Essentials of Aesthetic Surgery

522
Part VII Facial Surgery
implants focus on a fourth plane, the facial skeleton, thus producing three-dimensional
changes through facial augmentation.

three-dimensional augmentation. Proponents of the alloplastic techniques cite the

over time with tissue augmentation techniques.
Generally, alloplastic volume correction within the midface is combined with a
subperiosteal midface lift. This facilitates suspension of the midface soft tissues and

allowing volume correction of ptotic, atrophied midface soft tissues.
40
Surgical approaches for placement of alloplastic midface implants are through upper
gingivobuccal sulcus, subciliary, or transconjunctival incisions, which can be used for a
concomitant subperiosteal midface lift and/or lower blepharoplasty.
ENDOSCOPIC
Hester and colleagues,19,41,42 Byrd and Andochick,43 Hunt and Byrd,44 and Ramirez15,32
popularized the endoscopic approach to midface rejuvenation. Each surgeon reviewed

Greatest advantage of the endoscopic approach is the
thus preventing postoperative lower lid
distortion.

passive tightening of the orbicularis in a lateral direction passively tightens the orbital
septum, thus reducing herniated orbital fat and eliminating the need for direct fat
excision or repositioning.
Ramirez outlined the
• Wide subperiosteal and subfascial dissection
• En bloc mobilization of midface structures
• Periosteal release in the lower and medial boundaries of the cheek
• Strong suspensory element to maintain the cheek in its elevated position
Hester and colleagues used adjunctive procedures with endoscopic midface lift to

grafting to address prominent nasojugal grooves and tear trough deformities and/or

Byrd and Andochick and Hunt and Byrd emphasized the
:
• Indicated for patients with aging of central and upper face and is ideal for patients
with malar ptosis who simultaneously require periorbital rejuvenation
• Exclusively useful for patients with the following features:






augmentation.
• Complex operation that emphasized sound knowledge of anatomy of the midface
and upper lid

523
Chapter 40 Midface Rejuvenation
• Technique initially emphasized key dissection planes43 (Fig. 40-12):
approach to forehead
approach to temporal region
approach to the zygomatic arch
approach to the superior, lateral, and inferior orbital rim










Dissection plane to the zygomatic arch.
• Byrd’s technique evolved over a period of time to an endoscopic brow-midface lift
from previously described deep temporal lift, although anatomic planes used were
the same.
44
• Dissection and suspension of the midface complex as a single unit in the
planes allowed direct correction of the aging anatomy, with

TRANSPALPEBRAL MIDFACE LIFT
Used by selective surgeons41 and has high complication rates
Midface and lower lid addressed simultaneously as a single unit using a lower
blepharoplasty transcutaneous direct or endoscopic approach
Generally reserved for the more aging midface with associated lower eyelid aging
components
POSTOPERATIVE CARE
Generally directed toward prevention of complications and incorporates normal healing
process

Ice packs or cold compress can be applied to minimize edema.
A temporary Frost suture can be used in immediate perioperative period to protect the
lower eyelid from developing chemosis during early healing.

524
Part VII Facial Surgery
Strict blood pressure control is important to prevent hematoma.
Patient’s general vision should be evaluated if surgical dissection involves the lower eyelid.
Eye should remain lubricated with saline drops or lubricating ointment.
Patients are instructed not to use contact lenses or cosmetic makeup on suture lines.
Close follow-up postoperatively is necessary to reiterate patient instructions early in the
healing phase.
SURGICAL COMPLICATIONS AND TREATMENT
Chemosis is the most common complication from a
to the midface.
• Characterized by visible swelling of the conjunctiva
• Symptoms include epiphora, irritation or foreign body sensation, and mild visual
impairment.
• It presents within 1 week of surgery and can last up to 4 weeks, even longer in rare
circumstances
• Prevention is the best treatment, starting with lubrication of the cornea in surgery,
minimizing trauma and exposure.
can reduce postoperative chemosis.
• Treatment starts with eye lubrication with saline drops and ophthalmic lubricants.
• Ophthalmic steroid drops (Tobradex) can be helpful.
• Eye patches can be used if chemosis persists.

tarsorrhaphy should be considered.

• Most common complication from a approach
• Causes include excessive skin or muscle removal, lower lid laxity, middle or posterior
lamellar scarring, damage to pretarsal orbicularis oculi muscle, and even a small
hematoma.
• Characteristic features include lid retraction, scleral show, and ectropion.

with laxity of the tarsus.
• Patients who have are those with:

525
Chapter 40 Midface Rejuvenation


keratopathy.

• Epiphora is usually transient and resolves spontaneously.
• Infection is uncommon; however, it must be managed by antibiotics and vigilant
follow-up to prevent facial or periorbital cellulitis.
• Hematoma needs to be addressed in accordance with its severity, and generally
surgically.
• Corneal abrasions are uncommon but prevented by corneal lubrication.
• Minor visual changes such as diplopia are temporary and caused by edema.
• Nerve injuries are also generally temporary, resolving spontaneously in the
perioperative period.
• Complications from using barbed sutures generally are attributed to asymmetry
and suture migration or vector malposition, all of which usually require a surgical
approach.
• Complications from alloplastic implants include malposition, rotation, asymmetry,
bony resorption, local pain, and paresthesia; infection is rare. Treatment involves

• Fat grafting can overcorrect or undercorrect the deformity and may need to be
repeated to achieve symmetry.
TOP TAKEAWAYS

Detailed knowledge of the complex anatomy of the midface is crucial to
successful midface rejuvenation.

Accurate preoperative assessment of the contributing factors to facial aging is
the foundation to build successful facial rejuvenation.

Generalized facial aging is characterized by skin laxity, ptosis of soft tissue,
volume loss within the soft tissues, and changes within the skeletal structure of
the facial bones.

The subunits of the face do not age independent of each other; rather, they each

create a beautiful, harmonious face, correcting the changes that have occurred
in each segment of the face is essential.

