Aesthetic Plastic Surgery E-Book
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Aesthetic Plastic Surgery E-Book

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1398 pages
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Description

Aesthetic Plastic Surgery - edited by Sherrell J. Aston, MD, Douglas S. Steinbrech, MD and Jennifer L. Walden, MD - brings you the masterful expertise you need to achieve breathtaking outcomes for every cosmetic surgery procedure, including MACS lift, endoscopic mid and lower face rejuvenation, lid/cheek blending - the tear trough, cohesive gel breast augmentation, lipoabdominoplasty, and many more. A "who's who" of international authorities in plastic surgery explain their signature techniques, giving you all the know-how you need deliver the exceptional results your patients demand. Operative videos on DVD let you observe these techniques being performed in real time; and Expert Consult online access enables you to reference the text, download the images, and watch the videos from any computer.
  • Coverage of hot topics includes MACS lift, endoscopic mid and lower face rejuvenation, lid/cheek blending - the tear trough, the newest rhinoplasty techniques, cohesive gel breast augmentation, fat grafting techniques, details of the latest injectables and fillers, and many other highly sought-after procedures.
  • Operative videos - on DVD and online - let you see how leading experts perform more than 50 important techniques, including extended SMAS face lift, traditional inverted-T breast augmentation, and lipoabdominoplasty.
  • Nearly 1600 full-color photographs and illustrations demonstrate what to look for and what results you will achieve.
  • A consistent, extremely user-friendly organization guides you through history, evaluation, anatomy, technical steps, post-operative care, complications, and pearls and pitfalls for each procedure - giving you all the advice you need to make informed, effective decisions and avoid complications and disappointing results.
  • Expert Consult online access allows you to reference the complete contents, perform rapid searches, download the images, and watch the operative videos from any computer.
Your purchase entitles you to access the web site until the next edition is published, or until the current edition is no longer offered for sale by Elsevier, whichever occurs first. If the next edition is published less than one year after your purchase, you will be entitled to online access for one year from your date of purchase. Elsevier reserves the right to offer a suitable replacement product (such as a downloadable or CD-ROM-based electronic version) should online access to the web site be discontinued.

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Publié par
Date de parution 14 octobre 2012
Nombre de lectures 7
EAN13 9780702054372
Langue English
Poids de l'ouvrage 7 Mo

Informations légales : prix de location à la page 0,0920€. Cette information est donnée uniquement à titre indicatif conformément à la législation en vigueur.

Exrait

  • Coverage of hot topics includes MACS lift, endoscopic mid and lower face rejuvenation, lid/cheek blending - the tear trough, the newest rhinoplasty techniques, cohesive gel breast augmentation, fat grafting techniques, details of the latest injectables and fillers, and many other highly sought-after procedures.
  • Operative videos - on DVD and online - let you see how leading experts perform more than 50 important techniques, including extended SMAS face lift, traditional inverted-T breast augmentation, and lipoabdominoplasty.
  • Nearly 1600 full-color photographs and illustrations demonstrate what to look for and what results you will achieve.
  • A consistent, extremely user-friendly organization guides you through history, evaluation, anatomy, technical steps, post-operative care, complications, and pearls and pitfalls for each procedure - giving you all the advice you need to make informed, effective decisions and avoid complications and disappointing results.
  • Expert Consult online access allows you to reference the complete contents, perform rapid searches, download the images, and watch the operative videos from any computer.
  • Your purchase entitles you to access the web site until the next edition is published, or until the current edition is no longer offered for sale by Elsevier, whichever occurs first. If the next edition is published less than one year after your purchase, you will be entitled to online access for one year from your date of purchase. Elsevier reserves the right to offer a suitable replacement product (such as a downloadable or CD-ROM-based electronic version) should online access to the web site be discontinued.
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    Aesthetic Plastic Surgery
    Expert Consult

    Sherrell J. Aston, MD, FACS
    Professor of Surgery (Plastic), New York University School of Medicine, Chairman of the Department of Plastic Surgery, Manhattan Eye, Ear & Throat Hospital, New York, New York, USA

    Douglas S. Steinbrech, MD, FACS
    Clinical Associate Professor of Surgery (Plastic), New York University School of Medicine, Attending Physician, Plastic Surgery, Manhattan Eye, Ear & Throat Hospital, New York, New York, USA

    Jennifer L. Walden, MD, FACS
    Attending Surgeon, Program Director, Plastic Surgery, Manhattan Eye, Ear & Throat Hospital, New York, New York, USA
    Saunders
    Table of Contents
    Instructions for online access
    Cover image
    Title page
    Copyright
    Foreword
    Preface
    List of Contributors
    Dedication
    Acknowledgments
    Section 1: Office organization
    Chapter 1: Office practice of plastic surgery
    Part 1: Introduction of the practice needs
    Part 2: Marketing and practice enhancement
    Chapter 2: Clinical photography for the aesthetic patient
    Lighting
    Position
    Faces
    Breast images
    Body contouring views
    PA
    Integrity in photography
    The future of clinical photography
    Section 2: Anesthesia
    Chapter 3: Anesthesia in aesthetic surgery
    History of ambulatory anesthesia
    Preoperative evaluation – patient safety
    Preoperative medications
    Methods of anesthesia
    Office-based anesthesia
    Intraoperative considerations
    Postoperative considerations
    Complications
    Chapter 4: Postoperative nausea and vomiting
    The “big little problem”
    Risk factors for PONV
    Prophylactic treatment
    Common medications
    Ineffective medications
    Non-medical interventions
    Intractable nausea and vomiting
    Post-discharge nausea and vomiting
    Chapter 5: Patient safety in aesthetic surgery
    The process of patient safety
    How to create a culture of safety and quality (steps you do with your staff)
    Specific “problematic” topics in patient safety
    Section 3: Facelift
    Chapter 6: Facelift anatomy, SMAS, retaining ligaments and facial spaces
    Functional evolution of the face
    Regions of the face
    Layers of the face
    Anatomy over the cavities in the skeleton
    Anatomy and aging of the face
    Application of anatomy to surgical technique
    Chapter 7: Facelift with SMAS technique and FAME
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 8: The SMAS facelift – restoring facial shape in facelifting
    Introduction
    History
    Physical evaluation – patient planning
    Anatomic considerations
    Extended SMAS technique
    SMAS elevation
    Postoperative care
    Complications
    Chapter 9: Short scar facelift
    History
    Physical evaluation
    Technical steps
    Postoperative care
    Complications of the short scar facelift
    Chapter 10: Foundation facelift
    History
    Patient evaluation
    Anatomy
    Technical steps
    Results
    Postoperative care
    Complications
    Chapter 11: The “High SMAS” facelift technique
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 12: MACS facelift
    Introduction/key points
    Physical evaluation
    Indications
    Technical steps
    Results
    Postoperative care
    Summary/conclusions
    Chapter 13: The multi-vectored rhytidoplasty
    Chapter 14: The male facelift
    History
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Chapter 15: Endoscopic mid and lower face rejuvenation
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 16: Endoscopic facial rejuvenation
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Clinical case example
    Chapter 17: Facial rejuvenation in non-Caucasians
    History
    Anatomy and physiology of aging
    Aging in the African-American and Hispanic
    Evaluation
    Facial rejuvenation
    Chapter 18: Aesthetic facial microsurgery
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 19: Midface lift
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Section 4: The neck
    Chapter 20: Deep plane procedures in the neck
    Introduction
    History
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Chapter 21: Treatment of the male neck
    Introduction
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Chapter 22: Managing submandibular glands
    History
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Section 5: Browlift
    Chapter 23: Non-endoscopic limited incision browlift
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 24: Coronal browlift
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 25: Endoscopic browlift with internal fixation
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 26: Transblepharoplasty browlift
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Section 6: Suture suspension
    Chapter 27: Suture suspension for face and neck
    History
    Anatomy
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Chapter 28: Suture suspension for brow and upper face
    Introduction
    History
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Section 7: Blepharoplasty
    Chapter 29: Conventional upper and lower blepharoplasty
    History
    Physical examination
    Technical steps
    Postoperative care
    Complications
    Chapter 30: Lateral canthal suspension techniques
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 31: Lid–cheek blending: the tear trough deformity
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 32: Tarsal strip canthoplasty
    History
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Chapter 33: Blepharoplasty in the East Asian patient
    Introduction
    The history of Asian periorbital surgery
    Anatomy and physical evaluation
    Technical steps
    Postoperative care
    Complications
    Conclusion
    Chapter 34: Treatment of blepharoplasty complications
    History
    Complications in the early postoperative period (1st week)
    Complications in the intermediate post-operative period (1st–6th week)
    Complications in the late postoperative period (7th week and beyond)
    Section 8: Malar, chin and mandibular contouring
    Chapter 35: Autologous contouring the lower face
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 36: Alloplastic chin augmentation
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Acknowledgment
    Section 9: Rhinoplasty
    Chapter 37: Primary closed rhinoplasty
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 38: Primary open rhinoplasty
    History
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Chapter 39: Secondary rhinoplasty
    History
    Patient evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 40: Nasal tip grafting with an “anatomic tip graft” and sizers
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 41: Anatomic approach for tip problems
    History
    Preoperative evaluation
    Anatomy
    Technical steps
    Postoperative care
    Chapter 42: Correction of the deviated septum
    History
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Chapter 43: The ethnic rhinoplasty
    History
    African-American
    Hispanic
    Middle Eastern
    Asian
    Chapter 44: The Asian rhinoplasty
    Introduction
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 45: Correcting the cleft lip nose
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Section 10: Ear
    Chapter 46: Primary otoplasty and reconstruction
    Introduction
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Section 11: The breast
    Chapter 47: Traditional inverted-T breast reduction
    History and introduction
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 48: Mastopexy with and without augmentation
    History
    Physical evaluation
    Technical steps
    Preoperative assessment
    Postoperative care
    Complications
    Chapter 49: Pitanguy breast reduction
    History
    Physical evaluation
    Anatomy
    The classic Pitanguy breast reduction technique
    The rhomboid Pitanguy breast reduction technique
    Postoperative care
    Complications
    Chapter 50: Medial pedicle vertical mammaplasty
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 51: Periareolar Benelli mastopexy and reduction: The “Round Block”
    History
    Anatomy
    Physical evaluation
    Technical steps
    Complications
    Chapter 52: Breast implants: background, safety and general considerations
    Introduction
    History/implant development
    Safety and efficacy
    Complications
    Physical evaluation
    Chapter 53: Breast augmentation
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    CASE STUDY: PATIENT NO. 1
    CASE STUDY: PATIENT NO. 2
    Acknowledgment
    Chapter 54: The dual plane approach to breast augmentation
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 55: Cohesive gel breast augmentation
    History
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Patient examples
    Chapter 56: Difficult breast augmentations
    History
    Tuberous breast deformity
    Anterior thoracic hypoplasia
    Poland’s syndrome
    Chapter 57: Breast reconstruction
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 58: Nipple–areola reconstruction
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Section 12: Body contouring/bariatric massive weight loss
    Chapter 59: Pure aspiration lipoplasty
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 60: Complications and corrections of lipoplasty
    Introduction
    History
    Complications
    Local complications
    Conclusion
    Chapter 61: New concepts in fat grafting
    History
    Histology of the fat tissue
    Technical steps
    Histological evaluation
    Conclusion
    Chapter 62: Lipoabdominoplasty: Saldanha’s technique
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Conclusion
    Chapter 63: Lipoabdominoplasty: Advanced techniques and technologies
    Introduction
    Safety concerns over combining lipoplasty and excisional surgery
    Innovations in abdominoplasty
    VASER® ultrasonic lipoplasty combined with excision
    Ultrasonic cutting devices
    Technical considerations for Ethicon EndoSurgery Synergy® ultrasonic scalpel in lipoabdominoplasty
    Steps for lipoabdominoplasty
    Discussion
    Chapter 64: Non-surgical ultrasonic lipoplasty
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Aesthetic results
    Chapter 65: Ultrasound assisted liposuction
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 66: Abdominoplasty techniques
    History
    Physical evaluation
    Anatomy of the abdominal wall
    Technical steps
    Postoperative care
    Complications
    Chapter 67: Brachioplasty
    History
    Physical evaluation
    Technical steps
    The operation
    Postoperative care
    Complications
    Chapter 68: Belt lipectomy: Lower body lift
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 69: High lateral tension abdominoplasty
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 70: Gluteal augmentation
    History
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Section 13: Skin and facial resurfacing
    Chapter 71: Botox® for face, neck and brow
    History
    Physical evaluation
    Technical steps
    Post-treatment care
    Complications
    Chapter 72: Lip augmentation
    History
    Physical evaluation
    Anatomy and architecture of the lip
    Technical steps
    Postoperative care
    Complications
    Chapter 73: Structural fat augmentation of the face and hands
    History
    Evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 74: Hyaluronic acid injectable filler
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 75: Non-hyaluronic acid fillers for facial augmentation
    History
    Classification of fillers
    Physical evaluation
    Technical steps
    Postoperative care
    Complications
    Chapter 76: Laser resurfacing
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Chapter 77: Fractional resurfacing
    History
    Physical evaluation
    Anatomy for procedure
    Technical steps
    Postoperative care
    Complications
    Chapter 78: Total facial alloplastic augmentation
    Historical background
    The evaluation
    Applied anatomy for total alloplastic facial augmentation
    Technical steps of alloplastic facial augmentation
    Postoperative care
    Complications
    Chapter 79: Chemical peels and dermabrasion
    History
    Physical evaluation
    Anatomy
    Technical steps
    Postoperative care
    Complications
    Index
    Copyright

    SAUNDERS is an imprint of Elsevier Limited
    © 2009, Elsevier Limited. All rights reserved.
    First published 2009
    © Robert S. Flowers – Chapter 33 artwork
    The right of Sherrell J Aston, Douglas Steinbrech and Jennifer Walden to be identified as author/s of this work has been asserted by him/her/them in accordance with the Copyright, Designs and Patents Act 1988.
    No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: healthpermissions@elsevier.com . You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions .
    ISBN: 978-0-7020-3168-7
    British Library Cataloguing in Publication Data
    A catalogue record for this book is available from the British Library
    Library of Congress Cataloging in Publication Data
    A catalog record for this book is available from the Library of Congress


    Notice
    Medical knowledge is constantly changing. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the Publisher nor the author assume any liability for any injury and/or damage to persons or property arising from this publication.
    The Publisher


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

    Thomas D. Rees, MD, FACS
    At last, this book makes available a single volume text of aesthetic surgery that is truly of the 21st century that not only presents each subject in an organized and very readable format, but also provides for continuous, ongoing updating through the electronic miracles of the internet and the computer so that the reader does not have to wait for a period of years for another edition to keep current on any given topic by which time the first edition may be well out of date and behind the curve on new techniques and information.
    The availability of DVDs made in real time of actual surgical procedures, and videos add enormously to the appeal of this book. In the past, the best we could do to make the contents, both verbal and visual of the symposia that Dr. Aston and I put together was to result in a monograph of the proceedings and to make available tapes and DVDs of the operations performed in conjunction with the meetings; however, these were separate issues and not always coordinated to represent the efforts of the faculties drawn from experts from all over the world. Monographs evolving from meetings and symposia are difficult to bring to fruition. Faculty members are usually very busy professionals who resent giving the time to prepare their presentations in monograph form, and it is difficult and often presumptuous for the editors to rework the manuscripts to arrive at a common format. The contributing authors to this book were challenged by the continuous updating features as well as the accompanying DVDs and videos which really made their writing efforts live almost in real time, and avoided the often odious and unpopular task of having to rewrite their chapters in a few years time for yet another edition.
    I found the uniform format of each chapter in this volume to be most appealing and reader friendly, especially the absence of redundancy, i.e. history and personal philosophy. It is difficult to teach aesthetic surgery only by the written word. Aesthetic surgery expertise only comes with hands on experience. “Aesthetic Plastic Surgery” comes as close to reproducing an actual operating room environment as one can expect. At the very least the book is a practical companion to the real thing.
    Preface
    For the past twenty-nine years Dr. Thomas D. Rees and I co-chaired the Manhattan Eye, Ear & Throat Hospital Aesthetic Surgery Symposium, which brought together a multidisciplinary faculty of experts in just about every facet of aesthetic surgery. Attendees and patients from around the world have benefited from the carefully prepared presentations of the latest advances and tried and true aesthetic surgery techniques. The highly organized program format and, for the most part, rigidly controlled presentation times forced the faculty members to present ‘just the meat’ of their topic. There was no time for exhaustive historical reviews or philosophical discussions. The audience over the years has overwhelmingly given high reviews to this format. Dr. Rees and I discussed on numerous occasions various ways to harness the tremendous amount of material presented during these four- or five-day symposia (i.e. a monograph of the yearly meeting, videos, CDs or audio tapes). It was not done for various reasons. However, Dr. Rees did publish three textbooks that achieved worldwide success: (1) Cosmetic Facial Surgery by Dr. Thomas D. Rees and Dr. Donald Wood-Smith 1973 (2) Aesthetic Plastic Surgery 1980 to which I was a contributor and (3) Aesthetic Plastic Surgery, 1994 co-edited by Dr. Thomas D. Rees and Dr. Gregory S. Latrenta.
    Shortly after the 2005 MEETH symposium, one of my co-authors/editors Dr. Douglas S. Steinbrech proposed to me the idea of putting together a textbook based on the subject matter of the recently concluded meeting. After all, we had covered just about the entire field of aesthetic surgery. At first I was tepid to the idea; however, two weeks later Dr. Steinbrech showed up at my office with an outline for the book and ideas about how it could be produced efficiently. My associate Dr. Jennifer L. Walden was enthusiastic about the project and agreed to be one of the co-authors/editors. After several meetings we agreed on the book content (which was significantly different from the 2005 symposium), book format, style, authors and ‘nuts and bolts’. That product is what we have here.
    Drs. Steinbrech and Walden are wise and capable beyond their years. They are publishing, lecturing and operating. Most of the good ideas associated with this project should be credited to them. Dr. Douglas S. Steinbrech is a product of the New York University general surgery and plastic surgery residency programs. He is a busy member of the plastic surgery staff at MEETH and Lenox Hill Hospitals and is a favorite of our plastic surgery residents and fellows in teaching and demonstrating surgical techniques. Dr. Jennifer L. Walden, a native Texan, trained in the integrated plastic surgery program at the University of Texas Medical Branch and came to MEETH as an aesthetic surgery fellow in 2003. In addition to her busy private practice, she is the Program Director of our resident and fellows’ teaching program at MEETH and anyone who has ever met her knows she is a natural leader.
    This book is a multi-authored single volume text covering most areas of aesthetic surgery. It is not intended to be an encyclopedia of aesthetic surgery techniques but a select accumulation of contemporary procedures that are in frequent use by the authors. The authors are for the most part well known and/or with considerable experience in their topic. We are indebted to all of the authors as they gave of their time and work to make this book a reality. I hope that they will feel a sense of pride in contributing to this book and sharing their experience and knowledge.
    The chapters in this book were submitted online through a software program we had designed for this project. The authors configured their chapters to the template so as to provide to the reader the core material. The template provided to the authors stated the need for:

    1). Two concise paragraphs about the history surrounding this procedure.
    2). Physical evaluation.
    3). Three to five concise paragraphs about the anatomy relevant to this procedure.
    4). Seven to twelve paragraphs describing the technical steps for this procedure.
    5). One paragraph describing the post-operative care associated with this procedure.
    6). One paragraph describing the complications associated with this procedure and how you treat them.
    7). In bullet form list five Pearls and five Pitfalls.
    8). Summarize your procedure in ten to twenty precise steps.
    9). List no more than 10 of the most important references.
    With the leap forward in internet and computer technology, we have some exciting new additions to this textbook which include: an on-line virtual companion textbook with monthly updates of new material, hypertext links that allow jumping from one topic to another with just a click of the mouse, and a full complement of DVD and downloadable videos for viewing on a laptop.
    We also wanted this book to be analogous to Cameron’s Current Surgical Therapy for surgery residents, a useful book of pertinent and relevant topics that could easily be carried in one hand and taken on call or on rounds.
    The intended reader is any plastic surgeon interested in aesthetic surgery. We hope that young surgeons find it organized so as to provide concise details of the procedures and techniques contained and to add to their knowledge base. For some who are in the midst of their training this book may be their first exposure to some of the specific topics; however, we are confident that more experienced surgeons will also find it useful. All surgeons must constantly update their knowledge of contemporary procedures and strive for improved results. We hope this book helps with that process.

    Sherrell J. Aston, MD, FACS
    2009
    List of Contributors

    William P. Adams, Jr., MD
    Associate Clinical Professor, Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, TX, USA

    Alexander C. Allori, MD, MPH
    Post-Doctoral Research Fellow, Institute of Reconstructive Plastic Surgery Laboratories, New York University Medical Center, New York, NY, USA

    Al S. Aly, MD
    Assistant Professor of Surgery, University of Iowa College of Medicine, Coralville, IA, USA

    Sherrell J. Aston, MD, FACS
    Professor of Surgery (Plastic), New York University School of Medicine, Chairman of the Department of Plastic Surgery, Manhattan Eye, Ear & Throat Hospital, Past President, American Society for Aesthetic Plastic Surgery, New York, NY, USA

    Bruce W. Ayers, BA, CCRA
    Clinical Research Coordinator, Minimally Invasive Aesthetics, LLC, Beverly Hills, CA, USA

    Daniel C. Baker, MD
    Professor of Plastic Surgery, New York University, Institute of Reconstructive Plastic Surgery, New York, NY, USA

    Thomas J. Baker, MD
    Clinical Professor of Plastic Surgery at the University of Texas Medical Branch, Educational Foundation Professor for the International Society of Aesthetic Plastic Surgery (ISAPS), Voluntary Professor of Plastic Surgery, University of Miami School of Medicine, Miami, FL, USA

    Fritz E. Barton, Jr., MD, FACS
    Clinical Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Past President of the American Society for Aesthetic Plastic Surgery, Dallas Plastic Surgery Institute, Dallas Day Surgery Center, Dallas, TX, USA

    Louis C. Benelli, MD
    Plastic and Reconstructive Surgery, Department of Surgery, Bichat Hospital, University of Paris, Paris, France

    Thomas M. Biggs, MD
    Clinical Profesor of Plastic Surgery, Baylor College of Medicine, Houston, TX, USA

    Michael A. Bogdan, MD
    Private Practice, Southlake, TX, USA

    Ewaldo Bolivar de Souza Pinto, MD, PhD
    Santa Celília University, Santos, São Paulo, Brazil

    Fredric S. Brandt, MD
    Private Practice Coral Gables, FL and Manhattan, NY, Principal Investigator, Dermatology Research Institute, LLC, Coral Gables, FL, USA

    Kevin Brenner, MD
    Roxbury Clinic and Surgery Center, Beverley Hills, CA, USA

    A. Jay Burns, MD
    Clinical Assistant Professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA

    John L. Burns, MD
    Clinical Instructor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA

    Steven Byrd, MD
    Professor of Plastic Surgery, The University of Texas Southwestern Medical Center, Chief of Plastic Surgery Department, Children’s Hospital, Director/Managing Partner, Dallas Day Surgery Center, Partner, Dallas Plastic Surgery Institute, Dallas, TX, USA

    Claudio Cardoso de Castro, MD
    Chief & Professor, Plastic Surgery Service, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil

    Paulo Roberto Gomes Carneiro, MD
    Resident Doctor, Dr. Ewaldo Bolivar de Souza Pinto Plastic Surgery Service, Santos, São Paulo, Brazil

    Alex Cazzaniga, BS, MBA
    Director of Clinical Research, Dermatology Research Institute, LLC, Coral Gables, FL, USA

    Daniel J. Ceradini, MD
    Resident, Department of Plastic Surgery, New York University Medical Center, New York, NY, USA

    Mark A. Checcone, MD
    Assistant Professor, Head & Neck Surgery: Division of Facial Plastic Surgery, Washington University West County Office, Creve Coeur, MO, USA

    Ernest S. Chiu, MD, FACS
    Associate Professor of Surgery, Director of Plastic Surgery Research, Division of Plastic and Reconstructive Surgery, School of Medicine, Tulane University, New Orleans, LA, USA

    C. Spencer Cochran, MD
    Clinical Assistant Professor, Department of Otolaryngology-Head & Neck Surgery, University of Texas Southwestern Medical Center at Dallas Gunter Center for Aesthetics & Cosmetic Surgery, Dallas, TX, USA

    Mark A. Codner, MD
    Clinical Assistant Professor, Department of Plastic Surgery, Emory University, Private Practice, Paces Plastic Surgery, Atlanta, GA, USA

    Sydney R. Coleman, MD
    Assistant Clinical Professor, New York University Medical Center, Director, TriBeCa Plastic Surgery, New York, NY, USA

    Gustavo A. Colon, MD
    Clinical Professor, Tulane University, Metairie, LA, USA

    Albert E. Cram, MD, FACS
    Iowa City Plastic Surgery, Coralville, IA, USA

    Court Cutting, MD
    Professor of Surgery (Plastic Surgery), New York University Medical Center, New York, NY, USA

    Rollin K. Daniel, MD, FACS
    Clinical Professor of Plastic Surgery, University of California Irvine, Professor of Surgery, McGill University, Chief of Plastic Surgery, Royal Victoria Hospital, Newport Beach, CA, USA

    Leonora d’Ascensão Mansur, MD
    Member of the Brazilian Society of Plastic Surgery, Santa Helena, MG, Brazil

    Wojciech Dec, MD
    Resident, Department of Plastic Surgery, New York University Medical Center, New York, NY, USA

    José Abel de la Peña, MD
    Hospital Angeles de las Lomas, Mexico City, Mexico

    José Luis Martín del Yerro Coca, MD
    Head of the Departament of Plastic, Reconstructive and Asthetic Surgery, Hospital Quirón, Madrid, Spain

    Maurício Doi, MD
    Titular member of the Brazilian College of Surgeons, Associated Aspirant Member of the Brazilian Society of Plastic Surgery, Resident Doctor, “Dr. Ewaldo Bolivar de Souza Pinto” Plastic Surgery Service, Unisanta, São Paulo, Brazil

    Michael Edwards, PhD
    Plastic Surgery Insitute of Southern California, Thousand Oaks, CA, USA

    Rodrigo Federico, MD
    Resident Doctor, Dr. Ewaldo Bolivar de Souza Pinto Plastic Surgery Service, Rio de Janeiro, RJ, Brazil

    Roberto L. Flores, M.D.
    Assistant Professor of Surgery, Riley Hospital for Children, Indiana Univeristy Medical Center, Indianapolis, IN, USA

    Robert S. Flowers, MD
    The Flowers Clinic, Honolulu, HI, USA

    Peter Fodor, MD, FACS
    Past President, American Society for Aesthetic Plastic Surgery, Associate Clinical Professor, Dept of Plastic Surgery, UCLA Medical Center, Los Angeles, CA, USA

    Brandon Freeman, MD
    Aesthetic Fellow, Department of Plastic Surgery, University of Texas-Southwestern, Dallas, TX, USA

    Jack A. Friedland, MD, FACS
    Associate Professor of Plastic Surgery, Department of Plastic Surgery, Mayo Medical School, Past President, American Society for Aesthetic Plastic Surgery, Scottsdale, AZ, USA

    Allen Gabriel, MD
    Staff Physician, Clinical Research Director, Department of Plastic Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA

    Roy G. Geronemus, MD
    Clinical Professor of Dermatology, New York University, Director, Laser & Skin Surgery Center of NY, New York, NY, USA

    Ashkan Ghavami, MD
    Private Practice, Beverly Hills, CA, USA

    Mary K. Gingrass, MD
    Assistant Clinical Professor, Vanderbilt University School of Medicine, The Plastic Surgery Center of Nashville, Nashville, TN, USA

    Ronald P. Gruber, MD
    Clinical Assistant Professor, University of California, Adjunct Clinical Assistant Professor, Stanford University, East Bay Aesthetic Plastic Surgery Center, Oakland, CA, USA

    Jack P. Gunter, MD
    Clinical Professor, Department of Plastic Surgery & Clinical Professor, Department of Otorhinolaryngology, The University of Texas Southwestern Medical Center, Dallas, TX, USA

    Bahman Guyuron, MD, FACS
    Kiehn-DesPrez Professor and Chair, Department of Plastic Surgery, Case Western Reserve University/University Hospitals Case Medical Center, Lyndhurst, OH, USA

    Elizabeth J. Hall-Findlay, MD, FRCSC
    Plastic Surgeon, Banff Plastic Surgery, Banff, Alberta, Canada

    Haideh Hirmand, MD, FACS
    Clinical Assistant Professor of Surgery, Cornell Medical College, New York, NY, USA

    Erik A. Hoy, MD
    Resident, Department of Plastic Surgery, Brown University, Providence, RI, USA

    Dennis J. Hurwitz, MD, FACS
    Director, Hurwitz Center for Plastic Surgery, Clinical Professor of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA

    Nicanor G. Isse, MD
    The Isse Institute of Cosmetic Surgery, Inc., Newport Beach, CA, USA

    Elizabeth B. Jelks, MD
    Department of Ophthalmology, New York University School of Medicine, New York, NY, USA

    Glenn W. Jelks, MD, FACS
    Associate Professor of Surgery (Plastic Surgery), Associate Professor of Ophthalmology, New York University School of Medicine, New York, NY, USA

    Mark Jewell
    Past President, American Society for Aesthetic Plastic Surgery, Assistant Clinical Professor Oregon Health Science University, Portland, OR, USA

    Nolan S. Karp, MD
    Associate Professor of Plastic Surgery, New York University School of Medicine, Chief, Plastic Surgery Service, Tisch Hospital, New York, NY, USA

    Arnold W. Klein, MD
    Professor of Medicine and Dermatology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA

    Gil Kryger, MD
    Kryger Institute of Plastic Surgery, Thousand Oaks, CA, USA

    Val Lambros, MD, FACS
    Clinical Instructor in Surgery, University of California, Irvine, Newport Beach, CA, USA

    Walter Lampeter, CSA, RNFA
    Surgical Assistant, Department of Plastic Surgery, Manhattan Eye, Ear & Throat Hospital, New York, NY, USA

    Gary J. Lelli, Jr., MD
    Assistant Professor of Oculoplastic Surgery, Department of Ophthalmology, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA

    Oren Z. Lerman, MD
    Resident, The Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY, USA

    Richard D. Lisman, MD, FACS
    Clinical Professor of Ophthalmology, New York University School of Medicine, Director of Ophthalmic Plastic Surgery Services, New York University Medical Center and Manhattan Eye, Ear & Throat Hospital, New York, NY, USA

    Montien Lueprapai, MD
    Plastic Surgeon, Lerdsin Hospital, Bangkok, Thailand

    Vincent P. Marin, MD
    Clinical Instructor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA

    W. Jason Martin, MD
    Director, Aspen Institute of Plastic and Reconstructive Surgery, Aspen Valley Hospital, Aspen, CO, USA

    G. Patrick Maxwell, MD, FACS
    Clinical Professor of Surgery, Department Plastic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA

    Joseph G. McCarthy, MD
    Professor of Surgery (Plastic), Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY, USA

    Ricardo A. Meade, MD
    Clinical Instructor, University of Texas Southwestern Medical Center, Private Practice, Dallas Plastic Surgery Institute, Dallas, TX, USA

    Bryan Mendelson, FRCSE, FRACS, FACS
    President of the International Society of Aesthetic Plastic Surgery, Toorak, Victoria, Australia

    Joseph Michaels, V MD
    Body Contouring Fellow, Clinical Professor of Surgery, Division of Plastic Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA

    Colin M. Morrison, MSc, FRCS(Plast)
    Department of Plastic Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

    Newton Moscoe, MD
    Private Practice, Austin, TX, USA

    Foad Nahai, MD, FACS
    Paces Plastic Surgery, Atlanta, GA, USA

    Timothy Neavin, MD
    Aesthetic Surgery Fellow of Richard Ellenbogen, Los Angeles, CA, USA

    Carlos G.L. Neves, MD
    Specialist Member of the Brazilian Society of Plastic Surgery, SBCP, Titular Member of the Brazilian College of Surgeons, TCBC, Rio de Janeiro, RJ, Brazil

    Michael K. Newman, MD
    Clinical Instructor, Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA

    Ferdinand A. Ofodile, MD, FACS
    Clinical Professor of Surgery, Columbia University, Chief of Plastic Surgery, Harlem Hospital Center, New York, NY, USA

    Sheldon Opperman, MD
    Site Director, Department of Anesthesiology, Manhattan Eye, Ear & Throat Hospital, New York, NY, USA

    Salvatore Pacella, MD, MBA
    Attending Surgeon, Division of Plastic Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA

    Keyian Paydar, MD
    Resident, Division of Plastic and Reconstructive Surgery, University of California, Irvine, Irvine, CA, USA

    John A. Perrotti, MD
    Clinical Assistant Professor of Surgery, New York Medical College, Attending Surgeon, Manhattan Eye, Ear & Throat Hospital, New York, NY, USA

    Ivo Pitanguy, MD
    Professor of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Institute of Post-Graduate Medical Studies, Rio de Janeiro, RJ, Brazil

    Gerald H. Pitman, MD
    Clinical Professor of Surgery (Plastic Surgery), Institute for Reconstructive Plastic Surgery, New York University School of Medicine, New York, NY, USA

    Ronaldo Pontes, MD
    Chairman of the Clinic, Professor of Surgery, Fluminense Federal University, Niterói, RJ, Brazil

    Henrique N. Radwanski, MD
    Assistant Professor of Plastic Surgery, The Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Institute, Rio de Janeiro, RJ, Brazil

    Oscar M. Ramirez, MD
    Director of Esthetique Internationale, “The Center for Cosmetic Plastic Surgery Enhancement”, Clinical Assistant Professor, Plastic Surgery, The Johns Hopkins University, Timonium, MD, USA

    Emily Ridgway
    Resident, Harvard Division of Plastic Surgery, Boston, MA, USA

    Rod Rohrich, MD, FACS
    Professor and Chairman; Crystal Charity Ball Distinguished Chair in Plastic Surgery and the Betty and Warren Chair in Plastic and Reconstructive Surgery, Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA

    David J. Rowe, MD
    Assistant Professor of Plastic Surgery, Department of Plastic Surgery, University Hospitals Case Medical Center, Cleveland, OH, USA

    Gregory L. Ruff, MD
    Private Practice, Chapel Hill, NC, USA

    Pierre Saadeh, MD
    Program Director, Plastic Surgery, New York University School of Medicine, New York, NY, USA

    Alesia P. Saboeiro, MD
    Private Practice, Tribeca Plastic Surgery, New York, NY, USA

    Osvaldo Saldanha, MD
    Head of Plastic Surgery Service – UNISANTA, Santos, São Paulo, Brazil

    Narayana Pauline Serpa, MD
    Clinica Fluminense, Rio de Janeiro, RJ, Brazil

    David Michael Shafer, MD
    Aesthetic Surgery Fellow, Manhattan Eye, Ear & Throat Hospital, New York, NY, USA

    John W. Siebert, MD
    Professor of Surgery, University of Wisconsin School of Medicine Madison, WI, Adjunct Professor (Plastic Surgery), New York University Medical Center, New York, NY, USA

    Scott Lawrence Spear, MD
    Chairman and Professor, Deparment of Plastic Surgery, Georgetown Universtiy Hospital, Washington, DC, USA

    Douglas S. Steinbrech, MD, FACS
    Clinical Associate Professor of Surgery (Plastic), New York University School of Medicine, Attending Physician, Plastic Surgery, Manhattan Eye, Ear & Throat Hospital, New York, NY, USA

    David Stoker, MD, FACS
    Clinical Assistant Professor of Surgery, Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Marina del Rey, CA, USA

    James M. Stuzin, MD
    Assistant Professor of Surgery, Department of Plastic Surgery, University of Miami, School of Medicine, Miami, FL, USA

    Sean A. Sukal, MD, PhD
    Director, Sukal Skin Institute, Boca Raton, FL, USA

    Patrick K. Sullivan, MD
    Associate Professor, Plastic Surgery, Brown University, Providence, RI, USA

    Nicolas Tabbal, MD, FACS
    Clinical Associate Professor of Surgery, Institute for Reconstructive Plastic Surgery, New York University School of Medicine, New York, NY, USA

    Michèle Tardif
    Chirurgie plastique, Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada

    Steven Teitelbaum, MD, FACS
    Assistant Clinical Professor of Plastic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Oren M. Tepper, MD
    Resident, The Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY, USA

    Edward O. Terino, MD
    Medical Director, Plastic Surgery Institute of Southern California, Thousand Oaks, CA, USA

    Charles H. Thorne, MD
    Associate Attending Surgeon, Manhattan Eye, Ear & Throat Hospital, Associate Professor of Plastic Surgery, New York University School of Medicine, New York, NY, USA

    Patrick L. Tonnard, MD
    Coupure Centrum Voor Plastische Chirurgie, Ghent, Belgium

    Dean M. Toriumi, MD
    Professor, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology – Head and Neck Surgery, University of Illinois at Chicago, Chicago, IL, USA

    Andrew P. Trussler, MD
    Assistant Professor, Department of Plastic Surgery, University of Texas – Southwestern, Dallas, TX, USA

    Andrey Van Ass Malheiros, MD
    Resident Doctor, Dr. Ewaldo Bolivar de Souza Pinto Plastic Surgery Service, Rio de Janeiro, RJ, Brazil

    Alexis M. Verpaele, MD
    Coupure Centrum Voor Plastische Chirurgie, Ghent, Belgium

    Jennifer Walden, MD, FACS
    Attending Surgeon and Program Director, Plastic Surgery, Manhattan Eye, Ear & Throat Hospital, New York, NY, USA

    Richard Warren, MD, FRCS(C)
    Clinical Professor, Division of Plastic Surgery, University of British Columbia, Vancouver, BC, Canada

    Stephen M. Warren, MD
    Associate Professor of Surgery (Plastic), Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY, USA

    Adam Bryce Weinfeld, MD
    Attending Plastic Surgeon, University Medical Center, Brackenridge Dell Children’s Medical Center of Central Texas, Temple, TX, USA

    Michael Zelman
    Anesthesiologist, Lennox Hill Anesthesiology, New York, NY, USA
    Dedication
    This book is dedicated to my wife Muffie, whose patience and support are endless, and our daughters Ashleigh and Bracie as most of my time for this project was stolen from them on nights and weekends.
    Sherrell J. Aston, MD, FACS
    For Edward and Narge, Steinbrech and Jeffrey Sharp for all their support.
    Douglas S. Steinbrech, MD, FACS
    I dedicate this book to my parents, Dr. Richard and Shirley Walden, who have never once questioned my aspirations and dreams.
    Jennifer L. Walden, MD, FACS
    Acknowledgments
    We would like to acknowledge and thank Dr. Thomas D. Rees for writing the Foreword of this book. He set the standards for teaching aesthetic surgery.
    The current generation of aesthetic surgeons and those to follow are indebted to him. We are honored that he wrote the first page of this book.
    We would like to acknowledge Mr. Walter Lampeter, Certified Surgical Assistant, for his untiring effort as the technical editor of this book. When this project was in the early stages of development Dr. Steinbrech, Dr. Walden and I knew that our schedules would not permit either of us to be the point person as the day to day recipient of chapters submitted online. Needless to say most chapters required significant effort to process, coordinate the parts and then pass them online to us for the initial edits before being sent to Elsevier. Walter was essential to getting this book published. We will always be grateful for his hard work, easy going personality and coolness under pressure.
    We are also grateful to Sue Hodgson Publishing Director at Elsevier who was so helpful in making this book come to fruition. Her advice and guidance was superb. Her willingness to make this book be the way we wanted was inspiring and much appreciated. Elsevier is fortunate to have Sue represent their plastic surgery books division.

