Orthognathic Surgery

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CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
Consent for Otoplasty Surgery
_______
INSTRUCTIONS
Initial here
This document has been prepared to help your surgeon to educate and inform you about your otoplasty
surgery and its risks as well as alternative treatment options. It is important that you read this document
carefully and completely. Please initial each section on each page to indicate that you have read and
understand it. In addition, please sign the consent for surgery on the last page as proposed by your
surgeon.
______
INTRODUCTION
Initial here
Otoplasty is a surgical process that is used to reshape the ears. A variety of different techniques and
approaches may be used to reshape congenitally prominent ears or to restore damaged ears. Each
individual who is seeking otoplasty is unique both in terms of the appearance of his or her ears and his or
her expectations of the results that will be obtained with surgery. It is important that you fully discuss your
expectations with your surgeon before surgery.
______
ALTERNATIVE TREATMENTS
Initial here
Alternative forms of management consist of not undergoing an otoplasty operation at all or proceeding
with other more limited or more extensive surgical options.
_______
RISKS OF SURGERY
Initial here
Every surgical procedure involves a certain amount of risk. An individual’s choice to undergo an otoplasty
procedure is based on the comparison of the risk to the potential benefit. Although the majority of
patients do not experience the complications detailed below, you should discuss each of them with your
surgeon. Make sure that you understand all of the possible consequences of the otoplasty procedure that
is planned for you.
_______
BLEEDING
Initial here
It is uncommon to experience significant bleeding during or after otoplasty surgery. If postoperative
bleeding does occur, it may require emergency treatment to drain accumulated blood (i.e., hematoma).
Do not take any aspirin or similar anti-inflammatory medications for 2 weeks before or after surgery,
because this may increase the risk of bleeding.
2. Take the prescribed antibiotics as ordered and the pain medication as needed.
3. You may eat whatever you wish, but start out slowly, because the anesthesia may leave your stomach unsettled for
several hours.
4. Call the office for an appointment on the date specified at the time of discharge.
5. If there are any concerns while you are at home, contact your surgeon’s office at any time.
6. Before you arrive for your first office visit after surgery, purchase and bring along an elastic cloth ear band to be
used at night when you are sleeping. Your surgeon will instruct you with regard to its use.
Jeffrey C. Posnick, DMD, MD
Director, Posnick Center for Facial Plastic Surgery
Continued

1742 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
_______
INFECTION
Initial here
Infection is not common after otoplasty surgery. If an infection does occur, treatment that includes the
extended use of antibiotics or additional procedures may be necessary.
_______
CHANGES IN SKIN SENSATION
Initial here
Diminished sensation in the skin of the ear will occur and may not totally resolve after otoplasty surgery.
_______
TRAUMA
Initial here
Physical injury to the ear soon after otoplasty may disrupt the results of surgery. Care must be taken by
you to protect the affected ear from injury during the healing process. Additional surgery may be possible
to correct any damage that does occur.
_______
SKIN CONTOUR IRREGULARITIES
Initial here
Contour irregularities as well as visible and palpable wrinkling of skin and ear cartilage can occur after
otoplasty.
_______
SKIN SCARRING
Initial here
In some cases, excessive scars may result after otoplasty. Scars may be unattractive and of a different
color than the surrounding skin. Additional treatments or procedures may be possible to treat unfavorable
scarring.
_______
SURGICAL ANESTHESIA
Initial here
Both local and general anesthesia involve risk. Complications and injuries are possible with all forms of
surgical anesthesia and sedation.
_______
ASYMMETRY
Initial here
The human face is normally asymmetric, and this is especially true for the external ears. Typically, there
are differences between ears in terms of shape and size. There will also be variations from one side to the
other with regard to the results obtained with an otoplasty procedure.
_______
DELAYED HEALING
Initial here
Wound disruption or delayed healing is possible after otoplasty. Some areas of the ear may heal
abnormally or slowly. Occasionally, further procedures to manage the non-healed tissue may be required.
_______
ALLERGIC REACTIONS
Initial here
Local allergies to tape, suture material, or topical preparations can occur. Systemic reactions, which are
more serious, may also occur in response to the drugs used during surgery and prescription medicines.
Allergic reactions may require additional treatment.
_______
AGING EFFECTS
Initial here
Subsequent alterations in ear appearance may occur as a result of aging or other circumstances not
related to the otoplasty surgery.
_______
RELAPSE
Initial here
As a result of the resilient nature of ear cartilage, relapse (i.e., the springing back out of the ears) may
occur after surgery. Revisional surgery may be possible to improve the results if relapse occurs.

1743
CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
_______
PAIN
Initial here
Infrequently, chronic pain may occur as a result of nerves being injured or trapped in scar tissue after an
otoplasty.
_______
DEEPER SUTURES
Initial here
Deep (buried) non-absorbable sutures may spontaneously work their way through the skin, become
visible, or produce irritation and inflammation and thus require removal.
_______
UNSATISFACTORY RESULTS
Initial here
You may be disappointed with the results of surgery. If so, it may be possible to perform additional
surgery to improve your satisfaction.
_______
ADDITIONAL SURGERY
Initial here
The practice of medicine and surgery is not an exact science. Although good results are expected, there
is no guarantee or warranty expressed or implied with regard to the results that may be obtained. If
complications do occur, additional surgery or other treatment may be possible.
_______
HEALTH INSURANCE
Initial here
Most health insurance companies exclude coverage for operations to change the shape of the external
ears (otoplasty) or any complications that may occur in association with this surgery. Please carefully
review your health insurance subscriber-information pamphlet to clarify these issues.
_______
FINANCIAL RESPONSIBILITIES
Initial here
The cost of surgery involves several charges for the services provided, including the fees charged by your
surgeon (i.e., surgeon’s fees); the cost of surgical supplies and the use of the operating room (i.e., facility/
hospital charges); and the costs associated with anesthesia (i.e., anesthesiologist’s fees). Depending on
whether the cost of surgery is covered by your medical insurance plan, you will be responsible for
necessary copayments, deductibles, and all other charges that are not covered. Additional costs may
occur should complications develop from the surgery. Any secondary surgeries and all charges involved
with additional procedures (i.e., surgeon’s fees, facility/hospital charges, anesthesiologist’s fees) would
also be your responsibility.
_______
DISCLAIMER
Initial here
Informed-consent documents are used to communicate information about the proposed surgical
treatment as well as to disclose information about risks and alternative forms of treatment. The informed-
consent process attempts to define principles of risk disclosure that should generally meet the needs of
most patients in most circumstances.
Because every patient is unique, this informed-consent document should not be considered all-inclusive
with regard to defining other methods of treatment to consider and potential risks encountered. Your
surgeon will provide you with additional written and verbal information that is based on all of the facts of
your particular case and the current state of medical knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care.
Standards of medical care are determined on the basis of all of the facts involved in an individual case
and are subject to change as scientific knowledge and technology advance and practice patterns evolve.
Continued

1744 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
CONSENT FOR OTOPLASTY SURGERY
1. I hereby authorize my surgeon, __________, and such assistants as may be selected by my surgeon to perform the
following procedure: otoplasty.
2. I have received, read, and understand the following information sheets:
• Otoplasty (Reshaping of the Ears) Surgery
• Book chapter about otoplasty
• Consent for Otoplasty Surgery
3. I recognize that, during the course of the operation and the administration of anesthesia, unforeseen conditions may
necessitate different procedures than those stated above. I therefore authorize my surgeon, __________, and my
surgeon’s assistants or designees to perform such other procedures that are in the exercise of professional judgment
necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment
and that are not known to my surgeon at the time that the procedure is begun.
4. I consent to the administration of such anesthetics as are considered necessary or advisable. I understand that all
forms of anesthesia involve risk and the possibility of complications, injury, and even death.
5. I acknowledge that no guarantee has been given by anyone with regard to the results that may be obtained from this
procedure.
6. I consent to the photographing of me (head and neck region) before, during, and after surgery. These photographs
may be used by my surgeon for medical, scientific, or educational purposes now and in the future.
7. For the purposes of advancing medical education, I consent to the admittance of observers into the operating room.
8. I consent to the disposal of any body tissues or medical devices that may be removed.
9. THE FOLLOWING INFORMATION HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
• THE PREVIOUSLY DESCRIBED PROCEDURES TO BE UNDERTAKEN
• ALTERNATIVE PROCEDURES AND METHODS OF TREATMENT THAT I HAVE DECIDED AGAINST
• THE SPECIFIC RISKS AND POTENTIAL COMPLICATIONS OF THE PROCEDURES THAT I PLAN TO
UNDERGO
I CONSENT TO THE PROCEDURES AND THE ABOVE LISTED ITEMS (1 THROUGH 9). I AM SATISFIED WITH
THE EXPLANATION GIVEN TO ME.
________________________________________
___________________________
Patient (or Person Authorized to Sign for Patient)
Date
________________________________________
_____________________________
Witness
Date
References
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The growth pattern of the external ear.
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2. Adamson PA, McGraw BL, Tropper GJ:
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3. Barnes WE, Morris FA: Otoplasty: An
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4. Bauer BS, Margulis A, Song DH:
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5. Beam RB: Some characteristics of the
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8. Brown FE, Colen LB, Addante RR, Graham
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CHAPTER 39  Aesthetic Alteration of Prominent Ears: Evaluation and Surgery
12. Dancey A, Jeynes P, Nishikawa H: Acrylic ear
splints for treatment of cryptotia. Plast
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16. Elliott RA, Hoehn JG: Otoplasty for
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17. Elliott RA: Complications in the treatment
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18. Elliott RA: Otoplasty: A combined approach.
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19. Ely E: An operation for prominence of the
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20. Farkas LG: Anthropometry of normal and
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21. Farkas LG, Posnick JC, Hreczko T:
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22. Furnas DW: Correction of prominent ears by
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23. Furnas DW: Correction of prominent ears with
multiple sutures. Clin Plast Surg 5:491, 1978.
24. Furnas DW: Otoplasty for prominent ears.
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25. Gibson TW, Davis W: The distortion of
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26. Goulian D, Conway H: Prevention of
persistent deformity of the tragus and lobule
by modification of Luckett’s technique of
otoplasty. Plast Reconstr Surg 26:399, 1960.
27. Hardingham TE, Muir H: The specific
interaction of hyaluronic acid with cartilage
proteoglycans. Biochim Biophys Acta
279:401–405, 1972.
28. Hinderer UT, del Rio JL, Fregenal FJ:
Otoplasty for prominent ears. Aesthetic Plast
Surg 11:63, 1987.
29. Hirose T, Tomono T, Yamamoto K:
Non-surgical correction for cryptotia using
simple apparatus. In Foneseca J, editor:
Transactions of the 7th International Congress of
Plastic and Reconstructive Surgery, Rio de
Janeiro, 1979, Sao Paulo, Brazil, 1980,
Catgraf.
30. Hirose T, Tomono T, Matsuo K, et al:
Cryptotia: Our classification and treatment.
Br J Plast Surg 38:352–360, 1985.
31. Jeffery SL: Complications following correction
of prominent ears: An audit review of 122
cases. Br J Plast Surg 52:588, 1999.
32. Kaye BL: A simplified method for correcting
the prominent ear. Plast Reconstr Surg 40:44,
1967.
33. Kenny FM, Angsusingha K, Stinson D,
Hotchkiss J: Unconjugated estrogens in the
perinatal period. Pediatr Res 7:826–831,
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34. Klockars T, Rautio J: Embryology and
epidemiology of microtia. Facial Plast Surg
25:145–148, 2009.
35. Kösling S, Omenzetter M, Bartel-Friedrich S:
Congenital malformations of the external and
middle ear. Eur J Radiol 69:269–279, 2009.
36. Kurozumi N, Ono S, Ishida H: Non-surgical
correction of a congenital lop ear deformity
by splinting with Reston foam. Br J Plast Surg
35:181–182, 1982.
37. Lentz AK, Plikaitis CM, Bauer BS:
Understanding the unfavorable result after
otoplasty: An integrated approach to correction.
Plast Reconstr Surg 128: 536–544, 2011.
38. Luckett WH: A new operation for prominent
ear based on the anatomy of the deformity.
Surg Gynecol Obstet 10:635, 1910. Reprinted
in Plast Reconstr Surg 43:83, 1969.
39. Macgregor F: Ear deformities: Social and
psychological implications. Clin Plast Surg
5:347, 1978.
40. Matsuo K, Hirose T, Tomono T, et al:
Nonsurgical correction of congenital auricular
deformities in the early neonate: A preliminary
report. Plast Reconstr Surg 73:38–51, 1984.
41. Matsuo K, La Rusca I, Molea G: Non-surgical
correction of congenital auricular deformities.
Clin Plast Surg 17:383–395, 1990.
42. McDowell AJ: Goals in otoplasty for
protruding ears. Plast Reconstr Surg 41:17,
1968.
43. Merlob P, Eshel Y, Mor N: Splinting therapy for
congenital auricular deformities with the use of
soft material. J Perinatol 15:293–296, 1995.
44. Morestin MH: De la reposition et du
plissement cosmetiques du pavillon de
l’oreille. Rev Orthop 4:289, 1903.
45. Muraoka M, Nakai Y, Ohashi Y, et al:
Tape attachment therapy for correction of
congenital malformations of the auricle:
Clinical and experimental studies.
Laryngoscope 95:167–176, 1985.
46. Mustarde JC: The correction of prominent
ears by using simple mattress sutures. Br J
Plast Surg 16:170, 1963.
47. Mustarde JC: The treatment of prominent
ears by buried mattress sutures: A ten year
survey. Plast Reconstr Surg 39:382, 1967.
48. Mustarde JC: Correction of prominent ears
using buried mattress sutures. Clin Plast Surg
5:459, 1978.
49. Nakajima T, Yoshimura Y, Kami T: Surgical
and conservative repair of Stahl’s ear. Aesthetic
Plast Surg 8:101–107, 1984.
50. Owens N, Delgado DD: The management
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1965.
51. Park C: Correction of cryptotia using an
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52. Posnick JC: Aesthetic alteration of
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maxillofacial surgery in children and young
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45. pp 1143–1153.
53. Reynaud JP, Gary-Bobo A, Mateu J, Santoni
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54. Rigg BM: Suture materials in otoplasty.
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55. Rodriguez-Champs S: Our procedure for
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“first.” Plast Reconstr Surg 42:584, 1968.
57. Rubin LR, Bromberg BE, Walden RH, et al:
An anatomic approach to the obtrusive ear.
Plast Reconstr Surg 29:360, 1962.
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Nonsurgical correction of congenital ear
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Plast Surg 47:575–578, 1994.
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1944.