The aging midface is characterized by soft tissue attenuation of retaining
ligaments, leading to soft tissue ptosis. Facial bulges arise as the soft tissues
overlying the facial spaces become distended. The strong ligamentous
attachments to the dermis resist this distension and appear on the skin as deep
grooves.

Trauma to the lower eyelid is minimized by avoiding preseptal dissection.

Midface vector pull is oriented vertically, not laterally.

If present, correct horizontal lower lid laxity.



Volume loss should be replaced, as needed.

Successful surgical rejuvenation can be limited by inadequate or neglected skin
rejuvenation.

526
Part VII Facial Surgery
REFERENCES
1. Paul MD, Calvert JW, Evans GR. The evolution of the midface lift in aesthetic plastic surgery.
Plast Reconstr Surg 117:1809, 2006.


cheek area. Plast Reconstr Surg 58:80, 1976.
4. Tessier P. Facelifting and frontal rhytidectomy. In Transactions of Seventh International Confer-
ence on Plastic and Reconstructive Surgery, Rio de Janeiro, Brazil, Sept 1979.
5. Psillakis JM. Empleo de tecnicas de cirugia craniofacial en las ritidoplatias del tercio superior

6. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 86:53, 1990.
7. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg 90:1, 1992.
8. Barton FE Jr. The SMAS and the nasolabial fold. Plast Reconstr Surg 89:1054, 1992.
-
constr Surg 91:462, 1993.
10. Terino EO. Alloplastic facial contouring: surgery of the fourth plane. Aesthetic Plast Surg 16:195,
1992.
11. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 20:403,
1993.

1994.

Americana 20:393, 1994.
14. Isse NG. Endoscopic facial rejuvenation. Clin Plast Surg 24:213, 1997.
15. Ramirez OM. Endoscopic facial rejuvenation. Perspect Plast Surg 9:22, 1995.

imbrication. Plast Reconstr Surg 105:267, 2000.

mounds. Plast Reconstr Surg 110:885; discussion 897, 2002.
18. Harris PA, Mendelson B. Eyelid and midcheek anatomy. In Fagien S, ed. Putterman’s Cosmetic
Oculoplastic Surgery, ed 4. Philadelphia: Saunders Elsevier, 2008.
19. Hester TR, Szczerba S. Midface rejuvenation. In Nahai F, ed. The Art of Aesthetic Surgery:
Principles and Techniques. New York: Thieme Publishers, 2005.

of surgical treatment. Plast Reconstr Surg 121:258, 2008.

of the lower lid and lateral canthus. Plast Reconstr Surg 110:873; discussion 897, 2002.
22. Mendelson B, Jacobsen S. Surgical anatomy of the midcheek: facial layers, spaces, and the
midcheek segments. Clin Plast Surg 35:395, 2008.

implications for aesthetic blepharoplasty of the lower eyelids. Aesthetic Plast Surg 23:337,
1999.
24. Mendelson B, Hartley W, Scott M, et al. Age-related changes of the orbit and midcheek and
the implications for facial rejuvenation. Aesthetic Plast Surg 31:419, 2007.
25. Jelks GW, Glat PM, Jelks EB, et al. the inferior retinacular lateral canthoplasty: a new technique.
Plast Reconstr Surg 100:1262, 1997.

527
Chapter 40 Midface Rejuvenation
26. Shaw RB, Kahn DM. Aging of the midface bony elements: a three-dimensional computed
tomographic study. Plast Reconstr Surg 119:675, 2007.
27. Psillakis JM, Rumley TO, Camargos A. Subperiosteal approach as an improved concept for cor-
rection of the aging face. Plast Reconstr Surg 82:383, 1988.
28. DeFatta RJ, Williams EF III. Evolution of midface rejuvenation. Arch Facial Plast Surg 11:6, 2009.
29. Moss CJ, Mendelson B, Taylor GI. Surgical anatomy of the ligamentous attachments in the
temple and periorbital regions. Plast Reconstr Surg 105:1475, 2000.

Clin Plast Surg 35:569, 2008.


32. Ramirez OM. Three-dimensional endoscopic midface enhancement: a personal quest for the
ideal cheek rejuvenation. Plast Reconstr Surg 109:329, 2002.
33. Coleman SR. Facial augmentation with structural fat grafting. Clin Plast Surg 33:567, 2006.
34. Neuber F. [Fat transplantation] Chir Kongr Verhandl Dsch Gesellch Chir 20:66, 1893.
35. Miller CG. Cannula Implants and Review of Implantation Techniques in Esthetic Surgery. Chi-
cago: Oak Press, 1926.
36. Paul M. Barbed sutures for aesthetic facial plastic surgery: indications and techniques. Clin Plast
Surg 35:451, 2008.

Plast Surg 7:55, 2005.
38. Sasaki GH. Personal approach to the aging lower lid and face. Clin Plast Surg 35:407, 2008.
39. Terino EO, Edward M. The magic of mid-face three-dimensional contour alterations combining
alloplastic and soft tissue suspension technologies. Clin Plast Surg 35:419, 2008.

ed. Putterman’s Cosmetic Oculoplastic Surgery, ed 4. Philadelphia: Saunders Elsevier, 2008.
41. Hester TR Jr, Codner MA, McCord CD, Nahai F, Giannopoulos A. Evolution of technique of the
direct blepharoplasty approach for the correction of lower lid and midfacial aging: maximiz-
ing results and minimizing complications in a 5-year experience. Plast Reconstr Surg 105:393,
2000.
42. Hester TR Jr, Douglas T, Szczerba S. Decreasing complications in lower lid and midface rejuve-
nation: the importance of orbital morphology, horizontal lower lid laxity, history of previous
surgery, and minimizing trauma to the orbital septum: a critical review of 269 consecutive
cases. Plast Reconstr Surg 123:1037, 2009.
43. Byrd HS, Andochick SE. The deep temporal lift: a multiplanar, lateral brow, temporal, and upper
face lift. Plast Reconstr Surg 97:928, 1996.
44. Hunt JA, Byrd HS. The deep temporal lift: a multiplanar lateral brow, temporal, and upper face
lift. Plast Reconstr Surg 110:1793, 2002.

