Cosmetic Facial Surgery

Chapter 3  •  Clinical Digital Photography
33
FIGURE 3-24.  Inside of a commonly available ultraviolet (UV) skin scanner
with UV bulbs and a mirror for patient to see the extent of sun damage.
FIGURE 3-25.  Author taking a picture of a patient inside the skin scanner.
The image is made with the “auto” setting and no flash.
A
B
FIGURE 3-26.  Raw photographs (A) and processed photographs with blue hue removed and image converted to
grayscale (B).
folder system. For 99% of my image requirements, what I need
is to locate a given patient’s pictures by referencing the name of
the procedure they had done. Personally, I am much better at
remembering procedures than I am names.
In Windows, I use the Pictures folder to store all my images.
Within the Pictures folder, I made alphabetized subfolders for
each procedure I perform (Figure 3-27, A). Within these pro-
cedure folders, I make subfolders for individual patients, last
name first (see Figure 3-27, B). If I do a blepharoplasty on Sally
Smith, a folder titled “Smith, Sally” is made under the “Blepha-
roplasty” folder. Some surgeons prefer to further group the
procedure with subprocedure folders (e.g., “Smith, Sally” under
“Upper Eyelids” under “Blepharoplasty” under “Pictures”).
As stated, this system has worked quite well for me. If a
patient has a facelift and eyelid surgery, a folder with the indi-
vidual’s name is placed in both the “Blepharoplasty” folder and
the “Rhytidectomy” folder. If I want to find all pictures for Mary
Smith, a simple Windows search will bring up all pictures under
folders named “Mary Smith.” Some surgeons want to add much
more data to a given picture. This can easily be done but is too
time consuming for the average practice. The average surgeon
needs to be able to store images in an orderly fashion and
quickly locate them. The described archiving method provides
a simple means of doing that.
Data Recovery
If you use digital cameras with memory cards, sooner or later
you will lose data from a corrupt card, card failure, or inadver-
tent deletion. Numerous programs are available to recover
images and are simple to use.
Basically, the suspect or problem card is inserted into the
card reader and opened in the card reader. The software auto-
matically scans the card and retrieves lost images. This can be
very important and has saved me numerous times. Many prod-
ucts are available and can be found by doing an Internet search
for “digital image data recovery.” I have personally used a
product called Card Recovery (), which is
inexpensive and efficient.

34
Chapter 3  •  Clinical Digital Photography
A
B
FIGURE 3-27.  A, A simple, free, and effective means of archiving digital
images is to keep all images in the Windows Picture folder and create a
folder for each procedure the surgeon performs. B, Under the procedure
folders, new folders are made for each patient by specific procedure.
Conclusion
Digital photography is a mainstay of all cosmetic surgery prac-
tices. Just as surgeons take pride in their surgery, they must also
take pride in their photographs. Crisp, standardized, and con-
trolled pictures are representative of the surgeon, and shoddy or
deceptive images can degrade public perception of the surgeon’s
ability. Every effort should be made to control background,
lighting, lens, and editing. These tasks have never been easier,
and there is no excuse for poor photographs in this day and age
of advanced technology.
References
1. Niamtu J: Image is everything: pearls and pitfalls of digital photography
and PowerPoint presentations for the cosmetic surgeon. Dermatol Surg
30:81–91, 2004.
2. Niamtu J: Techno pearls for digital image management. Dermatol Surg
28(10):946–950, 2002 Oct.
3. Niamtu J: Digital photography. In Lowe NJ (ed): Textbook of facial rejuve-
nation: the minimally invasive combination approach. London, 2000,
Martin Dunitz, pp 307–319.
4. Niamtu J: Digital camera system: to use or not to use [response]. Int J
Cosmet Surg Aesthetic Dermatol 3:216–217, 2001.
5. Niamtu J: Digitally processed ultraviolet images: a convenient, affordable,
reproducible means of illustrating ultraviolet clinical examination. Dermatol
Surg 27(12):1039–1042, 2001 Dec.
6. Niamtu J: The Power of PowerPoint. Plast Reconstr Surg 108(2):466–484,
2001 Aug.
7. Niamtu J: Making Digital Images. J Am Orthod Soc 1(2):8–9, 2001.
8. Niamtu J: Digital Imaging for the Cosmetic Dermatologist Part II. Cosmet
Dermatol 14(2):23–26, 2001 Feb.
9. Niamtu J: Digital Imaging for the Cosmetic Dermatologist Part I. J Cosmet
Dermatol 14(1):21–24, 2001 Jan.

35
4
Anesthesia Considerations for
Cosmetic Facial Surgery
Local Anesthesia for Cosmetic
Facial Surgery
No one can argue that one of greatest medical advances in the
history of mankind was the discovery of local anesthetic agents.
Virtually no other single innovation has done so much so safely
to mitigate human suffering. Local anesthetics are agents that
reversibly block nerve conduction in a limited area when
injected or topically applied1 and exhibit their effect by blocking
noxious stimuli from reaching the brain.2
Proficiency in local anesthetic techniques is extremely impor-
tant for a successful cosmetic practice. It is vital from a patient-
care standpoint to ensure painless treatment with predictable
outcomes (having to rush a procedure because of inadequate
pain control is a bad experience for both surgeon and patient
and can effect surgical outcomes). From a marketing and
practice-growth standpoint, a gentle, painless doctor will get
many word-of-mouth referrals. Surgeons who are rough or fail
to utilize pain-control techniques will lose patients. Most
doctors receive formal training in local anesthetic techniques,
but a review of common anatomy and techniques by both the
novice and seasoned cosmetic surgeon is in the best interests of
patient care.
Although some patients requesting small-needle techniques
such as neurotoxins and injectable fillers ask for topical or inject-
able anesthetic augmentation, most patients “grin and bear it.”
Vanity seems to have a significant impact on analgesia!
Many nonablative resurfacing and skin-tightening tech-
niques are being developed and utilized. Pain control for these
procedures does not require general or intravenous (IV) anes-
thesia but is frequently beyond the effects of topical anesthesia.
As these new techniques and fillers become available, surgeons
will doubtless be refining their local anesthetic techniques; aug-
mentive pain control will be required. Once mastered, local
anesthetic techniques can assist cosmetic surgeons far beyond
the scope of injectables. They can be used for lesion removal,
facial implant placement, resurfacing, intense pulsed light (IPL),
and hair-removal procedures as well as a host of other uses to
obtund pain associated with cosmetic procedures of the head
and neck.
Mechanism of Action of Local Anesthetics
Local anesthetics block the sensation of pain by interfering with
the propagation of impulses along peripheral nerve fibers
without significantly altering normal resting membrane poten-
tials.3 Local anesthetics depolarize nerve membranes and prevent
achievement of a threshold potential. A propagated action
potential fails to develop, and conduction blockade is achieved.
This occurs through the interference of nerve transmission by
blocking the influx of sodium through the excitable nerve
membrane.4
Sensory Anatomy of the Head and Neck
The main sensory innervation of the face is derived from
cranial nerve V (trigeminal nerve) and the upper cervical nerves
(Figure 4-1).
Trigeminal Nerve
The trigeminal nerve is the fifth of the 12 cranial nerves. Its
branches originate at the semilunar ganglion (gasserian gan-
glion) located in a cavity (Meckel’s cave) near the apex of the
petrous part of the temporal bone. Three large nerves, the oph-
thalmic, maxillary, and mandibular, proceed from the ganglion
to supply sensory innervation to the face (Figure 4-2).
Often referred to as the great sensory nerve of the head and
neck, the trigeminal nerve is named for its three major sensory
branches. The ophthalmic nerve (V1), maxillary nerve (V2),
and mandibular nerve (V3) are literally “three twins” (trigemi-
nal) carrying sensory information of light touch, temperature,
Cervical nerve
Trigeminal nerve
FIGURE 4-1.  Sensory innervation of the head and neck is derived from
the trigeminal and upper cervical nerves.

36
Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
lacrimal.5 The frontal nerve divides into the supraorbital and
supratrochlear nerves, providing sensation to the forehead and
anterior scalp.
The nasociliary nerve divides into four branches, two of
which supply sensory innervation to the face. These two
branches are the infratrochlear nerve, which supplies sensation
to the skin of the medial eyelids and side of the nose, and the
ethmoidal nerve, which gives off a terminal branch called the
external (or dorsal) nasal nerve and innervates the skin of
the nasal dorsum and tip. The lacrimal nerve innervates the skin
of the upper eyelid.
Maxillary Nerve (V2)
The maxillary nerve, or second division of the trigeminal, is a
sensory nerve that crosses the pterygopalatine fossa, traverses the
orbit in the infraorbital groove and canal in the floor of the
orbit, and appears upon the face at the infraorbital foramen as
the infraorbital nerve.5 At its termination, the nerve divides into
branches which spread out upon the side of the nose, the lower
eyelid, and the upper lip, joining with filaments of the facial
nerve.5 Terminal branches include the following:
The zygomatic nerve arises in the pterygopalatine fossa,
enters the orbit by the inferior orbital fissure, and divides
at the back of that cavity into two terminal branches, the
zygomaticotemporal and zygomaticofacial nerves.
The zygomaticotemporal branch runs along the lateral wall
of the orbit in a groove in the zygomatic bone then passes
through a foramen in the zygomatic bone and enters the
temporal fossa. It ascends between the bone and sub-
stance of the temporalis muscle and pierces the temporal
fascia about 2.5 cm above the zygomatic arch, where it is
distributed to the skin of the side of the forehead (see
Figure 4-2, V2).5
pain, and proprioception from the face and scalp to the brain-
stem. The commonly used terms V1, V2, and V3 are shorthand
notation for cranial nerve V, branches one, two, and three,
respectively. In addition to nerves carrying incoming sensory
information, certain branches of the trigeminal nerve also
contain nerve motor components. (The ophthalmic and maxil-
lary nerves consist exclusively of sensory fibers; the mandibular
nerve is joined outside the cranium by the motor root.) These
outgoing motor components include branchial motor nerves
(nerves innervating muscles derived embryologically from the
branchial arches) as well as “hitchhiking” visceral motor nerves
(nerves innervating viscera, including smooth muscle and
glands). The trigeminal nerve exits the trigeminal ganglion and
courses backward to enter the mid-lateral aspect of the pons at
the brainstem.5
The ophthalmic nerve (V1) leaves the semilunar ganglion
through the superior orbital fissure, the maxillary nerve (V2)
leaves the semilunar ganglion through the foramen rotundum
at the skull base, and the mandibular nerve (V3) leaves the
semilunar ganglion through the foramen ovale at the skull base5
(see Figure 4-2, inset). The remainder of this chapter will only
discuss the sensory components of this nerve system as they
relate to local anesthetic blocking techniques for cosmetic facial
procedures.
Ophthalmic Nerve (V1)
The ophthalmic nerve, or first division of the trigeminal, is a
sensory nerve. It supplies branches to the cornea, ciliary body,
and iris; to the lacrimal gland and conjunctiva; to part of the
mucous membrane of the nasal cavity; and to the skin of the
eyelids, eyebrows, forehead, and upper lateral nose (see Figure
4-2, V1). It is the smallest of the three divisions of the trigeminal
and divides into three branches: the frontal, nasociliary, and
V1
V3
V3
V2
V1
V1
V2
V3
V2
A
B
FIGURE 4-2.  Main branches of the trigeminal nerve supplying sensation to the respective facial areas. Inset shows the trigeminal ganglion with the three
main nerve branches.

Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
37
include the fact that a single accurately placed injection can
obtund large areas of sensation without tissue distortion at the
operative site. Disadvantages of peripheral nerve block include
the sensation of numbness in areas other than the operative
site and the lack of hemostasis at the operative site from
vasoconstrictors.
It should be mentioned that individual anatomic variances
in patients are responsible for the sometimes unpredictable
effect of peripheral nerve block. Foraminal position, nerves
crossing the midline, accessory innervation, and nerve bifurca-
tion are just some factors that affect the predictability and
success or failure of local anesthetic nerve blocks. Nerves that
innervate areas close to the midline may receive innervation
from the contralateral side and require bilateral blocks. For
the multiple aforementioned reasons, some nerve blocks may
require augmentative infiltrative local anesthesia to obtain
adequate pain control.
Since many nerves are accompanied by corresponding veins
and arteries, aspiration should always be performed to prevent
intravascular injection.
Use of Topical Preanesthesia
Any person who has a pain-free dentist more than likely receives
topical mucosal anesthesia prior to having a dental block.
Topical anesthetics are more effective and faster acting on
mucosal surfaces, and some of the effects may be psychological,
but all patients appreciate the extra pain-control effort. The use
of a topical anesthetic agent on the lip mucosa will definitely
augment injections in that area, regardless of the blocking tech-
niques used. In the author’s practice, when a patient is seated
for lip augmentation injections, the assistant immediately
applies a liberal coating of “BLT” topical anesthesia (20% ben-
zocaine, 6% lidocaine, 4% tetracaine) to the patient’s lips and
oral mucosa inside the lips. The topical anesthetic will be in
contact with the mucosa for at least 10 minutes preinjection.
This product can be made at most local compounding pharma-
cies. It produces profound anesthesia in some patients and
negates the need for further blocking techniques. Some patients
will still require blocks, but topical anesthesia will assist by both
psychological and physiologic means. Many cosmetic surgeons
also use topical agents for cutaneous anesthesia. I always use
local infiltration of the perioral region; I believe in a painless
procedure. The patient will be happier, and I can personally do
a better job on a truly numb patient.
I have been performing local anesthetic blocks of the face for
30 years and initially used them while injecting the newer fillers
in the lips. The negative connotation of additional injections
and the added time needed for filler injection led me to look at
alternatives. After experimenting with various topical and local
anesthesia infiltration techniques, I now rarely utilize trigeminal
nerve blocks. Instead, I use the “mini block infiltration” tech-
nique, which has expedited appointments for lip filler injection
and has been a welcomed change on the part of the patient. The
technique has proven adequate for 100% of patients’ filler injec-
tion in the lips and/or nasolabial folds. The injections are per-
formed quickly and provide excellent local anesthesia for lip and
perioral injection.
The zygomaticofacial branch passes along the inferolateral
angle of the orbit, emerges upon the face through a
foramen in the zygomatic bone, perforates the orbicularis
oculi, and supplies the skin on the prominence of the
cheek (see Figure 4-2, V2).
As the maxillary nerve traverses the orbital floor and exits the
infraorbital foramen, it branches into a plexus of nerves with
the following terminal branches:
The inferior palpebral branches ascend behind the orbicularis
oculi muscle and supply the skin and conjunctiva of the
lower eyelid (see Figure 4-2, V2).
The lateral nasal branches (rami nasales externi) supply the
skin of the side of the nose (see Figure 4-2, V2).
The superior labial branches are distributed to the skin of the
upper lip, the mucous membranes of the mouth, and
labial glands (see Figure 4-2, V2).5
Mandibular Nerve (V3)
The mandibular nerve supplies the teeth and gums of the man-
dible, the skin of the temporal region, part of the auricle, the
lower lip, and the lower part of the face (see Figure 4-2, V3).
The mandibular nerve also supplies the muscles of mastication
and the mucous membrane of the anterior two-thirds of the
tongue. It is the largest of the three divisions of the fifth cranial
nerve and is made up of a motor and sensory root.5
Sensory branches of the mandibular nerve include the auric-
ulotemporal nerve, which supplies sensation to the skin cover-
ing the front of the helix and tragus (see Figure 4-2), and the
inferior alveolar nerve, the largest branch of the mandibular
nerve. It descends with the inferior alveolar artery and exits the
ramus of the mandible to the mandibular foramen. It then
passes forward in the mandibular canal, beneath the teeth, as
far as the mental foramen, where it divides into two terminal
branches, incisive and mental nerves. The mental nerve emerges
at the mental foramen and divides into three branches; one
descends to the skin of the chin, and two ascend to the skin and
mucous membrane of the lower lip.5 The buccal nerve supplies
sensation to the skin over the buccinator muscle.
Local Anesthetic Techniques
Infiltrative Peripheral Anesthesia Versus
Regional Nerve Block Anesthesia
Local anesthesia can be effectively obtained by infiltrations and
nerve blocks. Infiltrative local anesthesia applies to the injection
of the local anesthesia solution in the area of the peripheral
innervation distant from the site of the main nerve. An advan-
tage of infiltrative anesthesia is that no specific skill is necessary.
Only the selected area of innervation is involved, and vasocon-
strictors can improve local hemostasis. A drawback of infiltrative
local anesthesia is the distortion of the tissue at or around the
site of injection, which may obscure or hamper cosmetic
procedures.
A nerve block involves placing local anesthetic solution in
a specific location at or around the main nerve trunk or
branch, where it will effectively depolarize that nerve and
obtund sensation distal to that area. Advantages of nerve blocks