1746

40
Aesthetic Alteration of the Soft Tissues
of the Neck and Lower Face:
Evaluation and Surgery
JEFFREY C. POSNICK, DMD, MD
• Aging of the Facial Soft-Tissue Envelope
• Approach to Rejuvenation Surgery of the
Neck and Lower Face
• Facial Aging and Rejuvenation: Treatment
Pitfalls
• Conclusions
• Patient Education Materials
Aging of the Facial Soft-Tissue Envelope
Background
The layers of the face encompass the skin; the underlying
soft tissues, including the fat (subcutaneous and deep); the
mimetic muscles (superficial and deep); the investing fascia,
which is known as the superficial muscular aponeurotic system
(SMAS); the retaining ligaments; and the skeletal structural
support system (bones, cartilage, and teeth).4,18 The soft
tissues of the face will naturally descend with age, which
will result in progressive laxity and ptosis of the skin, the
subcutaneous tissue, the fat, and the fascia (i.e., the SMAS–
platysma layer) as well as the retaining ligaments. The facial
fat (subcutaneous and deep) may either atrophy (i.e.,
as a result of resorption) or hypertrophy (i.e., increase in
volume), and it is also affected by gravity over time. Facial
aging is dynamic and cumulative, and it is also affected by
hormonal and degenerative changes in the soft tissues. An
understanding of the pertinent biochemical and histologic
changes that tend to occur in the facial soft tissues with age
and through environmental exposures is an important
aspect to consider when developing a reconstruction and
rejuvenation treatment plan.
Soft-tissue aging is affected by genetic aspects, hormonal
changes, and environmental influences. For some individu­
als, the deeper soft-tissue envelope remains well preserved
while the superficial surface of the skin appears weathered.
For others, the surface skin remains youthful while the
deeper soft-tissue envelope loses structural landmarks with
cutaneous laxity. Extrinsic (environmental) forces that are
working on the skin include dehydration, inadequate nutri­
tion, temperature extremes, traumatic influences, chronic
exposure to strong ultraviolet sunlight, toxins (e.g., cigarette
smoke), and gravity. The intrinsic (genetic) effects have to do
with the individual’s basic soft tissues and their skeletal
morphology.15,73 Environmental (extrinsic) factors primarily
I agree with Fritz Barton when he stated the following: “The
shape of the human face is composed of a skeletal bony
framework that is covered by a soft tissue envelope. Overall,
skeletal proportions are probably the most important com­
ponent of facial attractiveness.”7
In my experience, the absence of an attractive cervical–
mental (neck–mandibular) angle most often is the result
of a developmental mandibular deficiency that predisposes
the affected individual to loose lower cheek and neck
skin, the noticeable bunching of fat in the neck area,
and the eventual presence of visible platysma bands that
worsens and becomes less attractive with age (see Chapters
19, 23, and 25).
This chapter is not intended to be a treatise that
addresses all of the details involved in facial soft-tissue
aging and rejuvenation options. Rather, the discussion
that follows provides perspective concerning the funda­
mental importance of the maxillomandibular skeletal
structures in the aging process of the neck and the
lower face. An approach to the management of the
anterior neck soft tissues in specific clinical settings is
also described.

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CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
result in dysplasia and structural alteration of the dermal
and epidermal layers of the skin, whereas intrinsic (genetic)
effects on the skin may result in atrophy and the loss of
structural dermal and epidermal components.19,20,29,84 An
individual’s hormone levels throughout life are also known
to have significant effects on the aging process.30 Aging is
associated with declining levels of several hormones, and it
is gender dependent. It is known that, in women, declining
estrogen levels are associated with cutaneous changes, many
of which can be reversed or improved via estrogen supple­
mentation. Studies of postmenopausal women indicate that
estrogen deprivation is associated with dryness, atrophy, fine
wrinkling, poor healing, and hot flashes.30,60 Epidermal
thinning, declining dermal collagen content, diminished
skin moisture, tissue laxity, and impaired wound healing
have been reported among postmenopausal women. The
soft-tissue effects of changing hormonal levels with age in
males are less well studied but presumed to be of equal
importance. The cumulative intrinsic (genetic) effects on the
skin can be seen histologically as epidermal thinning,
changes in the morphology of the keratinocytes, and a
decrease in the number of Langerhans cells and melano­
cytes. Environmental (extrinsic) aging effects on the skin
result in keratinocytic dysplasia and the accumulation of
solar elastosis, and they can result in cutaneous carcinogen­
esis (e.g., basal cell carcinoma, melanoma, squamous cell
carcinoma).
All individuals experience some degree of both extrinsic
(environmental) and intrinsic (genetic) aging simultane­
ously (Fig. 40-1). The genetic variability of an individual’s
skeletal framework and the degree and pace of soft-tissue
aging in each tissue layer makes a uniform template for
facial rejuvenation impractical. Visually, as the intrinsic and
extrinsic aging of the skin progress, there will be pigmentary
abnormalities, wrinkles (rhytids), and texture irregularities
that may result in a “weathered” appearance. Current think­
ing about aging also involves the concept that the gain or
loss of fat volume within the deep compartments leads to
changes in the shape and contour of the face.20 By contrast,
soft-tissue folds occur at the transition points between the
thicker and thinner superficial fat compartments. The tran­
sition points cause nasolabial folds, labiomental folds, sub­
mental creases, and preauricular folds.65,67 In the upper third
of the face, around the eyes, researchers have found that
suborbicularis oculi fat is composed of two distinct ana­
tomic compartments: the medial limbus and the lateral
canthus region. These researchers have also confirmed that
the lateral suborbicularis oculi fat extends from the lateral
canthus to the lateral orbital thickening.7 The deep medial
cheek fat is the most medial of the periorbital deep fat
compartments.51 In current clinical practice, periorbital
rejuvenation relies more on soft-tissue augmentation and
rearrangement than on tissue removal. In the midface, pro­
gressive skin laxity is often combined with the resorption of
subcutaneous fat and gravitational effects to result in char­
acteristic changes in the soft-tissue envelope.65 In the lower
third of the face, there may be ptosis of the chin soft tissues,
a loss of the delineation between the jawline and the neck,
the development of characteristic jowls, and looseness in the
neck skin (which, in the extreme, is characterized as resem­
bling a “turkey gobble”). In many individuals, prominent
vertical platysma bands develop in the submental region,
and there is often fat hypertrophy in the submental and
submandibular regions. These aging effects further hide or
eliminate an otherwise attractive and youthful neck–jaw
angle.
Frequent Soft-Tissue Facial
Aging Characteristics
• Forehead (horizontal) and glabellar (vertical) creases
• Ptosis (drooping) of the lateral eyebrows
• Redundant upper eyelid skin
• Lower eyelid laxity and wrinkles
• Lower eyelid (puffy) visible bags
• Deepening of the nasojugal grooves and the palpebral
malar grooves
• Ptosis (drooping) of the malar soft tissues
• Generalized facial skin laxity*
• Deepening of the nasolabial folds*
• Jowl formation*
• Loss of neck definition (neck–jaw angle) and excess fat
collection (hypertrophy) in the neck*
• Deep platysmal bands that are visible in repose and often
more obvious with function (e.g., facial expression)*
• Perioral wrinkles
• Downturn of the oral commissures
• Deepening of the labiomental creases
*These are facial soft-tissue aging characteristics that may be more or less
improved through traditional face and neck lift techniques.
Basic Principles of Midface and Neck Aging
and Rejuvenation
Achieve Facial Harmony
The goal is to help the individual look more like the way
they used to look rather than severe, operated on, or unnat­
ural.44,79,94,95 The recognition of any longstanding maxil­
lomandibular skeletal disharmonies is essential to the
achievement of enhanced facial aesthetics. If the surgeon
attempts to ignore baseline skeletal deformities and then
overcompensates with excessive soft-tissue maneuvers, the
outcome is likely to be suboptimal. Amateurish or overdone
face lifts often look excessively taut, radically defatted, or
overfilled (e.g., fat grafts, artificial fillers), or they may
involve irregularities from deep layer soft-tissue manipula­
tion. The “overoperated” face may also look startling and
unnatural from too much soft-tissue surgical alteration in
just one region or layer of the face while ignoring the others.
The entire face and all of its layers should be analyzed and
given consideration before focusing on just one aspect or
technique for rejuvenation.

1748 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 40-1  A 46-year-old woman first ar­
rived for the surgical assessment of a long­
standing bony mass in the left forehead
region. She underwent a computed tomogra­
phy scan that confirmed an osteoma without
intracranial involvement. She elected to not
undergo biopsy, recontouring, or removal at
that time. She returned 13 years later, when
she was 59 years old, to discuss facial aging.
Her concerns included webbing (platysma
bands) and loose skin of the neck; heavy
jowls; marionette lines; deep nasolabial folds;
puffiness and irregularities of the lower eye­
lids; hollowing in the temporal and cheek re­
gions; deepening of the labiomental crease;
and vertical wrinkles of the upper lip. She had
undergone Restylane injections of the nasola­
bial folds, the marionette lines, the labiomental
crease, and the lower eyelids with another
clinician but without satisfactory improve­
ment. She also had a short face growth
pattern (i.e., maxillomandibular deficiency).
During her teenage years, she had undergone
camouflage orthodontic treatment that in­
cluded upper bicuspid extractions to achieve
a neutralized occlusion. There was no dental
show with the upper lip in repose. With broad
smile, only half of the maxillary incisors were
visible. The upper lip appeared to have length­
ened slightly, and the lips appeared to be
more deflated (as compared with images
taken when the patient was 46 years old). She
stated that she received frequent comments
about looking “sad” or “unhappy.” She had a
history of an inability to breathe well through
the nose, loud snoring, restless sleeping, and
excessive daytime fatigue. An attended poly­
somnogram was carried out and confirmed
obstructive sleep apnea, with a respiratory
disturbance index of 24 events/hour with de­
saturations of up to 85%. A comprehensive
approach to improve dental health, open the
upper airway, and enhance facial aesthetics
was planned (see Chapters 23 and 25).
A, Frontal facial views at 46 and 59 years of
age. B, Oblique facial views at 46 and 59
years of age. C, Profile facial views at 46 and
59 years of age.
C
46 years of age
59 years of age
©Elsevier Inc.
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©Elsevier Inc.
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A
B

1749
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
possibly resurfacing procedures (e.g., dermabrasion, chemi­
cal peel, laser). Preventative measures of avoiding excessive
ultraviolet light exposure, cigarette smoke, temperature
extremes, dehydration, and nutritional deficiencies are
important.
Recognize the Negative Effects of Any Baseline
Maxillomandibular Skeletal Disharmony
Significant variation occurs in the aging of each individual’s
face and neck. Recognition that the shape of the neck is
fundamentally determined by the maxillomandibular skel­
eton is essential (Figs. 40-1 through 40-4).13,16,24,32,69,71,93 The
ideal neck configuration requires a well-proportioned facial
skeleton; it is often described as having a cervical–mental
(neck–jaw) angle of 105 to 120 degrees and a distinct man­
dibular inferior border. Interestingly, despite various asser­
tions and opinions by a handful of authors, in the absence
of a loss of the teeth or significant alteration of the dentition
through either natural attrition or dental restorative proce­
dures, no convincing data confirms significant changes in
the maxillofacial skeleton with aging (see Chapter 25).*
Approach to Rejuvenation Surgery of
the Neck and Lower Face
Traditional Face-Lift Approach to Rejuvenation
Face lifting was first performed during the early 1900s and
involved skin incisions around the ears, limited skin-flap
undermining, and then skin excision before wound closure.
In 1859, Gray defined a unique deep layer of tissue just
below the facial skin that was described as “superficial sub­
cutaneous fascia.” Not much changed until the 1970s, when
both Tessier and Skoog independently described the aes­
thetic benefit of manipulating this superficial subcutaneous
fascia as a separate component during face lifting for reju­
venation purposes. The superficial subcutaneous fascia was
recognized as investing the platysma muscles and fusing to
the parotid fascia as the facial extension of the cervical
investing fascia. It later came to be called the superficial
muscular aponeurotic system or SMAS, as mentioned previ­
ously.48 The SMAS envelopes the platysma muscles within
the neck and the lower cheek region. Superiorly, it termi­
nates as the investing layer of the superficial mimetic
muscles. Laterally, it fuses with the parotid capsule. Superi­
orly, it passes over the zygomatic arch to join the temporo­
parietal fascia. Tessier and Skoog were the first to include as
part of the face-lift technique not just the undermining and
excision of the skin but also the management of the so-called
SMAS–platysma layer. This required unique incisions,
undermining, redraping, and tightening of the SMAS–
platysma as part of the face-lifting procedure. Since the
initial contributions of Tessier and Skoog, every conceivable
recommendation has been made by surgeons for dissecting,
Achieve Volume Redistribution rather than Skin Tension
Throughout the body, the soft tissues external to the skel­
eton are anchored to the bony framework by osseocutane­
ous ligaments that pass directly from the dermis to the
periosteum in bare areas where there are no muscles that
separate them.22,39,49,62,63,67,80 The most prominent of these
retaining ligaments in the head and neck are in the cheek
and along the lateral border of the mandible. The retaining
ligaments that partition the cheek fat from the neck are
called the mandibular septum. A face lift that simply under­
mines the cheek soft tissues followed by excessive skin resec­
tion and then wound closure under tension does not
simultaneously manage the deeper soft tissues. Therefore, in
these circumstances, skin undermining and resection alone
will rarely achieve an attractive or youthful face. This limited
“skin-only” approach to face lifting with excessive skin
resection may also lead to unsightly scars, flap necrosis, or,
more commonly, distortions of key landmarks with the loss
of the natural facial curvatures. The use of face-lift tech­
niques that also modestly redistribute the deep soft-tissue
layers (i.e., the SMAS–platysma layer) in combination with
conservative skin removal and relaxed wound closure will
often result in the more pleasing contours that are associated
with a youthful and attractive appearance.
Recognize the Presence of Fat Atrophy and Hypertrophy
The process of aging involves not only gravitational effects
on the soft tissues and degenerative changes of the skin but,
in many cases, noticeable soft-tissue volume loss (deflation)
through the atrophy (resorption) of the fat.10,29,42,66,68,70,72,81
Frequent visual effects of descent in the face include the
deepening of the nasolabial folds, ptosis of the malar portion
of the superficial fat, and the accumulation of fat in the
jowls. The classic effects of deflation are seen most fre­
quently in individuals who have had lifelong thinness of the
face. The fat atrophy in these individuals is often visually
seen in the temporal fossa, periorbital, buccal, and perioral
regions. In other individuals, a pattern of simultaneous face
and neck fat hypertrophy as a result of weight gain will
occur with age. To avoid an amateurish face lift, a good
general rule for the surgeon to follow is to only cautiously
remove any fat above the inferior border of the mandible
and to be sure that an appropriate amount of fat is removed
below the mandibular inferior border. Although adding fat
to atrophied regions of the face is beneficial in principle, in
many individuals, the long-term success of these techniques
(i.e., autogenous fat grafting or the use of artificial fillers)
to achieve a natural-appearing rejuvenation remains a work
in progress.10
Recognize Degenerative Changes in the Skin
Face lifting will address gravitational changes in the soft-
tissue envelope, but it does not have an effect on the quality
of the soft tissues themselves.60,85 Face-lift procedures will
not treat wrinkles (rhytids), sun damage, creases, or age-
related pigmentation. If feasible, fine wrinkles and irregular
pigmentation are treated with good-quality skin care and
*References 6, 14, 17, 33, 37, 38, 40, 44, 45, 51-57, 64, 74, 75.
Text continued on p.1754