528
INDICATIONS AND CONTRAINDICATIONS
INDICATIONS

Static and dynamic perioral skin lines
Ptosis of the upper lip and deep nasolabial folds
Patient’s desire to improve aesthetic appearance of the lower face
CONTRAINDICATIONS

Congenital or medication-induced coagulopathy
Body dysmorphic disorder
Unrealistic expectations
Active infection
PREOPERATIVE EVALUATION
ANATOMY
The perioral region is bounded by:
• Nasolabial creases

• Nasal base
66%
33%
Upper lip
Lower lip
Lateral commissure
Vermilion border
Nasolabial crease
Philtrum
Cupid’s bow
The upper lip is smaller than the lower lip and is a third of the total lip volume.

Philtrum
Philtral columns
Philtral dimple
Cupid’s bow (a key anatomic feature of the upper lip)
Nasolabial crease

529
Chapter 41 Perioral Rejuvenation
PATIENT EVALUATION
The facial mimetics are studied in rest and in motion.
With increasing age, facial asymmetries will become more prominent.
The dental status is important.1,2,3
TIP: Aesthetically, 2 to 3 mm of the upper incisors may show in repose, but the full
length of the incisors should show while smiling.



patients (Fig. 41-2).
Algorithm for perioral enhancement. (DLL, Direct liplift; indirect liplift;
nasolabial angle.) © Oxford University Press.
YES
B

or ATROPHY

INADEQUATE incisor show

Strategies
• Conservative fat injection
• Conservative dermis fat graft
Strategies
• Gingival shortening
• Dermis fat graft
• Fat injection



Normal lip length

Short lip
Maxillary lengthening

• Without atrophy of lips


without dermabrasion
• With atrophy of lips

– Fat injection
• With dyschromias


without dermabrasion
• Without dyschromias

– Fat injection or string graft
Strategies

STATIC
DYNAMIC
(DYSCHROMIAS and
KERATOTIC CHANGES only)
Use laser resurfacing with or
without dermabrasion
A
TIP:

530
Part VII Facial Surgery
TREATMENT OPTIONS
Chemodenervation with neuromodulators

Fat grafting

Chemical peels
Surgical rejuvenation
INFORMED CONSENT
Well-designed informed consent can help to improve communications when problems
arise.
Address preoperatively the possibility of or

metabolism.
Before performing ablative skin resurfacing, patients should be informed of the
predicted immediate postoperative skin appearance, which can be temporarily

STRATEGIES AND TECHNIQUES
CHEMODENERVATION
Best addresses perioral rhytids and depressed corners of the mouth
Botulinum neurotoxin type A is the most widely used.

The muscle and are targeted.
2-5 units are used on each side.
The needle is inserted into peak of the Cupid’s bow, 2 to 3 mm above the vermilion
border.
Injection of the depressor anguli oris muscle will cause elevation of the oral
commissure.4
• This muscle can be found by asking the patient to depress the lower lip or frown.
The bulk of the muscle is palpable inferolateral to the oral commissure at the level of
the mandible.
TIP: Injecting 1 unit of botulinum toxin into the levator labii superioris muscle at its
origin on the maxilla (superolateral to the ala) creates a weakness of the central aspect
of the upper lip during smile, which eliminates gingival show.
SOFT TISSUE FILLERS see C

Poly-L-lactic acid (Sculptra, Galderma): Option for HIV patients with lipoatrophy

skin test
Human-based collagen (Cosmoderm and Cosmoplast, Allergan): Safer in terms of all
allergic reactions, does not require skin testing

531
Chapter 41 Perioral Rejuvenation



For skin injections, topical anesthetic can be used.

containing local anesthetic.

from cuspid-to-cuspid region.


Serial puncture (Fig. 41-3)
A
B
B, Serial puncture.
Lips


41-4).
Cupid’s bow becomes wider with age and should be
made narrower.
Approximately 10%-20% overcorrection is needed.
The lip proper, from the wet-dry junction to the
vermilion border, may be injected just deep to the
mucosa within the orbicularis oris muscle.
Placement posterior to the wet-dry junction along
the wet mucosa may enhance the lip volume and
projection.
The depth of the mental fold increases with age and
may require correction.
Approximate volume for augmentation of the lips ranges from 0.5-1.0 ml per lip.
CAUTION:

TIP: Use minimal volume in the upper lip above the vermilion border, because any
added volume may cause lengthening of the upper lip.
Cupid’s bow.

532
Part VII Facial Surgery

Filler is injected slightly medial to the actual fold (Fig. 41-5).


longevity (cross-medial or cross-hatching technique).



5
Injection might require two or more syringes for each fold.6
SENIOR AUTHOR TIP: A reasonable goal is 50% correction of the depth of the

animate or smile.
Parasagittal section of the lips, before and after enhancement with microfat, illustrating
Short needle
intradermal fat.)
y

Superior labial artery
Skin
Vermiliocutaneous
border (white roll)
Vermilion
Mucosa
Lip volume
fat graft with
blunt cannula
Lip definition:
fat graft with SNIF
(21-gauge needle)
Orbicularis oris
Inferior labial artery


lateral lip vermilion to the superolateral aspect of the chin.


correction.
Radial fanning technique from two independent injection sites, superior and inferior,
can lead to a smooth correction of the area.

533
Chapter 41 Perioral Rejuvenation
Overcorrection should not be done, because it can lead to lumps that are visible or felt
intraorally under the oral mucosa.7


care and makeup routines almost immediately.

after a treatment to minimize product migration/displacement.
Swelling and bruising can be minimized by avoiding the use of anticoagulant
medication and applying ice packs before and after a treatment, along with gentle
pressure.

Acnelike skin eruptions
Overcorrection and undercorrection
8
Skin necrosis
Infection (including viral)
TIP: As a general rule, nonpermanent, absorbable fillers can be injected more

TIP:
FAT GRAFTING see C
Besides increasing the volume, fat grafting immediately beneath the dermis can improve
the quality of the skin, decreasing wrinkles, decreasing pore size, and even reducing
scarring.