38
Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
Local Anesthetic Techniques for Blocking the
Main Sensory Nerves of the Head and Neck
A rudimentary knowledge of the neuroanatomy of the head
and neck can enable the cosmetic surgeon to perform painless
surgical procedures in this area. When used concomitantly with
general anesthesia or intravenous sedation, local anesthetic
blocks can decrease the amount of intravenous or inhalation
agents needed and provide excellent postanesthetic pain control.
Scalp and Forehead
The frontal nerve exits through a notch (in some cases a foramen)
on the superior orbital rim approximately 27 mm lateral to the
glabellar midline (Figure 4-5). This supraorbital notch is readily
Technique for Upper and Lower Lip Anesthesia
As soon as the patient is seated in the treatment room, a potent
topical anesthesia compound of 20% benzocaine, 6% lidocaine,
and 4% tetracaine is applied intraorally in the depth of the
anterior maxillary and mandibular vestibule. The vestibule is
the sulcus formed at the junction of the attached gingiva
and the unattached mucosa. The same topical is applied to the
external lip mucosa. A 1-mL syringe of 2% lidocaine, 1 : 100,000
epinephrine, and a 32-gauge needle are used. Injections of 0.2
to 0.3 mL of local anesthetic solution are given in four to five
areas between the canine teeth (Figure 4-3, A). The injection is
submucosal in the potential space between the mucosa and the
periosteum. This is a soft-tissue injection, so the needle need
not touch bone. If both lips are to be injected, the same proce-
dure is performed in the lower vestibule as well (see Figure 4-3,
B). After several minutes, the lips and perioral areas are ade-
quately anesthetized for filler injection. This infiltration, if done
properly, will approach the profound level and extent of anes-
thesia experienced with bilateral nerve block and is well suited
for cutaneous and vermilion filler injection of the lips. The area
anesthetized may extend to the nasal tip in the maxilla and to
the mentolabial fold in the mandible. Return of sensation gener-
ally progresses between 30 and 60 minutes. No significant ana-
tomic structures traverse this area of the vestibule, and the
author has experienced no complications with thousands of
these injections.
Technique for Nasolabial Fold Anesthesia
Using the 1-mL syringe with a 32-gauge needle, 0.1 to 0.2 mL
of local anesthesia is injected deep in the nasolabial fold (so as
not to distort the fold and effect filler accuracy) in two to three
areas from the nostril to the corner of the mouth (Figure 4-4).
Only a small amount of local anesthesia is required to produce
acceptable anesthesia. Although many practitioners use no anes-
thesia for cutaneous injection, I can attest to patient apprecia-
tion of this simple technique.
These simple techniques of maxillary and mandibular ves-
tibular and mucosal infiltration in conjunction with topical
mucosal anesthesia are safe, rapid, and effective ways to provide
local anesthesia for the cosmetic injection of fillers in the lips
and perioral and nasolabial regions.
A
B
FIGURE 4-3.  A, Multiple infiltration technique in the upper lip. B, Same technique for the lower lip.
FIGURE 4-4.  Deep local anesthesia injection to anesthetize the nasolabial
fold region. Generally 0.2 mL of local anesthesia is injected at two to three
points along the fold. Deep injection prevents obscuring the fold, which
would make the filler injection inaccurate.

Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
39
is measured 17 mm from the glabellar midline, and an injection
of 1 to 2 mL of 2% lidocaine, 1 : 100,000 epinephrine is given
(Figure 4-6, A). The supraorbital nerve is blocked by palpating
the notch (and or measuring 27 mm from the glabellar midline)
and injecting 2 mL of local anesthetic solution (see Figure 4-6,
B). The infratrochlear nerve is blocked by injecting 1 to 2 mL
of local anesthetic solution at the junction of the orbit and the
nasal bones (see Figure 4-6, C). In reality, one can block all three
of these nerves by simply injecting 2 to 4 mL of local anesthetic
solution from the central brow proceeding to the medial brow.
Figure 4-7 shows the regions anesthetized by the described
blocks.
Infraorbital Nerve Block
The infraorbital nerve exits the infraorbital foramen 4 to 8 mm
below the orbital rim in an imaginary line dropped from the
medial limbus of the iris6 or the pupillary midline. The anterior
superior alveolar nerve branches from the infraorbital nerve
before it exits the foramen, so some patients will manifest anes-
thesia of the anterior teeth and gingiva if the branching is close
to the foramen. Areas anesthetized include the lateral nose,
anterior cheek, lower eyelid, and upper lip on the injected side.
This nerve can be blocked by intraoral or extraoral routes. To
perform an infraorbital nerve block from an intraoral approach,
topical anesthesia is placed on the oral mucosa at the vestibular
sulcus just under the canine fossa (between the canine and first
premolar tooth) and left for several minutes. The lip is then
elevated, and a 112 -inch 27- gauge needle is inserted in the
sulcus and directed superiorly toward the infraorbital foramen
(Figure 4-8). It is unnecessary for the needle to enter the foramen
for a successful block. The anesthetic solution need only contact
the vast branching around the foramen to be effective. It is
imperative to use the other hand to palpate the inferior orbital
rim to avoid injecting the orbit; 2 to 4 mL of 2% lidocaine with
1 : 100,000 epinephrine are injected in this area for the infra­
orbital block.
The infraorbital nerve can also be very easily blocked by a
facial approach, and this is the author’s preferred route. It may
also be the preferred route in dental-phobic patients. A 32 gauge
12 -inch needle is placed through the skin and aimed at the
foramen in a perpendicular direction. An injection of 2 to 4 mL
SO
IT
ST
17 mm
27 mm
FIGURE 4-5.  The supraorbital nerve (SO) exits about 27 mm from the
glabellar midline, and the supratrochlear nerve (ST) is located approxi-
mately 17 mm from the glabellar midline. The infratrochlear nerve (IT) exits
below the trochlea.
A
B
C
FIGURE 4-6.  Forehead and scalp are blocked by a series of injections form the central to the medial brow.
palpable in most patients. After exiting the notch or foramen,
the nerve traverses the corrugator supercilii muscles and branches
into a medial and lateral portion. The lateral branches supply
the lateral forehead, and the medial branches supply the scalp.
The supratrochlear nerve exits a foramen approximately 17 mm
from the glabellar midline (see Figure 4-5) and supplies sensa-
tion to the middle portion of the forehead. The infratrochlear
nerve exits a foramen below the trochlea and provides sensation
to the medial upper eyelid, canthus, medial nasal skin, conjunc-
tiva, and lacrimal apparatus6 (see Figure 4-5).
When injecting this area, it is prudent to always use the free
hand to palpate the orbital rim to prevent inadvertent injection
into the globe! To anesthetize this area, the supratrochlear nerve

40
Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
area of the cartilaginous nasal dorsum and tip. This supplemen-
tary nasal block is accomplished by palpating the inferior rim
of the nasal bones at the osseous cartilaginous junction. The
dorsal nerve (anterior ethmoid branch of the nasociliary nerve)
emerges 5 to 10 mm from the nasal midline at the osseous
junction of the inferior portion of the nasal bones (the distal
edge of the nasal bones) (Figure 4-11). The dotted line in Figure
4-11 shows the course of this nerve under the nasal bones before
emerging.
Two often overlooked nerves in facial local anesthetic blocks
are the zygomaticotemporal and zygomaticofacial nerves. These
nerves represent terminal branches of the zygomatic nerve. The
zygomaticotemporal nerve emerges through a foramen on the
anterior wall of the temporal fossa. This foramen is actually
behind the lateral orbital rim posterior to the zygoma at the
approximate level of the lateral canthus (Figure 4-12).
Injection technique involves sliding a 112-inch needle behind
the concave portion of the lateral orbital rim. It is suggested
that one closely examine this area on a model skull prior to
attempting this injection; it will make the technique simpler.
To orient for this injection, the doctor needs to palpate the
lateral orbital rim at the level of the frontozygomatic suture
(which is frequently palpable). With the index finger in the
depression of the posterolateral aspect of the lateral orbital rim
(inferior and posterior to the frontozygomatic suture), the
operator places the needle just behind the palpating finger
about 1 cm posterior to the frontozygomatic suture (see Figure
4-12). The needle is then “walked” down the concave posterior
wall of the lateral orbital rim to the approximate level of the
lateral canthus. After aspirating, 1 to 2 mL of 2% lidocaine
1 : 100,000 epinephrine are injected in this area with a slight
pumping action to ensure deposition of the local anesthetic
solution at or about the foramen. Again, it is important to hug
the back concave wall of the lateral orbital rim with the needle
when injecting.
FIGURE 4-7.  Shaded areas indicate anesthetized areas from supraorbital
nerve (SO), supratrochlear nerve (ST), and infratrochlear nerve (IT) blocks.
A
B
FIGURE 4-8.  Intraoral approach for local anesthetic block of the infraorbital nerve.
of local anesthetic solution is given at or close to the foramen
(Figure 4-9). Again, the other hand must constantly palpate
the inferior orbital rim to prevent inadvertent injection into the
orbit. A successful infraorbital nerve block will anesthetize
the infraorbital cheek, the lower palpebral area, the lateral nasal
area, and superior labial regions, as shown in Figure 4-10.
The aforementioned techniques provide anesthesia to the
lateral nasal skin but do not provide anesthesia to the central
portion of the nose. A dorsal (external) nasal nerve block will
supplement nasal anesthesia by providing anesthesia over the

Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
41
Total Second Division Nerve Block
An efficient and simple technique to obtain hemimidfacial local
anesthesia is to block the entire second division or maxillary
nerve. This will anesthetize the entire hemimaxilla and the uni-
lateral maxillary sinus by blocking the pterygopalatine, infra­
orbital, and zygomatic nerves and their terminal branches. This
easily learned technique involves an intraoral approach at the
posterior lateral palate (Figure 4-15).
The maxillary nerve block via the greater palatine canal was
first described in 1917 by Mendel.7 The greater palatine foramen
is located anterior to the junction of the hard and soft palate
medial to the second molar tooth (see Figure 4-15, B). The
foramen is usually found about 7 mm anterior to the hard and
soft palate junction. This junction is seen as a color change, such
that the tissue overlying the soft palate is darker pink than the
tissue overlying the hard palate. The key to this block is to place
a 112-inch needle through the greater palatine foramen. It some-
times takes multiple needle sticks to localize the foramen, so the
palatal mucosa in this area is first infiltrated with 0.5 mL of
lidocaine to facilitate painless location of the greater palatine
foramen. A 112-inch 25- or 27-gauge needle is bent to a
45-degree angle and will usually easily negotiate the pterygo-
palatine canal, thereby placing the local anesthetic solution into
the pterygopalatine fossa. Reviewing the course of the maxillary
division of the trigeminal nerve (V2), the second division arises
from the gasserian ganglion in the medial cranial fossa and exits
the skull via the foramen rotundum (see Figure 4-15, C). The
nerve then traverses the superior aspect of the pterygopalatine
fossa, where it divides into three major branches: the pterygo-
palatine nerve, the infraorbital nerve, and the zygomatic nerve,8
which are targeted in this block.
Blocking the zygomaticotemporal nerve causes anesthesia in
the area superior to the nerve, including the lateral orbital rim
and the skin of the temple from above the zygomatic arch to
the temporal fusion line (Figure 4-13, ZT).
The zygomaticofacial nerve exits through a foramen (or
foramina in some patients) in the inferolateral portion of
the orbital rim at the zygoma. If the surgeon palpates the
junction of the inferolateral (the most southwest portion of
the right orbit) portion of the lateral orbital rim, the nerve
emerges several millimeters lateral to this point. By palpating
this area and injecting just lateral to the finger, this nerve
is successfully blocked with 1 to 2 mL of local anesthesia
(Figure 4-14). Blocking this nerve will result in anesthesia of
a triangular area from the lateral canthus and the malar region
along the zygomatic arch and some skin inferior to this area
(see Figure 4-13).6
A
B
FIGURE 4-9.  Facial approach for local anesthetic block of the infraorbital
nerve.
FIGURE 4-10.  Area of anesthesia from unilateral infraorbital nerve block.

42
Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
A
B
FIGURE 4-11.  The dorsal (external) nasal nerve is blocked subcutaneously at the osseous-cartilaginous junction of the distal nasal bones.
A
B
C
FIGURE 4-12.  The zygomaticotemporal nerve is blocked by placing the needle on the concave surface of the posterior lateral orbital rim.

Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
43
Transient diplopia of the ipsilateral eye may occur.10 This
results from the local anesthetic diffusing superiorly and medi-
ally to anesthetize the orbital nerves. The patient must be assured
that if this phenomenon occurs, it is transient.
Again, this technique will anesthetize all the terminal
branches of the maxillary nerve with a single injection.
Mental Nerve Block
The mental nerve exits the mental foramen on the hemiman-
dible at the base of the root of the second premolar (many
patients may be missing a premolar owing to orthodontic
extractions). The mental foramen is on the average 11 mm
inferior to the gum line (Figure 4-16). There is variability with
this foramen (like all foramina), but by injecting 2 to 4 mL of
local anesthetic solution about 10 mm inferior to the gum line
or 15 mm inferior to the top of the crown of the second pre-
molar tooth, the block is usually successful. In a patient without
teeth, the foramen is oftentimes located much higher on the jaw
and can sometimes be palpated. This block is performed more
superiorly in the denture patient. As stated earlier, entry into
the foramen is unnecessary; a sufficient volume of local anes-
thetic solution in the general area will be effective. Alternatively,
the mental nerve may be blocked with a facial approach, aiming
for the same target (see Figure 4-16, B).
When anesthetized, the typical distribution of numbness will
be the unilateral lip down to the mentolabial fold (but many
times, the anterior chin and cheek), depending on the indi-
vidual furcating anatomy of that patient’s nerve (Figure 4-17).
The inferior alveolar nerve also supplies sensory innervation to
the chin pad. The mylohyoid nerve may also innervate this area.
To augment or extend the area of local anesthesia on the chin,
an inferior alveolar nerve block (mandibular dental block) can
be performed instead of or with the mental nerve block. Addi-
tionally, local skin infiltration in that area may assist.
ZT
ZF
FIGURE 4-13.  Anesthetized areas from zygomaticotemporal (ZT) and
the zygomaticofacial nerve (ZF) block are illustrated.
A
B
FIGURE 4-14.  Zygomaticofacial nerve(s) are blocked by injecting the inferolateral portion of the orbital rim.
When the foramen is located, the needle should be gently
advanced. If significant resistance is encountered, the needle
should be withdrawn and redirected. Approximately 5% of the
population has been shown to have tortuous canals that impede
the needle tip, and in some patients this technique is not pos-
sible.9 It is vital to aspirate before injecting to prevent intravas-
cular injection. When the needle is properly positioned (usually
at a depth of 25 to 30 mm), the injection (2 to 4 mL) should
proceed over 30 to 45 seconds.

44
Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
upper second molar, and the needle is advanced halfway between
the thumb and index finger of the other hand that is grasping
the mandible (see Figure 4-18). An injection of 2 mL of 2%
lidocaine, 1 : 100,000 epinephrine is given in a pumping motion
to better the chances of anesthetic solution contacting the nerve
and foramen. The needle can be slightly bent as shown in Figure
4-18 to negotiate the sometimes outward curvature of the man-
dibular ramus. The surgeon should first aspirate to avoid intra-
vascular injection. Anesthesia from this block sometimes takes
5 to 10 minutes to ensue. Proficiency in this blocking technique
requires practice, but it is very useful in cosmetic facial proce-
dures. In addition, the ipsilateral tongue is usually anesthetized
with this block. The area anesthetized includes the lower teeth
and gums, the chin, and skin on the lateral chin. The inferior
alveolar nerve block frequently includes the mylohyoid nerve.
Inferior Alveolar Nerve Block (Intraoral)
Almost every person who has ever been to a dentist has had this
block and is aware of its effects, distribution, and duration. This
block is technically more difficult to master but is easily learned.
The basis of this technique involves the deposition of local
anesthetic solution at or about the mandibular foramen on the
medial mandibular ramus where the inferior alveolar nerve
enters the mandible (Figure 4-18).
Detailed description of this technique is beyond the scope
of this chapter. In brief, the patient is seated upright, and the
surgeon places the index finger on the posterior ramus and the
thumb in the coronoid notch on the anterior mandibular ramus
(see Figure 4-18). A 112-inch 27-gauge needle is then directed
to the medial mandibular ramus at the level of the cusps of the
A
B
C
FIGURE 4-15.  Maxillary nerve block is performed by locating the greater palatine foramen (A), inserting a bent needle up the
pterygopalatine canal (B) to inject local anesthetic into the pterygopalatine fossa (C). Notice the needle tip in the pterygopalatine
fossa on the far right image. As the second division traverses this area, it is blocked at the main trunk.
A
B
FIGURE 4-16.  The mental foramen is approached intraorally below the root tip of the lower second premolar (A) or from a facial
approach (B).

Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
45
pterygoid plate (Figure 4-19, 2). This technique requires more
experience and has more potential complications than the intra-
oral approach.
The technique for performing V3 block begins with the
patient in supine position with the head and neck turned away
from the side to be blocked. The patient is asked to open and
close the mouth gently so the operator can identify and palpate
the sigmoid notch.11 This is the area between the mandibular
condyle and the coronoid process (see Figure 4-19). This notch
is located about 25 mm anterior to the tragus. If one places a
finger 25 mm anterior to the tragus and opens and closes the
jaw, the mandibular condyle can be palpated with the jaw open.
When the jaw is closed, the finger will be over the sigmoid
notch. A 22-gauge 3-inch needle is inserted in the midpoint of
the notch and directed slightly cephalic and medial through the
notch until the lateral pterygoid plate is contacted (see Figure
19, 1).11 This is usually at a depth of 4.5 to 5 cm. Spinal needles
frequently have measuring stops that can be adjusted to the
position of original contact of the pterygoid plate. The needle
is then withdrawn to a subcutaneous position and carefully
“walked off” the posterior border of the pterygoid plate (see
Figure 4-19, arrows) in a horizontal plane until the needle no
longer touches the plate and is posterior to it. The needle depth
should be the same as the distance on the needle stop marker
when the pterygoid plate was originally contacted. The needle
should not be advanced more than 0.5 cm past the depth of the
pterygoid plate, because the superior constrictor muscle of the
pharynx can be pierced easily.11 When the needle is in appropri-
ate position, 5 mL of local anesthetic solution can be adminis-
tered. The area anesthetized is shown as “V3” in Figure 4-2.
Complications include hematoma formation and subarachnoid
injection.12 Again, this block should be learned in a proctored
situation and not be attempted by novice injectors.
FIGURE 4-17.  Anesthetized areas from a unilateral mental nerve block.
Owing to various anatomic factors, the area below the mentolabial fold or
at the midline may share other innervation.
A
B
FIGURE 4-18.  The target of the needle in the intraoral inferior alveolar nerve block is at the entrance of the nerve in the mandibular
foramen on the medial ramus. The needle can be slightly bent with a medial angle to negotiate the flaring anatomy of the ramus.
The mylohyoid nerve (inferior to needle) may or may not be blocked by this technique, depending upon its level of
branching.
In some patients, the mylohyoid nerve braches above the area
of inferior alveolar injection and in this case needs a specific
mylohyoid nerve block.
Mandibular Nerve (V3) Block (Facial Approach)
The mandibular nerve can also be blocked from a deep injection
where the nerve exits the foramen ovale posterior to the

46
Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
exception of the posterior area. This is anesthetized by blocking
the greater occipital nerve. One can also perform a ring block,
where wheals of local anesthetic are injected every several cen-
timeters around the entire scalp at about the level of the eye-
brows. About 30 mL of local anesthetic is required to perform
a scalp ring block.
Greater Occipital Nerve Block Technique for
Posterior Scalp Anesthesia
The greater occipital nerve arises from the dorsal rami of the
second cervical nerve and travels deep to the cervical muscula-
ture until it becomes subcutaneous slightly inferior to the supe-
rior nuchal line.12 It emerges on this line in association with the
occipital artery; the artery is the most useful landmark for locat-
ing the greater occipital nerve (Figure 4-21). The most efficient
patient position is sitting upright with the chin flexed to the
sternum.13 The nerve is identified at its point of entry to the
scalp along the superior nuchal line, a third to half the distance
between the mastoid process and the occipital protuberance in
the midline (see Figure 4-21). Another measurement for locat-
ing the artery is 2.5 to 3 cm lateral to the occipital protuber-
ance.14 The patient will report pain upon compression of the
nerve, and the point at which maximal tenderness is elicited can
be used as the injection site. A 25-gauge 58-inch needle is used
for the block. The occipital artery is just lateral to the greater
occipital nerve and can be used as a pulsatile landmark. Between
2 and 4 mL of local anesthetic solution can be infiltrated on
either side of the artery to ensure proximity to the nerve (see
Figure 4-24 for the dermatomes anesthetized by blocking the
greater occipital nerve).
Blocking the Scalp
As outlined earlier, the anterior scalp is anesthetized by injecting
the branches of V1 (supraorbital and supratrochlear nerves), and
V2 (the zygomaticotemporal nerve). The posterior scalp is
innervated by the greater and lesser occipital nerves, and the
greater auricular nerve supplies the lateral scalp (Figure 4-20).
By performing “brow block” (see Figure 4-7), cervical plexus
block (see Figure 4-22), and zygomaticotemporal block (see
Figure 4-12), most of the scalp is anesthetized, with the
1
2
FIGURE 4-19.  The mandibular nerve (V3) block places the local anesthetic
just posterior to the lateral pterygoid plate where the third division of the
trigeminal nerve exits the foramen ovale. The needle is walked off the
pterygoid plate (1), and the local anesthetic solution is deposited in  
the region of the third division of the trigeminal nerve (2).
Supratrochlear
artery
Supratrochlear
nerve
Supraorbital
artery
Supraorbital
nerve
Zygomatico-
temporal
nerve
Auriculo-
temporal
nerve
Lesser
occipital
nerve
Greater
occipital
nerve
Third occipital nerve
Superficial
temporal
artery
Posterior
auricular
artery
Occipital
artery
FIGURE 4-20.  Innervation of the scalp, where 1 = supratrochlear nerve,
2 = supraorbital nerve(s), 3 = zygomaticotemporal nerve, 4 = greater
auricular nerve, 5 = lesser occipital nerve, 6 = greater occipital nerve.
2
1
3
4
5
FIGURE 4-21.  The greater occipital nerve is in close proximity to the artery
of the same name (1). The nerve can be located by palpating the artery
and injecting just medial to it (2). Another landmark is injecting on the
nuchal line, one third to one half the distance between the mastoid promi-
nence and occipital protuberance (3 and 5). Number 4 in the diagram
shows the lesser occipital nerve.

Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
47
The cutaneous cervical nerve (cutaneus colli nerve, anterior
cervical nerve) arises from the second and third cervical nerves
and provides sensation to the anterolateral parts of the neck (see
Figure 4-22, B).
Cervical Plexus Block
Cervical plexus block is used in cosmetic facial surgery to
anesthetize the skin of the lateral or anterior neck, the posterior
lateral scalp, and portions of the periauricular area (see Figure
4-1). The technique involves positioning the patient lying back
with the sternocleidomastoid flexed. The mastoid process and
the transverse process of C6 (Chassaignac tubercle; approximate
level of the cricoid cartilage) are marked (see Figure 4-22, A).
This line is divided in half at the posterior border of the sterno-
cleidomastoid to determine the injection point.15
Another technique is to simply bisect the distance from the
origin and insertion of the sternocleidomastoid, without osseous
landmarks. The success of this block involves a larger volume of
local anesthesia diffusing and spreading out over a larger area
rather than absolute accuracy of the nerve position. Between 3
and 5 mL of local anesthetic solution are injected subcutane-
ously with the needle perpendicular to the skin. The needle is
then redirected superiorly, and another 3 to 5 mL are injected.
Finally, the needle is then directed inferiorly, and another 3 to
5 mL are injected. Figure 4-22, B shows the areas anesthetized
by a cervical plexus block.
Phrenic nerve involvement is rare with superficial cervical
plexus block (more common with deep cervical blocks) but
technically possible inasmuch as C3, C4, and C5 innervate the
diaphragm. Healthy patients can tolerate a hemiparalysis of the
diaphragm, but caution must be used in patients with cardio-
pulmonary problems; assisted ventilation may be required. It
must be kept in mind that a bilateral block could potentially
denervate the entire diaphragm. To prevent unwanted spread of
local anesthetic solution, this injection is just subcutaneous in
placement and never done bilaterally.
Local Anesthesia of the Neck
Innervation of the Cervical Plexus
The cervical plexus is formed from the ventral rami of the upper
four cervical nerves (Figure 4-22, B). Their dorsal and ventral
roots combine to form spinal nerves as they exit through the
intervertebral foramen. The anterior rami of C2 through C4
form the cervical plexus.5 The cervical plexus lies just behind
the posterior border of the sternocleidomastoid muscle, giving
off both superficial (superficial cervical plexus) and deep
branches (deep cervical plexus). The branches of the superficial
cervical plexus supply the skin and superficial structures of the
head, neck, and shoulder. The deep branches of the cervical
plexus innervate the deeper structures of the neck, including the
muscles of the anterior neck and the diaphragm (phrenic nerve),
and are not blocked for local anesthetic procedures.
Superficial Branches of the Cervical Plexus
The lesser occipital nerve arises from the second (and sometimes
third) cervical nerve and emerges from the deep fascia on the
posterolateral portion of the head behind the auricle, supplying
the skin and communicating with the greater occipital, the
greater auricular, and the posterior auricular branch of the
facial nerve.5
The greater auricular nerve arises from the second and third
cervical nerves and divides into an anterior and a posterior
branch. The anterior branch is distributed to the skin of the face
over the parotid gland and communicates in the substance of
the gland with the facial nerve.
The posterior branch supplies the skin over the mastoid
process and on the back of the auricle, except at its upper part.
A filament pierces the auricle to reach its lateral surface, where
it is distributed to the lobule and lower part of the concha. The
posterior branch communicates with the lesser occipital nerve,
the auricular branch of the vagus, and the posterior auricular
branch of the facial nerve.5
2
1
A
B
C
FIGURE 4-22.  The cervical plexus block is performed by making a line from the mastoid process (1) to the level of the transverse
process of C6 (2) then finding the point halfway between these two marks (X) just posterior to the sternocleidomastoid (dotted
line). Local anesthetic is then injected perpendicularly, superiorly, and inferiorly in this region. (Middle picture also shows the
greater occipital nerve, which is not part of the cervical plexus.)

48
Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
and safely blocked when the clinician possesses a thorough
understanding of the basic innervation patterns.
The entire sensory apparatus of the face is supplied by the
trigeminal nerve and several cervical branches. There exist many
patterns of nerve distribution anomaly, cross-innervation, and
individual patient variation, but by following the basic tech-
niques outlined in this chapter, the cosmetic surgeon should be
able to achieve pain control of the major dermatomes of the
head and neck. A basic dermatomal distribution is illustrated in
Figure 4-24 and can serve as a road map to local anesthesia of
the head and neck.
Tumescent Anesthesia
One of the most important recent contributions to the field of
cosmetic surgery was the introduction of tumescent anesthesia
by dermatologist Jeffery Klein.17-21 This occurred during a
unique time in cosmetic surgery when turf wars were being won
by limiting hospital privileges for non–core cosmetic trained
physicians. These political limitations constrained many capable
surgeons who were unable to easily practice their skills because
they were denied hospital privileges by various controlling and
competing specialties. Power in the boardrooms led to exclusion
in the operating rooms. The formulation and popularization of
tumescent anesthesia enabled thousands of physicians to prac-
tice safe and effective anesthesia in the office or ambulatory
surgery center environment and is considered the safest means
of cosmetic anesthesia for procedures such as high-volume
liposuction. By liberating the talents of many physicians from
numerous specialties, the field of cosmetic entered an exponen-
tial multispecialty growth.
Ear Block
Four nerve branches supply sensory innervation to the ear. The
anterior half of the ear is supplied by the auriculotemporal
nerve, which is a branch of the mandibular portion of the tri-
geminal nerve. The posterior half of the ear is innervated by two
nerve branches derived from the cervical plexus: the greater
auricular nerve and the lesser occipital nerve (see Figure 4-22,
B). The auditory branch of the vagus nerve innervates the
concha and external auditory canal.
Although these nerves can be individually targeted with
blocks, a circumferential infiltration (ring block) will anesthetize
the entire ear except for the concha and the external auditory
canal, which are innervated by the vagus nerve. The needle is
inserted into the skin at the junction where the earlobe attaches
to the head. The anesthetic should be infiltrated while the needle
is advanced to the subcutaneous plane. Infiltration is made in a
hexagonal pattern around the entire periphery of the ear (Figure
4-23). The conchal bowl and external auditory canal will need
separate infiltration. One should aspirate (as with all injections)
prior to injection to prevent intravascular injection.
Major Sensory Dermatomes of the Head
and Neck
A firm knowledge of the sensory neuroanatomy of the head and
neck is paramount to the practice of cosmetic facial surgery and
benefits both surgeon and patient. Although the pathways of
sensation for the head and neck are complex, they can be easily
FIGURE 4-23.  Blocking the entire ear (with the exception of the area sup-
plied by the vagus nerve) can be performed by inserting the needle at the
black dots and infiltrating along the dotted lines. This will anesthetize the
terminal branches of the auriculotemporal nerve, the lesser occipital nerve,
and the anterior and posterior branches of the greater auricular nerve. The
main trunks of these nerves could be blocked as detailed earlier in this
chapter, but this terminal infiltration technique may be more convenient.
FIGURE 4-24.  Major sensory dermatomes of the head and neck.
AC = anterior cervical cutaneous colli, AT = auriculotemporal, B = buccal,
EN = external (dorsal) nasal, GA = greater auricular, GO = greater occipital,
IO = infraorbital, IT = infratrochlear, LO = lesser occipital, M = mental,  
SO = supraorbital, ST = supratrochlear, ZF = zygomaticofacial,  
ZT = zygomaticotemporal.

Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
49
Tumescent liposuction, as the name implies, involves hyperin-
flation of the soft tissues with varied mixtures of local anesthesia
and epinephrine. A very common formulation for high-volume
liposuction is 1 L of normal saline with 50 mL of 2% lidocaine,
1 mL (1 amp) of 1 : 1000 epinephrine, and 2.5 mL of 8.4%
sodium bicarbonate for a final concentration of lidocaine of
0.1% and epinephrine of 1 : 1,000,000 (Box 4-1). In this
formula, bicarbonate is added to counteract the acidic nature of
the saline solution to decrease the pain of the injection and
increase analgesic potency. Although the maximum recom-
mended dose of lidocaine (as a sole medication) is 7 mg/kg to
a maximum dose of 500 mg, a recent study shows that local
anesthesia with diluted lidocaine at a dose 3.1 times higher than
the currently recommended dose (7 mg/kg) administered with
epinephrine yielded a peak plasma lidocaine level that was 72%
below the level considered safe (5 mg/mL)22 (see Box 4-2).
Alternatively, in small-area liposuction (e.g., the head and
neck), a smaller volume of a more concentrated solution may
be used. Box 4-2 shows a more concentrated formula that still
maintains safe lidocaine levels while providing more profound
local anesthesia and vasoconstriction.22
After the solution is freshly mixed, it can be injected into the
tissues by many means, including large syringes with an 18-gauge
spinal needle, hand pump devices, and dedicated tumescent
anesthesia mechanical pumping machines (Figure 4-25). The
goal is to infiltrate the subcutaneous tissues to an extremely
turgid level (described as “hard as wood”) to expand the tissues.
The effect of making the tissues tumescent is threefold. It
provides local anesthesia for pain control, hemostasis from the
epinephrine, and tissue hydrodissection in the subcutaneous
surgical plane (Box 4-3). For facelift and facial liposuction pro-
cedures, the solution is injected into the subcutaneous tissue.
For other procedures such as endoscopic brow and forehead lift,
the solution is injected at the periosteal level. When the tissues
blanch, adequate hemostasis and anesthesia are generally in
effect and will last for several hours. For facelift surgery, I
Box 4-2  Alternate Tumescent Formulaiton for Head and
Neck Procedures
Alternatively, in small-area liposuction (e.g., the head and neck), a smaller
volume of a more concentrated solution may be used with a more con-
centrated formula that still maintains safe lidocaine levels while providing
more profound local anesthesia and vasoconstriction.
0.25% lidocaine/1 : 400,000 epinephrine
50 mL 1% lidocaine
150 mL normal saline
0.5 mL 1 : 1000 ( 12 ampule) epinephrine
Box 4-3  Advantages of Tumescent Anesthesia
• Less blood loss.
• Bacteriostatic lidocaine may decrease risk of infections.
• Vasoconstriction minimizes absorption.
• Epinephrine may increase cardiac output, which in turn hastens hepatic
metabolism of lidocaine.
• Duration of anesthetic effect may last as long as 24 hours.
• Lidocaine may be given safely up to 45 mg/kg and even higher in
certain conditions.
Box 4-1  Common Formulation for High-Volume Tumescent Liposuction
and Liposuction
Tumescent Anesthesia Formulation (Final concentration 0.1% Lidocaine
with 1 : 1 million epinephrine)
1 L normal saline
50 mL 2% lidocaine
1 ampule epinephrine 1 : 1000
2.5 mL 8.4% sodium bicarbonate
commonly inject the entire face and neck at the beginning of
the case, and the anesthesia lasts for the duration. Alternatively,
the second side can be injected a half hour prior to beginning
surgery.
Conscious Sedation
Because of the numerous types of cosmetic facial surgery pro-
cedures and the varied specialists who perform it, ambulatory
office-based anesthesia can vary from simple local and tumes-
cent anesthesia to oral and IV sedation administered by the
surgeon and surgical team to full-blown general anesthesia
administered by an anesthesiologist. Obviously the type and
level of anesthesia depends upon numerous variables, including
the experience of the surgeon, the type of office facility and
equipment, the specific procedure, and the patient’s health.
Whereas 25 years ago, most IV sedation was performed by
trained anesthesia personnel, today many specialties perform
safe and effective ambulatory office IV sedation. We routinely
see this in oral and maxillofacial surgery offices, gastroenterol-
ogy/endoscopy practices, invasive cardiology practices, and cos-
metic surgery offices. With this shift to office-based accredited
surgery centers, the art and science of anesthesia must never be
taken lightly; the provider literally holds the patient’s life in his
or her hands during the sedation procedure. Any surgeon who
intends to use a surgical team must have or seek adequate train-
ing, state licensure, malpractice coverage, and proper monitor-
ing and emergency equipment to safely perform office-based
anesthesia. This chapter is not intended as a how-to guide
for conscious sedation but rather an overview of common
techniques.
Conscious sedation by definition involves a level of anesthesia
during which patients can respond to commands. Generally this
level of anesthesia is intended for relaxation and anxiolysis
and most importantly, the amnesia effect. There are numerous
means of delivery of conscious sedation, and the most
popular for cosmetic surgery are oral (enteral) and IV (paren-
teral) sedation.
Nitrous Oxide/Oxygen
Nitrous oxide was originally used as a party drug in the 1800s.
People would hold “nitrous follies” and breathe the gas for
revelry. At a demonstration, a user was running around and cut
his shin on a bench but did not feel pain. One of the observers,
a dentist, noted this reaction and later extracted a tooth on a
patient while administering nitrous oxide. This was the begin-
ning of today’s modern anesthesia. Although nitrous oxide was
soon replaced with chloroform and ether, it remained a

50
Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
A
C
B
FIGURE 4-25.  Tumescent anesthesia can be injected with a simple 60-mL syringe (A), a hand pump apparatus (B), or a dedi-
cated peristaltic pumping apparatus (C).
mainstay in the field of dentistry and anesthesiology. Nitrous
oxide is a very safe drug in that it is a sedative and analgesic but
is not metabolized. This means a patient can breathe nitrous
oxide for sedation and analgesia and drive home 15 minutes
later. Most of us have done this at dental visits. Portable nitrous
oxide/oxygen machines are readily available and are simple to
use. Generally a mixture of 50% nitrous oxide and 50% oxygen
is inhaled by the patient through a nasal hood; after several
minutes, the patient will feel a pleasant effect, a feeling of well-
being, and moderate analgesia. This can be used while injecting
neuromodulators or facial blocks. For procedures that preclude
a nasal hood, the nitrous/oxygen mixture is inhaled until the
effects are obtained, then the nasal hood is removed and intra-
oral local anesthetic blocks or actual lip filler are performed.
Most patients are familiar with nitrous oxide from dental visits
and readily accept the procedure. Although the drug has a long
history of being extremely safe, the provider must be familiar
with the phenomenon of diffusion hypoxia. Diffusion hypoxia is
said to occur at the termination of inhalation and is due to a
low blood-gas solubility coefficient when nitrous oxide washes
out of the blood in large volumes, diluting oxygen in the lung
alveoli and reducing alveolar oxygen tension, which then pro-
duces hypoxia. To counteract this, pure oxygen is inhaled for 3
to 5 minutes after the discontinuation of nitrous oxide. Although
this practice has been disputed, it remains the standard of care
in most settings.
Oral Sedation
Taking another cue from dentistry, oral conscious sedation can
provide extreme relaxation, sedation, and profound amnesia for
ambulatory office procedures. Many cosmetic surgeons are well
versed in the use of oral conscious sedation and use it safely and
effectively for cosmetic facial procedures. It must be noted that
some patients can be sensitive to oral medications and inadver-
tently enter a general anesthetic plane with severe respiratory
depression. Appreciating this, cosmetic surgeons who employ
oral conscious sedation must have proper monitoring and emer-
gency equipment as well as the training to manage respiratory
depression or respiratory arrest. When considering triazolam
(Halcion), which is the most popular oral sedative in dentistry,
the surgeon should monitor blood pressure, pulse rate, and
oxygen saturation. In addition, positive-pressure breathing

Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
51
2 patients with good general health. Diazepam 10 mg may be
given the evening before for anxiety.
Monitored Anesthetic Care Anesthetic Agents
Fentanyl is a narcotic that is 60 to 80 times more potent than
morphine and has a greater affinity for opiate receptors than
morphine. Fentanyl has a rapid onset of action (due to its ease
of crossing the blood-brain barrier) and a rapid clearance, with
99% of a single dose cleared from the plasma within 60 minutes.
Midazolam is a benzodiazepine and was introduced in the
late 1980s. It had numerous advantages over diazepam, includ-
ing shorter half-life, less active metabolites, shorter recovery
time, and lower incidence of thrombophlebitis. Midazolam’s
actions include anxiolysis, sedation-hypnosis, muscle relaxation,
amnesia, and anticonvulsant activity. Since it is water soluble,
it can also be administered orally. All benzodiazepines have the
potential to cause respiratory depression.
Ketamine is a sedative-hypnotic dissociative anesthetic agent
that produces profound dose-dependant analgesia without sig-
nificant respiratory depression. Ketamine has a sympathomi-
metic response through direct central nervous system (CNS)
stimulation, causing increased heart rate, blood pressure, and
cardiac contractility. Although increased secretion from the sali-
vary and respiratory mucous glands occurs, the drug is also a
bronchodilator (by relaxing smooth muscle as a result of sym-
pathomimetic effects).
Propofol is a non-water-soluble, nonbarbiturate, lipid-
emulsion, intravenous sedative-hypnotic. It does not produce
nausea and vomiting and actually has some antiemetic effect.
Propofol provides cardiovascular stability by exerting a central
sympatholytic effect that maintains a stable rate. Propofol
appears to cause few changes in the electrical activity of the heart
and is not associated with dysrhythmias.
The medications described herein are shown in Figure 4-26.
The Procedure
When the patient arrives at the office, a heart and lung exam is
performed, preoperative pictures are taken, surgical markings
are made, and the patient changes into surgical clothing. IV
access is obtained with a 22-gauge Angiocath, and this is con-
nected to a stopcock on a bag of normal saline. The technique
equipment (Ambu bag and an oxygen source) must be available
in the rare event of respiratory depression.
Patients undergoing oral sedation should be NPO for 8
hours before surgery and may not drive themselves home. Tri-
azolam 0.5 mg is commonly used and is an excellent drug for
oral sedation; it has a short half-life when compared to other
benzodiazepines and is eight times more effective than diazepam
as a hypnotic. The drug is better absorbed sublingually than
when swallowed, and the onset of effect is about 45 minutes.
This dose will cause relaxation but not deep sedation by itself.
Giving 0.75 mg concomitantly with nitrous oxide/oxygen
(50%/50%) will provide deeper, smoother conscious sedation
with excellent amnesia. The physiology of triazolam will have a
potential effect on both sides of the bell curve. About 2.5% of
patients may not respond to the oral medication and feel no
effect. About 2.5% of patients may experience a more profound
effect with respiratory depression.23 This further underlines the
necessity of properly monitoring vital signs and supporting
respiration if necessary.
Using oral sedation, local anesthesia and tumescent anesthe-
sia can be more easily performed and “take the edge off” the
procedure as well as provide amnesia about the surgery. If using
nitrous oxide/oxygen with the triazolam, the nasal hood can be
removed while facial blocks or tumescent anesthesia are admin-
istered and left off for the duration of the case once the patient
is numb.
Another common and safe method of oral sedation utilizes
triazolam 0.5 mg with an oral meperidine/Phenergan capsule
(Meprozine). The triazolam produces sedation and amnesia, the
meperidine produces analgesia, and the Phenergan produces an
antinausea effect. The dose is 1 Meprozine capsule (50 mg
meperidine, 25 mg Phenergan) and 0.5 mg of triazolam. Again,
with most minor cosmetic facial surgery procedures such as
liposuction, chemical peel, light laser, facial implants, small
facelifts, and blepharoplasty, once the local or tumescent anes-
thesia is administered, there is little need for deep sedation.
Intravenous Sedation
Whether a surgeon has core training in IV sedation or learns it
in postgraduate study, it can be a huge asset in cosmetic surgery.
Most common facial procedures can be performed safely and
effectively in the outpatient ambulatory office setting on healthy
patients. Again, as a disclaimer, no practitioner should ever
attempt advanced anesthetic techniques without proper training
and equipment. Although there are infinite techniques, medica-
tions, and practitioner preferences, I have found monitored
anesthetic care (MAC) to be the safest and most predictable
means of delivering anesthesia. This can be done with IV meds
alone or in conjunction with a medication pump to deliver
metered doses. It is very easy to pass from a conscious anesthetic
plane to a general anesthetic plane, so again, proper monitoring,
airway support, and emergency medications are required.
My favorite technique involves the use of a narcotic, a ben-
zodiazepine, ketamine, and propofol administered with a spe-
cialized nasal airway and supplemental oxygen via nasal cannula.
All patients are NPO for 8 hours and receive a preoperative
history and physical. This procedure is only performed on
American Society of Anesthesiology (ASA) class 1 and ASA class
FIGURE 4-26.  This image shows the common medications utilized for
monitored anesthetic care in the author’s practice.

