Core Procedures In Plastic Surgery: Cẩm Nang Các Quy Trình Cốt Lõi Trong Phẫu Thuật Tạo Hình

Core
Procedures
in Plastic
Surgery

Content Strategist: Belinda Kuhn
Content Development Specialist: Poppy Garraway
Content Coordinator: Trinity Hutton
Project Manager: Caroline Jones
Design: Miles Hitchen
Illustration Manager: Jennifer Rose
Illustrator: Antbits
Marketing Manager(s) (UK/USA): Katie Alexo

Core
Procedures
in Plastic
Surgery
Peter C. Neligan
MB, FRCS(I), FRCSC, FACS
Professor of Surgery
Department of Surgery, Division of Plastic Surgery
University of Washington
Seattle, WA, USA
Donald W. Buck II
MD
Assistant Professor of Surgery
Division of Plastic & Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
London, New York, Oxford, Philadelphia, St Louis, Sydney, Toronto
For additional online content visit expertconsult

SAUNDERS an imprint of Elsevier Inc
© 2014, Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further informa­
tion about the Publisher’s permissions policies and our arrangements with organizations such as the
Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.
elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
The following authors retain copyright of the following content:
Video clip 1.1 Periorbital Rejuvenation © Julius Few Jr.
Video clip 2.6 The High SMAS Technique with Septal Reset © Fritz E. Barton Jr.
Video clip 5.3 Post Bariatric Reconstruction-Bodylift © J. Peter Rubin.
Video clip 18.4 DIEP flap breast reconstruction © Philip N. Blondeel.
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluat­
ing and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
ISBN: 978-0-323-24399-5
e-book ISBN: 978-1-4557-2637-0
Printed in China
Last digit is the print number:  9  8  7  6  5  4  3  2  1

Contents
Preface
vi
List of Contributors
vii
Acknowledgments
x
Video Contents
xi

1 Blepharoplasty
1

2 Facelift
23

3 Rhinoplasty
46

4 Otoplasty
71

5 Abdominoplasty
79

6 Facial injuries
91

7 Local flaps for facial coverage
110

8 Cleft lip repair
134

9 Cleft palate
156
10 Lower extremity reconstruction
166
11 Chest reconstruction
185
12 Back reconstruction
196
13 Abdominal wall reconstruction
211
14 Breast augmentation
222
15 Mastopexy
233
16 Reduction mammaplasty
254
17 Implant based breast reconstruction
263
18 Autologous breast reconstruction using
abdominal flaps
278
19 Essential anatomy of the upper extremity
309
20 Examination of the upper extremity
342
21 Flexor tendon injury and reconstruction
358
22 Nerve transfers
375
23 Tendon transfers in the upper extremity
393
24 Extensor tendon injuries
414
Index
427

Preface
Time is a precious commodity and much as we would all love
to be able to take the time to sit back and read the full chapter
of a given topic before doing the case, life is not that generous.
Plastic Surgery 3rd Edition, published earlier this year, is an
encyclopedia of Plastic Surgery that contains detailed descrip­
tions of both the common and the uncommon conditions in
our specialty, as well as technical chapters on anatomy, opera­
tive technique etc. However, it is 6 volumes, and the online
version, though comprehensive, is even bigger. For that
reason, we put together this book, Core Procedures in Plastic
Surgery, which is condensed from the 6 Volume Textbook,
Plastic Surgery 3rd Edition. We chose the table of contents based
on feedback from focus groups containing residents and
attendings. It was evident these individuals wanted a quick
reference resource for some of the most common things they
see in day to day practice. They did not want a lot of words,
but they did want a lot of pictures and videos. We hope you
like the result.
In this book, we have compiled the 24 top procedures in
both aesthetic and reconstructive plastic surgery. Reference is
made to the chapters from which the content is extracted.
There is generous use of illustrations, schematic diagrams,
photographs, as well as videos extracted from the main text.
A short annotated bibliography is at the end of each chapter.
In addition, the book is littered with bulleted pearls of wisdom
highlighting key concepts of anatomy, technique, complica­
tions and outcomes, and pre- and post-operative considera­
tions. An icon appears beside the text or illustration to indicate
video content. We hope you will find this a useful addition to
your library. We have tried to design it to be intuitive and user
friendly and we hope that you will appreciate the condensed
format that makes for quick review in the OR or Clinic.
Peter C. Neligan
Donald W. Buck II

List of Contributors
Jamil Ahmad, MD, FRCSC
Staff Plastic Surgeon
The Plastic Surgery Clinic
Mississauga, ON, Canada
Robert J. Allen, MD
Clinical Professor of Plastic Surgery
Department of Plastic Surgery
New York University Medical Centre
Charleston, SC, USA
Sérgio Fernando Dantas de Azevedo, MD
Member
Brazilian Society of Plastic Surgery
Volunteer Professor of Plastic Surgery
Department of Plastic Surgery
Federal University of Pernambuco
Permambuco, Brazil
Daniel C. Baker, MD
Professor of Surgery
Insitiute of Reconstructive Plastic Surgery
New York University Medical Center
Department of Plastic Surgery
New York, NY, USA
Jonathan Bank, MD
Resident, Section of Plastic and Reconstructive
Surgery
Department of Surgery
Pritzker School of Medicine
University of Chicago Medical Center
Chicago, IL, USA
Fritz E. Barton Jr, MD
Clinical Professor
Department of Plastic Surgery
University of Texas Southwestern Medical
Center
Dallas, TX, USA
Miles G. Berry, MS, FRCS(Plast)
Consultant Plastic and Aesthetic Surgeon
Institute of Cosmetic and Reconstructive
Surgery
London, UK
Phillip N. Blondeel, MD, PhD, FCCP
Professor of Plastic Surgery
Department of Plastic and Reconstructive
Surgery
University Hospital Gent
Gent, Belgium
Kirsty U. Boyd, MD, FRCSC
Clinical Fellow – Hand Surgery
Department of Surgery – Division of Plastic
Surgery
Washington University School of Medicine
Saint Louis, MO, USA
Donald W. Buck II, MD
Assistant Professor of Surgery
Division of Plastic & Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
Giuseppe Catanuto, MD, PhD
Research Fellow
The School of Oncological Reconstructive
Surgery
Milan, Italy
James Chang, MD
Professor and Chief
Division of Plastic and Reconstructive Surgery
Stanford University Medical Center
Stanford, CA, USA
Robert A. Chase, MD
Holman Professor of Surgery – Emeritus
Stanford University Medical Center
Stanford, CA, USA
Philip Kuo-Ting Chen, MD
Director
Department of Plastic and Reconstructive
Surgery
Chang Gung Memorial Hospital and Chang
Gung University
Taipei, Taiwan, The People’s Republic of China
Mark W. Clemens, MD
Assistant Professor
Department of Plastic Surgery
Anderson Cancer Center University of Texas
Houston, TX, USA
Mark B. Constantian, MD, FACS
Active Staff
Saint Joseph Hospital
Nashua, NH (private practice)
Assistant Clinical Professor of Plastic Surgery
Division of Plastic Surgery
Department of Surgery
University of Wisconsin
Madison, WI, USA
Dai M. Davies, FRCS
Consultant and Institute Director
Institute of Cosmetic and Reconstructive
Surgery
London, UK
Michael R. Davis, MD, FACS, LtCol,
USAF, MC
Chief
Reconstructive Surgery and Regenerative
Medicine
Plastic and Reconstructive Surgeon
San Antonio Military Medical Center
Houston, TX, USA
Jorge I. de la Torre, MD
Professor and Chief
Division of Plastic Surgery
University of Alabama at Birmingham
Birmingham, AL, USA
Amir H. Dorafshar, MBChB
Assistant Professor
Department of Plastic and Reconstructive
Surgery
John Hopkins Medical Institute
John Hopkins Outpatient Center
Baltimore, MD, USA
Gregory A. Dumanian, MD, FACS
Chief of Plastic Surgery
Division of Plastic Surgery, Department
of Surgery
Northwestern Feinberg School of Medicine
Chicago, IL, USA
L. Franklyn Elliott, MD
Assistant Clinical Professor
Emory Section of Plastic Surgery
Emory University
Atlanta, GA, USA
Marco F. Ellis, MD
Chief Resident
Division of Plastic Surgery
Northwestern Memorial Hospital
Northwestern University, Feinberg School
of Medicine
Chicago, IL, USA
Julius W. Few Jr, MD
Director
The Few Institute for Aesthetic Plastic Surgery
Clinical Associate
Division of Plastic Surgery
University of Chicago
Chicago, IL, USA
David M. Fisher, MB, BCh, FRCSC, FACS
Medical Director, Cleft Lip and Palate Program
Division of Plastic and Reconstructive Surgery
The Hospital for Sick Children
Toronto, ON, Canada
Jack Fisher, MD
Department of Plastic Surgery
Vanderbilt University
Nashville, TN, USA
Neil A Fine, MD
Associate Professor of Clinical Surgery
Department of Surgery
Northwestern University
Chicago, IL, USA
Joshua Fosnot, MD
Resident
Division of Plastic Surgery
The University of Pennsylvania Health System
Philadelphia, PA, USA
Ida K. Fox, MD
Assistant Professor of Plastic Surgery
Department of Surgery
Washington University School of Medicine
Saint Louis, MO, USA

viii
List of Contributors
Allen Gabriel, MD
Assitant Professor
Department of Plastic Surgery
Loma Linda University Medical Center
Chief of Plastic Surgery
Southwest Washington Medical Center
Vancouver, WA, USA
Günter Germann, MD, PhD
Professor of Plastic Surgery
Clinic for Plastic and Reconstructive Surgery
Heidelberg University Hospital
Heidelberg, Germany
Barry H. Grayson, DDS
Associate Professor of Surgery (Craniofacial
Orthodontics)
New York University Langone Medical Centre
Institute of Reconstructive Plastic Surgery
New York, NY, USA
James C. Grotting, MD, FACS
Clinical Professor of Plastic Surgery
University of Alabama at Birmingham;
The University of Wisconsin, Madison, WI;
Grotting and Cohn Plastic Surgery
Birmingham, AL, USA
Dennis C. Hammond, MD
Clinical Assistant Professor
Department of Surgery
Michigan State University College of Human
Medicine
East Lansing
Associate Program Director
Plastic and Reconstructive Surgery
Grand Rapids Medical Education and Research
Center for Health Professions
Grand Rapids, MI, USA
Vincent R. Hentz, MD
Emeritus Professor of Surgery and Orthopedic
Surgery (by courtesy)
Stanford University
Stanford, CA, USA
Kent K. Higdon, MD
Former Aesthetic Fellow
Grotting and Cohn Plastic Surgery;
Current Assistant Professor
Vanderbilt University
Nashville, TN, USA
William Y. Hoffman, MD
Professor and Chief
Division of Plastic and Reconstructive Surgery
University of California, San Francisco
San Francisco, CA, USA
Joon Pio Hong, MD, PhD, MMM
Chief and Associate Professor
Department of Plastic Surgery
Asian Medical Center University of Ulsan
School of Medicine
Seoul, Korea
Ian T. Jackson, MD, DSc(Hon), FRCS,
FACS, FRACS (Hon)
Emeritus Surgeon
Surgical Services Administration
William Beaumont Hospitals
Royal Oak, MI, USA
Mark Laurence Jewell, MD
Assistant Clinical Professor of Plastic Surgery
Oregon Health Science University
Jewell Plastic Surgery Center
Eugene, OR, USA
Neil F. Jones, MD, FRCS
Chief of Hand Surgery
University of California Medical Center
Professor of Orthopedic Surgery
Professor of Plastic and Reconstructive Surgery
University of California Irvine
Irvine, CA, USA
Ryosuke Kakinoki, MD, PhD
Associate Professor
Chief of the Hand Surgery and
Microsurgery Unit
Department of Orthopedic Surgery and
Rehabilitation Medicine
Graduate School of Medicine
Kyoto University
Kyoto, Japan
Alex Kane, MD
Associate Professor of Surgery
Washington University School of Medicine
Saint Louis, WO, USA
Marwan R. Khalifeh, MD
Instructor of Plastic Surgery
Department of Plastic Surgery
Johns Hopkins University School of Medicine
Washington, DC, USA
Susan E. Mackinnon, MD
Sydney M. Shoenberg, Jr and Robert H.
Shoenberg Professor
Department of Surgery, Division of Plastic and
Reconstructive Surgery
Washington University School of Medicine
Saint Louis, MO, USA
Paul N. Manson, MD
Professor of Plastic Surgery
University of Maryland Shock Trauma Unit
University of Maryland and Johns Hopkins
School of Medicine
Baltimore, MD, USA
G. Patrick Maxwell, MD, FACS
Clinical Professor of Surgery
Department of Plastic Surgery
Loma Linda University Medical Center
Loma Linda, CA, USA
Kai Megerle, MD
Research Fellow
Division of Plastic and Reconstructive Surgery
Stanford Medical Center
Stanford, CA, USA
Luis Humberto Uribe Morelli, MD
Resident of Plastic Surgery
Unisanta Plastic Surgery Department
Sao Paulo, Brazil
Colin M. Morrison, MSc (Hons),
FRCSI (Plast)
Consultant Plastic Surgeon
Department of Plastic and Reconstructive
Surgery
Saint Vincent’s University Hospital
Dublin, Ireland
Hunter R. Moyer, MD
Fellow
Department of Plastic and Reconstructive
Surgery
Emory University, Atlanta, GA, USA
John B. Mulliken, MD
Director, Craniofacial Centre
Department of Plastic and Oral Surgery
Children’s Hospital
Boston, MA, USA
Maurizio B. Nava, MD
Chief of Plastic Surgery Unit
Istituto Nazionale dei Tumori
Milano, Italy
Peter C. Neligan, MB, FRCS(I), FRCSC,
FACS
Professor of Surgery
Department of Surgery, Division of Plastic
Surgery
University of Washington
Seattle, WA, USA
Jonas A Nelson, MD
Integrated General/Plastic Surgery Resident
Department of Surgery
Division of Plastic Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA, USA
M. Samuel Noordhoff, MD, FACS
Emeritus Superintendent
Chang Gung Memorial Hospitals
Taipei, Taiwan, The People’s Republic of China
Angela Pennati, MD
Assistant Plastic Surgeon
Unit of Plastic Surgery
Istituto Nazionale dei Tumori
Milano, Italy
Oscar M. Ramirez, MD, FACS
Adjunct Clinical Faculty
Plastic Surgery Division
Cleveland Clinic Florida
Boca Raton, FL, USA
Dirk F. Richter, MD, PhD
Clinical Director
Department of Plastic Surgery
Dreifaltigkeits-Hospital Wesseling
Wesseling, Germany
Eduardo D. Rodriguez, MD, DDS
Chief, Plastic Reconstructive and Maxillofacial
Surgery, R Adams Cowley Shock Trauma
Center
Professor of Surgery
University of Maryland School of Medicine
Baltimore, MD, USA