•  Figure 40-2  A woman in her mid 50s was referred from her general dentist to an orthodontist for the management of a longstanding Angle
Class II excess overjet malocclusion that had gradually resulted in deterioration of the posterior dentition. The orthodontist recognized that the
malocclusion resulted from a retrusive mandible and a constricted maxilla. With referral for surgical evaluation, the patient was found to have a
developmental jaw deformity, chronic obstructed nasal breathing, and a sleep history that was consistent with obstructive sleep apnea. Unfavorable
facial aging with a desire for an improved neck–chin angle was also discussed. An attended polysomnogram confirmed moderate obstructive sleep
apnea. The patient agreed to proceed with orthodontic treatment that included lower first bicuspid extractions to relieve dental compensation in
combination with jaw, intranasal, and facial surgery. The objectives were to open the upper airway, enhance the facial aesthetics, and achieve
improved long-term dental health. The patient’s surgical procedures included maxillary Le Fort I osteotomy in segments (horizontal advancement,
counterclockwise rotation, arch expansion, and correction of the curve of Spee); bilateral sagittal split ramus osteotomies (horizontal advancement
and counterclockwise rotation); osseous genioplasty (horizontal advancement); anterior approach to the soft tissues of the neck (cervical flap eleva­
tion, neck defatting, and vertical platysma muscle plication); and septoplasty and inferior turbinate reduction (see Fig. 25-1). A, Profile views before
and after reconstruction. Note the improved A-point–to–B-point relationship that was achieved as a result of maxillomandibular counterclockwise
rotation. B, Articulated dental casts that indicate analytic model planning. C, Lateral cephalometric radiographs before and after surgery. Note the
improved posterior airway space with pharyngeal expansion as a result of the orthognathic procedures.
B
C
Arch expansion
Mandibular counter-
clockwise rotation
Pharyngeal
airway expansion
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A
B
•  Figure 40-3  A woman in her early 50s was referred by a prosthodontist for surgical evaluation. There had been a gradual deterioration of the
dentition, at least partially as a result of the longstanding skeletal Class II excess overjet deep-bite malocclusion. Head and neck evaluation con­
firmed a retrusive mandible that also resulted in retroglossal airway obstruction. A desire for improved profile aesthetics was also discussed. A
comprehensive approach to dental rehabilitation, opening the upper airway, and facial rejuvenation and reconstruction was selected. Coordinated
endodontic, orthodontic, periodontic, prosthodontic, and surgical care was required. Periodontal treatment, extractions, dental implant placement,
restorative temporization, and orthodontic alignment were carried out. This was followed by surgery that included bilateral sagittal split ramus
osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical lengthening) with interpositional grafting; and
an anterior approach to the soft tissues of the neck (cervical flap elevation, neck defatting, and vertical platysma muscle plication). This was then
followed by crown lengthening and final dental restorations (see Fig. 25-6). A, Profile views before and after reconstruction and dental rehabilitation.
B, Oblique facial views before and after reconstruction and dental rehabilitation.
Continued

1752 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
C
D
Fully temporized
prior to surgery
12 mm advancement
and counterclockwise
rotation*
C, Articulated dental casts that indicate analytic model planning. D, Lateral cephalometric radiographs before and after
reconstruction.
• Figure 40-3, cont’d

1753
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
Orth
r ognathic Surg
r ery; J.C. Posnick
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r ery; J.C. Posnick
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r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
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A
B
•  Figure 40-4  A woman in her mid 50s was seen by a prosthodontist for the management of a deteriorating posterior dentition. She was con­
firmed to have secondary dental trauma as a result of a longstanding malocclusion. She was referred to an orthodontist and then for surgical
assessment. Head and neck evaluation confirmed a short face growth pattern with a Class II excess overjet deep bite and constricted maxillary
arch malocclusion. She had a lifelong history of obstructed nasal breathing, and her history was suggestive of obstructive sleep apnea (this was
confirmed with an attended polysomnogram). Facial aesthetic concerns included downturned corners of the mouth, deep perioral creases, early
jowl formation, weak profile, an obtuse neck–chin angle, and loose skin around the neck. The patient agreed to a comprehensive surgical and
dental rehabilitative approach. Periodontal evaluation, initial restorations, and orthodontic decompensation preceded surgery. The patient’s surgical
procedures included maxillary Le Fort I osteotomy (horizontal advancement, counterclockwise rotation, and vertical adjustment); bilateral sagittal
split osteotomies of the mandible (horizontal advancement and counterclockwise rotation); osseous genioplasty (horizontal advancement); an
anterior approach to the neck (cervical flap elevation, neck defatting, and vertical platysma muscle plication); and septoplasty, inferior turbinate
reduction, and nasal recontouring (see Fig. 25-7). A, Oblique facial views before and after treatment. B, Profile views before and after treatment.
Continued

1754 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
C
D
Maxillary counter-
clockwise rotation
Nasopharyngeal
airway expansion
12 mm advancement
counterclockwise
rotation
C, Articulated dental casts that indicate model planning. D, Lateral cephalometric radiographs before
and after treatment. Note the improved posterior airway space with pharyngeal expansion as a result of the orthognathic
procedures.
• Figure 40-4, cont’d
undermining, excising, adding to, or removing virtually all
of the tissue layers and cell types in the head and neck to
further enhance the aesthetic outcome.2-5,8,18,21,31,47,50,59,77,78
Many of the “innovations” in the area of face lifting have
proven to have little additional long-term value, and some
have resulted in increased complications and prolonged
recoveries. This was confirmed by Chang and colleagues in
a recently completed systematic review and comparison of
efficacy and complication rates among a variety of face-lift
techniques. The authors conclude that there are pros and
cons to each of a variety of face-lift techniques and that
there is no clear evidence that one is routinely superior to
another.9
A well-designed traditional face lift often confers much
benefit to the jowls (i.e., the mandibular line) and the neck
(Figs. 40-5 through 40-10). It can be an effective way to
soften the nasolabial folds, to lift the jowls back into the
face, to relieve the platysmal bands, to remove the loose skin
and excess fat of the neck, and to restore the neck–jaw angle
back to its baseline. This can change the overall facial shape
from rectangular back to that of a heart in a way that no
other soft-tissue treatment modality can provide. The basic

1755
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
•  Figure 40-5  A woman in her early 50s arrived for the evaluation of facial aging. She had satisfac­
tory skeletal proportions and no significant surface skin layer aging effects. She requested surgery to
diminish her jowls, to soften her nasolabial folds, and to reduce the amount of loose skin in her neck
region. She underwent a face lift that included periauricular and submental incisions; cheek and neck
flap elevation; superficial musculo-aponeurotic system flap elevation with postauricular transposition;
neck defatting; vertical platysma muscle plication; and skin resection and redraping. Asymmetric upper
eyelid ptosis was not addressed. A, Oblique facial views before and after surgery. B, Profile views
before and after surgery.
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osnicicicicicicicicicicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatathicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
osnicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicicicicicicicicicicicicicick
A
B
traditional face-lift approach requires the consideration of
the following:
• Skin incision placement (i.e., preauricular with tempo­
ral extensions and postauricular with occipital
extensions)
• Skin flap elevation and undermining (i.e., temporal,
cheek, postauricular, neck, and submental regions)
• Supraplatysmal, intraplatysmal, and subplatysmal defat­
ting (e.g., below the inferior border of the mandible
and chin, above the thyroid cartilage, and anterior to
and above the sternocleidomastoid muscles)

1756 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
A
•  Figure 40-6  A 50-year-old woman arrived for the evaluation of facial aging. She has satisfactory skeletal proportions and minimal skin surface
layer aging effects. She underwent a limited incision brow lift with suspension; blepharoplasty (elliptical excision of the upper eyelid skin and redrap­
ing of the lower lid tissue); and a face lift as described in the legend for Fig. 40-5. A, Oblique facial views before and after surgery. B, Profile views
before and after surgery.

1757
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
•  Figure 40-7  A woman in her late 50s
arrived for the evaluation of facial aging.
She had satisfactory skeletal proportions
but marked surface layer aging effects.
She elected to not undergo skin resurfac­
ing procedures. She agreed to a limited
incision brow lift with suspension, blepha­
roplasty (elliptical excision of the upper
lid skin and lower lid redraping), and a
face lift as described in the legend for
Fig. 40-5. A, Frontal views before and
after surgery. B, Oblique facial views
before and after surgery. C, Profile views
before and after surgery.
C
Or
Or
Or
Or
Or
O thththth
r ogn
gn
gn
gnatatathicicicicicic Su
Su
Su
S rg
r ery
ry
ry
ry
r ; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
osnicicicicicicick
Or
Or
Or
O ththth
r ogn
gn
gn
g atatathicicicici Su
Surg
r ery
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C. Pos
os
os
os
osnicicick
Or
Or
Or
Or
Or
Or
Or
Orthththththththtr ogn
gn
gn
gn
gn
gn
g atatatatatatatatathicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry; J.C.
C.
C Pos
o nicick
Or
Or
Or
Or
Or
Or
O thththththththth
r ogn
gn
gn
gn
gn
g atatatata hicicicicic Su
Su
Su
Su
Surg
r ery
ry
ry
ry
r ; J.C.
C.
C.
C.
C.
C.
C.
C Pos
os
o nicicicicicicick
Or
Or
Or
Or
Or
Or
O ththththththtr ogn
gn
gn
gn
gn
gnatatatathicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
r ; J.C.
C.
C.
C Pos
os
os
o nicicici k
Or
Or
Or
Or
O thththththth
r ogn
gn
gn
gn
g atatathicicic Su
Su
Su
S rg
r ery
ry
ry
ry
ry
r ; J.C.
C.
C Pos
os
os
os
osnicicicicicici k
A
B

1758 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 40-8  A woman in her early 40s requested an improved neck–chin angle and the relief of
hooding of the upper eyelids. She had a short face growth pattern that resulted in mildly deficient
lower anterior facial height and horizontal facial projection. She had a good airway and occlusion.
There was limited surface skin layer damage and aging effects. She underwent upper blepharoplasty
(elliptical skin incision) and a face lift as described in the legend for Fig. 40-5. A, Oblique facial views
before and early after surgery. B, Profile views before and early after surgery.
Or
Or
Or
Or
Or
Orthththththththththththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
o nicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
o nicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicicicicicicicick
A
B
• Platysma muscle management (i.e., vertical plication
versus the excision of bands)
• SMAS management (i.e., preauricular SMAS plication
versus SMAS elevation with postauricular flap
transposition)
• Redraping of the elevated skin flaps (i.e., in a supero­
posterior vector)
• Excision of redundant skin (e.g., temporal, preauricu­
lar, postauricular, occipital)
• Wound closure under minimum tension
Anterior Neck (Submental) Approach
to Rejuvenation
Background
Changes that occur in the neck with age can alter the
natural youthful facial curvatures and angles.* As people
age, characteristic changes tend to occur in the skin
and throughout the soft-tissue envelope. Soft-tissue
*References 12, 18, 23, 25-27, 34-36, 41, 46, 61, 83, 94, 95

1759
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
•  Figure 40-9  A woman in her early 50s with facial aging concerns. She had a mild long face growth
pattern but a satisfactory occlusion. The lower anterior facial height was slightly increased, which
resulted in mild lip incompetence and mentalis strain; this resulted in accentuated perioral creases.
She agreed to blepharoplasty (elliptical excision of the upper lid skin and redraping of the lower lid
tissue); osseous genioplasty (vertical reduction and horizontal advancement); and a face lift as
described in the legend for Fig. 40-5. A, Frontal views before and after surgery. B, Profile views before
and after surgery. Note the relief of the perioral folds and the mentalis strain as a result of vertical
reduction and advancement genioplasty.
Or
Or
Or
Or
Orthththththth
r ogn
gn
gn
gn
gn
gn
gn
g atatatatathicicicicicic Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
o nicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththtr o n
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatathicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
osnicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatathicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
osnicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
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A
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rejuvenation procedures that focus on the neck often include
the following: 1) cervical flap elevation; 2) the selective
removal of fat (above, in between, and below the platysma
muscles); 3) the tightening of the platysma muscles (in
the neck midline); and 4) the redraping of lax skin (i.e.,
skin retraction). In the presence of well-proportioned
(harmonious) maxillomandibular skeletal structures, the
combination of these procedures can generally be carried
out to achieve a preferred geometric angle between the
cylin­drical neck and the straight-line inferior border of
the jaw.12,18,23,25-27,34-36,41,46,61,83,94,95
Aging of the neck often presents in one of two classic
ways; it is primarily a reflection of the underlying skeletal
anatomy. One common pattern is what appears to be a long
neck with a sharp neck–jaw angle. This occurs in an indi­
vidual with preferred proportions and fullness of the jaws.
With aging, these patients may develop visible platysmal
bands but with the maintenance of a reasonable neck–jaw
angle and chin projection. A second common pattern of
presentation is seen in individuals with what appears to be
a short neck and a poorly defined neck–jaw angle. This is the
result of a baseline mandibular deficiency (e.g., combined

1760 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
•  Figure 40-10  A woman in her late 50s arrived for the evaluation of facial aging. She had satisfactory skeletal proportions and occlusion.
Her skin was thick but did not have major ultraviolet light damage. She agreed to a limited incision brow lift with suspension; blepharoplasty (ellipti­
cal excision of the upper eyelid skin and fat removal and redraping from the lower lids); and a face lift as described in the legend for Fig. 40-5.
A, Frontal views in repose before and after rejuvenation. B, Frontal views with smile before and after rejuvenation.