    Sherrell J. Aston, MD, FACS
    I would like to acknowledge my parents, Edward and Narge Steinbrech, and my entire family for their unflinching support over the years of my schooling and training.
    I also must pay tribute to mentors influential in my academic development: Dr. Frank C. Spencer, NYU, Chief Emeritus of the Department of General Surgery, Dr. Steven A. Rosenberg, Chief of the Surgery Branch of the National Cancer Institute at the National Institutes of Health, and Dr. Michael T. Longaker. They have all supported and inspired me throughout my training and research.
    Also, I have to thank Dr. Joseph G. McCarthy, my Chief at the NYU Institute of Reconstructive Plastic Surgery, who embodies the true spirit of the academic leader and has always said, “for a surgeon: research and writing only happens at night and on weekends.” Once again, he was correct.
    I am deeply grateful to Mr. Jeffrey W. Sharp and Dr. W. Rodney Sharp, whose words of encouragement have boosted this project forward from its very inception. Also, I am indebted to colleague and good friend, Dr. Pierre B. Saadeh, who must be given credit for being particularly instrumental in the genesis of this textbook.
    And, of course, special thanks are due to the indefatigable Dr. Sherrell J. Aston, whose talent may only be equalled by his sheer drive, and who didn’t need to edit another textbook, but took on this challenge with unbridled enthusiasm and stalwart dedication.

    Douglas S. Steinbrech, MD, FACS
    I would like to acknowledge my mentors who have helped me to become the surgeon that I am today. To Dr. Linda Phillips, who has served as a role model and mentor for me for the past twelve years; someone who makes being the chairman of the American Board of Plastic Surgery, dean of the medical school, chief of plastic surgery, and mother of four children look easy.
    And finally, Dr. Sherrell Aston, my senior associate and co-editor of this textbook; he is a gifted surgeon who has been an unwavering source of support and inspiration in my fellowship and private practice of aesthetic plastic surgery in New York. I would not be here today were it not for these people.

    Jennifer L. Walden, MD, FACS
    *******General Acknowledgement**********
    Dr. Aston, Steinbrech, and Walden would also like to thank all of the authors of this textbook for devoting hundreds of hours toward the preparation of their chapters. The quality of this textbook is directly related to their experienced insight and hard work.
    Section 1
    Office organization
    CHAPTER 1 Office practice of plastic surgery

    Gustavo A. Colon

    Part 1: Introduction of the practice needs

    Initial steps
    Before establishing a practice, you have to decide where it is that you want to live. However, deciding on an urban, suburban, or rural area may be somewhat difficult. The first thing that one has to evaluate is the number of plastic surgeons who are practicing within the community. It would be very difficult to establish yourself in an area where there are multiple plastic surgeons who already have appropriate referral sources, and it is best to look for a community in which there is a definite need for a plastic surgeon, either with a group or in solo practice or even in academic medicine.

    The location
    Before you finish training, you should investigate the area in which you are interested. Look at demographics, population growths, median incomes, growth of the city and/or community, and evaluate the statistics of the metropolitan areas, particularly where there is the greatest density of plastic surgeons. Speak to plastic surgeons in the community to get their opinions, concepts and ideas, which sometimes may be negative since they may not welcome a new, young, well-trained plastic surgeon. Our sources for potential practice locales are the American Medical Association, which offers a market area profile (MAPS) that includes information about community demographics, or the local Chamber of Commerce in the area in which you are considering relocating. The hospitals in the area can be of great assistance in getting and interpreting whatever data you may need, for example, hospitals will tell you the number of plastic surgeons on staff, then you can evaluate which plastic surgeons are servicing that health community, what the referral sources are and whether there is a need for a younger plastic surgeon.

    The practice
    The next decision you have to make is the type of practice that you would like to join, a multi-specialty group with a large number of different types of specialties, i.e. a Mayo Clinic or Cleveland Clinic type of setup, a group practice of plastic surgeons practicing together. Alternatively, you may share space with another plastic surgeon, to help him or her decrease their overheads and at the same time have full advantage of their established plastic surgical staff. You may prefer an academic position, in a teaching institution or a sponsored or salaried position in a hospital that allows you a private practice, but where you are dependent upon referrals from and to that specific entity. Finally, there is the independent model or solo practice.
    Let’s talk primarily about solo or group practices. Group practices, of course, provide economic security and a source of patients. All usually include built-in coverage for vacations and weekends, hopefully a congenial atmosphere of other plastic surgeons with whom you can discuss cases with access to appropriate equipment, and opportunities to pursue the area of specialization in which you are interested. Also, by practicing in an established geographic area with an established group you have instant name recognition.
    However, group practice may be somewhat difficult because there may be frustration at the loss of autonomy, dissatisfaction with the inability to make independent decisions, conflicts with associates and difficulty with financial matters, which may not have been properly addressed during the initial interviews and contract. Other certain points need to be established prior to going into a group practice:

    • Make sure that the philosophy of the group is the same as your philosophy, not only in the ethics of practice, but also in appropriate financial sharing of costs, billing, and remuneration.
    • Meet all the doctors you are working with and make sure that there is an aura of compatibility; understand what differences and competition may exist within the practice.
    • Speak to the youngest plastic surgeon or the last one who joined the group because they will be able to tell you what their frustrations and/or benefits are of being in a group practice.
    • Check the reputation of the group practice within the community, that the practice is viable, growing and that it does need another plastic surgeon.
    • Make sure that your spouse or significant other will be compatible with the spouses or significant others of the group. If the spouses are working in the same group practice, make sure that they will not be the controllers of your practice, otherwise this may cause a difficult professional and social situation.
    • All written contracts should be reviewed by an attorney and/or consultant who is looking after your benefit, not theirs. Never start work without a written contract, have it reviewed, make sure that it fits your philosophy of practice and that it is beneficial to both parties; it must be a win–win situation.

    Advisors
    You must have advisors to help you manage a successful practice. First of all you need to have an accountant or a CPA who will handle all your financial needs, help you set up initial office accounting systems and handle tax matters, prepare monthly income and expense statements and counsel you on investments. You will need an attorney who will review all your contracts, a banker who will loan or give you the credit line to start out initially, an insurance broker for liability needs and a real-estate broker to find you a new home or help you locate an office if you are going into solo practice. Perhaps ultimately you might need a management consultant to evaluate and manage your practice, but not initially. Management consultants usually come in after an established practice needs tweaking or perhaps some rearranging.

    Solo practice
    If you are starting out in an independent practice, you will need to obtain the appropriate state occupational licenses and you really need to apply early for privileges at the specific hospitals where you wish to practice. Once you have decided on the community in which you wish to practice, you need to look for office space. You have to decide whether you want to purchase or lease. Initially I think it is easier to lease than to purchase, to avoid excessive overheads. Find a house in a community which you think would be adequate for your family; your spouse and your children will follow you wherever you go, but choose a community which will be adaptable and comfortable for them.
    Once you decide on the area in which you wish to practice, you will have to begin to draw up an income and expenditure projection so that you can borrow the monies that you will need to start a practice and use as income for the initial months. Apply to the appropriate managed care programs and/or insurances which service the community, arrange for your liability, office insurance, office overhead, office liability, business interruption insurance, employee fidelity bonds, major medical insurance for you and your employees, disability, life and ultimately automobile insurance. Acquire an answering service, get a beeper, cell phone, print business cards and announcements, and arrange for accepting credit cards within your practice. From a social, professional standpoint, you need to meet referring physicians and interview prospective janitorial services and office personnel. Study your CPT codes and use appropriate billing of your services for the area.

    Office space
    There are certain rules for finding and designing your office space. You have to maintain privacy according to the HIPPA regulations. There has to be absolute privacy for the patients coming into your office. The waiting room has to be comfortable, and sizable to allow patients to sit comfortably. The secretarial staff should have an appropriate view of the waiting room to be able to welcome the patients, as well as keep an eye out as to what is going on in the waiting area. They should also be able to prevent any undue occurrences or pilfering of the material and/or furniture in the waiting area. Remember, the waiting room is the first contact that the patient has with your office. Your décor should make the statement that you want to make in your practice. Use the décor that is appropriate for your practice and which reflects you. Exam rooms should be practical, clinical, usable and comfortable for both the doctor and the patient. Please remember that first impressions are made in seven seconds, and you don’t get a second chance so the first impression of your office should be one that gives them a sense of trust.
    Supplies and equipment are something that will be difficult to evaluate. I think that all of us need to purchase the appropriate supplies for office management. You do not need to buy every piece of equipment that you see at a meeting or exhibit, but have appropriate equipment to handle any type of emergency. I would recommend that every office have an emergency CPR kit, computerize your office early. It is much easier to run a practice with computers. There are enough computer programs which are directed specifically to plastic surgery to make your life and that of your staff very easy, and in some instances paperless.

    Budget
    How much money do you need to establish a practice? Once again, it depends on your personal style, how extravagant do you want to be and how much you want to spend in your practice; middle of the road is always the best approach. As previously stated, you need to borrow money in order to support yourself for several months, so you have to establish a credit line and relationship with a bank. Will you get a better deal because you are a doctor? The answer is “no”. In the past, doctors were favored banking customers and could get loans at low interest with real flexible terms. I do not think that is the case at the present time. You will get a credit line knowing full well that the bank hopes that you will be a long-term customer. When borrowing money, certain things are required: past tax returns, a pro forma, which is a statement that projects the sources of income for the immediate future and that you will have an income to repay this loan over a period of time. At the same time, it will project your fees for expected surgical procedures, and the amount of income you expect to have over the next several months. They will also ask you for your estimated expenses, a financial statement and so bear in mind the five Cs which a bank will require: collateral for the loan, your capacity to pay the loan, capital that you have available, your character and any conditions for the loan.

    Summary
    Once you have established a practice and have opened your office, initially it is better that you keep it small if you are in solo practice. At the same time, if you are in a group practice it might be better to maintain a low professional profile rather than trying to go out and “corner the market” because this may create antagonism among your older colleagues who think you are nothing but a young upstart without experience, and they may not back you in difficult situations. Keep your staff small, good, reliable and make sure that they follow your principles and philosophy of practice. As far as your equipment is concerned, buy what you need, keep your office open at appropriate hours and be available.
    There are three things that make a doctor successful: ability, affordability, but above all availability. However, make sure that you charge patients for your services. Bill promptly; remember cheaper is not better. Do not practice to make money, just be a good physician and appropriate financial remunerations will follow. Do not commit fraud, do not lie to insurance companies, be honest about who you are and what you do and in your billing, and you will have a long successful practice. Do not do unnecessary surgery. Be honest to your patients and yourself, particularly when you are beginning; say that you are still learning but that you are a well-trained surgeon and that you can handle the complexities of any surgical procedure for which you were trained. Read and understand all managed care contracts. Do not negotiate with your patients and remember that maintaining a practice is dependent upon three things: reputation, reputation and reputation. Maintenance of the practice will depend on physician referrals, patient referrals, area of specialization, good results and constant monitoring. Do not create gimmicks to attract patients; do your job well enough to be an expert and the patients will come.

    The staff

    Employee empowerment
    Your staff should generate enthusiasm, teamwork and pride in their work, but with responsibility to you and your structured organization. The patient will choose you for surgery if you can accommodate them surgically and financially, and if they like you and your staff. Your staff must meet the patient’s needs by customization and individualization of care and services. The staff should follow this simple creed:

    1. Do the little things right.
    2. Go the extra mile.
    3. Always exceed the customer’s expectations.
    The aim of your staff is to encourage prospective patients to convert from might to want to will, and to create a service that will expand your market share. Therefore, when trying to bring a new plastic surgical service to the community, the goal is market expansion and revenue increase.

    Business development of plastic surgical services
    You need to use business tactics to accomplish the expansion objectives by:

    1. Developing a new product or service (plastic surgery).
    2. Raising or lowering prices to make financing more available.
    3. Creating a new promotion with advertising or internal marketing.
    4. Establishing a definite public relations effort through your staff.
    5. Developing new channels of distribution through your own patient population or other services (i.e. skincare line of products).
    6. Establishing plans and timelines to evaluate and track the service.
    Hence you have to develop a situation analysis in which you:

    • Analyze market trends and the needs of the service being introduced.
    • Determine the domestic, local, and international needs of the service.
    • Study the implications of new trends. (Is this something that is going to last or is it something that is going to come and go?)
    • Weigh the financial opportunities for this product or service. (Is it a product or service that only you are going to deliver or is the product or service so available that it is diluted?)
    • Evaluate the competition. What are they doing and how are they marketing?
    • Determine the risks of your endeavor.
    The service has to be visible, be convenient, and it must have a simple organizational layout with friendly and professional assistance. It must be priced fairly, be consistent and constant. Remember that in plastic surgery it is not a product that you are selling, it is a biological technical service, which is not returnable and not guaranteed with many variables. Besides product, the other three “Ps” of plastic surgery are:

    • Positioning, which is dependent on your reputation.
    • Price has never been a factor, because the consumer may equate expensive with better and cheaper with inexperience.
    • Promotion is the only element that can be used to expose the public to plastic surgery. Maintaining a practice depends on three things: reputation, reputation and reputation.
    So, be caring, concerned and available at all times for your patients. You want to be the plastic surgeon who will be in your prospective patient’s mind when and if they change the might to want to will. It takes about ten years to establish a good elective type practice, but it is good results and reputation that keep you established.

    Tips for a successful practice

    1. All patients should be appropriately billed; patients should know exactly what kind of service they are getting even if the service is free. When you do not charge, give the patient a bill with the appropriate discount so that they know how much you have discounted or not charged for the operative procedure.
    2. Treat patients very well and be their confidant and trustful physician, but do not make patients friends; maintain a social distance from your patient population. This does not mean that your friends cannot be patients, but do not try to socialize within your patient population.
    3. Patients will sue you for three things: because they do not like you, they do not like the bill and they do not like the surgery, or a combination of all three. So do not be surprised; it happens to all of us, just document accordingly.
    4. Do not fool around with patients, you can lose your license and it certainly is not appropriate ethically or morally.
    5. The office is like a confessional; nothing is ever discussed outside the office by you or your staff.
    6. Your specialty is plastic and reconstructive surgery, not cosmetic surgery, which is just part of our specialty.
    7. Don’t take yourself too seriously. Do not let life pass you by. Nobody is indispensable and plastic surgery is what you do for a living; it is not what you live for.

    Style, substance and communication
    What really attracts and maintains patients in your practice may not only be your surgical expertise, but your ability to communicate. So when you communicate, you have to project likeability, integrity, competence and sincerity. In other words, the patient has to like you to ultimately trust you for surgery.
    Improve your communication skills by the following:

    1. Listen to the patient, attentively.
    2. Make eye contact with the patient and sit down, be at their eye level to speak to them.
    3. Be positive in how you talk, but always speak the truth. Do not get defensive; once you get defensive with a patient, whether it is preoperative or postoperative, you are going to get into the guilt, hostility, arrogance cycle.
    4. Give useful information, be honest, concise, positive, truthful, reliable, memorable but factual and keep it simple.
    5. Your demeanor should be pleasant and sincere; smile appropriately and genuinely with patients.
    6. Have a friendly, open face, no frown or distant stare.
    7. Be interested in what the patient’s problem is. You should absolutely give them your full attention. Do not be in a rush to leave. Make them feel that in the few minutes that you are there, you have no other interests.
    8. Your body language should be cordial with appropriate gestures. In consultations, sit, touch the patient with professional concern, always make the effort to make contact with the patient physically as well as emotionally and mentally.
    9. Dress neatly and always talk calmly to the patient, in a warm distinct, deliberate tone with normal pitch and rate, using understandable language. Never be condescending or arrogant; remember communication is an intellectual act of love.

    Part 2: Marketing and practice enhancement

    How I market an aesthetic practice
    Marketing may enhance your practice, but it is reputation that makes the difference. In managing my practice, one of the things that I put first is my personal family life. I try always to remember that plastic surgery is a profession, not a lifestyle, and that you have to put things in perspective with definite priorities. At the same time, you have to be yourself and not try to imitate or be any other plastic surgeon. The priorities are basically simple: if you are satisfied professionally, growing and financially stable, doing what you like to do, why change?
    Several years ago, I began to evaluate my practice, how it had grown, and to look at the external factors and inherent factors that had pushed my practice to the point where I was. I found several things. I found out from questionnaires and focus groups among the patients and staff that I was a personable, caring physician, and a known factor in the plastic surgical community with a reputation, but that I was a bit quick with patients and seemed to have too many other things on my mind, and that I really needed to spend more time with the patients. Therefore, I began to formulate my practice into a much more patient-oriented centre, so that patients could obtain more information about aesthetic plastic surgery, not just from me, but from my staff. I hired a patient coordinator and began to evaluate the patient and track the results. We investigated why patients were scheduling, and the numbers of patients that were scheduled versus the number of new patients who were being seen. We began to instruct the patients during the initial consultation for a longer period of time, giving them a lot more information with videotapes, brochures, etc., and we began to evaluate the practice on a quarterly basis.
    All these things have put the practice into more focus so that it is more business-like, efficient and better organized. My philosophy was never planned. It just evolved over the years as an extension of my personal principles:

    My philosophy

    1. To identify my personal professional goals and to continue at a productive level.
    2. To emphasize the positive aspects of the practice.
    3. To realize my limitations and be happy in what you are and what you have achieved and try to plan for the future.
    4. To remember “ain’t nobody indispensable.”
    The following section integrates my personal concepts and philosophies for creating a continuous and successful plastic surgical practice.

    Why do patients come to you?
    Primarily they come because you are new and available. You are new in private practice and patients may feel that they can get a better financial deal, not because of your expertise. However, your surgical services are judged on the same standards of care of any other plastic surgeon, not only in your community, but nationwide.

    • Referrals. These usually come from physicians, patients, family, friends and staff, but they mostly come without much knowledge of plastic surgery or you. So make patients feel comfortable with you and trust you.
    • Do not sell surgery. The patient comes to you for one procedure, but don’t suggest that they have another operative procedure simply because you need experience. Occasionally, two operative procedures may go together such as a chin implant and a rhinoplasty, or rather than having a breast augmentation, the patient may need to have a mastopexy; but do not sell an operative procedure that they are not seeking. Patients need to feel that you are honest, sincere, truthful and dependable.
    • Be honest as to who you are. You are new in practice but well trained, available and competent.
    • When seeing another doctor’s patient: Do not accept a patient from another physician without calling him first and finding out the other side of the story. It is important to understand that what one patient tells you about another doctor may not be the entire truth.

    The initial consultation
    Cosmetic patients are nervous, guilty and feel sometimes that they are taking up your time in asking for silly elective procedures when you could be doing more “important” surgery. Patients are usually out of their element when they talk to you. The first consultation with a plastic surgeon is always the most difficult one. Put them at their ease.

    • Introduce yourself honestly, who you are and what you are. Address the patient with simplicity but respect.
    • Tell them of your experience or inexperience with surgery. If you are dishonest, it will come back to haunt you. If it is the first time that you are doing an operation, tell the patient it is the first time that you are doing such an operative procedure, but then tell them that you are a trained surgeon and this is a surgical procedure that should not be difficult to do, or that somebody will be there who has more experience to help you.
    • Never say don’t worry, because they are always worried and anxious. Just talk honestly and reassure the patient.
    • Never say everything will be okay, because it may not be and it may not turn out to be perfect.
    • Examine the patient thoroughly and vocalize all of your findings to them.
    • Explain your surgical plan to them and tell them it is only a plan, not a blueprint and that things can change during the operation.
    • Inform the patient thoroughly and honestly of common complications and problems that can occur, and even discuss complications that are not common.
    • In this day and age, it is important to be absolutely thorough in your discussion with the patient.
    • Do not get talked into or do surgeries that are not necessary.
    • Do not say money is not an object, because to them it may be. If things go wrong, it is what they are going to sue you for, money.
    • Do not sell or talk surgery in social situations. Discourage off-the-cuff consultations.
    First impressions:

    • They are made in seven seconds.
    • Your whole practice and you will be evaluated by the patient in how and what you say, what your staff says, and how they and you are perceived by them.
    • Good service leaves permanent good impressions and maintains a reputation.

    Patient characteristics

    • The driver. With these patients, it’s a quick consultation and a quick decision. They do not have time to be there for a long period of time. They want something done right away and a decision is made quickly. That patient will usually decide not to have the surgery as quickly as they make the decision to have the surgery. It is important that you spend some time with these patients and evaluate them. This type of patient is usually the high driving executive or the society matron who really does not have much time to spend with you. You are just another service person to them.
    • The talker. This patient comes in and takes time and wants multiple consults during the initial consultation. They usually have ten single-spaced typewritten pages of questions to discuss with you. You have to evaluate these patients immediately as to what their needs are and spend some time with them, making sure that they are realistic in their expectations, within a reasonable consultative period.
    • The planner. This one has his or her operation planned, and usually has decided how they want to have the surgery or what they don’t want to have in their surgery. They want to see if you and the surgery fit into their plan.
    • The thinker. One who asks few questions, wants you to make decisions and doesn’t talk much during the consultation. They have been thinking about the surgery and now want to think about you and consider what you have to say. This is the patient who will say, “You are the doctor; you tell me what I need!”
    • The shopper. Has seen other plastic surgeons and is comparing price, staff surgical availability, etc. Be yourself and don’t compete with other surgeons. Treat them with caution but without great expectations.

    Handling the patient postop
    Remember, it’s not over till it’s over. Patients are yours forever when you’re in practice. You never go off the service. If you lose a patient or they go some place else, you lost because that’s an unhappy patient.
    Postoperative handling of a patient is as technically important as the surgery. If there is a complication or problem, reassure the patient that “you and she/he will get through it together.”

    Things to do

    1. You change the dressings, you remove the sutures, or be there when somebody in your staff is going to do it, or explain to the patient why you won’t be there. Make sure that the patient sees you and feels that you are as concerned about their postoperative treatment as you were about getting them to the operating room.
    2. See the patient frequently whether they need it or not. They really need reassurance in the postoperative period, because many of them will get a postoperative depression.
    3. Be supportive of any patient. Answer their questions honestly, quickly and thoroughly. Many of them are undergoing a surgical procedure for the first time, and while for you it may be a routine postoperative situation, for them it is not.
    4. Be honest. If you see a problem, explain to the patient what it is. Tell them if there is a problem or complication, and explain your proposed plan of action. Remember, “just a little swelling” can get you just so far. Don’t blame a complication on a patient. Most problems that result between doctors and patients could have been resolved during the postoperative period. This is a golden period. They can love you or hate you in the immediate postoperative period.

    The difficult and unhappy patient
    Patients may be one of the following:

    • The demanding patient. I want the surgery when I want it and how I want it. That’s what I’m paying you for, and if you don’t do it the way I want you to do it, I won’t pay you.
    • The apologetic patient. This is a patient who comes in apologizing all the time for bothering you, apologizing for wasting your time when you have so many other important patients to see and sick patients to take care of. This is a patient who needs hand-holding. They need reassurance because they are very insecure about their situation and if you let them down, they may get paranoid.
    • The flirtatious patient is a patient who says, “Oh, I’ve heard so much about you. You’re the most wonderful doctor in the world,” but usually is shopping around for a reduced fee.
    • The hostile patient. “I’m not happy with my surgery.” “I’m not happy with you or your bill.” Your staff will tell you about the hostile patient, because they will have been extremely hostile to the staff a few visits before they get hostile with you.
    • The angry patient is a patient who is not happy with surgery. “I am not going to pay you.” “If you try to bill me, I will sue you.” Usually somebody has told them that the surgery was inappropriate and poorly done.
    • The negotiating patient is the patient who comes in and says, “I have a lot of friends waiting to have surgery. They want to see how I turn out. Couldn’t you please give me a discount?” Do not negotiate; make your fee appropriate for your services.
    • The fraudulent patient is the one who says, “Couldn’t we just call it something else and see if my insurance will pay for it?”

    Dealing with complications
    Complications happen.

    1. Try to identify the high-risk patient surgically and emotionally.
    2. Deformity vs. concern in a patient. If the concern is so much greater than the deformity or if the deformity is so much greater than the concern, you have a loaded situation and these patients need to have a reality check. You need to sit down and talk to them about exactly how they feel about themselves and how they see themselves and their self-images. They may have BDS (body dysmorphic syndrome).
    3. The multi-surgeon or multiple surgery patient. This is a very difficult patient. The patient has had multiple operative procedures and has visited multiple other surgeons. It is imperative that you speak to each of the surgeons who have operated on these patients, get their operative reports, and never accept a patient who won’t let you talk to the doctor (with appropriate consent) who operated on them beforehand. There are two sides to every story and that doctor may just very well tell you what you need to know, so that you don’t take this patient on as a problem case. You never want to be the last of a long list of problem surgeries.
    4. If a patient has a real or imagined surgical problem, it is important for you to be there for them. You must be their anchor. You must be their rock and make them realize that the problem is minimal and does not require surgery. Otherwise, they are going to go someplace else. Be supportive, positive, but honest.
    5. Talk to the family and patient and be careful how you phrase things. Also, when you speak to anybody other than the patient, make sure you have the patient’s permission. If you don’t, you may be violating the confidentiality of the doctor/patient relationship.
    6. Deal with the patient’s problems, not with your anxieties or fears. All complications get resolved. What doesn’t get resolved is your attitude toward them.


    Avoid the guilt/hostility/arrogance/counter hostility cycle!
    If you get into this cycle with a patient, you have really lost the game with them, because the patient will make you feel guilty, then you’ll feel hostile to the way they are reacting to their problem, and you are going to get arrogant with this patient and stop answering their phone calls. Ultimately you are going to get counter hostility from the patient towards you, and this generally creates a litigious situation.

    Effective internal marketing techniques for plastic surgery
    Plastic surgery is one of the most visual and media expectant specialties in medicine today. Credibility in plastic surgery is tenuous and difficult to achieve, even without marketing, but with the amount of external marketing that we see today, it is even more difficult to maintain any degree of professionalism within the medical community.
    Let us explore the acceptable internal marketing techniques that can be used effectively to promote plastic surgery, and even look at the methods that have been ineffective, counterproductive and cost prohibitive. The best marketing strategy for a plastic surgeon is to maintain patient loyalty and patient awareness in the specialty of plastic surgery.

    General overview
    Plastic surgery, unlike many other specialties, is enjoying an increasing growth and demand for services. Since the 1970s to the present, there has been a huge increase in plastic surgeries nationally; however, the increased competition from many other specialists who also do plastic surgery is increasing at an alarming rate. We compete for the upscale young, middle-aged men and women with discretionary income who are willing to pay for elective plastic surgical procedures.

    The faces of competition
    The competition, particularly in aesthetic surgery, is increasing. There is an increasing amount of marketing for plastic surgical patients from “marketeers”, hospitals and so-called “cosmetic surgery centers”. They all use media marketing and distribute patients among provider participants. However this high-profile marketing, which is supposed to attract patients with high to middle incomes for elective procedures, may not be as profitable because of the high cost of promotion and since the procedures are not paid for by third-party payers. So, there are large out of pocket costs to the patient, generating high fees, but necessary low reimbursements to outpatient facilities.
    The many “marketing programs” that attempt to generate patients for select plastic surgeons or “cosmetic surgeons” through generic marketing efforts, have diluted the quality of plastic surgery and perhaps put in jeopardy the quality of surgeons who may be marketing with a corporate entity.

    What is marketing?
    Marketing and advertising are not interchangeable terms. Marketing is a process of learning who your customers are, what they need, and what they want from your organization, thus allowing you to access that information (research) to make policy, service and programmatic decisions (planning), to implement new policies, services and programs. Then feedback is requested (testing, tracking) to let your customers (patients) know that you have responded to their needs and concerns (communications). Customer satisfaction is the ultimate goal of any marketing program. Marketing is the soul of commerce. It is a fundamental principle of commercial activity and has become a recognized modality in the health care delivery system in the United States.

    Definition of terms in marketing
    Basically, marketing is an activity which places the producer (physician) of a product (medical service, surgical or otherwise) into a mutually beneficial relationship with the potential customer (patient) of that product. The concept of marketing traditionally addresses the four Ps:

    1. The product or service, which is to be sold.
    2. The positioning of the produce in the marketplace.
    3. The price or cost of the product or service.
    4. The promotion of the product.
    We are going to concern ourselves with the last element, the appropriate, ethical, and financially efficient way of promoting our products, which are plastic surgical services.

    External marketing and advertising
    Because advertising combines creativity with marketing strategy, it does hopefully attempt to gain the best results for one’s dollar. Paid advertising, of course, allows one to control the timely placement of message and message content, and hopefully with careful planning and exposure, to create widespread awareness and ultimately increase patient flow into a physician’s office. With a good advertising campaign, a plastic surgeon can accomplish a successful public relations program that will create awareness, educate, be of generate interest, and hopefully enhance reputation.
    Unfortunately, such a creative advertising and marketing program from an external approach does cost a lot of money. This does not work as well as medical marketing companies would lead us to believe. Plastic surgeons who have approached their marketing strategies by heavy media advertising have found that it almost becomes cost prohibitive and that the dollar return may not ultimately generate the expected bottom line. While public advertising may be a part of a general marketing program, it certainly cannot be the only means of attracting patients who we wish to have in our practice. The question is, is it easier for a plastic surgeon to attract prospective patients by advertising only, or is it more effective to attract and retain new patients from one’s own practice and physician referrals by using other marketing techniques?

    Internal marketing
    The cost of promotion to bring in new patients to the practice can be significantly diminished if internal marketing programs are in place and effectively used. Very simply put, what one does is deputize patients, friends, relatives, and hopefully physicians to refer to your practice. It is important, therefore, in internal marketing to have a large or growing base of patients who will be interested in elective plastic surgical procedures, and at the same time approach groups outside your immediate practice circle through some effective cost-efficient external marketing techniques other than mass media advertising.
    Therefore, you must evaluate your practice:

    • Find out if your practice is enjoying a fair market share of existing patients.
    • Identify the most promising potential consumers of elective plastic surgical services for your practice and hopefully create new market sectors where patients can be tapped (aesthetic surgery, pediatric plastic surgery outpatient facility, skin care, etc.).
    • Are there new operative procedures that you can learn and put into practice so that your practice has an ever-expanding armamentarium of procedures for your patient population (microsurgery, craniofacial surgery, hand surgery)?
    The basic steps of developing a plan and strategy are:

    • Scrutinize your practice.
    • Find out what are its strengths and its weaknesses.
    • Define the service that you are providing.
    • Find who else you could employ to provide them.
    • Keep track of your competition and find out what they do right, what they do wrong, who they are, and why you are better or worse.
    Examine what promotional efforts you have had in the past. If you have not had any, then begin to develop some within your practice. You have to create a program that will enhance your image as an ethical, professional plastic surgeon and maintain a professional atmosphere that patients will be attracted to. The bottom line is that you have to be able to produce and the product is good results in plastic surgery. You can package your image any way that you want, but if you cannot produce a final result of good ethical quality plastic surgery, you will not survive, no matter how much marketing you create. Remember, reputation is the key.

    Things that you can do immediately to improve your practice

    Well-trained staff
    The best internal marketing tool is a well-trained staff. The staff person who answers your phone makes the first impression with prospective patients. As obvious as this seems, I have noticed that many doctors are probably not aware of how their phone is being answered. Patients should feel, from the very first phone call that their needs are your most important concern. They should also perceive that your appointment schedule and other aspects of your office management are handled in a highly efficient manner. These impressions can be easily conveyed if the person answering the phone uses appropriate language and a bright pleasant tone of voice. I advise against using an answering service or machine during normal business hours, including lunchtime; however, if you do, make sure that the service is coached in the proper way to handle your calls and that they identify your office and do not just say, “Doctor’s office.” Have a human being answer the phone, not a machine.

    Initial office visit
    The next step in creating a positive impression is the initial office visit. Office décor should be consistent with your practice and comfortably appealing. Avoid ostentatiousness as this may very well have a negative psychological effect on patients who may automatically assume they cannot afford you.

    Flow of patients
    The flow of patients in the office should be smooth; try to keep appointments with prospective patients comfortably separate from postop patients. We have all had those occasional patients who want to argue over fees or make other complaints; as minor as they may be, they are surely disconcerting to new patients. Remember, the patients want their doctor’s office to be well organized for psychological reasons as well as practical ones. After all, if a doctor’s office is chaotic, might not his operating room be similarly haphazard? You do not want such thoughts ever to enter a patient’s mind.
    Probably the best thing that I have done in my practice is to hire a patient coordinator. Typically, the patient coordinator will meet with the patient, either before or after his/her appointment. She will show the patient any videos, photos or computer images relative to the procedure of interest, discuss the patient’s history, expectations and answer questions, and put the patient at ease. It also helps the doctor compile a more complete profile of the patient than would be possible through a typically time-constrained consultation. Remember, it is vital that all staff members who deal with the patients are consistent in their approach; be sure you adequately prepare them through a comprehensive staff training program. You always want your staff to express your philosophy, plans and procedures, not their own personal ideas.

    Small touches
    Small touches are important. No patient ever visits our office without receiving a thank you note mailed out the next day. We also make a point of sending thank you’s to referring patients and physicians. Keep in touch with past patients, even if it is only a once-a-year mailing of a newsletter, practice brochure or patient questionnaire. People enjoy receiving information on new techniques in aesthetic surgery or being updated on changes within your practice. If you send out any kind of literature, invest the time and money to make the piece attractive. A poorly designed newsletter or brochure will not achieve positive results for your practice.
    Track patients through a computer system to make periodic mailings a relatively easy task. On a monthly basis, track potential surgical patients against new patients seen in consultation. At least once or twice a year compile and check this ratio. If the ratio is less than 50% of new patients actually scheduling for surgery, try to find out what is happening to the rest of your prospects. Consult your records for clues. This review is likely to suggest changes that you might make in your practice management and your personal style and/or your staff’s approach to patients. Use personal public relations rather than advertising to boost your image in the community. This will keep your promotional costs down. Offer seminars on aesthetic surgery or plan an open house in your office. Especially if you have an office surgical center, prepare your staff adequately for these kinds of professional or social interactions in or outside of your office.

    Personal contact
    In any patient contact, be personal. Show the patient through eye contact and brief touch that he or she has your respect. Jot down in your notes personal items, which the patient mentions such as a new job, an upcoming vacation, the wedding of a son or a daughter, etc. The next time you see your patient, ask her how the new job is or how the vacation to Bermuda went. The patient will be amazed at your memory and such inquiries will help convey genuine interest and maintain your concern in the patient. It is that kind of friendly professionalism which earns trust and shows that you are a caring physician.

    Happy and informed
    Remember, your most receptive audience are your patients. Keep them happy and informed. Remember, a happy patient, on average, will tell three or four other prospective patients about you, but an unhappy patient will spread the bad news to 20 or more patients. Remember, a professional, ethical reputation is the key.

    Steps in creating an internal marketing program

    Introduction
    In structuring practice enhancement, you must:

    1. Evaluate the needs of your practice.
    2. Plan a budget.
    3. Look critically at your practice.
    4. Look outside your practice.
    5. Plan and outline a program that fits you personally.
    Let’s look at these areas individually:

    1. Evaluate your practice

    A. Are you satisfied?
    B. Are you financially viable?
    C. Do you have a good patient mix?
    D. Are you growing?
    E. Where do you want to go with your practice?
    If the answer is “yes” to A–D then you need to go no further, but if the answer is “no” to any of them, then you need to proceed with a customized marketing program that fits your personal image.

    2. Plan a budget

    A. 10–15% of revenue to start.
    B. 5–7% of revenue to expand.
    C. 7–10% of revenue for new ventures.
    D. 3–5% of revenue to continue as you are after you have established a program.
    These percentages are estimates; budget what you can afford.

    3. Look at your practice

    A. Who are your patients?
    B. Who are your referrals?
    C. How good is your staff?
    D. What is your image?
    This is a real test of your ability to assess your present practice honestly, so that you can address the areas in your office that need tweaking.

    4. Look outside your practice

    A. Who is your competition?
    B. How is your location?
    C. Do you need to promote yourself?
    D. How does your practice measure up to others in your community?
    The bottom line of structuring is a practice enhancement program; after you have established such a program it is important that you evaluate and track your practice’s finances on a quarterly basis. You should only commit the monies that you can spare into any program. It takes at least 6–12 months to see any results of any marketing program. The results are never direct, but will show up in the number of patients that you see, the turnover of new patients to surgeries and obviously your profit and loss statement. Remember, you can do it yourself with minimal outside help. You know your practice better and plastic surgery better than anybody else. Just take the time to look at your practice. Remember that advertising is like a drug habit; once you start, you cannot stop it because that may be your source of new patients. And finally, do not let your overheads bury you!