Small areas of fat grafting can often be performed using local anesthesia.


Fat is harvested using Coleman cannulas and 10 ml syringes.
The syringes are capped and centrifuged for about 3 minutes at 3000 rpm.
Serum and oil are drained.
Fat is transferred to 1 ml insulin syringes for further injection.
A 16-gauge needle is used to make incisions, with care not to push a core of skin into
the subcutaneous plane.

534
Part VII Facial Surgery
At least 10 full-length needle passes per centimeter are made
technique).
Approximately 1.2-1.5 ml should be injected into the upper lip and 1.5-2 ml into lower
lip.
Overcorrection is usually needed to account for partial absorption.
TIP:
by pushing harder will create a fat surge that will cause irregularity.
CHEMICAL PEELS see C
Most commonly used peels:
(medium-level penetration, good safety

(used mostly as a primer for TCA peel)
(deepest penetration, but requires prolonged period of healing and has
a potential for cardiotoxicity)

IV sedation is usually adequate.
A cooling fan can be used to reduce the burning sensation.

Facial subunits should be marked so that the peel can be applied evenly to each
subunit.
A cotton-tipped applicator should be used.

Peeling agent is applied homogenously over the entire surface with a consistent
pressure.
TCA application may be repeated several times, depending on the depth of the
wrinkles, using light pressure.
Each skin area is treated with the same intensity.

begins before the treatment has been completed.
Follow-up treatment with petrolatum will reduce the sensation of tautness.
Herpes prophylaxis with acyclovir 400 mg three times daily is recommended for
3-5 days.
TIP: Pay special attention to the transition area between the facial skin and the lip,
which is often inadequately peeled. Treatment of this area is facilitated by stretching

along the lip.

535
Chapter 41 Perioral Rejuvenation
DERMABRASION see C
Mechanically removes the epidermis and dermis, usually with a diamond-powered
fraise
Ideally performed in the operating room because of exposure

IV sedation
Regional nerve block
General anesthesia in some cases

The operation site should be draped and disinfected carefully.

the application of treatment at an exact depth.
Skin tension must be maintained during the entire abrasion procedure.
Abrasion should be moved over the surface of the skin against the rotation of the
abrasion head at an angle of 90 degrees while applying light pressure.
is the most reliable indicator that the grinding
procedure has reached the optimal depth.9
Abrasion should not enter the subcutaneous plane.

bleeding has been created.
Gauze soaked with antibiotic ointment is placed over the wound.
The dressing can be removed after 24 hours.
The area should be treated with skin moisturizer for a further 8 days.
The skin needs to be protected from the sun, or patients should avoid the sun, for
3 months (pigment abnormalities).
LASER ABLATIVE RESURFACING see C


modality.
After disinfection of the operation site and anesthesia (e.g., blocking of the infraorbital

The laser is applied to the desired subunit, set at the recommended parameters for
tissue ablation (10 J/cm 2).10
The depth of ablation depends on the number of passes and the amount of cooling
time allowed between passes.
The clinical endpoint is a of the skin surface indicative that treatment
has reached
An occlusive dressing is applied after completion of the procedure (entire epidermis has
been removed).
TIP:

536
Part VII Facial Surgery

2 laser and usually shorter recovery time

The laser is guided evenly, section by section, over the area to be ablated.
Slight overlapping will not be harmful.
Wound discharge and crust formation are less pronounced after erbium:YAG laser
treatment and do not persist for as long as with CO2 laser treatment.11


• Ablative resurfacing procedures can cause herpes simplex virus (HSV) activation,
hyperpigmentation, and hypertrophic scarring.
• Before the procedure, patients are placed on a prophylactic course of oral antiviral
medications for 2 days.
• Rarely, a patient will develop a herpetic outbreak; the antiviral medication is
continued, at twice the prophylactic dose, for 1 week.
LIPLIFT see C

Can be done using local anesthesia

Patients are marked before injection and asked to review and approve the markings.

The planned full-thickness skin resection is performed, starting from the vermilion
border.
To decrease the chances of hypertrophic scarring, the vermilion and skin directly within
the philtral columns, corresponding to the prolabium, are not included in the resection.

side of the wound.
SUBNASAL LIPLIFT
Provides predictable increase in the vertical height of the red lip, without disruption of
upper lid anatomy, and improves the red/white lip ratio.12

Procedure can be performed using local anesthesia.

The marked incision begins at the alar crease and traverses the vestibule of the nose
within the nasal sill, following the subcolumellar–lip border bilaterally.
Upper lip skin is excised in a bullhorn shape. No muscle is excised, and meticulous
hemostasis is achieved.

subcutaneous sutures might be necessary to reduce tension.

537
Chapter 41 Perioral Rejuvenation
12 to 13 mm at phitral crest
Usually
remove 4-5 mm
Leave
12-13 mm
philtral crest
Usually remove 4 to 5 mm;
leave 12 to 13 mm philtral crest
Crest points anchored to septal perichondrium;
do not take excision lateral to alar base
Everted closure
Everted closure
Preoperatively
1 year postoperative
Subnasal liplift surgical technique.
LIP IMPLANTS
Implants are mostly used for



commonly used.
5
• Autologous (galeal fascia, palmaris longus)

538
Part VII Facial Surgery




Two small incisions are made in the corners of the mouth in the wet vermilion.
A special passer is available for delivery of the graft, or a standard tendon passer can be
used to bluntly tunnel from one incision to the other in the submucosal-subcutaneous
plane.
The implant sheet is grasped and carried through.

TIP: Massaging the graft smooths out the material and allows better placement.
COMPLICATIONS
Hypertrophic scarring, asymmetry, numbness, and lumpiness
Sensitivity to the implant material, extrusion, need for removal of the implant because
of hardening, interference with lip function, and sensation changes
TOP TAKEAWAYS




Well-designed informed consent can help to improve communications when
problems arise.

