilized hyaluronic acid [NASHA]) (package insert). Scottsdale, AZ: Medicis Aesthetics, Jan 2005. Hester TR, Codner MA. Discussion of Gunter JP, Hackney FL. A simplified transblepharoplasty subperiosteal cheeklift. Plast Reconstr Surg 103:2036-2039, 1999. Fulton JE, Parastouk N. Fat grafting. Dermatol Clin 19:523, 2001. Autologous adipose tissue has been used for tissue augmentation for more than a century.The technique still remains controversial, and some investigators have given up on fat transfer.The authors’ objective is to improve the retention of the fat graft by using less traumatic methods to collect the fat, concentrate it, and reinject it to obtain more reliable augmentations for the cosmetic improvement of tissue defects. Other than bruising, a rare case of bacterial infection, or an occasional divot at the donor site, autologous fat transfer has proved a useful method to improve contour defects. Baker TJ. Chemical face peeling and rhytidectomy: A combined approach for face rejuvenation. Plast Reconstr Surg 29:199, 1962.

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REVIEW QUESTIONS 1. Brow shaping cannot be manipulated by which muscle? a. Corrugators b. Frontalis c. Procerus d. Orbicularis oris 2. Perioral rhytids can be addressed with which of the following? a. Erbium laser b. Dermabrasion c. Restylane d. Dermal filler e. All of the above 3. Nasolabial folds: a. Can always be corrected with rhytidectomy b. Can always be corrected with fat grafts c. Can always be corrected with resurfacing d. None of the above 4. Fat injections: a. Always survive 100% b. Should always be overgrafted c. Survive equally regardless of the recipient site d. Should be injected with a 30-gauge needle e. None of the above 5. A nasolabial fold that has no significant skin crease is: a. Type Ia b. Type Ib c. Type II d. Type IIIb

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Chapter 16 Revisional Fat Grafting of the Cheek and Lower Eyelid Sydney R. Coleman If you don’t have time to do it right, when will you have time to do it over? John Wooten

Reoperative Problems Excessive orbital fat excision Tear trough depressions after fat excision Inadequate excision of lower eyelid fat Scleral show Malpositioned lower eyelid Persistent eyelid rhytids Hyperpigmentation after blepharoplasty

Deeper pores after blepharoplasty Residual malar fat pad Inadequate cheek shape or volume Asymmetry of cheeks after face lift Asymmetry of cheeks after silicone implants Visible silicone cheek implants Deformities of cheek size and shape after excision or suctioning

IATROGENIC AESTHETIC DEFORMITIES OF THE LOWER EYELID AND CHEEK It has long been assumed in plastic surgery that removal of the signs of aging in the eyelid and cheek would rejuvenate our patients’ aging faces. Surgeons extensively trained in the nuances of blepharoplasties and cheek lifts have operated under the premise that excising lower eyelid fat pads, ironing out the skin wrinkles, and flattening or skeletonizing the cheek would restore youthful contours . However , rather 403

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than rejuvenating, these procedures sometimes deformed these areas, transforming their appearance into something that is neither old nor young. This chapter explores the correction of lower eyelid and cheek deformities secondary to procedures designed to enhance and rejuvenate these areas.1,2

AESTHETIC CONSIDERATIONS

Although the perception of a beautiful cheek varies among different cultures, most consider a full cheek with distinct projection of the upper malar cheek to be the most attractive configuration.The green line in the lateral face marks the most promi - nent protuberance of the attractive cheek . This ridge begins in the midmalar region and runs posteriorly along a line drawn from the alar base to the base of the helix . Immediately cephalic to this line, the cheek gently curves inward to merge into the temple or into the lower eyelid. Caudal to this line, the malar cheek gradually slopes inward to form the buccal cheek. As the cheek slopes from the malar prominence to the eyelid in a youthful attractive cheek the fullness continues up until about 4 or 5 mm below the base of the eyelashes . At this level, a slight depression about 2 mm wide leads into the fullness that runs the length below the lower eyelashes. This depression and the fullness cephalic to it are more obvious on smiling. The anterior malar region in the young person is an area of variable fullness, similar to the fullness seen in the midmalar region.This fullness is considered attractive and youthful. Emptiness or a hollow appearance in this area, especially in the upper anterior malar along the tear trough region produces a tired and sad appearance , even in a young person.

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NORMAL AGING

Because malar cheek prominence occurs at the location of the boney cheek (the zygomatic arch), this prominence remains in the same location throughout most people’s lives. As fullness is lost in the cheeks, the skin drapes over the remaining fat , muscle and bone the exact shape of the zygomatic arch and other bones become

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more obvious and the subtle fullness that separates the facial muscles from the skin of the cheeks dissipates. Removing this physical stint of fullness has two obvious effects. First, the intrinsic tone of the orbicularis oculi muscles on the overlying skin becomes more prominent. Without the physical barrier of subcutaneous fullness, the resting orbicularis oculi muscles affect the skin by forming crow’s-feet. Second, as the fullness of the lower eyelid dissipates and the skin is in closer proximity to the dark muscle and darker veins, the color of the thin eyelid skin darkens. As the lower eyelid ages, the subcutaneous fullness of youth no longer hides the anatomical infraorbital contents. Muscles, fat and bones emerge to create a different topography in the region. The minimal transverse depression described above running slightly under the eyelashes deepens with age to extend down often to the infraorbital rim. As the fullness ebbs from this area, infraorbital fat pads, which were hiding under the youthful fullness, begin to emerge. Depending on the location and size of these fat pads, significant deformities (affectionately known as “bags”) can appear. This process has been improperly described as “herniation” in the past. However, this is not a weakening of the orbital septum; rather it is the natural loss of fullness that exposes the fat pads, which were always there. As the fat emerges, depressions form around the bulge. These typically are located in the tear trough in an oblique line running from the lateral nose at the level of the medial canthus down to the anterior malar cheek below the middle of the eyelid. As fullness is lost from the lower eyelids, the globe and orbital contents become more isolated from the surrounding face.3 Even though some enophthalmia occurs with aging, there is more loss of the surrounding orbital contents, so the globe becomes isolated from the boney orbital rim and the rest of the face. The loss of fullness of the malar prominence will result in a less youthful and healthy facial proportion, with the jowl area becoming more obvious. As this loss in fullness of the midface occurs, the malar prominences can become skeletonized, and progressive buccal hollowing further skeletonizes the face. Loss of facial fullness is a normal process. It can make a face appear more angular, but it also can make a face look anorexic or unhealthy. Adding dramatic fullness to the buccal area and feathering up into the lower eyelids creates a healthier appearance.4-7 Removing fullness accentuates the problem.

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EVALUATION AND TREATMENT RESTORING FATTY TISSUE Generalized, diffuse loss of fullness from the lower eyelid and cheeks occurs most commonly with advancing age. This is not necessarily fat. However, a lack of fatty tissue can occur in iatrogenic or drug-related situations, and occasionally the cause is idiopathic.

This patient presented after a face lift that further skeletonized her face. Her friends felt that she looked as if she had a terminal illness after the procedure. One year after one fat grafting session to the buccal cheeks, feathering up onto the malar cheeks and lower eyelids, the patient appears much healthier.

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PROVIDING LOWER EYELID SUPPORT

Depending on the patient’s intrinsic anatomy, along with his or her previous procedures and scarring, adding support to the lower eyelid and cheek can also elevate the position of the lower eyelid to relieve scleral show, as was done in this patient, who presented with scleral show and wrinkling of the lower eyelids after a transconjunctival lower blepharoplasty. He is shown 3 years after one session of structural fat grafting over the cheeks and the eyelids up to the ciliary margin of the lower eyelid. A dramatic elevation of the lower eyelid diminishes his scleral show. Note the softening of his wrinkles and filling of the infraorbital troughs.

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IMPROVING NORMAL EYELID COLOR AND TEXTURE With loss of subcutaneous fullness in the infraorbital region, the thin skin of the lower eyelids wrinkles and the color of the orbicularis oculi muscles and blood vessels can be seen through this thinned, poorly supported skin. Restoration of fullness to the lower eyelids and cheeks will soften wrinkles and crow’s-feet and can lighten infraorbital darkness. In areas of thicker skin of the periorbital region, pores can deepen with loss of fullness. When the pores deepen enough, they will begin lining up into wrinkles. Restoration of fullness will lessen the size of the pores and stop the deepening pores from lining up into wrinkles.

This woman complained that after an upper and lower blepharoplasty she was left with deep troughs running through her lower eyelids and cheeks that were worse than before the procedure. Fourteen months after the second of two fat grafting procedures, she has remarkable lightening of her skin with lessening of her pore size in the thick skin of her anterior malar region.

Chapter 16 Revisional Fat Grafting of the Cheek and Lower Eyelid

Using a ring flash further delineates the improvement in pore size and configuration as well as in color and shape of the lower eyelids and cheeks. In this patient, as in others, the signs of aging may be exaggerated by lower lid blepharoplasty when lower eyelid fat is removed, thereby emphasizing the progressive loss of fullness and further deepening the infraorbital region.7 When the swelling from the blepharoplasty has subsided, the lower eyelid can be left with increased wrinkling, deeper pores, deeper infraorbital troughs, and a malpositioned lower eyelid, as was evident in the patient pictured above.

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Restoration of Fullness to the Lower Eyelid and Cheek 1,8-10

PREPARATION FOR HARVESTING CHOICE OF HARVESTING SITE Since I have observed no clear correlation between donor site location and longevity of the implanted tissues, I select harvesting sites that enhance body contour and provide maximal accessibility to the patient in the supine position, which is the position used for almost all facial augmentation procedures. I most commonly use the abdomen and medial thighs as donor sites. When there is a paucity of abdominal or medial thigh fat because of prior liposuc - tion or low body fat levels, the suprapubic region , the anterior thighs, and the area above the knees are the next choices . If the patient is placed in the prone position , the posterior medial thigh , the lateral thigh , and the love handles are primary op- tions for donor tissue. The abdomen and love handles are the most common donor sites in men. As in the previous patient, I remove extra tissue from the central midline abdomen and ab- dominis rectus decussations to etch a “six-pack.” In patients with low body fat, es- pecially men , the abdomen and love handles may consist mostly of fi brous tissue with little available fat. Using the thighs as donor sites in these men is an alterna- tive. Even if there appears to be little fat present, harvesting blindly from the lateral thigh and inferior lateral buttocks can yield large quantities of fat. Care is taken to avoid the protuberance of the buttock since unsightly dimpling can result.

PLACEMENT

OF INCISIONS

Harvesting sites are accessed through incisions placed in creases, previous scars, stretch marks, or hirsute areas (circled in red) whenever possible. The pubic region is the most useful site since the abdomen, medial thigh, and anterior thigh can be reached with ease. To harvest fat from the upper abdomen and flanks, additional in - cisions can be made in the umbilicus and upper abdomen . With the patient in the supine position , the knee can be reached through a buttock crease incision . Occa- sionally an incision in the lateral hip can be used for access to the thigh also as well as the lower love handle . Incisions in the mid -back and lateral sacrum provide ac- cess to the love handles and the flank.

STERILE TECHNIQUE Meticulous sterile technique is always observed with careful attention to preoperative patient preparation with antiseptic soaps and an antiseptic agent such as povidone iodine . Bacterial contamination of the fatty tissue can result in infection that causes resorption of the grafted material.

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The choice of anesthesia for harvesting depends on the donor areas and on the projected volume of fat to be removed. For harvesting smaller volumes, local anesthesia using 0.5% lidocaine with 1:200,000 epinephrine is adequate.The lidocaine solution is first placed into the planned incision site through a sharp 25-gauge needle. Incisions are then made with a No. 11 blade. A blunt Lamis infiltrator attached to a 10 ml syringe is used to infiltrate the lidocaine solution into the projected sites of fatty tissue removal. Usually 1 ml of lidocaine is infiltrated for every milliliter of fat harvested. Epidural or general anesthesia is preferred for removal of larger volumes or when multiple sites are used. To ensure hemostasis, Ringer’s lactate in a concentration of 1:400,000 epinephrine is also infiltrated in a ratio of 1 ml of solution for each cubic centimeter of fat harvested using a blunt Lamis infiltrator. Superwet or tumescent techniques are not used during the harvesting phase. I believe that the motion of the harvested fat through large amounts of liquid may break up the parcels of fatty tissue into even smaller components of tissues and cells. This disruption of the intrinsic tissue architecture will decrease the potential survival of the subcutaneous tissues. If less than 1 or 2 cc of the harvested material in each syringe is fat, then as many as fifty 10 cc syringes may be necessary to obtain 60 cc of fat.This can prolong the procedure by hours.

HARVESTING INSTRUMENTATION Instruments for structural fat grafting should be efficient and minimally traumatic to the grafted tissue both during the harvesting and placement phases. A two-holed cannula with a blunt tip and dull distal openings placed extremely close to the end is used for harvesting.

Lumen

The tip of the cannula is completely blunt and has a shape reminiscent of a bucket handle. Sharp edges are minimized around the distal openings to encourage harvesting of small parcels of fat. The other end of the cannula is attached to a 10 ml Luer -Lok syringe . The distal openings of the harvesting cannula are the correct size and shape for harvesting the largest intact fatty tissue parcels that can easily pass through the lumen of the Luer-Lok syringe.

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Lumen

Parcels that can pass through the lumen of a Luer-Lok syringe will usually pass through the much smaller (17-gauge) lumen of the infiltration cannulas without clogging. If open or sharp cannulas are used, the fat may be harvested in long strips, which are difficult to infiltrate through a small cannula.

Dull opening

23 cm

Blunt tip

15 cm

The length of the harvesting cannula is usually 15 or 23 cm. On most cases, I find that curved harvesting cannulas are helpful for navigating the curves of the thigh and back or to better angle the cannulas into a superficial or deep plane.

TECHNIQUE Fatty tissue is harvested through the incisions made for infiltration of anesthetic solutions. These incisions are just large enough (usually 2 to 3 mm) to permit insertion of the tip of the harvesting cannula.

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The inserted cannula is attached to a 10 ml Luer-Lok syringe by the Luer-Lok connection.The plunger is pulled back gently to minimize negative pressure. Only 10 ml syringes are used for harvesting; these are small enough to be manipulated manually without locking devices. Larger syringes are more cumbersome, and pulling back even slightly on the plunger might create damaging negative pressures.

1-2 cc space

During the removal of fatty tissue, care is taken to minimize mechanical trauma to the fragile parcels of fat. The plunger of the syringe is gently manipulated to provide about 1 or 2 ml of negative pressure space in the barrel of the syringe while the cannula is pushed through the harvest site. This manipulation can only be done manually; plunger-locking devices should never be used during harvesting for transplantation. The high vacuums created by these devices or by pulling back too far on the plunger (more than 2 ml) can increase the negative pressure dangerously, potentially to the point of vaporization, the pressure at which water boils at room temperature, which may damage the fatty parcels of tissue. Initially excess fluid (from infiltrated local or other solution) may be noted in the harvested material.When substantial fluid is present, the syringe is placed on a table for several minutes to allow the fatty tissue to separate from the liquid component. Then the aqueous portion can be expressed by pressing on the syringe. The syringe with the refined fat is then reconnected to the cannula and harvesting continues until a greater quantity of fat has been obtained. This approach permits a larger amount of refined fat to be harvested and centrifuged at the same time and avoids wasting time by centrifuging a number of 10 ml syringes that yield only 1 or 2 ml of usable fatty tissue.

