Phẫu Thuật Trẻ Hóa Khuôn Mặt (Facial Rejuvenation Surgery)

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vii
Foreword
Facial surgery is a fascinating fi eld, and Barry
Jones has well explored its different aspects.
When he arrived in Paris to work with me as
my Fellow many years ago, the fi rst morning
he observed me doing a craniofacial case, and
then, with equal interest, a face lift that
afternoon.
The face is such a complex structure that it is
extremely helpful to be able to approach its dif-
ferent components without restriction, from the
deep skeletal foundation to the delicate cutane-
ous coverage.
Craniofacial surgery was developed by Paul
Tessier to enable radical correction of a distorted
facial skeleton, due to congenital anomalies or
resulting from trauma. To mobilize the frontal
bones, the orbits, or the maxilla, one has to
elevate the soft tissues from the skeleton using
incisions that will not damage the muscles or
nerves, leaving minimal scars. This was achieved,
respectively, through the coronal, lower eyelid
(infraciliary or transconjunctival), and vestibular
approaches.
These approaches allowed good exposure for all
kinds of various osteotomies and skeletal dis-
placements, without leaving any stigmata on the
soft tissue coverage. They also showed the pos-
sibility of mobilisation of the soft facial tissues in
relationship to the skull below. In 1979, Paul
Tessier presented the application of this principle
to fi ght against gravity and the sagging of the face
with age: the “mask lift” or subperiostal lift.
When the soft tissues are freed from the skeletal
attachment at the orbital and mid-face level, they
can be fi xed in a higher position.
Tessier also showed that the contour of the face
can be modifi ed by adding cranial bone grafts to the
malar bones. The current attention given to the
structural changes of the face has evolved from
this, as well as the trials to rebuild the projection
of the midface, from the suspension and plication
techniques used by W. Little to the fat grafting of
S. Coleman and various facial implants.
Now, of course, Barry Jones has broad experience
in both craniofacial and aesthetic facial surgery
himself, and agrees with me that the practice of
craniofacial surgery helps for the aesthetic evalu-
ation of the face, especially for the relationship
between the skeleton and the soft tissues. He has
therefore mastered remarkably well the different
aspects of facial aesthetic surgery.
The boundaries between reconstructive and aes-
thetic surgery are diffi cult to draw: a patient with
moderate facial retrusion is embellished by a
Lefort III advancement, an indication which is in
fact aesthetic. A sliding genioplasty improves the
neck and lower face, as well as the chin. It is also
not uncommon that a patient presenting with a
basal cell carcinoma requests during the same
operative session a blepharoplasty or a face lift,
and in that case, both the reconstructive and
aesthetic skills of the qualifi ed plastic surgeon are
solicited.
Barry Jones shares with me the vision of the aes-
thetic part of our speciality being addressed with
the same rigorously objective scientifi c and
medical approach as the rest of our speciality,
and surgery in general.
Daniel Marchac

ix
Preface
Aesthetic surgery is “dedicated to improvements
that actually surpass the normal . . . the stakes are
high, the margin for error is thin, and complica-
tions can be catastrophic” (D. Ralph Millard Jr).
Nowhere is this more valid than in the fi eld of
facial rejuvenation surgery.
In the Western world the population is ageing but
remaining fi tter, both physically and mentally,
than ever before. Economic and social changes
dictate that a greater number work beyond the
age of 60 – fi gures from the McKinsey Global
Institute suggest that while only 18% of Ameri-
cans between the age of 65 and 70 years contin-
ued in work in 1985; the fi gure is now almost
30%. Physical wellbeing, associated with youth,
is prized in our personal and working lives and
individuals wish to continue to see this refl ected
in their faces as they age. Consequently an
increasing number are seeking surgical assistance
to maintain or improve their facial appearance.
The pressures of modern life often dictate that
recovery or “downtime” after an operation is at
a premium and despite the increasing acceptance
of aesthetic surgery generally, many patients will
not want it known to their friends and family that
they have undergone an operation. Their wishes
are for a procedure which will produce the best
possible outcome which is stable and long lasting
with minimal or concealed scars, a quick recovery
and, above all, the fewest possible complications.
Reconciling these considerations with reality may
sometimes force a surgeon into adopting a prag-
matic stance when designing an operation rather
than that of the zealot who will always “go for
broke” to produce the ideal outcome whatever
the cost in terms of potential morbidity.
This book is not designed to be an encyclopaedic
text but rather a distillation of my preferred
techniques for facial rejuvenation which fi t these
criteria as far as is possible. It is effectively a
“how I do it now”, describing procedures which
have evolved over a very careful analysis of twenty
years clinical practice. I may choose more eso-
teric operations such as the sub-periosteal (mask)
lift or composite techniques in selected patients,
but these have a greater potential for delayed
recovery and require considerable experience on
the part of the operator.
This text, photographs and DVD are aimed at
residents and relatively inexperienced consultant
(attending) surgeons and should guide the reader
through all the essential operative steps to perform
safe, reliable and predictable facial rejuvenative
operations. Any young surgeon should be encour-
aged to visit and watch, at fi rst hand, acknowl-
edged experts in the fi eld. There is no doubt that
the “master and apprentice” system is the best
format to learn surgical technique: “by watching
the master and emulating his efforts in the pres-
ence of his example the apprentice unconsciously
picks up the rules of the art, including those
which are not explicitly known to the master
himself” (Polanyim. Personal knowledge: towards
a post-critical philosophy, London: Routledge
Keegan & Paul, 1973; 49–65).
The operation itself is but a part of a patient’s
overall care, and I have included advice with
regard to practice setup, patient selection, record
keeping and the avoidance of medico-legal prob-
lems, so important in the modern era. Peter For-
rester, my anaesthetist colleague, has provided a
guide for safe and stable anaesthetic and sedative
techniques particularly suited to this type of
surgery. My co-author, Rajiv Grover, has been
responsible for an extensive statistical analysis
of my work over recent years. He has super-
vised the editing of the operative DVD, distilled
the clinical pearls, bullet points and annotated

x
references (which serve as a guide to the wider
literature) and written the text of the chapter
devoted to facial anatomy.
The illustrations and DVD have been designed,
as far as possible, to demonstrate a view over my
right shoulder such as a visitor to the operating
room may see. I have referred to the surgeon as
“he” throughout for convenience but this refl ects
no gender bias! I have also assumed that he or
she is right handed, as I am, for clarity.
This book is designed with safety, reliability and
predictability as paramount considerations. I
hope the reader will fi nd it helpful in beginning
their own clinical practice in this demanding but
fascinating fi eld and, eventually, as a basis around
which to evolve new ideas born of personal expe-
rience and rigorous analysis.

Barry M Jones

London, May 2007
Preface

xi
Dedication
This book is dedicated to the rock upon which any success I may have had has been built –
my family, Janine, Huw and Georgina Jones.

xiii
Acknowledgements
The best advice one can offer any young surgeon
is to get the best training they possibly can. In
this I was exceptionally fortunate because of the
outstanding individuals I came into contact with
along the way. They revealed to me not only their
technical expertise, but a philosophy for life and
the practice of surgery for which I remain truly
grateful. I am pleased to have the opportunity to
acknowledge some of them here.
Although it is not a contemporary view, I still
believe that a broad experience of surgery in general
is an invaluable prerequisite for a Plastic Surgeon.
John Pendower guided my early surgical career,
and by example taught me much more than he will
have realised. Like my other general surgery
mentors he was himself trained in the Norman
Tanner school which provided a framework for
technical accuracy, effi ciency and predictability in
surgery, transferable to any specialty.
Mount Vernon Hospital, in its heyday, was a
hotbed of inspiration and innovation in Plastic
Surgery. Roy Sanders, Brian Morgan, Douglas
Harrison and Paul Smith led the fi eld in the UK.
I owe my Plastic Surgery training to them.
In 1984 I met Daniel Marchac and Paul Tessier
in Paris. At the time I had thought that hand and
microsurgery would be my specialist fi eld. A day
with each of them was all that was necessary to
make me quite certain that Craniofacial Surgery,
which until then I had never seen, offered an
irresistible challenge. It is impossible not to be
inspired by Paul, a truly great man. Daniel later
generously arranged for me to work as his fellow
which was a life changing experience profession-
ally and culturally! With him I saw and under-
stood the close link between craniofacial
techniques and facial aesthetic surgery which has
occupied me for the last twenty two years. It
continues to provide as much stimulation and
pleasure as on that fi rst day.
To all these men, and to the many fellows and
residents whose company I have enjoyed, I extend
my most grateful thanks.
Many people have been instrumental in the pro-
duction of this book. My co-authors, Rajiv Grover
and Peter Forrester whose contributions were of
the highest standard and timely! I am indebted
to the patients who have kindly given permission
to reproduce their clinical photographs or fi lm
their surgery. Gelly Morgan from Pretty Clever
Pictures produced the DVD which was recorded
at King Edward VII, Sister Agnes Hospital in
London. Professor Jean Fissette very kindly made
available to me the anatomy school at the Uni-
versity of Liege, Belgium. Here I carried out the
cadever dissections which were photographed by
Huw Jones. My secretaries, Sheila Killick and
Dee Allen and practice nurse, Janette Karaphillides,
have been invaluable, as always, assisting with
typing the manuscript, collating clinical photo-
graphs and many other unsung tasks. Sue Hodgson
and her colleagues, Marsha Bell and Cheryl Brant,
at Elsevier have guided the project through to
the end.
These many individuals, and others I have not
mentioned by name, have made the whole expe-
rience not only bearable but fun.

Barry M Jones

London, May 2007
It has been a privilege to be involved with this
unique project. My contribution would not have
been possible without the help of my offi ce staff:
Rita Farren and Jennie Toumadj as well as the
continued support of my family: Nikita, Serena
and Sophia.