Radiesse and Sculptra should not be used for lip augmentation because of their
high incidence of nodule formation.

Fat grafting immediately beneath the dermis can improve the quality of the skin,
decreasing wrinkles, decreasing pore size, and even reducing scarring.
REFERENCES

clinical correlations. Facial Plast Surg 21:3, 2005.

New York: Thieme Publishers, 1992.

2004.

Clin North Am 11:439, 2003.
5. Monhian N, Ahn MS, Maas CS. Injectable and implantable materials for facial wrinkles. In Papel
ID, ed. Facial Plastic and Reconstructive Surgery, ed 2. New York: Thieme Publishers, 2002.
6. Guyuron B. The armamentarium to battle the recalcitrant nasolabial crease. Clin Plast Surg
22:253, 1995.

539
Chapter 41 Perioral Rejuvenation
7. Perkins SW, Sandel HD IV. Anatomic considerations, analysis, and the aging process of the
perioral region. Facial Plast Surg Clin North Am 15:403, 2007.



20:47, 2004.

aesthetic results and complications. Plast Reconstr Surg 103:592, 1999.
11. Gregory R. Perioral laser rejuvenation. Semin Plast Surg 17:225, 2003.
12. Perkins NW, Smith SP Jr, Williams EF III. Perioral rejuvenation: complementary techniques and
procedures. Facial Plast Surg Clin North Am 15:423, 2007.

540
PREOPERATIVE EVALUATION
Consult with the patient to develop rapport while determining anatomic, psychological,
and medical suitability.
Establish baseline health and intercurrent illnesses, tobacco use, prior surgeries, and

surgical risk based on medical history.
Perform a systematic facial examination focusing on individual components and how
they interact with the whole to give the appearance of facial aging.
ASSESSING THE AGING FACE1
Facial aging is a function of soft tissue sagging, volume loss from atrophy, and skin
surface changes.
SKIN QUALITY
Skin thickness and elasticity are assessed.
Dermal atrophy occurs with age and actinic damage.
Thin, crêpey dermis is less elastic and less likely to maintain a smooth appearance after
redundant skin has been removed.
Trimming excess skin will address redundancy and reestablish some tone; however, the
degree that can be maintained over time is
SOFT TISSUE VOLUME
Subcutaneous fat is distributed
in discrete anatomic
compartments.
Facial fat compartments lose
2

musculoaponeurotic system
(SMAS) and platysmal laxity
contribute to the downward
migration of facial tissues that
develops with aging.
3
Alteration in fat distribution
and soft tissue laxity result in
a morphologic change from a
youthful “heart shape” to an
aged, square appearance
4 (Fig.
42-1).


The facial fat compartments and their aging
changes. Aging leads to an inferior migration of the
midfacial fat compartments and an inferior volume

extension of the buccal fat aggravates the inferior
migration of the medial cheek fat, middle cheek fat,
and sub orbicularis oculi fat.

541
Chapter 42 Facelift
Restoring volume and proper redistribution of soft tissue can help to restore the
appearance of youth.
SENIOR AUTHOR TIP:
wasting will generally achieve suboptimal improvement from both surface treatments of
facial skin and surgical lifts. Restoring lost facial volume using fat injections can produce

means. However, age-related facial atrophy rarely exists in isolation, and most patients
troubled by it are not always appropriately treated by fat injections alone. Isolated


results in an unusually large, unnatural appearance. It is more logical to perform fat
injections in conjunction with a facelift or after ptotic tissue has been treated.
SKELETAL SUPPORT
The facial skeleton loses volume and changes with age.5


and establish support for overlying soft tissue (Fig. 42-2) (see Chapters 27 and 40).
The bony orbit of a young female subject on the left and an older female subject on
the right. The aged orbit may be rejuvenated with volume augmentation.
FACIAL ANALYSIS
Assess and address the entire face as a whole to maintain facial harmony.
The key steps to consistent results are a thorough preoperative analysis and
development of an operative plan to address individual aesthetic needs.

Assess facial proportions. Forehead should represent the upper third of the face,
measured from hairline to pupil.
Note the presence of active and passive wrinkles on the forehead from frontalis
activation and on the glabella from contraction of the corrugators and procerus.
• Passive
wrinkles are best addressed by and will only be
minimally improved by chemodenervation or surgical lifts.
• and can be voluntary or
involuntary. Active wrinkles can be improved with and possibly

542
Part VII Facial Surgery
Evaluate medial and lateral brow position in relation to orbital shape and upper lid.
NOTE:


Identify lid ptosis, characterized by and
Both brow and eyelid ptosis should be addressed in the surgical plan.
Assess the amount of upper eyelid skin. Compensate for excess skin from lateral brow
hooding by manual repositioning of the lateral brow.

upper orbit.

Note the relationship of the orbital rim to the anterior surface of the globe (Fig. 42-3).
• provide better support for lid suspension.
• lack support and should be addressed by planning
additional or midface soft tissue augmentation.
Globe prominence may indicate thyroid disease that should be treated appropriately.
Assess lid tone and tarsal suspension using a lid snap-back test and lid distraction test.
Determine skin laxity and quality. Trimming of excess lower eyelid skin must be very
conservative to prevent complications.
Assess for laxity of the orbicularis muscle, sometimes evident by the presence of festoons.
Note bulging of fat, laxity of the orbital septum, and fat loss in the lower orbit.
Negative
vector
Neutral
vector
Positive
vector
Orbital vectors.

Examine skeletal proportions and the relationship of the bizygomatic diameter and
maxillary height.
Note the distribution of subcutaneous fat and tissue in relation to underlying bony
structure.
Assess depth and prominence of the nasolabial folds, which indicate volume loss and

Jowls indicate shelving from ptotic cheek tissue or excess fat that may need to be
addressed. Jowls can be accentuated by tethering at the mandibulocutaneous ligament
that should be released or by volume loss along the jawline that should be replaced.