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REFINEMENT AND TRANSFER To predict the volume of fat to be placed, the material infiltrated is mainly viable fatty tissue. As much of the oil, blood, water and extracellular components should be removed as is possible without causing significant damage to the tissues to be transplanted. After the fat has been harvested, the cannula is removed from the syringe and replaced with a plug. The preferred plug is called a dual-function Luer-Lok plug for capping and is available in most hospitals. This plug is twisted on to create a seal that will prevent spillage during the centrifuging process. A dual-function Luer-Lok plug for capping is preferred. After the Luer-Lok syringe is sealed, the plunger is removed from the proximal end of the syringe.

CENTRIFUGATION The lid on the centrifuge is then closed and locked, the timer is set at 3 minutes, and the centrifuge spins at about 3000 RPMs (the standard for most hematology centrifuges). After the rotor of the centrifuge has stopped, the technician can then remove the centrifuged syringes.

Upper level Least dense layer Oil from ruptured fat cells

Middle level (30% to 70%) Potentially viable parcels of tissue

Lowest level Most dense layer Blood, water, lidocaine

This separates the denser components from the less dense components to create the multiple layers noted previously . The upper level or the less dense level is composed primarily of oil, presumably from ruptured cells. The lipid portion is composed pri- marily of potentially viable parcels of tissue, with more oil present in the upper por- tion and denser connected tissue present in the lower portion.The lowest level is the densest layer and is composed primarily of blood , water , and lidocaine.

Chapter 16 Revisional Fat Grafting of the Cheek and Lower Eyelid

SEPARATION

OF

COMPONENTS

The oil layer is initially decanted before removing the plug from the Luer-Lok syringe . If the plug is removed before decanting , it will cause the vacuum that holds the contents in place to be lost, and the contents of the syringe will leak out dur - ing the decanting process . After the oil is decanted , the plug can be removed from the Luer-Lok connection. A collection vessel should be used during this maneuver, since the aqueous component will usually pour out of the syringe . Occasionally a small wad of tissue at the opening will prevent the fluid from exiting . If this hap - pens , a light tap on the proximal end of the syringe will usually free the obstruct - ing tissue and allow the aqueous portion to drain out. On rare occasions , it may be necessary to take a hemostat and pull out a bit of tissue from the aperture of the Luer-Lok syringe. Wicking the most superior portion of the harvested fat can facilitate further removal of the oily component of the harvested material. Codman neuropads, used for wicking,9 are placed into the surface of the refined fatty tissue. They will allow the oil to gradually wick in a superior direction after a few seconds. After 4 minutes, the wick is replaced with another piece of nasal packing. Wicking is performed at least twice. Even though it is important to spend an adequate amount of time wicking to remove as much oil as possible, every attempt should be made to minimize prolonged exposure of any of the parcels of cells to air . The plunger is then replaced after allowing the fatty tissue to slide down to the edge of the syringe . A finger should be pressed over the Luer-Lok aperture to control the fat slippage with air pressure. The plunger is then placed into the syringe and advanced to re- move the dead space. The fat can be stored in the 10 ml syringe in this fashion for brief periods of time before transferring to smaller syringes for infiltration. I only use 1 ml Luer-Lok syringes for placement of the tissue into the face and hands and 3 ml syringes for the body. As with the 10 ml syringe , the index finger on the Luer-Lok aperture controls the slippage of the fat back to the proximal end of the syringe . After filling the syringe to a little less than the level of the 0.3 ml mark on the barrel, the plunger is replaced and advanced to remove any dead space. The infiltration cannula is then attached to the syringe. The harvested, refined fat is now ready for infiltration.

ANESTHESIA FOR THE LOWER EYELID AND CHEEK A solution of 0.5% lidocaine with 1:200,000 epinephrine is infiltrated to provide adequate anesthesia of the area placing the least amount that is still effective to avoid significant distortion. Local anesthesia should be placed into the periorbital region using only the bluntest (Coleman type I) cannula. This is done to avoid

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damaging structures such as nerves and blood vessels, but also to avoid entering the lumen of an artery or vein during the injection of local. Damaging an artery or vein during infiltration of the local will interfere significantly with the surgeon’s ability to judge volumes and distribution of the grafted fat during placement. The vasoconstriction caused by the infiltration of epinephrine reduces the possibility of the cannula entering an artery or vein during the placement of fat. Epinephrine should be infiltrated into the periorbital region in every case to reduce the possibility of intraarterial injection.12 Even if the procedure is done under general anesthesia, epinephrine should be infiltrated.

THE INCISIONS

Eyebrow Low temple

Midmalar Commissure

Eyebrow Low temple

Midmalar

Commissure

For the cheek and lower eyelids, I use four primary incisions on each side: in the lateral eyebrow, in the lateral inferior temple at the level of the zygomatic arch, in the lower midmalar, and in the lateral lip.

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INFILTRATION CANNULAS

Type I

For periorbital placement of local anesthesia, for placement against the periosteum of the anterior malar region and for lateral malar placement, I use a type I Coleman cannula to minimize the chance of hematomas and to avoid damage to nerves.The use of type I cannulas when near arteries and veins reduces the possibility of cannulating a vessel and embolization.

Type II

When placing quantities of tissue deep, I will use a transition cannula, the type II. To follow the natural curvature of the maxilla and zygoma, I frequently will use a slightly curved cannula.

Type III

In the lower eyelids, I use type III Coleman cannulas during superficial placement. This allows better control when placing a thin layer of tissue between the orbicularis oculi muscle and the skin in these areas.

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LEVEL

OF INFILTRATION

Placement of fat in the immediately subdermal plane not only provides structural Orbicularis oculi support to the skin, which muscle helps eliminate wrinkles and reduce pore size, but also afOrbital septum fects skin color. It has been my experience that placement Infraorbital Maxilla fat of tissue immediately subdermal can lighten the eyelid skin. Presumably, this can be from providing a barrier to subdermal vessels and muscle or perhaps even a physical action of lightening the skin due to the yellow color of the fat. Unfortunately, this advantageous lightening can be obscured in the early weeks or even months of recovery by bruising, edema, and even hemosiderosis.  In the anterior malar folds, tissue is placed in every level from the periosteum to the skin; this pattern is continued over the entire malar region, extending out to the far lateral malar region and down to the buccal region.  In the lower eyelids superior to the infraorbital rim, the goal is to remain superficial at all times. In the infiltration of the lower eyelids themselves, tissue is placed immediately subdermal or in the orbicularis oculi muscles.8  In the midmalar and lateral malar cheeks, the placement is primarily deep to create structural support, but some tissue is usually placed superficially as well.  In the buccal cheek, the placement is primarily superficial. This helps with skin texture and lessens the possibility of damage to the underlying facial nerves. Approximate volume ranges for each area:  Superficial anterior malar fold: 1 to 2.5 cc  Between the anterior malar fold and nose: 0.25 to 1 cc  Infraorbital rim lateral to the anterior malar fold: 1 to 3.5 cc  Lateral eyelid: 0.025 to 1 cc  Anterior malar region: 1 to 4 cc  Midmalar cheek: 1 to 7 cc  Lateral malar cheek: 1 to 8 cc  Buccal cheek: 1 to 8 cc Special care should be taken in the lower eyelid, where even 0.1 cc is easily visible through thin eyelid skin. Only miniscule amounts should be placed with each withdrawal of the cannula. If a visible lump of fat is noted after infiltration, immediate measures should be taken to ensure that this “lump” will not be left behind after the swelling subsides.

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Digital pressure to alter the offending lump is usually the most reliable approach. However, if the visible piece of fat cannot be easily flattened or dispersed, removal by suctioning with an infiltration cannula may be indicated. Not feathering over the nose and leaving an area of depression between the nose and the anterior malar cheek are likely technical mistakes.

PLACEMENT TECHNIQUE

This 46-year-old woman presented 1 year after an “upper face lift” and a lower lid transconjunctival blepharoplasty. A few months after the procedure, she could see that “it would not be right . . . it would be worse than before .” She complained of looking tired, and not being able to recognize herself.

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With the patient’s input, a plan was designed for correction of her lower eyelids as well as her upper eyelids. Changes in shape were planned in the areas marked in green to restore subtle fullness, feathering out into the areas marked in yellow. The planned incision sites are marked in red. On the day of the procedure, we decided to also place a small amount of tissue into the lateral eyelid, especially on the left side. Green is used again on the markings directly on the face to delineate a change in shape.The orange delineates the limits of placement, as the yellow did in the drawings. The incisions are again indicated by the dark red marks at the commissures of the mouth, the midmalar region, anterior to the sideburns, and in the lateral brow.

To avoid injury to the infraorbital nerve and vessels , a relatively blunt , simple , curved cannula (type I or II) is used for fat placement into the deeper levels in the ante- rior malar fold. The curvature of the cannula allows the surgeon to hug the perios - teum against the maxilla during the first passes so that fat can be placed along the maxilla’s curved surface up to within millimeters of the lateral commissure of the anterior malar fold (tear trough ). Fat should be placed primarily under the actual fold , although some feathering is done above and below the fold against the perios- teum. In this patient 0.5 cc was placed into the anterior malar fold deep primarily next to the periosteum with a type II curved cannula.

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After establishing a small structural volume from the deep anterior malar fold, I bring the cannula to a more superficial level with each successive advancement and withdrawal of the cannula. As the placement becomes more superficial, the danger of harming the infraorbital nerve or vessels diminishes. Switching to a straight type III cannula gives the surgeon more control over the level of placement. The flatter surface at the end of the type III cannula allows the surgeon to guide the cannula under the muscle, into the muscle, and eventually against the skin.

Although some placement into the orbicularis oculi is desirable, I usually place a significant amount into a more superficial plane immediately subdermally. As the cannula becomes more superficial, blanching of the skin overlying the advancing cannula can be seen. The glistening steel-gray aperture of the cannula can be detected through the thin skin of the lower eyelid during many of the superficial passes.

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Although most tissue should be grafted centrally into the depths of the tear trough, feathering should occur superficially medial and lateral to the upper tear trough.

Feathering is critical anterior to the tear trough deformity toward the nose. A slight tissue deficiency usually exists between the anterior malar fold and the nose, which can be accentuated by the placement of an isolated volume into the anterior malar fold. Feathering extends medially to the anterior malar fold and should be extended much further than the surgeon might usually expect to cover deficiencies and promote a smooth surface appearance. Even if a deficiency is not noticeable at all preoperatively, the feathering should extend almost to the nose. In this patient 1 cc was placed into the anterior malar fold superficially next to the skin with a type III cannula.

Placement continues laterally in all the layers from superficial to deep against the periosteum, when present, and along the infraorbital rim. I usually graft tissue from the midmalar incision first before changing to the lateral or oral commissure approaches. More than half of the planned placement volume is placed from the midmalar incision along the infraorbital rim.

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After a structural volume of fat has been placed into the anterior malar fold and along the infraorbital rim from the lower midmalar incision, more tissue should be grafted from the lateral direction.This is placed running along the lateral half to two thirds of the lower eyelid. Usually I use a type I cannula from this direction, since damage to an artery or vein in this region can easily cause hematomas; however, I occasionally use a type II cannula because it pushes through the tissues better. A larger volume should be placed in the vertical and oblique direction than the transverse direction; I usually place around a quarter or more of the volume transversely. Although the amounts placed with each pass end up being more than with the vertical placement, care should be taken to avoid infiltrating too much tissue with each pass of the cannula. Especially when the level of placement is superficial, unattractive “worms” of tissue can be easily visible and difficult to remove.

In recent years I have been finishing off the lower eyelid placement with a more vertical approach to the medial lower eyelid from the ipsilateral oral commissure . This is usually accomplished with a 9 cm type III cannula. This allows a second di- rection of placement into the most medial part of the lower eyelid . The crosshatch - ing this creates improves the quality and stability of the structural placement and re- duces the possibility that the lines of grafted fat will be visible.

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To give more direction for the placement of volume and to encourage structural integrity, I often graft a quantity of structural fat from the oral commissure all the way out to the lateral infraorbital rim. In this patient 2.5 cc was placed into the right lateral orbital rim and 2.2 cc into the left lateral orbital rim using a type II cannula from the cheek and oral commissure incisions and using a type III cannula from the incision laterally in front of the hairline.

After finishing the placement into the anterior malar fold of the lower eyelid and the lateral orbital rim, I usually begin placement into the inferior portion of the an - terior malar fold in the cheek . It is easy to overlook this area , because the swelling that occurs from placement in the lower eyelid at the beginning of the procedure often makes the rest of the cheek look much larger than it is. Therefore the surgeon should plan the amount for placement into this area before the procedure . I most often use a type II cannula in this area and place it at varying levels, depending on my goals. If I am hoping to soften wrinkles, reduce pore size , or reduce acne scar- ring, I graft the tissue immediately under the skin. If I am attempting to disguise a bulge in the anterior cheek above the nasolabial folds, I place more of the tissue deep against the maxilla to counterbalance the bulge. In this patient 2.5 cc was placed into the right anterior malar fold and 2 cc into the left anterior malar fold superficially next to the skin with a type II cannula.

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A transition zone in the lateral eyelid is important to achieve the most aesthetic appearance; if placement along the infraorbital rim ends too abruptly at the lateral extent of the eyelid, a deepening of the wrinkles in that area (crow’s-feet) can occur. Therefore, even if the upper eyelid is not included in the surgical plan, feathering into the upper eyelid from the lateral eye gives a more natural appearance. This is especially true if infiltration into the upper eyelid is planned. Placement into the upper eyelid and lower eyelid without adding to the lateral eyelid will leave an unnatural hollow in this area. On the other hand, too much fullness in the lateral eyelid can create a bizarre bulge. Obviously, overplacement should be avoided. In general, I rarely place more than 1 cc into the lateral eyelid. To avoid hematoma formation, I always attempt placement into the lateral eyelid first with a type I cannula. Because of the fibrous ligaments and occasional scarring from previous procedures, placement with such a blunt cannula can be difficult. If this is the case, I will try a type II or even a type III cannula. To encourage stability, I approach the lateral eyelid from at least two different directions, either above or below and laterally. In this patient 0.5 cc was placed into each lateral eyelid with a type I cannula.

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Usually the circulating nurse records the amounts of tissue placed into each area, as well as the type of cannula used for placement, if appropriate.The amount is placed into the corresponding location on the face, but to avoid confusion at a later date, I name each area as I give the nurse the amount.

This patient had minimal swelling at the end of the procedure, with almost no bruising. In a case such as this, a relatively good idea of the final result can be obtained at the end of the case.

A dressing of one layer of Microfoam tape is applied over most of the areas that were infiltrated. This patient’s surgery was so recent that long-term follow-up is not possible at this time.

POSTPROCEDURE CARE At the end of the procedure , only a minimal amount of swelling is present in the cheeks. However , this appearance can be complicated by unusual amounts of bruis - ing , swelling or even hematomas . In the absence of these factors , the surgeon can become adept at estimating the final outcome from the post procedure condition . Of particular importance , any dips, lumps or irregularities will probably not resolve themselves. These problems should be addressed with the addition or removal of fat as appropriate . The incision sites are closed with 6-0 simple interrupted nylon suture.