Rajiv Grover

London, June 2007

1
CHAPTER 1
Introduction
The twenty-fi rst century prizes youth and vitality. The population is
generally fi tter and living longer. The generation gap has narrowed
following the revolution in culture and the power of youth stimulated
by The Beatles, Bob Dylan, Andy Warhol and their contemporaries,
so that parents are more likely to share interests such as music and
fashion with their children than was once the case. The presently
middle-aged children of the 1960s do not view themselves as ageing,
fi nding it diffi cult sometimes to accept the changes in appearance
that inevitably accompany the passage of time. What they see in the
mirror does not necessarily refl ect their inner well being. Increasingly,
women occupy senior positions of power and infl uence in the work-
place where physical suggestions of wisdom, born of maturity, may
be less valued than the expression of dynamic physical energy. The
burgeoning explosion of visual media constantly bombards us with
images (often digitally retouched!) of “perfect” people with the
implication that they represent an aspirational goal for everyone.
Working in parallel with these changes in society’s perception, medical
science and technology has reached a level of sophistication that can
offer the potential to mitigate the physical signs of ageing with low
risk. Survival is no longer the only principal effort (of modern medi-
cine): improvement of the quality of life is also important.1 As a
consequence, aesthetic surgery in general and facial aesthetic surgery
in particular has seen an unprecedented expansion in recent years.
In all aspects of surgery, but perhaps particularly aesthetic surgery,
safety is of paramount importance. A surgeon undertaking facial
aesthetic surgery requires a thorough grounding in plastic surgery
principles combined with a detailed knowledge of facial anatomy
from bone to skin. A thorough working knowledge of the evolution
of current surgical concepts is essential as is intimate acquaintance
with contemporary literature and techniques. Excellence in outcome
is probably as much operator dependent as technique dependent, i.e.,
a highly skilled surgeon is likely to produce a pleasing outcome
S E C T I O N 1

CHAPTER 1: Introduction
2
irrespective of the specifi c technique that he
chooses, but it is necessary to adapt one’s own
methods to the particular needs and physical
demands of an individual patient. As with other
fi elds in plastic surgery such as breast reconstruc-
tion, there is no “one-size-fi ts-all”; the surgeon
must be fl exible in his thinking, planning and
execution.
In an age when marketing, spin and image are
becoming an integral part of plastic surgical prac-
tice, it should be remembered that there is no
substitute for technical competence borne of
thorough training and experience. Some may be
tempted to pursue this type of surgery in the
expectation of fi nancial reward, but a real pas-
sion for the subject is the key to success. The
potential for supreme professional happiness is
doing what you would gladly do for free, for a
fee.2
Offi ce Organisation
Facial aesthetic surgery is labour intensive and
patients require a great deal of support before,
during and after their operation. Consulting
rooms (the surgeon’s offi ce) will refl ect the sur-
geon’s individual style and personality, but should
be welcoming and friendly rather than overly
clinical, which can be intimidating. Whatever
physical dimensions appear to be adequate early
in a career will almost inevitably become too
small in time; buy or rent the biggest space you
cannot afford! As a bare minimum there must be
a comfortable waiting area, an administrative
offi ce where the patient may have confi dential
discussions with a secretary, a room for removal
of stitches, etc., an area for medical photography,
and a consulting space which is not cramped. It
may be desirable to keep pre and post-operative
patients separated, but practicalities often make
this impossible.
The surgeon must have suffi cient support staff to
enable him to concentrate on the medical and
technical aspects of care without the distractions
of day-to-day organisation, scheduling, billing,
dressing changes, suture removal, etc. This
requires at least one secretary and one nurse.
Each must be technically competent, effi cient
and reliable, but in addition they need limitless
patience and a personality to put patients at their
ease. This requires some investment.
Clinical Records
The importance of complete and accurate record
keeping cannot be over stated. Hand-written
notes may be adequate if they are legible(!) and
descriptive, but type-written notes are superior.
Standard proformas (Fig. 1.1.1) can be very
helpful in providing clarity and effi ciency of time
when detailing a patient examination and surgical
plan. Good operation notes will be typed con-
temporaneously and refl ect an accurate descrip-
tion of exactly what was done and why it was
done (laptop computers leave no excuse
for failing to do this). Post-operatively, notes
should be recorded at every visit both by the
nurse and the surgeon. It must be remembered
that the patient’s records may be reviewed at
some time distant from the episode in question
by a third party, with no other knowledge of the
circumstances of their care. The reader should
easily gain an accurate picture of all that occurred.
Remember – if it is not written down it did not
happen!
Photographic Records
Good photographic records are as important to a
plastic surgeon as are radiographs to an orthopae-
dic surgeon. There must be a facility to take
well-lit, standardised and therefore comparable
photographs both pre and post-operatively. This

Section 1
3
Fig. 1.1.1 Facelift examination
proforma.

CHAPTER 1: Introduction
4
requires a constant background and lighting
together with a high quality SLR type camera. It
is immensely helpful to be able to show patients
their image instantly, and at post-operative
follow-up consultations to be able to demonstrate
their pre and post-operative appearance simulta-
neously (Fig. 1.1.2). The advent of digital pho-
tography has rendered this aim easy to achieve
and there are many suitable commercial systems
available.
Fig. 1.1.2 Plasma screen pre/post pictures.
REFERENCES
1. Rees TD. Aesthetic Plastic Surgery. Philadelphia: WB
Saunders; 1980.
2. Millard DR. Principalisation of Plastic Surgery. London: Little
Brown & Co.; 1986.

5
CHAPTER 2
The Initial Consultation
The primary purpose of an initial consultation is for the surgeon to
gain an insight into the patient’s needs and wishes and, when appro-
priate, to devise a suitable treatment plan. It is helpful to have the
patient complete a simple demographic pro forma questionnaire
before the consultation begins that will record details such as their
of date of birth, name, address, contact numbers, any medical aller-
gies, current medication, smoking habit and the patient’s primary
healthcare provider (general practitioner). Good communication is
essential between patient and surgeon and it should always be borne
in mind that the object of this type of surgery is to realise (when
possible) the patient’s desires and not necessarily what the surgeon
may want. Good listening skills are essential. An opening remark such
as “What can I do to help?” is likely to bear more fruit than asking
“What is the problem?” since most patients seeking facial aesthetic
surgery are essentially well.
Allow the patient to indicate the areas that concern them most, e.g.,
eyelids, jowls, neck, etc., since their subjective perception may be
quite different from the surgeon’s objective view. Background infor-
mation is essential to develop a complete picture of the patient’s past
medical history, focussing particularly on any signifi cant serious past
or chronic disease process, specifi c cardiovascular disease such as
hypertension, tendency to bruise or bleed, smoking habit, etc. In
discussing their surgical and anaesthetic history be aware that some
patients will not consider previous cosmetic surgery “an operation”
and it may be necessary to ask directly about this. An outline of their
domestic situation and of their occupation – asking “Do you work,
other than at home?” may elicit a more favourable response from a
woman than “Do you work?”! The nature of an individual’s occupa-
tion is particularly important since advice about recovery times may
vary, e.g., someone with a well-known face may be advised to take
a little longer in recovery than most. Information about smoking habit
is of crucial importance.
S E C T I O N 1

CHAPTER 2: The Initial Consultation
6
The physical examination should take place in a
comfortable well lit space with the surgeon’s eye
line at the same height as the patient’s eye line
(Fig. 1.2.1). The face should be examined in a
logical sequence. An impression is gained about
general skin quality, exposure to sun, pre-existing
conditions such as acne and any facial scarring ini-
tially. The brow height and pupil to brow distance
should be measured using callipers (Fig. 1.2.2).
The general confi guration of the eye and orbit –
positive or negative vector – should be recorded
together with the existence of any asymmetries
that, very frequently, will not have been noticed
by the patient. In the upper eyelid the position of
the lid margin in relation to the pupil should be
noted together with normal functioning of the
levator mechanism. Skin excess is examined with
the position of any fatty excess in the medial, pre-
aponeurotic and lateral compartments noted. The
position of the lateral canthus relative to the
medial must be noted together with the relative
relationship of the lower lid to the iris. A “snap
test” is performed – the patient is instructed not
to blink and the lower lid is pulled downwards and
Fig. 1.2.1 Patient examination:
patient/surgeon opposite each other.
Fig. 1.2.2 Pupil–brow/brow height
measurement.

Section 1
7
laterally (Fig. 1.2.3), holding the position for
approximately 10 seconds and then releasing. The
rapidity with which the lid returns to its resting
position is noted. This will detect any tendency to
canthal laxity and insipient or actual scleral show.
The existence and site of fatty “herniation” in the
lower lid is recorded with the depth of the naso-
jugal furrow. An impression is gained of the overall
facial confi guration, e.g., round, square, oval and
the degree of malar projection. Normal facial
nerve function is recorded. The presence and
extent of jowling is observed and, in the neck, skin
laxity, platysma laxity and the presence or absence
of platysma bands is recorded. Bony relationships
such as mandibular projection and dental occlu-
sion, which have a great infl uence on facial contour
and the outcome of soft tissue manipulation are
also noted.
When the examination is complete standard
facial photographic views (Fig. 1.2.4) are taken
and scrutinised with the patient. Discussion
whilst viewing photographs is immeasurably
helpful in defi ning the most appropriate treat-
ment plan to address a particular individual’s
desires and to point out any existing defects and
/or asymmetries that may not have been appar-
ent to the patient beforehand. This will facilitate
a full explanation of the potential benefi ts of any
planned surgery and, perhaps more importantly,
limitations and potential risks and complications
so that, should the patient choose to proceed,
truly informed consent may be given. Complica-
tions must be discussed in terms that a layperson
can easily understand including, when possible,
published percentage fi gures for their incidence.
Suffi cient time must be given for relevant ques-
tions to be answered. Practical issues of costs,
billing and scheduling of surgery are best dis-
cussed with the practice secretary so that the
surgeon’s attention is concentrated on the medical
aspects of care.
Fig. 1.2.3 Snap test.
Fig. 1.2.4 Standard facelift
photographic views.