ix
List of Contributors
Rod J. Rohrich, MD, FACS
Professor and Chairman Crystal Charity Ball
Distinguished Chair in Plastic Surgery
Department of Plastic Surgery;
Professor and Chairman Betty and Warren
Woodward Chair in Plastic and Reconstructive
Surgery
University of Texas Southwestern Medical
Center at Dallas
Dallas, TX, USA
Michelle C. Roughton, MD
Chief Resident
Section of Plastic and Reconstructive Surgery
University of Chicago Medical Center
Chicago, IL, USA
Michel Saint-Cyr, MD, FRCSC
Associate Professor Plastic Surgery
Department of Plastic Surgery
University of Texas Southwestern Medical
Center
Dallas, TX, USA
Cristianna Bonneto Saldanha, MD
Resident
General Surgery Department
Santa Casa of Santos Hospital
São Paulo, Brazil
Osvaldo Ribeiro Saldanha, MD
Chairman of Plastic Surgery
Unisanta
Santos
Past President of the Brazilian Society of
Plastic Surgery (SBCP)
International Associate Editor of Plastic and
Reconstructive Surgery
São Paulo, Brazil
Osvaldo Ribeiro Saldanha Filho, MD
São Paulo, Brazil
J. Peter Rubin, MD, FACS
Chief of Plastic Surgery
Director, Life After Weight Loss Body
Contouring Program
University of Pittsburgh
Pittsburgh, PA, USA
Joseph M. Serletti, MD, FACS
Henry Royster-William Maul Measey
Professor of Surgery; Chief
Division of Plastic Surgery
Vice Chair (Finance)
Department of Surgery
University of Pennsylvania
Philadelphia, PA, USA
Kenneth C. Shestak, MD
Professor of Plastic Surgery
Division of Plastic Surgery
University of Pittsburgh
Pittsburgh, PA, USA
Navin K. Singh, MD, MSc
Assistant Professor of Plastic Surgery
Department of Plastic Surgery
Johns Hopkins University School of Medicine
Washington, DC, USA
David H. Song, MD, MBA, FACS
Cynthia Chow Professor of Surgery
Chief, Section of Plastic and Reconstructive
Surgery
Vice-Chairman, Department of Surgery
The University of Chicago Medicine & Biological
Sciences
Chicago, IL, USA
Andrea Spano, MD
Senior Assistant Plastic Surgeon
Unit of Plastic Surgery
Istituto Nazionale dei Tumori
Milano, Italy
Scott L. Spear, MD, FACS
Professor and Chairman
Department of Plastic Surgery
Georgetown University Hospital
Georgetown, WA, USA
Alexander Stoff, MD, PhD
Senior Fellow
Department of Plastic Surgery
Dreifaltigkeits-Hospital Wesseling
Wesseling, Germany
John D. Symbas, MD
Plastic and Reconstructive Surgeon
Private Practice
Marietta Plastic Surgery
Marietta, GA, USA
Jin Bo Tang, MD
Professor and Chair
Department of Hand Surgery;
Chair
The Hand Surgery Research Center
Affiliated Hospital of Nantong University
Nantong, The People’s Republic of China
Patrick L. Tonnard, MD
Coupure Centrum Voor Plastische Chirurgie
Ghent, Belgium
Charles H. Thorne, MD
Associate Professor of Plastic Surgery
Department of Plastic Surgery
NYU School of Medicine
New York, NY, USA
Francisco Valero-Cuevas, PhD
Director
Brain-Body Dynamics Laboratory
Professor of Biomedical Engineering
Professor of Biokinesiology and Physical
Therapy
By courtesy Professor of Computer Science
and Aerospace and Mechanical Engineering
The University of Southern California
Los Angeles, CA, USA
Allen L. Van Beek, MD, FACS
Adjunct Professor
University Minnesota School of Medicine
Division Plastic Surgery
Minneapolis, MN, USA
Valentina Visintini Cividin, MD
Assistant Plastic Surgeon
Unit of Plastic Surgery
Istituto Nazionale dei Tumori
Milano, Italy
Richard J. Warren, MD, FRCSC
Clinical Professor
Division of Plastic Surgery
University of British Columbia
Vancouver, BC, Canada

Acknowledgments
This work was the brainchild of Donnie Buck and the details
were fleshed out by the core editorial team at Elsevier who
worked with me on the big book, Plastic Surgery 3e, Belinda
Kuhn, Louise Cook, ALexanrda Mortimer and Poppy Garra­
way. Poppy has run with it and made it a reality. Donnie has
condensed the chapters from the big book to compile this col­
lection and Caroline Jones has made sure that it is fit for press.
I am grateful to all of them for their hard work and dedication.
I am forever grateful to my partners at the University of
Washington under the leadership of Nick Vedder, for their
support. Finally, none of this would be possible without the
unwavering love and support of my wife Gabrielle and my
family.
PCN
I must first thank Sue Hodgson and Peter Neligan for believ­
ing in, and trusting, a young plastic surgery resident with this
incredible opportunity. Working on this book has been a tre­
mendous honor and I cannot thank Dr. Neligan enough for
his mentorship and guidance throughout the process. I owe a
debt of gratitude to the wonderful team at Elseiver, especially
Poppy Garraway, Belinda Kuhn, and Caroline Jones who kept
me on target and were responsible for making this book a
reality. I would also like to thank the authors, all masters of
their craft, for contributing the wonderful text, illustrations,
photographs, and videos that comprise this book. Finally,
I would like to thank my family, especially my children,
Benjamin and Brooke, for inspiring me daily, and my beauti­
ful wife Jennifer for her love, encouragement, and support –
without her none of this would have been possible.
DWB

Chapter 1: Blepharoplasty
1.1 Periorbital rejuvenation
Julius Few Jr. and Marco Ellis
Chapter 2: Facelift
2.1 Anterior incision
2.2 Posterior incision
2.3 Facelift skin flap
Richard J. Warren
2.4 Platysma SMAS plication
Dai M. Davies and Miles G. Berry
2.5 Loop sutures MACS facelift
Patrick L. Tonnard
From Aesthetic Plastic Surgery, Aston 2009, with permission from
Elsevier
2.6 The high SMAS technique with septal reset
Fritz E. Barton, Jr.
2.7 Facelift – Subperiosteal mid facelift endoscopic temporo-
midface
Oscar M. Ramirez
Chapter 3: Rhinoplasty
3.1 Open technique rhinoplasty
Allen L. Van Beek
Chapter 5: Abdominoplasty
5.1 Abdominoplasty
Dirk F. Richter and Alexander Stoff
5.2 Lipoadominoplasty (including secondary lipo)
Osvaldo Ribeiro Saldanha, Sérgio Fernando Dantas de Azevedo,
Osvaldo Ribeiro Saldanha Filho, Cristianna Bonneto Saldanha, and
Luis Humberto Uribe Morelli
5.3 Post bariatric reconstruction – bodylift procedure
J. Peter Rubin
Chapter 7: Local Flaps for Facial Coverage
7.1 Facial artery perforator flap
7.2 Local flaps for facial coverage
Peter C. Neligan
Chapter 8: Cleft Lip Repair
8.1 Repair of unilateral cleft lip
Philip Kuo-Ting Chen and Samuel M. Noordhoff
8.2 Unilateral cleft lip repair – anatomic subumit
approximation technique
David M. Fisher
8.3 Repair of bilateral cleft lip
Barry H. Grayson
Chapter 10: Lower Extremity Reconstruction
10.1 Alternative flap harvest
Michel Saint-Cyr
Chapter 13: Abdominal Wall Reconstruction
13.1 Component seperation innovation
Peter C. Neligan
Chapter 14: Breast Augmentation
14.1 Endoscopic transaxillary breast augmentation
14.2 Endoscopic approaches to the breast
Neil A. Fine
Chapter 15: Mastopexy
15.1 Circum areola mastopexy
Kenneth C. Shestak
Chapter 16: Reduction Mammaplasty
16.1 Spair technique
16.2 Marking the SPAIR mammaplasty
Dennis C. Hammond
16.3 Breast reduction surgery
James C. Grotting
Chapter 17: Implant Based Breast Reconstruction
17.1 Mastectomy and expander insertion: first stage
17.2 Mastectomy and expander insertion: second stage
Maurizio B. Nava, Guiseppe Catanuto, Angela Pennati,
Valentina Visitini Cividin, and Andrea Spano
17.3 Latissimus dorsi flap tecnique
Scott L. Spear
Chapter 18: Autologous Breast Reconstruction Using
Abdominal Flaps
18.1 Pedicle TRAM breast reconstruction
L. Franklyn Elliot and John D. Symbas
18.2 The muscle sparing free TRAM flap
Joshua Fosnot, Joseph M. Serletti and Jonas A. Nelson
18.3 SIEA
Peter C. Neligan
18.4 DIEP flap breast reconstruction
Philip N. Blondeel and Robert J. Allan
Chapter 20: Examination of the Upper Extremity
20.1 Flexor profundus test in a normal long finger
20.2 Flexor sublimis test in a normal long finger
20.3 Extensor pollicis longus test in a normal person
20.4 Test for the extensor digitorum communis (EDC) muscle
in a normal hand
20.5 Test for assessing thenar muscle function
20.6 The “cross fingers” sign
20.7 Static two point discrimination test (s-2PD test)
20.8 Moving 2PD test (m-2PD test) performed on the radial or
ulnar aspect of the finger
20.9 Semmes-Weinstein monofilament test. The patient
should sense the pressure produced by bending the filament
20.10 Allen’s test in a normal person
Video Contents

xii
Contents: Video
20.11 Digital Allen’s test
20.12 Scaphoid shift test
20.13 Dynamic tenodesis effect in a normal hand
20.14 The milking test of the fingers and thumb in a normal
hand
20.15 Eichhoff test
20.16 Adson test
20.17 Roos test
Ryosuke Kakinoki
Chapter 21: Flexor Tendon Injury and
Reconstruction
21.1 Zone II flexor tendon repair
Jin Bo Tang
Chapter 22: Nerve Transfers
22.1 Scratch collapse test of ulnar nerve
Susan E. Mackinnon and Ida K. Fox
Chapter 23: Tendon Transfers in the Upper Extremity
23.1 EIP to EPL tendon transfer
Neil F. Jones, Gustavo Machado and Surak Eo

©2014, Elsevier Inc. All rights reserved.
Chapter
1 
Blepharoplasty
• One should first conceptualize the desired outcome, then
select and execute procedures accurately designed to
achieve those specific goals.
• Several important principles are advocated (Box 1.1).
Anatomical pearls
Osteology and periorbita
• The orbits are pyramids formed by the frontal, sphenoid,
maxillary, zygomatic, lacrimal, palatine, and ethmoid
bones (Fig. 1.1).
• The periosteal covering or periorbita is most firmly
attached at the suture lines and the circumferential
anterior orbital rim.
• The investing orbital septum in turn attaches to the
periorbita of the orbital rim, forming a thickened
perimeter known as the arcus marginalis.
• This structure reduces the perimeter and diameter of the
orbital aperture and is thickest in the superior and lateral
aspects of the orbital rim.
• Certain structures must be avoided during upper lid
surgery.
■ The lacrimal gland, located in the superolateral orbit
deep to its anterior rim, often descends beneath the
orbital rim, prolapsing into the postseptal upper lid in
many persons.
■ The trochlea is located 5 mm posterior to the
superonasal orbital rim and is attached to the
periorbita. Disruption of this structure can cause
motility problems.
Lateral retinaculum
• Anchored to the lateral orbit is a labyrinth of connective
tissues, known as the lateral retinaculum, that are crucial
This chapter was created using content from
Neligan & Warren, Plastic Surgery 3rd edition,
Volume 2, Aesthetic, Chapter 8, Blepharoplasty,
Julius W. Few Jr. and Marco F. Ellis.
Brief introduction
• The eyelids are vital, irreplaceable structures that serve to
protect the globes. Their shutter-like mechanism is
essential to clean, lubricate, and protect the cornea. Any
disruption or restriction of eyelid closure will have
significant consequences for both the patient and the
surgeon.
• Instead of the common practice of excising precious
upper and, to a somewhat lesser degree, lower eyelid
tissue, it is preferable to focus on restoration of attractive,
youthful anatomy.
SYNOPSIS
■ Blepharoplasty is a vital part of facial rejuvenation. The traditional
removal of tissue may or may not be the preferred approach when
assessed in relation to modern cosmetic goals.
■ A thorough understanding of orbital and eyelid anatomy is
necessary to understand aging in the periorbital region, and to
devise appropriate surgical strategies.
■ Preoperative assessment includes a review of the patient’s
perceptions, assessment of the patient’s anatomy, and an
appropriate medical and ophthalmologic examination.
■ Surgical techniques in blepharoplasty are numerous and should be
tailored to the patient’s own unique anatomy and aesthetic
diagnosis.
■ Interrelated anatomic structures including the brow and the
infraorbital rim may need to be surgically addressed for an optimal
outcome.