52
Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
the 15-minute regimen, but a passive patient may only need the
alternating meds every 30 to 40 minutes. If patients become
light during anesthesia, they may also be given propofol in 2- to
5-mg doses to “smooth out” the anesthesia. Again, this drug can
induce general anesthesia and if used, airway support must be
at hand. My goal is to use the smallest amount of narcotic to
enable more rapid recovery and have less nausea and vomiting,
so I do not routinely alternate the fentanyl or meperidine
throughout the case, with the exception of patients who are very
pain responsive.
Most patients will recover in 30 to 45 minutes, although
cases lasting 4 to 5 hours may require a longer period. I have
used thousands of doses of ketamine over 30 years and have
never seen the described emergence delirium phenomenon where
patients have bad dreams and unpleasant feelings. On the con-
trary, when patients emerge and sometimes hallucinate, it is
usually very pleasant, especially if the stage is set preoperatively
that the experience is positive. Also, using a benzodiazepine with
ketamine seems to allay the severity of psychoactive effects.
During IV anesthesia, we also routinely give most surgical
patients 1 gm of cephalosporin antibiotic and 8 mg of dexa-
methasone to cover infection and swelling.
and dosages here described are for adult patients, although the
same technique can be used with children. At a minimum, all
MAC anesthesia patients are monitored for blood pressure,
pulse oximetry, and heart rate. End-tidal CO2 is also measured.
The patient is titrated with 5 mg of midazolam over several
minutes, then given 50 mcg of fentanyl (or 50 mg of meperi-
dine) over several minutes. At this point, the patient is still
talkative and responsive to normal conversation but usually
slurring words and feeling quite relaxed. Atropine 0.4 mg is also
given to dry oral secretions and stabilize vagal responses. When
the surgeon is ready to begin administering local or tumescent
anesthesia, 50 mg of ketamine is given IV over 1 minute. This
dose will produce dissociative anesthesia where the patient is
conscious and breathing but largely unresponsive. This generally
occurs within 1 to 2 minutes after administration and lasts
about 15 minutes. At this point, the patient has received the
narcotic, midazolam, and ketamine and is unresponsive to
painful stimuli. The local or tumescent is administered, which
will significantly reduce the amount of drugs needed for the
duration of the procedure. In fact, some practitioners will not
give any further anesthesia and rely totally on the local or
tumescent anesthesia for the remainder of the procedure.
For very short procedures, simply lifting the patient’s chin
and using supplemental oxygen via nasal cannula is sufficient. I
have done hundreds of procedures lasting over 4 hours with
MAC anesthesia as described, and for these cases I rely on a
Rusch tube (Southern Anesthesia, West Columbia, SC) for
airway assistance, with lidocaine jelly lubrication. This tube is
longer than a nasal trumpet but much shorter than an endotra-
cheal tube and keeps the posterior tongue from occluding the
pharynx (Figure 4-27). A paper punch is used to make a hole
in the side of the tube, and the oxygen cannula is cut from the
nose piece and inserted into the tube as an oxygen delivery
source at about 2 L/min. A capnograph can also be inserted into
the tube to measure end-tidal CO2.
Alternatively, a laryngeal mask airway (LMA) may be
used in the same manner as the Rusch tube but does require
an advanced level of airway skill to place and maintain
(Figure 4-28).
My basic regimen for anesthesia includes repeating the mid-
azolam or ketamine on a 15-minute alternating schedule. For
purposes of description, let’s say that we began the anesthesia at
noon and gave the fentanyl, midazolam, and ketamine at the
same time. The next step would be to repeat the midazolam
dose of 5 mg 15 minutes later, so that would be 12:15. Fifteen
minutes later (at 12:30), we would repeat the 1 mg dose of
ketamine, and at 12:45 we would alternate back to the mid-
azolam. So essentially, we are repeating the midazolam and
ketamine every 15 minutes. Again, I have done a plethora of
safe cases using this technique for procedures lasting 4 to 5
hours by simply repeating these dosages. The most common
situation is that after the first hour, most patients won’t need
the full dose, and half doses (2.5 mg of midazolam, 25 mg of
ketamine) can be used for the duration of the case. Or, full doses
can be used, but instead of giving them at 15-minute intervals,
the meds are alternated at 30 to 45 minutes. All of this titration
is based upon the patient’s level of consciousness, vital signs,
and cooperation. A patient who is in pain or restless may need
A
B
FIGURE 4-27.  A, Rusch tube in place, with tubing from the oxygen cannula
placed in the tube. B, Intraoral view of the Rusch tube in place, keeping
the tongue from obstructing the oropharynx and the patient from respira-
tory obstruction.

Chapter 4  •  Anesthesia Considerations for Cosmetic Facial Surgery
53
  2. Jastak JT, Yagiela JA, Donaldson D: Local anesthesia of the oral cavity.
Philadelphia, 1995, Saunders.
  3. Covino BG, Vassalo HG: Chemical aspects of local anesthetic agents. In
Kitz RJ, Laver MB, editors: Local Anesthetics: Mechanism of Action and
Clinical Use. New York, 1976, Grune & Stratton, pp 1–11.
  4. Hersh EV: Local anesthetics. In Fonseca RJ, editor: Oral and Maxillofacial
Surgery. Philadelphia, 2000, Saunders, pp 58–78.
  5. Gray H: Anatomy of the human body, ed 13, Philadelphia, 1918, Lea &
Febinger, pp 1158–1169.
  6. Zide BM, Swift R: How to block and tackle the face. Plast Reconstr Surg
101:840–851, 1998.
  7. Mendel N, Puterbaugh PG: Conduction, infiltration and general
anesthesia in dentistry, ed 4, Dental Items of Interest Publishing Co, 1938,
p 140.
  8. Mercuri LG: Intraoral second division nerve block. Oral Surg 47:9–13,
1979.
  9. Westmoreland EE, Blanton PL: An analysis of the variations in position
of the greater palatine foramen in the adult human skull. Anat Rec
204:383–388, 1982.
10. Malamed SF, Trieger N: Intraoral maxillary nerve block: an anatomical and
clinical study. Anesth Prog 30:44–48, 1983.
11. Brown DL: Atlas of regional anesthesia, Philadelphia, 1999, Saunders,
p 170.
12. Bonica TT, Buckley FO: Regional anesthesia with local anesthetics. In
Bonica JJ: The management of pain, 1990, Philadelphia, Lea and Febiger.
pp 1883–1966.
13. Wheeler AH: Therapeutic injections for pain management, eMedicine
(online):

Accessed March 9, 2010.
14. Gmyrek R: Local anesthesia and regional nerve block anesthesia, eMedicine
(online):

Accessed March 9, 2010.
15.
techniques/3103-cervical_plexis_block.html. Accessed March 9, 2010.
16. Larrabee W, Msakielski KH: Surgical anatomy of the face, New York, 1993,
Raven Press Ltd, p 83.
17. Klein JA: Tumescent technique for regional anesthesia permits lidocaine
doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990;16:
248–263.
18. Klein JA: The tumescent technique: anesthesia and modified liposuction
technique. Dermatol Clin Jul 8(3):425–437, 1990.
19. Klein JA: Tumescent technique chronicles: local anesthesia, liposuction,
and beyond. Dermatol Surg May 21(5):449–457, 1995.
20. Klein JA: Tumescent technique for local anesthesia improves safety in
large-volume liposuction. Plast Reconstr Surg Nov 92(6):1085–1098,
1993. discussion 1099–1100.
21. Klein JA: Anesthesia for dermatologic cosmetic surgery. In Coleman WP
III, Hanke CW, Alt TH, Asken S (eds): Cosmetic surgery of the
skin: principles and techniques, Philadelphia, 1991, BC Decker,
pp 39–45.
22. Ramon Y, et al: Pharmacokinetics of high-dose diluted lidocaine in local
anesthesia for facelift procedures. Ther Drug Monit 29:644–647, 2007.
23. Personal communication, Robert Campbell DDS, Richmond, VA, October
2008.
Alternatively, with proper training, a propofol infusion
pump may be utilized to safely and efficiently provide continual
anesthesia. These modern pumps are easy to operate and provide
continuous IV infusion of the anesthetic agent, which is calcu-
lated specifically for the patient in micrograms of propofol per
kilogram of body weight per minute. Generally, an induction
dose of ketamine (50 mg) and midazolam (5 mg) is given at the
beginning of the anesthetic and then the pump is activated. The
metered dosage can be adjusted to suit the vital signs and patient
response on the fly. In addition, the pump can provide bolus
amounts of anesthetic agent if the patient’s status should lighten.
Besides the safety, controlled anesthesia state, and convenience,
this technique allows the surgeon to initiate and control the
sedation without the staff administering medications, which is
illegal in some localities.
Conclusion
Although local and tumescent anesthesia can be utilized for
many cosmetic facial procedures, IV sedation is necessary for
other procedures. IV sedation is easily and safely performed by
trained individuals in the appropriate and monitored ambula-
tory office setting. IV anesthesia is not an art and science to be
taken lightly and should only be performed by individuals with
training in this area and with appropriate monitoring and life-
saving equipment and medications. Some surgical specialties
obtain anesthesia training in their residencies and others become
proficient through postgraduate training. In any event, the
patient’s life is on the line and is the responsibility of the
surgeon; no compromise in personnel, monitoring, equipment,
and safety should ever be made. The surgeon/anesthetist model
can work in the accredited ambulatory office environment on
healthy patients with adequately trained doctor and staff and is
a convenience for the doctor and patient when performed safely
and properly. Although surgery can frequently be learned by
reading and casual observation, IV anesthesia is an art and
science that takes years to master.
References
  1. Hersh EV, Condouis GA: Local anesthetics: a review of their pharmacology
and clinical use. Compend Contin Educ Dent 8:374–382, 1987.
A
B
C
FIGURE 4-28.  A-B, Laryngeal mask airway (LMS) device. C, Its use on an anesthetized patient for airway support.

54
5 
Mini Open Brow Lift
The Transfollicular Subcutaneous Approach
N
umerous techniques have been described to treat the
aging brow and forehead.1-22 Chapter 6 on endoscopic
brow and forehead lift (EBFL) will make it apparent
how advanced technology provided a new procedure that has
become very popular and probably represents the most common
contemporary brow lift technique. Despite its popularity, there
remain surgeons who do not favor EBFL. Some may be inti­
midated by the equipment and learning curve and prefer the
same coronal brow lift they learned decades ago. Other sur-
geons don’t like EBFL because they simply aren’t proficient
at it. They have the training, they have the instrumentation,
they do the procedure, but the results or longevity are lacking;
this is actually a common scenario. I have personally met com-
petent surgeons all over the world who have given up their
scope and switched back to a blade. “Endoscopic brow lift does
not work” is a statement frequently heard at meetings and
conferences, yet there are thousands of surgeons who attest that
it does!
Who is right and who is wrong? I certainly believe EBFL
works and still do the procedure, although I have had cases
that relapsed more frequently with this technique. I also have
patients who for various reasons are not suitable candidates
for EBFL, and I need another option: Enter the transfollicular
subcutaneous brow and forehead lift (TFSBFL), also referred
to as the trichophytic approach. This chapter will discuss
TFSBFL as an alternative to other brow lift techniques, includ-
ing EBFL.
Terminology plays an important role in understanding (or
misunderstanding) surgical procedures, so we will discuss it first.
Incisions made in front of hair follicles are termed trichophylic
(hair loving) because the follicles are not disturbed. Incisions
that transect intact hair follicles (transfollicular) have been
termed trichophytic,20,22-26 tricho meaning “hair” and phytic either
from the Greek phynai, “to be born,” or phyein, “to produce.”
Ask different surgeons the meaning of trichophylic and tricho-
phytic, and you are likely to get a variety of answers. I prefer to
use the term transfollicular to describe the incision used with
the mini open brow lift.
Open brow techniques have been around for decades and
were in fact the first brow lift techniques performed. The coronal
brow lift is the granddaddy of all techniques but has fallen out
of popularity owing to notable drawbacks such as hair loss,
nerve damage, raising the hairline, and the sheer aggressiveness
of the procedure. There are indications in which an open tech-
nique is desirable, and TFSBFL serves as an acceptable alterna-
tive to older coronal approaches.
When discussing the pluses and minuses of various brow lift
procedures, TFSBFL comes up a winner in many categories
(Table 5-1). It is the only commonly used brow and forehead
lift procedure that does not elevate the anterior hairline—very
important, especially in females. For patients with a low hair-
line, virtually any brow lift procedure is acceptable; a nominal
hairline elevation is not critical. For patients with higher hair-
lines (longer foreheads), no extra increase in the anterior hairline
Table 5-1  Relative Advantages of Subcutaneous Mini Open Brow and Forehead Technique Compared to Endoscopic Brow and Forehead Lift
Subcutaneous Mini Open Brow and Forehead Lift
Endoscopic Brow and Forehead Lift
No specialized instrumentation required
Significant specialized instrumentation required
Minor to moderate learning curve
Significant learning curve
Simple subcutaneous dissection
Requires extensive dissection of multiple tissue planes
No concern of frontal nerve injury
Frontal nerve injury more problematic
Direct-vision technique
Closed technique
Does not raise the hairline
Raises the hairline
Excellent improvement of forehead rhytids
Less dramatic improvement of forehead rhytids
Very low tension on brow suspension
Often extreme tension to fixate brow
Control of brow suspension over entire brow
Less precise control of brow suspension
Subcutaneous dissection, less edema, faster recovery
Subperiosteal dissection, extends recovery
Direct access to brow depressors
Indirect access to brow depressors
No need for osseous fixation
Usually requires osseous fixation
No need for overcorrection
Frequently overcorrected
Predictable longevity
Longevity varies among surgeons

Chapter 5  •  Mini Open Brow Lift
55
fixation points that are suspended with extreme tension in
selected regions (see Figure 5-2, B).
An additional advantage is that TFSBFL, being a subcutane-
ous technique, will have an impressive effect on the effacement
of horizontal forehead rhytids. This is possible because the skin
is dissected from the underlying frontalis muscle and then tight-
ened, which significantly improves horizontal wrinkles. Sub-
periosteal brow lifts are not nearly as effective at improving
horizontal forehead wrinkles, because they cannot effectively be
addressed from the subperiosteal plane. Direct access to the
brow depressors is another advantage when compared to endo-
scopic access; the treatment of these muscles is easier under
direct vision. There is no need for osseous fixation with the
TFSBFL, which is an advantage for both the surgeon and the
patient as many patients are adverse to having holes drilled in
their skull. Finally, there is no need for overcorrection with the
subcutaneous skin-excision technique and virtually no chance
for frontal nerve injury.
There are few disadvantages to the TFSBFL technique. One
relative disadvantage is that it is not reversible insofar as it is a
is acceptable, so these patients are optimum candidates for
TFSBFL (Figure 5-1). In fact, it can lower the hairline if the
superior scalp is freed.
A high hairline is not the only reason to use TFSBFL.
Another huge advantage is that it is a direct-vision procedure
and allows direct vision from scalpel to suture. No complex
instrumentation and digital equipment are required, making it
simpler. The learning curve is less complex than EBFL, and it
is very attuned to facelift surgery, which most cosmetic facial
surgeons are familiar with. The TFSBFL is a skin-excision tech-
nique and is simply a facelift for the forehead and brow. Sub-
cutaneous dissection, flap development, skin excision, and
resuturing techniques are virtually identical to rhytidectomy.
Being a subcutaneous procedure, there is less edema and ecchy-
mosis compared to other brow lift techniques. Since this is a
skin-excision technique, stability is excellent, and the result is
immediately evident. As the skin is excised all across the hori-
zontal width of the brow and the area resutured, the suspension
is dispersed across the entire brow hairline (Figure 5-2, A). This
is in extreme opposition to the EBFL, which only has several
FIGURE 5-1.  This group of beautiful women illustrates the variability of forehead height, all of which in this case are very
aesthetic.
A
B
FIGURE 5-2.  A, Typical incision length of the transfollicular subcutaneous brow and forehead lift. B, Typical length of endoscopic
brow lift incisions. In actuality, the TFSBFL has a shorter incision than the sum of the multiple endoscopic incisions.