CHAPTER 2: The Initial Consultation
8
When the patient leaves the offi ce they should
have a thorough understanding of what may be
achieved by an operation, the expected “down-
time”, the nature, benefi ts, risks and potential
complications of an operation, its costs and the
likely waiting time for surgery. This is facilitated
by the provision of detailed written information
for the patient to take home. A summary of the
consultation should be sent to the patient’s general
practitioner (GP). Many patients will refuse per-
mission for such a communication for a variety of
reasons – perhaps they live in a small community
and are concerned about confi dentiality or the GP
may be a family friend. The patient must be made
aware that it is in their best interests for their GP
to be kept fully informed, but if they still refuse
permission a full account of the consultation
should be sent, as a medical report, directly to
them with the request that they pass it on to their
GP. No pressure should be placed upon the
patient to schedule an operation there and then;
on the contrary, they are best advised to consider
the information given before reaching any conclu-
sion about whether or not they wish to proceed.
They should be encouraged to attend a further
consultation, at no extra cost, if they feel this
would be necessary or valuable.
Managing patient’s expectations is key to a satis-
factory outcome. In general a happy patient will
also produce a happy surgeon! It is essential that
both the patient and surgeon are on the same
wavelength and thinking along the same lines.
Each must feel comfortable with the other. It is
vital for both that unrealistic expectations or per-
sonality traits that are unfavourable are detected
before any intervention is carried out. Some par-
ticular characteristics should make the surgeon
wary:
• Beware the patient that will not wait or
is rude and abusive to the offi ce staff,
particularly if they are the personifi cation of
charm to the surgeon himself.
• Many patients will have a list of questions to
ask, but most of these should be answered as
a matter of course by the surgeon during the
consultation. An unreasonably long or
detailed list may indicate an abnormally
obsessive personality that cannot be
satisfi ed surgically. This is also true of the
individual with an extensive collection of
photographs of themselves or others,
particularly when they have been altered
digitally or otherwise.
• A supportive accompanying partner is
immensely helpful, but if the partner is
unreasonably dominant, speaks for the
individual or makes inappropriate remarks, it
may indicate an underlying disharmony that
may be accentuated in the post-operative
period.
• One should be wary of a patient who is over-
solicitous or fl attering in their manner to the
surgeon or of someone who is dismissive or
unreasonably critical of advice given by other
doctors.
• When a patient complains of a physical
defect that cannot be detected by the
surgeon, operative intervention should be
discouraged.
• One pre-operative visit is essential, two often
desirable and three occasionally necessary,
but more than this probably indicates an
individual who is unsure and best advised not
to proceed to an operation.
There are no hard and fast rules and certainly no
substitute for experience in developing the
insight necessary to avoid operating on patients
who are unlikely to be pleased with a surgical
outcome. There is no doubt that some
surgical personalities will fi nd this easier to
acquire than others. Nobody in this fi eld, no
matter how competent, will be correct in his
assessment on every occasion, but in general if
there is a real personality clash or the surgeon
feels uncomfortable, it is almost certainly best
not to operate. Remember, a reputation is built
as much on the patients you do not operate on as
those that you do.

9
CHAPTER 3
Surgical Equipment and
Operating Theatre Set-up
An operating theatre designed for facial aesthetic surgery does not
need to be excessively large, but it should have a separate room for
the induction of anaesthesia or intravenous sedation and a properly
equipped recovery facility. The operating table should not be exces-
sively wide since this will impede access to the face from either side.
Some surgeons fi nd a neurosurgical “horseshoe” headrest facilitates
access, but in any event it is essential that he can sit at the patient’s
head with his knees under the table. Many facial procedures occupy
several hours operating time, making comfort essential if the surgeon
is to maintain his concentration. A comfortable stool is vital, ideally
one whose height and position can be adjusted throughout the pro-
cedure by the surgeon. If a headlight is to be used (my preference)
it should be light in weight, fi t snuggly but not cause discomfort or
fatigue and provide well-focused illumination without distorting the
tissues’ natural colours.
The patient’s comfort is also of vital importance. The operating
table cushions must be soft and avoid any pressure on bony
prominences. The cover on which the patient lies should not be slip-
pery – facial procedures mandate an anti-Trendellenberg tilt and the
patient’s position must be stable with the head at the very top of
the table. This is of particular importance for endoscopic
browlifts. Some form of warming blanket to maintain the patient’s
temperature throughout the operation is essential, as is deep
venous thrombosis prophylaxis in the form of graded compression
stockings and pneumatic boots providing intermittent calf
compression.
Head drapes should be made of cotton, not paper. Disposable drapes
with sticky edges must be kept away from the endotracheal tube
since they can easily dislodge it when the head is moved from side
to side, and the tube itself is best protected within a transparent
camera drape (see Section 2 Chapter 1). For endoscopic browlifts I
S E C T I O N 1

CHAPTER 3: Surgical Equipment and Operating Theatre Set-up
10
prefer to be at the head of the table (above the
patient) with the scrub nurse to my right and the
assistant to my left. For all other facial proce-
dures the scrub nurse is best placed at the head
of the table with the surgeon alternating between
one side and the other as appropriate, with the
assistant opposite him. The anaesthetist sits at
the patient’s feet with his monitoring equipment
at this end of the table.
A few specialized instruments (Figs. 1.3.1–1.3.6)
will facilitate the surgery. Those illustrated com-
prise the Jones facelift set and are available from
Bolton Surgical Instruments, Sheffi eld, UK.
Fig. 1.3.1 Gorney Freeman and Tessier pattern dissecting
scissors.
Fig. 1.3.2 Small Deaver retractor and fi ne Stevens
tenotomy scissors.
Fig. 1.3.3 Coleman-style infi ltration and aspiration
cannulae.
Fig. 1.3.4 Mustarde-type suturing forceps and Barsky-
style multitoothed Adson forceps.
Fig. 1.3.5 Modeling paintbrush with unvarnished handle
and Pitanguy-type marking forceps.
Fig. 1.3.6 Humby-type hinged skin hook.

11
CHAPTER 4
Anaesthesia and Sedation
Peter Forrester Consultant Anaesthetist, London, UK
Facelift surgery presents the anaesthetist with a number of chal-
lenges, including problems relating to prolonged surgery, providing
induced hypotension, managing the airway during surgery on the face
and the administration of safe sedation. An additional consideration
is the contribution that anaesthesia might make to the reduction in
complications such as haematoma formation and the minimisation of
swelling and bruising in the early post-operative period.
Anaesthetic Assessment
It is unusual to be presented with a patient requesting facelift surgery
who has serious, concurrent medical problems. To some extent
patients are self-selecting, i.e., those with signifi cant medical disease
tend to already consider themselves unsuitable for surgery and hence
do not present for initial surgical consultation. Ideally patients should
be in the American Society of Anesthesiologists (ASA) Physical
Status Classifi cation categories 1 or 2; that is, either completely
healthy or having only mild systemic disease. Those with severe sys-
temic disease (ASA 3) may be suitable for facelift surgery but will
require very thorough work-up and counselling with regard to risks.
Anaesthesia for ASA 3 patients is beyond the scope of this chapter
and will not be discussed further.
As with any patient, the anaesthetist should undertake a thorough
assessment. Special attention should be given to a history of hyper-
tension, ischaemic heart disease, cerebro-vascular disease, asthma,
chronic obstructive pulmonary disease and smoking. As part of a
general, pre-operative examination the anaesthetist should particu-
larly note the level of blood pressure as well as assessment of the
upper airway including neck mobility and mouth opening.
Patients may present with undiagnosed borderline hypertension. In
the absence of target-organ damage, systolic blood pressures between
S E C T I O N 1

CHAPTER 4: Anaesthesia and Sedation
12
140–160 mmHg and diastolic pressures between
90–110 mmHg may not require deferment of
surgery on medical grounds. However, a systolic
blood pressure greater than 140 mmHg, on
admission to hospital, has been statistically asso-
ciated with an increased risk of haematoma for-
mation post-operatively. These patients can be
given a course of atenolol 50 mg daily for seven
days post-operatively to attenuate their blood
pressure during the period of maximum haema-
toma risk. When fully recovered from surgery
they must seek advice and assessment from their
own medical practitioner.
Choice of Anaesthetic
The choice of anaesthetic is general anaesthesia
or sedation with local anaesthesia. This choice
depends on the preference of the patient, the
surgeon and the anaesthetist, as well as the nature
of the surgery.
General anaesthesia is preferable if the surgery
includes either an endoscopic browlift, dissection
of the deeper facial planes or multiple facial pro-
cedures performed at the same time. Sedation
with local anaesthesia is best reserved for super-
fi cial facelift surgery that does not include a
browlift.
Sedation with local anaesthesia
The ASA describes a continuum of sedation
divided into four broad depths (approved by ASA
House of Delegates in 1999 & amended in
2004):
• Minimal sedation (anxiolysis) is a drug-
induced state during which patients respond
normally to verbal commands. Although
cognitive function and coordination may be
impaired, ventilatory and cardiovascular
functions are unaffected.
• Moderate sedation/analgesia (“conscious
sedation”) is a drug-induced depression of
consciousness during which patients respond
purposefully to verbal commands, either
alone or accompanied by light tactile
stimulation. No interventions are required to
maintain a patent airway, and spontaneous
ventilation is adequate. Cardiovascular
function is usually maintained.
• Deep sedation/analgesia is a drug-induced
depression of consciousness during which
patients cannot be easily aroused, but
respond purposefully following repeated or
painful stimulation. The ability to
independently maintain ventilatory function
may be impaired. Patients may require
assistance in maintaining a patent airway, and
spontaneous ventilation may be inadequate.
Cardiovascular function is usually
maintained.
• General anaesthesia is a drug-induced loss of
consciousness during which patients are not
arousable, even by painful stimulation. The
ability to independently maintain ventilatory
function is often impaired. Patients often
require assistance in maintaining a patent
airway, and positive pressure ventilation may
be required because of depressed
spontaneous ventilation or drug-induced
depression of neuromuscular function.
Cardiovascular function may be impaired.
Because sedation is a continuum the division
between one level and the next will, in practice,
be blurred. There will be a tendency for any
patient to drift from one level to the next. This
includes the possibility of a patient in level 3
(deep) sedation passing into general anaesthesia.
Many patients choose sedation rather than general
anaesthesia because they imagine it to be safer.
However, when requesting sedation these same
patients will often comment that they “don’t
want to know anything about it” or they “don’t
want to feel anything”. Complying with these
requests will necessitate using deep sedation. It
is the author’s belief that not only is there no
convincing evidence that deep sedation is safer
than a properly conducted general anaesthetic,