    Strategic plan

    Introduction
    A strategic plan is nothing more than future plans based on progressive ideas solidly backed by concrete facts and concepts. Remember, while one cannot predict the future, all new concepts and ideas come from somebody’s dream of what he/she would like to do or be. We have to see where we are today, where we want to go and where we would like to be realistically in the future. Hopefully, with organized planning, we will take all the right steps and do all the right things to achieve the proposed concepts.
    But to achieve a strategic plan, one has to sit down and formulate an overall concept, and certain questions need to be answered before formulating a plan.


    Questions

    1. What do you want to do? (MISSION).
    2. What are you today? (CURRENT STATE).
    3. What do you want to be? (VISION/FUTURE STATE).
    4. What do you have to do? (AREAS OF FOCUS).
    5. How do you get there? (STRATEGIES).
    6. How will you know when you are doing these things well? (TRACKING).
    Then create a stepwise overview project to organize the steps in putting any program into effect.

    Overview

    Step I: Project organization. (Decide where you want to go with your practice.)
    Step II: Information collection.
    Step III: Situational assessment. (What do you need to change to achieve these goals?)
    Step IV: Strategy development. (Develop a place with some professional assistance if needed.)
    Step V: Implementation. (Implement a reasonable approach which fits you.)

    Different plans for implementation

    Phase I

    1. Evaluate your practice.
    2. Evaluate your patient population.
    3. Evaluate your surgical mix.
    4. Create identifying images (logo).
    5. Streamline your office patient care.
    6. Discuss your new patient approach with staff.
    7. Develop brochures or use them more efficiently.
    8. Develop a newsletter. (May not give direct results and is very expensive and occasionally overdone.)
    9. Develop patient acknowledgment letters, cards and thank you notes.
    10. Develop patient follow-up letters.
    11. Develop representative programs for plastic surgery to prospective patient groups in or outside your office complex.
    12. Directory advertising. (Is just another yellow paper ad – unless you are first, e.g. AAAA Plastic Surgery.)
    13. Patient coordinator program in office.
    14. Use hospital marketing director to market plastic surgery.
    15. Direct media advertising.
    16. Tracking system for patients.
    17. Evaluate the costs of any program versus the bottom line.
    18. Abandon any program if results do not justify the expense.

    Phase II

    1. Paper trail of informational booklets, i.e. pre and postoperative instructions on all procedures.
    2. Personalized all-purpose book on plastic or aesthetic surgery.
    3. Elegant, stylish brochure about your practice.
    4. Personalized videotapes of procedures.
    5. Personalized informed consent and brochures.
    6. Website (important).
    7. Office surgery.
    8. A postoperative extended care facility.

    Phase III

    1. Open house for patients, public and physicians.
    2. Contracts with managed care programs (HMOs, PPOs, etc.).
    3. Financing for non-covered surgical services.
    4. To referral sources offer more than a letter of thank you or a Christmas present:
    a. to patients; offer discounts
    b. to doctors; offer discount to their patients and/or free consultations.
    5. Gifts to patients, i.e. flowers, scrub shirts, scarf, pocket calendar, cosmetics, etc.
    6. Amenities: facials, body massages, a day of luxury.
    7. Skincare/spa or service with cosmetics with logo (creams, lotions, anti-wrinkle creams, etc. – expensive investment).

    Conclusion
    Marketing is like a tree. It must be planted, allowed to take root, to grow and to leaf out before you can expect it to bear fruit. Before you begin any marketing program, take a hard and thorough look at where you are in relation to where you want to be. Look at your life-long goals and assess your areas of strength and areas in which you need to improve, not only in your practice, but in your own personal life and find out if professional marketing is something that you can feel comfortable with, that you can live with and that will fit into your overall financial strategies. To be successful, you have to communicate effectively that you can satisfy the patient’s needs as well as your personal needs. You have to choose the types of communication that are in line with your own comfort level, and follow those activities that you feel are appropriate for you as a surgeon and as an individual.

    Further reading

    Albrecht K, Zemks R. Service American – doing business in the new economy . Homewood, IL: Dow Jones-Irwin; 1989.
    Antin HB, Antin A. Secrets from the lost art of marketing . New Orleans: The Antin Marketing Group; 1992.
    Baum N. Marketing your clinical practice. Gaithersburg, MD, 1992
    Beckaham JD. Marketing your practice – a practical guide for physicians . Arlington Heights, IL: Health Market, Inc; 1993.
    Brown S, Nelson AM, Branhesh S, Wood S. Patient satisfaction pays . GaithersburgMD: Aspen Publications; 1995.
    Brown SW, Morley AP. Marketing strategies for physicians. A guide to practice growth . Oradell, NJ: Medical Economics Books; 1996.
    Colon GA, Church JM. Office surgery – old concept modernized. J Louisiana State Med Soc . 1982;134(5):7–9.
    Colon GA. Office surgery. Current Therapy in Plastic and Reconstructive Surgery. J Louisiana State Med Soc . 1988:416–419.
    Hillestad SG, Berkowitz E. Health care marketing plans: from strategy to action. Homewood, IL: Dow Jones-Irwin.
    Jewell M, Jewell M. Practice management . Newport Beach, CA: ASAPS; 1998.
    LeBoeuf M. How to get and keep the customer for life . New York: Putnam; 1997.
    McCormack M. What they Don’t Teach Your at the Harvard Business School . New York, NY: Bantam Books; 1997.
    Naisbitt J. Megatrends – ten new directions transforming our lives . New York, NY: Warner Books; 1997.
    Nelson AM, Wood S, Brown S, Branhesh S. Improving patient satisfaction. Gaithersburg, MD: Aspen Publications.
    Office management and practice management. Chicago, IL: ASPRS, 1987.
    Poppe F. 50 Rules to keep a client happy . New York: Harper and Row; 1988.
    Portnoy S, Stromberg E, et al. Acquiring and enhancing physician’s practices . New York: American Hospital Publishing; 1993.
    Practice development for residents. Chicago, IL: ASPRS, 1992.
    Quick J. A short book on the subject of speaking. New York, NY: McGraw Hill.
    Ramirez LD, Lowder JD, Lowder BL. Practice growth through effective patient relations (proven techniques for plastic surgeons to increase cosmetic surgery) . Salt Lake City, UT: Medical Marketing Service, Inc; 1999.
    Sachs L. Do-it-yourself marketing for the professional practice. Englewood Cliffs, NJ: Prentice-Hall.
    Starr P. The social transformation of American medicine . New York, NY: Basic Books; 1985.
    CHAPTER 2 Clinical photography for the aesthetic patient

    Val Lambros
    The world is filled with forms: objects, people and other things that we look at, identify, enjoy, define, interact with, and make judgments about. When we look at these we are not seeing the things themselves, we are seeing how they interrelate with the light that they are seen in.
    The word “photography” means “light writing”. The old saying that “a picture is worth a thousand words” is simply not true; a picture contains more and different information than words could possibly express. The goal of clinical photography is to observe conditions on the body, record them and record changes that happen to them. These recordings may be made for any number of reasons, but for a plastic surgeon the usual aim is to identify pre-existing conditions, modify them and to see how the modifications worked. Pictures are invaluable in the record of patient care for both the surgeon and the patient. They are referred to on each patient visit. They may show the steps to a surgical triumph. At worst they may need to provide a defense in a court of law.
    The body exhibits highly complex curvatures and shapes. Though not perceptual psychologists, we are amazed at how selective, limited and evanescent visual memory can be. It is common in our practice to have a patient say that a certain wrinkle “just appeared”, when wrinkles typically take years to emerge. We have noticed this in our own mirror. Many patients, insisting that they know every pore on their faces, for example, will be surprised when a fairly large feature is pointed out to them. With astonishing rapidity, sometimes within days, patients forget how they used to look, after an operation. The surgeon’s visual memory is frequently not much better.
    A surgeon’s analytic focus may be on a particular structure while not noticing an adjacent area a centimeter away, and a certain structure or configuration may be present before treatment and not noticed until afterwards. This latter situation is frustrating to patient and surgeon alike as the patient is convinced that there is a “new” problem as a result of surgery. The surgeon cannot prove otherwise without a good visual record. Similarly, areas remote to the surgery may be problematic and without photos there is no good way to analyze them.
    The desiderata of clinical photography are straightforward. One must be able to see the conditions present on a print or a screen, and one must see them in the same way at some future time. The images must be consistent over time in lighting and in position. Though simple in concept these are difficult to achieve in practice.
    Digital photography has advanced quickly to become the main tool used by plastic surgeons for clinical documentation. Digital imaging is less expensive, more flexible and easier to archive than film, though backup becomes an issue. The resolution of the images continues to improve. Early in the evolution of digital photography, digital point and shoot cameras were popular; however the image quality with small zoom lenses and small image sensors left much to be desired. 1
    Plastic surgery is a professional endeavor with high standards for record keeping. We prefer the use of digital SLRs (single lens reflex cameras) which use interchangeable lenses with more sophisticated flashes. Though a detailed explanation of CCD sensors, pixel dimensions and print size, and printed dots is beyond the scope of this chapter, we would note that for practical purposes the horizontal resolution (number of pixels of width of a certain image) times the vertical resolution (same) will give the pixel size of the image, usually measured in megapixels. Most commercial printers print at 300 pixels per inch for photographic quality. Thus a camera that has a resolution of 8 megapixels will be able to print at about 8 × 10 inches. Larger prints may be made with some reduction in quality. We think that a 4–5 megapixel range is a reasonable minimum for professional applications.
    The use of digital technology allows the taking of large numbers of images with essentially no unit increase in costs. At the time of this writing memory storage costs have plummeted, thus making storage and backup much less expensive than even a few years ago. Patient images may be stored in specialized programs that provide archiving with other functions. An example is the Mirror System from Canfield Scientific.

    Lighting
    Digital photography is a continuation of traditional photography, and the rules of exposure, lighting and composition are the same as they have been for the last 170 years.
    The exploration of light, shadow, form and position has been one of the triumphs of western art. Highly talented people have devoted careers to understanding these relationships and there is a sizeable literature on photography for these ends. Unlike portraiture, where the intent is to capture a face or body in a flattering way, or to reveal an essential truth about someone or something, the goals of clinical photography are not artistic. They should be an unremittingly honest designation of what is there. It is a visual transcription. 2
    What defines facial and bodily features in the world of daily life is the light one sees them in, or more properly the interplay of light and shadows that visually defines them. Tangential light shows wrinkles, contours and shapes in a very different way than hard anterior light or soft “wrap around” light, which flatten and minimize them ( Fig. 2.1 ).

    Fig. 2.1 On the left the patient is illuminated with an on-camera detachable flash; on the right a twin umbrella set up. These are both commonly used light sources. The on-camera flash is harsher and the sides of the face are not well-exposed. The tear troughs are better visualized however. Care has been taken here to slightly underexpose the images. With overexposure both images would be unrealistically without skin shadows.
    A recurring problem in the lighting of patient images is that certain details and contours are washed out or flattened so much by the light that they are not visible. Body cellulite or certain facial wrinkles are frequently not seen in anterior (flash) light, but highly visible in everyday vertical light.
    In general skin irregularities are best seen in tangential light. Shapes such as breasts, or body contours are best seen in slightly shaded light. Different light shows different things and there is no single light that will show everything, so compromises have to be made. The more attractive a particular lighting setup make the person look, the less likely it is to show the issues of skin and shape that are of interest to patients and surgeons.

    Lighting schemes
    Many plastic surgery lighting designs have been developed. They vary from on camera flashes of different complexities to external lights in different configurations. Portrait lighting is usually asymmetrical, i.e. the sides of the face or body are lit differently for purposes of interpretation of the subject. 2 In general clinical lighting should be symmetrical. If time, space, and temperament of the surgeon allow, we like the use of small silver twin umbrellas, mounted higher than the patient’s eye level. This light is somewhat forgiving, but shows reasonable skin detail and by shifting the lights up or down one can see greater degrees of skin detail. The disadvantage of this lighting is that it casts shadows across the nasolabial fold (NLF) and tends to overexpose the tear troughs ( Fig. 2.1 ).
    However this lighting scheme is versatile and has enough spread to show body contours well. Even without a dedicated photo room, small slaved flash units with diffusers may be attached to the wall. More vertical light gives very accurate body skin rendition, and so the lights may be elevated or bounced off the ceiling to show skin irregularities for body shots. Light boxes may be used, though we find this light overly flattering. All of these light sources have been used successfully in different offices and all have adherents. The clinical examples shown here use twin umbrella lighting. 1
    The assumptions made for the purposes of this chapter are that many surgeons do not have the room and inclination to set up external lights and most will use an on-camera flash.
    We prefer the use of a separate on-camera flash. This separates flash from the lens enough to add a tangential quality to the light (the built in flash in many digital cameras is so close to the axis of the lens that the light is flattened and details in the center of the frame tend to be washed out).
    If the camera is turned vertically, the lighting will fade slightly on the side of the subject opposite the flash. This is not necessarily a problem, though detail may be lost on the darker side. When a vertical orientation of the camera and flash are used it is important to have the flash pointing from anteriorly, i.e. in an oblique or lateral view the flash should be on the side of the face that the nose is pointing to, otherwise a shadow will be cast across the face.
    A small diffuser on the flash may remove some of the harshness and contrast of this kind of light. As with all aspects of practice some experimentation is necessary. Reproducibility of lighting is easy with this method. All the pictures are taken the same way. Though this style of lighting does not necessarily give the prettiest images it can be highly accurate (see figures).
    Other on-camera lighting systems are available and are useful for specialized applications. 3 We do not think that a ring light is very useful for clinical photography of body parts other than close-ups of the skin itself. The light that it casts is co-axial with the camera lens and is flat and shadowless by design. These attributes make the ring light useful in fashion photography, but it hides too many relevant skin contours to be recommended for clinical photography other than to illuminate deep into cavities, under flaps or for dermatologic reasons.
    Perspective changes occur when a three dimensional object is portrayed in two dimensions. In plastic surgery the classic example is a face taken full frame with a wide-angle lens (the distance from the subject to the camera is short) and a longer lens (the distance from the camera to the subject is greater). In the first case the central, closer part of the face will seem to bulge and the ears will seem to recede. In the second case the face will look flatter, the nose will get smaller and the ears will widen out ( Fig. 2.2 ). This effect is commonly ascribed to the lens, but is in reality solely a function of camera to lens distance. For body and face, a taking distance of 4–6 feet is adequate. We will use a lens of 105 mm (or 105 mm equivalence for most digital cameras) at a distance of about 5 feet for the face and a lens of 50 mm (or equivalent) for body. 4

    Fig. 2.2 Perspective changes are very clear here. The image on the left was taken at 5 feet, the image below at 2 feet and the image on the right at about 14 inches. The focal length of the lens is only material in the distance it takes to fill the frame from ear to ear. This effect is actually evident if one looks closely in a mirror at similar distances.
    Though highly sophisticated metering is available for modern cameras and is commonly used, for the purposes of lighting in a known room at a known distance we favor the use of manual exposures. The light and shutter speed are always the same, and the distances are constant. We think that an f-stop of a least 11–16 is necessary for enough depth of field to assure that the back and the front of the subject are in focus. For facial images we focus on the eyes.

    Position
    Standardization is easy when it comes to exposure and camera to subject distance. Standardization of position is very difficult. As with anything that is difficult, many attempts have been made to achieve similarity in position. For most clinical purposes we find that simply paying close attention to the preoperative position and carefully trying to match it by comparing photo to patient works well for the typical clinical situation. In attempting to match a patient to a photograph the tendency is to exaggerate the rotation. Rotation is usually easier to match than vertical position.
    Clinical pictures should have a strong element of ritual to them and should always be taken the same way. We put the patient on a rotating stool and once the AP is taken have her rotate without tuning the neck. For both face and body photography we find it helpful to place numbered cards or markers on the wall at 45 degree increments to help the patient face the appropriate direction. 5

    Faces
    For faces we prefer five basic images: AP right and left obliques, and both laterals. These views contain most of the necessary information about the face. We repeat this basic sequence as necessary for follow-up photos. Because the face is a mobile structure and because patients will animate in their mirrors and misremember how they looked in the past, we take smiling views in the AP obliques and lateral. These are valuable for general purposes and to show smiling induced chin ptosis. We will include as many dynamic images as necessary to show preoperative nerve function.
    We also take an AP of the neck from below with the platysma in repose and in animation and any other special views that the case may call for ( Fig. 2.3 ).

    Fig. 2.3 One half of the face series is shown. We like to take the oblique with the nasal tip at the mid-pupillary line. A smiling image is taken in each of the cardinal positions (not shown). Platysma views are taken as shown in repose and with animation and close-up views are taken of any other area of interest. Any other animation views are included as desired. Ears should be visible in pre- and postoperative images. Though it is frequently difficult to persuade patients to remove makeup, most can be convinced into clipping their hair back. These pictures should be ritualistic in their position.
    Eyelids are taken with the face pictures and in close-up in the AP in superior gaze as well as laterals ( Fig. 2.4 ).

    Fig. 2.4 A–C , Eyelid close-ups are illustrated.
    Photography of the nose is contained in the facial series. Anteroposterior images are taken (ensuring that the ears are equally visible to control rotation), obliques and lateral. In addition smiling views are taken of the AP and the lateral images to demonstrate the effect of the lip on the nose. In addition basilar views are taken, one looking directly up the dorsum and one with more head uptilt for a true basilar view. 3, 6 – 8 Camera viewfinders with grids are useful to align the eyes or ears for uniformity in position ( Fig. 2.5 ).

    Fig. 2.5 The nose series is contained in the face series, with AP oblique and lateral images. Smiling images are included in the AP and lateral. The only different view is the two basilar views of the nose, one looking up the dorsum and one more angled to look at the nasal base.

    Breast images
    These are simply AP obliques and laterals. We also include a relaxed and pectoralis contracting view such as pushing the hands on the hips, in the case of breast implants. Sometimes a forward leaning view is useful to demonstrate asymmetry ( Fig. 2.6A–D ).

    Fig. 2.6 A–D , Half of a breast series. The forward leaning view is helpful to show asymmetries.

    Body contouring views
    Here is where some flexibility with lighting can be helpful. The overall shape of the body is best seen in even light, but the quality of the skin is best seen with more vertical light. Umbrellas with slaved strobe light are very useful here as they may be elevated and lowered to show the desired contours.

    PA
    Additional detail images are taken of the knees, medial thighs and arms as necessary. We have the patient stand on a designated spot and then face markers on the wall of the room at 45 degrees apart for consistency of position. In some patients with excess skin a “diver’s view” is helpful to look at redundant skin. We think that the arms should be included in the pictures as arm position can influence the way the skin drapes on the torso and the torso may be made to look artificially good if the arms are elevated out of the picture area ( Fig. 2.7 ).

    Fig. 2.7 The skin contours can be most accurately judged if the lights can be elevated in a series like this. The pictures are taken in 45-degree increments with the patient facing markers on the walls of the room. In this case the breasts were imaged as well as the body. We find it helpful to take pictures of the knees and inner thigh separately. The arm position should be visible in the images.
    Arms are photographed in abduction with the elbow flexed vertically. When the arm is photographed end on from and below the elbow any redundancy in the skin is instantly visible. Focus is at the mid-arm ( Fig. 2.8 ).

    Fig. 2.8 The arms are taken in AP and PA views. The non-standard lateral view shows much more detail of the curvature of the inferior skin than the standard views.
    Standardization of color is difficult in digital photography. Even with correct exposure the images may be flat muddy or off color as they are downloaded from the camera.
    If we are using images for publication or presentation we will modify color and contrast to make the images look the same. Since as surgeons, we are usually looking at contours and not colors we try to make the skin tone as realistic as possible. As a point of photographic integrity we never change morphogenic pixels.
    There are numbers of programs that will allow editing of photos. The industry standard is Adobe Photoshop (Adobe Systems, San Jose, CA), a large complex program. A useful program at the time of this writing is Adobe Photoshop Elements, which is less expensive yet has all the functionality necessary for routine editing of images.

    Integrity in photography
    In the increasingly competitive world of cosmetic surgery where surgeons are trying to influence future patients, or in presentations for peers, or for other reasons, there is and has always been the temptation to alter photographs to make the results look better than they really are. Clinical photography is not designed to flatter the patient (or the doctor). It is a legal document designed to be a part of a medical record and show the conditions that existed at one or more points in time.
    Different light shows different things. Wrinkles hollows and other imperfection on the face and body are defined by the shadows that they cast. In the absence of shadows, wrinkles disappear and results can look miraculous. It is very possible to make the skin and other contours look far better than they really do by altering the direction, quality and brightness of the light, a practice sometimes seen in books, journals and presentations, where on occasion most of the clinical result is from the difference in photography. This may sometimes be a naïve mistake, but in fact most of the unflattering images are seen in the preoperative pictures and the better ones in the postoperative ones.
    It is not uncommon to see eyelid surgery presented with the light coming more vertically in the preoperative picture accentuating the upper lid shadow and tear trough and the postoperative lights coming from straight anterior, flattening these shadows. 9 Strangely both patients and doctors continue to be fooled by elementary tricks like this and be impressed with the results that they purport to show. The lighting and position should be the same. The ability of photo editing programs to alter images is a frightening part of the brave new digital world.
    Cosmetic surgery is still surgery, its practitioners went to medical school and did internships residencies and fellowships. They should be expected to maintain the ethical standards that they learned there. The light that is used for the preoperative photos should be used for the postoperative ones, and digital modifications to images should not include changing any morphogenic elements.

    The future of clinical photography
    The next step in fusing digital photography, computers and the patient will probably be in the use of 3-D cameras. These are highly sophisticated devices which capture the points that comprise the surface of an object and can reproduce them in any position and orientation. Changes can be made in perspective to match a 3-D to a 2-D image. Currently, accuracy of the surface image of such cameras is about a millimeter. Measurements can be taken along the surface of an image or point to point. In some applications volume differences may be measured. Clearly the quality and range of results that will be documented will be remarkable.

    References

    1. Galdino GM, Vogel JE, Vander K, Craig A. Standardizing digital photography: it’s not all in the eye of the beholder. Plast Reconstr Surg . 2001;108(5):1334–1344.
    2. Upton B, Upton J. Photography . Boston: Scott, Foresman and Company; 1989.
    3. Galdino GM, DaSilva D, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg . 2002;109(4):1421–1434.
    4. Dickason WL, Hanna DC. Pitfalls of comparative photography in plastic and reconstructive surgery. Plast Reconstr Surg . 1976;58:166.
    5. DiBernardo BE, Adams RL, Krause J, et al. Photographic standards in plastic surgery. Plast Reconstr Surg . 1998;102(2):559–568.
    6. Rohrich R, personal communication, February 2008.
    7. Daniel R, personal communication, February 2008.
    8. Guyuron B, personal communication, February 2008.
    9. Sommer DD, Mendelsohn MMD. Pitfalls of nonstandardized photography in facial plastic surgery patients. Plast Reconstr Surg . 2004;114(1):10–14.
    Section 2
    Anesthesia
    CHAPTER 3 Anesthesia in aesthetic surgery

    Michael Zelman, Daniel J. Ceradini

    History of ambulatory anesthesia
    The origins of anesthesia began with a series of events in the mid 1800s. While training in New York City, Crawford Long experienced the recreational use of ether and nitrous oxide during student parties: the so-called “ether frolics”. After starting his practice, he applied the use of diethyl ether to anesthetize a patient during removal of two small tumors from a man’s neck in 1842. He did not publish his methods until 1849, several years after the use of nitrous oxide was reported by Horace Wells and the first successful public demonstration of nitrous oxide by William T.G. Morton in 1846. These pioneers set the stage for the rapid integration of anesthesia into surgical practice, which proceeded over the latter half of that century.
    Shortly after World War I, with increasing popularity of office-based surgery, the utilization of a dedicated anesthesiologist in the office setting was first described by Ralph Waters in 1919. He described his experiences administering anesthesia in the surgeon’s office, where his responsibilities included supplying the operating room, recovery room, and his private doctor’s “loafing and smoking room”. He recognized the financial potential of his situation, and noted that success was intimately tied to the satisfaction of the surgeon. 1
    Later in the mid-20th century, with rising costs and inefficiency of inpatient care and increasing shortage of hospital beds, there was significant transition to outpatient surgery. In an effort to maximize patient throughput, cut costs, and maximize reimbursement, John Ford and Wallace Reed designed the first freestanding ambulatory surgicenter in Phoenix, Arizona in 1969. Most cases in this facility were performed under general anesthesia. Based on their drive for efficiency, this stimulated the development of anesthetic regimens and postoperative medications that would allow patients to return home sooner. These techniques continue to evolve today.
    Over 60% of all surgical procedures performed in the US are in an ambulatory setting. In aesthetic surgery, the vast majority of procedures are performed in the outpatient or office setting. Functional knowledge about of the practice of anesthesia and how it can be applied to the aesthetic surgeon’s practice is vital to success.

    Preoperative evaluation – patient safety
    Ambulatory anesthesia has evolved as a means of convenience, efficiency, and cost cutting to surgical practice. However, a critical determinant in these benefits is patient selection and safety. The objective of preoperative evaluation is to manage risk – to identify patients who are at low risk, and to reduce these risks at the time of surgery. In some cases the risk of anesthesia is equal to or greater than the surgical procedure at hand. There is no consistent classification of preoperative risk, but particular attention to details of the patient’s history, physical exam, and other diagnostic screening tools can determine whether surgery should be deferred while pre-existing medical conditions are addressed.
    The objective of anesthesia is to maintain a state of physiologic homeostasis during the stress of surgery. The physiologic response to surgery is similar to the “fight or flight” response, altering blood flow from non-vital organs to the brain and heart. In order to maintain homeostasis, preoperative determination of cardiac reserve, ability to exchange oxygen, and patient factors which may negatively impact these processes must be known. To this end, the Rule of Threes can simplify the approach to preoperative screening and focus practitioners on the aspects of the history and physical exam which influence patient outcomes in the perioperative period ( Table 3.1 ). 2 Exercise tolerance approximates cardiac reserve, and can be approximated using metabolic equivalents (METs). Several studies have demonstrated that the ability to do four or more METs correlates to improved perioperative outcomes. Walking five city blocks, climbing two flights of stairs, running over short distances, and participating in moderate recreational activity (i.e. dancing or golf) without the need to stop for rest is the equivalent of four METs.
    Table 3.1 The Rule of Threes Acute history 1. Exercise tolerance   2. History of present illness and its treatments   3. When the patient last visited with his or her primary care physician Chronic history 1. Medications and causes for their use and allergies   2. Social history including drug, alcohol, and tobacco use and cessation   3. Family history and history of prior illnesses and operations Physical examination 1. Airway   2. Cardiovascular   3. Lung, plus those aspects specific to the patient’s condition or planned procedure
    From Miller RD. Miller’s anesthesia, 6th edn. New York: Elsevier/Churchill Livingstone, 2005.
    As there is no reliable classification system of preoperative risk, a standardized approach to data collection in the preoperative period can facilitate decision making throughout the patient’s course. The initial collection should happen shortly after the decision to proceed with surgery in the surgeon’s office. In addition to medical history pertinent to the specific surgical procedure, a standard set of questions designed to identify risk factors should be answered, such as those found in the Preoperative and Preprocedure Assessment Clinic (PPAC) Form. 2 The physical exam should be similarly structured and standardized with some notable additions. Airway assessment is performed according to the Mallampati airway classification based on observations of oral structures visible with tongue maximally protruded, which correlates to ease of intubation ( Table 3.2 ). Additional factors to consider which may limit airway visualization are a short neck, limited cervical spine mobility, poorly mobile or retruded mandible.
    Table 3.2 Mallampati airway classification system I Faucial pillars, soft palate, uvula, tonsillar pillars visualized II Faucial pillars and soft palate visualized, uvula visualized III Soft palate, base of uvula visualized IV Soft palate only
    Based on the history and physical, patients are broadly classified according to their medical fitness. The current classification system endorsed by the American Society of Anesthesiology (ASA) is a modification of the Saklad classification developed in the 1940s. Useful more as a global assessment of preop status rather than a measure of risk, the ASA system classifies patients based on the presence of medical illness ( Table 3.3 ).
    Table 3.3 ASA classification system ASA class Medical conditions Common examples I Healthy, no co-existing medical illness   II Mild systemic disease with no functional limitation Asthma, hypertension, mild obesity, diabetes (well controlled) III Severe systemic disease with functional limitation Poorly controlled DM, stable angina, coronary artery disease IV Severe systemic disease that is a constant threat to life CHF, unstable angina V Moribund with death expected within 24 hours  
    Following a focused history and physical intake, surgeons must then determine the need for additional preoperative screening tests. The tendency of surgeons is to order a large range of ancillary tests, some of which are not necessarily indicated, in an effort to have any conceivable test result available to the anesthesiologist on the morning of surgery. This poses several potential problems. Testing not indicated by medical history may lead to treatment of borderline abnormalities, which may result in patient harm and distress. In addition, since most preoperative abnormalities are not documented in the chart, the failure to investigate abnormal tests is a greater risk of medico-legal liability than the failure to detect it in the first place. Therefore, the guidelines published by the American Society of Anesthesiologists (ASA) summarized in Table 3.4 should be utilized to determine the need for additional preoperative screening tests. In addition, preoperative evaluation should include tests relevant to the type of surgery being performed. For instance, if intraoperative and postoperative bleeding is a significant risk, then a baseline hematocrit should be included in the preoperative work-up.
    Table 3.4 Guidelines for preoperative screening tests (based on ASA standards) Preoperative test Indicated Not necessarily indicated Electrocardiogram Age >50 with cardiac risk factors Age >50 with no cardiac risk factors   Pre-existing cardiac or peripheral vascular disease     Hypertension     Diabetes mellitus     Metabolic disease   Chest radiograph Pre-existing cardiac or respiratory disease Smoking, advanced age, stable cardiac disease, stable COPD, recent URI   COPD or reactive airway disease   Complete blood count History of anemia Routine use not indicated   Hematologic disorder     Liver disease     More invasive procedures   Coagulation studies History of bleeding diathesis Routine use not indicated   Anticoagulant therapy Regional anesthesia (insufficient data)   Liver disease   Serum chemistries Endocrine disease Routine use not indicated   Renal or liver dysfunction     Medications affecting serum/urine electrolytes   Urinalysis Only select procedures (genitourinary procedures) Routine use not indicated Pregnancy testing Consider in all women of childbearing age     Uncertain pregnancy history  
    Adapted from American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2002;96:485–496.
    Based on current practice, patient assessment by the anesthesiologist frequently occurs on the morning of surgery. While adequate for the majority of patients without significant medical co-morbidity or risk factors, there is a select group of patients with significant medical problems or preoperative risk that would benefit from an evaluation well before surgery. It is the role of the surgeon to identify these patients and ensure they receive a focused assessment by an anesthesiologist to minimize their operative risk prior to the morning of surgery ( Table 3.5 ). Failure to do so may result in case cancellation which is frustrating for all parties involved.
    Table 3.5 Indications for preoperative anesthesia evaluation prior to day of surgery (based on ASA standards) General Medical condition prohibits daily activity or necessitates continual assistance   Hospital admission within 2 months for acute or exacerbation of chronic condition   Morbid obesity (BMI >30) Cardiovascular Angina, coronary artery disease, history of myocardial infarction   Symptomatic arrhythmias   Poorly controlled hypertension (DBP >110, SBP >160)   Congestive heart failure Respiratory COPD or reactive airway disease requiring chronic medication   Recent COPD or reactive airway disease exacerbation   History of airway surgery or unusual airway anatomy Endocrine Diabetes mellitus   Adrenal disease   Thyroid disease   Hepatobiliary disease Neurological Seizure disorder   CNS disease
    Adapted from American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2002;96:485–496 and Pasternak LR. Preoperative screening for ambulatory patients. Anesthesiol Clin North America 2003;21:229–242, vii.
    Finally, the decision is made on the method of anesthesia to use. There are a number of factors that influence this decision including medical history, nature of the procedure, length of surgery, facility resources, surgeon’s expertise, anesthesiologist’s expertise, and to some extent, patient preferences.
    The specific features of each method for anesthesia will be discussed later in this chapter.

    Preoperative medications
    Preoperative medication management is an important concept in optimizing patient physiology before they enter the operating theater. Conceptually, this can be viewed as a therapeutic opportunity to minimize preventable risk in an effort to improve patient outcomes. Specifically, the management of medical co-morbidities, patient anxiety, and predictable side effects of surgery and/or anesthetic agents should be addressed to ensure patient comfort throughout the perioperative period and minimize preventable complications.

    Maintenance medications
    In general, patients undergoing pharmacologic treatment for medical illness should continue taking most of their preoperative medications on the morning of surgery to maintain their steady-state physiology. Examples of such medications include anti-hypertensives, thyroid replacement, medications for symptomatic gastroesophageal reflux, and medications required to optimize pulmonary function (i.e. steroids). Notable exceptions to this guideline are anticoagulants and antiplatelet agents due to the increased risk of bleeding complications as well as oral hypoglycemic medications and insulin which should be adjusted according to blood glucose levels. In patients with more complex medical problems, consultation with a primary care provider is advised to individualize the patient’s needs perioperatively. Herbal supplements should be discontinued, often several days prior to surgery, as many have been shown to affect platelet function. Antidepressants or antianxiety medications can be continued with the exception of monoamine oxidase inhibitors, such as phenelzine (Nardil).

    Anxiolytics
    Patient anxiety is a significant consideration to address preoperatively for several reasons. The first is physiological. The anxiety associated with the anticipation of surgery, injection of local agents, and being aware of the surroundings during surgery can all have significant hemodynamic effects, which may affect the intraoperative anesthetic medications given during surgery. This potentially increases the incidence of postoperative complications, particularly nausea, vomiting, and blood pressure control. The second consideration is psychological. Anticipation of surgery often evokes psychological symptoms due to alterations in body image, previous traumatic experiences, unrealistic expectations about outcomes, and fear of pain or discomfort. A simple phone call from the surgeon or anesthesiologist on the evening prior to surgery has been shown to reduce this anxiety. Further, psychiatric disorders are not uncommon in the aesthetic population, and the risk of postoperative psychological complications (anxiety, post-traumatic stress, panic attacks) is predicted by their presence preoperatively. In this instance, premedication with an appropriate anxiolytic facilitates a more even psychological state throughout the perioperative period. Notably, in patients with pre-existing psychological disorders, anxiolytics are often continued in the postoperative period. The more common preparations of preoperative anxiolytics include oral valium taken on the morning of surgery (10–20 mg) and Versed IV/IM (2–4 mg) used immediately prior to entering the operating room.

    Antiemetics
    Postoperative nausea and vomiting (PONV) is a significant problem affecting approximately 30% of patients undergoing surgery with anesthesia, and results in delayed discharge, unplanned hospital admissions, and increased medical cost. In more severe cases, PONV can lead to wound dehiscence, aspiration, hematoma, and severe electrolyte disturbances. Prophylaxis is commonly used to reduce the risk of PONV, and includes the use of serotonin receptor antagonists (i.e. ondansetron), steroids, anticholinergics, benzamides (i.e. reglan), and butyphenones (i.e. droperidol). The specific management of PONV is the subject of a subsequent chapter and will not be discussed here.

    Antihypertensives
    While relatively hypotensive anesthesia is preferred by many surgical subspecialties, it is of particular importance in aesthetic surgery. Considering the elective and aesthetic nature of this type of surgery, hematoma is a dreaded complication of most procedures and is often correlated to the presence of pre-, intra-, or postoperative hypertension. Antihypertensive agents are used preemptively as the stress of surgery, infiltration, and awareness all may increase blood pressure significantly. Clonidine is a useful drug in this respect, as it reduces sympathetic outflow from the central nervous system, suppresses the peripheral efferent sympathetic pathways, lowers peripheral vascular resistance, and may have sedative effects. Transdermal forms of clonidine are very useful in the postoperative period to prevent hypertension in healthy patients. Alternatively, chlorpromazine (Thorazine) is a major tranquilizer which has a sedative effect while acting to lower blood pressure due to its potent α-antagonist activity.

    Methods of anesthesia
    Selecting the method of anesthesia is dependent on a number of factors including safety, efficiency, cost, patient preference, surgical expertise, availability of regional or local options, skill of the anesthesiologist, and capability of the facility. Ideally, the method chosen should have a relatively rapid onset, provide adequate amnesia and analgesia to facilitate performing the surgical procedure safely, and have a relatively short and complication-free recovery period. Although general anesthesia remains one of the most common techniques, there is an increasing popularity of local and nerve blocks combined with intravenous sedation (monitored anesthesia care) in the ambulatory setting.

    General anesthesia
    General anesthesia induces a state of unconsciousness and analgesia through the use of intravenous and inhaled agents, necessitating definitive airway management. It is not simply defined by the presence of an endotracheal tube. Use of general anesthesia in the ambulatory setting must be efficient and cost-effective. Although there is a higher incidence of anesthesia-related side effects when compared to other methods, general anesthesia remains the most widely utilized technique. This requires that specialized equipment, anesthesia machines, and medications are readily available in the facility.
    Airway management in general anesthesia is performed using either endotracheal intubation or the laryngeal mask airway (LMA). Endotracheal intubation is the most invasive method and offers the greatest control of the airway, particularly when there are changes in patient positioning intraoperatively. However, aside from these particular instances, there are specific criteria for intubation including airway protection (i.e. in patients at risk for aspiration), maintenance of airway patency, pulmonary toilet, and specific needs to maintain oxygenation (positive pressure ventilation, positive end-expiratory pressure). Endotracheal intubation is associated with a high incidence of postoperative patient complaints including sore throat, cough, and hoarseness.
    The alternative is the laryngeal mask airway (LMA), which is halfway between endotracheal intubation and mask anesthesia. The LMA causes minimal cardiovascular responses during insertion, is well tolerated during maintenance anesthesia, provides a relatively secure airway, and results in half as many airway-related complaints postoperatively. The device can also be re-used, frequently in the outpatient setting making it a cost-effective airway solution. However, the LMA does not protect the airway from aspiration, GERD, and upper airway bleeding, so its use is cautioned in patients at risk for these issues. Many anesthesiologists utilize the LMA during rhinoplasty because it acts as a mechanical barrier for blood, preventing it from entering the stomach during surgery which can lead to nausea and vomiting in the postoperative period.

