Cosmetic Derm PDF

Cosmetic Surgery
Melvin A. Shiffman Alberto Di Giuseppe

Editors
Cosmetic Surgery
Art and Techniques
Editors
Melvin A. Shiffman, M.D., J.D., FCLM Alberto Di Giuseppe, M.D.
Chair, Section of Surgery Institute of Plastic and Reconstructive
Newport Specialty Hospital Surgery, School of Medicine
Tustin, CA University of Ancona
USA Ancona
Italy
ISBN 978-3-642-21836-1 ISBN 978-3-642-21837-8 (eBook)

DOI 10.1007/978-3-642-21837-8
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2011941191
Springer-Verlag Berlin Heidelberg 2013

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This book is dedicated to the memory of my parents, Albert and Eva
Shiffman, who made me what I am today with encouragement and
sacrifices to send me to college and medical school.
The book is dedicated to my sister, Vivian Sadin (now deceased),
and my brother-in-law, Stan Sadin, who have been my very dearest
friends. Also to my loving daughter-in-law, Kim Shiffman, R.N., who
is the epitome of excellence in nursing, being both caring and efficient
in her work with newborn infants and who, at one time, was my
Recovery Room nurse. My wife, Pearl, has withstood constant
clattering on my computer and travels with me internationally while
I teach cosmetic surgery through lectures and workshops. She is my
constant companion. And to my compatriot and colleague,
Sid Mirrafati, M.D., with whom friendship is more like family.
My students, nationally and internationally, have been an
inspiration to me by their dedication to learning and enthusiasm to be
better physicians. But, most of all, their friendship.
I have to include those international surgeons who I have worked
with in lecturing at meetings who have become my dear friends and
who are colleagues of exceptional talent. To name a few, these include
Alberto Di Giuseppe, Anthony Erian, Afshin Fatemi, Julio Ferreira,
Giorgio Fischer, Pierre Fournier, Justin Hao, Enrique Hernandez-
Perez, Toma Mugea, Angelo Rebelo, Lina Valero, Fernando Pedrosa,
and Tetsuo Shu (now deceased). There are more but the list would be
endless. Books that I have edited, in Cosmetic Surgery, have resulted
in e-mail friendships with many surgeons who almost never say no to
my request for a chapter. These names run in the hundreds.
What more can I wish for in my 55 years as a physician and
36 years as a medical legal consultant?
Melvin A. Shiffman
Foreword
With this book, Cosmetic Surgery: Art and Techniques, published by Melvin A.
Shiffman M.D., J.D. and Alberto Di Giuseppe M.D., Cosmetic Surgeons now have a
complete encyclopedia in our field: Human Beauty Surgery
Mel should be especially congratulated as he has accomplished what he decided
years ago: to give recognition to our specialty of pure Cosmetic Surgery thanks to the
publication of a large series of books about our daily work that is ours for many years.
In the numerous already published volumes, he gives the groundwork where our prac-
titioners, experienced or beginners, can find teaching resulting from many years of
practice by experienced Cosmetic Surgeons coming from all around the world. This
book is very special among all the other ones already published as it is all encompassing
and is the first one in the literature about General Cosmetic Surgery. In the present time
teaching is audiovisual. Words of course are indispensable but a visible representation
of what has been said is crucial. We all know how important a diagram or a slide is.
As Napoleon the First used to say when he had to summarize his tactic before a
battle to make his mind up: a little drawing is better than a long talk. An image
focuses, zooms our attention, and stimulates our mind. We know that it enhances our
understanding on the strategy of a future procedure. It is acting as an impact.
This book will satisfy the readers as in its 68 chapters they can find carefully
described all the conventional reliable techniques as well as the most recent advances
offered today to our patients. The different procedures described are on the head and
neck, breasts, abdomen, limbs, liposuction, lipofilling, peeling, and hair grafting.
Many other chapters are dedicated to the different lasers, radio frequency, facial
implants, fillers, threads, and the use of stem cells and growth factors. Also included
are chapters on buttocks lift and implants, intimate surgery in women and men, anat-
omy, and the History of Cosmetic Surgery.
This important iconography explaining fully all the procedures will allow Cosmetic
Surgeons to obtain the best possible results, to avoid or decrease the number of com-
plications, major or minor, and to have a satisfied patient. Today, like before, one
should be conscious of the responsibilities that we have when modifying the face or
body of human beings and should be reminded always of the old surgical saying,
Better prepare and prevent than repair and repent. This underlines how important is
visual teaching.
As written by the highly talented and respected Richard Aronsohn, Founder of the
American Board of Cosmetic Surgery, Psychiatry works from the inside out.
Cosmetic Surgery works from the outside in. Both help people to enhance their self-
esteem and to feel good about themselves. As a matter of fact, Cosmetic Surgeons are
Surgical Psychiatrists. A good result makes patient and Surgeon happy. A complica-
tion or a poor result makes patient and Surgeon unhappy.
vii
viii Foreword
It is not possible to comment about all that is offered in this book, but the publishers
should feel happy to have included all the procedures or trends presently offered or
requested by our patients of the present time. It summarizes for the Surgeon in a very
short time the necessary different steps of an operation.
This book is an indispensable up-to-date tool needed by Cosmetic Surgeons as it
visualizes the present advances in our specialty allowing us to maintain and/or
enhance Human Beauty or to fight against the Aging process.
Paris, France Pierre F. Fournier, M.D.

Preface
Cosmetic (or aesthetic) surgery is a specialty of medical practice that has attracted
physicians from most countries around the world interested in improving the beauty
of the patient. Patients are flocking to cosmetic surgeons to improve their appearance
to meet the expectations of their own body image. Although cosmetic surgery is an
elective procedure, the medical indication for these procedures is to improve the
patients psychological needs. Since health care has improved and life span has been
prolonged, individuals are trying to preserve or return to their youthful appearance.
Technology and techniques have improved to make cosmetic surgery safer for the
patient and less invasive in some aspects so that patients can return to their normal
activities sooner and with shorter periods of discomfort.
This book on Cosmetic Surgery contains step-by-step descriptions of the proce-
dures (old, new, and modifications) with illustrations and/or color photos. The con-
tents include a history of cosmetic surgery, anatomy, anesthesia, head and neck
surgery, breast surgery, abdominal and thoracic surgery, and extremities and buttocks
procedures. Also described are labioplasty, total body lift following massive weight
loss, and penile enhancement. Dermatologic procedures are described including laser
rejuvenation, radiofrequency rejuvenation, and chemical peeling.
The international contributors are experts in their fields and have published exten-
sively in the medical literature. Some contributors are professors and many lecture at
international meetings and workshops on a regular basis. This book is comprehensive
and is an attempt to expose the student training in cosmetic surgery, the physician
starting in cosmetic surgery, and the experienced practitioner in cosmetic surgery to
the many aspects of aesthetic procedures that may improve their results and improve
patient safety.
The editors, in this book, are interested in producing a means of exposing all
surgeons to procedures commonly used to improve a patients appearance and satis-
faction. The learning mechanism used is step-by-step descriptions with illustrations
and color photos of the procedures. We hope that cosmetic surgeons will thus be able
to better understand a variety of the techniques.
Tustin, CA, USA Melvin A. Shiffman, M.D., J.D., FCLM
ix
Contents
Part I History and Anatomy
1. History of Cosmetic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Melvin A. Shiffman
2. Anatomy of the Face and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Peter M. Prendergast
3. Anatomy of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4. Anatomy of the Anterior Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . 57
5. Anatomy of the Eyelid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Oren G. Benyamini and Morris E. Hartstein
Part II Anesthesia
6. Regional Anesthesia for Cosmetic Surgery

of the Face and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Arnaud Deleuze, Marc Gentili, and Francis Bonnet
7. Liposuction with Local Tumescent Anesthesia
and Microcannula Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Bernard I. Raskin and Shilesh Iyer
8. Tumescent Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Melvin A. Shiffman
9. Anesthesia for Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Gary Dean Bennett
Part III Head and Neck
10. Facial Peels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Niti Khunger
11. Facial Resurfacing with the Ultrapulse Laser. . . . . . . . . . . . . . . . . . . . . 167
Bernard I. Raskin
xi
xii Contents
12. Capacitive Radiofrequency Skin Rejuvenation. . . . . . . . . . . . . . . . . . . . 195

Manoj T. Abraham and Joseph J. Rousso
13. Mesotherapy in Aesthetic Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Maya Vedamurthy
14. Upper Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Morris E. Hartstein
15. Lower Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Morris E. Hartstein
16. Blepharoptosis: The Check Ligament Technique . . . . . . . . . . . . . . . . . . 235
Antonio Stanizzi
17. Aesthetic Rhinoplasty Utilizing Various Techniques Depending
on the Abnormality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Fernando D. Burstein
18. Otoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Cristina Isac, Aurelia Isac, Tiberiu I. Bratu, and Nicolae Antohi
19. Brow Lift. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Shoib Allan Myint
20. Mid-Forehead Buttonhole Eyebrow Elevation . . . . . . . . . . . . . . . . . . . . 299
Harry Mittelman, Gregory J. Vipond, and Joshua D. Rosenberg
21. Facelift... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Phillip R. Langsdon and Courtney Shires
22. Short-Scar Purse-String Facelift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Amir M. Karam, L. Mike Nayak, and Samuel M. Lam
23. Modified Facelift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
24. Subperiosteal Face-Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Lucas G. Patrocinio, Tomas G. Patrocinio, Jose A. Patrocinio,
and Marcell M. Naves
25. Suture Facelift Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
26. Facial Implants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Bruce B. Chisholm
27. Fat Transfer to the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Melvin A. Shiffman
28. Facial Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
29. Ultrasound-Assisted Lipoplasty: Basic Physics,
Tissue Interactions, and Related Results/Complications . . . . . . . . . . . . 451
William W. Cimino
30. Facial Recontouring with Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Alberto Di Giuseppe and George Commons
Contents xiii
31. Chin, Cheek, and Neck Vaser Liposculpture. . . . . . . . . . . . . . . . . . . . . . 467

Alberto Di Giuseppe, George Commons, and Alessandro Scalise
32. An Integrated Technique for Facial Rejuvenation:
Adaptation to a Changing Clinical Environment . . . . . . . . . . . . . . . . . . 485
Moshe S. Fayman
33. Hair Restoration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Samuel M. Lam
34. Jowl and Neck Remodeling with Ultrasound-Assisted
Lipoplasty (VASER). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539
Part IV Breast
35. Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555

Lina Valero De Pedroza
36. The Inverted Dual Plane Mastoplasty Technique . . . . . . . . . . . . . . . . . . 571
Giovanni Di Benedetto, Luca Grassetti, Davide Talevi,
Daniele Bordoni, Manuela Bottoni, and Alessandro Scalise
37. Remodeling Breast and Torso with Combined Fat
Liposuction and Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585
Alfredo Hoyos
38. Breast Augmentation and Reconstruction with Fat Transfer . . . . . . . . 595
Todd K. Malan
39. The Staple-First Technique for Simultaneous Augmentation
Mastopexy for Moderately to Severely Ptotic Breasts . . . . . . . . . . . . . . 605
Ted S. Eisenberg
40. Circumareolar Nipple-Areola Complex Mastopexy
and Areolar Shifting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
Robert A. Shumway
41. Mastopexy/Breast Reduction with Short Inverted T Scar . . . . . . . . . . . 633
Toma T. Mugea
42. The Medial and Superior Pedicle Mastopexy
with Dual Plane Inverted-T Augmentation . . . . . . . . . . . . . . . . . . . . . . . 705
Tiberiu I. Bratu, Cristina Isac, Olariu Daniela, Grujic Daciana,
Dorina Mihaijlovic, and Nicolae Antohi
43. Breast Augmentation and Mastopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . 715
Toma T. Mugea
44. Periareolar Mammaplasty for the Treatment
of Massive Gynecomastia with Breast Ptosis. . . . . . . . . . . . . . . . . . . . . . 747
Marco Tlio Rodrigues da Cunha
45. Reduction Mammoplasty: The Piece of Art . . . . . . . . . . . . . . . . . . . . 755
Fahmy S. Fahmy and Mohamed Ahmed Amin Saleh
xiv Contents
46. The Moufarrege Total Posterior Pedicle Mammaplasty . . . . . . . . . . . . 775

Richard Moufarrege and Elia Botros
47. Mastopexy with Chest-Wall-Based Flap
and Pectoralis Muscle Loop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791
Ruth Maria Graf, Andr Ricardo DallOglio Tolazzi,
and Maria Ceclia Closs Ono
48. Hypertrophic Tubular Breast Reduction:
Surgical Technique with New Inframammary Fold Level . . . . . . . . . . . 805
Toma T. Mugea
49. Breast Reduction with Vaser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 857
Alberto Di Giuseppe, Michael Nagy, Mario Scaglioni,
and Elisabetta Petrucci
50. Gynecomastia: Scarless Male Breast Reduction with Vaser . . . . . . . . . 871
Alberto Di Giuseppe, Antonella Belligolli, Marina Pierangeli,
Davide Talevi, and Luca Grassetti
Part V Abdomen
51. Abdominoplasty: Aesthetics of the Anterior

Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887
52. Circular Lipectomy with Lateral ThighButtock Lift . . . . . . . . . . . . . . 907
Hctor J. Morales Gracia
53. The Horseshoe Abdominoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 925
54. Mini-Abdominoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 939
Bruce A. Mast
55. Ultrasound-Assisted Abdominal Liposuction . . . . . . . . . . . . . . . . . . . . . 949
Part VI Extremities and Buttocks
56. Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 973

Sumeet N. Makhijani, Alain Polynice, Jerome D. Chao,
and James G. Hoehn
57. Circumferential Para-Axillary Superficial
Tumescent (CAST) Liposuction for Upper Arm Contouring . . . . . . . . 981
Andrew T. Lyos
58. Thigh Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 993
Sadri Ozan Sozer and Francisco J. Agullo
59. Buttock Lift. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1001
Contents xv
60. Liposuction of Lower Extremities and Buttocks. . . . . . . . . . . . . . . . . 1011

Alberto Di Giuseppe, Guido Zannetti, and Daniele Bordoni
61. Buttock and Hip Enhancement with Implants . . . . . . . . . . . . . . . . . . . 1043
Jesus Benito-Ruiz
62. Liposculpture and Buttock Augmentation with Fat Grafting . . . . . . . 1063
Arturo Grau
63. Large Volume Fat Transplant to Buttocks and Legs
for Enhancement and Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . 1087
64. Treatment of Venous Insufficiency with Sclerotherapy . . . . . . . . . . . . 1093
Alessandro Frullini
Part VII Miscellaneous
65. Labioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1101

Cristina Isac, Aurelia Isac, Nicolae Antohi, and Tiberiu I. Bratu
66. Total Body Lift After Extreme Weight Loss . . . . . . . . . . . . . . . . . . . . . 1111
Dennis J. Hurwitz
67. Penile Enhancement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1127
Hassan Abbas Khawaja and Melvin A. Shiffman
68. Complications of Cosmetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135
Melvin A. Shiffman
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1185
Part I
History and Anatomy
History of Cosmetic Surgery
1
Melvin A. Shiffman
1.1 Introduction In 1792, Chopart [6] performed an operative proce-

dure on a lip using a flap from the neck. The first
In preparing a history of cosmetic surgery, it is, at times, American plastic surgeon was Mettauer, who, in 1827
difficult to separate reconstructive procedures from [6], performed the first cleft palate operation with
purely cosmetic procedures. Cosmetic (aesthetic) is instruments that he designed himself. Joseph [7] per-
beautifying surgery compared to plastic that is repair formed an otoplasty that resulted in his loss of his job
of a defect or deficit. Consider that reconstruction of (that he had since 1892) in 1896 at the University
the face is to beautify a distorted, abnormal appear- Polyclinic in Orthopedic Surgery headed by Professor
ing facial appearance. However, cosmetic (aesthetic) Julius Wolff.
surgery is considered to be only to beautify and not to In World War I, Gillies [8] developed many of the
reconstruct to obtain beauty. Obviously, there is some techniques of modern surgery in caring for soldiers
overlap between the two. suffering from disfiguring facial injuries. When the
Sushruta lays down the basic principles of plastic United States entered World War I, Blair was chosen to
surgery by advocating proper physiotherapy before the lead physicians in the treatment of craniofacial injuries
operation and describes various methods for different caused by trench warfare. As commander of the U.S.
types of defects, such as release of the skin for cover- Army Corps of head and neck surgeons, Blair worked
ing small defects [1], rotation of the flaps to make up with assistant Ivy to set up teams of surgeons and den-
for the partial loss [2], and pedicle flaps for covering tists to treat complex jaw injuries using Blairs 1912
complete loss of skin from an area [3]. He mentioned book as the standard operating manual [9]. After the
various methods including sliding graft, rotation graft, war, he formed one of the largest U.S. multidisciplinary
and pedicle graft. He also described labioplasty. All teams for the care of complex maxillofacial injuries at
the principles of surgery such as accuracy, precision, Walter Reed Hospital. For these efforts, he was known
economy, hemostasis, and perfection find an important as a leader in posttraumatic reconstruction.
place in Sushrutas writings on this subject. Blair contributed many outstanding clinical advances.
Tagliacozzi [4, 5] was considered by some to be the Although other surgeons had performed reconstructive
Father of Plastic Surgery even though his 47 pages operations using the delay phenomenon, Blair first
of illustrations and guidelines to reconstructive surgery defined the delay process in 1921 [10]. The follow-
were published in 1597, but when he died 2 years later, ing year, Blair published a paper on Reconstructive
his achievements died with him. Surgery of the Face, based on his war experience and
set the standard for craniofacial reconstruction [11].
Blair reported on a variety of reconstructive procedures
such as rhinoplasty for saddle nose [12], nasal defor-
M.A. Shiffman
mities associated with congenital cleft of the lip [13],
Chair, Section of Surgery, Newport Specialty Hospital,
Tustin, CA, USA cleft palate with orthodontic inclusion [14], correc-
e-mail: [email protected] tions of deformities of the external nose [15], primary
M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 3

DOI 10.1007/978-3-642-21837-8_1, Springer-Verlag Berlin Heidelberg 2013
4 M.A. Shiffman
closure of harelip [16], and use of switched lower lip subcutaneous tissue attached to the skin. He performed
flap for upper lip restoration [17]. In 1929, Blair and extensive undermining and severing of the suspensory
Brown [18] reported the first cleft lip repair that could ligaments (Coopers ligaments), and then wedge exci-
be reproduced accurately. This article was the first to sions of breast tissue in an inverted S shape involved
provide accurate details on measurements needed to the lateral aspect of the breast. This resulted in a high
perform cleft lip repairs. risk of skin and breast loss, and the technique was
Although plastic surgery was a specialty established largely abandoned.
during the First World War, there were only three expe- Schwarzmann [32] fashioned a periareolar cutis
rienced plastic surgeons in Britain when the Second bridge for maintenance of the blood supply to the
World War broke out in 1939. One of them was nipple. This allowed a superiorly based dermoglan-
McIndoe [19]. He set up a specialist hospital in East dular pedicle to revascularize the nippleareolar
Grinstead to treat airmans burn, which was caused complex. The Schwarzmann [33] maneuver was devel-
when a planes fuel tanks exploded. The unprotected oped that involved cleavage between skin and gland,
hands and face of the pilot could be severely burned. preserving a periareolar zone stripped of skin. Maliniac
McIndoe treated several hundred airmen, skillfully [34] used strips of dermis graft for stabilization of the
performing plastic surgery to give them new faces and breast. Maliniac [35] presented a two-stage breast
hands. Many of them went back to fly again. reduction in order to preserve the blood supply. Bames
[36] preserved the lateral and medial breast segments
and resected the superior portion to preserve perforating
1.2 Breast Reduction vessels. Aufricht [37] introduced an inferior pedicle
technique and showed a geometric method to plan the
Durston [20] gave a description of gigantomastia reduction rather than using a free hand method and
occurring suddenly in a 23- or 24-year-old woman. preserving perforating vessels by preserving the lat-
This woman developed ulcerations of the breasts that eral and medial segments of breast and resecting the
were painful and became considerably larger [21]. superior portion.
In another publication the same year, Durston [22] Reports on free nipple transplantation for reduc-
described that she died, and one breast weighed 64 lb tion mammaplasty included Conway [38], Conway
and the other about 40 lb. No cancer was found. and Smith [39], Marino [40], and May [41]. Maliniac
Dieffenbach [23] reported on aesthetic breast surgery [42] did total gland excision with nipple-areolar graft
involving a small incision in the inframammary fold. and deepithelialized the inferior flap that was folded
Pousson [24] reported removing a crescent-shaped superiorly under the superior flap. Wise [43] devised
section from the upper anterior portion of the breasts in a pattern to predetermine the shape of skin flaps
order to treat bilateral mammary hypertrophy. The skin (Fig. 1.1) and a horizontal dermal parenchymal
and subcutaneous tissues were excised down to the bridge for the preservation of the arteriovenous and
pectoralis fascia, and the breast was elevated and sus- cutaneous nervous system from above and below the
pended by suturing to the pectoralis fascia. dermal pedicle. Arie [44] described a superior pedi-
Guinard [25] reported on a patient with macromastia cle technique, and Gillies and Marino [45] described
using semicircular incisions in the submammary folds the periwinkle shell (spiral rotation) technique for
to remove a large amount of skin and breast tissue. moderate ptosis.
Morestin and Guinard [26] reported their experi- Strombeck [46] modified a keyhole pattern. He
ence with discontinuous resections of up to 1400 g extended the concept of a dermal bridge technique,
performed through an inframammary incision. Thorek described by Schwarzmann [33], to reintroduce the
[27] reported on breast amputation and free nipple dermal pedicle for nipple transposition. He used a
graft. Kraske [28] described reduction of large breast. pattern similar to that described by Wise [43]. This
Aubert [29] performed resection and transposition of was a horizontal dermal pedicle that consisted of the
the nipple. Hollander [30] described an inferolateral dermis of the two lateral pedicles to transpose the
excision of skin and breast tissue in order to eliminate nipple and create a fibrous balcony to prevent post-
the inframammary scar of the inverted-T incision. operative ptosis. The skin and gland above the areola
Biesenberger [31] noted the importance of leaving were excised.
1 History of Cosmetic Surgery 5
a b
Fig. 1.1 (a) First prototype suction machine with a motor- inside. (d) When thumb is released, there is no aspiration
driven cannula. (b) Second prototype motor suction machine. (Photos courtesy of Giorgio Fischer)
(c) Motor-driven cannula with cutting and rotating cylinder
6 M.A. Shiffman
Pitanguy [47] performed a horizontal dermal bridge Aiache [66] fashioned a superior pedicle technique for
and keel shaped resection of the gland from the the ptotic and moderately enlarged breast. Ribeiro [67]
inferior and central portions of the breast. It had excel- described an inferior pedicle technique. A vertical scar
lent results when used for limited breast reductions was avoided by bringing the nippleareola complex
(<300 g) and breast ptosis. under and through the superior skin flap and into posi-
Dufourmental and Mouly [48] introduced the lateral tion while tubing the inferior dermal pedicle. Orlando
wedge resection of skin, fat, and gland with a resultant and Guthrie [68] described a superior medial dermal
inferior oblique lateral scar. Preoperative markings pedicle. de Castro [69] described a modified Pitanguy
were made in the supine position. Strombeck [49] technique using curved incisions to define the medial
reported the use of the horizontal bipedicle procedure and lateral breast flap borders and resection of the
for reduction mammaplasty. Pitanguy [50, 51] described breast tissue on a horizontal plane. He believed this
the superior dermal pedicle technique. Wise et al. [52] modification produced breasts that were less tense and
used a modification of the breast amputation and more desirable in shape.
nippleareola transfer. Skoog [53] described a superior Cramer and Chong [70] reported on a unipedicle
laterally based dermal flap separated from the gland at cutaneous flap with areolarnipple transposition or
the subcutaneous level. He transposed the nipple on a an end-bearing, superiorly based flap. Weiner [71]
unilateral skin flap disconnecting nipple from gland. described the modified superior pedicle technique.
This was an intermediate procedure to free nipple trans- Wise [72] discussed nipple transposition versus nipple
plantation. Robertson [54] reported on the inferior flap transplantation. Courtiss and Goldwyn [73] described
mammaplasty in conjunction with free nipple grafting. an inferior dermal pedicle technique as an alternative
Hoopes and Jabalay [55] described amputation with to free nippleareola grafting in severe macromastia or
nippleareola transplant, and prosthesis. ptosis. The inferior dermal pedicle extends transversely
Hoopes [56] performed amputation and mamma- across the full length of the inframammary fold inci-
plasty for gigantomastia using nippleareolar transplant sion. A keyhole pattern, described by McKissock, was
and prosthesis. Hinderer [57] described dermopexy used. Robbins [74] described the technique of reduc-
with reduction and reported attaching dermis strips to tion mammaplasty with an inferior dermal pedicle.
help fixate the breast to the chest wall to support the Georgiade et al. [75] performed reduction mamma-
breast in 1972 [58]. McKissock [59] described the plasty utilizing an inferior pedicle nippleareola flap.
bipedicle vertical pedicle for nipple transposition that Marchac and de Olarte [76] tried to prevent ptosis
had simplicity of design and safety. by fixation of the gland to the pectoral fascia. Ribeiro
Lalardrie [60] reported a dermopexy with reduction [77] reported on the inferior dermal pedicle technique.
Dermal Vault technique. Meyer and Kesselring [78] described closure with an
Weiner et al. [61] described a modified superior L-shaped suture line. Galvao [79] described a method
dermal pedicle technique for nipple transposition. This of preserving the subdermal plexus of vessels with the
technique cannot be used if the nipple site is to be more nippleareolar complex detached from the breast gland
than 7.5 cm above its original position. Pontes [62] leaving a completely free deepithelialized superior-
described removal of the lower half of the breast start- and inferior-based dermal pedicle with only the subcu-
ing 2 cm below the inferior edge of the areola after taneous fat that is folded and the breast closed after
deepithelialization of the periareolar area and supe- resection of the gland. The nippleareola complex is
rior pedicle. The nippleareolar complex is placed brought out through the new position after complete
into position after closure of the breast. Regnault [63] closure.
reported on a reduction mammaplasty using the B Cardoso [80] used three dermal pedicles for nipple
technique that resulted in a lateral oblique scar without areolar complex movement in reduction of gigantomas-
a medial extension. Lalarde 64] performed reduction tia. Hester et al. [81] performed breast reduction utilizing
with transposition of the nipple. Gsell [65] described a the maximally vascularized central pedicle. Ren [82]
superior-based dermal flap similar to the McKissock described the periareolar mastopexy. Teimourian et al.
pedicle but transected at the inframammary end. This is [83] reported on reduction mammaplasty with liposuc-
risky since much of the blood supply to the paren- tion. Marshak [84] described a short horizontal scar
chyma is transected. Nippleareola necrosis may occur. mastopexy. Benelli [85] reported on the periareolar
mastopexy described as the round block technique. locations using broad and reliable pedicles. Shape and
Lejour et al. [86] introduced the vertical mammaplasty symmetry were ignored until the second procedure
without an inframammary scar. Georgiade [87] reported was performed several weeks subsequently. The sec-
on the inferior pedicle technique. ond procedure involved removing the excess lower
Lejour and Abboud [88] described a vertical mas- pole, shaping, and lifting the breast as well as maxi-
topexy without an inframammary scar combined with mizing symmetry between the two sides.
liposuction for breast reduction. Sampaio-Goes [89] Kraske [98] described his innovative single-stage
described periareolar mammaplasty with the double technique in 1923. In retrospect, it offered many of the
skin technique. Menesi [90] reported on a distally principles of the modern mastopexy and reduction
based dermal flap for gland fixation. Ren [91] reported operations. This technique removed the lower pole of
on reduction mammaplasty with a circular folded pedi- the breast tissue and avoided extensive undermining of
cle technique. Goes [92] performed the double skin the skin from the breast tissue. The breast tissue and
technique with application of polyglactin or mixed overlying skin were then tightened with the excess tis-
mesh to fix the gland with allogenic mesh using a sue laterally excised, leaving a traditional inverted-T
circular flap of dermis with a central pedicle. scar. Unfortunately, because the results were consid-
ered sub-optimal, it fell out favor. In contrast, despite
an extremely high rate of postoperative complications,
1.3 Mastopexy one of the most popular techniques in the first half of
the twentieth century was the Biesenberger procedure
Plastic surgery of the breast has been documented as [99]. This approach employed wide undermining of
early as 1669 when descriptions of postmastectomy the skin and excision of the lateral portion of the breast
reconstruction were reported. Some 200 years later, with rotation of the medially based nipple pedicle to a
Velpeau, in 1854 [93], published his analysis of more superior position. The skin was then tightened
mastoptosis. Descriptions of the modern mastopexy around the gland to provide shape.
procedure were first seen as early as the nineteenth cen-
tury. Many of these early approaches offered a signifi-
cant basis for the techniques which are currently 1.3.1 Evolution of the Modern Approach
utilized. Although the techniques mirrored those of the
reduction mammaplasty, the emphasis was placed on An anatomic-based approach was ultimately adopted,
correcting ptosis of the breast. Most of these proce- and Strombeck described a bilateral horizontal pedicle
dures involved elevation of the breast mound using in 1960 [46]. Primarily implemented for reduction of
suspension techniques. Poussons technique [94] and breast volume, a significant resection was performed
Vercheres mammaplasty [95] both relied on direct superiorly to the horizontal pedicle. The pedicle was
excision of skin superior to the nippleareolar complex. then imbricated along the vertical line from the nipple
With closure, the nipple and breast gland were elevated, areolar complex extending inferiorly. This glandular
providing a simple solution to breast ptosis. Dehner tightening was in fact similar to the vertical type reduc-
utilized a semi-lunar resection of the superior breast tion utilized currently and in addition helped establish
tissue and split the pectoralis muscle so the breast the principle of maintaining the attachments of the
tissue could be anchored to the periosteum of the ribs. breast parenchyma and the skin. Skin resection and
In 1882, the inframammary incision was first described closure were performed to remove excess skin rather
to facilitate tumor excision. It was implemented to than to tighten or lift the breast, again a hallmark of
facilitate mastopexy and reduction mammaplasty and current mastopexy techniques.
eventually was utilized by Passot in 1925 [96]. The McKissock [59] vertical bipedicle technique
Various pedicles to support the nippleareolar com- similarly offered a robust deepithelialized pedicle to
plex were described by the 1930s. Further evolution in supple the nipple. Resection was performed medially
the mastopexy resulted in refinement of technique and and laterally as well as beneath the thick vertical pedi-
analysis. One of the earliest techniques involved a two- cle. The pedicle was folded on itself to allow mobiliza-
stage approach which Joseph described in 1925 [97]. tion of the nipple, and the thick dermalparenchymal
The first stage transposed the nipples to their final flaps were then closed. The vertical bipedicle technique
8 M.A. Shiffman
eventually evolved into the inferior pedicle technique 1.3.2 Current Concepts
described by various authors [74, 100]. This approach
may currently be the most widely used technique, Autologous mastopexy procedures require rearrange-
particularly for reduction mammaplasty. It has been ment of the breast tissue with minimal volume reduc-
applied to the mastopexy procedures; however, a tion. Some of the techniques for reduction mammaplasty
criticism of the approach is that pedicle tends to drop, were more readily adaptable to this purpose than were
leading to recurrent ptosis and a boxy appearance of the others. As indicated, the vertical mastopexy reliably
breast. Alternatively, the superior pedicle first described perfused the nipple with limited transposition of the
by Weiner in 1973 [61] eliminated the inferior portion nippleareolar complex (NAC). Mobilization of the
of the vertical bipedicle reduction. The limitation of remaining tissue can be suspended superiorly deep to
this approach is the distance with which the nipple the superior pedicle. Additional procedures to recreate
can be safely transposed. As the long superior pedicle is breast fullness using autologous tissue have been
folded to elevate the nipple, the vascular supply is com- described using the dual-pedicle dermoparenchymal
pressed, and the risk of nipple slough is increased. mastopexy and the deepithelialized transverse rectus
Just as the vertical bipedicle led to single pedicle abdominis muscle pedicle, using the Flip-Flap mas-
techniques, the Strombeck operation was the precursor topexy [109, 110]. Lateral and inferior pedicles have
of the lateral and medial pedicle procedures. Originally been used to auto-augment the breast. Placement of the
described by Skoog [53], the lateral required resection autologous tissue flap deep to a strip of pectoralis
from the medial and inferior quadrants of the breast. muscle is reported to improve shape and maximize
The medial pedicle was also adapted from the hori- longevity of the lift. The use of the vertical bipedicle
zontal bipedicle technique. At the present, it is one of flap has also re-emerged, reported to minimize scar-
the most popular techniques if not the most frequently ring and preserve the blood supply to the nipple. Khan
employed technique for reduction mammaplasty. It [111] described a vertical scar bipedicle technique, a
also lends itself quite well for mastopexy procedures. combination for minimal scarring and robust blood
This approach can be combined with the vertical supply to the nippleareolar complex, as a further
mammaplasty. option for mastopexies.
While the importance of shaping the gland was rec- The vertical mastopexy eliminates the inframam-
ognized, significant emphasis was still placed on the mary scar and was introduced by Lassus [112] using
skin brassiere. These techniques utilized reshaping of the superior pedicle. Subsequent modification by Lejour
the skin envelope to tighten and lift the breast paren- [113] was to include the use of liposuction. The pur-
chyma [101, 102]. Unfortunately, these approaches did pose was to reduce the length of scar which extends
not provide durable results. To avoid the dermal beyond the inframammary fold onto the chest wall.
stretching that can occur with dermal mastopexies, The most recent modifications of the vertical mas-
both permanent and absorbable mesh have been des- topexy are based on the Hall-Findlay procedure [114].
cribed to reshape the breast parenchyma with an inter- Her proposal of a superior medial pedicle has led to
nal brassiere [103, 104]. The Benelli round block or the growing popularity of the vertical mastopexy.
periareolar purse string mammaplasty utilizes a per- The superior medial pedicle can be combined with
manent suture rather than mesh to tighten the breast auto-augmentation using either an inferior pedicle or
tissue [85]. In patients with limited breast ptosis, it a lateral pedicle. This tissue normally discarded in
effectively limits scarring and provides tightening the reduction mammaplasty is suspended deep to the
[105]. Subsequent descriptions have demonstrated nipple pedicle and securely suspended to avoid recur-
reliable and safe results using mesh to reshape the rent ptosis.
breast mound [106]. Most recently, the use of acellular The vertical only incision has been advocated as
dermal matrix has been employed to avoid the use of minimizing scars, but has also seen modifications to
mesh material, providing a more natural texture of the address its shortcomings. The Y-scar vertical mamma-
breast while achieving excellent early results. This plasty is an alternative to reduce further scar burden
approach also provides an effective method to cover [115]. Loustau et al. [116] used the owl technique
prosthetic breast implants and has been used in combined with the inferior pedicle in mastopexies.
reconstructive efforts [107, 108]. More recently, the addition of a short inframammary
scar has reduced the revision rate of the vertical mas- Bourget [125] described cases involving extensive
topexy procedures. The inframammary resection is of subcutaneous undermining and lipectomy. In 1927,
particular value in those patients who have significant Bames [126] noted that undermining skin could fur-
skin excess. ther improve results. Joseph, in 1928 [127], introduced
A variety of methods have been utilized to augment the post-tragal refinement.
the atrophic or hypoplastic breast tissue. These included Bettman [128] described the continuous temporal
percutaneous injection of foreign material (such as periauricular incision. Burian [129] emphasized wide
paraffin or silicone) and implantation of free dermal undermining and proposed methods of preoperative
fat grafts. The advent of breast prostheses allowed the skin markings with methyl violet.
use of an implant to fill out the breast volume in com- Passot [130] described a facelift with limited inci-
bination with tightening procedures [117]. Although sion and dissection, that had already been described by
augmentation mammaplasty does not truly lift the him in 1919 [131] and in his book, La Chirurgie
breast, mild cases of ptosis, particularly those with Esthetique des Rides du Visage, in 1917 [132].
involutional breast changes, can be corrected with Brown [133] emphasized using the ear to hide the
breast implant augmentation. Moderate ptosis can be facelifting incisions. Mayer and Swanker [134] coined
corrected using a circumareolar donut mastopexy the term rhytidoplasty. Hollander [135] stressed the
including the round bloc techniques with the use of an importance of a post-tragal incision, recommending
implant [118]. The combination of volume increase extending this under the earlobe and up into the hair-
and limited tightening allows correction of more sig- line. In 1960, Aufricht [136] proposed improving lon-
nificant ptosis than either approach alone. Improper gevity of the facelift procedure by suturing deep to fat.
implementation of this approach can lead to undesir- Pangman and Wallace [137] were the first to describe
able results, including widened periareolar scars. the superficial fascia, later known as the superficial
Moderate grade 2 ptosis can be addressed using the musculoaponeurotic system (SMAS). Pitanguy and
vertical scar mastopexy procedures, including the Ramos [138] emphasized the plication of the SMAS
Regnault B technique and Lejour/Lassus techniques. and repositioning of the malar fat as well as preserva-
Severe grade 2 ptosis and grade 3 ptosis usually require tion of the facial nerve. In 1968, Skoog developed a
inverted-T incisions regardless of the pedicle used or flap to elevate the platysma muscle of the neck and
whether an implant is placed. Pseudoptosis can be lower face without detaching the skin [139]. This was
addressed with augmentation and/or skin excision at reported in 1974 [140].
the lower pole, but nipple transposition can often be In 1976, Mitz and Peyronie [141] described the
avoided. superficial musculoaponeurotic system (SMAS). This
finding confirmed a fascial layer distinct from the
underlying parotidomasseteric fascia, which invests
1.4 Facelift the facial musculature. They found that the SMAS was
in a tissue plane continuous with the platysmal in the
Hollander, in 1932 [119], claimed that he carried out neck and the temporoparietal fascia in the scalp.
the first surgical facelift in 1901. Cantrell [120] wrote Fibrous adhesions to the overlying subcutaneous tissue
the first published report of surgical procedures for and skin allowed for SMAS manipulations to effect
improving facial wrinkles. Lexer, in 1931 [121], desired skin improvements.
described skin excision and undermining and claimed The SMAS rhytidectomy combines a subcutaneous
that he had performed a facelift surgery in 1906. Miller dissection with separate SMAS elevation via plication
[122] described a variety of surgical procedures for (pulling back, folding over, and suturing), as described
improving facial wrinkles by subcutaneously section- by Webster et al. in 1980 [142], or imbrication
ing key muscles. In 1926, Nol [123], the first female (advancement, shortening, and suturing), as described
cosmetic surgeon, claimed that she performed facelifts by Lemmon and Hamra [143].
in 1912. She described cosmetic surgeries and contrib- In 1988, Faivre [144] performed the deep temporal
uted to the early acceptance of vanity procedures. lift. The temporal soft tissues were elevated in the sub-
Joseph, in 1928 [124], claimed that he had performed musculoaponeurotic plane and fixed to the temporalis
facelift surgery in 1912. muscle. This produced correction of temporal, lateral
10 M.A. Shiffman
brow, and jugal ptosis. Psillakis et al. [145] reported a as resulting in complications including bleeding and
subperiosteal approach to the midface. The ptotic seromas [162, 170, 171]. In 1982, Schrudde [172]
malar skin, fat, and muscle were mobilized and sus- warned not to underestimate the possibility of
pended by anchoring the periosteum overlying the seroma, especially in the area of the thighs. This com-
lateral orbit, malar arch, and zygoma. Tessier [146] plication occurred in more than 30% of cases. In
performed subperiosteal facelifting. 1984, Schrudde [173] reported performing suction
The deep plane was pioneered by Hamra in 1990 lipectomy (lipexheresis) with a cannula that has a
[147], and composite rhytidectomy in 1992 [148] sharp leading edge with curettage performed using a
followed. Versions of this technique then evolved, as normal suction pump attached. The procedure was
the bi- and tri-plane dissections by Baker [149] and used for removing fat in the subtrochanteric and knee
modifications by Kamer [150]. Ramirez [151] reported regions and secondarily on the lower thighs although
a subperiosteal approach similar to Tessier. Kamer the procedure could be carried out on all parts of the
and Frankel [152] reported substantial improvement body. In 20 years, only 250 patients were treated using
upon moving to the deep plane lift, with fewer touch- strict criteria. He stated that if much fat is removed,
ups required. seroma cannot be avoided. Suction drainage and tight
Chrisman [153] described the use of liposuction compression bandages were used after surgery to pre-
with facelift. Ansari [154] introduced the S-lift, a vent seromas.
simplified facelift with smaller incision only anterior Vilain [174] described the use of a curette through a
to the ear. Hoefflin [155] reported on the extended small incision for fat removal of the knees and lower
supraplatysmal plane facelift with dissection over leg for residual fat deposits following skin and fat
the platysma and SMAS. Freeman [156] described the excisional surgery of the thigh. Only small amounts of
infra-orbital approach to the temporal lift as a viable fat are removed.
technique. Tonnard et al. [157] reported on a modified Fischer [175] first reported his technique of small
S-lift concept termed the minimal access cranial incision removal of fat deposits with the cellusuc-
suspension lift (MACS-lift). tiotome (Fig. 1.1). Fischer and Fischer [176] stated that
The region of the mass of cellulite is of no importance
because the operative technique remains the same for
1.5 Liposuction every part of the body The region to be treated is
sterilized and then injected with 2% carbocaine with
Dujarrier [158] reported a case of using a sharp uterine epinefrineOn the region affected by cellulite 3 min
curette through a small incision to remove fat of the incisions measuring 5 mm each are performed at a
calves and knees of a ballerina that resulted in femoral distance of one to the other of 10 cm. which creates an
artery injury that necessitated amputation. Pangman imaginary circle or a Z The primary important
was reported to have performed curettement of the instrument is the first which has the task of melting the
submental fat using a small uterine curette in the 1940s fat lobules and the same time vacuums the fat. This
although there is no literature to support this contention report established the techniques of:
[159]. Pangman and Wallace [137] reported perform- 1. All parts of the body with cellulite can be treated
ing facelifts and removing excess fat from the neck with the same technique.
with a curette or scissors or both. They established the 2. Use of local anesthesia (Carbocaine) with
use of the curette to remove fat. epinephrine.
There are reports that Schrudde [160] described 3. Small incisions (5 mm).
curettement of fat in 1964 [161, 162]; however, on 4. Multiple incisions apart from each other in a circle
translation of the article (in German) by Giebler or Z.
(personal communication translation of the article 5. Vacuum removal of fat.
9/28/10), there is, in fact, no mention of curette, curet- According to Fischer and Fischer [177], The patient
tage, or fat removal in the article. Schrudde, from is examined in a standing position Photographs are
1972 to 1984 [163169], described the use of the taken, in front, rear, and bi-lateral positionsGeneral
curette in removing fat deposits including the use of or local anesthesia is performed depending upon the
suction to remove the fat. The technique was reported surgeons normal practice A 1 cm incision is made in
Fig. 1.2 The planatome (Photo courtesy

of Giorgio Fischer)
Fig. 1.3 Swan-neck cannula and guided

cannula (first prototype) (Photo courtesy
of Giorgio Fischer)
the lowest point of the delimited area. Care should be 4. The planatome is a dissector and used to dissect
taken in placing the incision on the second leg in a posi- the subcutaneous planes in order to facilitate aspira-
tion asymmetrical to the incision on the first: this will tion. It was used to isolate from the deep layer a fat
disguise the post-operative scar completelyThe layer of 8 mm13 mm (Fischer G: personal com-
planatome (Fig. 1.2) is inserted through the inci- munication 9/5/10).
sionThe thickness of the dissected zone varies from 5. The opening of the cannula is directly downward
case to case and depends upon the consistency of the fat toward the muscles.
as well as the texture of the skinDissection is carried Fischer used the cellusuctiotome in 1977 (Fischer G:
out within the demarcation line in a clock-wise man- personal communication 8/10/10; Fournier PF: personal
nerThe tip of the Fischer handpiece is inserted into communication 8/10/10) when demonstrating the lipo-
the newly created pocket, taking care that the window suction procedure at Fourniers clinic (Fig. 1.3), La
of the instrument faces downward, towards the mus- Mouette, using fan-shaped tunnels and crossing tun-
cles. Drainage tubes were used on all patients. Of 245 nels as well as liposuctioning at various levels. He used
cases treated with this method, 12 cases (4.89%) had epinephrine in local anesthesia with sedation. The cel-
persistent formation of blood/serum, and 8 cases lusuctiotome device was a motor-driven cannula with a
(3.27%) had seroma after 1 month, with a total of rotating cylinder inside that was used to cut fat and was
8.16%. This report established the techniques of: connected to a suction machine. The cutting cylinder
1. Examination in a standing position. inside the cannula could be used by pressing a lever.
2. Use of general or local anesthesia. In 1980, Fischer began massage of the tumescent
3. Small incision (1 cm) asymmetrically placed in the fluids in 1980 to distribute the fluid in the tissues
extremities for riding breeches deformity. (Fischer G: personal communication 8/10/10). In 1982,
12 M.A. Shiffman
a guided cannula (Fig. 1.4) was produced with a sec- Kesselring and Meyer [179] developed a metal
ond overlying slide that moves over the surface of the curette (Fig. 1.5) that was attached to a suction to
skin while the suction cannula works at a depth of facilitate the task. The fat was curetted to detach the
1.5 cm (personal communication September 13, 2008). unwanted portions of fat, which were then aspirated
At the same time, the swan-neck cannula was devel- from the wound by the suction. Teimourian and Fisher
oped to make it easier for the surgeon to maintain a con- [180] stated that Schrudde performs suction curettage
stant depth in the fatty layer (personal communication in two stages in the lower legs after experiencing three
September 13, 2008). In 1992, Fischer (personal com- instances of considerable skin necrosis. and claimed
munication 8/10/10) [178] developed a table that could to have significantly expanded the use of a lipectomy
bring a patient from a supine position to an upright posi- procedure which heretofore had been restricted to the
tion. This allowed reversing the table to a supine posi- removal of strictly localized excess fat deposits by
tion if the patient became dizzy or faint. Liposuction curettage through a small incision (23 cm). The authors
could be performed in the same position as the marking, modified the fascia lata stripper and utilized it for
avoiding the distortion from reclining the patient. extensive body contouring; they were successful in
correcting relatively major fat deformities without caus-
ing any postoperative surgical deformities. Local use
included lipectomy of the ankles, calves, medial and
lateral thighs, flanks, and arms, and supplemental use
augmented standard operations for the lipectomy of the
thighs, buttocks, abdomen, upper and lateral chest-
axilla, and extremities. In 54 patients, there was dim-
pling in one patient, one hematoma, and seromas in
30%. Sensation usually returned within 36 months.
Illouz [181] favored a wet technique in which
hypotonic saline combined with hyaluronidase was
infiltrated into the adipose tissue and prior to suction
removal. He felt this would reduce trauma and decrease
bleeding. He mistakenly thought that the solution rup-
tured the fat cells. His techniques also included the use
of the Karman cannula and abortion suction machine.
In 1981, Illouz [182] stated that he started the technique
of lipolysisaspiration in 1977. He describes the use of
general anesthesia with hypotonic saline in the tissues
and used cannulas of different dimensions, from 5 mm
for the face to10 mm that he designed for the body. He
drained wounds for 48 h. Illouz [183] described lip-
odystrophies and the treatment with liposuction using a
10-mm cannula for the riding breeches, buttocks, and
Fig. 1.4 Fourniers Clinic where the liposuction operation was hips; an 8-mm cannula for the ankles, arms, knees, and
demonstrated in 1977 (Photo courtesy of Giorgio Fischer) abdomen; and a 5-mm cannula for the face.
Fig. 1.5 Metal suction curette of Kesselring

and Meyer [78]
Fig. 1.6 Fischers technique

was exclusively for
trochanteric lipodystrophies,
and the technique formed
cavities (Fournier and Otteni)
[189]
Fournier and Otteni [184] concluded that the use of results were obtained without the solution. They stated
a uterine curette employed to remove fat resulted in that the uterine curette was employed first by
irregularities, excess localized skin, and persistent Schruddebut it gavevariable results and compli-
lymphorrhea. They also stated that Fischers technique cations such as localized skin excess, uneven contour,
was exclusively for trochanteric lipodystrophies, and and lymphorrheaLater Fischer and Fischer
the technique formed cavities (Fig. 1.6), prolonged (1977) described the suction curettage, which was
drainage, secondary cutaneous and fat ptosis, lymph- directed exclusively to trochanteric lipodystrophy
orrhea, and irregularities. The authors described Illouzs produced unsightly results with irregular bulg-
technique for liposuction. ings and depressions (with the planatome) and
Vogt and Dicksheet [185], commenting on the 1981 persistent lymphorrhea in the cavity caused by the
article by Temourian and Fisher, stated that the tech- cellusuctiotome, despite the use of drainage for a
nique of Schrudde, Kesselring, and others greatly long timeEpithelialization of the cavity occurred
fell into disrepute a long time agoKesselringhas with secondary sagging of the skin. The authors used
abandoned the technique except for use in trochanteric postoperative suction drains for 2448 h except for
lipodystrophy, because of the high rate of complica- small areas such as double chin, ankles, knees, and
tions and unsatisfactory results. Pfulg [186] reported small trochanteric lipodystrophies where there is min-
a case of a patient who had suction curettage for fat imal drainage. Although hematomas and lymphorrhea
removal and developed hematomaseroma, skin necro- are theoretically possible, the authors did not have
sis, and anemia. He concluded that suction curet- any. There was bruising, edema, and temporary skin
tage to remove excess fat for body contouring may not irregularities. Permanent depressions, bulging, and
be such a simple and always successful procedure. asymmetry can usually be prevented and occur less
Chajchir et al. [187] devised instruments named often the more experienced the surgeon with this tech-
suction curette cannula. The cannulas (1.5 cm) had nique. Skin excess or sagging may happen after treat-
blunt ends with a 3-mm tube on the lateral side to allow ing trochanteric lipodystrophies in patients 35 years
regulation of airflow. The suction apparatus was modi- of age or older, or in those having poor skin tone, or
fied to produce 450500 mm vacuum to prevent venous when the trochanteric lipodystrophy is particularly
injury, cutaneous injuries, or depressions established large.
by the technique of low vacuum for liposuction. Illouz [190] described the possibility of grafting fat
Incisions were 1.53 cm. Suction drains were used on cells obtained during liposuction. He noted that with
all patients for 3040 days. Illouz [188] discussed the the dry technique of liposuction, 90% of the cells will
use of numerous subcutaneous tunnels that would be alive, and with the wet technique, 70% will be alive.
result in homogeneous contraction of the skin. Teimourian and Kroll [191] were the first to report the
Fournier and Otteni [189] reported the use of the use of endoscopy to see what occurs to the tissues after
dry technique, as opposed to Illouzs wet tech- suction curettage. Both major and minor vessels and
nique for liposuction, feeling that using a hypo- nerves were noted to be intact while small vessels were
tonic solution was unnecessary since exactly the same torn and bleeding. This kept the authors aware of
14 M.A. Shiffman
the possibility of hematoma and encouraged the theoretic potential complication; described the diagno-
authors to use drains in all of the cases. sis, prevention, and treatment of pulmonary embolism;
Dolsky [192] used the dry technique since he felt and described combined procedures with liposuction.
that large amounts of fluid obscured the field. In ten The book claimed the use of liposuction for lipomas,
patients, treated by the French technique with a breast reduction, defatting of flaps, LaunoisBensaude
lipolytic solution of Illouz, there was one patient with disease, Knickers Deformity, congenital and trau-
seroma (10%). In ten patients treated with the Teimou- matic lymphedema, hematoma evacuation, dog ears,
rian and Fisher technique, there were two patients with and removal of silicone (face and breast).
seromas (20%) and one patient with hematoma (10%). Fournier (personal communication 8/10/10) started
The dry technique with 125 patients had one patient syringe liposuction and cryoanesthesia in 1985. Isaacs
with seroma (0.8%). The authors opinion was that [196] introduced the hand-operated switch cannula,
the suction machine must draw as close to one eliminating the distraction of the foot pedal. Also, he
atmosphere of negative pressure as possible One used a control to lower the vacuum that could then be
atmosphere of negative pressure is necessary for this used as a backup suction. In 1987, Fournier [197]
technique to be a suction extraction of the fatty tissues advocated the use of the syringe for liposuction that he
rather than a curetting technique. The author states stated simplified the equipment needed, improved the
that After approximately 15 strokes, blood will quality of the results, and improved the reliability
become evident in the tubing. The instrument is of the procedure itself because the exact amount of
removed entirely to the level of the original incision adipose tissue can be obtained, and symmetrical work
and inserted into the next tunnel. Suction drains can be performed on the opposite of the body. Toledo
were used postoperatively for 4872 h after surgery. A [198] lectured on the use of superficial liposuction to
modified French cannula with blunt tip and dull-edged smooth out excess fat and to improve skin retraction.
aperture was used. Illouz and de Villers [199] reported that Illouzs
Morgan and Berkowitz [193] published a guide- refinements in lipolysis included the pinching test in
book to acquaint the reader about liposuction that was 1980; suction-assisted abdominoplasty and treatment
essentially useful for potential patient considering lipo- of gynecomastia in 1981; cross-tunnel dissection, peri-
suction. Hetter [194] stated that low-dose epinephrine pheral mesh dissection, and trials in systemic lipoma-
can lessen the blood loss from blunt suction lipectomy. tosis in 1982; and tapering technique, elimination of
The book on Franco-American Experience [195] drainage, and use in thinning of free flaps and in lym-
claimed that Illouz heard about the Fischer technique phedema in 1983. Illouz established the 10 command-
in 1977 at the International Congress of Plastic ments of adipoaspiration that included:
Surgeons, Mexico City, April 1977. The book stated 1. Create only tunnels.
that Illouz felt that undermining the treated area and 2. Be as gentle as possible.
leaving a cavity was wrong, and he postulated that 3. Respect the superficial layer of fat.
regular tunnels in the subcutaneous tissues would 4. It is not so much what is removed that is impor-
contract in a regular and even manner. Irregular tunnel- tant, but what is left behind.
ing would produce an inconsistent pattern of scar in 5. Use, anticipate, and estimate skin retraction
the subcutaneous tissues and result in irregularities. instead of fighting against it.
The book claimed that Illouzs first case was on a 6. Do not undertake an important resection that is
lipoma of the back in June 1977. A 6-mm steel abor- locally and generally dangerous.
tion cannula and standard suction machine were used 7. Indications should be restrictive.
for liposuction on several lipomas, and he felt that a 8. All fat resection is final.
blunt cannula with blunt hole would prevent bleeding. 9. Results in the operating room approximate the
The technique of dissecting injection hydrotomy was final results.
learned from Converse in 1962. The book stated that 10. This technique demands blind surgery.
Illouz created many tunnels at different levels and Prevention of problems was discussed, and it was
suggested making larger tunnels in the deep plane and stated that the principal problems were:
smaller tunnels in the more superficial layers of fat. 1. Choosing the wrong indications
The book discussed the fat embolus syndrome as a 2. Choosing inappropriate instruments
3. A poorly executed technique [213], Vaser (vibration amplification of sound energy

4. Inattention to postoperative complications at resonance) in 2002; and Mirrafati [214], external
Megaliposuction was started in 1990 by Fournier percussion massage-assisted liposuction (vibrotumes-
(personal communication 8/10/10). Gasperoni [200] cent liposuction).
reported subdermal liposuction for better skin retrac-
tion. Courtiss et al. [201] found that various concentra-
tions of epinephrine diluted in saline did not decrease 1.5.2 Tumescent Technique
fluid/blood loss compared to saline injection or no
injection at all. Gross et al. [202] described the use of In the early days of liposuction, the dry technique
low vacuum liposhaver cannula being adjustable for a was used with either local anesthesia or general anes-
rotating or oscillating blade cutting the fat with suction thesia. The technique used had no fluids, other than
extraction of fat. This was very similar to Fischer and local anesthesia, injected into the tissues and resulted
Fischers cellusuctiotome. in 2045% blood loss [201, 215218]. Liposuction
Elam et al. [203] stated that by reducing the nega- was limited to 20003000 mL because of the blood
tive suction pressure to 20 in. (508 mm) of mercury loss, and patients were frequently given transfusions
(negative pressure), there was clinical observation of a [215].
significant improvement in liposuction results as well The wet technique relies on infusions of 100300 mL
as a decrease in the amount of bruising, pain, and of normal saline into each site but has blood loss of
swelling in the postoperative period. Schaeffer [204] 1530% [219223]. With epinephrine added to the
described the use of a soft tissue shaver and endoscopy fluid, the blood loss is reduced to 2025%.
for removal of fat in the neck over the platysma and on The tumescent technique has improved the problem
the skin flap. Giese et al. [205] found that large-volume of blood loss reducing it to 17.8% [224, 225]. The
liposuction decreased systolic blood pressure and term superwet anesthesia has been used to describe
fasting insulin levels. the same fluid injection as with the tumescent tech-
nique [226]. This technique consists of an infusion of
saline with epinephrine and an aspirate removal of
1.5.1 Assisted Liposuction approximately 1:1. Local tumescent anesthesia usually
has a fluid infusion to aspirate of 2:1 or 3:1.
Ultrasonic liposuction was introduced by Zocchi [206].
The concept was that adipose cells could be treated
with ultrasound energy, presumably breaking up their 1.5.3 Local Tumescent Anesthesia
cell walls and facilitating fat aspiration. The American
Society of Plastic and Reconstructive Surgery quickly There appears to be much confusion in the medical
adopted ultrasonic liposuction; however, over time, literature concerning Kleins solution. No one is certain
problems were found with this technique. Internal as to what so-called Kleins solution contains and what
ultrasound (ultrasound tips contained within cannulas) a modification of Kleins solution is.
increased the risk of cutaneous burns and seroma Klein first reported the use of local tumescent anes-
formation. Apfelberg [207] described laser-assisted thesia in 1987 [227]. The report described solutions
liposuction. Silberg [208, 209] introduced external used that consisted of:
ultrasound-assisted liposuction. Fodor [210] reported 1. For general anesthesia:
power- assisted liposuction in 1999 in order to facilitate a. Normal saline 1,000 mL
the fat removal and decrease the work of the surgeon. b. Epinephrine 1 mg
Powered liposuction devices are largely electrically 2. For local tumescent anesthesia:
operated, but some air- driven devices are also avail- a. Normal saline 1000 mL
able [211]. There is an increase in the rate of fat har- b. Epinephrine 1 mg
vesting and the ease of use. Powered liposuction is c. Lidocaine 1000 mg
particularly useful for difficult fibrofatty areas such as The amount of tumescent solution compared to
male pseudogynecomastia or male love handles. Taufig removal of aspirate was 1:1. This is Kleins original
[212] reported hydro-jet liposuction in 2000; Jewel solution, and all the rest are modifications.
16 M.A. Shiffman
Klein, in 1990 [228], showed that 35 mg/kg was a care for liposuction were published by the American
safe amount of lidocaine to use for local tumescent anes- Academy of Cosmetic Surgery, the American Society
thesia. The solution utilized at that time consisted of: for Dermatologic Surgery in 2000 [234], the American
1. Normal saline 1000 mL Academy of Dermatology in 2001 [235], and the
2. Epinephrine 1 mg Indian Academy of Dermatology, Venereology and
3. Lidocaine 500 mg Leprology in 2008 [236].
4. Sodium bicarbonate 12.5 mEq
Klein, in 1993 [229], had changed the local tumes-
cent anesthesia solution to: 1.6 Otoplasty
1. Normal saline 1000 mL
2. Epinephrine 0.50.75 mg Sushruta, in Sushruta Samhita, described various
3. Lidocaine 5001000 mg reconstructive methods or different types of defects
4. Sodium bicarbonate 10 mEq like release of the skin for covering small defects, rota-
5. Triamcinolone 10 mg (optional) tion of the flaps to make up for the partial loss and
The mean tumescent solution compared to total pedicle flaps for covering complete loss of skin from
aspirate was 4609 mL:2657 mL or almost 2:1. an area such as earlobe reconstruction [237]. In 30 AD,
By 1995, Klein [230] had changed the tumescent Aulus Cornelius Celsus in De Medicina [238] referred
formula to: to repair of mutilated ears with advancement quadran-
1. Normal saline 1000 mL gle flaps [239]. Gaspari Tagliacozzi, in his treatise De
2. Epinephrine 0.50.65 mg Curtorium Chirurgia per Institionem, instructed sur-
3. Lidocaine 5001000 mg geons on how to reconstruct ears [240].
4. Sodium bicarbonate 10 mEq The first correction of protruding (large) ears (mac-
5. Triamcinolone 10 mg rotia) was by means of triangular excisions taken from
In 2000, Klein [231] described a variation of drugs the auricle described by de Martino in 1856 [241].
in the local tumescent solution according to the area Dieffenbach [242] attempted to correct the protrud-
being liposuctioned. The basic solution to be changed ing, or lop ear, deformity with postauricular skin
after checking for anesthesia completeness was: excision in the auriculocephalic sulcus with concho-
1. Normal saline 1000 mL mastoidal fixation. In 1968, Rogers [243] claimed that
2. Lidocaine 500 mg the origins of otoplasty for the prominent ear were by
3. Epinephrine 0.5 mg Eli [244] who described prominent ear correction that
4. Sodium bicarbonate 19 mEq consisted of postauricular skin excision, concho-
If the anesthesia was not adequate, then a variety of mastoidal fixation, and conchal strip excision. Keen
formulations were proposed for each area of the body [245] removed a narrow, V-shaped section of carti-
areas and ranged from lidocaine of 7501500 mg, epi- lage from the posterior surface of the auricle after a
nephrine from 0.5 to 1.5 mg, and sodium bicarbonate large section of skin had been excised. Monks [246]
of 10 mEq. Local tumescent anesthesia is used as the described removal of skin from the back of the ear
anesthetic for performing liposuction, especially with but if the cartilage was stiff, then excision of some
small cannulas (microcannulas). The same fluid can be cartilage. Cocheril [247] modified the original tech-
used with conscious sedation to provide the necessary niques by adding incision and excision of various
local anesthesia. parts of the conchal cartilage to improve the results.
Ostad [232] proposed that the maximum safe Haug [248] reported removal of triangular wedges of
tumescent lidocaine dosage was 55 mg/kg. cartilage along with excision of the skin on the pos-
terior surface of the auricle. In 1896, Joseph [249]
divided protruding ears into two types: the soft and
1.5.4 Guidelines the hard cartilage types. For ears of the soft cartilage
type, he advised excision of skin at the auriculomas-
Guidelines of care for liposuction were approved by toid angle. For the hard cartilage type, he advised
the American Academy of Dermatology in 1989 and resection of cartilage from the region along with
published in 1991 [233]. Additional guidelines of excision of skin.
Gersuny [250] sutured the perichondrium to the width of the beveled edge. The proper width should
mastoid periosteum. Morestin [251] bent the cartilage be made on the first attempt. A similar procedure is
and held it in place with nonabsorbable sutures. He carried out on the other edge of cartilage. The carti-
believed that the incision through the cartilage must lage does not require suturing; McDowell [264] made
extend well up to the upper and lower borders of the a precise placement of the main cartilage incision
cartilage. Payr [252] embedded a cartilage flap under from the posterior surface while continuously observ-
the periosteum. Miller [122] described his experience ing the marked line to follow on the anterior surface of
in the correction of various facial deformities includ- the ear. The knife point goes through the cartilage,
ing outstanding ears. Goldstein [253] described an and its continuing path is easily seen under the ante-
operation similar to Morestin, but he sutured the rior skin. This method allows for a quicker and more
cartilage to the mastoid periosteum. accurate incision than does the use of perforating
Luckett [254] resorted to a cartilage-breaking tech- needles.
nique consisting of crescent medial skin and cartilage Ruttin [265] anchored the cartilage with fascia lata
excision along the entire vertical length of the antiheli- strips. Kolle [266] corrected protruding (macrotia) ears
cal fold to restore the antihelical fold. However, this with excision of skin and an elongated ellipse of carti-
produced a sharp outline to the antihelical fold in some lage. Alexander [267] corrected ear prominence due to
cases. Luckett attempted to alleviate this problem with a high concha by incising and overlapping the posterior
several horizontal mattress sutures, as adapted from wall of the concha. Demel [268] advised the removal
Lembert, that allowed the flat surfaces of the concha of a large section of conchal cartilage to be turned on
and the antihelix to be apposed, not the edges of each, itself and pedicled beneath a bridge of periosteum over
as the sutures were tied tightly. the mastoid region. Eltner [269] tried to eliminate the
Modifications of Lucketts technique include: Barsky wrinkling of skin on the anterior surface, that occurred
[255] beveled the borders and kept an intact segment of with the Joseph and Morestin techniques, by excising
cartilage over the cartilage incisions by suturing the cut two triangles of cartilage with a common base from the
edges under a bridge; Baxter [256] made parallel inci- region of the concha. The skin and perichondrium
sions of the cartilage instead of a single one; Young were incised horizontally and then undermined before
[257] prolonged the cartilage incision to break the excision of the cartilage. Davis and Kitlowski [270]
spring and avoid suturing; Farina [258] varied the skin described the use of needles passed through and
incision and cartilage resection; Vidaurre [259] added through the auricle to mark the antihelix. They recom-
an incision for the anterior crus; Hatch [260] modified mended dipping the needles in a dye and then marked
Lucketts procedure by removing three separate, though the cartilage with a series of puncture points to assist in
continuous, crescent-shaped pieces of tissue, two of the incision and remodeling of the auricular cartilage.
which are cartilage and one of which is cartilage and MacColumm [271] and Young [272] combined the
fat in the lobule. This repositioning allowed the ear to Luckett technique of antihelical correction with ear-
open out in three separate and opposing directions lier techniques of conchal reduction that now forms
simultaneously to produce anatomic and aesthetic nor- the foundation for most of the modern otoplasty tech-
mality; Jones [261] excised a wider cartilage strip in niques for correcting the prominent ear deformity.
order to decrease the sharpness of the antihelical ridge; New and Erich [273] described a technique of exter-
Holmes [262] used a special gouge to make fish-like nal stay sutures that permitted and easy and flexible
scales up and down the proposed antihelix; Cloutier method of modeling the antihelix fold and maintaining
[263] divided the cartilage from the top of the ear to the infolding of the cartilage in position during healing.
the lobule, and the skin overlying the anterior surface Fishman and Fishman [274] used a through and
of the cartilage dissected off the cartilage approxi- through excision after premarking. The outer or lateral
mately 3/8 in. on each side. The upper and lower ends portion followed the curve of the helix closely extend-
of one edge of the cartilage are grasped with forceps ing beyond the crura of the antihelix at the upper end
and turned back so that the anterior side of the carti- and into and through the length of the fossa of the
lage faces the operator. The edge of the cartilage is concha at the lower end. The medial incision was in
beveled with a razor blade. The edge of the cartilage accordance with the amount of skin and cartilage
will curl, and the width of the curl will depend on the required to be excised. Subsequent modifications were
18 M.A. Shiffman
described by Pierce et al. [275], Dufourmental [276], skin is undermined laterally for a few millimeters on
and Paletta et al. [277]. the anterior surface of the auricle. The sulcus antiheli-
Borges [278] felt that Youngs technique had the cis transversus is incised completely through extend-
disadvantage of the middle ridge and the superior crus ing the incision into the previously incised cartilage of
being too sharp and does not conform to the normal the antihelix that breaks the spring of the inferior crus.
ear. He modified the technique by not excising the The cauda helicis is completely removed and the supe-
elliptical strip of cartilage from the concha but just rior crus crosscut by incisions to weaken the spring of
incising and criss-crossing it while excising the infe- the cartilage. A small transverse section of cartilage is
rior and internal strip from the concha so that it may removed from the upper end of the superior crus to
give bulk and roundness to the superior crus and medial completely break the spring of the antihelix and supe-
part of the antihelix. rior crus. Three or four surgical gut mattress sutures
McEvitt [279] used multiple parallel antihelical inci- are inserted in the perichondrium along the margins of
sions to soften the hard-edge contours of the corrected the original incisions in the cartilage and tied to form
antihelical fold. He also divided protruded ears into the new antihelical fold. Excess skin is excised and the
types. skin sutured closed.
Type 1: Ears of normal size with moderate protru- Jayes and Dale [282] modified the Luckett tech-
sion caused by underdevelopment of the normal fold of nique by also using antihelical incisions. Also, they
the antihelix. The concha and fossae are approximately classified the prominent ear into types.
normal in size, and their ratio to one another is Type 1: The antihelix is formed but is not folded
correct. The antitragus is not overprominent. back as sharply as in a normal ear, and the scapho-
Type 2: Large ears usually with marked protrusion, conchal angle is widened. The ear is small, and it will
underdevelopment of the fold of the antihelix, not be abnormally prominent, but if large it will defi-
overprominence of the antitragus, and wide scapha nitely stick out.
(fossa of the helix). Type 2: Superior crus of the antihelix is absent.
Type 3: Long narrow ears with little or no evidence The upper part of the scapha looks abnormally
of the antihelix. The structure seems curled forward. wide owing to the absence of the dividing ridge. The
The concha and fossae form a continuous hollow giv- whole upper part of the ear turns forward and tends to
ing the ear almost the appearance of a shell. They tend droop as it lacks the stiffening support of the superior
to be wide at the top and taper toward the lobule, being crus.
roughly triangular. Type 3: The whole of the antihelix is poorly formed,
Weaver [280] modified the technique of New and and the scapho-conchal angle is widely obtuse. The
Erich [273]. superior crus is absent. The inferior crus and the lower
Becker [281] described a procedure with an incision part of the antihelix, though visible, are very much flat-
through the skin and perichondrium in the postauricu- tened. The ear stands sharply out from the head at a
lar region of the margin between the scapha and the right angle.
concha, in the fossa antihelicis, and extended at the Type 4: The antihelix is totally absent. The ear is of
superior portion to the junction of the ear and temporal the fetal type curving smoothly outward and forwards
region, while at the inferior portion, it is extended from the head in the pane of the concha. This type of
down to the base of the antitragus close to the mastoid deformity is sometimes associated with microtia or
region. The skin and perichondrium are undermined relative shortness of the helix.
laterally almost to the mastoid angle and to the begin- Sercer [283] resected the anterior spine of the
ning rim of the helix. The ear is folded back against the helix, thinned the back of the concha, and excised an
head to show the new antihelix. Skin and cartilage are ellipse or myrtle-leaf piece of the retroauricular skin.
pierced by a needle and the posterior surface of the Kristensen [284] devised variations in skin resection
cartilage marked with methylene blue. The double row and cartilage incisions. Becker [285] described paral-
of marks delineates the posterior and anterior borders lel antihelical incisions held together by permanent
of the antihelix and superior crus. Two incisions are sutures to produce conical antihelical tubing in order
made through the cartilage along the markings, and a to soften the external contour of the corrected promi-
section of cartilage is removed from the antihelix. The nent ear. This was refined by Converse et al. [286] and
further elaborated by Converse and Wood-Smith [287] Morcellation of the antihelix through a direct lateral
and Wood-Smith and Converse [288]. incision was advocated by Ju et al. [300].
Straith [289] corrected unpleasant effects of oto- Crikelair and Cosman [301] described a new tech-
plasty by (1) running a cutaneous 0000 nylon suture nique for the prominent ear with combined concha and
just back of the cut edges of the concha and helix and antihelix deformity. A postauricualr incision parallel
(2) predetermining the correct height of concha and to the free border of the helix and 1 cm from the border
antihelix by folding the ear back and placing needles, is extended from the cephaloauricular angle superiorly
after which the needles are removed and the ear folded to the fleshy lobule inferiorly. An ellipse of skin can be
back to determine the amount of cartilage to be deter- excised using the incision line as the outer border.
mined and excised accordingly. (3) The formation of a Needles are passed posteriorly from the anterior sur-
normal curve of the antihelix can be predetermined by face of the ear just beneath the helix overhang, tipped
folding the ear back and placing the needles along the with methylene blue and then withdrawn. The wound
edges of the concha and triangular fossa. Usually a edges are slightly undermined and the methylene blue
strip no more than 2 mm wide is excised to give a markings identified on the cartilage. The auricular car-
normal appearance. tilage is cut through along this line from superiorly at
Surgical abrasion of the antihelix was described by the cephaloauricular angle inferiorly to where the tail
Stark and Saunders [290]. Mustarde [291293] simpli- of the helix begins. This separates the rim of the ear
fied these techniques by creating a conical antihelical from the major ear cartilage. The auricular cartilage is
tubing with permanent conchoscaphal mattress sutures. freed subchondrally on its anterior surface, and the
These sutures, placed full thickness through the carti- anterior dissection is carried forward in the upper part
lage of the concha and scapha in mattress fashion with- of the ear until the inferior crus of the helix is exposed.
out piercing the lateral skin, are particularly successful The middle and lower portion of the ear, the edge of
to treat the pliable cartilage of children. All cartilage the cavum concha, is similarly exposed. The anterior
tubing techniques depend on scarring to fill the tube cartilage surface is lightly striated (not through the
and lock the sculpted framework into position. full thickness of the cartilage) in at least three or four
Tamerin and Mirehouse [294] noted the tendency of directions. The cartilage will bend back on itself form-
the auricular cartilage in the region of the helix to ing the smooth roll of the antihelix. The acuteness
curl backward when it is incised near the free edge of of the roll can be increased by increasing the number
the ear and when it is separated from its anterior and decreasing the spacing of the striations. The redun-
lining perichondrium. Farrior [295] used the smallest dant auricular cartilage can be trimmed. The amount to
dermabrader to remove parallel concave troughs simi- be excised can be determined by replacing the helix
lar to the full-thickness wedges removed in the current over the auricular cartilage and observing the excess
technique. The strips that remain between the troughs from behind. The width removed affects the width of
give body and resilience to the ear. He used a method the new scaphoid fossa. The amount trimmed from the
of three incisions and an overriding cartilage strip in superior pole affects the vertical length of the ear.
the reconstruction of the antihelix proper. He did not The edge of the cavum concha is trimmed, and the tail
join the superior crus and conchal rim incisions but left of the helix is dissected free and excised. The anterior
an isthmus of cartilage at the junction of the crura as in skin flap is replaced on the cartilage and molded into
Straiths [289] method. its new contours. The postauricular incision is closed.
Pitanguy and Rebello [296] used an island technique In 1966, Barnes and Morris [302] reported use of
to cover visible cartilage ridges. Gibson and Davis the Stenstrem technique by elevating the skin from
[297], Chongchet [298], and Stenstrem [299] intro- the postauricular skin excision site and freeing tail
duced lateral cartilage weakening techniques to take of the helix from the conchal cartilage and the skin
advantage of the unique ability of a sheet of cartilage anteriorly. Half of a Brown-Adson tissue forceps was
to warp away from the injured surface. In the Chongchet introduced into the subcutaneous tunnel to make mul-
technique, the lateral scaphal cartilage is scored with a tiple superficial scratches along the antihelix and its
scalpel to form an antihelix. In the Stenstrem tech- crura. The ear can then be folded back quite easily and
nique, postauricular incision is used so that a short- held in its new position by simply closing the elliptical
tined rasp could be used to blindly scar the antihelix. skin defect. Kaye [303] developed a combination of
20 M.A. Shiffman
the Stenstrem technique of antihelical rasping and the An excellent algorithm was developed by Stal and
Mustarde concept of permanent mattress suture fixa- Hatef [313] for the analysis and treatment of the
tion to maintain the proper amount of antihelical roll prominent ear.
after a lateral rasp of the antihelix. Permanent sutures
are introduced through tiny lateral incisions along the
conchal crest, which are carried across the antihelical 1.6.1 Conclusions
fold and tied on the lateral side.
Further contributions of the Ely technique with Otoplasty history shows the development of the surgi-
conchomastoidal sutures include Owens and Delgado cal treatment of the prominent ear with a multitudinous
[304] and Furnas [305]. Spira et al. [306] combined variety of new and modified techniques. When per-
conchomastoidal suturing with conchoscaphal sutur- forming otoplasty, the surgeon should be thoroughly
ing with good results). Webster [307] stated that informed of the variety of procedures available.
regardless of the skill of the operator or the technique
of the operation, however, one falls short of the ideal
appearance in every case. Perfection is impossible to 1.7 Rhinoplasty
attain. He used a combination of ideas of many authors
plus individual interpretation. The essential concept is The history of cosmetic rhinoplasty started with plastic
thinking of the concha as one entity and the rest of the repair of the nose as early as the Edwin Smith Papyrus
ear, including the helix and antihelix area, as another that is thought to be at least 1700 years old. Although
unit. Wood-Smith [308] reported on correction of replacement of portions of the nose from injuries or
prominent lobules when the lower third of the ear pro- disease was the main indication for rhinoplasty,
trudes with a modified fishtail excision. Dieffenbach, in 1845 [242], introduced the concept of
Weerda [309], in cases of thick auricular cartilage reoperation to improve the cosmetic appearance of the
with low elasticity, used a diamond drill to weaken the reconstructed nose. Roe, in 1891, reduced the hump of
auricular cartilage immediately above and below the the nose. After that time, cosmetic rhinoplasty has
intended new antihelical fold and the antihelical crus been improved and modified by many authors.
through a retroauricular access. Full-thickness mattress
sutures of slowly absorbable suture material are placed
at the positions with the corresponding markings to fix 1.8 Early Rhinoplasty
the helix in the intended position.
Wegener [310] stated that the procedure that The Edwin Smith Papyrus (purchased in Egypt by
combined correction of protruding ears with reduc- Smith in 1862) is thought to be at least 1700 years old
tion of hyperplastic auricles had been developed by and copied from treatises at least 1000 years older
the author more than 30 years previously. During the [314]. Translated in 1930 by Breasted [315], the papy-
postauricular removal of the prominent cartilage in rus cited cases of a broken nose, a break in the nasal
a layer-by-layer fashion, the scalpel is used tangen- bone, and a comminuted fracture in the side of the nose
tially following the outline of the individual crural that were treated with insertion of plugs of linen satu-
curvature to the antihelix margin and the auricle rated with grease into the nostrils.
base. Falciform excision of the cartilage of the supe- The earliest recording of reconstruction of the nose
rior helix is performed starting from the anterior fold was Sushruta (Susruta) (approximately 600 BC) who
of the auricle peripherally toward the scapha. After an described in his Sushruta Samhita (Sushrutas Collec-
anterior skin sickle excision, a new helix margin is tion) an innovative method of rhinoplasty that was
created by eversion of the still intact skin of the poste- reconstruction following amputation of the nose as a
rior helix wall. The operation is finished by a wedge- punishment for crimes [316, 317]. This method is
shaped skin-cartilage excision of the superior part of mentioned as the Indian method of rhinoplasty in the
the helix. books of plastic surgery.
Horlock et al. [311] described a postauricular fas- In 1816, Carpue [318] published the account of
cial flap in otoplasty. Scuderi et al. [312] reported on a the successful performance of operative procedures
posterior auricular muscle flap in otoplasty. on British military officers, one who had lost his nose
to the toxic effects of mercury treatments while being incision for rhinoplasty that is frequently referred to as
treated for liver infection, and the other lost the nose the Rthi incision or technique [331]. Roy [332]
from a saber cut. He used the Indian rhinoplastic described a technique of lifting the nasal tip through a
reconstruction with a flap of skin taken from the mucosal incision separating the tissues from the colu-
forehead. In 1818, von Graefe [319] published his mella and from the tip of the nose to the nasal bones.
major work entitled Rhinoplastik. He modified the A costal cartilage graft was placed in the nasal vestibu-
Italian method using a free skin graft from the arm lar wound in direct contact with the quadrangular car-
instead of the original delayed pedicle flap. von tilage taking its support from the superior maxilla,
Pfolspeundt, in Buch der Bundth-Ertznei [320], pushing up the tip of the nose.
described a process to make a new nose for one who A number of different alloplastic materials were
lacks it entirely, and the dogs have devoured it by reported being used in rhinoplasty. Holt and Lloyd
removing skin from the cheek or forehead and sutur- [333] used methyl methacrylate, Cottle et al. [334]
ing it in place. used hyaluronidase, Voloshin [335] used Plexiglass,
and Nolting [336] used a steel bridge.
Goodman [337] initiated the shift from the closed
1.8.1 Cosmetic Rhinoplasty technique of rhinoplasty to an open technique, and this
was refined and popularized by Anderson et al. [338].
In 1845, Dieffenbach [242] wrote a comprehensive Gunter and Rohrich [339] described the open rhino-
text on rhinoplasty, entitled Operative Chirurgie, and plasty technique for secondary rhinoplasty that resulted
introduced the concept of reoperation to improve in a shift in surgical approach to secondary rhinoplasty.
the cosmetic appearance of the reconstructed nose. Sheen [340] described the use of a spreader graft to
In 1891, Monks [321] described the successful use of reconstruct the roof of the middle nasal vault following
heterogeneous free bone grafting to reconstruct saddle rhinoplasty.
nose defects. In 1891, Roe [322] presented an example
of his work with a young woman on whom he reduced
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Anatomy of the Face and Neck
2
2.1 Introduction Following a description of the hard tissue foundation,

the soft tissues of the face will be described, from
Safe and effective cosmetic surgical practice relies on a superficial to deep, in the following order:
clear knowledge and understanding of facial anatomy. 1. Superficial fat compartments
Techniques evolve and improve as the complex, lay- 2. Superficial musculoaponeurotic system (SMAS)
ered architecture and soft tissue compartments of the 3. Retaining ligaments
face are discovered and delineated through imaging, 4. Mimetic muscles
staining techniques, and dissections both intraopera- 5. Deep plane, including the deep fat compartments
tively and in the research laboratory on cadavers [1]. To
create a more youthful, natural-looking form, the sur-
geon endeavors to reverse some of the changes that 2.2 Facial Skeleton
occur due to aging. These include volumetric changes
in soft tissue compartments, gravitational changes, and Facial appearance is to a large extent determined by
the attenuation of ligaments. Whether the plan of reju- the convexities and concavities of the underlying facial
venation includes rhytidectomy, platysmaplasty, autol- bones (Fig. 2.1). The high cheekbones and strong
ogous fat transfer, implants, or endoscopic techniques, chin associated with attractiveness are attributable to
a sound knowledge of facial and neck anatomy will the convexities and projection provided by the zygo-
increase the likelihood of success and reduce the inci- matic bone and mental protuberance of the mandible,
dence of undesirable results or complications. respectively (Fig. 2.2). The facial skeleton consists of
This chapter describes the anatomy of the face in the frontal bone superiorly, the bones of the midface,
layers or planes, with some important structures or and the mandible inferiorly. The midface is bounded
regions described separately, including the facial nerve, superiorly by the zygomaticofrontal suture lines, infe-
sensory nerves, and facial arteries. The superficial riorly by the maxillary teeth, and posteriorly by
layers and topography of the neck are also described. the sphenoethmoid junction and the pterygoid plates.
The facial skeleton forms the hard tissue of the face and The bones of the midface include the maxillae, the
provides important structural support and projection zygomatic bones, palatine bones, nasal bones, zygo-
for the overlying soft tissues, as well as transmitting matic processes of the temporal bones, lacrimal bones,
nerves through foramina and providing attachments for ethmoid bones, and turbinates. The facial skeleton
several mimetic muscles and muscles of mastication. contains four apertures: the two orbital apertures, the
nasal aperture, and the oral aperture. The supraorbital
foramen (or notch) and the frontal notch are found at
the superior border of each orbit and transmit the
supraorbital and supratrochlear nerves, respectively.
P.M. Prendergast
Venus Medical, Dublin, Ireland The maxillary bones contribute to the nasal aperture,
e-mail: [email protected] bridge of the nose, maxillary teeth, floor of the orbits,

30 P.M. Prendergast
Fig. 2.1 Frontal view of the facial skeleton
10 26
11
8
7
12 25 24
6
13 23
14
22 4
15 5
3
16
21
17
1
18
19 20
1 Angle of mandible 14 Zygomaticofacial foramen

2 Ramus of mandible 15 Infra-orbital foramen
3 Body of maxilla 16 Anterior nasal aperture
4 Zygomatic process of maxilla 17 Intermaxillary suture
5 Zygomatic bone 18 Mental foramen
6 Greater wing of sphenoid bone 19 Mental protruberance
7 Zygomaticofrontal suture 20 Body of mandible
8 Zygomatic process of frontal bone 21 Anterior nasal spine
9 Frontal bone 22 Nasal septum
10 Supra-orbital notch 23 Lacrimal bone
11 Frontal notch 24 Frontal process of maxilla
12 Superior orbital fissure 25 Nasal bone
13 Inferior orbital fissure 26 Glabella
and cheekbones. The infraorbital foramen lies in the The mandible forms the lower part of the face. In
maxilla below the inferior orbital rim and transmits the midline, the mental protuberance gives anterior
the infraorbital nerve. The zygomaticofacial foramen projection to the overlying soft tissues. Laterally, the
transmits the zygomaticofacial nerve inferolateral to ramus of the mandible underlies the masseter muscle
the junction of the inferior and lateral orbital rim. and continues superiorly to articulate with the cranium
2 Anatomy of the Face and Neck 31
Fig. 2.2 Convexities of the facial skeleton
Temporal process of
zygomatic bone
Zygomatic bone
Zygomatic process
of maxilla
Mental protruberance of
mandible
through the coronoid process and condylar process from one another by delicate fascial tissue and septae
of the mandible. The mental nerve emerges from that converge where adjacent compartments meet
the mental foramen on the body of the mandible in to form retaining ligaments. The superficial fat com-
line vertically with the infraorbital and supraorbital partments of the face comprise the following: the naso-
nerves. labial fat compartment; the medial, middle, and lateral
As well as providing structural support, projection, temporal-cheek malar fat pads; the central, middle,
and protection of sensory organs such as the eyes, and lateral temporal-cheek pads in the forehead; and
the facial skeleton provides areas of attachment for the superior, inferior, and lateral orbital fat pads
the muscles of facial expression and the muscles of (Fig. 2.4). Nasolabial fat lies medial to the cheek fat
mastication (Fig. 2.3). pad compartments and contributes to the overhang of
the nasolabial fold. The orbicularis retaining ligament
below the inferior orbital rim represents the superior
2.3 Supercial Fat Compartments border of the nasolabial fat compartment and the
medial cheek compartment (Fig. 2.5). The middle
The pioneering work of Rohrich and Pessa [2], using cheek fat compartment lies between the medial and
staining techniques and cadaver dissections, has lateral temporal-cheek fat compartments and is
revealed a number of distinct superficial fat compart- bounded superiorly by a band of fascia termed the
ments in the face. These compartments are separated superior cheek septum. The borders of the middle
32 P.M. Prendergast
Fig. 2.3 Areas of muscle Procerus

attachments to the facial
skeleton Corrugator
supercilii
Orbicularis oculi
Temporalis
Upper orbital part
Palpebral part
Levator labii superioris
Lower orbital part
alaeque nasi
Zygomaticus major
Zygomaticus minor Masseter
Levator anguli oris
Nasalis: transverse part
Depressor septi
Nasalis: alar part
Temporalis
Buccinator
Platysma Masseter
Depressor anguli oris Mentalis

Depressor labii inferioris
cheek compartment, the inferior, and the lateral orbital adheres to the depressor anguli oris muscle and is
fat pad compartments converge to form a tougher band bounded medially by the depressor labii and inferiorly
of tissue called the zygomatic ligament [3]. The con- by bands of the platysma muscle. Premental and pre-
densation of connective tissue at the borders of the platysmal fat abut the jowl fat compartment.
medial and middle fat compartments correlates with The compartmentalized anatomy of the superficial
the masseteric ligaments in the same location [4]. The subcutaneous fat of the face has implications in the
lateral temporal-cheek fat pads span the entire face aging process. Volume loss appears to occur at
from the forehead to the cervical area. Its anterior different rates in different compartments, leading to
boundary, the lateral cheek septum, is encountered irregularities in facial contour and loss of the seam-
during facelift procedures with medial dissection from less, smooth transitions between the convexities and
the preauricular incision. In the forehead, its upper and concavities of the face associated with youthfulness
lower boundaries are identifiable as the superior and and beauty.
inferior temporal septa. Medial to the lateral temporal-
cheek fat compartment in the forehead, the middle
temporal fat pad is bounded inferiorly by the orbicu- 2.4 Supercial Musculoaponeurotic
laris retaining ligament and medially by the central System
forehead fat compartment. Above and below the eyes,
the superior and inferior orbital fat compartments lie In 1976, Mitz and Peyronie [5] published their descrip-
within the perimeter of the orbicularis retaining ligation of a fibrofatty superficial facial fascia they called
ment. These periorbital fat pads are separated from the superficial musculoaponeurotic system (SMAS).
one another medially and laterally by the medial and This system or network of collagen fibers, elastic
lateral canthi, respectively. The lateral orbital fat fibers, and fat cells connects the mimetic muscles to
compartment is the third orbital fat pad and is bounded the overlying dermis and plays an important func-
superiorly by the inferior temporal septum and inferi- tional role in facial expression. The SMAS is central to
orly by the superior cheek septum. The zygomati- most current facelift techniques where it is usually dis-
cus major muscle attaches, through fibrous septae, to sected, mobilized, and redraped. In simple terms, the
overlying superficial fat compartments along its length. SMAS can be considered as a sheet of tissue that
In the lower third of the face, the jowl fat compartment extends from the neck (platysma) into the face (SMAS
Fig. 2.4 The superficial fat Lateral Temporal-Cheek Middle forehead

compartments of the face (forehead)
Central
Lateral orbital
Medial
Superior
orbital
Middle
Inferior
orbital
Nasolabial
Lateral
temporal-cheek
Jowl
Pre-platysma fat
proper), temporal area (superficial temporal fascia), mouth to the overlying skin and has an important role
and medially beyond the temporal crest into the fore- in transmitting complex movements during animation.
head (galea aponeurotica). However, the precise anat- Over the parotid gland, the SMAS is relatively thick.
omy of the SMAS, regional variations, and even the Further medially, it thins considerably making it diffi-
existence of the SMAS are debated [6]. Ghassemi et al. cult to dissect. In the lower face, the SMAS covers the
[7] describe two variations of SMAS architecture. facial nerve branches as well as the sensory nerves.
Type I SMAS consists of a network of small fibrous Dissection superficial to the SMAS in this region pro-
septae that traverse perpendicularly between fat lob- tects facial nerve branches [8]. Above the zygomatic
ules to the dermis and deeply to the facial muscles or arch, the SMAS exists as the superficial temporal fas-
periosteum. This variation exists in the forehead, cia, which splits to enclose the temporal branch of the
parotid, zygomatic, and infraorbital areas. Type II facial nerve and the intermediate temporal fat pad.
SMAS consists of a dense mesh of collagen, elastic, Dissection in this area should proceed deep to the
and muscle fibers and is found medial to the nasolabial superficial temporal fascia, on the deep temporal fas-
fold, in the upper and lower lips. Although extremely cia, to avoid nerve injury. Although considered as one
thin, type II SMAS binds the facial muscles around the system or plane, the surgeon should be mindful of
34 P.M. Prendergast
Fig. 2.5 Ligaments and septa Superior temporal septum

between fat compartments of Interior temporal septum
the face
Orbicularis retaining Ligament
Medial canthus
Lateral canthus
Zygomatic
ligament
Lateral cheek
septum
Superior cheek septum

Masseteric
ligaments
Platysma-auricular ligament
Mandibular ligament
the regional differences in SMAS anatomy from supe- retaining ligament. The latter connects the periosteum
rior to inferior and lateral to medial. of the mandible just medial to the origin of depressor
anguli oris to the overlying dermis. This attachment
gives rise to the labiomandibular fold just anterior to
2.5 Retaining Ligaments the jowl. The masseteric ligaments are false retaining
ligaments that arise from the anterior border of the
True retaining ligaments are easily identifiable struc- masseter and insert into the SMAS and overlying
tures that connect the dermis to the underlying perios- dermis of the cheek. With aging, these ligaments atten-
teum. False retaining ligaments are more diffuse uate, the SMAS over the masseter becomes ptotic,
condensations of fibrous tissue that connect superficial and this leads to the formation of jowls [10]. Below
and deep facial fasciae [9] (Fig. 2.6). The zygomatic the lobule of the ear, the platysma-auricular ligament
ligament (McGregors patch) is a true ligament that represents a condensation of fibrous tissue where the
connects the inferior border of the zygomatic arch to lateral temporal-cheek fat compartment meets the pos-
the dermis and is found just posterior to the origin of tauricular fat compartment. During facial rejuvenation
the zygomaticus minor muscle [3]. Other true liga- procedures, true and false retaining ligaments are
ments include the lateral orbital thickening on the encountered and often released in order to mobilize
superolateral orbital rim that arises as a thickening of and redrape tissue planes. Extra care should be taken
the orbicularis retaining ligament, and the mandibular when releasing ligaments as important facial nerve
Fig. 2.6 The retaining

ligaments of the face
Orbicularis retaining ligament
Zygomatic ligament
Platysma-auricular (McGregors patch)
ligament
Masseteric ligament
Mandibular ligament
branches are intimately related to ligaments, such as Contraction raises the eyebrows and causes horizontal
the zygomatic and mandibular retaining ligaments. furrows over the forehead. Frontalis receives innervation
from the temporal branch of the facial nerve.
Orbicularis oculi acts as a sphincter around the eye.
2.6 Mimetic Muscles It consists of three parts, the orbital, preseptal, and pre-
tarsal parts. The orbital part arises from the nasal part of
The muscles of facial expression are thin, flat muscles the frontal bone, the frontal process of the maxilla, and
that act either as sphincters of facial orifices, as dila- the anterior part of the medial canthal tendon. Its fibers
tors, or as elevators and depressors of the eyebrows pass in concentric loops around the orbit, well beyond
and mouth. Frontalis, corrugator supercilii, depressor the confines of the orbital rim. Contraction causes the
supercilii, procerus, and orbicularis oculi represent eyes to squeeze closed forcefully. Superior fibers also
the periorbital facial muscles. The perioral muscles depress the brow. Preseptal orbicularis oculi arises from
include the levator muscles, zygomaticus major and the medial canthal tendon, passes over the fibrous
minor, risorius, orbicularis oris, depressor anguli oris, orbital septum of the orbital rim, and inserts into the
depressor labii, and mentalis. The nasal group includes lateral palpebral raphe. The pretarsal portion, involved
compressor naris, dilator naris, and depressor septi. In in blinking, overlies the tarsal plate of the eyelid and
the neck, the platysma muscle lies superficially and has similar origins and insertions to its preseptal coun-
extends into the lower face (Fig. 2.7). terpart. These muscles receive innervation from the
Frontalis represents the anterior belly of the occipito- temporal and zygomatic branches of the facial nerve.
frontalis muscle and is the main elevator of the brows. Corrugator supercilii arises from the superomedial
It arises from the epicranial aponeurosis and passes aspect of the orbital rim and passes upward and out-
forward over the forehead to insert into fibers of the ward to insert into the dermis of the middle of the
orbicularis oculi, corrugators, and dermis over the brows. brow. From its origin deep to frontalis, two slips of
36 P.M. Prendergast
Fig. 2.7 The mimetic facial

muscles Frontalis (medial)
Frontalis (lateral)
Depressor supercilii
Procerus

alaeque nasi Corrugator
Orbicularis oculi:
Pretarsal part
Preseptal part
Orbital part
Zygomatici
Compressor naris
Dilator naris
Orbicularis oris
Depressor septi
Depressor anguli oris

Mentalis
Depressor labii
Platysma
muscle, one vertical and one transverse, pass through and lateral aspect of the upper lip, respectively. They
fibers of frontalis to reach the dermis. The superficial receive their nerve supply on their deep surface from
and deep branches of the supraorbital nerve are inti- the zygomatic and buccal branches of the facial nerve.
mately related to corrugator supercilii at its origin and Zygomaticus major and minor lift the corners of the
are prone to injury during resection of this muscle. mouth.
Corrugator supercilii depresses the brow and pulls it Levator labii lies deep to orbicularis oculi at its origin
medially, as in frowning. from the maxilla just above the infraorbital foramen. It
Depressor supercilii is a thin slip of muscle that is passes downward to insert into the upper lip and orbicu-
difficult to distinguish from the superomedial fibers of laris oris. A smaller slip of muscle medial to this, levator
orbicularis oculi. It inserts into the medial brow and labii superioris alaeque nasi, originates from the frontal
acts as a depressor. process of the maxilla and inserts into the nasal cartilage
Procerus arises from the nasal bone, passes and upper lip. Both of these muscles are supplied from
superiorly, and inserts into the dermis of the glabella branches of the zygomatic and buccal branches of the
between the brows. It depresses the lower forehead facial nerve and elevate the upper lip.
skin in the midline to create a horizontal crease at the Levator anguli oris arises deeply from the canine
bridge of the nose. Chemodenervation of procerus and fossa of the maxilla below the infraorbital foramen and
corrugator supercilii to alleviate frown lines is one of inserts into the upper lip. It is innervated on its superfi-
the most common aesthetic indications for botulinum cial aspect by the zygomatic and buccal branches of
toxins. Procerus is sometimes debulked during endo- the facial nerve and elevates the corner of the mouth.
scopic brow lift procedures to reduce the horizontal Risorius is often underdeveloped and arises from a
frown crease. thickening of the platysma muscle over the lateral
Zygomaticus major and minor are superficial mus- cheek, the parotidomasseteric fascia, or both. It inserts
cles that originate from the body of the zygoma and into the corner of the mouth and pulls the mouth
pass downwards to insert into the corner of the mouth corners laterally.
Orbicularis oris acts as a sphincter around the mouth expression can move freely. Suborbicularis oculi fat
and its fibers interlace with all of the other facial mus- (SOOF) has two parts, medial and lateral [11]. The
cles that act on the mouth. The buccal and marginal medial component extends along the inferior orbital
mandibular branches of the facial nerve provide motor rim from the medial limbus (sclerocorneal junction) to
supply to orbicularis oris, which has various actions, the lateral canthus and the lateral component from the
including pursing, dilation, and closure of the lips. lateral canthus to the temporal fat pad. Between the
Depressor anguli oris arises from the periosteum of SOOF and the periosteum of the zygomatic process of
the mandible along the oblique line lateral to depressor maxilla, there is a gliding space, the prezygomatic
labii inferioris. Its fibers converge on the modiolus space [12]. This space is bounded superiorly by the
with fibers of orbicularis oris, risorius, and sometimes orbicularis retaining ligament and inferiorly by the
levator anguli oris. It is supplied by the marginal man- zygomatic retaining ligament (Fig. 2.8). The sublevator
dibular branch of the facial nerve and depresses the fat pad lies medial to the medial SOOF compartment
mouth corners on contraction. Depressor labii inferio- and represents the most medial of the deep infraorbital
ris arises from the oblique line of the mandible in front fat pads. This fat pad is an extension of the buccal fat
of the mental foramen, where fibers of depressor anguli pad, behind levator labii superioris alaeque nasi and is
oris cover it. It passes upward and medially to insert continuous below and laterally with the melolabial and
into the skin and mucosa of the lower lip and into fibers buccal extensions of the buccal fat pad [1]. The buccal
of orbicularis oris. fat pad is an aesthetically important structure that sits
Mentalis arises from the incisive fossa of the man- on the posterolateral part of the maxilla superficial
dible and descends to insert into the dermis of the chin. to the buccinator muscle and deep to the anterior part
Contraction elevates and protrudes the lower lip and of masseter. Functionally, it facilitates a free gliding
creates the characteristic peach-pit dimpling of the movement for the surrounding muscles of mastication
skin over the chin. Motor supply arises from the mar- [13]. As well as the medial extensions described
ginal mandibular nerve. above, it continues laterally as the pterygoid extension
Nasalis consists of two parts, the transverse part (Fig. 2.9). Buccal branches of the facial nerve and the
(compressor naris) and alar part (dilator naris). parotid duct travel along its surface within the parotido-
Compressor naris arises from the maxilla over the masseteric fascia after leaving the parotid gland.
canine tooth and passes over the dorsum of the nose to The galea fat pad lies deep to frontalis in the fore-
interlace with fibers from the contralateral side. It head and extends superiorly for about 3 cm [14]. It
compresses the nasal aperture. Dilator naris originates envelops corrugator and procerus and aids gliding of
from the maxilla just below and medial to compressor these muscles during animation. The retro-orbicularis
naris and inserts into the alar cartilage of the nose. It oculi fat (ROOF) is part of the galea fat pad over the
dilates the nostrils during respiration. Depressor septi superolateral orbital rim from the middle of the rim to
is a slip of muscle arising from the maxilla above the beyond the lateral part. It lies deep to the superolateral
central incisor, deep to the mucous membrane of the fibers of preseptal and orbital orbicularis oculi and
upper lip. It inserts into the cartilaginous nasal septum contributes to the fullness (in youth) and heaviness (in
and pulls the nose tip inferiorly. Nasalis and depressor senescence) of the lateral brow and lid.
septi receive innervation from the superior buccal With aging, the retaining ligaments under the eye
branches of the facial nerve. attenuate. This, together with volume loss in the super-
ficial and deep fat compartments, results in visible
folds and grooves in the cheeks and under the eyes
2.7 Deep Plane Including the Deep (Fig. 2.10).
Fat Compartments The deep cervical fascia covering sternocleidomas-
toid in the neck continues upward to ensheathe the
The superficial fat compartments described above lie parotid gland between the mandible and mastoid pro-
above the muscles of facial expression in the subcuta- cess. The layer of fascia covering the parotid gland and
neous plane. In the midface, the suborbicularis oculi fat masseter, termed parotidomasseteric fascia, continues
and deep cheek fat represent deeper fat compartments superiorly to insert into the inferior border of the zygo-
that provide volume and shape to the face and act as matic arch. In the temporal area, the corresponding
gliding planes within which the muscles of facial fascia in the same plane is present as deep temporal
38 P.M. Prendergast
Fig. 2.8 The prezygomatic Sub-orbicularis oculi fat (SOOF)

space. This space extends
anteriorly to the infraorbital
area Orbicularis oculi
Prezygomatic space
Zygomatic retaining ligament
Fig. 2.9 The buccal fat pad

and its extensions
Sublevator extension
Buccal fat pad
Pterygoid extension
Parotid duct
Melolabial extension
Facial nerve
Buccal extension
fascia, which inserts into the superior border of the above the zygomatic arch and in the upper face, facial
zygomatic arch. In the lower face, branches of the nerve branches lie superficial to the deep fascia and are
facial nerve lie underneath the deep fascia, whereas susceptible to injury during superficial dissections.
Tear trough Orbital septum
Orbicularis retaining ligment

Preperiosteal fat Orbicularis oculi
Sub-orbicularis oculi
Zygomatic retaining fat (SOOF)
ligament Prezygomatic space
Nasojugal groove
Nasolabial fold
Fig. 2.10 Frontal and lateral view of attenuated ligaments in the midface
2.8 Neck course, platysma covers the medial part of sterno-

cleidomastoid, transverse cervical and greater auricu-
Surgical rejuvenation of the neck is frequently lar nerves, cervical and mandibular branches of the
included in an overall plan of facial rejuvenation to facial nerve, the facial vessels, the submandibular
maintain harmony and enhance results. Cosmetic sur- gland, and inferior part of the parotid [17] (Fig. 2.12).
gical procedures in the neck typically address the Fibers insert into the border of the mandible, perioral
superficial structures: skin, subcutaneous fat, and plat- muscles, modiolus, and dermis of the cheek. Although
ysma. Occasionally, subplatysmal fat and even the variations exist [18], platysma usually decussates with
digastric muscles are partially resected to improve fibers from the other side 12 cm below the mandible.
neck contour [15, 16]. The aim of surgery is to As part of aging, its medial fibers attenuate or thicken
improve or restore the definition of the topographical to create platysmal bands. Functionally, platysma
landmarks of the neck. These include a sharp mento- depresses the mandible during deep inspiration but is
cervical angle, defined mandibular border, and promi- probably more important as a mimetic muscle to
nent anterior border of sternocleidomastoid. express horror or disgust. It is regarded as the inferior
The neck can be divided into anterior, posterior, most extension of the SMAS and is innervated by the
posterior cervical, and sternocleidomastoid regions cervical branch of the facial nerve.
(Fig. 2.11). Most cosmetic surgical intervention takes Between platysma and sternocleidomastoid, there
place in the anterior region or triangle. The contents of is a loose connective tissue layer termed the superficial
each region are described in Table 2.1. cervical fascia. This plane allows platysma to glide
Just beneath the skin in the anterior cervical triangle easily over sternocleidomastoid and enables effective
lies the platysma muscle. Platysma is a broad thin sheet minimally invasive suture lifting of platysma [19]. The
of muscle that arises from the fascia of the muscles of free edge of platysma is usually located about 3 cm
the chest and shoulders and passes upward over the below the border of the mandible just anterior to the
clavicles and neck toward the lower face. Along its anterior border of sternocleidomastoid.
40 P.M. Prendergast
Fig. 2.11 The triangles

of the neck
Submandibular Sternocleidomastoid
Submental
ANTERIOR
Carotid
Muscular
POSTERIOR
Table 2.1 Regions of the neck

Division Subdivision Contents
Anterior triangle Submandibular triangle Submandibular gland and nodes; facial and submental vessels;
hypoglossal, glossopharygeal, and mylohyoid nn.
Submental triangle Submental nodes and anterior jugular veins
Muscular triangle Sternothyroid and sternohyoid muscles, thyroid and parathyroid
glands
Carotid triangle Bifurcation of carotid, carotid body, hypoglossal, and vagus nn.
Sternocleidomastoid Sternocleidomastoid, carotid sheath with carotid a., internal jugular
v., vagus n., lymph nodes
Posterior triangle Supraclavicular triangle Part of brachial plexus, subclavian a., superficial cervical and
suprascapular vessels, termination of external jugular v.
Occipital triangle Accessory n., trunks of brachial plexus, occipital a., cutaneous
branches of cervical plexus
Posterior cervical Vertebral a., cervical plexus, nuchal muscles
The anterior cervical triangle is bounded posteriorly the temporal bone. It passes anteriorly and inferiorly
by the anterior border of sternocleidomastoid, anteriorly below the mandible toward the hyoid bone where it
by the median line of the neck, and superiorly by the becomes the digastric tendon. The digastric tendon
inferior border of the mandible. The triangle is further passes through the intermediate tendon and arises ante-
divided into submandibular, submental, muscular, and riorly as the anterior belly of digastric. The anterior
carotid triangles by digastric and omohyoid muscles belly inserts into the digastric fossa on the inferior bor-
(Fig. 2.11). An intermediate tendon, attached to the der of the mandible near the midline. Digastric muscle
greater horn of the hyoid bone, divides the digastric into serves to depress and retract the mandible and support
posterior and anterior bellies. The posterior belly arises the hyoid bone. It can be felt as a fleshy mass under the
from the mastoid notch behind the mastoid process of chin when the tongue is retracted.
Fig. 2.12 Neck region

showing platysma and
underlying structures
Greater auricular n.
Platysma
Transverse cervical n.
External jugular v.
2.9 Facial Nerve lower orbicularis oculi. Smaller branches continue

around the medial aspect of the eye to supply depres-
The facial nerve (seventh cranial nerve) provides motor sor supercilii and the superomedial orbicularis oculi.
innervation to the muscles of facial expression. It The buccal branch exits the parotid and is tightly
begins in the face by emerging from the stylomastoid bound to the anterior surface of masseter within the
foramen 68 mm medial to the tympanomastoid suture parotidomasseteric fascia. It continues anteriorly over
of the skull. Before entering the substance of the the buccal fat pad, below and parallel to the parotid
parotid gland, the posterior auricular nerve and nerves duct, to supply the buccinators and muscles of the
to the posterior belly of digastric and stylohyoid branch upper lip and nose. A second branch is occasionally
from the main trunk. Within the parotid gland, the present, but this travels superior to the parotid duct in
facial nerve divides into its main branches: temporal its course anteriorly.
branch, zygomatic branch, buccal branch, marginal The marginal mandibular nerve exits the lower part
mandibular branch, and cervical branch (Fig. 2.13). of the parotid gland as one to three major branches. It
The temporal branch of the facial nerve leaves the usually runs above the inferior border of the mandible,
superior border of the parotid gland as three or four but may drop up to 4 cm below it. About 2 cm poste-
rami. They cross the zygomatic arch between 0.8 and rior to the angle of the mouth, the nerve passes upward
3.5 cm anterior to the external acoustic meatus, and and more superficially to innervate the lip depressors.
usually about 2.5 cm anterior to it. At the level of the Although it remains deep to the platysma, it is vulner-
zygomatic arch, the most anterior branch is always at able to injury during surgical procedures in the lower
least 2 cm posterior to the lateral orbital rim. The tem- face at this location.
poral branches pass in an envelope of superficial tem- The cervical branch of the facial nerve passes into
poral fascia with the intermediate fat pad, superficial to the neck at the level of the hyoid bone to innervate the
the deep temporal fascia. The temporal branch enters platysma muscle.
frontalis about 2 cm above the brow, just below the
anterior branch of the superficial temporal artery.
There are up to three zygomatic branches of the 2.10 Sensory Nerves
facial nerve. The upper branch passes above the eye to
supply frontalis and orbicularis oculi. The lower branch The sensory innervation of the face is via the three
always passes under the origin of zygomaticus major divisions of the trigeminal nerve (fifth cranial nerve):
and supplies this muscle, other lip elevators, and the ophthalmic nerve, maxillary nerve, and mandibular
42 P.M. Prendergast
Fig. 2.13 Branches of the

facial nerve. Note: The greater
auricular, zygomaticotemporal,
infraorbital, and mental nerves
are sensory nerves Zygomaticotemporal
Infraorbital
Temporal br.
Zygomatic br.
Posterior auricular
Buccal br.
Mental
Greater auricular nv.
External jugularv. Marginal mandibular br.
Cervical br.
nerve. The ophthalmic nerve supplies the forehead, periosteum of the forehead 0.51.5 cm medial to the
upper eyelid, and dorsum of the nose via the supraor- superior temporal crest line.
bital, supratrochlear, infratrochlear, lacrimal, and The supratrochlear nerve exits the orbit about 1 cm
external nasal nerves. The maxillary nerve supplies media to the supraorbital nerve and runs close to the
the lower eyelid, cheek, upper lip, ala of the nose, and periosteum under the corrugator and frontalis. Its sev-
part of the temple through the infraorbital, zygomati- eral branches supply the skin over the medial eyelid and
cofacial, and zygomaticotemporal nerves. The maxil- lower medial forehead. The infratrochlear nerve is a ter-
lary nerve also supplies the maxillary teeth and nasal minal branch of the nasociliary nerve that supplies a
cavity via the alveolar nerves and pterygopalatine small area on the medial aspect of the upper eyelid and
nerves, respectively. The mandibular nerve has motor bridge of the nose. The external nasal nerve supplies
and sensory fibers. Its branches include the inferior the skin of the nose below the nasal bone, except for the
alveolar nerve, lingual nerve, buccal nerve, and auric- skin over the external nares. The lacrimal nerve supplies
ulotemporal nerve. These supply the skin over the the skin over the lateral part of the upper eyelid.
mandible, lower cheek, part of the temple and ear, the The infraorbital nerve is the largest cutaneous
lower teeth, gingival mucosa, and the lower lip branch of the maxillary nerve. It enters the face through
(Fig. 2.14). The greater auricular nerve, derived from the infraorbital foramen 2.73 cm from the midline in
the anterior primary rami of the second and third men and 2.42.7 cm from the midline in women, about
cervical nerves, supplies the skin over the angle of the 7 and 6 mm inferior to the inferior orbital rim in men
mandible. and women, respectively. The nerve appears from
The supraorbital nerve emerges from the orbit at the the foramen just below the origin of levator labii supe-
supraorbital notch (or foramen) 2.32.7 cm from the rioris. It supplies the lower eyelid, ala of the nose,
midline in men and 2.22.5 cm from the midline in and upper lip. The zygomaticofacial nerve arises from
women [20]. It has superficial and deep branches that the zygomaticofacial foramen below and lateral to the
straddle the corrugator muscle. Sometimes, these orbital rim and supplies skin of the malar eminence. The
branches exit from separate foramina, the deep branch zygomaticotemporal nerve emerges from its foramen
arising lateral to the superficial one. The deep branch on the deep surface of the zygomatic bone and supplies
usually runs superiorly between the galea and the the anterior temple.
Fig. 2.14 Sensory innervation of the face
SO
SI
GO
LO
L
ZT
CZ IT
AT
EN
ZF IO
GA B
C2/C3 M
Green = ophthalmic nerve (V1) Red and Blue = Cervical nerves (C2/C3)
Supraorbital nerve (SO) Greater occipital nerve (GO)
Supratrochlear nerve (ST) Lesser occipital nerve (LO)
Infratrochlear nerve (IT) Greater auricular nerve (GA)
External nasal nerve (EN)
Latrimal nerve (L)
Oronge = Maxillary nerve (V2)
Zygomaticotemporal nerve (ZT)
Zygomaticofacial nerve (ZF)
Infraorbital nerve (IO)
Purple = Mandibular nerve (V3)
Auriculotemporal nerve (AT)
Buccal nerve (B)
Mental Nerve (M)
The mental nerve is a branch of the inferior alveolar upper one-third of the ear, the external acoustic meatus,
nerve that exits the mental foramen in line vertically with tympanic membrane, as well as the skin over the tempo-
the infraorbital foramen, between the apices of the pre- ral region. Secretomotor fibers also pass via the auricu-
molar teeth. It is often visible and easily palpable through lotemporal nerve to the parotid gland.
stretched oral mucosa. It supplies the skin over the lower
lip and mandible. The buccal branch of the mandibular
nerve supplies the buccal mucosa and skin of the cheek, 2.11 Arteries of the Face
and the lingual nerve provides sensory innervation to the
anterior two-thirds of the tongue and the floor of the The skin and soft tissue of the face receive their arterial
mouth. The auriculotemporal nerve emerges from behind supply from branches of the facial, maxillary, and
the temporomandibular joint to supply the skin of the superficial temporal arteries all branches of the
44 P.M. Prendergast
Fig. 2.15 Arterial supply

to the face Internal carolid
Ophthalmic
Lacrimal
Supraorbital
Supratrochlear
Infratrochlear
Middle temporal
Superficial Infraorbital
temporal
Angular
Transverse facial
Intemal maxillary
Superior labial
Inferior labial
External carotid Facial
external carotid artery. The exception is a mask-like of the parotid, just before reaching the zygomatic arch,
area, including the central forehead, eyelids, and upper it gives off the transverse facial artery which runs
part of the nose, which are supplied through the internal inferior and parallel to the arch and supplies the parotid,
carotid system by the ophthalmic arteries (Fig. 2.15). parotid duct, masseter, and skin of the lateral canthus.
The facial artery arises from the external carotid The superficial temporal artery crosses the zygomatic
and loops around the inferior and anterior borders of arch superficially within the superficial temporal fas-
the mandible, just anterior to the masseter. It pierces cia. Above the arch, it gives off a middle temporal
the masseteric fascia and ascends upward and medially artery that pierces the deep temporal fascia and sup-
toward the eye. It lies deep to the zygomaticus and plies the temporalis muscle. Thereafter, about 2 cm
risorius muscles but superficial to buccinator and leva- above the zygomatic arch, the superficial temporal
tor anguli oris [21]. At the level of the mouth, the facial artery divides into anterior and posterior branches. The
artery sends two labial arteries, inferior and superior, anterior branch supplies the forehead and forms anas-
into the lips where they pass below orbicularis oris. tomoses with the supraorbital and supratrochlear ves-
The continuation of the facial artery near the medial sels. The posterior part supplies the parietal scalp and
canthus beside the nose is the angular artery. periosteum.
The maxillary artery is a terminal branch of the The ophthalmic artery is a branch of the inter-
external carotid with three main branches, mental, buc- nal carotid system (Fig. 2.15). Its branches include
cal, and infraorbital arteries. The mental artery is the the lacrimal, supraorbital, supratrochlear, infratro-
terminal branch of the inferior alveolar artery that chlear, and external nasal arteries. There is significant
passes through the mental foramen to supply the chin communication between the external and internal
and lower lip. The buccal artery crosses the buccina- carotid artery systems around the eye through several
tors to supply the cheek tissue. The infraorbital artery anastomoses. Inadvertent intra-arterial injection of
reaches the face through the infraorbital foramen and fillers for soft tissue augmentation around the eye
supplies the lower eyelid, cheek, and lateral nose. It can lead to occlusion of the central retinal vessels
anastomoses with branches of the transverse facial, and potentially blindness [2224]. To avoid this com-
ophthalmic, buccal, and facial arteries. plication, fillers should be injected in small volumes
The superficial temporal artery is the terminal using blunt cannulas and a careful retrograde injection
branch of the external carotid artery. In the substance technique [25].
References 13. Larrabee WF, Makielski KH, Henderson JL (2004) Cheeks

and neck. In: Larrabee WF, Makielski KH, Henderson JL
(eds) Surgical anatomy of the face. Lippincott Williams &
1. Gassner HG, Rafii A, Young A, Murakami C, Moe K,
Wilkins, Philadelphia, p 178
Larrabee WF (2008) Surgical anatomy of the face.
14. Zide BM (2006) ROOF and beyond (superolateral zone).
Implications for modern face-lift techniques. Arch Facial
In: Zide BM, Jelks GW (eds) Surgical anatomy around the
Plast Surg 10(1):919
orbit. The system of zones. Lippincott Williams & Wilkins,
2. Rohrich RJ, Pessa JE (2007) The fat compartments of the
Philadelphia, p 57
face: anatomy and clinical implications for cosmetic sur-
15. Rohrich RJ, Pessa JE (2010) The subplatysmal supramy-
gery. Plast Reconstr Surg 119(7):22192227
lohyoid fat. Plast Reconstr Surg 126(2):589595
3. Furnas DW (1989) The retaining ligaments of the cheek.
16. Connell BF, Shamoun JM (1997) The significance of digas-
Plast Reconstr Surg 83(1):1116
tric muscle contouring for rejuvenation of the submental
4. Stuzin JM, Baker TJ, Gordon HL (1992) The relationship of
area of the face. Plast Reconstr Surg 99(6):15861590
the superficial and deep facial fascias: relevance to rhytidec-
17. De Castro CC (2000) The changing role of platysma in face
tomy and aging. Plast Reconstr Surg 89(3):441449
lifting. Plast Reconstr Surg 105(2):764775
5. Mitz V, Peyronie M (1976) The superficial musculo-aponeurotic
18. De Castro CC (1980) The anatomy of the platysma muscle.
system in the parotid and cheek area. Plast Reconstr Surg
58(1):8088
19. Labbe D, Franco RG, Nicolas J (2006) Platysma suspen-
6. Gardetto A, Dabernig J, Rainer C, Piegger J, Piza-Katzer H,
sion and platysmaplasty during neck lift. Anatomical study
Fritsch H (2003) Does a superficial musculoaponeurotic
and analysis of 30 cases. Plast Reconstr Surg 117(6):
system exist in the face and neck? An anatomical study by
20012007
the tissue plastination technique. Plast Reconstr Surg
20. Zide BM (2006) Supraorbital nerve. Nuances/dissections
111(2):664672
from above. In: Zide BM, Jelks GW (eds) Surgical anatomy
7. Ghassemi A, Prescher A, Riediger D, Axer H (2003)
around the orbit. The system of zones. Lippincott Williams
Anatomy of the SMAS revisited. Aesthetic Plast Surg
& Wilkins, Philadelphia, p 77
27(4):258264
21. Berkovitz BKB, Moxham BJ (2002). Head and neck anat-
8. Wobig JL, Dailey RA (2004) Facial anatomy. In: Wobig JL,
omy. a clinical reference, Martin Dunitz, London, p 118
Dailey RA (eds) Oculofacial plastic surgery. Thieme, New
22. Silva MT, Curi AL (2004) Blindness and total ophthal-
York, p 5
moplegia after aesthetic polymethylmethacrylate injection:
9. Jones BM, Grover R (2008) Anatomical considerations. In:
case report. Arg Neuropsiquiatr 62(3B):873874
Jones BM, Grover R (eds) Facial rejuvenation surgery.
23. McCleve D, Goldstein JC (1995) Blindness secondary to
Mosby Press, London, pp 1822
injections in the nose, mouth, and face: cause and preven-
10. Mendelson BC, Freeman ME, Wu W, Huggins RJ (2008)
tion. Ear Nose Throat J 74:182188
Surgical anatomy of the lower face: the premasseter space,
24. Dreizen NG, Framm L (1989) Sudden unilateral visual loss
the jowl, and the labiomandibular fold. Aesthetic Plast Surg
after autologous fat injection into the glabellar area. Am J
32(2):185195
Ophthalmol 107:8587
11. Rohrich R, Arbique GM, Wong C, Brown S, Pessa JE (2009)
25. Coleman SR (2002) Avoidance of arterial occlusion
The anatomy of suborbicularis fat: implications for perior-
from injection of soft tissue fillers. Aesthet Surg J 22(6):
bital rejuvenation. Plast Reconstr Surg 124(3):946951
555557
12. Mendelson BC, Muzaffar AR, Adams WP (2002) Surgical
anatomy of the midcheek and malar mounds. Plast Reconstr
Surg 110(3):885896
Anatomy of the Breast
3
3.1 Introduction the incidence of such undesirable outcomes can be

reduced or eliminated.
The adult female breast represents a modified sudo-
riferous milk-producing gland of varying size and
shape. In addition to its role in lactation, the breast is 3.2 Surface Anatomy
an important feature of the development of secondary
sexual characteristics and is frequently modified sur- The breast occupies the anterior chest from the second
gically in order to enhance volume, shape, and posi- or third rib superiorly to the sixth rib inferiorly and
tion. It consists of skin and subcutaneous fat overlying from the sternal edge medially to the midaxillary line
superficial fascia that splits to envelop deeper adipose laterally (Fig. 3.1). The breast varies in shape and size
tissue, glandular tissue, and stroma. The breast is sus- depending on age, parity, body mass index, genetics,
pended and supported by fibrous tissue bands and and race. They can be hemispherical, conical, teardrop-
ligaments that determine the position and shape on shaped, pendulous, or flattened. On profile, the aes-
the chest wall. It has a rich sensory innervation and thetically ideal breast appears as a teardrop-shaped
vascular supply and an extensive network of lymphat- protuberance projecting at variable angles from the
ics that drain into several well-defined nodal groups chest wall. Its ventral surface forms a line that is almost
medially and laterally. In cosmetic surgery, various straight from the second rib to the nipple, while the
incisions and approaches to the breast are made to lower part from the nipple to the inframammary crease
manipulate the breast tissue or its supporting fascial is rounded (Fig. 3.2). In the non-pendulous breast, the
systems, insert prostheses, resect tissue, or fashion nipple is located over the fourth intercostal space.
more aesthetic positions and volumes. Injudicious Around the base of the nipple lies the areola, a circular
incisions or dissections in and around the breast area or skin containing numerous sebaceous glands
can result in poor aesthetic outcomes or, worse, com- and accessory glands that appear externally as small
plications such as sensory loss or hematoma. By bumps or whitish nodules. There are numerous mel-
studying and respecting the anatomy of the breast, anocytes in the epidermis of the nipple and areola,
which appear pink or brown, depending on skin type.
The inframammary crease represents the inferior
border of the base of the breast and is an important
aesthetic landmark. The crease usually lies over the
fifth rib medially with its lowest point at the sixth inter-
P.M. Prendergast
costal space [1]. The distance from the inferior margin
Venus Medical, Dublin, Ireland of the areola to the inframammary crease ranges from
e-mail: [email protected] 5 to 9 cm.

48 P.M. Prendergast
Deep pectoral fascia
Breast glandular tissue
Breast adipose tissue
Pectoralis major
Breast
Nipple
Areola
Fig. 3.1 Overview of breast anatomy
3.3 Fasciae and Ligaments

of the Breast
The superficial fascia divides to form an envelope for

the breast. Between the two layers of superficial fascia,
there are fine cords of connective tissue, termed as
Coopers ligaments. These pass through the paren-
chyma of the breast and provide architectural support,
preventing ptosis and laxity in the young adult breast.
Coopers ligaments stretch or attenuate during preg-
nancy, lactation, or in senescence, causing the breasts
to eventually droop and flatten.
The breast lies on the deep pectoral fascia. This is a
tough layer that is attached superiorly to the clavicle
and sternum and is continuous inferiorly with the
fascia covering the serratus anterior, rectus abdominis,
and external oblique muscles. Deep to pectoralis major
lies pectoralis minor, enveloped in a clavipectoral fas-
cia that extends laterally to fuse with the axillary fascia
Fig. 3.2 Breast contours on side profile
and superiorly to attach to subclavius and the clavicle.
3 Anatomy of the Breast 49
Fig. 3.3 Breast anatomy

showing transverse horizontal Skin
septum
Subcutaneous fat
Superficial pectoral fascia envelope
Breast tissue
Retromammary space
Deep pectoral fascia
Pectoralis major
Intercostal arteries
Transverse horizontal septum
Inframammary crease ligament
Inframammary crease
Between the deep layer of superficial fascia and the deep medial and lateral ligaments respectively.
deep pectoral fascia is a potential space, the retromam- The medial ligament attaches to the sternum, while the
mary space, over which the mammary gland glides. lateral ligament attaches to the axillary fascia at the
Wringer [2] describes a ligamentous structure that midaxillary line (Fig. 3.4). From the origin of the trans-
suspends the breast and transmits vessels and nerves to verse septum at the pectoral fascia, another fascial
the nipple. This transverse horizontal septum originates thickening passes to the dermis at the inferior border of
at the inferior border of the deep pectoral fascia at the the breast. The tethering effect on the dermis of this
level of the fifth rib and travels through the breast tissue ligament along its length forms the inframammary
to the skin and nipple (Fig. 3.3). Medially and laterally crease. The anatomy and even the existence of this so-
it continues along the border of pectoralis major as the called inframammary ligament here are debated [3, 4].
50 P.M. Prendergast
Fig. 3.4 Supporting

ligaments of the breast
Deep medial ligament
Horizontal fibrous
Deep cranial ligament septum
Deep lateral ligament
3.4 Breast Tissue piercing the pectoral fascia or in the fascia of the infra-
mammary ligament and crease.
Within the envelope of the superficial fascia lie
epithelial parenchymal tissue, stroma, and adipose
tissue. The epithelial parenchymal component com- 3.5 Blood Supply
prises about 1015% of the breast tissue, and the
remainder is stromal tissue and fat [5]. Variations in The breast receives its blood supply from branches
breast size are due predominantly to a difference in of the axillary, internal thoracic arteries, and inter-
the amount of adipose rather than glandular tissue. costal arteries (Fig. 3.6). The superior thoracic and
The glandular architecture of the breast consists of pectoral branches of the thoracoacromial artery arise
1520 lobes arranged radially deep to the nipple from the first and second part of the axillary artery
within the supporting stroma and fat. Each lobe con- respectively and pass medially between the pectora-
sists of several smaller lobules that drain into a single lis muscles to supply them and the breast. They
lactiferous duct. The lobules contain several blind- anastomose with the internal thoracic and upper
ending alveoli or acini that are potentially milk- intercostal arteries. The lateral thoracic artery arises
secreting. The lactiferous ducts, one per lobe, open from the axillary artery and gives lateral mammary
onto the nipple and function as a conduit for milk branches that course around the lateral border of
during lactation (Fig. 3.5). pectoralis major to supply the breast. Branches from
The stroma of the breast consists of loose connec- the subscapular artery, the largest branch of the axil-
tive tissue that surrounds and supports the ducts and lary artery, pass to the thoracic wall and breast and
lobules. Within the stroma and between the lobes, a anastomose with the lateral thoracic and intercostal
varying amount of adipose tissue contributes to the arteries. Perforating branches of the internal tho-
volume of the breasts. Although the breast is fairly racic artery provide the majority of blood to the
well-circumscribed, a distinct slip of glandular tissue breast. They traverse the first five or six intercostal
projects from the upper outer quadrant toward the spaces, enter pectoralis major, and course laterally
axilla deep to the pectoral fascia as the tail of Spence. to supply the breasts and skin. The first and second
Occasionally, normal glandular tissue can be found branches are usually the largest vessels supplying
Lobules
Lobes
Lactiferous duct
Lactiferous
Acini sinus
Fig. 3.5 Architecture of breast glandular tissue
the breasts. The anterior intercostal arteries arise thoracic, and second to fourth intercostal veins. The
from the internal thoracic artery in the upper six medial breast drains into the internal thoracic vein, lat-
intercostal spaces and pass laterally, first between eral breast to tributaries of the axillary vein and to the
the pleura and internal intercostals, then between intercostal veins. The intercostals in turn drain into the
the intercostales intimi and internal intercostals [6]. vertebral veins, azygous, and hemiazygous systems.
Perforating branches from the second, third, and
fourth intercostal arteries pass through the pectoral
muscles to supply the breast and skin. 3.6 Innervation
Variations in blood supply to the breasts exist.
In 18% of individuals, arterial supply is from all three The breast is innervated by sensory and sympathetic
of the above sources. In 30%, the axillary artery supplies efferent fibers from the anterior and lateral cutaneous
little or no blood to the breast, and in 50%, there is little branches of the second to sixth intercostal nerves
or no contribution from the intercostal arteries [7]. (Fig. 3.7). The anterior and lateral branches contribute
Venous drainage of the breast corresponds to the equally to the innervation of the breast. The fourth
arteries, with most drainage to the axillary, internal intercostal nerve supplies the nipple and areola with
52 P.M. Prendergast
Subclavian a.
Axillary a. Thoracoacromial a.
Superior thoracic a.
Lateral thoracic a.
Internal thoracica.
Perforating branches
Lateral mammary
branches of
posterior intercostal a.
Pectoral branches of
thoracoacromial a.
Lateral mammary branches
Medial mammary branches
Fig. 3.6 Arterial supply of the breast
Supraclavicular nn.
Anterior cutaneous branches of

intercostal nn.
Lateral cutaneous branches

of intercostal nn.
Fig. 3.7 Sensory innervation of the breast

Fig. 3.8 Muscles and nerves

around the breast
Pectoralis major
Thoracoacromial a.
Pectoralis minor
Lateral pectoral n.
Median n.
Axillarya a. Medial pectoral n.
Medial brachial
cutaneous n
Intercostobrachial n.
Long thoracic n.
Thoracodorsal n.
additional cutaneous branches from the third to fifth main sites for lymphatic drainage of the breast; at
nerves [8]. Skin incisions or traction on these sensory least three quarters of drainage is to the axillary
nerves during surgery may lead to transient dysaesthe- nodes (Fig. 3.9). A plexus of lymphatic channels
sias or sensory loss [9]. below the nipple, the subareolar plexus of Sappey,
Beneath the breast, pectoralis major is supplied on drains to nodes in the axilla, internal mammary
its deep surface by the lateral pectoral nerve. This nodes, and to the contralateral breast. Lymphatics
nerve is derived from the ventral rami of the fifth to from the medial breast follow the perforating vessels
seventh cervical nerves. It sends a ramus to the medial toward the sternal edge. They pass through pectora-
pectoral nerve in front of the axillary artery, to supply lis major and the intercostal muscles to the internal
fibers of pectoralis minor, before piercing the clavipec- mammary nodes. Most of the internal mammary
toral fascia to arrive at pectoralis major. The medial nodes are found in the first three intercostal spaces
pectoral nerve is derived from the eighth cervical and [10]. Skin from the anterior abdominal wall drains to
first thoracic nerves. It creates a loop with the lateral lymphatics along the superior epigastric vessels that
pectoral nerve and sends branches to the pectoralis empty into the internal mammary nodes. From the
minor and major (Fig. 3.8). internal mammary nodes, drainage is to mediastinal
Around the breast, the thoracodorsal nerve passes nodes, paraaortic nodes, bronchomediastinal trunks,
inferomedially from the posterior cord of the brachial and the right thoracic duct. The axillary nodes, which
plexus on the ventral surface of the subscapularis mus- drain most of the breast, have been identified, named,
cle to innervate the latissimus dorsi muscle. The long and classified as level I, level II, and level III nodes,
thoracic nerve arises from the fifth to seventh cervical depending on their relationship to pectoralis minor
nerves and innervates the serratus anterior. It is found as follows (Fig. 3.10).
posterior to the axillary vein at the level of the second Level I nodes are those found below pectoralis
rib. The intercostobrachial nerve represents a lateral minor. These include external mammary nodes, the
cutaneous branch of the second or third intercostal large axillary group of nodes, and scapular nodes that
nerves and supplies skin of the inner upper arm. lie on the subscapular vessels. Level II nodes lie behind
pectoralis minor and include central nodes and some
subclavian nodes. The central nodes are found in the
3.7 Lymphatic Drainage fatty tissue of the axilla and are easily palpable when
enlarged. Level III nodes lie between the upper border
The lymphatic drainage of the breast has important of pectoralis minor and lower border of the clavicle.
implications in breast cancer and its spread. The They comprise the subclavicular nodes on the axillary
axilla and the internal mammary nodes are the two vein and medial to the axillary vein nodes. One or two
54 P.M. Prendergast
Right subclavian lymphatic trunk Right lymphatic duct
Subclavicular nodes Right bronchomediastinal

lymphatic trunk
Apical nodes
Right brachiocephalic
vein
Central nodes
Humeral nodes
Interpectoral (Rotters) nodes
Parasternal nodes
Pectoral nodes
Subscapular nodes
Subareolar lymphatic plexus
Fig. 3.9 Lymphatic drainage of the breast
Level III
Level II
Level I
Parasternal
nodes
Fig. 3.10 Classification of

axillary nodes draining the
breast
additional nodes (Rotters nodes) can be found between 5. Morrow M, Khan S (2005) Breast disease. In: Mulholland
MW, Lillemore KD, Doherty GM, Maier RV, Upchurch GR
pectoralis major and minor.
(eds) Greenfields Surgery: scientific principles and practice,
4th edn. Lippincott Williams & Wilkins, Philadelphia, p 1251
6. Williams PL (1995) Grays Anatomy: the anatomical basis
of medicine and surgery, 38th edn. Edinburgh, Churchill
References Livingstone, p 1534
7. Skandalakis JE (2009) Embryology and anatomy of the
1. Bayati S, Seckel BR (1995) Inframammary crease ligament. breast. In: Shiffman MA (ed) Breast augmentation: principles
Plast Reconstr Surg 95(3):501508 and practice. Springer, Berlin, p 12
2. Wringer E, Mader N, Posch E, Holle J (1998) Nerve and 8. Jaspars JJ, Posma AN, Van Immerseel AA, Gittenberger-de
vessel supplying ligamentous suspension of the mammary Groot AC (1997) The cutaneous innervation of the female
gland. Plast Reconstr Surg 101(6):14861493 breast and nipple-areola complex: implications for surgery.
3. Nava M, Quattrone P, Riggio E (1998) Focus on the breast Br J Plast Surg 50(4):24959
fascial system: a new approach for the inframammary fold 9. Bengston BP (2009) Sensory nerves in the lower pole of the
reconstruction. Plast Reconstr Surg 102(4):10344105 breast encountered in breast (augmentation) surgery. Plast
4. Garnier D, Angonin R, Foulon R, Chavoin JP, Ricbourg B, Reconstr Surg 123(1):32e33e
Costagliola M (1991) Le sillon sous-mammaire: mythe ou 10. Sacre R (1989) Modern thoughts on lymph nodes in breast
realite? Ann Chir Plast Esthet 36(4):31319 cancer. Semin Surg Oncol 5(2):11825
Anatomy of the Anterior
Abdominal Wall 4
4.1 Introduction as follows: epigastrium, left and right hypochondrium,

umbilical, left and right lumbar, hypogastrium, and left
Surgical procedures aimed at improving the appearance and right iliac. Although they are commonly used to
of the abdomen typically remove fat through suction, describe clinical scenario, referred pain, and patho-
resect skin and soft tissue, plicate the myofascial logical processes in the intra-abdominal cavity, these
abdominal wall, or combine these procedures [1]. anatomical zones are also useful in cosmetic surgery
A sound knowledge of the layered anatomy and neuro- when describing body contour, scars and incisions,
vascular structures of the anterolateral abdominal wall extent of dissection or lipoplasty, hernias, and compli-
is a prerequisite for successful body contouring in this cations such as skin necrosis and postlipoplasty con-
region, and it helps reduce complications through judi- tour irregularities.
cious placement of incisions and appropriate dissection In slim, athletic individuals, surface markings on
and undermining without compromising the vascular the anterolateral abdominal wall are easily identifiable
supply. The bony and soft tissue landmarks of the (Fig. 4.2). The abdominal wall is bounded superiorly
abdominal wall should be identified and marked prior by the xyphoid process and costal margins and inferi-
to liposculpture or abdominoplasty to visualize ideal orly by the pubic crest, inguinal ligaments, and iliac
aesthetic contours and optimize placement and symme- crest. In the left and right hypochondria, fibers of ser-
try of incisions. This chapter describes the surface anat- ratus anterior interdigitate with the external oblique
omy, myofascial layers, important vessels, nerves, and muscles. The lateral borders of rectus abdominis are
lymphatics of the anterolateral abdominal wall. visible as the linea semilunaris, a curved depression
running vertically from the costal margin near the ninth
costal cartilage to the pubic tubercle on either side. In
4.2 Surface Anatomy the midline, a narrow vertical skin groove from the
xyphoid process to the umbilicus represents the fibrous
For descriptive purposes, two vertical and two hori- linea alba that runs the full length of the abdominal
zontal imaginary lines divide the anterior abdominal wall from the xyphoid process to the pubic symphysis
wall into nine segments (Fig. 4.1). The subcostal line [2]. Further horizontal tendinous intersections in the
and interspinous line pass horizontally between the rectus abdominis create the appearance of protrusions
costal margins and anterior superior iliac spines, or bulges when the muscle is well developed and over-
respectively. Vertically, a left and right midclavicular lying subcutaneous fat is minimal. The umbilicus is an
line form the nine segments with the horizontal planes aesthetically important landmark that represents the
scar following ligation of the umbilical cord where it
entered the fetus. Normally, it lies near the midline on
the anterior abdominal wall at the level of the fourth
P.M. Prendergast
Venus Medical, Dublin, Ireland intervertebral disc [3]. In cosmetic surgery, it presents
e-mail: [email protected] a novel approach site for body contouring or skin

58 P.M. Prendergast
Fig. 4.1 Divisions of the

anterior abdomen. MC
midclavicular, SC subcostal,
IS interspinous
xiphoid
serratus anterior
linea alba
linea semilunaris umbilicus
tendinous anterior superior

intersection iliac spine
external oblique
inguinal crease
Fig. 4.2 Surface markings of the abdominal wall

4 Anatomy of the Anterior Abdominal Wall 59
excision and itself is frequently reconstructed to layer varies in thickness depending on body habitus
improve the appearance of the abdomen, particularly and is amenable to reduction or partial excision during
following abdominoplasty where scarring may result lipoplasty and abdominoplasty, respectively. In the
in contracture or stenosis [4]. The inferior extent of the upper abdomen, Campers fascia tends to be more
anterolateral abdominal wall is visible as the inguinal fibrous compared to the lower, softer fat of the lower
groove, a depression below and parallel to the inguinal abdomen. This can easily be felt during suction or
ligament that runs from the anterior superior iliac spine ultrasound-assisted lipoplasty. A second, deeper layer
to the pubic tubercle. Below this is the upper limit of of superficial fascia exists in the lower abdominal wall
the anterior thigh. as Scarpas fascia. This layer is thin and membranous
and is loosely adherent to the underlying deep fascia
above the muscles, except in the midline where it
4.3 Skin firmly attaches to the linea alba. Superiorly and later-
ally, it becomes thinner and is continuous with the
The skin of the anterolateral abdominal wall is loosely superficial fascia of the thorax and back. Inferiorly,
attached to the underlying superficial fascia and fat. In Scarpas fascia forms a sheath for the penis or clitoris
nulliparous individuals with normal body mass indices, that is continuous with the deep fascia of the genitalia.
collagen and elastin fibers in the dermis allow smooth Campers fascia continues toward the scrotum in males
and even draping of the skin over the contours of the to become the dartos muscle, containing smooth mus-
abdomen. Langers lines are present as visible cleavage cle fibers. In the perineum, Scarpas fascia is a tough
lines that run parallel to the horizontally and anteroin- fibrous layer that inserts into the pubic arch as Colles
feriorly arranged collagen fibers in the skin. Incisions fascia [5]. Below the inguinal ligament, it is continu-
in the anterolateral abdominal wall should be made par- ous with the fascia lata of the upper and lateral thigh.
allel to these lines to ensure optimum apposition of
wound edges and avoid retraction and gaping of the
incision. Transverse or anteroinferior incisions also 4.4.2 Deep Fascia
respect the course of the nerves and vessels of the
abdominal wall, which run parallel to the cleavage Deep to Scarpas fascia, a thin layer of deep fascia lies
lines. Extensive stretching of abdominal skin following closely adherent to the flat muscles of the abdominal
pregnancy or in obese individuals disrupts dermal con- wall and their aponeuroses. This layer is continuous
nective tissue fibers, leading to stretch marks or striae inferiorly with the suspensory ligament of the penis
perpendicular to Langers lines. Immature striae appear and the deep fascia of the genitalia.
as prominent red or purplish lines, usually running ver-
tically in the lower abdominal skin, whereas mature
striae are less vascular and appear silvery or white. 4.4.3 Transversalis Fascia
Although difficult to treat, nonsurgical modalities such
as intense pulsed light, vascular lasers, skin resurfac- This thin connective tissue layer lies between the inner-
ing, and collagen stimulation procedures may improve most muscle of the abdominal wall and the extraperito-
the appearance of immature and mature striae. Skin neal fatty layer. It is continuous superiorly with the
excision during abdominoplasty is more definitive. connective tissue lining of the diaphragm and inferiorly
with the iliac and pelvic fascia. The spermatic cord (or
round ligament of the uterus) passes through the trans-
4.4 Fascia versalis fascia at the deep inguinal ring. The deep ring
is located at the midpoint between the anterior superior
4.4.1 Supercial Fascia iliac spine and the pubic symphysis about 1.25 cm
above the inguinal ligament (Fig. 4.4). The ring is
The subcutaneous tissue of the upper and lower bordered superiorly by arching fibers of transversus
abdominal wall is occupied by a fatty layer of superfi- abdominis, medially by the inferior epigastric vessels,
cial fascia known as Campers fascia (Fig. 4.3). This and laterally by fibers of internal oblique.
60 P.M. Prendergast
skin
Campers fascia
external oblique
Internal oblique
transversus abdominis
transversalis fascia
extraperitoneal fat
peritoneum
Fig. 4.3 Layers of the anterolateral abdominal wall. Campers fascia lies superficially and contains variable amounts of subcutaneous
fat. In the lower abdomen, Scarpass fascia exists as a second deeper layer that is adherent to the fascia overlying the muscle
rectus abdominis
transversus abdominis
internal oblique
external oblique
arcuate line
anterior superior iliac spine
inguinal ligament
aponeurosis of external oblique
femoral nerve
deep inguinal ring
Fig. 4.4 Inguinal region and

muscles of the lower intercrural fibers
abdominal wall. The arcuate
line is seen below the level of
femoral a & v
the umbilicus where the
aponeuroses of the flat
muscles pass anterior to superficial inguinal ring
rectus abdominis spermatic cord
Fig. 4.5 Muscles of the

anterolateral abdominal wall
5th 7th
costal cartilages
external
oblique m.
rectus
abdominis m.
internal tendinous
oblique m. intersection
transversus
abdominis m.
4.5 Muscles cartilages where rectus abdominis lies directly on the

chest wall and the transversus abdominis is continuous
The muscles and aponeuroses of the anterolateral with the thoracic muscles under the ribs. At the arcuate
abdominal wall form a strong, flexible structure that pro- line of Douglas below the level of the umbilicus, the
tect the abdominal viscera, facilitate movement of the posterior wall of the rectus sheath becomes deficient
trunk, and work synergistically with the diaphragm dur- where the aponeuroses of the flat muscles comprising it
ing respiration, micturition, and defecation (Fig. 4.5). course anteriorly to cover the anterior surface of rectus
When the fatty superficial fascial layer above the mus- abdominis (Fig. 4.6). The arcuate line lies in the upper
cles is thin and the muscles are toned, they also play an half of a line from the pubic symphysis to the umbilicus
important role in the aesthetics of the abdomen, as their and is consistently found to be at the level of the most
borders and prominences are visible. Attenuation and distal horizontal tendinous intersection or rectus abdo-
laxity in the abdominal wall muscles lead to protrusion minis [7]. Fibers from the flat muscles from each side
of the abdomen [6]. For the most part, the three flat decussate in the midline to form the linea alba with
abdominal muscles that occupy the lateral abdominal additional interweaving of superficial and deep fibers
wall become aponeurotic anteriorly at the midclavicular [8]. The rectus sheath is occupied primarily by the large
line. Between the midclavicular line and the midline, vertical paired rectus abdominis and also by the smaller
the aponeuroses of the three flat muscles form the rectus pyramidalis muscle in the lower abdomen.
sheath, a tough fibrous envelope that encloses the verti-
cal rectus abdominis muscles. Above the umbilicus, and
to a point just below it, the anterior wall of the rectus 4.5.1 External Oblique
sheath is formed by the aponeurosis of external oblique
and the anterior lamina of the internal oblique aponeu- This muscle forms the fleshy part of the lateral abdomi-
rosis. The posterior wall of the rectus sheath (deep to nal wall as its fibers pass inferiorly and inferomedially
rectus abdominis) comprises the posterior lamina of superficial to the other flat muscles (Fig. 4.5). It origi-
internal oblique aponeurosis and the aponeurosis of nates from the external surfaces of the inferior 78 ribs.
transversus abdominis. The exception is over the costal The most posterior fibers pass vertically from the lower
62 P.M. Prendergast
Fig. 4.6 Anatomy of the aponeurosis of

rectus sheath above and transversus abdominis posterior lamina
below the arcuate line of internal
aponeurosis of oblique
aponeurosis of anterior lamina
internal oblique
external oblique
linea alba
rectus
abdominis
above the arcuate line
below the arcuate line aponeuroses from all three

muscles pass anterior to
rectus abdominis
two ribs to insert into the iliac crest, creating a posterior then, as the pectineal ligament where it merges with the
free border. These fibers do not insert into the thora- periosteum.
columbar fascia and constitute the anterior border of The blood supply to external oblique is from inter-
the inferior lumbar triangle of Petit, with posterior and costal arteries superiorly and branches of the deep
inferior borders are formed by the latissimus dorsi and circumflex artery inferiorly with the iliolumbar artery
iliac crest, respectively [9]. Unusual cases of herniation supplying the inferior part of the muscle in a small
through Petits triangle have been reported [10]. percentage of the population [11]. External oblique is
External oblique becomes aponeurotic medially at the innervated from the anterior primary rami of the
midclavicular line and inferiorly at the spinoumbilical seventh to twelfth intercostal nerves.
line (between anterior superior iliac spine and umbili-
cus). The aponeurosis passes anterior to rectus abdomi-
nis as part of the rectus sheath and decussates with 4.5.2 Internal Oblique
aponeurotic fibers of the contralateral external oblique,
internal oblique, and transversus abdominis at the mid- The internal oblique is a broad thin flat muscle that runs
line. The external oblique aponeurosis passes the mid- deep to the overlying external oblique (Fig. 4.5). Fibers
line to be continuous with the aponeurosis of the of internal oblique originate from the thoracolumbar
contralateral internal oblique. Functionally, external fascia, the anterior two-thirds of the iliac crest and
oblique and the contralateral internal oblique can be lateral half of the inguinal ligament, run forwards and
considered as a digastric muscle since their simultane- upwards mostly perpendicular to fibers of external
ous action flexes and rotates the abdomen, as occurs oblique, to insert into the inferior borders and costal
when the shoulder is turned toward the contralateral cartilages of the lower three ribs, xyphoid process,
hip. The inferolateral fibers of external oblique, below linea alba, and pubic symphysis. At the midclavicular
the spinoumbilical line, turn backwards and upwards line, internal oblique becomes aponeurotic. Above the
between the anterior superior iliac spine and the pubic arcuate line, this aponeurosis splits at the lateral border
tubercle to form the inguinal ligament. Superior and of rectus abdominis to contribute to both anterior and
medial to the pubic tubercle, the superficial inguinal posterior parts of the rectus sheath. Below the arcuate
ring is a triangular-shaped defect in the external oblique line, the internal oblique aponeurosis passes as a single
aponeurosis that transmits the spermatic cord (or round sheet anterior to rectus abdominis. Lower medial fibers
ligament of the uterus) (Fig. 4.4). Medial and lateral of the internal oblique arch over the spermatic cord in
crura with fibers connecting them surround this ring. males and round ligament of the uterus in females to
Fibers from the medial end of the inguinal ligament insert into the pubic crest and pectineal line. Fibers of
turn posteriorly and then upwards along the pectineal underlying transversus abdominis join some of these
line of the pubic crest, first, as the lacunar ligament and fibers to insert into the linea alba as the conjoint tendon.
Internal oblique contributes to flexion, lateral flexion, in the upper abdomen. Rectus abdominis arises from
and rotation of the lumbar vertebrae with the other main the symphysis, crest, and pecten of the pubis and runs
muscles of the anterior abdominal wall, as well as rais- upwards to insert into the xyphoid process and costal
ing intra-abdominal pressure during forced expiration. cartilages of the fifth to seventh ribs. For most of its
The internal oblique is innervated by the ventral course, it runs in the tendinous rectus sheath formed by
rami of the lower six thoracic spinal nerves and the the aponeuroses of the three flat muscles described
iliohypogastric and ilioinguinal nerves (L1, L2). above. The inferior part of rectus abdominis is covered
only on its anterior surface by the rectus sheath, and
above the costal margin, the muscle lies directly on the
4.5.3 Transversus Abdominis costal cartilages. The paired rectus abdominis is sepa-
rated in the midline by the linea alba and by three to
Transversus abdominis lies deep to internal oblique four horizontal tendinous intersections; fibrous bands
and represents the innermost of the three flat muscles that are usually located at the level of the xyphoid pro-
of the anterolateral abdominal wall. Its fibers run cess, at the umbilicus, and halfway between these two.
transversely, except at its inferior part where fibers run A fourth tendinous intersection may be visible below
inferomedially parallel to fibers of internal oblique. the umbilicus and marks the location of the arcuate
Transversus abdominis originates from the thora- line. These tendinous bands are intimately related to
columbar fascia, the inner parts of the lower six costal the anterior wall of the rectus sheath. The lateral bor-
cartilages, the lateral two-thirds of the iliac crest and der of rectus abdominis is often visible as a groove in
the lateral third of the inguinal ligament. It passes the anterior abdominal wall between the ninth costal
medially to insert in the xyphoid process and linea alba cartilage and the pubic tubercle. Diastasis or separa-
with lower fibers forming the conjoint tendon with tion of the recti muscles at the midline with widening
fibers of internal oblique and inserting into the pecten of the linea alba occurs following pregnancy or as a
and crest of the pubis. Near the midline, transversus congenital deformity and may result in an abnormally
abdominis becomes aponeurotic and contributes to the convex abdominal contour. Plication of the anterior or
posterior part of the rectus sheath, except below the posterior rectus sheath, sometimes combined with pli-
arcuate line where its aponeurosis passes anterior to cation of the external oblique aponeurosis, improves
rectus abdominis. Unlike the two overlying flat muscles this myoaponeurotic deformity [13].
that become aponeurotic at the midclavicular line, Rectus abdominis is innervated by the ventral rami
transversus abdominis continues as a muscle for vari- of the inferior six or seven thoracic spinal nerves. Its
able distances toward the midline [12]. At the level of main action is to flex the trunk. Unlike the flat muscles,
the xyphoid process, muscle fibers pass behind rectus rectus abdominis contributes minimally to raising
abdominis and only become aponeurotic 23 cm from intra-abdominal pressure.
the linea alba. The aponeurosis broadens inferiorly
and is widest at the level of the umbilicus where it
starts about 56 cm from the lateral border of rectus 4.5.5 Pyramidalis
abdominis. Further down, the width of the transversus
abdominis aponeurosis again narrows. This small triangular muscle lies in the rectus sheath
Transversus abdominis is innervated by the ventral anterior to inferior part of rectus abdominis and is
rami of the inferior six thoracic spinal nerves and first absent in 20% of subjects. It arises from the pubic
two lumbar nerves. It acts to compress and protect the symphysis and inserts into the linea alba.
abdominal contents.
4.6 Arterial Supply

4.5.4 Rectus Abdominis
The anterolateral abdominal wall receives its blood
This vertically oriented paired strap muscle occupies supply from branches of the subclavian, external iliac,
most of the central part of the anterior abdominal wall. and femoral arteries as well as intercostal and lumbar
It is narrow and thick inferiorly and broader and flatter arteries directly from the descending aorta (Fig. 4.7).
64 P.M. Prendergast
Fig. 4.7 Arterial supply and

innervation of the anterior
abdominal wall internal
thoracic a.
thoracoabdominal
nn. musculophrenic a.
superior
epigastric a.
lateral cutaneous
branches posterior intercostal aa.
subcostal a.
T4 lumbar a.
anterior cutaneous
branches inferior epigastric a
L1 superficial
egigastric a.
iliohypogastric n.
ilioinguinal n. deep
circumflexiliac a.
superficial
circumflexiliac a.
4.6.1 Musculophrenic Artery 4.6.3 Inferior Epigastric Artery
The musculophrenic artery is one of the terminal The inferior epigastric artery arises from the external
branches of the internal thoracic artery. It runs behind iliac artery just proximal to the inguinal ligament. It
the fifth to ninth costal cartilages and supplies the mus- courses superiomedially deep to the transversalis fas-
cles of the anterolateral abdominal wall via direct cia medial to the deep inguinal ring and then pierces
branches and anastomoses with the posterior intercos- the fascia to lie deep to rectus abdominis below the
tal and deep circumflex iliac arteries. The musculo- arcuate line. Above the arcuate line, it lies between
phrenic artery also gives off the fifth to ninth anterior rectus abdominis and the aponeuroses of the posterior
intercostal arteries. rectus sheath. The inferior epigastric artery divides
into lateral and medial branches below the umbilicus,
with the lateral one usually being more prominent [15].
4.6.2 Superior Epigastric Artery It supplies the rectus abdominis and anastomoses with
the superior epigastric and posterior intercostal arter-
The other terminal branch of the internal thoracic ies. Smaller branches perforate rectus abdominis to
artery, the superior epigastric artery, travels inferiorly supply the skin over the lower abdominal wall and
between the costal and xyphoid attachments of the dia- around the umbilicus. Traction or torsional forces on
phragm to enter the abdominal wall anterior to trans- these pedicle vessels may compromise perfusion of the
versus abdominis. It passes inferiorly in the rectus transposed umbilicus following abdominoplasty. A
sheath under rectus abdominis and supplies this mus- broad subcutaneous base and a diameter of at least
cle as well as the overlying central abdominal skin 2.5 cm around the umbilicus will improve perfusion by
through perforating branches that pierce the muscle. In sparing more of the diverging perforating vessels to
contrast to the heterogenously arranged perforating the umbilicus [15]. Anastomoses across the midline
branches from the inferior epigastric artery, the anat- occur between medial and lateral deep inferior epigas-
omy of superior epigastric artery perforators tends to tric row perforators through the subdermal plexus [16].
be more predictable [14]. The superior epigastric artery Flap techniques for autologous breast reconstruction
has lateral and medial branches and anastomoses with require that these perforating arteries are preserved.
branches of the inferior epigastric artery about 4 cm Preserving posterior intercostal perforating arteries
superior to the umbilicus (Fig. 4.8). during lipoabdominoplasty may also reduce ischemic
Fig. 4.8 Sagittal section

through the abdominal wall
showing the level of the
arcuate line and the
skin
anastomosis of superior and
inferior epigastric arteries
above the umbilicus
subcutaneous fat
external oblique
superior and inferior epigastric
aponeurosis
arteries
ant. layer on internal

oblique aponeurosis post layer of internal oblique
aponeurosis
rectus abdominis transversus abdominis

aponeurosis
transversalis fascia
extraperitoneal fat
peritoneum
complications without compromising the aesthetic 4.6.5 Supercial Circumex Iliac Artery
result [17].
This small branch of the femoral artery passes below
and parallel to the inguinal ligament and supplies the
4.6.4 Deep Circumex Iliac Artery superficial fascia and skin of the inferolateral abdomi-
nal wall and the upper outer thigh.
The deep circumflex iliac artery arises from the external
iliac opposite the origin of the inferior epigastric and
runs parallel to the inguinal ligament before entering 4.6.6 Supercial Epigastric Artery
the vascular plane between transversus abdominis and
internal oblique. It supplies the inferolateral abdominal The superficial epigastric artery arises from the femoral
wall and has multiple anastomoses in this area. artery near the origin of the superficial circumflex iliac
66 P.M. Prendergast
Fig. 4.9 Veins and parasternal

lymphatics of the anterior lymph nodes
abdominal wall
axillary
lymph nodes
thoracoepigastric v.
sup. epigastric
superficial lymphatic
c. (deep)
vessels of the
abdominal wall
inf. epigastric
c. (deep)
superficial inguinal
lymph nodes
superficial
epigastric vein
artery and courses over the inguinal ligament toward to supply the skin and soft tissues of the lower anterior
the umbilicus in the subcutaneous tissues before anas- abdominal wall. The transverse course of the lumbar
tomosing with the inferior epigastric artery. It supplies vessels renders them less susceptible to injury during
the superficial tissues over the lower abdominal wall. abdominoplasty. As such, they play an important role
in preserving vascular supply to the flap, particularly
when vertically oriented vessels have been ligated.
4.6.7 Posterior Intercostal Arteries
The inferior two posterior intercostal arteries and sub- 4.7 Venous Drainage
costal artery have a circumferential course around the
abdominal wall before entering the rectus sheath at the Venous drainage of the abdominal wall is through
lateral border of rectus abdominis to anastomose with superficial and deep networks. A delicate subcutane-
the superior and inferior epigastric vessels. ous venous plexus drains superficial tissues above the
umbilicus to the lateral thoracic vein via the thora-
coepigastric vein (Fig. 4.9). Superficial veins below
4.6.8 Lumbar Arteries the umbilicus drain into the superficial epigastic and
superficial circumflex iliac veins, and from these, into
The lumbar arteries arise directly from the descending the great saphenous vein, femoral vein, iliac veins, and
aorta and travel around the anterolateral abdominal inferior vena cava. Drainage of the lower abdominal
wall toward the lower abdomen. Cutaneous branches tissues into the superior vena cava also occurs via
arise from the main vessels in the vascular plane the thoracoepigastric vein, a tributary of the axillary
between internal oblique and transversus abdominis vein. A portal-systemic anastomosis exists around the
umbilicus where paraumbilical veins that drain into the skin is supplied by the subcostal nerve (T12). The
the hepatic portal vein communicate with superficial subcostal nerve also innervates pyramidalis, when pres-
epigastric veins. The deep veins of the anterolateral ent. The iliohypogastric nerve is the superior terminal
abdominal wall generally follow the arteries of the branch of the anterior ramus of L1. Its cutaneous
same name: superior epigastric veins drain into the branches pierce the external oblique aponeurosis 2.5 cm
internal thoracic vein, inferior epigastric veins into medial and 2.0 cm inferior to the anterior superior iliac
the external iliac veins, and posterior intercostal veins spine to supply the skin over the iliac crest, above the
receive drainage from the lateral abdominal wall. inguinal crease, and hypogastric areas [18]. The second
terminal branch of L1, the ilioinguinal nerve, emerges
about 0.5 cm below the iliohypogastric nerve and sup-
4.8 Lymphatics plies the inner two flat muscles before traversing the
inguinal canal. Cutaneous branches innervate the mons
The lymphatic channels draining the abdominal wall pubis, scrotum, labium majus, and inner thigh. Incisions
follow the veins. Above the umbilicus, superficial in the anterior or anterolateral abdominal wall should
drainage is mostly to the axillary nodes, with some respect the orientation of the nerves within the der-
drainage to the parasternal nodes. Below the umbilicus, matomes to minimize postoperative dysesthesias and
the superficial tissues drain into the superficial inguinal muscular denervation.
lymph node chain along the inguinal ligament (Fig. 4.9).
Lymphatic drainage of the deeper tissues of the abdom-
inal wall is through channels that accompany the deeper
named veins and includes external iliac, common iliac, References
caval, and aortic lymph node groups.
1. Hunstad JP, Repta R (2009) Anatomical considerations in
abdominal contouring. In: Hunstad JP, Repta R (eds) Atlas
of abdominoplasty. Saunders Elsevier, Philadelphia, p 7
4.9 Innervation 2. Lumley JSP (2008) Surface anatomy: the anatomical basis
of clinical examination, 4th edn. Churchill Livingstone,
The skin, superficial fascia, and muscles of the antero- Edinburgh, p 98
3. Rohrich RJ, Sorokin ES, Brown SA, Gibby DL (2003) Is the
lateral abdominal wall are innervated by the anterior umbilicus truly midline? Clinical and medicolegal implica-
primary rami of the lower six thoracic (T7T12) and tions. Plast Reconstr Surg 112(1):259263
first lumbar (L1) spinal nerves (Fig. 4.7). These nerves 4. Shiffman MA (2005) Umbilical reconstruction in abdomi-
leave their respective intervertebral foramina and course noplasty. In: Shiffman MA, Mirrafati S (eds) Aesthetic
surgery of the abdominal wall. Springer, Berlin, p 147
around the thoracic and abdominal wall staying within 5. Snell RS (2008) Clinical anatomy by regions, 8th edn.
the confines of the dermatome they supply. Apart from Lippincott Williams & Wilkins, Baltimore, p 148
the first lumbar spinal nerve, which bifurcates, they do 6. Brauman D (2008) Diastasis recti: clinical anatomy. Plast
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7. Mwachaka PM, Saidi HS, Odula PO, Awori KO, Kaisha WO
dominal nerves lie in the neurovascular plane between (2010) Locating the arcuate line of Douglas: Is it of surgical
the internal intercostal and innermost intercostal mus- relevance? Clin Anat 23(1):8486
cles. When these nerves leave the confines of the thorax 8. Moore KL, Dalley AF, Agur AMR (2010) Clinically oriented
to enter the anterolateral abdomen, they lie between the anatomy, 6th edn. Lippincott Williams & Wilkins, Baltimore,
p 188
internal oblique and transversus abdominis muscle 9. Arslan OE (2005) Anatomy of the abdominal wall.
layers. At the level of the anterior axillary line, the tho- In: Shiffman MA, Mirrafati S (eds) Aesthetic surgery of the
racoabdominal nerves send lateral cutaneous branches abdominal wall. Springer, Berlin, p 10
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ated: two case reports. Am Surg 37(8):527530
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13. Nahas FX (2001) An aesthetic classification of the abdomen perforator and superficial inferior epigastric artery flaps.
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108(6):17871795 17. Kolker AR (2008) Improving esthetics and safety in
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Arterial and venous anatomies of the deep inferior epigastric
Anatomy of the Eyelid
5
Oren G. Benyamini and Morris E. Hartstein
5.1 Introduction in a shallower orbit or from bulging of orbital fat

behind the septum (Fig. 5.1) [13, 7].
The eyelid is a three-dimensional, multilayered, and Inferior to the sulcus is a fine horizontal skin line
dynamic organ that has crucial functional role in that is the upper eyelid crease. The crease corresponds
protecting and lubricating the eyes as well as being a to an area at or above the superior tarsal border and is
key feature in facial aesthetics. Understanding the created by the insertion of fibers from the levator
anatomy is critical for the surgeon to ensure that the palpebrae aponeurosis to the skin where it fuses with
eyelid continues in its functional capacity as well as the orbital septum. The lid crease also marks the tran-
undergo rejuvenation. sition between the looser preseptal skin and the tighter,
more adherent pretarsal skin. In Caucasian women, the
lid crease usually resides 10 mm above the lid margin,
5.2 Anatomy whereas in men, it is usually a little lower at 78 mm
above the lid margin. In Asians, the fusion of levator to
Beginning superiorly, external examination of the eye- septum occurs at or below the superior tarsal border,
lids reveals some key landmarks. The eyebrows reside resulting in a lower or even absent crease [1, 3, 4, 7].
just above the superior orbital rim in women and on the The periorbital region and eyelids are covered by
orbital rim in men. Below the superior orbital rim is very thin skin. The transition between the thicker
the sulcus which lies between the brow and the lid. eyebrow skin upper lid skin and the thicker malar skin
The sulcus can be deeper and more prominent with to the lower lid skin should be taken into account.
atrophy of orbital fat, a larger and deeper orbit, or after For example, the upper border of the upper blepharo-
overzealous fat removal during upper lid blepharoplasty incision should not incorporate the thicker brow
plasty. Alternatively, the superior sulcus may be fuller skin. The preorbital and preseptal skin has a very thin
subcutaneous layer with very little fat; whereas the
pretarsal skin lacks any fat at all (Fig. 5.2) [1, 3, 4].
The palpebral fissure, the opening between the
O.G. Benyamini upper and lower lids, measures approximately 30 mm
Department of Ophthalmology, Assaf Harofeh Medical Center, horizontally. In the primary position, the upper eyelid
Zerifin, Israel
rests 12 mm below the upper limbus, and the lower
M.E. Hartstein (*) lid rests on the lower limbus, creating a vertical palpe-
Department of Ophthalmology, Assaf Harofeh Medical Center,
Zerifin, Israel
bral fissure measurement of 1012 mm. It terminates
at the fusion of the upper and lower lids laterally. The
Clinical Associate Professor of Ophthalmology and
Plastic Surgery, Saint Louis University School of Medicine,
angle formed by this union is the lateral canthus, while
St. Louis, MO 63104, USA the point of fusion is termed the lateral commissure.
e-mail: [email protected] The lateral canthus maintains its position and stability

70 O.G. Benyamini and M.E. Hartstein
a b
Levator palpebrae
superioris muscle
ROOF
Superior tarsal
muscle (smooth)
Tarsal
(Meibomian glands)
Superior tarsus
Sebaceous glands
Cilia (lashes)
Openings of tarsal glands
Inferior tarsus
Orbicularis oculi
muscle (palpebral part)
Orbital septum
Orbitomalar ligament
SOOF
Fig. 5.1 Surface anatomy demonstrating differences full and more hollow superior sulcus and lateral canthal position
5 Anatomy of the Eyelid 71
superficial and deep connective tissue band to form the

LCT. The deep head attaches to the lateral orbital
tubercle (Whitnalls tubercle), a bony prominence
4 mm posterior to the lateral orbital rim. This is a
critical attachment point of the LCT as it maintains the
lid apposition to the globe. Also, the attachments of
the LCT are 3 mm higher at the lateral canthus than
the medial canthus [5, 6].
The malar crease arises from the lateral canthus and
descends in a 45 angle inferiorly and medially, where
it joins the nasojugular crease (tear trough) that arises
from the medial canthus and descends inferiorly and
medially in a similar angle. These lines meet 15 mm
below the center of the lower eyelid margin.
5.3 Orbicularis Oculi Muscle

Fig. 5.2 Skin marking for upper blepharoplasty. Upper limit
of incision should not incorporate thicker brow skin
The orbicularis oculi muscle, the main eyelid protractor
muscle, is responsible for eyelid closure. The concen-
trically arranged fibers are firmly attached to the under-
lying bony structures, as well as to the medial and
lateral canthi and upper and lower tarsi. The muscle
consists of three anatomical regions: orbital, preseptal,
and pretarsal. The orbital part of the muscle, which adheres
directly to the bony structures of the orbital rim, is
responsible for voluntary or forced eyelid closure.
The preseptal portion of the muscle overlies the orbital
septum, although a loose sheath of fibroadipose layer
may be found between the two. It is important to dis-
tinguish between this fat layer and the preaponeuorotic
fat pads that lie deep to the orbital septum. Laterally,
the preseptal orbicularis inserts 34 mm behind the lat-
Fig. 5.3 Cadaver dissection demonstrating lateral canthal eral commissure, deep to the orbital rim onto Whitnalls
tendon with its insertion to lateral orbital rim tubercle to form the lateral canthal ligament [3].
Medially, the muscle divides to an anterior or
by a deeper (subcutaneous) connection to bone the superficial head, which inserts to the anterior head of
lateral canthal tendon (LCT). The LCT is a fibrous the medial canthus, and a posterior, deep head, which
structure that integrates dense connective tissue (the invests the lacrimal sac and lacrimal fascia. This part
tarsus) to the bone (Fig. 5.3) [5, 6]. of the muscle supports both voluntary and involuntary
Both anterior and posterior lamella of the eyelids lid closure. The pretarsal portion of the orbicularis is
contribute to the formation and integrity of the LCT. firmly adherent to the anterior face of the tarsal plate.
The orbicularis oculi muscle, the protractor of the At the superior tarsal border, the muscle is joined by
eyelids, comprises part of the anterior lamella and is superficial fibers from the levator palpebrae aponeuro-
divided into an orbital and palpebral portion. The sis to form the lid crease. Laterally, the muscle has
palpebral portion of the orbicularis muscle is further insertions to the lateral canthal ligament. Medially, as
divided into a preseptal and pretarsal segment. The with the preseptal portion, the muscle also divides into
pretarsal portion is anterior to the tarsus. At the termi- an anterior and posterior heads. The posterior head
nation of the tarsus, the orbicularis continues as a inserts 4 mm deep to the posterior lacrimal crest.
Fig. 5.4 Dissection through

the orbicularis, and then the
orbital septum reveals the
medial fat pad of the upper lid
Suborbicularis Orbicularis oculi

oculifat
Inferior orbital rim
Orbitomalar ligament
Malar fat pad
Zygomaticus minor
Contraction of this portion of the muscle pulls the orbital septum provides a barrier between the orbit and
eyelids together, medially and posteriorly following its contents and the more superficial preseptal tissues.
the convexity of the globe. The anterior head inserts
into the anterior lacrimal crest and contributes to
involuntary blinking, the main function of the pretarsal 5.5 Fat Pads
orbicularis. The anterior and posterior portion of the
muscle engulf the lacrimal sac and compress it during Immediately posterior to the orbital septum are the
blinking. This creates negative pressure in the sac fat pads that serve to cushion and protect the globe
which facilitates tear drainage [3]. (Fig. 5.5). The upper lid has two main fat pads.
The orbicularis muscle in the lower lid attaches The central fat pad or the preaponeuorotic fat pad is
directly to the orbital rim medially, contributing to the usually larger, with more connective tissue and a
nasojugal groove. Laterally, the orbicularis attaches more yellow appearance. It is a useful landmark as it
via the orbitomalar ligament that arises from the lies just anterior to the levator palpebrae muscle. The
periosteum outside the orbital rim to the fascia on the trochlea, or the superior oblique muscle pulley,
underside of the orbicularis (Fig. 5.4) [6]. together with other looser connective tissue septa,
separates this pad from the medial fat pad which is
smaller, has less connective tissue, and is whiter in
5.4 The Orbital Septum appearance. Lateral to the central preaponeurotic fad
pad is the lacrimal gland. This structure that is whiter
The orbital septum is a multilayered condensed and more globular in appearance than the fat pads
fibro-connective tissue. It originates from the orbital rim should never be resected, although sometimes it may
at the arcus marginalis, where the periorbital fuses with need to be repositioned more superiorly. The lower
the periosteum of the anterior surface of the bones sur- eyelid harbors three distinct fat pads. The inferior
rounding the orbital cavity. Several millimeters above oblique always lies between the central and nasal
the superior tarsal border, the septum fuses with the fat pad and should be identified prior to resecting
levator aponeurosis. Together they insert into the ante- or sculpting any of the fat pads (Fig. 5.6). Anterior
rior surface of the superior tarsal plate. In the lower to the muscle, the central and nasal pads need to be
eyelid, the orbital septum inserts directly into the infe- separated in order to locate the muscle posteriorly.
rior tarsal plate in a similar fashion. Approximately The temporal fat pad is divided from the central pad
45 mm below the inferior tarsal border, the septum by the arcuate expanse of the inferior oblique
fuses with the lower lid retractors to form a single unit (Fig. 5.7). Sometimes, there is even a fourth fat pad
that inserts to the lower border of the inferior tarsus. The which lies temporally, more anteriorly on the lower
Fig. 5.5 (a) Dissection a

through the orbicularis, and
then the orbital septum
reveals the medial fat pad of
the upper lid. (b) The fat
pads of the upper and lower
lids with septum removed
b Preaponeurotic fat Trochlea
Lacrimal gland
Nasal fat pad
Medial fat pad

Laveral fat pad
Inferior oblique
muscle
Arcuate expansion of Middle fat pad

inferior oblique muscle
lid retractors. This fat pad may be missed during called Mullers. In the lower lid, the retractors are the
blepharoplasty, resulting in a temporal bulge [1]. capsulopalpebral fascia and the sympathetically inner-
vated inferior tarsal muscle [3].
The levator consists of two portions. The first por-
5.6 Eyelid Retractors tion is made of striated muscle, originates from the
orbital apex, and courses anteriorly for about 36 mm.
Counteracting the orbicularis oculi in each eyelid are At the level of the globe, the levator fans medially
two separate eyelid retractor muscles responsible for and laterally, creating Whitnalls suspensory ligament.
opening the eye. The upper eyelid has one major Whitnalls ligament is attached to the periorbital on both
striated voluntary muscle called the levator palpebrae sides. Medially, Whitnalls ligament is attached to the
and the sympathetically innervated smooth muscle trochlea and laterally to the fronto-zygomatic suture.
Fig. 5.6 Transconjunctival lower blepharoplasty. A cotton-

tipped applicator demonstrates the inferior oblique muscle
which is always located between the nasal and central fat pad
Fig. 5.8 Levator/Mullers recession demonstrating the upper

lid retractors
Fig. 5.7 Transconjunctival lower blepharoplasty. Temporal fat

pad separated by the arcuate expanse of the inferior oblique
As the muscle passes the level of Whitnalls it loses its

muscular nature and becomes the levator aponeurosis.
Medially, the aponeurosis attaches to the medial can-
thus. Laterally, it splits the lacrimal gland to its palpe-
bral and orbital lobules before it inserts into the medial Fig. 5.9 Transconjunctival approach demonstrating lower lid
canthal tendon. Centrally, the aponeurosis descends to retractors immediately posterior to the conjunctiva
approximately 25 mm superior to the upper border of
the superior tarsus where it fuses with the orbital septum
to insert into the anterior surface of the tarsal plate [3]. conjunctiva in its superior aspect. However, close to its
The second upper lid retractor, Mullers muscle, insertion into the superior tarsus, the muscle is more
originates from the underside of the levator muscle adherent to the conjunctiva (Fig. 5.8).
about 22 mm above the tarsus. This sympathetically The lower eyelid retractors are less defined than in
innervated smooth muscle is loosely attached to the the upper lid, and their action is less prominent. The
capsulopalpebral fascia and the inferior tarsal muscle oriented meibomian glands, which open into the lid
both originate as fibrous extensions of the inferior rectus margin. Posteriorly, the tarsus is lined with the palpe-
muscle. They encircle the inferior oblique muscle, before bral conjunctiva and together these comprise the poste-
the capsulopalpebral fascia inserting, together with the rior lamella of the eyelid (Fig. 5.10). The anterior
orbital septum onto the inferior tarsal border (Fig. 5.9). lamella consists of the orbicularis muscle and the skin.
The orbital septum can be thought of as the middle
lamella [3, 7].
5.7 Tarsus
The upper and lower tarsus are made of dense fibro- 5.8 Arterial Blood Supply
connective tissue to provide the eyelids their structural
support. The upper tarsus is 10 mm in vertical height, The eyelids receive a very rich blood supply. Terminal
while the lower tarsus is about 35 mm in its vertical branches of the internal carotid artery anastomose with
dimension. Each tarsal plate contains the vertically branches of the external carotid artery in the perior-
bital region via the lacrimal, supraorbital, supratro-
chlear, and dorsal nasal artery (Fig. 5.11) [3, 8].
The medial palpebral artery anastomoses with a ter-
minal branch of the external carotid artery the lateral
palpebral artery. In the upper lid, this anastomosis has
two well-defined vascular arcades. The superior mar-
ginal palpebral arcade lies on the anterior tarsal sur-
face 23 mm above the lid margin, and the peripheral
palpebral arcade lies above the superior tarsal border
between the levator aponeurosis and Mullers muscle.
In the lower lid, theres only one well-defined vascular
arcade, the inferior marginal arcade, which can be
found 23 mm below the lower lid margin on the ante-
rior surface of the tarsus. Other branches of the exter-
Fig. 5.10 Tarsal plate, which is about 100 mm in height in the
upper lid, demonstrating the vertically oriented meibomian
nal carotid include the superficial temporal artery,
glands facial artery, and infraorbital artery [3, 8].
Superior marginal arcade

Supraorbital artery
Superficial temporal
artery, frontal branch Supratrochlear artery
Superior medial
palpebral artery
Dorsal nasal artory
Lacrimal artery
Superior and
Nasal branch
inferior lateral
palpebeal arteries
Zygomafoofacial
artery
Angular artery
Transverse
facial artery
Infraorbital artery
Fig. 5.11 Arterial supply of

the eyelids Inferior marginal arcade
5.9 Venous Drainage of the Eyelids References
The venous drainage of the periorbital region follows a 1. Bedrossian EH Jr (2002) Surgical anatomy of the eyelids.
In: Della Rocca RC, Bedrossian EH Jr, Arthus BP (eds)
parallel path to the arterial supply, dividing into a deep
Ophthalmic plastic surgery. Decision making and tech-
system that drains to the orbital venous system and niques. McGraw-Hill, New York, pp 2541
a superficial system that eventually drains into the 2. Jordan D, Anderson R (1996) Surgical anatomy of the ocular
external jugular vein [3]. adnexa-a clinical approach. Ophthalmology monograph
9. American Academy of Ophthalmology, San Francisco
3. Anatomy (20102011) In Basic and Clinical Science Course
Sec 7: Orbit, Eyelids, and Lacrimal System. American
5.10 Nerve Supply Academy of Ophthalmology, San Francisco, part II chap
9:137149
4. Kakizaki H, Malhotra R, Selva D (2009) Upper eyelid
The orbicularis receives its motor innervations from a
anatomy: an update. Ann Plast Surg 63(3):336343
branch of the facial nerve via the zygomatic division. 5. Kakizaki H, Malhotra R, Madge SN, Selva D (2009) Lower
Some debate remains regarding the precise anatomy eyelid anatomy: an update. Ann Plast Surg 63(3):344351
of this nerve; however, it appears that the nerve 6. Harris PA, Mendelson BC (2008) Eyelid and midcheek
anatomy. In: Fagien S (ed) Puttermans cosmetic oculoplastic
fibers travel in a radial direction as they approach the
surgery, 4th edn. Elsevier, Philadelphia, pp 4562
lid margin. The levator muscle receives innervations 7. Gausas RE (2004) Advances in applied anatomy of the
from the oculomotor nerve, while Mullers is sympa- eyelid and orbit. Curr Opin Ophthalmol 15(5):422425
thetically innervated. Sensory innervations of the 8. Tucker SM, Linberg JV (1994) Vascular anatomy of the
eyelids. Ophthalmology 101(6):11181121
upper lid comes from trigeminal nerve via the lacri-
mal, supraorbital, supratrochlear, and infratrochlear
nerves. The lower lid receives sensory innervation via
the zygomaticofacial and infraorbital nerves [3].
Part II
Anesthesia
Regional Anesthesia for Cosmetic
Surgery of the Face and Neck 6
Arnaud Deleuze, Marc Gentili, and Francis Bonnet
6.1 Introduction 6.2 Anatomical Data
Plastic surgery has increased significantly because of 6.2.1 Innervation of the Face
the representation of ones personal image in the mod-
ern world. Moreover, a prolonged lifespan and extended The sensory innervation of the face depends mainly on
sun exposure cause an increase in the incidence of skin the trigeminal nerve which is derived from two roots,
tumors. In the U.S. the American Society for Aesthetic one sensory and one motor (Fig. 6.1). The cell bodies
Plastic Surgery recorded 11.7 million cosmetic proce- of the sensory root are grouped in the trigeminal gan-
dures in 2007: eyelid surgery was one of five most fre- glion located in the cervical cord, which presents a
quent operations [1]. The possibilities for cosmetic corporeal organization corresponding to the three parts
surgery and face reconstruction are multiple, and a relating to:
large number can be performed on an outpatient basis: 1. The ophthalmic nerve or V1
this is choice ground for face blocks. 2. The maxillary nerve or V2
The effectiveness of cephalic blocks is based on a 3. The lower jaw or mandibular nerve or V3
sound knowledge of nerve territories and their bound- The V3 nerve also contains motor fibers for masti-
aries. After some anatomical reminders, different tech- cation muscles: the temporalis muscle and the masseter
niques of anesthesia applied to each type of surgery muscle [2].
will be described. The realization of these blocks
follows the general rules of any anesthesia especially
with regards to clinical supervision and asepsis. These 6.2.2 The Ophthalmic Nerve (V1)
are techniques that fall within the framework of an
alternative to conventional general anesthesia and that 1. The ophthalmic nerve leaves the skull through the
can be combined with sedation. superior orbital fissure and has branches: the lacri-
mal nerve which innervates the conjunctiva, the
skin of the outer part of the eye, and the lacrimal
A. Deleuze, MD (*) gland.
Department of Anaesthetics and Intensive Care, lEsprance 2. The frontal nerve, which has a supraorbital and
Private Hospital, Mougins, France a supratrochlear branch innervating the upper eye-
e-mail: [email protected]
lid and the hemifront to the coronal suture,
M. Gentili, MD respectively.
Department of Anaesthetics and Intensive Care,
3. The nasociliary nerve which divides into several
Saint Grgoire Private Hospital, Rennes, France
branches.
F. Bonnet, MD
4. The long ciliary nerves innervating the eye.
Department of Anaesthetics and Intensive Care, Tenon
Hospital, Assistance Publique hpitaux de Paris, 5. The infratrochlear nerve innervating the skin of the
University Pierre & Marie Curie, Paris, France dorsum of the nose and the commissure of the eye.

80 A. Deleuze et al.
Fig. 6.1 According to the

Guide to Regional anesthesia
AstraZeneca 2001
nerf ophtalmique (V1)
nerf maxillaire (V2)
nerf mandibulaire (V3)
6. The anterior ethmoid which provides nerve nets for 3. Palatine nerves innervate the posterior part of the
the anterior ethmoid, nasal branches for the internal palate with a few branches for the veil and the
septum, and lateral wall of the nasal cavity, and tonsils.
ends in external nasal branch for the nasal bone, the 4. The terminal branch or infraorbital nerve exiting
tip of nose, and wing area. through the infraorbital foramen, innervating the
skin of the lower eyelid, cheek, nostril, and upper
lip.
6.2.3 The Maxillary Nerve (V2) Overall, the deep branches carry the sensitivity of
the mucosa (maxillary sinus, nasal cavity, gums, higher
1. The maxillary nerve exits the skull through the palatal vaults, and velum). The branches innervate the
foramen large circle and enters the rear end of intracranial temporal and parietal dura mater, and the
the pterygopalatine fossa maxillary. It then divides middle meningeal artery.
into several branches:
a. A meningeal and orbital branch for the ethmoi-
dal and sphenoidal sinuses 6.2.4 The Mandibular Nerve
b. A zygomatic branch to the skin of the temporal or Mandibular (V3)
region and the zygomatic bone
c. Dental upper branches, innervating the posterior, The mandibular nerve is a mixed nerve exiting the
middle, and upper molar teeth prior to the inci- skull through the foramen ovale and divided into two
sor-canine mass branches, the anterior and posterior sensory motor.
2. Pterygopalatine roots forming, with the sympathetic The sensation contingent is divided into:
and parasympathetic pterygopalatine ganglion, a 1. The buccal branch which innervates the skin and
complex with nasal branches to the sides of the the lining of the cheek.
nose; nasopalatine for the posterior part of the 2. The auriculotemporal nerve innervating the anterior
septum and the anterior part of the palate. part of the pinna, the ear, and temporal region.
6 Regional Anesthesia for Cosmetic Surgery of the Face and Neck 81
3. The inferior alveolar nerve divides into two termi- Infiltration of the supraorbital branch of the frontal
nal branches at the chin foramen: the incisive and nerve is performed at the supraorbital foramen located
chin nerve innervating the entire lower jaw (bone, on the orbital rim, on the eyebrow, directly above the
teeth, gums). centered pupil. The tip of the needle should point up
4. The lingual nerve innervating the anterior two thirds and out and will come into contact with the hole with-
of the tongue and floor of the mouth. out penetrating it. For infiltration of the supratrochlear
The motor contingent provides innervation of branch, the needle is directed into the angle formed by
mastication muscles and palati hammer muscles. The the upper edge of the orbit and nasal stops. The total
mandibular nerve carries VIIa fibers providing taste volume of local anesthetic is 46 mL. The injection is
sensitivity at the tip of the tongue and the propriocep- performed outside the bony canal to prevent neuronal
tion of facial expression muscles. damage due to high pressure [3, 4]. The infiltration of
the nerve will allow surgery on the outer portion of the
forehead and upper eyelid (Fig. 6.2).
6.3 Special Case of the Innervation If the infiltration is carried out bilaterally, surgery
of the Ear from the forehead to the coronal suture and the upper
eyelids is possible [5].
The auriculotemporal nerve innervates only a portion
of the ear; the rest is provided by several other contin- 6.5.1.2 The Internal Nasal Nerve
gent nerves. The posterior inferior part of the flag, the or Anterior Ethmoidal
external auditory canal, and the lobe are innervated by This nerve, after its exit from the supraorbital foramen,
the auricular branches of the cervical plexus surface. provides sensory innervation to the root and the ala.
The shell and the outer ear canal (Ramsay Hunt area) It divides into two branches: the internal nasal branch
are innervated through the Wrisberg (VIIa). The auric- and the nasolabial branch. The infiltration of the nerve
ular branch of the vagus (X) provides sensory innerva- is performed bilaterally. The internal nasal branch is
tion to the deep ear canal and the lower portion of the infiltrated by a subcutaneous injection at the root of the
eardrum. The eardrum, in turn, is innervated by nose, and the nasolabial branch is infiltrated by a sub-
Jacobsons nerve or the tympanic nerve which is a cutaneous injection into the nostril. These injections
branch of the glossopharyngeal nerve. are performed using a dermatological needle. A small
volume of local anesthetic is needed (about 46 mL).
Any extra-bone surgery of the nose can be performed
6.4 Innervation of the Cervical Region as well (Fig. 6.2). The supraorbital nerve block does
not interfere with the ability to open the eyelid [6].
The sensory innervation of the cervical region and the
occipital region is provided by the anterior branches
of the superficial cervical plexus, constituted by the 6.5.2 Nerve Block of the Infraorbital
first four cervical roots. The emergence of mastoid, Branch of the Maxillary Nerve (V2)
transverse, and clavicular branches from cervical
plexus is at the posterior part of the sternocleidomas- This nerve leaves the skull through the infraorbital
toid muscle. foramen, which lies directly below the center of the
pupil, 2 cm from the ala and 1 cm below the inferior
orbital rim. Once the foramen is located, the skin is
6.5 Anesthetic Techniques punctured and the needle is directed upward and out-
ward. The injection is performed outside the bony
6.5.1 Block Branches of the Ophthalmic canal to avoid neural damage due to excess pressure.
Nerve (V1) A volume of 34 mL of local anesthetic is sufficient.
This block anesthetizes the suborbital area, the upper
6.5.1.1 The Frontal Nerve lip, and the ala [7] (Fig. 6.2). The authors used a stimu-
After its emergence from the supraorbital foramen, the lator to locate the emergence of the nerve: when the
frontal nerve divides into two branches: the supraor- needle approaches the nerve in the infraorbital hole,
bital and supratrochlear rami. there is bilateral eye blinking. Once the motor response
Fig. 6.2 Based on the Guide nerf ophtalmique (V1)

to Regional anesthesia
AstraZeneca 2001
nerf maxillaire
(V2)
C2
C2
nerf mandibulaire
(V3)
C3
C3
C4 C4
is obtained, the current is progressively lowered from continuous perfusion of local anesthetic which ensures
0.6 to 0.8 mA and the injection of 37 mL of the solu- quality analgesia during surgery following particularly
tion provides an effective block [8]. A case of transient painful procedures such as cancer surgery [10].
diplopia has been reported [7].
6.5.3.2 Chin Nerve Block
The branch of inferior alveolar nerve leaves the anterior
6.5.3 Block of the Mandibular Nerve (V3) surface of the mandible through the mental foramen of
and Its Branches the chin. This hole is located directly above the lower
premolar and is easily identifiable using ones finger.
6.5.3.1 Mandibular Nerve Block The puncture site is 1 cm lateral to the foramen.
This is the only sensory-motor nerve of the face, and Once the needle goes through the skin, it is directed
thus using a nerve stimulator to locate the nerve is of downwards and inwards, while being careful not to
interest. Indeed, it provides sensory innervation to the inject into the canal. Two mL of anesthetic solution is
cheek, ear, lower lip, and the temple and has motor injected. This simple infiltration enables surgery on
branches to the masseter and temporal muscles. The the lower lip and chin (Fig. 6.2).
puncture site is located at the sigmoid fossa opposite
the tragus between the coronoid process and the 6.5.3.3 The Auriculotemporal Nerve
condyle. The puncture was performed using a 50-mm This part of the contingent sensory nerve V3 has
needle. The puncture axis is perpendicular to the plane subcutaneous branches which are opposite the tragus.
of the face at first, and then the needle takes a cranial It supplies the superficial temporal and auricular area.
direction. The motor response being sought is the The infiltration is performed simply by dermal infiltra-
closing of the lower jaw. Once the motor response has tion using 23 mL of local anesthetic, opposite the
been obtained, the current is reduced gradually from tragus. Surgery of the anterior part of the pinna, the ear
0.6 to 0.8 mA. Four to six milliliters of anesthetic solu- canal, and the superficial temporal region can thus be
tion is then injected into the nerve. performed.
This nerve can also be infiltrated by an injection per-
formed between the coronoid and condylar processes.
However, this technique has a high failure rate, and there 6.6 The Special Case of External
is a significant risk of puncturing the maxillary artery Ear Surgery
[9] or penetrating the orbit or skull [5]. It is therefore
recommended not to practice this technique without The sensory innervation of the ear is dependent on
the aid of a neurostimulator. It is also possible to leave several nerve branches. The auriculotemporal nerve is
a catheter in place near the mandibular nerve to have a infiltrated. In addition, a subcutaneous infiltration into
34 points in the area above and behind the atrial 6.10 Indications for Using a Face Block
auricular nerve block the auricular branches of the with Respect to the Operation
superficial cervical plexus, which provide sensory Itself and the Terrain
innervation to the lower posterior auricle, the external
ear canal, and the lobule. Surgery of all the external ear The choices of technique with regional blocks, which
is thus possible [11]. are often bilateral, depend on the indications for
surgery: this may include nasal surgery [5, 7], lifting
[15], lip surgery [16], or eyelid and lacrimal surgery
6.7 Special Case of External [17], or finally hair implants [18]. Face blocks are of
Auditory Canal particular interest in elderly patients or with fragile
patients, especially for skin tumors [19].
An injection at the junction of the pilosebaceous area
is performed to anesthetize the posterior external audi-
tory canal. The needle is directed into the major axis of 6.11 Local Anesthetics and Adjuvants
the ear canal, and 23 mL of local anesthetic is infil-
trated in a superficial manner. Regarding the anterior The injection of local anesthetics into the face requires
part of the conduit, 12 mL of local anesthetic is some specific knowledge which may affect their phar-
injected at the cartilage-bone junction. A spray of local macokinetics, of which intravascular resorption is one
anesthetic may also be used on the eardrum if paracen- possibility. Indeed there is a large amount of capillary
tesis-type surgery is contemplated [11]. absorption, and the immediate and massive absorption
of local anesthetic by the mucosa can generate plasma
levels comparable to those produced after an intrave-
6.8 Inltration of the Supercial nous injection [10]. The injection is, thus, performed
Cervical Plexus slowly, in small doses, after successive tests of aspira-
tion, while being aware of and respecting the maxi-
The superficial cervical plexus is formed by the ante- mum doses. A peripheral vein, minimal supervision
rior branches of the first four cervical roots. These including an electrocardiogram, blood pressure, and
emerge along the posterior border of the sternocleido- oxygen saturation are needed together with an oxygen
mastoid. They provide sensory innervation to the supply in case of sedation in elderly patients whose
neck, shoulders, and the back of the scalp like a cape. general condition is impaired: repeated verbal contact
The superficial cervical plexus block requires a set of is a good way of monitoring the patient, and it also
subcutaneous injections in a star shape along the pos- helps to reassure them.
terior border of sternocleidomastoid which involves Adrenaline solutions are widely used because they
the mastoid and ear branches of this plexus [12]. This reduce perioperative bleeding and prolong the anesthetic
simple infiltration is useful to know about when the block, but epinephrine solutions should be used with
surgery concerns an area on the edge of the face and care near terminal arteries (tip of nose, earlobe) or the
neck region (Fig. 6.2). orbit due to the risk of spasm of the central retinal artery
and ischemia. The benefit of adding adrenaline to reduce
the risk of secondary hematoma needs further verifica-
6.9 Regional Blocks in Relation tion: in a study combining non-randomized retrospec-
to Inltration Techniques tive and prospective data, Jones et al. [20] did not find
any significant impact on the occurrence of secondary
Face surgery, like many superficial operations, can be hematoma whether the solution was adrenaline or not.
achieved by simple infiltration techniques [13, 14]. The recommended concentration is 1/200,000. The
The interest of using a block rather than a simple most commonly used local anesthetics are 1% lidocaine,
infiltration is that this limits the quantity of product bupivacaine 0.25%, and 2% or 7.5% ropivacaine. For
injected. This latter is often underestimated, and there- short and painless surgery, lidocaine or mepivacaine
fore integument swelling can be avoided by using less are used. The maximum recommended dose for adults
anesthetic [14]. The infiltration may also be comple- is 7 mg/kg with a maximum dose of 500 mg [1].
mentary to an inadequate regional block. For long and painful surgery that requires postoperative
analgesia, it seems preferable to use ropivacaine. of having an average duration of analgesia of 15 h,

Ropivacaine has interesting intrinsic properties in this which is three times longer than that observed with
indication. In a study on frogs, Ackerman et al. showed 0.1% lidocaine.
that the duration of the analgesic effect of ropivacaine It is possible to achieve a continuous infiltration of
infiltration was greater than that obtained with bupiva- local anesthetic which is smooth and progressive
caine [21]. These results were confirmed with healthy using a volumetric infusion pump and a 3022 gauge
volunteers, but this advantage disappears with the use needle. The infiltration rate will vary depending on
of adrenaline solutions [22]. The same team had pre- the diameter of the needle and the anatomical site of
viously shown that ropivacaine has, if not vasocon- injection.
strictive properties, then at least not vasodilator ones, Injection volumes ranged from 10 to 1500 mL,
compared to other local anesthetics, which could depending on the surgical site and the patients weight
explain this effect [23, 24]. In all cases the plasma con- according to the currently recommended maximum
centrations, regardless of the local anesthetic used, are doses. Monitoring pre-, peri-, and postoperatively are
below critical levels but remain high for at least 2 h required as for any type of anesthesia. The contraindi-
[24]. The addition of sodium bicarbonate (1 mL at cations are the same as for the use of local anesthetic.
84/1000 for 10 mL) neutralizes the acidity of the local Solutions of local anesthetics containing adrenaline
anesthetic solution and reduces the burning sensation are a contraindication for finger and penis surgery.
at the point of injection [25]. Apart from classic liposuction, there are many
The injection of local anesthetic using a syringe and indications [29]:
needle is the usual technique to achieve local anesthe- Dermatologic surgery in adults or in children
sia by infiltration. Due to the limited doses of local Removal of lipomas
anesthetic that can be injected into a patient in this Surgery for varicose veins and leg ulcers
way, this technique is inadequate when local anesthe- Breast surgery (implants, gynecomastia)
sia is required for large areas. Moreover, the injection Pilonidal cyst
of large volumes may be responsible for pain related to Lymph node surgery
rapidly distended tissue. Plastic surgery (hair transplant, facelift, dermabrasion)
Tumescent local anesthesia was initially discov-
ered in 1892 [26], but it would take until 1990 to see
it appear in the context of liposuction without seda- 6.12 Conclusions
tion or anesthesia: the subcutaneous fat is injected
with large volumes of diluted lidocaine with epi- Regional anesthesia techniques in head and neck
nephrine [27]. This technique reduces bleeding, faci- surgery represent a set of different techniques which
litates dissection and reduces the occurrence of are reliable and reproducible. These techniques may
swelling and bruising, and allows prolonged analge- well be an alternative to general anesthesia in surgery
sia. Ramon et al. [1] conducted a prospective study of the face or neck, particularly when the patient
of surgical facial lifting with a solution of lidocaine requests them. Their simplicity should make their use
diluted by three with epinephrine 1:600,000. The more frequent.
total dose of lidocaine was 21 mg/kg injected over
20 min in the subcutaneous tissue of the face and
neck. The dosages of lidocaine showed between 2 References
and 12 h after injection, and plasma levels reached a
plateau at 1.2 mg/mL and a maximum plasma con- 1. Shapiro PA (2008) Anesthesia for outpatient cosmetic
centration of 2.25 mg/mL. This study strongly sug- surgery. Curr Opin Anaesthesiol 21:704710
2. Kahle W, Leonhardt H, Platzer W (1979) Anatomy of
gests that the high dilution of local anesthetic
the nervous system. Flammarion Medicine and Science,
combined with epinephrine limits the peak plasma Paris, pp 116120
concentration to well below what is considered toxic, 3. Smith DW, Peterson MR, De Berard SC (1999) Regional
despite a total dose which was well above the usually anesthesia. Nerve blocks of the extremities and face. Postgrad
Med 106(4):6973
recommended doses.
4. Navez M, Molliex S, Auboyer C (1997) The blocks of
More recently, ropivacaine has found a place in the face. Conferences updating the SFAR. Elsevier, Paris,
local tumescent anesthesia [28] and has the advantage pp 237249
5. Stromberg BV (1985) Regional anesthesia in head and neck Apropos of 166 cases surgically treated in 1986 and 1987.
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6. Ismail AR, Anthony T, Mordant DJ, MacLean H (2006) 20. Jones BM, Rajiv G (2004) Avoiding hematoma in cervicofa-
Regional nerve block of the upper eyelid in oculoplastic cial rhytidectomy: a personal 8-year quest. Reviewing 910
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7. Molliex S, Navez M, Baylot D, Prades JM, Elkhoury Z, 21. Akerman B, Hellberg IB, Trossvik C (1988) Primary
Auboyer C (1996) Regional anesthesia for outpatient nasal evaluation of the local anesthetic properties of amide agent
surgery. Br J Anaesth 76(1):151153 ropivacaine LEA-103. Acta Anaesthesiol Scand 32(7):
8. Bernard JM, Pron Y (2005) Nerve stimulation for regional 571578
anesthesia of the face: use of the blink reflex to confirm the 22. Cederholm I, Evers H, Lofstrom B (1991) Effect of intrader-
localization of the trigeminal nerve. Anesth Analg 101(2): mal injection of saline or a local anaesthetic agent on skin
589591 blood flow - a methodological study in man. Acta Anaesthesiol
9. Stajcic Z, Torodovic L (1997) Blocks of the foramen Scand 35(3):208215
rotundum and the oval foramen: a reappraisal of extraoral 23. Cederholm I, Evers H, Lofstrom JB (1992) Skin blood flow
maxillary and mandibular nerve injections. Br J Oral after intradermal injection of ropivacaine in various concen-
Maxillofac Surg 35(5):328333 trations with and without epinephrine evaluated by laser
10. Pascal J, Navez M, Molliex S (2000) Blocks of nerves of the Doppler flowmetry. Reg Anesth 17(6):322328
face. Prat Ranim Anesth 4(2):9499 24. Cederholm I, Akerman B, Evers H (1994) Local analgesia
11. Martin C, Navez M, Prades JM (1992) Local anesthesia and and vascular effects of intradermal ropivacaine and bupiva-
locoregional ENT. EMC In-ORL 20(980-A10):112 caine in various concentrations with and without the addi-
12. Junca A, Marret E, Goursot G, Mazoit X, Bonnet F (2001) tion of adrenaline in man. Acta Anaesthesiol Scand 38(4):
A comparison of ropivacaine and bupivacaine for cervical 322327
plexus block. Anesth Analg 92(3):720724 25. Bartfield JM, Gennis P, Barbera J, Breuer B, Gallagher EJ
13. Kays CR (1988) Regional versus local infiltration anesthesia (1990) Buffered versus plain lidocaine as a local anesthetic
of the face: case report and review. J S C Med Assoc 84(10): for simple laceration repair. Ann Emerg Med 19(12):
494496 13871389
14. Dicker RL, Syracuse VR (1978) Local anesthesia in facial 26. Scheich C (1892) Die infiltrationsansthsie (lokale ansth-
plastic surgery. Otolaryngology 86(3 Pt 1):461467 esie) und ihr verhltnis zur allgemeinen narkose (inhalation-
15. Chrisman B (1989) The facelift. J Dermatol Surg Oncol sansthesie). Vehrdtsch Ges Chir 1:121
15(8):812822 27. Kucera IJ, Lambert TJ, Klein JA, Watkins R, Hoover JM,
16. Spear SL, Mausner ME, Kawamoto HK (1987) Sliding Kaye AD (2006) Liposuction: issues for the cotemporary
genioplasty as a local outpatient procedure. A prospective anaesthesiologists. J Clin Anesth 18(5):379387
two-center trial. Plast Reconstr Surg 80(1):5567 28. Breuninger H, Hobbach PS, Schimek F (1999) Ropivacaine:
17. Hurwitz JJ, Merkur S, De Angelis D (2000) Outcome of sur- an important anesthetic agent for slow infusion and other
gery in older patients lachrymal. Can J Ophthalmol 35(1): forms of tumescent anesthesia. Dermatol Surg 25(10):
1822 799802
18. Seager DJ, Simmons C (2002) Local anesthesia in hair 29. Hanke CW, Sommer B, Sattler G (eds) (2001) Tumescent
transplantation. Dermatol Surg 28(4):320328 local anesthesia. Springer-Verlag, Berlin
19. Beauvillain C, Viale M, Rafady E, Litoux P, Legent F (1989)
Dermatologic facial surgery in patients over 70 years.
Liposuction with Local Tumescent
Anesthesia and Microcannula 7
Technique
Bernard I. Raskin and Shilesh Iyer
7.1 Background and History the wet technique utilizing an infiltrated hypotonic
saline and hyaluronidase solution to facilitate the fat
Tumescent liposuction is the process of suction- removal. While these early techniques were effective,
assisted aspiration of subcutaneous fat after infiltration they were associated with more trauma and potential
with a dilute crystalloid solution containing lidocaine, complications including hemorrhage, fluid loss, and
bicarbonate, and epinephrine. By definition, pure pain [46].
tumescent liposuction is performed entirely under Kleins invention of tumescent anesthesia revolu-
local anesthesia and excludes the use of general anes- tionized the field of liposuction. Klein described a
thesia or intravenous sedation [1]. However, while technique for aspirating adipose tissue entirely under
many surgeons adhere strictly to tumescent anesthesia local anesthesia with a dilute solution of lidocaine and
for all pain relief, other surgeons commonly utilize epinephrine. The technique provided excellent hemo-
supplemental oral or injected agents as anxiolytics or stasis, maintained fluid balance, and eliminated the
for enhanced sedation and/or pain management. need for general anesthesia and associated complica-
The concept of liposuction utilizing local tumes- tions. In conjunction with the innovation of tumescent
cent anesthesia and microcannulas was reported by anesthesia, small microcannulas were developed to
Klein [2] in 1987. Prior to this innovation, liposuc- more gently and precisely remove layers of adipose
tion techniques employed larger-diameter cannulas tissue to achieve a sculpting effect. These cannulas
under general anesthesia. The field of modern lipo- have a diameter of 10 to 20 gauge (0.582.7-mm inner
suction was first described by Fischer [3] in 1976 diameter) compared with the larger cannulas having a
and further expanded by liposuction pioneers Pierre diameter from 3 to 6 mm or greater. With the proper
Fournier and Yves-Gerard Ilouz. Initially, the proce- technique, liposuction utilizing microcannulas under
dure was performed with larger-diameter cannulas local tumescent anesthesia is an exceedingly safe and
under a dry technique until Ilouz of France introduced effective procedure with a relatively comfortable post-
operative recovery period for the patient [7].
B.I. Raskin (*) 7.2 Tumescent Anesthesia

Division of Dermatology, Department of Medicine,
Geffen School of Medicine UCLA, Los Angeles, CA, USA
7.2.1 Advantages of Tumescent
Advanced Dermatology & Cosmetic Care, Inc.,
28212 Kelly Johnson Parkway, Suite 245, Valencia, CA, USA
Anesthesia
The concept of tumescent anesthesia relies on infiltrat-
S. Iyer
Instructor in Clinical Dermatology, Department of Dermatology, ing a dilute solution of normal saline with lidocaine,
Columbia University Medical Center, Los Angeles, CA, USA bicarbonate, and epinephrine that is partially removed

88 B.I. Raskin and S. Iyer
in the lipoaspirate (1030%), but largely dissipates 7.2.2 Pharmacology of Tumescent

naturally from the subcutaneous tissue over several Anesthesia
hours after the procedure has been completed. This
slow absorption allows for gradual intravascular Tumescent anesthesia relies on the effects of lidocaine,
volume replacement and elimination of the lidocaine which acts by blocking the sodium ion flux across
over several hours without achieving toxic plasma nerve membranes and slowing the rate of depolariza-
lidocaine levels (over 5 mg/mL) [8]. This technique tion such that threshold potentials are not reached and
provides excellent anesthesia obviating the need for impulses are not propagated [15]. The tumescent
general anesthesia and the associated complications, concept works because lidocaines aromatic structure
and provides excellent hemostasis provided by the is lipophilic in nature. Lidocaine is therefore highly
vasoconstrictive effects of the epinephrine. Further- soluble in fat and has a high affinity for the subcutane-
more, owing to delayed lidocaine absorption, pro- ous compartment. When skin is excised after infiltrat-
longed anesthesia can last up to 18 hours, mitigating ing tumescent anesthesia, there is a marbled appearance
the need for postoperative analgesic medications [7]. and puddles of anesthetic solution are loculated within
Even with large area-aggressive liposuctions in the and between connective tissue septa. These lakes act as
authors experience, postoperative analgesia is rarely physical reservoirs of lidocaine. The lipophilic prop-
needed. The typical patient reports taking a mild nar- erty of lidocaine in the tumescent technique delays the
cotic postoperatively prior to bedtime only because absorption of lidocaine into the systemic circulation.
they worry about waking up with discomfort although The lidocaine is slowly absorbed from the subcutane-
all usually report no significant problems through the ous compartment over several hours owing to its
first night. The most common pain complaint on sub- affinity for the subcutaneous tissues, the relative hypo-
sequent days is mild soreness aggravated by movement vascular nature of the subcutaneous tissues, and the
and it is the exceptional patient that requires anything vasoconstrictive effects of epinephrine, all of which
beyond acetaminophen or ibuprofen over the next sev- minimize intravascular absorption of the lidocaine
eral days. [15]. Compression of the vasculature by the infused
In addition to its local anesthetic effects, an added fluid may also contribute to the slow absorption [8].
benefit of tumescent solution with lidocaine appears to After infiltration, clinical observation has determined
be an antibacterial effect. The antibacterial properties that optimal anesthesia and hemostasis occur after
of lidocaine are known and have previously been 1530 minutes. Greater duration of time may allow
reported [9, 10]. Contradictory studies, however, have additional anesthetic effect. Elimination of the lidocaine
questioned the antibacterial properties of lidocaine from the fat occurs over 48 hours, with peak plasma
when very low concentrations are used as in tumescent concentrations occurring around 12 hours. When utiliz-
fluid [11]. Nevertheless, although studies on this issue ing a maximum dose of 35 mg/kg, lidocaine concen-
are not definitive, physicians experienced in the tumes- trations have been shown to peak 1214 hours after
cent technique have noted a low rate of significant infiltration and were in the range 0.82.7 mg/mL [7].
clinical infections which may be attributed in part to With the tumescent anesthesia formulation, sig-
the antibacterial properties of lidocaine [5, 12, 13]. nificantly higher doses of lidocaine can be used com-
Addition of bicarbonate to lidocaine appears to enhance pared with the traditional upper limit of 7 mg/kg
the in vitro antibacterial effect [14]. lidocaine with epinephrine. Early work by Klein and
The tumescent liposuction procedure can be done Lillis [16] dramatically altered the manner in which
safely on an outpatient basis with rapid postoperative local anesthesia metabolism and safe dose determina-
healing. Many physicians, particularly dermatologists, tions were viewed. Now it is firmly established that
perform this procedure without additional intravenous 35 mg/kg lidocaine as performed in liposuction is a
sedation entirely in an office or minor procedure room safe level and studies indicate that levels up to 55 mg/
setting rather than a surgery center. More significant kg may be tolerated safely, presuming there are no
risks with liposuction occur with larger volume aspi- contraindications such as potential drug interactions
rants in a situation associated with general or deep- or underlying hepatic insufficiency [7, 8]. Caution
sedation anesthesia in contrast to standard tumescent must be exercised when using higher doses of lido-
anesthesia liposuction. caine in the range 5055 mg/kg as cases of mild
7 Liposuction with Local Tumescent Anesthesia and Microcannula Technique 89
nausea and vomiting have been reported, although mind the 3555-mg/kg upper limit and the volumes of
the plasma lidocaine levels were below 3.5 mg/mL infiltration needed, varying concentration levels can be
[17]. Doses exceeding 55 mg/kg are associated with utilized.
a 2% incidence of mild toxicity of nausea and vomit- Determining which the concentration of anesthetic
ing and the incidence is 10% or greater if dosages fluid to infuse has been empirically determined.
above 60 mg/ml are used. The cited threshold for Recently, in a study of 3,430 patients where the only
lidocaine toxicity is 5 mg/mL, although deaths have anesthesia was the tumescent lidocaine infiltration, it
been reported in the literature at lower levels. Those was determined that 500 mg/L (0.05%) was effective
patients, however, did not solely have tumescent lipo- for all areas treated and 400 mg/L (0.04%) was effec-
suction under local anesthesia [15]. tive for most areas treated. However, in this report, oral
Tumescent anesthesia is highly effective and has sedation was occasionally given. After infiltration, 30
an extraordinary safety profile when appropriate dos- to 60 minutes was allowed before lipoaspiration was
ing is used and strict guidelines are maintained. begun. If pain occurred during aspiration, the areas
According to the textbook Tumescent Technique by were reinfiltrated with tumescent anesthesia [18].
Klein [15], tens of thousands of tumescent liposuc- Epinephrine is a potent adrenergic agent that
tion patients have received 3550 mg/kg of lidocaine acts as a vasoconstrictor that enhances hemostasis
with no known reports of deleterious effect, which and prevents rapid systemic absorption of lidocaine
has proved the safety of tumescent local anesthesia from the subcutaneous tissues. Epinephrine dosing
for liposuction. was empirically derived, with experience showing
that doses of 0.51 mg/L (which yields a final epi-
nephrine concentration of 1:1,000,0001:2,000,000)
7.2.3 Tumescent Anesthesia Formulation provided consistent vasoconstriction with a low inci-
dence of tachycardia. The addition of epinephrine to
The tumescent fluid formulated for microcannula the mixture results in prolonged local anesthetic
liposuction most often consists of a concentration of effect and permits higher lidocaine doses by slow-
0.050.1% lidocaine. A typical standard 0.1% solution ing its absorption. Furthermore, the epinephrine pro-
contains a total of 1,000 mg lidocaine, 10 mEq sodium vides a dramatic hemostasis that substantially reduces
bicarbonate, and a concentration of 1:1,000,000 blood loss. Although higher concentrations of epi-
1:2,000,000 epinephrine in 1 liter of normal saline nephrine provide more effective hemostasis, patients
solution [15]. The full-strength 0.1% solution is useful should be monitored for tachycardia and hyperten-
when treating smaller areas (neck, jowls) or when sion. Thorough preoperative evaluations should be
treating those areas which tend to be more fibrous and performed and lower concentrations of epinephrine
tender (periumbilical abdomen, back, breasts, and considered in patients with underlying medical con-
female or male flanks). However, tumescent formula- ditions such as thyroid or cardiovascular disease.
tions vary depending on the clinical circumstance. Smaller areas over multiple sessions can be per-
Different concentrations of lidocaine are chosen formed if required. Premedication with clonidine
depending on the area and volume required. For may also be helpful (described in additional detail
instance, a 0.05% lidocaine formulation may be used below) in patients who may be sensitive to epineph-
when treating more extensive areas where larger rine effects [15].
amounts of fluid are required but the maximum safe The solubility of lidocaine is enhanced in acidic
dosing is to be maintained. Alternatively, extremely solutions but these are often more painful to inject.
sensitive areas such as the periumbilical region are Buffering of lidocaine solution with sodium bicarbon-
often resistant to 0.05 and 0.1% solutions and a 0.15% ate has been shown to decrease pain [19]. Because
mixture may be required. When infusing just a neck, non-acidic solutions cause the spontaneous degrada-
higher lidocaine concentrations can be used since only tion of epinephrine, it is recommended that anesthetic
smaller volumes of total fluid are required. This con- solutions be freshly mixed on the day of surgery
trasts with the abdomen and flanks, where significantly (Table 7.1) [15]. In the authors personal experience,
larger volumes are required, making use of higher hemostasis is more problematic with tumescent mix-
concentrations potentially problematic. Keeping in tures prepared the night before surgery.
Table 7.1 Standard Sodium Normal

tumescent anesthesia Lidocaine (mg) Epinephrine (mg) bicarbonate (mEq) saline (L)
formulation
0.15% lidocaine 1500 0.51 10 1
0.1% lidocaine 1000 0.51 10 1
0.075% lidocaine 750 0.51 10 1
0.05% lidocaine 500 0.51 10 1
7.3 Calculating the Maximum 7.4 Lidocaine Metabolism

Lidocaine Dose and Toxicity
The maximum lidocaine dose must be calculated for Metabolism of lidocaine occurs through the hepatic
each patient individually on the basis of the patients cytochrome enzymes which convert the lipophilic lido-
weight, which should be obtained on the day of surgery. caine to a hydrophilic molecule that can be more read-
Because of the clinical importance, the author strongly ily eliminated. Lidocaine is metabolized rapidly with
recommends that a patient is weighed rather than 70% elimination with first pass through the liver where
depending on a stated value. As an aside, the patient the molecule undergoes oxidative N-dealkylation.
who returns months later complaining about results has Lidocaine is largely metabolized by the cytochrome
often gained weight and the value documented in the P450 3A4 (CYP3A4) enzyme. Reduction in the cyto-
chart can save the surgeon considerable time with such chrome enzymes, either through downregulation or
a patient. A dose of 3555 mg/kg should not be competitive inhibition by other medications, can reduce
exceeded. For a 160-lb man, the maximum lidocaine the clearance of lidocaine and augment the potential for
dose is calculated as follows: 160 lb/2.2 = 72.3 kg (stan- lidocaine toxicity. Alternatively, parenchymal liver dis-
dard formula 2.2 lb per kilogram). The total dose range ease or decreased hepatic blood flow can also reduce
is from (35 72.3) to (55 72.3), i.e. from 2530.5 to the rate of lidocaine clearance [7, 20, 21].
3976.5 mg of lidocaine. Medications such as ketoconazole and erythromycin
The absolute upper limit of lidocaine is 3976.5 mg can impair lidocaine metabolism by inhibiting its cyto-
in this example. Various concentrations and volumes chrome P450-mediated metabolism. A thorough under-
of tumescent fluid can be used depending on the areas standing of lidocaine metabolism and drug interactions
being treated but the total dose of lidocaine should is essential prior to performing tumescent liposuction
not exceed 3976.5 mg. Thus, with a 0.1% lidocaine to avoid possible lidocaine toxicity. A report of medica-
solution, the total volume of fluid used should be less tion-related lidocaine toxicity after tumescent liposuc-
than 4 Liters. tion was attributed to concomitant use of sertraline or
The question arises as to which patients can tolerate flurazepam via their inhibitory effects on the cyto-
more than the absolute safe limit of 35 mg/kg of chrome P450 enzymes [21]. Table 7.2 includes a list of
lidocaine. Since lidocaine is lipophilic, then it stands to some CYP3A4 inhibitors that are clinically relevant
reason that thin individuals with reduced body fat when evaluating a patient preoperatively for liposuc-
would be at increased risk with higher doses. Similarly, tion. It should be emphasized that many medications
muscular men with minimal body fat could also be at are metabolized by the CYP3A4 enzyme system and
increased risk. In contrast, patients with higher overall the table shown is only a partial list. Furthermore, some
body fat content could reasonably be expected to toler- food ingredients such as naringenin and quercetin in
ate the 55 mg/kg dosing. The surgeon must also con- grapefruit juice can also have inhibitory effects on the
sider the impact of any other medications given, cytochrome system [20]; therefore, careful preopera-
especially intravenous agents that might conflict with tive evaluation for all possible CYP3A4 interactions
the same metabolic pathways. Consideration must also must be diligently performed. Each and every medica-
be given to the patients overall health status such as tion that the patient is taking along with their dietary
those with impaired hepatic function in deciding the and health habits should be closely reviewed for possi-
appropriate maximum dose. ble cytochrome P450 interactions.
Table 7.2 Drugs with potential cytochrome P450 interactions Table 7.3 Signs of lidocaine toxicity
Acebutelol Midazolam (Versed) Lidocaine
Acetazolamide Nadolol level (mg/mL) Signs of toxicity
Alprazolam (Xanax) Naringenin (grapefruit juice) 35 Nausea, vomiting, drowsiness,
Amiodarone (Cordarone) Nefazodone (Serzone) lightheadedness
Anastrozole (Arimidex) Nelfinavir (Viracept) 58 Tinnitus, paresthesias, CNS changes,
cardiovascular toxicity
Atenolol Nevirapine (Viramune)
>8 Coma, seizures, and severe cardiac
Cannabinoids Nicardipine (Cardene)
and respiratory depression
Carbamazepine (Tegretol) Nifedipine (Procardia)
Cimetidine (Tagamet) Norfloxacin(Noroxin)
Chloramphenicol Norfluoxetine
of lidocaine should be kept at or below 35 mg/kg.
Clarithromycin (Biaxin) Omeprazole (prilosec)
The same is true for those patients with decreased
Cyclosporine (Neoral) Paroxetine (Paxil)
Danazol (Danocrine) Pentoxyfylline
hepatic perfusion due to medications or cardiovascular
Dexamethasone Pindolol disease due to possible impaired lidocaine metabolism
Diazepam (Valium) Propranalol and toxicity [7, 15].
Diltiazem (Cardizem) Propofol The issue of medication interactions is especially
Erythromycin Quinidine (Quinaglute) important when considering the choice of ancillary
Esmobolol Remacemide medications. Careful attention must be paid to possible
Felodipine (Plendil) Ritanavir (Norvir) cytochrome P450 interactions when choosing prophy-
Fluconazole (Diflucan) Saquinavir (Invirase) lactic antibiotics, analgesics, and anxiolytics. For exam-
Flurazepam (Dalmane) Sertinadole ple, benzodiazepams are frequently administered orally
Flouxetine (Prozac) Sertraline (Zoloft) prior to tumescent liposuction. While most benzodiaza-
Fluvoxamine (Luvox) Stiripentol pams are metabolized by CYP3A4, lorazepam is not
Indinavir (Crixivan) Terfenadine (Seldane) and can be safely used without altering lidocaine
Isoniazid Thyroxine metabolism [15]. Thus, many liposuction surgeons favor
Itraconazole (Sporanox) Timolol
lorazapam as an anxiolytic. Usual dosing is 0.51.0 mg
Ketoconazole (Nizoral) Triazolam (Halcion)
although dosing to 2 mg may be utilized. The only
Labetalol Troglitazone (Rezulin)
disadvantage is a relatively slower onset compared to
Methadone Troleandomycin (TAO)
diazepam. Lorazapam has the benefit of a prolonged
Metoprolol Valprolic acid
Metronidazole (Flagyl) Verapamil (Calan)
half-life and thus can be given the night before for those
Mibefradil (Posicor) Zafirlukast (Accolate) patients with prohibitive anxiety and additional dosing
Miconazole (Monistat) Zileuton (Zyflo) may not be necessary before surgery.
In addition to concomitant medication use and
underlying medical disease, there are several factors
In patients on medications that affect the cyto- that should be considered in determining the maximum
chrome enzyme system, the dose of lidocaine used safe dose of lidocaine. Both male patients and thinner
during tumescent liposuction should be maintained at patients tend to have a lower volume of distribution for
or below 35 mg/kg in the authors opinion. If possible, lidocaine in the subcutaneous compartment and may
medications with cytochrome P450 interactions should not tolerate higher doses of lidocaine. Elderly patients
be discontinued prior to surgery. Because some medi- as well may not tolerate higher doses owing to dimin-
cations which are cytochrome inhibitors have a ished liver perfusion that occurs with age [21].
prolonged half-life and are tightly bound to plasma When lidocaine is employed properly, the risk of
proteins, at least 7 days should elapse between the time lidocaine toxicity is very low with the pure tumescent
that the medication is discontinued and the surgery liposuction technique. However, all surgeons practicing
date. As previously noted, patients with a history of tumescent liposuction should be familiar with the signs
liver disease or hepatic insufficiency should also be of lidocaine toxicity that occur when serum levels
treated conservatively. Generally, these patients should exceed 5 mg/mL (Table 7.3). Treatment of lidocaine
be treated only if hepatic transaminases and liver toxicity, which is beyond the purview of this text,
enzymes are in the normal range and the total dose includes supportive measures and seizure treatment.
The author advises that all liposuction surgeons be be used to produce the same sedative, anxiolytic, and
certified in advanced cardiac life support. anterograde amnestic effects as 1020 mg diazepam.
Nausea may occur with 2 mg and often only 1 mg is
needed. The drug has a half-life of 10 h or longer and
7.5 Alternative Anesthetic Agents frequently a dose taken the night before might be all
that is needed. Alternatively, a dose of 1 mg lorazepam
Various alternative tumescent formulations have been may be administered 1 hour prior to surgery [1].
utilized, including infusion of dilute epinephrine with- Clonidine has been popularized as an effective anal-
out local anesthesia with supplemental bupivacaine gesic with mild sedative and antianxiolytic properties
after surgery [22]. However, owing to bupivacaines at a single dose of 0.1 mg orally and can be safely used
effect on the myocardium, the potential for cardiotox- unless patients have low blood pressure or slow pulse.
icity is greater and its use is not advocated [23]. Use of It is also especially useful in patients who may be bor-
prilocaine 35 mg/kg was reported in the European lit- derline with regard to tachycardia and hypertension to
erature at and it was found to be safe. Methemo- maintain a lower heart rate and blood pressure during
globinemia is a potential side effect of prilocaine, surgery. Clinical effects begin 2040 minutes after
however, and there is a paucity of data in the literature ingestion. Repeated doses should not be given.
to date on this anesthetic agents use in liposuction Clonididine is a drug underappreciated by liposuction
[24]. At this time, the use of alternative anesthetic surgeons and should be recognized as an effective sup-
agents is not well studied and their safety profiles plement for analgesia, which can help minimize the
remain unclear. Lidocaine is well documented to be need for narcotics. Furthermore, clonidine may poten-
safe and effective in tumescent liposuction and remains tiate the anesthetic effects of lidocaine and enhance the
the standard in the USA. effects of opiates [15]. The authors frequently utilize
clonidine in various office surgeries such as fraction-
ated CO2 lasers, with tissue tightening technologies,
7.6 Ancillary Pharmacology or when blepharoplasty is performed under local
anesthesia.
The material in this section is presented only as a gen- Klein also advocates the use of 0.30.4 mg of intra-
eral discussion on alternative and additional drugs. venous atropine given in a dilute mixture after intrave-
The reader should be conversant with the medications nous access has been established to prevent vasovagal
before prescribing. events when clinically needed [15]. The authors have
The decision for prophylactic and perioperative never determined atropine to be necessary.
antibiotics has no current standard. As discussed ear- Midazolam is widely used by surgeons and anes-
lier, infection rates are extremely low with the tumes- thesiologists in cosmetic surgery both before surgery
cent technique. This may be related to lidocaine acting and as part of intravenous sedation. According to
as discussed earlier a few lines above [5, 9, 10]. Klein, 3% of patients require intravenous midazolam
Clinically, the decision for antibiotics at this time is at a dose of 1 mg during infiltration to supplement oral
determined by the surgeon. The authors routinely pre- clonidine and lorazapam. Midazolam has a short dura-
scribe prophylactic broad-spectrum antibiotics initi- tion of effect after a single dose. Problems with disin-
ated orally the day prior to surgery and repeated the hibition may occur with this drug but the amnestic
morning of surgery. It is essential that the antibiotic of effect is significant and often beneficial during the
choice is not metabolized by the CYP3A4 system so as infiltration phase where discomfort may be present in
to avoid interaction with lidocaine metabolism. select patients [15]. While respiratory depression is
Lorazepam by mouth (as low as 0.5 mg but usually possible, the drug may be immediately reversed with
12 mg) should be considered as the recommended intravenous Flumazacon [25].
sedative preoperatively because it is not metabolized There is a theoretical problem with concomitant use
by the cytochrome P450 system. Other benzodiaze- of beta-blockers in conjunction with epinephrine as
pams, including diazepam, may have interactions unopposed alpha stimulation could result. However, this
with lidocaine through the CYP3A4 system and are appears to be primarily a theoretical issue. In clinical
generally avoided. Orally administered lorazepam can practice, it appears that the absorption of epinephrine
from the tissue is too slow to result in a significant prob- are extremely common. Routinely, a warmed solution
lem. This problem has not surfaced in any of the major of the tumescent formula is prepared. Warm and neutral
studies on morbidity and mortality (see subsequent por- tumescent anesthetic solutions are beneficial for reduc-
tion of this chapter). As a result, patients on beta-blocking painful injections [29]. A temperature of 3740C
ers generally continue their usual doses [17]. However, has been reported to be ideal to maximize patient com-
if a modified tumescent technique is used and general fort upon infiltration [30]. The use of a bicarbonate
anesthesia is employed, the anesthesiologist should be buffer also helps to minimize discomfort. Water baths
advised to avoid the use of propranalol, owing to the are the most accurate way of achieving consistent tem-
potential for unopposed adrenergic stimulation [26]. peratures. If a microwave is utilized to heat the solution,
Narcotics are utilized by many liposuction surgeons make sure and allow the bag to stand for several min-
[27]. They may be provided as part of intravenous utes so that the heat will equalize since some regions
sedation and anesthesia or as supplemental analgesia can be excessively hot due to uneven heating.
for surgeons utilizing the local anesthetic liposuction The tumescent fluid is infiltrated first using a
approach. The combination of meperidine and antihis- 25-gauge spinal needle to sprinkle the fluid diffusely.
tamine has a long and established usage for all types of Once a small amount of fluid has been distributed over
pain management in various outpatient clinical circum- the area to be treated, a 20-gauge spinal needle is
stances and may be provided by intravenous or intra- subsequently used to infiltrate more fluid. Finally,
muscular routes. Sometimes doses as low as 10 mg can small incisions with a no. 11? blade or a 2-mm punch
be effective in the authors experience, although dosing are made in the skin and a 14-gauge multihole infiltra-
of 50 mg may be necessary. Naloxone should always be tion cannula is inserted into the subcutaneous plane to
available when administering narcotics. Butarphanol in achieve complete tumescence. Most surgeons utilize
low doses is a safe alternative [28]. Butarphanol has the same incision ports for infiltration that are used for
minimal respiratory depression and has the advantage fat aspiration. When performed in this stepwise fash-
of not requiring special narcotic storage or ordering ion, patient comfort is maximized. Although spinal
because of its low potential for abuse. This drug is needles may help with patient comfort, some surgeons
given in 1 mg increments and the authors favor IM opt to avoid these needles and use only the blunt infil-
injection. Onset takes about 5 minutes with peak effects tration cannulas as they are potentially less traumatic.
occurring over the next 15 minutes in the authors expe- During the infiltration process, attention must be
rience. The author usually uses a single 1 mg dose and paid to maintaining the needle at approximately a
follows up with another 1 mg in about 15 min if neces- 3045 angle with respect to the horizontal plane.
sary. Few, if any, patients experience nausea, making A fanlike pattern is utilized to ensure wide distribution
this another easy-to-use medication especially when of the fluid (Fig. 7.1). The surgeon at all times should
combined with 2550 mg of hydroxyzine. Butorphenol be aware of where the end of the needle resides to
lasts about 1 hour and interestingly appears to wear off avoid injury to thoracic and intra-abdominal structures.
quite abruptly with the patient transitioning from quiet Pinching the skin while infiltrating creates a tunnel for
comfort to pain complaints. Fentanyl in a 2550-mg the cannula resulting in more control of the cannula
dose may be substituted for meperidine, although cau- tip. When the infiltration cannula is used in the final
tion must be exercised as it is metabolized by the cyto- stages, it is passed in a plane that is parallel to the hori-
chrome 3A4. In general, with intravenous dosing, zontal plane. Fluid must be delivered to all levels of
fentanyl has a relatively short duration of action and fat. Infiltrating only the more superficial fat may clini-
causes less nausea and orthostatic hypotension [15]. cally give a tumesced feel to the skin, but the deeper fat
has not been anesthetized; therefore, it is recommended
that the deeper fat be infiltrated first. The subcutaneous
7.7 Tumescent Liposuction Technique tissue can be gently grasped and lifted during the
infiltration process to ensure that the deeper fat is anes-
7.7.1 Tumescent Fluid Inltration thetized and to prevent inadvertent injury to deeper
structures (Fig. 7.2).
Various techniques for fluid infiltration have been The tumescent fluid is infiltrated under pressure.
described and individual variations among surgeons Most physicians utilize pumps where the rate can
Fig. 7.1 Fanlike pattern from multiple sites for infiltration and Fig. 7.2 Fat being grasped and lifted to infiltrate deep layers
liposuction without injuring deeper structures
be preset and a foot pedal allows on/off control.