2
•
• Blepharoplasty
1
Figure 1.3  Lateral canthal tendon has separate superficial and deep components.
The deep component attaches inside the orbital rim at Whitnall’s tubercle. The
superficial component passes from the tarsal plates to the periosteum of the lateral
orbital rim and lateral orbital thickening. Both components are continuous with both
superior and inferior lid tarsal plates. (Adapted from Muzaffar AR, Mendelson BC,
Adams Jr WP. Surgical anatomy of the ligamentous attachments of the lower lid and
lateral canthus. Plast Reconstr Surg. 2002;110(3):873–884.)
Orbicularis fascia
Zygomatic bone
Temporalis
Maxilla bone
Coronoid process of mandible
Frontal bone
Lateral canthal tendon
Lateral orbital thickening
Tarsal plates
rim and deep temporal fascia by means of the lateral
orbital thickening.
• A deep component connects directly to the Whitnall
tubercle and is classically known as the lateral canthal
tendon (Fig. 1.3).
• The tarsal strap is a distinct anatomic structure that
inserts into the tarsus medial and inferior to the lateral
canthal tendon.
• The tarsal strap attaches approximately 3 mm
inferiorly and 1 mm posteriorly to the deep lateral
canthal tendon, approximately 4–5 mm from the anterior
orbital rim.
• It shortens in response to lid laxity, benefiting from
release during surgery to help achieve a long-lasting
restoration or elevation canthopexy (Fig. 1.4).
BOX 1.1  Principles for restoration of youthful eyes
• Control of periorbital aesthetics by proper brow positioning,
corrugator muscle removal, and lid fold invagination when
beneficial.
• Restoration of tone and position of the lateral canthus and, along
with it, restoration of a youthful and attractive intercanthal axis tilt.
• Restoration of the tone and posture of the lower lids.
• Preservation of maximal lid skin and muscle (so essential to lid
function and aesthetics) as well as orbital fat.
• Lifting of the midface through reinforced canthopexy, preferably
enhanced by composite malar advancement.
• Correction of suborbital malar grooves with tear trough (or
suborbital malar) implants, obliterating the deforming tear trough
(bony) depressions that angle down diagonally across the cheek,
which begin below the inner canthus.
• Control of orbital fat by septal restraint or quantity reduction.
• Removal of only that tissue (skin, muscle, fat) that is truly
excessive on the upper and lower lids, sometimes resorting to
unconventional excision patterns.
• Modification of skin to remove prominent wrinkling and excision
of small growths and blemishes.
to maintenance of the integrity, position, and function of
the globe and periorbital.
• These structures coalesce at the lateral orbit and support
the globe and eyelids like a hammock (Fig. 1.2).
• The lateral retinaculum consists of the lateral canthal
tendon, tarsal strap, lateral horn of the levator
aponeurosis, the Lockwood suspensory ligament,
Whitnall’s ligament, and check ligaments of the lateral
rectus muscle.
• They converge and insert securely into the thickened
periosteum overlying the Whitnall tubercle.
• Controversy exists surrounding the naming of the
components of the lateral canthal tendon.
• A superficial component is continuous with the
orbicularis oculi fascia and attaches to the lateral orbital
Supraorbital foramen
Supraorbital fissure
Infraorbital
fissure
Zygomaticofacial foramen
Greater wing
of sphenoid
Zygomatic
Superior orbital ridge
Optic foramen
Ethmoid
Lacrimal bone
and fossa
Maxilla
Infraorbital foramen
Frontal bone
Figure 1.1  Orbital bones. Frontal view of the orbit with foramina.
Orbicularis
Tenon’s capsule
Lateral canthal tendon
Medial canthal tendon
Fossa for lacrimal sac
Lateral check retinaculum
Medial check retinaculum
Medial rectus and sheath
Lateral rectus and sheath
Periorbita
Figure 1.2  Horizontal section of the orbit showing the lateral retinaculum formed
by the lateral horn of the levator, lateral canthal tendon, tarsal strap, the Lockwood
suspensory ligament, and lateral rectus check ligaments.

3
Anatomical pearls
• Adequate release of the tarsal strap permits a tension-free
canthopexy, minimizing the downward tethering force of
this fibrous condensation.
• This release along with a superior reattachment of the
lateral canthal tendon is key to a successful canthopexy.
Medial orbital vault
• A hammock of fibrous condensations suspends the globe
above the orbital floor. The medial components of the
apparatus include medial canthal tendon, the Lockwood
suspensory ligament and check ligaments of the medial
rectus.
• The medial canthal tendon, like the lateral canthal
tendon, has separate limbs that attach the tarsal plates to
the ethmoid and lacrimal bones.
• Each limb inserts onto the periorbital of the apex of the
lacrimal fossa. The anterior limb provides the bulk of the
medial globe support (Fig. 1.5).
Forehead and temporal region
• The forehead and brow consist of four layers: skin,
subcutaneous tissue, muscle, and galea.
• There are four distinct brow muscles: frontalis, procerus,
corrugator superciliaris, and orbicularis oculi (Fig. 1.6).
• The frontalis muscle inserts predominately into the
medial half or two-thirds of the eyebrow (Fig. 1.7),
allowing the lateral brow to drop hopelessly ptotic from
aging, while the medial brow responds to frontalis
activation and elevates, often excessively in its drive to
clear the lateral overhand. Constant contraction of the
Figure 1.4  The lateral canthal tendon inserts securely into the thickened
periosteum overlying Whitnall’s tubercle. The tarsal strap is a distinct anatomic
structure that suspends the tarsus medial and inferior to the lateral canthal tendon
to lateral orbital wall, approximately 4–5 mm from the orbital rim.
Tarsus
‘Tarsal strap’
Whitnall’s tubercle
Lateral canthal tendon
Orbital septum
Figure 1.5  The medial canthal tendon envelops the lacrimal sac. It is tripartite,
with anterior, posterior and superior limbs. Like the lateral canthal tendon, its limbs
are continuous with tarsal plates. The components of this tendon along with its
lateral counterpart are enveloped by deep and superficial aspects of the orbicularis
muscle. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular
Surgery. Philadelphia: Saunders; 2004:13.)
Superior limb, medial canthal tendon
Posterior limb, medial canthal tendon
Anterior limb, medial canthal tendon
Anterior and posterior lacrimal crests
Lacrimal fossa
Superciliary corrugator
Procerus
Frontalis
Orbicularis oculi
Pretarsal
orbicularis
Preseptal
orbicularis
Figure 1.6  Facial muscles of the orbital region. Note that the preseptal and
pretarsal orbicularis muscles fuse with the medial and lateral canthal tendons.
frontalis will give the appearance of deep horizontal
creases in the forehead (Fig. 1.8).
• The vertically oriented procerus is a medial muscle, often
continuous with the frontalis, arising from the nasal
bones and inserting into the subcutaneous tissue of the
glabellar region. It pulls the medial brow inferiorly and
contributes to the horizontal wrinkles at the root of the
nose. More commonly, these wrinkles result from brow
ptosis and correct spontaneously with brow elevation.
• The obliquely oriented corrugators muscle arises from the
frontal bone and inserts into the brow tissue laterally,
with some extensions into orbicularis and frontalis
musculature, forming vertical glabellar furrows during
contraction.
Eyelids
• There is much similarity between upper and lower eyelid
anatomy. Each consists of an anterior lamella of skin and

4
•
• Blepharoplasty
1
Upper eyelid
• The orbital septum originates superiorly at the arcus and
forms the anterior border of the orbit. It joins with the
levator aponeurosis, just superior to the tarsus. The sling
formed by the union of these two structures houses the
orbital fat.
• The levator palpebrae superioris muscle originates
above the annulus of Zinn. It extends anteriorly for
40 mm before becoming a tendinous aponeurosis
below Whitnall’s ligament. The aponeurosis fans
out medially and laterally to attach to the orbital
retinacula. The aponeurosis fuses with the orbital
septum above the superior border of the tarsus and
at the caudal extent of the sling, sending fibrous strands
to the dermis to form the lid crease. Extensions of the
aponeurosis finally insert into the anterior and inferior
tarsus. As the levator aponeurosis undergoes senile
attenuation, the lid crease rises into the superior orbit
from its remaining dermal attachments while the lid
margin drops.
• Müller’s muscle, or the supratarsal muscle, originates on
the deep surface of the levator near the point where the
muscle becomes aponeurotic and inserts into the superior
tarsus. Dehiscence of the attachment of the levator
aponeurosis to the tarsus results in an acquired ptosis
only after the Müller’s muscle attenuates and loses its
integrity.
• In the Asian eyelid, fusion of the levator and septum
commonly occurs at a lower level, allowing the sling and
fat to descend farther into the lid. This lower descent of
fat creates the characteristic fullness of their upper eyelid.
In addition, the aponeurotic fibers form a weaker
attachment to the dermis, resulting in a less distinct lid
fold (Fig. 1.10).
Frontalis
Figure 1.7  The frontalis muscle inserts predominantly into the medial half or
two-thirds of the eyebrow. The medial brow responds to frontalis activation and
elevates, often excessively, in its drive to clear lateral overhang.
Diagonal lines
Figure 1.8  Frontalis action. The frontalis muscle inserts into the medial two thirds
of the brow. Exaggerated medial brow elevation is required to clear the lateral
overhang and to eliminate visual obstruction. Constant contraction of the frontalis
will give the appearance of deep horizontal creases in the forehead. This necessarily
means that when the lateral skin is elevated or excised, the over-elevated and
distorted medial brow drops profoundly.
Orbicularis oculi
Upper tarsal plate
Capsulopalpebral fascia
Lockwood’s ligament
Muller’s muscle
Inferior rectus
Superior rectus
Levator palpebrae
Figure 1.9  Eyelid anatomy. Each eyelid consists of an anterior lamella of skin and
orbicularis muscle and a posterior lamella of tarsus and conjunctiva. The orbital
septum forms the anterior border of the orbital fat.
orbicularis muscle and a posterior lamella of tarsus and
conjunctiva (Fig. 1.9).
• The orbicularis muscle, which acts as a sphincter for the
eyelids, consists of orbital, preseptal, and pretarsal
segments.
• The pretarsal muscle segment fuses with the lateral
canthal tendon and attaches laterally to Whitnall tubercle.
Medially it forms two heads, which insert into the
anterior and posterior lacrimal crests (see Fig. 1.6).

A
B
C
D
6–8mm
8–13mm
0 to minimum
0 to minimum
Asian
Baggy eyelid
Deep set
(levator dehiscence)
Occidental
Figure 1.10  The anatomic variations in the upper eyelid displayed by different ethnic groups and the changes associated with senescence within each group allow for a
convergence of anatomy. (A) The normal, youthful Asian upper eyelid has levator extensions inserting onto the skin surface to define a lid-fold that averages 6–8 mm above
the lid margin. The position of the levator-skin linkage and the anteroposterior relationship of the preaponeurotic fat determine lid-fold height and degree of sulcus concavity
or convexity (as shown on the right half of each anatomic depiction). (B) In the case of levator dehiscence from the tarsal plate, the upper lid crease is displaced superiorly.
The orbital septum and preaponeurotic fat linked to the levator are displaced superiorly and posteriorly. These anatomic changes create a high lid crease, a deep superior
sulcus, and eyelid ptosis. (C) In the aging eyelid, the septum becomes attenuated and stretches. The septal extension loosens, and this allows orbital fat to prolapse forward
and slide over the levator into an anterior and inferior position. Clinically, this results in an inferior displacement of the levator skin attachments and a low and anterior
position of the preaponeurotic fat pad. (D) The youthful Asian eyelid anatomically resembles the senescent upper lid with a low levator skin zone of adhesion and inferior and
anteriorly located preaponeurotic fat. The characteristic, but variable, low eyelid crease and convex upper eyelid and sulcus are classic. (Adapted from Spinelli HM. Atlas of
Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:59.).

6
•
• Blepharoplasty
1
• It fuses with the orbital septum 5 mm below the tarsal
border and then inserts into the anterior and inferior
surface of the tarsus.
• The inferior tarsal muscle is analogous to Müller’s muscle
of the upper eyelid and also arises from the sheath of the
inferior rectus muscle. It runs anteriorly above the
inferior oblique muscle and also attaches to the inferior
tarsal border.
• The combination of the orbital septum, orbicularis, and
skin of the lower lid acts as the anterior barrier of the
orbital fat. As these connective tissue properties relax, the
orbital fat is allowed to herniate forward, forming an
unpleasing, full lower eyelid. This relative loss of orbital
volume leads to a commensurate, progressive hollowing
of the upper lid as upper eyelid fat recesses.
• The capsulopalpebral fascia and its overlying conjunctiva
form the posterior border of the lower orbital fat.
Transection of the capsulopalpebral fascia during lower
lid procedures, particularly transconjunctival
blepharoplasty, releases the retractors of the lower eyelid,
which can reduce downward traction and allow the
position of the lower lid margin to rise.
Retaining ligaments
• A network of ligaments serves as a scaffold for the
skin and subcutaneous tissue surrounding the orbit.
The orbital retaining ligament directly attaches the
orbicularis at the junction of its orbital and preseptal
components to the periosteum of the orbital rim and,
consequently, separates the prezygomatic space from the
preseptal space. This ligament is continuous with the
lateral orbital thickening, which inserts onto the lateral
orbital rim and deep temporal fascia. It also has
attachments to the superficial lateral canthal tendon (see
Fig. 1.3, Figs 1.12, 1.13). Attenuation of these ligaments
permit descent of orbital fat onto the cheek. A midface lift
must release these ligaments to achieve a supported,
lasting lift.
Blood supply
• The internal and external carotid arteries supply blood
to the orbit and eyelids (Fig. 1.14).
• The ophthalmic artery is the first intracranial branch of
the internal carotid; its branches supply the globe,
extraocular muscles, lacrimal gland, ethmoid, upper
eyelids, and forehead.
• The external carotid artery branches into the superficial
temporal and maxillary arteries. The infraorbital artery is
a continuation of the maxillary artery and exits 8 mm
below the inferomedial orbital rim to supply the lower
eyelid.
• The arcade of the superior and inferior palpebral arteries
gives a rich blood supply to the eyelids. The superior
palpebral artery consists of a peripheral arcade located at
the superior tarsal border – the area where surgical
dissection occurs to correct lid ptosis and to define lid
folds. Damage to a vessel within this network commonly
results in a hematoma of Müller’s muscle, causing lid
Septal extension
• The orbital septum has an adhesion to the levator
aponeurosis above the tarsus. The septum continues
beyond this adhesion and extends to the ciliary margin. It
is superficial to the preaponeurotic fat found at the
supratarsal crease. The septal extension is a dynamic
component to the motor apparatus, as traction on this
fibrous sheet reproducibly alters ciliary margin position
(Fig. 1.11). The septal extension serves as an adjunct to,
and does not operate independent of, levator function, as
mistaking the septal extension for levator apparatus and
plicating this layer solely results in failed ptosis
correction.
Lower eyelid
• The anatomy of the lower eyelid is somewhat analogous
to that of the upper eyelid.
• The retractors of the lower lid, the capsulopalpebral
fascia, correspond to the levator above.
• The capsulopalpebral head splits to surround and fuse
with the sheath of the inferior oblique muscle. The two
heads fuse to form the Lockwood suspensory ligament,
which is analogous to Whitnall’s ligament.
Muller’s muscle
Levator
aponeurosis
Tarsus
Septal
extension
Orbital
septum
Orbicularis
Figure 1.11  The orbital septum has an adhesion to the levator aponeurosis above
the tarsus. The septal extension begins at the adhesion of the orbital septum to the
levator and extends to the ciliary margin. It is superficial to the preaponeurotic fat
found at the supratarsal crease. (Adapted from Reid RR, Said HK, Yu M, et al.
Revisiting upper eyelid anatomy: introduction of the septal extension. Plast Reconstr
Surg. 2006;117(1):65–70.)