Section 1
13
but it is probable that deep sedation may be less
safe. It is at least disingenuous if not negligent to
allow a patient to make a choice based on a per-
ception of safety and then knowingly provide a
technique that fails to provide the best safety
profi le. Hence if a patient opts for sedation on
the grounds of improved safety they must under-
stand that this will necessitate using only minimal
or moderate sedation and they must understand
what they will experience during surgery under
these light levels of sedation. Patients who are
overly anxious about general anaesthesia tend not
to be ideal candidates, temperamentally, for
surgery under sedation with local anaesthesia.
The aim should be to have a relaxed and comfort-
able patient, sedated to level 1 or 2, who remains
cooperative during the procedure. Patients
sedated to level 3 may become disorientated
and uncooperative, sometimes requiring further
deepening to level 4, i.e., conversion to general
anaesthesia.
Numerous combinations of propofol, benzodiaze-
pines, opiates and ketamine have been described
as providing acceptable sedation for facelift proce-
dures. It is the author’s preference to use com-
bined propofol and remifentanil infusions. By
keeping the rate of the propofol infusion low the
respiratory depressant effect of the remifentanil
will be minimised. Although not a technique for
the tyro this combination can produce impressive
conscious sedation and analgesia associated with
the patient experiencing marked feelings of well-
being. The key to success lies in minimising the
patient response to the initial local anaesthetic
injections, and the analgesic component plays a
crucial part in this. For fi ve to ten minutes before
injection of the local anaesthetic solution the remi-
fentanil infusion should be run at between 0.1 and
0.15 μg/kg/min whilst the propofol is infused at a
rate low enough to just maintain consciousness.
This should allow injection of the local anaesthetic
without undue discomfort. At this point, if the
sedation is too deep and the analgesia inadequate
then the patient will become restless and unco-
operative. Oxygen supplementation may be given
throughout via a sponge nasal cannula and the
respiratory rate should be closely monitored. The
benzodiazepine, midazolam, may be added to
provide a useful amnesic component. However,
this addition will markedly potentiate the respira-
tory depressant effect of the propofol/remifent-
anil infusions and must be given with care, using
small increments administered slowly.
Although not a preferred technique, the rate of
propofol can gradually be increased to produce
deep sedation or general anaesthesia (levels 3 or
4). If the rate of remifentanil is kept at or below
0.05 μg/kg/min spontaneous respiration is usually
maintained in spite of the increased propofol
rate. Airway intervention will invariably be
required in this situation and the ConnellTM (Tyco
Healthcare) nasopharyngeal airway with built-in
oxygen delivery and carbon dioxide sampling
lines works well.
General anaesthesia
Facelift surgery, which often includes combina-
tions of procedures, may take two to fi ve hours
to complete. Well-established considerations
relating to anaesthesia for prolonged surgery will
apply. These include maintenance of body tem-
perature, fl uid balance, attention to pressure
points and deep venous thrombosis (DVT) pre-
vention. In relation to DVT prevention, full-
length
support
stockings
and
pneumatic,
sequential calf compression devices are routinely
used both during and after surgery. In General
Surgery it is well established that even mild post-
operative hypothermia may result in poor wound
healing, increased rates of infection and anasto-
mosis breakdown as well as platelet dysfunction
and increased bleeding. There is no reason to
assume that these effects will be any different in
a facelift patient and forced-air warming and
temperature monitoring are routinely used.
Fluid losses during surgery will be minimal and
hence there should be no requirement for large

CHAPTER 4: Anaesthesia and Sedation
14
volumes of intravenous fl uids to be given per-
operatively. One litre of balanced salt solution or
two litres for longer procedures, given slowly
during surgery followed by one litre during the
fi rst eight post-operative hours should be ade-
quate. The use of excessive operative intravenous
fl uids may result in either a full bladder causing
restlessness in the recovery room or frequent
visits to pass urine in the early post-operative
period. This increased patient activity may
increase facial swelling and the chances of devel-
oping a haematoma (see below). It is rarely nec-
essary to use a urinary catheter. After surgery
oral fl uid intake is allowed as soon as the patient
wishes.
When planning general anaesthesia for a facelift
an early consideration will be the choice of arti-
fi cial airway. The laryngeal mask airway (LMA)
appears to offer advantages for facelift surgery.
There is less pressor response on insertion and
emergence from anaesthesia is usually smoother
with less coughing when compared with tracheal
intubation. However, turning the head during
surgery may partially dislodge the LMA resulting
in loss of a clear airway.
As mentioned above, the ConnellTM (Tyco
Healthcare) nasopharyngeal airway may be used
for general anaesthesia in spontaneous breathing
patients. With this device the slightly extended
neck position commonly used during facelift
surgery is advantageous in helping to maintain a
clear airway.
For the vast majority of facelift operations it is
the author’s preference to use an oral, cuffed,
PVC, preformed tracheal tube of the RAE pattern
(south-polar). These tubes stay in place without
tying or taping to the face and allow for connec-
tors and catheter mounts to be positioned a little
away from the surgical fi eld. Passing the breath-
ing circuit through a sterile, clear camera-drape
sleeve and laying the resulting sterile circuit on
top of the sterile drapes allows the surgeon to
move the circuit and tube from side to side as
the head is turned whilst affording the anaesthe-
tist a clear view of the tracheal tube and breath-
ing circuit.
The choice of drugs to induce and maintain
anaesthesia is between a technique based on
inhalational agents (e.g., sevofl urane) and one
based on continuously infused drugs (e.g.,
propofol). This choice depends largely on the
preference and experience of the anaesthetist. It
is the author’s preference to use a technique
based on induction and maintenance with a pro-
pofol infusion supplemented with either fentanyl
of remifentanil. Controlled ventilation is with
oxygen/nitrous oxide or oxygen/air; the latter
resulting in a total intravenous anaesthesia (TIVA)
technique. TIVA can result in a better quality of
recovery with less post-operative nausea and
vomiting.
During an endoscopic browlift, dissection over
the supra-orbital ridges can produce intense sur-
gical stimulation. This response is attenuated by
opiates and remifentanil is particularly good in
this respect. Sensitivity in this area is the main
reason why endoscopic browlifts are diffi cult to
manage under sedation with local anaesthesia. If
the dissection extends into the orbit then a
sudden bradycardia may occur due to the well-
described oculocardiac refl ex.
Surgery is performed under a mildly hypotensive
anaesthetic. For a patient who is normotensive
pre-operatively with no history or evidence of
ischaemic heart disease or cerebro-vascular
disease the systolic blood pressure during surgery
is maintained in the range 85–90 mmHg. The
drug of choice is clonidine given slowly intrave-
nously in the dose range 50–150 μg following
induction. Clonidine is an alpha-2 adrenoceptor
agonist that produces hypotension, sedation and
analgesia. It has a mean plasma half-life of 13
hours. Its long duration of action means that it
continues to exert a useful effect in the early
post-operative period. This action helps to atten-
uate the sudden increase in blood pressure that

Section 1
15
may occur upon awakening from anaesthesia as
well as providing some useful post-operative
sedation.
Recovery (Post-Anaesthesia Care)
A facelift is not a procedure that benefi ts from
rapid emergence from anaesthesia and return to
full consciousness and activity. The occurrence
of post-operative haematoma, swelling and bruis-
ing will be reduced by careful attention to the
following:
• Avoidance of coughing on the tracheal tube
prior to extubation;
• Slow, smooth emergence from anaesthesia;
• Sitting the patient up;
• Management of blood pressure; and
• Control of pain and avoidance of restlessness
Many ways of extubating a patient without
causing them to cough have been described; none
are wholly effective. One of the more reliable
ways is to re-establish spontaneous breathing at
the end of surgery whilst maintaining full general
anaesthesia and then to remove the tracheal tube.
Prior to extubation a soft naso-pharyngeal airway
is inserted; this will maintain the airway after
extubation and cause less gagging than an oral
(Guedel-type) airway. Following extubation the
patient is transferred to a recovery trolley or bed.
Some anaesthetists exchange the oral tracheal
tube for a laryngeal mask at the end of surgery
and allow the patient to awaken with the LMA
in place.
Once in the recovery room (PACU) the patient
should be allowed to awaken slowly with no
excessive stimulation designed to encourage
arousal. They should be gradually sat up by pro-
gressive elevation of the head of the bed or trolley
whilst carefully monitoring their blood pressure.
As they begin to stir, the blood pressure will
usually rise more quickly and the head can be
elevated into a fully sitting position.
Any pain should be promptly treated with small
increments of intravenous morphine. If mild pain
is accompanied by a high or rapidly rising blood
pressure then small increments of intravenous
morphine should be given. Also, restlessness
should be treated with small increments of intra-
venous morphine. If pain has been excluded, a
high or rapidly rising blood pressure upon awak-
ening should be treated with increments of intra-
venous hypotensive drugs. Assuming no patient
contra-indication, increments of labetalol are
used to treat hypertension associated with a
tachycardia or hydrallazine for hypertension with
a slower pulse rate.
At the point of return to the ward the patient
should be fully sitting up, in a relaxed state, with
minimal pain and a systolic blood pressure of less
than 140 mmHg.
For a patient who is normotensive pre-opera-
tively their systolic blood pressure should remain
below 140 mmHg. In the fi rst 12 hours post-
operatively higher levels than this are treated
with nifedipine 5–10 mg sub-lingually.
The patient’s activity should be restricted on the
day of surgery. They are allowed to get up to go
to the bathroom/toilet but otherwise should rest,
sitting up in bed. Support stockings and pneu-
matic calf compression devices are routinely used
after surgery. Gentle mobilisation commences on
the morning after surgery. Any patient who fi nds
it diffi cult to relax post-operatively is prescribed
a low, regular dose of benzodiazepine; diazepam
2 mg three times a day.
Facelift alone or facelift with eyelid surgery are
not generally very painful procedures. After set-
tling with intravenous opiate in the recovery
room (PACU) most patients will have their
pain very adequately controlled with simple oral
analgesics such as paracetamol (acetaminophen)
with or without codeine. However, an endo-
scopic browlift either alone or as part of a com-
bination of facial procedures, will frequently

CHAPTER 4: Anaesthesia and Sedation
16
cause an unpleasant headache in the early post-
operative period. Conventional non-steroidal
anti-infl ammatory drugs (NSAIDs) such as diclof-
enac and ibuprofen should be avoided because of
their interference with platelet function. At least
one large retrospective study of haematoma
following facelift has confi rmed the signifi cant
association between NSAID usage and haema-
toma formation. Clinical and laboratory studies
indicate that COX-2 selective inhibitors have
little or no signifi cant effect on platelet aggrega-
tion, bleeding time or surgical bleeding. Using
these newer, COX-2 selective NSAIDS has
resulted in a marked reduction in the incidence
of troublesome headache after endoscopic brow
surgery with no increase in the rate of haema-
toma formation. Parecoxib 40 mg is given intra-
venously during surgery followed by celecoxib
100 mg
orally
twice
daily
after
surgery.
Questions have been raised over the use of
COX-2 drugs and a potential increase in cardio-
vascular complications. The incidence of these
complications appears to be dose and duration
related. Using a low dose (200 mg per 24 hours)
of celecoxib for only 24–48 hours should
minimise this risk. The manufacturer’s current
recommendations
and
cautions
should
be
heeded.
Post-operative nausea and vomiting (PONV) is
unpleasant for the patient and straining or retch-
ing may promote facial swelling and bleeding.
TIVA has a lower incidence of PONV when com-
pared with an inhalational technique. All facial
surgery patients receive prophylactic ondanse-
tron and any patient with a history of previous
PONV is given cyclizine additionally. The adop-
tion of TIVA and the ondansetron/cyclizine
strategy should result in an acceptably low inci-
dence of PONV.
In summary, the actual anaesthetic techniques
and drugs are very much a matter of personal
preference and are much less important than the
overlying principles. Particular importance is
placed on the careful management of emergence
from anaesthesia and the early post-operative
period as outlined above.