    Monitored anesthesia care
    Monitored anesthesia care (MAC) is defined as the presence of an anesthesiologist to monitor vital parameters or administer supplemental drugs to patients receiving local anesthesia for surgical procedures. Up to 50% of outpatient procedures could be performed with MAC, reducing the cost of perioperative care up to 80% compared to general anesthesia. The preoperative workup for MAC should be as rigorous as general anesthesia because in a very small fraction of cases, emergent intubation may be required. In general, patients suitable for MAC are cooperative patients who understand that they may be aware during the surgical procedure. These patients should have a favorable airway and are undergoing relatively short procedures (<3 h). Contingent on these parameters is the ability of the surgeon to provide excellent local anesthesia, either via field blocks or specific nerve blockade. MAC is associated with fewer post-anesthesia side effects and more rapid recovery and discharge. The main disadvantage of MAC is lack of airway control, and requires the anesthesiologist to carefully titrate medications to maintain spontaneous respiration while keeping the patient comfortable.

    Local anesthesia
    Local anesthesia is perhaps the most powerful method of anesthesia, and in skilled hands, is often the only method of anesthesia used. Local agents block nerve conduction by altering sodium conductance in neuron. Precision of placement (nerve blocks) and total dose (field blocks and infiltration) are important determinants in anesthetic effect. Central nervous system and cardiovascular toxicity are the most common serious adverse effects of local anesthetics and are directly related to dose and circulating plasma levels. The more common local agents and their clinical characteristics are listed in Table 3.6 .

    Table 3.6 Local anesthetic agents
    Considering the large percentage of plastic surgery procedures that involve the face, mastery of local anesthesia in the face is critical to facilitate patient comfort during a variety of office-based cases. Described eloquently by Zide in 1998, 3 complete sensory blockade of the face can be accomplished using eight precisely placed regional nerve blocks ( Fig. 3.1 ) with a minimal volume of anesthetic.

    Fig. 3.1 Regional nerve blocks in the face. Using eight precisely placed nerve blocks, the face can be completely anesthetized. Circles indicate the entry point of the needle, and arrows indicate the direction of insertion and infiltration.

    1. Infraorbital nerve
    The infraorbital foramen opens downward and medially, approximately 5–9 mm below the inferior orbital rim in the vertical plane of the medial limbus in forward gaze. This block is approached from in intraoral or percutaneous route between the alar base and nasolabial fold. The needle is inserted pointing towards the medial limbus and advanced until the foramen is entered directly or bony contact is made, at which time the needle is “walked” up the face of the maxilla injecting local anesthetic at points of contact until the foramen is found. Only 1–2 mL of local anesthetic is necessary for complete blockade of the infraorbital nerve. The nasal sidewall, lower lid, cheek, and upper lip (up to but often not including the commissure) are anesthetized using this technique.

    2. Mental nerve
    The mental nerve exits the foramen below the second mandibular bicuspid as a group of 2–3 fascicles, which arborize quickly to innervate the lower lip, vermillion, and chin. Frequently, manually distracting the lip over the second bicuspid at the level of the gingivobuccal sulcus visually exposes the mental nerve in its submucosal course, allowing for precise intraoral placement of 1–2 mL of local anesthetic. This anesthetizes the lower lip and upper chin, but often does not adequately affect the lower chin due to the deeper course of the lower mental nerve branches and sensory myohyoid nerve. To completely anesthetize the chin, the needle is almost completely withdrawn, redirected in a plane parallel with the face of the anterior mandible, and advanced in a supraperiosteal plane to just beyond the lower border of the mandible. Local anesthesia is deposited (2–3 mL) as the needle is withdrawn, anesthetizing the lower chin. Positioning behind the head of the patient facilitates this maneuver.

    3. Supraorbital and supratrochlear nerves
    The supraorbital and supratrochlear nerves are blocked using one approach based on their anatomic proximity. While palpating the supraorbital notch with one finger, the brow is distracted laterally with the thumb and the needle is inserted in the middle third of the eyebrow pointed towards the supraorbital notch beneath the corrugator muscles. Local anesthesia is deposited 1 cm prior to the notch, just above the notch, and medially at the nasal bone to include the infratrochlear nerve. The forehead and frontoparietal scalp from the temporal line of fusion to near midline and the medial half of the upper eyelid skin are anesthetized using this technique. It is important to counsel patients prior to this block that some degree of periorbital ecchymosis may occur.

    4. Dorsal nasal nerve
    The dorsal nasal nerve is a terminal branch of the anterior ethmoid division of the nasociliary nerve supplying the anterior septal mucosa, lateral nasal wall, ala, vestibule, and tip. It exits the nasal vault at the lower border of the nasal bone 5–10 mm lateral to the midline plane. While palating the distal ends of the nasal bones between the thumb and index finger, 1–2 mL of local anesthesia is injected 5–10 mm lateral to midline on both sides.

    5. Zygomaticotemporal nerve
    One of two distal branches of the zygomatic nerve, the zygomaticotemporal nerve exits a foramen posterior to the lateral orbital rim at or below the level of the lateral canthus to innervate an area posterior to the lateral orbital wall above the level of the canthus back to the hairline and up to the temporal line superiorly. While palpating the zygomaticofrontal suture, the needle is inserted approximately 5 mm inferior to this landmark and is advanced behind the lateral orbital rim to a point 10 mm below the level of the lateral canthus. Local anesthetic is deposited throughout the course of the needle during withdrawal.

    6. Zygomaticofacial nerve
    The second distal branch of the zygomatic nerve is the zygomaticofacial nerve, which exits via one or several foramina on the anterior surface of the zygoma. After locating the junction of the infraorbital and lateral orbital rim by palpation, 2 mL of local anesthetic is deposited 1–2 cm lateral to this landmark in a supraperiosteal plane anesthetizing a triangular area centered on the cheek prominence with the apex oriented inferiorly ending at the lower border of the anterior ramus of the mandible.

    7. Great auricular nerve
    The great auricular nerve emerges from behind the sternocleidomastoid muscle and continues superiorly along its surface to innervate the lower half of the ear, postauricular skin, and variable regions overlying the mandibular angle up to the tragus. The landmark for injection is located along a line 6.5 cm inferior from the external acoustic meatus that intersects the mid-axis of the sternocleidomastoid muscle. Local anesthetic is deposited on the anterior fascial surface of the muscle.

    8. Mandibular division of the trigeminal nerve (V3)
    The mandibular division of the trigeminal nerve innervates the majority of the cheek and pretragal regions, and is accessed via spinal needle through the sigmoid notch 1 cm posterior to the pterygoid plate. The sigmoid notch is palpated externally approximately 2.5 cm anterior to the tragus as the patient opens and closes the mouth. A small amount of superficial anesthetic is deposited here to account for a larger needle. Next, a 22-gauge spinal needle is inserted through the anesthetized area in a plane perpendicular to the face and advanced until contact with the pterygoid plate, taking note of how deep the needle has been advanced (usually around 4 cm, a plastic slide is useful in this capacity). The needle is then almost completely withdrawn, redirected to a point 1 cm posterior to the initial point of contact, and then advanced to the same depth measured previously. Following aspiration, 3–4 mL of local is deposited to numb the cheek area.

    Office-based anesthesia
    The concept of a surgeon operating from an office setting has been routinely practiced over several decades, but the recognition of office-based anesthesia (OBA) as a subspecialty of anesthesia is only a recent development. OBA is technically defined as the administration of anesthesia in a facility not licensed as an ambulatory surgery center, which operates and is integrated into the daily operations of a surgeon’s office. Practically speaking, there is a broad range of procedures which utilize OBA, from very minor surgical procedures, to much more invasive procedures. The level of surgical complexity that can be performed in this setting are highly dependent on the surgeon’s skill and level of comfort with the procedure. Regardless, patient selection is a critical factor in maintaining the efficiency, convenience, and cost-effectiveness of office-based procedures, and the standards of our specialty are outlined in a task force statement from the American Society of Plastic Surgeons (ASPS). 4 The basic clinical requirements for safe OBA can be summarized using the pneumonic POSEMED ( Table 3.7 ). 5
    Table 3.7 Requirements for safe office-based anesthesia P ositive pressure ventilation Small anesthesia machine or bag-mask apparatus O xygen Gas line or cylinders S uction One unit with a backup E mergency equipment Airway supplies, defibrillator, crash cart M onitors Electrocardiogram, blood pressure, pulse oxymetry D rugs ACLS/resuscitative agents, anesthetic agents, dantrolene
    According to the ASPS, plastic surgery performed under anesthesia other than minor local with minimal oral tranquilization should be performed in a facility that is accredited by a national or state-recognized agency (such as the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), the Accreditation Association for Ambulatory Health Care (AAAHC), or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)), certified to participate in the Medicare program under Title XVIII, or licensed by the state the facility is located in. 6 Accreditation in OBS affords several advantages to surgeons, including facility fee acquisition, regulation compliance, and a marketing advantage to patients familiar with office-based surgery. Reflecting the growing popularity of OBA, each accrediting agency has begun to tailor their criteria to smaller facilities to reduce the cost and administrative burden of accreditation.

    Intraoperative considerations

    Positioning
    Positioning and padding the patient in the operating room is often overlooked in the busy perioperative period. Anesthetized patients lack the normal defense mechanisms from pressure-induced injury, and are at risk for nerve, vessel, joint, and skin injury. Particularly in body contouring and breast procedures where several position changes are characteristic, attention to detail in orienting and padding the patient are required. According to the ASA Closed Claims Database (1970–1995), nerve damage (16%) was second only to death (32%) in the nature of liability claims settled with ulnar neuropathy and brachial plexus injuries being the most frequent. 7 As a result the ASA issued a practice advisory for the prevention of perioperative neuropathies, detailing the specific recommendations related to upper extremity, lower extremity, and padding (see summary in Miller 2 ).

    Thermoregulation
    Maintenance of thermal steady state requires that dissipative heat loss is balanced by heat production. During surgery, excessive heat loss and redistribution of heat from the core to peripheral tissues contributes to mild core hypothermia. Even mild levels of hypothermia (up to 3°C) can contribute significantly to surgical outcomes, increasing morbidity of cardiac outcomes, decreased resistance to surgical wound infections, impaired coagulation, and decreased postoperative comfort. Prospective randomized studies have demonstrated that mild intraoperative hypothermia is associated with delayed wound healing, prolonged hospitalization, and a 3-fold increase in the incidence of wound infection. 8
    Thus, in order to maintain steady state during surgery accurate core thermal monitoring must be used to identify thermal losses, while making an effort to minimize dissipative heat losses and supplementing heat production. Examples of heat supplementation include heated airway humidifiers, forced air warmers and blankets, and passive heat and moisture exchangers. For surgical procedures less than 60–90 minutes in length, forced warming devices are not likely to be cost-effective measures.

    Fluid management
    Optimizing cardiac function and oxygen delivery as well as maintaining electrolyte balance are the primary goals of intraoperative fluid management. For many aesthetic procedures, fluid management is relatively straight forward, balancing maintenance requirements with pre-existing, surgical, and insensible losses. However, there are several procedures where fluid management becomes more complicated. Liposuction is one such instance where large fluid volumes are instilled subcutaneously, allowed to dwell, then partially aspirated along with subcutaneous fat. Based on the volume of aspirate, there are specific resuscitation guidelines which should guide surgeons to maintain euvolemia in the perioperative period.

    Postoperative considerations
    Postoperative recovery is defined by three overlapping phases: early, immediate, and late recovery. Early recovery (phase I) describes the patient during emergence from anesthesia which begins with the discontinuation of anesthetic agents. During this phase, patients regain protective airway reflexes and motor function. Throughout early recovery, patients are assessed for criteria for discharge from the recovery room according to the Aldrete scoring system, which incorporates voluntary movement, respiration, circulation, consciousness, and oxygen saturation. 9 After attaining an adequate score, patients can be moved out of the recovery room to intermediate recovery (phase II), where they are prepared for discharge. With the development of shorter acting anesthetic regimens, the concept of “fast tracking” has emerged as a cost effective means of recovery. Typically, these patients achieve an adequate Aldrete score upon entering the recovery room, and can safely be moved to phase II saving valuable recovery room resources. However, the Aldrete scoring system does not account for postoperative emesis and pain, the two main contributors to delayed discharge. As a result, White proposed a modified scoring system to determine a patient’s eligibility for fast-track status. 10 Late recovery (phase III) occurs after discharge from the facility when patients return to their preoperative physiologic state.
    During phase II, the evaluation of patient suitability for discharge often is passed from the anesthesiologist to the practitioners staffing the unit. Standardized criteria are used to ensure patient safety and determine home readiness, and include vital signs, ambulation, nausea and vomiting, pain, and surgical bleeding. On average, patients meet these criteria within 1–2 hours of surgery. 11 The ability to tolerate oral intake is not a requirement for discharge, and patients should not be forced to drink liquids postoperatively; oral intake has not been shown to influence the incidence of nausea and vomiting. Routinely requiring patients to void postoperatively should also be avoided, unless the ability to void is an integral part of the surgical procedure.

    Complications
    The most frequent post-anesthetic complications such as nausea, vomiting, pain, and cardiovascular instability should be anticipated and addressed in the pre- and intraoperative periods to minimize the risk of patients developing issues in the recovery phase. Other common complications related to airway irritation (hoarseness, cough) are minor and will resolve spontaneously.
    Malignant hyperthermia (MH) is a potentially life-threatening complication of anesthesia that requires the availability of specific pharmacologic agents to treat a severe crisis. MH is a subclinical myopathy triggered by volatile inhalational agents or succinylcholine which manifests as a hypermetabolic state of tachycardia, hypercarbia, acidosis, rigidity and fever. Genetically linked to mutations in the RYR1 gene, MH can occur in patients with a family history or with no history at all. Onset can be rapid, occurring intraoperatively or in the postoperative period and should be rapidly identified and treated with dantrolene. Because of the potentially fatal outcomes of MH, all office and ambulatory centers that utilize inhalational agents or succinylcholine should be equipped with an adequate supply dantrolene to treat a fulminant malignant hyperthermic crisis.


    Pearls & pitfalls

    Pearls

    • The objective of anesthesia is to maintain a state of physiologic homeostasis during the stress of surgery.
    • Several studies have demonstrated that the ability to do four or more metabolic equivalents (METs) correlates to improved perioperative outcomes.
    • Preoperative medication management is an important concept in optimizing patient physiology before they enter the operating theater.
    • While relatively hypotensive anesthesia is preferred by many surgical subspecialties, it is of particular importance in aesthetic surgery.
    • Although general anesthesia remains one of the most common techniques, there is an increasing popularity of local and nerve blocks combined with intravenous sedation (monitored anesthesia care) in the ambulatory setting.
    • Local anesthesia is perhaps the most powerful method of anesthesia, and in skilled hands, is often the only method of anesthesia used.
    • Complete sensory blockade of the face can be accomplished using eight precisely placed regional nerve blocks with a minimal volume of anesthetic.
    • The recognition of office-based anesthesia (OBA) as a subspecialty of anesthesia is a recent development.

    Pitfalls

    • Preoperative evaluation is to manage risk – to identify patients who are at low risk, and to reduce these risks at the time of surgery. In some cases the risk of anesthesia is equal to or greater than the surgical procedure at hand.
    • Preop testing not indicated by medical history may lead to treatment of borderline abnormalities, which may result in patient harm and distress.
    • There is a select group of patients with significant medical problems or preoperative risk that would benefit from an evaluation well before surgery.
    • Postoperative nausea and vomiting (PONV) is a significant problem affecting approximately 30% of patients undergoing surgery with anesthesia.
    • The laryngeal mask airway (LMA) does not protect the airway from aspiration, GERD, and upper airway bleeding, so its use is cautioned in patients at risk for these issues.
    • Malignant hyperthermia (MH) is a potentially life-threatening complication of anesthesia that requires the availability of specific pharmacologic agents to treat a severe crisis.

    References

    1. Waters R. The downtown anesthesia clinic. Am J Surg . 1919;33(Suppl):71–73.
    2. Miller RD. Miller’s anesthesia , 6th edn. New York: Elsevier/Churchill Livingstone; 2005.
    3. Zide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg . 1998;101:840–851.
    4. Iverson RE, Lynch DJ. Patient safety in office-based surgery facilities: II. Patient selection. Plast Reconstr Surg . 2002;110:1785–1790. discussion 1791–1792 –
    5. Koch ME, Dayan S, Barinholtz D. Office-based anesthesia: an overview. Anesthesiol Clin North America . 2003;21:417–443.
    6. Iverson RE. Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting. Plast Reconstr Surg . 2002;110:1337–1342. discussion 1343–1346 –
    7. Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve injury associated with anesthesia: a closed claims analysis. Anesthesiology . 1999;90:1062–1069.
    8. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med . 1996;334:1209–1215.
    9. Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth . 1995;7:89–91.
    10. White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete’s scoring system. Anesth Analg . 1999;88:1069–1072.
    11. Chung F, Chan VW, Ong D. A post-anesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth . 1995;7:500–506.
    12. American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology . 2002;96:485–496.
    13. Pasternak LR. Preoperative screening for ambulatory patients. Anesthesiol Clin North America . 2003;21:229–242. vii
    CHAPTER 4 Postoperative nausea and vomiting

    David M. Shafer, Sheldon Opperman

    The “big little problem”
    The estimated incidence of postoperative nausea and vomiting (PONV) in the general surgical population ranges from 20% to 30% and up to 70% to 80% in high-risk patients. This adds significantly to the healthcare burden in terms of cost (extended hospital stay) and patient morbidity (prolonged disability). In fact, many patients rank PONV as the most distressing aspect of their hospital stay, reporting that PONV is a greater concern than postoperative pain. A recent survey found that patients are even willing to incur increased personal medical costs in an effort to reduce or prevent PONV.
    PONV is an important, but often disregarded, complication of the patient’s surgical experience. Plastic surgery procedures have the highest incidence of PONV ( Table 4.1 ). In fact, breast augmentation has a reported 8–10× higher incidence of PONV than other plastic surgery cases, with 42% immediate PONV and 43% incidence 24 hours after surgery. The ramifications range from physical (increased blood pressure potentiating postoperative bleeding, ecchymosis and edema) to psychological (unpleasant and uncomfortable experience for the patient). PONV is an often preventable cause of unanticipated hospital admissions, which leads to increased labor and material costs and disruption of patient flow through an already overburdened healthcare system. As the rate of elective outpatient procedures continues to grow, any effective effort to reduce or prevent unanticipated costs is certainly valuable.

    Table 4.1 Type of surgery as a risk factor for PONV. Plastic surgery has the highest odds ratio for PONV

    Risk factors for PONV

    Targeted prevention of PONV

    • Assessing patient risk factors ( Table 4.2 )
    – patient characteristics
    – type of anesthesia
    – type and length of surgery ( Table 4.1 and Fig. 4.1 )
    • Risk factor reduction
    • Aggressive prophylaxis/combination treatment ( Fig. 4.2 )
    – moderate-risk adults: 1 to 2 interventions
    – high-risk adults: 2 or more interventions
    – children: combination therapy
    • Salvage treatment if prophylaxis fails.
    Table 4.2 PONV risk factors Patient-specific Anesthetic-related Surgically-related

    Age
    Female
    Non-smoker
    History of PONV
    History of motion sickness
    Young age
    Migraine

    Volatile anesthetics
    Nitrous oxide
    Intraoperative opioids
    Postoperative opioids

    Duration of surgery
    Type of surgery
    Factors separated by patient-specific, anesthesia-related, and surgery-related.

    Fig. 4.1 Duration of surgery as a risk factor for PONV. As the duration of surgery increases up to 3 hours, the risk of PONV increases.

    Fig. 4.2 Patient management algorithm for PONV. Single or multiple interventions are used depending on risk factors.

    Prophylactic treatment
    Nausea and subsequent vomiting are controlled by two centers in the brain, the chemoreceptor trigger zone (CTZ) and the emetic center (EC). The CTZ is located in the area postrema and has five different receptors which lead to activation. These receptors also serve as targets for anti-emetic medications. Neuronal pathways connect the CTZ to the EC, which is located in the reticular formation. The EC is activated through these neural pathways from the CTZ or directly by the vagus nerve resulting from gastric distension.
    Known risk factors are the primary indication for PONV prophylaxis. As the number of risk factors increases, the risk of PONV increases. In fact, a patient with no risk factors has a PONV risk of 10%, while one risk factor gives a 20% risk. For each additional risk factor, the risk of PONV increases by 20% ( Fig. 4.3 ).

    Fig. 4.3 Compounding risk factors for PONV. The risk of PONV is directly proportional to the number of risk factors.
    Many risk factors cannot be changed (female gender, history of PONV), while other factors can potentially be addressed to reduce the risk of PONV. Specifically, if the surgical procedure can be performed under regional or local, rather than general anesthesia, there is a potential for significant reduction in PONV. Additionally, the approach to general anesthesia can be addressed to reduce PONV. As volatile anesthetics and nitrous oxide are known to be major contributors to PONV, their use should be minimized. On the other hand, total IV anesthesia (TIVA) utilizing propofol (Diprovan, AstraZeneca) has been shown to reduce PONV by up to 25%. Additionally, the use of opioids, both intraoperatively and postoperatively, is also a major risk factor for PONV. Substitution with non-opioid pain relievers, such as non-steroidal anti-inflammatory drugs (NSAIDs) can help prevent PONV. Finally, high-dose use of neostigmine has been shown to exacerbate PONV. However, this effect is dose-dependent and minimizing the dose decreases the risk for PONV.
    The individual patient risk factors should be considered when formulating a treatment plan. While prophylaxis is not required for low-risk patients (<1 risk factor), those patients with moderate risk (1–2 risk factors) require a targeted prophylaxis. Prophylaxis involves the use of one or more drugs from different classes of medications ( Table 4.3 ).
    Table 4.3 PONV medications Medication Class/mechanism Ondansetron (Zofran, GlaxoSmithKline) Dolasetron (Anzemet, Sanofi-Aventis) Granisetron (Kytril, Roche) Tropisetron (Navoban, Novartis) 5-HT 3 -receptor antagonists Dexamethasone (Decadron, Merck) Glucocorticoid Droperidol (Inapsine, Akorn Inc) Haloperidol (Haldol, Ortho-McNeil Pharmaceutical) Butyrophenones, antagonizes dopamine and alpha adrenergic receptors Dimenhydrinate (Dramamine, Pfizer) Anticholinergic Scopolamine (Transderm-Scop, Baxter) Anticholinergic Aprepitant (Emend, Merck) Substance P/NK 1 receptor antagonist Promethazine (Phenergan, Baxter) Peripheral H 1 -receptor antagonist
    Medications are separated by class and mechanism. Generic name (trade name, manufacturer).
    Combination therapy is superior to monotherapy. Moderate risk patients should be treated with medications of different classes to optimize PONV management. Common combinations include droperidol and dexamethasone or ondansetron and dexamethasone.
    High risk patients (more than two risk factors) may require triple therapy involving ondansetron, droperidol and dexamethasone. Additionally, every effort should be made to minimize anesthesia-related (regional or TIVA anesthesia instead of general anesthesia) and surgical-related (surgical duration) risk factors.
    Of note, since the most common antiemetic medications (droperidol, dexamethasone, and ondansetron) are all low cost, highly effective, and safe medications, many advocate aggressive prophylactic treatment with these medications regardless of patient risk profile.

    Common medications
    See Fig. 4.2 .

    5-HT 3 -receptor antagonists
    This class of drug includes ondansetron (Zofran, GlaxoSmithKline), dolasetron (Anzemet, Sanofi-Aventis), granisetron (Kytril, Roche), and tropisetron (Navoban, Novartis), which block serotonin 5-HT 3 receptors. The action occurs both centrally and peripherally, with the main action on the medulla oblongata. This class of drug is considered quite safe, as much higher doses are typically used in the prevention of chemotherapy-related nausea and vomiting. The recommended prophylactic dose of ondansetron (Zofran) is 4 mg IV administered at the conclusion of surgery .

    H 1 -receptor antagonist
    Promethazine (Phenergan, Baxter) is a phenothiazine derivative that competitively blocks H 1 -receptors producing an antihistamine and antiemetic effects. The dosing range of promethazine (Phenergan) is 12.5 to 25 mg given either PO, IM, or IV every four to six hours .

    Dexamethasone
    Dexamethasone (Decadron, Merck) is a high-potency, synthetic glucocorticoid with anti-inflammatory and immunosuppressant properties. When given at the beginning of a surgical procedure, dexamethasone has been show to prevent PONV. The initial recommended dose of dexamethasone (Decadron) is 4 to 5 mg . One study showed a similar effect of 4 mg dexamethasone versus 4 mg ondansetron. However, both medications are often used in combination therapy.

    Butyrophenones
    This class of drug is used as an antipsychotic and as an antiemetic, which antagonizes dopamine and alpha adrenergic receptors. Droperidol (Inapsine, Akorn Inc), haloperidol (Haldol, Ortho-McNeil Pharmaceutical) are the most commonly used. Droperidol (Inapsine) is usually given at a dose of 0.625 to 1.25 mg IV at the conclusion of surgery . However, recent concern was raised due to the FDA advisory for potential cardiovascular risks at higher doses. Droperidol and ondansetron have been shown to have similar efficacy. Haloperidol (Haldol), administered 0.5 to 2 mg IV, is also effective at the prevention of PONV without the side effects seen in the treatment of psychiatric disorders at higher does. Haloperidol does have a risk for QTc prolongation, so it is not a first-line recommendation.

    Dimenhydrinate
    This class of drug exhibits its anticholinergic effects through the inhibition of vestibular stimulation. Dimenhydrinate (Dramamine, Pfizer) is administered at a dose of 1 mg/kg IV. Optimal timing of dosing is not established.

    Transdermal scopolamine
    Scopolamine (Transderm-Scop, Baxter) is an anticholinergic medication which is administered via a transdermal patch. Ideal application of scopolamine is 4 hours prior to the surgical procedure , due to the slow onset of action. Each patch contains 1.5 mg scopolamine.

    Substance P/NK 1 receptor antagonists
    Substance P is an important neuropeptide released from primary nerve endings in the CNS and peripheral nervous system. It belongs to the tachykinin family of neurotransmitters and has a strong affinity for NK 1 receptors, which are highly concentrated in the brainstem vomiting center. Aprepitant (Emend, Merck) is a Substance P/NK 1 receptor antagonist available in both oral (40 mg given prior to induction of anesthesia) and IV forms (Fosaprepitant, Merck).

    Ineffective medications
    Several medications have been shown to be ineffective in the treatment of PONV. These include metoclopramide (Reglan, Baxter), ginger root, and cannabinoids such as nabilone (Cesamet, Valeant Pharmaceuticals International) and tetrahydrocannabinol.

    Non-medical interventions
    While this chapter concentrates on the medical prevention and therapy for PONV, one must also consider non-medical, complimentary approaches. Patient education about PONV should be included in preoperative counseling. Additionally, approaches such as acupressure (Sea-Band or Relief-Band) and meditation may be useful for those patients that are motivated by non-traditional methods.

    Intractable nausea and vomiting
    In the event that prophylactic measures to prevent PONV fails (PONV within 6 hours of administration of antiemetic or PONV without prophylaxis), aggressive salvage treatment must be initiated to prevent further worsening of PONV. The initial medication should be chosen from a class different than that used for prophylaxis. If no PONV prophylaxis was used, then the 5-HT 3 -receptor antagonists (ondansetron/Zofran) are the first-line treatment . However, lower doses may be just as effective (1 mg IV ondansetron versus 4 mg IV). An additional recovery regime includes 2 to 4 mg IV or dexamethasone, 0.625 mg of IV droperidol, and 6.25 mg IV of promethazine. Finally, under monitored conditions, 20 mg IV of propofol (Diprivan, AstraZeneca) can be administered for rescue therapy. If PONV returns more than six hours after first administration of antiemetic, then a repeat dose from the same class of medication is acceptable. Finally, inhaled isopropyl alcohol in the first 24 postoperative hours has been shown to be an effective intervention for nausea.

    Post-discharge nausea and vomiting
    While the major focus is on PONV in the in-patient and monitored setting, post-discharge nausea and vomiting (PDNV) presents a considerable obstacle. Nearly 80% of PONV occurs within 48 hours of surgery. However, 65% of patients do not experience PONV symptoms until after leaving the recovery room. With the increasing shift to ambulatory or out-patient, office-based surgery, PDNV prevention and treatment require greater attention. Prophylactic, combination therapy employed prior to, during, and after the procedure is most effective. Additionally, the oral disintegrating form of ondansetron (Zofran ODT, GlaxoSmithKline) is available in 4 mg and 8 mg doses for post-procedure treatment and scopolamine (Transderm-Scop, Baxter) patches are useful for continued post-procedure treatment.


    Pearls & pitfalls

    Pearls

    • Identify patient risk factors for PONV
    • Reduce baseline risk factors
    • Prophylactic measures are effective
    • Utilize combination therapy
    • Inhaled isopropyl alcohol is an effective postoperative intervention

    Pitfalls

    • Carefully identify risk factors
    • Recognize failed prophylaxis
    • Switch class of medication if same class already failed
    • Employ aggressive salvage therapy if needed
    • Be aware of delayed or post-discharge nausea and vomiting


    Summary

    1. PONV presents a common but often preventable phase of postsurgical care.
    2. One must first identify patients at highest risk for PONV (females, non-smokers, and previous history of PONV) and aggressively employ prophylactic measures.
    3. Single agent prophylaxis may be adequate for patients with no risk factors or a single risk factor.
    4. Combination therapy with multiple medications from different chemical classes is superior to mono-therapy when approaching patients with multiple risk factors.
    5. Salvage therapy employs additional medications from additional chemical classes.

    Further reading

    American Society of PeriAnesthesia Nurses. ASPAN’s Evidence-Based Clinical Practice Guideline for the Prevention and/or Management of PONV/PDNV. J PeriAnesthes Nurs . 2006;21(4):230–250.
    Apfel C. Postdischarge nausea and vomiting: risk assessment and treatment strategies. Anesthesiology News January . 2008:1–7.
    Cotton JW, Rowell LR, Hood RR, et al. A comparative analysis of isopropyl alcohol and ondansetron in the treatment of postoperative nausea and vomiting from the hospital setting to the home. AANA . 2007;75(1):21–26.
    Gan TJ, Consensus Guidelines for the Management of PONV. Littleton, CO: Medical Education Resources and Applied Clinic Education, 1 January 2008.
    Glass PS. Practice Guidelines for the Management of Postoperative Nausea and Vomiting: Past, Present, and Future. Internat Aesthes Res Soc . 2007;105(6):1228–1529.
    Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting. Ambulat Anesthesiol . 2007;105(6):1615–1628.
    Gan TJ, Sloan F, Dear Gde, et al. How much are patients willing to pay to avoid postoperative nausea and vomiting? Anesth Analg . 2001;92:393–400.
    Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be predicted? Anesthesiology . 1999;91:109–118.
    CHAPTER 5 Patient safety in aesthetic surgery

    Mark Jewell
    Much of my inspiration to write and teach about patient safety comes from Lucian Leape MD, my professor of pediatric surgery at the University of Kansas. Dr Leape ultimately left Kansas and went to Harvard School of Public Health, where he focused on patient safety and the ways that mistakes and errors in healthcare delivery could be minimized. Dr Leape was also one of the authors of Crossing the Quality Chasm 1 book which defined key quality issues in healthcare delivery. My thinking has been influenced by Steve Spear PhD and Mark Graban, who have gone beyond Dr Leape’s Institute of Medicine book, To Err is Human 2 by applying aspects of the Toyota Production System and Lean Manufacturing to healthcare delivery. 3, 4 While immediate focus has been on how to make the delivery of healthcare safer, there are other widespread defects of dignity, comfort, satisfaction and wasteful allocation of precious resources that will take longer to improve.
    In writing this chapter, I also looked to other areas where there have been remarkable advances in safety and defined processes to accomplish outcomes. When one looks at the data, as of January 2009, there has not been a fatality in United States domestic air carriers due to an accident for the preceding 24 months. This accomplishment relates to the application of CRM (crew resource management) processes for safety. This is centered around pre-flight briefings/debriefings, working with checklists, and dealing with errors. The recent effectiveness of CRM was proven in a crash of US Airways flight 1549 (January 2009) into New York’s Hudson River in which all passengers and crew survived, largely on the ability of the pilot and crew to manage the scenario of power loss at takeoff due to bird strikes.
    Whether it is a manufacturing (Toyota Production System, Lean Manufacturing) or aviation-based (CRM) process for the development of a patient safety, there are two different, yet effective processes that can be adapted to produce excellent programs that will make a difference in your clinic and surgical facility.

    The process of patient safety
    While we are concerned about serious episodes in healthcare delivery that involve harm to patients, the effective remedy is not to browbeat those who deliver care by demanding that they give safer care. What is needed is a fundamental redesign of the process and ways to cross as the book mentions, the “quality chasm” in delivering both quality and safety.
    If one looks for comparisons in other areas of American industry, large hospitals compare nicely with the likes of General Motors and Ford. Quality improvement in both GM/Ford and large hospitals is an episodic adventure, goal-oriented, and too often, a “special campaign” that lacks support from the workers. Although, progress has been made in some areas, there seems to be sometimes a greater focus on the “look what we have done” instead of this is how we do something well, time and time again. The presence of an unknown individual with a clipboard on the surgical unit usually heralds yet another ill-conceived quality or safety initiative.
    There are divergent approaches to quality improvement and patient safety in medical care. For individuals who work in hospitals, there is a distinct Joint Commission of the Accreditation of Healthcare Organizations (JCAHO) “JCAHO-mindset“ regarding policies, processes, and procedures about patient safety that seem to interfere with how surgeons function and how staff thinks that an operating room should function in the real world. For individuals who work in out of hospital environments, including office based surgery units, there seems to be less preoccupation with a “JCAHO boogeyman” and more on how patient safety and care quality can be improved with each patient interaction. Currently, a majority of patient care is rendered in facilities that are outside of a “JCAHO-blessed” workplace. Published reports in the literature substantiate that outcomes are as good or better in out-of-hospital surgical facilities that are accredited by other organizations. 5
    Too often in the JCAHO, approach to providing solutions for patient safety, important components of safety and quality are overlooked. For instance, the fixation with the “time out” exercise before starting surgery only covers a single dimension of a “surgical destination,” that says what procedure is being performed and the surgical site. What’s missing here is the really important stuff, like a status check of the patient in terms of “being ready for surgery.” I cannot think of a surgeon or the captain of an airliner ready for takeoff who would be angered if a subordinate gave them a status report that covered the requisites of prophylactic antibiotics having been administered, DVT prophylaxis, warming blanket to prevent hypothermia, and the implants that you specified are in the room. Otherwise, the “time out” does not allow for effective communication in a team-oriented workplace. 6
    There is literally no way in large hospital settings to stop a faulty process once it has been placed in motion. On the other hand, there is a reliance on alternative processes called “work-arounds” to remedy a faulty process. We all have been in the uncomfortable position of having a surgery underway and discover that needed items such as implants are nowhere to be found, or that the patient did not receive prophylactic antibiotics. If this occurred in a Japanese factory, a worker would pull the Andon cord to stop the production line when a defect was noted in order to stop the line and prevent defective work from occurring.
    All plastic surgeons want to avoid the downward spiral of complications, disfigurement, disability, re-operations, emotional distress, claims for professional liability, and increased regulatory oversight. If we look to other industries, namely aviation and Toyota automotive, there have been developed surprisingly effective processes to improve quality, minimize mistakes, and change a culture of workers.
    Achievement of a superior surgical outcome should always be followed by reflection on what went right and what mistakes were avoided as a means of learning how to repeat such results consistently. Conversely, when failures occur, progress toward improvement is often impeded when we engage in unscientific analysis or resort to naïve investigations, reprisals, and secretive behavior that is often seen in institutions. 7
    For example, the problem of deep vein thrombosis with ensuing pulmonary embolism remains a vexing safety issue in all surgical patients, yet simplistic responses by state regulatory agencies to limit office-based surgery do not prevent its occurrence or morbidity/mortality in other venues. What is needed here is for the real problem to be addressed through scientific inquiry that will provide solutions. Directed research by plastic surgery foundations would be a good starting point.
    Various approaches to reducing patient injuries, improving outcomes, and decreasing the cost of healthcare delivery have been suggested by organizations concerned with improvements in patient safety. Some represent Band-Aid patches to problems; others – such as careful hand-washing and safe-site surgery – are simply common sense. Ill-conceived patient safety initiatives can impair the credibility of better-conceived attempts to improve patient safety.
    At the time of this writing, physicians lack effective knowledge-management programs with which to capture and promulgate the lessons learned from both successful and unsuccessful surgical initiatives. If organizations within plastic surgery choose to raise the performance bar to improve patient safety, it is imperative that a structured framework of research and educational initiatives be set in place that will provide a comprehensive curriculum for our community of caregivers. Ideally such initiatives will take advantage of Internet-based technology and other electronic information resources so that meaningful data can be made available quickly and easily.