The amount of time required for infiltration can be
reduced by increasing the rate of lidocaine infusion but
this is often accompanied by increased patient discom-
fort and may require more premedication depending
on patient tolerance [31]. Additionally, rapid infusion
may result in patchy or uneven distribution and incom-
plete anesthesia and hemostasis. Meticulous infiltra-
tion with tumescence throughout the fat results in less
than 1% blood loss per liter of aspirate, whereas rapid
infiltration results in 7% blood loss per liter aspirated
(Fig. 7.3) [15]. It has been shown that serum levels of
lidocaine are not affected by the pressure or the rate of
Fig. 7.3 Fat aspiration in multiple planes with a fanlike pattern
infusion [32, 33]. Alternative methods include hanging
an intravenous bag with a pressure cuff. The surgeon
must monitor both the total volume infiltrated and the Hydrodissection with to tumescent fluid helps main-
total lidocaine dose carefully during the infiltration tain patient comfort in that the infiltration cannula is
process. To avoid errors, the authors label each IV bag not pushed through the tissue so much as the fluid is
and do not discard them until the case is completed. utilized to open the tissue beyond the cannula tip.
Infiltration is continued until the tissue has become Properly performed infiltration is slow and steady,
fully tumesced. The infiltrated areas have a firm, edem- allowing the cannula to slip between fibrous septa
atous quality to palpation. The skin is characterized by smoothly rather than imposing excessive traction as it
pallor and is slightly cool owing to the vasoconstrictive is pushed through resistant tissue.
effects of the tumescence. A peau dorange appearance The volume infiltrated is the minimal amount to
is undesirable and should be avoided. achieve complete local anesthesia. Empirically it is
usually on the order of 2:1 or 3:1 (fluid infiltrated to those areas of denser fat accumulations where more fat
expected volume of aspirated fat) [15]. Maximum is to be removed as well as those areas where less fat is
tumescence is not required for complete anesthesia or present. The markings should also designate the edges
vascular stabilization, and excess volumes should be of the region being treated where feathering will occur
avoided as it results in a more difficult liposuction. for optimal blending and cosmetic outcome [15].
Certain areas are typically more uncomfortable to After infiltration of the tumescent fluid, the surgeon
infiltrate. Generally, these are the more fibrous loca- should wait approximately 1530 minutes to allow the
tions such as the periumbilical region. Aspirating near tumescent fluid to reach maximum effect. As patients
scars such as abdominal scars can also be uncomfort- generally are awake during the tumescent liposuction
able, such as abdominal surgical scars. The authors procedure, they can be positioned precisely to allow
recommend infiltrating parallel to the scar on both for optimal liposuction.
sides and underneath before trying to dissect the fibrous Initially, smaller-diameter cannulas can be used to
underlying tissue. In the authors experience, the act of penetrate the subcutaneous tissue and create tunnels
infiltrating the tissue informs the surgeon of the rela- through which larger cannulas can be passed. Through
tive difficulty of the liposuction and also increases this method, intraoperative comfort will be maximized
awareness of borderline areas of the field such as under [27]. The cannula is generally passed through the same
the ribs. The surgeon can spend extra time infiltrating incisions used for infiltration of the tumescent fluid.
difficult areas to reduce any problems during the These entry points are strategically placed to be mini-
remainder of the procedure. mally visible after the patient has fully recovered.
Multiple entry points may be required to access the
entire area to be treated. Entry sites should be ran-
7.8 Microcannulas and Lipoaspiration domly placed without symmetry within any given area
that is being treated. This will ultimately produce the
The tumescent liposuction technique is nicely comple- most inconspicuous results.
mented by the use of microcannulas. These cannulas The fat is removed in layers, starting first with the
are designed to have a narrow diameter and may have deepest layers. The skin is lifted with the non-dominant
multiple apertures or only one or two holes. They vary hand to create a tunnel of tissue through which the can-
in length, so both large and small areas can be effec- nula is passed. A fanning pattern is used to remove an
tively treated and proximal and distal areas can be entire plane of fat. This fanning pattern can be repeated
reached from a single incision site. Microcannulas offer in different planes, starting in the deep subcutaneous fat
a number of advantages. First, owing to the small diam- and moving more superficially (Fig. 7.3) [15]. The end
eter, they are generally less painful as they penetrate point with tumescent liposuction is somewhat different
through the subcutaneous tissue. Additionally, the from that of non-tumescent techniques in that there is
smaller-diameter cannulas often pass more easily still fluid in the tissue after the appropriate amount of
through fibrous tissue, which is especially advanta- fat has been aspirated. Determining the end point is a
geous in specific areas such as the upper abdomen, matter of surgical experience and depends on tissue
back, and breasts. Generally, the microcannulas remove palpation and visual configuration.
small amounts of fat with each stroke. This allows for
gradual and precise removal of fat to prevent textural
irregularities and depressions and facilitates the art of 7.9 Postoperative Care: Open Drainage
sculpting. Although slower than larger cannulas, micro- and Compression
cannulas can ultimately be just as aggressive in remov-
ing large volumes of adipose tissue. Cannula size and The postoperative course following tumescent liposuc-
type is a matter of each surgeons individual preference tion is generally rapid and comfortable. However,
and a variety of cannulas can be used effectively patients must be well informed as significant edema,
depending on the surgeons experience and skill. purpura, and fluid drainage can occur. Furthermore,
Before beginning infiltration, the areas to be treated the drainage may be blood tinged and alarming to the
should be marked in a topographical fashion while the unprepared patient. The entry sites through which the
patient is standing. These markings should indicate liposuction is performed are not closed. Rather, they
remain open and serve as drainage points through essential, however, to make sure that larger vessels
which the tumescent fluid can flow resulting from a are not transected by the smaller-diameter cannulas
combination of compression and gravitational forces. which are potentially more traumatic than larger-
Open drainage can continue for up to 34 days and diameter cannulas [15]. As discussed earlier, there is a
appropriate absorbent dressings are required [15]. low rate of postoperative infection possibly owing to
Immediately after the procedure is completed, antibacterial properties of lidocaine [9, 10]. Periopera-
highly absorbent pads are applied. The pads are applied tive prophylactic antibiotic use may also help to mini-
under compressive elastic garments and left in place mize infection rates. Scarring is generally minimal
for 24 hours. They should be replaced as needed if they if microcannulas and small entry points are used.
become soaked and should be utilized until drainage Reduced scarring is a major advantage of the micro-
ceases. After the drainage has discontinued, the dress- cannula technique, but patients must still be warned of
ing should be changed to a mildly compressive support possible pigmentary alteration and even hypertrophic
garment. This dressing provides support and can help scarring in prone individuals. Patients should also be
to contour the skin as it retracts during the weeks fol- advised that persistent numbness or dysesthesia may
lowing liposuction. Heavy compression during this occur in treated areas, although this is usually not
period is unnecessary and may be counterproductive permanent [15, 35].
by impeding lymphatic drainage. Klein [34] has Textural irregularities, rippling, and dimpling are
described this two-phased postoperative compression complications associated with liposuction that are
system as bimodal compression. greatly minimized with the tumescent microcannula
Rapid return to normal function with tumescent technique. Because small volumes of fat are removed
liposuction can be dramatic. In general, for abdomen with each stroke, the fat can be removed in thin layers
and flanks, most patients prefer a few days of rest and to achieve a gradual and uniform reduction in the sub-
typically return to work 4 or 5 days after surgery. cutaneous layer. This allows for sculpting the tissue
However, with tumescent liposuction many patients with uniformity giving a smooth, even result.
rebound quickly and we have had patients leave on Some complications unique to or more pronounced
vacation the next day or return to work within a day or with the tumescent technique relate to the large vol-
two. This is because of the less traumatic nature of umes of lidocaine-containing fluid that are infiltrated.
tumescent liposuction under local anesthesia owing to Significant ecchymoses and edema can occur espe-
techniques of infiltration and use of microcannulas. cially in the scrotal/labial areas or the distal upper and
Skin retraction during the postoperative period occurs lower extremities. When performing liposuction of the
over several weeks (Fig. 7.4). Some postoperative edema abdomen, thighs, arms, or distal lower extremities,
in the treated fields may persist for a few weeks. Patients patients should be forewarned that this is normal for
need to be reassured that the final cosmetic outcome the postoperative course. Gradual resolution of the
will not be apparent for at least 2 months after the pro- purpura and edema occurs over several days following
cedure. Occasionally, touch-up procedures can be per- the procedure [15, 3436].
formed if needed but waiting at least 23 months or In some patients, seromas may form and larger
longer after the initial procedure is prudent. patients with a pannus where fluid can collect are at an
increased risk for this complication. Small seromas
generally spontaneously resolve but larger seromas
7.10 Complications may require aspiration of the fluid with a 20-gauge
needle [15, 36].
As with any surgical procedure, inherent risks and Skin ulceration secondary to necrosis is a rare com-
potential complications exist with tumescent liposuc- plication and can occur from excessive injury to the der-
tion. The advantage of the tumescent microcannula mis. Care must be taken to avoid superficial liposuction
liposuction technique is that the potential risks of in the dermis which can compromise the dermal and
liposuction are minimized. Given the excellent hemo- epidermal vascular supply. With the proper liposuction
stasis provided by the epinephrine in the tumescent technique, a superficial layer of fat should be left intact
fluid, the risk of postoperative bleeding is very low. and the dermis should be free from injury, thereby avoid-
Thorough knowledge of the underlying anatomy is ing the risk of skin ulceration and necrosis [15].
Fig. 7.4 Liposuction of lateral thighs and hips: (a) Preoperative; (b) postoperative
7.11 Safety of Tumescent Liposuction Surgery (ASDS) guidelines is considered very safe
and should be differentiated from more aggressive
A 1999 article detailing five deaths involved patients liposuction methods [1, 4244]. The ASDS data base
with systemic anesthesia, either intravenous sedation of over 300,000 procedures from 1995 to 2000 per-
or general anesthesia [37]. None of the patients had formed according to ASDS guidelines demonstrates
evidence of lidocaine toxicity. One developed abrupt no deaths [1].
EKG and physiologic changes within 30 seconds of Similarly, a 1988 survey encompassing 9,478 tumes-
being rotated from the prone to the supine position, cent liposuction procedures performed by dermatologists
which may have been related to severe hypotension without intravenous sedation documented no fatalities
that can develop with combinations of droperidol and [45]. A 1995 survey of 15,336 tumescent procedures as
fentanyl [38]. None of these patients had true tumes- performed by dermatologists showed no fatalities [12].
cent liposuction in that the tumescent fluid was not A 1999 analysis of malpractice claims from 1995 to
used as the main source of pain control. Three patients 1997 showed that dermatologists performing liposuc-
succumbed to intraoperative hypotension of unknown tion in the office had fewer malpractice claims than
cause; one from pulmonary thromboembolism and one plastic surgeons performing liposuction in the hospi-
from fluid overload. Only one patient had an elevated tal. The conclusion was attributed to the use of the
lidocaine level of 5.2 but this was after resuscitative tumescent liposuction technique and the smaller vol-
efforts. The author concluded that two of the cases umes of fat removed by dermatologic surgeons [46].
may have been caused by lidocaine toxicity, but this A more recent study published in 2009 assessed the
does not appear to be supported by the data [13]. safety of liposuction exclusively with tumescent anes-
In 2000, Coldiron [39, 40] reviewed reports of deaths thesia in 3,240 consecutive cases in which there were
in Florida and concluded that specific details were lack- no deaths and no hospitalizations. The nine minor
ing and that the complications were not specific to an complications encountered were liposuction related
office setting or involved tumescent liposuction. and unrelated to anesthesia or lidocaine [49].
The association with systemic anesthesia was seen Fatality risk factors with liposuction may include
95 liposuction deaths in a study of plastic surgeons general or intravenous sedation, multiple surgeries per-
[41]. The survey of 1,200 plastic surgeons performing formed concurrently, removal of large volumes of fat
a total of 496,245 procedures demonstrated a mortality during one procedure, inpatient setting, administration
of 1 in 5,224 procedures, which was computed to a rate of toxic doses of lidocaine combined with general/intra-
of 19.1 per 100,000; 47.7% occurred after office-based venous anesthesia, and intravenous fluid overload [47].
surgery and 16.9% after hospital-based surgery. The Dermatologists commonly rely on tumescent anes-
primary cause of death was thromboembolism in thesia as the primary pain management method during
23.4% of cases. None of the patients succumbed to liposuction. When intravenous or general anesthesia
lidocaine toxicity. is added, a variety of drugs that are metabolized by the
A survey of dermatologists was performed looking same cytochrome enzymes or reduce hepatic blood
at complications occurring from 1994 through 2000. flow may be utilized resulting in diminished lidocaine
Data were obtained on a total of 66,570 liposuction metabolism. Further, the subcutaneous tissue may be
procedures. No deaths occurred and the serious underinfused, which means the tissue may not be
adverse-event rate was 0.68% [13]. In this review, fully tumesced. It is thought that full tumescence pro-
procedures had been performed in non-accredited tects blood vessels in the fibrous septae by compres-
office settings, ambulatory surgical centers, and hospi- sion making liposuction less traumatic. Intravenous
tals. Adverse event rates were higher for tumescent sedation and general anesthesia are more frequent
technique liposuction combined with intravenous or when larger-volume liposuction is planned or in con-
intramuscular sedation than for tumescent technique junction with other cosmetic procedures. The
liposuction combined with oral or no sedation. Of the combination of multiple forms of anesthesia and the
45 adverse events recorded, only one is listed as combination of drug effects and large-volume lipo-
lidocaine toxicity. The conclusion was that tumescent suction may be the cause of the mortalities [41].
liposuction performed by dermatologic surgeons is One issue of concern is deep venous thrombosis
safe in an office setting [13]. leading to pulmonary embolism subsequent to liposuc-
Other studies have found that tumescent liposuction tion and its relationship to hormonal therapy.
as performed per the American Society of Dermatologic Butterwick [48] indicates that the incidence of deep
venous thrombosis with true tumescent liposuction 4. Flynn TC, Coleman WP, Field L, Klein JA, Hanke CW
(2000) History of liposuction. Dermatol Surg 26(6):
without general anesthesia or deep intravenous seda-
515520
tion appears no greater than the general incidence in 5. Klein JA (1993) Tumescent technique for local anesthesia
women on oral contraceptive or hormone replacement. improves safety in large-volume liposuction. Plast Reconstr
The conclusion is that these medications need not be Surg 92(6):10851095
6. Ilouz YG (1996) History and current concepts of lipoplasty.
discontinued prior to surgery unless additional risk
Clin Plast Surg 23(4):721730
factors are present, such as estrogen content greater 7. Klein JA (1990) Tumescent technique for regional anesthe-
than 35 mg/day. One additional recommendation is sia permits lidocaine doses of 35 mg/kg for liposuction.
proper fitting of postoperative garments to avoid con- J Dermatol Surg Oncol 16(3):248263
8. Ostad A, Kageyama N, Moy RL (1996) Tumescent anesthe-
stricting venous return and making sure women ambu-
sia with a lidocaine dose of 55 mg/kg is safe for liposuction.
late postoperatively. Graduated support hose were Dermatol Surg 22(11):921927
recommended for women with increased risk factors 9. Parr AM, Zoutman DE, Davidson JS (1999) Antimicrobial
of deep venous thrombosis [48]. activity of lidocaine against bacteria associated with noso-
comial wound infection. Ann Plast Surg 43(3):239245
10. Miller MA, Shelley WB (1985) Antibacterial properties of
lidocaine on bacteria isolated from dermal lesions. Arch
7.12 Guidelines for Maximum Volumes Dermatol 121(9):11571159
of Lipoaspiration 11. Craig SB, Concannon MJ, McDonald GA, Puckett CL
(1999) The antibacterial effects of tumescent liposuction
fluid. Plast Reconstr Surg 103(2):666670
Guidelines for safety establishing the maximum vol- 12. Hanke C, Bernstein G, Bullock S (1995) Safety of tumes-
ume of aspirate have been set by the American cent liposuction in 15,336 patients: National survey results.
Academy of Dermatology as 4,500 mL of fat and by Dermatol Surg 21(5):459462
13. Housman TS, Lawrence N, Mellen BG, George MN,
the ASDS as 5,000 mL of total fluid/fat [1, 36]. The
Filippo JS, Cerveny KA, DeMarco M, Feldman SR,
authors remove no more than 45 Liters of fat during Fleischer AB (2002) The safety of liposuction: results of a
each session. If patients have several areas requiring national survey. Dermatol Surg 28(11):971978
treatment, multiple sessions must be planned. Safety 14. Thompson KD, Welykyj S, Massa MC (1993) Antibacterial
activity of lidocaine in combination with a bicarbonate
of the tumescent liposuction technique is maximized
buffer. J Dermatol Surg Oncol 19(3):216220
when it is performed in compliance with these 15. Klein JA (2000) Tumescent technique: tumescent anesthesia
guidelines. and microcannular liposuction. Mosby, St Louis
16. Lillis PJ (1988) Liposuction surgery under local anesthesia:
limited blood loss and minimal lidocaine absorption.
J Dermatol Surg Oncol 14(10):11451148
7.13 Conclusions 17. Klein JA (1999) Anesthetic formulations of tumescent solu-
tions. Dermatol Clin 17(4):751759
Tumescent liposuction under local anesthesia with 18. Habbema L (2010) Efficacy of tumescent local anesthesia
with variable lidocaine concentration in 3430 consecutive
the microcannula technique allows for very safe and
cases of liposuction. J Am Acad Dermatol 62(6):988994
effective body sculpting and fat reduction entirely 19. Colaric KB, Overton DT, Moore K (1998) Pain reduction in
under local anesthesia. Thorough understanding of the lidocaine administration through buffering and warming.
pharmacology of lidocaine and implementation of the Am J Emerg Med 16(4):353356
20. Singer M, Shapiro LE, Shear NH (1997) Cytochrome
infiltration and aspiration guidelines and techniques
p4503A: interactions with dermatologic therapies. J Am
associated with tumescent microcannula liposuction Acad Dermatol 37(5 Pt 1):765771
are essential to achieve optimal outcomes. 21. Klein JA, Kassarjdian N (1997) Lidocaine toxicity with
tumescent liposuction. Dermatol Surg 23(12):11691174
22. Rohrich RJ, Beran SJ, Fodor FB (1997) The role of subcuta-
neous infiltration in suction assisted lipoplasty: a review.
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31. Hanke CW, Coleman WP, Lillis PJ, Narins RS, Buening JA, 43. Coleman WP, Hanke CW, Glogau RG (2000) Does the
Rosemark J, Guillotte R, Lusk K, Jacobs R, Coleman WP specialty of the physician affect fatality rates in liposuction?
(1997) Infusion rates and levels of premedication in tumes- A comparison of specialty specific data. Dermatol Surg
cent liposuction. Dermatol Surg 23(12):11311134 26(7):611615
32. Butterwick K, Goldman MP, Sriprachya-Anunt S (1999) 44. Scarborough D, Bisaccia E (2001) Patient safety in the out-
Lidocaine levels during the first two hours of infiltration of patient surgical setting. Cosmet Dermatol 14:10
dilute anesthetic solution for tumescent liposuction: rapid 45. Bernstein G, Hanke CS (1988) Safety of liposuction:
versus slow delivery. Dermatol Surg 25(9):681685 a review of 9478 cases performed by dermatologists.
33. Rubin JP, Bierman C, Rosow CE (1999) The tumescent J Dermatol Surg Oncol 14(10):11121114
technique: the effect of high tissue pressure and dilute epi- 46. Coleman WP 3rd, Hanke CW, Lillis P, Bernstein G, Narins R
nephrine on absorption of lidocaine. Plast Reconstr Surg (1999) Does the location of the surgery or the specialty of the
103(3):990996 physician affect malpractice claims in liposuction? Dermatol
34. Klein JA (1999) Post-tumescent liposuction care: open drain- Surg 25(5):343347
age and bimodal compression. Dermatol Clin 17(4):881889 47. Hanke CW, Coleman WP 3rd (1999) Morbidity and mortal-
35. Rostan EF, Madani S, Clark RE (1998) Tumescent liposuc- ity related to liposuction. Questions and answers. Dermatol
tion: fat removal for medical and cosmetic purposes. N C Clin 17(4):899902
Med J 59(4):244247 48. Butterwick KJ (2002) Should dermatologic surgeons dis-
36. Lawrence N, Clark RE, Flynn TC, Coleman WP (2000) continue hormonal therapy prior to tumescent liposuction?
American Society for Dermatologic Surgery Guidelines of Dermatol Surg 28(12):11841187
Care for Liposuction. Dermatol Surg 26(3):265269 49. Habbema L (2009) Safety of liposuction using exclusively
37. Rao RB, Ely SF, Hoffman RS (1999) Deaths related to tumescent local anesthesia in 3240 consecutive cases.
liposuction. N Engl J Med 340(19):14711475 Dermatol Surg 35(11):17281735
Tumescent Technique
8
Melvin A. Shiffman
8.1 Introduction 2. For local tumescent anesthesia:

(a) Normal saline 1,000 mL
In the early days of liposuction, the dry technique was (b) Epinephrine 1 mg
used with general anesthesia. The technique used had no (c) Lidocaine 1,000 mg
fluids injected into the tissues, except perhaps local anes- The amount of tumescent solution compared to
thesia, and resulted in 2045% blood loss [16]. Liposuct- removal of aspirate was 1:1.
ion was limited to 2,0003,000 mL because of the blood Klein, in 1990 [16], showed that 35 mg/kg was a safe
loss, and patients were frequently given transfusions [2]. amount of lidocaine to use for local tumescent anesthe-
The wet technique relies on infusions of 100300 mL sia. The solution utilized at that time consisted of:
of normal saline into each site but has blood loss of 1. Normal saline 1,000 mL
1530% [711]. With epinephrine added to the fluid, 2. Epinephrine 1 mg
the blood loss is reduced to 2025%. 3. Lidocaine 500 mg
The tumescent technique has improved the problem 4. Sodium bicarbonate 12.5 mEq
of blood loss, reducing it to 17.8% [12, 13]. The term Klein, in 1993 [12], had changed the local tumes-
superwet anesthesia has been used to describe the cent anesthesia solution to:
same fluid injection as with the tumescent technique 1. Normal saline 1,000 mL
[14]. This technique consists of an infusion of saline 2. Epinephrine 0.50.75 mg
with epinephrine and lidocaine and an aspirate removal 3. Lidocaine 5001,000 mg
of approximately 1:1. Local tumescent anesthesia 4. Sodium bicarbonate 10 mEq
usually has a fluid infusion to aspirate of 2:1 or 3:1. 5. Triamcinolone 10 mg (optional)
The mean tumescent solution compared to total
aspirate was 4,609 mL:2,657 mL or almost 2:1.
8.2 Local Tumescent Anesthesia By 1995, Klein [17] had changed the tumescent
formula to:
Klein reported the use of local tumescent anesthesia in 1. Normal saline 1,000 mL
1987 [15]. The report described solutions used that 2. Epinephrine 0.50.65 mg
consisted of: 3. Lidocaine 5001,000 mg
1. For general anesthesia: 4. Sodium bicarbonate 10 mEq
(a) Normal saline 1,000 mL 5. Triamcinolone 10 mg
(b) Epinephrine 1 mg In 2000, Klein [18] described a variation of drugs in
the local tumescent solution according to the area
being liposuctioned. The basic solution to be changed
M.A. Shiffman
after checking for anesthesia completeness was:
Chair, Section of surgery Newport Specialty Hospital,
Tustin, CA, USA 1. Normal saline 1,000 mL
e-mail: [email protected] 2. Lidocaine 500 mg

102 M.A. Shiffman
3. Epinephrine 0.5 mg 1,000 mL normal saline and 1 mg epinephrine in

4. Sodium bicarbonate 19 mEq patients having general anesthesia or peridural regional
If the anesthesia was not adequate, then a variety of block (with lidocaine). The volume of tumescent fluid
formulations were proposed for each area of the body to extracted fluid was 1:1.
areas and ranged from lidocaine of 7501,500 mg, epi- In the facial area, the total lidocaine should proba-
nephrine from 0.5 to 1.5 mg [12, 1426], and sodium bly not exceed 7 mg/kg early in the injection since
bicarbonate of 10 mEq. absorption of the lidocaine peaks in 515 min until the
Local tumescent anesthesia is used as the anesthetic epinephrine takes effect at 15 min. The face is highly
for performing liposuction, especially with small vascular, and epinephrine takes 15 min to cause ade-
cannulas. The same fluid can be used with conscious quate vasoconstriction. There is a second peak of lido-
sedation to provide the necessary local anesthesia. caine in 8 to 14 h. Lidocaine in facial tumescence can
exceed a total of 490 mg in a 70-kg patient if infused
slowly. The more rapid the infusion, the lower the
8.3 Tumescent Technique blood level of lidocaine will need to be to result in
toxicity.
Compared to local tumescent anesthesia, the tumescent
technique is used to diminish blood loss and bruising,
provide fluid replacement, and act as a local anesthetic 8.4 Discussion
after surgery. The tumescent technique is used with con-
scious or deep sedation or general anesthesia. The solu- Most patients in the authors practice prefer not to be
tion utilized is a variation on local tumescent anesthesia awake during the liposuction procedure. They are
with the main elements being the fluid, either normal frightened and anxious and have heard things from
saline or lactated Ringers (1,000 mL), and epinephrine friends or over the internet about the gross methods
1 mg for vasoconstriction. There is some use for the used in liposuction. Watching or hearing the sounds
inclusion of lidocaine but not at the levels necessary for (machines and talking) with the liposuction procedure
local tumescent anesthesia. The expected tumescent is abhorrent to some patients. Just the thought of the
fluid to total aspirate is usually 1:1. slightest discomfort during the procedure is enough for
The authors formula for the tumescent technique some patients to prefer general anesthesia or deep
with general anesthesia or deep sedation consists of: sedation. There have been instances of surgeons per-
1. Lactated Ringers 1,000 mL forming liposuction with local tumescent anesthesia
2. Epinephrine 1 mg where the patient has complained about pain and the
3. Lidocaine 250 mg surgeon would not reinject tumescent fluid or avoid the
Sodium bicarbonate, 12.5 mEq, is added and lido- painful area since the procedure is almost done.
caine increased to 350 mg if local tumescent anesthe- The use of the tumescent technique combined with
sia with or without conscious sedation is utilized. low vacuum [28] has resulted in minimal blood loss,
The total aspiration, except for rare cases, does not better patient satisfaction with the results of liposuc-
exceed 5,000 mL. Tumescent fluid, with 250 mg lido- tion, and less bruising. The idea is to fill the areas to be
caine in 1,000 mL, having a total of 5,000 mL admin- liposuctioned with enough fluid to swell the tissues but
istered gives a total of 1,250 mg lidocaine, which is not cause blanching. Injection of fluid begins with
well under 35 mg/kg in most patients. This allows tunnels in the deep subcutaneous tissues and ends in
5,000 mL total aspirate (1:1), and in a 70-kg (150 lbs) tunnels in the superficial fat. Total aspirate usually
patient, the lidocaine infused is 17.9 mg/kg. In con- approximates the amount of infusate without con-
trast, local tumescent anesthesia using 500 mg lido- sciously attempting to get them equal.
caine per liter in a 70-kg patient requires 7,000 mL of Liposuction is stopped in any tunnel that produces
tumescent fluid to obtain 3,500 mL total aspirate (2:1), blood. It is possible to infuse more tumescent fluid
and the total lidocaine is 3,500 mg or 50 mg/kg. if the preliminary results are not satisfactory to the
Cardenas-Camarena [27] reported the use of the surgeon, blood is beginning to appear in some of the
tumescent technique with the fluid consisting of tunnels, and more liposuction is required.
8 Tumescent Technique 103
References 15. Klein JA (1987) The tumescent technique for lipo-suction.

Am J Cosm Surg 4(4):263267
16. Klein JA (1990) Tumescent technique for regional anesthe-
1. Dillerud E (1991) Suction lipoplasty: a report on complica-
sia permits lidocaine doses of 35 mg/kg for liposuction.
tions, undesired results, and patient satisfaction based on
3511 procedures. Plast Reconstr Surg 88(2):239246
17. Klein JA (1995) Tumescent technique chronicles: local
2. Courtiss EH, Choucair RJ, Donelan MB (1992) Large-
anesthesia, liposuction, and beyond. Dermatol Surg 21:
volume suction lipectomy: an analysis of 108 patients. Plast
449557
Reconstr Surg 89(6):10681079
18. Klein JA (2000) Tumescent formulation. In: Klein JA (ed)
3. Ersek RA (1990) Severe and mortal complications.
Tumescent technique: tumescent anesthesia & microcannu-
In: Hetter GP (ed) Lipoplasty: the theory and practice of
lar liposuction. Mosby, St. Louis, pp 187195
blunt suction lipectomy, 2nd edn. Little, Brown, Boston, pp
19. Greco RJ (1997) Massive liposuction in the moderately obese
223225
patient: a preliminary study. Aesthet Surg J 17(2):8790
4. Drake LA, Ceilley RI, Cornelison RL, Dobes WL, Dorner W,
20. Hanke CW, Bernstein G, Bullock S (1995) Safety of
Goltz RW, Lewis CW, Salasche SJ, Chanco Turner ML,
tumescent liposuction in 15,336 patients. Dermatol Surg
Alt TH et al (1991) Committee on Guidelines of Care for
21:459462
Liposuction. J Am Acad Dermatol 24:489494
21. Kaplan B, Moy RL (1996) Comparison of room temperature
5. Hetter GP (1989) Blood and fluid replacement for lipoplasty
and warmed local anesthetic solution for tumescent liposuc-
procedures. Clin Plast Surg 16(2):245248
tion: a randomized double-blind study. Dermatol Surg 22:
6. Courtiss EH, Kanter MA, Kanter WR, Ransil BJ (1991)
707709
The effect of epinephrine on blood loss during suction
22. Lillis PJ (1990) Tumescent technique for liposuction surgery.
lipectomy. Plast Reconstr Surg 88(5):801803
Dermatol Clin 8(3):439449
7. Goodpasture JC, Bunkis J (1986) Quantitative analysis of
23. Narins RS, Coleman WP (1997) Minimizing pain for lipo-
blood and fat in suction lipectomy aspirates. Plast Reconstr
suction anesthesia. Dermatol Surg 23:11371140
Surg 78(6):765772
24. Ostad A, Kageyama N, Moy RL (1993) Tumescent anesthe-
8. Gargan TJ, Courtiss EH (1984) The risks of suction lipec-
sia with a lidocaine dose of 55 mg/kg is safe for liposuction.
tomy: their prevention and treatment. Clin Plast Surg 11(3):
Aesthet Plast Surg 17:205209
457463
25. Samdal F, Amland PF, Bugge JF (1994) Plasma lidocaine
9. Clayton DN, Clayton JN, Lindley TS, Clayton JL (1989)
levels during suction-assisted lipectomy using large doses of
Large volume lipoplasty. Clin Plast Surg 16(2):305312
dilute lidocaine with epinephrine. Plast Reconstr Surg
10. Dolsky RL (1990) Blood loss during liposuction. Dermatol
93(6):12171223
Clin 8(3):463468
26. Toledo LS (1991) Syringe liposculpture: a two-year experi-
11. Hetter GP (1990) Blood and fluid replacement. In: Hetter
ence. Aesthet Plast Surg 15:321326
GP (ed) Lipoplasty: the theory and practice of blunt suction
27. Cardenas-Camarena L, Tobar-Losada A, Lacouture AM
lipectomy, 2nd edn. Little, Brown, Boston, pp 191195
(1999) Large-volume circumferential liposuction with
12. Klein JA (1993) Tumescent technique for local anesthesia
tumescent technique: a sure and viable procedure. Plast
improves safety in large-volume liposuction. Plast Reconstr
Surg 92(6):10851098
28. Elam MV, Packer D, Schwab J (1997) Reduced negative
13. Pitman GH (1996) Tumescent liposuction: operative tech-
pressure liposuction (RNPL): Could less be more? Int J
nique. Oper Tech Plast Reconstr Surg 3(2):8893
Aesthet Restor Surg 3(2):101104
14. Matarasso A (1997) Superwet anesthesia defines large-
volume liposuction. Aesthet Surg J 17(6):358364
Anesthesia for Aesthetic Surgery
9
Gary Dean Bennett
Dedication
To my mother, Mary Ellen Bennett (19172009), whose enduring love, support, and
encouragement know no boundaries.
9.1 Introduction Regulatory agencies such as American Association

of Accreditation of Ambulatory Surgery (AAAASF)
Nearly 75% of all elective surgery is performed in an and Accreditation Association for Ambulatory Health
outpatient setting [1]. As much as 25% of all outpa- Care (AAAHC) have helped establish minimum stan-
tient surgeries are performed in physicians offices [2]. dards of care for surgical locations where anesthe-
More than 50% of aesthetic plastic surgeons perform sia is administered. Ambulatory anesthesia has even
most of their procedures in an office setting [3]. Clearly, become a formal subspecialty of anesthesia with the
economic considerations play a major role in the shift establishment of the Society of Ambulatory Anesthesia
to ambulatory surgery. Because of greater efficiency, (SAMBA) in 1984. An evaluation of 1.1 million outpa-
these outpatient surgical units have greater cost-effec- tients revealed that the mortality rate after ambulatory
tiveness [4]. Also, these outpatient settings allow the anesthesia was 1.5 per 100,000 cases [7]. No deaths
patient more convenient access to medical treatment occurred in 319,000 patients who were monitored in
and provide a greater degree of privacy to the patient, accordance with ASA standards [8, 9].
particularly when aesthetic procedures are performed. As a consequence of the shift away from hospital-
Advances of monitoring capabilities and the adoption based surgery, the surgeon has adopted a more impor-
of monitoring standards of the American Society of tant role in the medical decision making with respect
Anesthesiologists (ASA) are credited for a reduction to anesthesia. Frequently, the surgeon decides on the
of perioperative morbidity and mortality [5]. Advances location of surgery, the extent of the preoperative eval-
in pharmacology have resulted in a greater diversity of uation, the type of anesthesia to be administered, the
anesthetic agents with rapid onset, shorter duration of personnel to be involved in the care and monitoring of
action, and reduced morbidity [6]. The advent of mini- the patient, the postoperative pain management, and
mally invasive procedures has further reduced the need the discharge criteria used. Therefore, it is incumbent
for hospital-based surgeries. upon the surgeon to understand current standards of
anesthesia practice. If the surgeon chooses to assume
the role of the anesthesiologist, then he or she must
adhere to the same standards that are applied to the
G.D. Bennett
anesthesiologist. While the morbidity and mortality of
Department of Anesthesiology, Chapman Medical Center,
Orange, CA, USA anesthesia have decreased [10, 11], risk awareness of
e-mail: [email protected] anesthesia and surgery must not be relaxed.

106 G.D. Bennett
9.2 The Surgical Facility preserving protective reflexes (LPPRs), then, accord-
ing to the law in some states of the USA, the surgical
The surgeon is largely responsible for deciding which facility must be accredited by one of the regulatory
facility the procedure is to be performed. Surgical agencies (AAAASF, AAAHC, or the JCAHO) [19, 20].
facilities may be divided into five main categories: However, many states in the USA currently do not
1. Hospital-based inpatient have regulations pertaining to office-based proce-
2. Hospital-associated ambulatory surgical units dures. Regardless of which type of facility is selected
3. Freestanding surgical center with short-stay or the type of anesthesia planned, the standard of care
accommodations should be equivalent to the standards set for hospitals
4. Freestanding surgical centers without short-stay [21]. Practice guidelines that specifically pertain to
accommodations office-based procedures have been developed by the
5. Office-based operating rooms ASA and the American Society of Plastic Surgeons
Each of these choices has distinct advantages [2224]. The American Society for Aesthetic Plastic
and disadvantages. While convenient, economical, and Surgery has decreed that its members only operate in
private, office-based surgery is associated with up to office-based settings that have been accredited by any
four times the mortality as surgeries performed at cer- one of the three accrediting agencies.
tified freestanding ambulatory surgical centers [12]. The operating room must be equipped with the type
Moreover, the types of complications that occur with of monitors required to fulfill monitoring standards
surgeries in office-based settings are more severe than established by the ASA [25], as well as proper resuscita-
those that occur in the certified ambulatory surgical tive equipment and resuscitative medications [26, 27].
centers. Domino reported that 21% of the complica- The facility must be staffed by individuals with the
tions that occurred as a result of procedures performed training and expertise required to assist in the care of
in certified ambulatory surgical centers were fatal, the patient [27, 28]. Emergency protocols must be estab-
whereas 64% of the adverse outcomes that resulted lished and rehearsed [29]. Optimally, the surgical facil-
from procedures performed in office-based settings ity must have ready access to a laboratory in the event a
were fatal. Forty-six percent of the complications that stat laboratory analysis is required. Finally, a transfer
occurred in the office-based settings were considered agreement with a hospital must be established in the
to be avoidable, while only 13% of the complications event that an unplanned admission is required [26, 27].
were considered avoidable in the certified ambulatory
surgical centers [13].
Grazer and de Jong [14] evaluated data of a survey 9.2.1 Personnel
of 1,200 aesthetic surgeons pertaining to liposuc-
tions performed between 1994 and 1998. Of 496,245 One of the most critical elements of a successful sur-
procedures, 95 deaths were documented. Forty-six gical outcome is the personnel assisting the surgeon.
percent of these deaths followed procedures performed Qualified and experienced assistants may serve as
in office-based settings, while 26% followed hospital- valuable resources, potentially reducing morbidity and
based procedures. Sedation of pediatric patients per- improving efficiency of the operating room [30, 31].
formed in the office results in a greater incidence of With an office-based operating room, the surgeon is
permanent neurological injury and death compared to responsible for selecting the operating room personnel.
when sedation is administered in the hospital [15]. An anesthesiologist or a certified nurse anesthetist
Patients with a risk of ASA III undergoing major (CRNA) may administer anesthesia. The surgeon may
surgical procedures such as abdominoplasty should prefer to perform the surgery using exclusively local
preferentially be treated at hospital-based or hospital- anesthesia without parenteral sedation, especially in
associated surgical units rather than an office-based limited procedures such as liposuctions with the
operating room [1618]. Ultimately, patient safety tumescent technique [32]. However, many surgeons
should be the paramount factor in the final decision. add parenteral sedative or analgesic medications with
If the intended surgical procedure requires general the local anesthetic. If the surgeon chooses to adminis-
anesthesia or enough sedative-analgesic medication to ter parenteral sedative-analgesic medications, then
increase the probability of loss of the patients life another designated, licensed, preferably experienced
9 Anesthesia for Aesthetic Surgery 107
individual should monitor the patient throughout the Table 9.1 Guidelines for preoperative testing in healthy
patients (ASA 111)
perioperative period [33]. Use of unlicensed, untrained
personnel to administer parenteral sedative-analgesic Age Test
medications and monitor patients may increase the 1240a CBC
risks to the patients. It is also not acceptable for the 4060 CBC, EKG
nurse monitoring the patients to double as a circulating Greater than 60 CBC, BUN, Glucose, ECG, CXR
a
nurse [34]. Evidence suggests that anesthesia-related Pregnancy testing for potentially childbearing females is
recommended
deaths more than double if the surgeon also adminis- Adapted from Roizen et al. [52]
ters the anesthesia [35]. Regardless of who delivers
the anesthesia, the surgeon should preferably maintain
current Advanced Cardiac Life Support certification and use of dietary supplements which could contain
(ACLS) and all personnel assisting in the operating ephedra, should be disclosed by the patient.
room and recovery areas must maintain Basic Life A family history of unexpected or early health con-
Support certification [36]. At least one ACLS-certified ditions such as heart disease, or unexpected reactions,
health provider must remain in the facility until the such as malignant hyperthermia, to anesthetics or other
patient has been discharged [37]. medications should not be overlooked. Finally, a com-
plete review of systems is vital to identifying undi-
agnosed, untreated, or unstable medical conditions
9.3 Preoperative Evaluation that could increase the risk of surgery or anesthesia.
Last-minute revelations of previously undisclosed
The time and energy devoted to the preoperative prepa- symptoms, such as chest pain, should be avoided.
ration of the surgical procedure should be commen- Indiscriminately, ordered or routinely obtained pre-
surate with the efforts expended on the evaluation and operative laboratory testing is now considered to have
preparation for anesthesia. The temptation to leave limited value in the perioperative prediction of mor-
preoperative anesthesia preparation of the patient as bidity and mortality [4145]. In fact, one study showed
an afterthought must be resisted. Even if an anesthesi- no difference in morbidity in healthy patients without
ologist or CRNA is to be involved later, the surgeon preoperative screening tests versus a control group
bears responsibility for the initial evaluation and prepa- with the standard preoperative tests [46]. Multiple
ration of the patient. Thorough preoperative evaluation investigations have confirmed that the preoperative
and preparation by the surgeon increase the patients history and physical examination is superior to labora-
confidence, reduce costly and inconvenient last-minute tory analysis in determining the clinical course of
delays, and reduce overall perioperative risk to the surgery and anesthesia [4751]. Guidelines for the
patient [38]. If possible, the preoperative evaluation judicious use of laboratory screening, particularly in
should be performed with the assistance of a spouse, healthy patients, are now widely accepted (Table 9.1)
parent, or significant other so that elements of the [52]. Additional preoperative tests may be indicated
health history or recent symptoms may be more readily for patients with prior medical conditions or risk fac-
recalled. tors for anesthesia and surgery (Table 9.2) [53].
A comprehensive preoperative evaluation form is a Consultation from other medical specialists should
useful tool to begin the initial assessment. Information be obtained for patients with complicated or unstable
contained in the history alone may determine the diag- medical conditions. Patients with ASA III or VI risk
nosis of the medical condition in nearly 90% of patients designations should be referred to the appropriate med-
[39]. While a variety of forms are available in the ical specialist prior to elective surgery [33]. The consul-
literature, a checklist format to facilitate the patients tants role is to determine if the patient has received
recall is probably the most effective [40]. Regardless optimal treatment and if the medical condition is stable.
of which format is selected, information regarding all Additional preoperative testing may be considered nec-
prior medical conditions, prior surgeries and types of essary by the consultant. The medical consultant should
anesthetics, current and prior medications, adverse also assist with stabilization of the medical conditions
outcomes to previous anesthetics or other medications, in the perioperative period if indicated. A complete
eating disorders, prior use of antiobesity medication, written report from the medical consultant regarding
108 G.D. Bennett
Table 9.2 Common indications for additional risk-specific testing

Electrocardiogram
History Coronary artery disease, congestive heart failure, prior myocardial infarction, hypertension, hyperthyroidism,
hypothyroidism, obesity, compulsive eating disorders, deep venous thrombosis, pulmonary embolism, smoking,
chemotherapeutic agents, chemical dependency, chronic liver disease
Symptoms Chest pain, shortness of breath, dizziness
Signs Abnormal heart rate or rhythm, hypertension, cyanosis, peripheral edema, wheezing, rales, rhonchi
Chest X-ray
History Bronchial asthma, congestive heart failure, chronic obstructive pulmonary disease, and pulmonary embolism
Symptoms Chest pain, shortness of breath, wheezing, unexplained weight loss, and hemoptysis
Signs Cyanosis, wheezes, rales, rhonchi, decreased breath sounds, peripheral edema, abnormal heart rate or rhythm
Electrolytes, glucose, liver function tests, BUN, creatinine
History Diabetes mellitus, chronic renal failure, chronic liver disease, adrenal insufficiency, hypothyroidism, hyperthy-
roidism, diuretic use, compulsive eating disorders, diarrhea
Symptoms Dizziness, generalized fatigue or weakness
Signs Abnormal heart rate or rhythm, peripheral edema, abnormal breath sounds, jaundice
Urinalysis
History Diabetes mellitus, chronic renal disease, and recent urinary tract infection
Symptoms Dysuria, urgency, frequency, and bloody urination
Adapted from Roizen et al. [53]
the patients medical status should be given to the Table 9.3 The American Society of Anesthesiologists Physical
surgeon prior to scheduling the surgery. A hastily scrib- Status Classification
bled note from the medical consultant stating cleared ASA CLASS I A healthy patient without systemic
for surgery is entirely inadequate and could potentially medical or psychiatric illness
delay the surgery or result in perioperative complica- ASA CLASS II A patient with mild, treated, and stable
tions. If the surgeon has concerns about a patients systemic medical or psychiatric illness
ability to tolerate anesthesia, a telephone discussion ASA CLASS III A patient with severe systemic disease
with an anesthesiologist or even a formal preoperative that is not considered incapacitating
anesthesia consultation may be indicated. ASA CLASS IV A patient with severe systemic,
Certain risk factors, such as previously undiagnosed incapacitating, and life-threatening
hypertension, cardiac arrhythmias, and bronchial asthma disease not necessarily correctable
by medication or surgery
may be identified by a careful physical examination.
Preliminary assessment of head and neck anatomy to ASA CLASS V A patient considered moribund and
not expected to live more than 24 h
predict possible challenges in the event endotracheal
intubation is required may serve as an early warning to
the anesthesiologist or CRNA even if a general anes- coexisting medical conditions a patient has, the greater
thetic is not planned. For most ambulatory surgeries, the the risk for perioperative morbidity and mortality [33,
anesthesiologist or CRNA evaluates the patient on the 54]. Identification of preoperative medical conditions
morning of surgery. helps reduce perioperative mortality.
A variety of indexing systems have been proposed
to help stratify patients according to risk factors. One
9.3.1 Preoperative Risk Assessment such classification, first proposed in 1941 [55], later
modified in 1961 by Dripps et al. [56], and finally
The ultimate goals of establishing a patients level adopted by the ASA in 1984 (Table 9.3) [57], has
of risk are to reduce the probability of periopera- emerged as the most widely accepted method of preop-
tive morbidity and mortality. As previously discussed, erative risk assessment. Numerous studies have con-
the preoperative evaluation is the crucial component firmed the value of the ASA system in predicting which
of determining the patients preoperative risk level. patients are at a higher risk for morbidity [58] and mor-
There is compelling evidence to suggest that the more tality [5961]. Goldman and Caldera [62] established a
multifactorial index based on cardiac risk factors. This diseases. Surgeons who perform outpatient surgery,
index has repeatedly demonstrated its usefulness in especially office-based surgery, and particularly those
predicting perioperative mortality [63, 64]. Physicians surgeons who chose to administer sedative or analgesic
should incorporate one of the acceptable risk classifica- medication, must appreciate how these medical condi-
tion systems as an integral part of the preoperative tions may increase the risk of anesthesia in the surgical
evaluation. patient. Furthermore, the surgeon should maintain a
Multiple authors have documented the association current working understanding of the evaluation and
between morbidity and mortality and the type of surgery treatment of these medical conditions.
[6568]. The consensus of these studies confirms the
increased risks of perioperative complications for more
invasive surgeries, surgeries with multiple combined 9.4.1 Cardiac Disease
procedures, surgeries with prolonged duration, and sur-
geries with significant blood loss [69]. After reviewing Cardiac-related complications, including myocardial
1,200 office-based facial plastic surgeries, 86% of which infarction and congestive heart failure, are the leading
exceeded 240 min, Gordon and Koch concluded that causes of perioperative mortality [72, 73]. Most patients
increased morbidity or mortality was not associated with with heart disease can be identified with a careful preop-
the duration of surgery [70]. Nevertheless, the American erative history and physical examination [51]. Since 80%
Society of Plastic Surgeons has recommended that pro- of all episodes of myocardial ischemia are silent [74, 75],
cedures not exceed 6 h and that procedures should be a high index of suspicion for silent ischemia must
completed by 3:00 P.M. [23]. be maintained when assessing asymptomatic patients
While studies correlating the amount of fat aspi- with risk factors for heart disease, such as smoking,
rate during liposuction or the amount of tissue hypertension, diabetes mellitus, obesity, hyperlipidemia,
removed during abdominoplasty with perioperative or family history of severe heart disease. Patients with
morbidity and mortality have not been performed, it known cardiac disease must be evaluated by the internist
would not be unreasonable to extrapolate conclusions or cardiologist to ensure the medical condition is opti-
from the previous studies and apply them to abdomi- mally managed. When anesthesia is planned, patients
noplasty and liposuction. Liposuction surgeries with with significant heart disease should preferentially
less than 1500 mL fat aspirate are generally consid- undergo surgery at a hospital-based surgical unit rather
ered less invasive procedures, while liposuctions than a physicians office.
aspirating more than 3000 mL are considered major Most studies have consistently demonstrated that
surgical procedures [27]. As blood loss exceeds patients who have suffered previous myocardial infarc-
500 mL [69] or the duration of surgery exceeds 2 h, tions have a dramatically greater risk of reinfarction
morbidity and mortality increase [58, 71]. Guidelines and death if surgery is performed less than 6 months
presented by the American Society for Dermatologic after the cardiac event [7678]. Subsequent studies
Surgery, the American Academy of Dermatology, suggesting a lower rate of reinfarction [79, 80] involved
the American Society of Plastic Surgeons, and the patients who were hospitalized in the intensive care
American Academy of Cosmetic Surgery have con- unit with invasive hemodynamic monitoring. These
cluded that for office-based liposuction, the total studies may not have relevance to patients undergoing
supernatant fat and fluid should be limited to less elective ambulatory surgery. At this time, the prudent
than 5000 mL [13]. choice remains to postpone elective surgeries for at
least 6 months after myocardial infarction.
Goldman et al. [62] established a cardiac risk index
9.4 Anesthesia in Patients which has been useful in identifying patients with
with Preexisting Disease intermediate risk for cardiac complications in the peri-
operative period [63]. Patients with a score greater
Over the past 30 years, the morbidity and mortality of than 13 should be referred to a cardiologist for preop-
surgery have steadily declined [11]. One hypothesis to erative evaluation. Dipyridamole thallium scanning
explain this decline has been the greater recognition of and dobutamine stress echocardiography have proven
preoperative risk factors and the improved periopera- useful in predicting adverse perioperative cardiac
tive medical management of patients with coexisting events [81]. One reliable and simple screening method
110 G.D. Bennett
to evaluate cardiac status is exercise tolerance. The metabolism of medications vary significantly and often
ability to increase the heart rate to 85% of the age- unpredictably in the obese patient [95].
adjusted maximal heart rate is a reliable predictor of Given the increased risk of perioperative morbidity
perioperative cardiac morbidity [82]. and mortality of anesthesia, morbidly obese patients
Despite years of investigation, no one anesthetic (BMI > 35) undergoing major surgery and anesthesia
technique or medication has emerged as the preferen- of any type should preferentially be restricted to a hos-
tial method to reduce the incidence of perioperative pital-based surgical facility. In general, these patients
complications in patients with cardiac disease [83, 84]. should not be considered candidates for ambulatory
Regardless of which anesthesia technique is selected, surgery. Anesthesia delivered in the office setting
scrupulous monitoring should serve as the framework should be restricted to patients with BMI less than 30.
for safe anesthetic management. Wide hemodynamic While premedication with metaclopromide (Reglan,
fluctuations and tachycardia must be avoided to prevent Wyeth Pharmaceuticals), a dopamine-receptor antago-
ischemic episodes in the perioperative period. nist, increases gastric motility and lowers esophageal
sphincter tone [96, 97], a troubling association between
single-dose metachlopromide and tardive dyskinesia
9.4.2 Obesity [98] has limited the routine use of this medication in
preoperative preparation of the patient. A histamine-
The prevalence of obesity (BMI > 30) in the USA is receptor blocking agent such as ranitidine (Zantac,
estimated to be 34% of the population, while the preva- Glaxo) used with metaclopromide the evening before
lence of overweight and obesity combined (BMI > 25) and the morning of surgery reduces the risk of pulmo-
is estimated to be 68% [85]. It is reasonable to assume nary aspiration [99].
that patients undergoing certain aesthetic surgical pro- Because of the increased risks of deep venous throm-
cedures such as major liposuction or abdominoplasty bosis (DVT) [100] and pulmonary embolism (PE) in
have a greater incidence of obesity. The most widely the obese patient [101], prophylactic measures such as
accepted method of quantifying the level of obesity is lower extremity pneumatic compression devices and
the body mass index (BMI), which is determined by early ambulation should be used.
weight (kg)/height (M) [2]. Patients with a BMI over 25 An undetermined number of patients self-administer
are considered overweight; those with a BMI over 30 herbal dietary supplements. Many of these supple-
are considered obese, while a BMI over 35 indicates ments contain ephedra alkaloids which may predispose
morbid obesity [86]. the patient to perioperative hypertension and cardiac
The risk factors associated with obesity such as arrhythmias [102]. Some of these herbal products may
diabetes mellitus, hypertension, heart disease, sleep result in the increased incidence of bleeding as a result
apnea, and occult liver disease [87] should concern cli- of intrinsic anticoagulant properties of these herbal
nicians administering anesthesia to patients with obe- supplements similar to warfarin. Antiobesity medica-
sity. A thorough preoperative evaluation must rule out tions such as aminorex fumarate, dexfenfluramine
these occult risk factors prior to elective surgery. (Redux, Wyeth-Ayerst), fenfluramine (Pondimin,
Anatomical abnormalities make airway control chal- AH Robins), and phenterimine (Ionimine, Adipex-P,
lenging [88] and endotracheal intubation hazardous Fastin, Oby-Cap, Obenix, Oby-trim, and Zantryl,
[89]. The combination of a higher gastric volume and various manufacturers) are associated with pulmonary
lower pH with a higher frequency of esophageal reflux hypertension and valvular heart disease, even with as
results in a higher risk of pulmonary aspiration [90] in little as 2 months of use. While most patients develop
the obese patient; pulmonary function can be severely symptoms such as palpitations, dyspnea, chest pain,
restricted even in an upright position [91]. In the supine and irregular heart rate, murmur, and edema, some
position, pulmonary function is even further reduced patients remain asymptomatic [103].
[92]. Pulmonary function is further compromised in the Patients who have developed pulmonary hyper-
anesthetized patient. Because of these cardiopulmonary tension and valvular heart disease as a result of these
abnormalities, obese patients develop hypoxemia more medications are predisposed to fatal cardiac arrhyth-
quickly [93]. This respiratory impairment may persist mias, congestive heart failure, and intractable hypoten-
up to 4 days after surgery [94]. Even distribution and sion. Some authors advocate a cardiac evaluation with
echocardiogram and continuous wave Doppler imag- the incidence of cardiac ischemia [111]. Labetolol
ing with color-flow examination for any patient who (Normodyne, Trandate), an antihypertensive agent
has taken these antiobesity medications prior to sur- with combined alpha-adrenergic and beta-adrenergic
gery. Sustained hypotension may not respond to ephed- blocking properties, administered in 510 iv mg doses
rine, a popular vasopressor. Phenylephrine is the every 10 min, is also a safe and effective alternative to
treatment of choice for hypotension occurring in these treat both hypertension and tachycardia [114].
patients [103]. Nifedipine (Procardia, Pfizer), 10 mg sl, a potent
systemic and coronary arteriolar dilator, effectively
reduces blood pressure and may be administered in a
9.4.3 Hypertension conscious patient. The effect of nifedipine may be
additive if given with narcotics or inhalational anes-
Early studies revealed a significantly increased risk of thetic agents. Because nifedipine and lidocaine are
perioperative mortality in patients with untreated both highly protein bound, caution must be exercised
hypertension [104, 105]. The reduction in mortal- when administering nifedipine after high-dose lido-
ity from cardiovascular and cerebrovascular disease caine tumescent anesthesia has been administered to
resulting from proper treatment of hypertension has avoid possible toxic effects of the lidocaine [115].
been widely accepted [106108]. Although still some- For severe hypertension, hydralazine (Apresoline,
what controversial, most authors concur that preopera- Novartis), a potent vasodilator, may be useful in
tive stabilization of hypertension reduces perioperative 2.55 mg doses iv at 1015 min intervals. The effects
cardiovascular complications such as ischemia [109 of hydralazine may be delayed up to 20 min and its
111]. Patients with undiagnosed or poorly controlled effects prolonged. Hydralazine may cause tachycar-
hypertension should be identified early in the preop- dia or hypotension, especially if the patient is hypov-
erative preparation process and referred to the family olemic [116].
physician or internist for evaluation and treatment.
Physicians should not mistakenly attribute severe
hypertension to the patients preoperative anxiety. 9.4.4 Diabetes Mellitus
Because of the risk of rebound hypertension, anti-
hypertension medications should be continued up to Although patients with diabetes mellitus have a sub-
and including the morning of surgery [112], except for stantially increased surgical mortality rate than nondia-
angiotensin-converting (ACE) inhibitors, which have betic patients [117], these complications are more likely
been associated with hypotension during induction of to be a consequence of the end-organ disease such as
general anesthesia [113]. cardiovascular disease, renal disease, and altered wound
Mild to moderate perioperative hypertension may healing [54, 118, 119]. While evidence suggests that
be a response to inadequate general or local anesthesia tight control of blood sugar in insulin-dependent dia-
or pain control. In these cases, pain is usually accom- betics slows the progression of end-organ disease [120],
panied by other signs, such as the patients complaints, tight control is associated with additional risks such as
tachycardia, and tachypnea. If hypertension persists hypoglycemia and even death [121].
despite additional local anesthetic or analgesic medi- The preoperative evaluation should identify dia-
cation, then treatment of the blood pressure is indi- betic patients with poor control as well as medical con-
cated. Moderate to severe blood pressure elevations ditions associated with diabetes such as cardiovascular
occurring during the surgery or during recovery should disease and renal insufficiency. Diabetic patients have
be treated using one or more of the antihypertensive a greater incidence of silent myocardial ischemia
agents available. [122]. Minimum preoperative analysis includes fasting
Perioperative hypertension, especially if the hyper- blood sugar, glycosylated hemoglobin, electrolytes,
tension is accompanied by tachycardia, may be treated BUN, creatinine, and EKG. If any doubt exists regard-
with a beta-adrenergic blocking agent such propranolol ing the patients medical stability, consultation should
in judiciously administered, intravenous doses of 0.5 mg be obtained from the diabetologist, cardiologist, or
iv at 1015 min intervals. Even small doses of a beta- nephrologist. Patients with brittle diabetes or with
adrenergic blocking agent have been shown to reduce other coexisting medical conditions should be referred
112 G.D. Bennett
to a hospital-based surgical unit, especially if general Table 9.4 Grade of dyspnea while walking
anesthesia is contemplated. Level Clinical response
The goal of perioperative management of stable type 0 No dyspnea
I or type II diabetic patients is primarily to avoid hypo- 1 Dyspnea with fast walking only
glycemia. Although patients are generally NPO after 2 Dyspnea with one or two blocks
midnight prior to surgery, a glass of clear juice may be walking
3 Dyspnea with mild exertion (walking around
taken up to 2 h prior to surgery to avoid hypoglycemia.
the house)
Patients with type I diabetes should not administer 4 Dyspnea at rest
insulin, and patients with type II diabetes should not
Adapted from Boushy et al. [128]
take oral hypoglycemia agents the morning of surgery.
Diabetic patients should be scheduled the first case in
the morning to minimize the risk of hypoglycemia dur- [128]. Using a simple grading scale, the patients pre-
ing the NPO period. After the patient arrives, a preop- operative pulmonary function can be estimated
erative fasting glucose should be checked and then, an (Table 9.4).
infusion of 5% dextrose is generally initiated at 12 mL/ Patients with level 2 dyspnea or greater should
kg/h and continued until oral fluids are tolerated in the be referred to a pulmonologist for more complete
recovery period. Usually, one half of the patients evaluation and possibly further medical stabilization.
scheduled dose of insulin is administered after the The benefits of elective surgery in patients with level
intravenous dextrose is begun [123]. 3 and 4 dyspnea should be carefully weighed against
For surgeries longer than 2 h, at least one periph- the increased risks. Certainly, this group of patients
eral blood glucose should be measured, especially if would not be considered good candidates for outpa-
the patient is receiving general anesthesia. Blood glu- tient surgery.
cose above 200 mg/dL may be effectively managed Since upper respiratory infection (URI) may alter
with a sliding scale of insulin [124]. Treatment regi- pulmonary function for up to 5 weeks [129], major
mens directed toward tighter control of the blood surgery requiring general endotracheal anesthesia
sugar, such as continuous insulin infusions, do not should be postponed, especially if the patient suffers
necessarily improve the perioperative outcome [125, residual systems, such as fevers, chills, coughing, and
126]. It is imperative that prior to discharge, patients sputum production, until the patient is completely
be able to tolerate oral intake without nausea and asymptomatic.
vomiting. A final glucose level should be checked While many studies confirm that patients who
prior to discharge. smoke more than 12 packs of cigarettes daily have a
higher risk of perioperative respiratory complications
than non-smokers, cessation of smoking in the imme-
9.4.5 Pulmonary Disease diate preoperative period may not improve patients
outcome. In fact, patients risk of perioperative com-
Bronchial asthma, chronic bronchitis, chronic obstruc- plications may actually increase if smoking is stopped
tive pulmonary disease, obesity, history of smoking, immediately prior to surgery. A full 8 weeks may be
and recent upper respiratory infection are the most required to successfully reduce perioperative pulmo-
common medical conditions which may influence pul- nary risk [130].
monary function in the perioperative period. An esti- If the physical examination of asthmatic patients
mated 4.5% of the population may suffer some form of reveals expiratory wheezing, conventional wisdom dic-
reactive airway disease [127]. If these medical condi- tates that potentially reversible bronchospasm should
tions are identified in the preoperative history, a thor- be optimally treated prior to surgery. Therapeutic
ough evaluation of the patients pulmonary function agents include inhaled or systemic, selective beta-
should ensure. As with other medical conditions, a adrenergic receptor type-2 agonists such as albuterol
careful history may help separate patients with these (Ventolin, Glaxo, Proventil, Proair, Teva) as a sole
medical conditions into low- and high-risk groups, agent or in combination with anticholinergic such
especially since the degree of preoperative respiratory as ipratropium (Atrovent, Boehringer Ingelheim)
dyspnea closely correlates with postoperative mortality and locally active corticosteroid such as beclomethasone
dipropronate (Beclovent, Vanceril) medications [131]. monitoring, including visual observation, must be
Continuing the asthmatic medications up to the time especially vigilant to avoid perioperative respiratory
of surgery [132] and postoperative use of incentive arrest in patients with SAS.
spirometry [133] have been shown to reduce postop- For patients with severe SAS, particularly those with
erative pulmonary complications. additional coexisting medical conditions such as cardiac
With regard to treated stable pulmonary disease, or pulmonary disease, surgery performed on an outpa-
there are no conclusive, prospective, randomized stud- tient basis is not appropriate. For these high-risk patients,
ies to indicate which anesthesia technique or medica- monitoring should continue in the intensive care unit
tions would improve patient outcome. until the patients no longer require parenteral analge-
sics. If technically feasible, regional anesthesia may be
preferable in patients with severe SAS. Postoperatively,
9.4.6 Sleep Apnea Syndrome patients with any history of SAS should not be dis-
charged if they appear lethargic or somnolent [142].
Sleep apnea syndrome (SAS) may be a result of an During the preoperative evaluation of the obese
abnormality of the respiratory control center of the patient, a presumptive diagnosis of SAS may be made
brain in central sleep apnea or obstruction of the upper if the patient has a history of loud snoring, long pauses
airway in obstructive sleep apnea (OSA) which is the of breathing during sleep (more than 10 s), as reported
most common cause of SAS. Many patients present by the spouse, or daytime somnolence [143]. If SAS is
with a combination of central sleep apnea and OSA, suspected, patients should be referred for a sleep study
also referred to as mixed sleep apnea. According to the to evaluate the severity of the condition.
National Commission on Sleep Disorders Research,
nearly 20 million Americans suffer with SAS. Unfor-
tunately, the majority of patients with SAS remain 9.4.7 Malignant Hyperthermia
undiagnosed [134]. The incidence of sleep apnea Susceptibility
increases among obese patients [134, 135]. Since the
target population for many aesthetic surgical proce- Patients with susceptibility to malignant hyperthermia
dures such as major liposuction and abdominoplasty (MH) can be successfully managed on an outpatient
includes patients with morbid obesity, SAS becomes a basis after 4 h of postoperative monitoring [144].
more relevant concern. Triggering agents include volatile inhalation agents
OSA is a result of a combination of excessive such as halothane, enflurane, desflurane, isoflurane,
pharyngeal adipose tissue and inadequate pharyngeal and sevoflurane. Even trace amounts of these agents
soft tissue support [136]. During episodes of sleep lingering in an anesthesia machine or breathing circuit
apnea, patients may suffer significant and sustained may precipitate an MH crisis. Succinylcholine and
hypoxemia. As a result of the pathophysiology of OSA, chlorpromazine are other commonly used medications
patients develop left and right ventricular hypertrophy which are known triggers of MH. However, many non-
[137]. Consequently, patients have a higher risk of triggering medications may be safely used for local
ventricular dysrhythmias and myocardial infarction anesthesia, sedation-analgesia, postoperative pain con-
[138]. trol, and even general anesthesia [145]. Nevertheless,
Most medications used during anesthesia, includ- anesthesia for patients suspected to have MH suscepti-
ing sedatives such as diazepam and midazolam, bility should not be performed at an office-based set-
hypnotics such as propofol, and analgesics such as ting. Standardized protocol to manage MH (available
fentanyl, meperidine and morphine, increase the risk from the Malignant Hyperthermia Association of the
for airway obstruction and respiratory depression in United States, MHAUS), supplies of dantrolene
patients with SAS [139]. Death may occur suddenly (Dantrium, Procter and Gamble Pharmaceuticals),
and silently in patients with inadequate monitoring and cold intravenous fluids should be at the surgical
[140]. A combination of anatomical abnormalities facility for all patients. Preferably, patients with MH
makes airway management, including mask ventila- susceptibility should be referred to an anesthesiologist
tion and endotracheal intubation, especially challeng- for prior consultation. Intravenous dantrolene [146]
ing in obese patients with OSA [141]. Perioperative and iced intravenous fluids are still the preferred
114 G.D. Bennett
Table 9.5 Clinical pharmacology of commonly used local anesthetics infiltrative anesthesia in adults (70 kg)a
Maximum dose Maximum dose
(without epinephrine) Duration (with epinephrine)
Concentration Duration of Total Total of action Total Total
Agent (%) action (min) mg/kg mg mL (min) mg/kg mg mL
Lidocaine 1.0 3090 4 300 30 60120 7 500 50
Chloroprocaine 1.0 2030 10 700 70 3060 14 1000 100
Mepivacaine 1.0 4590 4 300 30 60120 7 500 50
Prilocaine 1.0 3090 5 350 35 60120 8 550 55
Etodocaimne 0.5 120180 4 300 60 180240 5.5 400 80
Bupivacaine 0.25 120240 2.5 175 70 180240 3 225 90
Ropivacaine 0.2 120240 2.7 200 80 180240 2.7 250 100
Levobupivicaine 0.25 120240 2.5 185 75 180240 3 225 90
a
Individual doses may vary depending on ethnic background, individual sensitivities, body habitus, or coexisting medical
conditions
Adapted from Covino and Wildsmith [147], and Berde and Struchartz [148]
treatment for MH. MHAUS may be contacted at 800 Table 9.6 Medications inhibiting cytochrome oxidase P450
3A4
98-MHAUS, and the MH hotline is 800-MH HYPER.
Amiodarone Fluoxetine Nifedipine
Atenolol Itraconazole Paroxetine
Carbamazepine Isoniazide Pentoxifylline
9.5 Anesthesia for Aesthetic Surgery
Cimetidine Labetolol Pindolol
Clarithromycin Ketoconazole Propofol
Anesthesia may be divided into four broad categories:
Chloramphenicol Methadone Propranolol
local anesthesia, local anesthesia combined with
Cyclosporine Methyprednisolone Quinidine
sedation, regional anesthesia, and general anesthesia. Danazol Metoprolol Sertraline
The ultimate decision to select the type of anesthesia Dexamethasone Miconazole Tetracyline
depends on the type and extent of the surgery planned, Diltiazam Midazolam Terfenidine
the patients underlying health condition, and the Erythromycin Nadolol Thyroxine
psychological disposition of the patient. Fluconazole Nefazodone Timolol
Flurazepam Nicardipine Triazola
Verapamil
9.5.1 Local Anesthesia Adapted from Shiffman [153]
A variety of local anesthetics are available for infiltra-

tive anesthesia. The selection of the local anesthetic up to 35 mg/kg were found to be safe if administered
depends on the duration of anesthesia required and in conjunction with dilute epinephrine during liposuc-
the volume of anesthetic needed. The traditionally tion [155]. With the tumescent technique, peak plasma
accepted, pharmacological profiles of common anes- levels occur 624 h after administration [155, 156].
thetics used for infiltrative anesthesia for adults are Doses up to 55 mg/kg have been found to be within
summarized in Table 9.5 [147, 148]. the therapeutic safety margin [157]. However, guide-
The maximum doses may vary widely depending lines by the American Academy of Cosmetic Surgery
on the type of tissue injected [149], the rate of admin- recommend a maximum dose of 4550 mg/kg [37].
istration [150], the age, underlying health, and body Since lidocaine is predominantly eliminated by
habitus of the patient [151], the degree of competitive hepatic metabolism, specifically cytochrome oxidase
protein binding [152], and possible cytochrome inhibi- P450 34A, drugs that inhibit this microsomal enzyme
tion of concomitantly administered medications [153]. may increase the potential of lidocaine toxicity [153,
The maximum tolerable limits of lidocaine (Xylocaine) 158]. Table 9.6 [153] lists some of the more common
have been redefined with the development of the medications, which inhibit the cytochrome oxidase sys-
tumescent anesthetic technique [154]. Lidocaine doses tem. Propofol and Versed, commonly used medications
for sedation and hypnosis during liposuction, are also ged as another alternative local anesthetic with
known to be cytochrome P450 inhibitors. However, a prolonged duration of action for infiltrative anes-
since the duration of action of these drugs is only thesia, peripheral nerve blocks, and central anesthesia,
14 h, the potential inhibition should not interfere including epidural and intrathecal anesthesia. Except
with lidocaine at the peak serum level 612 h later. for a somewhat longer duration of the sensory block in
Lorazepam is a sedative which does not interfere with central anesthesia, the pharmacokinetics of levobupiva-
cytochrome oxidase and is preferred by some authors caine are virtually indistinguishable from bupivacaine.
[159]. However, levobupivacaine has a wider therapeutic
Certainly, significant toxicity has been associated safety margin with less cardiotoxic potential and less
with high doses of lidocaine as a result of tumescent CNS and cardiac depressant effects compared to bupi-
anesthesia during liposuction [155]. The systemic tox- vacaine [165, 166].
icity of local anesthetic has been directly related to the Indeed, during administration of infiltrative lido-
serum concentration by many authors [32, 152, 155 caine anesthesia, rapid anesthetic injection into a
157, 159, 160]. Early signs of toxicity, usually occur- highly vascular area or accidental intravascular injec-
ring at serum levels of about 34 mg mL for tion leading to sudden toxic levels of anesthetics result-
lidocaine, include circumoral numbness, lightheaded- ing in sudden onset of seizures or even cardiac arrest or
ness, and tinnitus. As the serum concentration increases cardiovascular collapse has been documented [167,
toward 8 mg/mL, tachycardia, tachypnea, confusion, 168]. One particularly disconcerting case presented by
disorientation, visual disturbance, muscular twitching, Christie confirms the fatal consequence of a lidocaine
and cardiac depression may occur. At still higher serum injection of 200 mg in a healthy patient [169]. Seizure
levels above 8 mg/mL, unconsciousness and seizures and death occurred following a relatively low dose of
may ensue. Complete cardiorespiratory arrest may lidocaine and a serum level of only 0.4 mg/100 mL or
occur between 10 and 20 mg/mL [152, 159, 160]. 4 mg/mL. A second patient suffered cardiac arrest with
However, the toxicity of lidocaine may not always cor- a blood level of 0.58 mg/100 mL or 5 mg/mL [170].
relate exactly with the plasma level of lidocaine pre- Although continued postmortem metabolism may arti-
sumably because of the variable extent of protein ficially reduce serum lidocaine levels, the reported
binding in each patient and the presence of active serum levels associated with mortality in these patients
metabolites [152] and other factors already discussed were well below the 820 mg/mL considered necessary
including the age, ethnicity, health, and body habitus to cause seizures, myocardial depression, and cardio-
of the patient, and additional medications. respiratory arrest. The 4 mg/mL level reported by
Ropivacaine (Naropin, AstraZeneca) and levobupi- Christie [169] is uncomfortably close to the maximum
vacaine are long-lasting local anesthetics with less car- serum levels reported by Ostad et al. [157] of 3.4 and
diovascular toxicity than bupivacaine and may be a 3.6 mg/mL following tumescent lidocaine doses of
safer alternative to bupivacaine if a local anesthetic of 51.3 and 76.7 mg/kg, respectively. Similar near toxic
longer duration is required [148, 161]. The cardiovas- levels were reported in individual patients receiving
cular toxicity of bupivacaine and etidocaine is much about 35 mg/kg of lidocaine by Samdal et al. [170].
greater than lidocaine [148, 161, 162]. While bupiva- Pitman and Klein [171] reported that toxic manifesta-
caine (Marcaine, Sensorcaine) toxicity has been tions occurred 8 h postoperatively after a total dose of
associated with sustained ventricular tachycardia and 48.8 mg/kg which resulted from a 12-h plasma lido-
sudden profound cardiovascular collapse [163, 164], caine level of 3.7 mg/kg. Ostad et al. [157] conclude
the incidence of ventricular dysrhythmias has not been that because of the poor correlation of lidocaine doses
as widely acknowledged with lidocaine or mepiva- with the plasma lidocaine levels, an extrapolation of
caine (Carbocaine) toxicity. In fact, ventricular tachy- the maximum safe dose of lidocaine for liposuction
cardia or fibrillation was not observed despite the use cannot be determined. Given the devastating conse-
of supraconvulsant doses of intravenous doses of lido- quences of lidocaine toxicity, physicians must exercise
caine, etidocaine, or mepivacaine in the animal model extreme caution while attempting to push the accept-
[161]. able safe limits to ever-higher levels of tumescent
Levobupivacaine (Chirocaine, AstraZeneca), an anesthesia. Physicians must consider the important
S() isomer of the racemic bupivacaine, has emer- variables affecting susceptibility of individual patients
116 G.D. Bennett
to lidocaine toxicity before boldly going where no liposuction. Although local anesthetics of the aminoester
surgeon has gone before, especially since plasma class such as procaine, chloroprocaine, tetracaine, or
lidocaine levels typically peak after the patient is at cocaine are associated with allergic reactions, true
home. allergic phenomena to local anesthetics of the amino-
Topical anesthetics in a phospholipid base have amide class, such as lidocaine, bupivacaine, ropivacaine,
become more popular as a technique for administering and mepivacaine, are extremely rare [171, 176]. Allergic
local anesthetics. Application of these topical agents reactions may occur to the preservative in the multidose
may provide limited anesthesia over specific areas vials. Tachycardia and generalized flushing may occur
such as the face for minor procedures including limited with rapid absorption of the epinephrine contained in
laser resurfacing. EMLA (eutectic mixture of local some standard local anesthetic preparations. The devel-
anesthetics), a combination of lidocaine and prilocaine, opment of vasovagal reactions after injections of any
was the first commercially available preparation. This kind may cause hypotension, bradycardia, diaphoresis,
topical anesthetic preparation must be applied under pallor, nausea, and loss of consciousness. These adverse
an occlusive dressing at least 60 min prior to the reactions may be misinterpreted by the patient and even
procedure to develop adequate local anesthesia [172]. the physician as allergic reactions [176]. A careful his-
Even after 60 min, the anesthesia may not be com- tory from the patient describing the apparent reaction
plete and the patient may still experience significant usually clarifies the cause. If there is still concern about
discomfort. Many physicians prefer to use their own the possibility of true allergy to local anesthetic, then
customized formula, which they obtain from a com- the patient should be referred to an allergist for skin
pounding pharmacy. Frequently, the patient is given testing [177].
the topical anesthetic to be applied at home prior to In the event of a seizure following a toxic dose of
arrival to the office or surgical center. However, these local anesthetic, proper airway management and oxy-
compounded formulas are not monitored by the FDA, genation maintenance are critical. Seizure activity may
and compounding pharmacies may vary in the quality be aborted with intravenous diazepam, 1020 mg intra-
control standards. Some of the formulas may contain venously (iv); midazolam, 510 mg iv; or thiopental,
up to 40% local anesthetics in various combinations. 100200 mg iv. Although the ventricular arrhythmias
This type of preparation could deliver up to 400 mg per associated with bupivacaine toxicity are notoriously
gram of ointment to the patient. The application of intractable [163, 164], treatment is still possible using
30 g of a compounded formula containing a total of large doses of atropine, epinephrine, and bretylium
40% local anesthetic over a wide area with subsequent [178, 179]. Some studies indicate that lidocaine or
occlusive dressing could expose the patient to amiodarone should not be used during resuscitation of
12,000 mg of local anesthetic. Studies have demon- local anesthetic-induced arrhythmias [148, 180].
strated that systemic absorption of local anesthetic Numerous case reports have emerged describing
after application of topical local anesthetic is limited to successful resuscitation of intractable ventricular
less than 5% [173, 174]. Even with limited systemic arrhythmias and asystole which were induced by
absorption, the development of toxic blood levels of acute bupivacaine, lidocaine, and ropivacane toxicity
local anesthetic, with the ensuing catastrophic results, using intravenous infusions of 20% lipid emulsions
would not be hard to envision if a large quantity of a (Intralipid, Baxter, Liposyn, Hospira) [181186].
concentrated compounded anesthetic ointment were Research in animals has confirmed the rescue effects
applied under an occlusive dressing. There has been at of intravenous lipid emulsions for local anesthetic
least one case report of death after application of a toxicity [187].
compounded local anesthetic ointment while prepar- The recommended dosage of 20% lipid emulsion is
ing for aesthetic surgery [175]. Physicians who pre- 1.5 mL/kg iv over 1 min, repeated every 5 min until
scribe compounded topical local anesthetics to patients adequate circulation is restored [188]. Marwick et al.
prior to surgery should reevaluate the concentration of [186] reported recurrence of ventricular tachycardia
these medications as well as the total dose of medica- 40 min after successful resuscitation with lipid infu-
tion that may be delivered to the patient. sion. For surgical centers where local anesthetics are
Patients who report previous allergies to anesthet- routinely used for large cases or regional anesthesia,
ics may present a challenge to surgeons performing having at least 1000 mL of a 20% lipid emulsion in
Table 9.7 Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesiaa
Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although
cognitive function and physical coordination may be impaired, airway reflexes and ventilatory and cardiovascular functions are
unaffected
Moderate sedation/analgesia (conscious sedation) is a drug-induced depression of consciousness during which patients
respond purposefullyb to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are
required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained
Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but
respond purposefullyb following repeated or painful stimulation. The ability to independently maintain ventilatory function may
be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained
General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.
The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a
patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced
depression of neuromuscular function. Cardiovascular function may be impaired
Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners
intending to produce a given level of sedation should be able to rescuec patients whose level of sedation becomes deeper than
initially intended. Individuals administering moderate sedation/analgesia (conscious sedation) should be able to rescuec
patients who enter a state of deep sedation/analgesia, while those administering deep sedation/analgesia should be able to rescuec
patients who enter a state of general anesthesia
a
Monitored anesthesia care does not describe the continuum of depth of sedation, rather it describes a specific anesthesia service in
which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic
procedure
b
Reflex withdrawal from a painful stimulus is NOT considered a purposeful response
c
Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway manage-
ment and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended
level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of seda-
tion. It is not appropriate to continue the procedure at an unintended level of sedation
Reproduced with permission from Wolters Kluwer [190]
reserve for emergency resuscitation of local anesthetic- Sedation may be defined as the reduction of the level
induced cardiac arrhythmias has been suggested as a of consciousness, usually resulting from pharmacologi-
reasonable precaution [186]. cal intervention. The level of sedation may be further
Pain associated with local anesthetic administration divided into four broad categories: minimal sedation
is due to pH of the solution and may be reduced by the (anxiolysis), moderate sedation/analgesia (formerly
addition of 1 mEq of sodium bicarbonate to 10 mL of referred to as conscious sedation), deep sedation/
anesthetic [189]. analgesia, and general anesthesia (Table 9.7) [190].
Conscious sedation, an outdated term, is occasionally
still used to distinguish a lighter state of anesthesia with
9.5.2 Sedative-Analgesic a higher level of mental functioning whereby the life-
Medications (SAM) preserving protective reflexes (LPPRs) are indepen-
dently and continuously maintained. Furthermore, the
Many aesthetic surgical procedures are performed patient is able to respond appropriately to physical and
with a combination of local anesthesia and supplemen- verbal stimulation [191].
tal sedative-analgesic medications (SAM) adminis- Life-preserving protective reflexes (LPPRs) may
tered orally (po), intramuscularly (im), or intravenously be defined as the involuntary physical and physio-
(iv). Procedures performed under local or regional logical responses that maintain the patients life which,
anesthesia generally are accompanied with SAM. The if interrupted, result in inevitable and catastrophic
goals of administering supplemental medications are physiological consequences. The most obvious exam-
to reduce anxiety (anxiolysis), the level of conscious- ples of LPPRs are the ability to maintain an open air-
ness (sedation), unanticipated pain (analgesia), and, way, swallowing, coughing, gagging, and spontaneous
in some cases, to eliminate recall of the surgery breathing. Some involuntary physical movements such
(amnesia). as head turning or attempts to assume an erect posture
118 G.D. Bennett
Table 9.8 Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia
Minimal sedation Moderate sedation/analgesia Deep sedation/
anxiolysis (conscious sedation) analgesia General anesthesia
Responsiveness Normal response Purposeful response to Purposeful response Unarousable even
to verbal verbal or tactile stimulation following repeated or with painful stimulus
stimulation painful stimulation
Airway Unaffected No intervention required Intervention may be Intervention often
required required
Spontaneous Unaffected Adequate May be inadequate Frequently
ventilation inadequate
Cardiovascular Unaffected Usually maintained Usually maintained May be impaired
function
Committee of Origin: Quality Management and Departmental Administration (Approved by the ASA House of Delegates [190] on
October 27, 2004, and amended on October 21, 2009)
Reported with permission from Wolters Kluwer [187] 2/23/10
may be considered LPPRs if these reflex actions occur vided by the anesthesiologist or the CRNA. The term
in an attempt to improve airway patency such as expel- local standby is no longer used because it mischar-
ling oropharyngeal contents. The myriad of homeo- acterizes the purpose and activity of the anesthesiolo-
static mechanisms to maintain blood pressure, heart gist or CRNA.
function, and body temperature may even be consid- Surgical procedures performed using a combination
ered LPPRs. of local anesthetic and SAM usually have a shorter
As the level of consciousness is further depressed recovery time than similar procedures performed under
to the point that the patient is not able to respond regional or general anesthesia [193]. Using local anes-
purposefully to verbal commands or physical stimulation, thesia alone, without the benefit of supplemental medi-
the patient enters into a state referred to as deep seda- cation, is associated with a greater risk of cardiovascular
tion. In this state, there is a significant probability of loss and hemodynamic perturbations such as tachycardia,
of LPPRs. Ultimately, as total loss of consciousness arrhythmias, and hypertension particularly in patients
occurs and the patient no longer responds to verbal com- with preexisting cardiac disease or hypertension [194].
mand or painful stimuli, the patient enters a state of gen- Patients usually prefer sedation while undergoing sur-
eral anesthesia [187, 188, 190, 191].During general gery with local anesthetics [195]. While the addition of
anesthesia, the patient most likely looses the LPPRs and sedatives and analgesics during surgery under local
cardiovascular function may be impaired. Table 9.8 anesthesia seems to have some advantages, the use of
[190] summarizes the changes that occur during the four SAM during local anesthesia is certainly not free of
stages of sedation analgesia. risk. A study by the Federated Ambulatory Surgical
In actual practice, the delineation between the lev- Association concluded that local anesthesia with sup-
els of sedation becomes challenging at best. The loss plemental medications was associated with more than
of consciousness occurs as a continuum. With each twice the number of complications than with local
incremental change in the level of consciousness, the anesthesia alone. Furthermore, local anesthesia with
likelihood of loss of LPPRs increases. Since the defini- SAM was associated with greater risks than general
tion of conscious sedation is vague, current ASA anesthesia [71]. Significant respiratory depression as
guidelines consider the term sedation-analgesia a more determined by the development of hypoxemia, hyper-
relevant term [33]. Monitored anesthesia care (MAC) carbia, and respiratory acidosis often occurs in patients
has been generally defined as the medical management after receiving minimal doses of medications. This
by a qualified physician or certified registered nurse respiratory depression persists even in the recovery
anesthetist (CRNA) of a patient receiving local anes- period [196, 197]. Houseman determined that during
thesia during a diagnostic or therapeutic procedure liposuction, the risk of serious complications is greater
with or without the use of supplemental medications to when the procedures are performed with sedation than
support the life of and provide comfort and safety to when the procedures are performed under local anes-
the patient [192]. MAC usually refers to services pro- thesia without sedation [198].
One explanation for the frequency of these com- Midazolam, however, is more rapidly metabolized,
plications is the wide variability of patients responses allowing for a quicker and more complete recovery
to these medications. Up to 20-fold differences in the for outpatient surgery [207]. Because the sedative,
dose requirements for some medications such as anxiolytic, and amnestic effects of midazolam are
diazepam and up to fivefold variations for some nar- more profound than other benzodiazepines and the
cotics such as fentanyl have been documented in recovery is more rapid, patient acceptance is usually
some patients [199, 200]. Even small doses of fenta- higher [209]. Midazolam is an excellent choice as a
nyl as low as 2 mg/kg, considered by many physicians supplement to sedation, regional, or general anesthesia
as sub-clinical, produce respiratory depression for to relieve concerns about potential recall after anesthe-
more than 1 h in some patients [201]. Combinations sia. However, the amnestic effect of midazolam or
of even small doses of sedatives, such as midazolam, other benzodiazepines may be an undesirable effect if
and narcotics, such as fentanyl, may act synergisti- the patient actually chooses to have recall of the proce-
cally (effects greater than an additive effect) in pro- dure or if the patient cannot recall important instruc-
ducing adverse side effects such as respiratory tions issued by the physician.
depression and hemodynamic instability [202]. The Since lorazepam is less affected by medications
clearance of many medications may vary depending altering cytochrome P459 metabolism [210], it has
on the amount and duration of administration, a phe- been recommended as the sedative of choice for lipo-
nomenon known as context-sensitive half-life. The suctions which require a large-dose lidocaine tumes-
net result is increased sensitivity and duration of cent anesthesia [159]. The disadvantage of lorazepam
action to medication for longer surgical cases [203]. is the slower onset of action and the 11 to 22-h elimi-
Because of these variations and interactions, predict- nation half-life, making titration cumbersome and
ing any given patients doseresponse is a daunting postoperative recovery prolonged [207, 210]. All ben-
task. Patients appearing awake and responsive may, zodiazepines are reversed by flumazenil (Romazicon,
in an instant, slip into unintended levels of deep seda- Roche) [207].
tion with greater potential of loss of LPPRs. Careful Generally, physicians who use SAM, titrate a
titration of these medications to the desired effect combination of medications from different classes
combined with vigilant monitoring are the critical to tailor the medications to the desired level of seda-
elements in avoiding complications associated with tion and analgesia for each patient. Typically, seda-
the use of SAM. tives such as the benzodiazepines are combined with
Supplemental medication may be administered via narcotic analgesics such as fentanyl (Sublimaze,
multiple routes including oral, nasal, transmucosal, Janssen), meperidine (Demerol, Sanofi Winthrop),
transcutaneous, intravenous, intramuscular, and rectal. or morphine during local anesthesia to decrease pain
While intermittent bolus has been the traditional associated with local anesthetic injection or unan-
method to administer medication, continuous infusion ticipated breakthrough pain. Fentanyl has the advan-
and patient-controlled delivery result in comparable tage of rapid onset and duration of action of less
safety and patient satisfaction [204, 205]. than 60 min. However, because of synergistic action
Benzodiazepines such as diazepam (Valium, with sedative agents, even doses of 2550 mg can
Hoffmann-La Roche Inc.), midazolam (Versed, result to respiratory depression [202, 211]. Other
Hoffmann-La Roche Inc.), and lorazepam (Ativan, medications with sedative and hypnotic effects such
Biovail and Baxter) remain popular for sedation and as a barbiturate, ketamine, or propofol are often
anxiolysis. Patients and physicians especially appreci- added. Adjunctive analgesics such as ketorolac may
ate the potent amnestic effects of this class of medica- be administered for additional analgesic activity. As
tions, especially midazolam. The disadvantages of long as the patient is carefully monitored, several
diazepam include the higher incidence of pain on intra- medications may be titrated together to achieve the
venous administration, the possibility of phlebitis effects required for the patient characteristics and
[206], and the prolonged half-life of up to 2050 h. the complexity of the surgery. Use of pre-packaged
Moreover, diazepam has active metabolites which may combinations of medications defeats the purpose of
prolong the effects of the medication long after the the selective control of each medication and is not
immediate postoperative recovery period [207, 208]. advised [33].
120 G.D. Bennett
More potent narcotic analgesics with faster onset of rapid recovery than similar infusions with midazolam
action and even shorter duration of action than fenta- [220]. Patient-controlled sedation with propofol has
nyl include sufentanil (Sufenta, Janssen), alfentanil also been shown to be safe and effective [221].
(Alfenta, Akorn), and remifentanil (Ultiva, Glaxo- Propofol has no known pharmacological antagonist.
SmithKline and Abbott). These narcotic analgesics Initially, the use of propofol was limited to anesthe-
may be administered using intermittent boluses or con- siologists and nurse anesthetists primarily because of
tinuous infusions in combination with other sedative the rapid and often unanticipated transition from mini-
or hypnotic agents. However, extreme caution and mal to deep sedation. The frequent complication of
scrupulous monitoring are required when these potent sudden apnea and hypotension associated with the
narcotics are used because of the risk of respiratory use of propofol requires airway management and
arrest, particularly when used in combination with resuscitative skills. Because of its overall efficacy
other sedative or analgesic medications [212, 213]. during moderate sedation, propofol became attractive
Use of these medications should be restricted to the to physicians of other specialties such as gastroin-
anesthesiologist or the CRNA. A major disadvantage tenterology, pulmonology, and emergency medicine
of narcotic medication is the perioperative nausea and for outpatient procedures [222]. However, the FDA
vomiting [214]. All narcotic medications are reversed required the package labeling of propofol to include
by naloxone (Narcan, DuPont). the statement, should be administered only by per-
Many surgeons feel comfortable administering sons trained in the administration of general anesthesia
SAM to patients. Others prefer to use the services of and not involved in the conduct of the surgical/diag-
an anesthesiologist or CNRA. Prudence dictates that nostic procedure [223].
for prolonged or complicated surgeries or for patients Contending that propofol can be safely adminis-
with significant risk factors, the participation of the tered by a registered nurse under physician supervi-
anesthesiologist or CRNA during procedures requiring sion, these physician groups have advocated that
sedative-analgesia is preferable. Regardless of who the FDA change the labeling requirements so that
administers the anesthetic medications, the monitoring the use of propofol for moderate sedation could be
must have the same level of vigilance. expanded to include other medical specialties. How-
Propofol (Diprivan, AstraZeneca), a member of ever, the American Society of Anesthesiologists and
the alkylphenol family, has demonstrated its versa- the American Association of Nurse Anesthetists issued
tility as a supplemental sedative-hypnotic agent for a joint statement urging adherence to the packaging
local anesthesia and regional anesthesia. Propofol recommendations because of concerns of potential
may be used alone or in combination with a variety of complications which could occur during moderate and
other medications. The rapid metabolism and clear- deep anesthesia with the administration of propofol by
ance of propofol result in faster and more complete individuals not trained in the management of patients
recovery with less postoperative hangover than other under anesthesia [224]. Any physician who intends to
sedative-hypnotic medications such as midazolam and use propofol sedation must be proficient in the man-
methohexital [193, 215]. The documented antiemetic agement of potential complications associated with
properties of propofol yield added benefits of this propofol, particularly the management of apnea and
medication [216]. The disadvantages of propofol airway obstruction [225229].
include pain on intravenous injection and the lack of Fospropofol disodium (Lusedra, Eisai), a water-
amnestic effect [217]. However, the addition of 3 mL based, phosphorylated prodrug of propofol, was
of 2% lidocaine to 20 mL of propofol reduces the approved by the FDA in May of 2008 for use during
pain on injection with no added risk. If an amnestic MAC by physicians trained in the administration of
response is desired, a small dose of a benzodiazepine, general anesthesia. Fospropofol is rapidly metabolized
such as midazolam, 25 mg iv, given in combina- by alkaline phosphatases into propofol, formaldehyde,
tion with propofol, provides the adequate amnesia. and phosphate. Fospropofol shares the hypnotic, anxi-
Rapid administration of propofol may be associ- olytic, sedative, and antiemetic properties of propofol.
ated with significant hypotension, decreased cardiac However, because fospropofol is water-based, intrave-
output [218], and respiratory depression [219]. nous administration is not associated with pain, a
Continuous infusion with propofol results in a more significant advantage over propofol. The time to loss
of consciousness, time to peak effect, and duration of as a sedative, hypnotic, and antiemetic medication.
action of fospropofol is longer compared to those of Rather than causing global CNS depression like
propofol. Fospropofol shares the similar decreases barbiturates, droperidol results in more specific CNS
of mean arterial pressure, tachycardia, and respiratory changes similar to phenothiazines. For this reason, the
depression with propofol, although fospropofol cataleptic state caused by droperidol is referred to as
resulted is less apnea than propofol. The optimal dose neuroleptic anesthesia [235]. Droperidol has been
to induce moderate sedation during colonoscopies and used effectively in combination with various narcotic
bronchoscopies was 6.5 mg/kg, while the dose to medications. Innovar is a combination of droperidol
induce deep sedation was 8 mg/kg. Subsequently, one and fentanyl. While droperidol has minimal effect on
quarter of the original dose was administered every respiratory function if used as a single agent, when
4 min to maintain the level of sedation. The time to combined with narcotic medication, a predictable
discharge for patients who received either propofol or dose-dependent respiratory depression may be antici-
fospropofol was significantly faster than for those pated [236]. Psychomimetic reactions such as dys-
patients who received a midazolam and meperidine phoria or hallucinations are frequent, unpleasant side
combination. Most subjects who received fospropofol effects of droperidol. Benzodiazepines or narcotics
experienced varying degrees of mild to moderate reduce the incidence of these unpleasant side effects
perineal itching, burning, or paresthesias that were when used in combination with droperidol [237].
resolved after a few minutes without treatment. Extrapyramidal reactions such as dyskinesias, torti-
Transient myoclonus was also reported in some of the collis, or oculogyric spasms may also occur, even with
participants. Like propofol, fospropofol has no known small doses of droperidol. Diphenhydramine usually
pharmacological antagonist [230]. reverses these complications [238]. Hypotension may
Barbiturate sedative-hypnotic agents such as occur as consequence of droperidols alpha-adrenergic
thiopental (Pentothal) and methohexital (Brevital), blocking characteristics. One rare complication of
while older, still play a role in some clinical settings. droperidol is the neuroleptic malignant syndrome
In particular, methohexital, with controlled boluses, (NMS) [239], a condition very similar to malignant
1020 mg iv, or limited infusions, remains a safe and hyperthermia (MH), characterized by extreme tem-
effective sedative-hypnotic alternative with rapid recov- perature elevations and rhabdomyolysis. The treat-
ery. However, with prolonged administration, recovery ment of NMS and MH is essentially the same.
from methohexitial may be delayed compared to propo- While droperidol has been used for years without
fol [231]. Barbiturate medications have no known phar- appreciable myocardial depression [237], a surprising
macological reversing agent. announcement from the Federal Drug Administration
Ketamine (Ketalar, Pfizer), a phencyclidine warned of sudden cardiac death resulting after the
derivative, is a unique agent because of its combined administration of standard, clinically useful doses
sedative and analgesic effects and the absence of [240]. Unfortunately, despite studies which refute
cardiovascular depression in healthy patients [232]. the FDA s conclusions [241] and an expert panels
Because the CNS effects of ketamine result in a state opinion supporting the use of droperidol [242],
similar to catatonia, the resulting anesthesia is often this potential complication makes the routine use of
described as dissociative anesthesia. Although gag and this once very useful, cost-effective medication diffi-
cough reflexes are more predictably maintained with cult to justify given the presence of other alternative
ketamine, emesis and pulmonary aspiration of gastric medications.
contents are still possible [233]. Unfortunately, a Butorphanol, buprenorphine (Buprenex, Reckitt
significant number of patients suffer distressing post- Benckiser), and nalbuphine (Nubain, Endo) are three
operative psychomimetic reactions [234]. While con- synthetically derived opiates which share the proper-
comitant administration of benzodiazepines attenuates ties of being mixed agonistantagonist at the opiate
these reactions, the postoperative psychological seque- receptors. These medications are sometimes preferred
lae limit the usefulness of ketamine for most elective as supplemental analgesics during local, regional, or
outpatient surgeries. general anesthesia because they partially reverse the
Droperidol (Inapsine, Janssen), a butyrophenone analgesic and respiratory depressant effects of other
and a derivative of haloperidol, an antipsychotic, acts narcotics. While these medications result in respiratory
122 G.D. Bennett
depression at lower doses, a ceiling effect occurs at 9.5.3 General Anesthesia

higher dose, thereby limiting the respiratory depres-
sion. Still, respiratory arrest is possible, especially if While some authors attribute the majority of complica-
these medications are combined with other medications occurring during and after aesthetic procedures
tions with respiratory depressant properties [243]. to the administration of systemic anesthesia [32,
While the duration of action of butorphanol is 23 h, 253], others consider sedation and general anesthesia
nalbuphine has a duration of action of about 36 h and safe and appropriate alternatives in indicated cases
buprenorphine up to 10 h with a peak effect occurring [27, 171, 254, 255]. In fact, Klein correctly acknowl-
after 3 h, making these medications less suitable for edges that most of the complications attributed to
surgeries of shorter duration. Finally, if a patient has midazolam and narcotic combinations occurred as a
been taking narcotic analgesics for the treatment of a result of inadequate monitoring [32]. Although signifi-
chronic pain condition, the addition of an agonist cant advances have been made in the administration of
antagonist medication for the procedure could precipi- local anesthetics and supplemental medications, the
tate withdrawal symptoms. use of general anesthesia may still be the anesthesia
Dexmedetomidine (Precedex, Abbott), an alpha2- technique of choice for many patients undergoing
adrenoreceptor agonist, with eight times the affinity aesthetic surgical procedures. General anesthesia is
and the anxiolytic, sedative, and analgesic properties especially appropriate when working with patients suf-
of clonidine, is another recent addition to the available fering extreme anxiety, high tolerance to narcotic or
medications for sedation-analgesia. [244]. Dexmedeto- sedative medications, or if the surgery is particularly
midine has also been shown to reduce the sympathetic complex. The goals of a general anesthetic are a smooth
response to anesthesia and surgery. Several studies induction, a prompt recovery, and minimal side effects,
have demonstrated the safety and effectiveness of such as nausea, vomiting, or sore throat.
this medication for outpatient procedures [245247]. Older volatile inhalation anesthetic agents, halot-
Although dexmedetomidine has less respiratory hane, enflurane (Ethrane, Baxter), and isoflurane
depression when compared to other medications, the (Forane, Baxter) [256] are still in use because of the
delayed recovery time compared with other alterna- cost-effectiveness and the long-established safety,
tives, the relative expense of the medication, and reliability, and convenience of use in selected patient
the potential adverse effects of hypotension and populations. Because of the risk of halothane hepatitis
bradycardia have led some authors to conclude that and MH, halothane should not be used in adults unless
the potential usefulness of this medication for outpa- there is a specific indication. Any halogenated volatile
tient procedures requiring sedation-analgesia may be inhalation anesthetic may cross-react and precipitate
limited [248]. hepatitis in patients who have previously suffered
Chloral hydrate, the first and oldest of the medica- halothane hepatitis [257]. Inhalation anesthetics should
tions developed for sedation, was first synthesized in not be used in patients who have experienced any
1832. Chloral hydrate and nitrous oxide combina- postoperative hepatotoxicity.
tions have been used for sedation, particularly in the The newer inhalation agents, sevoflurane (Ultane,
pediatric population for office-based procedures, Baxter) and desflurane (Suprane, Anaquest), share
including dental work and diagnostic procedures, the added benefit of rapid onset of action and emer-
for many years primarily because of the convenience gence [256, 258, 259]. However, these newer agents
of the oral chloral hydrate dosing (70 mg/kg). Many are associated with higher costs, especially desflurane
of these procedures have been performed in non- due to the high total anesthetic consumption during
accredited offices without the monitoring recom- normal surgical procedures [259] and the requirement
mended by the ASA Guidelines. As a result, this of a heated vaporizer.
combination of medications has resulted in complica- Nitrous oxide, a long-time favorite anesthetic inha-
tions in a significant number of patients primarily due lation agent, although popular because of its shorter
to hypoxemia [249]. Many of these complications duration of action and low cost, is associated with post-
may have been avoided with proper patient monitor- operative nausea and vomiting [260] and perioperative
ing. Table 9.9 summarizes the recommended doses hypoxemia. With the advent of the shorter-acting inha-
for SAM [250252]. lation agents, sevoflurane and desflurane, the necessity
Table 9.9 Common medications and dosages used for sedative analgesiaa
Medication Bolus dose Average adult dose Continuous infusion rate
Opioid analgesics rapid onset, short duration of action (sedative, analgesic)
Alfentanil 57 mg/kg 3050 mg 0.20.5 mg/kg/min
Fentanyl 0.30.7 mg/kg 2550 mg 0.010.02 mg/kg/min
Remifentanil 0.250.5 mg/kg 1030 mg 0.0250.1 mg/kg/min
Sufentanil 0.050.15 mg/kg 2.57.5 mg 0.10.5 mg/kg/h
Opioid analgesics slower onset, long duration of action (sedative, analgesic)
Meperidine 0.2 mg/kg 1020 mg iv, 50100 mg im NA
Morphine 0.02 mg/kg 12 mg iv, 510 mg im NA
Opiate agonistantagonist analgesics long duration of action (sedative, analgesic)
Buprenorphine 25 mg/kg 0.10.3 mg NA
Butorphanol 27 mg/kg 0.10.5 mg NA
Nalbuphine 0.070.1 mg/kg 47.5 mg NA
Benzodiazepines (sedative, anxiolytic, hypnotic, amnestic)
Diazepam 0.050.1 mg/kg 57.5 mg NA
Lorazepam 0.010.02 mg/kg 12 mg NA
Midazolam 0.0300.075 mg/kg 2.55.0 0.501.0 mg/kg/min
a2-adrenergic agonists (sedative, hypnotic, analgesic)
Dexmedetomidine 1 mg/kg 2070 mg 0.20.7 mg/kg/min
Alkylphenols (sedative, antiemetic)
Fospropofol 6.5 mg/kg 120400 mg NA
Propofol 0.20.5 mg/kg 1050 mg 1075 mg/kg/min
Barbituate (sedative, hypnotic)
Methohexital 0.20.5 mg/kg 1020 mg 1020 mg/kg/min
Thiopental 0.51.0 mg/kg 2550 mg 2050 mg/kg/min
Phencyclidine (dissociative hypnotic, sedative, analgesic)
Ketamine 0.20.5 mg/kg 1020 mg 510 mg/kg/min
a
Based on an average weight of 70 kg. These doses may vary depending on age, gender, underlying health status, and other
concomitantly administered medications
Adapted from Philip [250], SaRego et al. [251], and Fragen [252]
of nitrous oxide is much less compelling. Table 9.10 vecuronium, and pancuronium), may allow for faster
[256259, 261, 262] summarizes the available inhala- and more predictable recovery from neuromuscular
tion anesthetics and some of the significant clinical blockade [271]. The anesthesiologist or CRNA should
characteristics. preferentially be responsible for the administration
The development of potent, short-acting sedatives, and monitoring of a general anesthesia when these
opioid analgesics (Table 9.11) [250252, 262267], medication regimens are being used.
and neuromuscular blocking agents (NMBAs)
(Table 9.12) [268270] has resulted in medication reg-
imens that permit the use of intravenous agents exclu- 9.5.4 Preoperative Preparation
sively for surgical procedures requiring general
anesthesia. Most of these medications can also be used Generally, medications which may have been required
during general anesthesia in combination with other to stabilize the patients medical conditions should be
sedative (Table 9.9) and inhalation agents (Table 9.10) continued up to the time of surgery. Notable excep-
using modified doses for each type of combination tions include anticoagulant medications, monoaomine
[263]. Sugammadex (Bridion, Schering-Plough), a oxidase inhibitors (MAO) [272, 273], and possibly
novel synthetic cyclodextrin neuromuscular relaxant the angiotensin-converting enzyme (ACE) inhibitor
reversal agent, which acts by selectively binding the medications [274, 275]. It is generally accepted that
steroidal neuromuscular blocking agents (rocuronium, MAO inhibitors, isocarboxazid (Marplan, Oxford
124 G.D. Bennett
Table 9.10 Inhalation Agent MACa(%) Significant clinical considerations

anesthetics
Rapid onset and recovery
Desflurane 6.0 Fastest rate of recovery of all inhaled agents
Only volatile agent that does not reduce pulmonary resistance.
Induction by inhalation
poorly tolerated
Requires heated vaporizer
Most expensive inhalation agent
Increased risk of MH in susceptible patients
Nitrous oxide 105 Non-halogenated
May cause diffusion hypoxia and increase PONV
Megaloblastic bone marrow depression may occur after 12 h of
exposure
Sevoflurane 1.71 Induction by inhalation, well tolerated in adults and children
Potentially nephrotoxic only after prolonged exposure
No cases of renal failure have been reported
Slower onset and recovery
Enflurane 1.68 Rarely used in the USA
Halothane 0.76 Induction by inhalation in children, well tolerated
Hepatitis occurs in 1:10,000 adults
Should not be used in adults
Induction by inhalation in children, well tolerated
Isoflurane 1.12 Induction by inhalation poorly tolerated
a
Minimum alveolar concentration required for immobility in 50% of subjects exposed to a noxious
stimulus
Table 9.11 Common Average Continuous

intravenous medications and Medication Bolus dose adult dose infusion rate
dosages used for general
Opioids
anesthesiaa
Alfentanil 25100 mg/kg to 7 mg 0.52 mg/kg/min
Fentanyl 315 mg/kg 2001,000 mg 210 mg/kg/h
Remifentanil 12 mg/kg 70140 mg 0.11.0 mg/kg/min
Sufentanil 0.252 mg/kg 20160 mg 0.51.5 mg/kg/h
Alkylphenols (sedative, antiemetic)
Fospropofol 6.5 mg/kg 200450 mg NA
Propofol 13 mg/kg 75200 mg 50150 mg/kg/min
Barbituates
Methohexital 12 mg/kg 75150 mg 50100 mg/kg/min
Thiopental 34 mg/kg 200300 mg 70100 mg/kg/min
Imidazoles
Etomidate 0.20.6 mg/kg 1040 mg NA
Phencyclidines
Ketamine 0.52.0 mg/kg 35150 mg 15100 mg/kg/min
a
Based on an average weight of 70 kg. These doses are for sole use of the agent listed and may vary
depending on age, gender, underlying health status, and other concomitantly administered medi-
cations. Doses may change if additional medications are added
Table 9.12 Intubating Significant clinical characteristics

Neuromuscular Medication dosea
blocking agents for
Longer duration of action and slower onset of action
general anesthesia
d-tubocurarine 0.5 mg/kg Oldest agent. Causes hypotension through ganglionic
blockade and histamine release
Pancuronium (Pavulon) 0.1 mg/kg Causes tachycardia and hypertension through vagal
blockade
Intermediate duration of action with faster onset of action
Atacurium (Nimbex) 0.5 mg/kg Metabolized by ester hydrolysis and Hoffman
degeneration
Can be used in patients with kidney failure
Causes histamine release and hypotension and tachycardia
Cisatacurium (Nimbex) 0.2 mg/kg Metabolized by Hoffman degeneration
Can be used in patients with kidney failure
Less histamine release than atacurium
Rocuronium (Zemuron) 1.0 mg/kg The fastest onset of action of all non-depolarizing
NMBAs
Vecuronium (Norcuron) 0.1 mg/kg Not stable in solution. Requires mixing
Shorter duration of action with faster onset of action
Gantacurium 0.4 mg/kg Metabolized by ester hydrolysis and cysteine adduction
Cysteine may be used for reversal
Causes histamine release and hypotension and tachycardia
only at higher doses, less than atacurium
Not yet available in the USA
Succinylcholine 1.0 mg/kg The only depolarizing agent available
The fastest most reliable onset of action of all NMBAs
The shortest duration of action of all NMBAs
Most popular NMBA for rapid sequence induction
Causes skeletal muscle fasciculations and masseter rigidity
May result in severe postoperative myalgias
Causes hyperkalemia in some patients
Increases intracranial and intraocular pressure
May induce MH in susceptible patients
May result in prolonged block in patients
with pseudocholinesterase deficiency
a
Pertains to adults only. Doses may vary in patients depending on weight, body habitus, or medical condi-
tions or additional medications added
Pharmaceuticals Services), paragyline (Eutonyl, discontinuing any of these medications outweigh the
Abbott), phenelzine (Nardil, Pfizer), selegiline benefits of the proposed elective surgery, the patient
(Emsam Transdermal Patch, Bristol-Meyers Squibb, and physician may decide to modify the preoperative
Eldepryl, Deprenyl, Somerset Pharmaceuticals), and medication regimen or to postpone, modify, or even
tranylcypromine (Parnate, Glaxo Smith-Kline), be cancel the proposed surgery.
discontinued 23 weeks prior to surgery, especially for Previous requirements of complete preoperative
elective cases, because of the interactions with narcotic fasting for 1016 h are considered unnecessary by
medications, specifically hyperpyrexia, and certain many anesthesiologists [276, 277]. More recent inves-
vasopressor agents, specifically ephedrine [272, 273]. tigations have demonstrated that gastric volume may
Patients taking ACE inhibitors, captopril (Capoten, be less 2 h after oral intake of 8 oz of clear liquid than
Bristol-Myers Squibb), enalapril (Vasotec, Merck), after more prolonged fasting [278]. Furthermore, pro-
and lisinopril (Prinivil, Merck, Zestril, Zeneca), may longed fasting may increase the risk of hypoglycemia
have a greater risk for hypotension during general [279]. Many patients appreciate an 8-oz feeding of
anesthesia [275]. Diabetics may require a reduction in their favorite caffeinated elixir 2 h prior to surgery.
dosage of their medication. However, if the risks of Preoperative sedative medications may also be taken
126 G.D. Bennett
with a small amount of water or juice. Abstinence PONV [290]. Even though many patients do not suffer
from solid food ingestion for 1012 h prior to surgery PONV in the recovery period after ambulatory anes-
is still recommended. Liquids taken prior to surgery thesia, greater than 35% of patients develop PONV
must be clear [280], e.g., coffee without cream or after discharge [291]. A recent Cochrane review of all
juice without pulp. medications to control PONV, prepared by Carlisle
Healthy outpatients are no longer considered at risk and Stevenson, is the most comprehensive evaluation
for gastric acid aspiration, and therefore, routine use of of the safety and efficacy to date [292].
oral antacids, histamine type-2 (H2) antagonists, or Droperidol (Inapsine, Akorn), 0.6251.25 mg iv,
gastrokinetic medications is not indicated. However, an extremely cost-effective antiemetic [293], has been a
patients with marked obesity, hiatal hernia, or diabetes popular treatment for perioperative nausea and vomiting
mellitus have higher risks for aspiration. These patients for many years. However, troublesome side effects such
may benefit from selected prophylactic treatment as sedation, dysphoria, and extrapyramidal reactions have
[281]. Sodium citrate, an orally administered, non- been described [294]. In 2001, the FDA issued a black
particulate antacid, rapidly increases gastric pH. box warning concerning a fatal cardiac arrhythmia, tor-
However, its unpleasant taste and short duration of sades de pointes, due to prolongation of the QT interval
action limit its usefulness in elective surgery [96]. after low doses of droperidol [240]. These complications
Gastric volume and pH may be effectively reduced seemed to preclude the widespread use of droperidol alto-
by H2-receptor antagonists. Cimetidine (Tagamet, gether. However, after a closer analysis of the reported
Glaxo), 300 mg po 12 h prior to surgery, reduces cases of cardiac complications following the use of dro-
gastric volume and pH. However, cimetidine is also peridol, one study refuted the FDAs determination that the
a potent cytochrome oxidase inhibitor and may administration of droperidol, in doses less than 1.25 mg,
increase the risk of reactions to lidocaine during caused the reported cardiac complications [241]. The
tumescent anesthesia [282]. Ranitidine (Zantac, FDAs conclusion has been further challenged following
Glaxo), 150300 mg po 90120 min prior to surgery a review of all the pertinent data by an expert panel from
[283], or famotidine (Pepcid, Merck), 20 mg po Duke University Medical Center in 2003 [242].
60 min prior to surgery, are equally effective but have Ondansetron (Zofran, Pfizer), a seratonin antago-
a better safety profile than cimetidine [284]. nist, 48 mg iv, one of the most effective antiemetic
Omeprazole (Prilosec, Astra Zeneca), 20 mg po, medications available, is generally not associated with
which decreases gastric acid secretion by inhibiting the sedative, dysphoric, or extrapyramidal sequelae [295,
proton-pump mechanism of the gastric mucosa, is a safe 296]. The antiemetic effects of ondansetron may
and effective alternative to the H2-receptor antagonists reduce PONV for up to 24 h postoperatively [297].
[284]. Metaclopramide (Reglan, Baxter and Schwarz The effects of ondansetron may be augmented by the
Pharma),1020 mg po or iv, a gastrokinetic agent, which addition of dexamethasone, 48 mg iv [298], or dro-
increases gastric motility and lowers esophageal sphinc- peridol, 0.6251.25 mg iv [299]. Ondansetron is avail-
ter tone, may be effective in patients with reduced gas- able in a parenteral preparation and as orally
tric motility, such as diabetics or patients receiving disintegrating tablets and oral solution. Other effective
opiates [97, 214]. However, extrapyramidal side effects, serotonin antagonists, granisetron (Kytril, Roche),
such as permanent dystonic reactions, which have been 1 mg iv, and dolasetron mesylate (Anzemet, Aventis
reported to occur with just one dose, limit the routine Pharmaceuticals), 12.525 mg iv, share the efficacy of
use of the medication [97, 98, 214]. ondansterone but have half-lives twice that of ondan-
Postoperative nausea and vomiting (PONV) remains sterone [300, 301]. Granisetron is also available in a
one of the more vexing complications of anesthesia transdermal preparation.
and surgery [285]. In fact, patients dread PONV more Promethazine (Phenergan, Baxter), 12.525 mg
than any other complication, even postoperative pain po, pr, or im, a phenothiazine, one of the first H1-
[286]. PONV is the most common postoperative com- receptor antagonists available for the treatment of
plication [287], the most important factor in determin- nausea and vomiting, is still in use today by many
ing length of stay after ambulatory anesthesia [288], physicians for prophylaxis of PONV, especially in
and the most common cause of postoperative patient combination with narcotic analgesics. In 2009, the
dissatisfaction [289]. Use of prophylactic antiemetic FDA issued a warning regarding severe tissue damage
medication has been shown to reduce the incidence of and gangrene following the use of intravenous or
Table 9.13 Antiemetic Antiemetics Dose (mg) Route Significant adverse effects
medications
Aprepitant 4080 po Headache
Dexamethasone 410 iv, im Slow onset, fluid retention
Dimenhydrinate 2550 po, iv, im Sedation, hypotension
Diphenhydramine 2550 po, iv, im Sedation, hypotension
Dolasetron 12.525 iv Headache, possible arrhythmia
Droperidol 0.6252.5 iv Sedation, dysphoria, extrapyramidal
symptoms, cardiac arrhythmias
Fosaprepitant 115 iv Injection site pain
Granisetron 1 iv Headache, tachycardia
Hydroxyzine 2550 po, iv, im Sedation, hypotension
Metachlopromide 1020 po, iv Tardive dyskinesia, dystonic reactions
Ondansterone 48 iv, im, sl Headache, tachycardia
Prochlorperazine 510/25 po, im, pr Dysphoria, extrapyramidal symptoms,
oculogyric crisis
Promethazine 12.525 po, im, pr Sedation, extrapyramidal symptoms,
dystonic reactions, vascular necrosis
Scopolamine 0.2 im, iv, tc Sedation, disorientation, dry mouth,
blurred vision, tachycardia, psychosis
subcutaneous promethazine administration. Because (Benedryl, McNeil), 2550 mg po, im, or iv; dimenhy-
of the anticholinergic properties, promethazine use in dranate (Dramamine, Pfizer), 25 50 mg po, im, or iv;
patients with prostatic hypertrophy may result in uri- and hydroxyzine (Atarax or Visaril, Pfizer), 50 mg
nary retention. Prochlorperazine (Compazine, Glaxo po or im [306], may also be used to treat and prevent
Smith Kline), 510 mg po or im and 25 mg pr, is PONV with few side effects except for possible rare
another older antiemetic phenothiazine that is still in hypotension and postoperative sedation [307].
use for PONV. Once again, sedation and extrapyrami- A very a simple, effective and often overlooked
dal effects may complicate the routine prophylactic method of nausea control in the perioperative period is
use of these medications [98, 214]. the use of inhaled isopropyl alcohol, the type contained
Dexamethasone is another safe, cost-effective alter- in widely available single-use alcohol prep pads [308].
native for the prevention and treatment of perioperative While this method has developed as a popular folk
nausea and vomiting with an efficacy equal to remedy for nausea, recent studies have confirmed its
droperidol and ondansterone [284, 302]. A single iv safety and efficacy. This treatment seems to be most
dose of 10 mg dexamethasone has rare reported side effective for nausea associated with vasovagal reactions.
effects and may be combined with other antinauseant Recent advances in the control of nausea and
and antiemetic medications [298]. Because of its vomiting have focused on the neurokinin type 1 (NK1)-
delayed onset of action, dexamethasone should be receptor antagonists such as aprepitant, 40 mg po, for
administered early in the perioperative period [301]. oral dosing and fosaprepitant, 115 mg iv, the lyo-
Preoperative atropine, 0.4 mg im; glycopyrrolate, philized prodrug of aprepitant, for intravenous dosing
0.2 mg im; and scopolamine, 0.2 mg im, anticholinergic (Emend, Merck). NK1 receptors are highly concen-
agents once considered standard preoperative medica- trated in the chemoreceptor trigger zone (CTZ) of the
tions because of their vagolytic and antisialogic effects, emetic center of the brainstem. Substance P, a pain-
are no longer popular because of side effects such as dry mediating neurotransmitter, is a member of the family
mouth, dizziness, tachycardia, and disorientation [303]. of NK peptides [309]. A recent study concluded that
Transdermal scopolamine (Scopoderm TTS, Novartis 40 mg of aprepitant resulted in a significant reduction
Pharma) applied 90 min prior to surgery effectively of nausea and vomiting in the first 24 h after balanced
reduces PONV. However, the incidence of dry mouth anesthesia compared to ondansterone [310]. Table 9.13
and drowsiness is high [304], and toxic psychosis is summarizes these antiemetic medications.
a rare complication [305]. Urinary retention may The selection of anesthetic agents may also play
result from anticholinergic in patients with prostatic a major role in PONV. The direct antiemetic actions
hypertrophy. Antihistamines, such as diphenhydramine, of propofol have been clearly demonstrated [311].
128 G.D. Bennett
Anesthetic regimen utilizing propofol alone or in com- euphoria and may decrease the requirements for other
bination with other medications is associated with sig- sedative medication. The level of anxiolysis and seda-
nificantly less PONV [264]. Although still controversial, tion is still greater with the benzodiazepines than with
nitrous oxide is considered by many authors a prime the opioids. Premedication with narcotics has been
suspect among possible causes of PONV [260, 312, shown to have minimal effects on postoperative recov-
313]. Use of opiates is also considered a culprit in the ery time. However, opioid premedication may increase
development of PONV and the delay of discharge after PONV [322, 323].
outpatient surgery [214, 314316]. Adequate fluid Antihistamine medications, such as hydroxyzine,
hydration has been shown to reduce PONV [317]. 50100 mg im or 50100 mg po, and diphenhydramine,
One goal of preoperative preparation is to reduce 50 mg po, im or 25 mg iv, are still used safely in com-
patients anxiety. Many simple, non-pharmacological bination with other premedications, especially the opi-
techniques may be extremely effective in reassuring oids, to add sedation and to reduce nausea and pruritis.
both patients and families starting with a relaxed, However, the anxiolytic and amnestic effects of these
friendly atmosphere and a professional, caring, and antihistamines are not as potent as the benzodiazepines
attentive office staff. With proper preoperative prepa- [306]. Barbiturates, such as secobarbital and pentobar-
ration, pharmacological interventions may not even be bital, once standard premedications, have largely been
necessary. However, a variety of oral and parenteral replaced by the benzodiazepines and other agents.
anxiolytic-sedative medications are frequently called Postoperative PE is an unpredictable and devastat-
upon to provide a smooth transition to the operative ing complication with an estimated incidence of
room. Diazepam, 510 mg po, given 12 h preopera- 0.15%, depending on the type of surgical cases, and
tively, is a very effective medication, which usually a mortality rate of about 15% [324]. Risk factors for
does not prolong recovery time [318]. Parenteral diaz- thromboembolism include prior history or family
epam, 510 mg iv or im, may also be given preopera- history of DVT or PE, obesity, smoking, hyperten-
tively. However, because of a long elimination half-life sion, use of oral contraceptives or hormone replace-
of 2448 h and active metabolites with elimination ment therapy, and patients over 60 year of age [325].
half-life of 50120 h, caution must be exercised Estimates for the incidence of postoperative DVT
when using diazepam, especially in shorter cases, so vary from 0.8% for outpatients undergoing hernior-
that recovery is not delayed [208]. Pain and phlebitis rhaphies [326] to as high as 80% for patients under-
with iv or im administration also reduces the popular- going total hip replacement [324]. Estimates of fatal
ity of diazepam [206]. PE also vary from 0.1% for patients undergoing
Lorazepam, 12 mg po or sl, 12 h preoperatively, general surgeries to up to 15% of patients undergo-
is also an effective choice for sedation or anxiolysis. ing major joint replacement [324]. While a recent
However, the prolonged duration of action may prolong national survey of physicians performing tumescent
recovery time after shorter cases [319]. Midazolam, liposuction in a total of 15,336 patients indicated
510 mg im 30 min preoperatively or 25 mg iv that no patient suffered DVT or PE [327], only 66
minutes prior to surgery, is a more potent anxiolytic- physicians who perform liposuction responded out of
sedative medication with more rapid onset and shorter 1,778 questionnaires sent, which is a mere 3.7%
elimination half-life compared to diazepam [320]. response rate. A review of 26,591 abdominoplasties
While midazolam is available in an oral syrup prepara- revealed nine cases of fatal PE, or 0.03%, but gave no
tion for children because of unpredictable results, it is information regarding the incidence of non-fatal PE
not considered a useful alternative for preoperative [328]. Other reports suggest that the incidence of pul-
medication in adults [321]. Oral narcotics, such as monary embolism after tumescent liposuction and
oxycodone, 510 mg po, may help relieve the patients abdominoplasty may be more common than reported
intraoperative breakthrough pain during cases under [329333]. One study revealed that unsuspected PE
sedative-analgesic anesthesia with minimal potential may actually occur in up to 40% of patients with who
perioperative sequelae. Parenteral opioids, such as develop DVT [333].
morphine, 510 mg im or 12 mg iv; meperidine, Prevention of DVT and PE should be considered an
50100 mg im or 1020 mg iv; fentanyl, 1020 mg iv; essential component of the perioperative management.
or sufentanil, 12 mg iv, may produce sedation and Although unfractionated heparin reduces the rate of
fatal PE [334], many surgeons are reluctant to use this Table 9.14 Anatomical characteristics that identify a
potentially difficult airway
prophylaxis because of concerns of perioperative
hemorrhage. The low-molecular-weight heparins, 1 Prodigious upper incisors
enoxaparin (Lovenox or Clexane, Sanofi-Aventis), 2 Prominent overbite
dalteparin (Fragmin, Pfizer), and ardeparin 3 Space between incisors with maximum oral opening less
than 3 cm (less than 2 finger widths)
(Normiflo, Wyeth-Ayerst), are available for prophy-
4 Inability to completely visualize uvula (Mallampati class
lactic indications. Graduated compression stockings III or IV)
and intermittent pneumatic lower extremity compres- 5 Thyromental mental distance less than 3 finger widths
sion devices applied throughout the perioperative 6 Short or thick neck anatomy (circumference great
period until the patient has become ambulatory are than 60 cm)
considered very effective and safe alternatives in the 7 Reduce cervical range of motion (i.e., due to degenera-
prevention of postoperative DVT and PE [335, 336]. tive joint disease or trauma)
8 Inability to voluntarily prognath mandible
Even with prophylactic therapy, PE may still occur up
9 Limited mandibular joint compliance
to 30 days after surgery [337]. Physicians should be
10 Narrow or highly arched palate
suspicious of PE if patients present postoperatively
with dyspnea, chest pain, cough, hemoptysis, pleuritic
pain, dizziness, syncope, tachycardia, cyanosis, short- Table 9.15 Critical decisions during the management of a
ness of breath, or wheezing [325]. difficult airway
1 Awake intubation (with or without fiber-optic devices)
versus intubation after induction of general anesthesia
2 Maintenance or suppression of spontaneous ventilation
9.5.5 Airway Management (i.e., with muscular paralysis)
3 Use of ventilation aids (e.g., LMA or Combitube
Maintaining a patent airway, ensuring adequate esophageal/tracheal airway)
ventilation, and prevention of aspiration of gastric con- 4 Call for help from another physician qualified in airway
tents are the goals of successful airway management. management
Because the consequences of complications related to 5 Invasive intubation (e.g., retrograde wire intubation,
airway management misadventures are so potentially cricothyrotomy, tracheostomy)
6 Abandon intubation attempts and awaken the patient
devastating, this important topic warrants special focus.
Indeed, an analysis of closed claims confirms that
complications due to airway mismanagement generate A critical element of airway management is the preop-
one of the highest numbers of legal claims [338]. erative airway assessment. Proper crisis preparation
Because of the inherent pathology associated with is critical to the avoidance of airway management
many aesthetic surgery patients, such as cleft palate, disasters. One consideration often acknowledged by
hypoplastic facial malformations, post-traumatic or experienced anesthesiologists is that the presence of
post-neoplastic resection deformities, reconstruction full facial hair often conceals potential facial anoma-
deformities, or morbid obesity, many patients underlies that could make intubation more challenging.
going various aesthetic surgical procedures should be Table 9.14 summarizes important anatomical charac-
classified as higher risk due to airway abnormalities. teristics that identify a potentially difficult airway dur-
Physicians administering anesthesia to patients under- ing the preoperative airway assessment modified from
going aesthetic surgery should study the difficult the ASA Task Force on Management of the Difficult
airway algorithm published by the American Society Airway [339]. These abnormalities could legitimately
of Anesthesiologists (ASA) [339]. be referred to as the terrifying ten traits.
Surgeons who perform procedures without the Table 9.15 summarizes critical decisions during the
assistance of an anesthesiologist are obligated to management of a difficult airway modified form the
understand these critical airway issues as well. In the ASA Difficult Airway Algorithm [340].
majority of cases, simple airway obstruction during In general, for airways that could potentially present
moderate or deep sedation may be easily relieved by a serious challenge to the physician, the awake, fiberop-
gently elevating the anterior mandible with one finger, tic-assisted approach with sedation is the initial prefer-
a maneuver aptly described as the finger of life. ential course of action. Maintenance of spontaneous
130 G.D. Bennett
ventilation is usually a safer alternative than suppres- 9.5.6 Perioperative Monitoring

sion of spontaneous ventilation with very difficult air-
ways. When airway trauma is evident due to multiple The adoption of standardized perioperative monitoring
unsuccessful attempts at direct laryngoscopy or intuba- protocol has resulted in a quantum leap in perioperative
tion, or there is an inability to ventilate the patient with patient safety. The standards for basic perioperative
an occlusive mask or ventilatory assist devices (LMA: monitoring were approved by the ASA in 1986 and
LMA North America, Inc. San Diego, California or amended in 1995 [25]. These monitoring standards are
Combitube Esophageal/Tracheal Airway: Tyco- now considered applicable to all types of anesthetics,
Kendall, Mansfield, MA), it is always advisable to including local with or without sedation, regional, or
awaken the patient and proceed on another day. Invasive general anesthesia, regardless of the duration or com-
airway management should be reserved for emergency plexity of the surgical procedure, regardless of whether
situations that may otherwise result in significant mor- the procedures are performed in the office or the hospital
bidity or mortality. The anesthesiologist should have a setting, and regardless of whether the surgeon or anes-
pre-prepared difficult intubation tray or cart available thesiologist is responsible for the anesthesia. Vigilant,
for every case. continuous monitoring and compulsive documentation
It would not be an exaggeration to state that the facilitates early recognition of deleterious physiologi-
laryngeal mask airway (LMA) has transformed airway cal events and trends, which, if not recognized promptly,
management for elective and emergency airway con- could lead to irreversible pathological spirals, ulti-
trol. The LMA can be a life-saving alternative to main- mately endangering a patients life.
tain an open airway during difficult intubations. The During the course of any anesthetic, the patients
LMA may also serve as airway support for cases that oxygenation, ventilation, circulation, and temperature
may not require full endotracheal intubation during should be continuously evaluated. The concentration
both adult [341] and pediatric procedures [342]. of the inspired oxygen must be measured by an oxygen
LMAs of various sizes should be available within easy analyzer. Assessment of the perioperative oxygenation
reach during any surgical procedure regardless of the of the patient using pulse oximetry, now considered
type of anesthesia used. Facial aesthetic surgeries that mandatory in every case, has been a significant
require unrestricted access to the oral cavity and lower advancement in monitoring. This monitor is so critical
facial regions often require nasotracheal intubation. to the safety of the patient that it has earned the nick-
Obviously, this procedure requires an anesthesiologist name the monitor of life. Evaluation of adequate
with extensive training and experience to avoid serious ventilation includes observation of skin color, chest
complications to the upper airway. Techniques that wall motion, and frequent auscultation of breath
facilitate safe nasotracheal intubation are: sounds. During general anesthesia with or without
1. Pretreatment of the nasopharynx with a vasocon- mechanical ventilation, a disconnect alarm on the
strictor (oxymetolosine 0.05%, Afrin, Schering) anesthesia circuit is crucial. Capnography, a measure-
2. Nasotracheal tube one size smaller than the size ment of respiratory end-tidal CO2, is required not only
normally used for orotracheal intubation when the patient is under moderate sedation, deep
3. Prewarming the endotracheal tube to 45C sedation, or general anesthesia but also during the
4. Progressively dilating the nasopharynx with lubri- postoperative recovery period. Capnography provides
cated rubber nasopharyngeal tubes after induction the first alert in the event of airway obstruction,
5. Copious lubrication of the endotracheal tube with a hypoventilation, or accidental anesthesia circuit dis-
dental anesthetic lubricant (with benzocaine 10%) connect, even before the oxygen saturation has begun
6. Preflexing the tip of the endotracheal tube just prior to fall. The use of capnography should also be applied
to intubation to negotiate the nasopharyneal curve to patients recovering from sedation-analgesia or gen-
7. Using curved intubating forceps (Magill) to direct eral anesthesia because of the potential for respiratory
the endotracheal tube through the larynx arrest during recovery. All patients must have continu-
When these preparations are employed, compli- ous monitoring of the electrocardiogram (ECG)
cations related to nasotracheal intubation, such as peri- and intermittent determination of blood pressure (BP)
operative nasopharyngeal bleeding or nasopharyngeal and heart rate (HR) at a minimum of 5-min inter-
trauma, are rare [343]. vals. Superficial or core body temperature should be
monitored. Of course, all electronic monitors must position avoiding extreme abduction, extension, or
have preset alarm limits to alert physicians prior to the flexion to prevent traction on peripheral nerves. A pillow
development of critical changes. under the knees in the supine position may reduce the
While the availability of electronic monitoring pressure on the low back and avoid postoperative back
equipment has improved perioperative safety, there is pain. Prolonged immobilization of the head may result in
no substitute for visual monitoring by a qualified, localized alopecia from follicular pressure necrosis.
experienced practitioner, usually a CRNA or an anes- Maintaining neutral head position during laryngoscopy
thesiologist. During surgeries using local anesthetics may reduce postoperative neck pain. Documentation of
with SAM, if a surgeon elects not to use a CRNA or an proper positioning and frequent checks of positioning
anesthesiologist, a separate, designated, certified indi- may be helpful in the defense in the event of a legal claim
vidual must perform these monitoring functions [33]. due to an unanticipated perioperative nerve injury.
Visual observation of the patients position is also Patients eyes should be protected from inadvertent con-
important in order to avoid untoward outcomes such as tact to avoid ocular injuries such as corneal abrasions.
peripheral nerve or ocular injuries. Hypothermia should be avoided during extended surgi-
Documentation of perioperative events, interven- cal procedures using FDA-approved warming devices
tions, and observations must be contemporaneously such as the Bair-Hugger, Arizant Healthcare Inc. Make-
performed and should include BP and HR every 5 min shift warming devices such as heated IV bags, heated
and oximetry, capnography, ECG pattern, and temper- water bottles, electric blankets, warming lights, or forced
ature at 15-min intervals. Intravenous fluids, medica- heated air are absolutely contraindicated due to the high
tion dosages in mg, patient position, and other likelihood of severe burn injuries [346, 347].
intraoperative events must also be recorded. Proper
documentation may alert the physician to unrecog-
nized physiological trends that may require treatment. 9.5.7 Perioperative Fluid Management
Preparation for subsequent anesthetics may require
information contained in the patients prior records, Management of perioperative fluids probably gener-
especially if the patient suffered an unsatisfactory out- ates more controversy than any other anesthesia-related
come due to a previous anesthetic regimen. Treatment topics. Generally, the typical, healthy, 60-kg patient
of subsequent complications by other physicians may requires about 100 mL of water per hour to replace
require information contained in the records, such as metabolic, sensible, and insensible water losses. After
the types of medications used, blood loss or fluid totals. a 1012 h period of fasting, a 60-kg patient may be
Finally, compulsive documentation may help exoner- expected to have an approximately 1 L volume deficit
ate a physician in many medical-legal challenges. on the morning of surgery. This deficit should be
When local anesthesia with SAM is used, monitor- replaced iv over the first few hours of surgery. In addi-
ing must include an assessment of the patients level of tion to the fluid deficit, induction of general anesthesia
consciousness as previously described. For patients is usually accompanied by vasodilatation which
under general anesthesia, the level of consciousness requires compensatory iv fluid administration of
may be determined using the bispectral index (BIS), a approximately 0.5 mL/kg, or 300 mL. The patients
measurement derived from computerized analysis of usual maintenance fluid needs may be met during sur-
the electroencephalogram. When used with patients gery with an iv crystalloid solution such as lactated
receiving general anesthesia, BIS improves control of Ringers solution.
the level of consciousness, rate of emergence and Replacement fluids may be divided into crystalloid
recovery, and cost control of medication usage [344]. solutions, such as normal saline (0.9% NaCl) or bal-
Given that 18% of malpractice claims against anes- ance salt solution (lactated Ringers solution); colloids,
thesiologists are related to peripheral nerve injuries such as fresh frozen plasma, 5% albumin, plasma pro-
occurring in the perioperative period [345], scrupulous tein fraction, or hetastarch; and blood products contain-
attention to patient positioning during anesthesia is ing red blood cells, such as packed red blood cells.
critical, especially for prolonged cases under general Generally, balanced salt solutions may be used to
anesthesia. Elbows, knees, and feet should be carefully replace small amounts of blood loss. For every mL of
padded and the extremities should be placed in a neutral blood loss, 3 mL of fluid replacement is usually required
132 G.D. Bennett
[348]. However, as larger volumes of blood are lost, administered intravenously and as tumescent infusate.
attempts to replace these losses with crystalloid reduces This replacement formula presumes a ratio of infusate
the serum oncotic pressure, one of the main forces sup- to aspirate of greater than 2 to 1. If the ratio is less than
porting intravascular volume. Subsequently, crystalloid one, more generous replacement fluids may be required
rapidly moves into the extracellular space. Intravascular since hypovolemia may occur [18]. The determination
volume cannot be adequately sustained with further of fluid replacement is still not an exact science, by any
crystalloid infusion [349]. At this point, many authors means. Because of the unpredictable fluid require-
suggest that a colloid solution may be more effective in ments in patients, careful monitoring is required,
maintaining intravascular volume and hemodynamic including possible laboratory analysis such as CBC
stability [350, 351]. Given the ongoing crystalloid- and BUN [18]. To avoid hypothermia, particularly dur-
colloid controversy in the literature, the most practi- ing longer or more extensive surgical procedures, all
cal approach to fluid management is a compromise. intravenous or tumescent fluids should be prewarmed
Crystalloid replacement should be used for estimated to 40C (104F). During prolonged surgical proce-
blood losses (EBL) less than 500 mLs, while colloids, dures under sedation-analgesia, care must be taken not
such as hetastarch, may be used for EBLs greater than to administer too much fluid to avoid patient discom-
500 mLs. One milliliter of colloid should be used to fort due to a distended urinary bladder.
replace 1 mL of EBL [348]. However, not all authors The estimation of perioperative blood and fluid loss
agree on the benefits of colloid resuscitation. Moss and during surgical procedures is not a trivial task.
Gould concluded that isotonic crystalloid replacement, Observers in the same room frequently have wide dis-
even for large EBLs, restores plasma volume as well as crepancies in the estimated blood loss. In some surgi-
colloid replacement [352]. cal procedures, unrecognized blood loss may occur.
For patients undergoing liposuction with less than Substantial amounts of blood can seep around and
1500 mL of fat extraction using the tumescent tech- under the patient, unnoticed by the surgeon, only to be
nique, studies have determined that postoperative discovered later as the nurses apply the dressing.
serum hemoglobin remains essentially unchanged Because of subcutaneous hematoma formation and the
[353]. Therefore, intravenous fluids beyond the deficit difficulty of measuring the blood content in the aspi-
replacement and the usual maintenance amounts are rate during large-volume liposuction, estimating the
generally not required [27, 171, 353, 354]. As the vol- EBL during liposuction may be a particularly daunting
ume of fat removed approaches or exceeds 3000 mL, task. Fortunately, the development of tumescent tech-
judicious iv fluid replacement, including colloid, may nique has dramatically reduced perioperative blood
be considered depending on the patients hemodynamic loss during liposuction surgeries [32, 358].
status [27]. Fluid overload with the possibility of pul- The blood content in the aspirate after tumescent
monary edema and congestive heart failure following liposuction has varied between less than 1% [355, 358]
aggressive administration of infusate and intravenous and 8% [356]. To underscore the difficulty of estimat-
crystalloid solutions has become a legitimate concern ing the EBL, the range of the determined blood loss in
[18, 171, 354357]. Using the tumescent technique one study was 01002 mL or 041.5% of the aspirate
during which subcutaneous infusion ratios of 23 mL for liposuctions removing 10005500 mL of fat [356].
for 1 mL of fat is aspirated, significant intravascular Samdal et al. [358] admitted that the mean fall of post-
hemodilution has been observed [355]. A 5-L tumes- operative hemoglobin of 5.2% (4.9%) was higher
cent infusion may result in a hemodilution of 10%. than anticipated. The authors suggested that previous
Plasma lidocaine near toxic levels, combined with an estimates of continued postoperative blood extravasa-
increased intravascular volume, may increase the risk tion into the surgical dead space may be too low and
of cardiogenic pulmonary edema, even in healthy may be greater than the EBL identified in the aspirate.
patients [152, 355, 357]. Mandel [359] concluded that unappreciated blood loss
While crystalloid replacement regimen during lipo- continues for several days after surgery, presumably
suction may vary, Pitman et al. [356] advocate limiting due to soft tissue extravasation, and that serial postop-
iv replacement to the difference between twice the vol- erative hematocrit determinations should be used,
ume of total aspirate and the sum of iv fluid already especially for large-volume liposuctions.
The decision to transfuse a patient involves multiple several liters more than the amount of aspirate [357]
considerations. Certainly, the EBL, health, age, esti- or in cases with minimal blood loss with adequate
mated preoperative blood volume of the patient, and hydration.
the hemodynamic stability of the patient are the pri-
mary concerns. The potential risks of transfusions,
such as infection, allergic reaction, errors in cross 9.6 Recovery and Discharge
matching, and blood contamination should be consid-
ered. Finally, the patients personal or religious prefer- The same intensive monitoring and treatment which
ences may play a pivotal role in the decision to occurs in the operating room must be continued in the
transfuse. Cell-saving devices and autologous blood recovery room under the care of a designated, licensed,
transfusions may alleviate many of these concerns. and experienced person for as long as is necessary to
Healthy, normovolemic patients, with hemodynamic ensure the stability and safety of the patient, regardless
and physiologic stability, should tolerate hemoglobin of whether the facility is a hospital, an outpatient
levels down to 7.5 g/dL [360]. Even for major surgical surgical center, or a physicians office. During the ini-
procedures or large-volume liposuction using the tial stages of recovery, the patient should not be left
tumescent technique, transfusions are rarely necessary alone while hospital or office personnel attend to other
[27]. Once the decision to transfuse is made, 1 mL of duties. Vigilant monitoring including visual observa-
RBCs should be used to replace every 2 mL of EBL tion, continuous oximetry, continuous ECG, and inter-
along with replacement colloid or crystalloid [348]. mittent BP and temperature determinations must be
Serial hematocrit determination, although sometimes continued. Because the patient is still vulnerable to
misleading in cases of fluid overload and hemodilu- airway obstruction and respiratory arrest in the recov-
tion, is still considered an important diagnostic tool in ery period, continuous visual observation is still the
the perioperative period to assist with decisions regard- best method of monitoring for this complication. Sup-
ing transfusion. An estimate of the patients volume plemental oxygenation should be continued during the
status and possibly hemoglobin content of the blood initial stages of recovery and continued until the patient
may be routinely determined by newer, non-invasive is able to maintain an oxygen saturation above 90% on
pulse oxygenation-type monitors in the future. room air.
During longer, extensive surgical procedures and The most common postoperative complication is
large-volume liposuction monitoring, the urine output nausea and vomiting. The antiemetic medications pre-
using an indwelling urinary catheter is a useful guide viously discussed, with the same consideration of
to the patients volume status. Urinary output should potential risks, may be used in the postoperative period.
be maintained at greater than 0.5 mL/kg/h. However, Because of potential cardiac complications, droperi-
urinary output is not a precise method of determining dol, one of the most commonly used antiemetic, is now
the patients volume status since other factors, includ- considered by the FDA unsafe unless the patient has
ing surgical stress, hypothermia, and the medications no cardiac risk factors and a recent 12-lead ECG was
used during anesthesia, are known to alter urinary normal without prolongation of the QT interval [240].
output [361]. Therapeutic determinations based on a Ondansetron, 48 mg iv or sl, is one of the most effec-
decreased urinary output become even more chal- tive and safe antiemetics [295299]. Postoperative sur-
lenging since oliguria may be a result of either hypov- gical pain may be managed with judiciously titrated iv
olemia or fluid overload and congestive heart failure. narcotic medication such as meperidine, 1020 mg iv
In general, use of loop diuretics, such as furosemide, every 510 min; morphine, 12 mg iv every 510 min;
to accelerate urinary output makes everyone in the butorphanol, 0.10.2 mg iv every 10 min; or hydro-
operating room feel better but does little to elucidate morphone, 0.10.2 mg iv every 510 min. However,
the cause of the reduced urinary output, and in cases of when using narcotic medications to control postopera-
hypovolemia, may worsen the patients clinical situa- tive pain, scrupulous monitoring in accordance with
tion. However, a diuretic may be indicated if oliguria the ASA Guidelines [25] must be maintained because
develops in the course of large-volume liposuction of the risk of delayed respiratory depression which
where the total infusate and intravenous fluids is could result in respiratory or cardiac arrest.
134 G.D. Bennett
Following large-volume liposuction, extracellular Table 9.16 Ambulatory discharge criteria

fluid extravasation or third spacing may continue for 1 All life-preserving protective reflexes, i.e., airway,
hours postoperatively leading to the risk of hypoten- cough, gag, must be returned to normal
sion, particularly if the ratio of tumescent infusate to 2 The vital signs must be stable without orthostatic
changes
aspirate is less than one [357]. For large-volume lipo-
3 There must be no evidence of hypoxemia 20 min after
suction, blood loss may continue for 34 days [359]. the discontinuation of supplemental oxygen
Crystalloid or colloid replacement may be required in 4 Patients must be oriented to person, place, time, and
the event of hemodynamic instability. situation (4 times)
The number of complications that occur after dis- 5 Nausea and vomiting must be controlled, and patients
charge may be more than twice the complications should tolerate po fluids
occurring intraoperatively and during the immediate 6 There must be no evidence of postoperative hemorrhage
or expanding ecchymosis
recovery period combined [362]. Accredited ambula-
7 Incisional pain should be reasonably controlled
tory surgical center must have established discharge
8 The patient should be able to sit up without support and
criteria. While these criteria may vary, the common walk with assistance
goal is to ensure the patients level of consciousness 9 Patients should be discharged in the care of a responsible
and physiological stability. It is usually not necessary adult
to urinate prior to discharge for most patients. The fol- 10 Patients should not drive for at least 24 h if sedatives or
lowing is one example of discharge criteria that may be analgesics were used
used (Table 9.16). Modified from Mecca [363]
Use of medications intended to reverse the effects
of anesthesia should be used only in the event of sus- the use of flumazenil and naloxone is the recurrence of
pected overdose of medications. Naloxone, 0.10.2 mg the effects of the benzodiazepine or narcotic after 12 h.
iv, a pure opiate-receptor antagonist, with a therapeutic If the patient has already been discharged to home after
half-life of less than 2 h, may be used to reverse the these effects recur, the patient may be at risk for over
respiratory depressant effects of narcotic medications, sedation or respiratory arrest [364, 367]. Therefore,
such as morphine, demerol, fentanyl, and butorphanol. routine use of reversal agents, without specific indica-
Because potential adverse effects of rapid opiate rever- tion, prior to discharge is ill advised. Patients should be
sal of narcotics include severe pain, seizures, pulmo- monitored for at least 2 h prior to discharge if these
nary edema, hypertension, congestive heart failure, reversal agents are administered [33].
and cardiac arrest [364], naloxone must be adminis- Physostigmine (Antilirium, Forest), 1.25 mg iv, a
tered by careful titration. The effective half-lives of centrally acting anticholinesterase inhibitor, functions
many narcotics exceed the half-life of naloxone. as a non-specific reversal agent which may be used to
Naloxone has no effect on the actions of medications, counteract the agitation, sedation, and psychomotor
such as the benzodiazepines, the barbiturates, propo- effects in the central nervous system caused by a vari-
fol, dexmedetomidine, or ketamine. ety of sedative, analgesic, and inhalation anesthetic
Flumazenil, 0.10.2 mg iv, a specific competitive agents [368, 369]. Neuromuscular blocking drugs, if
antagonist of the benzodiazepines, such as diazepam, required during general anesthesia, are usually reversed
midazolam, lorazepam, may be used to reverse exces- by the anesthesiologist or CRNA prior to emergence in
sive or prolonged sedation and respiratory depression the operating room with anticholinesterase inhibitors
resulting from these medications [365]. The effective such as neostigmine (Prostimine, ICN) or edropho-
half-life of flumazenil is 1 h or less [366]. The half- nium (Enlon, Bioniche Pharma, Tensilon, Valeant
lives of the benzodiazepines exceed the half-life of flu- Pharmaceuticals, or Reversol, Organon) [270].
mazenil. The benzodiazepines have effective half-lives Occasionally, a second dose may be required when the
greater than 2 h and, in the case of diazepam, up to patient is in the recovery room.
50 h. Many active metabolites unpredictably extend the In the event patients fail to regain consciousness dur-
putative effects of the narcotics and benzodiazepines. ing recovery, reversal agents should be administered. If
Because the effective half-lives of most of the ben- no response occurs, the patient should be evaluated
zodiazepines and many of the narcotics exceed that of for other possible causes of unconsciousness, including
flumazenil and naloxone, a major risk associated with hypoglycemia, hyperglycemia, hyponatremia, cerebral
vascular accidents, or cerebral hypoxia. If hemody- 13. Domino KB (2001) Office-based anesthesia: lessons learned
from closed claims project. ASA Newsl 65(6):911
namic instability occurs in the recovery period, causes
14. Grazer FM, de Jong RH (2000) Fatal outcomes from lipo-
such as occult hemorrhage, hypovolemia, pulmonary suction census survey of cosmetic surgeons. Plast Reconstr
edema, congestive heart failure, or myocardial infarc- Surg 105:436446
tion must be considered. Access to laboratory analysis 15. Cote CJ, Notterman DA, Karl HW, Weinberg JA,
McCloskey C (2000) Adverse sedation events in pediatrics:
to assist with the evaluation of the patient is crucial.
a critical incident analysis of contributing factors. Pediatrics
Unfortunately, stat laboratory analysis is usually not 106(4 pt 1):805814
available if the surgery is performed in an office-based 16. Pasternak LR (1995) Screening patients: strategies and stud-
setting. ies. In: McGoldrick KL (ed) Ambulatory anesthesia: a prob-
lem-oriented approach. Williams & Wilkins, Baltimore, p 17
The above text is meant to serve as an overview
17. Kohn RLF (1985) Preoperative assessment and premedica-
of the extremely complex subject of anesthesia. It is tion. In: Smith G, Aitkenhead AR (eds) Textbook of anes-
the intent of this chapter to serve as an introduction to thesia. Churchill Livingstone, New York
the physician highlighting salient considerations in the 18. Fodor PB (1995) Wetting solutions in aspirative lipoplasty: a
plea for safety in liposuction. Aesthetic Plast Surg 19:379380
perioperative management of patients and should not
19. West Group. Wests Annotated California Codes, Business
be considered a comprehensive presentation. The phy- and Professions Code. 3A Article 11.5, Section 2216
sician is encouraged to seek addition information on 20. West Group. Wests Annotated Codes, Health and Safety
this broad topic through the other suggested readings. Code. 38B, Chapter 1.3, Section 1248
21. Morell RC (2000). OBA questions, problems just now rec-
At least one authoritative text on anesthesia should
ognized, being defined. Anesthesia Patient Safety Foundation
be considered a mandatory addition to the physicians Newsletter 15(1): 1-3
office references. 22. American Society of Anesthesiologists (2000) Guidelines
for officebased anesthesia. 2000 Directory of Members.
ASA, Park Ridge, pp 480510; and ASA Newsletter 2000:
64(1)
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analysis. Anesthesiology 80:806810 mazenil: current status and future prospects. Acta Anaes-
348. Tonnesen AS (1994) Crystalloids and colloids. In: Miller R thesiol Scand Suppl 108:3542
(ed) Anesthesia, 4th edn. Churchill Livingstone, New York, 368. Bourke DL, Rosenberg M, Allen PD (1984) Physostigmine:
pp 15951618 effectiveness as an antagonist of respiratory depression and
349. Linko K, Malelaine A (1989) Cardiorespiratory function psychomotor effects caused by morphine or diazepam.
after replacement of blood loss with hydroxyethyl starch Anesthesiology 61(5):523528
120, Dextran-70, and Ringers lactate in pigs. Crit Care 369. Hill GE, Stanley TH, Sleutker CR (1977) Physostigmine
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350. Hankeln K, Radel C, Beez M, Laniewski P, Bohmert F 24:707711
(1989) Comparison of hydroxyethyl starch and lactated
Ringers solution in hemodynamics and oxygen transport
of critically ill patients in prospective cross over studies.
Crit Care Med 17(2):133135 Additional Recommended Reading
351. Dawidson I (1989) Fluid resuscitation of shock: current
controversies. Crit Care Med 17(10):10781080 Miller RD (2010) Millers anesthesia, 7th edn. Churchill
352. Moss GS, Gould SA (1988) Plasma expanders: an update. Livingstone Elsevier, Philadelphia
Am J Surg 155(3):425434 Roizen MF, Fischer SP, White PF (eds) (1997) Ambulatory
353. Jaen C (1997) Study on the possible hydroelectric dis- anesthesia and surgery. WB Saunders, Philadelphia,
orders induced by lipoaspiration with the tumescent pp 155172
Part III
Head and Neck
Facial Peels
10
Niti Khunger
10.1 Introduction performing chemical peels should aim to standardize

their peeling procedures in order to eliminate the
Facial peeling with chemicals or chemical peeling is a maximum number of variables that can affect depth of
procedure, where a chemical agent or combination of facial peels.
agents of defined strength is applied to the skin, causing The introduction of nonablative lasers and light
a controlled destruction of the layers of the skin. This is therapy systems initially led to a decline in the use of
followed by regeneration and remodeling leading to chemical peels, but lasers are still very expensive to
improvement of texture and surface abnormalities. acquire and maintain. Till these newer nonablative
The concept of skin peeling to beautify the skin by light therapies become more predictable, affordable,
the use of chemicals and natural products has been and widely available, chemical peels continue to be an
used since the time of Cleopatra. She used sour milk, extremely useful armamentarium in the treatment of
containing lactic acid whereas French women used common conditions such as skin rejuvenation, photoa-
old wine containing tartaric acid for beauty baths. ging, hyperpigmentation, and acne. Newer, safer, and
The modern era of chemical peeling began with more effective peeling agents, such as mandelic acid,
MacKee [1] who used phenol as a peeling agent to lactic acid, pyruvic acid, phytic acid, etc., and current
treat facial scars. Peeling procedures attracted wide peeling options such as combination peels, sequential,
interest at that time because of the remarkable results segmental, and switch peels have led to resurgence in
they achieved, and peeling formulas were closely the use of chemical peels [2]. Sound knowledge of
guarded secrets. Finally, scientific investigations were peeling agents, peeling procedures, and experience are
undertaken, and various agents are now being used for still essential to achieve cosmetically pleasing results.
chemical peeling with newer agents being added day Hence, chemical peeling is a versatile tool that can
to day. help build a good aesthetic practice.
The objective of chemical peeling is to cause
destruction at the required depth without scarring.
Chemical peels are divided according to the depth as 10.2 Basic Principles and Mechanism
very superficial, superficial, medium depth, and deep of Action
peels. The depth of peeling is controlled by many
factors: the most important being the strength and Chemical peels have a sound scientific, histological,
characteristics of the peeling agent. Every physician chemical, and toxicological basis. The basic principle
of chemical peeling is to cause injury to the skin at a
required depth and allow regeneration and remodeling
N. Khunger
to take place, without causing permanent scarring.
Department of Dermatology, V.M. Medical College
& Safdarjang Hospital, New Delhi, India Various peeling agents are available. It is essential to
e-mail: [email protected] understand basic chemistry of these agents, anatomy

148 N. Khunger
of the skin, and the skinchemical interactions, in 10.3 Histological Classication

order to optimize treatment [3]. Peeling agents basically of Peels and Peeling Depths
act by either of three mechanisms:
1. Metabolic Chemical peels are divided according to the depth of
2. Caustic necrosis as very superficial, superficial, medium depth,
3. Toxic and deep peels (Table 10.1). Superficial peels are more
Alpha hydroxy acids (AHAs) are weak acids and frequently used, whereas deep peels have been sup-
include common peeling agents such as glycolic acid, planted by lasers and light devices to a greater extent.
mandelic acid, pyruvic acid, lactic acid, citric acid, There are many variables that can modify the depth
etc. They act by metabolic action by interfering with of the peel.
the functioning of enzymes such as kinases, sulfo-
transferases, and phosphotransferases, which attach
sulfate and phosphate molecules to the corneocytes. 10.3.1 Peeling Agent
This causes desquamation of corneocytes, leading to
epidermal desiccation and shedding, followed by The peeling agent and its concentration is the most
regeneration. A single light AHA peel can replace the important factor in determining the peel depth.
epidermis in 2 weeks [4]. In higher concentrations of Generally, the higher the concentration of the peeling
free acid, they act as caustic agents that cause epider- agent, the greater is the depth. However, in combina-
molysis or skin necrosis. In the dermis, there is an tion peels, peeling agents can be combined at lower
induction of inflammatory response with deposition concentrations to achieve greater depths. In addition,
of glycosaminoglycans and new collagen formation. concentration of the peeling agent can vary, with dif-
Salicylic acid is a beta hydroxy acid and has kera- ferent brands and formulations of the same peeling
tolytic properties. It causes dissolution of the intercel- agent. Hence, while peeling a patient, one must not
lular cement substance and hence reduces corneocyte interchange the brand of the peeling agent, even if it
adhesion. It is lipophilic and easily penetrates the indicates the same concentration.
sebaceous follicles and hence is useful in acne. It also
has comedolytic and anti-inflammatory properties.
When applied over large areas, it can be absorbed in 10.3.2 Duration of Contact
the systemic circulation and cause salicylism.
Trichloroacetic acid (TCA) is a strong acid and has This is important with AHA peels, particularly glycolic
a caustic action. It causes coagulation of proteins, acid. The longer the duration of contact, the greater is
which is seen visually as frosting. TCA causes destruc- the depth achieved. This is not significant with TCA
tion of cells, the depth depending on the concentration, and salicylic acid, where concentration is important.
with stimulation of collagen in the dermis. Regeneration
of dermal collagen starts within 23 weeks whereas
the increase in papillary dermal collagen and the pro- 10.3.3 Availability of Free Acid
duction of elastic fibers continue for 6 months [5]. It is
self-neutralizing and is not absorbed into the systemic The availability of free acid in the formulation is
circulation. important. The pKa of the solution is the pH at which
Phenol and resorcinol have a toxic action on the half is in acid form. A lower pKa means that more free
cells. They cause enzyme inactivation and protein acid is available for action. Though many products
denaturation and increase permeability of cell mem- advertise the acid percentage, the pKa is a more accu-
branes leading to cell death. Resorcinol has a weaker rate determinant of strength of the peeling agent.
action as compared to phenol. Phenol is absorbed in
the systemic circulation and can cause cardiac, renal,
and hepatic toxicity. 10.3.4 Method of Degreasing the Skin
At the same, pH and concentration applying a
greater volume of acid on the skin of course induce Vigorous degreasing of the skin can increase penetra-
greater necrosis. tion and cause hotspots to develop.
10 Facial Peels 149
Table 10.1 Histological classification of chemical peels

Type of peel Histological level Agents Indications
Very superficial Exfoliation of the stratum Glycolic acid 3050% applied for 12 min Active acne
corneum, without any TCA 10% applied as one coat Skin brightening
epidermal necrosis Jessners solution one to three coats
Resorcinol 2030% applied for 510 min
Superficial Necrosis of part or entire Glycolic acid 5070% applied for 210 min, Ephelides
epidermis, not below depending on the type and thickness of the skin
the basal layer TCA 1030% Epidermal melasma
Jessners solution four to ten coats
Resorcinol 4050% applied for 3060 min
Medium Necrosis of the epidermis, Glycolic acid 70% applied for 315 min, Lentigines
papillary dermis up depending on the type and thickness of the skin
to the upper one third TCA 3550% Dermal melasma
of the reticular dermis Glycolic acid 70% plus TCA 35% Superficial acne scars
Jessners solution plus TCA 35%
Deep Necrosis of the epidermis, papillary Phenol 88% Superficial wrinkles
dermis up to mid-reticular dermis BakerGordon phenol formula
10.3.5 Technique of Application papulosa nigra, and lentigo all affect penetration of
the peeling agent.
If the peeling agent is rubbed when applying on the Hence, it is essential to standardize the peeling
skin, it achieves a greater depth than if it is painted on agents used, procedure of priming the patient, cleaning
the skin. The number of coats applied as in Jessners and degreasing the skin, and method of application so
solution and the degree of frosting as with salicyclic as to maintain the required depth of the peel.
acid peel can cause variations in the peel depth.
10.4 Peeling Agents

10.3.6 Priming Agents
Currently, a wide and often confusing variety of peel-
The application of low concentrations of glycolic acid, ing agents are available. For beginners, it is better to
tretinoin or salicylic acid during the period of pre-peel start chemical peeling with a few tried and tested prod-
priming causes thinning of the stratum corneum. This ucts from reputed manufacturers, where the strength of
leads to greater penetration of the chemical agent. the peeling agent is standardized. The learning curve
for aesthetic peels should begin with fewer peels and
lower concentrations. Once experience is gained, higher
10.3.7 Location of Peel strengths and deeper peels can be more safely and con-
fidently used. It should be remembered that there can
A facial peel will have greater depth as compared to a be tremendous variability between formulations and
non-facial peel, where the skin is thicker at the same brands, even at the same concentration, which can lead
concentrations. to unexpected outcomes and complications.
A comparison of the common peeling agents is
given in Table 10.2.
10.3.8 Characteristics of Patients Skin
If the patient has thick oily skin, penetration is less 10.4.1 Newer Peels and Combination Peels
as compared to thin dry skin. The level of photodam-
age, actinic damage, and presence of irregular superfi- Many newer peels have been introduced that are gen-
cial lesions such as seborrheic keratoses, dermatoses tler, with lower concentrations, and available singly as
150 N. Khunger
well as in combinations. Many of these patented acids, citric acid, malic acid, and various agents in
peels have added antioxidants and humectants to combination [6].
make them potent, with improved tolerance and less Combination peels have the benefit of increased
irritant potential. These newer peels include mandelic efficacy, without increased risk of complications. The
acid, lactic acid, pyruvic acid, phytic acid, polyhydroxy action of individual agents at lower concentrations
Table 10.2 Comparison of the common peeling agents

End point/
Agent Indications Precautions neutralization Advantages Disadvantages
Alpha Photoaging Timing is Timing begin Long shelf life Great variability in
hydroxy Skin freshening important with 3 min and Well tolerated reactivity and
acids Fine wrinkling Watch out for gradually Do not produce efficacy
Rough-textured skin erythema and hot increase time systemic Sometimes difficult
Epidermal melasma spots or endpoint toxicity to judge the end
Pigmented acne Grayish erythema point
Superficial acne scars discoloration due Neutralization Wounds and scarring
to epidermolysis with sodium can occur in higher
Do not leave the bicarbonate 15% concentrations
room while doing or water Have to be
the peel neutralized
Expensive
Can cause PIH in
darker skin types
Salicylic Comedonal acne Do not apply Concentration, Safe in all type Causes burning
acid Inflammatory acne over large surface begin with 20%, of skins IVI when applied
Pigmented acne scars areas to avoid gradually Inexpensive Can be absorbed
Superficial acne scars absorption increase Predictable when applied over
Oily skin Adequate amounts concentration response large areas and
Enlarged facial pores of water to be Endpoint Causes a cause salicylism
Superficial given after the pseudofrosting pseudofrost Contraindicated in
pigmentation peel Neutralization End point is patients allergic to
As sequential peels not required, easy to judge aspirin
to increase penetration washed with Lipophilic Cannot be used in
of other peeling water Anti-inflammatory pregnancy and
agents Comedolytic lactation
Photoaging Limited depth of
Skin texture peeling
abnormalities
TCA Acne scars Use with Concentration, Inexpensive Highly hydrophilic
photoaging precaution begin with Stable Can lose efficacy
Textural changes in darker skin 1015%, No systemic when repeatedly
Freckles types gradually toxicity exposed to air
Lentigines increase Peel depth Can cause prolonged
Plain warts concentration correlates with PIH
Endpoint the intensity Can cause scarring
frosting of the frost
Neutralization End point is
not required, easy to judge
washed with No need for
water neutralization
Retinoic Acne Do not use in Well tolerated Yellow in color
acid hyperpigmentation patients with without burning Has to be left on for
Photoaging sensitive skin Comedolytic at least 4 h
Safe in darker skin Can cause excessive
types peeling
10 Facial Peels 151
Table 10.2 (continued)

End point/
Agent Indications Precautions neutralization Advantages Disadvantages
Phenol In skin type III Monitor cardiac Endpoint frosting Deep peel useful for Can cause systemic
Photoaging activity Neutralization not deep wrinkles and toxicity cardiac,
Moderate to severe with pulse oximeter required post-acne scars renal, hepatic
wrinkles Give adequate Dramatic results with High risk of cardiac
Moderate to severe hydration during the a single peel arrhythmias
post-acne scars procedure to Has anesthetic effect Requires an OT
Adjunct to other reduce systemic setup
aesthetic procedures toxicity Presence of
such as blepharoplasty Peeling is completed anesthetist
In darker skin type in one zone before Not an office
IIIIV, with extreme proceeding to procedure
caution the next, carried out Prolonged downtime
Mild to moderate over 90 min Can cause perma-
dyschromias nent hypopigmenta-
Mild wrinkles tion in darker skins
Post-acne scars
complements each other, without increasing their 8. Mandelic acid 15% + lactic acid 15%: A low-
concentration. strength peel for sensitive skin, useful for acne and
Some of the popular combination peels are: photoaging.
1. Jessners solution: Lactic acid 14 g, salicylic acid 9. Mandelic acid 30% + lactic acid 40%: Useful for
14 g, resorcinol 14 g with ethanol added to make sensitive skin.
100 mL. Useful for acne, photoaging, dyschromia. 10. Fluor-Hydroxy pulse peel: A combination of
2. Modified Jessners solution: Lactic acid 17%, 5-fluorouracil 5% and glycolic acid 70% lotion
salicylic acid 17 g, citric acid 8% with ethanol (Drogaderma, Brazil). It is useful for actinic
added to make 100 mL. Less toxic as resorcinol is keratoses and disseminated actinic porokeratoses.
replaced by citric acid.
3. Melaspeel KH (Sesderma peels, Spain): Lactic
acid 10%, citric acid 10%, kojic acid 5%, hydro- 10.4.2 Choosing the Correct Peel
quinone 2%, salicylic acid 2%. Useful for hyper-
pigmentation. Facial peeling is a useful technique in the treatment of
4. Glicopeel K (Sesderma peels, Spain): Com- common cosmetic disorders such as photodamage,
bination of glycolic acid 33%, citric acid 10%, facial pigmentation including melasma, post-inflam-
kojic acid 10%, lactic acid 9%, salicylic acid 5%, matory hyperpigmentation (PIH), acne and post-acne
willow herb extract, and bearberry extract. Useful scars, mild facial scarring, and for skin rejuvenation
for hyperpigmentation and photoaging. (Table 10.3).
5. SM Peel (Timpac Engineers, India): Salicylic acid Some peels are more appropriate for certain condi-
20%, mandelic acid 10% in gel form. Useful in acne. tions and for particular skin types. The choice of the
6. Easy Phytic Peel (Skin Tech, USA): Slow release peeling agent should be individualized, and a patient
AHA combination peel with phytic acid, glycolic may require different peeling agents at different
acid, lactic acid, and mandelic acid that does need periods of time for maximum benefit. Thus, it is
neutralization. Useful for hyperpigmentation, important to choose the right peel at the right time for
acne, and photoaging. the right patient. The choice of the peeling agent
7. Cosmelan (Mesoestetic, Spain): Azelaic acid, depends on two important factors: the depth of the
kojic acid, phytic acid, ascorbic acid, arbutine, treating condition and the skin type of the patient.
titanium dioxide. Useful for hyperpigmentation A guide to initial selection of peeling agents is given
including melasma. in Table 10.4.
152 N. Khunger
Table 10.3 Indications and contraindications of chemical 10.5 Patient Management

peeling
Indications 10.5.1 Counseling
A. Pigmentary disorders
1. Resistant melasma Adequate counseling before treatment is very essential
2. Post-inflammatory hyperpigmentation (PIH) to avoid disappointment and potential legal problems
3. Pigmented cosmetic dermatitis
at a later stage. Explanations about the nature of
4. Lichen planus pigmentosis, ashy dermatosis
treatment, expected outcomes, time taken for recovery
5. Freckles
of normal skin, and the importance of maintenance
6. Lentigines
B. Acne
regimens are essential components of a counseling
1. Comedonal acne program. It is always advisable to downplay the degree
2. Macular hyperpigmented post-acne scars of improvement expected. Discussion of side effects,
3. Superficial mild post-acne scarring likely and unlikely complications, particularly on pig-
4. Ice-pick scars mentary changes and alternative treatments available
5. Acne excorie should be done prior to starting facial peeling. If need
C. Cosmetic be repeated consultations are done, utilizing the inter-
1. Photoaging vening period for starting home care products. This
2. Fine wrinkling breathing space also helps in judging the ability of the
3. Actinic keratoses patient to follow prescribed skin care.
4. Seborrheic keratoses
5. Dilated pores
Contraindications 10.5.2 Consent Forms, Documentation,
A. Active infection in the area to be peeled
and Photographs
B. Herpes simplex
C. Folliculitis, furuncles
Informed consent is a legal document whereby a person
D. Open wounds
gives consent to perform a procedure based upon an
E. Preexisting inflammatory conditions
1. Seborrheic dermatitis
understanding of the facts given by the treating physician.
2. Photosensitive dermatitis The patient should be explained the need for treat-
3. Atopic dermatitis ment, expected outcomes, duration of the procedure,
4. Contact dermatitis number of sittings that may be required, approximate
5. Psoriasis cost of treatment, likely complications, consequences
6. Rosacea of nontreatment, and modes of alternative treatments.
F. Drug ingestion Signing the consent form should not be a casual affair
1. History of taking photosensitizing medications like getting signature on a dotted line and should be
G. Patient characteristics signed by an informed patient. In the case of teenagers
1. Uncooperative patient (1318 years), it is better to take the signatures of both
2. Patient with unrealistic expectations the minor and the parent. The patient should feel free to
3. Patients with body dysmorphophobic disorders ask questions, and sufficient time should be devoted to
4. Occupations with extensive sun exposure expectation alignment between the patient and physi-
H. Allergy
cian. The patient should also be given written instruc-
1. Allergic to contents of peeling agent
tions detailing pre- and post-peel care.
I. Heavy smoking
Photographic records are very important since patients
J. Pregnancy
often do not remember the initial condition. Every effort
K. For medium depth and deep peels, in addition to the
above should be made to standardize the photographs, includ-
1. History of abnormal scarring ing three views, front, right, and left side, distance, light-
2. Keloids ing, and background. The progress should be monitored
3. Atrophic skin regularly at every peel. Consent for photographs should
4. Isotretinoin use in the last 6 months be incorporated in the consent form. Proper records of
10 Facial Peels 153
Table 10.4 Selection of peeling agents for common indications and expected response
Expected
Indication Depth Peeling agents response
Facial pigmentation
Melasma Epidermal SA, MA, combination peels Good
Dermal/mixed Combination peels Fair/poor
Freckles Epidermal SA, MA, TCA Good
Lentigines Mixed TCA Fair
Pigmented cosmetic dermatitis Dermal Combination peels Fair/prolonged
PIH Epidermal/dermal SA, MA Good/fair
Acne
Comedonal acne Epidermal SA, MA, low-strength TCA 1015% Good
Pigmented scars Epidermal MA, combination peels Good
Mild atrophic scars Upper 1/3 dermis SA, GA, PA, phytic acid Good/fair
Ice-pick scars Deep dermis CROSS 50100% TCA Good/fair
Aesthetic
Rejuvenation Epidermal SA, GA Good
Dilated pores CROSS 50100% TCA Good/fair
Fine wrinkles Upper dermis GA, combination peels Good
Moderate wrinkles Upper 1/3 dermis Phenol Fair/poor
Photoaging
Dyschromia Epidermal Very carefully Good/fair
SA, MA
Actinic/seborrheic keratoses Epidermal Fluorouracil Good/fair
GA glycolic acid, MA mandelic acid, PA pyruvic acid, SA salicylic acid
the procedure, peeling agent used, concentration, and supply and delays wound healing should avoid deep
details of treatment given pre-peel and post-peel should chemical peels for at least 612 months.
be maintained. Occurrence of any complications and Contraindication of chemical peeling in patients
their treatment should also be recorded. using isotretinoin is controversial. Though there
have been reports of abnormal scarring in patients
on isotretinoin, following resurfacing procedures,
10.5.3 Patient Evaluation practically, it is hardly seen with chemical peels.
Precautions may be required when performing deep
The patient should be thoroughly evaluated at the first phenol peels.
visit. It is easier to fill a pro forma so that no issues are Assessment of skin phototype, tendency to
missed. Occupation, hobbies, and level of sun expo- post-inflammatory hyperpigmentation (PIH), thick
sure are important. Patients on photosensitizing drugs oily skin, thin dry skin, sensitive skin, wound heal-
or suffering from photosensitive disorders are at higher ing use of facial scrubs, retinoids, AHAs can all
risk of PIH, particularly in darker skin types. If there is affect penetration of peeling agents and should be
a history of herpes simplex, prophylactic acyclovir asked for.
or valacyclovir should be given to avoid scarring.
Conditions that can cause delayed healing such as
chronic smoking, immunosuppression, and radiation 10.5.4 Pre-peel Care
over the area to be peeled should be ruled out as such
patients are at high risk of complications, particularly Pre-peel care is called priming the skin prior to peel-
with deeper peels. Patients who have undergone recent ing. It is the first step towards performing safe and
facelifts or any surgery where extensive undermining effective peels. Priming is ideally started at least
of the face has been done that compromises blood 24 weeks before the peel. The goal of priming the
154 N. Khunger
skin is to assist in producing uniform penetration Table 10.5 Reagents and equipment for facial peels
of the peeling agent, accelerate wound healing, and Reagents
reduce risk of complications. Chemical peeling agents with varying concentrations
Retinoic acid and alpha hydroxy acids like glycolic correctly labeled
acid cause thinning of the stratum corneum and help Glycolic acid 20%, 35%, 70%
to achieve increased uniform penetration of the peel- TCA 10%, 15%, 25%, 100% (for CROSS technique)
Salicylic acid 20%, 30%, 50%
ing agent. Retinoic acid applied for at least 2 weeks
Mandelic acid 40%
prior to peeling has been reported to reduce re-
Combination peels for acne, dyschromia, rejuvenation,
epithelialization time after peeling. In addition, any according to choice and availability
agent that is likely to be used immediately post-peel Neutralizing solutions
or for maintenance therapy should be applied as a Cold water
priming agent to detect intolerance. This is especially Syringe filled with normal saline to irrigate the eyes, in
important with regard to sunscreen use and hydroqui- case of accidental spillage of reagent in the eyes
none, which can have devastating effects if reactions Alcohol or spirit for cleansing
develop after a peel. Acetone for degreasing
In darker skinned patients and in those at risk of Equipment
PIH, the use of hypopigmenting agents like hydro- Cap or headband to pull back the patients hair
quinone, kojic acid, arbutin, etc., before the peel Glass cups to hold the peeling agent
greatly reduces the chances of PIH. Priming also Cotton tip applicators, ear buds, small brush or fine
toothpicks for application
helps to enforce patient compliance. Patients who
2 2 gauze pieces
do not follow instructions are at risk for poor
Timer for glycolic acid peels
results post-peel and should not be taken up for facial
Handheld fan for patient comfort
peeling.
Gloves
Broad spectrum sunscreens against UVA, UVB,
and visible light, with minimum SPF 30 should be
given. In patients with sensitive skin, the physical sun- The required peeling agent is poured in a glass bea-
screens containing zinc oxide or titanium dioxide are ker, and neutralizing agent is also kept ready. The
safer than chemical sunscreens. label should be carefully checked. The peeling agent
is then applied either with a brush or cotton-tipped
applicator without dripping of the agent. The chemical
10.6 Peeling Technique agent is applied quickly on the entire face divided into
cosmetic units beginning from the forehead in an
Chemical peeling is a simple technique that can be upward direction, then the right cheek, nose, left
performed as an office outpatient procedure, with cheek, and chin in that order. The perioral, upper and
very few requirements (Table 10.5). However, deep lower eyelids, if required, are treated last (Fig. 10.1).
phenol peels should be carried out in a fully equipped Feathering strokes are applied at the edges to blend
surgical suite. with surrounding skin and prevent demarcation lines.
The patient should be adequately counseled and A handheld cooling fan helps to reduce burning of the
primed. A consent form is signed, and photographs skin. The patient should not be left alone, and a strict
are taken. Contact eye lenses are removed, and the watch should be kept for redness, hot spots, and
patient is asked to wash the face with soap and water epidermolysis. The peel is neutralized as required
to remove makeup, dirt, and grime. The hair is pulled according to the peeling agent. AHA peels require
back with a hair band or cap. The patient is made to neutralization with sodium bicarbonate but can also
lie down with head elevated to 45 and eyes closed. be washed away with copious amounts of water. While
The skin is inspected for abrasions or inflammation other peels like TCA peel and salicylic acid peels are
that should be avoided. Sensitive areas where the self-neutralizing and can be washed away with water.
peeling agent can collect, like the inner canthus of the The skin is gently dried with gauze, and the patient
eye and nasolabial folds, are protected with petrola- is asked to wash with cold water till the burning
tum or Vaseline. The skin is cleaned with alcohol subsides. The patient is then asked to apply a sun-
and then degreased with acetone, using 2 2 gauze screen, before leaving the clinic, along with post-peel
pieces. instructions.
10 Facial Peels 155
Fig. 10.2 Pseudofrost on application of salicylic acid due to

crystallization
ascorbic acid have better permeability. Maintenance

treatment is an important component of any peeling
Fig. 10.1 Cosmetic units of the face and order of application of regimen and should be continued to maintain results.
a chemical peel
10.8 Acne and Post-acne Scars

10.7 Post-peel Care
Acne is one of the most common skin diseases in
Facial peeling makes the skin very sensitive to sunlight clinical practice. Topical and systemic therapies are
and heat. This can lead to sunburn, erythema, and post- the mainstay of treatment. Patients frequently have poor
inflammatory hyperpigmentation. Hence, adequate sun self-image, depression, and anxiety due to acne, and it
protection is most important in the immediate post-peel can affect the quality of life. Hence, effective manage-
period till re-epithelialization is complete. Broad spec- ment of acne can have a relevant positive impact on
trum sunscreens that have been started in the priming the acne patient. Chemical peeling in active acne is
period should be applied ideally every 2 h. Light mois- an adjuvant therapeutic technique that can help in early
turizers may be used in case of excessive dryness and resolution of lesions. It is indicated in comedonal acne
desquamation. The patient should be warned to avoid and mild to moderate inflammatory acne. Superficial
picking at the exfoliating lesions, which can lead to and ice-pick post-acne scars can also be treated with
excessive erythema and PIH. In darker-skinned indi- peeling agents.
viduals, who are prone to PIH, hypopigmenting agents Salicylic acid 2030% is the peeling agent of choice
should be started as soon as possible. Retinoids and in acne as it has keratolytic and anti-inflammatory
glycolic acid should be started only after complete re- properties. The advantage is that since it is lipophilic in
epithelialization. In the post-peel period, the barrier nature, it can easily penetrate the pilosebaceous appara-
function of the skin is compromised, and topical agents tus. It is effective in all grades of active acne because of
can penetrate more easily. This is an advantage, and its comedolytic and anti-inflammatory properties. It is
appropriate creams should be applied according to the also safer in darker skin phototypes IVVI. A pseudof-
condition being treated; e.g., in the treatment of rost is formed which is easy to visualize; hence, it can
melasma, hypopigmenting agents like hydroquinone, be applied evenly, without skip areas (Fig. 10.2).
glabridin, arbutin or kojic acid along with topical Glycolic acid in low strengths, 2035%, TCA 1015%,
156 N. Khunger
Fig. 10.3 (Left) Active acne with persistent pigmented macules. (Right) Following treatment with 40% mandelic acid peels, six
peels at two weekly intervals
and Jessners solution are other agents that can be used combination is that salicylic acid is lipophilic and
for acne. Newer peeling agents in acne include man- anti-inflammatory, whereas mandelic acid also has
delic acid 3050%, tretinoin 15%, lactic acid 4090%, antibacterial properties. Glycolic acid 2050% and
and pyruvic acid 4050%. pyruvic acid 4070% are alternative peeling agents
and are useful when there is less inflammation but
more superficial scars.
10.9 Comedonal Acne
If there are many comedones, comedone extraction is 10.11 Post-acne Pigmentation

done first followed by a 20% salicylic acid peel. This
allows better penetration of the peeling agent and has- For post-acne pigmentation, combination peels are
tens improvement. Closed comedones are first pierced more effective and safer as compared to single agents.
with a No. 26 needle; contents are extracted out with Low-strength glycolic acid 20%, kojic acid, lactic acid,
a comedone extractor, and then, the peel is applied. citric acid, and salicylicmandelic peels repeated every
The peels can be repeated weekly in thick oily skins 2 weeks are safer, particularly in darker skin types
or every 24 weeks in dry skins. Tretinoin peels con- (Fig. 10.3).
taining 15% retinoic acid are also effective.
10.12 Supercial Post-acne Scars

10.10 Inammatory Papulopustular Acne
Sequential peels with salicylic acid 30% followed
Salicylic acid 2030% and mandelic acid 40% are by glycolic acid 5070%, or salicylic acid 2030%
the peeling agents of choice. They can also be followed by TCA 1535%, depending on the skin type
combined for greater efficacy. The advantage of this are effective but should be used cautiously in patients
10 Facial Peels 157
prone to PIH. Combination peels containing glycolic 65100% TCA is applied to the bottom of the ice-pick
acid, pyruvic acid, and lactic acid are safer, though scar with a wooden toothpick, which leads to destruc-
they require larger number of sessions [7]. tion of the epithelial tract. This is followed by col-
lagenization in the healing phase and filling up of the
depressed ice-pick scar. It causes momentary, mild, tol-
10.13 Ice-Pick Acne Scars CROSS erable burning on application, and no anesthesia is
Technique required. After cleaning and degreasing the skin with
acetone, the acid is carefully applied up to the depth of
Ice-pick acne scars are deep and difficult to eradicate, the scar, using a fine pointed wooden tip of a toothpick,
even with lasers. A technique using high strength of taking care to avoid spillage on the surrounding skin
the peeling agent TCA called CROSS technique (chem- (Fig. 10.4). The skin is stretched to reach the bottom of
ical reconstruction of skin scars) has been found to be the scar. There is immediate blanching with an intense
useful as a simple office procedure [8]. In this technique, white frost due to coagulation of epidermal and dermal
proteins. A sunscreen is then applied. Within 13 days,
crusts are formed which fall off in 35 days. Collagen
formation may take 23 weeks and can continue up to
46 weeks. A sunscreen is applied in the daytime, and
0.05% tretinoin and 5% hydroquinone cream are
applied at night for a minimum of 4 weeks to prevent
post-inflammatory hyperpigmentation. On an average
of about 25% improvement of scars takes place with
one session. The procedure may be repeated two or
three times at intervals of 24 weeks. The advantage of
the CROSS technique is that since the adjacent normal
tissue and adnexal structures are spared, healing is more
rapid with a lower complication rate than conven-
tional full-face medium to deep chemical resurfacing
(Fig. 10.5). However, PIH can commonly occur in
patients with darker skins; hence, the patient should be
primed adequately with hypopigmenting agents prior
Fig. 10.4 Application of 100% TCA by the CROSS technique, to the procedure, and these should be continued till
by stretching the skin, and using a fine wooden toothpick improvement [9].
Fig. 10.5 (Left) Ice-pick post-acne scars. (Right) After treatment with the CROSS technique using 100% TCA
158 N. Khunger
Table 10.6 Common causes of facial pigmentation be repeatedly advocated, particularly in patients with
Epidermal Dermal outdoor occupations. Glycolic acid 612% is also
Melasma Melasma useful as a priming agent in patients with thick uneven
Freckles Post-inflammatory hyperpigmentation skin. Topical retinoids should be used cautiously to
Lentigines Pigmented cosmetic dermatitis avoid retinoid dermatitis and inflammation, which
Post-inflammatory Drug-induced can aggravate pigmentation. Low strengths such as
hyperpigmentation melanoses
tretinoin 0.025% or adapalene 0.1% applied for short
Epidermal nevi Actinic lichen planus
durations initially are preferred. The strength and dura-
Lichen planus pigmentosus
tion of application of the priming agent should be
Periocular melanoses
increased gradually if the patient has sensitive skin.
Nevus of Ota
Pigmentary demarcation lines
Facial peeling should also be done cautiously in darker
skin types due to the increased risk of PIH. It is always
safer to use lower strength of peeling agents either
sequentially or in combination to achieve desired
10.14 Facial Pigmentation results. E.g., applying 20% salicylic acid followed by
1015% TCA or 35% glycolic acid is safer as com-
Facial pigmentation can be due to various disorders, pared to 70% glycolic acid or 35% TCA used alone.
which should be identified before treatment so as to Various combinations of peeling agents are available
select the appropriate peeling agent (Table 10.6). for facial pigmentation and found to be quite effective
Therapy should be selected according to the etiology for long term use, even in darker skins (Fig. 10.6).
and depth of the pigmentation. The primary approach Peels may give variable responses for hyperpigmenta-
to the treatment of facial pigmentation is topical tion; hence, a small test peel may be done in the
hypopigmenting agents, which inhibit synthesis of postauricular or temple area to detect unpredictable
melanin and photoprotection with sunscreens that responses. This is particularly common with glycolic
inhibit activity of the melanocyte. Chemical peels are acid, TCA, and resorcinol. A low concentration of
adjuvant measures that remove excess melanin and the peeling agent should be used first, and the concen-
hasten improvement. The Q-switched Nd:YAG laser tration should be increased gradually, depending on
causes disruption of melanin and is primarily useful in response. All precautions should be undertaken to
nevus of Ota, freckles, lentigines, and epidermal nevi. avoid excessive inflammation. It is safer to combine
Melasma is one of the commonest causes of facial peels in lower concentrations to increase depth rather
pigmentation and often recalcitrant to treatment. It than increase concentration of a single agent. One can
requires a combination of agents to improve melasma, also customize the peel to the individual face to get
along with prolonged maintenance therapy. The main- optimum results and vary the peeling agents according
stay of treatment of facial pigmentation is topical to response. Areas with thick, oily, damaged skin may
therapy, which should also be used for priming the require a deeper peel, while thinner, dry skin zones
skin of at least 46 weeks before chemical peeling. may only require a superficial peel. Following a peel,
Hydroquinone 25% as tolerated is the gold standard the area of hyperpigmentation and scaling can show
for hyperpigmentation. If the pigmentation worsens, increased pigmentation initially that can alarm the
the possibility of ochronosis must be kept in mind. patient. The skin may become more sensitive post-peel
A biopsy will confirm the diagnosis, and hydroqui- and lower strengths of retinoids or glycolic acid should
none must be stopped. Ochronosis is seen more be used if this happens.
commonly with high concentrations like 10%, and it In a study of 40 Indian patients with melasma, with
is not very common in lower concentrations up to 5%. Fitzpatrick skin types IIIV, the group of 20 patients who
If hydroquinone causes irritation, alternative agents were treated with serial 3040% glycolic acid peels along
such as azelaic acid 1020%, kojic acid 2%, arbutin with a modified Kligmans formula showed a signifi-
5% can be used. Sun protection is very important as it cantly better response as compared to 20 patients who
is a common aggravating factor in facial pigmentation, were treated with the modified Kligmans formula alone
and a combination of physical methods such as hats [10]. Adverse events were minimal in both groups, with
and umbrellas and chemical agents like broad spec- two patients in the peel group developing PIH. Similar
trum sunscreens, including physical sunscreens, should results were observed in another study of recalcitrant
10 Facial Peels 159
Fig. 10.6 (Left) Pretreatment persistent melasma. (Right) Three years after treatment with mandelic acid 40%, eight peels at two
weekly intervals, with maintenance of improvement
melasma treated with serial glycolic acid peels [11]. complexion, dilated pores, vascular lesions, and tex-
Focal TCA has also been safely used in benign pig- turally rough skin. Ultraviolet light exposure activates
mented facial lesions in darker skin types [12]. matrix degrading metalloproteinase enzymes includ-
Inflammation plays a key role in causing PIH due to ing collagenase. Cytokines are released from keratino-
release of cytokines that stimulate activity of melanocytes. The cumulative effect of these changes is chronic
cytes. Hence, controlling inflammation with topical dermal inflammation. The features of photoaging vary
and, if required, systemic steroids is an essential part with the skin types. In individuals with lighter skin
of post-peel care when treating hyperpigmentation. color, Fitzpatrick IIII, wrinkles are more common
Bleaching agents like hydroquinone, kojic acid or aze- and appear early along with an increased occurrence of
laic acid combined with tretinoin or glycolic acid are premalignant and malignant skin lesions including
useful for PIH. Re-peeling with very superficial peels actinic keratoses, basal cell carcinoma, squamous cell
may give good response if PIH persists, in spite of carcinoma, and melanoma. In contrast, in darker skin
therapy beyond 24 weeks [13]. Chemical peels can individuals, there is less wrinkling and reduced inci-
also improve dermal pigmentation by causing a con- dence of malignancy, whereas pigmentary abnormali-
trolled low-grade inflammation that can stimulate ties are more common.
phagocytosis of excess dermal melanin (Fig. 10.7). Topical therapy using broad spectrum sunscreens,
retinoids, polyhydroxy acids, salicylic acid along
with hypopigmenting agents such as hydroquinone or
10.15 Photoaging and Facial azelaic acid and cosmeceuticals containing arbutin,
Rejuvenation licorice, unsaturated fatty acids, soy extracts, ide-
benone, copper peptides, serine protease inhibitors,
Photoaging is defined as the superimposed effects of resveratrol, etc., is useful for treatment as well as
photodamage due to chronic ultraviolet light exposure priming the skin [14]. Due to changes in lifestyle
on intrinsically aging skin. It is characterized by wrin- and depletion of ozone layer in the atmosphere, the
kles, mottled pigmentation, laxity of the skin, sallow exposure to harmful UV rays of the sun has increased,
160 N. Khunger
Fig. 10.7 (Left) Pretreatment dermal pigmentation due to lichen planus pigmentosis. (Right) Two years posttreatment with a series
of combination peels, 12 combination peels at two weekly intervals and maintenance of improvement
leading to skin aging becoming more common and papulosa nigra, these should be treated prior to peel-
evident in younger individuals in their twenties and ing. Young patients with minimal skin damage often
thirties. Being a regenerative organ, the skin can be respond best to a series of light superficial peels
stimulated to repair and renew itself. Hence, skin (lunch time peels) in combination with a good skin
rejuvenation techniques are becoming very popular, care program. The alpha hydroxy acids are particu-
with a marked preference for minimally invasive larly good agents for photoaging because of their
techniques with reduced downtimes. The physician dermal effects. Glycolic acid 3570%, pyruvic acid
should evaluate the nature of skin and the degree of 50%, and lactic acid 90% are peeling agents of choice.
photodamage, techniques available, and active cos- Pyruvic acid is an a-keto acid which is converted
meceutical agents that work for skin rejuvenation physiologically to lactic acid. Ghersetich et al. [15]
before management. treated 20 patients with Glogaus photoaging types I
Facial peeling is a good technique to hasten and II, with pyruvic acid 50% in a series of four peels
response in photoaging. The physician should be at monthly intervals. A smoother texture, reduction in
aware that mature skin is generally dry, thinner, sen- fine wrinkles, and lightening of areas of hyperpig-
sitive, and intolerant to many products, and many mentation were observed, with minimal side effects.
geriatric patients are on systemic medications that Salicylic acid has also shown to be effective for pho-
can cause photosensitivity or pigmentation. These toaging. In a study of 50 women with mild to moder-
factors should be taken into account while selecting ate photodamage, salicylic acid reported improvement
patients for chemical peels. Superficial peels are use- in pigmented lesions, surface roughness, and reduc-
ful for pigmentary changes, whereas medium depth tion in fine lines [16]. Medium depth peeling is more
and deeper peels are indicated for wrinkling. If there useful to treat photodamage, but it should be used
are any growths like seborrheic keratoses, dermatoses cautiously in darker skin types [17]. Combination
10 Facial Peels 161
peels with 70% glycolic acid and 35% TCA are effec- with predominant hyperpigmented lesions benefit from
tive. The use of deep phenol peels has declined due to higher concentrations of hydroquinone, kojic acid, and
the availability of safer and effective modalities such citric acid along with glycolic acid. Patients with sen-
as fractional ablative and nonablative lasers. sitive skin can tolerate lactic acid and mandelic acid
safely and benefit from lower strength peeling agents
in combination.
10.16 Customizing Peels and Techniques Sequential peels use more than one peeling agent at
a time in a sequential manner. They are deeper peels
Various peeling agents with differing mechanisms and indicated for conditions that have a dermal compo-
of action are available, making peeling a very versa- nent such as mixed melasma, lichenoid pigmentation,
tile procedure for different skin types and skin condi- and PIH (Fig. 10.8).
tions. The cosmetic units of the face often differ in Facial peeling can also be combined with other
the same patient and may have different requirements. techniques to increase the penetration or a comple-
Application of the peeling agents can thus be custom- mentary effect [18]. Techniques such as micro-
ized to optimize outcomes. Various formulations are dermabrasion [19], sandabrasion [20, 21], nonablative
available in combination peels, and the precise formula lasers [22], botulinum toxin [23], fillers [23], bleph-
may be adjusted to meet each patients needs [2]. aroplasty, and face lifts can be effectively combined.
Patients with oily thick skins and acne will require Each facial concern is customized and addressed indi-
higher concentrations of salicylic acid, while patients vidually with the appropriate modality.
a b
Fig. 10.8 Dermal melasma after 2 weeks single sequential peel. (a) Before treatment. (b) After salicylic acid peel. (c) Application
of glycolic acid, hydroquinone. (d) Two weeks after single sequential peel
162 N. Khunger
c d
Fig 10.8 (continued)
10.17 Complications adverse events as most complications can be minimized

when detected early and treated promptly. Prolonged
Every physician performing chemical peels must have erythema, crusting, vesiculation painful erosions, and
adequate knowledge about prevention, early detection, pruritus are early signs and should be treated immedi-
and management of complications [2426]. ately. Pre-peel priming regimens should be religiously
followed, and the patient should avoid scrubs and pro-
cedures immediately before peels as it can lead to
10.17.1 Prevention uneven peeling. Any facial skin disorder such as sebor-
rheic dermatitis, atopic dermatitis, contact dermatitis,
The first step in prevention is identifying patients that etc., should be treated before peeling.
are at a higher risk of complications. These include The physician should not use too many peels of dif-
skin types IIIVI who are at a higher risk of PIH, ferent manufacturers as peels from different sources,
patients with thin, dry, sensitive skin with a reddish even with the same labeled concentrations, can have
hue, poor wound healing and those with outdoor occu- varying results. It is better to be familiar with fewer
pations, on photosensitizing drugs, and a history of peels on a regular basis and develop safe procedures.
sunburn. Peeling should also be performed cautiously When trying out a new peel, or peeling an apprehensive
in patients who are uncooperative and have unrealistic patient, it is preferable to do a test peel on the preau-
expectations. Counseling the patient regarding ricular area, or a small area on the lesion on the fore-
expected results and emphasizing the importance of head or temple area, rather than a full-face peel. Ideally,
post-procedure precautions and treatment is essential one should start with the lowest concentration and
in preventing complications. The physician should gradually titrate upwards. For the beginner, it is better
communicate to the patient early warning signs of to combine different agents at lower concentrations and
10 Facial Peels 163
Table 10.7 Complications of chemical peels

Topical Systemic Ocular
Pigmentary changes post-inflammatory Toxicity resorcinol, salicyclic acid, and phenol, Chemical conjunctivitis
hyperpigmentation and hypopigmentation when applied over large areas Corneal abrasions
Lines of demarcation Laryngeal edema it is a rare complication, with
Infection bacterial (Staphylococcus, symptoms of stridor, hoarseness of voice, and
Streptococcus, Pseudomonas), viral tachypnea developing within 24 h of chemical peeling
(herpes simplex), and fungal (Candida)
Persistent erythema
Scarring
Allergic reactions
Milia
Acneiform eruptions
Textural changes
use superficial peels rather than use a high concentra-

tion of a single peeling agent or deeper peels. The phy-
sician must have a thorough knowledge of selecting the
right peeling agent at the right concentration. The label
and concentration should be checked before applica-
tion. The neutralizing agent should be kept ready, in
case termination of the peel is required before the
scheduled time.
To avoid ocular complications, the head must be ele-
vated during the peel. The inner and outer canthi of the
eyes must be protected with Vaseline, especially when
performing a periocular peel. The peel should never be
passed over the eyes, and a syringe filled with saline
should be at hand in case of accidental spillage in the
eye. If TCA or GA enters the eye, it should be flooded
with normal saline, and for phenolic compounds, the
eye should be flooded with mineral oil [27].
While applying the peel, vigorous scrubbing should
be avoided as it can lead to patchy and deeper peeling
than required.
10.17.2 Management
Fig. 10.9 Hyperpigmentation following peeling
The potential complications that can occur are given in

Table 10.7. Hyperpigmentation is the commonest com- When hyperpigmentation occurs, triple combination
plication occurring after peels (Fig. 10.9). It can occur creams containing hydroquinone, tretinoin, and ste-
any time after the peel and can be persistent if inade- roids are useful. Hypopigmentation is commonly seen
quately treated. It is important to educate the patient immediately after a superficial peel and is due to
about avoiding sun exposure and use of broad spec- removal of excess melanin and sloughing off of the
trum sunscreens before and indefinitely after the peels. epidermis. In medium depth peels, the hypopigmenta-
Priming the patient with suitable topical hypopigment- tion can be more prolonged till melanocytes migrate
ing agents such as hydroquinone, kojic acid, and arbu- from the surrounding skin and adnexae. In deep peels,
tin is an important part of the peeling regimen and permanent hypopigmentation is common. This may
should be strictly enforced in the post-peel period. not be noticeable in fair types I and II skins but can
164 N. Khunger
development of papules and erythema, it may be a sign

of contact dermatitis to a topical application. It is very
important to recognize and treat this as soon as possi-
ble, as a delay in treatment can lead to worsening in the
outcome of the peel. Hence, no new topical agents
should be introduced in the maintenance regime after a
peel to avoid this complication. Scarring is a dreaded
complication and fortunately very uncommon after
superficial peels but can occur with medium depth and
deep peels. Patients with a history of poor wound heal-
ing, keloid formation, and developing post-peel infec-
Fig. 10.10 Epidermolysis, vesiculation, and edema in the peri-
ocular region following 50% glycolic acid peel, without signifi- tion are at a higher risk of scarring. The temple area,
cant erythema mandibular area, upper lips, and the chin are areas
prone to developing scars. Abnormal scarring has been
have disastrous consequences in darker skins. In addi- reported with patients on isotretinoin. In severe cases,
tion, phenol has a direct toxic effect on the melano- there can be ectropion or eclabion.
cytes and can cause a permanent hypopigmentation
with a peculiar alabaster look. Hence, deep peels are
better avoided in darker skin types. 10.18 Systemic Complications
Bacterial infection is uncommon, but if it occurs, it
should be treated aggressively with oral and topical Systemic complications are more common with deep
antibiotics to prevent scarring. Herpetic outbreaks pres- phenol peels. When applied over large areas over a
ent with painful erosions and should be treated with short period of time or under occlusion, phenol can
antiviral therapy. Prophylactic antiviral therapy should cause systemic toxicity by absorption. The most com-
be given preferably to all patients undergoing medium mon adverse effect is cardiotoxicity that presents in the
depth and deep peels and continued till complete re- form of arrhythmias [28]. Hence, cardiac status must
epithelialization. For superficial peels, it should be be continuously monitored, and intravenous hydration
given in those patients with history of herpes simplex. be given along with the peel. Peeling must be done in
Candidial infection may occur in immunocompromised small segments and completed before moving to the
patients, diabetics, and patients with oral thrush. It next cosmetic unit to reduce systemic absorption. If
presents with superficial pustules with a background of arrhythmia develops, the peel must be stopped, and
erythema and is treated with topical clotrimazole 1% intravenous (IV) lignocaine should be administered.
cream and systemic antifungals such as fluconazole Since phenol is metabolized in the liver and excreted
50 mg or ketoconazole 200 mg per day. Post-peel ery- by the kidney, it should not be used in patients with
thema generally fades in 35 days after superficial hepatic or renal disease.
peels, 1530 days after medium peels, and 6090 days Resorcinol can also produce toxicity if applied in
after deep peels. However, prolonged erythema may be excess. Diarrhea, vomiting, severe headache, dizzi-
a sign of inadvertent deeper peeling and impending ness, drowsiness, bradycardia, dyspnea, and paralysis
scarring and should be treated promptly with short are presenting features. The best way to avoid resor-
duration potent topical steroids. Edema in the periocu- cinism is to restrict the area of application or limit the
lar region can occur and is managed with application of concentration of resorcinol.
ice. In severe cases, a short course of systemic steroids Toxicity with salicylic acid is not observed when it
may be given. Epidermolysis causing vesiculation and is applied on the face but has been reported when large
blistering may be seen, particularly with AHA peels amounts of 50% salicylic acid paste are applied to 50%
(Fig. 10.10). Prolonged burning can occur particularly or more of the body surface, under occlusion. Salicylism
if topical retinoid or glycolic acid is applied immedi- is characterized by tinnitus, dizziness, abdominal
ately after peels or there is prolonged sun exposure. cramps, and deafness.
Application of bland emollients and sunscreens are Though peels can cause complications, they are
effective, and in severe cases, topical steroids like uncommon in well-trained hands if done with proper
hydrocortisone or fluticasone may be required. Pruritus precautions following safety guidelines for different
may occur after peeling. If it is severe and occurs with types of skins [29].
10 Facial Peels 165
10.19 Conclusions 5. McCollough EG, Langsdon PR, Maloney BP (1996)

Chemical peel with phenol. In: Roenigk RK, Roenigk HH
(eds) Dermatologic surgery, principles and practice, 2nd
There has been a tremendous increase in procedural edn. Marcel Decker Ltd., Oxford, pp 11471160
techniques for skin rejuvenation, and the trend is 6. Khunger N (2009) Newer peels. In: Khunger N (ed) Step by
increasing for procedures that are noninvasive or mini- step chemical peels. Jaypee Brothers Medical Publishers
Ltd, New Delhi, pp 160177
mally invasive, requiring little downtime. The majority
7. Wang CM, Huang CL, Hu CT, Chan HL (1997) The effect
of chemical peeling procedures fit into this category. of glycolic acid on the treatment of acne in Asian skin.
The advantage of chemical peeling is that it is flexible, Dermatol Surg 23(1):2329
effective, and safe with minimal complications. It is a 8. Lee JB, Chung WG, Kwahck H, Lee KH (2002) Focal
treatment of acne scars with trichloroacetic acid: chemical
simple office procedure, requiring no machines, afford-
reconstruction of skin scars method. Dermatol Surg 28(11):
able to every physician, and easy to learn and practice. 10171021
There is a wide variety of chemical agents available, 9. Bhardwaj D, Khunger N (2010) An assessment of the effi-
and treatment can be individualized, according to skin cacy and safety of CROSS technique with 100% TCA in the
management of ice pick acne scars. J Cutan Aesthet Surg
type and requirement of the patient. The downside to
3(2):9396
peeling is that it is a slower process. Multiple sessions 10. Sarkar R, Kaur C, Bhalla M, Kanwar AJ (2002) The combi-
are required with superficial peels to achieve accept- nation of glycolic acid peels with a topical regimen in the
able cosmetic results. Results are not permanent, and treatment of melasma in dark-skinned patients: a compara-
tive study. Dermatol Surg 28(9):828832
maintenance peels are often required. Post-peel, pig-
11. Erbil H, Sezer E, Ta tan B, Arca E, Kurumlu Z (2007)
mentary changes are common in inexperienced hands, Efficacy and safety of serial glycolic acid peels and a topical
especially in darker skins. regimen in the treatment of recalcitrant melasma. J Dermatol
Facial peeling results in removal of superficial skin 34(1):2530
12. Burns RL, Prevost-Blank PL, Lawry MA, Lawry TB, Faria
lesions, reducing excess pigmentation, regeneration of
DT, Fivenson DP (1997) Glycolic acid peels for postinflam-
new tissue with improvement of the skin texture, and matory hyperpigmentation in black patients. A comparative
long lasting therapeutic and cosmetic benefits. There is study. Dermatol Surg 23(3):171174
a tremendous variability of response to chemical peels; 13. Chun EY, Lee JB, Lee KH (2004) Focal trichloroacetic acid
peel method for benign pigmented lesions in dark-skinned
hence, physicians must standardize their peeling agents
patients. Dermatol Surg 30(4 Pt 1):512516
and techniques in order to maintain results. A patient 14. Sachdev M (2010) Cosmeceuticals. In: Khunger N, Sachdev
may require different peeling agents at different concen- M (eds) Practical manual of cosmetic dermatology and
trations over a period of time, and these should be cus- surgery, 1st edn. Mehta Publishers, Pune, pp 214223
15. Ghersetich I, Brazzini B, Peris K, Cotellessa C, Manunta T,
tomized and selected accordingly for maximum benefit.
Lotti T (2004) Pyruvic acid peels for the treatment of
The mix and match options and customizing techniques photoaging. Dermatol Surg 30(1):3236
give chemical peeling a newer dimension for treating 16. Kligman D, Kligman AM (1998) Salicylic acid peels for the
patients optimally, with greater versatility and satisfac- treatment of photoaging. Dermatol Surg 24(3):325328
17. Kadhim KA, Al-Waiz M (2005) Treatment of periorbital
tion, and enhanced safety at the same time. Hence,
wrinkles by repeated medium-depth chemical peels in dark-
chemical peeling is a versatile tool that can help build a skinned individuals. J Cosmet Dermatol 4(1):1822
good aesthetic practice, with minimal investment. 18. Khunger N (2009) Combination therapies. In: Khunger N
(ed) Step by step chemical peels, 1st edn. Jaypee Brothers
Medical Publishers Ltd., New Delhi, pp 220234
19. Briden E, Jacobsen E, Johnson C (2007) Combining super-
References ficial glycolic acid (alpha-hydroxy acid) peels with micro-
dermabrasion to maximize treatment results and patient
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Chemical peeling and resurfacing, 2nd edn. Mosby Year 20. Harris DR, Noodleman FR (1994) Combining manual der-
Book, St. Louis, pp 15 masanding with low strength trichloroacetic acid to improve
2. Khunger N, Arsiwala S (2009) Combination and sequential actinically injured skin. J Dermatol Surg Oncol 20(7):
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1st edn. Jaypee Brothers Medical Publishers Ltd, New Delhi, 21. Khunger N (2010) Acne scar revision. In: Khunger N,
pp 202218 Sachdev M (eds) Practical manual of cosmetic dermatology
3. Dewandre L (2006) The chemistry of peels and a hypothesis and surgery, 1st edn. Mehta Publishers, Pune, pp 230252
of action mechanisms. In: Rubin MG (ed) Chemical peels, 22. Effron C, Briden ME, Green BA (2007) Enhancing cosmetic
1st edn. Elsevier Inc., Philadelphia, pp 112 outcomes by combining superficial glycolic acid (alpha-
4. Deprez P (2007) Alpha-hydroxy acids: histology and factors hydroxy acid) peels with nonablative lasers, intense pulsed
influencing penetration. In: Deprez P (ed) Textbook of light, and trichloroacetic acid peels. Cutis 79(1 Suppl
chemical peels. Informa Healthcare, New York, pp 5354 Combining):48
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23. Landau M (2006) Combination of chemical peelings with 26. Coleman KM, Coleman WP (2006) Complications of chemi-
botulinum toxin injections and dermal fillers. J Cosmet cal peeling. In: Rubin MG (ed) Chemical peels. Procedures in
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by step chemical peels, 1st edn. Jaypee Brothers Medical injury to the eye from trichloroacetic acid. Dermatol Surg
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137170 Indian J Dermatol Venereol Leprol 74(Suppl):S5S12
Facial Resurfacing with
the Ultrapulse Laser 11
Bernard I. Raskin
11.1 Introduction This chapter will focus on CO2 treatment of photoa-

ging and acne scars. Other conditions may effectively
While ablative fractional systems are the current choice be treated such as certain localized skin cancers, xan-
for significant results, ablative laser skin resurfacing thelasma, epidermal nevi and possibly in skin cancer
with the Ultrapulse laser represents the gold standard prevention [36]. Benefits of CO2 and Er:YAG resur-
for facial skin modification and enhancement [1, 2]. facing in reducing p53 gene expression have recently
This chapter may appear solely of historical interest to been documented [7].
many; however, laser surgeons with many years of
experience recognize the superior results possible with
full ablative CO2 lasering. The author has considerable 11.2 History
expertise with ablative laser resurfacing and fraction-
ated CO2 systems. Definitely the new technology of Skin resurfacing was accomplished in a relatively satis-
fractionated ablative lasers offers distinct advantages. factory manner before lasers with deep chemical peels
However, there exists a subset of patients with rela- or specialized machine dermabrasion with either a dia-
tively fair complexion, moderate or severe elastosis and mond wheel or wire brush [8]. For strong chemical
rhytides, or substantial acne scars in which the ultra- peels, phenol was commonly used by plastic surgeons
pulse CO2 is beneficial. These patients often have while dermatologists preferred trichloroacetic acid regi-
accompanying loose skin and would not typically mens [9]. Phenol peels were considered to be the deepest
improve sufficiently with fractionated treatments due peeling agent, and interestingly postoperative late-onset
to the lack of skin tightening compared to the ultra- hypopigmentation with this agent was well recognized.
pulse full ablative resurfacing. Thus, the original ultra- Post-inflammatory hypopigmentation with trichloroa-
pulse laser is still effective for an array of skin conditions cetic acid was also seen but was less problematic than
and circumstances when used on the right patient. The with phenol. Dermabrasion was also popular, but was
laser primarily reviewed in this chapter is the ultrapulse more technique and practitioner dependent, the learning
system on which most literature is based. curve was substantial, and results variable [10]. Further
dermabrasion as performed with a motorized device
spread microscopic skin particles, blood, and infectious
debris widely into the air and those microscopic particles
B.I. Raskin remained in the local room air for hours. Neither peels
Division of Dermatology, Department of Medicine, nor dermabrasion resulted in collagen tightening [11].
UCLA Geffen School of Medicine, Los Angeles,
Ultrapulse laser resurfacing of nonacne scars on the face
California, USA
compares favorably to dermabrasion [12]. However,
Advanced Dermatology & Cosmetic Care,
peels and dermabrasion suffered from variable efficacy,
28212 Kelly Johnson Parkway, Suite 245,
Valencia, California, USA lack of consistent reproducibility, and depth control
e-mail: [email protected] issues [13].

168 B.I. Raskin
Continuous wave CO2 lasers were problematic for differing skill levels and qualifications entered the
skin resurfacing and were primarily effective for spot market. Ultrapulse full face resurfacing evolved almost
lesion ablation. The ultrapulse technology was the first overnight into a highly requested cosmetic treatment
to utilize a high powered short duration pulse of energy. prompted by media publicity. Articles featuring physi-
The ultrapulse laser was introduced in the early 1990s, cians and their Ultrapulse were in leading newspapers
[14] and once the clinical benefits were elucidated, the and demonstrations shown on national TV shows [17].
technique gained popularity quickly [15]. Over time A cosmetic market was created and the laser was being
this type of laser became immensely popular through widely utilized before solid clinical studies were pub-
the mid-1990s. The Ultrapulse (the actual name is lished. Much of the first couple years use was empiri-
Ultrapulse 5000C) was produced by Coherent Laser cal based on anecdotal observations. Eventually the
which through various iterations is now Lumenis complexity in producing consistent results became
Corporation. Ultrapulse lasering has been available as apparent. Pain management during the procedure was
part of the ActiveFx and Deep Fx line of fractionated an issue and only later were methods such as tumes-
CO2 lasers produced by Lumenis. (The author has cent anesthesia introduced for this surgery. Also this
no financial relationship with the manufacturer.) laser caused significant down time with concomitant
Competitors utilizing a scanning technology had issues in the postoperative period and problems such
entered the market for full face resurfacing lasers as delayed healing and wound infections. The risk of
shortly after the Ultrapulse was introduced although scar induced by the laser was not appreciated early on,
the ultrapulse prevailed in the marketplace even though and only later did a conservative approach become the
clinical equivalence was established [16]. The initial standard technique. Early hyperpigmentation was frus-
Ultrapulse lasers utilized a 3-mm spot and surgeons trating to patients and late-onset hypopigmentation
became adept at treating a full face in a tedious fash- was not initially considered to be problematic but sub-
ion. The next technological achievement was the emer- sequently became a troubling issue [18].
gence of the scanner handpiece (computer pulse Over time the popularity waned. Part of this reduc-
generator) with a 2.25-mm spot size which made this tion involved physicians recognizing that the ultrapulse
system practical and increased the accuracy of the spot technology simply was not effective in a number of the
pattern affording the surgeon a number of choices in conditions in which it was being utilized, such as
spot placement and density along with size options for melasma. The ultrapulse system was introduced when
the patterns chosen. This allowed efficient lasering there were only two other cosmetic lasers: the original
with a high degree of accuracy and predictability. A pulse dye laser and the Q switched YAG both of which
subsequent model produced by Lumenis was the had limited benefit. Botox was not yet available, and
Ultrapulse Encore which had a smaller spot size and the only filler was Collagen. The ultrapulse became the
thus somewhat different numerical settings to achieve workhorse for various conditions in which it was sub-
equivalent energies delivered to the skin. However, optimal. Eventually the erbium laser was introduced
most literature cited on this subject was written before making more superficial resurfacing possible and then
the Ultrapulse Encore entered the marketplace, and the first nonablative technologies entered the market.
thus settings and descriptions noted in this chapter More to the point, popularity of the Ultrapulse suc-
reflect the Ultrapulse 5000C. cumbed to the same media fervor that created it: a sub-
The ultrapulse system was the first laser that pro- stantial media outpouring of laser catastrophes with
vided substantial clinical improvement with a true associated stories relating to substandard physician
wow factor. This afforded laser surgeons the oppor- training through short weekend conferences. Botox
tunity to modify acne scars, substantially reduce morphed into the media darling and the IPL photofa-
rhytides, provide improved skin tone, and reduce facial cial became the must have technology for noninva-
redundancy by tightening collagen. sive rejuvenation although CO2 resurfacing induces
The ultrapulse system was a major technological significantly more rhytid reduction than IPL [19, 20].
innovation literally advancing laser surgery by light Subsequently fractionated technology utilizing nonab-
years. The technology was embraced rapidly and with lative 1,440 and 1,540 wavelengths attained promi-
great enthusiasm. This laser was unlike any previously nence. Lumenis introduced the first CO2 fractionated
on the market and initially did not appear to require a device known as the ActiveFX in 2005 and this was
significant learning curve. A great many physicians of followed by the microfractional CO2 DeepFX in 2007.
11 Facial Resurfacing with the Ultrapulse Laser 169
The current platform combines the ActiveFX and ulation at high temperatures as occurs from CO2 laser
DeepFX and original ultrapulse laser capability. causes cell necrosis and ultimately a clinical burn.
That being said, the author is of the opinion that the However, lower heat levels in the adjacent tissue cause
original Ultrapulse technology offers a substantial ben- thermal damage rather than necrosis. Depending on the
efit to a limited group of patients whose skin is some- temperature reached, the thermal damage may be revers-
where between the fractionated CO2 and a facelift, or ible and new proteins production is stimulated. As an
have substantial acne scars. For this laser, a conserva- interesting aside, physiological defensive responses
tive approach is now recognized as the preferred method exist to increased temperature. Normal protein synthesis
[21]. Patients must not be risk averse and they need a is inhibited and specific proteins known as heat shock
clear understanding of the procedures limits along proteins are induced and these specific proteins provide
with the fact that full improvement may take months. In relative resistance to additional thermal injury. Most
general, patients should be relatively fair complected. human cells withstand temperatures up to 40C. Survival
They must be capable of carefully following postopera- at higher temperatures depends on exposure time and
tive protocols. And importantly patients must tolerate a temperature. The rate of thermal denaturation is tem-
common frustrating time early in the postoperative perature dependent, and heat increases the rate of dena-
period where their face is crusted and edematous. These turation. Laser-induced thermal injury follows the
issues will be discussed further in the chapter. Arrhenius model which documents that the rate of dena-
turation is exponentially related to temperature and pro-
portionally to time [23]. Small temperature changes
11.3 Laser Technology and Tissue result in more substantial denaturation rates while
Interaction increased time at a particular temperature causes only a
proportional change. Thus, small increases in heat dra-
Laser tissue interactions are complex. In general, tissue matically increase the speed of protein denaturation.
effects occur only when light is absorbed. The light Therefore, laser systems for resurfacing must be
carries its energy as a photon. Absorption occurs when designed to achieve specific temperature ceilings so that
the photon interacts with a chromophore (also known the rate of damage is controlled.
as an absorbing molecule). Many chromophores are Near a critical temperature which varies depending
specific for certain light wavelengths and energies. on the tissue type there is a rapid coagulation event
Once the photon is absorbed by the chromophore, the this means the effect on tissue at a given temperature
photon ceases to exist and all the energy is transferred varies depending on the tissue type. This accounts for
resulting in an excited state. Different types of excited the well-established histologic boundaries of dermal
states occur depending on the wavelength and energy. coagulation in laser or burn injuries. For instance, in
For instance, ultraviolet leads to an electronic excita- the dermis, elastin is extremely thermally stable and
tion of the chromophore resulting in a different type of survives boiling without evidence of injury. Type 1
damage which impacts the DNA. Infrared rays cause collagen which is the predominant collagen subtype in
vibrational excitation leading to heating. In the epider- the dermis has a sharp melting point transition to a
mis, absorption is the dominant process over the spec- fibrillar form at between 60C and 70C. At or above
trum of 20010,600 nm. However, in the dermis, these temperatures, collagen denaturation occurs and
wavelength-dependent scattering by collagen fibers scars become more likely. Thus, the goal of CO2 abla-
prevails. Therefore, penetration of light into the dermis tive laser therapy is to vaporize the epidermis, and
is attenuated by this scattering, thus reducing the lasers minimize an underlying zone of necrosis where colla-
impact [22]. Different technologies have been devel- gen has been heated above 70C, and yet create a
oped to address chromophores in the epidermis or der- deeper thermal injury zone within the dermis where a
mis while minimizing impact on adjacent structures. temperature maximum of 6070C has occurred.
In dermatologic applications, either visible or infra- Minimizing the zone of necrosis occurs by reducing
red light predominates and most laser tissue interac- bulk dermal heating by preventing dermal tempera-
tions produce heat. When the temperature is raised tures in excess of 6070C.
substantially, essential structures within the cells dena- Reducing the probability of additional bulk dermal
ture resulting in loss of function by protein unfolding heating requires maintaining the laser pulse at approxi-
and by coagulation of macromolecules. Thermal coag- mately equal to or shorter than the thermal relaxation
170 B.I. Raskin
time (TRT) of the target. When a pulse longer than the laser water absorption is so substantial and efficient
TRT is used, heat is not confined to the target structure that almost all laser heat is contained within the vapor-
and may dissipate beyond the target into surrounding ized water and minimal heat transfers to the adjacent
tissues causing collateral damage. To clarify this con- tissue. The 10,600 nm wavelength is well absorbed by
cept, in CO2 resurfacing, the epidermis is vaporized in water although not quite as efficiently as the erbium
under 1 ms and most of the heat imparted to the epider- laser. However, the water absorption precludes the
mis is carried away into the air as steam when the tis- laser beam from penetrating into the skin, and there-
sue water reaches boiling within that 1 ms. The fore CO2 is effective primarily at the skin surface
remaining heat is in the char and this heat dissipates in (although fractional lasers do penetrate further due to
all directions. If the epidermis were to be heated slower the technology of the equipment). Because water
for instance over several milliseconds, vaporization absorption is not nearly as efficient as the erbium yag
temperature would still be reached but while being laser, part of the beams heat is in the vaporized water
heated a portion of that heat would be dissipating in all from the skin surface and the remainder of the heat dif-
directions at the same time, resulting in overheating fuses into the underlying tissue creating collagen dam-
adjacent tissue. Thus, the concept of TRT is extraordi- age. The penetrating heat creates a zone of tissue
narily important. These concepts have been further necrosis and another zone of collagen injury. The zone
refined with the advent of fractionated systems. of collagen injury is a necessary component to create
The target TRT is related to its size and shape, with tissue tightening and rejuvenation. The key to under-
the TRT proportional to the square of its size. The TRT standing and utilizing the pulsed CO2 laser was to
for epidermis is about 1 ms; therefore pulsed systems maximize the zone of injury while minimizing the
must deliver large energy boluses in a maximum of zone of necrosis. Overutilizing laser energies would
1 ms. For CO2 systems, achieving selective ablation of cook the skin causing substantial necrosis and sub-
skin with minimal collateral thermal injury occurs optimal results.
when approximately 5 J/cm squared is delivered in The theory of the ultrapulse CO2 system relied on
under 1 ms to the surface [24]. heating and vaporizing epidermal tissue before the tis-
Different lasers variably affect the skin at the sur- sues natural thermal relaxation time allowed heat to
face and deeper levels. Visible light lasers emanate in dissipate into deeper levels. To create this effect, a
the 500700 nm wavelength and have variable targets laser pulse required enough energy to vaporize and this
based on size and chromophore absorption the pulse was established to be about 5 J/cm2 and yet be deliv-
dye laser is an example of a visible light system. These ered within the 1 ms thermal relaxation time of the epi-
lasers can penetrate the skin in the right conditions dermis [25]. With these energies, skin temperature
without adversely affecting the surface. Infrared lasers reaches 120200C. In this way, the heat was removed
range from the mid-700 nm wavelength through the from the tissue as steam from the vaporized water,
10,600 nm CO2 laser wavelength. Low wavelength leaving behind a thin layer of desiccated collagen, pro-
infrared lasers are beneficial for treating chromophores teins, cellular debris, thin underlying layer of necrosis
that are subsurface such as hair and vessels due to good and below that was a zone of injury. Therefore, a rapid
beam penetration into the skin which is usually accom- increase in skin temperature causes a rapid tissue vapor
plished by protecting the epidermis with cooling. pressure to develop by boiling water within the cells
Shortening the beam duration by Q switching a midin- and instantaneous tissue vaporization occurs. The
frared laser such as the 1,064 nm wavelength makes it superficial layer has most of the energy deposited and
suitable for small targets such as tattoo pigment which is instantly vaporized. This results in measurably
has an extremely short TRT. The CO2 laser creates a reproducible tissue ablation with each pass. With the
wavelength of 10,600 nm. The beam is generated by a ultrapulsed CO2 laser, this has been established to be
gas-filled laser tube using CO2 as the emission source, 80150 mm [26].
and thus the name CO2 laser. Physiologically, three events occur: epidermal abla-
As the infrared wavelength is increased, water tion due to vaporization of tissue, immediate dermal
becomes the main target. The most efficient water collagen contraction in the zone of injury, and delayed
absorption occurs at the 2,940 wavelength of the long-term dermal collagen remodeling which may
erbium yag laser. With a purely pulsed erbium yag require months.
The biological benefits of ablative resurfacing are in downtime, healing issues, postoperative discomfort,
primarily in the dermis [27]. Acute tissue contraction and potential permanent skin color changes. Extrafacial
occurs with 1 or 2 passes and derives from thermal applications are severely limited due to scarring although
denaturation of collagen. Collagen formation in the long-term resolution of epidermal nevi has been reported
superficial dermis has been correlated with thermal [6, 34]. Be that as it may, ablative resurfacing remains a
denaturation and acute tissue tightening [28]. The powerful tool for rejuvenation of the aging face and can
exact role of immediate contraction on long-term skin be effective in treatment of other conditions such as
tightening and collagen formation is not well under- actinic chelitis [35] and scar resurfacing [36].
stood. Regardless delayed collagen remodeling and Because of issues with potentially permanent post-
new collagen synthesis along with extracellular matrix treatment hyper- and hypopigmentation, lighter com-
production occur as a result of tissue wounding, wound plected patients tend to do better overall. Fitzpatrick
healing reaction, fibroblast activation, and resorption skin color significantly limits treatment opportunities;
of elastotic collagen fibers although the mechanisms of however success has been reported in darker com-
action are obscure. plected individuals using lower laser settings [37, 38].
Biochemical events in the postoperative process With olive or Fitzpatrick 24 complected ethnic groups
have recently been reviewed by Orringer [29]. While a such as from Mediterranean areas, South America, or
detailed discussion is beyond the intent of this chapter, Asia a posttreatment period of hyperpigmentation may
in summary, the production of type 1 procollagen and result, although this usually improves over time [39]. In
type 3 procollagen messenger RNA peaks at about 89 a report on treating Fitzpatrick type 4 patients, postin-
times baseline levels at approximately 21 days post flammatory hyperpigmentation was the most common
laser and remain elevated for at least 6 months. These complication and lasted about 4 months although true
changes are preceded or accompanied by alterations in hypopigmentation was not encountered [40]. Treating
messenger RNA levels of cytokines including interleu- darker than Fitzpatrick 4 may be performed but carries
kin 1B, tumor necrosis factor-alpha, and transforming significant risk for color anomalies. Other technologies
growth factor-beta-one. Increases were also identified have evolved that are more specialized or more effec-
in messenger RNA levels of several MMP variants tive in differing conditions, including nonablative tech-
with levels of fibrillin and tropoelastin elevations nologies, fillers, and neuromodulators. Many conditions
delayed for several weeks. These biochemical changes are now treated with multiple modalities in combina-
proceed through a well-organized wound healing tion programs to maximize improvement with reduced
response with alterations in dermal structure. The downtime.
quantitative changes may be helpful for future com- Full face ablative procedures should be considered
parisons of other therapeutic modalities. as a major cosmetic surgery because of the nature of
In summary, then, how does carbon dioxide resur- the procedure, healing process, and risks. As such
facing work? CO2 resurfacing is effective because patients should have a significant cosmetic problem.
first and foremost the laser creates a precise, predict- The cosmetic issue should not otherwise be amenable
able, uniform superficial thermal injury. The thermal to more conservative treatments or where only limited
nature of the injury stimulates greater collagen depo- improvement would occur with less invasive modali-
sition than nonthermal ablative wounds of equivalent ties. Examples of appropriate problems include severe
depth [30]. or substantial acne scars of the face, significant perio-
ral static creases or rhytides, and patients with moder-
ate-to-severe facial rhytides. Nondynamic periocular
11.4 Patient Selection lines may significantly improve. Patients with non-
melasma pigmentation may experience an excellent
Ablative CO2 laser treatment is currently utilized result. Patients with somewhat loose facial skin and
primarily for facial skin and can be problematic if used mild-to-moderate jowl formation will also benefit.
on the neck due to the risk of hypertrophic scars [31, 32]. However, patients clinically requiring a face lift
Ablative lasers are the gold standard, yet in many ways procedure often have skin that is too loose for ablative
are far from ideal. Optimal benefits occur with appropri- laser to help them. Similarly patients with severe der-
ate patient candidates [33]. Epidermal wounding results matochalasis or significant lower lid herniated fat may
172 B.I. Raskin
not sufficiently improve to warrant the time, expense, In terms of patient selection, this procedure requires
and risk of ablative lasering. The author has seen mild- detailed counseling regarding the nature of the proce-
to-moderate dermatochalasis and lower lid bulges sig- dure, downtime, healing process, and risks. Patients
nificantly improve although bulging should not be the should exhibit the capacity to understand the concepts
main reason laser is chosen. of this type of surgery. Various laser procedures in the
In the authors opinion, patients fixated on one current marketplace are widely advertised as mini-
particular problem such as a single line or one small mally invasive, so substantial counseling is necessary
anatomical area are poor candidates because the in the authors opinion to be certain that patients under-
improvement may be less than desired leading to an stand the procedure, risks, and dynamic aspects of
unhappy person. Patients who are most satisfied in the healing and final results. Typically, the author has an
authors experience typically suffer from a number of initial consultation and arranges a second visit before
related cosmetic issues and are happy if they can the laser procedure for a more complete discussion and
appreciate global improvement: The more satisfied review.
individuals have a number of problems such as actinic Importantly, patients should be able to tolerate frus-
dyspigmentation, areas of rhytides, mild jowl forma- tration, anxiety, and waiting for final results. There is a
tion, and static perioral creases. That type of patient will period during early healing when the face often looks
experience reasonable or significant improvement in all terrifying to the patient or family and patients incapa-
areas although no single region will be perfect. But the ble of coping do not handle this period well. The author
combination of improvements provides a much more has found that patients tolerance of this interim phase
youthful vigorous image with brighter appearing skin. determines their overall satisfaction and happiness.
Acne scars are another area where substantial A patient fixated on the fear they felt during that early
improvement often occurs [41, 42]. However, higher stage healing may never get past that aspect mentally
laser settings may be necessary; so those with the fair- and measures the overall results by the impact of those
est complexion are the most appropriate candidates. early anxieties.
Often acne scar patients are women in their 50s with More than with any other laser, this procedure
the complaint that the scars did not bother them until a requires that the patient and surgeon communicate and
few years previously and had become difficult to con- work well together primarily due to issues in the peri-
ceal. These scars appear worse with age due to sagging operative and prolonged postoperative time. The author
skin. In the authors experience, this group of patients typically discusses full face ablative laser procedures
achieves considerable satisfaction due to improvement as a journey that the surgeon and patient undertake
in the scars and tightening of the skin. However, acne together. In this regard, the surgeon needs to be aware
scars never completely resolve; so in selecting patients that not all apparently good candidates are appropriate
for acne scars, care must be exercised to avoid those for this laser treatment, and the physicians staff can be
with unreasonable expectations of a complete cure. helpful in elucidating awareness of issues that might
Surgeons should be aware of other medical and result in a problem patient.
social issues in the patient selection process. Patients Postoperative anxiety and depression after major
with significant underlying illness may be poor candi- cosmetic surgery is well recognized. This is the type of
dates. Those with infectious processes that pose risk to procedure where postoperative anxiety or depression
the operator such as Hepatitis B, C, or HIV may not be may occur. Patients should be counseled in advance of
appropriate. Patients with high alcohol consumption the procedure about this common problem.
may be problematic. Importantly smokers, even recent
former smokers, may be suboptimal candidates or can
expect increased postoperative problems and healing 11.5 Contraindications
issues.
Unreasonable expectations are a major problem The most significant contraindication is isotretinoin
with ablative resurfacing. These individuals are under- (Accutane) use within the prior 612 months.
going a substantial procedure with significant down- Isotretinoin is felt to increase the risk of scar forma-
time, costs, and require considerable postoperative tion. Most physicians feel a 6-month period after
care. If those individuals expectations are unmet, isotretinoin is sufficient, but some advocate waiting
intense frustration and anger may result. an entire year. Another contraindication is a face lift
procedure within 3 months before or after laser resur- MRSA infection although delaying surgery would
facing. Laser resurfacing increases the metabolism probably be advised.
and a recent prior rhytidectomy may temporarily
compromise adequate blood flow for current demand.
Similarly most physicians wait about 3 months after 11.6 Preoperative Evaluation
laser before a rhytidectomy is contemplated [43]. and Instructions
However, performing a blepharoplasty at the same
time is not problematic [44, 45]. Because of the plume, it is recommended that appro-
Treating the neck may be contraindicated [46]. priate laboratory studies for Hepatitis C, HIV, and
However, a published study of 1,851 patients treated Hepatitis B are obtained. As this is a significant cos-
on the neck with conservative settings demonstrated metic procedure, routine laboratory evaluation should
only 2 focal pigmentary areas of depigmentation and encompass CBC, renal and hepatic status to avoid
both of those were sites of herpes infections [47]. medical problems manifesting in the immediate post-
Newer modalities are available such as IPL or fraction- operative time. Female patients of childbearing age
ated nonablative or ablative systems to address this should be pregnancy tested.
challenging area. Patient medications list should be accurate. There is
Patients with a history of radiation therapy to the minimal bleeding, but it is recommended to discon-
area, or diseases such as scleroderma are not candidates. tinue agents such as aspirin appropriately in advance.
Keloid formers on the face area should be excluded. Preoperative photographs should be of high quality
Koebnerizing entities such as psoriasis or vitaligo are and a backup made as these photos are necessary in
relative contraindications because they could worsen in determining the improvement achieved.
the affected area after laser. Similarly lupus and discoid Many physicians perform ablative lasering under
lupus would be relative contraindications. conscious sedation and parameters in that regard must
Patients should be in need of a significant cosmetic be adhered to as necessary in the preoperative stage. If
procedure and understand the consent and ramifications tumescent anesthesia is to be utilized, the surgeon
of the lasering. Caution should be exercised with smok- should be familiar with any medications that may inter-
ers. Hepatitis and HIV patients are considered a con- fere with lidocaine metabolism. The planned preopera-
traindication in terms of staff exposure. Patients with tive and postoperative medications should be discussed
underlying conditions such as immune-compromised and prescriptions given to avoid miscommunication.
states or on mediations which interfere with healing Whether oral or injected, sedatives, anxiolytics, or
response such as prednisone are relative contraindica- analgesics of some type are generally utilized and
tions. Darker complected patients, especially those with therefore transportation needs and assistance at home
documented histories of postinflammatory pigmenta- should be addressed in advance. Postoperatively, the
tion, are relative contraindications. Patients with facial face is covered with dressings and anxiolytics and nar-
keloids or hypertrophic scars would not be considered cotics are often necessary in the immediate postopera-
candidates depending on the cause of the scarring. tive setting, so discussing these aspects at the
Pulmonary status may be a relative contraindication if preoperative evaluation is beneficial. The author typi-
conscious sedation is anticipated as patients with pul- cally tries to answer all questions and have patients
monary limitations such as smokers may require oxy- sign consent at the preoperative evaluation, and then
gen during the procedure and the fire hazards of oxygen again on the day of surgery.
during laser surgery should be appreciated. Patients are also given a list of items they need to
Another contraindication is patients who cannot have, such as ice bags for post-op care (the author likes
wear a metal protective contact lens. Active Herpes bags of frozen peas or corn), towels for placement over
type I is an absolute contraindication due to the the pillow at night, and ibuprofen.
risk of a herpes infection suffusing the lasered skin
over the entire face. A current MRSA infection would
also contraindicate surgery in the authors opinion, 11.7 Preoperative Medications
although there are no specific guidelines for address-
ing nasal carriers. Unanswered questions include There has been in general a uniform opinion that her-
whether to proceed if any close family exhibits an pes prophylaxis is necessary before a substantial CO2
174 B.I. Raskin
resurfacing procedure [48]. Typically medications are 11.9 The Day Prior to Laser
initiated at least the night before with treatment level
dosing of acyclovir 400 mg QID or equivalent dosing Patients should be instructed to shampoo vigorously
with valcyclovir or famciclovir [49]. Even patients the night before or the morning of surgery. Antiviral
with no clinical history of herpes may harbor the virus. and antibiotics should be started at least the night
The medications are commonly continued 57 days or before. Patients should purchase several bags of frozen
until significant healing has occurred [50]. peas or frozen corn to treat the face after surgery the
Preoperative antibiotics have been commonly uti- unopened packages are used to soothe the burning
lized typically with cephalosporins. In a study of 356 sensation in the hours after surgery. Any specific
patients, prophylactic intranasal mupirocin was inef- dressing components should be prepurchased.
fective but ciprofloxacin was advocated as advanta- Postoperative prescriptions should be filled. Calling
geous because of prevention of both gram-positive and the patient the day before to review the medications,
gram-negative infection [51]. Candida infections can verify transportation issues, and answer last minute
occur after laser and diflucan dosing preoperatively or questions will make the procedure and immediate
in the postoperative period has been advocated by aftermath smoother.
some practitioners [52]. In the current environment,
MRSA could be anticipated as an infectious agent and
use of doxycycline may be appropriate. In general, 11.10 Treatment Protocol: Safety
antibiotics are continued by most surgeons for a num- Precautions and Preoperative
ber of days depending on preference. Decisions on Preparation
antibiotics and antifungals must be individualized and
are best left to individual physician judgment. Surgeons must take appropriate safety precautions for
If the procedure is to be under local anesthesia, themselves and staff, and this is the first step in
lorazapam 12 mg can be beneficial. Because of the treatment. Protective specialized sub-micrometer filter
long half-life, a dose at night before surgery can last laser face masks for laser procedures must be worn.
through the surgical period. The author advocates clo- Appropriate eye shields for CO2 laser are necessary.
nidine 1 mg orally about an hour before surgery as this The suction must be a specialized HEPA smoke evacu-
drug has both anxiolytic and analgesic benefits. If ation unit with adequate vacuum and the correct filter-
strictly local anesthesia is utilized, surgeons can con- ing system. The filters on these units must be replaced
sider an oral narcotic before surgery. regularly and there is generally an indicator on the
suction device. The assistant should be previously
trained to maintain the suction tip within 1 cm of the
11.8 Consent laser. Keeping the suction tip within 1 cm is 98.6%
efficient in removing the plume; however, with the
Consent should include cautions about scarring and suction tip 2 cm from the treatment site, efficiency
dyspigmentation which may be temporary or perma- drops to 50% [53].
nent, and the need for sun protection during the first Fire is always a risk, and paper gowns and towels
months of healing to help avoid hyperpigmentation. should be avoided. In general cloth drapes are pre-
Specifically the high probability of permanent hypop- ferred, and these can be moist to additionally reduce
igmentation should be noted. Risks of anesthesia risks. A soaking wet towel is recommended to be
should be discussed. Even with eye shields, the author within hand reach so that any spontaneous fire may
counsels about potential eye damage. Fire risk exists be immediately blotted. Alcohol should never be uti-
with this laser and should be mentioned as a risk. lized in the immediate preoperative period as ignited
Infections should be listed on the consent including alcohol burns with an invisible flame and can widely
MRSA and herpes. Delayed healing may occur. It is spread before being recognized. Plastic materials
important to note that there can be no guaranty of can also be ignited. Leaving the laser in active mode
results and additional procedures or other modalities may result in an inadvertent laser discharge. Laser-
of treatment are often necessary. Consent should ignited plastic endotracheal tube fires can result in
include that late development of hypertrophic scars release of toxic fumes directly into the airway and
may occur. death [54].
Facial skin preparation is at the surgeons discre- begins at about 25 cc of infiltrated xylocaine. If per-
tion. The author prefers normal saline as a surgical formed completely under local, the xylocaine is fur-
prep. Eye protection is best accomplished with metal ther modified by adding bicarbonate to reduce injection
protective contact lenses, which should be designed discomfort.
for laser use. Plastic contact lenses can transfer heat Regional blocks are initiated first by injecting the
to the cornea and are contraindicated. Eye protection supraorbital, infraorbital, and mental nerves. Other
methods commonly used with the IPL such as opaque injection sites are at the superior aspect of the phil-
tape eye coverings are not appropriate for ablative trum at the base of the nose, and along the lateral
CO2 lasers. While lasering around the eyes, addi- aspect of the proximal nasal sidewall from the nasal
tional protection is afforded by covering the eye with root to the nasal cheek sulcus. However regional
a moist tongue blade. Opaque goggles can be utilized blocks alone are insufficient for total face anesthesia,
in the alert patient but caution is necessary to keep which requires routine skin infiltration over a wide
the goggles over the eyes at all times. However, metal area. While most of the forehead blocks nicely with
contact lenses designed for laser use allow for laser the supraorbital blocks, the central portion often
treatment of both upper and lower lids and rhytides requires additional skin infiltration. Similarly the lat-
laterally. eral forehead and temple is best blocked by infiltrat-
When patients lay supine, the anatomy changes and ing from the midbrow to the temple hairline in the
determining which areas to laser can be challenging. deep subcutaneous tissue. The upper and lower eye-
Therefore, all areas should be pre marked on the skin lids must be infiltrated. The preauricular regions are
while sitting. This will help establish which areas will particularly uncomfortable and require infiltration, as
be treated at different laser settings. Marking deep does the region along the mandible. For diffuse infil-
rhytides is helpful in determining subsequently during tration, the author typically injects in the superficial
surgery if additional passes are necessary. fat in a fan-like distribution. Anesthesia occurs slower
due to infiltration in the fat but less anesthetic is
required.
11.11 Treatment Protocol: Anesthesia Alternatively, a tumescent anesthesia mixture can
be suffused into the subcutaneous fat using a .1% lido-
Lasering may be accomplished under conscious seda- caine mixture (lidocaine, epinephrine, bicarbonate
tion or with local anesthesia. The author prefers con- mixture as described in the chapter on tumescent lipo-
scious sedation in an ambulatory surgical center suction) [56]. While this is effective, patients appear
environment for enhanced patient comfort although quite edematous postoperatively which can be disturb-
the procedure is equally well performed under local ing to them. Tumescing the tissue can impair visual
anesthetic. The primary issues with conscious sedation aspects allowing rhytides that might need an additional
involve supplemental oxygen and the increased fire pass to be overlooked in treatment.
hazard conferred. Some surgeons utilize minimal con- Laser resurfacing has benefited from the advent of
scious sedation without oxygen and others prefer effective topical agents [57]. However eye damage in
delivering O2 via an LMA tube. Wrapping the LMA the form of corneal abrasions has occurred [58].
with aluminum foil or wet gauze has been advocated to Topical anesthetics have been incorporated with con-
prevent combustion [55]. scious sedation to avoid the need for local infiltration
Even with conscious sedation, local infiltration of [59]. Cold air cooling combined with oral analgesia
anesthesia is helpful. Infiltrating lidocaine reduces the has been used without injecting xylocaine for localized
need for deeper sedation and thus minimizes O2 sup- single-pass treatment of the periorbital and perioral
plementation. The author has found that approximately regions [60].
2025 cc of xylocaine 1% with epinephrine 1:100,000 In the authors experience, local anesthesia works
is the minimum necessary for full facial local infiltra- effectively for one laser pass but supplemental infiltra-
tion including regional blocks. This amount is below tions may be necessary for any area treated with a sec-
the 7 mg/kg toxicity level (approximately one 50 cc ond pass. Areas that have been lasered are often
bottle of 1% xylocaine with 1:100,000 epinephrine for uncomfortable until final dressings are applied but this
the average sized patient). Caution should be utilized if can be ameliorated by spraying the lasered area with a
a 2% xylocaine is used because the toxicity level 50-50 mixture of lidocaine 1% and saline.
176 B.I. Raskin
11.12 Treatment Protocol: Laser Settings excessive heat is delivered to the skin beyond that
required for immediate vaporization leaving the skin to
The Ultrapulse laser allows adjustment of laser energy act as a heat sink. This caused deep zones of necrosis
output, the density of the pulse pattern, the shape of the and bulk heating resulting in skin burns or scars.
pattern of pulses on the skin, and the size of that shaped
pattern. The pulse duration is a preset 1 ms and each
individual pulse in the pattern is about 2 mm in 11.13 Treatment Protocol: Laser
diameter. Technique
The setting for the shape of the pattern of pulses is
at the discretion of the surgeon as pattern shape makes Before treatment, the laser is tested on a wet tongue
no difference in treatment. The main issue is to treat blade to assess the settings (Figs. 11.111.5). Treatment
the entire face or specific region and not overlap may begin on any area of the face. The assistant must
because overlap can cause tissue burn. The size of the keep the suction tip within 1 cm of the laser area to
pattern chosen is relevant because a smaller size is aspirate the splatter. The laser is properly positioned
considerably less painful if the procedure is performed for the immediate area to be treated, and once trig-
under local. Treating with a larger pattern size makes gered, the handpiece is held in place until the dot pat-
the procedure more efficient, but if patients complain tern has been laid down on the skin. The handpiece
of pain the discomfort diminishes when the pattern should be held so that the laser beam hits the skin in a
size is reduced. perpendicular direction in order to maintain the proper
The laser output is measured in millijoules. overlap pattern of the generated laser pulses. The oper-
Commonly 250 or 300 mJ is optimal for the rapid skin ator can quickly see by the pattern laid down if the
heating necessary to reach the critical immediate tissue laser was in proper position as all the pulses will be
vaporization stage. Eyelids are treated at a maximum perfectly symmetrically arranged. This is sometimes
of 250 mJ. 175 mJ is often utilized just inferior of the challenging because of the size of the handpiece and
mandible for feathering to reduce an abrupt color natural curvature of the areas to be treated. Using a
change postoperatively. smaller sized arrangement of pulses often minimizes
The most important setting is the density value. The problems in difficult areas. A fine white char is seen in
density determines spacing between dot pattern of the pattern of pulse dots.
pulses and settings vary from complete separation to The most important aspect of treatment is to avoid
varying degrees of overlap. Surgeons have become overlap of treated areas [61]. Overlap is identified by
more conservative over the years. While in the past set- a black char on the skins surface. The white char
tings of 6 or 7 were common (2030% overlap), typi- acts as a heat sink since there is no water left for
cally density settings now are 5 or 6 (1020%) for vaporization in that area. High peak temperatures
treatment. Density settings of 3 or 4 are used for the approaching 400C can occur with pulse stacking
feathering zone. The problem with high density is that [62]. Therefore overlapping treated areas may result
Fig. 11.1 (a) Preoperative markings showing areas to be between laser passes to avoid laser burns. (d) Metal contact
emphasized, feathered, and avoided. Deeper creases are indi- lenses are in place. Plastic lenses are contraindicated. In addi-
vidually marked. The area along the mandible will be treated at tion, a wet tongue blade can be held just below the lid margin to
a lower setting due to increased risk of scar formation. Patient cover the eyelashes and help in stretching the skin. The laser
had upper and lower blepharoplasty at the time of surgery. (b) beam is safe on a wet tongue blade and allows the laser to be
Smoke evacuation (amber colored) is held very close to laser. used immediately adjacent to the lid margin without damaging
All drapes outside the surgery area are moist to reduce the risk eyelashes. (e) Wiping face with saline gauze between passes. In
of fire. (c) Partial treatment. The lasered area should appear even many cases, the char slides off easily, but often vigorous rubbing
and white. Small areas of honey-colored crusts are a result of is necessary for removal. The char must be removed between
stacked pulses from laser overlap when the edge of one pattern passes, because the desiccated debris of the char acts as a heat
of pulses overlaps onto another. Focal overlap is unavoidable sink when lasered, reducing vaporization and causing signifi-
and not problematic, but larger areas of overlapping pulses can cantly higher heat buildup in tissue
result in burns. Areas must be wiped clean with wet saline gauze
a b
c d
e
178 B.I. Raskin
a b
c d
Fig. 11.2 (a) Preoperative. Notice deep perioral creases and improve within weeks. (e) Day 20: In many patients, the redness
prominent nasolabial fold. (b) Day 3: After dressing removal. improves relatively quickly leaving a persistent pink tone that is
Crusting is present in areas at edge of bandages. (c) Day 5: Once easily covered with cosmetics. Any areas of persistent intense
the skin begins epithelializing, the process proceeds quickly. (d) erythema need to be carefully followed as this may be indicative
Day 8: The skin has epithelialized completely. At this stage, of early scar formation. (f) Day 60: Mild hyperpigmentation is
patients can begin applying makeup but should begin with small present and a subtle erythema persists, although both issues are
test sites for any product used to avoid irritation. Sunscreen and easily covered with cosmetics. Topical steroids and hydroquino-
sun avoidance are particularly important during early healing. nes are helpful, and sun avoidance is mandatory. (g) Day 88:
Moderately intense erythema may persist but usually begins to Erythema and mild hyperpigmentation are improved
e f
Fig. 11.2 (continued)
in skin burns. After some practice and experience Or alternatively, after the first pass is completed and
with the laser, the operator develops the ability to lay the char removed, these spaces can be touched up
the pulse pattern down next to the previously treated with a smaller pattern of pulses.
site without overlap. However, not uncommonly Typically larger size patterns are used for the
small spaces between pulse patterns may be dis- cheeks and forehead while smaller pattern sizes are
cerned and these do not necessarily need to be treated. necessary for around the eyes and nose. When work-
180 B.I. Raskin
a b
c d
Fig. 11.3 (a) Preoperative. (b) Day 2: After removal of nonoc- makeup but redness still apparent. Skin is significantly brighter.
clusive dressings. (c) Day 3: Crusting is still present in areas of (g) Day 53: Well healed. She requires only small application of
deeper laser treatment. (d) Day 4: The patient has now epitheli- makeup to cover the erythema. (h) Day 74: No makeup. Overall
alized in most areas although crusts persist in the perioral region. redness has resolved, and patient has dramatically improved
(e) Day 7: Well epithelialized. Notice focal area of persistent skin tones and softening. The laser lift from collagen contrac-
erythema on right upper lip just superior to vermilion. Author tion helps reduce the nasolabial folds and provide for a more
uses high potency steroids for a short time for any area suspi- volumized appearing face
cious for early scar formation. (f) Day 9: Patient now wearing
e f
g h

182 B.I. Raskin
a b
c d
Fig. 11.4 (a) Day 1: Preoperative. Notice irregular pigmenta- ness still apparent. Skin is significantly brighter. (f) Day 53:
tion on cheek. (b) Day 2: Areas of the right cheek already have Erythema easily covered with cosmetics. (g) Day 74: Without
epithelialized. (c) Day 4: (d) Day 7: This patient has a relatively cosmetics. Face tones are now even and brighter. Lip creases
mild erythema. (e) Day 9: Patient now wearing makeup but red- substantially reduced
e f
ing around the eyes, the eyelashes can be swept aside full face treatments. The mandibular line should be
and protected using a wet tongue blade allowing marked prior to surgery and this represents the most
treatment very close to the lash line. Care must be inferior part of the face to be treated. Once on the
taken to avoid the eyebrows as those hairs may take neck, the risk of scar is significantly increased and
months to regrow if lasered. Treatment may be car- only a low energy lower density feathering should be
ried up to the vermilion. A wet gauze should be used in a thin strip immediately below the mandibular
inserted in the mouth over the teeth as laser energy line. The goal of feathering is to smooth the color
destroys enamel. The earlobes should be included on transition since the lasered area heals lighter. Other
184 B.I. Raskin
Areas of thicker skin often require more passes as do

areas of greater photodamage. Because of increased
healing times and risk, many laser surgeons no longer
treat to maximum end points, preferring to compro-
mise between extent of benefit, risk of scar, and poten-
tial postoperative hypopigmentation.
Optimal results will be achieved if the operator
sees the skin tightening while lasering. This can be
quite dramatic and is primarily noticeable on the
cheeks, malar areas, and lids although can be seen on
other areas as well. The author prefers to choose set-
tings that demonstrate tightening on the first laser pass
and thus if possible avoid the risks of deeper laser
treatment with a second pass. Alternatively, one must
avoid lasering too deep with the first pass, and thus in
some individuals a second pass is necessary to induce
immediate tissue contraction. As a test, after starting
an area, a small amount of the white char is gently
removed with saline-soaked gauze and moist pink skin
should be visualized similar to superficially denuded
Fig. 11.5 (a) Day 3: After removal of dressings. Patients fre- skin or superficial second degree burns. A tan or buff
quently have crusting around mouth and eyes in areas at edge of color means the deeper collagen has been impacted
dressings. The next several days require frequent follow-up vis- and settings should be reconsidered depending on the
its for emotional support. At this stage, patients wash frequently
and cover with thin layers of emollients to avoid crust buildup.
clinical circumstance. It is not uncommon while doing
Antibiotic ointments are avoided to reduce the complication of a touch up second or third pass on individual rhytides
contact dermatitis slowing epithelialization to see a buff colored area and this is considered a cau-
tion point although patients generally heal without
more current technologies provide superior results on noticeable problems. Seeing a wide area of buff color-
the neck at lower risk. ation after removing the char signifies a deeper laser-
Evaluating color of the tissue while lasering is nec- ing. A deep procedure may provide enhanced results
essary to determine depth of penetration. After wiping but at increased risk. Many patients who need the sub-
with moist saline, the rehydrated papillary dermis stantial tightening that can occur with second or third
appears pink due to the presence of an intact papillary passes also share the highest risk due to thin elastotic
dermal plexus. Additional laser passes extends dam- skin with poor physiologic reserve. Physician judg-
age into the deeper papillary dermis and a tan color is ment and experience are the determining factors.
noticeable and at this point distinct tissue contraction In many patients, a single pass will complete the
should be obvious. Most surgeons rarely proceed procedure [64]. Single-pass laser resurfacing can yield
beyond a tan coloration. After an additional pass or beneficial results with faster healing and reduced
passes, a yellowish hue analogous to a wet chamois adverse events [65]. In a study of 50 patients treated
cloth is noted. This represents the upper reticular der- with one pass, there were no episodes of hypopigmen-
mis, and proceeding beyond this depth with additional tation or scar [66]. With a single-pass treatment, the
passes is not recommended due to the risk of thermal char does not need to be removed because vigorous
damage to adnexal structures from which reepithelial- wiping with saline-soaked gauze may result in addi-
ization develops [63]. Yellow brown discoloration that tional injury [67]. Post-op care can be initiated as
is persistent after wiping indicates thermal necrosis described subsequently and the patient discharged.
and should be considered an absolute contraindication The number of laser passes to perform is individu-
to further laser passes in that area. alized. Factors that determine additional passes include
End points of laser treatment are when wrinkles or the surgeons judgment of the effect of the first pass,
scars are no longer visible, or no further skin tighten- Fitzpatrick skin color type, and extent of rhytides or
ing is noted, or when yellowish discoloration is present. acne scars, character of the skin, and whether the
patient is a smoker. Second and/or third passes can be 11.14 Laser Protocol: Localized Areas
localized to individual areas or even select rhytides.
Acne scars generally require additional sculpting with In some patients only a regional treatment is planned,
second or third passes and the location determines how such as the perioral or periocular region for rhytides.
deeply areas can be treated with tolerance greater on Regional areas should be designed around normal ana-
the central face than the lateral cheeks or forehead as tomical boundaries encompassing a complete cosmetic
areas with sebaceous skin are more forgiving. Keep in unit, for example, extending to the nasolabial fold for
mind that those who are fair with fine-pored skin and treating the upper lip [69]. When treating the periocu-
fewer apparent adnexa tend to be at a higher risk for lar area the tear trough serves as the lower margin;
late-onset hypopigmentation [68]. however, the lateral margin can be more difficult to
If a second pass is intended, then the face is cleaned determine. The problem with localized treatment is
with saline-soaked gauze. In some patients, the char is that the skin may ultimately heal lighter than the
adherent and vigorous wiping is necessary while in untreated adjacent skin. This can result in an owl eye
others, the char slides off easily. The author advises look or a white upper lip and/or chin. If treating local-
iced saline since heat is retained in the skin and may ized acne scars on a cheek, a white circle may form.
cause further damage as is well established in burn Patients with the lightest colored skin tolerate local-
injuries. Under local anesthesia, the patient often com- ized treatments since the contrast post surgery is not as
plains of heat and burning rather than pain after a treat- noticeable. Female patients who regularly wear
ment. After removal of char, chilled saline-soaked makeup may be unconcerned about discoloration if
gauze is applied to the entire face for a few moments advised in advance. Some surgeons treat the entire face
until the burning sensation subsides. with a lower setting such as 250 mJ at a density 4 or 5
The face is evaluated from several angles and resid- and then focus higher energies on the regional site to
ual scars or rhytides are identified. Energy settings for try and avoid color anomalies. If treating the neck,
second passes may be the same or lower than the ini- very conservative settings are necessary and details on
tial setting. The face must be wiped dry before laser- this aspect were addressed in the contraindications
ing because the laser photons are then simply absorbed section above.
by water on the skins surface. The author typically
uses the same millijoule setting but reduces the den-
sity by 1 setting except in the immediate periocular 11.15 Laser Protocol: Postoperative
region where both density is reduced by 1 and the mil- Dressings and Subsequent
lijoule setting diminished by 50 (for example from Wound Care
300 to 250 mJ). A second pass may be performed over
the entire face although the author does not usually CO2 laser is the precise application of heat to the skin.
find benefit from doing the forehead twice. Or the sec- The end result is a defined skin burn creating a thin
ond pass may be on an area such as portions of the layer of necrosis and an adjacent region of injury. In the
cheeks to enhance tightening, or just on individual immediate moments after the procedure has been com-
scars or lines. It is recommended to avoid extensive pleted, patients complain of both pain and an uncom-
second passes in the immediate preauricular area or fortable burning sensation. Residual heat in the skin is
along the jaw line because those areas are more prone known to continue resulting in additional injury.
to hypertrophic scar formation. Treating just scars or Therefore the patients skin should be covered in chilled
lines on a second or third pass slows epithelialization saline gauze, and the author keeps the skin chilled for
in those areas which is noticeable over the next several 10 min or until patients indicate the skin feels cold.
days but only rarely results in additional long-term Some surgeons do not utilize dressings feeling that
hypopigmentation. The surgeon must recognize that the risk of infection is reduced compared to occluded
rhytides or scars may not be amenable to complete skin [70]. However, patients often find the experience
resolution with laser and thus avoid multiple passes. unpleasant and pain is more difficult to manage. More
Examples of difficult areas are individual upper lip commonly is a nonstick dressing regimen [71, 72].
lines, deeper cheek lines, and focal scars. The author Various occlusive dressing types have been utilized
recommends that three passes is the maximum to uti- [73, 74]. In a recent comparative study of available
lize for any specific site. dressings, Flexzan was considered most efficacious,
186 B.I. Raskin
and this is consistent with the authors approach [75]. their appearance frightening and should be counseled
Among the various dressings available the author pre- in advance. Over the next few days the face is washed
fers Flexzan. This dressing usually adheres to lasered several times daily, and the hair shampooed to avoid
skin but is easy to remove. The dressing is cut to fit and crust buildup which may harbor bacteria. Aquaphor
applied over all areas including as much of the eyelid use will be hourly initially but then decrease as the
as possible and up to the lips. A mesh stockinette is skin heals. Some physicians recommend acetic
applied over the head to hold it in place. acid applications to reduce the chance of Candida
Use of occlusive dressings for 48 h followed by infection.
open wound care with occlusive ointments achieves Generally, with a single-pass laser treatment, epi-
the benefits of occlusive dressings while minimizing thelialization occurs within 57 days, and after
additional costs and the increased risks of infection 710 days, patients are resuming normal activities and
from prolonged occlusion [76]. The author covers the wearing makeup. Additional time to epithelialize is
skin with Aquaphor Healing Ointment or similar oint- required if lasering was deeper. Infections may occur
ment. Antibiotic preparations are avoided to reduce before epithelialization and these must be treated early
irritation and contact dermatitis. Among the various and aggressively both topically and orally. If an abnor-
dressings available the author prefers Flexzan. This mal area is identified, the skin must be cultured for
dressing usually adheres to lasered skin but is easy to bacteria, fungi, and herpes.
remove. The dressing is cut to fit and applied over all The skin has a bright pink-red appearance once it has
areas including as much of the eyelid as possible and epithelialized. This diminishes over the next several
up to the lips. A mesh stockinette is applied over the weeks. Some surgeons advocate vitamin C applications
head to hold it in place. or steroid creams during this time period. Patients must
The most common complaint in the hours after sur- wear sun screens. The skin is still friable once it has
gery is a persistent burning sensation and feelings of epithelialized, and patients often complain of small ero-
anxiety. It is not known if this is just residual damaged sions over the next several days after the skin appears
nerve endings, or persistent heat in the skin. Diazapam healed. These erosions generally heal without problems.
is effective postoperatively, and frozen corn or frozen Surgeons must be aware of any persistently red area or
pea bags can be held against the skin. Narcotics in the region of firmness as this often indicates early hypertro-
immediate postoperative period do not seem to reduce phic scar formation, and these areas must be aggres-
the symptoms of heat or anxiety. Most patients then take sively treated early with high potency steroid creams.
a narcotic at night and the usual stated reason is to avoid Posttreatment erythema may be prolonged for a
being woken up in pain. Overall pain management is not duration of 34 months. A persistent erythema may
problematic for most patients, and hydrocodone or sometimes lead to hyperpigmentation. The author treats
codeine at routine dosing is sufficient although most erythema lasting longer than a few weeks with a short
patients do well on acetaminophen or ibuprofen. course of topical steroids and vitamin C creams [77].
The patient is typically followed up the next day, at Commonly patients undergo a period of hyper pig-
which time the dressing has commonly come loose mentation, especially if they have sun exposure. This
around the eyes and mouth and developed superficial can be managed with high potency steroids and hydro-
crusting in those areas because they have dried out. The quinone. Most hyperpigmentation gradually resolves
patient is instructed to apply aquaphor frequently with a but may require months.
cotton applicator to the crusted areas on the periphery.
On the second or third postoperative day, the patient
is instructed to remove the dressing in the shower. The 11.16 Results
Flexzan dressing loosens from the skin easily when it
becomes soaked. The patient is instructed to cleanse Wrinkles and sun damage do well with CO2 resurfacing
the face with water or a very mild soap and blot dry. [78]. Improvement with full face ablative laser resur-
Aquaphor should be applied in a very thin layer hourly facing can be dramatic with substantial improvement in
or as needed whenever the face skin feels dry or gritty, rhytides, good skin tightening, and a brighter skin color
but only very thin layers are necessary to avoid buildup bereft of dull brown hues (Figs. 11.611.9). Considerable
that may look like infection. Patients at this time find tightening due to collagen shrinkage may be obtained [79].
a b
Fig. 11.6 (a) Preoperative. Patient has dull sallow appearing in the jowl. The cheeks appear lifted and more full due to the
skin, jowl formation, and irregular dyspigmentation. Perioral laser lift effect of collagen contraction, and the tear trough is
creases and prominent nasolabial folds are present. (b) Six reduced. Pigmentation is more even and skin tones brighter.
months posttreatment. Patient declined fillers and neurotoxins. Mild hyperpigmentation persists
She has achieved smoothing of the nasolabial fold and reduction
a b
Fig. 11.7 (a) Preoperative 56-year-old female with solar elas- and acne scars less apparent. Dull brown tones are no longer
tosis, dyspigmentation, mild acne scars, and dullness of the skin. present, and nasolabial fold is softened
(b) Seven weeks posttreatment, skin is brighter and more vibrant
188 B.I. Raskin
a b
Fig. 11.8 (a) Preoperative patient with significant sun damage, youthful complexion. Skin tones are even and creases dimin-
mottled pigmentation, early jowl formation, and creased areas ished. Jowls are tightened and the laser lift effect of collagen
on chin. (b) Eight weeks post laser, patient has brighter, more contraction gives the face a more volumized appearance
a b
Fig. 11.9 (a) Preoperative 57-year-old female with dyspig- ened. Face appears more full and eyebrows lifted from the laser
mentation and jowl formation. (b) Six months after laser, skin lift of collagen contraction. Skin tones are brighter and more
color is brighter and jowls reduced. Perioral creases have soft- vibrant. Overall patient appears years younger
However residual rhytides often remain, especially on occurs over months and the maximum benefit may not
upper lip smokers lines and around the perioral area. be seen for 6 months or longer [81]. Overall improve-
Deep creases around the eyes persist, although static ment of wrinkles can be 5090% [8284]. Fine lines
and dynamic lines show improvement. Dermatochalasis especially those around the eyes improve substantially
may improve significantly [80]. Final improvement more than deep rhytides and creases.
a b
Fig. 11.10 (a) Area of delayed healing at day 12. Any slow laser treatment may go on to heal with discoloration or scar. (b)
healing site must be cultured for both bacteria and herpes. The Six months later, skin color is brighter and jowls reduced. Perioral
site should be debrided gently and frequently. Most persistent creases have softened. Face appears more full and eyebrows
superficial incompletely epithelialized areas eventually heal lifted from the laser lift of collagen contraction. Skin tones are
without problems. Areas not healing because of localized deep brighter and more vibrant. Overall patient appears years younger
The initial substantial improvement often appears However, fractionated lasers, either ablative or nonab-
to diminish after 2 or 3 months leading to patient dis- lative, offer additional alternatives beyond the scope of
satisfaction. However, the collagen remodeling so this chapter [88].
important to the final result is only just beginning and
patients need to be counseled about the healing
process. 11.17 Complications
Overall acne scars improve moderately, and severe
acne scars are less responsive than mild or moderate Complications and problems have been discussed
scars although improvement of about 80% in moderate throughout this chapter (Fig. 11.10). Complications
atrophic acne scars has been reported [85]. In a study may occur because of the patients overall health or lack
of fractional CO2 lasers for acne scars, after two or thereof and also additional factors such as excessive
three treatments, a 2550% benefit was shown in atro- sunlight during the postoperative period or smoking.
phy, texture, and overall improvement [86]. Therefore, Many complications are avoidable with proper commu-
ultrapulse ablative resurfacing is the superior tech- nication and patient selection based on the patients
nique for acne scars and the difference in the two stud- underlying status and by avoiding excessive lasering.
ies cited is reflective of clinical experience although in Proper preoperative skin preparation, postoperative
the authors impression, acne scar improvement is wound management, adequate physician training, and
variable and not always consistently predictable with physicians awareness reduce the frequency and severity
either modality. Acne scar patients continue to improve of complications [89]. Be that as it may, complications
for up to 18 months with 11% improvement noted are a fact of surgery exacerbated by patient behavior,
between months 6 and 18, which are longer than for underlying clinical status and unknown factors.
patients with photoaging [87]. Patient skin color clearly Acute complications include infections. Bacteria
is a determining factor in laser choice and the nonabla- and fungi must be considered. Poor or slow epithelial-
tive fractional laser may be a viable option [11]. ization may indicate infection. Reactivation herpes can
190 B.I. Raskin
spread through the entire lasered area. Obviously lips or eyes, there can be contraction forces causing
infection can lead to scar formation or persistent dis- anatomical distortion.
coloration [90]. In a study of 354 patients treated with Late-onset hypopigmentation is considered both
occlusive dressings, the infection rate was 1.13%, and a complication and expected result. Hypopigmentation
three of the infections occurred 35 weeks after the is relatively uncommon with an incidence of
procedure, thus delayed infections can occur [91]. approximately 16% and is seen more frequently in
Common problems include acne flares and milia. patients with significant actinic bronzing with scattered
Contact dermatitis may occur. Short-term issues include lentigines [33]. This may occur months after treat-
hyperpigmentation that generally resolves with treatment often a year later. In fact the lightening of the
ment but may persist months [92]. Erythema is expected skin is part of the benefit in making people appear
after laser resurfacing, and generally resolves after sev- more youthful and vigorous and certainly women
eral weeks. However prolonged erythema becomes a typically require less makeup application. Skin light-
complication because of patient unhappiness. Prolonged ening is not specific to laser since it is seen with deep
erythema may last for months. Erythema is thought to chemical peels also. However the hypopigmentation
represent the effects of epidermal immaturity, reduced is disturbing to many patients and often precludes
melanin absorption of light, reduced dermal optical men from having the procedure. Younger females in
scattering, and increased blood flow due to injury [93]. particular find the color difference between the neck
Operator influence may occur from use of tretinoin pre- and face to be problematic, probably because in gen-
or postoperatively and from mechanical trauma from eral they do not wear as much makeup as older
excessive rubbing with wet gauze intraoperatively [94]. women. Repigmentation has been accomplished with
Persistent erythema can eventually result in hyperpig- topical photochemotherapy [99].
mentation, and therefore should be treated with steroid Eye damage from the laser is possible if eyes are
preparations and vitamin C creams. inadequately protected. Other unusual complications
Other less frequent problems include prolonged reported include a granulomatous reaction and a case
nonhealing where an area of the skin simply does not of parapharyngeal abscess from a postoperative skin
reepithelialize. Often these are culture negative and staph infection [100]. Multiple warts after a CO2 resur-
poorly responsive to antibiotics. Delayed wound heal- facing have been described [101].
ing may lead to hypertrophic scar and the pulsed dye Occasionally severe complications supervene
laser may be beneficial [95]. beyond the capabilities of the treating surgeon. In a
Short-term issues include hyperpigmentation that report on 50 CO2 laser resurfacing patients treated at a
generally resolves with treatment but may persist months burn center over a 5-year period, wounds that had not
[92]. Frequency of hyperpigmentation is variable but epithelialized within 1421 days were debrided and
has been reported to occur in 2535% with the higher treated with split skin graft or bioengineered skin sub-
percentage in darker skin [96, 97]. In a mouse study, stitute [102]. Late complications include hyperemia,
both prelaser and postlaser UV exposure correlated with pigmentation issues, and hypertrophic scars. Ultraviolet
postoperative hyperpigmentation and also adversely light avoidance was critical and hyperpigmentation
impacted texture changes and fibrosis [98]. Pigmentation was treated with 810% hydroquinone, with hypertro-
can be very distressing to patients. Various pre- and phic scars treated by injection and acrylic plastic face
posttreatment therapy combinations have been advo- masks used for pressure therapy. Fortunately this level
cated but results are inconsistent. The most effective of complication is extremely rare and is probably even
treatment combines topical steroids and hydroquinone more infrequent as resurfacing protocols have become
with an emphasis on sun prevention and protection. more conservative.
Delayed-onset scar formation is relatively rare, but
must be treated early. As noted above, this will often pres-
ent as a persistent red often somewhat indurated area and 11.18 Conclusion
at an early stage often improves within a couple of weeks
with super high potent steroids such as clobetesol. Full face ablative CO2 laser treatments have been
Deep lasering can cause slow healing and scar for- superseded in most patients with new modalities and
mation. Unfortunately when this occurs around the combination treatments of less invasive technologies.
However for a segment of people with significantly 14. Lumenis promotional material from www.aesthetic.lumenis.
com/pdf/PB_1013680_A_upenc_A2090.pdf, 09/01/2011.
damaged skin or substantial acne scars, this laser
15. Fitzpatrick RE (1996) Pulsed carbon dioxide laser resurfac-
method can be very beneficial, especially in those who ing of photoaged facial skin. Arch Dermatol 132:395402
otherwise can only achieve a similar improvement after 16. Ross EV, Grossman MC, Duke D et al (1997) Long term results
months and repeated treatments with less aggressive after CO2 laser skin resurfacing: a comparison of scanned and
pulsed systems. J Am Acad Dermatol 37:709718
therapy at ultimately a higher financial cost. Even uti-
17. Authors personal observations, Raskin, Bernard I.
lizing multiple treatments sessions of less aggressive 18. Laws RA, Finley EM, McCollough ML, Grabski WJ (1998)
therapy, results often do not achieve the gold standard Alabaster skin after carbon dioxide laser resurfacing with
of ultrapulse fully ablative CO2 laser therapy. The risks histologic correlation. Dermatol Surg 24:633636
19. Bitter PH (2000) Nonionvasive rejuvenation of photodam-
of the procedure and ability of the patient to understand
aged skin using serial, full face intense pulsed light treat-
and comply with the protocol must be evaluated in ments. Dermatol Surg 26:835843
determining which patient is a candidate. 20. Hedelund L, Bjerring P, Egekvist H (2006) Ablative versus
non ablative treatment of perioral rhytides. A randomized
controlled trial with long term blinded clinical evaluations
and non invasive measurements. Lasers Surg Med 38:
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35. Laws RA, Wilde JL, Grabski WJ (2000) Comparison of niques, Sorin Eremia ED. Cambridge University Press, New
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36. Greenbaum SS, Rubin MG (1999) Surgical pearl: the high laser resurfacing using a supplemented topical anesthesia
energy pulsed carbon dioxide laser for immediate scar resur- protocol. Arch Dermatol 139:12791283
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37. Ruiz-Esparza J, Gomez JMB, De La Torre OLG (1998) cream during erbium laser resurfacing. Dermatol Surg
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40. Sriprachya-anunt S, Marchell NL, Fitzpatrick RE, Goldman Dermatol 140:13331336
M, Rostan EF (2002) Facial resurfacing in patients with 61. Ross EV, Barnette DJ, Glatter RD (1999) Effects of overlap
Fitzpatrick skin type IV. Lasers Surg Med 30:8692 and pass number in CO2 laser skin resurfacing: a study of
41. Shim E, Tse Y, Velazquez E, Kamino H, Levine V, Ashinoff residual thermal damage, cell death, and wound healing.
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42. Bernstein LJ, Kauvar ANB, Grossman MC, Geronemus RG tion of skin with a clinical CO2 laser system: implications
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44. Alster TS, Doshi SN, Hopping SB (2004) Combination sur- 65. Ruiz-Esparza J, Gomez JMB (1999) Long term effects of
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45. Apfelberg DB (1996) The ultrapulse carbon dioxide laser 66. Tanzi EL, Alster TS (2003) Single pass carbon dioxide ver-
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Dermatol Surg 25:162165 (1999) The effect of wiping on skin resurfacing in a pig
47. Kimer SI, Chotzen VA, Silva SK (2006) Safe and effective model using a high energy pulsed CO2 laser system.
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48. Horton S, Alster TS (1999) Preoperative and postoperative ing. Dermatol Ther 18:227241
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49. Alster TS, Nanni CA (1999) Famciclovir prophylaxis of 70. Atiyeh BS, Dham R, Costagliola M et al (2004) Moist
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Dermatol Surg 24:331334 infections following full face CO2 laser resurfacing and
78. Goodman GJ (1998) Carbon dioxide laser resurfacing: pre- occlusive dressing use. Dermatol Surg 26:3236
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82. Fitzpatrick RE, Goldman MP, Satur NM et al (1996) Pulsed Pulsed carbon dioxide laser resurfacing of photoaged facial
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83. Alster TS, Garg S (1997) Treatment of facial rhytides with a ide laser resurfacing. Dermatol Surg 24:315320
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98:791794 laser resurfacing: increased risk of side effects after UV
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85. Apfelberg DB (1997) A critical appraisal of high energy Laser resurfacing induced hypopigmentation: histologic
pulsed carbon dioxide laser facial resurfacing for acne scars. alterations and repigmentation with topical photochemo-
Ann Plast Surg 38:95100 therapy. Dermatol Surg 27:515520
86. Chapas AM et al (2008) Successful treatment of acneiform 100. Rendon-Pellerano MI, Lentini J, Eaglstein WE et al (1999)
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87. Walia S, Alster TS (1999) Prolonged clinical and histologic 101. Torezan LA, Osorio N (2000) Development of multiple
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ing. Semin Cutan Med Surg 15:200207
Capacitive Radiofrequency
Skin Rejuvenation 12
Manoj T. Abraham and Joseph J. Rousso
12.1 Introduction Radiofrequency (RF) energy is electromagnetic radi-

ation in the range of 3300 GHz. Solta Medical, Inc.
Skin rejuvenation procedures, particularly those that (formerly Thermage, Inc.), based in Hayward, California,
deal with rhytids and skin tightening, are a necessary has pioneered the aesthetic application of nonablative
skill set in the arsenal of the aesthetic clinician. In RF skin tightening. Thermage, Inc., was initially granted
general, plastic surgical techniques provide the most FDA regulatory clearance for treatment of periorbital
dramatic improvement. Resurfacing lasers (traditional wrinkles and rhytids in November 2002. This was
or fractionated), dermabrasion, deep chemical peels, followed by clearance for full-face treatment in June
and coblation are considered standard ablative nonsur- 2004. In January of 2006, the FDA expanded its clear-
gical tools for skin-rejuvenating procedures. However, ance to treatment of all skin surface wrinkles and
longer duration of recovery, scarring, pigmentary changes, rhytids. Although there are a growing number of other
and other complications are more common with surgi- devices and technologies available for nonablative skin
cal and ablative procedures due to the very nature of tightening, none of these have the accumulation
these treatments. As a result, noninvasive methods of published studies reporting efficacy compared to
have become increasingly popular, and there is signifi- Thermage [138]. In addition, Thermage treatment
cant demand for effective, proven methods of nonabla- protocols have had time to evolve through several gen-
tive skin rejuvenation. The senior author has found erations, ensuring safety and more consistent and
nonablative capacitive radiofrequency to be a success- effective results [32, 34, 37].
ful and well-received approach for nonsurgical skin Thermage systems utilize the companys proprietary
tightening in his private practice. technology, incorporating large monopolar capacitive
electrodes to deliver RF energy into the skin while
concurrently protecting the skin surface with a cryo-
gen cooling spray. Current flows from the device via
M.T. Abraham (*) the treatment tip, through the skin and out through a
Facial Plastic, Reconstructive & Laser Surgery, PLLC,
grounding pad applied to the patient. This creates a
Poughkeepsie, NY, USA
reverse thermal gradient in the skin, with cooling of
Facial Plastic and Reconstructive Surgery,
the epidermis while simultaneously achieving precise
Department of Otolaryngology
Head & Neck Surgery, volumetric heating of the deeper dermis. As a result,
New York Medical College, there is partial denaturation of the collagen within the
Valhalla, NY, USA dermis without injury to the skin surface [1, 19]. Initial
contraction of the skin collagen network in the dermis
J.J. Rousso occurs immediately as the collagen fibrils reanneal.
Department of Otolaryngology Head & Neck Surgery,
Tightening continues as a healing response is triggered
The New York Eye & Ear Infirmary,
New York, NY, USA within the dermis, leading to an overall increase in skin
e-mail: [email protected] collagen content [12, 30].