17
CHAPTER 1
Anatomical Considerations
A sound anatomical knowledge is the cornerstone to understanding
the mechanism of facial ageing and its surgical correction. The pre-
vention of surgical complications is paramount in this discipline where
the patient presents, not with a defect requiring reconstructive repair,
but with normal anatomy and therefore the expectation of a perfect
outcome. Avoiding injury to vital structures is not only achieved by
knowing where these anatomical structures lie, but also knowing
where and in which plane dissection can proceed without risk.
Anatomy is therefore the sine qua non to achieving excellence and a
safe outcome in facial rejuvenation surgery.
The tissues of the face lie conceptually in concentric layers. Outer-
most is the skin followed by the subcutaneous tissue which is mainly
fatty. Below this is the fi bro-fatty layer referred to as the superfi cial
musculo aponeurotic system (SMAS). Deep to the SMAS lies the
mimetic muscles of the face and below that is the deep facial fascia
that protects the facial nerve. These layers will be explored in
sequence with relation to their functional anatomy as applied to
operative technique.
Subcutaneous Layer
The subcutaneous layer of the face and neck is predominantly com-
prised of fatty tissue with some fi brous septae connecting the
dermis to the deeper layers of the SMAS and mimetic muscles which
transmit facial movement to the surface. Rather than being a uniform
layer there are defi nite regions where the superfi cial fat has greater
depth, especially in the malar, jowl, premental, and preplatysmal
S E C T I O N 2

CHAPTER 1: Anatomical Considerations
18
areas (Figs. 2.1.1–2.1.2). These so called fat pads
are responsible for normal facial contour, and
changes in their distribution occur with ageing.
Loss of volume in the malar fat pad along with
its downward migration produce a reduction of
cheek prominence as well as development of the
nasolabial crease as the descent is limited by
fi brous attachments of the lip elevators to the
dermis along this line. In contrast, excess fat
deposition in the region of the jowl and in the
pre-platysmal plane are common stigmata of
ageing. The surgical correction of these changes
include fat removal in the submental and jowl
areas along with lifting and emphasis of the malar
fat pad utilising a volumetric approach in cases
with signifi cant volume loss.
Retaining Ligaments
Condensations of fi brous connective tissue that
weave between the soft tissues of the face and neck
that anchor the superfi cial layers to fi rmer under-
lying structures are termed retaining ligaments.
Based on anatomical studies these can be divided
into true retaining ligaments that attach between
the dermis and periosteum (zygomatic, mandi-
bular and orbital) and false retaining ligaments
Jowl
fat pad
Premental
fat pad
Preplatysmal
fat pad
Galea fat pad
Malar
fat pad
Fig. 2.1.1 Subcutaneous fat.
Fig. 2.1.2 Subcutaneous fatty layer.

Section 2
19
(platysma–auricular and masseteric) that connect
the deep facial fascia to the superfi cial facial fascia
and subcutaneous tissue (Fig. 2.1.3).
True retaining ligaments
The zygomatic retaining ligament or McGregor’s
patch takes origin from the zygomatic arch and
body of the zygoma extending through the upper
part of the malar fat pad and inserting in the
dermis of the overlying skin. It is a strong, easily
identifi able structure and usually has a sizeable
artery and vein within it (Fig. 2.1.4). The man-
dibular ligaments originate in the parasymphysial
region of the mandible just medial to the origin
of the depressor anguli oris muscle and insert into
Intermediate
temporal fat pad
Platysma-auricular
ligaments
Masseteric ligaments
Mandibular ligaments
Orbital ligaments
Subcutaneous fat
and temporoparietal
fascia with frontal
branches of facial
nerve and superficial
temporal artery
Temporalis
fascia
Zygomatic ligaments
Fig. 2.1.3 Retaining ligaments.
Fig. 2.1.4 Zygomatic retaining ligament. Note the
adjacent artery

CHAPTER 1: Anatomical Considerations
20
the overlying dermis (Fig. 2.1.5). An additional
ligament that functions as a true retaining liga-
ment is the connective tissue attachment at the
supero-lateral orbital margin. This orbital retain-
ing ligament is centered over the zygomatico-
frontal suture and is a thickening of the periorbital
septum that runs around the orbital rim (Figs.
2.1.6 and 2.1.7).
False retaining ligaments
These ligaments are more broadly based than the
true retaining ligaments and act like Velcro patches
to attach the superfi cial facial tissues to the deep
facial fascia and structures below. The masseteric
cutaneous ligaments emanate from the anterior
border of the masseter and insert into the dermis
Zygomaticus major
muscle
Buccal-maxillary
retaining ligaments
Zygomatic retaining
ligaments
(McGregor’s patch)
Orbital retaining
ligaments
Mandibular retaining
ligaments
Fig. 2.1.5 Mandibular retaining ligament.
Fig. 2.1.6 True retaining ligaments with
orbital ligament at zygomatico-frontal
suture.
Fig. 2.1.7 Orbital retaining ligament.

Section 2
21
of the mid cheek. The platysma–auricular liga-
ments form a thick fascial condensation from the
posterior–superior border of the platysma near
the lobule of the ear to the SMAS and skin overly-
ing the angle of the mandible (Fig. 2.1.8).
The buccal–maxillary retaining ligaments are
unique in that they have both true and false
ligamentous components. The true component
is the upper part of this retaining ligament
that arises from periosteum in the region of
the zygomatico–maxillary suture. The false
fi bres arise more inferiorly and together they
suspend the medial part of the midface as well
as supporting the malar fat pad (Figs. 2.1.9 and
2.1.10).
Frontal branch of
facial nerve
Zygomatic arch
Superficial layer of
SMAS enveloping
face and neck
Zygomatic ligaments
(McGregor’s patch)
Superficial fat
Frontal branch of superficial
temporal artery and frontal branch
of facial nerve within temporo-
parietal fascia and galea (SMAS)
Buccal-maxillary
ligaments
Platysma-auricular
ligament
Fig. 2.1.8 Platysma–auricular ligaments.
Fig. 2.1.9 Buccal–maxillary
ligaments.
Fig. 2.1.10 Buccal–maxillary ligament.

CHAPTER 1: Anatomical Considerations
22
Functional anatomy
Retaining ligaments are essentially fi xed struc-
tures that allow facial soft tissues to pivot around
them, producing grooves such as the marionette
lines in the lower face. With age these ligaments
attenuate and along with loss of elasticity of the
overlying skin give rise to the stigmata of ageng
(Fig. 2.1.11). The zygomatic ligaments help to
suspend the malar fat pad. As this support
weakens, the malar soft tissue migrates down-
ward and along with redundant skin hangs over
the nasolabial sulcus to form a deep groove.
Similar attenuation of the masseteric ligaments
allows migration of the cheek tissues below the
mandibular border that is limited anteriorly by
the mandibular ligament, therefore giving rise to
the jowl. Surgical correction of the mid face and
jowl therefore must re-suspend this soft tissue
drift to compensate for attenuation of its support
as well as releasing the inhibitory effect which
retaining ligaments have on the skin in the zygo-
matic and mandibular area to permit adequate
re-draping.
Superfi cial Musculo
Aponeurotic System
The tissues of the face consist conceptually in
concentric layers. Below the skin and subcutane-
ous fat is the superfi cial facial fascia. This is a
discrete layer, although in different parts of the
head and neck it is constituted by either muscle,
fascia or fi bro-fatty tissue, hence it is referred to
as the superfi cial musculo aponeurotic system
(SMAS). Below this lie the mimetic muscles of
the face and below them the deep facial fascia
which protects the facial nerve when surgical
dissection is performed in the “sub-SMAS” plane.
The deep fascial fascia, best defi ned in the area
known as the parotido-masseteric fascia, covers
the parotid duct, buccal fat pad and facial vessels
as well as the facial nerve.
“Marionette”
furrow
“Crow’s feet”
or orbital
laughter lines
Preauricular
lines
Cheek lines
Chin lines
Lip lines
Deepening
nasolabial
furrow
Vertical and
horizontal
glabella furrows
Transverse brow
furrows
Commisural lines
Neck lines
Platysma bands
Reduced malar
prominence
Nasojugal
furrow
Jowl
Thinning
upper lip
Cheek hollows
Fig. 2.1.11 Stigmata of ageing.

Section 2
23
The SMAS that extends from the neck into the
scalp varies in thickness from one region to
another. Above the zygomatic arch it is a thick
layer forming the temporoparietal fascia and
galea aponeurotica within the scalp (Fig. 2.1.12).
Below the zygomatic arch it is thick over the
parotid gland but becomes much thinner over the
masseter and is thinnest in the malar region. Infe-
riorly it is represented by the platysma muscle.
The modern concept of the SMAS is that it forms
a functional layer distributing the force of the
facial muscles, but it is in fact made up from
several layers that fuse to produce the discrete
SMAS itself. Below the zygomatic arch the SMAS
contributes to the fascial covering of the superfi -
cial mimetic musculature (orbicularis oculi, zygo-
maticus major, zygomaticus minor and platysma
in the neck). This concept of the SMAS forming
a discrete layer as well as splitting to envelope
some of the mimetic muscles is referred to as
investiture (Fig. 2.1.13). The SMAS plays a vital
role in facial rejuvenation surgery where suspen-
sion of this plane is the key support of the skin
Parotid duct
Temporalis muscle
Intermediate temporal
fat pad between superficial
and deep layers of
temporalis fascia
Deep SMAS
(parotid-masseteric fascia)
Buccal fat pad
SOOF
Superficial SMAS,
orbicularis, zygomaticus major
and minor, risorius and
platysma muscles on flap
Temporalis fascia
Buccal-maxillary
ligaments
Masseteric ligaments
Fig. 2.1.12 The subcutaneous musculoaponeurotic
system – SMAS.
Fig. 2.1.13 Drawing of SMAS and superfi cial muscles with investiture

CHAPTER 1: Anatomical Considerations
24
that is re-draped rather than pulled during face-
lift closure.
Facial Muscles
The facial muscles work in synchronous groups
with contraction and relaxation allowing for the
varied expression produced by the human face.
The facial muscles are interwoven with fi bres
from the SMAS that through their interconnec-
tions with the skin allow muscular contraction to
be conveyed to the surface allowing for facial
expression. The facial muscles will be considered
in two groups: periocular, perioral and the neck.
Periocular muscles
The periocular muscles consist of elevators and
depressors of the brow and forehead as well as the
musculature of the eyelid. The frontalis is the
chief elevator of the eyebrow and consists of
paired fl at muscle bellies extending from the galea
of the scalp to insert in the dermis of the brow.
There are numerous fi brous septae that attach
from the muscle itself to the skin of the forehead
so that it moves as one unit. It is innervated by the
frontal branch of the facial nerve (Fig. 2.1.14).
The primary depressors of the brow are the cor-
rugator supercilii and lateral fi bres of the orbicu-
laris oculi that antagonise the action of the
frontalis. The corrugator muscles originate from
the frontal bone near the superomedial orbital
rim. Fibres of the muscle belly pass obliquely and
laterally to insert in the dermis of the skin above
the middle third of the eyebrow. Through its
course the muscle fi bres pass from deep to super-
fi cial and therefore traverse the frontalis muscle
to reach their dermal insertion. The muscle belly
is looped by the deep and superfi cial branch of
the supraorbital nerves that are at risk during
endoscopic browlifting at the time of corrugator
Depressor supercillii
muscle
Corrugator
supercilli muscle
Temporal crest
Frontalis muscle
Procerus muscle
Fig. 2.1.14 Periocular muscles.