7
Anatomical pearls
Innervation: trigeminal nerve and facial nerve
• The trigeminal nerve along with its branches provides
sensory innervations to the periorbital region (Fig. 1.15).
• A well-placed supraorbital block will anesthetize most of
the upper lid and the central precoronal scalp.
• The maxillary division exits the orbit through one to
three infraorbital foramina. It provides sensation to the
skin of the nose, the lower eyelids, and the upper lid.
• The facial nerve supplies motor function to the lids
(Fig. 1.16).
• Innervation of facial muscles occurs on their deep
surfaces.
• Interruption of the branches to the orbicularis muscle
from the periorbital surgery or facial surgery may result
in atonicity due to partial denervation of the orbicularis
with loss of lid tone or anomalous reinnervation and
possibly undesirable eyelid twitching.
• The frontal branch of the facial nerve courses
immediately above and is attached to the periosteum of
the zygomatic bone. It then courses medially
approximately 2 cm above the superior orbital rim to
innervate the frontalis, corrugators, and procerus muscles
from their deep surface.
• A separate branch travels along the inferior border of the
zygoma to innervate the inferior component of
orbicularis oculi.
ptosis for 2–8 weeks postoperatively. Likewise, on the
lower lid, the inferior palpebral artery lies at the inferior
border of the inferior tarsus.
• The supratrochlear, dorsal nasal, and medial palpebral
arteries all traverse the orbit medially. Severing these
arteries during fat removal, without adequately
providing hemostasis, may lead to a retrobulbar
hematoma, a vision-threatening complication of
blepharoplasty.
Figure 1.12  The orbicularis muscle fascia attaches to the skeleton along the
orbital rim by the lateral orbital thickening (LOT) in continuity with the orbicularis
retaining ligament (ORL). (Adapted from Ghavami A, Pessa JE, Janis J, et al. The
orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr
Surg. 2008;121(3):994–1001.).
Orbicularis oculi
Orbicularis retaining
ligament
Nasal bone
Maxilla bone
Frontal bone
Zygomatic bone
Orbicularis retaining ligament
Lateral orbital thickening
Corrugator supercilii
Figure 1.13  The orbital retaining ligament (ORL) directly attaches the orbicularis
oris (OO) at the junction of its pars palpebrarum and pars orbitalis to the
periosteum of the orbital rim and, consequently, separates the prezygomatic space
from the preseptal space. (Adapted from Muzaffar AR, Mendelson BC, Adams Jr
WP. Surgical anatomy of the ligamentous attachments of the lower lid and lateral
canthus. Plast Reconstr Surg. 2002;110(3):873–884.)
Orbicularis oculi
Prezygomatic space
Orbitomalar ligament
Septum orbitale
Globe
Figure 1.14  Arterial supply to the periorbital region.
Dorsal nasal artery
Lateral nasal artery
Inferior palpebral artery
Angular artery
Supraorbital artery
Infraorbital artery
Superficial temporal
artery
Lacrimal artery
Zygomaticofacial artery
Transverse facial artery
Facial artery
Supratrochlear artery
Medial palpebral artery (superior)
1. Peripheral arcade
2. Marginal arcade
Medial palpebral artery
(inferior)
Infraorbital nerve
Infratrochlear nerve
Supratrochlear nerve
Supraorbital nerve
Lacrimal nerve
Zygomaticofacial
nerve
Zygomaticotemporal
nerve
Figure 1.15  Sensory nerves of the eyelids.

8
•
• Blepharoplasty
1
• In a relaxed forward gaze, the vertical height of the
aperture should expose at least three-quarters of the
cornea with the upper lid extending down at least
1.5 mm below the upper limbus (the upper margin of the
cornea) but no more than 3 mm. The lower lid ideally
covers 0.5 mm of the lower limbus but no more than
1.5 mm.
• In the upper lid, there should be a well-defined lid crease
lying above the lid margin with lid skin under slight
stretch, slightly wider laterally.
• Ideally, the actual pretarsal skin visualized on relaxed
forward gaze ranges from 3 to 6 mm in European
ethnicities.
• The Asian lid crease is generally 2–3 mm lower, with the
distance from lid margin diminishing as the crease moves
toward the inner canthus.
• Patients of Indo-European and African decent show 1 to
2 mm lower than European ethnicities.
• The ratio of distance from the lower edge of the eyebrow
(at the center of the globe) to the open lid margin to the
visualized pretarsal skin should never be less than 3–1
(see Fig. 1.1), preferably more.
• Scleral show is the appearance of white sclera below the
lower border of the cornea and above the lower eyelid
margin. In general, sclera show is contradictory to
optimal aesthetics and may be perceived as a sign of
aging, previous blepharoplasty, or orbital disease (e.g.,
thyroid disease).
• More than 0.5 mm of sclera show beneath the cornea on
direct forward gaze begins to confer a sad or melancholy
aura to one’s appearance.
• The intercanthal axis is normally tilted slightly upward
(from medial to lateral) in most populations.
• Exaggerated tilts are encountered in some Asian, Indo-
European and African-American populations.
Preoperative considerations
• A thorough history and physical examination should be
obtained – including an ophthalmic history (see Box 1.2).
• Physical exam should include evaluation for symmetry;
globe shape, position and appearance; signs of aging; lid
appearance; lid function and relative laxity.
• In the upper lid, excessive skin due to loss of elasticity
and sun damage is one of the major causes of an aged
appearance in the periorbital area.
• In addition to relaxed skin changes, excessive fat
herniation can cause bulging, resulting in a heavy
appearance to the upper lid area.
• Aging changes in the lower lid include relaxation of the
tarsal margin with scleral show, rhytides of the lower lid,
herniated fat pads resulting in bulging in one or all of the
three fat pocket areas, and hollowing of the nasojugal
groove and lateral orbital rim areas.
• Hollowing of the nasojugal groove area appears as dark
circles under the eyes, mostly because of lighting and the
shadowing that result from this defect.
• Contact lens wear poses particular risks when eyelid
surgery is performed.
Youthful, beautiful eyes
• The characteristics of youthful, beautiful eyes differ from
one population to another but generalizations are
possible and provide a needed reference to judge the
success of various surgical maneuvers.
• Attractive, youthful eyes have globes framed in
generously sized horizontal apertures (from medial and
lateral), often accentuated by a slight upward tilt of the
intercanthal axis (Fig. 1.17).
• The aperture length should span most of the distance
between the orbital rims.
Figure 1.16  Anatomy of the brow and temporal region. The light green opaque
area denotes the deep temporal fascia and the periosteum where sutures may be
used to suspend soft tissue. Wide undermining, soft tissue suspension and
canthopexy are safely performed here.
Temporal branches (facial nerve VIII)
Zygomatic branches (facial nerve VIII)
Figure 1.17  On relaxed forward gaze, the ideal upper lid should rest approximately
2 mm below the upper limbus. The lower lid ideally covers 0.5 mm of the lower
limbus. The ratio of distance from the lower edge of the eyebrow to the open lid
margin to the pretarsal skin ratio should be greater than 3.
3–5X
X

9
Operative techniques
• If ptosis exists, the type of repair depends upon the
severity of the ptosis and the reliability of the levator to
recreate smooth, upper lid elevation.
• Pseudoptosis occurs when excess upper lid skin covers
the eyelid, depressing the eyelashes, forming hooding
and simulating ptosis.
• Photographic evidence of this is often necessary for
insurance purposes when a levator aponeurosis repair or
an excisional blepharoplasty is planned.
• Brow ptosis is a common aspect of facial aging. It adds
weight and volume to the upper eyelid to develop, or
exacerbate, eyelid ptosis.
• The ability to differentiate the causes of droopy eyelids
– brow ptosis (brow weight resting on the eyelids),
dermatochalasis (excess skin), and blepharoptosis (levator
attenuation or dehiscence) – will enable the surgeon to
select the proper correction.
• There is a normal 10–12 mm projection of the globe seen
in a lateral, as measured from the lateral orbital rim at
the level of the canthal tendon to the pupil.
• Proptosis and enophthalmos are relative anterior and
posterior displacement of the globe, respectively. Hertel
exophthalmometry can be used to quantitate the degree
of relative projection for documentation purposes.
• Assessment of tear production is a necessary but
unreliable task.
• The Schirmer test:
■ Placing filter paper strips in the lateral third of the
lower eyelid.
■ After 5 min, normal tear production should be greater
than 15 mm; 5–10 mm indicates borderline tear
secretion, and below 5 mm is hyposecretion.
• No other area of cosmetic surgery is more dependent
on accurate photography than the periorbital region
(Box 1.3).
• Before surgical planning, one must have a meaningful
conceptualization of the desired result. Only then can the
surgical maneuvers required be organized in a
meaningful way (Box 1.4).
Operative techniques (Video 1.1)
Simple skin blepharoplasty
• When skin-only excision is elected, it should occur
above the supratarsal fold or crease, leaving that
structure intact – this retains most of the definition of an
existing lid fold.
• Long-term contact lens wearing hastens the process of
drying out the eyes.
• Traditional blepharoplasty techniques consistently
produce vertical dystopia with increased scleral exposure,
making the lens wear difficult if not dangerous.
• Ptosis and canthopexy surgery may alter the corneal
curvature and require that contacts be refitted.
• The patient should discontinue contact lens wear in the
perioperative period to allow healing without the need to
manipulate the eyelids.
• Dry irritated eyes before surgery will lead to irritated
eyes after surgery, and the surgeon may be blamed.
• Treatment options include artificial tears, ointment,
anti-inflammatory drops, and punctal plugs or punctal
closure.
• Exophthalmos, unilaterally or bilaterally, associated with
a thyroid disorder should be completely stabilized for
approximately 6 months before elective aesthetic surgery.
• Eyelid measurements are documented for use during
ptosis surgery and, if necessary, for insurance purposes.
• In the typical person with the brow in an aesthetically
pleasing position, 20 mm of upper lid skin must remain
between the bottom of the central eyebrow and the upper
lid margin to allow adequate lid closure during sleep, a
well-defined lid crease, and an effective and complete
blink.
• In the eyelid of the white individual, the aperture
(distance between the upper and lower eyelids) average
is 10–12 mm.
• The margin reflex distance (MRD), measured from the
light reflex on the center of the cornea to the upper eyelid
margin, ranges from 3 to 5 mm.
• True blepharoptosis is defined by the degree of upper lid
infringement upon the iris and pupil.
• As the MRD decreases towards zero, the severity of
blepharoptosis increases.
• Before method selection, the levator function must be
determined by measuring the upper eyelid excursion
from extreme downward gaze to extreme upward gaze; it
generally ranges from 10 to 12 mm.
BOX 1.2  Important information to obtain during history and
physical examination
• Medication use: particularly anticoagulants, anti-inflammatory
and cardiovascular drugs, and vitamins (especially vitamin E).
• Herbal supplement use: herbs represent risks to anesthesia and
surgery, particularly those affecting blood pressure, blood
coagulation, the cardiovascular system, and healing.
• Allergies: medication and type.
• Past medical history: especially hypertension, diabetes,
cardiovascular and cerebrovascular disease, hepatitis, liver
disease, heart disease or arrhythmias, cancer, thyroid disease,
and endocrine disease.
• Bleeding disorders or blood clots.
• Psychiatric disease.
• Alcohol and smoking history.
• Recreational drug use, which may interact with anesthesia.
• Exposure to human immunodeficiency virus and hepatitis virus.
• Any history of facial herpes zoster or simplex.
BOX 1.3  Recommended photographic views
• Full face, upright (at rest) frontal, oblique, and lateral views.
• Full face, upright, and smiling.
• Direct periorbital views in upward gaze and downward gaze and
with eyes gently closed.
• A view with a finger slightly elevating the brows with the eyes
open and another with the eyes closed.
Video
1.1

10
•
• Blepharoplasty
1
• The supratarsal fold is located approximately 7–8 mm
above the ciliary margin in women and 6–7 mm in men.
• The upper marking must be at least 10 mm from the
lower edge of the brow and should not include any thick
brow skin.
• The use of a pinch test for redraping the skin is helpful.
• The shape of the skin resection is lenticular in younger
patients and more trapezoid-shaped laterally in older
patients.
• The incision may need to be extended laterally with a
larger extension, but extension lateral to the orbital rim
should be avoided if possible, to prevent a prominent
scar (Fig. 1.18).
Figure 1.18  Simple skin excision blepharoplasty. (A) Digital traction and light pressure by the surgeon allow smooth quick incisions. (B) The skin may be elevated with the
orbicularis muscle in one maneuver, proceeding from lateral to medial. (C) The orbital septum is then opened, exposing the preaponeurotic space. The underlying levator
aponeurosis is protected by opening the septum as cephalad as possible. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia:
Saunders; 2004:64.)
A
B
C
Incision
Skin and orbicularis muscle resection
Pressure on globe causes
medial fat pad bulge
Levator aponeurosis
Orbital septum
Central fat pad (preaponeurotic)
on levator aponeurosis
BOX 1.4  Preoperative periorbital plan
The preoperative periorbital plan should include the following:
• The patient’s specific concerns and desires for improvement.
• Brow position.
• Lower eyelid tonicity.
• Eyelid ptosis, retraction, or levator dehiscence.
• Exophthalmos or enophthalmos.
• Supraorbital rim prominence or hypoplasia.
• Suborbital malar and tear trough deformities.
• Excision of necessary skin, muscle, and fat – only if necessary.

11
Operative techniques
• A small septotomy is made at the superior aspect of the
skin excision into each fat compartment in which
conservative resection of redundant fat has been planned.
• The fat is teased out bluntly and resected using pinpoint
cautery.
• This fat usually includes the medial or nasal
compartment, which contains white fat.
• Similarly, the medial markings should not be extended
medial to the medial canthus because extensions onto the
nasal side wall result in webbing.
• At the conclusion of the case, the patient should have
approximately 1–2 mm of lagophthalmos bilaterally.
Figure 1.19 displays the predictable, restorative outcomes
that can be achieved with skin excision alone.
Anchor (or invagination blepharoplasty)
• Anchor blepharoplasty involves the creation of an upper
eyelid crease by attaching pretarsal skin to the underlying
aponeurosis.
• Advantages of an anchor blepharoplasty are a crisp,
precise, and well-defined eyelid crease that persists
indefinitely.
• Disadvantages are that it is more time-consuming,
requires greater surgical skills and expertise, and
encourages greater frontalis relaxation as a result of more
effective correction of the overhanging pseudoptotic skin.
• Key components of the anchor blepharoplasty include:
■ Minimal skin excision (2–3 mm) extending cephalad
from the tarsus.
■ A 1–2 mm sliver of orbicularis must be removed in
proportion to the amount of skin removed.
■ A small pretarsal skin and muscle flap are dissected
from the aponeurosis and septum adhesion.
■ After sharply disinserting the aponeurosis from the
tarsus, pretarsal fatty tissue can be removed to debulk
the pretarsal skin.
■ Mattressed anchor sutures are placed connecting the
tarsus to the aponeurosis and pretarsal skin (Fig. 1.20).
■ Finally, a running suture approximates the preseptal
skin incision.
Orbital fat excision
• A relative excess of retroseptal fat may be safely excised
through an upper eyelid blepharoplasty incision.
Figure 1.19  (A) Preoperative and (B) postoperative photograph depicting predictable results with simple skin excision blepharoplasty.
A
B
Figure 1.20  Anchor blepharoplasty technique. Attaching the dermis of the
pretarsal skin flap to the superior aspect of the tarsus and to the free edge of the
aponeurosis. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular
Surgery. Philadelphia: Saunders; 2004:69.)