56
Chapter 5  •  Mini Open Brow Lift
carbon dioxide (CO2) laser resurfacing is contemplated, the
endoscopic approach is favored; the thicker flap can tolerate
aggressive laser without the risk of flap devitalization. On the
contrary, TFSBFL is dependent upon a thin subcutaneous flap
that can only be lightly lasered to maintain viability.
Surgical Technique
The patient is marked preoperatively in the holding area. The
area of maximum brow elevation is decided with the patient
looking in the mirror. This area generally corresponds to the
lateral pupillary limbus but is personal preference (Figure 5-3).
The proposed incision can also be marked preoperatively, which
can assist the novice surgeon, but in reality it is just as easy to
perform this in surgery. Although it is commonly discussed as
the junction of the medial and lateral brow being the area of
maximum elevation, I personally feel that this varies on every
patient and I always seek input from the patient when deciding
how and where to elevate the brows. In addition, the medial
brow should not be over elevated as this leads to the unnatural
or overdone appearance in patients.
The instrumentation for TFSBFL is extremely simple and
similar to facelift surgery. I prefer round scalpel handles, #11
scalpel blades, pickups, comb, marking pen, suction, retractors
(lighted are preferable), a radiowave or electrosurgical unit,
and 4-0 gut, 5-0 gut, and 6-0 nylon sutures. The TFSBFL can
easily be performed with local or tumescent anesthesia, but
I most often use intravenous (IV) sedation because I am usually
performing numerous other procedures simultaneously.
As outlined in Chapter 6, Brow and Forehead Lifting, I
perform simultaneous blepharoplasty on 99% of my brow
patients (Figure 5-4). I do, however, temper the amount of skin
removal and the incision outline of the upper blepharoplasty
when performing concomitant brow lift, regardless of approach
(Figures 5-5 and 5-6).
The entire brow and forehead is injected with tumescent
anesthesia, and the actual hair incision is injected with lidocaine
skin-excision technique. An endoscopic brow and forehead lift
that was overcorrected could be reversed in the first several
weeks by removing the fixation and redissecting the pockets.
There is no easy means of reversing TFSBFL after the skin has
been removed. Another relative disadvantage is the public or
collegial perception that open brow lifts are excessive or anti-
quated. This thinking is mostly a result of opinions concerning
older coronal brow lifts. Endoscopic proponents claim that
EBFL is a minimally invasive procedure. This is simply not true.
Only the actual incisions are less invasive. In reality, EBFL is
the most aggressive brow lift technique, traversing numerous
tissue planes and necessitating cranial fixation. Comparatively,
TFSBFL is a very conservative procedure. There is the stigma
of a visible incision for several weeks, but when this procedure
is performed correctly, the incision is rarely a concern. Multiple
authors have described various subcutaneous approaches for
brow and forehead lifting.10-14
Diagnosis
The diagnosis for TFSBFL is the same as for endoscopic tech-
niques. Once it is determined that a patient needs or wants a
brow lift, a decision is made as to what technique to employ.
When deciding which technique to use, I consider several
factors. First and foremost is the position of the patient’s hair-
line. If the patient already has a naturally high hairline with a
long forehead, I do TFSBFL by default; I have yet to meet a
patient with a high hairline and long forehead who desires
additional hairline elevation. Another scenario is a patient with
a significantly rounded frontal bone or frontal bossing. Exag-
gerated curvature makes an endoscopic technique more difficult
because the surgeon is “working over a ledge,” and the straight
scope is tangential to the rounded frontal bone. Some patients
will request TFSBFL when they find out that the endoscopic
technique will require drilling into the skull.
Anticipated use of laser skin resurfacing also factors into
which approach to choose. If aggressive, high-fluence, multipass
A
B
FIGURE 5-3.  The surgeon and patient decide the area of maximum brow elevation (A), which frequently corresponds to the
lateral limbus of the pupil. This area is marked with an arrow for intraoperative reference. The irregular incision can also be
marked about 5 mm into the hairline and extends in younger patients to just past the desired area of maximum elevation (B).

Chapter 5  •  Mini Open Brow Lift
57
incision is to craft the incision to allow hair regrowth through
the surgical scar, thus camouflaging it. Elevating the brow and
forehead without raising the hairline is the other important
aspect of this operation.
The transfollicular (trichophytic) incision does not happen
by accident and requires some level of skill to perform properly.
Most surgical skin incisions are made with the scalpel blade
perpendicular to the skin surface, which produces a flat interface
on both sides of the healing skin. The trichophytic incision is
made using an extreme angle of bevel when incising. The scalpel
is actually held at a 10- to 20-degree angle, which almost makes
the scalpel appear perpendicular to the skin surface (Figure 5-8).
It is of extreme importance to keep the scalpel at the same angle
along the entire incision. Again, the angulation of the incision
is the crux of this procedure.
The incision pattern is also very critical for a naturally
appearing hairline scar. First and foremost, the incision should
never be made anterior to the hairline. The trichophylic
incision totally avoids any hair follicles. This may sound good
in theory and will definitely be easier to incise and close, but
the aesthetics are frequently unacceptable. In my opinion, it
should never be attempted. I frequently hear surgeons advocate
the prehairline incision but continually see patients in my office
who were treated elsewhere and have unacceptably visible
trichophylic incisions. There are few straight lines in nature.
Also important is the fact that there is no such thing as a
“natural hairline.” Only a toupee or a bad hair transplant
produces a true “hairline” (Figure 5-9). Making a straight-line
prefollicular incision on a patient’s forehead can make them an
“incision cripple” for life, with a visible and often hypopig-
mented scar. A natural hairline is not a line at all but a gradual
transition of follicular density from the very thin and sparse
vellus anterior hairs to the area of more follicular density where
the hairline thickens (Figure 5-10).
The transfollicular (trichophytic) incision is a totally differ-
ent animal in design. First and foremost, the incision is designed
to “cut across” existing hair follicles and is intentionally placed
2%, 1 : 100,000 epinephrine (Figure 5-7). It is important to
remember that this is a subcutaneous procedure, and the anes-
thesia must be injected subcutaneously. The eyelid surgery is
performed first, which allows the local anesthesia and vasocon-
strictor to take effect in the brow.
Crafting the Incision
There are few surgeries totally defined by a specific incision, but
this is one of them. The technicality and quality of the transfol-
licular incision can make or break the aesthetic success of the
mini open brow lift. The basic premise of this highly specific
A
B
FIGURE 5-4.  Image illustrates the relative importance of simultaneous blepharoplasty with browlift procedures. This patient
underwent transfollicular subcutaneous brow and forehead lift as evidenced by her elevated brows in the postoperative image
(B). Even with the elevated brows, she has redundant eyelid skin that could have been corrected with simultaneous blepha-
roplasty. She later opted for his procedure.
10 mm
10 mm
FIGURE 5-5.  In conventional blepharoplasty, 20 mm of upper lid skin is left
intact, and skin in excess of that can be removed (blue outline). When
performing simultaneous brow lift, about one third of the normal amount
of skin is removed so as not to cause lagophthalmos (red outline).

58
Chapter 5  •  Mini Open Brow Lift
A
B
FIGURE 5-6.  A, When performing conventional
blepharoplasty, a lateral sweep of the incision is
usually performed to address lateral hooding.  
B, When performing blepharoplasty with brow lift,
there is no need to include the lateral sweep. The
brow lift will address hooding, so a tapered incision
is used. This image shows outlines used for con-
ventional blepharoplasty. It must be kept in mind
that only one third of this amount of skin would be
removed with simultaneous brow lift.
A
B
FIGURE 5-7.  Before surgery, the brow and forehead are injected with tumescent anesthesia. A, The anesthetized area includes
the entire forehead to about 3 cm into the hairline and inferiorly to the nasal radix and the superior orbital rims bilaterally. The
lateral extension is to the temporal crests bilaterally. B, The actual intraoperative tumescent anesthesia injection.
10 - 20 degrees
A
B
FIGURE 5-8.  To properly make the trichophytic incision, the scalpel is held at a 10- to 20-degree angle to ensure an extreme
bevel of the skin surface.

Chapter 5  •  Mini Open Brow Lift
59
about 5 mm posterior to the anterior hairline. The optimum
placement of this incision is at the region of the follicular
density change from the thin, sparse anterior hairs to the denser
follicles of the “actual” hairline which averages about 5 mm it
the hairline (Figure 5-11, A). After the incision is made, excess
skin trimmed, and the flap replaced, the transected follicles will
lie under the newly placed flap, which is beveled (see Figure
5-11, B). As the wound matures (over several weeks), the hair
bulbs of the transected follicles begin to grow through the thinly
beveled flap (see Figure 5-11, C). When fully mature, most of
the transected follicles will regrow through the flap and effec-
tively camouflage the scar (see Figure 5-11, D).
The first step to successful TFSBFL and an aesthetic scar is
a firm understanding of this incision. The bevel of the incision
is critical and must be the same angle on both flaps. The first
incision is an extreme bevel, and the second incision on the
excess skin must be cut at the same angle and bevel as the initial
incision. There are several reasons for this. The beveled flap will
transition from subcutaneous to dermal to epidermal. The thin
dermal/epidermal interface allows a thin enough transition to
allow the underlying follicles to perforate the flap. To illustrate
this transition, Figure 5-12 shows a beveled incision on a lemon
peel; the white region corresponds to the dermis, and the yellow
region corresponds to the epidermis.
Incision Position
I stated earlier that linear prefollicular incisions produce unaes-
thetic scars. It is appropriate to mention at this point that even
irregular geometric incisions are unfavorable when placed ante-
rior to the hair follicles (Figure 5-13). Incision position is
critical.
The TFSBFL incision is optimally placed about 5 mm pos-
terior to the most anterior hairline, which corresponds to the
change in follicular density from sparse to thick. To be effective,
this incision must be placed posteriorly enough to transect
several rows of hair follicles; otherwise there are no follicles to
regrow through the scar (Figure 5-14).
A
B
FIGURE 5-9.  A, A linear prefollicular brow incision is not an acceptable
option because it produces a very unnatural hairline that is a giveaway of
poor surgical technique. B, An abrupt hairline is not seen in nature and is
reminiscent of a toupee.
FIGURE 5-10.  A natural hairline is not really a “hairline” at all but rather a gradual transition from sparse, thin, and vellus hairs to
an increasing density of the “actual” hairline.

60
Chapter 5  •  Mini Open Brow Lift
B
C
A
FIGURE 5-11.  A, The trichophytic incision is transfollicular and must be made posterior enough to intentionally transect several
rows of intact hair follicles. It is important to cut across these follicles but leave hair bulbs intact in most of the transected hairs.
These hairs will in turn grow through the incision scar. B, The transected follicles lying under the beveled skin flap. C, The
transected follicles will regrow hair through the thinly beveled skin flap.
Incision Geometry
Keeping with incision design, the next aspect to be addressed is
incision geometry. Understanding that the incision is placed
about 5 mm into the hairline, the configuration can be regular
with large or small triangles or irregular with random undulat-
ing geometry. Different surgeons prefer one of these configura-
tions over the others. Proponents of large triangular incisions
say that the incision, skin excision, and reapproximation of the
trimmed flap is less laborious. My experience with the larger
triangular configured flaps has been poor; this intentional geom-
etry is obvious after healing (Figure 5-15).
Some surgeons prefer much smaller triangular incisions. I
have experienced acceptable results with this type of incision
but have mixed feelings about using small triangles. The
increased surface area makes for a much more complex incision,

Chapter 5  •  Mini Open Brow Lift
61
D
E
E
D
D
Scalp
A
B
FIGURE 5-12.  This representation of the extreme bevel scalp incision (A) shows the beveled incision on the scalp and the
reversed bevel incision on the underside of the forehead flap. A representation is comparatively illustrated in B, in which this
lemon has been sliced with an extreme beveled incision. D, Dermis; E, epidermis.
FIGURE 5-13.  Any incision placed anterior to the hairline, regardless of
being linear or irregular, has the potential to produce unacceptable
scarring.
FIGURE 5-14.  Correct placement of the transfollicular subcutaneous brow
and forehead lift incision is at the junction of the follicular density change
from the sparse to thicker hairs, which is about 5 mm posterior to the
hairline in the average patient.
D, When fully mature, many of the transected follicles will have repopulated and grown through the original
scar, providing effective camouflage.
FIGURE 5-11, cont’d

62
Chapter 5  •  Mini Open Brow Lift
excision, and especially suturing (Figure 5-16). It heals with
acceptable results but is simply more time intense. Additionally,
as the triangles become smaller they become more like a straight
line, which is unfavorable.
After experimenting with all the common geometric incision
patterns, I have settled on a random, irregular, undulating inci-
sion pattern (Figure 5-17). This incision is made by using the
scalpel in a reciprocating manner much like filleting a fish. The
pattern is basically irregular and reminiscent of ventricular
fibrillation on an ECG. When I teach this technique to resi-
dents, I tell them to incise like they’ve had too much coffee. The
incision pattern and the angle of the cut are both critical factors
in the success of this technique. If a patient has a prominent
widow’s peak, it is better to cut through the lower third of the
apex instead of following the distinct V shape of the peak.
Otherwise the angles are too conspicuous with the final scar.
A
B
FIGURE 5-15.  A, The larger triangular incision geometry favored by some surgeons; I do not favor this approach. B, The larger
triangles produce a correspondingly abrupt scar.
FIGURE 5-16.  Small triangles create an aesthetic scar but are much more
time intense to incise, trim, and suture. (Courtesy Todd Owsley, DDS,
MD.)
FIGURE 5-17.  In the author’s experience, an irregular, random, undulating
incision has produced the best postoperative scar. The pattern of this
incision resembles ventricular fibrillation on an ECG rhythm strip.
The extent of the incision is commensurate with the amount
of aging changes specific to the patient. Younger patients
without extreme lateral brow hooding can be treated with
shorter incisions, because the amount of lateral dissection is less.
In the younger patient, the incision and dissection only need to
be made to a point just lateral to the maximum desired arch of
the brow (Figure 5-18). In other words, as the dissection is made
over the brow and it begins to be released, the dissection can
stop just past the area of maximum arch. This usually corre-
sponds the lateral limbus. When this area is released and the
brow is significantly arched, there is no need to continue lateral
dissection (Figure 5-19, A).
In the older patient or those with significant lateral hooding,
increased lateral dissection will be required, thus a wider inci-
sion and dissection (see Figure 5-19, B). With this technique,
no incision is ever carried lateral to the temporal crest.