Section 2
25
resection (Fig. 2.1.15). This muscle is supplied
by the frontal branch of the facial nerve and
depresses the medial brow as well as being
responsible for vertical glabellar lines.
The paired procerus muscles are also innervated
by the frontal branch of the facial nerve and
originate from the nasal bones in a paramedian
position. Their fi bres extend obliquely upwards
and insert into the skin of the glabella, therefore
giving rise to horizontal lines over the root of the
nose (Fig. 2.1.16). This muscle is often debulked
at the time of endoscopic browlifting to reduce
the horizontal component of the frown.
Perioral and neck muscles
The perioral muscles consist of elevators of the
upper lip, elevators and depressors of the corner
of the mouth and depressors of the lower lip
Procerus muscle
Supratrochlear
nerve
Superficial
branch of
supraorbital nerve
Deep branch of
supraorbital nerve
Medial
orbital wall
Frontalis muscle
Galea fat pad
Frontal bone
covered
by periosteum
Orbicularis
muscle
Corrugator
muscle
Fig. 2.1.15 Endoscopic view of
periocular muscles.
Fig. 2.1.16 Procerus muscle.

CHAPTER 1: Anatomical Considerations
26
(Fig. 2.1.17). Although inserting in the body of
the lip, the dermal adhesions at the periphery of
the upper lip produced by the four lip elevators
(zygomaticus major, zygomaticus minor, levator
anguli oris and levator labii superioris) create the
nasolabial crease between the nose and corner of
the mouth. The labiomandibular or “marionette”
crease is formed by the equivalent dermal adhe-
sion of the depressor anguli oris muscle with a
minor contribution from the highest fi bres of the
platysma which form the risorius.
The zygomaticus major and minor arise from the
body of the zygoma and insert in the extreme
lateral (upper lip itself as well as modiolus) and
mid section of the upper lip, respectively. They
are the chief muscles responsible for the zygo-
matic smile and due to their superfi cial nature
are vulnerable to injury during facelifting. They
are supplied by the zygomatic branch of the facial
nerve on their deep surface (Fig. 2.1.18). This
confi guration has importance in the extended
SMAS procedure described by Stuzin; as long as
the dissection remains superfi cial to the zygo-
maticus major the nerve will be safe.
The risorius is a thin fl at muscle that may also be
a continuation of the platysma extending up into
the lower face. When present as a separate muscle
it takes origin from the parotid fascia and inserts
into the skin of the corner of the mouth drawing
it down and laterally. The depressor anguli oris
is a triangular-shaped muscle that arises from the
anterior mandibular border lateral to the man-
dibular retaining ligament. It inserts into the
modiolus and lateral part of the lower lip where
contraction conveys sadness. Orbicularis oris is
the sphincter muscle of the mouth and consists
Depressor labii
inferioris muscle
Levator anguli
oris muscle
Zygomatic
major muscle
Risorius muscle
Zygomatic
minor muscle
Superficial head
of orbicularis oris
muscle
Levator labii
superioris
muscle
Mentalis muscle
Depressor anguli
oris muscle
Platysma muscle
Levator labii
superioris
alaeque nasi
muscle
Fig. 2.1.17 Perioral musculature.
Fig. 2.1.18 Zygomaticus major muscle and nerve. Note
the nerve entering on the deep surface of muscle.

Section 2
27
of many layers with insertion of the other peri-
oral muscles into it. Loss of mass within this
muscle takes place with ageing and contributes
to the thinning seen with senescence.
The platysma is a paired fan-shaped muscle
arising from the cervical fascia in the upper
deltoid and pectoral regions with insertion into
the modiolus as well as the lower lip along with
the depressor musculature (Fig. 2.1.19). The
cervical portion, which is responsible in part for
the tone of the youthful neck, becomes attenu-
ated with age giving rise to loss of the cervico-
mental angle. The medial edge of each platysma
muscle can hypertrophy under such circum-
stances to form cervical bands, visible through
the skin, which may need dividing at the time of
neck lift in order to rejuvenate this region.
Cardoso de Castro’s anatomic studies led him to
classify the relationship of the two platysma
muscles and their interdigitation in the submen-
tal region:
• Type 1 (75%): interdigitation of the upper
1–2 cm below the mandible;
• Type 2 (15%): deccusation of muscle from
mandible to thyroid cartilage; and
• Type 3 (10%): no deccusation of muscle
fi bres.
This confi rms the clinical observation that in
most patients there is little interdigitation of the
muscles.
The Facial Nerve
Having exited the skull base via the stylomastoid
foramen, given off the post auricular nerve and
the branch to the posterior belly of digastric and
stylo-hyoid muscles, the main trunk of the facial
nerve usually bifurcates into the upper (temporo-
zygomatic) and lower (cervico-facial) divisions as
it approaches the postero-medial border of the
parotid gland. As it passes forward within the
substance of the gland it lies between the superfi -
cial and deep lobes. These divisions give rise to
the main branches of the facial nerve (temporal,
zygomatic, buccal, mandibular and cervical). At
its anterior border the branches come to lie on the
Platysma muscle
Preplatysmal
fat pad
Depressor anguli
oris muscle
Platysma-
auricular
ligaments
Fig. 2.1.19 Platysma musculature.

CHAPTER 1: Anatomical Considerations
28
surface of the masseter muscle deep to the parot-
ido-masseteric fascia (Fig. 2.1.20).
The temporal or frontal nerve is the smallest
branch and has the least number of interconnec-
tions being a terminal branch in the majority of
patients. This branch becomes superfi cial once it
crosses the zygomatic arch that it traverses at the
junction of its posterior third and anterior
two-thirds. (Figs. 2.1.21 and 2.1.22). It runs
within the temporoparietal fascia to supply
the frontalis muscle, upper fi bres of orbicularis
oculi, procerus and corrugator supercillii. Due
to the superfi cial path of this nerve it can easily
be damaged during dissection in the temporal
region, and great care must be taken to stay deep
to the temporoparietal fascia during the lateral
dissection of an endoscopic browlift (Fig.
2.1.23).
The zygomatic and buccal branches of the facial
nerve travel medially across the surface of the mas-
Temporal crest
Frontal branch of
facial nerve
Temporal fat pad
Superficial branch
of supraorbital nerve
Supratrochlear nerve
Deep branch of
supraorbital nerve
Temporoparietal
fascia
Superficial and
deep layers of
deep temporal
fascia
Fig. 2.1.20 The facial nerve trunk and its major branches.
Fig. 2.1.21 Temporal nerve and
relationship to the zygomatic arch.
Fig. 2.1.22 Temporal branches of the facial nerve
crossing zygomatic arch (indicated by scissors).

Section 2
29
seter muscle under the parotidomasseteric fascia
where they are relatively well protected. At the
anterior border of this muscle they pass over the
buccal fat pad in the same plane as the parotid duct
and facial vessels (Fig. 2.1.24). As the zygomatic
and buccal branches pass forward they supply the
superfi cial mimetic muscles (lower fi bres of orbi-
cularis oculi, zygomaticus major, zygomaticus
minor and levator labii) on their deep surface.
The mandibular branch of the facial nerve exits
the cover of the parotid gland at its lower pole
(Fig. 2.1.25 and 2.1.26) and then dips below the
Subplatysmal fat
Facial nerve
(cervical branch)
Greater auricular
nerve
External jugular
vein
Submandibular gland
Platysma muscle
on flap
Facial nerve (marginal
mandibular branch)
Masseter muscle
Parotid gland
Retaining
mandibular ligament
Anterior jugular
vein
Fig. 2.1.23 The temporal branch of the facial nerve.
Fig. 2.1.24 Buccal and zygomatic branches of the facial
nerve.
Fig. 2.1.25 The mandibular branch of the facial nerve.
Fig. 2.1.26 The mandibular branch of
the facial nerve.

CHAPTER 1: Anatomical Considerations
30
margin of the mandible to lie 1–2 cm inferior to
its lower border. This distance can be 3–4 cm in
elderly patients with loose cervical tone and par-
ticularly when the neck is extended as it may be
during facelifting. Once the nerve crosses the
facial vessels it usually runs above the level of
the mandibular border, although it remains under
the cover of the platysma muscle for its entire
course. As the platysma muscle is very thin in
most patients undergoing facial rejuvenation
surgery the mandibular branch is vulnerable to
damage due its superfi cial position. If the dissec-
tion remains superfi cial to the platysma the nerve
is safe, but any sub-platysmal dissection should
be performed cautiously staying 2–3 cm below
the mandibular border. The cervical branch is the
most inferior of the facial nerve branches and
below the parotid travels deep to the platysma
muscle that it supplies. Injury to it can produce
the “pseudo marginal mandibular palsy” described
by Ellenbogen.
Sensory nerve supply
The sensory innervation of the face is primarily
through the branches of the trigeminal nerve and
the cervical plexus. The cutaneous supply of the
trigeminal nerve is distributed through its three
divisions (ophthalmic, maxillary and mandibular)
(Fig. 2.1.27).
TRANSVERSE
CERVICAL
MANDIBULAR
DIVISION
MAXILLARY
DIVISION
OPTHALMIC
DIVISION
LESSER OCCIPITAL
AURICULOTEMPORAL
GREATER AURICULAR
Fig. 2.1.27 Sensory branches of trigeminal and cervical plexus.