543
Chapter 42 Facelift

Note the presence of marionette lines from the oral commissures to the mandibular
border.
Assess for volume loss in the lips and lengthening of the upper lip. Note degree of
upper incisor show at rest.
The presence of a weak chin should be discussed with the patient and possibly
addressed in the surgical plan.
Deep perioral rhytids are important to note and will improve with facelifting.
Proper treatment will require skin resurfacing as an additional part of the surgical plan.

Assess for presence of soft platysmal bands visible in repose, and hard bands visible
with platysmal activation.
Soft bands will respond to repositioning of lax platysma (i.e., platysmaplasty), whereas
hard bands will require platysmal myotomy.

and location, this can be addressed by liposuction or direct excision.
The amount of skin laxity is important to note; however, addressing the skin in isolation
without considering the underlying structures will result in a modest improvement at
best.
SENIOR AUTHOR TIP: For many patients, subplatysmal fat accumulation, sub-
mandibular salivary gland “ptosis,” and digastric muscle hypertrophy will contribute

preplatysmal to subplatysmal, and the small amount of subcutaneous fat present in
a typical patient presenting for a facelift is needed to preserve a soft, youthful neck.

had lifelong cervicomental fullness. In these patients, partial subplatysmal lipectomy will

lateral submental triangle, lateral to the anterior belly of the digastric muscle and medial
to the mandibular border. Glands lying deep to the plane tangent to the inferior border
of the mandible and ipsilateral anterior belly of the digastric muscle do not disrupt neck
contour and will usually not require treatment. However, glands protruding inferior to
this plane are likely to be problematic if excess cervical fat is removed and redundant
skin excised. A small subgroup of patients will have digastric muscles with large, bulky
anterior bellies that are evident as linear paramedian submental fullness. As in the
case of large submandibular glands, large digastric muscles are frequently hidden by

myectomy should be considered.
SURGICAL PLAN
A surgical plan should include all the individual components of the face noted on facial
analysis.
Failure to address all the units comprehensively may lead to facial disharmony and less
than optimal results.

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Part VII Facial Surgery

rejuvenation will often include surgery for the neck, brow, eyelids, and perioral region in
addition to complimentary skin treatments.
Preoperative photography is essential for planning and for documenting operative
changes (see Chapter 3).
FACELIFT TECHNIQUES
There are as many facelift techniques as there are facelift surgeons. However, common
themes allow generalization of certain methods and approaches. Rather than describing
the technique attributed to each surgeon, the principles are listed below. Understanding
the principles allows surgeons to compare methods and critically analyze “new”
techniques as they are introduced.
TECHNIQUE PRINCIPLES

incision may extend onto the temporal hairline but does not
extend posteriorly.
is needed to address skin redundancy in the neck.
may be required to directly address platysmal banding and
deep-layer neck problems, i.e., subplatysmal fat, submandibular glands, and digastric
muscles.
are used in a minimally invasive approach to the brow and midface.
can be used to access the brow ligaments and
corrugators, or for lower lid canthopexy.
can be used as an
alternative approach to lifting the midface.

involves placement of direct sutures to fold over and suspend the mobile
SMAS to the immobile SMAS in a vector perpendicular to the line of suturing. No

SMAS (SMASectomy).
3



Ptotic facial soft tissue is ideally elevated by repositioning the SMAS in a vector
perpendicular to the long axis of the zygomaticus major muscle.
Redundant skin should only be trimmed in a slightly more horizontal vector.

postoperatively.

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Chapter 42 Facelift
FACELIFT PLANES


SMAS is addressed with a pure plication or with a partial SMAS resection and primary
repair in the direction of the desired vector.
A pure subcutaneous lift, without addressing the SMAS, is rarely performed today.
SENIOR AUTHOR TIP: Skin was meant to serve a covering function and not a structural
or supporting one. Using skin as the vehicle to support sagging deep-layer tissue
corrupts its function and results in abnormal tension and related secondary problems,
including poor scars, tragal retraction, earlobe malposition, and a tight, unnatural
appearance. Relying on the SMAS to lift sagging facial tissues circumvents this problem,
because it is an inelastic structural layer capable of providing sustained support.

closure can be done under normal skin tension.

A plane is developed deep to the SMAS to allow mobilization and imbrication in the
desired vector.

SMAS over the parotid and zygoma must be lifted to allow adequate mobilization.
SMAS can be mobilized as an independent layer or with the overlying skin.
Sub-SMAS dissection may result in more prolonged swelling and recovery from greater
disruption of lymphatics.
This technique is often referred to as a deep plane lift, although this term can be
inaccurate, because deeper planes exist, which are described in the following text.

An avascular plane is developed between the periosteum and SMAS over the zygoma
and periorbital rim.
Approach is from a temporal incision to lift the upper face and midface as a single unit.
Malar soft tissue is lifted and suspended independently from the temporal fascia.

A subperiosteal plane is developed similarly to access dissection in craniofacial
reconstruction.

achieve repositioning.
Malar augmentation with soft tissue repositioning or by direct access and placement of
implant is easily achieved.
Neck and perioral region are not adequately addressed, and supplementation with
another technique may be needed.

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Part VII Facial Surgery
My preferred technique is a lamellar
high-SMAS facelift. In a lamellar dissection, the skin and SMAS are elevated as separate



skin tension, hairline displacement, and objectionable wrinkle shifts. Planning the upper

arch allows elevation of not only the lower cheek and jowl but also the midface and
infraorbital regions.
ADJUNCTIVE PROCEDURES
To enhance the overall results, additional procedures can be performed in conjunction with
a facelift. In addition to performing surgical lifts to address the forehead, eyelids, lips, and
neck, the following adjunctive procedures are often required.
AUTOLOGOUS FAT GRAFTS


Results vary with surgeon and technique, and patients need to be informed that repeat
injection may be necessary to achieve desired volume and contour.
SKELETAL AUGMENTATION
Bony prominences can be accentuated to achieve a youthful appearance by
augmenting the skeleton.
Malar or mandibular augmentation can be achieved with silicone or porous
polyetheylene implants or subperiosteal placement of calcium hydroxyapatite.
SKIN RESURFACING

structural changes achieved by the facelift.
Skin quality can be improved with controlled injury to the surface to promote new
collagen deposition and reactive contraction.
Mechanism of injury is not as critical as depth to promote changes.

works by causing mechanical injury to ablate the surface layer (see
Chapter 20).


works by causing both ablation and heat injury (see Chapters 16 and 17).
• Uniform treatment can be delivered with computer precision.

work by causing chemical injury (see Chapter 19).
• Trichloroacetic acid (TCA) and phenol-croton oil are most commonly used.
• Depth is determined by the concentration, time of application, and number of layers
applied.