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SPECIAL DRESSINGS Placement of a layer of Microfoam tape on the lower eyelids from below the ciliary margin extending out past the limits of fat placement seems to help reduce swelling more than any other single factor in my experience. While distracting out the lateral eyelids, I place the Microfoam tape over the lateral eyelid to more or less stint the area and keep the patient from squinting as easily. Over the malar and buccal cheeks, I also place one layer of Microfoam tape. No Reston foam is used in this area. In addition, if a chin-neck bandage is used, care should be taken to avoid pressure on the newly augmented malar cheeks.

MASSAGE When the dressings are removed, sometimes between 3 and 5 days, the office staff will instruct the patient in a gentle downward rolling massage to encourage lymphatic drainage of the swelling. Patients are encouraged to perform this massage 4 to 6 times a day for one minute on each lower eyelid. I also suggest iced compresses; however, I tell patients to avoid ice dressings that might press in an irregular fashion on the lower eyelid, especially after a difficult placement.

PATIENT EXAMPLES

This 50-year-old patient presented after a face lift and blepharoplasty complaining that although she felt tighter, she thought that she did not look younger. In particular, she was bothered that her lower eyelids were developing dark circles and fine crêpiness.

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As exemplified in the next two patients, markings before 1995 did not include limits of placement.Therefore the green markings in this patient and the following one delineate the major amount, but do not necessarily identify the extent of feathering; 0.7 cc was placed into each tear trough on this patient, with significant feathering above and below the marked area.The area of grafting extended over into the malar cheek anteriorly and out toward the mid cheek where a diffuse general infiltration was performed from the lower lit to the buccal area. Over the entire lateral infraorbital rim out to the midmalar region, another 7.5 cc was placed on the right and 5.5 cc on the left.

The patient returns 1 year after placement with feathering from the infraorbital rim into the anterior malar and mid -malar regions . Fat was also placed into the glabella , forehead and temples , but not the upper eyelids below the eyebrow . Dur- ing the year since the procedure , the patient had not used Retin-A and had no chemical peels or laser therapies.

Chapter 16 Revisional Fat Grafting of the Cheek and Lower Eyelid

Not only is the tear trough or anterior malar fold filled in completely, but also the quality of the skin over the region has improved dramatically. The crosshatching of fine wrinkles over the entire lower eyelid is replaced with a smooth, tight and full eyelid devoid of wrinkles in the locations of fat placement. Pores, which in the preoperative views had been previously hidden in the depths of wrinkles, are now visible as separate entities. A sharp demarcation can be discerned at the most cephalic placement of the fat grafts where the fine wrinkling that was present preoperatively contrasts with the smooth, fuller eyelid below.

The patient returned at 3 years and 7 months after the described fat placement with no further periorbital procedures. She used Retin-A intermittently during the last 2 years, but not consistently . The oblique view of the upper face and closeup of the left lower eyelid shows continued improvement of the texture of skin over- lying all of the areas of placement over the last 2 years and 7 months. As in the 1-year close-up of the lower eyelids, there is a sharp demarcation from the lower eyelid where fatty tissue was placed and the cephalic area where it was not. The skin appears to be even smoother without any additional fullness in the tear trough, and the area above continues to have the fine wrinkling present preoperatively . I have observed this improvement in skin texture with many patients from 4 months to a year and then from a year to 2 or 3 years . There is the possibility that fatty tissue placed immediately subdermally may be able to repair or otherwise im- prove the quality of skin over a long period of time.7

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The patient returned at 8 years with no further periorbital procedures. She has an obvious retention of the entire volume visible in the 1-year and 3-year photographs, but with some loss of the textural improvements seen earlier.

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Correction of Special Problems Following Fat Grafting to the Orbital Region INFRAORBITAL IRREGULARITIES The most likely complications of fat grafting are infraorbital irregularities. If 1⁄ 10 cc is placed into the lower eyelid, a lump can occur. Infiltration into the lower eyelid should never be in increments of greater than 1⁄ 30 cc.

This 48-year-old man went to a well-known and respected plastic surgeon, who attempted fat grafting to the lower eyelids and cheeks.When he returned to the plastic surgeon with multiple irregularities, the surgeon injected catabolic steroids into the transplanted fat. According to the patient, the steroid injections made the irregularities more noticeable, and he developed hyperpigmentation with thinning of the skin in the areas of the injections. This result is most likely from one of two causes. The surgeon infiltrated the fat in increments that were too large and/or the surgeon tried to place fat and then mold it into the shape he wanted. Both of these can result in irregularities. The treatment of this problem is removal of the fat with restoration of a smoother layer by reinfiltration. The most common technique that I use is simply to take a type I cannula and apply negative pressure with a 3 cc syringe over the irregularities. Occasionally, I have also performed open removal of infiltrated fat in the lower eyelids, but the trauma from the open removal is much greater than from a closed suctioning. Unfortunately, this usually will take more than one time.

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This patient is shown before and then after two attempts at fat removal to remove these irregularities followed by structural fat grafting to the area.

OVERCORRECTION IN THE INFRAORBITAL REGION After the surgeon understands the technique of structural fat grafting to the lower eyelids, and obtains consistently smooth results, the next common problem is overcorrection. This is manifest by slight fullnesses especially in the anterior malar fold. The treatment of this is also suctioning with a type I cannula connected to a small syringe.

KEY TECHNICAL MANEUVERS APERTURE DIRECTION AND REMOVAL

OF

GRAFTED FAT

Although the direction of the aperture is not usually a concern, since the fat is grafted by placement during the withdrawal phase, the direction of the cannula aperture is important during any attempt at removal of superficially placed fat. I suggest keeping the cannula facing upward toward the skin and maneuvering the cannula so that the fat is between the cannula and the skin. With the cannula in this position, a little gentle suctioning with a curetting motion will often remove most of the superficially placed tissue.

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During infiltration of the lower eyelids, I use my thumb to guide and to protect the globe. My thumb can also be used to detect the correct level for placement and guide the cannula to that level whether deep or superficial. When the cannula is grafting tissue onto the periosteum or in even more superficial planes, this added sensory input can be helpful, particularly along the entire infraorbital rim, from the medial commissure to the lateral commissure.

As the placement moves to a more superficial plane, sometimes it is helpful to place traction on the skin to detect more accurately the position of the cannula. This can be accomplished by pulling the skin with the fingers of the left hand. In addition, when approaching the cephalic lower eyelid, traction on the upper eyelid can provide better visualization of the skin of the lower eyelid.

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MALAR PROMINENCE: AN IMPORTANT LANDMARK Identify the prominence of the cheek preoperatively and maintain it at that proposed height. The attractive malar prominence usually is most protuberant along a line running from the alar base to the base of the auricular helix. I mark this line using diamonds with the patient standing and participating. This keeps me oriented during the placement of the malar prominence . If the markings are not visible while the malar prominence is being determined, careful attention should be paid to the above landmarks to ensure that the prominence will be maintained in an attractive direction and level.

USE

OF A

TYPE III CANNULA NEAR VEINS AND ARTERIES

From the eyebrow incisions and the lateral temple sideburn incision, I am always concerned about the potential for disrupting a vein or artery and precipitating a dreaded hematoma. That is the reason I always try to use a type I cannula through those incisions. However, there are times that it is difficult to remain in the proper plane with a type I or the tissues are too fibrous for placement with a type I. In those situations, I first try to force a plane in the tissue with a type I or II. Then af- ter a plane is somewhat established, I will switch to a type III for placement. Un- fortunately, it does not always work, but it has been helpful many times.

V-DISSECTOR

IN THE

PERIORBITAL REGION

Although I occasionally will use a V-dissector to free up adhesions or scars in the periorbital region, I do not use routinely. To avoid the accidental use of this more destructive instrument , I remove the V-dissector from my field during placement of periorbital structural fat.

CONCLUSION Supporting the midface and lower eyelids should be a consideration in any attempt at rejuvenation. Simply excising and suspending structures in this area can create unnatural and unhealthy appearances. Many of these problems can be improved on by restoring support or fullness with structural fat. However, the lower eyelid in particular is probably the most difficult area for struc - tural fat grafting. If the surgeon is not intimately familiar with the properties of transplanted fat in the lower eyelid, areas of excess fullness and even irregularities or small lumps will be visible through the skin when the swelling resolves . The lower eyelid is not the area to learn transplanting fat. Augmentation in this region should only be attempted after a surgeon has performed enough grafting in other areas to approach the lower eyelid with confidence in the technique.

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References —With Key Annotated References 1. Coleman SR. Structural Fat Grafting. St Louis, Quality Medical Publishing, 2004. The author’s technique for fat grafting to provide long-term natural rejuvenation in the face and body is described, with guidance for mastering this technique for facial rejuvenation, adjustment of facial proportions, hand rejuvenation, and correction of liposuction and postsurgical deformities. Detailed information is provided on incisions, levels of infiltration, volume ranges, technical considerations, key strategies, most likely technical mistakes, and possible complications. 2. Coleman SR. My view: Structural fat grafting. Aesthetic Surg J 18:386-388, 1998. 3. Coleman SR, Grover R.The anatomy of the aging face: Volume loss and changes in 3-dimensional topography. Aesthetic Surg J 26:54-59, 2006. 4. Chajchir A, Benzaquen I. Liposuction fat grafts in face wrinkles and hemifacial atrophy. Aesthetic Plast Surg 10:115-117, 1986. The idea of correcting soft tissue defects with an injection of fat obtained by liposuction is presented. The technique is described and the results are demonstrated in several patients treated over a period of 1 year. 5. Coleman SR. Structural fat grafts: The ideal filler? Clin Plast Surg 28:111-119, 2001. A description of the characteristics of fat as an ideal filler is provided, as well as the keys to the technique behind successful fat grafting. 6. Carraway JH, Coleman SR, Kane MAC, et al. Periorbital rejuvenation. Aesthetic Surg J 21:337-343, 2001. 7. Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg 118 (3 Suppl):108S-120S, 2006. 8. Coleman SR. The technique of periorbital lipoinfiltration. Oper Tech Plast Reconstr Surg 1:20-126, 1994. Coleman’s first article on fat grafting described a new technique with results that demonstrated every indication of permanence.The technique described is almost identical to the current structural fat technique. Patient examples demonstrate the use of infiltrated fat for rejuvenation of the eyelids and cheeks, elimination of the lower lid tear trough deformity, softening of “herniating” lower lid fat, reduction of infraorbital fat and correction of exophthalmus. 9. Carraway JH, Mellow CG. Syringe aspiration and fat concentration: A simple technique for autologous fat injection. Ann Plast Surg 24:293-296; discussion 297, 1990. 10. Chajchir A, Benzaquen I, Wexler E, et al. Fat injection. Aesthetic Plast Surg 14:127-136, 1990. 11. Coleman SR. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthetic Surg J 22:555-557, 2002.

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REVIEW QUESTIONS 1. In considering the aesthetic ideal, the most prominent protuberance of the cheek should extend along a ridge that runs from the: a. Lateral canthus to the tragus b. Oral commissure to the ear lobule c. Alar base to the base of the helix d. Alar base to the ear lobule e. Midnasal sidewall to the tragus 2. Which is not a result of loss of soft tissue fullness in the cheek/lower eyelid? a. Easier ability to discern the orbicularis oculi tone beneath the skin and the resultant crow’s-feet b. Darkening of eyelid skin caused by closer approximation of skin to darker muscle and overlying veins c. Diffuse loss of subcutaneous soft tissue overlying infraorbital septum facilitating easier perception of infraorbital fat “bags” d. Enophthalmia and more pronounced isolation of the globe from the surrounding face e. Inferior drift of the bony malar cheek prominence 3. Which of the following is an indication for structural fat grafting? a. Inadequate cheek fullness following iatrogenic, pharmacologic, or idiopathic intervention b. Scleral show c. Lower eyelid hyperpigmentation d. Eyelid wrinkling e. All of the above 4. When harvesting fat in preparation for structural fat grafting: a. Only abdominal/flank fat should be used, because fat harvested from other anatomic sites may have decreased longevity b. Minimize mechanical trauma to the lipocytes by using plunger-locking devices during harvesting, which provide a constant amount of negative pressure c. Remove as much oil from the harvested fat as possible by “wicking” d. Superwet or tumescent techniques should be used when harvesting large volumes of fat or when multiple harvest sites are used e. The 10 cc syringes used during centrifuging should be used for placement/injection of fat; transfer of fat into smaller syringes for injection exposes the fat to unnecessary additional trauma

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5. Infiltration of fat into the lower eyelid should never be in increments of greater than: a. 1 cc b. 0. 25 cc c. 0. 1 cc d. 0. 33 cc e. 0. 01 cc

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Surgery of the Eyes, Nose, and Ears

Chapter 17

Reoperative Blepharoplasty James H. Carraway, James R. Miller, and Bradley K. Lewis

The face is the mirror of the mind, and eyes without speaking confess the secrets of the heart. Saint Jerome

Reoperative Problems Hematoma Epiphora Infection Corneal abrasion Lagophthalmos Visual problems Dry-eye syndrome

Scars Undercorrection Ptosis Incomplete or excessive orbital fat excision Inadequate lid crease Increased scleral show and ectropion Lower lid retraction and notching

I

t has been well documented that with the greater longevity of the general pop - ulation, the growing acceptance of plastic surgical procedures in general, and the simple desire of people to look better , the number of individuals seeking aesthetic surgery , and eyelid and facial aesthetic surgical procedures in particular, has in- creased. As younger individuals seek primary aesthetic surgery, there is a growing subpopulation of patients who want revisions and secondary operations to address the effects of aging . As more procedures are performed , more postblepharoplasty complications occur. The purpose of this chapter is to discuss the prevention , diag - nosis , and management of the most common complications after blepharoplasty.1 441

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PATIENT EVALUATION When a patient returns after blepharoplasty with an obvious problem or deficiency , he or she should be fully evaluated for the possibility of conservative or operative treatment . If the first operation was performed by another surgeon , the patient should be given the opportunity to return to the operating physician after it is explained that complications can occur and that the original surgeon can most likely take care of the problem . At that time, patients will usually declare their intentions. Some patients take the reassurance to heart and return to the original surgeon, whereas others have already lost confidence. These patients may even be angry about the re- sults of the first surgery and not wish to return to the original operating surgeon. When faced with postoperative blepharoplasty complications in one ’s own patient or in a patient from another surgeon , the surgeon should determine the cause of the patient ’s complaints , obtain a thorough history , and perform a physical examination, not only for medicolegal reasons and to establish a diagnosis, but also to gain rap- port with the patient. Patients with long-standing complications from previous bleph- aroplasty surgery often manifest a wide range of intense emotions including anxi- ety, fear, anger, and guilt. The best approach is to acknowledge the situation and attempt to work through these feelings with the patient. The patient should be encouraged to explain any concerns. These concerns may differ from the surgeon’s, and for this reason it is good to prepare a patient preoper - atively for potential postoperative problems . We explain to the patient preopera - tively that although the postoperative result will, in all likelihood , be acceptable and pleasing to both the patient and the surgeon, there is always a risk of a postopera- tive problem that the surgeon, the patient, or both may evaluate as a condition that necessitates a postoperative revision . To this end , it is good to evaluate the aesthetic postoperative results with the patient while assessing the postoperative problem. A thorough patient history detailing current and past medical problems is essential in a complete preoperative evaluation. Conditions such as hypertension, diabetes mellitus, cardiovascular disease, thyroid disorders, and menopause should be identified and optimally managed before elective surgery is performed. Specific questions about eye problems should also be posed.The first line of questioning and examination should focus on eye function itself. Is the patient having problems with vision , such as blurred or partial vision loss? Tear function , redness , irritation of the sclera and cornea , and the blinking mechanism must be considered . The patient can reveal much if the surgeon listens carefully . A history of eye irritation that is worse on waking but that clears during the day may indicate that the eyes are not closing well during sleep as a result of lid tightness. During the day the patient is able to forcefully blink and overcome the dryness that occurs with nonclosure . The patient may state that the eyes feel so tight that blinking is difficult. A thorough ophthalmologic examination should also be performed to evaluate visual acuity, visual fields, muscle balance, intraocular pressures, fundoscopy, and asym -

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metries. Particular attention should be paid to patients with poor protective mechanisms, such as dry eye, absent Bell’s phenomenon, facial nerve palsy, and weakness in lid closure. Other eyelid diseases such as rosacea of the eyelid, blepharitis, and ocular pemphigoid should be diagnosed. Individuals with a history of using artificial tear substitutes or antihistamines should have tear production and tear film assessed using the Schirmer test for lacrimal secretion. The Schirmer test, which measures tear production, is usually performed after a small amount of topical anesthetic is instilled in the eye. In our experience, performing the Schirmer test in an irritated eye without topical anesthetic leads to excessive tearing, which alters the results and fails to give an accurate assessment of tearing function. If tear secretion is less than 10 to 12 mm, close attention must be paid to the actual function of the lids and a history of eye irritation. A thoughtful review of the potential causes of this problem, and complicating factors must be undertaken.