12
•
• Blepharoplasty
1
• Inflammation-mediated tightening can enhance septal
integrity.
• Septal plication aid is unnecessary and may induce a
brisk, restrictive inflammatory response.
Blepharoptosis
• During upper blepharoplasty, with the septum open and
the aponeurosis and superior tarsus exposed, there is an
ideal opportunity to adjust the level of the aperture.
• Inappropriate aperture opening can be due to upper lid
ptosis or upper lid retraction.
• True ptosis repair involves reattachment of the levator
aponeurosis to the tarsus, with or without shortening of
applicable structures (e.g. aponeurosis, Müller’s muscle,
and tarsus).
• There are a variety of techniques to address
blepharoptosis but they are outside the scope of this
chapter. There is a significant learning curve to
performing a ptosis repair, and even then, the ability to
get perfect symmetry is elusive.
• In the setting of mild upper eyelid ptosis (approx. 1 mm),
where the decision has been made to avoid a formal lid
ptosis procedure, selective myectomy of the upper eyelid
orbicularis can be performed to widen the lid aperture.
• The amount of muscle to be resected depends on a host
of factors, including the severity of relative lid ptosis,
brow position, and fold disparity (Fig. 1.22) and is
titrated depending on the amount of effect desired.
• For 1 mm or less of relative upper lid ptosis, resection of
at least 3–4 mm of orbicularis is required.
• No attempt is made to close orbicularis muscle in
this resection, which could increase the risk of
lagophthalmos.
The key components of formal lid ptosis correction include:
• Correct identification of the distal extensions of the
aponeurosis and the orbital septal extension.
• The superior edge of the tarsus is freed from any dermal
or tendinous extensions.
• Leaving a small cuff of filmy connective tissue (approx.
1 mm) on the tarsus will minimize bleeding from the
richly vascularized area.
• Ensure that there is complete hemostasis by use of a fine
forceps cautery, lifting all lid tissues away from the
cornea and globe before cauterizing.
• Anchor the upper third of the tarsus to the remaining
levator with 5–0 silk suture, placed as a horizontal
mattress.
• The lid should be flipped to ensure that the suture is not
exposed posteriorly on the tarsus, which could cause a
troublesome corneal abrasion.
• If performed under sedation or local anesthetic, the
level should be checked by having the patient open
the eye.
• For cases under general anesthetic, one should attempt to
create one to two times the amount of lagophthalmos
relative to the preoperative ptosis.
• If there is any medial or lateral retraction or ptosis, the
central suture should be repositioned medially or
• Yellow fat in the central compartment is usually more
superficial and lateral.
• Gentle pressure on the patient’s globe can reproduce the
degree of excess while the patient lies recumbent on the
operating room table (Fig. 1.21).
• Overall, undercorrection is preferred to prevent
hollowing, which can be dramatic and recognized as an
A-frame abnormality.
• The attenuated orbital septum may be addressed by
using selective diathermy along the exposed caudal
septum.
Figure 1.21  Simple skin excision blepharoplasty. (A) The medial fat pad may
require digital pressure to expose and grasp; however, care should be taken not to
overly resect fat when using digital pressure techniques. (B) Closure may then be
performed with a combination of interrupted and running intracuticular sutures.
(Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery.
Philadelphia: Saunders; 2004:65.)
A
B
Medial fat pad removed
Intracuticular running
suture
Closure
Interrupted sutures
Whitnall’s ligament
Levator aponeurosis

13
Operative techniques
A
B
Levator plication
Orbital septum
and underlying
(preaponeurotic) fat
Levator aponeurosis
Figure 1.22  (A,B) Once the upper lid is incised, the levator may be modified (shortened/lengthened) in a number of ways, including simple plication. A suborbicularis skin
flap can also be developed allowing access to preaponeurotic fat. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders;
2004:69).
laterally as many times as needed, with adjustment to a
pleasing lid height and contour.
• Both sides should be completed before the suture is
permanently tied.
Lower lid blepharoplasty
• Lower blepharoplasty has evolved substantially.
Although excellent aesthetic results can be achieved with
transcutaneous lower blepharoplasty, lid retraction and
ectropion are concerning complications. Conservative
excisional techniques center on the concept of fat
preservation. Transconjunctival lower blepharoplasty,
although more conservative, does not eliminate the risk
of lid malposition. An effective, lasting procedure should
address the extrinsic and intrinsic support of the eye,
which is weakened during the aging process.
Transconjunctival blepharoplasty
• Transconjunctival blepharoplasty is the preferred
procedure for fat reduction in patients without excess
skin and with good canthal position.
• It is less likely to lead to lower lid malposition than a
transcutaneous approach.
• It minimizes but does not eliminate postoperative lower
lid retraction.
• Transection of the lower lid retractors can cause a
temporary rise in the lid margin, especially if they are
suspended during the healing period.
• Previously suspected septal scarring through
transconjunctival fat excision has not been shown to
significantly alter lid posture or tonicity.
• The lower lid retractors (capsulopalpebral fascia and
inferior tarsal muscle) and overlying conjunctiva lie
directly posterior to the three fat pads of the lower lid.
• A broad and deep transconjunctival incision severs both
conjunctiva and retractors but typically should not incise
the orbital septum, orbicularis, or skin.
• The conjunctival incision is made with a monopolar
cautery needle tip at least 4 mm below the inferior border
of the tarsus – never through the tarsus (Fig. 1.23).
• A preseptal approach is obtained by entering the
conjunctiva above the level of septal attachment to the
capsulopalpebral fascia.
• A retroseptal approach involves a 1.5–2 cm incision
lower down in the fornix, and is typically used to
excise fat.
• It is preferable to leave the transconjunctival incision
open.

14
•
• Blepharoplasty
1
wide access to the orbital fat, even helping to prolapse
the fat into the wound. The thin film of synovium-
appearing capsule encasing the orbital fat is opened,
releasing the fat to bulge into the operative field
(Fig. 1.24).
• Once fat is removed through a transconjunctival
incision, excess skin can be removed through a
subciliary position.
• Fat reduction may leave skin excess, leading to
wrinkling.
• Suturing the wound may trap bacteria or cause corneal
irritation.
• Conjunctival closure, when it is elected, is simplified by a
monofilament pull-out suture that enters the eye
externally, closes the conjunctiva, and exits through the
skin and is taped.
• The incision through the conjunctiva and retractors gives
excellent access to the orbital fat.
• A 6–0 silk traction suture passed through the inferior
conjunctival wound and retracted over the globe gives
Figure 1.23  The transconjunctival approach to the retroseptal space may be in one of two ways: preseptal or retroseptal. The preseptal route requires entry into the
suborbicularis preseptal space above the fusion of the lower lid retractors and the orbital septum. This will allow direct visualization of the septum, and each fat pad can be
addressed separately in a controlled fashion. (A) A conjunctival stay suture is placed deep in the fornix and traction is applied superiorly while the lid margin is everted. This
causes the inferior edge of the tarsal plate to rise toward the surgeon. (B) The conjunctiva and lower lid retractors are incised just below the tarsal plate entering the
suborbicularis preseptal space. This plane is developed to the orbital rim with the assistance of the traction suture and a nonconductive instrument. (C) The conjunctiva and
lower lid retractors are incised just below the tarsal plate entering the suborbicularis preseptal space. This plane is developed to the orbital rim with the assistance of the
traction suture and a nonconductive instrument. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:86.)
B
A
C
Conjunctiva is divided longitudinally
just below the tartsal plate
Retroseptal approach
Pretroseptal (suborbicularis) approach
Nonconductive retractor
Conjunctiva is tented and secured with a stay suture
Orbital septum
Inferior tarsal plate

15
Operative techniques
Figure 1.24  (A) The orbital septum may then be punctured and the inferior oblique muscle identified and preserved. (B) The fat pad may be addressed individually
in-keeping with preoperative plans with either resection, repositioning, conservation or any combination of the these techniques. (Adapted from Spinelli HM. Atlas of
Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:87.)
A
B
Lateral, central and medial fat pads (left to right)
Conjunctiva retracted superiorly
Inferior oblique muscle
Reposition fat pads transconjunctivally
Remove fat pads if they bulge
Orbital septum opened
• A conservative “skin pinch” can be done to estimate
skin removal, or alternatively, skin can be tightened
by skin resurfacing with chemical or laser peels
(Fig. 1.25).
• One should be careful not to incise the orbital septum,
which leads to increased postoperative retraction.
• This procedure works particularly well when there is an
isolated fat pad, especially medially, accessed through a
single stab incision through the conjunctiva.
Transcutaneous blepharoplasty
• A subciliary incision can be used to develop a skin flap or
a skin-muscle flap.
• With either method, pretarsal orbicularis fibers should
remain intact.
• For the skin-muscle flap, skin and preseptal orbicularis
are elevated as one flap, while with a skin flap, the
muscle and its innervation can be preserved.

16
•
• Blepharoplasty
1
• Access to the medial and central fat pads is by the
subciliary or transconjunctival incision.
• The minor degree of lateral fat pad prominence is
generally insufficient to affect any change with
repositioning.
• A supraperiosteal or a subperiosteal dissection of
8–10 mm caudal to the inferior orbital rim permits
tension-free placement.
• The fat can be secured in place with interrupted
absorbable sutures.
• Patients must be warned that various degrees of fat loss
and hardening are possible. There is also a rare but
described possibility of restrictive strabismus related to
aggressive fat mobilization and fixation.
Orbital septum plication
• In this procedure, the herniated septum is plicated and
repositioned to its normal anatomic site within the orbit.
• The fat is replaced in the retroseptal position to regain its
original anatomic integrity (Fig. 1.26).
• Periorbital fat, muscle, and skin can be addressed with
either approach.
• Once the plane deep to the orbicularis is entered,
dissection continues between the muscle and the orbital
septum down to the level of the orbital rim.
• Periorbital fat can be excised through small incisions in
the septum.
• The fat can also be retropositioned using
capsulopalpebral fascia placation, or it can be transferred
into the naso-jugular fold.
Orbicularis muscle fibers and skin can be excised at closure.
• Care must be taken with muscle excision, which can lead
to orbicularis denervation and lid malposition.
Orbital fat transposition
• An alternative to excising prominent orbital fat is to
redrape the pedicled fat onto the arcus marginalis.
• Patients with tear trough deformities who have
prominent medial fat pads are excellent candidates.
Figure 1.25  (A) Simple skin excision lower eyelid blepharoplasty. (B) Typical removal of redraped skin or skin-muscle from the lower lid, which can be the shape of an
obtuse triangle, with the largest amount sacrificed laterally.
A
B
A
Inferior orbital septum
Inferior orbital rim
Capsulopalpebral fascia
Protruding inferior orbital fat
B
Inferior orbital septum
Inferior orbital rim
Capsulopalpebral fascia
Figure 1.26  (A,B) Schematic representation of procedure for lower eyelid. Note that only the inferior orbital septum is plicated and sutured to the inferior orbital rim.
(Adapted from Sensöz O, Unlu RE, Percin A, et al. Septoorbitoperiostoplasty for the treatment of palpebral bags: a 10-year experience. Plast Reconstr Surg. 1998;
101(6):1657–1663.)

17
Operative techniques
the lower eyelid at an elevated level due to the
unopposed action of the pretarsal orbicularis.
Orbicularis suspension
• Orbicularis repositioning can be used to eliminate
hypotonic and herniated orbicularis muscle, soften
palpebral depressions, and shorten the lower lid to cheek
distance.
• The main steps include:
■ Elevation of a skin muscle flap.
■ Release of the orbicularis retaining ligament and
resuspension of the orbicularis – frequently after
lateral canthopexy.
■ Along the entire infraorbital rim, the orbicularis
retaining ligament is divided.
■ Additional medial dissection is performed to release
the levator labii when a tear trough deformity is
present.
■ The skin muscle flap is draped in a superior lateral
vector rather than a pure vertical vector.
■ Excision of skin and muscle are performed by
removing a triangle of tissue lateral to the canthus,
thereby minimizing the amount of tissue removed
along the actual lid margin.
■ The lateral suspension of the orbicularis is to the
orbital periosteum.
■ Lower lid support is gained by resuspension of the
anterior (skin and muscle) and posterior lamellae
(tarsus by canthopexy).
• Three to four 5–0 polyglycolic acid sutures are placed in a
vertical fashion from medial to lateral.
• The protruding fat pads are invaginated and the integrity
of the thin, flaccid septum is restored.
• Additional support may be gained with septo-
orbitoperiostoplasty variation which plicates the flaccid
septum and secures it to the periosteum of the inferior
orbital rim.
• Because no disruption of the eyelid anatomy occurs,
complications related to lid malposition such as lid
retraction, scleral show, and ectropion are reduced.
Capsulopalpebral fascia plication
• The capsulopalpebral fascia can be plicated to the orbital
rim either through a transcutaneous or a
transconjunctival approach.
• In the transcutaneous method, dissection is carried out
between the orbicularis and the septum down to the
orbital rim; the capsulopalpebral fascia is then sutured to
the orbital rim.
• In the transconjunctival method, the capsulopalpebral
fascia is divided from the tarsus, and orbital fat is
retroplaced, its position maintained by suturing the
capsulopalpebral fascia to the periosteum of the orbital
rim using a continuous running 6–0 nonabsorbable
suture.
• The conjunctival gap of a few millimeters is allowed to
reepithelialize (Fig. 1.27).
• One advantage of the transconjunctival approach is the
division of lower eyelid depressors, which helps maintain
A
Inferior orbital septum
Fascioseptal triangular space
B
Upper (ciliary) flap
Lower (ocular) flap made up
of conjunctiva inferior tarsal
muscle capsulopalpebral fascia
Figure 1.27  (A,B) Suturing the lower capsulopalpebral flap to the arcus marginalis to reduce and contain the herniated fat. (Adapted from Camirand A, Doucet J, Harris J.
Anatomy, pathophysiology, and prevention of senile enophthalmia and associated herniated lower eyelid pads. Plast Reconstr Surg. 1997;100(3):1535–1538.)