196 M.T. Abraham and J.J. Rousso
12.2 Indications Table 12.1 Minimally invasive procedures that can be

combined effectively with capacitive RF skin rejuvenation
Nonablative capacitive RF treatment is most appropriate Surgical procedures

for patients with mild to moderate aging and wrinkling Facial and neck liposuction
of the skin. The treatment is best suited to address deeper Blepharoplasty
rhytids (such as the nasolabial folds and marionette Percutaneous suture techniques
Nonsurgical treatments
creases in the face) rather than fine, superficial crepe
Chemodenervation
papertype wrinkles along the skin surface. This relates
Tissue fillers
to the epidermis being protected during the treatment
Intense pulsed light and nonablative lasers
(fine skin surface wrinkles and dyschromias are best Microdermabrasion and superficial chemical peels
treated by fractionated or more traditional ablative
methods of skin resurfacing).
Patients with significant skin laxity or those with
Table 12.2 Contraindications to capacitive RF skin rejuvenation
noticeable underlying structural ptosis are not ideal
Absolute contraindications
candidates for the procedure, but those who are not
Metallic skin art or tattoo that cannot be removed
interested in surgical options for rejuvenation may still
Implanted medical device
obtain a theoretical antiaging benefit from collagen
(Pacemaker, defibrillator, etc.)
stimulation in the skin. Similarly, patients who have
Pregnancy
had a surgical lift may benefit from this maintenance Relative contraindications
effect. It is the senior authors experience that patients Dermatologic conditions
with thinner skin typically achieve a more dramatic Collagen-vascular or autoimmune diseases
result. Patient with thicker, more sebaceous skin may Impaired collagen production (radiation, metabolic, etc.)
require more than one treatment session.
Capacitive RF skin rejuvenation is nonablative and
depends on energy delivery based on tissue resistance It is essential that patients have realistic expecta-
rather than absorption of laser light energy, and can tions of the subtle improvements expected with capacitive
therefore be used with all Fitzpatrick sun-reactive skin RF skin rejuvenation. Patients must understand that
types. It follows that since RF energy is not light- dramatic surgical- or ablative-type results are not pos-
based, pigmentary dyschromias, hair, and capillary sible currently with this technology. Patients must
and vascular ectasias are all relatively unaffected by also understand that although there is some initial con-
capacitive RF treatment (it is possible that there is tour change, skin texture and tone will continue to
some reduction in capillary dilation due to the increased improve gradually for several months after the treat-
skin collagen content). Nonablative lasers and intense ment. Depending on each patients individual biology
pulsed light systems are more effective for these appli- and reaction to the treatment, additional treatments
cations, and can be packaged and performed in con- may be necessary. Adequate periprocedure patient
junction with capacitive RF skin rejuvenation. counseling is a key component of ensuring patients
Thermage treatment can also be combined with satisfaction with the procedure [4, 10].
other minimally invasive office-based or surgical pro- When performed alone, there are few contraindica-
cedures to obtain a cumulative result (Table 12.1) [24, tions to Thermage treatment (Table 12.2).
29]. Of note, animal histology studies have shown
inflammatory changes associated with tissue fillers in
the skin after capacitive RF treatment, but a clinical 12.3 Treatment Considerations
study by Alam et al. indicated that there was no signifi-
cant morphological change in the filler material or sur- 12.3.1 Analgesia
rounding tissue when RF treatment was performed in
patients 2 weeks after deep dermal injection with Despite newer multiple-pass treatment algorithms that
hyaluronic acid derivatives or calcium hydroxylapatite require less energy to be delivered at one time, capaci-
[21, 29, 38]. tive RF treatment is uncomfortable. There is an initial
12 Capacitive Radiofrequency Skin Rejuvenation 197
cooling sensation as the cryogen cooling spray is 12.3.3 Disposable Costs

applied, overcome by a burst of heat as RF energy is
delivered, followed by cooling again. The most recent All Thermage treatment tips are disposable. They are
generation of Thermage systems (the CPT system) designed for single use per patient and are electroni-
utilizes an enhanced energy delivery algorithm weav- cally programmed to stop firing after a preset num-
ing microbursts of RF energy and cryogen cooling ber of pulses. Other Thermage system disposable item
within each treatment pulse, combined with a vibrating costs are listed in Table 12.4.
handpiece to reduce discomfort. According to internal
studies by the manufacturer, patients uniformly toler-
ated treatment better even though the newer treatment 12.4 Technique
tips are four times more effective in heating tissue to
the target temperature. 12.4.1 Site Preparation
Since a typical full-face and upper neck treatment
with the 1.5-cm2 tip involves 600 RF pulses and can It is ideal if Thermage treatment is performed in a pri-
take an hour to perform, some form of anesthesia can vate procedure room, with the patient positioned on a
help optimize patient comfort. Most patients with comfortable adjustable chair or procedure table. The
appropriate temperament are able to tolerate treat- provider is typically seated on a supportive surgeons
ment using oral narcotic analgesics (oxycodone, hydro- stool. Playing soft music can help the patient relax.
codone) and short-acting anxiolytics (lorazepam, Patients are instructed to arrive with the areas to be
alprazolam). Topical anesthetics are counterproductive treated clean and free of any makeup or other skin care
as they numb the epidermis and the cooling sensation, product. If hair bearing skin is to be treated, it is best if
but are not effective in alleviating the discomfort of the hair is shaved or trimmed in advance. The treat-
penetrating RF heat [30]. Local injection anesthetics ment area is exposed and, if necessary, cleansed with
can alter skin resistance and interfere with proper RF mild soap and water. All metal accoutrements are removed.
energy delivery [9, 12, 32]. Sedation or general anes- The grounding pad is applied to an area distant from the
thesia should only be utilized by experienced pro- treatment site.
viders, since the additional safety measure of patient
feedback is removed.
12.4.2 Energy Settings
12.3.2 Tip Selection Studies by Zelickson et al. [1] have revealed that mul-
tiple treatment passes over the same area using lower-
A variety of Thermage treatment tips are available energy settings creates more collagen change compared
depending on the treatment site and treatment goals to a single treatment at a higher-energy level. Avoiding
(Fig. 12.1). The appropriate tip is selected based on the very high energy settings has the additional benefit of
size of the treatment tip and the depth of penetration of making the treatment more tolerable, and decreasing
the RF energy. Face procedures are commonly per- the likelihood of potential complications [1, 34, 37].
formed with the 1.5-cm2 medium-depth treatment tip, Coupling fluid is liberally applied throughout treat-
although a 3-cm2 tip is also available (Table 12.3). For ment to ensure uniform energy delivery. Complete,
eyelid procedures, the smaller 0.25-cm2 superficial- even contact of the electrode with the skin surface is
depth treatment tip is appropriate. The much larger necessary to initiate cooling and RF delivery. An initial
deep tip is suited for large surface area procedures on test pulse is performed prior to beginning treatment to
the body (abdomen, flanks, arms, buttocks, thighs) allow the machine to calibrate skin resistance.
this tip has a surface area five times larger than the The patient is asked to provide feedback using a
1.5-cm2 face tip and penetrates 79% deeper according 04-point scale (0 nothing, 1 warm, 2 hot, 3 very
to the manufacturer. This uniform, deeper volumetric hot, 4 burning), with treatment settings calibrated to a
penetration of the RF energy may help with cellulite 22.5 level. With the 1.5-cm2 tip, this usually translates
treatment. to a setting of 6196 J/cm2 in most areas.
Fig. 12.1 Components of the Thermage CPT nonablative RF handpiece which vibrates to provide improved patient comfort is
skin rejuvenation system (Solta Medical, Inc., Hayward, CA). pictured in the middle, and some of the various disposable treat-
The computer-controlled RF generator unit with integrated ment tips are seen at bottom right. The use of the treatment grid
cryogen cooling unit is seen on the left, the ergonomic treatment to guide delivery of each treatment pulse is depicted in the inset
Table 12.3 Algorithm rules and clinical premises. Typical number of firings using the 1.5-cm2 tip to treat the face
Rule Clinical premise Evidence
First XY Cover maximum surface Every square centimeter treated has Published article demonstrating
pass area in a contiguous 5-20% of collagen volume denatured the relationship between
region of desired (setting dependent). More contiguous collagen volume affected
tightening/toning. surface area achieves greater tightening and the treatment setting.
of XY plane.
Addl. XY Additional Passes along Additional passes achieve incremental Clinical observations led
passes vectors of tightening, correction through tightening of the to published histology work
similar to facelift vectors. more easily mobilized tissue adjacent showing cumulative collagen
Isolate by physical to the targeted area of correction. damage with multiple passes.
manipulation of the skin.
Final Z Final passes to correct Tightening in the Z-axis, particularly Observations if Z-axis contour
passes excessive tissue laxity or in the mid and lower face, creates a changes during treatment. Pilot
contour change due to fat narrowing and lifting effect histology suggests both fibrous
and/or fibrous septae laxity. incremental to XY axis tightening. septae and fat involvement
Courtesy of manufacturer
Table 12.4 Thermage system disposable costs Energy levels are reduced where needed. For instance,
RF treatment tips when treating the face, lower energy (4461 J/cm2) is
Cryogen canisters utilized in areas of thinner skin (around the orbital rim
Grounding pads and lower neck), over vulnerable superficial fat pads
Coupling fluid (temporal, malar), and over sensory nerve trunks (greater
Treatment grid auricular, supraorbital, infraorbital, mental). Visible
Fig. 12.2 Schematic Volumetric Heating:

indicating 3D volumetric 3-D Tightening along X,Y & Z Planes
tightening of the dermis.
Tightening of the fibrous
septa in the subcutaneous Epidermis
tissue helps contour in the Dermis
Y
Z-plane (Graphic courtesy
of the manufacturer)
Fat Cells
Z Septae
Muscle
Visualize tightening in 3 dimensions
tightening, erythema of the skin, and excessive patient RF energy is known to conduct through collagen-based
discomfort are all subjective clinical end points of treat- fibrous septa that surround fat locules in the subcuta-
ment for each specific area on the skin. neous tissue [11]. Additional shrinkage and definition
can be accomplished by targeting the fibrous septa in
this 3D Z-plane. This strategy works well in areas
12.4.3 Treatment Planning of fullness such as the submental and jowl regions.
Stacking of treatment pulses on top of each other
The manufacturer-supplied ink grid is used to guide without at least 2 min in between pulses is generally
treatment topography (Fig. 12.1). The grid is useful in not recommended due to concerns of excessive heat
knowing exactly where to position the treatment tip for buildup, but can be used effectively in experienced
each RF pulse, adjacent to the previous treatment site, hands to achieve further tissue sculpting in this
without skipping areas or causing undue overlap. After Z-plane [25].
the initial pass of RF treatment has been completed, The total number of treatment pulses required for
when making the next pass over the same area, the different zones of the face and neck is tabulated in
intersection of the grid lines is used. In this manner, by Table 12.3 (Figs. 12.3 and 12.4). It is usually not nec-
switching back and forth on the grid on each subse- essary to treat skin that is densely adherent (over the
quent pass, an even application of RF energy is ensured nasal dorsum, ear, and scalp, for instance).
throughout. Upper lid skin is distracted onto the orbital rim and
The treatment plan is best visualized in 3D away from the globe prior to treatment when using the
(Figs. 12.212.4) (Table 12.5). One or two initial medium-depth tip, although the eye lid skin can be
passes are performed to cover the entire treatment area treated directly with the superficial-depth treatment tip
to achieve uniform contraction of the collagen skin (haptic plastic corneal shields are placed to protect the
scaffold in the X-Y plane. Additional passes are then entire globe) [35].
performed along vectors perpendicular to the relaxed
skin tension lines of the skin to achieve maximal lift-
ing and tightening in the direction desired. In the 12.5 Aftercare
face, superior and lateral vectors are targeted to lift,
tighten, and stretch the skin around the lips, nasola- If other complementary procedures are to be done
bial folds, and marionette creases, similar to a surgi- concurrently (Table 12.2), they should be performed
cal face-lift. after Thermage treatment is completed [9, 11, 18, 28].
Fig. 12.3 Computer graphic

depicting treatment algorithm 1st Two Passes = 80 160 REPs
for the upper face *XY Pass = 20 40 REPs
Total = 100 - 200 REPs
Periorbital Wrinkles Vector Passes

*Based on using 1.5 cm2
FAST Tip
*Only one pass over temple region
Fig. 12.4 Computer graphic

1st Two Passes = 300 - 400 REPs
depicting treatment algorithm
for the mid/lower face. XY Pass = 40 - 80 REPs
The first two treatment passes Z Passes = 60 -120 REPs
(purple) cover all of the areas Total = 400 - 600 REPs
depicted. The XY treatment
pass (red) overlaps the purple
areas, and the Z treatment
pass (green) overlaps both the
red and purple areas. REP
radiofrequency energy pulse
(Images courtesy of
manufacturer)
Mid & Lower Face and Neck: Contour Passes
*Based on using 1.5 cm2 FAST Tip
If Thermage is performed alone, aftercare is minimal. recommended. Patients are instructed to avoid using ice
Most patients can resume normal activities immedi- or anti-inflammatory medications which may blunt the
ately after the procedure. Routine sun protection is healing response and impede collagen stimulation.
Table 12.5 Treatment Treatment area (all units 1st XY Additional Final Z
algorithm to achieve in square centimeters) pass XY passes passes Total
tightening in 3D
Periorbital/ Wrinkles 100 50 N/A 150
forehead Brow effect 24 N/A 124
Mid and lower/ Nasolabial fold 240 50 20 310
face and neck Jawline 90 20 350
Neck alone 100 50 N/A 150
Full face and neck 340 120 40 500
Courtesy of manufacturer
The numbers shown above are to provide guidance as to the number of firings required for an
average size face and shouldnt be taken as absolute Always use as many firings as needed to
complete the algorithm
12.6 Results 12.7 Complications
Initial skin tightening due to thermally mediated Compared to invasive surgical procedures and ablative
collagen tightening is seen as the treatment end point. methods of skin rejuvenation, the incidence of compli-
Results are most impressive in patients with thin skin cations following capacitive RF treatment is extremely
and moderate laxity. Gradual thickening, toning, and low [2, 410, 13, 1822, 26, 27, 32]. Clinically notice-
lifting of the skin peaks a few weeks after treatment able asymmetry is unlikely if treatments are performed
and continues for 4 months or longer, as a result of uniformly and treatment guidelines are followed. A
increased collagen production in the skin [210]. mild amount of transient erythema and edema is com-
Contour changes seen in the face typically include mon after the procedure, and resolves within a few
24 mm of brow elevation, smoothing of the nasola- days. On rare occasion, low-dose oral steroid therapy
bial folds and marionette creases, and better definition may be useful, but it is avoided unless necessary since
of the jaw line and cervicomental angle (Fig. 12.5 and the inflammatory and healing response is what is felt
12.6) [215, 17, 18, 2427]. to trigger new collagen formation.
Intrinsic characteristics of the skin, such as pore size, There can be some numbness of the skin (in the face
acne, and tone, are also improved [2, 16, 17]. The patient and neck often in the distribution of the greater auricular
is spared the incisions, complications, and recovery time nerve), possibly as a result of perineural inflammation.
associated with traditional plastic surgery procedures. Numbness may take a few weeks to recover, but perma-
Collagen stimulation in the skin may also provide a nent nerve injury has not been reported [24]. Localized
theoretical antiaging benefit by replenishing collagen inflammation of superficial muscles like the platysma
lost during aging. in the neck can cause temporary ridging or lumping,
A single Thermage treatment is sufficient in most which may take a month or two to dissipate. Anecdotally,
patients, especially those with thinner skin who do not patients who have the greatest evidence of inflammation
have significant underlying structural ptosis. Additional appear to get the most amount of skin tightening.
treatments can provide cumulative results. Results If the treatment tip is not kept completely flat against
typically last several years in patients who adhere to the skin surface, arcing of RF energy can occasionally
a healthy lifestyle. The senior author has re-treated cause a small <5-mm superficial burn [4, 6, 32]. In the
patients with Thermage 35 years after initial treatment, senior authors experience, these are self-limited and
with very good patient satisfaction, perhaps because of can be treated with topical antibiotic ointment. The
continually improved technology and treatment algo- treatment tip has built-in sensors which continuously
rithms. As with any procedure, setting realistic patient monitor temperature and surface pressure. RF energy
expectations is crucial to achieving patient satisfaction delivery is aborted if measurements are outside a safe
[4, 10]. threshold, making significant skin burns unlikely.
Figs. 12.5-12.6 Typical patient results 9 months after nonabla- ThermaCool system. Lifting and stabilization of the brow,
tive capacitive RF treatment of the face and neck using a 900- tightening of the eyelid ski, and improvement in the jaw line and
pulse 1.5-cm2 medium-depth tip and eyelid treatment with the midface profile are evident. (Left) Pretreatment. (Right)
225-pulse 0.25-cm2 shallow-depth tip with the original Following treatment
The complication of greatest concern with capacitive 5. Narins DJ, Narins RS (2003) Non-surgical radiofrequency
facelift. J Drugs Dermatol 2(5):495500
RF treatment is localized over tightening of subcutane-
6. Fitzpatrick R, Geronemus R, Goldberg D, Kaminer M,
ous collagen-based fibrous septa or possible fat atro- Kilmer S, Ruiz-Esparza J (2003) Multicenter study of non-
phy resulting in skin surface irregularity [22]. This invasive radiofrequency for peri-orbital tissue tightening.
complication was more common initially when single- Lasers Surg Med 33(4):232242
7. Nahm WK, Su TT, Rotunda AM, Moy RL (2004) Objective
pass high-energy regimens were being followed, often
changes in brow position, superior palpebral crease, peak
with the patient under profound anesthesia [4, 22, 32]. angle of the eyebrow, and jowl surface area after volumetric
The senior author has found in two patients with this radiofrequency treatments to half of the face. Dermatol Surg
complication, the indentations improved over the 30(6):922928
8. Fritz M, Counters JT, Zelickson BD (2004) Radiofrequency
course of a few months without any additional inter-
treatment for middle and lower face laxity. Arch Facial Plast
vention, most likely as a result of new collagen forma- Surg 6(6):370373
tion. Other treatments including autologous fat transfer 9. Alster TS, Tanzi E (2004) Improvement of neck and cheek
have been advocated [22]. With current lower-energy laxity with a non-ablative radiofrequency device: a lifting
experience. Dermatol Surg 30(4 Pt 1):503507, Hughes P,
multiple-pass treatment algorithms and in experienced
comment in Dermatol Surg 2004;30(11):1430
hands, complications in general are rare. 10. Bassichis BA, Dayan S, Thomas JR (2004) Use of a non-
ablative radiofrequency device to rejuvenate the upper one-
third of the face. Otolaryngol Head Neck Surg 130(5):
397406
12.8 Conclusions 11. Jacobson LG, Alexiades-Armenakas M, Bernstein L,
Geronemus RG (2003) Treatment of nasolabial fold and
Capacitive RF skin treatment provides an additional jowls with a noninvasive radiofrequency device. Arch
avenue of skin rejuvenation, especially for patients not Dermatol 139(10):13711372
12. Ruiz-Esparza J (2004) Noninvasive lower eyelid blepharo-
interested in invasive surgical options. Candidates for
plasty: a new technique using nonablative radiofrequency on
treatment must be made aware of the limitations of the periorbital skin. Dermatol Surg 30(2 Pt 1):125129
procedure and the gradual nature of the changes seen. 13. Ruiz-Esparza J, Gomez JB (2003) The medical face lift: a
Patients with significant skin laxity or underlying noninvasive, nonsurgical approach to tissue tightening in
facial skin using nonablative radiofrequency. Dermatol Surg
structural ptosis should be counseled that capacitive
29(4):325332
RF treatment does not currently achieve the dramatic 14. Hsu TS, Kaminer MS (2003) The use of non-ablative radiof-
changes provided by traditional surgery, although there requency technology to tighten the lower face and neck.
is a theoretical antiaging benefit to stimulating colla- Semin Cutan Med Surg 22(2):115123
15. Iyer S, Suthamjariya K, Fitzpatrick RE (2003) Using a
gen formation in the skin. Combining RF treatment
radiofrequency energy device to treat the lower face: a treat-
with other nonsurgical or minimally invasive proce- ment paradigm for a nonsurgical facelift. Cosmet Dermatol
dures can achieve a more significant result. Future 16:3740
developments and refinement of RF technology will 16. Ruiz-Esparza J, Gomez JB (2003) Nonablative radiofre-
quency for active acne vulgaris: the use of deep dermal heat
undoubtedly expand the role of capacitive RF treat-
in the treatment of moderate to severe active acne vulgaris
ments for facial and body rejuvenation. (thermotherapy): a report of 22 patients. Dermatol Surg
29(4):333339
17. Fisher GH, Jacobson LG, Bernstein LJ, Kim KH, Geronemus RG
(2005) Nonablative radiofrequency treatment of facial lax-
References ity. Dermatol Surg 31(9 Pt 2):12371241
18. Finzi E, Spangler A (2005) Multipass vector (mpave) tech-
1. Zelickson BD, Kist D, Bernstein E et al (2004) Histological and nique with nonablative radiofrequency to treat facial and
ultrastructural evaluation of the effects of a radiofrequency- neck laxity. Dermatol Surg 31(8 Pt 1):916922
based non-ablative dermal remodeling device: a pilot study. 19. Meshkinpour A, Ghasri P, Pope K, Lyubovitsky JG, Risteli J,
Arch Dermatol 140(2):204209 Krasieva TB, Kelly KM (2005) Treatment of hypertrophic
2. Abraham M, Chiang S, Keller G, Rawnsley J, Blackwell K, scars and keloids with a radiofrequency device: a study of
Elashoff D (2004) Clinical evaluation of non-ablative radiofre- collagen effects. Lasers Surg Med 37(5):343349
quency facial rejuvenation. J Cosmet Laser Ther 6(3):136144 20. England LJ, Tan MH, Shumaker PR, Egbert BM, Pittelko K,
3. Koch RJ (2004) Radiofrequency non-ablative tissue tighten- Orentreich D, Pope K (2005) Effect of mono-polar radiofre-
ing. Facial Plast Surg Clin North Am 12(3):339346 quency treatment over soft-tissue fillers in an animal model.
4. Abraham MT, Ross EV (2005) Current concepts in non- Lasers Surg Med 37(5):356365
ablative radiofrequency rejuvenation of the lower face and 21. Shumaker PR, England LJ, Dover JS, Ross EV, Harford R,
neck. Facial Plast Surg 21(1):6573 Derienzo D, Bogle M, Uebelhoer N, Jacoby M, Pope K
(2006) Effect of mono-polar radiofrequency treatment over treatment of striae distensae: a report of 37 Asian patients.
soft-tissue fillers in an animal model: part 2. Lasers Surg Dermatol Surg 33(1):2934
Med 38(3):211217 31. Wu WT (2007) Achieving optimal results with thermage
22. Narins RS, Tope WD, Pope K, Ross CE (2006) Overtreatment using mesoanesthesia and revised treatment parameters.
effects associated with a radiofrequency tissue-tightening Aesthet Surg J 27(1):9399
device: rare, preventable, and correctable with subcision and 32. Weiss RA, Weiss MA, Munavalli G, Beasley KL (2006)
autologous fat transfer. Dermatol Surg 32(1):115124 Monopolar radiofrequency facial tightening: a retrospective
23. Kushikata N, Negishi K, Tezuka Y, Takeuchi K, analysis of efficacy and safety in over 600 treatments.
Wakamatsu S (2005) Is topical anesthesia useful in nonin- J Drugs Dermatol 5(8):707712
vasive tightening using radiofrequency? Dermatol Surg 33. Alam M, Levy R, Pajvani U, Ramierez JA, Guitart J, Veen H,
31(5):526533 Gladstone HB (2006) Safety of radiofrequency treatment
24. Kushikata N, Negishi K, Tezuka Y, Takeuchi K, Wakamatsu S over human skin previously injected with medium-term
(2005) Non-ablative skin tightening with radiofrequency in injectable soft-tissue augmentation materials: a controlled
Asian skin. Lasers Surg Med 36(2):9297 pilot trial. Laser Surg Med 38(3):205210
25. Lack EB, Rachel JD, DAndrea L, Corres J (2005) 34. Dover JS, Zelickson B, 4-Physician Multispecialty Consensus
Relationship of energy settings and impedance in different Panel (2007) Results of a survey of 5,700 patient monopolar
anatomic areas using a radiofrequency device. Dermatol radiofrequency facial skin tightening treatments: assessment
Surg 31(12):16681670 of low-energy multiple-pass technique leading to a clinical
26. Sadick N, Sorhaindo L (2005) The radiofrequency frontier: end point algorithm. Dermatol Surg 33(8):900907
a review of radiofrequency and combined radiofrequency 35. Carruthers J, Carruthers A (2007) Shrinking upper and lower
pulsed-light technology in aesthetic medicine. Facial Plast eyelid skin with a novel radiofrequency tip. Dermatol Surg
Surg 21(2):131138 33(7):802809
27. Hodgkinson DJ (2009) Clinical applications of radiofre- 36. Biesman BS, Pope K (2007) Monopolar radiofrequency
quency nonsurgical skin tightening. Clin Plast Surg 36(2): treatment of the eyelids: a safety evaluation. Dermatol Surg
261268 33(7):794801
28. Sukal SA, Geronemus RG (2008) Thermage: the nonabla- 37. Bogle MA, Ubelhoer N, Weiss RA, Mayoral F, Kaminer MS
tive radiofrequency for rejuvenation. Clin Dermatol 26(6): (2007) Evaluation of the multiple pass, low fluence algo-
602607 rithm for radiofrequency tightening of the lower face. Lasers
29. Abraham MT, Mashkevich G (2007) Monopolar radiofre- Surg Med 39(3):210217
quency skin tightening. Facial Plast Surg Clin North Am 38. Anolik R, Chapas AM, Brightman LA, Geronemus RG
15(2):169177 (2009) Radiofrequency devices for body shaping: a review
30. Suh DH, Chang KY, Son HC, Ryu JH, Lee SJ, Song KY and study of 12 patients. Semin Cutan Med Surg 28(4):
(2007) Radiofrequency and 585-nm pulsed dye laser 236243
Mesotherapy in Aesthetic Medicine
13
Maya Vedamurthy
13.1 Introduction 13.2 Common Applications

of Mesotherapy
Mesotherapy is a technique of delivering small quanti-
ties of vitamins, minerals, amino acids, conventional Mesotherapy is used in the treatment of:
medications, and preparations directly into the meso- 1. Cellulite
derm to promote a biological response and reverse 2. Weight loss and body sculpting
pathology in the treated area [1, 2]. 3. Local fat deposits xanthelasma, lipoma
Mesotherapy was invented by Michel Pistor in 1952 4. Alopecia
to treat conditions in rheumatology, sports traumatol- 5. Facial rejuvenation wrinkles, skin tightening
ogy, infectious diseases, vascular diseases and mainly 6. Hyperpigmentation
as a pain-relieving technique [3]. Pistor described Other dermatologic conditions purported to benefit
mesotherapy as smallest dose, infrequently in the using mesotherapy [1]:
correct location. The proposed mechanism of action 1. Acne
of mesotherapy is that solutions injected intracutane- 2. Melasma
ously remain in the area longer than they would by 3. Eczema
deeper injection as these solutions continually pene- 4. Hypertrophic or keloid scars
trate into the deeper tissues. Mesotherapy therefore 5. Leg ulceration
appears to be a unique technique to administer medi- 6. Photoaging
cines local to the pathology while the skin serves as a 7. Pruritus
natural time release system. 8. Psoriasis
Traditional Mesotherapy has now evolved into a 9. Striae distensae
new era of aesthetic medicine where it is employed 10. Telangiectasias
in cosmetic applications such as removal of fat and 11. Venous stasis
cellulite, and body contouring. The North American 12. Vitiligo
experience began when Bissoon learned the technique
in France and later popularized it in America.
13.3 Candidate Selection
Adults between the ages of 18 and 75 years in good

physical and medical health and with realistic expecta-
M. Vedamurthy
tions are candidates for mesotherapy. A detailed medi-
Consultant Dermatologist, Department of Dermatology,
Apollo Hospitals, Chennai, TN, India cal history and physical examination is mandatory to
e-mail: [email protected] administering mesotherapy.

206 M. Vedamurthy
13.4 Contraindications to Mesotherapy 13.5.3 Chemicals That Act as Antioxidants

and Are Claimed to Decrease
1. Pregnancy and lactation Pigmentation
2. Insulin-dependent diabetes
3. History of strokes 1. Glutathione
4. History of cancer 2. Ascorbic acid
5. History of thromboembolic phenomena 3. Glycolic acid
6. Patients on medications like aspirin, warfarin, hepa- 4. Pyruvate
rin, etc.
7. Severe heart disease
8. Active kidney or hepatic diseases 13.5.4 Chemicals That Stimulate
9. Allergy to one of the components Hair Growth
1. Buflomedil
13.5 Products Commonly Used 2. Minoxidil
in Mesotherapy 3. Finasteride
The products selected for mesotherapy are based on

the pharmacology. There is a wide range of products 13.5.5 Vitamins
for various indications. Sometimes a combination of
these products is used to achieve desired results. When 1. Vitamin C is used for hyperpigmentation and
the ingredients are reconstituted, they must be used melasma. It acts as an antioxidant and helps in col-
within 24 h or discarded [4]. lagen and elastin production.
2. Vitamin A is used in antiaging treatment to improve
fine lines.
13.5.1 Fat/Cellulite 3. Biotin is used in treatment of alopecia.
1. Phosphatidylcholine
(a) Polyunsaturated phosphatidylcholine extracted 13.5.6 Minerals
from soy bean lecithin
(b) Increases cholesterol solubility Minerals like copper, zinc, magnesium, and chromium
(c) Modifies cholesterol and triglyceride metabo- are used to improve skin elasticity.
lism excellent fat burner
2. Organic silicium
(a) Increases lipase production
3. l-Carnitine 13.6 Equipment and Materials
(a) Vehicles used to transform fat into energy Required
within the cell
1. Mesotherapy Products (Fig. 13.1)
(a) All ingredients must be water soluble, isotonic,
13.5.2 Skin Rejuvenation nonallergenic, and sterile.
2. Syringes
1. CRP 1000 (a) Usually 1 mL, 5 mL, 10 mL, and 20 mL syringes
(a) Has multivitamins, cytokines, and copper pep- depending on the indication.
tides for cellular stimulation and improving col- 3. Needles
lagen and elastin synthesis Meso needles or the so-called Lebel needle
2. Hyaluronic acid (Fig. 13.2) is commonly used for face and neck rejuve-
(a) Improves hydration nation, 4-mm 30-gauge mesotherapy needles and for
3. Organic silicium fat and cellulite treatment, 6-mm 30-gauge mesother-
(a) Increases collagen production apy needle or inch 30-gauge needles.
13 Mesotherapy in Aesthetic Medicine 207
Fig. 13.1 Mesotherapy products
Fig. 13.2 Lebel needles
13.7 Multi-injectors (Fig. 13.3) 13.9 Mesopen (Fig. 13.5)
A practical process is using sterile multi-injectors with Mesopen is a device used to inject small areas more
needles ready to be used with Luer tip in different effectively and quickly.
diameters, i.e., 27 gauge30 gauge. Circular multi-
injectors can be used for all body parts with 5 or 7
needles. Linear or right multi-injectors with 3 or 5 13.10 Micromesotherapy Device
needles can be used for all body parts. (Fig. 13.6)
A one-use system in micromesotherapy is an evolution

13.8 Mesogun (Fig. 13.4) of conventional mesotherapy. Here, the use of skin
injection therapy in the form of a shallow cone with an
The Mesogun can be used for all body parts and allows ultra thin 2-mm needle of 23 gauge in the middle
for different injection techniques. allows injection in the superficial layer of the dermis
208 M. Vedamurthy
Fig. 13.3 Meso needle

multi-injectors
Fig. 13.4 Mesogun
(papillary layer). This micro therapy will overcome the

undesirable risks and effects on the surface area treated
with conventional mesotherapy.
Fig. 13.5 (a) Mesopen. (b) Needle tip
13.11 Needle-Less Mesotherapy

(Fig. 13.7)
This device sends an electrical wave that pushes meso- 13.12 Mesotherapy Injection
therapy ingredients painlessly through the skin without Techniques
needles through a technology known as isophoresis.
1. Uses ultrasound and/or iontophoresis technology Mesotherapy involves injecting microquantities of
2. Probably about 20% efficiency compared to tradi- mesoproducts in the right place using one of the
tional mesotherapy following techniques as it determines the quality of the
3. Less traumatic and painless results obtained (Fig. 13.8).
Fig. 13.6 Micromesotherapy device
13.12.1 Intraepidermal Fig. 13.7 Needle-less mesotherapy
First described by Perrin, intraepidermal is the most

superficial of the techniques. Here, the basal layer is 1. Depth: 24 mm at an angle of 3060 into superfi-
not penetrated. cial dermis
1. Depth: 1 mm within the epidermis 2. Less pain, pinpoint bleeding
2. Simples, painless, no bleeding 3. Large surfaces covered
3. Large surfaces covered 4. Ideal for scalp and rejuvenation treatment
4. Ideal for patients with low pain threshold
5. Ideal for facial rejuvenation 13.12.4 Point by Point (Fig. 13.11)
13.12.2 Papular (Fig. 13.9) First described by Dr. Pistor, point by point is an injec-
tion of 0.02 mL to 0.05 mL of solution made by per-
1. Depth: 2 mm dermoepidermal junction pendicularly inserting the entire length of a 4 mm or
2. Painful 6 mm needle, its entire length.
3. Useful for treatment of wrinkles and hair loss Depth of 4 mm with precise single injection is into
4. MesoBotox deep dermis. This is ideal for fat reduction.
13.12.3 Nappage (Fig. 13.10)

13.13 Getting Started for Mesotherapy
With the syringe held at 3060 angle from the skin
and while applying light and constant pressure on the 1. Patient selection
syringes plunger, the physician flicks the wrist to 2. Evaluation of the patient physical and mental
infuse a drop of the solution [5]. health
210 M. Vedamurthy
Fig. 13.8 Mesotherapy

injection slides
Intra-epidermal - 1mm
Epidermis
Papular - 2 mm
Dermis
Nappage - 2 - 4mm
Point by Point - 4 mm
Hypodermis
Mesoperfusion - >4 mm
excessive fat. Sodium deoxycholate is a major fea-

ture of an injectable phosphatidylcholine formulation
used for localized fat dissolution [7]. The injected
formula helps to break the existing fat cells which
the body naturally flushes out. The detergent action
of this treatment may be used for post liposuction
irregularities. However, this treatment cannot replace
liposuction.
13.15 Ingredients: Fat-Burning

Mixture/Formula
1. Phosphatidylcholine: 5 mL
Fig. 13.9 Papular method 2. Organic silicium: 5 mL
3. Rutin and Melilot: 2 mL
4. Artichoke extract: 5 mL
3. Explain position of mesotherapy in current clinical 5. l-Carnitine: 5 mL
practice
4. Education of patient
5. Discuss treatment alternatives 13.16 Injection Technique
6. Obtain an informed written consent
7. Photographic documentation 1. Perform procedure with the patient lying down.
2. Map the area to be treated and disinfect with iodized
product.
13.14 Indications and Their 3. Topical anesthesia/ice may be used to minimize
Protocols pain discomfort.
4. No gun used because injection should go deep. Use
Localized fat reduction [6] for abdomen, hips, a long 30-gauge needle.
buttocks, thighs, love handles, and upper arms, also 5. Ideal depth: 1 cm.
known as mesolipo, lipodissolve, and flab jab, has 6. Pinch the fatty area and inject perpendicular to the
attracted a lot of interest from physicians and the skin.
general public as body-contouring technique. It can 7. Injection spacing point: every 23 cm.
target specific areas or spots where the body stores 8. Injection amount: 0.20.8 mL.
Fig. 13.10 (a) Nappage manual method. (b) Nappage using Mesogun. (c) Immediately after treatment
Dose usually not to exceed 500 mg per session at

13.17 Post Treatment least initially to see side effects if any.
Lipomas [8], Buffalo hump, double chin
Start massage 72 h later and continue daily between (Fig. 13.12).
treatments to decrease incidence of nodules.
13.18.1 Formula
13.18 Treatment Schedule
1. 1 session per week for 610 sessions 2. Organic silicum: 2 mL
2. 1 session every 2 weeks till results Inject directly into the area 0.1 mL/point every
3. 1 session per month up to 5 months 1 cm2 cm.
212 M. Vedamurthy
Fig. 13.11 Point by point
13.18.2 Treatment Schedule

b
1. 1 session per week for 45 sessions
2. Good indication
13.19 Eyebags/Xanthelasma [9]
Lower eyelid bags have been treated using phosphati-

dylcholine [10]
13.19.1 Formula Eyebags
2. Organic silicum: 5 mL
Fig. 13.12 (a) Double chin patient before treatment. (b) After
13.19.2 Formula Xanthelasma treatment
2. Saline solution: 1 mL 13.20.1 Formula
3. Procaine/Lidocaine: 0.5 mL
Exercise extreme caution. Dose is 0.1 mL every 2 cm 1. 10 mL syringe volume
2. Hyaluronidase: 4 mL
13.19.3 Treatment Schedule 4. Aminophylline: 2 mL
5. Artichoke: 1 mL
1 session every 2 weeks until disappearance 6. Procaine 2%: 1 mL
13.20 Cellulite (Fig. 13.13) 13.20.2 Injection Technique
One of the most popular indications for mesotherapy is 1. Manual application using 5-mL syringe with 6-mm
cellulite treatment [11]. 30-gauge meso needle or multi-injectors.
a 13.20.4 Side Effects
1. Local: Bruising, swelling, redness, infection, skin

necrosis
2. Systemic: Liver toxicity, demyelination of nerves
13.21 Skin Rejuvenation
13.21.1 Mesolift, Mesoglow (Fig. 13.14)
One of the simplest formulations of mesotherapy is

used for skin rejuvenation [12]. Mesotherapy with
hyaluronic acid is found to be an effective treatment
for skin photoaging as confirmed by ultrasound [13].
Sites included face, neck, hands, and dcollet
(Fig. 13.15). Other indications are:
b 1. Antiwrinkle
2. Hydration, tightening
3. Acne scars
13.21.2 Formula
13.21.2.1 Antiwrinkle
1. CRP 1000: 5 mL
2. Hyaluronic acid 2 mL or MesoBotox
13.21.2.2 Hydration, Tightening

1. Multivitamins: 1 mL
2. Hyaluronic acid: 1 mL
3. Retin A 0.01%: 1 mL
Fig. 13.13 (a) Cellulite patient before treatment. (b) After 4. Glycolic acid 1%: 1 mL
treatment
5. Procaine 2%: 1 mL
6. Multritrace 5: 1 mL or IAL system
2. Mesogun application using 5-mL syringe with 13.21.2.3 Injection Technique

6-mm 30-gauge meso needle. 1. Position the patient lying down
3. Perform procedure with patient lying down. 2. Disinfect area to be treated
4. Map and disinfect the area to be treated. 3. Topical anesthesia is useful
5. Inject the drugs smoothly and slowly. 4. Manual or Mesogun application with 6-mm
6. Ideal depth: 46 mm. 30-gauge meso needle
7. Injection spacing: 12 cm part. 5. Ideal depth: 24 mm
8. Injection amount: 0.2 mL per injection. 6. Injection spacing: 0.52 cm apart
9. Injection method: Nappage or point by point. 7. Injection amount: 0.150.2 mL
8. Injection method: Nappage or point by point
13.20.3 Treatment Schedule 13.21.2.4 Post Treatment

Mesomask (Fig. 13.16) may be used after each treat-
1. 1 session per week for 610 sessions ment. This allows all products to penetrate deeper in
2. Maintenance: 1 session per month the skin to give a better effect. Mesomask (Fig. 13.17)
214 M. Vedamurthy
a 13.21.2.5 Treatment Schedule

1. One session per month for 3 months
2. Maintenance: every 34 months
13.21.2.6 Acne Scars (Fig. 13.18)

1. Hyaluronic acid 2% or 3.5%: 5 mL
2. Saline solution: 2 mL
13.21.3 Injection Technique
1. Patient lying down position

2. Topical anesthesia
3. Subcision followed by injection gives best
results
b One session per month for 3 months
13.22 Alopecia (Pattern Baldness)
Mesotherapy can be useful in hair loss by supplying

nutrition, restoring microcirculation, and inhibiting
5-alpha reductase.
13.22.1 Ingredients
1. Biotin
2. Zinc
3. Minoxidil
4. Finasteride
5. Dutasteride
6. Buflomedil
Fig. 13.14 (a) Skin rejuvenation patient before treatment. 13.22.2 Formulas Commonly Used
(b) After skin rejuvenation
1. Biotin 10 mg/ml: 4 ml
2. Minoxidil 0.2%: 2 ml; or Biotin 10 mg/mL: 4 ml
3. Dutasteride/Finasteride: 2 ml
contains a mixture of calcium sulfate, talc, and orange
oil. One hundred fifty grams of powder is mixed with
room-temperature water to form a paste that is applied 13.22.3 Injection Techniques
for 15 min as a mask over a gauze on the face.
Mesomask is usually applied after every mesolift 1. Patient lying down position
procedure. 2. Disinfect area to be treated
a b
Fig. 13.15 (a) Mesomask product for rejuvenation. (b) Hand rejuvenation. (c) Neck, decollate
3. Topical anesthesia 6. Injection depth: 14 mm

4. Manual application: 3 mL syringe with 4-mm 7. Injection spacing: 1 cm apart
30-gauge meso needle 8. Injection amount: 0.2 mL per injection
5. Mesogun: 5 mL syringe with 6-mm 30-gauge 9. Injection method: Nappage
meso needle 10. Total volume injected: 68 mL
216 M. Vedamurthy
Fig. 13.16 Mesomask application

Fig. 13.18 (a) Acne scars patient before treatment. (b) After
treatment
13.22.6 Formula
1. Glutathione: 5 mL
2. Vitamin C: 2 mL
3. 1% Glycolic acid: 1 mL
13.22.7 Injection Techniques
1. Patient lying down

2. Disinfect the area
3. Topical anesthesia desirable
Fig. 13.17 Mesomask product 4. Manual or Mesogun application with 30-gauge
6-mm meso needle
5. Injection depth: 24 mm
13.22.4 Treatment Schedule 6. Injection spacing: 0.51 cm apart
7. Injection amount: 0.10.2 mL
1. One session per week for 1 month
2. One session per month till results
3. Maintenance: 1 session every 13 months 13.22.8 Injection Method
Nappage or papular
13.22.5 Melasma/Pigmentation
(Fig. 13.19)
Melanin is produced form tyrosine. If glutathione is
1. 1 session per week for 1 month
available, the metabolism produces more phaeomela-
2. 1 session per month till results
nin which is lighter in color.
a b
Fig. 13.19 (a) Hyperpigmentation patient before treatment. (b) After treatment
Table 13.1 Common mesotherapy formulations for specific 13.23.1 Actions of MesoBotox
conditions
Conditions Formulations 1. Reduction in fine wrinkles
Alopecia Minoxidil, finasteride, multivitamins 2. Shrinkage of open pores
Cellulite Pentoxiphylline, hyaluronidase or 3. Reduction in sebaceous secretions
collagenase, carnitine, calcium, 4. Skin tightening
pyruvate, aminophylline or caffeine,
coumarin, artichoke, melilot, or
5. Reduction in sweating
ginko biloba
Facial rejuvenation Lipoic acid, DMAE, multivitamins,
hyaluronic
acid, tretinoin 13.24 Mechanism of Action
Herpetic neuralgia Lidocaine, acyclovir, corticosteroids
Hyperpigmentation Vitamin C, Glutathione, Glycolic 1. Superficial muscle fibers are paralyzed leading to
acid compensatory contraction of deeper fibers giving
There are no standardized dosages or ingredients rise to tightening effect.
2. Chemodenervation of sebaceous glands.
There are dosages and ingredients may vary common 3. Tissue edema from paralysis of lymphatic vessel
mesotherapy formulations for specific conditions smooth muscle.
(Table 13.1).
13.25 Injection Technique

13.23 MesoBotox or Intradermal Botox
1. Dilution: 1:10 with normal saline
Developed by Koreans. 2. Injection method: papular
218 M. Vedamurthy
13.26 Treatment Schedule References
1. Once a month for 36 months 1. Rotunda AM, Kolodney MS (2006) Mesotherapy and
phosphatidylcholine injections: historical clarification and
review. Dermatol Surg 32(4):465480
2. Pistor M (1976) What is mesotherapy? Chir Dent Fr
13.27 Complications of Mesotherapy 46(288):5960
3. Brown SA (2006) The science of mesotherapy chemical
13.27.1 Local anarchy. Aesthet Surg J 26(1):9598
4. Matarasso A, Pfeifer TM (2005) Mesotherapy for body
contouring. Plast Reconstr Surg 115(5):14201424
1. Tenderness
5. Mrejen D, Perrin JJ (2003) Mesotherapie et Rachis, Editions.
2. Bruising S.F.M CERMIIe de France, CRM Champagne
6. Hexsel D, Serra M, Mazzuco R, Dal Forno J, Zechmeister D
3. Burning or itching (2003) Phosphatidylcholine in the treatment of localized fat.
4. Urticaria [14] J Drugs Dermatol 2(5):511518
5. Pain 7. Rotunda AM, Suzuki H, Moy RL, Kolodney MS (2004)
6. Swelling Detergent effects of sodium deoxycholate are a major
feature of an injectable phosphatidylcholine formulation
7. Skin necrosis used for localized fat dissolution. Dermatol Surg 30(7):
8. Ulcers [15] 10011008
9. Abscess [16] 8. Bechara FG, Sand M, Sand D et al (2005) Ultrasound controlled
10. Hyperpigmentation injection lipolysis of lipomas with phosphatidylcholine in
patients with familial multiple lipomatosis. In: American
11. Non-tuberculosis mycobacterial infection [17] Society for Dermatologic surgery and American College of
12. Rare granulomatous panniculitis [18], koebner- Mohs Micrographic Surgery and Cutaneous Oncology,
ization, granuloma annulare Combined Annual Meeting, Atlanta, 2730 October 2005
9. Maggie S (1988) Treatment of xanthelasma with phosphati-
dylcholine. In: 5th international meeting of mesotherapy,
13.27.2 Systemic Paris, 1988
10. Ablon G, Rotunda AM (2004) Treatment of lower eyelid
1. Flushing pads using phosphatidylcholine: clinical trial and review.
2. Vagal response Dermatol Surg 30(3):422427
11. Rotunda AM, Avram MM, Avram A (2005) Cellulite; is
3. Allergy there a role for injectable? J Cosmet Laser Ther 7(34):
4. Dizziness, Nausea 147154
5. Liver toxicity 12. Amin SP, Phelps RG, Goldberg DJ (2006) Mesotherapy
6. Demyelination of nerves for facial skin rejuvenation: a clinical, histologic and electron
microscopic evaluation. Dermatol Surg 32(12): 14671472
13. Lacarrubba F, Tedeschi A, Nardone B, Micali G (2008)
Mesotherapy for skin rejuvenation: assessment of the sub-
13.28 Conclusions epidermal low-echogenic band by ultrasound evaluation
with cross sectional B-mode scanning. Dermatol Ther
21:S1S5
Although mesotherapy sounds like a new technique, 14. Urbani CE (1994) Urticarial reaction to ethylene diamine in
dermatologists have been using similar injection tech- aminophylline following mesotherapy. Contact Dermatitis
niques to treat keloids and hypertropic scars with ste- 31(3):198199
roids. Physicians practicing mesotherapy should 15. Al Khenaizan S (2008) Facial cutaneous ulcers following
mesotherapy. Dermatol Surg 34(6):832834
possess a good knowledge of the products used to 16. Garcia-Navarro X, Barnadas MA, Dalmau J, Coll P,
ensure safety to the patients. Products whose mecha- Gurgu M, Alomar A (2008) Mycobacterium abscessus
nism of action is well understood and whose adverse infection secondary to mesotherapy. Clin Exp Dermatol
effects and doses are well studied should be chosen. 33(5):658659
17. Sanudo A, Vallejo F, Sierra M, Hoyos JG, Yepes S, Wolff
Until more controlled and published studies are avail- JC, Correa LA, Montealegre C, Navarro P, Bedoya E,
able in the literature, dermatologists should exercise Sanclemente G (2007) Nontuberculosis mycobacteria infec-
caution. However, the future of this technique depends tion after mesotherapy. Preliminary report of 15 cases. Int J
on the clinical and experimental studies to establishing Dermatol 46(6):649653
18. Davis MD, Wright TI, Shehan JM (2008) A complication of
the safety and efficacy of mesotherapy, also known as mesotherapy. Non infectious granulomatous panniculitis.
intradermotherapy. Arch Dermatol 144(6):808809
Upper Blepharoplasty
14
Morris E. Hartstein
14.1 Introduction whether or not they use artificial tear supplements.

Schirmer testing, though not completely reliable, is
The goal of upper blepharoplasty is to create an still one objective way of measuring tear quantity and
aesthetically pleasing upper lid and brow complex. In should be performed on every patient. A quicker mea-
recent years, we have come to appreciate that aging surement can be obtained using Zone-Quick (Oasis,
changes in the lid can reflect volume loss, and rejuve- Glendora, CA) in which the threads are placed in the
nation of the upper eyelid reflects volume restoration inferior fornix of the eyelid for only 15 s. Some bleph-
and not just a simple removal of tissue. aroplasty patients may note functional symptoms such
When evaluating the potential blepharoplasty patient, as a tired look, may actually complain of reduced
it is important to determine whether or not there is also a visual field especially when reading, and/or headaches
ptosis component in the eyelid examination, and if so, from chronic brow elevation.
whether or not this will be addressed during the bleph- The eyelid is a dynamic structure which provides
aroplasty surgery. For instance, patients may suffer from protection to the globe as well as conveys facial expres-
mild ptosis, but are really much more bothered by the sion. When considering a patient for upper blepharo-
dermatochalasis and thus would only need to undergo plasty, it is helpful to go through the following anatomic
blepharoplasty. Alternatively, marked dermatochalasis checklist.
may mask significant ptosis which may become more
apparent postoperatively if not corrected. Even if you are
not surgically addressing the ptosis, it should certainly 14.2 Brows
be pointed out to the patient preoperatively with a mirror
or photos so there are no surprises postoperatively. As Brow ptosis can contribute to fullness in the upper lid.
always, preoperative counseling and discussion is key. Most patients will show some degree of brow asym-
The state of the cornea is very important to exam- metry, and this should be pointed out to the patient pre-
ine with regards to dry eye symptoms. The patient operatively. It is also important to note where the true
should be questioned about dry eye symptoms and border of brow is located (this may be obscured by
plucking of the brow hairs).
M.E. Hartstein
Department of Ophthalmology, 14.3 Bony Orbits
Assaf Harofeh Medical Center, Zerifin, Israel
Clinical Associate Professor Smaller orbits result in crowding and fullness of the
of Ophthalmology and Plastic Surgery,
Saint Louis University School of Medicine,
superior sulcus. Larger orbits result in a deeper and
St. Louis, MO 63104, USA more hollow sulcus. These differences in orbit size
e-mail: [email protected] will affect what is achievable in surgery.

220 M.E. Hartstein
14.4 Eyelid Skin (Fig. 14.2). This is a crucial step for the procedure
and needs to be precise. I use the patients own creases
The amount and quality of skin in the lids should be if they are readily apparent and symmetrical
noted. If there is swelling of the lid, this may be a (Fig. 14.3). If there is a faint or nonexistent crease,
sign of thyroid disease or other inflammatory eyelid then markings are made 810 mm centrally in women
conditions. This should be worked up and treated and 78 mm central height in men, with the medial
preoperatively. and lateral ends tapering about 1 mm lower. In Asian
individuals, the crease runs lower an important fac-
tor to keep in mind when performing eyelid surgery
14.5 Orbital Fat on these patients. At the medial aspect, care should
be taken not to extend the marking past the punctum.
The location and prominence of the fat pockets should If it is necessary to carry the incision further, once the
be noted. Laterally, what appears to be fat may indeed punctum is reached, the marking should flare superi-
be a prolapsed lacrimal gland. orly for about 2 mm to reduce the chance of develop-
ing of medial canthal web postoperatively (Fig. 14.4).
Laterally, the incision can flare superiorly once the
14.6 Procedure lateral canthus is reached. The upper line of the inci-
sion is determined by how much skin is to be removed.
A basic set of instruments used in blepharoplasty is in Using a forceps, the tissue can be pinched while the
Fig. 14.1. The author prefers having bipolar cautery lid margin is observed for rotation. Usually, more tis-
available as well as monopolar unit. The procedure sue is excised laterally than medially (Fig. 14.5). A
begins with marking the lid crease, and I prefer using useful guideline is to try and leave approximately
a fine-tipped marking pen (Devon, fine tip, #61, 20 mm from the brow to the lid margin after pinching
Cardinal Health), as this is much more precise the skin to be removed (Fig. 14.6).
Fig. 14.1 Basic set of instruments for blepharoplasty

14 Upper Blepharoplasty 221
a b
Fig. 14.2 (a, b) Fine-tip surgical marking pen is crucial for accurate marking of lid creases and area to be excised
Fig. 14.3 The eyelid crease is marked in the preexisting crease

of the patient using the fine-tip marking pen
Fig. 14.4 The medial aspect of the incision reaches the

It is the authors preference to first mark, then inject, punctum where it then curves superiorly for 12 mm in order to
to allow time for the epinephrine to take effect while avoid medial canthal webbing
the patient is prepped. A variety of different local
anesthetic solutions may be employed; however, a
50:50 mixture of 2% lidocaine with epinephrine and solution may be buffered with sodium bicarbonate in
0.5% or 0.75% bupivacaine (with or without epineph- order to increase the comfort of injection by changing
rine) is preferred. The final epinephrine concentration the pH. Hyaluronidase is usually not necessary. The
should be 1:100,0001:200,000. The local anesthetic local anesthetic is infiltrated just beneath the skin.
222 M.E. Hartstein
Fig. 14.5 The pinch technique demonstrates the amount of

tissue which can be excised without causing eversion of the lid
margin
Fig. 14.7 The 15c blade is smaller and finer and better suited to
eyelid surgery than a standard 15 blade
Fig. 14.6 From the edge of the true brow to the lid, margin
should measure approximately 200 mm after substrating the
amount of excised tissue. This is a helpful guideline in order to
avoid postoperative lagophthalmos
Intravenous sedation may be used well and in some

cases even general anesthesia. Following injection,
topical proparacaine or tetracaine is instilled in the
eyes, and the patient undergoes a full face prep with a
head drape and split sheet leaving the entire face
exposed. Most patients feel more comfortable with the
entire face left open, and both eyes can be compared
Fig. 14.8 The 15c blade is used to incise just through the skin
during the procedure. After additional topical anesthe- along the demarcated line. Alternatively, a sharp Wescott scis-
sia with proparacaine or tetracaine, a rigid corneal sors, CO2 laser, Ellman, or Colorado needle may be used
(or eye) shield is placed to protect the globe during the
procedure.
The incision is made with a #15c blade (smaller radiofrequency unit (Ellman International, Inc,
profile than a standard #15) along the demarcated Oceanside, NY), or CO2 laser. A skin or skin-muscle
line(s) (Figs. 14.7 and 14.8). Alternatively, one may flap is excised. Previously, many blepharoplasty sur-
use a sharp Wescott scissors, Colorado needle, Ellman geries included automatic removal of the skin and
Fig. 14.9 In most cases, removing a skin flap only is sufficient

to achieve the desired effect. Even if the orbicularis is to be Fig. 14.10 Following removal of the skin flap and hemostasis,
removed as well, it is safer to do it in stages so as not to inadver- the orbicularis muscle layer is intact
tently penetrate deeper and injure the levator muscle
brow region. The ROOF fat should be left intact or at

orbicularis together (Fig. 14.9). For the beginning most repositioned if there is significant descent.
surgeon, it is recommended to excise a skin flap first At this point, the awake patient can be asked to
and then consider orbicularis removal. While some open their eyes and the lids are examined for symmetry.
patients need to have both layers removed, skin removal If this is satisfactory, them incision closure is
alone can achieve most of the desired effects of bleph- performed. The lid crease may be reformed, if desired,
aroplasty sparing the orbicularis muscle is more and this helps to control the precise level of the crease.
protective of the eye in terms of maintaining the blink This may be accomplished by passing a few inter-
as well as creating a volume in the upper lid. rupted 60 absorbable sutures, through one or both
Hemostasis is obtained with bipolar or monopolar edges of the wound while incorporating a bite of
cautery (Fig. 14.10). With an assistant retracting the the edge of the levator aponeurosis or the pretarsal
superior skin edge and applying gentle pressure to the orbicularis (Figs. 14.12 and 14.13). Alternatively,
globe, the fat pockets are made to bulge anteriorly. these sutures may be passed from inferior orbicularis
Currently, it is recommended to debulk/excise the to levator edge to superior orbicularis. These sutures
medial fat pad if indicated and, more rarely, excise also can serve to imbricate the orbicularis muscle
the central fat pad so as not to create a hollow appear- thereby creating more volume for the upper lid. The
ance or so-called A-frame deformity. Once in the skin incision is closed with a running suture, using
suborbicularis plane, as the fat bulges, the overlying 60 plain gut or a nonabsorbable suture such as 60
capsule is divided and the fat allowed to prolapse. silk or polypropylene. Antibiotic ointment is applied
Additional local anesthetic may be necessary at this (Fig. 14.14).
point. The fat is excised/debulked using the clamp Cold compresses are placed immediately after
and cut method, CO2 laser, or monopolar cautery surgery and then continued at frequent intervals for the
(Fig. 14.11). Laterally, care should be taken not to con- next 48 h. The patient is advised to keep his/her head
fuse the lacrimal gland with a lateral fat pad (the lacri- elevated, such as sleeping on several pillows, in order
mal gland tends to be whiter in color and firmer in to minimize postoperative edema. Antibiotic ointment
texture). Lacrimal gland prolapse can contribute to the is applied up to 3 times daily for a week with artificial
lid fullness, and the gland may need to be repositioned tears used as needed for possible dry eye symptoms.
into the lacrimal gland fossa. Also, previously the Patients are usually seen in the office at 57 days
ROOF fat was routinely sculpted or excised, which postoperatively, and at this point, any nonabsorbable
would only contribute to deflation of the temporal sutures may be removed.
224 M.E. Hartstein
Fig. 14.11 The orbicularis may be button-holed medially in Fig. 14.13 When the crease suture is tied, it sets the crease at
order to sculpt or excise the fat pocket, in this case with the the desired height. By imbricating the orbicularis muscle poste-
Colorado needle. The central fat pocket is rarely removed riorly, the crease suture also serves to augment the volume of the
upper lid. Several crease sutures can be placed but I usually
place them medially and centrally while laterally just closing
skin to skin
Fig. 14.12 The lid crease is reformed by passing a suture

through both edges of wound while incorporating a bite of the
edge of the pretarsal orbicularis
Fig. 14.14 (a) Preoperative. (b) Postoperative following upper

blepharoplasty
14.7 Complications
Retrobulbar hemorrhage is a rare but devastating com- Mild lagophthalmos and exposure keratitis (dry
plication of eyelid surgery. Patients should be instructed eye) are probably the most common complications.
to call their surgeon for significant eyelid swelling. Usually these are self-limiting in most cases. The
Preoperative screening and counseling for potential patient may need to use artificial tear supplements for
anticoagulants is a necessity. a short period postoperatively. In more severe cases of
dry eye, patients may be required to frequently instill 14.8 Conclusions

lubricating drops and ointments and place punctal
plugs. In addition, oral doxycycline may be helpful to Upper blepharoplasty can be a highly rewarding pro-
correct meibomian gland dysfunction which can con- cedure. It is critical to understand the relevant eyelid
tribute to dry eye after surgery. In rare cases, a corneal anatomy. Previous concepts of simply removing as
ulcer may develop, requiring the eyelids be closed much tissue as possible have yielded to a greater
temporarily with a tarsorrhaphy. appreciation of what constitutes a youthful and
Asymmetric eyelid creases may result from poor aesthetic upper eyelid.
incision marking or from lack of crease fixation
sutures. In general, it is easier to raise a low crease than
to lower a high crease. If the patient is unhappy with References
crease asymmetry, one should discuss using the higher 1. Hartstein ME, Kikkawa D (2009) How to avoid blepharo-
crease as a guide. plasty complications. Oral Maxillofac Surg Clin North Am
Oversculpted deep superior sulcus may result from 21(1):3141
over-aggressive skin/orbicular removal and/or fat 2. Older JJ (1995) Ptosis repair and blepharoplasty in the adult.
Ophthalmic Surg 26(4):304308
removal. To correct this deformity, residual fat pads
3. Pacella SJ, Codner MA (2010) Minor complications after
may be mobilized and advanced or fat/filler injections blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and
may be performed [13]. scleral show. Plast Reconstr Surg 125(2):709718
Lower Blepharoplasty
15
Morris E. Hartstein
15.1 Introduction globe protrudes anterior to the rest of the lower lid and
midface, may be at higher risk for lid malposition post-
The cookie-cutter approach is to be discouraged in any operatively if not addressed properly.
cosmetic procedure but nowhere more so than in lower Lower lid laxity is evaluated by the distraction test
blepharoplasty. It is crucial to evaluate the patient and and the snapback test. The lid should be able to be
discuss with them preoperatively what exactly bothers distracted not more than 68 mm from the globe. In the
them about their lower lids. For example, is it the bags? snapback test, the lid is pulled downward and allowed to
The wrinkles? The dark circles? All of the above? snapback to the globe. With significant laxity, the lid
A standard ocular exam is part of the standard pre- will not return to the globe until the next blink. These
operative evaluation for lower blepharoplasty, espe- are lids which are at risk for postoperative lower lid mal-
cially checking for dry eye and previous LASIK surgery. position if not addressed surgically. In addition, address-
In addition, the following checklist can be helpful. ing the laxity can enhance the result of the surgery.
The quality and amount of excess skin are noted. In lower lid blepharoplasty, it is crucial to address
Redundant or lax skin can also be a function of attenu- each of the layer of the lid complex: skin, muscle, fat,
ated orbicularis muscle. The fat pockets are then vector, and the canthus. Properly addressing each of
observed while the patient looks straight ahead and in these aspects of the lid will ensure a great chance of
upward gaze. Gentle pressure on the globe can make success in lower lid rejuvenation.
these areas bulge further. Chronic eyelid edema may be
a sign of thyroid disease, and the presence of festoons
should be noted. If there is a prominent lateral fat pad, 15.2 Procedure
this should be noted as it is sometimes overlooked intra-
operatively. Hypertrophic orbicularis along the lid mar- Topical proparacaine is placed in the eye, a corneal
gin can lead to fullness in this area. Finally, it is important shield is placed, and the lower lid is digitally retracted
to note the relationship of the lower lid to the midface, by the assistant. Local anesthetic 50:50 mixture of 2%
noting if there is malar fat lad descent or prominent tear lidocaine and .75% bupivacaine with epinephrine
trough deformity. Negative vector patients, where the (1:100,0001:200,000) is injected subconjunctivally
(Fig. 15.1). The needle is then directed into the fat
pockets as well as the infraorbital nerve. A cotton-
M.E. Hartstein tipped applicator is used to ballott the globe, and this
Department of Ophthalmology, causes the inferior fornix to prolapse. An incision is
Assaf Harofeh Medical Center, Zerifin, Israel
made several millimeters beneath the inferior tarsal
Clinical Associate Professor border from the caruncle to the lateral canthus
of Ophthalmology and Plastic Surgery,
(Figs. 15.2 and 15.3). A traction suture is placed through
Saint Louis University School of Medicine, St. Louis,
MO 63104, USA the superior aspect of the incision to enhance exposure
e-mail: [email protected] and to protect the globe (5-0 Vicryl, 4-0 silk). Dissection

228 M.E. Hartstein
Fig. 15.1 With the assistant everting the lid, local anesthetic is
given subconjunctivally. Additional local anesthetic is given into
the fat pockets as well as to the infraorbital nerve
Fig. 15.4 (a) Dissection is carried out along the lower lid
Fig. 15.2 With the lid everted and with gentle pressure on the retractor until (b) the fat pads are easily visible. Additional local
globe, an incision is made several millimeters below the inferior anesthetic can be given at this point
tarsal border. Note the corneal shield
is carried out inferiorly, staying close to the conjunctiva

and lower lid retractors (Fig. 15.4). Blunt dissection
with a cotton-tip can be helpful as well. A Desmarres
retractor is then used to retract and placed over the
inferior orbital rim, causing the fat pockets to prolapse.
Additional local anesthetic can be given at this time
prior to opening up the capsule surrounding the fat
pockets. The capsule is gently divided across the length
of the incision, and the fat should easily prolapse. At
this point, it is helpful to take a cotton-tipped applicator
and use it to bluntly dissect between the nasal and cen-
tral fat pads in order to indentify the inferior oblique
muscle (Fig. 15.5). Once the muscle is visualized, the
Fig. 15.3 The transconjunctival incision is carried out from the fat pockets can be safely addressed. After opening the
caruncle to the lateral canthus capsules surrounding the fat, the fat can be teased out
15 Lower Blepharoplasty 229
Fig. 15.5 The overlying capsules are gently divided to allow Fig. 15.7 The fat may also be removed by the clamp and cut
the fat to prolapse. A cotton-tipped applicator is placed between method
the nasal and central fat pad to identify the inferior oblique
muscle
Fig. 15.6 The nasal fat pad is debulked/resected using the Fig. 15.8 Special attention must be paid to the lateral or temporal
coagulation setting on the Colorado needle fat pad. This pad is sometimes overlooked until it is noticed
postoperatively
using a forceps and cotton-tipped applicator. If the goal to the periosteum (Fig. 15.9). The prolapsed fat pads
is to excise the fat, it can be removed using a Colorado can be gently sculpted. A suture (e.g. 6-0 Prolene) is
needle on the coagulation setting (Figs. 15.615.8). It is then passed through the skin side in a previously
often necessary to supplement the anesthesia with addi- marked area just beneath the tear trough, coursing
tional injections into the fat. Fat is usually removed along the anterior inferior orbital rim (Fig. 15.10).
down to the level of the inferior orbital rim. The suture needle is then weaved through the fat pads,
In a more fat-conserving blepharoplasty, the fat can passed over the anterior rim again to exit through the
also be repositioned in the intra-SOOF plane [1]. A skin alongside just the first suture. Sometimes, the
pocket is created by dissecting just over the perios- medial and central fat pad can be weaved using the
teum under the orbicularis muscle for a distance of not same suture needle, or separate sutures and needles
more than 10 mm inferior to the rim so as not to dis- may be passed for each compartment. The temporal
rupt the orbicularis nerve fibers. This can be done with pad in these cases is usually removed. When the suture
an elevator or by spreading with scissors just anterior is tied, the repositioned fat is advanced over the infe-
230 M.E. Hartstein
Fig. 15.9 If fat repositioning is to be carried out, a pocket is

developed in the preperiosteal plane using a scissors to spread
bluntly or an elevator
Fig. 15.11 When the suture is tied over a bolster, the fat is
redraped over the inferior orbital rim
Fig. 15.10 A suture is passed from the skin side, over the
inferior rim where it is weaved through the fat and then passed
back out through the skin
Fig. 15.12 Bolster in place. Repositioning the fat in this fash-
ion may also provide midrace elevation
rior rim (Figs. 15.11 and 15.12). This maneuver may
also create some elevation of the midface after the
orbicularis is freed. The conjunctival incision is not easier to perform than a full canthoplasty, the can-
closed. Additional fat may be injected as well for fur- thopexy is also less powerful. Still, a simple suture
ther volume enhancement. canthopexy procedure can be very effective when
Once the fat is taken care of, attention can now be combined with a transconjunctival approach. When
directed to the anterior lamella. If there is lid laxity, the lower lid retractors are released, this allows the lid
this should be addressed, and several options are avail- to migrate upward, and when combined with the can-
able. Suture canthopexy provides tightening of the lid thopexy, this can ensure a stable lid position during the
during at least the postoperative period. Technically healing phase. In cases of severe laxity or in cases
Fig. 15.13 Blunt dissection through a buttonhole incision in Fig. 15.15 Pulling on the 5-0 Vicryl to ensure a proper
the orbicularis down the lateral rim periosteal bite is taken
Fig. 15.14 A 5-0 Vicryl suture is passed through the periosteum Fig. 15.16 The 5-0 Vicryl suture is passed through the orbicularis
over the lateral orbital rim in a mattress fashion
combined with a translid subperiosteal midface lift, a canthal angle, and blunt dissection is carried out to the
full canthoplasty, i.e. tarsal strip procedure, may be orbital rim. By making a buttonhole incision and
warranted [2]. bluntly spreading, there is less chance of orbicularis
It is useful to address the orbicularis muscle. Atten- denervation (Fig. 15.13). A 5-0 Vicryl suture is passed
uation of the orbicularis may be partly responsible for through the periosteum of the lateral rim (Figs. 15.14
the tear trough deformity and for some of the aging and 15.15). The suture is then hitched (Little JW
effects seen in the lower lid region. Tightening the personal communication) to the orbicularis muscle
orbicularis laterally can also help to support the lid in a mattress fashion (Fig. 15.16). When tied, this
without altering the canthal appearance which may elevates the lid, and may help efface the tear trough.
occur with a tarsal strip canthoplasty. This is also use- Excess skin can be resected in the form of a skin
ful in patients with a significant distraction test of the pinch, and with the underlying orbicularis support,
lid. A lateral incision is made just lateral to the lateral a large amount of skin can be safely resected
232 M.E. Hartstein
Fig. 15.17 Excess skin is now addressed through a skin pinch Fig. 15.19 Following skin excision, the skin easily redrapes
using Adson forceps. The skin may also be addressed with laser
resurfacing
Fig. 15.18 Only the pinched skin is excised no orbicularis is Fig. 15.20 The 5-0 Vicryl is tied down, elevating and securing
taken the orbicularis and supporting the lower lid and canthus
(Figs. 15.1715.19). Closure is with 6-0 Prolene or anesthesia injection around the inferior oblique, but
6-0 plain gut sutures, closing from the medial to this is usually transient.
temporal direction to decrease chances of a dog-ear
laterally (Figs. 15.2015.22). Alternatively, the skin
can be tightened with a laser. 15.3 Complications
Postoperatively, the patient uses eye drops and
ointment to be placed in the eye. Often an antibiotic/ Similar to upper blepharoplasty, patients undergoing
steroid combination can be used. Cold compresses are lower blepharoplasty may develop dry eyes, persistent
applied for 48 h and the patient is instructed to call if edema/chemosis, allergic reactions, etc. Sometimes,
there is significant swelling. Some patients may report residual fat may be noted especially laterally. Con-
diplopia immediately postoperatively as a result of versely, patients may have too much fat removed and
Fig. 15.21 Excess skin at the lateral canthus is removed Fig. 15.23 (a) Preoperative. (b) Postoperative
tive vector eyes [3]. Careful preoperative assessment

and intraoperative attention can help to easily avoid
this complication.
15.4 Conclusions
Lower blepharoplasty can be a challenging procedure.

However, with careful preoperative planning and by
addressing each layer of the lid complex, one can
achieve successful rejuvenation of the lower lid region
(Fig. 15.23).
Fig. 15.22 Skin pinch and lateral incision are closed using
interrupted 6-0 Prolene or 6-0 plain gut sutures References
1. Hartstein ME, Kikkawa D (2009) How to avoid blepharo-
suffer from a hollow-appearing lid. More conservative plasty complications. Oral Maxillofac Surg Clin North Am
fat removal or repositioning can help avoid this prob- 21(1):3141
lem. If it does occur, it can be corrected with filler 2. Jordan DR, Anderson RL (1989) The lateral tarsal strip revis-
ited. The enhanced tarsal strip. Arch Ophthalmol 107(4):
injections; however, the periorbital area is one of the
604606
least forgiving on the face, so care should be taken. 3. Mohadjer Y, Holds JB (2006) Cosmetic lower eyelid bleph-
One of the most common and distressing complica- aroplasty with fat repositioning via intra-SOOF plane.
tions of lower blepharoplasty is eyelid malposition in Ophthal Plast Reconstr Surg 22(6):409413
4. Shorr N, Fallor MK (1985) Madame Butterfly procedure:
the form of lid retraction ectropion or both. This com-
combined cheek and lateral canthal suspension procedure for
plication is most often associated with the subciliary post-blepharoplasty, round eye, and lower eyelid retraction.
approach, lack of attention to lid laxity, and/or nega- Ophthal Plast Reconstr Surg 1(4):229235
Blepharoptosis: The Check
Ligament Technique 16
Antonio Stanizzi
16.1 Introduction 4. Can be implemented early, unlike other traditional

techniques, even under 1 year of age, when it is
This technique was pioneered by Holmstrm and more important to operate in severe cases to prevent
Santanelli in 2002 [1, 2] and provides for the use of the amblyopia [9].
suspensor ligament of the conjunctival fornix or check 5. This technique has no substantially recurrences.
ligament which, once suitably insulated, is attached to The main disadvantages of this technique are essen-
the tarsus. It is a flexible structure due to laxity of the tially the following believes:
capsule of Tenon in this area. Originally Holmstrom 1. The author believes that it is not so easy to find it
proposed its use in the treatment of congenital bleph- and make a correct check ligaments isolation.
aroptosis [3], which it is not the levator aponeurosis, 2. The determination of the correction has no objec-
but it is the levator muscle to have functional deficits. tive parameter of evaluation, and it depends on the
Under these conditions, traditional techniques of sensitivity of the surgeon, who must evaluate a
resection and shortening of the levator aponeurosis number of variables such as the type of ptosis, its
were subject to frequent and early recurrences, and the severity, the characteristics of the ligament which
techniques of suspension to the frontalis muscle, may vary from individual to individual, as it has
reserved for otherwise intractable cases, have several been managed and isolated, etc.
problems, not least having to make adjustments in sub- This involves a subjective final evaluation by the
jects with secondary growth [48]. surgeon that can predispose to hypo or hyper correc-
The check ligament technique has interesting tion. It seems reasonable to expect 30% of minor revi-
advantages: sions to change the level of correction obtained in the
1. The check ligament is a flexible structure indepen- first instance. When the secondary correction is
dent of the levator muscle and therefore can be used required, there are some advantages in performing it
in all conditions with an intrinsic deficit of this within the first week when the scar is not yet consoli-
muscle. dated, and all plans and structures can be isolated more
2. The check ligament is a vascularized structure, so it easily again. It is not always possible to have a full
is not necessary to use grafts of autologous or syn- aesthetic result, but in almost all cases, you can get a
thetic material as it is required in the techniques of good functional result. For all these reasons, the appli-
suspension to the frontalis muscle. cation of this technique can be extended to all cases,
3. No adjustment is necessary in subjects in secondary congenital or acquired, characterized by a poor func-
growth. tion of the levator muscle [1013].
Another indication is the treatment of acquired
involutional blepharoptosis early onset, at a young age,
where the quality of levator aponeurosis does not offer
A. Stanizzi
Cl. of Plastic Surgery, Ospedali Riuniti, Ancona, Italy guarantees on maintaining the level of correction in the
e-mail: [email protected] time after its shortening [14].

236 A. Stanizzi
In all these cases, the check ligament technique is the early hours, the drainage of a part of the exudates
now the treatment of choice. through the wound, with less postoperative edema.
The dressing consists in the application of ophthal-
mic ointment with steroids and antibiotics and wet
16.2 Description of the Technique gauze (saline solution), to be renewed several times
during the day. Ice is also applied at intervals during
It begins with an incision at the level of upper eyelid the first two days. In this way, the wound is kept clean
crease, with removal of a small amount of skin and because the wet gauze absorbs exudates, and the ice
orbicularis muscle. Then the levator aponeurosis is helps to reduce postoperative edema.
separated from the tarsus, in its central third, and the The level of correction obtained is checked within
tarsal plate cartilage exposed. The dissection proceeds the first 24 days, and if its not satisfactory, its pos-
in a plan between the conjunctiva, in depth, and levator sible to proceed to a revision. In any case, whatever the
aponeurosis and Mller muscle on the surface. The degree of correction obtained, it must always leave
dissection continues until the superior conjunctival possible the normal obstruction of the eyelid in both
fornix, the capsule of Tenon is reached. In this area, it the waking and sleep. A small fissure during sleep may
presents a laxity, so it can be hung and, with a gentle residual for the first weeks or even be permanent but
traction, protruded. At this point, you proceed with its must be limited (12 mm) and not create any discom-
carefully isolation, separating the conjunctiva from the fort to the patient.
check ligament until the correct amount needed is
obtained. Hemostasis must be very accurate.
After completing its isolation, the check ligament is 16.2.1 Case 1
attached to the tarsus with 3 nonabsorbable 6-0 inter-
rupted suture. At this stage, the surgeon must decide, This 17-years-old male had right congenital secondary
subjectively, the amount of correction to be made. If the blepharoptosis.
operation is conducted under local anesthesia and the When he was 6 years old, he was treated by levator
patient can cooperate, an initial reference may be to ask aponeurosis resection (other surgeon), and there was
the patient to open their eyes and place the lid margin recurrence after few months. A check ligament repair
between the pupil and the iris margin, but each case must was performed (Fig. 16.1).
be assessed individually. Established the degree of cor-
rection the dissected plans are simply repositioned with-
out requiring any resection of the levator aponeurosis. 16.2.2 Case 2
The operation ends with the skin suture with 6-0
nylon, interrupted sutures. This kind of suture offers This 18-month-old male had congenital blepharoptosis
the advantage of getting a scar concave, to better recre- of the left side. A check ligament repair was performed
ate the fold of the supratarsal crease, and to allow in (Fig. 16.2).
Fig. 16.1 This 17-years-old male had right congenital secondary hung and gently pulled. (k) The check ligament is fixed to a
blepharoptosis. When he was 6 years old, he was treated by suture to make its management easier. (l) The check ligament is
levator aponeurosis resection (other surgeon), and there was pulled over the tarsal plate, ready to be sutured on it. (m) The
recurrence after a few months. (a) Preoperative. (b) Preoperative first suture is placed in the middle. (n) Another two sutures are
planning. The incision is made at level of the superior supra- placed on later and medial side of the check ligament. Be careful
tarsal crease. In this case, the incision is to be the same as the the sutures remain in the tarsal plate and do not reach the con-
previous surgical treatment. (c) Infiltration of local anesthe- junctiva of the eyelid. (o) The suture of the check ligament to the
sia (45 mL of lidocaine 2% with epinephrine 1:100.000). tarsus has been completed. (p) Note the three sutures (Nylon
(d) Incision. (e) A small amount of skin and orbicularis muscle 6-0) over the check ligament. (q) The levator and Mller mus-
is removed. (f) The levator aponeurosis is exposed. (g) Detach- cles are replaced without any resection. (r) Level of correction
ment of the levator aponeurosis from tarsus. (h) Dissection starts obtained is verified. (s) Suture of the skin with interrupted
following the plane between the conjunctiva on the deep side sutures. It allows a better definition of the supratarsal crease and
and the levator and Mller muscles on the superficial side. Note the drainage of part of the exudation, with less postoperative
the tip of the scissor under the conjunctival plane. (i) The dissec- edema. (t) (1) Application of ophthalmic ointment with antibi-
tion reaches the superior conjunctival fornix. (j) The check liga- otic and steroid. (2) Dressing with wet gauze. (u) Two days post-
ment, represented by a laxity of the capsule of Tenon, can be operative. (v) Two weeks postoperative
16 Blepharoptosis: The Check Ligament Technique 237
a b
c d
e f
238 A. Stanizzi
g h
i j
k l

m n
o p
q r

240 A. Stanizzi
s t1
t2

a b
c d
Fig. 16.2 (a) Preoperative 18-months-old male with congenital right blepharoptosis. (b) Ten days postoperative after check ligament
procedure. (c) Eight months postoperative. (d) Note normal closure of the eyelids. (e) Good elevation of the eyelid
242 A. Stanizzi
16.2.3 Case 3 16.2.7 Case 7
Congenital right blepharoptosis in a 2 years-old male A 22-years-old male with acquired posttraumatic
(Fig. 16.3). blepharoptosis of the right side with complete paraly-
sis of the levator muscle (Fig. 16.7).
16.2.4 Case 4
16.2.8 Case 8
A 18-years-old female with acquired bilateral bleph-
aroptosis (Fig. 16.4). A 72-years-old female with congenital bilateral asym-
metrical blepharoptosis. Familial disease with her
mother and sister affected as well (Fig. 16.8).
16.2.5 Case 5
A 42-years-old male with acquired right blepharoptosis 16.2.9 Case 9

for 15 years (Fig. 16.5).
A 64-years-old male with acquired bilateral bleph-
aroptosis (Fig. 16.9).
16.2.6 Case 6
Acknowledgments My personal thanks to Prof. Hans Holmstrm
A 54-yeasr-old female with acquired blepharoptosis of whose teaching have allowed me to learn and implement this
the left side for 20 years (Fig. 16.6). technique.
a b
c d
Fig. 16.3 (a) Preoperative 2-years-old male with right con- closure of the eyelid. (d) Good elevation of the eyelid. (e) Six
genital blepharoptosis. (b) Three years postoperative. Aesthetic years postoperative and the result is maintained
result is not perfect but the functional result is good. (c) Normal
244 A. Stanizzi
a a
Fig. 16.4 (a) Preoperative 18-years-old female with acquired

bilateral blepharoptosis. (b) Two years postoperative
Fig. 16.5 (a) Preoperative 42-years-old male with acquired right

blepharoptosis for 15 years. (b, c) and (d) One year postoperative
a b
d
c
Fig. 16.6 (a) Preoperative 54-years-old female with acquired blepharoptosis of the left side for 20 years. (b) Preoperative poor function
of the levator muscle. (c) One year postoperative. (d) Good elevation of the eyelid
a b
c d
Fig. 16.7 (a, b) Preoperative 22-years-old male with acquired posttraumatic blepharoptosis of the right side with complete paralysis
of the levator muscle. (c) One year postoperative (d) Normal closure
246 A. Stanizzi
a a
b b
Fig. 16.8 (a) Preoperative 72-years-old female with congenital

bilateral asymmetrical blepharoptosis. Familial disease with her
mother and sister affected as well. (b, c, d) One year postopera-
tive. Normal closure and good elevation of the eyelids
Fig. 16.9 (a) Preoperative 64-years-old male with acquired

bilateral blepharoptosis. (b, c, d) One year postoperative. Good
elevation and normal closure of the eyelids.
References 7. Philandrianos C, Galinier P, Salazard B, Bardot J, Magalon G

(2010) Congenital ptosis: long-term outcome of frontalis
suspension using autogenous temporal fascia or fascia lata in
1. Holmstrm H, Santanelli F (2002) Suspension of the eyelid
children. J Plast Reconstr Aesthet Surg 63(5):782786
to the check ligament of the superior fornix for congenital
8. Wasserman BN, Sprunger DT, Helveston EM (2001)
blepharoptosis. Scand J Plast Reconstr Surg Hand Surg
Comparison of materials used in frontalis suspension. Arch
36(3):149156
Ophthalmol 119(5):687691
2. Holmstrm H, Bernstrm-Lundberg C, Oldfors A (2002)
9. Lin LK, Uzcategui N, Chang EL (2008) Effect of surgical
Anatomical study of the structures at the roof of the orbit with
correction of congenital ptosis on amblyopia. Ophthal Plast
special reference to the check ligament of the superior fornix.
Scand J Plast Reconstr Surg Hand Surg 36(3):157159
10. Wagner RS (1990) Surgical options for congenital ptosis
3. Iljin A, Zielinska A, Karasek M, Zielinski A, Omulecka A
with poor levator muscle function. Semin Ophthalmol 5(4):
(2007) Structural abnormalities in the levator palpebrae
176182
superioris muscle in patients with congenital blepharoptosis.
11. Whitehouse GM, Grigg JR, Martin FJ (1995) Congenital
Ophthalmic Surg Lasers Imaging 38(4):283289
ptosis: results of surgical management. Aust N Z J Ophthalmol
4. Scuderi N, Chiummariello S, De Gado F, Alfano C, Scuderi
23(4):309314
G, Recupero SM (2008) Surgical correction of blepharopto-
12. Dayal Y, Crawford JS (1966) Evaluation of the results of
sis using the levator aponeurosis-Mllers muscle complex
surgery to correct congenital ptosis of the upper eyelid. Can
readaptation technique: a 15-year experience. Plast Reconstr
Med Assoc J 94(22):11721177
Surg 121(1):7178
13. Deenstra W, Melis P, Kon M, Werker P (1996) Correction of
5. Park DH, Choi WS, Yoon SH, Shim JS (2007) Comparison of
severe blepharoptosis. Ann Plast Surg 36(4):348353
levator resection and frontalis muscle transfer in the treatment
14. Carraway JH (1988) Cosmetic and functional considerations
of severe blepharoptosis. Ann Plast Surg 59(4):388392
in ptosis surgery. The elusive perfect result. Clin Plast
6. Fan J (2001) Frontalis suspension technique with a tempo-
Surg 15(2):185193
ral-fasciae-complex sheet for repairing blepharoptosis.
Aesthetic Plast Surg 25(3):147151
Aesthetic Rhinoplasty Utilizing
Various Techniques Depending 17
on the Abnormality
Fernando D. Burstein
17.1 Introduction
The nose is the central and most prominent aesthetic

facial landmark. It divides the face into two halves and
defines many of the common measures of facial pro-
portions (Fig. 17.1). When in balance with the rest of
the face, it is an important component of perceived
facial beauty. When it is too prominent, too short, too
wide, or off center, it can contribute to facial dishar-
mony. Rhinoplasty can be an important adjuvant pro-
cedure when combined with surgery of the jaws or
surgery for facial aging. There have been many books,
articles, and seminars on the subject with ardent opin-
ions as to the merits of a particular philosophy or sur-
gical technique. It is apparent that many different
approaches can yield gratifying results in the proper
hands. The following is a personal approach to aes-
thetic rhinoplasty based on the authors experience
with over 5,000 procedures over 25 years. This is the
basic approach that the author has demonstrated and
taught to the plastic surgery residents. This chapter is a
brief synopsis of a methodology that has provided con-
sistent good results with a minimum of aesthetic, func-
Fig. 17.1 Measuring ideal facial proportions using Ricketts
tional, or postoperative problems.
Golden Rule
17.2 Consultation
The initial consultation for a patient requesting primary

F.D. Burstein
Division of Plastic and Reconstructive Surgery,
aesthetic rhinoplasty should include a detailed medical
Emory University, Atlanta, GA, USA history, review of any previous nasal procedures, and
careful attention to the patients stated aesthetic goals.
Center for Craniofacial Disorders, Childrens Healthcare
of Atlanta, Atlanta, GA, USA The nose should be examined externally, and with a
e-mail: [email protected] nasal speculum, any anatomic or functional anomalies

250 F.D. Burstein
should be documented and brought to the patients greatly decrease operative and postoperative bleeding.
attention. A speculum examination of the nasal cavity Along with better visualization during the procedure,
can give important clues to potential functional problems the patients postoperative discomfort will be greatly
that could be aggravated by aesthetic nasal surgery. reduced. Pledgets impregnated with 4% cocaine are
These concerns should be discussed with the patient placed between the inferior and middle turbinate to
and, if necessary, addressed at the time of aesthetic sur- anesthetize and constrict the mucosa. The supratro-
gery. Overall facial aesthetics should be discussed with chlear, supraorbital, infraorbital, and anterior ethmoidal
particular emphasis on the underlying bony anatomy of nerves are blocked with 0.25% mepivacaine with epi-
the face. A patient with what appears to be a dispropor- nephrine, and the subcutaneous nasal tissues are infil-
tionately large nasal pyramid may, in fact, have a small trated (Fig. 17.2). If septal work is to be done, the septal
chin which is amplifying the disharmony. An overly mucosa is also infiltrated. Less than 10 cm3 is used for
projected nasal tip may be more prominent in a patient all injections. It is useful to allow 15 min for maximal
with maxillary retrussion and so forth. A lateral cepha- vasoconstriction to occur before starting the operation.
lometric radiograph can be useful in verifying the clini-
cal impression in cases of skeletal disharmony.
In addition to external examination, photographic 17.4 Surgery
documentation is essential for documentation and treat-
ment planning. At a minimum anterior posterior and An external rhinoplasty approach is used in nearly
right and left profile views are recommended. A worms all of the aesthetic nasal operations, and the author
eye view can be helpful in patients with a wide nasal has done so for nearly 20 years. There are advantages
base. Computerized imaging is an essential part of my and disadvantages to both the external and internal
surgical preparation and an important tool for enhancing approaches to rhinoplasty, but on balance, the author
communication with the patient. The staff images the much prefers the external approach. The exposure
patient, and a written consent is obtained documenting afforded by this approach is wonderful for teaching
that the images are potential results and may vary. The purposes since cause and effect of various maneuvers
author is very wary of the patient that demands a nose can be easily demonstrated. Important technical points
that she or he sees in a movie magazine. The computer- that will minimize undesirable results include meticu-
ized images are used as a real-time guide during the lous closure of the columellar incision and careful reat-
procedure. In formulating a surgical plan, the author tachment of suspensory and connecting ligaments that
considers the patients desires, the relevant anatomy, are taken down for exposure. It is important to let the
and the results of computerized images. This plan is patient know that there will be numbness of the nasal
presented to the patient and discussed in detail to insure skin for several weeks and that often the nose will feel
that their expectations are realistic. An outlined plan indurated during the healing process. These conditions
based on these factors may look something like this: are temporary, but in cold climates, care must be taken
1. Dorsal hump bony and cartilaginous. Reduce dor- to avoid nasal frostbite until sensation returns.
sum with slight concavity. Reduce supra tip septum. For purposes of clarity, the author has divided the
2. Wide bony pyramid. Bilateral lateral osteotomies operative procedure into several distinct steps. These
with infracture. are described in the order that the author recommends
3. Amorphous wide nasal tip. Cephalic trim, intradomal performing, which is a logical progression that avoids
sutures, and graft tip. Reduce alar base width. repetition and redundancy, allowing an orderly and
predictable procedure. There are countless variations
on every step of the rhinoplasty procedure based on
17.3 Anesthesia anatomic factors, the surgeons preferences and experi-
ence, and surgical goals. The basic technique employed
The author performs all aesthetic nasal surgery under is broken down into several logical progressive stages
a general endotracheal anesthetic supervised by a from which creative variations can be added according
board-certified anesthesiologist. Only minor revisions to the surgeons experience. These steps are illustrated
are done under local with oral sedation. The proper for instructive purposes for reductive rhinoplasty with
topical and infiltrative anesthetic administration will tip modification.
17 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality 251
Fig. 17.2 Administration Supraorbital n.

of infiltrative and topical
anesthetic in preparation for
rhinoplasty. Note that block
of all sensory innervation and
mucosal vasoconstriction are Supratrochlear n.
key to successful surgery and
recovery
Infraorbital n.
Anterior ethrnold n.
Cocainized pledgett
17.4.1 Exposure
The location and design of the columellar incision is

critical. Placing the incision in the distal third of the
columella hides it from the frontal view and makes dis-
section easier (Fig. 17.3). A stair-step incision breaks
up the incision line thus camouflaging it since no seg-
ment is more than 34 mm in length. Alignment of the
incision is facilitated by simply fitting the right angles
back together at the end of the procedure. The nasal
skin is quite adherent in this area, and a fine #69 beaver
blade is recommended for the initial dissection. Using
a thumb hook, the nasal vestibular skin is everted dem-
onstrating the edge of the lower lateral cartilages. The
incision is carried from the columella along the edge of
the cartilages from medial to lateral leaving a 5-mm rim Fig. 17.3 Location and design of external rhinoplasty incision.
of intact vestibular skin. Leaving this rim will prevent Note right angles. This hides scar and makes accurate reapproxi-
visible scars and distortion of the rim. Sharp scissor mation possible
252 F.D. Burstein
Fig. 17.4 Septal harvesting.

Note that both dorsal and
caudal septal struts are
maintained. Approach is
through external incision
going between footplates
Ethmoid
Nasal septum
(1.5 cm. intact)
Harvest
Vomer
1 cm. intact
dissection of the lower lateral cartilages is carried out from the septum (Fig. 17.4). A 1-cm caudal strut and a
until they are fully exposed. The rest of the dissection 12-cm dorsal strut are left intact as the central septum
over the dorsum is easily carried out with blunt scis- is harvested with a swivel knife. The septal mucoper-
sors, protecting the skin with an elevator. At this stage, ichondrium is then sutured back together with a mat-
the entire external nasal anatomy will be visible. I take tress suture of 4-0 gut (Fig. 17.5). This obliterates a
a moment to correlate the actual anatomy with my sur- potential dead space and hematoma formation making
gical plan at this stage and modify it as necessary. packing unnecessary. Next, the periosteum of the dor-
Important anatomic points are the amount of cartilagi- sum is elevated with a Joseph elevator; this allows the
nous versus bony dorsal hump, thickness of the skin, rasp to work without interference. Coarse to fine rasps
intradomal fat versus cartilage width. are used to bring the bony dorsum down to the desired
level; no osteotomes are used. This allows gradual,
controlled contouring of the bony dorsum under direct
17.4.2 Dorsum visualization (Figs. 17.6 and 17.7). The cartilaginous
component is then trimmed using either septal right
After exposure has been achieved, the dorsal component angle scissors or a #11 scalpel blade. The nasal skin
can be addressed. If septal grafts are required, they are flap is frequently returned to its original position, and
obtained at this point by dissecting between the medial the dorsum is palpated as well as visually inspected
crura and carefully separating the mucoperichondrium several times as the profile is adjusted a millimeter at
Fig. 17.5 Resorbable

mattress sutures placed Remnant of
between septal nasal septum
mucoperichondrium flaps
obliterating dead space.
No packing is used
Mucoperiosteum
a time until the profile matches the patients desires. lines of the osteotomy-enhancing stability. Care should
The computerized imaging photos are invaluable in be taken to control the osteotome to avoid perforat-
this step. In some instances, the upper lateral cartilages ing the nasal mucosa, which can result in bleeding.
may need to be trimmed along their juncture with the This technique results in an osteotomy that is flush
septum to reduce projection of the dorsum. The mucosa with the maxilla preventing a visible or palpable
should be carefully dissected prior to trimming to rocker deformity and is inherently stable. No pack-
avoid penetrating into the nasal cavity. Reduction of ing is necessary to hold the nasal bones in place. Once
the nasal dorsum will almost always result in a flatten- the osteotomies are complete, attention is turned to the
ing of the dorsum or open roof as the peak of the nasal tip.
bony cartilaginous dorsum is removed (Fig. 17.7).
Lateral osteotomies can minimize this effect while at
the same time reducing the apparent nasal bony width 17.4.3 Tip
which is often desirable. A 2-mm straight osteotome
is often used for the lateral osteotomies. No tunnels The plethora of variations of nasal tip anatomy makes
are necessary before introducing the osteotome at the tip work a creative part of rhinoplasty. There are many
level of the pyriform aperture. The tip of the osteot- maneuvers that can be performed to achieve the desired
ome should be flush with the maxilla and follows nasal tip results. The particular techniques employed
the juncture of the nasal bones and maxilla to the level will depend on the patients goals, the quality and
of the medial canthus, where it is turned at a right thickness of the overlying nasal skin, and the available
angle, to the long axis of the nasal bones, continuing graft material. Most often, the lower lateral cartilages
the osteotomies toward the nasal dorsum (Fig. 17.8). will be too wide, and initial trimming is required. The
The 2-mm osteotome produces a perforated paper cartilages are incised with a micro tip coagulator nee-
effect by leaving the periosteum attached along the dle cautery sparing the mucosa and remove the desired
254 F.D. Burstein
Fig. 17.6 Exposure of dorsum. Bony dorsum modified with coarse to fine rasps. The cartilaginous dorsum is reduced with #11
scalpel. Insert shows flattening of dorsum with open roof being created
segment with sharp scissors (Fig. 17.9). Care is taken

not to damage the lower border of the upper lateral
cartilage especially at its juncture with the septum to
preserve the internal nasal valve. A minimum of 4 mm
of rim cartilage should be left intact to provide airway
support to the external valve.
For patients requiring only minimal narrowing of
the nasal tip with reasonably thin skin, this cephalic
trimming may be all that is required to achieve the
desired aesthetic result. It can be coupled with suturing
of the footplates and domes to further narrow and proj-
ect the tip. Only resorbable 5-0 PDS sutures are used
for this. It is important that the tip-defining point be the
lower lateral cartilages and not the septum to prevent a
poly-beak deformity. It may be necessary to trim the
distal septum if it projects beyond the most distal point
of the dome. If the tip is still too wide or the lateral
Fig. 17.7 Open roof as result of bringing down nasal bones and aspect of the domes too rounded, a simple bruising
septum. This creates a flattened dorsum that should be addressed using a cartilage crusher, while protecting the mucosa,
Fig. 17.8 Lateral osteotomy

technique. A perforated
paper effect is achieved.
Periosteal attachments also
help with the stability of the
osteotomies Lateral osteotomies
Periosteal bridges
can soften this curve while insuring nasal airway

support (Fig. 17.10).
In cases where the tip is bifid or under projected
or the skin is too thick to show the desired highlights
tip, grafting may be indicated. Autologous tissues
in rhinoplasty are used only to avoid problems with
rejection, infection, and extrusion that can occur with
prosthetic materials. In primary rhinoplasty, the septum
and other cartilaginous trimmings provide a plethora
of materials that can be sculpted to achieve an aestheti-
cally pleasing tip. Some basic graft types are the
cephalic trim materials, septal columellar, shield and
button grafts (Figs. 17.1017.13). In almost all cases,
the edges of the grafts should be softened or bruised Fig. 17.9 Nasal tip. Lower lateral cartilage is trimmed leaving
to prevent an edge effect. The degree of softening a 4-mm rim of intact cartilage to support external nasal valve
256 F.D. Burstein
Fig. 17.10 Composite

of various tip-modifying
techniques. Note bruising
of lateral crura to reduce
nostril convexity. Tip grafts
to define and project tip can
be stacked if necessary
Bruised
alar cartilages
Tip grafts
Fig. 17.11 (a) Submental

vertex view of nasal tip
showing broad bifid tip with
lack of projection. (b) Tip Tip grafts
projection increased by
suturing domal cartilages.Tip
definition improved with
onlay grafts
a b
required will depend on how thick the nasal skin is and perichondrium to maintain structural integrity. The
how thick the graft is. If the skin is very thick, requir- graft should be placed on top of the native lower lateral
ing a more substantial graft to show highlights, the cartilages exactly where the tip-defining points are
edges of the grafts can be beveled with a scalpel rather desired. The placement can be checked by simply
than bruised with a cartilage crusher to retain stiffness. unfurling the nasal skin flap and inspecting the effect.
The cephalic trimmings are thin supple grafts that can The septal cartilage can be used for a variety of grafts
be doubled over and stacked to fine tune nasal tip including shield shapes and button shapes. These grafts
projection; care should be taken to preserve the thin are fairly substantial and relatively rigid making them
(Figs. 17.15 and 17.16). A small pocket is created at

the level of the nasal spine, and the graft is inserted
contacting the spine. The medial crura and footplates
are secured to the strut graft with mattress sutures and
then walked to the tip. As the dome is reached, nasal
tip width is converted to tip projection. The angle of
the strut relative to the medial crura and footplates of
the graft insertion will help to determine the nasolabial
angle. The strut should not project beyond the domes.
Additional grafts can then be added as required. After
the tip work has been completed, the skin is closed
with 5-0 Prolene at the stair-step incision and 5-0 chro-
mic for the intranasal portion.
17.4.4 Base Width

Fig. 17.12 Shield type tip graft being applied. Note that the
highest point of graft will be tip-defining point After closing all incisions, the base width is evaluated
and compared to the desired width on the imaging pho-
tographs. This step is undertaken only after all tip and
dorsal modifications have been completed. Columellar
grafts, intradomal sutures, and other maneuvers that
increase tip projection will tend to narrow the nasal
base. A diamond-shaped pattern of skin and mucosa
is removed from the floor of nose just medial to the
alar attachments to the facial skin (Fig. 17.17). This
hides the incision intranasally while allowing signifi-
cant width reduction. In addition, it preserves the natu-
ral curvature of the lateral crura avoiding a grafted look
seen with alar excision techniques. Absorbable sutures
are used for closure.
17.5 Special Situations in Primary

Aesthetic Rhinoplasty
Surgery of the non-European ethnic nose can seem

intimidating. In the USA, the most common ethnic
groups seeking aesthetic nasal improvement are those
Fig. 17.13 Columellar strut graft between lower lateral carti- of African American and Asian lineage (Fig. 17.18).
lages. It will provide support allowing for tip narrowing and Most commonly, the tip width and projection are the
rotation primary concerns. Occasionally, the dorsum is also an
issue. The first step is, as always, communicating with
ideal for patients having thicker skin. Columellar grafts the patient as to realistic goals and expectations. The
are used to provide tip support and projection as well imaging computer is a valuable adjuvant in this regard.
as to rotate the tip-defining point to the desired angula- Keep in mind that almost all patients wish to keep
tion (Fig. 17.14). In cases of a hooked or droopy tip, their ethnic nasal identity and simply desire improve-
they are often combined with trimming of the distal ment in terms of proportions, tip definition, or dorsal
dorsal septum to shift the tip in an upward direction height (Fig. 17.19). The authors preference is to only
258 F.D. Burstein
a c
b1 b2
Fig. 17.14 (a) Male complaining of hooking of nose with a decrease plunging. (c) Postoperative following columellar strut
plunging tip and prominent hump. He desires a natural appear- graft. Note decrease in dorsal hump and increased nasal labial
ance. (b) Columellar strut graft used to rotate tip upward and angle as tip rotates upward
Fig. 17.15 (a) Young

a b
woman with large nasal
dorsal hump and resulting
plunging tip. Plunging made
worse with facial animation.
(b) Postoperative after bony
and cartilaginous dorsum
reduction, columellar strut
and tip grafting
a b
Fig. 17.16 (a) Patient desiring aesthetic improvement. Note plunging tip, dorsal hump, and amorphous tip. (b) Postoperative after
dorsal hump reduction, cephalic tip trimming, columellar strut, and shield grafting to tip improve aesthetics
260 F.D. Burstein
a1
a2
b c
Fig. 17.17 (a) Technique used to decrease nasal base width. wide tip. (c) Postoperative following cephalic trim, intradomal
Incisions are well hidden. (b) Preoperative young woman desir- sutures, and small crushed round cartilage graft to tip. Nasal
ing aesthetic improvement of nose. Complains of amorphous base narrowed
Fig. 17.18 (a) Preoperative

woman complaining of
a
excessive tip and alar width
as well as lack of tip
definition. Note shortened tip
on lateral view. Wants to
maintain ethnic characteristics
and look natural.
(b) Postoperative after alar
base reduction, cephalic trim,
dome placation, and stacked
septal shield grafts to
lengthen tip
use autologous tissues to augment the tip or dorsum. cartilage is harvested. Next, the cephalic margins of
The most frequent complaint is an amorphous wide the lower lateral cartilages are trimmed, and the lat-
tip. In these cases, the standard external approach is eral crura remnant is often bruised to convert the cur-
used. vature from convex to slightly concave. This maneuver
Often a fibro fatty collection between the domes is will help in refining the tip. If tip support is deficient,
present, splaying the tip. This tissue is removed, the the septal cartilage can be used as a columellar graft
septum is exposed between the footplates, and the advancing the medial crura on this pillar of support.
262 F.D. Burstein
a b
Fig. 17.19 (a) Preoperative young man complaining of overall width of nose, dorsal hump, and wide nostrils. (b) Postoperative
following takedown of hump, alar base reduction, cephalic trim, and small shield graft to tip
These septal and/or cephalic trimmings are then used 17.5.1 Dressings and Postoperative
to create a tip-defining point. If modest dorsum aug- Care
mentation is desired, a stacked septal graft is ideal.
Alternatively, a bruised conchal graft can be used. No intranasal packing is used. The nose is dressed with
For the rare cases of extreme dorsal deficiency, a steri-strips and a thermoplastic dressing. Oral analge-
carved costal cartilage graft is preferred to prosthetic sics, 3 days of oral antibiotics, and a Medrol dose pack
materials. Great caution should be used in contem- are prescribed. Cold packs and head elevation are rec-
plating lateral narrowing osteotomies if the nasal ommended. Showering is allowed the next day. The
bones are short since the osteotomies may be quite columellar sutures and splint are removed in 57 days,
unstable and result in less dorsal projection if they and normal activity, including exercise, can be resumed.
collapse into the nasal vault. Finally, after all inci- This regimen results in minimal postoperative discom-
sions have been closed, the alar base is addressed. fort and swelling. Most patients take little if any of the
The diamond excision can be carried right to the junc- prescribed narcotics and report minimal discomfort.
ture of the nares and facial skin allowing a marked The patient can see an approximation of the final result
narrowing of the nasal base without visible scars. This as soon as the dressings are removed. As part of the
maneuver can also soften nares flaring. I have not had preoperative preparation, written instructions and edu-
either hypertrophic or keloid scars form from the cation on perioperative care are given to the patient and
nasal incisions. verbally reviewed before and after the procedure. Mild
swelling and numbness can be expected for 46 weeks. obtuse cervical mental angle can benefit from HOM
The final result will take 912 months to see as grafts (Fig. 17.21). Most often, advancement is indicated in
heal and residual skin edema gradually resolves. order to improve the profile, in conjunction with reduc-
tive rhinoplasty, but vertical reduction or lengthening
is also possible. In older patients, an additional benefit
17.6 Revisional Surgery of HOM with advancement is improvement in the neck
profile. HOM is done through an intraoral approach
Despite the surgeons best efforts, minor revisions may using pre-bent titanium plates available in 2 mm incre-
be necessary. In the authors experience, a 4% revision ments. This allows fairly precise correlation to the
rate has been consistent from year to year. At least 9 patients computerized imaging profile. Care is taken
and preferably 12 months is waited before considering to avoid the inferior alveolar nerve as it exits the men-
revisional surgery. Most of the revisions involve minor tal foramen and to keep the osteotomy at least 5 mm
dorsal rasping, scar revision, or alar width adjustment. below the cuspid roots. The mentalis muscle is reat-
Almost all can be done in an office setting under local tached with resorbable sutures, and supporting tape is
with oral sedation. placed on the chin for 5 days.
17.7 Adjuvant Procedures 17.8 Conclusions
Genioplasty (Horizontal Osteotomy of the Mandible, Aesthetic rhinoplasty can seem daunting to the young
HOM) plastic surgeon starting practice. A simple, systematic
HOM is often performed in conjunction with approach to rhinoplasty will help link cause and effect
aesthetic rhinoplasty. Most frequently, it is done to for the surgeon. The use of the external direct approach
balance facial proportions (Fig. 17.20). Patients with allows immediate feedback on the operating table
retromicrogenia, vertical midface hyperplasia, or an improving the consistency of results.
a
a1 a2
Fig. 17.20 (a) Technique for

HOM. Note osteotomy well
below mental foramen and
tooth roots. Leaving muscles
attached to the inner cortex of
the advanced chin will tighten
the neck improving cervical
mental area in older patients.
(b) Preoperative young
woman complaining of
having a nose that is too Digastric and platysma
prominent. Note retrusive placed under stretched
chin increasing perceived after advancement
disproportion of nose.
(c) Postoperative after HOM,
5-mm straight advancement,
and reduction of nasal
dorsum. Note improvement in
overall facial proportions
264 F.D. Burstein
b c
a b

patient with retrussive long
chin and dorsal hump before
and after surgery. (b)
Postoperative after HOM
designed to move forward
7 mm and upward 3 mm,
nasal dorsum reduced
References 9. Johnson C, Toriumi D (eds) (1990) Open structure rhino-

plasty. W.B. Saunders Co, Philadelphia
10. Kamer F, Churukian M (1984) Shield graft for the nasal tip.
1. Bronz G (1999) The role of the computer imaging system in
Arch Otolaryngol 110(9):608610
modern aesthetic plastic surgery. Aesthetic Plast Surg 23(3):
11. Kamer F, Pieper P (2004) Nasal tip surgery: a 30 year
159163
experience. Facial Plast Surg Clin North Am 12(1):8192
2. Cardenas-Camarena L, Guerrero M (1999) Use of cartilagi-
12. Kawamoto H (2000) Osseous genioplasty. Aesthetic Surg J
nous autografts in nasal surgery: 8 years of experience. Plast
20:509516
13. Ortiz-Monesterio F, Olmedo A, Oscoy L (1981) The use of
3. Correa A, Sykes J, Ries W (1999) Considerations before
cartilage grafts in primary aesthetic rhinoplasty. Plast
rhinoplasty. Otolaryngol Clin North Am 32(1):714
4. Daniel R (1992) The nasal tip: anatomy and aesthetics. Plast
14. Rees T (ed) (1980) Aesthetic plastic surgery. W.B. Saunders
Co, Philadelphia, pp 51387
5. Daniel R, Lessard M (1984) Rhinoplasty: a graded aesthetic-
15. Rohrich R, Muxaffar A, Janis J (2004) Component dorsal
anatomical approach. Ann Plast Surg 13(5):436451
hump reduction: the importance of maintaining dorsal
6. Fruscella P (1997) Cephalometric analysis and postopera-
aesthetic lines in rhinoplasty. Plast Reconstr Surg 114(5):
tive results in aesthetic rhinoplasty. Aesthetic Plast Surg
12981308
21(2):7985
16. Sheen J, Sheen A (1998) Aesthetic rhinoplasty, 2nd edn.
7. Greer S, Matarasso A, Wallach SG, Simon G, Longaker MT
C.V. Mosby Co, St Louis
(2001) Importance of the nasal-to-cervical relationship to
17. Williams EF 3rd, Lam SM (2002) A systematic, graduated
the profile in rhinoplasty surgery. Plast Reconstr Surg
approach to rhinoplasty. Facial Plast Surg 18(4):215222
108(2):522531
8. Guyuron B (1988) Precision rhinoplasty. Part I: the role of
life size photographs and soft tissue cephalometric analysis.
Otoplasty
18
Cristina Isac, Aurelia Isac, Tiberiu I. Bratu,
and Nicolae Antohi
18.1 Introduction 18.2 History
Prominent ears are a relatively common congenital Dieffenbach (1845) [2] was the first who excised the
deformity with an incidence in Caucasians of 5%. Two postauricular skin and used a conchomastoidal fixation.
thirds of the patients have a positive family history, In 1881, Ely [3] added a conchal strip excision. Luckett
inherited as an autosomal dominant trait. In most of (1910) [4] introduced the concept of antihelical fold
the cases, they are diagnosed at birth and there is no restoration; his technique consisted in skin and cartilage
sex predilection [1]. Prominent ears represent a source excision along the antihelical fold followed by horizontal
of great distress psychologically and emotionally and mattress sutures [14]. Attempts of softening the contour
may induce serious behavioral problems in children. A of the antihelix were made afterwards by Becker (1952)
well-performed otoplasty results in a truly gratifying [5] and Converse et al. (1955) [6]. Mustard (1963)
patient. [7] introduced the concept of conchoscaphal perma-
nent mattress sutures for creation of a smooth, natural-
looking antihelical fold.
Gibson and Davis [8] showed in 1958 that the carti-
lage has a very important ability it warps away from
C. Isac (*) the injured surface. This led to different techniques of
Department of Plastic Surgery, University Hospital for Plastic
creating the antihelical fold by scoring sharply with the
Surgery and Burns, University of Medicine and Pharmacy
Carol Davila, Bucharest, Romania scalpel its anterior surface (Chongchets technique, 1963
e-mail: [email protected] [9]) or with a rasp (Stenstroems technique, 1963 [10]).
A. Isac Conchal reduction has been performed by excision or
Department of Plastic Surgery, University Hospital for Plastic using conchomastoidal sutures, a technique introduced
Surgery and Burns, Bucharest, Romania by Furnas (1968) [11] and modified by Spira [12] by
using a posterior flap of cartilage, based laterally adja-
T.I. Bratu cent to the antihelix, that is elevated and sutured to the
Brol Medical Center Private Clinic, Timisoara, Romania
mastoid process. The maneuver serves to bring the con-
Department of Plastic and Reconstructive Surgery, University cha closer to the scalp and thus reduces the protrusion.
of Medicine and Pharmacy Victor Babes, Timisoara, Romania
Approximately 200 techniques have been described
over the years, which include bending, suturing, excis-
N. Antohi
ing, scoring, and repositioning the auricular cartilage
University Hospital for Plastic Surgery and Burns,
Bucharest, Romania through posterior or even anterior approaches [13]. This
demonstrates that no one technique is ideally used single
University of Medicine and Pharmacy Carol Davila,
Bucharest, Romania for correction of the prominent ear. Most of the favorable
e-mail: [email protected] results are achieved using a combination of techniques.

268 C. Isac et al.
a b
superior crus
scaphoid fossa
fossa triangularis
helix
inferior crus
cymba conchae
radix helicis
antihelix
cavum conchae
tragus
antitragus
incisura intertragica helical tail
lobule
Fig. 18.1 (a) Anatomy of a normal ear (anterior surface). (b) Anatomy of a normal ear (posterior surface)
18.3 Anatomy of the Normal Ear The veins drain into the posterior auricular, superfi-
cial temporal, and retromandibular veins. The innerva-
In order to obtain maximal aesthetic outcomes, it is tion of the external ear is provided by the greater
absolutely imperative for the surgeon to thoroughly auricular nerve (C2C3), the auriculotemporal nerve
understand the unique anatomical features of such a (V3), the lesser occipital nerve, and the auricular branch
complex and varied structure, such as the ear. of the vagus (Fig. 18.3) [16].
The ear is composed of cartilage and skin with its The superior margin of the ear corresponds to the
subcutaneous tissue. The cartilage has many convolu- level of the brows, and the inferior margin corre-
tions and folds, and it is more malleable and soft in the sponds to the columella. The length of a normal adult
younger person. ear is 5.56.5 cm, and the width measures 5060%
By 3 years of age, the ear reaches approximately of its length (3.5 cm) [17]. The auriculo-cephalic
85% of its maximal dimensions. Ear width reaches its angle reaches 2530 in men and 21 in women [17].
mature size at around 7 years, and ear length matures The scapho-conchal angle usually measures 90 or
at around 13 years [14]. In all, it is appreciated that the less.
ear is fully developed by 7 years, so that by this time, The helix projects laterally from the scalp
it is the appropriate timing for correction. 1012 mm at the superior pole, 1618 mm at the
Figure 18.1 shows the normal surface anatomy of midpoint, and 2022 mm at the lobule. This corre-
the ear. The arterial supply of the ear comes from the sponds to a conchal bowl depth of 15 mm. The helix
posterior auricular, superficial temporal, and occipital should project 25 mm beyond the antihelix on frontal
arteries (Fig. 18.2). view [14].
18 Otoplasty 269
Fig. 18.2 Arterial supply of the ear
Superficial temporal artery
Posterior auricular artery
Auriculotemporal n.
Lesser
occipital n.
Vagus n.
Great auricular n.
Fig. 18.3 Nerve supply of the ear
270 C. Isac et al.
a b
Fig. 18.4 (a) Absence of antihelical fold. (b) Deep concha
18.4 Anatomy of the Prominent Ear antihelical fold with obtuse scapho-conchal angle and
increased depth of conchal bowl and auriculo-cephalic
The anatomical features describing prominent ears angle.
may be summarized as follows:
1. Absence of an adequate entire antihelix or a part of
it root, superior, or inferior crus; as a result, the 18.5 Goals of Otoplasty
conchoscaphal angle is greater than 90 up to as
much as 150 or more; as a consequence, the scapha The main goal of otoplasty is to achieve a permanent
is flattened, the cephalo-auricular angle is widened, correction with natural-looking ears that do not appear
and the upper pole is rotated externally. to have been operated on [1]. The goals can be sum-
2. A large and deep concha. marized as follows:
3. Inadequate helical rim (insufficient helical curling) 1. Creation of a smooth, rounded, well-defined antihe-
with or without anterolateral displacement of the lix, with the helix seen beyond the antihelix on the
tail of the helix or protrusion of the helical root. front view
4. Excessive antitragal protrusion. 2. Conchal reduction
5. Abnormal, overprojected lobule. 3. Conchomastoidal angle of 25 or less
The prominent ear features are usually combined, 4. Conchoscaphal angle of 90 or less
although there may be cases in which only one of the 5. Symmetrical ears within 3 mm of variation from the
deformities is present. They may also coexist with contralateral ear
macrotia. Usually, both ears are affected but not always Nonsurgical intervention is successful only if
both of them have the same underlying abnormalities. applied within the first 3 days of birth with surgical
Any surgical procedure should address the underlying tape [18]. An appropriate timing for the operation
anatomical defect and attempt to correct it. A single would be around 5 years old, before the child goes to
one approach or technique is obviously not appropriate school but when he is old enough to cooperate with the
for all clinical cases. postoperative regimen, although intervention at
Figure 18.4 shows an example of prominent ear that younger ages doesnt affect in any way the growth of
result from two typical features: underdevelopment of the ear [19].
18 Otoplasty 271
The desired antihelical fold is determined by gentle

digital pressure on the helix and marked accordingly
(Fig. 18.6).
A row of ink marks is made on the anterior skin with
a 25-gauge needle (with or without methylene blue); the
marks run superiorly to the supposed superior crus site,
then along the length of the helix till its tail (Fig. 18.7).
The posterior row of marks is thus made simultaneously,
corresponding exactly to the anterior ones (Fig. 18.8).
The goal is to maintain intact the helical shape.
A posterior cutaneous incision is made, extending
from the upper corner of the fossa triangularis to the
Fig. 18.5 Skin incision made for both Mustard and Furnas antitragus. The lateral extent of the skin excision is
sutures placement made 12 mm medial to the posterior row of marks.
An ellipse of skin of about 1-cm width is excised
(Fig. 18.9) depending on how much the ear needs to be
reduced in width.
18.6 Surgical Procedures The skin is undermined for a distance of about
3 mm toward the helical rim as well as on the poste-
Most of the techniques used focus on the creation of a rior surface of the concha for about 2 cm with small,
natural antihelix, conchal setback, or a combination of curved, blunt-tipped scissors. The medial dissection
them. The authors describe in the following section can reach the postauricular sulcus, even the mastoid
their most often used technique and continue by dis- periosteum if Furnas sutures are planned. The dis-
cussing other techniques published in literature. The section is performed in the supraperichondrial plane.
preferred authors technique has been originally Preserving the perichondrium intact on the surface
described by Chongchet [9], modified by Tolhurst [20] of the cartilage avoids sutures pulling through it. The
and others (Colpaert-[21], Fatih Peker-[22]). cartilage is incised immediately beyond the upper
The incisions made on the posterior surface of part of the incision, leaving a strip of helix intact
the ear vary, depending on the goals of the procedure. (Fig. 18.10).
If Mustard sutures are planned, the skin incision is The incision in the cartilage extends parallel to the heli-
placed in the center of the posterior surface; if Furnas cal rim from beyond the superior crus to the tail of the
sutures are taken into consideration, the skin incision helix, following the contour of the helical fold. The helical
is designed closer to the mastoid area (Fig. 18.5). tail is left in place if not displaced. If it is rotated, we make
Hemostasis is achieved with bipolar cautery always a full-thickness cut which through the helical tail , which
(monopolar cautery damages the cartilage at the slight- allows a better folding back of the cartilage; if the helical
est contact [23]). tail is enlarged, we excise part of it. The anterior surface of
the cartilage and perichondrium is then dissected free from
the skin on a sufficient surface (Fig. 18.11).
18.6.1 Authors Preferred Technique The dissected cartilage is then folded posteriorly so
that an antihelical fold is created with the superior crus
The operation is generally performed under general (Fig. 18.12).
anesthesia in patients younger than 810 years of age The shape of the new antihelix is checked, and, if
or local anesthesia in adults. Appropriate full facial appropriate, the anterior surface may be scored or be
and hair preparation is carried out, and moist cotton abraded (using for example a Brown-Adson forceps).
pledgets are inserted in the ear canals. The scoring is accomplished using a no. 15 blade,
The anterior and posterior subcutaneous surfaces are taking care to make only partial-thickness cartilage
infiltrated with 1% Xylocaine and epinephrine 1:100,000 incisions on the anterior surface of the scapha and
with a 30-gauge needle. Bilateral great auricular nerve concha.
blocks with 0.25% bupivacaine may be performed for Scoring the anterior surface of the cartilage will
postoperative analgesia. allow the upper portion to fold back. In this manner,
272 C. Isac et al.
a b
Fig. 18.6 (a) Gentle digital pressure on the upper pole of the ear determines the formation of the antihelical fold. (b) Superior crus
of the antihelical fold marked
Fig. 18.7 Anterior row of marks corresponding to the supposed Fig. 18.9 Posterior skin excision
superior crus site
Fig. 18.8 Posterior row of marks Fig. 18.10 Cartilage incision

18 Otoplasty 273
a a
b
b
Fig. 18.11 (a) Anterior cartilage dissection. (b) The anterior Fig. 18.12 (a) Partial-thickness cartilage scoring on the ante-
and posterior surface of the conchal and scaphal cartilage are rior surface. (b) Cartilage folded on itself
dissected free
(Fig. 18.14). Fluff dressings are placed in front of the

the antihelical fold is formed and simultaneously the ear, and some gauzes are also placed behind the ear.
concha is diminished. The folded cartilage, forming a A moderately compressive dressing and an elastic
tube, is sutured on itself with three 4-0 clear nylon strap are applied.
mattress sutures (Fig. 18.13).
A similar technique for creating the antihelical fold
is used by Laberge [24] (who does not suture the folded 18.6.2 Creation of the Antihelix
cartilage) and Nordzell [25] (who abrades the anterior
surface and sutures the medial edge of the incised car- The antihelical fold can be created using horizontal
tilage to the lateral one, overlapping them). Davis [15] scapho-conchal Mustard sutures [7] three to four 4-0
folds the cartilage in a similar manner but through an clear braided nylon sutures on a half-circle, round, non-
anterior approach; he scores the anterior surface with- cutting needle, including the anterior perichondrium,
out using any sutures. We believe that suturing the car- taking care not to include the anterior auricular skin (a
tilage prevents a recurrence of the deformity. If the method to avoid this complication is hydrodissection,
concha is still large, a wedge resection of the concha proposed by Brent [26] infiltration of the anterior
may be performed. auricular skin with saline solution prior to placement of
The posterior incision is sutured with 5-0 running the suture). To mark the location of the Mustard
suture after careful hemostasis. A dressing consisting sutures, many surgeons use a hypodermic needle
of strips of cotton moistened in mineral oil or alcohol charged with methylene blue drawn back from the ante-
is used for packing the various depressions of the ear rior to the posterior surface of the auricle. Pearl [27]
274 C. Isac et al.
Fig. 18.14 Dressing the postoperative ear strips of cotton

packing various depressions of the ear
Fig. 18.13 (a) The folded cartilage is sutured on itself with 4-0
clear, nonabsorbable mattress sutures. (b) Final view of the car-
tilage folded, sutured, and scored
proposed another method of marking the placement of

Mustard sutures: he uses 5-0 black nylon sutures
placed in full thickness through the cartilage so that
they are easily visible on the posterior surface at the
desired location of the antihelical fold.
The most upper suture is placed between upper
scapha and fossa triangularis to create the superior
crus. The suture is not tightened, but is put on a hemo-
stat (Fig. 18.15).
The next horizontal mattress suture is placed Fig. 18.15 Mustard scapho-conchal sutures
between scapha and lateral concha. All of the 3-4
sutures are left long and then lightly tightened to see if
the desired shape of the antihelical fold is achieved. In addition to placement of the Mustard sutures, it
The lowermost Mustard suture is often placed from is frequently necessary to score the anterior surface of
the cauda helicis to the concha [23]. The bowstringing the cartilage in order to increase its pliability. The scor-
resulting from tying the knots will be subsequently ing can be done by various methods with the blade,
filled with fibrous tissue [28]. with an Adson-Brown forceps, with an otobrader. The
18 Otoplasty 275
a b
Mastoid
fascia
Conchal
cartilage
Origin of
sternocleidomastoid
muscle
Fig. 18.16 (a) Furnas sutures (concha-mastoid sutures) (From Furnas [23]). (b) Sutures Mustard and Furnas in place
scoring should be done deep enough to determine carti- The conchal hypertrophy can be treated using one
lage folding away from the cuts but, in the same time, of the following procedures:
not as a full-thickness penetration which results in a 1. Placing the antihelical fold more medially on the
sharp, undesirable antihelical edge which would be a concha (either by cartilage folding or by sutures)
telltale sign of the operation. Stenstroem introduced the will reduce the height of the concha.
technique using the otobrader that nowadays has his 2. Concha-mastoid sutures (Furnas sutures) [11] placed
name [10]. The scoring is performed by inserting the medial to Mustard sutures; the technique is adwe-
instrument via a small tunnel which begins from a quate for conchal depth less than 2.5 cm and should
slot found on the edge of the cartilage next to the tail be tried before conchal resection techniques. The
of the helix. The device reaches the anterior surface of posterior surface of the concha is adequately exposed
the cartilage, and the scoring is performed on this sur- through a posterior skin incision over the concha.
face exactly at the level where the antihelical fold is The anterior and posterior skin flaps are elevated.
desired to be formed. Gibson and Davis [15] demon- The posterior auricular muscle and ligament are
strated that the cartilage warps away from the surface excised, and the mastoid fascia is exposed over
being scored. 2 cm. The concha setback is achieved through four
For upper pole overprojection, the helical root can 4-0 clear nylon mattress sutures placed in an ante-
be attached to the temporalis fascia through a longitudi- rior-to-posterior direction in order to avoid external
nal 5-mm incision at the base of the helix. A horizontal auditory canal stenosis. The bites should hold the
mattress suture is used to decrease the helical-temporal fascia strong enough and should contain the carti-
angle and decrease the upper pole projection. Webster lage together with anterior and posterior perichon-
indicates a slight overcorrection of the upper pole to drium. Care should be taken to avoid taking in the
allow for postoperative changes. bites on the anterior auricular skin. Tension is
adjusted to hold the conchal bowl back. Tying of the
sutures will bring the concha closer to the mastoid,
18.6.3 Conchal Correction reducing the overall projection of the ear
(Fig. 18.16).
The conchal deformity should be addressed first, so as Spira and Stal use a laterally based conchal car-
to minimize the need for excessive Mustard sutures tilage flap sutured to the mastoid periosteum which
tightening [17]. brings the concha closer to the scalp. The flap offers
276 C. Isac et al.
a robust anchorage to the periosteum with a cartilaginous parts are approximated; the concha
decreased tendency to obstruct the external audi- may be excised with skin through an anterior
tory canal [12]. approach, as, in some authors opinion, the excess
In case of a too deep a concha, using only Furnas skin left after cartilage excision may not shrink
sutures could make the tragus too proeminent. In down enough. There has been no proven advantage
this case conchal excision is also indicated. of an anterior versus a posterior approach [14]. If
3. Wedge excision of the concha (technique appro- the antitragus is prominent, the resection comprises
priate for conchal depth more than 2.5 cm); the the lower conchal bowel and the ponticulus may
excessive conchal cartilage is excised as an ellipse also be thinned [14]. Bauer underlined the impor-
through a posterior approach, and the remaining tance of conchal resection in the prominent ear
Fig. 18.17 (a) Elliptical conchal excision. (b) Concha excised. (c) Anterior aspect of the ear immediately after conchal excision
18 Otoplasty 277
Fig. 18.18 Fishtail excision of the skin on the posterior side of

lobule
18.6.4 Correction of the Protruding Lobule
correction where more cartilage than skin is excised Some consider lobule protrusion to be due to an excess
[29]. The author states that hypertrophy of the con- of skin; others consider the cause as being a prominent
cha is a common denominator of prominent ears, tail of the helix. A prominent lobule is a frequent fea-
and it is most frequently underappreciated and ture encountered with prominent ears. Placement of
under-addressed. With even limited resection and Mustard sutures often exacerbates this finding.
resuturing of the cut concha, the antihelix yields to There are several techniques for setback of the pro-
the posterior placement of sutures. The scar on the truding lobule that usually utilize a combination of skin
anterior surface is hardly visible if done correctly, resection and plicating sutures [16]. A wedge of carti-
just inside the antihelical rim. The shape of the lage may be excised in the inferior part of the concha,
cartilage resected is crescent, and the edges are which will allow both the lobule and the antitragus to
approximated with 5-0 clear nylon sutures. Conchal rotate toward the mastoid. If the lobule is still promi-
resection is a very versatile method and provides a nent, a plicating suture is applied between the helical tail
proven, reproducible, and effective way for correct- and the concha cavum (ponticulus). Having the helical
ing virtually all prominent ears [29, 30]. Even a tail moved in several positions allows the surgeon to
limited amount of conchal resection results in less- observe the effect it has on the lobule. The appropriate
ened spring and increased ease of shaping the anti- position can be found and the helical tail anchored to the
helix (Fig. 18.17) [31]. concha. A vertical excision (ellipse or fishtail/dumbbell)
4. Scoring the anterior surface of the concha to deter- of the skin on the posterior side of the lobule positioned
mine it to warp posteriorly (according to Gibsons with its maximal width at the point of maximal lobule
principle). Scoring of the entire anterior surface of prominence (Fig. 18.18) will complete the procedure.
the concha reduces the tension on the subsequently A procedure described by Gosain [18] is to make an
placed mattress sutures [32]. incision on the posterior part of the lobule, extending
278 C. Isac et al.
The patient is asked to wear a light elastic headband

for at least 3 weeks; the patient is also told not to par-
ticipate in contact sports for 1 month.
18.8 Results
A few of the patients treated with various methods are

shown in the Figs. 18.2018.25.
18.9 Complications
18.9.1 Early Complications
Hematoma is secondary to incomplete hemostasis dur-

ing surgery. If encountered, sutures should be removed
and the blood collection drained as soon as possible to
prevent subsequent infection or even skin necrosis.
Infection occurs in case of improper sterile surgical
technique, as a consequence of a late hematoma, or
in case of dehiscence secondary to excessive tension
during closure [14]. Infections are rare, as blood sup-
ply to the ear is rich; however, when they are encoun-
tered especially when periosteum is disrupted during
Fig. 18.19 Immediate postoperative appearance
abrasion, they should be promptly treated with intrave-
nous antibiotics. Chondritis, a consequence of infec-
perpendicularly from the postauricular one. A suture tion, is a surgical emergency and can lead to serious
is passed from the endpoint of the incision to the deformities of the ear if left untreated with immediate
mastoid fascia and mastoid skin. Tightening the knot debridement of devitalized tissues.
will set back the lobule. Spira [28] uses a wedge exci- Skin loss (necrosis) appears as a consequence of an
sion followed by a deep dermis-to-scalp periosteum untreated hematoma or of dressings applied exceed-
suture. ingly tight, obstructing the venous circulation. How-
ever, the skin of the ear can be widely undermined
due to the rich blood supply, especially the subdermal
18.7 Postoperative circulation.
Most of the patients develop significant ecchymosis

after this procedure (Fig. 18.19). 18.9.2 Late Complications
Patients are asked to take an oral antibiotic (usually
a first-generation cephalosporin) for 5 days. Dressing Abnormal scar formation, either hypertrophic or
gauzes may be impregnated with heparin gel 1000 IU keloid, is controlled with serial intralesional steroid
on the anterior surface [32] (reduces the risk of postop- injections.
erative hematoma) and Betadine cream on the poste- Recurrence of the deformity is caused by failure of
rior surface of the ear. The patient is usually discharged the suture (either break or fatigue the knot loosens
on the day of surgery and is seen after 24 h to check for and unties), insufficient breaking of the cartilage
hematomas or excessively tight dressing. Sutures are sprung by scoring, or insufficient number of sutures. It
removed at 10 days postoperative. Hair may be washed requires reoperation with replacement of the sutures to
after 67 days. correct it not earlier than 6 months.
18 Otoplasty 279
Fig. 18.20 (a) Preoperative eleven-year-old boy with a lack of protruding lobule, a plicating suture together with excision of the
antihelical fold definition, conchal bowl hypertrophy, and promi- helical tail and dumbbell skin excision was applied (photos: b1, b2)
nent lobules. (photos: a1, a2) (b) One month postoperative after (c) Pre- and post-operative lateral view with antehelix reconstruction
cartilage folding was used for the antihelix and concha. For the (photos: a3, b3)
280 C. Isac et al.
Residual deformity may consist in any one of the Narrowing of the external auditory canal [34] occurs
following aspects: irregular contour of the antihelix when the concha is set back too far posteriorly due to
with sharply ridged appearance (corrected by curet- incorrect placement of concha-mastoid sutures.
tage, camouflage with temporalis fascia, or an anteri- Complications with Mustard sutures: kinking within
orly based conchal cartilage flap swiss-rolled into the the antihelix, sutures cutting out, suture extrusion, sinus
posterior surface of the released antihelical fold, as formation [14], and projection of the lobule. Suture
described by Widgerow [33]), lack of the normal curve extrusion may be prevented by a postauricular fascial
of the superior crus, residual large scapha or concha, flap as described by Horlock [35].
narrow external auditory canal. Obliterated postauricular sulcus due to excessive
Telephone ear deformity is caused by excessive skin resection can be corrected with a zigzag incision,
setback of the middle third of the helical rim and approximation of the skin triangles points, and filling
aggressive resection of the concha combined with the remaining points with skin grafts [14].
undercorrection of the antihelical rim in the upper-
most pole of the helix and incomplete correction of
the lobule position. Correction requires reoperation 18.10 Conclusions
and appropriate antihelical fold and lobule
positioning. Prominent ears are relatively frequent with high aes-
Postsurgical appearance consists of a too verti- thetic and psychological impact on the patient.
cally oriented antihelical fold instead of a gentle ante- One of the most important steps in otoplasty is
rior curve due to incorrect placement of Mustard the correct analysis of each ear deformity. Generally,
sutures [34]. Irregularities of helical contour exces- techniques that employ cartilage scoring or abrasion
sively set back (overcorrection) may also lead to a should be used cautiously and only superficial, as they
postsurgical appearance. all run the risk of cartilage weakening and visible
Reverse telephone ear deformity occurs when the irregularities. Another important caveat is to preserve
upper and lower thirds of the ear are set back correctly, the perichondrium on both the anterior and posterior
but the antihelix and especially the concha protrude. surfaces, as it lessens the risk of sutures pulling
The cause is failure to recognize and address the through the cartilage and a subsequent recurrence of
enlarged concha during the procedure. the deformity.
18 Otoplasty 281
Fig. 18.21 (a) Preoperative 13-year-old boy with a lack of anti- nique (photos: b1, b2) (c) Pre- and post-operative lateral view
helical fold and large, deep concha. (photos: a1, a2) (b) Six with antehelix reconstruction (photos: a3, b3)
months postoperative after the antihelix was created and the con-
cha reduced with cartilage folding, scoring, and suturing tech-
282 C. Isac et al.
Fig. 18.22 (a) Preoperative 6-year-old boy with unilateral pro- the concha reduced with cartilage folding, scoring, and suturing
eminent ear and lack of antehelical fold and deep concha. technique (c) Pre- and post-operative lateral view
(b) Two weeks postoperative after the antihelix was created and
18 Otoplasty 283

284 C. Isac et al.
Fig. 18.23 (a) Preoperative 28-year-old girl with unilateral proeminent ear and lack of antehelical fold. (b) One month postoperative
after the antihelix was created using Mustard and Furnas sutures. (c) Pre- and post-operative lateral view
18 Otoplasty 285
Fig. 18.24 (a) Preoperative 28-year-old man with prominent ears. (b) One month following Mustard and Furnas sutures and
conchal excision
286 C. Isac et al.
Fig. 18.25 (a) Pa. Preoperative six-year-old boy with proeminent ears and lack of antehelical fold and deep concha. (b) Two
weeks post-operative after the antihelix was created and the concha reduced with cartilage folding, scoring, and suturing technique
18 Otoplasty 287
With the technique presented, the authors have seen 3. Ely ET (1881) An operation for prominence of the auricles.
Arch Otolaryngol 10:9799
no changes in the position of the ear in the long-term
4. Luckett WH (1910) A new operation for prominent ears
follow-up. The procedure allows the creation of the anti- based on the anatomy of the deformity. Surg Gynecol Obst
helix and simultaneously reduction of the concha with 10:635637
immediate evaluation: The method has a short learning 5. Becker OJ (1952) Correction of the protruding deformed
ear. Br J Plast Surg 5(3):187196
curve, is quick and safe, offering good long-lasting
6. Converse JM, Nigro A, Wilson FA, Johnson N (1955)
results and a low recurrence rate. Various techniques Technique for surgical correction of lop ears. Plast Reconstr
described in the literature are also presented. Most often, Surg 15(5):411418
a combination of all these needs to be used. 7. Mustard JC (1963) The correction of prominent ears using
simple mattress sutures. Br J Plast Surg 16:170178
Patients are generally happy and satisfied if the ears
8. Gibson T, Davis WB (1958) The distortion of autogenous
are symmetrically set back to within 11.5 cm of the cartilage grafts: its cause and prevention. Br J Plast Surg
scalp [28]. The operation can be very successful but 10:257274
can also be a source of distress if not carried out with 9. Chongchet V (1963) A method of antihelix reconstruction.
Br J Plast Surg 16:268272
close attention to all details. Accurate preoperative
10. Stenstroem SJ (1963) A natural technique for correction
diagnosis and planning and careful execution of the of congenitally prominent ears. Plast Reconstr Surg 32:
technique are critical to obtaining a good, long-lasting, 509518
satisfying result. 11. Furnas DW (1968) Correction of prominent ears by conchal
mastoid sutures. Plast Reconstr Surg 42(3):189193
12. Spira M, Stal S (1983) The conchal flap: an adjunct in oto-
plasty. Ann Plast Surg 11(4):291298
References 13. Erol O (2001) New modification in otoplasty: anterior
approach. Plast Reconstr Surg 107(1):193202
1. Yugueros P (2001) Otoplasty: the experience of 100 14. Janis J, Rohrich R, Gutowski KA (2005) Otoplasty. Plast
consecutive patients. Plast Reconstr Surg 108(4):10451051 Reconstr Surg 115(4):60e172e
2. Dieffenbach JE (1845) Die operative chirurgie. F.A. 15. Davis J (1987) Aesthetic and reconstructive otoplasty. New
Brockhaus, Liepzig York, Springer
288 C. Isac et al.
16. Preuss S, Eriksson E (2000) Prominent ears. In: Achauer B 27. Pearl C, Wallace R (2009) New technique for marking the
(ed) Plastic surgery: indications, operations and outcomes. location of Mustard horizontal mattress sutures. Plast
Mosby, St. Louis, pp 10571065 Reconstr Surg 123(5):14681470
17. Janz B, Cole P (2009) Treatment of prominent and constricted 28. Spira M (1999) Otoplasty: what I do now a 30-year
ear anomalies. Plast Reconstr Surg 124(1 suppl):27e37e perspective. Plast Reconstr Surg 104(3):834840
18. Gosain A (2003) A novel approach to correction of the 29. Bauer B, Margulis A, Song DH (2005) The importance of
prominent lobule during otoplasty. Plast Reconstr Surg conchal resection in correcting the prominent ear. Aesthet
112(2):575583 Surg J 25(1):7279
19. Gosain A, Kumar A, Huang G (2004) Prominent ears in children 30. Bauer B (2002) Combined otoplasty technique: chondro-
younger than 4 years of age: what is the appropriate timing for cutaneous conchal resection as the cornerstone to correc-
otoplasty? Plast Reconstr Surg 114(5):10421054 tion of the prominent ear. Plast Reconstr Surg 110(4):
20. Tolhurst DE (1972): The correction of prominent ears, Br J 10331040
Plast Surg 25:261265 31. Bauer B (2005) Evolution and refinements in otoplasty
21. Colpaert Steven, Missotten Frans (2005): Otoplasty for techniques. In: Nahai F (ed) The art of aesthetic surgery:
prominent ears:personal technique and review of 150 con- principles and techniques. Quality Medical Publishing,
secutive cases, Eur J Plast Surg 28:179185 St. Louis, pp 14641495
22. Fatih Peker, Celikoz B (2002): Otoplasty: anterior scoring 32. Perez-Macias JM (2008) Management of prominent ears:
and posterior rolling technique in adults, Aesth Plast Surg personal approach. Aesthetic Plast Surg 32(2):196199
26:267:273 33. Widgerow A (2002) Revision otoplasty: the contracted anti-
23. Furnas D (2002) Otoplasty for prominent ears. Clin Plast helical fold. Plast Reconstr Surg 110(3):827830
Surg 29(2):273288 34. Hoehn J (2005) Otoplasty: sequencing the operation for
24. Caouette-Laberge L, Guay N, Bortoluzzi P, Belleville C improved results. Plast Reconstr Surg 115(1):5e16e
(2000) Otoplasty- anterior scoring technique and results in 35. Horlock N (2001) The postauricular fascial flap as an adjunct
500 cases. Plast Reconstr Surg 105(2):504515 to Mustard and Furnas type otoplasty. Plast Reconstr Surg
25. Nordzell B (2000) Open otoplasty. Plast Reconstr Surg 108(6):14871490
106(7):14661472
26. Brent B (2008) Hydrodissection as key to a natural-appearing
otoplasty. Plast Reconstr Surg 122(4):10551058
Brow Lift
19
Shoib Allan Myint
19.1 Introduction
In the past 20 years, brow lifting has taken an evolu-

tionary course from the original coronal procedure to
the newly endoscopic approach. There have been many
debates as to which type is the best procedure. One
thing for certain is there is no foolproof method for
brow lifting. Each surgeon must determine what pro-
cedure works in their hands with predictable and con-
sistent results depending on the patient and their
expectations. The positioning of the eyebrow is crucial
for maintaining periorbital symmetry that is aestheti-
cally pleasing to the human eye. There have been for-
mulas described for positioning the ideal brow based
on bony and soft tissue anatomy. This position varies
from patient to patient depending on their unique facial
feature. The positioning is affected by many factors
such as brow elevator and depressor muscles, genetics,
gravity, skin laxity, surgery, trauma, and the patients
expressivity. All or some of these factors result in brow
ptosis. Although each eyebrow has its own shape, posi-
tion, and contour, in general, the female eyebrow Fig. 19.1 Female eyebrow position
should lie approximately at or above the superior orbital
rim with the tail higher than the head (Fig. 19.1).
The male eyebrow should be at the level of the supe- 19.2 Anatomy
rior orbital rim with a less curved configuration
(Fig. 19.2). This chapter will discuss the three most When planning brow surgery, the imbalance between
common brow lifting techniques: endoscopic, direct, the elevators (frontalis muscle) and the depressors
and trichophytic. (orbicularis oculi, depressor supercilii, corrugators,
procerus) must be addressed (Fig. 19.3). The frontalis
muscle originates at the skin and superficial fascia of
S.A. Myint the orbicularis muscle. It inserts into the galea aponeu-
Department of Ophthalmic Plastic and Reconstructive Surgery,
rotica. The main function of the frontalis muscle is to
Valley Hospital, University Medical Center,
Las Vegas, NV, USA elevate the eyebrows, and it is responsible for the trans-
e-mail: [email protected] verse rhytids in the forehead. The corrugator muscle

290 S.A. Myint
Fig. 19.2 Male eyebrow position Fig. 19.4 (a) Preoperative. (b) Following endoscopic brow lift
medial lower forehead. Like the depressor supercilii,

the procerus depresses the head of the brow. It is
responsible for the horizontal rhytids at the radix of
the nose. These muscles are critical in understanding
eyebrow anatomy and its function. If the depressor
muscles are not addressed in an appropriate fashion,
results may be suboptimal in procedures such as the
endoscopic approach. Botox can also be administered
to these depressor muscles 2 weeks prior to surgery.
19.3 Endoscopic Brow Lift

Fig. 19.3 (1) Frontalis. (2) Orbicularis. (3) Depressor super-
cilii. (4) Procerus. (5) Corrugator The goal of endoscopic brow surgery is to elevate the
eyebrow, decrease forehead rhytids, decrease vertical
originates at the medial orbital rim and inserts into the glabellar rhytids, improve lateral canthal hooding, and
frontalis muscle and the skin of the eyebrow. It primar- decrease infrabrow skin (Fig. 19.4). Every surgeon will
ily elevates the head of the brow, with descent of the need to accomplish some or all of these goals depend-
tail. It is responsible for the glabellar frown lines. The ing on the patient. Give the patient a mirror and discuss
orbicularis oculi muscles originate at the medial orbital realistic expectations. Remember that skin hanging
rim and the medial canthal tendon and inserts at the over the eyelid margin in the lateral periorbital area
medial aspect of the bony orbit. It depresses the total (Connells sign) is a hallmark of forehead ptosis and
brow and is responsible for vertical rhytids. The will need a brow lift, not blepharoplasty. Also take into
depressor supercilii muscle also originates at the account the fact that women tend to pluck and shape
medial orbital rim and medial canthal tendon and it their brow area to give the illusion that it is higher.
inserts on the medial aspect of the bony orbit. It is Do not let this fool you. Two useful preoperative quan-
responsible for depressing the head of the brow. The titative measurements are the glide test and the frame
procerus muscle originates at the nasal bone fascia height. The glide test measures brow excursion in
and upper cartilages. It inserts onto the skin at the the medial, central, and lateral portions of the eyebrow.
19 Brow Lift 291
Fig. 19.5 Planes Deep subgaleal release

of dissection Subperiosteal release
Deep galeal fat
Arcus marginalis
Orbital fat
Orbital septum
Fig. 19.6 Temporal crescent

and extent of dissection
Central
Pocket
Temporal
Line
Temporal
Pocket
Temporal
Port
Extent of
Dissection
The frame height measures the distance from mid pupil 19.3.1 Marking
to the top of the brow. The best results of an endo-
scopic brow lift typically occur with frame heights of Marking is critical when planning for this surgery.
1.52.0 cm and glide test of 2.03.0 cm. Most surgeons There is a temporal crescent (temporal line, conjoint
will lift the eyebrow approximately 1.02.0 cm. There tendon), which separates the temporal pocket from the
are two planes of dissection, subperiosteal and subgal- frontal pocket (Fig. 19.6). This crescent is the fusion
eal (Fig. 19.5). The subperiosteal approach results in of the galea aponeurotica. It can be palpated along
less blood loss, doesnt move the hair line down, and is the lateral portion of the superior orbital rim and it
the preferred choice for most surgeons. extends superolaterally. It is more pronounced when
292 S.A. Myint
temporal (Fig. 19.7). The amount and placement of

these incisions will depend on the surgeons learning
curve in using the endoscope. For a beginning sur-
geon, the two paracentral, two lateral, and two tempo-
ral incisions might be an easier approach. The central
incisions are marked at or 1 cm behind the hairline
extending 1.01.5 cm in length. The paramedian
incisions are marked approximately 4 cm lateral to
prevent injury to the superficial branches of the
supraorbital nerve, which supply sensation in that
region. This incision is parallel to the tail of the brow
in women (typically at the lateral limbus). It can be
moved slightly medially in men to prevent a high arch.
The temporal markings are done 2.5 cm posterior to
Fig. 19.7 Incision: two paramedian, two lateral, and two the hairline extending 23 cm in length. The midline
temporal
of this incision is perpendicular to a line drawn from
the nasal ala to the lateral canthal angle. In the pres-
ence of male pattern baldness, these incisions can be
made behind the fringe line. The trajectory course of
the temporal branch of the facial nerve is outlined to
avoid contact (Fig.19.8). This nerve courses from the
lower portion of the tragus to 1.5 cm above the tempo-
ral brow. It originates deep near the parotid gland and
crosses over the periosteum of the zygoma. The nerve
then becomes more superficial and runs on the deep
surface of the temporal parietal fascia before entering
the undersurface of the frontalis muscle (Fig. 19.9).
2.0 2.0 2.0 The supraorbital nerve is marked approximately
2.4 cm from midline and the supratrochlear nerves
about 1.6 cm from midline (Fig. 19.10). An arch
extending 23 cm above the orbital rim is marked to
prevent injury to the superficial branches of the
supraorbital nerve. The supraorbital nerve can emerge
1 cm above the orbital rim in 40% of patients. This is
the safety zone for blunt dissection.
19.3.2 Anesthesia
Fig. 19.8 Facial nerve
Local infiltration of a mixture of 2% lidocaine
with 1:100,000 epinephrine and 0.5% Marcaine with
the patient clenches the jaw. This temporal line must 1:200,000 epinephrine is used for the forehead
be released to connect the frontal and temporal pock- and temporal areas. Generally, monitored intrave-
ets. The temporal branch of the facial nerve runs along nous (IV) sedation is given. Local blocks can also be
the temporal pocket which makes this the most critical performed in the region of the supraorbital, supra-
area of dissection. The incision areas are marked as trochlear, lacrimal branch of the trigeminal nerve,
follows: either one central, two paramedian, and two zygomaticotemporal and zygomaticofacial nerve
temporal, or two paracentral, two lateral, and two branches if desired. The arcus marginalis along the
19 Brow Lift 293
Fig. 19.9 Facial nerve (fn). Temporal branch (tb). Superficial temporal fat pad (stfp). Deep temporal fascia (dtf). Superficial tem-
poral fascia (stf). Superficial temporal artery (sta). Zygomatic arch (za)
superior orbital rim across the entire eyebrow is also

infiltrated.
19.3.3 Incisions
The central and paramedian incisions are made down to

the periosteum. The temporal incisions are made down
to the superficial layer of the deep temporal fascia. This
is a shiny white layer, which does not move. The tem-
poral branch of the facial nerve runs superficial to this
layer under the superficial temporal fascia. It is very
important to stay along the superficial layer of the deep
Fig. 19.10 Supraorbital and supratrochlear nerves bundles temporalis fascia to avoid damage to this nerve.
294 S.A. Myint
19.3.4 Dissection
The temporal and frontal pockets are then connected

through the temporal crescent by detaching the crescent,
which is the fusion of the galea aponeurotica (Fig. 19.11).
Blunt dissection in the frontal pocket is continued to
2 cm above the supraorbital rim (Fig. 19.12). Endoscopic
dissection can then be continued towards the arcus mar-
ginalis from lateral canthus to lateral canthus. The
periosteum should be completely released here for ade-
quate elevation. The success of this procedure is depends
on complete release of the periosteum at the arcus mar-
ginalis along the entire brow. If needed, the corrugators,
depressor supercilii, and orbicularis muscles can be
addressed to prevent regeneration and possible descent
of the brow postoperatively. These myotomies are done
with caution not to injure the supratrochlear vessels.
Some surgeons will myotomize the orbicularis muscle
lateral to the supraorbital nerve. When dissecting
endoscopically through the temporal incision, the zygo-
maticotemporal vein (sentinel vein) will be seen about
Fig. 19.11 Frontal and temporal pockets
2.5 cm above zygomaticotemporal arch (Fig. 19.13).
This is a landmark for the temporal branch of the facial
nerve, which lies superior to it.
19.3.5 Fixation
After the release is completed, fixation becomes

the choice of the surgeon. There have been many
fixation methods from K wire, external screws, bone
tunnels, and LactoSorb screws. I prefer using Endotine
from Coapt (Fig. 19.14). It is consistent and predict-
able. A 4-mm drill bit is used to drill a hole at the
anterior edge of the paramedian or lateral incisions
on both sides. The Endotine is placed and the brow
lifted with the patient sitting up to a desired height and
secured. The vectors will depend on the individual
patient. The Endotine will dissolve in approximately
68 months.
19.3.6 Closure
Surgical staples are used to close the incisions. In the

temporal region, a 4-0 PDS suture can be used to
reapproximate the superficial temporal fascia to the
deep fascia to pull the crows feet and elevate the tail
laterally if needed. Fig. 19.12 Blunt dissection
19 Brow Lift 295
19.3.7 Postoperative Care
A Kerlex pressure dressing (The Kendall Company,

Mansfield, MA) is placed around the forehead for 48 h.
Oral antibiotics can be given along with a Medrol dose
pack (Pharmacia and Upjohn, Kalamazoo MI). Patient
is seen 1 day postoperatively. Scalp numbness can per-
sist for 3 months, and hair shock can result in some
alopecia, which will grow back.
19.3.8 Complications
The most serious complication is injury to the temporal

Fig. 19.13 Sentinel vein branch of the facial nerve. Hematomas and infec-
tions are rare with meticulous dissection and hemosta-
sis. A surgical drain can be placed if there is any
doubt of postoperative hemorrhage. The drain is typi-
a
cally removed in 12 days. Postoperative neuropraxia
is usually temporary if it occurs.
19.4 Direct Brow Lift
The direct brow lift is a simple procedure mostly

reserved for those patients not too concerned with
visible scarring. The closer a surgery is performed to
the eyebrow, the more effective it is. The incision can
be placed at the brow hair or an existing forehead
b crease. This chapter will discuss the ciliary incision.
Vertical brow
Canthal
19.4.1 Preoperative Evaluation
Malar
The evaluation is preferred with the patient sitting
upright with relaxed frontalis muscle action. A 1:1
ratio is used in determining the amount of skin to be
excised and the amount to be lifted. The eyebrow is
elevated to the appropriate position and marked in
relationship to a reference point, typically the corneal
light reflex. The lateral central and medial points are
marked. An elliptical skin incision is marked with the
inferior marking at the cilia and the superior at the
desired height (Fig. 19.15). This extends from the head
of the brow to the tail, being careful not to extend too
Fig. 19.14 (a) Endotine. (b) Vectors of pulling far laterally to minimize a visible scar. If there is exces-
sive lateral hooding of the eyebrow, either a temporal
lift or endoscopic lift should be entertained. The
supraorbital notch is marked to avoid injury.
296 S.A. Myint
a 6-0 nonabsorbable suture in a vertical or horizontal

mattress fashion to allow some degree of skin ever-
sion. This will flatten as scarification takes effect.
Ophthalmic antibiotic ointment and oral antibiotic

of choice is given postoperatively. Bandaging is not
Fig. 19.15 Direct brow markings
necessary. Ice packs 15 min every hour while awake is
recommended for the first 2448 h. Sutures are typi-
cally removed in 1014 days. Patient is to avoid any
sun exposure to that area during the healing process.
19.4.5 Complications
Most commonly, hematomas can occur if intraopera-

tive hemostasis is not achieved properly. This can be
avoided with meticulous surgical technique. Damage
to the temporal branch of the facial nerve is usually
not encountered here. Although infections are rare,
they can be avoided with oral antibiotics. Brow hair
Fig. 19.16 Beveled incision 45 loss can occur if the incision is not beveled or placed
incorrectly.
19.4.2 Anesthesia
Local infiltration of 2% Lidocaine with 1:100,000 epi- 19.5 Trichophytic Brow Lift
nephrine mixed with 0.5% Marcaine with 1:200,000
epinephrine is the anesthesia of choice infiltrated along For patients who have a high hairline or a long fore-
the entire eyebrow length. IV sedation can also be con- head, a trichophytic or subcutaneous brow lift is an
sidered if needed. excellent approach. This will bring the hairline down
and lift the brow, making it more aesthetically appeal-
ing for the patient (Fig. 19.17). Because of the plane of
19.4.3 Procedure dissection, the forehead creases will be less visible
with this procedure.
The incision is made with an extreme bevel of 45
parallel to the follicles to prevent any hair loss
(Fig. 19.16). The incision on the superior marking 19.5.1 Anesthesia
follows with the blade angled in the same direction
to provide adequate apposition and eversion of the Local infiltration with a mixture of lidocaine and
wound edges. Care should be taken at all times to Marcaine with epinephrine or tumescent infiltration
stay superficial near the supraorbital neurovascular can be used below the dermis and above the frontalis
bundle. Only skin and subcutaneous tissue are excised. muscle. This procedure can be either done with straight
Meticulous hemostasis is highly recommended to pre- local or localized monitored anesthesia.
vent postoperative hematoma.
Wound closure is accomplished with buried subcu-
taneous 5-0 Vicryl suture. Each suture must be per- 19.5.2 Marking and Incision
fectly aligned in the plane horizontal to the wound
edges. This layer must be done with great precision to Again, the incision in this type of brow lift is critical to
avoid a significant scar. The skin closure is done with prevent hair loss and significant unacceptable scarring.
19 Brow Lift 297
a the neurovascular bundles of the supratrochlear and

supraorbital nerves are visualized. The undersurface
of the flap should have subcutaneous fat. Dissection
of the neurovascular bundle in a vertical fashion
will release adhesions and allow access to the eyelid.
The procerus and corrugator muscles can be addressed
here with gentle release.
19.5.4 Closure
Cutbacks are usually made approximately 20 mm

b depending on the patient. Removing the excess skin is
done in a bevel fashion following the geometric inci-
sion to prevent a step off. Retention sutures with 4-0
gut or surgical staples are placed at the cutbacks cen-
tral, medial, and lateral. Subcutaneous closure and skin
closure are done with 5-0 gut suture. The scar is impec-
cable if the geometric incision is done meticulously.
Typically no bandage is required. Antibiotic ointment

Fig. 19.17 (a) Preoperative. (b) Following trichophytic
brow lift
to the wound, oral antibiotics, and a Medrol dose pack
is given for 1 week. If desired, a Kerlex dressing may
be placed for 24 h. Patient is seen the next day, then in
One should never make a horizontal pretrichial inci- 1 week. Ice is given for 2448 h. No drain is required.
sion as it will routinely cause an unacceptable scar.
The markings should be positioned approximately
5 mm posterior to the hairline in an irregular and ran- 19.5.6 Complications
dom fashion. This is the area where the follicular den-
sity changes. The eyebrow should mostly elevate at its Hair loss and scarring are the two most common prob-
peak at the lateral two thirds (lateral limbus) in women. lems seen with the trichophytic lift. Therefore, it is
In younger patients, this is the lateral extent of the inci- very important to pay attention to details. As in the
sion. In patients with lateral hooding, this incision can other brow procedures, hematoma and infection can
extend out to the lateral tail of the brow. It is very also be encountered. One must be prepared to handle
important that the incision is extremely beveled at these issues if they arise. They can be prevented with
1020 with an 11 blade. This extreme bevel is for the good hemostasis and postoperative care.
hair shaft to regrow through the skin flap. When cau-
terizing, it is important to be very careful not to destroy
the hair follicles.
Suggested Reading
Holcomb JD, McCollugh EG (2001) Trichophytic incisional
19.5.3 Procedure approaches to upper facial rejuvenation. Arch Facial Plast
Surg 3(1):4853
Pretunneling can sometimes make the dissection easier. Isse NG (1997) Endoscopic facial rejuvenation. Clin Plast Surg
Facelift scissors can also be used in the subcutaneous 24(2):213231
Nesi FA, Gladstone GJ, Myint S, Brazzo BG, Black EH
plane (below dermis and above frontalis muscle). This
(2001) Ophthalmic and facial plastic surgery: a compen-
dissection is carried down to just above the supraor- dium of reconstructive and aesthetic techniques. Slack Inc.,
bital rim. With lighted retractors and good exposure, Thorofare
Mid-Forehead Buttonhole
Eyebrow Elevation 20
Harry Mittelman, Gregory J. Vipond,
and Joshua D. Rosenberg
20.1 Introduction forehead furrows develop. Similarly, with repeated

contraction of the glabellar muscles, the procerus, cor-
The upper third of the face encompasses the region rugator supercilii, and depressor supercilii, the hori-
from the trichion superiorly to the nasion inferiorly zontal and diagonal glabellar furrows develop along
and from temporal line to temporal line laterally. with muscular hypertrophy. In the upper lid, derma-
Within this zone, the glabellar, brow, upper lid, and tochalasis leads to hooding of the eyelid skin while fat
forehead regions are further subdivisions. Some sur- pseudoherniation and orbicularis oculi hypertrophy
geons would also include the entire periorbital com- can lead to lid fullness.
plex. While not always receiving the same emphasis as With regard to the brow, it is classically taught that
the lower two-thirds of the face, failure to address the with advancing age, the brow descends, especially in
upper third can lead to an uneven facial rejuvenation its temporal aspect. This is due to a combination of
and an unnatural, operated look. forehead dermatochalasis, facial laxity, and hypertro-
A youthful upper facial third consists of a smooth phy of the brow depressor muscles. The accepted ideal
forehead without transverse furrows, a smooth glabel- brow configuration [1] varies with patient gender. In
lar region without the horizontal procerus and diagonal both men and women, the medial edge of the brow
corrugator supercilii furrows, and an eyebrow in its begins at the intersection of a vertical line drawn from
gender-specific ideal position without evidence of the lateral edge of the nasal ala with the medial can-
lateral hooding or crows feet. Additionally, the upper thus. It is described as club-shaped. In women, it arches
eyelid has a well-defined supratarsal crease without over the supraorbital rim with its peak at the lateral
significant dermatochalasis or fat pseudoherniation. limbus or lateral canthus. The lateral edge of the brow
With advancing age, certain characteristic changes is at the same vertical height as the medial edge and
occur. With repeated contraction of the frontalis mus- ends at the intersection of a line drawn through the lat-
cle and deformation of the forehead skin, horizontal eral aspect of the nasal ala intersecting with the lateral
canthus. The thickness of the eyebrow may vary by
H. Mittelman (*) person, but generally tapers from the thick medial edge
Mittelman Plastic Surgery, Los Altos, CA, USA
to a thin lateral edge. In men, the length of the eyebrow
Associate Clinical Professor, Department of Otolaryngology, is similar, but the shape varies. The position is rela-
Stanford University Medical Center, Palo Alto, CA, USA
tively flat and lies along the supraorbital rim. The
thickness also remains relatively constant without any
G.J. Vipond
discernable taper. However, it is important to realize
VIP Facial Artistry, Arcadia, CA, USA
e-mail: [email protected] that this configuration needs to be individualized. To
maintain a natural appearance, the patients eyebrow
J.D. Rosenberg
Mittelman Plastic Surgery, Los Altos, CA, USA position must be restored to its former youthful one,
e-mail: [email protected] not to a new position or shape.

300 H. Mittelman et al.
While it is generally accepted that the lateral por- less morbidity than the coronal lift. An older survey
tion of the brow descends due to limited support by the conducted by Elkwood et al. [6] did conclude that while
frontalis muscle and relative strengthening of the both open and endoscopic techniques were considered
orbicularis oculi with its concomitant brow depression efficacious, the younger surgeons were more likely to
action, the change of the medial brow is more contro- use the endoscopic techniques while senior surgeons
versial. Freund and Nolan showed that brow lifts were more likely to use open methods. However, with
depicted in the medical literature often elevated the more experience with the endoscopic approach, many
medial brow to a position above the supraorbital rim surgeons have returned to open techniques due to
and created a medial brow shape that was flat and not unpredictability of results both in the amount and dura-
arched like the accepted ideal [2]. Matros et al. [3] per- tion of brow elevation [7]. Additionally, it was found
formed an objective photographic study which com- that the endoscopic approach was more technically dif-
pared eyebrow position between two cohorts: a 20- to ficult, could in fact elevate the hairline, and could lead
30-year-old group and a 50- to 60-year-old group. to late-onset development of subcutaneous venous dila-
Comparing positions at the medial canthus, pupil, and tation in the temporal and forehead areas. Another
lateral canthus, they found that the eyebrow position study by Cilento and Johnson [8] found that, in the
was significantly higher at the pupil and medial can- review of 1,004 procedures, open procedures had a
thus. They concluded that given the paradoxical eleva- complication rate equal to or lower than published rates
tion of the mid and medial brow with aging, further in endoscopic brow lift series. They also found that
surgical elevation would lead to a result that is neither patient acceptance of surgical approach depended in
youthful nor aesthetically pleasing [3]. a large part by the way in which it was presented to
There are numerous means used in rejuvenation of the patient. They concluded that the selection of the
the brow area. Nonsurgical means include botulinum appropriate technique should be based on a balance
toxin A and the use of skin fillers. Ahn et al. [4] dem- between patient characteristics and desires and physi-
onstrated that botulinum toxin led to lateral brow ele- cians abilities.
vation through paralysis of the eyebrow depressors, Regarding open techniques, there are a number of
and that the amount of temporal eyebrow elevation advantages and disadvantages to each approach. Con-
achieved with proper injection is approximately equiv- siderations include gender of patient, hairline, presence
alent to the temporal eyebrow elevation achieved at 1 of forehead rhytids, need for forehead rejuvenation ver-
year after endoscopic forehead elevation. Other non- sus change in eyebrow position. It is important to note
surgical techniques include filler placement to improve that forehead rejuvenation and eyebrow elevation are
lateral hooding and skin resurfacing techniques such not synonymous, and it is possible to elevate the eye-
as fractional carbon dioxide (CO2) laser resurfacing for brow without elevating the forehead or hairline. The
skin texture and tightening [5]. The biggest disadvan- objectives of an eyebrow lift should be superior reposi-
tage to these nonsurgical techniques is their lack of tioning of the eyebrow with precise contouring; long-
permanence and need for repeat treatment. lasting, dependable, and reproducible results; minimal
While the longevity of surgical techniques may neurovascular morbidity; acceptable incisions; and
be debatable, it is generally agreed that it outlasts minimal complications. Unfortunately, there is not a
nonsurgical methods. There are a number of different consensus on one such surgical approach.
techniques including open, encompassing coronal, pre- The Mid-Forehead Buttonhole Eyebrow lift is the
trichial, trichophytic, direct, bilateral temporal, trans- authors preferred method of eyebrow elevation due to
blepharoplasty, and mid-forehead, and minimal incision a very cosmetically acceptable incision, easy access to
techniques, such as endoscopic and featherlift/barbed the brow in the subcutaneous plane, and very precise
suture methods. Open techniques are generally viewed control of eyebrow elevation, with a high margin of
as more traditional, although many consider the coro- safety and low morbidity. The incision is made in a
nal lift as the gold standard in forehead rejuvenation. forehead rhytid with or without skin excision. It does
With the advent of endoscopic technology, many not address glabellar musculature and may eliminate
were quick to embrace endoscopic brow lifts as they the need for upper blepharoplasty in a small minor-
involved minimal incisions, did not change the hairline, ity of patients. Although the senior author (H.M.)
were popular with patients, and offered potentially has been using this technique for almost 10 years, the
20 Mid-Forehead Buttonhole Eyebrow Elevation 301
longevity of the eyebrow elevation is still uncertain.

Nonetheless, the Mid-Forehead Buttonhole Eyebrow
lift remains an easily learned, effective means of
accurately restoring a youthful eyebrow position and
contour.
20.2 Technique
In general, preoperative assessment of the brow lift

patient involves assessment of the need for eyebrow
lift alone or eyebrow lift with concurrent upper bleph-
aroplasty. The hairline must also be analyzed: male
pattern baldness both current and future, hair density,
and high temporal hairline in women. The skin thick- Fig. 20.1 The Mid-Forehead Buttonhole incision is designed
ness and oil content should be examined along with within a natural forehead rhytid. Ideally, a static rhytid is chosen,
but if not present, the incision may be made within a dynamic
the laxity of the forehead skin-muscle complex. Bony
furrow
contour is also important and it is essential to evaluate
eyebrow symmetry and to demonstrate any preopera-
tive asymmetry to the patient. Preoperative photo- This measurement is performed at the apex of brow
graphs include the anterior-posterior (AP) view both contour and is tapered to form an ellipse encompass-
with neutral expression and with eyebrow elevation ing the entire region of brow to be elevated. Any con-
and lateral and oblique views, which help demon- current surgical incisions are marked, and the face is
strate lateral hooding. As with any procedure, informed then sterilely prepped and draped. Local anesthetic
patient consent is essential, with attention given to the is infiltrated in the subcutaneous plane in the area of
possibility of a visible scar and the unpredictable lon- the ellipse and skin inferior to the ellipse all the way to
gevity of result with possible return of brow ptosis. just below the superior orbital rim. While the senior
The incision is designed within a natural forehead author (H.M.) generally performs these procedures
rhytid (Fig. 20.1). It is centered over the lateral two- under general anesthesia, the junior author (G.V.) pri-
thirds of the brow, and a rhytid close to the brow is marily performs them under local anesthetic with oral
ideally chosen. If both the medial and the lateral brow sedation.
are to be addressed, separate incisions should be The skin incision is made with a scalpel, and under-
planned. On occasion, the junior author (G.V.) tries to mining of the ellipse is performed in a plane just super-
use a different level of rhytid on each side so as to ficial to the frontalis muscle (Fig. 20.2). The skin and
avoid symmetrical incisions and better camouflage the subcutaneous tissue are removed, exposing the fascia
scar. If a well-defined skin rhytid is not present at rest, of the frontalis. Undermining is performed in the
the patient is asked to elevate his or her eyebrows and subcutaneous plane inferiorly, medially, and laterally
the incision is drawn along a dynamic rhytid. A pro- until the orbicularis oculi muscle is in view (Fig. 20.3).
posed skin ellipse is then drawn centered about the The inferior extent is the muscle overlying the superior
incision line. The senior author (H.M.) prefers to esti- orbital rim. Meticulous hemostasis is ensured through-
mate the vertical dimensions of the ellipse. However, out the procedure using bipolar cautery to minimize
the junior author (G.V.) has changed his technique to thermal damage to the tissues and neurovascular struc-
include a measurement of the skin ellipse. The incision tures. The orbicularis is then palpated to ensure mobil-
is drawn along the rhytid, and then the eyebrow is ele- ity to the desired eyebrow position (Fig. 20.4).
vated to its ideal position. Using a ruler, the amount of Once the ideal position is determined, the muscle is
elevation needed for the correct position is noted and secured using a modified purse-string suture (Fig. 20.5).
then overcompensated by 1 mm. This measurement is The junior author prefers to use 5-0 Polypropylene
then divided in half and represents the vertical dimen- suture. Beginning at the medial edge of the incision, the
sion of the ellipse above and below the incision line. first bite is horizontal through the frontalis muscle and
Fig. 20.2 The skin incision is made with a scalpel, and Fig. 20.4 The orbicularis oculi is palpated to ensure adequate
undermining is performed in the subcutaneous tissue superficial mobility to the desired brow position
to the frontalis muscle. The ellipse of skin is excised with the
underlying subcutaneous tissue, avoiding the fascia of the fron-
talis muscle
a
Fig. 20.3 Subcutaneous undermining is done medially, later-

ally, and inferiorly until the orbicularis oculi is in view
grasps the periosteum of the frontal bone. The second

bite is through the orbicularis oculi using three consec-
utive throws (Fig. 20.6). The suture is then tightened
until the brow is elevated to the desired position and
then tied down in a buried fashion. The assistant sup-
ports the brow inferiorly while the suture is being tied
Fig. 20.5 (a) The orbicularis oculi is suspended using a modi-
to avoid any change in the brow position. Depending
fied purse-string suture of either 5-0 or 6-0 Polypropylene.
on the length of the elliptical incision, this modified The first bite is through the periosteum of the supraorbital fron-
purse-string suture is repeated as needed to ensure tal bone. (b) Intraoperative
Fig. 20.6 The second bite is through the orbicularis oculi using Fig. 20.8 The dermis is reapproximated using 5-0 or 6-0
three consecutive throws. The brow is elevated to the desired Monocryl suture to ensure no tension on the skin edges
position and then tied with square knots
portion of the procedure as meticulous closure is essen-

tial to ensure a minimally visible incision. The dermis
is closed using either 5-0 or 6-0 monofilament long-
term absorbable suture, such as Monocryl (Ethicon,
Inc.), so that there is minimal tension on the epidermal
closure (Fig. 20.8). The epidermis is then closed using
6-0 Polypropylene in a simple and vertical mattress
fashion. The junior author (G.V.) prefers to place inter-
rupted vertical mattress sutures along the length of the
incision for optimal skin eversion and then use a sim-
ple continuous suture to complete the epidermal
approximation. Petroleum jelly or antibiotic ointment
may be applied to the incision and a nonadhesive dress-
ing, such as Telfa (The Kendall Company, Ltd.), may
be used to apply light pressure. Sutures are removed in
two stages: The continuous suture is removed on post-
operative day 4 or 5, and SteriStrips (3 M,
St. Paul, MN) are placed in between the remaining ver-
Fig. 20.7 The modified purse-string suture is repeated as nec- tical mattress sutures. All sutures are removed by post-
essary along the length of the brow for optimal elevation and operative day 7, and the incision is again reinforced
contour of the brow
with SteriStrips which are allowed to fall off on
their own. Patients are encouraged to call with any
even elevation of the brow (Fig. 20.7). In the junior concerns and follow-up photos are generally taken at 3
authors (G.V.) experience, this typically involves a and 12 months postoperatively.
total of three sutures. One advantage of multiple sutures
is that the brow can be elevated by different amounts at
each suture, thereby allowing more precise control of 20.3 Discussion
brow contour which is especially useful for the female
eyebrow. Ideal eyebrow configuration and position is an essential
Once the orbicularis suturing has been completed, component of a youthful, refreshed face. While many
thorough hemostasis is ensured. The incision is then techniques exist to reposition the eyebrow and address
closed. This is generally the most time-consuming the aging in the upper one-third of the face, there is an
Fig. 20.9 (a, b) Preoperative (left) patient with congenital right brow symmetry and in lateral hooding even though no concomi-
brow ptosis. Postoperative (right) after right Mid-Forehead tant upper blepharoplasty was performed
Buttonhole eyebrow lift. There is significant improvement of
absence of any one optimal technique. There is much important to note that the Mid-Forehead Buttonhole
debate on the merits of various procedures with regard Technique elevates and configures the eyebrow but
to technical difficulty, precision, complications, proce- does not address the forehead complex in terms of skin
dure length, recovery time, and longevity of result. The excess, rhytides, and forehead or glabellar muscula-
ideal procedure would accurately restore a youthful ture. The approach does, however, involve an ellipti-
eyebrow position and configuration, have minimal cal excision of lateral brow skin. Both authors prefer
morbidity, and would be long lasting in its result. The to address the muscular component of brow aging,
Mid-Forehead Buttonhole Technique was developed namely the horizontal forehead creases and glabellar
to address concerns with both the invasiveness and furrows, with neurotoxin administration of botulinum
sequelae of the coronal brow approach as well as toxin A. It is their opinion that appropriate chemi-
the unpredictability of the endoscopic approach. It is cal treatment allows a natural look which, although
Fig. 20.10 (Left) Preoperative male patient with concerns of lateral brow position. (Right) Postoperative following Mid-Forehead
Buttonhole eyebrow lift
temporary, is completely reversible with time and may While there are many benefits of the Mid-Forehead
be reproduced with minimal risk and discomfort. Buttonhole Technique, there are also some limitations.
There are numerous advantages of the Mid-Forehead The incision is made in a forehead rhytid (static if
Buttonhole Technique. The surgical approach involves a possible, otherwise in a dynamic crease), and patients
minimal dissection in the subcutaneous plane, allowing must be informed of the resultant scar. In order to min-
excellent visualization of the involved anatomy. The imize any visible scar, the skin closure must be meticu-
dissection is technically easier than either the coronal or lous and may be time-consuming compared to the
endoscopic approached, but the skin closure must be endoscopic approach. Additionally, the Mid-Forehead
meticulous and may take longer. Due to the proximity of Buttonhole Technique does not address glabellar or
the dissection to the target area, the orbicularis oculi frontalis musculature. If treatment is needed in these
may be elevated directly at the level of the eyebrow, areas, the authors prefer to use botulinum toxin type A.
thereby allowing a very accurate elevation and the ability Both authors find that the results of this procedure are
to differentially elevate different components of the not as predictable as rhytidoplasty or blepharoplasty,
brow, creating a youthful contour to the brow, rather but are equivalent or more predictable than the endo-
than elevating it as a unit. There is less risk of morbidity scopic approach, although less predictable than the
compared to the endoscopic of coronal approaches with coronal approach.
regard to ecchymosis, edema, pain, and recovery time. Potential complications involved with the Mid-
There is no risk of trauma to either the supraorbital or Forehead Buttonhole Technique include the need for
supratrochlear neurovascular bundles. Additionally, this scar revision, although neither author has experienced
procedure may be done in the office under local anes- this to date. There is also the potential for hematoma or
thesia and requires inexpensive surgical instrumenta- seroma formation. A mild pressure dressing over the
tion. As each brow is addressed on an individual basis, incision and area of undermining may be used for the
they may be elevated independently, thereby improving first 24 h, but is rarely needed beyond that point. Pain
on preoperative asymmetry. In fact, the junior author or headache may be seen postoperatively, especially
(G.V.) has performed surgery on a patient with long- with forced eye closure. This phenomenon is explained
standing right unilateral brow ptosis with good position to patients preoperatively and resolves with time. The
of the left brow. Figure 20.9 demonstrates the improve- senior author (H.M.) has also experienced two cases of
ment in symmetry obtained with performing a unilateral paresthesia over the V1 (supraorbital/trochlear) nerve
brow lift. In contrast to the coronal or trichophytic distribution which have been transient in nature.
approaches, the Mid-Forehead Buttonhole Technique Figures 20.1020.18 demonstrate some of the
does not elevate the hairline and is not limited to patients typical pre and postoperative results from the Mid-
with a receding hairline. Forehead Buttonhole Technique.
Fig. 20.11 (Left) Preoperative male patient with concerns of lateral brow position. (Right) Postoperative following Mid-Forehead
Buttonhole eyebrow lift
Fig. 20.12 (Left) Preoperative female who had concerns of brow position and lateral hooding. (Right).Postoperative after undergo-
ing Mid-Forehead Buttonhole eyebrow lift. No concomitant blepharoplasty was performed
Fig. 20.13 Preoperative (left) and postoperative (right) AP views of a female patient who wanted a more dramatic eyebrow lift who
also underwent concomitant upper blepharoplasty
Fig. 20.14 (Left) Preoperative photograph of a female with concerns of lateral hooding and eyebrow position after a previous upper
lid blepharoplasty. (Right) Postoperative photograph after bilateral Mid-Forehead Buttonhole eyebrow lift
Fig. 20.15 Preoperative (Left) and two month postoperative degree of frontalis hyperfunction needed to keep her brow in an
(Right) AP views of a female patient who underwent the Mid- elevated position which is significantly improved post-opera-
Forehead Buttonhole eyebrow lift with both medial and lateral tively without the use of Botulinum toxin
incisions. The preoperative photograph demonstrates the significant
Fig. 20.16 (Left) Preoperative female with significant brow ptosis, upper and lower lid dermatochalasis, and fat pseudoherniation.
(Right) Early postoperative following Mid-Forehead Buttonhole eyebrow lift with concomitant upper and lower lid blepharoplasty
Fig. 20.17 (Left) Preoperative female patient. (Right) Postoperative after undergoing Mid-Forehead Buttonhole eyebrow lift with
concomitant upper blepharoplasty
Fig. 20.18 (Left) Preoperative female patient with significant lateral hooding. (Right) Postoperative after Mid-Forehead
Buttonhole eyebrow lift with excellent improvement in both brow position and lateral hooding
20.4 Conclusions In the experience of the authors, the Mid-Forehead

Buttonhole Technique for eyebrow elevation pro-
There are several important surgical concepts when vides comparable or better results than other sur-
considering approaches to the eyebrow. The closer gical approaches with less risk and morbidity in
the incision is to the target structure, namely the eye- exchange for small, well-camouflaged, mid-forehead
brow, the more effective and accurate the lift. The mid- scars.
forehead location for small incisions maximizes the
surgical result with minimal risks, including scar visi-
bility. The ability to fixate the orbicularis oculi to the References
supraorbital periosteum improves eyebrow elevation
and contour in combination with the elliptical skin 1. Ellenbogen R (1983) Transcoronal eyebrow lift with con-
excision of the mid-forehead procedure. Finally, comitant upper blepharoplasty. Plast Reconstr Surg 71(4):
490499
despite all of the various surgical approaches to the 2. Freund RM, Nolan WB III (1996) Correlation between brow
eyebrow, no perfect, consistent, long-lasting, and pre- lift outcomes and aesthetic ideals for eyebrow height and
dictable eyebrow lift procedure exists. shape in females. Plast Reconstr Surg 97:13431348
3. Matros E, Garcia JA, Yaremchuk MJ (2009) Changes in 6. Elkwood A, Matarasso A, Rankin M, Elkowitz M, Godek CP
eyebrow position and shape with aging. Plast Reconstr Surg (2001) National plastic surgery survey: brow lifting techniques
124:12961301 and complications. Plast Reconstr Surg 108(7):21432150
4. Ahn MS, Catten M, Maas CS (2000) Temporal brow lift using 7. Chiu ES, Baker DC (2003) Endoscopic brow lift: a retro-
botulinum toxin A. Plast Reconstr Surg 105(3):11291135 spective review of 628 consecutive cases over 5 years. Plast
5. Punthakee X, Kelle GS, Vose JG, Stout W (2010) New tech- Reconstr Surg 112(2):628633
nologies in aesthetic blepharoplasty and brow-lift surgery. 8. Cilento BW, Johnson CM (2009) The case for open forehead
Facial Plast Surg 26(3):260265 rejuvenation. Arch Facial Plast Surg 11(1):1317
Facelift
21
21.1 Introduction exhibit a loss of skin elasticity, sagging of the cheek

tissues and cervical platysma, and who may also have
The facelift procedure has undergone several modifi- excess neck fat. Patients who enjoy average weight, an
cations over the last century since first explained by aesthetic facial bony contour and a high posteriorly
Hollnder in 1901 [1]. The various techniques differ in positioned hyoid bone are usually better candidates
the length and placement of the incision, the extent than those who have thin tissues, are overweight, or
of undermining and dissection, and the handling of who have a low-anteriorly placed hyoid.
the SMAS. Methods include simple skin dissection, Patients should be psychologically stable, possess
superficial musculoaponeurotic system (SMAS) sus- realistic expectations, and demonstrate a comprehen-
pension, SMAS undermining, deep plane, extensive sion of the limitations of the facelift procedure. In my
skin undermining, and other variations. The subcuta- practice, the details are usually discussed on three
neous facelift with imbrication of the SMAS is still occasions prior to surgery. Patients must also under-
the most commonly used technique [2]. This chapter stand that no surgical rejuvenation procedure can
focuses on our method of a skin-SMAS lift. remove facial asymmetries, improve the general facial
deflation that occurs with aging, halt aging, remove
wrinkles or facial expression lines, or restore the
21.2 Indications deteriorated condition of skin. Other techniques, not
included with the facelift procedure, might be consid-
Although there are many variations of the facelift ered or needed to address facial atrophy, wrinkles, skin
procedure, the goals remain the same. These include deterioration, asymmetries, and/or future aging.
removing excess fat and repositioning tissue to achieve
a more youthful, yet natural lift. The authors tech-
nique involves the removal of any excess cervical
fat, repositioning the SMAS and platysma, and remov- 21.3 High Points
ing excess cervical and facial skin. Ideal candidates
are those in good health with good vascularity who 1. The incisions are placed in reference to the hairline,
lobule, tragus, and postauricular crease. The authors
attempt to preserve the temporal sideburn at the level
P.R. Langsdon () of the superior portion of the ear. In female patients, a
The Langsdon Clinic, Germantown, TN, USA
post-tragal incision is used, and in male patients, the
Division Facial Plastic Surgery, University of Tennessee Health incision carried in front of the tragus. Postauricularly,
Science Center, Memphis, TN, USA
the incisional mark is carried into the postauricular
sulcus and then along the posterior hairline.
C. Shires
2. The SMAS layer is deep to the subcutaneous fat
Department of Otolaryngology-Head and
Neck Surgery, University of Tennessee Health Science Center, and superficial to the parotid fascia and invests the
Memphis, TN, USA mimetic musculature of the face and neck. It is
312 P.R. Langsdon and C. Shires
generally thought to be continuous from the tem- 21.4 Surgical Technique

poroparietal fascia to the platysma. The SMAS is
also inclusive of the orbicularis oculi and orbicularis Sedation should only be undertaken in a state approved
oris muscles [35]. This connection and investment and yearly inspected setting that is restricted by safety
system allows for plication and/or imbrication of the guidelines (or by a similar legitimate governing orga-
SMAS to support the sagging system and add lon- nization) (Figs. 21.121.38). All emergency equip-
gevity and efficacy to a facelift. The SMAS is directly ment, proper personnel, and appropriate emergency
connected to the skin in the central portion of the medications should be present. In our facility, the
face, contributing to support in this area when the patient is administered diazepam 20 mg orally, dimen-
system is suspended lateral and/or superiorly. It is hydrinate 200 mg orally, and prednisone 40 mg orally
the opinion of the senior author that skin suspension 1 h prior to surgery. The patient is also administered an
alone does not provide as good longevity of results. oral antibiotic. It may take an hour or slightly longer
3. Great attention is paid to elevation and placement for the diazepam to have full effect.
of the tragus and earlobe. Tragal skin is elevated Local anesthesia is undertaken with 1% xylocaine
in a very superficial, almost dermal plain, thereby containing 1:100,000 epinephrine to include the inci-
leaving as much deep tissue as possible to prevent sion lines and the circumferential periphery of the flap
postoperative contracture. When closing the skin, margins. The area to be undermined is injected with
the neotragal skin is left redundant to avoid for- % xylocaine containing 1:200,000 epinephrine.
ward displacement of the tragus by skin contrac- Intravenous sedation is optional, but can be very help-
ture. The earlobe is placed in a position that is about ful during the injection of local anesthesia. Intravenous
cm superior to the position where it naturally sedation may be offered and must be monitored in an
lies in the unrepaired state. This overcorrection pre- appropriate setting. It is usually delayed until the oral
vents the lobe from being pulled too far inferiorly diazepam has been fully absorbed. We accomplish
during the natural healing process. intravenous sedation with diazepam in 2.5 mg doses
4. Two important securing sutures are placed when and/or hydromorphone in 0.25 or 0.5 mg doses admin-
redraping the elevated flap, one at the most superior istered in 5 min intervals until the patient is relaxed.
postauricular point and one at the junction of the The 5 min interval allows for complete circulation and
horizontal temporal incision and the superior extent time for the physician to adequately observe the respi-
of the preauricular incision. These sutures anchor ratory impact of the dose, before additional sedation is
the skin for trimming. administered.
5. The author has found that preserving the mandibular
ligament area vessels results in better flap vascular-
ity. Therefore, minimal undermining should be per-
formed in this area unless enough vasculature is
preserved in other regions of the face lift to sustain
adequate capillary flow.
6. Significant submental tissue and platysmal banding
will not be improved unless submental muscular pli-
cation and skin redraping is performed along with
elevation and support of facial tissues. Other proce-
dures might be needed and/or recommended such as
blepharoplasty, forehead lift, chin augmentation, etc.
The patient should also understand that a rhytidec-
tomy will only help reposition tissues. It will not
replace volume loss or improve wrinkled skin.
Ancillary procedures, the injection of facial fillers and
chemical peel, are often recommended as necessary.
7. Anesthetic technique for this procedure varies from Fig. 21.1 Preoperative marking in a female, including a post-
surgeon to surgeon. tragal mark
21 Facelift 313
Fig. 21.2 Preservation of the temporal sideburns and incisional Fig. 21.4 Submental marking
marking in a male, which travels in front of the tragus in a preau-
ricular crease. The extent of skin undermining is marked approx-
imately 5 cm from the incision site
Fig. 21.5 Incision used for platysmal plication and submental

lipectomy
Fig. 21.3 Incisional mark carried into the postauricular sulcus

extending onto the posterior hairline forming a short gentle
curve along the hairline
The senior author believes in preserving the tem-

poral sideburn at the level of the superior portion of
the ear. Therefore, a horizontal mark is usually placed
in this location to prevent the migration of hair to a
point superior to the cephalic portion of the ear. The
resulting incision may then be reused in future facial
rejuvenation procedures without elevation of the
sideburn area and loss of temporal hair. Instead of
shaving the patients hair, parted segments on either Fig. 21.6 Elevation of the anterior neck skin flap
Fig. 21.7 Elevation of the anterior neck skin flap Fig. 21.9 Liposuction of the anterior neck
Fig. 21.10 Submental lipectomy showing excised fat strip
Fig. 21.8 Liposuction of the anterior neck
side of the incision are twisted and wrapped with

paper tape.
The mark is continued in the preauricular groove
found just in front of the curvature of the auricle. In
female patients, a post-tragal mark (12 mm behind
the tragus) is incorporated to hide the scar. In male
patients, the incisional mark is usually carried in front
of the tragus in a preauricular crease. The author usually Fig. 21.11 Submental lipectomy showing excised fat strip
21 Facelift 315
Fig. 21.12 Plication of medial borders of platysma muscle Fig. 21.15 Beveling of the blade during the incision behind the
tragus and along the temporal hairline
Fig. 21.13 After placement of platysmal plication sutures Fig. 21.16 Undermining of the skin beginning at the tragus,
preserving subdermal tissue attachments to the deep tissue
Fig. 21.14 Beveling of the blade during the incision behind the Fig. 21.17 Undermining of the skin beginning at the tragus,
tragus and along the temporal hairline preserving subdermal tissue attachments to the deep tissue
Fig. 21.18 Undermining the remainder of the facial skin from Fig. 21.20 Asterisks showing areas of the mandibular ligament
laterally to medially, in a supraSMAS (subdermal) layer to a point vessels
averaging 5 cm from the incision, following the preoperative
marking plan. The assistant is shown providing counter-traction
Fig. 21.21 SMAS-ectomy showing removal of 3 1 cm strip of

SMAS down to the parotid fascia
Fig. 21.19 Elevated flap
leaves an area of non-hair-bearing skin between the

tragus and sideburn in male patients. The mark then
curves around the earlobe.
Postauricularly, the incisional mark is carried into
the postauricular sulcus. Some surgeons stop the inci-
sion low in the postauricular sulcus. However, we have
found the resulting bunching of skin unsatisfactory to
the patient in the early postoperative period. Therefore,
we extend the mark up the postauricular sulcus and
onto the posterior hairline forming a short gentle curve
along the hairline. This extension of the postauricular
incision allows for removal of excess skin and the pre-
vention of bunching. The extent of skin undermining is Fig. 21.22 Beginning suture through the periosteum of the
marked approximately 5 cm from the incision site. zygomatic arch
21 Facelift 317
Fig. 21.23 Suture directed inferiorly Fig. 21.25 Suture directed anteriorly
Fig. 21.24 Suture directed inferiorly Fig. 21.26 Suture directed superiorly
The submental area is addressed first. A 1.52 cm excessive subplatysmal fat, facelift scissors are used to
horizontal incision is placed in the submental crease or remove fat between the medial borders of the plat-
a few millimeters posterior to the crease. This place- ysma. The platysma muscles are then medialized to
ment will ensure that the incision remains well hidden each other and suspended to tissue deep to the medial
in the submental region with superior and posterior subplatysmal fat removal with interrupted buried
movement of the adjacent skin during the facelift. A sutures of 3-0 Vicryl. Three to four interrupted sutures
2.5 cm incision may be necessary for visualization are placed, beginning from the deepest point of the
during platysmal plication. Subcutaneous elevation of new cervical angle, and continued to the area of the
the anterior neck skin flap is performed with facelift submental incision.
scissors, maintaining a 2-mm cuff of fat on the deep A #15 blade is used to make the incisions in the
surface of the skin. Submental lipectomy may be per- preoperative periauricular markings. The incision is
formed with a 4-mm liposuction cannula connected to carried through the dermis and is beveled across the
wall suction. The medial borders of the platysma are direction of the hair follicles in hair bearing temporal
plicated with 3-0 Vicryl buried mattress sutures. In and posterior hairline skin. This maneuver allows the
patients with a poorly defined cervicomental angle and hair to grow through the incision line.
Fig. 21.27 Suture directed again through the periosteum of the Fig. 21.29 First securing stitch at the highest postauricular
zygomatic arch point with a surgical staple once the skin is draped in a posterior-
superior vector
Fig. 21.30 Second securing staple at the junction of the

horizontal temporal incision and the superior extent of the preau-
ricular incision
Countertraction is provided by the assistant. Hemostasis

Fig. 21.28 Suture plicating the depression created by the lifting is achieved with bipolar cautery under direct visualiza-
suture tion. The dissection continues forward until the dissec-
tion of the previously raised neck flap is reached.
The skin is then undermined using facelift scissors Minimal dissection should be performed in the area of
beginning at the tragus, leaving as much subdermal tis- the mandibular ligament vessels in order to prevent
sue as possible attached to the deep tissue. A thin tra- flap necrosis unless other regions of the face or neck
gal flap minimizes tragal contracture during the are spared of extensive undermining.
postoperative healing phase. The remainder of the With the skin flap adequately elevated, SMAS-
facial skin is then fully undermined in a supraSMAS ectomy is performed. A 1 3 cm strip of SMAS is
(subdermal) layer to a point averaging 5 cm from the excised in the preauricular area down to the parotid fas-
incision, following the preoperative marking plan. cia. The SMAS is then plicated in a posterior-superior
21 Facelift 319
Fig. 21.31 Removal of excess cheek skin from the temple, Fig. 21.33 Removal of excess cheek skin from the temple,
around the lobule, and over the tragus around the lobule, and over the tragus
Fig. 21.32 Removal of excess cheek skin from the temple, Fig. 21.34 Removal of excess cheek skin from the temple,
around the lobule, and over the tragus around the lobule, and over the tragus
vector using a 2-0 Ethibond or 2-0 Vicryl suture. The Free fat grafts are placed as necessary to fill suture
suture is secured at the zygomatic periosteum and depressions.
placed through the SMAS creating a purse string The skin is draped in a posterior-superior vector
loop. The suture is first continued inferiorly, then and secured at the highest postauricular point with
directed anteriorly, and then posterior-superiorly to an interrupted 2-0 nylon suture or surgical staple.
return back to the zygomatic periosteum, creating a This is followed by a second securing suture or sta-
teardrop loop. The SMAS suspension will elevate the ple at the junction of the horizontal temporal incision
jowl, neck, and nasolabial fold. This SMAS suture and the superior extent of the preauricular incision.
often leaves a trough deformity that is closed with The redundant skin is then resected in a manner
interrupted plication sutures across the depression. creating minimal skin tension. If any dimpling or
Fig. 21.35 Removal of excess occipital skin Fig. 21.37 Removal of excess occipital skin
Fig. 21.36 Removal of excess occipital skin Fig. 21.38 Skin repaired and patient ready for dressing
bunching of skin is noted, further undermining can mated with a 5-0 plain gut suture in a running inter-
be performed. The neotragal skin is left redundant to locking fashion, using a 4-0 Vicryl for additional
avoid forward displacement of the tragus by skin support as necessary. The postauricular closure,
contracture. The earlobe is placed in a position that above the posterior portion of the earlobe and below
is about cm superior to the position where it the level of the hairline, is performed in a manner
naturally lies in the unrepaired state. This overcor- that leaves 1 cm gaps between sutures. This helps
rection prevents the lobe from being pulled too far prevent the accumulation of blood beneath the flaps.
inferiorly during the natural healing process, thus A penrose drain is brought out through the postau-
preventing the pixie earlobe deformity. The skin ricular incision at the midlevel of the incision. A
along the postauricular occipital hair is reapproxi- separate incision is not made for the drain. The
mated with surgical staples. The skin edges in the preauricular and tragal skin is closed using 5-0 plain
non-hair-bearing postauricular areas are approxi- gut in a running interlocking fashion. The hair
21 Facelift 321
bearing temporal scalp incision is closed with sta- Nerve injury may be sensory or motor. Sensory
ples. The submental incision may be closed with 5-0 reduction is common and not considered a complica-
plain gut suture in a running interlocking fashion. tion; rather a normal consequence of surgery. Care
Any collected blood is expressed from under the must be taken when dissecting deep to the fascia over-
flaps via the postauricular closure gaps. Xeroform lying the sternocleidomastoid muscle to avoid injuring
gauze is placed over the incisions. Then, a second layer the greater auricular nerve [6]. Branches of the facial
of light dressing is applied with 4 4 gauze pads and a nerve become very superficial as they continue anteri-
cotton wrap, applying only very gentle pressure over orly from the parotid masseteric fascia. The marginal
the periauricular area, lower face, and neck. Lastly, a mandibular branch is at risk as it crosses the mandibu-
light elastic wrap is placed over the dressing. The elas- lar margin, deep to the platysma muscle and the super-
tic wrap is removed 4 h after placement. ficial layer of the deep cervical fascia. The most
The patient is evaluated the following day. The commonly injured branch of the facial nerve during
remaining dressing is removed, and the incisions are facelift surgery is the frontal branch. This branch
cleaned with hydrogen peroxide and dressed with becomes superficial at the zygomatic arch and travels
Vaseline. The Penrose drain is removed. The patient just beneath the subcutaneous tissues underlying the
is instructed to keep the head of the bed elevated 30, SMAS layer. The nerve travels 1.52 cm in front of the
avoid strenuous activities, not bend over, and not turn auricle and halfway between the lateral orbital rim and
his or her head. the temporal tuft of hair [7]. The author has never
experienced a major motor or sensory nerve injury.
Masterful knowledge of facial nerve and greater auric-
21.5 Complications ular nerve anatomy will prevent most major nerve
injuries. The majority of facial nerve paralysis that
Complications occur in any surgical procedure and the appears immediately after surgery is due to the local
facelift is no exception. Hematoma formation is pos- anesthetic, stretch, or compression. These nerve inju-
sible but can be minimized with meticulous surgical ries usually resolve with time [6].
hemostasis, proper patient selection, and the cessation Deep infection is rare, as is cellulitis. Antibiotic
of all medications, herbs, vitamins, and red wine that prophylaxis is used routinely. Treatment of cellulitis
may cause bleeding. All patients should be counseled should cover Staphylococcus and Streptococcus. These
to discontinue medications, herbs, vitamins, etc., that infections can usually be treated without permanent
may cause bleeding 2 weeks prior to surgery. Large sequela.
hematomas should be treated to avoid skin flap necro-
sis and can usually be easily expressed through the
postauricular skin closure gaps. 21.6 Conclusions
Flap necrosis might occur at the distal ends of
flaps where blood supply is most tenuous. Most com- Over time, many approaches to the facelift procedure
monly necrosis occurs in the mastoid region because have been developed. However, the goals of facelifting
the flap is the thinnest at this site, and this area is still remain to remove excess cervical fat, tighten the
farthest away from the blood supply [6]. This would SMAS and platysma, and remove excess cervical and
most commonly be an issue in heavy smokers, who facial skin. Facelifting can result in a younger yet natu-
are not consciously accepted as patients. Caution ral appearance in the hands of experienced surgeons
should be exercised in smokers or patients with dia- (Fig. 21.39). In order for both the patient and surgeon
betes, collagen vascular disease, or Raynauds dis- to have the best possible results, it is essential for the
ease. However, the senior author does not consider physician to obtain a comprehensive medical history
these situations or conditions necessarily contraindi- and to understand the patients expectations from the
cations to facelifting. Smokers should be counseled surgery and for the patient to understand the limita-
to reduce or discontinue smoking at least 2 weeks tions of the facelift procedure. Certain pearls regarding
prior to surgery. We do not accept candidates who the location of incisions, undermining technique, and
smoke over one half pack per day. Undermining is placement of closure sutures can help in achieving an
limited in these patients. optimal outcome.
Fig. 21.39 (a) Preoperative a b

patient. (b) Postoperative
facelift with upper and lower
blepharoplasty
References General References

1. Hollander E (1932) Plastiche (kosmetische) operation: Baker TJ, Gordon HL (1971) The temporal face lift (mini-lift).
kristiche darstellung ihres gegenwartigen standes. In: Plast Reconstr Surg 47(4):313315
Klemperer G, Klemperer F (eds) Neue Deutsche Klinik. Duminy F, Hudson DA (1997) The mini rhytidectomy. Aesthetic
Urban and Schwarzenberg, Berlin Plast Surg 21(4):280284
2. Baker SR (2005) Rhytidectomy. In: Cummings CW (ed) Fulton JE, Saylan Z, Helton P, Rahimi AD, Golshani M (2001)
Otolaryngology: head & neck surgery. Mosby, Philadelphia, The S-lift facelift featuring the U-suture and O-suture com-
pp 714748 bined with skin resurfacing. Dermatol Surg 27(1):1822
3. Gossain AK, Yousif NJ, Madiedo G, Larson DL, Matloub Joseph J (1928) Verbesserung meiner Hangewangenplastik
HS, Sanger JR (1993) Surgical anatomy of the SMAS: a rein- (Melomioplastik). Dtsch Med Wochenschr 54:567
vestigation. Plast Reconstr Surg 92(7):12541263 Onizuka T, Hosaka Y, Miyata M, Ichinose M (1995) Our mini-
4. Ghassemi A, Prescher A, Riediger D, Axer H (2003) Anatomy facelift for orientals. Aesthetic Plast Surg 19(1):4958
of the SMAS revisited. Aesthetic Plast Surg 27 Saylan Z (1999) The S-lift: less is more. Aesthetic Surg J
(4):248264 19:406
5. Accioli de Vasconcellos JJ, Britto JA, Henin D, Vacher C Stephenson KL (1970) The mini-lift, an old wrinkle in face
(2003) The fascial planes of the temple and face: an en-bloc lifting. Plast Reconstr Surg 46(3):226235
anatomical study and a plea for consistency. Br J Plast Surg Tonnard PL, Verpaele A, Gaia S (2005) Optimising results from
56(7):623629 minimal access cranial suspension lifting (MACS-lift).
6. Gillman GS et al (2008) Face lift (rhytidectomy). In: Myers Aesthetic Plast Surg 29(4):213220
EN (ed) Operative otolaryngology: head and neck surgery. Yarborough JM, Beeson WH (1986) Aesthetic surgery of the
Saunders, Philadelphia, pp 845855 aging face. Mosby, St. Louis, p 142
7. Perkins S, Dayan S (2002) Rhytidectomy. In: Papel ID (ed)
Facial plastic and reconstructive surgery. Thieme, New York,
pp 153170
Short-Scar Purse-String Facelift
22
Amir M. Karam, L. Mike Nayak, and Samuel M. Lam
22.1 Introduction operations do not necessarily result in bigger or better

results. Innovative surgeons, such as Baker [7] and
Despite the expanse of novel facial rejuvenation tech- Saylan [8], who developed the Lateral SMASectomy
nologies available today, the gold standard for correction and the S-Lift, respectively, began to popularize proce-
of the senescent jaw line and neck remains rhytidectomy. dures that focused on shorter incisions, supra-SMAS
Facelift surgery has continued to evolve since the first dissection, and a vertically oriented lifting vector.
cases described nearly a century ago [16]. In many These concepts were in direct opposition to conven-
ways, we have come full circle. In the early 1900s tional dictums. The rationale was simple; however,
through the 1970s, the original skin-only rhytidectomy these novel techniques illustrated the potential for
remained the predominate method. Following the identi- excellent naturally enhancing results, decreased poten-
fication of SMAS in the late 1970s, the surgical tech- tial morbidity, and surgical expediency. This became
niques became increasingly more sophisticated and the bases for their continued popularity.
complex. This continued through most of the 1990s and
peaked with the description of the composite facelift
technique described by Hamra [5]. 22.2 The Evolution of the Short-Scar
These operations required a longer and slower learn- Purse-String Facelift
ing curve and carried a considerably higher morbidity
and postoperative healing time. The question came up In 1999, Saylan [8] reported on the S-Lift. Saylans
by several surgeons: Do the results justify these more S-Lift was the first purse-string facelift and involved a
involved procedures? The paradigm began to slowly SMAS plication technique that was intended to provide
shift as surgeons began to realize that perhaps bigger an even less invasive facelift procedure. It featured a
short, preauricular-only incision, short flap, and double
purse-string sutures that were anchored to the perios-
teum of the posterolateral zygomatic arch. The proce-
A.M. Karam
dure was intended to be performed under local anesthesia,
Carmel Valley Facial Plastic Surgery, San Diego, CA, USA which was very appealing to many patients. Though the
e-mail: [email protected] technique was considerably more conservative, it deliv-
L.M. Nayak ered efficacious results for both men and women
Department of Otolaryngology-Head and Neck Surgery, between the ages of 40 and 50 years. The most obvious
Nayak Plastic Surgery and Skin Enhancement Center, shortcoming was the inability to significantly improve
St. Louis University, St. Louis, MO, USA
the cervicomental angle and overall neck laxity.
Tonnard et al. (2002) [9] described the MACS
S.M. Lam (*)
Willow Bend Wellness Center, Lam Facial Plastics Surgery
(minimal access cranial suspension) lift, which was a
Center & Hair Restoration Institute, Plano, TX, USA significant advance in purse-string facelift. By per-
e-mail: [email protected] forming additional undermining onto the lateral face

324 A.M. Karam et al.
a b
Fig. 22.1 (a) Before surgery. (b) One year following short scar purse-string facelift with a limited submentoplasty (Photo courtesy
of L. Mike Nayak)
and jowl region, adding judicious submental liposuction, we owe credit to him for the advances he has made to the
and using larger purse-string sutures to more effec- purse-string facelift (Figs. 22.1 and 22.2).
tively capture the cranial border of the platysma, over-
all results were improved, especially in heavier faces
or those with more cervicomental laxity than the S-Lift 22.3 Surgical Technique
could correct.
In 2004, Brandy [10, 11] introduced a modification 22.3.1 Surgical Markings
of the S-Lift of Saylan. Since then, the operation has
continued to become more refined. Compared to the Figure 22.3 illustrates the typical incision marking
original S-Lift, Brandys modified purse-string facelift used, beginning as a short, intensively beveled preau-
involves postauricular undermining, and undermining ricular trichophytic incision that continues into a
of a larger region in the lateral neck, which more aggres- preauricular, posttragal incision. This incision then
sively corrects the platysma-SMAS complex. The lift is continues for a variable degree into a postauricular
more vertically oriented compared to the S-Lift, which incision. In patients with mild laxity or excellent skin
further corrects the cervical laxity. The ability to cor- tone, the incision may terminate at the base of the con-
rect greater degrees of neck and jowl laxity broadens chal bowl. In a very lax, photodamaged skin, the inci-
the indications to include individuals of all ages. sion will likely need to be carried up to the helix-hair
This chapter is largely based on this modification and touch-point, then back down the hairline as a beveled,
22 Short-Scar Purse-String Facelift 325
a b
Fig. 22.2 (a) Before surgery. (b) One year following short-scar purse-string facelift. This patient underwent simultaneous neck
liposuction and limited submentoplasty as well (Photo courtesy of L. Mike Nayak)
trichophytic occipital hair edge incision. Average with 0.25% lidocaine hydrochloride with 1:400,000
undermining distances are then drawn 5 cm anterior to epinephrine using a 21 gauge spinal needle and making
the tragus incision line, 5.5 cm anterior to the earlobe certain to remain in the subcutaneous space.
along the angle of the mandible, and 6 cm inferior to In patients who have the presence of superficial
the earlobe (Fig. 22.4). In general, the less elastic the submental fat, a standard submental liposuction is
skin, the more prone it is to postoperative sweeping performed. In patients with a moderate degree of
from a strictly vertical lift, and the more aggressive the submental platysmal banding, a medial platysmaplasty
skin undermining will need to be to prevent this. is preformed to the level of the hyoid following the
elevation of a submental skin flap. Back cuts are made
in the platysma to enhance the cervicomental angle.
22.4 Anesthesia Next, an incision is initiated at the temporal hairline.
Subcutaneous undermining is begun with a Bard-Parker
When performed under local anesthesia, diazepam No.15 blade and then completed using the facelift
10 mg is then administered orally, and a combination scissors. The most critical aspect of the skin undermin-
of 2.5 mg of midazolam and 50 mg of meperidine ing is to make certain that the flap is not excessively
hydrochloride is given intramuscularly prior to the thin at the predicted site where the V-shaped advanced
initiation of the procedure. flap opposes the scalp (at the superior attachment of
The patient is then brought into the operating room the pinna). This region is most susceptible to necrosis
at which time the face is prepped with povidone-iodine and should be as thick as possible, without capturing the
solution. The area to be undermined is infiltrated superficial temporoparietal fascia. Upon completion of
Fig. 22.3 Surgical markings. The markings are begun on the in length. The hockey stick is usually 1.53.5 cm in length but
tragus and extend along the front of the ear and 3 mm behind the will vary in size depending upon the amount of excessive poste-
temporal hairline. Notice how the line meanders along the anat- rior neck skin available for Burrows triangle excision during the
omy of the ear. This creates a much less detectable scar. The line procedure (Photo courtesy of Dominic Brandy)
is extended 2 mm above the posterior earlobe crease and is 4 cm
all of the aforementioned undermining, thorough purse string is the anchor suture. The diameter of this
hemostasis is accomplished. purse string is about 45 cm and extends down to the
At this point in the procedure, the encircling double cranial portion of the platysma just below the angle of
purse-string submuscular aponeurotic system (SMAS) the mandible (Fig. 22.4). Each bite is roughly 1.5 cm
plication is performed. First, 1/4% lidocaine hydro- long, taking bites deep enough to engage the fibrous
chloride with 1:400,000 epinephrine is injected into SMAS (not just subcutaneous fat) but not so deep as to
the site of the anchor sutures. These injections are per- jeopardize the facial nerve.
formed with a 1-in. 30-gauge needle and are extended The second anchoring stitch is now performed
all the way down to the zygomatic arch 1.5 cm away eccentric to the first. The needle enters 3 mm above
from the skin edge of the tragus, which should be and 3 mm medial to the knot of the first purse string.
safely behind the expected course of the frontal branch This anchor suture is placed in the periosteum of the
of the facial nerve. The choice of suture is dependent zygomatic arch similar to the first suture. Four to five
on the surgeons performance and ranges from 2 to 0 1.5-cm-long grasps through the SMAS are taken in a
green braided nylon (Ethibond) to 0 or 1 purple poly- directly inferior direction (Fig. 22.4), taking care to
dioxanone (PDS). The anchoring suture is placed continue well beyond the angle of the mandible before
1.5 cm away from the skin edge, directly over the turning anteriorly to ensure the capture of several
posterior zygomatic arch. The suture needle should solid bites of the cranial border of the platysma in the
scrape bone and should grasp the periosteum before submandibular region. The remainder of the 1.5-cm-
surfacing. The postero-superior position of the first long grasps follows the outer edge of the undermined
22 Short-Scar Purse-String Facelift 327
5 cm
1 cm
5.5 cm 4 cm
6 cm
a b c
Fig. 22.4 (a) The undermining should be 1 cm below the to five 1.5-cm-long grasps of SMAS are made in a directly
inferior border of the brow, 5 cm anterior to the tragus parallel to inferior direction. The next four 1.5-cm-long grasps will be of
the floor, 5.5 cm anterior to the earlobe along the mandible, 6 cm platysma and should follow directly behind the edge of skin
directly inferior to the earlobe, and 2.54.0 cm away from the undermining. Once the surgeon has reached the same height as
earlobe crease. (b) Purse-string pattern. Following placement of the superior aspect of the second anchor suture, superficial
the first anchor suture, a series of 11.5 cm bites of fibrous grasps are made directly toward the second anchor suture. The
SMAS starting (posteriorly) and extending down toward the last grasp of tissue before hitting the second anchor suture will
angle of the mandible and then extending back up toward the be the third anchor suture and should be 3 mm deep. The second
anchor point. The diameter of this first purse string is 45 cm. (c) and third anchor sutures will thus create a V-shaped anchoring
The second 1.5 cm anchor suture (indicated by grey) starts 3 mm point for the platysma, jowl, and midface (Figure courtesy of
superior and 3 mm lateral to the first anchor sutures knot. Four Dominic Brandy)
zone toward the periorbital region. The first four grasps 5-0 polydioxanone (PDS) sutures. The deep sutures
along the line of undermining will tighten platysma from the temporal hairline to the superior attachment
with the remaining grasps tightening the SMAS. Note of the ear are tacked down to the temporalis fascia.
the overlapping of the grasps in the lower neck and These tacking sutures are critical for stabilization and
midface areas (Fig. 22.4). These overlaps prevent anchoring of the flap. Once these are completed, the
rip-through in an area where the tissues can sometimes 5-0 polydioxanone (PDS) sutures are placed through-
be frail. out the length of the remaining incision. After all deep
When the second purse string arrives at the same sutures are placed, the skin is sutured with a running
height as its origin anchor suture, 1.5-cm grasps of 6-0 fast-absorbing gut suture.
SMAS are made toward this higher anchor suture Patients are asked to wash the incisions 3 times per
(3 mm above the first anchor suture). The last grasp, day with a mild soap. Antibiotic ointment is applied
before meeting the second anchor suture, should be a to all incisions for 45 days. Antibiotics are typically
third anchor suture creating a V-shaped double anchor- prescribed. A cold compress is placed under the chin
ing point for the larger second purse-string suture. This strap for the first 23 days. At 1 week, the patient can
third anchor suture is not as deep as the first two but apply water-based makeup to all incision sites. Patients
should at least be 3 mm deep. Once again, five throws are seen in 1 week, 6 weeks, 3 months, and 1 year
of the suture are made and a 2-mm suture end is left. postoperatively.
As soon as the encircling double purse string is
completed, thorough hemostasis is accomplished and
the redundant skin is excised. The skin drape vector 22.5 Complications
can vary from patient to patient. While the vector usu-
ally has a predominantly vertical direction, in patients Complications were found to be rare with this approach.
with extensive photoaging, a more posterior skin drape The authors experienced a 1% incidence of flap skin
may be required to prevent upward striae in the healing necrosis (>1 cm2) at the level of the superior helix.
skin flap. The flap is inset using a combination of deep Conservative wound care was used with spontaneous
resolution. Hematomas requiring evacuation occurred mind, it is essential to balance the risk-benefit ratio
at a rate of 1%. These were managed by simple aspira- when comparing operative techniques. Patients today
tion in the office on postoperative day 1 without the are less accepting of long downtimes and relatively
need for re-exploration. Hypertrophic scarring of the high-risk exposure. They want meaningful results in
postauricular incision occurred in 1% of the cases. the safest way possible. In our experience, many
This was managed with steroid injection without com- patients prefer improvement over perceived perfection
plication or need for scar revision. There were no cases if it means less downtime, less risk, and lower potential
of permanent or temporary facial nerve weakness. All of having an unnatural or over-operated appearance. As
patients had temporary anesthesia over the undermined a result of its vertical advancement, the vertical purse-
area that resolved in approximately 3 months. string facelift combines the simplicity and safety of a
To date, the results have been extremely gratifying superficial rhytidectomy technique while providing
with patient satisfaction being very high. Naturally, the substantial rejuvenating outcomes to the lower face,
durability of the results must always be questioned neck, and midface. Patient recovery ranges from 1 to
when evaluating a novel technique. Though the 1-year 2 weeks. The potential for serious long-term complica-
photos shown in Figs. 22.122.3 illustrate anatomic tion (i.e., motor nerve damage or distorted facial soft-
stability of the surgical outcomes, several studies have tissue contour) is limited. To date, consistency and
evaluated this concept in comparative studies. In 1996, patient satisfaction have been extremely high.
Aston et al. [12] performed a prospective comparison
of limited incision and limited dissection techniques
(Lateral SMASectomy and standard SMAS) to more References
extensive techniques (composite and extended SMAS
1. Lexer E (1910) Zur Gesichtplastik. Arch Klin Chir 92:749
facelifts). The results did not illustrate a detectable dif-
2. Joseph J (1921) Plastic operation on the protruding cheek.
ference in outcomes between these techniques. Their Dtch Med Wochenschr 47:287
conclusion was that the increased morbidity, surgical 3. Ramirez OM, Pozner JM (1996) Subperiosteal minimally
risks, and convalescence associated with these more invasive laser endoscopic rhytidectomy: the SMILE facelift.
extensive approaches may not be warranted in the aver-
4. Toledo LS (1994) Video-endoscopic facelift. Aesthetic Plast
age facelift patient. Later, Prada et al. [13] published a Surg 18(2):149152
split-face study comparing the Lateral SMASectomy 5. Hamra ST (1992) Composite rhytidectomy. Plast Reconstr
with the MACS lift (purse-string facelift). In this study, Surg 90(1):113
6. Ullmann Y, Levy Y (2004) Superextended facelift: our
at 2 years, there was no detectable difference in result
experience with 3,580 patients. Ann Plast Surg 52(1):814
durability between the SMASectomy and the purse- 7. Baker DC (1997) Lateral SMASectomy. Plast Reconstr Surg
string facelift side. The overall conclusion of these 100(2):509512
studies is that as long as something is done to funda- 8. Saylan Z (1999) The S-lift for facial rejuvenation. Int J
Cosmetic Surg 7(1):1823
mentally reposition and stabilize the SMAS and plat-
9. Tonnard P, Verpaele A, Monstrey S, Van Landuyt K,
ysma, the results will be meaningful and enduring. As Blondeel P, Hamdi M, Matton G (2002) Minimal access cra-
an extension of this concept, the choice of technique nial suspension lift: a modified S-lift. Plast Reconstr Surg
should be based on achieving the best results with the 109(6):20742086
10. Brandy DA (2004) The QuickLift: a modification of the
least risk, morbidity, and convalescence.
S-lift. Cosmetic Dermatol 17:251360
11. Brandy DA (2005) The Quicklift: featuring an encircling
double purse-string plication technique with blunt neck/jowl
22.6 Conclusions undermining for tightening of the sagging SMAS, platysma
and skin. Am J Cosmetic Surg 22(4):223232
12. Ivy EJ, Lorenc ZP, Aston SJ (1996) Is there a difference?
A variety of surgical approaches exist to rejuvenate the A prospective study comparing lateral and standard SMAS
lower face and neck. When comparing these approaches, face lifts with extended SMAS and composite rhytidecto-
it is tempting to focus primarily on the potential results mies. Plast Reconstr Surg 98(7):11351143
13. Prado A, Andrades P, Danilla S, Castillo P, Leniz P (2006)
each of these procedures can achieve. However, it is
A clinical retrospective study comparing two short-scar
equally, if not more, important to remember that these face lifts: minimal access cranial suspension versus lateral
procedures are elective and cosmetic. Keeping this in SMASectomy. Plast Reconstr Surg 117(5):14131425
Modied Facelift
23
23.1 Introduction tissues may require specific cervical surgical maneuvers

in addition to the upper mini lift procedure.
Humans, by nature, have always sought to maintain The mini lift is simply a more minor version of facial
the appearance of youth. In ancient times, various skin suspension. There are variations of the mini facelifting
treatments, derived from wine and fruit were used in technique among surgeons, but the basic principle is the
an attempt to improve aging skin [1]. As the art and same. The procedure is designed to resuspend the sag-
science of medicine and surgery evolved over the last ging tissues. The theoretical difference between a mini
century, the quest moved from the application of facelift and a facelift is that the mini facelift is less exten-
creams and potions, into the operating room. sive and causes less swelling and bruising. Therefore,
Hollnder [2] published an account of a surgical lift theoretically, the patients require less recovery time.
performed in 1901 for the removal of excess facial skin
or wrinkles. Joseph [3] was the first to emphasize the
effect of aging skin on women trying to gain employ- 23.2 Indications
ment and the benefits of cosmetic surgery
The techniques for the facelift have continued to The ideal candidate is a patient with early facial sag-
evolve since those early reports. Techniques include ging who demonstrates a comprehension of the limita-
simple skin dissection, superficial musculoaponeurotic tions of the mini lift procedure. In my practice, the
system (SMAS) suspension, SMAS undermining, deep details of the differences are usually discussed on three
plane, and extensive skin undermining; or various occasions prior to surgery. Additionally, the patient must
combinations of the above. Additional treatments of the understand that no surgical rejuvenation procedure can
forehead and eyelids may or may not be included with a remove facial asymmetries, improve the general facial
surgical facial rejuvenation procedure. This chapter deflation that occurs with aging, halt aging, remove
focuses on the mini facelift technique that treats the wrinkles or facial expression lines, or restore the dete-
lower cheeks and jowls. Depending on several factors, riorated condition of skin. Other techniques, not included
the mini lift may or may not improve the neck. If the with the mini lift procedure, might be considered or
neck tissues require significant improvement, then these needed to address facial atrophic deflation, wrinkles,
skin deterioration, asymmetries, and/or future aging.
P.R. Langsdon ()
Division Facial Plastic Surgery, University of Tennessee
Health Science Center, Memphis, TN, USA
23.3 High Points
The Langsdon Clinic, Germantown, TN, USA
1. The SMAS (superficial musculoaponeurotic system)
C. Shires
Department of Otolaryngology-Head and Neck Surgery,
layer is found deep to the subcutaneous fat and super-
University of Tennessee Health Science Center, ficial to the parotid fascia. The SMAS invests the
Memphis, TN, USA mimetic musculature of the face and neck. It is
generally thought to be continuous from the tem-

poroparietal fascia to the platysma [46]. The SMAS
is also inclusive of the orbicularis oculi and orbicu-
laris oris muscles [46]. This connection and invest-
ment system allows for plication and/or imbrication
of the SMAS to support the sagging system and add
longevity and efficacy to a facelift. The SMAS is
directly connected to the skin in the central portion of
the face, contributing to support in this area when the
system is suspended laterally and superiorly. It is the
opinion of the senior author that skin suspension
alone does not provide the longevity of results that
can be obtained by also suspending the SMAS.
2. The mini facelift involves limited skin undermin-
ing; this is an advantage in patients who smoke and
desire some facial rejuvenation. Hematoma forma-
tion is also less likely with a short skin flap. Fig. 23.1 Patient preoperative marking
3. A mini lift targets early to moderate jowling and will
not improve any condition or region of the face not
included in the procedure. For instance, significant
submental tissue and platysmal banding, will not be
improved as it would with a lower facelift performed
in conjunction with submental muscular plication
and extensive skin redraping. Other procedures might
be needed and/or recommended and the patient
should understand that volume replacement and skin
wrinkle improvement will not occur with a mini lift.
Ancillary procedures such as neck liposuction with
or without platysmal plication, chin augmentation,
forehead procedures, and upper and lower blepharo-
plasty may be performed along with the mini lift.
Volume replacement or skin resurfacing may also be
needed in some patients. It should be fully explained
what reasonable results are possible with differing
techniques and patients should understand and accept
the limitations of this procedure.
4. Anesthetic technique for this procedure varies from
surgeon to surgeon, and from patient to patient. The Fig. 23.2 Patient preoperative marking
author attempts to use oral or intravenous (IV) seda-
tion. The medication selected depends on the emergency medications should be present. In our
patients health and expected response to several facility, the patient is administered diazepam 20 mg
different medications. orally, dramamine 200 mg orally, and prednisone
40 mg orally 1 h prior to surgery. An oral antibiotic
is also administered. It may take an hour or slightly
23.4 Surgical Technique longer for the diazepam to have full effect. Patient
(Figs. 23.123.11) tolerances vary.
Local anesthesia includes 1% xylocaine containing
Sedation should best be undertaken in a facility with 1:100,000 epinephrine buffered with NaHCO3 to
strict guidelines and regulatory oversight. All emer- anesthetize the incision lines and the circumferen-
gency equipment, proper personnel, and appropriate tial periphery of the flap margins. The area to be
23 Modified Facelift 331
Fig. 23.6 Suture directed inferiorly