Other common problems found in patients who are to undergo secondary blepharoplasty include tearing, corneal irritation, rounded lateral canthus, bowing of the lower eyelid, and increased scleral show, all of which should be evaluated before secondary blepharoplasty is performed. In primary gaze the patient must be examined for these conditions and for poor closure on standard blinking. Muscular tone of the lower lid should be determined to prevent postoperative ectropion. Asking the patient to gently squeeze the lids closed helps the surgeon to evaluate the condition of the pretarsal orbicularis oculi muscle.To test for lid retraction or tightness, the patient is asked to look upward. If there is lid laxity, ectropion or significant scleral show may be obvious. Other methods for testing lid laxity or tightness include the snap-back test and the pinch test. The snap-back test is performed by pulling the lower eyelid down and then releasing it. With the pinch test, the eyelid is folded away from the globe on itself to determine whether there is more than 6 to 8 mm excess.

Inferior retractor muscle

Inferior tarsal plate

Inferior rectus muscle

Orbital septum Orbicularis oculi muscle

Inferior oblique muscle Capsulopalpebral fascia

In evaluating lid tightness, one must consider that three layers compose the lower lid: the external layer of skin, the middle layer of orbicularis oculi muscle and orbital septum, and the deeper layer of capsulopalpebral fascia and conjunctiva.

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If, after blepharoplasty, the skin is tight but the deeper layers seem to be more relaxed on digital palpation, it is likely that appropriate treatment with massage will be sufficient. The patient must be instructed in the technique: the index finger pad is placed on the lower lid flat against the pretarsal muscle area, pushing slightly inward with an upward sweep to stretch the superficial and deeper tissues as much as possible. This maneuver stretches the capsulopalpebral fascia, reduces edema in the lower lid, and allows expansion of the lid in the vertical direction, which is important for recuperation of motility in the lower lid. Pinching or pulling the eye laterally is not sufficient to correct stiffness or vertical shortening. If it is not possible to push the lower lid up, massage may not be of any value. Therefore, using digital palpation, the surgeon can determine whether one or more layers are involved in lid tightness and can develop an appropriate treatment plan.

Most eyelids that have undergone blepharoplasty have lost some elasticity. Elasti - city of the lower lid is assessed by placing the index finger or tip of the thumb un- der the midpart of the ciliary margin and gently pushing in the upward direction. In a normal eyelid, it is possible to push the lower lid gently to the level of the up- per limbus . In the postblepharoplasty patient , this lid can usually be pushed to the upper limbus; however, some degree of tightness or stiffness of the tissue may be noted (left). If a patient has a significant scleral show, which may be the result of scar tissue causing some contracture of the capsulopalpebral fascia, the lower lid cannot be brought up to a reasonable level with digital palpation (right).

Chapter 17 Reoperative Blepharoplasty

Levator palpebrae superioris muscle function, the state of the lateral canthal tendon , and degree of lid retraction are important factors that should be assessed preoper- atively. The patient should be observed to determine how well the eye closes with casual blinking in contrast to voluntary lid closure . Furthermore , when the patient exhibits epiphora , the location of lacrimal puncta and lashes should be assessed . Fi- nally , the medial canthal area should be checked for webbing, and the lateral can- thal area should be evaluated for excess rhytids or crow’s-feet. The patient should be reminded that surgery will not remove all of the wrinkling and that other pro- cedures may be necessary to improve the skin’s appearance , such as chemical peel , collagen injection , or dermabrasion (see Chapter 15 ). Malar pad prominence may be made more obvious by blepharoplasty and in fact may worsen the first few months postoperatively . Resolution may require steroid injection, minute liposuc- tion, and/or extended secondary lower lid blepharoplasty. Certain concomitant conditions may require surgical procedures in addition to secondary blepharoplasty . When secondary blepharoplasty is considered , the surgeon must determine whether upper lid improvement may be obscured by significant eyebrow ptosis. Brow laxity should be evaluated and corrected before secondary blepharoplasty is performed. To see whether a brow lift would benefit the patient , the proper position of the brows can be evaluated by elevating both brows with the fingers to a normal anatomic position at the supraorbital rim . Another condition to consider is hypoplastic malar complex , which is manifested by shallow orbits , prominent globes , and increased scleral show . With the use of malar implants , lat - eral canthopexy , lateral tarsal strips to horizontally shorten the lid, or a malar lift, this problem may be improved. The location and extent of excess lid skin should be assessed. Excess skin creating a skin fold or an extra set of wrinkles can sometime detract from the postoperative result. If there is wrinkling of the skin of the upper or lower eyelids, further treatment by skin excision, brow lift, or even chemical peel might be indicated. If the skin wrinkling is in the lateral and upper eyelid area and a maximum amount of skin has been excised, perhaps the patient should be offered the option of a brow lift . Ideally , brow lift should be discussed with every patient before blepharoplasty simply so the issue will have been broached and the patient will be prepared for the possible need for secondary brow lift (see Chapters 12 and 13). The presence of excess orbital fat should be assessed. Gentle pressure applied to the globe with the lids closed helps to define the location and extent of fat pockets bulging against the orbital septum . If a fat pad is prominent postoperatively , the patient must be informed that some residual fat pad exists and should be removed either through a transcutaneous or transconjunctival route. Determining the location of the upper lid in relation to the pupil and measuring palpebral fissures and lid creases are important parameters in assessment and planning. Preexisting asymmetry of brows and lid creases should be noted.The lid margin and lid creases should be evaluated for level and symmetry , and their dimensions

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should be recorded. Removal of large amounts of upper lid skin in a patient with extensive dermatochalasis may uncover a minimal lid margin asymmetry that becomes obvious once the patient has healed and the bruising has subsided. In such a case it is best to document this preexisting asymmetry preoperatively by taping the lids and photographing the patient. If postoperative ptosis exists after removal of eyelid dermatochalasis, the patient often believes that the asymmetry has been caused by the surgeon. If this asymmetry is an obvious problem that either existed before surgery or was caused by the surgery, the patient must be apprised of a technique that will help to solve this problem and obtain eyelid symmetry. Before a secondary procedure is performed, the goals of secondary surgery must be outlined thoroughly for the patient—possibly more than for the original surgery— and informed consent obtained. The physician should carefully describe the limitations of the planned secondary operation, emphasizing that no procedure is perfect and that even after corrective surgery, additional revisions may be required. The surgeon should describe what the proposed surgery can and cannot do and present the potential risks of the surgery. The purpose of the discussion leading to informed consent is to provide enough information to enable the patient to make an intelligent decision as to whether to proceed with further surgery. The aspect of cost to the patient must be considered. If an unhappy patient with a complication is referred to a surgeon, the insurance carriers will often support a claim for surgery to correct the difficulty. For example, cicatricial ectropion occurring after blepharoplasty is a problem that is usually covered by insurance carriers. However, if a lot of attention is paid to the fact that this problem occurred after blepharoplasty, the insurance reviewers may conclude that although there is a true physical problem, this is something the patient has “done to himself,” and they will resist paying. Therefore, if the surgeon makes a point in communications with the insurance company of calling the problem a postblepharoplasty complication, the insurance company will often review this information and decide to “let the blepharoplasty surgeon take care of the problem” and not pay for the correction. However, if this defect is simply referred to as a cicatricial ectropion, which it surely is, the insurance carrier might be more inclined to reimburse the costs for this reoperation. Documentation of problems by written history, physical examination, and photographs is imperative. Both frontal and lateral preoperative views with proper head positioning are excellent not only for postoperative comparison but also for preoperative and intraoperative evaluation.

TIMING Timing is an important consideration in reoperation after blepharoplasty. Often the patient with eyelid problems will present 1 or 2 years postoperatively, when it is clear that the condition has improved as much as possible with conservative meas-

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ures and that corrective surgery or other maneuvers are indicated. However, in the case of the patient who presents 1 day or 1 week postoperatively with a distinct problem, there is some controversy as to when operative procedures should best be performed. This determination relates mostly to the severity of the postoperative defect. In some cases simple manipulation by massage, intermarginal tarsorrhaphy, or traction sutures will solve the problem. If a patient has a defect that can be partially solved by manipulation or massage but needs to be followed up with surgery, it is best to proceed with the manipulation therapy and then perform the necessary surgery at the earliest possible date. We tend to proceed with operative intervention as soon as possible, simply because the patient is so miserable and because if the problem is not corrected early, it will compound itself. For example, if a patient is unable to close the eye and this condition persists for only a few days, the corneal changes that occur are temporary and can easily be reversed. However, if this situation is allowed to persist for a long time, a corneal ulceration and scar will develop, leaving a defect that is not so easily reversed and that may lead to a lifetime of difficulties with the eye. Therefore, in terms of timing reoperative blepharoplasty, early intervention and correction of the problem are often performed as early as possible to prevent the cycle of corneal or scleral exposure and perpetuation of the problem.

SKIN MARKINGS AND INCISIONS Upper eyelid crease symmetry may be the most important aspect of successful blepharoplasty. Skin markings and incisions are thus critical and must be based on an accurate and reproducible technique. Absolute symmetry of lid creases is generally not present preoperatively, and likewise seldom exists postoperatively. Attention to technical detail remains crucial in avoiding gross lid crease disparities. Complete and precise stabilization of the eyelid is necessary to accurately control the placement and depth of the skin incisions. The inferior incision of the upper eyelid should never be less than 9 mm above the lash line or lid margin. Inappropriate placement of an incision may result in a lower-than-normal eyelid crease. Failure to recreate skin attachments to the levator aponeurosis may also result in a lower-than-normal eyelid crease. Aggressive medial skin excision and placement of the skin incision too close to the lid margin may result in webbing or a pseudoepicanthus.VY plasty or serial Z-plasties may be used to correct this problem. At least 7 mm of separation between the lateral extent of the upper and lower eyelid incisions should be maintained to prevent webbing or unpleasant scarring. Rounding of the lateral canthus and temporal retraction of the lower lids can result from inappropriate placement of the lower lid incision. The lower lid incision is made within 1 mm of the lash line, and the temporal extension should be only slightly below the horizontal position to prevent lateral pull.

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COMPLICATIONS As with all types of surgery, blepharoplasty is associated with certain complications. Traditionally complications have been grouped into two categories: minor, associated with limited functional disturbance and minimal aesthetic problems, and major, associated with functional loss and more severe aesthetic deformities. Similarly, complications can be categorized as temporary, lasting for several days to weeks but being self-limited, and more permanent, lasting for a protracted period of time and requiring medical and surgical treatment. These distinctions are somewhat arbitrary, however, as seemingly minor complications, if unrecognized and untreated, can lead to several weeks or months of prolonged treatment or to the need to reoperate.

HEMATOMA Small localized hematomas discovered under skin or skin-muscle flaps can be evacuated with needle aspiration or stab wound drainage after spontaneous clot dissolution 7 to 10 days postoperatively. Evacuation should be thorough and may be repeated to avoid residual areas of organized clot, which can result in persistent nodular irregularities or cicatrix deep within the lid or in subcutaneous tissue.

VISION LOSS Vision loss or blindness from orbital hemorrhage is the most devastating and serious complication associated with blepharoplasty.The incidence is low, occurring in less than 1 in 40,000 patients or less than 0.4% of cases.2,3 The most serious threat to vision results from retrobulbar hemorrhage and hematoma. Bleeding within the orbit produces increased intraocular pressure with subsequent central retinal artery occlusion and/or optic nerve ischemia by direct compression. Both mechanisms potentially result in vision loss.The exact cause of retrobulbar hemorrhage has been debated with several theories expounded, but vascular injury seems to be the most common explanation.Vision loss from orbital hemorrhage is associated with opening of the orbital septum and subsequent fat excision. Hemorrhage related to vessel injury from injection of local anesthetics, traction on posterior vessels during aggressive fat resection, or poorly controlled fat pad vessels that have retracted deep into the orbit seems to be the culprit.3,4 Orbital hemorrhage is most likely to occur when the vasoactive effect of epinephrine has dissipated, followed by rebound vasodilation, or during a hypertensive episode up to several days postoperatively.5 To decrease the risk of retrobulbar hemorrhage:  Maintain normal blood pressure.  Inject anesthetics with care.  Manipulate orbital fat gently during dissection.  Ensure meticulous hemostasis.  Place the patient in a head-up position postoperatively.  Provide pain-control measures.  Instruct the patient to avoid strenuous activity.

Chapter 17 Reoperative Blepharoplasty

Preoperatively, any patient history of prior intraocular eyelid surgery, comorbid medical conditions such as hypertension, and the use of medications that interfere with clotting or platelet function should be determined. Signs and symptoms characteristic of orbital hemorrhage include severe pain, ophthalmoplegia with diplopia and diminished visual acuity, increased ecchymosis of the eyelids, and proptosis. The orbit will feel tense and resistant. If orbital hemorrhage is suspected, examination should include assessment of visual acuity, fundoscopic visualization, and tonometry to evaluate intraocular pressures. When retrobulbar hematoma is recognized in the immediate postoperative period, medical and surgical treatment should be instituted promptly to decompress the orbit. A patient undergoing blepharoplasty, especially when the surgery is performed on an outpatient basis, should be made aware that the incidence of unusual pain, diminished visual acuity, sudden increased orbital swelling, and other problems should be immediately relayed to the surgeon, who in turn should be readily available to initiate appropriate therapy (see Chapter 5).

Treatment of Retrobulbar Hematoma         

Administer acetazolamide (Diamox) and/or mannitol unless contraindicated medically. Return the patient to the operating suite to remove sutures. Open the wound to allow egress of accumulated blood. Provide immediate pain relief (we prefer intravenous morphine). Perform immediate visual acuity check. Examine the retina to determine the status of the retinal vessels. Consider surgical release of the lateral canthal tendon. Insert a cottonoid wick or a Penrose drain into the hematoma site. Closely monitor the evacuation site and assess the wound status visually.