18
•
• Blepharoplasty
1
• Next, the lateral retinaculum and tarsal strap are bluntly
dissected off the periosteum 5 mm in both directions
(Figs 1.4, 1.29).
• A double-armed 4–0 Prolene or Mersilene is used to
suture the tarsal plate and lateral retinaculum to the inner
aspect of the lateral orbital rim periosteum above the
Whitnall tubercle.
• Periosteum is thickest at the superior and lateral orbital
rim, making it a secure suture site.
• The mattress suture is placed through the periosteum
within the lateral orbital rim to maintain the posterior
position of the lid margin against the globe.
• Bone canthopexy is technically possible through upper
and lower lid incisions but is technically demanding.
• Wide exposure through a coronal brow lift provides the
ideal environment and access.
• Bone fixation gives a profoundly longer lasting result
than does periosteal fixation.
• Drill holes (1.5 mm drill bit) are placed 2–3 mm posterior
to the lateral orbital rim.
• The inferior and superior holes are separated by 5–10 mm
to allow suture separation and ligation (Fig. 1.30).
• The vertical position of the lateral canthal suture is
dependent on eye prominence and preexisting canthal
tilt. Patients with prominent eyes and negative vector
morphology are at higher risk for lid malposition
and require additional vertical support of the lateral
canthus.
• While the standard position of the lateral canthopexy
suture is most commonly at the lower level of the pupil,
patients with prominent eyes or negative vectors require
additional vertical positioning of the lateral canthal
support suture at the superior aspect of the pupil.
• Lateral canthoplasty, which includes surgical division of
the lateral canthus, is recommended for more significant
lower lid laxity, defined by lid distraction >6 mm away
from the globe.
• Lateral canthotomy, cantholysis of the inferior limb of the
lateral canthal tendon, and release of the tarsal strap are
performed.
• This dissection is followed by a 2–3 mm full-thickness lid
margin resection, depending on the degree of
tarsoligamentous laxity.
• The lateral commissure is carefully reconstructed by
aligning the anatomical grey line with 6–0 plain gut.
• Final fixation to the lateral orbital periosteum can be as
described above.
Midface lifting
• The middle third of the face, or midface, lies between
the lateral canthal angle and the top of the nasolabial
fold. It includes the lateral canthal tendon, the medial
canthal tendon, the skin, fat, and orbicularis oculi muscle
of the lower eyelids, the sub–orbicularis oculi fat pad, the
malar fat pad, the orbitomalar ligament (orbicularis
ligament), the orbital septum, and origins of the
zygomaticus major and minor muscles and levator labii
superioris.
• This technique is best suited for patients with scleral
show, lid laxity, and a negative vector, which put them at
risk for lid malposition in the postoperative period.
• Disadvantages are it inherently disrupts the orbicularis,
which may lead to denervation, and mobilization of the
levator labii muscles may put the buccal branch of the
facial nerve at risk.
Canthopexy
• A lateral canthopexy can establish an aesthetically and
functionally youthful eyelid and reduce the incidence of
lower lid malposition and scleral show (Fig. 1.28).
• It has become an integral part of a lower lid
blepharoplasty and midface lifting.
• A lateral canthopexy is recommended for moderate lid
laxity, which is considered <6 mm of lid distraction away
from the globe.
• This technique takes advantage of a bluntly dissected
tunnel extending from the lateral upper lid
blepharoplasty incision into the lateral aspect of a lower
lid incision.
Figure 1.28  (A) Preoperative and (B) 5-year postoperative photograph of a patient
with a lower lid blepharoplasty and canthopexy.
A
B

19
Operative techniques
Figure 1.29  (A–C) Periosteal canthopexy. The inferior ramus of the lateral canthal
tendon is secured and elevated to a raised position inside the orbital rim. Tension
free suspension occurs with release of the tarsal strap and lateral orbital thickening.
A
B
C
Figure 1.30  The canthopexy suture series for a two-layered canthopexy. (A) The
canthopexy suture fixating the tarsal tail into the drilled hole. (B) The second-layer
orbicularis suture. (C) Lateral sutures fix the lateral orbicularis to the deep temporal
fascia. (D) If a midface lift is elected, an inferior drill hole can be made to fixate the
midface tissues. (E) Bury the knot into the drill hole.
A
B
C
D
E
• When evaluating the midface for aesthetic surgery, all the
structures listed above must be considered.
• The author’s preferred technique includes approaching
the midface through a transconjunctival incision.
• After repositioning or resection of orbital fat, the midface
is elevated in a supraperiosteal plane.
• The attachment of the orbicularis oculi muscle to the
orbital septum is preserved.
• Adequate release of the remaining, lax orbitomalar
ligament then permits malar fat pad suspension in a

20
•
• Blepharoplasty
1
Figure 1.31  Midface lift. (A) The arrow in red depicts the plane of dissection to the midfacial structures in the cheek in a supraperiosteal approach. (B) Wide undermining
of the periorbital ligamentous structures and lateral retinaculum may be transconjunctival or through the upper blepharoplasty incision. (C) Canthopexy and cheek suspension
then proceed sequentially. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:129.)
B
A
C
Cheek flap is elevated and
sutured to deep temporal fascia or
periosteum of lateral orbital rim
Single mattress suture repair
Extent of sub-orbicularis muscle/
malar fat pad/SMAS undermining
Buccal fat pad
SMAS
Zygomaticus
Malar fat pad
SOOF
Orbitomalar ligament
Malar bag
Orbicularis oculi
Orbital septum
Orbital fat
Access via upper or lower blepharoplasty incision
superolateral vector to the lateral orbital rim and
temporoparietal fascia (Fig. 1.31).
• Canthopexy is then performed to redrape lower eyelid
skin and recreate a youthful intercanthal angle. Finally, a
skin only resection of the lower lid may be necessary to
address any redundancy.
Postoperative considerations
• All patients are advised to expect swelling, bruising,
some degree of ptosis, and tugging sensation on gazing
upward. Although complete recovery takes months,

21
Further reading
patients generally look presentable approximately 2–3
weeks after surgery.
• Surgical literature has not advocated compression
bandaging of the eyes after surgery. If one chooses not to
use gently compressive bandages, postoperative edema
can be reduced with cool compresses for up to 20 min
intermittently during the initial 36 hours postoperatively.
• Patients are advised against using frozen compresses
directly over their face in the setting of previous
anesthetic use and pain medication.
• Additional recommendations include having the patient
lie in a semi-recumbent position while resting and to
avoid bedrest.
• Prescriptions for rewetting drops, Lacri-Lube® and
antibiotic ophthalmic ointment can be given to reduce the
incidence of exposure keratoconjunctivitis and dry eye
symptoms in the immediate postoperative period.
• Patients are permitted to shower the next day and use
antibiotic ointments as needed, for routine incisional care.
• It is also suggested that patients refrain from using
contacts and to minimize the use of prescription
eyeglasses.
• When no canthopexy is performed, half-inch Steri-Strips,
retracted superiorly, are applied as a “cast” (with benzoin
or Mastisol for security). This treatment tends to reduce
lid retraction. Alternatively, a Frost suture placed in the
lower lid margin and fixed to the brow suspends the lid
during early healing.
Complications and outcomes
• Asymmetry is common postoperatively and can be
caused by edema, bruising, and asymmetric sleep
posture, but it also predictably follows undiagnosed
preoperative asymmetry, including mild ptosis, made
worse by the weight of postoperative edema.
• Patients should be advised that no reoperations are
indicated before 8 weeks, and then only if the lids have
stabilized and no edema or bruising is seen.
• The need for reoperations is infrequent, but when ptosis
or exophthalmos is involved, incidence increases
significantly to 10–30%.
• Retrobulbar hemorrhage is the most feared complication
of eyelid surgery. Any complaint of severe orbital pain
needs to be examined immediately, especially that of
sudden onset.
• Acute management involves immediate evaluation,
urgent ophthalmologic consultation and a return to the
operation for evacuation of the hematoma.
• Medical treatments, in addition to operative exploration,
include administration of high flow oxygen, topical and
systemic corticosteroids and mannitol.
• Acute loss of vision mandates bedside suture removal
and decompressive lateral canthotomy.
• Peribulbar hematoma, in contrast, does not threaten
vision. It usually results from bleeding of an orbicularis
muscle vessel. Small hematomas may resolve
spontaneously, though larger hematomas can be
evacuated in the office.
• Visual changes, including diplopia, are generally
temporary and can be attributed to wound reaction,
edema and hematoma. Any damage to the superficial
lying oblique muscles can be permanent and lead to
postoperative strabismus. Conservative management is
recommended; refractory cases should be referred to an
ophthalmologist.
• The most common complication after blepharoplasty is
chemosis. Disruption of ocular and eyelid lymphatic
drainage leads to development of milky, conjunctival and
corneal edema.
• Chemosis can be limited by atraumatic dissection, cold
compresses, elevation and massage.
• It is usually self-limited and resolves spontaneously,
though prolonged chemosis can be treated with topical
steroids.
• Dry eye symptoms are also frequently cited in the
postoperative phase. Patients may complain of foreign
body sensation, burning, secretions and frequent
blinking.
• Ocular protection can be achieved medically with liberal
use of corneal lubricants.
• Additional complications such as lower lid malposition,
lagophthalmos, undercorrection, asymmetry, and
iatrogenic ptosis all require careful observation and
photographic documentation.
• Reoperation should be performed no earlier than 3
months later.
Further reading
Codner MA, Wolfi J, Anzarut A. Primary transcutaneous
lower blepharoplasty with routine lateral canthal
support: a comprehensive 10-year review. Plast
Reconstr Surg. 2008;121(1):241–250.
Few JW. Rejuvenation of the African american periorbital
area: dynamic considerations. Semin Plast Surg.
2009;23(1):198–206.
Few’s survey-based study shows that one must prioritize a
patient’s ethnic identity and heritage when approaching the
periorbital area in African-Americans.
Flowers RS. Canthopexy as a routine blepharoplasty
component. Clin Plast Surg. 1993;20(2):351–365.
Flowers RS, Nassif JM, Rubin PA, et al. A key to
canthopexy: the tarsal strap. A fresh cadaveric study.
Plast Reconstr Surg. 2005;116(6):1752–1758.
Flowers and colleagues detail the anatomy of the lateral
orbital retinaculum and highlight the importance of full
dissection to achieve a tension-free canthopexy.
Hirmand H. Anatomy and nonsurgical correction of tear
trough deformity. Plast Reconstr Surg. 2010;125(2):
699–708.
Mendelson BC. Fat preservation technique of lower-lid
blepharoplasty. Aesthet Surg J. 2001;21(5):450–459.
Results shown in Mendelson’s article demonstrate the safe,
reproducible outcomes of a skin-only blepharoplasty and help
swing the pendulum away from aggressive, fat excisional
techniques.

22
•
• Blepharoplasty
1
Rohrich RJ, Coberly DM, Fagien S, et al. Current concepts in
aesthetic upper blepharoplasty. Plast Reconstr Surg.
2004;3:32e–42e.
This continuing medical education article provides a concise
description of upper eyelid aging and a step-by-step guide to
popular rejuvenation techniques.
Spinelli HM. Atlas of aesthetic eyelid and periocular surgery.
Philadelphia: Saunders; 2004.
Zide BM. Surgical anatomy around the orbit: the system of
zones. 2nd ed. Philadelphia: Lippincott, Williams &
Wilkins; 2006.
Muzaffar AR, Mendelson BC, Adams Jr WP. Surgical
anatomy of the ligamentous attachments of the lower
lid and lateral canthus. Plast Reconstr Surg.
2002;110(3):873–884.
Reid RR, Said HK, Yu M, et al. Revisiting upper eyelid
anatomy: introduction of the septal extension. Plast
Reconstr Surg. 2006;117(1):65–70.
This cadaveric and histologic study identifies an
extension of the orbital septum that must be identified and
spared when performing a levator advancement for
blepharoptosis.

©2014, Elsevier Inc. All rights reserved.
Chapter
2 
Facelift
■ Expansion of volume in the neck and lateral jaw line
which leads to the formation of jowls and fullness of
the neck (Fig. 2.1).
• Aging of the face occurs in all its layers, from skin down
to bone; no tissue is spared. The surgical significance of
this concentric layer arrangement is:
■ Dissection can be done in the planes between the
layers.
■ Anatomical changes in each of the layers can be
addressed independently, as required to treat the
presenting problem.
• Skin aging over time is both intrinsic and extrinsic. The
net result is that facial skin loses its ability to recoil, a
condition called elastosis.
• Intrinsic aging is the result of genetically determined
apoptosis. The skin becomes thinner; there is a decrease
in melanocytes, a reduced number of fibroblasts, and a
loss of skin appendages. In the dermal matrix, there is
fragmentation of the dermal collagen and impairment of
fibroblast function.
• Extrinsic forces include sun exposure, cigarette smoke,
extreme temperatures, and weight fluctuations.
• Important anatomic figures have been included:
(Figs 2.2–2.8).
Preoperative considerations
• The quality of surgical result will be affected by many
patient-related factors including the facial skeleton, the
weight of facial soft tissue, the depth and location of
folds, and the quality of the skin.
• Some issues can be reversed, others attenuated, and some
may not be correctable at all.
• Incipient hypertension is common in the general
population and can promote postoperative hematomas if
it is not identified prior to surgery.
This chapter was created using content from
Neligan & Warren, Plastic Surgery 3rd edition,
Volume 2, Aesthetic, Chapter 11.1, Facelift: Princi­
ples, Richard J. Warren, Chapter 11.2, Facelift:
Introduction to deep tissue techniques, Richard
J. Warren, Chapter 11.3, Facelift: Platysma-SMAS
plication, Dai M. Davies and Miles G. Berry,
Chapter 11.4, Facelift: Facial rejuvenation with loop
sutures, the MACS lift and its derivatives, Mark
Laurence Jewell, Chapter 11.5, Facelift: Lateral
SMASectomy, Daniel C. Baker, Chapter 11.7,
Facelift: SMAS with skin attached –“the high
SMAS” technique, Fritz E. Barton Jr., Chapter 11.8,
Facelift: Subperiosteal facelift, Oscar M. Ramirez.
Brief introduction
• The classic stigmata of the aging face include:
■ Visible changes in skin, including folds, wrinkles,
dyschromias, dryness, and thinning.
■ Folds in the skin and subcutaneous tissue created by
chronic muscle contraction: glabellar frown lines,
transverse forehead lines, and crow’s feet over the
lateral orbital rim.
■ Deepening folds between adjoining anatomic units: the
nasojugular fold (tear trough), nasolabial folds,
marionette lines, and submental crease.
■ Ptosis of soft tissue, particularly in the lower cheek,
jowls and neck.
■ Loss of volume in the upper two-thirds of the face
which creates hollowing of the temple, the lateral
cheek, and the central cheek.