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Chapter 42 Facelift



care will result in a smoother operative course, reduction in complications, and faster
recovery.
ANESTHESIA
If general anesthesia is used, endotracheal tube position should be adjustable during
the procedure to allow access to all incision sites.
The use of lidocaine with epinephrine injection during a facelift is nearly routine to


sedation, depending on the surgeon’s and the patient’s comfort level.
SENIOR AUTHOR TIP: I perform most facelifts with the patient under deep sedation

patient to be heavily sedated without compromise of the airway. However, muscle
relaxants are not given, and the patient can be allowed to breathe spontaneously. An

and to trigger coughing and bucking when the patient emerges from the anesthetic.
INTRAOPERATIVE MANAGEMENT
A well-rehearsed plan of execution is necessary to maintain a steady surgical cadence to
reduce operative time without compromising technical precision.

unobstructed view of the patient’s entire face, neck, and scalp.
Warming blankets should be used to maintain the patient’s body temperature
throughout the procedure.
Injection of local anesthetic with epinephrine should be timed before making incisions



postoperative hematoma.
Prevention of postoperative nausea is critical and treated with a multimodal approach
of antiemetics given at the beginning of the procedure.
A smooth extubation and emergence from anesthesia should be stressed.
POSTOPERATIVE CARE


3 days.
Postoperative hypertension can lead to a hematoma and should be prevented.

pressure control during and after surgery.
• IV labetalol can be given in 5-10 mg boluses for breakthrough hypertension.

acts as a potent sedative antiemetic.

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Part VII Facial Surgery
Standing orders for antiemetic medications are given to control postoperative nausea
and vomiting.
Patients should ambulate the day of surgery if possible. The importance of staying
mobile at home after discharge is emphasized.
Salt and excessive intake of water, which can exacerbate swelling, are restricted.
SENIOR AUTHOR TIP:
a pillow. A small cylindrical neck roll is allowed if a patient requests it. This posture

and obstruction of regional lymphatics that inevitably occur if the patient is allowed
to elevate the head on pillows. All patients are shown an elbow-on-knees position that
ensures an open cervicomental angle while sitting. Patients should have a soft diet but

alcohol for 2 weeks after surgery. Patients should begin showering and shampooing
no later than 3 days after the procedure. The neck drain is left in place for 5 days,
which reduces the likelihood that any small collections will form and speeds the overall
resolution of edema and ecchymosis in the neck.
COMPLICATIONS
HEMATOMA
More common in than females
Usually occurs within the postoperatively
to prevent skin necrosis.

• Male sex
• Preoperative hypertension
• Postoperative rebound hypertension
• Qualitative platelet disorders from medication or supplements
Small (<5 ml) hematomas can be evacuated by needle aspiration.

and prolonged distortion.
INFECTION
Surgical site infections can occur in up to 2% of patients.
The most common organisms are and
Most appear at the about 5-7 days after surgery.
They usually respond well to drainage and oral antibiotic therapy with minimal
sequelae.
DELAYED WOUND HEALING
Skin necrosis is more commonly seen with subcutaneous facelifts (4%) than with sub-
SMAS dissections (1%).3

limited whenever possible.

549
Chapter 42 Facelift
It is more likely to occur when is applied to skin closure.
or
NERVE INJURY
The is the most often recognized nerve injury after a facelift.
Transient neurapraxia of the marginal mandibular or frontal branches of the facial nerve
can occur.
Most neurapraxias resolve within a few weeks, but can persist for several months.
Injury to the buccal branch, although reportedly the “most common,” can go unnoticed
because of cross-covering branches.
Permanent facial nerve injuries are rare and can be prevented by clearly understanding
the anatomy and respecting the “danger zones” (Fig. 42-4).
Supraorbital/
supratrochlear nerves
Mental nerve
Infraorbital nerve
Temporal branches
of facial nerve
Zygomatic and
buccal branches of
facial nerve
Marginal mandibular
branch of facial nerve
Great auricular nerve
1
2
3
4
5
6
7
Facial danger zones: Motor and sensory nerves.
TOPICAL SKIN MAINTENANCE
Topical skin care helps to maintain and preserve the longevity of facelift results and
improves patient satisfaction.
Counseling and recruiting patients to become active participants in their care is
essential in implementing a successful regimen.

Successful skin care maintenance includes:
Nonsoap cleansers help to preserve natural lipid barriers between cells.
Slow, gradual exfoliation can be achieved with alpha-hydroxy acids and
retinols.
Melanin production and deposition can be inhibited using
hydroquinone, kojic acid, or azelaic acid.
Use of a sunscreen and physical blockers with an SPF 30 or greater
will absorb up to 97% of harmful radiation. Topical antioxidants such as vitamins C
and E can also be applied to protect against photodamage.
Tretinoin is the only topical agent, other than chemical peels, that

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Part VII Facial Surgery
TOP TAKEAWAYS

Facial aging is a function of soft tissue sagging, volume loss from fat atrophy,
and skin surface changes.

Trimming excess skin will address redundancy and reestablish some tone;
however, the degree that can be maintained over time is limited by the residual
skin elasticity.


be corrected with a browlift rather than a blepharoplasty.

For many patients, subplatysmal fat accumulation, submandibular salivary gland

neck deformity.

The care delivered in the operating room and during recovery is as essential to

REFERENCES

Surg 10:21, 2005.
2. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for
cosmetic surgery. Plast Reconstr Surg 119:2219, 2007.
3. Marten TJ.