EPIPHORA Epiphora is usually a transient problem, resolving in days. It is caused by edema distorting the lacrimal canaliculi , but persistent ocular irritation from another cause should be ruled out . Refractory punctal eversion can be corrected by cautery ap- plied below the lacrimal canaliculus on the conjunctival side to produce contrac - tion and inversion of the lid margin at the level of the lacrimal punctum . Naso- lacrimal duct obstruction has rarely been reported after blepharoplasty . A canalicular laceration detected at surgery should be promptly repaired primarily to ensure ade- quate tear drainage postoperatively.

INFECTION Infection after blepharoplasty is rare. Minor inflammation , generally associated with sutures , resolves uneventfully after suture removal . Orbital cellulitis , orbital abscess , and dacryocystitis after blepharoplasty have been reported but are extremely un-

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common and probably are related to the extensive vascularity of the eyelid and its inherent resistance to infection. If cellulitis develops, early diagnosis and prompt, aggressive therapy consisting of antibiotic administration and /or incision and drainage are indicated.

CORNEAL ABRASION Corneal abrasions must be avoided by taking intraoperative precautions to protect the globe. Drying is prevented by corneal lubrication , with frequent instillation of balanced salt solution or arti ficial tears . A contact shell can be used for protection. The surgical wound should be sponged minimally during surgery and , when sponging is necessary , a soft wick sponge should be used to avoid corneal and scleral abrasion.

LAGOPHTHALMOS Lagophthalmos is relatively common after blepharoplasty, especially in patients un - dergoing both upper and lower eyelid blepharoplasty . In the presence of a normal Bell’s phenomenon, this condition is usually asymptomatic. In addition, it is usually self -limiting and transient , and generally resolves in several days as edema subsides . Dry -eye symptoms may be managed in the interim with lubricating drops and ointments. Initial therapy should include vigorous massage of the eyelids and eye- squeezing exercises . Taping the eyelids closed at night before sleeping, the use of a plastic moisture chamber, and insertion of protective contact lenses may be added to the regimen if needed. If these conservative measures fail after a short period, cicatricial lid retraction caused by levator aponeurosis adhesions or excessive skin excision should be suspected. Gentle downward traction on the upper eyelid margin may allow the surgeon to palpate septal adhesive bands and to determine whether there is an obvious lack of skin. Lid retraction resulting from ipsilateral thyroid ophthalmopathy or contralateral lid ptosis (Hering-Breuer reflex) should also be considered in the differential diagnosis. If the problem is caused partially or totally by excessive skin excision , a full -thickness skin graft is appropriate . Cicatricial adhesions are corrected by surgical release and creation of a new eyelid crease. Elevation of the lower eye- lid has also been described for treatment.

VISUAL PROBLEMS When a patient has visual and ocular problems postoperatively, ophthalmologic in - tervention must be performed as soon as possible . Drying of the cornea can cause alterations in visual acuity . Persistent need for ointments can also change visual acu - ity and instill in patients a fear that their vision is deteriorating . Massage and peri- orbital edema also can alter a patient’s astigmatism to a slight degree and can cre-

Chapter 17 Reoperative Blepharoplasty

ate a problem with vision that the patient had not experienced before. In addition , widening an extremely narrow palpebral fissure , which before aided the patient with “pinhole vision ,” can create problems because the patient can no longer rely on this pinhole vision mechanism. It is not uncommon for patients to require ad- justment of their glasses or a change in their prescription after eyelid surgery in the absence of any complications or prolonged swelling. Muscle imbalance, although uncommon, can occur after injury to the superior oblique tendon or the inferior oblique muscle. Excessive cautery use in the supe - rior nasal quadrant places the superior oblique tendon at risk for damage . During secondary lower blepharoplasty the inferior oblique muscle is at risk, because pre- vious scarring distorts the normal anatomy . This problem may also occur with pri - mary transconjunctival blepharoplasty . Early postoperative diplopia may be stimu - lated by edema and may be transient . As with postoperative ptosis , conservative management should be continued as long as improvement is noted . However , sig - nificant postoperative diplopia with diminished motility may be an early sign of retrobulbar hemorrhage; immediate evaluation and treatment are indicated.

DRY-EYE SYNDROME The patient with postoperative dry-eye syndrome is very unhappy, and this annoy - ing and not uncommon sequela has become increasingly recognized by plastic sur- geons .6,7 Minimal or subclinical forms of dry-eye syndrome exist , making detailed preoperative evaluation essential . Even minimal widening of the palpebral fissures with blepharoplasty can produce keratopathy in patients with low tear production . Patients in their fifties or sixties (when tear production is diminished ), women re- ceiving estrogen replacement therapy , patients with contact lens intolerance, or those with a history of increased sensitivity and dryeye irritation are especially at risk for dry -eye syndrome . The Schirmer test , lactoferrin immunoassay test, blink- ing rate, and preoperative assessment of the orbit , lid, and adnexal anatomy are im- portant adjuncts in the preoperative evaluation of these patients.7-9 Patients with absent Bell’s phenomenon and signi ficant diminution of tear production are not suitable candidates for aesthetic blepharoplasty. Dry-eye syndrome is treated with early postoperative massage of the lower lids to maintain laxity and upward motility , massage of the upper lids (if tight ) to maintain the same level of laxity and correction of any factors that predispose to additional drying of the cornea or sclera . Ectropion or extreme stiffness of the lower lid that prevents upward movement on blinking and scleral show must be corrected (see pp. 459-472 and Chapter 18). A temporary lateral intermarginal suture tarsorrhaphy may help to overcome the symptoms of dry eye for several weeks until the massage process has loosened up the lower lid. If the temporary intermarginal tarsorrhaphy suture helps to solve the problem of dryness, it may be necessary to perform a per- manent lateral tarsorrhaphy, which would give longlasting relief . This procedure can be performed in an aesthetically acceptable manner to improve lateral canthal

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support. If the eyelid cannot close because of problems with either denervation of the facial nerve to the upper eyelid or excessive removal of the orbicularis oculi muscle in the upper lid, a gold weight may be placed to aid in lid closure.

DELAYED HEALING Delayed or prolonged healing is unusual and may be associated with extensive cautery use or excessive edema, ecchymoses, and scarring, each of these factors be- ing patient dependent. Conspicuous cicatricial scarring is unusual but may be re- lated to improper incision placement , which is best avoided by meticulous tech - nique . Hypertrophic scarring may result from wound separation secondary to hematoma , trauma , or premature suture removal . Massage , topical steroid cream , and occasionally injection of triamcinolone ( Kenalog ) are the mainstays of treat- ment. Dermabrasion has also been used to successfully treat supraciliary scarring.

HYPERPIGMENTATION Hyperpigmentation of the lower lids from excessive ecchymoses and prolonged absorption of blood is a cosmetic problem. The risk of this is reduced with the use of a skin-muscle flap technique. With extensive skin flap elevation, there may be more edema, ecchymoses, and vasolymphatic obstruction, predisposing to hyperpigmentation. Any congenital preexisting periocular pigmentation is generally not corrected with routine blepharoplasty; this limitation should be discussed in the preoperative consultation with the patient. Dermabrasion or a light chemical peel may be considered if blepharoplasty does not improve this condition.

SCARS The management of scars around the lids is often a challenge. A patient who has a small scar around the lateral canthus that is creating a little pull in the lateral can- thal or lower lid area is anxious to have this defect corrected as soon as possible. However, judicious nonintervention early in the postoperative course is probably the wisest choice. Teaching a patient the art of massaging the lids is very important. Hypertrophic and contracting scars are best managed by direct digital pressure on the scar, preferably against the underlying bony orbital rim. In some instances, hypertrophic scars may be injected with a small amount of a weak solution of triamcinolone . We inject approximately 0.2 ml of Kenalog 10 into an area of hypertrophic scarring to resolve some of the scar tightness. For the patient who is massaging the lower lid and needs only a little extra help, this injec- tion may help to gain better position and function . Blindness has been reported after steroid injection in the eye area , and therefore small quantities must be used ; the injection of a large bolus into any one particular area is avoided . Instead small injections in multiple areas are performed . Steroid injection can cause atrophy of the subcutaneous tissue, and therefore injections should be made deep to the skin rather than just in a subdermal area.

Chapter 17 Reoperative Blepharoplasty

Other ancillary procedures are sometimes necessary. If the lateral canthus is dragged into a downward position, a lateral canthoplasty in the form of a Z can be performed. If there is scar contracture in either the medial or lateral area of the lids in the blepharoplasty incision lines, Z-plasty can be used. Care must be taken to make the Z-plasty limbs large enough so that they will release the scar deeply. If the limbs are too large, however, the scars may show, particularly in the medial canthal area.

UPPER LID PROBLEMS UNDERCORRECTION Undercorrection of the upper eyelid as the result of too little fat or skin excision is a relatively common postoperative complication and is usually easy to remedy. The previous excision, scar line, and the nature of the problem should be evaluated. If there seems to be excess skin but the distance from the eyebrow to the lid margin is shortened, an anchor blepharoplasty technique without skin excision will probably take up the excess skin. Occasionally, failure to recognize an unusually low eyelid crease can result in inadequate upper lid skin excision. More common, however, is the failure to recognize patients with brow ptosis, which results in excessive fullness and apparent redundant upper eyelid skin. Complaints of ocular fatigue and evidence of continuous occipitofrontalis muscle action with resultant deep forehead furrows are related findings. Failure to recognize and correct brow ptosis can lead to excessive upper skin excision, producing poor functional and aesthetic results. Methods of estimating the degree of brow ptosis have been described, as well as techniques of correction, including direct excision of brow skin and subcutaneous tissue, temporal brow lift, coronal forehead lift, and browpexy techniques.6,10-13 To treat excessive skin of the upper eyelids, the excess is directly excised, the lid fold is anchored to a deeper level, or the brow is lifted partially or completely. If there is excess skin that is simply manifested by wrinkling, a chemical peel may be performed. If the excess skin is obviously caused by brow ptosis, the need for a brow lift, either direct or coronal, should be discussed with the patient. If there is simply an excess skin fold that can be excised, this technique can easily be explained to the patient and performed. If the upper lid crease is not clearly defined after surgery and this lack of definition allows wrinkling and apparent skin excess, this situation can be corrected by further deepening of the sulcus with an anchor blepharoplasty technique.

INCOMPLETE

OR

EXCESSIVE ORBITAL FAT EXCISION

Less than optimal results can be associated with both incomplete and excessive orbital fat resection.14 Excessive fat excision can result in an overly accentuated superior sulcus. If bilateral, the results may not be necessarily poor aesthetically, but if unilateral, the results are clearly unacceptable and obvious because of the asymmetry.The surgeon and patient must decide whether to further resect the remaining fat on the contralateral eye or to augment the depression defect to equalize the result.

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PTOSIS Ptosis may be considered a postoperative problem, but the most common “cause” of ptosis is the failure to recognize this condition preoperatively. Often preoperative ptosis is not visualized because of dermatochalasis, which hides the lid margin from view. Appreciation of ptosis preoperatively allows levator aponeurosis adjustment during blepharoplasty; the technique employed is generally dictated by the surgeon’s preference. Ptosis can occur if the levator aponeurosis is injured during blepharoplasty. If the aponeurosis is cut during blepharoplasty, ptosis will not immediately result but will occur only later in the postoperative course. Other etiologic factors include (1) inappropriate high placement of sutures in the aponeurosis during supratarsal fixation and (2) traction dehiscence of the aponeurosis caused by the blepharoplasty procedure, which was unrecognized by the surgeon. Conservative management should be followed as long as improvement is noted. However, if ptosis persists for more than several weeks, surgical exploration should be undertaken. Most often, dehiscence or transection of the aponeurosis is found, requiring appropriate aponeurosis advancement and repair. Minimal ptosis secondary to supratarsal fixation usually resolves with massage over a 2- to 3-week period. Again, if ptosis persists, reexploration is indicated.

Mild ptosis of left eyelid

Preoperative markings

To correct postoperative ptosis, it is wise to plan a procedure that will give great accuracy and near or total symmetry with the contralateral eyelid. We have found that secondary aponeurosis plication offers the best possibility of a predictable result. Usually the amount of postoperative ptosis is only approximately 1 mm.

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Intraoperative exposure of aponeurosis

Immediate postoperative view

Markings for aponeurosis plication

Six-week postoperative view

By plication of the aponeurosis 3 mm per each millimeter of ptosis, the lid level is usually brought up to proper position. When correction of secondary ptosis is planned, one must keep in mind that anesthetizing only one lid makes it difficult to note symmetry at the operating table.Therefore we anesthetize both upper eyelids, paralyzing the eyelid being corrected as well as the contralateral lid to prevent artificial alteration of lid height differences. After anesthetic infiltration of both upper eyelids, aponeurosis plication is the procedure of choice for secondary ptosis repair after blepharoplasty.

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INADEQUATE LID CREASE

Preoperative view

After a primary procedure fails to create a good lid crease, the simple attachment of the orbicularis oculi muscle to the aponeurosis, or the anchor blepharoplasty technique, creates a clear, well-defined upper eyelid crease. To this end, incision to the previous scar, exposure of the aponeurosis, suture of the orbicularis oculi muscle with a permanent stitch to the aponeurosis, and simple closure establish this lid crease nicely. In our experience, suturing the orbicularis oculi muscle to a higher point on the aponeurosis may cause ptosis or lagophthalmos of the eyelid. Therefore the orbicularis oculi muscle should be sutured directly to the aponeurosis lying underneath it. If a technique is used in which the skin margin is sutured to the aponeurosis, it has been our experience that this maneuver creates an irregular or sharp lid fold that is not forgiving in terms of minor variations from the contralateral eyelid.15

Intraoperative exposure of aponeurosis

Anchoring of orbicularis oculi muscle to aponeurosis

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Postoperative view

In other words, symmetry is easier to achieve with the orbicularis oculi muscle-toaponeurosis technique.This procedure can be gratifying and can take up the apparent additional skin that may be present after blepharoplasty when a clear lid crease has not been created.

LOWER LID PROBLEMS INCOMPLETE OR EXCESSIVE ORBITAL FAT EXCISION Excessive fat excision of the lower lid can result in inferior eyelid concavity and a prominent orbital rim with the appearance of sunken eyes.Volume augmentation is the treatment of choice. Underresection of fat can likewise produce suboptimal aesthetic results. A temporal fat pad is the most commonly underresected area of fat in the lower lid. Even if this region has been resected, a bulge may sometimes appear in the lateral area, creating the need for a secondary procedure to remove even more fat. In the upper lid, the medial fat pad tends to be the most difficult to completely eliminate, causing one side to appear more prominent in this area postoperatively. The most common residual fat pad after blepharoplasty in our experience is the lower lateral fat pad. Despite apparent adequate removal at the time of primary blepharoplasty, this fat pad will sometimes manifest as an additional bulge. Removal of this fat can be performed via the transconjunctival route, which is fairly straightforward for the experienced surgeon. If this treatment method is not a consideration, removal through the reopened transcutaneous route is indicated. The additional application of cautery to some of the lateral tissue overlying the lower lateral fat pad area after secondary fat pad removal is helpful for reducing muscle bulk.