    How to create a culture of safety and quality (steps you do with your staff)

    1. Identify areas where improvement is needed, i.e. your reoperation rate in breast augmentation.
    2. Establish a goal, i.e. making elective surgery safer by lowering the re-operation rate.
    3. Defining (map) the process that needs improvement.
    4. Develop documents and tools that enable the process to be defined better for patients and staff (Cycle of Care) concept.
    5. Minimize mistakes and errors that can occur in the process.
    6. Eliminate work-arounds in the process.
    7. Measure your progress against benchmark values.
    8. Institutionalize your progress and use it as a way to start other quality and safety programs.
    Here are some additional thoughts on how to develop a systematic approach to safety:

    • Put patient at center of process
    – Increase awareness and accountability for their own safety and clinical decisions
    • Safety is a management and leadership priority
    – Empower staff to troubleshoot and innovate
    – Communicate and verify safety practices
    – Help each other achieve safe outcomes
    • Staff accountability
    – Recognize and deal with staff underperformance
    – Non-punitive error reporting.
    Delivery of operational excellence requires that work-arounds are eliminated and ambiguities regarding decision areas in planning, care delivery, and patient management. As Steven Spear wrote in his Harvard Business Review article, 3 “People confront the same problems, encountered every day, for years, manifested as irritations, inefficiencies, and occasionally catastrophes.” Poor designed systems are set ups for failure and trying harder by working around the problem is not the correct way to solve it. It is only through the efforts of all involved that a better design evolves to avoid defective work or unsafe care. When caregivers are involved in the solution to a problem, there is generally improvement of a process, versus top-down management.
    At ASAPS, a dedicated group of physicians, led by James Matas MD, undertook a project to develop the “ Cycle of Care ” product. 8 This was the first time that the entire cycle of care was looked at from the first interaction with a patient until their chart was put back in the record room at the end of the care cycle. By defining a process and the critical inflection points, care could be improved. From an information systems perspective, the amount of information available to make a determination that a patient meets criteria for safe surgery helps make this a simple yes or no decision. Forms and check lists are useful for surgical planning and to document what has been accomplished in preparing for surgery ( Box 5.1 ). Aftercare teaching is equally important regarding wounds, drains, nausea, and danger signs.

    Box 5.1
    Forms and check lists for surgical planning.


    The Cycle of Care was envisioned as a “backbone” that could be customized by the end user as a way to lay out the roadmap of what happens during the care of a patient. It is an effective way to help understand what has been accomplished in preparing a patient for surgery and documents the quality of care delivered. This also helps minimize mistakes in planning for surgery, aftercare, and medications ( Fig. 5.1 ).

    Fig. 5.1 ASAPS Cycle of Care.
    In addition to the Cycle of Care concept, other areas of patient safety deserve attention. These represent significant areas where improvements can be made to prevent a majority of problems:

    1. Timely administration of IV antibiotics before surgery.
    2. Avoidance of hypothermia during and after surgery.
    3. DVT prophylaxis (foot pumps and fractionated heparin).
    4. Avoidance of dry eyes during deep sedation or general anesthesia.
    5. Effective management of lidocaine-containing wetting solutions along with volumes of lipoaspirate during lipoplasty.
    6. Documentation of allergies, currently used prescription and over-the-counter medications, herbal/dietary supplements, and smoking status during the preoperative planning for surgery.
    7. Placing the patient at the center of the process by having increased awareness and accountability for their own safety and clinical decisions.

    Specific “problematic” topics in patient safety

    Methycillin-resistant Staphylococcus aureus (MRSA)
    The matter of MRSA whether community-acquired or hospital-acquired is problematic even in a practice that is oriented towards aesthetic surgery 9 . It requires a different mindset for all caregivers in terms of meticulous hand washing, use of alcohol or alcohol-chlorhexidine hand sanitizers, protective gloves, disposal of medical waste, and sanitation of the patient care areas and surfaces. MRSA can be brought into the office by something as innocuous as a stitch abscess or impetigo on a child who is accompanying their parent during an office visit. Suspected infections in patients should be cultured and MRSA-effective drugs administered, if a Gram-stain is positive for cocci, pending culture and sensitivities to confirm MRSA.

    Smoking and nicotine use
    Smoking remains an area of risk in aesthetic surgery. Rees, 10 in 1984, described a 13-fold increase in skin necrosis in smokers undergoing rhytidectomy. Other reports show increased risk for other procedures involving flaps. Nicotine remains a very addictive drug, with a high rate of recidivism in those trying to stop its use. I have found it necessary to give patients enough time to successfully stop smoking before surgery of 6 weeks versus shorter periods of time. There still is no consensus on what is the minimum amount of time that a patient has to be 100% smoke-free to be safe from nicotine-induced skin necrosis. It is useful in the preoperative examination to have a patient attest to their smoking and nicotine status. If there is concern regarding compliance, a dipstick urinary continine test can be performed. I have found it helpful not to do the testing on the day or surgery, but two weeks before the scheduled date in order to have time to fill the time, if the test is positive and surgery cannot be performed. 11

    Deep vein thrombosis (DVT)
    Even in aesthetic surgery, DVT can occur. Reinisch studied DVT during rhytidectomy and noted 84% of the DVT and pulmonary embolisms were associated with general anesthesia. 12 The take-home message here is that effective measures such as foot pumps or sequential compression stockings must be used to minimize risk. Chemoprophylaxis with low molecular weight heparin, interestingly added the risk of a 16% hematoma complication. 13
    Abdominoplasty remains a situation with increased morbidity and mortality as compared to other aesthetic procedures. There has been surprisingly no research into why abdominoplasty is 20 times more lethal than lipoplasty. 14 DVT prophylaxis, early mobility, and the avoidance of Foley catheters and bedpans appear to be successful in diminishing the risk of complications. 15
    The matter of estrogen supplements and oral contraceptives still lacks consensus regarding management in the perioperative period. If you elect to have a policy on the discontinuation of oral contraceptives by patients undergoing elective surgery on grounds that you are trying to diminish risk of DVT, be certain to recommend alternative forms of birth control.

    Lipid emulsions for the treatment of lidocaine/bupivicaine toxicity
    The use of Intralipid as a means to resuscitate asystole and CNS toxicity is a novel approach to treat lidocaine and bupivicaine toxicity. 16 Additional information may be found at www.lipidrescue.org

    Beta-blockers in patients undergoing elective surgery
    The use of beta-blockers in patients with documented coronary artery disease has been shown to decrease mortality. While most aesthetic surgery patients are ASA I–II classification, there are individuals that are ASA III, with stabilized systemic disease, hypertension, coronary artery disease, who seek aesthetic and reconstructive procedures. The use of beta-blockers to mitigate perioperative myocardial infarction and arrhythmia is a consideration. 17

    Plavix®/aspirin withdrawal in patients who have cardiac stents
    The use of stent devices for the treatment of coronary artery disease is commonplace. Besides the use of drug-eluting stents to limit restenosis, adjunctive treatment includes anti-platelet drugs such as aspirin and Plavix ® (clopidogrel). Decisions to withdraw stent patients from the anti-platelet therapy deserve forethought and discussion with the patient’s cardiologist. Informed consent discussions in stent patients is essential to cover the potential for myocardial infarction and stent occlusion. Late stent thrombosis can occur in situations where patients have completed the recommended 12 months of anti-platelet therapy. 18


    Summary
    As a surgeon, you are in the best position to define a culture of safety and quality both in the office and your surgical unit. Much progress can be made in quality and safety if you look at the cycle of care and determine where improvement is needed. If problems occur, take the time to analyze the mistakes that were made and improve the process versus making the same mistake twice. The ASAPS Cycle of Care product is an excellent starting point for you to develop a process of safety and quality.

    References

    1. Institute of Medicine. Crossing the quality chasm . National Academies Press; July 2001. 337 pp
    2. Corrigan J, Kohn L, Donaldson M. To err is human: building a safer health system , 1st edn. National Academies Press; 15 April 2000. 287 pp
    3. Spear S. Fixing healthcare from the inside, today. Harvard Business Review . September 2005.
    4. Graban M. Lean Hospitals: Improving quality, patient safety, and employee satisfaction, 1st edn, Productivity Press, University Park, IL
    5. Jewell M. Medical errors in aesthetic plastic surgery. Aesthet Plast Surg . 2003;23(2):108–109.
    6. Keyes G, Singer R, Iverson R, McGuire M, Yates J, Gold, Thompson D. Analysis of outpatient surgery center safety using an internet-based quality improvement and peer review program. Plastic Reconstr Surg . 2004;113(6):1760–1770.
    7. Jewell M. Patient safety data: how it can improve our performance. Aesthet Surg J . 2004;24(4):346–348.
    8. The American Society for Aesthetic Plastic Surgery. Cycle of Care Workbook. ASAPS . 2006.
    9. Chambers H. Community acquired MRSA-resistance and virulence converge. NEJM . 2005;352:1485–1487.
    10. Rees T, Liverett D, Guy C. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plastic Reconstr Surg . 1984;73(6):911–915.
    11. Jewell M. Smoking in plastic surgery. In: ASPS Patient Consultation Resource Book . The American Society of Plastic Surgeons; 2006.
    12. Reinisch J, Bresnick S, Walker J, Rosso R. Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis. Plastic Reconstr Surg . 2001;107(6):1570–1575.
    13. Durnig P, Jungwirth W. Low-molecular-weight heparin and postoperative bleeding in rhytidectomy. Plast Reconstr Surg . 2006;118(2):502–507.
    14. Hughes C. Reduction of lipoplasty risks and mortality: An ASAPS survey. Aesthet Surg J . 2001;21:120–127.
    15. Stevens WG, Vath S, Stoker D. “Extreme” cosmetic surgery: a retrospective study of morbidity in patients undergoing combined procedures. Aesthet Surg J . 2004;24:314–318.
    16. Weinberg G. Lipid rescue resuscitation from local anaesthetic cardiac toxicity. Toxicol Rev . 2006;25(3):139–145. [Review] –
    17. Poldermans D, Boermsa E. Beta-blocker therapy in non-cardiac Surgery. NEJM Editorial . 2005;353:412–414.
    18. Vaknin-Assa H, Assali A, Ukabi S, Lev EI, Kornowski R. Stent thrombosis following drug-eluting stent implantation. A single-center experience. Cardiovasc Revasc Med . 2007;8(4):243–247.
    Section 3
    Facelift
    CHAPTER 6 Facelift anatomy, SMAS, retaining ligaments and facial spaces

    Bryan Mendelson
    Anatomically correct facial rejuvenation surgery is the basis for obtaining natural appearing and lasting results. The complexity of the anatomy of the face, and especially that of the midcheek, accounts for the formidable reputation of facial surgery. This is to the extent that many surgeons design their rejuvenation procedures around an avoidance of anatomical structures, and thereby limit the intent to camouflaging of the aging changes.
    The purpose of this chapter is to establish a foundation for the advancement of facial rejuvenation surgery by defining clear general principles as the basis for a sound conceptualization of the facial structure.
    A proper anatomical understanding is fundamental to mastery in facial rejuvenation for several reasons. The pathogenesis of facial aging is explained on an anatomical basis, and particularly the variations in individual patients. This is the basis of preoperative assessment from which follows a rational plan for the correction of the changes. The anatomy explains the differences between the many procedures available and the apparent similarities in their results. An accurate intraoperative map of the anatomy is essential for the surgeon for efficient and safe operating with minimal morbidity, and specifically addressing appropriate concern for the facial nerve.

    Functional evolution of the face
    The anatomy of the face is more readily understood when considered from the perspective of its evolution and the function of its components ( Fig. 6.1 ). Located at the front of the head, the face provides the mouth and masticatory apparatus at the entrance to the embryonic foregut, as well as being the location for the receptor organs of the special senses: eyes, nose and ears. The skeleton of the face incorporates a bony cavity for each of these four structures. Those for the special senses have a well-defined bony rim, in contrast to the articulated broad opening of the jaws covered by the oral cavity. The soft tissues of the face, integral to facial beauty and attraction, are in reality, dedicated entirely to their functions.

    Fig. 6.1 Functional evolution of the facial skeleton, from the primordial vertebrate, fish through to the primate chimpanzee (center) and to the human. The facial skeleton supports four bony cavities whose size and location relate to their specific function. The eyes move to the front for stereoscopic binocular vision, while the nasal aperture is reduced, due to the lesser importance of olfaction. The ear remains in its original location, at the back of the face. The location of the orbits alters subsequent to cranial growth, which creates a new upper third of the face.
    The soft tissue overlying each cavity undergoes modifications to form the cheeks, including the lips, the eyelids, the nose, and the ears. For each there is a full thickness penetration through the soft tissue, around which superficial facial muscles are located for control of the aperture of the functioning shutter. This is most evident for the lids and lips in the human. While the primary function of the sphincteric shutters is to protect the contents of the cavities, they are further adapted to a higher level of functioning for the additional roles of expression and communication. The degree of precision required for this important secondary function requires the muscles to be more finely tuned and the soft tissue fixation modified, to allow mobility. The balance between these two opposing functions, movement and stability, is integral to the facial structure. Aging brings with it a change of the youthful balance, leading to an altered expression on activity and at rest. It is a major surgical challenge to restore the youthful balance following rejuvenation surgery and to have normal dynamic appearance.


    Principle
    The combination of continued movement and delicate fixation of the tissues is the basis for the ligamentous laxity that predisposes to the characteristic sagging changes of the aging face.

    Regions of the face
    The traditional approach to the face in thirds (upper, middle and lower) while useful, limits conceptualization, as it is not based on the evolving structure. The significant muscles of facial expression are all located on the front of the face (anterior aspect) predominantly around the eyes and mouth, where their effect is seen in communication. For these functional reasons the anterior aspect of the face contains the more delicate expressive areas, which are prone to developing aging changes ( Fig. 6.2 ).

    Fig. 6.2 Regions of the face. The fixed lateral face (shaded) overlies the masticatory structures and is separated from the mobile anterior face by the vertical line of facial ligaments (red). These ligaments are, from above: temporal, lateral orbital, zygomatic, masseteric and mandibular. The muscles of facial expression are within the anterior face. The midcheek is split obliquely into two separate functional parts in relation to the two adjacent cavities. The periorbital part above, (blue) and the perioral part below (yellow), share the midcheek and meet at the midcheek groove (oblique dotted line).
    In contrast, the lateral face is relatively immobile as it passively overlies the structures to do with mastication, which are all deep to the investing deep fascia. These are the temporalis and masseter on either side of the zygomatic arch, along with the parotid and its duct. The only superficial muscle in the lateral face is the platysma in the lower third, which reaches no higher than the oral commissure. Internally, a distinct boundary separates the mobile anterior face from the lateral face. The vertically oriented line of retaining ligaments attached to the facial skeleton forms this boundary ( Fig. 6.2 ).


    Principle
    The anterior aspect is the region of the face requiring rejuvenation.
    From the perspective of priorities in rejuvenation surgery, the midcheek is the most important area of the face, because of its prominent central location between the two facial expression centers, the eyes and the mouth. The periorbital and the perioral parts overlap in the midcheek ( Fig. 6.2 ). The periorbital part overlies the body and orbital process of the zygoma, while the perioral part overlies the maxilla, a bone of dental origin. The functional parts are inherently mobile and meet at the relatively immobile boundary that extends in an oblique line across the midcheek. This is the midcheek groove formed by the dermal extensions of the zygomatic ligaments ( Fig. 6.3 ). 1

    Fig. 6.3 The internal structure of the midcheek is revealed by its surface anatomy when aging changes are present. The two functional parts of the midcheek relate to the underlying cavities and are separated by the oblique line of the midcheek groove (3) which overlies the skeleton. The midcheek has three segments. The lid–cheek segment (blue) and the malar segment (green) are within the periorbital part and are adjacent to the nasolabial segment (yellow) in the perioral part, which overlies the vestibule of the oral cavity. The three grooves defining the boundaries of the three segments interconnect like the italic letter Y . The palpebromalar groove (1) overlies the inferolateral orbital rim and the nasojugal groove (2) overlies the inferomedial orbital rim, then continues into the midcheek groove (3). Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek segments Clin Plast Surg 2008;35:395–404.
    The soft tissue of the anterior face is further subdivided according to: where it overlies the skeleton and: where it overlies a bony cavity. The soft tissue is modified where it forms the lid and the mobile cheek because there is no underlying deep fascia. The transitions that define the part of the cheek overlying bone (the malar segment), and the mobile extensions (lower lid and the mobile cheek, nasolabial segment) are not visible in youth due to the shape of the youthful midcheek, which has a compacted rounded fullness. Subsequently, these transitions do become visible due to aging laxity in the midcheek.

    The facial nerve in relation to regions of the face
    The level in which the facial nerve branches travel relates to the region of the face ( Fig. 6.4 ). In the lateral face below the zygomatic arch the branches remain deep to the investing deep fascia. In the anterior face (and above the lower border of the zygoma) the branches are more superficial in relation to their muscles. The transition in levels occurs at the retaining ligament boundary, which is the last position of stability before the mobile anterior face. The nerves are protected here as they course outward to their final destination

    Fig. 6.4 The layers of the face. The five layers of the scalp are a prototype of facial anatomy and the simpler basis for the more complex structure elsewhere on the face. Layer 4 is the most changed layer, consisting of alternating spaces and ligaments. The course of the facial nerve changes level at the ligamentous boundary transition from the lateral to the anterior face. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek segments; Clin in Plast Surg 2008;35:395–404.

    Layers of the face
    The principles of facial structure can be summarized quite simply:

    1. The scalp is the basic prototype for understanding facial anatomy, as it is the least differentiated part of the face ( Fig. 6.4 ).
    2. The face is constructed of concentric soft tissue layers over the bony skeleton.
    3. The five layers of the scalp are: (i) skin; (ii) subcutaneous; (iii) musculo-aponeurotic; (iv) areola tissue; (v) deep fascia.
    4. The layers are not homogenous over the face proper, as they are modified in areas of function.
    5. The key areas of function overlie the bony cavities , especially the eyelids and the cheeks and mouth.
    6. A multilinked fibrous support system supports the dermis to the skeleton ( Fig. 6.5 ). The components of the system pass through all layers. 2
    7. At the transition between that over the skeleton to that overlying the cavities (eyelids and mouth) there is a modification of the anatomy.
    8. The complexity of the facial structure results from the balance required between mobility and stability (ligamentous support).

    Fig. 6.5 The ligaments of the multi-link fibrous support system of the face can be likened to a tree. This system attaches the soft tissues to the facial skeleton; it links all layers of the face. The retaining ligaments are attached to the periosteum and deep muscle fascia and fan out via a series of branches into and through the SMAS. In the outer part of the subcutaneous layer, the increased number of progressively finer retinacular cutis fibers securely grasp the dermis.
    It should be remembered that the complexity of the facial structure is entirely due to the bony cavities and their functional requirements. Transitional anatomy occurs at the boundary of the cavities, as in the scalp where the complexity of the glabella occurs where the forehead adjoins the orbital and nasal cavities. Here, the deeper facial muscles and related retaining ligaments attach to the skeleton.

    Details of the layers

    Layer one – skin
    The structural collagen of the dermis is the outermost part of the fibrous support system and is intrinsically linked, both embryologically and structurally, with the collagenous tissue of the deeper layers. The thickness of the dermal collagen relates to its function, and tends to be in inverse proportion to its mobility. The dermis is thinnest on the eyelids and thickest on the forehead and nasal tip. The thinner, more mobile dermis is susceptible to an increased tendency for aging changes.

    Layer two – subcutaneous
    The subcutaneous layer has two components: (i) the subcutaneous fat , which provides volume and mobility, is supported by (ii) the fibrous retinacular cutis that connects the dermis with the underlying SMAS. Both components vary in amount, proportion and arrangement according to the specific region of the face.
    In the scalp, the subcutaneous layer has a uniform thickness and consistency of fixation to the overlying dermis, whereas, over the face proper, the subcutaneous layer has considerable variation in thickness and attachment. In the high function mobile areas bordering an aperture such as the pretarsal part of the eyelid and the lips, this layer is compacted and subcutaneous fat is not present, so that the layer appears to be non-existent.
    Each of the three midcheek segments has a distinctly different thickness of subcutaneous fat. The subcutaneous layer is thinnest in the lid–cheek segment adjacent to the lid proper. In the malar segment the layer is moderately thick and uniform, whereas it is markedly thicker in the nasolabial segment, which has the thickest layer of subcutaneous fat of the face. Where the subcutaneous fat is thicker, the retinaculum fibers are lengthened and more prone to weakness and distension. The thick subcutaneous fat in the nasolabial segment is named the malar fat pad , which is confusing terminology given that its position is predominately medial to the prominence of the zygoma in the perioral part of the midcheek 3, 4 ( Fig. 6.2 ).
    Within the subcutaneous layer, the attachment to the overlying dermis is stronger than on its deep surface, due to the tree-like arrangement of the retinacular cutis fibers ( Fig. 6.5 ). In superficial, i.e. subdermal, dissection of the subcutaneous layer, many fine retinacula cutis fibers are encountered. At the interface with the underlying layer 3, there are fewer, though larger fibers and less subcutaneous fat, which appears not to descend fully to the interface where it overlies the superficial muscles, orbicularis oculi and platysma.
    This explains why surgically the subcutaneous layer can be more easily dissected off the outer surface of the underlying muscle layer (orbicularis oculi and platysma) than over other parts of layer 3.
    The retinacular fibers are not uniform across the face, but vary in their orientation and arrangement according to the region. This variation mirrors the anatomy of the underlying 4th layer. As will be more apparent when the 4th layer is discussed, the line of retaining ligaments continue vertically through the subcutaneous layer to form septae, that form boundaries which compartmentalize between more mobile areas. 5 Accordingly, where the subcutaneous layer overlies spaces (in the 4th layer) there are no vertically oriented subcutaneous ligaments extending through. In contrast, the retinacular fibers overlying the spaces have a predominantly horizontal orientation, being in strata-like layers that are less restrictive to underlying movement.


    Clinical correlation 
    The variation in the arrangement of the retinacular cutis fibers accounts for the variability in ease of subcutaneous dissection between different parts of the face. Where the subcutaneous dissection overlies a space and the retinacular cutis fibers are more horizontal, the subcutaneous layer tends to separate relatively easily, often with simple blunt dissection. Where the subcutaneous dissection directly overlies a facial ligament, the vertical septae are responsible for a firmer adhesion between the SMAS and the dermis. Sharp dissection is usually required for release here.

    Layer three – musculo-aponeurotic
    To fulfill its functional role, the face contains skeletal muscle within its soft tissue structure. These ‘intrinsic’ muscles of facial expression are fundamentally different to skeletal muscles beneath the deep fascia, which move bones, because they move the soft tissues of which they are a part. All the muscles of the face are within this layer, enclosed to a varying degree within a fascial covering and lining. The muscles are all derived from the embryonic second branchial arch. The muscle precursors migrated into the facial soft tissues in a series of laminae, each lamina being innervated by its own branch of the facial nerve. While the definitive muscles have subsequently lost continuity with their origin, the facial nerve branches remain, like the vapor trail of an airplane, as an indicator of the migratory path.

    Fig. 6.6 Evolution of the facial muscles. The migratory path of the evolving muscles, including their connections and the multiple levels of the muscles, explain the definitive location of the facial nerve branches. The mandibular lamina splits into two trunks around the oral cavity. The upper trunk, the infraorbital lamina separates early for the developing midcheek while the mandibular lamina continues into the lower third. The two laminae later reconnect at the modiolus, which explains the two buccal trunks of the facial nerve. The infraorbital lamina in turn splits around the orbital cavity as well as branching to different depth levels.
    In the anterior face, the migrated muscle masses are mainly located over and around the orbital and oral cavities. The double innervation of corrugator supercilii demonstrates the dual origins of the muscle from the supraorbital as well as the infraorbital migrating muscle mass.
    In the prototype scalp, the third layer demonstrates key principles about the facial muscles. The superficial muscle, occipito-frontalis, moves the overlying soft tissues including the skin of the scalp and forehead. While the muscles have a minimal area of bony origin, which is remote (on the superior nuchal line), they have an extensive area of insertion into the overlying soft tissues.
    The fibrous sheath enclosing the frontalis and occipitalis is continuous across the entire scalp, whereas the enclosed muscles are discontinuous. Where the fascia is present without intervening muscle, the superficial and deep layers of the sheath are apposed and fused to form the galea aponeurotica . This is the basis for the aponeurotic part of the 3rd layer. The superficial fascial layer is thin where it overlies the muscle, and in areas such as over the forehead, muscle fibers extend into the subcutaneous layer. In contrast, the deep layer of the fascia is thicker, more supporting and provides a gliding surface at the interface with the underlying 4th layer. The original description of the SMAS (superficial muscloaponeurotic system) in 1976 was essentially a description of this 3rd layer, as is applies to the mid and lower thirds of the face. 6 The flat superficial muscle component predominates in some areas of layer 3, while in areas without muscle the aponeurotic element predominates.
    When a scalp flap is elevated, the flap naturally separates from the periosteum following release of minimal attachments in layer 4. A scalp flap, being a natural fusion of the outer three layers, is a composite unit , both anatomically and functionally. The fibrous component of the outer three layers is the superficial fascia of the face . The SMAS is the deepest of the three layers of the composite unit. In the mid and lower face the composite structure is also present, although less obviously apparent.


    Principle
    A composite flap is a naturally integrated anatomical structure.
    Layer 3 is a continuous generic layer of the face, which for descriptive purposes has different names to locate the particular part of the superficial fascia. Galea is the name of the scalp part and temporoparietal fascia where this layer extends over the temple, whereas over the orbital rim and upper cheek it is the orbicularis muscle and its fascia.
    The definitive muscles in level 3 have a layered arrangement. The broad flat muscles form the superficial layer that covers the anterior aspect of the face: frontalis overlies the upper third and orbicularis oculi the middle third. The platysma, over the lower third extends onto the lateral face, presumably related to jaw movement, which functionally dominates the lower third. The superficial muscles are more closely related to the overlying subcutaneous layer than they are to the deeper structures. The superficial flat muscles have a minimal direct attachment to the bone. They are indirectly stabilized to the skeleton by a ligament, located at the lateral border of the muscles. The frontalis is fixed by the superior temporal ligament along the superior temporal line, the orbicularis oculi is stabilized by the main zygomatic ligament at its inferolateral border and the platysma is stabilized at its upper border by the upper key masseteric ligament ( Fig. 6.15 ).
    The composite three-layer structure of the face suggests it would be no less logical to use the SMAS as a ‘surgical carrier’ for the overlying soft tissue layers, than it is with a scalp flap.
    The deeper muscles within layer 3 are concentrated only in areas of greater function, which is to do with the bony cavities. For the upper third they are corrugator supercilii and procerus. Around the oral cavity, the deeper muscles are the elevators (zygomaticus major and minor, levator labii superioris, levator anguli oris) and depressors (depressor anguli oris, depressor labii inferioris) of the oral sphincter. Compared to the superficial muscles, the deep muscles arise from a relatively larger origin on the skeleton close to the target soft tissue and have a short course through layer 4 to a more focused area of insertion. Interestingly, the deeper intrinsic muscles of the eyelids, the levator and capsulopalpebral fascia arise not from these facial muscles, but have an orbital origin.

    Layer four
    In the scalp, layer 4 is a gliding plane, without structure, other than the loose areolar tissue that allows movement of the overlying composite superficial fascia secondary to contraction of occipito-frontalis. There are no structures traversing the layer and impeding movement. However, where the scalp is attached at its boundary with the temple along the superior temporal line and across the superior orbital rim there is a form of ligamentous attachment. This anatomical arrangement illustrates the basic pattern of layer 4.
    In the scalp the anatomy of the fourth layer is so inherently simple and safe for surgery that a subgaleal scalp flap is the easiest and most natural layer in which to dissect. In contrast, layer 4 over the face proper, is the most complex and most dangerous level to dissect. This complexity results from the compaction of the midcheek components during vertebrate evolution, such that the cavities and the structures to do with their dynamic activity are in such close approximation that they overlap. In addition, layer 4 is the battleground in which the fight between mobility and stability is played out.
    The following structures are contained within layer 4, but each is distributed in different areas:

    1. Retaining ligaments of the face.
    2. The deep layer of the intrinsic muscles.
    3. Soft tissue spaces.
    4. Non-mobile areas of important anatomy.
    5. Facial nerve branches.
    The complexity of the anatomy within layer 4 becomes simplified when it is understood how these structures are arranged. The following principles assist with this understanding:

    • Overlying the skeleton, layer 4 is essentially composed of a series of ‘spaces’ and non-mobile areas of important anatomy.
    • The spaces are mobile functional areas. Each space has a definite boundary and minimal fixation.
    • The boundaries tend to be the least mobile part of the soft tissue.
    • The retaining ligaments are located within and reinforce the boundaries that separate the different functional areas.
    • The intrinsic muscles of the deeper layer attach to the bone within the boundaries.
    • Superficially, the muscles insert into the mobile soft tissues in layer 3, in the area of maximum mobility.
    • All the deep muscles of clinical significance attach to the bony border of the oral cavity.
    • The retaining ligaments and muscle origins share a bony origin at the boundary.
    • A line of ligamentous attachment continues around the perimeter of the bony cavities.


    Principle
    The five-layered soft tissue anatomy should be considered in its two variants:

    1. that overlying the skeleton, and
    2. that overlying the bony cavities.
    To allow physical movement of the soft tissue over the rigid skeleton subsequent to contraction of the superficial muscles, the soft tissue of the face incorporates a unique anatomical arrangement in the form of a series of spaces. Movement is possible only because of the presence of spaces beneath the muscles. The spaces are located between places of fixation. The facial spaces are in two forms:

    1. Spaces provided by the bony cavities; the preseptal and conjunctival spaces of the eyelids within the orbit and the vestibule of the oral cavity beneath the lips and the nasolabial segment of the cheeks.
    2. Soft tissue spaces overlying the facial skeleton between the bony cavities. The series of tissue spaces between level 3 and level 5 are voids in the attachment of the mobile soft tissues to the underlying skeleton.


    Fig. 6.7 Relationship between muscles and underlying spaces. Movement occurs where there is muscle in layer 3 and a related space in layer 4. The spaces are, from above: the preseptal space of the lower lid, the prezygomatic space, the masticator space for the buccal fat pad and the premasseter space.


    Principle
    Where there is a muscle in the face there is always a related space.
    The significance of the spaces is only now becoming appreciated. The spaces are not only essential for function; their presence explains much about the changes that occur with facial aging. The appearance with aging of malar mounds, jowls and labiomandibular folds is due entirely to changes of previously unrecognized facial soft tissue spaces. 7

    Retaining ligaments of the face 
    The retaining ligaments of the face are located in specific locations. 8, 9 These are in between areas of movement (spaces). The trunks of the ligaments pass out through layer 4 as part of the multilinked fibrous support system . 2, 10 These structures were not originally thought of as being ligaments as they are not part of the musculoskeletal system and do not have the typical appearance of ligaments, such as the cruciate ligament. However, a ligament is, by definition, a fibrous structure that binds or ties adjacent structures. The soft tissue ligaments take varied forms consistent with the functions of the face.

    Fig. 6.8 The three morphologic forms of facial ligaments. Moss CJ, Mendelson BC, and Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 2000;105:1475.
    The lateral face immediately in front of the ear is not a mobile area. This zone of no movement extends forward of the ear cartilage for 25 to 30 millimeters due to an important, but little appreciated, area of ligamentous attachment the platysma auricular fascia (PAF). 11 The PAF is unique because it is two layers formed into one structure. It consists of a diffuse area of layer 4 ligament that binds the SMAS with the underlying parotid masseteric fascia and parotid capsule. It includes the part of the SMAS (layer 3) between the ear cartilage and posterior border of the platysma. It is both part of the SMAS (layer 3) as well as ligament (layer 4). The retinacular cutis overlying the PAF is ‘dense’ because it does not overlie a space. Forward of the anterior border of the PAF where the platysma is present, the soft tissue layers are mobile.

    Clinical correlation 
    The unique qualities of the PAF are important for facelifting. When a traditional SMAS facelift is performed it is not easy to elevate the preauricular SMAS (as it involves splitting the fused components of the PAF). This dissection is difficult because it is not a natural plane of separation as it is, for example, when elevating the SMAS where it overlies a space. The fused PAF gives strength to the tissues, which is an advantage for holding sutures used to fix the advanced mobile SMAS and posterior platysma.
    If tightening laxity of the anterior face is to be achieved, when operating through the lateral face, the surgeon must bypass the vertical line of retaining ligaments if they remain sufficiently strong to be providing resistance to any traction effect ( Fig. 6.10 ).

    Fig. 6.10 Concept of level 4 of the anterior face. Note the ligamentous boundaries around the entrance to both bony cavities and areas of reinforced ligament.
    In the anterior face the ligaments are arranged around the entrance of each bony cavity. As there are not any retaining ligaments from within the bony cavities to provide support for the mobile shutters of the lids and lips, there is a compensatory gathering of the ligaments at the last place available for skeletal support.

    Sub-SMAS facial spaces 
    The sub-SMAS layer 4 is largely composed of ‘spaces’. 7 These intervals have defined boundaries and in the boundaries are located the retaining ligaments. The spaces are by definition safe spaces , because there are no structures within and no structures cross through the spaces. This is important for the surgeon, as all facial nerve branches are outside the spaces. Because spaces allow movement, laxity develops more of the space than occurs in the ligamentous boundaries. This differential laxity accounts for much of the characteristic changes of aging.


    Principle
    The soft tissue spaces offer the surgeon ‘predissected’ areas, which avoids the need for dissection. This means reduced bleeding, bruising and risk of facial nerve trauma.
    When operating in the upper temporal space , in the interval between the superficial temporal (temporoparietal) fascia and the surface of the underlying deep temporal (temporalis muscle) fascia, simple blunt dissection only is sufficient to separate the loose areolar tissue and convert a potential space into a real space. A different surgical approach is required when the ligamentous boundaries are released as the temporal branches of the facial nerve branches are in proximity.
    The ligamentous boundary that separates the forehead space from the upper temporal space is the superior temporal septum , which originates along the superior temporal line (the zone of fusion). 8 Within the temple a second fibromembranous ligamentous structure, the inferior temporal septum , crosses the outer surface of the deep temporal fascia and separates the upper temporal space from a lower triangular-shaped zone containing detailed temporal anatomy. The superior temporal septum and the inferior temporal septum meet at the respective corners of the triangular-shaped temporal ligament (also called orbital), 12 an area of ligamentous adhesion to the underlying periosteum and adjacent deep temporal fascia ( Fig. 6.11 ). 13

    Fig. 6.11 Ligamentous anatomy of the temple and the upper temporal space. The boundaries of the space are the superior temporal septum (STS) and inferior temporal septum (ITS), which are extensions of the temporal ligament adhesion (TLA). No structures cross the temporal space. The TLA continues medially as the supraorbital ligamentous adhesion (SLA). Inferior to the temporal space is the triangular-shaped area of detailed temporal anatomy (stippled). Crossing level 4 in this area are the medial and lateral branches of the zygomatico-temporal nerve (ZTN) and the sentinel vein. The temporal branches of the facial nerve (TFN) course on the underside of the temporoparietal fascia over the area immediately inferior to the inferior temporal septum. The periorbital septum (PS; green) is on the orbital rim at the boundary of the orbital cavity. The lateral orbital thickening (LOT) and the lateral row thickening (LBT) are parts of the periorbital septum. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 2000;105:1475.
    As seen in the prototype forehead and temple, the fourth layer is composed of a series of spaces that are separated by boundaries containing the facial ligaments, the deeper facial muscles and facial nerve branches. Because of the greater movement of the middle and lower thirds of the face, soft tissue spaces are more required.
    The prezygomatic space overlies the prominence of the body of the zygoma and allows displacement of the orbicularis oculi, pars orbitale, in its roof ( Fig. 6.12 ). 14

    Fig. 6.12 A&B , The prezygomatic space overlies the body of the zygoma. The origins of the zygomatic muscles extends under the floor. The roof is formed by the orbicularis oculi lined by the SOOF (suborbicularis oculi fat). The upper ligamentous border formed by the orbicularis retaining ligament is not as strong as the zygomatic ligament reinforced lower border. Mendelson BC, Muzaffar AR, and Adams WP, Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002;110:885.
    The triangular-shaped space correlates with the shape of the bony platform and is bounded above by the orbicularis retaining ligament and inferomedially by the line of zygomatic ligaments. Contraction of the overlying muscle results in visible zygomatic smile lines inferior to the horizontal crows feet lines. With aging laxity of the roof these zygomatic lines become increasingly prominent and may eventually be present at rest. Further laxity may result in a bulge of the roof of the space at rest, the so-called malar mounds, or malar bags (also called malar crescent). The presence of these changes indicates laxity of the orbicularis for which tightening is the treatment. When operating in the prezygomatic space it is logical and inherently safer to use blunt dissection with an appropriate surgical instrument, or finger. 15
    The premasseter space in the lower third of the lateral face is analogous with the temporal space in overlying the deep fascia of a muscle of mastication. 10 Opening of the jaw without restriction from the overlying soft tissue requires that movement of the soft tissues be provided by the premasseter space. Eventually, laxity develops in the platysma roof of the space and its attachment along the inferior and anterior boundaries leading to the bulging that forms the jowl and the labiomandibular fold ( Fig. 6.13 ).
    The masticator space (also called the buccal space because of its content, the buccal fat pad) is different in character being on the anterior face ( Figs 6.7 , 6.13 ). It underlies the midcheek medial to the masseter. Similar to the oral cavity, the masticator space facilitates movement of the overlying nasolabial segment of the midcheek. Aging results in weakness of support of the boundaries and roof especially from attrition of the masseteric ligaments. As a result, the platysma becomes less closely bound to the masseter, allowing the masticator space to bulge inferiorly below the level of the oral commissure and into the lower face ( Fig 6.15 ). With major descent, the buccal fat comes to overlie the anterior border of the lower masseter, such that the fullness of the displaced fat increases the prominence of the labiomandibular fold.

    Fig. 6.13 The rhomboidal-shaped premasseter space overlies the lower half of the masseter. The roof of the space is formed by platysma in the SMAS. The posterior border is defined by the anterior edge of the strong PAF and the anterior border is reinforced by the masseteric ligaments near the anterior edge of the masseter. The inferior boundary is mesenteric-like and does not contain any ligament. Weakness of attachment of the platysma roof at the inferior boundary leads to the formation of the jowl directly behind the strong mandibular ligament. The masticator space containing the buccal fat is anterior to the upper masseteric ligaments. All facial nerve branches course around and outside the space. The surgically important mandibular branch, after leaving the fixed PAF, courses under the inferior boundary of the space then rises onto the highly mobile outer surface of the mesenteric inferior border before reaching the mandibular ligament.
    With kind permission from Springer Science+Business Media: Surgical anatomy of the lower face; the premasseter space, the jowl, and the labiomandibular fold. Aesth Plast Surg 2008; 32(2), 185–195, Mendelson, Freeman et al., Figure 3. 10
    Surgical access to the masticator space is through the weakened borders with the adjacent spaces, either the premasseter space or oral cavity or the periosteum over the lower zygoma.