1761
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Oblique facial views before and after rejuvenation. D, Profile views before and after rejuvenation.
• Figure 40-10, cont’d

1762 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
maxillomandibular deficiency, primary mandibular retrog­
nathia, or a long face growth pattern with sagittal deficiency
and clockwise rotation of the maxillomandibular complex;
see Figs. 40-2, 40-3, and 40-4). Individuals with this type
of neck experience facial aging prematurely and in a more
detrimental way. In the presence of sagittal deficiency of the
mandible, when any degree of neck soft-tissue laxity occurs
and even with small amounts of submental and suprapla­
tysmal fat accumulation, further loss of the clear separation
between the chin and neck (i.e., an obtuse neck–jaw angle)
can be expected. Skeletal (orthognathic) procedures to
reconstruct the jaws toward Euclidean proportions will have
a dramatic positive effect on the facial aging of this latter
group of individuals (see Figs. 40-2, 40-3, and 40-4). Com­
pleting traditional face and neck soft-tissue lifting proce­
dures alone in the presence of a deficient maxillomandibular
skeletal framework can be disappointing and, in some cases,
disastrous. The surgeon should view the overlying soft-
tissues as just the icing on the cake and not as the cake itself.
The failure to recognize these anatomic realities is respon­
sible for much clinician frustration and many suboptimal
“face-lift” results.
A fundamental clinical observation is that the visual
appearance of aging in the neck is greatly influenced by the
baseline maxillomandibular skeletal anatomy. The ideal
horizontal mandibular plane relative to the vertical cylindri­
cal neck (i.e., an angle of 105 to 120 degrees) will abnor­
mally slump downward and backward when the mandibular
skeletal framework is deficient and clockwise rotated (i.e.,
long face growth pattern; see Chapter 21).
An example of the negative effects of the skeleton on the
soft-tissue surface anatomy is seen in the presence of primary
mandibular deficiency with excess overjet (see Chapter 19).
Not only will the lower lip be flaccid with a deep labiomen­
tal fold (curl), but the soft tissues directly over the bony
chin are bunched and ptotic, and the soft-tissue structures
of the neck are cramped together to result in a double (soft-
tissue) chin. In the presence of mandibular deficiency, the
chin seems to fall directly into the neck without any sem­
blance of a normal “right-angle” curvature (see Fig. 40-2, A
and B).
When both the maxilla and the mandible lack vertical
height and horizontal projection (i.e., short face growth
pattern; see Chapter 23), the cheeks often appear to be puffy.
There will be deep nasolabial folds, heavy jowls, perioral
creases, and downturned oral commissures that compound
the negative effects of the observed obtuse neck–jaw angle.
The deficient maxillo-mandibular skeletal anatomy seen
in the adult, as described above, will have been present since
the teenage years; however, it appears to be more aestheti­
cally objectionable with aging as the overlying soft tissues
progressively lose tone and become lax.
Patient Selection
The best candidates for a neck lift through a limited submen­
tal incision are those with a harmonious and proportionate
maxillomandibular skeleton and those who do not require
or request soft-tissue rejuvenation above the mandibular
border or angle. A thorough evaluation by the surgeon fol­
lowed by a realistic discussion with the patient is required
to clarify these issues. To avoid an unhappy patient after
surgery, any limitations of an anterior (submental) neck-lift
approach should be clarified in advance.
Appropriate patient selection (i.e., for a traditional face
lift versus an anterior submental neck lift) is based primarily
on the degree of skin laxity. Zins proposed a useful grading
scale for neck skin laxity: Grade I (no laxity); Grade II (mild
laxity); Grade III (moderate laxity); and Grade IV (severe
laxity)95:
Grade I patients may only require closed liposuction.
However, even Grade I patients frequently benefit
from an open approach to fully access and then
remove subplatysmal fat.
Grade II patients are good candidates for an anterior
(submental) approach to neck rejuvenation. Their
limited lax skin should be expected to retract in a
favorable way.
Grade III patients can often be managed with an anterior
(submental) approach to the neck. They will require
wide cervical flap elevation with meticulous attention
to release all septae and ligaments to achieve maximum
skin retraction and to avoid unfavorable visible irregu­
larities after surgery. Full disclosure with regard to the
limitations of an anterior neck lift and the setting of
realistic expectations are especially relevant for the
Grade III patient to avoid later disappointment.
Grade IV patients are not good candidates for an anterior-
only approach to the neck and should be considered
for a traditional face lift. Unless skin is excised (i.e.,
with a traditional face-lift approach), residual laxity
will provide a suboptimal result.
Cervical Flap Elevation and Neck Defatting
Some teenagers and young adults and many middle-aged
adults benefit aesthetically from neck defatting.1 The fat
removal is typically carried out in the region below the
inferior border of the mandible, above the thyroid cartilage,
and anterior to the sternocleidomastoid muscles. Whether
by liposuction, direct scissors excision, or a combination of
the two the objective is to remove appropriate adipose cells
deep to the skin and superficial to the platysma muscles.
Below the chin in the midline, where there is a tendency for
the separation of the platysma muscles, excess fat also fre­
quently accumulates. If the platysma muscles are in continu­
ity (i.e., if there is no dehiscence), then surgical separation
is required to expose the excess submental fat for removal.
Closed neck liposuction without skin-flap undermining
is preferentially carried out only in those patients with no
skin laxity and minimal excess neck fat and who do not
require platysma separation to remove submental fat. This
situation is more commonly seen in teenagers and young
adults. In all other patients, cervical flap elevation is com­
pleted first.

1763
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
cartilage as well as intraplatysmal and subplatysmal defatting
below the chin as described previously.
After cervical flap elevation and appropriate defatting,
the medial border of each platysma muscle is identified
and joined in the midline with the use of a series of
interrupted sutures. The vertical platysma plication extends
from just above the thyroid cartilage to approaching the
bony chin. Some surgeons prefer a continuous running
suture; however, this author believes that such a suture
is more likely to result in vertical ridging. As long as
the lateral cervical investing fascia remains reasonably
tight, elevation of the neck sling can be accomplished
through this anterior (submental) approach, without the
need for a simultaneous traditional face lift (i.e., preau­
ricular and postauricular incisions, cheek flap elevation,
lateral SMAS tightening, and skin excision). Nevertheless,
a traditional face-lift approach remains the best way to
maximize neck tightening, because skin removal is also
possible.
The anterior (submental) neck approach is preferred to a
traditional face lift in individuals with reasonable skin elas­
ticity who are not overly concerned about the aging of their
cheek region (i.e., aging of the jowls and the nasolabial
folds). An anterior submental approach will not satisfy indi­
viduals who need and expect improvements in the frontal
view (i.e., a reduction of the jowls, a softening of the naso­
labial folds, and the management of the malar and eyelid
regions) or in those with moderate or greater degrees of neck
skin laxity.94,95
Anterior Neck (Submental) Approach: Step-By-Step
Surgical Technique (Fig. 40-11) (
Video 16)
Positioning on the Operating Room Table
• Place the patient supine on the operating table with his
or her head on the Mayfield horseshoe in the neutral
neck position.
Anesthesia
• When the procedure is carried out in conjunction with
orthognathic surgery, general anesthesia is administered
through a nasotracheal cuffed (RAE) tube. The nasotra­
cheal tube will already have been secured to the cartilagi­
nous septum with suture (#0 Ethibond).
• The application of ophthalmic eye ointment and the
insertion of corneal shields deep to the eyelids will also
already have been performed.
Medications
• Administer intravenous antibiotics (Cefazolin 17 mg/
kg/dose, max: 1 gm).
• Administer steroids via an intravenous bolus (Dexameth­
asone 0.5 mg/kg/dose, max: 8 mg).
Preparation and Draping
• After the completion of the orthognathic procedures
(including the removal of the throat pack and the place­
ment of interocclusal elastics), the patient is reprepped,
Generally, the cervical skin undermining extends up to
the inferior border of the mandible and chin, laterally to
and over the surface of the sternocleidomastoid muscles,
and inferiorly past the thyroid cartilage toward the clavicles.
In those with only moderate skin laxity, adequate release of
all cutaneous septae and cutaneous ligaments will generally
allow for skin contracture during healing without the need
for skin resection. After surgery, skin irregularities and adhe­
sions will persist if inadequate undermining was accom­
plished. A second procedure would then be required to
complete the undermining. The surgeon should also avoid
uneven fat removal and excessive defatting in the neck,
because this can result in contour irregularities between the
skin and the platysma muscles. Ptotic submandibular sali­
vary glands may also affect an otherwise satisfactory result.
This author does not favor either partial submandibular
gland resection or intracapsular gland dissection and repo­
sitioning, because the incidence of associated complications
is high.28,76,82 Close to the midline and just below the chin,
overaggressive fat removal may result in an unnatural con­
cavity, which is a stigma of an amateurish cervical defatting.
In some cases, prominent hypertrophy digastric muscles
may benefit from “shaving” (i.e., scissors excision) in the
region just below the chin.11
Management of the Platysma Muscles
and Cervical Fascia
The platysma muscles are enveloped by the cervical investing
fascia on each side. The muscles run from just over the
inferior border of the mandible (i.e., the lower cheek) and
down to and over the clavicles across the curve of the neck.
With contracture, the muscle fibers shorten and bowstring
(i.e., form vertical bands) away from the midline of the
neck. This bowstringing tendency is restrained by the cervi­
cal investing fascia. In most individuals, the thin midline
cervical fascia tends to attenuate with age; this explains the
fascial dehiscence with a pulling away of the platysma
muscle on each side from the neck midline that is observed
later in life. Initially, bowstrings are only present with active
contraction; eventually, however, passive platysmal banding
is observed.
A platysmaplasty can be a useful component of neck
rejuvenation. Through a 3- to 4-cm incision that is made
adjacent to a natural submental crease, subcutaneous under­
mining is performed that allows for the separation of the
neck skin from the platysma muscles. The extent of cervical
flap elevation should be dependent on the degree of skin
laxity. Even after flap elevation, there are limits to the skin’s
ability to redrape during healing without irregularities or
residual laxity. Those with greater skin laxity (i.e., Grade IV
patient and some Grade III patients) are not good candi­
dates for an anterior (submental) neck approach, as dis­
cussed earlier in this chapter.
Most individuals who require platysmaplasty will also
benefit from neck region fat removal being carried out
simultaneously. This includes supraplatysmal defatting out to
the sternocleidomastoid muscles and down to the thyroid

1764 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 40-11  Illustrations that demonstrate the anterior (submental) approach for neck rejuvenation as described in the text. A, Illustration of
the neck region in the operating room in preparation for an anterior (submental) rejuvenation procedure. The submental incision is marked. A knife
(no. 15 blade) is used to initiate the skin incision. Important underlying landmarks are indicated, including the thyroid cartilage; the sternocleido­
mastoid muscle on each side; the platysma muscles with central dehiscence; and the accumulated fat. B, Illustration that demonstrates the elevation
of the cervical flaps after the completion of the submental incision. Instruments that are in place include double skin hooks with one at each side
of the submental wound. The assistant’s hands are positioned over the clavicle to provide counter tension to the double hook located at the sub­
mental incision. In this way, the neck skin in the region of the cervical flap elevation is taut. A Stevens scissors is then used to complete the dis­
section in the exact location where the neck skin is placed under tension. The green shaded area indicates the extent of planned supraplatysma
dissection for cervical flap elevation. C, Illustration after cervical flap elevation that demonstrates liposuction in progress. A no. 7 curved plastic
cannula is used in the supraplatysma plane laterally and in the subplatysma in the midline below the chin. D, Illustration that demonstrates vertical
platysma muscle plication in progress. A lighted retractor is in place to provide exposure for the direct visualization of the platysma muscle dehis­
cence. The surgeon uses a long needle driver and a long forceps to place interrupted sutures (3-0 Vicryl) for the achievement of vertical platysma
muscle plication. There is also a close-up illustration of the wound with a lighted retractor in place. The long forceps elevates the edge of the
platysma muscle on the right side. A needle driver is used to place a suture through the elevated platysma edge. Several interrupted sutures are
already in place from just above the thyroid cartilage.
A
B
C
D

1765
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
• The lighted retractor is also used to confirm adequate
hemostasis. A guarded electrocautery device is used to
control any bleeding vessels.
Defatting Above, in Between, and Below
the Platysma Muscles
• Supraplatysma defatting is carried out via open liposuc­
tion with the use of a no. 7 curved plastic cannula.
• With the use of a lighted retractor under direct vision,
any remaining clumps of fat are extracted via either
liposuction or sharp scissors removal.
• If the platysma muscles are intact (i.e., without dehis­
cence), they are separated in the midline just below the
chin to expose the submental fat pad.
• Subplatysmal fat is removed with the use of open lipo­
suction via a no. 7 curved plastic cannula or sharp scis­
sors excision.
• In the interdigastric space, fat is removed or resected to
be flush with the anterior digastric bellies.
• If there is prominent elevation of the digastric muscles,
the edges are resected with a scissors.
Platysmaplasty
• Consideration is given to tightening the platysma muscle
sling. Dehiscence of the muscles in the midline may be
seen from the thyroid cartilage below to the bony chin
above.
• The lighted retractor is useful to directly visualize the
platysma muscles.
• Vertical platysma muscle plication is carried out with
interrupted sutures (3-0 Vicryl).
• Typically, eight to ten interrupted sutures are placed.
Skin Closure
• Before wound closure, the redraped cervical flaps are
inspected to confirm the absence of irregularities caused
by residual attached cutaneous septae or cutaneous
ligaments.
• The wounds are again inspected with the lighted retrac­
tor and the electrocautery device to confirm adequate
hemostasis.
• If oozing is poorly controlled, consideration is given to
the placement of a suction drain.
• The fascia layer of the submental wound is closed with
interrupted sutures (5-0 Vicryl).
• The skin edges are approximated with running suture
(6-0 nylon).
Placement of Dressing
• A mildly compressive chin and neck dressing is placed
(e.g., a Jobst neck/chin strap).
Postoperative Care
• Two days after surgery, the chin/neck dressing is
removed, and the patient is allowed to shower (includ­
ing the head and neck region) and shampoo the hair.
The dressing is replaced by the patient for an additional
3 days.
and additional sterile drapes are placed over the ones that
are already there.
• Reprep entire neck below the clavicles, the face, and the
postauricular regions with the use of Betadine solution
(do not use soap, alcohol, Hibiclens, and so on).
• Draping is completed with exposure of the neck just
inferior to the sternal notch and clavicles. Exposure of
the entire neck, the external ears, and the lower face is
also accomplished.
Instrumentation
• New sterile gloves are provided to the operating team.
• New sterile instrument sets are opened.
Surgical Markings
• Locate and use a surgical pen to mark the extent of
planned cervical flap elevation, including the following:
• The inferior border of the mandible and the chin
• The anterior border of the sternocleidomastoid
muscles
• The thyroid cartilage and below toward the clavicles
• Locate and use a surgical pen to mark the proposed 3- to
4-cm submental incision.
Local Anesthesia
• Injection 50 mL of tumescent solution (epinephrine
1 : 1000, 1 mL; bupivacaine plain, 10 mL; 0.9% sodium
chloride, 500 mL) within the designated surgical field.
The injection is made below the skin and above the
platysma muscles.
Submental Incision
• Use a knife (no. 15 blade) to complete the 3- to 4-cm
submental incision.
Elevation of the Cervical Flaps
• A wide double skin hook is placed on either side of the
complete submental incision. With the use of the skin
hooks spreading in opposing directions, tension sepa­
rates the wound.
• A long Stevens scissors is used to elevate the cervical
flaps. Stretch-tension is achieved on the skin of the cervi­
cal flap to be elevated; this is accomplished with the
double skin hook at the submental wound and the assis­
tant’s hands over the neck skin above the clavicle. The
Stevens scissors is then used to blindly separate the skin
and the subcutaneous flap from the underlying platysma
muscles throughout all planned locations on both sides
of the neck.
• The dissection continues down past the thyroid cartilage
toward the clavicles and laterally just above the anterior
border of each sternocleidomastoid muscle.
• The dissection continues superiorly to the inferior border
of the mandible. Caution is used to avoid injury to
the marginal mandibular branch of cranial nerve VII.
• The lighted retractor is then used to confirm the com­
plete release of the cervical flaps from all cutaneous
septae and cutaneous ligaments.