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INCREASED SCLERAL SHOW AND ECTROPION The most common complications of lower lid blepharoplasty are increased scleral show and ectropion, which share similar etiologies. Exposure keratopathy may result from lid retraction, especially if upper lid blepharoplasty was also performed. Patients with poor corneal tear film and corneal dehydration quickly become symptomatic with even minimal scleral show. However, although ectropion of the lower lid and lid retraction with scleral show are often associated with dry-eye symptoms, the results of the Schirmer test may be normal or increased. The causes of scleral show and ectropion are varied and additive.16 Measurements should be taken to avoid excessive skin and muscle resection from the lower lid. Careful attention to the position of the lid margin relative to the limbus, precise cephalad redraping of the lower lid flap without tension, and having the patient open the mouth or gaze upward while the amount of necessary resection is evaluated are techniques to better estimate the amount of lower lid redundancy for accurate resection during blepharoplasty.

Causes of Postblepharoplasty Ectropion     

Excessive skin removal Excessive fat removal Excessive muscle removal Scar contracture Damage to orbicularis oculi muscle

    

Adhesions of the orbital septum Hematoma Lax lid margin Proptosis Unilateral high myopia (elongated eyeball)

From Carraway JH, Mellow GC.The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 85:971, 1990.

Although excessive skin removal will cause ectropion, it is not necessarily the principal cause. Excessive fat and muscle removal can also play a role. The lower lid pretarsal orbicularis oculi muscle and its innervation must not be disrupted. Damage to the pretarsal orbicularis oculi muscle, especially by deep lateral dissection with division of facial nerve innervation, reduces its ability to support the lid postoperatively. Another cause of scleral show is excessive edema in the lids with resul - tant thickening that , combined with the pull of gravity , causes the lid to become fixed to deeper tissues in the orbital rim area, bringing the lid position downward. Scar contracture in the septum and the capsulopalpebral fascia, and unnecessary suturing of the orbital septum , are also implicated as causative factors . Hematoma may produce a severe cicatrix deep within the lid or in the subcutaneous tissue , and inflammation of the fat pockets can produce inflammatory bands between the pocket and the skin, causing contracture of the scar and pulling the lower lid down - ward .17 ,18 Factors predisposing to postoperative scleral show , eyelid bowing , or ec- tropion include a unilateral large globe that is unmasked by blepharoplasty , early Grave ’s disease , shallow orbits , hypoplastic malar eminences , and incipient senile ectropion . The last condition is manifested by hypotonicity or flaccidity of the lower lids or weakened canthal tendons.

Chapter 17 Reoperative Blepharoplasty

Scleral show, punctal eversion, lower lid hypotonicity, and lateral canthal tendon laxity must be appreciated preoperatively so that surgical tightening of the lower lid or lateral canthal elevation can be made a part of the operative plan. When scleral show or ectropion is recognized postoperatively, effective treatment should be instituted without delay to avoid an irreversibly fixed lower lid.16 Scleral show or ectropion is best managed initially with conservative methods such as massage and/or injection of minute amounts of steroids. The use of an intermarginal tarsorrhaphy or Frost suture may be required. If these measures are unsuccessful, surgery may be necessary, with excision of scar tissue, release of the capsulopalpebral fascia, skin grafting, and/or insertion of a lid spacer such as cartilage, sclera, or fascia lata. In addition, horizontal eyelid shortening, lateral canthal tendon plication, tarsal strip procedure, or dermal pennant flap technique may be used to tighten and lift the lower lid. Surgery should be reserved for failure of conservative methods.

LOWER LID RETRACTION When it becomes obvious postoperatively that simple massage will not result in tissue relaxation and improvement of the lid retraction, an operative procedure may be necessary. To select the proper operative procedure from the wide array of techniques available, it is helpful to separately consider the various components of the lower lid problem that must be corrected.

Options for Correction of Lower Lid Retraction Problem

Corrective Procedure

Relaxed tarsal margin

Wedge excision tarsectomy Tarsal strip procedure Lateral canthopexy

Shortness of skin

Full-thickness graft Extensive massage

Deep lamellar scar contracture

Release of capsulopalpebral fascia Add spacer of sclera, fascia, or cartilage

Combination problems

Fascia sling Release of capsulopalpebral fascia Skin graft Tightening of tarsal margin

If the lower lid seems to have lost adequate motility in the upward vertical direction, one must evaluate the deep lamella. If the skin is adequate and the tarsal margin is tight, release of the middle layer or lamella is the treatment of choice. Although this area can be approached via the transconjunctival route, often there is scarring of the orbital septum and the deeper capsulopalpebral fascia, and it is hard to release all of this scar tissue from a transconjunctival approach. Therefore an infraciliary incision is made to reopen the blepharoplasty wound, and the orbicularis

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oculi muscle is preserved in the pretarsal area. The pretarsal and preseptal planes are split, allowing access to the orbital septum and the capsulopalpebral fascia. A sharp No. 15 blade is used to push on the fibers, which are tense when a skin hook is placed on the lower lid, and to separate the tight tissue, allowing complete release of the lid in the vertical direction. The lid is then pulled with traction on the middle, medial, and lateral areas, and complete separation of the scar tissue is performed. This maneuver allows upward motility. At that point hemostasis is obtained, and the need for a spacer graft may be considered. If the orbicularis oculi muscle seems to have adequate length, and if there is good substance to the lower lid, then a spacer probably will not be needed. However, if the lid is atrophic and thin, and the orbicularis oculi muscle itself is poor in character, then a cartilage graft may be necessary.

After blepharoplasty, this patient had a retracted, tightly scarred left lower eyelid that was immobile . The deep lamellar scar and capsulopalpebral fascia of the left eye were released. A cartilage graft was not necessary. Postoperatively the eyelid was soft and mobile. Lateral canthopexy19 may be performed if there is dehiscence of the lateral canthal tendon , downward displacement of the lateral canthal tendon , or need for minimal movement of the lateral canthus in the upward and lateral direction . Dermal pen- nant canthopexy described by Jelks and Jelks20 is a convenient way to isolate the lat- eral canthal tendon, mobilize it in an upward and lateral direction, and anchor it to the lateral orbital rim. This procedure does not give as good a “ pull ” to the tarsal margin as the tarsal strip procedure or wedge excision tarsectomy, simply because

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it is not possible to get enough movement in the lateral direction in many cases. In addition, if the patient has significant scleral show laterally, or if there is significant relaxation of the tarsal margin, a procedure in addition to canthopexy such as release of the capsulopalpebral fascia, skin graft, and/or insertion of a spacer graft between the relaxed edges of capsulopalpebral fascia may be indicated.

Wedge Excision Tarsectomy When scleral show is present, wedge excision tarsectomy is an option, but this technique has limited usefulness. Wedge excision tarsectomy (modified Szymanowski) may be performed when the tarsal margin is relaxed and the lateral canthus does not need to be repositioned further laterally. To perform this procedure, the tarsus should be excised with perpendicular cuts, but the pretarsal orbicularis oculi muscle should be spared. Preserving this muscle maintains continuity of innervation to the remainder of the pretarsal orbicularis oculi muscle segment medial to the excision area, which is important for the blink reflex. If there is proptosis or exophthalmos, a wedge excision may be contraindicated because it tends to shorten the lid and pull it behind the axis of the anterior part of the eye, thus increasing exposure of the cornea and sclera. In that instance a sling procedure using either tarsal strip or fascia to pull the lid in the upward direction is indicated.

Tarsal Strip Procedure The tarsal strip procedure takes up where wedge excision and lateral canthopexy leave off in terms of correction of moderate or moderately severe deformities.

Preoperative markings

Excision of tarsus

Postoperative closure

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Inferior tarsal plate

Attachment to lateral orbital rim periosteum

Tarsal strip

The tarsal strip procedure allows preservation of the pretarsal muscle, upward “slinging” of the lower tarsal margin, and shortening of the tarsal margin in a horizontal dimension. In addition, because the surgical approach is made through the lateral fissure, the capsulopalpebral fascia is completely released, which in itself is an extremely valuable maneuver in the case of contracture of the deep lamella. This procedure is performed by making an incision in the lateral fissure, grasping the lateral tarsal margin and elevating it away from the attachments to the lateral orbital rim inferiorly, and then releasing the capsulopalpebral fascia to about the middle part of the lower lid. The lid margin then can be brought upward about 1 cm higher than the usual point of attachment at Whitnall’s tubercle. The amount of lid to be deepithelialized and sutured to the lateral orbital rim is determined, and deepithelialization of the anterior, superior, and posterior areas of the tarsal strip is performed. After deepithelialization, and with the pretarsal orbicularis oculi muscle segment spared, the tarsal strip is brought up and sutured to the anterior border of the lateral orbital rim about 6 to 10 mm higher than the normal position. This maneuver allows the lid margin to come up and, with the release of the deeper scar tis-

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sue, corrects any lid retraction problems. The preservation of the pretarsal orbicularis oculi muscle prevents the usual postoperative droop that may occur within 1or 2 weeks after the tarsal strip procedure is performed. In the literature no mention of the preservation of the pretarsal orbicularis oculi muscle is made, but we believe it is an important step in the overall success of the procedure.

This procedure has been gratifying to use in many cases of bowing of the lower lid with exposure of the sclera. Although some surgeons have noted that this technique creates smaller eyes, this has not been our experience. A normal almondshaped eye seems to be the rule rather than the exception.

In more severe cases of lower lid retraction, use of a fascia sling from the fascia lata area to actually pull the lid margin up may be indicated.

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Medial canthal tendon

Attached to drill hole in lateral orbital rim

We perform fascia sling procedures by taking a direct excision of fascia from the fascia lata and threading this 2 to 3 mm wide piece of fascia from the medial canthal tendon to the lateral orbital rim through a drill hole. This fascia sling runs between the pretarsal muscle and the tarsal plate.

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Full-Thickness Graft A full-thickness graft is indicated when there is an actual shortage of skin. If a postoperative blepharoplasty problem is approached and release of the tightness of the tarsal margin is performed, leaving a definite skin deficit, then a full-thickness graft is the best option. One reason for leaving the pretarsal muscle in place when correcting a lower lid deformity is to facilitate placement of a full-thickness graft directly on top of the muscle for optimal take. The best donor sites for a full-thickness graft include the upper lid skin that has been thinned by removing the orbicularis oculi muscle and postauricular skin. The latter should be thinned well so that it will not have a bulky appearance. The fullthickness graft should be slightly larger than the defect but not more than 20% larger. If the graft is larger than the defect by a large margin, then some excessive wrinkling of the graft will occur. Usually the graft is sutured in place with a running 6-0 Prolene or nylon suture. If the graft is more than 0.5 mm wide, a bolus dressing is usually left in place over the sutures. An intermarginal tarsorrhaphy stitch may be placed to reduce lid motion, and a patch is placed over the eye after bacitracin ointment is applied.

Cartilage Graft If it is determined that lower lid retraction cannot be corrected by wedge excision or a tarsal strip procedure, another method of correction can be considered. If loss of the substance of the tarsal margin and lid seems to be the major problem, reconstitution of this thickness of the lower lid with a cartilage graft from the nasal septum may be a good approach. This technique offers the possibility of adding some bulk to the lower lid, makes massage easier, and gives more support to push the lower lid upward. The underlying principle is to place a stiff material in the lower lid that helps to push the lid margin up to a higher level, thus overcoming the lid retraction. The traditional grafts have been banked sclera, ear cartilage graft, or split nasal septal cartilage graft, which is our preference. Banked sclera is a good stiffener of the lower lid, but it causes inflammation for a longer period of time than autologous cartilage and also tends to have some curling problems. In addition, scleral grafts, unless irradiated or kept in absolute alcohol, may pose a risk of transmission of the AIDS virus. Although this possibility is very unlikely because of donor selection, it is a consideration that must be kept in mind. Ear cartilage is a good alternative for lower lid grafting, but it can be somewhat bulky and is more difficult to delicately sculpt and put in place than septal cartilage.

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Mucoperichondral flap

Septal cartilage

Septal cartilage graft

If a split nasal septal cartilage graft is considered, the patient history must be reviewed. Prior submucous resection or septoplasty precludes the use of this graft in most instances unless adequate cartilage is available for harvest without jeopardizing the integrity of the septum. The nasal septum is evaluated preoperatively to determine whether it is straight enough to use as a flat graft for the lower lid. The graft donor site is approached through a standard L-shaped incision at the mucocutaneous junction as for a submucous resection. The mucoperichondrium is elevated from the hyaline cartilage for a distance large enough to allow the unimpeded harvest of the graft. A 4 mm strut is left in the caudad and dorsal septum, and an incision is made through the cartilage to the mucoperichondrium on the contralateral side. A periosteal elevator is then inserted, and the mucoperichondrium is lifted from the contralateral side of the septum. Once the mucosa is lifted from both sides of the septum and has been freed so that some “working space” has been created, sharp scissors are used to cut the superior and inferior limbs of the graft. Posteriorly it is best to use a small periosteal dissector to separate the cartilage from the perpendicular plate and vomer at its point of insertion. The template for the graft, which is usually a piece of glove paper, is then laid onto the graft and a section is cut to size.

The cartilage is held between the thumb and forefinger of the nondominant hand while a No . 10 blade is used to gradually split the edge of the cartilage to the point that it separates into two parts. The cartilage is usually thick enough so that it can be split down the middle . As the cartilage is split, the two edges separate away from the split and the pieces of cartilage take on a slight concave -convex curvature con - sistent with the scoring or shaving of cartilage in the usual manner.

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After splitting of the cartilage is complete, the graft size is reappraised and the graft is placed in a pocket that has been dissected under the pretarsal muscle, and almost up to the lid margin.

Tarsal plate

Graft

The graft is then sutured in place between the edges of the released capsulopalpebral fascia and anchored to the medial and lateral tarsal plate, with the dorsal part of the graft left in a somewhat straight plane. This configuration pushes the lower lid into a straighter position, helps to overcome the lid retraction, and prevents the capsulopalpebral fascia from healing back to itself.

Graft

In addition, after seating the graft as noted, the capsulopalpebral fascia and any middle lamellar scar tissue can be excised right down to the conjunctiva, which should be left intact. At that point the lid margin is elevated, good support for the lid margin has been created, and enough lower lid laxity secondary to the release of the capsulopalpebral fascia is present that it is possible to maintain this position by diligent massage postoperatively.

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Cartilage graft

This patient had lower lid retraction after blepharoplasty. Deep scar tissue was released and steroids were injected. A cartilage graft was then inserted to support the lower lid. Postoperatively splinting and Frost sutures were used to temporarily secure the elevated position of the lower lids.

Chapter 17 Reoperative Blepharoplasty

LOWER LID NOTCHING Lower lid notching occasionally occurs when wedge excision tarsectomy is performed with the primary blepharoplasty. In this instance, reexcision of the wedge area, leaving the pretarsal muscle intact, can be done. A small Burow’s triangle of skin may also be removed close to the wedge of tarsus to prevent puckering of the skin adjacent to the wedge excision. In cases of hypertrophic scarring, one important principle must be kept in mind. The hypertrophic scar is usually formed as a result of tension and can be overcome only by release of the tension on the scar. Release can be achieved by Z-plasty or full-thickness graft.