Fig. 23.3 Elevated flap
Fig. 23.4 Beginning suture through the periosteum of the zygo-

matic arch Fig. 23.7 Suture directed anteriorly
Fig. 23.5 Suture directed inferiorly Fig. 23.8 Suture directed superiorly
Fig. 23.9 Suture directed again through the periosteum of the

zygomatic arch Fig. 23.11 Skin repaired and patient ready for dressing. The
nylon suture was not used in this patient
hydromorphone in 0.25 mg or 0.5 mg doses adminis-

tered in 5 min intervals until the patient is relaxed. The
5 min interval allows for complete circulation and time
for the physician to adequately observe the impact of
the dose upon respiration, before additional sedation is
administered.
The author believes in preserving the temporal side-
burn at the level of the superior portion of the ear.
Therefore a horizontal mark is usually placed in this
location to prevent the migration of hair to a point
superior to the cephalic portion of the ear. The result-
ing incision may then be reused in future facial rejuve-
nation procedures without elevation of the sideburn
area and loss of temporal hair.
The marking is continued in the preauricular groove
found just in front of the curvature of the auricle. In
female patients, a post-tragal mark (12 mm behind
Fig. 23.10 Suture plicating the depression created by the lifting the tragus) is incorporated to hide the scar. In male
suture
patients, the incisional mark is usually carried in front
of the tragus in a preauricular crease. Usually, an area
undermined is injected with 1/2% xylocaine contain- of non-hair-bearing skin between the tragus and side-
ing 1:200,000 epinephrine. Intravenous sedation is burn is preserved in male patients. The mark then
optional, but can be very helpful during the injection of curves around the earlobe.
local anesthesia. If offered, the patient should be moni- Postauricularly, the incisional mark is carried into the
tored in an appropriate setting. Intravenous sedation postauricular sulcus. Some surgeons stop the incision
is usually delayed until the oral diazepam has been low in the postauricular sulcus. However, some patients
fully absorbed (11.5 h). We accomplish intravenous find the resulting bunching of skin, however temporary,
sedation with diazepam in 2.5 mg doses and/or to be unsatisfactory in the early postoperative period.
Therefore, the mark is extended up the postauricular approximated with a 5-0 plain gut suture. Deeper 4-0
sulcus and on to the posterior hairline, forming a short Vicryl may be placed prior to skin repair if additional
gentle curve along the hairline. This extension of the support is necessary. The postauricular crease closure,
postauricular incision allows for removal of excess skin above the posterior portion of the ear lobe and below
and the prevention of bunching. the level of the hairline is performed in a manner that
The extent of skin undermining is marked approxi- leaves 1-cm gaps between sutures. This loose closure
mately 4 cm from the incision site. allows any excess tissue fluids or blood to escape.
A #15 blade is used to make the incisions in the Just prior to applying the dressing, any collected
preoperative periauricular markings. The incision is blood is expressed from under the flaps via the postau-
carried through the dermis and is beveled across the ricular closure gaps. A light dressing is applied with 4 4
direction of the hair follicles in hair-bearing temporal gauze pads and a cotton wrap, applying only very gentle
and posterior hairline skin. This maneuver allows the pressure. A light elastic wrap is placed over the dressing.
hair to grow through the incision line. The elastic wrap is removed 4 h after placement. Excess
The skin is then undermined beginning at the tra- dressing pressure could prevent natural subdermal blood
gus, leaving as much subdermal tissue as possible flow and is avoided as much as possible.
attached to the deep tissue. A thin tragal flap mini- The patient is evaluated the following day. The
mizes tragal contracture during the postoperative remaining dressing is removed and the incisions are
healing phase. The remainder of the facial skin is then cleaned with hydrogen peroxide and dressed with
fully undermined in a supra-SMAS (subdermal) layer Vaseline.
to a point averaging 4 cm from the incision, following
the preoperative marking plan. Hemostasis is achieved
with bipolar cautery under direct visualization. 23.5 Complications
With the skin flap adequately elevated, the SMAS
is then plicated in a posterior-superior vector using Complications occur with any surgical procedure and
2-0 Vicryl suture. The suture is secured at the zygo- the mini lift is no exception. However, mini lift sur-
matic periosteum and placed through the SMAS, creat- gery should have less opportunity for complications
ing a purse string loop. The suture is first continued than a full facelift since there is less tissue undermin-
inferiorly, then directed anteriorly, and then posterior- ing. Hematoma formation is possible but can be mini-
superiorly to return back to the zygomatic periosteum, mized with meticulous surgical hemostasis, proper
creating a teardrop loop. This SMAS suture often leaves patient selection, and cessation of all medications,
a trough deformity that is closed with interrupted plica- herbs, vitamins, and red wine that may cause bleed-
tion sutures across the depression. Free fat grafts are ing. All patients should be counseled to discontinue
placed as necessary to fill suture depressions. medications, herbs, vitamins, etc. that may cause
The skin is draped in a posterior-superior vector bleeding 2 weeks prior to surgery. Large hematomas
and secured at the highest postauricular point with should be treated to avoid skin flap necrosis, but the
an interrupted 2-0 nylon suture. This is followed by a senior author has not seen large hematomas associ-
second securing suture at the junction of the horizontal ated with this limited flap procedure. If a small accu-
temporal incision and the superior extent of the preau- mulation of blood is seen the following morning it is
ricular incision. The redundant skin is then resected in usually easily expressed through the post-auricular
a manner creating minimal skin tension. The neotragal skin closure gaps.
skin is left redundant to avoid displacement of the Flap necrosis might occur at the distal ends of flaps
tragus by skin contracture. The earlobe is placed in a where blood supply is most tenuous. This is a very infre-
position that is about 1/23/4 cm superior to the posi- quent occurrence with limited flap elevation and would
tion where it naturally lies in the unrepaired state. This most commonly be an issue in heavy smokers, who are
overcorrection prevents the lobe from being pulled too not consciously accepted as patients. Caution should be
far inferiorly during the natural tissue relaxation pro- exercised in smokers or patients with diabetes, collagen
cess that occurs over the first postoperative year, thus vascular disease, or Raynauds disease. However, the
preventing the pixie ear lobe deformity. Skin edges are senior author does not consider these situations or
a b
Fig. 23.12 (a) Preoperative patient. (b) Postoperative following minilift with forehead lift
conditions necessarily as contraindications to mini lift- 23.6 Conclusions

ing. Smokers should be counseled to reduce or discon-
tinue smoking at least 2 weeks prior to surgery. The mini lift is not a replacement for a classic face-
Sensory or motor nerve injuries are possibilities. lift, but it provides an option for patients who do not
Sensory reduction is common and not considered a present with advanced facial aging or those who are
complication; rather a normal consequence of surgery. unwilling to undergo a more extensive procedure
The senior author has never experienced a major motor (Fig. 23.12). There is relatively less risk, less morbid-
or sensory nerve injury. Masterful knowledge of facial ity, less surgical time, and less down time for the mini
nerve and greater auricular nerve anatomy will prevent lift patient. Patients also enjoy the reduced postopera-
most major nerve injuries. Compression nerve injuries tive restrictions. The mini lift has proven to provide a
usually resolve with time. high degree of patient satisfaction for those who
Deep infection should be rare, as should cellulitis. understand the limitations, are realistic, and are emo-
Antibiotic prophylaxis is used routinely. tionally stable.
References General References

1. Yarborough JM, Beeson WH (1986) Aesthetic surgery of the Baker TJ, Gordon HL (1971) The temporal face lift (mini-lift).
aging face. Mosby, St. Louis, p 142 Plast Reconstr Surg 4(4):313315
2. Hollander E (1932) Plastische (kosmetische) Operation: Duminy F, Hudson DA (1997) The mini rhytidectomy. Aesthetic
Kritische Darstellung ihres gegenwartigen Standes. In: Plast Surg 21(4):280284
Klemperer G, Klemperer F (eds) Neue Deutsche Klinik. Fulton JE, Saylan Z, Helton P, Rahimi AD, Golshani M (2001)
Urban and Schwartzenberg, Berlin The S-lift facelift featuring the U-suture and O-suture com-
3. Joseph J (1928) Verbesserung meiner Hangewangenplastik bined with skin resurfacing. Dermatol Surg 27(1):1822
(Melomioplastik). Dtsch Med Wochenschr 54:567 Onizuka T, Hsaka Y, Miyata M, Ichinose M (1995) Our mini-
4. Gossain AK, Yousif NJ, Madiedo G, Larson DL, Matloub facelift for orientals. Aesthetic Plast Surg 19(1):4958
HS, Sanger JR (1993) Surgical anatomy of the SMAS: a rein- Saylan Z (1999) The S-lift: less is more. Aesthet Surg J 19:406
vestigation. Plast Reconstr Surg 92(7):12541263 Stephenson KL (1970) The mini-lift, and old wrinkle face
5. Ghassemi A, Prescher A, Riediger D, Axer H (2003) Anatomy lifting. Plast Reconstr Surg 46(3):226233
of the SMAS revisited. Aesthetic Plast Surg 27(4):248264 Tonnard PL, Verpaele A, Gaia S (2005) Optimising results from
6. Accioli de Vasconcellos JJ, Britto JA, Henin D, Vacher C minimal access cranial suspension lifting (MACS-lift).
(2003) The fascial planes of the temple and face: an en-bloc Aesthetic Plast Surg 29(4):213220
anatomical study and a plea for consistency. Br J Plast Surg
56(7):623629
Subperiosteal Face-Lift
24
Lucas G. Patrocinio, Tomas G. Patrocinio,
Jose A. Patrocinio, and Marcell M. Naves
24.1 Introduction accentuates and no longer covers the bulge of herni-

ated orbital fat. This produces the double contour
Fullness of the cheek represents youthfulness. It is deformity characteristic of the aging orbital/midface
important to understand the anatomic changes associated complex. The vertical aperture of the eye elongates,
with aging and have a clear vision of what needs to be creating a more round shape with increasing scleral
accomplished for correction. Aging process initiates show. As tarsoligamentous laxity increases, the lateral
during the third decade, affecting the lower lid and commissure often descends, creating a more inferior
midface together, and in response to gravitational slant from medial to lateral commissure. Eyelid tone
forces, the fat and soft tissues of the cheek drift down- decreases, exhibited by skin and muscle laxity. A volume
ward in relation to the underlying bony skeleton. In loss of the midface also contributes to the aging pro-
this process of aging, a constant hollowness of the cess. Finally, the collapse of the zygomaticus major
midface develops. As a result, a patient may display an and minor muscles, which suspend the ligamentous
appearance that is tired, old, or sad [1]. and muscular connections of the midface, results in a
Weakening of the malar and orbital ligaments is a droop of the corner of the mouth and deepens the
major component of the aging process. The result is a labiomental fold (Fig. 24.1) [2].
downward and medial displacement of the malar fat pad The purpose of the face-lift procedure is to reverse
and other soft tissues over the fixed ligaments of the the aging process that has occurred. This can be
nasolabial fold. The fat over the malar eminence is left achieved through various techniques that have been
standing, accentuating the malar bag. Another anatom- developed to date. The evolution of face rejuvenation
ical change that occurs is the weakening of the orbital consists in deciding which facial plane is going to be
ligaments, which contributes to hollowness under the accessed [3].
orbit. The malar fat pad, which in youth was at the On the beginning of the twentieth century, the prior
level of the orbital rim, falls downward and medially, technique consisted of interrupted incisions placed both
producing this hollowness. This concavity, which is in front of and behind the ears in natural wrinkles and
below the convexity of the ocular globe and orbital fat, were combined with limited strips of excised skin [4, 5].
Then, there were the first descriptions of extensive skin
undermining and lipectomy. More recently, the discov-
ery of the SMAS (superficial musculoaponeurotic sys-
tem) improved the technique (plication, suture, partial
L.G. Patrocinio (*) T.G. Patrocinio J.A. Patrocinio sectioning, etc.), aiming long-lasting results. Trying to
M.M. Naves address the nasolabial fold, which so far has not been
Division of Facial Plastic, Department of Otolaryngology,
modified by other techniques, the deep plane and com-
Medical School, Federal University of Uberlandia, Uberlandia,
MG, Brazil posite face-lift were describe. They consisted in a
e-mail: [email protected] deep SMAS dissection, accessing the nasolabial fold;

338 L.G. Patrocinio et al.
Fig. 24.1 (Left) Youthful

contours. (Right) Aged Aging face Youthful face
anatomical findings
Increased
Short vertical
vertical eyelid
eyelid lenght
length
Periorbital
Inferior orbital
hollowing
rim
Tear trough
deformity High malar fat
pad
Low malar
fat pad
Soft nasolabial fold
Proeminent
nasolabial fold
Platysmal ptosis
Jowling
however, its use has been increasingly questioned utilizing the subperiosteal approach in the upper and
because of the risk of facial nerve injury [6]. Moreover, middle thirds of the face with an extensive coronal inci-
Barton, in 1992, showed with histologic sections as well sion. Following the studies of Tessier, Psillakis [1012],
as cadaver and clinical dissections that the SMAS Santana [13], and others have improved the application
became the investing fascia of the zygomaticus major of subperiosteal dissection in face rejuvenation. Isse
and minor muscles in the medial cheek, providing sup- [14] and Ramirez [1517] led to the popularization of
port for the clinical finding that the nasolabial crease this technique in United States with the introduction
was minimally improved by traction on the SMAS [7]. of the endoscope. Others described correction of mid-
Recent studies emphasize the central third of the facial aging using the transblepharoplasty approach
face, often referred as midface, the most difficult region [1820]. To address the atrophy of soft tissues, particu-
of the face to effectively address. In 1979, Paul Tessier larly the subcutaneous fatty layer, other techniques
[8, 9] revolutionized the treatment of the aging face were described [2125].
reducing signs of aging in young and middle-aged patients. The authors describe their preferred technique for
He applied his innovative and extensive experience subperiosteal face-lift and discuss its indications, com-
in craniofacial surgery to aesthetic plastic surgery by plications, advantages, and limitations.
24 Subperiosteal Face-Lift 339
Table 24.1 Patient classification with lower-lid and/or midfacial changes

Group Characteristics Surgical technique
1 Postseptal fat herniation with taut skin; no lower-lid skin laxity Transconjunctival blepharoplasty
or excess and no midfacial changes (young patients)
2 Laxity and/or excess of lower-lid skin, with or without postseptal Transblepharoplasty fat reposition
fat herniation; minimal midfacial changes or vertical descent of
the malar soft tissue
3 Lower-lid aging with descent of lid/cheek junction; skeletalization Subperiosteal transblepharoplasty midface-lift
of the orbital rim and deepening of the nasolabial fold; no lower-
lid malposition or deformities of the lateral canthus
4 Lower-lid aging with descent of lid/cheek junction; skeletalization Transtemporal midface-lift
of the orbital rim and deepening of the nasolabial fold; lower-lid
malposition (scleral show)
24.2 Preoperative Evaluation In this chapter, the transtemporal endoscopic sub-

periosteal face-lift (Group 4) is described, which is the
A complete medical history has to be obtained before technique the authors use most often.
any aesthetic surgery of the face, including allergies,
medications, medical problems, previous surgery, drink-
ing, and smoking habits. Smoking cessation is advocated 24.4 Surgical Technique
before and after surgery; however, patient disagreement
may not affect final results due to the thickness of the The surgery is usually performed with the patient
flap created during the subperiosteal face-lift. As well, under sedation, and local anesthesia (2% lidocaine
emotional and psychological evaluation is important for with 1:100.000 epinephrine) is infiltrated in all areas of
elective aesthetic surgery. Preoperative photographs are planned surgery for anesthesia and vasoconstriction.
essential, helping on preoperative planning, intraopera- The surgeon is positioned upwind to the patients head
tive decisions, patient communication, and medicolegal and the video on the left.
documentation. At the time of the preoperative consulta- Important anatomic structures to consider are the
tion, the patients are oriented about the planned procedure frontal branch of the 7th nerve and the infraorbital neu-
with written and verbal information provided. Written rovascular bundle. The important dissection planes
informed consent is also requested [3]. include the dissection deep to the temporoparietal fas-
Subperiosteal face-lift is especially advantageous to cia along the deep layer of the deep temporalis fascia
patients who had undergone other face-lift procedures, and the subperiosteal midface dissection. The surgical
need skin resurfacing and/or soft tissue augmentation (fat technique is divided into 3 major steps: (1) the endo-
graft or alloplastic implants). The association to forehead- scopic creation of a temporal pocket, (2) mobilization
lift is common and produces excellent results [26, 27]. of the midface by subperiosteal dissection, and (3) ele-
Ramirez [1517] and Psillakis [1012] demonstrated that vation and suspension of the mobilized midface to the
subperiosteal face-lift could be applied across the full deep temporalis fascia.
spectrum of facial aging. On the temporal region, a 35 cm incision, perpen-
dicular to the temporal line, is placed 3 cm behind the
hairline. The dissection is performed to identify the
24.3 Patient Classication deep layer of the deep temporalis fascia (Fig. 24.2). As
and Approach Selection the pocket is enlarged, the endoscope is introduced for
visualization. The frontal branch of the 7th nerve is
A preoperative classification of patients is essential for contained in the overlying temporoparietal fascia,
both diagnosis and approach planning. Each one of the which is analogous to the SMAS found in the lower
following categories represents patients with specific face, facilitating the mobilization of the entire zygo-
lower-lid and/or midfacial changes (Table 24.1). matic arch periosteum and protecting the frontal branch
Fig. 24.2 Cadaver dissection showing the temporoparietal fascia

(forceps) and the underlying deep temporalis fascia
of the facial nerve from injury. Identification of the

superficial temporal fat pad is an important landmark
that assures the surgeon that the frontal branch of the
facial nerve is lateral to the endoscope.
The dissection continues medially and inferiorly
exposing the medial third of the zygomatic arch and
orbital rim. An incision is made on the zygoma perios- Fig. 24.3 Extent of undermining for the transtemporal subpe-
teum, and lower subperiosteal elevation is performed riosteal face-lift
to malar imminence, gingival buccal sulcus, and naso-
labial fold. It is important to respect the arcus margin- main points: Bichats fat pad, malar fat pad, and subor-
alis, the confluence of the periosteum of the orbital rim bicularis oculi fat (SOOF) (Fig. 24.4). The first point is
and the periorbital tissues, in order to minimize the the B point (Bichats fat pad). It is located in a point
risk of edema and lid eversion in the final result. Care of intersection of a vertical line from the lateral canthus
is taken to avoid damage to the infraorbital nerve. and a horizontal line from the nasal base. Suspension
The dissection is extended to the pyriform aperture of this point promotes volumetric augmentation of the
medially, the oral vestibular mucosa inferiorly, and the midface, elevation of the corner of the mouth, and res-
superior/anterior border of the masseter muscle later- toration of a triangular face. The second point is the
ally. All the dissection detach the eyelids, external can- M point (malar fat pad), and it is located in a point of
thi and Lockwood ligaments, parotid fascia inferiorly intersection of the same previous vertical line and a
and temporalis fascia superiorly, zygomatic muscles horizontal line from the superior margin of the nasal
and levator labii superioris, and other muscles from ala. The third point is the S point (SOOF). This point
their superior origins (Fig. 24.3). The periosteum is is located in a point of intersection of a vertical line
very thin medially and a careful dissection avoids mus- form the most lateral portion of the brow and a hori-
cle injury. Complete periosteum release and division zontal line from the inferior orbital rim.
must be accomplished to avoid incomplete suspension. These three previously marked points are lifted
The final step involves suspension of the mobilized using Casagrande needle [28] (similar to Reverdin nee-
midface to the deep temporal fascia by using three 3-0 dle, but smaller) for passing the 3-0 polyester suture
polyester sutures (Ethibond, Ethicon, Inc., Somerville, (Fig. 24.4). The needle is introduced transcutaneously
NJ) to secure the cheek. The sutures are crossed through the B point and, with endoscopic view, is
and secured to the deep temporalis fascia, creating driven through the temporal incision. Then, the polyes-
appropriate superior and lateral vectors of force. ter suture is passed through the needles guide-hole and
Systematization of the midface-lifting is made by three is returned to the Bichats fat pad area. Keeping the
is sutured with uninterrupted 4-0 nylon (Ethilon,

Ethicon, Inc., Somerville, NJ).
24.5 Postoperative Care
Compressive bandage is kept during the first 610 h

postoperatively.
Supportive taping is placed for 7 days.
Another bandage is used for 7 days more after tap-
ing is removed.
Lid incision skin stitches are removed in the 7th
postoperative day.
Temporal incision skin stitches are removed in the
10th postoperative day.
Antibiotics are started prior to surgery and contin-
ued for 7 days after surgery.
24.6 Pitfalls and Complications
In spite of all care during the surgery, complications can

occur. Prevention of complications is the best approach
to managing them. Well-recognized complications of
face-lift surgery include hematoma, hair loss, skin slough,
hypertrophic scarring, infection, and motor nerve or sen-
Fig. 24.4 The systematization of the three main points for mid- sory nerve injury. Major complications including cardio-
face-lifting: Bichats fat pad (B point), malar fat pad (M point),
and suborbicularis oculi fat (S point) pulmonary emergency, anesthetic disaster, or death are
fortunately extremely rare [29, 30].
Hematoma and seroma are the commonest complica-
needle inside the soft tissues, a change of direction is tions after face-lift. Major hematomas occur in the first
performed to grasp more tissue, and the needle is driven 1012 h postoperatively, due to hypertension, medica-
to the temporal incision again. There, the suture is tion use, bleeding abnormality, intraoperative technique,
removed from the needle and it sutured to the deep tem- cough, retching, and agitation. Expanding hematoma is a
poralis fascia. The same procedure is performed at the feared complication requiring prompt return to operative
M point and the S point, bilaterally (Fig. 24.5). room for inspection, hemostasis, supportive taping, and
At the deep temporalis fascia, the Bichats fat pad is compressive dressing. Due to the bloodless plane of dis-
suspended and sutured medially, the malar fat pad cen- section, hematomas are extremely rare. Small hemato-
trally, and the SOOF laterally. Such fixation lengthens mas and seromas can be either observed, needle aspirated,
the zygomatic muscles and the soft tissue of the cheeks, or rolled through openings in the incision.
correcting tear-trough deformity, softening the nasolabial Long-lasting edema, sometimes more than 3 months,
fold. The zygomatic area is also well modeled because may occur and is due to the extensive undermining,
the zygomatic muscle insertions are reinserted in a especially at the zygomatic arch. It is advocated to avoid
higher position. Both sides must be suspended and fix- dissection over the whole zygomatic arch. Massage is
ated concomitantly (interchanging one suture of each recommended after 7 days of surgery.
side) to avoid asymmetries (Fig. 24.6). Nerve injury is one of the frightening complications
The temporal scalp incision is closed by securing the by patients. Nerve damage is frequently transient as a
temporoparietal fascia from the anterior edge of the result of anesthetic infiltration, direct injection into the
incision to the deep temporalis fascia posteriorly. The skin nerve, blunt dissection injury, edema of the nerve
Fig. 24.5 Midface suspension by sutures

anchored to the deep temporalis fascia
Fig. 24.6 (Left) Preoperative iatrogenic ectropion caused by superiosteal face-lift, in which lid skin excision was performed after
midface suspension. (Right) Postoperative outcome of the correction with canthoplasty and skin graft
Fig. 24.7 (Left) Preoperative. (Right) Immediate postoperative outcome of the midface-lift when the surgeon pulls the sutures
sheath, traction, or cautery trauma. Injury of branches The lateral orbital skin excess can be avoided by:
of the facial nerve can be prevented with a careful dis- maximizing the lateral skin excision via temporal-brow
section under the superficial layer of the deep temporal incisions; and by a wider preperiosteal lateral and supe-
fascia, as the temporal branch of the facial nerve is rior undermining via the lateral extensions of the lower-
located superficially within the temporoparietal fascia. lid incisions, allowing the lateral orbital tissues to more
Temporary numbness is caused by interruption of effectively redrape with elevation of the brow.
small sensory branches. Sensibility always recovers, Lateral canthal anchoring procedures are used to
although it may take months to do so. provide excellent lid support and avoid canthal defor-
Hypertrophic scarring is frequently attributable to mity. A simple canthopexy is used in most of the cases.
excessive tension on the incision closure. Nevertheless, Canthotomy with horizontal lower-lid shortening is
some patients develop hypertrophic scars despite the used only in older patients who exhibit more severe
best efforts of the surgeon. Diluted triamcinolone can degrees of laxity.
be injected into the scars, and usually improves the The lower-lid malposition can be avoided by a
appearance of the scar considerably. suture fixation of the musculoligamentous cheek flap
Asymmetries are rare. They are usually due to the to the periosteum of the lateral orbital rim and deep
learning curve of the procedure. Careful bilateral suture temporal fascia, providing secure elevation of the mid-
of the three points of suspension using the lateral can- face and minimizing postoperative midfacial descent.
thus as a parameter is an important rule to follow. An By performing the skin excision as usual for an iso-
augmentation of the face width may be noted, due to fat lated lower-lid blepharoplasty, and before the subpe-
pads repositioning in a superior and lateral position. riosteal cheek lift is performed, the amount of skin
When using the transblepharoplasty lower-lid app- excision is reduced compared with performing the skin
roach, there are other concerns. We should be careful excision after the cheek lift has been performed and
to avoid complications as lateral orbital skin excess, can- stabilized to the lateral orbital rim, avoiding lower-lid
thal deformity, and lower-lid malposition. skin overresection (Fig. 24.7).
Patient satisfaction is imperative for face-lift sur- in several ways. Making an effort for a long-lasting
gery. Although physicians try to help patients under- procedure, the SMAS dissection and plication, or par-
stand why complications occur, patients do not fully tial sectioning can be done; however, this procedure
expect that complications will happen to them. Indeed, has a longer learning period.
any complication detracts from the quality of the out- During the past 30 years, various modifications and
come. As such, it is difficult for both surgeons and changes to these traditional face-lift techniques have
patients to accept complications. been developed. These have varied in scope, incisions,
and level of tissue dissection.
In 1979, Tessier [9] applied his innovative and
24.7 Discussion extensive experience in craniofacial surgery to aes-
thetic plastic surgery by utilizing the subperiosteal
The earliest recorded contributions to the field of facial approach in the upper and middle thirds of the face.
plastic surgery came from ancient Egypt and India His extensive use of the coronal incision allowed him
over 2,500 years ago. In 1901, surgeons in Germany to effect increased lifting of the temporal region and
performed the first modern face-lift [4]. In these proce- the lateral canthus by a subperiosteal dissection of the
dures, they excised ellipses of facial skin without any zygoma down to the maxilla, thereby reversing the
tissue undermining. In 1920 and 1921, Bettman [31] changes in midfacial aging.
and Bourguet [32] were independently credited with In the 1980s, the emphasis turned to improving the
the first subcutaneous rhytidectomy. Unlike previous midface, traditionally the most difficult region of the
procedures, this one consisted of extensive undermining face to effectively address. This was accomplished
and lipectomy. This subcutaneous face-lift was the face- through the introduction of the deep plane and com-
lift most commonly performed prior to the 1970s. posite rhytidectomy, which was pioneered by Hamra
Subcutaneous dissection of a variably sized skin flap in [35]. He realized that by undermining the orbicularis
the face and neck is performed, followed by redraping oculi muscle through a lower blepharoplasty approach
of the skin flap, excising the excess skin, and closing and joining this with the face-lift dissection, he could
the incisions, mostly indicated on young, thin individ- create a composite flap that was composed of the orbic-
uals with minimal ptosis of deep structures and no sub- ularis oculi, cheek fat, and platysma muscle. Reposi-
mental fullness. Advantages of this technique include tioning the composite flap corrected these three ptotic
ease of operation, limited postoperative edema due to areas while maintaining their relationship with each
limited dissection, no risk of facial nerve injury, and a other and the skin. The SMAS and skin are dissected
smooth contour of the face immediately following the together as a single flap, rather than independently.
procedure. The major disadvantage of the subcutane- The advantage of this procedure is that theoretically
ous lift is the fact that the deeper tissues of the neck the flap is better vascularized and less likely to
have not been lifted. slough. The disadvantage of the technique is the mag-
More recently, technique modifications have occurred nitude of the procedure and the prolonged recovery
to address the dissatisfaction with the lack of long term period, and a higher risk of nerve damage.
correction that occurred with the classic skin under- Barton, in 1992, [7] showed with histologic sections
mining from the procedures described in the early as well as cadaver and clinical dissections that the
1900s. In 1974, Skoog [33] described a technique in SMAS became the investing fascia of the zygomaticus
which the fascia and platysma muscle were under- major and minor muscles in the medial cheek, provid-
mined to the level of the nasolabial fold and jowl in an ing support for the clinical finding that the nasolabial
attempt to address the lower third of the face. In 1976, crease was minimally improved by traction on the
the discovery of the superficial musculoaponeurotic SMAS.
system (SMAS) by Mitz and Peyronie [34] confirmed Psillakis et al. [1012] described the subperiosteal
the existence of a fascial layer investing the facial midface-lift as an open, nonendoscopic procedure.
mimetic musculature. It is also important to note that Their technique involved subperiosteal dissection of
this was the first approach that advocated the effective- the midface through a coronal incision in combination
ness of imbrication as a rhytidectomy technique. The with an eyebrow lift. They thought that since the
SMAS may be incorporated into the face-lift operation SMAS was firmly attached to the periosteum through
the facial muscles, subperiosteal undermining was periosteum over the lateral orbital rim. They determine
necessary for adequate mobilization of the cheek. the amount of skin excision before the subperiosteal
Isse [14] and Ramirez [1517] were pioneers in devel- dissection was performed, avoiding lower-lid malposi-
oping the endoscopic approach to the midface. Ramirez tion or having to perform a lateral canthoplasty.
noted that the midface dissection had several compo- Subperiosteal face-lift fascinated many authors
nents, which required careful elevation of the suborbicu- since it raises the eyebrows, eyelid lateral corners,
laris oculi fat pad with the underlying periosteum along forehead, glabella, cheeks, and nasolabial fold, reach-
the inferior orbital rim and malar areas. By starting his ing the middle third of the face. This technique includes
dissection in the temporal area and creating a tunnel less incision, use of endoscope, better fixation (espe-
between the malar-zygomatic arch and the temporal cially of the cheeks), allows for more ancillary proce-
pocket, he was able to suspend the midface suborbicu- dures, repositioning of the Bichats fat pad, and jowl
laris oculi fat pad to the temporal fascia. He approached treatment.
the zygoma from the superior direction along the deep Subperiosteal face-lift is indicated for patients with
temporalis fascia as Psillakis did. However, at 23 cm significant aging and ptosis of the oval center of the
above the arch, he incised both the superficial and deep face, tear-trough deformity, scleral show in severe
layers of the deep temporalis fascia to gain access to the malar pockets, in cases of past facial fractures, when
zygomatic arch to separate the periosteum and overlying there is the need for simultaneous resurfacing, in cases
soft tissue, as the frontal branch of the 7th nerve remained of facial implants that need to be changed, when there
superficial to their dissection. He suspended the midface is a need for soft tissue augmentation with fat transfer,
by placing sutures through the periosteum and the SOOF and even in smokers.
and the periosteum just superior to the zygomaticus As a result of the procedure, the cheek advances
major origin. Each suture was then secured to the deep upward and backward, and a tremendous amount of
temporalis fascia. vertical lift is produced. The fat pad is repositioned,
Several authors have advocated the nonendoscopic reducing the orbital hollow and the double contour
elevation of the midface through lower-eyelid blepharo- deformity. A volume augmentation is enhanced by
plasty incisions. In 1996, Hester, Codner, and McCord meloplication that fills in both the orbital hollow and
[18] published The Centrofacial Approach for Corr- the cheek hollow. The nasolabial fold is diminished.
ection of Facial Aging Using the Transblepharoplasty The oral frown is diminished, to a degree. Malar
Subperiosteal Cheek Lift. This technique was designed bags are diminished, to a degree.
to correct midfacial aging by a central, direct approach, The advantages of the subperiosteal face-lift include:
avoiding extensive peripheral to centra11.6 ptl dissec- easier correction of prominent midface wrinkles, lateral
tion in the subcutaneous, subSMAS, deep plane, or suborbital bulging caused by brow ptosis, and ptosis of
periosteal plane. In 1996, Cardim [19] described a deep soft tissue and orbital festoons; not compromis-
subperiosteal blepharoplasty to correct midface aging. ing the blood supply to overlying tissue, especially for
Similar to this technique, in 1997, Paul [20] published cigarette smokers and those who have thinner tissue;
the periosteal hinge flap as a method of correcting mid- and reduced possibility of facial nerve injury when
face aging. This technique produced vertical elevation compared with any other intermediate plane.
of the midface by suspending the subperiosteal cheek The subperiosteal face-lift technique, as originally
flap to a dissected orbital rim periosteal flap. Canthopexy described by Tessier, has benefited from significant
was not routinely performed. technologic advances in medicine. The endoscope
Moelleken [36] described a superficial subciliary now allows extensive subperiosteal undermining of
cheek lift with the use of a single subciliary incision facial soft tissue through minimal access incisions.
with suborbicularis dissection of the malar fat pad Improved understanding of facial anatomy and the
(superficial to the zygomaticus major and minor mus- facial aging process now allows surgeons to reposition
cles) and fixation to the intermediate temporalis fas- and remodel the soft tissue envelope with excellent
cia located just lateral to the lateral orbital rim. Gunter aesthetic results. Restoration of facial volume can
and Hackney [37] presented a technique in which the be achieved with the subperiosteal techniques descri-
cheek is undermined in the subperiosteal plane bed and can be applied to the full spectrum of patients
with fixation of the ptotic malar fat pad to the thick with long-lasting results.
Correct diagnosis of the aging changes in the mid- As the distance from the infraorbital rim to the
face, therefore, dictates the most appropriate choice of malar fat pad increases, the nasolabial folds deepen
surgical approach. If the findings are confined predom- and the aging perioral changes are evident; midface-
inantly to the periorbital area, with only mild descent lifting should be considered along with blepharoplasty.
of the cheek structures evident, blepharoplasty utilizing The subperiosteal face-lift is ideal because all areas of
a variety of techniques may be all that is required to midface aging, from the lower eyelid to the perioral
restore a youthful appearance to the midface. Classical area, can be addressed with a single exposure, and the
transconjunctival or skinmuscle blepharoplasty is effects of gravity can be directly opposed by a 180-degree
effective when the problem is confined to fat pseudoh- vertical vector. The transtemporal approach offers a
erniation and skin excess, without deepening of the good possible reversion of the aging effects on the
nasolabial fold. When mild cheek descent is present midface, especially when associated to forehead-lift
with resultant thinning of the soft tissues over the (Figs. 24.924.11). On the other hand, the subpe-
infraorbital rim and/or deep nasolabial folds are pres- riosteal midface-lift through lower-lid incision, com-
ent, blepharoplasty with fat repositioning is more bined with lateral canthal anchoring procedures, should
appropriate (Fig. 24.8). Fat repositioning is especially be used when the patients present lower-lid malposi-
indicated when a negative vector is present and the tion (scleral show) and/or deformities of lateral
bony orbital rim lies posterior to the plane of the cor- canthus.
nea. These patients often have scleral show preopera- Subperiosteal midface-lift can be enhanced with
tively, which will often be exacerbated with fat removal injection of fat graft (lipotransfer) [38]. Coleman, in
as in the traditional blepharoplasty. 1994, [21] published his philosophy and technique of
Fig. 24.8 (Left) Preoperative female patient. (Right) Ten months postoperative after undergoing blepharoplasty with fat repositioning

Fig. 24.9 (Left) Preoperative male patient. (Right) Eighteen months postoperative after undergoing subperiosteal midface-lift
Fig. 24.10 (Left) Preoperative female patient. (Right) Two years postoperative after subperiosteal midface-lift
Fig. 24.11 (Left) Preoperative female

patient. (Right) One year postoperative after
subperiosteal midface-lift and endoscopic
forehead-lift
Fig. 24.12 (Left) Preoperative female. (Right) Eighteen months postoperative following subperiosteal midface-lift and injection of
fat graft to the nasolabial folds
soft tissue augmentation and lifting with fat grafting. References

He advocated that the technique of lipoinfiltration
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and facialplasty. In: MacCarthy J (ed) Plastic surgery, vol 3.
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ance in more cases with more severe loss of midface 2. Patrocinio LG, Patrocinio JA, Couto HG, Muniz de Souza
volume (Fig. 24.12). Ramirez also described his H, Carvalho PM (2006) Subperiosteal facelift: a 5-year
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3. DeFatta RJ, Williams EF 3rd (2009) Evolution of midface
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Suture Facelift Techniques
25
25.1 Introduction neck using various suture materials and designs. These
include barbed and non-barbed sutures, coned sutures,
In recent years, minimally invasive facial rejuvenation and slings using materials such as polypropylene,
procedures have become more popular. From 1997 polytetrafluoroethylene, and polycaproamide sutures.
to 2008, surgical cosmetic procedures in the USA Although still in its infancy, the practice of suture
increased by 180% whereas non-surgical cosmetic lifting to improve facial contours, restore appropriate
procedures in the same period increased by more than tissue projection, and redefine bony landmarks has
750% [1]. Patients seek minimally invasive treatments been widely adopted. Despite this, published data on
that do not require prolonged recovery periods, are low safety, efficacy, and long-term results remains scant
risk, inexpensive, and provide results that look natural. [6]. Unfortunately, the furor and media-driven hype
These include chemodenervation with botulinum tox- over suture lifts, touted as lunchtime facelifts or
ins, soft tissue augmentation using injectable implants, 1-hour mini-lifts, often generate unrealistic expecta-
laser skin resurfacing, and skin tightening using a tions amongst potentially suitable patients, or sway
variety of light and radiofrequency-based technologies patients who would best be treated with a conventional
[2]. Non-surgical procedures improve hyperdynamic rhytidectomy into believing they can achieve similar
and static wrinkles, volume loss, and skin surface results with a suture facelift [7]. Nevertheless, these
imperfections but do not address ptosis of deeper tis- innovative techniques should be embraced rather than
sues including the malar fat pad and the superficial discarded so that they can be further studied, improved
musculoaponeurotic system (SMAS). Although an and refined, and eventually find their rightful place in
open facelift remains the gold standard for sagging aesthetic surgery and medicine. In the authors view,
skin, fat, and the SMAS in older patients, less invasive suture facelift techniques currently provide a better
measures using various suture systems and designs alternative to non-surgical tissue tightening devices
provide a novel alternative for younger patients with such as radiofrequency and infrared light for patients
early signs of aging. Suture facelift techniques are used who would benefit from lifting mild to moderate ptosis,
as adjunctive measures during traditional open proce- but they do not replace open facelift procedures for
dures [3], as a complement to less invasive open tech- those with more severe ptosis or excessive skin laxity
niques [4], or as closed procedures without dissection (Table 25.1).
through minimal incisions or punctures [5]. This chap-
ter will focus on closed suture lifting techniques, com-
monly referred to as thread lifts, for the face and 25.2 Concept
The goal of any facial rejuvenation procedure is to

restore the youthful appearance of the skin and facial
P.M. Prendergast
Venus Medical, Dundrum, Dublin 14, Ireland features and create contours, proportions and shapes
e-mail: [email protected] that are generally perceived as being attractive. These

356 P.M. Prendergast
Table 25.1 Advantages of suture lifting techniques The rationale for treatment using suture facelift
Advantages for the patient Advantages for the surgeon techniques is to reverse early signs of aging by lifting
Performed under local Short learning and suspending tissues that have begun to drop. By
anesthesia curve repositioning soft tissue in this way, not only are the
Short downtime Performed in office setting sagging tissues lifted, but volume is also restored in
Minimal or hidden scars High patient demand important areas, such as the midface. Even a lift of
Provide subtle, natural- Useful adjunct to other
510 mm in the midface area restores the beauty tri-
looking rejuvenation surgical and non-surgical
Relatively inexpensive procedures angle by changing the shape of the face from one that
Can be repeated over time is rectangular to a heart-shaped one that is more pleas-
ing and youthful. Suture techniques are not intended to
correct more advanced signs of aging where signifi-
cant skin laxity is present. Similarly, excessive fatty
include a gently arching brow in females, high, defined deposits in the face, submental area, and neck are not
cheekbones, full cheek anteriorly with smooth lid- improved with suture facelift techniques alone, partic-
cheek junction, and a clearly defined jawline. Several ularly when the overlying skin is tight. These problems
classifications for facial aging have been proposed that require more aggressive measures such as rhytidec-
describe senescent changes in the upper, middle, and tomy and lipoplasty.
lower thirds of the face as well as the neck [8]. Gravity Closed suture lifting techniques employ sutures of
facilitates the aging process by providing a vertically various types and designs to either loop around or
inferior vector for tissue that has lost elasticity, under- spear subcutaneous fat or fascia and lift or suspend it
lying structural support, or both [9]. Volume changes in a predetermined vector. The author performs suture
are usually involutional and are now known to occur lifts under regional and infiltrative local anesthesia
both in the underlying bony skeleton [10, 11] as well only without sedation. These minimally invasive pro-
as the soft tissues. In the forehead and temples, thin- cedures can be performed in an office-based setting,
ning of subcutaneous fat reduces the buffer between through minimal incisions or punctures, and allow a
skin and the underlying hyperdynamic muscles of quick return to normal activities. They offer appropri-
facial expression, resulting in horizontal and vertical ately selected patients a natural-looking rejuvenation.
forehead lines. As periorbital bony support decreases For the physician, the learning curve is short and sev-
and tissues become lax, the brow drops to a horizontal eral hands-on workshops and preceptor courses are
position below the level of the supraorbital ridge, available throughout the world [12].
resulting in dermatochalasis. In the midface, the malar
fat pad descends gradually from its normal position
over the zygoma. This descent leads to several aging 25.3 Patient Selection
traits. As the fat falls away from the lid-cheek junction,
the lower lid appears to lengthen and the infraorbital The ideal patient for a suture facelift has mild ptosis of
area above the cheek develops a crescent-shaped hol- one or more of the following areas: brow, lateral can-
low or tear trough deformity. The nasolabial fold deep- thus, malar fat pad, jowls, and neck. Even mild ptosis of
ens as the malar fat pad superolateral to it drops. these areas can produce a sad or sullen look and lifting
Further inferolateral descent of the malar fat pad by a few millimeters will change the overall counte-
accentuates the jowls and flattens the cheek superiorly. nance to a more pleasing one (Fig. 25.1). Visible tear
In the jowls, fat deposition rather than involution is troughs, flattened anterior cheeks, and deepened naso-
typical and this reduces jawline definition characteris- labial folds are evidence of descent of the malar fat
tic of a youthful appearance. Aging in the neck begins pads and all improve with suture elevation of the fat
with mild skin laxity and hypertrophy of the platysma pads alone. Suture lifting of the face and neck are
muscle, which appears as vertical bands. This pro- appropriate when there is interruption in the definition
gresses to prominent sagging platysmal bands and of the jawline and an increase in the cervicomental
horizontal folds, with varying degrees of submental fat angle. Most suitable candidates are 3045 years old,
accumulation and submandibular gland ptosis. although the author has successfully treated patients
25 Suture Facelift Techniques 357
a b
Fig. 25.1 (a) Preoperative. (b) After suture facelift showing subtle rejuvenation
ranging from 27 to 66 years. Skin laxity should not be lifting. There was no one procedure from which all
excessive and facial volume should be normal or others evolved. Rather, separate inventors and pio-
slightly reduced. Expectations should be realistic in neers independently developed their own techniques
terms of both the extent of lifting and the longevity of using different concepts and materials, from coun-
the results. One maneuver used by the author to deter- tries as disparate as Russia and the USA [13]. Some
mine suitability and likely results achievable from a sutures have tiny projections called barbs or cogs
suture lift is shown in Fig. 25.2. The surgeons index along their length to grasp tissue; another has tiny
fingers are placed at the points where the sutures pur- cones for the same purpose; and others are non-
chase on the subcutaneous tissues and lifted about barbed and designed to simply pass around tissue
10 mm. This degree of lifting is realistic and achievable like a sling. Newer sutures and techniques are emerg-
in most selected cases. Instructions are provided to the ing as the demand for minimally invasive procedures
patient prior to the procedure (Table 25.2). Following a continues [14]. A classification for suture lifting
detailed discussion including all potential risks and techniques is presented in Table 25.4. There is a lack
complications, a consent form is signed (Table 25.3). of evidence that one technique or system is superior
to the others. As such, personal experience, training,
and perhaps even marketing influence the decision
25.4 Suture Types and Materials to adopt one method over another. The author uses
absorbable non-barbed sutures for the upper and
There are several sutures in use today to lift the face lower thirds of the face, coned sutures for the mid-
and neck. The wide variation in both suture type and face, and either non-absorbable or coned sutures for
operative technique reflects the origins of suture the neck.
25.4.1 Barbed Sutures

a
Although the concept of barbed sutures began in 1956
[15], their use for facial rejuvenation was first reported
in the 1990s [16]. Barbed sutures are designed with tiny
hook-like projections cut into their long axes. The func-
tion of the barbs is to grasp tissue, distribute forces
along the length of the barbed portion of the suture, and
elevate or compress tissue in the direction of the barbs.
Over the last decade, several barbed sutures have been
brought to market that vary in length, number of barbs,
orientation, and arrangement along the suture, as well
as insertion and deployment characteristics.
25.4.2 Non-anchored Bidirectional

Barbed Sutures
b
In 1998, Sulamanidze invented a non-absorbable
polypropylene suture with barbs on both halves of the
suture converging toward the central portion (Fig. 25.3).
Sulamanidze called these sutures Aptos threads
(APTOS, Moscow, Russia), referring to the anti-ptosis
procedure they perform. Aptos threads are available in
2-0 and 3-0 sizes and in various lengths. They are
inserted into the subcutaneous tissues of the face in pre-
determined paths by threading them through an 18 G
spinal needle. Once the needle is removed, the suture
remains in place with either end protruding from the
skin. The soft tissue is then fashioned around the barbs,
as slight traction is applied to each end. This has the
c effect of bunching up subcutaneous fat along the length
of the suture and lifting the tissues in a vector perpen-
dicular to the long axes of the sutures (Fig. 25.4). In this
way, the malar fat pad can be made to lift superolaterally
and project anteriorly, and the jawline can be made to
straighten by lifting the jowls [17, 18]. After manipulat-
ing the tissue to create the desired effect, the ends of the
suture are trimmed and pushed under the skin.
The Happy Lift Double Needle (Promoitalia
International Srl, Rome, Italy) is a newer polypropyl-
ene suture with bidirectional barbs arranged conver-
gently. Unlike Aptos threads, there is a straight needle
swaged to either end of the suture, obviating the need
for a spinal needle for placement (Fig. 25.5). The barbs
Fig. 25.2 Assessing a patient for a suture lift. The surgeons on Happy Lift threads are forked, presumably to
finger lifts the tissues 10 mm. (a) Temporal lift. (b) Lower face- improve purchase on the tissues (Fig. 25.6). The
lift. (c) Neck lift
concept of these threads is the same as Aptos, and the
placement is similar, although more acute angles are
Table 25.2 Pre-operative instructions: suture lift

1. DO NOT SMOKE for 2 weeks prior to and 2 weeks after surgery. Smoking reduces blood circulation, slows down healing
and may increase complications.
2. DO NOT TAKE ASPIRIN or products containing aspirin for 2 weeks prior to or following your scheduled surgery. Aspirin
affects your bloods ability to clot and could increase your tendency to bleed during surgery or during the post-operative period.
3. DO NOT TAKE DIETARY SUPPLEMENTS for 2 weeks before and after surgery. These include vitamins, ginger, Ginkgo
biloba, garlic, ginseng, and fish oils. They may increase your risk of bleeding and bruising during and following surgery.
4. DO NOT DRINK ALCOHOL for 5 days prior to surgery. Alcohol may increase your risk of complications such as bruising.
5. IF YOU DEVELOP A COLD, COLD SORE, FEVER, OR ANY OTHER ILLNESS PRIOR TO SURGERY PLEASE
NOTIFY US.
6. WASH HAIR ON THE DAY PRIOR TO SURGERY.
7. LEAVE JEWELRY AND VALUABLES AT HOME. Do not wear wigs, hairpins, or hairpieces.
8. AVOID WEARING MAKEUP OR FACIAL MOISTURIZERS.
9. SURGERY TIMES ARE ESTIMATES ONLY. You could be at the clinic longer than indicated.
10. HAVE A LIGHT BREAKFAST on the morning of surgery. Your suture lift procedure will be performed under local
anesthesia without sedation.
I HAVE READ AND FULLY UNDERSTAND THE ABOVE ITEMS 110.
Table 25.3 Consent for suture lift procedure

What is a suture lift?
A suture lift is a thread lift procedure in which a special thread (e.g. polycaproamide or polypropylene) is passed under the skin,
looped around, or inserted through fat or other tissue such as the superficial musculoaponeurotic system (SMAS) and retracted
back to lift areas of the face or neck. It is minimally invasive, requiring a small incision or puncture, often placed behind the
hairline. The procedure is performed under local anesthesia.
Suitability for a suture lift
You will be assessed thoroughly beforehand to determine if you are suitable or not. Typically, patients who are suitable have
mild drooping or sagging of cheeks, jowls, neck, or brow, and are otherwise in good physical and mental health. If you have
more severe sagging, a suture lift might not be appropriate, and you will be advised on alternatives.
Procedure
A number of markings are made on the treatment area. Then a small incision is placed, usually behind the hairline where it is out
of sight, and a stitch is passed under the skin in the fat or under muscle or fascia (layer above muscle). Sometimes a small patch
is placed in the incision to secure the sutures. The tissues are gently retracted and the suture is tied, securing the lift. Finally, if
present, the skin incision is closed.
Special precautions
You should not proceed with this procedure if you are pregnant or breast feeding, or if you are allergic to local anesthetic agents.
If you have medical conditions or are on certain medications, such as aspirin, steroids, or warfarin, treatment may be deferred, so
you need to give your doctor your complete medical history. You should avoid taking vitamins and herbal supplements such as
Ginkgo biloba and St Johns Wort for 2 weeks before treatment.
Potential risks and complications of a suture lift procedure
A small cannula (like a needle) is passed under your skin. As such, there is always a small risk of damage to structures under the
skin, including the facial nerve, other nerves, and blood vessels, causing facial weakness, numbness, or bleeding. Weakness,
although extremely rare, may be permanent. Numbness usually resolves or improves over time You may experience some
swelling, bruising, and pain following the procedure. As with any injectable or invasive procedure, you may develop an
infection, though the chance is low. You will receive a course of prophylactic antibiotics for 1 week following your treatment.
Benefits and outcomes of treatment
It is usual to notice immediate lifting of the treatment area. You may see some bunching of skin near the hairline. This is
normal and resolves after about 34 weeks. There is a small possibility that the procedure will fail if the suture cuts through the
fat and tissue under the skin. Adhering to aftercare instructions will lessen this risk. Benefits of a suture lift will last a variable
period of time, depending on the individual, and no guarantee of results or longevity of results is given. It is usually possible to
reverse or repeat the procedure if required.
Alternatives to a suture lift procedure
Alternatives to a suture lift procedure include non-invasive skin tightening using infrared light or radiofrequency, other suture lift
procedures, a surgical face lift procedure, or indeed no treatment at all.
Initial:___________
(continued)
Table 25.3 (continued)

CONSENT FOR SUTURE LIFT PROCEDURE
Please answer the following questions by ticking the appropriate box
Have you previously undergone a suture lift or facelift procedure? Yes No
If yes, specify: ________________________________________
Do you have any known allergies? Yes No
If yes, specify: ________________________________________
Are you currently taking any of the following medications: warfarin, Yes No
aspirin, plavix, steroids?
Are you pregnant or breast feeding? Yes No
Have you previously completed a New Patient Data Form at Venus Yes No
Medical Beauty?
Please state if you have any other medical conditions, allergies, or are taking any medications not previously outlined in the New
Patient Data Form:
I have read the information on the suture lift procedure outlined on this form and fully understand the nature of treatment, all
clinical implications and potential risks involved. I have had the opportunity to ask questions to my satisfaction. I understand that
it is my right to withdraw consent to treatment at any time. I consent to being photographed prior to treatment and understand
that this photograph will remain the property of Venus Medical Beauty and may be used for educational or academic purposes.
I willingly accept and consent to treatment with the suture lift procedure.
Patient signature _____________________________________________ Date ______________________
PRINT _____________________________________________
OFFICIAL USE ONLY

I have explained to the patient the suture lift procedure. I have outlined the expected benefits of treatment, as well
as any potential risks, complications, and side-effects of treatment. I have given the patient the opportunity to read
the literature pertaining to this treatment and clarified any further questions and queries where they existed. I have
explained alternatives to treatment, including no treatment.
Doctor signature _____________________________________________ Date ______________________

PRINT _____________________________________________
possible due to the ease of insertion using the attached stable temporalis or mastoid fascia [19]. This 60-cm
needles. There is little information in the literature on long thread has a 4-cm smooth central portion, a 20-cm
the use of these threads. section on either side of this with convergent barbs,
and a smooth portion measuring 8 cm at either end.
This so-called Woffles thread is passed subcutaneously
25.4.3 Anchored Bidirectional along the chosen vector through an 18 G spinal needle
Barbed Sutures via two stab incisions. The needle passes from the
inferior incision, through the subcutaneous fat, and
In 2002, Wu devised a bidirectional barbed polypro- bites the deep temporalis or mastoid fascia superiorly.
pylene suture to elevate soft tissue and anchor it to One arm of the thread passes from the inferior to
Table 25.4 Classification for closed suture lifts

Type Subtype Suture
Barbed suture Bidirectional barbed Non-anchored 1. Aptos suture (APTOS, Moscow, Russia)
lifts 2. Happy Lift Double Needle (Promoitalia Int Srl, Rome, Italy)
Anchored 1. Woffles sutures (Singapore)
2. Articulus (previously Surgical Specialties Corp., Reading, PA)
3. Happy Lift Revitalizing threads (Promoitalia Int Srl, Rome,
Italy)
4. I-Lift Tensor Threads (Argentina)
Unidirectional barbed 1. Isse Endo Progressive Facelift suture (KMI Inc, Anaheim, CA)
2. Contour Threads (previously Surgical Specialties Corp.,
Reading, PA)
3. Happy Lift Ancorage (Promoitalia Int Srl, Rome, Italy)
Non-barbed Subcutaneous lift 1. Curl lift using polypropylene
suture lifts 2. Malar fat pad sling using ePTFEa (Gore-Tex Inc, Flagstaff,
Ariz)
SMAS lift 1. Serdev technique using polycaproamide
Coned suture 1. Silhouette suture (Silhouette Lift, Kolster Methods Inc.,
lifts Corona, CA)
a
Expanded polytetrafluoroethylene
Fig. 25.3 Aptos

polypropylene suture with
bidirectional barbs
superior incision via the spinal needle as far as the original Aptos thread but to either end a straight needle
smooth central portion of the thread. The needle is is attached. The two needles are lightly fused, enabling
then removed and reinserted through the superior inci- a single entry point. After the two needles puncture the
sion to the lower one so the other arm of the thread can skin as one whole, they are broken apart and take two
be passed in the same way. The needle is removed, and different courses. The point of anchorage using this
the two ends emerging from the superior incision are technique is the point of entry: zygomatico-cutaneous
lifted. This traction lifts the tissues at the smooth end ligaments for a midface lift or temporalis fascia for an
of the thread and fastens the thread ends in the deep eyebrow lift.
fascia via the downward facing barbs (Fig. 25.7). Both Ruff, an American plastic surgeon, did extensive
ends of the sutures are either cut flush with the fascia work and research on the use of barbed sutures for tis-
or tied to each other above it. Wu has developed sec- sue approximation as well as facial rejuvenation [20].
ond and third versions of this technique by inverting In 2001, he obtained a patent for his barbed sutures
the V so that both free ends are in the face (Fig. 25.8), and insertion devices and formed Quill Medical.
and interlocking two sutures to reduce the likelihood Working with Surgical Specialties Corporation, Ruff
of cheese-wiring through the soft tissues at the point developed and marketed his barbed sutures for face-
of maximal tension. lifting under the name Contour Threads. Although
A second version of the Aptos thread by Sulamanidze Angiotech has since acquired Quill Medical, and
employs the same bidirectional barbed suture as the Contour Threads are no longer in distribution, they
Fig. 25.4 Free-floating Aptos sutures with lifting vectors in the

brow, malar fat pad and jawline
were used widely [2123]. One version of Contour

Threads, called Articulus, is an anchored bidirectional
barbed suture. It consists of a 55-cm clear polypropyl-
ene suture with two 17-cm straight needles swaged to
the ends. The central 5 cm of the suture is smooth and
adjacent to this there are two 15-cm barbed sections. Fig. 25.5 Double Needle Happy Lift suture with bidirectional
The barbs are convergent toward the central portion. barbs
Each needle is attached to a 10-cm non-barbed section
(Fig. 25.9). Placement of the Articulus is via a small
incision in the temporal hairline. One of the needles clear polypropylene sutures vary in size for face, neck
is passed distally through the temporal incision, taking and brow lifting (Fig. 25.11).
a bite of deep temporal fascia, and exiting in the
midface, lateral to the nasolabial fold. The second
needle follows along a similar vector but exits more 25.4.4 Unidirectional Barbed Sutures
inferiorly. The thread ends are then held as the skin and
fat pad are walked up the barbed suture until their The early bidirectional free-floating Aptos sutures,
elevated position provides a satisfactory enhancement marketed in the USA as FeatherLift, were modified by
(Fig. 25.10). The barbs prevent slippage of the elevated Isse who designed a unidirectional barbed suture. The
tissues whilst the non-barbed central portion of the Isse Endo Progressive Facelift suture (KMI Inc,
thread is anchored superiorly to the temporalis fascia. Anaheim, CA) is a polypropylene thread measuring
To prevent cheese-wiring, this portion can be rein- 25 cm with the distal 15 cm bearing 50 unidirectional
forced with a non-absorbable Gore-Tex pledget. barbs. Isse describes his technique of closed melopli-
I-Lift Tensor Threads, a company based in Argentina cation using six threads for each malar fat pad [24].
and Spain, produce other anchored bidirectional barbed Through a temporal incision, a small area of dissection
sutures called I-Lift sutures. These non-absorbable, is carried toward the zygomatic arch between the
Fig. 25.6 Happy Lift suture

with bifid barb morphology
superficial and deep temporal fascia. A 20 G 16-cm

spinal needle is used to thread each barbed suture
through the malar fat pad. Once the needle is removed,
Fig. 25.7 Woffles bidirectional suture in situ
the sutures are lifted, trimmed and secured to the
deep temporal fascia by tying the smooth ends to a
neighboring suture. The upward-facing barbs engage The Happy Lift Anchorage sutures (Promoitalia
the fibrofatty tissue of the malar fat pad and elevate it International Srl, Rome, Italy) provide a similar
to a more youthful position. This also reduces the method of suspension to Contour Threads, although
appearance of the tear trough, nasojugal fold, and soft- differences exist. These include a greater barb den-
ens the nasolabial fold. sity on Anchorage sutures (10 barbs per 1.6 cm)
Contour Threads (Surgical Specialties Corp., compared to Contour Threads (7 barbs per 1.6 cm),
Reading, PA) were pioneered by Ruff and patented in and a different barb-morphology (Fig. 25.13). Happy
2004. The original and most widely used design was Lift sutures are now also available in both non-
the 25-cm, 2-0 polypropylene suture which contains absorbable polypropylene and slowly absorbable
helicoidally arranged unidirectional barbs along its polydioxanone.
middle 10 cm. On one end there is a half-circle needle
for anchoring to fascia and on the other a 7-in. taper-
point straight needle for thread placement (Fig. 25.12). 25.4.5 Non-barbed Sutures
The straight needle is passed, in a serpentine course,
through small stab incisions in the scalp or behind the Bukkewitz described the first suture suspension lift for
ear, and exits at the brow, lateral to the nasolabial fold cosmetic enhancement in 1956 [25]. He used a strip of
or near the midline of the neck. The straight needle is nylon, inserted subcutaneously, to retract and improve
then removed and the superior end of the thread is a ptotic buccolabial fold. Starting in 1966, Guillemain,
secured by suturing it to the fascia. With the patient in working with Galland and Clavier, started lifting all
the sitting position, the distal end of the suture is held areas of the face by passing tendons or nylon into the
and the tissues are pushed up along the cogs to lift and tissues with a Reverdin needle and in their 1970 publi-
contour the brow, midface, or neck. Finally, the distal cation gave the technique the term curl lift [26].
ends of the sutures are cut flush with the skin. Despite Since then, other materials used to sling and suspend
being the most widely used barbed suture suspension drooping tissues include polypropylene (Prolene),
technique in the USA, there is limited data on their expanded polytetrafluoroethylene (Gore-Tex), and
efficacy and longevity [21]. polycaproamide (Polycon).
Fig. 25.10 Contouring following the insertion of the Articulus

suture. The end of the suture is held as the tissues are pushed
Fig. 25.8 Woffles inverted suture in situ up along the barbs. The ends of the suture are then cut flush with
the skin
again toward the scalp incision just parallel to the first

passage. The other end of the thread exits, and the two
ends are lifted and tied. This is a simple, quick tech-
nique to lift subcutaneous fat but the smooth inelastic
polypropylene suture tends to cut through the soft
tissue at the point of lifting and results are short-lived.
Erol and Hernandez-Perez described simplified
Fig. 25.9 Articulus suture. This is a clear polypropylene suture
with two 17-cm straight needles, a smooth 5-cm central portion, suture suspension techniques to elevate the brow using
two 15-cm barbed sections and a 10-cm non-barbed portion nylon and polypropylene, respectively [27, 28]. Small
adjacent to each needle. The barbs converge toward the central punctures are made at the hairline and at the level of
portion the brow to allow passage of the sutures in the subcu-
taneous plane using a needle (Fig. 25.15). In Erols
25.4.6 Non-absorbable Non-barbed technique, the brow is suspended in the elevated posi-
Sutures tion it assumes when the patient lies supine. Following
infiltration of lidocaine 2% with 1:200,000 adrena-
Mendez Florez revisited Guillemains curl lift tech- line, four stab incisions are made using a #11 blade,
nique and designed a straight double-bevel needle two directly above the lateral brow and two at the
to pass the polypropylene suture into the tissues temporal hairline. A 4/0 nylon suture is passed from
(Fig. 25.14) [26]. A small puncture is made in the the medial to lateral brow incisions and the needle is
cheek or brow and another one behind the hairline. then cut from the suture. Then an angiocatheter is
The straight needle passes through the lower incision passed subcutaneously from the lateral hairline inci-
and exits via the one in the scalp to receive one end of sion to lateral brow incision and the end of the suture
the thread. Then the thread is retracted back into the is passed through the eye of the catheter. The angio-
wound to a point just cephalad to the inferior puncture. catheter is withdrawn, bringing the suture out through
Here, the needle is rotated 180 and tunneled once the lateral hairline incision. The same maneuver is
Fig. 25.11 Bidirectional

barbed polypropylene sutures
with swaged needles from
I-Lift Tensor Threads
sions to bring the suture to the medial incision. A knot

is made to hold the eyebrow in position so that it does
not drop inferiorly when the patient stands upright.
Hernandez-Perez uses 3-0 polypropylene and a Keith
needle to lift the brow in a similar manner and pro-
poses that the loose tissues of the lateral brow, the
undermining effect of the Keith needle, and the
postoperative fibrosis that occurs along the sutures is
enough to hold the brow in place without cheese-
Fig. 25.12 The Contour Thread. A 25 cm, 2-0 polypropylene wiring. These brow-lift procedures require superficial
suture with helicoidally arranged unidirectional barbs along its passage of needles, just under the skin, to avoid injur-
middle 10 cm. On one end there is a half-circle needle for ing the temporal division of the facial nerve where it
anchoring to fascia and on the other a 7-in. taper-point straight
needle for thread placement passes about 2 cm above the lateral brow.
For midface rejuvenation, permanent sutures or
slings elevate the malar fat pad without the need for
long incisions, undermining or dissection [3]. Sasaki
describes his technique using either permanent CV-3
expanded polytetrafluoroethylene (Gore-Tex Inc,
Flagstaff, Ariz) or 4-0 clear Prolene sutures. The suture
system used consists of a CV-3 Gore-Tex suture, a
3-0 braided Vicryl suture, a 3 8 mm Gore-Tex anchor
graft, a second 4 4 mm anchor graft, two 10-cm
Keith needles and a 4-0 dyed Prolene guide suture
(Fig. 25.16). Two stab incisions using a #11 blade are
made along the nasolabial fold and a 1.5-cm incision is
made in the temple 1 cm above the hairline. The first
Keith needle with suture slings attached passes through
the upper incision near the nasolabial fold and travels
Fig. 25.13 The Happy Lift sutures have ten regularly spaced subcutaneously, through the malar fat pad, and exits
barbs per 1.6 cm of barbed portion from the temporal incision. The second needle passes
through the same incision at the nasolabial fold, but in
performed for the medial end so that both ends are a course parallel to the first needle, and also exits
exiting from the hairline incisions. Finally, the through the incision behind the hairline. Then the
angiocatheter is passed from the medial to lateral inci- braided Vicryl suture is used like a gigli saw to cut
Fig. 25.14 Double-bevel

needle used for curl lift
a b
c
d
Fig. 25.15 Brow suspension using a simple suture. (a) Two the lateral temporal incision. (d) The same maneuver is repeated
stab incisions are made at the lateral brow and two at the tempo- so that a loop is created and both suture ends exit at the medial
ral hairline. (b) A suture is passed from the medial brow incision hairline incisions. The suture is tied to suspend the brow in an
to the lateral one and the needle is cut from the suture. (c) An elevated position
angiocatheter is passed subcutaneously to bring the suture end to
Keith Needle 3-0 Vicryl Braided 4-0 Blue Prolene

4-0 Clear Prolene
Suture Guide Suture
Suspension Suture
Gore - Tex Anchor

Graft (3x8mm)
Temporal Gore-Tex
Anchor Graft
(4x4mm)
Fig. 25.16 Sasakis suture suspension system for elevation of the malar fat pad
through any dermal attachments at the nasolabial

puncture site before the Gore-Tex sling and anchor
graft are pulled under the skin through the puncture.
The dyed Prolene suture is used to guide the anchor
graft into place, or to retrieve the graft if it does not lie
correctly. Once the Gore-Tex sling is in place and the
malar fat pad is suspended adequately, the Vicryl and
guide sutures are removed and the Gore-Tex ends are
secured by passing them through the second 4 4 mm
anchor graft and suturing them to the deep temporal
fascia using a French-eye needle (Fig. 25.17). This
technique can also be performed during open proce-
dures, or with some dissection along the deep temporal
fascia to create a pocket anteriorly past the brow [29].
Yousif describes his technique using expanded polytet-
rafluoroethylene (Gore-Tex MycroMesh, W.L. Gore
and Associates, Flagstaff, Ariz.) to lift the malar fat pad
in a vertical vector, although this is a true sling and not
a suture and is performed as an open procedure [30].
The Aptos Needle, invented by Sulamanidze, con- Fig. 25.17 Elevation of the malar fat pad using polypropylene
sists of a smooth non-barbed polypropylene suture slings with Gore-Tex anchor grafts
attached to the middle of a double-pointed needle
(Fig. 25.18) [16]. Midface elevation is achieved using rejuvenate the neck. For this, an incision is made in the
the suture to loop around the tissues to lift them in retroauricular area and a 2-0 Prolene suture is placed in
different superior vectors. The double-point allows the mastoid fascia as a holding suture. By passing the
passage of the needle in a loop without the need to long Aptos Needle from one retroauricular incision to
completely exit the skin so that the suture remains in the contralateral side, without completely exiting the
the same plane throughout its course. A single incision skin as above, the suture is brought from one side to
need only be made and the sutures are anchored to the the other subcutaneously, and functions as a sling.
periosteum of the lateral or inferior orbital rim Each end of the suture is tied to the holding sutures,
(Fig. 25.19). A similar longer Aptos Needle is used to securing them to the mastoid fascia. More than one
suture can be placed in this way until the tissues are

lifted and the cervicomental angle is restored.
Giampapa described a similar suture suspension tech-
nique to improve the cervicomental angle using Prolene
in combination with liposuction and partial platysma-
plasty through a submental incision [31].
25.4.7 Absorbable Non-barbed Sutures
Serdev, a Bulgarian cosmetic surgeon, improved upon

Guillemains original and Mendez-Florezs revised
curl lift techniques by using slowly absorbable non-
barbed semi-elastic polycaproamide sutures to lift
moveable tissues and secure them to stable structures
such as deep fascia or periosteum [3234]. Using
curved suture-passing needles (Fig. 25.20), the braided,
antimicrobial sutures are passed through the platysma
Fig. 25.18 Aptos needles are designed to pass through tissues
of the neck, the superficial musculoaponeurotic system
without the need to exit completely. This keeps the suture in the
same plane throughout its course (SMAS) of the mid and lower face, the malar fat pad,
and the superficial temporal fascia of the upper face.
These tissues are gently lifted and suspended by pass-
ing the suture ends under the mastoid fascia, perios-
teum, or deep temporal fascia. These suspension
techniques improve the cervicomental angle and defi-
nition of the jawline, reduce the appearance of jowls,
elevate the malar fat pad, and lift the corner of the eyes
and tail of the brow (Fig. 25.21). There are certain
advantages of Serdevs techniques. The propensity of
the sutures to cheese-wire through the tissues is less
because the SMAS, and not just subcutaneous fat, is
lifted. The braided sutures also yield somewhat to
movement due to their elasticity. Using special needles,
the sutures are anchored to deep fascia or periosteum
through tiny punctures only, obviating the need for
incisions or skin closure. The polycaproamide sutures
absorb over 23 years, an obvious advantage for suture
lifting where subsequent procedures are likely as the
aging process continues. These simple but effective
suture suspension techniques will now be described
for the upper, mid, lower face, and neck.
25.4.7.1 Upper Face (Fig. 25.22)

The suture facelift technique in the temporal area pro-
vides a subtle but important rejuvenation of the upper
face by lifting the tail of the eyebrow, the lateral can-
thus, and the upper cheek. In the periorbital area, ele-
vation of soft tissues by 13 mm provides noticeable
Fig. 25.19 Suture suspension using Aptos needles. The sutures
are passed like slings around the tissues of the midface and rejuvenation (Figs. 25.23 and 25.24). Markings are
anchored to periosteum on the infraorbital rim made at the proposed incision points. The first is along
a and above the deep temporal fascia between each upper

and lower point. The superficial temporal fascia is a
continuation of the galea over the frontalis muscle and
the SMAS of the middle and lower thirds of the face.
Stab incisions using a #11 blade are made at the marked
points. The curved needle is passed from the upper
medial incision to the lower medial incision, under the
superficial temporal fascia but above the deep tempo-
ral fascia. To find this plane, lift a tuft of hair above the
path of the needle and pass the needle deeply. There
should be a thick layer of tissue covering the needle
b
following passage, but it should not be so deep that the
patients head rocks when the needle is moved. This
indicates that the needle has passed under the deep
temporal fascia. Once the needle tip exits the inferior
point, a USP #2 polycaproamide sutures is passed
through the eye of the needle and the needle is with-
drawn. Next, the needle is passed in the superficial
subcutaneous plane from the lower lateral incision to
the lower medial incision and the suture end is threaded
through the needles eye and brought to the lower lat-
eral incision. The suture is above the superficial tem-
poral fascia along this line. Then the suture is brought
from the lower lateral to the upper lateral incision
under the superficial temporal fascia as before. Finally
the needle is passed into the upper medial incision,
taking a bite of periosteum and deep temporal fascia
along the superior temporal fusion line, and exits
from the upper lateral incision. The suture is brought
from this incision to the upper medial one so that both
ends exit from the same incision. The suture ends are
Fig. 25.20 (a) Curved suture passing needles for percutaneous lifted gently to elevate the superficial temporal fascia
SMAS lifting techniques. (b) Braided anti-microbial slowly
absorbable polycaproamide sutures are used to lift and anchor
(temporal SMAS) along the hairline, and elevate the
moveable tissues to stable ones tail of the brow and upper face. The suture is tied and
the incision points, if inverted or tethered down, are
released using the tip of a mosquito. The incisions heal
a line drawn perpendicular to the tail of the eyebrow, quickly by secondary intention. A small amount of
just behind the temporal hairline. A second point is bunching of skin is usual along the hairline but this
made just behind the hairline 45 cm inferior to the contracts and disappears in 12 weeks. This technique
first point. Two further points are made superior to the provides an instant rejuvenation, particularly around
first points, along the desired vector lines of lift. One the eyes (Fig. 25.25).
of these points should be along the superior temporal
crest line where the deep temporal fascia attaches to 25.4.7.2 Midface (Fig. 25.26)
periosteum. The hair is tied or retracted to expose the Traditional rhytidectomy procedures that include
skin at the marked points. After skin preparation and resection, retraction, or plication of the SMAS often
sterile draping, local anesthesia using lidocaine 12% do not achieve optimal elevation of the malar fat pad
with 1:200,000 adrenaline is injected along the pro- and midface. The triangular malar fat pad is oriented
posed path of the suture: subcutaneously between the with its base along the nasolabial fold and apex over
lower two points, on the periosteum between the upper the zygoma. It is superficial to the medial part of the
two points, and under the superficial temporal fascia SMAS and adherent to the overlying skin. Retracting
Fig. 25.21 Suture lift of

SMAS (moveable) to deep B
fascia or periosteum Superior temporal fusion line
(non-moveable) through
minimal incision (red dots). D Hairline
The red area shows area of
zygomatic arch over which A
the facial nerve passes Suture plane
(0.83.5 cm from external C A >> B: Under STF
acoustic meatus). STF G F A >> C: Above STF
superficial temporal fascia, (subcutaneous)
C >> D: Under STF
DTF deep temporal fascia D >> B: Under TM
E >> F: subcutaneous,
Catching SMAS atzygomatic
H arch
E >> G: Subcutaneous
F >> G: Under TM
E J >> H: Subcutaneous,
Catching SMAS (platysma)
at J and mastoid fascia at H
Zygomatic extension of SMAS
the SMAS in this region does not elevate the malar fat the incision at the nasolabial fold to make sure the
pad, and may deepen the nasolabial fold. Repositioning incision has passed thoroughly through the dermis.
the malar fat pad using the suture suspension tech- Using the curved needles, a USP#2 or USP#4 poly-
nique restores the beauty triangle of the face, softens caproamide suture is passed from the nasolabial fold
the nasolabial fold, and reduces the lower lid length. incision to the temporal incisions, forming a sling
The vector of lift to achieve this is superolateral. around the malar fat pad. A braided suture such as
Three punctures are made: two in the temporal hair- Vicryl can be passed together with the polycaproam-
line over the temporal fascia and one just lateral to ide suture. This second suture is used to cut through
the nasolabial fold. An artery forceps is inserted into the dermis or other connections to the skin that might
Fig. 25.22 Upper face (temporal) SMAS lift using slowly superficial subcutaneous plane (above STF) and the suture end is
absorbable polycaproamide sutures. The SMAS is called the threaded through. (e) The suture is brought to point D under STF
superficial temporal fascia (STF) in the temporal area and the as before. (f) Now both ends of the suture are exiting at the upper
galea aponeurotica medial to this over the forehead. (a) Four incisions. (g) The needle is passed deep into point B until it
points are marked as shown and stab incisions using a #11 blade reaches periosteum. (h) A deep bite is taken, underneath the
are made. One of the superior incisions (B) is made along the deep temporal fascia, and the needle receives the suture end at
superior temporal crest line (red dots). (b) The curved needle is point D. (i) The needle is retracted so that both ends exit at point
passed under the STF (above the deep temporal fascia) from B. The sutures are gently lifted and tied. This lifts the STF, tail
point B to A. (c) A USP#2 or #4 polycaproamide suture is passed of the brow and upper face. The suture is cut and buried by
through the eye of the needle and the suture is brought back from applying traction to the puncture site with the tip of an artery
point A to B. (d) The needle is passed from point C to A in the forceps
a b
c
e f
g h

i curved needles. As well as lifting the malar fat pad

superiorly, it projects anteriorly and improves infraor-
bital volume loss (Fig. 25.27).
25.4.7.3 Lower Face (Fig. 25.28)

Descent of the lower face and jowls obscures jawline
definition and changes the shape of the face from a
desirable inverted triangle or heart-shape to an unde-
sirable rectangular one. To lift the jowls, the zygomatic
extension of the SMAS is lifted using an absorbable
non-barbed suture and anchored to temporalis fascia
above the ear. Three points are marked: two above the
ear in the hairline and one just below the zygomatic
arch in front of the lobule of the ear. Lidocaine with
adrenaline is infiltrated in the subcutaneous plane
between the three points, and deeper on the periosteum
between the upper two points. Stab incisions using a
#11 blade are made at the three points. The tip of an
artery forceps is used to puncture through the entirety
of the dermis at the lower point to reduce the likeli-
hood of dimpling. A curved needle is passed subcuta-
neously from the upper anterior incision downwards
toward the lower incision. At the level of the zygo-
matic arch, a slightly deeper bite is taken to catch the
a SMAS. It is important to stay within 8 mm from the
external acoustic meatus at this level to avoid injury to
the facial nerve. The nerve always passes over the
zygomatic arch between 8 mm and 3.5 cm from the
external acoustic meatus, and usually about 2.5 cm
from it [35]. After biting SMAS, the needle comes
superficially and exits through the lower incision and
the suture is passed through the eye of the needle. The
b needle is withdrawn and a similar maneuver is made in
order to pass the suture from the lower incision to the
upper lateral incision. The needle is then passed deeply
into the upper lateral incision to catch the periosteum
under the temporal fascia and exits from the upper
medial incision to receive the suture end. In the correct
position under this deep fascia, any movement of the
needle should rock the patients head. The suture end
Fig. 25.23 (a) Preoperative. (b) After temporal SMAS lift
using absorbable sutures. Even a 12-mm lift makes the eyes is brought through to the upper lateral incision where
look less tired the two ends can be lifted gently and tied. The lifting
of the zygomatic extension of the SMAS as well as the
attached overlying skin should smooth the jawline and
cause a depression or dimple at the nasolabial fold even lift part of the neck (Fig. 25.29). Any dimpling or
incision. Once the skin is smooth at the site of lifting, inversion of skin at the puncture sites is released using
the Vicryl suture is removed and the remaining sus- the tip of an artery forceps. Some bunching in front
pension suture sits in place. The suture is then of the ear is normal and resolves spontaneously in
anchored beneath the deep temporal fascia using the 12 weeks.
a b
Fig. 25.24 (a) Preoperative. (b) After temporal SMAS lift to lift the tail of the brow in a younger patient
a b
Fig. 25.25 (a) Preoperative. (b) Immediately after temporal SMAS lift
Fig. 25.26 Closed suture suspension of the malar fat pad. (a) A from the anterior temporal incision along the other line and
point is marked just lateral to the nasolabial fold and two points receives the ends of the sutures. (h) The needle and sutures are
in the temporal hairline. The markings represent the proposed withdrawn, creating a loop around the malar fat pad. (i) The
course of the suture to lift the malar fat pad in a superolateral Vicryl suture is grasped and a sawing motion is used to cut
vector. (b) Lidocaine with epinephrine is infiltrated subcutane- through any dermal attachments at the inferior puncture until the
ously along the marked lines. (c) Using a #11 blade, stab inci- skin is smooth. The Vicryl suture is then removed. (j) The needle
sions are made at the three points. (d) The dermis is fully is passed between the temporal incisions, below the deep tempo-
penetrated at the inferior incision to minimize dimpling of the ral fascia, and the polycaproamide sutures are brought through
skin. (e) The curved needle is passed along the lower line from one incision. (k) The sutures are lifted gently to elevate the malar
the posterior temporal incision and exits at the incision lateral to fat pad, and tied. The punctures are allowed to heal by secondary
the nasolabial fold. (f) A USP#4 polycaproamide suture, together intention. A steristrip or 6-0 suture is used to seal the puncture at
with a 3-0 Vicryl suture, are passed through the eye of the needle the nasolabial fold
and withdrawn to the temporal incision. (g) The needle is passed
a b
c e
f G

j
25.4.7.4 Neck (Fig. 25.30)
Mild to moderate ptosis of the neck can be treated using
suture lifting alone, or in combination with lipoplasty
to remove fat under the chin, along the jawline and
in the jowls. The suture suspension technique using
absorbable sutures is simple and quick. After infiltra-
tive local anesthesia, two skin punctures are made: one
behind the ear over the mastoid and one in the upper
neck over the anterior border of the sternocleidomas-
toid muscle. The needle is passed through the upper
point, deeply at first to include the mastoid fascia or
periosteum, and advanced in a sinusoidal path superfi-
k cially under the skin toward the lower point. Before
exiting from the lower incision, a deeper bite is taken to
catch the platysma. A USP# 2 polycaproamide suture is
threaded through the needle and brought back to the
retroauricular incision. Another pass is made, taking a
parallel course to the first pass, and the end of the suture
is passed from the lower to upper incision so that both
ends of the suture exit behind the ear. The sutures
are retracted enough to lift the platysma and improve
the contour of the neck, and tied. If there is dimpling of
the skin at the lower puncture, an artery forceps tip is
passed into the incision and gently lifted until the
dimple is softened. Bunching of skin along the length
of the suture improves without intervention.
a b
Fig. 25.27 (a) Preoperative.

(b) After suture lift of the
malar fat pad. Note the
anterior projection of the
cheek and improvement in
tear trough hollows. A
temporal SMAS lift has also
improved dermatochalasis of
the lateral brow
a b
c d
g
h i
j
k
Fig. 25.28 Lower SMAS suture facelift. (a) Local anesthesia is from incision G to point E and receives the distal end of the suture.
infiltrated subcutaneously in front of the ear and under the tempo- (h) The needle is withdrawn so that a sling around the SMAS is
ral fascia above the ear. (b) Three stab incisions are made at points created. (i) To anchor the suture superiorly, the needle is passed
E, F, and G. (c) An artery forceps is used to penetrate the full under the deep temporal fascia above the ear from point G to point
thickness of the dermis at point E. (d) The curved needle is passed F. Moving the needle in this plane should move the patients
in the subcutaneous plane from point F toward point E. At the whole head. (j) The suture end is passed through the tip of the
lower border of the zygomatic arch a deeper bite is taken to catch needle and the needle is withdrawn. (k) Both ends exit from the
the zygomatic extension of SMAS. (e) The needle is advanced incision G. Lifting the sutures lifts the patients jowls and even
superficially and exits at point E. A USP#2 or USP#4 polycapro- neck as the SMAS is suspended. The suture is tied. (l) The inci-
amide suture is threaded through the eye of the needle. (f) The sions are lifted to bury the knot
needle is withdrawn. (g) The needle is passed subcutaneously
a b
Fig. 25.29 (a) Preoperative. (b) After lower suture facelift. There is an improvement in the jawline as well as the platysmal bands
of the neck
a b
c d
e f
g h
25.4.8 Coned Sutures end (Fig. 25.31). Included with Silhouette Sutures are
2 0.5 cm polypropylene mesh patches for anchorage
Isse designed a polypropylene suture with regularly to deep fascia. These coned sutures are particularly
spaced knots along its length and small floating cones useful for midface and neck rejuvenation and can be
made of poly-L-lactic acid. He modified his earlier performed under local anesthesia through minimal
barbed polypropylene suture for several reasons. incisions [36]. There is evidence that coned sutures
Firstly, he felt a suture with knots would be stronger offer a more secure and stable lifting than most popu-
than a suture designed with cuts to create barbs, since lar barbed sutures and are more resistant to struc-
the tensions applied to the barbs are prone to linear tural damage in human tissues [37]. The author uses
shredding where the barbs meet the body of the suture. Silhouette Sutures alone or in combination with non-
Secondly, the cones are made of a material that incites barbed absorbable sutures for midface, lower face, and
an inflammatory response and stimulates collagen to neck lifting. The technique of midface and neck lifting
secure the sutures over time. Finally, Isse believed the using Silhouette Sutures is described below.
biomechanics of the cone design would be inherently
stronger than most barbed sutures. Isses suture is cur- 25.4.8.1 Midface (Fig. 25.32)
rently marketed as the Silhouette Suture (Silhouette The patient is marked in the sitting position. A line is
Lift, Kolster Methods Inc., Corona, CA). This is pre- drawn from the lobule of the ear to the modiolus.
sented as a clear 3-0 polypropylene suture with 11 Sutures should not cross this line as animation and
cones and multiple knots to prevent slippage of the movement at the mandible may lead to disruption. The
cones and to hold them equidistant from each other proposed path for the sutures is marked along the sides
within the tissues. The cones are made of poly-L-lactic of the face. These markings reflect the appropriate lift-
acid and absorb over 810 months. There is a 20.3-cm ing vectors, which are superior and superolateral. The
20 G straight needle swaged to the distal end of the inferior points mark the exit sites for the needles and
suture and a 26-mm half-circle needle to the proximal start about 1 cm lateral to the nasolabial fold with
Fig. 25.30 Neck lift using suture suspension technique. (a) advanced again through the same puncture, taking a serpentine
Local anesthetic is infiltrated superficially along lines h to j. An course through the superficial tissues, and exits at the distal inci-
incision using a #11 blade is made behind the ear (h) and over sion to receive the end of the suture. (f) The needle is retracted
the anterior border of the sternocleidomastoid muscle (j). (b) A again so that both suture ends exit at the retroauricular incision.
curved needle is passed from incision h toward incision j. Just (g) Retracting the sutures lifts the neck and improves the cervi-
before exiting at j, the needle takes a deeper bite to catch the comental angle. If there is a dimple at the inferior incision, this
platysma muscle (SMAS). (c) The needle exits and a USP#2 is released with an artery forceps. (h) The sutures are tied and
polycaproamide absorbable suture is passed through the tip. (d) cut. Slight bunching along the length of the suture is normal and
The needle is retracted through point h. (e) The needle is resolves spontaneously in 23 weeks
Fig. 25.31 (a) Silhouette

suture. A straight needle
a
is swaged to one end of
the polypropylene suture
and a half-circle needle
to the other. There are knots
and cones along its length.
(b) Absorbable poly-l-lactic
acid cones
1.5 cm between each point. The vector lines converge mine how many cones are needed to run the length of
in the temporal area, behind the hairline, where a 3-cm the malar area. If all of the cones are left on the suture,
mark is made for the incision site. After skin prepara- some of the proximal ones may be visible under the
tion and sterile draping, the marked areas are infiltrated thin skin of the temple area, or they may catch on the
with 2% lidocaine with 1:200,000 epinephrine. A 3-cm superficial temporal fascia when the suture is retracted.
incision is made in the temporal area and diathermy is The author usually cuts three to four cones from the
used for hemostasis. The superficial temporal fascia is distal end of the suture after they exit at the inferior
exposed, grasped, and opened, exposing the shiny, points. The suture is passed in the deep subcutaneous
white deep temporal fascia. A small 1.5 cm 0.5 cm plane from the temporal incision, along the marked
patch of polypropylene mesh is placed on the deep path, to the exit points. To do this, the straight needle
temporal fascia and sutured in place. The first Silhouette enters the tissues just above the superficial temporal
suture is measured externally over the cheek to deter- fascia under direct vision at the upper incision. The
Fig. 25.32 Silhouette suture midface lift. (a) The patient is (h) The straight needle is passed just superficial to the superficial
marked in the sitting position. The inferior points start about temporal fascia (STF) at the temporal incision, and through the
1 cm lateral to the nasolabial fold. Subsequent points are spaced substance of the cheek to exit at the first of the marked points.
1.5 cm apart. (b) A 23-cm incision is made in the temporal area The STF splits into two leaves just inferior to the hairline and the
behind the hairline where the vector lines converge. (c) The temporal branch of the facial nerve travels through its layers.
superficial temporal fascia is grasped and opened. (d) The shiny Staying superficial to the STF avoids inadvertent injury to
white deep temporal fascia is exposed. (e) A 1 1.5 cm piece the nerve. (i) The Silhouette suture is slowly pulled through the
of polypropylene mesh is cut and placed in the wound on the midface until the cones emerge from the inferior puncture. A
deep temporal fascia. (f) The mesh is sutured to the deep tempo- number of cones (usually two to four) can be cut from the suture
ral fascia using a 4-0 non-absorbable suture. (g) The Silhouette at this time. (j) The suture is then cut distal to one of the knots
suture is placed over the face to measure how many cones will and retracted to lift the malar fat pad. Each suture is tied to a
span the malar fat pad and midface without extending into neighboring one, and anchored to the deep temporal fascia and
the upper face. This determines how many cones, if any, mesh, before closure in two layers
should be cut from the distal end of the suture after placement.
a b
c e
g
h effect on the tissues can be seen. The proximal half-

circle needle is passed through the superficial temporal
fascia at the incision and then the needle is passed
through both the deep temporal fascia and the anchored
polypropylene mesh. The suture is not tied until all
other sutures have been passed. Usually a total of four
sutures are placed on each side of the midface. Once
all of the sutures are in place, the half-circle needles
are cut from the proximal ends and each suture is gen-
i tly lifted and tied to its neighboring suture. The tempo-
ral incision is closed in two layers. A gentle lift is
sufficient to elevate the malar fat pad and even jowls
and provide pleasing results (Fig. 25.33).
25.4.8.2 Neck (Fig. 25.34)

The coned Silhouette sutures are also used to lift mild
to moderate ptosis of the neck. If ptosis is coupled with
significant submental and submandibular fatty depos-
its, lipoplasty combined with the Silhouette lift is more
j appropriate [34]. The author commonly uses ultra-
sound-assisted lipoplasty (VASER) combined with
Silhouette sutures for this purpose. For the Silhouette
suture lift, markings are made from behind the ear,
along the neck under the line of the mandible to a point
just proximal to the midline. Alternatively, this line
can continue across the midline to a point just distal to
it. A 1-cm retroauricular incision is made and the first
suture is passed in the subcutaneous fat along the line
of marking, and exits at the distal point. The author
prefers to continue across the midline, so that the
suture acts as a sling to support and lift the midline and
Fig. 25.32 (continued) improve the cervicomental angle. To bring the suture
across the midline, the needle should first exit from a
non-dominant hand gently grasps the tissues over the point just proximal to the midline. Before the needle
needle as it passes through the temple and then malar exits completely from the skin, with the proximal end
fat pad, maintaining the same depth throughout. If the of the needle still under the skin, the needle is turned
suture passes too superficially it may catch the dermis around so that the proximal end of the needle with the
and result in irregularities. If it passes too deeply it suture attached is now advancing toward the midline.
risks injury to facial nerve branches, particularly the It is advanced to a point just distal to the midline where
frontal branch as it passes between the layers of the a stab incision with a #11 blade is made to allow the
superficial temporal fascia lateral to the eye. The nee- blunt end of the straight needle to emerge. Once the
dle should exit the skin at the inferiorly marked points suture is seen, it is cut from the needle and the needle
perpendicularly to avoid catching the dermis. The is removed from the site. The suture end is pulled until
straight needle is pulled through until the cones begin the most distal knot on the suture is just visible. The
to emerge from the skin. At this point, one or more suture is cut just distal to the knot and the proximal end
cones can be cut from the suture as outlined above, of the suture at the retroauricular incision is gently
making sure not to pull through any cones that are to retracted. The coned portion of the suture passes across
remain on the suture. The suture is cut just distal to one the midline and provides a lifting along its length as
of the knots and retracted proximally so that the lifting well as a suspension of the submental area. Usually
two sutures are passed on either side of the neck. The techniques described in this chapter do not involve
proximal ends of the sutures are secured to the mastoid dissection or undermining. The relatively atraumatic
fascia using the half-circle needles and tied to one insertion of sutures, although advantageous in terms of
another. The incision is then closed. downtime, means there is less inflammation and fibro-
sis around the sutures, which can dislodge or migrate
or potentially become disrupted in the tissues. Careless
25.5 Postoperative Care handling of the face or neck following a suture lift can
disrupt the sutures or result in cheese-wiring of the
Although suture facelift techniques are minimally tissues through the sutures. Ideally, the treatment area
invasive and performed through small incisions or should be taped and a head garment should be worn
punctures, postoperative care is important. The closed for 34 days to immobilize the tissues (Fig. 25.35).
Fig. 25.33 (a) Preoperative. (b) After midface and lower face lift using Silhouette and polycaproamide sutures respectively
Fig. 25.34 Coned (Silhouette) suture lift of the neck. (a) point on the contralateral side. (e) A stab incision is made to
Markings are made behind the ear and along the neck under the allow the blunt end to emerge with suture attached. The suture is
mandible to a point about 2 cm proximal to the midline. A second cut. (f) The end of the suture is grasped and pulled through until
point is marked 2 cm distal to the midline. (b) After local infiltra- the first knot is visible. The suture is cut again just distal to the
tion of lidocaine with epinephrine along the marked points, a knot. (g) The half-circle needle is used to pass the proximal end
1 cm retroauricular incision is made and the Silhouette needle is through the mastoid fascia for anchorage. (h) A second suture is
passed subcutaneously toward the midline. (c) The needle exits at passed in the same way parallel to the first one. Both sutures are
the first point proximal to the midline. (d) The needle is redi- retracted to lift the neck, and tied to one another. The retroauricu-
rected so the blunt end advances across the midline toward the lar incision is closed with interrupted sutures
a b
c d
f

Fig. 25.35 Tape and head garment are used to immobilize the
tissues for 34 days following a suture lift
Patients should be instructed to avoid excessive facial

animation, chewing gum, and laughing for a week
and to be gentle when handling the face or neck for 25.6 Complications
46 weeks following the procedure. This includes
cleansing or applying make-up upwards along the Patients tolerate suture lift procedures well under infil-
vector of lifting rather than downwards against the trative local anesthesia with complementary regional
sutures. Following the procedure, the author adminis- nerve blocks if required. These methods are preferred
ters cephalexin for 5 days and tramadol for 3 days as as they eliminate unnecessary risk associated with
needed if simple analgesia is insufficient to control intravenous sedation or general anesthesia. Mild
discomfort. Normal sequelae following suture lifts edema, ecchymosis, tenderness, and transient bunch-
include edema, ecchymosis, and point tenderness over ing of overlying skin are common following suture
the suture-ends. To reduce swelling, the patient is lifts. Complications include infection, bleeding, palpa-
advised to use cold packs and sleep with the head bility, visibility, skin irregularities, migration, extru-
elevated for a few days. A clear instruction leaflet sion, prolonged pain, nerve injury, and asymmetries
should be provided, including a contact telephone (Figs. 25.36 and 25.37) [3840]. These complications
number in case the patient has any concerns following should be prevented by proper placement of appropri-
the procedure (Table 25.5). A follow-up appointment ate sutures using sterile techniques. If they do occur,
is arranged in 1 week, at which time sutures, if present, they often resolve spontaneously or can easily be
are removed. treated (Table 25.6).
Table 25.5 Postoperative instructions: suture lift

IF YOU EXPERIENCE EXCESSIVE PAIN OR BLEEDING, FULLNESS, OR SPREADING REDNESS IN TREATMENT
AREAS, OR FEVER, PLEASE CALL US IMMEDIATELY.
1. Do not massage or rub vigorously the treatment area for at least 4 weeks; this could disrupt the sutures under the skin.
2. Wear the head garment 24 h/day for 3 days and then in bed at night for a further 1 week.
3. Continue to refrain from smoking for at least 2 weeks during the healing process. Smoking affects blood supply and
nourishment to skin and soft tissues.
4. Complete the prescribed course of antibiotics.
5. Be gentle when brushing your hair until your stitches are removed.
6. There may be some bunching of skin near the hairline following the lift. This will soften out over 14 weeks, depending on
skin quality.
7. You may experience a tighter sensation over your face where skin has been retracted. Some of this tightness will lessen over
12 weeks as the skin relaxes into its new position.
8. You may experience some swelling, bruising, or tenderness over the first week but this will subside and fade over time. If you
notice increasing redness, swelling, and tenderness a few days after the procedure that was not there before, call our clinic.
This may be a sign of infection, which is uncommon.
9. If you received skin stitches you will need to return to the clinic after 57 days for removal.
I HAVE READ AND FULLY UNDERSTAND THE ABOVE ITEMS 19.
___________________________ ___________________
Patient Signature Date
a b
Fig. 25.36 (a) Dimpling of skin at the right nasolabial fold incision following a suture suspension lift. (b) After subcision using an
18 gauge needle to release dermal attachments
25.7 Conclusions have mild tissue laxity or ptosis and realistic expecta-
tions. The results are usually subtle and natural and
There has been a dramatic increase in patient demand often make the patient appear a few years younger.
for non-surgical cosmetic procedures in the last The author combines suture facelift techniques
decade. Suture facelift techniques offer a quick, safe, with other non-surgical procedures such as botuli-
and effective rejuvenation by elevating soft tissues num toxins, fillers, and cheek and lip enhancement
and restoring the youthful contours of the face and (Fig. 25.38). Combined approaches using different
neck. The aim is to lift tissues that have dropped, sutures and methods in the same patient are also
restore the beauty triangle by creating a heart-shaped appropriate and may provide superior results than one
face, and improve definition of the jawline and neck. method alone. Longevity of results following a suture
Patients who benefit from suture facelift techniques facelift is variable and depends on several factors,
a b
Fig. 25.37 (a) Palpable and visible cones in the temple following a Silhouette suture lift. (b) Spontaneous improvement after
2 months without intervention. Cutting a few cones from the distal end of the suture after placement will prevent this problem
Table 25.6 Complications of suture facelift techniques

Complication Prevention Management
Skin irregularities 1. Avoid superficial placement of suture in dermis 1. Conservative, massage
and dimpling 2. Release dermis with artery forceps during procedure 2. Subcision
3. Remove suture and redo procedure
Palpability 1. Avoid patients with thin, translucent skin 1. Conservative, massage if absorbable
or visibility 2. Place sutures in deep subcutaneous plane, or deeper 2. Remove if barbed, non-absorbable
Migration 1. Use anchored sutures 1. Trim sutures
or extrusion 2. Bury sutures when appropriate 2. Remove sutures completely
Prolonged pain 1. Use absorbable sutures 1. Remove sutures
or nerve injury 2. Avoid path of facial nerve 2. Analgesia
Asymmetries 1. Proper marking 1. Add or remove sutures to restore symmetry
2. Equal tension bilaterally
Infection 1. Ensure sterile technique 1. Antibiotics
2. Prophylactic antibiotics 2. Remove sutures
3. Keep hair out of punctures and incisions
Bleeding or 1. Use lidocaine with epinephrine for infiltrative local anesthesia 1. Pressure hemostasis
hematoma 2. Use diathermy for temporal incisions 2. Conservative for ecchymosis and hematoma
3. Discontinue antiplatelets, vitamins, and herbal 3. Drainage for large hematoma (rare)
supplements before procedure
including the sutures used, the lifting technique, the wear a head garment for 3 days, and handle the face
patients tissues, and the aftercare. For a stable lift, and neck carefully for 6 weeks. Once the patient
the author prefers to employ techniques that lift the understands what can be achieved with suture facelift
SMAS rather than just the subcutaneous fat, and to techniques, the limitations, and the value of combina-
use coned sutures to elevate the fibrofatty malar fat tion procedures for optimum results, the likelihood of
pad. To improve healing, patients must stop smoking success and satisfaction for both patient and surgeon
for at least 2 weeks before and after the procedure, is high.
a b
Fig. 25.38 (a) Preoperative. (b) After suture facelift combined with cheekbone and lip enhancement using temporary fillers
References 8. Shiffman MA (2008) Facial aging: a clinical classification.

In: Shiffman MA, Mirrafati SJ, Lam SM (eds) Simplified
facial rejuvenation. Springer, New York, pp 6567
1. The American Society for Aesthetic Plastic Surgery (2008)
9. Vleggaar D, Fitzgerald R (2008) Dermatological implications
Cosmetic surgery national databank statistics. ASAPS web-
of skeletal aging: a focus on supraperiosteal volumization for
site www.surgery.org
perioral rejuvenation. J Drugs Dermatol 7(3):209220
2. Hodgkinson DJ (2009) Clinical applications of radiofre-
10. Mendelson BC, Hartley W, Scott M, McNab A, Granzow
quency: nonsurgical skin tightening (Thermage). Clin Plast
JW (2007) Age-related changes of the orbit and midcheek
Surg 36(2):261268
and the implications for facial rejuvenation. Aesthetic Plast
3. Sasaki G, Cohen AT (2002) Meloplication of the malar fat
Surg 31(5):419423
pads by percutaneous cable-suture technique for midface
11. Kahn DM, Shaw RB (2008) Aging of the bony orbit: a three-
rejuvenation: outcome study (392 cases, 6 years experi-
dimensional computed tomographic study. Aesthetic Surg J
ence). Plast Reconstr Surg 110(2):635654
28(3):258264
4. Paul MD (2008) Barbed sutures for aesthetic facial plastic
12. Master course in suture facelift techniques: European
surgery: indications and techniques. Clin Plast Surg 35(3):
College of Aesthetic Medicine (ECAM). Website www.
451461
ecamedicine.com
5. Hochman M (2007) Midface barbed suture lift. Facial Plast
13. Kress DW (2008) The history of barbed suture suspension:
Surg Clin N Am 15(2):201207
applications, and visions for the future. In: Shiffman MA,
6. Villa MT, White LE, Alam M, Yoo S, Walton RL (2008)
Mirrafati SJ, Lam SM (eds) Simplified facial rejuvenation.
Barbed sutures: a review of the literature. Plast Reconstr
Springer, New York, pp 247256
Surg 121(3):102e108e
14. Bisaccia E, Kadry R, Rogachefsky A, Saap L, Scarborough DA
7. Teitelbaum S (2006) Enthusiasm versus data: how does an
(2009) Midface lift using a minimally invasive technique and a
aesthetic procedure become hot? Aesthetic Surg J 26(1):
novel absorbable suture. Dermatol Surg 35(7):10731078
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15. Alcamo JH (1964) Surgical suture. US patent 3,123,077 29. Keller GS, Namazie A, Blackwell K, Rawnsley J, Khan S
16. Sulamanidze MA, Sulamanidze GM (1998) Flabby, ageing (2002) Elevation of the malar fat pad with a percutaneous
face. A new approach. In: II Congress on Aesthetic and technique. Arch Facial Plast Surg 4(1):2025
Restorative Surgery, 1998, Moscow, p 15 30. Yousif NJ, Matloub H, Summers AN (2002) The midface
17. Sulamanidze M, Sulamanidze G (2009) APTOS suture lift- sling: a new technique to rejuvenate the midface. Plast
ing methods: 10 years of experience. Clin Plast Surg 36(2): Reconstr Surg 110(6):15411553
281306 31. Giampapa VC, DiBernardo BE (1995) Neck recontouring with
18. Sulamanidze M, Fournier PF, Paikidze TG, Sulamanidze G suture suspension and liposuction: an alternative for the early
(2002) Removal of facial soft tissue ptosis with special rhytidectomy candidate. Aesthetic Plast Surg 19(3):217223
threads. Dermatol Surg 28(5):367371 32. Serdev NP (2001) Ambulatory temporal SMAS lift by mini-
19. Wu W (2004) Barbed sutures in facial rejuvenation. mal hidden incisions. Int J Cosm Surg 1(2):2027
Aesthetic Surg J 24(6):582587 33. Serdev NP (2001) Lower SMAS-platysma facelift using
20. Ruff G (2006) Techniques and uses for absorbable barbed hidden retro-lobular approach. Int J Cosm Surg 1(3):1319
sutures. Aesthetic Surg J 26(5):620628 34. Serdev NP (2002) Serdev suture method for ambulatory
21. Garvey PB, Ricciardelli EJ, Gampper T (2009) Outcomes in medial SMAS facelift. Int J Cosm Surg 2(4):15501562
threadlift for facial rejuvenation. Ann Plast Surg 62(5): 35. Zide BM (2006) The facial nerve: cranial nerve VII. In: Zide
482485 BM, Jelks GW (eds) Surgical anatomy around the orbit. The
22. Kaminer MS, Bogart M, Choi C, Wee S (2008) Long-term system of zones. Lippincott Williams & Wilkins, Philadelphia,
efficacy of anchored barbed sutures in the face and neck. pp 1941
Dermatol Surg 34(8):10411047 36. Gamboa GM, Vasconez LO (2009) Suture suspension tech-
23. DeLorenzi CL (2006) Barbed sutures: rationale and technique for midface and neck rejuvenation. Ann Plast Surg
nique. Aesthetic Surg J 26(2):223229 62(5):478481
24. Lee S, Isse N (2005) Barbed polypropylene sutures for midface 37. Sasaki GH, Komorowska-Timek ED, Bennett DC, Gabriel
elevation: early results. Arch Facial Plast Surg 7(1):5561 A (2008) An objective comparison of holding, slippage, and
25. Bukkewitz H (1956) Die Nade Tecnik der subcutanen pull-out tensions for eight suspension sutures in the malar
Gewebsrafung einer schnittlosen Korrekturmethode bei kos- fat pads of fresh-frozen human cadavers. Aesthetic Surg J
metischen Brust und Gesichtoperationen. Zentralbl Chir 28(4):387396
81(29):11851192 38. Lee CJ, Park JH, You SH, Hwang JH, Choi SH, Kim CH
26. Fournier PF (2008) The curl lift: a rediscovered technique. (2007) Dysesthesia and fasciculation: unusual complica-
In: Shiffman MA, Mirrafati SJ, Lam SM, Cueteaux CG tions following facelift with cog threads. Dermatol Surg
(eds) Simplified facial rejuvenation. Springer, Berlin, pp 33(2):253255
285291 39. Silva-Siwady JG, Diaz-Garza C, Ocampo-Candiani J (2005)
27. Erol O, Sozer SO, Velidedeoglu HV (2002) Brow suspen- A case of Aptos thread migration and partial expulsion.
sion, a minimally invasive technique in facial rejuvenation. Dermatol Surg 31(3):356358
Plast Reconstr Surg 109(7):25212532 40. Helling ER, Okpaku A, Wang PTH, Levine RA (2007)
28. Hernandez-Perez E, Khawaja HA (2003) A percutaneous Complications of facial suspension sutures. Aesthetic Surg J
approach to eyebrow lift: the Salvadorean option. Dermatol 27(2):155161
Surg 29(8):852855
Facial Implants
26
Bruce B. Chisholm
26.1 Introduction The goal of alloplastic implant placement in the

treatment of the aging face is restoration of esthetic
Facial rejuvenation requires volume retention, replace- facial balance through replacement of lost volume and
ment, and soft tissue support. The procedure can be support. Loss of soft tissue volume and support are the
surgical, nonsurgical, temporary, or permanent. The leading causes of facial aging and the subsequent loss
temporary, nonsurgical options include injection with of the esthetic balance of the face. The aging face is a
hyaluronic acid, autologous fat, calcium hydroxylapa- changed look for the patient. The primary goal of a
tite, poly-l-lactic, and others. Permanent nonsurgical facial implant is not to change a patients appearance
options include injection with polymethylmethacry- but to restore the youthful volume, support, and facial
late. Most surgical procedures are temporary unless an balance.
alloplastic implant is placed. In addition, a patient may request to change their
A facial implant is the most effective surgical tech- appearance or augment a congenitally atrophic chin,
nique to permanently restore facial volume, support, midface, or zygoma.
and esthetic balance. The implant reliably restores lost While the midface and chin are best restored with
volume and soft tissue support to create a natural, an alloplastic implant, the remainder of the face is
youthful appearance. The procedure is permanent but more difficult to augment with an implant. The angle
can be reversed. and body of the mandible can be augmented with an
Coleman [1, 2] demonstrated the importance of alloplastic implant or fat. The clinical results achieved
restoring facial volume with autologous fat. Coleman with fat will be temporary, and implant placement can
demonstrated that moving atrophic structures to new be technically challenging. The best option for the
locations was not as effective as the additional volume periorbital region remains a series of fat injections
and support obtained from fat grafting [3]. Fat is an or one of the nonpermanent synthetic fillers such as
excellent material for volume restoration and to pro- hyaluronic acid.
vide support, but lacks reliable long-term results and The aged, skeletonized appearance of the thinning,
requires numerous surgical procedures [4]. The mid- atrophic face results from loss of volume and soft tis-
face and chin regions are more effectively treated with sue support more than from additional or excess skin
an alloplastic implant. The augmentation is permanent (Fig. 26.1). Procedures to replace, maintain, and sup-
and requires one procedure. With experience, alloplas- port soft tissue are the most important procedures per-
tic implant placement is fast, reliable, predictable, and formed in facial rejuvenation. Restoration of skin and
postoperative complications are minimal. soft tissue tension through surgical lifting augments a
well-supported face that has had the youthful balance,
support, and volume restored [5].
B.B. Chisholm
The region of the midface most affected by volume
Department of Surgery, Eisenhower Medical Center,
Rancho Mirage, CA, USA loss is the central region located below the midpupil-
e-mail: [email protected] lary line (Fig. 26.2). The zone below the midpupillary

394 B.B. Chisholm
Fig. 26.3 Small silastic midface implant
line has generous soft tissue volume and support during

youth but severely atrophies, becomes skeletonized,
and descends with age. Subsequently, the youthful bal-
ance is lost.
The zygoma and zygomatic arch have less soft
tissue volume during youth, and the atrophic changes
of aging are less dramatic. Primary alloplastic implant
restoration is rarely utilized in these zones as it will
change the patients appearance by widening the face.
A wider-appearing face and a changed appearance is
not the goal for most patients.
Fig. 26.1 Midface atrophy with facial collapse Patients at or near ideal weight will benefit from
midface alloplastic augmentation after 40 years of age.
Patients with significant additional body weight may
maintain volume and support in the midface region.
The soft tissue chin envelope atrophies less than the
midface. The chin does not usually require alloplastic
support until the sixth or seventh decade unless the
patient has microgenia.
The midface is a broad region and the soft tissue of
the entire region atrophies with advancing age. The
maximum point of surgical augmentation corresponds
to the maximum height of the implant. The original
submalar implant [6] provided support but failed to
adequately address the surrounding midface atrophy.
In addition, the submalar implant will not continue to
support the entire midface with advancing age. The
submalar implant also requires screw fixation to remain
stable. Therefore, a midface shell (Fig. 26.3) is used on
every patient to augment, support, and maintain the
midface. It is individually trimmed to provide custom-
ized augmentation for each patient. The broad base
provides permanent augmentation and support of the
entire midface, restores the natural youthful appear-
ance without changing the youthful appearance, and
does not require screw fixation to remain stable. The
Fig. 26.2 Maximum midface atrophy located vertically at
midpupillary line and horizontally at the nasal ala m4-1 midface shell by Hanson (Hanson Medical, Inc.,
26 Facial Implants 395
Fig. 26.5 Midface implant used to guide outline of planned

surgical pocket
Fig. 26.4 Point of maximum atrophy of midface marked with

an X
Paso Robles, CA, USA) and the CSM1 shell by

Implatech (Implatech, Inc., Ventura, CA, USA) are Fig. 26.6 Outline of midface implant with maximum projec-
used on 99% of the patients. A larger implant may be tion marked with an X
used if atrophy or underlying lack of skeletal support is
moderate to severe. In addition, the patient may request An outline of the ideal implant location is made on
a fuller face. the cheek with the maximum projection of the implant
centered over the area of maximum atrophy (Figs. 26.5
and 26.6). Care is taken to not allow the implant to
26.2 Technique touch the skin. A small incision is made in the canine
fossa with iris scissors (Fig. 26.7). Care is taken to
The patient is marked preoperatively. An X is placed at keep the incision anterior, conservative, and close to
the point of maximum midface atrophy (Fig. 26.4) and the buccal reflection. A periosteal elevator is used
is generally located below the midpupillary line verti- to create an exact subperiosteal pocket corresponding
cally and approximately at the nasal ala horizontally. to the ideal location drawn on the cheek (Fig. 26.8).
The area of maximum atrophy is easily identified The dissection extends over the superior fibers of the
visually. masseter muscle at the zygomatic arch (Fig. 26.9). The
The surgical procedure is performed under light implant is scored with a no. 15 blade on the external
sedation. The head and neck is prepped and draped in surface to allow better adaptation to the underlying
the usual sterile fashion Antibiotics are started 1 day malar and midface contour (Figs. 26.10 and 26.11).
preoperatively and continued 5 days postoperatively. The implants are soaked in a solution containing cefa-
The patient is instructed to rinse with Peridex twice a zolin, vancomycin, and gentamicin. The antibiotic
day beginning the day before surgery and continue for solution is also used to irrigate the subperiosteal pocket
5 days after surgery. (Fig. 26.12).
396 B.B. Chisholm
Fig. 26.9 Release of soft tissue over anterior zygomatic arch
Fig. 26.7 Mucosal incision made with iris scissors in anterior,

superior buccal reflection
Fig. 26.10 Scoring of midface implant with surgical blade
Fig. 26.8 Creation of subperiosteal pocket with periosteal

elevator
The implant is custom trimmed and placed in the

surgical pocket (Figs. 26.13 and 26.14). Fixation is
not required. The implant should not move anterior/ Fig. 26.11 Scored midface implant
posterior or inferior/superior. If the surgical pocket is
over-dissected and there is implant movement, the The incision is closed with a double-layer 4-0
implant must be secured with sutures. Screws are not chromic gut. The left side is completed and symmetry
required. verified. Total surgical time is 1020 min.
Fig. 26.12 Irrigation of surgical pocket with antibiotic solution Fig. 26.15 Extended anatomic silastic chin implant
Fig. 26.13 Placement of small silastic midface shell implant Fig. 26.16 Small submental incision in submental crease
Fig. 26.14 Placement of small silastic midface shell implant Fig. 26.17 Periosteal elevator used to make subperiosteal
pocket
398 B.B. Chisholm
Fig. 26.18 Irrigation of surgical pocket with antibiotic solution Fig. 26.19 Silastic chin implant partially placed in pocket
26.3 Postoperative 26.5 Complications
Minimal bruising with moderate edema is expected. Two thousand two hundred and fifty-six implants were
Normal physical activity can be resumed in several placed over the last 6 years. There were four infec-
days. tions. There have not been any infections since the
initiation of antibiotic irrigation of the surgical pocket
4 years ago. There were no facial nerve injuries.
26.4 Discussion Dysesthesia of the upper lip was reported in three
patients that resolved over time.
The chin implant is an extended silastic anatomic No hematomas or seromas were reported. Irrigation
implant (Fig. 26.15). The small (size 1) is used for of the surgical pocket was required in one patient after
the majority of female patients, and small to medium autologous fat used for facial augmentation was found
(size 2) is used for the majority of male patients. An in the surgical pocket.
incision is made in the submental crease (Fig. 26.16).
Dissection is completed to the periosteum. An exact
subperiosteal pocket is made on the anterior, inferior 26.6 Conclusions
mandibular border (Fig. 26.17). The mental nerve is
protected at all times. The implant is soaked in antibi- Alloplastic augmentation of the aging, atrophic face is
otic solution and the pocket is irrigated with the antibi- invaluable to a natural, long-term result. The proce-
otic solution (Fig. 26.18). The implant is placed in the dure is fast and predictable (Figs. 26.2026.26).
pocket (Fig. 26.19) and secured with three 4-0 polyg- Augmentation of the midface during a facelift proce-
lycolic sutures. Closure is completed with 5.0 polygly- dure restores esthetic balance and produces a perma-
colic and 6.0 plain gut sutures. nent result.
Fig. 26.20 (a) Preoperative. (b) Six months postoperative after facelift, small midface implants, upper and lower blepharoplasty,
and laser skin resurfacing
400 B.B. Chisholm

a b
(b) Seven months
postoperative after facelift,
small midface implants, and
laser skin resurfacing

a
(b) Six months postoperative
following facelift, small
midface implants, upper
blepharoplasty, and laser skin
resurfacing
b
402 B.B. Chisholm

a b
after rhinoplasty, small
anatomic chin implant, and
small midface implants
a b
Fig. 26.24 (a) Preoperative. (b) Six months postoperative following facelift, small midface implants, blepharoplasty, and laser skin
resurfacing
a b
Fig. 26.25 (a) Preoperative. (b) Six months postoperative after facelift, small midface implants, and laser skin resurfacing
a b

facelift, small midface and
chin implants, blepharoplasty,
and laser skin resurfacing
404 B.B. Chisholm
References 4. Shiffman MA, Kaminski MV (2001) Fat transfer to the face:

technique and new concepts. Facial Plast Surg Clin N Am
9(2):229237
1. Coleman SR (1997) Facial recontouring with lipostructure.
5. Little JW (2000) Three dimensional rejuvenation of the
midface: volumetric resculpture by malar imbrication. Plast
2. Coleman SR (2006) Facial augmentation with structural fat
grafting. Clin Plast Surg 33(4):567577
6. Binder WJ, Schoenrock LD, Terino EO (1994) Augmentation
3. Hamra ST (2002) A study of the long-term effects of malar
of the malar-submalar/midface. Facial Plast Surg Clin N Am
fat repositioning in facelift surgery; short-term success but
2:265283
long term failure. Plast Reconstr Surg 110(3):940951
Fat Transfer to the Face
27
Melvin A. Shiffman
27.1 Introduction where vascularity is excellent, has an excellent chance

for fat survival.
The minimally invasive technique using autologous fat The only relative drawback has been the resorption
transplantation has become a standard procedure in of some of the fat graft. With proper technique, approx-
facial rejuvenation. It is simple, inexpensive, permanent, imately 3070% of the fat is retained. Low-speed, short-
and effective. Injectable fillers, such as collagen and time centrifugation of the fat decreases the fluid in the
hyaluronic acid, are only temporary and, therefore, transplant and reduces the apparent loss of graft by
have minimal indication. Gore-Tex, which is a permanent compacting the fat and separating out the excess liquid.
material, may extrude or be palpable. Since 1994, Since some of the apparent graft loss is the resorption
when Adatasil (silicone) was approved by the Federal of fluid from the transplanted fat, there is less fluid in
Drug Administration (FDA) for use in ophthalmic centrifuged fat and, therefore, more mass retained.
problems, the use of silicone injected into other areas A newer concept to facilitate graft retention is the
of the body is called an off-label use and is considered use of albumin during the harvesting and transfer
legal if it is used for a specific patient with a specific phases. Albumin reduces the colloid osmotic pressure
product and there is no advertising. disparity between the low colloid osmotic pressure of
Autologous fat can be used to augment facial struc- the fat graft with saline, epinephrine, lidocaine, and
tures, rejuvenate rhytids, or fill depressed scars or defects sodium bicarbonate and the interior of the fat cells.
of the face. Since the introduction of liposuction in The higher the difference in colloid osmotic pressure
1975 [1] for body contouring, there has been an easy between the cells and the surrounding fluids, the more
way to obtain fat for transplantation through very small fluid that will enter the cells and the more the likeli-
incisions. The use of the tumescent technique for hood of cell destruction. If the colloid osmotic pres-
retrieving large amounts of fat for transfer has reduced sures between the fat cells and the surrounding fluid
the amount of blood loss and made the technique safer with albumin are almost equal, the more likely there
[2]. Although some reports have shown that fat trans- will be improved fat survival and retention.
fer had disappointing results in some cases, the success
of fat transfer is operator dependent and can be quite
successful if attention is paid to the details of the tech- 27.2 History of Fat Transfer
niques of the procedure. The transfer of fat to the face,
Since Neuber [3], in 1893, reported that transplanted fat
can be used to fill in a depressed area of the face, there
have been many reports [414] that have shown that fat,
in pieces, can be transplanted and survive in various
M.A. Shiffman
areas of the body. Since, liposuction was conceived by
Tustin, CA, USA Fischer and Fischer in 1974 [15] and put into practice in
e-mail: [email protected] 1975 [1]. The aspirate has been used to fill defects

406 M.A. Shiffman
and for contouring [1622]. Aspirated fat should be a

atraumatically washed in physiologic solution to remove
blood, which would allow better fat survival [23].
Certain principles of fat transfer have evolved [20,
2468] over the years, which include aspiration at lower
vacuum rather than at atmospheric pressure (Fig. 27.1).
It is essential to avoid desiccation of the fat during
transfer. Fat that is present for over 60 days after trans-
fer will survive and grow, and fat grafts survive when
there is vascular ingrowth. The survival of free fat used
as an autograft is operator dependent and requires deli-
cate handling of the graft tissue, careful washing of the
fat to minimize extraneous blood cells, and installation
into a site with adequate vascularity. There is evidence b
that fat cells will survive and that filling of defects is not
from the residual collagen following cell destruction.
There is some loss of fat after transplant, and most sur-
geons will overfill the recipient site.
27.2.1 Insulin
Some physicians have added insulin to the fat in prepa-

ration for transplantation [19, 69, 70]. The theory is
that insulin inhibits lipolysis. Sidman [71] found that
insulin decreases lipolysis. Hiragun et al. [72] stated
that theoretically insulin may induce fibroblasts to pick
up the lipid lost and become adipocytes. Chajchir et al.
[73] found that the use of insulin did not show any
positive effect on adipocyte survival during transplan- Fig. 27.1 Hematoxylin eosin stain 200. (a) Central core of fat
with 95100% intact fat cells that was harvested with a 3-mm
tation compared to fat not prepared with insulin. cannula at 500 mm mercury vacuum. (b) Periphery of core
with >10% fat cell disruption (arrow) when harvested with a
3-mm cannula at 700 mm mercury vacuum
27.2.2 Centrifugation
Some physicians centrifuge the adipose tissue to ual centrifuge (about 2000 rpm), eject the unwanted
remove blood products and free lipids to improve the solution, and transfer the fat
quality of the fat to be injected [6971]. Asken [42] Chajchir et al. [72] centrifuged 1 mL of bladder fat
stated that his method of reducing the material to be pad from mice (both at 1000 rpm for 5 min and
injected to practically pure fat is to place the fat-filled 5000 rpm for 5 min) and injected this into the subder-
syringe with a rubber cap (the plunger having been mis of the malar area. Microscopically, after 12
previously removed and kept in a sterile environment) months, there were macrophages filled with lipid drop-
into a centrifuge. The syringe is then spun for a few lets, giant cells, focal necrosis of adipocytes, and cyst-
seconds at the desired rpm and the serum, blood, and like cavities of irregular sizes and shapes. After 12 months
liquefied fat collect in the dependent part of the following injection, no recognized adipocytes
syringe Toledo [70] reported that for facial injec- could be found. Total cellular damage was present in
tion we spin the full syringes for 1 minute in a man- both groups.
27 Fat Transfer to the Face 407
fat. Each time the trigger is pulled, 0.1 mL is deposited.

Asaadi and Haramis [55] described the use of a gun
with a disposable 10-mL syringe for fat injection.
Niechajev and Sevcuk [60] utilized a special pistol and
a blunt-type cannula, with 2.3-mm internal diameter,
to inject the fat. Berdeguer [74] used a lipo-transplant
gun to inject fat into areas to be enhanced. Fulton et al.
[68] stated that it is beneficial for a beginning surgeon
to use a ratcheted pistol for injection as this gives a
more uniform injection volume.
27.3 Albumin in Improving

Fat Cell Survival
27.3.1 Oncotic Pressure
When a molecule is greater than 10,000 D (dalton

arbitrary unit of mass equal to the mass of the nuclide of
carbon-12 or 1.657 1024 g), it is called a colloid and is
capable of generating an oncotic pressure if it is restricted
to one side of a semipermeable membrane. Colloid
restricted to one side of a semipermeable membrane cre-
ates an osmotic gradient measured in millimeters of
Fig. 27.2 Hematoxylin eosin stain 200. Centrifugation at mercury. Very small molecules and ions such as sodium,
3600 rpm for 1 min showing cell compaction potassium, glucose, and urea easily cross a capillary mem-
brane and can increase osmolarity toward isotonicity to
Brandow and Newman [73] found that centrifuga- prevent red blood cells from taking up water and bursting.
tion of harvested fat did not after the microscopic Osmolarity is measured by freezing point depression, and
structured integrity of cells. Spun and unspun samples the greater the number of particles in solution, the colder
were examined and were similar. Fulton et al. [68] the solution must be before it will freeze.
noted that centrifuged fat, 3 minutes at 3400 rpm,
works well for small volume transfers, but not for large
volume transfers into breasts, biceps, or buttocks. Low 27.3.2 Colloid Osmotic Pressure
rpm centrifugation for a short time will compact the fat
cells and not destroy them (Fig. 27.2). In determining the colloid osmotic pressure (COP), the
LandisPappenheimer equation [75] takes into account
that soluble proteins, whether albumin, globulin, or
27.2.3 Ratchet Gun for Injection fibrinogen, are highly negatively charged:
Newman and Levin [23] designed a lipo-injector with

COP = 2.1(TP) + (0.16 TP 2) + 0.009 TP3
gear-driven plunger to inject fat tissue evenly into
COP = Colloid Osmotic Pressure
desired sites. Fat injected with excessive pressure in
the barrel of a syringe can cause sudden injections of TP = Total Protein
undesired quantities of fat, which will pour into recipi-
ent sites. Agris [44] stated that a ratchet-type gun Positively charged sodium ions surrounding the core
allows controlled accurate deposition of autologous protein attract and hold water, thus accumulating more fluid
408 M.A. Shiffman
on one side of the semipermeable membrane. The combina- 27.5 Preoperative Consultation
tion of the oncotic pressure of the protein and the osmotic
pressure of the sodium ions resulting in an increased The patient is carefully examined in relation to the
pressure gradient is called the colloid osmotic pressure. specific complaint for which the patient has come in
Albumin is 69,000 D, whereas globulin is 150,000 for consultation. A description of the physical problem
D and fibrinogen 400,000 D. Since it is the number of needs to be recorded with appropriate measurements.
molecules that are held on one side of the semiperme- Pictures should be taken before any procedure is under-
able membrane that creates COP, albumin will create taken, and postoperative photos taken at an appropriate
the most pressure because 1 g of albumin has twice as interval of time when healing is completed.
many molecules as globulin and five times the number If there are other problems detected by the physi-
of molecules as fibrinogen. Starch molecules, found in cian, other than that of which the patient complains,
Hetastarch and Dextran, should not be used for fat this must be recorded and possible treatment explained
transfer since such molecules are too large to be evacu- to the patient so that steps may be taken to correct other
ated through the lymphatics and will cause localized deficits not previously identified by the patient or so
edema in the interstitial space. that the patient understands that adequate correction
may require other procedures. At the same time, the
patient must not be talked into procedures that are not
27.3.3 Avoiding Hypo-oncotic really wanted by the patient. An interval of time may
Trauma in Fat Transfer be needed for the patient to think about what surgery
may be necessary and to seek other consultations.
When Kleins solution or any modification is used in har- The patient must understand the need for using
vesting fat, the infranatant of the harvested fat contains autologous fat as a filler substance in comparison to
1.11.2 g% protein. The normal level is 2.04.0 g%. When other fillers presently available. To conform to the
one ampule of concentrated human albumin (12.5 g in standard of care for informed consent, the patient must
50 mL) is added to 1 L of tumescent solution or 8.3 mL have sufficient information to be knowledgeable about
added to a 60-mL harvesting syringe, the harvested fat the procedure, the possible material risks and compli-
contains 2.6 g% protein. Three washes of harvested fat cations, and the alternatives and their possible material
also increase the difference in colloid osmotic pressure risks. Someone in the office must take time to explain
and, therefore, it is necessary to add 18.75 g of albumin to this information, and the physician must at least make
each liter of washing solution. Adequate time must be sure the patient understands the procedure, risks, and
allowed between each wash to allow the fat cells to pack alternatives, and answer any questions about the pro-
above the infranatant layer. The process can be acceler- cedure. It is suggested that the physician include in the
ated by centrifugation. The supranatant oil must be record the statement that the surgical procedure was
removed before insertion of the fat into the recipient site. discussed as well as viable alternatives and all material
risks and complications.
27.4 Indications for Fat Transfer

27.6 Technique
There are a variety of indications for fat transfer, which
can be distilled down to the following: Fat survival depends upon the careful handling of fat
1. Fill defects during harvesting, cleansing, and injecting. Harvesting
a. Congenital is performed by liposuction in areas of fat with
b. Traumatic alpha-2 receptors where the fat responds poorly to
c. Disease (acne) diet such as the abdominal or lateral thigh areas (genetic
d. Iatrogenic fat) [42]. The fat can be retrieved with liposuction
2. Cosmetic using a 2.03.0-mm cannula or needle (1416 gauge)
a. Furrows (rhytids, wrinkles) with syringe (1050 mL).
b. Refill of lost supportive tissue (aging) The fat should be cleansed with a physiologic
c. Enhancement solution of normal saline or lactated Ringers by gen-
Fig. 27.3 (a) Fat retrieval

a b
with supranatant fat and
infranatant fluid of blood and
local tumescent fluid. (b) Fat
following washing with
sterile saline
tly mixing and decanting the infranatant liquid con- Injection of the fat is with a needle (18 gauge) or
sisting of tumescent fluid, serum, and blood cannula (1.52.0 mm) uniformly distributed into tun-
(Fig. 27.3). Fat can be concentrated with the use of nels in multiple layers to fill the defect (Figs. 27.4 and
centrifugation at 3600 rpm for 2 min. This allows less 27.5). With depressed scars, the attachments to the
need for as much overfilling (3050%) as is usually skin should be subcised before fat injection. The use of
used. Kaminski [76] has proposed the addition of the ratchet gun for injection does not damage fat cells
12.5 g of concentrated human albumin for each [77].
1000 mL of Kleins solution used for harvesting and The areas of the face that can be enhanced include
18.5 g for each 1000 mL of washing fluid in order to the cheeks (malar, submalar), lips, and chin (mentum)
maintain the normal extracellular oncotic pressure (Fig. 27.6). The brows may be lifted with fat transfer to
necessary to prevent the influx of solution into the the forehead, and indentations can be improved in
cells with possible rupture. Alternatively, 8.3 mL of almost any area of the face. Rhytids in the glabella,
human serum albumin can be added to a 60-mL har- nasolabial fold, and marionette lines can be improved.
vesting syringe. If the glabella is to be injected, the patient should be
410 M.A. Shiffman
a b
Fig. 27.4 (a) Fat transferred to 1-mL syringe with small cannula attached. (b) Injecting fat into face with palm of hand pressing on
the plunger
a b
Fig. 27.5 (a) Ratchet gun with 1-mL syringe and cannula. (b) Fat being injected with ratchet gun
informed of the rare possibility of blindness. Any area usually with small amounts of fat. If small amounts
of the face can have a depressed scar elevated by subci- of fat (under 50 mL) are retrieved, then one may
sion and fat transfer. expect the possibility of bruising or infection in the
donor site.
The injection of autologous fat may be associated
27.7 Complications with the following risks:
1. Loss of fat volume (the most frequent problem)
There are very few serious complications of autolo- 2. Possible need for repeat injection(s) of fat
gous fat transfer. Since it is the patients own tissue, 3. Bruising, hematoma
there is no rejection phenomenon or allergic reac- 4. Swelling (especially with over injection)
tion. The harvesting of large amounts of fat using 5. Asymmetry
liposuction is prone to the complications of lipo- 6. Prolonged erythema (usually temporary over a short
suction in the donor area but facial fat transfer is period of time)
a1 a2 a3
b1 b2
c1 c2 c3
Fig. 27.6 A 60-year-old female with atrophy of facial fat. (a) Preoperative. (b) Fat transfer markings in submalar area. (c) Four
years postoperatively
412 M.A. Shiffman
7. Scar that is depressed or thickened (rare except in 12. Peer LA (1956) The neglected free fat graft. Plast Reconstr
Surg 18:233
the area of liposuction)
13. Peer LA (1950) Loss of weight and volume in human fat
8. Tenderness, pain grafts. Plast Reconstr Surg 5:217
9. Fibrous capsule around fat accumulation (from 14. Peer LA (1959) Transplantation of tissues, transplantation
too much fat injected into one area) of fat. Williams and Wilkins, Baltimore
15. Fischer G (1997) The evolution of liposculpture. Am J
10. Fat cyst (mass)
Cosmet Surg 14(3):231239
11. Infection (rare) 16. Fischer G (1976) First surgical treatment for modeling
12. Microcalcifications (has not been reported in the face) bodys cellulite with three 5 mm incisions. Bull Int Acad
13. Central nervous system damage or loss of sight Cosmet Surg 2:3537
17. Fischer A, Fischer G (1977) Revised technique for cellulitis
from retinal artery occlusion (can occur with injec-
fat reduction in riding breeches deformity. Bull Int Acad
tion in the glabellar area) Cosmet Surg 2(4):4043
14. Plus all of the problems following liposuction if a 18. Bircoll M (1982) Autologous fat transplantation. The Asian
large amount of fat is removed Congress of Plastic Surgery, Feb, 1982
19. Illouz YG (1986) The fat cell graft: a new technique to fill
depressions. Plast Reconstr Surg 78(1):122123
20. Johnson GW (1987) Body contouring by macroinjection of
27.8 Conclusions autologous fat. Am J Cosmet Surg 4(2):103109
21. Bircoll MJ (1984) New frontiers in suction lipectomy.
Second Asian Congress of Plastic Surgery, Pattiyua, Feb,
Autologous fat transfer has been a very successful
1984
filler in the facial area. If care is taken in the transfer 22. Krulig E (1987) Lipo-injection. Am J Cosmet Surg
process and postoperatively, there will be 4060% fat 4(2):123129
survival on the first transfer. At times a second or even 23. Newman J, Levin J (1987) Facial lipo-transplant surgery.
Am J Cosmet Surg 4(2):131140
third fat transfer (using the patients frozen fat) may be
24. Verderame P (1909) Ueber fettransplantation bei adharenten
necessary to reach the volume best for the patient. knochennarben am orbitalran. Klin Montsbl Augenheilkd
7:433
25. Lexer E (1911) Ueber freie fettransplantation. Klin Ther
Wehnschr 18:53
References 26. Kanavel AR (1916) The transplantation of free flaps of fat.
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2. Klein JA (1987) The tumescent technique for liposuction 68:705706
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5. Verderame P (1909) Ueber fettransplantation bei adharenten 30. Neuhof H (1923) The transplantation of tissues. D. Appleton
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47:433442 31. Guerney CE (1938) Experimental study of the behavior of
6. Lexer E (1910) Freie Fettransplantation. Dtsch Med free fat transplants. Surgery 3:679692
Wochenschr 36:640 32. Hilse A (1928) Histologische ergebuisse der experimentel-
7. Bruning P (1914) Cited by Broeckaert TJ, Steinhaus J len freien fettgewebstronsplantation. Beitr 2 Path Anal U Z
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plastic surgery. MacDonald & Evans Ltd, London, pp 1541 plant. Plast Reconstr Surg 11(5):404412
10. Straatsma CR, Peer LA (1932) Repair of postauricular fis- 36. Hausberger FX (1955) Quantitative studies on the develop-
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620621 Anat Rec 122(4):507515
11. Cotton FJ (1934) Contribution to technique of fat grafts. N 37. Schorcher F (1957) Fettgewebsver pflanzung bei zu kneiner
Engl J Med 211:10511053 brust. Munch Med Wochenschr 99(14):489
38. Van RL, Roncari DA (1978) Complete differentiation of adi- to improving graft survival. Plast Reconstr Surg 90(6):
pocyte precursors: a culture system for studying the cellular 10221030
nature of adipose tissue. Cell Tiss Res 195(2):317329 58. Carpaneda CA, Ribeiro MT (1993) Study of the histologic
39. Van RL, Roncari DA (1982) Complete differentiation in vivo alterations and viability of the adipose graft in humans.
of implanted cultured adipocyte precursors from adult rats. Aesthetic Plast Surg 17(1):4347
Cell Tissue Res 225(3):557566 59. Carpaneda CA, Ribeiro MT (1994) Percentage of graft
40. Saunders MC, Keller JT, Dunsker SB, Mayfield FH (1981) viability versus injected volume in adipose autotransplants.
Survival of autologous fat grafts in humans and mice. Aesthetic Plast Surg 18(1):171965
Connect Tissue Res 8(2):8591 60. Niechajev I, Sevchuk O (1994) Long-term results of fat
41. Illouz YG (1985) New applications of liposuction. In: Illouz transplantation: clinical and histologic studies. Plast Reconstr
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macro techniques. Am J Cosmet Surg 4:111121 62. Fagrell D, Enerstrom S, Berggren A, Kniola B (1996) Fat
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of mechanical stress on adipocyte morphology and metabo- of three different kinds of fat transplants. Plast Reconstr
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44. Agris J (1987) Autologous fat transplantation: a 3-year 63. Jones JK, Lyles ME (1997) The viability of human adipo-
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45. Bircoll M (1988) Autologous fat transplantation: an evalua- Surg 14:275279
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5(4):283288 421425
46. ASPRS Ad-Hoc Committee on new Procedures (1987) 65. Sattler G, Sommer B (1997) Liporecycling: immediate and
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47. Billings E Jr, May JW (1989) Historical review and present 66. Ullmann Y, Hyams M, Ramon Y, Peled IJ, Linderbaum ES
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48. Markman B (1989) Anatomy and physiology of adipose tis- 67. Fulton JE Jr (1992) Breast contouring by autologous fat
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Bioactivation of free-fat transfers: a potential new approach 1(4):231235
Facial Fillers
28
28.1 Introduction Most fillers are presented in pre-filled syringes for

injection at various depths in the skin and subcutaneous
The development of biocompatible, temporary, and tissues depending on the filler used and specific indica-
long-lasting fillers for soft tissue augmentation has tion (Fig. 28.2). Lines and wrinkles require dermal
had a significant impact on the practice of cosmetic injections, whereas facial volumizing and contouring
surgery. Injectable fillers reduce and soften wrinkles, require deeper injections, either in the subcutaneous
enhance features, and provide facial volume and con- tissues or supraperiosteal plane. Temporary and perma-
touring in procedures that are performed either under nent fillers can be further classified depending on their
local anesthesia or under general anesthesia concur- origin or source: xenogenic, allogenic, bacterial, syn-
rently with open surgical procedures. In recent years, thetic, or combination fillers (Table 28.1). This chapter
there has been a paradigm shift in cosmetic surgery provides a summary of these fillers, and describes the
from a focus on lifting and excisional techniques to techniques for facial rejuvenation using temporary
one on procedures that add and restore volume to the hyaluronic acid fillers and long-lasting calcium hydrox-
face. This change in practice reflects our better under- ylapatite. It is the authors view that permanent syn-
standing of facial aging and the significance of volume thetic fillers may be useful in selected individuals who
loss, both as a result of fat atrophy and bony resorption request long-lasting results and understand the poten-
[1, 2]. The asynchronous volume loss in the different tial sequelae following complications with permanent
superficial and deep fat compartments of the face leads fillers, but should not be used as first-line treatments
to contour irregularities and folds that define the signs for aesthetic purposes.
of aging [3]. The midface flattens, tear trough hollows
under the eyes appear, nasolabial folds deepen, and
oral commissures give the mouth a downturned appear- 28.2 History
ance (Fig. 28.1). With appropriate use of fillers, either
in the skin, subcutaneous, or supraperiosteal plane, The use of facial fillers began at the end of the nine-
all of the effects of aging due to volume loss are teenth century when Neuber harvested blocks of free
improved or corrected, often without the need for inva- fat from the upper arms and transferred them to con-
sive surgery. When surgical procedures such as rhyti- cave defects in the face [5]. At the turn of the century,
dectomy are appropriate, the complementary use of Gersvny used paraffin as an injectable filler for cos-
fillers provides a third dimension to facial rejuvena- metic enhancement [1]. Paraffin was initially embraced
tion with superior, more natural-looking results than as a safe, inexpensive, and effective way to rejuvenate
lifting alone [4]. the face. As experience increased, significant complica-
tions such as paraffinomas and product migration
occurred and the popularity of paraffin as a filler dwin-
P.M. Prendergast
Venus Medical, Dublin, Ireland dled quickly [6]. In 1911, Bruning first reported the use
e-mail: [email protected] of autologous fat injections to fill a post-rhinoplasty

Fig. 28.1 Signs of facial

aging
Orbitopalpebral sulcus
Tear trough
Bony resorption
Nasojugal groove
Flattened cheek
Nasolabial fold
Perioral lines
Oral commisure
Lip atrophy
Cosmoderm and Cosmoplast received FDA approval in

2003. In 1989, Balazs identified hyaluronic acid as an
appropriate facial filler because of its biocompatibility
and lack of immunogenicity [9]. In 1998, the first
efficacy studies of non-animal-stabilized hyaluronic
acid (Restylane, Q-Med, Uppsala, Sweden) were per-
formed. In 1999, the product was purified further to
reduce immunogenicity and hypersensitivity reactions.
In 2003, after 4 years of use in Europe, Restylane was
approved in the USA by the FDA and has maintained a
large share of the hyaluronic acid filler market since.
Fig. 28.2 Injectable facial fillers
Other FDA-approved hyaluronic acid fillers include
Restylane, Perlane, Juvederm, Elevess, and Prevelle
deformity [7]. With the introduction of liposuction in Silk. In Europe, many more hyaluronic acid and other
1975, several authors reported their experience using fillers are available for soft tissue augmentation [10].
aspirated fat as a facial filler with promising results [8]. Although testing of fillers by the FDA delays approval
The early development of a bovine collagen gel in the in the USA, it is likely that many of the fillers currently
1960s by Gross and Kirk led, in 1981, to the Food and available in Europe will become available for use in the
Drug Administration (FDA) approval of Zyderm I USA in the near future [11].
(INAMED Aesthetics, CA), an injectable bovine col-
lagen filler. Zyderm II, a similar product with a higher
concentration of collagen, was introduced in 1983 and 28.3 Types of Fillers
Zyplast, a bovine collagen cross-linked with glutaral-
dehyde to increase longevity, received FDA approval in 28.3.1 Collagens
1985. About 20 years following the approval of bovine
collagen in the USA, a bioengineered human collagen The first FDA-approved dermal fillers were a group of
was developed to obviate the need for skin testing collagen products derived from the hides of a closed
and reduce the incidence of hypersensitivity reactions. herd of cattle in the USA. The three products within
28 Facial Fillers 417
Table 28.1 Classification of temporary and permanent facial fillers

Xenogenic
Bovine collagen (temporary) Zyderm I, Zyderm II, Zyplast (Allergan, Irvine, CA, USA)
Hyaluronic acid derived from cockerel combs Hylaform, Hylaform Fineline, Hylaform Plus (no longer marketed
(avian) (temporary) in the USA)
Allogenic
Bioengineered human collagen (temporary) Cosmoderm, Cosmoplast (Allergan, Irvine, CA, USA)
Bacterial
Hyaluronic acid derived from streptococcus Restylane, Restylane Fine Lines, Restylane Lipp, Perlane, Sub-Q (Q-Med,
equi (temporary) Uppsala, Sweden); Teosyal Fine Lines, Teosyal Global Action, Teosyal
Deep Lines, Teosyal Ultra, Teosyal Ultimate (Teoxane, Geneva,
Switzerland); Juvederm Ultra, Juvederm Ultra Plus, Juvederm Voluma,
Juvederm Smile (Allergan, Irvine, CA, USA); Elevess (Anika
Therapeutics, MA, USA); Prevelle Silk, Puragen (Mentor Corp., Santa
Barbara, CA, USA); Belotero (Merz, Germany)
Synthetic
Calcium hydroxylapatite (long-lasting) Radiesse (Bioform Medical, San Mateo, CA, USA)
Polyacrylamide (permanent) Aquamid (Contura Int., Soeborg, Denmark)
Polyalkylimide (permanent) Bio-Alcamid (Polymekon, Italy)
Purified polydimethylsiloxane (permanent) Silikon-1000 (Alcon Laboratories, Fort Worth TX, USA)
Combination
Polymethylmethacrylate + bovine collagen Artefill (Artes, San Diego,
(long-lasting) CA, USA)
Hyaluronic acid + dextranomeres (long-lasting) crm-DEX, crm-DX (Biopolymer GmbH & Co. KG, Montabaur, Germany)
the group, Zyderm I, Zyderm II, and Zyplast, were of those with negative initial skin tests prove to be
used extensively for over two decades for treating allergic to bovine collagen. Therefore, a second test
facial wrinkles and folds, until hyaluronic acid fillers 2 weeks after the initial one should be performed. The
received FDA approval in 2003 and became more inconvenience and delay in treatment with skin testing
popular. The bovine collagens consist of 9598% type prompted the search for a collagen-based filler that is
I collagen and up to 5% type III collagen presented in non-immunogenic. A bioengineered collagen, derived
0.52.5-mL syringes and suspended in phosphate from human tissue, received FDA approval for soft
buffered saline with 0.3% lidocaine. Zyderm I con- tissue augmentation in 2003. Cosmoderm I contains
tains 35 mg/mL of bovine collagen for superficial 35 mg/mL of collagen that is purified and screened
injection in the papillary dermis to correct fine lines. for viral and bacterial pathogens. Like Zyderm I, Cos-
Since saline absorbs soon after injection, overcorrec- moderm I is injected in the superficial dermis for fine
tion by up to 200% is required to achieve satisfactory lines. Cosmoplast, like Zyplast, is cross-linked with
results that last up to 3 months. Zyderm II contains glutaraldehyde and injected in the deep dermis and
65 mg/mL of collagen for deeper injection in the lips for deep wrinkles and lip enhancement. Despite
papillary dermis to correct deeper lines. Some over- the evolution in collagen products in terms of immu-
correction is required with Zyderm II to achieve satis- nogenicity, shortcomings include the need to overcor-
factory final results. Zyplast, the most robust in this rect, the relatively short residence times in tissues, and
family of bovine collagens, contains 35 mg/mL of the potential for serious adverse effects such as vascu-
collagen cross-linked with glutaraldehyde. Zyplast is lar occlusion or compression [12].
suitable for nasolabial folds, marionette lines, and to
define the vermilion border of the lip. No overcorrec-
tion is required, and results last 34 months. About 28.3.2 Hyaluronic Acid Fillers
3% of the population is allergic to bovine collagen. As
such, double skin testing is required prior to treatment Hyaluronic acid (HA) is a naturally occurring polysac-
with these products. About 0.1 mL of Zyderm I is charide that is ubiquitous in the extracellular matrix of
injected into the dermis of the forearm and inspected all animal tissues and consists of regularly repeating
for erythema, swelling, pain, and pruritus. Up to 12% units of d-glucuronic acid and N-acetyl-d-glucosamine
Table 28.2 Comparison of hyaluronic acid fillers

HA Particle Cross- Degree of Elastic
concentration size linking cross- modulus
Source (mg/mL) (mm) agent linking (%) (G) (Pa)
Restylane Streptococcus equi 20 300 BDDE 1.2 660
Juvederm Ultra Streptococcus equi 24 300 BDDE 2 105
Prevelle Silk Streptococcus equi 5.5 350 DVS 12 230260
Hylaform Plusa Cockerel combs 5.5 700 DVS 12 140220
BDDE 1,4-butanediol diglycidyl ether, DVS divinyl sulfone
a
Hylaform is no longer promoted in the USA
and Teosyal range are viscoelastic gels that are not

sliced or sized into particles during the manufacturing
process. Biphasic particulate gels, such as the Restylane
group of products, are passed through screens during
the manufacturing process, so that Restylane Fine Lines
has 200,000 particles per milliliter of product, Resty-
lane has 100,000 particles, Perlane has 10,000, and
Restylane Sub-Q is thicker with just 1000 particles per
milliliter (Fig. 28.3). Products with a higher concentra-
tion of cross-linked HA or larger particle sizes are gen-
erally indicated for deeper injection in the dermis and
subcutaneous tissues to correct deep folds or for facial
Fig. 28.3 Particulate hyaluronic acid filler contouring and may have higher tissue residence times
compared to products with lower concentrations of
[13]. It provides structural support to tissues by attract- cross-linked HA or smaller particle sizes.
ing up to 1000 times its weight in water. The HA bio-
polymer shows no tissue or species specificity, a feature
that has led to the development of hyaluronic acid fill- 28.3.3 Calcium Hydroxylapatite
ers for human injection from both avian and bacterial
sources. In its natural state, non-cross-linked hyaluronic Radiesse (Bioform Medical, San Mateo, CA, USA) is
acid has a half-life of approximately 24 h before it is a long-lasting temporary filler consisting of calcium
broken down in the skin by hyaluronidase and free hydroxylapatite microspheres of 2545-mm diameter
radicals into carbon dioxide and water [14]. The impor- suspended in a carboxymethylcellulose gel carrier. The
tant differences between currently available HA fillers calcium hydroxylapatite found in Radiesse is identical
include the source of HA, concentration of HA in each to that found in the matrix of bone. Radiesse is biocom-
syringe, agent used for cross-linking HA polymers, patible and provides long-lasting correction of deep
degree of modification and cross-linking, amount of wrinkles and folds and contouring of facial features
free unmodified HA present, and whether the product such as cheekbones and the nasal dorsum. Following
is monophasic (cohesive gel) or biphasic (particulate). injection, the microspheres undergo fibrous encapsula-
In addition, the elastic modulus (G) of a gel is a mea- tion and provide a network of scaffolding for collagen
sure of its firmness and resistance to deformation when ingrowth from surrounding tissue. Although the gel
a force is applied [15]. A comparison of two groups carrier absorbs over about 2 months, tissue ingrowth
of HA fillers is shown in Table 28.2. Most currently provides long-lasting results until the calcium hydrox-
marketed HA fillers are derived from the biofermenta- ylapatite microspheres degrade over several months to
tion of Streptococcus equi bacteria and are presented years [16]. Radiesse is an opaque, white, viscous prod-
in pre-filled syringes with volumes ranging from 0.5 to uct presented in 0.3-, 0.8-, and 1.5-mL syringes
3.0 mL. Monophasic products such as the Juvederm for injection in the dermalsubcutaneous junction or
Table 28.3 Summary of permanent fillers

Product Composition Indications Complications
Artefill (Antes, San Polymethylmethacrylate Deep wrinkles and folds Granulomas, palpable nodules
Mateo, CA, USA) microspheres (2040 mm) in
3.5% bovine collagen + 0.3%
lidocaine
Aquamid (Contura A/S, 2.5% hydrophilic polyacryl- Facial contouring Migration, granuloma, infection,
Soeborg, Denmark) amide gel in 97.5% water delayed inflammatory reactions
Bio-Alcamid (Polymekon, 97% hydrophilic Facial contouring, treatment Palpable nodules, implant
Italy) polyalkylimide gel of lipoatrophy migration, infection, delayed
inflammatory reactions
Silikon-1000 (Alcon Int., Polydimethylsiloxane oil Wrinkles, lipoatrophy, acne Granulomas, migration, palpable
Fort Worth, TX, USA) (1000 cSt) scarring (microdroplet nodules
technique)
Evolution (ProCytech, Polyvinyl microspheres Moderate to deep wrinkles Inflammatory reactions
France) (40 mm) suspended in and folds
polyacrylamide gel
subcutaneous plane through 27- or 28-gauge needles. 28.4 Choosing the Right Filler
Compared to hyaluronic acid fillers, Radiesse feels
firm following injection, although this softens some- The decision to choose one facial filler over another
what over a few days. Superficial injections, injections depends on a number of factors, including the particular
in the mucosa, and lip injections with Radiesse should indication, injector experience, patient expectations,
be avoided to prevent lumps, nodules, and granulomas. and local restrictions and availability. Hyaluronic acid
Typically, the results following soft tissue augmenta- fillers have become the gold standard for temporary soft
tion with Radiesse last about 1218 months [17]. tissue augmentation in most countries, and now super-
sede bovine and human collagen in the USA as the
most popular choice. In general, finer, less viscous
28.3.4 Permanent Fillers products are indicated for superficial wrinkles and lines,
such as those above the lip, in the skin of the cheeks,
The concept of permanently correcting an imperfec- and around the eyes. Thicker hyaluronic acid fillers
tion with an injectable filler or providing aesthetic with larger gel particle sizes, higher elastic moduli, and
enhancement with permanent results is attractive. a greater degree of modification and cross-linking are
However, it must be remembered that facial aging is a appropriate for deep, subcutaneous or supraperiosteal
dynamic process. A filler implant that corrects volume placement during facial contouring. Thicker gels placed
loss or improves facial contours in a 35-year old patient superficially may create unsightly ridges or palpable
may look out of place 10 years later when overlying lumpiness, whereas finer gels placed deeply below the
skin and surrounding tissues have become thin, invo- dermis provide insufficient projection of tissues and
luted, or ptotic. More importantly, complications asso- absorb quickly. Manufacturers endeavor to cater for all
ciated with permanent injectable fillers are generally indications by providing a selection of products with
more difficult to treat than the transient side-effects varying viscosity, particle size, and HA concentration
typical of temporary fillers such as hyaluronic acid (Table 28.4). Some fillers, such as Radiesse, are too vis-
[18]. Nevertheless, several permanent fillers are avail- cous and firm for superficial placement and should only
able, most of which are synthetic polymers or combi- be placed at the dermis-subcutaneous junction or sub-
nation materials. Table 28.3 provides a summary of the dermal plane. The firmness of Radiesse provides excel-
most common permanent fillers available today. lent structural support, making it ideal for deep
Artefill (Artes Medical, San Diego, CA, USA) is cur- nasolabial folds, cheekbone enhancement, and non-
rently the only FDA-approved permanent filler, indi- surgical nose reshaping [19, 20]. Injections of Radiesse
cated to treat nasolabial folds. in the superficial dermis or lips have a propensity for
Table 28.4 Authors choice of filler for facial rejuvenation

Indication Filler Needle/cannula choice
Nasolabial folds (superficial) Teosyal Global Action, Restylane 30 G " needle
Nasolabial folds (deep) Teosyal Deep Lines, Perlane, Radiesse 27 G " needle
Oral commissures Teosyal Deep Lines, Perlane 27 G " needle
Lip enhancement Teosyal Kiss, Restylane Lipp 27 G " or 28 G " needle
Perioral (smokers) lines Restylane, Teosyal Global Action 30 G " needle
Tear trough hollows Restylane, Perlane 30 G " or 27 G " needle
Upper eyelids Restylane 30 G " needle
Anterior cheek Teosyal Ultimate, Restylane Sub-Q 21 G 2" or 18 G 3" cannula
Cheekbones Radiesse 27 G 1 " needle
Nasal dorsum Radiesse 27 G " needle
Glabellar linesa Restylane, Teosyal Global Action 30 G " needle
a
First-line treatment for the glabella is botulinum toxin type A
nodule formation [21]. Soft fillers should be used to

augment naturally soft facial compartments, such as the
buccal and malar fat pads. As such, large volume
hyaluronic acid fillers such as Restylane SubQ,
Juvederm Voluma, and Teosyal Ultimate are ideally
suited to provide smooth anterior projection of the
cheeks lateral to the nasolabial folds. For tear trough
hollows in the medial infraorbital area, conservative
volumes of a small particle hyaluronic acid filler should
be placed deep to the orbicularis oculi muscle on the
periosteum to avoid visible and palpable lumpiness.
Several HA fillers designed for lip enhancement have
been introduced that are soft enough to provide natural
results but robust enough to optimize longevity in this
dynamic area. These include Teosyal Kiss, Restylane
Lipp, and Juvederm Ultra Smile. Although collagens
such as Zyplast and Cosmoplast do not provide lasting
results, they provide crisp definition rather than just
volume to the vermillion border of the lip. When start-
ing the practice of injectable fillers, the author recom-
mends using hyaluronic acid products only as they tend
to be more forgiving than long-lasting fillers and,
although rarely necessary, can be reversed using
hyaluronidase [22]. Fig. 28.4 Indications for facial fillers. Blue: basic techniques;
green: Advanced techniques
28.5 Pretreatment Considerations cations are commonly performed and technically sim-
ple. Advanced techniques require more precision, are
28.5.1 Patient Selection less forgiving, or involve contouring of features rather
than just filling lines. With all filler treatments, patients
There are several basic and advanced indications for should have realistic expectations and understand that
injectable fillers in facial rejuvenation. These are the aim is to soften folds and lines or improve features
shown in Fig. 28.4 and listed in Table 28.5. Basic indi- and proportions, rather than eliminate lines altogether
Table 28.5 Areas amenable to treatment with injectable facial

a
fillers
Common Less common
Nasolabial folds Tear trough
Lip border Upper eyelid
Lip body Nasal dorsum
Oral commissures Columella of nose
Vertical lip lines Philtrum of lip
Fine lines Jawline
Zygomatic arch Brow
Malar fat pad Chin
Acne scars Glabella, crows feet, and
forehead linesa
a
First line treatment is botulinum toxin type A b
or create perfection. The value of combining soft tissue

augmentation with other aesthetic medical procedures
such as botulinum toxins and skin resurfacing should
be emphasized, particularly if the patient seeks more
dramatic results. Facial assessment begins during the
consultation while the patient is speaking by observing
the activity of the muscles acting on the mouth. Often,
there is a discrepancy in the activity of the right and left
levator labii muscles during animation, resulting in
asymmetry of nasolabial fold depth that is resistant to Fig. 28.5 (a) Assessing the nasolabial fold. (b) Folds that soften
correction using fillers alone. Any asymmetry should with gentle lateral traction are treated successfully with fillers
be brought to the attention of the patient before treat-
ment and documented with photography. The face is
inspected from the front and side profiles to determine lid-cheek complex [23]. The aim of injectable fillers
the presence and extent of tear trough hollows, nasoju- under the eye is to create a smooth lid-cheek junction,
gal grooves, malar flattening, nasolabial folds, mario- so that the lid blends seamlessly with the cheek, with-
nette lines, lip height and projection, chin projection, out a groove or depression between them (Fig. 28.6).
nose shape, and perioral and cheek lines. Effacing the Atrophy of midface volume results in a cheek that
nasolabial fold with gentle lateral traction on the skin of falls away from the lid, giving the appearance of
the cheek indicates that fillers are likely to soften the a longer lower eyelid and bags under the eyes.
fold satisfactorily (Fig. 28.5). Similarly, if skin traction Restoring a smooth lid-cheek junction is achieved by
above the lip softens vertical rhytids, fillers in this area placing filler along the tear trough groove, and often
are likely to be of benefit. Minimal or no improvement complementing this with volume in the malar area
in the lines with this maneuver is common with etched anteriorly, to lift the cheek and efface the nasojugal
in lines that require more aggressive measures such as groove that runs further laterally from the tear trough
CO2 laser skin resurfacing. (Fig. 28.7).
Rejuvenation of the infraorbital area with fillers Botulinum toxin type A is the treatment of choice
alone can be challenging, particularly when there is for hyperdynamic lines in the upper third of the face:
skin laxity or prominent infraorbital fat pads. Never- glabellar lines, horizontal forehead lines, and perior-
theless, appropriate use of fillers in the right candidate bital lines. For etched-in lines or deep glabellar lines
can produce dramatic results, sometimes obviating the that remain despite chemodenervation, dermal fillers
need for surgery. The value of soft tissue augmenta- should be considered. Fillers injected in very dynamic
tion in this area is appreciated when one studies the areas such as the glabella without chemodenervation
a b
Fig. 28.6 (a) Before. (b) After hyaluronic acid fillers. The nasojugal groove has been effaced, improving the smooth convexity of
the lid-cheek complex
a b
Fig. 28.7 (a) Before. (b) After 1-mL hyaluronic acid filler placed at the preperiosteal level in each tear trough and 2 mL in each
malar area to improve volume and smooth contour irregularities
first may lead to migration and premature absorption. 28.5.2 Contraindications

Adverse effects associated with fillers in the upper face
include vascular compromise in the glabellar area and Contraindications to treatment with fillers include a
palpable lumps in the thin skin around the eye [24]. known allergy to any ingredient within the product,
Table 28.6 Guidelines for anesthesia in facial soft tissue augmentation

Area Anesthesia Volume per side (mL)a
Nasolabial folds Infraorbital n. blocks 12
Top lip, vertical rhytids above lip Infraorbital n. blocks + midline frenulum 12
Bottom lip, chin Mental n. blocks + midline frenulum 12
Oral commissures Mental n. blocks 1
Anterior malar area Infraorbital n. block + infiltrative anesthesia (with epinephrine) 23
Tear trough, infraorbital Infraorbital n. (percutaneous approach) 0.5
Cheekbones, zygomatic arch Infraorbital n. + zygomaticofacial n. blocks topical cold 23
a
Total maximum lidocaine dose should not exceed 4 m/kg (plain) or 7 mg/kg (lidocaine with epinephrine)
active inflammation or infection in the treatment area, efficacy and endpoint of augmentation. Regional nerve
anticoagulation, and unrealistic expectations. For med- blocks provide excellent anesthesia for soft tissue aug-
icolegal reasons, the author also defers treatment for mentation procedures and allow large areas to be anes-
anyone who is pregnant or breastfeeding. Patients on thetized, often at sites distant to the proposed treatment
antiplatelet therapy such as aspirin should be advised area. The author uses plain 2% lidocaine for most
that bruising is likely if they wish to proceed. regional blocks, providing a rapid-onset anesthesia that
lasts less than 1 h. For augmentation of the malar area
using a blunt cannula, infiltrative local anesthesia using
28.5.3 Preparation lidocaine with 1:200,000 epinephrine is useful for two
reasons. Firstly, the vasoconstrictive effects of epineph-
In order to minimize posttreatment ecchymosis, patients rine serve to limit ecchymosis from blunt trauma in the
are advised to stop aspirin, anti-inflammatory medica- cheek. Secondly, the volume of filler required for opti-
tion, and nutritional and herbal supplements such as mum enhancement is loosely determined by analyzing
fish oils, vitamin E, ginger, garlic, Ginkgo biloba, and the effect the local anesthetic alone has on the tissues.
St. Johns Wort at least 7 days before the treatment. If 3 mL of anesthetic produces sufficient augmentation,
Patients should be warned that swelling, transient ery- then the same volume of hyaluronic acid can be placed
thema, and bruising are possible, and should plan their immediately afterward.
social activities accordingly. Herpes simplex prophy- The supplementary use of topical ice or cold packs
laxis with an antiviral such as valaciclovir (500 mg per is often helpful, particularly for areas where nerve
day) can be commenced 2 days prior to treatment in blocks are less accurate or produce incomplete anesthe-
patients susceptible to cold sores, particularly for lip sia, such as the lateral cheeks, or when superficial vaso-
enhancement. A consent form describing the procedure constriction is desirable. For lip enhancement, small
in detail, after-effects, risks, benefits, potential compli- volumes of infiltrative anesthesia into the labial frenula
cations, and alternatives to treatment should be pro- in the midline supplement infraorbital and mental nerve
vided and signed by the patient before treatment. blocks. Table 28.6 provides a list of guidelines for anes-
Finally, good quality photographs should be taken from thesia in soft tissue augmentation of the face.
frontal, oblique, and side views using a digital camera.
28.7 Materials
28.6 Anesthesia
Fillers are available in different volumes in pre-filled
Adequate pain relief should be provided to patients syringes. Although needles of appropriate gauge are
prior to injectable filler treatments. Topical anesthesia often included within the product packaging, this does
alone using creams containing lidocaine, benzocaine, not preclude the use of other needles. However, whilst
tetracaine, prilocaine, or mixtures often do not provide it is acceptable to use a larger bore needle, longer nee-
adequate anesthesia, particularly for sensitive areas dle, or blunt cannula in place of the needle provided,
such as the lips. Infiltrating the treatment area with needles of smaller internal diameter than the one pro-
local anesthesia is simple and effective, but may distort vided should not be used. The rheological (flow) prop-
the tissues and interfere with the ability to assess the erties of the filler as well as gel particle size may not
technique is indicated for superficial wrinkles and

lines, such as those along the cheeks, lateral to the
oral commissures, or in the glabellar area. A series
of extremely superficial, quick injections are made at
34-mm intervals so that one droplet fuses into the next
along the wrinkle. Only less viscous hyaluronic acid
fillers should be injected using this technique. The nee-
dle should be changed once or twice during the treat-
ment to ensure it remains as sharp as possible.
2. Linear retrograde threading
To place filler along a fold or groove, the needle is
inserted to the desired depth, advanced, and withdrawn
slowly as product is expressed into the cavity created by
the needle in front of it. For nasolabial folds, the depth
is usually the deep dermis. For vertical lip rhytids, the
needle is placed perpendicular to the lines in the super-
Fig. 28.8 Blunt cannulas for subcutaneous placement of fillers
for facial contouring ficial dermis. This technique is also used to define the
vermilion border or enhance the body of the lips.
allow adequate expression through needles of smaller Although it is difficult to be sure of the precise depth of
internal diameter. Longer needles (11") are useful the needle in the skin, steady resistance is felt when the
for lip and cheek enhancement where single long passes needle is advanced through the dermis, whereas the
facilitate the procedure with less needle punctures. subdermal plane offers little resistance to the needle. If
Blunt cannulas are ideal for facial contouring and cheek the color of the needle is visible through the skin, the
enhancement where 34 mL of hyaluronic acid is needle is too superficial and should be withdrawn and
placed in the deep subcutaneous tissues and over the reinserted before placing any product (Fig. 28.11).
periosteum through a single skin puncture. For hyaluro- Hyaluronic acid filler that is injected too superficially
nic acid, the author employs blunt cannulas ranging in using this technique may result in an unsightly bluish
size from 22-gauge to 18-gauge of various lengths tinge or visible thread of filler that may take over a
(Fig. 28.8). Before injections, the skin is prepared using year to degrade. To reduce the likelihood of intravascu-
70% isopropyl alcohol wipes. Other materials required lar injection in the periorbital area, the syringe should be
for augmentation using injectable fillers include local aspirated gently before injection, followed by slow ret-
anesthetic, sterile gauze, 3 mL syringes, needles, cold rograde movement of the syringe as the filler is placed.
packs, and gloves. 3. Perpendicular buttress
This technique is indicated for deep nasolabial folds
that tend to overhang the crease despite placement of
28.8 Indications and Technique filler along its length using the linear retrograde thread-
ing technique. After a column of filler is placed into
28.8.1 General Technique and medial to the crease in the usual way, multiple short
threads are placed intradermally perpendicular to the
The following general techniques are used to inject crease to add support and reduce ptosis (Fig. 28.12). A
fillers superficially for lines and folds and deeply for robust filler such as calcium hydroxylapatite (Radiesse)
facial contouring or volume enhancement (Fig. 28.9): works well using this buttress technique.
1. Superficial droplet 4. Fanning
The tip of the needle (usually 30-gauge) is barely The needle is inserted, often to the hilt, and filler is
injected into the skin at approximately a 30 angle, injected during withdrawal as in linear retrograde
as superficially as possible, and tiny droplets (0.005 threading. However, before the needle tip exits the skin,
0.01 mL) are placed. A small wheal-like appearance it is redirected so that further product is placed next to
or localized blanching is acceptable because the drop- the first thread. The maneuver is repeated, through the
lets are so small and settle quickly (Fig. 28.10). This same needle puncture, until a fan or triangular-shaped
Fig. 28.9 Techniques for filler injections. (a) Superficial droplet. (b) Linear retrograde threading. (c) Perpendicular buttress.
(d) Fanning (e) Cross-hatching. (f) Depot. (g) Push technique
5. Cross-hatching
A grid-like pattern of filler is placed through mul-
tiple injection points so that the first series of threads
lie parallel to one another. A second series of threads is
then placed perpendicular to the first threads. This
technique provides structural support to an anatomic
area and builds up volume over features, such as the
cheeks. It is particularly appropriate for firm, collagen-
stimulating fillers such as calcium hydroxylapatite
(Radiesse), where a scaffolding of filler is laid down to
allow tissue ingrowth over time.
6. Depot
A bolus or depot injection of filler is placed deeply
to provide volume and project tissues anteriorly. The
Fig. 28.10 Superficial droplet technique. Small wheals appear depot technique should only be performed using blunt
as small droplets of hyaluronic acid filler are placed in the super-
cannulas to avoid intravascular injection. For malar
ficial dermis
enhancement, the author uses a combination of the
depot and fanning techniques through a single punc-
a ture lateral to the modiolus.
7. Push
This novel technique has been described for filling
the tear trough [25]. Using a fine blunt cannula, a small
depot of filler is placed supraperiosteally in the infraor-
bital groove. Then this small pool of filler is pushed
or massaged gently using the thumb along the tear
trough deformity medially. The technique avoids mul-
tiple punctures with a needle, and could be applied to
other facial areas.
b 28.8.2 Nasolabial Folds

(Figs. 28.13 and 28.14)
The folds are assessed in the upright position to deter-

mine the depth and predict the volume of filler required
for correction. Deeper folds generally require larger
volumes and more viscous fillers such as Radiesse,
Perlane, or Teosyal Deep Lines. Fine lines along the
fold should be treated with the superficial droplet
technique. Fillers are injected at different depths dur-
ing the same treatment to address both deep folds and
superficial rhytids. With the patient reclined at a 45
Fig. 28.11 Linear retrograde threading. (a) Needle placed too angle, an infraorbital nerve block is performed. The
superficially with color of needle visible. (b) Correct placement
in the dermis
extent of the fold is determined by gently pushing
the tissue toward the nasolabial crease. The needle is
layer of filler is laid down. The fanning technique is measured over the skin to determine a puncture site
usually employed at the superior part of the nasolabial that will allow the needle tip advance to the most
fold beside the nasal alae, at the oral commissures, and cephalad part of the crease. Filler is placed in the
in the cheeks. deep dermis using both linear retrograde threading
and fanning techniques. At first, a sufficient volume of of the nasolabial fold, a dimple or tethered area is
filler should be placed in the triangle beside the ala of often encountered where the zygomatici have dermal
the nose. Then, as filler is placed inferiorly along the attachments. Softening the fold here requires superfi-
crease, it is important to stay slightly medial to the cial placement of small volumes of filler, using the tip
fold to create a smooth transition between the skin of of the needle to gently subcise or cut the dermal
the upper lip and the nasolabial fat. At the inferior part attachments where possible.
a b
c d
e f
Fig. 28.12 Perpendicular buttress technique. (ad) The needle threads are placed in the deep dermis perpendicular to the fold.
shows the direction and placement of filler along the nasolabial (g) Before. (h) After 1.3-mL Radiesse in each nasolabial fold
fold and perpendicular to it. (e) Long threads of filler are placed using perpendicular buttress technique
in the deep dermis along and just medial to the fold. (f) Short
g h
28.8.3 Oral Commissures (Fig. 28.15) lifted, the fanning technique is used to support the
mouth corners and fill along the commissure toward
Fillers placed in the oral commissures lifts the mouth the chin.
corners and creates a pleasant countenance. Placing a
small amount of filler in this area is almost always
indicated during lip enhancement. To treat the oral 28.8.4 Lips (Figs. 28.1628.18)
commissures, the extent of the groove can be assessed
by gently pushing the jowl toward the chin. The index Both the vermilion border of the lip and the body of
finger of the non-injecting hand lifts the mouth corner the lip can be augmented using fillers. Although
into the desired position. Then the thumb stabilizes hyaluronic acid is the most commonly used filler,
the lower-lip skin to allow the needle pass easily into collagen may also be used for the border to provide
the dermis at the correct depth. The needle is mea- crisp definition. Fillers with long-lasting microspheres
sured over the commissure such that the tip reaches such as calcium hydroxylapatite and permanent fillers
into the upper lip when advanced to its hilt. To achieve should not be used for lip enhancement. For aestheti-
a successful lift, the needle must be in the superficial cally pleasing proportions, the bottom lip to top lip
dermis with the distal third of the needle immediately height should be approximately 1:0.6, although this
adjacent to the vermilion border. Two or three passes sometimes varies according to personal preference.
may be necessary to place adequate threads using the For anesthesia, infraorbital and mental nerve blocks
linear retrograde technique. Injections in this area are performed, supplemented with 0.5 mL of anesthe-
that are too deep may worsen the oral commissure sia in the mucosa at the midline around the upper and
rather than improve it. Once the lip edge has been lower frenula.
a midline. Shorter needles may be used near the philtrum

for accurate placement along the lip border without
distorting the angles of Cupids bow. Gentle moulding
in this area is used to maintain sharp definition. For
experienced physicians, a thin thread of filler can also
be placed along the philtrum ridges from the vermil-
ion to the columella, using the non-injecting hand
to feel the needle and hold the thread of filler in place
as the needle is withdrawn (Fig. 28.17). Augmenta-
tion of the vermilion border improves definition and
also reduces vertical lip rhytids in older patients and
smokers who experience bleeding of lipstick above
the lip.
b
To improve overall lip volume and provide some lip
eversion, filler is injected into the body of the lip
(Fig. 28.18). The lip is everted slightly with the non-
injecting finger and a suitable hyaluronic acid is
injected deeply into the lip at the point where the wet
mucosa meets the dry epidermis. A continuous sau-
sage-like tube of filler should be placed along the
length of the body of the lip, except for the lateral
34 mm, where filler may distort the shape of the lip
and make the mouth look wider. When the needle is
withdrawn each time, the lip should be grasped gently
with sterile gauze to prevent bruising and moulded so
c that the product is distributed evenly. Equal volumes
should be placed on either side, unless an asymmetry
exists before the procedure. Usually, 1 mL is sufficient
to provide subtle lip enhancement, or even less if the
border only is being treated. Mild swelling is usual and
subsides within a few hours.
28.8.5 Perioral Lines (Fig. 28.19)
One of the most commonly requested treatment areas

is the skin above the lip, where vertical lines radiate
Fig. 28.13 Filling the nasolabial fold. (a) Filler is injected in from the vermilion border. These perioral lines are par-
the deep dermis starting at the superior aspect of the fold. (b)
ticularly common in smokers with hyperdynamic
The area adjacent to the nasal ala should be filled to soften the
fold superiorly. (c) The fold is effaced using the linear retrograde orbicularis oris muscles and poor skin quality. Sun
threading technique inferiorly toward the mouth exposure and normal senescent changes due to loss of
fat, collagen, and elastin in the skin are also responsi-
To enhance the vermilion border, the needle is ble. To reduce perioral lines, a thin sheet of hyaluronic
placed at or just above the vermilion border, in the acid filler is placed in parallel threads into the superfi-
white roll, a tube-like structure that gives the lip cial dermis. The threads act as scaffolding that lifts the
border its definition. Using the linear retrograde tissues and softens the rhytids. Very superficial place-
threading technique, small volumes are injected along ment in the upper papillary dermis should be avoided
the length of the border, from the commissure to the to prevent lumpiness. Complementary use of botulinum
a b
Fig. 28.14 (a) Before. (b) Immediately after 1-mL Teosyal Deep Lines in each nasolabial fold
toxin to partially denervate orbicularis oris will enhance also a less forgiving area prone to swelling, puffiness,
the results and may prolong the tissue residence of and lumpiness with improper technique or poor patient
the filler. For lines that do not respond to either of these selection. Patients with very lax skin or excessive pro-
modalities, deep complete or fractional CO2 laser trusion of orbital fat should not be treated. An under-
resurfacing usually works well. standing of the complex anatomy in this area is
essential before addressing it with fillers (Fig. 28.21).
When the orbital and zygomatic retaining ligaments
28.8.6 Tear Trough (Fig. 28.20) attenuate, fat protrudes below the eye, bags begin to
form, and the tear trough and nasojugal folds become
Filling the tear trough hollow in the medial infraorbital prominent. Small volumes (<0.5 mL) of lidocaine with
area with even small volumes of hyaluronic acid can epinephrine are injected transcutaneously over the
result in significant rejuvenation. Unfortunately, it is periosteum around the infraorbital nerve. After waiting
Fig. 28.15 Lifting the mouth corners with fillers. (a) The oral of filler is placed in the superficial dermis just lateral to the
commissure is assessed in the resting position. (b) The index vermilion border. Further threads should be placed as required
finger of the non-injecting hand lifts the mouth corner to the until the lip edge remains elevated. (f) The needle is measured
desired position. (c) The thumb stabilizes the lower lip skin. over the skin medial to the fold. (g) Filler is placed medial to the
(d) The needle is measured externally to determine the point oral commisure to support the lift and soften the fold here (h)
of entry. The needle tip should reach the upper lip. (e) A thread After 0.5-mL hyaluronic acid, the mouth corner appears elevated
a b
c d
e f
g h
a b
c d
e f
g h
a During the procedure, the patient is asked to gaze

upward intermittently to delineate the tear trough,
which becomes more pronounced as the orbital fat
bulges outward. It is imperative to protect the globe by
placing the fingers of the non-injecting hand along the
orbital rim. This technique can also be performed using
fine bore blunt cannulas through one or two skin punc-
tures [26]. The skin in the tear trough area is extremely
thin, making it important to place the filler deeply
under the muscle, either in the prezygomatic space or
in the preperiosteal fat. Subdermal injections in this
area can only be performed if microdroplets are used
[27]. To efface the tear trough hollow, the author usu-
ally injects 0.40.5-mL hyaluronic acid per side during
an initial treatment, with further filler placed 23 weeks
b
later at a follow-up visit if required.
28.8.7 Malar Fat Pads (Fig. 28.22)
A youthful midface is characterized by smooth con-

vex curves from the lower lid with full anterior malar
fat pads (Fig. 28.23). The anterior cheek should blend
seamlessly with the lower lid, nasolabial fat pad, lat-
eral cheek, and tissue over the lateral orbital rim so
light is reflected from the smooth contours. The apex
or most anteriorly projecting part of the cheek is usu-
ally over the zygoma, just below the lateral canthus.
First, an infraorbital nerve block is performed using
the intraoral approach. Then a small bleb of anesthe-
sia is raised using a 30-gauge needle in the dermis just
Fig. 28.17 (a) Before. (b) After lip border enhancement and
enhancement of the philtrum lateral to the modiolus. To make an entry site for an
18-gauge cannula, a 16-gauge needle is used to punc-
ture the skin. Further infiltrative local anesthesia using
10 min, the needle is placed perpendicularly first to lidocaine and epinephrine is performed with deep
reach periosteum, then withdrawn 1 mm and tunneled injections into the site of augmentation with a long
slowly medially under orbicularis oculi to reach the 27-gauge needle. After waiting 10 min for adequate
medial extent of the tear trough. After aspiration, small vasoconstriction, the blunt cannula is used to deposit
aliquots of filler are placed under orbicularis oculi and hyaluronic acid using the depot and fanning tech-
the orbital retaining ligament as the needle is with- nique. In order to create seamless transitions between
drawn. Gentle massage after each injection ensures the the contours, filler must be placed close to the orbital
filler is in the correct position behind the muscle. rim, deeply in the buccal fat pad, into the sublevator
Fig. 28.16 Defining the lip borders. (a) A " or 1" needle is should be placed all the way to the midline to enhance the
ideal for placing fillers along the border of the lip. (b) A thread of Cupids bow. (f) A small bolus can be placed just prior to the
filler is placed all the way to the cupids bow, at or just above the needle exiting the skin where the philtrum line meet the lip. (g)
vermilion border in the white roll of the lip. (c, d) Using Gentle moulding enhances the philtrum. (h) To define the lower
the linear retrograde threading technique, filler is placed from the lip, a thin thread is placed at or just below the vermilion border
cupids bow to a point just short of the lip edge laterally. (e) Filler along the entire length of the lip
a b
c d
Fig. 28.18 Lip volume enhancement. (a) Slight eversion of the to a point just medial to the lateral border of the lip. (c) The
lip with the non-injecting hand exposes the mucocutaneous needle is placed deeply into the body of the lip. (d) A thin sau-
(wet-dry) junction. (b) Filler should be placed from the midline sage of filler is placed as the needle is withdrawn
space deep to levator labii near the nose, along the nique is usually indicated for patients who are
medial part of the zygomatic arch, and feathered from 2550 years old who have reasonable soft tissue cov-
the most prominent part over the zygoma toward the erage. Filler implants injected in patients who have
lower third of the face. The index finger feels for the very thin faces may look excessively prominent and
tip of the cannula at the infraorbital rim where it unnatural. The aim is to create subtle definition so
advances below the orbicularis oculi muscle. The that a shadow is cast along the zygomatic area
author typically places 1.54 mL of Teosyal Ultimate (Fig. 28.25). Firm, robust fillers such as Radiesse are
or Restylane Sub-Q on each side to achieve satisfac- particularly well suited for enhancing and defining
tory results. bony features such as the cheekbones. The area is
marked bilaterally to ensure symmetry. Infraorbital,
zygomaticofacial, and zygomaticotemporal nerve
28.8.8 Cheekbones (Fig. 28.24) blocks can be used for anesthesia, supplemented with
topical cooling where necessary. Most of the filler is
Soft tissue augmentation over the zygomatic arch and placed over the zygomatic arch and below the lateral
zygoma provide an attractive youthful appearance canthus over the zygoma, with feathering into the
characterized by high, defined cheekbones. This tech- malar and buccal areas. Threads of filler are placed at
a b
c d
Fig. 28.19 Perioral rejuvenation using fillers. (a) The depth (c) Thin threads are placed perpendicular to the lines across the
and distribution of perioral rhytids is determined by gently upper lip in the superficial dermis. (d) Further compression
compressing the skin above the lip. (b) The skin is stabilized. produces fewer lines once sufficient filler has been placed
the dermal-subcutaneous junction using the fanning nerve to anesthetize this area. Then a filler such as
and cross-hatching techniques. A long needle facili- Radiesse is injected along the periosteum, moulding
tates placement with fewer puncture sites. With cal- gently until the nasal dorsum appears straight. Asian
cium hydroxylapatite, approximately 1.32-mL filler patients often request a more prominent nasal bridge.
on each side achieves satisfactory enhancement. Once To achieve this, filler is placed more proximally, start-
placed, firm moulding into place with the fingertips ing at the glabella and blending with the nasal dorsum.
flattens the subcutaneous threads of filler and helps Filler should be placed in small volumes deeply on the
blend the augmented soft tissue with the surrounding periosteum to reduce the likelihood of intravascular
area. injection that could lead to skin necrosis in this area.
To lift the tip of the nose, a small depot injection of
hyaluronic acid is placed in the subnasale at the junc-
28.8.9 Nose (Fig. 28.26) tion of the columella and the upper cutaneous lip. An
injection of botulinum toxin in the depressor septi
Even minor alterations to the shape of the nose with muscle complements this by alleviating the downward
temporary fillers can produce immense patient satis- pull on the tip of the nose.
faction. The most common indication is filling the tis-
sue between the nasion and rhinion (Fig. 28.27). The
nasion lies at the root of the nose in the midline and the 28.8.10 Chin
rhinion is the junction of the bony and cartilaginous
dorsum of the nose in the midline. A small amount of To enhance the chin, a depot injection is placed on the
plain lidocaine is placed around the infratrochlear anterior aspect of the mentum in the midline. About
a b
c d
Fig. 28.20 Augmenting the infraorbital hollows. (a) The nee- withdrawn a fraction, redirected toward the medial canthus,
dle is placed along the periosteum just below the infraorbital and glides deep to the orbicularis oculi above the periosteum.
margin. (b) Markings can be made to define the extent of infraor- After gently aspirating on the syringe, small aliquots are placed
bital volume loss. (c) The needle is measured over the skin first using linear retrograde threading, releasing pressure on the
so that the needle tip reaches the medial extent of the hollow, plunger before the needle is withdrawn superficial to the muscle.
short of the angular vessels. (d) The needle passes deeply first (f) These steps are repeated along the extent of the tear trough
until the tip touches the periosteum. (e) Then the needle is hollow until adequate correction is achieved
e f
2 mL of hyaluronic acid placed on the periosteum is augmentation, injected through a 29- or 30-gauge
usually sufficient. needle. Even without anesthesia, injections in the eye-
lid are well tolerated. Topical anesthesia may be used,
but infiltrative anesthesia should not be used because
28.8.11 Supraorbital (Fig. 28.28) of its propensity to cause tissue distortion. After mark-
ing the hollows, tiny threads of filler are placed under
Elevation and anterior projection of the lateral third of the dermis and orbicularis oculi and gently mas-
the eyebrow is achieved by injecting approximately saged against the supraorbital ridge to ensure an even
0.5 mL of filler along the periosteum under the brow. distribution. The orbital septum lies deep to the ROOF.
Placing the filler a fraction inferior to the level of the The septum is very thin, and covers the subseptal fat
brow has the effect of pushing the hair of the brow medially and the lacrimal gland laterally. Injections
superiorly. should remain superficial to avoid penetrating the
orbital septum. The needle will enter the correct
plane by gently pinching up the skin and placing the
28.8.12 Eyelids (Fig. 28.29) needle into the tented area. Tiny aliquots of filler are
placed during the initial treatment to avoid complica-
Periorbital volume loss results in deepening of the tions, with additional augmentation at a second visit
superior orbitopalpebral sulcus with a visible bony if required. Results using hyaluronic acid fillers last
orbital rim. Improving this sunken eye appearance about 68 months. A similar technique using fat has
with fillers requires carefully placed injections in also been described [28].
the retroorbicularis oculi fat (ROOF) pad behind the
eyelid (Fig. 28.21). This is a particularly unforgiving
area and should only be performed by those with 28.8.13 Combination Approaches
extensive experience using fillers. If too much filler is
placed, or if the filler is injected in the skin, the eyelid Volume loss is only one facet of the aging process.
may appear swollen with visible bumps and uneven- Other aging features, such as hyperdynamic lines,
ness. Successful augmentation in this area softens ptosis, and various skin pigmentation and textural
the appearance and provides a more youthful look irregularities are addressed using injectable, laser, and
(Fig. 28.30). The author uses Restylane for periorbital minimally invasive procedures in combination with
Fig. 28.21 Components

of periorbital volume loss and
correction using hyaluronic
acid filler Orbitopalpebral sucus
Tear trough
Nasojugal fold
Orbicularis oculi
Retroorbicularis oculi
fat (ROOF)
Hyaluronic acid filler
Orbital retaining ligament
Suborbicularis oculifat
(SCOF)
Hyaluronic acid filler

Preperiosteal fat
Prezygomatic space
Zygomatic retaining
ligament
Fig. 28.22 Soft tissue augmentation of the midface. (ac) With the finger on the orbital rim, the cannula is inserted to the
Filler is placed medially and laterally along the orbital rim and periosteum and filler is placed deep to the muscles and in the
inferior to it, protecting the globe with the finger resting on the subcutaneous tissue using the fanning technique. (h) Smooth
orbital rim. (d) The skin is anesthetized by raising a dermal anterior projection of the cheek following 3-mL hyaluronic acid
bleb. (e) A puncture is made using a 16-gauge needle. (f, g) filler
a b
c d
e f
the techniques described above. The combination of In the upper face, botulinum toxin type A is the
multiple procedures provides synergy, enhancing over- most appropriate first-line treatment for hyperdynamic
all results without creating an unnatural appearance lines in the lateral periorbital area, glabella, and fore-
(Fig. 28.31). head. One injection of botulinum toxin in the lower
Fig. 28.23 (a) Flattening of

the midface. (b) Improvement a b
after soft tissue augmentation
with 3-mL Teosyal Ultimate
using an 18-gauge cannula
eyelid below the eyelash partially denervates pretarsal each procedure can achieve individually. To improve
orbicularis oculi and softens the appearance of the lid- the definition of the jawline, suture lifting of the lower
cheek junction, particularly when fillers have also been face and soft tissue augmentation of the prejowl sulcus
placed in the tear trough (Fig. 28.30). Carbon dioxide with fillers can be performed together. Softening the
laser skin resurfacing is the gold standard for treating chin with botulinum toxin also compliments the use of
photoaged skin and etched-in lines lateral to the fillers in the mental crease.
orbit and around the mouth. For glabellar frown lines,
botulinum toxin is the first-line treatment unless con-
traindicated, followed 2 weeks later by dermal fillers 28.8.14 Aftercare
when chemodenervation has been achieved but deep
lines remain. Patients should receive verbal and written instructions
In the midface, suture lifting techniques complement following injectable filler treatments. Although patients
soft tissue augmentation with fillers by elevating the are advised to massage the face after treatments with
malar fat pad. Superior and superolateral lifting vectors stimulating agents such as Sculptra, gentle handling is
soften the nasolabial fold and improve volume defi- more appropriate for most other fillers. Manipulating
ciency in the tear trough. Radiofrequency and infrared soft, pliable fillers such as hyaluronic acid following a
light devices for tissue tightening may also improve treatment may lead to displacement or lumpiness.
laxity, but the lifting effect of these external technolo- Excessive animation, such as laughing or chewing
gies is subtle. Fine perioral lines above the lip respond gum, should also be avoided, particularly following
to a combination of ablative resurfacing, dermal fillers, filler injections in dynamic areas such as the nasola-
and conservative doses of botulinum toxin. bial folds. Some swelling, erythema, and bruising are
Combined suture lifting of the lower face and filling normal after most injectable treatments. The patient
of the oral commissures provides better results than should be reassured, and cold packs can be applied as
a b
c d
e f
Fig. 28.24 Cheekbone enhancement using calcium hydroxy- through further injections medially over the prominent zygoma.
lapatite. (a) The area to be enhanced is marked carefully. This (e, f) Further injections are made from the medial aspect of the
should be quite high over the zygomatic arch and taper toward zygomatic arch to blend with the previously placed filler and
the zygoma. (b, c) The fanning technique is used to place filler in feather over the infrazygomatic area
the superficial subcutaneous plane. (d) Augmentation continues
a b
Fig. 28.25 (a) Before. (b) After cheekbone enhancement with 1.5-mL Radiesse on each side
desired for the first few hours. Mineral make-up can be Normal after-effects associated with the use of
used to camouflage ecchymosis. Prophylaxis with injectable fillers include transient swelling, erythema,
valaciclovir may be considered in patients who have and ecchymosis. The incidence and nature of more
frequent herpes simplex outbreaks, particularly before serious complications depend on the type of filler used
injections in or around the lips. and area injected. Minor complications due to superfi-
cial injections include visible or palpable lumpiness.
Allergic or inflammatory reactions associated with
28.9 Complications hyaluronic acid fillers have been documented, but are
rare [30]. Granulomatous reactions are more likely with
With the greatly increased use of injectable temporary collagen stimulating synthetic products such as pol-
and permanent facial fillers in recent years, there has ymethylmethacrylate and poly-l-lactic acid. These
been an increase in reported complications [29]. Proper may be treated with intralesional steroid injections.
training in basic and advanced techniques, a thorough Several treatments with small volumes of triamcino-
knowledge of soft tissue and facial anatomy, and an lone acetonide injected directly into the granuloma may
understanding of the indications, limitations, and be required [31]. Some of the most serious complica-
potential side effects with each of the currently used tions associated with fillers occur due to inadvertent
fillers are required to reduce the incidence of unneces- intravascular injection. In the glabellar tissue, this
sary complications [18]. Using only temporary fillers may lead to skin necrosis. Reports of iatrogenic visual
with high safety profiles such as hyaluronic acid also loss due to intravascular injection of collagen and fat
serves to reduce serious complications [12]. in the periorbital area exist [32]. Other significant
a b
Fig. 28.26 Nose reshaping using fillers. (a) The soft tissue is be placed from a point just proximal to the rhinion. (c) The filler
lifted upward and the needle is placed deeply on the periosteum. is moulded gently to create the desired degree of augmentation
After aspiration, small volumes are injected. (b) Filler can also or straightening
a b
Fig. 28.27 (a) Before. (b) After 0.3-mL Radiesse in the proximal nasal dorsum
a b
c d
Fig. 28.28 Filler enhancement of the lateral brow. (a) An intra- linear retrograde threading technique. (c) Before. (d) After
dermal injection of local anesthetic is made. No other anesthesia enhancement with 0.4-mL Perlane per side
is required. (b) Filler is injected along the periosteum using the
complications, such as implant migration, infection, [37]. The author routinely performs skin testing with
and delayed inflammatory reactions, are more likely hyaluronidase before treatment as hypersensitivity
with permanent fillers [3336]. reactions and angioedema can occur [38]. Hyaluronidase
Immediate posttreatment swelling and erythema do (e.g., Hyalase 1500 IU/amp) is reconstituted with
not require treatment, although topical ice packs may saline and small volumes are injected directly into the
accelerate resolution. In order to minimize bruising, lump or area that has been overfilled. Reconstituting
lidocaine with epinephrine can be used for infiltrative 1500 IU with 10 mL saline produces a 150 IU/mL
local anesthesia, except when treating areas with end- solution. The volume of this reconstituted hyaluroni-
arteries, such as the nose. Although slight lumpiness dase solution injected should equate to the volume of
usually resolves spontaneously, gentle massage is HA that requires removal. Breakdown of the filler can
advised to improve a discrete lump that bothers the be expected within hours.
patient. Although rarely necessary, hyaluronic acid
fillers may be dissolved quickly using hyaluronidase
a b
c d
e f
Fig. 28.29 Treating the superior orbitopalpebral sulcus (sunken thread of filler is placed, the lid is gently massaged against the
eyelid) with hyaluronic acid. (a) Mark the groove under the supraorbital rim. (fh) Injections of tiny aliquots of filler con-
brow where there is volume loss. (b) Gently pinch up the eyelid tinue medially along the orbitopalpebral sulcus until the groove
and insert a 30-gauge needle. (c) The needle should be under the has been corrected. (i, j) The filler is gently moulded against the
dermis or orbicularis oculi in the retroorbicularis oculi fat underlying periosteum to ensure evenness
(ROOF). (d) Lifting the needle reveals the depth. (e) After each
g h
i j
a b
Fig. 28.30 (a) Before. (b) After periorbital rejuvenation with hyaluronic acid and botulinum toxin: 0.2-mL Restylane in each orbi-
topalpebral sulcus, 0.5-mL Restylane in each tear trough, and 4U Dysport in each inferior pretarsal orbicularis oculi
a b
Fig. 28.31 (a) Before. (b) After botulinum toxin for upper face hyperdynamic lines, hyaluronic acid fillers in the nasolabial folds
and oral commissures, and a lower face suture suspension lift
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21. Jansen DA, Graivier MH (2006) Evaluation of a calcium 34. Chrastil-La Towsky B, Wesley NO, MacGregor JL, Kaminer
hydroxylapatite-based implant (Radiesse) for facial soft-tissue MS, Arndt KA (2009) Delayed inflammatory reaction to
augmentation. Plast Reconstr Surg 118(3 Suppl):22S30S Bio-Alcamid polyacrylamide gel used for soft-tissue aug-
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Ultrasound-Assisted Lipoplasty:
Basic Physics, Tissue Interactions, 29
and Related Results/Complications
William W. Cimino
29.1 Introduction Ultrasonic surgery is the use of metal probes

vibrating at low ultrasonic frequencies (2060 kHz) to
Safe and effective use of ultrasonic instrumentation for achieve a desired surgical effect in tissues. The probe
lipoplasty requires an understanding of both the tech- design, the frequency of vibration, and the surgical
nology and associated surgical methods that differ sig- technique all play a role. To be clear, it is the vibrating
nificantly in many ways from the basic tools and metal tip of the probe interacting with the tissue that is
methods of suction-assisted lipoplasty. This chapter of concern; it is not sonic radiation or some other mys-
presents the basic physics and tissue interactions for terious phenomenon. It is complex, but understand-
ultrasound-assisted lipoplasty, the benefits of proper able. Ultrasonic surgical instruments are in common
use of this technology, and complications associated use as dental descalers (from the 1950s and 1960s), for
with improper use of this technology. phacoemulsification (from the 1960s and 1970s), for
neurosurgery (from the mid-1970s), for laparoscopic
surgery (from the 1980s and 1990s), and for lipoplasty.
29.2 Basic Physics First-generation ultrasonic lipoplasty devices arrived
in the late 1980s and early 1990s, second-generation
Over the past decade and a half, there have been three devices arrived in the mid-1990s, and the third-
distinct generations of ultrasonic instrumentation for generation device arrived in the early 2000s.
lipoplasty introduced to the market. In each subsequent The basic ultrasonic surgery system has an elec-
generation, there have been design changes that tronic generator that interacts with an ultrasonic hand-
improve the safety, efficacy, and usability of the equip- piece. The ultrasonic handpiece has an ultrasonic
ment. In the following section, the basic physics of motor, most often composed of PZT crystals that con-
ultrasonic instrumentation is explained and used to vert electrical energy to vibratory motion. The vibra-
describe the differences in each of the three genera- tory motion is passed to a probe that vibrates in
tions of ultrasonic instrumentation for lipoplasty. First- resonance with the handpiece. The electronic circuits
generation ultrasonic instrumentation is represented in the generator maintain vibration at the selected reso-
by the SMEI Sculpture technology; second-generation nant frequency and adjust the amplitude of vibration
ultrasonic instrumentation is represented by the Mentor based on controls on the generator. Vibration frequen-
Contour Genesis and Lysonix 2000/3000 technologies; cies for ultrasonic systems for lipoplasty range from
and third-generation ultrasonic instrumentation is rep- 22 to 36 kHz. There is no significant difference in tis-
resented by the Sound Surgical VASER technology. sue effect across this frequency range; it simply alters
the lengths of the resonant pieces by changing the
wavelength of the vibration. Because the devices must
resonate, the lengths are multiples of wavelength.
W.W. Cimino
Louisville, CO, USA The ultrasonic probe and handpiece vibrate longitu-
e-mail: [email protected] dinally at the designed resonant frequency. This means

452 W.W. Cimino
that standing waves are established in the probe and consistent and strong coupling agent. The data show
handpiece such that the tip of the probe experiences that first- and second-generation ultrasonic devices,
maximum longitudinal motion, on the order of a peak- when run in the range of clinically effective amplitudes,
to-peak displacement of a few thousandths of an inch, deliver between 20 and 30 W of power to the water
barely visible to the naked eye. The amplitude is a bath. The third-generation devices typically delivery
function of the vibration frequency and the amplitude 1015 W of power to the water bath, generally 50% of
setting. It is important to understand that the vibration the power of the earlier generation devices. However,
is not lateral, i.e., transverse to the long axis of the the third-generation devices deliver the reduced overall
probe. When transverse vibration occurs, as it some- power with much greater efficiency [1]. The measure
times can with smaller diameter or longer probes, it of efficiency developed was the energy per unit active
has a very strong audible zing. Such a vibration can volume at the tip where the active volume of the tip can
easily fracture the ultrasonic probe because the probe be determined by measurements of the tip geometry.
was not designed to accommodate bending stresses. It This measured data showed that the design of the tip
is also important to visualize standing waves in the greatly influences the efficiency of the coupling. First-
probe as opposed to a single back and forth motion of and second-generation devices possess efficiencies in
the entire probe. A reciprocating powered cannula the range of 100175 mJ/mm3 in the clinically usable
device moves the cannula back and forth as a solid amplitude range, whereas the third-generation technol-
unit. Ultrasonic probes vibrate with standing waves ogy has efficiencies in the range of 175250 mJ/mm3 in
and thus achieve the ability to concentrate energy the clinically usable range. In summary, third-generation
at the tip of the probe. The peak-to-peak vibration technology was able to roughly double the efficiency
amplitudes and probe dimensions for the various first-, while cutting the power applied in half.
second-, and third-generation ultrasonic devices for The various probe designs shown in Fig. 29.1 can
lipoplasty have been summarized [1]. The available be used to explain this result. The probe on the left is a
vibration amplitudes for the various devices are of 5-mm probe with two aspiration holes and a relatively
actual little consequence. What matters is the available flat front surface. The majority of the frontal surface is
power at the tip of the device, which does scale with active on this probe. Thus, when the probe is pressed
amplitude, but is also a function of frequency. Thus, into tissues strongly, there is strong coupling of the
lower amplitudes and higher frequencies can achieve ultrasonic energy from the face of the probe. The sec-
the same level of power as higher amplitudes and lower ond probe from the left is a golf-tee design, having a
frequencies. concave surface at the front of the tip. The active area
Electrical power into the generator or amplitude for this probe is inside the concave recess and will not
of vibration is a not useful indicator of actual power for contact tissue unless the tissue is pulled into the recess
effecting tissues. Power deposited in tissues is a func- with suction or unless the probe is pressed strongly
tion of the generator setting, but also a strong function into a tissue area. Thus, the useful active area for this
of the coupling between the tip of the probe and the probe design is actually quite small. The outside ring
tissues. A vibrating tip that is pressed strongly into around the outside diameter of the probe will act as an
tissue will couple significantly more energy to the tissue ultrasonic knife when vibrating, which will be dis-
than the same tip that is gently touching the same tis- cussed later. The energy density along the outside ring
sue. Furthermore, the design and shape of the vibrating is very high, resulting in the cutting action.
tip will strongly influence how much power is coupled The fourth probe from the left (Fig. 29.1) is a
to the tissue and where on the tip the energy will be smooth hemispherical tip. This style is from the first-
concentrated. Thus, what was needed was a measure of generation UAL technology. This active area for this
the maximum acoustic power that could be coupled probe is actually only a small portion in the center of
from a probe with a specific design and a selected the hemispherical dome. The efficiency of such a
amplitude of vibration. This information has been mea- design is very low, and the energy intensity is very
sured and reported [1]. In short, a water bath was used high at the active area.
as a repeatable and reliable way to assess the power All of the ringed or grooved probes shown in
available from ultrasonic devices. Water is a very effec- Fig. 29.1 are from third-generation technology. The
tive medium in which to assess power because it is a grooves act to increase the active area for each probe,
29 Ultrasound-Assisted Lipoplasty: Basic Physics, Tissue Interactions, and Related Results/Complications 453
Fig. 29.1 Different

lipoplasty probe designs.
From left: second-generation
5-mm hollow, second-
generation 5-mm golf-tee
hollow, third-generation
4.5-mm 3-ring solid,
first-generation 4-mm solid,
third-generation 3.7-mm
3-ring solid, third-generation
2.9-mm 3-ring solid, and
third-generation 2.2-mm
2-ring solid
Table 29.1 Relative partitioning of energy based on number

of rings
Probe % Front % Side Tissue
3.7-0 100 0 Extreme fiber
3.7-1 65 35 Fibrous
3.7-2 55 45 Moderate
3.7-3 42 58 Soft
on a percentage basis, is coupled from the sides of the

probe tip and less is coupled from the front surface of
the tip. Thus, a probe with more grooves will not glide
as well in fibrous tissue and is more suited to softer
tissues. A probe with fewer grooves will have more
energy at the front of the tip and will thus penetrate
Fig. 29.2 Four identical probes except for number of rings fibrous tissues better.
The extent or reach of the energy from the surface
of the probe is a common question and concern. While
and the small flat disk at the center of the hemispherical some energy does radiate away from the tip, such
end increases the useful active area of the tip portion. energy is excessively weak and not capable of tissue
This probe design has significantly decreased energy disruption. The very long wavelength (on the order of
density due to the distribution of the total energy deliv- 5 cm) means that the energy quickly passes through
ered by the probe across a much greater area. The effi- any tissues and does not concentrate or focus at distal
ciency of this style of probe is much greater than locations. The active energy is associated with the zone
first- or second-generation designs. very near to the metal vibrating tip. Experiments with
The impact of the grooves can be examined and tissues, tissue phantoms, fingers, and other mediums
quantified. Figure 29.2 shows four identical probes can be used to show that the effective zone around
except for the number of rings at the tip. The efficiency a vibrating tip is limited to approximately 0.5 mm
of each probe can be measured as well as the distribu- from the surface of the tip. If tissue is outside of this
tion of the energy around the vibrating tip. The grooves distance then generally it will not be impacted in any
have surfaces that are perpendicular to the vibratory way. Therefore, effective use of an ultrasonically
motion. More grooves have more surfaces and hence vibrating probe requires that the probe tip be placed in
more coupling. Table 29.1 shows the relative partition- contact with all targeted tissues. It is not analogous to
ing of the energy for the four probes. Note that as the an air brush or some other device that has effect at a
number of grooves increases, more and more energy, distance.
454 W.W. Cimino
Pulsed delivery of energy further reduces the easily fragmented/emulsified by the device, even
average energy but maintains peak energy densities. though much of the cavitation has been suppressed.
This is analogous to the techniques used to calm the One can also reduce the amplitude of the device until
thermal delivery in continuous wave lasers. Short cavitation is either greatly reduced or not present, and
bursts of intense (peak) energy achieve the desired then apply the device to submerged tissue. While
effect but limit the overall thermal energy deposition. slower, the fragmentation/emulsification process is
The duration of the pulse must be short enough and the still observable. Further still, one can excise a sample
number of pulses per second must be large enough to of fatty tissue, say from an abdomen, with no infused
achieve the desired effect. Less than about ten pulses fluid, and apply the device directly in an open air envi-
per second results in non-significant differences rela- ronment. The fatty tissue will still dissolve or fragment
tive to continuous wave. quickly. Thus, while cavitation may be present, it is
not the predominant tissue interaction.
A thermal theory has been advanced. This theory
29.3 Tissue Interactions holds that ultrasonic energy essentially melts the
adipose tissue. Certainly it is possible to generate
The interaction between the tip of the ultrasonic heat with an ultrasonic probe device. However, this is
probe and the tissue is a complex function of three the opposite of the surgical and treatment objectives.
different phenomena and is further strongly influ- The addition of copious amounts of wetting solution
enced by the technique of the surgeon. The three and proper probe motion will ensure that no significant
basic tissue interactions are (1) cavitation, (2) ther- heat is generated. Some small amount of heat will
mal, and (3) mechanical. always be generated by a high-frequency vibrating
The cavitation theory was the original theory that probe. However, the amount and distribution of the
was advanced for the interaction between the ultra- thermal energy can be easily controlled and managed
sonic device and the fatty tissue. The theory holds that such that the fragmentation/emulsification process can
the ultrasonic energy at the tip of the probe induces an occur without untoward thermal effects. The amount of
acoustic field that causes gases dissolved in the tissue heat generation has been measured and quantified [1].
and fluids to accumulate in bubbles which are then The mechanical theory holds that when the rapidly
acoustically driven to grow in size until they become moving metal tip of the ultrasonic probe encounters
unstable, at which time they implode. The implosion is tissue, it creates high-energy vibration-induced impact
a violent process that releases energy in the form of and flow conditions that fragment/emulsify adipose
shock waves and heat. The implosion actually only tissue. High and low pressures, rapid acoustic stream-
releases a very small amount of energy per bubble ing, and impacts with fast-moving metal surfaces, indi-
because the bubbles are very small. The net energy vidually and in combination, are enough to fragment/
is the sum of the many bubbles that are being gener- emulsify the tissue [2, 3].
ated by the ultrasonic energy at the tip of the probe. All three types of interaction are likely to be present
The cavitation bubbles exist as a beard around the tip in most situations, to varying degrees. The design of
of the ultrasonic probe, seemingly attached to the the instrumentation and the technique used by the sur-
probe surface and extending no more than a millimeter geon will influence how much of each interaction is
therefrom. The bubbles exist at profile changes in the present. With regard to design, probes that are run at
tip, not along smooth surfaces parallel to the axis of excessive amplitudes, or which have smooth overall
vibration. shapes, are inefficient and will result in more thermal
There is significant energy present in these zones of energy deposition and less mechanical fragmentation.
cavitation bubbles, no doubt it is enough to damage or Probes with flat or concave front surfaces will gener-
lyse adipose cells. However, the question remains as to ate excessive cavitational energy that ultimately con-
whether or not this is the primary interaction with tis- verts to thermal energy and also have very high energy
sue. For example, one can examine the interaction densities along these surfaces. Mechanical efficiency
between the ultrasonic probe and tissue which is sub- is optimized by probe designs with many surfaces per-
merged in degassed water that has a significantly pendicular to the axis of vibration and the elimination
increased cavitation threshold. The tissue can still be of sharp edges. With regard to surgical technique, use
of sufficient wetting solution and consistent probe Fat

movement will eliminate thermal issues. The vibrating
tip should not be strongly pressed into any tissue as
this removes the protective fluid and strongly couples Increasing
fragmentation Muscle
the ultrasonic energy to the tissue, resulting in a strong
thermal energy deposition (end-hit). Large diameter Collagen
Bone
probes should be avoided as they possess excessive
vibrational energy and require significant pushing to Increasing tissue strength
get through the tissue unless the amplitude is turned
way up, again resulting in excessive vibrational energy Fig. 29.3 The effect on increasing tissue strength on
applied to the tissues. fragmentation rate
29.4 Results from Ultrasound

Instruments
This section focuses on results enabled by use of

ultrasonic instrumentation from the perspective of the
physics and tissue interactions. Results based on before
and after pictures from lipoplasty surgeries are widely
available elsewhere.
With proper design and proper surgical technique,
the mechanical tissue interaction discussed above can
be made to dominate the tissue interactions. The
advantage of such a combination is that the ultrasonic
energy can be made to be tissue selective. The basis for
the tissue selectivity is the strength of the various Fig. 29.4 Soft emulsified tissue and fluids subsequent to
tissues relative to the strength of the ultrasonic application of ultrasonic energy
energy [2, 3]. Figure 29.3 shows the fundamental situ-
ation. As the tissue strength increases, the effect of the abdominoplasty sample where an incision has been
ultrasonic energy decreases. The ultrasonic energy placed to reveal the emulsified tissues, subsequent to
level can be adjusted so that tissues with lower strengths the application of the ultrasonic energy. The sparing
are fragmented/emulsified (fatty tissues) while tissues of the collagen structures, vessels, and nervous tissue
with higher strengths are relatively undamaged. This is is shown in Fig. 29.5. Because the emulsified tissue/
the key to success with ultrasonic instrumentation. fluids can be more easily removed with less avulsive
Whereas suction-assisted avulsive trauma is not selec- trauma than with traditional suction-assisted lip-
tive (anything pulled into the suction port is torn and oplasty, more of the tissue matrix can be spared, as
removed), properly designed ultrasonic instrumenta- shown in Fig. 29.5. The body thus experiences less
tion can be tissue selective. This phenomenon is the tissue trauma than if the visible tissue matrix was
basis for the use of ultrasonic energy in the neurosur- extensively torn, resulting in faster healing, smoother
gery field where similar-type ultrasonic devices are results, and less pain. Further, the reduced tissue matrix
used to fragment and aspirate brain tumor tissue while trauma results in significantly reduced blood loss, as
sparing as much nervous tissue and vascular tissue as has been shown when comparing use of third-genera-
possible. In fact, this phenomenon was the genesis of tion technology to suction-assisted lipoplasty in the
the application of ultrasonic energy to the lipoplasty back [4]. This study found six to seven times less
procedure. blood in the aspirate for the third-generation technol-
When done properly, ultrasound-assisted lipoplasty ogy versus SAL.
fragments the adipose tissue and creates a soft emul- Because the ultrasonic instrumentation is less trau-
sion. Figure 29.4 shows the soft emulsion in an matic to the tissue matrix, it can be used to enhance
456 W.W. Cimino
a the structures in this layer are torn or removed, leaving

the skin less attached to the lower layers. The skin
therefore does not experience the contractive loading
of the connective tissue and tends to settle on the lower
layers and scar/heal in place with very little contrac-
tion. In the alternative, if the superficial layer can be
successfully defatted resulting in a volume reduction
in the superficial layer but leaving the majority of the
tissue matrix intact, then the skin will settle/heal sub-
ject to the elastic loading generated during the healing
process to eliminate volume. There are two keys to
successful defatting of the superficial layer: (1) the
b technology and technique used must result in minimal
trauma to all tissues except the adipose cells; and (2)
the technology and technique used must be applied
uniformly and evenly in the superficial layer.
The objective of proper application of ultrasonic
energy to the lipoplasty procedure is to reduce avulsive
trauma to the tissue matrix which thereby promotes
smoother results with more skin retraction, faster heal-
ing, less bleeding, and less pain. These results can be
produced only with proper and appropriate application
of ultrasonic energy. Early generation UAL devices
had many design characteristics that precluded the
c achievement of these objectives, as described above in
Basic Physics and below in Complications.
29.5 Complications
This section discusses complications related directly

to the design and use of ultrasonic instrumentation for
lipoplasty. Complications related to surgical error or
judgement for lipoplasty surgery or patient-specific
situations are not discussed.
Complications can be lumped into two general
categories: (1) pilot error which are complications due
to a surgeons lack of knowledge concerning (a) proper
use of the ultrasonic instrumentation, (b) tissue effects,
Fig. 29.5 (a, b, c) Spared collagen and vessel tissue
(c) surgical endpoints, (d) energy delivery; and (2) ultra-
sonic instrumentation design issues such that result in
skin retraction in lipoplasty. Skin retraction is excessive energy delivery or inefficient energy delivery.
maximized when the superficial fatty layer (underside Pilot error issues can be described as technique issues,
of the dermis to one centimeter below the underside of and the design issues can be described as technology
the dermis) is thinned but minimally traumatized, issues.
meaning that the connective tissue and vascular struc- By far the largest concern and most frequent com-
ture in this superficial layer remain as undamaged as plication can be described as skin burns. This type of
possible. If this superficial layer is thinned with complication is most often a pilot error, but can also
suction-assisted lipoplasty devices, the result is that be related to design. Both are discussed below.
29.5.1 Burns at the Incision Site placement of a protective towel so that when the probe
is moved to a position such that it would be in contact
An ultrasonically vibrating probe will create heat with skin, it is instead pressing on the towel. One layer
through friction when pressed into the skin. The single of towel is usually not sufficient as it will conduct heat
most important factor is called coupling. In short, rapidly to the skin below. A folded towel with two
this refers to how hard the vibrating probe is pressed or to three layers provides sufficient protection in almost
torqued into the skin. An incision site acts as a fulcrum all instances. The towel may be wet or dry as long as
point. During suction-assisted lipoplasty, the surgeon sufficient layers (folds) are used.
frequently and commonly torques or lifts the suction
cannula about the incision fulcrum, largely without
complication, although skin abrasion and stretching 29.5.3 End-Hits
will occur. With an ultrasonically vibrating probe, such
a technique will result in immediate heating of the End-hits are simply pressing (poking) the vibrating tip
edges of the incision, especially if the incision is too of the probe into the underside of the dermis. This
small and the skin is tightly sphinctered around the most often happens when the anatomy curves away
vibrating probe. Skin ports have been designed to insu- from a flatter area and the probe is advanced so that the
late the vibrating probe from the skin incision edges tip pokes into the skin, resulting in a concentration of
and do a very good job. However, even skin ports will energy at the tip of the probe. End-hits will most often
heat if the vibrating probe is torqued about the incision leave small points of hyperpigmentation that heal over
site and will thus heat the skin edges through the skin time. End-hits are 100% avoidable by maintaining a
port. The proper technique is to avoid torquing and probe orientation as flat as possible with the skin
lifting of the vibrating probe about the incision point. surface and by avoiding the tendency to reach around
Straight radial strokes without torquing eliminate cou- a corner.
pling at the incision fulcrum and heating of the skin
edges. Common mistakes include lifting the probe to
try to reach around a curved body area or pushing the 29.5.4 Contribution of Excessive Amplitude
probe to extend the action of the tip beyond the reach
of the probe. Additional incisions easily solve these As the amplitude of vibration in the probe is increased,
problems. Torquing at the incision is by far the most the potential to generate heat through friction also
common mistake of surgeons early in their experience increases. Amplitude should be set at the minimum
with ultrasonic instrumentation, especially if they are value which allows for graceful gliding motion of the
classically trained in suction-assisted lipoplasty. probe without significant hanging or drag. Directly
related to this issue is the proper choice of the probe for
the type of tissue. One style of probe is not appropriate
29.5.2 External Burns Away for all tissue types. Fibrous tissues require smaller diam-
from the Incision Site eter probes and probes with less coupling. Softer tissue
allows for larger probe diameters and probes with more
The vibrating probe can be pressed into unprotected coupling. If a larger diameter probe is used in fibrous
skin away from the incision site and will cause a fric- tissue, excessive vibration amplitude will be required to
tion burn. It usually appears as a line blister where get the probe to pass through the tissue. This is the
the probe was momentarily pressed into the skin and source of many of the complications associated with
most often happens where rounded areas of skin are first- and second-generation ultrasonic instrumentation.
contacted when the surgeon tries to keep the probe flat
and parallel to the skin. The most frequent areas are
the pouch between the suprapubic area and the 29.5.5 Complications Associated
umbilicus when the surgeon is working in the epigas- with Volume of Wetting Solution
trium through the umbilicus and the buttock when
working in the banana rolls or medial thighs. This Ultrasonic instrumentation requires more wetting
type of skin burn is 100% preventable with proper solution than suction-assisted lipoplasty. The wetting
458 W.W. Cimino
solution provides thermal protection to the tissues, 29.5.7 Complications Associated

aids in forming a soft emulsion for removal with aspi- with Overapplication
ration cannulae, and ensures wide and uniform distri- of Ultrasonic Energy
bution of epinephrine for vasoconstriction. Two of
these three benefits are not required for suction- Any energy source can be overused or overapplied,
assisted lipoplasty. When insufficient wetting solution and the same holds true for ultrasonic energy. Safe
is used, patients may experience prolonged edema, and effective guidelines for ultrasonic energy ampli-
induration, a tingling/burning sensation, or increased tude and duration have been developed and are sup-
pain. Use of sufficient wetting solution will largely, if plied as general guidelines with the instrumentation.
not completely, eliminate these problems. Suction- Generally speaking, 1 min of ultrasonic time per
assisted lipoplasty generally and widely uses a 1:1 100 mL infused into an area results in good emulsifi-
ratio for wetting fluid in to estimated aspirate out, cation and no postoperative problems. With experi-
most commonly referred to as the superwet tech- ence and sufficient wetting solution, 1 min and 30 s
nique. Other techniques use more wetting solution, of ultrasonic time per 100 mL of infused wetting
with upper ranges as high as 2:1 or 3:1. Ultrasound- solution is commonly used. As ultrasonic time
assisted lipoplasty requires a range of 1.5:1 to 2:1. approaches 2 min per 100 mL of infused wetting
This amount of fluid generally eliminates the potential solution, the complications described above related
complications discussed above and is widely and to the volume of wetting solution begin to become
successfully used in ultrasound-assisted lipoplasty more pronounced. Fortunately almost all of the
surgery. Other than skin burns, the most frequent com- targeted adipose tissue can usually be addressed
plaint related to use of ultrasound-assisted lipoplasty before the 1 min 30 s per 100 mL infused limit is
devices is prolonged healing or edema, or pain. This reached. It is important to note that not all ultra-
result can almost always be directly correlated with sonic instrumentation can be treated similarly in this
use of insufficient fluid. Suction-assisted lipoplasty regard. First- and second-generation UAL devices are
surgeons are often slow to adopt the increased require- generally much too powerful to be used with these
ments for wetting solution in ultrasound-assisted time/amplitude guidelines and should be adjusted
lipoplasty, believing that the familiar 1:1 should be accordingly.
sufficient. It is important to the final result and to the
comfort of the patient postoperatively that sufficient
wetting solution be used. 29.5.8 Complications Associated
with Instrumentation Design
29.5.6 Complications Associated The original ultrasonic instrumentation for lipoplasty

with Aggressive Aspiration was the SMEI Sculpture system. This system had large
diameter probes with blunt smooth ends. Such a
Once the adipose tissue has been emulsified, it does design has no area of ultrasonic activity except the
not require aggressive avulsive aspiration. Special can- central portion of the hemispherical tip, a very small
nulas have been designed to rapidly remove the emul- area. This design was so inefficient that extended
sified tissues and fluids with minimal avulsive trauma. application was required to produces emulsification.
When the emulsified tissues and fluids have been This design thus resulted is unnecessarily extended
removed, an amount of traditional suction-assisted lip- application times.
oplasty with its attendant avulsive trauma may be Second-generation devices added a central lumen
required to achieve the final contour. If the avulsive to the vibrating probes for aspiration. The central
suction phase is pursued aggressively, it will destroy lumen was approximately 2 mm in diameter on a
the benefit and gains of the ultrasonic phase, namely 5-mm probe. Usually a 1.82.0-mm aspiration can-
the emulsification of the adipose tissue with no avul- nula is much shorter than the 2732-cm lengths of
sive trauma. Thus, it is important not to use overly these ultrasonic probes, specifically because aspira-
aggressive aspiration subsequent to the ultrasonic tion with such a small diameter lumen is extremely
emulsification phase. slow and applicable to only small volumes. Thus, a
very slow aspiration system was combined with large

and powerful 5-mm ultrasonic probe. Surgeons had
the mistaken concept that the aspirated tissues that
they were seeing in the suction tubing was immedi-
ately related to the effect of the ultrasound that they
were applying to the tissues happening as they were
visualizing the aspirant. This is not correct. The tran-
sit time for the aspirant up the 2-mm lumen was on
the order of 25 s while the tip was vibrating at
22,00027,000 times per second. Only a single to a
few hits of the vibrating probe are required to frag-
ment the adipose tissue in a particular area, requiring
only thousandths of a second. Thus, surgeons tended
to continue apply excessive ultrasonic energy because
they were working with a time constant of 25 s or
more (visual) and the ultrasound was effective with a
time constant of a few thousandths of a second.
Further, adipose tissue and saline were essentially
frothed in the vibrating aspiration channel, chang-
ing the color and texture of the aspirant relative to the
actual emulsified tissue/fluids in the body, further dis-
torting the perception of the surgeon. Further still, the Fig. 29.6 A 5-mm hollow golf-tee ultrasonic probe
vacuum at the tip of the vibrating probe pulled tissue
up against the vibrating probe tip and strongly
increased coupling, unnecessarily damaging tissue. lipoplasty. These are pictures of bad surgery, not
Ultrasonically vibrating probes generate an acoustic pictures of results of ultrasonic instrumentation for lip-
pressure that pushes tissue away from the probe, thus oplasty. If indeed these pictures are the result of a sur-
minimizing excessive application of energy unless gery where ultrasonic instrumentation was used, the
the probe is pressed strongly into the tissue. All third- disastrous results could have been easily avoided with
generation ultrasound technology for lipoplasty is (1) sufficient use of wetting solutions (2) appropriate
solid probe technology for these reasons, and the application of ultrasonic energy addressing both duration
complications associated with a central lumen for of application and amplitude of vibration, and (3) proper
aspiration have been eliminated. and reasonable aspiration of the emulsified tissues, thus
A golf-tee type tip design was introduced with the limiting the avulsive trauma of the suction cannula.
second-generation Lysonix 2000 system (Fig. 29.6).
This design had a concave tip with a central lumen and
a reasonably sharp edge around the edge of the tip. 29.6 Conclusions
When vibrated at ultrasonic frequencies, the sharp
edge becomes very sharp, in fact making this probe Ultrasound-assisted lipoplasty is now a stable and
design a powered curette. This design is thus respon- growing method of lipoplasty. Applications have been
sible for many of the reported complications with early expanded from basic body contouring to contouring of
generation UAL systems. the face and neck, breast, and other delicate areas such
For the past decade, there has been wide circulation as the knees and ankles. New applications and treat-
of certain photos showing large areas of necrosed skin ments are under investigation such as for the perma-
related to the use of ultrasonic instrumentation for nent treatment of axillary hyperhidrosis. Complications
lipoplasty. While such a result could be produced resulting from first- and second-generation ultra-
through improper and excessive use of ultrasonic instru- sonic technology/devices have been largely elimi-
mentation, the same result could be produced through nated; firstly, by significantly improved third-generation
improper and excessive use of suction-assisted instrumentation design, and secondly, by significantly
460 W.W. Cimino
improved information and understanding of proper References

techniques and surgical endpoints when using ultra-
sonic instrumentation for lipoplasty. Published studies 1. Cimino WW (2001) Ultrasonic surgery: power quantification
and efficiency optimization. Aesthet Surg J 21(3):233240
now show the substantial decrease in blood loss when 2. Cimino WW, Bond LJ (1996) Physics of ultrasonic surgery
using third-generation UAL technology compared to using tissue fragmentation: Part I. Ultrasound Med Biol
SAL. Ultrasonic technology for lipoplasty has pro- 22(1):89100
gressed from initial high excitement with rudimen- 3. Bond LJ, Cimino WW (1996) Physics of ultrasonic surgery
using tissue fragmentation: Part II. Ultrasound Med Biol
tary first-generation technology to waning excitement 22(1):101112
with second-generation technology to stable and grow- 4. Garcia O, Nathan M (2008) Comparative analysis of blood
ing acceptance and utilization with third-generation loss in suction-assisted lipoplasty and 3rd-generation internal
technology. ultrasound-assisted lipoplasty. Aesthet Surg J 28:430435
Facial Recontouring
with Liposuction 30
30.1 Introduction 30.3 Technique
In the last decade, the demand for aesthetic procedures The probe is always the 2.2-mm diameter, utilized with
has increased, but for less invasive, less traumatic tech- 30% continuous mode for fibrous tissue, or 30% Vaser
niques. Patients look for a faster return to work/life, mode. Generally, between 2 and 3 min of application is
and mostly they seek a youthful, smooth, nonpulled sufficient to fully undermine each sector of the head
appearance. and neck area (jowls, chin, mandible, cheeks, etc.).
If the neck is heavy with a lot of local fat to be emulsi-
fied for facial debulking and contouring, allow another
30.2 Technologies 1 min minimum for the deeper fat layer.
To remove emulsified fat or to remove infiltrated
Results with liposuction were generally good, but solution, perform gentle aspiration with a 1.8-mm can-
inconsistent, and with insufficient skin retraction. nula at low aspiration power. Gentle manual shaping
Earlier generations of ultrasonic devices were poten- and pressure are utilized to help the solution to come
tially too powerful or aggressive for easy, safe, and out. Tumescence is a temporary status, and in the face
meticulous head and neck applications. Complications, and neck, fluids are absorbed faster than elsewhere.
although minimal, were more threatening. Heavy faces occur in many of the potential candi-
Vaser technology represents an advanced tool, dates for Vaser facial contouring. Overweight and
available on the market since 2001, which offers guar- obese patients often require a general thinning or soft-
antee of safety and quality and allows great results in a ening of the cheeks and lower third of the face
simple manner in expert hands. Training with Vaser for (Fig. 30.2). Figure 30.3 is a patient with an undefined
face and neck is not difficult, but requires technical face, fatty cheeks and chin, no mandibular line defini-
skills and finesse in working close to the subcutaneous tion, no orbital cheek sulcus, and no preparotid natu-
layer with a fine (2.2-mm diameter) titanium probe ral depression. This patient underwent a Vaser face
(Fig. 30.1). contouring of cheeks, jaw line, chin, and nasolabial
folds. A total of 400 mL tumescent fluid was infused
and 8 min Vaser applied. Seventy-five milliliters of
fat was aspirated. The result appears natural and well
A. Di Giuseppe (*) defined.
Institute of Plastic and Reconstructive Surgery,
Figure 30.4 is patient with heavy neck and cheeks,
School of Medicine, University of Ancona, Ancona, Italy
e-mail: [email protected] mostly obese or overweight, and with no definition at
chin and neck due to fat accumulation over platysma
G. Commons
Plastic Surgery Center of Palo Alto, Palo Alto, CA, USA muscle. There is a double chin and no neck and jaw
e-mail: [email protected] definition or cheek orbital protrusion. Extensive Vaser

462 A. Di Giuseppe and G. Commons
Fig. 30.1 Vaser probes

2.2 mm 1015 cm. Skin
protectors and 1.8-mm
aspiration cannula
emulsification gives a better look, younger and fitter the orbital nasal area, cheeks, and preparotid areas
appearance, and more pleasant face. All areas were were softened and redefined.
softened and redraped.
North American population is a mix of different
ethnic races, including Hispanic, Afro-Cuban, Latin, 30.4 Complications
Asian, and others. The patient in Fig. 30.5 is a 44-year-
old Hispanic overweight woman whose natural appear- In over 500 cases operated on by two surgeons, there
ance of the face was unable to be improved with a were no significant complications such as nerve defi-
hypocaloric regime. With Vaser of the neck, chin, and cits, burns, or skin necrosis. The results were pleas-
jaw, the areas were reduced in volume of fat. The skin ing to patient and surgeon. No surgical redo was
was fully mobilized in order to redrape nicely. Even requested.
30 Facial Recontouring with Liposuction 463
Fig. 30.2 (a) Preoperative patient with a heavy face. (b) Postoperative following Vaser debulking

patient with heavy face,
a
cheeks, chin, and mandible.
(b) Postoperative following
Vaser
b
30 Facial Recontouring with Liposuction 465
Fig. 30.4 (a) Preoperative patient with heavy face, neck, and cheeks. (b) Postoperative after Vaser of the chin, cheeks, and neck.
Note the new mandibular line and submental and chin contouring

44-year-old Mexican type, a
Spanish profile, and bulky
face. (b) Postoperative
following Vaser contouring of
the neck, cheeks, and chin
b
Chin, Cheek, and Neck Vaser
Liposculpture 31
Alberto Di Giuseppe, George Commons,
and Alessandro Scalise
31.1 Introduction 31.4.2 Incisions
Vaser-assisted face and neck contouring should only Incisions are placed under the chin and in front of/
be performed by surgeons experienced with the Vaser behind ears (bilaterally). Possible bilaterally in the
system for fatty tissue emulsification. At least ten cases neck at the lowest anticipated level of treatment.
of standard Vaser-assisted lipoplasty are recommended
before moving to application to the face and neck.
31.4.3 Infusion
31.2 Indicated Patients (Fig. 31.1)
The face/neck are more vascular and have more inner-
Patients seeking contouring of the neck and jowl areas vations than typical fat layers in the body. Epinephrine
who have heavy neck and/or chins with moderate to at 1:500,000, Lidocaine at 0.30.5%. Wait 810 min.
good skin tone and where extra volume is expected to Infuse with a small-diameter blunt infusion cannula
be excess fatty tissue. (2.0 mm or smaller, 14 gauge or smaller), not a nee-
dle. Infuse uniformly and evenly into any and all
locations where the Vaser or the suction cannula may
31.3 Informed Consent be used. Typical expected infusion volume is 200
400 mL in total (both sides and submental), depend-
Include use of photos for educational purposes. ing on size of patient and areas to be treated. Infuse
slowly: 100 mL/min.
31.4 Technique (Figs. 31.231.7)
31.4.1 Preoperative Marking and Planning 31.4.4 Skin Protection
There should be a strategic plan for volume removal Used in each incision. Use the black skin ports with
(locations). the orange silicone discs. Suture the skin port disc
into place (three anchor sutures) using 3-0 or 4-0
nylon. Make sure the knots are tight as the silicone
A. Di Giuseppe (*) A. Scalise
disc tends to cause the knots to unwind. These skin
Department of Plastic and Reconstructive Surgery,
University of Ancona, Ancona, Italy ports protect the incision edges and greatly reduce
e-mail: [email protected] visible incision scarring. Stretch the incisions and
G. Commons tissues below the incision with a hemostat to ease
Private Practice, Palo Alto, CA, USA insertion.

468 A. Di Giuseppe et al.
INDICATED PATIENTS
Patients seeking contouring of the neck and jowl areas
who have heavy neck and/or chins with moderate to
good skin tone and where extra volume is expected to be
excess fatty tissue
Fig. 31.1 Patient indications
MARKING AND INCISIONS
Strategic plan for volume

removal and associated
marking.
Landmarks
Lower border of
mandible
Cricoid
Thyroid cartilage
Divide neck into thirds
infiltrating about 100cc
in each
Fig. 31.2 Marking and incisions
31.4.5 Emulsication Fig. 31.3 Neck and chin is divided into four sub-units. Each
allows around 50 mL of tumescent solution or less
A 2.2-mm diameter (17 cm long) or 2.2-mm diameter

(8 cm long) probes, 2040% amplitude, Vaser mode. amplitude for a moderate/average fat. Move to 40%
Begin with the short 2.2 probe if possible. Twenty per- amplitude if face is fibrous. Never exceed 40% with
cent amplitude if face/neck is very soft. Thirty percent the 2.2 mm probes, they may break. Apply Vaser until
31 Chin, Cheek, and Neck Vaser Liposculpture 469
Fig. 31.6 Tunnels as appear after Vaser undermining
31.4.6 Aspiration
A 2.4 mm cannula with gentle port patterns. Avoid

aggressive use of suction. Apply the suction only as
Fig. 31.4 Vaser 2.2 mm in action, set at 30% of power, through long as it takes to remove the emulsified fluids and
earlobe incision tissue. Expected aspiration volumes are 25125 cm3,
depending on infused volume, size of patient, and
areas treated. Suction phase should be as short and
atraumatic as possible. Remember: its not what you
take out but what you leave behind that is the key to
smooth and even skin redrape and retraction. Two
small stab incisions are sometimes placed in the lat-
eral aspects of the neck at the lowest point of treat-
ment and left open for drainage purposes. A small
suction cannula with no vacuum applied is passed
through the stab incisions to open channels into the
treated areas.
31.4.7 Massage/Press
Massage and press the treated areas to push any

Fig. 31.5 Vaser undermining in a classic face lift remaining free fluids out of incisions.
targeted fat is emulsified, likely 23 min total per side 31.4.8 Postoperative Taping/Dressing/
depending on volumes, with an additional 23 min Support
under the chin depending on how the Vaser was applied
on the sides. Total Vaser time 610 min depending on The key is gentle, even compression to help the skin
patient and infused volumes. Try to achieve the tar- redrape and settle into position and to prevent ripples
geted 610 min of Vaser time to minimize aspiration or folds in the skin. Consider the following options:
trauma. cotton pads with elastic wraps, cold compresses, and
a
Fig. 31.731.9 (continued)
Figs. 31.731.9 (a) Preoperative 50-year-old patient, with while left hand controls depth of action. Movements have to be
heavy neck, heavy chin, lack of cheek definition, neck laxity, gentle, avoiding too deep action. (l) Treating the lateral side. (m)
and upper and lower blepharochalasis. (b) Preoperative mark- Using Ventex 1.8 mm suction cannula to evacuate emulsion. (n)
ings. (c) Starting tumescent infiltration with blunt needle and Continuing aspiration. (o) Vaser system. Timing: 9.40 min of
syringe. (d) Tumescent in central neck. (e) Tumescent in man- action. (p) Completing aspiration, removing skin adhesion,
dible region. (f) Temporary suture of chin incision to avoid fluid checking undermining and free skin. (q) Checking thickness of
reflow. (g) Suturing on place skin protector. (h) Other skin pro- the neck flap. (r) Procedure ended. (s) Suture of skin incision
tector at the ear lobe incision. (i) After 11 min, the surgeon starts with 60 nylon. (t) Postoperative garment, to be worn 3 days full
Vaser 2.2 mm probe undermining on the superficial layer. Power time and then for 2 weeks night time. (u) Postoperative jowl-
is set at 30% of total. (j) Vaser on action from chin incision on chin-neck contouring
the deeper layer, to emulsify fat. (k) Right hand guides the probe,
e f
g
h

k l

q r
s t


Fig. 31.8 (a) Preoperative 38-year-old patient. (b) Postoperative following jowl-chin-neck contouring
a b
Fig. 31.9 (a) Preoperative 37-year-old patient. (b) Postoperative after jowl-chin-neck contouring
a b
Fig. 31.10 (a) Preoperative 27-year-old male. (b) Postoperative after jowl-chin-neck contouring
Fig. 31.11 (a) Preoperative 42-year-old patient. (b) Postoperative following jowl-chin-neck contouring, blepharoplasty, and malar lift
Fig. 31.12 (a) Preoperative 42-year-old female. (b) One year postoperative following jowl-chin-neck contouring
a b
Fig. 31.13 (a) Preoperative 45-year-old patient. (b) Postoperative neck-jowl-chin contouring
a b
Fig. 31.14 (a) Preoperative 38-year-old patient. (b) Postoperative after neck Vaser
Fig. 31.15 A preoperative 32-year-old patient with heavy face. Postoperative following Vaser debulking
silicone foam padding. Elastic face garments typically for 5 min with small head, twice a week for a minimum
applied for 24 days, then overnight for 12 weeks, of 3 weeks.
depending on preference. Keep head elevated at night.
31.5 Discussion
31.4.9 Follow-up
Usually the technique is performed under local tumes-
One day, 1 week, 6 weeks, 6 months, as needed. cent anesthesia and intravenous sedation. The opera-
External ultrasound and light massage may be benefi- tion is an office procedure. The procedure is simple,
cial. Protocol for external ultrasound: setting of 10 W and there are good results (Figs. 31.831.17).
Fig. 31.16 (a) Preoperative 45-year-old patient with heavy face. (b) Postoperative after Vaser chin, cheeks, and neck definition
Fig. 31.17 (a) Preoperative 25-year-old patient with heavy face. (b) Postoperative following Vaser facial contouring
General References 2. Shiffman MA, Di Giuseppe A (2010) Body contouring: art,

science, and clinical practice. Springer, Berlin
1. Shiffman MA, Di Giuseppe A (2006) Liposuction: principles
and practice. Springer, Berlin
An Integrated Technique
for Facial Rejuvenation: Adaptation 32
to a Changing Clinical Environment
Moshe S. Fayman
32.1 Introduction The process of facial aging is not yet fully understood.
Several researchers have shown in recent years that soft
Changing aesthetic surgery market place environment tissue descent is probably not a major factor. Rather, a
as well as deeper understanding of the mechanism of complex process of boney and soft tissue deflation in
facial aging led to a change in the authors philosophy certain areas of the face (malar, submalar) and volume
in planning and performing facial rejuvenation surgery increase in other areas (jowls, sub mental) is responsi-
in recent years. The purpose of this presentation is to ble for the aged face appearance. Therefore, volume
share this experience. restoration becomes a logical way to restore a youthful
In recent years, the public is being increasingly appearance [39].
exposed to media preaching minimally invasive proce- The value of fat autotransplantation has been
dures as an alternative to traditional face lift per- advocated and popularized by several researches. Fat
formed by plastic surgeons. The public is led to believe grafting has been shown to successfully restore dep-
that the results of the lesser interventions are similar to leting facial volumes on a long-term basis. The pres-
those produced by surgery. Advantages cited for mini- ence of stem cells within the transplanted fat offers the
mally invasive techniques include lesser cost, lesser added advantage of neovascularization of surrounding
risks, and minimal downtime required for recovery. tissues.
Face lift has been shown repeatedly to be the only cos- These considerations led the author to change
metic operation in a downtrend when annual figures of his philosophy and to develop an integrated facial reju-
operation performed are being analyzed [1, 2]. In the venation surgical approach based on the following
authors opinion, adaptation of the traditional face lift principles:
to a smaller yet effective procedure is essential if plas- 1. Short incision preauricular, retrotragal, extended
tic surgeons strive to continue dominating the market around the caudal border of the sideburn [1012].
place of facial rejuvenation procedures. 2. Limited subcutaneous undermining, essentially not
Another interesting consequence of the ever- beyond anterior border of the parotid gland.
increasing popularity of the use of fillers for facial 3. Development of a small superficial musculoaponeu-
rejuvenation is the increasing recognition of selective rotic system (SMAS) flap that is vertically lifted
enhancement of facial aesthetic unit volumes as an and suspended to the deep temporal fascia. The
effective strategy in facial rejuvenation. anterior portion of the flap provides correction of
the jowls as well.
4. Liberal use of micro fat grafting over the malar
areas, nasolabial folds, marionette lines, and tear
M.S. Fayman
troughs [13, 14].
Rosebank Clinic, Johannesburg,
South Africa 5. Limited lateral brow lift done through a short inci-
e-mail: [email protected] sion in the caudal border of the temporal hair line.