1766 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Contour Irregularities
Contour irregularities may result from underresection, over­
resection, or the removal of supraplatysmal subcutaneous
fat. When this does occur, it is generally seen either low in
the neck toward the thyroid cartilage or laterally toward the
sternocleidomastoid muscles. The removal of retained fat is
managed secondarily with surgery; this is easier to deal with
than areas of overresection that require grafting.
Midline Ridging
Midline ridging after vertical platysma muscle plication may
occur with the extensive use of non-resorbable sutures in the
presence of very thin overlying skin. This author believes that
the placement of a continuous running suture (rather than
individual interrupted sutures) may be more likely to result
in ridging. In those few circumstances in which significant
midline ridging occurs, secondary surgery with suture
removal and platysma recontouring may be beneficial.
Residual Submental Fullness or Hollowing
Subplatysma midline defatting is carried out to reduce
excess fullness. After the separation of the platysma muscles,
defatting down to the level of the digastric muscles is usually
beneficial.11 If residual fullness remains as a result of inad­
equate fat removal, this can be managed secondarily to
finish the job. Excessive defatting in this region often creates
a submental hollow with a resulting “operated” look. Sec­
ondary grafting may be beneficial.
Visible Unsightly Digastric Muscle Ridging
Partial resection (shaving) of the digastric muscles is not
typically necessary but should always be considered on the
basis of the presurgical evaluation and the intraoperative
findings.
Submandibular Gland Ptosis
Prominent submandibular glands are seen in a subgroup
of patients. Gland ptosis should be noted during the pre­
operative office evaluation. In these cases, a thoughtful pre­
operative discussion with the patient about his or her
expectations and then limiting surgery appropriately may
be best. This author does not favor either partial subman­
dibular gland resection or intracapsular release and reposi­
tioning. The risk of complications (i.e., salivary gland
drainage, hematoma, nerve damage, contour irregularities)
may be greater than any cosmetic advantage. This explains
why the surgical manipulation of the submandibular gland
has not achieved general acceptance.
Direct Anterior Neck Skin Excision
In general, this author does not favor direct skin removal
from the anterior neck with the use of Z-plasty, W-plasty,
or other similar procedures. The resulting scars are fre­
quently objectionable, although some surgeons favor these
approaches for selected older men. It would be very difficult
to justify such procedures for a young person, especially a
• The dressing is removed daily for showering and then
replaced until 5 days after surgery.
• Submental sutures are removed on the fifth postopera­
tive day.
• Antibiotics are discontinued after 5 days.
• No sports participation or direct facial trauma is allowed
for 5 weeks.
Complications and Unfavorable Results
Hematoma
The incidence of hematoma with an anterior (submental)
neck approach using the techniques described in this chapter
is not common. The use of a lighted retractor confirms
satisfactory hemostasis under direct vision at operation.
Proper patient selection (i.e., non-hypertensive, not taking
platelet-inhibiting medications or supplements) and a
smooth emergence from anesthesia (i.e., control of blood
pressure and vomiting) are also essential. A compression
dressing as described is helpful to limit swelling after surgery.
This author has not found it necessary to routinely place
drains.
Skin Necrosis
The incidence of skin necrosis in properly selected patients
and with the use of sound flap elevation techniques is
uncommon. The occurrence of flap necrosis may be signifi­
cantly higher in those with vascular occlusive disorders and
in smokers (see Chapters 16 and 25).
Infection
Wound infection is not common after neck lift surgery as
described in this chapter. The use of perioperative antibiotics
is indicated. Close postoperative communication between
the surgeon and the patient is essential to ensure prompt
treatment if infection does occur. Infection is treated with
appropriate antibiotics and drainage procedures.
Nerve Injury
The incidence of facial nerve injury (i.e., of the marginal
mandibular branch) is low as long as the field of dissection
remains below the inferior border of the mandible and
above the platysma muscle laterally.
Skin Irregularities
Skin irregularities are primarily the result of inadequate
cervical flap undermining with the incomplete release of all
cutaneous septae and cutaneous ligaments extending the
borders of flap dissection. In properly selected cases and
with the complete release of septae and ligaments, neck skin
has the unique ability to contract without the need for
resection. However, those individuals with moderate or
greater degrees of laxity before surgery cannot be expected
to achieve optimal results without skin excision (i.e., a tra­
ditional face-lift approach). Irregularities may also result
from a hematoma that is slow to resolve. Skin irregularities
related to inadequate undermining that persists are managed
secondarily by extending the degree of undermining.

1767
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
complaint and the surgeon’s immediate expertise.43,58,78,79,86-92
To best ensure a successful outcome and a satisfied patient,
a comprehensive discussion of pertinent findings should
precede any compromised treatment delivered (Figs. 40-12
and 40-13).
When a clinician attempts to achieve facial rejuvenation
by overcompensating with a soft-tissue–only approach (i.e.,
the excessive injection of fillers or overtightening of the
facial soft tissues) without addressing baseline skeletal defor­
mities and disproportions, a suboptimal result is more likely.
A fundamental principle is that both smile aesthetics and
optimal neck rejuvenation are highly dependent on accept­
able dental harmony and reasonable maxillofacial skeletal
proportions, respectively.
In addition, overlooking baseline upper airway obstruc­
tion as a result of maxillomandibular deficiency is not ideal
for two reasons. First, the clinician has the obligation to
inform patients of their health needs. Second, if a surgical
procedure is undertaken (i.e., face lifting under anesthesia),
then any baseline airway compromise (e.g., obstructive
sleep apnea) may increase perioperative risk.
Pitfalls of a “Dental-Only Approach” to
Facial Rejuvenation
When a middle-aged woman consults a restorative dentist or
an orthodontist with a chief complaint of an unattractive
smile, it is tempting for the clinician to only consider the
alignment, shape, and color of the teeth (see Fig. 40-3). If
the dentition and occlusion cannot be adequately improved
through a combination of restorative dentistry and ortho­
dontic mechanics, a dentofacial deformity should be sus­
pected. The consulted orthognathic surgeon may then be
tempted to limit the discussion to the “simplest way” to
correct the occlusion (i.e., one-jaw surgery) without fully
considering skeletal dysmorphology, facial aesthetics, or any
baseline upper airway issues (e.g., chronic nasal obstruction,
obstructive sleep apnea). For example, the individual with a
long face Class II anterior open-bite growth pattern may
arrive to the surgeon with a request from the orthodontist to
“close the bite.” It may be possible to achieve an acceptable
occlusion with surgically assisted rapid palatal expansion
and further orthodontic alignment. Doing so may resolve
the open bite, but it is unlikely to address the following:
• Gummy smile
• Lip incompetence
• Chronic nasal obstruction
• Baseline obstructive sleep apnea
• Appearance of a “big” nose, “flat” cheekbones, and
“weak” chin
• Negative-vector globe/eyelid relationship
Full disclosure to the individual regarding the limitations
of an isolated dental or occlusion-only approach and the
potential advantages of selecting a more comprehensive
reconstruction best ensures patient satisfaction.
younger woman. If skin removal is required, a traditional
face lift is more likely to result in patient satisfaction (i.e.,
less-visible scars and preferred neck rejuvenation).
Facial Aging and Rejuvenation:
Treatment Pitfalls
Pitfalls of a “Soft-Tissue–Only Approach”
to Facial Rejuvenation
When a middle-aged woman consults a cosmetic surgeon
to discuss aging in the lower face and neck, she may typi­
cally ask about the following:
• A weak-appearing chin
• A double (soft-tissue) chin and excess neck fat
• Loose neck skin and a poor neck–jaw angle
• Deep nasolabial folds
• Heavy jowls
• Marionette lines and perioral lines, creases, or folds
The surgeon may discuss with the patient non-surgical
and surgical options that include the following:
• The injection of non-autogenous “fillers”
• The injection of autogenous fat grafts
• Skin care and resurfacing techniques
• Anterior neck surgical procedures
• A spectrum of face-lift surgical options
If baseline maxillomandibular skeletal disproportions are
pronounced, the surgeon is likely to suggest the following:
• The injection of fillers and fat grafts to augment the
recognized skeletal deficiencies
• The placement of “hard” implants (e.g., Silastic,
porous polyethylene) to augment the recognized skel­
etally deficient regions (i.e., the chin; the angles of the
mandible; and the perinasal, infraorbital, and zygo­
matic regions)
The surgeon may neglect to consider patient-specific
smile aesthetics or jaw dysmorphology when discussing treat­
ment options. Interestingly, the patient is not likely to intui­
tively equate these aspects. In addition, neither the patient
nor the surgeon is likely to consider the potential cause-and-
effect relationship between skeletal dysmorphology and baseline
breathing difficulties (i.e., maxillomandibular deficiency and
obstructive sleep apnea; see Chapter 26).
The reasons why a surgeon may not fully consider the
interrelationships of soft-tissue facial aging and jaw dysmor­
phology; baseline breathing difficulty and jaw dysmorphol­
ogy; and smile aesthetics and dental disharmony may relate
to a tendency for clinicians to suggest treatment options that
they are most familiar with and personally able to perform.
A preferred approach is to educate the patient about
pertinent aspects that may go beyond the original chief

1768 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Or
Or
Or
Or
Or
Or
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O ththththththththththththththththththth
r ogn
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g atatatatatatatatata hicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
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ry
ry; J.C.
C.
C.
C Pos
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gn
gn
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g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
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Su
Su
Surg
r ery
ry
ry
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ry; J.C.
C.
C.
C.
C Pos
os
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Or
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Orththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
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g atatatathicicicicicicic Su
Su
Su
Su
Su
Su
Su
Surg
r ery
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ry
ry
ry
ry
ry
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ry
ry
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ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
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os
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o nicicicicicicicicicicicicicicicicicicicicicicicicicicici k
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Orthththththth
r ogn
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g atatatatata hicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
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r ery
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ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
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osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicici k
A
B
•  Figure 40-12  A woman in her 50s requested evaluation for a “weak chin” and unfavorable neck
aesthetics. Since her teenage years, she was known to have significant mandibular deficiency and a
degree of maxillary hypoplasia. She underwent orthodontic treatment only and has a stable occlusion.
Maxillary and mandibular osteotomies with advancement would best restore Euclidean proportions,
open the airway, and rejuvenate the face (see Chapters 23 and 25). She was not prepared to undergo
further orthodontics or an orthognathic approach. A compromised treatment plan was agreed to that
included osseous genioplasty (vertical lengthening and minimal horizontal advancement) with interpo­
sitional bloc hydroxyapatite grafting and an anterior approach to the neck (cervical flap elevation, neck
defatting, and vertical platysma muscle plication). A, Frontal views before and after surgery. B, Oblique
facial views before and after surgery.
Difficulty achieving an optimal outcome may also occur
when the restorative dentist or the orthodontist has overo­
ptimistic expectations of what can be achieved through
limited “surgical cosmetic” procedures. For example, the
dental team may incorrectly assume that, if they are able to
improve the occlusion in an individual with mandibular
deficiency, then a chin implant will resolve the aesthetic
concerns (see Fig. 38-1). It should be within the collabora­
tive skill set of the treating orthodontist and the consulting
orthognathic surgeon to broadly evaluate the patient’s dental
rehabilitative, jaw reconstruction, and rejuvenation needs.
Pitfalls of a Segmental Soft-Tissue Approach
to Facial Rejuvenation
At times, a surgeon will be asked to perform a limited “seg­
mental” soft-tissue approach to an individual’s facial aging.
For example, the patient shown in Fig. 40-14 pre­sents with

1769
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
D
Or
Or
Or
Or
O thththth
r ogn
gn
gn
gn
gn
g atatatatatata hicicicicicicicicicicicicicicicicicicicicici Su
Su
Su
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Su
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r ery
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C.
C.
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C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C. Pos
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osnicicicicicicicicicicicicicicicicicicick
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Orthththththththththththththththththththththththththththth
r ogn
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g atatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
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r ery
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C.
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C.
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C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
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osnicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicici k
C
C, Profile views before and after reconstruction. D, Lateral cephalometric
radiographs before and after reconstruction.
• Figure 40-12, cont’d
a degree of brow ptosis; asymmetric upper eyelid ptosis and
hooding; lower eyelid fat protrusion; deep nasolabial and
perioral folds; heavy jowls; and neck submental soft-tissue
fullness that involves all of the layers (i.e., skin, platysma,
and fat). There is also notable surface-layer skin aging and
a degree of maxillomandibular deficiency.
The patient requested the management of only the soft-
tissue aging issues in the neck and jowls. This limited goal
was reasonably achieved with a face lift. However, residual
aging affecting the upper face (i.e., the brow and eyelids)
was not addressed, which explains the suboptimal result.
The surgeon’s agreeing to a compromised soft-tissue “seg­
mental” rejuvenation approach should be with full disclo­
sure to the patient to avoid any misunderstandings.
Conclusions
The layers of the face include the skin, the underlying soft
tissues and the skeletal structural support system (i.e., the
bone, the cartilage, and the teeth). The soft tissues of the
face will naturally descend with age. These and other soft-
tissue changes occur throughout the face and neck and
will alter the natural youthful facial curvatures. Neverthe­
less, an unavoidable fact is that the visual appearance of
aging in the neck is greatly influenced by the baseline
maxillomandibular skeletal framework. Consideration
should be given to reconstructing the jaws toward Euclid­
ian proportions, when feasible, before extensive soft-tissue
procedures are undertaken.
Standard soft-tissue neck rejuvenation procedures remain
an important part of the surgeon’s armamentarium and
include cervical skin flap undermining and elevation; defat­
ting below the mandible platysmaplasty; and traditional
face lifting. The clinician’s knowledge of common patterns
of dentofacial skeletal dysmorphology and their expected
negative effects on soft-tissue aging—in combination with
up-to-date methods for reconstruction and rejuvenation—
best ensures optimal patient care.

1770 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
•  Figure 40-13  A man in his early 50s was in a bicycle accident and sustained a displaced nasal fracture and an upper lip laceration.
During the consultation, he also discussed a lifelong concern about a weak profile and, with age, the progressive laxity of the neck soft
tissues. A lateral cephalometric and Panorex radiograph confirmed the nasal fracture and the microgenia. The patient had a stable occlu­
sion without excess overjet. The nasal fracture required closed reduction with packing, and the upper lip laceration was approximated with
suture for primary closure. The patient also underwent an osseous genioplasty (vertical lengthening and horizontal advancement) with
interpositional bloc hydroxyapatite grafting and an anterior approach to the soft tissues of the neck (cervical flap elevation, neck defatting,
and vertical platysma muscle plication). He is shown before and 3 months after the procedures. A, Frontal views before and after surgery.
B, Oblique facial views before and after surgery.