USE OF ALLOPLASTIC IMPLANTS FOR LOWER LID SPACER SUPPORT MECHANISM Although the use of cartilage grafts21 is an excellent choice, sometimes this cartilage is not available because of the previous submucous resection/septoplasty or because of a severely deviated septum. Both of these situations make the cartilage graft from the nasal septal area a poor choice. Additionally, use of ear cartilage for a spacer often results in a mild to moderate irregularity of the lower lid which does not show the type of smoothness that we like to see for a good aesthetic result. The basic purpose for using either an alloplastic implant or the cartilage graft is to furnish stiffness and support to slightly push the lower lid up. Comparison of a stiff spacer to other techniques such as tarsal strip, lower lid sling, or buccal mucosa to the conjunctival surface all have their advantages, but may leave something to be desired. A fascia sling support to the lower lid can be very useful when there is simply laxity of the lower lid without much scar pulling the lid in the downward direction. When there is a lot of scar tissue, it is best to release the scar and overcome the cicatricial retraction with a stiffener of some sort. Use of a buccal mucosal graft to the conjunctival side allows release of the capsulopalpebral fascia and placement of a full-thickness palatal graft, which allows the lid to come up. However, this tissue does not have the stiffness needed to actually hold the lid up. It is for this reason that it is preferable to use a stiffener such as cartilage graft or alloplastic implant to perform this maneuver. Medpor (Porex Corporation, Newnan, GA), has become available for this application. This material does not have to be harvested from the nasal septum, sticks to the tissue once it is implanted, and furnishes the same support that a cartilage graft was able to furnish in my patients. With the use of the Medpor implant, I have been able to almost completely eliminate the use of nasal septal cartilage grafts and find that the support for the middle portion of the lower lid is the best that I have seen for any technique. Sometimes, with lateral inferior drift, a tarsal strip or canthopexy procedure may also be indicated to augment the use of the lower lid implant. However, it is the implant that can give support to the middle portion of the lower lid. This support cannot be provided as effectively by any other technique. I have also used this technique for both postcosmetic and reconstructive surgical problems.

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OPERATIVE TECHNIQUE

The patient is prepared in the usual manner and, under local anesthesia, a standard infraciliary incision, as used in a blepharoplasty, is made. The skin is elevated off of the pretarsal and the preseptal muscle using a skin hook, and a blue mark is placed in the area of entry to the submuscular space. The muscle is split about 4 or 5 mm below the lid margin. Once the muscle is split, the inferior pocket is created in the submuscular plane so that the implant can rest inferiorly. The superior pocket must be carefully dissected to elevate or “roll” up the orbicularis pretarsal muscle off of the rather narrow and friable lower tarsal plate. It is sometimes difficult to see the plane between the muscle and the tarsal plate, but it is essential to have that space created well so that the edge of the implant can fit high up into the lid margin preventing either roll-out ectropion or roll-in entropion. Once this is done, a useful technique is to take a little bit of the thin cardboard that comes in suture packs and make a prototype for the size of implant that is needed to lift the lid margin. The paper model is usually cut and put in place and then trimmed to give support to the middle, lateral, or medial part as needed. Any portion of the prototype that is too high will be seen later in the form of a slight bulge or a slight prominence of the Medpor. Once the model is cut, the Medpor implant can be approximated to size and positioned. Then, using the fingertips and a hemostat, the curve of the Medpor implant is made to conform to the convex surface of the globe in the horizontal direction. Once this curve is given to the implant, it can be put in place and the lower edge of the implant settled below on the orbital rim margin or adjacent

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tissue. The muscle is then closed with several 6-0 nylon sutures that are inverted. This gives complete coverage of the implant from the skin side and prevents extrusion of the implant. The skin is also closed using 6-0 nylon sutures. A tape support is placed on the lower lid for about 3 days until the sutures are removed. On the third postoperative day, the patient is instructed to massage the lid in the upward direction so that the whole lid unit is mobile, but within the mobile lid unit there is a stiffener to support the middle part of the lower lid. This has been an ideal situation, and I ( J.H.C.) have performed about 20 of these implant procedures with no extrusion, and with the reoperative rate of 3 of 20, which amounted to only trimming down a small prominent portion of either the medial or lateral part of the implant where it had become prominent with time.This procedure gives an excellent clinical result.

PATIENT EXAMPLES

This 59-year-old patient has bilateral scleral show with extreme laxity of the lids. It was felt that a tarsal strip would augment but not completely correct this problem, and that a spacer or stiffener would be indicated for use.

Two months postoperatively, with Medpor implant spacers in place, a normal contour to the lids is evident and the scleral show has been overcome. The patient has ptosis of the left upper lid, which is to undergo correction at a later date.

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This 65-year-old patient had a previous blepharoplasty with problems including lid retraction of the right lower lid. Placement of a spacer is indicated to give good support to the lid.

Two months postoperatively, the patient shows good support to the lower lid and normal contour. Good closure was achieved in the lower lid.

UPPER AND LOWER LID PROBLEMS Some problems are encountered in both the upper and lower eyelids after blepharoplasty . The most common problems are inadequate removal of skin , inadequate removal of orbital fat, irregular or hypertrophic scars , and excessive removal of skin or fat. In addition , it is possible to either denervate or excise pretarsal muscle of ei- ther the upper or lower lid, causing difficulty with lid closure. With overcorrection of upper lid skin, there are generally two approaches to improvement. The first is to recreate the defect of the original incision and to insert a full-thickness skin graft. A good donor area for a full-thickness skin graft of the upper lid does not exist but a thinned postauricular graft is probably the best option. Full-thickness skin grafts heal reasonably well and often are imperceptible postoperatively. However, some hypertrophy around the edges of these grafts can occur, mak - ing them visible. Another technique is to simply incise the scar line, reopening the wound , and have the patient massage the site over the next few days until the wound heals.The patient is instructed to tape the lids in the closed position before sleeping. This technique will allow the upper lid to heal in the stretched position.

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Overresection of skin in the lower lid can be diagnosed by good motility of the lid in the upper direction, but obvious shortage of the skin with eversion of the lid margin. Correction is best achieved by recreating the defect where the skin was excised and then placing a full-thickness graft from the postauricular area. In the lat - eral orbital area , the scar must deflect laterally and downward rather than upward. Overcorrection by about 30% to 40% is generally adequate; any more than that gives the scar a “crumpled” appearance. Inadequate excision of fat is not uncommon in the lower lid; the lateral pocket is sometimes missed even by experienced surgeons . There is a “secondary ” fat pad in the lateral lower lid that may not be evident during the original blepharoplasty procedure but may present as a bulge laterally after fat has been removed from the middle and medial pockets. Although simple reentry into the wound and excision of this fat as a small bolus is somewhat of a nuisance to have to do because the fat is so minimal, it is the most common cause for reoperative blepharoplasty surgery. Inadequate removal of fat in the upper lid manifests most often as a bulge in the medial corner ; it too must be resected . This fat can be removed with minimal dif- ficulty through a small incision with the patient under local anesthesia. Although inadequate skin removal is better than excessive skin removal, it must be corrected, especially in patients who are particular about obtaining the absolute maximal effect from the operative procedure . Some patients may simply have a few wrinkles on squinting or a tiny fold of skin in the lateral upper lid and they may re- quest that this excess skin be removed . One must be careful not to be pushed by the patient to the point that excessive amounts of skin are removed.This situation leads to lid retraction or lagophthalmos , possibly resulting in corneal drying and injury . It is better to perform a secondary resection of skin than to insert a skin graft be- cause of overresection during secondary blepharoplasty. If patients requesting secondary surgery for skin excision or fat removal were initially operated on by another surgeon, it is wise to test the motility of the lower lid in particular and to ask the patient about closure of the eyes during sleep. If a pa - tient’s eyes do not close during sleep because the upper lids are lagging , then addi- tional skin resection will serve only to make this condition worse and cause corneal problems . A Schirmer test must be performed to determine whether the patient has marginal tearing abilities or in fact has dry eyes.

ADJUNCTIVE TECHNIQUES TO IMPROVE THE BLEPHAROPLASTY RESULT CHEMICAL PEEL Most patients are placed on a regimen of topical glycolic acid and tretinoin (RetinA) products when they are first evaluated for aesthetic surgical procedures. The application of the combination of these two agents reduces fine wrinkles, causes peel - ing and some thickening of the skin , and tends to improve healing from surgical procedures or chemical peels at a later date. Many glycolic acid products are avail-

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able; most creams or gels range in strength between 8% and 12%. Tretinoin is available in a gel as well as a cream form and it comes in different strengths. It is best to warn the patient that these products will cause some redness and peeling. The patient should be instructed not to go outside without applying sunscreen, and to remain in the sunshine for only a short period of time. Trichloroacetic acid is also used after blepharoplasty when fine wrinkles and crêpey skin seem to persist (see Chapter 15). If the glycolic acid and tretinoin combination does not improve skin problems, then 35% trichloroacetic acid may be used on the upper lids to tighten the skin as well as to reduce fine wrinkles. It is best to prepare the skin with tretinoin application for 4 to 6 weeks before the use of trichloroacetic acid products. Treatment with this topical acid can be performed with minimal preoperative sedation and analgesia. Although it causes some burning, a small handheld fan helps to alleviate this sensation, which lasts for only a few minutes. Good results are achieved, but the patient cannot be promised more than simple improvement of minor wrinkles and tightening of relaxed or crêpey skin.

Residual fine wrinkles around the eyes persisted after blepharoplasty in this patient, and she wished to have their appearance diminished. A 35% trichloroacetic acid peel was performed that resulted in the resolution of some rhytids. The Baker phenol formula is also useful in patients who are fair skinned and have fine wrinkles. The disadvantage of the Baker phenol formula is that it causes a loss of pigmentation in the skin around the eyes; to some patients this result is unaccept-

Chapter 17 Reoperative Blepharoplasty

able. However, for patients who want to pursue elimination of their wrinkles, the Baker phenol peel is an excellent modality to eradicate 70% to 80% of the existing periorbital rhytids and relaxed skin. The “down-time” is much greater after peels with phenol than with trichloroacetic acid and is slightly greater with trichloroacetic acid peels than with a glycolic acid and tretinoin regimen.

SECONDARY BROW LIFT When a patient requires a brow lift after blepharoplasty, the surgeon must determine the level of lift indicated. For excess lateral skin, sometimes a simple lateral ellipse might be adequate to eliminate that small area of excess skin.

After blepharoplasty this patient had residual brow ptosis. A direct brow lift with ex - cision of excess lateral skin was performed with good results. If the patient has wrinkles in the brow and a direct excision is acceptable, midfore - head direct excision of skin will achieve a satisfactory lift of the midbrow and lat- eral brow area. This technique is not helpful for midbrow or medial brow droop - ing. If the patient realizes after blepharoplasty that a coronal lift would have been preferable (as originally advocated by the surgeon), a coronal lift can be performed either at the hairline or with a classic coronal incision. The advantages and disad - vantages of each level of incision should be carefully considered and discussed with the patient. The merits of a secondary brow lift, when indicated, cannot be over - estimated (see Chapters 12 and 13). Sometimes the patient simply cannot be con- vinced at the time of the first surgery that a brow lift is really indicated , but must wait to see the postoperative result before proceeding with brow lifting.

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References —With Key Annotated References 1. Codner MA, Day CR, Hester TR, et al. Management of mundane to complex blepharoplasty problems. Perspect Plast Surg 15:15, 2001. 2. Shorr N, Cohen MS. Cosmetic blepharoplasty. Ophthal Clin North Am 4:17, 1991. 3. Lisman RO, Hyde K, Smith B. Complications of blepharoplasty. Clin Plast Surg 15:309, 1988. 4. Heine JB, Hueston JT. Blindness after blepharoplasty: Mechanism and early reversal. Plast Reconstr Surg 61:347, 1978. 5. Gradinger GP. Problems and complications in lower lid blepharoplasty. In Kaye BL, Gradinger GP, eds. Symposium on Problems and Complications in Aesthetic Plastic Surgery of the Face. St Louis: Mosby, 1984, p 252. 6. Rees TD, Aston SJ, Thorne CM. Blepharoplasty and facialplasty. In McCarthy JG, ed. Plastic Surgery. Philadelphia: WB Saunders, 1990, p 2320. 7. Rees TD, Jelks GW. Blepharoplasty and the dry eye syndrome: Guidelines for surgery? Plast Reconstr Surg 68:249, 1981. 8. Jelks GW, McCord CD Jr. Dry eye syndrome and other tear film abnormalities. Clin Plast Surg 8:803, 1981. 9. Rees TD, LaTrenta GS. The role of the Schirmer’s test and orbital morphology in predicting dry eye syndrome after blepharoplasty. Plast Reconstr Surg 82:618, 1988. 10. Wilkins RB, Hunter GJ, McCord CD, et al, eds. Oculoplastic Surgery, 2nd ed. New York: Raven, 1987, p 451. 11. Horton CE, Murphy JB. Secondary blepharoplasty. In Kaye BL, Gradinger GP, eds. Symposium on Problems and Complications in Aesthetic Plastic Surgery of the Face. St Louis: Mosby, 1984, p 264. 12. McCord CD, Doxanas MT. Browplasty and browpexy: An adjunct to blepharoplasty. Plast Reconstr Surg 86:248, 1990. 13. McKinney P, Mossier RD, Zukowski ML. Criteria for the forehead lift. Aesthetic Plast Surg 15:141, 1991. 14. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 96:354, 1995. With aging, the periorbital area reveals progressive exposure of underlying skeletal anatomy compared with the areas of the lower face, where thicker soft tissues cover underlying bony landmarks.The author describes a technique to preserve lower eyelid fat and advance it beyond the infraorbital rim. This procedure is especially suggested in secondary procedures correcting overresection of orbital fat or deformities resulting from malar augmentation. 15. McCord CD. The correction of lower lid malposition following lower blepharoplasty. Plast Reconstr Surg 103:1036, 1999. Lower eyelid malposition is the most common complication after lower eyelid blepharoplasty.When malposition occurs, it is imperative to correct it using the most efficient method.The author presents methods for correcting both minor and severe cases. 16. Carraway JH, Mellow GC. The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 85:971, 1990. Ectropion and scleral show are the most common complications after lower lid blepharoplasty.This article discusses preoperative evaluation, operative techniques, postoperative treatment, and postoperative measures to prevent ectropion after blepharoplasty. 17. Tenzel RR. Surgical treatment of complications of cosmetic blepharoplasty. Clin Plast Surg 5:517, 1978. 18. Nesi FA, Katzen LB, Li Vecchi JR. Complications of blepharoplasty. In Smith B, Della Roca R, Nesi F, et al, eds. Ophthalmic Plastic and Reconstructive Surgery. St Louis: Mosby, 1987, p 732.

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19. McCord CD, Boswell CD, Hester TR. Lateral canthal anchoring. Plast Reconstr Surg 112:222, 2003. Surgeons performing aesthetic or reconstructive surgery procedures on the lower lid or midface through the lower lid should be comfortable with canthal anchoring procedures (canthoplasty and canthopexy). This article discusses the principles involved in canthal support for patients undergoing aesthetic and reconstructive surgery, variations in surgical techniques required to perform canthal anchoring in a variety of patients, the significance and techniques of canthal anchoring as they relate to aesthetic and reconstructive lower lid surgery, and the effect of canthal anchoring on the function of the upper and lower lids and eyelid fissure shape. 20. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 20:417, 1993. 21. Carraway JH, Den MJ. Refinements in ptosis surgery using frontalis sling technique. Operative Tech Plast Reconstr Surg 1:113, 1994.