486 M.S. Fayman
a b
c d
Fig. 32.1 Photography. The importance of standardized pho- taken with a direct flash, softening the fat lobules. (d) Photo
tography is illustrated on this woman who had no surgery. (a) taken with a soft flash. The patient was supine; fat lobules are
Photo was taken with a soft light flash. (b) Photo taken with a sinking into the orbits
soft flash in upper gaze accentuating the fat lobules. (c) Image
6. Conservative upper blepharoplasty [15]. aesthetic goals. If the patient photos are not available,
7. Pinch-type lower blepharoplasty, fat preserving, images of previous patients with similar aging fea-
and utilization of fat flaps to correct tear troughs tures are used to demonstrate the surgeons intents and
when applicable. surgical plans.
Each patient has at least two consultations before
surgery to allow for various considerations time to
32.2 Surgical Technique sink in. Patients who come from out of town are not
operated the same day to allow for a second consulta-
32.2.1 Preoperative Assessment tion before surgery.
Risk assessment and management includes dis-
The consultation focuses on the patients concerns couraging smoking for at least two weeks before
and expectations. The aesthetic goal is defined at an surgery.
early stage to be rejuvenation restoration of a youth- Examination focuses on documenting the individual
ful refreshed look, rather than an attempt to match an aging changes of the patient as well as standardized phys-
idealized look. The patient is asked to bring a young ical examination chart. Standardized photographic docu-
age images of the face to assist in determining the mentation is performed as well (Figs. 32.1 and 32.2).
32 An Integrated Technique for Facial Rejuvenation: Adaptation to a Changing Clinical Environment 487
a b
Fig. 32.2 Patient who had no surgery to her eyelids. (a) Soft flash producing a shadow which accentuates the fat bags. (b) Direct
flash photo camouflages the bag. The type of flash used is reflected in the pupils
32.3 Anesthesia incision is placed in the supratarsal skin crease with

the eyes closed. The extent of skin excision is deter-
Midazolam 7.515 mg orally is used for premedica- mined when the patient opens his/her eyes. A mini-
tion. Alternatively, intravenous (IV) Midazolam is mum of 25 mm of skin height is confirmed to be left in
used. Anesthesia employs Propofol infusion supported the upper eyelid. Lower blepharoplasty incision is
with Ultiva at the time of local anesthetic infiltration. marked in the subciliary skin crease and extends later-
The face is infiltrated with local anesthetic solution ally into the inferior skin crease of the crow foot.
consisting of 200 mL saline 0.9% with 20 mL of ligno- Excess for submental lipoplasty is gained through
caine 2% and 20 mL bupivacaine 0.5%. No adrenaline stab wounds in the postauricular sulcus, through the
is used. Sodium bicarbonate solution 0.5 mL is added. facelift incision, and/or through a stab wound in the
The volume of solution used varies, usually in the chin skin crease.
range of 160200 mL, depending on patients size and
extent of surgery. The eyelids are infiltrated with ligno-
caine 2% solution mixed with adrenaline 1:80,000. 32.4.1 Skin Flap Undermining and SMAS
Flap Mobilization
32.4 Incision Flap undermining is limited to the anterior and inferior

border of the parotid gland. It is done in the subcutane-
The facial incision is preauricular, retrotragal, extend- ous plan only. A small SMAS flap is developed just
ing around the caudal border of the sideburn anteriorly cephalad to the mandibular angle. The flap is devel-
to a distance sufficient to avoid any dog ears after the oped anteriorly to the anterior border of the parotid
vertical lift of the facial skin (Fig. 32.3). The lateral gland (Fig. 32.4). This flap is sutured with heavy 2-0
brow lift incision is placed in the temporal hair line, PDS sutures which are anchored to the deep temporal
approximately 15 mm long, with the center vertically fascia at the superior border of the zygoma arch. Three
above the tail of the eyebrow. Upper blepharoplasty of such sutures are used to accomplish differential lift
488 M.S. Fayman
a b
Fig. 32.3 Healed incision in two patients six months after surgery
a b
Skin incision
SMAS flap
Fig. 32.4 Small SMAS flap design. (a) The flap is confined to sutured to the Deep Temporal Fascia of the cephalad zygoma
the anatomical boundaries of the parotid gland 12 cm cephalad arch border with 2-0 PDS sutures
to the lower angle of the mandible. (b) The flap is lifted and
of the neck, mandibular border, and jowl, respectively. and rupture rate (clinical observation unsupported with
A fourth suture is sometimes employed at the supero- scientific evidence).
anterior aspect of the wound. This suture is anchored When injected into perioral creases, the 1-mL
to the zygoma periosteum. It serves to pull the midface syringe is attached to a 22-gauge needle and injected
soft tissue complex over the malar area [16]. No under- in a sub- or intradermal position as the needle is
mining of the temporal skin and no deep dissection withdrawn.
into the neck are performed. Skin lift is vertical. When
the patient presents with excessive neck skin laxity,
vertical creases form caudal to the ear lobe. Extension 32.4.3 Lateral Brow Lift
of the postauricular incision is then required to address
this issue. On rare occasion (10%, usually patients of Lateral brow lift has been simplified over the years
more advanced age), an incision across the mastoid from the endoscope-assisted technique to the direct
skin is required. The lift is pure vertical. The wound is subcutaneous approach. The expected course of the
closed with 4-0 Polyglecaprone 25 suture (Ethicon, temporal branch of the facial nerve is marked on the
Monocryl) in key position and 6-0 rapid dissolving skin. A 15-mm incision is performed in the temporal
plain gut (Ethicon 1916) running suture for skin. Small hairline with the center placed vertically above the tail
suction drain is used for the first 24 h to avoid small of the eyebrow. Dissection is developed in a subcuta-
seroma formation. neous plan in a caudal direction to a distance of
1015 mm. The cephalad dissection is developed in a
subgaleal plan exposing the deep temporal fascia. A
32.4.2 Micro Fat Grafting 40 Polyglecaprone 25 suture is used to suspend the
forehead skin to the deep temporal fascia. Elevation of
Micro fat grafting is liberally employed in the vast 23 mm of the eyebrow tail is typically accomplished.
majority of patients. Fat is harvested usually from the This stage is performed before final decision on amount
abdomen. 0.9 mm blunt needle attached to a 1-mL of skin excision of the upper eyelid is undertaken. The
syringe with a Luer Lock is employed in filling the tear wound is closed with 6-0 rapid dissolving plain gut
trough, and slightly larger diameter needles are used for suture (Fig. 32.8).
the malar areas, nasolabial folds, marionette lines, and
upper and lower lips. Fat is injected deeply, just above
the periosteum of the tear trough (Fig. 32.5), into the 32.4.4 Upper Blepharoplasty
subcutaneous fat over the malar eminence, and into the
muscles in the area of the marionette lines. The injec- The skin incision is performed and a sliver of orbicu-
tion technique involves approach from different direc- laris oculi is resected laterally if excessive hooding is
tions and injections in different plans as to build a present in that area. Resection of lateral muscle con-
structural volume of the transplanted fat. The volume tributes to a minimal elevation of the tail of the eye-
used varies according to patients requirements. Some brow (1 mm or so). On occasion, a medially pedicled
overcorrection is done. Typical volumes are: muscle flap is used to fill a medial hollow appearance.
Malar areas: 58 mL per side (Figs. 32.6 and 32.7) In most cases, only skin excision with underlying mus-
Nasolabial folds: 24 mL per fold cle plication is used to restore youthful volume of the
Lips: 1 mL for each hemi lip (upper and lower) and upper lid (Figs. 32.9 and 32.10) [15].
0.5 for the upper lip tubercle; superficial intra- Medial lobule of fat is removed when necessary.
muscular injections is employed in the lips Suspension of the lower lobe of the tear gland is rarely
Marionette line: 12 mL per side required.
A 2-mm liposuction needle attached to a 10-mL
syringe with a Luer Lock is used to harvest the fat. Fat
is transferred to a 1-mL syringe using a coupler. The 32.4.5 Lower Blepharoplasty
fat is injected gently as the needle is withdrawn. The
fat is not processed after harvesting because mechani- In most patients, subciliary incision is performed. Orbic-
cal processing increases fat cell membrane damage ularis oculi muscle integrity is generally maintained,
490 M.S. Fayman
a b
Fig. 32.5 (a) Fat grafting to the tear trough is performed with a 0.9-mm blunt needle in the supraperiosteal plane. The fat is injected
as the needle is withdrawn. (b) Preoperative patient. (c) Nine months postoperative
predominantly the pre-tarsal muscle plate. Lobules of over the periosteum is performed with a 0.9-mm blunt
fat, if present, are mobilized and used as small fat flaps needle attached to a 1-mL syringe with a Luerlock.
sutured over the tear trough just above the periosteum. Lateral muscle suspension is used as a routine to sup-
If fat lobules are too small to be used and tear trough port the eyelid past the peak of the swelling. Rapidly
does present an aesthetic concern, fat grafting directly absorbing suture (Vicryl 6-0 Ethicon V0032) is used
Fig. 32.6 Fat grafting to malar areas. (a) Preoperative 62-year-old patient. (b) Eight months after secondary rhytidectomy, 15 years
after her first operation. Seven milliliters of fat was grafted to each malar areas
for this purpose (Figs. 32.11 and 32.12). Skin excision modification of the technique described by Sadove
is conservative and performed in the lateral section of [17]. In extreme cases, the fat lobules can be trimmed
the wound (pinch lower blepharoplasty). (Fig. 32.15) or used over the orbital malar groove
In selective patients, a transconjunctival blepharo- (Fig. 32.16).
plasty is employed. Fat flap mobilization and suture
over the tear trough is accomplished (Fig. 32.13).
When indicated, midface advancement over the 32.5 Results
malar area is accomplished through the lower lid inci-
sion, as described by Fayman et al. [16] (Fig. 32.14). Seven hundred and fifty-two consecutive patients
When the tear trough does not present an aesthetic operated over an 8-year period were reviewed. There
concern but the fat lobules are prominent, a septal were 631 (84%) women and 121 men (16%). A variety
tightening suture is employed (Fig. 32.15). This is a of surgical steps were individually assembled to
492 M.S. Fayman
Fig. 32.7 Fat grafting in a patient with asymmetrical facial fat loss/mild Romberg Syndrome case. She is presented 1 year after
single session of asymmetrical facial fat grafting
meet individual patients objectives. Follow-up varied spontaneously in less than a month and both were
between 6 months and 8 years with median follow-up attributed to liposuction cannula damage during
of 3 years (Figs. 32.1732.29). liposculpture of the submandibular triangle. Slow
wound healing at cephalad corner of the sideburn
wound occurred in one patient, healing spontaneously
32.5.1 Complications in less than 2 weeks. The patient was a smoker who did
not quit before surgery.
Incidence of hematoma was 0.5%. Long-term facial Patients satisfaction was assessed by direct ques-
nerve injury did not happen. Marginal mandibular tioning during postoperative visits and documented in
branch paresis occurred in two patients, both resolved patients charts. It is estimated to be very high.
32.6 Discussion similar to the surgical procedure but without the

downtime required after surgery and without the
The modern patient is characterized by the following surgical risks involved.
features: 3. The patient is typically well read after long research
1. Expectations are sky high. of the internet and other media. Patients are often
2. The patients patience is reduced, and he/she expects misinformed by their own research.
instant gratification. This characteristic is media 4. The modern patient typically requests several pro-
driven and is nourished by promises of nonsurgical fessional opinions before making up his/her mind
facial rejuvenation that can produce improvement with regard to which surgeon to choose and what
a b
Fig. 32.8 (a) Preoperative. (b) Eight months after lateral brow after skin-only secondary blepharoplasty along with lateral
lift and excision of a lateral sliver of orbicularis oculi muscle is brow lift. She demonstrates a 2-mm elevation of the tail of her
demonstrated in this patient. Elevation of 3 mm of the tail of the eyebrow
eyebrow is evident. (c) Preoperative patient. (d) Four months
494 M.S. Fayman
c d
technique to follow. The conflicting opinions often The approach presented employs certain principles.
lead to patients confusion and sometimes anxiety, The extensive subSMAS dissection [1822] has been
as the patient finds herself in a situation of having to discontinued for several reasons:
decide between conflicting professional views. 1. Postoperative swelling has been significantly
As a result, the concept of trust me, I am a Doctor reduced (shorter downtime).
and I will do whats best for you is no longer market- 2. The risk of permanent facial nerve damage has been
able. The consultation is more interactive. The patient reduced to virtually nothing.
takes a more proactive part in planning the operations 3. Results appear as good if not better than those
compared to previous years. The author finds this obtained with radical techniques. Long-term trophic
dynamics easy to adjust to and that the informed skin changes associated with extensive subcutaneous
consent has developed to a professional dynamics dissection are presumably attributed to diminished
well beyond its Medico-legal value. blood supply to the skin caused by the subcutaneous
a b
Fig. 32.9 (a) Preoperative. (b) One year after skin excision hence increasing the volume of the upper eyelid while maintain-
only in upper blepharoplasty followed with wound closure ing the integrity of the muscle
results in folding of the underlying orbicularis oculi muscle,
scar tissue formation. These changes appear to be lower lid fat in the area of the nasojugal or orbital malar
less severe with the limited skin undermining tech- depressions. It is this last group of patients who benefits
nique. The lifting component of the surgery is from injections of fillers or fat into the tear trough inden-
based on gliding rather than undermining tissue tation or tightening of the capsulopalpebral fascia [23].
planes as described by Mendelson [21]. Fat grafting is being used extensively. Fat is recog-
4. The technique is simple, easy to master, and easy to nized as valuable filler as well as a source of stem cells
teach, yet it is highly effective. It addresses to the which contributes to the refreshed look of the overly-
concept of rejuvenation through filling deflated ing skin due to improved vascularity.
selective fat compartments. Incision length has been reduced, further improving
In recent years, the tear trough has been the focus of the perception of a smaller procedure.
attention of many publications. It is now well recognized This is a retrospective review of a large series of a
that several factors contribute to the tear trough forma- single surgeons experience aimed at developing and pre-
tion. These factors include difference in skin texture, senting a personal philosophy of surgical facial rejuvena-
thickness, and color present at the junction of the lower tion adjusted to changing target clientele demands. The
lid and the cheek skin. Another factor consists of inden- surgical strategy represents a large number of surgical
tation of the skin and over expansion/bulging of the techniques assembled to a surgical plan individualized to
496 M.S. Fayman
a specific patients requirements. Careful analysis of the sight. Incidence of long-term facial nerve injury was
patients desires and signs of aging are obviously manda- reduced to 0 in this series. Incidence of hematoma
tory for correct selection of the surgical technique. formation was reduced from 1.8% to 0.5%. Incidence
Comparison to the historical controls indicates a of wound healingrelated issues was substantially
shorter time out of work and shorter time out of public reduced as well.
Fig. 32.10 (a) Medially pedicled orbicularis muscle flap used to reduce upper lid lateral fullness and to increase the medial hollow
appearance. (b) Preoperative. (c) Six months after surgery
b c

498 M.S. Fayman
Arcus
Marginalis
b c
Fig. 32.11 (a) Upper and lower blepharoplasty with fat grafting blepharoplasty with fat grafting to the tear trough and lateral
to the tear trough and lateral lower lid suspension. (b) Preop- lower lid suspension
erative. (c) Six months postoperative following upper and lower
Fig. 32.12 (a) Utilization of the fat lobules as vascularized fat patient. (f) Postoperative after upper blepharoplasty including
flaps over the tear trough (b) Intraoperative mobilization maneu- skin and trimming of her nasal lobule of fat. Lower blepharo-
ver. (c) Preoperative. (d) One year after surgery. (e) Preoperative plasty included mobilization of fat lobules over tear troughs
c
500 M.S. Fayman
e f

b c
Fig. 32.13 (a) Advancement of Zygomaticus major muscle origin and surrounding tissues in treatment of mild festoons as described
by Fayman et al. [16]. (b) Preoperative. (c) One year postoperative
502 M.S. Fayman
b c
Fig. 32.14 (a) Capsulopalpebral fascia tightening in the treat- (c) Seven months after surgery. (d) Preoperative. (e) One year
ment of lower lid bags without a prominent tear trough. 5-0 non- postoperative
absorbable suture is used to tighten the fascia. (b) Preoperative.
d e

504 M.S. Fayman
Fig. 32.15 (a) Preoperative. (b) Six months postoperative after trimming of fat lobules as indicated in severe cases. The lateral
suspension suture elevated the arcus marginalis by 23 mm
a b
Fig. 32.16 (a) Preoperative. (b) Five months postoperative after lower blepharoplasty, and a vascularized fat flap was used as filler
over the lateral orbital margin (arrows)
Fig. 32.17 (a) Preoperative. (b) Six months postoperative after The patient shows an elevation of 3 mm in the position of the tail
rejuvenation procedure consisting of the following components: of the brow. The temporal hairline scar is inconspicuous
skin-only upper blepharoplasty and bilateral lateral brow lift.
506 M.S. Fayman
Fig. 32.18 (a) Preoperative. (b) Nine months postoperative malar triangles, nasolabial folds, marionette lines, and upper and
after rhytidectomy that included bilateral upper blepharoplasty, lower lips. The incision was extended to the postauricular
bilateral lateral brow lift, submental lipectomy, and fat graft to sulcus
Fig. 32.19 (a) Preoperative. (b) Postoperative following the elevation, submental lipoplasty, and fat grafting to nasolabial
short incision rhytidectomy that included the following compo- folds and marionette lines
nents: bilateral upper blepharoplasty, bilateral lateral brow
b
508 M.S. Fayman
Fig. 32.20 Limitations

a
of the technique. (a)
Preoperative patient. (b) One
year after an operation that
included the following
components: face lift, upper
and lower blepharoplasty,
brow lift, fat grafting to
nasolabial folds and
marionette lines, extensive
submental lipectomy, and
perioral peel with Hershey
medium strength solution
(phenol/croton oil). At this
time, she was unhappy with
residual skin excess in her
submandibular triangle. (c)
This was treated with direct
excision under local
anesthesia. (d) One week
later, the patient satisfaction
was dramatically improved
Fig. 32.21 (a) Preoperative. (b) Postoperative after facial neck skin required extension of the incision up the postauricular
rejuvenation that included upper blepharoplasty and fat graft to sulcus and across the mastoid skin
tear troughs, nasolabial folds, and marionette lines. The heavy
c d
b
510 M.S. Fayman
a b c
Fig. 32.22 (a) Thirty years ago. (b) Preoperative showing orbicularis oculi during skin-only upper blepharoplasty and
aging changes. The loss of volume in her cheeks, upper eye- extensive fat grafting to her cheeks and lips that were successful
lids, and lips is evident. (c) Postoperative after folding of the in restoring her youthful features
Fig. 32.23 Small surgical intervention in this case included a small SMAS flap suspension and fat grafting to perioral areas. The
patient returned to near normal life style in a week
Fig. 32.24 (a) Preoperative 63-year-old patient. (b) One year lines; submental lipoplasty; and SMAS lift. Because of the
postoperative after rhytidectomy that included the following excess cervical skin, the incision was extended to the post
components: upper and lower blepharoplasty (skin only); fat auricular sulcus
grafting to malar triangles, nasolabial folds, and marionette
512 M.S. Fayman
Fig. 32.25 Similar extent surgery to the patient in Fig. 32.24 was performed in this case, with the exception of perioral peel with
Hershey medium to strong solution. One year follow-up is presented
a b

patient requesting facial
rejuvenation as well as
enhancement of her chin.
(b) Two years postoperative
following insertion of a small
chin implant that was wired to
the lower border of the
mandible. She shows
improved lower facial
harmony as well as sustained
rejuvenation
514 M.S. Fayman
Fig. 32.27 (a) Preoperative. (b) Eight months postoperative following a short incision facelift, upper and lower blepharoplasty, and
fat grafting to malar triangles and nasolabial folds
a b
Fig. 32.28 (a) Preoperative patient desiring minimal intervention. These patients often benefit from fat grafting only. (b) Six
months postoperative after a single session of fat grafting of 15 mL of abdominal fat per side
Fig. 32.29 (a) Preoperative patient in her late 40s. (b) Ten months after short incision rhytidectomy with minimal fat grafting.
Rhinoplasty was done at the same surgical session
516 M.S. Fayman
Acknowledgment This work is dedicated with loving memory 9. Connell BF, Semlacher RA (1997) Contemporary deep
to my father Yedidia. His wisdom, survival skills in face of layer facial rejuvenation. Plast Reconstr Surg 100(6):
extreme adversities and his personal sacrifice have set the 15131523
platform to my achievements. Upon his giant shoulders I am 10. Baker DC (1997) Lateral SMASectomy. Plast Reconstr Surg
humbly standing. 100(2):509513
The author gratefully acknowledges the art work and 11. Saylan Z (2002) Purse string-formed plication of the SMAS
illustrations produces by Dr. Estelle Potgieter. with fixation to the zygomatic bone. Plast Reconstr Surg
110(2):667671
12. Tonnard P, Verpaele A (2005) 300 MACS-lift short scar
rhytidectomies: analysis of results and complications. Eur J
References Plast Surg 28:198
13. Lambros V (1992) Fat contouring in the face and neck. Clin
1. DAmico R, Saltz R, Rubric RJ, Kinney B, Haeck P, Gold AH, Plast Surg 19(2):401414
Singer R, Jewell ML, Eaves F 3rd (2008) Risks and opportuni- 14. Pu LL, Coleman SR, Cui X, Ferguson RE Jr, Vasconez HC
ties for plastic surgeons in a widening cosmetic medicine mar- (2008) Autologous fat grafts harvested and refined by the
ket: future demand, consumer preferences, and trends in Coleman technique: a comparative study. Plast Reconstr
practitioners services. Plast Reconstr Surg 121(5):17871792 Surg 122(3):932937
2. American Society of Plastic Surgeons (2009) Report on 15. Fagien S (2010) The role of the orbicularis oculi muscle and
2008 Statistics. Available at: http://wwwplasticsurgery.org/ the eyelid crease in optimizing results in aesthetic upper
Media/stats/2008-US-cosmetic-recostructive-plastic- blepharoplasty: a new look at the surgical treatment of mild
surgery-minimally-invasive-statistics.pdf. Accessed 21 Mar upper eyelid fissure and fold asymmetry. Plast Reconstr
2010 Surg 125(2):653
3. Stuzin J (2007) Restoring facial shape in face lifting: the 16. Fayman MS, Potgieter E (2002) Zygomaticus major
role of skeletal support in facial analysis and midface soft- advancement as an adjunct to lower blepharoplasty. Aesthetic
tissue repositioning. Plast Reconstr Surg 119(1):362376 Plast Surg 26(1):2630
4. Pessa JE (2000) An algorithm of facial aging: verification of 17. Sadove RC (2007) Transconjunctival septal suture repair
Lambros theory by three-dimensional stereolithography, for lower lid blepharoplasty. Plast Reconstr Surg 120(2):
with reference to the pathogenesis of midfacial aging, scleral 521529
show, and the lateral suborbital through deformity. Plast 18. Tessier P (1989) Le lifting facial sous-perioste. Ann Chir
Reconstr Surg 106(2):479488 Plast Esthet 34(3):193197
5. Pessa JE, Zadoo VP, Yuan C, Ayedelotte JD, Cuellar FJ, 19. Mitz V, Peyronie M (1976) The superficial musculoaponeu-
Cochran CS, Mutimer KL, Garza JR (1999) Concertina rotic system (SMAS) in the parotid and cheek area. Plast
effect and facial aging: nonlinear aspects of youthful skeletal Reconstr Surg 58(1):8088
remodeling, and why, perhaps, infants have jowls. Plast 20. Stuzin JM, Baker TJ, Gordon HL (1992) The relationship of
Reconstr Surg 103(2):635644 the superficial and deep facial fascias: relevance to rhytidec-
6. Ricketts RM (1982) The biological significance of the divine tomy and aging. Plast Reconstr Surg 89(3):441449
proportion and the Fibonacci series. Am J Orthod 81(5): 21. Mendelson B (2001) Surgery of the superficial muscu-
351370 loaponeurotic system: principles of release, vectors, and
7. Zadoo VP, Pessa JE (2000) Biological arches and changes to fixation. Plast Reconstr Surg 107(6):15451552
the curvilinear form of the aging maxilla. Plast Reconstr 22. Hamra ST (1992) The composite rhytidectomy. Plast
Surg 106(2):460466 Reconstr Surg 90(1):113
8. Owsley JQ (1983) SMAS-platysma face lift. Plast Reconstr 23. Lambros V (2007) Observations on periorbital aging. Plast
Surg 71(4):573576 Reconstr Surg 120(5):13671376
Hair Restoration
33
Samuel M. Lam
33.1 Introduction suitable candidate, educate that patient about the risks
and benefits of a procedure, discuss intelligently non-
The field of hair restoration has evolved rapidly over surgical options that may support or replace surgical
the past two decades from one of unsightly plug grafts hair restoration, and to understand the effect(s) of sur-
now to state-of-the-art, undetectable follicular hair gical intervention. Knowing when not to operate can
transplantation. Despite these advances, less than ideal be as important if not more so than when to operate.
work is still being performed almost every day due to This section touches upon the basics of hair loss and
unskilled practitioners, poor technicians, and/or uneth- what every physician should know to perform safe hair
ical delivery of medicine. Although this chapter cannot transplant surgery.
completely close ones knowledge gap, it can open vis-
tas for a prospective physician to seek knowledge else-
where and to learn via clinical exposure to experienced 33.3 Male Pattern Baldness and Medical
physicians in the industry. In the book Outliers, Options for Hair Loss
Malcolm Gladwell has suggested that it takes 10,000 h
in a discipline to achieve mastery of it [1]. The great The most common indication for surgical hair trans-
zen master, Lao-Tzu, has said that a journey of a thou- plant surgery is male pattern baldness. Contrary to
sand miles begins with a single step [2]. Hopefully this what many claim that hair loss stems from ones mater-
chapter will engage the reader enough to begin a journal grandfather, the precise inheritance pattern is poly-
ney towards 10,000 h and a thousand miles in a fasci- genetic and also not clearly elucidated at this time.
nating, rewarding, and engaging field of cosmetic However, one can clearly state with certainty that male
enhancement. pattern baldness is not static but progressive in nature
with the pattern of loss, the extent of loss, and the onset
and rate of loss being variable. Due to the ongoing
33.2 Understanding Hair Loss nature of male hair loss, surgical hair transplantation
and Hair Replacement into a younger man, e.g., in his teens or early twenties,
can be fraught with risk since the transplanted hair
Before a physician can even contemplate surgical hair from the occipital region into the frontotemporal or
transplantation, he or she must first possess a requisite crown areas will remain for perpetuity while surround-
knowledge of hair loss processes so as to select a ing native hair continues to diminish. As the supply of
donor hair dwindles with each transplant, the area of
baldness will inexorably continue to expand such that
S.M. Lam
a transplanted pattern that appears natural at the time
Willow Bend Wellness Center, Lam Facial Plastic Surgery
Center & Hair Restoration Institute, Plano, TX, USA of transplantation may become an unnatural one over
e-mail: [email protected] time that cannot be fixed if all donor hair is eventually

518 S.M. Lam
depleted. The metaphor of painting an ever-increasing Type II 5-alpha reductase, the enzyme responsible for
canvas with ever-diminishing paint is a good one to converting testosterone into dihydrotestosterone (DHT).
understand this dilemma. In genetically susceptible men, DHT can lead to hair
The psychological issue of transplanting a young loss in areas that are genetically programmed for hair
male patient who may be desperate in their pleas for loss, e.g., the frontotemporal, midscalp, and crown
intervention makes resisting a surgical option even regions. By limiting the serum levels of DHT, the rate of
more difficult. Although male hair loss may be unac- hair loss can be slowed down, and a proportion of vellus
ceptable to many men at any age group, it may be par- hairs can be reconverted into thicker, terminal hairs.
ticularly difficult to bear for the younger male patient Daily ingested finasteride takes about 612 months to
who is both at his social prime as well as depressed show the optimal desired aesthetic regrowth of hair with
that he does not resemble his peers, most of whom ongoing maintenance of hair counts compared with
have not begun to experience hair loss. The conflict of controls in studies that extend out 5 years following start
interest also arises in that the physician must decide of taking the medication [5]. Finasteride has been asso-
not to operate on a very young patient despite the ciated with clinical side effects that include diminished
potential for financial remuneration for a procedure. libido, erectile dysfunction, decreased sperm count, and
Whether to operate or not on a young male patient is breast tenderness, with a combined incidence of 3.8%
complex and is predicated upon multiple factors: age compared with 2.1% for placebo, reaching statistical
of patient, pattern and rate of hair loss, psychology of significance only when all side effects are combined.
the patient, usable donor density and extent, among Fifty-eight percent of men showed resolution of symp-
other factors. The beginning surgeon is advised to be toms with ongoing usage and reversibility of side effects
careful with any patient below 30 years of age due to with cessation [6]. Women of childbearing age should
the multiplicity of judgment required. not handle crushed pills, as ingestion of the product can
Today, we have nonsurgical options for male pat- lead to teratogenic male hypospadia.
tern baldness that can be very effective in slowing Minoxidil (marketed as Rogaine by Pfizer, New
down the process of hair loss and also reversing early York, NY) is topically applied twice daily to the scalp
signs of hair loss. Therefore, the two FDA-approved and is now over the counter in the United States. It is
medications, oral finasteride and topical minoxidil, manufactured in two strengths 2% for women and
can be excellent solutions for almost every man losing 5% for men. The major side effect with the generic
hair but be particularly beneficial to the younger male minoxidil is a contact dermatitis that has been mark-
patient just beginning to lose hair. Male pattern bald- edly reduced in the foam version by removing the irri-
ness involves hairs that evolve from thick, terminal tant propylene glycol and is sold only in 5% strength,
hairs into wispy, fine vellus hairs that eventually then which is still on patent by Rogaine. The side effect that
disappear altogether. Finasteride and minoxidil work can be experienced in women is secondary hair growth
to reconvert some of these fine vellus hairs back into due to systemic absorption, which is the rationale for
thick, terminal hairs. Once the individual is entirely the 2% lower concentration recommended for women.
bald (so-called slick baldness), the medications have The mechanism of action of Rogaine is not well estab-
little effect. In short, the earlier the medications are lished but proposed that it acts as a potassium channel
started, the greater the impact on reversing and slow- agonist, an epidermal cellular stimulant, and/or a local
ing down ones hair loss. However, if the products are vascular stimulant. Unlike finasteride, minoxidil starts
eventually stopped, all the gains that occurred during to work faster between 6 weeks and 3 months but
the use of the products evaporate. with optimal gains like finasteride observed between
Finasteride is an oral medication that at the 5 mg dos- 6 months and a year. The one caveat that should be
age (marketed as Proscar by Merck, Whitehouse Station, explained to patients is that minoxidil can convert hairs
NJ) is effective both for hair loss [3] as well as for pros- from telogen into anagen phase, meaning that telogen
tatic hyperplasia. Finasteride at the 1 mg daily dosage hairs can be actively shed in the first few weeks follow-
(marketed as Propecia by Merck) is intended only for ing the start of minoxidil application.
hair loss with no greater benefit for alopecia with larger As mentioned, minoxidil and finasteride each work
doses than the recommended 1 mg [4]. The effect of through independent mechanisms to counteract the
finasteride occurs by virtue of the medicine inhibiting miniaturization, i.e., the conversion from terminal to
33 Hair Restoration 519
vellus hairs, but the two products can work synergisti- 33.4 Female Pattern Baldness
cally for optimal gains. Men who can afford both the
cost and expense should consider using both together Although male pattern baldness remains the most com-
to achieve best results. Studies in postmenopausal mon indication for hair transplantation, female hair
women with finasteride have been equivocal in show- transplantation has become increasingly more popular
ing any improvement [7, 8], and as stated, premeno- owing to both improved techniques and burgeoning
pausal women should not take finasteride due to the public awareness of this option. The two most com-
teratogenic risk. mon indications for female hair transplant surgery
For younger patients who may not be safe candi- include hairline lowering for women born with a high
dates for hair transplant surgery, these medications hairline and hair restoration for female pattern bald-
may be the safest and brightest hope to slow down and ness that involves loss of central hair density with or
somewhat reverse the hair loss process. However, these without hairline reframing. Like with male hair loss,
medications can and should be considered for even the process of female pattern baldness must be under-
patients who are undergoing hair transplant surgery for stood before a transplant procedure can be safely
three reasons. First, the hair loss process is slowed undertaken. Given the more complex nature of female
down, meaning that the need for another hair trans- pattern baldness, the physician must undertake a more
plant session may be staved off for a longer while. thorough preoperative investigation in many cases
Second, when the miniaturized hairs are converted before the decision for surgery may be made.
back into terminal hairs, the added effect can make the Almost a third of women after 30 years of age lose
hair transplant result look even better with added visual some degree of hair, which can be emotionally as dev-
density. Third, if there are a lot of miniaturized, vellus astating as for men if not more so since it is not socially
hairs in the area for transplantation, several months of acceptable for a woman to lose hair. In addition, as hair
medical management with minoxidil and/or finasteride can be an alluring sign of female sexuality, hair loss
can minimize what is known as telogen effluvium, or may impact a womans psyche more profoundly.
shock loss that occurs weeks to months after a trans- Oftentimes, hair loss in women can be partially
plant procedure. For all of these reasons, medical inter- addressed with a metabolic evaluation that focuses on
vention can be an important adjuvant therapy even to common indications that predispose to female hair loss
those who consider hair transplant surgery. including a low serum iron level (particularly ferritin),
Male pattern baldness in the crown or vertex region hypothyroidism, and other hormonal imbalances (a
represents a distinct entity that should be discussed high dehydroepiandrosterone sulfate [DHEAS], lower
separately. Although all hair loss is progressive, crown estrogen, etc.). Women should also be considered to be
hair restoration can be particularly challenging for sev- placed on minoxidil during this investigation process
eral reasons. First, the whorl pattern that must be recre- in order to attempt regrowth of hair but also because
ated can be technically much more difficult for a postoperative hair shedding is much more common in
beginning surgeon than covering baldness elsewhere women than in men, which is stabilized by several
on the scalp. Second, the crown area will continue to months of minoxidil application.
widen leaving a transplanted result exposed over time. Female pattern baldness can be recognized in sev-
As a general rule to be conservative, a crown is not eral manifestations. The most prevalent type of hair
transplanted unless the patient is over 35 years of age loss according to Elise Olsen is a Christmas tree pat-
to minimize the chance of depleting usable donor hair tern: with the hair parted in the middle and the woman
to cover the expanding region of alopecia. Third, looking downward, a pattern of hair loss with the apex
because the crown rests on the vertical plane of the of the tree toward the crown can be observed [9]. The
scalp and has grafts that splay open in a whorl, the hairline can be involved or spared in any pattern of
same number of grafts allocated to the frontal scalp female hair loss. The Ludwig classification for hair
will have a much less dense appearance in the crown. loss describes three grades of diffuse hair loss with
A patient should be aware of the limited hair density Grade 1 being minimal exposure to Grade 3 being
following a single session of hair transplant in the extensive in nature, so much so that a wig may be more
crown unless the crown hair loss is not extensive to appropriate to achieve the desired result as a surgical
begin with. procedure will most likely fall short. The third type of
520 S.M. Lam
recognized female hair loss is a male pattern baldness loss conditions other than a basic review of male and
type with frontotemporal recession and less commonly female pattern baldness. Nevertheless, in order to be a
isolated crown hair loss. safe hair transplant surgeon, the reader should be well
When working with female pattern hair loss, it is versed with recognizing types of scarring alopecias
important to target areas of maximal deficiency and to like discoid lupus and lichen planopilaris or nonscar-
discuss with the patient realistic outcomes, as usable ring alopecias like alopecia areata in order to avoid
donor hair can be less robust than in men. A primary operating on these patients who would fail a surgical
goal in women with diffuse central hair loss is to deter- transplant [10]. It is not so important that the physician
mine whether the procedure can be undertaken to correctly identifies each type of hair loss pattern and
achieve a desirable result or whether the patient should treats it appropriately but that the hair loss pattern be
just wear a hairpiece. Further, if a transplant is enter- recognized to be a kind of hair loss for which a trans-
tained, then it should be contemplated how to target plant procedure would be unsafe so that a referral to a
areas of hair loss in such a way that maximal hairstyl- dermatologist can be made prior to considering a trans-
ing can be afforded. For example, a woman who parts plant or in lieu of one. At times, active scarring alope-
her hair in the center could have the central forelock cias can be trichologic emergencies in which a delay in
and the central part region focused on with a T-shaped diagnosis and therapy can lead to devastating and irre-
distribution of grafting or, alternatively, a woman who versible hair loss.
parts from left to right could have the frontal region
transplanted and the left part filled in a more concen-
trated pattern to resemble an L-shape. Due to the com- 33.6 Hair Transplantation Step-by-Step
bination that is often present in women with extensive Technique
hair loss and limited donor hair, these selective pat-
terns for transplantation may need to be undertaken to 33.6.1 General Principles
achieve the desired results and women should be coun-
seled accordingly. In order to recreate natural hair patterns, a surgeon must
The other common (albeit less so) indication for understand how hair naturally grows on the head, spe-
female hair transplant is female hairline lowering for a cifically in the hairline, central midscalp, temple/tem-
woman who is born with a high hairline and desires a poral point [11], lateral hump, posterior midscalp
more feminine-shaped hairline. The design for a female (vertex transition point), and crown [12]. These hair
hairline is almost the opposite in many respects to a directions are important to understand so that a physi-
male hairline in that the hair angles are angled to repli- cian can recreate the natural angle and orientation of
cate a cowlick in the center and the frontotemporal hair when he or she creates the recipient sites, which
shape is curved and closed. The beginning surgeon will be further discussed in the appropriate section
should not attempt to work with designing female hair- (Fig. 33.1, Table 33.1). In addition, generalized patterns
lines until male hairlines are mastered, as female hair- of male hair loss must be recognized, and the reader is
lines can be much more difficult to do well. A detailed encouraged to study the Norwood pattern of hair loss
description of surgical technique lies beyond the scope that appears in almost every basic hair transplant text-
of this chapter. Also, as a counterpoint, women who book. Looking at individuals with a full head of hair
have high hairlines that are not receding can be consid- and studying the hair angles can be very helpful, espe-
ered suitable candidates at a young age since they are cially in someone with a relatively closely shorn head
not susceptible like men to rapidly advancing hairlines where the exit angles are more apparent. Also, looking
and generalized hair loss. at individuals with various patterns of hair loss will
help guide a physician to understand what patterns
appear in nature and what may appear surgical even to
33.5 Other Types of Hair Loss the untrained eye because that pattern does not fit a
natural one. This basic study should be undertaken dili-
Unless the reader is a dermatologist, conditions that gently well before the first hair transplant is planned so
would be contraindicated for hair restoration would be that the design can conform to the rigors of nature
missed. Obviously, this monograph cannot hope to rather than a preconceived notion of what nature is,
encompass a thorough discussion of all types of hair which may otherwise be wrongly envisioned.
a b
Fig. 33.1 These photographs show the angle (up and down tilt) centimeter in which the orientation changes to match the lateral
and direction (side to side orientation) of how hair grows across hump (top green arrow). The lateral hump shows a progressive
various regions of the head, which should be mimicked when cascading downward with each successive row (green arrows).
designing recipient sites and followed during graft placement (see Of note, the angles are very low. (b) The crown is designed in a
Table 33.1). (a) The anterior hairline has a low anterior angle and whorl pattern in which the angles are less acute vis--vis the scalp
forward direction (black arrows). The midscalp has the same rela- than other regions (blue arrows; note: the direction is shown but
tively low angle and straightforward direction except in the lateral the angle is not clearly shown in this photograph)
Table 33.1 Angle and direction of recipient sites for each region of the scalp
Location Angle Direction
Anterior hairline Low (1030) Anterior
Temporal hairline Very low (010) Follow sweep of temple hair
Lateral hump Low (1020) Cascading from forward progressively
downward (Fig. 33.1)
Midscalp Medium (2030) Anterior
Vertex transition point Low (2045) Slight radial arrangement
Crown Medium to high (3045 for the upper half of the Whorl
whorl and 1520 for the lower half of the whorl)
33.6.2 Anesthesia ing the experience as comfortable and as pleasant as

possible is mandatory if the physician would like that
Most offices perform hair transplant entirely under the patient return in the future. The sedation only needs
local anesthesia with or without an oral sedative. Some extend for several minutes to permit the physician to
offices (like ours) prefer an intravenous sedation infiltrate the first lidocaine ring block circumferentially
combination of midazolam and fentanyl for improved around the head (Tables 33.233.4). Once that is infil-
pain control and relative amnesia of the experience trated, the subsequent bupivacaine block performed at
(Fig. 33.2). Given the fact that hair restoration is often- the end of donor closure can be done without any dis-
times a repeated procedure in a patients lifetime, mak- comfort in most cases. Specific injectable anesthesia
522 S.M. Lam
Fig. 33.2 Room schematic

with the nurse sedation
provider about to administer
Level II anesthesia consisting
of midazolam and fentanyl.
Of note, the background
shows the back table where
medications are mixed, a
Mayo stand with the
instruments for donor
harvesting and closure, and
the dissection table with
magnifying visors and cutting
stations
Table 33.2 Surgical tray Table 33.3 Medications/injectable tray

Universal multiblade handle with 35 No. 10 blades Donor tumescent solution (250 mL 0.9% sodium chloride,
Spacers for the multiblade handle of varying sizes (2.0 mm, 1.25 mL epinephrine 1:1,000, 12.5 mL lidocaine 2% plain)
2.5 mm, 5.0 mm, etc.) (empty 10 cm3 syringe, 18G 1 needle to draw tumescent, 23G
No. 10 blade on a standard scalpel handle 1 needle to inject)
Metzenbaum scissors 1% lidocaine with epinephrine buffered (9 mL lidocaine 1%,
0.1 mL epinephrine 1:1,000, 1 mL 8.4 sodium bicarbonate) 1
Tissue forceps
syringe with 27G 1 1/2 (for donor anesthesia)
Microserrated scissors (for creation of a trichophytic incision)
1% lidocaine plain with added epinephrine (10 mL lidocaine
3-0 nylon or 3-0 polypropylene suture 1%, 0.1 mL epinephrine 1:1,000) 1 syringe with 27G 1 1/2
Suture scissors (for recipient anesthesia)
Standard needle holder Bupivicaine 0.25% with 1:200,000 epinephrine, 0.1 mL
Towel clamps (57) triamcinolone 40 mg/mL (10 cm3 syringe filled with 25G 1
Versi handle with solid wire needles (16G, 17G, 18G, 19G, 1/2 needle) (for donor area)
and 20G) Bupivicaine 0.25% with 1:200,000 epinephrine (10 cm3
(Alternatively, standard 16G, 17G, 18G, 19G, and 20G syringe filled with 25G 1 1/2 needle) (for recipient area)
needles and a hemostat to bend the needles) Recipient tumescent solution (100 mL 0.9% sodium chloride,
(Optional blades SP 90, SP 91, 2 mm chisel-point or 0.5 mL epinephrine 1:1,000, 5.0 mL lidocaine 2% plain,
sharp-point blade, SM 62 if planned for MUG transfer) 1.0 mL triamcinolone 40 mg/mL)
recipes (Tables 33.233.4) will be discussed in the way. For recipient site creation, the headrest is
appropriate sections below as part of the surgical flow returned to its original position, and the patient is
algorithm. reclined supine for the frontotemporal region (Fig. 33.3)
Another feature of the surgical room is the operat- and relatively upright for crown design (Fig. 33.4).
ing chair that should be easily reclined and positioned (These details are repeated in the recipient-site cre-
upright as well as all positions in between upright ation section).
and supine (Fig. 33.2). The headrest and shoulder A surgical light preferably mounted to the ceiling
design should be relatively small and unobtrusive so (alternatively that could be on rollers and a pole) that
that the surgeon can work easily in this space. Also, for can be focused and positioned should be used to direct
the early stages of the procedure (ring block, donor light where it is needed on the scalp for every phase of
harvesting, and donor closure), the patient is seated the procedure: donor harvesting, donor closure, recipi-
upright with the headrest removed or tilted out of the ent site creation, and graft placement.
Table 33.4 Suppliers A to Z specialty surgical www.atozsurgical.com 1-800-843-6266

Ellis Instruments, Inc. www.ellisinstruments.com 1-800-218-9082
Mediquip Surgical www.mediquipsurgical.com 1-800-951-9989
Fig. 33.3 In order to

facilitate relatively low angles
for the frontotemporal region,
the patient is placed supine
with the surgeon sitting
behind the patient. By doing
so, the surgeons hand
naturally is angled so that the
angle of the recipient-site
instrument is situated low
vis--vis the anterior scalp
Fig. 33.4 In order to angle

the crown hairs higher than in
the frontotemporal region, the
surgeon stands behind the
patient to make the crown
recipient sites with the
patients chair more in an
upright position
33.7 Hairline Design hairline. For the sake of clarity and conciseness, the
rules for designing a white male hairline will be elabo-
Before anesthesia is administered, the hairline is rated. The variations for Asian, African, and female
designed with the patient as fully awake as possible so hairlines lie beyond the scope of this writing.
that the design and extent of reconstruction can be With the patient sitting upright in front of the phy-
mutually agreed upon before embarking on the proce- sician, the physician can use an eyebrow pencil to cre-
dure itself. Hairline design requires artistic judgment ate the preliminary outline of a hairline and finesse
as much as understanding the parameters of a natural the hairline until the patient and the physician are in
524 S.M. Lam
agreement. At that point, a black permanent marker which coincide with a vertical line that arches upward
can be used to outline the hairline right in front of the from the lateral canthus (Fig. 33.5). If the hairline
eyebrow pencil so that it does wipe off during the pro- passes this lateral point, the hairline will appear unnat-
cedure. Nevertheless, the surgeon must always be ural because any hair that resides lateral to the lateral
mindful of the marked line, as it is still liable of being canthus is considered temporal hair, which has a dif-
rubbed off with repeated wipes of the gauze. ferent shape and direction than the horizontal hairline.
The hairline is designed in general to match the The patient is asked to look downward, and the sur-
patients head, i.e., a narrower design for a narrower geon then ensures that the two lateral points are at the
head and a wider design for a wider head. The hairline same lateral extent and at the same anterior posterior
consists of two components, the frontal hairline (the position on the scalp, i.e., they appear symmetrical.
horizontal component) and the temporal line (or verti- The reason for this examination is that many patients
cal line that frames the hairline laterally). Temporal have asymmetrical degrees of temporal hair loss, which
reconstruction is an advanced topic, and the reader is must be reconstructed so that a more symmetrical out-
advised not to undertake temporal reconstruction until come is achieved.
the basic hairline design has been mastered. Creating With these three points established, the surgeon
very flat recipient sites that are well angled and graft then draws a convex curve (convex side facing anteri-
placement with the correct curl of the graft (see the orly) across the central anterior point, which can then
Graft Placement section below for details on curl) are be gently curved in a concave manner at or just lateral
mandatory for a natural temporal point reconstruction, to the midpupillary line to reach the lateral points on
both of which are hard to master for the novice surgeon. each side. When the three points are joined, the phy-
Accordingly, in order to make the hairline appear natu- sician must first eyeball whether the line appears
ral, the hairline cannot be placed too anteriorly if there symmetrical, natural, and well designed for the
is significant temporal hair loss or the created horizon- patients anatomy, degree of hair loss, and age. This
tal hairline will not match the absent temporal hairline. latter point is more complex. If the patient is younger
This condition is known colloquially as a lid effect, with a greater degree of hair loss and poor donor den-
i.e., the hairline juts too far anterior vis--vis a lost tem- sity, the physician may opt for a more conservative
ple. Temple and horizontal hairline unzip at a relatively hairline because the patient may require multiple more
equal rate. That is why a hair system, also known as a sessions in his lifetime and also risk running out of
hairpiece or toupee, can look unnatural despite it being usable donor hair to fill in future hair loss. Conversely,
a modern, woven variety if it is placed too far anteriorly an older patient with mild hair loss and robust donor
vis--vis a missing temporal hairline. density may have a slightly more aggressive hairline
The opposite is true as well. If the horizontal hair- design all the while keeping in mind that appropriate
line is positioned so conservatively that it is placed frontotemporal recession and hairline shape should be
very high on the horizontal plane of the scalp, then the constructed that would be natural for an older gentle-
hairline will fail to provide a proper aesthetic frame to mans age. Similarly, working with a younger patient,
the face. This very conservative design, albeit safe, some frontotemporal recession may be desirable in
will not achieve one of the principal goals for a frontal order to ensure that the hairline ages well with ongoing
hair transplant, i.e., to make the face appear more hair loss.
attractive by framing the upper border of it. In order to After the three points have been constructed, the
determine the lowest acceptable anterior midline point, physician must look at the design from all angles to
the patient is viewed from profile and a point is drawn make sure that the design appears natural. From the
that bisects the horizontal plane with the vertical plane frontal view, the lateral points should not be so low
at a 45-degree angle (Fig. 33.5). This transition from that the hairline proceeds inferiorly from medial to lat-
the horizontal scalp to the vertical scalp (or forehead) eral. Similarly, from profile view (this point is critical),
is considered the lowest acceptable anterior point for a the hairline must be either a flat line if it is a more
hairline any lower would put hair unnaturally on the aggressive hairline or preferably slope upward from
forehead. the anterior midline point to the lateral point (Fig. 33.5).
Once this position is determined, the surgeon then In any case, it cannot slope downward from the ante-
defines the lateral termini of the horizontal hairline, rior midline point to the lateral canthal point. This is
a b
Fig. 33.5 (a) Drawn hairline in which X represents the lowest acceptable point of the midline portion of the hairline should be
acceptable midline point, and Y and Z are the two lateral points where the horizontal scalp intersects at a 45-degree angle to the
defined as the lateral extent of the hairline, corresponding to a vertical forehead. Also of note, the drawn line should be either
vertical line drawn through the lateral canthus. Any hair lateral to flat or sloping upward toward the temple, never downward, i.e.,
this design should be considered temporal hair. (b) Proposed the midline point must reside inferior to the lateral point when
hairline. (c) Proposed hairline. Black lines indicate that the lowest viewed on profile. (d) Proposed hairline. (e) Proposed hairline
simply unnatural. The hairline should be observed he will judge it. After the hairline has been confirmed
with the patient looking downward, and finally the sur- with the patient and the permanent marker used to
geon should stand behind the patient and together reinforce the initial drawing, the physician then looks
observe the hairline in a mirror. At times a hairline that through the scalp to determine planned areas for recon-
looks perfectly straight from in front of the patient struction (Fig. 33.6). Since this task is relatively
does not look that way from behind the patient while straightforward, the permanent marker can be used as
peering at a mirror. The rationale for this is unclear, but the initial ink. When the patients hair is wet and the
what is clear is that the patient who will only be exam- patient is supine, different areas of thinning will be
ining his hairline in the mirror will be dissatisfied with noted and the distribution can be adjusted. However, it
the hairline since this is the only vantage with which is important to mark planned areas of reconstruction
526 S.M. Lam
problems: transplanted hair that is lost over time using

unsafe donor hair and also the potential for an exposed
scar. The widest area of safe donor hair resides about
two fingerbreadths above the helical rim no more ante-
riorly than the tragus and arches downward toward the
midline in the region of the occipital protuberance.
Again, this is considered the widest area of safe donor
hair but may be deemed relatively unsafe in a younger
patient who is rapidly losing hair or in an older patient
who already has hair loss into this region. Besides age
and degree of hair loss, the physician should study for
signs of anterograde hair loss (hair loss coming down
from the upper temple and the crown into the planned
donor harvest) as well as retrograde hair loss (hair loss
coming up from the neck and just above the helix).
These so-called whisker hairs or general thinning in a
retrograde fashion are ominous signs that hair loss will
eventually encompass the planned area of donor har-
vesting. Obviously, judgment must come with accu-
mulated experience to predict (or rather estimate) the
probability of future hair loss and what would be an
appropriate and acceptable donor area of harvest based
on these limitations. Although the surgeon can aim
Fig. 33.6 Surgical markings performed at the start of the proce- more superiorly in the midline than the occipital protu-
dure across the recipient area permit cordoning off regions for berance for harvesting with the expressed limitation
different planned graft sizes and density distribution. The front
3 cm represents the hairline zone. The oval in the midline behind
of the anterograde crown hair loss that may encroach
the hairline represents the anterior central forelock. The circle on the donor site, the surgeon should not aim far below
behind this oval represents the remainder of the central forelock the nuchal ridge, which represents neck skin and which
does not close well or heal well.
when the patient has dry hair and is still upright in a Typically, the donor strip should be planned for
sitting position for three reasons. First, that is the way approximately no greater vertical width than 1 cm and
that the patient will view himself. Second, the surgeon can be even further contracted based on perceived ten-
has a clear grasp of planned areas well before donor sion and the history of multiple previous hair trans-
harvesting. Third, the surgeon can use two mirrors to plant sessions that may compromise donor closure and
confirm more absolutely with the awake patient that healing. It is advisable for the physician (whether nov-
the planned areas to be reconstructed are what the ice or experienced) to always shoot for a more conser-
patient desires. Also, the physician can then point out vative harvest and wish he could have taken more than
areas that may be of secondary importance and rebuilt take too much and fail to close the wound without ten-
only if sufficient grafts remain toward the end of the sion or worse at all. This is a very undesirable situation
operative case. in which to find oneself. As a cautionary tale, if the
wound does not close without tension, it should be left
open to granulate inward with daily return visits, wet-
33.8 Donor-Site Selection to-dry dressings, and planned delayed secondary clo-
sure. Forced primary closure under tension and/or
The donor site where the donor strip will be harvested concurrent wound undermining are contraindicated
must be determined for shaving then harvesting. The and can lead to disastrous complications of irreversible
donor area must be evaluated for safety. Safety donor hair loss and/or poor wound healing.
implies that the area to be harvested will not be lost A permanent marker can be used to outline the
with future hair loss regression, which will lead to two planned trajectory for harvest so that the assistant can
shave just a few millimeters beyond the proposed har- a

vest area in preparation for donor harvesting. Before
shaving, the hair above the planned area for shaving is
taped upward with 1 clear plastic tape to facilitate
both shaving and harvesting. (Of note, the patient
should be reminded not to cut his hair shorter than 2
so that the donor wound is sufficiently covered during
the healing process.) The 1 clear plastic tape is then
used to pick up any loosed shaved trimmings from the
surgical field before donor harvesting. A loose ACE
bandage is then placed around the head immediately
below the shaved donor area, and a folded 4 4 gauze
is inserted circumferentially around the head to cap-
ture any blood that may trickle down during donor har-
vesting. The patient is now ready for sedation and the
start of the procedure.
b
33.9 Donor Harvesting and Closure
With the intravenous line started and the patient sedated,

10 mL of 1% lidocaine with 1:100,000 epinephrine is
used to infiltrate the posterior half of the head immedi-
ately below the planned area for harvesting (Fig. 33.7)
and an additional 10 mL of 1% lidocaine with 1:100,000
epinephrine is infiltrated into the front half of the head
below the planned hairline to anesthetize the hair-
line (Fig. 33.7). At this point, the patients head may
Fig. 33.7 (a) With the intravenous line started and the patient
be unsteady, and the assistant can be used to hold the
sedated, 10 mL of 1% lidocaine with 1:100,000 epinephrine is
patients head steady, as the surgery proceeds. used to infiltrate the posterior half of the head immediately
Before the donor strip can be harvested, the donor below the planned area for harvesting and (b) an additional
area must be aggressively tumesced with donor tumes- 10 mL of 1% lidocaine with 1:100,000 epinephrine is infiltrated
into the front half of the head below the planned hairline to anes-
cent solution (250 mL 0.9% sodium chloride, 1.25 mL
thetize the hairline
epinephrine 1:1,000, 12.5 mL lidocaine 2% plain) in
order to minimize hair transection (by aligning the
hairs) and by reducing the risk of nerve and blood
supply damage (Fig. 33.8). The mechanism by which for a 2530 cm harvest, approximately 150250 mL of
the underlying nerve and blood supply are protected tumescent fluid is required to accomplish this task. It is
with tumescence is that the harvesting blade will be important to tumesce not only the 1 cm planned donor
positioned so that there is a cushion between the donor strip but also above, below, and to the lateral extent of
hairs and the nerve and blood supply below. As a meta- the donor strip so that there are no curved edges where
phor, think of a ship floating over the corals at high transection would be more likely. Further, the tumes-
versus low tide. At low tide the ship will scrape and cence is injected into the subcutaneous plane and not
damage the corals, and at high tide the ship will not subgaleally as the intention is to expand the subcutane-
touch the corals. The ship is the blade; the water or ous plane away from the subgaleal plane. However,
tide is the tumescence; and the corals are the nerve and with sufficient tumescence, it is inevitable that some of
vasculature. the tumescent fluid will be absorbed into the subgaleal
Donor harvesting should only begin when the area plane, which is expected. As the tumescence is rapidly
is blanched, flat, and feels firm to the touch. Typically absorbed, it is important to have the Versi blade with
528 S.M. Lam
a transected, the Versi handle is adjusted slightly upward

until the harvest appears to be yielding untransected
hairs. Conversely, if the upper hair shafts appear more
transected, the Versi handle is adjusted downward until
the strip harvest appears free of transection. Accordingly,
harvesting should be a precise, slow, and deliberate
process with constant checking and rechecking for
transection and depth. The depth of the blades should
be such that they are deep enough to pass through the
base of the follicles but not so deep as to pass near or
worse yet through the galea. The depth of each blade is
adjusted depending on the depth of that blade vis--vis
b the observed harvesting depth, i.e., just below the hair
follicles but just above the galea. Fine fingertip control
rather than broad hand movements should be used so
that maximal control is exercised for a harvest with
minimal transection. Large transection of hair follicles
creates three definable problems: (1) poor yield so that
the aesthetic result may be compromised, (2) difficult
graft dissection in which many transected follicles must
first be removed, and (3) poor donor wound healing in
which entrapped, transected follicles can create cysts
and disturb ultimate wound healing. In order to further
facilitate donor harvesting, loupe magnification is very
Fig. 33.8 (a) Photograph shows the appearance of the donor
helpful to micro-evaluate hair transection during every
area during early tumescence and (b) at the end right before millimeter of the donor harvest.
donor harvesting when approximately 200 mL of tumescence At this point, the two ends of the donor strip are
has been infiltrated joined with a free-hand Personna No. 10 blade follow-
ing the hair angles to minimize transection (Fig. 33.11).
blades outfitted ready to harvest before tumescence is The donor strip can also be truncated vertically at the
initiated. halfway point or a third of the way across so that graft
Typically, today we prefer a Versi blade outfitted dissection can begin after a shorter strip is removed.
with two blades spaced between 9.5 and 9.75 mm Using atraumatic tissue forceps, the donor strip is
apart, which allows a single pass of both blades to har- grasped and retracted, and Metzenbaum scissors are
vest a strip of equal width (Fig. 33.9). In the past, mul- used to harvest the donor strip along the base of the
tiple blades were used for harvesting but increased the follicle leaving about 2 mm of fat below the bulb but
risk of transection, albeit facilitating graft dissection. remaining well above the galea (Fig. 33.12). The
Using single blades at a time is more time intensive but removal of the donor strip should proceed very slowly
also increases the risk that the incision width will be and deliberately taking care to avoid transection of any
variable throughout the harvest. Personna No. 10 visible nerves or blood vessels. By minimizing transec-
blades are preferred over Bard-Parker No. 10 blades tion of the underlying nerve and blood supply, postop-
due to the sharpness of the former over the latter. erative discomfort (from nerve ensnarement or
A right-handed surgeon begins the harvest from the transection) can be considerably lessened and wound
right side of the patients head and proceeds toward the healing and graft growth (by leaving the blood supply
left side of the head. The initial entry of the blade should intact) can be optimized. It is ideal if in the majority of
be matched to the observed exit angle of the hair folli- cases that electrocautery is minimized or avoided
cles and passed a centimeter forward to determine entirely, as cautery can risk nerve and blood supply
whether the angle creates a clean harvest or engenders damage as well as follicular and skin injury (Fig. 33.13).
transection (Fig. 33.10). If the hair bulbs appear to be With solid donor tumescence and careful harvesting of
Fig. 33.9 A Versi blade

outfitted with 2 Personna No.
10 blades and separated by
spacers to a total width of
9.75 mm
Fig. 33.12 Using atraumatic tissue forceps, the donor strip is

grasped and retracted, and Metzenbaum scissors are used to har-
Fig. 33.10 Donor harvesting progresses at a slow, deliberate vest the donor strip along the base of the follicle leaving about
pace, constantly checking and adjusting for any hair transection, 2 mm of fat below the bulb but remaining well above the galea
as well as proper depth of each blade. Note in the upper flap, the
clean harvest with limited transection of hair shafts
Fig. 33.13 Donor strip removed and relatively bloodless field

achieved by virtue of meticulous harvesting. The goal is to avoid
Fig. 33.11 The two ends of the donor strip are joined with a injury to the neurovascular supply by bluntly dissecting the
free-hand Personna No. 10 blade following the hair angles to donor strip from nerve and blood vessels and to minimize or
minimize transection eliminate cautery use
530 S.M. Lam
the donor strip, electrocautery should be able to be

avoided in over 90% of operative cases. Immediately
when the donor strip is removed, it must be placed into
a chilled saline bath within which it remains until it is
ready for dissection.
Before donor closure, judgment should be rendered
as to whether a trichophytic closure should be under-
taken. A trichophytic closure can help to minimize the
visibility of the scar by permitting hairs to grow
through the scar and thereby limit the linear aspect of
the scar itself. However, a trichophytic closure does
not guarantee a good outcome. Sometimes scars still
widen. In fact, meticulous donor harvest with minimal
transection and a careful wound closure are more
important factors for good wound healing than a
Fig. 33.14 Towel clamps are used along the entire length of
trichophytic closure performed at the end of donor har- the incision to align the wound edges and remove tension from
vesting. Trichophytic closures are not uniformly a the wound edges by forcing residual tumescent fluid out of the
good solution in every case. The wound edge itself if wound prior to closure
reharvested can create distorted hair follicles, increas-
ing transection during graft dissection and more unus- wound to the other until the wound is closed. Whether
able grafts. Because the wound is now separated by an a one or two-layered closure is performed is controver-
additional 1 mm, wound tension is increased. Therefore, sial. The author chooses to perform a two-layer closure
the author does not perform a trichophytic closure in only when discernible tension is observed. Otherwise,
individuals with high wound tension or have a planned in over 80% of wound closures, a single 3-0 nylon
procedure in the near future, e.g., if the frontotemporal suture is used in a running, nonlocking fashion to close
region was transplanted and the plan is for a crown the wound. If a trichophytic closure is performed, the
transplant in a year or two. upper epidermal edge must overlie the lower raw
The trichophytic closure is performed by removing wound edge appropriately. If not, the wound edges
a single millimeter of the inferior epidermal wound should be aligned flush without tension. The terminal
edge at a tangent using sharp, microserrated scissors knot for the 3-0 nylon should be placed as an air knot
and toothed forceps for countertraction. The raw edge to allow some release of tension through slack. Also,
created should be relatively uniform to minimize the the knot should be positioned just distal to the incision
risk of cyst formation and poor wound healing. After line so that the knot does not put pressure on the inci-
the trichophytic edge is created, the depth of the wound sion during sleep, which can be uncomfortable for the
is copiously irrigated with saline solution and any skin patient. The needle is passed through the midfollicular
edges or transected follicles are removed with toothed level to minimize strangulating or inverting the follicle
forceps under loupe magnification, as foreign bodies with too deep a bite. Each suture throw is placed at 45
can create undesirable cysts and compromise wound (Fig. 33.15) so that the skin suture will lie perpendicu-
healing. After this evaluation, towel clamps are used lar to the skin edge, which is particularly helpful to
along the entire length of the incision to align the ensure wound edge overlaps in a trichophytic closure.
wound edges and remove tension from the wound Towel clamps are then progressively removed as the
edges by forcing residual tumescent fluid out of the suture closes the incision length.
wound prior to closure (Fig. 33.14). After the donor incision is closed, the patient is
If there is tension in the wound, then a two-layer administered a long-lasting ring block consisting of
closure can be contemplated. A 3-0 polyglactin suture 9 cm3 of bupivicaine 0.25% with 1:200,000 epineph-
is passed without a knot at the end temporarily held by rine with 0.1 cm3 of triamcinolone 40 mg/mL into the
a clamp at one end of the wound as it is passed in the posterior half of the head below the donor closure
subcutaneous plane immediately below the follicular and 10 cm3 of straight bupivicaine 0.25% with
bulb and weaved back and forth from one side of the 1:200,000 epinephrine along the anterior half of the
Fig. 33.15 Each suture throw is placed at 45 so that the skin Fig. 33.17 Grafts dissected into 1-hair, 2-hair, 3-hair, and
suture will lie perpendicular to the skin edge. The depth of the multiple follicular unit grafts (from left to right). Also, standard
needle is situated at the midfollicular level to minimize ensnare- needles bent to the depth of the graft length are paired with their
ment of the follicles in the wound respective grafts. In this case, the 19-G needle lies next to the
1- and 2-hair grafts; the 18-G, with a 3-hair graft; and the 16-G,
with a graft containing two follicular units
before the patient is placed in a supine position being

readied for recipient site creation. A cushioned neck
support is a valued amenity for patient comfort when
the patient reclines back during the recipient-site
phase of the procedure.
33.10 Recipient Site Creation
Recipient site creation is the pinnacle of artistry that a

physician can express in that the pattern created reflects
the artistic interpretation and judgment based on avail-
able graft yields to make the proposed design. Recipient
Fig. 33.16 After the donor incision is closed, the patient is the sites are the slits or holes into which the hair grafts will
administered a long-lasting ring block consisting of 9 mL of ultimately be placed. In order to create excellent recip-
bupivicaine 0.25% with 1:200,000 epinephrine with 0.1 mL of ient sites, the physician must have a good understand-
triamcinolone 40 mg/mL into the posterior half of the head
ing of how hair angles and directions naturally flow on
below the donor closure and 10 mL of straight bupivicaine
0.25% with 1:200,000 epinephrine along the anterior half of the a nonbalding scalp. Further, the physician must be able
head below the proposed hairline along the same trajectory as to allocate the proper sized grafts that would create a
the initial ring block natural result (grafts with finer hairs and fewer hairs of
12 hairs per graft) along the anterior hairline, central
head below the proposed hairline along the same tra- crown, and temple and a visually dense result (grafts
jectory as the initial ring block (Fig. 33.16). The ACE with thicker hairs and greater number of hairs of 34
bandage around the head holding the folded 4 4 hairs per graft along the central midscalp) (Fig. 33.1).
gauzes used to soak any trickling blood is removed As a point of clarification, hairs that grow on the head
off the head. Then the hair around the incision site is do not grow as discrete single hairs but grow instead in
checked for any hairs trapped under the sutures, 1-, 2-, 3-, and 4-hair clusters known as follicular units
which are pulled free from ensnarement. Finally, the (Fig. 33.17). For the sake of clarity, we will discuss
donor incision is cleaned with a saline spray bottle graft dissection and recipient site creation in terms of
532 S.M. Lam
follicular unit distribution rather than breaking follicu- Another important concept besides angle and
lar units into smaller divisions or making larger grafts direction is the distribution of recipient sites relative to
containing several follicular units. one another, i.e., how they are positioned vis--vis one
The fundamental prerequisite to understanding another and how tight (or dense) they are made. All
recipient sites is knowledge of how hair naturally recipient sites should be interlocked rather than placed
grows on the head. The angle and direction are the two in a parallel arrangement (Fig. 33.18). Interlocking
ways to describe how the recipient site can be created one row behind the next can create less visible see-
to match this natural pattern (Table 33.1). The angle through, more tightly pack the recipient sites together,
refers to the tilt of the recipient site anterior to poste- and allow more easy graft placement (since the grafts
rior. The direction refers to the turn of the recipient site will not compete for the relative same physical space).
from left to right. Table 33.1 shows the angles and The density of how close to space the recipient sites
directions for each part of the scalp. In the anterior relative to one another is a matter of judgment and
hairline, it is very important that the angle be very low, experience. In general, the hairline should not be too
i.e., angled anteriorly very acutely, because hairs that open or the grafts may be visible as distinct grafts. In
are tilted too far perpendicularly can look grafty and addition, areas of primary importance for visual den-
also increase visual see-through (Fig. 33.1). The rea- sity should be more tightly arranged like the central
son that a low angled graft looks more natural is that forelock, the region that lies in the midline immedi-
the viewer has a much harder time seeing the insertion ately behind the hairline. The central forelock is an
point of the graft, where it can look unnatural. In addi- area of priority because it reinforces the hairline and
tion, the reason that the low angled graft adds to visual since it is situated in the midline creates visual density
density is that it casts a shadow on the bald scalp like for a viewer looking at the patient from almost every
an awning, whereas a vertically positioned graft fails frontal angle: straight on, being situated to the left of
to do that. Always remember that grafts along the ante- the patient or to the right.
rior hairline and anterior midscalp should be angled as As mentioned, 1-hair follicular unit (FU) grafts
low as possible to improve naturalness and visual den- need to be distributed along the hairline, 2-hair FU
sity. One can almost not go too low in angulation but grafts placed immediately behind 12 hairs of single
easily can create too high an angle. The opposite is hair FUs, followed by a region of 3-hair grafts then
true for the crown region (which is an advanced topic). 4-hair grafts. This increasing size of grafts matches the
The angulation for the recipient sites in the crown way hair gradually becomes visually denser on a natu-
should be relatively higher so that the grafts create a ral scalp. There are many ways to create recipient sites.
volume effect and shadow as it arches upward. The The easiest, least expensive method is to take standard
direction in the hairline and midscalp is straightfor- 16-, 18-, 19-, and 20- G needles and bend them so that
ward with no turn to the left or right. It is a natural they can be used to make the recipient sites (Fig. 33.17).
tendency for the hand to curve to the left on the left Generally, 16G accommodates a 4-hair graft or larger;
hand side and curve to the right on the right side of the an 18G, a 3-hair graft; a 19G, a 2-hair graft; and a 20G,
head. This splaying of the recipient sites creates grafts a 1-hair graft. Obviously, hair caliber will determine
that splay open like a book, which limits visual density the exact needle size that will fit a certain FU size. The
and exacerbates ease of hair combing. The grafts must surgeon should examine a dissected graft to determine
be aimed directly forward except for the lateral 35 mm the length of the needle matched to the length of the
where the grafts can gently turn laterally to match the graft, which is then bent twice: once to the length of
sweep of the temporal hair. In order to facilitate a lower the graft and the second time to make the needle
angulation of grafts, the patient is positioned com- straight again. The double bending of the needle also
pletely supine with the surgeon sitting behind the facilitates having a hub to check the depth of the inci-
patient so that the surgeons hand naturally creates a sion. Once 23 sites are made with a needle for each
low angle (Fig. 33.3). The opposite is recommended needle size, the surgeon and assistant test that the dis-
for the crown. In order to keep angles of the crown sected graft easily but snugly fits into the respective
higher, the patient is kept sitting somewhat upright and recipient site. The graft should not slide too deeply
the physician stands behind the patient to make the into the site and should snugly fit into the site without
recipient sites (Fig. 33.4). being compressed. If all the different sized recipient
a b
c d
Fig. 33.18 (a) The first line of the central forelock is created as forelock. The hairline is completed with a finely irregular undu-
the first step in recipient site creation. (b) The central forelock lation of only 23 mm in span including isolated sentinel hairs
and the posterior midscalp are then completed from front to back that are situated anterior to the anterior hairline to further soften
prioritizing density in the anterior portion (central forelock) the hairline appearance. The reader should note how the direc-
from the remaining midscalp posteriorly. (c) Left side: The hair- tion of the recipient sites all face directly forward, i.e., no splay-
line transition zone that will consist of smaller 3-hair to 2-hair ing, and also are tightly interlocked relative to one another.
grafts is built forward from the initial front line of the central (d) The hairline completed on the right side
sites correctly match the graft sizes and no readjust- site tumescence is infiltrated sequentially from start to
ment is needed, then the surgeon can begin to make finish in 10-mL increments.
all of the recipient sites according to calculated graft At this point, as the surgeon begins to create all of
yields. the recipient sites, he or she must prioritize critical
Before endeavoring to create all of the recipient areas, e.g., the hairline and central density, before
sites, the physician should infiltrate the recipient bed working on less critical regions like the posterior mid-
with recipient tumescent fluid (100 mL 0.9% sodium scalp before grafts run out. However, to create a natu-
chloride, 0.5 mL epinephrine 1:1,000, 5.0 mL lido- ral hairline, the actual hairline cannot appear to be a
caine 2% plain, 1.0 mL triamcinolone 40 mg/mL). rigidly straight line. In order to accomplish this task,
Unlike the donor tumescence, the physician can the central forelock is created first from front to back
sequentially tumesce each region that he or she is and then the hairline is created forward from the first
working on and continue to add tumescence as the sur- row of the central forelock (Fig. 33.18). The physician
geon progresses to each adjacent area. The reason for must think of the hairline like a coastline: from a dis-
the tumescence is the same as for the donor tumes- tance it appears relatively straight but on close inspec-
cence, i.e., to protect the underlying neural and vascu- tion there is an irregular jaggedness. This irregularity
lar supply for optimal graft growth and minimal should not span more than 23 mm in distance, as a
trauma. In general, about 50100 mL of total recipient hairline that is too saw-toothed can look as artificial as
534 S.M. Lam
too straight a line. Also in the first row of the hairline

in order to further soften the look, so-called sentinel
hairs should be placed consisting of one-hair grafts
that occasionally jut out 12 mm in front of the formal
first row of the more solid hairline (Fig. 33.18).
Temporal point, female hairline, and crown recon-
struction are more advanced topics that fall outside of
the scope of this narrative. However, a component to
lost hair known as the lateral hump is worth discuss-
ing. In severe cases of baldness, not only can the hair-
line recede and the crown be exposed but the hair that
falls on the side of the head can also become exposed
over time. This region that falls along the sides of the
head is known as the lateral hump, or parietal hump. It
is the region that lies immediately behind the anterior
temporal hairline. The design and shape of the lateral Fig. 33.19 Slivering involves dissecting a single row of follicular
hump must be recognized and treated differently than units by breadloafing the donor strip. It is the first step necessary in
from the central midscalp in that the hair angle and graft dissection before individual grafts can be dissected out
direction are distinctly different. Unlike the adjacent
midscalp in which almost all hairs are directly straight basic review of technique should be undertaken so that
anteriorly, the upper portion of the lateral hump is the physician understands what is entailed with graft
directed anteriorly then gradually begins to fall down- dissection and graft placement.
ward with each successive row until the angle for the What is important is to recognize how critical
5th6th row approximately will become almost straight superlative graft dissection is to the process of a natu-
downward facing (Fig. 33.1). The lateral hump is tech- ral and properly growing transplant result. If the grafts
nically not as difficult to reconstruct but it is still a rela- are left out to desiccate, heavily and arbitrarily manip-
tively advanced region to treat. In more advanced cases ulated, or poorly cut, the results will be poor growth,
of hair loss, the lateral hump actually looks like a kinky hair growth, or hair compression/failure to
hump, i.e., like an inverted U-shape that touches or growth, respectively. Having an excellent graft dissec-
does not touch anymore the U-shape of the lateral mid- tion team must be a priority for any physician working
scalp. Depending on the degree of donor hair density in the field. Unlike cosmetic rhinoplasty for example,
and the patients expectations, the lateral hump can the assistant team is heavily influential to the ultimate
just be built upward to touch the midscalp in a U-shape outcome of the procedure for the above-enumerated
configuration or built upward to the point that there is reasons.
more confluence between the lateral midscalp and the Here are the principles of good graft dissection. In
lateral hump. The angulation of the scalp for the lateral preparation for graft dissection, the grafts are always
hump should be quite low in order to minimize the hair kept in a chilled saline bath, or equivalently con-
sticking upward into the hair unnaturally. trolled osmotic-balanced solution. They are not left
out to desiccate. During graft dissection, the grafts
are frequently sprayed with a saline spray bottle to
33.11 Graft Dissection maintain a moist environment. If the grafts begin to
appear matte-like in appearance, they have been left
Graft dissection (taking the donor strip and converting too long unattended and risk failure to grow when
it into individual hair grafts) and graft placement (plac- transplanted. The first step during graft dissection is
ing the dissected grafts into the recipient sites) are to sliver the donor strip, a process in which the initial
typically the preserve of the hair transplant assistant cut is transverse across the donor strip like cutting a
team. Therefore, a detailed exposition of technique loaf of bread (Fig. 33.19). After slivering, the indi-
falls beyond the scope of this chapter. Nevertheless, a vidual slivers that contain one layer of undissected
grafts can then be cut into individual grafts. The act

of slivering requires gentle, nonforceful pressure to
glide the No. 10 Personna blade through the donor
strip so that one layer of nontransected hairs is pro-
duced. The blade is gently run back and forth through
the donor strip constantly changing angles slightly so
that the knife passes to reveal a single layer of grafts
without damage to the hair shafts during slivering.
After slivering, the grafts are dissected into indi-
vidual follicular unit grafts of 14 hairs (Fig. 33.17),
counted, and separated into these respective size hairs
for later placement. The extra fat below each graft is
dissected away to leave 1 mm of fat below the hair
bulb. Using microscopic aid or illuminated magnifica-
tion for all phases of graft dissection (including sliver- Fig. 33.20 For a right-handed placer standing on the patients
ing), the assistant is always mindful only to grasp the right side of the head and placing on that right side, placement is
relatively easier. For the right-handed placer standing on the
epithelial edge of the graft without pinching any part patients left side to fill in the left side requires special skill in
of the hair shaft, which can cause the hair either to which the hand hovers above to tuck in the graft
grow poorly or to grow out kinky due to the manipula-
tive damage. As always, the grafts are kept moistened
at all times. When the grafts are separated into their
respective sizes, they are folded into a moistened Telfa
pad and placed back into a chilled saline bath in prepa-
ration for graft placement.
33.12 Graft Placement
Graft placement represents the final stage in hair resto-

ration in which the dissected grafts are then placed into
the created recipient sites. Meticulous care for graft
placement will ensure an excellent outcome given that
all the previous constraints have been met. With visor
loupe magnification, the assistant positions the patient
upright and places grafts one at a time into the recipi-
Fig. 33.21 With visor loupe magnification, the assistant posi-
ent sites based on matching graft to recipient-site size. tions the patient upright and places grafts one at a time into the
For a right-handed placer standing on the patients recipient sites based on matching graft to recipient-site size.
right side of the head and placing on that right side, Using a #5 Jewelers forceps, the assistant holds onto the epider-
mis and atraumatically inserts the graft into the recipient site
placement is relatively easier. For the right-handed
placer standing on the patients left side to fill in the
left side requires special skill in which the hand hovers atraumatically inserts the graft into the recipient site
above to tuck in the graft (Fig. 33.20). All graft place- (Fig. 33.21). The graft should be placed a little shy of
ment should be undertaken with great care and requires 1 mm above the surrounding tissue. If it is placed
a level of maturation and experience. too high above the surface, the graft will desiccate and
The assistant places the Telfa pad carrying the fail to survive or alternatively create a cobblestoned
grafts of a certain size on the dorsum of the nondomi- appearance with an uneven epithelial surface. If the
nant hand for easy access. Then using a #5 Jewelers graft is placed flush to the surrounding skin or below,
forceps, the assistant holds onto the epidermis and the graft will look pitted, which is also unnatural. Also,
536 S.M. Lam
epidermal cysts can form since the graft was buried in which the comb is gently run across the hair at a
under the skin. This problem can be significantly worse distance away from the scalp to limit injury to the
if the assistant fails to recognize that he or she is stack- donor and recipient areas. The patient should also
ing one graft under another graft that becomes more refrain from hair-care products for the first 3 days.
deeply buried, a complication that arises from this Minoxidil should be ceased 2 days prior to hair trans-
incorrect piggybacking method. Also, significant time plant and resumed no sooner than 5 days afterward. If
delay in graft dissection and placement leads to hours the patient has never been on minoxidil, it is worth a
of time that the grafts remain ex vivo, which can in 72-h skin test with the product on a nonsensitive area
turn compromise longevity. However, with proper han- like the chin area to eliminate the possibility of an
dling and submersion in an appropriate chilled bath, unexpected contact dermatitis in the region of trans-
grafts should not suffer any significant compromise if planted hairs.
dissected and placed within 812 h of harvest time. The reason that a low-concentration of steroid is
One more technical detail is that grafts have a natu- mixed into the recipient tumescence is that it has been
ral curl, meaning that the hair typically does not found that injectable steroid has a greater impact on
grow out straight from the epidermis but has a gentle limiting postoperative edema than almost any other
curve. The curl should be aimed so that the curl aims factor. That being said, there is no consensus on patient
downward toward the scalp for proper growth and not positioning to limit postoperative edema with some
upward or side-to-side. purporting that a semi-inclined position is preferable,
At the end of graft placement, the physician and whereas others contend that a fully recumbent position
team should reevaluate all sites to make certain that all is desirable.
the recipient sites are properly filled and that the grafts On the tenth postoperative day, the patient returns
appear undisturbed and placed correctly according to for suture removal. At this office visit, the patient is
size and depth. The patients scalp should be gently also evaluated for any residual scabbing. If so, the
cleaned with saline spray being careful not to disturb patient is counseled on gentle methods to remove the
the grafts during this final process. remaining scabbing in an atraumatic fashion. Soaking
the hair in gentle lotion for 510 min before entering
the shower will help condition the scabs more readily
33.13 Postoperative Care and Follow-Up to fall off. With this method, all scabs should be gone
by several days after suture removal. Also, all ques-
33.13.1 Postoperative Care tions are answered, and the patient is given a return
visit of 4 months after to evaluate how grafts may be
Following a hair transplant procedure, the patient is beginning to appear.
likely to experience some minimal swelling (at times
significant) for several days to a week and if the nerves
were protected only mild to moderate achiness or dis- 33.14 Timing for Hair Growth
comfort in the donor incision. Ice packs applied to the
donor incision and forehead (but not onto the recipi- Hair typically begins to grow more visibly between 6
ent-site area itself) can help relieve some discomfort and 12 months following a procedure. However, at
and/or swelling. Narcotic prescription may help on an 34 months many patients are showing signs of early
as-needed basis for further pain relief. Generally, a hair growth, with only a minority having a robust
prescription is given and the patient advised to fill it result that is already apparent. A few patients require
just in case it becomes necessary. a longer time before the hair growth becomes substan-
The patient is advised not to shower for 24 h and tial with a full expression of the final or near final
immersive bathing is not permitted in any situation for result occurring between 18 and 24 months following
the first few weeks following a transplant procedure. the transplant procedure (Fig. 33.22 and 33.23). Hairs
The shower must be performed with minimal shower- normally grow on the head in an asynchronous pat-
head pressure and only blotting with a towel rather tern, i.e., some hairs are in anagen, whereas others are
than wiping of the scalp. The patient is advised that a in telogen and catagen, and need to relearn this
brush with short bristles rather than a comb is preferred asynchrony after hairs have been transplanted. This
a b
Fig. 33.22 (a) Preoperative 41-year-old male. (b) Fourteen months following a single hair transplant session in which approxi-
mately 5,000 hairs were transplanted into the frontotemporal region
a b
Fig. 33.23 (a) Preoperative 47-year-old male. (b) Two years following a single hair transplant session in which close to 5,000 hairs
were transplanted into the frontotemporal region
readjustment takes 1824 months to occur. Therefore, 33.15 Conclusions

there may be periods like 1012 months afterward
that hair growth may actually seem to lessen or the Hair restoration is as much an art as it is a science. Too
result dip somewhat based on these normal fluctua- often cosmetic surgeons look at it as a stepchild of
tions until asynchrony is restored. other cosmetic procedures. This bastardized approach
538 S.M. Lam
can lead uniformly to poor outcomes. Superior hair inhibitor, in men with male pattern hair loss. J Am Acad
Dermatol 41(4):555563
restoration is predicated on substantial experience, art-
5. Kaufman KD, Girman CJ, Round EM, Johnson-Levonas AO,
istry, but most of all commitment and passion for Shah AK, Rotonda J (2008) Progression of hair loss in men
excellence without compromise. with androgenetic alopecia (male pattern hair loss): long-
term (5-year) controlled observational data in placebo-treated
patients. Eur J Dermatol 18(4):407411
Acknowledgment The author has no financial affiliation
6. Merck-sponsored study. For information, contact Merck
whether direct or indirect with any of the stated companies but
directly: Merck and Co., Inc., Professional Services-DAP,
has listed the contact information simply in order to aid the
WP127, PO Box 4, West Point, PA 194860004
reader.
7. Price VH, Roberts JL, Hordinsky M, Olsen EA, Savin R,
Bergfeld W, Fiedler V, Lucky A, Whiting DA, Pappas F,
Culbertson J, Kotey P, Meehan A, Waldstreicher J (2000)
References Lack of efficacy of finasteride in postmenopausal women
with androgenetic alopecia. J Am Acad Dermatol 43(5 Pt 1):
1. Gladwell M (2008) Outliers: the story of success. Little 768776
Brown and Co, New York 8. Iorizzo M, Vincenzi C, Voudouris S, Piraccini BM, Tosti A
2. Tzu L (2006) Tao Te Ching: a New English version. Harper (2006) Finasteride treatment of female pattern hair loss. Arch
Perennial Modern Classics, New York Dermatol 142(3):298302
3. Kaufman KD, Olsen EA, Whiting D, Savin R, DeVillez R, 9. Olsen EA (2001) Female pattern hair loss. J Am Acad
Bergfeld W, Price VH, Van Neste D, Roberts JL, Hordinsky Dermatol 45(3 Suppl):S70S80
M, Shapiro J, Binkowitz B, Gormley GJ (1998) Finasteride in 10. Shapiro J (2002) Hair loss: principles of diagnosis and man-
the treatment of men with androgenetic alopecia. Finasteride agement of alopecia. Martin Dunitz, London
Male Pattern Hair Loss Study Group. J Am Acad Dermatol 11. Mayer ML, Perez-Meza D (2002) Temporal points: classifi-
39(4 Pt 1):578589 cation and surgical techniques for aesthetic results. Hair
4. Roberts JL, Fiedler V, Imperato-McGinley J, Whiting D, Olsen Transplant Forum Int 12:147158
E, Shupack J, Stough D, DeVillez R et al (1999) Clinical dose 12. Ziering C, Krenitsky G (2003) The Ziering whorl classifica-
ranging studies with finasteride, a type 2 5-alpha-reductase tion of scalp hair. Dermatol Surg 29(8):817821
Jowl and Neck Remodeling
with Ultrasound-Assisted 34
Lipoplasty (VASER)
34.1 Introduction minimal trauma, low energy, and safe surgical

planes.
The author has utilized internal ultrasound solid probe 6. To contour difficult areas such as the mandible
to face and neck since 1996 in order to defat heavy border, the neck line, and the chin.
faces or to undermine neck lax skin and possibly 7. To access to facial surgery even in patients who
achieving skin retraction. At that time, sculpture ultra- refused major open surgery operations, which
sound device (by SMEI, Italy), with a solid probe of normally leads to a longer recovery time.
2.5 mm diameter and 17 cm long, was used [1]. When Under those circumstances, what was called the
utilizing the solid probe in the face, the power admin- harmonic lift was offered as an alternative technique
istrated was 30% of the total potential of the ultra- in facial contouring surgery.
sound tool in order to reduce undesired side effects of
ultrasound energy (heat, essentially). The aim of the
technique was: 34.2 Patient Selection
1. To reduce numbers and extension of scars of the
face for remodeling procedures of face and neck. The harmonic lift can be used in young patients with
2. To perform under local tumescent anesthesia, essen- fatty necks and cheeks as well as in older patients with
tially the majority of facial contouring surgery. loose skin and wrinkles. Each patient is evaluated as to
3. To induce skin retraction, in face and neck, even in the aims of surgery such as treatment of crows feet,
lax skin, avoiding major open surgery operation nasolabial and commissural folds, jowls, and waddle
such as standard face-lift. neck.
4. To undermine and induce skin retraction with a The procedure is appropriate in the following type
minimal trauma by utilizing a solid probe and the patients:
ultrasound energy instead of an open approach and 1. Face- and neck-lift in Fitzpatrick type 46, thus
a scalpel. avoiding keloid formation and post-inflammatory
5. To debulk heavy faces, neck, jowls, with a smooth hyperpigmentation that may occur with skin rejuve-
device able to emulsify fat in specific target with nation with laser or peel.
2. Young patients who require only treatment of
chubby cheeks and double chin.
A. Di Giuseppe (*) 3. To enhance neck definition with chin augmentation.
School of Medicine, Institute of Plastic and Reconstructive
4. To substitute for endoscopic forehead-lift in balding
Surgery, University of Ancona, Ancona, Italy
e-mail: [email protected] scalps.
5. To achieve dermal stimulation and retraction in the
G. Commons
Plastic Surgery Center of Palo Alto, Palo Alto, CA, USA neck beyond areas amenable to laser resurfacing.
e-mail: [email protected] 6. To release acne scarring of the cheeks.

7. In secondary and tertiary face-lifts when partial

removal of the skin is a questionable procedure but
the central face needs further tightening.
Other indications include rhytids in the malar area,
crows feet, frontal, nasolabial, glabella (horizontal
and vertical), and neck as well as descent of the cheek
fat, ptosis of the lateral eyebrows, laxity of the upper
lids, jowls, and diffuse acne scarring of the cheeks and
neck.
34.3 Technique of Facial Liposculpture
Lines are drawn on the face to show the full area of

undermining, the vectors of muscle tension, relaxation
creases and folds, and crisscrossing lines of tunneling
and dermal stimulation. Incisions are placed at differ-
ent sites to allow ease of access depending on the target Fig. 34.1 Incision lines
areas (Fig. 34.1). In the forehead, incisions are vertical
to avoid nerve damage and are at the hairline, midline
or frontal recess. Temporal incisions are parallel to the advanced subdermally, and the tip of the probe tents
hairline while submental incisions are at the submental the skin while it is withdrawn. Blanching of the skin
crease. Preauricular incisions are made at the earlobe, occurs with treatment and is more noticeable in the
and upper and lower eyelid incisions are at blepharo- patient with ruddy complexion. The skin softens and
plasty sites. smoothes following use of the probe.
The use of the tumescent technique reduces bleed- The sequence of dissection starts with the submen-
ing and bruising and decreases surgical time. Modified tal area and neck from the submental and earlobe inci-
Kleins solution [2] used contains 1,000 mL of |normal sions. The probe is then used over the mandible, cheek,
saline with 1 mL epinephrine (15 mg), and 500 mg and temple reaching the nasolabial fold, side of the
lidocaine. Intravenous sedation is generally utilized, nose, and the crows feet in a radiating fashion through
but when general anesthesia is used with lidocaine, it the earlobe incision. An upper eyelid incision allows
is reduced to 200 mg and sodium bicarbonate is elimi- access to the glabella and central portion of the fore-
nated. Approximately 350500 mL of solution is uti- head releasing the cutaneous insertion of the corruga-
lized on each side. A blunt-tipped, 14-gauge cannula is tor and procerus muscles without altering skin
used to infiltrate the subcutaneous tissues of the neck, sensation. The rest of the forehead is dissected through
jowls, cheeks, temple, and brow. Digital pressure aids a separate hairline incision (Fig. 34.2).
in directing and expanding the fluid evenly. The fat emulsion and tumescent fluid are evacuated
by gentle massage of the areas. When the incisions are
closed with skin sutures, epifoam is applied to the skin,
34.3.1 Ultrasonic-Assisted Dissection and a chin strap is also applied. Ice packs are used on
the face and orbital regions are not covered by the
Ultrasonic dissection is performed with a titanium foam. A supporting garment is applied for 1 week, and
solid probe (sculpture by SMEI, Italy) that is 15 cm in then for 2 weeks more, nighttime (Fig. 34.3).
length [3, 4]. The areas include frontal from the hair- Any other cosmetic procedure can be performed at
line to the brow, glabella, dorsum of the nose, temple, the same time including upper and lower blepharo-
lateral canthal region (crows feet), cheeks to nasola- plasty, platysmaplasty, face-lift, neck-lift, chin or cheek
bial grooves, chin, jowls, and anterior neck from chin implants, temporal-lift, forehead-lift, skin rejuvenation
to sternal notch (anterior triangles). The probe is with laser or chemical peel, and fat transfer.
34 Jowl and Neck Remodeling with Ultrasound-Assisted Lipoplasty (VASER) 541
two of them improving over 2 months. One patient

required surgical release of the subdermal scar and asked
for a more extensive surgery, a standard open face-lift
with SMAS. There were no instances of nerve injury,
alopecia, or a vascular necrosis. The ultrasonic-assisted
facial rejuvenation was safe, effective, and reproducible.
The results were comparable to more extensive, difficult
surgeries with higher morbidity, risks, and costs.
34.4 Technique of VASER (Vibration

Amplication of Sound Energy
at Resonance) Neck Lipoplasty
34.4.1 Indications
Heavy neck and/or chin with moderate to good skin

Fig. 34.2 Tension lines of action tone and where extra volume is expected to be excess
fatty tissue. Patients may seek good predictable aesthetic
outcome (contouring of the neck/jowls) with maximum
safety, fast recovery, and minimum downtime.
The protocol establishes that VASER-assisted neck
contouring should only be performed by surgeons
already experienced with the VASER system for fatty
tissue emulsification, which means at least 20 cases
of standard liposelection are recommended before
moving to application to face and neck. Indicated
patients are those who are seeking contouring of the
neck and jowl areas, who have heavy neck and/or chins
with moderate to good skin tone, and where extra
volume is expected to be excess fatty tissue.
34.4.2 Marking and Incisions
There should be a strategy plan for volume removal

and associated marking. Landmarks include the lower
border of mandible and thyroid cartilage.
Fig. 34.3 Face-supporting garment

34.4.3 Anesthesia
34.3.2 Complications The neck is divided into thirds, and local tumescent
fluid is infiltrated, about 100 mL in each third.
Two patients developed postoperative hematomas, which The face and the neck are more vascular and have
required aspiration; however, both were hypertensive more innervations of typical fat layers in the body.
and noncompliant with their medications. Contour The concentration of adrenaline should be increased
deformities of the neck were noted in three patients with to 1:500,000 and the concentration of lidocaine to
0.30.5% in order to guarantee enough analgesia and 34.4.7 Aspiration/Cleaning

vasoconstriction of the area.
Two small stab incisions are sometimes placed in
the lateral aspects of the neck at the lowest point of
34.4.4 Incisions treatment and left open for drainage purposes. A small
suction cannula with no vacuum applied and passed
Incisions are placed under the chin, and in front of or through the stab incisions to open channels into the
behind ears (bilaterally), earlobe, chin, and lower neck treated areas. At the end, it is advisable to massage
(Fig. 34.2). Possible placement may be bilaterally in the and press tissues to express emulsified tissues and
neck at the lowest anticipated level of treatment. The fluids out of incisions. The emulsified fat and fluids
surgeon must wait between 8 and 10 min before starting can be massaged out or will drain out of the incisions
the surgery until the effects of lidocaine and adrenaline on its own.
begin. It is advisable to infuse with a small-diameter
blunt infusion cannula (2. 0 mm or smaller, 14 gauge or
smaller). Never use a needle. The infusion should be 34.4.8 Postoperative
uniform and into all locations where the VASER or the
suction cannula may be used. The infusion should be The recommended dressing will make a gentle
slow, 100 mL per min, with gentle action. compression to help the skin redraped and settle into
position and aid to prevent ripples or folds in the skin.
The options include cotton pads with elastic wraps,
34.4.5 Skin Protection cold compresses, silicon foam padding, elastic face
garments typically applied for 24 days, than over-
Skin protection should be used in all incisions, utiliz- night for 12 weeks, depending on preference. Keep
ing the black skin parts with the orange silicone discs. head elevated overnight for 4 weeks to help edema to
The discs should be stitched into place (three anchor last quicker. The typical follow-up is 1 day, 1 week,
sutures are necessary) using 30 or 40 nylon. The sur- 6 weeks, 6 months, and as needed. Protocol for external
geon must make sure the knots are tight as the silicon ultrasound and for light massage (LPG Endermologie)
disc tends to cause the knots to unwind. The skin ports or just lymphatic massage may be beneficial.
protect the incision edges and reduce visible incision External ultrasound 10 W for 5 min with small head
scarring. Stretch the incisions and tissues below the twice a week for 34 weeks is recommended as an
incision with a hemostat to ease insertion. alternative to endermologie, to soften tissue.
34.4.6 Emulsication 34.5 Discussion
Utilize the 2.2-mm diameter (18 cm long) or 2.2-mm There has been a lot of interest in the use of ultrasonic
(11 cm long) probes, initially with the VASER mode at liposuction for body contouring. Skin retraction has
20% or 40% maximum of the power of the system. been reported as a result of the concomitant use of
The 20% amplitude in face and neck works well when internal ultrasound from the large amount of fat
the tissues encountered are soft. The 30% amplitude is removed, removal of subdermal fat, skeletonization of
better for moderate/average fat. The 40% amplitude is the superficial fascial system, and thermal effects on
indicated if face is fibrous. Never exceed 40% with the the subdermal surface and collagenous structures of the
2.2-mm probes, they may break. Apply VASER until superficial fascial system [58]. The theories of the
targeted fat is emulsified, likely 23 min total per side cause of skin contraction include collagen constriction
depending on volumes, with additional 23 min under due to thermal injury, defatting the superficial layer
the chin depending on how the VASER was applied on results in contraction of the retained structures (skin),
the sides. The total VASER time is 610 min depend- and gentle stimulation allows contraction through
ing on patients and infused volumes. The surgeon must controlled damage.
try to achieve the targeted 610 min of VASER time to Facial aging is due to fat and skin ptosis and not
minimize aspiration trauma. muscle or facial ptosis. Therefore, the supra-SMAS
plane is ideal for the harmonic lift with ultrasonic 7. Skin necrosis (0.3% of clinical cases)
rejuvenation of the face. The osteofascial dermal 8. Burn (0.2% of clinical cases)
ligaments can be released or attenuated in this plane Despite the fact that burn and skin necrosis were
allowing direct contouring of the malar, nasolabial, largely the less common related complications, and
jowl, and submental fat collections. Fat removed close represented really a rare issue, the potential risk of
to the under surface of intact skin results in skin retrac- these two complications was overemphasized. A major
tion with permanent contour changes. issue was introduced by many authors in literature,
Postoperative care requires careful nursing assis- probably because these two related to procedure com-
tance, punctilious wound protection, and prolonged plications were not seen with the other technique of
seclusion of elaborate makeup. Recovery time varies liposuction (superficial, traditional, power assisted).
from 4 to 14 days. The postoperative care is limited to The task force established by the American Society
the use of Reston foam and elastic compression ban- of Aesthetic Plastic Surgery (ASAPS), by the American
dages that are changed by the patient. Although there Society of Plastic and Reconstructive Surgery
are no histological examinations in this study, there (ASPRS), by the Educational Foundation, etc., met
have been previous reports on the results of subdermal many times in order to establish safety criteria of utili-
ultrasound and liposuction [9, 10]. The long-term zation of ultrasound energy in body contouring
results have not been evaluated and are probably surgery.
related to the type of skin, patients age and sex, and The first safety indication, to prevent complications
the long-term effect of ultrasound energy. such as burn and skin necrosis, was to avoid the utiliza-
Disadvantages are the cost of ultrasonic machine, tion of the ultrasound probe close to the underlying
increased hassle factor in the operating room, and skin dermis that was really, on the contrary, the most
machine dependency, but after achieving proficiency important step of the harmonic lift. However, only
in using the machine, there is no turning back because working superficially with a solid ultrasound probe,
it is addicting. The conclusion, at that time, was that the surgeon can undermine the cutaneous and subcuta-
the harmonic lift is a safe, effective, and reproducible neous layers, assembling a skinny but vascularized flap,
form of skin remodeling. It can be performed under more prone to retract and adapt to a reduce body vol-
local, regional, or general anesthesia and can be ume. The great misunderstanding in those years, which
repeated with no increase in surgical difficulty or led to and created confusion and mixing of clinical
cumulative effect. Advantages include negligible blood data, was due to the fact that all the complications-
loss and pain, short and uncomplicated recovery, and related data came through the utilization of the two
simple postoperative care. The results are comparable most diffused ultrasound tools, in the U.S. market: The
to those obtained with more extensive surgery that fre- Contour Genesis, by Mentor (Santa Barbara, California),
quently involves overnight stay, higher risks, increased and the Lysonics (by Inamed Corporation).
morbidity, and higher costs. These two ultrasound tools have similar technical
The author has found a lot of skepticism around the characteristics:
utilization of ultrasound energy in the face, mainly 1. High energy
related to the potential risks of burns. In the USA, from 2. Hollow probes, with simultaneous ultrasound energy
1995 to 2000, a series of articles published in medical administration, thus emulsification and simultane-
literature pointed out the increasing number of compli- ous, subsequent aspiration
cations related to body contouring procedures when 3. 5.0-mm large probe
ultrasound energy was involved [11]. The SMEI sculpture tool was a less powerful tool,
The analysis of all these complications, though with solid titanium probes, with no aspiration at time
there is a difficulty in assembling all the clinical data, of emulsification (which were, and are, two different
brought to the following results: clinical phases).
1. Seroma (30% of body contouring cases) In 2001, Cimino [12] published an article on power
2. Delayed wound healing (18% of clinical cases) quantification and efficiency of ultrasound energy.
3. Prolonged edema (15% of clinical cases) This article was of capital importance to understand
4. Dysesthesia (12% of clinical cases) all the mistakes made by the two main American
5. Fibrosis (8% of clinical cases) manufacturers in assembling the two most common
6. Asymmetries (4% of clinical cases) ultrasound tools.
Fig. 34.4 Sculpture by SMEI

(bottom) and infiltration
peristaltic pump (top)
1. Too much energy which produced an unnecessary of the ultrasound technique for fat emulsification
overheating, which increased the side effects of (Fig. 34.4).
ultrasound (seroma, mainly) without enhancing the Fortunately, in 2001, a new ultrasound device,
results and the clinical outcomes. called VASER, (by SST-Denver, Colorado, USA), was
2. Too large probes, with low efficacy in transmitting introduced in the U.S. market (Fig. 34.5). This new
energy to the tip, and thus reducing the emulsifica- tool has new features as:
tion rate. 1. New designed probes, of different caliber and shape.
3. Poor design of the tip of the probe due to lack of 2. The tip is designed (with one, two, three rings), to
technological research, with a reduced efficacy of increase the efficiency of the emulsification, which
the system in order to raise the rate of emulsifica- now affects not only the tip, but also the sites of the
tion; the manufacturer increased the power of the last part of the shaft (Fig. 34.6).
tools. 3. The number of rings is related to the efficacy of the
The two main ultrasound devices were far from a emulsion depending on the type of tissue encoun-
good technical standard, technologically were low- tered (more or less fibrotic, type of fat, more or less
developed machines, and the majority of complica- dense).
tions came from these limits. As a matter of fact, with 4. New generator of ultrasound energy, with less power,
the sculpture SMEI machine, the author has never but with optimization of the distribution of energy at
had the complications pointed out in the literature in the different frequencies and wave length. High effi-
those years, which progressively destroyed the name ciency with less energy, which means less-related
Fig. 34.6 Different probes with one, two, and three rings at the
top of the shaft
Fig. 34.5 VASER system ultrasound (top), Ventex aspiration

(bottom), and infiltration (top right)
complications due to overheat of the system. So far, in

the last 5 years of the VASER Ultrasound Generation,
no report of burn or skin necrosis has been published.
An insignificant percentage of seroma was reported.
5. New aspiration system, the so-called Ventex, with a
new pathway expressly designed for increasing the
rate of aspiration, without damaging the tissue, thus
aspirating noble structures, as vessels nerves,
elastic tissue, and impossible to be blocked by undue
aspiration of wrong tissue. Skin protector, expres- Fig. 34.7 Skin ports
sively designed to prevent tissue damages from fric-
tion injuries, related to the consecutive passages of
the probe from the same entrance point (Fig. 34.7). The role of dermis in the subcutaneous anatomical
6. Reduced extension entrance scar of skin, to allow structure has been under valuated in the past.
introduction of the solid titanium probes that are Rudolph (1977) [13] first described the importance
smaller in diameter (standard probe varies from of the dermis layer for skin retraction. In plastic
2.2 mm to 3.7 mm). The facial probe is 2.2 mm large. surgery, it is commonly known that a split skin graft
Even the site of entrance is now compatible with the (no dermis left) is not really indicated to cover joint
typical diameter of the standard liposuction cannulas areas (as elbow) for the possibility of leading to skin
(between 2 and 4 mm of diameter). retraction, thus functional problems to the area. If a
Fig. 34.8 The thinner the

subcutaneous fat, the greater
the contraction
The thinner the

subcutaneous fat, the
greatest retraction
is achieved
UAL solid titanium probe

works close to the dermis,
to thin the subcutaneous
fat, and achieves contraction
Fig. 34.9 Layers of Layers of subcutaneous emulsification with vaser UAL

subcutaneous emulsification
with VASER UAL
S=superficial
I=intermediate
P=deep
full thickness graft is utilized (with a layer of dermis [14, 15]. Emulsifying the body fat, and thus conserving
but no fat), the same area is less prone to contraction the connective, supporting structure of the subcutane-
and to functional problems (Fig. 34.8). ous tissue (Fig. 34.9), the skin retracts much more than
This aspect has never been considered in skin in standard condition. If the surgeon can harvest a
contraction after ultrasound-assisted body contouring well-vascularized skin dermal flap with the auxiliary
use of an instrument that helps preparing such a surgi- jowls, neck) or just extensively undermine the
cal plane, the potential of skin retraction is maximized interested areas, counting on a deep, severe, intense
in a safe procedure (Fig. 34.10). skin retraction and simulating the effect of a subcuta-
The surgeon using the VASER technique for face neous rhytidectomy but without cutaneous scars [16]
and neck contouring can emulsify fat areas (chin, (Fig. 34.1134.15).
Fig. 34.10 Fat thickness Fat thickness varies in different body areas
varies in different body areas
Thigh and abdomen are the thickest
area
Back anf face are the thinnest
Back Thigh
Fig. 34.11 (a) Preoperative 38-year-old male. (b) Postoperative following jowl, chin, and neck contouring
Fig 34.11 (continued)
a b
Fig. 34.12 (a) Preoperative 37-year-old patient. (b) Postoperative after neck, chin, and jowl contouring
Fig. 34.13 (a) Preoperative 28-year-old male with heavy cheeks and chin retrusion. (b) One month following VASER of cheeks
and neck for contouring and intraoral chin implant
Fig. 34.14 (a) Preoperative 43-year-old male with neck and chin hypertrophy. (b) Postoperative after cervical UAL and chin
implant
a b
Fig. 34.15 (a) Preoperative 44-year-old obese female. (b) Postoperative following neck, jowl, and cheek UAL
References 9. Pitman GH (1993) Liposuction and aesthetic surgery.

Quality Medical Publishing, St. Louis
1. Di Giuseppe A, Menna G (2000) The harmonic lift: ultrasonic 10. Fodor PB, Watson J (1998) Personal experience with ultra-
assisted skin remodelling. Int J Cosm Surg Aesth Dermatol sound assisted lipoplasty: a pilot study comparing ultrasound
2(2):125131 assisted lipoplasty with traditional lipoplasty. Plast Reconstr
2. Klein J (2000) Tumescent technique. In: Klein J (ed) Tumescent Surg 101(4):11031116
anesthesia & microcannular liposuction. Mosby, St Louis 11. Scheflan M, Tazi H (1996) Ultrasonically assisted body
3. Grotting JC, Beckestein MS (1999) The solid probe tech- contouring. Aesthetic Surg J 16:117122
nique in ultrasound-assisted lipoplasty. Clin Plast Surg 26(2): 12. Cimino WW (2001) Ultrasonic surgery: power quantifica-
245254 tion and efficiency optimization. Aesthetic Plast Surg J
4. Rohrich RJ, Beran SJ, Kenkel JM (1998) Ultrasound assisted 21(3):233241
liposuction. Quality Medical Publishing, St. Louis 13. Rudolph R, Guber S, Suzuki M, Woodward M (1977)
5. Illouz YG (1990) Study of subcutaneous fat. Aesthetic Plast The life cycle of the myofibroblast. Surg Gynecol Obstet
Surg 14(3):165177 145(3):389394
6. Gibson T (1990) Physical properties of skin. In: McCarthys 14. Becker H (1992) Subdermal liposuction to enhance skin
plastic surgery. W.B. Saunders Co, Philadelphia contraction: a preliminary report. Ann Plast Surg 28(5):
7. Gibson T, Kenedi RM (1970) The structural components 479484
of the dermis. In: Montagna W, Bentley JP, Dobson L, 15. Gasparotti A (1992) Superficial liposuction: a new applica-
Montagna W, Bentley JP, Dobson L (eds) The dermis. tion of the technique for aged and flaccid skin. Aesthetic
Appleton-Century-Crofts, New York Plast Surg 16:141153
8. Southwood WF (1955) The thickness of the skin. Plast 16. Shiffman MA, Di Giuseppe A (2006) Liposuction: princi-
Reconstr Surg 15(5):423429 ples and practice. Berlin, Springer
Part IV
Breast
Breast Augmentation
35
35.1 Introduction cost of surgery. Before surgeon and patient decide to

have the surgery performed and sign the patients
Over the past 20 years, the author had the opportunity informed consent, in the authors experience, a spe-
to operate on different social profile women: fashion cialized consultation in plastic aesthetic and cosmetic
models, beauty contestants, executive working women, surgery of the breast has to go through seven steps:
and housewives. Each group needed a specific breast 1. Medical record
augmentation surgery. Over the last two decades, the 2. Psychological interview
anatomy of breast implants has evolved bringing 3. Photographic computerized imaging
patients and surgeons the possibility of having better 4. Actual vs. future breast size
results with surgery. The demanding patient is perma- 5. Deciding which implant the patient needs
nently in contact with virtual information and is often 6. Surgeons suggestions
pushing her surgeon for a better and natural result. 7. Patients informed consent
Today and in the future, thanks to technology, we as
surgeons will address the problems of breast augmen-
tation with better cosmetic and anatomical results. 35.2.1 Medical Record
A complete medical record is important in order to

35.2 Consultation visualize any physical condition that will place the
patient in an adequate condition to avoid complications
One of the most frequent requests from patients plan- in the immediate postoperative period. These condi-
ning breast augmentation is the normal appearance of tions include urinary infection, diabetes, pregnancy,
the new breast. Size of the breast has always been a autoimmune diseases, and others that should be cleared
normal size please for every individual when search- during consultation. It is of great help to standardize
ing for breast augmentation. Cup for the bra size is a the medical record and ask the patient to fill it in.
constant question, and every patient has to define her
own size or the desired one.
Consultation concerns itself with these and other few 35.2.2 Psychological Interview
concerns about complications, durability of the implant,
surgical approach, medical fees, and economical After finishing an accurate medical record, the patient
is asked to have a psychological interview with a psy-
chologist; whose aim is to distinguish any psychotic,
neurotic, obsessive compulsive traits, or even a body
L.V. De Pedroza
dysmorphic disorder. Once this interview ends, the
Plastic and Reconstructive Surgery, Universidad del Valle,
Bogota DC, Colombia, S.A psychologic profile enables us to continue the consul-
e-mail: [email protected] tation and schedule the surgery.

556 L.V. De Pedroza
35.2.3 Photographic Computerized We find that the best results in terms of reaching an
Imaging aesthetic anatomical appearance are achieved with
implants with high profile, soft touch gel, microtex-
This wonderful tool of photographic technology guides tured, and round shaped when the volume does not
the clinical evaluation for performing an aesthetic exceed 450 mL. When the expected volume needs a
diagnosis of the patient and to visualize her desired volume more than or equal to 500 mL, the author
final result in terms of size of the new breast, position prefers anatomical devices in order to avoid the
of the nipple-areola complex, and diameter of the are- undesirable bulging in the superior pole and, on the
ola. Patients who undergo this session gain a better other hand, obtain a better natural shape and a fuller
understanding of their anatomy, their future change inferior pole.
after surgery, and finally, they end the process by exer-
cising their minds placing a tactile image of themselves
in a paper. Computer imaging has been often misun- 35.4.1 Surgeons Suggestions
derstood and should never be used to show the patient
the final result, but to have the patient show us how During this last consultation step, the author suggests an
they would like to appear! approximative volume in terms of cup size that will look
This photographic session is given to the patient better in the patient. We never compromise the proce-
with a legend below. The following photographs are dure by suggesting a determined volume of the implant
not intended to show you a result; they are a techno- prior to surgery, it will be given after surgery with all the
logical tool to understand your minds image and per- literature and attachments on the implant box.
form a surgery according to your requests. Patients leave the operating room with the desired
breast shape and size after a meticulous process guided
by the anterior steps related.
35.3 Actual Versus Future Breast Size
In the next interview with the patient, the surgical 35.4.2 Patients Informed Consent
approach is explained for the individual case; the
patient is sized with her own bra and often different At this time, the patient is informed about the surgical
sizes of bra, running from 32 to 40 and cups from A to procedure, possible complications, breast device,
DD. This method helps the author to understand the recovery, medical fees, coast of the implant, prepara-
patients actual size and the new size desired, while tion before surgery, and postoperative instructions.
asking her to wear a blouse with the new bra on. Again, Surgery is scheduled for at least 6 days after the first
this step helps the patient visualize her future breast consultation. During this period, patients may have
enlargement in vivo before surgery. time to understand their new appearance and some-
times a few questions arise before surgery in one more
interview with the surgeon.
35.4 Deciding Which Implant
the Patient Needs
35.5 Processes to Optimize the Surgery
It is often helpful to keep many samples of different
kinds of implants that include smooth, textured, micro- Following the processes in the consultation steps
textured, anatomical, high profile, medium profile, enables surgeons to optimize breast augmentation
saline. With those samples, patients understand quality which transforms the procedure as an objective approach
and shape of those selected for them. Then the author and not a subjective (surgeons) surgery, as performed
suggests the kind of implant chosen for every individ- in the past. Engineering processes are the tools to qual-
ual patient depending on the amount of breast tissue ity control; surgeons can evaluate and apply these tech-
she has and the pocket placement in the subglandular niques to redefine patients long-term outcomes and
or submuscular position. obtain a satisfactory result and a satisfied patient.
35 Breast Augmentation 557
1. Prioritize and project the patients tissues by choos- 35.6.3 Know the Ideal Beautiful Normal
ing implant pocket location to assure optimal long-
term tissue coverage of the implant and by avoiding Since Normal is our goal, any Plastic and Recons-
implant sizes or projection that are likely to cause tructive surgeon must know normal beauty. Each
excessive stretching, tissue thinning, and parenchy- decade brings new patterns, but beauty by itself has its
mal atrophy. own meaning. According to Plato (420348 B.C.),
2. Implement objective, tissue-based clinical evalua- beauty and function in their perfect expression are syn-
tion, preoperative decisions, operative planning, onymous. St. Thomas Aquinas, concept known as
and implant selection. Angelical Doctor, was one of the great philosophers
3. Prioritize and consider implant design, filler distri- of the Catholic Church in the thirteenth century. He
bution dynamics, and implant-soft tissue dynamics proclaimed beauty to be Integritas, proportion et
during operative planning. claritas Harmony, proportion, and clarity. Kant
4. Design and dissect the implant pocket to fit the claimed that beauty is simplicity. Mortimer Adler,
implant selected. University of Chicago philosopher, stated that beauty
5. Minimize trauma and bleeding and apply prospec- brings pleasure, and life without beauty is not enriched.
tive hemostasis principles. David Hume, 200 years ago, stated beauty is not only
a quality of things, it exists only in the mind who con-
templates it, every mind perceives beauty differently.
35.6 Principles in Breast Augmentation Probably, the most important key to what each of us
sees as beautiful is our previous experience.
Dr. Ralph Millard introduced the author to the
principles in plastic surgery; the philosophical
rationalization of acting and thinking when per- 35.6.4 Seek Insight into the Patients
forming a surgical plan. True Desires
1. Correct the order of priorities.
2. Diagnose before treating. Frequently, a Plastic Surgical Aesthetic consultation
3. Know the ideal beautiful normal. involves four determinations: diagnosis, plan of treat-
4. Seek insight into the patients true desires. ment, fees, and scheduling of the surgery. There is a
subtle fifth dimension that is more important than all the
other four: The surgeon must get on the same wave
35.6.1 Correct the Order of Priorities length as the patient, so that he has insight into the
patients true desires. This is not necessarily what the
Performing breast augmentation is a complex surgery patient says she wants, not what most patients want, not
that involves: (1) tissue coverage, (2) incision place- what you want, it is what she (the patient) really wants!
ment, (3) pocket placement, (4) volume desired by the
patient, and (5) volume suggested by the surgeon. All
decisions should be placed together to produce breast 35.7 Clinical Evaluation
enlargement and breast shaping. and Aesthetic Diagnosis
Optimizing any process to evaluate the patient during

35.6.2 Diagnose Before Treating consultation will enable surgeons to perform a breast
augmentation surgery with the best choice for approach,
An accurate diagnosis of breast condition will guide selection of breast implant design, implant pocket
the surgeon to perform the indicated surgery. Dis- location, assure optimal long-term tissue coverage of
tinguishing from atrophic breast tissue, hypotrophic the implant, adapt implant dynamics to the patients
breast, asymmetries, skin appendage and thickness, anatomy depending of skin quality, avoiding over pro-
elasticity, weight, gravitational, and aging influences jection, avoiding excessive stretching, tissue thinning,
will help differentiate what the patient is facing. and parenchymal atrophy.
558 L.V. De Pedroza
The ultimate objectives of any breast enlargement from 24 to 37 years old, often with at least one or two
runs between speedy recovery, reducing complications pregnancies, what is found usually its an atrophic
and reoperation rates, and minimizing negative aes- breast tissue. The enlargement goals often seek an
thetic results such as displacement, capsular con- objective: natural filling and shaping of her breast,
tracture, enlargement of the nipple-areola complex, searching for what was lost, when she had a youthful
retractions of the incision approach, or noticeable scar filled breast. Volume desired in these cases may fit a
when placing it at the submammary fold instead at the bra cup sizes B and/or C. A housewife concerning
expected new one. The surgeon may have a meticulous about breast augmentation may have different expecta-
vision of these items, enough tools to perform a natural tions and depending of the height and weight, what is
enhanced breast enlargement, but in failing to transmit a common request between these patients is to recover
this expectation to the patient, he dooms the surgery. a lost volume and younger appearance, usually obtained
Should patient expectations exceed reality, no matter by mixing a breast lifting with a breast augmentation.
how brilliant the surgery and its results turn out to be, In the authors experience in performing surgeries
the patient will never be happy, and the procedure has to fashion models and beauty contestants, these
thus failed in its primary goal. patients ages range between 17 and 24 years old, and
Two categories of breast augmentation exist: breast breast augmentation seeks full cup B, never trespass-
enlargement (breast stuffing) and breast enlargement ing to a C cup. Their natural low profile breasts are like
(filling and shaping the breast) with optimal control of the angelical, innocent, and child in an adult body
distribution of fill and long-term aesthetic results, appearance in a thin frame.
while minimizing tissue compromises and reoperation Also, after the age of 50, skin elasticity is excessive;
rates. Stated another way, augmentation can either ptosis may be the rule and breast enlargement is often
optimally fill a breast acknowledging breast dimen- a combination with breast lifting. When combining
sions and tissue characteristics (fit and fill) and force these two procedures, the use of a mammary implant
tissues to a desired result. means a tool to fill a lost youthful appearance.
Understanding excess skin elasticity and breast tis-
sue atrophy most commonly present at the postpartum
and postfeeding periods will give guidelines to distin- 35.9 Surgical Approaches
guish a ptotic breast from an atrophic one when per-
forming a subglandular implant location. 35.9.1 Periareolar Incision Location
1. Rippling is often produced by a textured and low
filling gel implant with a poor tissue coverage. The periareolar incision approach to breast augmenta-
2. Breast stuffing reveals both poor tissue coverage and tion is very popular in some areas of Europe and South
poor pocket dissection accompanied by an incorrect America. Surgeons can place implants in all pocket
excess volume implant and poor skin elasticity. locations via this technique. No valid scientific studies
Finally, breast augmentation depends on anatomi- confirm the option that the periareolar incision pro-
cal dimensions of the chest of the patient, inframam- duces a superior or best incision compared to the infra-
mary fold position, cleavage, breast tissue (either mammary incision location. Advocates of this location
muscle or glandular) coverage, skin elasticity, and incision often state that visualization and control of
breast position on the chest (ptosis). pocket dissection provides an excellent access. The
authors opinion is that patients with an areola diame-
ter less than 3 cm are not the best candidates for this
35.8 Patients Prole approach. This means that our incision should be at
least 2 cm long, and tissues will not have the flexibility
Not every woman has the same professional or social to permit the insertion of an implant base width over
profile, it may also depend on her age, height, and 10 cm, risking torn skin, and enlarging the incision to
weight. We as surgeons deal with different kinds of a visible position. The trauma produced to the skin
breast enlargements, and in the globalized world we edges often results, under these conditions, in a hyper-
live in, different culture groups that must be recog- trophic scar. Inserting any breast implant via periareolar
nized. A professional business woman of ages ranging approach exposes the implant to more endogenous
bacteria in the breast parenchyma, compared to other substantially higher device failure rate over time
approaches. However, scientific studies fail to confirm compared to latest generation form stable, silicone cohe-
higher infection rates and capsular contracture pathologic sive gel implants.
scarring. When planning to choose an implant base
width exceeding a diameter of 10 cm or more, a stable
cohesive gel implant, or a small diameter areola, the 35.9.3 Inframammary Incision Location
periareolar incision location is impossible. The
approach is also not an optimal choice for patients with This approach most frequently used through North
any history of parenchymal breast disease. America requires that surgeons preoperatively plan the
location of the new inframammary fold. Advocates of
this technique state that it provides the best direct
35.9.2 Umbilical Incision Location vision access, achieves a less traumatic access, requires
no specialized instrumentation, is applicable to all
This today is the least used approach for breast aug- types of implants with maximal accuracy and options,
mentation. One of the most valid reasons in the authors and no additional incision is required for secondary
experience is how distant from the breast unit the inci- procedures.
sion is located and how excellent management of the
endoscopic instrumentation is needed for the surgeon
to expose the tissues with this approach. Published 35.9.4 Axillary Incision Location
reports and observation during live surgery demonstra- (Figs. 35.1 and 35.2)
tions of the techniques point out difficulties in predict-
ing and assuring precise pocket locations. The axillary incision approach is the closest location to
The umbilical approach limits implant options to reach both the submuscular and the subfascial pocket.
inflatable implants, and inflatable implants leave a Surgeons with optimal skill sets can place many kinds
Fig. 35.1 (a) Preoperative. (b) Fourteen years after axillary approach, submuscular pocket with round, microtextured, and high
profile implants. (c) Axillary close up of the left and right axila after 14 years of surgery, notice that you can barely see the scars
560 L.V. De Pedroza
of available implants accurately and precisely via the This approach facilitates the off visible location of
axillary approach. Only anatomic shaped implants the incision and permits a well-hidden scar, which in
cannot be precisely placed, as well as the foam coated the experience of the author performing this procedure
implant due to its known high adhesivity thus creating for more than 20 years, there was a 0.0001% rate of
misplacement of the implant at the end of the hypertrophic scar occurrence perhaps due to lack of
procedure. tension of tissues.
Fig. 35.2 (a) Preoperative 22-year-old female. Three years postoperative using submuscular axillary approach and inserting
375 mL extra-high profile, microtextured, and round-shaped implants
Critical neurovascular structures such as the axillary when surgeons dissect excessively posteriorly in the
artery and vein and the brachial plexus are adjacent to axillary fat pad.
the axillary incision site, and rare injuries to these Potential tradeoffs of the axillary approach that are
structures have been reported. The intercostobrachial usually temporary and nevertheless cause postopera-
and medial brachial cutaneous nerves course through tive morbidity include: (a) transient axillary fluid col-
the axillary fat, and injuries to these structures occur lections, (b) difficulty and delay in shaving the axilla,
562 L.V. De Pedroza
a b
Fig. 35.3 (a) Periareolar incision and submuscular placement. (b) Severe retraction of the areola due to deficient closure technique
(c) transient sensory loss in the axilla and upper arm, areolar incision location. The subareolar skin is sur-
(d) and fibrous bands in the axilla. Even if the incidence rounded by an orbicular smooth fiber muscle, this
of these tradeoffs is extremely low, surgeons should functional anatomy should be reconstructed at the
inform the patient of those when discussing incision moment of closure avoiding future disability in terms
alternatives. of contracture of the areola.
The axillary approach is not an optimal choice for Surgeons can definitely impact surgical-related fac-
patients with glandular ptosis and does not provide tors by implementing quantitative tissue assessment
optimal control for correction of tubular breast as well and proven processes for implant selection, optimizing
as for severe constricted lower pole breasts. techniques that preclude the necessity of unnecessary
postoperative adjuncts, and following a predetermined
surgical plan process.
35.10 Complications and Management
Breast augmentation is a totally elective cosmetic sur- 35.10.2 Wrinkling

gery. When a patient is choosing a breast enlargement,
she is choosing to place a medical device that is not nec- Wrinkling is a frequent cosmetic unpleasant result
essary to place into the body. Patient education through often produced by: (1) poor tissue coverage, or (2)
consultation will transform knowledge and understand- poor design and dissection of the pocket, which does
ing to difficult situations that may occur in the postop- not fit the implant and remains tight at the moment of
erative period. Most frequently, these complications surgery. These two conditions make a wrinkling aspect
arise when surgeons did not predict enough tissue cov- often requiring reoperation that could be avoided eas-
erage, did not recognize previous ptotic or constricted ily in the preoperative planning pocket placement and
breast, did not follow an atraumatic surgical procedure dissection.
avoiding bleeding, or taking care of aseptical measures
at the time of placing the implant inside the pocket.
35.10.3 Asymmetry
(Figs. 35.435.6)
35.10.1 Retraction at the Site of Incision
(Fig. 35.3) Mislocation of one or both implants respond to migra-
tion in the immediate postoperative period mostly
Suturing technique during closure of the wound may when pocket dissection at the submuscular plane is
avoid unpleasant retraction mostly present at the peri- poor and liberation of the inferior costal margin of the
muscle was not performed. A poorly defined surgical 35.10.4 Ptosis and Augmentation
procedure in relation with the fit and fill pocket Mammaplasty (Figs. 35.7 and 35.8)
placement and dissection will end in asymmetries that
should be corrected by a secondary procedure, also When ptosis is not diagnosed, skin elasticity becomes
predictably avoided creating better skills for surgery worse. Glandular atrophy does not mean good tissue
and optimizing surgical techniques. coverage, and any devices weight enhances the
a b
Fig. 35.4 (a) Poor definition of pocket dissection. (b) Inferior border of the muscle pulls the implant in an upward position
(right breast)
Fig. 35.5 (a) Preoperative. Both implants are located at the emply inferior pole. (b) One week postoperative after correction
superior pole due to poor dissection and lack of liberation of with periareolar approach and submuscular pocket placement
the muscle costal insertion. Notice the superior bulging and the
564 L.V. De Pedroza
a b
Fig. 35.6 (a) Excessive pocket dissection creating symmastia. (b) Lateral migration of the implant
preexisting ptosis. This is the best opportunity to sug- 2. Lowering the inframammary fold too far down dur-
gest a lifting augmentation mammaplasty during the ing a submuscular dissection and leaving the sub-
consultation period and avoid an unpleasant result and mammary constricted lower pole attached to the
an unhappy patient. muscle. Correction of this deformity needs a sec-
ondary revision mammaplasty that includes:
(a) Opening the constricted lower pole and sub-
35.10.5 Double Bubble Deformity mammary fold.
(b) Lifting the unnatural abdominal skin coverage
Double bubble deformity is usually present under the of the implant.
events such as: (c) Fixation of a new, anatomical upper placed sub-
1. Lack of diagnosis of a lower pole constricted mammary fold to the costal edges, often fifth to
breast. sixth rib edge, nevertheless lower.
a b
Fig. 35.7 (a) Poor pocket dissection keeping a tight implant in poles. This is considered a severe cosmetic deformity. (b) Ptosis
a preexisting ptosis. The device has been located very medially before surgery becomes worse with a subglandular pocket
and inside the anterior axillary line, leaving empty the lateral
35.10.6 Capsular Contracture trauma and bleeding, eliminating contamination of the

(Figs. 35.935.11) implant during insertion, and by creating an ample but
fittable pocket thus creating favorable conditions for
Understanding dynamics of scarring tissue or fibrous scarring tissue formation in order to prevent excessive
tissue will clarify a respectable position back of the contractility of the capsule.
ring to prevent capsular contracture. Fibrous scarring
tissue is a contractile and retractile tissue formation in
response to an injury. It is an adhesive cement 35.10.7 Infection
incharged to close an open wound or repair an injury
to tissues. Prolonged inflammation and excessive pro- It is clear that infection tends to be more and more
liferation of fibroblasts are natural responses to exces- infrequent due to protocols of surgery steps and asep-
sive tissue damage during surgery. Bleeding, excessive tical measures of managing implants during insertion.
cautery, seromas, and bacterial contamination help the Should this dangerous situation occurs, it is an imper-
formation of a hard nonelastic contractile capsule ative indication to remove both implants, debride tis-
around the implant, no matter any excellent product sue, and apply intravenous antibiotic therapy, selected
device used. by antibiogram and cultivation of the pathogenic
This dynamic tendency to contraction can be pre- germ. Replacement of the implants is suggested after
ventable by designing a fit and fill pocket, minimizing 6 months of the healing process.
566 L.V. De Pedroza
Fig. 35.8 (a) Preoperative a

34-year-old patient seeking
augmentation mammaplasty.
Large areola diameter and
grade II ptosis and
periareolar glandular atrophy.
(b) One month postoperative
after periareolar mastopexy,
subglandular pocket, and
round, ultra-high profile, and
textured implants
Fig. 35.8
(continued) b
568 L.V. De Pedroza
Fig. 35.9 (a) Preoperative patient with capsular contracture grade IV in a subglandular position and with large areola diameter.
(b) Two months postoperative with reduction of the areolar diameter and implants in the submuscular position
Fig. 35.10 Severe calcification of the capsular tissue
Fig. 35.11 Low profile, smooth, and

round implant from the subglandular
pocket, total capsulectomy was performed
Hall-Findlay E (2002a) Vertical breast reduction with a medi-

General References ally-based pedicle. Aesthet Surg J 22(2):185194
Hall-Findlay E (2002b) Pedicles in vertical breast reduction and
Andrades P (2008) Understanding modern breast reduction mastopexy. Clin Plast Surg 29:379391
techniques with a simplified approach. J Plast Reconstr Hammond DC, Alfonso D, Khuthaila DK (2008) Mastopexy
Aesthet Surg 61(11):12841293 using the short scar periareolar inferior pedicle reduction
Brennan W (2007) Transumbilical breast augmentation: a prac- technique. Plast Reconstr Surg 121(5):15331539
tical review of a growing technique. Ann Plast Surg Karp N (2007) Mastopexy and mastopexy augmentation. In:
59(3):243249 Thorne CH (ed) Grabb and Smiths plastic surgery, 6th edn.
Cho BC, Yang JD, Baik BS (2008) Periareolar reduction mam- Lippincott Williams & Wilkins, Philadelphia
moplasty using an inferior dermal pedicle or a central pedi- Lejour M (1996) Vertical mammaplasty for breast hypertrophy
cle. J Plast Reconstr Aesthet Surg 61(3):275281 and ptosis. Oper Tech Plast Reconstr Surg l3(3):189198
Dowden R (2001) Keeping the transumbilical breast augmenta- Mathes S (2006) Trunk and lower extremity mastopexy. In:
tion procedure safe. Plast Reconstr Surg 108(5):13891400 Mathes S, Hertz VR (eds) Plastic surgery, 2nd edn. Elsevier
Foustanos A, Zavrides H (2007) Double-flap technique: an alterna- Saunders, Philadelphia
tive mastopexy approach. Plast Reconstr Surg 120(1):5560 Nahabedian MY (2007) Explantation of 41-year-old implants
Fox J (2005) Superior pedicle reduction mammaplasty. Aesthet following primary breast augmentation. Ann Plast Surg
Surg J 25(4):406412 58(1):9194
Ges J (2003) Periareolar mastopexy: double skin technique Page D (1987) Diagnostic histopathology of the breast. Churchill
with mesh support. Aesthet Surg J 23(2):129135 Livingstone, Edinburgh
570 L.V. De Pedroza
Restifo R (1996) Amputation/free nipple graft reduction mam- Spear S, Howard MA (2003) Evolution of the vertical reduction
maplasty. Oper Tech Plast Reconstr Surg 3(3):184188 mammaplasty. Plast Reconstr Surg 112(3):855868
Roehl K, Craig ES, Gmez V, Phillips LG (2008) Breast reduc- Spear S, Giese SY, Ducic I (2001) Concentric mastopexy revis-
tion: safe in the morbidly obese? Plast Reconstr Surg 122(2): ited. Plast Reconstr Surg 107(5):12941299
370378 Tebbetts JB (2001) Patient evaluation, operative planning, and
Rohrich R (2004) The limited scar mastopexy: current concepts surgical techniques to increase control and reduce morbidity
and approaches to correct breast ptosis. Plast Reconstr Surg and reoperations in breast augmentation. Clin Plast Surg
114(6):16221630 28(3):501521
Seify H, Sullivan K, Hester TR (2005) Preliminary (3 years) Tebbetts JB (2002) A system for breast implant selection based
experience with smooth wall silicone gel implants for a pri- on patient tissue characteristics and implant-soft tissue
mary breast augmentation. Ann Plast Surg 54(3):231235 dynamics. Plast Reconstr Surg 109(4):13961409
Spear S (2006) Synmastia after breast augmentation. Plast Tebbetts JB (2006a) Five critical decisions in breast augmenta-
Reconstr Surg 118(7 suppl):168S171S tion using five measurements in 5 minutes: the high five
Spear S (2007) Breast reduction inverted-T technique. In: decision support process. Plast Reconstr Surg 118(7 suppl):
Thorne CH (ed) Grabb and Smiths plastic surgery, 6th edn. 35S45S
Lippincott Williams & Wilkins, Philadelphia Tebbetts JB (2006b) Dual plane breast augmentation: optimiz-
Spear S, Boehmler JH 4th (2006) Clemens MW augmentation/ ing implant-soft-tissue relationships in a wide range of breast
mastopexy: a 3-year review of a single Surgeons practice. types. Plast Reconstr Surg 118(7 suppl):81S98S
Plast Reconstr Surg 118(suppl 7):136S149S
The Inverted Dual Plane
Mastoplasty Technique 36
Giovanni Di Benedetto, Luca Grassetti,
Davide Talevi, Daniele Bordoni, Manuela Bottoni,
and Alessandro Scalise
36.1 Introduction The dual plane inverted technique consists, such as in

the classical dual plane method, in positioning the pros-
Breast augmentation is one of the most common pro- thesis partially under the pectoralis major muscle and par-
cedures in plastic surgery. In the USA, almost 300,000 tially under the mammary gland. The difference,
mammary augmentations are performed yearly. Aes- compared to the classical method, consists in covering the
thetic breast augmentation is usually performed in a implant using the lower third of the pectoralis major mus-
retromammary plane (behind the breast parenchyma), cle, thus leaving the implant to be covered by the mam-
when breast parenchyma is enough to cover the implant mary gland on the upper two thirds, so creating a kind of
or in case of active sport patients, or in a retropectoral lifting of the breast, obtaining a mastopexy effect [4].
plane (behind pectoralis muscle and serratus) in all
other cases. In some cases, where mammary gland is
mostly located on the lower pole, the implant can be 36.2 Technique
partially placed behind the pectoralis major muscle
and partially behind the breast parenchyma [1] (partial The short version of the technique includes performing
retropectoral). This technique originally described by the skin incision, and the gland is passed through until
Tebbetts [2] is better known as dual plane augmentation the pectoralis major muscle layer is reached. An inci-
technique. sion through the muscle fibers, respecting their direc-
The technique, as it was originally described, consists tion, is then performed, creating a submuscular pocket
in positioning the prosthesis partially behind the pecto- mostly located under the lower third of the muscle
ralis major muscle on the upper pole and partially behind itself. After that, the implant is inserted, the lower part
the breast parenchyma in the lower pole [3]. Using this been located under the undermined muscle, the upper
procedure, the results obtained appear more natural part been located under the mammary gland. Before
looking and has a very nice pear-shaped breast. The suturing the gland with single sutures, covering the
authors describe a modified dual plane technique, mostly muscle and the implant, a suction drain is inserted.
indicated when a mastopexy has to be performed. Subcuticular and skin suture is performed. Mild dress-
ing of the lower pole of the breast is finally performed.
In one case, a 50-year-old patient was seen after a
subglandular mastoplasty in 2003, followed by vertical
scar mastopexy in 2007. The surgical problems included
G. Di Benedetto (*) L. Grassetti A. Scalise (1) recurrence of breast ptosis (sternal notch-areola
D. Talevi D. Bordoni M. Bottoni border distance, 22 cm on the right side, 25 cm on the
Department of Plastic and Reconstructive Surgery, left side), (2) widening of periareolar and vertical scars,
Marche Polytechnic University Medical School, Ancona, Italy
and (3) mammary parenchyma with 3-cm ptosis
e-mail: [email protected]; [email protected];
[email protected]; [email protected]; [email protected]; (Fig. 36.1). The procedure consisted of undermining
[email protected]; [email protected] the lower third of the pectoralis major muscle and

572 G. Di Benedetto et al.
a b
Fig. 36.1 Preoperative patient front view (a) with 3 cm ptosis of the mammary parenchyma, mostly visible in the lateral view (b)
Prosthesis
Tower third of
Lower third of
the Pectoralis
the Pectoralis
Major Muscle
Major Muscle
Fig. 36.2 The lower third of the pectoralis major muscle is Fig. 36.3 The prosthesis is inserted under the lower third of the
undermined, and a pocket is prepared underneath the muscle muscle
preparing a pocket underneath the muscle (Fig. 36.2). (Fig. 36.8). Once dermal tissue is reached, the scal-
The prosthesis is inserted under the lower third of the pel deepens through mammary tissue (Fig. 36.9).
muscle (Fig. 36.3). The final position of the prosthesis Glandular dissection is done (Fig. 36.10) until the
is the upper two thirds subglandular and the lower third muscular fascia and undermining of the Chassaignac
submuscular (Fig. 36.4). space between gland and muscular fascia. Implant
The technique in detail includes preoperative mark- is removed from submuscular plane. Preparation of
ing (Fig. 36.5) of the infraclavicle notch and a straight pocket is done by initial partial splitting of the pecto-
line to the umbilicus. The new position of the nipple ralis major muscle following muscle fibers direction.
(19-20 cm from the notch), the new areola (4-cm size Dissection is done to create an inferior muscular
of diameter) and the inframammary fold are marked. pocket (Fig. 36.11). Suction drainage is placed in the
General anesthesia is used. The new areola submuscular plane (Fig. 36.12). Prosthesis implanta-
is defined with marker (Fig. 36.6). A vertical tion (Fig. 36.13) with the mentor HP highly coesive
incision is used to remove old scar (Fig. 36.7). gel CPG Low 323, 260 mL, is performed. The implant
De-epithelialization is performed with scalpel is positioned in the submuscular pocket after ade-
36 The Inverted Dual Plane Mastoplasty Technique 573
Prosthesis
Lower third of
the Pectoralis Fig. 36.6 New areola defined with marker
Major Muscle
Fig. 36.4 Final position of the prosthesis is subglandular in the

upper two thirds and submuscular in the lower third
Fig. 36.7 Vertical incision to remove old scar

Fig. 36.5 Preoperative drawing: marking the infraclavicle
notch and straight line to umbilicus. A clear asimmetry of the
breast is observed
quate undermining (Fig. 36.14). The split pectoralis is sutured (Fig. 36.17) with 3/0 Vicryl interrupted
muscle sling is sutured to the glandular layer with suture. The deep dermis is sutured with 3/0 Vicryl.
an upward rotation in order to re-create the lower The four cardinal points are sutured for the areola
pole new fold, reinforced (Fig. 36.15). Lower pole (Fig. 36.18). Multiple layers are sutured (Fig. 36.19)
covering is with upward rotation of the split pectora- by interrupted Vicryl 3/0, 4/0, and subcuticular con-
lis major muscle (Fig. 36.16). The lower-pole pocket tinuous Monocryl 4/0.
Fig. 36.9 Once dermal tissue is reached, the scalpel deepens

through mammary tissue
Fig. 36.10 Glandular dissection until muscular fascia and

undermining of the Chassaignac space between gland and mus-
cular fascia. Implant removal from submuscular plane (silicone
smooth gel round implants 220 mL)
Fig. 36.8 (a) De-epithelialization starts in a superficial dermal

layer. (b) De-epithelialization is completed. (c) Care must be
taken to tiny skin island removal
b Fig. 36.12 Prosthesis implantation of Mentor HP highly cohe-

sive gel CPG low 323, 260 mL
Fig. 36.11 Preparation of pocket. (a) Initial partial splitting of

the pectoralis major muscle following muscle fibers direction.
(b) Dissection to create an inferior muscular pocket. Suction
drainage placed in the submuscular plane Fig. 36.13 The implant is positioned in the submuscular pocket
after adequate undermining
The old areola scar is excised (Fig. 36.20). The new

areola is marked (Fig. 36.21). The pectoralis major
muscle is incised following muscle fibers direction
(Fig. 36.22). Monopolar electrocautery is utilized for
splitting the muscle (Fig. 36.23). Partial capsulectomy
is performed after removing the old implant
(Fig. 36.24). After completing the capsulectomy
(Fig. 36.25), suction drainage is positioned in lateral
Fig. 36.14 The split pectoralis muscle sling is sutured to the

glandular layer with an upward rotation in order to recreate the
lower pole new fold, reinforced
Fig. 36.15 Lower pole covering with upward rotation of the Fig. 36.17 Deep dermis suture with 3/0 Vicryl
split pectoralis major muscle
Fig. 36.16 Suturing the lower pole pocket with 3/0 Vicryl Fig. 36.18 Four cardinal points suture for areola
interrupted suture
axilla (Fig. 36.26). The skin is sutured (Fig. 36.27). of round, highly cohesive gel breast implants
The results after 3 and 6 weeks are good (Fig. 36.28). (Fig. 36.29).
2. A -25-year-old patient with bilateral breast
hypotrophy, breast asymmetry, right breast smaller
36.3 Clinical Cases than left, and inframammary crease displacement,
right side higher than left. She had an inverted
1. A 35-year-old patient with mild breast type 2 glan- dual plane technique performed through infra-
dular ptosis and mild breast asymmetry postpar- mammary approach with placement of anatomic
tum underwent the inverted dual plane technique breast implants 320 mL on the right and 280 mL
with inframammary approch, inserting 280 mL on the left (Fig. 36.30).
Fig. 36.19 (a) Multiple

layers suturing by interrupted
a b
Vicryl 3/0 and 4/0, and (b)
subcuticular continuos
Monocryl 4/0
Fig. 36.20 Old areola scar
Fig. 36.22 Pectoralis major muscle is incised following the

direction of the muscle fibers
Fig. 36.21 Marking the new areola

Fig. 36.25 Breast after having completed the capsulectomy
Fig. 36.23 Monopolar electrocautery is utilized for splitting

the muscle
Fig. 36.26 Suction drainage positioned in lateral axilla
Fig. 36.24 Partial capsulectomy is performed after old implant

removal
Fig. 36.27 Sutured to the skin

Fig. 36.28 Early result:

(a) Three weeks
a
postoperative. (b) Six
weeks postoperative

b
a b
Fig. 36.29 (a) Preoperative 35-year-old patient, with mild nique, with inframammary approach. Breast implants selected:
breast type 2 glandular ptosis and mild postpartum breast asym- 280 mL, round, highly cohesive gel implants
metry. (b) Postoperative following inverted dual plane tech-
a b
Fig. 36.30 (a) Preoperative 25-year-old patient with bilateral nique through inframammary approach using anatomical breast
breast hypotrophy, breast asymmetry, right breast smaller than implant 320 mL on the right and anatomical breast implant
left, and inframammary crease displacement, right side higher 280 mL on the left side
than left. (b) Postoperative following inverted dual plane tech-
References 3. Khan UD (2007) Muscle-splitting breast augmentation: a

new pocket in a different plane. Aesthetic Plast Surg 31(5):
553558
1. Regnault P (1977) Partially submuscular breast augmenta-
4. Esposito G, Gravante G, Marianetti M, Delogu D (2006)
tion. Plast Reconstr Surg 59(1):7276
Reverse dual-plane mammaplasty. Aesthetic Plast Surg
2. Tebbetts JB (2001) Dual plane breast augmentation: optimiz-
30(5):521526
ing implant-soft-tissue relationships in a wide range of breast
types. Plast Reconstr Surg 107(5):12551272
Remodeling Breast and Torso
with Combined Fat Liposuction 37
and Grafts
Alfredo Hoyos
37.1 Introduction that it is possible, by careful handling of transplanted

fat, to improve the survival of this tissue. Fat has many
A feminine body that is aesthetically pleasing involves attributes of the ideal filler, although the long-term
different concepts of beauty. These concepts are as old results are technique-dependent, especially on the breast
as humanity itself. A rounded, well-shaped breast, nar- area, achieving divergent results [1]. Also, the concern
row waist, and wider hips are symbols of fertility, of misguidance in cancer detection should be taking
encoded in our human brains to preserve the species. into account [2,3].
The delicate equilibrium between these different ana- The waistline can be easily molded by liposuction.
tomical features has been modified by external factors However, the waist is influenced mostly by the bony
like race, trends and fashion, and ultimately, by health. structures of the rib cage and the hip bones, and above
Mainly the relationship between the breast size and all, of the distance between these two. The more the
shape and the contour of the hip-waist line are the key distance, the narrower the waist can be. The goal is to
for obtaining a good result. narrow the upper back and enhance the hip area to emu-
The improvement of these features can be accom- late the desired hour-glass shape in female, with a wider
plished in many ways. The use of implants in the breast apex on the hip line. To augment the hip region, the
area is the gold standard: the results are aesthetically only option is the use of fillers, specifically fat grafts
pleasant, reproducible, and reliable in most patients. and reshaping through liposuction of the waistline.
Nowadays, there is an increasing demand for aesthetic
enhancement in the breast area; some factors can lead
to think alternatives of implants. The use of fat grafts 37.2 Anatomy (Fig. 37.1)
in the breast area has been spread in recent times.
Using free-fat autologous grafts as a filling material An appealing feminine shape tends to preserve the
was first proposed in 1893 by Neuber, the idea rapidly hour glass, conferring special attention to the breast
gained enthusiasm and endorsements. Since then, fur- and hip areas. The breast has a rounded shape as
ther clinical works by Guerrerosantos [4,5], Bircoll defined by the breast gland contour. Some of the ana-
[6], Coleman [710], and others [1124] have shown tomical features surrounding the breast gland are
important to enhance the shape and the relative volume
of the gland: the triangular area between the subclavic-
ular line in junction with the deltoid muscle, the axil-
lary portion of the gland, or Spence tail; and the area
A. Hoyos
surrounding the lateral pole of the gland, which should
Santa Barbara Surgical Center,
Bogota, Colombia be absent of fat following a lazy S. The breast itself
e-mail: [email protected] for this purpose is divided into upper and lower poles.

586 A. Hoyos
Fig. 37.1 Anatomic areas of

the breast. The upper (blue)
and lower (green) poles. The
subclavicular negative space
(orange). The surrounding
tissue around the gland
(purple)
Fig. 37.2 Hip-thorax distance and ratio, indications for fat requires waist liposuction, in some cases even hip liposuction.
grafting on the short torso (left) combined with waist and upper There is a correlation between the V- (short), square- (intermedi-
back liposuction. Intermediate torso (center), indication for ate). and A-shaped (long) torso with the Hip-thorax distance and
waist liposuction + optional fat grafting. Long torso (right) only ratio
37 Remodeling Breast and Torso with Combined Fat Liposuction and Grafts 587
Fig. 37.3 The axillary and

inframammary crease
approach to multilayer fat
grafting (submuscular,
intramuscular, subglandular).
Notice the upper pole as the
only point for subdermal
filling
The torso is considered as an aesthetic unit that has in the posterior view, and the trochanteric depressions
many factors of influence: one is the full length of the are marked.
torso, so the female torso can be divided into short, Deep layer lipoplasty: Under general anesthesia,
medium, or long. In the hip area, the indication for fat proceed to infiltrate tumescent solution with 1,000 mL
grafting is defined by the relationship between the tho- of normal saline, 50 mL of lidocaine 1%, and 1 ampule
rax and the hip. In a posterior view, the ideal feminine of epinephrine 1:1,000. The ratio of infiltration and
shape is when the thorax is smaller than the hip. There volume of fat removed is approximately 2:1. The aspi-
are three basic contours (Fig. 37.2): ration of fat includes all the major contour deformities.
1. A shape when thorax-hip ratio is < 1 Special attention is paid to the waistline and the lateral
2. Squared when the ratio is 1:1 axillary region.
3. V shape: > 1 Superficial lipoplasty: in the superficial layer, aspi-
Square and V shape are indication for fat grafting. ration sculpting the anatomical muscular lines is per-
Additionally, a V shape should be treated by extensive formed. In VASER patients, it was used in 80% pulsed
liposuction and waist liposuction. Also, the distance mode using a 2.9-mm probe (Sound Surgical Technologies,
between the rib cage versus iliac crest determines the Denver, CO). Subdermal liposuction is performed fol-
indication for fat grafting and/or upper back liposuction. lowing the muscular limits using ventX cannulas (Sound
Surgical Technologies, Denver, CO). This can produce a
better result through a better skin retraction [25,26].
37.3 Surgical Technique
Marking: in stand up position, outline the gland. Mark 37.4 Fat Grafting (Figs. 37.3, 37.4)
the areas that need more projection (specially the supe-
rior pole of the breast), to be treated with fat transplan- Fat is harvested with 4-mm blunt cannula from other
tation. The surrounding area of the breast, essentially sites to an empty sterile bottle trap. One gram of cefa-
the lateral and lower portion, to be resected by liposuc- zoline is added to the trap. Decantation was the only
tion. In the hip area, the point of maximum projection process used to separate the fat cells from the saline
588 A. Hoyos
a b
Fig. 37.4 (a) Preoperative. (b) Postoperative after fat removal grafting has been performed yet. (c) Axillary approach for fat
in the surrounding area of the breast. Notice the improved shape grafting: pinching the pectoralis muscle in order to differentiate
and the augmentation appearance by subtraction of the fat, no fat the supramuscular and submuscular layers
and serosanguineous components. In the breast area,

axillary approach allows fat grafting in the supramus-
cular and submuscular layers. The average of injec-
tion is 100250 mL per side. In the hip region the
access is made by combining lateral and gluteal fold
incisions, with an average of 50150 mL per side.
37.5 Results
The combined multi lamellar lipoplasty plus fat graft- Fig. 37.5 Preoperative left breast and postoperative right breast
ing resulted in safe and effective results (Fig. 37.5) showing the combination of fat removal in the lateral portion
Combined fat grafting and extraction is a safe, low cost, surrounding the breast and the immediate result after fat graft-
ing. In this patient, periareolar reduction was performed
and effective alternative to implants or liposuction
alone. In the hip area, the combination of liposuction
and fat grafting in an anatomical approach led to a more
feminine shape in most patients (Figs. 37.637.10).
a b
Fig. 37.6 (a) Preoperative. (b) Six months postoperative after fat liposuction in a lazy S and grafting in the breast in anatomical
areas, plus fat grafting in the supramuscular and submuscular layers. Periareolar reduction was performed at the same time
a b
Fig. 37.7 (a) Preoperative A

shape in hip-thorax ratio. (b)
Postoperative following only
liposuction in the waistline
and hip areas
590 A. Hoyos

a b
patient with a squared shape
in hip-thorax ratio. (b)
Postoperative after the
combination of fat extraction
in the waist line and fat
grafting in the hip areas
a b

patient with a V shape in
hip-thorax ratio. (b)
Postoperative after the
grafting in the hip areas.
Additional fat extraction was
performed in the thoracic area
to create an hour-glass shape

a b
patient with a V shape in
hip-thorax ratio. (b)
Postoperative following the
grafting in the hip areas.
Additional fat extraction was
performed in the thoracic area
to create an hour-glass shape
592 A. Hoyos
References: 20. Chajchir, A (1996) Fat injection: long-term follow-up. Aesth

Plast Surg 20: 291
21. Pereira LH, Radwansky H (1996) Fat grafting of the buttock
1. Horn GA (2002) New concept in male reshaping: anatomi-
and lower limbs. Aesth Plast Surg 20:409
cal pectoral implants and liposculpture. Aesth Plast Surg
22. Lewis CM (1992) Correction of deep gluteal depression by
26:23-25
autologous fat grafting. Aesth Plast Surg 16: 247
2. Benito-Ruiz J (2002) Buttock implants for male chest
23. Guerrero-Santos J (1996) Long term survival of free fat
enhancement. Plast Reconstr Surg 112:1951
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3. Novack BH (1991) Alloplastic implants for men. Clin Plast
Surg 20:403
Surg 18(4):829-855
24. Toledo L (2001) Fifteen years of fat injections. Presented At
4. Pereira LH, Sabatovich O, Santana KP, Pincanco R (2006)
The XXVIII Colombian Society of Plastic Surgery Annual
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Meeting, Cali, Colombia, November 8-12
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25. Hudson DA, Lambert EV, Bloch CE (1990) Site selection
5. Marks MW, Argenta LC, Izenberg PH, Mes LGB (1991)
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Management of chest wall deformity in male patients with
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26. Moore JH, Kolaczynski JW, Morales LM et al (1995)
cussion 679-681
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6. Marks MW, Argenta LC, Lee DC (1984) Silicone implant
effects of local anesthesia with lidocaine. Aesth Plast Surg
correction of pectus excavatum: Indications and refinement
19:335
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27. Sommer B, Sattler G (2000) Current concepts of graft sur-
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28. Chajchir A (1993) Comparative experimental study of
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Clin Plast Surg 18:823-838
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9. Ersek RA, Schaeferele M, Beckham PH, Salisbury MA
29. Carpaneda CA, Ribeiro MT (1994) Percentage graft viabil-
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Breast Augmentation and
Reconstruction with Fat Transfer 38
Todd K. Malan
38.1 Introduction Procedures Ad-Hoc Committee position paper in

which they deplored the use of autologous fat injec-
38.1.1 The Longstanding Bias Revisited tion in breast augmentation. Their conclusion, which
was merely an opinion of the committee members,
Fat transfer breast augmentation has remained a highly was made without reference to any scientific studies.
controversial procedure following its introduction in Despite this lack of rigorous and objective evalua-
the late 1980s. Lipo-aspiration was in its infancy with tion, nearly all research and experimental studies
protocols and techniques rapidly evolving when in came to a halt.
1987, Bircoll and Novak [1] described the use of mod- In the following decades since, many advances in
erate volumes of lipo-aspirated fat for the purposes fat harvesting and lipo-remodeling techniques have
of breast augmentation and reconstruction. Their resulted in a renewed interest in utilizing fat for breast
attempts to advocate lipo-remodeling of the breast reconstruction and augmentation. The demonstrated
were not well received [24]. Early fat grafting stud- improved viability of grafted fat using strict protocols
ies had demonstrated less than optimal survival such as established by Coleman [5, 6] and the demon-
rates of 2550% leading opponents to conclude that strated ability to differentiate postsurgical change from
multiple lipo-augmentation procedures would be premalignant calcification utilizing the latest standards
required to provide even modest results. In addition, in breast imaging [7] have bolstered the argument to
there was strong disapproval regarding the potential reevaluate this long standing bias. This resurged inter-
risks of microcalcifications and cysts that could interest culminated following the latest ASPS/Plastic
fere with mammography. All despite a lack of good Surgery Educational Foundation task force report of
scientific data to support their concerns and without March 2009 in which was stated that
mention of studies that clearly demonstrated the same Fat grafting may be considered for breast augmentation
concerns of mammographic interference in well- and correction of defectshowever results are dependent
accepted procedures such as breast reduction, recon- on technique and surgeon expertiseFat grafting to the
struction, and augmentation with implants. This breast could potentially interfere with breast cancer
detection; however, no evidence was found that strongly
controversy culminated into the 1987 ASPS New suggested this
Clearly we are witnessing a new era of objective

and scientific-based approach to fat transfer breast
augmentation and at a time when we have the advantage
of utilizing recent advancements in fat harvesting
techniques and the use of adipose-derived stem cell
T.K. Malan, M.D.
Innovative Cosmetic Surgery Centers, Scottsdale, AZ, USA therapy. The future truly looks bright for this alternative
e-mail: [email protected] approach to standard implant augmentation.

596 T.K. Malan
38.2 Operative Technique
38.2.1 Indications
Fat transfer may be considered to be a viable alternative

to implants in the majority of patients seeking
cosmetic breast augmentation. The ideal candidate is
the patient who has developed focal filling defects of
her breast as a result of normal age-related fat atro-
phy, childbearing, breast-feeding, or weight loss. In
these cases, transferred fat acts to merely replace lost
volume. Poor graft survival as a result of hypoxia
caused by tissue tension is for the most part avoided
in these patients with ample empty space. For the
patients seeking to enlarge their breast, certain con-
Fig. 38.1 Breast measurements
siderations should be addressed. A modest increase
of a 12 bra cup size or 220 mL of breast volume
change is a realistic expectation. Fat transfer does not
correct ptosis and is of limited value in tubular defor-
mities without the use of tissue expanders. Fat will
enhance the natural shape of the breast but should not
be used to create the artificial appearance of the
implant that has become so socially accepted and for
some patients a desirable result. A historically sig-
nificant concern had been the availability of ade-
quate fat stores for a graft specimen. This is
becoming less of an issue given the improved viabil-
ity of graft specimen utilizing recent advances in
fat-harvesting technology. Although protocols have
not been widely accepted, it is prudent to con- Fig. 38.2 Preoperative breast marking. Upper of the breast
sider baseline breast mammography, ultrasound, divided into four quadrants and lower into two quadrants.
and magnetic resonance imaging (MRI) evaluation Areas of greatest deficiency noted in green marker. Frequently,
prior to lipo-augmentation. this will be in the upper outer quadrants. The notation above the
left breast is a reminder that 30 mL of extra fat is to be placed in
this smaller breast based on a base width which is 1.5 cm less
than on the right
38.2.2 Preoperative Planning
Patients are provided with preoperative counseling Careful photo documentation and measurements
with an emphasis on ensuring that they understand the should be performed. A determination of the degree of
variability of outcomes inherent with fat transfer due to breast ptosis and asymmetry should be ascertained.
the ability to harvest adequate volumes of fat, the ulti- The base width measurement of the breast will aid
mate fat survival, and the patients own fluctuations of in determining the degree of asymmetry and assist in
weight postoperatively. Patients should understand and calculating the volume of fat needed to correct asym-
agree to the importance of continued annual postoper- metry. The author has found that as a general rule,
ative breast monitoring with mammography, ultra- 20 mL of fat should be used to correct each 1 cm of
sound, and perhaps MRI. A fair and balanced review discrepancy between breast base widths (Fig. 38.1).
of the advantages and disadvantages of the widely The preoperative marking of the breast must be indi-
accepted method of implant augmentation should be vidualized to the surgeons own style, but dividing the
discussed with the patient. breasts into multiple quadrants and clearly marking the
38 Breast Augmentation and Reconstruction with Fat Transfer 597
areas of greatest volume deficit will assist in ensuring

the best aesthetic outcome (Fig. 38.2).
As with any liposuction procedure, fatty deposits that
will be used for harvesting should be well marked and
photo documentation performed. The widely accepted
concept of fat memory should also be considered.
Very commonly patients will have particular fat reserves
that are the first areas in which they gain weight and the
last areas in which they lose weight. These storage cen-
ters can provide a graft specimen that will respond
similarly regardless of its newly transplanted position.
Anesthesia options should be based on the comfort
level of the surgeon and the patients expressed desires.
Fig. 38.3 Reinjection cannula with Leur lock syringe for rein-
In my experience, the majority of patients tolerate
jection. Similar lumen sizes prevent clogging and tissue trauma
adipose harvesting under local tumescent anesthesia
followed by syringe-based fat transfer utilizing tumes-
cent technique with or without a combined breast block [12]. In a recent study [13], manometer testing of a
anesthetic technique. One of the major factors deter- standard lipo-aspiration pump technique resulted in
mining the volume of potential graft to be injected is pressures that exceeded 20 in. Hg. A syringe-based
the free space available in which fat can be placed method utilizing a 60-mL spring or clicker lock
without causing tissue tension leading to hypoxia. resulted in pressures exceeding 18.5 in. Hg. The meth-
Tumescent technique will result in some of this valuable ods described by Coleman of utilizing a 10-mL syringe
space being utilized by the anesthetic media. Con- with no more than a 2 mL of negative pressure result
sideration should be made to tumescence the breast in approximately 3 in. Hg of negative pressure.
early in the procedure utilizing the lowest volume of Clearly the Coleman method appears to be the most
safe high concentration solution to allow a degree of advantageous in regard to minimizing pressure; how-
absorption while harvesting is undertaken. Other seda- ever, this method is considered slow and cumbersome
tion techniques such as general anesthesia or intrave- by many surgeons. More recently, manufacturers
nous (I.V.) sedation may also be considered. have focused on developing equipment to enhance
atraumatic loosening of the fat utilizing ultrasonic,
hydrostatic, and infrasonic forces. The resulting small
38.2.3 Atraumatic Fat Harvesting particulate fat samples thus require less negative pres-
and Preparation sure to harvest and significantly decrease the harvest-
ing time. With these devices, pressures of less than
Recent advancements in lipo-harvesting techniques 10 in. Hg are sufficient to rapidly extract small par-
and equipment have provided the surgeon with many ticulate loose fat.
alternatives to the poor graft survival resulting from
longstanding high-pressure standard cannula extrac- 38.2.3.2 Atraumatic and Anaerobic
tion techniques. Although considerable controversy Fat Handling
exists over the preferred method, in general, it is widely The use of specifically designed and well-made har-
believed that to improve graft survival, consideration vesting cannulas free of internal surface irregularity
should be made to achieving the following: and with distal openings that do not exceed the lumen
diameter of the standard Luer lock will help to mini-
38.2.3.1 Low-Pressure Technique mize trauma to harvested tissue and prevent clogging
of Fat Aspiration during reinjection (Fig. 38.3). Historically, it has been
Several studies have demonstrated the adverse effects a common practice to centrifuge fat in an effort to
on cell viability utilizing high-pressure suction tech- remove excess blood, tumescent solution, and free
niques [811]. It is generally accepted that a pressure oils that could occupy valuable space in the breast and
of less than 15 in. of mercury (inches Hg) is desirable enhance inflammatory response, which may decrease
598 T.K. Malan
(Fig. 38.5). The curved shape and spatulated tip aids in

ensuring the cannula placement in the subdermal and
slightly deeper subcutaneous plane. The cannula is
advanced, and deposition of fat only occurs during with-
drawal. Small syringes help the surgeon to control the
amount of fat deposited as well as the use of a thumb
pump maneuver wherein the surgeon lightly and
intermittently places pressure on the plunger as the
cannula is withdrawn. Although classic fat injection
relies upon intramuscular placement as the preferred
Fig. 38.4 Microdroplet deposition of fat vascular bed, this is largely avoided in fat transfer
breast techniques. Deep muscular injection into the
pectoralis is difficult and results in increased surgical
graft survival. However, even minimal centrifuging risks, postoperative pain, and less than ideal distension.
will lead to torsional damage of the adipocytes [14, 15]. The arborization of vessels near the subdermal layer
Filtering and washing of the fat-utilizing devices such helps to ensure adequate blood supply to graft depos-
as the PureGraft system (Cytori, Inc.) will permit the ited there (Fig. 38.6). In addition, a similar volume of
removal of unwanted excess contaminates and fluid in fat injected superficially will provide greater distention
a sterile-closed system thus avoiding the need for and filling effect then when placed intramuscularly.
harmful centrifuging. Likewise, much smaller volumes of fat are needed to
create the same filling effect of a large submuscular
implant. Placement of fat in the breast parenchyma
38.2.4 Transferring Fat should be avoided. This is not the ideal vascular plane
and may cause unnecessary confusion on breast imag-
Revascularization is essential in promoting graft reten- ing studies. Cysts and calcifications that may occur
tion. Multiple factors must be considered when deter- with subcutaneous placement will aid in the radio-
mining the selection of harvesting tools, fat processing graphic differentiation from premalignant parenchy-
techniques, transfer techniques, and the site of implan- mal disease. Of primary concern is to not overfill the
tation. The overall objective should be the microde- breast. Classic teaching employed the use of over dis-
position of fat into the areas of greatest vascularity. tension to compensate for inevitable loss of some
Appropriate harvesting and preparation should yield degree of graft due to necrosis. This is not ideal in a
small droplets of fat ready for injection. It is essential closed space such as the breast. Overfilling results in
to deposit fat in small individual particles as clumping clumping of fat, necrosis, and increased tissue pressure
will simply result in necrosis (Fig. 38.4). Multilayer inhibiting venous return. Even a few extra mL of fat
injections utilizing 3-mL syringes and transfer cannu- over ideal may result in the death of many times as
las with a single directed small opening assist in con- much fat. Avoid creating a peau dorange effect.
trolling the location and volume of fat placed. The Avoid continuing to inject while the tissue is under
author prefers the use of a curved 2-mm cannula with such high pressure that fat passively extrudes from
a spatulated tip and a single opening directed upward incisions.
Fig. 38.5 Curved 2-mm

cannula with a spatulated tip
and a single opening directed
upward
Fig. 38.6 Fat injected in the

subdermal and immediate
subcutaneous layers. Prevents
fat drifting after injection,
maximizes volume changes,
and improves blood flow to
graft
38.2.5 Technique (Figs. 38.738.18)
Following marking (Fig. 38.2), the fat is removed from

the donor site with the Body-Jet system with Lipocollector
(Eclipse Medical) to harvest the fat under low pressure
(12 in. Hg). Smooth, slow, even passes of harvesting can-
nula with care taken to not torque the tissue or to rapidly
vent cannula causing splash injury as fat rushes into
collector. The Lipocollector drains excess tumescent
solution utilizing a 300-micron filter leaving minimally
Fig. 38.7 Body-Jet system with Lipocollector (Eclipse processed fat (Fig. 38.8). The fat is transferred to the
Medical) being used to harvest fat under low pressure (12 in. PureGraft (Cytori, Inc.) bag where it is washed,
Hg). Smooth, slow, even passes of harvesting cannula with care filtered, and degree of tissue wetness controlled,
taken to not torque the tissue or to rapidly vent cannula causing
splash injury as fat rushes into collector thus avoiding harmful centrifuging (Fig. 38.9 38.10).
Fig. 38.8 (a) Lipocollector

drains excess tumescent
solution utilizing a
300-micron filter leaving
minimally processed fat (b)
Minimally processed fat
ready for transfer to
Puregraft (Cytori, Inc.)
600 T.K. Malan
Fig. 38.9 Fat is transferred to the PureGraft (Cytori, Inc.) bag

where it is washed, filtered, and degree of tissue wetness con-
trolled, thus avoiding harmful centrifuging
With the PureGraft discard bag, free oil, cellular debris,

blood, and excess fluid are discarded. Filtered and
washed fat is transferred into 3-mL Luer lock
syringes.
Periareolar incisions are made with 16-gauge
needle. A syringe with curved, spatulated, 15 cm,
2 mm, and single superficially directed opening is
placed in the immediate subdermal plane and the fat
injected with 3-mL syringes into the subdermal and
subcutaneous layers. First one side is filled, and then
the other side is filled to match the first side.
Fig. 38.10 PureGraft discard bag. Free oil, cellular debris,

blood, and excess fluid are discarded
38.3 Discussion
Recent studies have recognized the importance of use of paracrine signaling and endogenous growth
adipose-derived stem and regenerative cells (ADRCs) factors, ADRCs aid in preventing early graft apopto-
in fat graft survival, repair, and regeneration of dam- sis, macrophage recruitment, and inflammatory
aged tissue, as well as a source for multipotent stem response. Perhaps most promising is the demonstrated
and mesenchymal stromal cells [16, 17]. Through the ability of ADRCs to aid in revascularization of tar-
Fig. 38.13 Syringe with curved, spatulated, 15 cm, 2 mm, and

single superficially directed opening placed in the immediate
subdermal plane
Fig. 38.11 Filtered and washed fat being transferred into 3-mL
Luer lock syringes
Fig. 38.14 Fat injection into subdermal and subcutaneous

layer
Fig. 38.12 Periareolar incisions made with 16-gauge needle Fig. 38.15 Changes seen following injection
602 T.K. Malan
Fig. 38.16 Fat prepared

for injection into 3-mL
syringes. Recording
of volumes used
patient compliance, and the induced temporary tissue

distention can lead the surgeon to incorrectly over-
fill the breast thus leading to venous stasis and graft
hypoxia.
Autologous fat transfer for breast augmentation
and reconstruction is once again a viable option to
traditional implants and reconstruction. Further stud-
ies and continued advances in techniques and tech-
nology are currently progressing at a rapid pace.
Fig. 38.17 Right breast filled
Perhaps soon this longstanding bias will become but
a historical footnote from which valuable lesson may
be learned regarding decisions based on opinion as
opposed to facts.
References
1. Bircoll M, Novack BH (1987) Autologous fat transplanta-
tion employing liposuction techniques. Ann Plast Surg
18(4):327329
Fig. 38.18 Both breasts filled 2. Linder RM (1987) Fat autografting [letter to the editor].
3. Hartrampf CR Jr, Bennett G (1987) Autologus fat from
geted tissue. Although widely used in Europe and liposuction for breast augmentation [letter to the editor].
Asia, these techniques are in their infancy in the United Plast Reconstr Surg 80(4):646
States. Our early results have been encouraging and 4. Ettelson CD (1987) Fat autografting [letter to the editor].
may well have a significant impact on the recognition
5. Coleman SR (1995) Long-term survival of fat transplants.
of fat as preferred filler in the near future. Aesthetic Plast Surg 19(5):421425
Recently, much attention has been given to the use 6. Coleman SR (1997) Facial recontouring with lipostructure.
of external breast tissue expanders to aid in creating Clin Plast Surg 24(2):347367
7. Pierrefeu-Lagrange AC, Delay E, Guerin N et al (2006)
greater potential space for graft placement. Although
Evaluation radiologique des seins reconstruits ayant
interesting in concept, in our experience these devices beneficies dun lipomodelage. Ann Chir Plast Esthet
add significant cost to the procedure and have a poor 51:1828
8. Shippert RD (2006) Autologus fat transfer, standardization. 14. de Pedroza LV (2000) Fat transplantation to the buttocks and
Am J Cosmet Surg 23:2127 legs for aesthetic enhancement or correction of deformities:
9. Hopping S (2001) Autologous fat transfer to the lips. long term results of large volumes for transplant. Dermatol
In: Shiffman MA (ed) Autologous fat transplantation. Marcel Surg 26(12):11451149
Dekker, New York, pp 113125 15. Donofrio LM (2000) Structural autologous lipoaugmen-
10. Niechajev I, Sevcuk O (1995) Long-term results of fat trans- tation: a pan-facial technique. Dermatol Surg 26(12):
plantation: clinical and histologic studies. Plast Reconstr 11291134
Surg 95(5):496506 16. Gimble A, Guilak F (2003) Adipose-derived adult stem
11. Shiffman MA, Mirrafati S (2001) Fat transfer techniques: cells: isolation, characterization, and differentiation poten-
the effect of harvest and transfer methods on adipocytes tial. Cytotherapy 5(5):362369
viability and review of the literature. Dermatol Surg 27(9): 17. Vallee R, Ct JF, Fradette J (2009) Adipose-tissue
819826 engineering: taking advantage of the properties of human
12. Elam MV, Packer D, Schwab J (1997) Reduced negative adipose-derived stem/stromal cells. Pathol Biol 57(4):
pressure liposuction: could less be more? J Aesthet Restor 309317
Surg 5:101104
13. Shippert RD (2009) Vacuum pressures during autologus fat
transfer (AFT): a study of the closed syringe type and other
aspirator pressures. Am J Cosmet Surg 26:230235
The Staple-First Technique
for Simultaneous Augmentation 39
Mastopexy for Moderately
to Severely Ptotic Breasts
Ted S. Eisenberg
The Challenge
39.1 Introduction
Even the most experienced surgeon finds simultaneous

augmentation mastopexy surgery to be very challeng-
ing, so much so that some physicians advocate a staged
approach doing the lift first, followed at least several
months later by the breast augmentation. The goal of
augmentation mastopexy in moderately to severely
ptotic breasts [1, 2] is to remove as much lax skin as
possible after placement of the implants without com-
promising the circulation to the skin. The challenge
(Fig. 39.1) comes from knowing how much tissue to
remove in the face of opposing tissue forces or vectors
[3]: The skin is first stretched out by the implants and
then, during the lift, removed and tightened to make
the breasts as firm as possible.
For many years, Eisenberg did a one-stage or simul-
taneous augmentation mastopexy for moderately to
severely ptotic breasts, using the common skin patterns Fig. 39.1 Opposing vectors: Augmentation stretches skin;
[46] that have been developed to accomplish this goal. mastopexy tightens skin
This approach involved having to do multiple trim-
mings of skin on one breast and back to the other to the final shape before making an incision. The outside
achieve maximum tightness and symmetry. of the skin staples is marked, the staples removed, and
In 2003 Eisenberg reversed the approach of draw- then the skin deepithelialized within these marks. This
ing a pattern, deepithelializing skin within the pattern, area to be deepithelialized is much greater than any
and then tailor tacking tissues together [7]. Now the prior pattern.
tailor tack of all the tissues is used first to previsualize This approach eliminates multiple skin trimmings
and simplifies the challenge. It allows the surgeon to
accurately determine the amount of tissue to be
removed regardless of the implant size, degree of pto-
sis, and quality of tissue [8]. It also provides maximum
T.S. Eisenberg
Nazareth Hospital, 2375 Woodward Street, Suite 102,
tightening without compromising circulation to the tis-
Philadelphia, PA, 19115 USA sues and addresses any degree of asymmetry without
e-mail: [email protected] relying on any predetermined pattern.

606 T.S. Eisenberg
Fig. 39.2 The preoperative Suprasternal

markings are made in the a Notch
sitting position. Note that
the inframammary markings
Bisecting Line
are made with the arms raised
m
3c
-2
Horizontal cm
Line of Apex 21
of New NAC
2 cm above
Nipple Mark
Inframammary
Crease
(IMC)
Lateral Medial
8cm - 9cm lines
Inframammary Marks with Arms Raised
39.2 Technique partially resemble the inverted-T pattern [9], they are
only guidelines and not an actual pattern.
39.2.1 Preoperative Markings Each breast should be bisected with a line regardless
of the position of the nipple (Fig. 39.2). This line cor-
The patient should be marked while in the standing or relates with the center of the width of each breast. The
sitting position. Although my preoperative markings nipple position is marked (approximately 1921 cm for
39 The Staple-First Technique for Simultaneous Augmentation Mastopexy for Moderately to Severely Ptotic Breasts 607
shorter women and 2123 cm for taller women) from

the suprasternal notch to this bisecting line. I cross-
reference the nipple location made on the bisecting line
by placing my finger behind her breast at the inframam-
mary crease (IMC) and projecting an imaginary point
from there to the anterior surface of the breast. I then
pick whichever is the higher point, between the bisect-
ing nipple location and the anterior projected point for
the new nipple position. While nipple location should
be tailored to the individual, a sternal notch-to-nipple
distance of 2123 cm and an inferior limb distance of
57 cm have been considered average or desirable mea-
surements [10].
The apex of the new nipple areolar complex (NAC)
is marked 2 cm above the nipple mark on the bisecting
line. In order to identify this apex mark of the new
NAC position after tailor tacking, a horizontal line is
Fig. 39.3 Breast augmentation is performed with saline
drawn at this time to designate this upper limit of the implants in a subpectoral (dual plane) position
nipple placement. Lines are drawn from the apex of
the new NAC to either side of the existing areola;
these lines should measure approximately 89 cm. The augmentation is always done prior to mastopexy.
These guidelines will eventually represent the vertical The implants are placed in the dual plane (subpec-
distance from the apex of the NAC to the IMC (4 cm torally) through the central area of the IMC line; the
for the NAC and approximately 45 cm from the base incision is approximately 34 cm with saline implants
of the NAC to the IMC). and 56 cm with silicone gel implants. This incision
The best way to mark the medial and lateral edge lim- is closed with 2-0 and 4-0 Vicryl (Fig. 39.3). The skin
its of the (IMC) incision is to have the patient raise her is not closed at this time. I have used a range of saline
arms above her head. Then a mark is made where the implants from 375 to 775 mL, with an average of
breast fold meets the IMC medially and laterally, and a 500 mL, and with the greatest asymmetric disparity in
line is drawn to connect these two marks in the IMC. a patient being 225 mL (left breast 700 mL, right breast
This is the maximum horizontal component of the 475 mL).
inverted T. Eisenberg often shortens the edge limits
approximately 1 cm on each side.
39.4 Mastopexy: Invagination of Tissues
and Stapling
39.3 Intraoperative Preparation
and Augmentation Then, mastopexy begins (Figs. 39.439.6) by placing
three surgical staples (Weck Visistat 35W-Teleflex
The patient is placed in the supine position with arms Medical; Research Triangle Park, NC): one at the
abducted 90 from her sides to create maximum stretch medial and one at the lateral edges of the newly drawn
of the breast skin. I believe it is critical to do this so inframammary line and one at the apex of the new
excessive skin is not resected. Antiembolic lower NAC. I do this instead of drawing the actual inverted-T
extremity sequential compression devices are placed pattern; I then use these three marks as the starting
prior to the patient being anesthetized. Also, 5,000 points of my stapling.
units of subcutaneous heparin are given to minimize The distal point of the medial 89-cm line (drawn
the chance of pulmonary embolism. A Foley catheter to the existing areola) is stapled to the middle of the
and perioperative antibiotics are used, and postopera- newly drawn IMC (MM1) (Figs. 39.7 and 39.8). Then,
tive nausea and vomiting (PONV) [11] precautions are the distal point on the lateral line (Figs. 39.7 and 39.9)
administered. is stapled to the same place (LL1). The redundant
608 T.S. Eisenberg
a b
Fig. 39.4 The apex of the new nipple areola complex (NAC) is stapled first
a b
Fig. 39.5 The medial border of the inframammary crease (IMC) is stapled second
a b
Fig. 39.6 The lateral border of the IMC is stapled third

Fig. 39.7 After the distal
Bisecting Line
point of the medial and lateral
areolar line is stapled to the
center of the IMC, first lateral
and then medial invagination
of breast tissues and stapling
commence
Apex
Staple
Lateral Medial
Direction of
invagination
and stapling
L M
Lateral L1 M1 (IMC)
(IMC) Medial
Staple Staple
Middle of the IMC incision
a b
Fig. 39.8 The medial areolar line is stapled to the middle of the IMC
breast tissue is then pulled and invaginated in an inf- The same process of invagination and stapling,
eromedial direction (Fig. 39.10), and stapled from the whether by fingers or with forceps, is performed from
lateral IMC staple to the middle of the IMC. This the apex of the new NAC in an inferior direction to the
sequence of stapling allows maximum lateral tighten- middle of the IMC, keeping the nipple buried and out of
ing and maintains maximum medial breast fullness. harms way (Fig. 39.12). The same sequence is followed
This process is then repeated from the medial staple to on the opposite breast. Excess tissue (a dog-ear) com-
the middle of the IMC (Fig. 39.11). This allows for the monly appears at the NAC apex staple. To smooth and
greatest projection of the breast mound. flatten it, the apex staple is pulled in an inferolateral
610 T.S. Eisenberg
Fig. 39.9 The lateral areolar line is stapled to the middle of the
IMC b
b
Fig. 39.11 (a) Medial breast invagination and (b) stapling.
This creates maximal breast projection
direction and stapled. The same apex staple is then

pulled in an inferomedial direction and stapled
(Fig. 39.13). This maneuver reduces a bunching of
excess tissue at the apex of the new NAC.
A nipple areola marker (3842 mm), or cookie
cutter, is bathed with methylene blue using a Q-tip
and placed on the breast mound; the 12 oclock posi-
tion of the cookie cutter coincides with the apex staple
(Fig. 39.14). Both breasts and nipple positions are
checked for symmetry.
With a sterile skin marker, all of the staples are
outlined in one continuous line (Fig. 39.15). It is
Fig. 39.10 (a) lateral breast invagination and (b) stapling. This not necessary to draw a line below the staples at
creates medial fullness the IMC, because the IMC line was already drawn
preoperatively. To assist in reapproximation, guideline 39.5 Deepithelialization

marks are placed medially and laterally at the base
of the NAC (X, X1) and again approximately 4 cm The skin of one breast is infiltrated with a local anes-
inferior to the NAC at the juncture of the inverted T thetic containing a vasoconstrictor of 1:400,000 epi-
(Y, Y1). nephrine. To minimize compromising the circulation
All staples are then removed (Fig. 39.16). to the nipple, infiltration around the NAC is not done.
a a
b
b
Fig. 39.12 (a) Central breast invagination and (b) stapling. Fig. 39.14 New areola position is marked
from apex to IMC
Fig. 39.13 Apex suture is stapled to manage dog-ear Fig. 39.15 (a, b) The staples are then outlined with a skin marker,
and guideline marks (X, X1, Y, Y1) are made
612 T.S. Eisenberg

b
Bisecting Line
Horizontal
Line of Apex
of New NAC
Apex
Staple
Lateral Medial
Cookie Cutter
for New NAC
X X1
Y Y1
Lateral Medial
Staple Staple
The existing NAC is minimally stretched to prevent orientation of the nipple and reapproximation of the
excessive flattening and then marked with the cookie nipple to its new position.
cutter. Next, the new NAC is tattooed in the 12, 3, The cookie cutter mark is now incised with either a
6, and 9 oclock positions with a 20-gauge needle 10- or 15-blade scalpel. Next, the skin within the new
and methylene blue. This is done to facilitate proper staple markings not outside the markings is incised
with a 10-blade scalpel. Then, deepithelialization is

performed inferiorly to superiorly in a one-piece en
bloc resection with hemostats and a 20-blade scalpel;
of course, care is taken not to deepithelialize the nipple
itself (Fig. 39.17).
For easier closure, the cautery is used to make
a relaxing incision through the dermis to allow mob-
ilization of the NAC and the skin. These relaxing
incision areas are approximately 0.5 cm in from the
medial and lateral limbs and 2 cm below the NAC
(Fig. 39.18).
Fig. 39.16 All staples are removed
Bisecting Line
A
Lateral Medial
G1 G1
D2
D A1
X x1
E G G E1
D1
C B
Y Y1
H F
Fig. 39.17 (a) The shaded

area of the diagram represents C1 B1
the skin to be resected.
(b) The corresponding
pictures show this area of
skin, (c) which has been H1 F1
deepithelialized in one step
(en bloc). Notice the nipple
has been preserved Middle of the IMC incision
614 T.S. Eisenberg
b with 3-0 Vicryl (Ethicon) (AA1). The inferomedial point

(BB1) of the medial limb is sewn with 3-0 Vicryl suture
to the middle of the IMC and reinforced with an adjacent
suture. Next, the inferomedial point of the lateral limb is
sutured in a similar fashion (CC1). The 6 oclock posi-
tion of the NAC is then sutured with 3-0 Vicryl to the
superior medial aspect of both the medial and lateral
limbs as a corner stitch (DD1D2). Then, the medial
and lateral limbs (EE1), which represent the vertical
component from the base of the NAC to the IMC, are
approximated to each other with buried 3-0 Vicryl suture
in an interrupted fashion. This is followed by alternating
closure between the medial segment (FF1) of the IMC,
the quadrants of the NAC (GG1), and the lateral segment
(HH1) of the IMC, also in an interrupted fashion. The
skin is approximated with 5-0 Monocryl (Ethicon) in a
running suture along each segment. Attention is then
turned to the other breast, duplicating the entire technique,
c starting again with the infiltration.
The NACs should be pointing downward app-
roximately 510 because the vertical limb from the
NAC to the IMC will stretch sometimes twice its ini-
tial distance of 45 cm to 810 cm. This causes the NAC
to eventually have the illusion of being raised upward.
39.7 Dressings and Final Result

The incisions are dressed with dry sterile Steri-Strips
(1/2 4 in. Suture Strip Plus, Derma Science, Princeton,
NJ) (Fig. 39.19i), Bacitracin-impregnated Adaptic
gauze, and an ABD pad secured loosely with 3-in.
paper tape. Drains were not used for this patient and, in
general, are not recommended. Patients are placed in
their support bras in the recovery room.
Postoperatively, the implants are pressed flat and
high by being in a limited space, flattened by the pec-
toral muscle, and raised by the mastopexy. It takes
approximately 912 months to see the final settled
position of the implant and breast shape, but approxi-
mately 80% of the appearance is apparent at 3 months
(Figs. 39.2039.22).
Fig. 39.18 Relaxing incisions are made through the dermis as
described
39.8 Possible Complications

39.6 Skin Closure (Fig. 39.19)
The downside of the modified inverted-T closure
Special attention is then paid to the sequence of skin clo- is that it is not uncommon to have a small area of
sure, which is performed first in the areas of highest tissue dehiscence at the juncture of the inverted T in the
tension. The 12 oclock position of the NAC is sutured inframammary fold. In my experience, the largest area
Bisecting Line
Horizontal
Line of Apex
of New NAC
(A-A1)
Lateral Medial
(G-G1) (G-G1)
(D-D1-D2) corner stitch
X X1
(E-E1)
Y Y1
(B-B1)
(C-C1)
(H-H1) (F-F1)
Fig. 39.19 (a) In alphabetical order, all corresponding points are 6 oclock position of the NAC to the superomedial/superolateral
reapproximated from the areas of tightest to loosest closure with skin points, correlating to DD1D2. (f) Medial limb closure
subcutaneous 3-0 Vicryl suture. (b) The 12 oclock position of the correlates to EE1. (g) Subcutaneous closure with 3-0 Vicryl
areola suture in the picture correlates to AA1. (c) Inferomedial suture alternates between the areas designated FF1, GG1, and
skin closure correlates to BB1. (d) Inferolateral skin closure HH1. (h) Subcuticular closure with 5-0 Monocryl suture. (i)
correlates to CC1. (e) A corner suture reapproximates the Steri-Strip closure
616 T.S. Eisenberg
b c
d
e
measured approximately 1 cm and spontaneously than the outside lines, this skin dehiscence may have
healed within a couple of weeks with the use of topi- been prevented. Placing the arms in abduction may
cal Silvadene. Eisenberg attributes this complication also help minimize this complication.
to having been more aggressive in the initial surgeries Scar hypertrophy is rare, but if it develops, it can be
with the skin resection. By following the inside lines managed with topical creams, such as Mederma, or
(of the new marking made around the staples) rather topical compression with gel sheets. Another approach
h i
a b
Fig. 39.20 (a) Preoperative 36-year-old, 5-foot and 5-inch, 145-lb patient. (b) Ten months postoperative following bilateral aug-
mentation/mastopexy with 575-mL (left) and 625-mL (right) saline implants
is an intradermal steroid injection with Kenalog-10, sualization, which assists in creating more symmetry.
with or without surgical excision of the scar. There was no recurrent ptosis. Some surgeons have
One study suggests that major complications can expressed concern that removing only skin for the
occur, such as skin or nipple loss [12]. The most mastopexy may not provide enough support to the
common complications reported in one series of 186 lifted breast and may possibly allow for bottoming
augmentation mastopexy patients [13] reviewed were out. In fact, it has been suggested that interposition-
saline implant deflation (5.9%), areola asymmetry ing a dermal graft might minimize or eliminate recur-
(2.7%), recurrent ptosis (1.92.2%) [14], capsular rent ptosis [15]. The Eisenberg has not found this
contracture (2.2%), and poor scarring (2.2%), and the bottoming out to be the case and suggests that per-
overall revision rate over a 42-month follow-up period haps the current methods and patterns do not permit
was 16.6%. The revision rate for 150 mastopexy-only for the maximum resection of tissues. Maximum
patients with a 3-year follow-up was 8.6%. Their con- resection is needed to compensate for the natural
clusion is that this procedure is safe and effective. limited stretching of the vertical component (or NAC
Eisenberg had no incidences of nipple areolar to IMC distance), which is the culprit area of recurrent
malposition because the approach allowed for previ- ptosis or bottoming out.
618 T.S. Eisenberg
a a
b b
c c
Fig. 39.21 (a) Preoperative. (b) Thirteen days postoperative. Fig. 39.22 (a) Preoperative. (b) Three months postoperative.
(c) One month postoperative. Shows an early progression of (c) Nine months postoperative. Shows a later progression of
breast shape that is a reflection of the muscle relaxing and the breast shape
skin stretching
39.9 Discussion implant. Also, there is less chance of capsular contraction

and less interference with mammographic evaluation.
In the staple-first approach, tailor tacking with staples Furthermore, subpectoral placement may be preferable
permits maximum skin tightening and allows for pre- for women with thin or weakened breast tissue. There
visualization of symmetry before a one-piece skin is also less chance of infection [18]. The final closure
resection. Stapling should precede any committed resembles that of the inverted T, which is preferred
excisions of the planned skin designs [16]. because the horizontal scar in the IMC can be minimal
Previsualization by stapling gives the surgeon an and the closure allows for adequate vertical raising of
extra measure of reassurance and confidence that the the NAC and horizontal shortening of the lower breast.
tissues will come together, the vascular supply of the One study, with a patient satisfaction rate for the
tissues will not be compromised, and the breasts will inverted T of 92%, reported that this technique was
be symmetric. Plus, by eliminating the need for multi- advantageous in getting a better aesthetic result because
ple skin trimmings, the procedure is quicker. it compensated for the excess skin laterally in the infra-
The modified inverted-T pattern is preferred to be mammary fold and significantly corrected the mam-
used as a guideline for mastopexy deepithelialization; mary tissue in both the superior and inferior mammary
however, a surgeon can choose whatever pattern he or poles [2].
she prefers and still utilize the staple-first technique to This versatile stapling technique allows for the use
get the maximum resection of tissue. A disadvantage of of a wide variety of implant sizes. This technique has
preoperative skin markings drawn not as a guideline but also been used for patients who had bilateral mas-
as a template for deepithelialization is that these pat- topexy only. It is also useful in correcting asymme-
terns can stretch dramatically when the implants are tries, for example, a unilateral hypomastia and/or a
placed, thereby rendering the markings obsolete [17]. unilateral ptosis. This previsualization technique might
The staple-first approach is effective for both augmen- prove useful in other areas of cosmetic surgery where
tation mastopexy and straight mastopexy. To determine bilateral symmetry is the goal, such as a facelift or
which surgery is needed, at the preoperative consultation, brachioplasty.
the patients are asked, When you are standing in front of
a mirror with your bra on, are you happy with the size of
your breasts and how you fill out your bra, or do you wish
39.10 Conclusions
they were a little bigger? If the response is, I am happy
with how I look in my bra, then Eisenberg recommends
The staple-first technique takes the guesswork and
mastopexy only. If the desire is to be bigger, then mas-
anxiety out of augmentation mastopexy. With the
topexy with augmentation are combined. On occasion, a
adage of measure twice, cut once, it is very comforting
woman wants to be smaller, then mastopexy is discussed
to preview the end result before having to cut skin
with a small breast reduction.
when performing this complex surgery. This approach
The implant should always be placed before any tis-
has significantly simplified what was for me a very
sue is removed for mastopexy [16]. Eisenberg has
challenging operation, allowing me to achieve consis-
found, and it has been reported, that at times after
tent symmetry regardless of the implant size used or
implantation, there is a false sense of adequate lifting
the amount of skin to be resected.
of the NAC and breast when the patient is supine as
opposed to sitting up. You should proceed with the
preplanned mastopexy and not let this implant place-
ment change your mind. If mastopexy is not performed, References
the preoperative ptosis will reappear when sitting [2].
Although implants can be placed in the subglandu- 1. Regnault P (1976) Breast ptosis. Definition and treatment.
lar plane, I preferred to place them in the subpectoral 2. Cardenas-Camarena L, Ramirez-Macias R (2006)
dual-space plane, because it looks more natural when Augmentation/mastopexy: how to select and perform the
the pectoralis muscle covers the upper portion of the proper technique. Aesthetic Plast Surg 30(1):2133
620 T.S. Eisenberg
3. Spear SL, Giese SY (2000) Simultaneous breast augmentation 12. Spear S (2003) Augmentation/mastopexy: surgeon, beware.
and mastopexy. Aesthetic Surg 20:155164 Plast Reconstr Surg 112(3):905906
4. Wise RJ, Ganon JP, Hill JR (1963) Further experience with 13. Stevens WG, Stokes DA, Freeman ME, Quardt SM, Hirsch
reduction mammoplasty. Plast Reconstr Surg 32:1220 EM, Cohen R (2006) Is one-stage breast augmentation with
5. Kirwan L (2007) Breast autoaugmentation. Can J Plast Surg mastopexy safe and effective? A review of 186 primary
15(2):7376 cases. Aesthet Surg J 26(6):674681
6. Regnault P (1966) The hypoplastic and ptotic breast: a com- 14. Stevens WG, Freeman ME, Stoker EA, Quardt SM, Cohen
bined generation with prosthetic augmentation. Plast R, Hirsch EM (2007) One-stage mastopexy with breast aug-
Reconstr Surg 37(1):3137 mentation: a review of 321 patients. Plast Reconstr Surg
7. Whidden PG (1978) The tailor-tack mastopexy. Plast 120(6):16741679
Reconstr Surg 62(3):347354 15. Karacaoglu E (2009) Single stage augmentation mastopexy:
8. Parsa AA, Jackowe DJ (2010) A new algorithm for breast a novel technique using autologous dermal graft. Ann Plast
mastopexy/augmentation. Plast Reconstr Surg 125(2):75e77e Surg 63(6):600604
9. Marchac D (1990) Reduction mammoplasty with a short 16. Spear SL, Dayan JH, Clemens MW (2009) Augmentation
horizontal scar. In: Goldwyn R (ed) Reduction mamma- mastopexy. Clin Plast Surg 36(1):105115
plasty. Little, Brown and Co, Boston, pp 317336 17. Pinsky MA (2005) Radial plication in concentric mastopexy.
10. De la Torre JI, Vasconez LO (2005) Breast mastopexy. Aesthetic Plast Surg 29(5):391399
Available at: http://emedicine.medscape.com/article/1273551- 18. Eisenberg TS (2009) Silicone gel implants are back so
overview. Accessed 16 Dec 2008 what? Am J Cosmet Surg 26:57
11. Eisenberg TS (2008) Breast augmentation: minimizing post-
operative nausea and vomiting (PONV), maximizing patient
satisfaction. Am J Cosmet Surg 25:264268
Circumareolar Nipple-Areola Complex
Mastopexy and Areolar Shifting 40
Robert A. Shumway
40.1 Introduction
Cosmetic breast surgery has become an extremely

important and pervasive global phenomenon. Virtually,
all aesthetic surgeons who practice this amazing sur-
gical art of breast enhancement possess one vitally
important and common goal, i.e., we try to make each
and every pair of human female breasts appear attrac-
tive and symmetrical. Lejour said breast surgery is one
of the most difficult operations in cosmetic surgery
because we should produce a beautiful, symmetrical,
and durable result with minimal scars [1]. Therefore, it
behooves every cosmetic breast surgeon to become an Fig. 40.1 A semicircular or a complete/full circle intradermal
incision is appropriately designed around the NAC and excised
expert in creating aesthetic looking breasts without
in the shape of a crescent or donut
excessive scarring. The circumareolar and periareolar
lifts have been developed and designed to achieve
this rather lofty goal.
Periareolar and circumareolar mastopexy surgeries
are utilized to optimize the position, shape, size, sym-
metry, and location of the nipple-areolar complex
(NAC) on breast mounds. A semicircular or a com-
plete/full circle intradermal incision is appropriately
designed around the NAC and excised in the shape
of a crescent or donut (Fig. 40.1). The resulting
breast skin envelope defect retains the reticular dermis
fully intact for a suitable and strong closure (Fig. 40.2).
The wound is securely closed with several layers of
sutures in a way that will afford a shift in the posi-
tion, shape, or size of the NAC (Fig. 40.3). The result- Fig. 40.2 The resulting breast skin envelope defect retains the
ing translocation of the NAC should produce a more reticular dermis fully intact for a suitable and strong closure
favorable NAC shape and an improvement in the

R.A. Shumway
appearance of the breast (Fig. 40.4).
Surgery, Scripps Memorial Hospital Campus, HM Poole
Building, La Jolla, CA, USA Furthermore, breast augmentation coupled with
e-mail: [email protected], [email protected] Benelli or crescent mastopexies is also a very compatible

622 R.A. Shumway
a b
Fig. 40.3 (a, b) The wound is securely closed with several layers of sutures in a way that will afford a shift in the position,
shape, or size of the NAC
a b
Fig. 40.4 (a) Preoperative. (b) Postoperative the resulting translocation of the NAC should produce a more favorable NAC shape and
an improvement in the appearance of the breast
procedure. An augmented breast may need NAC NAC size and position on properly sized breast mounds
repositioning or shaping because the larger breast will possessing well-camouflaged scars.
now exhibit different physical proportions and dimen-
sions. Thus, improved breast appearance and geometry
is an achievable goal of the coupled NAC Shift and 40.2 Technique
breast augmentation operation (Fig. 40.5) [2].
The Benelli concentric mastopexy is highly useful Anesthesia for NAC mastopexies is relatively simple.
because it is surgically reproducible and always repeat- Monitored conscious sedation anesthesia in a certified
able [3]. Cosmetic surgeons from all around the world surgical facility coupled with local anesthesia is the
can master these aesthetic techniques and surgically authors choice of anesthesia options because local
repeat this procedure without creating extensive cica- injections are painful. To be sure, it is very wise to
trix. This type of lift and shift is very effective for minimize or eliminate any patient discomfort from all
patients who possess pseudoptosis, glandular ptosis, or cosmetic breast surgery. Local intradermal infiltration
Grade I ptosis (Fig. 40.6). Even Grade II ptosis can of the previously marked periareolar skin is accom-
be adequately treated with the circumferential NAC plished by using a thin 27-gauge needle and injecting
mastopexy matched with a suitable breast implanta- 1% lidocaine with 1:100,000 epinephrine buffered
tion [4]. This combination can create a very satisfac- by a one-tenth volume of 8.4% sodium bicarbonate
tory cosmetic result (Fig. 40.7). In short, the overall solution. After waiting a full 10 min, a sterile breast
beauty of female breast appearance is greatly improved procedure, complete with intravenous (IV) access and
by achieving bilateral symmetry with appropriate perioperative antibiotics, is now initiated.
40 Circumareolar Nipple-Areola Complex Mastopexy and Areolar Shifting 623
Depending on circumstances, excision of periareolar communication), one breast will usually require more
skin can be great or relatively small for circumareolar skin excision relative to the contralateral side (Fig. 40.9).
mastopexy (Fig. 40.8). Because there is always asym- Accordingly, even after appropriate augmentation, the
metry between breasts, i.e., Breasts are sisters, not breasts will still possess some asymmetry. Therefore, the
twins (Mangubat AE, American Board of Cosmetic breast with the most NAC ptosis or asymmetry is always
Surgery Review Course, Dallas, March 4, 2000, personal lifted or shifted first followed by a matching lift to the
other side. As a general rule of thumb, a nipple posi-
tion that is centered on the breast mound and located about
midway between the elbow and the shoulder will usually
provides a nice aesthetic result. Please remember that
after the first breast has been lifted and secured by a
strong suture closure, the opposite NAC is lifted and/or
shifted to match the position and size of its sister.
Circumareolar lifts come in all sizes (Fig. 40.10).
Of course, breasts with a very high degree of ptosis
will require much greater breast skin excision and sub-
sequent lift. However, a standard half-depth crescent
skin incision (semicircular in nature) may be all that is
required to rotate or medialize a moderately asymmet-
Fig. 40.5 Improved breast appearance and geometry is an rical NAC into a better overall position (Fig. 40.11).
achievable goal of the coupled NAC shift and breast augmenta- This half-depth skin incision and subsequent upper
tion operation
Fig. 40.6 This type of lift and shift is very effective for patients who possess pseudoptosis, glandular ptosis, or Grade I ptosis.
(a) Preoperative. (b) Postoperative
624 R.A. Shumway
a b
Fig. 40.7 Circumferential NAC mastopexy matched with a suitable breast implantation can create a very satisfactory cosmetic
result. (a) Preoperative. (b) Postoperative
Fig. 40.8 Depending on circumstances, excision of periareolar Fig. 40.10 Circumareolar lifts come in all sizes
skin can be great or relatively small for circumareolar mastopexy
Fig. 40.9 Because there is always asymmetry between breasts, Fig. 40.11 A standard half-depth crescent skin incision (semi-
one breast will usually require more skin excision relative to the circular in nature) may be all that is required to rotate or medialize
contralateral side a moderately asymmetrical NAC into a better overall position
Fig. 40.12 The strong dermal connection to the superficial tho- Fig. 40.14 A superior-medial periareolar incision for breast
racic fascia (STF), the periareolar wound closure itself is very implantation can be utilized. and the NAC incision is camou-
supportive which creates the lift without undermining breast skin flaged within a crescent or en bloc lift
Fig. 40.13 The TUBA approach to eliminate dissection through

breast parenchyma
Fig. 40.15 After deepithelialization at the papillo-reticular

skin removal will leave the reticular dermis in place dermal junction, a white fibrous blanket of reticular dermis is
available for secure closure
as the papillary dermis and epidermis are removed.
The resultant denuded skin defect is a tough reticular through breast parenchyma (Fig. 40.13). However, a
dermis consisting of a strong bed of collagen fibers superior-medial periareolar incision for breast implan-
that are closely attached to the underlying breast fat. tation can be utilized, and the NAC incision is camou-
This remaining deep dermis is tightly bound to the flaged within a crescent or en bloc lift (Fig. 40.14).
underlying superficial layer of the anterior superficial After deepithelialization at the papillo-reticular
thoracic fascia (STF) while Coopers ligaments link dermal junction, a white fibrous blanket of reticular
this fascia through the breast and into the deep layer of dermis is now available for secure closure (Fig. 40.15).
the STF [5]. As a result of this strong dermal connec- The surgical orientation and closure of the resulting
tion to the STF, the periareolar wound closure itself is donut or crescent can now be used to achieve several
very supportive which creates the lift without under- desirable results. These advantages may include NAC
mining breast skin (Fig. 40.12) [6]. reduction, NAC lifting, NAC reshaping, and NAC
The periareolar mastopexy is often used in con- shifting in any desirable direction. Additionally, any
junction with breast augmentation. The author often combination of the above actions is possible for the
uses the TUBA approach to eliminate dissection best cosmetic result (Fig. 40.16).
626 R.A. Shumway
Fig. 40.16 NAC reduction, NAC lifting, NAC reshaping, and Fig. 40.18 The author uses the circumareolar and the extended
NAC shifting in any desirable direction in any combination is crescent approach in order to achieve the most favorable results
possible for the best cosmetic result
Fig. 40.17 The diameter and circumference of each NAC must Fig. 40.19 The surgical goal is to create an even closure with-
be carefully measured and evaluated out excessive skin pucker
The diameter and circumference of each NAC must

be carefully measured and evaluated (Fig. 40.17). The
arc length of the crescent, extended crescent, or Benelli
lift will determine the extent of NAC movement and
shape of the closure. The author uses the circumareolar
and the extended crescent approach in order to achieve
the most favorable results (Fig. 40.18). The circumareo-
lar Benelli lift may also require a purse-string suture clo-
sure technique in addition to routine closure techniques.
However, it is important to know that the purse-string
suture closure technique may contribute to unfavorable
NAC deprojection. Regardless of this concern, the surgi-
cal goal is to create an even closure without excessive
skin pucker (Fig. 40.19). Since we are sewing a larger
circle to a smaller circle or a long semicircle to a shorter
Fig. 40.20 Since a larger circle is sewn into a smaller circle or
semicircle, there will always be some minor skin pleat- a long semicircle to a shorter semicircle, there will always be
ing of the tissues (Fig. 40.20). Fortunately, subsequent some minor skin pleating of the tissues
a b
Fig. 40.21 Subsequent and progressive healing with a tincture of time will smooth out any minor tissue irregularity
a b
Fig. 40.22 Six- to nine-centimeter lifts are possible with extensive circumareolar lifts used upon larger breasts. (a) Preoperative.
(b) Postoperative
and progressive healing with a tincture of time will superficial as the stitch moves toward the epidermis
smooth out any minor tissue irregularity (Fig. 40.21). of the NAC (small circle). Next, include a generous
The shape, position, and extent of the breast skin horizontal bite into the larger circles dermis in order
closure will determine your initial closure result. to evenly close the large circle to the small circle as
For example, 6- to 9-cm lifts are possible with exten- the closure proceeds to completion (Fig. 40.24). A
sive circumareolar lifts used upon larger breasts permanent running 2-0 or 3-0 subcuticular nylon can
(Fig. 40.22). Interestingly, there are many different be used in a purse-string fashion for improved clo-
types of closure methods and a plethora of closure sure and reinforcement. Alternatively, several subcu-
materials, but a first- and second-layer closure of run- ticular nylon pull through sutures may be used and
ning and interrupted monofilament sutures seems to later removed after several weeks of wound healing
function best. Braided suture, such as Vicryl, is not (Fig. 40.25). Smaller 5-0 or 6-0 running or simple
used because it may eventually erode through the interrupted nylon sutures may be added superficially
skin and later extrude before it fully dissolves. A to reinforce and reapproximate the epidermis, as
combination of interrupted 2-0, 3-0, and 4-0 Monocryl needed, for perfect closure (Fig. 40.26). Also, during
sutures can be used to first tack the wound together closure, the bimanual anti-tension pinch maneuver
(Fig. 40.23). It is important to bury the suture knots from your surgical assistant is paramount for obtain-
with an initial deep dermal bite that becomes vertically ing the best closures.
628 R.A. Shumway
Fig. 40.23 A combination of interrupted 2-0, 3-0, and 4-0 Fig. 40.25 Several subcuticular nylon pull through sutures
Monocryl sutures can be used to first tack the wound together may be used and later removed after several weeks of wound
healing
Fig. 40.24 A generous horizontal bite into the larger circles

dermis in order to evenly close the large circle to the small circle
as the closure proceeds to completion
There are several helpful supportive and protective

dressings that will help promote excellent would
healing. After suture closure of the NAC, use several
one-half-inch wide, flesh-colored, sterile, anti-tension Fig. 40.26 Smaller 5-0 or 6-0 running or simple interrupted
strips on the clean and dry incision. Suitably, cut nylon sutures may be added superficially to reinforce and reap-
Telfa covered by clear Opsite works well to keep the proximate the epidermis, as needed, for perfect closure
a b
Fig. 40.27 The patient must keep the NAC incisions clean and dry. (a) Preoperative. (b) Postoperative
a b
Fig. 40.28 Occasionally, a mixture of intradermal triamcinalone with one-tenth volume of 5-flourouracil solutions is injected on an
every-other-week basis into persistent hypertrophic scars. (a) Preoperative. (b) Postoperative
wound dry and sterile. Place and secure (using paper excellent postoperative wound care are very impor-
tape) several sterile, soft 4 4 gauzes over each NAC. tant concepts to fully consider with any revision
Then, use a soft jog bra with gentle compression, as cases. Occasionally, a mixture of intradermal triamci-
needed, overnight. Check on the patient with a phone nalone with one-tenth volume of 5-flourouracil solu-
call the evening of surgery and be sure to evaluate tions is injected on an every-other-week basis into
your patient the next morning. Sterile Opsite and persistent hypertrophic scars (Fig. 40.28). But even
Steri-strip dressing changes should occur, as needed, best of all, the periareolar mastopexy may be per-
throughout the healing process with appropriate oral formed on multiple occasions throughout the life of
antibiotics. The patient must keep the NAC incisions the patient by using the techniques described.
clean and dry. In the future, topical scar care with
New Gel or other topical treatments may eventually
become appropriate (Fig. 40.27). 40.3 Complications
If the periareolar incision heals in a suboptimal
fashion, the hypertrophic scars can always be excised Complications from circumareolar mastopexy are
and re-excised, again and again. However, 36 months generally much less severe than the complications
of time may be necessary before revision is advis- from traditional Wise pattern or vertical mastopex-
able. The use of monofilament suture material and ies. Since there is no breast skin undermining with
630 R.A. Shumway
a b
Fig. 40.29 Periareolar scarring can be significant. (a) Preoperative. (b) Postoperative
a b
Fig. 40.30 Hyperpigmentation or hypopigmentation can be a problem. (a) Preoperative. (b) Postoperative
periareolar mastopexies, there are no failed glandular Lactation and breast-feeding should not be affected
flaps, fat necrosis, hematomas, seromas, or nipple because glandular disruption does not occur with
denervation. However, periareolar scarring can be NAC lifts.
significant (Fig. 40.29), and hyperpigmentation or
hypopigmentation can be problematic (Fig. 40.30).
Wound infection and dehiscence or even NAC necro- 40.4 Discussion
sis are distinct possibilities, but are rather rare. Breast
and NAC asymmetry may be related to breast volume Now, let us compare the circumareolar mastopexy and
or NAC position, shape, and size. Thus, after about masto-shifting techniques to other mastopexy tech-
6 months, all under-corrected or asymmetrical lifts niques. The vertical, modified vertical, horizontal and
can be safely improved with redo surgery via IV inverted T mastopexies are all better suited for the
sedation or with just straight local anesthesia. Any surgical treatment of Renault Grade III ptosis because
loss in nipple sensation from a circumareolar mas- they entail extensive and long surgical incisions with
topexy is temporary in nature because the fourth probable undermining of breast tissue when performing
lateral intercostal cutaneous nerve to the nipple is not these mastopexies. However, these other mastopexies
violated. However, an implanted breast can cer- are only available at a substantial price: a lot of scarring.
tainly sustain permanent changes in nipple sensation The resulting lollipop and anchor scars may be totally
because breast augmentation surgery can most cer- unacceptable to many patients. Also, full mastopexies
tainly affect the lateral intercostal cutaneous nerves. are obviously plagued by much higher rates of wound
dehiscence and postoperative discomfort. Breast aug- shape, shift, size, position, and elevate the NAC as
mentation and the traditional mastopexy may well be a needed. This type of surgery has a low complication
Recipe for Disaster in some circumstances [7, 8]. rate and provides for the best possible surgical scar.
True, breast reduction can be directly accomplished The entire operation can be repeated as often as
with larger incision approaches, but you also must needed and can be effectively taught to all cosmetic
absorb the risk of flap necrosis. On the other hand, the breast surgeons.
extended crescent and Benelli mastopexy can safely be If appropriately utilized, the circumareolar mas-
combined with liposuction reductions of the breast or topexy elevates the patient and surgeon onto a new
with breast implant augmentation cases [4, 9]. Problems cosmetic plateau. So, in this fashion, Dr. Benelli [3]
with breast-feeding can occur with traditional mas- and other prominent cosmetic surgeons [16] have,
topexy because of glandular incisions or resections that indeed, brought us just a little closer to our overall
cause sensitivity changes to the nipple itself [10]. worldwide goal: Beautiful and symmetrical breasts
Thankfully, sensitivity changes of the NAC are rarely a without all the scars!
problem with circumareolar mastopexy.
Revision surgery is more difficult with the standard
mastopexy. If surgical revision is required after a wise References
pattern mastopexy, there can be extensive reopening of
the existing breast envelope scars and possible skin 1. Lejour M (1999) Vertical mammaplasty: update and appraisal
of late results. Plast Reconstr Surg 104(3):771781
pigmentation complications (hypopigmentation or
2. Shumway RA (2009) Crescent mastopexy. In: Shiffman MA
hyperpigmentation) or even hypertrophic scarring (ed) Mastopexy and breast reduction: principles and practice.
[11]. Revisions for breast asymmetry can be difficult Springer, Berlin, pp 5563
to fully achieve using standard mastopexy approaches, 3. Benelli L (1990) A new periareolar mammaplasty: the round
block technique. Aesthetic Plast Surg 14(2):93100
and flattening of the lower breast pole can create shape
4. Elliott LF (2002) Circumareolar mastopexy with augmenta-
deformities. Hematomas, seromas, delayed healing, tion. Clin Plast Surg 29(3):337347
increased infection rate, necrosis, scarring, skin puck- 5. Cooper AP (1840) On the anatomy of the breast. Longman,
ering, mastitis, breast-feeding difficulties, and loss of Orme, Green, Brown and Longmans, London
6. Lockwood T (1999) Reduction mammaplasty and mastopexy
sensation all have to be taken into account again with
with superficial fascial system suspension. Plast Reconstr
all revision procedures [12]. Alternatively, the cir- Surg 103(5):14111420
cumareolar mastopexy is a repetitive procedure, in 7. Handel N (2006) Secondary mastopexy in the augmented
nature, with less downtime or discomfort. Most impor- patient: a recipe for disaster. Plast Reconstr Surg 118(7 Suppl):
152163
tantly, all prospective patients who receive mastopexy
8. Spear SL (2006) Secondary mastopexy in the augmented
surgery must be warned of every possible complica- patient: a recipe for disaster. Discussion. Plast Reconstr Surg
tion [13]. In todays medicolegal environment, to err 118(7 Suppl):166167
on the conservative surgical approach may be the most 9. Gruber R, Denkler K, Hvistendahl Y (2006) Extended
crescent mastopexy with augmentation. Aesthetic Plast Surg
prudent. In other words, todays cosmetic surgeon sim-
30(3):269274
ply cannot sustain major complications for elective 10. Craig RD, Sykes PA (1970) Nipple sensitivity following
procedures [14]. reduction mammaplasty. Br J Plast Surg 23(2):165172
11. Cruz-Korchin N, Korchin L (2003) Vertical versus wise
pattern breast reduction: patient satisfaction, revision rates
and complications. Plast Reconstr Surg 112(6):15731578
40.5 Conclusions 12. Serafin D (1976) Anatomy of the breast. In: Georgiade NG (ed)
Reconstructive breast surgery. Mosby, St. Louis, pp 1829
Circumareolar NAC mastopexy and areolar nipple- 13. Gurber RP, Jones HW Jr (1980) The Donut mastopexy:
indications and complications. Plast Reconstr Surg 65(1):
shifting procedures are very powerful surgical tools.
3438
Furthermore, these lifts are reproducible by other cos- 14. Shiffman MA (2009) Medical legal aspects. In: Shiffman
metic surgeons throughout the world, and they can be MA (ed) Mastopexy and breast reduction: principles and
safely combined as multiple procedure operations practice. Springer, Berlin, pp 681686
15. Lejour M (1994) Vertical mammaplasty and liposuction of
including augmentation mammaplasty or liposuction
the breast. Plast Reconstr Surg 94(1):100114
reduction of the mammary glands [15]. Periareolar 16. Renault P (1976) Breast ptosis. Definition and treatment.
breast lifts are extremely versatile and can be used to Clin Plast Surg 3(2):193203
Mastopexy/Breast Reduction
with Short Inverted T Scar 41
Toma T. Mugea
41.1 Introduction how to improve the shape of the reduced breast and the
position of the nippleareola complex (NAC). Very
Breast surgery is one of the most difficult fields of aes- large breasts were better managed by the technique of
thetic surgery because of the complexity of surgical McKissock [3], in 1972. This replaced the widely per-
procedures and the relative guidelines defining the aes- formed Strombeck [1] technique. Soon thereafter, in
thetic perfect breast. Authors [17] present different 1977, an inferior pedicle technique was proposed by
dimensions as representative for the aesthetic perfect Robbins [4]. This technique became popular, and it is
breast, which means something ideal, which needs no still used for relieving breast hypertrophy and ptosis.
further improvement! At the same time, it is impossi- The author uses Robbins technique, with several tech-
ble to impose a single standard of breast beauty to nical variations that eliminate the main drawback of
women who are so entirely different from the point of the original procedure: the long submammary scar.
view of their height, weight, and constitutional type. The modification includes a precise preoperative
The essential goals of breast reduction or mastopexy breast assessment by a special computer program
are to get a predictable result, to retain nipple sensitiv- based on TTM chart [5], precise planning and marking
ity and the possibility of lactation, and to obtain an prior to surgery, and several combined maneuvers
excellent aesthetic appearance. There are many surgi- based on the breast fascial and ligamentous anatomy.
cal procedures for reduction mammaplasty. Each pres- The inverted T method is the most commonly used
ents particular advantages in terms of indications, technique [14, 68]. It is regarded as predictable and
vascular preservation, technique design, ease of real- reliable in outcome, can be used in a complete range of
ization, minimum scarring, maintenance of innerva- sizes, and is easy to learn. The short inverted T scar
tion, long-term results, and so on. procedure with inferior pedicle is indicated when the
Strombeck [1] set a gold standard with his mam- degree of ptosis increased to grade II or grade III and
maplasty technique in 1960. A few years later, for mild to moderate macromastia is present.
small reductions and for mastopexies, Pitanguy [2] The skin is reduced and distributed to the required
showed how to minimize the submammary scar and size and shape in the same time with parenchyma,
which fills this new skin envelope. The horizontal
branch of the inverted T scar is shorter and situated
just above the inframammary fold line, being very well
hidden (Fig. 41.1).
T.T. Mugea, M.D, Ph.D. To emphasize the accuracy of computer program
Medestet Clinic, Cluj-Napoca, Romania and Professor for breast reduction/mastopexy, and the predictable
of Plastic and Aesthetic Surgery, Department of Plastic
result using Robbins technique, the full range of breast
and Aesthetic Surgery, Oradea Medical University,
Oradea, Romania dimensions, like in a panel, is presented. All the cases
e-mail: [email protected] show also the long-term results.

634 T.T. Mugea
a unit. Simple cutaneous flaps without dermoglandular

support are not used. Nipple sensibility, lactation, and
vascularization are preserved by the inferior pedicle,
including nippleareola complex (NAC) neurovascu-
lar pedicle and inferior breast mould.
41.2.3 Disadvantages
1. Good plan for the surgery needed.

2. Exact preoperative measurements must be done and
recorded in a special chart.
b
3. Computer assessment of patient data can take some
time (usually 3 min).
4. Longer learning curve because of preoperative
breast assessment by computer program.
5. Sometimes dog ears can be present at the end of the
horizontal T line (small revision needed).
Although the technique is suitable for the majority
of patients, problems can occur when there is a mild
ptosis and the breast tissue is very firm. The inferior
pedicle is short and does not fold enough behind to
lateral flaps, generating a tension in NAC, with a
droopy appearance when the pillars are sutured.
Fig. 41.1 Short inverted T scar appearance on (a) right and
(b) left breasts
41.2.4 Undesirable Patients
41.2 General Information About 1. Severe weight loss (more than 15 kg)
the Procedure 2. Low collagen quality
3. Smokers, drug abusers
41.2.1 Indications 4. Psychosocial problems
5. Unrealistic expectations
The primary indications of the procedure are:
1. Mammary hyperplasia of moderate to severe degree
2. Ptosis of moderate to severe degree 41.2.5 Operative and Postoperative Times
3. Young patient with good soft tissue elasticity and
tonus Operation time required averages 2 h and 30 min.
Hospital stay is for 24 h.
Drains usually stay in for 12 h.
41.2.2 Advantages Recovery is usually in 7 days.
1. Precise planning of the surgery

2. Predictable results 41.3 Breast Shape and Contour:
3. Patient satisfaction with good aesthetic result visi- Surgical Anatomy
ble next day after the surgery
4. Low incidence of complications Breast shape and contour are influenced by:
This technique provides a stable and long-lasting 1. The volume of breast parenchyma
suspension along an exactly defined line, using the 2. The amount and location of the subcutaneous and
glandular and fascial structures of the breast as one intraparenchymal fat
41 Mastopexy/Breast Reduction with Short Inverted T Scar 635
3. The body contour of the chest wall Subclavius muscle
4. The muscular covering and thickness First rib

5. The tightness and elastic quality of the skin Superficial layer Clavipectoral
The fascial attachments of the breast to the underly- of superficial fascia fascia
Second rib
Deep layer
ing chest wall also influence breast appearance. of superficial fascia
Pectoralis major
muscle
Superficial layer Pectoralis minor
of deep fascia muscle
Retromammary space
with suspensors ligaments Deep layer
41.4 Breast Fascias of deep fascia
Coopers ligaments
The breast develops and is contained within support- Breast mould

ing layers of superficial fascia. The superficial layer of
this superficial fascia is the outer layer covering the
breast parenchyma located near the dermis and is not
always distinct from it. More distinct is the superficial Sixth and seventh ribs
fascias deep layer on the deep posterior surface of the
Rectus abdominis muscle
breast. A loose areolar area is interposed between the
inframammary crease ligaments
deep layer of the superficial fascia and the superficial
layer of the deep fascia that covers the outer layer of
Fig. 41.2 Breast and pectoral fascias (After Nahai [9], modified)
musculature chest wall.
The retromammary space will allow the breast tis-
sue to have a natural gliding over the chest. The super-
ficial layer of the deep fascia overlays the outer surface the superficial pectoral fascia. At the upper and middle
of the pectoralis major, the upper portion of the rectus pectoral fascia, many thin fibers are found between the
abdominis, the medial serratus anterior, and the exter- pectoral fascia and the deep layer of the superficial fas-
nal oblique muscle in the lower central breast. This cia of the breast [11].
fascia is thinner over the muscular portions of the pec-
toralis major and serratus anterior [9].
The connective tissue that supports structures of the 41.5 Breast Suspensor Ligaments
breast (Coopers ligaments) runs from the deep muscle
fascia, through the breast parenchyma, to the dermis of Breast suspensor ligaments, described by Wringer
the overlying skin (Fig. 41.2). The attachments of [12], consist of a horizontal septum, which originates
these suspensory ligaments between the deep layer of and emerges from the pectoral fascia at the level of the
the superficial fascia and the deep muscular fascia are fourth intercostal space and traverses the entire breast
not tight and allow the breast mobility. These attach- from medial to lateral, heading toward the nipple. This
ments can be stretched and attenuated by weight is the central neurovascular pedicle of the breast. The
changes, pregnancy, and aging, which can result in horizontal septum divides the gland into a cranial and
excess breast mobility over the chest and ptosis. This a caudal part, which are delimitated from each other by
is the main problem in performing mastopexy for loose connective tissue located above the horizontal
women who lose weight more than 20 kg in a short septum [13]. At its borders, the septum curves upward
time. Breast mound is gliding all over the chest, bor- into vertical ligaments, which attach the breast to the
rowing skin also from the epigastric and hypochon- sternum and axilla, guiding vessels and nerves to the
drial areas, making the preoperative plan and drawing nippleareola complex also.
more difficult. At the thoracic wall, the medial and lateral ligaments
At the upper pole of the breast, near the second rib each have a deep and a superficial origin. This suspen-
space, the pectoral fascia tightly connects with the sory connective tissue not only connects the mamma to
superficial fascia of the breast, and it is difficult to dis- the thoracic wall but also has superficial insertions into
sect bluntly [10]. Here is the meeting point of three the skin, both medially, laterally, and caudally. These
fascias, hanging to the clavicle. The superficial layer of superficial ligaments determine the actual border of the
the superficial fascia joins the deep layer of superficial breast. Medially, the superficial ligament is rather weak,
fascia (including between them the breast mould) and but caudally, it connects with the inframammary crease
636 T.T. Mugea
Fig. 41.3 Ligamentous Deep

suspension of the mammary Cranial ligament
gland (After Wringer [12],
modified)
Deep
Lateral ligament
Superficial
Lateral ligament
Deep
Medial ligament
Fibrous septum
a b c
Fig. 41.4 The lifting effect of the breast suspensory ligaments tightening during arm elevation
ligament [1416]. Laterally, it fulfills a strong suspension also connects with Coopers ligamenta suspenso-
sory function by attaching to the axillary fascia along ria, which extended from the mammary fascia and
the midaxillary line (Fig. 41.3). insert into the skin. So, even platysma contraction can
The shaping effect of this suspensory connective produce a mild lifting effect on the breast mould
tissue was able to be demonstrated by increasing the through the breast suspensory ligament connections
upward tension on the medial and lateral ligaments, (Fig. 41.5). Wringer [12] demonstrates that the breast
which resulted in a distinct lifting and shaping of the is a well-structured organ, and the courses of its main
entire breast (Fig. 41.4). The medial and lateral liga- vessels and nerves as well as its ligamentous suspen-
ments merge into the superficial mammary fascia from sion are predictable, and could be of value and rele-
an anterior direction. Thus, the ligamentous suspen- vance in clinical application [14].
a b
Fig. 41.5 (a) No contraction of platysma. (b) Breast skin vertical gliding centimeters just during platysma (SMAS) contraction
41.6 Breast Development and Ptosis In the glandular ptosis, the breast and inframam-
mary fold glide over the chest.
In the normal growing phase, the breast can be consid- In the true breast ptosis, the breast and nipple glide
ered to have a hemispheric shape, with the nipple in over the chest, but the inframammary fold is at the
the middle, in the most prominent point (Fig. 41.6). same level [1517].
As the breast will gain weight, because of the gravity Botti [18] proposes a new classification scale of
and ligament tightening, the breast mould will trans- breast tissue and nippleareola complex ptosis,
late in the lower two-thirds of the breast vertical according to the distance between these and the infra-
meridian, together with the nippleareola complex mammary fold level. The breast ptosis degree is
(Fig. 41.7). assessed by the distance between the lower pole of
Age, gravity, breast volume, and decreased elasticity the breast and the inframammary fold level
contribute to a gradual lowering of the breast landmarks (Fig. 41.9).
over time as a woman gets older and experiences normal Nippleareola complex 1st degree = 01 cm
physiologic changes. The extent of this descent depends (NAC) 2nd degree = 12 cm
primarily on the volume of the breast and the elasticity of 3rd degree = 24 cm
the tissues. The breast mould and central pedicle will 4th degree > 4 cm
change the position, according to the gravity (Fig. 41.8). Breast tissue 1st degree = 01 cm
In breast pseudoptosis, only the breast mould is 2nd degree = 12 cm
hanging. The nipple and the inframammary fold are at 3rd degree = 24 cm
the same level like in the normal situation (Fig. 41.8). 4th degree > 4 cm
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Fig. 41.6 Breast mould development and natural gliding on the and the red one the initial nipple level. Breast central and infe-
chest wall. (Left) Teenager. (Middle) Young female. (Right) rior pedicles follow the breast mould in its descending
Adult female. The blue lines represent the breast mould limits, movement
Fig. 41.7 Breast hypertrophy

followed by breast ptosis as
the breast volume decreases.
(Left) Breast hypertrophy.
(Right) True breast ptosis
According to Botti, the NAC/breast ptosis degree lines between the acromion apophysis of scapula bone
code could have different kinds of combinations and the superior edge of the pubic bone, and the Spino
between 1/1 and 4/4. Manubrial Triangle (SpSpMn), defined by the lines
To better define the position of the nippleareola between the manubrium (sternal notch) and the antero-
complex on the chest wall, we use two inverted trian- superior iliac spine points (Fig. 41.10).
gles, which are specific for the trunk as landmarks: Considering the natural evolution with aging,
the Acromion Pubic Triangle (AcAcPb), defined by the normal nipple position is downward gliding, on the
Fig. 41.8 The three types of breast ptosis, according to the ptosis. The dotted line shows the breast upper pole level
nipple position and inframammary fold level [17]. (Left) (anatomical landmark); the continuous line shows the sixth rib
Pseudoptosis. (Middle) True breast ptosis. (Right) Glandular level, where normally is the inframammary fold level
a b
Fig. 41.9 Patient with right breast ptosis NAC 3/Breast 4 (Botti classification)
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a b
Fig. 41.10 Normal nipple position related to the inverted triangles in (a) young female. (b) Mature female with breast ptosis
external margins of the inverted triangles, corre- and a simplified formula for determining the breast
sponding to a high position in young teenagers and to weight: breast weight = (35 sternal notch to nipple dis-
a low position in elder female patients. The aesthetic tance + 60 nipple to inframammary crease distance)
perfect position is in the upper part of the triangles, 1,240, and this can easily be calculated at the bedside.
close to the junction point of the external margins The chart and computer program are able to pro-
(Fig. 41.11). vide the ideal aesthetic dimensions of that breast and
The author noticed the difficulty in defining in a as Breast Golden Number [23]. In order to have a
unique way the breast volume, position, and propor- basis for this new classification, we accept ten rules as
tion related to the patient. Also, there are different following:
ways of defining breast hypertrophy as small, moder- 1. All aesthetic breasts fit the Breast Golden Number.
ate, or severe type, depending on the extra weight 2. Aesthetic breast volume (ABV) depends on BGN.
added. The combination between glandular and fatty 3. If the volume decrease = simply ptosis.
tissue, for a defined volume, gives the breast weight, 4. If the volume increase = breast hypertrophy and
which is difficult to be assessed before the operation. ptosis.
Three-dimensional imaging of the breast including 5. All hypertrophic breasts are ptotic.
mammography, biostereometric measurements, and 6. Breast hypotrophy = below aesthetic breast volume.
magnetic resonance imaging (MRI) have been reported 7. Small hypertrophy = ABV + 50% extra volume.
as accurate measurements of breast volume [19], but 8. Moderate hypertrophy = ABV + 100% extra volume.
require special equipments not always available to the 9. Severe hypertrophy = ABV + 150% extra volume.
surgeon. The highest precision in volume calculation has 10. Gigantomastia = ABV + over 200% extra volume.
been showed by MRI [20, 21]. Recently, Descamps [22] In the breast hypertrophy diagram (Fig. 41.12), we
described preoperative anthropomorphic measurements take as example an aesthetic breast with 350 cc, and
a b
Ac Mn Ac Ac Mn Ac
Sp Sp Sp Sp
Pb Pb
Fig. 41.11 (a) Nippleareola complex natural gliding process. (b) Aesthetic perfect position related to the inverted triangles
increase the volume with 50% for each type of hyper- ciated with autoimplant or breast implant is the
trophy up to gigantomastia. The final shape of the indication.
breast depends on its weight over skin and suspensor Because of skin and soft tissue quality, the aesthetic
fibro-fascial element quality (Fig. 41.13). outcome of the surgery is sometimes less predictable.
Apart from the aesthetic breast, in strong connec- If there is no skin excess and only empty breast, breast
tion with applied surgical procedure, we found six augmentation with implant is the choice, and this case
types of breasts according to glandular volume and does not belong to this type of ptosis.
ptosis (Fig. 41.14 and Table 41.1): In type I ptotic breast, small hypertrophy is natu-
1. Type 0 small volume and skin excess (empty rally accompanied by ptosis, and usually these ladies
breast) wear a B- or C-cup bra size. Mastopexy without glan-
2. Type I small hypertrophy dular excision is the solution. Short inverted T scar
3. Type II moderate hypertrophy or vertical scar technique will ensure a good and stable
4. Type III severe hypertrophy and tight soft tissue aesthetic result.
5. Type IV severe hypertrophy and loose soft tissue In type II ptotic breast, moderate hypertrophy is
6. Type V gigantomastia obvious accompanied by visible ptosis, and these
In type 0 ptotic breast, all ptotic breasts without sig- ladies wear a C-cup bra size. Mastopexy with small
nificant glandular volume, like empty breast founded glandular resection is necessary and allows good and
after severe weight loss or aging, are included. All the predictable results.
following types of breasts (from type I to type V) can In type III ptotic breast, there is a severe hypertrophy
be converted in one certain situation to this type 0, los- with tight soft tissue, indicating a heavy breast with the
ing volume by glandular hypotrophy. Mastopexy asso- elastic properties preserved. Usually, these ladies wear
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Breast Hypertrophy Diagram
100% = 350cc
example 50% 100% 150%
200%
350 525 700 875 1050

Gg CC Volume
Ae Sm Md SV
Ae - Aesthetic Breast Volume

Gg - Gigantomastia
Sm - Small Hypertrophy
Md - Moderate Hypertrophy
Sv - Severe Hypertrophy
Fig. 41.12 Breast hypertrophy diagram
a Breast Volume & Projection b Breast Volume & Projection
Gg
No Gravity ! + Gravity ! Ae - Aesthetic Breast Volume
Gg Ae - Aesthetic Breast Volume Sv Sm - Small Hypertrophy
Sm - Small Hypertrophy
Md - Moderate Hypertrophy
Md - Moderate Hypertrophy Md Sv - Severe Hypertrophy
Sv - Severe Hypertrophy
Sm Gg - Gigantomastia
Gg - Gigantomastia IMF - Inframammary Fold Level
Ae
Sm IMF - Inframammary Fold Level
Md Ae
SV IMF
IMF 200% Same Inframammary Fold Level
150%
100%
50%
Fig. 41.13 Breast volume and projection diagram according to gravity and suspensor fibro-fascial element quality. Inframammary
fold level glides downward up to the stretched limits
Glandular Volume & Ptosis

Classification
0 I II III IV
V
Type 0 - Small Volume & Skin Excess (Empty Breast)
Type I - Small Hypertrophy
Type II - Moderate Hypertrophy
Type III - Severe Hypertrohy & Tight Soft Tissue
Type IV - Severe Hypertrophy & Loose Soft Tissue
Type V - Gigantomastia
Fig. 41.14 Glandular volume and ptosis classification
Table 41.1 Glandular volume & ptosis classification in 10 excision. The gland is hanging over the chest and can
words be mobilized around its base. The upper pole of the
All aesthetic breasts fit the breast golden number breast is empty, and the inframammary fold is longer,
Aesthetic breast volume (ABV) depend on BGN as it used to be when the breast was full, and lower situ-
If the volume decrease = simply ptosis ated on the chest. Breast reduction with full horizontal
If the volume increase = breast hypertrophy & ptosis inverted T scar is usually necessary to drape the
All hypertrophic breast are ptotic breast mould and to avoid the dog ears of the scar.
Breast hypotrophy = below ABV In type V ptotic breast, we include gigantomastia, a
Small hypertrophy = ABV + 50% extra volume rare condition characterized by excessive breast growth
Moderate hypertrophy = ABV + 100% extra volume
and can be physically and psychosocially disabling for
Severe hypertrophy = ABV + 150% extra volume
the patient. Symptoms include mastalgia, infection,
Gigantomastia = ABV + over 200% extra volume
postural problems, back pain, and chronic traction
injury to 4th/5th/6th intercostal nerves with resultant
a D-cup bra size and have marks over the shoulders loss of nipple sensation. It is also associated with
accompanied by neck and back pain. The social life is decreased fetal growth during pregnancy [24]. Being
severely affected. This type of breast is a good indica- over D cup, bra wearing is usefuless.
tion for breast reduction with short inverted T scar. Gigantomastia etiology can be idiopathic, obesity-
In type IV ptotic breast, there is a severe hypertro- associated, juvenile, pregnancy-induced, or drug-
phy with loose soft tissue. These cases derived from induced [24]. Unfortunately, this classification has no
type III when they lose weight. The skin and soft tissue direct impact on the surgical strategy adopted by the
have no elasticity and do not retract after the breast plastic surgeon toward the correction of ptosis, the
644 T.T. Mugea
amount of breast to be removed, and the technique to for, or to see what other procedures are offered.
be used [25]. It is commonly taught that an inferior Meantime, they can have a cup of tea, coffee, or water.
pedicle technique is only appropriate if the distance Also, they will be watched by the staff, and nervous,
from the nipple to inframammary fold is less than easily irritable, demanding, or strange patients can be
15 cm (on the basis of a 2:1 ratio). noticed to the surgeon, to be more delicate and alert
In reality, provided the pedicle is not completely about possible problem case.
removed from the chest wall, there will be numerous
perforators entering into the pedicle along its length. In
addition, it does not necessarily follow that ptosis will 41.7.3 Consultation
increase the nipple to inframammary fold distance
[12]. The author performed inferior pedicle reductions, The secretary or the assistant will introduce the patient
Robbins technique, on several gigantomastia patients in our office in a very polite and respectful way, and
with good effect. There have been numerous reports standing up we present ourselves and shake hands with
in the literature using inferior pedicle techniques and the patient, inviting him/her to have a sit, in front of us,
showing no increase in complication rate with resection but not too close.
weights of over 1,000 g [21, 26]. The office is large enough (at least 25 m2), friendly,
well exposed to the light, decorated with artistic feel-
ing, including paintings, plants, some antiques (horo-
41.7 Consultation: Step by Step loge, etc.), and some of representative diplomas or
awards the author received. On the desk, some fresh
41.7.1 Appointment flowers with nice colors will give a piece of nature
inside, relaxing the atmosphere.
Usually, the patient will contact the clinic by phone or After usual ID medical records, the author starts
e-mail and will receive an appointment in one day at talking about the specific patient problem, encourag-
one specific hour. ing him/her to explain, in his/her own terms, com-
At the moment, according to the National Medical plaints and desires. If the patient is alone, especially
College and National Committee for Medical Clinic without relatives, it is better to try to understand the
Accreditation, the following points are defined: real motivation for the surgery, the psychical status of
1. No advertisement will be tolerated, except for per- the patient, and how realistic are the complaints and
sonal information (to give the possibility for a sur- also the demands for the surgery. It is always better to
geon to get known and to give some information on have an assistant (secretary, nurse, or doctor) during
his activities). the consultation and especially when the patient is
2. Advertisement should be objective and pertinent. examined. This will take place in another room, close
3. Any advertisement using a before/after argument and connected with the office, where the patient will
will be banned as well as those using a financial be invited to go and prepare (undressed) for the exam-
argument (the ones promising a second intervention ination and let us know when he/she is ready by
free of costs, awards consisting in aesthetic surgery knocking on the door. If the companion wants to
devices or procedures). assist, he/she can do it but only with the patients
4. Every advertisement should include a paragraph consent.
explaining the risks, unwanted effects, and post-
treatment.
41.8 Patient Examination and Breast
Measurements
41.7.2 Waiting
In order to achieve the best aesthetic results in breast
Even if the patient came in time, he/she must spend augmentation, using a simple kit (Fig. 41.15) the sur-
around 15 min in the waiting room, to relax, breeze, geon must evaluate each breast before the surgery, in
accommodate with the place, watch and read the terms of position, proportion, symmetry, volume, soft
exposed brochures according to the problem she came tissue elasticity, skin excess, and ptosis degree. Any
with arms relaxed and lifted. In order to demonstrate the

inframammary fold level, useful also in tubular breasts
examination, special pictures are taken with breast sus-
tained and gently pulled by the assistant. For ptotic breasts,
we take also pictures with the body bended at 45, front
and lateral view, to demonstrate the gravitational effect on
the breast mould and the neck of the breast (the attach-
ment base to the trunk). After severe weight loss, breast
mould may look like rocks in socks (Fig. 41.17).
According to the TTM chart, the surgeon can docu-
ment and show to the patient breast problems, even
small asymmetries. Body height, weight, pregnancies,
weight loss, and pinch test are very important elements
in defining body mass index (BMI), skin, and soft
tissue quality.
After collecting the data in the chart, we fill the boxes
nominated in the TTM Computer Program for breast
reduction (Fig. 41.18), organized in similar sections
to the chart. The surgeon has to select the calculate
icon situated in the right upper corner of the table, and
automatically the computer will list, in red color, what
are the ideal breast dimensions for the patient. If the
patient is overweight (supraponderal), the computer
will list also the ideal dimensions for each parameter,
allowing the user to see and compare these at once.
Fig. 41.15 During patient examination and measurements, a Using this program, the surgeon can show to the
simple set of instruments are used (ruler, caliper, marking pen, patient the connections between body height and
pencil)
weight, trunk dimensions, and corresponding breast
dimension, simulating different cases. They will under-
chest and breast scars or stretch marks will be recorded. stand that there are no standards in aesthetic surgery,
The areola diameter (vertical and horizontal) will be only proportions. Each case will have its own aesthetic
also measured. breast dimension, according to the body. This is the
During patient examination, the surgeon and his Breast Golden Number (BGN).
assistant will fill in the TTM chart, which includes The connections between BGN and other distances
the breast and body parameters needed for an objec- found in aesthetic breasts are as follows:
tive aesthetic evaluation of the breast (Table 41.2 and BGN = ideal aesthetic triangle (between manubrium
Fig. 41.16, Fig. 41.17). The patient will be asked and nipples)
about breast-feeding: how long it was, how easy (did BGN = inframammary fold length
they use to milk by pump or manually), did they have BGN = breast horizontal meridian
any inflammatory events, and since when did they BGN = breast circumference in the aesthetic
stop breast-feeding. breast
Special attention will be given for nippleareola BGN = breast vertical meridian
complex, in terms of pigmentation, widening, scars, BGN: 2 = breast medial meridian
crusts, and discharges from the nipple. Breast mound BGN: 2 = breast lateral meridian
and axilla will be focused on clinical examination, to BGN: 3 = breast inferior meridian
detect any eventual lumps or nodules. Until now, this is the only program available for
Standard breast photos are taken after examination, breast assessment, allowing precise preoperative plan-
and loaded in the patient electronic file version. These ning for breast reduction or mastopexy in order to
include standing front, profile and oblique exposition, achieve aesthetic results. This is used for every case,
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Table 41.2 Chart for Patient Name: Code: Date:

computer program
Hegiht (cm): Weight (Kg): Pregnancies: Weight Loss:
Pinch Test (cm): P= R= Tight: Normal: Loose:
Chest problems:
Ac Mn Ac Mn
Ax St Ax
Ni Ni
Ni Ni
Aesthetic Triangle Breast Horizontal Meridian
Sp Sp
Pp
Nipple Position
Breast Circumference Breast Diameters
Trunk measurements
Breast Verticall Meridian
Mn - Pb =
Ac - Ac =
Sp - Sp =
Ni
Chest Circumference
Inframammary Fold Length
Mx Ch =
Ni Ch =
Breast Inferior Meridian
Infra Ch =
Relaxed / Stretched
Notes:
demonstrating its accuracy in the last 10 years. At the tests and other medical examination that will be neces-
follow-up, the author can also demonstrate the present sary. This will be done by accredited laboratories and
situation of the breast and how it has evolved over time. clinics, recommended by the surgeon or patients
After the first consultation and examination, accord- general practitioner.
ing to the patient desires, based on photos and com-
puter program, and sometimes using free drawing on
the consultation file, the surgeon will explain in detail 41.9 Examination and Investigations
what the problems are and what can be done to solve
them. If the patient understands the procedure, includ- Usually, before the surgery, there is a set of examination
ing the risks of incidents and accidents and complica- and investigations that should be done (Table 41.3).
tions related to the anesthesia also, she will receive a Full blood count (FBC): This will demonstrate ane-
printed document containing these things and the lab mia. This increases the risk of intraoperative hypoxia
Fig. 41.16 Breast and trunk

measurements, during
a
examination
Mn - Pb:
distance between
Mn (Manubrium Notch) &
Pb (Pubis Superior Edge)
Ac - Ac:
distance between
Lateral Edges of the
Acromion Bones
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c
Sp - Sp
distance brtween the

Antero Superior Spina
of lliac Bone
Mn - Ni Triangle

e
Inverted Triangles
Nipple Areola Complex
Position
f
Soft Tissue Elasticity
Pinched (P) Relaxed (R)
P R
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g Breast Vertical Diameter
(BVD)
the distance between
Breast Upper Pole &
Inframammary Fold Level
h
Breast Horizonal Diameter
(BVD)
the distance between
Sternal and Axilar Edges
of the Infarmammary Fold
(measured wirh a caliper).


i
Axillary Chest Circumference
(Ax-Ch)
Chest Circumference
measured at
the Axilla Level
j Areola Diameters
Areola Vertical Diameter
Areola Horizontal Diameter

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k
Nipple Chest Circumference
(Ni - Ch)
Chest Circumference
measured over
the most projected points
of the breasts
l
Infra Chest Circumference
(Infra - Ch)
Chest Circumference
measured at
the Inframammary Fold Level


m
Breast Medial Meridian
St-Ni:
distance between
Sternal Inframammary Fold End
& Nipple
n
Breast Lateral Meridian
Ax-Ni:
distance between
Axillary Inframammary Fold End
& Nipple
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o Breast Horizontal Meridian
BHM
distance between
Sternal & Axillary End of the
Inframammary Fold,
over the Nipple
p Breast Circumferencre
BC
the Longer Distance between
Sternal & Axillary End
of the Inframammary Fold,
following the shape
of the breast
q
Inframammary Fold Length (Infra Length)
the distance between the Sternal and Axillary End

of the Inframammary Fold.
r
Breast Superior Meridian
BUP - Ni distance
Breast Upper Pole (BUP) at
the Horizontal Line of the
Axillary Chest Circumference

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s
Breast Inferior Meridian
Ni - IMF distance
Nipple to
Inframammary Fold
t
Breast Vertical Meridian
BVM
BUP to Inframmamary Fold
distance over the Nipple


u
Glandular Ptosis Score
(G.Botti)
Lower Pole of the Breast to
Inframammary Fold distance
v
Nipple Areola Complex
Ptosis Score (G.Botti)
Nipple to
Inframammary fold distance

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Fig. 41.17 Standard

preoperative photos for breast a b
surgery
c d
e f g
h i j
k l m
Fig. 41.17 (continiued)

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TTM program for Breast Reduction/Mastopexy
Fig. 41.18 TTM program for breast reduction/mastopexy, with actual and ideal dimensions and surgical plan
Table 41.3 Examination and investigations Liver function tests (LFT): Does the patient have any
Full blood count (FBC) Glycemia underlying malnutrition? This may affect the patients
Blood platelet count Transaminase ability to heal.
Group Protein electrophoresis Blood type: Anticipating that there may be a
Goagulation test Urea and electrolytes requirement for blood, but not routinely for this proce-
PCV Urinalysis dure, the patients blood type is identified and held,
Hemoglobin HIV, HbSAg, HCV pending a possible (later) request for units of blood or
ECG blood products.
Chest X-ray Clotting: Clotting and platelet function is relevant
Mamography for the many patients who take aspirin or warfarin and
Breast ultrasound also for patients with known clotting disorders. Some
patients used to take vitamins, supplements, and garlic
or increased cardiac workload. It is also useful as a which can induce coagulation problems. Also, dur-
baseline measure of hemoglobin if the proposed opera- ing full moon faze, amazingly, we noticed a higher
tion is expected to cause substantial blood loss. incidence of bleeding.
Urea and electrolytes (U&E): These detect underly- Urinalysis: Urine dipstick or analysis is useful to
ing renal deficiency and possibility of developing acute detect undiagnosed diabetes or urinary tract infection.
renal failure (ARF) after major surgery. They may also ECG, chest X-ray, mammography, and breast ultra-
influence the choice of drugs given within the anesthetic. sound: These are necessary.
Every breast must have in the files, before surgery, consent for the surgery and anesthetic procedure
sonologic examination including the mammography (Table 41.5).
and echography. Sometimes, an MRI (magnetic reso- According to the clinic policy, the patient has to
nance imaging) can be necessary, if the sonologist con- pay the full price of the procedure at least 2 weeks
siders. This can detect glandular problems, and the before admission. No discount, partial payment, or
surgery will be performed, according to the protocol, bank guaranty will be admitted. For all the services
by a team including the oncologic surgeon. paid, the patient will receive a receipt. Patient bag-
For patient safety, every segment of tissue excised ging for financial favors, promising that they will be
from the breast will be sent to the histopathology in advertising our clinic and bring new patients among
separate containers. Also, any fluid from a cyst eventu- their friends, will be erased from the list. Accepting
ally opened will be swabbed and sent to the bacteriol- patients with this kind of behavior in private practice
ogy for culture and antibiogram. is equivalent to an opened gate for problems after
the surgery. They will become demanding, unhappy
with the results, whatever will be, and will turn out
41.10 Airway Assessment (Done into an enemy and bad advertising person. According
by Anesthesiologist) to the patients desire, and waiting list, the surgeon will
schedule the date of the operation.
How easy or difficult it will be to intubate a patient
depends on the following points:
1. Are they obese? 41.13 Patient Preparation
2. Do they have a short neck and small mouth? for the Operation
3. To what extent can they open their mouth?
4. Is there any soft tissue swelling at the back of In the surgery day, the patient should come at least 6 h
the mouth or any limitations in neck flexion or before the procedure, with necessary personal things
extension? for self hygiene and cosmetic makeup. After admis-
sion, the patient will have a shower, to clean the skin
and remove all ointments and change into the hospital
41.11 Patient Information Sheet dressing. All the jewelries and values will be returned
to the relative or stored in a special safe compartment.
The patient is given an information sheet in detail to Nails will be cleaned and prepared for pulse oximeter
read at home. She can make notes about questions and measurements. The nurse in charge will check the
problems to discuss at the next consultation, before the blood pressure, heart rate, and temperature and will
surgery (Table 41.4). have a talk with the patient, explaining how the things
will go before and after the surgery.
The surgeon will ask the patient to come in the
41.12 Final Preoperative Consultation examination room, and the drawing will be done accord-
ing to the previous measurements, which will be
After the first consultation, the patient goes home and checked again, in front of the assistant. This will repre-
digests the information and experience acquired dur- sent the surgical plan. Some experienced surgeons used
ing the first visit to the surgeon. If she makes the deci- to do this on the operation table, with the patient sitting
sion to have the surgery and will do the medical in front of them, quickly, like a free hand work. The
investigations recommended, she is scheduled for a author does not like this, because we must be concen-
second appointment. trated on the plan, using a ruler and calipers, in an accu-
At the second consultation, the surgeon will check rate manner. This operation should be the most important
the results from the recommended investigation and procedure for that operating day, and the team prepared
will discuss in more detail the procedure, including for this. Before the operation, the surgeon should have
risks and unfavorable possible events. Special atten- 1015 min to relax and clean the mind from all prob-
tion will be paid for scars and wound healing. In lems especially bad things. The surgical plan is always
front of the assistant, the patient will read and sign the done by the surgeon and not by his assistant.
662 T.T. Mugea
Table 41.4 Reduction mammaplasty Patient information sheet

Reduction mammaplasty is a surgical intervention meant to solve issues related to excessively big and/or drooping (sagging)
breasts. Oversized breasts are caused by excessive glandular tissue or fat. Excessive breast volume and size causes the stretching
and distension of mammary ligaments, and thus breast drooping and the loss of feminine shapes.
This state has a negative psychological effect upon women, similarly to undersized breasts which cause embarrassment and
frustration. Moreover, there are physical issues related to oversized breasts discomfort, spine, neck, shoulder, and back pain
which become prevalent. Participation in a normal social life is limited, patients suffering from mammary hypertrophy avoiding
dance, aerobic gymnastics, or other activities producing body swinging or graceless movement of the breasts.
If this state is not corrected before adulthood, it may affect posture (compensatory contraction of muscles causes spine deforma-
tion). Moreover, oversized breasts hinder normal ventilation of the inframammary fold and skin maceration, with bacterial or
mycotic suprainfection. Other problems, minor but still important, are the need for special lingerie (large-size bras) and
difficulties in finding clothes that fit properly.
The treatment of this condition is not new, and it has been practiced for more than 50 years. The purpose of this operation is to reduce
the volume and weight of ones breasts and to adjust their position. This involves removing mammary tissue and adjusting the contour
of the breasts. Moreover, it is necessary to adjust the areolanipple complex in conformity to the new shape of the breast.
In addition to usual medical tests, you are required to do a preoperative ultrasound and mammography, to identify any problems
related to the hypertrophied glandular tissue, and to be able to develop the therapeutic plan.
Being an operation of considerable significance, it is recommended that the patient be healthy, outside her period, and not
recovering from another condition. Any treatment with aspirin, vitamins, and garlic or administration of contraceptives must be
stopped at least 3 weeks before the operation. In addition, you are required to refrain from smoking 23 weeks before and 1
week after the operation. You are required not to eat or drink on the day of the operation.
The operation is performed under general anesthesia and takes about 23 h.
The scars will be inverted T shaped. From the circular scar around the areola, a vertical line runs toward the inframammary fold,
where there is a horizontal incision, with one end toward the sternum area and the other toward the side of the breast. However,
there will be scars, and if they are hidden in the natural contour lines, most of them will spontaneously meliorate within 6 months.
The position of these scars and all the other questions you might have shall be discussed in detail during the medical exam.
In order to prevent accumulation of blood in the operated area and complications related to this fact, you shall have a surgical
drain on each side of your body for 1 or 2 days. You shall be released from hospital as soon as no drainage will be noticed and
tubes tacked out. We are using high-quality resorbable sutures to make sure the scar is as small as possible. An adhesive
substance will be sprayed on the skin, and a special dressing will be applied to ensure an optimum healing. There will be no
stitches to remove.
Postoperative care
It is necessary that you remain one or two nights in the clinic. Postoperative medication shall include antibiotics, vitamins, and
analgesics, and normal diet shall be progressively re-introduced in the first 24 h. Antibiotic oral treatment shall be continued for
5 days. Moreover, if we identify the presence of anemia, you shall be administered oral iron supplements.
Postoperative pain is moderate in intensity and may be countered with analgesic medication, which may be administered as
many times as necessary. The postoperative protection dressing is to be changed daily for 7 days. In order to prevent postopera-
tive discomfort and ensure the optimum conditions for an aesthetic cicatrization, it is recommended that you avoid demanding
physical activity and wear a bra at all times for 6 weeks.
We recommend that you should not expose your skin to sunlight or UV tanning lights for the first 3 months after the operation.
It takes about 1 year for the scars to mature and the breast to reach its final shape.
We strongly recommend that you come for the follow-up and medical examinations at 1 and 6 months after the surgery.
Complications
Besides general complications, common to all surgical interventions (allergic reactions, hemorrhage, infections, necrosis of soft
parts), there may be complications specific to this type of operation.
Breast-feeding issues may sometimes arise after the operation. If you plan to have a baby in the future, it is recommended that
you postpone the surgical intervention because a new pregnancy will modify the shape and size of your breasts, and the final
aesthetic result may as well be partially affected.
It is recommended that mammary reduction be performed minimum 6 months after interruption of breast feeding, because only
after this interval breasts usually return to a functionally neutral state.
The sensibility of the areola may be partially or totally lost depending on the technique performed. There may be sometimes a
sensation of numbness in the scar area. The breasts might also be asymmetrical after the operation. However, considering the
fact that, even under normal circumstances, breasts are not usually identical, the wish to obtain a perfect postoperative symmetry
is sometimes unrealistic.
There are few cases in which scars are of a considerable size requiring postoperative revision.
The results of this operation are very good and full of satisfaction for the patient.
A typical comment after the operation is: If I knew how easy it is, I would have done long ago!
Table 41.5 Consent form for surgical intervention

1. The undersigned.I hereby consent to the treatment:
.
And I authorize Prof. Dr. Toma Mugea and his collaborators, to perform upon myself or the patient I am representing as
legal guardian, the surgical intervention and/or related treatments.
2. I hereby agree that the operation/procedures performed, which could support the progress of medical science or be used for
educational purposes only, be recorded, on condition that my/the patients identity remains confidential.
3. Prof. Dr. Toma Mugea has explained to me the purpose of the intervention, and all alternatives to the recommended
treatment have been presented, including the alternative excluding any treatment.
4. I have been offered the opportunity to ask questions, and I have received complete and satisfactory answers to all of my
questions.
5. Prof. Dr. Toma Mugea informed me of all risks and complications that may arise.
Besides general complications typical of all surgical interventions (allergic reactions, hemorrhage, hematoma, ecchymosis,
necrosis of soft parts, thrombosis, embolism) which may get worse and pose a threat to my life, there may be complications
specific to this type of operation.
These have been explained to me during the medical examination, and I have also read them in the documents I have been
given on that occasion. In addition, I have been informed on postoperative care.
6. I do understand that there might be unforeseen situations during the operation, which might require interventions different
from those agreed upon, and I hereby authorize Prof. Dr. Toma Mugea and/or his assistants to make appropriate decisions on
the best course of treatment.
7. I do agree to the administration of the indicated type of anesthesia, and I consent/do not consent to blood transfusion, if
required.
8. I hereby declare that I am not aware of suffering from a contagious illness or being infected with a virus which might
determine a contagious disease.
9. I am aware of and I know the fact that there are no guarantees with respect to the result of the intervention.
10. In case of litigation, the parties shall benefit from the provisions of the legislation in force.
The Medestet Clinic shall benefit from assistance from Romanian Aesthetic Surgery Society in pursuit of its interests.
11. I hereby declare that I have been informed on the contract terms, and being aware of the above-mentioned risks and
complications, I consent to the recommended treatment.
Patient... Signature. Date
Legal Trustee..
Witness. Address..
Signature..
To make the patient more relaxed, 2 hours before the mion, supero-anterior iliac spine, and pubis. The
surgery, he/she will receive 7.5 mg midazolam tablet. inframammary fold with its medial and lateral end point
Midazolam is a short-acting drug in the benzodiazepine is marked (Fig. 41.19). After marking these reference
class that is used for treatment of acute seizures and for points, the length of the inframammary fold is deter-
inducing sedation and amnesia before medical proce- mined and the midpoint of the fold marked (Fig. 41.20).
dures. It has potent anxiolytic, amnestic, hypnotic, anti- To obtain a proportional breast in terms of position,
convulsant, skeletal muscle relaxant, and sedative volume, and shape with the body, the distance of man-
properties. Midazolam has a fast recovery time and is the ubrium to new nipple position and also the breast cir-
most commonly used benzodiazepine as a premedication cumference should be equal to the length of the
for sedation. An intravenous (IV) line will be set up. patients actual inframammary fold. This is the key to
the breast mastopexy/reduction.
During the breast reduction, a significant part of
41.14 Surgical Plan the mammary gland is removed, and the remaining
skin envelope will have a smaller weight to support
The entire procedure is designed before surgery, with the and will retract. This is called the coil spring rule in
patient sitting and arms placed to the sides. The follow- breast surgery [27], and, in order to compensate, we
ing clue points and lines are marked: manubrium, acro- have to add 10% at the distance calculated for the new
664 T.T. Mugea
a b
Fig. 41.19 Inframammary fold with its medial and lateral end points
Because the upper pole of the breast is flat at the

marking time, when the breast cone is filled, the nip-
ples new position with breast tissue behind it will be
pushed forward, like a pendulum, and the manubrium
nipple distance will become shorter (from an aesthetic
point of view), with the nipple situated in a higher
position than desired. To correct this, we add 10%
extra length to the calculated manubriumnipple dis-
tance for the new nipple position.
To define the new nipple location, the ruler passed
behind the neck to the nipples (Fig. 41.22), and a dot-
ted line marked the inner side of the ruler. The meeting
point between this line and MnNi distance, located
according to the 10% correction rule, will be the new
Fig. 41.20 Inframammary fold length and the midpoint of the nipple position. In this case, it is 21 cm from the
fold marked manubrium notch (19 cm + 2 cm (representing
10%) = 21 cm).
manubrium to nipple length. If not, the nippleareola Using a ruler, step by step points are marked situ-
complex will have a higher location than planned. ated at 9.5-cm distance from the medial and from the
The same 10% value should be added in the case of lateral edges of the inframammary fold (Fig. 41.23).
breast ptosis, according to the pendulum rule This will define the level of vertical T branch and
(Fig. 41.21) [27]. represent half of the inframammary fold length
O (9.5 cm). The Wise pattern keyhole is selected,

corresponding to the 5-cm diameter areola, and hold-
ing the upper pole of the key at 2.5 cm superior to the
marked nipple point, the keyhole branches are
enlarged until these meet the dotted lines correspond-
ing to the vertical branches of inverted T
(Fig. 41.24). According to TTM chart, NiInfra dis-
tance should be 7 cm (1:3 from inframammary fold
length), and the length of each vertical T branch
will have, in this case, 5 cm because 2 cm came from
areola diameter (Fig. 41.25). At the inframammary
c line midpoint, a small triangle is defined with 1-cm-
O
+ 10% length branches (Fig. 41.26). This will dissipate the
suture tension from one to three points, when the final
B
A suture will be done to close the T. To close the hori-
zontal T branch, one larger triangle will be marked
10% on each side, from the end point of the vertical T
B branch to the inframammary midpoint triangle
(Fig. 41.27). With full marking done, a photo will be
taken for the files.