1771
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
D
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
C, Profile views before and after surgery. D, Lateral cephalometric radiographs before and after surgery.
• Figure 40-13, cont’d

1772 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
•  Figure 40-14  A woman in her mid 50s
arrived with a request for neck rejuvena­
tion. Over the years, excess loose skin
had developed around her neck. She had
a mild degree of maxillomandibular defi­
ciency that was characterized as dimin­
ished lower anterior facial height and
limited horizontal projection. The surface
layer of the skin was thin with spotty pig­
mentation and wrinkling. She also had
significant brow and upper eyelid ptosis.
She did not wish to undergo an orthogna­
thic correction, and she refused rejuvena­
tion of the brow and eyelids at this time.
She requested a segmental soft-tissue
surgical approach that was restricted to
the neck and jowls. Her face lift was car­
ried out as described in the legend for Fig.
40-5. The aesthetic results are limited as
a result of the inability to manage upper-
face soft-tissue aging and the maxillo­
mandibular skeletal deficiency. A, Frontal
views before and after surgery. B, Oblique
facial views before and after surgery.
C, Profile views before and after surgery.
C
Or
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g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
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1773
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
Patient Education Materials
Neck Liposuction Surgery
Liposuction and direct excision are surgical techniques that are used for the removal of excess fatty tissue. They are
appropriate procedures to use in the neck region, and they may be carried out through a small incision below the chin.
The presence of firm, elastic skin in the neck region will result in the most favorable contours after fat removal.
During liposuction, a cannula (i.e., a thin tube with an opening near the end) is inserted, and the surgeon moves it
back and forth under the skin while high-pressure suction removes the unwanted fat. Fat removal in the neck can be
done alone or in conjunction with other procedures (e.g., platysma muscle tightening, genioplasty, jaw-straightening
surgery).
After the neck liposuction procedure, a tight-fitting dressing is applied to limit swelling and to help your skin conform
smoothly to the new shape of your underlying tissue. Within 1 week, the stitches are removed. Depending on whether
other procedures were carried out simultaneously, most people are then ready to go back to their work environment.
INSTRUCTIONS FOR NECK LIPOSUCTION SURGERY
The purpose of these instructions is to help you to prepare for and then recover from your operation with as little
discomfort and inconvenience as possible.
Preoperative Instructions
1. Do not take any aspirin, aspirin-containing products, or aspirin-like products for at least 2 weeks before and 2
weeks after surgery. Aspirin and aspirin-like products tend to increase bleeding during surgery and bruising
postoperatively.
2. You should not smoke for at least 2 weeks before surgery and 2 weeks afterward. Smoking jeopardizes wound
healing, it may result in lung congestion, and it will hinder optimal results.
3. Starting at least 2 days before surgery, we request that you shower and shampoo your hair at least once per day.
The morning of surgery, shower and shampoo your hair again.
4. Do not eat or drink anything after midnight the night before surgery, not even a sip of water.
5. Be sure to make arrangements for someone to accompany you home after surgery, because you will not be
allowed to drive.
6. We will give you a prescription for pain control and another for antibiotics. You may wish to fill them before the date
of surgery.
Postoperative Instructions
1. Applying a cold compress to the anterior neck region during the initial 36 hours after surgery will reduce swelling
and discomfort.
2. Keep your head and upper back elevated when resting and sleeping for the first week after surgery.
3. You may eat whatever you wish, but start out slowly, because the anesthesia may leave your stomach unsettled for
several hours.
4. Maintaining some compression in the neck region for at least 1 week after surgery may be helpful to minimize
swelling and for the healing of the skin to the deeper structures of the neck. This is achieved with a specialized
neck pressure garment that is applied during surgery. Your surgeon will also provide you with specific instructions
about the neck dressing.
5. For men, shaving with an electric razor maybe preferred until you become comfortable with the changes in the
sensation of the neck skin region.
6. Get lots of rest and perform minimal physical activity during the first week after surgery. You may then gradually
increase your activity back to normal by 4 to 6 weeks after your operation as per instructions from your surgeon.
7. Palpable small lumps and a tight feeling in the neck just below the chin are common findings. These will gradually
improve during the final phase of healing.
8. Call the office for an appointment to see your surgeon on the date specified at the time of discharge.
9. If there are concerns at any time, contact your surgeon’s office. After hours, the answering machine message will
advise you about how to proceed.
Jeffrey C. Posnick, DMD, MD
Director, Posnick Center for Facial Plastic Surgery

1774 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Consent for Neck Liposuction Surgery
_______
INSTRUCTIONS
Initial here
This is a document that has been prepared by your surgeon to help educate and inform you about your
suction-assisted lipectomy (liposuction) surgery and its risks as well as alternative treatment options. It
is important that you read this information carefully and completely. Please initial each section on each
page to indicate that you have read and understand it. When all of your questions are answered,
please also sign the consent for surgery on the last page as proposed by your surgeon.
_______
INTRODUCTION
Initial here
Liposuction and direct excision are surgical techniques that are used for the removal of excess fatty
tissue. They are appropriate procedures to use in the neck region, and they are carried out through a
small incision below the chin. The presence of firm, elastic skin will result in the most favorable neck
contour after fat removal. During liposuction, a cannula (i.e., a thin tube with an opening near the end)
is inserted, and the surgeon moves it back and forth under the skin while high-pressure suction
removes the unwanted fat.
Fat removal in the neck can be done alone or in conjunction with other procedures (e.g., platysma
muscle tightening, genioplasty, jaw-straightening surgery). After the liposuction procedure, a tight-fitting
dressing is usually applied to the neck to limit swelling and to help the skin conform smoothly to the
new shape of the underlying tissue. Within 1 week, the stitches are removed. Depending on whether
other procedures were carried out simultaneously, most people are then ready to return to their work
environment.
_______
ALTERNATIVE TREATMENT
Initial here
Alternative forms of management include the decision to not treat the fatty deposits with surgery. Diet and
exercise regimens may be of benefit for the overall reduction of excess body fat. In some patients, the
removal of excess skin in the neck with the use of a more extensive neck lift or face lift technique may
be required in addition to liposuction. Risks and potential complications are also associated with these
and other alternative forms of treatment.
_______
RISKS OF NECK LIPOSUCTION SURGERY
Initial here
Every surgical procedure involves a certain amount of risk. An individual’s choice to undergo a neck
liposuction procedure is based on the comparison of the risk to the potential benefit. Although the
majority of patients do not experience the complications described below, you should discuss each of
them with your surgeon.
_______
PATIENT SELECTION
Initial here
Individuals with poor skin tone, medical problems, obesity, or unrealistic expectations may not be
candidates for neck liposuction.
_______
BLEEDING
Initial here
It is possible, although unusual, to have a significant bleeding episode during or after neck liposuction.  
If postoperative bleeding does occur, urgent treatment to drain accumulated blood or to control
ongoing bleeding may be required. Do not take any aspirin or aspirin-like medications for 2 weeks
before surgery, because this may increase the risk of bleeding. Individuals with poorly controlled
hypertension are also at risk.
______
INFECTION
Initial here
Infection is not common after neck liposuction surgery. If an infection does occur, treatment that includes
a change in antibiotics or additional surgery may be necessary.

1775
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
Continued
_______
SKIN SCARRING
Initial here
Although good wound healing after neck liposuction is expected, abnormal scarring may occur within the
skin and the deeper tissues. Additional treatments, including surgery, may be helpful to treat abnormal
scarring.
______
CHANGES IN SKIN SENSATION
Initial here
A decrease in skin sensation after neck liposuction may occur. This usually resolves over a period of time.
_______
SKIN DISCOLORATION AND SWELLING
Initial here
Skin discoloration and swelling normally occur after neck liposuction. In rare situations, swelling and skin
discoloration may persist.
_______
SKIN CONTOUR IRREGULARITIES
Initial here
Contour irregularities, palpable wrinkling, and depressions in the skin may occur after liposuction.
Additional treatments, including surgery, may be helpful to manage skin contour irregularities.
_______
NECK ASYMMETRY
Initial here
It may not be possible to achieve a symmetric appearance with neck liposuction procedures. Factors
such as skin or muscle tone and bony prominences also contribute to the noticeable asymmetry of the
facial features.
_______
LONG-TERM EFFECTS
Initial here
Subsequent alterations in neck contour may occur as a result of aging, weight loss or gain, or other
circumstances not related to liposuction.
_______
SURGICAL ANESTHESIA
Initial here
Both local and general anesthesia involve risk. Complications are possible with all forms of anesthesia
and sedation.
_______
ALLERGIC REACTION
Initial here
Local allergies to tape, suture materials, or topical preparations have been reported. Systemic reactions,
which are more serious, may occur in response to drugs that are used during surgery or prescription
medications taken afterward.
_______
HEALTH INSURANCE
Initial here
Most health insurance companies exclude coverage for cosmetic procedures such as liposuction or for
any related complications that may occur. Please carefully review your health insurance subscriber
information.
________
ADDITIONAL SURGERIES THAT MAY BE NECESSARY
Initial here
There are many variable conditions in addition to risks and potential surgical complications that may
influence the long-term results of neck liposuction. Although complications occur infrequently, the risks
cited are those that are particularly associated with neck liposuction. The practice of medicine and
surgery is not an exact science. Although good results are expected, there is no guarantee or warranty
expressed or implied with regard to the results that may be obtained.

1776 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
________
FINANCIAL RESPONSIBILITIES
Initial here
The cost of surgery involves several charges for the services provided, including the fees charged by your
surgeon (i.e., surgeon’s fees); the cost of surgical supplies and the use of the operating room (i.e.,
facility/hospital charges); and the costs associated with anesthesia (i.e., anesthesiologist’s fees).
Depending on whether the cost of surgery is covered by your medical insurance plan, you will be
responsible for necessary copayments, deductibles, and all other charges that are not covered.
Additional costs may occur should complications develop from the surgery. Any secondary surgeries
and all charges involved with additional procedures (i.e., surgeon’s fees, facility/hospital charges,
anesthesiologist’s fees) would also be your responsibility.
________
DISCLAIMER
Initial here
Informed-consent documents are used to communicate information about the proposed surgical
treatment as well as to disclose information about risks and alternative forms of treatment. The
informed-consent process attempts to define principles of risk disclosure that should generally meet the
needs of most patients in most circumstances.
Informed-consent documents should not be considered all-inclusive with regard to defining other
methods of treatment and potential risks encountered. Your surgeon will provide you with additional
written and verbal information that is based on all of the facts of your particular case and the state of
medical knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care.
Standards of medical care are determined on the basis of all of the facts involved in an individual case
and are subject to change as scientific knowledge and technology advance and as practice patterns
evolve.
CONSENT FOR NECK LIPOSUCTION SURGERY
1. I hereby authorize my surgeon, __________, and such assistants as may be selected by my surgeon to perform the
following procedure:
• Neck region liposuction.
2. I have received, read, and understand the following information sheets:
• Neck Liposuction Surgery
• Consent for Neck Liposuction Surgery
3. I recognize that, during the course of the operation and the administration of anesthesia, unforeseen conditions may
necessitate different procedures than those stated above. I therefore authorize my surgeon, __________, and my
surgeon’s assistants or designees to perform such other procedures that are in the exercise of professional judgment
necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment
and that are not known to my surgeon at the time that the procedure is begun.
4. I consent to the administration of such anesthetics as are considered necessary or advisable. I understand that all
forms of anesthesia involve risk and the possibility of complications, injury, and even death.
5. I acknowledge that no guarantee has been given by anyone with regard to the results that may be obtained from this
procedure.
6. I consent to the photographing of me (head and neck region) before, during, and after surgery. These photographs
may be used by my surgeon for medical, scientific, or educational purposes now and in the future.
7. For the purposes of advancing medical education, I consent to the admittance of observers into the operating room.
8. I consent to the disposal of any body tissues or medical devices that may be removed.
9. THE FOLLOWING INFORMATION HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
• THE PREVIOUSLY DESCRIBED PROCEDURES TO BE UNDERTAKEN
• ALTERNATIVE PROCEDURES AND METHODS OF TREATMENT THAT I HAVE DECIDED AGAINST
• THE SPECIFIC RISKS AND POTENTIAL COMPLICATIONS OF THE PROCEDURES THAT I PLAN TO
UNDERGO

1777
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
I CONSENT TO THE PROCEDURES AND THE ABOVE LISTED ITEMS (1 THROUGH 9). I AM SATISFIED WITH
THE EXPLANATION GIVEN TO ME.
________________________________________
_________________
Patient (or Person Authorized to Sign for Patient)
Date
________________________________________
__________________
Witness
Date
Anterior Neck Lift Surgery
Liposuction and direct excision are surgical techniques that are used for the removal of excess fatty tissue. They are
appropriate procedures to use in the neck region, and they may be carried out through a small incision below the chin.
During liposuction, a cannula (i.e., a thin tube with an opening near the end) is inserted, and the surgeon moves it
back and forth under the skin while high-pressure suction removes the unwanted fat.
Depending on the quality of your skin and underlying muscles, an anterior neck lift procedure may be beneficial. An
anterior neck lift is carried out through the same small incision as liposuction. By elevating the neck skin away from the
deeper structures, there is a tendency for the skin to tighten in a positive way during the healing process. If skin laxity
is extensive, then a more traditional face lift procedure (i.e., with incisions in front of and behind the ears) would be
beneficial to directly remove the excess skin.
Just deep to the skin of the neck, there is a thin, sheet-like muscle layer (i.e., the platysma muscles) that may also
become lax and benefit from surgical tightening. Platysma muscle tightening (i.e. platysmaplasty) can be performed in
conjunction with cervical (neck) skin undermining as described to further improve the shape and contour of the neck.
After the anterior neck lift procedures, (i.e., cervical flap undermining, fat removal, and platysmaplasty), a tight-fitting
dressing is usually applied to limit swelling and to help the skin conform more smoothly to the new shape of the
underlying tissue. Within 1 week, the stitches are removed. Depending on whether other procedures are carried out
simultaneously, most people then return back to their work environment.
INSTRUCTIONS FOR ANTERIOR NECK LIFT SURGERY
The purpose of these instructions is to help you to prepare for and then recover from your operation with as little
discomfort and inconvenience as possible.
Preoperative Instructions
1. Do not take any aspirin, aspirin-containing products, or aspirin-like products for at least 2 weeks before and 2
weeks after surgery. Aspirin and aspirin-like products tend to increase bleeding during surgery and bruising
postoperatively.
2. You should not smoke for at least 2 weeks before surgery and 2 weeks afterward. Smoking jeopardizes wound
healing, it may result in lung congestion, and it will hinder optimal results.
3. Starting at least 2 days before surgery, we request that you shower and shampoo your hair at least once per day.
The morning of surgery, shower and shampoo your hair again.
4. Do not eat or drink anything after midnight the night before surgery, not even a sip of water.
5. Be sure to make arrangements for someone to accompany you home after surgery, because you will not be
allowed to drive.
6. We will give you a prescription for pain control and another for antibiotics. You may wish to fill them before the date
of surgery.
Continued