Section 2
31
The ophthalmic division gives rise to the supra-
orbital (deep and superfi cial branches), supra-
trochlear, infratrochlear, external nasal and
lacrimal branches. The supraorbital and supra-
trochlear are the most important nerves of sur-
gical signifi cance, particularly with respect to
endoscopic browlifting. The supraorbital nerve
leaves the orbit near the mid-pupillary line via
a bony notch, although it can exit through a
foramen up to 1 cm above the orbital rim. The
supratrochlear nerve leaves the orbit 1 cm medial
to the supraorbital nerve. The supraorbital nerve
usually exits as a single nerve trunk that divides
into deep and superfi cial branches straddling the
corrugator muscle. However, the deep branch
may emerge separately, through a more superi-
orly placed foramen and care must be taken not
to injure it during endoscopic browlift surgery.
In contrast, the supratrochlear nerve generally
exits the orbit as several small branches that
course through the corrugator muscle.
The maxillary division of the trigeminal nerve
innervates the skin of the midface via its infra-
orbital, zygomaticofacial and zygomaticotem-
poral branches. The infraorbital nerve is the most
clinically signifi cant and reaches the cheek via the
infraorbital foramen of the maxilla that lies
around 1 cm below the inferior orbital rim in the
mid pupillary line. This lies below the origin of
the levator labii superioris muscle and should be
preserved in the subperiosteal mid face dissec-
tion of a volumetric facelift.
The mandibular division of the trigeminal nerve
supplies the facial skin via the auriculotemporal,
buccal and mental nerves. The auriculotemporal
nerve runs with the superfi cial temporal artery
and therefore may be injured during open face-
lifting that requires ligation of that vessel to
reduce the risk of late haematoma. The resulting
numbness to the upper anterior surface of the ear
is, however, usually only temporary as this area
has signifi cant overlap in dermal supply. The
mental nerve that supplies sensation to the skin
over the parasymphyseal area of the mandible is
a continuation of the inferior alveolar nerve and
exits the mental foramen that lies 2 cm below
the lip margin in the mid pupillary line. It is at
risk surgically during genioplasty where its loca-
tion must be clearly avoided in order to prevent
injury to the nerve.
The cervical region and two-thirds of the cutane-
ous supply to the ear are provided by branches of
the cervical plexus (transverse cervical and
greater auricular nerves). Both are derived
from cutaneous rami of the 2nd and 3rd cervical
nerve roots. The greater auricular nerve enters the
neck from the posterior border of the sterno-
cleidomastoid muscle where it pierces the deep
fascia 6.5 cm vertically below the lower border of
the external auditory canal (Figs. 2.1.28 and
Fig. 2.1.28 The greater auricular nerve emerging from
the posterior border of the sternomastoid muscle.

CHAPTER 1: Anatomical Considerations
32
2.1.29). Its course is very superfi cial on the surface
of the sternocleidomastoid muscle and great care
Greater auricular
nerve
External jugular
vein
Platysmal muscle
Preplatysmal
fat pad
Depressor anguli
oris muscle
Platysma-
auricular
ligaments
must be taken to avoid damaging it during rhytid-
ectomy when dissecting in the neck.
Fig. 2.1.29 The greater auricular
branch of cervical plexus.
Clinical pearls
Subcutaneous layer
The stigmata of ageing include loss of the
triangular face shape seen in youth. This is partly
due to volume loss and descent of the malar fat
pad.
In contrast to volume loss in the mid face, excess
fat deposition in the jowl and submental region
are stigmata of ageing that benefi t from surgical
resection either directly or by gentle liposuction.
Retaining ligaments
Facial rejuvenation surgery aims to “reconstruct”
the lack of support to the soft tissues created by
the attenuation of the retaining ligaments at the
same time as releasing their inhibitory eff ect on
the skin to allow re-draping.
SMAS
The SMAS is used surgically as a structural vehicle
for safely lifting the soft tissues of the face and
neck through its network of attachments to the
facial soft tissues and skin.
As the SMAS lies in a plane above that of the
mimetic muscles and facial nerve, dissection
below this aff ords a plane of relative safety in
facial dissection.
Care must be taken above the zygomatic
arch where the concentric facial layers are
compressed and the temporal branch of the
facial nerve is superfi cial lying within the
temporoparietal fascia.
Periocular muscles
Endoscopic browlifting allows division of the
corrugator musculature and care must be taken to
avoid damage to the looping superfi cial and deep
branches of the supraorbital nerve which pass
around this muscle.
Sweeping movements with the endoscopic punch
rather than a scissor reduce this risk as the nerve
branches can be visualised.

Section 2
33
Clinical pearls—cont’d
Perioral muscles
To prevent injury to the zygomatic branch of the
facial nerve, care must be taken to stay in a plane
superfi cial to the zygomaticus muscles when
dissecting the midface as the nerve is deep to
them and supplies their undersurface.
These muscles are, however, easily tented upwards
when retracting the skin of the cheek during face
lifting so care must be taken not to enter a deeper
plane in error.
Facial nerve
The mandibular nerve lies under cover of
the platysma that is very thin in the elderly,
rendering the nerve superfi cial in facial
dissection.
The course of the mandibular nerve is usually
below the border of the mandible in the posterior
neck. It can descend by a further 1–2 cm with neck
extension as is often the case during rhytidectomy.
Care must therefore be taken in subplatysmal
dissection to stay well below the border of the
mandible.
Sensory supply
Avoiding damage to the greater auricular nerve is
achieved by dissecting vertically down the neck
parallel with its course rather from behind as it is
easier to follow the nerve once it has been located.

35
CHAPTER 2
Pre-operative Preparation
Pre-operative preparation for facial aesthetic surgery is relatively
simple. A full, detailed medical and surgical history is essential (see
Section 1 Chapter 2), but no haematological testing is necessary in
the absence of a specifi c indication. The need for ECG or other spe-
cialized examination is determined by the anaesthetist who must be
informed of any health concerns well before the planned surgical
date. Patients who smoke should be encouraged to stop at least two
weeks pre-operatively and informed in simple language of the
increased risk to skin viability (“at worst the skin may turn black and
die”). When asking about any medication the patient may be taking,
remember that many individuals do not consider non-prescription
drugs, vitamins and homeopathic remedies as “medication”. Anything
that inhibits platelet function such as aspirin, aspirin-containing
products, vitamin E and multivitamins that contain it, non-steroidal
anti-infl ammatory drugs, garlic capsules, ginko biloba, etc., should be
avoided for at least two weeks before surgery. A written list of sub-
stances to avoid should be provided. Some suggest that vitamin C
promotes wound healing and many patients ask about the use of
arnica to reduce bruising – neither will do harm but no fi rm evidence
of effi cacy exists. Alcohol intake on the day before surgery should be
modest – no more than a glass of wine. If there is a strong history
of herpes simplex virus (HSV) infection it is prudent to treat pro-
phylactically with acyclovir 500 mg bid beginning 48 hours pre-
operatively and continuing for fi ve days afterwards if any cutaneous
resurfacing is contemplated or peri-oral structural fat grafting is
planned.
The patient should wash her hair with Hibiscrub on the day before
surgery. They are best advised to come to hospital without make-up
and are admitted on the day of surgery. Time must be allowed on
admission for the patient to discuss any persisting anxieties and to
clarify exactly what is to be done. Generally my nurse will visit the
patient before I do to run through the procedure again, to be sure
S E C T I O N 2

CHAPTER 2: Pre-operative Preparation
36
they know what to expect in terms of dressings,
post-operative care, follow-up appointments,
etc., and to identify any last minute worries. This
should reassure even the most anxious individual.
The anaesthetist will also examine the patient
(see Section 1 Chapter 4) and explain exactly
what anaesthesia or sedation involves. Having
examined the patient again, relevant facial mark-
ings are made using a felt-tip skin marker with
the patient in a sitting position. These include
any areas for treatment by syringe suction, par-
ticularly the jowl and submental region and any
other unusual facial features that may dictate a
variation in operative technique, e.g., platysma
bands (Fig. 2.2.1). The consent form is usually
signed on the ward. The surgeon must be certain
that the patient fully understands the content,
and to this end I usually read it to them and
translate any jargon into simple English. It is not
necessary to repeat, in writing, the pre-operative
explanation of limitations and potential risks and
complications, but it is helpful to record on the
consent form the date on which these discussions
took place.
The patient’s hair may be prepared pre-opera-
tively on the ward or in the operating room fol-
lowing the induction of anaesthesia or intravenous
sedation. No shaving is necessary. Standard com-
mercial hair gel will facilitate the parting of the
hair along the planned incision lines. In the region
of the temple and mastoid, the hair anterior to
the incision line can be gathered and folded into
clumps and then secured with half inch ribbon
gauze. The hair posterior to the incision line can
usually be simply tied into a pony tail with the
same ribbon gauze (Fig. 2.2.2).
Once on the operating table the patient is placed
in a supine position with an anti-Trendelenberg
tilt of 15–20° and the head resting either on a
head ring of the fi rm rubber type or a neurosurgi-
cal head rest. A small sand bag is placed under
the shoulders, but care must be taken not to
hyper-extend the neck. A warming blanket is
essential to avoid excessive cooling during the
operation (Fig. 2.2.3).
Fig. 2.2.1 Pre-operative marking for facelift.
Fig. 2.2.2 Preparation of hair for facelifting.
Fig. 2.2.3 Patient positioned on table with warming
blanket.

Section 2
37
The face is cleaned using a mild antiseptic solu-
tion such as chlorhexidine (protecting the eyes)
and then rinsed with saline. A cotton (not paper)
head towel is draped beneath the head and the
remainder of the patient covered by standard
draping techniques. If the procedure is being
carried out under general anaesthesia with oro-
tracheal intubation, the anaesthetic tubing is
enclosed within a transparent endoscopic camera
drape so that it can be easily moved as the
patient’s head is turned and will not have tension
applied to it by the overlying drapes. If the pro-
cedure is being done under local anaesthesia then
the nasal oxygen delivery system and CO2 moni-
toring can be similarly incorporated in a camera
drape (Fig. 2.2.4).
The Order of Operative Procedures
If a full facial rejuvenation is planned, i.e., endo-
scopic browlift, blepharoplasty and facelift, it is
advisable to carry out the browlift surgery fi rst.
This will eliminate the risk of over-resection of
upper lid skin in a blepharoplasty causing lagoph-
thalmos when blepharoplasty and endobrow are
combined. Similarly, it is preferable to perform
lower lid blepharoplasty before facelift since if
the reverse order is followed the risk of excising
too much skin from the lower eyelid is increased
because of the apparent support to the lower lid
from the facelift. Of lesser importance is the fact
that blepharoplasty is a more delicate procedure
requiring fi ne control on the surgeon’s part that
may be more easily accomplished at the begin-
ning than at the end of a long procedure.
Surgical Technique
Excellent vision is an essential pre-requisite, and
this is facilitated by the use of a fi bre optic surgi-
cal headlight or lighted retractor.
It is helpful to have a routine both from the point
of view of the nursing staff and for later review
of surgical cases. I always operate on the left side
of the face fi rst. The patient’s head is turned
toward the right side and the head drape secured
with three skin staples, pulling the hair upwards
as the drape is applied to expose the incision sites
(Fig. 2.2.5).
For details of specifi c operative techniques please
see the remainder of Sections 2 and 3.
Dressings and Post-operative Care
At the end of the procedure the patient’s hair is
washed and dried. If liposuction, an Owsley type
or open Feldman platysmaplasty has been carried
out in the neck an adhesive foam support is applied
(see Fig. 2.3.40). A light dressing of paraffi n gauze,
dressing gauze and cotton wool is secured with
Fig. 2.2.4 Camera drape used to cover endotracheal
tube.
Fig. 2.2.5 Application of head drape for facelifting.