Fig. 41.21 Pendulum rule in the breast surgery. In mastopexy
and breast reduction, the bottom of the breast is pushed upward, The operating theater should be clean, in order, and
and as the result, the upper pole is pushed forward together with large enough (2530 m2) to allow the devices, and
the NAC. O = the midclavicular point, A = the inframammary fold anesthetic and surgical team to work without fear of
level, B = the new position for NAC without correction, C = the
touching somebody else. Inside the operating theater,
NAC achieved position after the operation without position cor-
rection, D = the correct position of the NAC maintained at the the temperature should be around 20C and fresh air
aesthetic planed level. The distance OD is 10% longer that OC available by conditioning devices that will keep it at
Fig. 41.22 Defining the new nipple location

666 T.T. Mugea
Fig. 41.23 Marking the level of vertical T branch
Fig. 41.24 The keyhole branches are enlarged until they meet the dotted lines corresponding to the vertical braches of inverted T
the desired parameters. A nice classical music in the 41.16 Breast Ptosis Type 0: Small Volume
background will make a friendly ambiance for the and Skin Excess (Empty Breast)
patient and also the operating team.
Patient comes into the operating theater with a dis- The patient is placed lying down (Fig. 41.28), with the
posable cap and dressed with a large gown, which arms secured horizontally at 90. The operation field is
will be removed by the nurse before sitting on the prepared with Betadine solution, and after covering
table. In tranquility, the anesthetic team will proceed patient with sterile drapes, the key points are marked
to put an intravenous (IV) line and connect the patient by small intradermal injections with Methylene Blue
to the monitors. The anesthesia will be with oral intu- on both breasts. This is necessary to avoid the dissipa-
bation. When the patient is asleep, the radiofrequency tion of the drawings during the operation. A special
bipolar electrocautery will be connected, and the cutting ring, with a hole centering the nipple position,
scrub nurse will prepare the table with instruments. will mark the new areola diameter (Fig. 41.29).
a b
Fig. 41.25 The vertical T branch measurement
a b
Fig. 41.26 At the inframammary line midpoint, a small triangle is defined with 1-cm-length branches
According to the drawings we make on both breasts, without tension, and will prevent the bed scars during
the intradermal incisions with No. 15 blade scalpel, the healing process.
and start the deepithelialization, carefully, from the The author likes to do the glandular incision
inframammary fold level, using a sharp scissors (Fig. 41.32), using No. 21 cold blade. In this way, we
(Fig. 41.30). When the deepithelialization is com- keep the margins clean, without thermal damage, and
pleted, using the electrocautery, the transdermal inci- allow a normal wound healing. To help in this maneu-
sions are started, saving a 5-mm margin from the skin ver, the assistant holds the key points of the incisions
(Fig. 41.31), which will be used at the closing sutures. with skin hooks, and with the left hand we push gently
This marginal dermis will hold the skin in the suture the lateral side of the gland, which is hanging, is pushed
668 T.T. Mugea
Fig. 41.27 Inverted T

short scar marking
Inverted T
Short Scar Marking
B
D
AB = BC + CD
a b
Fig. 41.28 Markings on the operating table
gently medially. This incision should be done through central neurovascular pedicle runs to the nippleareola
the gland mould, if possible, at once, down to the ret- complex. Also, in difficult cases with breast ptosis
roglandular space, carefully not to open the muscular after severe weight loss, the breast mound can glide
pectoralis major fascia. This point is very important, vertically and horizontally, over the chest cage, for
because along this retroglandular space, the breast several centimeters, and the incision can fall into a
a a
Fig. 41.29 (a) Key points marking by small intradermal injec- Fig. 41.30 (a) Intradermal incisions with No. 15 blade scalpel
tions with Methylene Blue. (b) A special cutting ring will mark are made according to the drawings. (b) Deepithelialization is
the new areola diameter started, carefully, from the inframammary fold level using a
sharp scissors
wrong plane. Incisions are completed superiorly, and margin. Suction drain is placed in the retroglandular
the inferior pedicle is well mobilized (Fig. 41.33). space and attached to the sterile bag with mild negative
A key dermal suture with 2/0 Vicryl holds the are- pressure.
ola together with the lateral and medial cutaneous flaps The skin suture (Fig. 41.37) is performed with
at the superior end of the vertical T branch intracuticular running stitch with 5/0 PDS. The whole
(Fig. 41.34), and bought breast pillars, lateral and incision length is taped with SteriStrip changed every
medial, are sutured with 2/0 Vicryl in front of the infe- 7 days, for 36 weeks. Patients are asked to wear bras-
rior pedicle, holding the breast mould (Fig. 41.35). siere for 6 weeks.
The second layer is a reverse dermohypodermic suture Type 0 ptotic breast includes all ptotic breasts
(Fig. 41.36), with 2/0 Vicryl, and includes the anterior without significant glandular volume, like empty
layer of the superficial fascia of the breast. This suture breast found after severe weight loss or aging. All
technique allows minimal tension skin repair, with the following types of breasts (from type I to type V)
more predictable scarring, using the two to three mar- can be converted in one certain situation to this type
ginal deepithelialized area left close to the skin flap 0, losing volume by glandular hypotrophy. Mastopexy
670 T.T. Mugea
a b
c d
Fig. 41.31 Transdermal incisions, saving a 5-mm margin from the skin
associated with autoimplant or breast implant is the ideal dimensions of her breast to be aesthetic. In this
indication. Because of skin and soft tissue quality, specific case, the Breast Golden Number is 20 cm.
the aesthetic outcome of the surgery is sometime less Preoperative draw plan is done according to the sug-
predictable. If there is no skin excess and only empty gested breast dimensions. The new nipple position will
breast, breast augmentation with implant is the be located at the meeting point between the midclavicu-
choice, and this case does not belong to this type of lar to nipple line and the inverted triangles. Postoperative
ptosis. breast dimensions (Fig. 41.41) and preoperative and
6-month photos can be seen in Fig. 41.42.
Case 1
This is a patient (Fig. 41.38) with breast ptosis type 0
(Fig. 41.39). She had one pregnancy and lost 15 kg. Her 41.17 Breast Ptosis Type I: Small
breasts look empty. No glandular excision is needed, Hypertrophy
only volume redistribution. The horizontal T branch
is shorter than the inframammary fold length. In type I ptotic breast, small hypertrophy is naturally
The patients body and breast actual parameters are accompanied by ptosis, and usually these ladies wear a
introduced into the computer program (Fig. 41.40), and B- or C-cup bra size. Mastopexy without glandular
the computer listed in the red color what should be the excision is the solution. Short inverted T scar or
a b
Fig. 41.32 Breast incision, down to the retroglandular space, laterally and medially
vertical scar technique will ensure a good and stable

aesthetic result (Fig. 41.43).
Case 2
This case presents a patient with small breast hypertro-
phy and glandular ptosis (Fig. 41.44). Breast actual
dimensions, ideal parameters (in red), and surgical
plan are shown in Fig. 41.45. A small amount of glan-
dular tissue has to be removed. For this, the inferior
pedicle is completely released from the superior and
central breast segments. Pedicle width is identical with
the horizontal T branch length (Fig. 41.46), which is
around half of the inframammary fold length.
The dermal incision is performed with radiofrequency
needle point, preserving 2 mm dermal margin close to the
skin (left picture). Vertical incisions are deep to the ret-
roglandular tissue (Fig. 41.47). Because in the upper pole
of the breast there is a small amount of glandular tissue,
usually there is no need for excision. In this area, we
excise only the skin and keep in place all the fatty tissue.
Fig. 41.33 Incisions are completed superiorly, and the inferior

pedicle is well mobilized
672 T.T. Mugea
a b
Fig. 41.34 Key dermal suture holds together the areola with lateral and medial cutaneous flaps at the superior end of the vertical
T branch
a b
Fig. 41.35 Both breast pillars, lateral and medial, are sutured in front of the inferior pedicle
a a
b
b
Fig. 41.37 The skin suture is performed with intracuticular

Fig. 41.36 Second layer is a reverse dermohypodermic suture
running suture with 5/0 PDS
The glandular tissue to be excised is mainly located nipple and the thoracic wall is maintained by the hori-
in the central and lateral quadrants of the breast. From zontal breast septum (Fig. 41.48) and its attached neu-
the top of the dermoglandular flap, including the rovascular layers [12, 14].
nippleareola complex, the dissection progresses in a To obtain a good breast projection and to avoid the
caudal direction along the loose layer of the fourth ptosis of the breast tissue, several reverse sutures with
intercostal space by blunt preparation (Fig. 41.48). 2/0 Vicryl are used, deep in the lateral and medial
Here, the retromammary space changes its direction pillars tissue. This will include the medial and lateral
and merges into a layer of loose connective tissue in a suspensor ligaments of the breast, sutured in front of
vertical plan, heading toward the nipple [14]. the dermoglandular pedicle of the nippleareola com-
The caudal part of the gland together with the hori- plex (Fig. 41.49). Postoperative photos at 7 days
zontal septum is left intact. The glandular excess from (Fig. 41.50) and breast dimensions are listed in
the central area is excised, preserving at least 2 cm of Fig. 41.51. New NAC location is in the aesthetic
tissue behind the NAC. The connection between the position.
674 T.T. Mugea
Fig. 41.38 Preoperative patient
Fig. 41.39 Breast ptosis type

0 (empty breast) Breast PtosisType 0
Small Volume &
Skin Excess (Empty Breast)
Same Length of
Short TScar &
Pedicle Width
+
Authoprosthesis
?Breast Implant
resection is necessary and allows good and predictable

41.18 Breast Ptosis Type II: Moderate results Fig. 41.52.
Hypertrophy
Case 3
In type II ptotic breast, moderate hypertrophy is obvi- The patients breast dimensions and surgical plan are
ous, accompanied by visible ptosis, and these ladies in Fig. 41.53. Postoperative breast dimensions and
wear a C-cup bra size. Mastopexy with small glandular photos at 6 months are shown in Fig. 41.54.
TTM program for Breast Reduction / Mastopexy
Fig. 41.40 Actual breast dimensions, ideal parameters (in red), and surgical plan
41.19 Breast Ptosis Type III: Preoperative marking, with relaxed skin holding the
Severe Hypertrophy breast, shows 20-cm inframammary fold length and
and Tight Soft Tissue not 22 cm as we measured in the consultation room,
without breast support. Based on this 20 cm, all mark-
In type III ptotic breast, there is a severe hypertrophy with ing has been done (Fig. 41.58). In this case, pedicle
tight soft tissue, indicating a heavy breast with the elastic width is shorter than horizontal T line, allowing
properties preserved (Fig. 41.56). Usually, these ladies good skin and glandular excision, from medial and lat-
wear a D-cup bra size and have marks over the shoulders eral breast quadrants. Also, the horizontal T line
accompanied by neck and back pain. The social life is (11 cm) is shorter than inframammary fold length
severely affected. This type of breast is a good indication (Fig. 41.59, 41.60).
for breast reduction with short inverted T scar.
Case 4 41.20 Breast Ptosis Type IV:

This case represents a 23-year-old young lady with Severe Hypertrophy
168-cm height and 68-kg body weight (Fig. 41.57). and Loose Soft Tissue
She has severe breast hypertrophy and ptosis (Nipple
5/Gland 7), without any pregnancy or weight loss. In In type IV ptotic breast, there is a severe hypertrophy
her case, pinch test shows 3-cm soft tissue thickness with loose soft tissue (Fig. 41.61). These cases derived
and for relaxed tissue test 6 cm, demonstrating that she from type III when they lose weight. The skin and soft
has normal skin elasticity. tissue have no elasticity and do not retract after the
676 T.T. Mugea
Fig. 41.41 Postoperative measurements
Fig. 41.42 Six months postoperative
breast excision. The gland is hanging over the chest lower situated on the chest. Breast reduction with full
and can be mobilized around its base. The upper pole horizontal inverted T scar is usually necessary to
of the breast is empty, and the inframammary fold is drape the breast mould and to avoid the dog ears of
longer, as it used to be when the breast was full, and the scar.

I: small hypertrophy
Breast Ptosis type l
Small hypertrophy
5 cm
5 cm
19 cm 9,5 cm
Same Length of
Short T Scar &
pedicle Width
+/- 5 cm
Glandular Excision
9,5 cm
19 cm
Fig. 41.44 Actual breast dimensions, ideal parameters (in red), and surgical plan
678 T.T. Mugea
Fig. 41.45 Preoperative
a b
Fig. 41.46 Skin deepithelialization on the marked area
Case 5 sions. To prove it, the author did a simulation with the
This case and her twin sister have identical bodies computer program (Fig. 41.63), supposing that she
and breasts, and both lost more than 10 kg in a few had 10 kg more, and in this case, the BGN became
months, facing severe breast hypertrophy and pto- 22 cm (21.80 cm).
sis. In this patient, the inframammary fold length This case was done using a modified Robbins tech-
(22 cm) is larger than what she was supposed to have nique, following the preoperative planning in the TTM
in her condition, according to the chart (Fig. 41.62). program for breast reduction and mastopexy.
Because she lost weight, the breasts are smaller, but Postoperatively, the BGN is 22 cm, as supposed to be
the inframammary fold length is still larger. The skin according to the computer simulation (Fig. 41.64 and
and inframammary ligaments changed their length, Fig. 41.65, Fig. 41.66). Because this patient has a twin
shortening up to the elasticity limit. If the patient con- sister, operated in the same day for a similar problem,
tinues to lose weight, the breasts will look like empty this is a very good example of computer program effi-
bags hanging over the chest, kipping the same dimen- ciency allowing predictable results.
a a
Fig. 41.47 (a) Dermohypodermal incisions. (b) Vertical incisions
Fig. 41.48 The central breast pedicle and fibrous septum
infection, postural problems, back pain, and chronic

41.21 Breast Ptosis Type V: traction injury to 4th/5th/6th intercostal nerves with
Gigantomastia resultant loss of nipple sensation. It is also associated
with decreased fetal growth during pregnancy [24].
In type V ptotic breast, we include gigantomastia, a Being over D cup, bra wearing is not useful.
rare condition characterized by excessive breast growth Gigantomastia etiology can be idiopathic, obesity-
and can be physically and psychosocially disabling for associated, juvenile, pregnancy-induced, or drug-
the patient (Fig. 41.67). Symptoms include mastalgia, induced [24]. Unfortunately, this classification has no
680 T.T. Mugea
Fig. 41.49 (a) Internal brassiere made by suturing the medial final running intradermal suture, done with 5/0 PDS, starts from
and lateral pillars, including the medial and lateral suspen- the ends of the horizontal line of the scar to the center, with a
sory ligaments, in front of the NAC dermoglandular pedicle. shortening effect
(b) Internal brassiere with reverse dermohypodermic suture. The
Fig. 41.50 One week postoperative
Fig. 41.51 Postoperative breast measurements

682 T.T. Mugea

II with moderate hypertrophy
Breast Ptosis Type II

Moderate Hypertrophy
5 cm
5 cm
19 cm 9,5 cm
Same Length of
Short T Scar &
Pedicle Width
+ 5 cm
Glandular Exision
9,5 cm
19 cm
direct impact on the surgical strategy adopted by the Preoperative planning has been done according to the
plastic surgeon toward the correction of ptosis, the computer program (Fig. 41.69, 41.70).
amount of breast to be removed, and the technique to Postoperative result at 7 days and breast measure-
be used [25]. ments correspond to the aesthetic result and Breast
It is commonly taught that an inferior pedicle tech- Golden Number for her case. At 6 months, the breast
nique is only appropriate if the distance from the nip- keeps the shape and proportion and has a natural
ple to the inframammary fold is less than 15 cm (on appearance (Figs. 41.71 and 41.72, 41.73).
the basis of a 2:1 ratio). In reality, provided the pedicle
is not completely removed from the chest wall, there
will be numerous perforators entering into the pedicle 41.22 After Surgery
along its length. In addition, it does not necessarily
follow that ptosis will increase the nipple to inframam- The patient will go back to the ward, usually for 24 h,
mary fold distance [12]. The inferior pedicle reduc- and will receive painkillers, antibiotics (Cefalexin tab-
tions, Robbins technique, have been performed on lets 500 mg, three times in a day), for 3 days, and if
several gigantomastia patients with good effect. There necessary Clexane (Enoxaparin sodium Per syringe:
have been numerous reports in the literature using 20 mg/0.2 mL). In patients with a moderate risk of
inferior pedicle techniques and showing no increase in thromboembolism, the recommended dosage is 20 mg
complication rate with resection weights of over or 40 mg once daily by subcutaneous injection. In
1,000 g [12, 26]. patients with a high risk of thromboembolism, the dos-
age should be 40 mg administered once daily by sub-
Case 6 cutaneous injection.
This case represents a 33-year-old young lady, with a Enoxaparin treatment is usually prescribed for an
70-cm height and 85-kg body weight, with gigan- average period of 710 days. Longer treatment dura-
tomastia and severe breast ptosis (Nipple 6/Gland 8) tion may be appropriate in some patients, and the treat-
(Fig. 41.68). She had one pregnancy and lost only 4 kg. ment should be continued for as long as there is a risk
b TTM program for Breast Reduction / Mastopexy
5cm
5 cm
19 cm 9,5 cm
5 cm
19 cm
Fig. 41.53 (a) Preoperative. (b) Preoperative plan based on computer program for breast reduction
of venous thromboembolism and until the patient is receive IV solutions (5% glucose, Ringers) according to
ambulatory. the body weight, and as soon the patient will tolerate,
Because we are doing the surgery in the afternoon, will start natural feeding. The dressing will be done,
the patient will stay in the clinic overnight, with monitor leaving in place the SteriStrips (adherent paper tape),
for BP, HR, and a pulse oximeter. For next hours will and the suction drain will be mobilized and removed in
684 T.T. Mugea
Fig. 41.54 Five months postoperative.
Fig. 41.55 Postoperative result with breast new dimensions

Fig. 41.56 Breast ptosis

type III: severe hypertrophy
and tight soft tissue Breast Ptosis Type III
Severe Hypertrophy &
Tight Soft Tissue
5 cm
6 cm
22 cm 11 cm
Short T scar
Narrower pedicle
+ 6 cm
Glandular &
Skin Excision 11 cm
22 cm
Fig. 41.57 (a) Preoperative. (b) Preoperative breast dimensions and surgical planning
686 T.T. Mugea
b TTM program for Breast Reduction / Mastopexy
the next 24 h if the drainage is below 20 ml. Over the they are encouraged to come also whenever they feel
SteriStrips, sterile cotton gauze will be applied and sus- it is necessary. Patients do not start sportive activity,
tained with the bra, adapted to the new breast size. especially rhythmic movements with a pendulum-
The patient will leave the clinic with oral antibiotics like shaking of the breasts, sooner than 6 months.
for 3 days, sterile cotton gauze, and mild painkiller
treatment. Next day, they can have the shower without
dressing (the wound is protected by SteriStrips), and 41.23 Possible Complications
after that the sterile cotton gauze is applied under the
bras. The patient can start to do her usual social activ- Postoperatively, patients and surgeon can face differ-
ity in 23 days, and go back to work in 714 days. ent problems, which can be included as complications
They have to wear bras almost all the time for 6 weeks, related to surgery, planning, or therapy. Breast asym-
and after this time, they have to wear bras during the metries, bottoming out, bed scars, or high position of
day for 6 months. NAC are not considered as surgical complications, as
First medical follow-up will be at 7 days. At the they are related to the surgeons preoperative planning
first control, the SteriStrips are changed, and the and intraoperative maneuvers.
patient is taught how to do it at home, once a week Early complication after mastopexy can be:
for the next 4 weeks, and to protect the wound and 1. Bleeding
ensure a good scar appearance. The patient comes 2. Hematoma
for a visit also at 1 and 6 months and at 1 year, and 3. Venous stasis on the NAC
Fig. 41.58 Preoperative marking (a) According to the pendu- Marking the end point of vertical line of inverted T. (c) Short
lum rule, the new nipple position will be at 22 cm from the inverted T scar limit (yellow arrow) and deepithelialized pedi-
sternal notch. (b) Horizontal T branch length marked at 11 cm. cle (red arrow)
Keyhole arms meeting the horizontal T branch at 7.5 cm.
688 T.T. Mugea
Fig. 41.60 (a) Forty-eight hours after surgery. (b) Thirty days after the surgery. (c) Six months postoperative. (d) Two years after
the surgery

690 T.T. Mugea

type IV: severe hypertrophy Breast Ptosis Type IV
and loose soft tissue
Loose Soft Tissue
5 cm
6 cm
22 cm 22cm
Full scar length
Narrow pedicle
+
Glandular & 6 cm
Skin Excision
11 cm
22 cm
4. Ischemia At this kind of reintervention, two pairs of drains

5. Necrosis are used to prevent clotting formation on the tubes and
6. Infection to allow, if necessary, the wound irrigation. The first
These complications have to be recognized as soon intervention is a mild suction through the drains and
as possible and treated without delay in the appropriate not a hard one, to prevent the tissues from locking the
manner. The surgeon must consider the patient safety tubes holes. In all the cases, after 24 h, the drains are
as a priority, without the shame to assume that compli- removed without problems. At 1 week after the sur-
cation. All these complications can be small, moder- gery, in this case, except for the skin oozing on the left
ate, or severe, and lack of attention can allow them to side, the breasts appear similar (Fig. 41.71b). Since the
pass into the next stage of gravity. The surgeon has to patient lost weight after 1 year, mild ptosis is still
assist himself at the first dressing, and keep an eye on present.
the patient if anything is not working as has to be. This For venous stasis on the NAC, which can be a pre-
dressing is as important as the surgery itself, and liminary stage for intravascular thrombosis and skin
nobody can delegate this responsibility. necrosis, we used to do, in mild cases, small stab inci-
In our practice, even if we had a small incidence of sions with No. 11 blades. If the areola congestion is
all kinds of early postoperative complications (less significant, we will do tangential skin deepithelializa-
than 2%), bleeding and hematoma was the main reason tion on the affected area. On the top of the areola, we
for reintervention (Fig. 41.74). The common situation apply heparin-soaked gauze to allow the bleeding. This
is a small continuous bleeding and clots on the drain- dressing has to be changed every 23 h until the new
age tubes, which will lead to blood accumulation and vascular connections allow the normal venous drain-
hematoma formation. The breast looks bigger, under age. The areola skin will heal in several weeks without
tension, with bruising around the scars and is tender. significant scars. Also, leeches can be used.
Even if the bleeding stops, surgery has to be performed Ischemia and tissue necrosis are the most danger-
with general anesthesia to evacuate the clots and check ous complication after breast reduction and mastopexy.
the hemostasis (Fig. 41.75). The tissues are washed If there is no infection over this necrosis, the wound
with saline solution and Betadine, and a new pair of will heal by itself with secondary reepithelialization.
drains are inserted through a new skin hole. Small necrotic areas can be present usually at the
Fig. 41.62 Preoperative plan for patient with 50-kg body weight. In this situation, BGN is 20.46 cm (red arrow)
points of tension, where the flap corners meet. with wound fluids have to be sent for the bacteriologi-
Sometimes, the suture material passes through the der- cal examination and antibiogram. The IV treatment
mal skin and becomes contaminated with bacteria. A with identified antibiotics has to be completed with
local infection started in this condition (Fig. 41.77). If anticoagulants because of high risks of thrombosis
infection is present, the wound must be opened and and pulmonary embolism. All the dressings have to
necrotic tissue excised. The wound will be washed be done under general anesthesia to be as aggres-
with hydrogen peroxide and Betadine solution. Boric sive as the infection is. Usually, after 48 h, when the
acid crystals, like a powder, is applied over the wound, patient is well and there are signs of local recovery,
even if it is unpleasant for the patient. This acid will with bleeding from the small granulating tissue present
keep away the wound contamination and will allow a and swabs adherent to the tissues, closing of the breast
quicker reepithelialization. Usually, there is no need wound can be performed. All the flap margins have to
for revision surgery in these cases. be excised about 5 mm, up to the normal tissues, with
If there is a severe infection and all mammary good bleeding, and the sutures done as initially. Drains
glands involved, under general anesthesia, all the are necessary for 24 h.
sutures have to be removed, necrotic tissue excised, Later, bad outcomes after mastopexy are related to
and the flaps washed with hydrogen peroxide and the surgical technique, patients tissue qualities, patient
Betadine solution. The opened wound has to be cov- following received advices, body weight changes,
ered with normal saline solutionsoaked gauze. As physiological events (pregnancy, breast-feeding), and
soon as the suspicion of infection is present, swabs aging.
692 T.T. Mugea
5cm
6 cm
22 cm 22cm
6 cm
11 cm
22 cm
Fig. 41.63 Computer program simulation for patient with 60-kg body weight. In this situation, BGN is 21.80 cm (red arrow)
Fig. 41.64 Preoperative pictures

Fig. 41.65 Forty-eight hours postoperative
Fig. 41.66 Preoperative breast dimensions

694 T.T. Mugea

type V: gigantomastia
Breast Ptosis Type V
Gigantomastia
7 cm
10 cm
26 cm 26cm
Full scar length

Narrow pedicle
+
Large Glandular & 10 cm
Skin Excision 13 cm
26 cm
a b
Fig. 41.68 Preoperative patient with gigantomastia
1. Areola asymmetries 7. Bad scars, which can be:

2. Bed shape of the areola (a) Hypertrophic
3. Loss of areola sensitivity (b) Wide
4. Breast asymmetries (c) Keloidal
5. Breast bed shape (d) Painful
6. Breast volume not related to the patients body and (e) Hypo/hyperpigmented (Fig. 41.78)
trunk dimensions (f) With bed position, visible outside the bra
Fig. 41.69 Preoperative breast dimensions and computer program.
Fig. 41.70 Preoperative marking for breast reduction

696 T.T. Mugea
Fig. 41.72 Postoperative result at 7 days

Fig. 41.73 Postoperative 6 months after surgery
a a
b b
Fig. 41.75 Intraoperative, checking hemostasis. New drains

inserted through another skin opening
Fig. 41.74 Postoperative hematoma of the left breast

698 T.T. Mugea
Fig. 41.76 (a) Preoperative. (b) One week after the surgery and reintervention. (c) One year after the surgery
Usually, one complication is not alone and some- 41.24 Conclusions

times can be associated with many others, leading
to disasters (Fig. 41.79). In this situation, it is In breast aesthetic surgery, the most important things
almost impossible to correct the aesthetic outcome. are (Fig. 41.81):
Only a small improvement can be expected 1. Breast evaluation
(Fig. 41.80). 2. Patient desire
a b
Fig. 41.77 Local infection and wound healing after mastopexy
a b
Fig 41.78 Scar depigmentation in a case with vitiligo

700 T.T. Mugea
Fig. 41.79 Postoperative disasters in breast surgery

Fig. 41.80 (a) Preoperative patient with NAC situated too high, The long vertical scar from the top of the areola is the price for
wide scars, and ptotic breasts, type 0. (b) Surgical technique lowering the NAC position. If an implant will be inserted, NAC
for NAC repositioning and scar correction. (c) Postoperatively, will have again an upper position, because the lower pole of the
the breast is still empty, but the NAC is in the normal position. breast will be filled
702 T.T. Mugea
Glandular Volume & Ptosis Classification
0 I II III IV
V
Type III - Severe Hypertrophy & Tight Soft Tissue
Type V - Gigantomastia
Type 0
Small Volume & Skin Excess (Empty Breast)
Same Length of
Short T Scar &
Pedicle Width
+
Authoprosthesis
?Breast Implant
Type I Small Hypertrophy
5cm
5 cm
Same Length of 19 cm 9,5 cm

Short T Scar &
Pedicle Width
+/
5 cm
9,5 cm
Glandular Excision
19 cm
Fig. 41.81 The final concepts

Type II
Moderate Hypertrophy
5cm
5 cm
Same Length of 19 cm 9,5 cm

Short T Scar &
Pedicle Width
+/
5 cm
9,5 cm
Glandular Excision
19 cm
Type III
Tight Soft Tissue
5cm
6 cm
Short T scar 22 cm 11 cm
Narrower pedicle
+
Glandular &
Skin Excision
6 cm
22 cm
11 cm
Type IV
Loose Soft Tissue
5cm
6 cm
Full scar length
Narrow pedicle 22 cm 22cm
+
Glandular &
Skin Excision
6 cm
11 cm
22 cm

704 T.T. Mugea

Type V
Gigantomastia
7cm
10 cm
Full scar length 26 cm 26cm

Narrow pedicle
+
Large Glandular &
Skin Excision 10 cm
13 cm
26cm
3. Accurate planning of surgical procedure 13. Bayati S, Seckel BR (1995) Inframammary crease ligament.
4. Simple surgical technique
14. Wringer E (1999) Refinement of the central pedicle breast
5. Predictable results reduction by application of the ligamentous suspension.
6. Avoiding postoperative complications Plast Reconstr Surg 103(5):14001410
7. Patient satisfaction 15. Nava M, Quattrone P, Riggio E (1998) Focus on the breast
fascial system: a new approach for inframammary fold
reconstruction. Plast Reconstr Surg 102(4):10341045
16. Muntan CD, Sundine MJ, Rink RD, Acland RD (2000)
References Inframammary fold: a histologic reappraisal. Plast Reconstr
Surg 105(2):549556
1. Strombeck JO (1960) Mammaplasty: report of a new 17. Regnault P (1976) Breast ptosis, definition and treatment.
technique based on the two-pedicle procedure. Br J Plast Clin Plast Surg 3(2):193203
Surg 13:7990 18. Botti G (2004) Mastoplastiche Estetiche, Atlante di Chirurgia
2. Pitanguy I (1967) Surgical treatment of breast hypertrophy. Plastica Pratica. SEE Nicodemo & C snc, Firenze, p 251
Br J Plast Surg 20(1):7885 19. Sommer NZ, Zook EG (2009) Prediction of weight in breast
3. McKissock PK (1972) Reduction mammaplasty with a reduction surgery. In: Shiffman MA (ed) Mastopexy and breast
vertical dermal flap. Plast Reconstr Surg 49(3):245252 reduction: principles and practice. Springer, Berlin, pp 1921
4. Robbins TH (1977) A reduction mammaplasty with areolar- 20. Kovacs L, Eder M, Hollweck R, Zimmermann A, Settles M,
nipple based on an inferior dermal pedicle. Plast Reconstr Schneider A, Endlich M, Mueller A, Schwenzer-Zimmerer
Surg 59(1):6467 K, Papadopulos NA, Biemer E (2007) Comparison between
5. Mugea TT (2001) A new system for breast assessment using breast volume measurement using 3D surface imaging and
TTM chart. In: The 17th international congress of the French classical techniques. Breast 16(2):137145
Society of Aesthetic Surgery, Paris, 1921 May 2001 21. Bulstrode N, Bellamy E, Shorira S (2001) Breast volume
6. Hidalgo DA, Elliot LF, Palumbo S, Casas L, Hammond D assessment: comparing five different techniques. Breast
(1999) Current trends in breast reduction. Plast Reconstr 10(2):117123
Surg 104(3):806815 22. Descamps MJL, Landau AG, Lazarus D, Hudson DA (2008)
7. Hidalgo DA (1999) Improving safety and aesthetics in inverted A formula determining resection weights for reduction
T scar breast reduction. Plast Reconstr Surg 103(3):874886 mammaplasty. Plast Reconstr Surg 121(2):397400
8. Giovanoli P, Meuli-Simmen C, Meyer VE, Frey M (1999) 23. Mugea TT (2009) Breast reduction algorithm using TTM
Which technique for which breast? A prospective study of chart. In: Shiffman MA (ed) Mastopexy and breast reduc-
different techniques of reduction mammaplasty. Br J Plast tion: principles and practice. Springer, Berlin, pp 275289
Surg 52(1):5259 24. Dancey A, Khan M, Dawson J, Peart F (2008) Gigantomastia
9. Nahai F (2005) The art of aesthetic surgery: principles and tech- a classification and review of the literature. J Plast Reconstr
niques. Quality Medical Publishing Inc, St. Louis, p 799 Aesthetic Surg 61(5):493502
10. Graf RM, Bernades A, Auerswald A, Damasio RC (2000) 25. Mojallal A, Comparin JP, Voulliaume D, Chichery A, Papalia
Subfascial endoscopic transaxillary augmentation mamma- I, Foyatier JL (2005) Reduction mammaplasty using superior
plasty. Aesthetic Plast Surg 24(3):216220 pedicle in macromastia. Ann Chir Plast Esthet 50(2):118126
11. Jinde L, Jianliang S, Xiaoping C, Jiaqing L, Qun M, Bo L 26. ODey D, Prescher A, Pallua N (2007) Vascular reliability of
(2006) Anatomy and clinical significance of pectoral fascia. nipple areola complex-bearing pedicles: an anatomical micro
Plast Reconstr Surg 118(7):15571560 dissection study. Plast Reconstr Surg 119(4):11671177
12. Wringer E, Mader N, Posch E, Holle J (1998) Nerve and 27. Mugea TT (2002) Rules in breast aesthetic surgery. In: The
vessel supplying ligamentous suspension of the mammary 4th international congress of Romanian Aesthetic Surgery
gland. Plast Reconstr Surg 101(6):14861493 Society, Bucharest, 35 Oct, 2002
The Medial and Superior Pedicle
Mastopexy with Dual Plane 42
Inverted-T Augmentation
Tiberiu I. Bratu, Cristina Isac, Olariu Daniela,

Grujic Daciana, Dorina Mihaijlovic,
and Nicolae Antohi
42.1 Introduction difficult to achieve. Moreover, the technique has the

potential for serious complications, such as skin necro-
Augmentation mastopexy is a challenging operation sis, NAC necrosis, and breast and implant infection. As
about which there are a variety of opinions. It is consid- Spear stated, breast augmentation alone is a fairly
ered a difficult operation, implying the risk of compli- simple operation, mastopexy is a relatively simple
cations; that is why many surgeons choose to perform operation, but when performing augmentation mas-
it as a two-stage procedure [1]. Adequate shape is still topexy, his advice is Surgeon, beware! [2].
The goals of augmentation mastopexy procedure
are, besides enlargement of the breast to the volume
desired by the patient, elevation of the gland and NAC
and conversion of a ptotic, discoid-shaped breast into a
more youthful conical or slightly round breast [3].
T.I. Bratu (*)
University of Medicine and Pharmacy Victor Babes, County The inverted-T or anchor pattern mastopexy is
Hospital Timisoara, Casa Austria, str. Bulbuca 10, Brol the most widely used technique. Various pedicles have
Medical Center, str. Franyo Zoltan, 6, Timisoara, Romania been proposed, such as superior, inferior, superoinfe-
rior (McKissock), and lateral [4].
C. Isac
Department of Plastic Surgery, University Hospital
for Plastic Surgery and Burns, University of Medicine and 42.2 Preoperative
Pharmacy Carol Davila, Calea Grivitei 218, Bucharest,
Romania
e-mail: [email protected] The preoperative assessment is performed with regard
to skin condition, degree of ptosis, and asymmetry. The
O. Daniela D. Mihaijlovic
Brol Medical Center Private Clinic, cup that the patient is wearing is determined by sub-
str. Franyo Zoltan, Timisoara 6, Romania tracting the chest circumference at the inframammary
e-mail: [email protected] crease from the circumference of the breast measured
D. Grujic at the NAC while the patient is wearing a bra. The
University of medicine and Pharmacy Victor Babes, degree of breast ptosis is established using Regnault
Brol Medical Center Private Clinic Timisoara, Romania
classification, and any asymmetry is recorded. The
e-mail: [email protected], [email protected]
approximate desired size of the breast is determined,
N. Antohi
and the appropriate size of the implant is chosen, tak-
University of Medicine and Pharmacy Carol Davila,
Bucharest, Romania ing into account that a cup represents approximately
200 mL or 200 g of breast tissue and that during a mas-
Department of Plastic Surgery, University Hospital for Plastic
Surgery and Burns, Calea Grivitei 218, Bucharest, Romania topexy, some breast tissue needs to be removed in order
e-mail: [email protected] to avoid excessive lower pole fullness [5, 6].

706 T.I. Bratu et al.
Fig. 42.2 Glandular excision from the lateral part of the breast
Fig. 42.1 Rectangular cutaneoglandular flap to be excised
Anyway, the diameter of the NAC should be larger

than the diameter of the keyhole in order to avoid
42.3 Marking Technique stretching of the NAC and widened scars.
This represents the most important part of any plastic

surgery procedure on the breast. With the patient in a sit- 42.4 Operative Technique
ting or standing position, arms beside, a midsternal line
is traced from the sternal notch to the umbilicus. The A circumferential cut is made around the NAC of the
midmammary lines are then marked. These lines begin desired size. The usual measurement in our cases is
from the midclavicular point (about 7 cm from the sternal between 38 and 42 mm. The skin within the markings is
notch) and follow the meridian of the breast, parting the deepithelialized, excepting the NAC and the inferior
base of the breast in two halves. They usually cross the rectangle (the latter is excised). Full-thickness cuts are
nipple, but this is not a necessary condition. The NAC made across the inframammary fold and the lateral bor-
may be placed laterally or medially from the breast der of the deepithelialized area. The skin incisions are
meridian. The inframammary folds are traced. The ideal completed, keeping 5 mm of dermis on the skin margin.
nipple position is marked on the breast meridian, taking The glandular tissue is elevated off the pectoralis major
into consideration the patients height and the position of muscle. The incisions are deepened through the paren-
the inframammary fold. It is usually marked at or 1 cm chyma towards the muscular plane. The dissection
lower from the anterior projection of the inframammary should be kept in an oblique or perpendicular direction,
fold on the breast. The superior border of the areola is depending on the amount of existent glandular tissue and
marked 2 cm superior to the new nipple position, and trying to preserve an adequate size of the pillars.
then the Wise pattern is used or the keyhole is marked Glandular excision from the lateral part of the breast may
freely by pushing the breast to either side of the midline, be performed as necessary at this point (Fig. 42.2). The
and the lateral and medial limits of the skin resection are caudal extension of the superomedial flap is progres-
traced down from either end of the areolar arc. sively detached from the muscular plane, beveling the
The patient is then placed in the supine position. The dissection cephalad and downward to the pectoralis mus-
markings of the inframammary fold incisions are kept cle. A glandular-adipose flap with a superior and medial
as short as possible, and the extreme ends of these are pedicle is thus raised. The cephalic extension of the sub-
connected with the caudal points of the keyhole pattern. glandular undermining is represented by the second rib.
A rectangular cutaneoglandular flap of the inferior pole The inferior insertions of the pectoralis major are
which is going to be excised is also marked (Fig. 42.1). identified (Fig. 42.3) and the lateral border of the muscle
The NAC to be incised is marked with a standard is incised, as well as the costal insertions. The submus-
circular cookie cutter of various diameters, depending cular pocket is formed and extended as needed
on the dimensions of the breast and the patients desire. laterally to the anterior axillary line, superiorly to about
42 The Medial and Superior Pedicle Mastopexy with Dual Plane Inverted-T Augmentation 707
Fig. 42.3 Incision of the inferior costal insertions of the pectoralis

major muscle
Fig. 42.5 Superomedial glandular pedicle sutured
Fig. 42.4 The submuscular pocket created
2 cm from the clavicle, and medially up to 1 cm from

the midline (Fig. 42.4). Only the inferomedial sternal Fig. 42.6 Lateral closure of the pedicle to the pectoralis and
thoracic fascia in its inferior part
insertions of the pectoralis muscle are divided. The
implant is inserted after hemostasis is carefully per-
formed. As in a usual simple breast augmentation, it is drain is placed and brought out through a stab wound
important to verify that the implant does not have any inferolaterally.
folds or wrinkles, that it is well settled, and that both The opposite breast is then addressed in a similar
implants are at the same level. manner. The circumareolar skin is tightened down
The areola is sutured into the keyhole with a two- using the round-block technique if considered neces-
layer closure. sary. A permanent, braided, subcuticular running
The glandular flap is sutured in its inferior part to suture is advanced under the skin at about 12-cm
the thoracic fascia with 3-0 Monocryl. This represents intervals and then tied down as the skin is gathered
the key point of the technique, which ensures a stable around. The knot is buried in a small hole performed in
padding of the lower pole of the implant (Fig. 42.5). the dermis. A 3845-mm stainless steel nipple marker
The lateral part of the pedicle is sutured to the lateral is used, depending on the desired dimensions of the
pillar in a similar manner (Fig. 42.6). A closed suction subsequent nippleareola complex. Otherwise, a
procedures plastic surgeons currently performed

because nearly every variable that determines the
ultimate shape of the breast is being manipulated to
some degree [10]. The use of a proper surgical tech-
nique, besides providing aesthetic improvement,
greatly minimizes complications [11].
Among the factors that significantly affect both the
short- and long-term outcome of the mastopexy proce-
dure are skins elasticity, the degree of ptosis, and breast
asymmetry [12].
Various techniques of mastopexy have been described,
Fig. 42.7 Final result
including crescent mastopexy, periareolar round-
block (Benellis technique) [13], Lassus [14] vertical
simple double layer with absorbable sutures is per- scar technique modified later by Lejour [15], Chiari
formed followed by running subcuticular suture. [16] short-scar mastopexy, and anchor or T types.
The final skin closures are done using 4-0 absorb- Any of the methods mentioned above can be associ-
able PDS and 5-0 absorbable intradermal running ated with parenchymal reshaping and/or augmentation
sutures (Fig. 42.7). The wounds are dressed with by means of implants. Description of the first tech-
SteriStrips. The breasts are supported with dressing niques of breast lift was published in the 1950s, but
retention tape both on the upper and inferior pole. reports of the association of mastopexy with augmen-
tation did not appear until mid-1960s.
Breast augmentation mastopexy represents an alter-
42.5 Discussion native when augmentation is desired as an adjunct. It
allows achieving a nice shape of the breast by virtue of
Between January 2004 and September 2009, 117 women a better fill of the envelope with the implant, while, at
aged 1848 (mean 33 years) underwent surgery using the same time, limits the length of the scars, as there is
the technique described. The average follow-up period less skin to be excised, compared with the simple mas-
was 1.5 years. All the patients presented with ptosis in topexy technique. The implant can reduce the degree
varying degrees. Round or anatomic implants were of breast lift needed and may help preserve the lift
used depending on the degree of ptosis and patients once it is performed, adding longevity to the result.
preference (Fig. 42.8). However, the added risks of augmentation mamma-
The degree of satisfaction with the aesthetic result was plasty to mastopexy must also be considered. The risks
89%. There were only minor complications, with an include an increased chance of wound problems and
overall incidence of 3%. The most frequent complica- dehiscence if there is any tension on the suture lines,
tions were scar widening, residual ptosis, hypertrophic infection, implant exposure, and excessive scarring.
scarring, and flattening of the breast. The risk of implant extrusion is increased especially
Mastopexy and simultaneous augmentation has at the inverted-T incisions. These problems can be
been a challenge to plastic surgeons in terms of ach- avoided by keeping skin resection to a minimum at the
ieving symmetry, natural shape, and long-lasting, beginning of the procedure and resecting more skin
consistent results. Among the guiding principles of after the implant has been put in place [17]. There is an
mammaplasty, besides glandular modification, skin increased risk for nippleareola complex malposition
redraping, and safe NAC transposition, a very impor- (too high or too low) and for nipple sensation loss.
tant one is achieving long-term stability of the breast Achieving the shape and the size desired is more
shape. There still is a lot of controversy about difficult in a simple mastopexy. There are also the
combining augmentation and mastopexy in the inherent risks of the implants (malposition, capsular
same surgical procedure [79]. As Hammond stated, contracture rates for capsular contracture in the com-
it proved to be one of the most difficult breast bined procedure are not yet documented).
a b
Fig. 42.8 (a) Preoperative. (b) Forty-eight hours postoperative
The padding of the inferior pole of the implant is Whereas the neurovascular supply is usually not
an issue not frequently addressed. We consider this compromised by formal mastopexy alone, the addi-
issue a very important one, because the implant, due tion of the augmentation procedure may cause sig-
to gravity, may cause inferior pole gland atrophy and nificant alteration in blood supply to the NAC,
consequences on the skin in the long run. The secu- glandular tissue, or skin flaps [17]. If the NAC is
rity provided by the inferior pole covering consists in designed on two simultaneous pedicles, the NAC
preventing tension over the T incision confluence survival safety increases considerably. We use this
and reducing the risk of implant extrusion. It gives in procedure in our technique: we preserve two integral
this way an extra support to the dermis and a good pedicles (medial and superior ones) and insure a
implant coverage. A good padding of the inferior good padding of the inferior pole with the entire
pole provides not only a nice shape, but also a safe parenchyma kept on these two pedicles. Moreover,
and stable result. the final shape of the gland is enhanced by the dual
Another important issue in our opinion is repre- plane technique in which the gland sliding on the
sented by the safety of the nippleareola complex. It pectoral muscle permits a nice molding on the
is well known that NAC blood supply could be pro- implant, avoiding the double bubble deformity.
vided by means of various pedicles. The blood sup- The complications encountered during augmenta-
ply to the nippleareola complex and the skin flaps tion mastopexy procedure include nipple-areolar
should be carefully considered before proceeding necrosis, poor scarring, implant infections, implant
with augmentation mastopexy, especially in those malposition, and contour deformities. Some surgeons
women with severe ptosis when a formal Wise- consider that the risks of complications are increased
pattern mastopexy is to be performed. In their zeal to by combining augmentation and mastopexy [18].
correct a womans severe ptosis, surgeons must However, in the hands of an experienced surgeon, sat-
remain vigilant of the blood and nerve supply in isfying results can be achieved by means of a more
relation to the incisions made for both the augmenta- comfortable and less expensive procedure for the
tion and the mastopexy parts of the procedure. patient (Figs. 42.942.12).
a b
Fig. 42.9 (a) Preoperative. (b) and (c) One year postoperative after one-stage mastopexy and 325 cc high-profile round Mentor
implants for breast ptosis, one year postop
a b
Fig. 42.10 (a) Preoperative. (b) and (c) 7 months postoperative 300 cc round Mentor implants and breast lift
a b
Fig. 42.11 (a) Preoperative. (b) 9 months postop. (c) Postoperative after 350 cc round high-profile implant for the left breast and
200 cc round moderate-profile implant and mastopexy for the right breast in a breast asymmetry and ptosis
a b
Fig. 42.12 (a) Preoperative. (b) and (c) 3 months postoperative 250 cc round Mentor implants and breast lift
42.6 Conclusions 3. Persoff M (2009) Breast augmentation with mastopexy. In:

Shiffman MA (ed) Breast augmentation: principles and
practice. Springer, Berlin, pp 257275
The main goal in treating ptosis is the achieving a well- 4. Nicolle FV (1984) Reduction mammoplasty and mastopexy:
shaped, well-proportioned, viable breast with intact a personal technique. Aesthetic Plast Surg 8(1):4350
sensation. This goal can be achieved with proper selec- 5. Persoff MM (2003) Vertical mastopexy with expansion aug-
mentation. Aesthetic Plast Surg 27(1):1319
tion of patients and careful planning and execution of
6. Persoff M (2003) Mastopexy with expansion-augmentation.
the surgical technique [19, 20]. Aesthet Surg J 23(1):3439
Mastopexy associated with augmentation has his- 7. Nahai F, Fisher J (2007) Augmentation Mastopexy: To stage
torically challenged plastic surgeons imagination. It is or not. Aesthetic Surgery Journal 27(3):297305
8. Spear SL, Giese SY (2000) Simultaneous breast augmenta-
true that mastopexy, plus implantation, is not as simple
tion and mastopexy. Aesth Surg J, 20:155
as each of these surgeries alone, but, by taking into 9. Stevens G, Stoker D (2006) Is one-stage breast augmenta-
consideration the details of a proper surgical technique, tion with mastopexy safe and effective? A review of 186
good results are maximized [11]. primary cases. Aesthetic Surgery Journal, 26(6):67481
10. Hammond DC (2006) Augmentation mastopexy: general
Lifting and augmentation of the ptotic breast can be
considerations. In: Spear SL (ed) Surgery of the breast: prin-
done with various methods of skin pattern resection ciples and art, 2nd edn. Lippincott Williams & Wilkins,
(crescent periareolar, circumareolar, vertical, or anchor Philadelphia, pp 14031416
type), each type also including an implant. The tech- 11. Cardenas-Camarena L, Ramrez-Macas R (2006)
Augmentation/mastopexy: how to select and perform the
nique presented herein has the advantage of a safer
proper technique. Aesthetic Plast Surg 30(1): 2133
NAC pedicle, decreasing the risk of necrosis, and an 12. Elliott LF (2002) Circumareolar mastopexy with augmenta-
improved padding of the inferior pole of the implant, tion. Clin Plast Surg 29(3):337347
which decreases long-term complications (skin isch- 13. Benelli L (1990) A new periareolar mammaplasty: the round
emia and necrosis) and achieves a nicer shape of the
14. Lassus C (1986) New refinements in vertical mammaplasty.
breast, leading to satisfactory results over the mid and Chir Plast 6:8
long terms. 15. Lejour M (1993) Vertical mammaplasty. Plast Reconstr Surg
The novelty of the technique described consists in 92(5):985986
16. Chiari A Jr (1992) The L short-scar mammaplasty: a new
increasing the safety of augmentation mastopexy by
means of a double pedicle that provides a secure blood 17. Grotting J (2006) Mastopexy. In: Mathes S (ed) Plastic sur-
supply to the NAC and, on the other hand, secures the gery, 2nd edn. Saunders Elsevier, Philadelphia, pp 4786
lower pole, preventing tension on the suture at the T 18. Spear SL, Pelletiere CV (2004) One-stage augmentation
combined with mastopexy: aesthetic results and patient sat-
confluence and reducing the risk of implant extrusion
isfaction. Aesthetic Plast Surg 28(5):259267
and palpability. In the same time a nicer shape is 19. Auersvald A, Auersvald L (2009) Crescent mastopexy with
achieved on a long-term basis. augmentation. In: Shiffman MA (ed) Breast augmentation-
principles and practice. Springer, Berlin, pp 277281
20. Borovikov A (2004) Use of myofascial flaps in aesthetic
References breast surgery. Aesthet Surg J 24(4):331341
1. Gorney M, Maxwell PG, Spear SL (2005) Augmentation

mastopexy, panel discussion. Aesthet Surg J 25(3):275284
2. Spear SL (2003) Augmentation/mastopexy: surgeon,
beware. Plast Reconstr Surg 112(3):905906
Breast Augmentation
and Mastopexy 43
Toma T. Mugea
43.1 Introduction Breast ptosis etiology is not only related to the

natural evolution of the mammary gland during preg-
From the aesthetic point of view, breast ptosis is simi- nancies, weight gain or loss, or aging, but also
lar with the hanging of the lower pole of the breast induced by iatrogenic breast augmentation using
below the inframammary fold level, without relation silicone implants. This new type of augmented
with the breast volume, which can vary in this associa- ptotic breast represents the most difficult problem
tion from type zero (empty breast) to type five (gigan- to be solved because we are dealing with a complica-
tomastia). This new classification proposed by the tion of breast augmentation, and usually these
author is practical, defining the breast not only as a patients are very careful with their own image. They
bidimensional structure (the relative position of the already had an aesthetic procedure, and they believe
nipple and lower pole of the breast to the inframam- that their breast should be the same as initially, with-
mary fold level), but also as a tridimensional one, out thinking about body aging and implant weight
including the breast volume into the skin envelope. influence on soft tissues. Pitfalls in breast augmenta-
The big difference between breast ptosis with hyper- tion (Table 43.1) represent, sometimes, the first step
trophy and breast ptosis with hypotrophy consists in for an unending chain of problems for both patient
the surgical solution to solve the problem. If in the and surgeon.
hypertrophic ptotic breast the main surgical goal is to The high rate of complications in this kind of proce-
reduce at the same time both the volume and skin sur- dures (breast augmentation and mastopexy) done at
face, in the hypotrophic ptotic breast, we have to deal the same time demonstrates not only the technical
with two divergent objectives to increase the breast difficulties in selecting the appropriate surgical proce-
volume and to reduce the skin surface. dure for each clinical case, but also the high risk of
For this reason, breast ptosis represents a continu- jeopardizing the vascular supply of the nippleareola
ous challenge for plastic surgeons, difficult to be solved complex or skin flaps, especially in revision secondary
when peoples are more demanding and expecting the cases.
best results with minimal scars, less money, and short
postoperative recovery time.
Table 43.1 Pitfalls in breast augmentation

1. Wrong patient
2. Wrong indication
3. Wrong associated surgery
T.T. Mugea
Department of Plastic and Aesthetic Surgery, Oradea Medical 4. Wrong pocket dissection
University, Oradea, Romania 5. Wrong IMF definition/suture
6. Wrong implant position
Medestet Clinic, Cluj-Napoca, Romania
e-mail: [email protected] 7. Wrong implant selection

716 T.T. Mugea
There are relatively large number of possibilities to lower two thirds of the breast vertical meridian,
do combinations between mastopexy techniques (peri- together with the nippleareola complex (NAC). Age,
areolar [1, 2], vertical [3], or Wise pattern [4] mark- gravity, breast volume, and decreased elasticity con-
ings) and different ways to insert the implant, pocket tribute to a gradual lowering of the breast landmarks
position (subglandular [5], partial submuscular [6], or over time, as a woman gets older and experiences nor-
subfascial [7]), and implant selection in terms of vol- mal physiologic changes. The extent of this descent
ume, shape, and filler solution. Unfortunately, there is depends primarily on the volume of the breast and the
also a larger list of possible associated complications elasticity of the tissues. The breast mound and central
that can occur even in experienced hands. This is why pedicle will change position according to gravity
some surgeons name these combined procedures the (Fig. 43.2).
recipe for disaster [8, 9] in breast aesthetic surgery In breast pseudoptosis, only the breast mound is
(Fig. 43.1). hanging. The nipple and the inframammary fold are at
the same level like in the normal situation. In glandular
ptosis, the breast and inframammary fold glide over
43.2 Breast Development and Ptosis the chest. In true breast ptosis, the breast and nipple
glide over the chest, but the inframammary fold is
Breast shape and contour are influenced by: at the same level. For this situation, according to
1. The volume of breast parenchyma. Regnaults classification [10], there are three grades of
2. The amount and location of the subcutaneous and ptosis, depending on the nipple and breast lower pole
intraparenchymal fat. position according to the inframammary fold level.
3. The body contour of the chest wall. Grade 1: Nipple at the level of the inframammary fold,
4. Its muscular covering and thickness. above the lower contour of the gland.
5. The tightness and elastic quality of the skin. Grade 2: Nipple below the level of the inframammary
In the normal growing phase, the breast can be con- fold, above the lower contour of the gland.
sidered to have a hemispheric shape, with the nipple in Grade 3: Nipple below the level of the inframammary
the middle in the most prominent point. As the breast fold, at the lower contour of the gland.
gains weight, because of the gravity and ligament The limit to Regnaults breast ptosis classification
tightening, the breast mound will translate into the is related to the difference between moderate and
Fig. 43.1 Recipe for disaster cases after breast augmentation and mastopexy. (a) Patient with large scar. (b) Tubula breast corec-
tion. (c) Hanging breast over high sitated implant
43 Breast Augmentation and Mastopexy 717
severe ptosis situations, where only the nipple position Breast tissue 1st degree = 01 cm
defines the severity of ptosis. The lower contour of the 2nd degree = 12 cm
gland level according to the inframammary fold level 3rd degree = 24 cm
has no influence in the definition of breast ptosis sever- 4th degree > 4 cm
ity. This has been corrected by Botti [11] classifica-
tion, who proposes a new classification scale of breast According to Botti [11], the NAC/breast ptosis
tissue and nippleareola complex ptosis, according to degree code could have different kinds of combina-
the distance between these and the inframammary fold tions between 1/1 and 4/4.
level (Fig. 43.3). In daily practice, based on different classifications
from the literature [12], the author noticed the difficulty
Nippleareola complex 1st degree = 01 cm in defining in a unique way the breast volume, position,
(NAC) 2nd degree = 12 cm and proportion related to the patient. Also, there are
3rd degree = 24 cm different ways of defining breast hypertrophy as small,
4th degree > 4 cm moderate, or severe type, depending on the extra weight
718 T.T. Mugea
Fig. 43.2 The three types of breast ptosis, according to the the continuous line show the sixth rib level, where normally is
nipple position and inframammary fold level [10]. The dotted the inframammary fold level
lines show the breast upper pole level (anatomical landmark);
a b
Fig. 43.3 Patient with right breast ptosis NAC 3/Breast 4 (Botti classification)
added. The combination between glandular and fatty In the breast hypertrophy diagram, take as example an
tissue, for a defined volume, gives the breast weight, aesthetic breast with 350 mL, and increase the volume
which is difficult to be assessed before the operation. with 50% for each type of hypertrophy up to gigantomas-
In the last version of the computer program, a personal tia. The final shape of the breast depends on its weight
formula was used for breast volume assessment [13] based over skin and suspensor fibrofascial elements quality.
on the Breast Golden Number [14], breast vertical merid- Apart of the aesthetic breast, in strong connection
ian, breast perimeter, chest circumference at the inframam- with applied surgical procedure, there are six types
mary fold level, chest circumference at the inframammary of breasts according to glandular volume and ptosis
fold level over the breasts, and the distance between lower (Fig. 43.4):
pole of the breast and inframammary fold level. This for- In type 0 ptotic breast, all ptotic breasts without
mula is accurate only for breast ptosis cases. significant glandular volume are included, like
Evaluation starts based on the chart and computer empty breast founded after severe weight loss or
program that are able to provide the ideal aesthetic aging. All the following types of breasts (from
dimensions of that breast, as Breast Golden Number. type I to type V) can be converted in one certain
In order to have a basis for this new classification, ten situation to this type 0, losing volume by glandular
rules are accepted: hypotrophy. Mastopexy associated with autoim-
1. All aesthetic breasts fit the Breast Golden Number plant or breast implant is indicated. Because of
2. Aesthetic breast volume (ABV) depends on BGN skin and soft tissue quality, the aesthetic outcome
3. If the volume decrease = simply ptosis of the surgery is sometime less predictable. If there
4. If the volume increase = breast hypertrophy and is no skin excess and only empty breast, breast
ptosis augmentation with implant is the choice, and this
5. All hypertrophic breasts are ptotic case does not belong to this type of ptosis.
6. Breast hypotrophy = below aesthetic breast volume In type I ptotic breast, small hypertrophy is natu-
7. Small hypertrophy = ABV + 50% extra volume rally accompanied by ptosis, and usually these
8. Moderate hypertrophy = ABV + 100% extra ladies wear a B- or C-cup bra size. Mastopexy with-
volume out glandular excision is the solution. Short inverted
9. Severe hypertrophy = ABV + 150% extra volume T scar or vertical scar technique will ensure a
10. Gigantomastia = ABV + over 200% extra volume good and stable aesthetic result.
Glandular Volume & Ptosis

Classification
0 I II III IV
V
Type III - Severe Hypertrophy & Tight Soft Tissue
Type V - Gigantomasia
Fig. 43.4 Glandular volume and ptosis classification

720 T.T. Mugea
a
Mn Ac Ac
MnPb: Ac-Ac:
Sp Sp:
distance between distance between the
Lateral Edges of the distance between the
Mn(ManubriumNotch) &
Acromion Bones Antero Superior Spina
Pb(Pubis Superior Edge)
of Iliac Bone
Pb Sp Sp
Breast Vertical Diameter Breast Horizontal Diameter

b (BVD) (BHD)
Areola Diameters
the distance between the distance between

BUP
Breast Upper Pole & Sternal and Axilar Edges Areola Vertical Diameter
AVD
Inframammary Fold Level St Ax of the Infarmammary Fold Areola Horizontal
IMF AHD Diameter
(measured with a caliper).
Nipple Chest Circumference Infra Chest Circumference

c (Ni-Ch) (Infra-Ch)
Breast Perimeter Length
BPL
Circular Breast Length

Chest Circumference
Chest Circumference at the
measured over
measured at Infarmammary Fold Level.
the most projected points
of the breasts the Inframammary Fold Level
d Breast Vertical Meridian Glandular Ptosis Score Nipple Areola Complex

(G.Botti) Ptosis Score (G. Botti)
BVM
BUP
BUP to Inframmamary Fold Lower Pole of the Breast to Nipple to
IMF
distance over the Nipple Inframammary Fold distance Inframammary Fold distance
Ni
Fig. 43.5 Breast and trunk measurements, during examination
In type II ptotic breast, moderate hypertrophy is of breast is a good indication for breast reduction
obvious accompanied by visible ptosis, and these with short inverted T scar.
women wear a C-cup bra size. Mastopexy with In type IV ptotic breast, there is a severe hyper-
small glandular resection is necessary and allows trophy with loose soft tissue. These cases derived
good and predictable results. from type III when they lose weight. The skin and
In type III ptotic breast, there is a severe hyper- soft tissue have no elasticity and do not retract after
trophy with tight soft tissue, indicating a heavy the breast excision. The gland is hanging over the
breast with the elastic properties preserved. Usually, chest and can be mobilized around its base. The
these women wear a D-cup bra size and have marks upper pole of the breast is empty, and the inframam-
over the shoulders accompanied by neck and back mary fold is longer, as used to be when the breast
pain. The social life is severely affected. This type was full, and lower situated on the chest. Breast
reduction with full horizontal inverted T scar is Because mastopexy and breast augmentation are
usually necessary to drape the breast mound and to being done, are going to be done in the same proce-
avoid the dog ears of the scar. dure, the patient measurement data are introduced in
Type V ptotic breast, including gigantomastia, is both computer programs, and so the computer can sim-
a rare condition characterized by excessive breast ulate what will be necessary to do. and the computer
growth and can be physically and psychosocially can simulate on computer programs what will be nec-
disabling for the patient. Symptoms include mastal- essary to do. For mastopexy, the program (Fig. 43.6b)
gia, maceration/infection, postural problems, back shows not only the preoperative breast volume and
pain, and chronic traction injury to 4th/5th/6th NAC location, but also the marking points and dis-
intercostal nerves with resultant loss of nipple tances where to place the incisions in order to achieve
sensation. It is also associated with decreased fetal the Breast Golden Number (in this case, BGN = 20).
growth during pregnancy [12]. Being over D cup, Breast augmentation computer program (Fig. 43.6c)
bra wearing is usefulness. suggests in this case an anatomical implant CPG style
Standard breast photos are taken after examination 313 from Mentor chart with 240 mL, but our decision
(Fig. 43.5) and loaded in the patients electronic file. was to insert a 323 style with 260 mL. This implant has
These include standing front, profile, and oblique posi- a narrow base and a bigger projection for the same height,
tion with arms relaxed and lifted. In order to demon- corresponding to our intention to better correct the severe
strate the inframammary fold level, useful also in ptosis degree for the empty breast. Computer programs
tubular breast examination, special photos are taken show the preoperative breast volume as 181 mL.
with the breast suspended and gently pulled by the
assistant.
43.3 Breast Augmentation and Wise According to the preoperative marking, the surgical
Pattern Mastopexy for Breast procedure starts with the deepithelialization of the
Ptosis Type 0 inferior NAC pedicle (Fig. 43.7). Using a radiofre-
quency needle, two transdermal vertical incisions are
Breast ptosis type 0 (Fig. 43.6) is the most undesirable made deep to the adipose tissue, at 5 mm to the skin
situation a surgeon can dream to deal with if a breast margin. This will allow NAC pedicle gliding upward
augmentation should be done in the same time with a and lateral pillar advancement to the medial line. The
mastopexy procedure. The skin is in excess without periareolar and vertical dermohypodermal sutures are
elasticity, and the marking for the excision and new done at this moment using 2/0 Vicryl, in separate
NAC location has to be done carefully, stretching the reverse way.
skin as will be with the implant inserted. Except for A separate incision for retromusculofascial approach
the cases where the periareolar mastopexy is indicated, will be done at the lateral branch of the inframammary
the Wise pattern skin resection is the most efficient deepithelialized line (Fig. 43.8), and the procedure
procedure by which both the horizontal and vertical will continue as in a routine retromusculofascial dual
dimensions of the skin brassiere in the ptotic breast plane breast augmentation [9, 18]. The retrofascial dis-
can be reduced. section will be done first up to the upper third of the
From a vascular point of view, the inferior pedicle major pectoralis muscle in this specific case with type
allows better lateral and medial reshaping than do 0 breast ptosis (Fig. 43.9), to allow the free muscular
superior-based flaps [15]. This is because the inferior- retraction after division. Also, the deep layer of super-
based flap originates from a dermoglandular pedicle ficial fascia will be opened along the inframammary
that is based on the fourth, fifth, and sixth intercostal fold, about 2 cm superior to the inframammary crease
perforating vessels of the internal mammary vessel. ligament, like a glandular window to allow the
Even the dermis of the flap can be divided, as long as implant to fill the lower pole of the breast (Fig. 43.10).
the inferior portion of the transversely oriented septum This deep layer of superficial fascia is like a curtain
of the breast is not violated, because the perforators are in front of the implant, quite significantly represented
located along the septum [16]. in some cases.
722 T.T. Mugea
a Computer Program Breast Reduction / Mastopexy
Computer program Breast Augmentation
Fig. 43.6 (a) Preoperative patient with breast ptosis type 0. (b) Computer program for mastopexy to be done. (c) Breast augmenta-
tion computer program
b Computer Program Breast Reduction / Mastopexy
Transdermal
Incision
Deepithelialised
Skin
Retro musculo fascial
Approach
Fig. 43.7 (Left) Wise pattern inferior pedicle flap. (Right) Transdermal incisions for lateral flap mobilization and retromusculofas-
cial dual plane approach for implant pocket
724 T.T. Mugea
Periareolar
Purse String
Suture
Retro Musculo Lateral Flaps Purse String

Fascial Approach Pillars Suture Suture
Retrofascial
Dissection
Glandular
Window
Deepithelialized
Flap
Fig. 43.8 Separate incision for retromusculofascial approach at

the lateral branch of the inframammary deepithelialized line
Fig. 43.10 Retrofascial dissection with glandular window
from lateral to medial, parallel to the inframammary

fold and 1 cm above it. The pectoral muscle division
stops at the medial edge of the inframammary fold
(Fig. 43.9) joining the retrofascial dissection level.
The retropectoral dissection continues according to
the anatomical landmarks.
Especially in the cases with thin tissues, excessive
medial or superior release of pectoralis muscle risks
the creation of superior window-shading or unnatural
medial breast fullness. Sometimes on the sternal side,
there are muscular fibers placed like a curtain, in layers
with more lateral origin that the main muscular body,
over the ribs. This must be carefully divided after
bipolar cauterization, because they can cover and hide
Fig. 43.9 Major pectoralis level of division intercostal perforators from the internal mammary
artery. Also this division will allow a good implant
position in the medial side of the pocket.
The retropectoral dissection starts laterally, close After meticulous hemostasis, a suction drain will be
to the inframammary fold where the space is easiest placed for 24 h through a separate stab incision and
to enter because there are no attachments to pectora- anatomical implant inserted in the pocket. The author
lis minor or serratus anterior and, is carried out supe- uses, in this case, Mentor anatomical implant CPG
rior up to the nippleareola complex, and then style 323 with 260 mL. Digital control will check the
medially. Now the pectoralis muscle is clean, with implant to be well placed, in a gentle tension, and cov-
two dissected spaces anterior and posterior to its ered by the major pectoralis muscle without twisting.
belly. Holding the pectoralis fibers with an anatomi- The wound closure will start suturing, with 2/0
cal forceps, the muscle origin division starts easily Vicryl in separate points, the deepithelialized flap at
The follow-up should be done at 7 days and at 1 and

Retro Musculo 6 months after the surgery. The patient has to come for
Fascial Pocket
breast assessment, including pictures and measure-
ments at 1 and 3 years. Patients are encouraged to
come whenever they feel it is necessary, especially if
Anatomical something changes in their biological life (weight,
Silicon pregnancy).
Implant
43.5 Postoperative Result
Postoperative consultation will include breast mea-

surements (Fig. 43.12) and standard photos, which
will be transferred to the computer program as con-
trol file (Fig. 43.13). Breast volume increased from
preoperative volume 181 mL to postoperative vol-
Dermal
Sling ume 413 mL, after breast augmentation with 260 mL
silicone implant. There is no arithmetic addition of
volumes, because the soft tissues have been com-
Glandular
Window pressed by the device. Computer program shows that
postoperatively the Breast Golden Number was almost
achieved for this case. Nice natural appearing breasts
with stable result even at 6 months demonstrate the
accuracy of the planning and of the surgical procedure
Fig. 43.11 Postoperative position of anatomical structures. (Fig. 43.14).
Deepithelialized flap covers the thoracic fascia
43.6 Mastopexy and Breast

the thoracic fascia (Fig. 43.11). This will give a stronger Reconstruction for Subcutaneous
support for the implant in the weaker point of the lower Mastectomy
pole of the breast, protecting also the inframammary
fold suture from tension. The second suture layer will This is a particular case of a 45-year-old female
approximate the thoracic fascia to dermis using 2/0 (Fig. 43.15a) who came asking for a breast reposi-
Vicryl reverse stitches in separate points. The final tioning without breast augmentation. The preopera-
shape of the breast can now be seen, and the wound tive pictures and breast measurement introduced into
closure completed easily by a continuous running the computer program (Fig. 43.15b) guided the preop-
suture with 5/0 resorbable PDS, for all areas. erative marking. The operation start as a short inverted
The whole incision length is taped with SteriStrips T scar mastopexy and turned out to be for the right
changed every 5 days, for 36 weeks. A gentle hold- breast would start as a short inverted T scar mastopexy
ing adherent bandage will be applied starting with sev- (Fig. 43.16) and for the right breast a reconstruction
eral horizontal loops at the inframammary level, with mastopexy.
followed by several loops covering the upper pole of The patients medical history and clinical exami-
the breasts in an alternative way (left breast and right nation did not show any breast problem. The
breast). This dressing will hold the whole structure as mammography was described as according to the nor-
a unit for several days. Usually, the suction drains are mal group of age, and the patient was scheduled for the
removed at 24 h. operation, without ultrasound medical report, which
Patients are asked to wear brassiere for 6 weeks. was supposed to come later.
Gentle touch of the breasts is permitted but without Even with preoperative checking list, because of a
massage which can lead to an implant rotation. human error, this case escaped without full senologic
726 T.T. Mugea
Computer Program BreastAugmentation
Fig. 43.12 Postoperative breast measurements in the computer control file
Fig. 43.13 One month postoperative

Fig. 43.14 (a) Preoperative patient. (b) One month postoperative (c) Six months Postoperative
728 T.T. Mugea
Fig. 43.15 (a) Preoperative patient. (b) Computer program for mastopexy and preoperative measurements
examination documents at the file, and the surgeon dis- tectomy with immediate breast reconstruction with an
covered the fibrocystic aspect of the right breast only anatomical silicone implant (Fig. 43.17).
during the operation, when the inferiorly based NAC After subcutaneous mastectomy, for the right breast
pedicle was already prepared. Facing this tight situa- reconstruction, a retropectoral pocket was prepared.
tion, with multiple cysts full with fluids discharging in Knowing the breast diameters and preoperative left
the wound and the mastopexy with inferior NAC pedi- breast volume as 269 mL, a 225 mL Mentor anatomical
cle done by half, it was a hard decision to take what to implant CPG style 323, high projection was chosen.
do next. As the ultrasound report confirmed the intra- A suction drain was placed for 48 h. The surgical
operative findings for the right breast, the left one procedure for the left breast went without incidents,
being normal, we decided to do a subcutaneous mas- following the short inverted T scar technique [14].
blood coagulation on the deepithelialized areas. Every

23 h, some drops with diluted heparin solution were
applied on the first gauze layer, changing only the top
layer gauze. Leeches for medical use were not available
at that moment. Except for a small area of areola necro-
sis, the wound healed without aesthetic problems
(Fig. 43.19).
NAC The postoperative result at 6 months (Fig. 43.20)
Dernal pedicle shows an acceptable breast volume, shape, and posi-
tion since the patient did not want any breast
augmentation.
This particular case is presented to emphasize the
ability of inferior dermal pedicle to support NAC
vascularization, like a randomized flap. The few favor-
able points for this outcome were:
1. Length and width of the flap was quite similar
(11/10 cm).
2. NAC flap was deepithelialized on the whole sur-
Fig. 43.16 (Left) Wise pattern for mastopexy, with deepitheli- face, allowing vascular drainage.
alization. (Right) NAC inferior pedicle
3. Areola congestion management using tangential
deepithelialization and heparin-soaked gauze.
4. Taping the breast with adherent paper allows a good
Retro Muscular contact between NAC dermal pedicle and skin flaps,
Pocket
for capillary circulation reestablishment.
5. Active suction drain prevents fluid accumulation
Subcutaneous and further complications related to it.
Mastectomy
Anatomical Shape
Silicon Implant 43.7 Breast Augmentation and
Periareolar Mastopexy Revision
Surgery
Breast augmentation is one of the most demanded aes-

thetic surgery procedure in private practice, and now
we are happy to do this from a financial point of view.
But we do not have to forget that now we are also oper-
NAC Dermal Flap ating on cases done years ago, with old types of
devices, old technology, and with old surgical
Fig. 43.17 Postoperative position of the anatomical structures techniques.
Influenced by media, people usually are asking for
big implants without paying attention to the breast
The right breast was taped with adherent paper and trunk proportions and without thinking for the
around the base (Fig. 43.18) to decrease the free space future. As the population of augmented women ages,
around the implant and prevent early displacement. and also had physiological transformations during
Tangential areola deepithelialization has been done in pregnancy, breast feeding, or weight changes, greater
several points to allow the bleeding and decrease venous numbers will require some combination of breast
congestion until the local circulation reestablished uplift, capsular surgery, and implant exchange. Also,
(Fig. 43.18). Also, on the top of the areola, heparin- the adverse effects of implant weight on breast anat-
soaked gauze was placed for about 3 days to prevent omy and physiology like tissue atrophy, thinning, and
730 T.T. Mugea
Fig. 43.18 Tangential areola deepithelialization to allow bleeding and decrease venous congestion
a b c
Fig. 43.19 Wound healing of the right breast areola. (a) Seven days. (b) One month. (c) Six months
stretching, combined with reduction of blood supply augmentation except the aesthetic appearance and did not
to the skin and nipple, are the main factors increasing know the device trademark or the volume used.
the risks of combined secondary surgery and merit The computer program for mastopexy is designed
careful attention [8]. only for Wise pattern technique, but can be used
In the case of a patient with retroglandular breast for breast volume evaluation and future NAC location
augmentation done 15 years ago (Fig. 43.21), with (Fig. 43.21).
saline-filled round implant in a skinny patient through
a wide inframammary approach, turned out to look
like hanging rocks on the chest. Mentor, one of the 43.8 Preoperative Plan and Surgical
twon FDA-approved breast implant manufacturers, Technique
performed a study that documented patients
complications with the product. In an FDA meeting Because of the patients preoperative poor condition
presentation in March 2000, they found that 43% of with very thin soft tissue cover on the implant, prepec-
saline implant patients reported a complication within toral implant position, and inframammary scar, a peri-
3 years [17]. Ten percent of those complaints were of areolar mastopexy was planned combined with old
severe capsular contracture. implant removal and new implant insertion through
Even the implants shape had rippling, defined quite the same inframammary approach (Fig. 43.22). The
obvious and covered with a very thin soft tissues the cap- pocket had to be changed from prepectoral to dual
sular contraction corresponds to stage Baker III (grade plane retromuscular capsular position.
III the breast is firm and looks abnormal) the patient After preoperative preparation of the patient,
did not have any other complaint regarding the breast according with the markings (Fig. 43.23), the surgery
Fig. 43.20 (a) Preoperative. (b) Six months postoperative
is started with dermal incision to delimitate the sutures and running intradermal suture with 5/0 PDS
deepithelialized areas on areola. The second step of (Fig. 43.24b).
the procedure started with areola deepithelialization The surgery continued with inframammary
and marginal dermohypodermal incision, saving a approach. Old scar will be excised in an elliptical
5-mm margin from the skin, which will be used at shape with 6/0.5 cm dimensions, followed by capsular
the closing sutures. This marginal dermis will hold incision of the same length. A small amount (few mL)
the skin in the suture without tension and will pre- of synovial-like fluid discharge and was been sent to
vent poor scars during the healing process. Areola the lab for bacteriologic examination. The capsule was
released and undermined like a mushroom about about 2 mm thick, close to the skin, and not adherent
0.5 cm around the dermal edges of central pedicle to the implant. Implant removal has been done without
(Fig. 43.24a). incidents, and the measured volume (done by immer-
The wound diameter will be decreased to the desired sion in a certain amount of water) show 400 mL of
diameter of 5 cm using a purse string suture with 2/0 saline. A specimen from the periprosthetic capsule,
Vicryl and then sutured to the dermohypodermic layer including a few millimeters of soft tissue close to it,
of the new skin margin with reverse separate 2/0 Vicryl was sent for histopathology, for records.
732 T.T. Mugea
The pocket looked clean, with some fibrotic bridges wound was closed in two layers using 2/0 Vicryl inter-
between cupola and the floor at the medial and lateral rupted sutures.
edges. The capsule floor, including pectoral fascia, had The whole incision length is taped with Steri-Strips
been removed up to the level of the superior edge of changed every 7 days, for 36 weeks. Patients are
the pocket, followed by several 34-cm-long radial asked to wear a special brassiere for 6 weeks to hold
incisions of the capsular cupola. the implant in the same position. Postoperatively, mild
The pectoralis major muscle looks very thin and venous congestion was noted on some areas of the
has been divided close to the sternal origin [18], areola, which healed without problems (Fig. 43.25b).
preserving about 1-cm-small inferior stump. A suction The suction drains are removed in 36 h, and patient is
drain with mild negative pressure was placed using a discharged in 48 h after the operation with oral antibi-
lateral stab incision. Considering the computer otics (cefalexine) for 3 days.
program advice, experience, and local conditions, it The postoperative follow-up at 7 days and 30 days
was decided to insert a Mentor CPG anatomical show an acceptable result, with good breast position
implant, style 323 with 260 mL, and 5.3-cm projection and proportion with the chest, achieving the Breast
in a retromuscular capsular position (Fig. 43.25a). The Golden Number (Figs. 43.25c and 43.26).
Fig. 43.21 (a) Preoperative patient. (b) Breast measurements and computer program for mastopexy. (c) Breast measurements and
computer program for implant selection
c Computer Program Breast Augmentation
10 years previously. For the first 5 years, the postopera-

43.9 Breast Augmentation and Wise tive outcome was fine, without problems, and the patient
Pattern Mastopexy Revision was happy with the result. After a pregnancy with 12-kg
Surgery body weight variation and 2 months breast feeding, the
breast become ptotic, with folds visible on the upper
This patient (Fig. 43.27) had a retroglandular breast pole and implants palpable close to the skin in the lower
augmentation with 230 mL saline-filled Polytech pole. She came with the implant passport and discharge
Silimed implant through an inframammary approach letter from the clinic where she had the operation done,
734 T.T. Mugea
Periprosthetic
Capsula
Periprosthetic
Capsula
Retro Musculo Capsular

Dual Plane Pocket
Periareolar
Deepithelialized Skin
Inframammary
Approach
Fig. 43.22 (Left) Preoperative position of breast implant. (Right) The operation plan
a b c
Fig. 43.23 Preoperative marking for periareolar mastopexy
a b
Periareolar
Purse
String Suture
Inframmary
Scar
Fig. 43.24 (a) Round block periareolar mastopexy (areolar release). (b) Periareolar mastopexy with purse-string suture
a b
Retro Musculo capsular
Dual plane pocket
Anatomical
Silicon lmplant
Periprosthetic
Capsula
Dermo Capsular
Flap
c Computer Program Breast Augmentation
Fig. 43.25 (a) Postoperative position of breast implant and anatomical structures. (b) Twenty four hours postoperative showing
partial areolar venous congestion. (c) Postoperative result with Breast Golden Number achieved
and the senologic examination confirmed the saline- with short inverted T scar (Fig. 43.29) and implant
filled silicone implant with the retroglandular pocket replacement with a silicone gel device (Fig. 43.30) in a
and a thin preprosthetic capsule (Fig. 43.28). A small new retromuscular capsular pocket (Fig. 43.31).
line of intracapsular fluid was detected. Preoperative marking (Fig. 43.32) was done with
Clinical consultation and breast measurements lead the computer dimensions. According to the preop-
to the decision to perform a Wise pattern mastopexy erative marking, the surgical procedure starts with
736 T.T. Mugea
Fig. 43.26 (a) Preoperative. (b) Seven days postoperative. (c) One month postoperative
a b c
d e f
Fig. 43.27 Preoperative patient in standard positions
the deepithelialization of the inferior NAC pedicle this moment using 2/0 Vicryl, in separate reverse way,
(Fig. 43.33). Using a radiofrequency needle, two trans- covering the dermocapsular inferior NAC pedicle. The
dermal vertical incisions are cut, deep to the adipose final intradermal suture will be done at the end of the
tissue, at 5 mm to the skin margin (Fig. 43.33). This surgery. A separate incision (5 cm length) for implant
will allow the NAC pedicle to glide upward and lateral removal and new pocket creation will be done at the
pillars advancement to the medial line. The periareo- lateral branch of the inframammary deepithelialized
lar and vertical dermohypodermal sutures are done at line (Fig. 43.34), using the radiofrequency device.
738 T.T. Mugea
A small amount of synovial-like fluid was found

in the pocket and samples were sent to bacteriol-
ogy for examination. The thin periprosthetic capsula
(Fig. 43.35) covering the implant was not adherent
to the device, and the pocket looks to be a little bit
larger, allowing the implant to move gently inside.
Periprosthetic
Capsula The implant shield had a textured surface covered with
multiple spots of white fibrotic tissue (Fig. 43.35) that
condensed behind the valve. In one case, a condensed
band was found connected to the periprosthetic cap-
sule (Fig. 43.36) lifting the implant valve and allowing
the saline fluid leaking from the device.
The host reaction to the implant as a foreign body
includes three layers:
1. First layer represented by the periprosthetic capsule.
2. Second layer is the synovial-like fluid inside
periprosthetic capsule.
3. Third layer covers the implant texture and is inti-
mately adherent to it.
A specimen from the periprosthetic capsule, including
few millimeters of soft tissue close to it, was sent to the
histopathology, for records. The removed breast implants
Fig. 43.28 Preoperative patient with implant in place had the volumes unchanged from the initial operation,
230 mL. The pocket looked clean, without fibrotic bridges
Computer Program Breast Reduction / Mastopexy
Fig. 43.29 Breast and trunk measurements and computer program for mastopexy
Computer Program Breast Augmentation
Fig. 43.30 Patient measurements and computer program for breast augmentation
Retro Musculo The pectoralis major muscle that looks thin was
Capsular Pocket divided close to the sternal origin, preserving about
1-cm-small inferior stump. A suction drain with mild
Periprosthetic negative pressure was placed using a lateral stab inci-
Capsula sion. Considering the computer program advice, our
experience, and local conditions, it was decided to
insert a Mentor CPG anatomical implant, style 323
with 195 mL, and 4.8-cm projection in a retromusculo-
Deepithelialized capsular position.
Periareolar Skin The wound closure will start suturing, with 2/0
Dermo Cutaneous
Lateral Flaps Vicryl in separate points, the corresponding deepithe-
lialized flap and periprosthetic capsule to the thoracic
fascia (Fig. 43.37). This will give a stronger support
Inframammary for the implant in the weaker point of the lower pole of
Approach
the breast, protecting also the inframammary fold
suture from tension.
The second suture layer approximated the thoracic
fascia to dermis using 2/0 Vicryl reverse sutures in
Fig. 43.31 Operation plan separate points. The whole wound closure was com-
pleted by a continuous running suture with 5/0 resorb-
between cupola and the floor. The capsule floor, includ- able PDS, for all areas. At the end of the surgery, the
ing pectoral fascia, was removed up to the level of the lower pole of the implant will be sustained by the NAC
superior edge of the pocket, followed by several 34-cm- dermal capsular inferior pedicle covered by the dermal
long radial incisions of the capsular cupola. cutaneous lateral flaps (Fig. 43.38).
740 T.T. Mugea
a b c
d e f
Fig. 43.32 Preoperative marking for short inverted T scar mastopexy
The incisions lines were taped with Steri-Strips will hold the whole structure as a unit for several
(Fig. 43.39) changed every 5 days, for 36 weeks. days. Usually, the suction drains can be removed at
A gentle holding adherent bandage will be applied 24 h. Postoperative result (Fig. 43.39) at 1 and
starting with several horizontal loops at the infra- 6 months shows a nice shape of the breast, with
mammary level, followed by several loops cover- good NAC position, and a breast volume well fitted
ing the upper pole of the breasts in an alternative with the patients body weight and dimensions
way (left breast and right breast). This dressing (Fig. 43.40).
Deepithelialised Skin
NAC
Inferior Pedicle Transdermal
Incisio
Retro Musculo
Capsular Approach
Fig. 43.33 (Left) Wise pattern for mastopexy, with deepithelialization. (Right) NAC inferior pedicle
Periareolar
Purse String
Suture
Retro Musculo Lateral Flaps

Fascial Approach Pillars Suture
Fig. 43.35 (a) Periprosthetic capsule. (b) Removed saline-

filled silicone breast implants
Fig. 43.34 Separate incision for retromusculofascial approach

at the lateral branch of the inframammary deepithelialized line
742 T.T. Mugea
Retro Musculo
Capsular Pocket
Anatomical
Silicon
Implant
Dermo Capsular
Sling
Dermo
Capsular
Flap
Fig. 43.37 Postoperative situation of the breast implant and

anatomic structures
NAC
Fig. 43.35 (continued) Dermo cutaneous

Lateral Flaps
NAC
Dermo Capsular
Inferior Pedicle
Inverted T Scar
Fig. 43.38 Dermocapsular inferior pedicle covered by the lat-

eral dermocutaneous flaps
Fig. 43.36 Fibrotic tissue from the periprosthetic capsule lift-

ing the implant valve
Fig. 43.39 (a) Early postoperative result with Steri-Strip tapes over the suture lines. (b) One month postoperative. (c) Six months
postoperative
744 T.T. Mugea
Computer Program Breast Augmentation
Fig. 43.40 Postoperative breast dimensions and volume correspond to the Golden Number
43.10 Conclusions 9. Preoperative patient evaluation and combined

computer program for breast augmentation and
Several points have to be emphasized: breast reduction are useful for a good planning
1. Breast augmentation has to be considered a high- and postoperative assessment.
level procedure. 10. To share our experience with difficult cases,
2. Breast augmentation is the beginning of a series of recognizing our mistakes is more useful than a pre-
revision surgery in most of the cases, sooner or sentation with huge series with excellent results.
later.
3. The heavier the implant is, the higher the risk of
long-term complications will be.
4. The inframammary approach in first session of References
breast augmentation is more convenient for a sec-
1. Benelli L (1990) A new periareolar mammoplasty: the
ondary procedure. round block technique. Aesthetic Plast Surg 14(2):93100
5. Retrofascial pocket for breast implant is the first 2. Bartels RJ, Strickland DM, Douglas WM (1976) A new
choice, allowing a revision surgery with retropec- mastopexy operation for mild or moderate breast ptosis.
toral switch.
3. Lejour M (1994) Vertical mammoplasty and liposuction of
6. Periprosthetic capsule can be used as a comple- the breast. Plast Reconstr Surg 94(1):100114
mentary support of the breast implant. 4. Wise RJ (1956) Preliminary report on a method of planning
7. Combined operations in the same procedure have the mammoplasty. Plast Reconstr Surg 17(5):367375
5. Cronin TD, Gerow RM (1964) Augmentation mammoplasty:
a high risk of complications.
new natural feel prosthesis. In: 3rd international congress of
8. Revision surgery for breast augmentation and mastopexy plastic surgery, excerpta medica international congress series
has to be carefully planned for vascular risk. no. 66. Excerpta Medica, Amsterdam, 1964, pp 4149
6. Regnault P (1977) Partially submuscular breast augmenta- congress of oriental society of aesthetic plastic surgery,
tion. Plast Reconstr Surg 59(1):7276 Tokyo, 13 Nov 2010
7. Graf RM, Bernardes A, Rippel R, Araujo LR, Damasio RC, 14. Mugea TT (2009) Breast reduction algorithm using
Auersvald A (2003) Subfascial breast implant: a new proce- TTM chart. In: Shiffman MA (ed) Mastopexy and breast
dure. Plast Reconstr Surg 111(2):904908 reduction: principles and practice. Springer, Berlin, pp
8. Handel N (2006) Secondary mastopexy in the augmented 275289
patient: a recipe for disaster. Plast Reconstr Surg 118 15. Loustau HD, Mayer HF, Sarrabayrouse M (2008) The owl
(7 Suppl):152S163S technique combined with the inferior pedicle in mastopexy.
9. Spear S (2003) Augmentation/mastopexy: surgeons beware. Aesthetic Plast Surg 32(1):1115
Plast Reconstr Surg 112(3):905906 16. Widgerow AD (2005) Breast reduction with inferior pedicle
10. Regnault P (1976) Breast ptosis: definition and treatment. fascial suspension. Aesthetic Plast Surg 29(6):532537
Clin Plast Surg 3(2):193203 17. FDA (2004) Section on complications, FDA breast implant
11. Botti G (2004) Mastoplastiche estetiche, atlante di chirurgia consumer handbook
plastica pratica. SEE Nicodemo & C snc, Firenze, p 251 18. Mugea TT (2009) Submuscular fascial dual plane breast
12. Dancey A, Khan M, Dawson J, Peart F (2008) Gigantomastia augmentation. In: Shiffman MA (ed) Breast augmentation:
a classification and review of the literature. J Plast Reconstr principles and practice. Springer, Berlin, pp 415429
Aesthet Surg 61(5):493502
13. MugeaTT (2010) Computer program for breast reduction
and mastopexy. In: Presented at the 12th international
Periareolar Mammaplasty
for the Treatment of Massive 44
Gynecomastia with Breast Ptosis
Marco Tlio Rodrigues da Cunha
44.1 Introduction Andrews et al. [12], in 1975, described a periareolar

approach for breast reduction. Ribeiro [13], in 1975, used
Gynecomastia surgeries have continued to evolve, but an inferior pedicle flap with the aim of projecting the mam-
treating massive and excess skin male breasts with mary cone and stabilizing its shape. Davidson [14], in 1979,
minimal incisional scarring is still challenging. removed excess skin in concentric circles limiting the final
Simon et al. [1], in 1973, described a clinical clas- scar to a circle at the periphery of the areola. Benelli [15],
sification after analysis of 77 cases of gynecomastia: in 1988, presented a permanent periareolar circling to avoid
Grade 1, small, visible breast enlargement without skin late widening of the nipple-areola complex. Martins [16],
redundancy; Grade 2A, moderate breast enlargement in 1991, described a periareolar mammaplasty with flap
without skin redundancy; Grade 2B, moderate enlarge- transposition. Kornstein and Cinelli [17], in 1992, reported
ment with skin redundancy; Grade 3, marked breast an inferior pedicle flap associated to a superiorly based
enlargement with marked skin redundancy. chest wall flap to reposition the nipple-areola complex,
The first description of a surgical treatment was resulting in a periareolar and inframammary scar.
made by Paulus of Aegina [2] (A.D. 635690) using a The authors reported the use of the periareolar
semilunar inframammary incision. Dufourmental [3], mammaplasty, with an inferior pedicle flap including
in 1928, described an infra-areolar marginal incision, the nipple-areola complex, to correct a male breast
divulged by Webster [4] in 1946. The transareolar mam- ptosis, as prior note in 1993 [18].
mary incision was published by Pitanguy [5] in 1966. The aim of the present technique is to evaluate
Many surgical difficulties are found in Group 2B the use of the periareolar skin approach associated
and 3, where excess skin is present. Some authors with inferior or superior pedicle flaps that include the
describe excess skin resection using a half-moon nipple-areola complex.
located at the borders of areola [6]; others utilize verti-
cal [7, 8], transverse [2], or oblique [9] skin ellipses.
Free graft [10] as well as superior pedicle [7] and 44.2 Technique
bipedicle flaps [2] are employed to elevate the nipple-
areola complex in large gynecomastia. Joseph [11], in The criteria adopted for patient selection were: breast
1925, published a method of female mammaplasty, in ptosis, massive gynecomastia, and skin excess.
two stages, where the nipple-areola complex is trans- Skin markings (Fig. 44.1) are performed with a
planted by means of an inferior pedicle flap. longitudinal line dividing the breast in two equal
halves (meridian), as well as the inframammary crease.
The breast meridian is marked:
Point A, 1726 cm from the sternal notch
M.T.R. da Cunha
Point B, 46 cm or more (in special cases) proxi-
Department of Plastic Surgery, Federal University
of Tringulo Mineiro, Uberaba, MG, Brazil mally to the inframammary crease
e-mail: [email protected] Point C, half the distance between points A and B.

748 M.T.R. da Cunha
a are joined, obtaining an oval-shaped form. The new

areola is marked with 3 cm diameter.
The breast meridian line was not always marked
passing on the nipple-areola complex. This allowed for
replacing the areola more medially or laterally when
necessary.
The surgery is performed under general anesthesia
CM
and topic infiltration with saline 1:400,000 epineph-
26
rine solution (Fig. 44.2). Liposuction is performed

17 using a 3-mm cannula at pectoral fascia plane and
A then superficially. This avoids dish-like deformity
and makes easier to remove the excess adipoglandu-
lar tissue from adjacent tissues. The excess skin
D C E
LINE marked is removed in its total thickness. The infra-
C areolar area is carefully deepithelialized preventing
injuries in the pedicle of the flap. An inferior pedicle
B 4 6cm
is made embodying the nipple-areola complex (used
in 8 of 19 cases) or a superior pedicle is used (in 11
INFRAMAMMARY cases). The flap thickness is reduced to that of the
CREASE patients subcutaneous tissue and its width to approx-
imately 5 cm. The flap is freed from the remnant skin
BREAST that covers it anteriorly, undermining it until next to
MERIDIAN inframammary crease in inferior pedicle cases. In the
superior pedicle cases after skin removal, a hemi-
circular incision is made distal to the nipple-areola
b complex. The excess adipoglandular tissues are easily
removed next to the flap, inside and outside the area
of skin resection. Hemostasis is carefully made under
direct vision. The tip of the flap is fixed to the anterior
pectoral fascia with four cardinal sutures, 1726 cm
from the sternal notch, in the breast meridian. The
superior pedicle nipple-areola complex does not need
to be sutured to the pectoral fascia or to be freed from
the remnant proximal skin. Double permanent peri-
areolar circling is made using 5-0 monofilament
nylon, closing the purse until 3 cm in diameter.
A catheter for suction drainage is placed through an
inframammary stab.
Fig. 44.1 Preoperative markings in patient with Grade 2B Sutures in U unite the areola to the periareolar
enlargement according to Simons classification (a) representa- purse-string skin. An occlusive dressing, lightly
tional drawing. (b) Clinical case compressive, is applied.
A transverse line, perpendicular to the breast merid- 44.3 Postoperative Care

ian, is marked passing on point C (line C). On line C,
the points D and E are marked by means of bidigital 1. Suction drainage is maintained for 25 days.
pinching, bringing them near, equidistant from the 2. The sutures are removed on the seventh to twelfth
breast meridian line. Excessive tension should be postoperative day.
avoided in this maneuver. The points A, D, B, and E 3. Compressive dressing is kept for 28 weeks.
44 Periareolar Mammaplasty for the Treatment of Massive Gynecomastia with Breast Ptosis 749
a c
b d
Fig. 44.2 (a) Left breast with point A at 21 cm from sternal the areola. (f) Aperture to remove residual adipoglandular tissue.
notch. (b) Liposuction is performed deeply at pectoralis major (g) Incision on inferior pole of the deepithelialized area. (h) Two
fascia and then superficially to make easier the glandular resec- purse-string sutures are made to prevent from late widening of
tion and to avoid the dish-like deformity. (c) Pinch test after nipple-areola complex. (i) Closure of purse-string sutures leav-
liposuction showing the differences between right breast and ing 2.5 cm circular raw area. (j) Half-buried horizontal mattress
still not operated left breast. (d) Skin incisions keeping the are- sutures complete the procedure
ola with 3 cm diameter. (e) Excess skin deepithelialized around
750 M.T.R. da Cunha
e f
g h
i j
44.4 Complications 4. Infection: 1 case

5. Bulging in the inferior pole of the breast:
1. Postoperative bleeding: 1 case 2 cases
2. Seroma: 2 cases 6. One patient with skin hypoesthesia that lasted for
3. Areola enlargement: 1 case 30 days
44.5 Discussion When there is marked tension in the suture, the purse
string should be closed approximately 20% more
Most of the difficulties in the surgical treatment of the than the desired areolar diameter. In our hands, this
gynecomastia are due to the restrict size of the incision procedure was not always effective. It is important that
that prejudices the illumination of the operative field the diameter of the skin that will be removed should
and the hemostasis. The transareolar mammary [5] and not exceed twice that of the new areola in regular cases.
infra-areolar marginal incisions [3, 4] are not always In massive gynecomastia, the amount of skin to be
efficient to correct gynecomastia with marked skin removed is only limited by tension on bidigital pinch-
redundancy and to elevate the nipple-areola complex. ing and by position of the areola. The patient should be
Skin resections by means of inverted T technique advised about the possibility of a second-stage proce-
[11] and vertical [7, 8] and transverse [9] skin ellipses dure to remove residual skin and adipose tissue.
result in long scars and can leave the breast cone like. The redundant adipoglandular tissue in the inferior
The illness stigma is replaced by a scar stigma, espe- pole of the breast is credited to the fear of thinning
cially in patients with hairless chest wall. excessively the base of the inferior pedicle flap.
The authors used the periareolar mammaplasty with The use of 2-0 monofilament nylon suture in the
skin markings similar to those described by Martins periareolar purse string in our first cases led to extru-
[16], in 1991, associated with an inferior pedicle flap sion of the suture material and infection in one case.
including the nipple-areola complex. The fixing of the This problem was solved with the use of 5-0 monofila-
flap to the anterior pectoral fascia did not significantly ment nylon and performing a tensionless purse string.
reduce the areola mobility due to its contact with the The marking of point B, 4 cm proximal to the infra-
flap pedicle and not directly with the fascia. mammary crease, seemed to limit its elevation until
One of the greatest disappointments of the periareo- the desired position of nipple-areola complex in some
lar mammoplasties in female patients is due to the cases. Its marking, 12 cm higher or more if necessary,
flattening of the breast cone. This is one of the least would be better to adequately bring the purse string to
desired events in gynecomastia operation. the new position of the areola.
The authors believe that the widening of the nipple- The use of the periareolar skin resection associated
areola complex resulted from a small undermining of to inferior or superior pedicle flaps gave a high index
the remnant skin and tension in the suture by insuffi- of satisfaction to our patients and would be another
cient closure of the permanent periareolar circling. option in well-selected cases (Figs. 44.3 and 44.4).
Fig. 44.3 (a) Preoperative patient with severe gynecomastia. (b) Skin markings (right breast) for superior pedicle technique keeping
more medial toward the breast meridian to keep the nipple-areola complex medially. (c) Three months postoperatively
752 M.T.R. da Cunha

a b
Fig. 44.4 (a) Preoperative patient with massive gynecomastia. (d) One year postoperative. (e) Periareolar scar and just proxi-
(b) Intraoperative wide operative field and superior pedicle mally a hypertrophic scar from the removal of a dysplastic mel-
with a medially positioned areola. (c) Immediate postoperative. anocytic nevus
754 M.T.R. da Cunha
References 10. Wray RC, Hoopes J, Davis GM (1974) Correction of

extreme gynaecomastia. Br J Plast Surg 27(1):3941
11. Sinder R (1989) Mamaplastia redutora histrico.
1. Simon BE, Hoffman S, Kahn S (1973) Classification and
In: Ribeiro L (ed) Cirurgia Plstica da Mama. MEDSI, Rio
surgical correction of gynecomastia. Plast Reconstr Surg
de Janeiro, pp 135
51(1):4852
12. Andrews JU, Yshizuki MM, Martins DM, Ramos RR
2. Ward CM, Khalid K (1989) Surgical treatment of grade III
(1975) An areolar approach to reduction mammaplasty.
gynaecomastia. Ann R Coll Surg Engl 71(4):226228
Br J Plast Surg 28(3):166170
3. Dufourmental L (1928) Lincision arolaire dans la chirur-
13. Ribeiro L (1975) A new technique for reduction mamma-
gie du sein. Bull Mem Soc Chir Paris 20:9
plasty. Plast Reconstr Surg 55(3):330334
4. Webster JP (1946) Mastectomy for gynecomastia through
14. Davidson BA (1979) Concentric circle operation for massive
semicircular intra-areolar incisions. Ann Surg 124:557
gynecomastia to excise the redundant skin. Plast Reconstr
5. Pitanguy I (1966) Transareolar incision for gynecomastia.
Surg 63(3):350354
15. Benelli L (1988) Technique de plastie mammaire: le round
6. Letterman G, Schurter M (1972) Surgical correction of
block. Rev Fr Chir Esth 13:711
massive gynecomastia. Plast Reconstr Surg 49(3):259262
16. Martins PA (1991) Mamaplastia periareolar com trans-
7. Hrinakova MF (1983) Reduction mammaplasty in seri-
posio de retalhos. Rev Bras Cir Plast 6:810
ous gynecomastias using a single superiorly based flap.
17. Kornstein AN, Cinelli PB (1992) Inferior pedicle reduction
In: Transaction of the VIII international congress of plastic
technique for larger forms of gynecomastia. Aesthetic Plast
surgery, Montreal, 1983, p 535
Surg 16(4):331335
8. Pers M, Breteville-Jensen G (1972) Reduction mammo-
18. Cunha MTR, Bento JFB (1993) Periareolar mammaplasty
plasty based on vertical vascular pedicle and tennis ball
for treating gynecomastia with breast ptosis. Prior note. Rev
assembly. Scand J Plast Reconstr Surg 6(1):6168
Soc Bras Cir Plast Est Reconstr 8(1, 2, 3):125130
9. Dufourmental C, Mouly R (1961) Plastie mamaire par la
methode oblique. Ann Chir Plast 6:45
Reduction Mammoplasty:
The Piece of Art 45
45.1 Introduction presenting complaints of women with excessively

large breasts. These symptoms are either eliminated or
The female breast is one of the most attractive aesthetic markedly improved by reduction mammaplasty. After
areas in female anatomy. Representation of breasts in surgery, many of these women enjoy a totally new out-
fine arts is best represented in Ingres erotic paint Turkish look, cured from their medical complaints and pursue
Bath (Fig. 45.1) and others. All paints are eloquent tes- activities that were previously unavailable to them.
timonies to the important role that feminine beauty and This chapter will review the anatomic basis for many
depiction of breasts play in societies. Our perception of of the breast reduction operations, summarize most of
what constitutes beautiful and sensuous breasts have not the literature, and discuss the senior authors (FSF) pre-
changed for the past 2,500 years. The size, shape, and ferred technique on reduction mammaplasty.
symmetry of the breasts can have a dramatic effect on the
womens well-being. Reduction mammaplasty is cer-
tainly one of the operations; plastic surgeons can signifi- 45.2 History
cantly contribute to a womans quality of life. Surgery
has repeatedly shown high patient satisfaction rate. Breast reduction surgery continues to evolve and is
Many women with excessively large breasts might being refined constantly with a large number of proce-
suffer from poor self-esteem, altered self-image, and dures. Each presents particular advantages in terms of
other psychological effects. In addition, women whose indications, vascular preservation, technique design,
breasts are abnormally large relative to their body built ease of realization, minimum scarring, maintenance of
are frequently limited in their choice of clothing and innervation, and long-term results.
lifestyle. They may find it difficult to exercise, to play As early as the sixth century AD, Paulus Aegineta
sports, and to participate in other daily activities. In described details of reduction mammaplasty for the
short, a womans breast size can affect her attitudes, correction of gynecomastia. Hans Schaller performed
career choices, and personal life in many ways. a reduction mammaplasty by breast amputation in
Medical conditions like skin lacerations and inter- 1561 [1]. Dieffenbach [2] was the first to perform a
trigo, chest tightness, chronic headaches as well as reduction mammaplasty in a female, leaving the scar
breast, neck, back, and shoulder pain are common in the inframammary fold. Thomas [3] and Guinard [4]
emphasized the inframammary fold as an entrance site
for the surgical correction of excessive breast tissue.
F.S. Fahmy (*) Most of the operations performed in the late 1800s
Department of Plastic Surgery,
and early 1900s aimed at correcting ptosis. Various
Countess of Chester Hospital, Cheshire, UK
e-mail: [email protected] types of skin and glandular excision were involved, all
of which attached or suspended the breasts into a
M.A.A. Saleh
Plastic Surgery Department, Ain Shams University, higher position on the chest wall, but without true nip-
Cairo, Egypt ple-areola complex (NAC) transposition. The concept

756 F.S. Fahmy and M.A.A. Saleh
Fig. 45.1 The Turkish Bath

painting by Ingres in 1862
of nipple-areola complex transposition was advanced marking the breast that produced accurate and
between 1909 and 1925. Morestin in 1909 [5] was prob- reproducible resection of parenchymal tissue with
ably the first to transpose the nipple-areola, followed by minimal complications and satisfactory breast shape.
Villandre, cited in 1925 and referring to patient whom Subsequent refinements in breast reduction surgery
he operated on in 1911 [6], and Lexer [7]. evolved around pedicle designs to preserve vascularity
The next stage in the evolution of breast reduction and place the scars in more aesthetic sites. Various ori-
surgery concentrated on the better understanding of entations of the breast dermal and parenchymal pedicles
the blood supply of the skin, mammary gland, and were described. Strombeck [12] described a horizontal
nipple-areola. The subdermal blood supply to the dermal bipedicle flap that helped maintain innervation
breast skin and gland was carefully considered. to the nipple-areola complex. McKissock [13] described
In 1937, Schwarzman [8] recommended leaving a a vertical bipedicle flap; Weiner [14], a superiorly based
periareolar dermal ring to enhance arterial and venous flap; Orlando and Guthrie [15], a superomedially based
blood supply to the nipple-areola. This maneuver flap; and Courtiss and Goldwyn [16] and Georgiade
improved viability of the nipple-areola complex, facil- [17] used inferiorly based flaps (Fig. 45.2).
itated its transfer, and was a start for techniques involv- Several authors since have described additional
ing deepithelialized nipple pedicle flaps. innervation to the breast, Marchac [18], Ges [19],
The importance of preoperatively marking the inci- Lejour [20], and Lassus [21], facilitating vertical and
sions was emphasized by Bames in 1948 [9]. The fol- short-scar reduction techniques. Although some of
lowing year, Aufricht [10] remarked that ultimate breast these techniques were developed in the late 1960s and
form is determined by the postsurgical skin brassiere. 1970s, its only been in the last few years that they
Wise in 1956 [11] described a pattern for preoperatively have gained widespread popularity.
45 Reduction Mammoplasty: The Piece of Art 757
45.3 Pathology remain quite small (9). The pathophysiology of breast

hypertrophy is thought to be an abnormal end-organ
Massive breast enlargement or gigantomastia (juvenile response to circulating estrogens [2628]. Jabs et al.
virginal hypertrophy of the breast) was first described [29] showed normal levels of estrogen and the usual
by Durston [22]. It is defined as yielding at least number of estrogen receptors in women with mam-
1,800 g of tissue per side during reduction mamma- mary hypertrophy, evidence of some womens hyper-
plasty [23, 24]. It is characterized by massive enlarge- sensitivity to the hormone.
ment of the breast tissue to enormous proportions, Eliasen [30] noted changes consistent with atypical
predominantly manifests in early puberty between 11 ductal hyperplasia in the surgical specimens obtained
and 14 years of age and most often manifests with the from five of nine young women who underwent reduc-
first menses [23, 25]. tion mammaplasty for hypertrophy, none of them
Massive breast enlargement consists primarily of showed any signs of breast carcinoma. This study sug-
fibrous tissue and fat, while the glandular elements gests that ductal hyperplasia may also play a role in the
a b
c d
Fig. 45.2 Various

orientations of the breast
dermal and parenchymal
pedicles. (a) Horizontal
bipedicled flap. (b) Vertical
bipedicle flap. (c) Superiorly
based flap. (d)
Superomedially based flap.
(e) Inferiorly based flaps

e
etiology of breast hypertrophy. Kupfer et al. [31] nant women, and surgical reduction is the primary
reviewed the literature of juvenile breast hypertrophy therapy for recurrence [23].
and presented their experience in two patients, mother A hormone assay is not indicated, especially in a
and daughter, which suggested to them a familial pat- person who has normal secondary sex characteristics
tern to the disease. [23].Although early studies showed that hormone sup-
pression was ineffective in the management of gyneco-
mastia, Baker and associates [32] reported a successful
45.4 Gigantomastia experience with tamoxifen combined with reduction
mammaplasty.
The mainstay of treatment in gigantomastia is radical The differential diagnosis of unilateral massive breast
surgery. Free nipple grafting is frequently required to hypertrophy in adolescent girls includes fibroadenoma,
obtain an adequate reduction. Recurrence of gigan- cystosarcoma phyllodes, virginal hypertrophy (unilat-
tomastia is a recognized risk, particularly among preg- eral), breast hamartoma, and trauma [23, 33, 34].
45.5 Indications for Surgery In a third prospective study, the authors examined
the effectiveness of surgical breast reduction in the
Breast size that is out of proportion to body habitus has relief of established symptoms of macromastia [47].
a profound effect on the musculoskeletal system. Many Analysis showed that 50% of operative subjects
patients complain of neck and shoulder strain, head- reported breast centered pain all or most of the time in
aches, breast pain, back pain, persistent rashes in the the upper back, shoulders, neck, and lower back preop-
intertriginous areas, a heavy anterior chest, and occa- eratively. This number decreased to less than 10%
sionally, paresthesia of the ulnar side of the hand. postoperatively. Preoperatively, the study subjects had
These women tend to show poor posture, with deep recorded significantly lower scores in all the health
shoulder grooving from bra straps, stretch marks, and domains of the quality-of-life assessment tools and in
rashes under the breast. In extreme cases, degenerative the mental and physical component summary scores.
arthritis of the cervical and thoracic spine has been Postoperatively, the operative subjects had higher aver-
noted. Letterman and Schurter [35] discuss the ana- age scores than the national norms in seven of the eight
tomical basis for these signs and symptoms, and con- domains and had significant improvement from their
cur with others that reduction mammaplasty may be preoperative evaluation in all eight domains (P < 0.05).
curative. The authors conclude that breast hypertrophy has a
The psychological benefits of restoring propor- significant impact on womens health status and qual-
tion between a womans breasts and her physique are ity of life. Pain was found to be a prominent symptom
difficult to quantify, but most surgeons believe they in this disease process, and both pain and overall health
are considerable. Despite various studies of reduction status were considerably improved by reduction mam-
mammaplasty showing favorable results [3643], the maplasty. They also concluded that patients with
surgical indications for reduction mammaplasty remain symptomatic hypermastia treated with conservative
unclear and subject to different interpretations by third- measures such as weight loss, special bras, and medi-
party payers. Surgery is the only real option available cations did not provide effective or permanent relief of
to reduce the breast size. Hormonal therapy, as such, is symptoms.
ineffective. Supportive brassieres are temporary mea- The above-mentioned studies, in contrast with pre-
sures to relief symptoms by transferring the discomfort viously published data, are very well-designed, pro-
to other areas. spective analyses of randomized series that definitively
Netscher et al. [44] studied whether breast size demonstrate the disease process and medical indica-
alone was responsible for the presenting complaints of tions for reduction mammaplasty, as well as validate
neck and back pain in patients seeking breast reduc- the effectiveness of reduction surgery in the treatment
tion. The authors found that symptomatic hypermastia of symptomatic hypermastia. The aim will be to dis-
is better defined by a constellation of symptoms rather perse these data to third-party payers and have them
than volume of tissue removed. There was no correla- adopt these guidelines as they are making determina-
tion between a womans weight and symptoms associ- tions regarding breast reduction surgery coverage.
ated with large breast size; overweight women had a
different symptom complex than those with large
breasts. The authors conclude that symptomatic hyper- 45.6 Aesthetic Concerns
mastia can be defined by a set of disease-specific phys-
ical and psychosocial symptoms which are not related There is great variation as regards heights, weights,
to patient age or weight. body shapes, and physical conditions of women seek-
Kerrigan and coworkers [45, 46] investigated the ing reduction mammaplasty, no single breast dimension
quality of life of women with breast hypertrophy. The will serve all. Surgeons should individualize each
authors conclude that breast hypertrophy has a signifi- patients desires regarding ultimate breast size and
cant impact on womens quality of life. Symptoms are shape in light of her age, physique, and surgical limita-
more important than breast volume in determining tions. Although all candidates for reduction mamma-
which women have the greater health burden. plasty want to have their breasts made smaller, most do
not wish their breast size to be out of proportion to vertical limbs. This ultimately affects the amount of
their build. Aufricht [10], Penn [48], and Berry [49] the tissue resected and the postoperative shape. Few, if
caution against trying to recreate a virginal appearing any, of such techniques have gained total popularity
breast; rather, the goal of reduction should be a smaller or acceptance by the plastic surgeons. The freehand
but slightly pendulous, mature looking breast. marking technique is probably the most widely used
As famously said by Sir Harold Gillies, much that we technique. Devices such as template [11, 16, 51],
do in plastic surgery involves a battle between beauty shaped wires, goniometers, and geometrical techniques
and blood supply. Over the years, the battle extended to have also been recommended [16, 5256]. Some of
include minimizing scars. Breast reduction is no differ- these devices have stood the test of time; others have
ent. The underlying principles of breast reduction and been modified or abandoned.
mastopexy surgery have evolved significantly in the past The free hand technique, being the most widely
20 years. Breast bottoming out occurs most frequently used, requires experience and practice in order to
with inferior pedicle techniques in which much of the achieve the desired results. Multiple devices have been
breast shape depends on skin tension. Other techniques created to facilitate markings including templates,
incorporate additional parenchymal support without keyhole patterns, goniometers, etc. The standard pat-
skin tension or skin shaping, and bottoming out can be tern with a fixed angle of 110 between the two seg-
controlled for excellent long-term results. ments was further modified by McKissock [13] to
The multitude of different techniques and modifica- allow for adjustment of the angle to the widely vari-
tions with regard to pedicle choice, scar position and able breast shapes. The Wise keyhole pattern marking
length, or breast shaping reflects the challenge for is influenced by the surgeons experience.
every plastic surgeon to achieve an aesthetic shape The standard patterns and devices are rigid methods
with long-term stability and with minimal scars in that may achieve symmetrical markings, not necessar-
mammoplasty. This inspired the senior author (FSF) to ily symmetrical outcome. They do not account easily
describe his own breast reduction marking technique to preexisting breast asymmetry. Devices may also be
and develop a new surgical approach. not readily available in all hospitals. This factor could
be a disadvantage to the surgeon who practices in more
than one hospital.
45.7 Authors (FSF) Preferred Technique The inherent difficulties of these techniques, the
lack of flexibility, and the need to memorize different
The problem of macromastia has been the object of the measures and mathematical calculations, on some
efforts of many plastic surgeons since late nineteenth occasions, made me alter the approach of my preop-
century. In the USA alone, nearly 40,000 women erative marking. Over the last 15 years, the author
undergo breast reduction each year [50].. (FSF) has developed and evolved the Sitting, Oblique,
For the senior author (FSF), breast reduction pres- and Supine (SOS) marking technique. This method is
ents both artistic and technical challenges. The surgery dependent on the natural breast fall and is aimed to
aims to reduce the vertical and horizontal planes, shape guide on the appropriate angle between the two verti-
the parenchyma, reposition the nipple-areola complex, cal limbs, each breast on its individual merits. It would
and resect redundant skin. The surgery on paired be applicable in most breast reduction and mastopexy
organs has the added challenge of symmetry. The surgery; however, the author (FSF) used it largely in
added effect of recumbence alters the shape and posi- the inferior pedicle technique.
tion of the breast. The classic breast shape, as we know
it, exists in the erect posture. Much of the outcome of
our work as plastic surgeons is determined by preop- 45.7.1 Preoperative Marking:
erative planning and designing. The availability of The SOS Marking Technique
numerous marking techniques of breast reduction and
mastopexy and the abundance of further modifications The patient is marked preoperatively in three
over the last decennia are clear indications that none of positions.
the approaches have proven to be ideal. 1. Sitting (Fig. 45.3)
The majority aim is to achieve some degree of This position is adopted to mark the midline, mid-
precision in determining the angle between the two clavicular point (usually 7.5 cm from the sternal notch),
a b
Fig. 45.3 Patient in sitting position. (a) Gentle pressure on usually 7.5 cm lateral to the sternal notch. (c) The superior limit
the breast mound clearly defining the inframammary fold. of the vertical limb marked with reference to the inframammary
(b) The breast meridian marked from the midclavicular point, fold
and the breast meridian. The breast meridian is marked vertical limbs is then marked with reference to the
as a straight line joining the midclavicular point to the inframammary fold. This marks the possible future
current nipple-areola complex (NAC) extending down position of the NAC. The distance from the midclavic-
to the inframammary fold. The superior limit of the ular point to the superior limit of the vertical limbs is
b c
Fig. 45.4 Patient in the supine position. (a) Marking of the inframammary fold, arrow pointing to the dart. (b) Marking of the
medial limb. (c) Marking of the medial limb completed
then measured, and the same measure is used to mark made intraoperatively to minimize the length of the
the contralateral NAC. future inframammary scar, start with a short incision
2. Supine (Fig. 45.4) and extend as necessary, cut as you go approach. A
The supine position is used to mark the inframam- dart coinciding with the breast meridian is marked
mary fold incision and the medial limb of the vertical along the inframammary incision line. This aids in
markings. Whilst the patient is lying flat, the infra- reducing tension on the wound at the time of skin clo-
mammary fold is marked, while applying very gentle sure. While remaining in the supine position, the breast
pressure on the breast mound. Every effort should be will naturally fall laterally. A straight line is drawn
b
Fig. 45.6 Patient in sitting position marking the length of the
vertical limbs
limit of the vertical limbs to the dart. This marks the

lateral limb of the left breast.
Finally, the patient is returned to the sitting position.
The medial and lateral vertical limbs are measured at a
length of 7 cm from the superior limit of the vertical
limbs (Fig. 45.6).
The above are all the required preoperative mark-
ings. The author (FSF) now tends to join the vertical
limbs to the medial and lateral ends of the inframam-
mary marking intraoperatively. This is carried out in a
cut as you go fashion aiming at avoiding dog ears and
Fig. 45.5 Patient in the oblique position. (a) Right oblique also minimizing the length of the inframammary scar.
position, marking the left lateral limb. (b) Left oblique position, The new NAC is usually marked at the end of the
right lateral limb marked procedure, after the resection is completed. The lower
margin of the NAC is approximately 45 cm cephalad
joining the superior limit of the vertical limbs to the from the inframammary fold dart.
dart. This will indicate the medial limb of the vertical Over the years, the SOS marking has been found to
limbs. be a versatile technique dependent on the natural breast
3. Oblique: Left and Right (Fig. 45.5). fall. The breast is viewed as a dynamic organ requiring
The oblique position is mainly to mark the lateral the individual analysis of each breast (Figs. 45.745.9).
limb of the vertical markings. The patient is marked in The natural fall of the breast spontaneously generates
the left and right oblique position. In the left oblique the desired angle between the vertical limbs, accounting
position, the right breast will naturally adopt a medial for any existing asymmetries. Marking the patient in
position. A straight line is marked joining the superior the supine position has the added advantage of clearly
limit of the vertical limb to the dart. This marks the identifying the inframammary fold. Marking in the sit-
lateral limb of the right breast. While in the right ting position only, as referred to in other techniques,
oblique position, the left breast will adopt a medial may present difficulty in defining the inframammary
position. A straight line is marked joining the superior fold in large ptotic breasts. There are no specific
Fig. 45.7 (a) Preoperative. (b) Six months postoperative
a b
Fig. 45.8 (a) Preoperative. (b) Two weeks postoperative

a b
Fig. 45.9 (a) Preoperative. (b) Six months postoperative following resection of 1,800 g/side
devices required in this technique. There is no need to emphasis on defined anatomical dissection planes,
memorize any particular reference points apart from respecting and understanding the principles of the vas-
the three standard landmarks, the inframammary fold, cularity of the flaps. This has greatly reduced the post-
the sternal notch, and the midclavicular point. There is operative complications with minimal revision rate.
minimal handling of the breast, hence minimizing On those principles, the 3-plane dissection surgical
human errors. approach was developed, and the author (FSF) has also
Undoubtedly, there is a learning curve for any been able to reduce the length of the inframammary
new technique. The SOS in my view is relatively easy scar to be slightly longer than the width of the pedicle,
to learn by the beginners and easy to adopt by the particularly in mastopexy and small reductions.
experienced. It is readily available, not requiring major Preoperatively, the breasts are marked in the sitting,
alterations to our current practice and account for the oblique, and supine positions, as previously described
great diversities in the shape and size of the breasts. [57]. Intraoperatively, all the markings are scored
(superficially incised) using a #10 blade and #15 blade
for the nipple incision (Fig. 45.9). This is to avoid loss
45.7.2 Surgical Technique by rubbing off the markings.
A large swab is used as a tourniquet around the
Breast reduction is a constantly evolving surgery. For breast base (Fig. 45.10). This helps to stabilize the
the author (FSF), the inferior pedicle with the inverted breast during the deepithelialization and early part of
T-shaped scar stood the test of time. It is a versatile the dissection and reduces the intraoperative bleeding.
technique, suitable for the small and large reductions, The base of the pedicle is approximately 7 cm wide.
gives flexibility in sitting the nipple-areola position, The inferior pedicle is deepithelialized. On completion
hence minimizing the risk of a too high nipple-areola of deepithelialization, the medial and lateral flaps are
complex. Over the years, as much as the author (FSF) raised using the 3-plane dissection modification.
has developed the technique in the preoperative mark- Laterally, an avascular anatomical plane (mastec-
ing, the surgical approach changed with particular tomy plane) is created and followed between the breast
Fig. 45.10 Scoring and

incision of the nipple-areola
complex. A large swab is used
as a tourniquet around the
breast base
Once dissection is complete following the planes, the

thickness of the lateral, central, and medial flaps should
be optimal with no need to excise tissue from any of the
flaps. The main bulk of the breast tissue will be on the
pedicle. Reduction or excision can then be performed
under direct vision, from the bulky pedicle, avoiding
any potential danger of compromising the vascularity of
the pedicle. At this stage, a marker suture is inserted at
the 12 oclock position of the nipple. This aids in allo-
cating the nipple and its correct orientation when deter-
mining its position after closure of the rest of the
incisions. Under no circumstances should pull be exerted
on this marker suture, to avoid compromising the blood
supply. The breast skin flaps are undermined medially
Fig. 45.11 Laterally, an avascular anatomical plane (mastec-
tomy plane) is created
as far as the sternocostal junction and superiorly as far
as the clavicle. The author (FSF) tends to avoid lateral
undermining, to limit the lateral fullness. One vacuum
and subcutaneous tissue down to the pectoralis fascia. drain is inserted per side and sutured lateral to the infra-
This plane is easier to locate laterally and follow mammary incision. The T-junction is sutured to the apex
towards the breast meridian (Fig. 45.11). This yields a of the dart along the inframammary incision, a few mil-
lateral flap of adequate and uniform thickness, reducing limeters above the inframammary fold thereby reducing
the risk of postoperative fat necrosis and avoids bulky tension. The flaps are sutured as a composite unit includ-
lateral flaps. This plane is more uniform and easier to ing the subcutaneous fat and the dermis to avoid deglov-
follow compared to the literature-recommended 1-cm ing the skin from the underlying subcutaneous fat
thickness of the flaps. (Fig. 45.12). These modifications reduce the risk of
Medially, the breast is dissected in a perpendicular skin necrosis and wound dehiscence at the T-junction.
fashion down to pectoralis fascia. This ensures medial Monocryl, 3/0, is used as a deep subcutaneous suture
fullness and helps to create a breast cleavage. The tour- and 4/0 Monocryl subcuticular. Generally speaking,
niquet at the base of the breast is removed at this stage. suturing should start from the medial and lateral sides of
Centrally, a plane joining the medial and lateral por- the inframammary incision towards the breast meridian.
tions is created. This helps to reduce the risk of dog ears.
a 45.7.3 Complications
The above approach has demonstrated a very low

complication rate over the years. Retrospectively,
review of 125 patients was performed. The age range
was between 18 and 68 years, with a mean age of 34.
The BMI range was between 21 and 35. This included
both smokers and nonsmokers. The mean resection
weight was 539 g per breast (range, 2551,600 g).
The overall complication rate including nipple
necrosis, hematoma, seroma, dog ears, wound dehis-
cence, fat necrosis, delayed wound healing/wound
dehiscence at T-junction, hypertrophic scarring, and
further surgical revision was less than 10%. The com-
b bination of the preoperative marking technique and the
refinement of the surgical approach have provided me
with a successful recipe and an excellent tool in the
utilization of the inferior pedicle in all types of reduc-
tion and mastopexy, accommodating well in existing
asymmetry and reducing the commonly known post-
operative complications.
The revision rate over the years has been kept to a
minimal. The intraoperative surgical modifications
demonstrated a lower complication rate compared to
other published data. The flaps are dissected in a fash-
ion that follows anatomical planes. The mastectomy
plane followed laterally and the perpendicular plane
medially down to pectoralis fascia, help to reduce the
Fig. 45.12 (a) Inappropriate suturing that may result in risks of fat necrosis, enhances medial fullness, and
T-junction breakdown as a result of degloving the skin from the reduces lateral fullness that could result from thick
underlying fat. (b) The recommended suturing at the T-junction, uneven flaps. The dart along the inframammary inci-
as composite flaps
sion together with the composite suturing technique
helps to reduce tension on the suture line and main-
Once all the incisions are sutured, 45 cm is tains the vascularity of the apices of the flaps as one
measured from the dart along the vertical limb of the unit. The reliability of the approach is supported by the
scar. This presents the base of the future nipple-areola relatively low complication rate compared to other
complex. The nipple-areola complex is approximately published data.
4 cm in diameter. Once this is marked, the disk of skin The overall complication rate was shown to be less
and underlying subcutaneous fat is excised, the previ- than 10%, compared to the literature-reported rates
ous nipple suture mark is followed, and the nipple is ranging from 13.6%, described by Bolger et al. in 1987
delivered in its new position. Monocryl, 4/0, is used [58], to 50%, described by both Dabbah et al. [39] and
for both the deep suturing and the subcuticular for the Davis et al. in 1995 [41]. A recent paper by Hunter and
nipple-areola complex. Ceydeli in 2006 [59] reports a complication rate of
Half-inch suture strips are used to support the suture 23.7%.
lines; a Mepore dressing is then applied. Finally, a Dissections that follow the anatomical plane,
layer of Microfoam is applied as a supportive dressing, including the lateral mastectomy plane flaps together
cross your heart style. The dressings are reduced down with medial thick flaps down to pectoralis fascia, result
to Steri-Strips 1 week later. Two weeks postoperative, in more uniform flaps that have less likelihood of fat
all the dressings are removed. necrosis. This is combined with the wound closure of
a a
b
b
Fig. 45.13 (a) Preoperative. (b) Five months after surgery
Fig. 45.14 (a) Preoperative. (b) Twelve weeks after surgery

the skin flaps as a composite unit, maintains the vascu-
larity of the skin flaps, and avoids the potential deglov-
ing of the epidermis and dermis from the underlying much tissue will have to be resected to attain the
subcutaneous tissue. This reduces the morbidity of desired breast size (Table 45.1).
such a common procedure and improve aesthetic out- These figures should be taken only as a rough esti-
come (Figs. 45.1345.15). mate when formulating the surgical plan. Surgical
experience and different techniques will have much
more influence on final breast size than the resection
45.8 Breast Size After Reduction guidelines.
Mammoplasty
Regnault [60] states that the amount of tissue that is to 45.9 Complications of Breast Reduction
be removed during reduction mammaplasty depends
on the ratio of breast girth to chest girth. Chest girth is General complications of reduction mammaplasty
determined first and equals the circumference of the include hematoma, fat necrosis, infection, poor wound
chest measured under the arms. Breast girth is mea- healing particularly at the T-junction with partial or
sured across the nipples and should encompass the complete disruption of the suture line, hypertrophic
fullest part of the breasts. If breast girth exceeds chest scarring, breast asymmetry, under or over reduction,
girth by 1 in., cup size is an A; 2 in., B; 3 in., C; 4 in., persistent pain, and change in breast shape over time.
D; and 5 in., DD. He offers a rule-of-thumb for how Reduction mammaplasty might affect:
Table 45.1 Rule-of-thumb for how much tissue will have to be

a resected to attain the desired breast size
Chest circumference For each cup
in inches reduction size remove (g)
3234 100
3638 200
4244 300
4446 400
flowmetry with clinical examination. He measured

perfusion of identical spots on the areola preopera-
tively and immediately after inset of the nipple-areola
complex into its new position. He concluded that if the
post transfer blood flow was thought to be less than
50% of the preoperative value, the pedicle should be
explored. The author emphasizes that laser Doppler
flowmetry can be a helpful adjunct to clinical tests of
perfusion, particularly in darkly pigmented areolas.
Roth et al. [62] studied absolute Doppler values of
b nipple perfusion before and after reduction mamma-
plasty. Nipple perfusion immediately postoperative
averaged 4.8 mL/min/100 g in patients who had
no complications of surgery. In patients who had
minor complications or gross necrosis, the nipple
perfusion value was 1.4 and 0.8, respectively. Values
in the range of 1.02.0 mL/100 g indicate marginal
perfusion. Values <1.0 signify inadequate perfusion
and warrant suture removal or consideration for
exploration or free nipple grafting. The author rec-
ommends the laser Doppler for monitoring nipple-
areolar perfusion in large reductions and particularly
in dark-skinned patients who are difficult to evaluate
clinically.
Perbeck et al. [63] used laser Doppler flowmetry
and fluorescein flowmetry (FF) to evaluate viability of
Fig. 45.15 (a) Preoperative patient with enlarged ptotic right the nipple-areola complexes in undergoing reduction
breast. (b) After surgery mammaplasty. By LDF, there was a 2.5 increase in
circulation to the skin over preoperative levels after
deepithelialization. When epinephrine was injected,
45.9.1 Vascularity of the Nipple and Areola the circulatory increase was only 1.5 the preoperative
level.
The complications of reduction mammaplasty are Tracy and associates [64] used laser Doppler flow-
related primarily to insufficient vascularity of either metry to assess the blood supply of various types of
the skin flaps or the pedicle on which the nipple-areola pedicles undergoing reduction mammaplasty. In the
complex is based. Confirmation of adequate nipple immediate postoperative period, areolar perfusion
perfusion is usually based on clinical exam and can be declined by 23% (Skoog technique), by 18% (central
ascertained by laser Doppler flowmetry (LDF) and pedicle technique), and by 21% (inferior pedicle
fluorescein flowmetry. technique). Two weeks after breast reduction, LDF
Hallock [61] evaluated patients undergoing breast values were 12% below baseline (Skoog technique),
reduction and compared the quantitative laser Doppler 2% above baseline (central pedicle), and 44% below
baseline (inferior pedicle). While this is an interesting pedicles compared with superior pedicles. Anterior
study, they are technique dependent with varying suc- and lateral branches of the second through fourth inter-
cess in different surgeons hands. costal nerves were found in both groups and became
more superficial near the areola. The authors conclude
that careful deepithelialization of the pedicle is a must
45.9.2 Nipple Sensation to keep the superficial nerves intact near the areolar
border.
Loss of sensation to the nipple is a well-known com- Hamdi et al. [70] analyzed breast sensation after
plication of reduction mammaplasty. Townsend [65] superior versus inferior pedicle mammaplasty. They
finds only eight of 46 breasts had no return of sensa- showed decreased nipple sensibility in both groups
tion following nipple grafting which varies from 2 to which was documented at 3 months. The breast skin
12 months. had better sensation after superior pedicle techniques,
Slezak and Dellon [66] documented lower sensory while the areola had slightly better sensation after infe-
thresholds in the nipple, areola, and periareolar skin of rior pedicle techniques. No patient had a completely
women who had gigantomastia (D-cup or greater) insensible NAC at 6 months.
compared with the same parameters in small-breasted Greuse [71] prospectively assessed breast sensitiv-
women. The authors postulate that this may be related ity after Lejours vertical mammaplasty (with superior
either to increased surface area of large breasts with a pedicle). Assessments were done preoperatively and
constant number of nerve fibers, or the result of a 3, 6, and 12 months postoperatively using Semmes
stretching intercostal nerves caused by the breast Weinstein monofilaments (constant pressure thresh-
enlargement. Patients underwent breast reduction by old), heated and cooled metal probes (for hot and cold
McKissock technique and amputation with free nipple perception), calipers (for static and moving two-point
graft. Thirteen patients were evaluated perioperatively discrimination tests), and a Biotensiometer (to mea-
using vibrometers and SemmesWeinstein testing. sure the vibration threshold). Their study was divided
Nine patients available for follow-up, six had better into two subgroups: Group I had sternal notch to nip-
sensation, two were less sensitive, and nipple sensation ple less than 29 cm and less than 500 g of tissue
was unchanged in one. In the amputation group, some removed; group II had sternal notch to nipple greater
sensory loss was noted early postoperatively, but it than 29 cm and more than 500 g of tissue resected.
improved with time. In group I, there was an initial postoperative decline
Gonzalez et al. [67] quantified nipple-areolar sensa- in sensitivity, although eventually returned to their
tion pre and postoperative using SemmesWeinstein normal level. In group II, although sensitivity to
pressure threshold testing. They adopted the central temperature and vibration diminished on the nipple-
parenchymal pedicle technique or a laterally based areola, patients did not complain of decrease in breast
inferior pedicle technique. Overall, nipple sensitivity sensation.
was lost in 9.5% of breasts, and they correlated with
increasing breast size and corresponding amount of
resection, as when <440 g per breast was resected, 45.9.3 Breast-feeding
nipple sensation was retained 100% of the time.
Temple and Hurst [68] studied 45 women undergo- Aboudib [72] compared the late results of reduction
ing inferior pedicle breast reduction. Pressure thresh- mammaplasty by the Pitanguy technique in 39 patients
old measurements were taken preoperatively and at 2 who did not become pregnant after surgery (group A)
and 6 weeks, postoperatively. They noted significant and 11 patients who did (group B). There were no
improvement at 26 weeks. Only 2% of breasts had significant differences between the groups in terms
nipple numbness at 6 weeks. of weight gain, breast volume, or breast ptosis. Nine
Hamdi et al. [69, 70] looked at breast sensation after women in group B (91%) reported normal lactation
superior pedicle versus inferior pedicle mammaplasty. and breast-feeding. The other two women reported
The cadaveric study was designed to quantify the nerve decreased milk secretion and did not nurse.
branches preserved in the pedicles during reduction Marshall et al. [73] studied breast-feeding in
surgery. They found slightly more branches in inferior women after reduction mammaplasty. The patients
abilities to nurse were recorded for up to 3 months was unreliable and they recommend mammograms
after delivery, 93% wished to breast-feed, and on dis- 3 months postoperative to establish a baseline from
charge, 73% were doing so. After 3 months, the num- which to track postsurgical changes. They also men-
ber had dropped to 27%. All babies except one born of tioned that excisional biopsy should be done if there is
a mastopexy patient required complementary feeds. In any doubt about the diagnosis suggested by the imag-
the control population of nonreduced patients, 82% ing modalities.
were breast-feeding on discharge from the hospital Titley et al. [77] analyzed histologic findings in
and 54% were still breast-feeding after 3 months. reduction mammaplasty specimens. The retrospective
Seven percent of babies were able to feed entirely study included 295 reduced breasts. They noticed
from the breast without complementary feedings. 25.6% were abnormal, although no premalignancy or
Although, no single operation was clearly superior in overt cancer was identified. By questionnaire, the
avoiding transection of the lactiferous ducts, the authors determined that 89% of British plastic sur-
author recommends leaving all functional breast tis- geons routinely sent breast reduction specimens for
sue attached to the nipple in a physiologic manner pathologic study [and] 42% had seen at least one case
whenever possible. of breast cancer reported from this tissue. They rec-
Harris et al. [74] examined breast-feeding ability ommend routine histopathologic study of reduction
and behavior in reduction mammaplasty patients using mammaplasty specimens in all patients over 40 and in
inferior pedicle technique. The authors surveyed 68 younger patients when risk factors for breast cancer
women who had breast reduction, 29% (20) had are present or the tissue appears grossly abnormal at
become pregnant after surgery. All of them lactated, surgery. Mammography was also recommended for
seven (35%) nursed their infants for at least 2 months, patients 5064 years old.
nine (45%) nursed for up to 2 weeks, and the other four zmen et al. [78] reviewed 274 breast specimens
did not attempt breast-feeding because of insufficient revealing three breast carcinomas (1.1%). The authors
milk production. comment that this is higher than previously reported
Brzozowski et al. [75] examined 78 women who rates for incidental carcinomas in breast reduction
had children after their breast reduction using inferior specimens. Their recommendations are as follows:
pedicle technique. He found that 41 (52.6%) did not 1. Perform a thorough physical examination in all
attempt to breast-feed, 14 (17.9%) were unsuccessful, patients preoperatively and mammography in those
15 (19.2%) breast-fed exclusively, and eight (10.3%) over 35 years old.
breast-fed with formula supplementation. Postpartum 2. Order intraoperative frozen sections of any suspi-
breast engorgement and milk production was experi- cious areas.
enced by 31 of the 41 patients who did not attempt to 3. Send all reduction specimens for pathologic
breast-feed. The authors conclude that breast-feeding examination.
is possible post-reduction mammaplasty, and that the 4. Accurately mark specimen location.
percentage of patients who successfully do so is com- 5. Have the pathologist perform histologic examina-
parable to the proportion in the general population. As tion as if it were a breast cancer specimen.
part of the informed consent process, these data should Mandrekas et al. [79] described the clinical and
be reviewed with patients of childbearing age before radiologic features of fat necrosis after breast reduc-
reduction surgery. tion surgery. They mentioned that the use of electro-
cautery during mammaplasty may trigger necrotic
changes in breast fat, which are difficult to differenti-
45.9.4 Interference with Cancer Screening ate from breast carcinoma. Surgical resection with
scalpel may lessen this problem.
Because of the extensive dissection in reduction mam- At the present time, most plastic surgeons continue
maplasty, some authors have expressed concern about to send all reduction specimens for histopathologic
the possibility that postoperative fibrosis and scarring diagnosis. Specimens should be marked accurately
may interfere with breast cancer detection. as to medial, central, and lateral quadrants to help
Beer et al. [76] retrospectively assessed their ability the pathologist localize the lesion, if found. Preopera-
to diagnose breast tumors after reduction. Ultrasound tive mammography is to be performed according to the
recommendations for breast cancer screening issued by Samdal et al. [81] documented the value of infiltrat-
the American Cancer Society in 1997. These include: ing dilute epinephrine for the control of intraoperative
1. Breast self-exam every month for women age 20 bleeding. Blood loss was reduced by more than 50%
and over. when compared with the non infiltrated side.
2. Clinical breast exam every 3 years for women age Epinephrine injection was associated with no instance
2040. of flap compromise or postoperative bleeding.
3. Clinical breast exam and mammography every year
for women 40 and older.
Analysis of the complications associated with dif- References
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Breast sensation after superior pedicle versus inferior pedicle 26(2):211215
The Moufarrege Total Posterior
Pedicle Mammaplasty 46
46.1 Introduction and Principles number of women, be appropriate. However, they can
lead to vicious positioning errors such as offset nipples
The particular philosophy of the Total Pedicle consists positioned too centrally, too high, too outward or too
of the entire exposure of the breast on all its anterior, inward.
superior, inferior, external and medial sides, preserv- The authors landmarks are defined by the junction
ing the integrity of its posterior aspect with its attaches of two lines.
to the muscles of the thoracic wall [14]. The denuded I. The first one being the breast axis. This does not
breast gland is then sculpted on an open sky basis and correspond necessarily to the mid-clavicular line
acts itself as pedicle for the nipple areolar complex nor passes absolutely by the present nipple. It is the
(NAC) [15]. The gland and its NAC are so vascular- vertical axis of the breast that divides the frontal
ised by the vessels perforating the pectoralis major aspect of the breast in two equal halves (Fig. 46.1).
muscle which constitutes 7080% of the vascular sup- Whichever is the preoperative position of the nip-
ply of the breast [25]. This explains the absolute vas- ple, the new nipple must be on that vertical axis. If
cular security of that pedicle, compared to the security not, errors occur and we obtain an offset nipple.
of the traditional thin pedicles [13, 5]. II. The second landmark line is the one passing
through the submammary fold. The new nipple
should be placed on that line (Fig. 46.2). All in all,
46.2 Technique the new nipple should be positioned at the junction
of these two lines (Fig. 46.3) [3, 5].
46.2.1 Marking III. Practically the surgeon starts by drawing the breast
axis. This will be better defined by choosing two
Markings are done on the patient in a vertical position. median points, one upper and one lower, at equal
None of the traditional measures between point-marks, distance from the internal and lateral limits of
such as the distance between the nipple and the the breast and joining them by a vertical line
suprasternal notch, the one between the two nipples or (Fig. 46.4).
the distance between one nipple and the midsternal With practice and repetition, the designation
line, are used. These measures could, in a certain of the axis will be done automatically and with
ease. Once the breast axis is established, the sur-
geon will place his hand, and mainly his index, in
the fold under the breast. He will draw on the new
R. Moufarrege (*) E. Botros breast axis the position of the new nipple, exactly
Department of Plastic Surgery, Hcte-Diel Hospital,
at the level of the inframammary fold. The upper
Montreal University, Montreal, QC, Canada
e-mail: [email protected]; pole of the areola will then be situated 2 cm higher
[email protected] (Fig. 46.5).

776 R. Moufarrege and E. Botros
Fig. 46.1 The breast axis

passes through the center of
the clavicle in the right breast
but not the left one
c a
a
c
d o b
o b
a b
Fig. 46.3 The new nipple is at the junction of the two vertical
b axises and the horizontal submammary line
For the drawing, Aufricht keyhole will be

adopted but with important modifications. The
Aufricht keyhole was traditionally round. By clos-
ing it, chances are that it will turn into an ellipsoid
vertical shape. It is suggested to modify it by start-
ing with an ellipsoid Aufricht keyhole which,
when closed, will turn into a perfect round shape
(Fig. 46.6).
Logically, one cannot remove the same skin surface
Fig. 46.2 The submammary fold line passes simply horizon- on all breasts of all sizes at all ptosis degrees. The
tally in the submammary fold of the breast author personally adapts the surface of removed skin
46 The Moufarrege Total Posterior Pedicle Mammaplasty 777
to the degree of ptosis, contrary to the traditional mam- keyhole arms opening will be at an angle of 90
maplasties. Therefore, the author (RM) divides patients (Fig. 46.7).
into three categories [3, 5]: Category II: There is ptosis; the nipple is below
Category I: There is no ptosis; the nipple is at the the inframammary fold. The breast at the level of the
level of the inframammary fold. In this case, the fold is thick, full, and consistent. In this case, the
keyhole arms opening will be at an angle of 140
(Fig. 46.8).
Category III: The nipple is below the inframam-
mary fold but at the level of that fold, the breast is
empty, without any consistency. In this case, the
keyhole arms opening will be at an angle of 180
(Fig. 46.9).
The surgeon will thus place the center of the key-
hole on the vertical axis of the breast. The level of the
inframammary fold of the upper limit of the keyhole
a A will be 2 cm above this point. The keyhole arms will
a
adopt the orientation defined by the ptosis angles (90,
140, and 180) and are extended without any breaks,
like two meridians of the Earth globe, until their junc-
tion on the inframammary fold on the vertical axis of
the breast (Fig. 46.10) [3, 5].
b B
o
b
46.2.2 Incision
The surgeon will start the periareolar incision leaving

a diameter of 4 cm in the NAC. He defines and pro-
ceeds to this deepithelialization of a dermal flap sur-
Fig. 46.4 The design of the breast axis is made by the use of two rounding the NAC and down to the inframammary
horizontal virtual lines at two different levels (a and b). The mid-
dle point of each line is defined and the breast axis is then obtained
fold. This dermal surface, 46 cm large, will have a
by joining the two last points with a vertical straight line vertical length depending on the ptosis and the breast
size, from 6 to 20, if not 30 cm in large hypertrophies
Fig. 46.5 Designing the new

nipple position and the
Aufricht keyhole
Fig. 46.6 (a) Round keyhole

gives an ellipse when closed.
(b) Ovaloid keyhole gives a
circle when closed
a b
I I III III
90
180
Fig. 46.7 Category I. No ptosis, angle 90 Fig. 46.9 Category III. Ptosis with emptiness at the inframam-
mary fold level, angle 180
The surgeon will respect laterally, at the level of the

medial axillary line, that areolar tissue covering the
II II lateral wall of the thorax on the serratus muscle, in
order to preserve the fourth, fifth, and sixth intercostal
140 nerves which are in charge of the erogenous sensation
of the nipple (Fig. 46.15) [2, 3, 5].
Fig. 46.8 Category II. Ptosis with fullness at the inframam- On the upper limit of the breast, opening the
mary fold level, angle 140 Pectoralis Major fascia will help create a convex and
very attractive superior profile (Fig. 46.16) [5].
At this stage, the breast is entirely stripped from its
(Fig. 46.11) [15]. This deepithelialization will be cutaneous cover and will be always attached by its
made easier with the use of vertical striations which posterior aspect to the muscular plan of the thoracic
will be removed easily in a very short time of 12 min wall. However, in the center of the breast there will
(Fig. 46.12) [5]. The surgeon will make the incision remain a certain surface of the skin with roughly a
around the dermis first and continues along the pre- horseshoe shape covering the internal and the external
established drawings (Fig. 46.13). quadrants of the breast, meant to be removed and the
upper quadrant meant to remain (Fig. 46.17) [2, 3, 5].
46.2.3 Undermining or Denuding the Breast

46.2.4 Resection
All the skin of the breast is undermined making a divi-
sion between the glandular tissue and the subcutane- The exposed breast will undergo an open sky basis
ous fat. This is a real nonvascularised plan. This sculpture. The resection will start with the medial
operation is made easy with the use of skin rakes hold- quadrant and will be minimal. On the contrary, all the
ing the tissue vertically while a ten scalpel blade makes external quadrant of the breast with the axillary exten-
the separation, shaving the glandular tissue. This is sion will be removed. The entire gland consisting in
performed on the lateral flap, the medial flap and the the upper and lower quadrants will be preserved and
upper flap until the limit of the breast gland is reached conserved from the higher limit of the gland to the
(Fig. 46.14) [2, 3, 5]. inframammary fold (Figs. 46.18 and 46.19) [2, 3, 5].
90 180
A C
5
cm cm
5
B D
Fig. 46.10 Extending the keyhole arms in a meridian manner
Fig. 46.11 Periareolar incision with a 4 cm diameter. Desig-

nation and deepithelialization of the dermal inferior vault Fig. 46.12 Strip deepithelialization
Fig. 46.15 The surgeons forceps shows the areola area on the
lateral thoracic wall where the fourth, fifth, and sixth intercostal
nerves pass
Fig. 46.13 Incisions first around the dermal vault, then along
the external pre-design
Fig. 46.16 Opening the pectoralis major fascia at the upper

limit of the breast
Fig. 46.14 Denuding the frontal aspect of the breast by sepa-

rating the gland from the subcutaneous fat
The resection will be performed with a long

movement of scalpel dividing the gland by a bevelling
movement from the superficial surrounding the deepi-
thelialized area, widening down to the base of the central
glandular pedicle, medially and laterally (Fig. 46.20).
46.2.5 Reconstitution
Reconstitution starts by positioning the areola in its Fig. 46.17 Aspect of the breast after undermining the sur-
new location with two diametrically opposed sutures rounding flaps and before resection
Fig. 46.19 The remaining gland after the reduction held in the
surgeons hand
Fig. 46.18 The surgically resected piece of the gland. On the

left side, one can see the internal quadrant resection. On the right
side is the large main piece consisting of the whole external
quadrant
Fig. 46.20 The beveled

movement of division
assuring conservation of the
main neurovascular elements
in the base of the gland close
to the muscle
at 12 oclock and 6 oclock, followed by the closing of horizontal section between 3 and 7 cm (Figs. 46.23
the vertical incision under the NAC. This will have, 46.25) [6, 7].
depending on the case, a 620 cm length or even more Closing will continue by positioning sutures wher-
(Figs. 46.21 and 46.22) [2, 3, 5]. ever necessary, without any tension. This is very
In the authors (RM) philosophy of the importance important and real: Actually the division between the
of the breasts ratios respect (The Moufarrege Golden skin and the underlying gland will provide the skin,
Ratio of the Breast), the author conserves 6 cm of not only with the most harmonious and most attractive
length on that vertical scar under the nipple and shapes, but also with a closing capacity without any
changes all the excess of the length into an inverted tension, guaranteeing an increased security to the qual-
T which will have, in most of cases, a rather short ity of the conserved skin (Figs. 46.2646.37).
Fig. 46.21 Positioning the

nipple areolar complex (NAC)
in its new location
Fig. 46.22 Closing the

vertical line before
transformation into an
inverted T
R=12 R=6 R=4 R=3 R=2,4 R=2 R=1,7 R=1,5 R=1,3 R=1,2 R=1,1 R=1 R=0.002
Soin juvenile Soin acufte harmonious Rapports acceptables Rapports anonmaux

Juvenile Harmonious Acceptable Abnormal ratics
R R R R R R R R R R R R R
12 6 4 3 2.4 2 1.7 1.5 1.3 1.2 1.1 1 0.9
Soin juvenile Soin acufte harmonious Rapports acceptables

Juvenile Harmonious Acceptable Abnormal ratics
Rapports anonmaux
Fig. 46.23 The graph shows breast lengths and allows determi- most harmonious breasts the ratio of height over projection
nation of the ratios between the height and the projection and should be equal or higher than 2
their effect on the appearance of the breast. Thus to obtain the
> 6cm
Fig. 46.25 The three acceptable incisions in the Moufarrege

Total Posterior Pedicle. Simple purse incision is only applicable
in very small breast and ptosis
Fig. 46.24 Transformation of the too long vertical incision into

an inverted T
Fig. 46.26 Closing without

tension
Fig. 46.27 (Upper)

Preoperative. (Lower) Six
months postoperative
Fig. 46.28 (Upper)

Preoperative patient with
symmastia. (Lower) Three
months postoperative after
correction with a simple
inverted T incision
46.3 Breast Lifting and Lifting 46.4 Advantages

with Augmentation
The Total Pedicle is secure. The landmarks serving for
The same principles apply in breast lifting with the drawings ensure perfect breast positioning. The pedicle
same measures and the same angles and skin resection, quality represented by the entire remaining gland, the
but without breast gland reduction. It is a very secure preservation of the perforating vessels, the security of
technique to combine lifting and augmentation in the glandless cutaneous flaps remodelling the whole remain-
same time [25]. ing breast, covering it with a compliant elastic envelope
Fig. 46.29 (Upper)

Preoperative. (Lower) Three
lifting plus augmentation
Fig. 46.30 (Upper)

Preoperative 36-year-old
female. (Lower) Three years
postoperative
provides to this technique a wage of a high harmonious nerves assure functional properties of breast feeding and
shape. The preservation of the galactophoric ducts and erotogenic sensation of the nipple, hardly encountered
the continuity of the fourth, fifth and sixth intercostals in other traditional mammaplasties.
Fig. 46.31 (Upper)

female. (Lower) Five years
postoperative
Fig. 46.32 (Upper)

months after breast lift
Fig. 46.33 (Upper)

female. (Lower) Three years
postoperative
Fig. 46.34 Best way to treat tuberous breast

Fig. 46.35 A 37-year-old

female, pre-operative and
30 months post-operative
face and profile
Fig. 46.36 (Upper)

months postoperative
Fig. 46.37 (Upper)

Preoperative. (Lower)
Postoperative
References 4. Moufarrge R (1979) A new reduction mammaplasty with a

vertical posterior pedicle. Quebec Society of Plastic Surgery
Convention
1. Moufarrge R, Muller GH, Beauregard G, Papillion J, Boss
5. Moufarrge R. The Moufarrege total posterior pedicle mam-
JP (1982) Mammoplastie avec pdicule dermoglandulaire
maplasty. http://www.emedicine.com/plastic/topic488.htm
infrieur. Ann Chir Plast 27(3):249254
6. Moufarrge R (2005) Anatomical and artistic breast consid-
2. Moufarrge R, Beauregard G, Boss JP, Papillion J (1985)
erations. Ann Chir Plast Esthet 50(5):365370
Reduction mammaplasty by the total dermoglandular pedicle.
7. Moufarrge R, Dionyssopoulos A, Aymeric A, Sauvageau J
(2010) Existe-t-il un rapport entre les incisions et la forme
3. Moufarrege R (1990) The total dermoglandular pedicle
finale d un sein? Ann Chir Plast Esthet 55(2):111134
mammaplasty. In: Georgiade GS, Riefkohl R (eds) Aesthetic
surgery of the breast. Saunders, Philadelphia, pp 371386
Mastopexy with Chest-Wall-Based
Flap and Pectoralis Muscle Loop 47
Ruth Maria Graf, Andr Ricardo DallOglio Tolazzi,
and Maria Ceclia Closs Ono
47.1 Introduction this chapter, consists in a predefined vertical incision

with whatever redundant skin that remains after
The evolution of all surgery, including breast surgery, excising the vertical ellipse, associated with a vari-
is persistent and ongoing [114]. The great advances able periareolar skin resection closed with a round-
by Wise [15], Pitanguy [16], Lassus [1719], Lejour block suture. This is best described as circumvertical
[2023], Benelli [24], and others have brought us to excision. If reduction is necessary, it can easily be
the close of the twentieth century. These techniques carried out in this technique by removing the desired
have not only simplified the operative plan but have amount either vertically under the breast or from its
also contributed to a shorter scar and a more aesthetic base. There is no limit to the amount of breast tissue
breast. that can be removed.
This chapter describes a maneuver designed to
give a better shape to the breast. This maneuver
involves the use of a chest-wall-based flap of breast 47.2 Technique
tissue that is moved into the upper pole of the breast
and held in place by a loop of pectoral muscle under Marking is done with the patient in the upright posi-
which it is passed. The technique can be used with tion. Lines are drawn first straight down the midline
different kinds of incisions: standard inverted T, from the suprasternal notch to the xyphoid process and
short T, L-shaped incisions, or periareolar vertical second, from a point 5 cm from the suprasternal notch
incisions. Our choice, and the technique described in at the clavicle to the nipple-areola complex (NAC) and
then straight down to the inframammary fold. A point
at 1720 cm on the suprasternal-NAC line is marked
(point A) which will be the top of the areola. On the
breast line, 24 cm above the inframammary fold point
D is marked. This distance varies between 2 and 4 cm
R.M. Graf, M.D., Ph.D. (*)
depending on the size of the breast (Fig. 47.1). The
Hospital de Clinicas da Universidade Federal do Parana, breast is then gently displaced laterally (a technique
Rua Solimes, 1175, Curitiba, PR, Brazil described by Lejour), and a line is drawn parallel to the
e-mail: [email protected] midline, connecting point A and D. A similar line is
A.R.D. Tolazzi, M.D. drawn with the breast displaced medially. A distance
Plastic Surgery Unit, Federal University of Paran, of 58 cm is measured from point D upward on the
Curitiba, PR, Brazil
medial and lateral lines (points B and C). It should be
pointed out that the tension resulting from this dis-
M.C.C. Ono, M.D.
Plastic Surgeon, Member of the Brazilian
placement should be firm enough to allow adequate
Society of Plastic Surgery, Curitiba, PR, Brazil skin resection but not so tense as to create difficulty
e-mail: [email protected] with closure. This distance varies also in accordance

792 R.M. Graf et al.
Fig. 47.1 Basic markings of vertical technique. Lines are mammary crease not <11 cm (superior right). The breast is gen-
drawn straight down the midline from the suprasternal notch to tly, with the Lejour maneuver, displaced laterally (inferior left)
the N-A complex. Point A, 20 cm from the clavicle, which will and medially (inferior right) to obtain the vertical lines. The
be the top of the areola (superior left), from a point 5 cm from suprasternal notch is noted to be at the cephalad edge of the
the suprasternal notch at the clavicle to the N-A complex and bone, not down into the notch
then straight down parallel to the midline line, crossing the infra-
with the size and laxity of the breast. Gently curved 47.3 Operative Procedure
lines are drawn from point A to point B and C. Line
A-B should never be closer than 9 cm to the midline The patient is placed supine on the operating table and,
and line A-C, never <10 cm from the anterior axillary after induction with general or epidural anesthesia
line. (local is possible) and prepped and draped, the incision
The variation in distances of point D to the infra- markings are infiltrated subdermally (except superior
mammary fold and of lines B-D and C-D allows to the areola), with diluted epinephrine-saline solution
the surgeon the latitude of adjustments, depending on (1:100,000). The area of the skin demarcated by lines
the size of the breast. The larger the breast is planned A-B, A-C, B-D, and C-D is deepithelialized (Fig. 47.2),
to be, the greater these distances are marked. These leaving the NAC (4.55 cm in diameter) in place. An
distances, however, should never exceed 4 and 8 cm, incision is made in the dermis transversely along lines
respectively. B-D and C-D, passing 1 cm below NAC. This is the
An additional detail is that points B and C should be beginning of the creation of the chest-wall-based flap
marked slightly closer to each other, so when they are (Fig. 47.3). Along the vertical lines, this incision is
closed there will be no significant tension. beveled inward for 12 cm to preserve tissue on the
47 Mastopexy with Chest-Wall-Based Flap and Pectoralis Muscle Loop 793
Fig. 47.2 The vertical lines cross at the midbreast line, 24 cm a gently curved line is drawn from point A to point B (inferior
above the inframammary fold, and point D is made (superior left) and again from point A to point C (inferior right). Line A-B
left); a distance of 58 cm is measured on the medial and lateral should never be closer than 9 cm to the midline and line A-C,
lines and point B and C are placed, respectively (superior right); never <10 cm from the anterior axillary fold
Fig. 47.3 Patient at the operating table with skin demarcation with the vertical lines and the chest-wall-based flap
Fig. 47.4 Deepithelization and dermis incision following (inferior left) pillars for closure later; a large hook is placed in
demarcation, 2 cm above points B and C (superior left); along the N-A complex and the breast is lifted straight up, and dissec-
the vertical lines, this incision is beveled inward for 12 cm so tion of the breast tissue from point B-C is carried out 1 cm below
as to preserve tissue on the medial (superior right) and lateral the areola, proceeding to the pectoral fascia (inferior right)
medial and lateral pillars. After preserving this tissue, pectoral fascia. This freely mobile, totally chest-wall-
the incisions continue inward and away from the flap based flap is comprised of breast tissue that in other
so creating a broad base for the mammary flap. This procedures bottoms out but in this procedure is being
dissection is carried to the chest wall with minimal transposed into the upper pole where it will be fixed.
amount of subcutaneous tissue being left on the skin as The breast tissue is retracted upward and cephali-
dissection is carried to the inframammary fold. cally and dissected off the pectoral fascia up to the
After this dissection has been performed laterally second intercostal space, creating a space in the upper
and medially, a large hook is placed in the NAC and pole of the breast into which the flap will be fixed.
the breast is lifted straight up. Then, and incision is Before this, however, a strip of pectoral muscle approx-
made in the breast tissue from points B to C, proceed- imately 810 cm long and 1.52 cm wide is marked
ing to the pectoral fascia. Great care must be taken at with methylene blue. Its caudal or inferior line is at the
this point not to undercut the flap (chest wall pedicle). cephalic end of the flap base (Fig. 47.6).
The flap is now freely mobile and is based on vessels This muscle strip is elevated incorporating no more
from the fifth and sixth intercostal spaces as a perfora- than one half of the muscle (the posterior fascia of the
tor flap (Figs. 47.4 and 47.5). The flap is free from all muscle is not violated), and the donor site is closed
of the four sides: superior, lateral, inferior, and medial. with 2-0 nylon. This muscle loop will be used to hold
Its very important that the flap not be restrained; if it the flap in position in the upper pole. The flap is then
is, continuous dissection should be extended to the passed under the pectoral loop into the space of the
Fig. 47.5 The incisions continue inward and away from the the skin as dissection is carried to the inframammary fold
flap so the base is broad. This dissection is carried to the chest (superior); undermining of chest-wall-based flap maintaining
wall with a minimal amount of subcutaneous tissue being left on the large base (inferior)
upper pole of the breast. It is very important that all closure) was 8001,000 g, including the liposuction in
dermal elements on the flap be completely passed the lateral aspect of the breast. The chest-wall-based
under this loop. The dermis of the flap is then sutured flap, however, can be used in any breast size.
to the pectoral fascia with a running 2-0 nylon suture, After reducing the excessive breast tissue (Fig. 47.7),
starting laterally and finishing medially. If after pass- one interrupted suture of 2-0 nylon is placed in the
ing the flap under the loop there seems to be excessive superior breast tissue and the pectoral fascia just
tension on the loop causing pressure on the flap, the cephalic to the flap (at the second intercostal space) in
loop can be released by additional dissection laterally order to lift the undermined breast tissue and improve
(medial dissection could disrupt the origin of the upper pole projection.
muscle) (Fig. 47.6). Closure starts with suturing the pillars with 2-0 nylon
With the flap in the correct position and the breast in several layers. Its preferable to place the needle later-
suspended by the hook in the NAC, breast tissue excess ally deeper than medially to preserve more fullness
is removed. At this step of the surgery the reduction is medially. Deep dermis of the superior vertical wound is
made in accordance with the breast size and the desire sutured placing together the subareolar points B and C.
of the patient. The main block of tissue is removed as an A round-block suture is done around the NAC to
inverted central kill, from the base of the breast laterally homogeneously distribute the periareolar skin and to
and less amount centrally to reduce the base and the reduce tension on the NAC (Fig. 47.8). Eight cardinal
excessive projection of the breast. The largest reduction points are marked in the periareolar skin and in the
with this technique (vertical incision and circumvertical areola. The running suture is done using a 3-0 colorless
Fig. 47.6 A strip of pectoral muscle approximately 810 cm right); passage of chest-wall-based flap under the bipedicled
long and 1.52 cm wide is marked with methylene blue just muscular flap and closure of the donor site (inferior left); suture
superior to the base of the chest-wall-based flap (superior left) of the flap to the second intercostal space (inferior right)
and elevated leaving the deep half of the muscle intact (superior
nylon. Passing through the deep dermis of the outer 47.4 Discussion
skin and the areolar deep tissue, the suture takes small
amount of tissue between the markings in the areola Although the classic inverted T incision mamma-
and large bites right on the markings of the periareolar plasties are easy-learning techniques for young plastic
skin. Tensioning the suture reduces the periareolar surgeons and give more reproducible results on the
circumference up to the desired diameter for NAC operating table, they have several drawbacks that
(about 4.5 cm). should be reassessed [25, 26]. The short vertical inci-
Starting from point D, vertical skin is closed with sion dogma (near 5 cm) associated with an inferior
interrupted sutures of 3-0 Monocryl. Anchoring the horizontal resection pattern of the skin and paren-
deep dermis to the underneath pillars, these sutures chyma leads the breast to a broad and flat cone shape,
elevate the whole vertical component, placing the point with poor projection, which tends to worsen with time
D at the level of the new inframammary fold. So, the [25, 27, 28]. All this issues and the concern of scar
final vertical scar will end up at the level or slightly length promoted the development of new techniques
above the new inframammary crease. Final skin clo- for breast surgery.
sure is done with a running intradermal suture of 4.0 Although the history of vertical mastopexy dates
Monocryl (Fig. 47.9). No drains are routinely used. back to Lotsch [29] and Dartigues [30], and later
Fig. 47.7 Resection of the excessive breast tissue (superior lateral breast columns (inferior left) and closure of points B and
left); suture of the upper breast tissue to the pectoral muscle C (inferior right)
superior to the flap (superior right); suture of the medial and
extended to breast reduction by Ari [4], it was other- this problem. Daniel [42] associated a bipedicled flap
wise lost to surgical history until Lassus [1719] of major pectoralis muscle to keep Ribeiros flap in a
resumed interest in the decade of the 1960s. Using higher position, further minimizing the bottoming out
adjustable markings, an upper pedicle for the areola phenomenon. The authors have proposed some modifi-
and central breast reduction, Lassus has employed ver- cations to the mammary flap, describing it as totally
tical reduction mammaplasty in a wide range of breast based on the chest wall and held in place by the pectoral
hypertrophies. It was then modified and popularized by loop [3336]. There are also other flaps described in the
Lejour [2023] and several other authors [27, 3138]. literature [43].
In 1990, Levet [39] described a pure posterior pedicle Since 1994, these flaps have been performed in
flap for breast reduction. During all this time, innumer- inverted T, oblique or L scar, and, more recently, in
ous authors observed that breast descent and loss of vertical scar mammaplasties. The approach was
upper pole fullness (bottoming out) was often seen in switched from inferior pedicle flaps to flaps based
their own work and the work of others. Ribeiros tech- only in the thoracic wall vasculature, completely
nique [40, 41], which uses an inferior pedicle flap trans- detached from the dermis and structures around, main-
posed into the upper pole, provided improvement of taining the overlying dermis in order to give better
Fig. 47.8 The round block is done around the N-A complex. small amount of tissue. Tensioning the suture reduces the cir-
Eight cardinal points are marked at the skin and at the areola to cumference up to the desired diameter accommodating a 4.5-cm
spread regularly the areola. To close the skin and reduce wound nipple-areolar complex (superior). Starting from point D, skin is
tension around the areola, a round-block suture is made all the closed with 3-0 Monocryl in the deep dermal tissues with inter-
way around the periareolar skin with 3-0 colorless nylon. This is rupted sutures anchoring the vertical wound to the tissue of the
a running suture passing through the deep dermis of the outer deep pillars, continuing suturing until reaching the subareolar
skin and the areolar deep tissue. In the external skin, the suture skin, so the vertical scar is kept at the same level as the new
is passed on the markings, taking a big amount of tissue, and at inframammary crease (inferior)
the areola, the suture is passed between the markings, taking
Fig. 47.9 Final skin closure with shortening of vertical incision and round-block suture around the areola
Fig. 47.10 Skin markings of the vertical technique (left); comparison of skin resection between vertical scar technique (red ink) and
inverted T or Wise pattern (blue ink) (right)
support and shape to the flap after fixation to the is fixed. With this technique, we observed that we
underlying pectoral fascia. Figure 47.10 demonstrates remove less breast tissue compared with other tech-
minimizing of the scar in the vertical technique when niques that do not use the chest-wall-based flap and
compared with a technique using a Wise pattern [15]. that the breasts have a narrower base. In our experi-
The upper pole of the breast maintains more volume, ence, the average amount of breast tissue resected was
and the vertical scar is placed above or at the level of 250 g, which is less than in other techniques we have
the new inframammary crease with minimal breast used without the thoracic flap. In great hypertrophies
descent. or severe ptosis, the point D should be marked higher
The length of the chest-wall-based flap changes above the inframammary fold, up to 4 cm. This maneu-
according to the distance between the areola and infra- ver is done to leave the skin and subcutaneous tissue of
mammary crease. Its upper limit is located 1 cm below the lower breast pole as part of the thoracic wall, with
the inferior edge of the areola, and the lateral borders a higher new inframammary crease. Redundant skin is
extend to the medial and lateral breast contours. Its removed in the vertical excision and the circumareolar
base extends to the inframammary crease with 68 cm round-block excision.
of width and 4 cm of thickness, with its vascular pedi- The exceeding skin in the vertical branch observed
cle based on intercostal vessels of the fifth and sixth during surgery can be closed with a subcuticular suture
intercostal spaces. The bipedicled muscle flap (pecto- that shortens this scar. During the first 2 months of the
ralis loop) is situated immediately above the base of postoperative period, there is an accommodation with
the breast tissue flap, with 1.52 cm of width and no need to remove skin horizontally in the inferior
810 cm of length. It should be dissected in the same portion of this scar, as suggested by Marchac [44]. A
direction of the muscle fibers, with the caution to round-block suture is done around the areola with the
elevate no more than one half of the muscle thickness, purpose to reduce even more the length of the vertical
superficially. The posterior fascia of the muscle is not scar by compensating skin excess around the areola.
violated, leaving intact the ganglionar chain between Some advantages of this technique are as follows
the minor and the major pectoralis muscles, which is (Figs. 47.1147.14):
responsible for part of the lymphatic drainage of the 1. Long lasting breast projection and upper pole full-
breast. ness with the patient in both supine position and
It is possible to use this combination of techniques decubitus. The areola remains in a good location
for mastopexy only, when there is no breast tissue in and very little breast descent occurs (minimal bot-
excess to be removed, or for breast reduction, when the toming out).
resection of excessive breast tissue is done in the col- 2. A vertical scar that does not cross the new infra-
umns or base of the breast, after the thoracic wall flap mammary crease, and with better quality due to less
Fig. 47.11 Preoperative 30-year-old patient with breast ptosis (superior); 6 months postoperative mastopexy with vertical scar and
the use of the chest-wall-based flap (inferior)
skin tension, which was achieved through internal in the upper pole with a bipedicled major pectoralis
sutures of breast tissue. muscle flap, it is observed in long-term follow-up that
3. A narrower breast base due to the vertical principle a minimal scar resulted, the shape was better, and that
of parenchyma resection and approximation of there was maintenance of upper pole fullness and mini-
breast pillars. mal bottoming out, thus keeping NAC in the optimal
position of breast projection (Fig. 47.15).
This technique accomplishes this with a vertical
47.5 Conclusions scar that does not extend bellow the inframammary
fold. In older techniques, breast shape was determined
The achievement of a good aesthetic result in mamma- by skin tightening, and as the skin stretched, the shape
plasty requires an adequate shape, minimal scar, NAC was lost. By this technique, breast tissue is divided,
complex on the top of breast projection, and a relatively moved into its desired position, and fixed by the pecto-
narrow base. With the traditional techniques, breast ral loop, thus maintaining a youthful appearance for
shape has been accomplished with dermal sutures that the breast. Therefore, its shape does not depend on
would relax along the years, resulting in a descent of all skin closure for contour, but the specific tissue that
breast tissues (skin stretches with time). usually bottoms out is transposed and stably held into
By performing the vertical scar technique associated in the upper pole. This is another step in the evolution
with a chest-wall-based flap and holding it in position of breast surgery.
Fig. 47.12 Preoperative 25-year-old patient with mild breast ptosis (superior); 2 years after vertical mastopexy (inferior)
Fig. 47.13 Preoperative 35-year-old patient with breast hyper- inferior) and 2 years after touch up with horizontal scar at the
trophy and ptosis (left superior and left inferior); 1 year after lower (right superior and inferior)
vertical mastopexy (middle and right superior; middle and right
Fig.47.14 Preoperative (left superior and inferior); 10 years postoperative (right superior and inferior)
Fig. 47.15 Skin markings of the vertical technique (left); passing the chest-wall-based flap under the pectoral loop (middle) and
schematic lateral view of the flaps (right)
References 25. Ramirez OM (2002) Reduction mammaplasty with the

owl incision and no undermining. Plast Reconstr Surg
109(2):512522
1. Lexer E (1923) Ptosis operation. Clin Monatsbl Augenh
26. Atiyeh BS, Rubeiz MT, Hayek SN (2005) Refinements of
70:464
vertical scar mammaplasty: circumvertical skin excision
2. Hollnder E (1924) Die operation der mamahypertrophie
design with limited inferior pole subdermal undermining
und der hangebrust. Deutsche Med Wochenschr 50:1400
and liposculpture of the inframammary crease. Aesthetic
3. Lotsch GM, Gorhbandt E (1955) Operationen an der weibli-
Plast Surg 29(6):519531
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27. Pallua N, Ermisch C (2003) I becomes L: modification
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of vertical mammaplasty. Plast Reconstr Surg 111(6):
Am Cir Plast 3:2328
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5. Dufourmentel C, Mouly R (1961) Plastic mamaire par la
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6. Elbaz JS, Verheecke G (1972) La cicatrice en L dans les
29. Lotsch F (1923) Uber Hangebrustplastik. Zentralbl Chir
plasties mammaires. Ann Chir Plast 17(4):283288
50:1241
7. Regnault P (1974) Reduction mammaplasty by the
30. Dartigues L (1925) Traitement chirurgical du prolapsus
Btechnique. Plast Reconstr Surg 53(1):1924
mammaire. Arch Franco Bel Chir 28:313
8. Meyer R, Kesselring UK (1975) Reduction mammaplasty
31. Hall-Findlay E (1999) A simplified vertical reduction mam-
with an L-shaped suture line. Development of different
maplasty shortening the learning curve. Plast Reconstr Surg
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9. Horibe K, Spina V, Lodovici O (1976) Mamaplastia redu-
32. Hall-Findlay E (2002) Vertical breast reduction with a medi-
tora: nuovo abordaje del mtodo lateral oblcuo. Cir Plast Ib
ally-based pedicle. Aesthetic Plast Surg 22(2):185194
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33. Graf R, Biggs TM, Steely RL (2000) Breast shape: a tech-
10. Ely JF (1981) Guidelines for reduction mammaplasty. Ann
nique for better upper pole fullness. Aesthetic Plast Surg
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pessoal. Rev AMRIGS (Porto Alegre) 26(3):207214
Reduction mammaplasty and mastopexy with shorter scar
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and better shape. Aesthet Surg J 20:99106
35. Graf R, Biggs TM (2002) In search of better shape in mas-
13. Ges JC (1992) Periareolar mammaplasty with mixed mesh
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36. Graf R, Res de Araujo LR, Rippel R, Neto LG, Pace DT,
14. Ges JC (1996) Periareolar mammaplasty: double skin
Biggs TM (2003) Reduction mammaplasty using the verti-
technique with application of polyglactine or mixed mesh.
cal scar and thoracic wall flap technique. Aesthetic Plast
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15. Wise RJ (1956) A preliminary report on a method of plan-
37. Mottura AA (2003) Circumvertical reduction mastoplasty:
ning the mammaplasty. Plast Reconstr Surg 17(5):367375
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24. Benelli L (1990) A new periareolar mammaplasty: round
Hypertrophic Tubular Breast
Reduction: Surgical Technique 48
with New Inframammary Fold Level
Toma T. Mugea
48.1 Introduction 48.2 Breast Shape and Contour:

Surgical Anatomy
The mammary glands, a distinguishing feature of
mammals and a primary symbol of femininity, begin Breast shape and contour are influenced by:
development early in embryologic life and only culmi- 1. The volume of breast parenchyma in each quadrant,
nate in the postpartum lactation of the adult female. 2. The amount and location of the subcutaneous and
Congenital breast malformations occur in 26% [1] intraparenchymal fat,
with its range in severity from the relatively minor to 3. The body contour of the chest wall,
major chest wall deformities. Minor malformations 4. Its muscular covering and thickness, and
may not even be recognized, while major deformities 5. The tightness and elastic quality of the skin.
may cause significant functional, psychological, and The fascial attachments of the breast to the under-
aesthetic concerns. lying chest wall also influence breast appearance.
These malformations generally fall into one of two The breast develops and is contained within support-
categories, the presence of supernumerary breast tissue ing layers of superficial fascia. The superficial layer
or the absence or underdevelopment of breast tissue. of this superficial fascia is the outer layer covering
The absence or underdevelopment or underdevelop- the breast parenchyma, located near the dermis and is
ment of breast tissue is less common than the presence not always distinct from it. The more distinct is the
of supernumerary tissue. These conditions may be uni- superficial fascias deep layer on the deep posterior
lateral or bilateral and result from partial or complete surface of the breast. A loose areolar area is inter-
underdevelopment of the mammary bud. posed between the deep layer of the superficial fascia
The condition can affect the ability of women to and the superficial layer of the deep fascia that covers
breast-feed, but other physical aspects of fertility and the outer layer of musculature chest wall.
pregnancy are not affected by the condition. The retromammary space will allow the breast
tissue to have a natural gliding over the chest. The
superficial layer of the deep fascia overlays the
outer surface of the pectoralis major, the upper
portion of the rectus abdominis, the medial serratus
anterior, and the external oblique muscle in the
T.T. Mugea, M.D, Ph.D.
Professor of Plastic and Aesthetic Surgery, Plastic and lower central breast. This fascia is thinner over the
Aesthetic Surgery, Oradea Medical University, Oradea, muscular portions of the pectorals major and serra-
Romania tus anterior [2].
Medestet Clinic, Cluj-Napoca, Romania The connective tissue that supports the structures of
e-mail: [email protected] the breast (Coopers ligaments) runs from the deep

806 T.T. Mugea
muscle fascia, through the breast parenchyma, to the

dermis of the overlying skin (Fig. 48.1).
The attachments of these suspensor ligaments
between the deep layer of the superficial fascia and the
deep muscular fascia are not tight and allow the breast
mobility. These attachments can be stretched and
attenuated by weight changes, pregnancy, and aging,
which can result in excess breast mobility over the
chest and ptosis. This is the main problem in perform-
ing mastopexy for women who lose weight more than
20 kg in short time. Breast mould is gliding all over the
chest, borrowing skin also from the epigastric and
hypochondrial areas, making the preoperative plan
and drawing more difficult.
At the upper pole of the breast, near the second rib
space, the pectoral fascia tightly connects with the
superficial fascia of the breast, and it is difficult to
dissect bluntly [3]. Here is the meeting point of three
fascias, hanging to the clavicle. The superficial layer
of the superficial fascia joins the deep layer of super-
Natural milk lines ficial fascia (including between them the breast
Subclavius muscle
First rib
Superficial layer Clavipectoral

of superficial fascia fascia
Second rib
Deep layer
of superficial fascia Pectoralis major
muscle
Superficial layer Pectoralis minor
of deed fascia muscle
Retromammary space
with suspensors ligaments Deep layer
of deep fascia
Coopers ligaments
Breast mould
Sixth and seventh ribs
Rectus abdomins muscle

Fig. 48.1 Breast and pectoral
fascias (After Nahai [2], Inframammary crease ligaments
modified)
48 Hypertrophic Tubular Breast Reduction: Surgical Technique with New Inframammary Fold Level 807
Fig. 48.2 Breast mound development and natural gliding on inferior pedicles follow the breast mould in its descending move-
the chest wall. The blue lines represent the breast mould limits, ment. (Left) Teenager. (Middle) Young female. (Right) Adult
and the red one the initial nipple level. Breast central and female
mould) and the superficial pectoralis fascia. At the nipple glide over the chest, but the inframammary fold
upper and middle pectoral fascia, many thin fibers are is at the same level [6, 7].
found between the pectoral fascia and the deep layer
of the superficial fascia of the breast [4].
In the normal growing phase, the breast can be 48.3 Breast Embryology
considered to have a hemispheric shape, with the
nipple in the middle, in the most prominent point Normal breast embryologic development follows
(Fig. 48.2). As the breast will gain weight, because of several stages, with three main participants:
the gravity and ligament tightening, the breast mould 1. Number of breast cells (glandular and stromal)
will translate in the lower two thirds of the breast 2. Superficial fascia of the thorax
vertical meridian, together with the nipple areola 3. Signaling elements (endocrine, paracrine, and auto-
complex. crine signals).
Age, gravity, breast volume, and decreased elasticity During the fourth week of gestation, paired ectoder-
contribute to a gradual lowering of the breast landmarks mal thickenings termed mammary ridges or milk lines
over time, as a woman gets older and experiences develop on the ventral surface of the embryo from the
normal physiologic changes. The extent of this descent axillae to the medial thigh [8, 9]. In normal human
depends primarily on the volume of the breast and the development, these ridges disappear except at the level
elasticity of the tissues. The breast mould and central of the fourth intercostal space, where the mammary
pedicle will change the position according to the gland subsequently develops [9].
gravity. During the fifth week of gestation, the remnant of
In breast pseudoptosis, only the breast mould is the mammary ridge ectoderm begins to proliferate (the
hanging. The nipple and the inframammary fold are at primary mammary bud), and during the seventh week,
the same level like in the normal situation. In the glan- grow downward as a solid diverticulum into the under-
dular ptosis, the breast and inframammary fold glide lying dermis. Progressively, superficial fascia is reverted
over the chest. In the true breast ptosis, the breast and as a finger glove and becomes double by folding
808 T.T. Mugea
in front of the breast, with a strong round ring in the the tissues in a tight way during the growing phase.
middle, and a single layer sheet covering the deep sur- During the breast development, these fibrous structures
face of the breast (Fig. 48.3). became more tight and evident as suspensors ligaments
Between dermis, superficial fascia, and deep fascia of Cooper, which join the two layers of the superficial
over the trunk, there are fibrous structures which hold fascia and extend to the dermis of the overlying skin
a b
Suspensor
Ligaments
Skin Superficial
Fascia Central Superficial
Primary Mammary Fascia
Mammary Deep Bud Deep Layer
Bud Fascia
Superficial Mammary
Fascia Bud
Ring Branches
c d
Superficial
Fascia
Central
Mammary Superficial
Central
Bud Fascia
Mammary Superficial
Deep Layer
Bud Fascia
Deep Layer
Mammary
Superficial
Bud
Fascia
Branches Superficial
Ring Mammary
Fascia Bud
Ring Branches
Fig. 48.3 Normal breast and its embryologic development

f Superficial Fascia
e
Suspensor
Superficial Layer Ligaments
Susperficial
Fascia Suspensor
Cooper Deep Layer
Ligaments
Ligaments
Central
Mammary Superficial
Bud Fascia Areola
Deep Layer
Deep
Mammary Fascia
Superficial Bud
Fascia Superficial
Branches
Ring Fascia
Ring
Inframammary
Crease
Glandular Lobes Ligament
and the deep pectoral fascia [810]. The superficial hypertrophies or asymmetries is always the variable
layer of the superficial fascia is absent under the areola, thickness of the parenchymal layer.
because here is the place of mammary bud invagination At term, approximately 1520 lobes of glandular
into the mesenchyme [11]. tissue have formed, each containing a lactiferous duct.
During the remainder of gestation, this bud contin- The lactiferous ducts drain into retroareolar ampullas
ues lengthening and branching to form the lactiferous that converge into a depressed pit in the overlying skin.
ducts, corresponding to five directions: one central Stimulated by the inward growth of the ectoderm, the
and four to the corners generating a pyramid like mesoderm surrounding this area proliferates, creating
image. This is a very special moment, when each bud the nipple. The surrounding areola is formed by the
branch can develop normally, generating a proper ectoderm during the fifth month of gestation. The
number of future breast lobules or can be stopped. All areola also contains other epidermal glands, including
these events are under strong regulation of local glands of Montgomery (sebaceous glands that serve to
growth factors. lubricate the areola).
The breast is ready as future projection, and only At birth, the breast is composed of radially arranged
the hormonal influence at puberty will allow the full mammary lobes, like a cone, draining via lactifer-
reading of this program. It seems that if some breast seg- ous ducts into ampullas that empty onto the nipple
ments will have less glandular tissue and less hormonal (Fig. 48.3). The nipple appears as a small pit in the
receptors, the pyramid will not be symmetric. Wuringer center of a thickened areola containing a few glands of
[12] describes the division of the mammary parenchyma Montgomery.
into two parts by the horizontal fibrous septum includ- Shortly after birth, the nipples become everted from
ing the vascular and nervous membranes attached to it. proliferation of the surrounding mesoderm, and the
The bipartition of the parenchyma may be explicable as areolas develop a slight increase in pigmentation.
an invagination of the ectoderm cranially and caudally The initial phase occurs between birth and puberty,
from the inductive mesenchyme, and it may be seen as a during which time the supporting stromal structures and
fusion of two mammary glands. According to Wuringer ducts enlarge in proportion to the increase in body size
[13], the reason for volume differences in breast of the individual, but no lobular development occurs.
810 T.T. Mugea
Stages of breast development. If pregnancy occurs, the glands complete their dif-
ferentiation and reach functional maturity with the
At puberty, elongation and thickening of the intralobular-branched ducts forming buds that become
ductal system occur, and the breast volume increases secretory alveoli. The epithelial cells of the alveoli
primarily from deposition of fat and deve- begin to accumulate the cytoplasmic organelles nec-
lopment of periductal connective tissue. This essary to sustain lactation in the postpartum period.
development is generally complete by age 20 years
(Fig. 48.2). Breast changes during pregnancy.
Gestational Age:
19 Weeks 31 Weeks
7 Weeks
Breast Volume:
293ml 381ml 398ml
By age 40 years, the mammary glands begin to atro- The author postulates that the embryological origin
phy. During and after menopause, the altered hormonal of tuberous breast deformity could be related to a simul-
environment leads to a senescent state, with involution taneous coexistence of several pathogenic factors:
of the glandular component and replacement with con- 1. Tight superficial fascia, which does not allow the
nective tissue and fat. primary mammary bud to penetrate inside and
advance into the mesoderm. As a result, the mam-
mary bud cannot develop as normal in the superfi-
48.4 Tubular Breast Etiology cial fascia glove and, without local paracrine
signals (growth factors), will stop the development
A tuberous breast is basically caused by incom- at one stage, in one or more direction.
plete development of the mammary gland, usually 2. Local signaling defect for bud branches to develop.
in the two inferior quadrants, and probably as a 3. Lack of bud development by a self-defect, partially
result of adhesion of the two layers of breast fascia or complete.
followed by formation of a constrictive ring around The author considers this situation as credible for
the areola [14]. tuberous breast etiology because:
Many authors have referred to the embryology of 1. There is a silent congenital disease.
breast development, but the theories put forward are 2. There is a growing process starting at puberty.
far from satisfactory. Pers (1968) [15] postulated that In tubular breast, it seems that the quality and quan-
there is failure of tissue differentiation in a limited tity of the hormonal stimulus is not different from
zone of the fetal thorax. Mandrekas [16] considers normal, but the lower quadrants (Fig. 48.4), which
that the absence of the superficial layer of the super- are the most affected, have less glandular tissue and
ficial fascia underneath the areola [8, 11], coupled less hormonal receptors. This corresponds to caudal
with the constricting ring[17] formed by the thick- parenchymal layer described by Wuringer [13].
ening of the superficial fascia [18] especially in the 3. In type III, the breast tissue grows in front of one
lower pole of the breast, inhibits the expansion of fibrotic ring level (Fig. 48.5), corresponding to the
the developing breast and leads to a herniation of the superficial fascia reverse haul for invagination,
breast parenchyma toward the nippleareola where the central buds stop to advance and branch
complex. into the mesoderm.
a b
Superficial Susperficial
Fascia Fascia Suspensor
Suspensor Ligaments
Ligaments
Central Superficial
Mammary Fascia
Deep Layer Areola
Bud
Cranial & Central
Glandular Lobes
Superficial Mammary
Fascia Bud
Ring Branches Superficial
Fascia Inframammary
Ring Crease
Ligament
Fig. 48.4 Tubular breast missing inferior glandular lobes development. This corresponds to type II tubular breast
812 T.T. Mugea
a b
Superficial
Superficial Fascia Suspensor
Fascia Ligaments
Suspensor
Ligaments Central
Central Mammary
Mammary Gland Undeveloped
Bud Mammary
Mammary Gland
Bud
Branches Areola Inframammary
Crease
Inframammary Ligament
Crease
Superficial Ligament
Fascia Superficial
Ring Fascia
Ring
Fig. 48.5 Tubular breast missing all peripheral quadrants from the pyramid. Only central part of the mammary gland developed.
This corresponds to type III tubular breast
4. In type I or type II, the breast tissue can expand and anced and making a proper bra fit impossible without
develop normally in the unaffected segments. custom tailoring.
5. Breast hypertrophy can occur even in this congeni- Additionally, nipples and areolas may be consid-
tal malformation for type I or type II. ered too large or too small for the breasts they occupy.
6. The high level of inframammary fold is always While this is a very subjective topic, it can still be trou-
present, corresponding to the horizontal septum bling to any woman who views her body as
described by Wuringer [12, 13] with central neuro- abnormal.
vascular pedicle (Fig. 48.2). Throughout the breasts development and evolution
7. Areola is enlarged as a normal expanded tissue. alterations often appear due to volume excess (hyper-
Superficial fascia and apparent constricting ring are trophies) or absence of volume (atrophy, hypotrophy)
not the cause but the result of the growth defect, and unequal development (asymmetries) or malforma-
because this ring is close to the deep fascia, and there tions (tuberous breasts).
is no breast tissue behind this level. Otherwise, a It is impossible to impose a single standard of breast
clepsydra shape of the breast supposes to be present, beauty to women who are so entirely different in
and its not the case in clinical cases. height, weight, and constitutional type. Therefore, we
need to discover the sizes that are aesthetically right
for each particular woman, starting from her main
48.5 Aesthetic Breast Analysis parameters: height, weight, trunk height (the distance
between manubrium notch and the pubis), width
Some women are born missing one or both breasts across the shoulders, and pelvic width at the level of
and/or nipples. There are many reasons for this to the anterior superior iliac spines. These parameters
occur, but the effect is devastating. Alternately, all will be included into a computer program (TTM
tissues might be present, but simply do not develop patent) and will give the Breast Golden Number,
properly. This is called breast hypoplasia or sometimes representing the breast dimensions which correspond
breast hypotrophy. Typical breasts can also be affected to the aesthetical proportion between the breast and
by size and proportion issues. Most breasts are not the body. This computer program came after a com-
symmetrical, and it is common for women to have plex assessment of the breast and body in 50 cases of
up to a 30% size discrepancy from one side to the Caucasian females with aesthetic breasts, in harmony
other. However, sometimes, this difference in size is with their body, which looks also aesthetically pleas-
extremely pronounced, making the body appear unbal- ant [19].
Table 48.1 TTM chart

with breast and trunk
measurements
In order to achieve the best aesthetic results in 48.6 Breast Score for Soft Tissue Elasticity
breast augmentation, the surgeon must evaluate each
breast before the surgery, in terms of position, propor- To estimate skin tightening and soft tissue elasticity,
tion, symmetry, volume, soft tissue elasticity, skin we use the Pinch Test in the upper pole of the breast.
excess, and ptosis degree (if exists). TTM chart We grasp the biggest amount of skin and soft tissue that
includes the breast and body parameters [19] needed can be moved over the pectoralis fascia. If two dots are
for an objective aesthetic evaluation of the breast marked on the skin in the pinched situation, we can do
(Table 48.1). the measurements also for relaxed one (Fig. 48.6).
814 T.T. Mugea
a Soft Tissue Elasticity Assessment
Relaxed (R) : Pinch Test (P)
8 cm : 3 cm = 2,5 cm
b
Soft Tissue Elasticity Score
R:P<2 Tight = Score 1
R:P=23 Normal = Score 2
R:P>3 Loose = Score 3
Fig. 48.6 Pinch test for soft tissue elasticity assessment
If the Deep Pinch Test shows an R:P ratio <2, this The difference between stretched and relaxed infe-
corresponds to a tight situation, and the Breast Score rior meridian, in cm, will give the Skin Excess Score
for Elasticity is 1. that will be 1 for 1 cm excess, 2 for 2 cm excess, and 3
If the Deep Pinch Test shows the R:P ratio to be between for 3 cm excess.
2 and 3, this corresponds to a normal soft tissue elasticity
situation, and the Breast Score for Elasticity is 2.
If the Deep Pinch Test shows the R:P ratio >3, this 48.8 Breast Score for
corresponds to a loose soft tissue or skin excess, and Volume
the Breast Score for Elasticity is 3.
Getting experience, the plastic surgeon can appreci- Especially in terms of volumes, implant selection in
ate directly after the Pinched Test, the tight, normal, or breast augmentation depends on the actual existing
relaxed situation, corresponding to the Breast Score breast volume, evaluated by the difference between the
for Soft Tissue Elasticity 1, or 2, or 3. Breast Golden Number (BGN) and the Breast Vertical
Meridian (BVM) (Fig. 48.8).
In cases with severe breast hypotrophy or amastia,
48.7 Breast Score for Skin BVM will be close or similar with Breast Vertical
Excess Diameter. As the breast mould is growing, the BVM
will increase in dimensions, and the aesthetic breast
Because in breast augmentation, the lower third of the will be similar with the BGN. If the difference in cm
breast will be expanded to get maximum nipple projection, between BGN and BVM is 1, or 2, or 3, or more, the
we should know the amount of extra skin that can be corresponding Breast Volume Score will be 1 (mild
available. For these, we do the inferior meridian measure- hypotrophy), 2 (moderate hypotrophy), or 3 (severe
ments in relaxed and in stretched situation (Fig. 48.7). hypotrophy).
a Skin Excess Score

Stretched - Relaxed Inferior Meridian
8,5 cm 6 cm = 2,5 cm
b Skin Excess Score

Stretched (S) - Relaxed (R)
1 cm = No Extra Skin = Score 1
2 cm = Moderate Excess = Score 2
3 cm = Good Skin Excess = Score 3

Fig. 48.7 (a) Relaxed and stretched inferior meridian measurements. (b) Soft tissue elasticity assessment
48.9 Breast Score for Ptosis and the third number for Breast Volume. In cases with
ptosis, the fourth number will be added (Fig. 48.10).
To evaluate the ptosis degree (Fig. 48.9), we take the
Inframammary Fold Length from Breast Circumference
(BC). If the difference in cm between BC and IMF is 48.11 Tubular Breast: Short Denition
1, or 2, or 3, the corresponding Breast Ptosis Score will and Classication
be 1 (mild ptosis), 2 (moderate ptosis), or 3 (severe
ptosis). Even if in the literature there are many terms for tubular
breast definition, tuberous breasts, tubular breasts,
snoopy breasts, herniated areolar complex, domed
48.10 Breast General Score nipple, nipple breast, constricted breast, lower-pole
hypoplasia, and narrow-based breast are some of the
The final breast assessment, named Breast General Score names used to describe this deformity or the so-called
(BGS), will include in order the first number for Soft new deformities that, under careful inspection, are no
Tissue Elasticity, the second number for Skin Excess, different from the original one described by Rees and
816 T.T. Mugea
Fig. 48.8 Breast Volume

Score evaluated by the a Glandular Volume Score
difference between Breast
Golden Number (BGN) and
Breast Vertical
Meridian (BVM)
BGN BVM
BGN = Breast Golden Number
BVM = Breast Vertical Meridian
b Glandular Volume Score

BGN BVM = 0 Normal Volume
1 cm = Small Hypotrophy = Score 1
2 cm = Moderate Hypotrophy = Score 2
3 cm = Severe Hypotrophy = Score 3
a Breast Ptosis Score
BC IMF
BC = Breast Circumference
IMF = Inframammary Fold
b Breast Ptosis Score

0 = No Ptosis
Fig. 48.9 Breast Ptosis Score

1 cm = Small Ptosis = Score 1
is 0 for the right breast and 3 2 cm = Moderate = Score 2
for the left breast. Left Breast
Circumference is 26 cm, and 3 cm = Moderate Plus = Score 3
the BGN is 19 cm
a
Score 113 Score 213
b
Score 222 Score 232
Fig. 48.10 Clinical cases with different Breast General Scores (BGS)
818 T.T. Mugea
c
Score 323 Score 333 + ptosis 2
d Asymmetry & Breast Hypotrophy

BGS = 333 + 2 BGN = 19 cm BGS = 323
Areola Size = Normal Areola Size = Normal

IMF = Normal IMF = Shrot & High Situated
All Meridians = Normal All Meridians = Smaller then BGN

e Score 211 Score 210
f Severe Breast Hypotrophy

BGS = 223 BGN = 19 cm IMF = 14 cm
Areola Size = Normal

IMF = Short & High Situated
All Meridians = Smaller then BGN

820 T.T. Mugea
Aston [17]. In its full expression [2022], the deformity To conclude and make a simple definition, the
is characterized by: author considers that tubular breast represents a con-
1. A small breast, minimal breast tissue, sagging genital breast deformity with:
2. A breast parenchyma volume reduction 1. Asymmetric breast meridians
3. A cylindrical rather than a conic shape 2. Short inframammary fold length
4. A relatively reduced base circumference both on 3. High situated inframammary fold level (short breast
the vertical and horizontal axes vertical diameter)
5. Unusually wide spacing between the breasts Tubular breast classification is similar to Grolleau
6. A constricting ring that herniates the nippleareola [18], but with a precise definition:
complex Type I (inferior and medial meridians shorter
7. Areolar hypertrophy (enlarged, puffy areola) inferomedial quadrant hypoplasia)
8. Hypoplasia of the lower mammary quadrants Type II (inferior, medial, and lateral meridians
9. A submammary fold situated too high shorter inferior quadrant hypoplasia)
Fig. 48.11 (a) Teenager patient with apparently normal shape I B on the right side and tubular breast type I C on the left side.
but with hypotrophy of right breast and left breast with tubular No areola widening
disease type I B. (b) Five years later with tubular breast type
Type III (all meridians shorter than normal all got some volume, they would have a certain degree of
quadrant hypoplasia except central segment) ptosis (Fig. 48.11). Wide areola is not included in the
According to the glandular volume correction, each definition because it is present only in some cases
type of tubular breast can be with: (Fig. 48.12), usually after breast enlargement. The
1. Severe breast hypoplasia inframammary fold stays at the same level, in a higher
2. Moderate hypotrophy or normal breast volume position than normal, and the breast development in
3. Hypertrophic breast. the other quadrants, except the inner inferior one,
Because all tubular breasts have a high situated generates the breast asymmetry and ptosis. The breast
and short inframammary fold length, as soon as they mould is hanging over the inframammary fold.
a Tubular Breast Type I B & I C
Right Breast = Type I B Left Breast = Type I C
b Tubular Breast Type III A & I B
Right Breast = Type III A Left Breast = Type I B
Fig. 48.12 Different types of tubular breast according to the new proposed classification
822 T.T. Mugea
c Tubular Breast Type II A
d Tubular Breast Type II A
Right breast with severe hypoplasia
e Tubular Breast Type II B

f Tubular Breast Type II B
g Tubular Breast Type II C
h Tubular Breast Type III A

824 T.T. Mugea
48.12 Tubular Breast: Congenital a moderate breast hypotrophy, so she got a Type II B
Disease in Twin Sisters Case tubular breast according to our classification.
Second twin sister (Fig. 48.15) has tubular breast
The author found a rare and interesting case of twin Type II C with short and high situated inframammary
sisters, both with tubular breasts, moderate thoracic fold, wide areola, and inferior quadrant hypotrophy.
scoliosis, and sternal depression in the upper part. Because she has breast hypertrophy (breast volume
Their mother has normal breasts (Fig. 48.13), with bigger than normal), according to our classification,
normal development and ptosis according to her age she got a Type II C tubular breast.
and three pregnancies in the past. Both sisters have a The lifting effect on the breast created by rising the
Type II tubular breast. arms (Fig. 48.16) demonstrates the strong connection
First twin sister (Fig. 48.14) has tubular breast Type between breast suspensory ligaments, breast mould,
II B with short and high situated inframammary fold, and the superficial fascia ring showed at the areola
wide areola, and inferior quadrant hypotrophy. She has margin (red arrow) for twin sister A.
a b c
Fig. 48.13 Mothers twin sister breasts
a b c
Fig. 48.14 Twin sister A with tubular breast type II B

a b c
Fig. 48.15 Twin sister B with tubular breast type II C
Fig. 48.16 (a) Mother.

(b) Sister A. (c) Sister B
826 T.T. Mugea

b

c
Comparing the picture from the mother and twin 48.13 Treatment Goals and Surgical
sisters in this position, we can see how the suspensory Options
ligaments lift almost all the volume in tubular breasts,
like a hammock, demonstrating in this way that the The main goal of tubular breast treatment is to restore
lower glandular quadrants are hypotrophic. a normal breast shape. To achieve this, it has to:
To explain how this complex congenital disease 1. Expand breast circumference
affects in the same way the twin sisters is a real 2. Expand skin envelope in lower pole
challenge, allowing speculation about genetic program, 3. Release fibrotic constriction at the superficial fascia
signals, and growing factors involved. ring
828 T.T. Mugea
4. Lower the inframammary fold level (inferior NAC pedicle and inframammary crease liga-
5. Increase breast volume (when appropriate) ment) (Fig. 48.18).
6. Reduce areola size and correct herniation (when Actually, deepithelialization is being done on the
appropriate) thoracic skin up to the level we want to be the new
7. Correct nipple location and breast ptosis (when inframammary fold level, and we glide into caudal
appropriate). direction the lateral flaps and suture to it in an inverted
Every attempt is made to correct the deformity in a T scar. Wechselberger [39] presents also a deepitheli-
single stage operation. Many techniques have been alized skin flap, but that is anchored to the periosteum
described, reflecting the reconstructive challenge of of the fifth or sixth ribs to reconstruct the inframam-
this deformity. The main concepts in reshaping the mary fold in double-bubble postoperative deformity.
deformed breasts are: This technique is simple, easy to learn, and allows
1. Periareolar mastopexy techniques to reduce areola breast reduction with inferior based pedicle for nipple
and reposition the nipple areola complex [17, areola complex in the same time with lowering of the
2031] inframammary fold at the desired level, without fear of
2. Breast parenchyma redraping by inferior pole radial jeopardizing the NAC vascularity. Also the lowering of
scoring, mobilization, or division [1618, 30, 3234] the inframammary fold level by deepithelialized skin
3. Augmentation with permanent implant or expand- ellipse can be associated with a round block mastopexy
able permanent implants [29, 35, 36] for tubular breast Type II B.
4. Reconstruction by autogenous tissue [15, 37, 38] In this way, the fullness of the inferior breast quad-
5. Breast reduction when appropriate [15, 39] rants is restored, when the medial and lateral breast
limits (breast horizontal diameter) are close to the
normal situation, as in Type II tubular breast.
48.14 Tubular Hypertrophic Breast Type
II C Correction 48.14.1 Advantages
The majority of surgical techniques for tubular breast 1. Precise planning of the surgery with predictable
correction are focusing on the hypoplastic breast, con- breast shape.
stricting ring with wide areola and high position, and 2. Patient satisfaction with good aesthetic result visible
the inframammary fold. next day after the surgery.
The problem of hypertrophic tubular breast has a 3. Areola reshaping with a natural appearance.
relatively low incidence, and the surgical techniques 4. Inverted T scar is better accepted than a Z-plasty,
described represent either a reduction mammaplasty which is more visible on the lower part of the breast.
with a superiorly based dermal pedicle and resection This technique provides a stable and long lasting
of the inferior portion of the breast, resulting in an suspension along an exactly defined line, using the
inverted T scar [15, 40], or a modification of Maillard glandular and fascial structures of the breast, as one
Z-plasty technique [15, 41]. unit. Nipple sensibility and vascularization are preserved
Also, type I B or type I C deformities were treated by the inferior pedicle.
so far by circumareolar mastopexy and reduction
mammaplasty with a superiorly based glandular
pedicle (Lejour-type reduction/mastopexy) in hyper- 48.14.2 Disadvantages
trophic or adequately sized breasts [15, 18] and a
lateral dermoglandular flap to fill the lower medial 1. A strong limitation of this technique came from the
quadrant [18]. condition that the available length of lateral flaps
For type II C tubular breast (Fig. 48.13), the clinical must have together, at least, the same dimension
appearance corresponds to hypertrophic breasts, with like the new inframammary fold length.
wide areola and short inframammary fold, highly 2. Operation time required: average 2 h and 30 min,
situated. no longer than a routine breast reduction.
Based on the anatomical data, the author suggests a 3. Hospital stay for 24 h.
new technique for lowering the inframammary fold 4. Drains usually for 12 h.
level (Fig. 48.17), without disturbing the local anatomy 5. Recovery usually in 7 days.
Fig. 48.17 Breast reduction

technique for type II C tubular
breast, telescoping the inferior a
pedicle and caudal gliding of
inframammary fold
Deepithelialised
Skin Flap
Old
Inframammary
Fold Level
Old Tubular Areola
New
Inframammary
Fold Level
Deepithelialised
Periareolar Skin
Inferior
Dermoglandular
Flap Pedicle
b
NAC
Deepithelialised
Skin Flap
Old
Inframammary
Fold Level Pectoralis
Fascia
New
Inframammary
Fold Level
Deepithelialised
Thoracic Skin Inferior Dermoglandular
Flap Pedicle
48.15 Patient Consultation Standard breast pictures are taken after examination
and loaded in the patient electronic file version. These
Patient appointment, waiting, consultation, clinical include standing front, profile and oblique exposition,
examination with breast measurements, informed with arms relaxed and lifted. In order to demonstrate
consent, and preoperative preparations are done in the the inframammary fold level and the neck of the
same way as has been presented in details in our chap- breast (the attachment base to the trunk) useful for
ter about breast reduction/mastopexy in this book. tubular breast examination, special pictures are taken
830 T.T. Mugea
Superficial Layer
Superficial Fascia
Pectoralis
Deep Layer Fascia
Superficial Fascia
Central
Pedicle
Old
Inframammary
Fold Level
Inframammary
Inferior Crease Ligament
Dermoglandular
Flap Pedicle
New
Inframammary
Fold Level
Fig. 48.18 Postoperative position of old inframammary fold level, inferior pedicle, and inframammary crease ligament location
inside the breast mould (left) and the normal breast anatomy (right)
with breast sustained and gently pulled out by the Till now, this is the only program available for
assistant (Fig. 48.19). breast assessment, allowing precise preoperative plan-
According to the TTM chart (Table 48.2), the sur- ning for breast reduction or mastopexy, in order to
geon can document and show to the patient the breast achieve aesthetic results. We create and use it for every
problems, even small asymmetries. Body height, weight, case, demonstrating its accuracy in the last 10 years.
trunk measurements, and standard breast measurements At the follow-up, we can also document the present
are very important elements for defining Breast Golden situation of the breast and how it was the evolution in
Number (BGN) and Breast General Score (BGS). time.
After collecting the data in the chart, we fill the After the first consultation and examination,
boxes nominated in the TTM program for breast reduc- according to the patient desires, based on pictures and
tion (Fig. 48.20), organized in similar sections as the computer program, and sometimes using free drawing
chart. The surgeon has to select the calculate named on the consultation file, the surgeon will explain in
icon situated in the right upper corner of the table, and details what the problems are and what can be done to
automatically, the computer will list, in red color, what solve it.
are the ideal breast dimensions for the patient. If the patient understands the procedure, including
Because in this case we have a patient with a tubu- the risks of incidents and accidents and complications
lar breast type II C, the inframammary fold length related to the anesthesia also, she will receive a printed
(16 cm) is significant shorter that supposed to be in a document containing these things and the lab tests and
normal case (2023 cm). other medical examination necessary.
a b c
d e f
g h i
Fig. 48.19 Patient with hypertrophic tubular breast type II C. Note the short (16 cm) and high situated inframammary fold, wide
areola (14/10 cm diameters), and small breast vertical diameter (8 cm) with a big Breast Vertical Meridian (43 cm)
832 T.T. Mugea
j k l
m n
48.16 Final Preoperative Consultation In front of the assistant, the patient will read and
sign the consent for the surgery and anesthetic proce-
After first consultation, the patient goes home and dure (Consent Form).
digests the information and experience acquired According to the clinic policy, the patient has to pay
during the first visit to the surgeon. If she takes the the full price of the procedure at least two weeks before
decision to have the surgery, she will undergo the admission. No discount, partial payment, or bank guar-
medical investigations recommended, and she will be anty will be admitted. For all the services paid, the
scheduled for a second appointment. patient will receive a receipt. Patients begging for
At the second consultation, the surgeon will check financial favors, promising that they will be advertis-
the results from the recommended investigation and ing our clinic and bring new patients among their
will discuss in more detail the procedure, including friends, will be erased from the list. Accepting patients
risks, and unfavorable possible events. Special atten- with this kind of behavior in private practice is equiva-
tion will be paid for scars and wound healing. lent to an opened gate for problems after the surgery.
Fig. 48.20 TTM Junior program for breast reduction/mastopexy, with actual and ideal dimensions
They will become demanding, unhappy with the representing the new inframammary fold and mark the
results, whatever will be, and will turn out into an midpoint of it (Fig. 48.22). The new inframammary
enemy and bad advertising person. fold length to be surgically created is 19 cm, shorter
According to the patient desire, and waiting list, the than the end result, which will be 21 cm, according to
surgeon will schedule the date of the operation. the Breast Golden Number.
Because the upper pole of the breast is flat at the
marking time, when the breast cone is filled, the nipples
48.16.1 Surgical Plan new position with breast tissue behind it will be pushed
forward, like a pendulum, and the manubriumnipple
The entire procedure is designed before surgery, distance will become shorter (form aesthetic point of
with the patient sitting and arms placed to the sides. view), with the nipple situated in a higher position than
The following clue points and lines are marked: manu- desired. To correct this, we add 10% extra length to the
brium, acromion, supero-anterior iliac spine, and calculated manubriumnipple distance for the new nip-
pubis. ple position. To define the new nipple location, the ruler
The inframammary fold with its medial and lateral passed behind the neck to the nipples, and a dotted line
end point is marked. The new inframammary fold mid- marked the inner side of the ruler. The meeting point
point level should correspond to the six ribs, on medio- between this line and Mn-Ni distance, located accord-
clavicular descending line, and is situated 2 cm below ing to the 10% correction rule, will be the new nipple
the old inframammary fold level (Fig. 48.21). After position, in this case, 21 cm from the manubrium notch
marking these reference points, we draw the line (19 + 2 cm, representing 10%, = 21 cm).
834 T.T. Mugea
Table 48.2 TTM chart with

breast and trunk
measurements for patient with
short inframammary folds
(16 cm) and wide areola
diameters, right 14/10 cm and
left 12/8 cm. Breast vertical
diameter is 8 cm shorter than
horizontal one. Normal is
11 cm
In order to avoid all this calculations, sometimes presented in this book at mastopexy with short inverted
boring for a surgeon, we created a new version of TTM T scar chapter.
program for breast reduction and mastopexy, able to Using a ruler, we mark step by step the points situ-
show instantly all the measurement to do the preopera- ated at 9 cm distance from the medial and from the
tive marking of the breast based on Breast Golden lateral edges of the inframammary fold. This will
Number. This is TTM Advance version (Fig. 48.23). define the level of vertical T branch and represent
All the marking steps are similar with our demonstration half of the inframammary fold length (9 cm).
Fig. 48.21 Surgical plan for

breast reduction and
inframamary fold caudal 8 cm
21 cm Mn New Ni Breast
gliding
Vertical Diameter
9 cm
IMF
5 cm
2 cm
27 cm Mn Ni
14 cm
Areola
Vertical Diameter
15 cm Ni - IMF
Deepithelialised
Periareolar Skin
New Areola Margin
Deepithelialised
Skin Flap
Pectoralis
Fascia
Old
Inframammary
Inferior Fold Level
Dermoglandular
Fig. 48.22 Intraoperative Flap Pedicle New
view with inferior Inframammary
dermoglandular pedicle and Fold Level
new inframammary fold level
836 T.T. Mugea
Fig. 48.23 TTM Advanced program for breast reduction/mastopexy, with suggested marking dimensions
We select the Wise pattern keyhole, corresponding tranquility, the anesthetic team will proceed to put an
to the 5 cm diameter areola, and holding the upper pole IV line and connect the patient to the monitors. The
of the key at 2.5 cm superior to the marked nipple anesthesia will be with oral intubation.
point, we enlarge the keyhole branches until these meet When the patient is asleep, the radiofrequency bipo-
the doted lines corresponding to the vertical branches lar electrocautery will be connected, and the scrub
of inverted T. nurse will prepare the table with instruments. The
According to TTM chart, NiInfra distance should operation field is prepared with Betadine solution, and
be 7 cm (1:3 from Inframammary Fold Length), and after the patient is covered with sterile drapes, the key
the length of each vertical T branch will have in this points are marked by small intradermal injections with
case 5 cm, because 2 cm came from areola diameter. Methylene Blue on both breasts. This is necessary to
With full marking done, a picture will be taken for the avoid the dissipation of the drawings during the opera-
files (Fig. 48.24). tion. A special cutting ring, with a hole centered on the
nipple position, will mark the new areola diameter.
According to the drawings, the intradermal incisions
48.16.2 Surgical Technique on both breasts are made with No. 15 blade scalpel,
and deepithelialization started carefully from the
The patient comes into the operating theater with a dis- new inframammary fold level using a sharp scissor
posable cap and dressed with a large gown that will be (Fig. 48.25). When the deepithelialization is com-
removed by the nurse before sitting on the table. In pleted, using the electrocautery, the transdermal
a b
Fig. 48.24 Final preoperative marking of the patient
incisions are started, saving a 5-mm margin from the Key dermal stitch with 2/0 Vicryl holds together
skin, which will be used at the closing sutures. This areola with lateral and medial cutaneous flaps, at the
marginal dermis will hold the skin in the suture with- superior end of the vertical T branch and bought
out tension and will prevent the bad scars during the breast pillars, lateral and medial, are sutured with 2/0
healing process. Vicryl, in front of the inferior pedicle, holding the
The glandular incision is made using No. 21 cold breast mould. Second layer is a reverse dermohypo-
blades. In this way, the margins are kept clean, with- dermic stitch, with 2/0 Vicryl, and includes the ante-
out thermal damage, and allow normal wound healing. rior layer of the superficial fascia of the breast. Suction
To help in this maneuver, the assistant holds the key drain is placed in the retroglandular space and attached
points of the incisions with skin hooks, and with the to the sterile bag, with a mild negative pressure.
left hand, the lateral side of the gland that is hanging The skin suture (Fig. 48.27) is performed with
is gently pushed to medially. This incision should be intracuticular running suture with 5/0 PDS.
done through the gland mould, if possible, at once, The whole incision length is taped with SteriStrips
down to the retroglandular space, carefully not to open changed every 7 days, for 36 weeks. Patients are
the muscular pectoralis major fascia. This point is asked to wear brassiere for 6 weeks.
very important, because along this retroglandular
space, the breast central neurovascular pedicle runs
to the nippleareola complex. The dermoglandular 48.16.3 Postoperative Result
excess from lateral and medial flaps will be carefully
excised, according to the plan. Incisions are completed At the end of the operation, even the NAC is centering
superiorly, and the inferior pedicle is well mobilized the breast mould on both sides (Fig. 48.28) and they look
(Fig. 48.26). divergent because of lateral position on the chest wall,
838 T.T. Mugea
a b
Fig. 48.25 Deepithelialization completed at the new level of at the closing sutures. The dermoglandular excess from lateral
the inframammary fold, inferior NAC pedicle, and a 5-mm and medial flaps (red arrows) will be excised
margin from the skin flaps (yellow arrows), which will be used
a b
15 cm
Dermoglandular
Pedicle Length
5 cm
9 cm
16 cm
19 cm
Fig. 48.26 Glandular excision completed and NAC inferior pedicle released and still attached to the thoracic wall at the old
inframammary fold level
a b
Fig. 48.27 Breast reduction completed. Patient lying on the operating table
a b
c d
Fig. 48.28 NAC normal position centring the breast mould after the surgery
840 T.T. Mugea
Fig. 48.29 (a) Preoperative. (b) One month postoperative after breast reduction and lowering of the inframammary fold level for
tubular breast type II C
which is round. At 1 month after the surgery (Fig. 48.29), 48.17 Tubular Breast Type II B Correction
comparative photos show a good result, with breast with Round Block Mastopexy
reduction and lowering of the inframammary fold level. and New Inframammary Fold Level
Postoperative breast measurements (Fig. 48.30) show by Skin Deepithelialization
the breast golden number achieved by horizontal meridian,
vertical meridian, and inframammary fold length, except 48.17.1 Case Presentation
the distance between the nipples, which is bigger. Another
example for this surgical technique applied on tubular When tubular breast is Type II B (Fig. 48.33), there is
breast Type IIC (twin sister B from Fig. 48.17) is repre- no need for glandular excision, and the shape of the
sented in Fig. 48.31 (preoperative pictures) and 48.32 breast can be modified by Benelli periareolar mastopexy
(postoperative pictures).
Fig. 48.30 Postoperative breast measurements show the breast golden number achieved by horizontal meridian, vertical meridian,
and inframammary fold length, excepting the distance between the nipples
associated with inframammary fold lowering using the 48.17.2 Preoperative Plan
deepithelialization technique.
Patient breast measurements (Table 48.3) demon- Surgical objectives (Fig. 48.35) for this case are to
strate breast ptosis (nipple located at 2 cm outside reduce the areola diameters according to the desired
acromio-pubian line on the inverted triangles), short dimensions and correct NAC position using Benelli
inframammary fold (17 cm), small breast vertical technique, and lowering the inframammary fold with
diameter (7 cm), and wide areola (12/11 and 2 cm by deepithelialization. Breast volume does not
11/10 cm). change. The fullness of the tissues in the new skin
The TTM program shows the ideal breast dimen- surface will enhance also the breast vertical diameter
sion (Fig. 48.34) with Breast Golden Number as 20.66 apart of the 2 cm achieved by the lowering of the
(almost 21 cm). inframammary fold level.
842 T.T. Mugea
Fig. 48.31 Tubular Breast Type IIC (twin sister B from Fig. 48.17). Preoperative pictures with marking plan
Fig. 48.32 Postoperative picture at 24 hours (superior raw) and Preoperative pictures with marking plan (Fig.48.33) and postop-
one month after the surgery (inferior raw). This patient with erative results (Fig.48.34) show the achievement of a quite nor-
tubular breast Type IIC and severe chest malformation (twin sis- mal shape and position of the breasts
ter B from fig. 48.17) had a similar operation technique.
For these purposes, the areola will be reduced up to with the risk of jeopardizing the vascularization.
5 cm using a deepithelialized flap technique and the Finally, we may obtain a new shape of the breast, close
skin excess of the superior meridian up to achieve to the normal one (Fig. 48.38).
21 cm distance from sternal notch to nipple.
For inferior meridian (Fig. 48.36), skin excision
will reduce NiInfra to 7 cm, and the elliptical exci- 48.17.3 Surgical Technique
sion in the inframammary fold (4 17 cm) will allow
its caudal gliding with 2 cm. Benelli round block After preoperative preparation of the patient, early
technique and areola ring partially released from the described in this book in breast reduction chapter,
central pedicle (Fig. 48.37) allow obtaining a better according with the drawings, we start the surgery with
shape of the areola, without too much flattening, but dermal incision to define the deepithelialized areas on
844 T.T. Mugea
Table 48.3 Patient breast

measurements demonstrate
breast ptosis (nipple located at
2 cm outside acromio-pubian
line on the inverted triangles),
short inframammary fold
(17 cm), small breast vertical
diameter (7 cm), and wide
areola (12/11 and 11/10 cm)
Fig. 48.33 Preoperative patient with tubular breast type II B
areola and inframammary fold (Fig. 48.39). The infra- Second step of the procedure starts with areola
mammary fold ellipse is deepithelialization (Fig. 48.40) deepithelialization and marginal dermohypodermal
and the wound sutured with reverse dermohypodermal incision of the central flap with electrocautery, saving
sutures with 2/0 Vicryl from the middle. The final a 5-mm margin from the skin, which will be used at
wound closure is done with 5/0 PDS resorbable running the closing sutures. This marginal dermis will hold the
intradermal suture, and then the distance between the skin in the suture without tension and will prevent the
new inframammary fold and the level of periareolar bed scars during the healing process. The wound diam-
excision (Fig. 48.41) which is supposed to be 5 cm is eter is decreased to the desired diameter of 5 cm, using
checked. a purse string suture with 2/0 Vicryl (Fig. 48.42).
846 T.T. Mugea
Fig. 48.34 TTM Junior program for patient
Areola is released and undermined like a mush- 48.17.4 Postoperative Result

room about 0.5 cm around the dermal edges of cen-
tral pedicle (Fig. 48.43) and then sutured to the Even postoperatively the patient has a small conges-
dermohypodermic layer of the new skin margin with tion areas on the areolas (Fig. 48.44), the wound
reverse separate 2/0 Vicryl sutures and running intrad- healed without other problems, and the inframammary
ermal suture with 5/0 PDS. fold looks fine at 1 month. New breast measurements
The whole incision length is taped with SteriStrip introduced into the computer program show the
changed every 7 days, for 36 weeks. Patients are achieving of Breast Golden Number, 21 cm in her
asked to wear brassiere for 6 weeks. case.
a b
7 cm 11 cm - Breast
21 cm Mn - New Ni Breast Vertical Diameter
21 cm Mn - Ni
Vertical Diameter
IMF
24 cm Mn - Ni 5 cm 2 cm
7 cm Ni - IMF
11 cm Ni - IMF
c d
Superficial Layer
Deepithelielised Superficial Fascia
Areola
Areola Ring
Deep Layer
Areola Superficial Fascia
Deepithelielised central pedicle
Skin Pectoralis
Benelli Round Block Fascia
Central
Pedicle
New
Inferior
Inframammary Fold
Pedicle
Inframammary
Crease Ligament
New
Inframammary
Fold Level
Fig. 48.35 (a) Preoperative plan for tubular breast type II B. released from the central pedicle. New inframammary fold done.
(b) Surgical plan for skin excision in the inferior meridian. (d) Postoperative schema of anatomic elements
(c) Benelli round block and deepithelialized areola ring partially
848 T.T. Mugea
Fig. 48.36 Surgical plan for New Areola Deepithelielised

skin excision in the inferior Diameter Old Areola Ring
meridian
5 cm
5 cm
Old Inframammary
Fold Level
2 cm
New Inframammary
Fold Level
Deepithelielised
Areola
Areola Ring
Areola
Deepithelielised Central Pedicle
Skin
Benelli Round Block
New
Inframammary Fold
Fig. 48.37 Benelli round

block and deepithelialized
areola ring partially released
from the central pedicle
Superficial Layer
Superficial Fascia
Deep Layer
Superficial Fascia Pectoralis
Fascia
Central
Pedicle
Inferior
Pedicle
b
Inframammary
Crease Ligament
New
Inframammary
Fold Level
Fig. 48.38 Postoperative anatomic elements
Fig. 48.39 Dermal incision to delimitate the deepithelialized

areas on areola and inframammary fold
a b
Fig. 48.40 Suturing the deepithelialized inframammary fold

850 T.T. Mugea
c d
a a
Fig. 48.41 Areola to inframammary fold distance is now 5 cm,

according to the plan
Fig. 48.42 (a) Marginal dermohypodermal incision of the cen-

tral flap with electrocautery, saving a 5-mm margin from the
skin. (b) Purse-string suture with 2/0 Vicryl (right picture)
a b
Fig. 48.43 Areola released about 0.5 cm around the dermal edges of central pedicle and sutured to the dermohypodermic layer of
the new skin margin with reverse separate 2/0 Vicryl sutures and running intradermal suture with 5/0 PDS
Fig. 48.44 (a) Seven days postoperative. (b) One month postoperative. (c) One month postoperative new inframammary fold.
(d) Postoperative dimensions of the breast
852 T.T. Mugea
d TTM program for Breast Reduction / Mastopexy
Comparative pictures before and after the proce- embryological evolution steps to be understood and
dure (Fig. 48.45) show tubular breast type II B correc- clarified. The new tubular breast type classification
tion, with minimal scaring, placed in easy hidden we use is a tool which allows a better definition of
areas like periareolar and inframammary fold. surgical objectives and surgical techniques to be
applied.
To obtain good postoperative results, a proper
48.18 Conclusions preoperative evaluation is needed including breast
general score, with data filled into the chart and
Tubular breasts represent a real challenge for plas- computer program for breast reduction/mastopexy
tic surgery, and there is no single procedure to cor- (Fig. 48.11).
rect it. Still there are anatomical details and

(b) Postoperative a
c
854 T.T. Mugea

d
13. Wringer E (1999) Refinement of the central pedicle breast

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1. Hammond DC (2008) In: Atlas of aesthetic breast surgery, 14. Gabka JK, Bohmert H, Blondeel PN (2008) Tuberous (tubu-
Elsevier Health Sciences, Saunders Elsevier Inc., p 187 lar) breast deformity, plastic and reconstructive surgery of
2. Nahai F (2005) The art of aesthetic surgery: principles the breast, 2nd edn. Thieme, Berlin
and techniques. Quality Medical Publishing, Inc., St Louis, 15. von Heimburg D, Exner K, Kruft S, Lemperle G (1996) The
p 1799 tuberous breast deformity: classification and treatment. Br J
3. Graf RM, Bernades A, Auerswald A, Damasio RC (2000) Plast Surg 49(6):339345
Subfascial endoscopic transaxillary augmentation mamma- 16. Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas D,
plasty. Aesthetic Plast Surg 24(3):216220 Lambrinaki N, Ioannidou-Mouzaka L (2003) Aesthetic recon-
4. Jinde L, Jianliang S, Xiaoping C, Xiaoyan T, Jiaqing L, Qun M, struction of the tuberous breast deformity. Plast Reconstr Surg
Bo L (2006) Anatomy and clinical significance of pectoral fas- 112(4):10991108
cia. Plast Reconstr Surg 118(7):15571560 17. Rees TD, Aston SJ (1976) The tuberous breast. Clin Plast
5. Regnault P (1976) Breast ptosis, definition and treatment. Surg 3(2):339347
Clin Plast Surg 3(2):193203 18. Grolleau JL, Lanfrey E, Lavigne B, Chavoin JP, Costagliola M
6. Nava M, Quattrone P, Riggio E (1998) Focus on the breast (1999) Breast base anomalies: treatment strategy for tuberous
fascial system: a new approach for inframammary fold breasts, minor deformities, and asymmetry. Plast Reconstr
reconstruction. Plast Reconstr Surg 102(4):10341045 Surg 104(7):20402048
7. Muntan CD, Sundine MJ, Rink RD, Acland RD (2000) 19. Mugea TT (2009) Breast assessment and implant selection
Inframammary fold: a histologic reappraisal. Plast Reconstr using the TTM aesthetic breast chart. In: Shiffman MA (ed)
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8. Hughes LE, Mansel RE, Webster DJ (1989) Breast anatomy Berlin, pp 85109
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(eds) Benign disorders and diseases of the breast: concepts tuberous breasts. Aesthetic Plast Surg 30(3):294300
and clinical management. Bailliere Tindal, London, pp 514 21. Pacifico MD, Kang NV (2007) The tuberous breast revis-
9. Osborne MP (1991) Breast development and anatomy. In: ited. J Plast Reconstr Aesthet Surg 60(5):455464
Harris JR, Hellman S, Henderson IC, Kinne DW (eds) Breast 22. Panchapakesan V, Brown MH (2009) Management of tuber-
diseases, 2nd edn. J. Lippincott Co, Philadelphia, pp 113 ous breast deformity with anatomic cohesive silicone gel
10. Bostwick J III (2000) Anatomy and physiology. In: Bostwick J breast implants. Aesthetic Plast Surg 33(1):4953
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Quality Medical Publishing, St. Louis, pp 8993 sia. Plast Reconstr Surg 41(4):307310
11. Moore KL (1988) The integumentary system. In: Moore KL 24. Snyder GB (1974) Planning an augmentation mammaplasty.
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4th edn. Saunders, Philadelphia, pp 426428 25. Williams G, Hoffman S (1981) Mammoplasty for tubular
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32. Muti E (1996) Personal approach to surgical correction of skin flap. Ann Plast Surg 50(4):433436
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Breast Reduction with Vaser
49
Alberto Di Giuseppe, Michael Nagy,
Mario Scaglioni, and Elisabetta Petrucci
49.1 Breast Reduction Protocol

(Figs. 49.149.34)
Vaser-assisted breast reduction and lift should only be

performed by surgeons experienced with the Vaser
system for fatty tissue emulsification. At least ten cases
of standard Vaser-assisted lipoplasty are recommended
before moving to application to the breast.
49.1.1 Patient Indications
Patients seeking a reduction in breast volume with

minimal or no scarring and minimal postoperative
pain. A breast lift procedure may be needed (simulta-
neously or secondarily) to adjust nipple location and
breast shape. The procedures and methods discussed
below are applicable only to patients with breasts hav-
ing a good amount of fatty tissue as determined by
mammography, physical exam, and history. These
A. Di Giuseppe (*)
Institute of Plastic and Reconstructive Surgery, Fig. 49.1 In a woman, decreasing the weight of the breast by
School of Medicine, University of Ancona, gently elevating the gland will cause the nipple-areola complex to rise
Ancona, Italy
M. Nagy
procedures will not work well on patients with breasts
Division Plastic and Reconstructive Surgeon, Personal having a very high percentage of glandular/breast tis-
Enhancement Center, Organization Toms River, New Jersey, sue. Patients with breast nodules or other suspicious
Toms River, NJ, USA tissues are not indicated.
M. Scaglioni E. Petrucci
University of Ancona,
49.1.2 Informed Consent
Ancona, Italy
e-mail: [email protected]; [email protected] Include use of photos for educational purposes.

Fig. 49.2 Breast reduction with liposuction (by Courtiss)
Fig. 49.4 Preoperative mammograms. Note the retromammary

space which contains plenty of fat to be addressed. The breast
parenchyma is preserved
49.1.3 Preoperative Screening

and Mammograms
Determination of approximate percentages and locations

of fatty tissue, mixed fatty/glandular tissues, and glandu-
lar/breast tissues by mammography and physical exam.
49.1.4 Preoperative Marking and Planning
Estimate volume to be removed from each breast.