1778 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
Postoperative Instructions
1. Applying a cold compress to the anterior neck region during the initial 36 hours after surgery will reduce swelling
and discomfort.
2. Keep your head and upper back elevated when resting and sleeping for the first week after surgery.
3. You may eat whatever you wish, but start out slowly, because the anesthesia may leave your stomach unsettled for
several hours.
4. Maintaining some compression in the neck region after surgery may be helpful to minimize and reduce swelling and
for the healing of the skin to the deeper structures of the neck. Each situation is unique, and your surgeon will
advise you with regard to this matter.
5. For men, shaving with an electric razor may be preferred until you become comfortable with the changes in
sensation in the neck skin region.
6. Get lots of rest and perform only minimal physical activity during the first week after surgery. You may then gradually
increase your activity back to normal by 4 to 6 weeks after your operation as per instructions from your surgeon.
7. Palpable small lumps and a tight feeling in the neck are common findings. These will gradually improve during the
final phase of healing.
8. Call the office for an appointment to see your surgeon on the date specified at the time of discharge.
9. If there are concerns at any time, contact your surgeon’s office. After hours, the answering machine message will
advise you about how to proceed.
Jeffrey C. Posnick, DMD, MD
Director, Posnick Center for Facial Plastic Surgery
Consent for Anterior Neck Lift Surgery
_______
INSTRUCTIONS
Initial here
This is a document that has been prepared by your surgeon to help educate and inform you about your
anterior neck lift surgery and its risks as well as alternative treatment options. It is important that you
read this document carefully and completely. Please initial each section to indicate that you have read
and understand it. In addition, please sign the consent for surgery on the last page as proposed by
your surgeon.
_______
INTRODUCTION
Initial here
Liposuction is a surgical technique to remove excess fatty tissue. It is an appropriate procedure to use in
the neck region, and it is carried out through a small incision below the chin. During liposuction, a
cannula (i.e., a thin tube with an opening near the end) is inserted, and the surgeon moves it back and
forth under the skin while high-pressure suction removes the unwanted fat.
Depending on the quality of your skin and underlying muscles an anterior neck lift procedure may be
beneficial. The anterior neck lift is carried out through the same small incision just below the chin. By
elevating the neck skin away from the deeper structures, there is a tendency for the skin to tighten in a
positive way. If skin laxity is extensive, then a more traditional face lift procedure may be required to
directly remove the excess skin.
Just deep to the skin of the neck, there is a thin, sheet-like muscle layer (i.e., the platysma muscles) that
may also become lax and benefit from surgical tightening. Platysma muscle tightening (platysmaplasty)
can be done in conjunction with cervical (neck) skin undermining and fat removal as described to
further improve the shape and contour of the neck.
_______
ALTERNATIVE TREATMENT
Initial here
Alternative forms of management may include the decision to not treat the neck soft-tissue concerns with
surgery at all. Diet and exercise regimens may be of benefit for the overall reduction of excess body fat.
The direct removal of excess skin (i.e., a traditional face lift) may be advantageous in addition to the fat
removal and skin redraping procedures (i.e., the anterior neck lift) that you are currently planning to
undergo. Risks and potential complications are also associated with these and other alternative forms
of treatment.

1779
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
_______
RISKS OF NECK REJUVENATION PROCEDURES
Initial here
Every surgical procedure involves a certain amount of risk. It is important that you understand the risks
involved with the anterior neck rejuvenation procedure that is planned for you. An individual’s choice to
undergo a surgical procedure is based on the comparison of the risk to the potential benefit. Although
the majority of patients do not experience these complications, you should discuss each of them with
your surgeon.
_______
PATIENT SELECTION
Initial here
Individuals with poor skin tone, medical problems, obesity, or unrealistic expectations may not be
candidates for a neck rejuvenation procedure.
_______
BLEEDING
Initial here
It is possible, although not usual, to have a significant bleeding episode during or after surgery. If
postoperative bleeding occurs, it might require urgent treatment to drain the accumulated blood or to
control any ongoing bleeding. Do not take any aspirin or anti-inflammatory medications for 2 weeks
before surgery, because this may increase the risk of bleeding. Individuals with poorly controlled
hypertension are also at risk for postsurgical bleeding.
______
INFECTION
Initial here
Infection is not usual after this type of surgery, and you will be given perioperative antibiotics to limit this
risk. If an infection occurs, a change in antibiotics and additional surgery may be necessary.
_______
SKIN SCARRING
Initial here
Although good wound healing after neck rejuvenation is expected, abnormal scars may occur within the
skin and the deeper tissues. Additional treatments, including surgery, may be beneficial to treat
abnormal scarring.
______
CHANGE IN SKIN SENSATION AND LIP FUNCTION
Initial here
A decrease in skin sensation after neck rejuvenation may occur. Diminished neck skin sensation may not
totally resolve.
_______
SKIN DISCOLORATION AND SWELLING
Initial here
Skin discoloration and swelling normally occur after neck rejuvenation. In rare situations, swelling and skin
discoloration may persist.
_______
SKIN CONTOUR IRREGULARITIES
Initial here
Contour irregularities, or palpable wrinkling may occur in the skin after neck rejuvenation. Additional
treatments, including surgery, may be beneficial to manage skin contour irregularities.
_______
NECK ASYMMETRY
Initial here
It may not be possible to achieve a symmetric appearance with neck rejuvenation procedures. Factors
such as skin or muscle tone and bony prominences may also contribute to a noticeable asymmetries.
_______
SEROMA
Initial here
Fluid accumulation infrequently occurs in areas where neck rejuvenation has been performed. Additional
treatments or surgery to drain accumulations of fluid may be necessary.
Continued

1780 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
_______
LONG-TERM EFFECTS
Initial here
Subsequent alterations in facial contour may occur as a result of aging, weight loss or gain, or other
circumstances not related to the specific procedures that have been carried out.
_______
SURGICAL ANESTHESIA
Initial here
Both local and general anesthesia involve risk. Complications are possible with all forms of anesthesia
and sedation.
_______
ALLERGIC REACTION
Initial here
Local allergies to tape, suture materials, or topical preparations may also occur. Systemic reactions, which
are more serious, may occur in response to drugs that are used during surgery or prescription
medication taken afterward.
_______
HEALTH INSURANCE
Initial here
Most health insurance companies exclude coverage for cosmetic operations such as neck rejuvenation or
any related complications that may occur. Please carefully review your health insurance subscriber
information.
_______
ADDITIONAL SURGERIES THAT MAY BE NECESSARY
Initial here
There are many variable conditions in addition to risks and complications that may influence the long-term
results of a neck rejuvenation procedure. Although complications occur infrequently, the risks cited are
those that are particularly associated with a neck rejuvenation procedure. Other complications and risks
can occur but are even more uncommon. If complications do occur, additional surgeries or other
treatments may be necessary. The practice of medicine and surgery is not an exact science. Although
favorable results are expected, there is no guarantee or warranty expressed or implied with regard to
the results that may be obtained.
________
FINANCIAL RESPONSIBILITIES
Initial here
The cost of surgery involves several charges for the services provided, including the fees charged by your
surgeon (i.e., surgeon’s fees); the cost of surgical supplies and the use of the operating room (i.e.,
facility/hospital charges); and the costs associated with anesthesia (i.e., anesthesiologist’s fees).
Depending on whether the cost of surgery is covered by your medical insurance plan, you will be
responsible for necessary copayments, deductibles, and all other charges that are not covered.
Additional costs may occur should complications develop from the surgery. Any secondary surgeries
and all charges involved with additional procedures (i.e., surgeon’s fees, facility/hospital charges,
anesthesiologist’s fees) would also be your responsibility.
_______
DISCLAIMER
Initial here
Informed-consent documents are used to communicate information about the proposed treatment of a
disease or condition as well as to disclose information about risks and alternative forms of treatment.
The informed-consent process attempts to define principles of risk disclosure that should generally
meet the needs of most patients in most circumstances.
However, informed-consent documents should not be considered all-inclusive with regard to defining
other methods of care and potential risks encountered. Your surgeon may provide you with additional
written and verbal information that is based on all of the facts of your particular case and the state of
medical knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care.
Standards of medical care are determined on the basis of all of the facts involved in an individual case
and are subject to change as scientific knowledge and technology advance and as practice patterns
evolve.

1781
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
CONSENT FOR ANTERIOR NECK LIFT SURGERY
1. I hereby authorize my surgeon, __________, and such assistants as may be selected by my surgeon to perform the
following procedure: neck rejuvenation surgery that includes the removal of fat, cervical (neck skin) undermining, and
platysma muscle plication.
2. I have received, read, and understand the following information sheets:
• Anterior Neck Lift Surgery
• Consent for Anterior Neck Lift Surgery
3. I recognize that, during the course of the operation and the administration of anesthesia, unforeseen conditions may
necessitate different procedures than those stated above. I therefore authorize my surgeon, __________, and my
surgeon’s assistants or designees to perform such other procedures that are in the exercise of professional judgment
necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment
and that are not known to my surgeon at the time that the procedure is begun.
4. I consent to the administration of such anesthetics as are considered necessary or advisable. I understand that all
forms of anesthesia involve risk and the possibility of complications, injury, and even death.
5. I acknowledge that no guarantee has been given by anyone with regard to the results that may be obtained from this
procedure.
6. I consent to the photographing of me (head and neck region) before, during, and after surgery. These photographs
may be used by my surgeon for medical, scientific, or educational purposes now and in the future.
7. For the purposes of advancing medical education, I consent to the admittance of observers into the operating room.
8. I consent to the disposal of any body tissues or medical devices that may be removed.
9. THE FOLLOWING INFORMATION HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
• THE PREVIOUSLY DESCRIBED PROCEDURES TO BE UNDERTAKEN
• ALTERNATIVE PROCEDURES AND METHODS OF TREATMENT THAT I HAVE DECIDED AGAINST
• THE SPECIFIC RISKS AND POTENTIAL COMPLICATIONS OF THE PROCEDURES THAT I PLAN TO
UNDERGO
________________________________________
_____________________________
Patient (or Person Authorized to Sign for Patient)
Date
________________________________________
_____________________________
Witness
Date
I CONSENT TO THE PROCEDURES AND THE ABOVE LISTED ITEMS (1 THROUGH 9). I AM SATISFIED WITH
THE EXPLANATION GIVEN TO ME.
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1783
CHAPTER 40  Aesthetic Alteration of the Soft Tissues of the Neck and Lower Face: Evaluation and Surgery
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2010.

Volume 1  •  pp 1-1058  •  Volume 2  •  pp 1059-1784
I1
Index
I1
Index
A
Accelerated osteogenic
orthodontics, 164-165
Acetaminophen, 142-143
Achondroplasia, 91
Acid-etch techniques, 162
Activated appliances, 142. See also
Appliances.
Active self-ligating brackets, 161.
See also Brackets.
Active unilateral condylar
hyperactivity, 860-861
Acromegaly, 102
Adequate face-mask ventilation,
319
Adhesives and cements, 162
Adult dentofacial disharmony,
945-991. See also Dentofacial
disharmonies.
comprehensive dental
rehabilitation and,
982
facial aging and rejuvenation,
983-986
craniofacial morphologic
changes, 985-986
mandibular skeletal changes,
986
midface aging, 984-985
morphologic differentiation,
985-986
periorbital aging, 984-985
special considerations for,
983-984
functional assessments for,
945-981
previous suboptimal facial
surgery and, 983
recovery considerations,
987-988
body dysmorphic disorder,
987
clear objective setting
strategies, 987
dysesthesia, 987-988
nerve injuries, inferior
alveolar, 987
nerve injuries, infraorbital,
987-988
nerve injuries, mental, 987
patient age, 988
physiologic effects, 987
psychological effects, 987
realistic expectations and,
987
sensory loss, 987-988
sensory recovery, 988
special medical considerations
for, 945
techniques for, 945, 946f-981f
temporomandibular disorders
(TMDs) and, 981-982. See
also Temporomandibular
disorders (TMDs).
treatment considerations for,
982-983
wound healing risk factors for,
982
Aesthetics
aesthetic alterations
chin, 1564-1612
ears, prominent, 1703-1745
fundamentals of, 337-351
soft tissues, face vs. neck,
1746-1783
aesthetic ideals, facial, 337-351.
See also Ideal facial
aesthetics.
aesthetic objectives, prominent
ears, 1706. See also
Prominent ears.
aesthetic units
fronto-forehead, 1230
maxillary/nasal base, 1230
orbito-naso-zygomatic, 1230
posterior cranial vault, 1230
Affricative airstream obstructions,
236
Age and aging considerations
age-related macular
degeneration, 12
facial aging, 983-986
periorbital aging, 984-985
recovery issues, 988
AHI. See Apnea-hypopnea index
(AHI).
Airstream obstructions, affricative,
236
Airways
benchmark parameters checklist,
323
continuous positive airway
pressure (CPAP), 1009
difficult, 319
management techniques,
308-336
back-up plans, 318-319
decision factors for, 317, 318f
dentofacial deformity
considerations for, 318f,
319-320
difficult airway guidelines,
319
extubation, benchmark
airway parameters
checklist for, 323
extubation, criteria for,
321-322
extubation, planning for, 322
extubation, strategies for, 321
face-mask ventilation,
adequate, 319
head examinations, 317-318
intubation strategies, 319
lower jaw forward protrusion,
inability to, 317
Mallampati test, 318
mouth-opening ability, 317
neck examinations and,
317-318
neck extension, limited,
317-318
oxygenation maintenance,
318
perioperative, 317-323
preintubation preparation,
320-321
presurgical airway evaluations,
319
thyromental distance, 318
tracheal intubation,
complication prevention
and, 318-319
nasal, 287-307. See also Nasal
airway considerations.
case study of, 298f-300f,
302-304
chronic obstructive nasal
breathing, 287-295
COG-ENT chronic
rhinosinusitis study, 301
historical perspectives of,
287
Le Fort I down-fracture
osteotomies, 287-288,
293f-295f, 296-297
maxillary arch expansion,
290f, 297-301
nasal floor recontouring,
290f, 295f, 297-301,
298f-300f
Nasal Obstruction Symptom
Evaluation (NOSE)
survey, 296
quality-of-life issues, 301
residual postoperative nasal
obstruction, 297
Alberti, Leon Battista, 345
Alexander the Great, 341-342,
341f
Alginate impressions, 380f-385f,
415
Allogenic grafts, 622-623. See also
Grafts and grafting.
Allografts, 608. See also Grafts and
grafting.
Alloplastic grafts, 620-622, 636.
See also Grafts and grafting.
Alloy
arch wires, 162
brackets, 142
Alterations, aesthetic. See also
Aesthetics.
chin, 1564-1612
ears, prominent, 1703-1745
fundamentals of, 337-351
soft tissues, face vs. neck,
1746-1783
Alveolar bone, 177-178
American Journal of Dental Science
(1849), 26
Analytic model-planning. See also
Planning techniques.
mandible-first, 424-440. See also
Mandible-first analytic
model-planning.
advantages of, 424, 425f-426f
case studies, hemifacial
microsomia (HFM),
339f, 365b, 430b,
430f-436f, 433b. See also
Hemifacial microsomia
(HFM).
centric relation (CR),
424-427
clinical settings for, 439
execution of, 428-429
technical aspects of, 428-429
techniques for, 429
standard, 374-423. See also
Standard analytic
model-planning.
accuracy of, 389f-393f,
406-407
alginate impressions,
380f-385f, 415
cast impressions, 380f-385f,
415
components of, 374,
375f-404f
controversies of, 405-408
direct visual examinations,
408
Erickson Model Table for,
389f-393f, 406-407.
See also Erickson
Model Table.
face-bow registration and
transfer, 375f-385f,
408-416, 409f-415f
goals of, 374-405, 420
intermediate splint
contraction, maxilla
positioning, 417-418
key measurements, 408
key steps for, 375f-393f,
407
reorientation. mandibular
cast, 418
reorientation, maxilla, 417
requirements of, 406-407
segmentation, maxilla, 417
semi-adjustable articulators,
408-416
spatial relationship captures,
408-416
standard facial records, 408
studies of, 419-420
Anatomic crowns, 172, 173f
Anatomic roots, 172, 173f
Anchorage devices, temporary
(TADs), 142-143
Anchorage roles, 143
Ancient Greek scholars, 18-20
Andrews, Lawrence F., 24-25, 24f
Note: Page numbers followed by
“b” indicate boxes; “f” figures; “t”
tables.
Adult dentofacial disharmony
(Continued)
Airways (Continued)