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REVIEW QUESTIONS 1. Lower eyelid massage for postoperative blepharoplasty tightnesss is performed in what direction? a. Inward and upward b. Pinch and pull the lower lid away from the eye c. Lateral stretching d. Downward stretching 2. When orbital hemorrhage is suspected, examination should include all of the following except: a. Assessment of visual acuity b. Fundoscopic examination c. Tonometry to exclude elevated intraocular pressure d. Schirmer test 3. Which is the most common residual fat pad after blepharoplasty? a. Upper medial b. Lower medial c. Lower lateral d. Lower middle 4. What is the best procedure to correct lower eyelid scar contracture? a. Tarsal wedge excision b. Tarsal strip c. Cartilage graft versus Medpor implant d. Lower lid sling 5. Placement of a Medpor implant in the lower lid should be in what anatomic plane? a. Just deep to the skin b. Just deep to the orbicularis oculi muscle c. Deep to the capsulopalpebral fascia d. Inline with the conjunctiva 6. The following is true regarding the Schirmer test in secondary blepharoplasty: a. It is not helpful in individuals with a history of use of antihistamines and artificial tear substitute b. If the tear secretion is less then 10 to 12 mm, the lids may be inadequately functioning c. Is best performed without topical anesthetic in the eye d. Excessive tearing occurs when the Schirmer test is performed under topical anesthesia e. Most secondary blepharoplasty cases demonstrate lacrimal gland hypose - cretion

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7. The treatment of retrobulbar hematoma includes all of the following except: a. Administration of acetazolamide (Diamox) or mannitol b. Removal of sutures c. Release of the lateral canthal tendon d. Patch, head elevation, and observation e. Placement of a cottonoid wick into the hematoma site 8. All of the following can cause postblepharoplasty ectropion except: a. Excessive skin removal b. Excessive fat removal c. Laxity of the orbital septum d. Damage to the orbicularis oculi muscle e. Proptosis 9. The best approach to the lower lid for correction of lower lid retraction is: a. Transconjunctival approach b. Infraciliary approach c. Combined transconjunctival and lateral canthotomy d. Lateral conthotomy approach e. Infraorbital approach 10. Which of the following would be contraindicated in lower lid laxity with proptosis? a. Wedge excision tarsectomy b. Tarsal strip procedure c. Lateral canthopexy d. Lateral canthoplasty e. Fascial sling

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Chapter 18 Reoperative Lower Lid Blepharoplasty Mark A. Codner and M. Keith Hanna

To go too far is as bad as to fall short. Confucius

Reoperative Problems Lid malposition Ectropion Dry eyes Scarring Lateral canthal dehiscence Bleeding

Infection Retrobulbar hematoma Corneal abrasion/ulceration Chemosis Visual problems/visual loss

L

ower blepharoplasty has been called one of the most challenging procedures in plastic surgery and is also one of the most commonly requested and performed aesthetic procedures. With the increase in the number of procedures performed, there is also an increase in the incidence of postblepharoplasty complications. Today there are two evolving trends in blepharoplasty: (1) toward more aggressive techniques to maximize the aesthetic outcome and (2) toward more conservative techniques to minimize the risk of complications. This has created a dichotomy with the pendulum swinging between the two sides with techniques such as transblepharoplasty subperiosteal midface lifts on one side and “no-touch” blepharo - plasty using a transconjunctival approach and skin pinch or laser resurfacing on the

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other. Lid retraction and ectropion are the most common complications that occur after lower blepharoplasty and the most common causes for reoperative surgery. Interestingly, these complications occur after all techniques from both ends of the spectrum.

Transconjunctival lower blepharoplasty does not, in fact, eliminate the risk of lid malposition, as some of the original publications suggest, and as shown in the patient above. Because complications after lower blepharoplasty cannot be entirely eliminated, the goal of surgical techniques is to minimize the risk.Therefore, rather than blaming a particular blepharoplasty technique or, even worse, blaming the surgeon, the risk factors that might predispose certain patients to complications should be recognized before surgery.

Müller’s muscle

Lateral canthal tendon Lockwood’s ligament Inferior tarsal muscle

Posterior reflection of medial canthal tendon Anterior reflection of medial canthal tendon Lacrimal sac fossa

Arcuate expansion

Knowledge of the anatomy supports the hypothesis that untreated posterior lamellar tarsoligamentous laxity is the primary cause of lid malposition. Patients with minimal laxity often require lateral canthopexy, whereas patients with significant

Chapter 18 Reoperative Lower Lid Blepharoplasty

laxity may require a lateral canthoplasty. In addition to lateral canthal support, orbicularis suspension should be performed to support the anterior lamella.This fundamental principle of two-point fixation of the anterior lamella and the posterior lamella significantly reduces the risk of complications. All blepharoplasty techniques are complex, technically demanding procedures with little margin for error. Patients present with lid malposition and ectropion from our own practices and are also referred from other practices. In addition to the prevention of complications in primary cases, the purpose of this chapter is to provide a logical sequence for both conservative and surgical correction of complications after lower lid blepharoplasty in secondary cases. Unfortunately, patients and surgeons may find themselves needing to revisit the reconstructive procedure to correct a serious sequela after what began as a cosmetic endeavor. Successful and predictable techniques should be used to turn the situation around and restore the shape and position of the eyelid. The most common technical error is to perform “too little” in an attempt to quickly satisfy an unhappy patient.

PATIENT EVALUATION The goal of primary blepharoplasty is to restore a more youthful appearance to the periorbital area while minimizing complications. Minimizing the risk of complications begins with the preoperative evaluation. Objective assessment of specific disease processes and physical findings will help identify patients who are at high risk for complications. These findings have been used in the development of an algorithm to determine which surgical procedures to perform.1 The goal of reoperative lower blepharoplasty is to restore the shape of the eyelid to the preoperative appearance while correcting the functional problems caused by corneal exposure. The first consideration when evaluating a patient with complaints after blepharoplasty is to reassure the patient that corrective revision surgery is possible and can be performed. Many patients are devastated by the appearance of their eyes as well as the discomfort associated with corneal exposure. It is very important to restore hope through reassurance. If a colleague performed the initial procedure, the patient should be given the option to return to the previous physician. Most patients usually have had secondary procedures that were unsuccessful because the approach was insufficiently aggressive. Lateral tarsorrhaphy and canthopexy without a lower lid spacer are the most common attempts that have been made, usually without success. Although suture tarsorrhaphy can temporize some of the symptoms associated with corneal exposure and can reduce chemosis,

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it cannot generally correct lid malposition. In addition, reoperative lower lid surgery for lid malposition is much more complicated than primary lower blepharoplasty and is associated with a higher rate of revision. In our own practice, the incidence of reoperative surgery after primary procedures is less than 5%, whereas the incidence after secondary corrective procedures is approximately 25%.

LID RETRACTION

Anterior lamella

Posterior lamella

Tarsal plate Skin

Lid retractors

Muscle Skin shortage

Scar contracture

Septum (middle lamella)

Patients need to understand that their eyelid position can be improved, but this will often require more than one operation. Retightening the lateral canthal angle is the most common tertiary procedure required after revision surgery. This should be explained to the patient, as well as that in any surgery complications can result from scarring, hematoma, and the downward retractive forces of healing that occur after blepharoplasty. Lid malposition is not commonly caused by the removal of too much skin—this is the most common misconception that patients may use to point blame toward the surgeon. If a patient chooses not to return to the previous surgeon or if you feel that the surgery is beyond the scope of that practice, then you should discuss alternative treatment plans with the patient. As a matter of courtesy, communication with the primary surgeon should be considered. In the initial evaluation the surgeon determines what technique was performed, the timing of the procedure, and any known complications that may have occurred after surgery, such as hematoma, excessive swelling, or chemosis. Determining the cause of the patient’s complaints should be the primary goal when evaluating a postblepharoplasty complication. A thorough history and physical examination

Chapter 18 Reoperative Lower Lid Blepharoplasty

should be obtained for diagnostic purposes as well as for medicolegal documentation.This is also a time to develop a relationship with the patient, who probably exhibits a wide range of emotions. When obtaining the history of the patient’s complaints, the surgeon should ask specific questions about eyelid function as well as appearance: Is there any visual impairment, tearing, dry eyes, irritation of the cornea or sclera, blinking function, or a sensation of a foreign body or “sand” in the eye? The surgeon’s questions should explore any predisposing medical conditions that would increase a patient’s risk for complications after eyelid surgery, such as pemphigus, rosacea, Graves’ disease, benign essential blepharospasm, dry-eye syndrome, and certain neuromuscular disorders such as myasthenia gravis.2 All of these disorders increase the risk of complications after blepharoplasty.

Lid snap-back test

Bell’s phenomenon

The physical examination should include evaluation of visual acuity, testing of the extraocular muscle, and assessment of the protective mechanisms of lid closure and for Bell’s phenomenon. The extent of lagophthalmos should be measured. When a patient complains of irritation, dry eye, or foreign-body sensation, a slit-lamp examination should be considered to reveal possible corneal abrasion or ulceration. Fluorescein eyedrops will appear fluorescent when viewed with an ultraviolet light at an area of corneal epithelial injury. A pattern of dryness should be evaluated, which ap-

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pears as a transverse linear band across the lower part of the cornea that corresponds to the degree of lagophthalmos. Although this pattern of exposure can be treated with liberal ophthalmic antibiotic ointments and patching at night, a deeper corneal ulcer should be cause for immediate referral to an ophthalmologist for evaluation because of the risk of superinfection, scarring, and perforation.

Complaints of dry eye should also be evaluated with a Schirmer’s test, which measures baseline tear production.3 A Schirmer’s test using an anesthetic should be performed in patients presenting for primary blepharoplasty with symptoms of dry eye, which are most commonly elicited by a history of contact lens intolerance. This test is conducted by first placing a topical anesthetic (tetracaine) in the eye to avoid irritation and stimulation of excess tearing. The fornix is dried with a tissue, and the test strip is placed in the lateral part of the lower lid fornix and left in place for 5 minutes. The patient should be instructed to look forward to avoid a corneal abrasion while the strips are in the lateral fornix, which can injure the cornea if the patient looks to the side. Tear secretion of less than 10 mm at 5 minutes is considered abnormal; such a patient is at increased risk for corneal dryness. Therefore conservative brow lift and/or upper blepharoplasty should be performed to minimize lagophthalmos as well as to prevent lower lid malposition. Secondary cases should include close inspection of the lower lid, which should also be examined for entropion, ectropion, rounded lateral canthus or phimosis, canthal webbing, improper alignment of the lower lid margin, shortening of the horizontal aperture, increased scleral show, and lid tone. Lower lid laxity should be carefully evaluated before primary blepharoplasty. Tarsoligamentous laxity can be determined by the snap test or the pinch test.The snap test is accomplished by pulling the lower lid down and releasing it. Normal tone is present when the lid retracts to the globe immediately.

Chapter 18 Reoperative Lower Lid Blepharoplasty

The pinch test is performed by distracting the lower lid away from the globe and measuring the distance.These tests help determine the type of lateral canthal tightening procedure that should be performed. Lid distraction of 1 to 2 mm indicates good tone and requires minimal lower lid tightening or a preventative canthopexy depending on the blepharoplasty technique. Canthopexy should be considered for moderate laxity demonstrated by 3 to 6 mm of distraction, and canthoplasty is recommended for lid distraction greater than 6 mm.4 Patients with lid retraction or ectropion should be similarly evaluated. In addition, the lid should be pushed in a superior direction with the index finger in the midpupillary line to evaluate posterior lamella scar contraction. If the eyelid appears to have excess skin that can be stretched at least to the level of the pupil but is restricted by the posterior lamella, which prevents the lid from being elevated to the level of the pupil, then these patients have primary posterior lamella retraction of the lower lid.This requires release of the posterior lamella and lid spacer. On the other hand, if the lid is limited by the skin, the primary problem is a shortage of anterior lamellar skin, which is commonly present with actinic damage. In addition to a lid spacer, this problem requires a cheek advancement to recruit skin into the lower lid or a skin graft.

Although ectropion most commonly involves the central and lateral aspect of the lid margin , isolated medial ectropion warrants additional discussion . Medial ectropion displaces the inferior punctum away from apposition to the globe , resulting in im-

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paired lacrimal drainage. Patients will often present with epiphora, in contrast to the symptoms of dry eye often associated with ectropion. Furthermore, medial ectropion requires additional techniques to reposition the inferior punctum against the globe. A medial canthoplasty and fascia suspension of the tarsoligamentous sling are the most successful methods for correcting a medial ectropion. Although lateral canthoplasty and lower lid spacer grafts are effective for correcting central and lateral ectropion, correction of medial ectropion may be inadequate with these techniques. The function of the eyelids should be examined by asking the patient to blink to determine whether the patient can completely close the eyelids during normal blinking. The three types of blink should be evaluated: involuntary, voluntary, and forced. These different blinking mechanisms recruit additional orbicularis muscle heads recruiting pretarsal, preseptal, and orbital orbicularis fibers, respectively. Although the upper lid orbicularis functions to create the majority of the blink mechanism, the lower lid is a dynamic structure that also moves superiorly and medially with each blink. Furthermore, the lower lid orbicularis deep heads contribute to the lacrimal pump, which can also be impaired with ectropion. If the lid cannot be closed, the physician must then determine whether this is caused by edema, deficiency of skin, scarring, or lateral canthal dehiscence.

With dehiscence or loosening of the lateral canthus, the eyelid is not well anchored to the lateral orbit, and orbicularis contraction during blinking will cause nasal migration and rounding of the lateral canthus or “fish-mouthing” of the eyelids.5 This has a significant impact on the ability of the lids to close. The normal dynamic component of lid closure is impaired. In addition to lateral canthal support to restore lid shape, bony fixation of the entire lateral canthal mechanism, including the lateral canthal tendon to the upper lid, is required to restore functional closure.

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The shape of the eyelid is also an important consideration when evaluating a postblepharoplasty patient. The margin of the lower lid most commonly is positioned at or just above the inferior limbus. Upper lid crease

Upper lid fold

Upper lid sulcus

Lateral canthus Medial canthus Canthal tilt

Nasojugal groove

Lower lid crease Eyelid-cheek junction

Negative canthal tilt

Positive canthal tilt

The anatomic relationship between the lateral and medial canthus is termed the canthal tilt.The most common finding is a positive lateral canthal tilt, when the lateral canthus is 1 to 2 mm superior to the level of the medial canthus. Another good visual reference to eyelid shape is the amount of exposed sclera on each side of the cornea, the nasal and lateral scleral triangles. The lateral scleral triangle is normally larger and more pointed than the nasal scleral triangle. Any deviation from these vi - sual keys of the “normal ” eyelid shape may indicate the need for a lateral canthal tightening procedure. For secondary cases, it is vitally important to have patients provide a photograph of their eyelid shape before the complication . Careful analy- sis of the patient’s lid shape usually reveals the desired outcome by the patient. Cor- rection of severe ectropion may tighten the lower lid to elevate the position , which may result in a lid that is more straight or more tight than before surgery. Thus a gentle S-shaped curve of the lower lid may not be possible , and this should be dis- cussed in detail with the patient before corrective lid surgery.

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Prominent eye

Deep-set eye

Another extremely important aspect of the preoperative assessment is measuring globe position or eye prominence. Many surgeons have discussed the importance of recognizing eye prominence preoperatively as well as the increased incidence of complications after blepharoplasty in patients with prominent or morphologically prone eyes.3,5-12 A Hertel exophthalmometer can be used to provide an objective measurement of the globe position in relation to the lateral orbital rim.

Canthal Fixation Point Normal eye prominence (15-17 mm)

At pupillary line 4 mm inside lateral orbital rim

Exophthalmic placement (>17 mm)

More superior and anterior

Enophthalmic placement (