Strategic plan for volume removal. Controlling the
final shape and contour requires careful selection of vol-
umes to be removed, similar in concept to standard open
breast reduction. The mammogram will provide guidance
as to the location and amounts of fatty tissues and mixed
Fig. 49.3 Fibrofatty breast tissue. This is the ideal candidate
fatty/glandular tissues. In general, the central cone, a
for this type of operation. Breast must be essentially fatty to
allow ultrasound energy to emulsify this component. Skin must 6-cm-diameter circle around the nipple and 23 cm deep
not be lax and ptosis must be minimal is not to be treated with the Vaser. This area is often
49 Breast Reduction with Vaser 859
a b
Fig. 49.5 (a) Preoperative planning as in standard breast reduction. (b) Skin incisions are marked at the inframammary, periareolar,
and axillary areas
Fig. 49.6 (a) Superwet infusion: deep, intermediate, and super- ultrasound. Tumescent solution is made by 1,000 mL of saline
ficial. (b) It is essential to have a meticulous infiltration of the solution plus 1 mL of adrenaline
superficial layers and wait for 10 min minimum before starting
Fig. 49.7 Superficial undermining of breast skin envelope with Fig. 49.9 Probe in action from axillary incision and periareolar
3.7-mm probe. Deep emulsification with 2.9-mm probe incision for undermining of the superficial skin envelope. Deep
emulsification with probe through inframammary skin incision
Fig. 49.8 Vaser probes: 1, 2, and 3 rings in 2.9- or 3.7-mm Fig. 49.10 Deep layers treated with 2.9-mm probe. Superficial
probes layers with 3.7-mm probe
Fig. 49.11 Skin incision

Fig. 49.14 Other skin protector at the periareolar incision
Fig. 49.12 Tumescent infiltration
Fig. 49.15 Skin protectors at periareolar, inframammary, and

axillary incisions
Fig. 49.16 Breast tissue with markings and skin protector on

site. Note the red area surrounding the areola, where most of the
Fig. 49.13 Skin protector sutured on site breast parenchyma is located, has to be avoided
Fig. 49.19 Undermining continues through axillary incision

Fig. 49.17 Vaser in action through periareolar incision, on
superficial layers
Fig. 49.18 Undermining continues under the breast skin Fig. 49.20 Lateral part of breast treated with Vaser
envelope
constituted by mainly glandular tissue. The recommended 49.1.6 Patient Positioning

approach is to remove the fatty tissues in the deeper planes
first and observe the changes in the shape and volume of The patient is kept in supine position with arms at 90.
the breast. Then move to the lateral and medial quadrants
for additional volume removal and shaping.
49.1.7 Incisions
49.1.5 Anesthesia
Inframammary crease (central) and axillary incisions
Breast reduction with Vaser is generally performed are used. Incisions may be placed in locations that will
under general anesthesia or with local tumescent anes- be excised if a subsequent breast-lifting operation is to
thesia and intravenous sedation. be performed.
Fig. 49.21 VentX cannula starts aspiration of the emulsified

tissue
Fig. 49.24 Verifying skin thickness after aspiration
Fig. 49.22 Emulsified fat coming out from breast
Fig. 49.25 Aspiration on the lateral side
49.1.8 Infusion
Epinephrine at 1:500,000. Wait for 10 min. Infuse with

blunt infusion cannula, not a needle. Infuse uniformly
and evenly into any and all locations where the Vaser
or the suction cannula may be used, not a needle.
Infuse uniformly and evenly into any and all locations
where the Vaser or the suction cannula may be used.
Infuse at least 2 times the estimated total aspirate vol-
Fig. 49.23 Aspiration continues from inframammary approach ume to be removed. Additional fluid may be used in
Fig. 49.29 Aspiration from axillary incision
Fig. 49.26 Aspirate from one breast
Fig. 49.30 Contralateral side
Fig. 49.27 Aspiration from deep layers
Fig. 49.28 Aspiration from periareolar incision Fig. 49.31 Breast massaging for emulsion cleaning
Fig. 49.34 Special dressing with Epi-foam
Fig. 49.32 Immediate result For larger volumes (5001,500 mL), use 3.7-mm
diameter, 24-cm VASER probes, either one or two
grooves, depending on how fibrous. Two grooves for
softer breast. One groove for more fibrous breast. 70%
80%90%, Vaser mode. Apply Vaser until fat is thor-
oughly emulsified, at least 1 min per 100 mL infused.
49.2 Aspiration
Use 3.7-mm-diameter SST-6 style VentX cannula for

initial debulking and shaping and 3.0-mm SST-6 for
final shaping and contouring. Massage the breast and
push any remaining free fluids out of incisions.
Fig. 49.33 Postoperative. Note early correction of breast 49.2.1 Breast Lift
ptosis
A mastopexy procedure may be combined with the
areas that will be dissected to decrease bleeding. Vaser volume reduction to remove excess skin and/or
The breast will easily accommodate extra fluid. provide additional lift to the breast (Figs. 49.3549.38).
The different levels of desired lift and volume removal
will guide the choice of the mastopexy selected.
49.1.9 Skin Protection Several different approaches are discussed below, each
based on volume removed and the desired amount of
Skin protection is used at each incision site. Skin pro- lift. Other types of mastopexy may be considered.
tection is not needed if skin is to be excised. For grade I to low grade II ptosis, expected volume
is from 300 to 700 mL per breast. Vaser volume reduc-
tion is without mastopexy. No scars. The expected lift
49.1.10 Emulsication is 24 cm. For low grade II to high grade II ptosis,
expected volume is from 400 to 1,000 mL per breast.
For smaller volumes (100500 mL), use 2.9-mm diam- Vaser volume reduction is with periareolar mastopexy.
eter, 24-cm probe, 70%80%90%, Vaser mode. Expected lift is 46 cm. Periareolar incision only. Note
Seventy percent of the breast is very soft. Move to 80% that the tension in the periareolar scar will be signifi-
or 90% if breast is more fibrous. Apply Vaser until fat cantly reduced by the reduction in breast volume. Grade
is thoroughly emulsified, at least 1 min per 100 cc II to grade III ptosis, expected volume is from 500 to
infused. 1,500 mL per breast. Vaser volume reduction is with
vertical mastopexy. Expected lift is 68 cm. Periareolar 49.3 Vaser in Breast-Shaping

and short vertical incisions. Note that the tension in the Procedures Associated
periareolar scar will be significantly reduced by the with Passot Reduction Technique
reduction in breast volume. Grade II to grade III ptosis,
very large volumes. Vaser volume reduction with Passot The so-called button mammaplasty was the most
reduction. Inframammary scar and periareolar scar. famous breast reduction technique of the nineteenth
Drain each breast with a Jackson Pratt flat 710-mm century. This was introduced by Passot, in 1925, and
drain for 12 days. Antibiotics and anti-inflammatory was also known as the no-vertical scar reduction
drugs are used for 35 days postoperative. Postoperative (Fig. 49.39). The technique is a horizontal flap
taping/dressing/support using Epi-foam and support bra. inferiorly based to vascularize the breast tissue. Vaser
Follow-up mammograms are at 6 months and 2 years. is utilized to emulsify the upper breast quadrants.
Fig. 49.35 (Left) Preoperative 32-year-old patient with medium breast hypertrophy (Right) Postoperative after 550 mL of aspirate
for size. Numbers explain new midclavicular notch to nipple position (a) front view, (b) oblique view
Fig. 49.36 (Left) Preoperative 29-year-old patient with middle breast ptosis. (Right) Postoperative after 450 mL of aspirate for size.
Numbers explain new midclavicular notch to nipple position (a) front view, (b) oblique view
Fig. 49.37 (Left) Preoperative 26-year-old patient with breast ptosis and inverted nipple-areola complex. (Right) Postoperative fol-
lowing 550 mL of aspirate for size. Numbers explain new midclavicular notch to nipple position (a) front view, (b) oblique view
Fig. 49.38 (Left) Preoperative 24-year-old patient. (Right) One week postoperative after 450 mL of aspirate for size. Numbers
explains new midclavicular notch to nipple position (a) front view, (b) oblique view
Fig. 49.39 Passot breast reduction
General References
Shiffman MA, Di Giuseppe A (2006) Liposuction, principles
Shiffman MA, Di Giuseppe A (2010) Body contouring, art,
science, and clinical practice. Springer, Berlin
Gynecomastia: Scarless Male Breast
Reduction with Vaser 50
Alberto Di Giuseppe, Antonella Belligolli,
Marina Pierangeli, Davide Talevi,
and Luca Grassetti
50.1 Introduction 1. It is not selective, thus implies mechanical destruction

of all breast tissue components.
Gynecomastia can be present in men in three different 2. It is often a bloody procedure, because of the rich
forms (Fig. 50.1): vascularization of the area.
1. Pure the majority of breast parenchyma is It is ineffective to treat pure gynecomastia, as male
affected. breast tissue is resistant to mechanical destruction with
2. Fatty the majority of breast tissue is formed cannula, due to his fibrotic component.
by fat. In order to improve results of SAL to gynecomastia,
3. Mixed a combination of both previous situations. the author has introduced Vaser over the past 10 years.
50.2 Treatment 50.3 Procedure
In the past, [2] SAL (Suction Assisted Lipoplasty) has Ultrasound study or mammography can be done to
been proposed as priority treatment for standard gyne- assess composition of breast parenchyma, though clin-
comastia (Fig. 50.2). The technique presents the ical evaluation offers an easy diagnosis.
following limits: Vaser in gynecomastia utilizes three different
probes:
1. 3.7 mm 1 or 2 rings for superficial undermining.
2. 2.9 mm, 1 ring for deep tissue emulsification.
A. Di Giuseppe (*)
3. 2.9 mm arrow tip for hard fibrotic glandular
Ancona University, Ancona, Italy destruction.
The operation is performed under local anesthesia
Institute of Plastic and Reconstructive Surgery, School
of Medicine, University of Ancona, Ancona, Italy plus intravenous sedation. In the alternative, general
e-mail: [email protected] anesthesia can be considered in big cases or when is
A. Belligolli M. Pierangeli D. Talevi part of a body contouring procedure.
Ancona University, Ancona, Italy
e-mail: [email protected]; [email protected];
[email protected], [email protected]
50.3.1 Technique (Fig. 50.3)
L. Grassetti
Skin incisions are performed at the inframammary
Ancona University, Ancona, Italy crease and axilla [1]. Tumescent fluid is infiltrated with
a blunt cannula into the superficial and deep layers.
Ancona University School of Medicine, Ancona, Italy After tumescent infiltration, wait for 15 min. A skin
e-mail: [email protected] dilator is used to allow skin-protector positioning. The skin

Fig. 50.1 (a) Different types

a b
of gynecomastia. (b) Pure
gynecomastia. (c) Mixed
gynecomastia. (d)
Gynecomastia associated with
breast ptosis
protector is placed in the incision. Superficial under- drainage is placed and used for 24 h. Epifoam is used
mining is performed with a 3.7-mm solid probe 1 for dressing and a garment is applied.
ring. The result of the treatment of mixed gynecomastia
After Vaser emulsification suction is applied to is shown in Fig. 50.4. Pure gynecomastia treatment is
remove the emulsified fat. After completing removal described in Fig. 50.5, and the results of treatment are
of emulsified tissue, the flap is checked for thinning. shown in Fig. 50.6. The results of clinical cases are
No zones of adhesion remained should remain. Suction shown in Figs. 50.750.9.
50 Gynecomastia: Scarless Male Breast Reduction with Vaser 873
b
Skin
Pectoralis muscle
Muscle fascia
Rectus muscle
Fig. 50.2 (a) Gynecomastia with SAL (suction-assisted lipoplasty). (b) Gynecomastia with SAL, by periareolar incision
b c
d e
f g
h i
l m
Fig. 50.3 (a) Preoperative markings. (1) Skin incisions at infra- 3.7 mm solid probe 1 ring. (j) Superficial undermining with
mammary crease and axilla. (2) Green marks pure breast tissue. probe. (k) Emulsion flowing out. (l) After completing removal
(b) Set of instrumentation for Vaser. (c) Tumescent infiltra- of emulsified tissue, check flap thinning. (m) Verifying full
tion with blunt cannula. (d) Superficial and deep layers infiltra- undermining, no zones of adhesion remaining. (n) Aspirate from
tion. (e) Tissue expanding. (f) After tumescent infiltration, one site. (o) Suction drainage for 24 h. (p) End of surgery
wait 15 min. (g) Skin dilator to allow skin protector positioning. Symmetry. (q) Epifoam Dressing. (r) Garment
(h) Skin protector in place. (i) Superficial undermining with
n o
p q

a b
Fig. 50.4 Mixed gynecomastia. (a) Preoperative. (b) Postoperative following Vaser liposuction
a b
c d
f
e
g
h i
Fig. 50.5 (a) Pure gynecomastia. (b) Markings. (c) Tumescent effect in selective fibrotic tissue. Vaser mode, at this stage, may
infiltration, superwet. (d) Vaser continuous mode. (e) Vaser set be useful to progress in fibrotic tissue. (h) The new Vaser probe
at 80% of total power. (f) Skin protector on site. (g) The new in action. (i) Result after emulsification of mammary region,
arrow probe. Note the shape of the tip which radiates energy to thorax, and selective destruction of breast male fibrotic tissue.
destroy fibrotic male breast, working as a scalpel. The side still (j) Suction drainage on site
emulsify as a standard probe. The combined action doubles the
a b
Fig. 50.6 (a) Preoperative patient with pure gynecomastia. (b) Postoperative
Fig. 50.7 (a) Preoperative 37 year-old patient with from previous treatment with SAL. (b) Postoperative
a b
Fig. 50.8 (a) Preoperative 50 year-old patient with pure gynecomastia. (b) Postoperative
Fig. 50.9 (a) Preoperative 29 year-old patient with pure gynecomastia. (b) Postoperative
References 2. Shiffman MA, Di Giuseppe A (2010) Body contouring: art,

science and clinical practice. Springer, Berlin
Part V
Abdomen
Abdominoplasty: Aesthetics
of the Anterior Abdominal Wall 51
Fahmy S. Fahmy and Mohamed Ahmed
Amin Saleh
51.1 Introduction 51.2 History
Beauty and body aesthetics has its roots as far as The modern surgical era dates back to 1870, when
30,000 BC. Body contouring had been made by such body contouring and different abdominoplasty proce-
external methods as tattooing or scarification and the dures were described to achieve better aesthetic out-
wearing of girdles [1]. come or to hide abdominal scar. Surgeons who were
The concepts of beauty and ideal weight may have repairing umbilical hernias did the first dermolipec-
varied over time and among cultures; a firm, toned tomy, having the advantage of technically facilitating
abdomen, and a narrow waistline have been univer- the hernia repair and relieving the patient from the
sally admired since antiquity. The appeal of full hips hanging skin.
and a slender waistline is rooted in the Darwinian phi- Abdominoplasty was described in different coun-
losophy known as evolutionary psychology which tries and popularized. Kelly, in 1899 [3], was the first
states that women must be desirable and attractive so to report the procedure in the United States, calling
that they are more sought after for reproduction [2]. it transverse abdominal lipectomy. He underwent
Numerous articles have been written about the dif- herniorrhaphy through a transverse incision across
ferent techniques of the abdominoplasty procedure and both flanks, without undermining, and the umbilicus
date back from over a century ago. Abdominoplasty was sacrificed.
not only deals with the excess redundant skin of the Preservation of the umbilicus was first reported by
anterior abdominal wall but also corrects diastasis of Gaudet and Morestin 1905 [4] while repairing large
the rectus as well as the external oblique muscle. hernias along with the resection of the excess abdominal
The abdominoplasty procedure needs to be tailored to skin and fat. In Germany Weinhold 1909 [5] reported
the trunk anatomy and to the aesthetic goals. It is a proce- the cloverleaf incision, a combination of vertical and
dure that also requires sculpting ability and the knowledge oblique incisions to improve the contour of the abdom-
to place the incision to suit the particular body type. inal wall. Desjardin, in 1911 [6], reported the excision
of excess skin and fat weighing over 22.4 kg through
vertical abdominal incision. This was followed by
F.S. Fahmy (*) Babcock in 1916 [7] who was the first to report vertical
Department of Plastic Surgery,
Countess of Chester Hospital, Cheshire, UK
elliptical resection with wide undermining of the
e-mail: [email protected] abdominal wall. In 1918, Schepelmann [8] modified
M.A.A. Saleh
the Babcock elliptical incision into a transverse tear-
Plastic Surgery Department, Ain Shams University, drop incision extending from the xyphoid to the pubis
Cairo, Egypt (Fig. 51.1).

a b surgeons that favored the transverse incision, (2) those

that favored the vertical incision (3) and a combination
of vertical and transverse incisions (Fig. 51.2).
Grazer 1973 [22], Pitanguy 1975 [23] (extensive
undermining, muscle tightening and compression dress-
ing), Regnault 1972 [24] (W shaped incision), Baroudi
1975 [25], Baker et al. 1977 [26] (the template method)
and Planas 1978 [27] (the vest over pants technique).
This period between 1970s and the 1980s emphasized on
contour refinements, the low transverse incision, small
umbilicus and long term contour results (Fig. 51.3).
Lockwood 1995 [28] assumed that discontinuous
undermining allows effective loosening of the abdomi-
nal flap while preserving vascular perforators, and with
Fig. 51.1 Vertical techniques of abdominoplasty. (a) Babcock
aging and weight fluctuations (including pregnancy),
(b) Schhepelmann
abdominal skin relaxation occurs primarily in the ver-
tical direction from the xyphoid to the pubis in the
Low transverse elliptical abdominal lipectomy was lower abdomen, but the opposite occurs in the epigas-
described by Jolly in 1911 [9]. This was followed by tric region. He concluded that the ideal abdominoplasty
Thorek in 1924 [10] as he removed the excess skin and pattern would resect as much or more laterally than
fat down to the fascia in a wedge-shaped form. He centrally, leading to more natural abdominal contours.
called the technique plastic adipectomy. He described The introduction of suction-assisted lipectomy
the removal of the umbilicus if required in a crescent which was popularized by Kesselring and Meyer 1978
excision, and transplanting it as a composite graft. In [29] and Illouz 1983 [30], emphasized the concept of
1931, Flesch-Thebesius and Wheisheimer [11] modi- sculpturing and body contouring to get the best results
fied the Thorek incision and included the umbilicus. In when combined with abdominoplasty procedure.
1949, Pick [12] reported his technique, followed by Liposuction not only popularized mini-
Barsky in 1950 [13] which was a modification of the abdominoplasty procedure, but also led to the devel-
Thorek transverse incision with the addition of the opment of minimally invasive surgery endoscopic
vertical incision at its ends. abdominoplasty that would provide aesthetic improve-
Belt-like fashion incision was first introduced by ment of the abdominal wall laxity, rectus muscle dia-
Somalo in 1940 [14]. Gonzalez-Ulloa [15], Vilain, and stasis, and would minimize the resultant scar.
Dubouset [16] reported circular abdominoplasty simi- Mini-abdominoplasty was of limited use and it was
lar to that described by Pick and Barsky technique. first introduced by Elbaz and Flageul in 1971 [31], and
The four quadrants resection technique was described was modified by Glicenstein in 1975 [32]. After the
by Galtier in 1955 [17]. introduction of liposuction, Wilkinson and Swartz in
Modern concepts of abdominoplasty through low 1986 [33], and Greminger 1987 [34] reported their
transverse abdominal incision with wide undermining series of patients.
and transposition of the umbilicus described by Vernon Endoscopically assisted techniques, such as plica-
in 1957 [18]. This was followed by Dufourmental and tion of the rectus fascia through an umbilical incision
Mouly in 1959 [19], including the Vernon technique by using an endoscopic retractor, were described by
and a small vertical incision at the midline. Spadafora Marques et al. 1990 [35]. These approaches were
1965 [20] described a similar technique to Vernons, described as prefascial endoscopic abdominoplasty
but he lowered the incision to a less conspicuous site. [36, 37]. Nahas, in 1993 [38], underwent a cadav-
In 1967, Callia [21] reported a similar incision to that eric study using the laparoscopic approach to poste-
of Spadaforas with a lower incision below the ingui- rior rectus diastasis repair. Scheflan (International
nal crease not only to get a less conspicuous scar, but Endoscopic Symposium, Hannover, October 1994,
also had added advantage of lateral thigh lift. To sum- personal communication) performed laparoscopic
marize the evolution of the techniques up to 1967, the plication of the rectus muscle in a single patient.
abdominoplasty procedure can be categorized into: (1) Zukowski et al. 1998 [39] introduced endoscopic
51 Abdominoplasty: Aesthetics of the Anterior Abdominal Wall 889
a b c d
Fig. 51.2 A combination of vertical and transverse incisions. (a) Pick, Barsky (b) Galtier (c) Weinhold (d) Flesch-Thebesius and
Wheisheimer
a b c
d e f g
Fig. 51.3 Horizontal techniques of abdominoplasty. (a) Kelly (b) Thorek (c) Gonzalez-Ulloa (d) Baroudi (e) Pitanguy (f) Grazer
(g) Regnault
intracorporal abdominoplasty in 85 patients com- and effectively plicates the rectus fascia, thereby
paring their technique with the traditional open reducing abdominal wall laxity. It also has a rate of
abdominoplasty. They concluded that the endoscopic morbidity in a skilled laparoscopists hands no greater
intracorporal abdominoplasty reduces operative scars than with traditional open abdominoplasty.
51.3 Pathology of the rectus abdominis muscles and extensive striae.

Weight gain during pregnancy is an important concern
Heredity and environmental factors play an important of patients, and consists of three major components:
role in a persons body shape. The pathophysiology of muscle, fat, and water. The volumetric increase of the
the abdominal contour deformities includes few ele- abdominal contents during pregnancy causes laxity of
ments with variable degrees. These could be: redun- the musculoaponeurotic system and diastasis of the
dant, flaccid skin, excessive adipose tissue, muscular rectus muscle plus stretching of the skin [41].
diastasis, musculoaponeurotic laxity, and scar defor- It is generally believed that separation of the rectus
mities, including striae. muscles occurs in all pregnancies and can never be
Heredity is the primary determinant of our basic restored by exercise alone. Post partum, most patients
body habitus. It is hereditary that causes the unsightly, will experience a gradual tightening of skin over sev-
diet-resistant fat bulges in many individuals of aver- eral months. If redundancy remains after 6 months, the
age weight. In the female, these inherited accumula- condition is probably permanent. Stretch marks occur
tions usually occur in a gynecoid distribution in the in 90% of pregnant white women and are believed
lower abdomen, hips, saddlebags, and inner thighs. In to be caused by increased estrogen levels, additional
males, accumulations of diet-resistant fat occur in an stress on tissues, and an increase in the relaxin hor-
android distribution in the flanks, abdomen, and chest. mone. Striae are considered to be a form of dermal
Heredity may also be responsible for weak lower- scarring that follows rupture and separation of dermal
abdominal muscles, which results in a round, procollagen with subsequent filling in of the gap. Other
tuberant abdomen. Tall individuals with a marked important factor of pregnancy is the scar associated
lordotic posture may have a protruding abdomen. with cesarean section [41].
Environment plays an important role, as in very
obese patient with a lifestyle of little exercise and a
high caloric intake. Abdominal surgery, and some 51.4 Classication
neurologic lesions, may result in a bulging abdomen
from weakened or denervated muscles. Time, repeated Despite the recent changes in abdominal contour oper-
weight loss, and weight gain (weight fluctuation) have ations, the objectives continue to be (1) maximum
additional deleterious effects on skin tone. This may resection of excess skin, (2) reduction of subcutane-
vary from a hanging abdominal panniculus to severely ous adipose tissue volume, and (3) elimination of mus-
dimpled cellulite-type skin. Aging as a natural process culoaponeurotic laxity to produce a slimmer, flatter
plays an important role in increasing or decreasing and abdomen.
redistribution of fat, loss of body muscles mass, and The aims of the ideal surgical procedure should
loss of tissue elasticity [40]. be to:
Lower abdominal bulges can result from the ten- 1. Accomplish the goals through the least conspicuous
dency for fat accumulation in the lower abdomen as incision, conforming to preferred clothing styles.
well as from an absence of the posterior rectus sheath 2. Address specific anatomical deformities.
below the arcuate line of Douglas. Intraperitoneal fat 3. Suit a wide range of patients.
(visceral adipose tissue) is not treated by any abdomi- 4. Treat adjacent aesthetic units while respecting the
nal contour procedure; it accumulates with age and is integrity of contributing skin vascular territories.
more likely to be found in men. Women also accumu- 5. Require the least amount of operative, hospitaliza-
late this type of fat as they approach menopause. tion, and recovery time.
Greminger [34] has illustrated that the bony structure 6. Produce minimal morbidity and postoperative dis-
of the torso and pelvis determines the basic dimensions ability [42].
(short or long waist) of the abdomen. This leads Flexible systems of treatment have been devised
to a general impression of the patients overall body and developed by numerous authors for this purpose.
habitus. Matarasso, in 1989 [43], classified abdominal defor-
Pregnancy is one of the major causes of stretched mities based on severity of the skin, fat, and muscular
abdominal musculoaponeurotic systems and loose flaccidity, and selects the most appropriate surgical tech-
skin. The deformity may vary from merely a rounded nique for abdominal contouring according to the degree
protruding lower abdomen to one with severe diastasis of deformity (Table 51.1). Later in 1995, Matarasso [44]
Table 51.1 Matarassuo abdominoplasty classification system

Category Skin Fat Musculofascial system Treatment
Type I Minimal laxity Variable Minimal flaccidity Suction-assisted lipectomy
Type II Mild laxity Variable Mild lower abdominal flaccidity Mini-abdominoplasty
Type III Moderate laxity Variable Moderate lower and/or upper abdominal flaccidity Modified abdominoplasty
Type IV Severe laxity Variable Significant lower and/or upper abdominal flaccidity Standard abdominoplasty
with suction lipectomy
Table 51.2 Minimal access subtypes of the abdominoplasty system

Category Skin Fat Musculofascial system Treatment
Type 1a Minimum laxity Minimum flaccidity Extended SAL
Type 2a Mild laxity (vertical scar) V Mild lower abdominal flaccidity Open mini
Type 3a Minimum laxity V Lower/upper abdominal flaccidity Endoscopic muscle access
Table 51.3 Pitanguy classification of aesthetic abdominal deformities

Type Clinical presentation Suggested technique
I Abdominal lipodystrophy without skin flaccidity; absence Liposuction
of diastasis or hernia
II Moderate abdominal lipodystrophy with diastasis Mini-abdominoplasty or endoscopic abdominoplasty
III Accentuated abdominal lipodystrophy with cutaneous Standard abdominoplasty
flaccidity and excess; presence of diastasis; with or
without associated scar
IV Skin flaccidity and/or lipodystrophy, with diastasis or Atypical approach
eventration; associated scar
O Marked generalized abdominal lipodystrophy with These patients are not ideal candidates for abdominoplasty,
absence of excess skin and should be prepared for surgery by strict clinical
treatment to lose weight
subsequently updated his classification treatment scheme epigastrium. Type IV: (A) significant skin and fat
to incorporate subtypes (Table 51.2). excess, no diastasis of the recti muscle treated with tra-
Pitanguy, in 1995 [45], presented his classification ditional abdominoplasty and UAL of flank, type (B)
(Table 51.3). treated with traditional abdominoplasty, diastasis
Rohrich et al. [46] used a modified Matarasso clas- repair and UAL of flank.
sification that is based on clinical assessment of the Regnault [46] performed anterior sheath plication
degree of skin redundancy, amount of abdominal fat, in 90% of patients requesting abdominoplasty, as he
skin thickness and tone, and status of the abdominal believes that most women who have had multiple preg-
musculature. Abdominal deformities were classified nancies have some laxity of the musculoaponeurotic
into IV types, each is subdivided into an or b, accord- fascia, if not true diastasis recti. Although Pitanguy
ing to the presence or absence of muscle diastasis. [47] documented only 3% of patients with diastasis
Type I: (A) no skin and fat excess, and no diastasis recti in his series of 539 patients, he routinely rein-
of the recti muscle treated with Ultrasound assisted forces the musculoaponeurotic wall as part of the
liposuction (UAL)or suction assisted liposuction abdominoplasty procedure.
(SAL) alone, type (B) treated as before with or without Nahas [48] developed an objective classification for
endoscopic diastasis repair. Type II: (A) mild skin and abdominoplasty based on the musculoaponeurotic
fat excess, no diastasis of the recti muscle treated with deformity (Table 51.4) (Fig. 51.4).
(UAL) or (SAL) alone, type (B) treated with UAL or Jackson and Downie [49] recommend additional
SAL with or without endoscopic diastasis repair. Type horizontal plication when laxity is still noted after
III: (A) moderate skin and fat excess, no diastasis of vertical rectus plication, as reported by Grazer and
the recti muscle treated with UAL, type (B) treated Goldwyn [50]. Abramo, Viola, and Marques [51]
with infraumbilical-Mini abdominoplasty and UAL of perform transverse epigastric and suprapubic plication
Table 51.4 Classification and treatment of abdominal wall deformities based on muscloaponeurotic deformity
Myofascial
deformity
type Clinical finding Treatment
A RD Secondary to pregnancy PRS
B RD and laxity of the lateral and PRS and L-shaped plication of the external oblique aponeurosis
infraumbilical aponeurotic layer
C Congenital lateral insertion of the Release and undermining of the recti muscles from their posterior recti
recti muscle sheaths and advancement of these muscles to the midline
D RD and poor waistline RD and poor waistline PRS and advancement of the external oblique muscles
Types of Abdominal Deformity and Their Correction

Type A Type B
156.972
RD
L R L R
Rectus diastasis secondary to pregnancy Rectus diastasis with laxity of the musculoaponeurotic layer
Type C Type D
EOM
RM
CRD PS
L R L R
Congenital lateral insertion of the rectus muscles at the
costal margins and probable herniae
Fig. 51.4 Types of abdominal deformity and their correction. congenital lateral insertion of the rectus muscles at the costal
Type A: rectus diastasis secondary to pregnancy. Type B: rectus margins and probable hernia. Type D: rectus diastasis and poor
diastasis with laxity of the musculoaponeurotic layer. Type C: waistline definition. (Reprinted from Nahas [48])
in addition to longitudinal pleating for the entire length involves transverse plication as opposed to the more
of the rectus muscles, in what they call a lying H traditional vertical closure.
pattern. Alternative techniques consisting of vertical De Pina [53] resects the medial margins of the rectus
and lateral plication may improve the waistline and muscles and plicates the posterior sheath to improve
prevent epigastric bulging. Crdenas Restrepo and abdominal wall contour. Psillakis [54] advocates suturing
Munoz Ahmed [52] reported that their technique the aponeurosis of the external oblique muscles to the
rectus fascia. He also excised the 7th and 8th rib carti- different ages. Modifications of position and thickness
lage, to narrow the waist and decrease the diameter of the of the tissues will alter the aesthetic appearance of the
upper abdomen [55]. abdomen due to the changes of the light reflections
Van Uchelen et al. [56] assessed the long-term dura- and shadows. Therefore, the basic surgical principle
bility of vertical plication of the anterior rectus sheath today in abdominoplasty is to sculpture the tissues,
with an absorbable material. Questionnaires and ultra- reshaping the light reflections and shadows by giving a
sound investigation of the competence of the fascia was new tension in the musculoaponeurotic layer, by sculp-
done at a mean of 64 months. The authors recommend turing the overlaying fat on the cutaneous envelope,
against the use of absorbable material for musculofas- and by resecting excess skin when it is present [55].
cial plication as 40% of his patients had residual or
recurrent diastasis.
51.6 Preoperative Assessment
and Patient Selection
51.5 Aesthetics of the Anterior
Abdominal Wall 51.6.1 Medical History
The abdominal wall is formed by the relationship An accurate assessment of the patients deformities and
between the osteomuscular system, the subcutaneous their medical history are essential for a successful
fibro adipose tissue, and the skin. This relationship abdominoplasty procedure. Surgeons must take into con-
gives the appearance of an aesthetic contour with light sideration all aspects of the patients medical history.
reflection produced by prominences and shadows Most patients requesting body contour improve-
resulting from depressions. In the midline from the ment will be women, so detailed history of previous
xyphoid to the navel a shadow is formed by the depres- pregnancies should be asked for: number of pregnan-
sion of the medial sulcus. Lateral to this sulcus, there cies and miscarriage, the number of children, and
are two vertical wide strip reflections produced by whether the woman has a history of cesarean section is
the prominence of the rectus muscle that joint under important. A female patient who has had more than
the umbilicus, forming a mound. one pregnancy is certainly more likely to have devel-
More lateral and slightly more posterior to these oped rectus muscle diastasis. They should be ques-
prominences, there are two wide strips of shadows tioned regarding her desire for future pregnancies, and
called semilunar sulcus, in a lyre form, produced by surgeons should advise their patients to wait until their
the depressions formed by the insertion of the skin at families have been completed before proceeding with
the fascia of the oblique muscles, which are inserted definitive abdominal body contour improvement.
into the external margin of the rectus muscles and into Significant medical problems that may affect the
the inguinal ligaments and pubis. More laterally, the outcome of surgery include a history of hypertension,
profile of the abdomen is formed by the thoracic cage coronary artery disease, chronic obstructive pulmo-
superiorly, the pelvis inferiorly, and the waist in nary disease, diabetes mellitus, hepatitis C, and human
the middle (Fig. 51.10). The waist extends 710 cm immunodeficiency virus. Knowledge of the possible
between the inferior costal ribs and the iliac crest. The allergies and intake of medications, whether prescribed
shape of the waist is also dependent on the superior or over-the-counter herbs, Aspirin, nonsteroidal anti-
aperture of the pelvis. The larger the pelvis, the more inflammatory drugs, warfarin, and other products that
accentuated the waist. The waist can be absent when may adversely affect the coagulation mechanism is
the pelvis is small, when the distance between the pel- important so that the patient may be instructed to dis-
vis and the ribs is reduced, or when muscular atony or continue them for an appropriate period before under-
fat deposits are present. going surgery.
In the inferior extremity of the shadow of the medial The effects of smoking on delayed wound healing
sulcus, a more accentuated shadow is formed by the are well known, that is why Patients should be asked
triangular depression of the navel. Spatially, it is situ- about smoking history (active or passive, number and
ated 1 or 2 cm over a transverse plane that corresponds type of smoking, and duration), and they should be
to the third or fourth lumbar vertebra. The shape of the asked to abstain from smoking for a significant period
navel varies from person to person and also varies at before and after surgery.
Prevention is the key to reduce the incidence of Most stretch marks are located in the lower half of
deep venous thrombosis and pulmonary embolism. the abdomen, extending laterally to the flanks. Many
Surgeons should ask for: a previous history of deep of these will be removed along with the skin and sub-
venous thrombosis or pulmonary embolism, history of cutaneous tissue flap. If a hernia is present, its repair is
malignancy, inherited or acquired thrombophilia, obe- essential for aesthetic improvement. However, a large
sity, heart failure, use of oral contraceptives, history of hernia may require complex repair before the perfor-
spontaneous miscarriages, pregnancy within the past mance of an abdominoplasty for aesthetic improve-
3 months, age older than 40 years, presence of varicose ment, which would then subsequently be performed at
veins in the lower extremities, and recent surgery with a later date. Diastasis of the rectus abdominis muscles,
the use of general anesthesia [57, 58]. whether mild, moderate, or severe, is usually corrected
An additional factor that is of significance is a his- at the time of the abdominoplasty.
tory of intra-abdominal operations. The location of The flaccidity and laxity of skin of the abdomen
scars is important in determining the plan of correc- below the umbilicus, is treated by redraping with exci-
tion. Patient height and weight should be asked about sion of the excess skin and soft tissue along the inferior
and measured. Tall, lean individuals will have an margin. Flaccid skin above the umbilicus is treated by
easier postoperative course and a different appear- redraping of the abdominal flap and liposuction, and in
ance than an obese, short individual, who may require severe cases, it may require a staged reverse abdomi-
more procedures for body contouring. The patients noplasty. Laxity of the adjacent areas of the flanks and
weight should be stable for at least 3 months, and if thighs can be treated with liposuction, but in more
he or she is overweight, it is advisable that they lose severe cases, high-lateral-tension abdominoplasty pro-
weight down to a desired goal before proceeding cedures along with extension of the incision laterally
with surgery. A history of abdominal hernia and a should be considered.
thorough gastrointestinal history, such as irritable After all these issues are considered, patients are then
bowel syndrome or inflammatory bowel disease, staged according to the abdominoplasty system of clas-
should be covered as well. sification, and patients concerns regarding the extent of
surgery, tolerance of possible complications, recovery,
and incisions all play a role in the decision making.
51.6.2 Physical Examination
The physical examination should be detailed. The sys- 51.7 Authors Preferred Method
tems examined should include the heart and lungs as
well as other areas of the body involved in the patients Abdominoplasty is certainly a very common proce-
complaint. Examination of the patient is performed in dure in cosmetic surgery. Initial impression and maybe
the standing, sitting, supine, lateral, and lateral hip- experience would suggest it is an easy operation to
flexed (divers) positions to evaluate skin, subcutane- perform. The more I did over the last 20 years, the
ous fat, and muscle layers. more I understood and appreciated its challenges. It
The patients general appearance including the might appear easy on the surface but undoubtedly task-
abdomen, location of scars should be documented and ing to overcome its challenges and to achieve our ulti-
photographed. Supra-umbilical scars can present cer- mate goal of perfection. Is the incision design; straight
tain problems, such as impaired blood supply of the or curved, high or low, short or long? Is the recti, divar-
superior flap, difficult dissection in the scar area, or icated or not, plicate or not? If we plicate, is it before
patient dissatisfaction with the scar still visible postop- or after flexing the operating table, absorbable or non-
eratively. Most infraumbilical scars are removed dur- absorbable, 1 or 2 stitches, and interrupted or continu-
ing abdominoplasty [59]. Adhesions of the skin at the ous? The umbilicus relocation, is it high or low or just
level of the waist are not uncommon, and these bands right? Is the umbilicus central or off-center? Even
can essentially divide the abdominal excess skin into more, is the umbilical incision for relocation trans-
superior and inferior segments. There is a significant verse, longitudinal, circular, semicircular, or facing up
risk of ischemia of the abdominal flap if extensive or down? Is the incision large enough or too small with
release of these adhesions is attempted; discontinuous the pending umbilical phimosis? What a dilemma,
undermining is preferable [60]. even this little structure creates such a controversy! In
Fig. 51.6 Umbilical stay suture and marking for plication

Fig. 51.5 Midline and transverse suprapubic marking
fact the shape, size, and orientation of the umbilicus extent of the abdominal apron fold, as marked by the
could be a reflection of youth, hence its significance! two lines (pre-operatively). Two sutures along my pre-
Planes of dissection, planes of excision of abdominal vious midline marking, one supra umbilical and one in
apron, do they exist, can they be identified? Excision the pubic area, are used to further demarcate the
of abdominal apron, is it conservative or as tight as midline.
possible closure? How can I achieve symmetry? How A 10-blade is used for the transverse abdomino-
can I avoid the potential complications with particular plasty incision along the markings indicated before.
reference to seromas? I will aim to address the above This incision is shelved cephalad for 23 cm, leaving
in the following step-by-step approach: more fat on the abdominal/pubic area along the full
1. Incision length of the incision. This helps to avoid future tether-
Preoperatively, the patient is marked in the standing ing of the abdominoplasty scar. It provides a padding
position (Fig. 51.5): to support the final scar.
(a) A straight line extending from the xiphisternum 2. Surgical Dissection and Planes
to the center of the vulval region marks the mid- As the dissection proceeds cephalad, this should be
line of the abdomen. This helps in the future in a plane superficial to the Scarpas fascia (thin, glis-
planning of transposing the umbilicus. tening, transparent, mobile layer of fascia). This layer
(b) Right and left longitudinal lines (often cross- harbors a number of lymphatics and may help to reduce
ing the ASIS) on either side, demarcating the future seromas. I continue my dissection with a no. 10
extent of the folding of abdominal apron (usu- blade locating and cauterizing any perforators, prefer-
ally the lateral extent of my incision is short of ably before dividing them. It can be more time-con-
those two lines). This may in cases extend suming to cauterize the blood vessels after they have
beyond the ASIS. In slim patients with little been divided and retracted in the abdominal wall. Its a
folding, the ASIS is my most lateral extent of false economy to try and rush the dissection of the
the incision. abdominal apron; more time will be needed to achieve
(c) A transverse marking along the fold created by adequate hemostasis.
the abdominal apron. A circle is then marked around the existing umbili-
Intraoperatively, you must make sure that the oper- cus. Two skin hooks are used on either end of the circle
ating table allocated, can be flexed to the required posi- to lift the umbilicus. A no. 15 blade is then used full
tion. Under a general anesthetic, the patient is in the thickness incision around the market circle. This will
supine position. Now mark your incision. The incision help to skeletonize the umbilicus from its attachment
is usually designed just above the pubic area (hairy to the abdominal skin. A marker stitch is then placed at
part) in the middle then extending slightly up and lat- the 12 oclock of the umbilicus. This helps in alloca-
eral towards the ASIS. This incision can stop short of tion and future orientation of the umbilicus, at the time
the ASIS or extend further, just short of the lateral of its transposition (Fig. 51.6).
Fig. 51.7 Flexed portion

of the table
The dissection of the abdominal apron then con- knots are at the xiphisternum and pubic area, away
tinues approaching the umbilical stalk, I divide the from the umbilicus, therefore avoiding palpable knots
infraumbilical apron along the infraumbilical preopera- in slim patients.
tive midline marking. The umbilical stalk is then totally Hemostasis is checked again and two low-suction
skeletonized from the surround abdominal apron. The vacuum drains are inserted, one on either side of the
dissection then proceeds cephalic as far as the xiphister- abdominal wall. The drains puncture wounds are in
num in the midline and costal margins laterally, preserv- the hairy pubic area on either side of the midline. I tend
ing the Scarpas fascia layer on the abdominal wall. to suture my drains.
3. Plication of Recti (Fig. 51.651.8) 4. Excision of Abdominal Apron (Fig. 51.9)
Once the extents of my dissection are reached, the A midline 3/0 Monocryl subcutaneous suture is
operating table is then flexed. The abdomen /patient inserted in the middle line between the pubic area and
should be paralyzed at this stage. The authors have not the advanced supra-umbilical skin. This suture should
been able to adhere to fixed degree of flexion. It be under very little tension. The abdominal apron on
depends on the patient, the abdominal apron, abdomi- either side of this suture is held with two lanes on either
nal wall, etc. Generally speaking with the flexion can side. With a gentle inferior and slightly medial traction
range from 30 to 70 at the hip region. Hemostasis is on the aprons, a transverse line with slight convexity
further achieved. Two longitudinal lines are marked facing inferior is drawn extending laterally from
extending from the costal margin down to the pubic the midline Monocryl suture to adjoin the lateral end
margin lateral to the divaricated/weak area of the of the transverse suprapubic abdominal incision. The
abdominal wall. There are no clear indicators or land- triangular flap inferior to this line on each side presents
marks for the width between those three lines. It can the apron to be excised. You must look and check,
range from 3 to 7 cm depending on the extent of the there is enough laxity there to close the abdominal
divarication. Two looped-nylon zero sutures are used. wound following excision of the apron.
The first suture starts just above the umbilicus in a con- With a no. 10 blade a perpendicular is incision
tinuous fashion towards the xiphisternum. The suture along the marked line is undertaken (Fig. 51.10). This
bites in the anterior rectus sheath tend to be in an continues deeper until approximately half way through
oblique fashion to avoid cheese-wiring the sheath. At the flap; we will notice a white shiny layer. This is
the xiphisternum level, an Aberdeen knot is done to the Scarpas fascia (Fig. 51.11). This is the level that
finish the stitch. The second looped continuous nylon dictates the thickness of your abdominal flaps to be
suture starts just below, but very close to the umbilical sutured at the end of the surgery. It is at the Campers
stalk and proceeds to finish in an Aberdeen knot at the fascia level that you need to shelve your dissection
level of symphysis pubis. Note that the two Aberdeen plane from a perpendicular to a cephalad direction.
a a
Fig. 51.9 (a) Marking of the apron to be excised. (b) Marking

of the apron to be excised. (c) Final marking of the two sides of
the apron to be excised
Fig. 51.8 (a) Upper part of the rectus plicated. (b) Upper part summary, the excised abdominal apron should have
of rectus plicated (umbilicus to xyphosternum). (c) Plication of more fat than skin, excised superiorly (Fig. 51.12).
lower part completed (umbilicus to symphysis pubis)
5. Skin Closure
This is even more so at the lateral extent of the excised The abdominal wound is closed in two layers
abdominal apron to reduce any potential of a dog ear. starting from lateral to medial. The first lateral suture
Adhering to the Campers fascia plane would ensure should be aimed to eliminate any dog ears. The sub-
that the remaining abdominal flaps are uniform. In cutaneous stitch is usually inserted more lateral in
b
Fig. 51.10 Incision of apro
the upper abdominal flap compared to the lower flap

of the abdominal incision. This helps to eliminate
any dog ears. For subcutaneous suturing, 3/0
monocryl is used, while 4/0 Monocryl is used as a
subcuticular suture. Before complete subcutaneous
closure (Fig. 51.13), the umbilicus is transposed/
relocated.
6. Umbilical Relocation
The neo-umbilicus is repositioned before com-
plete closure of the transverse wound. I introduce my
hand (Fig. 51.14) through this wound holding the
umbilical stalk, between my index and middle fin-
gers. The two fingers point directly up towards the c
abdominal apron. This point is marked and presents
the future umbilical site. A number of incisions have
been advocated in the literature all aiming to achieve
an umbilicus as near natural appearance as possible. I
tend to use a V-shaped incision with the two vertical
limbs widely separated and symmetrical on either
side of the midline. This incision is extended deeply
to be of full thickness. The incision has to be large
rather than small to avoid umbilical phimosis
(Fig. 51.15). The umbilical stay suture is then deliv-
ered through this incision. For skin closure, 4/0
Monocryl subcutaneous suture and 6/0 Prolene inter-
rupted suture is used.
The transverse abdominoplasty incision is then com-
pletely sutured using the 3/0 subcutaneous Monocryl
and the 4/0 subcuticular Monocryl (Fig. 51.1651.19). Fig. 51.11 Identification of Campers fascia layer
Fig. 51.12 Excised apron
Fig. 51.15 Neoumbiilicus
Fig. 51.13 Partial wound closure
Fig. 51.16 Wound closure complete
7. Dressings
Suture strips (half inch) and Mepore dressings are
used to cover all the wounds. Microfoam is then
directly applied to achieve some pressure on the abdo-
men as a whole. An abdominal pressure garment is
then applied after rolling the patient from side to side
to apply it. The patient is then transferred to the bed,
maintaining the flexed position.
51.8 Postoperative Care
The patient is nursed on the ward, maintaining the

intraoperative flexed position. They are encouraged to
Fig. 51.14 Hand introduced for umbilical repositioning start mobilization within the first 24 h, with the back
a b
Fig. 51.17 (a) Preoperative patient. (b) Six weeks postoperative following abdominoplasty
somewhat flexed to alleviate any tension on the suture Abdominoplasty is certainly one of the most gratifying
line. The drains are removed within 2448 h, and the operations with high satisfaction rate. Equally, it has its
patient is advised to wear their own pressure garment, challenges and potential risks that can be avoided in a
cycling-short style, once the drains are removed and large number of cases.
before leaving the hospital. The pressure garment is
worn day and night for 6 weeks after the surgery.
I found that this approach reduces dramatically any 51.9 Complications
chance of seroma formation. This is minimal in my
practice. Complications following abdominoplasty might occur
The patient is seen 1 week post-surgery for removal at any time despite adequate surgical technique and
of umbilical sutures, and 2 weeks later for full inspec- patient care. These might range from patient discom-
tion of all the wounds. fort, pain, further surgical intervention, or up to a life
The author (FSF) has conducted an ultrasound study threatening condition. Patients should be informed
to assess the longevity and durability of plication of about these possible complications prior to surgery,
the recti. This was a prospective study with a 1 year and surgeons should be aware of their prevention and
follow-up period. All the corrected diastasis was main- management.
tained within 1 year with the use of the looped non- In 1977, Grazer and Goldwyn [50] published their
absorbable Nylon suture. results of a survey of the members of the American
a b
Society of Plastic Surgeons. The report represented a those with infraumbilical plasties (1.43%) or full
minimum 10,490 abdominoplasties. The presence of abdominoplasties with horizontal scars (4.60%).
wound infection, dehiscence, hematoma, and skin loss Complications could be classified into: imme-
were manifested in decreasing order of occurrence. diate, early and late ones. Immediate complications
Hematomas developed in more than 600 cases. Almost of surgery can be life threatening and include deep
half of all had to drain serum or blood from at least one venous thrombosis, pulmonary emboli, fat emboli, and
patient, and 39% of surgeons reported skin loss in at hematoma. Fat embolism is a rare syndrome that is
least one patient. In addition, 47% of surgeons reported manifested by the clinical triad of respiratory distress,
frequent contracture of the umbilicus. They noted that cerebral dysfunction, and petechial rash. It manifests
the frequencies of complications were inversely related within the first 2 postoperative days and is treated sup-
to the surgeons experience. portively with corticosteroids [64]. Grazer and Goldwyn
Hensel et al. [61] retrospectively reviewed abdomi- [50] reported a 1.1% incidence of deep venous throm-
noplasty patients over a 15-year period in an attempt to bosis and 0.8% incidence of pulmonary embolism.
identify factors that affected the outcome. The overall The exact cause of venous thrombosis in the setting
complication rate was 32%; 1.4% was major compli- of abdominoplasty remains unknown. It is thought to
cations. The revision rate was 43%, and complications result from interference of superficial venous drainage
were significantly higher in smokers and in patients from the legs and pelvis caused by increased abdominal
with diabetes or hypertension, and they were magni- pressure [65]. Matarasso recognized this tight under-
fied in obese patients (86%). Similarly, Vastine et al. wear syndrome in an abdominoplasty patient caused
[62] noted 80% complications of abdominoplasty in by the postoperative use of an abdominal binder [66].
obese patients. Losken et al. [67, 68] showed that intra-abdominal
Chaouat et al. [63] reviewed the records of 258 pressure was significantly increased following trans-
women who had abdominoplasty. They showed sig- verse rectus abdominis musculocutaneous flap harvest,
nificantly a higher rate of skin necrosis for patients particularly in bipedicled transverse rectus abdominis
who had T-type abdominoplasty (35.5%) than for musculocutaneous flaps closed primarily without mesh
and the serious complications of thromboembolism other procedures. Voss et al. [70] showed higher
were realized in these patients. In contrast, Al-Basti morbidity, longer operative times, and hospital stay
et al. [69] studied obese (body mass index more than when abdominoplasty was combined with other com-
34), multiparous patients, measuring intra-abdominal mon gynecologic operations, with increased incidence
pressure before and after plication, finding a statisti- of pulmonary embolus (6.6%), whereas no pulmonary
cally significant increase in intra-abdominal pressure emboli occurred in patients having only single pro-
that was not related to the clinically complications. cedures. Hunter et al. [71] confirmed the high risk of
Controversy regarding the increased incidence of pulmonary emboli in patients with combined abdomi-
complication rate if abdominoplasty combined with nal lipectomy and gynecological procedures. On the
other hand, Hesteler [72], Cardoso De Castro and by an average of 2 days when the surgeries were
Cupello [73], and Gemperli et al. [74] found similar combined.
morbidity and complication rates among patients who Early complications include infection, skin necro-
had abdominoplasty combined with other procedures. sis, umbilical necrosis, seroma, and hematoma. Their
Finally, other than a significant risk of blood transfu- order varies in the literature, but the most commonly
sion, Shull and Verheyden [75] found no increased reported are wound infection, dehiscence, hematoma/
morbidity and the hospital length of stay was reduced seroma, and skin loss [76]. Van Uchelen et al. [77]
reported that the most alarming complication was 10% Wound dehiscence and skin necrosis occur with
incidence of injury to the lateral femoral cutaneous attempts of surgeons to close the skin as tightly as pos-
nerve. This can result in permanent sensory loss along sible. Intraoperative flexion of the trunk adds to this
the anterior, lateral, and posterior thigh that is usually tension and usually this position is not tolerated by
not interfering with the patients daily activities and most of patients in the postoperative period, especially
they become used to it over a long period of time. if the patient has a chronic back problem. Very tight
Wound infection in any clean surgery, occurs in 1% of skin closure might lead to vessel stretching, spasm,
patients in an outpatient and 3% in a hospital. It is not and then clotting, causing flap necrosis which is usu-
unusual for slight erythema to occur around the sutures ally in its central midportion.
without actual significant infection, and the wound Other contributing factors include: smoking, poorly
should be watched very carefully for progression of the controlled diabetes mellitus, hematoma, seroma, infec-
infection that may require intravenous antibiotics [77]. tion, prior abdominal scar, and concomitant abdominal
Most surgeons place patients on prophylactic antibiotics, liposuction [77].
administered intravenously before and during the surgical Shiffman [82] mentioned that a subcostal scar from
procedure, and oral supplements during the immediate previous surgeries disrupts the vascular supply to the
postoperative period [78]. skin flap medial to the scar, and may result in flap
Infections not responding to antibiotics may require necrosis. This could be prevented by minimizing the
consultation with an infectious disease specialist and amount of flap resected, and leaving at least a 46-cm
may indicate early necrotizing fasciitis, sepsis or toxic space between the inferior point of the scar and the cut
shock syndrome that can be fatal. This may be indi- edge of the skin flap, or by resecting the central portion
cated by lethargy, fever, and elevated white count. of the abdominal flap leaving a midline scar.
Wound debridement, followed by prompt treatment When liposuction is performed, it is recommended
with appropriate intravenous antibiotics according to that the superficial fat compartment be avoided, and that
tissue and blood cultures is essential in these serious liposuction performed below Scarpas fascia to limit
complications [77]. vascular compromise and contour irregularities [43, 83,
The large surface area of dissection extending from 84]. Matarasso [85] described the critical areas of the
the Mons pubis to the xiphoid process together with abdominal wall to liposuction at the time of abdomino-
the patients movement, results in the formation of plasty. He also concluded that abdominoplasty may be
excessive serous fluid and development of seroma. combined with liposuction if the central upper abdomi-
Saldanha et al. [79] noted that Seroma can best be nal area has cautious liposuction, and the areas lateral to
prevented by the placement of postoperative drains. this central area have limited liposuction.
Pollock and Pollock [80] placed quilting sutures, Late complications may be unavoidable or may be
attaching the undersurface of the adipose tissue of the caused by a technical error made at the time of surgery.
abdominal flap to the anterior surface of the underly- These include asymmetry of the abdominal contour,
ing muscular fascia in an attempt to decrease the empty recurrent diastasis of the rectus abdominis muscles,
space. They reviewed 65 abdominoplasty procedures hypertrophy, and keloid formation (usually attribut-
that were not drained, and found no hematoma, seroma, able to the patients genetic propensity). Occasionally,
or skin flap necrosis. reoperation to correct hypertrophic scarring, umbilical
Pitanguy [76] stressed on preventing seroma by stenosis, excision of excess residual abdominal skin or
avoiding desiccation of the dissected tissues, maintain- subcutaneous adipose tissue, secondary correction of
ing rigorous hemostasis, and appropriate placement of rectus diastasis, or additional lipoplasty to improve a
drains. He also routinely used a 2-kg custom-designed contour irregularity of the abdominal wall may be
anterior abdominal wall plaster shield for the first necessary [78].
2 days postoperatively to assure even and firm pressure
over the dissected abdominal flap.
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Circular Lipectomy with Lateral
ThighButtock Lift 52
Hctor J. Morales Gracia
52.1 Introduction Obesity and morbid obesity rates have increased in

the last decade all over the world and so the bariatric
Patients with body contour deformities are amongst surgery and consequently the number of post-bariatric
the challenges that plastic surgeons most frequently or massive weight loss patients that successfully have
face. These body contour deformities vary from patient lost weight and recurred (needed, asked for) to plastic
to patient in number, intensity, and anatomical location surgery. Initially, in post-bariatric plastic surgery, the
depending on racial and genetic factors, and these are procedures were merely paniculectomies, cutting out
worsened with overweight and even more with obesity. the skin excess, careless of the resultant scar placing,
These patients usually have tried different weight- and ignoring the body aesthetic units and symmetry,
reduction methods including diets, reductive massages, without improving body contouring and shaping, and
amphetamines, exercise, etc. Nevertheless, the major- yet the patients were satisfied. There was no experi-
ity do not succeed, and they fall in to a vicious cycle ence in this kind of patients, but later, different plastic
that only increases the problem. surgeons started to create new procedures and some-
Those who succeed in losing weight end up with times modified pre-existent procedures to improve
skin and soft tissue laxity problems. Some of these them, observing all the principles of the aesthetic plas-
patients have magical beliefs about liposuction, think- tic surgery, placing the scars following the aesthetic
ing that these will solve all their contour deformities. units of the body, getting the best possible symmetry,
Therefore, it is vital that plastic surgeons inform their shape, and volume to obtain a nice silhouette.
patients about the limitations of liposuction, the risks The post-bariatric surgery patient is a much more
of a radical liposuction, and the need for an appropri- difficult patient than the moderately overweight patient
ate surgery. Most patients present a number of body in getting an aesthetic result. To perform the surgery,
contour deformities that cannot be corrected in one they must be weight stable; that can be achieved in
single surgical stage. Some will require three or more approximately 18 months after bariatric surgery. They
surgical stages. For these reasons, I decided to create a must also be in good nutritional shape. When they
treatment program that combines several body contour come to the plastic surgeon, some of them have lost a
techniques without increasing the surgical risk. With lot of the fat tissue; in these cases, the skin and subcu-
this program, its possible to change the patients sil- taneous tissue are very thin, and the fixation mecha-
houette (body contour), helping them to recover their nisms of the connective tissues to the muscular fascia
self-esteem and break the vicious obesity cycle [1]. have excessive laxity which makes it easy to evaluate
the amount of skin resection using the pinch maneuver
and easy to control bleeding. But without fat, its
almost impossible to get a nice female body shape, and
H.J. Morales Gracia
in a couple of months, the tissues that were tightened
CER Ciruga Plstica Esttica y Reconstructiva,
Monterrey, Nuevo Len, Mexico get loose; the tissues lost elasticity and due to elasticity
e-mail: [email protected] loss have excessive laxity. That is why we often see

908 H.J.M. Gracia
LATERAL SUPRA
UPPER ANTERIOR
GLUTEAL RESULTANT IDEAL
AND POSTERIOR
AREA OR FLANK SCAR SILHOUETTE
MARKING LINES
(LOVE HANDLES) LINE
UPPER
MARKING LINE
LOWER
ANTERIOR AND LOWER
POSTERIOR MARKING
MARKING LINES LINE
INTER
GLUTEAL GLUTEAL
TROCHANTERIC CREASE MIDLINE
HORIZONTAL AREA LATERAL
SUPRA PUBIC (SADDLE BAGS) GLUTEAL
MARKING LINE RECESS
OBLIQUE
PARANGUINAL
ASCENDING TROCHANTERIC
MARKING LINE LIPOSUCTION
INCISION
Fig. 52.1 The lift corrects the ptosis and improves the shape, size, and skin texture of the gluteus, making them appear round and
youthful
cases of circular lipectomies in post-bariatric patients 2. To lift the lateral thigh, eliminating cellulite by
with badly located asymmetrical scars with a complete tightening the skin (Fig. 52.2)
lack of female silhouette, no volume at the gluteal area, 3. To eliminate redundant flank tissue (Fig. 52.3)
and residual skin excess in the abdomen for some 4. To lessen the amount and size of (and sometimes
patients. The asymmetrical and/or misplaced scars eliminate) the middle and lower back adipose cutane-
could be due to either bad planning or displacement of ous folds, therefore reducing waist size (Fig. 52.4)
the scar because the fixation sutures did not hold the 5. To reduce the redundant skin and fat of the abdo-
tissues that were extremely lax and weak and could be men and to tighten the rectus abdominis and exter-
even worse if there is still residual weight on the legs nal oblique muscles when needed, thus improving
or buttocks. That is why in this case, we must plan the abdomen and waist shape (Fig. 52.5)
properly following the aesthetic units of the body and 6. To break the vicious cycle of obesity
place as many fixation sutures as possible, and we 7. To leave a single circular scar that can be hidden with
must team up with the bariatric surgeons and nutri- a thong and that may be planned and placed according
tional assistance staff to assure patients weight and to the patients dressing habits and of course respect-
nutritional stability prior to cosmetic surgery in order ing the aesthetic units of the body (Fig. 52.6)
to succeed. One of the advantages of the stable post-
bariatric patient is that the skin becomes very thin so
they usually tend to form less-conspicuous, almost 52.3 Indications
invisible scars.
This surgery is indicated in thin, normal, and a little
overweight patients with loose and redundant skin and
52.2 Objectives with Circular Lipectomy subcutaneous tissue and even in patients with moderate
obesity and obesity (Fig. 52.7). It can also be indicated
There are several objectives that we seek to achieve only to lift the buttocks to improve the size and shape
with this circular lipectomy: and eliminate cellulite (Figs. 52.8 and 52.9). The
1. To lift and to improve the shape, size, and skin tex- author frequently combine the Circular Lipectomy
ture of the gluteus, making them look round and -Lateral Thigh-Buttock Lift with breast surgery, either
youthful (Fig. 52.1) mastopexy or breast augmentation, but it can also be
52 Circular Lipectomy with Lateral ThighButtock Lift 909
PTOSIS
Fig. 52.2 The lift improves the silhouette and eliminates cellulite by tightening the skin of the lateral thigh
combined with brachioplasty if needed in post-bariat- marking line at the posterior midline, 35 cm above
ric patients, numbering the areas to be corrected and the intergluteal crease. A convex line lightly ascendant
making a surgical plan in order to reduce the number is traced until it reaches the gluteal midline and then
of surgical stages within safety limits. extends caudally following the line of the inferior edge
of the lateral supragluteal fat pad (love handles) until it
reaches the upper edge of the lateral gluteal recess.
52.4 Preoperative Markings The contralateral side is marked in the same way,
forming a seagull-wing-shaped line (Fig. 52.9). The
For preoperative markings, the patient stands while the upper marking line is marked at the midline, 2 or 3 cm
trochanteric area that needs liposuction is outlined. above the expected or desired suture line. It starts at
The supragluteal and lateral supragluteal areas (flanks) the midline usually 57 cm above the inferior edge of
that will be resected are marked starting with the lower the resection with lightly ascending curved line
910 H.J.M. Gracia
Fig. 52.3 Circular lipectomy eliminates redundant flank tissue
extended laterally just over the lateral supragluteal fat crease. The upper margin is a curved line with its upper
deposit (flanks). It is important to consider that the fur- end located above the umbilicus (at the lowest),
ther an incision is from the midline, the more lax the depending on the case, and extended laterally until it
subcutaneous tissue and its superficial fascial system meets the inferior margin line. The posterior and ante-
are [2]. The expected suture line at the lateral aspect of rior marking lines are then joined in the most conve-
the flanks will be located 57 cm below the upper limit nient way for each case.
of resection. Once both lines are marked, the vertical
distance of midline is 57 cm and of the lateral aspect
of the flanks is 1425 cm (Fig. 52.9). The pinching 52.5 Surgical Technique
maneuver on the flank facilitates marking on thin
patients [3]. The abdominoplasty is then marked con- An intravenous line is set, and the anesthesiologist
ventionally. A horizontal line of 1012 cm, located just administers light intravenous sedation with 50 mcg/kg
above the pubic hair line, is traced, extended laterally of mydazolam, 1mcg/kg of fentanest, 1 g of cephalot-
and following an ascending line parallel to the inguinal ine every 6 h, 50 mgs of ranitidine every 12 h, and
Fig. 52.4 Circular lipectomy lessens the amount and size (sometimes eliminates) of the middle and lower back adipose cutaneous
folds
5,000 U of subcutaneous heparin. Wlth the patient in a the superficial fascial system and subcutaneous tissue
lateral decubitus position the epidural catheter is intro- of the upper edge of the lateral thigh flap because
duced at the L2-L3 level and in cases in which breast they are going to be used for closure. The resection of
surgery will also be performed, a second epidural cath- the supragluteal and lateral supragluteal tissue starts
eter is introduced at T6T7. A Foley catheter is set, dividing (cut the flap in two) (Fig. 52.10) the flap at
and the patient is changed to a prone decubitus the posterior midline to facilitate the undermining
position. and the resection; then, the incision is made on or fol-
The surgery starts with the trochanteric dry liposuc- lowing the superior or upper marking line, and then
tion of the deep fat. If liposuction is not needed, the the incision of the lower or on the lower or inferior
cannula is used to undermine and free the trochanteric marking line is made both starting from medial to lat-
area to facilitate the lift using a 4-mm cannula through eral. The whole thickness of the subcutaneous tissue
a small, oblique 7-mm incision located at the inferior is resected, exposing the fascia thoracolumbalis in
posterior edge of the trochanteric markings, being the mid-lower back area and laterally the aponeurosis
careful not to damage or compromise the integrity of of the latissimus dorsi and external oblique muscles
912 H.J.M. Gracia
Fig. 52.5 The abdomen and waist shape are nicely improved
Fig. 52.6 The scar is placed at the limits of the bodys aesthetic units and can be hidden by a thong
Fig. 52.7 Circular lipectomy in a 35-year-old obese patient who refused bariatric surgery has significantly improved buttocks and
abdomen
914 H.J.M. Gracia
Fig. 52.8 The size, shape, uneven aspects, and cellulite of the buttocks are totally corrected by the lift
Fig. 52.9 Preoperative markings are done immediately before surgery with the patient standing
916 H.J.M. Gracia
Fig. 52.10 Cutting the supragluteal flap in two at the midline

facilitates the undermining and resection
[4]. The caudal limit of the undermining is just to the

level of the inferior line of the markings. Once the
undermining and resection are completed, the lower
flap is manually pulled up to confirm that the resec-
tion has been adequate and to establish the vector of
the lifting at several points and marking them the way
we like it (Fig. 52.11). In moderately obese patients,
it is difficult to establish by using the pinch maneuver
the amount of tissue to be resected; a partial resection
is made to facilitate the undermining and also to
establish the definitive level of the resection. In most
Fig. 52.11 Overlapping maneuver allows a more precise com-
patients, the tissue resection is greater than the initial plementary resection
marking because the flap displacement increases
once the tissue is resected, facilitating an overlapping
maneuver of the upper over the lower flap and allow- contour deformities. When the resection is excessive,
ing a more precise, complementary resection. This is the wound closure will be difficult, and the tension
especially important at the flanks because an insuffi- on the suture may result in dehiscence or widening
cient resection will not correct the cellulite or the of the scar.
Fig. 52.13 Posterior suture ends laterally, leaving dog ears
necessary are placed on each side following the trac-

Fig. 52.12 Gluteal flap pull up maneuver over the fascia thora- tionfixation suture line in order to pull up the flap and
columbalis and muscles to mark traction and fixation suture
line
reduce tension on the subcutaneous and subdermal
sutures, favoring better scar quality. A 2.5-mm-exter-
nal-diameter perforated tube is placed as suction
drainage. The subcutaneous tissue is sutured with zero
Once the resection is completed, a combined maneu- Prolene, taking enough subcutaneous tissue, with its
ver is performed that shifts the upper and lower flaps to superficial fascial system, on both flaps and then tak-
define and mark the traction axis of the lateral thigh ing some of the aponeurosis of the underlying muscles.
and gluteal lift (Fig. 52.11). The gluteal flap is pulled Ten to twelve of these sutures are placed on each side.
up over the fascia thoracolumbalis, the aponeurosis of The subdermal layer is then closed with 3-0 Monocryl
the latissimus dorsi, and external oblique muscles to inverted sutures, and there is no need for intradermal
mark traction and fixation suture line (Fig. 52.12). suture. The posterior suturing is finished, leaving a dog
The wound closure starts with zero monofilament ear on each side before moving the patient to the supine
Prolene sutures, to fix midline, taking enough subcuta- position (Fig. 52.13). The abdominoplasty begins with
neous tissue, with its superficial fascial system, at mid- the skin resection as marked. The rectus abdominis
line on the inferior flap and then enough tissue of the muscle is plicated (Fig. 52.14) as is the external oblique
aponeurosis of the fascia thoracolumbalis at the mid- muscle when needed. The wound is closed in two lay-
line. As many of these sutures (every centimeter) as ers, and suction drainages are left. At the end of the
918 H.J.M. Gracia
Fig. 52.14 Rectus abdominis muscle plication significantly improves the abdominal silhouette
surgery, the patients wear a compressive girdle with The resected tissue weight varied from 1.3 to 1.5 kg
shoulder straps to suspend the buttocks during ambula- with an average of 3.6 kg.
tion. The patients spend one night at the clinic and Twenty-nine patients had abdominal seroma. In ten
receive autologous blood if needed [5, 6]. They start patients, the seroma extended to the flank (or it was iso-
walking the next morning and are discharged at noon. late formed at the flank and back), and six patients pre-
They are examined on the sixth postoperative day sented seroma leakage through the wound at the
when the drains and umbilicus stitches are removed. posterior midline. This problem was spontaneously cor-
Examination is continued weekly for the first month rected during the first 34 weeks. Seroma leakage through
and then monthly for a year [1]. the wound has been prevented by placing thin suction
drain tubes on the back. There were two cases of partial
dehiscence, one was 7 cm long, and the other was 5 cm
52.6 Complications long. One of the dehiscence cases was on the flank site
of maximum tension and the other was in the supra-
Over the past 10 years, circular lipectomy has been gluteal area. There were three cases of micro-dehiscence
performed with lateral thigh and buttock lift in over at the posterior midline, resulting from difficulty in
100 patients. No major complications have occurred. suturing the tip of the upper flap and/or favored by pos-
All the patients had a fast recovery, beginning ambula- terior seroma draining through. Therefore, the incision
tion the morning after the surgery and wearing the design was changed to eliminate the tip of the seagull-
compressive girdle with gluteal suspension. Some wing flap (Fig. 52.9) and place posterior drains. In the
patients indicated pain in the lumbar area, but it did not last 60 cases, there has been no complication other than
prevent them from walking. It was easier for the most few abdominal seroma.
obese patients to walk because of their decrease in Excellent results were achieved on non-obese
weight and reduced circumference due to the elimina- patients who had thin torsos, producing an ideal sil-
tion of excess skin and fat folds. Their heart rate and houette (Figs. 52.15 and 52.16). In the moderately
blood pressure decreased after surgery. The body con- obese patients, the correction was also very good, sig-
tour deformities involved were corrected in all the nificantly improving the silhouette at the waist, the
patients, with very good aesthetic results. The average gluteus, and lateral thigh. The ideal silhouette was not
fat volume obtained by liposuction was 400 g. obtained in patients with other body contour deformities
Fig. 52.15 Excellent results in patients with mild obesity of the lower body with thin torso
that were left untreated, such as the internal thighs, the caused by dehiscence in one case but in the absence of
upper back, the trunk, and the arms. The resulting scar skin dehiscence in the remaining three cases
was located at the limits of the aesthetic units and (Fig. 52.17). In four patients, the scar was high, two
could be covered by thongs and bikinis in most of the presented asymmetry of the supragluteal scar. The
cases. In six patients, the scar could not be covered by wide scars at the flanks that were not preceded by
a thong, requiring normal underwear or bikinis, dehiscence were probably due to technical failure
because of scar widening or asymmetry. Four patients because this area of maximum tension requires metic-
presented unilateral widening of the scar at the flanks, ulous suturing. It is also possible that liposuction of the
920 H.J.M. Gracia
Fig. 52.16 Ideal silhouette is obtained with circular lipectomy in mild overweight patients
neighboring area compromised the integrity of the tations. During the first 2 months, the gluteal shape
superficial fascial system, producing subcutaneous and projection on the lateral view are very poor, and
dehiscence. I found that the scars were less conspicu- the buttocks look flat, but around the fourth month, the
ous in non-obese patients than in obese patients. In all area becomes round and youthful (Fig. 52.18).
the cases, the results were greater than patients expec- The results were consistently good.
52.7 Discussion
The circular lipectomy with lateral thigh and buttock

lift is based on previous experiences of several
surgeons [2, 3, 717]. The circular lipectomy of
Gonzlez Ulloa was designed to eliminate the redun-
dant skin and fat tissues of the abdomen, flanks, and
lower back, but it did not improve the lateral thighs
and buttock contour or lift them either. The resultant
scar was higher than that left by the authors proce-
dure, requiring compensation triangles that left verti-
cal scars. Liposuction [ 7, 13, 14 ] , together with
the body contour surgery techniques of Baroudi,
advanced the treatment of body contour deformities
[6, 1012]. The different combinations proposed by
Baroudi have similar incisions, but the posterior ones
are lower, and the ones of the abdomen are different
[6]. Lockwood used incisions on the lower body lift
that are similar to those we use but lower and with
different design and marking of the area of resection
[17]. His results are outstanding but require several
stages. Also, he does not perform this procedure on
moderately obese patients. With the circular lipec-
tomy, it is possible to achieve several objectives in
one stage:
1. The gluteus is lifted and its size and shape is
improved.
2. The lateral thigh is lifted, improving the contour
and tightening the skin, eliminating cellulite.
3. The number and size of adipose cutaneous folds of
the lower and middle back are decreased, improv-
ing the waist silhouette.
4. Redundant flank tissue is eliminated.
5. Excessive abdominal skin and fat are eliminated.
6. The rectus abdominis muscle is plicated, improving
the waistline and abdominal silhouette.
7. The circumferences of the abdomen, waist, hips,
and thighs are significantly decreased.
8. The only scar left can be placed according to the
patients dressing habits and can be covered by a
thong in most cases [1].
Fig. 52.17 Scar widening at the flank in the absence of
dehiscence
922 H.J.M. Gracia
Fig. 52.18 (a) Flat gluteal shape and projection at 1 month after surgery. (b) Three months after surgery with buttocks starting to
appear better. (c) One year after surgery with round and youthful buttocks
References 9. Illouz YG, De Villers YT (1989) Body sculpturing by lip-

oplasty. Churchill-Livingstone, New York
10. Couch N, Laks H, Pilon RN (1974) Autotransfusion in three
1. Baroudi R, Keppke EM, Tozzi-Neto F (1974) Abdominoplasty.
variations. Arch Surg 108(1):121122
11. Lockwood TE (1988) Fascial anchoring technique in medial
2. Baroudi R (1984) Body sculpturing. Clin Plast Surg
thigh lifts. Plast Reconstr Surg 82(2):299304
11(3):419443
12. Lockwood TE (1991) Superficial fascial system (SFS) of the
3. Baroudi R (1984) Lipolysis combined with conventional sur-
trunk and extremities: a new concept. Plast Reconstr Surg
gery. In: Hetter GP (ed) Lipolysis: the theory and practice of
87(6):10091018
blunt suction lipectomy. Little Brown, Boston
13. Lockwood TE (1991) Transverse flank-thigh-buttock-lift
4. Baroudi R (1989) Body contouring surgery. Clin Plast Surg
with superficial fascial suspension. Plast Reconstr Surg
16(21):263277
87(6):10191027
5. Gonzalez-Ulloa M (1959) Circular lipectomy with transposi-
14. Lockwood T (1993) Lower body lift with superficial fascial
tion of the umbilicus and aponeurolytic technique. Ciruga
system suspension. Plast Reconstr Surg 92(6):11231125
27:394409
15. Morales-Gracia HJ (2003) Circular lipectomy with lateral
6. Gonzlez-Ulloa M (1960) Belt lipectomy. Br J Plast Surg
thigh-buttock lift. Aesthetic Plast Surg 27(1):5057
13:179186
16. Newman MM, Hamstra R, Block M (1971) Use of banked
7. Illouz YG (1984) Illouzs technique of body contouring by
autologous blood and elective surgery. J Am Med Assoc
liposis. Clin Plast Surg 11(3):409417
218(6):861863
8. Illouz YG (1985) Surgical remodeling of the silhouette by
17. Testut L, Jacobs O (1952) Tratado de anatoma topogrfica.
aspiration liposis or selective lipectomy. Aesthetic Plast Surg
Salvat Editores S.A., Barcelona
9(1):721
The Horseshoe Abdominoplasty
53
53.1 Denition of Abdominoplasty (b) The extrinsic treatment consists in the removal
of excess tissue. This removal will act on the
Abdominoplasty is the functional and mainly aesthetic stretch line by two means:
restoration of the abdomen covering the skin in which (i) Possible removal of the stretch lines area.
the internal structure and skin appearance have been (ii) Expansion of this area will create a trompe-
destroyed following several aggressions consisting in lil improving effect.
important gain and loss of weight or the appearance 2. Skin excess treatment:
of serious stretch marks following one or multiple In the last 100 years, several abdominoplasty types
pregnancies. have been developed and can be classified in three
categories:
(a) Abdominoplasties treating the horizontal excess
53.2 Skin Answers to Different of skin (Fig. 53.1) [112]
Aggressions (b) Abdominoplasties treating the vertical excess
of skin (Fig. 53.2) [1315]
Depending on the body type and the individual consti- (c) Abdominoplasties treating both vertical and
tution, the answer to these aggressions will be of two horizontal excess of skin (Fig. 53.3) [1620]
types: The horseshoe abdominoplasty is classified in the
1. Intrinsic response: Stretch lines third category (Fig. 53.4) [19, 20].
2. Widening of the abdomen skin:
(a) Horizontally
(b) Vertically
53.4 The Horseshoe
Abdominoplasty
53.3 Principle of Abdominoplasty
53.4.1 Generalities
1. Stretched skin treatment:
(a) There is no intrinsic way of treatment. The Inspired by the partial inferior abdominoplasty
phenomenon is irreversible. described by El Baz [21, 22], the horseshoe abdomi-
noplasty is a mixed type of abdominoplasty thus
allowing the treatment of vertical and horizontal skin
R. Moufarrege (*) E. Botros
excesses with a horseshoe incision around the
Department of Plastic Surgery-Hotel, Dieu of Montreal
Hospital, Montreal University, QC, Canada Mount-of-Venus pubic area, avoiding the large
e-mail: [email protected], incisions in the classical abdominoplasties (Fig. 53.5)
[email protected] [19, 20].

a b c
Fig. 53.1 Vertical abdominoplasties to treat horizontal excess of skin (widening of the waist). (a) Babcock. (b) Scheppelmann.
(c) Kuster
a b c d
e f g
Fig. 53.2 Horizontal abdominoplasties for vertical excess of skin treatment. (a) Kelly. (b) Thorek. (c) Gonzales-Ulloa. (d) Baroudi.
(e) Pitanguy. (f) Grazer. (g) Regnault
53 The Horseshoe Abdominoplasty 927
a b
c d e
Fig. 53.3 Mixed abdominoplasties. (a) Pick, Barsky. (b) Galtier. (c) Weinhold. (d) Flesh-Thebesus, Weisheimer. (e) Moufarrge
53.4.2 Indications and Limitations 1. Slim patient without any fat to be removed under
the remaining skin
Although a horseshoe abdominoplasty ranges from a 2. Patient without stretch lines at the level of the upper
very small partial inferior abdominoplasty until very flap edge
high extended abdominoplasties with undermining In the authors practice, horseshoe abdomino-
reaching the thoracic ribs, its indications are very lim- plasties do not represent any more than 5% of abdom-
ited and must meet very strict criteria. If the patient inoplasty indications. If both of these two conditions
does not meet these conditions, it is better to opt for a are not met, one can be forced to complete the horse-
classical incision with a very low curved line with an shoe with a vertical medial incision after a resection
upper concavity [20]. Conditions allowing the use of of the wedge with upper summit and inferior basis in
the horseshoe are: order to absorb the non-adaptable stretch lined edge
Fig. 53.4 Traction orientation in the horseshoe Fig. 53.5 The horseshoe first incision
against the inferior horseshoe around the pubic areas Entire umbilical reconstruction is performed in the
(Figs. 53.6 and 53.7) [20]. abdominoplasties, including those with low upper-
concave incision. The umbilicus is separated from all
attachments with the fetal remnants of the umbilical
53.4.3 Surgical Technique cord, and we close the resultant small hernia with a
2-0 cross stitch of polyglycolic acid (Vicryl, Dexon,
Once the indication for a horseshoe abdominoplasty is Polysorb).
established, the horseshoe is drawn (Fig. 53.5). In The surgeon will evaluate at this stage the extent of
order to allow a better absorption of all the skin excess skin resection, that is to say, the level of the superior
resulting from the resection of the abdominal skin, a incision in the undermined flap. This level will be
special effort is made to extend the inferior extremities defined more securely by the mean of a medial vertical
of the horseshoe as far as possible (Fig. 53.8). The incision starting at the middle of the inferior edge of
upper flap is then elevated. Obviously, if the dermacha- the horseshoe and progressing upward until reaching,
lasis involves the supraumbilical area, undermining after many trials, the exact level of the skin resection
extends until the ribs (Fig. 53.9). On the contrary, if the (Fig. 53.9). This level is reached by bringing together
dermachalasis does not involve the supraumbilical progressively the extremity of that vertical incision to
area, undermining will stop at the umbilicus. Laterally, the middle of the lower horseshoe edge (Fig. 53.9).
undermining will extend to the superior anterior iliac The thighs are not bent over the abdomen to remove
spine (Fig. 53.9). As soon as dermachalasis is consid- excess of skin, and closure is completed without ten-
ered to involve the supraumbilical area, undermining sion. Once the upper limit of the incision designed, the
will involve the umbilicus. The authors philosophy in cutaneous resection is performed in two halves of
the management of the umbilicus is very different from ellipse with their upper extremity perpendicular to the
the way it is treated in the traditional abdominoplasties. vertical temporary medial line and their lower extremity
Fig. 53.6 The wedge a b

supplemental resection and its
result. (a) Wedge design (b)
Final scars
Fig. 53.8 First incision, extending the inferior extremity as far

as possible
Fig. 53.7 Vertical medial scar over the horseshoe
making a 10 angle with the inferior extremity of the 53.5 Reconstruction of the Umbilicus
lower edge of the horseshoe (Fig. 53.10).
In the authors classical abdominoplasties when the Once the upper flap is attached against the center of the
horseshoe design cannot be applied, resection is com- lower horseshoe edge, it is time to delimitate the posi-
pleted with the removal of the fascia superficialis under tion of the new umbilicus. This will not have any rela-
the remaining skin until ribs. This is not necessary in case tionship with the old umbilicus. It will be situated at
of horseshoe abdominoplasty because the subcutaneous half distance between the two superior anterior iliac
fat is very thin, i.e., 1015 mm. If the patient presents spines.
any muscle diastasis, the muscle plication of the rectus The incision is marked having a much curved smile
abdominis is performed before the reconstruction. shape with upper concavity. Its dimensions are
a b
b
c
d d
g e
f
90
b
10
e f
Fig. 53.11 Incision for the umbilical reconstruction
The muscular space seen through the umbilicus that

is about 15 15 mm is allowed to granulate spontane-
ously. This will be completed within 23 weeks and
b will result with a natural umbilicus avoiding that dis-
graceful appearance of round scar and a cylinder lead-
ing to the muscular wall.
Closing of the horseshoe will continue progres-
sively by always dividing every space between the
sutures in two equal parts (Figs. 53.1453.17).
53.6 Drainage
An aspirating drain (Jackson Pratt type) is inserted in

the dead space between the skin flap and the muscles
and is removed when it will drain less than 25 mL
daily; this will take between 5 and 10 days.
Fig. 53.10 (a) Excised skin before removal. (b) Excised skin 53.7 Precautions and Contraindications
once completely separated from the remaining abdominal skin
Scar revision could be necessary after a year. The sur-
geon has to warn the patient of such a possibility.
15 15 mm (Fig. 53.11). The dermis of the upper flap It is absolutely contraindicated to proceed to any
is liberated of its subcutaneous fat and fixed on the abdominoplasty in case of an active-smoking context.
aponeurosis with a high kick-up of that small flap up in The author requests smoking cessation 3 months before
order to obtain a certain curtain effect on the upper and after surgery.
middle of the umbilicus (Fig. 53.12). That suture point
is called the superior cardinal point. The inferior cardi-
nal point is 15 mm below. Anchoring the two extremi- 53.8 Results
ties of the incision is continued against the aponeurosis
with a pushdown technique with a 2-0 polyglycolic The patients have been happy with the results
acid suture (Fig. 53.13). (Figs. 53.1853.20).
Fig. 53.9 (a) Different levels of skin resection depending on resection height with a medial vertical incision in the upper
the skin laxity and dermachalasis degree. The area designed by undermined flap. (f) Approximation of the central point between
A represents the undermining surface. (b) Abdomen after the the upper and lower incision after the delimitation of the skin to
skin resection. (c) Undermining the upper flap after skin exci- be excised. This approximation is only a maneuver to confirm
sion. (d) Designing the excision and the undermining lines. (A) the right height of the excision
Undermining limit. (B) Excision limit. (e) Evaluation of the
Fig. 53.12 (A) Umbilical A B

reconstruction, undermining
of the U-shape flap. (a)
Muscle. (b) Muscle
aponeurosis. (c) Subcutaneous
fat. (d) Inferior area of the
umbilicus. (B) Belly button
reconstruction: anchoring
dermis at 12 oclock (up) and
6 oclock (down)
a b
Fig. 53.13 (a) Anchoring the four cardinal points of the belly button. (b) Reconstructed belly button
Fig. 53.14 First suture in the closing procedure Fig. 53.16 Third series of sutures
Fig. 53.17 (a) Fourth series of sutures. (b) End of the horse-
shoe closing. In this patient, the incision continues in the inner
Fig. 53.15 Second series of sutures thigh fold in a combined abdomen and inner thigh lifting
Fig. 53.18 (Left)

Preoperative. (Right)
Postoperative
Fig. 53.19 (Left)

Postoperative
Fig. 53.20 (Left) Preoperative. (Right) Postoperative

References 12. Regnault P (1975) Abdominoplasty by the W technique.

13. Babcock WW (1916) The correction of the obese and
1. Kelly HA (1910) Excision of the fat of the abdominal
relaxed abdominal wall with special reference to the use of
wall-lipectomy. Surg Gynecol Obstet 10:229231
buried silver chain. Am J Obstet Gynecol 74:596611
2. Thorek M (1924) Plastic surgery of the breast and abdomi-
14. Schepelmann E (1918) ber Bauchdeckenplastik mit beson-
nal wall. Charles C. Thomas, Springfield
derer Bercksichtigung des Hngebauches. Beitr Klin Chir
3. Thorek M (1939) Plastic reconstruction of the female breast
3:372
and abdomen. Am J Surg 43:268278
15. Kuster H (1926) Operation bel Hngebrust und Hngeleib.
4. Gonzalez-Ulloa M (1960) Belt lipectomy. Br J Plast Surg
Monstsschr Geburtsh Gynk 73:316
13:179186
16. Galtier M (1955) Traitement chirurgical des obsits de la
5. Baroudi R (1984) Body sculpturing. Clin Plast Surg 11(3):
paroi abdominale avec ptose. Mem Acad Chir 8l(1213):
419443
341344
6. Baroudi R, Moraes M (1991) Philosophy, technical princi-
17. Galtier M (1962) Obesity of the abdominal wall with ptosis
ples, selection, and indication in body contouring surgery.
(pendulus abdomen): surgical treatment. Presse Med 70:
135136
7. Pitanguy I (1967) Abdominal plastic surgery. Hospital
18. Weinhold S (1909) Bauchdeckenplastik. Zentralbl Gynk
(Rio J) 71(6):15411556
38:1332
8. Pitanguy I (1971) Technique for trunk and thigh reductions.
19. Moufarrge R (1997) The Moufarrge horseshoe abdomino-
In: Transactions of the fifth international congress of plastic
plasty. Aesthetic Surg J 17(2):9196
and reconstructive surgery, Butterworth, Melbourne 1971,
20. Moufarrge R (2005) Horseshoe abdominoplasty. In:
pp 12041210
Shiffman MA, Mirrafati S (eds) Aesthetic surgery of the
9. Pitanguy I, Yobar AA, Pires CE, Matta SR (1974) Aspectos
abdominal wall. Springer, Berlin, pp 121129
atuais das lipectomias abdominais. Bol Cir Plast Rev Bras
21. Elbaz JS, Flageul G (1979) Plastic surgery of the abdomen.
Cirurgia 19:149
Masson Publishing, New York, p 3961
10. Grazer FM (1973) Abdominoplasty. Plast Reconstr Surg
22. Elbaz JS, Flageul G (1989) Liposuccion et Chirugie Plastique
51(6):617623
de lAbdomen. Masson, Paris, p 74
11. Rgnault P (1972) Abdominal lipectomy: a low W incision.
International Journal of Aesthetic Plastic Surgery
Mini-Abdominoplasty
54
Bruce A. Mast
54.1 Introduction [4, 5]. This procedure can also offer an understandable
compromise for the patient who is not an ideal candi-
Patients with contour irregularities of the abdominal date for mini-abdominoplasty, but is unwilling to put
wall present with varied histories and varied physical forth the physical or financial outlay necessitated by
findings. Some patients have had a massive weight the full abdominoplasty [6].
loss from bariatric surgery or non-surgical efforts.
Others have had more modest weight loss, while many
have had changes of weight and skin quality related 54.2 Clinical Findings and Patient
to changes from aging, pregnancy, and childbirth. Selections
Therefore, each patient needs to be carefully assessed,
and based on the characteristics of each individual, the Ideal candidates for the mini-abdominoplasty are dis-
proper type of contouring procedure can be provided pleased with their lower abdominal contour, especially
[1]. The assessment must evaluate the component when sitting. Often times, they are thin, physically fit,
irregularities of the abdominal wall which consist of and active, but distraught over their appearance in
varying degrees of adiposity, loose or redundant skin, clothes due to the lower abdominal bulge. Full exami-
and laxity of the musculofascial units [2]. When these nation of the patients abdomen is done in several posi-
components affect the majority of the abdominal wall, tions: supine, sitting, standing, and the diving position.
particularly the supraumbilical region, a standard full This provides a full appreciation of the degree of
abdominoplasty with or without liposuction is usually excessive soft tissue and the extent of musculofascial
indicated. However, an operation of this magnitude laxity. Careful palpation of the abdomen in the supine
may not be necessary for those who present with more position allows assessment of rectus diastasis and the
limited or isolated deformities confined to the lower superior extent of the diastasis. It further permits detec-
abdomen. These patients can be treated very effec- tion of abdominal wall hernias. The sitting position
tively with a mini-abdominoplasty, with or without will show a roll of excessive or loose soft tissue with a
liposuction of the abdominal wall or flank [3]. Mini- lower abdominal bulge that may not be noticeable in
abdominoplasty can provide these patients with excel- standing or supine position. The excess of tissue con-
lent correction of their abdominal deformities with fined to the lower abdomen is confirmed with the
significantly less morbidity and faster recovery than patient standing, while downward traction is asserted
that which is associated with a full abdominoplasty to the abdominal skin, demonstrating the absence of
sufficient laxity or excess above the umbilicus to bridge
the gap to the pubis required for a full abdominoplasty.
The diving, or waist-flexed, position allows the loose
B.A. Mast
skin to fall away from the abdominal wall and pro-
University of Florida, Gainesville, FL, USA vides further assessment. In general, musculofascial
e-mail: [email protected] weakness and the loose skin should be confined to the

940 B.A. Mast
infraumbilical abdomen. Diastasis of the rectus should skin over the umbilicus is indicative of excessive laxity
be limited to the infraumbilical region or only 1 or of the upper abdominal soft tissue that would not be
2 cm superiorly (Table 54.1, Figs. 54.154.3) fully corrected with a standard mini-abdominoplasty
Contraindications to mini-abdominoplasty are lax- (Table 54.2, Figs. 54.4 and 54.5).
ity of the abdominal musculofascial components above Some patients will have adiposity of the upper
the umbilicus, excessive or disproportionate soft tissue abdomen and flanks. Examination should specifically
in the upper abdomen, generalized laxity or soft tissue address these areas, especially in regard to excess skin.
excess of the entire abdominal wall, upper abdominal If mild to modest fat accumulation is present, then lipo-
hernias (usually incisional hernias), and patients suction can be combined safely with the procedure.
presenting after massive weight loss. Such patients However, an assessment of the degree of supraumbili-
generally have excessive skin throughout the abdo- cal fat and the extent of skin laxity must be accurately
men. As a general guideline, ptosis of supraumbilical judged so that loose skin will not be problematic after
surgery (Fig. 54.6).
Table 54.1 Ideal candidate for mini-abdominoplasty

Clinical feature Description 54.3 Operative Technique
Body type Overall fit and trim; not obese
Abdominal contour Lower infraumbilical bulge Mini-abdominoplasty is a procedure in which
Excess tissue Confined to lower abdomen infraumbilical skin is excised, and the umbilicus is not
Musculofascial laxity Lower abdomen only translocated. The extent of skin excision varies with
Rectus diastasis No more than 2 cm above umbilicus individual circumstances. In most cases, liposuction is
Fig. 54.1 Ideal patient for mini-abdominoplasty. (Upper photos before surgery; lower photos after surgery)
54 Mini-Abdominoplasty 941
Fig. 54.2 Good candidate for mini-abdominoplasty. Greater skin laxity than patient in Fig. 54.1 mandates greater skin excision and
longer final scar. (Upper, before surgery; lower, after surgery)
also done. A mini-abdominoplasty in an ideal patient be provided for proper positioning within the panty
will be described. The authors preferred methods will line or swimsuit line. It is best to have the patient wear
be presented with alternatives discussed subsequently. her favored swimsuit during the markings to assure
As with all body-contouring procedures, the patient that the final scar will be hidden. However, it should be
is marked preoperatively. As marking is started in the stressed to the patient that the final position of the scar
standing position, the proposed placement of the scar cannot be guaranteed rather best efforts are put forth to
is confirmed with the patient such that assurance can place the scar favorably.
942 B.A. Mast
Fig. 54.3 Excellent

candidate for
mini-abdominoplasty.
Very little redundant skin
and fat, but diastasis clearly
extends above the umbilicus.
(Upper, before surgery;
lower, after surgery)
The transverse pubic incision is marked in the region

Table 54.2 Contraindications for mini-abdominoplasty
of the superior aspect of the pubic hairline. This mark
Clinical feature Description
should be no higher than 68 cm above the superior
Body type Obese
aspect of the introitus in the midline. If a Pfannenstiel
Abdominal contour Excessive or disproportionate
upper abdominal bulging
scar is present, the incision line should be inferior to it
Excess tissue Includes upper abdomen or entire so that the associated subcutaneous fibrosis that tethers
abdomen the skin to the fascia can be removed. In most patients,
Musculofascial laxity Involves supraumbilical the incision needs to be extended past the pubis bilater-
abdomen ally to allow visualization of the abdominal muscula-
Incisional/ventral hernia ture and permit appropriate skin excision and closure.
Rectus diastasis Extends well above umbilicus The lateral extension extends up the inguinal crease to
Fig. 54.4 This patient will obviously be inadequately treated with a mini-abdominoplasty. Excessive or redundant skin and adipose
exists throughout the entire abdomen
Fig. 54.5 This 38-year-old woman has delivered triplets. abdomen (note the mild ptosis of the skin above the umbilicus),
Casual inspection is deceiving, while a full examination demon- and rectus diastasis extends from pubis to xyphoid. Full abdomi-
strates the extent of the abdominal deformity. There is virtually noplasty is indicated
no excess fatty tissue, but her skin is loose throughout the
about the level of anterior superior iliac spine or further. one-third to one-half of the vertical height of the skin
The upper excision line is not drawn until the flap is between the pubis and the umbilicus. If the excision is
raised intraoperatively. However, for purposes of plan- more than this, it will likely lead to excess tension
ning, the skin to be excised usually encompasses about upon closure causing upward migration of the scar or
944 B.A. Mast
Fig. 54.6 This 43-year-old woman would like abdominal con- confined to the infraumbilical abdomen. She was treated with
touring. She has adiposity extending well above the umbilicus mini-abdominoplasty and full abdominal and flank liposuction.
and to the flanks, while the excess skin and bulging is mostly (Preoperative on right; postoperative on left)
excessive distortion of the umbilicus. If liposuction is Mini-abdominoplasty can be performed under

planned for the upper abdomen, flanks, iliac crests, or several types of anesthesia. The author prefers a general
thighs, these areas are also marked, while the patient is anesthetic, but intravenous sedation combined with
standing. At the completion of marking, all the mark- local anesthetic is also used [710]. In the latter tech-
ings should be demonstrated and explained to the nique, bilateral ilioinguinal nerve blocks are adminis-
patient with confirmation of scar placement. tered, combined with direct infiltration of the incision
Table 54.3 Anesthesia used for mini-abdominoplasty

Type Advantages Disadvantages
IV sedation with local anesthetic 1. CRNA or anesthesiologist 1. Potentially more pain
2. Limited time in recovery room 2. Muscular plication may be more difficult
3. Low incidence of postoperative nausea
4. Lowest risk for thromboembolic
complications
General anesthesia 1. Maximum patient comfort 1. Usually need anesthesiologist
2. Maximum muscular relaxation 2. Higher potential for postoperative
nausea
3. Longer time in recovery room
4. Increased risk for thromboembolic
complications
Epidural 1. Excellent patient comfort 1. Need IV sedation in addition to epidural
2. Excellent muscular relaxation 2. Potential complications related
to epidural
3. Need specialized anesthetist/
anesthesiologist
4. Increased risk for thromboembolic
complications
line with the local anesthetic. Tumescent liposuction This preserves perforating vessels that perfuse the
solution consisting of 0.01% lidocaine with 1:000,000 abdominal skin such that the risk of ischemia is very
epinephrine is also infiltrated into the lower abdominal low. If an abdominal wall hernia is present, this must
wall in the region of flap elevation. This augments the be repaired prior to the liposuction to avoid intestinal
anesthetic affect and provides greater patient comfort injury.
[11, 12]. The use of epidural anesthesia has been spo- Upon completion of the liposuction, the abdominal
radically reported, but the potential complications as incision is created and carried through Scarpas fascia
well as possible prolongation of pre-discharge recov- down to the loose areolar plane just superficial to the
ery must be considered (Table 54.3). If the operation to anterior rectus sheath and external oblique fascial
be performed is only a mini-abdominoplasty, then aponeuroses. The skin and subcutaneous tissues are
intravenous sedation combined with local anesthetic is then elevated off the abdominal fascia superiorly
easily applicable. However, if combined with liposuc- and laterally. The superior extent of mobilization is to
tion, breast surgery, or another procedure, then the the point where the diastasis recti cease, usually no
total length of the procedure must be considered, more than a few centimeters above the umbilicus. If
affecting the selection of anesthetic, but also mandat- supraumbilical dissection is necessary, the umbilicus
ing consideration of prophylaxis for deep venous remains attached to the abdominal skin and the muscu-
thrombosis and the use of body-warming devices. lar wall, and care must be exercised around the umbili-
If liposuction of the abdomen is to be done, then the cal stalk to avoid devascularization. Lateral mobilization
superwet technique is used. Suction is usually done of the flap is continued to about the level of the anterior
prior to elevation of the lower abdominal flap since this axillary line. If the anesthesia being used is intrave-
more readily allows the tumescent solution to remain nous sedation with local anesthetic, electrocautery
in place without proximity to a large open surgical site, should be avoided in ligation and division of larger
through which the fluid can easily egress. However, perforating vessels since these often contain sizable
this may not be possible in the upper central abdomen sensory nerves. The electrical current is transmitted
without the use of a cannula access incision at the into these nerves causing severe pain despite the rest of
upper aspect of the umbilicus. If this is needed, the the field being completely anesthetic. In such circum-
patient must be informed of this incision preopera- stances, suture ligation and sharp division should be
tively. The entire upper abdomen extending laterally employed. These procedures will allow sufficient ante-
can be suctioned fairly aggressively since the abdomi- rior retraction of the skin unit such that abdominal wall
nal flap will not be elevated much above the umbilicus. plication can be done under direct visualization.
946 B.A. Mast
have a relative laxity if the inferior diastasis is corrected

aggressively. A balance between the upper and lower
abdominal wall myofascial unit must be achieved.
Following plication, the excessive skin and subcu-
taneous tissue is retracted inferiorly to overlap the
lower suprapubic incision. Aggressive excision that
results in a very tight closure should be avoided. This
could cause gross distortion of the umbilicus as well as
unfavorable scarring due to tension. In addition to a
wide scar, a very tight closure could also lead to supe-
rior migration of the scar as the looser pubic soft tissue
is pulled upward. Such a circumstance could lead to
a scar that is difficult to hide in the patients swimsuit
of choice. To avoid these results, skin excision is
judged with the patient nearly flat with the operating
Fig. 54.7 Plication of the diastasis of the rectus muscles
table barely flexed. With the abdominal flap pulled
inferiorly at an appropriate tension, the midline point
of excision is marked, and the flap is incised longitudi-
Dissection and retraction of the abdominal skin flap nally in the midline. This point is secured temporarily
permits inspection of the musculofascial component of to the lower incision line in the midline. This leaves
the abdominal wall and the anatomic cause of laxity two lateral triangles of excess tissue that can be
that contributes to the abnormal external contour. appropriately marked and excised.
Rectus diastasis is primarily confined to the infraumbil- Prior to closure, it is occasionally necessary to judi-
ical region, although some patients may have a more ciously defat the advancing abdominal flap or the pubic
minor aspect extending above the umbilicus. However, soft tissue centrally so that the opposing tissues have
even in these patients, the majority of the laxity is in the same thickness and an appropriate contour can be
the lower abdomen. The laxity is corrected by muscu- achieved. A closed suction drain is placed via a small
lofascial plication, providing reconstruction of the incision within the pubic hair or through the incision
correct anatomic relationships of the abdominal wall line laterally. Scarpas fascia is then approximated
musculature. This should result in parallel alignment with interrupted absorbable suture. The midline suture
of the rectus muscles with a straight-line juxtaposition also incorporates the abdominal fascia just above
at the linea alba. Accordingly, plication is undertaken the pubis, acting to stabilize the position of the scar and
to remove the resultant bulging and restore a flat prevent superior migration with time. The skin is closed
abdominal wall. The plication lines on the anterior rec- with subdermal dissolvable monofilament and skin
tus sheaths are marked to guide suture placement. The adhesive. The soft tissues surrounding the suture line
elliptical or crescent marks come together in the mid- are infiltrated with bupivicaine without epinephrine to
line just above the suprapubic incision line and meet provide postoperative analgesia. In all cases, the umbi-
superiorly at the upper aspect of the diastasis (Fig. 54.7). licus will be distorted to some degree, usually with a
The plication is done with inverted figure-of-eight slight vertically elongated appearance (Figs. 54.154.3,
braided nylon sutures. These permanent soft sutures 54.5 and 54.6). An umbilicus to pubis distance of 9 cm
require few knots, avoiding postoperative palpability, is a good parameter to use for a normal anatomic
even in the thinnest patients. Alternatively, a running relationship that provides a pleasing appearance. If this
permanent monofilament suture can be used. If plica- distance is significantly less than 9 cm, particularly in
tion is necessary superior to the umbilicus, sutures shorter patients, then translocation to the appropriate
must be carefully placed so as to avoid strangulation of position through a vertical, elliptical, midline inci-
the umbilical stalk. Others have described methods of sion may be necessary. Overall appearance within the
vertical and transverse plication that may be applicable parameters of the patients particular body habitus
when the extent of laxity is not fully corrected by dictates the necessity of umbilical translocation, and
a standard midline plication [13]. Correction of the preoperative assessment should allow counseling to
inferior diastasis must be done with care so as to avoid alert the patient to the potential need for this maneuver
bulging of the upper abdomen. This area may now and the resultant scar.
54.4 Postoperative Care radiation (including tanning booths) for at least

6 months following surgery and the use of various scar
An abdominal binder or appropriate liposuction lotions/gels or silicone patching for scar management.
compression garment is placed after the surgery.
The patient is discharged home after post-anesthesia
criteria are met and instructed to leave the dressings 54.6 Conclusions
and compression in place until seen for the first
postoperative office visit within 48 h of the proce- As with most deformities treated by plastic surgery, it
dure. The patient is instructed to avoid strenuous is important to analyze each deformity based on its
activities and heavy lifting for at least 1 month after various components and customize procedures to
surgery. The surgical drain is usually removed within each particular patient. The mini-abdominoplasty rep-
1 week. After 1 month of healing, the patient is per- resents such an approach. With careful patient selec-
mitted to gradually resume a workout regimen and is tion, a significant aesthetic deformity can be corrected
cleared for all activities as tolerated after 6 weeks of with minimization of morbidity and convalescence
healing. while providing the patient with a high standard of
care and a high level of satisfaction (Fig. 54.6).
54.5 Complications
References
Virtually, all complications or adverse outcomes that
1. Sozer SO, Agullo FJ, Santillan AA, Wolf C (2007) Decision
can occur with a full, standard abdominoplasty or lipo-
making in abdominoplasty. Aesthetic Plast Surg 31(2):
suction also apply to mini-abdominoplasty, but occur 117127
much less frequently, since the surgery is not as exten- 2. Matarasso A (1996) Classification and patient selection in
sive. The mini-abdominoplasty uses incisions and dis- abdominoplasty. Oper Tech Plast Reconstr Surg 3:714
3. Shestak KC (1999) Marriage abdominoplasty expands the
sections that are considerably smaller, while abdominal
mini-abdominoplasty concept. Plast Reconstr Surg 103(3):
skin resection is of lesser quantity permitting the patient 10201031
to remain completely supine or erect following surgery. 4. Greminger RF (1987) The mini-abdominoplasty. Plast
This results in less pain and discomfort and affords a Reconstr Surg 79(3):356364
5. Wilkinson TS, Swartz BE (1986) Individual modification in
quicker recovery such that most patients can return to
body contour surgery: the limited abdominoplasty. Plast
work within 7 days. Since the flap elevation is somewhat Reconstr Surg 77(5):779783
limited, hematomas, seromas, flap ischemia, and wound 6. Mast BA, Hurwitz DJ (1996) Mini-abdominoplasty. Oper
dehiscence occur very infrequently less than 10% of Tech Plast Reconstr Surg 3:3841
7. Byun MY, Fine NA, Lee JYY, Mustoe TA (1999) The
the time [3]. Additionally, the mini-abdominoplasty
clinical outcome of abdominoplasty performed under
minimizes potential adverse aesthetic outcomes that conscious sedation: increased use of fentanyl correlated
occasionally occur with full abdominoplasty, such as with longer stay in outpatient unit. Plast Reconstr Surg
straightening of the waistline, incisional dog-ears, and 103(4):12601266
8. Bitar G, Mullis W, Jacobs W, Matthews D, Beasley M,
difficulty concealing scars within swimwear. Never-
Smith K, Watterson P, Getz S, Capizzi P, Eaves F III (2003)
theless, suboptimal results can occur as with any body- Safety and efficacy of office-based surgery with monitored
contouring procedure. Upper abdominal bulging may anesthesia care/sedation in 4778 consecutive plastic surgery
result from overzealous musculofascial plication caus- procedures. Plast Reconstr Surg 111(1):150156
9. Byrd HS, Barton FE, Orenstein HH, Rohrich RJ, Burns AJ,
ing intra-abdominal decompression via a less tight
Hobar PC, Haydon MS (2003) Safety and efficacy in an
upper abdomen. Additionally, some patients may still accredited outpatient plastic surgery facility: a review of 5316
have residual skin excess or lower abdominal bulge, consecutive cases. Plast Reconstr Surg 112(2):636641
usually due to their preoperative condition being more 10. Rosenberg MH, Palaia DA, Bonanno PC (2001) Abdom-
inoplasty with procedural sedation and analgesia. Ann Plast
amenable to a mini-abdominoplasty rather than full
Surg 46(5):485487
abdominoplasty, but not being the ideal candidate for 11. Abramson DL (1998) Tumescent abdominoplasty: an ambu-
the mini-abdominoplasty. For such patients, careful latory office procedure. Aesthetic Plast Surg 22(6):404407
preoperative assessment and counseling on the limita- 12. Nguyen TT, Kim KA, Young RB (1997) Tumescent mini
abdominoplasty. Ann Plast Surg 38(3):209212
tions of the procedure is vitally important. Maximum
13. Cardenas Restrepo JC, Munoz Ahmed JA (2002) New tech-
scar quality is achieved by the avoidance of excessive nique of plication for miniabdominoplasty. Plast Reconstr
tension at closure, complete elimination of ultraviolet Surg 109(3):11701177
Ultrasound-Assisted Abdominal
Liposuction 55
55.1 Introduction for body contouring is not new [9, 10]. Early experience
using ultrasound-assisted lipoplasty was met with dis-
Liposuction of the abdomen is one of the most commonly appointment due to the high rate of complications [11].
performed cosmetic surgical procedures worldwide. In The powerful large-diameter (46-mm) probes of the
the United States alone, over 200,000 liposuction proce- first-generation devices emulsified fat with ease, but the
dures were performed in 2009 [1]. Since Dujarrier first trade-off was a high rate of thermal injuries such as
described his crude technique of fat removal using a burns and seromas. Second-generation devices featured
uterine curette in 1921, the safety and predictability of hollow ultrasound-emitting 5-mm cannulas that aspi-
lipoplasty techniques have improved dramatically [26]. rated simultaneously with ultrasound delivery. The
Some of the landmarks in the evolution of modern lipo- removal of protective wetting solution during delivery
suction include the early work by Giorgio and Arpad of energy to the tissues probably contributed to the com-
Fischer, who popularized the use of blunt cannulas for plications seen with this technology. The enthusiasm for
atraumatic suction-assisted fat removal, and the intro- ultrasound-assisted lipoplasty seen in the 1990s quickly
duction of the tumescent technique by Klein in 1987 faded, with few advocating the benefits of the technol-
[7, 8]. Although the tumescent technique remains the ogy [12]. In 2000, Sound Surgical Technologies LLC
gold standard for anesthesia in most internal lipoplasty of Louisville, Colorado, introduced a third-generation
techniques, there have been several refinements in the ultrasound device for assisted lipoplasty called Vaser, an
techniques themselves as well as the technologies and acronym for vibration amplification of sound energy
instruments utilized for fat destruction and aspiration. at resonance. This innovative technology supersedes
These include the development of smaller multi-holed earlier devices by employing less ultrasound energy
cannulas for smoother, more-precise results and the to achieve optimum emulsification of fatty tissues for
introduction of various assist devices designed to make small or large areas, reducing collateral damage and
it easier on the surgeon, easier on the patient, or both. side effects [13]. Following tumescent anesthesia, solid
Power-assisted lipoplasty employs motor-driven suction titanium probes emulsify fat without removing the pro-
cannulas that gyrate forwards and backwards at high tective wetting solution. Gentle suction follows with
frequencies to disrupt and remove fat mechanically with specially designed small-diameter cannulas designed to
minimal effort. Laser-assisted lipoplasty techniques use minimize trauma to vessels, nerves, and the fibrous
fine Nd:YAG laser-emitting probes to emulsify fat tissue matrix [14]. Ultrasound devices for assisted lipo-
through photomechanical or thermal destruction, with suction are summarized in Table 55.1. Since its intro-
or without subsequent aspiration. The concept of using duction less than a decade ago, the Vaser technology has
ultrasound to emulsify fat prior to or during aspiration been widely adopted and is the authors method of
choice for lipoplasty of the body and face. This chapter
describes the materials and method of abdominal lipo-
P.M. Prendergast
Venus Medical, Dundrum, Dublin 14, Ireland suction using third-generation ultrasound-assisted Vaser
e-mail: [email protected] technology.

Table 55.1 Technologies used for ultrasound-assisted liposuction

Technique Description Examples
First-generation ultrasound-assisted Powerful ultrasound-emitting solid 46-mm probes applied SMEI, Casales
lipoplasty to emulsify fat before aspiration. High complication rate
(burns, seromas) due to power
Second-generation ultrasound-assisted Powerful ultrasound-emitting hollow 5-mm cannulas with Lysonix, Mentor
lipoplasty simultaneous emulsification and aspiration
Third-generation ultrasound-assisted Less-powerful, grooved solid probes (2.24.5 mm) emulsify fat VASER
lipoplasty efficiently before aspiration
55.2 Technology ultrasound, specially designed VentX suction cannulas

are introduced for fat removal (Fig. 55.4). VentX
The Vaser console consists of an integrated system cannulas are designed to minimize trauma to tissues by
including all the elements required for flow rate- balancing the total area of the ports with the cross-
controlled infiltration of tumescent fluid, tissue- sectional area of the cannula. The port holes on these
selective destruction of fat, negative pressure aspiration, cannulas are smaller than those on standard liposuc-
and collection of fat in disposable canisters (Fig. 55.1). tion cannulas of the same diameter. A small hole in the
Foot pedals control infiltration and ultrasound deliv- handpiece of the suction cannula also facilitates easy
ery, and dials on the digital display component adjust flow of aspirate through the tubing, even when the
flow rate and ultrasound power output. The solid tita- cannula is in the patient. This has been termed the
nium probes used to emulsify fat before aspiration are VentX effect [15].
small in diameter and contain grooves at the distal ends
in such an arrangement that ultrasound energy is deliv-
ered both from the tip and from the sides (Fig. 55.2). 55.3 Preoperative Considerations
A three-ringed probe delivers more energy from the
sides of the probe compared to a two- or one-ringed The ideal candidate for abdominal liposuction has a
probe and results in a larger halo of fat destruction normal body mass index (BMI), good skin tone, protu-
around the tip of the probe as it passes through the fat. berant areas of exercise- and diet-resistant fat, and no
A one-ringed probe, on the other hand, delivers most comorbid illness. Obese patients and those with exten-
of its energy from the tip and is used for more aggressive striae, skin laxity, or aprons of adipose tissue
sive removal of fibrous fat. In addition to the number are not ideal and may benefit more from abdomino-
of grooves, probes vary in diameter from 2.2 to 4.5 mm. plasty or combined lipoabdominoplasty procedures.
For ultrasound-assisted abdominal liposuction, the Similarly, patients with abdominal protrusion second-
3.74.5-mm probes are most useful, depending on ary to abdominal wall weakness or diastasis of the rec-
the volume of fat present (Table 55.2). Before use, the tus muscles achieve superior results with myofascial
solid titanium probes are gently screwed into the hand- plication. Importantly, patients undergoing liposuc-
piece and tightened with a probe wrench with minimal tion should have realistic expectations. Demands to
force (Fig. 55.3). An appropriately sized protective remove all fat should not be entertained. A detailed
cover is placed over the hilt of the probe near the hand- explanation of the procedure should be given, including
piece. The Vaser system also allows pulsed or continu- potential risks and complications, and expected out-
ous delivery of ultrasound energy. Pulsed delivery comes should be discussed. It is helpful to explain that
(Vaser mode) delivers approximately ten bursts of efforts to remove all fat are likely to result in a poor
energy per second and reduces the absolute energy result, skin irregularities or laxity, and increase the risk
delivered to the tissues. This is useful for delicate areas of complications such as hematomas, seromas, and
or superficial sculpting to reduce the incidence of com- asymmetry. Once the patient understands the concept
plications such as burns and seromas. Following the of body contouring, as opposed to simply removing fat,
emulsification phase of the lipoplasty procedure with and has realistic expectations, the likelihood of a suc-
55 Ultrasound-Assisted Abdominal Liposuction 951
Fig. 55.1 The Vaser

integrated system
cessful outcome is higher. During a detailed history and comorbid disease, BMI, presence of scars or abdominal
physical examination, any factors that influence the wall hernias, condition of skin, and the patients expec-
patients suitability or planning for the procedure are tations. If the patient is suitable and wishes to proceed,
carefully documented. These include drug allergies, a second preoperative visit is scheduled to conduct rou-
medications that interact with lidocaine, presence of tine preoperative blood tests, measurements for a prop-
Fig. 55.2 The solid titanium probes used for Vaser-assisted lip- The arrow probe (shown here third from the right) is indicated
oplasty. Probes for body contouring vary in diameter from 2.9 to for extremely fibrous tissue (e.g., gynecomastia) and is rarely
4.5 mm and in number of grooves at their distal end from 1 to 3. used for abdominal sculpting
Table 55.2 Authors preferred Vaser probe selection according to volume of fat and density of tissues for abdominal UAL
Density Volume Probe Mode* Energy
Soft Very large 4.5 mm (2 grooves) Continuous 7080%
Soft Mediumlarge 3.7 mm (3 grooves) Continuous 7080%
Soft Small 2.9 mm (3 grooves) or 3.7 mm Continuous or pulsed 7080%
(2 grooves)
Slightly fibrous Mediumlarge 3.7 mm (2 grooves) Continuous 8090%
Slightly fibrous Small 2.9 mm (3 grooves) or 3.7 mm Continuous 8090%
(1 groove)
Very fibrous Mediumlarge 3.7 mm (2 grooves) or 3.7 mm Continuous 8090%
(1 groove)
Very fibrous Small 2.9 mm (3 grooves) Continuous 8090%
*All superficial ultrasound delivery within 1015 mm of the dermis should be performed on pulsed mode
erly fitting postoperative compression garment, and 55.4 Materials

preoperative photographs (Fig. 55.5). The author rou-
tinely prints outpatient photographs before the proce- The tumescent technique is currently the method of
dure and creates new contours by drawing on the photos choice for liposuction and ultrasound-assisted liposuc-
using marker pens (Fig. 55.6). This exercise helps tion and obviates the need for general anesthesia or
the surgeon visualize the final result and decide how sedation. As such, the procedure can be performed
much fat should be taken. More importantly, it helps safely in the office-based setting, allowing the patient
determine what should be left behind to achieve aes- to return home the same day [16]. For office-based
thetically pleasing contours. It also highlights asymme- abdominal liposuction, an essential stock inventory
tries and the need to sculpt differently on either side. includes premedications, medications for tumescent
Consent forms, pre- and postoperative instruction leaf- anesthesia, and emergency medications (Table 55.3).
lets, and a prescription for preoperative antibiotics and As well as the Vaser system itself, a range of probes,
analgesia are provided to the patient during the preop- VentX cannulas, the ultrasonic handpiece and cable,
erative work-up. instruments including scalpel, #11 blade, scissors,
a b
c d
Fig. 55.3 Probe connection to the Vaser handpiece before (c) The probe is gently tightened. (d) A protective cover is
use. (a) The solid titanium probe is screwed into the handpiece. screwed into the handpiece to cover the hilt of the probe
(b) The handpiece fits snugly into the supplied probe wrench.
Fig. 55.4 VentX cannula tips

with total area of ports
balanced with cross-sectional
diameter of cannula to reduce
tissue trauma
needle holder, artery forceps, skin ports, and consum- 55.5 Tumescent Anesthesia
ables such as needles, syringes, 4-0 skin sutures, sterile
gauze, and drapes are required (Fig. 55.7). Ancillary During tumescent anesthesia, a mixture of physiologic
materials include a patient monitor, vacuum autoclave, saline, lidocaine, epinephrine, and sodium bicarbon-
and warming bath for tumescent solution. ate is infiltrated into the subcutaneous fatty layer until
a state of tumescence is reached. Tumescence is 8.4% w/v sodium bicarbonate and 1 mg epinephrine.
characterized by firm, swollen tissue that is turgid and Each bag should be clearly labeled immediately after
somewhat fixed. Depending on the desired concentra- adding each medication (Fig. 55.8). Tumescent solu-
tion of lidocaine in the tumescent solution, each bag is tion has some unique properties that contribute to
prepared by adding 5001,000 mg of lidocaine to 1 L its remarkable safety and efficacy in the practice of
of normal (0.9%) saline and then adding 12.5 mL liposuction:
a b
c d

patient for abdominal
liposuction, including
the flanks. (a) Left anterior
oblique. (b) Frontal. (c) Right
anterior oblique. (d) Left
lateral. (e) Posterior. (f) Right
lateral

e f
a b c
Fig. 55.6 Contouring plan for abdominal liposculpture. The preoperative photographs are printed so that markings can be made to
determine where and how much fat should be removed. (a) Frontal. (b) Left lateral. (c) Posterior
1. The dilution of lidocaine with saline to concentrations 2. Epinephrine has a dual role. It causes vasoconstric-
of 0.050.1% and dispersion in fatty tissue alter the tion in the subcutaneous fat, creating an almost
pharmacokinetics entirely. The maximum safe dose bloodless field and reduces blood loss to less than
of lidocaine with epinephrine increases from 7 to 1% of liposuction aspirate. The vasoconstriction
55 mg/kg [17]. also slows systemic absorption of lidocaine so that
Table 55.3 Inventory of essential stock medications for 55.6 Technique

office-based liposuction
Premedications 55.6.1 Marking
Cephalexin 500 mg
Ciprofloxacin 500 mg (penicillin-allergic patients) With the patient standing, markings are made first on
Lorazepam 1 mg the anterior abdomen using Sharpie fine permanent
Solpadol (paracetamol + codeine)
skin markers. The author uses different colors to map
Tumescent anesthesia
out the areas to be contoured, bony landmarks, areas
Physiologic 0.9% saline 1-L bottles
of caution, scars, and proposed incision sites (Fig. 55.9).
Lidocaine 2% plain
8.4% w/v sodium bicarbonate
Concentric rings represent prominences of fat to be
Epinephrine 1-mg ampules sculpted. Straight lines that radiate from these are areas
Emergency medications for less aggressive debulking or feathering. In practice,
Oxygen almost the entire abdomen and flanks should be sculpted
Salbutamol (inhaler/nebulizer) as one aesthetic unit rather than treating only localized
Atropine 1-mg ampules pockets of fat. The flanks should be marked by outlin-
Clonidine 0.1-mg tablets ing areas where fat interferes with the natural curve or
Hydrocortisone 100-mg ampules contour from the back to the hips. Two incisions are
Chlorpheniramine 10-mg ampules usually made close to the midline of the back and at the
upper outer buttock.
Superficial lipoplasty is required for slimmer
serum levels of lidocaine rise slowly and peak only patients who seek an athletic look. In these cases, mark-
414 h after infiltration [17]. ings should outline soft tissue landmarks such as the
3. Tumescent local anesthesia allows liposculpture linea alba, border of rectus abdominis (linea semiluna-
to be performed in the awake patient, eliminat- ris), and inguinal fold (Fig. 55.10). In males, the fleshy
ing the risks of intravenous sedation and general outline of external oblique and horizontal tendinous
anesthesia. intersections of rectus abdominis are marked.
Fig. 55.7 Materials for ultrasound-assisted liposuction using Vaser technology

Fig. 55.8 One-liter bags of tumescent solution containing normal saline, lidocaine, sodium bicarbonate, and epinephrine. The bags
should be clearly labeled immediately after preparation
55.6.2 Positioning and Draping 55.6.3 Inltration
Superabsorbent drapes are placed on the operating Up to 3 L of tumescent fluid may be required for ultra-
table to reduce pooling of tumescent fluid under the sound-assisted liposuction of the abdomen and flanks.
patient during infiltration. These are covered with ster- As such, warming the fluid to 3740C prior to
ile towels (Fig. 55.11). The patient is placed in the infiltration may prevent hypothermia and reduce pain
supine position initially to contour the anterior aspect [18]. Warmed solution does not reduce the ability of
of the abdomen. The hands are positioned behind the epinephrine to cause the profound vasoconstriction nec-
patients head in order to expose the flanks so that essary for a relatively bloodless fat compartment.
feathering can be performed from the anterior lower Thorough infiltration of deep and superficial layers
and upper incisions (Fig. 55.12). The skin is prepared of the entire anterior abdomen is performed through
with a chlorhexidine wash, and sterile surgical drapes inferior and superior incisions using a small-diameter
isolate the anterior abdomen. Sterile paper towels, (17-gauge) blunt infiltration cannula (Fig. 55.14). A
rather than drapes, are used for the sides to allow fluid homogenous fluid-filled fat compartment is essential to
to soak through to the superabsorbent drapes under- transmit sound energy during UAL and prevent thermal
neath rather than run over the drapes onto the floor. injuries to the skin or within the tissues. The author
Once the front is completed, the patient turns to the commences tumescent infiltration in the deep layer of
prone position for skin preparation of the back and fat above the deep fascia using slow, deliberate strokes,
flanks, and new drapes are used to isolate the treatment while the other hand palpates the tissue externally,
area (Fig. 55.13). always aware of the location of the tip of the cannula.

marking. (a) Female patient
a
with multiple scars from
previous abdominal surgeries.
Red marker indicates areas
where liposculpture should be
cautious or avoided. (b) Male
patient. Note plan to feather
lipoplasty to flanks from the
anterior abdomen. Green
marker indicates proposed
incision sites
A moderate infusion rate of 200 mL/min is sufficient before continuing to allow complete diffusion of the
but may be reduced to 150 mL/min in tough fibrous tumescent fluid to all compartments within the subcuta-
areas such as the upper abdomen to reduce discomfort. neous tissues, including the intralobular compartments
Once the tissues swell and become firm, the cannula can around the adipocytes. Since tumescence is a temporary
be brought to the sensitive superficial tissue close to the state, a top-up immediately prior to emulsification of fat
dermis. Superficial infiltration should produce a dim- might be required to reestablish the firmness and turgid-
pled, peau dorange appearance in the overlying skin ity that stabilizes the tissues [19].
(Fig. 55.15). This improves tumescence, fixes the tis-
sues somewhat, and provides a fluid medium for more
delicate, superficial work close to the dermis. Once 55.6.4 Emulsication
tumescence is achieved in the entire anterior abdomen,
skin ports are sutured into the incisions using a 4-0 Once 30 min have elapsed since the end of infiltra-
suture to stem the flow of tumescent fluid and prepare tion, anesthesia, vasoconstriction, and tumescence are
for Vaser-assisted lipoplasty (Fig. 55.16). It is necessary usually sufficient to commence delivery of ultrasound.
to wait 2530 min following the end of infiltration A blunt instrument is used to ensure the port tip is
under the dermis with a patent channel for the Vaser

probes between the port entry and target plane
(Fig. 55.17). An appropriately sized and grooved Vaser
probe is selected depending on the volume of fat
present and whether the tissues are soft or fibrous
(Table 55.2). When there is minimal resistance during
infiltration of tumescent fluid during the initial step,
the author starts with the 3.7-mm three-grooved probe
in the lower abdomen using 80% energy in continuous
mode. When the tissues feel tough and fibrous, the 3.7-
mm two-grooved probe is selected using 8090%
energy. Before the probe is inserted, a wet towel, folded
twice, is placed around the port to avoid inadver-
tent thermal injury should the probe come in contact
with the skin (Fig. 55.18). Gentle but deliberate, long
to-and-fro strokes are made with the operating hand
like the bow movements of a cellist (Fig. 55.19).
Movements should be graceful and continuous with no
torquing which could conduct excessive heat through
the skin port and result in a burn. Some resistance is
Fig. 55.10 For superficial ultrasound-assisted liposuction in
slim patients, soft tissue landmarks such as the linea alba and
felt as the probe gently creates tunnels through the fat,
linea semilunaris are marked. A concavity in the epigastrium is but it should not stop the probe in its path or require
also desirable for an athletic appearance grasping and pushing of the probe with the operating
a b
Fig. 55.11 (a) Superabsorbent drapes placed under the patient prevent pooling of tumescent fluid. (b) The absorbent drapes are
covered with sterile disposable towels
its course, taking care not to tether the dermis by

coming superficial at one point (Fig. 55.20). Once
there is little or no resistance in the deep fat layer, the
probe is brought more superficially for further con-
touring, leaving at least 1 cm of superficial fat to
support the dermis and preserve the delicate subder-
mal vascular plexus (Fig. 55.21). The 4.5-mm probe
and three-grooved 3.7-mm probes, designed for deb-
ulking, should be avoided in the superficial layer.
Similarly, pulsed (Vaser mode) delivery is preferred in
the superficial tissues using lower energies (6070%).
Ultrasound delivery continues from each of the ports
until the entire anterior abdomen is treated. As treat-
ment continues, emulsified fat usually pours from the
skin ports (Fig. 55.22). The endpoint is loss of resis-
tance throughout the treatment planes. This usually
requires 6070 s of ultrasound delivery/100 mL of
tumescent fluid infiltrated. If it is found that access is
Fig. 55.12 Patient in supine position with hands behind head difficult during the procedure without levering the
for lipoplasty of the anterior and anterolateral abdomen probes, no hesitation should be made to place extra
incisions to ensure a complete treatment. As well as
emulsifying fat in the ipsilateral side, the probes are
long enough to pass to the contralateral side, and this
crisscrossing maneuver is important for smooth, even
results. As well as emulsifying all marked areas to a
point of minimal or no resistance, feathering should be
done by emulsifying to a lesser degree in border areas
to create smooth transitions between contours.
55.6.5 Aspiration
Once emulsification is complete, skin ports are removed

and an appropriately sized aspiration cannula is inserted.
The author uses the 3.7-mm VentX cannula for initial
debulking followed by the 3.0-mm cannula for further
refinements and superficial aspiration. The operating
hand moves forwards and backwards radially like the
spokes of a wheel with a continuous graceful move-
ment. Excessive force should not be required. The non-
dominant hand stabilizes the tissues over the cannula
and feels for the tip so that it stays in the correct plane
(Fig. 55.23). The pinch test is performed intermit-
Fig. 55.13 Patient in prone position for treatment of the flanks tently to determine how much superficial fat remains
(Fig. 55.24). Unless skin quality is poor, the use of
hand. If excessive resistance is encountered, energy is Vaser with superficial liposuction allows redraping of
increased to 90%, or an alternative probe is selected. skin and results in excellent skin retraction (Fig. 55.25).
The probe should course at an even depth throughout The endpoint is reached when the desired amount of
a b
c d
e f
Fig. 55.14 Tumescent infiltration of the abdomen. (ae) The above the umbilicus is approached from the upper two incisions,
cannula passes radially around the entire abdomen through ensuring to infiltrate thoroughly right up to the dermis around
the lower and upper incisions. The nondominant hand can be the umbilicus. (h) As infiltration proceeds in every plane, the
used to grasp the tissue over the costal margin or push the ribs tissues become firm and rigid and the overlying skin begins to
down when passing over the ribs to reach the tough fibrous fat blanch due to vasoconstriction. (i) The flow rate can be reduced
of the upper abdomen. (f) Infiltration of the flanks also begins to 150 mL/min for the fibrous upper abdominal region
from the lower incisions with the patient supine. (g) The area
debulking and improvement in body contour has been drainage of tumescent anesthetic fluid, resolution of
achieved based on the pinch test and careful inspection edema, systemic clearance of disrupted fat cells that
from different vantage points in the operating room. remain in the tissues, and skin retraction all contribute
A little under correction is appropriate, since further to improved results during the postoperative period.
g h
Fig. 55.15 Infiltration of the flanks with tumescent fluid. As Fig. 55.16 Skin ports are sutured into the incisions to stem the
the superficial tissues are infiltrated, the skin develops a peau flow of tumescent fluid and prepare for the insertion of the ultra-
dorange appearance sound probes
Fig. 55.17 A blunt probe is inserted to ensure the port is patent Fig. 55.18 A wet towel is folded and placed around the port to
and create an initial channel so the probe can glide easily into the protect the skin from the shaft of the ultrasound probe
correct plane
Although results following Vaser of the abdomen can 55.7 Discussion

be appreciated as soon as 12 weeks following surgery
(Figs. 55.2655.28), the final result with complete skin The introduction of vibration amplification of sound
retraction in the abdomen takes 46 months. energy at resonance (Vaser) technology has brought a
resurgence in UAL for body contouring. Improved
probe design and energy efficiency with Vaser allow a
55.6.6 Postoperative Care significant reduction in power delivery to the tissues
[20]. Although the learning curve is short and the
When all areas are treated, the abdomen and flanks are safety record of Vaser is excellent, specific training in
massaged or milked towards the incision sites to the use of internal ultrasound for lipoplasty and the
expel pools of residual tumescent fluid. Sterile dress- technology itself is essential. Workshops and certifica-
ings are applied to the incisions that are left open to tion programs in the use of Vaser are available for plas-
drain. A tightly fitting compression garment is applied, tic surgeons, dermatologists, and for other specialists
without foam, to keep the surface smooth, help skin who wish to incorporate body contouring procedures
retraction, reduce edema, and provide comfort for into their hospital or office-based setting [21]. Although
the patient. This is worn for 2 weeks day and night, the extra step required for ultrasound-assisted abdomi-
followed by another 2 weeks during the daytime only. nal liposuction adds to the operating time, in the
Antibiotics are continued for 5 days, and analgesia authors view, this is irrelevant given the benefits
is taken as required. When tenderness has subsided, gained. These include more precise contouring, ease of
usually 12 weeks following the procedure, a course use in fibrous tissues, the ability to work superficially,
of manual lymphatic drainage or Endermologie greater skin retraction, and a quick and uncomplicated
helps soften tissues and reduce edema. postoperative recovery.
a b
c d
e f
g h
Fig. 55.19 Vaser emulsification of fat. (ad) Extent of treat- lower incisions. Note the finger placed in the umbilicus to feel
ment over abdomen from one incision. (eh) The probe passes for the probe tip as it emulsifies fat circumferentially around it
forwards and backwards in the deep fat first through upper and
Fig. 55.20 The Vaser probe has tethered the dermis by coming Fig. 55.22 Emulsified fat pours from the skin ports during
superficial or catching fibrous septae. The probe should be with- ultrasound delivery to the tissues
drawn completely to release the irregularity and replaced at the
correct depth
b
Fig. 55.23 Aspiration phase. The skin ports are removed and
the VentX cannula is inserted to remove the emulsified fat. The
nonoperating hand stabilizes the tissues over the cannula tip as it
passes forwards and backwards with minimal effort
Fig. 55.21 (a) Superficial use of Vaser in the abdomen and

(b) flank. The shape of the probe is visible through the skin.
Energy delivery should be reduced, and pulsed mode only should
be used in the superficial layers to avoid thermal injuries
a b
c d
Fig. 55.24 (a-d) The pinch test is performed intermittently during aspiration to check the amount of subcutaneous fat remaining.
Thickness should be the same throughout the abdomen to get even results without asymmetries or irregularities
Fig. 55.25 Superficial liposuction is possible in patients with

normal skin tone and allows more refined sculpting with good
postoperative skin redraping and retraction
a b
Fig. 55.26 (a) Preoperative. (b) Two weeks following abdominal UAL with Vaser under local anesthesia in a male patient. Contours
have improved despite residual postoperative edema
a b
Fig. 55.27 (a) Preoperative. (b) Seven days after UAL. Results continue to improve for up to 4 months following the procedure
a b
Fig. 55.28 (a) Preoperative. (b) Eleven days following UAL with Vaser in a female patient. Skin retraction is usual following
ultrasound delivery to the superficial tissues
References liposuction on adipose tissue: a biochemical approach. Plast

1. The American Society for Aesthetic Plastic Surgery: cos- 10. Zocchi ML (1999) Basic physics for ultrasound-assisted
metic surgery national databank statistics 2009. ASAPS lipoplasty. Clin Plast Surg 26(2):209220
website www.surgery.org (accessed in 2011) 11. Grolleau JL, Rouge D, Chavoin JP, Costagliola M (1997)
2. Flynn TC, Coleman WP III, Field LM, Klein JA, Hanke CW Severe cutaneous necrosis after ultrasound lipolysis: medicole-
(2000) History of liposuction. Dermatol Surg 26(6): gal aspects and review. Ann Chir Plast Esthet 42(1):3136
515520 12. Fodor PB (2004) Personal experience with ultrasound-
3. Coldiron BM, Healy C, Bene NI (2008) Office surgery inci- assisted lipoplasty: a pilot study comparing ultrasound-
dents: what seven years of Florida data show us. Dermatol assisted lipoplasty with traditional lipoplasty. Plast Reconstr
Surg 34(3):285291 Surg 113(6):18521854
4. Housman TS, Lawrence N, Mellen BG, George MN, Filippo 13. De Souza Pinto EB, Abdala PC, Maciel CM, dos Santos
JS, Cerveny KA, DeMarco M, Feldman SR, Fleischer AB F de P, de Souza RP (2006) Liposuction and VASER. Clin
(2002) The safety of liposuction: results of a national survey. Plast Surg 33(1):107115
Dermatol Surg 28(11):971978 14. Garcia O Jr, Nathan N (2008) Comparative analysis of
5. Coleman WP III, Hanke CW, Lillis P, Bernstein G, Narins R blood loss in suction-assisted lipoplasty and third-generation
(1999) Does the location of the surgery or the specialty of internal ultrasound-assisted lipoplasty. Aesthet Surg J 28(4):
the physician affect malpractice claims in liposuction? 430435
Dermatol Surg 25(5):343347 15. Cimino WW (2006) VASER-assisted lipoplasty: technology
6. Hanke CW, Lee MW, Bernstein G (1990) The safety of der- and technique. In: Shiffman MA, Di Giuseppe A (eds) Lipo-
matologic liposuction surgery. Dermatol Clin 8(3):563568 suction principles and practice. Springer, Berlin, pp 239244
7. Fischer A, Fischer G (1976) First surgical treatment for 16. Prendergast PM (2010) Liposculpture of the abdomen in an
molding bodys cellulite with three 5 mm incisions. Bull Int office-based practice. In: Shiffman MA, Di Giuseppe A
Acad Cosm Surg 3:3537 (eds) Body contouring: art, science, and clinical practice.
8. Klein JA (1987) The tumescent technique for liposuction Springer, Berlin, pp 219237
surgery. Am J Cosm Surg 4:236267 17. Ostad A, Kageyama N, Moy RL (1996) Tumescent anesthe-
9. Grippaudo F, Matarese M, Macone A, Mazzocchi M, sia with a lidocaine dose of 55 mg/kg is safe for liposuction.
Scuderi N (2000) Effects of traditional and ultrasonic Dermatol Surg 22(11):921927
18. Yang CH, Hsu HC, Shen SC, Juan WH, Hong HS, Chen CH 20. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA
(2006) Warm and neutral tumescent anesthetic solutions are (2002) Clinical application of VASER-assisted lipoplasty: a
essential factors for a less painful injection. Dermatol Surg pilot clinical study. Aesthet Surg J 22(2):131146
32(9):11191122 21. Master course in VASER liposculpture: European College of
19. Sattler G, Sattler S (2007) Physiodynamic concept of tumes- Aesthetic Medicine (ECAM). Website www.ecamedicine.com
cence. In: Hanke CW, Sattler G, Sommer B (eds) Textbook of (accessed in 2011)
liposuction. Informa Healthcare, Boca Raton, Florida, p 43, 5
Part VI
Extremities and Buttocks
Brachioplasty
56
Sumeet N. Makhijani, Alain Polynice,
Jerome D. Chao, and James G. Hoehn
56.1 Introduction The first aesthetic brachioplasty was described in 1954

by Correa-Iturraspe and Fernandez [2]. However, numer-
Even to this day, brachioplasty continues to be a ous other techniques have been presented over the last
cosmetic challenge to the plastic surgeon. A compro- 50 years in order to produce a more optimal result. Famous
mise must often be made between the presence of surgeons such as Pitanguy and Lockwood have each
unsightly scars and the aesthetic desires of the patient. advanced our understanding of the ideal shape and con-
Nonetheless, secondary to the greater number of tour of the upper extremity, the placement of scars, and the
massive weight loss patients and the popularity of the ability to achieve long-lasting results. In addition, the iso-
procedure, the number of brachioplasties performed lated or concomitant use of liposuction has also been an
has increased every year since 2000 [1]. important adjunct in the brachioplasty procedure.
This atlas chapter on brachioplasty illustrates our
technique for producing an aesthetically pleasing
result. The following pictures are taken in the pre-,
intra-, and postoperative settings with associated figure
S.N. Makhijani (*) legends describing the key points of each step of the
Division of Plastic Surgery, Department of Sugery,
procedure. It has been our experience that attention to
Bassett Medical Center, Cooperstown, NY, USA
e-mail: [email protected] these important details and a focus on a stepwise and
reproducible method will lead to consistently excellent
A. Polynice
Private practice, Williams Center Plastic surgery Specialists, results and a satisfied patient.
Latham, NY, USA
J.D. Chao 56.2 Technique
Private practice, Certified Plastic Surgery of New York, PLLC,
Latham, NY, USA
The preoperative sequence is described in
Figs. 56.156.12.
J.G. Hoehn
The operative sequence is described in
Division of Plastic Surgery, MC-61, Albany Medical College,
Albany, NY, USA Figs. 56.1356.21.
e-mail: [email protected] Postoperative results are in Fig. 56.22.

974 S. Makhijani et al.
Fig. 56.1 Standard anterior preoperative photograph of patient. Fig. 56.4 The patient is asked to contract his or her bicep, and
The patient is in standing position with arm positioned at 90 of the bicipital groove is marked
elbow flexion. Notice the lipodystrophy of the arm, most notably
along the inferior aspect
Fig. 56.2 Use of the pinch test to determine the amount of Fig. 56.5 The mark placed at the bicipital groove is then placed
excess tissue to be resected underneath the index finger, and traction is applied inferiorly on
the skin. A second mark is placed one fingerbreath above the
mark identifying the bicipital groove. This mark is above the
surgeons middle finger in the figure and will serve as the supe-
rior line of resection
Fig. 56.3 Marking performed along the anterior-inferior aspect

of the arm. A similarly placed line is positioned posteriorly
inferiorly. This area will be liposuctioned. Care is taken to
not liposuction too aggressively as this may lead to contour
irregularities
56 Brachioplasty 975
Fig. 56.6 The pinch test is again used to determine the b

amount of tissue to be resected based on the marks. It is critical
to not pinch too tight as this may lead to vertical bands upon
closure
Fig. 56.9 (a) The marks are connected. A line is drawn from
the medial epicondyle to the line above the bicipital groove mark
to the anterior axillary mark. (b) Note the fishtail marking
approaching the anterior axillary line. A vertical line is drawn
within the axilla that continues inferiorly to connect with the
posterior mark as determined by the pinch test
Fig. 56.7 The medial epicondyle of the arm is identified by
palpation and marked
Fig. 56.8 With the arm in standard position and the shoulder
rotated a few degrees anteriorly, a mark is placed inside the ante-
rior axillary fold. This will serve as the superior point of the
axillary incision. By locating this point inside the anterior axil-
lary fold, the axillary scar will be well hidden by the fold
Fig. 56.10 The pinch test is again performed between the b

anterior and posterior lines to verify that a vertical band is not
created, and the appropriate amount of tissue is in the planned
resection
Fig. 56.12 (a) Measurement taken of the width of the area to be

excised on the right arm. (b) Symmetrical measurement taken of
the width of the left arm
Fig. 56.11 Final preoperative markings. Note the circular area

marked on the distal arm adjacent to the medial epicondyle that
denotes an area to be liposuctioned. A similar-sized area is
marked on the posterior upper arm
Fig. 56.13 Intraoperative photograph of the right arm. Note the

preoperative markings as well as the sterile drape utilized
a b
Fig. 56.14 (a) An incision is made near the medial epicondyle as well as on the posterior arm. (b) Infiltration of standard tumescent
solution is carried out, with approximately 500 mL per arm. (c) Completed infiltration
Fig. 56.16 After liposuction has been completed
Fig. 56.15 (a) Liposuction is performed on the anterior upper

arm. A 3- or 4-mm cannula is used. (b) Liposuction is performed
on the posterior and inferior upper arm b
Fig. 56.17 (a) Adair clamps or sharp atraumatic clamps are

placed along the anticipated lines of resection. By doing so, the
surgeon can verify the lack of vertical bands across the arm.
(b) Note the smooth contour of the arm
Fig. 56.18 Incisions are made utilizing the previously described Fig. 56.20 Closure of the superficial fascial system (SFS) is
marks. Electrocautery is used to excise the outlined area. Care is performed using 2-0 Vicryl in a simple buried interrupted
taken to stay above the muscle fascia, thus preserving the neuro- fashion
vascular and lymphatic structures of the arm
Fig. 56.21 Final result after closure of the SFS. Note the
absence of vertical banding which has been resolved by redistri-
b bution of the closure tension. The skin can be closed in a multi-
tude of ways, but the authors approach is closure with 3-0 PDS
suture in a simple buried interrupted fashion followed by the
application of Steri-strips. A light compression dressing is then
applied from elbow to axilla
Fig. 56.19 (a) Sequential reclamping of the incision utilizing

Adair clamps preliminarily closes the area of excision. Failure to
do so in a timely manner could result in intraoperative swelling
resulting in a closure with tension. (b) Note the tendency of vertical
banding to occur. This banding will be resolved upon closure of
the incision
Fig. 56.22 Postoperative views (a) Post-operative up close anterior views. (b) Post-operative up close posterior views. (c) Post-operative
anterior and posterior views of bilateral arms
References plastic-surgery-minimally-invasive-statistics.pdf. Accessed 8

Apr 2009
2. Correa-Iturraspe M, Fernandez JC (1954) Dermolipectomia
1. American Society of Plastic Surgeons. 2000/2007/2008
braquial. Prensa Med Argent 41(34):24322434
National Plastic Surgery Statistics. Available at http://www.
plasticsurgery.org/Media/stats/2008-cosmetic-reconstructive-
Circumferential Para-Axillary
Supercial Tumescent (CAST) 57
Liposuction for Upper Arm
Contouring
Andrew T. Lyos
57.1 Introduction liposuction alone or with minibrachioplasty has offered

a reliable technique for arm contouring which maxi-
Today, preoccupation with fitness has made muscular mizes retraction of the skin [46].
definition in the female a sought after goal [13].
Well-proportioned arms and upper back with muscular
development are the goal of todays physically fit 57.2 Technique
women and prominently featured in todays fashion
[46]. The increase in bariatric surgery for the morbidly 57.2.1 Patient Classication
obese has added to the group interested in aesthetic
improvement of their arms. Rejuvenation of the upper Patients are classified according to the scheme proposed
arms continues to provide a challenge to both the sur- by Teimourian et al. (Table 57.1, Fig. 57.1) [17].
geon and patient. Aging of the upper arm is extremely Category 1: Minimal to Moderate Subcutaneous
variable and depends on numerous factors, the most Fat with Minimal Skin Laxity: Patients generally have
important of which appears to be genetics, the consis- circumferential increase in fat volume but adequate
tency of upper body-toning exercises, obesity and the skin tone and elasticity. These patients do well with
variations of weight throughout life. The net result is circumferential liposuction of the arm and para-axillary
an unaesthetic appearance with skin laxity and lip- area. Relatively small amounts of fat are removed.
odystrophy of various degrees with the most severe Ultrasonic-assisted liposuction is not required.
form frequently designated the bat-wing deformity. Category 2: Generalized Accumulation of Sub-
Traditional liposuction of the upper arms has failed cutaneous Fat with Moderate Skin Laxity: Patients
to meet the expectations of our patients. Commonly generally have an increased volume of fatty tissue cir-
reported undesired sequelae of liposuction of the arms cumferentially as well as noticeable loss of skin elastic-
include worsening of skin laxity and wrinkling, central ity with ptosis. Circumferential liposuction encourages
over-ressection on the inferior brachial border, and the skin tightening. Minibrachioplasty may be required.
lack of regional harmony [79]. Brachioplasty proce- Ultrasonic energy can encourage enhanced skin retrac-
dures improve contour but are frequently unacceptable tion frequently reducing the need for skin excision.
to our patients due to the undesired sequelae of wid-
ened, misplaced or hypertrophic scars, contour irregu- Table 57.1 Upper arm contouring classification
larities, numbness, and skin necrosis [1016]. CAST
Category 1 Minimal arm fat with good skin
tone
Category 2 Moderate fat with moderate skin
A.T. Lyos laxity
Division of Plastic Surgery and the Bobby R. Alford
Category 3 Marked excess skin and fat
Department of Otorhinolaryngology and Communicative
Sciences, Baylor College of Medicine, Houston, TX, USA Category 4 Minimal to moderate fat and
e-mail: [email protected] marked excess skin

982 A.T. Lyos
a b
c d
Fig. 57.1 Upper arm contouring categories: (a) Category 1, (b) Category 2, (c) Category 3, (d) Category 4
Category 3: Generalized Obesity and Extensive the greater is the potential for skin retraction, thereby
Skin laxity: Patients generally have more significant reducing the length of the brachioplasty scar.
lipodystrophy and skin laxity. Obese patients typically
accumulate a large volume of fat in the para-axillary
region and upper arm. Ultrasonic-assisted circum- 57.2.2 Preoperative Marking
ferential liposuction maximizes the potential for ade-
quate skin retraction. Minibrachioplasty confided to The upper extremity can be conceptualized as consisting
the axilla is frequently required for group 3 individu- of nine zones (Fig. 57.2). Distal forearm, upper back,
als. The larger the volume of fat removal, the better the deltoid, axilla, and lateral pectoral extensions are
prognosis for skin retraction with CAST liposuction included for regional harmony. Patients requesting arm
and the shorter the brachioplasty scar if required. reduction were marked in the preoperative area in stand-
Category 4: Minimal Subcutaneous Fat and Exten- ing position. The arms were marked in abducted posi-
sive Skin Laxity: These individuals demonstrate marked tion with 90 flexion at the elbow. Preoperative markings
skin laxity and depletion of subcutaneous fat. Full bra- divide the arm and contiguous para-axillary regions
chioplasty is capable of producing an aesthetically into nine zones (Fig. 57.3). For individuals with exces-
pleasing contour of the arm and straight inferior bra- sive skin laxity in addition to lipodystrophy, a minibra-
chial boarder. The surgical scars can be detouring, par- chioplasty is designed. Puncture site is marked at the
ticularly in those individuals who have Fitzpatrick anterior and posterior axilla, medial and lateral distal
IIIVI skin type and those who scar poorly. CAST arm 1.5 cm proximal to the olecranon. Infrequently, a
liposuction combined with a minibrachioplasty con- puncture site is marked in the middle third of the poste-
fined to the axillae can produce improvement of the rolateral arm. Preoperative marks were checked with
upper arm with some residual skin laxity, particularly the arms in adducted relaxed position to ensure appro-
distally. As noted, the larger the volume of fat removed, priate placement for minimal deductibility.
57 Circumferential Para-Axillary Superficial Tumescent (CAST) Liposuction for Upper Arm Contouring 983
a a
Fig. 57.3 Preoperative marking anterior and posterior left arm:

(a) Anterior. (b) Posterior
may be increase by the addition of 150 mL of 1%

lidocaine (1,500 mg) and 3 mL of 1:1,000 epinephrine.
The surgeon must be aware of the dose of lidocaine
being administer and keep the total lidocaine dose well
below 35 mg/kg [18, 2123]. The volume of infiltrate is
typically 8001,500 mL per arm.
Fig. 57.2 Right arm para-axillary area with nine anatomical 57.2.4 Position
zones: (a) Anterior. (b) Posterior
Arm contouring in the lateral decubitus position is
preferred. Although arm contouring can be performed
57.2.3 Anesthesia
in the prone and supine position, access to the para-
axillary region is limited. The lateral decubitus posi-
CAST liposuction of the arms may be performed under
tion allows for circumferential treatment.
local or general anesthesia. It is the authors preference
to treat the arms under general anesthesia while per-
forming liposuction of multiple areas. Superwet or 57.2.5 Surgical Technique
tumescent anesthesia is utilized for hemostasis, com-
partment magnification, and postoperative analgesia Arm contouring is most frequently performed as part of
[18, 19]. A greater volume of infiltration is utilized to total body contouring. When done so, the procedure is
minimize the thermal effect if ultrasonic-assisted lipo- performed in an AAAA certified surgery center with
suction (UAL) is required [20]. For procedures per- the assistance of a board-certified anesthesiologist. The
formed under general anesthesia, to each 3 L of lactated patient is prepped in standing position to the level of the
ringers are added 50 mL of 1% lidocaine (500 mg) and axilla. She is then placed on the operative table on a bean
3 mL of 1:1,000 epinephrine. For procedures performed bag in supine position. After achieving adequate general
under local anesthesia, the concentration of lidocaine endotracheal anesthesia, she is draped in a sterile fashion.
984 A.T. Lyos
a The patient is turned to the lateral decubitus position,

and an axillary roll is placed. The arm and upper fore-
arm are prepped with Betadine and wrapped in a sterile
towel from the elbow down, covering IV tubing and
anesthesia-monitoring devices (Fig. 57.4). The arm is
then place on a mayo stand padded with a pillow and
covered with a sterile towel. The arm is freely mobile,
offering the advantage of access to all incision sites. The
incisions are made with an 11 blade. Tumescent fluid is
infiltrated under pressure to achieve a peau dorange
appearance. In the lateral decubitus position, typically,
the back, hips, thighs, and buttocks are treated before the
b arms to allow additional time for vasoconstriction.
The arm is conceptually divided into three regions
anteromedial, anterolateral, and posterolateral (Fig. 57.5).
CAST liposuction of the arms is site specific with pre-
tunneling and/or deep liposuction, superficial, or all-layer
liposuction. Circumferential pre-tunneling is performed
with a 3-mm Mercedes cannula through multiple access
sites. Ultrasonic-assisted liposuction (UAL), when uti-
lized, is performed with a Mentor Contour Genesis
(Mentor Corp., Dallas, TX) utilizing a 20-mm solid-tip
cannula with a generator setting of 75. Treatment is
Fig. 57.4 Position of the upper arm. (a) Preoperation. limited to 23 min for the posterolateral and para-axillary
(b) Positioning and draping
region utilizing the posterior axillary incision.
Anterolateral
Anteromedial
Fig. 57.5 Cross section Posterolateral

of the left arm demonstrating
three anatomical regions:
medial, anterolateral, and
posterolateral
a a
b b
Fig. 57.6 CAST liposuction of the anteromedial upper arm Fig. 57.7 CAST liposuction of the anterolateral upper arm
through (a) anterior axillary incision and (b) distal incision through (a) anterior axillary incision and (b) distal ulnar incision
Circumferential liposuction is performed most aggres- 57.2.5.3 Posterolateral

sively in the posterolateral (one-third), less aggressively Ultrasonic energy is delivered through the posterior
in the anterolateral (one-third), and least aggressively in axillary incision as described. All-layer liposuction is
the anteromedial (one-third). performed with deep, superficial, and subdermal lipo-
suction frequently required (Fig. 57.8). A 3 20-mm
57.2.5.1 Anteromedial Mercedes cannula is used initially. For larger volume
Pre-tunneling is performed from the olecranon and extractions, a 4 30-mm cannula enables access to the
axillary sites longitudinally (Fig. 57.6). If the pinch entire length of the posterolateral compartment. Avoid
test is 10 mm or less, only pre-tunneling is done. No over-ressection of the central region (zones 2 and 3) by
liposuction is performed under thin, anteromedial skin checking the pinch test frequently.
due to the propensity for wrinkling, especially near the
axilla. Cross tunneling and/or deep suctioning is per- 57.2.5.4 Para-Axillary
formed from the middle third of the arm to create a Ultrasonic-assisted liposuction is particularly useful
final pinch test of 1015 mm. for the deltoid region, and upper back (zones 7 and 8).
No ultrasonic energy is delivered to the axilla proper
57.2.5.2 Anterolateral (zone 6). The fat is evacuated with 3- and 4-mm
Superficial liposuction from the anterior axillary site, Mercedes cannulas (Fig. 57.9). More aggressive lipo-
dorsoradial arm, and mid arm is performed with a suction is performed with a 3-mm Gasperotti to encour-
3 20-mm Mercedes cannula (Fig. 57.7). The final age the formation of a confluent layer of collagen
pinch test should be 914 mm. forming circumferentially around the arm connecting
986 A.T. Lyos
a a
b b
Fig. 57.8 CAST liposuction of the posterolateral upper arm Fig. 57.9 CAST liposuction of the para-axillary upper arm
through (a) posterior axillary incision and (b) distal radial through (a) posterior axillary incision and (b) anterior axillary
incision incision
to the trunk. The axilla, deltoid, and lateral pectoral used as reported previously [46]. The Reston foam
extensions are treated with a 3-mm Mercedes cannula is removed the following day. Non-adherent Reston
to minimize wrinkling. The suture sites are closed with or Lipofoam is applied, and a surgical compression
a single 5-0 nylon suture. garment which extends below the elbow is placed.
The Reston may be kept in place for up to 1 week
depending on the degree of skin laxity. The compres-
57.2.6 Postoperative Care sion garment is worn at all times for 6 weeks. For more
severe skin laxity, an additional 4 weeks of compres-
Care is taken in applying Reston foam. The author pre- sion at least 12 h/day is recommended. The sutures are
fers Reston foam to the non-adherent Lipofoam for removed at 67 days. Frequent inspection for seromas
CAST liposuction of the arms. The adherent side to is required for 6 weeks postoperatively. Persistent
the Reston is covered with Bacitracin ointment or postoperative pain most frequently represents a seroma
Vaseline to allow adherence yet minimize the risk of which should be treated with serial aspiration and
blistering. With the arm extended, the circulating nurse compression. Painful bands or scar tissue or focal nod-
grasps the anterolateral skin to elevate the dependent ules representing fat necrosis are treated with massage
posterolateral skin, and the sheet of Reston is placed and microinjection of 0.2 cc triamcinolone (2 mg/mL).
under the posterolateral skin to re-drape sagging skin Injection is performed deep to avoid thinning of the
smooth along the posterior arm. Wrinkling is directed skin. Limited range of motion of the shoulder due to
anterolaterally. The arm is wrapped with a 4-in. ace axillary tightness is treated with massage and range of
wrap from the elbow proximally. Drains are no longer motion exercises.
57.3 Minibrachioplasty Technique confluence (lattice) of collagen deposition during

healing which promotes regional harmony. Small can-
The minibrachiolasty incision is marked in the nulas (34 mm) are utilized to minimize the risk of
preoperative area with the arm abducted 90 from the contour irregularities. Liposuction is performed from
trunk. The crease marking the junction of the medial multiple directions in a multilayered approach. Circum-
arm with the axilla is located. The skin to be excised is ferential liposuction is performed most aggressively in
marked with a symmetric ellipse of tissue measuring the posterolateral (one-third), less aggressively in the
46 cm by 1215 cm in length. All attempts are made anterolateral (one-third), and least aggressively in the
to confine the resulting scar to the axilla and avoid anteromedial (one-third). For this reason, the majority
delectability, particularly posterior. The procedure can of the delivery of the ultrasonic energy and the extrac-
be performed in lateral decubitus position; however, tion of fat are done in lateral decubitus position through
the author prefers to perform both minibrachioplasties a puncture site in the posterolateral axillary fold [46].
in supine position following the completion of the Liposuction through the posterior axillary incision min-
CAST liposuction. The dermatolipectomy is per- imizes the risk of over-ressection posterolaterally in
formed initially leaving the superficial fascia intact to zones 2 and 3 and allows for excellent access in the
avoid injury of the vital structures located in the axilla. axilla and para-axillary region (zones 6, 7, and 8).
Metzenbaum scissors are then used, spreading in the For individuals with moderate fat and moderate skin
direction of the axillary vessels to identify the axillary laxity (Category 2), the application of ultrasonic energy
vein. After locating the axillary vessels, superficial with tumescent infiltration allows for compartment
fascial system suspension sutures are placed of 2-0 magnification and greater fat removal. Extraction of the
Vicryl. Four to five sutures are pre-placed and tagged emulsion with small cannulas results in a smoother
prior to securing. Care is taken to incorporate the appearance and enhanced skin retraction. Extraction
superficial layer of axillary fascia to prevent migration with small cannulas is done utilizing a multilevel, mul-
of the scar [14, 2426]. Advancement is performed tidirectional approach. The majority of the liposuction
centrally to minimize standing cones. Standing cones is done in the posterolateral arm where there is gener-
are excised anteriorly, if required. The subcutaneous ally the greatest adiposity. The skin of the posterior lat-
tissue is closed with 3-0 Vicryl. A subcuticular suture eral arm is thickest and has the greatest potential for
of 4-0 clear PDS is placed. Interrupted 4-0 nylon contraction. Care is taken to avoid over-resection in the
sutures are placed to re-enforce the incision and thin-skinned areas of the anterolateral and anterome-
removed at 56 days. Postoperative care is similar to dial arm. This is particularly important in individuals
CAST liposuction of the arms with the exception that with photoaged Fitzpatrick I and II skin types, to mini-
range of motion of the arms, particularly abduction, is mized worsening of wrinkles and ptosis in these areas.
limited for 46 weeks following surgery. For individuals with marked excess of skin and fat
(Category 3), CAST liposuction alone may provide the
degree of correction. In general, the greater the amount
57.4 Discussion of fat removal, the less likely skin excision will be
required. Skin excision in the form of minibrachio-
CAST liposuction of the arms differs from traditional plasty offers the advantage of tightening of the skin in
(standard) tumescent liposuction of the arms as follows. zones 1 and 2 in the anteromedial and posterolateral
Traditional tumescent liposuction of the arms involves skin with an incision hidden in the axilla. No improve-
deep liposuction over the posterolateral arm feather- ment in the skin tightness of the skin anteromedially
ing of anteromedially and anterolaterally without cir- or of the skin in zones 3 and 4. The scar of the mini-
cumferential treatment and without ultrasonic energy. brachioplasty is in general well tolerated as it rarely
Standard tumescent liposuction has the potential to widens or becomes hypertrophic. Although additional
worsen skin laxity and sagging. CAST liposuction com- skin can be excised, the dimension of the excised skin
bines several principles to obtain more predictable aes- needs to be confined to the axilla, particularly posteri-
thetic results. Circumferential treatment of the upper orly, to avoid visibility from behind. An additional
arm and para-axillary region creates a subcutaneous advantage is that excised skin reduces the hair-baring
988 A.T. Lyos
skin of the axilla and reduces hydrosis. As the distal wrinkling of the skin of their arms, just as they will
skin margin of the excision is longer than the proximal have wrinkling elsewhere. They will generally accept
margin, early postoperative wrinkling is common, an imperfect result which appears natural. CAST lipo-
which improves within several months. Reported vari- suction provides improvement which the patients per-
ations of modified brachioplasties or limited incision ceive as being more natural than the improvement
techniques leaving scars extending out of the axilla resulting from a brachioplasty with anteromedial scar-
have been reported [2, 17, 2426]. Extension may be ring of the arm. It is important to avoid over-resection
in the form of a T or an L or may extend posteriorly to anteromedially in zone 4 which results in wrinkling
the back. These reported techniques relied primarily above the elbow. Performing CAST liposuction and
on skin excision rather than liposuction. minibrachioplasty does not obviate traditional brachio-
Individuals with minimal to moderate fat and plasty in the future. For those with minimal to moderate
marked excess of skin (Category 4) who are seeking fat and extreme skin laxity, traditional brachioplasty
arm rejuvenation are increasing due to the prevalence may provide the best alternative. Individuals well suited
of bariatric surgery. Elderly women will invariably have for traditional brachioplasty are those over the age of

26-year-old female. (b) Nine
months after CAST
liposuction with removal
of 600 mL of fat on the
right and 550 mL of fat
from the left

b
60 years who are Fitzpatrick I or II skin types without fixing it with Reston foam facilitating re-draping and
personal or family history of abnormal scarring. Dis- stabilization of the skin [4, 5, 8]. Weekly checks for
advantages of traditional brachioplasty involve scar- seromas are required for the first 4 weeks. Seroma for-
ring, possible delayed healing, and numbness. Great mulation is decreased with reduced duration of ultra-
care must be taken in the discussion of the risks involved sonic energy delivery and the use of a greater number
in a traditional brachioplasty and in the informed con- of liposuction access sites. Postoperative compression
sent process [14, 16]. is required for 6 weeks for optimal aesthetic results.
Meticulous postoperative care is vital to obtaining The primary attraction of CAST liposuction with or
good results. Compression is essential to achieve accu- without minibrachioplasty is enhanced skin retraction
rate re-draping of the skin. Most frequently, the skin is with minimal scarring compared to a traditional brachi-
loose and sagging posteriorly. Pulling the skin antero- oplasty (Figs. 57.10 and 57.11). Extensive preoperative
laterally to smooth any wrinkles anterior medially then education is advisable. Realistic expectations should be
990 A.T. Lyos
stressed in terms of the amount of improvement which 57.5 Conclusions

can be anticipated. Photographs of patients who have
undergone liposuction, with and without minibrachio- Liposuction of the arms in patient with aged and flac-
plasty, as well as full brachioplasty should be available cid skin has traditionally produced disappointing
to demonstrate realistic results and sites of surgical results. CAST liposuction was developed to maximize
scars. A financial policy should be spelled out prior to skin retraction and regional harmony by compartment
the procedure regarding financial obligations should a magnification followed by circumferential treatment
secondary procedure be required. of the arm and adjacent aesthetic units. Rigorous

55-year-old female. (b) Five
CAST liposuction with
removal of 800 mL of fat on
the right and 800 mL of fat
from the left

b
patient selection and education are essential as the seromas and wrinkling are not uncommon. The patient
goal of CAST liposuction is improvement, not perfec- must be aware that there may be a need for a second-
tion. The postoperative care is demanding in order to ary surgical procedure in the form of a modified bra-
achieve accurate skin re-draping requiring complete chioplasty to treat redundant skin in the axilla and
patient compliance. Minor complications including upper arm.
992 A.T. Lyos
References 15. Pascal JF, Le Louarn C (2005) Brachioplasty. Aesthetic

Plast Surg 29(5):423429
16. Knoetgen J, Moran SL (2006) Long-term outcomes and
1. American Society of Plastic Surgeons (2009) 20002008
complications associated with brachioplasty: a retrospective
National plastic surgery statistics. Available at: http://www.
review and cadaveric study. Plast Reconstr Surg 117(7):
plasticsurgery.org/media/stats/2008 US-cosmetic-plastic-
22192223
surgery-minimal invasive-statistics.pdf. Accessed 25 Apr 2009
17. Teimourian B, Malekzadeh S (1998) Rejuvenation of the
2. Vogt PA, Baroudi R (1994) Brachioplasty and brachial
upper arm. Plast Reconstr Surg 102(2):545551
suction-assisted lipectomy. In: Cohen M (ed) Mastery of
18. Klein JA (1990) Tumescent technique for regional anesthe-
plastic and reconstructive surgery, 1st edn. Little, Brown,
sia permits lidocaine doses of 35 mg/kg for liposuction.
Boston, pp 22192236
3. Lillis PJ (1999) Liposuction of the arms. Dermatol Clin
19. Rohrich RJ, Beran SJ, Fodor PB (1997) The role of sub-
17(4):783797
cutaneous infiltration in suction assisted lipoplasty. Plast
4. Gilliland MD, Lyos AT (1997) CAST liposuction of the arm
improves aesthetic results. Aesthetic Plast Surg 21(4):225229
20. Kenkel JM, Robinson JB, Beran SJ et al (1998) The tissue
5. Gilliland MD, Lyos AT (1997) CAST liposuction: an alter-
effects of ultrasound assisted lipoplasty. Plast Reconstr Surg
native to brachioplasty. Aesthetic Plast Surg 21(6):398402
102(1):213220
6. Gilliland MD (2002) Ultrasound-assisted circumferential
21. Klein JA (1993) Tumescent technique for local anesthesia
para-axillary superficial liposuction effect on arm contour.
improves safety in large volume liposuction. Plast Reconstr
Oper Tech Plast Reconstr Surg 8(2):100101
Surg 92(6):10991100
7. Illouz YG, DeVillers YT (1989) Body sculpting by lip-
22. Matarasso A (1999) Lidocaine in ultrasound assisted lip-
oplasty. Churchilll Livingstone, Edinburg, pp 279281
oplasty. Clin Plast Surg 26(3):431439
8. Schlesinger L (1990) Suction assisted lipectomy of the upper
23. Samdal F, Amland PF, Bugge JF (1994) Plasma lidocaine
arm: a four cannula technique. Aesthetic Plast Surg 14:271274
levels during suction-assisted lipectomy using dilute lido-
9. Grazer FM (1992) Atlas of suction assisted lipectomy.
caine. Plast Reconstr Surg 93(6):12171223
Churchill Livingstone, New York, pp 139140
24. Richards ME (2001) Minimal-incision brachioplasty: a
10. Correa-Iturraspe M, Fernandez JC (1954) Dermolipectomia
first-choice option in arm reduction. Aesthet Surg J 21(4):
brachuial. Prensa Med Argent 41(34):24322436
301308
11. Baroudi R (1975) Dermolipectomy of the upper arm. Clin
25. Richards ME (2005) Reassessing minimal-incision brachio-
Plast Surg 2:485494
plasty. Aesthet Surg J 25(2):175179
12. Guerrero-Santos J (2004) Brachioplasty. Aesthet Surg J 24:
26. Abramson DL (2004) Minibrachioplasty: minimizing scars
16161619
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13. Pitanguy I (1980) Aesthetic plastic surgery of the upper and
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14. Lockwood T (1995) Brachioplasty with superficial fascial
system suspension. Plast Reconstr Surg 96(4):912920
Thigh Lift
58
58.1 Introduction
The thighs are a remarkably challenging area to obtain

esthetical and functional satisfaction from a patients and
from a surgeons standpoint. Skin laxity in the medial
thighs is one of the first signs of aging in the thighs. The
medial thigh is characterized by early relaxation and
very poor retraction, even after liposuction. The develop-
ment of these contour alterations can be accredited to
lack of exercise, body weight variations, and genetics.
These deformities are very difficult to correct with diet
and exercise alone. A full analysis of the patients defor-
mities and degree of laxity must be undertaken prior to
operative planning. Liposuction can be utilized in patients
with excess subcutaneous tissue without skin laxity.
Aggressive liposuction can result in contour abnormali-
ties. Yet, liposuction often fails to address the thin nature
of the medial thigh skin and its poor retraction.
A combination of removal of subcutaneous tissue
and excision of skin is often necessary to produce opti- Fig. 58.1 Dotted line depicts deep fascial structures for medial
mal results. An isolated horizontal crescenteric medial thigh lift anchoring, including ischial periosteum, Colles fascia,
thigh lift is reserved for patients with isolated medial pubis, and inguinal ligament
thigh ptosis and vertical skin laxity. If the patient also
has circumferential or horizontal skin laxity, then a thigh, the medial thigh lift must be combined with a
vertical extension should be added to the thigh lift. circumferential body lift or a spiral lift.
When there is circumferential thigh ptosis, which The classic medial thigh lift was characterized by
necessitates lifting of the anterior, lateral, and posterior multiple problems, including inferior migration and
widening of scars, deformity of the vulva and labia by
traction, and early recurrence [1, 2]. The use of deep
anchoring sutures to the deep layer of the superficial
S.O. Sozer (*) F.J. Agullo
fascia of the perineum, or Colles fascia, has eliminated
Department of Surgery, Texas Tech University Health Sciences
Center, El Paso, TX, USA many of these problems [3]. Furthermore, the anterior
extensions of the thigh lift can be anchored to the pubis
El Paso Cosmetic Plastic Surgery Center, El Paso, TX, USA
e-mail: [email protected]; and inguinal ligament, and the posterior extensions to
[email protected] the ischial periosteum (Fig. 58.1).

994 S.O. Sozer and F.J. Agullo
Fig. 58.2 Spiral lift. Tissue

excised extends from the
inner inside crease of the
buttocks, along the inguinal
crease and anterior iliac spine,
spiraling above the buttocks
and meeting the contralateral
incision at the sacrum
The vertical thigh lift involves a significant visible 58.2 Technique

scar on the extremity extending from the growing to
the knee. A transverse scar component is usually nec- 58.2.1 Preoperative Markings
essary and depending on the patient may be extended
only anteriorly or posteriorly. Some patients, espe- Preoperative markings are a crucial component to
cially postbariatric weight loss patients, may require successful surgery and to achieving desired results.
an anterior and posterior resection resulting in a Patients are marked preoperatively in standing posi-
T-shaped scar. tion with the knees apart. The symmetry of the inci-
A spiral lift provides a total thigh lift. Through sions is evaluated while patient is standing.
a single incision easily concealed by underwear, the When performing only a medial thigh lift, the inguinal
procedure results in a medial, anterior, lateral, and crease and inferior buttock crease are marked. This is where
posterior thigh lift (Fig. 58.2). As originally the scar will remain after the procedure is completed. The
described by the authors, it is often combined with extent of the resection is then calculated by lifting the
autologous buttock augmentation with a dermal fat medial thigh with a standard pinch test (Fig. 58.3).
flap [4]. When adding a vertical component to the proce-
It is not within the realms of this chapter to discuss dure, a line is drawn slightly posterior to the medial
circumferential body lifts, but this procedure can easily midline of the thigh extending from the inguinal crease
be added to a medial or vertical thigh lift and performed to the knee. This marks where the final scar will be
at the same time. The combination also results in a located. By marking it slightly posterior, the patient
total thigh lift and is often utilized in massive weight enjoys the psychological benefits of not seeing the scar
loss patients. when looking in the mirror. The length of the vertical
58 Thigh Lift 995
Fig. 58.3 Patient with

massive weight loss, with
a b
isolated medial thigh ptosis.
Medial thigh crescenteric lift
markings are illustrated. (a)
anterior and (b) posterior
views. Patient also has
markings for circumferential
abdominoplasty with
autologous buttock
augmentation
Fig. 58.4 Massive weight

loss patient with vertical and
a b
horizontal thigh skin laxity.
Markings for vertical thigh
lift are illustrated with an
anterior horizontal medial
thigh component. (a) anterior
and (b) posterior views.
Patient also has markings for
circumferential
abdominoplasty with
autologous buttock
augmentation
scar can be modified according to the patients defor- posterior to the line using the pinch test. Care must
mities and at times, may be made into a short scar. be taken not to exaggerate the amount of resection,
The extent of resection is then marked anteriorly and allowing for intraoperative swelling (Fig. 58.4).
a b c
Fig. 58.5 Preoperative markings. Tissue to be excised is marked in red ink, the dermal fat flaps are marked in dark blue ink, and
areas of liposuction marked with blue concentric circles. (a) anterior, (b) lateral, and (c) posterior views
For a spiral lift, a line is drawn starting at the lateral excised down to the gluteus maximus fascia and con-
portion of the inferior gluteal fold, extending medially nective tissue of the ischial tuberosity. The inferior
to the upper inner thigh, proceeding interiorly and ante- edge of the wedge excision is then anchored in a
riorly through the pudendal region, moving along the cephalad and medial direction to the connective tissue
inguinal line through the anterior iliac spine to the pos- surrounding the ischial tuberosity and gluteus maxi-
terior iliac crest, above the buttocks, and to the sacrum. mus fascia with 2-0 polydioxanone (PDS). The objec-
At the sacrum, the line from the contralateral side is tive is to lift the posterior thigh and shorten and elevate
joined forming a V. If the patient does not require a but- the inferior gluteal fold. The skin and subcutaneous
tock lift, the lines do not have to be joined at the sacrum, tissues are then closed in layers.
but should extend posteriorly to allow for sufficient lat- If performing a vertical component, the area marked
eral thigh lift. The pinch method is utilized to estimate to be excised is liposuctioned aggressively after infil-
the amount of possible skin resection (Fig. 58.5). trating with tumescent solution. The liposuction does
not extend past the area to be excised. The posterior
line is then incised, and the skin is raised anteriorly.
58.2.2 Surgical Technique Due to the aggressive liposuction, only a network of
connective tissue is visible, making elevation of the
58.2.2.1 Medial and Vertical Thigh Lift skin easy and preserving lymphatics and vessels. This
The patient is first placed in the prone position under also allows for preservation of the greater saphenous
general anesthesia with the legs abducted. Compression vein. The authors do not commit to the previously
hoses and sequential compression devices are placed marked anterior line of resection. Instead, tailor tack-
for induction to avoid venous thrombosis. The medial ing is done to avoid overresection. More often than
thigh is liposuctioned in the standard fashion after not, the anterior line of resection is lesser than the ini-
tumescent infiltration when indicated. tially marked one due to intraoperative swelling.
The wedge excision of the inferior gluteal fold and The patient is then turned supine, reprepped, and
posterior portion of the medial thigh is accomplished redraped, again with the legs abducted shoulder-width
and left for completion once the patient is rotated to apart. The medial thigh lift is liposuctioned in
the supine position. Skin and subcutaneous tissue are the standard fashion after infiltration of tumescent
58 Thigh Lift 997
solution. If performing a vertical extension, liposuc- previously described. Thereafter, resection of a crescent
tion is not performed outside of the area to be excised. of redundant skin and fat at the superior medial thigh
The anterior medial thigh crescent of skin and spiraling from the flank towards the infragluteal fold is
subcutaneous tissue is excised, taking care to preserve made, thus joining the previous flank and infragluteal
the deep fat and lymphatics. The inferior margin of excision sites. The Lockwood retractor is used for
the incision is then suspended superiorly from the limited undermining of the anterior and lateral thigh in
superficial fascial system to the superficial perineal an inferior fashion deep to the superficial fascial sys-
(Colles) fascia medially, inguinal ligament anteriorly, tem. The medial thigh is not undermined. The medial
and periosteum of the anterior superior iliac spine thigh lift is then completed as described above.
laterally with polydioxanone (PDS). The superior
and inferior edges are then approximated in a layered 58.2.2.3 Postoperative Care
fashion with subdermic running absorbable polyglac- Immediately after surgery, a compressive garment is
tin 910 (3/0 Vicryl) and subcutaneous running absorb- used and kept for 4 weeks. Patients are encouraged to
able poliglecaprone 25 (4/0 Monocryl). use knee high compression stockings to decrease edema.
Patients are allowed to rest in bed in the most comfort-
58.2.2.2 Spiral Lift able position for them, usually supine. Ambulation is
The patient is placed in the prone position under general started the same day or the next morning depending on
anesthesia with legs abducted to expose the medial thigh concurrent procedures. Sitting is not restricted.
and to maximize lateral resection. Traditional deep and The patient may return to normal activities between 1
superficial liposuction of the flanks and back is performed and 2 weeks, depending on concurrent procedures and
after the subcutaneous tissue is infiltrated with tumescent the extent of the medial thigh lift. Patients often complain
solution consisting of 1 L of Hartmanns solution with of pain at the deep anchor points of the medial thigh lift,
1 mg of epinephrine and 10 mL of 1% lidocaine. and reassurance and pain medications are suggested.
The posterior portion of the medial thigh lift is accom- Complications that can occur after thigh lift include
plished in the same fashion as previously described. delayed wound healing, scar migration, seromas,
The marked supragluteal and flank wedges of skin dehiscences, lymphoceles, bad scarring, infection,
are resected down to the fascia, and the gluteal flaps bleeding, nerve compression, neuromas, and sensory
are deepithelialized. The inferior border of the flap is loss. Dehiscence can be avoided with good technique
dissected at an oblique angle so that the base of the flap and tension-free closure. This is usually a result of
lies more inferior to allow for greater caudal mobility. overresection of tissues. Scar migration is avoided
The superior, medial, and lateral borders are dissected with solid anchoring to Colles fascia, inguinal liga-
in a plane perpendicular to the underlying fascia. ment, and ischial periosteum. Seromas and lymphoce-
A pocket is then created for insertion of the flap by les present 46 weeks after surgery and typically
undermining the buttock skin and subcutaneous tissue resolve with aspiration and localized pressure. The use
caudally in the plane above the fascia, extending it a of liposuction of the area to be excised has dramati-
sufficient length to reach the inferior gluteal crease. cally decreased the incidence of lymphoceles. Sensory
The superior aspect of the flap is then detached in an loss is traditionally limited to the area around the scar
intramuscular plane inferiorly until the flap can be and resolves over a period of 6 months. Some patients
rotated caudally 180 into the pocket and anchored may require an additional more limited reduction in
to the fascia with polyglactin 910 (3/0 Vicryl) suture. the future due to recurrence of excess skin due to the
The remaining buttock skin is then pulled superi- poor elasticity in massive weight loss patients.
orly over the flap and a drain is placed in each side.
The lateral thigh is undermined inferiorly deep to the
superficial fascial system using a Lockwood retractor. 58.3 Conclusions
The superficial fascial system is then approximated
with polyglactin 910 (0 Vicryl), and the skin and sub- Contour surgery of the thighs represents a challenging
cutaneous tissue is closed in a layered fashion. area for the surgeon. Today, many procedures and
At this point, the patient is turned to the supine combinations exist to improve the contour of the
position with the legs abducted to expose the medial thighs. Proper patient and technique selection is key
thighs. Liposuction is performed where necessary as in obtaining the desired results (Figs. 58.658.8).
Fig. 58.6 (Left) Before

surgery. (Right) Following
medial thigh lift in
combination with
circumferential body lift
Fig. 58.7 (Left) Before

surgery. (Right) Postoperative
after vertical thigh lift with
full medial thigh lift and
58 Thigh Lift 999
Fig. 58.8 (Left) Preoperative.

(Right) Postoperative after
a
spiral lift. (a) Anterior, (b)
Lateral, and (c) posterior
views
b

c
Techniques such as deep fascial anchoring and aggres- 3. Lockwood T (1988) Fascial anchoring technique in medial
sive liposuction of the areas to be excised have thigh lifts. Plast Reconstr Surg 82(2):299304
4. Sozer SO, Agullo FJ, Palladino H (2008) Spiral lift: medial
decreased the incidence of complications often associ- and lateral thigh lift with buttock lift and augmentation.
ated with thigh contouring procedures. Aesthetic Plast Surg 32(1):120125
References
1. Lewis J (1957) The thigh lift. J Int Coll Surg 27(3):330334
2. Planas J (1975) The crural meloplasty for lifting of the
thighs. Clin Plast Surg 2:495503
Buttock Lift
59
59.1 Introduction of moderately increasing buttocks volume, but does

not directly address ptosis [815]. Both techniques
The trunk, buttocks, and thighs represent areas of achieve rounder and fuller buttocks, but are not appli-
increased patient interest and surgical technique modi- cable in the presence of ptotic, long, or sagging but-
fication. Recently, there has been an increase in patients tocks. Options for buttocks lifting include the upper
seeking buttocks augmentation and contour restora- lift [16, 17], dermo-tuberal-anchorage lower lift [18],
tion. The multiple indications for buttock lifting lateral lift, and medial butterfly lift [18].
include ptosis, excess skin, asymmetry, double infra- The inferior gluteal lift described by Gonzalez [19]
gluteal fold, and long buttocks. A buttock lift can be is a very powerful and effective tool in the appropriate
achieved with several different techniques depending candidate. It improves the inferior gluteal fold and the
on the patients contour and needs. skin and subcutaneous tissue of the superior posterior
When performing buttock contouring procedures, thigh. The procedure is indicated in patients with mild
one must keep in mind the main factors that comprise buttock ptosis with excess skin and subcutaneous
ideal buttocks. Endpoints considered aesthetically tissue in the inferior gluteal fold or banana fold. It
pleasing include maximum gluteal projection at the can also be used to improve a double infragluteal fold,
midlevel of the buttocks, verified by a horizontal line to correct infragluteal fold asymmetry, or to shorten a
from the point of maximal projection of the mons long buttock when combining it with an upper buttock
pubis. Another sign is a short infragluteal fold with a lift. It is indicated when the maximum point of buttock
downward slope that does not extend past the union of fullness is at the mid to upper portion of the buttocks,
the semitendinosus muscle with the biceps femoris, which should coincide with the level of the pubic sym-
which is medial to the midaxial line of the thigh [1]. physis [3]. If the maximum point of fullness falls below
Other indications of an aesthetic contour include a this line, then a superior approach and/or augmenta-
V-shaped crease in the proximal portion of the gluteal tion should be contemplated [17]. Furthermore, the
crease and lumbar hyperlordosis [24]. inferior gluteal lift technique is contraindicated when
Gluteal implants have been described with various the excess skin and subcutaneous tissue extends later-
rates of complications and difficulties, hindering wide ally toward the trochanteric area because this would
acceptance [57]. Lipografting is an effective means force the incision to extend laterally, resulting in a long
infragluteal fold.
A lateral buttock lift is indicated to correct moderate
S.O. Sozer (*) F.J. Agullo
Department of Surgery, Texas Tech University Health
cases of trochanteric laxity. This technique is usually
Sciences Center, El Paso, TX, USA incorporated into extended abdominoplasties and/or
El Paso Cosmetic Plastic Surgery Center, El Paso, TX, USA
flankplasties. When indicated, the regularly excised tis-
e-mail: [email protected]; sue can be utilized as an anteriorly (Fig. 59.1) or poste-
[email protected] riorly (Fig. 59.2) based dermal fat flap to provide

Fig. 59.1 (a) (Left) Preoperative. (Right) After lateral buttock lift or flankplasty with dermal fat flap to provide fullness in lateral
upper thigh. (b) Dermal fat flap
59 Buttock Lift 1003
Fig. 59.2 (a) (Left) Preoperative. (Right) Following lateral buttock lift or flankplasty with dermal fat flap to provide fullness in
upper lateral buttocks. (b) Dermal fat flap
fullness in the hips or superolateral gluteal area,

respectively. This procedure can be combined with fat
grafting to obtain greater volume and projection of the
buttocks.
The authors routinely utilize the upper buttock lift
with split muscle flap autoprosthesis augmentation in
cases of buttock ptosis and loss of volume since most
of our population presents with more advanced defor-
mities and routinely request a lift with augmentation.
A number of adipocutaneous flaps to address gluteal
augmentation in different settings have been described
in this region [16, 2025]. Most of these flaps originate
within the superior gluteal region and maintain volume
in the top half of the buttocks, lacking the ability to
reach the mid portion of the buttocks. The ideal flap
should be versatile, not vascularly compromised, result
in a superior gluteal concavity, and give the maximum
projection at the midlevel of the buttocks. In 2005, the
authors reported a series of turnover dermal fat flaps
for buttock augmentation in bariatric and aesthetic
patients undergoing lower body lifts in order to prevent
a flattened buttocks contour [25]. After more than 200
cases, the technique has evolved to include a portion of
the gluteus maximus muscle resulting in a better blood
supply to the flap, more caudal reach, and dramatic
decrease in fatty necrosis. The technique can be applied
to isolated buttock lifts [17], spiral lifts [26], and cir-
cumferential buttock lifts in bariatric and non-bariatric Fig. 59.3 Preoperative markings for buttock lift with autopros-
patients [25]. thesis augmentation
The inferior line is designed utilizing the pinching

59.2 Technique method to estimate the amount of possible skin resec-
tion. The direction of elevation of the ptotic buttocks is
59.2.1 Preoperative Markings caudal and slightly medial. These lines can be contin-
ued anteriorly with abdominoplasty or spiral lift mark-
Preoperative markings are a crucial component to ings given the appropriate indications.
successful surgery and to achieving desired results. A dermal fat flap originating between the superior
Patients are marked preoperatively in prone and stand- and inferior lines is marked within the medial two-
ing positions. The symmetry of the incisions is evalu- thirds of the supragluteal tissue marked for excision.
ated while patient is standing (Fig. 59.3). The flap is demarcated medially 23 cm lateral from
The superior or cephalic line is marked first. By the the midline. The lateral demarcation of the flap is
end of the procedure, this line will be lowered by 1 or approximately three quarters of the distance from the
2 cm and will dictate the localization of the final scar. midline to the posterior axillary line and may range
The line is drawn starting above the intergluteal crease between 5 and 15 cm in width depending on the patients
extending in a curvilinear fashion a few centimeters body habitus, buttock contour, and desired result.
bellow the iliac crest. At the sacrum, the line from the The gluteal flap is based randomly on superior glu-
contralateral side is joined forming a V, creating an aes- teal artery perforators. Perfusion to the skin overlying
thetically pleasing V-shaped crease [2123]. This will the gluteal region is supplied by 2025 perforating
form a scar that is slightly arched, follows the skins branches of the superior and inferior gluteal arteries,
tension lines, and is easily concealed by underwear. both of which branch from the internal iliac artery
Fig. 59.4 Deepithelialization of buttock flaps and removal of

sacral and flank skin and subcutaneous tissue, leaving deep fat
attached
Fig. 59.5 Creation of pocket above gluteus maximus fascia and

anchoring of flap Fig. 59.6 (a, b) Photo depicting elevation of flap with split gluteus
maximus muscle to allow for inferior mobilization of flap
[2730]. The abundant vascular supply of the gluteal

region provides robust perfusion to surrounding tissue areas marked with fat deposits is performed following
flaps [16]. the traditional method.
Depending on the patients contour deformities, the The marked wedge of supragluteal skin to be
areas of liposuction are marked. Liposuction is rou- excised is resected leaving the subscarpal fat to aid in
tinely performed in the flanks, sacrum, and posterior lymphatic drainage. The marked gluteal flap is then
thigh, following the aesthetic units of the buttocks and deepithelialized (Fig. 59.4). The flap is dissected down
accentuating its final contour. to the fascia at a perpendicular angle superiorly, medi-
ally, and laterally. The inferior border of the flap is dis-
sected inferiorly in an oblique angle to the level of the
59.2.2 Surgical Technique fascia. A pocket is created for insertion of the flap by
undermining the buttock in the plane above the gluteus
The patient is placed in the prone position under general maximus fascia and extending it a sufficient length to
anesthesia with the lower extremities slightly abducted. approach the inferior gluteal crease (Fig. 59.5). The
Liposuction is performed in the flanks, sacral area, below fascia in the superior, medial, and lateral border of the
the infragluteal crease, and other areas dictated by the dermal fat flap is divided. The flap is then raised by
patients contour deformities. The subcutaneous tissue is partially dividing the superior insertion of the gluteus
infiltrated of tumescent solution consisting of 1 L of maximus muscle to the posterior iliac spine and
Hartmann solution with 1 mg of epinephrine and 10 mL sacrum. The Gluteus maximus is then split in order to
of 1% lidocaine. Deep and superficial liposuction of the allow the flap to rotate caudally 180 (Fig. 59.6).
a
a b
Deepithelialized
Pocket
undermined
Split muscle flap rotated

and soft tissue flap folded for
increased fullness
Fig. 59.7 (a) Flap rotated inferiorly and secured inferiorly to gluteus maximus fascia in previously created pocket. (b) Drain
placement and suspension of buttock skin and subcutaneous tissue over flap
The superior superficial tip of the flap is cut to assess The patient is then placed in the supine position,
for adequate blood flow. The flap is rotated caudally and other concurrent procedures may be performed.
180 into the pocket and anchored to the fascia with
polyglactin 910 (3/0 Vicryl) suture. Securing the deepi-
thelialized surface upside down gives the flap a more 59.2.3 Postoperative Care
rounded and implant-like shape. The remaining buttock
skin is pulled in the reverse direction to cover the flap Immediately after surgery, a compressive garment
and two drains are placed (Fig. 59.7). The superficial is used and kept for 4 weeks. Patients are allowed to
fascial system is repaired with polyglactin 910 (0 Vicryl), rest in bed in the most comfortable position for them,
and the tissues are closed in a layered fashion. usually supine. Ambulation is started the same day or
Fig. 59.8 (Left) Preoperative.

(Right) Postoperative after
autoprosthesis buttock
augmentation with
the next morning depending on concurrent procedures. without extending the procedure significantly (<30 min).
Sitting is not restricted. The creation of an autologous buttock implant from a
The drains are left in place for 710 days and are split muscle flap provides additional projection during
removed once the drainage is <30 mL/day. In our expe- autologous buttock augmentation. The flap has reliable
rience, isolated inferior gluteal lifts or horizontal thigh circulation, requires minimal additional operating
lifts do not require drainage since there is not a large time, does not increase operative morbidity, and can be
dead space. The patient may return to normal activi- custom designed for each patient. The flap achieves
ties between 1 and 2 weeks, depending on concurrent maximum projection at the midportion of the buttocks
procedures. and creates a supragluteal concavity at the same time.
The procedure allows for a more substantial augmen-
tation when compared to fat grafting, and in our expe-
59.3 Conclusions rience, is safer than implants, while allowing for a lift
at the same time. It has proven to be a reliable proce-
The high satisfaction rate, the ease of concealing the dure that can be utilized in isolated buttock lift with
incision with clothing, and the low complication augmentation, circumferential body lift, and spiral lift
rate suggest that this is a reliable, versatile technique (Figs. 59.859.11).
Fig. 59.9 (Left) Preoperative

patient with buttock
elongation and ptosis. (Right)
Postoperative following
isolated buttock lift and
autoprosthesis augmentation.
Note the point of maximal
gluteal projection is at a
parallel line with the mons
pubis
Fig. 59.10 (Left)

Preoperative patient with
prior buttock augmentation
using round 270 mL silicone
implant that resulted in ptosis
and double bubble
appearance. (Right)
Postoperative after removal of
implants and buttock lift with
autoprosthesis augmentation
Fig. 59.11 (Left)

Postoperative following spiral
lift with autoprosthesis
buttock augmentation
References 8. Cardenas-Camarena L, Lacouture AM, Tobar-Losada

A (1999) Combined gluteoplasty: liposuction and lipoinjec-
1. Mendieta CG (2006) Classification system for gluteal evalu- tion. Plast Reconstr Surg 104(5):15241531
ation. Clin Plast Surg 33(3):333346 9. Chajchir A (1996) Fat injection: long-term follow-up.
2. Cuenca-Guerra R (2004) What makes buttocks beautiful? Aesthetic Plast Surg 20(4):291296
A review and classification of the determinants of gluteal 10. Chajchir A, Benzaquen I (1989) Fat-grafting injection
beauty and the surgical techniques to achieve them. Aesthetic for soft-tissue augmentation. Plast Reconstr Surg 84(6):
Plast Surg 28(5):340347 921934
3. Cuenca-Guerra R, Lugo-Beltran I (2006) Beautiful buttocks: 11. Lewis CM (1992) Correction of deep gluteal depression
characteristics and surgical techniques. Clin Plast Surg by autologous fat grafting. Aesthetic Plast Surg 16(3):
33(3):321332 247250
4. Centeno RF, Young VL (2006) Clinical anatomy in aesthetic 12. Matsudo PK, Toledo LS (1988) Experience of injected fat
gluteal body contouring surgery. Clin Plast Surg 33(3): grafting. Aesthetic Plast Surg 12(1):3538
347358 13. Pereira LH, Radwanski HN (1996) Fat grafting of the but-
5. Bartels RJ, OMalley JE, Douglas WM, Wilson RG (1969) tocks and lower limbs. Aesthetic Plast Surg 20:409416
An unusual use of the Cronin breast prosthesis. Case report. 14. Peren PA, Gomez JB, Guerrerosantos J, Salazar CA (2000)
Plast Reconstr Surg 44(5):500 Gluteus augmentation with fat grafting. Aesthetic Plast Surg
6. Buchuk L (1986) Complication with gluteal prosthesis. Plast 24(6):412417
Reconstr Surg 77(6):1012 15. Toledo LS (1991) Syringe liposculpture: a two-year experi-
7. Ford RD, Simpson WD (1992) Massive extravasation of ence. Aesthetic Plast Surg 15(4):321326
traumatically ruptured buttock silicone prosthesis. Ann Plast 16. Pascal JF, le Louarn C (2002) Remodeling body lift with
Surg 29(1):8688 high lateral tension. Aesthetic Plast Surg 26(3):223230
17. Sozer SO, Agullo FJ, Palladino H (2008) Autologous aug- dermal fat rotation flaps: a novel technique for autologous
mentation gluteoplasty with a dermal fat flap. Aesthet Surg augmentation gluteoplasty. Plast Reconstr Surg 117(6):
J 28(1):7076 17811788
18. Gonzalez R (2006) Buttocks lifting. In: Gonzalez R (ed) 25. Sozer SO, Agullo FJ, Wolf C (2005) Autoprosthesis buttock
Buttocks reshaping and the posterior body contour. Editora augmentation during lower body lift. Aesthetic Plast Surg
Indexa, Rio de Janeiro 29(3):133137
19. Gonzalez R (2005) Buttocks lifting: the dermo-tuberal 26. Sozer SO, Agullo FJ, Palladino H (2008) Spiral lift: medial
anchorage technique. Aesthet Surg J 25(1):1523 and lateral thigh lift with buttock lift and augmentation.
20. Agris J (1977) Use of dermal-fat suspension flaps for thigh Aesthetic Plast Surg 32(1):120125
and buttock lifts. Plast Reconstr Surg 59(6):817822 27. Foster RD, Anthony JP, Mathes SJ, Hoffman WY, Young D,
21. Centeno RF (2006) Autologous gluteal augmentation with Eshima I (1997) Flap selection as a determinant of success
circumferential body lift in the massive weight loss and in pressure sore coverage. Arch Surg 132(8):868873
aesthetic patient. Clin Plast Surg 33(3):479496 28. Ichioka S, Okabe K, Tsuji S, Ohura N, Nakatsuka T (2004)
22. Colwell AS, Borud LJ (2007) Autologous gluteal augmenta- Distal perforator-based fasciocutaneous V-Y flap for treat-
tion after massive weight loss: aesthetic analysis and role of ment of sacral pressure ulcers. Plast Reconstr Surg 114(4):
the superior gluteal artery perforator flap. Plast Reconstr 906909
Surg 119(1):345356 29. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A
23. Gonzalez R (2006) Buttocks lifting: how and when to use (1993) The gluteal perforator-based flap for repair of sacral
medial, lateral, lower, and upper lifting techniques. Clin pressure sores. Plast Reconstr Surg 91(4):678683
Plast Surg 33(3):467478 30. Park C, Park BY (1988) Fasciocutaneous V-Y advance-
24. Raposo-Amaral CE, Cetrulo CL Jr, Guidi Mde C, Ferreira ment flap for repair of sacral defects. Ann Plast Surg 21(1):
DM, Raposo-Amaral CM (2006) Bilateral lumbar hip 2326
Liposuction of Lower Extremities
and Buttocks 60
Alberto Di Giuseppe, Guido Zannetti,
and Daniele Bordoni
60.1 Introduction fundamentally different manner than earlier versions

of ultrasonic instrumentation for a lipoplasty, namely,
Suction-assisted lipoplasty (SAL) is generally regarded ultrasound-assisted lipoplasty (UAL). The primary
as safe and effective with well-known and well- differences are that the Vaser system delivers signifi-
documented clinical results and potential complica- cantly less power to the tissues while simultaneously
tions. For this method of lipoplasty, the fundamental increasing fragmentation/emulsion efficiently com-
mechanism of tissue removal is avulsion, i.e., the fatty pared to UAL devices and eliminates the simultaneous
tissue is pulled into a hollow suction cannula by vacuum aspiration feature of UAL devices.
and then avulsed or torn by the movement of the can- Ultrasonic energy was introduced to the plastic
nula. Results and potential complications are a direct surgery community in the form of ultrasound-assisted
function of the avulsive/cutting process. lipoplasty in the late 1980s and early 1990s. UAL tech-
Vaser-assisted lipoplasty (VAL) presents a funda- nology was characterized by large-diameter (5 mm)
mental change in the treatment and subsequent removal ultrasonic cannulas, simultaneous aspiration and emul-
of targeted fatty tissues. The fatty tissue is first selec- sion, continuous energy delivery, and sharp-edged ele-
tively emulsified using ultrasonic frequency vibrations ments at the cannulas ends, usually associated with the
delivered on a metal probe, and then the emulsified tis- suction port holes. UAL technique was characterized by
sues are removed using a gentle, minimally avulsive generally longer application times than SAL due to low-
aspiration process. The Vaser systems high selectivity efficiency ultrasonic cannula designs to create the emul-
for fatty tissue results in decreased overall damage to sion and low-efficiency aspiration due to the small
the tissue matrix comprised of fat cells, vessels, nerves, (2 mm) suction lumens in the ultrasonic cannulas. While
structural tissues, and lymph tissue. Vaser-assisted both excellent results and complications were reported,
lipolasty uses ultrasonic frequency vibrations to emul- there was no clear understanding of the causes for the
sify the fatty component of the tissue matrix but in a excellent results or the complications other than the
unfortunate general assignment to ultrasonic energy.
Vaser technology uses ultrasonic frequency vibra-
A. Di Giuseppe (*)
Institute of Plastic and Reconstructive Surgery, School tions but delivers the energy to the tissues in a substan-
of Medicine, University of Ancona, Ancona, Italy tially different manner than UAL. In brief, VAL
e-mail: [email protected] technology is characterized by small-diameter probes
G. Zannetti (2.23.7-mm diameters), pulsed delivery of the ultra-
Department of Plastic and Reconstructive Surgery of, sonic energy, and grooved probe designs that provide
Bologna, Italy
energy dissipation along the sides of the probes in
addition to the front face of the probes. VAL technique
D. Bordoni
is characterized by procedure times similar to or shorter
Institute of Plastic and Reconstructive Surgery,
School of Medicine, University of Ancona, Ancona, Italy than typical SAL procedure times and incision sizes
e-mail: [email protected] comparable to SAL. The amount of power delivered to

Table 60.1 Partitioning, 80% Efficiency Applicable

H2O power, and efficiency Probe % Front % Side Power (W) (mJ/mm) tissue type
for four Vaser probes
3.70 100 0 5.1 80 None
3.71 65 35 7.9 125 Fibrous
3.72 55 45 9.3 150 Moderate
3.73 42 58 12.1 195 Soft
the tissues and a method of measuring the efficiency of from the sides of the probe as well as the front surface
each probe design (including other ultrasonic devices) of the probe, the energy is less concentrated and results
are summarized in the research published by Cimino. in a softer and more effective emulsion of the fatty tis-
sue. The number of grooves determines the relative par-
titioning of the vibratory energy. Four identical 3.7-mm
60.2 Vaser Technology probes were evaluated as having zero, one, two, and
three grooves.
The technological advancements incorporated into For the 3.7-mm probes, the partitioning, the power
Vaser technology are designed to deliver the absolute for an 80% setting, and efficiency (80%) characteristics
minimum amount of vibratory energy to the tissues and are in Table 60.1. The results show that increasing the
still achieve the desired emulsification/fragmentation of number of grooves moves more energy to the sides of
the fatty component of the tissue matrix. These advance- the probe. Note also that the overall power and effi-
ments include the use of small-diameter solid probes in ciency also rise, meaning that the probes with more
the range of 2.23.7 mm, grooved probe designs to grooves are not only more efficient but are able to con-
increase efficiency, pulsed delivery of the vibratory tact more tissue. The applicability of the different probe
energy to reduce the average energy delivered, gentle- designs to different types of tissue (soft to fibrous) is
aspiration-cannula designs to reduce tissue avulsion discussed in detail in the next section on VAL tech-
while maintaining aspiration performance, and refined nique. The reader is referred to [1] for a more detailed
instrumentation design with regard to size and weight to discussion of methods and meanings related to the
provide more artistic use and movement. power and efficiency calculation.
The amount of energy delivered to the tissues by an The Vaser system can deliver the vibratory energy
ultrasonically vibrating probe is roughly proportional to to the tissues in two different forms. The first is called
the square of the diameter of the ultrasonic probe or can- continuous wave, a form where the vibration is on
nula, meaning that small reductions in diameter result in continuously at constant amplitude, commonly used
significant reductions in delivered energy. Therefore, in previous-generation UAL devices. The second form
the design objective is to utilize the smallest possible is pulsed mode, a form where the vibratory energy is
diameter probe that accomplishes the desired emulsifi- delivered in short-duration bursts, referred to as Vaser
cation in reasonable time. Generally speaking, probes mode. The advantage of Vaser mode is that the peak
smaller than about 2 mm in diameter are too flexible to energy is delivered in short burst (the on condition)
control (unless they are very short), and probes larger and is strong enough to emulsify fatty tissue while the
than about 4 mm in diameter present excessive amounts average energy delivered over time is reduced com-
of energy to the tissues. The performance tradeoff is that pared to continuous mode. Vaser mode delivers around
these smaller-diameter probes have reduced contact area ten bursts per second to the tissues, fast enough so that
with the tissue and will therefore take longer to achieve the Vaser is generally imperceptible to the surgeon
the desired emulsification. To increase the efficiency of and fast enough so that the resultant on/off effect is
the emulsification process and decrease the operative uniform, smooth, and repeatable with regard to emul-
time, grooves have been added to the tips of the probes sification of the tissue. If the burst rate is less than
to provide additional emulsification. With this grooved about ten times per second, then the on/off effect of
design, tissue that contacts the sides of the probes will the device begins to present a timing issue to the sur-
be emulsified in addition to the emulsification that geon with regard to the forward and backward strokes
occurs on the front surface of the probe, significantly of the device and also tends to produce less-consistent
increasing the emulsification efficiency and decreasing results because of the physical spacing of the on
operative time. Because the vibratory energy is dissipated periods in the tissue.
60 Liposuction of Lower Extremities and Buttocks 1013
Emulsified fatty tissue is more easily removed with abdomen when working in the upper abdomen
aspiration cannulas than non-emulsified fatty tissue. and near creased buttocks. Note: A single towel
Therefore, only gentle aspiration is required. A series layer will not protect the skin from prolonged
of emulsion cannulas, called the VentX cannulas, were contact with the vibrating probe or if the probe is
designed for efficient emulsion removal and minimal levered strongly into the skin through the towel. If
trauma to the tissue matrix. prolonged contact or strong levering is unavoid-
able, use a triple-folded towel to ensure skin
protection.
60.3 VAL Technique 4. Probe selection. Use the correct probe (see the
chart). Use initial settings as suggested in the
The following guidelines cover safe and effective use chart. Adjust the setting so that the probe moves
and application of the Vaser system for VAL including smoothly through the tissue. If the probe is drag-
the infusion, emulsification, and aspiration phases. ging or struggling, then all of the energy will be
used to penetrate the tissue, and very little emul-
sion will occur. In this case, move the amplitude
60.3.1 Infusion up a notch or two. If this does not solve the prob-
lem, then switch to a probe designed for more
1. Infusion. Use sufficient and appropriate amounts of fibrous tissues (see the chart).
wetting solution. Make sure that the wetting solu- 5. Probe movement. Keep the probe moving at all
tion is uniformly and evenly distributed in the times. Move it smoothly at a speed that the tissue
intended fragmentation volume. A gentle firmness and amplitude setting will allow without exces-
and fullness in the targeted area is desirable. Allow sive pushing. Do not let the probe sit (vibrate) on
sufficient time for vasoconstrictive requirement the location. A speed just slightly slower than stan-
(usually at least 10 min minimum for 1:1,000,000 dard suction cannula movement is appropriate.
concentrations). Apply wetting solution slightly 6. Torquing. Do not torque the probe! Move the
beyond the marked boundaries and in all potential probe in and out like spokes of a well; do not level
port locations. If you cannot achieve a sufficient dis- (torque) the probe sideways or up and down. The
tribution of fluid, then do not use the Vaser system in skin protector should not be used as a fulcrum!
that location. The targeted ratio of wetting solution Torquing will lever the probe into the skin protec-
in to total aspirate out is approximately 1.5:1. If tor so that frictional rubbing can cause heat build-
more than a 2:1 ratio is used, the Vaser system begins up in the skin protector.
to lose efficiency due to the presence of excessive 7. Application time and surgical endpoints. Look for
fluid. If less than a 1:1 ratio is used, then there will a loss of resistance to probe movement in all
not be enough fluid to easily form emulsion. areas of the intended fragmentation volume as the
primary indicator of the surgical endpoint. Initial
application (continuous or Vaser mode) is for every
60.3.2 Emulsication 200 mL of wetting solution infused at a site. This
guideline usually results in only partial emulsifica-
2. Incision protection. Skin ports are designed to pro- tion of the target volume. (These times are ONLY
tect the incision edges during the fragmentation suggestions; your requirement will be dictated by
phase with minimal incision size (~4-mm inci- many factors that cannot be covered in this short
sion) and also protect the incision edges during the space.) Special note: For the upper abdomen, use
suction phase. The skin ports should go in easily; 1 min of ultrasonic applications for every 200 mL
otherwise, the incision is too small or the port is of wetting solution infused until experience allows
hooked on the underside of the dermis. otherwise.
3. Skin protection. Use a towel (wet or dry) to cover 8. End-hits. Prevent end-hits or punching into the
the skin near the skin port. This protects the skin dermis from below. Place incisions so that probe
in the accidental situation where the probe is movement is generally parallel to the skin. Do not
levered into any exposed skin near the skin port. try to go around tight corners this may result in
This is especially important across the lower potential end-hit or torquing of the probe.
Table 60.2 Tissue type, Vaser probe selection, mode, and amplitude setting
2.9-mm/ 3.7-mm/ 3.7-mm/ 3.7-mm/
Continuous 3-groove 3-groove 2-groove 1-groove
Tissue type mode Vaser mode (any length) (any length) (any length) (any length)
Very soft Yes Yes 6080 7080 7080
Soft Yes Yes 6080 7090 7090 7080
Medium Yes Yes 7090 8090 8090 7090
Fibrous Yes 2.9 mm only 8090 8090 8090
Very fibrous Yes No 8090 8090
9. Cross-tunneling. Cross-tunneling is highly desir- probes. If the expected volume (single anatomical
able for more uniform fragmentation and to site) is between 500 and 1,000 mL, then consider
improve the subsequent aspiration performance. using either the 2.9-mm probes or the 3.7-mm
10. Fee air vibration. Keep the tip of the probe inside probes, depending on how fibrous the tissue is and
the patient at all times. Do not vibrate the probes the nature of the anatomical site. If the expected
in free air, or they may be subject to cracking. volume is over 1,000 mL (single anatomical site),
11. Dry application. Do not reapply the Vaser probe then consider using the 3.7-mm probes.
after a site has been aspirated (the site is dry). For a given diameter, probes with more grooves
One of the most critical understandings necessary (rings) fragment tissue more efficiently, but do not
for successful VAL is the proper choice of the probe penetrate fibrous tissues as easily because a signifi-
for the tissue type, tissue volume, and anatomical cant amount of the vibratory energy is coupled from
location. The key elements are (1) the diameter of the the sides of the probe as opposed to the front surface.
probe and (2) the number of grooves located at the tip Therefore, for a given diameter, probes with fewer
of the probe. The smaller-diameter 2.9-mm probes all grooves (rings) are more appropriate for fibrous tis-
have three grooves for maximum efficiency and can be sues. If the tissue is too fibrous for a selected 3.7-mm
used on tissue from soft to fibrous because of their probe design, select a probe with fewer rings. For
small diameter. The 3.7-mm probes may have one comparison purposes, a 3-ring 3.7-mm probe distrib-
groove, two grooves, or three grooves and should be utes approximately 70% of its energy from the sides
selected based on the tissue type and intended applica- and 30% from the front surface. A 2-ring 3.7-mm
tion. Tissue type ranges from very soft to very fibrous probe distributes approximately 50% of its energy
in five grades as shown in Table 60.2. The probe design from the sides and 50% from the front surface. A
and appropriate amplitude settings for each tissue type 1-ring 3.7-mm probe distributes approximately 30%
are shown. of its energy from the sides and 70% from the front
1. DO NOT VIBRATE THE PROBES IN FREE AIR. surface.
Always keep the tip of the probe, at least the distal Smaller-diameter probes will penetrate fibrous tis-
12 cm, in contact with tissue or fluids and inside sues more easily than larger-diameter probes, irrespec-
the patient and skin port before initiating vibra- tive of the number of rings. The 2.9-mm-diameter
tion. Vibrating the probes in free air can lead to probes all have 3 rings because their smaller diameter
cracking of the probe due to unintended transverse allows penetration of even the most fibrous tissues
vibrations. with 3 rings.
2. The 3.7-mm probes are intended for rapid debulk- General recommendations: Use the 3.7-mm
ing and contouring of medium to large volumes of 2-groove for most applications, 7080% amplitude.
soft to fibrous tissue. Use the 3.7-mm 3-groove for larger volumes of very
3. The 2.9-mm probes are intended for debulking and soft tissue (7080% amplitude) or the 3.7-mm 1-groove
fine contouring of smaller volumes of soft to for more fibrous tissues (7080% amplitude). Use the
extremely fibrous tissue and for sensitive areas. 2.9-mm 3-groove probes for smaller volumes, sensi-
4. GENERAL VOLUME CONSIDERATIONS. If a tive areas, fine contouring, or very fibrous tissues (60
single anatomical site is expected to yield less 80% amplitude). Ninety percent amplitude may be
than about 500 mL, then consider using the 2.9-mm used with any probe, but consider selecting a probe
more appropriate for the fibrousness of the tissue

if 90% amplitude is required for smooth, gliding
motion.
Use continuous mode for general use, if tissues are
S
quite fibrous, or for higher speed fragmentation. Use
Vaser mode for more delicate work, softer tissues, or I
for finer sculpting.
P
60.4 VentX Cannula
1. The VentX effect significantly increases the effi-

Fig. 60.1 Layer of subcutaneous emulsification with Vaser
ciency of aspiration when large amounts of fluid/
UAL. S superficial, I intermediate, P deep
tissue are in the suction tube. The suction tube will
always appear to be empty because the VentX effect
does not have a strong impact on suction perfor- 60.5 Technique
mance during the final feathering and finishing steps
because very little tissue/fluid is in the suction tube. The main characteristic of Vaser relies in the capability
2. The port size (slow width and length) and the can- to work as well as in the intermediate and deep fat
nula diameter determine the application of the can- layers (as in standard liposuction) as in the superficial
nula, the speed of the cannula, and the aggressiveness layer (Fig. 60.1). Its similar to what has been described
of the cannula. The VentX cannulas use a port size in superficial liposuction, but with the ability to target
that maximizes tissue and fluid removal speed while only the thin fat layer, preserving vascularization,
reducing suction trauma by incorporating generally innervation, of the superficial dermal plexus. This abil-
smaller port sizes that are optimized for the diame- ity preserves from devascularization of the skin. Care
ter of the cannula. For more accurate comparison should be used to prevent too aggressive removal of
between different types of cannulas, it is best to fat in this layer [2].
compare cannulas with approximately equivalent Fat thickness varies from anatomical sites: on the
port sizes rather than equivalent diameters because back, there is only one layer of fat, while in the thigh
the port size determines the size and volume of the there all the three classic layers represented: superfi-
avulsed tissue particles. cial, intermediate, and deep (Fig. 60.2).
The recommended approach to selection of a VentX The surgeon must adapt his behavior to the ana-
cannula is to use a diameter one size larger than you tomic site where he works. In order to recreate the
would normally use because the port sizes on the natural appearance of the lower body, the patient posi-
VentX cannulas are smaller than those found on tradi- tion must respect the gravity forces, by bending the
tional suction cannulas. surgical bed 3045%.
The 4.6-mm SST-6 pattern is designed for rapid Figure 60.3 is a 43-year-old patient who presents
emulsion removal and debulking with small ports for with a history of previous liposuction in flanks, tro-
reduced suction trauma. The port size on this cannula chanters, buttocks, and thighs. She required correction
is slightly smaller than the port size on a traditional of adverse outcomes and residues of lipodystrophy,
3.7-mm Mercedes. The 2.7-mm SST-6 pattern is and harmonization of the natural lines of the body.
designed for general debulking and shaping with less Planning the trochanter and flank lipodystrophy means
suction trauma than a standard 2.7-mm Mercedes. The to draw correctly the new lines of concavity in har-
port size on this cannula is slightly smaller than the mony with the rest of the body. Treated areas in this
port size on a traditional 3.0-mm Mercedes. The 3.0- patient are upper abdomen, periumbilical region, hips,
mm SST-6 pattern is designed for finishing and feath- thighs, front and inner thighs, trochanters, and inner
ering, or slightly slower but less-traumatic debulking. buttocks. Vaser liposuction of the lower extremities
The port size on this cannula is slightly smaller than and buttocks has excellent results with few complica-
the port size on a traditional 2.4-mm Mercedes. tions (Figs. 60.460.8).
Fig. 60.2 Fat thickness

varies in different body areas.
Thigh and abdomen are the
thickest areas. Back and face
are the thinnest
Back Thigh
Fig. 60.3 (a) Preoperative 48-year-old female. (b) Correction most effective. This phase is called undermining of the skin
of trochanter deformity. The hand placed and compressing the integuments from the underlying fat tissue. (z) To protect the
trochanter helps to define the new line to be sculptured. (c) Zone skin from friction injuries, it is advisable to place a wet gauze.
of adherence. (d) Correction of flank deformity. The hand The action of the probe follows the classic multiangular pattern.
compresses the flank excess and helps to draw the new line. (aa) The probe is directed on the trochanter and on the gluteus.
(e) Preoperative marking. Yellow is volume to be reduced, green (bb) The probe is placed at the infero-posterior thigh region, the
are areas to enlarge with adipose tissue, and red are areas to be so-called banana fold. (cc) The interior thigh region is treated on
avoided. (f) Positioning. (g) Positioning on the operating table, the superficial and deep layers. (dd) Verifying complete under-
pillow to raise the iliac spines. (h) The back of the operating mining of skin from subcutaneous tissue. (ee) Rounding the glu-
table is tilted to favor the gravity of the tissues. (i) Preoperative teus. Upward rotation of the skin after full undermining of
markings and preparation of the field with broken bed and superficial layers. (ff) Vaser timing: 15 min and 25 s in continu-
catheterization of the patient. (j) Sterilization of the field. ous action. (gg) After completing Vaser emulsification, the sur-
(k) Incision under buttock for infiltration with tumescent solu- geon starts aspiration of emulsified fat. (hh) While the first
tion. (l) Complete the tumescent infiltration in the posterior thigh surgeon continues aspiration of the emulsified fat, the assistant
and trochanter. (m) Tumescent infiltration in two layers: superfi- starts the application of ultrasound on the contralateral side. This
cial and deep. (n) The infiltration and temporary suturing of the helps shorten operating time. (ii) Body contouring is a step-by-
entry holes are completed. (o) The Vaser system: upper is the step procedure. With a 1.8-mm cannula, the surgeon verifies the
ultrasound system, under is the infiltration and suction pump, contour of the trochanter with a vertical action. All the skin must
and right is the 5-lb bag of the tumescent solution containing be free of adhesion from underlying layers. (jj) The cannula is
the local anesthetic Naropin and the vasoconstrictor adrenaline. used continuously, carefully modeling the trochanter and banana
(p) Once the tumescence on left side is completed, start infiltra- fold. The flap must be uniform, and this is where mistakes can be
tion on right side. (q) The infiltration speed is fixed at 200 mL/ made easily. Too much aspiration in this phase causes a depres-
min. (r) Infiltration of the interior knee. (s) After removal of the sion. (kk) The aspirate from one site. (ll) The appearance of the
suture, the dilator is introduced to spread the skin incision to new gluteal, trochanter, and upper thigh shape at the end of the
allow the insertion of the skin protector. (t) Skin protector on procedure. (mm) New shape of buttock, lateral gluteal sulcus,
site. (u) The 2-ring 3.7-mm probe is tested in the saline solution and trochanter. (nn) Bed is bent to increase gravity effect of the
in order to verify the correct sound and vibration of the probe. tissue. See the new contour of buttock thigh at the end of the
(v) Vaser probes; 1, 2, and 3 rings in 2.9- or 3.7-mm probes. surgery. (oo) Position at the end of the surgery. (pp) Infiltration
(w) New probe: one-ring 4.5-mm probe for large volume of the anterior thigh. (qq) Vaser to anterior thigh. (rr) See the
emulsification. (x) After waiting for a minimum of 10 min for color of aspirate, virtually bloodless. (ss) The surgeon completes
allowing adrenaline to work, the Vaser probe is introduced aspiration and modeling on one side while the assistant performs
in the skin protector and starts the action. (y) The probe works ultrasound on the contralateral side. (tt) Postoperative patient.
initially in the superficial subdermal layers where tumescent is Left: preoperative. Right: postoperative
b
Fig. 60.3 (continued) c
Gluteal
depression
over great
trocanter
d


g
h
i j

m n

r s
v w

x y

aa bb
cc

dd
ee ff

gg hh
ii
jj

kk ll
nn
mm
oo

pp qq
rr
ss


tt

PRE PLAN POST

a
Fig. 60.4 Thirty-eight-year-old female. (a) front view/back view; (b) Oblique view/ profile view
PRE PLAN POST

PRE PLAN POST

a
Fig. 60.5 Forty-two-year-old female. (a) front view/back view; (b) oblique view
PRE PLAN POST

b

Fig. 60.6 Forty-four-year-old female with asymmetry of spine and lipodystrophy. (a) back view (b) front view
Fig. 60.7 Thirty-three-year-

old female. (Left)
a
Postoperative. (a) front view;
(b) back view; (c) profile
view
b

c
Fig. 60.8 Thirty-four-year-

a
old female. (left) Preoperative.
(right) One week postopera-
tive. (a) back view; (b) front
view; (c) oblique view; (d)
oblique view; (e) profile view;
(f) profile view
b
Fig. 60.8 (continued) c
d
Fig. 60.8 (continued) e
f
References 2. Shiffman MA, Di Giuseppe A (2010) Body contouring: art,

science and clinical practice. Springer, Berlin
Buttock and Hip Enhancement
with Implants 61
Jesus Benito-Ruiz
61.1 Introduction The buttock is round and firm. Most of its projection
and fullness lies in the central area. The outer area can
Buttocks, together with breasts, are the most relevant be shallow. The most difficult area to address is the
and important areas of the feminine appearance. In the lower portion. Implants are not effective in this area,
Mediterranean culture, many women seek advice to and other procedures, such as liposuction or direct exci-
improve these areas. Liposuction is the main tool used sion of the skin, may be required.
to sculpt the buttocks, hips, and subgluteal areas to The anthropological proportion (in all cultures)
provide a more harmonious contour. However, some between the waist and the buttocks is 0.7. This has
patients exhibit some degree of atrophy, which can be been correlated with sexual attraction and to the poten-
solved by grafting their own fat or by using implants. tial for fertility in females.
Some authors reported extremely good results exclu- Cuenca-Guerra and Quezada [9] studied 1,320 pho-
sively for fat autografting [13]. Others favored the tographs of nude women and measured 132 women to
use of gluteal implants [48] or a combination of both establish several landmarks that contribute to the
approaches. beauty of the buttocks. These are:
Men also seek enhancement of their buttocks; how- The greater projection of the buttocks coincides
ever, in their case, the goal is to achieve a more muscu- with an imaginary line that runs through the upper
lar, masculine appearance. aspect of the pubis (Fig. 61.1).
Lateral depression. This hollow area on the lateral
aspect of each buttock is formed at its deepest point
61.2 Buttocks between the greater trochanter and the belly of the
gluteal muscles (Figs. 61.1 and 61.2).
61.2.1 Aesthetics of the Buttocks Infragluteal fold. This horizontal crease is located
under the ischial tuberosity. It has a gentle upper
When defining the beauty of the buttocks, one should concavity, and it should not reach beyond the center
consider the anatomical areas surrounding them, includ- of the thigh. It is an indicator of ptosis (Fig. 61.2).
ing the hips, thighs, waist, and back; thus, several areas Supragluteal fossettes. These are two hollows
should be analyzed to obtain the best surgical results. located on either side of the medial sacral crest.
They are formed in their deepest part by the poste-
rior superior iliac spine (Figs. 61.2).
V-shaped crease. Formed by two lines arising in
J. Benito-Ruiz the proximal portion of the gluteal crease. Directed
Department of Plastic and Aesthetic Surgery, toward the supragluteal fossettes, these lines are
Antiaging Group Barcelona, Clnica Tres Torres,
formed by the insertion of the gluteus maximus in the
Barcelona, Spain
e-mail: [email protected], lumbodorsal aponeurosis. They can be enhanced by
[email protected] liposuction over the sacrum (Figs. 61.2).

1044 J. Benito-Ruiz
An additional feature that may contribute to the

beauty of buttocks is lumbar hyperlordosis, which
gives the illusion of a more projected buttock.These
authors also established that, in a profile view, the
distance between the greater trochanter and the
point of maximal projection of the buttock should
be twice the distance between the greater trochanter
and the pubis (Fig. 61.1).
Centeno [10] distinguishes eight aesthetic units:
Two symmetric flank units
One sacral triangle unit
Two symmetrical gluteal units
Two symmetrical thigh units
One infragluteal diamond unit
Roberts [11] described significant variations in aesthetic
ideals among ethnic groups in the United States. Asian
Americans prefer a shorter buttock with a higher point of
maximum projection, providing the illusion of longer legs
and a more balanced proportion between the torso and the
extremities. Hispanic and African Americans seem to pre-
fer more projection compared with either Asian Americans
or White Americans. A higher point of maximum projec-
tion, deeper lumbosacral depression, and an absence of lat-
eral thigh depressions also appear to be favored by African
Americans. White Americans seem to prefer a more athletic
Fig. 61.1 The maximal projection of the buttock is at the level
of the pubis. The optimal projection is when the distance between ideal, with greater definition of the muscular and bony anat-
the trochanter and the apex of the buttock is twice the distance omy and less anteriorposterior projection.
between the trochanter and the pubis
61.2.2 Relevant Anatomy
Awareness of the different anatomical structures of

the gluteal region is necessary to avoid any undesired
injuries. The fat of the subcutaneous tissue, which is
located under the skin, is fibrous and contains many septa
that run through it and join the muscular fascia and the
skin. This particular disposition is responsible for some
of the retractions that can be observed in this area.
The gluteus maximus originates from the lateral
margin of the sacrum, the posterior superior iliac crest,
and, to a lesser extent, the coccyx and sacrotuberous
ligament from whence its fascicles are directed down-
ward and obliquely toward the iliotibial tract and the
greater trochanter. The gluteus medius is easily distin-
guished from the gluteus maximus because of its verti-
cally oriented fibers and its disposition, which is
slightly more lateral and is covered by the gluteus
Fig. 61.2 The main landmarks of the buttock, as described
maximus. It is located in a triangular area delimited by
by Cuenca-Guerra and Quezada [9]. 1. Lateral depression. 2. the anterior superior iliac spine, the tubercle of
Infragluteal fold. 3. Supragluteal fossettes. 4. V-shaped crease the iliac crest, and the greater trochanter. The gluteus
61 Buttock and Hip Enhancement with Implants 1045
Fig. 61.3 Anatomy. Observe the relationship between the exit Fig. 61.4 Subcutaneous placement of the implant should not be used.
of the sciatic nerve and the position of the implant. A line from In this case, the implants are clearly seen at the bottom of his buttocks
the coccyx to the trochanter marks the exit of the nerve
maximus covers, at its lowest portion, the piriformis, 61.2.3 Techniques Available
obturator, and quadratus femoris muscles.
The motor innervation of the gluteus maximus is Gonzalez-Ulloa [12] introduced the possibility of
effected by the inferior gluteus nerve, which comes placing implants for buttock augmentation in the sub-
from the pelvis to the gluteal area, crossing the great cutaneous plane. However, this position is associated
sciatic foramen posterior and medial to the sciatic with too many complications and yields poor aesthetic
nerve. The gluteus branch is the first collateral (infe- results (displacement, irregularities, and capsular con-
rior gluteal nerve) and arises next to the inferior border tracture) (Fig. 61.4).
of the piriformis muscle. As soon as it arises, the infe- In 1984, Robles et al. [4] described a technique that
rior gluteal nerve divides, and its branches run between involves the insertion of implants in the space between
the muscle and its anterior fascia. the gluteus maximus and the gluteus medius via a verti-
The gluteus minimus and the sciatic foramen with the cal incision in the sacrum. However, in this method, the
piriformis muscle are located under the gluteus medius. undermining must not pass below the inferior border of
Under the piriformis muscle, the sciatic nerve leaves the the pyramidal muscle to avoid sciatic compression by
pelvis to run over the deeper muscle layer (gemellus and the prosthesis, which, in some cases, is placed too high.
obturator muscles) to enter the thigh. The exit of the sci- In 1996, Vergara and Marcos [5] reported the pos-
atic nerve from the pelvis occurs at the level of a line that sibility of using implants inside the gluteus maximus
joins the coccyx with the greater trochanter, a little more but did not establish a method for achieving this. These
than a third of the way along a line from the posterior authors did not show the levels and limits of the under-
superior iliac spine to the ischial tuberosity. It then mining in detail; however, in 2003 [6], they provided a
descends to about halfway between the ischial tuberosity detailed method, describing their technique as intra-
and the greater trochanter. This is an important landmark muscular and establishing that a 3-cm thickness was
because the lower edge of the implant will be placed necessary to cover the implant properly. De la Pea [7]
over this area in the intramuscular technique (Fig. 61.3). described a technique for subfascial placement and
1046 J. Benito-Ruiz
Fig. 61.5 Choosing the implant depends on the type of the buttock. In short buttocks (left), round implants have to be placed.
In long and/or flat buttocks (right), oval implants are preferred
designed new implants for this particular position. projection of the buttock, we prefer oval implants,
The implants were bigger and were positioned lower whereas if the buttock projects over the sacrum, the
compared with the intramuscular technique. The pro- author chooses the round implant for short and medium
cedure was devised to avoid the problems related to buttocks and the oval one for long buttocks (Fig. 61.5).
high-positioned implants, leaving a double bubble The round implants are manufactured in three
deformity. Gonzlez [8] described his technique for volumes: 200, 250, and 300 mL. The oval implants come
the proper placement of the implants within safe in volumes of 115, 215, 290, 360, and 450 mL. Round
boundaries (the XYZ method) using intramuscular implants provide a higher projection compared with oval
placement, similar to Vergaras technique. ones (mean, 1 cm more). The volume of the implant
depends on the measurements performed. We routinely
measure the vertical distance between the iliac crest and
61.2.4 Choosing the Implant the line between the coccyx and the trochanter and trans-
versely between a line drawn from the posterior iliac
The author uses implants manufactured by Polytech spine to the lateral edge of the gluteus maximus. Taking
(Dieburg, Germany). The implants can be round into account that these measurements are performed on
(smooth), as described by Robles, or oval (smooth or the surface of the buttock, without considering the thick-
textured; Vergara). Choosing the implant depends on ness of the muscle, we choose an implant that is 2 cm
the volume that is desired but mainly on the shape of smaller than the aforementioned measurements.
the buttock. For short buttocks, the best option is a
round implant, whereas for long or flat buttocks, the
best option is an oval implant. For men, we also prefer 61.2.5 Surgical Technique
oval implants as we want to get a more squared, oblique
shape. For women, the option of choice is the round The author always combines liposuction with the place-
implant unless the buttock is longer than it is wide ment of the gluteal implants. Markings are performed in
or unless it is flat. As a rule of thumb, if the projection a standing position. The areas to be liposuctioned are
of the sacrum in the lateral view is greater than the drawn, namely, the lumbar, presacral, and subgluteal
Fig. 61.6 When enhancing a buttock, not only an implant is Fig. 61.7 The incision is placed 23 cm above the coccyx.
placed, but also we have to address the surrounding areas. A subcutaneous tunnel is performed over the muscle, and then
Liposuction is performed at the lumbar and infragluteal areas blunt dissection is performed parallel to the muscle fibers
(shadowed). The implant is placed between the cranial attach-
ments of the gluteus maximus muscle and the line joining the
coccyx and the trochanter incisions for the cannulas are performed separately
from the incision for the placement of the implant. Only
areas. The hip is also treated if it is very voluminous. 3- and 4-mm cannulas are used for the liposuction, and
The goal of liposuction around the buttocks is to enhance drains are never placed in the aspirated areas.
the projection and the shape of the central area of the For the placement of the implant, the intramuscular
buttock, where the implant will be placed (Fig. 61.6). technique described by Vergara and Marcos [5] is uti-
The implants are placed in the two upper thirds of the lized. After isolating the anus with a polyvinylpyrroli-
buttocks. A line is drawn between the coccyx and the done-impregnated gauze, a 7-cm incision is performed
greater trochanter. This line corresponds to the exit of in the intergluteus sulcus, about 23 cm above the coc-
the sciatic nerve through the foramen and under the piri- cyx (i.e., the lower limit for the pocket between the
formis muscle. The implant will also be placed laterally coccyx and the trochanter). We leave an intact strip of
to a line drawn from the upper posterior iliac spine. skin of 34 mm in the middle of our incision. This strip
The patient is placed in the ventral decubitus posi- is deepithelialized and is used to anchor the closing
tion with a small pillow under the pelvis to flex the hips stitches. This prevents wound dehiscence, which is the
slightly. In our view, this position helps the dissection main complication of the procedure in our experi-
of the pocket where the implant will be placed. Peridural ence. The subcutaneous tissue lateral to this strip is
or general anesthesia is used, depending on the patients incised down to the presacral fascia, and a short tunnel
preference. The markings are checked again as they is created under the fascia of the gluteus maximus
move slightly in relation to the bony landmarks. muscle. This creates a tunnel that is 10 cm in length,
The author always starts the procedure by perform- slightly oblique, and parallel to the muscle fibers
ing liposuction. The areas to be aspirated are infiltrated (Figs. 61.7 and 61.8). The approach to the pocket is
with Ringer lactate + adrenaline 1/1,000,000. The stab made in the muscle, with a blunt dissection parallel to
1048 J. Benito-Ruiz
the muscular fibers. Using a finger, we slip on the bone

and start the intramuscular dissection, leaving a thick-
ness above this area of 23 cm. Although dissection
is started using a finger, the handle of a Langebeck
retractor is then used. This is a good blunt maneuver to
create the pocket without damaging the muscle ceil-
ing. It is very important not to make the pocket parallel
to the surface (it should be oblique, following the axis
of the pelvis, 3045 downward) as there is a risk of
piercing the muscle at its lateral aspect, which may
lead to extrusion of the implant into the subcutaneous
area (Fig. 61.9). The limits of the pocket are the iliac
crest and its gluteus attachments at the upper aspect,
the lateral edge of the gluteus major at the lateral aspect
(medial to a line centered at the greater trochanter), and
Fig. 61.8 Initial subcutaneous tunnel showing the gluteus the inferior line between the coccyx and the trochanter.
maximus
Fig. 61.9 The dissection in

the muscle has to be
performed following the
inclination of the iliac bone
(middle and lower). If the
dissection is performed as in
the upper, we will pierce the
muscle, and the implant will
extrude laterally
Fig. 61.10 Intraoperative. (Left) Textured oval implant, 250 mL, just before insertion. (Right) The implant has been placed at the
right buttock. Observe the difference with the left side
placed (Fig. 61.10). This can be slightly hazardous and

requires patience from the surgeon and the assistant.
The implant should be intramuscular so a layer of glu-
teus maximus muscle is left between the implant and
the deeper structures (sciatic nerve) (Fig. 61.11).
Drains are not usually placed. The muscle incision is
closed using 20 Vicryl sutures. The closure has to be
perfectly performed to try to separate the implant from
the subcutaneous and sacral tunnel completely.
The skin is then closed using 30 Vicryl sutures.
A small, 8-French drain is left under negative pressure
in the subcutaneous tunnel, which is extracted through
a stab incision and never via the sacral wound. The
interrupted subcutaneous sutures are anchored to the
deepithelialized strip of dermis left in the midline of
the access. Finally, the skin is closed with a buried,
intradermal 30 Monocryl suture.
The wound is dressed, and a girdle is placed. The
patient is placed on antibiotics and anti-inflammatory
drugs for 7 days. The patient can get up and sit 24 h after
the operation; however, she/he has to avoid the dorsal
decubitus position for 56 days. Patients cannot exer-
cise for 5 weeks and should wear a girdle at all times.
Fig. 61.11 The prosthesis is placed intramuscularly. A layer of Lymphatic drainage of the aspirated areas is advised
muscle will be protecting the sciatic nerve immediately during this period (two sessions/week). After this period,
underneath they can resume normal activity (Figs. 61.1261.19).
The pocket is packed with wet gauze while we dissect

the contralateral pocket. 61.2.6 Complications
Once both pockets have been created, the space is
checked, and any remaining muscular fiber is broken The commonest complication encountered is wound
bluntly or via electrocautery under direct vision using breakdown. This happened in 10% of the authors
an optic-light fiber retractor. The implants are then patients. One case developed infection. If there is a
1050 J. Benito-Ruiz
Fig. 61.12 (Above) Preoperative 56-year-old male patient. (Below) 6 months postoperative with smooth, round, 250-mL implants
good separation between the subcutaneous tunnel with the surgical approach used for the placement of
and the intramuscular pocket, wound dehiscence and implants. Bruising and ecchymosis are common, but
infection do not compromise the implants. It is for this no hematoma requiring surgical intervention has been
reason that we try to make a tight, waterproof clo- encountered. Hematoma can provoke some pain and
sure of the muscular incision. Since we introduced a discomfort to the patient.
modification for skin closure by leaving a presacral Temporal sciatic nerve compression with pain can
dermal strip, we have not experienced any wound happen in some patients as the lower edge of the
dehiscence. implant is located over the sciatic foramen. The intra-
Other potential complications include seroma, muscular technique prevents the placement of the
hematoma, sciatic nerve compression and pain, and implant directly on the nerve; however, the postopera-
implant displacement. tive pain and Lasgue sign that some patients experi-
Seroma has not been observed thus far; however, ence shortly after the operation seem to be related to
this could be correlated with the liposuction rather than the tension of the muscle and the extra volume caused
Fig. 61.13 (Above)

Preoperative 35-year-old male
patient. (Below) Postoperative
with smooth, round, 250-mL
implants
by the surgical hematoma. It is self-limited and can caudally. Patients must not engage in any exercise
be treated with nonsteroidal anti-inflammatory drugs before the fifth postoperative week.
(ibuprofen 600 mg tid) and relaxant drugs (metocarba-
mol 380 mg tid).
Implant displacement is avoided by not performing 61.3 Hip Implants
an extensive dissection of the pocket, especially later-
ally. Because the plane of placement is intramuscular, Since the introduction of the highly active antiretroviral
it is extremely important to keep in mind the surgical therapy for human immunodeficiency virus (HIV)
anatomy of the area and achieve a superior flap or cov- infection in 1996, a range of adverse effects collec-
ering of the implant that is at least 3 cm in thickness tively termed lipodystrophy have been described,
[6]. The author observed a case of upward displace- including metabolic (dyslipidemia and insulin resis-
ment of the implant in a patient who started muscular tance) and physical alterations [13, 14]. These can be
training very early. It was solved surgically by closing divided into central adiposity and peripheral atrophy.
the pocket at its upper limit and making a capsulotomy The atrophy is especially visible in the face and in the
1052 J. Benito-Ruiz
Fig. 61.14 (Above) Preoperative 32-year-old female patient. (Below) Postoperative with 290-mL, smooth, oval implants
lower extremities, where it is characterized by thin legs of the feminine hips, so we devised a method to enhance
with very noticeable veins and buttock flatness. Our both the frontal and the profile contours [15].
efforts as plastic surgeons are focused on palliative
treatments for these physical changes.
Men can compensate for the lack of fatty tissue by 61.3.1 Technique
hypertrophying the muscle; however, in women, this
might produce a masculine appearance. Buttock implants All markings and designs are made while the patient is
alone are not able to provide the typical rounded contour upright (Fig. 61.20). For hip implants, the pocket is
Fig. 61.15 (Above) Preoperative 27 year-old male. (Below) Postoperative with 250 mL, smooth, round implants
centered slightly below the greater trochanter. Before with the trochanteric pocket. The implant is placed
the operation is started, the markings have to be under the fascia of the tensor muscle (Fig. 61.24). The
redrawn as they rise when the patient is in the prone wound is closed in layers.
position. A 4-cm incision is made on the edge of the Patients can sit and perambulate 24 h after the sur-
iliac crest, posterior to the anterior iliac spine and at gery, must wear a compressive girdle for 1 month, and
the level of the tensor fascia latae muscle (Fig. 61.21). must refrain from physical activities (exercise) for
The fascia of this muscle is identified and sectioned 5 weeks.
(Fig. 61.22). Dissection follows a downward direction For hip enhancement, 100-mL oval implants are
under the fascia, and the pocket for the implant is cre- used in all cases. So far, the author has operated on
ated just over the hip joint (Fig. 61.23). This can be a eight cases: six patients with HIV infection and retro-
difficult area to dissect as it is also the area of insertion viral therapy and two cases after gender reassignment
of the tendon of the gluteus maximus muscle. Great surgery. In one case, the hip implant slipped into the
care must be taken not to connect the buttock pocket buttock pocket. The patient underwent surgery again
1054 J. Benito-Ruiz
Fig. 61.16 (Above) Preoperative 30 year-old female. (Below) Postoperative with 300 mL, smooth, round implants
during which a connection between the buttock and for this area, but the gluteal oval implant works well
the hip was discovered. The implant was positioned for this purpose. The implant must be strictly under
on the fascia latae, and the connection was closed. the fascia of the tensor fascia latae muscle to avoid
A capsular contracture of the implant developed on visualization of the edges of the implant. Subcutane-
this side. ous placement yields worse results, with visualization
Silicone implants provide enhanced projection of the edges of the implant and encapsulation (as
in this area and yield a lateral curvilinear contour observed in one of our cases). Extreme care is neces-
(Figs. 61.25 and 61.26). There are no specific implants sary in creating the pocket to avoid connecting the
Fig. 61.17 (Above) Preoperative 25 year-old female. (Below) 1 year postoperative with 250 mL, smooth round implants
space under the fascia latae to that under the gluteus alternative to implants in this area, and it is the first
maximus muscle. option we think of when faced with these cases. Implant
Displacement is potentially the commonest compli- augmentation in the hip area is indicated when fat graft-
cation that can happen with this technique. Thus far, we ing is not possible because of a lack of donor sites or
do not know how the implant will behave in the long because we want to ensure the result without being con-
term, with the movement of the hip and the pressure cerned about fat resorption. The two techniques could
exerted here by the greater trochanter. Fat grafting is an be used simultaneously to obtain a better projection.
1056 J. Benito-Ruiz
Fig. 61.18 (Above)

Preoperative 40 year-old
female. (Below) Postoperative
with 250 mL, smooth, round
implants
Fig. 61.19 (Above) Preoperative 53 year-old female. (Below) Postoperative with 290 mL, smooth, oval implants. She had a long
buttock with a pronounced lateral depression
1058 J. Benito-Ruiz
Fig. 61.20 Typical markings

for a HIV patient with
lipodystrophy. The author
marks the areas to be
aspirated and the position for
the implants (250 mL oval for
the buttock and 100 mL oval
for the hip)
Fig. 61.21 Technique for placement of an implant over the hip.

The incision is made at the iliac crest, behind the upper iliac
spine. A subcutaneous tunnel is performed caudally and the
incision is performed at the fascia of the muscle. The tunnel goes Fig. 61.22 Intraoperative: incision at the fascia lata. The mus-
downward under the fascia lata to the trochanter cle is in the depth of the hole
Fig. 61.23 Position of the

implant under the fascia lata
at the level of trochanter
Fig. 61.24 Placement of the 100 mL oval implant

1060 J. Benito-Ruiz
Fig. 61.25 (Above)

female with HIV
lipodystrophy. (Below)
Postoperative after 290 mL
oval implants for her buttocks
and 100 mL oval implants for
her hips
Fig. 61.26 (Above)

male-to-female patient.
(Below) Postoperative with
oval 100 mL implants to
enhance the hip area
1062 J. Benito-Ruiz
References 9. Cuenca-Guerra R, Quezada J (2004) What makes buttocks

beautiful? A review and classification of the determinants of
1. Crdenas-Camarena L, Lacouture AM, Tobar-Losada A gluteal beauty and the surgical techniques to achieve them.
(1999) Combined gluteoplasty: liposuction and lipoinjec- Aesthetic Plast Surg 28(5):340347
tion. Plast Reconstr Surg 104(5):15241531 10. Centeno R (2006) Gluteal aesthetic unit classification: a tool
2. Roberts TL 3rd, Toledo LS, Badin AZ (2001) Augmentation to improve outcomes in body contouring. Aesthetic Surg J
of the buttocks by micro fat grafting. Aesthetic Surg J 21(4): 26(2):200208
311319 11. Roberts TL (2005) Gluteal augmentation course. Presented at the
3. Mendieta CG (2003) Gluteoplasty. Aesthetic Surg J 23(6): Aesthetic Meeting 2005, Annual Meeting of the American Society
441455 for Aesthetic Plastic Surgery, New Orleans, LA, April 2005
4. Robles J, Tagliapietra J, Grandi M (1984) Gluteoplastia de 12. Gonzalez-Ulloa M (1991) Gluteoplasty: a ten-year report.
aumento: implante submuscular. Cir Plast Iberolatinoamer- Aesthetic Plast Surg 15(1):8591
icana 10:4 13. Carr A (2003) HIV lipodystrophy: risk factors, pathogenesis,
5. Vergara R, Marcos M (1996) Intramuscular gluteal implants. diagnosis, and management. AIDS 17(Suppl 1):S141S148
Aesthetic Plast Surg 20(3):259262 14. Carr A, Samaras K, Burton S, Law M, Freund J, Chisholm DJ,
6. Vergara R, Amescua H (2003) Intramuscular gluteal implants: Cooper DA (1998) A syndrome of peripheral lipodystrophy,
15 years experience. Aesthetic Surg J 23(2):8691 hyperlipidaemia and insulin resistance in patients receiving
7. de la Pea JA (2004) Subfascial technique for gluteal aug- HIV protease inhibitors. AIDS 12(7):F51F58
mentation. Aesthetic Surg J 24(3):265273 15. Benito-Ruiz J, Fontdevila J, Manzano M, Serra-Renom JM
8. Gonzlez R (2004) Augmentation gluteoplasty: the XYZ (2006) Hip and buttock implants to enhance the feminine con-
method. Aesthetic Plast Surg 28(6):417425 tour for patients with HIV. Aesthetic Plast Surg 30(1):98103
Liposculpture and Buttock
Augmentation with Fat Grafting 62
Arturo Grau
62.1 Introduction 62.2 Technique
The buttocks are perhaps the most admired feminine 62.2.1 Preoperative Care
attribute. It is possible to augment and/or model the
gluteus region with fat grafting after a prior liposuc- Complete blood and heart tests are run prior to sur-
tion. Getting perfect results in liposuction and buttock gery, and 1 g of cefalexin and 500 mg of Cipro are
augmentation with fat grafting is, however, remark- administered to the patient orally 6 h prior to
ably challenging. Despite its long learning curve, we surgery.
can get very satisfactory results and a lot of patient
satisfaction. Taking it as a standardized procedure,
it becomes reproducible and avoids complications. 62.2.2 Preoperative Markings
Getting good results with this procedure begins with
good patient selection, the way the markings are made, The preoperative markings are very important for good
the use of a standardized technique, and controlling the results, especially in LS. It is very important to define
patient in the postoperative period. what we want to take out, so these fat deposits are
Localized fat deposits can be treated with liposuc- marked with circles in black. The more the number of
tion, and the fat harvested can be used for modeling of circles that define the fat deposits, the more fat there is
the gluteus area. The author has very good outcomes to take out. It is important to do these markings with
with the results of fat grafting in an intramuscular the patient standing up. This way you can note all the
plane. Permanent results depend on the survival of the excessive fat in the contour of the patient (Fig. 62.1).
adipocytes. The blood supply in the muscular plane is The markings in blue limit the areas where the fat will
much richer than in the subcutaneous plane, so the fat be grafted.
grafted in the muscles of the buttock area is more likely The results can be appreciated right after finishing
to survive. Making small tunnels of 35 mL per path surgery (Fig. 62.2), and the results are long lasting
during the withdrawal of the cannula in the intramus- while the patient maintains her body weight after
cular plane guarantees the survival of these fat cells. surgery. If the patient gains weight again after sur-
gery, the results are not going to be the same, because
she will not gain fat in the same way she used to
A. Grau (not in the waist where all the fat is extracted). The
Facial and Body Cosmetic Surgery, Director of Multiclinica
patient that gains weight after fat transfer augments
Medical Center President, Paraguayan Academy of Cosmetic
Surgery (PACS), International Member of the AACS the size in her arms and legs in larger proportions than
Asuncin, Paraguay before.