    Areas of important anatomy 
    Over the lateral face, on either side of the zygomatic arch, are two similar areas containing important anatomy ( Fig. 6.9 ). These have not been specifically mentioned in the surgical literature, so for purposes of description they are named here as the lower temporal and upper masseteric areas of important anatomy, as they are neither spaces nor ligaments. By definition they are not spaces, as they contain anatomical structures and are not lined by membrane. They both have soft fat protecting their contents, and can be gently opened, like a space using precise dissection.

    Fig. 6.9 Topographical anatomy of level 4 over the lateral face. Ligaments (red), spaces (blue) and the areas of important anatomy (stippled). The largest area of ligament, the PAF, dominates the posterior part of level 4 at the least mobile part of the face. The lateral face transitions into the anterior face at the vertical line of retaining ligaments. Immediately above and below the arch of the zygoma are the triangular-shaped areas that contain the important anatomy proceeding from the lateral face into the anterior face.
    The lower temporal area of important anatomy between the upper temporal space and the arch is the passageway from the lateral face into the upper third ( Fig. 6.11 ). The temporal branches of the facial nerve are suspended from the roof in a wafer-like strata of protective fat, immediately inferior to the inferior temporal septum. The contents, which cross the area from deep to superficial, include both zygomatico-temporal nerve branches and the sentinel vein.
    The upper masseteric area of important anatomy, between the inferior border of the arch and the premasseter space is the route from the lateral face through to the midcheek and upper jaw. Here, structures course along, but do not cross from deep to superficial. These include the anterior extension of the parotid gland, its accessory lobe and the parotid duct. The zygomatic branch is above and the upper buccal trunk of the facial nerve is inferior to the duct.
    Careful dissection in this area may be required to access the lateral zygomatic and upper masseteric ligaments.

    Facial nerve branches 
    Confidence in the performance of facial surgery comes from understanding the course of the facial nerve branches, and this is based on the anatomy of the facial layers as previously described. The nerve branches remain deep to layer 5 in the lower two thirds of the lateral face. The final pathway of the nerves to the anterior face is on the underside of the muscles in layer 3.

    Clinical correlation 
    The facial nerve branches are ‘at greatest risk’ where they transverse layer 4 to access layer 3. The nerves cross this level in predictable locations, in relation to the vertical ligamentous line defining the lateral face/anterior face transition where they are under the protection of the retaining ligaments ( Figs 6.4 , 6.7 ).
    The temporal and mandibular branches are the most important facial nerve branches in terms of surgical risk. The temporal branches gain the underside of layer 3 immediately on leaving the parotid, inferior to the zygomatic arch. These branches course within a wafer-like layer of fat contained in a fibrous envelope suspended from the underside of the temporal SMAS, as they course over the arch and the lower temporal triangle, where they are immediately inferior to the inferior temporal septum ( Fig. 6.11 ). The temporal branches can be safely avoided by maintaining the plane of dissection directly on the outer surface of the deep temporal fascia and avoiding compression neurapraxia from retractor pressure.
    The mandibular branches are at risk where they are fixed by having a close relationship to ligament. Initially, this is within the PAF, and then well anteriorly by the mandibular ligament ( Fig. 6.13 ). Over most of its course, where it is in relation to the premasseter space, the nerve is mobile. The absence of retaining ligaments along the mandible between the PAF and the mandibular ligament allows an inherent mobility of the tissue. For this reason, it is not necessary to dissect in the immediate vicinity of the mandibular branch in order to correct laxity of the platysma overlying the jaw and submandibular triangle.

    Layer five
    The deepest soft tissue layer of the face is the deep fascia. This is in the form of periosteum overlying the bony skeleton, which has, for the most part, a mobile covering of preperiosteal fat through which pass the attachments for the deep facial muscles and the facial ligaments. In the mobile soft tissue shutters covering the bony cavities, there is no periosteum and the fifth layer is not a structural layer but a mobile lining layer derived from the cavity. That is conjunctiva or oral mucosa.
    Over the lateral face the muscles of mastication largely conceal the skeleton and here the deep fascia equivalent is the deep temporal and masseteric fascia, which also provide attachment for retaining ligaments. The investing layer of deep cervical fascia is the corresponding layer in the neck. The deep fascia is traditionally taken to be the deep boundary of the territory for aesthetic surgery. However, in recent times this boundary is transgressed for subperiosteal ‘lifting’ and for bone contouring procedures. In the neck it is incised for access to the deeper located submandibular gland.
    The periosteum is the carrier for all the overlying structures when a subperiosteal upper third or mid-facelift is performed. The effect of its displacement is transmitted through all levels of the multi-ligamentous support system
    Inherently the anatomy of the periosteum imposes limitations, which require special surgical considerations:

    1. An overcorrection is required to compensate for the ‘lift lag’ phenomenon. This is to compensate for the accumulated aging changes throughout the entire ligamentous support system to the dermis, in order to transmit sufficient effect to obtain the desired changes of shape and tone to the skin.
    2. There is inherently more benefit from subperiosteal lifting where the overlying soft tissue layers are more tightly attached. This occurs overlying the skeleton, but is less so over the bony cavities as there is no periosteum in the eyelid or the mobile part of the cheek.
    3. Because of the unyielding nature of periosteum, an extensive undermining is needed beyond the immediate area for intended correction. The alternative is to perform a ‘periosteal release’, that is to incise the periosteum at the boundary. This boundary release is commonly performed along the superior orbital rim and less consistently along the boundary with the lateral face.

    Layer six
    Layer six is a natural plane entered by a subperiosteal dissection to create a space. In the scalp, the periosteum separates so readily from the frontal bone that the surgeon must be cautious not to unintentionally ‘strip’ the periosteum. Yet the periosteum is firmly attached where there is ligament at the periphery, along the superior temporal line and across the superior orbital rim.
    On the face proper, the periosteum follows the same pattern of attachment, being similar to the other layers in not having a uniform attachment. It mirrors the anatomy of the 4th layer. Where the muscles and ligaments at the boundaries of the overlying 4th layer pass through into bone, the periosteum is tightly adherent, as it is at suture lines and foraminae. Elsewhere, the periosteum is not strongly attached.

    Anatomy over the cavities in the skeleton
    The layered anatomy, as described over the lateral aspect of the face, is modified where the orbital and oral cavities are present over the anterior face ( Fig. 6.1 ). The gaps in the bone surface, due to the presence of the cavities, make up about half of the surface area of the skeleton and necessitate modifications to the layered structure.
    Most of the movement of the face results from the muscular activity in the soft tissues overlying the spaces, and the surrounding periorbital tissues for the orbits. The movement occurring on the lateral face is essentially passive, secondary to active movement of the muscles on the anterior aspect of the face around the eye and the mouth, and to jaw movement.
    Retaining ligaments are a feature of the skeletal anatomy and are not present in the spaces. Because layer 5 deep fascia is not present over the bony cavities, there is no base for ligament attachment. As ligaments do not exist over the cavities, there is not the same vertical reinforcement through to the retinacular cutis.
    Around the bony rims there are anatomical and functional transitions between the relative stability over the fixed area of skeletal attachment and the high mobility of the soft tissue shutters over the bony cavities. This is mainly in layer 4, where there is a concentration of ligaments around the bony rims, at the last available place for soft tissue ligament fixation before the void of the bony cavity ( Fig. 6.14 ).

    Fig. 6.14 The anatomy over the midcheek skeleton and adjacent bony cavities, showing the relationship of soft tissue spaces to bone cavity spaces. Soft tissue transitions are located along the rim of the bony, orbital and oral cavities. The prezygomatic space is separated from the preseptal space of the lower lid by the orbicularis retaining ligament, and from the vestibule of the oral cavity by the line of zygomatic ligaments. The ligaments continue through the soft tissue layers to provide dermal attachments, which are manifest on the skin surface as cutaneous grooves. The prezygomatic space allows mobility of the outer cheek where it overlies the zygoma, but it does not extend medially over the maxilla. Movement of the medial cheek is enabled by the soft preperiosteal, (level 4) fat.
    The generic 5 layer concept also explains the soft tissue anatomy where it overlies the bony cavities. The submuscular space of the lower lids, between the septum orbitale and the overlying preseptal orbicularis, allows mobility of the lids. This space contributes to the pattern of aging changes, particularly the development of lower lid bags. The oral cavity is the largest of the facial spaces and allows movement of most of the midcheek as well as of the lips.
    The layers undergo significant adaptations as they leave the bone surface and continue over the orifices. Only the outer three-layer composite superficial fascia forms these soft tissue extensions that are in the form of a composite flap. The SMAS layer within the flap extension has the sphincteric orbicularis muscle around the free edge of the soft tissue aperture of the lids and lips. The facial ligaments in (layer 4) that normally support the composite soft tissue shutters do not exist over the cavities. They are remote where they are condensed along the rim of the bone. This is the basis for the periorbital ligament around the orbital rim, of which the lower lid part is the orbicularis retaining ligament, which stabilizes the overlying orbicularis to the orbital rim periosteum ( Fig. 6.11 ). The orbicularis does not have any attachment to the septum orbitale, (deep fascia) directly beneath, other than the attachments of the orbicularis to the medial and lateral canthal tendons and the nearby orbital rim periosteum.
    The lining layer beneath the composite shutters is derived from the underlying cavity (conjunctiva, oral mucosa).
    The extent of the oral cavity has a major impact on the facial structure and on aging of the face. The vestibule of the oral cavity covers a large area of the surface of the maxilla and of the mandible ( Fig. 6.14 ). The part of the skeleton underlying a space is unavailable for ligamentous attachment for support of the soft tissue cover over this large area. Accordingly, the non-attached cheek overlying the oral cavity is the least supported and most mobile part of the face. The indication for a facelift is largely to correct the changes that occur in this poorly supported part of the cheek around the lips.

    Anatomy and aging of the face
    The youthful face has the appearance of rounded fullness. Laxity gradually develops in the boundaries of the spaces consequent on the repetitive movement that occurs with expression and jaw function. The laxity develops most in the roof of the spaces (level 3). The membranous lining of the spaces undergoes distension in proportion to the degree of laxity developing in the adjacent retaining ligaments, although these are not uniformly affected by laxity. For example, in the lower face the lower masseter ligaments at the anterior boundary of the premasseter space undergo attrition, yet the nearby mandibular ligament remain strong and resist laxity ( Fig. 6.15 ).

    Fig. 6.15 The facial spaces and their role in aging of the face. Youthful (left), aged face (right). Distension of the facial spaces occurs secondary to laxity of their ligamentous boundaries. This process is most pronounced in the roof of the spaces: lower lid bags (preseptal space of lower lid), malar mounds (prezygomatic space), nasolabial folds (vestibule of oral cavity), jowls (premasseter space) and labiomandibular folds (masticator space). Greater laxity occurs in the lower facial spaces due to movement of the jaw. The masseteric ligaments, illustrated, along the anterior border of the masseter, undergo attrition with distension on aging, so that the overlying platysma loses its close relation with the masseter and mandible, leading to the development of jowls and labiomandibular folds.
    As aging changes progress, the bulging over the spaces contrasts with the restriction imposed by the ligaments at the boundaries. These do not bulge as much and form the cutaneous grooves ( Fig. 6.3 ).


    Principle
    The pattern of laxity in the roof and walls of the spaces largely determine the characteristic appearance of the changes of aging.

    Application of anatomy to surgical technique
    Many facelift techniques deliver comparable results. However, the difference on closer analysis is in the extent of harmonious facial shape achieved and the balance between skin tension and shape. Excessive tension flattens natural shape. This is anatomical, and specifically determined by the level in which the dissection has been performed and the layer used for redraping ( Fig. 6.16 ). 16

    Fig. 6.16 The alternative levels for dissection and redraping in facelifts. Dissection can be performed through any one of three alternate layers, namely: subcutaneous (layer 2), sub-SMAS (layer 4) and subperiosteal (layer 6) (for the upper two thirds of the face). Redraping is performed on the mobilised layer according to the dissection plane. These are: skin (Layer 1), SMAS (Layer 3), and periosteum (Layer 5) A subcutaneous dissection (2) allows not only redraping of the mobilised layer 1, but also tightening of the surface of the revealed deeper layer, SMAS where it overlies a space.
    The dissection is performed to gain access to the lax tissues of the anterior face. The advancement is applied directly to the layer that has been mobilized on the upper surface of the dissection plane. There are three possible layers on which to apply the traction force: skin (layer 1); SMAS (layer 3); and periosteum (layer 5), this layer being the carrier for the overlying (undissected) tissue. When a subcutaneous dissection is performed, there is also the option to tighten the exposed surface of the deeper layer (SMAS because the underlying SMAS does not need to be dissected where it overlies a space). The SMAS here is inherently mobile and the laxity can be tightened by plication or imbrication.
    The more superficial the carrier layer for the overlying lax soft tissues, the more direct and the effective is the benefit of the redraping on layers 1 and 2. Accordingly, periosteal redraping has the least benefit for major laxity of the skin and subcutaneous layer.

    Application to facelift, levels of dissection
    When a facelift is initiated over the lateral face, the level of dissection can be changed at the transition to the anterior face, e.g. subcutaneous for lateral face extended to sub-SMAS for the anterior face, or vice versa. Because the objective of the surgery is correction of the laxity of the mobile anterior face, the level of dissection used for the lateral face is of secondary importance.

    Level 4: sub-SMAS
    Understanding the anatomy of layer 4 allows sub-SMAS dissection to be utilized in a proactive manner. This provides many advantages based on the fact that the spaces are naturally predissected areas, so the surgical dissection is quick, easy and atraumatic. The surgical approach is commenced with a subcutaneous dissection, which is extended forward until over the posterior part of the roof of the appropriate space. The space is then entered, using traction on the layer 3 roof. Once inside the space, blunt dissection only is used to define the boundaries.
    If dissection anterior to the space is required, the position of the ligaments and nerves is indicated by the knowledge that they are located within the boundaries. Precise dissection is now used to locate the residual retaining ligaments by their tethering effect and then to release the ligaments as is necessary. In younger patients this step is more difficult, as more ligament is present and it is tighter because of less aging attrition.
    The anatomy of the relationship of the nerves to the ligaments here provides a guide to the technique. Because the facial nerve branches are immediately adjacent to the ligaments, precise dissection is now necessary. Blunt scissors are used in a gentle spreading motion oriented in a vertical, i.e. outward direction. This provides maximum effect on the ligament while, at the same time, having a nerve-sparing effect. The surrounding areolar and fatty tissues separate to clearly reveal the ligament and any related nerves. Now, under visual control, the ligament yields to the tissue stretching force while the nerve, being more mobile and obliquely oriented, is not tightened and can be dislodged out of the way, being unaffected by the controlled stretching force.
    The spaces can be used, like stepping stones, to safely navigate across the face. In fact, the spaces have long been used in facial surgery, without considering them in these conceptual terms. Some examples include:

    • The transconjunctival (space) approach to access the preseptal space of the lower lid.
    • The deep temporal lift dissection from the upper temporal space, around the lateral orbital rim, into the prezygomatic space.
    • The premasseter approach to the masticator space, used to reduce displaced buccal fat and to tighten laxity of the overlying superficial fascia lateral to the oral commissure.


    Principle
    It is inherently easier and safer to enter the SMAS where it overlies a space, rather than where it is fixed by ligament.
    When the ‘ deep plane facelift ’ was introduced, the term ‘deep’ referred to dissection in level 4, deep to the SMAS. 17 Although not clear at that time, the deep dissection was only over the lateral face 18 as the level of dissection changed to more superficial (deep subcutaneous level 2) at the transition to the anterior face and over the level 3 muscles, orbicularis and zygomaticus major. 3, 4 The deep plane procedure evolved into the ‘ composite facelift ’, 18 the difference being that the sub-SMAS plane of dissection was also used in the anterior face. Sub-SMAS dissection over the midcheek can be approached either through the lateral approach (extended SMAS) 19 or directly the through anterior face via the lower lid (zygorbicular dissection). 18, 20

    Level 2: subcutaneous
    The subcutaneous layer is unique in having a thickness. This provides options regarding the level within the layer to perform the dissection


    Principle
    The ease of dissection varies at different levels within the subcutaneous layer.
    When performing a subcutaneous dissection, knowledge of the spaces in level 4 is beneficial in explaining the easier dissection where the subcutaneous layer overlies superficial muscle, especially over orbicularis oculi and platysma. Movement of the muscle is associated with a lesser attachment of the subcutaneous layer at this interface, while the orientation of the retinacular fibers is more horizontal overlying the surgical spaces (beneath the muscle).


    Principle
    At any point in the subcutaneous layer the orientation of the retinacular cutis fibers reflects the underlying anatomy of level 4.
    The intended role for the fibrous retinacular cutis in the rejuvenation determines which level within the subcutaneous layer to perform the dissection. If the skin flap is to be used for the redraping, the fibrous retinacular component should be left on the flap by performing a ‘deep’ level of subcutaneous dissection. If external plication of the anterior SMAS is the objective, a deep subcutaneous level of dissection is required to visualize the outer surface of the SMAS. 21, 22 This level of deep subcutaneous dissection at the interface with level 3 has been given several names: the superficial musculoaponeurotic plane (SMAP) 11 and the extended supraplatysma plane (ESP). 23
    Alternatively, when a ‘separate’ SMAS flap is to be used, it is advantageous to keep most of the retinacular cutis mass attached to the SMAS, as this optimizes the strength of the thin SMAS flap. This is achieved with a superficial level of subcutaneous undermining, the so-called, ‘thin skin flap’. 24, 25


    Principle
    The shape of the face is the product of the shape of the facial skeleton and of the quality of attachment of the overlying soft tissues.


    Summary
    This chapter has been structured to assist the reader to develop a conceptual understanding of facial anatomy. It is the missing framework on which to attach the detailed anatomical information now available in the literature. Once understood, this anatomical information becomes the knowledge needed for clinical application, and when enhanced by surgical experience it provides the key for the advancement of the quality of facial rejuvenation.

    References

    1. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek; facial layers, spaces, and the midcheek segments. Clin Plast Surg . 2008;35:395–404.
    2. Mendelson BC. Chapter: Extended sub-SMAS dissection and cheek elevation. Clin Plast Surg . 1995;22:325–339.
    3. Owsley JQ. Lifting the malar pad for correction of prominent nasolabial folds. Plast Reconstr Surg . 1993;91:463.
    4. Owsley JQ, Fiala TG. Update lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg . 1997;100:715.
    5. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg . 2007;119:2219–2227.
    6. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg . 1976;58:80.
    7. Mendelson BC, Advances in understanding the surgical anatomy of the face. Eisenmann-Klein M, Neuhann-Lorenz C. Innovations in plastic and aesthetic surgery, Springer Verlag, New York, 2007;141–145.
    8. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg . 1989;83:11.
    9. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: Relevance to rhytidectomy and aging. Plast Reconstr Surg . 1992;89:441.
    10. Mendelson BC, Freeman ME, Woffles W, Huggins RJ. Surgical anatomy of the lower face; the premasseter space, the jowl and the labiomandibular fold. Aesth Plast Surg . 2008;32:185.
    11. Furnas D. The superficial musculoaponeurotic plane and the retaining ligaments of the face. In: Psillakis JM, ed. Deep face – lifting techniques . New York, NY: Thieme Medical Publishers, 1994.
    12. Knize DM, ed. The forehead and temporal fossa. Philadelphia: Lippincott Williams and Wilkins, 2001.
    13. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg . 2000;105:1475.
    14. Mendelson BC, Muzaffar AR, Adams WP, Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg . 2002;110:885.
    15. Aston SJ. The FAME Procedure. Presented at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons, Dallas, Texas, November 9–13, 1996.
    16. Mendelson BC. Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation. Plast Reconstr Surg . 2002;109:824–825.
    17. Hamra ST. Deep-plane rhytidectomy. Plast Reconstr Surg . 1990;86:53.
    18. Hamra ST. Composite Rhytidectomy. Plast Reconstr Surg . 1992;90:1.
    19. Stuzin JM, Baker TJ, Gordan HL, Baker TM. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg . 1995;22(2):295–311.
    20. Hamra ST. The zygorbicular dissection in composite rhytidectomy: An ideal midface plane. Plast Reconstr Surg . 1998;102:1646.
    21. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS plication for the treatment of prominent nasolabial folds and restoration of normal cheek contour. Plast Reconstr Surg . 1995;96:1279.
    22. Trepsat F. Cornette de Saint-Cyr B, Delmar H, Goin J.-L, Thion A. Les nouveaux liftings. Ann Chir Plast Esthet . 1994;39:597.
    23. Hoefflin S. The extended supraplatysmal plane (ESP) facelift. Plast Reconstr Surg . 1998;101:494.
    24. Connell BF, Gaon A. Surgical correction of aesthetic contour problems of the neck. Clin Plast Surg . 1983;10:491.
    25. Connell BF. Neck contour deformities. The art, engineering, anatomic diagnosis, architectural planning, and aesthetics of surgical correction. Clin Plast Surg . 1987;14:683.
    CHAPTER 7 Facelift with SMAS technique and FAME

    Sherrell J. Aston, Jennifer Walden

    History
    Surgery of the deep layer tissues of the face and neck is now established as a permanent part of facelift operations. There is no clear consensus as to how to treat the midface and its related nasolabial fold. Skoog introduced tightening of the midface superficial fascia and platysma muscle in the late 1960s, and Mitz and Peyronie verified the anatomy of the superficial musculoaponeurotic system (SMAS) in 1976. Surgery of the midface developed subsequent to descriptions of the retaining ligaments of the cheek, as the focus of facial rejuvenation extended to correction of the nasolabial fold. Masseteric-cutaneous and lateral zygomatic-cutaneous ligament release allowed lifting of the SMAS to correct the lower face below the zygoma. However, approaches to the prezygomatic SMAS developed in an effort to gain harmony of the upper and lower parts of the face. In this effort two different approaches are in use:

    1. Wide skin undermining and separate dissection of a SMAS platysma flap.
    2. Very limited skin undermining in the cheek and the dissection beneath the SMAS layer in continuity with the skin.
    In the deep plane facelift the plane of the dissection for the lateral segment of the face is in the sub-SMAS plane, but more anterior the plane changes to become more superficial overlying the zygomatic muscles, therefore the cheek fat remains adherent to the skin flap. The composite facelift technique (this technique later modified by Hamra with the zygoorbicular dissection) continues the sub-SMAS dissection beneath the central part of the malar fat including the prezygomatic SMAS and the orbicularis oculi muscle and its fascia. Mendelson has noted that this prezygomatic space is a surgically safe space that can be entered through the lower eyelid or laterally through a space between the temporal and the zygomatic branches of the seventh nerve as is performed in the FAME (finger assisted malar elevation) technique.

    Physical evaluation

    • Evaluate the face in general for the bone structure of the entire face including the forehead, orbits, zygomas, zygomatic arches, maxilla, mandible, mentum, as well as the lips, nose and teeth.
    • Evaluate skin quality and laxity, fat deposits and/or bulges in the face and neck.
    • Evaluate midface thickness, laxity, and mobility to finger tip manipulation.
    • Evaluate nasolabial folds, and labiomandibular folds if present.
    • Evaluate neck including fat deposits, platysma muscle anatomy, hyoid position, thyroid cartilage contour and submandibular gland position.
    • Evaluate the malar area for bony contour and the thickness of the soft tissue lying medial to the zygomaticus major muscle.
    • Evaluate the lower eyelids for the integrity and function of the orbicularis oculi muscle.
    • Evaluate the lower eyelids for prominence of herniated fat, prominence of the bony orbital rim, palpebromalar grove and nasojugal grove.
    • Determine patient’s main concerns.
    • Make detailed photographs.

    Anatomy
    The midcheek can be understood as part of the midface and refers to a part of the cheek medial to a line extending from the frontal process of the zygoma to the oral commissure and from the lower lid above to the nasolabial fold below. It is composed of two functionally distinct parts including the prezygomatic part over the body of the zygoma and maxilla and infrazygomatic part below, as described by Mendelson ( Ch. 6 ). A major determinant of the shape of the midface is the underlying skeleton as it connects the orbital and oral cavities and provides a bony platform for their skeletal attachments and retaining ligaments of each muscle. The aging changes that appear in the midcheek largely reflect the effect of laxity and ptosis of the soft tissues relative to the underlying skeleton. This affects the upper face by revealing the anatomy of the orbit, with exposure of the bony orbital rim inferiorly, palpebromalar groove laterally, and nasojugal groove medially. The displaced soft tissue accentuates the nasolabial fold and reveals lower lid fat bulges. With soft tissue descent, laxity of the structures of the prezygomatic space including the orbital retaining ligament at its uppermost aspect and its roof (pars orbitale of the orbicularis oculi) are resisted by the zygomatic-cutaneous ligaments below. When visibly enlarged this area forms the clinical entity known as the malar mounds, also termed malar bags and malar crescent. It should be noted that the presence of the malar septum was described by Pessa and Garza and Pessa et al. to explain the clinical appearance of a black eye, and explain the anatomic basis of malar mounds and malar edema. Malar mounds should be distinguished from the malar fat pad. The anatomical terminology regarding this area can be somewhat confusing, as the malar fat pad is also simply known as malar fat.
    Specifically, the malar fat pad is a term used to describe the subcutaneous fat of the medial cheek that exaggerates the nasolabial fold. The malar fat pad is a localized thickness of the subcutaneous panniculus adiposus ( Fig. 7.1 ). The malar fat pad is of maximum thickness centrally in youth with a well-defined border at the nasolabial crease and less discrete border in the upper face as it blends imperceptibly into the lower lid with a gradual decrease in thickness over the prominence of the orbital rim and zygoma. The malar fat has upper, middle and lower components. The fullness of the nasolabial fold is in large part caused by the medial and inferior migration of the soft tissue medial to the zygomaticus major muscle (primarily the malar fat pad). It is triangular in shape with its base along the nasolabial crease, and its apex overlies the body of the zygoma. The malar fat pad firmly attaches to skin. It is easily separated from underlying fascia, and the malar fat pad moves forward and down perpendicular to the nasolabial crease during the aging process.

    Fig. 7.1 Malar fat pad is a localized increase thickness of the panniculus adiposis.
    The prezygomatic space overlies the body of the zygoma and the origins of the lip elevator muscles. It extends to the posterior border of the body of the zygoma and can be accessed from the lower temporal region and lower lid. The floor is a thick layer of preperiosteal fat with an overlying thin membrane which covers the origins of the muscle bellies of the lip elevators. The upper border of the space is formed by the orbicularis retaining ligament, which separates the preseptal from the prezygomatic space and becomes confluent at the inferolateral orbital rim with the broad lateral orbital thickening that overlies the frontal process of the zygoma. The zygomatic-cutaneous neurovascular pedicle is the only structure crossing this space as Mendelson has previously elucidated. The roof of the space is the orbicularis oculi and its investing fascia, which is contiguous with the temporoparietal fascia laterally. The inferior wall of the prezygomatic space is lined by a continuation of the preperiosteal membrane and the most cephalad of the zygomatic-cutaneous ligaments as they extend between the origins of the lip elevator muscles through the subcutaneous fat to the dermis. With blunt dissection in this space, as in the FAME procedure, the smooth surface of this membrane remains intact and preperiosteal fat remains attached to the underlying facial bones. Mendelson has noted that the prezygomatic space can be entered from (1) the lower eyelid; (2) the temporal area; (3) laterally passing between the seventh nerve branches as performed with the FAME procedure to enter the prezygomatic space ( Fig. 7.2 ).

    Fig. 7.2 Mendelson’s description of the prezygomatic space and the three access routes, lower lid, temporal and lateral.
    Reproduced with permission from Mendelson BC, Muzaffar AR, Adams WP, Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002;110:885–896.

    Technical steps
    The senior author (SJA) began using the FAME technique in the early 1990s as a procedure in conjunction with a standard SMAS/platysma facelift to improve the midface and nasolabial fold. The FAME technique (finger assisted malar elevation) is a composite technique designed to elevate skin, lateral orbicularis oculi muscle, and reposition the malar fat pad. This technique is used in combination with skin undermining and a SMAS/platysma flap to correct the remainder of the laxity in facial and cervical areas. The description given here is as performed for approximately 14 years. Recent modifications since February 2006 will be described below.
    In the temporal area the skin is undermined sharply for approximately half the distance between the ear and lateral canthus. The right index finger is rotated medially and inferiorly so as to separate the orbicularis oculi muscle from the temporal fascia; the lateral canthus is easily reached ( Fig. 7.3 ).

    Fig. 7.3 The right index finger is advanced across the temporal area separating the orbicularis oculi muscle from the temporal fascia.
    Next, the facial and cervical skin flap undermining, as indicated for the individual, is completed. In the midface skin undermining is carried medially to approximate the course of the zygomaticus major muscle. In the lower face, when indicated by skin redundancy, undermining may be carried medially to the labiomandibular fold. The mandibular ligament is divided in most patients. Any anterior platysma procedures are completed. Complete submandibular and submental skin undermining and anterior platysma procedures are frequently indicated. Necessary anterior platysma procedures are performed prior to lateral platysma and cheek work.
    Attention is now returned to the lateral canthus. With the index finger pulp surface down under the orbicularis oculi muscle pressure is exerted downward, inferiorly, and medially across the malar prominence ( Fig. 7.4A&B ). The orbicularis oculi muscle and the malar fat pad separate rather easily from the underlying fascia overlying the preperiosteal fat thus entering the prezygomatic space ( Fig. 7.4C ). The entire malar fat pad in undermined with the index finger going to near the nasal alar attachment ( Fig. 7.4D ). The index finger is turned over with the pulp surface up in order to permit leverage for complete mobilization of the malar fat pad. Bimanual palpation with one index finger in the “deep plane” helps evaluate malar fat pad thickness and mobility ( Fig. 7.5 ).

    Fig. 7.4 A , The index finger is passed under the lateral orbicularis oculi muscle. B , The index finger is turned to pass under the orbicularis oculi muscle and to enter the prezygomatic space. C , The index finger is advanced into the prezygomatic space under the orbicularis muscle and the malar fat pad. D , The index finger is advanced to the base of the prezygomatic space.

    Fig. 7.5 Bimanual palpation determines the thickness of the malar fat pad and mobility.
    At this point the levels of dissection have been established (1) subcutaneously and (2) underneath the malar fat pad and orbicularis oculi (in the deep plane and a composite flap). The subcutaneous soft tissue bridge separates the two planes at the lower quarter of the malar prominence. Redraping of the composite flap in a cephaloposterior direction with the emphasis on the vertical vector will demonstrate repositioning of the malar fat pad to its earlier location over the malar prominence. If more mobility is needed for repositioning of the malar fat pad, the subcutaneous bridge is dissected until the desired mobility of the composite flap is achieved.
    Next, attention is directed to developing a SMAS/platysma flap. The lateral border of the platysma muscle is incised at the anterior border of the sternocleidomastiod muscle and carried from the angle of the mandible inferiorly 7–8 cm below the angle of the mandible. Subplatysmal dissection is carried medially for 4–7 cm, depending on the amount of platysma mobility needed for the individual patient. The zygomatic arch is palpated with fingertips to determine its exact location, and an incision is made through the SMAS along the lower border of the zygomatic arch extending from approximately 5 mm anterior to the base of the tragus to approximately 1 cm from the subcutaneous bridge separating the deep plane and subcutaneous plane.
    A SMAS flap is developed going inferiorly to join the subplatysmal dissection and going medially anterior to the parotid gland until the desired flap mobility is obtained. The SMAS platysma flap and, when indicated, anterior platysma procedures give independent control for lower facial and cervical contouring. The SMAS/platysma flap is elevated and rotated in the cephaloposterior direction with the vectors of lifting and repositioning according to the anatomy of the patient and the desired facial contouring.
    Excess SMAS is then resected along the horizontal SMAS incision line and sutured to the incised SMAS edge. In the preauricular area the SMAS is then cut vertically creating a small SMAS flap, which is positioned behind the ear and sutured to the sternocleidomastoidmastoid fascia to help with jawline contouring. The lateral platysma is sutured to the sternocleidomastoid muscle fascia. Final jawline fat contouring is carried out by open suction lipectomy or sharp dissection.
    The description of the technique above is as performed by the senior author for approximately 15 years. Most cases were performed without malar fat pad fixation to the zygoma. However, in some patients the malar fat was sutured to the periosteum of the zygoma to help maintain the vertical vector. In February 2006 the senior author modified the technique by extending the SMAS flap through the subcutaneous bridge between the deep plane and the subcutaneous plane. It is now an extended SMAS flap joining the FAME composite deep plane flap, thereby giving more mobility to the malar soft tissue ( Fig. 7.6A&B ). The SMAS flap is not excised but sutured to the temporal fascia (high lamella fixation) in order to maximize the vertical vector of the midface repositioning ( Fig. 7.7A ). The elevated malar fat pad is sutured to the periosteum of the zygoma in a vertical vector ( Fig. 7.7B ). In patients with a thin or poor quality SMAS, the FAME technique can be performed with plication of the SMAS. Likewise, a smasectomy can be performed with the FAME in patients where it is desirable to excise facial fat.

    Fig. 7.6 A , Extended SMAS flap showing dissection medial to the zygomaticus major and joining the FAME dissection. B , Intraoperative photograph showing zygomaticus major muscle and gauze in the prezygomatic space.

    Fig. 7.7 A , Vertical vector elevation of extended SMAS flap and malar fat pad. B , Flap sutured to temporal fascia and zygoma at lateral canthus. Excess preauricular SMAS flap transposed and sutured to sternocleidomastoid fascia.
    Redraping of the skin flap in the cephaloposterior direction repositions the malar fat pad and orbicularis oculi muscle. In general, the maximum vertical vector possible is desired in order to return the malar soft tissue onto the malar prominence. An incision is made beneath the temporal hairline so as not to narrow or elevate the sideburn. A Burrow’s triangle is excised so as to place only minimal tension on the elevated and rotated skin flap. Excess tension will only result in scar migration and add nothing to the lift. In the vast majority of patients, an incision along the anterior hairline is avoided entirely. When a small “dog ear” is present at the end of the transverse incision under the hairline, a small anterior hairline incision (5 to 7 mm) will eliminate the “dog ear” and permit restoration of the sideburn shape and position. The remainder of the skin flap is trimmed and sutured in a routine fashion. The FAME procedure can be performed with a short scar facelift technique or conventional scar technique, where the posterior scar is curved in the mastoid hair so as to be as almost imperceptible. Pre- and postoperative views of patients who have undergone a facelift with the FAME technique are shown ( Figures 7.C1 – C5 ).

    Fig. 7.C1 A 58-year-old-patient following facialplasty with FAME technique, extended SMAS/platysma flap, endoscopic browlift and lower lid blepharoplasty. Postoperative photographs show lower and midface repositioning and lateral orbicularis tightening.

    Fig. 7.C2 A 59-year-old patient 10 months postoperative facialplasty with FAME technique, extended SMAS, laternal platysma dissection, high lamella fixation, chin implant, 4-lid blepharoplasty, erbium laser resurfacing lower lids and rhinoplasty. Postoperative photographs show repositioning of mid and lower facial soft tissue and lateral orbicularis tightening.

    Fig. 7.C3 A 58-year-old patient 1 year postoperative facialplasty with FAME technique, SMAS/platysma flap procedure and 4-lid blepharoplasty. Postoperative photographs show repositioning of thick, heavy midface and lateral orbicularis tightening.

    Fig. 7.C4 A 55-year-old patient 2 years postoperative facialplasty with FAME technique, SMAS/platysma flap procedure, 4-lid blepharoplasty and chin implant. Postoperative photographs show mid and lower face correction and lateral orbicularis oculi tightening.

    Postoperative care
    Standard postoperative facelift care is used. A facelift dressing is placed in the operating room and removed the first day after surgery. Treatment of hypertension and maintenance of blood pressure is stressed especially in the perioperative period, and drains are usually removed on the first postoperative day. The following information is typical of that given to our facelift patients.

    Sample instructions for the facelift patient

    General

    • Take pain medication as prescribed.
    • Do not take aspirin, ibuprofen or any products containing these drugs, as they can cause bleeding problems after surgery. Tylenol is permissible. Also avoid vitamin E and multivitamins containing vitamin E. Stop herbal and homeopathic medications, as some may cause bleeding after surgery.
    • Abstain from alcohol for a minimum of 7 days post-op. Do not drink alcohol when taking pain medications.
    • Do not smoke, as smoking delays healing and increases the risk of complications.
    • Following surgery, sleep on your back for 2 weeks. Keep head elevated on two pillows while sleeping.
    • You may shampoo 24 hours after removal of the drainage tubes. Hair is generally shampooed on the 2nd postoperative day. Wash hair daily for two weeks following surgery. Use a cool setting on the hair dryer. Do not use rollers for 1 week after surgery. Do not color hair or use harsh chemicals prior to 2 weeks post-op.
    • Soft foods are easier to consume post-op.
    • Always use a strong sunblock, if sun exposure is unavoidable (SPF 30 or greater).
    • You may use cold compresses for comfort and to help decrease the swelling.

    Activities

    • Start walking as soon as possible. This helps to reduce swelling and lowers the chance of blood clots in the legs.
    • Do not drive until you are no longer taking any pain medications (narcotics), and can turn your neck easily.
    • No strenuous activities, including sex and heavy housework, for at least 2 weeks. (Walking and mild stretching are permissible).

    Incision care

    • The area of sutures must be washed gently and thoroughly.
    • Keep incisions clean and inspect daily for redness or signs of inflammation.
    • You may use makeup after the sutures are removed; new facial makeup can be used to cover up bruising, but not on the incisions until 48 hours after suture removal. It is important to gently remove all makeup.