Chapter 5  •  Mini Open Brow Lift
63
Once the incision is made, the next step is to “pretunnel”
the subcutaneous flap (Figure 5-20). This step is not performed
by all surgeons, but I truly feel it is worth the small amount of
time required. It is absolutely critical to make the flap dissection
in the subcutaneous plane. The correct plane is below the dermis
(including some subcutaneous fat) and above the frontalis
muscle. This can be a difficult dissection for the novice surgeon,
but by pretunneling the flap, the proper flap is much more easily
defined. In addition, the pretunneling provides an impressive
amount of dissection and makes the remainder of the flap dis-
section much easier.
After the pretunneling maneuver, the actual flap dissection
is begun. Again, this is a subcutaneous dissection made below
the dermis and above the frontalis muscle. The dissection is
performed with facelift scissors, and it is imperative to remain
in the subcutaneous plane (Figure 5-21). If adequate pretunnel-
ing was performed, much of the actual flap dissection can be
performed with the index finger. The inferior extent of the flap
is made “blindly” to a level of 2 to 3 cm above the orbital rim.
The amount of subcutaneous fat in the forehead is variable, but
the flap is lipocutaneous in nature (Figure 5-22). At this point
a retractor is inserted, and the operation is performed with
direct vision. A lighted fiberoptic retractor greatly facilitates the
surgery.
With this technique, the incision never goes lateral to the
temporal crests regardless of the extent of hooding. It is very
easy to dissect in the lateral brow region without violating the
FIGURE 5-18.  The area undermined on a younger patient without significant
lateral brow ptosis is shown in yellow. The blue areas indicate the lateral
extension of the incision used in older patients or those with more hooding
and lateral brow ptosis.
A
B
FIGURE 5-19.  A, A narrow incision is used in a patient without significant
lateral brow hooding. B, A wider incision is required for lateral extension
in a patient with significant lateral hooding.
A
B
FIGURE 5-20.  A, Pretunneling maneuver to begin dissection under the flap.
B, Pretunneling dissectors. Inset shows a magnification of the dissector
tips.

64
Chapter 5  •  Mini Open Brow Lift
endoscopic approach. There is more play with less damage in
the subcutaneous approach as the surgeon is dealing with nerve
branches and not the nerve trunk.
For those surgeons who are not familiar with the subcutane-
ous brow approach, the various peripheral nerves and vessels are
visible and can be preserved with direct vision. Figures 5-26 to
5-28 show various anatomic structures frequently encountered
during TFSBFL.
As the dissection proceeds, hemostasis is critical to prevent
blood loss and hematoma formation. The incised scalp at the
hairline can bleed throughout the case, and many of the small
vessels will either stop spontaneously or during suturing. Sig-
nificant bleeders can be cauterized, but the crux of this entire
surgical approach is the preservation of hair follicles at the inci-
sion. If cauterization is used, a fine-tipped cautery instrument
is necessary for precision coagulation to preserve the delicate
hair follicles (Figure 5-29). Another area where problematic
bleeding can occur is around the “sentinel” vein (or related
structures) near the lateral orbital rim.
As the inferior dissection proceeds, nerves are gently freed
from the surrounding tissues or avoided all together if not an
obstacle or not interfering with the lift. It is imperative to release
the eyebrows completely for effectiveness and stability of the lift,
so the surgeon must dissect past the brows and into the upper
lids in most cases. Since the patient is in the supine position,
the brow will almost self-elevate when the appropriate adhesions
and tethers are released with the scissors. When the brow is
passively released and elevated to the proper arch, the dissection
is basically sufficient. This will differ from patient to patient.
Younger patients may only need dissection and elevation to the
area of maximum arch, and older patients may need dissection
to the lateral orbital rim. (Figures 5-30 and 5-31).
In the glabellar area at the midline of the nasal radix, blind
dissection can proceed as far inferiorly as required and is usually
carried to the level of the nasofrontal suture (Figure 5-32).
At this point, the brow depressors can be addressed. One of
the prime advantages of the subcutaneous dissection technique
is that the dermal/muscle interface can be separated with
temporal crests (Figure 5-23). In addition, the frontal nerve is
not in jeopardy in the subcutaneous plane.
Once enough inferior dissection has been performed to
accommodate retractors, the remainder of the procedure is per-
formed with direct vision (Figure 5-24). As the dissection nears
the orbital rims, and hence the neurovascular bundles, blunt
dissection can be done with the blunt end of a scalpel handle
or blunt spreading of scissors. In the area of the neurovascular
bundles, direct vision should always be used. I have found blunt
facelift scissors good for gently spreading the perineural tissues
without disrupting the nerves and vessels. The initial approach
is with the scissors used horizontally (Figure 5-25, A). The
bundles can actually be dissected further by turning the scissors
vertically and gently stretching the tissues (see Figure 15-25, B).
The neurovascular bundles can be gently stretched without per-
manent damage while dissecting in the subcutaneous plane.
This is somewhat different from attempting to maneuver the
nerve as it exits the foramen in the subperiosteal plane in the
A
B
FIGURE 5-21.  Initial dissection is performed with facelift scissors, with great care to remain below the dermis and above the
frontalis muscle. The dissection is made “blindly” to a level several centimeters above the orbital rim.
FIGURE 5-22.  Lipocutaneous flap is shown; underlying frontalis muscle is
evident.

Chapter 5  •  Mini Open Brow Lift
65
A
B
FIGURE 5-23.  There is no need to continue dissection past the temporal crest; lateral brow subcutaneous dissection can easily
be done through the standard-width incision. A, More aggressive lateral incision extension (still short of the temporal crest).
B, If necessary, lateral orbital rim can be dissected through an incision, without extra lateral temporal extension.
A
B
FIGURE 5-24.  A, After the flap is developed enough to accommodate
retractors, remainder of procedure can be done with direct vision.  
B, Several fiberoptic retractors that provide superior vision and retraction
in tight spaces.
dissection and thereby vastly improve the horizontal and vertical
forehead rhytids (Figure 5-33). This degree of improvement
cannot be achieved with subperiosteal endoscopic techniques in
which the dermal/muscle interface remains intact. With endo-
scopic subperiosteal access to the brow depressors, they must be
addressed from below by incising the periosteum. The opposite
relationship exists with TFSBFL. In the subcutaneous approach,
the brow depressors lie below the plane of dissection. Anatomi-
cally, the mimetic muscles are subcutaneous and have bony
origins with dermal insertions. These muscular attachments and
fusion regions are never as specific and isolated as shown in
textbook drawings but rather have fan-shaped interdigitations
where the fibers of one muscle mesh with those of another
(Figure 5-34). To access the brow depressors (paired corrugators
supercilii and procerus muscles), the surgeon must incise
inferior to the lipocutaneous flap. These muscles have dermal
insertions, so some of the musculature is cleaved by subcu­
taneous dissection and sometimes visible during the dissection
(Figure 5-35).
As with other forms of brow lifting, these muscles are fre-
quently interrupted, incised, or excised to assist the result and
stability of the brow lift. Most of my brow lift patients are
treated with neurotoxins preoperatively, but I still will treat the
procerus and corrugators with the TFSBFL technique. My pre-
ferred method of addressing the brow depressors is to simply
transect them using the Ellman radiowave microneedle (Ellman
International, Oceanside, NY). On the coagulation mode, the
procerus bellies are transected horizontally, and the corrugators
supercilii muscle bellies are transected at an angle (Figure 5-36).
With a short brow incision, access to this area is more difficult;
a wider incision allows more access. It is also important to
remember that the supratrochlear nerve pierces the corrugator
supercilii muscle, and wearing loupes at this point is valuable.
After muscle transection, a long, narrow hemostat can be used
to further disrupt the muscles if desired. Over disruption or
excision of this musculature can produce splayed brows, unnat-
ural animation, or visible depression, so moderate intervention
is all that is necessary.
After adequate mobilization of the entire brow and forehead
to the point of anticipated brow arch and passiveness, and after
the depressors are addressed, all areas are again checked for

66
Chapter 5  •  Mini Open Brow Lift
A
B
FIGURE 5-25.  Gentle spreading and teasing with facelift scissors can assist dissection around the neurovascular structures.
The scissors are initially used horizontally (A) and then turned vertically parallel to the long axes of nerves and vessels (B).
B
A
FIGURE 5-26.  Direct-vision subcutaneous dissection can expose and preserve numerous perforating nerves and blood vessels.
These structures have a component of elasticity in this plane; they do not hinder brow elevation and are preserved.
FIGURE 5-27.  White arrows show a longitudinal sensory nerve fiber (more
than likely the deep branch of the supraorbital nerve) intimate with the
frontalis muscle. These structures are easily identified and preserved with
the mini open approach.
FIGURE 5-28.  A large vein is seen running superficial to the right frontalis
muscle. This is an unusually large vessel and is probably engorged due
to the ensuing surgery. This approach with direct vision allows preservation
of such structures or hemostasis if they are disrupted.

Chapter 5  •  Mini Open Brow Lift
67
FIGURE 5-29.  An Ellman radiowave bipolar electrode with microtips is used
for hemostasis, with care to protect the surrounding follicles.
FIGURE 5-30.  Facelift scissors undermining the eyebrow in the subcutane-
ous plane inferior and caudad to the brow.
A
B
FIGURE 5-31.  A scalpel handle can be used to assist atraumatic dissection under the brow and into the upper lid if necessary.
The pictured patient required significant sub-brow dissection to free the ptotic brow and related tissues.
A
B
FIGURE 5-32.  A notched dissector is shown in demonstration (A) and intraoperatively (B) dissecting the glabella and nasal radix
region.

68
Chapter 5  •  Mini Open Brow Lift
A
B
FIGURE 5-33.  Glabellar rhytids result from continual dermal wrinkling and action of underlying brow depressors. A stellar advan-
tage of the subcutaneous dissection technique is that the dermal muscular interface can be interrupted. A, Vertical glabellar
rhytids. B, Subcutaneous interruption of this area, which will smooth skin and efface rhytids.
1
2
3
FIGURE 5-34.  Main depressors of the medial brow are (1) the paired cor-
rugators supercilii, (2) the procerus, and (3) the medial orbicularis. Gener-
ally, the corrugators and procerus muscles are disrupted with the
transfollicular subcutaneous brow and forehead lift technique. It is impor-
tant to remember that the surgeon is dissecting these muscles below the
subcutaneous surgical plane.
P
NVB
FIGURE 5-35.  Depending on the plane of dissection, the brow depressors
can sometimes be visualized during dissection. Shown here are the pro-
cerus muscle (P) and the neurovascular bundles (NVB) of the right supra-
trochlear and supraorbital nerves.
A
B
FIGURE 5-36.  A, Transection of the procerus and corrugators supercilii muscles (dotted line) with the radiowave microneedle.
B, Another view of the transection of brow depressors.

Chapter 5  •  Mini Open Brow Lift
69
almost 30 mm in older patients. This may be disconcerting to
the novice surgeon, and he or she must keep in mind that the
skin is elastic and the patient supine. When the patient resumes
upright position, gravity will pull the skin and brow slightly
inferior. I have personally underestimated this distance and did
not elevate the brow enough on several patients during my
learning curve, but I have never overelevated a brow when using
20 mm of cutback distance as a guide. It does make sense to err
on the conservative side. More skin can always be removed later,
but this procedure is not reversible, and it is possible but more
difficult to lower the brow in revision.
One other important factor is that the central cutback may
be begun at 15 mm. Although this region usually approaches
20 mm as well, most patients do not look natural with an
overly elevated medial brow, which can produce a surprised
appearance. In the central cutback, I always begin with 15 mm
of cutback and adjust appropriately. Elevation in the midline
will rejuvenate a ptotic glabella by tightening this area. This
part of the procedure is more art than science, and the surgeon
and staff must evaluate the exact desired brow position. Unlike
endoscopic brow lift where the maximum elevation is desired,
there is no need to overcorrect the brow in the subcutaneous
technique. What you see is pretty much what you get with this
technique. Fortunately, both brows seem to rise symmetrically,
hemostasis. At this point, one can easily appreciate the amount
of forehead skin redundancy when the flap is pulled downward
(Figure 5-37).
The next step is to address the excess skin to be excised, and
this is very similar to facelift surgery in most respects. Gravity
pulls the scalp posteriorly, so it is important for the assistant to
manually elevate the scalp to a forward position so the precise
amount of skin excess can be determined. Figure 5-38 shows
the incision in the passive position and the assistant elevating
the scalp forward to determine the true skin excess. Failure to
elevate the posterior scalp anteriorly can result in an inaccurate
estimate of skin excess.
At this point, skin cutbacks are made and key sutures placed
to bear the tension of the elevation in three areas. The average
skin cutback distance is 20 mm in the lateral regions (Figure
5-39). The lateral cutbacks are made in the region of anticipated
maximum brow arch or elevation. As stated earlier, this corre-
sponds to the junction of the middle and lateral third of the
brow or the lateral limbus of the corresponding eye. Not all
patients have the same amount of brow excess skin, and there
is no “cookbook” measurement of cutback distance. Experience
has shown that the average patient in need of a brow lift will
have on average at least 20 mm of excess skin, but I have made
skin cutbacks to 12 to 15 mm in younger patients and up to
A
B
FIGURE 5-37.  Two views of the amount of skin redundancy seen after complete subcutaneous dissection.
A
B
C
FIGURE 5-38.  A, Gaping incision after dissection. B, Scalp being elevated anteriorly. C, Amount of true skin excess.

70
Chapter 5  •  Mini Open Brow Lift
but it is important for the surgical team to visually inspect for
symmetric elevation. If one brow is higher or lower than the
other, the appropriate incision cutback must be addressed.
Once the proper cutback is made, a key suture of 4-0 gut is
used to secure the forehead skin to the scalp. Some surgeons
advocate staples or synthetic sutures such as Prolene for these
key sutures, but my experience has proven that 4-0 gut suture
produces the most aesthetic scar. The key sutures (just as in
rhytidectomy) will bear the tension of the suspended flap, and
the remainder of the wound closure will be tension free. (Figures
5-40 and 5-41) The degree of lift can be customized across the
entire brow by controlling the amount of skin removal based
on the preferred vectors of lift (Figure 5-42). Figure 5-43 shows
another view of the key sutures and the respective positions
elevated. In cases of extreme ptosis or in patients with thick
tissues and muscle (like males), additional cutbacks and key
sutures can be placed to reinforce the suspension and take more
A
B
FIGURE 5-39.  A, A skin cutback at the lateral scalp, measured at 20 mm (B).
A
B
FIGURE 5-40.  The central and both lateral 4-0 gut key sutures are placed. These sutures will bear all the incision tension, and
the remainder of the closure is tension free.
FIGURE 5-41.  The three cutback incisions with key sutures. The dotted
lines represent the areas elevated.