1064 A. Grau
a b c
d e
Fig. 62.1 Markings should be made in the standing position. Black markings indicate fat to be extracted. Note double circles where
greater amount of fat deposits are present. Blue marking indicate gluteal region for fat injection. Front view (a), back view (b), mid
front view (c), mid back view (d). The result immediately after finishing surgery in (e)
62 Liposculpture and Buttock Augmentation with Fat Grafting 1065
Fig. 62.2 (a) Preoperative. a

(b) Two years postoperative
1066 A. Grau

b
62.3.1 Anesthesia
The anesthesia is a peridural or epidural block with a

catheter with light sedation so that the patient does not
feel any pain at all and there is no concern about lido-
caine toxicity, since sometimes the infiltration volume
exceeds 2 L. If you have a well-trained anesthesiologist
who is used to doing this block, which is quite frequent
in women giving birth, you do not have anything to worry
about. Also with this anesthesia, the buttocks (where you
do not do tumescent anesthesia) are also blocked, so you
can do the fat grafting without pain whatsoever.
Then again if you are not able to find a good and
trustworthy anesthesiologist in your area, the tumes-
cent technique of anesthesia is always recommended.
Since most of the times this anesthesia is combined
with sedation, during the fat grafting it will be neces-
Fig. 62.3 The infiltration cannula is a 2-mm Klein infiltration
sary to do more sedation because the gluteus area is cannula with the length enough to reach the upper abdomen
not infiltrated with tumescent solution at any time. from the pubic area (30 cm)
Infiltration will deform this area, and it will be impos-
sible to determine what amount of fat to inject.
Anesthesia of the upper back, arms, and submental For the infiltration, a peristaltic pump is used that
fat is under tumescent. rotates in both directions allowing to infiltrate and suc-
tion with the same pump. The infiltration cannula is a
2-mm Klein infiltration cannula (Fig. 62.3) with the
62.3.2 Inltration length enough to reach the upper abdomen from the
pubic area (30 cm). Infiltration is done at a medium
Since epidural block anesthesia is used, lidocaine is velocity while liposuction is done at full speed. Equal
not necessary in the infiltration solution. Only amounts of solution are to be infiltrated on each side of
2 ampules of epinephrine per liter of saline solution at the areas, so it is important to measure the amount in
room temperature are used for the infiltration solution. each area. The infiltration should be symmetrical, and
With this concentration of epinephrine, there is much that will help obtain better results.
less blood loss during the procedure and the infiltration
ratio is as a super wet technique rather than a tumes-
cent one since the author has not seen any difference in 62.3.3 Liposculpture
over 9 years in the blood loss with both techniques.
The author started out with the tumescent that had The cannulas used are Mercedes style 3, 4, and 5 mm
1 ampule of epinephrine and moved on to 2 ampules wide and from 20 to 30 cm long. The thinner the can-
that really stopped the blood loss in a crucial way. nula, the more forgiving it is, so those who are starting
After that there was no real difference in super wet or out should be careful and start out with the thinner can-
tumescent. The author prefers super wet (1 L of infil- nulas. For trouble areas such as the trochanteric region,
tration distributed in front side and 1 L on the back inner thighs, and lower abdomen, 3-mm cannulas
side) because you have more control of the fat you are should be used unless the patient is really overweight,
taking out and you can appreciate the color of the fat and only in these cases should a 4-mm cannula be
harvested. The author has infiltrated more than 3 L of used. The peristaltic pump is then set to aspirate
this solution many times with absolutely no side effects switching the direction, and all the fat is harvested in
because of the epinephrine. the same sterile saline solution bag (Fig. 62.4).
1068 A. Grau
Fig. 62.4 The peristaltic

pump infiltrates the solution
a
and afterwards aspirates the
fat by changing the direction
of rotation. All the fat is
harvested in the same sterile
saline solution bag (a). A
closer view of the fat
harvested in the sterile saline
solution bag. Note the yellow
color of the fat extracted due
to the high concentration of
epinefine (two amps per liter)
and low aspiration pressure of
the peristaltic pump (just 4
mm/hg).
The cannula incisions should be made in areas that mark of the bra will be in the back. All these incisions
will be hidden by the bikini garments. Just two 5-mm are hidden by the bikini. Now, the incisions performed
incisions are performed in the pubic area for the whole on the outer side for the trochanteric deformity are just
abdomen and front side of the waist (Fig. 62.5). Two on top of the marking. These will be seen, so they need
incisions are performed in the bikini line just outside to be as small as possible, and using a thin (3-mm)
of the Michaelis rhomboid and one inferior to it for cannula is better.
treating the fat deposits of the back side of the waist, It is better to divide the body in areas or zones to
hips, and Michaelis rhomboid (Fig. 62.6). For the obtain greater and more-symmetrical results. The abdo-
upper back, two incisions are performed where the men is divided into four zones: upper right, upper left,
Fig. 62.5 Two 5-mm incisions are performed in the pubic area
for the whole abdomen and front side of the waist b
Fig. 62.7 A 3-mm, 30-cm-long cannula is used for the upper

Fig. 62.6 Two incisions are performed in the bikini line just
abdomen. Equal amounts of saline infiltration and fat extraction
outside of the Michaelis rhomboid and one inferior to it for treat-
should be performed for achieving symmetry, beginning from
ing the fat deposits of the back side of the waist, hips, and
the mid abdomen (a) and moving to the outter abdomen (b) in a
Michaelis rhomboid
windshield wiper motion
lower right, and lower left. Equal amounts should be har- below the marking (Fig. 62.12). The trochanteric region
vested from each side, and it is important to start out is done with this same 3-mm, 25-cm-long Mercedes
liposculpturing the fat from the most distant area from cannula from an incision just superior to the markings,
the incision point, so the fat harvested is brought towards also starting from the most distant part marked, going
the incision. This is very important if you do not want to very superficial, and bringing the fat harvested from
leave depressions in the area. Start out with a 3-mm, that area towards the incision (Fig. 62.13). This is the
30-cm-long cannula for the upper abdomen (Fig. 62.7). only area where one goes from superficial to the deep
Then go to the waist with a 4-mm, 25-cm-long cannula plane and one has to be very careful, harvesting the fat
(Fig. 62.8), to end up in the lower abdomen with a 3-mm, in a windshield wiper motion to not leave any depres-
20-cm cannula (Fig. 62.9). Preoperative and postopera- sions. The back side of the waist, the hips, and the back
tive of the abdomen and waist are shown in Fig. 62.10. are all done with a 4-mm cannula that can be from 25 to
The inner thighs are done with a 3-mm, 2025-cm 30 cm long (Fig. 62.14). The waist is the only area that
cannula depending on the length of the legs from an permits the surgeon to withdraw all the fat, leaving
incision just below the marking (Fig. 62.11). The knees almost nothing, and the harvest begins in the deep
are done with the same cannula from an incision just plane moving on to the superficial plane.
1070 A. Grau
a a
b b
Fig. 62.8 A 4-mm, 25-cm-long cannula is the best for the waist.
Here all the fat should be extracted to create a thin waist. Always Fig. 62.9 A 3-mm, 20-cm-long cannula for the lower abdomen.
beginning from the inner area (a) and moving to the outer area. Here a small cushion of fat should be always left to obtain a
Here one can grab the fat with the left hand so the cannula can natural look. If excessive fat is extracted from the lower abdo-
extract more fat leaving this area with only skin and muscle (b). men, it could look too flat and odd. Also it can be left with
depressions. Always from the center (a) to the outer area (b) in
a windshield wiper motion
62.3.4 Buttock Augmentation
of every surgeon to make and shape each buttock
The last liter of fat aspirated is used for the grafting, (Fig. 62.17). It should be done calmly and with no
and it is recollected in a special autoclavable container hurry. When the cannula finds some obstruction in its
device made for this purpose that allows the remaining path, it must be extracted and reinserted.
solution to be drained after decantation (Fig. 62.15). After a few intramuscular injections are done,
One gram of cefazolin is put into the fat harvested, and sometimes it is necessary to graft superficial into
nothing else is added. The use of platelet-rich serum the subcutaneous fat also, to model some buttocks that
can be used. do not shape well with only the intramuscular grafting.
The fat is then loaded into a 60-mL syringe from The amount of fat grafted goes from 60 to 500 mL, but
the container (Fig. 62.16). Now it is ready to be grafted the usual amount goes from 180 to 360 mL per side.
into the buttocks. With a 2.5-mm cannula, 1215 cm The results are visible immediately after surgery
long, the fat is grafted into the muscles of the buttock (Fig. 62.18). CT scans have been made on one patient to
region. The grafting is started from a deep to a superfi- show the survival of the fat over time: The pre-injection
cial plane, and the injection is done during the with- scan where the muscle is shown intact, the postoperative
drawal of the cannula. Small tunnels are made of 5 mL at 7 days where the graft is visible inside the gluteus
each. So it is necessary to make many tunnels, and the major muscle, and after 3 months where the graft is
modeling of the area is done in this manner. It is the art organized and living inside the muscle (Fig. 62.19).
a b
Fig. 62.10 (a) Preoperative. (b) Immediate Postoperative of the abdomen and front side of the waist. The back side is done after
finnishing the front side and turning the patient to ventral decubitus
a b
Fig. 62.11 The inner thighs are done with a 3-mm, 20 to 25-cm- the leg and bending the knee is the best way to extract this area (a).
long cannula depending on the length of the legs and the amount of Always begin from the front side and move to the back side (b). I
fat to extract, from an incision just below the marking. Care should divide the inner leg in three compartments. Front, mid and back.
be taken to only extract the exact amount of fat and not leave any Always finish one compartment before moving to the following
depressions, since it is very easy to over resect in this area. Opening
1072 A. Grau
Fig. 62.12 The knees are

done with the same cannula
from an incision just below
the marking. The fat is easier
to extract in an open leg
position
62.3.5 Wrapping
After finishing the procedure, the patient is wrapped

with skin color 5-cm Micropore. This avoids swelling
and also decreases pain in the first few days postopera-
tive. This wrapping is taken out at day 5 postopera-
tively (Fig. 62.20). To avoid pain during the withdrawal
of the wrapping, it is recommended that the patient
should shower with warm water just prior to taking it
off so that it will be wet and this way it comes off
easily.
62.3.6 Postoperative
Fig. 62.13 The trochanteric region is done with the same
Immediately after surgery, a compressive garment is 3-mm, 25 cm cannula from an incision just superior to the mark-
ings, also starting from the most distant point marked and har-
used over the tape wrapping and recommended to be
vesting the fat towards the incision point. Here it is important to
used for at least the first 15 days postoperative. Patients go from superficial to the deeper plane. This way it is easier to
are allowed to be in any position in bed, but most fre- maintain the natural curve of the female thigh without leaving
quently, sideways or ventral decubitus. Ambulation is depressions that are very easily left in this area
started the next morning after taking out the Foley cath-
eter left during surgery and the immediate postopera-
tive. The patients are encouraged to ambulate. Lymphatic sics are used for the first few days, and this way they
drainage and 3-MHz ultrasound is also recommended to can manage pain a lot better.
help avoid swelling, 3 times a week for the first month.
The patient may return to normal activities after day 5
and to exercise after the month. Abdominal muscle 62.4 Complications
exercises are not allowed until 2 months after surgery.
Patients do complain of pain over all the waist area, Since antibiotics are used even before surgery is per-
which is the place where all the fat is extracted and formed, there has not been a case of infection after
where the most trauma is done. Morphine-like analge- surgery. Seven years ago, there was one case of
a b
Fig. 62.14 (a and b) LS of the waist from the two incisions extracted can be measured, to extract the same amount on the
done in the back. Here a 4-mm, 25 to 30-cm-long cannula is second side. This will help achieve symmetry. The change in the
used. All the fat should be extracted in order to achieve a thin contour is already visible after just finishing one side. (e) LS of
waist. (c) LS of the hip. (d) It is very important to finish one side Michaelis rhomboid, left side finished. (f) The whole LS of the
first before beginning the second. This way the amount of fat rhomboid finished.
1074 A. Grau
e to 6 months postoperative. The usual time for the

swelling to disappear is 24 months. Hyperesthesia
and paresthesia are possible complications but are
mostly temporary and disappear in a few months
postoperative.
Hyperpigmentation and hypopigmentation of the
skin are possible complications and disappear with
dermatologic treatment, but mostly over time.
62.5 Conclusions
Liposculpture and buttock augmentation are procedures

that can be combined together and represent a real chal-
f
lenge for the surgeon, over all for the beginning one. If
care is taken in making it a standardized procedure, the
surgeon will achieve better outcomes and more patient
satisfaction (Figs. 62.2162.24). The use of the equip-
ments detailed in this presentation such as the peristal-
tic pump and the aseptic fat container helps achieve
good results with lower risks. Absolutely no treatment
is done to fat harvested in this technique except the
addition of an antibiotic after simple decantation, and
the results are fabulous with cases documented after
more than 6 years. It is a safe and reproducible proce-
dure in well-trained hands. The surgeon starting out
with this procedure should go from less aggressive
Fig. 62.14 (continued) extraction of the fat deposits to not leave sequelae as
depressions and asymmetry. But in time, one can go to
more aggressive extraction to really create changes in
hematoma on one inner thigh that resolved with the contour of who is seeking to look better.
drainage and volume transfusion of packed red blood
cells.
Prolonged edema is frequent, especially in the
waist, where all the fat is taken away, sometimes up
Fig. 62.15 (a) The last liter of fat aspirated is used for the grafting, and it is recollected in a special autoclavable container device
made for this purpose. (b) Allows the remaining solution to be drained after decantation
1076 A. Grau
Fig. 62.16 The fat is loaded into a 60-mL syringe from the container
Fig. 62.17 (a) A 2,5-mm 1214-cm cannula is used for the

intramuscular fat injection. (b) The cannula goes inside the glu-
teus muscles and the injection is done during the withdrawal of
the cannula only injecting 3 to 5 mL per path
Fig. 62.18 The results are visible immediately after finishing bra will be hiding them. These are necessary for LS of the upper
surgery. Taking a photo at this time will show the patient how back, where one can not reach from the bottom incisions. In
she will look after the swelling diminishes, that will occur in 3 some cases to achieve a good buttocks contour, some fat must be
to 4 months postoperative. (a) Preoperative. (b) Immediate post- injected superficially in the subcutaneous plane to give the but-
operative, note the incisions in the upper back done where the tocks the proper shape
1078 A. Grau
a b
Fig. 62.19 (a) CT scan before the injection. (b) CT scan 7 days after the IM injection of fat. (c) CT scan 3 months after injection
showing permanent fat retention. (d) The same patient before surgery. (e) 5 days postoperative. (f) 3 months postoperative.
(g) 4 years postoperative
d e
f g

1080 A. Grau
a b
Fig. 62.20 (a) Wrapping with 3 layers of Micropore tape postoperative. (b) The use of some gauze between the skin and the tape
can help with the withdrawal. (c) The gauze prevents excessive sticking of the tape
Fig. 62.21 (a) Preoperative 25-year old female. (b) One month postoperative following liposculpture, buttocks augmentation with
fat injection and breast augmentation. Notice the persistent swelling at one month. (c) Fourteen months after surgery

1082 A. Grau
a b c
d e
Fig. 62.22 (a) Preoperative 22-year old female back view. before surgery. These details must be observed by the surgeon
(b) 5 days postoperative, same view. Notice that only one tro- before surgery. (c) Preoperative half-side view. (d) Immediate
chanteric area was treated due to a asymmetry that she had postoperative. (e) 15 days postoperative
a b c
d e f
Fig. 62.23 (a) Preoperative 21-year-pld female weighing 52 with 15-kg weight gain. (e) Secondary liposculpture to treat new
kg. (b) Immediately after LS and Buttock augmentation (c) Two fat deposits. (f) Immediate postoperative after secondary LS. (g)
months postoperative with 8-kg weight gain. Notice the fat Preoperative front-side view. (h) Two months after surgery with
gained in legs and buttocks. Almost no fat gained in the waist 8-kg weight gain. (i) Three years after surgery with 15-kg weight
where all the fat is extracted. (d) Three years postoperative gain. (j) Markings for secondary LS
1084 A. Grau

g h
i j

27-year old female. (b) Five a b
days after LS and buttock
augmentation. (c) One month
after surgery still with
persistent edema. (d) Fourteen
months after surgery with a
12-kg weight loss. Notice that
the buttock still conserves the
same volume and shape as the
one month after photo (c)
c d
1086 A. Grau
Bibliography Coleman SR (1995) Long-term survival of fat transplants: con-

trolled demonstrations. Aesthetic Plast Surg 19:
421425
Roberts TL III, Toledo LS, Badin AZ (2001) Augmentation of
Fodor PB (1999) Defining wetting solutions in lipoplasty. Plast
the buttocks by micro fat grafting. Aesthetic Surg J 21(4):
Reconstr Surg 103:15191520
311319
Pereira LH, Radwanski HN (1996) Fat grafting of the buttocks
Shiffman MA (1998) Medications potentially causing lidocaine
and lower limbs. Aesthetic Plast Surg 20:409416
toxicity. Am J Cosmet Surg 15:35
Fodor PB (2002) Secondary lipoplasty. Aesthetic Surg J
Fodor PB (1993) Superficial liposuction. Aesthet Plast Surg
22(4):337348
13:1014
Lewis CM (1992) Correction of deep gluteal depression by
Jackson RF, Dolsky RL (1999) Liposuction and patient safety.
autologous fat grafting. Aesthetic Plast Surg 16:247250
Am J Cosmet Surg 16(1):2123
Gasparotti M, Lewis CM, Toledo LS (1993) Superficial liposcu-
Fodor PB (1995) Wetting solutions in aspirative lipoplasty: a plea
lpture. Springer, New York
for safety in liposuction. Aesthetic Plast Surg 19:379380
Large Volume Fat Transplant
to Buttocks and Legs for 63
Enhancement and Reconstruction
63.1 History tion of the human body using large volumes of fat tis-
sue harvested by the liposuction technique. Supporting
The author started with this technique early 1992 fol- this theory was the history of extensive related uses of
lowing requests and expectations of patients who were small quantities of fat tissue described in the medical
very sensitive about the culture of beauty and requested literature since 1893 to correct defects in soft tissues
enlargement of the volume of buttocks, calves, and and also encouraged by the pure concept of a graft as it
ankles. Surgical techniques to enhance buttocks or is described in plastic surgery, such as skin graft or hair
calves volume at that time, consisted of placement of graft.
silicone implants below the gluteus maximus muscle
in the buttocks or over the internal gemellus muscle
for calves. There was no other technique known by 63.2 Technique
the author to enlarge ankles.
Those surgical techniques with placement of sili- 63.2.1 Fat Retrieval
cone implants had been performed by the author; how-
ever, they were characterized by various inconveniences, Any anatomical area from below the neck is good to
such as (1) very painful within the 20 postoperative retrieve fat tissue. I will mention those areas of major
days, (2) very poor aesthetic results, and (3) permanent concentration of volume such as the arms, back, abdo-
and/or long-term disabilities consisting of persistent men, hips, knees, and buttocks.
pain when approaching the sitting position or when-
ever wearing heels. Seeking to obtain the optimal aes-
63.2.2 Method
thetic results, reducing the recovery period, searching
for the ideal and persistent filler material that reduces
Tumescence with 1,000 mL saline and 1 mL epineph-
the side effects, and avoiding physical or aesthetic
rine is performed in any area used as a donor site. Five
complications, it was decided to adopt the fat grafting
to ten minutes before harvesting are required to achieve
tissue as a technique of beautification and reconstruc-
maximum hemostasis and to obtain a clean tissue.
63.2.3 Liposuction
L.V. De Pedroza
Plastic and Reconstructive Surgery, Universidad del Valle, Liposuction is performed with a mixture of ultra-
Medellin Bogot, D.C, Colombia, South America
e-mail: [email protected] sonic assisted liposuction and traditional liposuction

1088 L.V. De Pedroza
at low pressure with machine. The introduction of 63.2.7 Why to Choose Fat as a Tissue Filler
ultrasound assisted liposuction was made in 1997
and has been used to the present time. Since 1991, Fat tissue has three of its large list of characteristics
machine liposuction has been performed at low which makes it the ideal tissue filler:
pressure. 1. It is composed of cells that have the property to be
hypertrophic.
2. It is composed of cells able to grow in volume, and
63.2.4 Fat Tissue Graft at the same time, it is a hyperplasic tissue.
3. It has a large amount of cells able to grow in vol-
The fat tissue graft is placed in sterile glass flasks that ume (Hyperplasic nature). This property makes it
have been vapor sterilized. An amount of 13 L and the ideal souffl to fill a depressed or deformed
more is kept sterile with no contact with air until natu- anatomical area.
ral decantation of the cells is done. This takes about
1525 min to happen.
63.2.8 Ideal Placement of the Fat Graft
63.2.5 Decantation The nature of human anatomy places fat tissue under
the skin surface and over the muscular structure.
After the natural separation of the fat is done by Also, intraperitoneally, fat covers all the abdominal
placing the fat cells into the surface and the tumes- organs and structures with a large amount of the fat
cent liquid on the bottom of the flasks, harvested tis- cushion named epiplon. The authors work was
sue is ready to be transferred to a sterile syringe. For based on sculpting the normal anatomy of the human
large volumes, a 60-mL syringe is used, and for body by reshaping and relocating fat tissue, and the
small volumes, a 10-mL syringe is used to inject the goals initially were based on enhancing the volume
graft. of buttocks, ankles, and calves for beautification. The
graft was placed under the skin following the normal
anatomic growth and existence of the fat tissue.
63.2.6 Materials Grafting large volumes of fat tissue is of great help
as a total body tissue filler and is great to reconstruct
1. Cannulas from 3 to 5 mm wide are used to harvest body deformities from traumatic, congenital, or iatro-
tissue. If tissue is retrieved with a 3-mm cannula, genic. It produces excellent results in cosmetic
injection of the graft is performed with a 3-mm enhancement and is a long-term survival tissue that is
cannula. well tolerated and low in risks if the graft is adequately
2. Blunt cannulas to harvest and blunt cannulas to manipulated by preventing its contamination and pre-
graft are used. serving the survival of its cells while harvesting it.
3. Liposuction machine at low pressure (350 Hg) is
used to preserve the integrity of the cells which
could be disrupted under high vacuum pressure. 63.2.9 Sinopsis of the Large Volume Fat
4. Syringe liposuction is recommended for small Transplant Technique
amounts of fat tissue transplant.
5. Centrifugation of small amount of fat tissue to be (a) Materials:
transplanted over the face and hands is recom- 3 to 5 mm cannulaes.
mended in order to obtain a more precise quality Syringe suction.
of graft free of liquid and avoid unnecessary Machine suction low pressure.
edema. 3 to 5 mm cannulaes blunt for injection.
6. Avoid washing or exposing to the air is the main purpose Tumescence with 1000 cc saline and 1 mg
of manageability of the graft preserving its viability and Epinefine.
preventing its contamination, as a priority. Sterile glass 1000 cc flacks.
63 Large Volume Fat Transplant to Buttocks and Legs for Enhancement and Reconstruction 1089
(b) Donor sites areas: 4. Normal to the touch

Arms. 5. No side effects if manipulated sterile
Back. 6. Easy handling
Hips. 7. Long lasting permanent in life
Abdomen. 8. No functional changes
Buttocks. 9. It is a fat cells graft, not a fat (liquid) or oil
Knees. injection
(c) Methods:
Traditional suction machine.
Syringe suction. 63.4 Complications
U.S. Assisted liposuction.
Centrifugation for small amounts of fat trans- The author has had a small amount of slight complica-
plant tissue (for face and hands) tions, varying from skin vesicles from the skin tape,
(d) Recipient areas: redness, and edema of the ankles for 20 days postoper-
Buttocks. atively. There was one case of erysipelas that occurred
Hips. for traumatic reasons and was treated with penicillin
Muscular atrophies in Legs, Arms, Ankles. without losing the fat transplant volume injected over
(e) Manipulation of the graft: the legs. In summary; the clinical results and satisfac-
No washing. tion of our patients, the long term follow up, today 16
Natural decantation 1525 minutes in the sterile years of experience with this technique; makes us rec-
glass flasks. ommended it to all of our patients with reconstructive
Storage for 3045 minutes with NO contact with and cosmectic purposes.
air.
Direct suction from patients -to flasks-to sterile
syringes-to patient again as a graft. 63.5 Discussion
(f) Amount of fat volume transplanted:
Area Amount (mL) Since 1992 to the present year, the author has per-
Each buttock 240700 formed 3,720 cases of fat transplant to the buttocks
Each leg 150400 (Figs. 63.163.4). Thirteen hundred of those cases had
Each ankle 120280 calf and ankle enlargement together, and 722 cases had
Each hip 300750 reconstructive purposes. Sixteen hundred and ninety-
eight cases were performed for cosmetic purposes.
The average age of those patients ranged from 18 to
63.3 Specic Qualities of Fat Transplant 75 years old. Female patients were the 89% of the total
operated patients. Aging process produces an early
1. Fat is an autologous tissue appearance of sagging buttock, as early as in the
2. Hyperplasic tissue (large number of cells) 47-year-old females, and progresses every 5 years. The
3. Each fat cell has a hypertrophic capacity to grow in ideal filler product for rejuvenating and aging buttock
volume (the souffl effect) area is fat tissue harvested in large volumes.
a b
Fig. 63.1 (a) Preoperative 58-year-old female with aging process of the buttocks with wrinkles and loss of volume. (b) Eight
months postoperative after 300 mL of fat transfer to each side

28-year-old female requesting
increased volume of buttocks.
(b) One year following fat
retrieval from abdomen,
waist, and hips and transfer
of 300 mL of fat to each
buttock
63 Large Volume Fat Transplant to Buttocks and Legs for Enhancement and Reconstruction 1091

b
a b

27-year-old male with
agenesis of gemellus muscle
of the right leg. (b) Seven
years after 350 mL fat graft
over the agenetic musculature
of the right leg

72-year-old male with a
skinny legs. (b) Two and
one half years after 300 mL
fat transfer to each calf and
ankle
b
Treatment of Venous Insufciency
with Sclerotherapy 64
Alessandro Frullini
64.1 Introduction The year 2000 represented the turning point in foam
sclerotherapy when the three-way tap technique was
Sclerotherapy of varicose veins is the injection of drugs introduced, that was capable of preparing a good
capable of transforming the walls of varicose veins into extemporary foam with extremely reduced cost. An
fibrotic cords. This has been used for many years in the ideal injection of air-based SF should be made no more
treatment of varicose veins, but the last 15 years has rep- than 15 s after generation.
resented a true renaissance of sclerotherapy. This was
due to the introduction of sclerosing foam in this field.
The sclerosing foam (SF) is a mixture of gas and a 64.2 Technique
liquid solution with tensioactive properties. The behav-
ior of a sclerosing foam is different when injected as Foam can be used in every kind of classical sclerother-
compared to the action of a liquid solution because it apy, but larger trunks and recurrences are the best indi-
forms a coherent bolus inside the vein that avoids any cations. Smaller veins or teleangectasias are not the best
mixing of the drug with blood. In this way, it is possi- indication for SF as for those small vessels the ideal
ble for the very first time to achieve full control of drug active concentration of sclerosant is easily reached with
concentration inside the vein and time of contact liquid too. The author reserves polidocanol (POL) foam
between the sclerosing agent and the endothelium. (or very seldom sodium tetradecyl sulfate STS) for
Using a liquid sclerosing agent the true effect on resistant cases or for telangectatic matting that, on the
endothelium is due to the specific concentration of contrary, is a very good indication for SF. Tessaris foam
sclerosant in a vein for a desired time. The combina- is difficult to push into these small vessels, but reducing
tion of ideal time with ideal concentration gives opti- the liquid to air ratio to 1:2 or 1:1 ameliorates quality
mal sclerosis. This is easily achieved in smaller veins and durability of foam, enhancing safety and results.
like telangiectasias (where sclerotherapy has never Reports on a reversible neurological and visual
presented a problem), but is difficult to obtain in large deficit have been published with liquid and foam scle-
veins like the great saphenous vein. The liquid sclero- rosants. Despite the opinion of many authors on a rela-
sant is diluted with the amount of blood inside the vein tionship between foam sclerosants and patent foramen
itself, but a sclerosing foam pushes away almost all the ovale (PFO) on the development of such side effects,
blood creating a virtually bloodless field where the the author has investigated the possible production of
ideal condition for sclerotherapy is achieved. vasoactive substances from the vein after the injection
of an irritative agent as a sclerosant drug. In such con-
dition, in an experimental model on rats, augmented
release of Endothelin 1 was observed. The author is
A. Frullini
studying the possible role of Endothelin in the genesis
Studio Medico Flebologico, Figline Valdarno, Florence, Italy
e-mail: [email protected], of neurological and visual disturbances after sclero-
[email protected] therapy and present results seem encouraging. Among

1094 A. Frullini
the major complications, a partial DVT (deep vein a

thrombosis) has been reported after sclerotherapy for
varices. However, in every case, the DVT was asymp-
tomatic and without sequelae at 3 months.
Many new options are now offered to patients and doc-
tors: surgery, thermal ablation (endo venous laser abla-
tion, radiofrequency closure and steam obliteration) and
endovenous chemical ablation (foam sclerotherapy).
Sclerotherapy is a treatment capable of achieving
good results in a safe and less invasive manner than
surgery or every other technique.
Thermal techniques are only a different way of
treating the saphenous trunk using a method that
is something very similar to surgical intervention:
b
The patients are in a (semi)operating room, a sterile
field is prepared, and anesthesia is given. Phlebectomies
will be done on tributaries in most cases. The only dif-
ference is that in the stripping operation the same fiber
(stripper) is retrieved, and a junctional ligature is made.
Moreover, gentle invaginating stripping under local
anesthesia seems to me less invasive, when properly
done, than laser ablation or radiofrequency closure.
If a different treatment of saphenous insufficiency
is to be found, at this time, only foam sclerotherapy
has the ideal prerequisites: it is cheap, 10 min for the
whole procedure, easy to perform for a trained doctor,
tributaries are treated at the same time as the saphen-
ous vein, and return to daily activity is resumed after a
15-min walk. No anesthesia is required at all and post-
treatment pain is absolutely absent.
Moreover, venous insufficiency it is not simply a Fig. 64.1 (a) Typical red and blue telangiectasia that is the best
defect that must be eliminated. It is a true disease with field of application of liquid sclerotherapy. (b) Larger telangi-
ectasias that are easily accessed but they carry a higher risk for
a natural evolution. The simplicity of foam sclerother- pigmentation
apy makes the treatment easily accepted by patients
even if more sessions are needed in subsequent years
to stabilize this condition. Neither surgery, nor thermal polidocanol is the preferred drug at a concentration rang-
ablation can claim the same benefits. This probably ing from 0.25% to 0.5%, the latter generally used.
means that foam sclerotherapy is going to become the Holding syringes in the proper way is the first step.
ultimate treatment for venous insufficiency, replacing The non dominant hand is the most important as it is the
every other treatment for most cases. one that flat and stabilize the target area (Fig. 64.2).
Keeping the syringe as parallel as possible to the skin is
very important. For this reason smaller 1 mL syringes
64.3 Sclerotherapy for Spider Veins could be useful. The vessel blanches during injection
and keeping the needle inside the vein for few seconds
Sclerotherapy plays a major role in the treatment of more prevents backflow of blood in telangiectasia before
telangectasias. Despite many physicians reserve such the onset of a good spasm (Fig. 64.3). Eccentric com-
treatment only for blue telangiectasias, sclerotherapy of pression with cotton rolls is not useful in my experience
tiny red telangiectasias can be successfully accomplished for red telangiectasia but keeping a digital compression
with good technique and little magnification (Fig. 64.1). or maintaining the needle inside the treated vein for a
Foam sclerotherapy is seldom necessary and liquid longer time until spasm appearance is advisable.
64 Treatment of Venous Insufficiency with Sclerotherapy 1095
Fig. 64.2 The non-dominant hand holds the skin creating a

b
firm surface on which needle enters easily and precisely
Fig. 64.3 Maintenance of the needle in situ for some time

avoids immediate blood refilling of the vessels
Figure 64.4 shows spider veins before and after

treatment with polidocanol 0.5% with follow up at
6 months. Foam sclerotherapy could be sometimes
useful like in larger telangiectasia with risk of bleed-
ing. In this case, polidocanol 0.5% foam Tessari
method with a lower air to liquid ratio (1:2) was used
achieving a good immediate spasm (Fig. 64.5). Fig. 64.4 Spider veins. (a) Before treatment. (b) After treat-
ment with polidocanol 0.5%. (c) Follow up at 6 months
64.3.1 Complications great saphenous vein insufficiency. The poor esthetic

outcome caused large disappointment in the patient and
Besides from general complications (e.g., allergy), for only several years later the pigmentations reabsorbed.
spider veins treatment local complications are few if Cutaneous necrosis is very rare if not impossible using
proper technique is used and avoiding treatment in liquid polidocanol 0.5% according to proper doses and
patients with reflux on major axes. In Fig. 64.6 the patient administration technique but it is a possible complication
was treated for spider veins notwithstanding a severe of foam sclerotherapy for teleangectasias (Fig. 64.7).
1096 A. Frullini
a c
Fig. 64.5 (a) Blue bleb in CVI with high risk of bleeding. (b) Treatment of blue bleb with foamed polidocanol 0.5% (three way
technique). (c) Optimal spasm immediately after sclerosing foam injection
64.4 Sclerotherapy for Larger Veins Patients are thoroughly examined with duplex ultra-
sound in the standing position and treatment is per-
In the authors experience, more than 80% of saphenous formed in a supine position. The target vein is accessed
insufficiency can be effectively treated with echogu- in a transverse scan but with lateral access. This makes
ided foam sclerotherapy. Inguinal and popliteal recur- the injection much easier (Fig. 64.9).
rences (Fig. 64.8) are the best indications but truncal A class 2 (3040 mmHg) thigh level is then used for
varices with a diameter below 1.2 cm have a similar late 1 month. Occasional blood collection inside treated veins
outcome of stripped saphenous veins. is aspired directly or under echo-guidance (Fig. 64.10).
64 Treatment of Venous Insufficiency with Sclerotherapy 1097
Fig. 64.7 Small cutaneous necrosis after foamed sodium tet-

radecylsuphate injection of red telangiectasias
Fig. 64.6 (a) Severe pigmentation occurred after sclerotherapy

for telangiectasia in a patient with previously untreated greater
saphenous vein insufficiency. (b) Partial resolution of pigmenta-
tion after several years (after surgical stripping of the GSV) Fig. 64.8 (a) Large varicose veins of the poplitea fossa. This is
a good indication for foam sclerotherapy as surgery may be
complex in such condition. (b) The success rate of treatment in
saphenous veins below 1.2 cm of diameter at medium follow up
after sclerotherapy are similar to surgery
1098 A. Frullini
a b
Fig. 64.9 (a) Echoguided sclerotherapy of SSV insufficiency with foamed polidocanol 3% (lateral injection with tranversal scan of
the target vein). (b) Thrombectomy is easily accomplished after saline solution injection and using a 20 gauge needle
b c
Fig. 64.10 (a) for sclerosed

veins located deeply, echo-guided
thrombectomy is very helpful.
Failing in retrieving blood
confirms the good quality
of vein occlusion (occlusion test).
(b) Great saphenous vein
insufficiency. (c) Two years after
echoguided foam sclerotherapy
with polidocanol 3%
Part VII
Miscellaneous
Labioplasty
65
Cristina Isac, Aurelia Isac, Nicolae Antohi,
and Tiberiu I. Bratu
65.1 Introduction The attention that this kind of operation has gained is
mainly due to increased media popularization. Women
Labia minora reduction is the most common female geni- are becoming more and more aware of genital area
tal surgery performed nowadays. Most consider that ide- appearance nowadays. Although some women seek sur-
ally, labia minora and clitorial hood should not protrude gical reduction because of functional impairment, most
past the labia majora, although labia minora anatomy is do apply for surgery because of psychological distress.
extremely variable and normal variants are the rule. The causes for labial enlargement are not very clear.
Enlarged or deformed labia minora are a source of low They may be congenital, present from birth, or, more
self-esteem and sexual inhibition, from the aesthetic point commonly, from puberty, or may be acquired (chronic
of view, but they may be a source of functional impair- irritation and inflammation, repetitive trauma, exoge-
ment, as well. They can cause discomfort with wearing nous androgens, after pregnancy or with age) [1].
tight-fitting clothes, during sports (cycling, walking), sit- The most important benefits of labial reduction sur-
ting, or sexual activities. They may impair appropriate gery, apart from the aesthetic outcome, are a better
hygiene, may cause constant irritation and pruritus. hygiene, less chronic irritations, and lack of interfer-
ence with sexual intercourse [2].
Even a minimal variation of what is perceived to be
C. Isac (*) the norm can cause significant emotional distress
Department of Plastic Surgery, University Hospital for Plastic and impact on patients quality of life [3].
Surgery and Burns, University of Medicine and Pharmacy
Carol Davila, Bucharest, Romania
A. Isac
65.2 Anatomy
Department of Plastic Surgery , University Hospital for Plastic
Surgery and Burns, Bucharest, Romania Figure 65.1 demonstrates the normal female genitalia
e-mail: [email protected] anatomy. The labia minora are two cutaneomucosal
N. Antohi folds located between the labia majora. The free border
University Hospital for Plastic Surgery and Burns, Bucharest, extends from the clitoris to the posterior commissure
Romania
(fourchette).
University of Medicine and Pharmacy Carol Davila, It is widely accepted that labia minora are naturally
Bucharest, Romania
not perfectly symmetrical, with one labium being
larger than the other. The patients should be warned
T.I. Bratu
about this and told that perfect symmetry can be,
Brol Medical Center Private Clinic, Timisoara, Romania
anyway, hardly achieved after surgery.
Department of Plastic and Reconstructive Surgery
Most commonly, both labia are diffusely enlarged
University of Medicine and Pharmacy Victor Babes,
Timisoara, Romania from the clitorial hood to the posterior fourchette;
e-mail: [email protected] sometimes, only one labium is enlarged.

1102 C. Isac et al.
flaps. This technique preserves the normal edge of the

labia with less chance of scar constriction and tender-
ness [1]. Many variations of this technique have been
described which will be briefly presented herein.
The central wedge and clitorial hood reduction is
the preferred techniques performed by the authors. As
it was described by Alter [1], the central wedge exci-
sion can be extended laterally. The inner wedge is
designed as a V with its tip to the vagina. The wedge
excision is designed to excise the most protuberant
part of the labium, be it more anteriorly or posteriorly
placed. More frequently this redundant tissue is
centrally located (Fig. 65.2). The angle and extent of
the wedge resection vary depending on the cutaneous/
mucosal excess and laxity.
Care is taken to excise the exact amount necessary.
Excising too much will produce tension on the inci-
sion line with high risk of wound dehiscence and
vaginal introitus narrowing. In order to avoid excis-
ing too much tissue, the surgeon should place two or
three fingers inside the introitus and stretch the labia
Fig. 65.1 Anatomy of the female external genitalia
minora [4].
The frenulum of the clitoris extends to the upper
part of the labium minor. Frequently, the inner and
65.3 Surgical Techniques outer excision does not have the same shape. The outer
wedge excision may be prolonged laterally and anteri-
Up to now, there has been no consensus concerning the orly to the excess clitoral hood or redundant lateral
best procedure for labia minora reduction. Traditionally, labium if these ones exist. This excision takes the form
labia minora were reduced by amputation and oversewing of a hockey-stick (Fig. 65.3) [1].
the edges. Thus, by removing the labial contour, the labial In case the excess of the clitoral hood is either medial
edge is represented by the scar line. The method had or lateral, these clitoral folds can be excised conserva-
a great disadvantage: the labial edge was not preserved, tively as separate lateral or medial ellipses. The clitoris
the normal labial contour is lost and, as a consequence, the should never be exposed after hood excision. The inter-
circular scar retraction narrowed the vaginal introitus. The vening subcutaneous tissue is carefully preserved while
resulting scar can cause chronic irritation in contact with the leading labial edge is carefully reapproximated.
clothes and may interfere with sexual intercourse. The technique is performed as follows. A single dose
The more recently developed techniques are based of antibiotic (usually a first generation cephalosporin) is
on preservation of the normal free labial edge. The administered before the operation. The anesthesia is
goals of any one used technique should be: general or regional.
1. Reproducibility First the markings are drawn with the patient in the
2. Hidden scars which do not interfere with the labial lithotomy position.
edge A solution containing lidocaine 1% and epinephrine
3. Noninterference with sexual activity 1:100,000 is injected into the labia. Marcaine may be
4. Long-term stable results used instead of lidocaine to reduce postoperative pain.
A technique widely and safely used is the excision Fifteen minutes are awaited for the epinephrine to
of a central V-wedge from the most protuberant part achieve its maximum vasoconstriction effect. Doing
and suturing of the anterior and posterior remaining so will reduce bleeding and intraoperative edema/
65 Labioplasty 1103
Fig. 65.2 Surgical markings showing planned internal V

markings b
Fig. 65.3 External hockey-stick extension of the V excision for

excess lateral labium; separate elliptical excision for clitorial hood
ecchymosis, shorten operative time and prolong the

anesthetic effect [5]. The blade is directed obliquely,
beveling the incision away from the outer margins, so Fig. 65.4 (a) Inner wedge excision, obliquely directed, pre-
as to preserve enough subcutaneous tissue (Fig. 65.4). serving as much subcutaneous tissue as possible. (b) Excision
Preserving as much subcutaneous tissue as possible completed and careful hemostasis
is essential to a good subcutaneous closure which
avoids wound dehiscence and fistula formation. Careful
hemostasis of the fine vessels is critical for a good subcutaneous tissue is closed in layers with 50 PDS
outcome. or Monocryl (Fig. 65.6). The internal incision is closed
The leading labial edge is closed with one mattress with a running suture and the external one with either
suture to prevent wound separation (Fig. 65.5). The a running or interrupted sutures 50 PDS (Fig. 65.7).
1104 C. Isac et al.
a a
Fig. 65.6 (a) Subcutaneous tissue closure in layers. (b)

Subcutanoeus tissue closure completed
There are quite a few other techniques that have

been described all of which have the same principles of
preserving the labial free edge and hidden incisions.
Maas and Hage [6] developed a technique in which
the labia are resected in a W fashion (in a complementary
manner on the lateral and medial aspects of each labium)
so as the resulting edges are sutured interdigitated in order
Fig. 65.5 (a) Leading labial edges approximated. (b) One to prevent labial edge scar retraction. The remaining
separate mattress suture placed at the leading labial edge
length of the labia is kept to a minimum of 1 cm. The
authors stated that the zigzag technique described leaves
no continuous scar at the labial edge and prevents trans-
The lateral clitorial hood is closed with 50 Monocryl verse or longitudinal scar contraction. The labials edge
in the subcutaneous tissue and subcuticular or running roundness is preserved, and the anteroposterior color
50 or 60 Monocryl, or PDS (Fig. 65.8). change is gradual (in the wedge technique, the sudden
One important thing that has to be underlined is the change in color from the lighter anterior one to the darker
closure in layers with a good approximation of the posterior one may be a drawback, although minor).
subcutaneous tissue which helps in preventing wound For the same goal, Felicio [3] used an S-shaped
dehiscence, especially since the area is most often incision. Giraldo [7] reports on a central wedge exci-
humid and difficult to be kept dry. sion and a 90- Z-plasty.
65 Labioplasty 1105
a a
b b
Fig. 65.7 (a) Internal incision closure with a running suture. Fig. 65.8 (a) External incision and clitorial hood closure.
(b) Internal incision sutured (b) Immediate postoperative view
Munhoz [4] reported on a posterior wedge resection postoperatively. The postoperative discomfort is mini-
and superior pedicle flap. He states that the labial edge mal, and swelling subsides within 4 weeks. Sutures are
is preserved, the skin texture and color are similar, and removed at 10 days.
the technique is simpler and less aggressive. There is Postoperatively, the patients are asked to rest and
no horizontal or longitudinal scar contraction. However, to maintain good local hygiene in order to prevent
the tip of the flap may suffer in smokers and patients infection. The surgical wounds should be kept as dry
with comorbid-associated diseases. as possible. The patient is instructed to apply local
Choi and Kim [2] proposed another technique: antibiotic ointment for 710 days. Baths and sexual
de-epithelialization of the central lateral and medial activities are to be avoided for 45 days.
parts of the labia followed by reapproximation of the
margins of the raw surfaces.
65.5 Results
65.4 Postoperative If meticulously performed, labioplasty is a safe method

which can bring excellent patient satisfaction. It is a
The patient may be discarded on the day of the opera- rather simple operation performed on an outpatient basis
tion. The dressing consists of a simple gauze between which should make part of any plastic surgeons arma-
the labia minora for approximately 2 weeks. Oral mentarium. The results are very good. Some of the
administration of antibiotics is continued for 5 days authors results are presented in (Figs. 65.965.13).
1106 C. Isac et al.
Fig. 65.9 (a) Preoperative 13-year-old female with severe asymmetric bilateral labia minora hypertrophy. (b) Three months
postoperative after central wedge excision labial resection
65.6 Complications (cycling, walking), and sitting. In these cases, as well

in those where the social well-being of the patient is
Labial edge separation (wound dehiscence), hematoma, influenced by aesthetic concerns resulting in lack of
and infection should be promptly treated, as they can self-confidence and low self-esteem (although variation
result in an unaesthetic scar, distortion of the remaining in size is normal), surgery is indicated.
labia minora edge and local fibrosis. Labial fistula also Currently, although minor labia enlargement repre-
requires prompt excision and suturing. Among the late sents a well-recognized physical deformity, there is
complications are cited widened scars, wound retrac- still no consensus regarding its definition. Munhoz [4]
tion, prolonged discomfort, dog-ears formation, over- takes a limit of 3 cm beyond which labia minora are
resected labia, labia minora asymmetry, and persistent regarded as hypertrophic (they are measured horizon-
hypertrophy. The revisions rate for wound dehiscence tally from the midline when placed in lateral traction
or fistula formation is greater in smokers. with minimal tension). Other authors extend this limit
to 4 cm, even 5 cm. However, individual preference is
taken into consideration in most cases.
65.7 Discussion Warren et al [8] recently proposed an algorithmic
approach of surgical procedures based on the degree
Hypertrophic labia minora are functionally and psy- of labial hypertrophy and the patients preference:
chosocially bothersome. They interfere with personal deepithelialization for minor hypertrophy; for labia
hygiene, with sexual intercourse, with various sports measuring more than 4 cm, the superior pedicle
65 Labioplasty 1107
Fig. 65.10 (a) Preoperative 25-year-old woman. (b) Six months postoperative after central wedge labial resection and lateral clito-
rial hood resection
technique [1, 4] is chosen if the patient desires to retain 4. There is less chance of chronic tenderness of the
the naturally darker labial edge, if not, the edge exci- scar line [1]
sion technique [3] is performed. 5. The innervation from pudendal nerves is maximally
A poorly performed labioplasty can be very depres- preserved
sive for the patient. On the other hand, a well-performed 6. There is less impairment in sensation or sexual
labioplasty can achieve excellent results and the new dysfunction
aspect can greatly enhance self-esteem. In addition to the 7. The aesthetic outcome is very satisfactory
aesthetic outcome, better local hygiene, relief of chronic One disadvantage is the sudden change in color
irritation, and less interference with sexual intercourse from the more pinkish anterior flap to the more
have been reported as the main additional benefits [4]. brownish and darker posterior one. This discrepancy in
The advantages of the central wedge excision tech- color is rarely an issue.
nique are: Some other pathologies less encountered are
1. Preservation of the free labial edge the free border has atrophy of the labia minora (treated with autoge-
a natural, nonredundant appearance from the clitoris to nous fat grafting) and labia major hypertrophy
the commissure, with no scar prone to contracture. (which may be treated either with excisions in the
2. Hidden scars interlabial sulcus, medially, and in the hair-bearing
3. The technique is less aggressive, simple and skin laterally Hunter [5] or syringe liposuction
straightforward Felicio [3]).
1108 C. Isac et al.
a b
Fig. 65.11 (a) Preoperative 22-year-old woman with bilateral labia minora hypertrophy. (b) Central wedge excision technique
immediate postoperatively and the fragments of tissue resected. (c) One month postoperative
65.8 Conclusions The central wedge excision technique with or

without lateral clitoral hood excision is a simple and
Female genital appearance is an important issue nowa- consistent technique which gives satisfactory results
days. The success of the procedures depends on patient for the patients seeking solution to this kind of
selection, careful preoperative planning, and meticu- problem, be it only aesthetically or as well functionally
lous execution of the surgical technique. Preoperative bothersome. Reduction of the labia improves psycho-
patient evaluation is critical in appreciating the optimal social and physical comfort and sexuality in some
amount of tissue to be resected [9]. women [6, 10].
65 Labioplasty 1109
Fig. 65.12 (a) Preoperative 33-year-old woman with marked labia minora enlargement. (b) Preoperative markings. (c) Three
months after central inner wedge excisions with lateral hockey-stick extension and separate elliptical clitoral hood excisions
1110 C. Isac et al.
a b
c d
Fig. 65.13 (a) 38-year old female with markedly enlarged bilateral labia minora. (b) Preoperative marking of central wedge excision
(c) 3 months postoperative result. (d) Resected tissue shown
6. Maas S, Hage J (2000) Functional and aesthetic labia minora

References reduction. Plast Reconstr Surg 105(4):14531456
7. Giraldo F, Gonzalez C (2004) Central wedge nymphectomy
1. Alter G (2008) Aesthetic Labia minora and clitorial hood with a 90-degree Z-plasty for aesthetic reduction of the labia
reduction using extended central wedge resection. Plast minora. Plast Reconstr Surg 113(6):18201825
Reconstr Surg 122(6):17801789 8. Warren Ellsworth, Mort Rizvi (2010): Techniques for labia
2. Choi HY (2000) A new method for aesthetic reduction of minora reduction: an algorithmic approach. Aesth Plast
labia minora (the deepithelialized reduction labioplasty). Surg 34:105110
Plast Reconstr Surg 105(1):419422 9. Girling VR, Salisbury M (2005) Vaginal labioplasty. Plast
3. Felicio Y (2007) Labial surgery. Aesthet Surg J 27(3):322328 Reconstr Surg 115(6):1792
4. Mendonca A, Filassi J (2006) Aesthetic labia minora reduc- 10. Koning M, Zeijlmans I (2009) Female attitude regarding
tion with inferior wedge resection and superior pedicle flap labia minora appearance and reduction with consideration of
reconstruction. Plast Reconstr Surg 118(5):12371247 media influence. Aesthet Surg J 29(1):6670
5. Hunter J (2008) Considerations in female external genital
aesthetic surgery techniques. Aesthet Surg J 28(1):106107
Total Body Lift After Extreme
Weight Loss 66
Dennis J. Hurwitz
66.1 Introduction thighs and flat breasts, she exhibited an androgynous

figure. Due to her weight loss and prior breast reduc-
Total Body Lift (TBL) surgery is the aesthetic correction, her breasts were broad and flat with the upper
tion of skin laxity of the torso in as few stages as safely poles empty and the lower poles full and elongated.
possible. TBL surgery may also include recontouring Her loose-skinned torso is broad and boxy, without a
the upper arms and thighs. The goal is to address all defined waist. Her abdomen has two large sagging
body contour changes after weight loss, aging, and/or rolls and a ptotic mons pubis. Her buttocks are sag-
pregnancies as the case may be. TBL entails coordina- ging and flat. Her thighs are large with sagging skin.
tion of multiple body contouring operations. Conceived Her mild upper arm fullness was of no concern. Her
in 2002, TBL surgery continues to evolve. The varia- preoperative laboratory screening was normal, and
tions are as diverse as the presentations. she was placed on a high protein, arginine, and glu-
This chapter is a photographic essay of a recent tamine amino acids, vitamins, and minerals 2 weeks
TBL operation on a 43-year-old massive weight loss prior to the procedure.
patient, which not only removed undesirable excess Twelve days after her TBL surgery and prior to
and lax skin but also used her tissues to sculpture a flying home, a series of images captured the results
female form. The individual operations will be pre- (Fig. 66.2). She had barbed suture suspension of
sented as well as the relationship between them. She her breasts to the pectoralis muscle, leaving a better
will have bilateral suture suspension mastopexy, shaped, and it projected her breasts with distinct
abdominoplasty, lower body lift with adipose fascial and properly positioned inframammary folds (IMF).
flap, bilateral vertical medial thigh plasties, and ultra- An extended central high tension lipoabdominoplasty
sonic-assisted lipoplasty of her trunk. She is 5 ft 5 in. tightened, straightened, and sculptured her feminine
tall, weighs 147 lb. She had lost 90 lb after Roux- abdomen, with a well-positioned, depressed umbili-
en-Y gastric bypass 2 years prior to her body con- cus. Her mons pubis plasty leaves a lifted and prop-
touring surgery. She is unhappy about the appearance erly shaped mons. Her lower body lift and adipose
of her thighs, torso, buttocks, waist, and breasts fascial augmentation lifted and filled out the but-
(Fig. 66.1). She recognized that in addition to unac- tocks, augmented her hips, and defined her waist.
ceptable loose and protuberant skin of her torso and Cosmetic and excision site liposuction (ESL) with a
spiral thigh plasty and medial vertical extensions gave
her proportioned, tightly formed inverted cone thighs.
To accomplish this feminine metamorphosis in 7 h,
D.J. Hurwitz detailed planning is needed, and a team of five sur-
Department of Plastic Surgery, New York-Presbyterian
geons and a physician assistant are enlisted. Published
Hospital, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA techniques are employed along with a host of recent
e-mail: [email protected] refinements.

1112 D.J. Hurwitz
Fig. 66.1 Total Body Lift

case: preoperative 54-year-old
woman who lost 100 lb
2 years earlier. She has
hanging skin and ptotic
breasts on a distinctly
masculine body build
66.2 Marking continued laterally just below the crest of the anterior
superior iliac spines. The patient is turned lateral decu-
On the night prior to her TBL surgery, she was marked bitus with the upside leg abducted. This inferior inci-
for her multiple operations (Fig. 66.3). Her abdomino- sion line is continued directly posteriorly. The lax
plasty is marked first with her lying in bed, pulling up lateral thigh skin falls to the hip where it is gathered to
on her upper abdominal skin. A vertical line is drawn mark the point that the superior incision line crosses the
from the commissure of the labial majora to beyond her lateral torso. Firm gathering between that point and the
umbilicus. A transverse line extending 6 cm on either inferior incision line along the lateral thigh encom-
side of this midline marking is drawn over the pubic passes the width of resection over the hip. Pushing the
region 8 cm from the labial commissure. This line is buttock cephalad, the lower line along the lateral thigh
66 Total Body Lift After Extreme Weight Loss 1113
Fig. 66.2 Twelve days after

Total Body Lift, she is healing
well throughout. Her loose
and hanging skin has been
corrected. Her tightened
abdomen has a subtle
curvaceous form leading to a
depressed umbilical region.
Retention and advancement
of fatty adipose flaps have
symmetrically augmented her
breasts and buttocks, filled out
her hips, and narrowed her
waist. Her infragluteal folds
are well demarcated with
rounded definition separating
the lower buttocks from her
posterior thighs. Her scars are
symmetrical and well
positioned. Her breasts have
minimally improved
projection and superior
pole fill
is drawn across the buttocks to the upper aspect of the When she drops the buttocks, the lines which were
intergluteal cleft. The upper line extends from the supe- drawn horizontally on each side become hemi-elliptical.
rior point at the hip to the lower back midline so as to Within the center of these ellipses over each upper but-
include all excess skin of the lower back and superior tock, an area for flap deepithelialization is drawn, which
buttocks. The patient is then turned to the opposite lat- are about 12 cm long and 10 cm wide. These are aligned
eral decubitus and goes through the same maneuver to each central buttock. Between these two islands of
and drawing. The patient then stands, and lower body skin that will be used for augmentation of the buttocks
lift incisions are leveled, and the two excision gaps over in the lower midline of the back, we plan to discard a
the upper buttocks are checked by pinching. These pre- segment of skin and fat.
viously drawn lower buttock incision lines are checked The umbilicus is then outlined in a 2-cm by 3-cm
for proper placement and symmetry and are adjusted. shield-like manner. Transverse lines are drawn, extending
1114 D.J. Hurwitz
Fig. 66.3 Completed

markings for her single stage
correction, designed to shape,
to remove loose skin, and to
feminize her contours by the
selective retention and
removal of adipose tissue.
The marking process is
described in the text.
The operation very closely
followed these markings.
The incisions are indicated by
the solid black lines for the
circumferential lower body
lift and abdominoplasty, and
the medial thigh vertical lines
for the thigh plasty. The plus
marks are within areas of
ultrasonic-assisted lipoplasty
of the epigastrium and
anterior thighs. The inner
thigh excision will first
undergo radical excision site
liposuction. The obliquely
crosshatched paramedian
posterior buttock excisions
are separated by a central
excision of skin and fat as
marked
from the umbilicus and parallel to the groins to the lateral medial thigh to beyond the palpable ischial tuberosity
superior torso point for excision of all skin between the posteriorly. With the leg then adducted, and the loose
umbilicus and the pubic area of the lower abdominal medial thigh skin pushed to pubis, a parallel line is
wall. The adequacy of this resection is confirmed by drawn to include all this loose medial thigh skin. With
pinch and gathering of the tissues. Final confirmation her hip moderately flexed and her foot flat on the table
awaits upper incision and superior flap undermining and the leg adducted, I could then move the skin of
during surgery. the anterior thigh medially to draw a straight line along
She is then laid supine on the exam table for mark- the medial thigh from the ischial tuberosity to the
ings of her medial thighs. With the right thigh abducted, medial condyle of the knee. That line places the closure
an incision line was drawn between the pubic area and between the mid axial thigh and the posterior thigh.
groin and continued between the labia majora and Then, by gathering tissue in the middle of the thigh,
Fig. 66.4 The operation

starts prone with the thighs
strapped to arm boards
abducted 45. The foot of the
table is dropped to allow an
assistant to perform excision
site liposuction (ESL) of the
medial thighs followed by the
posterior thigh plasty. The
markings are for to the lower
body lift and posterior and
medial thigh lifts.
Crosshatched marks indicate
the area for deepithelialization
for the dermal adipose fascial
buttock augmentation. The
skin and fat between the flaps
will be excised
the posterior thigh skin could be pulled up, and a 66.3 Operation
roughly 8-cm-wide excision along the medial posterior
thigh was drawn, tapering it toward the labia majora. On the day of surgery, the faintly visible surgical
Those markings were highlighted and the thighs markings were remarked, and she was escorted to the
pushed together, creating a mirror image on the oppo- operating room. Sequential automatic pressure stock-
site medial thigh. That faint image was redrawn and ings are activated. She is induced under general anes-
checked for adequacy of skin and fat excision. The thesia on the OR gurney. Through a large-bore
anterior thigh was rather full of fat, and it was marked angiocatheter, 500 mL of her blood is removed into
for 12 plus removal of extra fat during the operation. citrated transfusion bags, and that volume of blood is
Next, we marked the current inframammary fold replaced with saline, a process of normovolemic
(IMF) of each breast and determined that the right fold hemodilution performed by our anesthesiologist. Her
was 2 cm too low, and the left IMF was 4 cm too low. blood is left in the room to be administered toward the
That decision was reinforced by her complaint that her end of the operation. She is covered with a sterile sur-
bra was needed to pull the base of her breasts. It slipped geons gown to facilitate rolling her prone onto the
up over the lower pole left of her breast when she operating room table. Her face and endotracheal tube
pulled up her bra to raise her breasts. The current and are cradled in a special foam rubber headrest. All pres-
raised IMF positions were registered over the sternum. sure points are padded with extra foam rubber. The
Furthermore, she disliked the fullness of the lower pole foot of the operating room table is dropped as each leg
of her breasts, the empty upper poles, and poor projec- was secured to arm boards that are adducted 30 from
tion of the nipples. She thought her nipple position was the table (Fig. 66.4). Her upper body is covered and
slightly low. She disliked her left lateral chest fullness, warmed with a Bair Hugger.
so it was marked for liposuction. While I took her pho- She is prepped with povidone-iodine solution and
tographs, a final assessment of her markings were draped in a sterile manner. Three liters of injectable
made and minor adjustments drawn, followed by high- saline are prepared with a gram of Ancef, 5 ampules of
lighting with indelible ink. She washed with chlorhexi- epinephrine, and 60 mL of 1% Xylocaine. Using an
dine the night before and the morning of her operation. infusion pump at 350 mL per minute, this fluid mixture
She self-administered a Fleets enema. is infused with a blunt multiholed 2-mm cannula along
1116 D.J. Hurwitz
Fig. 66.5 The steps of the buttock augmentation from the head Fig. 66.6 Buttock lift: (Upper) The left buttock skin flap is
of the table. (Upper) The inferior and superior lower body lift advanced over the flap and temporarily held in place with a
incisions have been made. The paramedian dermal adipose fas- towel clamp, allowing definitive marking of the posterior thigh
cial island flaps are isolated and droop laterally. There is an exci- plasty. The resected gap between the flaps is narrowed. (Lower)
sion gap between the flaps. And the buttock space over the Towel clamps have temporarily closed the lower body lift inci-
gluteus maximus muscles has been dissected as exposed by sion. The faded transverse dashed line is the predicted lower
retraction rakes. (Lower) The two flaps for augmentation suture incision if there had been no flap augmentation of the buttocks.
advanced into their pockets after limited superior undermining With the buried tissue, more skin is needed for the closure
the lower body lift incision lines, over the gluteus max- adipofascial flaps are excised down to the muscular
imus, and within the two medial thigh excision sites. fascia. Lateral to the adipofascial flaps, about one-third
Three simultaneous operations are commenced. On of the fat and all of the skin are removed. After a lim-
each side of the lower body lift, a surgeon and assistant ited back cut is made, the adipofascial flaps are suture
deepithelialize the adipofascial island flaps, while the advanced with #1 braided Polysorb into the pockets
physician assistant is at the foot of the table suctioning over the gluteus maximus muscle (Fig. 66.5). The but-
fat from the posterior and medial thighs. After the tock skin is then advanced over the adipofascial flap
deepithelialization of the adipose fat flaps, the two and towel-clipped securely into position to the supe-
upper teams make the inferior incision of the lower rior incision of the lower body lift (Fig. 66.6). Several
body lift along superior border of the buttocks to the key sutures of 0-Polysorb were placed, and then the
lateral thighs at the depth of the fascia lata. The paral- closure was completed with a running #2 PDO Quill
lel superior incision of the lower body lift borders the SRS, and at the lateral extent of the incision, a single
adipofascial flap and continues over the hips toward suture of 0-Novofil secures the closure.
the umbilicus (Fig. 66.5). The skin and fat are elevated As the lower body lift incision is being closed, pre-
over the superior half of each gluteus maximus muscle viously marked crescent excisions of skin are remarked
from the paramedian midline to the lateral buttocks. at the inferior portion of the buttocks, extending onto
Then, the midline skin and fat bridging the two the posterior thigh and ending as a narrow taper at the
Fig. 66.7 Posterior thigh plasty: begins with remarking the Fig. 66.8 (Upper) The left leg has been adducted back on the
excision after completion of the lower body lift. (Upper) ESL of operating room table to allow for suture advancement of the pos-
the vertical medial thigh plasty leaves the defatted depression. terior thigh subcutaneous fascia to the exposed ischial perios-
(Lower) The excess upper posterior thigh skin has been removed teum with #1 braided absorbable suture. (Lower) Both legs are
down to fascia lata back on the table as the second (right) posterior thigh is about to
be advanced to the ischial tuberosity by tying the place with
large sutures. The wounds are then closed in two layers with #1
PDO Quill and 30 Monoderm
lateral thigh. The vertical medial thigh planned
excision site is a depressed strip due to radical liposuc-
tion performed by the authors physician assistant. ischial tuberosity, a two-layer closure with #1 Quill
First, saline tumescent fluid with epinephrine and SRS (Angiotech Pharmaceuticals, Vancouver, Canada)
Xylocaine is infused, followed by passing the LySonix in the subcutaneous tissues is followed by 30
4 mm golf tee tip inline suction probe for about 10 min Monoderm in the dermis (Fig. 66.9). Finally, the pos-
when the resistance has dissipated and then vigorous terior limb of the vertical thigh plasty excision is made
liposuction with a 5-mm-diameter multiholed cannula through the skin and superficial fat. Prior to turning the
for subtotal removal of fat deep to the vertical excision patient supine, medial thigh incision was temporarily
(Fig. 66.7). This excision of skin and fat extends deep approximated with skin staples, and the lower body lift
to gluteus maximus fascia through the fascia lata to closure is covered with Indermil glue.
nearly expose the ischial tuberosity (Fig. 66.7). The With completion of the posterior portion of the
subcutaneous fascia and posterior thigh flap are operation, the patient is turned supine. We wrap her in
advanced and secured to the ischial tuberosity perios- a sterile surgical gown and roll her over onto the await-
teum with several #1 braided absorbable sutures ing gurney and then slide her back onto the operating
(Fig. 66.8). These sutures are tied after all are placed room table. Her legs are then placed in a slightly frog-
and after the leg is brought from its abducted position leg position (Fig. 66.10). The table was slightly flexed,
from arm boards onto the returned footrest to the table and she was again prepped and draped. To maintain
(Fig. 66.8). With the posterior thigh secured to the body temperature, the Bair Hugger forces warm air
1118 D.J. Hurwitz
Fig. 66.9 At the completion

of the operation in the prone
position, both the lower body
lift and posterior thigh
incisions are closed with flap
augmentation of the buttocks,
revealing the tight-skinned
and curvaceous lower back,
buttocks, and posterior and
lateral thighs. The posterior
medial thigh plasty incision
is temporarily closed with
staples. The wide separation
of the buttocks exposing the
anus is temporary
over the upper body, head, and arms while simultane- make undermined openings and allow for preservation
ous operations are being performed on the medial of abdominal perforators (Fig. 66.12). When it is clear
thighs and the abdomen. One team starts the abdomi- that the upper abdominal flap can be pulled down to
noplasty, and a second team completes the vertical the predetermined lower skin markings, that lower
thigh plasty that was started with excision site liposuc- incision is made from hip to hip across the pubis to the
tion (ESL) and incision of the posterior incision line. muscular fascia, except over the groins where the inci-
The abdominoplasty starts with preparation of the sion stops at Scarpas fascia. The skin resection over
epigastric skin flap. First, the transverse superior the groins leaves behind sub-Scarpal fat (Fig. 66.13).
abdominoplasty incision is made across the umbilicus The midline rectus fascia over the rectus muscle is
(Fig. 66.10). The umbilicus was cut out, leaving a imbricated with a small needle number #2 PDO, 14 cm
shield-like 3 cm long umbilicus with dissection down long thread run in a horizontal mattress suture along
to abdominal wall. Ultrasonic-assisted lipoplasty of and after placement of the first 2 bites on either side of
the epigastrium is done, first with the LySonix probe the central area with a double-armed suture (Fig. 66.14).
and then followed by the multiple 20-hole graded can- The PDO suturing continues until the abdominal wall
nula liposuction. Very little bleeding occurs. The mid- is palpably tight.
line of the flap was then directly undermined along the The umbilicoplasty includes central high tension on
linea alba from the umbilicus to the sternal notch the superior abdominoplasty flap. The skin and stalk
(Fig. 66.11). The dissection in the midline also allowed have been previously isolated. Three sutures of 20
for preservation of mid rectus perforating vessels as Maxon are placed in the rectus fascia at the 3, 6, and
much as possible. There is no weakness or diastema of 9 oclock position around the stalk of the umbilicus
the rectus fascia above the umbilicus, so no imbrica- and left long with the needles attached. A 30 Prolene
tion of the upper abdominal fascia is performed. is placed at the 12 oclock position of the skin of the
The superior abdominal wall skin flap is directly isolated umbilicus (Fig. 66.15). The umbilicus is too
undermined only several centimeters, and then the rest long, so it is foreshortened with horizontal mattress
of the undermining to and slightly beyond the costal sutures from base of the umbilicus to mid stalk of
margin was performed with LaRoe undermining for- the umbilicus using 30 Maxon at the 3, 6, 9, and
ceps (ASSI, Westhury, New York) that were used to 12 oclock positions. These were tied tight, telescoping
Fig. 66.10 The patient has been turned supine and prepped performs the bilateral mastopexy. (left) The abdominoplasty
with Betadine for a two-team approach to her abdominoplasty begins with the superior incision, which extends transversely to
and vertical thigh plasty. Her upper body, arms, neck, and head either side of the umbilicus and then circumscribes the umbili-
will be warmed with a Bair Hugger. Upon completion of the cus. (right) The incision is carried through the subcutaneous tis-
abdominoplasty and while the second team is performing the sues to the abdominal wall fascia
upper transverse portion of the thigh plasty, the first team
Fig. 66.11 The superior abdominal flap is undermined for several centimeters. (left) Except in the midline where it continues to the
xyphoid. (right) Midline undermining ends at the paramedian transrectus perforators
Fig. 66.12 After the midline undermining is completed. (left) The spreading underminer is used to create parallel tunnels,
A special spreading discontinuous underminer, LaRoe under- leaving behind the perforators
mining forceps, is used, which is lying on the abdomen. (right)
1120 D.J. Hurwitz
Fig. 66.13 After mobilizing

the superior abdominoplasty
flap to determine the level
of the lower incision, it is
made across the groins and
pubis. (Left) The excess skin
and fat of the lower abdomen
are being dissected off the
abdominal wall, leaving
subfascia Scarpas fatty layer
with its neurovasculature.
(Right) At the abdominal
midline, the excess tissue
is removed directly from
white rectus fascia
the umbilicus 5 mm shorter (Fig. 66.15). The table is umbilical stalk causes high central tension to the epi-
flexed, and the patient is placed in Trendelenburg. The gastrium and umbilication of the abdominal flap tissue
superior abdominal flap is advanced and held in place around the umbilicus. The closure tension along the
to the groin and pubic incision with towel clamps. mons pubis is reduced.
While the left side of the abdominoplasty incision The umbilicoplasty is completed with a running
is being closed with vertical running suture of #2 PDO, 30 Prolene between the umbilicus skin edge and the
the central high tension abdominoplasty and umbilico- skin of the abdominal wall. Through stab wound
plasty are performed. incisions in the pubic area, #10 Jackson-Pratt drains
After sighting the umbilicus up to the overlying were placed along the lower abdominal wall incision
abdominal skin, the umbilicoplasty opening is made and sutured in place with 30 Prolene. The abdomi-
approximately 3 cm superior to this sighting by deepi- noplasty incision is closed with #2 PDO and 30
thelialization of a 2.5-cm-wide shield-like opening. Monoderm.
An inverted Y pattern incision is drawn on the deepi- Meanwhile after limited cosmetic liposuction of the
thelialized skin (Fig. 66.16). The inverted Y is incised anterior thighs, the planned excision of vertical medial
full thickness through the fat and fascia of the subcuta- thigh skin is removed. Since radical ESL was per-
neous tissue, about 3 cm thick. No fat is removed. The formed, only the skin itself is removed through scalpel
previously placed 20 Maxon sutures in the abdominal cuts along the undersurface of the dermis (Fig. 66.17).
fascia are pulled through the umbilicoplasty incision A finger breath pathway is made with blunt dissection
and sutured as a horizontal mattress to the two lateral through the abdominal flap is preserved. The ellipsoid
and one inferior small deepithelialized flaps. The 30 excision site is approximated with towel clips. As no
Prolene suture at the 12 oclock position of the umbili- skin laxity is detected, no edgewise further excision is
cus is sutured to the apex of the inverted Y opening in done. The vertical thigh wound is closed with running
the advanced abdominal flap. After the abdominal wall horizontal mattress of #1 PDO Quill suture, followed
flap is brought down in position and held there with by 30 Monoderm.
towel clips, we tie each of the three Maxon sutures Once the abdominoplasty closure has started, the
from the rectus fascia to the corresponding deepitheli- horizontal crescent-shape skin excision of the medial
alized small inverted Y flaps. Advancing these three thigh plasty is performed. While the thigh plasty is
deepithelialized flaps inferiorly to the base of the being completed by another team, surgeon DJH went
Fig. 66.14 (Left) The width of the midline diastema is marked cial gap. (Right) The four throws of the Quill suture is pulled
by methylene blue. (Middle) Four throws of a horizontal running tight with each end, ready to suture close the central abdominal
mattress suture of #2 PDO barbed threads span the central fas- laxity
Fig. 66.15 (Left) The

umbilicus has a single 30
Prolene suture in the
12 oclock position. At its
fascial base, there are 20
Maxon sutures placed at 3, 6,
and 9 oclock positions which
were marked with methylene
blue. (Right) With the
suspension sutures left untied,
the height of the umbilicus
is shortened with horizontal
30 Maxon sutures
1122 D.J. Hurwitz
Fig. 66.16 Final steps of her umbilicoplasty: (Upper left) The passageway is made though the abdominal flap. (Lower left)
pull-through site for the new umbilicus is deepithelialized. The The previously placed three untied sutures are pulled through
subcutaneous neurovasculature is preserved Y demarcates three the umbilicus opening. (Lower middle) The 30 Prolene umbi-
small flaps. The site was placed on the advanced abdominal flap licus skin suture is closed to the 12 oclock position. (Lower
2 cm superior to the umbilical base on the abdominal wall. right) The three fascial sutures are sutured to the dermal flaps
(Upper middle) Incising an inverted Y incision creates three and tightly tied to umbilicate the abdominal wall flap. The clo-
small deepithelialized flaps. (Upper right) An inverted Y drawn sure is completed with a circumferential umbilical running 40
with Methylene Blue demarks three small flaps, a fingerbreadth Prolene
ahead and performed the suture suspension mastopexy. a T-type plasty between the vertical and horizontal
The preoperative markings between the mons and labia portions of the medial thigh plasty. Closure is with 20
majora and the medial thigh are checked now that the Quill and 30 Monoderm.
final tension of the abdominoplasty and the thigh plasty During the completion of the medial thigh plasty,
has been achieved. The mons plasty is performed by the suture suspension mastopexy is being performed
excising the skin only on either side of the mons, 6 cm on the previously reduced breasts. The central 40% of
from the midline down to the labia and closing. It is the inferior scar is incised (Fig. 66.19). The breast is
important to leave the fibrofatty tissue as preservation elevated off the pectoralis muscle to the second rib
leaves the lymphatics. After removal of the excess skin between the paramedian perforating vessels of the
and fat between the labia majora and upper thigh, sternum to the lateral border of the large flat muscle;
Colles fascia is identified so that several large braided #2 barbed Prolene Quill SRS suspends the breast as it
sutures approximate the medial thigh subcutaneous is advanced on the pectoralis muscle. The first bite
fascia to it (Fig. 66.18). Then 0-PDO Quill closes goes through the pectoralis muscle to grab the second
the horizontal crescent excision of the skin, creating rib periosteum (Fig. 66.19 upper right). The 2 large
Fig. 66.17 Progression of the vertical limb of the thigh plasty and incising against the dermis. (Middle left) There is a bed of
that is being performed by the second team while the abdomino- connective tissue, neurovasculature with a fine layer of adipose
plasty is being done by the first. (Upper left) The perimeter inci- tissue. (Middle right) Towel clips approximate the tissue. (Lower)
sion is made, and the distal half of the skin is detached. (Upper The two-layer closure of #1 PDO Quill and 30 Monoderm up to
right) The skin is detached through multipronged rake retraction the transverse portion of the medial thigh plasty
bites are taken along the undersurface of the breast

gland that had been elevated off the chest wall, deep
enough to get substantial pull but not too deep to get
dimpling in the skin (Fig. 66.19). After 2 breast bites
were placed, each about the size of the 38-mm tapered
needle that comes with the barbed Prolene suture, hori-
zontal sutures from each of the descending threads are
placed about the third rib, through the pectoralis mus-
cle (Fig. 66.19). This suturing is repeated twice until
reaching the sixth rib. The inferior portion of the inci-
sion is undermined with LaRoe forceps over the costal
margin. The inferior inframammary fold flap is then
sutured up to the position at the 5th rib using the #2
Fig. 66.18 With all the flaps in place under appropriate tension,
barbed Prolene, and then the subcutaneous tissue along
the skin suturing begins around the umbilicus along the abdomi- the inframammary fold is closed with 0 Quill followed
noplasty and horizontal portions of the medial thigh plasties by 30 Monoderm.
1124 D.J. Hurwitz
Fig. 66.19 These are four

images of the suture
suspension mastopexy.
(Upper left) The mastopexy
begins with an incision along
the entire IMF scar of the
right breast. The clear,
double-needle Polyethylene
Quill suture lies on the breast.
(Upper right) The first suture
is placed deeply through the
pectoralis muscle over and
almost into the second rib.
(Lower left) Each limb of the
double-armed suture takes
two deep bites taken into the
undersurface of the upper
breast. The medial thread is
seen. (Lower right) The breast
has been suture suspended
with a three-series step-
ladder-like suspension
Body metamorphosis is complete at the end of her garments, and twice a day electrophysiological massage
TBL surgery on the operating room table (Fig. 66.20). with Hivamat. Pain was initially controlled with intrave-
Surgical bra and long leg thigh garments are then nous patient-controlled analgesia (PCA), which was
placed. The patient received her 500 mL of saved blood, changed to oral oxycodone 3 days later. Healing went
and 7 h after the operation began, she was taken to the well, except for two small mid buttock wounds, which
post-anesthesia recovery room. She was started on took 3 months of dressings to close. Three months later,
Lovenox 40 mg subcutaneously twice a day until her dis- the patient is pleased with all areas of her Total Body
charge 3 days later. Her postoperative swelling was mini- Lift, except for the poor projection of the upper poles of
mized with a low salt diet, properly fitted compression her breasts (Fig. 66.21).
Fig. 66.20 At the completion

of the TBL, the patient is supine
in the semi-Fowlers position.
The skin is tight, reshaping
completed, and the scars are well
positioned
Fig. 66.21 The satisfied patient

sent me these photos of her
3-month result. Compare with
Fig. 66.1
Penile Enhancement
67
Hassan Abbas Khawaja and Melvin A. Shiffman
67.1 Introduction point 2. Threads at the back end are held in a fine artery
forceps. Threads at the advancing end are cut with a
fine small straight scissors, flush with point 2. Threads
Fillers used for penile enhancement include fat, bovine are slightly retracted at the back end, and they go sub-
collagen, and collagen of human and pork origin [1, 2]. cutaneously [4, 5]. Now threads are cut at point 1, in a
However, a variety of other dermal and subdermal similar fashion. Now, some traction is exerted with fin-
injectable fillers can be used, but all of these have gers away from point 1, towards the pubis. This leads
potential risks and complications. The authors have to burial of threads at point 1. If difficulty is experi-
utilized Gore-Tex (polytetrafluoroethylene) and silk enced here in burying the threads, blunt end of a
threads alone, and with fat together as lipo-Gore-Tex smaller sized KH needle is used to push ends of threads
in the penis with satisfactory results [3, 4]. subcutaneously. The results are adequate enhancement
(Fig. 67.5).
67.2 Penile Thread Enhancement

67.3 Lipo-Gore-Tex Penile Enhancement
Threads, Silk No 2/0 or Gore-Tex (polytetrafluoroethyl-
ene) CV 2, are used with a KH needle (Figs. 67.167.4) Gore-Tex implants are inserted first as described previ-
[3, 4]. It is absolutely important to avoid ventral and ously. Fat is harvested necessarily from the pubic area
dorsal midline areas for thread insertion, otherwise and also from the lower abdomen and hip if required.
damage to the urethra and vessels can take place leading Fat is completely removed from the pubic area via a
to hematomas, infection, urethral damage, extravasation 3-mm keel cobra tip cannula. No stitch is applied to
of urine subcutaneously, stricture, stone formation in the entry point. Compression is applied postoperatively to
urinary tract, and other complications [3, 4]. the pubic area. After decantation, purified fat is trans-
KH needle with attached silk threads (or Gore-Tex ferred using 2 points distally at 3 and 9 oclock posi-
threads), 23 in number, is passed subcutaneously, tions using the smaller fat transfer cannula [6, 7] (8 cm
from point 1 towards point 2, along the marked path- long, 1 mm broad). A maximum of 4050 cc of fat is
way. The KH needle with silk threads is now exiting transferred (Fig. 67.6). It is important to avoid the 6
and 12 oclock positions, for inserting fat transfer can-
nulas, so that urethral and vascular damage is avoided.
H.A. Khawaja (*) Threads must be inserted prior to fat injection, which
Cosmetic Surgery & Skin Center, Lahore, Pakistan
should be slow and retrograde. If threads are inserted
e-mail: [email protected], [email protected]
after fat transfer, the advancing needle, leads to destruc-
M.A. Shiffman
tion of fat cells. Triple antibiotic ointment and oral
Tustin, CA, USA antibiotics (cefadroxil monohydrate) are continued for
e-mail: [email protected] up to 7 days postoperatively.

1128 H.A. Khawaja and M.A. Shiffman
Fig. 67.1 KH (Khawaja

Hernandez) needle with silk
thread entering at point 1
2 1
AVOID VENTRAL & DORSAL MIDLINES
Fig. 67.2 KH needle with

silk thread traversing
pathway from point 1 to 2
2
1
Fig. 67.3 KH needle with

silk thread exiting point 2
2 1
2 1
4 3
Fig. 67.4 Similarly, 6 5
threads are passed all AVOID VENTRAL & DORSAL MIDLINES
around the penis, avoiding
8 7
the midline areas for thread 10 9
insertion. Threads can be 12 11
passed either from the base
toward the distal end or
vice versa
67 Penile Enhancement 1129
a a
Fig. 67.5 (a) Preoperative. (b) After penile thread enhancement Fig. 67.6 (a) Preoperative. (b) After lipo-Gore-Tex penile
enhancement
67.4 Complications experience, about 20% of patients are sensitive to Gore-

Tex. It is advisable to perform a small Gore-Tex Needle
Extrusion and infection are two common complications Thread Test to check sensitivity of the patient few weeks
of penile thread enhancement [35, 9]. However, infec- prior to insertion of Gore-Tex in the penis. Penile fat
tion is rare with proper antibiotic coverage. Due to the transfer complications are absorption, infection, cysts,
monofilamentous nature of silk, we do not use silk calcifications, skin necrosis, sinus formation, hemato-
threads along with fat in the penis. Granulomas, and mas, seromas, skin pigmentation, penile distortion, ure-
allergic reaction to Gore-Tex, also take place. In our thral distortion, calculi in the urinary tract, lipomatosis,
Fig. 67.7 Pubic pit after localized liposuction Fig. 67.8 Lipomatosis in the penis
embolism, etc. [1, 2, 6, 8]. However, following a careful

technique with slow, even, and retrograde injection of
fat, avoiding large spurts of fat, using proper antibiotic
coverage, and injecting no more than 4060 cc of fat per
session, these complications usually do not take place.
67.4.1 Pubic Pit
Liposuction of the pubic fat can increase length of the

organ up to 1 in. or more, depending on the amount of
fat present in the pubis. Localized superficial liposuc-
tion immediately above the base of the penis can result
in the formation of pubic pit (Fig. 67.7). Generalized
superficial liposuction should be carried out above the
base of the penis to avoid this depression.
67.4.2 Penile Lipomatosis

Fig. 67.9 Double bubble penis
Penile lipomatosis can take place when 100 cc or more
fat is transferred into the penis. Absorption takes place in
some fat areas, while hypertrophy/hyperplasia in other gravitational pull, and due to the peculiar anatomy of
areas leading to this condition (Fig. 67.8). Liposhifting the organ, penile mounds can form.
can be performed to correct this deformity. A variety of dermal and subdermal facial fillers can
also be used for penile augmentation. These includes
calcium hydroxylapatite, e-aminocaproic acid, hyaluronic
67.5 Double Bubble Penis acid, hyaluronic acid and ethyl methacrylate, hydroxy-
apatite, hydroxymethylmethacrylate and ethylmethacry-
A double bubble penile deformity can take place as a late in hyaluronic acid solution, methacrylate and
result of uneven fat injection, inexperience of the sur- acrylate, methacrylate and copolymer, patient-derived
geon, performing fat transfer, after collagen, liquid plasma emulsion, polyoxyethylene fatty acid and elastin
silicone, or after injecting a variety of dermal/subder- copolymer gel, polyacrilamide hydrogel (unpolymer-
mal fillers into the penis (Fig. 67.9). As a result of ized acrylamide monomer), polyacrylamide hydrogel
with polyvinyl microspheres, polyalkylimide, polydim- cysts that develop intermittently for 2 years or more.
ethylsiloxane oil (silicone), polyethylene microspheres, Incision and drainage relieves the pain, and intermit-
polylactic acid, and polyvinyl alcohol, polyvinyl micro- tent systemic or intralesional steroids provide relief in
spheres suspended in Polyacrylamide Gel [1031]. some patients. Ashinoff [19] stated that 33.5% of
However, all of them have potential risks and complica- patients have localized reaction when tested to bovine
tions associated with their use. collagen. In those patients who have negative skin
Collagen should not be injected into patients with a testing, 15% still get an allergic reaction that usually
history of autoimmune diseases, such as dermatomyo- subsides in 46 months; however, it can last up to
sitis, lupus erythematosus, or rheumatoid arthritis 2 years. Adverse reactions include bruising, reactiva-
[10]. Charriere et al. [11] reported a positive skin test tion of herpes, and bacterial superinfection can occur.
in 3.8% of patients and adverse reactions in 2.3% of Artecoll has short-term side effects that include swell-
patients with negative skin testing. Bentkover [12] ing, bruising, and sensitivity. Zyderm and Zyplast can
looked at the relevant biology of facial fillers and both have allergic reactions. Intra-arterial injection is
found that bovine collagen is the most immunogenic suspected in several cases of unilateral blindness
filler. Porcine and bioengineered human collagen because of retinal artery occlusion.
implants have very low immunogenicity, but allergic Complications of bovine collagen that were described
reactions and elevations of IgG are possible. Cross- by Grossman [10] include bruising that should resolve in
linking and concentration affect the longevity of col- several day, temporary swelling, a white bump or raised
lagen fillers. Most allergic reactions are localized and area from injecting too superficially that may last for sev-
consist of swelling and redness at the treatment site eral months, necrosis and subsequent scar formation,
[13]. Infections, such as recurrent herpes simplex, allergic reactions seen as erythematous papules, streaks,
abscess formation, tissue necrosis, and granulomatous or plaques. Homicz and Watson [20] described systemic
foreign body reactions were reported infrequently reactions to bovine collagen consisting of arthralgias,
[14]. Cooperman et al. [15] noted adverse reactions myalgia, fever, and pruritis in less than 5 per 1,000
occurred to pretesting of Zyderm I in 3% of patients. patients.
In addition, 1.3% of patients experienced adverse Autologous cultured fibroblasts serve as injectable
reactions despite a negative pretest. Reactions ranged protein repair systems for correction of acne scars,
from localized swelling to induration, erythema, and rhytides, and other facial scars [21]. The system uses
pruritis. Onset ranged from immediate to 3 weeks the patients own cultured fibroblasts to correct con-
after implantation. DeLustro et al. [16] found an esti- tour deformities over time. Cosmoderm and Cosmoplast
mated 0.4% adverse reactions to bovine collagen after contain lidocaine and should not be used in patients
one to seven treatments. Hanke et al. [17] described with severe allergies manifested by a history of ana-
sterile abscess (may be an atypical form of allergic phylaxis or in patients with known lidocaine hyper-
reaction) being seen more with Zyplast, and skin sensitivity. Longevity, 36 months. Cymetra is not
necrosis has occurred in a significant number of recommended in patients exhibiting autoimmune con-
patients when Zyplast is injected into the glabellar nective tissue disease, contraindicated in infected or
area. Hanke [18] described the following adverse nonvascular sites. Since Cymetra is supplied in an
reactions to bovine collagen: transient erythema, antibiotic-supplemented medium, it should not be
bruising, and needle marks that were temporary. Also used in patients sensitized to those specific antibiotics.
noted were local necrosis, infection, surface deformities Longevity, 39 months. Dermologen is an aseptically
(beading), intermittent swelling, and systemic com- processed suspension of collagen fibers prepared from
plaints such as arthralgias, myalgia, headaches, nau- human donor tissue obtained from U.S. tissue banks and
sea, urticarial rashes, and partial blindness (injection lasts 36 months but has been known to last 9 months. It
in glabella area). Three percent of patients had posi- takes two to three injection sessions over several months
tive pretreatment skin tests. Less than 1% of patients in order to show maximal improvement.
with negative pretesting demonstrated allergic reac- Patients over 60 years are not candidates for Isolagen
tions. Cystic-abscess reactions are rare and occur most because their skin is not capable of producing vigor-
commonly with Zyplast treatment and start with pain ous fibroblasts [19]. The cells are alive and cannot be
followed by erythema and swelling. There are tender stored so that careful planning and a reliable patient are
essential. Correction may take 34 months because the 6. Khawaja HA, Hernandez-Perez E (2002) Fat transfer review:
controversies, complications, their prevention and treatment.
fibroblasts take time to produce new collagen [19].
Int J Cosmet Surg Aesthet Dermatol 4(2):131138
Gradual improvement may be seen over 18 months. 7. Fournier PF (1991) Fat transfer. In: Parish LC, Lask GP
Fagien [22] described the problem with Autologen (eds) Aesthetic dermatology. Mc Graw Hill, New York, pp
was that the tissue donor was the recipient but noted that 267275
8. Reed HM (1994) Augmentation phaloplasty with girth
in a survey of 100 patients, that 98% would opt to use
enhancement employing autologous fat transplantation: a
their own skin. Donor skin of 5 cm [2] yields 1 cc of preliminary report. Am J Cosmet Surg 11:8590
collagen. This can be stored refrigerated in BioBank 9. Schoenrock LD, Repucci AD (1993) Gore-Tex in facial
for at least 5 years. The skin is processed by Collagenesis plastic surgery. Int J Aesthet Restor Surg 1:6368
10. Grossman KL (2000) Facial scars. Clin Plast Surg 27(4):
Laboratories (Previously manufactured by Collagenesis
627642
(Beverly, Massachusetts)) that is very similar to Cymetra. 11. Charriere G, Bejot M, Schnitzler L, Ville G, Hartmann DJ
However, Collagenesis filed Chap. 11 in the U.S. (1987) J Am Acad Dermatol. Reactions to a bovine colagen
Bankruptcy Court in Boston (#19656). Apesos and implant. Clinical and immunologic study in 705 patients.
21(6):12031208
Muntzing [23] found only a small subset of patients is
12. Bentkover SH (2009) The biology of facial fillers. Facial
willing to donate skin for Autologen. Cosmoderm and Plast Surg 25(2):7385
Cosmoplast have adverse reaction including infection, 13. Siegle RJ, McCoy JP, Schade W, Swanson NA (1984) Intradermal
reactivation of herpes simplex, and local necrosis (rare), implantation of bovine collagen: humoral responses associated
with clinical reaction. Arch Dermatol 120(2):183187
and injection into dermal vessels may cause vascular
14. Rzany R, Zielke H (2006) Complications. In: de Maio M,
occlusion, infarction, or embolic phenomena. Lack Rzany B (eds) Injectable fillers in aesthetic medicine.
of permanency from collagen of human origin has Springer, Berlin, pp 6777
been described by a number of authors [2428]. Hyper- 15. Cooperman LS, Mackinnon V, Bechler G, Pharrisse BB
(1985) Injectable collagen: a six-year clinical investigation.
pigmentation over injection sites has been reported [29].
Moody and Sengelmann [30] described pretesting with 16. DeLustro F, Smith ST, Sundsmo J, Salem G, Kincaid S,
human collagen had reactions of mild, self-limited, and Ellingsworth L (1987) Reaction to injectable collagen:
nontender erythema. Apte et al. [31] reported on cases results in animal models and clinical use. Plast Reconstr
Surg 79(4):581594
of choroidal infarction following subcutaneous injec-
17. Hanke CW, Hingley HR, Jolivette DM, Swanson NA,
tion of human collagen in the forehead. Evolence (col- Stegman SJ (1991) Abscess formation and local necrosis
lagen of pork origin) is not to be used in patients that after treatment with Zyderm or Zyplast collagen implant.
are hypersensitive to any collagen products or porcine J Am Acad Dermatol 25(2 Pt 1):319326
18. Hanke CW (1998) Adverse reactions to bovine collagen. In:
products, or if there is a history of severe allergies. Side
Klein AW (ed) Tissue augmentation in clinical practice: pro-
effects of Evolence include swelling, bruising, erythema, cedures and techniques. Marcel Dekker, Inc., New York
pain, and palpable lumpiness. 19. Ashinoff R (2000) Overview: soft tissue augmentation. Clin
Plast Surg 27(4):479487
20. Homicz MR, Watson D (2004) Review of injectable mate-
rials for soft tissue augmentation. Facial Plast Surg 20(1):
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21. Boss WK Jr, Usal H, Chernoff G, Keller GS, Lask GP, Fodor
1. Hernandez-Perez E, Marroquin-Burgos R (1993) Fat injec- PB (2000) Autologous cultured fibroblasts as cellular ther-
tion of the penis: a personal technique. Am J Cosmet Surg apy in plastic surgery. Clin Plast Surg 27(4):613626
10:135138 22. Fagien S (1998) Facial soft tissue augmentation with autolo-
2. Hernandez-Perez E, Albarran FV (1999) Fat grafting in gous and homologous injectable collagen (Autologen and
male and female genitalia. Int J Cosmet Surg 7(1):8791 Dermologen). In: Klein AW (ed) Tissue augmentation in
3. Khawaja HA, Hernandez-Perez E (2002) Gore-tex review: clinical practice: procedures and techniques. Marcel Dekker,
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Int J Cosmet Surg Aesthet Dermatol 4(4):337343 23. Apesos J, Muntzing MG II (2000) Autologen. Clin Plast
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1(1):8 Aging 7:32
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Ophthalmic, plastic and reconstructive surgery. WB Saunders, 31. Apte RS, Solomon SD, Gehibach P (2003) Acute choroidal
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Complications of Cosmetic Surgery
68
Melvin A. Shiffman
68.1 Introduction 68.2.1 Asymmetry
Aesthetic surgery is an elective surgery in order to beau- If care is not taken in the initial marking prior to
tify the patient. Patients do not expect to have complica- surgery, asymmetry may result. The midline should be
tions, but the possible risks and complications have to marked above the umbilicus and in the area of the
be explained to the patient so that he/she can make a pubis. If there is a very fatty abdominal wall, the mid-
knowledgeable decision concerning whether or not to line at the level of the pubis can be located either by
have the surgery. Complications may occur without any visualizing the anterior junction of the vulva or care-
deviation from the standard of care, and the surgeon has fully spreading the pubic hair to find the direction of
to be aware as to what are the possible risks and compli- the hairs that diverge to each side at the midline.
cations, their prevention, and their treatment for every The transverse lower abdominal incision line should
procedure he/she may plan to do. This will allow early be marked preoperatively so that the distance from the
diagnosis and timely treatment of a complication. midline is equal on each side. The height of the ends
The rare and unusual complications are a challenge of the lateral extensions should be equidistant from
to each surgeon, so particular attention should be paid some measurable point superiorly or inferiorly, such as
to understand which ones they are and how to diagnose the anterior superior tubercle or the level of the top of
and treat them. the ilium.
The amount of skin excised is determined by firm
traction on the skin flap at an equidistant point on each
68.2 Abdominoplasty side from the midline of the flap. This will prevent
excessive tension on one side of the flap compared to
Complications following abdominoplasty can occur at the other.
any time with any patient despite adequate surgical Care must be taken to center the umbilicus to pre-
technique and patient care. These problems may cause vent asymmetry involving the umbilicus.
patient discomfort, delay recovery, require further sur- Excessive fat or skin can be surgically excised to
gery, or threaten the patients survival. The surgeon correct asymmetry. Fat can also be liposuctioned in
should be aware of the possible complications, their areas of excess.
prevention, their timely diagnosis, and their treatment.
The possible risks and complications must be dis-
cussed with the patient prior to surgery. 68.2.2 Bleeding (Bruising, Hematoma,
Exsanguination)
M.A. Shiffman
The presence of bruising following any surgical proce-
Tustin, CA, USA dure is accepted as a known consequence of the proce-
e-mail: [email protected] dure [13]. When a swelling filled with blood appears

1136 M.A. Shiffman
in the abdominal wall shortly after surgery, the surgeon and clotting of the vessels, which is followed by necro-
must make a decision as to careful observation or some sis and disruption of the wound. Usually, the wound
form of drainage. When a hematoma first appears, the does not pull far apart because the sutures lateral to the
clot can be aspirated only with great difficulty. Over disrupted area hold the wound together.
time (a few days), the fibrin precipitates and the Other contributory causes include smoking, poorly
remaining fluid can be more easily aspirated with a controlled diabetes mellitus, underlying hematoma or
needle. If the hematoma is not aspirated, the serosan- seroma, and too much activity by the patient. Many
guinous fluid in the pocket will slowly become a typi- surgeons close the wound tightly with the patient
cal serous fluid and thus a pseudocyst. When the slightly flexed. The surgeon then expects the patient to
hematoma is increasing in size, surgery should be seri- remain in that position for several weeks even while
ously considered to ligate the bleeder surgically by walking around. Compliance with these instructions is
exploring the wound and emptying the clot. Mohammad usually poor since it is virtually impossible to maintain
[3] reported a 9% incidence of hematoma. this position for any length of time, especially if the
Bleeding from the wound is easier to monitor than patient has a history of back problems.
hidden bleeding. Compression dressings, bed rest, and Treatment for dehiscence should be conservative
ice packs sometimes will control the bleeding. If there allowing the wound to slowly slough the necrotic tis-
is persistent bleeding, surgical exploration is essential. sue, and the wound should heal by secondary intention
The wound is opened, any hematoma evacuated, and if the wound cannot be sutured closed because of
the bleeder(s) ligated or electrocoagulated. The wound excessive tension. The necrotic tissue can be debrided
may be closed with or without drainage, but it is safer at appropriate intervals of time. Usually, the scar will
with a catheter or penrose drainage. contract sufficiently to form a slightly widened scar
The presence of orthostatic hypotension should be a that can be revised if necessary (if the patient is dis-
warning that there may be inadequate fluid replace- satisfied with the appearance).
ment or excessive blood loss. Fluid should be replaced
if the hypotensive episodes persist. If there is no pro-
longed response, then there is probably excessive 68.2.4 Dogears
blood loss even if there is no apparent bleeding from
the wound or expanding hematoma. Immediate hemo- The closure of the transverse lower abdominal wound
globin (Hgb) and hematocrit (HCT) should be obtained, is started with a suture in the midline to properly posi-
and if there is a significant drop from the preoperative tion the new umbilicus. The wound should then be
studies, then replacement of fluids should be rapid closed starting laterally on each side to give a flattened
with volume expanders such as Hespan or albumin. A appearance to the most lateral regions of the wound. If
20% drop in Hgb or HCT is a reason enough to con- there is excessive fatty tissue in the region where doge-
sider blood replacement since these studies do not ars usually form, this tissue should be excised prior to
equilibrate for 2448 h. Admission to a hospital emer- the closure.
gency room may be necessary to monitor the patient Many times small dogears will resolve within
over a period of time in order to determine if blood 3 months without treatment. When there are persistent
replacement is necessary. dogears for more than 3 months, these can be excised
under local anesthesia, usually in an elliptical form.
Very large dogears and fullness in the area can be
68.2.3 Dehiscence treated by liposuction as well as excision.
Dehiscence following abdominoplasty usually occurs

at the tightest point of the abdominal incision closure 68.2.5 Edema, Persistent
[1, 4]. This point is the center of the flap at the attach-
ment in the region of the pubis. The area darkens and When edema is persistent, over 3 months, and does
necrosis may occur followed by disruption of the clo- not respond to conservative measures such as com-
sure, sometimes with the wound pulling apart. The pression, liposuction with tumescent solution should
tight closure elongates the vessels resulting in spasm be considered. Too much liposuction may result in
68 Complications of Cosmetic Surgery 1137
damage to the skin or indentations. Therefore, the midline, and the tightly pulled abdominal skin flap
liposuction should be conservative. At the same time, closure is susceptible to necrosis unless enough space
there should be a determination as to whether there is (at least 6 cm) is left between the old scar and the
persistent edema or just too much residual fat. transverse closure line to allow vascularity to the tri-
angle. It is helpful to place less tension on the flap
closure so that stretching of the vessels and thrombo-
68.2.6 Infection, Sepsis ses are not added to the problem. Sometimes, the use
of a different type of resection may be necessary to
Wound infection is a known consequence of any clean prevent necrosis. This usually means the addition of a
surgery, occurring in 1% of patients in an outpatient or vertical midline scar [5].
office surgical center and 3% in a hospital [1]. It is not The best treatment is observation with debridement
unusual for slight erythema to occur around the sutures as needed and allowing the wound to heal by second-
without actual significant infection. If significant ary intention. Placing skin grafts in a granulating
wound erythema occurs while the patient is on antibi- abdominal wound will shorten the healing time but
otics, the dosage may be increased or the antibiotic will not allow the wound to contract enough to decrease
changed. The wound should be watched very carefully the extent of scarring. It is surprising how small the
for progression of the infection that may require intra- scar can be after complete healing and contraction
venous antibiotics that can be given as an outpatient or even if the whole lower abdominal wall has been
in the hospital. Infections not responding to antibiotics involved with necrosis. Scar revision is usually neces-
may require consultation with an infectious disease sary for wide or irregular scars.
specialist and may indicate early necrotizing fasciitis
or may evolve into toxic shock syndrome that can be
fatal. Complete blood count (CBC) should be obtained 68.2.8 Necrotizing Fasciitis
as well as wound, where possible, and blood cultures.
Uncontrolled infection can be life threatening if Necrotizing fasciitis is a result of infection from
sepsis occurs. This may be indicated by fever, elevated Streptococcus or mixed infection, frequently with
white count, and lethargy. Prompt treatment with anaerobic organisms. The infection results in thrombo-
appropriate intravenous antibiotics is essential. sis of the subcutaneous vessels including vessels enter-
ing the fascia and underlying muscles. The tissues
become necrotic and require debridement as well as
68.2.7 Necrosis proper antibiotics. Cultures of the tissues may reveal
the offending organism(s). The wound should then be
Necrosis is more likely to occur if the patient is a allowed to granulate and can be skin grafted when all
smoker, if concomitant mid upper abdominal liposuc- the necrotic tissue has been removed and granulations
tion is performed, or if there has been prior extensive are present.
liposuction to the abdominal wall [1, 2, 4]. Smokers
may say they will stop smoking, but there are some
who will continue to smoke despite all the admoni- 68.2.9 Need for Further Surgery
tions. There is nothing that can be done if the patient
does not stop smoking completely. The necrosis will There are a variety of reasons for further surgery
progress to its fullest extent, not only in the lower being necessary following abdominoplasty. These
abdomen but also at times in the periumbilical area and include asymmetry, irregularities, dogears, necrosis,
upper abdomen. inadequate skin resection, significant scar (hypertro-
Poorly controlled diabetes mellitus, very tight phic or keloid), umbilical stenosis, or excessive fat
wound closure, underlying hematoma or seroma, and requiring liposuction. If a patient has excessive fat
infection may contribute to the cause and extent of the prior to the abdominoplasty and the fat is not liposuc-
necrosis. If the patient has a prior transverse upper tioned at the same procedure, the patient should be
abdominal scar (i.e., cholecystectomy, gastrectomy, informed about the probable future need for liposuc-
splenectomy), the triangle formed by the scar, the tion before surgery.
1138 M.A. Shiffman
68.2.10 Perforation of Intraabdominal 68.2.12 Recurrent Protrusion

Viscus of Abdominal Wall
It is possible to perforate the bowel when repairing an Some patients have very lax abdominal wall muscles,
umbilical hernia, ventral hernia, or incisional hernia at and there is a tendency for recurrent protrusion after
the same time as performing the abdominoplasty by a seemingly adequate fascial repair. This can be
not opening the hernia sac to observe for attached improved with repeat closure of the abdominal wall
bowel or placing the sutures superficially only in well- fascia in the midline with the combination of lat-
exposed fascia. Closing the midline fascia in a patient eral wall (external oblique aponeurosis) tightening.
with a very loose abdominal wall may not produce a This repair can also be performed for the patient
tight abdominal wall, and imbrication of the external who has recurrent protrusion from loosened or dis-
oblique fascia bilaterally would be necessary. The rupted sutures.
junction of the external oblique fascia and the rectus
muscle sheath may have a Spigelian hernia, usually
just below the level of the umbilicus since the fascia is
very thin at that point. 68.2.13 Scarring (Widened, Thickened,
Any patient complaining of more postoperative Hypertrophic, Keloid)
abdominal pain than the usual patient or persistent
severe pain should be examined for rebound tender- Wide scars are frequent following abdominoplasty
ness and absent bowel sounds. The patient should because of the need for a tight closure to get a flat
be observed very carefully and at appropriate short abdomen [2]. When the skin loosens after 6 months,
intervals of time to rule out perforation of a viscus, it is possible to resect the scar in order to make it
blood vessel, or bladder. Abdominal x-ray series thinner.
may be indicated and possibly observation in the Certain individuals are prone to get hypertrophic
hospital. If intraabdominal bleeding is suspected, scars although this is unpredictable. Hypertrophic
Hgb and HCT should be tested. If necessary, insert- scars may resolve without treatment. Keloid scars
ing a needle with a catheter sheath into the abdomi- occur in 15% of blacks, Asians, and Hispanics. There
nal cavity, removing the needle, and then inserting are a variety of treatments available, usually used in
sterile saline and observing for drainage of blood combination. Recurrence of keloids is common.
should be done.
If a perforation is diagnosed, immediate surgical
intervention is indicated. Preoperative antibiotics
should be started. The abdomen should be care- 68.2.14 Sensory Loss
fully explored for possible multiple perforations, and
any observed bowel perforations should be closed Loss of sensation in the abdominal wall is more com-
after thorough irrigation of the abdominal cavity. mon when liposuction is performed at the same time as
Early intervention may prevent a severe infectious abdominoplasty [1, 6]. This sensory change is usually
process. temporary and resolves without treatment.
Injury to the lateral femoral cutaneous nerve has
been reported [1, 6]. This can result in permanent sen-
68.2.11 Recurrent Panniculus sory loss along the anterior, lateral, and posterior thigh.
It is possible to explore and reanastamose a transected
Patients should be forewarned that weight gain after nerve if the nerve ends can be found and a large section
abdominoplasty could result in recurrent fatty abdo- of the nerve has not been removed. This type of sur-
men with panniculus that might require another surgi- gery must be performed in a timely manner in order to
cal procedure. Pregnancy after abdominoplasty is a have any success. Usually, the sensory loss is not in
risk for causing loose skin, stretching the muscles and areas that will interfere with normal activity, and
the midline, and striae. This may result in the need for patients may become used to the sensory loss over a
repeat abdominoplasty. long period of time.
68.2.15 Seroma in the moderate-risk category [9]. High-risk category

would be major surgery in patients over 40 years of
The use of drains following abdominoplasty usually age with recent history of deep vein thrombosis or pul-
prevents the accumulation of blood but may not pre- monary embolism, extensive pelvic or abdominal sur-
vent seroma formation [13, 7, 8]. The large flap with gery for malignancy, and major orthopedic surgery of
an empty space extending from xyphoid to pubis is the lower extremities.
readily filled with serous fluid with patient movement Predisposing risk factors include age over 40 years,
that results in the rubbing together of raw tissues. If malignancy, obesity, prior history of thromboembo-
there is a palpable fluid collection, this can be aspi- lism, varicose veins, recent operative procedures, and
rated and compressed to allow the tissues to seal. If thrombophilia. These risks are further modified by
aspiration does not resolve the problem, injecting room duration and type of anesthesia, preoperative and
air to fill the cavity after fluid aspiration will almost postoperative immobilization, level of hydration, and
always result in sealing the cavity. Introduction of air the presence of sepsis [10]. Medical problems associ-
may have to be repeated if there is a larger cavity. ated with increased risk include acute myocardial
This method is less traumatic than excision of the infarction, stroke, and immobilization [11]. Estrogen
pseudocyst. therapy and pregnancy are common risk factors while
uncommon factors include lupus anticoagulant, neph-
rotic syndrome, inflammatory bowel disease, poly-
68.2.16 Skin Overhanging Scar cythemia vera, persistent thrombocytosis, paroxysmal
nocturnal hemoglobinuria, and inherited factors such
If not enough skin is resected in abdominoplasty or if as antithrombin III deficiency, protein C deficiency,
the transverse lower abdominal scar becomes adherent protein S deficiency, plasminogen activator deficiency,
to the underlying fascia, there may be a visible overlap elevated plasminogen activator inhibitor, and homo-
of the skin over the scar. This may require revision by cystinuria [12].
resecting the excess skin and/or freeing up the skin Superficial calf vein thrombosis, proximal deep
scar attachment to the deeper tissue. vein thrombosis, and fatal pulmonary embolus increase
in incidence as the risk category increases from low to
high.
68.2.17 Thromboembolism
68.2.17.2 Clinical Manifestations
Patients who undergo surgery are at risk for venous Superficial thrombophlebitis (an inflamed vein)
thromboembolic complications. This is especially crit- appears as a red, tender cord. Deep-vein thrombosis
ical in a cosmetic surgery patient who, having an elec- may be associated with pain at rest or only during
tive procedure, would not expect to have the morbidity exercise with edema distal to the obstructed vein. The
or mortality associated with thromboembolic disease. first manifestation can be pulmonary embolism. There
The cosmetic surgeon must be aware of the possibility may be tenderness in the extremity, and the tempera-
of thromboembolism in every patient and should take ture of the skin may be increased. Increased resistance
a careful history to disclose predisposing risk factors. or pain on voluntary dorsiflexion of the foot (Homans
The surgeon should also be aware of the clinical mani- sign) and/or tenderness of the calf on palpation are
festations of pulmonary embolus in order to make a useful diagnostic criteria.
timely diagnosis. Pulmonary embolism is usually manifested by one
of three clinical patterns: (1) onset of sudden dyspnea
68.2.17.1 Risk Factors with tachypnea and no other symptoms, (2) sudden
Minor surgery <30 min in patients over 40 years of age pleuritic chest pain and dyspnea associated with find-
without additional risk factors and uncomplicated sur- ings of pleural effusion or lung consolidation, and (3)
gery in patients under 40 years of age without addi- sudden apprehension, chest discomfort, and dyspnea
tional risk factors are in the low-risk category. General with findings of cor pulmonale and systemic hypoten-
surgery in patients over 40 years of age lasting >30 min sion. The symptoms occasionally consist of fever,
and patients under 40 years on oral contraceptives are arrhythmias, or refractory congestive heart failure.
1140 M.A. Shiffman
68.2.17.3 Diagnosis Dextran can result in cardiac overload, and high-

Deep-vein thrombosis is best diagnosed with duplex dose aspirin (1,0001,500 mg/day) has limited efficacy
ultrasonography which combines pulsed gated Doppler in preventing deep-vein thrombosis. In cosmetic sur-
evaluation of blood flow with real-time ultrasound gery, the use of aspirin or heparin may result in postop-
imaging. Other diagnostic tests include x-ray venogra- erative bleeding.
phy, radionuclide venography, radioisotope-labeled The best prophylaxis for low-risk cosmetic surgery
fibrinogen, ultrasonography, and impedance plethys- patients would appear to be mechanical methods includ-
mography. Liquid crystal thermography detects ing knee compression stockings and early ambulation.
increases in skin temperature and is a useful adjunct to For low-risk patients, the knees should be slightly
ultrasonography or impedance plethysmography. flexed and extremity compression avoided [14].
Ventilation-perfusion lung scan (VP scan) is a safe,
sensitive means of diagnosing pulmonary embolism.
Isotope pulmonary perfusion scan (Q scan) is more spe- 68.2.18 Hereditary Hypercoagulable States
cific with inclusion of the isotope ventilation scan (V
scan). The definitive diagnosis can be made by pulmo- Patients with a family history of thrombosis, early-
nary arteriography, but VP scan can give a high degree onset or recurring thrombosis, thrombosis at unusual
of certainty. Arterial blood gas typically shows reduc- sites, or warfarin-induced skin necrosis should be eval-
tion in PaO2 and PaCO2 while electrocardiogram shows uated for possible underlying inherited hypercoagula-
tachycardia but is best used for ruling out myocardial ble disorders.
infarction. Chest x-ray may show basilar atelectasis, Antithrombin III (AT-III) is a heparin cofactor that
infiltrates, pleural effusion, or cardiac dilatation. allows heparin to inactivate primarily factor IIa but also
factors IXa, Xa, XIa, and XIIa [15]. A deficiency in
68.2.17.4 Prophylactic Treatment AT-III predisposes to thrombosis by allowing uncon-
Low-risk general surgical patients may be treated with trolled activity of many of the coagulation factors.
graduated compression stockings applied during sur- Endothelial surfaces have receptors called throm-
gery, early ambulation, and adequate hydration [13]. bomodulin that function as anticoagulants because of
Keeping the knees flexed on pillows during surgery and the ability to neutralize thrombin. The thrombin-
avoiding local compression on any areas of the legs are thrombomodulin complex activates protein C, a vita-
helpful. All patients are treated the same if there are any min K-dependent factor that is facilitated by protein S,
low risk factors. The type of surgery does not matter as another vitamin K-dependent factor. Activated pro-
long as general anesthesia or intravenous sedation is teins C and S metabolize activated factors V and VIII,
given. Compression stockings (2030 mm support hose which results in downregulating the coagulation sys-
is adequate) are applied in the operating room, and tem. Patients with protein C deficiency may have
ambulation is begun when the patient is awake and recurrent episodes of superficial thrombophlebitis as
capable of ambulating with assistance. When the patient well as thromboembolism [16]. Patients with protein S
is ambulating on a regular basis during the day, the deficiency experience more arterial thromboembolism
compression stockings can be removed. including stroke [17]. Deficiency in protein C or S may
For moderate risk patients, low-dose heparin (5,000 present as neonatal purpura fulminans in the newborn
units 2 h before surgery and then every 812 h until or skin necrosis in adults treated with warfarin, a drug
ambulatory), low-molecular-weight heparin (LMWH), known to cause a sudden fall in protein C or S.
dextran, or aspirin is recommended. Alternatively, Venous thromboembolism occurs in one out of
graduated compression stockings or intermittent pneu- every thousand people with activated protein C resis-
matic compression started during surgery are used tance (APC-R) responsible for up to 64% of the cases.
continuously until ambulatory, or a combination of APC-R is due to a single point mutation in the FV
both is recommended [10]. gene for clotting factor V. This mutated FV may be
All high-risk patients should be treated with low- referred to as factor V Leiden (FVL), FV:Q506 allele,
dose heparin or LMWH and combined pharmacologic or APC-gene and is less efficiently degraded by APC.
and mechanical methods. A hypercoagulable state results from impairment of
the inactivation of factor V by activated protein C. 5. Involvement of three or more organ systems:
This creates a lifelong increased risk of thrombosis a. Gastrointestinal (vomiting, diarrhea at onset)
and thromboembolism. b. Muscular (myalgia, elevated CPK)
Within the intact vessel, thrombin binds to throm- c. Mucous membrane (conjunctiva, oropharynx)
bomodulin on the endothelial cell acting as an antico- d. Renal (BUN or creatinine >2 times normal)
agulant bay activating the protein C system. Activated e. Hepatic (bilirubin, SGOT, SGPT >2 times
protein C (APC), potentiated by cofactor protein S, normal)
downregulates the activity of the coagulation system f. Hematologic (platelets <100,000)
(limits clot formation) by cleaving and inhibiting fac- 6. Negative results on the following studies (if
tors V (FV) and VIII [1820]. obtained):
APC testing can be performed with DNA genotyp- a. Blood, throat, or cerebral spinal fluid (CSF)
ing. This can differentiate acquired from inherited cultures
APC-R. Approximately 10% of patients with APC-R b. Serologic tests for Rocky Mountain spotted
phenotype lack the FV mutation (genotype), and the fever, leptospirosis, and measles
diagnosis of APC-R in these patients will be missed Treatment consists of surgical debridement for
[21]. The combination of phenotype and genotype necrosis, antibiotics, circulatory and respiratory care,
information aids in establishing prophylactic and ther- anticoagulant therapy for disseminated intravascular
apeutic guidelines. coagulation, and immunoglobulin [28]. Experimental
Asymptomatic patients with APC-R who have never approaches have included use of antitumor necrosis
had a thromboembolic event, as well as their family factor monoclonal antibodies and plasmapheresis.
members, should receive counseling regarding the
implications of the diagnosis and information concern-
ing the signs and symptoms of venous thromboembo- 68.2.20 Umbilical Stenosis
lism [22]. Short-term prophylaxis with heparin should
be considered when there are high-risk circumstances The advent of a contracting scar around the umbilicus
encountered such as immobilization, surgery, trauma, following abdominoplasty is not rare. There have been
or obstetrical procedures. After a thrombotic event, different methods proposed for doing the umbilical
these patients need extended anticoagulation, balancing reconstruction during abdominoplasty in order to pre-
the risk of bleeding against the risk of recurrence when vent stenosis. The umbilical stenosis may result in
therapy is discontinued. Empirical treatment is for at chronic inflammation and drainage that the patient needs
least 1 year after two episodes of thromboembolism to have addressed. At the same time, a stenosed umbili-
and lifelong treatment after three episodes [23]. cus is not a normal-looking umbilicus. Reconstruction
of the stenosis can be surgically performed.
68.2.19 Toxic Shock Syndrome

68.2.21 Umbilicus: Loss or Off Center
Toxic shock syndrome has been reported in breast aug-
mentation [2426]. The syndrome is caused by the The umbilicus should be evaluated for deviation from
exotoxins (superantigens) secreted with infection from the centerline preoperatively. If deviation is present,
Staphylococcus aureus and group A Streptococci [27]. then this should be pointed out to the patient, discussed
Knowledge of the criteria for diagnosis is important in with the patient, and recorded in the medical record.
order to treat this potentially fatal disease. These The deviation may need to be adjusted at the time of
include [27]: surgery. Imbrication of the fascia next to the umbilical
1. Fever (>102o) stalk on the side opposite the deviation will result in
2. Rash (diffuse, macular erythroderma) centering the umbilicus.
3. Desquamation (12 weeks after onset, especially of The centerline of the abdomen must be marked pre-
palms and sole) operatively. The umbilicus should be brought through
4. Hypotension the abdominal wall at the appropriate height and in
1142 M.A. Shiffman
the marked midline. A deviated umbilicus can cause Postoperatively, the surgeon should check the
patient distress and result in litigation. patient at appropriate intervals of time depending on
When performing a modified abdominoplasty with- the extent of surgery, patient age, and patient.
out release of the umbilicus, there will usually be devi- Awareness of the early symptoms or physical findings
ation of the umbilicus inferiorly from removal of the of a complication is essential in order to make a timely
excess skin. The patient must be informed of this prob- diagnosis. Proper studies should be obtained and treat-
lem preoperatively since the lowered umbilicus may ment begun as soon as possible in order to avoid a dan-
not look normal especially in a bathing suit. The nor- gerous or life-threatening problem.
mal umbilicus is at the level of the iliac crests. If a diagnosis of a complication is difficult for the
When the umbilical stalk is denuded of all the fat attending surgeon to make, early consultation should
during abdominoplasty, the blood supply should not be be obtained. If the surgeon intends to leave the area for
disturbed since it comes through the underlying fascia. any reason, the patient should be informed and ade-
However, if a full abdominoplasty is performed fol- quate medical coverage obtained. This should be a sur-
lowing a modified abdominoplasty, where the base of geon who is experienced in performing the same
the umbilicus has been transected and the umbilicus surgery performed on the patient. Any important or
lowered, the blood supply may not be sufficient and critical patient problem must be relayed to the cover-
necrosis of the umbilicus may occur. The physician ing physician and records made available when
should be forewarned in a patient who has had a prior necessary.
abdominoplasty or tummy tuck to look for this possi-
ble problem by obtaining the prior surgeons records.
Smoking is a major cause of necrosis following 68.3 Breast Augmentation
abdominoplasty, and this may affect the umbilicus or
the periumbilical region. Needless to say, the patient 68.3.1 Areolar Retraction
must stop smoking at least 2 weeks prior to surgery
and for 2 weeks after surgery. There still remains the Areolar retraction occurs from fibrotic bands extend-
problem of the patient who says smoking will be ing from the dermis of the areola to the underlying fas-
stopped, but in actuality the patient continues to smoke. cia (Fig. 68.1). Treatment consists of changing the
When this information is divulged after surgery to the implant from the submuscular position to the submam-
surgeon or medical staff, there may be difficulties get- mary position. Transection or resection of the fibrous
ting the patient to stop smoking even when necrosis band alone will almost always result in recurrence of
is severe. The medical record should be excruciat- the indentation.
ingly complete with every conversation, phone call,
and recommendation.
68.3.2 Asymmetry
68.2.22 Discussion Asymmetry is a frequent problem since most females,

prior to surgery, have either one nippleareolar com-
The combination of liposuction with abdominoplasty is plex (NAC) lower that the other or one breast larger
associated with an increase in the risks and complica- than the other. Preoperative photos will show the dif-
tions. Fat embolism syndrome has been reported [29] as ference, and this should be pointed out to the patient
well as an increased incidence of thromboembolism. before surgery.
Necrosis is more common, possibly because of injury to Postoperative asymmetry may be prevented by
the cutaneous vascular system. Matarasso warns about doing a reverse crescent mastopexy for the higher
the problem with liposuction of the mid upper abdomen NAC.
at the same time as performing abdominoplasty.
Benvenuti [30] reported an increased incidence of
inguinal hernias following abdominoplasty. Obesity 68.3.3 Autoination, Spontaneous
has been associated with increased complications
following abdominoplasty, 80% in obese and 33% in There have been reports of spontaneous autoinflation
non-obese patients [31]. of implants [3236].
a 68.3.4 Axillary Banding
Transient axillary banding has been noted in patients

following transaxillary approach to breast augmenta-
tion [3740]. Maximovich [37] reported that micro-
scopic examination (done by Ellenbogen) showed the
band to be lymphatic in origin.
The band is more likely a phlebitis of a superfi-
cial vein of the axilla and medial upper arm (branch
of basilic vein) [41, 42] that is another form of
Mondors disease. A superficial lymphatic vessel
has never been reported to form a thick subcutane-
ous band and superficially would not be large enough
to form a fibrous band that would be palpable and
b visible.
68.3.5 Bleeding, Hematoma
Manifestations of bleeding into the implant pocket

after surgery include swelling, increasing pain, and
tenderness. This should be treated with urgent surgi-
cal decompression with removal of implant, complete
cleansing of blood and clots in pocket, coagulation or
ligation of any bleeders, and reinsertion of the implant
(after cleansing with antibiotic solution). Drains are
usually not necessary. Any residual blood in the pocket
may result in capsule contracture. Instances of late
bleeding, weeks after surgery, have occurred.
Bleeding from the incision site should be treated
with local compression for at least 6 min (normal max-
imum of bleeding time). If this does not control the
bleeding, the wound should be explored and the offend-
ing vessels ligated or coagulated.
68.3.6 Bottoming Out
Bottoming out is a result of the implant sliding infe-

riorly behind the breast. This is usually caused by
the weight of a large implant and/or the patients
physiology (thin, weak fibrous capsule). This can be
treated by capsulorrhaphy suturing the lower portion
of the fibrous capsule at the inframammary fold
(securing the deep tissues by including muscle fascia
or periosteum) together with permanent suture,
supporting the inferior part of the capsule with a
hammock capsulorrhaphy [43], or by internal mas-
Fig. 68.1 Areolar retraction. (a) Preoperative. (b) Postoperative topexy with imbricating sutures of the anterior
with areolar retraction
fibrous capsule [44].
1144 M.A. Shiffman
Fig. 68.3 Nerve entrapment. Arrow shows the fourth intercos-

tal nerve on the fibrous capsule of the implant
have a similar success rate. Capsulectomy is usually

associated with more bleeding and longer surgery time.
External compression capsulotomy is not recommended
since it has been associated with bleeding and implant
rupture and is painful if sedation is not used.
Fig. 68.2 Calcifications in fibrous capsule
Instead of surgical treatment of capsule contracture,
there have been proposals that Accolate (Zafirlukast,
68.3.7 Calcications AstraZeneca Pharmaceuticals, Delaware) be used.
There has been some success with softening of the
Any long-standing fibrous capsule can develop calcifi- capsule with the drug. The dose is 20 mg twice daily.
cations (Fig. 68.2). These are usually asymptomatic.
The calcifications appear benign on mammography.
When the fibrous capsule is thick and calcifications 68.3.9 Chronic Pain
occur, capsule contracture may be present as well.
Calcifications may be associated with the presence of Chronic pain can occur following breast augmentation
the implant stabilization patch [45]. from capsule contraction, nerve entrapment (Fig. 68.3),
If the calcifications are extensive and associated with neuromas, or submuscular placement of the prosthesis.
symptomatic capsule contracture, capsulectomy should With fourth intercostal nerve entrapment, the pain may
be performed rather than capsulotomy. Otherwise, the be sharp or burning in character starting in the lateral
remaining calcified fibrous capsule may be palpable. breast, over the nerve, and radiating to the nippleareolar
complex. Regional block of the fourth intercostal nerve
may help but usually surgical neurolysis is necessary.
68.3.8 Capsule Contracture Delayed onset (years) of breast and subscapular
pain was reported in 8 out of 146 patients who had
Baker grade III or IV usually need surgical revision with submuscular (under pectoralis major and serratus ante-
capsulotomy or capsulectomy. Both of these procedures rior muscles) placement of the prostheses [46].
68.3.10 Double Bubble There have been other reports of lactation following
breast augmentation [49, 50]. Bromocriptine 1.25 mg
The cause of the appearance of a double bubble is daily orally will usually resolve the problem.
usually the implant placed under the pectoralis major
muscle and the inframammary fold lowered. The
attachment of the skin to the underlying fascia from 68.3.14 Idiosyncratic Allergic Reaction
the original inframammary fold, if it is not adequately
broken up during surgery, gives the appearance of a There is one report of an idiosyncratic reaction to
double bubble (Fig. 68.6). During surgery, the liga- textured Becker expander saline implants [51]. The
ment between the muscle fascia and skin should be patient developed erythematous papules and pustules
transected, and it may be necessary to make multiple that showed a perivascular lymphohistiocytic infiltrate,
incisions into the fibrous tissue before expanding the which resolved with removal of the implants. The
crease with the finger and/or a dissection paddle. This textured shell patch was placed on the skin and itching,
can be resolved postoperatively by postoperative com- hives, and urticarial plaques developed under the patch.
pressions to push the fold outward (Fig. 68.4).
The treatment would be to take the implant out of
the subfascial space and replacing it into the submam- 68.3.15 Improper Implant Placement
mary space. The use of Gore-Tex or autologous fat to
fill the defect is unnecessary. The implants may be placed too high because of inad-
equate dissection of the pocket at the inframammary
fold (Fig. 68.6). This is most common during the learn-
68.3.11 Elevated Platinum Levels ing phase of the umbilical approach. More often, the
implant shifts upward when the patient is at home and
There has been one report by Lykissa and Maharaj remains in that position too long. Postoperatively,
[47] that studied the platinum levels in a variety of compressing the superior portion of the breasts with an
tissues of patients who have had silicone and saline ace bandage will usually prevent the upward shift of
implants for augmentation. There was an increase in the prostheses. In the umbilical approach for breast
the levels of platinum in implant patients, which was augmentation, there is a learning curve to produce an
higher than the normal population. However, there are adequate pocket and compression to keep the implant
no symptoms or disorders attributed to these elevated in position. Many times in the umbilical approach, the
levels. implant will slowly settle into the proper position.
When a patient requests a large cleavage fold, there
is only so much the surgeon can do depending on the
68.3.12 Fibrotic Retraction nipple position and what placement of the implant cen-
tered under the nipple will do. Placing the implant too
Fibrosis at the inferior margin of the implant is rare medial just to make cleavage is a serious error since
(Fig. 68.5). It is probably caused by excessive scarring this is a cosmetic procedure and nipples shifted out-
in the area such as with capsule contracture. ward are aesthetically poor (Fig. 68.7).
68.3.13 Galactorrhea 68.3.16 Infection
Rothkopf and Rosen [48] reported on a patient with Infection is manifested by erythema, increasing pain,
galactorrhea following breast augmentation. The pro- swelling, and at times purulent drainage. If purulent
lactin levels in the patient were elevated. It was pre- drainage is present, the wound should be opened and
sumed that the lactation was secondary to prolactin the implant removed. The pocket is cleansed with anti-
elevation due to stimulation of the thoracic nerve end- biotic solution and the wound drained. The implant
ings that produced impulses that travel via the dorsal can be replaced at least 3 months after complete wound
nerve roots to the hypothalamus and pituitary causing healing. Any sooner frequently results in recurrent
a rise in prolactin secretion. infection.
1146 M.A. Shiffman
c
b
Fig. 68.5 Fibrotic retraction
Fig. 68.7 Implant placed too medial to give the patient more
cleavage. (a) Preoperative. (b) Postoperative
improvement, the implant should be removed, cultures

taken, the wound cleansed with antibiotic solution, and
a drain placed in the pocket. Again, implant replace-
ment is not done until at least 3 months have passed
after the wound is completely healed.
68.3.17 Lactation Problems
There have been reports of inability to produce enough

Fig. 68.6 Implant placed too high breast milk to breast-feed an infant following breast
augmentation [27, 5254].
If there are symptoms without purulent drainage, The causes of unsuccessful lactation include inad-
there may be mastitis rather than infection. The patient equate glandular development [27], the periareolar
is treated by increasing the dose of the antibiotic given approach [52], severed milk ducts [52], altered nipple
postoperatively or by a new antibiotic for 2448 h. sensation [52], and lack of or little breast changes
If there is improvement, then the antibiotics can be during pregnancy with little or no postpartum engorge-
continued until there is resolution. If there is no ment [52].
Fig. 68.4 (a) Immediate postoperative double bubble with sub- using firm pressure several times at least four times daily to
muscular implant. (b) Treatment consists of compressing the stretch the attachment. (c) One month after treatment. Only
inframammary fold with the ipsilateral hand and then compress- minimal attachment remains that resolved completely after
ing the upper breast and implant with the contralateral hand 3 months
1148 M.A. Shiffman
during the operation on the left side, but this was

alleviated by the administration of oxygen. The basis
for the migration was believed to be from a large defect
of the chest wall, breast massage after surgery, and the
difference in pressure between the outside and the
inside of the chest wall. However, it is this authors
opinion that initially there was perforation into the tho-
racic cavity during surgery as the cause of the sudden
dyspnea during the procedure, and this evolved into
the large defect in the chest wall with subsequent
migration of the implant.
Fig. 68.8 Scar malposition with inframammary incision sites
too high on the breast
68.3.21 Mondors Disease
68.3.18 Late Bleeding After Breast
Augmentation Mondors disease (superficial breast phlebitis, scleros-
ing breast phlebitis) is an obliterative phlebitis of the
There are multiple reports of late bleeding into the thoracoepigastric vein, frequently with a history of
pocket after breast augmentation [28, 5559]. Some of trauma. The phlebitis normally crosses the anterior chest
the causes have been attributed to chronic inflamma- region and breast from the epigastrium or hypochon-
tory reaction to the polyurethane-coated implant, gran- driac region to the axilla. The symptoms are usually a
ulating tissue with new capillary ingrowth, and the use red linear cord attached to the skin and not to the
of corticosteroids in the saline prosthesis. Another deep fascia with slight to no discomfort (Fig. 68.9).
cause that should be ruled out is blood dyscrasia. Manifestations usually disappear in 36 weeks without
treatment. For discomfort, minor analgesics and the
application of heat will help. Injection of steroids is not
68.3.19 Malposition of the usually necessary and surgical transection unnecessary.
Inframammary Scar A recent suggestion by Rassel, Borsand, and Jonov
for symptomatic Mondors disease is to stabilize the
Breast augmentation scars should be as inconspicuous proximal portion of the vessel with the operators
as possible. Scars can be hidden in the transumbilical thumb, and very firm pressure is placed along the direc-
approach as well as axillary approach. Axillary scars tion of the vessel with the operators opposite thumb as
can get thickened. The position of an inframammary if milking the vessel (Fig. 68.10). While the opera-
scar should be close to the inframammary crease, tors upper hand is stabilizing the vessel, the inferior
within a centimeter, but not in the crease itself since hand applies a firm downward stroke. This disrupts the
this can result in irritation of the scars by the bras- cord and resolves the problem including the pain.
sieres elastic band or wire rubbing the scar.
If the incision is placed too far above the inframam-
mary fold, it will cause a problem when performing a 68.3.22 Myospasm of Pectoralis
repeat augmentation and inserting a larger prosthesis. Major Muscle
This can result in an inframammary scar to appear
even higher on the breast and away from the inframam- Myospasm with spontaneous myoclonic jerks of the
mary fold (Fig. 68.8). left pectoralis muscle was reported following subpec-
toral breast augmentation [61]. This disorder that did
not respond to Klonopin, excision of a segment of the
68.3.20 Migration of Implant lateral pectoral nerve, or open capsulotomy and
transection of the pectoralis major muscle head to the
There is one report of a left breast implant migrating humerus needed explantation to relieve the spasms.
into the thoracic cavity [60]. An axillary approach had The presumptive cause was myospasm from a mechan-
been used and the patient developed sudden dyspnea ical irritation of the nerve from the implant.
a susceptible to complications such as infection and

necrosis. In combination with other factors such as
uncontrolled diabetes, smoking, or hematoma, the risk
of problems increases.
68.3.24 Neurologic Injury
The axillary approach to cosmetic breast surgery is an

excellent alternative to the inframammary, periareolar,
areolar, and umbilical incisions. The scar is rarely vis-
ible except with the arms raised but does occasionally
become hypertrophic. The risks associated with this
approach include all the usual risks of any breast
implant surgery plus the possibility of neurologic dam-
age, both motor and sensory.
The surgeon must be aware of the risks of the axil-
lary approach and convey those risks to the patient to
b allow a knowledgeable and informed consent to the
procedure. The surgery must be performed with cau-
tious attention to the nerves in the area and the meth-
ods to avoid injury to those nerves.
There can be a chronic pain syndrome not only
from injury to the fourth intercostal nerve but to other
sensory nerves higher on the chest wall.
68.3.24.1 Brachial Plexus

Injury to the brachial plexus is most often caused, at
the time of surgery, by positioning the arm in an
abducted position more than 90 from the side of the
body. Those patients susceptible to this type of injury
usually have some form of actual or potential thoracic
outlet syndrome. If the head is turned in the opposite
direction during surgery, there is even more likelihood
for brachial plexus nerve or vascular compression.
There is rarely a need to keep the arm abducted more
than 85 except, perhaps, in making the initial skin
incision at the high point of the axilla in the axillary
approach to breast augmentation.
Fig. 68.9 Mondors disease Although the brachial plexus may be at risk with
the axillary approach to cosmetic breast surgery, the
68.3.23 Necrosis plexus is superior to the axillary vessels and is most
likely to be injured when bleeding occurs from vessel
The causes of necrosis include prior radiation therapy disruption and a hemostat or clip is placed to control
for breast cancer, uncontrolled diabetes followed the bleeding without clearly visualizing the surround-
by infection, late diagnosis of hematoma, smoking ing structures. This type of injury can occur following
(Fig. 68.11), infection, electrocoagulation too close to a long period of compression to control the bleeding
the skin (Fig. 68.12), or a combination of these factors without direct injury from a hemostat or clip. There
(Figs. 68.13 and 68.14). Radiation reduces the vascu- can be permanent injury to the inferior cord of the
larity of the exposed area that makes the breast more brachial plexus (ulnar nerve distribution).
1150 M.A. Shiffman
a b
c d
Fig. 68.10 Mondors disease involving axilla. (a) Thumb firmly on proximal portion of the cord. (b) Opposite thumb on distal por-
tion of cord for firm stretch of cord. (c) Prior to stretch type of manipulation. (d) After manipulation
The brachial plexus has three cords from which the augmentation from any approach, but it is theoretically
infraclavicular branches are derived (Table 68.1). The possible to injure the nerve when doing a very wide
long thoracic nerve (nerve of Bell) is located along the pocket dissection during a capsulectomy or in making
side of the chest wall on the outer surface of the serra- a megapocket in a patient with an extremely large
tus anterior supplying filaments to each of its digita- implant (over 800 mL). The one medical legal case
tions. This nerve is not normally at risk during breast [62] encountered by the author was with a permanent
a a
b
b
Fig. 68.11 (a) Preoperative. (b) Residual scarring of left breast

following breast augmentation in a smoker
long thoracic nerve injury causing a winged scapula in Fig. 68.12 Skin necrosis with residual scar from electrocoagu-
a patient who had simple capsulotomies for breast lation too close to the skin
implants and not utilizing an axillary incision. The
neurosurgeon expert witness testified that the long tho- injured by dissecting too superiorly when forming a
racic nerve was injured by brachial plexus compres- submuscular pocket. Injury to the lateral anterior tho-
sion; however, he did not remember that the nerve has racic nerve may affect the strength of the pectoralis
three roots (fifth, sixth, and seventh cervical) which do major muscle which flexes, adducts, and rotates the
not pass through the thoracic outlet but descend behind arm medially.
the brachial plexus and form the long thoracic nerve The medial anterior thoracic nerve enters and inner-
inferior to the outlet. The most likely cause of injury in vates the pectoralis minor muscle, and two or three
this case was excessively tight dressings which com- branches end in the pectoralis major muscle. The nerve
pressed the long thoracic nerve against the chest wall supplies the lower sternocostal and abdominal portions
below the axilla or an unrecorded fall with injury to the of the pectoralis major muscle as well as the pectoralis
lateral chest wall. minor muscle. This nerve is lateral to the lateral ante-
The lateral anterior thoracic nerve crosses the axil- rior thoracic nerve. The medial anterior thoracic nerve
lary artery and vein piercing the coracoclavicular fas- may be injured when dissecting a retropectoral pocket
cia and enters the deep surface of the pectoralis major using the axillary approach when the lateral edge of
muscle. It sends a filament to join the medial anterior the pectoralis major muscle is not identified before dis-
thoracic nerve in front of the axillary artery. The nerve secting under the muscle and by approaching the mus-
supplies the clavicular, manubrial, and sternal portions cle from too superior a position. Injury to the medial
of the pectoralis major muscle. This nerve can be anterior thoracic nerve leaves no clinical muscle deficit
1152 M.A. Shiffman
Fig. 68.14 Patient post right lumpectomy and radiation therapy

for breast cancer had breast augmentation. Hematoma was diag-
nosed 1 week postoperatively, and because of the late diagnosis,
necrosis of the right nippleareolar complex occurred
Table 68.1 Infraclavicular branches of the brachial plexus

Cord Nerve Spinal origin
Lateral Musculocutaneous 5,6,7 C
Lateral anterior thoracic 5,6,7 C
Lateral head of median 6,7 C
Medial Medial anterior thoracic 8 C, 1 T
Medial antebrachial cutaneous 8 C, 1 T
Medial brachial cutaneous 8 C, 1 T
Ulnar 8 C, 1 T
Medial head of median 8 C, 1 T
Posterior Upper subscapular 5,6 C
Lower subscapular 5,6 C
Thoracodorsal 5,6,7 C
Axillary 5,6 C
Radial 5,6,7,8 C, 1 T
since the nerve only sends a few fibers to the pectoralis

major muscle and mainly supplies the pectoralis minor
muscle which helps to adduct the arm by rotating the
scapula downward and forward.
Fig. 68.13 (a) Diabetic patient, post lumpectomy and radiation
therapy for cancer of the right breast, had bilateral augmentation
68.3.24.2 Intercostal Nerves
mammoplasty. Capsule contracture occurred on the right side The sensory nerves, which are unrelated to the brachial
lifting the breast; there was uncorrected left breast ptosis, and plexus, likely to be injured during the axillary approach
the patient had an infection developed in the wound and implant include the intercostobrachial nerves and the lateral
pocket followed by necrosis. (b) Skin retraction following
removal of the right implant
branches of the third and fourth intercostal nerves.
When forming a subpectoral pocket, injury to the
nerves is more likely to occur if the dissection is not

started anteriorly against the fascia of the pectoralis
major muscle prior to dissecting along the lateral edge
and then under the muscle.
One cause of injury to the fourth intercostal nerve is
placing a large implant (over 400 mL) in a subpectoral
pocket without making sure the nerve is carefully dis-
sected free from the intercostal muscles if the implant
impinges on the nerve. The nerve may not be transected,
but if folded posteriorly with implant compression,
there can be anesthesia of the nippleareolar complex
and/or a chronic pain syndrome with associated scar-
ring around the nerve.
68.3.24.3 Nerve Injury

The most common mistake after making the axillary
skin incision at the highest point of the axilla is
Fig. 68.15 Periareolar scar indentation
approaching the lateral edge of the pectoralis major
muscle from a superior-lateral direction rather than
from an antero-medial-inferior position. The proper (Fig. 68.15) (Mirrafati SJ (2007) Personal communi-
method is to make the skin incision and then pull the cation, August 27, 2007). The cause has been attrib-
skin antero-medially over the lateral edge of the muscle uted to the technique, after the skin incision, of
and slightly inferiorly followed by dissecting down- extending the dissection under the skin in an oblique
ward onto the muscle exposing the lateral edge [63]. method pointing inferiorly to avoid damage to the
By carefully staying on the muscle fascia and dissect- breast ducts or to dissect around the inferior portion of
ing around the muscle edge and under the muscle, the the breast gland to avoid cutting through the breast tis-
submuscular pocket can be formed without approach- sue. This creates a potential space after closure of the
ing any of the axillary nerves. skin incision since the subcutaneous fat may not line
Elective intraoperative division of the medial tho- up properly to fill the space under the skin. The usual
racic (pectoral) nerve denervates the lower third of the method is to dissect straight down through the breast
pectoralis minor muscle making it more flaccid and tissue to form the underlying pocket in the submam-
has been used clinically to allow more anterior breast mary or subpectoral space. Cutting through the breast
projection and to minimize postoperative flexion- tissue does not destroy any major ducts but does cut
induced breast deformity in the patient with retromus- smaller ductules. There have been no infections directly
cular breast implants [64, 65]. There was no clinical attributed to transecting the small ductules.
problem described with transection of the nerve.
Arm position during surgery with abduction to 90
or greater may result in brachial plexus or vascular 68.3.26 Pneumothorax
compression which can cause temporary or permanent
nerve damage. The surgeon should always be aware of Care must be taken when performing breast augmenta-
arm positioning at the beginning of surgery so that tion under local anesthesia. Any sharp needle inserted
excessive abduction does not occur. The elbow should into the tissues around the breast has the potential of
be padded to prevent ulnar nerve paresis. perforation into the pleural space causing a pneu-
mothorax or tension pneumothorax.
When an implant pocket is made in the retropec-
68.3.25 Periareolar Scar Indentation toral area, there is the possibility of pneumothorax
when a bleeder is electrocoagulated in the intercostal
There have been some instances of depression of space. This can leave a hole in the pleura. If noted at
the periareolar scar following breast augmentation the time of surgery, insert a Robinson catheter in the
1154 M.A. Shiffman
pleural space, complete the procedure, and insert the a

implant. Have the anesthesiologist expand the lungs
or, if under local anesthesia, have the patient take a
deep breath and then withdraw the catheter. The
implant will plug the small opening until fully healed.
General anesthesia can cause a pneumothorax [66]
when too much pressure is used in bagging the patient
especially if the patient has lung blebs. It is possible
for a spontaneous pneumothorax to occur when a lung
bleb ruptures without general anesthesia.
If a pneumothorax is suspected, a chest x-ray should
be taken. A pneumothorax that is less than 15% can be b
observed with repeat chest x-ray. If the air is increas-
ing or if the air is over 15%, then a tube should be
inserted into the chest, usually at the anterior second
intercostal space and connected to an underwater seal.
An unusual cause of pneumothorax in breast aug-
mentation was described by Fayman et al. [67]. Four
patients developed bilateral and one unilateral pneu-
mothorax after transaxillary approach to submuscular
placement of implants. Two patients were symptomatic.
The assumption was that air was trapped in the subpec-
toral pocket that was sealed by the implant and wound
Fig. 68.16 Rippling in a patient with textured saline implants
closure. The air was forced into the pleural cavity as a
result of the high pressure created in the subpectoral
pocket by the advancing implant. The problem was 68.3.29 Serous Fluid Drainage
resolved by placing a large-bore suction catheter into
the subpectoral pocket before the implant was inserted. Seroma is a tumor-like collection of serum in the tis-
sues. This postoperative collection of seroma fluid can
occur in breast augmentation surgery [68] and can result
68.3.27 Rippling in increased morbidity and in chronic serous drainage.
In a histopathologic study, it was noted that sero-
With the use of the saline implants, the problem of rip- mas may incite an inflammatory reaction that subse-
pling (skin waviness) has appeared more often. This is quently becomes a contributing factor in persistent
usually with the use of textured saline implants seroma formation [69].
(Fig. 68.16) and can be resolved by converting to a Movement of the textured implant in the pocket
smooth implant. may cause chronic tissue irritation and inflammation
with subsequent seroma formation. Removing and
exchanging a textured implant for a smooth one will
68.3.28 Scar: Hypertrophic, Keloid usually resolve the problem. If a smooth implant is in
place, then consider exuberant granulation tissue as a
Scars can be thickened, hypertrophic, or keloid. The possible cause. Exploration of the wound and curetting
thickened or hypertrophic scar can be treated with all the granulations will allow healing.
compression, silicone sheeting, or steroid injection.
Some hypertrophic scars will resolve spontaneously.
Keloid scars can be treated with the same modalities as 68.3.30 Synmastia (Symmastia)
the hypertrophic scar, bleomycin, 5-flourouracil, and/
or surgical excision. The keloid scar will recur in most Syn means with, together (Greek) while sym in the
instances but perhaps not quite as thick. dictionary always refers to the Greek syn. Therefore
a the midline with the implants removed and suturing

the anterior fibrous capsule to the underlying fibrous
capsule and fascia or periosteum bilaterally and then
doing lateral capsulotomies before replacing the
implants. The excess capsule can be excised or elec-
trocoagulated to expose a healing surface.
68.3.31 Thromboembolism
Patients who undergo surgery are at risk for venous

thromboembolic complications. This is especially crit-
ical in the cosmetic surgery patient who, having an
elective procedure, would not expect to have the mor-
bidity or mortality associated with thromboembolic
disease. The cosmetic surgeon must be aware of the
b possibility of thromboembolism in every patient and
should take a careful history to disclose predisposing
risk factors. The surgeon should also be aware of the
clinical manifestations of pulmonary embolus in order
to make a timely diagnosis.
68.3.31.1 Risk Factors

Minor surgery <30 min in patients over 40 years of age
without additional risk factors and uncomplicated sur-
gery in patients under 40 years of age without addi-
tional risk factors are in the low-risk category. General
surgery in patients over 40 years of age lasting >30 min
and patients under 40 years on oral contraceptives are
in the moderate-risk category [9]. High-risk category
would be major surgery in patients over 40 years of
age with recent history of deep vein thrombosis or
pulmonary embolism, extensive pelvic or abdominal
surgery for malignancy, and major orthopedic surgery
of the lower extremities.
Predisposing risk factors include age over 40 years,
Fig. 68.17 Synmastia secondary to dissection of the pockets to malignancy, obesity, prior history of thromboembo-
the midline of the sternum. (a) without tension (b) with tension
lism, varicose veins, recent operative procedures, and
thrombophilia. These risks are further modified by
both spellings are correct. Synmastia is a fusion of duration and type of anesthesia, preoperative and
both breasts in the midline or, in breast augmentation postoperative immobilization, level of hydration, and
means the meeting or near meeting of both prostheses the presence of sepsis [10]. Medical problems associ-
in the midline. ated with increased risk include acute myocardial
Synmastia can be the result of dissection of the infarction, stroke, and immobilization [11]. Estrogen
pockets to the midline of the sternum thus weakening therapy and pregnancy are common risk factors while
the medial tissues which allows the implant to migrate uncommon factors include lupus anticoagulant, neph-
medially (Fig. 68.17) or of thin and weak tissues near rotic syndrome, inflammatory bowel disease, poly-
the sternum that, postoperatively, are pushed medi- cythemia vera, persistent thrombocytosis, paroxysmal
ally by the implants. Treatment consists approaching nocturnal hemoglobinuria, and inherited factors such
1156 M.A. Shiffman
Table 68.2 Thromboembolism protocol

Adult Deep Vein Thrombosis Prevention Assessment & Physician Orders
Instructions:
RN to complete Risk Factors & obtain physician orders & lab orders from MD
When complete< nursing to send a copy to the Pharmacy Department
Risk Factors (Circle ALL that apply) Physician Orders (check all that apply)
1 Minor Surgery Total Risk
1 Age between 41 to 60 years Points Level
1 History of prior major surgery (less than 1 month) 0 to 1 LOW Early aggressive mobilization
1 Varicose veins
Anti-embolism stockings
1 Inflammatory bowel disease
Sequential compression device
1 Swollen legs (current) Moderate
2 Heparin 5,000 units SQ every 12 hrs
1 Obesity
1 Oral contraceptive or hormone replacement therapy
Lovenox 40mg SQ daily
2 Age between 61 to 74 years Lovenox 30mg SQ every 12 hrs
2 Malignancy present or within last 6 months
2 Major surgery (more than 45 minutes)
Anti-embolism stockings
2 Laparoscopic surgery (more than 45 minutes)
2 Confinement to bed (more than 72hrs pre & post admission) Heparin 5,000 units SQ every 12 hrs
2 Immobilizing cast (less than 1 month)
3 to 4 High
2 Central venous access (less than 1 month) Heparin 5,000 units SQ every 8 hrs
3 History of DVT/PE Lovenox 40mg SQ daily
3 Family history of thrombosis Lovenox 30mg SQ every 12 hrs
3 Age 75 years or older Warfarin mg daily
Major surgery with additional risk factors
3 Anti-embolism stockings
(MI,CHF,sepsis, COPD)
Medical patient with additional risk factors (MI,CHF,sepsis,
3 Lovenox 40mg SQ daily
history of stroke, serious lung diseases, pneumonia)
5 or SCD + Lovenox 40mg SQ daily
3 History of increased clotting time Highest
more SCD + Heparin 5,000 units SQ
5 Elective total hip and/or knee replacement
every 8 hrs
5 Hip, pelvis or leg fracture (less than 1 month) Lovenox 30mg SQ every 12 hrs
5 Stroke (less than 1 month) (decrease to once daily when
5 Multiple traume (less than 1 month) strating coumadin)
Total Points
Absolute contraindications for anticoagulation: Laboratory Orders:
Active hemorrhage form wounds, drains, lesions CBC every other day if heparin or lovenox are
Heparin use in herparin-induced thrombocytopenia administered
Severe trauma to head, spinal cord or extremities with Daily PT/INR if warfarin is administered
hemorrhage within 4 weeks (parameters)
Active intracerebral or gastrointestinal hemorrhage Additional Lab orders (specify)
Known hypersensitivity to herparin or pork products (for heparin)
Warfarin therapy for contemplated major surgery
Risk Assessment completed by:
Signature:
Physician signature:
Date: Time:
Date: Time:
as antithrombin III deficiency, protein C deficiency, Preoperative risk assessment should be determined
protein S deficiency, plasminogen activator deficiency, in every patient (Table 68.2).
elevated plasminogen activator inhibitor, and homo-
cystinuria [12]. 68.3.31.2 Clinical Manifestations
Superficial calf vein thrombosis, proximal deep Superficial thrombophlebitis (an inflamed vein)
vein thrombosis, and fatal pulmonary embolus increase appears as a red, tender cord. Deep-vein thrombosis
in incidence as the risk category increases from low to may be associated with pain at rest or only during
high. exercise with edema distal to the obstructed vein. The
first manifestation can be pulmonary embolism. There capable of ambulating with assistance. When the
may be tenderness in the extremity and the tempera- patient is ambulating on a regular basis during the day,
ture of the skin may be increased. Increased resistance the compression stockings can be removed.
or pain on voluntary dorsiflexion of the foot (Homans For moderate risk patients, low-dose heparin (5,000
sign) and/or tenderness of the calf on palpation are units 2 h before surgery and then every 812 h until
useful diagnostic criteria. ambulatory), low-molecular-weight heparin (LMWH),
Pulmonary embolism is usually manifested by one dextran, or aspirin may be utilized. Alternatively, gradu-
of three clinical patterns: (1) onset of sudden dyspnea ated compression stockings or intermittent pneumatic
with tachypnea and no other symptoms, (2) sudden compression started during surgery are used continu-
pleuritic chest pain and dyspnea associated with find- ously until ambulatory, or a combination of both is rec-
ings of pleural effusion or lung consolidation, and (3) ommended [14]. Intermittent pneumatic compression is
sudden apprehension, chest discomfort, and dyspnea more effective than graduated compression stockings.
with findings of cor pulmonale and systemic hypoten- All high-risk patients (unlikely in cosmetic sur-
sion. The symptoms occasionally consist of fever, gery) should be treated with low-dose heparin or
arrhythmias, or refractory congestive heart failure. LMWH and combined pharmacologic and mechani-
cal methods.
68.3.31.3 Diagnosis Dextran can result in cardiac overload, and high-
Deep-vein thrombosis is best diagnosed with duplex dose aspirin (1,0001,500 mg/day) has limited efficacy
ultrasonography which combines pulsed gated Doppler in preventing deep-vein thrombosis. In cosmetic sur-
evaluation of blood flow with real-time ultrasound imag- gery, the use of aspirin or heparin may result in postop-
ing. Other diagnostic tests include x-ray venography, erative bleeding.
radionuclide venography, radioisotope-labeled fibrino-
gen, ultrasonography, and impedance plethysmography. 68.3.31.5 Hereditary Hypercoagulable
Liquid crystal thermography detects increases in skin States
temperature and is a useful adjunct to ultrasonography Patients with a family history of thrombosis, early-
or impedance plethysmography. onset or recurring thrombosis, thrombosis at unusual
Ventilation-perfusion lung scan (VP scan) is a safe, sites, or warfarin-induced skin necrosis should be eval-
sensitive means of diagnosing pulmonary embolism. uated for possible underlying inherited hypercoagula-
Isotope pulmonary perfusion scan (Q scan) is more spe- ble disorders.
cific with inclusion of the isotope ventilation scan (V Antithrombin III (AT-III) is a heparin cofactor that
scan). The definitive diagnosis can be made by pulmo- allows heparin to inactivate primarily factor IIa but also
nary arteriography, but VP scan can give a high degree factors IXa, Xa, XIa, and XIIa [15]. A deficiency in
of certainty. Arterial blood gas typically shows reduc- AT-III predisposes to thrombosis by allowing uncon-
tion in PaO2 and PaCO2 while electrocardiogram shows trolled activity of many of the coagulation factors.
tachycardia but is best used for ruling out myocardial Endothelial surfaces have receptors called throm-
infarction. Chest x-ray may show basilar atelectasis, bomodulin that function as anticoagulants because of
infiltrates, pleural effusion, or cardiac dilatation. the ability to neutralize thrombin. The thrombin-
thrombomodulin complex activates protein C, a vita-
68.3.31.4 Prophylactic Treatment min K-dependent factor that is facilitated by protein
Low-risk general surgical patients may be treated with S, another vitamin K-dependent factor. Activated pro-
graduated compression stockings applied during sur- teins C and S metabolize activated factors V and VIII,
gery, early ambulation, and adequate hydration [13]. which results in downregulating the coagulation sys-
Keeping the knees flexed on pillows during surgery tem. Patients with protein C deficiency may have
and avoiding local compression on any areas of the recurrent episodes of superficial thrombophlebitis as
legs are helpful. The type of surgery does not matter as well as thromboembolism [16]. Patients with protein
long as general anesthesia or intravenous sedation is S deficiency experience more arterial thromboembo-
given. Compression stockings (2030 mm support lism including stroke [17]. Deficiency in protein C
hose is adequate) are applied in the operating room, or S may present as neonatal purpura fulminans in
and ambulation is begun when the patient is awake and the newborn or skin necrosis in adults treated with
1158 M.A. Shiffman
warfarin, a drug known to cause a sudden fall in Staphylococcus aureus and group A Streptococci.
protein C or S. Knowledge of the criteria for diagnosis is important
Venous thromboembolism occurs in one out of in order to treat this potentially fatal disease. These
every 1,000 people with activated protein C resistance include:
(APC-R) responsible for up to 64% of the cases. 1. Fever (>102o)
APC-R is due to a single point mutation in the FV 2. Rash (diffuse, macular erythroderma)
gene for clotting factor V. This mutated FV may be 3. Desquamation (12 weeks after onset, especially of
referred to as factor V Leiden (FVL), FV:Q506 allele, palms and sole)
or APC-gene and is less efficiently degraded by APC. 4. Hypotension
A hypercoagulable state results from impairment of 5. Involvement of three or more organ systems:
the inactivation of factor V by activated protein C. a. Gastrointestinal (vomiting, diarrhea at onset)
This creates a lifelong increased risk of thrombosis b. Muscular (myalgia, elevated CPK)
and thromboembolism. c. Mucous membrane (conjunctiva, oropharynx)
Within the intact vessel, thrombin binds to throm- d. Renal (BUN or creatinine >2 times normal)
bomodulin on the endothelial cell acting as an antico- e. Hepatic (bilirubin, SGOT, SGPT >2 times
agulant bay activating the protein C system. Activated normal)
protein C (APC), potentiated by cofactor protein S, f. Hematologic (platelets <100,000)
downregulates the activity of the coagulation system 6. Negative results on the following studies (if
(limits clot formation) by cleaving and inhibiting fac- obtained):
tors V (FV) and VIII [1921]. a. Blood, throat, or cerebral spinal fluid (CSF)
APC testing can be performed with DNA genotyp- cultures
ing. This can differentiate acquired from inherited b. Serologic tests for Rocky Mountain spotted
APC-R. Approximately 10% of patients with APC-R fever, leptospirosis, and measles
phenotype lack the FV mutation (genotype), and the Treatment consists of surgical debridement for
diagnosis of APC-R in these patients will be missed necrosis, antibiotics, circulatory and respiratory care,
[22]. The combination of phenotype and genotype anticoagulant therapy for disseminated intravascu-
information aids in establishing prophylactic and ther- lar coagulation, and immunoglobulin. Experimental
apeutic guidelines. approaches have included use of antitumor necrosis
Asymptomatic patients with APC-R who have never factor monoclonal antibodies and plasmapheresis.
had a thromboembolic event, as well as their family
members, should receive counseling regarding the
implications of the diagnosis and information concern- 68.4 Breast Augmentation:
ing the signs and symptoms of venous thromboembo- Subfascial Pocket
lism [23]. Short-term prophylaxis with heparin should
be considered when there are high-risk circumstances 68.4.1 Introduction
encountered such as immobilization, surgery, trauma,
or obstetrical procedures. After a thrombotic event, The subfascial approach to breast augmentation has
these patients need extended anticoagulation, balancing had very good results with few complications. Surgeons
the risk of bleeding against the risk of recurrence when planning to perform the procedure should first observe
therapy is discontinued. Empirical treatment is for at the technique and, better yet, get hands-on training.
least 1 year after two episodes of thromboembolism The inexperienced surgeon is more likely to have com-
and lifelong treatment after three episodes. plications. The usual risks and complications follow-
ing breast augmentation should be discussed with the
patient prior to the surgery as well as the risk of mis-
68.3.32 Toxic Shock Syndrome placement of the implant below the pectoralis major
muscle instead of above the muscle.
Toxic shock syndrome has been reported in breast aug- The purpose of the subfascial pocket is to have less
mentation [2426]. The syndrome is caused by the capsule contracture and rippling while avoiding the sub-
exotoxins (superantigens) secreted with infection from muscular problem of distortion with muscle tension.
68.4.2 Difculty Dissecting the Pocket edema and faster recovery than with submuscular or
subglandular placement.
Parsa et al. [70], without having been trained for this Munoz et al. [74] had no capsule contractures in the
procedure, performed subfascial pocket dissection in 42 patients with the subfascial approach followed for
three patients. They had difficulties with the dissec- 16 months.
tion, shredded the fascia, found it time-consuming,
and had increased blood loss. Experienced, trained
surgeons have no difficulty dissecting the pocket, have 68.4.5 Discussion
little difficulty with bleeding, and can perform the
surgery in the same or less time than in doing the sub- There are other reports on the use of the subfascial
mammary or subpectoral pocket. placement of prostheses [7577].
Duman et al. [78] performed research using rabbits
that showed that the capsule formed was thinner and
68.4.3 Incorrect Pocket less cellular in the fascia-covered implant group than
in the control group without fascia covering. Fascial
It is possible to place the prosthesis in a subpectoral tissue may decrease capsule formation and probably
pocket accidentally instead of the intended submammary capsule contraction.
pocket. This can occur with blind dissection or even with Capsule contracture occurs less often with the sub-
the endoscope. Endoscopically, in the subpectoral pocket, fascial pocket than with the submuscular implant
the anterior muscle may not be visible through the fat placement without the problem of the pectoralis major
layer under the muscle and may appear to be the fat muscle causing distortion with contraction.
under the breast. Posteriorly, the pectoralis major muscle
should be visible if submammary, and the ribs should be
visible if subpectoral, but the pectoralis minor muscle, 68.4.6 Conclusions
which arises from the third, fourth, and fifth ribs and
inserts into the coracoid process of the scapula, may be The subfascial placement of implants has fewer compli-
mistaken for the pectoralis major muscle. cations than some of the other approaches. Training is
necessary in order to perform the procedure properly.
68.4.4 Reported Complications

68.5 Breast Augmentation:
Stoff-Khalili et al. [71] described the complications in Transumbilical Approach
69 patients having the subfascial approach. Baker
grade III capsule contracture occurred in 2.6% and 68.5.1 Introduction
Baker grade IV in 0.0%. Rippling was noted in 1.5%
of patients, and there were no patients with hematoma The transumbilical approach to breast augmentation
or seroma. has a few complications that differ from approaches
Graf et al. [72] reported on 263 patients with endo- from the axilla, areola, or inframammary region.
scopic transaxillary subfascial approach and had six Although the literature may seem to suggest that using
patients with grade II capsule contracture (2.3%), three the endoscope is essential, many experienced surgeons
patients with unilateral hematoma (1.1%), and eight using the transumbilical approach do not rely on the
patients with implant malposition requiring surgical endoscope to check for bleeding or implant position.
intervention (3%). There were no patients with implant
distortion from muscle contraction.
Ventura and Marcello [73] had 63 patients with sub- 68.5.2 Reports of Complications
fascial approach. There were two patients (2%) with
Baker grade II capsule contracture and one patient with Johnson and Christ [79] had 91 patients with the tran-
excess drainage that required surgical exploration. sumbilical approach for submammary breast augmen-
There were no seromas or infections, and there was less tation. One patient had excessive bleeding at the time
1160 M.A. Shiffman
of surgery and required an inframammary incision to there is usually a layer of fat under the muscle that may
control the bleeder. Implant deflation occurred in one be mistaken for the fat under the breast tissue. When
patient, and two patients had subpectoral implantations viewed posteriorly, the pectoralis minor muscle may
that were corrected through submammary incisions. not be distinguished from the pectoralis major muscle
Vila-Rovira [80] reported on 145 patients using the since it arises from the upper margins of the third,
transumbilical approach. There were no cases of hema- fourth, and fifth ribs, and from the aponeuroses cover-
toma or infection. Postoperative pain was described as ing the intercostal muscles. The muscle fibers pass
mild. There were some cases of postoperative edema. upward and lateralward and converge to form a flat
Twenty percent of patients had capsule contracture with tendon that inserts into the coracoid process of the
75% Baker grade I, 15% grade II, 6% grade III, and 4% scapula. The endoscopic examination is not perfect for
grade IV. Rippling occurred in 30% of patients (saline determining implant pocket position.
implants were used in all 145 patients with 80% smooth An instrument to change implants from the subg-
and 20% textured). Some patients had asymmetry, but landular to the subpectoral position was described by
some of them were due to undetected preexisting ana- Rey [84]. This instrument can be used without a sepa-
tomical deformities. Areola sensory changes were tran- rate incision by developing the correct pocket (sub-
sitory. A fibrous cord along the tunnel tract was muscular) with the bullet dissector, inserting the
detectable in two cases but resolved after 68 weeks. implant into the subpectoral space, and then removing
Caleel [81] reported on 513 patients. One patient the implant from the false pocket. Rey developed
had bleeding, two patients had postoperative hema- another instrument to lift the pectoralis muscle via the
toma, one patient had implant leak, and three patients umbilical incision and then placing the implant into
had inadequate implant pocket dissection. the correct pocket.
Sudarsky [82] operated on 90 patients of which 70
had follow-up. One patient had accidental submuscu-
lar entry into the pocket, and there were four capsule 68.5.4 Implant Postoperatively Too High
contractures.
Songcharoen [83] treated 93 patients with the tran- This may occur because the inframammary fold por-
sumbilical approach. There were no infections, 1% tion of the pocket was not dissected low enough, or
hematoma at the tunnel area, 3% implant leakage, and with a well-developed low pocket, the implant may not
4% with unequal breast size. have migrated downward enough to fill the inframam-
mary fold. This complication is more frequent with the
inexperienced surgeon. This is a well-known compli-
68.5.3 Incorrect Implant Pocket Position cation of the transumbilical approach.
Usually, the tunnel extending lateral to the nipple and

the breast not elevated will place the dissector in the 68.5.5 Capsule Contracture
submammary plane on blunt dissection. If the tunnel is
placed medial to the nipple while the breast is lifted, the The capsule contracture rate Baker grade II to IV is 5%
pocket is usually in the subpectoral plane. Certainly, it with saline implants in the submammary position [80].
is a known complication of the transumbilical approach According to the Inamed Aesthetics statistics [85], the
to get the implant in the incorrect plane by accident. capsule contracture rate with saline implants for Baker
The problem of not positioning the implant in the grade III/IV is 7.2% for 1-year cumulative occurrence
correct plane, submammary or subpectoral, may be by and 8.7% for 3-year cumulative occurrence.
accident, may be from inexperience, or endoscopic The causes of capsule contracture include patients
examination may have fooled the surgeon. When the biophysiology, infection, bleeding, silicone oil leak-
implant pocket is placed in the submammary position, age, and foreign bodies (talc from gloves, dust?). The
the endoscope will show fat visible superficially (ante- umbilical approach has very little bleeding [8689]
riorly) and the pectoralis major muscle visible posteri- compared to other approaches, and this may be the
orly. However, when a subpectoral pocket is formed, reason for the lower capsule contracture rate.
68.6 Breast Reduction
68.6.1 Calcications
Yalin et al. [90] reported on mammographic and ultra-

sonographic findings of calcifications following breast
reduction (Fig. 68.18). Masses were seen with coarse
and thick spiculations, irregular margins, central radio-
lucencies, and amorphous and pleomorphic, dystro-
phic, coarse and branching microcalcifications. There
were eggshell-like oil cyst calcifications. Fat necrosis
and oil cysts are associated with all types of surgical
procedures in the breast.
Parenchymal redistribution, asymmetry, scarring, Fig. 68.18 Calcifications following breast reduction
parenchymal or retroareolar linear bands and calcifica-
tions, high position of the nipple, and discontinuity of cases having breast reduction followed for over 10 years
the ducts were reported by Brown [91] and Miller [92]. after surgery, there were 18 cases of breast cancer. The
Mendelson [93] noted skin thickening of the lower expected number for the incidence of breast cancer in
pole of the breast around the incision sites in the peri- the normal population would be 30.28 cases.
areolar area and inframammary fold. Spicules were
thicker and more curvilinear than the fine and straight
spiculations of breast cancer. There were needle-like 68.6.3 Cyanotic NippleAreolar Complex
calcifications.
Mitnick et al. [94] reported calcifications following The patient should be seen on the first postoperative
breast reduction were found within the skin of the day in order to evaluate the nippleareolar complex for
breast, mainly at a periareolar location. cyanosis. If there is any question of the blood supply to
Mitnick et al. [95] noted suspicious mammographic the nippleareolar complex, test for capillary refill that
findings including 31 stellate lesions, 20 regions of should be less than 6 s. Six seconds or more requires
grouped calcifications, 2 nodules, and 1 area of trabe- that the wound sutures be removed to relieve the ten-
cular markings. Adenocarcinoma was diagnosed by sion and check the pedicle for rotation. With an
fine needle biopsy in five patients. There was a higher anchor incision, the sutures can be removed along
incidence of contralateral breast cancer in patients who the lower half of the areola and along the vertical por-
had cancer on one side and breast reduction on the tion of the wound. If necessary, remove all sutures and
other side. allow secondary healing. Nitropaste has not been effec-
Heywang-Kobrunner [96] reported calcifications of tive in preventing necrosis. Continued cyanosis with
fat necrosis and oil cysts that are round and have ring- refill of 6 s or more may be best treated with nipple
or eggshell-like wall calcifications with radiolucent areolar transplant.
centers.
68.6.4 Excessive Breast Reduction

68.6.2 Cancer
Some surgeons use techniques that consistently reduce
Breast cancer has been diagnosed intraoperatively [97 the breast excessively. A patient with a DD should not
99] and in the postoperative specimen following reduc- be made an A cup but should be made a cup size that is
tion [100]. This is the reason why all patients for breast adequate for the height and weight. Agarwal [102] has
reduction should have a preoperative mammogram. described a flap augmentation for excessive breast
Lund et al. stated that breast reduction may reduce reduction. Most of the time, implants can be used to
the incidence of future breast cancer [101]. Of 1,245 augment the breast to a proper size.
1162 M.A. Shiffman
68.6.5 Fat Necrosis a
As with any necrosis problem, there can be loss of

vascular supply to parts of the fat along incision sites.
This can result in postoperative drainage of an oily
substance or a mass that may have to be treated with
excision or drainage. An untreated area of fat necrosis
may result in a fat cyst followed by calcification.
68.6.6 Hematoma
Excessive bleeding with hematoma should be treated b

with exploration, evacuation of the hematoma, and
coagulation of any bleeders. It is probably prudent to
place a suction catheter or penrose in the space for at
least 24 h.
68.6.7 High NippleAreolar Complex
The cause of a postoperative high nippleareolar

complex is either bottoming out of the breast where
the breast falls behind the nippleareolar complex to
a more inferior position or because the surgeon has
Fig. 68.19 High nippleareolar complexes secondary to bot-
not adjusted to a lower position for the large breast toming out. (a) without bra. (b) with bra
weight stretching the skin (Fig. 68.19). The new
nipple point, instead of being at the inframammary
fold, should be adjusted 12 cm lower for the heavy
breast.
68.6.8 Infection
Infection should be treated with proper antibiotics, if

possible following culture and sensitivity. Cellulitis is
most often a strep infection. An abscess needs open
drainage with culture and sensitivity.
68.6.9 Necrosis
Necrosis of skin flaps can occur from inadequate

Fig. 68.20 Postoperative necrosis following breast reduction in
blood supply, torsion of the pedicle, excessive tension a diabetic with infection
on the skin or compression of the pedicle, thin flaps,
hematoma causing excessive tension, smoking, and
uncontrolled diabetes especially with infection (Fig. Treatment consists of debriding the necrotic areas,
68.20). Necrotizing ulceration was reported by Berry keeping the open wounds clean with saline soaks,
et al. [103]. and secondary closure when the granulations have
properly formed. If secondary closure fails, then the

wound should be left open to close on its own.
68.6.10 Neurological
Pressure sensation (using the Pressure-Specified

Sensory Device) of the breast was measured at nine
points of the breast by Ferreira et al. [104]. All 25
patients had decreased sensation in all points measured
when the upper medial pedicle technique was used.
Hamdi et al. [105] noted loss of sensitivity of the
nippleareolar complex (NAC) with superior and infe-
rior pedicle techniques that resolved with the change
to the latero-central pedicle technique.
68.6.11 Pain
Gonzalez et al. [106] reported that headache, neck

pain, back pain, shoulder pain, and bra strap groove
pain present in 6092% of patients and 97% of patients
had at least three of these pain symptoms preopera-
tively. All patients had reduction of their pain, and
25% had complete elimination of pain symptoms after
reduction mammaplasty.
Chronic breast pain can occur following breast
reduction [107].
Fig. 68.21 Residual pigmented areola tissue along the vertical
scar following breast reduction
68.6.11.1 Phantom Breast Pain
Phantom breast pain at the site of the original nipple
locations has been reported following breast reduction
[108]. This was resolved with explanation to the patient
of the origin of the pain and with nonsteroidal anti-
inflammatory analgesics.
68.6.12 Retained Excess Areola
In patients for breast reduction with very large areolas,

the Wise pattern has to be modified to allow removal of
all the excess areola. Otherwise, the pigmented area of the
residual areola will mar the cosmetic result (Fig. 68.21).
68.6.13 Scar
Hypertrophic (Fig. 68.22) and keloid scars can occur

with any surgical wound. Fig. 68.22 Hypertrophic scar
1164 M.A. Shiffman
68.6.13.1 Pathology Inadvertent injection of steroids deep to the scar may

Hypertrophic scars can be distinguished from keloid result in steroid fat atrophy.
scars microscopically. Both are characterized by exces-
sive deposits of collagen in the dermis and subcutane-
ous tissues following trauma or surgical injuries with 68.6.14 Steroid Fat Atrophy
collagen bundles that appear stretched and aligned in
the same plane. Collagen bundles in keloids are thicker The treatment for fat atrophy secondary to steroid
and more abundant and form acellular node-like struc- injection has usually been with the use of fillers,
tures in the deep dermis. including autologous fat.
The author has a patient who was a postreduction
68.6.13.2 Clinical Manifestations mammoplasty with implant augmentation patient with
Keloids may have a genetic predisposition and occur in postoperative hypertrophic scars that had been treated
1520% of blacks, Hispanics, and Asians. Hypertrophic in the inferior medial aspect of both breasts with ste-
scars are confined to the area of injury while keloids roids resulting in complete loss of the fat of the inferior
grow beyond the confines of the original wound and medial portions of the breast fat 1 year before being
can appear nodular. Hypertrophic scars may regress seen (Fig. 68.23). While performing a capsulotomy for
without treatment while keloids rarely regress. The capsule contracture of the right breast, 300 mL of
scars can cause disfigurement, contractures, pain, and saline was injected as tumescent fluid into the inferior
itching. medial quadrants of both breasts for a total of 600 mL.
Thirty days after the procedure, the inferior medial
68.6.13.3 Treatment quadrants of the breast were found to be filled out to
Keloids and hypertrophic scars can be treated with normal proportions with fat.
intralesional corticosteroids alone or in combination Apparently, the steroids cause loss of the fat in the
with surgical excision, superficial radiation, laser, cry- cell but do not destroy the fat cells. Placing the steroid
otherapy, or pressure therapy. Silicone sheeting used crystals back in emulsion form allows the body to
8 h daily for 36 months is helpful in reducing the remove these as foreign substances.
height of a thickened scar. Keloids tend to recur in
about 80% of patients with most types of treatment.
Other therapeutic agents [109] include 5-fluorouracil, 68.6.15 Discussion
verapamil (calcium blocker), bleomycin, interferon-a-
2b, histamine antagonist, or colchicine (with or without Some form of complication occurs in about 10%
penicillamine and b-aminopropionitrile). of patients. Mandrekas [110] reported the incidence
Surgical excision of keloids followed by superficial of:
radiotherapy for two treatments, one per day, is very Hematoma 0.3%
helpful. The best way to remove the keloid surgically Nipple and/or pedicle necrosis 0.8%
is to excise the scar leaving about 1 mm of scar cir- Wound dehiscence 4.6%
cumferentially and closing the wound with sutures in Hypertrophic scars 3.3%
the scar edges. The use of steroid in the edges of the Loss of sensitivity of the nipple 1.3%
wound closure may be helpful in reducing the amount
of scarring.
In using corticosteroids, care should be taken to 68.7 Facelift
inject the drug into the middle of the lesion. If injected
too superficially, there may be visible spots of chalky 68.7.1 Asymmetry
material. There may be pain with injecting steroids
into the scar because there is very little to give to Asymmetry results from excess excision of skin from
the tissues and local anesthesia may be necessary. one side of the face or from unequal pull on the flaps,
The author uses a combination of triamcinolone not in the same direction, on each side. Distortion of
(40 mg/mL), 0.20.4 mL, 5-fluorouracil, 1 mL (50 mg), the earlobe is common if the closure is performed
and 1 mL 0.5% lidocaine with epinephrine for the under any tension around the bottom of the ear.
injection. Hypopigmentation in the scar may occur. Revision surgery may have to be performed.
Fig. 68.23 (a) Fat atrophy of the inferior medial quadrants of both breasts following steroid injections of the scars. (b) Thirty days
after tumescence with 300 mL saline on each side showing the fat content of the inferior medial quadrants to be normal
68.7.2 Bleeding sues are friable, the wound may have to be allowed to
heal with secondary intention.
Postoperative bleeding may occur if the vessels are not
completely ligated or electrocoagulated.
Other causes of bleeding include: 68.7.4 Dogear
1. Surgical technique
2. Aspirin or nonsteroidal anti-inflammatory drugs A dogear may occur in the temporal region or the pos-
(NSAIDS) terior neck. Most will tend to resolve over a few
3. Hypertension months. It is easier to repair the dogear at the end of
4. Anticoagulation drugs (coumadin) the surgical procedure, but revision may be performed
5. Blood dyscrasia at a secondary surgery.
6. History of easy bruising
68.7.5 Ear Deformities

68.7.3 Dehiscence
Excessive tension is the usual cause of ear deformity.
Tight wound closure with tension may result in wound Excision of skin around the ear should be performed
dehiscence. This may require resuturing but if the tis- after tension sutures have been inserted above the ear
1166 M.A. Shiffman
and behind the ear. Secondary surgery may be neces-

sary to correct a deformity.
68.7.6 Edema
Edema usually subsides within the first few weeks.

Chronic edema should be investigated for causes
other than the surgery. Diuretics are not usually
recommended.
68.7.7 Hair Loss
Hair loss can occur as the result of a tight closure and

tension on the hair-bearing tissues. Most of the time,
the hair will regrow over time. Repair of the area of
Fig. 68.24 This patient had an S-lift and 1 week after surgery
chronic hair loss may require excision (after 6 months) began to have a swelling of the right cheek. On examination
of the bare region, or hair transplantation can be there was a soft swelling that became an indentation when
performed. compressed by the finger. Simple observation with mild mas-
sage of the area allowed the problem to resolve that originated
from too tight a closure of the purse-string S suture in the
parotid fascia
68.7.8 Hematoma
An expanding hematoma (pain and swelling of the

side of the face) is a surgical emergency and requires 68.7.11 Necrosis
early wound exploration with evacuation of the hema-
toma and ligation of bleeder, and probably needs to be Necrosis can be the result of the flaps being too thin or
drained at the time of closure [111]. the closure being too tight. Smokers are very suscep-
tible to flap necrosis if the smoking is not completely
stopped prior to and after surgery [113]. Especially
68.7.9 Infection dangerous is electrocoagulation of bleeders on the skin
flap. The oozing of blood on the skin flap should be
Infection is rare (11 in 6,166 cases or 0.18%) [112]. treated with compression only.
Inflammation may be treated with topical steroids,
and any infection should be treated with appropriate
antibiotics. Heat applied locally is helpful. 68.7.12 Neurological
Any of the facial sensory or motor nerves in the area of

68.7.10 Irregularities the facelift may be injured. Especially susceptible are
the branches of the facial nerve and the anterior and
Irregularities may be the result of coming too close to posterior auricular nerves. Prevention is a necessity.
the skin in developing the facial flap. Indentations of The surgeon should understand facial anatomy and the
the skin following facelift surgery can be treated with three-dimensional relationship of the nerves.
a filler, preferably autologous fat. In one case, inden- Temporary paresis can occur with injection of local
tation occurred from a very tight S suture in a modi- anesthesia into the area of the nerve or from traction on
fied facelift (S-lift) (Fig. 68.24). This resolved over a the nerve. This type of paralysis can be observed until it
couple of months without treatment except massage clears. If there is any question of motor nerve transec-
of the area. tion, then studies should be performed to establish nerve
conduction. Early repair of a transected nerve will aid a

in more complete and earlier return of function.
68.7.13 Pain
Persistent facial pain is rare. If acute, following sur-

gery, this may suggest an expanding hematoma. If
chronic, branches of the sensory cervical nerves may
have been injured. The pain will usually subside within
6 months. Nerve blocks may give temporary relief.
68.7.14 Pigmentation Changes

b
Hyperpigmentation may follow facial ecchymoses even
with full resolution of the bruising. Sunlight exposure
may increase the possibility of hyperpigmentation.
Patients with telangiectasias may have developed
more after rhytidectomy.
68.7.15 Salivary Fistula
Sutures placed deep in the parotid fascia (part of the

SMAS) can result in a salivary fistula (rare) (Fig. 68.25).
Treatment would require removal of the offending
suture, bland diet, and Donnatol four times daily to
reduce the salivary flow. The fistula usually heals very
c
readily with this treatment.
68.7.16 Scar
Scars are usually a physiologic response to injury and

may be hypertrophic or keloid. Keloid scars can be
hereditary. Tight closure can contribute to a widened
scar (Fig. 68.26).
There are a variety of treatments for keloids and
hypertrophic scars including steroid injection, surgery,
5-fluorouracil injection, silicone gel sheeting, bleomy-
cin injection, or a combination of these.
Fig. 68.25 (a) Patient developed a soft swelling a few days

68.7.17 Seroma after modified facelift. This was drained with a suction catheter.
The wound drained 120 mL clear fluid daily. (b) Following
removal of the vacuum reservoir there was no drainage after
Seroma may occur following an unrecognized hema- 1 min. (c) Following biting of a wedge of lime, there was drain-
toma under the skin flap. Syringe with needle drainage age starting at the end of the catheter within 5 s. The diagnosis
followed by compression may resolve the problem. of salivary fistula was confirmed
1168 M.A. Shiffman
Table 68.3 Fatal outcomes from liposuction [38]; 496,245

cases from 1994 to 1998; 130 fatalities (1/3817 cases or
26/100,000 [0.026%])
Disorder Fatalities
Thromboembolism 30
Abdomen/viscus perforation 19
Anesthesia/sedation/medication 13
Fat embolism 11
Cardiorespiratory failure 7
Massive infection 7
Hemorrhage 6
Unknown 37
Fig. 68.26 Scar at the anterior inferior portion of the ear 68.8.2 Asymmetry
following S-lift. Surgical revision was necessary
If the patient has asymmetry of the abdominal wall
Open drainage with suction catheter can be used for preoperatively, this should be pointed out to the patient
persistent seroma. and recorded with adequate photos. More fat may have
to be removed from one side or one area because of the
asymmetric accumulation.
68.7.18 Thromboembolism Asymmetry can be avoided by being aware of the
amounts of fat and fluid removed from each side of
As with any surgery, especially under general anesthe- the abdomen so that there is no large discrepancy.
sia, the risk of thrombembolism is always present. Observing the results carefully at the end of liposuc-
Prophylactic measures should be taken. tion may disclose further areas that need correction.
Asymmetry can be corrected by removing more fat
from the excess area, liposhifting fat into the depressed
68.8 Liposuction area, or reinjecting autologous fat.
Asymmetry that is present postoperatively may
68.8.1 Introduction need revision liposuction for removal of excess fat
from those areas affected. If there is a deficit in any
Liposuction may be associated with a variety of com- area that needs correction, injection of autologous fat
plications, most of which can be avoided. The more may be considered.
aggressive the liposuction, especially in the superfi-
cial subcutaneous tissues and with large amounts of fat
removal, the more likely a complication will occur. It is
not so much what is removed that is important, but what 68.8.3 Bleeding, Hematoma
is left behind [114]. The surgeon performing liposuction
must be cognizant of the risks and complications from the Tumescent technique in liposuction has reduced the
procedure, how to prevent them, and how to treat them. amount of bleeding to a degree that is usually minimal.
Early recognition of a complication is essential, and To prevent or limit bruising, the patient must be fore-
treatment should be started in a timely fashion. The warned to stop all aspirin containing products, non-
surgeon must inform the patient of the complication, steroidal anti-inflammatory drugs (NSAIDS) such as
its probable or possible cause or causes, the proposed ibuprofen, and herbals at least 2 weeks before and for
treatment, and the length of time before complete 2 weeks after surgery. Excessive liposuctioning in a
recovery. Consultation may be obtained and should be single area may cause bloody fluid to appear in the
done in a timely manner. tubing, and this should forewarn the surgeon not to
Fatal complications can occur (Table 68.3) [115]. continue surgery in that area unless further tumescent
solution is used. Compression over the areas of lipo-

suctioning will help to limit bruising. This includes
the use of garments, stretch tape, and foam dressings
(polyurethane pads).
Bleeding following liposuction may appear as
bright red blood coming from the incision site or may
be hidden and appear as orthostatic hypotension when
the patient tries to sit up or stand. Postoperative diz-
ziness and feeling faint should not be considered a
drug reaction or dehydration until after the Hgb or
Hct is checked. Intravenous fluid resuscitation may
be enough if the bleeding is not over 15% of the blood
volume, but some patients with more blood loss may
require Hespan, Dextran, albumin, or blood to restore
the blood volume. A low Hgb or Hct does not neces-
sarily require transfusion. The patients clinical status
is more important, and if vital signs are stable, con-
servative measures may be taken such as volume
replacement. The patient who has had an acute epi- Fig. 68.27 Indentation after liposuction of thighs
sode of bleeding and stabilizes with low Hgb or Hct
may be followed for at least a week, at which time the
Hgb and HCT should start to rise. It may take a few the key for prevention. Remember that excessive
weeks for the blood count to come back to normal, compression of an extremity can result in venous
but usually, the patient can resume normal activity thrombosis and possible embolic disorder.
after the Hgb reaches 8 g. If the bleeding continues Repeat liposuction (in an amount to break up the
and conservative measures do not work, surgical edematous tissues and flatten the region) of the area
exploration may be necessary. This is more likely with tumescent technique is usually helpful after several
with other concomitant procedures such as abdomi- months but must be followed by adequate compression
noplasty since compression in the areas of the lipo- dressings.
suctioning will usually stop any bleeding from small
vessels.
Hematoma in the tissues can be treated conserva- 68.8.5 Depressions (Grooves, Waviness)
tively with aspiration. This should be distinguished
from bruising that requires no treatment. A hematoma Excessive or superficial liposuction too close to the
that becomes a persistent untreated mass will form a skin may result in depressions (Fig. 68.27). Superficial
seroma and then a chronic pseudocyst. The pseudocyst liposuction should not get closer than 1 cm below the
can be treated with aspiration followed by injection of skin in most areas except the face and neck, and smaller
an equal amount of room air. This will usually cause cannulas (<3.5 mm) should be utilized in comparison
the walls to adhere to each other and prevent further to the deep liposuction that can be performed with can-
accumulation of fluid. nulas over 3.5 mm (3.55.0 mm depending on the
thickness of the fat layer).
Depressions can be corrected by selectively lipo-
68.8.4 Chronic Edema suctioning the areas around the depression and filling
the indented area with autologous fat [116]. If the
An infrequent occurrence, persistent edema in the area indentation is noted while performing the liposuc-
of liposuction can be distressing to the patient. This tion, autologous fat can be injected at that time. It is
may be due to excessive trauma to the tissues, but lipo- possible to fill defects with the liposhifting tech-
suction is a traumatic procedure causing so-called nique by tumescing the areas around the depression,
internal burn-like injury. Proper compression is usually loosening the fat with multiple criss-crossing tunnels,
1170 M.A. Shiffman
and molding the fat into the defect by rolling a large reported to improve with high-dose methylprednisolone
cannula (610 mm) across the prepared areas toward [131]. Huemer et al. [132] felt that heparin, cortisone,
the depression [117]. and dextran have not demonstrated a beneficial effect.
The skin scar may become depressed and is usually
due to the suction staying on when the cannula is
removed and reinserted multiple times. This can be 68.8.8 Fibrosis
prevented by turning off the suction before removing
the cannula or by having a finger vent in the handle of Subcutaneous nodularity following liposuction is often
the cannula. a fibrotic reaction, usually with an inflammatory com-
ponent, that can be a residual of hematoma or seroma.
Infection, especially mycobacterial, can leave a mass
68.8.6 Dissatisfaction with Results that will not resolve. Trauma to a surgical area result-
ing in a mass will usually resolve over time without
The surgeon performing liposuction should try to gain treatment unless there is an inflammatory component.
some insight into the patients body image. In other Normal scar formation will mature over 6 months and
words, exactly what does the patient want and expects then soften. The complete evolution of a scar can take
for the results of liposuction. Some expectations are a year, but the biochemical changes are complete in
more than what can be delivered by the surgeon. 6 months.
A detailed explanation of the limits to the procedure
of liposuction, the risks and complications, and the 68.8.8.1 Evaluation and Treatment
presence of irregularities or asymmetries is an impor- A postsurgical mass should be evaluated clinically to
tant beginning for the patient to understand that sur- rule out hematoma or seroma. Needle aspiration, under
gery, on the average, does not get perfect results. sterile conditions, can frequently make the diagnosis.
Preoperative explanation that further refinements may If the mass persists for more than 3 weeks without evi-
have to be performed to better approach the patients dence of some resolution, ultrasound evaluation should
expectations. be considered even if fluid cannot be aspirated. If
Beware of the dysmorphic personality where the serous fluid is found on ultrasound, the radiologist
patient does not have a significant problem but per- should aspirate the liquid and inject an equal amount
ceives a severe problem. This type of patient dwells on of room air. Reevaluation by ultrasound in 1 week will
a problem that does not really exist, and the surgeon usually show resolution, but if any fluid persists, repeat
can never satisfy that patient. aspiration with injection of room air should be
performed.
If an infection is present, usually with erythema and
68.8.7 Fat Embolism tenderness, aspiration of the pus with culture and sensi-
tivity (C & S) should be performed. Usually, the patient
Fat embolization results from release of fat droplets is already on antibiotics, and the medication may need
into the systemic circulation [29, 118121]. Fat embo- to be stopped for 24 h before attempting a C & S. The
lism syndrome (FES) is an infrequent consequence of antibiotics may need to be increased in dosage or
fat embolization with pulmonary distress, mental sta- changed. Residual subcutaneous fibrotic changes will
tus changes, hypoxemia, pyrexia, tachycardia, throm- resolve over time if the infection is properly treated.
bocytopenia, and petechial rash [122124]. Incision and drainage may be necessary if the abscess is
Studies that can be used for diagnosing fat embo- large and/or does not respond rapidly to the antibiotics.
lism include computerized tomography (CT) [125127] Following liposuction, folds in the garment can
and magnetic resonance imaging (MRI) [128, 129]. result in indentations and subcutaneous fibrosis. The
Treatment consists of general supportive measures garment should be checked on the first postoperative
with maintenance of fluid and electrolyte balance and day and the patient informed on how to prevent or limit
administration of oxygen, and endotracheal intubation folds in the garment (especially an abdominal binder).
and mechanical ventilatory assistance when necessary If subcutaneous fibrosis occurs, early treatment for the
[130]. Treatment of respiratory symptoms has been problem should be undertaken. Early treatment will
resolve the complication more rapidly than waiting for

the fibrosis to mature.
The conservative course of treatment for residual
fibrosis from any source consists of:
1. Start Medrol DosPak (7 day treatment taking the
full daily dose each day at one time with food).
2. At day 7, start nonsteroidal anti-inflammatory med-
ication (NSAID) daily for at least 8 weeks.
3. Ultrasound may be started at least 3 weeks after
surgery to the area at 3 W for 15 min twice weekly
for at least 16 treatments. Treatment within 3 weeks
of surgery may cause hematoma or seroma.
4. If there is no response after 8 weeks of ultrasound
treatment, injections into the fibrous tissue with Fig. 68.28 Liposuction with postoperative infection from
5-fluorouracil (5FU) at 50 mg doses may be mycobacterium resulting in scars on thighs after drainage proce-
attempted on a weekly basis until resolution of the dures and excisions of masses
mass. This can be combined with small doses of
steroid (1020 mg triamcinolone). 68.8.10 Infection
If steroids are used, the injection should be care-
fully administered into the fibrous mass, being careful The occurrence of infection in a clean surgery case is
that the fluid does not extrude into the surrounding approximately 1% in outpatient surgery centers and
fatty tissues. This may cause fat atrophy, which can be office surgeries and 3% in hospital surgeries. The ten-
easily treated by tumescing the tissues with normal dency to consider liposuction as minor surgery with
saline solution so that the precipitated steroid is reab- minimal care about sterility in the surgery suite can
sorbed. The mixture the author uses is 1 mL 5-fluorou- be detrimental to the patient. Serious infections have
racil (50 mg), mL triamcinolone [40 mg/mL] (total been documented following liposuction [133, 134].
20 mg), and 1 mL lidocaine (0.5%) with epinephrine Necrotizing fasciitis [135137] and toxic shock syn-
diluted in 1 mL of 0.5% lidocaine with epinephrine. drome [138, 139] have been reported. The combina-
Surgical intervention with resection of the mass can tion of both necrotizing fasciitis and toxic shock
result in a skin scar that may not have been present syndrome can occur in the same patient (Farber GA
previously, indentation from removal of tissue, and (1999) Personal communication, January 18, 1999).
possibly a residual fibrous mass again. Surgery is a last When an infection appears 10 days to 6 weeks after
resort after conservative measures have been tried for surgery and is in the form of a mass with overlying
at least 6 months. Indentations that result from surgery erythema, mycobacterium should be considered. This
may require autologous fat transfer. may be very difficult to diagnose through cultures of
the purulent discharge, but the physician must be per-
sistent. Vigorous prolonged treatment may be neces-
68.8.9 Hyperpigmentation sary. Rifampin, 600 mg two to three times weekly
combined with isoniazide, pyrazinamide, ethambutol,
Hyperpigmentation following liposuction can be in and/or streptomycin should be used for up to 6 months.
the scars or in the area of the liposuction. If there is Side effects include hepatitis, arthralgias, thrombope-
bruising and the patient gets into the sun, the skin nia, nephritis, optic neuritis, gastrointestinal distress,
overlying the operated area can develop an increase in and flu syndrome. An infectious disease consultant is
pigmentation. usually necessary. Scarring is not uncommon espe-
Treatment consists of 4% hydroquinone, cream or cially if the abscesses are drained surgically through
gel, rubbed into the affected area twice daily. During the large incisions or persistent fibrous masses are excised
day an effective sunscreen should be utilized and unnec- (Fig. 68.28). If there is a persistent fibrous mass fol-
essary sun exposure must be avoided or protective cloth- lowing proper antibiotic treatment, and drainage if
ing worn. Sun exposure will cause repigmentation. necessary, the mass can be injected with steroids.
1172 M.A. Shiffman
Postsurgical infection should be diagnosed as early maximum [139]. Lidocaine occurs in the body as
as possible in order to prevent more serious manifesta- unbound pharmacologically active lidocaine and pro-
tions of the infection such as necrosis, septicemia, or tein bound inactive lidocaine. Factors affecting the
toxic shock. Blisters may presage the appearance of protein binding of lidocaine include age, stress, obe-
necrosis and should be treated and observed closely. sity, hepatic function, renal function, cardiac disease,
There are various dressings that may cause blisters cigarette smoking, use of oral contraceptives, beta
such as tape on the skin and Reston foam. Any signifi- blockers, tricyclic depressants, histamine-2-blockers,
cant erythema is an indication of inflammation or inhalation anesthetics, and anorexiants [147].
infection and should be treated as such with antibiotics
and close follow-up.
68.8.13 Loose Skin
68.8.11 Lidocaine Anaphylaxis Certain areas of the body being liposuctioned are prone
to develop loose skin because of the amount of fat that
The injection of lidocaine in small amounts as a local needs to be removed and the lack of complete skin
anesthetic has been associated with death from allergic retraction. Those areas most likely to have this prob-
reaction to the preservative, methylparaben [140, 141]. lem include:
Anaphylaxis has been reported with lidocaine admin- 1. Abdomen: especially with large panniculus
istration [142145]. Lidocaine is not a completely 2. Arms: especially elderly patients and very fat
benign medication, and the surgeon should be aware patients
and prepared for acute allergic reactions. 3. Medial thighs: postoperative loose skin is a major
Treatment with ephedrine, oxygenation, and intra- problem in a large percentage of patients
venous fluids can relieve the symptoms. Steroids may Treatment for the loose skin requires a surgical
be necessary, and if there is bronchospasm, intubation approach with significant scars. Abdominoplasty, usu-
may have to be done. ally modified, may have to be performed to resolve
loose hanging skin of the lower abdomen, brachio-
plasty to resolve loose hanging skin of the arm, and
68.8.12 Lidocaine Toxicity thighplasty for the loose skin of the medial thigh.
There is very little treatment for lidocaine toxicity

except for supportive measures. This problem can eas- 68.8.14 Median Nerve Compression
ily be avoided by keeping the lidocaine at a safe level
through the use of less than 35 mg/kg or, when abso- Acute median nerve compression has been reported
lutely necessary, a maximum of 55 mg/kg in the total [148] in three patients from the administration of large
tumescent fluid. The more rapid the infiltration of the amounts of intravenous fluids during liposuction. The
lidocaine, the more likely there will be lidocaine toxic- edematous compression of the nerve resolved with
ity. The epinephrine effect causing vascular contrac- elevation of the extremities and use of diuretics. The
tion takes 15 min following injection. Therefore, the range of intravenous fluids was 4,0006,000 mL.
lidocaine can be rapidly absorbed for the first 15 min. Obviously, the anesthesiologist in each case did not
However, just because a surgeon has infiltrated, with- understand that small amounts of intravenous fluids
out mishap, 5060 mg/kg lidocaine in hundreds of should be administered in liposuction cases, limiting
cases does not necessarily imply either that such a the amount to 250 mL or less per hour.
large dose of lidocaine can be given with impunity, nor
that this dose recommendation is safe [146]. If gen-
eral anesthesia is used, the lidocaine total can be much 68.8.15 Necrosis
less or omitted.
A careful history must be taken to make sure the There may be skin necrosis after liposuction if the
patient has not been taking cytochrome P450 inhibi- cannula comes too close to the skin and disrupts the
tors that may result in lidocaine toxicity even with the subdermal plexus of vessels. Chronic smokers who do
total lidocaine dosage within the usually accepted not stop smoking before and after surgery have a high
incidence of necrosis. Necrosis is more likely to occur that can divert the direction of the cannula [115, 149,
with the use of cannulas with sharp edges and turning 150]. The nondominant hand should always feel the
the openings toward the skin surface. Combining end of the cannula. When the cannula is not palpable,
excessive liposuction of the mid upper abdomen and the surgeon should reassess his technique and consider
full abdominoplasty increases the risk of necrosis of the possibility of perforation. Under local tumescent
the abdominoplasty flap. anesthesia, perforation can be detected at the time of
Necrotizing fasciitis has been reported following surgery by the presence of abdominal pain.
liposuction [135137]. This disorder is an infection If there is unusual abdominal pain or chest pain
with fulminant streptococcal group A infection or postoperatively such as increasing pain or severe pain,
mixed bacterial infection frequently with anaerobes perforation must be considered. It may be difficult to
that involves the subcutaneous tissues and deep fascia, examine the abdomen directly by pressure because
producing thrombosis of the subcutaneous vessels and liposuction alone will cause pain in the area. The pres-
gangrene of the underlying and surrounding tissues. ence of rebound tenderness usually indicates peritoni-
Treatment requires surgical debridement, antibiotics, tis. Flat plate and upright abdominal x-rays may show
and, when necessary, hyperbaric therapy. free air if the bowel is perforated. The patient may
have to be observed in the hospital if there is the pos-
sibility of viscus perforation.
68.8.16 Need for Further Surgery Vascular perforation that causes significant blood
loss will result in abdominal pain, orthostatic hypoten-
Since the surgeon can ordinarily improve the contour sion, and shock. Insertion of a small catheter (Angiocath)
deformities by about 50%, the patient may not be satis- into the abdominal cavity and the instillation of some
fied with the results. There also may be a need to refine sterile saline can produce bloody drainage consistent
or correct the original procedure because of complica- with vascular injury. If the blood is totally retroperito-
tions such as irregularities (grooves, waviness, and neal, CT scan may be necessary. Emergency explor-
indentations), asymmetries, perforation of vessel or atory laparotomy is usually indicated.
viscus, excessive scarring, bleeding, hematoma or Liposuction over the ribs can be aided by the use of
seroma, loose skin, necrosis, necrotizing fasciitis, and pressure on the lower ribs with the flat portion of the
infection. The patient should be warned preoperatively nondominant hand that will result in the cannula easily
of this possibility. going over the ribs instead of under with perforation
into the chest. Severe chest pain, especially with dysp-
nea, may indicate perforation into the chest. Chest
68.8.17 Neurologic Problems x-ray will usually show a pneumothorax. Insertion of a
chest tube will relieve the pain and dyspnea.
Decreased sensation or sensory loss may occur but is
almost always temporary. Chronic pain may be due to
a small neuroma but is more often due to injury to the 68.8.19 Pulmonary Edema
underlying fascia or muscle. Injection of local anes-
thetic into the area of pain will usually relieve the com- Pulmonary edema has been reported [151], which was
plaint for a short period of time. Multiple injections presumed to be from rapid- and high-volume hypo-
may be necessary to relieve the pain permanently. dermoclysis. Pitman [152], commenting on this case,
A neuroma can be surgically resected. If a scar in believed that the cause of the pulmonary edema was
the tissues (subcutaneous fat, fascia, or muscle) is teth- from excessive parenteral fluids being given.
ered to the skin, there may be chronic unrelieved pain. Ordinarily, most individuals can tolerate large amounts
The pain may have to be treated by release of the scar. of intravenous fluids, up to 2,000 mL/h, since the
fluids enter the extravascular tissues within 15 min
of administration. However, where there is a large
68.8.18 Perforation of Vessel or Viscus amount of subcutaneous fluid from the tumescent
technique, the pressure of the fluid in the tissues does
Perforation of the abdominal wall is most likely to not allow a gradient for the intravenous fluid to diffuse
occur in the presence of hernia or abdominal wall scar out of the vessels.
1174 M.A. Shiffman
68.8.20 Scars repeated every few days. If the collection can be

reached through one of the liposuction incisions, a
Significant scars following liposuction are not fre- drain can be inserted to reduce the fluid and kept in
quent. It is rare to see hypertrophic scars or keloids. place with compression dressings that need to be
Poor placement of incisions may result in easily visible changed every couple of days. Prophylactic antibiotics
scars. Some scars may become depressed if the suction may be used during the time the drain is in place. If the
on the cannula is maintained each time the cannula is collection becomes chronic (over 4 weeks), the fluid
withdrawn from the incision. If using a machine for should be aspirated and an equal amount of room air
vacuum, either stop the machine before withdrawal or injected into the cavity to cause irritation (Fig. 68.29).
use cannulas with a vent hole in the thumb portion of Compression dressings are necessary after each such
the handle for easy release. treatment. Another method that is available but requires
Incision sites may be irritated by the multiple fast adequate anesthesia is curetting the lining of the cavity
passes of the cannula resulting in a reddening around through a small incision or through one of the liposuc-
or in the scar. Steroid cream will resolve the problem. tion scars. If the liposuction is combined with abdomi-
The incision performed should be slightly larger than noplasty and a chronic seroma occurs, the pseudocyst
the cannula. Some surgeons use a plastic plug in the may be excised through the abdominal scar, but this
incision while performing liposuction that will prevent may leave a visible deformity.
the cannula from rubbing on the skin.
The use of large incisions is not indicated since
most cannulas are 6 mm or less and, more often than 68.8.22 Thromboembolism
not, are 4 mm or less. Some surgeons use microcan-
nulas (under 2 mm), but this requires many more skin Superficial thrombophlebitis (an inflamed vein)
incisions and the liposuction takes longer to perform. appears as a red, tender cord [115]. Deep-vein throm-
The treatment of hypertrophic or keloid scars bosis may be associated with pain at rest or only dur-
includes steroid injection, radiation, reexcision, sili- ing exercise with edema distal to the obstructed vein.
cone gel sheeting, pressure therapy, or a combination The first manifestation can be pulmonary embolism.
of these [153]. The combination of steroid and 5-fluo- There may be tenderness in the extremity, and the tem-
rouracil has been helpful in treatment. None of the perature of the skin may be increased. Increased resis-
treatments is permanently effective for keloids in a tance or pain on voluntary dorsiflexion of the foot
large percentage of patients; however, hypertrophic (Homans sign) and/or tenderness of the calf on palpa-
scars have a tendency to resolve on their own over a tion are useful diagnostic criteria.
period of time. Pulmonary embolism is usually manifested by one
Skin necrosis will usually result in a significant of three clinical patterns: (1) onset of sudden dyspnea
scar. Treatment may require excision and careful with tachypnea and no other symptoms, (2) sudden
closure. pleuritic chest pain and dyspnea associated with find-
ings of pleural effusion or lung consolidation, and (3)
sudden apprehension, chest discomfort, and dyspnea
68.8.21 Seroma with findings of cor pulmonale and systemic hypoten-
sion. The symptoms occasionally consist of fever,
The collection of serous fluid in the liposuction area arrhythmias, or refractory congestive heart failure.
may be due to irritation of the tissues by the traumatic Medium- and high-risk patients for thromboem-
procedure but is more frequently the result of concom- bolism (over the age of 40 years, prior history of
itant over suctioning of a single area with undermining thromboembolic disorder, surgery over 1 h, obesity,
of a flap allowing a cavity to form. Sometimes a hema- postoperative immobilization, estrogen therapy) should
toma may appear first and be replaced over time with have the necessary precautions taken in the periopera-
serosanguinous fluid and then serous fluid. tive period [9]. These include compression stockings
A persistent collection of fluid following liposuc- (TEDS) or intermittent compression garments. Failure
tion may be treated with needle aspiration followed by to warn female patients to stop estrogens (birth control
adequate compression dressings. This may need to be pills or replacement therapy) at least 3 weeks prior to
surgery and 2 weeks after surgery increases the risk of who develops shortness of breath or chest pain must be
thromboembolism [154]. Liposuction of the abdomen considered to have the possibility of pulmonary embo-
in combination with abdominoplasty is especially lism, and a ventilation-perfusion lung scan obtained.
risky for the occurrence of pulmonary embolism. The use of intravenous heparin can be lifesaving and,
Thromboembolism has to be diagnosed early if at times, may be started even before the diagnosis is
death is to be prevented. Any postoperative patient confirmed.
a b
Fig. 68.29 (a) Preoperative 43-year-old patient with history of seroma (arrow) 1 week following one injection of room air into
liposuction of thighs 6 years previously. (b) One week after cir- the seroma. This shows marked decrease in the size of the cavity.
cumferential liposuction of legs with seromas of both legs. (c) The left thigh was injected one time with room air and had com-
Areas of seroma marked after 5 months of repeated needle aspi- plete closure of the seroma. A second injection of room air into
rations and use of drains. (d1) Ultrasound of right thigh seroma the right seroma resulted in complete closure
(arrow) 5 months postoperatively. (d2) Ultrasound of right thigh
1176 M.A. Shiffman

d
68.8.23 Toxic Shock Syndrome 5. Involvement of three or more organ systems:

a. Gastrointestinal (vomiting, diarrhea at onset)
There have been reports of toxic shock syndrome, b. Muscular (myalgia, elevated CPK)
which is a potentially fatal disorder [137, 138, 155]. c. Mucous membrane (conjunctiva, oropharynx)
The syndrome is caused by the exotoxins (superanti- d. Renal (BUN or creatinine >2 times normal)
gens) secreted with infection from Staphylococcus e. Hepatic (bilirubin, SGOT, SGPT >2 times
aureus and group A Streptococci [156]. Knowledge of normal)
the criteria for diagnosis is important in order to treat f. Hematologic (platelets <100,000)
this potentially fatal disease. These include [157]: 6. Negative results on the following studies (if
1. Fever (>102o) obtained):
2. Rash (diffuse, macular erythroderma) a. Blood, throat, or cerebral spinal fluid (CSF)
3. Desquamation (12 weeks after onset, especially of cultures
palms and sole) b. Serologic tests for Rocky Mountain spotted
4. Hypotension fever, leptospirosis, and measles
Treatment consists of surgical debridement for hypertension, coughing, or too much motion of the
necrosis, antibiotics, circulatory and respiratory care, implant especially with textured implants. Medications
anticoagulant therapy for disseminated intravascular should be considered, especially aspirin and nonsteroi-
coagulation, and immunoglobulin [158]. Experimental dal anti-inflammatory drugs (NSAIDS). The use of
approaches have included use of antitumor necrosis Toradol after cosmetic procedures is a breach of the
factor monoclonal antibodies and plasmapheresis. standard of care since it is a drug that will inhibit plate-
let reaction and cause bleeding.
Hematoma should be treated immediately by
68.8.24 Conclusions evacuation and coagulation of active bleeders since
distention of the tissues from the hematoma may result
Complications of liposuction are best avoided when in tissue necrosis especially of the nippleareolar
possible. The surgeon should be aware of the methods complex.
to prevent and the available treatments for the various
complications. Aggressive liposuction by removing
very large amounts of fat and doing very superficial 68.9.4 Bottoming Out
liposuction in order to get more skin retraction can be
associated with an increase in complications. It may be Most mastopexies do not fix the breast to the chest
preferable to remove less than 5,000 of fluid and fat at wall by sutures and, therefore, the weight of the breast
each sitting and repeat the procedure at a later date can cause inferior migration with bottoming out as
than perform large volume or megaliposuction. The the result. This will usually require fixation of the
risk of complications may then be reduced. breast to the underlying pectoralis major fascia with
permanent sutures to hold the breast in a high-enough
position and prevent future downward migration.
68.9 Mastopexy
68.9.1 Introduction 68.9.5 Flattening of the Breast
Each form of mastopexy has its own types of compli- The periareolar mastopexy is very prone to flattening
cations. Some general principles from many years of of the breast, and patients should be forewarned of this
past experience are presented to help the surgeon mini- possible problem.
mize and possibly avoid the complications.
68.9.6 Infection
68.9.2 Asymmetry
Possible infection can occur with any surgical proce-
Most patients have some asymmetry before surgery dure. With the inset of fever and/or erythema, the sur-
and should be specifically discussed with the patient. geon should always be aware of possible inflammation
Correction of the asymmetry can be performed at the versus infection. Usually, the patient is on antibiotics
time of surgery. Sometime the postoperative asymme- after surgery, and a decision has to be made as to
try is from the procedure because of improper marking, whether to increase the dose of the medication or start
not following the original markings, or because there is a different antibiotic. If there is drainage, then culture
uneven healing and scarring from the procedure. and sensitivity should be done and appropriate antibi-
otic utilized when the particular offending germ or
germs are known.
68.9.3 Bleeding, Hematoma An abscess must be drained surgically and the cav-
ity irrigated with saline. A drain (penrose or suction
As with any surgical procedure, hemostasis at the time catheter) is usually necessary. If an implant is present,
of surgery is important. However, postoperative bleed- the implant should be removed if the pocket is involved
ing is usually due to causes other than missing bleed- and the implant replaced at least 3 months after com-
ers at the time of surgery. Clots can be dislodged from plete healing has occurred.
1178 M.A. Shiffman
Fig. 68.30 Necrosis following periareolar mastopexy
Fig. 68.32 Poor implant position following mastopexy
excised taking care not to disrupt the circumareolar

purse-string suture that holds the scar from spreading.
68.9.9 Poor Implant Position
If a breast augmentation is performed with the mas-

Fig. 68.31 Pleating following periareolar mastopexy
topexy, it is possible to place the implant in the proper
position since the pocket is determined preoperatively
68.9.7 Necrosis with marking prior to the breast lift (Fig. 68.32). This
pocket position may need to be adjusted following the
Necrosis, especially of the nippleareolar complex, is mastopexy and before the implant is placed or after the
unusual but can occur when the blood supply has been implant is in the pocket and the patient examined in a
compromised (usually from prior breast surgery) or sitting position.
when there is infection or hematoma (Fig. 68.30).
Tight closure of the skin can result in necrosis if the
vessels become stretched and thrombose causing inter- 68.9.10 Recurrent Breast Ptosis
rupted blood supply. There is a slightly increased inci-
dence of necrosis when breast augmentation is Recurrent breast ptosis is usually a problem of loose
concomitantly used at the time of the mastopexy. skin and gravity. Without fixation of the breast to the
underlying pectoralis major fascia by permanent
sutures, the breast may descend postoperatively either
68.9.8 Pleating within months or years.
The effect of closing the periareolar type of mastopexy

is prone to a pleating effect since the larger outer rim 68.9.11 Scar
is attached to a shorter inner rim, and the discrepancy
results in pleating (Fig. 68.31). This usually resolves Any surgical scar can become hypertrophic or keloid
without treatment in 612 months. However, when the (Fig. 68.33). Tight skin closure may result in widening
pleating persists, the excess tissue may need to be of the scar except with the purse-string suture(s) of the
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Index
A B
Aboudib, J.H., 770 Babcock, W., 887, 888
Abramo, A.C., 891 Bacterial infection, 164
Abscess, 218, 1131, 1177 Baker, D.C., 323
Accolate, 1144 Baker, S.B., 758
Acne, 152, 154 Baker, S.R., 10
scars, 155157, 172, 185, 186, 213, 214, 539, 540 Baker, T.J., 888
Aegineta, P., 755 Bames, H.O., 4, 9, 756
Ahn, M.S., 300 Banding, 979
Aiache, A.E., 6 Barnes, W.E., 19
Alam, M., 186 Baroudi, R., 888, 889, 921, 926
Al-Basti, H.B., 902 Barsky, A.J., 17, 888, 889, 927
Alexander, G., 17 Barton, F.E., 338, 344
Allergy, 116, 218, 232, 360, 410, 422, 443, 1129, 1131, Bauer, B., 276
1132, 1145 Baxter, H., 17
Alopecia, 520, 541 Becker, O.J., 18, 267
Alter, G., 1102 Beer, G.M., 771
Amastia, 814 Benelli, L., 8, 621, 622, 708, 747, 791, 840
American Society of Anesthesiologists Benelli round block, 847, 848
physical status classification, 108 Berdeguer, P., 407
Anaphylaxis, 1172, 1179 Bettman, A.G., 9, 344
Anderson, J.R., 21 Bichats fat pad, 340, 341, 345
Andrews, J.U., 747 Biesenberger, H., 4, 7
ANF. See Antitumor necrosis factor (ANF) Bircoll, M., 585
Ansari, P., 10 Bissoon, 205
Antithrombin III, 1156 Blair, V.P., 3, 4
Antitumor necrosis factor (ANF), 1177 Bleeding, 223, 333, 341, 388, 390, 557, 565, 686, 750, 1095,
Apfelberg, D., 15 1135, 1136, 1143, 1148, 1149, 1159, 1160, 1165, 1168,
Apte, R.S., 1132 1169, 1177, 1179
Aquinas, 557 Blepharochalasis, 471
Areolar retraction, 1142 Blepharoptosis, 235, 236, 242246
Ari, G., 4, 797 Blindness, 44
Arrhythmias, 1139, 1157, 1174 Body mass index (BMI), 110, 645, 950, 951
Asaadi, M., 407 Borges, A.F., 18
Asken, S., 406 Botti, G., 637, 638, 717, 720
Aston, S.J., 328 Bottoming out, 760, 1143, 1177
Asymmetry, 225, 311, 329, 388, 390, 410, 429, 543, 562, 563, Bourguet, J., 9, 344
572, 576, 581, 582, 605, 616, 617, 623, 624, 630, 631, Bradycardia, 164
645, 694, 712, 760, 768, 809, 830, 908, 919, 1001, 1106, Brandow, 399
1135, 1137, 1142, 1160, 1164, 1168, 1173, 1177, 1179 Brandy, D.A., 324
Atrophy, 152, 311, 329, 394, 395, 421, 729, 1043 Breast, 1178
Aubert, V., 4 pseudoptosis, 716
Aufricht, G., 4, 9, 756 ptosis, 4, 69, 705, 708, 710, 724, 1178
Aufricht keyhole, 776 Breasted, J.H., 20
Auriculo-cephalic angle, 268 Brent, B., 273
Autologous tissue, 1088 Brow lift, 485, 489, 505, 506
Axillary banding, 1143 Brown, A.M., 9

DOI 10.1007/978-3-642-21837-8, Springer-Verlag Berlin Heidelberg 2013
1186 Index
Bruising, 218, 398, 410, 429, 441, 1050, 1131, 1132, Courtiss, E.H., 6, 15, 858
1135, 1169 Cramer, L., 6
Bruning, 415 Crikelair, G.F., 19
Brzozowski, D., 771 Crows feet, 299, 539
Buccolabial fold, 363 Cuenca-Guerra, R., 1043, 1044
Bukkewitz, H., 363 Cupello, A.M., 903
Burian, F., 9 Cupids bow, 433
Burn, 462, 543, 950 Cyst, 406, 412
Buttock implant, 1007 Cystosarcoma phyllodes, 758
Buttock ptosis, 1004 Cysts, 588, 728, 1129, 1131, 1161
Cytochrome P458, 91, 92, 114, 115, 119
C
Calcification, 569, 585, 588, 1129, 1144, 1161 D
Caleel, R.T., 1160 Dabbah, A., 772
Callia, W., 888 Dartigues, L., 796
Campers fascia, 59, 897 Davidson, B.A., 747
Cantrell, J.A., 9 Davis, J.S., 17
Capnography, 130 Davis, M., 772
Capsule contracture, 1144 Davis, W.B., 273
Capsulorrhaphy, 1143 Debridement, 1137, 1141, 1158, 1162, 1173
Cardenas-Camarena, L., 102 de Castro, C.C., 6, 903
Crdenas Restrepo, J.C., 892 Dehiscence, 616, 630, 767, 901, 904, 921, 947, 1050, 1136,
Cardim, V.L.M., 345 1164, 1165
Cardiotoxicity, 164 DeLustro, F., 1131
Cardoso, A.D., 6 de Martino, G., 16
Carpue, J.C., 20 Demel, R., 17
Cellulite, 205, 206, 212, 217, 908, 914, 916 De Pina, D.P., 892
Cellulitis, 321, 334 Depressions, 1169
Celsus, A.C., 16 Dermabrasion, 161, 167, 185
Chajchir, A., 13, 406 Dermatochalasis, 307
Chaouat, M., 901 Descamps, M.J.L., 640
Charriere, G., 1131 Desjardin, P., 887
Chassaignac space, 574 Diastasis, 900, 904, 946
Chemical peel, 147155, 167, 185, 540 Dieffenbach, J.E., 20, 21
Chemosis, 232 Dieffenbach, J.F., 4, 16, 267, 755
Chiari, A., 708 Diplopia, 232
Choi, H.Y., 1105 Diving position, 939
Chondritis, 278 Dogear, 487, 611, 766, 767, 947, 1106, 1136, 1137, 1165
Chongchet, V., 19, 267, 271 Dolsky, R.L., 14
Chopart, F., 3 Double bubble, 564, 709, 1008, 1130, 1145
Chrisman, B.B., 10 Dripps, 108
Christie, J.L., 115 Dry eye, 225, 232
Cilento, B.W., 300 Dubouset, J., 888
Cimino, W.W., 543, 1012 Dufourmentel, C., 6, 18, 772
Circular lipectomy, 907, 908, 910, 911, 913, 920, 921 Dujarrier, 10, 949
Cloutier, A.M., 17 Duman, A., 1159
Cocheril, R., 16 Durston, W., 4, 757
Coleman, S.R., 346, 393, 585, 587 DVT. See Venous thrombosis (DVT)
Colles fascia, 997, 1122 Dyschromia, 186
Colpaert, S, 271 Dyspnea, 110, 112, 164, 1139, 1174
Columellar grafts, 257, 259
Coma, 91
Connells sign, 290 E
Converse, J.M., 14, 18, 19, 267 Ear lobe
Conway, H., 4 deformity, 333
Cooperman, L.S., 1131 Ecchymosis, 305, 388, 1050
Coopers ligaments, 4, 48, 625, 635, 805, 808 Ectropion, 342
Corneal ulcer, 225 Edema, 96, 110, 191, 217, 223, 232, 305, 341, 388, 398, 543,
Cor pulmonale, 1139, 1174 967, 1136, 1137, 1156, 1166, 1169
Correa-Iturraspe, M., 973 Edwin Smith Papyrus, 20
Cottle, M.H., 21 Eisenberg, T.S., 605, 617
Index 1187
Elam, M.V., 15 Gasperotti, 985

Elbaz, J.S., 888, 925 Gaudet, F., 887
Eliasen, C.A., 757 Gemperli, R., 903
Elkwood, A., 300 Genioplasty, 263
Ellenbogen, R., 1143 Georgiade, N.G., 6, 756
Eltner, E., 17 Gersuny, R., 17
Ely, E.T., 16, 267 Gersvny, 415
Ely technique, 20 Giampapa, 368
Embolism, 1130 Gibsons principle, 277
End-hits, 1013 Gibson, T., 19, 267
Erol, .O., 364 Giebler, 10
Erythema, 164, 186, 191, 441, 445, 904, 1131, 1132, 1137, 1172 Giese, S.Y., 15
Estrogen, 99, 1139, 1155, 1174 Gigantomastia, 640, 643, 679, 682, 694, 704, 758
Exsanguination, 1135 Gillies, H.D., 3, 4
Giraldo, F., 1104
Glands of Montgomery, 809
F Glicenstein, J., 888
Fagien, S., 1132 Glogaus photoaging types, 160
Faivre, J., 9 Gluteal implant, 1001
Farina, R., 17 Ges, J.C., 7, 756
Farrior, R.T., 19 Goldman, L., 108
Fat atrophy, 1165 Goldman, M.P., 109
Fat emboli, 901 Goldstein, M.A., 17
Fat embolism syndrome, 1142, 1168, 1170 Goldwyn, R.M., 756
Fat embolus syndrome, 14 Goniometers, 760
Fat graft, 489, 495, 506, 510, 514, 515, 586588, 590, 591, Gonzalez, F., 770, 1163
1055, 1070, 1088, 1089 Gonzlez, R., 1046
Fat necrosis, 986 Gonzalez-Ulloa, M., 888, 889, 921, 926, 1045
Fat transfer, 193, 540, 585, 588, 591, 592, 1082 Goodman, W.S., 21
Fatty necrosis, 1004 Gordon, N.A., 109
Fayman, M.S., 491, 501 Gosain, A., 277
Feathering, 956 Graf, R.M., 1159
Felicio, Y., 1104 Granulating, 1137
Female pattern baldness, 519 Granulations, 1154, 1162
Female pattern hair, 520 Granuloma, 218, 1129
Fernandez, J.C., 973 Granulomatous, 443
Fibrosis, 543, 942, 1145, 1170, 1171 Grazer, F.M., 106, 888, 889, 891, 900, 901, 926
Fibrous, 4, 412, 1160 Greminger, R.F., 888, 890
capsule, 1144 Greuse, M., 770
fat, 950 Grolleau, J.L., 820
Fischer, A., 949 Gross, C.W., 15, 416
Fischer, G., 5, 10, 11, 1315, 87, 405 Grossman, K.L., 1131
Fishman, L.Z., 17 Gsell, F., 6
Fitzpatrick skin type, 158, 171, 184, 982, 987, 989 Guerrerosantos, 585
Fitzpatrick types, 539 Guillemain, 363
Flankplasty, 1002, 1003 Guinard, A., 4
Flesch-Thebesius, M., 888, 889, 927 Guinard, M., 755
Florez, M., 364 Gunter, G.P., 21
Fodor, P.B., 15 Gunter, J.P., 345
Fournier, P.F., 11, 1315, 87 Gynecomastia, 84, 747, 751, 753, 871, 872, 874, 877, 879, 880,
Freeman, M.S., 10 882, 883, 952
Freund, R.M., 300
Fulton, J.E., 407
Furnas, D.W., 20, 267, 275, 276 H
Hall-Findlay procedure, 8
Hamdi, M., 770, 1163
G Hammond, D.C., 708
Galactorrhea, 1145 Hamra, S.T., 10, 323, 344
Galland, 363 Hanke, C.W., 1131
Galtier, 927 Harris, L., 771
Galtier, M., 888, 889 Hatch, M.D., 17
Gasperoni, C., 15 Haug, R., 16
1188 Index
Hematoma, 47, 132, 252, 295297, 321, 328, 333, 341, 390, J
398, 410, 492, 631, 686, 697, 767, 768, 901, 947, 1050, Jabs, A.D., 757
1051, 11351137, 1143, 1149, 1159, 1160, 1162, 1164, Jackson, I.T., 891
1166, 11681171, 11771179 Jayes, P.H., 18
Hensel, J.M., 901 Johnson, G.W., 1159
Heparin, 1140, 1141 Jolly, R., 888
Hernandez-Perez, E., 364 Jones, E.H., 17
Hernia, 951 Joseph, J., 3, 7, 9, 16, 17, 21, 329
Hester, Jr, T.R., 6, 345, 903
Hetter, G.P., 14
Heywang-Kobrunner, S.H., 1161 K
Hinderer, U.T., 6 Kamer, F.M., 10
Hiragun, A., 406 Kaminski, M.V., 409
Hoeffiin, S.M., 10 Kaye, B.L., 19
Hollnder, E., 9, 311, 329 Keen, W.W., 16
Holmes, E.M., 17 Kelly, H.A., 887, 889, 926
Holmstrm, H., 235 Keloid, 152, 205, 218, 262, 278, 539, 694, 904, 1137, 1138,
Holt, J.A., 21 1154, 1163, 1164, 1174, 1178, 1179
Homans sign, 1174 Keratitis
Homicz, M.R., 1131 exposure, 224
Hoopes, J.E., 6 Kerrigan, C.L., 759
Horlock, N., 20, 280 Kesselring, U.K., 13, 888
Houseman, T.S., 118 Keyhole, 777, 779, 836
Huemer, G., 1170 Keyhole pattern, 760
Hunter, G.R., 902 Klein, A.W., 1067
Hypermastia, 759 Klein, J.A., 15, 16, 8789, 92, 101, 122, 949
Hyperpigmentation (PIH), 151153, 158, 159, 161, 163, 174, Kleins solution, 408, 409, 540
186, 190, 205, 217, 218, 457, 630, 631, 694, 1076, Kligmans formula, 158
1132, 1167, 1171 Kolle, F.S., 17
Hyperplasia, 1130 Koltun, R.K., 21
Hyperplasic, 1088 Kornstein, A.N., 747
Hypertension, 109, 111, 116, 341, 901, 1165 Kraske, H., 4, 7
Hypertrophic, 1088, 1106 Kristensen, H.K., 18
Hypertrophic scars, 185, 205, 218, 262, 328, 343, 558, 560, Kupfer, D., 758
629, 694, 753, 767, 1137, 1138, 1149, 1154, 1163,
1164, 1174, 1178, 1179
Hypertrophy, 278, 299, 638, 641644, 646, 670, 671, 674, 678, L
682, 690, 694, 702, 703, 719, 757759, 777, 801, 808, Laberge, L., 273
809, 812, 824, 828, 831, 1106, 1130 Lacrimal gland, 223
Hypoesthesia, 750 prolapsed, 220
Hypoglycemia, 125 Lagophthalmos, 224
Hypopigmentation, 163, 174, 185, 190, 630, 631, 694, 1076 Lalardrie, J.P., 6
Hypotension, 98, 121, 1141, 1158, 1169, 1174, 1176 Lasgue sign, 1050
Hypothermia, 131 Laser, 167170, 172, 174, 176174, 186, 190, 223, 232, 437,
539, 540
Lassus, C., 8, 708, 756, 791, 797
I Lejour, M., 7, 9, 708, 756, 770, 791, 797
Illouz, Y.G., 11, 13, 14, 87, 888 Lejour maneuver, 792
Indentations, 1137, 1173 Lembert, 17
Infection, 96, 174, 185, 278, 295, 321, 334, 388, 390, 398, 412, Lemmon, M.L., 9
423, 445, 565, 630, 631, 690, 691, 699, 750, 768, 901, Letterman, G., 759
904, 1049, 1129, 1137, 1145, 1147, 1152, 1159, 1160, Lexer, E., 9, 756
1162, 1166, 1168, 11701173, 11771179 Lid laxity, 227
Inframammary fold, 4, 47, 49, 564, 582, 605, 608610, Lidocaine toxicity, 88, 98
612615, 617, 633, 637, 641, 644, 652657, 664, 665, Local anesthetic toxicity
667, 669671, 675, 682, 705, 706, 716721, 724, 747, lipid emulsion, 116
755, 761, 763, 775777, 791, 793796, 798, 799, Lockwood, T., 888, 973, 997
805807, 809, 812, 814, 821, 824, 828834, 838, 840, Losken, A., 901
841, 844851, 862, 886, 1115, 1123, 1143, 1145, 1147 Loss of sight, 412
Israel, J., 21 Lotsch, G.M., 796
Isse, N.G., 338, 345, 361, 381 Loustau, H.D., 8
Index 1189
Luckett, W.H., 17, 18 Morgan, W.R., 14

Lund, K., 1161 Moufarrge, R., 781, 927
Lykissa, E.D., 1145 Mouly, R., 772
Lymphoceles, 997 Munhoz, A.M., 1105, 1159
Munoz Ahmed, J.A., 892
Muscular plication, 329
M Mustard, J.C., 19, 20, 267, 271, 273275, 277, 280
MacColumm, D.W., 17 Myalgia, 1141, 1176
MacKee, 147 Myospasm, 1148
Macromastia, 759
MACS. See Minimal access cranial suspension (MACS)
Maillard, G.F., 828 N
Malignant hyperthermia, 113 NAC. See Nippleareolar complex (NAC)
Maliniac, J.W., 4, 772 Nahai, F., 635
Mandel, M.A., 132 Nahas, F.X., 888, 891, 892
Mandrekas, A.D., 771, 811, 1164 Nasojugal groove, 422
Mangubat, 623 Nasolabial fat pad, 433
Marchac, D., 6, 756 Nasolabial fold, 31, 39, 186, 189, 191, 319, 338, 345, 363, 365,
Marino, H., 4 370, 389, 420, 421, 423, 426, 427, 429, 430, 441, 489,
Marionette lines, 191, 506, 508, 511 506, 508, 511, 514, 540
Marques, A., 888, 891 Necrosis, 96, 148, 169, 218, 278, 321, 327, 333, 406, 435, 443,
Marshall, D.R., 770 462, 541, 543, 588, 631, 690, 766769, 901, 1129,
Martins, P.A., 747 1131, 1136, 1137, 11401142, 1149, 1151, 1152, 1157,
Mastitis, 1147 1161, 1162, 1166, 11721174, 1178, 1179
Matarasso, A., 890, 901, 904 Necrotizing fasciitis, 904, 1137, 1171, 1173
Matarassuo Nerve compression, 1172
abdominoplasty classification system, 891, 892 Nerve entrapment, 1144
Matros, E., 300 Nerve injury, 295, 321, 334, 341, 384, 388, 390, 462, 496,
Maximovich, S.P., 1143 541, 1153
Mayer, D.M., 9 Netscher, D.T., 759
May, H., 4 Neuber, F., 405, 585
McDowell, A.J., 17 Neuroma, 1173
McEvitt, W.G., 18 New, G.B., 17, 18
McGregors patch, 34, 35 Newman, J., 407
McIndoe, A., 4 Nippleareolar complex (NAC), 1152, 1161
McKissock, P.K., 6, 7, 633, 705, 756 Nol, S., 9
McKissocks technique, 770, 772 Nolting, H., 21
Melasma, 151, 153, 158, 159, 161, 216 Nordzell, B., 273
Mendelson, B., 495
Mendelson, E.B., 1161
Menesi, L., 7 O
Mesogun, 207, 215, 216 Obesity, 109, 110, 112, 901, 907, 908, 916, 920, 921, 982,
Methemoglobinemia, 92 1142, 1155
Mettauer, J.P., 3 Orlando, J.C., 6, 756
Meyer, R., 6 Ostad, A., 16
Michaelis rhomboid, 1068 Owens, N., 20
Microcalcifications, 412 zmen, S., 771
Migration, 1148
Millard, 557
Miller, C.C., 9, 17 P
Minimal access cranial suspension (MACS), 323, 324, 328 Pain, 129, 186, 218, 305, 388, 390, 412, 759, 768, 900, 1050,
Mirrafati, S., 15 1087, 1124, 1143, 1144, 1163, 1167, 1174, 1179
Mitnick, J.S., 1161 Paletta, F.X., 18
Mitz, V., 9, 344 Pangman, W.J., 9, 10
Moelleken, B., 345 Parsa, F.D., 1159
Mohammad, J.A., 1136 Passot, R., 7, 9, 866, 870
Mondors disease, 1143, 11481150 Passot technique, 866
Monks, G.H., 16, 21 Paul, M.D., 345
Moody, B.R., 1132 Paulus of Aegina, 747
Morbid obesity, 907 Payr, E., 17
Morestin, H., 4, 17, 756 Pearl, C., 273
1190 Index
Peau dorange, 958, 962, 984 Ricketts, 249

Peker, F., 271 Rippling, 1154, 1159
Perbeck, L., 769 Robbins technique, 644, 682
Perforation, 1138, 1168, 1173 Robbins, T.H., 6, 633
Pers, M., 811 Robertson, D.C., 6
Petits triangle, 62 Roberts, T.L., 1044
Phlebitis, 119 Robles, J., 1045
Pick, J.F., 888, 889, 927 Roe, J.O., 20, 21
Pierce, G.W., 18 Rogers, B.O., 16
Pinch test, 813814, 916, 960, 966, 974, 975, 985, 995, 996, 1004 Rohrich, R.J., 31, 891
Pistor, M., 205, 209 ROOF, 70. See Retro-orbicularis oculi fat (ROOF)
Pitanguy, I., 6, 9, 633, 791, 888, 889, 891, 904, 926, 973 Roth, A.C., 769
Pitman, G.H., 115, 132, 1173 Rothkopf, D.M., 1145
Planas, J., 888 Round block, 798, 799
Planatome, 11 Roy, J.N., 21
Plato, 557 Rudolph, R., 545
Pleating, 1178 Ruff, G., 361
Pneumothorax, 1153 Ruttin, E., 17
Pollock, H., 904
Pontes, R., 6
Pousson, M., 7 S
Protein C, 1140, 1141, 11561158 Saldanha, O.R., 904
Protein S, 1140, 11561158 Salivary fistula, 1167
Pseudocyst, 904, 1136 Samdal, F., 115, 772
Pseudoptosis, 623, 637, 807 Sampaio-Goes, J.C., 7
Psillakis, J.M., 10, 338, 339, 344, 345, 892 Santana, P.M., 338
Ptosis, 10, 34, 219, 289, 290, 345, 389, 437, 542, 558, 561, Scapho-conchal angle, 268
563565, 576, 617, 623, 630, 634, 638, 640, 641, 644, Scarpas fascia, 59, 60, 904, 945
666, 669673, 678, 682, 690, 694, 701, 755, 763, 777, Scars, 4, 6, 7, 9, 11, 19, 96, 147, 151, 152, 156, 164, 171, 172,
778, 783, 801, 815, 817, 818, 824, 858, 865868, 908, 178, 185, 277, 278, 296, 297, 301, 328, 332, 343, 356,
940, 942, 1001, 1008 409, 412, 467, 545, 560, 565, 572, 577, 617, 621, 622,
Ptotic, 363 630, 631, 633, 634, 661, 671, 687, 690, 694, 699, 701,
Pulmonary edema, 132, 1173 702, 706, 716, 735, 747, 751, 755, 760, 761, 765, 768,
Pulmonary emboli, 901, 902 791, 799, 800, 828, 841, 857, 866, 892, 901, 904, 907,
Pulmonary embolism (PE), 129, 893, 1140, 1155, 1157, 908, 912, 919, 921, 931, 941, 944, 946, 947, 951, 956,
1174, 1175 975, 986, 987, 993995, 997, 1004, 1106, 1107, 1113,
Pulmonary embolus, 1139 1124, 1125, 1131, 11361139, 1148, 1149, 1153, 1154,
Pyriformis, 1045 1163, 1167, 1170, 1171, 1174, 1178, 1179
hypertrophy, 616
indentation, 1153
Q Schaeffer, B.T., 15
Quezada, J., 1043 Schaller, H., 755
Scheflan, 888
Schepelmann, E., 887, 888
R Schrudde, J., 10, 13
Ramirez, O.M., 338, 339, 345, 352 Schwarzmann, E., 4, 756
Ramsay Hunt area, 81 Scuderi, N., 20
Rash, 1141, 1176 Seizure, 91, 116
Rassel, 1148 Sensory loss, 1138
Raynauds disease, 321, 333 Sepsis, 904, 1137
Rees, T.D., 815 Sercer, A., 18
Regnault, P., 6, 768, 888, 889, 926 Seroma, 10, 96, 341, 398, 543, 565, 631, 750, 767, 895, 904,
Regnaults classification, 716 918, 947, 950, 989, 991, 997, 1050, 1129, 1137, 1139,
Renault, P., 630 1154, 1159, 1167, 1168, 1170, 1171, 11731175
Ren, W.T., 6, 7 Serosanguinous, 1136
Rthi, A., 21 Sheehan, J.E., 21
Retro-orbicularis oculi fat (ROOF), 223, 437 Shiffman, M.A., 904
Reverse telephone ear deformity, 280 Shull, B.L., 903
Rey, R.M., 1160 Sidman, R.L., 406
Ribeiro, L., 6, 747 Silberg, B.N., 15
Ribeiros technique, 797 Simon, B.E., 747
Index 1191
Simons classification, 748 Thrombosis, 1094, 1140, 1141, 1156, 1157, 1169, 1174
Skin Titley, O.G., 771
burns, 456458 Toledo, 406
contracture, 333 Tolhurst, D.E., 271
pleating, 626 Tonnard, P., 10, 323
Skoog, T., 6, 9, 344, 772 Townsend, P.L., 770
Skoog technique, 769 Toxic shock syndrome, 904, 1137, 1141, 1158, 1171, 1176
Sleep apnea, 113 Tracy, C.A., 769
Slezak, S., 770 Trichloroacetic acid, 167
SMAS. See Superficial musculoaponeurotic system (SMAS) Tuberous breast, 787
Smith, E., 20 Tubular, 811
Smoking, 109, 112, 152, 153, 321, 334, 359, 492, 634, 767, Tubular breast, 805, 811, 812, 815823, 827828, 831, 840, 842
893, 931, 1136, 1137, 1142, 1149, 1151, 1172 Tumescent anesthesia, 175, 953
Songcharoen, S., 1160 Tumescent technique, 102, 132
Spadafora, 888
Spira, M., 275, 278
Stal, S., 20 U
Stark, R.B., 19 Umbilical hernia, 1138
Stenstrem, S.J., 19, 267 Umbilical stenosis, 1137, 1141
Stenstrem technique, 20 Upper arm contouring classification, 981
Steroid fat atrophy, 1164
Stoff-Khalili, M.A., 1159
Straith R.E., 19 V
Stroke, 1140, 1155 Van Uchelen, J.H., 893, 903
Strombeck, J.O., 4, 68, 633, 756 Vascular ectasias, 186
Suborbicularis oculi fat (SOOF), 3739, 70, 229, 340, 341, 345 Velpeau, A.A.L.M., 7
Sulamanidze, 358, 361, 365 Venous thrombosis (DVT), 99, 110, 894
Superficial musculoaponeurotic system (SMAS), 9, 10, 29, Ventral hernia, 1138
3234, 311, 312, 318, 319, 321, 323, 326330, 333, Ventura, O.D., 1159
337339, 344, 355, 369, 373, 379, 381, 390, 485, 487, Verchere, 7
488, 510, 511, 541 Vergara, R., 1045
Sushruta, 16, 20 Vernon, S., 888
Suslov, 21 Vidaurre, S., 17
Swelling, 218, 223, 410, 429, 441, 445, 995, 1132, 1143 Vilain, B., 10
Synmastia (Symmastia), 784, 1154, 1155 Vila-Rovira, R., 1160
Villandre, C., 756
Viola, J.C., 891
T Vitamin K, 1140
Tachycardia, 116, 129 Vitiligo, 205
Tachypnea, 1139 Vogt, T., 13
Tagliacozzi, G., 3, 16 Voloshin, M.R., 21
Tail of Spence, 50 von Graefe, K.F., 21
Tamerin, J., 19 von Pfolspeundt, H., 21
Taufig, 15 Voss, S.C., 902
Tear trough, 185, 227, 231, 420, 421, 423, 430, 486, 490, 491,
498, 502, 508
Tebbetts, 571 W
Teimourian, B., 6, 14 Weaver, D.F., 18
Telangiectasias, 205, 1094, 1095, 1167 Webster, G.V., 20
Telephone ear deformity, 280 Webster, R.C., 9
Temourian, 13 Wechselberger, G., 828
Temple, C.L., 770 Weerda, H., 20
Tessier, P., 10, 338, 344, 345 Wegener, H.E., 20
Thigh plasty, 1123 Weiner, D.L., 6, 8, 756
Thigh ptosis, 993 Weinhold, S., 887, 889, 927
Thomas, T.G., 755 Weir, R.F., 21
Thoracic outlet syndrome, 1149 Wheisheimer, K., 889, 927
Thorek, M., 4, 888, 889, 926 Whitnalls ligament, 73
Thromboembolism, 98, 682, 902, 11391142, 1155, 1157, Whitnalls tubercle, 71
1158, 1168, 1174, 1175, 1179 Widgerow, A.D., 280
Thrombophlebitis, 1139, 1156, 1157 Wilkinson, T.S., 888
1192 Index
Wise keyhole, 760 Y

Wise pattern, 629, 706, 709, 716, 721, 723, 730, 733744, 799, Yalin, C.T., 1161
836, 1163 Young, F., 17, 18
Wise, R.J., 4, 6, 791
Woods, J.E., 772
Wood-Smith, D., 19, 20 Z
Wrinkles, 329, 330 Zecha, P.J., 904
Wringer, E., 49, 636, 809, 812 Zelickson, B., 187
Wu, W., 361 Zocchi, M., 15
Zukowski, M.L., 888
X
Xanthelasma, 212

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Cosmetic Surgery

Melvin A. Shiffman Alberto Di Giuseppe

ISBN 978-3-642-21836-1 ISBN 978-3-642-21837-8 (eBook)

Library of Congress Control Number: 2011941191

Springer-Verlag Berlin Heidelberg 2013

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Paris, France Pierre F. Fournier, M.D.

Tustin, CA, USA Melvin A. Shiffman, M.D., J.D., FCLM

Part I History and Anatomy

1. History of Cosmetic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

6. Regional Anesthesia for Cosmetic Surgery

Part III Head and Neck

10. Facial Peels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

12. Capacitive Radiofrequency Skin Rejuvenation. . . . . . . . . . . . . . . . . . . . 195

31. Chin, Cheek, and Neck Vaser Liposculpture. . . . . . . . . . . . . . . . . . . . . . 467

35. Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555

46. The Moufarrege Total Posterior Pedicle Mammaplasty . . . . . . . . . . . . 775

51. Abdominoplasty: Aesthetics of the Anterior

Part VI Extremities and Buttocks

56. Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 973

60. Liposuction of Lower Extremities and Buttocks. . . . . . . . . . . . . . . . . 1011

Part VII Miscellaneous

65. Labioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1101

1.1 Introduction In 1792, Chopart [6] performed an operative proce-

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 3

Fig. 1.2 The planatome (Photo courtesy

Fig. 1.3 Swan-neck cannula and guided

Fig. 1.5 Metal suction curette of Kesselring

Fig. 1.6 Fischers technique

3. A poorly executed technique [213], Vaser (vibration amplification of sound energy

2.1 Introduction Following a description of the hard tissue foundation,

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, 29

Fig. 2.1 Frontal view of the facial skeleton

1 Angle of mandible 14 Zygomaticofacial foramen

Fig. 2.2 Convexities of the facial skeleton

Fig. 2.3 Areas of muscle Procerus

Depressor anguli oris Mentalis

Fig. 2.4 The superficial fat Lateral Temporal-Cheek Middle forehead

Fig. 2.5 Ligaments and septa Superior temporal septum

Superior cheek septum

Fig. 2.6 The retaining

Fig. 2.7 The mimetic facial

Levator labii superioris

Depressor anguli oris

Fig. 2.8 The prezygomatic Sub-orbicularis oculi fat (SOOF)

Zygomatic retaining ligament

Fig. 2.9 The buccal fat pad

Tear trough Orbital septum

Orbicularis retaining ligment

2.8 Neck course, platysma covers the medial part of sterno-

Fig. 2.11 The triangles

Table 2.1 Regions of the neck

Fig. 2.12 Neck region

2.9 Facial Nerve lower orbicularis oculi. Smaller branches continue

Fig. 2.13 Branches of the

External jugularv. Marginal mandibular br.

Fig. 2.14 Sensory innervation of the face

Fig. 2.15 Arterial supply