24
•
• Facelift
2
and the location of the hairline in the temple, the
sideburn, and posterior to the ear.
• A careful assessment of the overlying skin is also
important to determine if anything of a non-surgical
nature is indicated before, during, or after facelift
surgery.
• Excellent photographic documentation of the
preoperative face is very important, and should include
frontal, oblique, and profile views. Other optional views
include the smile and close up views of the neck in
repose and with platysma contracture.
Operative techniques
Subcutaneous facelift
• Classic procedure that tightens excess skin, and relies
completely on skin tension to shift underlying facial soft
tissue against the force of gravity.
• Advantages: relatively safe, relatively easy to do, and
patient recovery is rapid.
• Effective for the thin patient with excess skin, and
minimal ptosis of deep soft tissue.
• Disadvantage: skin placed under tension to support
heavy underlying soft tissue will stretch, leading to a loss
of surgical effect.
• Uncontrolled hypertension is a contraindication for
surgery, while controlled hypertension is not a
contraindication.
• Smokers have been shown to exhibit delayed wound
healing due to microvasoconstriction and abnormal cell
function.
• Nevertheless, there are significant short-term effects
which can be reversed by abstaining from tobacco use for
2–3 weeks prior to surgery.
• Prior to surgery, the entire face should be properly
assessed.
• The face should be assessed as a whole – looking for the
equality of facial thirds, the degree of symmetry, and the
overall shape (round, thin, wide).
• Surgeons should develop an organized way to examine
all the zones of the face: forehead, eyelids, cheeks, the
perioral area, and the neck.
• With the diversity of surgical techniques available, a
surgeon should think like a sculptor – considering the
face in three dimensions with a view to adding tissue in
some areas, removing tissue in other areas, and
repositioning tissue where indicated.
• The ear should be examined with a thought to the
potential placement of incisions.
• Important factors: the size and orientation of the earlobe,
the angle of attachment of the tragus, the difference in
character of the cheek skin and tragal skin, and the size
of the tragus, the density of the hair surrounding the ear,
Figure 2.1  The aging face exhibits changes in the skin, superficial wrinkles, deeper folds, soft tissue ptosis, loss of volume in the upper third and middle third and
increased volume in the lower third.
Peri oral wrinkles
Buccal fat pad ptosis
Expansion and ptosis of jowl fat
Elongating upper lip
Excess preplatysmal and
subplatysmal fat
Platysma muscle laxity
Malar fat descent
Frontalis contraction
Lateral brow ptosis
Temporal fat pad atrophy
Upper lid sulcus hollowing
Obicularis oculi laxity
Obicularis contracture
Lower lid laxity
Loss of midface fat
Transverse forehead creases
Temporal wasting
Crow’s feet
Tear trough
Cheek descent
Midface flattening
Nasolabial folds
Thinning lips
Marionette lines
Jowls
Transverse neck folds
Platysma bands
Vertical neck pleats

25
Operative techniques
• Attempts to overcome this problem with excess skin
tension may lead to distortion of facial shape, abnormal
re-orientation of wrinkles, and local problems at the
incision line including stretched scars and distorted
earlobes.
Facelift incisions (Video 2.1; Video 2.2)
• In the temple area, the incision can be placed in the hair,
at the anterior hairline, or a hybrid of the two, with an
incision in the hair plus a transverse extension at the base
of the sideburn (Fig. 2.9A,B).
• The advantage of the incision in the hair is that it is
hidden, but when the flap is drawn up, the anterior
hairline and sideburn will shift; the degree of this
depending on skin laxity.
• If the incision is placed at the anterior hairline, the scar is
potentially more visible, but there will be no shift of the
hairline.
Figure 2.2  The malar fat pad is a triangular area of thickened superficial fat with
its base along the nasolabial fold, and its apex over the superolateral malar
prominence.
Malar fat pad
Orbicularis oculi
Zygomaticus major
• A transverse incision at the base of the sideburn is a
compromise solution, which ameliorates much of the
hairline shift, while preserving a largely hidden scar.
• Several factors should be assessed before committing to
an incision within the temple hair.
• A preoperative estimate of skin redundancy will give the
surgeon some sense of how far the skin flap will move.
• The distance between the lateral orbital rim and the
temporal hairline should be assessed.
• In youth, this distance is generally <4–5 cm, while in
older patients, the distance increases.
• If the distance is already excessive, or if the expected
movement of the temporal hairline will create a distance
over 5 cm, then an incision in the hair should be avoided
(Fig. 2.9C).
• Anterior to the ear, the incision can be pretragal, or along
the tragal edge (Fig. 2.9D,E).
• The advantage of the tragal edge incision is that it is
hidden, but care must be taken to thin the flap covering
the tragus in order to simulate a normal tragal
appearance.
• Before committing to a tragal edge incision, the quality of
tragal skin and that of facial skin must be compared; if
the difference between the tragal skin and facial skin is
too great, a tragal edge incision should be avoided.
• A pretragal incision is preferred in men as the hair-
bearing portion of the cheek skin will not be drawn up
onto the tragus.
• Around the earlobe, the incision can be placed either in the
cleft of earlobe attachment or 1–2 mm distal to the cleft,
leaving a cuff of skin along the earlobe. This cuff will
ease the process of insetting the earlobe on skin closure.
• In the retroauricular sulcus, the incision can be placed
directly in the conchal groove as it courses superiorly.
• The incision is often carried as high as the level of the
external auditory canal, or slightly higher, at the level of
the antihelix.
• An extension of the retroauricular sulcus incision toward
the occipital hair-bearing region should be made when
there is a need to remove excess redundant neck skin.
• A “short scar” facelift is one which avoids the occipital
incision, and will suffice for many patients.
• The principle objectives for the occipital incision are to
gain access to the neck in order to take up redundant
neck skin, while making the incision as invisible as
possible with little or no distortion of the occipital
hairline (Figs 2.10, 2.11).
• Either the temple dissection or the postauricular dissection
can be done first, depending on surgeon preference.
• In the postauricular area, the flap is firmly attached to the
deep cervical fascia of the sternocleidomastoid and the
mastoid.
• This is the most common location to see skin flap
necrosis, so the flap should be raised sharply under direct
vision, keeping the dissection against the underlying
deep fascia in order to maintain flap thickness.
• As the dissection continues inferior to the earlobe level,
the surgeon must be cognizant of the great auricular
nerve, where it is most at risk over the posterior border
of the sternocleidomastoid.
Video
2.1
Video
2.2

Figure 2.3  (A) Superficial facial fat is compartmentalized by vertically running septae. In the midcheek, from medial to lateral, these compartments are the nasolabial,
medial, middle, and lateral compartments. The nasolabial and medial compartments make up the malar fat pad. (B) The deep facial fat is also compartmentalized by septae.
The deep medial fat pad (here stained blue) is bounded above by the orbicularis retaining ligament, medially by the pyriform aperture, and laterally by the zygomaticus
major (ZM) muscle and the buccal (labeled B) fat pad. (C) Over the body of the zygoma, the sub orbicularis oculi fat (SOOF) is deep fat. It is seen here with a medial
portion (yellow) and a lateral portion (stained blue). It is bounded medially by deep medial fat pad (stained red). (A Courtesy of Rohrich RJ, Pessa JE. The fat compartments
of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227; B,C Courtesy of Rohrich RJ, Pessa JE, Ristow B. The
youthful cheek and the deep medial fat compartment. Plast Reconstr Surg. 2008;121(6):2107–2112).
A
Lateral
Middle
Medial
Nasolabial
ORL
ORL
SCS
Nasolabial
Medial
Middle
Lateral
SOOF
ZM
B
C

27
Operative techniques
Figure 2.4  Muscles of facial expression. The solid lines demonstrate overlying skin creases caused by repeated contraction of the underlying muscles.
Galea aponeurotica
Procerus
Corrugator supercilii
Nasalis
Zygomaticus minor
Zygomaticus major
Levator anguli oris
Buccinator
Masseter
Orbicularis oris
Frontalis
Orbicularis oculi, pretarsal portion
Orbicularis oculi, preseptal portion
Orbicularis oculi, orbital portion
Levator labii superioris alaeque nasi
Levator labii superioris
Auricularis anterior
Risorius
Depressor septi nasi
Platysma
Depressor anguli oris
Depressor labii inferioris
Mentalis
Figure 2.5  Facial soft tissue is tethered to underlying bone by the orbital, zygomatic and mandibular ligaments. Soft tissue is tethered to underlying deep fascia by the
masseteric cutaneous ligaments and by an area of attachment anterior and inferior to the earlobe, known by a number of different terms: platysma auricular ligament
(Furnas), platysma auricular ligament (Mendelson), parotid cutaneous ligament (Stuzin), and a distinct area anterior to the earlobe known as Lore’s fascia.
Zygomatic ligaments
Temporal fat pad
Superficial layer of deep
temporal fascia
Upper edge of temporal fat
Orbital ligament
Platysma auricular fascia
Depressor anguli oris
Platysma
Obicularis oculi
Obicularis oris
Temporalis
Temporal crest
Frontalis
Occipitalis
Buccinator
Sternocleidomastoid
Tympanoparotid
(Lore’s) fascia
Mentalis
Nasalis
Mandibular ligament
Risorius
Zygomaticus minor
Masseteric ligaments
Zygomaticus major

Figure 2.6  Mendelson’s interpretation of soft tissue attachments. The fixed
posterior soft tissue is held in place by the platysma auricular fascia (large red
area). The anterior face is fixed by a vertical column of attachments: orbital
ligament, lateral orbital thickening (superficial canthal tendon), zygomatic
ligaments, masseteric ligaments, and mandibular ligament). The so-called “fixed
SMAS” is that portion attached to the parotid and the posterior border of the
platysma. Anterior to this, is the “mobile SMAS”.
Figure 2.7  The great auricular nerve crosses the midportion of the
sternocleidomastoid at McKinney’s point, which is 6.5 cm inferior to the external
auditory canal. It usually travels about 1 cm posterior to the external jugular vein.
Anterior to McKinney’s point, the nerve is covered by the superficial cervical fascia
(SMAS), but at the posterior border of the sternocleidomastoid, the nerve is
subcutaneous. The most common point of injury is at the posterior border of the
sternocleidomastoid muscle.
Great auricular nerve
External jugular vein
6.5cm
McKinney’s point
Figure 2.8  Major sensory nerves of the face.
Ophthalmic nerve V1
Zygomaticotemporal nerve
Zygomaticofacial nerve
Supra-orbital nerve
Supratrochlear nerve
Infratrochlear nerve
External nasal nerve
Lacrimal nerve
Infra-orbital nerve
Buccal nerve
Mental nerve
Auriculotemporal nerve
Maxillary nerve V2
Mandibular nerve V3

29
Operative techniques
Figure 2.9  (A) The traditional hidden incision in the temple hair is appropriate when the temporal hairline will not be shifted adversely. (B) A temple incision along the
hairline is used if a hidden incision will adversely shift the hairline. (C) The distance from the lateral orbital rim to the temporal hairline should not exceed 5 cm. (D) The
retrotragal incision follows the edge of the tragus. (E) The pretragal incision is placed in the pretragal sulcus.
A
B
C
D
E
• By keeping the dissection in the subcutaneous plane, the
great auricular nerve will be protected.
• In the temple, if the incision has been made along the
anterior hairline, dissection is begun directly in the
subcutaneous plane. If the incision has been made in the
hair-bearing scalp of the temple, dissection can be carried
out in one of two planes: superficial to the superficial
temporal (temporoparietal fascia) which will continue
directly into the subcutaneous facelift plane, or between the
superficial temporal fascia and the deep temporal fascia.

30
•
• Facelift
2
Figure 2.10  (A) When there is minimal to moderate skin shift expected, an
appropriate incision will curve from the retroauricular incision directly into the
occipital hair. (B) When a greater amount of skin is to be excised, a “Lazy S”
incision, which partly follows the occipital hairline, is an appropriate choice.
Figure 2.11  The traditional incision for a facelift flap curves vertically or slightly
anteriorly in the temple, follows the contours of the ear, both anteriorly and
posteriorly, and then angles into the posterior scalp.
• If the deeper approach is used, the dissection proceeds
quickly against deep fascia, but at the anterior hairline,
the dissection plane must transition into the
subcutaneous facelift plane.
• This change of plane results in a narrow ribbon of
superficial temporal fascia which will contain the
superficial temporal artery and vein and branches
of the auriculotemporal nerve which must be divided
(Fig. 2.12A).
• The superficial plane preserves the superficial temporal
fascia and vessels, but can injure the hair follicles during
the dissection unless care is taken (Fig. 2.12B).
• Anterior to the anterior hairline, the subcutaneous plane
is then developed.
■ The level of dissection normally leaves 1–2 mm of fat
on the dermis.
■ This results in a large random pattern skin flap the
survival of which will entirely depend on the
subdermal plexus.
• In the upper face, this dissection continues anteriorly
until the orbicularis oculi is encountered where it
encircles the lateral orbital rim. Depending on the type of
deep plane surgery planned, the midcheek dissection
may stop short of the malar fat pad, or alternatively,
carry on over the fat pad, freeing it from the overlying
skin in the temple and cheek.
• Lower in the cheek, immediately anterior to the ear and
the earlobe, the skin is tethered to underlying structures
by secure fascial attachments, but beyond this area, the
subcutaneous dissection proceeds relatively easily.
• Once the skin flaps anterior and posterior to the ear have
been raised, the two dissections are joined.
• The dissection can then be extended into the neck as far
as the technique requires (Figs 2.13, 2.14). (Video 2.3)
• After elevation of the subcutaneous tissues, management
of the deep tissues can proceed, if needed.
• Once the deep tissues have been managed, skin flap
mobilization and closure is performed:
■ Most techniques advance the skin flap along an
oblique vector which is slightly more posterior than
the vector for repositioning deep tissues.
■ In certain techniques, surgeons employ a nearly
vertical vector to the skin flap.
■ One concept is to place the skin flap “where it lies”,
using the vector which facial skin naturally assumes
when the patient is lying in the supine position.
■ Another guide is to advance the skin flap toward the
temple along a vector which is perpendicular to the
nasolabial fold.
• The anterior anchor point is immediately adjacent to the
helix of the ear at the junction of the hair-bearing scalp.
• This will be the first of two anchor points; it can be held
in place with a half buried mattress suture in order to
minimize the chance of a visible suture mark (Fig. 2.15).
• Posteriorly, the skin flap should be drawn along a vector
which roughly parallels the body of the mandible.
• The second anchor point will be at the superior most
extent of the postauricular sulcus at the point where the
incision starts to transition posteriorly. Once again, a half
buried mattress suture can be used.
Video
2.3

31
Operative techniques
Figure 2.12  (A) Facelift flap has been raised in two different planes, initially deep
to the superficial temporal fascia, against the deep temporal fascia (seen as an oval
window), with a change of planes near the anterior temporal hairline into the
subcutaneous plane. The “mesotemporalis” is a bridge of tissue which develops
between these two planes. In order to unify the planes, it has been divided with
ligation of the superficial temporal artery. (B) Facelift flap has been raised in a
single subcutaneous plane, with dissection directly on the superficial temporal
fascia and deep to the hair follicles of the scalp. The purple line outlines the course
of the anterior branch of the superficial temporal artery.
A
B
Figure 2.13  Subcutaneous facelift flap has been raised.
• At this point, trimming of the overlapping flap and
suturing can be done in the temple and in the occipital
region.
• The facelift flap is redraped in the desired direction with
gentle tension.
• Attention is then turned to trimming excess skin around
the ear, with absolutely no tension on the closure.
• If a tragal edge incision is used, the tragal flap is thinned
and hair follicles are removed.
• In the retroauricular sulcus, there is normally little or no
skin to be trimmed if the posterior flap has been correctly
positioned.
• Earlobe inset is done last and is designed to angle 15°
posterior to the long access of the ear (Fig. 2.16).
• Skin trimming around the earlobe should be
conservative.
• Tension on the earlobe can lead to distortions such as the
pixy ear deformity and the malpositioned earlobe.
Midfacelift (blepharoplasty approach)
• In an attempt to lift the tissue immediately inferior to the
infraorbital rim (the midface), an approach through the
lower lid was developed which involves a subciliary or a
transconjunctival blepharoplasty type incision followed
by a dissection down over the face of the maxilla.