Chapter 5  •  Mini Open Brow Lift
71
into place. There is a certain amount of error built into the
trimming, owing to the elastic nature of the forehead skin. The
final incision comes together nicely even if the geometry is not
100% exact on both the scalp and the forehead skin. With
experience, it is easy to “freehand” the trimming (Figure 5-45),
but inexperienced surgeons may prefer to mark the excision
lines with an Allis clamp or flap-marking device (Figures 5-46
and 5-47).
Regardless of the method used, it is imperative to make the
incision on the forehead flap at the exact same extreme bevel
that was used for the initial scalp incision. If the angle is not
the same for both flaps, an uneven tissue thickness will occur
instead of the extreme bevel overlap. The final scar will not be
smooth but have “step off.” Technically, the initial scalp incision
is an extreme bevel, and the forehead skin excision is made to
the same bevel angulation. Figure 5-48 shows the excess skin
being trimmed at the same extreme bevel as the primary scalp
tension off the final incision, although three sutures are usually
adequate.
Most surgeons place the key suture at the base of the V
of the cutback incision. I have found this to leave a more
noticeable scar in the final result because of the tension on the
incision. I now make a Y-shaped incision with a scalpel at
the base of the cutback, and this produces a superior scar
(Figure 5-44).
After the key sutures are placed, the next step is to trim the
excess skin. This is an integral part of the procedure and has a
direct effect on the quality of the postoperative scar. The various
geometry of the initial scalp incision can make this step intimi-
dating to the novice surgeon. A common question is how to
duplicate the pattern of the first incision when removing excess
skin. Fortunately this is much easier than it would appear.
Although close attention must be paid to duplicating the
geometry of the first incision, it seems to automatically fall
FIGURE 5-42.  Close attention to the desired vectors of improvement is
needed when making cutbacks and placing key sutures. Brow position
can be customized and controlled across the entire forehead, enabling
the surgeon to lift some portions of the brow higher than others.
FIGURE 5-43.  Occasionally in a larger lift or in a patient with thick and tena-
cious tissues, extra cutbacks and key sutures can be placed to bolster
the repair.
A
B
FIGURE 5-44.  By making a Y-shaped incision at the base of the skin cutback, a more aesthetic scar is achieved in the final
result.

72
Chapter 5  •  Mini Open Brow Lift
FIGURE 5-45.  A #11 scalpel blade is used to duplicate the exact extreme
bevel angle and geometry of the initial scalp incision.
A
B
FIGURE 5-46.  An Allis clamp is used to mark the geometry of the scalp flap on the forehead flap The outlines then serve as a
template to guide the surgeon with the excision. A, The Allis clamp makes the template markings. B, The scalp is incised on
the indented markings.
A
B
FIGURE 5-47.  A flap-demarcating clamp (KLS Martin, Jacksonville, FL) can also be used to demarcate the geometry of the
scalp flap.
incision. Figure 5-49 shows the excised excess forehead skin
with some anterior hairs. The excised tissue should contain
about 5 mm of excised hair, and the operator must keep in mind
that this hair is not actually gone. Since these hairs were incised
at an extreme bevel, many hair follicles are preserved and will
regrow through the incision scar. Some of the finest solitary,
thin, vellus anterior hairline hairs will be sacrificed, but this is
generally not a significant drawback of the approach. If the
patient desires a higher hairline, the incision can be placed more
posteriorly in the scalp to include more hair follicles in the exci-
sion. If the patient desires a lower hairline, the posterior scalp
can be undermined, released, and pulled inferiorly.
When the skin is excised and the surgeon is happy with the
incision, interrupted subcutaneous 5-0 gut sutures are placed
across the entire incision to strengthen the repair (Figure 5-50).
Some surgeons advocate a longer-lasting suture such as 4-0
Vicryl, but I have found these to “spit” though the flap weeks
or months later and cause unnecessary scaring. The 5-0 gut
subcutaneous sutures have proven very effective in terms of
strength and scar aesthetics. Figure 5-51 shows the incision
closed with 4-0 gut key sutures and 5-0 gut interrupted subcu-
taneous sutures. Figure 5-52, A shows the subcutaneous closure,
and Figure 5-52, B shows the final closure with 5-0 gut. I believe
that a running 6-0 nylon suture provides the most aesthetic scar,
but I frequently use 5-0 gut running or interrupted sutures as
well; although it takes slightly longer for the scar to mature, the
final difference is the same. In addition, the patient need not
return for suture removal. I have never noticed a less aesthetic
outcome when using running versus interrupted sutures.

Chapter 5  •  Mini Open Brow Lift
73
Interrupted sutures do extend the closure time. Figure 5-53
shows final skin closure with 5-0 gut interrupted sutures.
Similar to facelift surgery, simultaneous CO2 laser resurfac-
ing can be performed over the lipocutaneous forehead flap. This
treatment should only be performed by surgeons experienced
at laser resurfacing over flaps. Although I treat the non-
undermined facial tissues with high-fluence multipass CO2 laser
resurfacing, I only treat the undermined flap with a single non-
débrided flap at about half the fluence of the non-undermined
skin (Figure 5-54). Figure 5-55 shows a patient treated with
A
B
FIGURE 5-48.  A, Excess skin being trimmed in a “freehand” manner with a #11 scalpel blade. B, Trimmed left side and
untrimmed right side of the skin flap.
FIGURE 5-49.  Excised excess forehead skin. It must be kept in mind that
if an extreme bevel was used with the initial incision, many of the follicles
are preserved and will regrow through the incision scar.
FIGURE 5-50.  Subcutaneous 5-0 gut sutures are placed across the entire
width of the incision at closure.
high-fluence multipass CO2 laser resurfacing on the central oval
of the face but a single nondébrided pass at a lower fluence over
the forehead flap.
At this point, the procedure is complete, and the hair is
washed with hydrogen peroxide and sterile saline (Figure 5-56).
Figure 5-57 shows a patient immediately after TFSBFL before
leaving the office.
Although some surgeons use postoperative dressings with
TFSBFL, I never do, and I have never experienced a single
hematoma or seroma. This procedure is not disfiguring in terms
of swelling and bruising when performed as a standalone opera-
tion, but ecchymosis and edema are seen when concomitant
periorbital and facial procedures are performed. Figure 5-57
shows a patient immediately after TFSBFL. Figure 5-58 shows
a typical patient 24 hours postop.
Most patients generally take 7 to 10 days off work after
TFSBFL, although some go back earlier if there is no bruising.
If the patient can wear bangs for several weeks, the entire scar
is camouflaged, although I have performed this procedure on
numerous females who wear their hair back. The patient is seen
24 hours postoperatively to make sure there is no hematoma or
seroma. They return at 10 days for suture removal if nylon
suture was used.
FIGURE 5-51.  Trimmed incision closed with 4-0 gut key sutures and 5-0
gut subcutaneous sutures.

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Chapter 5  •  Mini Open Brow Lift
A
B
FIGURE 5-52.  A, Subcutaneous closure with 5-0 gut suture. B, Final skin closure using a running 5-0 gut suture.
FIGURE 5-53.  Incision was closed with interrupted 5-0 gut sutures.
FIGURE 5-54.  Carbon dioxide (CO2) laser resurfacing can be performed
over the undermined lipocutaneous forehead flap but is performed at a
lower fluence and/or density than for nonundermined facial tissues.
FIGURE 5-55.  Patient is shown immediately after high-fluence multipass
CO2 laser resurfacing of the face, but a single lower-fluence, nondébrided
pass over the undermined forehead flap.
FIGURE 5-56.  After the procedure, hair is washed with hydrogen peroxide
and sterile saline. A plastic bag is used to catch the washing solutions.

Chapter 5  •  Mini Open Brow Lift
75
If performed properly, the TFSBFL incision begins healing
quickly. New growth of hairs can usually be seen growing
around and through the scar within the first several weeks
(Figure 5-59). Patients are variable in terms of scar maturation.
Some patients heal very well in the first 6 weeks, whereas others
may take 90 days for the scar to mature and be covered with
new hair. The 3-month mark shows great improvement for the
average patient, and if the scar is unacceptable at this point,
revision can be accomplished and will be discussed later. After
performing many of these procedures, I have never had any
patient unhappy with their scar or require a permanent change
of hairstyle. I have revised six to seven patients, and it was
usually at my suggestion, not the patient’s. Figures 5-60 to 5-62
show rather typical cases at various stages of healing. Figures
5-63 and 5-64 show before-and-after images of well-healed
TFSBFL incision scars. Figure 5-65 shows a less aesthetic
but acceptable scar when compared to the other illustrations.
Figures 5-66 to 5-74 show before-and-after pictures of TFSBFL
patients.
Complications
Complications for TFSBFL include flap devitalization, unaes-
thetic scars, asymmetry, overcorrection, undercorrection, and
postsurgical relapse. In my hands, this procedure has actually
proven more stable than the endoscopic technique inasmuch as
I have seen postoperative relapse with the endoscopic technique
but not with the subcutaneous approach.
Out of almost 100 TFSBFL procedures, I have seen several
patients with minor necrosis at the incision site and have only
had a single patient with significant tissue loss. This patient was
a smoker and not only lost tissue in the forehead flap but also
bilaterally in the facelift flaps (Figure 5-75). The defect matured
and was treated with CO2 laser resurfacing. There remains per-
manent hypopigmentation, and the patient is considering per-
manent tattoo to blend the skin color.
As with any periorbital procedure, ecchymosis is variable
with TFSBFL. Although most patients have minor bruising,
occasionally some will exhibit significant ecchymosis in the
presence of normal coagulation studies (Figure 5-76).
As mentioned earlier in the chapter, I perform simultaneous
blepharoplasty with 99% of brow lifts, regardless of technique
(also see Chapter 6). The only time I do not is on very young
FIGURE 5-57.  Patient 1 hour after transfollicular subcutaneous brow and
forehead lift.
FIGURE 5-58.  Patient 24 hours after transfollicular subcutaneous brow and
forehead lift, upper blepharoplasty, lower transconjunctival blepharoplasty,
and periorbital CO2 laser resurfacing.
A
B
FIGURE 5-59.  5 weeks after transfollicular subcutaneous brow and forehead lift; notice the hair regrowth through the scar.

76
Chapter 5  •  Mini Open Brow Lift
Preop
1 Week
1 Month
3 Months
A
B
C
D
FIGURE 5-60.  Before surgery (A); 1 week (B), 1 month (C), and 3 months (D) after transfollicular subcutaneous brow and
forehead lift. I no longer use staples as key sutures.
patients or on those patients with previous blepharoplasty or
brow lift where lagophthalmos may be eminent. The patient
shown in Figure 5-77 did not opt for simultaneous blepharo-
plasty as suggested, and although her brow lift was successful,
she later returned for blepharoplasty. Performing both proce-
dures at the same time (with conservative blepharoplasty) will
make happier patients, with a better outcome for the surgeon
as well.
Since gut suture can be used in this procedure for key, sub-
cutaneous, and skin closure, there are advantages in not having
to remove sutures. As stated earlier, the inflammatory reaction
with resorbable sutures is increased compared to nylon sutures
removed at 10 days. The advantage of dissolvable sutures is that
the wound need not be disturbed or the patient and office
inconvenienced by a suture-removal appointment. Over the
course of the years, I have seen occasional patients who exhibit
allergic reactions to resorbable sutures (Figure 5-78). These
patients progress to uneventful healing, but the appearance of
a normalized scar takes longer.
A rare but notable caveat is to be aware of permanent eyebrow
makeup on some patients. I am a firm believer that one of the
worst things patients can do is to use permanent tattoo makeup
anywhere. It rarely looks natural and can be asymmetric, which
can pose problems after cosmetic surgery. The patient shown in
Figure 5-79 had permanent eyebrow tattoo makeup years before
surgery. The tattoo procedure was obviously asymmetric, and
this was amplified after the TFSBFL. Examination of her postop
image shows her actual brow hairs to be symmetric but her
tattoos extremely skewed. The left brow tattoo was partially
removed with CO2 laser. This is the subtle type of observation
that must be pointed out preoperatively and in the consent
process.
Undertreatment and overtreatment are problems with any
surgery. I have yet to overtreat a TFSBFL and am fortunate; it
is a very problematic situation. I have had several patients in
whom I was too conservative, and they required revision
TFSBFL. Although this is an inconvenience, it is a far better
situation than attempting to repair an overcorrection. The
patient in Figure 5-80 was treated with TFSBFL and simultane-
ous blepharoplasty and appeared normalized intraoperatively.
She returned 6 months later with a suboptimal correction, and
her surgery was revised by opening the entire previous incision
and repeating the procedure.
Figure 5-81 shows another case of undertreatment in the
before-and-after pictures. The medial brow was elevated, but
this patient needed more lateral-brow elevation. Figure 5-82
shows a revision surgery (not the same patient as Figure 5-81)
where only lateral skin excess was removed.
Hairline Scar Considerations
Some patients present with a large and well-defined widow’s
peak. When this exact geometry is followed with the incision,
a noticeable triangle can result (Figure 5-83). I have had more
aesthetic scars by cutting across the lower third of the peak and
not attempting to replicate the triangle.
Text continued on page 85.

Chapter 5  •  Mini Open Brow Lift
77
7 Days
14 Days
90 Days
A
B
C
FIGURE 5-61.  A–C, 7 days, 14 days, and 90 days after transfollicular
subcutaneous brow and forehead lift.
Preoperative
2.5 Months
6 Months close
A
B
C
FIGURE 5-62.  Before surgery (A); 21 2 months (B) and 6 months (C) after
transfollicular subcutaneous brow and forehead lift.

78
Chapter 5  •  Mini Open Brow Lift
A
B
FIGURE 5-63.  A, Before surgery; B, 90 days after transfollicular subcutane-
ous brow and forehead lift.
A
B
FIGURE 5-64.  A, Before surgery; B, 2 years after transfollicular subcutane-
ous brow and forehead lift.
A
B
FIGURE 5-65.  Patient’s scar is less aesthetic than the previous examples but is acceptable to the patient.

Chapter 5  •  Mini Open Brow Lift
79
A
B
C
D
E
F
FIGURE 5-66.  Patient 6 months after transfollicular subcutaneous brow and forehead lift (B). Note that the left brow was lower in the preoperative image
(A) and remains somewhat less elevated. No blepharoplasty was performed on this patient. C–F, Close-up views illustrating good lateral lift of the brow.

80
Chapter 5  •  Mini Open Brow Lift
A
B
FIGURE 5-67.  A, Before surgery; B, 30 months after transfollicular subcutaneous brow and forehead lift, lower transconjunctival
blepharoplasty, and periorbital CO2 laser resurfacing.
A
B
C
FIGURE 5-68.  A, Before surgery; 1 year (B) and 2 years (C) after transfollicular subcutaneous brow and forehead lift.
A
B
C
FIGURE 5-69.  A, Before surgery; 1 year (B) and 2 years (C) after transfollicular subcutaneous brow and forehead lift.

Chapter 5  •  Mini Open Brow Lift
81
A
B
FIGURE 5-70.  A, Before surgery; B, 2 years after transfollicular subcutaneous brow and forehead lift.
A
B
FIGURE 5-71.  A, Patient has significant asymmetry, with the left brow being lower. B, This was nicely corrected with the transfol-
licular subcutaneous brow and forehead lift.
A
B
FIGURE 5-72.  Before (A) and after (B) transfollicular subcutaneous
brow and forehead lift.