I2
Index
Andrews’ standard analyses,
363-367
Anesthesia and related
considerations, 308-336
blood replacement needs and,
313-317
approaches to, 313
complex surgeries, 315t-316t
controversies in, 314-317
historical perspectives of, 314
studies of, 314
convalescence, at home/
outpatient and, 325
outpatient regimens, 325
patient education materials
for, 326
physical therapy, 328b-330b
convalescence, in-hospital and,
323-325
airway needs, 323
antibiotics, 325
diet and nutrition, 324
discharge criteria, 325
intravenous (IV) fluid
therapy, 324
monitoring equipment,
323-324
nasal medications, 325
nausea management, 324
pain management, 325
settings for, 323
vomiting management, 324
wound care, 324
deliberate hypotensive anesthesia
(DHA), 308-313
complications of, 310
historical perspectives of,
308-309, 311-313
inducement techniques for,
309
mean arterial pressure (MAP)
and, 309, 318
monitoring during, 310
organ function effects of,
309-310
orthognathic surgery-specific
effects of, 310-313
patient positioning and, 309
hemorrhage depressors and, 311
blood loss limitation effects
of, 311
desmopressin, 311
tranexamic acids, 311
perioperative airway
management and,
317-323. See also
Perioperative airway
management.
back-up plans, 318-319
decision factors for, 317,
318f
dentofacial deformity
considerations for, 318f,
319-320
difficult airway guidelines,
319
extubation, benchmark
airway parameters
checklist for, 323
extubation, criteria for,
321-322
extubation, planning for, 322
extubation, strategies for, 321
face-mask ventilation,
adequate, 319
head examinations, 317-318
immediate preintubation
preparation, 320-321
intubation strategies, 319
lower jaw forward protrusion,
inability to, 317
Mallampati test, 318
mouth-opening ability, 317
neck examinations and,
317-318
neck extension, limited,
317-318
oxygenation maintenance,
318
presurgical airway evaluations,
319
thyromental distance, 318
tracheal intubation,
complication prevention
and, 318-319
upper airway trauma
prevention, 318
Angle, Edward H., 20-23, 20f-22f
Anterior limit lines, 363-367,
364f-365f
Anthropometric considerations,
1159
Anthropometric surface analyses,
363
Antibiotics, 325
Antihelical folds
creation vs. deepening,
1709f-1710f, 1712-1713
marking of, 1712
too-sharp, 1714
Apert syndrome, 1184-1200,
1190f-1193f, 1707f-1709f
obstructive sleep apnea (OSA)
and, 996. See also
Obstructive sleep apnea
(OSA).
reconstruction staging for,
1251-1254
skeletal growth, environmental
and neuromotor effects on,
115
Apex, root, 172, 173f
Apnea-hypopnea index (AHI),
992-1000
Apnea, sleep, 992-1058. See also
Obstructive sleep apnea
(OSA).
airway management and, 1002
central sleep apnea, 1000
in childhood, 1000-1002
clinical characteristics of,
993-1000, 995f, 997f-998f
clinical evaluations for, 997-999
diagnoses of, 993-1000
etiology of, 992
functional obstruction sites,
995f, 997f, 1000
prevalence of, 992
public health burden of, 1049
risk factors for, 996-997
severity of, 993-1000
studies of, 992
treatment options for,
1011f-1045f
treatment rationales for, 993
A-point to B-point relationships,
367
Appliances. See also Orthodontic
considerations.
activated, 142
fixed, 156-163
arch wires, 162
auxiliary attachments, 161
banding vs. bonding,
161-162
bracket materials of, 161-162
cements and adhesives, 162
clear brackets, 161
design of, 161-162
edgewise appliances, 156-161
historical perspectives of,
156-161
intra-oral bracket auxiliaries,
162-163
prescriptions for, 161
rotational control of, 161
removable, 163-164
clinical judgment and, 164
functional appliances,
163-164
historical perspectives of, 163
Invisalign, 164
retention appliances, 164
vs. temporary skeletal
anchorage (TADs), 166
Applied orthodontic force, 142
Arch
maxillary
constriction, 640-685
expansion, 290f, 297-301
syndromes, brachial, 73-77,
76f-77f, 1095
wires, 162
Architectural orders, Greek, 342,
343f-344f
Aristotle, 18-20, 340-341
Articulation tests, 237, 237b
Articulators, semi-adjustable,
408-416
Ascending ramus defects,
623-626
Aseptic necrosis, 506-508,
506f-507f
Assessment-related considerations
clinical evaluations, 351-369.
See also Planning
techniques.
approaches to, 351
global head and neck
assessments, 351-360.
See also Global head and
neck assessments.
cervical spine range-of-
motion (ROM),
current, 360
mastication factors, 227-263
nasal airway factors, 287-307.
See also Airways.
orthodontic factors, 135-170
psychosocial factors, 209-226
seven critical aspects, 351-360
speech-related factors, 227-263
swallowing factors, 227-263
Associated complications,
475-542. See also
Complication-related
considerations.
for chin, oblique osteotomies,
525-527
fixation factors, 479-481,
481f
general factors, 475-486
patient education materials for,
527
risk factors, 475-486
for sagittal split ramus
osteotomies (SSROs),
mandibular, 486-504
Astragalizontes (Polykleitos),
338-339, 338f-339f
Asymmetric Class III dentofacial
deformity, 807. See also
Asymmetric mandibular
excess.
Asymmetric mandibular excess,
807-865. See also Excess
patterns.
clinical characteristics and types
of, 807, 809f-853f
condylar hyperactivity
active unilateral, 860-861
type I, 854-855
type II, 855-860
etiology of, 807, 809f-853f, 863
hemimandibular elongation,
855-860
hemimandibular hyperplasia
(HMH), 854-855
high partial condylectomy,
860-861
jaw growth maturity
assessments, 860
misdiagnosis of, 807, 808f
presurgical orthodontic
treatments, 861
studies of, 853
surgical approaches, 861-862
chin asymmetry influences,
861
complications of, 862
informed consent
considerations for, 862
malocclusion and, 862
patient education for, 862
temporomandibular disorders
(TMDs) and, 862-863
At home/outpatient convalescence,
325. See also Convalescence.
anesthesia considerations and,
308-336. See also
Anesthesia and related
considerations.
outpatient regimens, 325
physical therapy, 328b-330b
Attached gingiva, 174-176,
174f-175f
Attachment apparatus lesions, 180
Attended polysomnography, 999
Auditory distortion speech errors,
237-240
Augmentation implants, 636
Autogenous blood banking, 313
Autogenous iliac donor sites,
609-614. See also Donor sites.
Autogenous rib donor sites,
623-626. See also Donor sites.
Autografts, 608. See also Grafts
and grafting.
Auxiliary attachments, 161
Avascular age-related macular
degeneration, 12
Avascular necrosis theory, 1531
Axis, ear, 1706
B
Background perspectives. See
Historical perspectives.
Back-up plans, 318-319
Bacterial plaque, 181
Anesthesia and related
considerations (Continued)
Appliances (Continued)
Associated complications
(Continued)

Volume 1  •  pp 1-1058  •  Volume 2  •  pp 1059-1784
I3
Index
Bad split, 477
BAHA options. See Bone-anchored
hearing aid (BAHA) options.
Bandeau, 18
Banding vs. bonding, 161-162
Bandolet, 18
Banking blood, 313
Bariatric surgery, 1002-1008
Barrow, G.V., 28
Baseline eating disorders, 218
Baseline maxillomandibular
skeletal disharmony, 1748f,
1749, 1750f-1754f
Baseline mental health, 218
Basic concepts
blood loss and fluid
replacement, 308-336
convalescence, 308-336
definition and prevalence, 61-68
facial perspectives, 1-17
formation influences, 69-134
historical perspectives, 18-60
mastication considerations,
227-263
nasal airway considerations,
287-307
orthodontic considerations,
135-170
periodontal considerations,
171-208
psychosocial considerations,
209-226
speech-related considerations,
227-263
swallowing considerations,
227-263
techniques
airway management,
308-336
anesthesia, 308-336
temporomandibular disorders
(TMDs), 264-286
BCLP. See Bilateral cleft lip/palate
(BCLP).
BDD. See Body dysmorphic
disorder (BDD).
Beauty, 337
Beauty, definitions of, 337
Begg, Raymond, 24, 24f
Behaviors, high-risk, 218
Bell, William H., 32, 32f, 41-47
Benchmark airway parameters
checklist, 323. See also
Airways.
Bending response, 137
Bilateral cleft lip/palate (BCLP),
1371-1440. See also
Cleft-orthognathic surgeries.
in adolescents, 1373-1428
coordinated team approach,
1372
facial growth implications of,
1371-1372
in infants, 1371-1372
jaw deformities and, 1428
orthodontic approaches, 898,
1428
orthognathic approaches,
1374f-1427f, 1429-1431
alveolar cleft management,
1431
chin deformity management,
1432
controversies of, 1433-1436
distraction osteogenesis
(DO), 1373, 1436
down-fracture, cleft maxilla,
1431
evolution of, 1429
horizontal advancement, cleft
maxilla, 1431
initial surgical healing, 1432
large residual palatal fistula,
closure of, 1433-1434
Le Fort I osteotomies,
modified, 1430-1431
Le Fort I osteotomies,
standard, 1429-1430
Le Fort I osteotomies,
three-segment,
1430-1431
mandibular deformity,
management of, 1432
maxillary reconstruction,
staging of, 1433
mobilization, cleft maxilla,
1431
nasal cavity, management of,
1431-1432
nose, management of,
1431-1432
pitfalls of, 1431-1432
residual oronasal fistula,
closure of, 1431
studies of, 1432-1433
timing of, 1373
unresolved issues of,
1433-1436
vertical lengthening, cleft
maxilla, 1431
presurgical assessments,
1428-1429
residual deformities, 1373-1428
treatment protocols, 1372-1373,
1374f-1427f
Bimaxillary dental protrusive
growth patterns, 897-944
clinical characteristics of, 898,
942
dental findings for, 898
functional aspects of, 898
orthodontic approach
historical perspectives of, 899
studies of, 899-940
techniques, 900f-939f
prevalence of, 897
radiologic findings for, 898-899
surgical approaches, 940-941
complications of, 941
informed consent and, 941
malocclusion after, 941-942
patient education for, 941
postsurgical considerations,
941
temporomandibular disorders
(TMDs) and, 942. See
also Temporomandibular
disorders (TMDs).
treatment pitfalls of, 899
Binder syndrome, 1159-1181
anthropometric explanations of,
1159
approaches to
comparisons, 1179-1180
current, 1160-1177,
1160f-1176f
characteristics of, 1159-1160
controversies of, 1177-1179
historical perspectives of, 1159
skeletal stability, post-
reconstruction, 1177
method comparisons, 1177
patient comparisons, 1177
result comparisons, 1177
unresolved issues of, 1177-1179
Binding, prominent ears,
1739-1740. See also
Prominent ears.
Biocoral alloplastic materials, 614
Bioelectric theory, 137-141
Biofax alloplastic materials, 614
Biologic envelopes, 136
Biologic mechanisms, grafts,
607-609. See also Grafts and
grafting.
bone morphogenic proteins
(BMPs), 607
comparisons of, 607
osteoconduction, 607, 608f
osteogenesis and, 607
osteoinduction and, 607
Biologic width, 175-176
Biosynthetic corneas, 12
Biotype considerations, 156
Bisphosphonates, 142-143
Blair, Vilray P., 22-23, 26-32, 27f,
29f-30f
Blood banking, 313
Blood loss and fluid replacement,
308-336
Blood replacement and related
considerations, 308-336
convalescence and. See
Convalescence.
deliberate hypotensive anesthesia
(DHA), 308-313. See also
Anesthesia and related
considerations.
complications of, 310
historical perspectives of,
308-309, 311-313
inducement techniques for,
309
mean arterial pressure (MAP)
and, 309, 318
monitoring during, 310
organ function effects of,
309-310
orthognathic surgery-specific
effects of, 310-313
patient positioning and, 309
hemorrhage depressors and, 311
blood loss limitation effects
of, 311
desmopressin, 311
tranexamic acids, 311
perioperative airway
management and, 317-323
replacement needs and, 313-317
approaches to, 313
complex surgeries, 315t-316t
controversies in, 314-317
historical perspectives of, 314
studies of, 314
BMI. See Body mass index (BMI).
BMPs. See Bone morphogenic
proteins (BMPs).
Body dysmorphic disorder (BDD),
219, 987
Body mass index (BMI), 995-996,
995f
Bonding vs. banding, 161-162
Bone-anchored hearing aid
(BAHA) options, 1151-1152
Bone grafts and grafting
alloplastic grafts, 636
for ascending ramus defects,
623-626
autogenous rib donor sites,
623-626
costochondral donor sites,
623-626
procedures for, 623-626,
624f-625f
biologic mechanisms of,
607-609
bone morphogenic proteins
(BMPs), 607
comparisons of, 607
osteoconduction, 607,
608f
osteogenesis and, 607
osteoinduction and,
607
cartilage grafting, nasal
reconstruction,
626-636
autogenous ear (conchal)
cartilage donor sites,
629-630
autogenous nose (septal)
cartilage donor sites,
610f, 626-629
procedures for, 626-629,
627f-629f
for condyle defects, 623-626
autogenous rib donor sites,
623-626
costochondral donor sites,
623-626
procedures for, 623-626,
624f-625f
facial skeleton augmentation,
636
goals of, 636
for interpositional defects and
gaps, mandible vs. maxilla,
609-623
allogenic grafts, 622-623
alloplastic grafts, 620-622
autogenous iliac donor sites,
609-614
corticocancellous bloc donor
sites, 614-620, 615f
human sterile freeze-dried
iliac grafts, 622-623
particulate cancellous donor
sites, 609-614
porous hydroxyapatite bloc
implants, 620-622,
621f-622f
procedures for, 609-613,
610f-613f, 616-620,
616f-620f
options for, 607-609
porous polyethylene
augmentation implants,
636
prevalence of, 607
types of, 608-609
allografts, 608
autografts, 608
graft substitutes, 608-609
Bilateral cleft lip/palate (BCLP)
(Continued)
Binder syndrome (Continued)