    What to expect

    • Swelling, bruising and numbness is normal and to be expected.
    • Expect to feel tightness and a pulling sensation in your face and neck, especially when turning your head.
    • Face may look and feel strange and distorted from the swelling.
    • Men need to shave behind their ears, where beard-growing skin is repositioned.
    • Expect a bruised and puffy face for 7–14 days, although some patients do not bruise at all. Wearing scarves, turtlenecks and high-collared blouses masks the swelling and discoloration.
    • By the third week, you will look and feel much better.
    • Final result is not fully realized for approximately 3 months.

    Follow-up care

    • Sutures are usually removed from in front of the ear in 3–5 days.
    • Remaining sutures and metal clips, if used, are usually removed in 8 days.
    • If a drainage tube is inserted, it will be removed in 1–2 days.

    Complications
    Possible complications are those of a standard facelift. Serious complications from facelift surgery are extremely rare. As with any surgical procedure, complications and risks can often be minimized if the operation is performed by an experienced surgeon who has performed many facelifts. Complications of any facelift include bleeding (hematoma), infection, prominent or widened scars, alopecia, or nerve damage. Sequelae specific to the FAME facelift that patients should be advised of is the possibility of midface edema that resolves usually over the first 2 to 3 months. However, all facelift techniques have some edema that resolves over this amount of time.


    Pearls & pitfalls

    Pearls

    • Apply firm downward fingertip pressure when dissecting across the temporal area to go under the orbicularis oculi muscle. This establishes the plane you want to be in.
    • Inject anesthetic hemostatic agent perpendicular to the face of zygoma so as to infiltrate prezygomatic space.
    • Apply fingertip pressure downward on malar bone to go under malar fat pad.
    • Dissect prezygomatic space completely to mobilize entire malar fat pad.
    • Use absorbable sutures (PDS, Vicryl, and Monacryl) to secure malar fat pad to periosteum.

    Pitfalls

    • Failure to dissect under the orbicularis oculi muscle laterally, therefore injuring the muscle and delaying the return of lower lid function.
    • Failure to dissect under malar fat pad at its apex; therefore dissection will probably not be in the prezygomatic space but tear the malar fat pad.
    • Injury to the small motor branch that crosses the upper zygomaticus major muscle to innervate the lateral orbicularis oculi muscle.
    • Subcutaneous dissection medial to zygomaticus major muscle.
    • Performing the procedure on a patient with thin malar fat pads.


    Summary of steps

    1. Infiltrate face and neck with anesthetic hemostatic solution.
    2. Infiltrate prezygomatic space.
    3. If indicated undermine anterior neck skin through a submental incision and perform anterior platysma procedure through submental incision.
    4. Dissect sharply in the subcutaneous plane in the preauricular area and temporal area half distance to lateral canthus.
    5. Rotate index finger downward and medially going under the lateral orbicularis oculi muscle.
    6. Complete skin undermining as needed in cervical area.
    7. Complete midcheek undermining in subcutaneous plane up to the lateral border of the zygomaticus major muscle.
    8. Place index finger under lateral orbicularis oculi and push downward against malar bone so as to go under the apex of the malar fat pad.
    9. Push index finger into the prezygomatic space and release the entire malar fat pad.
    10. Bimanual palpation of malar fat pad to determine malar fat pad thickness.
    11. Test mobility of this composite flap.
    12. Perform lateral platysma and SMAS procedure (SMAS, extended SMAS, plication or smasectomy) as indicated for the individual patient.
    13. Rotate and elevate the extended SMAS flap (most often used technique) and secure to temporalis fascia (high lamella fixation).
    14. Redrape composite skin flap and determine position of the elevated malar fat pad with vertical vector.
    15. Secure malar fat pat with 4-0 PDS to zygoma approximately 1 cm lateral to lateral canthus.
    16. Redrape and trim skin flap, suture skin and place drains.
    17. Apply dressing.

    Further reading

    Aston SJ. The FAME technique, presented at the Aging Face Symposium . New York, NY: Waldorf Astoria Hotel; 1993.
    Aston SJ. Platysma-SMAS cervicofacial rhytidoplasty. Clin Plast Surg . 1983;10(3):507.
    Barton FE, Jr. The aging face: rhytidectomy and adjunctive procedures. Select Read Plast Surg . 2001;9(19):22.
    Barton FE, Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg . 1992;90:601.
    Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg . 1998;102:1646.
    Mendelson BC. Discussion; A study of long-term effect of malar fat repositioning in face lift surgery: short term success but long-term failure, by Sam T. Hamra, MD. Plast Reconstr Surg . 2002;110(3):952.
    Mendelson BC. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg . 2002;110(3):885.
    Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg . 1993;91:463.
    Skoog T. Rhytidectomy – A personal experience and technique, presented at the Seventh Annual Symposium of Cosmetic Surgery. Cedars of Lebanon Hospital, Miami, FL. 1973.
    Stuzin JM, Baker TJ, Baker TM. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg . 1995;22:295.
    CHAPTER 8 The SMAS facelift – restoring facial shape in facelifting

    James M. Stuzin

    Introduction
    The works of Skoog, Mitz and Peyronie enlightened plastic surgeons to the possibility of repositioning descended facial fat to the anatomic position of youth, providing an alternative to skin envelope tightening to enhance contour in the aging face. The recognition that sub-SMAS dissection offered a technical solution for facial rejuvenation spawned multiple anatomic studies to delineate an accurate understanding of facial soft tissue anatomy. This led to further investigations which more clearly defined both the anatomic and morphologic changes which occur in the aging face, leading to a plethora of technical approaches for facial rejuvenation. In reviewing the literature, good results can be seen utilizing what appears to be very different technical approaches. In reality, most of these seemingly different technical procedures share a common theme that contour restoration is predominantly through the re-elevation of facial fat as opposed to skin envelope tightening. While good results are possible through a variety of techniques, in my opinion, all methods have advantages, disadvantages and limitations, with the ultimate result often dependent upon underlying skeletal support and the quality of facial soft tissues for a particular patient. From my perspective, the key to consistent results in facelifting is not the particular technique utilized, but rather the preoperative aesthetic analysis and how the operative plan is individualized according to the aesthetic needs of the patient.
    To consistently improve facial shape in facelifting requires the surgeon to accurately understand both facial anatomy and the anatomic changes which have occurred in aging for a particular patient, appreciate the importance of underlying skeletal support in formulating the treatment plan, and incorporating one’s aesthetic vision into a surgical destination which is appropriate for a specific patient.

    History
    All early facialplasty procedures were limited to skin excision and wound closure without subcutaneous undermining. Bames described subcutaneous face and neck undermining, skin redraping, and excision of excess skin. The continuous incision described by Bettman and subcutaneous undermining recommended by Bames essentially established the basic facelift procedure for the next 40 years.
    Skoog described a technique of dissection of the superficial fascial layer in the face in continuity with the platysma muscle in the neck and advancement of the myofascial unit in a cephaloposterior direction. This was the beginning of the modern era in facelifting. Mitz and Peyronie used cadaver dissections to define the limits of the superficial musculoaponeurotic system (SMAS) in the face and noted that tightening of this layer would be beneficial in facialplasty. SMAS-platysma facelifting, wide skin undermining, and extensive fat removal soon gained worldwide popularity. Surgery of the tissue layers deep to the skin of the face and neck is now established as an essential part of cervical and facialplasty operations. Many surgeons have described different SMAS-platysma techniques to improve the cervicofacial area and to remedy problems not corrected by conventional facialplasty.
    Furnas, in 1989, described the retaining ligaments of the midface, which led to a better understanding of anatomic areas where facial soft tissue is supported and the involvement of these ligaments in leading to the anatomic changes that occur with aging. These ligaments were further defined by others who felt that loss of the support from the retaining ligament system allowed facial fat to descend inferiorly in the face, deepening the nasolabial fold and forming facial jowls with aging. The importance and location of the retaining ligaments led to modifications in procedures involving retaining ligament release in sub-SMAS dissection, the primary goal of these procedures being to reposition descended facial fat back to the anatomic location of youth. Other surgeons, preferring subperiosteal rather than sub-SMAS dissection to reposition fat, developed procedures whose similar goal is to resuspend descended malar fat to the malar eminences using the subperiosteal plane. A combination of subperiosteal and subcutaneous lifting has also been described.

    Physical evaluation – patient planning

    • Skin quality and elasticity.
    • Age.
    • Subcutaneous fat accumulation.
    • Contour change developing from attenuation of deep layer support, i.e. jowling, deep nasolabial fold; and platysma banding with cervical obliquity.
    • Degree of facial deflation.
    • Degree of skeletal support – malar prominence, mandibular ramus height and length of mandibular body.
    • The relationship between malar convexity and submalar concavity.

    Anatomic considerations
    The anatomic basis that allows rhytidectomy to be performed safely is that the facial soft tissue is arranged as a series of concentric layers. This concentric arrangement allows dissection within one anatomic plane to proceed completely separate from structures lying within another anatomic plane. The layers of the face are the (1) skin; (2) subcutaneous fat; (3) SMAS (superficial facial fascia); (4) mimetic muscles; (5) parotidomasseteric fascia (deep facial fascia); and (6) plane of the facial nerve, parotid duct, buccal fat pad, and facial artery and vein.
    The anatomic components of facial soft tissue anatomy, which are essential for the surgeon attempting to master sub-SMAS dissection to understand include the following:

    1. Although there is variation in the thickness of the various layers from patient to patient, structures within each layer are anatomically constant. On a two-dimensional basis, the facial nerve exhibits a variety of branching patterns, but on a three-dimensional basis, the facial nerve always lies within a specific anatomic plane. This anatomic arrangement allows the surgeon to perform extensive sub-SMAS dissection safely, as long as the dissection proceeds at a level superficial to the plane of the facial nerve.
    2. There is significant variability in terms of the thickness of the superficial fascial layer (SMAS). This variability of SMAS thickness is obvious from patient to patient. Also, the thickness of the SMAS will vary from one region of the face to another. Overlying the parotid gland, within the temporal region (temporoparietal fascia) and within the scalp (galea), the superficial fascia (SMAS) represents a substantial, discrete layer. As the superficial fascia is traced anteriorly in the face, overlying the masseter, buccal fat pad, and into the malar region, the SMAS tends to become thinner and less substantial. To elevate the superficial fascia in these areas requires precise dissection, so that the flap is thick enough to be useful in facial contouring.
    3. The muscles of facial expression are arranged in four anatomic layers which overlap one another. The muscles that are encountered in facelifting, including the platysma, orbicularis oculi, zygomaticus major and minor, and risorius muscle, are all superficially situated mimetic muscles. This is in contrast to deeply situated mimetic muscles such as the buccinator and mentalis muscle. Most of the muscles of facial expression lie superficial to the plane of the facial nerve. Because these muscles are superficial to the plane of the facial nerve, they receive their innervation along their deep surfaces. The only muscles within the facial soft tissue architecture that lie deep to the plane of the facial nerve are the mentalis, buccinator, and levator anguli oris muscles. Because these muscles lie deep to the plane of facial nerve, they receive their innervation along their superficial surfaces.
    4. The muscles of facial expression, which are situated superficially within the facial soft tissue architecture and are involved with the movement of facial skin, are invested by the superficial fascia, which lines both the superficial and deep surfaces of these muscles. Because these muscles are invested by superficial fascia, this SMAS-mimetic muscle complex forms a single anatomic and functional unit whose components work together to move facial skin during animation.
    5. Deep to the SMAS-mimetic muscle complex lies the deep facial fascia. The deep facial fascia represents a continuation of the superficial layer of the deep cervical fascia cephalad into the face. Where this fascial layer is identified, it is given specific nomenclature. Overlying the parotid gland, the deep fascia is termed “parotid fascia” or “parotid capsule”; overlying the masseter muscle, it is termed “masseteric fascia”; and in the temporal region, it has been termed “deep temporal fascia.” The significance of the deep facial fascia is that all the facial nerve branches within the cheek lie deep to the deep facial fascia. Typically, these nerve branches course deep to the deep fascia until they reach the muscles of facial expression that they innervate, at which point they penetrate the deep fascia to innervate these mimetic muscles along their deep surfaces ( Fig. 8.1 ).

    Fig. 8.1 A , Cadaver dissection after SMAS-platysma elevation within the cheek exposing the underlying parotid gland, the anterior border of parotid (marked in ink), and the parotid-masseteric fascia (held in forceps). The surgical significance of the parotid-masseteric fascia is that the facial nerve branches within the cheek are always deep to this anatomic layer. B , Cadaver dissection after elevation of the parotid-masseteric fascia exposing the underlying masseter muscle and the marginal mandibular nerve as it crosses the facial artery and vein.
    From Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441.
    In an overview of the architectural arrangement of the facial soft tissue, the essential point to grasp is that there is a superficial component of the facial soft tissue that is defined by the superficial facial fascia and includes the SMAS and those anatomic components that move facial skin (including superficially situated mimetic muscle invested by SMAS, the subcutaneous fat, and skin). This is in contrast to the deeper component of the facial soft tissue, which is defined by the deep facial fascia and those structures related to the deep fascia (including the relatively fixed structures of the face, such as the parotid gland, masseter muscle, periosteum of the facial bones, and facial nerve branches) ( Fig. 8.2 ). As the human face ages, many of the stigmata that are typically seen in aging relate to a change in the anatomic relationship that occurs between the superficial and deep facial fascia.

    Fig. 8.2 Facial soft tissue is maintained in a normal anatomic location by a series of supporting ligaments. The zygomatic and mandibular ligaments are examples of osteocutaneous ligaments that originate from the periosteum and insert directly into the dermis. The masseteric cutaneous and parotid cutaneous ligaments are formed as a coalescence between the superficial and deep facial fascias. Rather than originating from periosteum, these ligaments originate from relatively fixed facial structures such as the parotid gland and the anterior border of the masseter muscle. Attenuation of support from the retaining ligaments is responsible for many of the stigmata seen in the aging face.
    From Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992;89:441.

    Extended SMAS technique
    Except perhaps in the younger facelift patient, most individuals undergoing rhytidectomy will benefit from tightening of the superficial fascial layer. Restoration of support to the underlying deeper facial soft tissues has become an integral part of the rejuvenation of the aging face. If the SMAS is thin and tenuous, plication of this layer is a useful alternative to formal SMAS elevation. Nonetheless, in my opinion, better contouring and longer lasting results are obtained following a formal dissection of the superficial fascia.
    In skin flap dissection, it is important to develop uniform skin flaps during the subcutaneous undermining, with care to leave some fat intact along the superficial surface of the SMAS. If the skin flaps are dissected such that no fat is left along the superficial surface of the SMAS, then the SMAS becomes more difficult to raise, appearing thin, tenuous and prone to tearing. Much of the contouring that I obtain in my facelift has to do with elevation and fixation of the SMAS layer. The more substantial the SMAS flap, often the better long-term results that can be obtained in terms of facial contouring. Transillumination when performing subcutaneous dissection is a useful technique in allowing precise skin flap elevation.
    I usually carry the subcutaneous skin flap dissection well into the malar region and usually the skin overlying the lateral two-thirds of the zygomatic eminence is undermined. I prefer to stop the skin undermining several centimeters lateral to the nasolabial fold rather than undermining the skin to this facial landmark. This is to limit the dissection of the skin flap in the medial aspect of the cheek, subsequently preserving the attachments from the SMAS to facial skin. The preservation of these attachments, followed by adequate undermining of the superficial facial fascia (SMAS), will allow the surgeon to re-elevate facial skin through SMAS rotation rather than to redrape the superficial fascia completely independent of skin flap redraping. The ability to re-elevate and resuspend facial skin through SMAS rotation, in my opinion, produces a more pleasing aesthetic result in most patients, and preserves some of the peripheral vascularity to the facial skin flap.

    SMAS elevation
    The dissection of the superficial fascia allows the surgeon to re-elevate jowl and descended malar fat back upward into the face toward their previous normal anatomic location. In patients with prominent nasolabial folds, and significant malar pad descent, it has been my feeling that the SMAS dissection should extend into the malar region in an effort to re-elevate the malar fat pad back upward overlying the zygomatic eminence. An added benefit of performing a more extensive anterior dissection of the SMAS is that it frees this layer from the restraint of both the zygomatic and masseteric ligaments, and this anterior release provides for a more complete elevation of the facial fat below the oral commissure and along the anterior portion of the jowl.
    The incisions for extended SMAS dissection begin approximately 1 cm inferior to the zygomatic arch to ensure frontal branch preservation ( Fig. 8.3 ). This horizontal incision is continued several centimeters forward to the region where the zygomatic arch joins the body of the zygoma. At this point, the malar extension of the SMAS dissection begins with the incision angling superiorly over the malar eminence toward the lateral canthus for a distance of 3 to 4 cm. On reaching the edge of the subcutaneous skin flap in the region of the lateral orbit, the incision is carried inferiorly at a 90 degree angle toward the superior aspect of the nasolabial fold. A vertical incision is designed along the preauricular region, extending along the posterior border of the platysma to a point 5 to 6 cm below the mandibular border. In essence, the malar extension of the SMAS dissection simply represents an extension of a standard SMAS dissection into the malar region in an attempt to obtain a more complete form of deep layer support.

    Fig. 8.3 In patients with prominent nasolabial folds, I perform what I term an extended SMAS dissection. By this, I mean I extend the SMAS dissection into the malar region in an attempt to re-elevate ptotic malar fat back upward over the zygomatic prominence. The incisions begin at the junction where the zygomatic arch joins the body of the zygoma. From this point, the incision in the SMAS is angled superiorly toward the lateral canthus and along the lateral orbital rim. The incision in the SMAS is then carried medially and inferiorly toward the peripheral extent of skin flap undermining, angling toward the uppermost portion of the nasolabial fold (the amount of subcutaneous undermining is shaded in pink, whereas the amount of SMAS undermining is shaded in yellow).
    From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, pp. 254–255.
    The SMAS in the malar region is then elevated in continuity with the SMAS of the cheek. When elevating this flap, the fibers of the orbicularis oculi, as well as the zygomaticus major and minor, are usually evident and the flap is elevated directly along the superficial surface of these muscles. It is important to carry the dissection directly external to these muscle fibers, where a natural plane exists, remembering that the facial nerve branches lie deep to these muscular bellies. The malar SMAS is then elevated until the flap is freed from the underlying zygomatic prominence. Freeing of the SMAS completely from the zygomatic attachments is an important technical point in obtaining the mobility necessary to reposition the malar soft tissue superiorly. To obtain this mobility usually also requires a division of the upper fibers of the masseteric cutaneous ligaments, which will expose the underlying body of the buccal fat pad. The cheek portion of the SMAS dissection is performed beginning directly overlying the parotid gland and then extending this dissection anterior to the parotid utilizing a combination of sharp and blunt dissection toward the anterior border of the masseter ( Fig. 8.4 ).

    Fig. 8.4 A&B , The malar-SMAS dissection is then performed in continuity with the cheek-SMAS dissection. Dissecting in the malar region carries the dissection directly along the superficial surface of the zygomaticus major and usually exposes the lateral aspects of the zygomaticus minor as well. To obtain adequate mobility in terms of SMAS dissection, it is necessary to elevate the malar portion of the dissection completely from the zygomatic eminence and free it from the zygomatic ligaments. To obtain mobility in terms of SMAS movement affecting the jowl contour, the uppermost portions of the masseteric cutaneous ligament commonly are divided, especially where they merge with the zygomatic ligaments of the malar area. If these fibers are not divided, they will restrict the upward redraping of jowl fat. This diagram and intraoperative photograph illustrate the typical degree of mobilization performed in the extended SMAS dissection.
    From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, pp. 254–255.
    In most patients, following extended SMAS dissection of the cheek and malar regions, mobility of the soft tissues lying lateral to the nasolabial fold remains restricted unless the dissection is carried more medially. This restriction in movement results from the undivided retaining ligaments which originate medial to the zygomaticus minor. To improve mobility, I commonly continue malar pad elevation medially in an area where we have not subcutaneously undermined the skin. This dissection is carried directly in the plane between the malar fat and the superficial surface of the elevators of the upper lip. It is usually quite easy to delineate this level of dissection after the malar SMAS elevation is complete, and the superficial surface of the elevators of the upper lip is visualized. The scissors are then inserted directly superficial to the elevators of the upper lip, and blunt dissection is quickly performed by pushing the scissors in a series of passes bluntly toward the nasolabial fold. We find that when we insert the scissors in the proper plane, the dissection quickly glides through the malar soft tissues and we usually will feel a “snap” as we dissect through the remaining retaining ligaments. Once these structures are divided, one notes greater mobility when traction is applied to the malar portion of the SMAS flap, translating into greater movement along the uppermost portion of the nasolabial fold ( Fig. 8.5 ).

    Fig. 8.5 It is commonly necessary to extend the malar SMAS dissection more peripherally than the subcutaneous dissection to obtain adequate flap mobility of the soft tissues lateral to the nasolabial fold. This portion of the dissection is easily performed by simply inserting the scissors in the plane between the superficial surface of the elevators of the upper lip and the overlying subcutaneous fat. Once the scissors are inserted in the proper plane, the surgeon bluntly dissects in a series of passes past the nasolabial fold (area marked in green). As long as the scissors remain superficial to the elevators of the upper lip, motor nerve injury will be prevented. Two or three passes are usually required to obtain adequate flap mobility.
    From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, p. 257.
    Repositioning and closure of the SMAS is then performed. The malar SMAS flap is advanced superiolaterally over the zygomatic prominence in a direction perpendicular to the nasolabial fold, and usually paralleling the zygomaticus major muscle. After superior and lateral advancement, if a malar augmentation is not planned, the excess tissue can be excised and the flap securely fixated to the zygomatic periosteum with interrupted sutures. In many patients, I incorporate Vicryl mesh (an absorbable mesh) into the SMAS fixation to improve the tensile strength of SMAS closure ( Figs 8.6 , 8.7 ).

    Fig. 8.6 The vectors of redraping of the extended SMAS flap are determined according to the preoperative evaluation of the patient and are generally more cephalad than skin flap redraping.
    From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, p. 259.

    Fig. 8.7 Diagram illustrating how the excess SMAS, rather than being excised, is rolled onto itself (forming a double layer of SMAS thickness). Once the roll has been formed, it is fixated to the periosteum of the zygomatic buttress using permanent sutures. It is important to obtain a secure intraoperative fixation, and emphasize that fixation is as important as adequate SMAS mobilization. A small piece of Vicryl mesh is typically incorporated into the roll of the SMAS to improve its tensile strength.
    From Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face, 2nd edn. St. Louis: Mosby-Year Book, 1996, p. 263.
    If significant platysma banding is present, a platysmaplasty is performed through a submental incision. I typically approximate the medial edges of the platysma extending from the mentum caudally toward the base of the neck, followed by a transverse platysma myotomy performed low in the neck to alleviate tension along the platysma closure ( Figs 8.8 – 8.12 ).

    Fig. 8.8 After edge-to-edge approximation of the platysma from the mentum to the cricoid cartilage, some form of muscle release is performed. This usually consists of a horizontal cut extending from the midline to the anterior border of the sternocleidomastoid muscle. The key to platysma transection is to perform it low in the neck.

    Fig. 8.9 A , Preoperative appearance of a 59-year-old male following a 90 pound weight loss from a gastric bypass procedure. Notice the significant areas of facial deflation along the infraorbital rim, lateral orbital rim and malar region. Also notice the radial expansion of skin and fat lateral to the nasolabial fold, most marked on the right side. Not only does malar fat descend, but attenuation of the retinacular connections among skin, fat and deep facial fascia lateral to the nasolabial line allows prolapse of soft tissue, which accentuates nasolabial prominence. B , Postoperatively, the areas of deflation along the infraorbital rim, lateral orbital rim, and malar region are improved as facial fat has been repositioned into these regions. The nasolabial folds are somewhat improved after malar pad repositioning, but correction is incomplete, especially on the right. Malar pad elevation helps to flatten the prominent nasolabial fold, but does little to correct radial expansion, with the skin lateral to the nasolabial line remaining prolapsed from its attachments to the facial skeleton.
    From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362–376.

    Fig. 8.10 A&B , Long, thin faces often benefit from an enhancement of malar volume. SMAS dissection and facial fat repositioning carried anteriorly over the zygomatic eminence allows the surgeon to restore malar volume, thereby increasing bizygomatic diameter. When malar volume is enhanced, the face appears wider, detracting from the relatively excessive facial length.
    From Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg 2007;119:362–376.

    Fig. 8.11 A , Preoperative appearance. Note that facial shape is oval, secondary to malar deflation, associated with an increase in submalar fullness. B , Postoperatively, following malar pad elevation, malar volume is enhanced in association with a restoration of submalar concavity, producing a more angular appearance to facial shape.

    Fig. 8.12 A , Preoperatively, this patient shows a similar blunting of the relationship between the malar and submalar regions. B , Postoperative appearance. Enhancing malar volume (and bizygomatic diameter) and restoring the concavity within the submalar region make the face appear more angular, as well as vertically shorter.

    Postoperative care
    The patient is provided with specific instructions about postoperative care. Some surgeons provide the patient with a printed list, whereas others prefer to give the instructions verbally.
    If the patient is healing well at the end of a week or 10 days, return is advised in 2 to 3 weeks for a routine postoperative visit and again in 6 weeks. The patient is instructed to return or call at any time if there are any questions about the postoperative course.
    During the first week the patient is allowed to walk and is encouraged to be up and about as much as is reasonably possible. Strenuous physical activities such as tennis, water-skiing, and golf are not permitted for 5 or 6 weeks. A good basic rule is: “If it hurts, don’t do it.”
    The following postoperative recommendations have proven helpful for most patients:

    • Pressure dressings are not used. A light facelift dressing is placed for the first 24 hours.
    • The head of the bed is elevated at all times, but flexion of the patient’s neck is avoided because this may compromise circulation to the cervical flap.
    • Appropriate pain and sleep medications are given; strong narcotics are rarely required.
    • The patient may go to the bathroom with assistance on the first postoperative day and as desired thereafter.
    • The first dressing is changed after 24 hours. At this time, the wounds are inspected and no further dressing is utilized.
    • Preauricular sutures are removed on the fifth or sixth postoperative day.
    • All sutures are removed by the tenth postoperative day.
    • Antibiotics are routinely used preoperatively and for 5 days postoperatively. My current preference is Levaquin, 500 mg once daily, begun the night prior to surgery.
    • If crusty or oozing, wounds are cleaned with hydrogen peroxide and coated with a topical antibiotic ointment.

    Complications
    No surgical procedure exists without complications. The surgeon must be able to recognize and deal with these problems. The most common complications after rhytidectomy are:

    • Hematoma (70% of all rhytidectomy complications).
    • Postoperative edema.
    • Ecchymosis.
    • Nerve injury.
    • Unacceptable scarring (hypertrophic).
    • Skin slough.
    • Seromas.
    • Contour irregularities.
    • Infection.
    • Patient dissatisfaction.


    Pearls & pitfalls

    Pearls

    • Improving technical control through contouring the superficial facial fascia and platysma provides for a more consistent, aesthetically pleasing result which is natural in appearance.
    • Patient selection is probably the most critical factor when determining the success of a proposed aesthetic procedure.
    • Although aging represents a complex process, many of the stigmata developing in the aging face involve a change in the relationship between the superficial and deep facial fascia, with the superficial unit of the facial soft tissue descending inferiorly in relation to the fixed deeper structures of the face.
    • The prime advantage of performing skin undermining separately from SMAS dissection is that it allows these two layers to be redraped along vectors which are independent of one another.
    • The importance of incision quality cannot be overemphasized in diminishing the stigmata that the patient has undergone a surgical procedure.

    Pitfalls

    • Imprecise subcutaneous undermining of the skin flap can lead to a paucity of fat being left along the superficial surface of the SMAS, making it difficult or impossible to raise the SMAS as a discrete anatomic layer, limiting its usefulness in facial contouring.
    • Not extending the release of the SMAS anterior to the adherence of the retaining ligaments limits the movement of this layer, thereby limiting surgical control in terms of restoring facial shape.
    • Vertical skin tension to tighten the face often produces an unnatural surgical appearance to the postoperative result and can be avoided by utilizing the superficial fascia to vertically reposition facial fat.
    • Imprecise incision design and skin flap inset can lead to noticeable scars, hairline shifts, tragal and earlobe distortion. Limiting skin tension by utilizing the SMAS to restore facial shape provides the surgeon with greater control in terms of scar perceptibility.
    • Attempting to improve cervical contour through lateral platysma tension and closed suction lipoplasty of the neck provides less consistent results than approaching platysmaplasty anteriorly through a submental incision.


    Summary of steps for extended SMAS procedure

    1. Tragal margin incision design which respects the aesthetic units of the tragus and preserves the tragal insisura.
    2. The use of transillumination to allow precise skin flap undermining which preserves the fat along the superficial surface of the SMAS provides greater consistency in SMAS flap elevation.
    3. Limiting subcutaneous undermining over the buccal recess and buccinator allows this region of the cheek to be repositioned through SMAS rotation producing greater control in terms of submalar contour and jowl correction.
    4. The incision of the extended SMAS dissection parallels the zygomatic arch and then extends superiorly over the malar eminence in the area where the arch joins the body of the zygoma.
    5. Releasing the SMAS from the restraints of the retaining ligaments until the SMAS moves freely requires the surgeon to carry the dissection into the mobile region of the SMAS which lies anterior to the retaining ligaments over the malar eminence and parotid.
    6. Vectoring the SMAS should be patient-specific and should be determined preoperatively with the patient in an upright position. Variation in vectors between the right and left side of the face are common.
    7. Secure fixation of the SMAS, often incorporating Vicryl mesh into the closure improves consistency in shaping and postoperative results.
    8. Approaching platysmaplasty through a submental incision and suturing the platysma from the mentum to the base of the neck provides greater control in cervical contouring.
    9. Meticulous hemostasis leads to a low hematoma rate and more rapid postoperative recovery.
    10. Placement of drains along the base of the neck prior to closure promotes rapid postoperative recovery.
    11. Precise skin flap inset and closure with minimal tension, especially along the tragus and earlobe leads to control of scar perceptibility.

    Further reading

    Baker TJ, Gordon HL, Stuzin JM. Surgical rejuvenation of the face , 2nd edn. St. Louis: Mosby; 1996.
    Bames H. Truth and fallacies of face peeling and facelifting. Plast Reconstr Surg . 1927;126:86.
    Barton FE, Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg . 1992;90:601.
    Connell BF. Neck contour deformities: The art, engineering, anatomic diagnosis, architectural planning, and aesthetics of surgical correction. Clin Plast Surg . 1987;14:683.
    Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg . 1990;85:333.
    Furnas D. The retaining ligaments of the cheek. Plast Reconstr Surg . 1989;83:11.
    Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg . 1976;58:80.
    Owsley JQ, Jr. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg . 1993;91:463.
    Skoog T. Plastic surgery – New methods and refinements . Philadelphia: W.B. Saunders; 1974.
    Stuzin JM. Restoring facial shape in facelifting: The role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg . 2007;119:362.
    Stuzin JM, Baker TJ, Baker TM. Refinements in facelifting: Enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg . 2000;105:290.
    Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg . 1995;22:295–311. –
    Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: Relevance to rhytidectomy and aging. Plast Reconstr Surg . 1992;89:441.
    CHAPTER 9 Short scar facelift

    Daniel C. Baker

    History
    The short scar facelift with lateral SMASectomy was developed out of a demand from younger female patients (aged mostly in their forties) who sought facial rejuvenation but were adamantly opposed to any scarring behind the ears. These patients objected to the posterior hairline distortion, hypertrophic scars, and hypopigmentation that they often observed in their friends or mothers who had undergone facelifts. They were embarrassed to wear their hair up or in a ponytail.
    My first experience with short scar facelift occurred in 1990, when I operated on a young woman who had submental and submandibular fat and early jowling, but good cervical skin elasticity. I performed lipoplasty of the neck and jowls with wide subcutaneous undermining in the face, detaching the malar and masseterocutaneous ligaments. A pure skin lift was done with no retroauricular scars. The result was excellent, and this experience prompted me to adopt this procedure for all my younger patients with similar anatomic features.
    In 1992 I began to incorporate the lateral SMASectomy technique to the facelift operation for women in their forties. I noticed that vertical elevation of the face had a beneficial effect on the cervical skin. Lax cervical skin was tightened because the soft tissues of the face and neck are linked anatomically. Between 1990 and 1998 I performed this operation, which had no retroauricular scars, on a total of 204 young female patients. The results were “ponytail friendly” for these young, active women.

    Physical evaluation
    See Figs 9.1 – 9.8 .

    Type I: The ideal candidate for short scar facelift
    See Figs 9.1 and 9.2 .

    Fig. 9.1 Presentation of a type I patient, an ideal candidate for minimal incision rhytidectomy.

    Fig. 9.2 Type I patient undergoing short scar facelift with plication only. A–C , Preoperative. D–F , 1 year postoperative.

    • Age early to late forties, occasional fifties.
    • Aging primarily facial.
    • Early jowling.
    • Slight cervical skin laxity.
    • May have submental fat.
    • May have microgenia.
    • Good cervical skin elasticity.
    • Physically active, wears hair up or ponytail.

    Type II: The good candidate for short scar facelift
    See Figs 9.3 and 9.4 .

    Fig. 9.3 Presentation of a type II patient, a good candidate for minimal incision rhytidectomy.

    Fig. 9.4 Type II patient undergoing short scar facelift with plication only. A–C , Preoperative. D–F , 1 year postoperative.

    • Age late forties to late fifties.
    • Moderate jowls.
    • Moderate cervical skin laxity.
    • Submental/submandibular fat.
    • May have microgenia.
    • No active platysma bands.

    Type III: The fair candidate for short scar facelift
    See Figs 9.5 and 9.6 .

    Fig. 9.5 Presentation of a type III patient, a fair candidate for minimal incision rhytidectomy.

    Fig. 9.6 Type III patient undergoing short scar facelift with open submental SAL, liposuction, plastysmaplasty and lateral SMASectomy. A–C , Preoperative. D–F , 1 year postoperative.

    • Age late fifties to early seventies.
    • Significant jowls.
    • Moderate cervical skin laxity.
    • Submental/submandibular fat.
    • Platysma bands on animation.
    • May have microgenia.
    • Some secondary rhytidectomy.

    Type IV: The poor candidate for short scar facelift
    See Figs 9.7 and 9.8 .

    Fig. 9.7 Presentation of a type IV patient, a poor candidate for minimal incision rhytidectomy.

    Fig. 9.8 A–F , Although this patient has a nice improvement after undergoing short-scar rhytidectomy, the 1-year postoperative result demonstrates persistent cervical laxity extending to the sternal notch. The patient was not happy and required neck revision with a classic retroauricular incision. This much cervical laxity can only be corrected with wide through-and-through undermining and removal of excess skin via the retroauricular occipital incision.

    • Age late sixties and seventies.
    • Significant jowls.
    • Poor cervical skin elasticity.
    • Skin folds below cricoid.
    • Submental/submandibular fat.
    • Platysma bands on animation.
    • Deep cervical creases.

    Technical steps

    Incisions
    When the temporal hairline shift is assessed as minimal, the preferred incision is well within the temporal hair. With this incision, it is often necessary to excise a triangle of skin below the temporal sideburn at the level of the superior root of the helix ( Fig. 9.9 ).

    Fig. 9.9 Preferred and optional incisions for minimal incision rhytidectomy.
    However, when a larger skin shift is anticipated (frequently the lift is more vertical with a short scar facelift) or the distance between the lateral canthus and the temporal hairline is greater than 5 cm, the incision is made a few millimeters within the temporal hairline. Although this is a compromise, the alternative of a receding temporal hairline is rarely acceptable to female patients. When the incisions are executed properly, these scars heal well.

    Skin flap elevation
    All skin flap undermining is carried out under direct vision with scissors dissection to minimize trauma to the subdermal plexus and preserve a significant layer of subcutaneous fat on the undersurface of the flap. I prefer subcutaneous dissection in the temporal region because the skin seems to redrape better. I believe that hair loss results primarily from tension rather than superficial undermining. Subcutaneous dissection in the temporal region must be performed carefully to avoid penetrating the superficial temporal fascia that protects the frontal branch of the facial nerve. All dermal attachments between the orbicularis oculi muscle and the skin are separated up to the lateral canthus ( Fig. 9.10 ).

    Fig. 9.10 Extent of subcutaneous undermining in temporal area, cheek, and lateral neck. If excess fat is present, closed or open liposuction, superficial to the platysma, is executed in submental and submandibular areas. When necessary, medial platysma approximation is performed via the submental incision.
    Dissection extends across the zygoma to release the zygomatic ligaments but stops several centimeters short of the nasolabial fold. I have never felt that further dissection provides significant benefits; on the contrary, the only result is increased bleeding. In the cheek, dissection releases the masseteric-cutaneous ligaments and, if necessary, the mandibular ligaments.
    Subcutaneous dissection continues over the angle of the mandible and sternocleidomastoid for 5 to 6 centimeters into the neck. This exposes the posterior half of the platysma muscle. If a submental incision has been made, the facial and lateral neck dissection is connected through-and-through to the submental dissection.

    Open submental incision with medial platysma approximation
    After many years, I seldom open the neck anymore, except in unusual cases. I have found that I can achieve excellent results with closed lipoplasty and strong lateral platysma pull. With short scar facelifting in patients with active platysma bands on animation, the medial approximation provided another vector to enhance the cervicomental recontouring.
    The submental incision is made either in the submental crease or just anterior to it. The subcutaneous dissection is performed with the patient’s neck hyperextended. Undermining is usually to the level of the thyroid cartilage and angle of the mandible. Suction-assisted lipoplasty is then performed with a large, single-hole cannula under direct vision. Direct fat excision is carried out, if necessary, but to avoid depressions, no subplatysma fat is removed ( Fig. 9.11 ).

    Fig. 9.11 Vectors of superolateral elevation of SMAS-platysma and vectors of medial approximation of anterior platysma in the submental area above the hyoid.
    The medial borders of the platysma muscle are identified and elevated for several centimeters. To break the continuity of the bands, a wedge of muscle is removed at the level of the hyoid. The medial borders of the muscle are then sutured together with interrupted buried 4-0 PDS (ETHICON, Inc., Somerville, NJ).