CHAPTER 2: Pre-operative Preparation
38
elastic net (Fig. 2.3.41). Gentle emergence from
anaesthesia without coughing is essential, together
with the avoidance of hypertension in the recov-
ery phase and the provision of adequate analgesia
(see Section 1 Chapter 4).
The dressing and drains are removed on the fi rst
post-operative morning. The hair is washed again
and most patients leave hospital. In my practice
approximately 75% of patients are hospitalized
for 24 hours, 20% choose to stay for 48 hours
and the remainder stay for a longer period.
Instructions given with regard to rest, the avoid-
ance of strenuous activity, sleeping with the head
elevated, etc., are reinforced before discharge.
We ensure that the patient has emergency contact
telephone numbers in the event of advice being
needed and readmission to hospital is possible at
any time if required. A written summary contain-
ing details of the operation is sent to the GP on
the day of discharge. This may be sent directly
to the patient in the form of a medical report if
they have refused permission for communication
with their GP.
An appointment is made for review and suture
removal at six to eight days post-operatively. At
this meeting there must be adequate time avail-
able to discuss any concerns that the patient may
have. Assuming all is well a further routine follow
up appointment is made for three months later,
but it is emphasized that the patient may return
at any time if they wish.
At the three month visit a careful physical exami-
nation is carried out. Photographs are taken and
reviewed with the patient together with their
pre-operative images. Again suffi cient time must
be allowed for the discussion of any uncertainties
or anxieties. If necessary, a further appointment
is made. It is vital that the patient does not feel
rushed at any stage and that all their questions
are answered as fully as possible.

39
CHAPTER 3
SMASectomy
Surgical Technique
The planned incision line is marked; an unvarnished, fi ne, modelling
paint brush with Bonney’s blue ink is the most suitable tool for this.
In the temporal region the incision begins within the hairline with its
angle lying at the intersection of a vertical line running upwards from
the helical root and an oblique line joining the alar base and lateral
canthus. It runs inferiorly toward the helical root above which a small
posteriorly angled V is marked to allow inferior rotation of the tem-
poral hairline later. It then follows the natural line of the helix, con-
tinuing in a retrotragal position with a distinct angle at the inferior
most point of the tragus anteriorly so that the tragus itself is well-
defi ned, before continuing along the line of lobule and cheek. Poste-
riorly, the incision line extends on the ear, i.e., anterior to the
junction of conchal and mastoid skin to a point opposite the root of
the helix. A vertically orientated V is then marked onto the mastoid
skin following which the incision extends well within the hairline of
the mastoid and upper neck terminating with a downward back-cut
to allow anterior rotation of the hair at the end of the procedure, so
avoiding an unnatural step in the hairline (Figs. 2.3.1 and 2.3.2).
S E C T I O N 2
Fig. 2.3.1 Incisions marked (anterior).
Fig. 2.3.2 Incisions marked (posterior).

CHAPTER 3: SMASectomy
40
Two points are then tattooed using a needle and
Bonney’s blue ink to allow precise measurement
of skin movements during surgery. The fi rst is at
the root of the helix and the second at the point
at which the incision turns posteriorly in the
mastoid region (Figs. 2.3.3 and 2.3.4).
A small roll of paraffi n gauze is then inserted as
an ear plug to prevent blood and/or fl uid running
into the external ear canal.
Infi ltration
Tumescent solution (200 mL) is infi ltrated into
the subcutaneous tissues of the face and neck.
The composition of the solution is: 500 mL
Ringer lactate, 25 mL 0.25% Marcaine, 25 mL
1% lignocaine, 1.25 mL triamcinolone 40 mg/ml,
1500 U hyaluroni-dase. The solution contains no
adrenaline.
The infi ltration is most easily accomplished by
making the incision above the helix and the ante-
rior part of the mastoid incision so that a blunt
infi ltration cannula can be inserted. A blunt
cannula will follow the tissue planes much more
easily and accurately than a sharp needle and the
infi ltration itself is accomplished using 50 mL
Luer lock syringes (Fig. 2.3.5). With the infi ltra-
tion complete on the left side only, the resultant
swelling is obvious (Fig. 2.3.6).
Suction Lipectomy
Frequently, suction lipectomy, using a syringe-
based system, is indicated in the submental
region. The head is placed in a neutral position
Fig. 2.3.3 Key points tatooed (anterior).
Fig. 2.3.4 Key points tatooed (posterior).
Fig. 2.3.5 Tumescent infi ltration using blunt cannula and
50 ml Luer lock syringe.
Fig. 2.3.6 Left side of face only tumesced.

Section 2
41
once more and two small stab incisions made
beneath the mandible. Fifty to a 100 mL of
tumescent solution are infi ltrated using the same
blunt cannula instrument as described above. A
blunt aspiration cannula and 10 mL syringe are
used to accomplish the suction lipectomy. For a
right-handed surgeon this is most easily carried
out from the patient’s left-hand side using his
left hand on the skin to judge the depth of the
cannula and the right hand to control the cannula
and syringe itself. The use of two incisions enables
criss-crossing of the liposuction tunnels that will
produce a smoother result (Figs. 2.3.7 and
2.3.8). At the end of this procedure the two inci-
sions are closed using a single 5/0 prolene
suture.
The head is turned to the left once more and,
when indicated, liposuction to the jowl region
performed. If no structural fat grafting has been
done then the best access is via a stab incision at
the modiolus within the vermilion of the lip.
Again, the left hand gives an indication of the
depth of the cannula, which must be superfi cial
to the platysma muscle whilst the right hand
controls the cannula and syringe. Approaching
the jowl from the medial aspect rather than
lateral aspect renders it much less likely that the
Fig. 2.3.7 Submental liposuction
using syringe system and crossed
tunneling.
Fig. 2.3.8 Submental liposuction using syringe system
and crossed tunneling.

CHAPTER 3: SMASectomy
42
cannula will stray into the sub-platysmal space
putting the marginal mandibular branch of the
facial nerve at risk. Closure of the incision of the
modiolus is not usually necessary (Fig. 2.3.9).
Making the Incisions
The remainder of the incision is then completed
using a 15 blade, taking particular care to follow
the tragus accurately. A swab is placed in the
post-auricular region and the anterior dissection
carried out fi rst. For a right-handed surgeon, on
the patient’s left-hand side, it is most convenient
to begin in the temporal area using Gorney type
scissors and a double skin hook to bluntly sepa-
rate the skin from the superfi cial fascia. The
superfi cial temporal vessels lie just beneath the
skin and are less likely to be injured if this
manoeuvre is carried out bluntly than if a knife
is used (Fig. 2.3.10).
The continuation in the retrotragal region is with
a 15 blade, again using a double pronged skin
hook to elevate the skin leaving the assistant sup-
porting the temporal skin with the fi rst double
hook (Fig. 2.3.11).
Once the tragal skin has been elevated the
remainder of the anterior dissection can be com-
pleted using a blunt ended scissors such as the
Tessier design. The technique is “sharp”, i.e.,
cutting with the scissors using a downward
motion, not blunt burrowing. The surgeon ele-
vates the skin using a double skin hook held in
Fig. 2.3.9 Liposuction of the jowl via the modiolus.
Fig. 2.3.10 Temporal dissection started with scissors.
Fig. 2.3.11 Dissection of tragus.

Section 2
43
his left hand, the little fi nger of which rests on
the surface of the skin so that the thickness of
the skin fl ap can be judged (Fig. 2.3.12).
Particular care must be taken in the region of
ligamentous attachments, e.g., the zygomatic
retaining ligament (McGregor’s patch), where
the skin may be tented inward and is at risk of
injury from beneath with the scissors. Again, if
the surgeon’s left hand is resting on the skin this
Fig. 2.3.12 Dissection of cheek fl ap.
Fig. 2.3.13 Zygomatico-cutaneous (McGregor’s) ligament
(note cutaneous depression, arrow).
risk is minimized. The dissection continues ante-
riorly beyond the zygomatic retaining ligament
(Fig. 2.3.13) over the body of the malar bone
and the lateral most aspect of the orbicularis
occulae (Fig. 2.3.14).
Inferiorly, the dissection extends toward the
nasolabial furrow and over the margin of the
mandible into the neck. If blood pressure control
is adequate, bleeding is not usually profuse and
at this point a damp swab may be packed into
the anterior aspect of the dissection whilst atten-
tion is turned to the dissection of the mastoid
and neck region (Fig. 2.3.15).
The assistant may retract the ear either with a
double pronged skin hook or a stay suture. The
dissection of the mastoid skin, like the skin in the
Fig. 2.3.14 Extent of cheek fl ap dissection.
Fig. 2.3.15 Anterior dissection “packed off ”.

CHAPTER 3: SMASectomy
44
temple, is most easily accomplished initially using
Gorney type scissors that will tend to cleave it
in the correct plane (Fig. 2.3.16).
As the dissection descends inferiorly over the
mastoid region, care must be taken since there is
no natural plane of cleavage. The dissection must
be sharp, either with scissors or a knife and must
stay superfi cial to the sternomastoid fascia. The
skin over the mastoid is very thin and care must
be taken not to penetrate it. The great auricular
nerve is vulnerable as it pierces the deep fascia
at a point 6.5 cm inferior to the root of the lobule.
The nerve is very superfi cial and particular care
must be taken to avoid injuring it (Figs. 2.3.17
and 2.3.18).
A hinged skin hook of the Humby design is used
to facilitate the joining of the anterior and poste-
rior dissections, the lobule is attracted superiorly
by the assistant while the surgeon elevates the
skin with the Humby hook. This is best com-
pleted with the Gorney scissors (Fig. 2.3.19).
Descending into the neck, the assistant should
elevate the skin fl ap using a Deaver retractor
whilst the surgeon places the platysma under
posterior traction with a swab held in the left
Fig. 2.3.16 Posterior dissection begun with scissors.
Fig. 2.3.17 Great auricular nerve (arrow) pierces deep
fascia 6.5 cm inferior to tragus.
Fig. 2.3.18 Great auricular nerve (arrow) piercing deep
fascia.
Fig. 2.3.19 Humby hinged hook used to retract skin
fl aps.