32
•
• Facelift
2
Figure 2.14  (A) Traditional subcutaneous flap dissection with no submental incision. (B) Traditional subcutaneous flap dissection with submental incision.
A
B
• Performed in either the subperiosteal plane, which
requires an inferior periosteal release, or in a
supraperiosteal plane.
• After mobilization of the cheek mass the soft tissue is
fixated superiorly, either laterally along the lateral orbital
rim, or more vertically with anchoring to the bone of the
infraorbital rim.
• Disadvantages of the midfacelift: steep learning curve,
and high incidence of revisions.
SMAS plication (Video 2.4)
• Patients are prepared as for a standard facelift with
tumescent infiltration (20 mL 0.5% bupivacaine and 1 mL
1 : 1000 adrenaline in 200 mL normal saline) into the
subcutaneous plane.
• The incision extends vertically in the temporal scalp,
along the anterior helical sulcus, then passes post-tragal,
and on occasion into the postauricular sulcus (Fig. 2.17).
• A postauricular extension is used where required and
subcutaneous dissection tailored to each patient.
• The anterior SMAS is grasped in a postero-superior
direction to provide a satisfactory effect on the jowl
(Fig. 2.18).
• The key suture, using 2-0 PDS (Johnson & Johnson
Medical Ltd), is then inserted to attach this SMAS to the
relatively immobile pre-auricular parotid-masseteric
fascia.
Video
2.4

33
Operative techniques
Figure 2.15  Diagram shows typical skin flap redraping along an oblique direction
which is slightly less vertical than the vector along which deep tissues are moved.
There is considerable variation in this; however, some techniques involve a more
horizontal vector while other techniques utilize a nearly vertical vector.
Figure 2.16  The earlobe should be inset with the long axis of the earlobe (dotted
line) about 15° posterior to the long axis of the ear itself. If the earlobe is pulled
forward, an unnatural appearance results.
Proper insetting of the ear lobe
A
B
Figure 2.17  Incision and area of subcutaneous dissection employed with the
PSP-lift. Note that the posterior extension is not always required, but is useful where
excess skin remains in the neck after SMAS plication.
• Further sutures complete plication of the cervical
platysma, below the mandibular angle, to the mastoid
fascia (Fig. 2.19) and any surface irregularities are
addressed by suture imbrication with 3-0 Vicryl (Johnson
& Johnson).
• Excess SMAS in the infra-lobular region is excised,
following hydrodissection, and closed with 3-0 Vicryl.
• Following meticulous hemostasis, excess skin, with low
tension traction only, is trimmed and the wound closed
over a small suction drain with 4-0 and 6-0 nylon.
• A light, compressive facelift dressing remains overnight
and is removed with the drain the following morning.
These can be similarly removed immediately prior to
discharge in day-case patients.
• Sutures are removed at 4–6 days.
MACS-lift (Chapter 11.4) (Video 2.5)
• The patient is marked before the start of the procedure;
key points are the planned incision, the degree of
undermining, and the location of suture loops.
• The degree of skin flap undermining typically extends
inferiorly just past the mandibular angle and anteriorly
5–6 cm in front of the ear.
Video
2.5

34
•
• Facelift
2
Figure 2.18  Placement of the first and key suture, which takes a generous bite of
anterior SMAS and tractions it postero-superiorly onto the parotido-masseteric
fascia. It can be trialed and its effect easily measured externally by observing
reduction of the jowl and effacement of the nasolabial fold as the SMAS is
tractioned and the suture tied.
Figure 2.19  Tying the key suture produces a “dog-ear” of SMAS that produces a
convenient malar autoaugmentation. A second suture passes between the posterior
platysma and the mastoid fascia to complete the effect on the jowl and commence
the necklift.
• If an extended MACS-lift is planned, undermining is
marked over the malar prominence.
• If autologous fat grafting is considered, the fat is
harvested, processed, and injected at the beginning, prior
to the incisions for the MACS-lift.
• Local anesthetic containing epinephrine is injected along
the incision line.
• The short scar incision extends from the earlobe below
to the anterior hairline above.
• It follows the attachment of the earlobe from the
retroauricular crease, around to the anterior attachment
of the earlobe, following the tragal edge, the anterior
helical attachment to the root of the helix, then across the
lower portion of the sideburn and up the anterior
hairline.
• Anteriorly, the incision is made in a zigzag pattern
1–2 mm within the hairline.
• In the standard MACS-lift, the incision is carried up to
the level of the lateral canthus, while in the extended
MACS-lift, the incision extends up to a point opposite the
tail of the eyebrow.
• The deep temporal fascia anchor point is chosen to avoid
the superficial temporal vessels and the temporal branch
of the facial nerve.
• Small scissors are used to create a window in the
subcutaneous tissue approximately 1 cm above the
zygomatic arch and 1 cm in front of the helical rim in
order to expose the deep temporal fascia (Fig. 2.20).
• When placing the suture into the temporalis fascia, the
author sews away from the temporal vessel location.
• A single anchor point is used for both the neck loop and
the cheek loop in order to diminish the amount of suture
used and the palpability of knots. Absorbable
monofilament sutures such as 0-polydiaxonone are
preferred over non-absorbable polypropylene or braided
polyester suture.
• The suture loop for the neck is placed first. Going
inferiorly in the natural sulcus that is anterior to the
tragus, firm bites between 1 cm and 1.5 cm long are taken
into the SMAS.
• Progressing inferiorly past the angle of the mandible, two
or three suture bites are taken into the platysma before
the suturing is directed upward and back to the anchor
point.
• A U-shaped loop about 1 cm wide is created and the knot
is then tied at the anchor point under tension.
• Should additional reinforcement of the neck be desired,
2-0 polydioxanone sutures can be placed from the

35
Operative techniques
Figure 2.20  The short scar incision has been made, and the skin flap raised. The
zygomatic arch is marked in purple. Note the marks on the skin designating the
location of the suture loops. The scissors are dissecting a window down to the deep
temporal fascia which will be used as the anchor point for the vertical and cheek
suture loops.
Figure 2.21  (A,B) Cadaveric example demonstrating placement and the effect of
the vertical neck suture. The orientation is vertical, and neck traction depends on
achieving excellent suture purchase of the platysma muscle below the angle of the
mandible.
A
B
platysma into the fascial zone of adherence just below the
tragus (Lore’s fascia) or from the platysma to the mastoid
fascia.
• Suture knots in this area should be inverted to avoid knot
palpability through the skin (Fig. 2.21).
• The cheek loop is placed next. It originates at the same
anchor point from the deep temporal fascia. Taking bites
of the SMAS, suturing progresses inferiorly just anterior
to the first loop and then curves more anteriorly, creating
a wider loop above the jowl extending anteriorly as far as
the skin flap has been raised.
• The overall angle of the cheek loop is approximately
30° across the cheek, as compared to the vertical neck
loop.
• The suture is then tied under tension.
• Once the cheek loop is tied, it is possible to add a third
loop for elevation of the malar fat; this constitutes the
“extended MACS-lift” variant.
• A different anchor point is used anterior to the temporal
branch of the facial nerve.
• This point can either be the deep temporal fascia just
lateral to the lateral orbital rim, or the periosteum of the
zygoma, approximately 1.5 cm lateral to the lateral
canthal area.
• Access to either of these anchor points requires a small
window in the orbicularis muscle where the fibers run
vertically.
• This purse-string suture travels obliquely toward the
malar fat pad where at a point 2 cm below the lateral
canthus, the direction is reversed, creating a narrow
U-shaped loop that is tight under tension.
• Tissue bunching is an integral problem with the MACS
suture loops. It is resolved with imbrications with 4-0
polyglactin braided suture.
• Before leaving the deep tissue, it is necessary to place the
skin flap over the tissue and observe for unresolved
bunching and tissue tethering at the margins of the
undermined area.
• Scissor removal of protruding fat may be needed
in order to produce a smooth tissue surface inside the
loops.
• Imbrication of tissue in the region just anterior to the
tragus is important in order to preserve this normal
sulcus.
• The skin flap is then redraped along a vertical axis and
the excess skin is resected.
• The author’s personal technique uses approximately
1 cc of fibrin glue (5 units/mL dilution) that is sprayed
on the flaps and held for 3 min. This diminishes
ecchymosis formation and eliminates the requirement
for drains. Care must be given to not apply excessive
fibrin glue as it can interfere with revascularization of the
flaps.
• Wound closure is performed with absorbable 5-0
monofilament in the deeper layers and 5-0 and 6-0
polypropylene skin sutures placed as interrupted and
continuous (horizontal mattress).

36
•
• Facelift
2
Lateral SMASectomy (Chapter 11.5)
• Virtually all of the author’s procedural facelifts are
performed with the patient under monitored intravenous
propofol sedation. Patients are given oral clonidine,
0.1–0.2 mg, 30 min before surgery to control their blood
pressure.
• The face and neck are infiltrated with local anesthesia,
0.5% lidocaine with 1 : 200 000 epinephrine.
• Incisions are made in similar fashion as described above
in the Subcutaneous facelift section.
• When the temporal hairline shift is assessed as minimal,
the preferred incision is well within the temporal hair.
• When a larger skin shift is anticipated or the distance
between the lateral canthus and temporal hairline is
>5 cm, an incision a few millimeters within the temporal
hairline is preferred.
• In short scar facelifting, efforts are made to end the
incision at the base of the earlobe, but sometimes a short
retroauricular incision is often necessary to correct a
dog-ear after the facial flap rotation (Fig. 2.22).
• Subcutaneous dissection is performed as outlined above.
• Dissection extends across the zygoma to release the
zygomatic ligaments but stops several centimeters short
of the nasolabial fold.
• In the cheek, dissection releases the masseteric-cutaneous
ligaments and, if necessary, the mandibular ligaments.
• Subcutaneous dissection continues over the angle of the
mandible and sternocleidomastoid for 5–6 cm into the
neck, which exposes the posterior half of the platysma
muscle.
• If a submental incision has been made, the facial
and lateral neck dissection is connected through to
the submental dissection.
• Some surgeons may employ closed suction assisted
Lipoplasty in the neck and jowls.
• The outline of SMASectomy is marked on a tangent from
the lateral malar eminence to the angle of the mandible,
essentially in the region along the anterior edge of the
parotid gland.
• In most patients, this involves a line of resection
extending from the lateral aspect of the malar eminence
toward the tail of the parotid gland.
• Usually, a 2–4 cm segment of superficial fascia is excised,
depending on the degree of SMAS-platysma laxity
(Fig. 2.23).
• In SMAS resection, the author likes to pick up the
superficial fascia region of the tail of the parotid,
extending the resection from inferior to superior in a
controlled fashion.
• When SMAS resection is being performed, it is important
to keep the dissection superficial to the deep fascia and
avoid dissection into the parotid parenchyma.
• The various vectors accomplish corrections of the anterior
neck, the cervicomental angle, the jowls, and the
nasolabial fold.
• The first key suture grasps the platysma at the angle of
the mandible and advances it in a posterosuperior
direction; it is secured with 2-0 Maxon (United States
Surgical Corp., Norwalk, CT) to the fixed lateral SMAS
overlying the parotid.
• This action lifts the cervical platysma and cervical skin.
Figure 2.22  Incisions and extent of skin undermining.
Preferred incision
Optional temporal
incision for
recessed hairlines
Usual extent of
subcutaneous
undermining to
lateral canthus
and release of
malar ligaments
Submental incision
in normal skin crease.
Undermining
connects laterally
Optional preauricular
or intratragal incision
Subcutaneous undermining
into neck allows for
exposure of platysma
and skin redraping
Usual lower border of
undermining

37
Operative techniques
• After SMAS resection, interrupted 3-0 PDS buried sutures
are used to close the SMASectomy, fixed lateral SMAS
being evenly sutured to more mobile anterior superficial
fascia.
• Vectors are usually perpendicular to the nasolabial fold.
• The last suture lifts the malar fat pad, securing it to the
malar fascia.
• If firm monofilament sutures are used, such as PDA or
Maxon, the sutures should be buried and sharp ends on
the knot trimmed.
• Final contouring of any SMAS or fat irregularities along
the suture line is completed with scissors.
• Skin redraping and closure completes the procedure
(Fig. 2.24).
Extended SMAS technique (Chapter 11.6)
(Figs 2.25-2.28)
SMAS with skin attached – the “high SMAS
technique” (Chapter 11.7) (Video 2.6)
• The initial incision location in the temporal area depends
upon what is to be done with the forehead.
• If a bicoronal or hairline incision is to be utilized for the
forehead, then that extension is used for the cheek
dissection.
• If only an endoscopic approach or no forehead surgery is
planned, then only a horizontal sideburn incision is done.
Figure 2.23  Lateral SMASectomy.
Lateral SMASectomy
extends from tail of
parotid to lateral
canthus
Resection is at interface of
fixed and mobile SMAS
Width of resection
determined by SMAS laxity
and desired de-bulking
Undermining posterior border
of platysma for advancement
to mastoid
Last suture lifts
malar fat pad
Temporalis fascia
Zygomatic arch
Plication of
mobile to fixed SMAS
Figure 2.24  Optional plication of SMAS, for thin faces when debulking is not indicated.
Video
2.6