    Lateral SMASectomy including platysma resection
    In the SMAS-platysma resection, the level of the resection is superficial to the parotid masseteric fascia that overlies the facial nerve branches. The outline of the SMASectomy is marked on a tangent from the lateral malar eminence to the angle of the mandible, essentially in the region along the anterior edge of the parotid gland. In most patients this involves a line of resection extending from the lateral aspect of the malar eminence toward the tail of the parotid gland. Frequently, orbicularis oculi muscle fibers are exposed at the superior limit of the excision. Usually a 2 to 4 centimeter segment of superficial fascia is excised, depending on the degree of SMAS-platysma laxity.
    In SMAS resection, I like to pick up the superficial fascia in the region of the tail of the parotid, extending the resection from inferolateral to supero-medial in a controlled fashion. When SMAS resection is being performed, it is important to keep the dissection superficial to the deep fascia and avoid dissection into the parotid parenchyma. Note that the size of the parotid gland varies from patient to patient; consequently, the amount of protection for the underlying facial nerve branches will also vary. Despite this, as long as the dissection is carried superficial to the deep facial fascia, ensuring that only the superficial fascia is resected, facial nerve injury as well as parotid gland injury will be prevented. In essence, this is a resection of the superficial fascia in the same plane of dissection as one would normally raise a SMAS flap.

    Vectors
    The following vectors are illustrated: (1) vectors of elevation of the SMAS-platysma and (2) vectors of superolateral elevation of the SMAS-platysma and medial approximation of the anterior platysma in the submental area above the hyoid bone. The various vectors accomplish corrections of the anterior neck, the cervicomental angle, the jowls, and the nasolabial fold. The first key suture grasps the platysma at the angle of the mandible and advances it in a posterosuperior direction; it is secured with figure-of-eight 2-0 Maxon sutures (Davis & Geck, Danbury, CT) to the fixed lateral SMAS overlying the parotid gland. This lifts the cervical platysma and cervical skin, helps to define the jawline, and improves contouring in the submandibular region.
    The lines of closure of the lateral SMAS-platysma in the cheek and the lateral neck and medial platysma approximation in the submental area are depicted. Excess fat in the mastoid and submandibular areas is removed by liposuction. After SMAS resection, interrupted 3-0 PDS buried sutures are used to close the SMASectomy; the fixed lateral SMAS is evenly sutured to the more mobile anterior superficial fascia. Vectors are perpendicular to the nasolabial fold. The last suture lifts the malar fat pad, securing it to the malar fascia. It is important to obtain a secure fixation to prevent postoperative dehiscence and relapse of the facial contour ( Figs 9.12 and 9.13 ).

    Fig. 9.12 Design of SMAS-platysma resection. The level of resection is superficial to the parotid masseteric fascia that overlies the facial nerve branches.

    Fig. 9.13 Vectors of elevation of SMAS-platysma.

    Skin closure, temporal fascia and earlobe dog-ears
    After SMAS and platysma approximation, some tethering of the skin might appear at the anterior extent of the subcutaneous dissection because of the pull of the underlying SMAS. This can also occur in the lower eyelid with elevation of the malar fat pad. Further subcutaneous undermining is necessary to free these tethers, allowing the skin to redrape.
    The first key skin suture rotates the facial flap vertically and posteriorly to lift the midface, jowls, and submandibular skin. Suture fixation is at the level of the insertion of the superior helix. I like to use a buried 3-0 PDS through the temporal fascia with a generous bite of dermis on the skin flap. Closure is under minimal to moderate tension. Staples are used to close any incisions in the hair. A wedge is usually removed at the level of the sideburn to preserve the hairline. If an anterior hairline incision has been made, I like to close it with buried 5-0 Monocryl sutures (Ethicon, Inc.) and 5-0 Nylon sutures. Extra time and attention must be spent on this closure to eliminate any dog-ears and obtain the finest scar.
    Excess skin is then trimmed from the facial flap so that there is no tension on the preauricular closure. Wound edges should be “kissing” without sutures. Trimming at the earlobe must also be without tension, and the skin flap is tucked under the lobe with 4-0 PDS sutures, taking a bite of earlobe dermis, cheek flap dermis, and conchal perichondrium to minimize tension. A small dog-ear might be present behind the earlobe; this is easily trimmed and tailored into a short incision in the retroauricular sulcus. A closed suction drain is usually brought out through a separate stab in the retroauricular sulcus ( Fig. 9.14 ).

    Fig. 9.14 Intraoperative and immediate postoperative views of a 64-year-old woman who underwent lateral SMASectomy via minimal incision rhytidectomy with anterior hairline incision. A , SMAS-platysma resection and temporal hairline incision are outlined. B , Area of SMAS resection; resected SMAS in forceps. C , SMAS reapproximation. D , Forceps pull in the direction of the key skin vector as excess skin is excised. E , Fitting the skin flap to the earlobe and removing the dog-ear from the retroauricular sulcus. F , Final closure with a suction drain in the neck.
    Reproduced with permission from Baker, DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy. Aesthet Surg J 2001;21:68–79.

    Postoperative care

    • Suction drains benefit cervicofacial flaps for 48 hours.
    • Bulky soft head dressing for 48 hours.
    • Strict postop blood pressure control for 72 hours.
    • Elastic chin strap applied for 1 week in patients with complete neck undermining.
    • Soft diet, no lifting, bending for 1 week, no exercise 2 weeks.

    Complications of the short scar facelift

    Hematoma: 1.5%.
    Facial paralysis (all resolved in 2 months): 0.3%.
    Infection (abscess): 0.8%.
    Skin slough (minor): 1.0%.
    Hypertrophic scars: 2.0%.
    Suture granuloma (PDS): 3.5%.
    Ear lobe deformity: 0.8%.
    Retroauricular pleating: 2.0%.
    Temporal hairline scar revision: 3.0%.
    Cervical tightening in poorly selected patients: 2.0%.


    Pearls & pitfalls

    Pearls (advantages of short scar facelift)

    • Requires less dissection.
    • Requires a less invasive procedure.
    • Is associated with less scarring and earlobe areas.
    • Avoids posterior hairline distortion.
    • Allows easier hematoma evacuation.
    • “Ponytail friendly”.

    Pitfalls (disadvantages of short scar facelift)

    • Requires more vertical skin lift.
    • Can make it difficult to fit in dog-ears in temporal.
    • Requires time for temporal hairline scar to smooth.
    • Requires time for retroauricular sulcus/earlobe scar.
    • Limits neck exposure to smooth.
    • Occasionally causes skin fold at base of earlobe.
    • Not applicable to patients with severe cervical laxity.


    Summary of steps

    1. The best candidates for short-scar rhytidectomy are younger, with better skin elasticity and minimal cervical laxity.
    2. When the temporal hairline shift is assessed as minimal, the preferred incision is well within the temporal hair.
    3. Perform lipoplasty before elevating skin flaps and avoid oversuctioning. Whenever possible, I prefer closed SAL in the neck and jowls.
    4. If active prominent platysma bands are present, open the neck and undermine to perform medical platysma approximation.
    5. Plication is always preferred in patients with thin faces.
    6. A lateral SMASectomy is performed when debulking is aesthetically beneficial.
    7. For maximal midface correction, extend plication or SMASectomy over the malar eminence just short of the lateral commissure.
    8. If a lateral SMASectomy is performed, keep the dissection superficial to the deep fascia to avoid the parotid gland and facial nerves.
    9. After plication or SMASectomy, the last suture lifts the malar fat pad securing it to the malar fascia.
    10. Not every patient is a candidate for the short scar technique; some will benefit more from classic retroauricular and occipital incisions.
    11. Finally, do not compromise the end result just to have a shorter scar.

    References

    1. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Plast Reconstr Surg . 1979;64:781–795.
    2. Baker DC. Complications of cervical rhytidectomy. Clin Plast Surg . 1983;10:543–562.
    3. Baker DC. Deep dissection rhytidectomy: A plea for caution. Plast Reconstr Surg . 1994;93:1498–1499.
    4. Baker DC. Lateral SMASectomy. Plast Reconstr Surg . 1997;100:509–513.
    5. Baker DC. Lateral SMASectomy. Semin Plast Surg . 2002;16:417–422.
    6. Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy: Evolution and application. Aesthetic Surg J . 2001;21:14–26.
    7. Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy: Operating Strategies. Aesthetic Surg J . 2001;21:68–80.
    8. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: Anatomical variations and pitfalls. Plast Reconstr Surg . 1979;64:781–795.
    9. Baker DC. Hamra ST, Owsley JQ, et al. Ten year follow-up on the twin study. Presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, New Orleans, LA, April 2005.
    10. Baker DC, Chiu ES. Reducing the incidence of hematoma requiring surgical evacuation following male rhytidectomy: A 30-year review of 985 cases. Plast Reconstr Surg . 2005;116(7):1973–1985.
    CHAPTER 10 Foundation facelift

    Gerald H. Pitman

    History
    Foundation facelift, formerly known as deep-plane lift, is characterized by elevation of a composite musculo-cutaneous flap of facial and upper cervical soft tissues. As the flap is rotated to a more lateral and cephalad position, it dramatically corrects tissue laxity, and rejuvenates the face. The foundation facelift is particularly effective in softening the nasolabial fold. The thickness and excellent vascularity of the flap produce long-lasting and natural results.
    Skoog described use of a composite flap for facelift in his landmark textbook, published in 1974. In 1980, Lemmon and Hamra reported their experience with Skoog’s technique. Hamra subsequently combined the foundation facelift with a trans-palpebral, vertical mid-facelift and named the dual operation composite rhytidectomy. Pina reported his experience with composite rhytidectomy in 1997. Pitman created a video in 2000, clarifying the applied anatomy of the operation’s composite, musculo-cutaneous flap.

    Patient evaluation
    Foundation facelift is particularly useful in certain classes of patients.

    • Patients who have had a previous SMAS-platysma operation and in whom the remaining SMAS-platysma may be insubstantial and/or scarred can still have a robust flap when the subcutaneous tissues and skin remain integrated with the SMAS-platysma as in the foundation facelift.
    • Because the foundation facelift flap has a particularly strong blood supply, typical of musculo-cutaneous flaps, this operation is a good choice for smokers and other patients in whom the vascularity of the facelift flap may be suboptimal.
    • The dissection plane deep to the SMAS-platysma is an avascular plane, and operations in this plane are bloodless, rarely eventuating in hematomas. The foundation lift, then, is a good choice for patients at increased risk for postoperative bleeding.
    • Because the foundation facelift flap is thick and has a robust blood supply, it can be elevated to the nasolabial fold and even on to the lip without fear of flap necrosis, even when the flap is pulled up under some tension. This operation, is a champion technique for flattening deep nasolabial folds.
    Patient evaluation is directed towards identifying anatomical features which will be particularly well treated with the foundation facelift. Conversely, some anatomical features are better treated with other techniques. Evaluation proceeds as follows.

    • Evaluate the skin of the face and neck and underlying soft tissues for laxity and loss of elasticity. Laxity is characterized by excess and redundant skin. Loss of elasticity means that the skin does not easily snap back after being put under stretch, and mitigates against a superior and long-lasting result. These patients should be warned that an early secondary operation may be necessary.
    • Severe sun damage, as evidenced by rhytids, thinning of the skin, and pigmentary changes, should also be noted and pointed out to the patient. These actinic changes are little improved by facelifting, and the patient should be aware of the limitations imposed by solar damage to the skin.
    • Ptosis of the platysma, evidenced by vertical bands in the anterior neck, will almost always require anterior platysma plication for correction.
    • Note presence of excess fat in the neck, as removal of this excess is a sine qua non for creating a youthful neck and jaw line.
    • Jowling and deep nasolabial folds should be noted. These hallmarks of facial aging are well-treated with foundation facelift.
    • Descent of the malar fat pad is also a cardinal sign of aging. Its correction requires movement of the fat pad and skin in a vertical, cephalic direction.
    • The quality and thickness of the preauricular skin and the presence of fine hairs on the skin should be noted in women and men. Thick, hair-bearing skin in either sex is a relative contraindication to using a retrotragal incision, since transposing the thickened, hair-bearing skin to cover the tragus will obscure the fine detail of this important anatomic landmark.

    Anatomy
    From its origin in the lower neck, the platysma muscle extends to the lower cheek, covering a portion of the lower parotid gland before inserting into the perioral muscles at the corner of the mouth ( Fig. 10.1 ). The investing fascia of the platysma continues cephalad in the cheek as the SMAS (superficial musculo-aponeurotic system). The SMAS lies superficial to the masseter muscle and the buccal fat pad, before continuing in a cephalic direction to invest the deep and superficial layers of the zygomatic major and minor.

    Fig. 10.1 Extent of the SMAS-platysma in the upper neck and cheek.
    The defining feature of the foundation facelift is elevation of the SMAS-platysma, subcutaneous fat, and overlying skin as a unified flap. The SMAS-platysma is the integrated foundation of this musculo-cutaneous, composite flap. In the upper neck and lower cheek, the platysma is the deepest layer of the flap ( Fig. 10.2 ); in the mid and upper cheek, the platysma continues as the SMAS and forms the deepest layer of the flap ( Fig. 10.3 ).

    Fig. 10.2 Cross section of the foundation facelift flap at the level of the lower lip. Facial nerve branches yellow, facial artery red, facial vein blue.

    Fig. 10.3 Cross section of the foundation facelift flap at the level of the upper lip.
    Safe and facile performance of the foundation lift requires the surgeon to possess an intimate knowledge of the three-dimensional course of the facial nerve as its branches traverse the musculo-fascial planes of the cheek and upper neck.
    As the nerve branches exit the parotid gland, they lie deep to two important fascial planes:

    • The more superficial and thicker plane is the SMAS-platysma.
    • Just deep to the SMAS-platysma is a thin layer of fascia lying just superficial to the nerve branches.
    – In the lower and mid- cheek, this thin layer of fascia is the easily recognizable masseteric fascia. The buccal branches of the facial nerve course over the outer surface of the masseter muscle covered by the masseteric fascia ( Figs 10.2 and 10.3 ).
    – Some of the buccal branches head in a more cephalad direction and proceed superficial to the buccal fat pad where they are covered by the very thin and delicate buccal fascia. The buccal fascia is, in turn covered by the SMAS ( Fig. 10.3 ). In the mid and upper cheek, the zygomatic and buccal branches are under cover of the buccal fascia.
    • As the zygomatic and buccal branches course in a cephalad direction, they are covered by the zygomaticus major and minor muscles ( Figs 10.3 and 10.4 ).
    • A more complete understanding of the anatomy of the foundation facelift is obtained by studying an artist’s representation of the surgeon’s view when the flap is elevated ( Fig. 10.5 ). The platysma is elevated with the subcutaneous fat and skin in the lower cheek. In the mid and upper cheek, the platysma becomes the SMAS and is also elevated with the subcutaneous fat and skin. The malar fat pad in the upper cheek also remains attached to the skin and is elevated as the skin is mobilized and repositioned. Note the course of the branches of the facial nerve as they exit the anterior border of the parotid gland, but remain covered by masseteric fascia, buccal fascia, and the zygomaticus major.

    Fig. 10.4 Cadaver dissection showing zygomatic and buccal branches of facial nerve proceeding deep to the zygomaticus major.
    Cadaver dissection by David A. Stoker, M.D., from Pitman GH. Foundation facelift. In: Nahai F. The art of aesthetic surgery: Principles and techniques. St. Louis: Quality Medical Publishing, 2005. (With permission.)

    Fig. 10.5 Surgeon’s view of foundation facelift flap. Facial nerve branches lie within the parotid gland until they exit from the anterior border of the gland at which time they are deep to the masseteric fascia, the buccal fascia, and the zygomaticus major. Nerve branches are shaded to indicate they are covered by the aforementioned structures.
    David A. Stoker, M.D., from Pitman GH. Foundation facelift. In: Nahai F. The art of aesthetic surgery: Principles and techniques. St. Louis: Quality Medical Publishing, 2005. (With permission.)

    Technical steps

    Positioning
    The patient is placed supine on the operating table. Intermittent compression boots are placed on the calves and ankles prior to induction. The operating table is flexed slightly at the hips and knees. The head is kept in a neutral position except when working in the neck at which time the headpiece is dropped towards the floor so that the neck can be easily extended, improving visualization deep in the neck.

    Anesthesia
    If only the face and upper neck are treated, the operation can be performed under local anesthesia. When eyelids, brow and lower neck are treated synchronously with the face, the procedure will last more than two hours, and general anesthesia is used for patient comfort and safety.
    Oral endotracheal intubation ensures a secure airway, permitting the anesthesiologist to move well away from the head of the table and out of the operative field, yet still have control over the airway and ability to monitor end-tidal carbon dioxide.
    The endotracheal tube is sutured to an upper incisor and wrapped with sterile drapes. The anesthesia circuit remains in the operative field, on top of the drapes, and is easily repositioned during surgery as the patient’s head is turned side to side.

    Marking the patient
    Prior to surgery, anatomic landmarks are drawn on the face and neck with the patient standing ( Fig. 10.6 ). The drawn lines indicate:

    • the point of origin and course of zygomaticus major and minor;
    • the nasolabial and labiomental creases;
    • the anterior border of parotid gland;
    • the lateral border of platysma in neck which, for most patients, is aligned with the anterior border of the parotid;
    • the inferior border of the mandible; and
    • the limit of dissection in the lower neck.

    Fig. 10.6 Patient is shown following induction. Anatomic landmarks and line of submental incision were drawn preoperatively with the patient standing. Ink lines denote the point of origin and course of the zygomaticus major and minor, the nasolabial and labiomental folds, the inferior border of the mandible, the anterior border of the parotid gland in the face, and the lateral border of the platysma in the neck. This last line is a continuation of the approximate anterior border of the parotid gland in the face. A transverse line across the lower neck indicates the approximate inferior limit of the cervical dissection.
    The line of the submental incision is also marked preoperatively with the patient standing so the surgeon can plan the incision in the least visible area ( Fig. 10.7 ).

    Fig. 10.7 The submental incision is a four centimeter transverse line placed in the most inconspicuous position adjacent and parallel to the submental crease. The incision may be in the crease itself or slightly caudad to the crease, as shown here. The incision is placed wherever it is best hidden.
    The remainder of the incision lines is drawn after intubation. The periauricular incision starts in the temporal area ( Fig. 10.6 ). A vertical incision extending three or four centimeters into the hairline cephalad to the roll of the helix is used when access is required to the temporal area for a temporal and/or brow lift. The incision continues caudad along the helical roll to the tragus where, for most patients, it follows the edge of the tragus, and then continues along the prelobular crease ( Fig. 10.6 ) before coming around the lobule to the retroauricular crease ( Fig. 10.8 ). The incision follows the course of the retroauricular crease cephalad before traversing the retroauricular skin and then proceeding along the occipital hairline for three centimeters after which it turns posterior into the occipital hair.

    Fig. 10.8 Retroauricular and occipital portion of the incision.
    When a temporal and/or browlift is not performed, the incision starts as a horizontal line extending from the point at which the helical rim joins the face to the anterior portion of the temporal hairline ( Fig. 10.9 ). This incision can be extended vertically along the temporal hairline to take out excess skin. A pretragal incision is used when the preauricular skin is excessively thick and would blunt fine tragal detail if used to cover the tragus.

    Fig. 10.9 Dotted lines indicate alternative incisions at temporal hairline and in preauricular crease.
    Lastly, if there is little excess skin in the neck, the postauricular incision can be limited to the retroauricular crease ( Fig. 10.10 ).

    Fig. 10.10 Planned retroauriclar incision limited to the retroauricular crease.

    Operation
    The entire face and neck operative area is infiltrated with lidocaine 0.25% with epinephrine 1 : 200,000. Approximately 100 mL is used for each side of the face and neck.
    The head and neck are prepped with sterile povidone-iodine solution prior to draping.
    Surgery starts 20 minutes after injection. Following an initial preauricular incision, a thick skin flap is elevated superficial to the parotid fascia. Dissection stops at the line demarcating the anterior border of the parotid ( Fig. 10.11 ).

    Fig. 10.11 Limit of initial preauricular dissection. Skin flap includes most of fat superficial to parotid fascia.
    The skin with a thin layer of subcutaneous fat is elevated with the scalpel from the retroauricular and occipital area as far as the inked line denoting the lateral border of the platysma in the neck. This dissection is joined to the lower cheek dissection ( Fig. 10.12 ).

    Fig. 10.12 Dissection in the retroauricular and occipital area. Flap contains skin and 2–3 mm of subcutaneous fat. Initial dissection is to lateral border of platysma indicated by ink line on skin.
    The skin of the neck overlying the platysma is also elevated using a long curved Mayo scissors. A 2–3 mm thickness of subcutaneous fat is kept with the skin. Residual fat on the platysma is excised with scissors or cautery. This dissection exposes the platysma from the mandibular border to as low in the neck as necessary. If laxity in the neck is severe, dissection will extend to the clavicle ( Fig. 10.13A,B ).

    Fig. 10.13 Dissection superficial to platysma in upper ( A ) and lower ( B ) cervical area. Skin flap is raised with 2–3 mm of fat attached. Excess fat remaining on platysma is excised using scissors or cautery.
    Subcutaneous dissection of the cheek flap is extended to the temporal area in the plane superficial to the superficial temporal fascia. This dissection continues to the region of the lateral border of the orbicularis oculi and the origin of the zygomaticus major and minor ( Fig. 10.14 ).

    Fig. 10.14 Superficial dissection of cheek flap completed. Dissection in the superficial plane ends 1 cm before reaching the anterior border of the parotid gland. The inked line beneath flap is drawn superficial to the parotid gland from near the origin of the zygomaticus major, above, to the region of the tail of the parotid gland, below. This inked line will be the line of entry to the deep plane.
    Entry to the deep plane is via scalpel incision through the SMAS-platysma along a line parallel to and 1 cm posterior to the anterior border of the parotid gland ( Fig. 10.15 ). The surgeon grasps the cut edge of the platysma and begins separation of the platysma from the underlying parotid fascia using a pair of Stevens scissors ( Fig. 10.16 ). As soon as the dissection proceeds in an anterior direction beyond the edge of the parotid gland, the platysma becomes much less adherent to the underlying masseteric fascia, and spreading of the scissors in a plane perpendicular to the plane of dissection easily separates the platysma from the masseteric and adjacent buccal fascia. Dissection is rapid and bloodless to the region of the modiolus and labiomental line ( Fig. 10.17 ).

    Fig. 10.15 Incision through the SMAS-platysma along a line 1 cm posterior to the anterior border of the parotid gland. Note separation of SMAS-platysma tissues along line of incision. Parotid fascia is exposed in the depth of the caudad portion of the incision.

    Fig. 10.16 Sharp and blunt separation of the platysma from the underlying parotid fascia.

    Fig. 10.17 Completed dissection in the lower cheek. Retractor elevates platysma. Beginning at the line of the incision to the deep plane (purple ink line) one sees parotid fascia, and masseteric fascia covering facial nerve branches.
    The upper cheek is dissected in the deep plane by finding the origin of the zygomaticus major near the most prominent portion of the malar eminence and then dissecting superficial to the zygomaticus major until the surgeon reaches the nasolabial fold ( Fig. 10.18 ). The malar fat pad remains with the skin and is part of the elevated upper cheek flap. The upper and lower cheek dissections are connected by bluntly separating the remainder of the connections between the zygomaticus major and the skin.

    Fig. 10.18 Retractor holds superficial tissues of upper cheek including malar fat pad. Zygomaticus major muscle is limit of deep dissection. Purple line in mid and lower cheek is the cut edge of entry into the deep plane in the mid and the lower cheek.
    Upon completion of the dissection of the right cheek and neck, the patient’s head is turned to the right and an identical dissection is performed on the left side. If the cervical soft tissues are lax, or, there is excess fat in the submental area, the anterior neck is approached through a 4 cm transverse submental incision (see Fig. 10.7 ). The submental skin is dissected away from the underlying platysma, leaving a 2–3 mm layer of fat on the undersurface of the skin. This dissection joins with the lateral dissections from the right and left sides. The entire submental and submandibular areas are then exposed, and any excess fat overlying the platysma is excised through the central submental and right and left lateral incisions. If necessary, the platysma is imbricated in the midline with a running 3-0 Monocryl suture ( www.ethicon.com ).
    The patient’s head is turned to the left and the right SMAS-platysma flap is used to elevate and tighten the lower cheek and upper neck tissues ( Fig. 10.19 ). The undersurface of the platysma and overlying subcutaneous tissue of the upper neck and cheek are sutured to the parotid fascia anterior to the earlobe with two sutures of 2-0 Maxon ( www.ussurgical.com ) ( Fig. 10.20 ).

    Fig. 10.19 SMAS-platysma and attached overlying skin are elevated and tightened using Bonney forceps.

    Fig. 10.20 A , A 2-0 Maxon is placed in the undersurface of the platysma and B , sutured to the fixed parotid fascia anterior to the right earlobe. Two such sutures are placed, one above the other. When the sutures are tied the skin will be elevated and tightened.
    The upper portion of the cheek flap is pulled upwards and laterally enough to increase dental show but not under extreme tension ( Fig. 10.21 ). The upper cheek flap is then sutured with 3-0 Monocryl to the skin anterior to the point at which the helical rim joins the preauricular skin ( Fig. 10.22 ). The suture also includes a bite of the deep temporal fascia to prevent anterior migration of the helix.

    Fig. 10.21 Skin of upper cheek pulled vertically upwards and laterally. Note increased dental show.

    Fig. 10.22 Appearance of cheek after suturing upper platysma to parotid fascia and placement of pilot suture from skin flap to skin anterior to helical rim.
    With the cervical skin under minimal tension, the excess skin behind the ear is marked and excised ( Fig. 10.23 ). A suction drain is placed under the cervical flap at its most dependent area and leads out through an occipital stab wound. The occipital and hairline incisions are closed with staples ( Fig. 10.24 ). The skin flap at the retroauricular crease will be sutured to the ear under no tension with absorbable 4-0 plain sutures.

    Fig. 10.23 A , Postauricular skin placed under no tension and excess marked. B , Skin of occipital flap shown after excision of excess with single staple holding flap in place. Note absence of tension and alignment of occipital hairline.

    Fig. 10.24 Closure of occipital hairline over Jackson–Pratt suction drain.
    Excess skin in front of the ear is marked and trimmed so that skin edges touch the ear. The skin overlying the tragus is thinned by excising the subcutaneous fat with Stevens scissors. The cheek flap is sutured to the ear with interrupted 5-0 nylon sutures. The neotragal skin is sutured with 5-0 fast-absorbing plain gut ( www.ethicon.com ) ( Fig. 10.25 ).

    Fig. 10.25 Preauricular closure with 5-0 plain gut approximating skin over the tragus. Remainder of preauricular incision is closed with 5-0 nylon. Note lobule is angled back 30°. Transverse ink mark caudad to temporal hair will be used to lower the hairline.
    Excess skin in the temporal area is removed and the temporal hairline is lowered by incising the previously drawn transverse temporal hairline incision ( Fig. 10.25 ). A triangle of skin is marked and excised at the point of insertion of the helical rim to the cheek ( Fig. 10.26 ). After removing the excess skin above the point of insertion of the helical rim, the temporal hair flap is brought down and approximated to the adjacent skin in front of the ear, thus lowering the temporal hairline ( Fig. 10.27 ).

    Fig. 10.26 Incision at bottom of temporal hairline has been made, and temporal hair-bearing skin flap is elevated with hook. Excess non hair-bearing skin has been marked with ink and will be excised.

    Fig. 10.27 Excess non hair-bearing skin has been excised from in front of ear. Hair-bearing temporal flap has been stapled into position. Hairline is lowered and reapproximated.

    Results
    Results are highly rejuvenating and durable, yet natural in appearance. The nasolabial folds and midface are particularly well addressed by foundation facelift. In the past, the technique sometimes produced suboptimal results in the neck because the change in planes from deep to the platysma in the cheek to superficial to the platysma in the neck limited the surgeon’s ability to tighten the cervical platysma from the lateral approach. Use of the corset platysmaplasty technique in conjunction with foundation facelift has, however, obviated this limitation ( Fig. 10.28 ).

    Fig. 10.28 Sixty-four-year-old woman shown before ( A , C , E ) and six months following ( B , D , F ) a foundation facelift, chin implant, and corset platysmaplasty. Patient also underwent bilateral upper and lower lid blepharoplasties. She refused chemical peel for the lower lids.

    Postoperative care
    At conclusion of surgery, a light, compressive, head and neck dressing is placed on the patient. Patients stay one night following surgery at a hotel across the street from the operating room under the care of a registered nurse trained in the special needs of facelift patients.
    Patients are kept calm and well-sedated to encourage rest and smooth recovery. I see the patients the next morning to remove dressings and drains. Patients with extensive dissection in the neck may retain their drains until seen in the office for suture removal.
    All sutures and any remaining drains are removed in the office 4–5 days following surgery. Light exercise may be resumed at 3 weeks postoperatively. More vigorous exercise is resumed at 6 weeks. Patients are informed that they will be presentable for work or appearing outside their home at 2 weeks, although significant swelling and bruising may still be present at that time. By 3 weeks, bruising in most patients is gone, although most patients will not want to resume important social engagements until 6 weeks after surgery.

    Complications
    The commonest serious complication associated with facelift is postoperative bleeding, frequently associated with high blood pressure which is more common in men than in women. All patients are screened for hypertension by history and by physical examination. Even patients with borderline or labile hypertension are sent for evaluation and optimization of blood pressure control. Some internists are understandably reluctant to vigorously treat minimal blood pressure elevations given the known side effects of some of the therapeutic agents. I generally have a conversation with the internist explaining the possible postoperative consequences of even minimal blood pressure elevations, so that the internist understands the importance of optimization of blood pressure control prior to facelift surgery.
    Although deep venous thrombosis and pulmonary embolism are relatively uncommon, they can have devastating and sometimes fatal consequences. Patients who are seriously overweight or have multiple positive risk factors are generally refused surgery until they have reduced their risk. All patients are treated with intermittent compression devices during surgery.
    Skin necrosis, hair loss, and excessive postoperative scarring are most frequently associated with technical issues such as excessive thinning of flaps or excessive tension at the suture line. Avoidance of excess tension is the best prophylaxis for excessive scarring and hair loss.
    Infections are uncommon with or without prophylactic antibiotics. Treatment is rest, elevation, antibiotics, and surgical drainage if indicated.


    Pearls & pitfalls

    Pearls

    • Have an intimate knowledge of the three dimensional anatomy of the facial nerve as it traverses the musculo-fascial planes of the face. Perform cadaver dissections to obtain this knowledge.
    • Avoid excessive tension, especially at the skin closure.
    • Use atraumatic technique to avoid injury to the subdermal vascular plexus.
    • Investigate postoperative pain at the bedside immediately. Pain is a cardinal sign of postoperative hematoma.
    • No single operation is optimal for all patients. Be prepared to vary technical details depending on the particular needs of your patient.

    Pitfalls

    • Avoid operating on obese patients. Obtaining quality results is difficult and sometimes impossible. Complication rates are higher.
    • Avoid serious medical complications by participating with the patient’s internist in optimizing medical status prior to surgery.
    • Do not underestimate the scope of the surgery to your patients. The more areas treated, the longer the recovery.
    • Point out skin inelasticity, actinic damage, and other factors potentially limiting the results prior to surgery. Be prepared to offer ancillary treatments such as peels and lasers to mitigate the limitations of skin inelasticity and sun damage.
    • Do not over-promise.

    Further reading

    Hamra ST. Composite rhytidectomy. Plast Reconstr Surg . 1992;90:1–13.
    Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg . 1990;86:53–63.
    Gosain AK, Yousif NJ, Madiedo G, et al. Surgical anatomy of the SMAS: A reinvestigation. Plast Reconstr Surg . 1993;92:1254–1263.
    Lemmon ML, Hamra ST. Skoog rhytidectomy: A five-year experience with 577 patients. Plast Reconstr Surg . 1980;65:283–292.
    Mendelson MC, Freeman ME, Wu W, et al. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesth Plast Surg . 2008;32:185–195.
    Mitz V, Peyronie M. The superficial musculo-aponeuric system (SMAS) in the parotid and cheek area. Plast Reconstr Surg . 1976;58:80–88.
    Pina DP. Asthetic and safety considerations in composite rhytidectomy: A review of 145 patients over a 3-year period. Plast Reconstr Surg . 1997;99:670–678.
    Pitman GH. The deep-plane demystified. Videotape . St Louis: Quality Medical Publishing; 2000.
    Rudolph R. Depth of the facial nerve in face lift dissections. Plast Reconstr Surg . 1990;85:537–544.
    Skoog T. Plastic Surgery: New Methods and Refinements . Philadelphia: WB Saunders; 1974.
    CHAPTER 11 The “High SMAS” facelift technique

    Fritz E. Barton, Jr., Ricardo A. Meade

    History
    The High SMAS technique was developed in the 1980s as a modification of the procedure described by Tord Skoog in 1974. 1 Anatomic studies 2, 3 have documented the benefit of leaving the skin and subcutaneous mass attached to the SMAS in facial rejuvenation.
    The initial challenge was to do so, yet still mobilize the cheek mass adequately. The second goal in designing this procedure was to lift the entire malar and mandibular subcutaneous cheek mass, as a single unit suspended by the SMAS. 4 No portion of this repositioning technique was to place the skin on any form of greater than normal tension.

    Physical evaluation

    • Assess the overall quality and volume of the soft tissues.
    • Examine the skeletal proportions of the face (height of the maxilla, bi-zygomatic diameter, chin projection, etc.)
    • Evaluate the subcutaneous facial fatty mass particularly looking at variations in volume, shape and position. The malar area descends into the upper buccal region, the anterior cheek descends over the nasolabial fold and the buccal fat accumulates as a “jowl”. The shape turns from an oval shape to a squared appearance. Volume changes affect both the amount of improvement without augmentation as well as the sequence of the operation.
    • Note whether or not there is shelving of the orbicularis over a prominent malar membrane attachment (malar crescent).
    • Assess the depth and prominence of the nasolabial fold as an index of cheek descent.
    • Analyze the contour of the fatty cheek mass at the mandibular border by looking for jowls. If present, manually reposition the cheek with the patient sitting and feel the thickness of the jowl fat. Here the prominence of the mandibulocutaneous ligament is assessed.
    • Evaluate the resting dermal tension to measure the tone of the patient’s skin. Actinic exposure and smoking deteriorates dermal quality at a much more rapid rate manifesting clinically as fine lines in the perioral area for example.
    • Lastly, rule out any scars from prior surgery.

    Anatomy
    We view the cheek as having two components: the lower two-thirds being the subcutaneous cheek mass; and the upper one-third corresponding to the lower eyelid with its ptotic periorbital structures. Lower eyelid suspension is a necessary adjunct to high SMAS cheek suspension because the two areas overlap.
    The sub-SMAS dissection at the level of the zygomatic arch and higher should be performed bluntly. This is safe because the frontal branch of the facial nerve runs deep to the SMAS over the periosteum of the zygomatic arch. Sharp dissection to the anterior border of the parotid is safe. Beyond the anterior border, the dissection should be performed bluntly to avoid the buccal branches of the facial nerve. The plane of dissection as one progresses centrally should stay superficial to the zygomaticus major muscle to avoid peripheral facial nerve branches.

    Technical steps
    Begin the dissection by elevating the skin flap in the preauricular area about 4 to 5 cm. Elevate only the skin that you anticipate removing. Perform subcutaneous dissection above the zygomatic arch in the lateral orbital area to release the cutaneous attachments of the crow’s feet and to facilitate a smooth redraping of the temporal skin. This maneuver also exposes the superficial side of the upper SMAS that will be divided later ( Fig. 11.1 ).

    Fig. 11.1 Extent of subcutaneous dissection.
    Fritz E. Barton Jr., The ‘high SMAS’ face lift technique. Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.
    From the mastoid, carry subcutaneous dissection below the mandible to join the anterior neck dissection, if present. In the neck, the skin and platysma are managed as separate layers because more skin than platysmal advancement is desired. A separate submental approach is added when defatting or when midline platysmal plication is indicated ( Fig. 11.2 ).

    Fig. 11.2 Strong medial tension above the hyoid; lax below the hyoid.
    Fritz E. Barton Jr., The ‘high SMAS’ face lift technique, Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.
    Begin dissecting the SMAS in the cheek just anterior to the tragus leaving a cuff for later suturing. Maintain the upper lateral corner of the SMAS at the root of the helix to serve as a point of later fixation. Proper SMAS dissection depth can be safely established here because the facial nerve is well protected by the substance of the parotid gland. Anatomically, the SMAS is fused to the parotid capsule.
    From a surgical standpoint, establish the plane by delaminating the parotid capsule until only a thin layer of fascia remains over the gland ( Fig. 11.3 ). Once the SMAS dissection is established, carry the dissection forward to the anterior border of the parotid. It is at this point that the facial nerve branches exit the parotid, requiring that you change dissection from sharp to blunt. Vertical spreading will release the remaining restricting fibers, the so-called masseteric cutaneous ligaments , exposing the translucent masseteric fascia that covers the facial nerve branches. It is important to visually check for the presence of this filmy fascia over the masseter muscle to confirm that the dissection in the buccal area is superficial to the facial nerve branches.

    Fig. 11.3 Transition of the SMAS dissection plane.
    Fritz E. Barton Jr., The ‘high SMAS’ face lift technique. Aesthetic Surgery 2002;22(5):481–486, with permission of Elsevier.
    Now carry the dissection down the anterior surface of the sternocleidomastoid muscle for division of the cervical fascia and lower platysma with a 3-cm anteriorly oriented turn (towards the hyoid) to make a short “hockey stick” horizontal release and allow upward movement of the SMAS and cheek. This maneuver is performed carefully under direct visualization of the subplatysmal structures due to the proximity to the marginal mandibular branch of the facial nerve. The lateral border of the platysma may adhere to the tail of the parotid capsule, placing the proximal portion of the marginal mandibular facial nerve branch at risk if a lateral approach is used. The safest way to traverse this area is from the inside out.

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