Techniques, ed 2. New York: Thieme Publishers, 2010.

computed tomographic study. Plast Reconstr Surg 129:263, 2012.
5. Shaw RB Jr, Katzel EB, Kolz PF, et al. Aging of the facial skeleton: aesthetic implications and
rejuvenation strategies. Plast Reconstr Surg 127:374, 2011.

551
PERTINENT ANATOMY
The nasolabial fold is a combination of complex mechanisms consisting of skin, adjacent
redundant cheek, the nasal ala, the lip, and dermal attachments of the various interacting
and overlapping facial mimetic muscles with independent vectors of interaction, all

1-8
OBSERVATIONS ABOUT THE NASOLABIAL FOLD
AFTER ANATOMIC DISSECTION
GROSS DISSECTION
The fold is a that separates the fatty cheek from the dense upper
lip.
The nasolabial fold is a discrete unit with distinct anatomic boundaries.9
Upper lip mimetic muscles insert into the orbicularis oris at the level of the fold.
The exact arrangement of the muscular insertions into the dermis along the nasolabial
fold is but perhaps this is what contributes to the uniqueness of every
person’s nasolabial fold.

in the cheek region.
The zygomaticus major and minor, levator labii superioris, and levator labii superioris
alaeque nasi lie beneath the subcutaneous tissues.
The levator anguli oris and buccinator muscles are deeper.
The mimetic muscles abut the overlying dermis only when they reach the orbicularis
oris border.
Medial to the fold is a paucity of subcutaneous fat between the dermis and orbicularis
oris, where skin is adherent to the sphincter directly.
The upper lip levators are protected by a generous amount of subcutaneous fat from
their origin on the zygoma and maxilla to their insertion into the orbicularis oris and
modiolus.

552
Part VII Facial Surgery
6: Fibrovascular structure that forms a dense, compact, mobile mass.

tractors) or diverging away from (orbicularis oris) the center
• Center is situated about 1.5 cm away from the labial commissure.
• Texture, volume, and thickness (about 1 cm) can be palpated on bidigital
examination.

TIP:
in order to address clinical changes that occur and select appropriate and individualized
treatment.
HISTOLOGIC OBSERVATIONS
Responses to several publications3,4,5-7,10 on microscopic anatomy around the nasolabial
fold have overlapping, complementary elements:
• The various mimetic muscles eventually insert into the entire perioral sphincter,
composed of orbicularis muscle and modiolus.
• The zygomaticus major and minor, modiolus, and levator labii superioris have
cutaneous slips extending intermittently into the nasolabial fold dermis.

from the levator muscles of the upper lip, and (3) striated muscle bundles
originating in the fold fascia.
• The lip elevator muscles and the “fold muscles” course down the lip to traverse the
orbicularis oris and insert into the dermis of the (1) upper lip, (2) the cutaneous
vermilion junction, and (3) the vermilion.


nasolabial fold fascia, traveling in many directions at the fold.
THE SMAS AND THE NASOLABIAL FOLD
Understanding the unique relationship between the nasolabial fold and the SMAS is
critical to improving the aging face in this transitional zone of the central face. Histologic
examinations elucidating the two have increased our understanding towards improving
the nasolabial fold, whether surgically or nonsurgically.
Complementary and supporting histologic evidence from various dissections gave rise
to certain conclusions about the SMAS and the nasolabial fold.3,11
The SMAS continues anteriorly up to the level of zygomaticus major muscle, at which
point it seems indistinguishable from the investing fascia of the muscle.
The attenuated SMAS also invests the undersurface of the zygomaticus muscle similar

A natural plane of dissection follows the deep surface of the SMAS behind the
zygomaticus major muscle and into the buccal space.

553
Chapter 43 Nasolabial Fold

deep fascial leaves and envelops zygomaticus major and minor muscles.
No separate subcutaneous extension of the SMAS appears to exist.
DYNAMICS OF THE NASOLABIAL FOLD
The movement of the nasolabial fold encompasses the complex anatomy and is a unique
interaction between skin, the various facial mimetic muscles, adjacent fatty soft tissue

expression of emotions. Following are some clinical observations
4,12:
Individual facial muscles retain their identity and can be stimulated to contract
independently.

control expressions, ranging from partial to full expression of the same emotion.
Elevation of the upper lip (or smiling) deepens the nasolabial fold in all people.
involves contracting single muscles and can produce discrete, unique dimples
along the fold.
• These discrete contour irregularities (dimpling) are the only sign of muscle action in
a face that is in repose.
Full smiling exaggerates dimpling.

depressions.4
• A comma-shaped crease lateral to commissure
• A dimple above the modiolus
• A narrow puckering along the fold in the upper lip (prominent at the beginning of
the lip elevation but consumed by a full smile)
• Shallow dimple next to the nasal ala in the upper fold
• Some people have one dimple, and others none, but rarely are two dimples present
in a person.
THE HUMAN SMILE
Actions of the muscles surrounding the nasolabial fold and mouth give rise to the
human smile, and one author noted the nasolabial fold as a keystone to the

10,13,14
The smile is formed in


originating at the fold.





In death, the nasolabial fold is retained.
The fold is shallow in babies and deepest in elderly people.

554
Part VII Facial Surgery
Rubin’s classic work on smiling.
a
b
c
j
k
l
d
e
f
g
h
i
o
o

a Caput annular of the levator labii superioris of the upper lip
b The rest of levator labii superioris


e Upper part of the buccinator
f Caninus

g The lower part of the buccinator
h Depressed angularis
i Risorius

j Platysma
k Depressor labii inferioris
l Mentalis
o Orbicularis oris circles the mouth
WHAT DEEPENS THE NASOLABIAL FOLD?
Deep folds are a sign of aging, and the mechanism and dynamics of the fold contribute
to the gradual deepening of the folds. The following factors contribute to the
deepening of the folds
4:
• Redundant skin in the overlying cheek
• Ptosis of the subcutaneous fat above the nasolabial fold

555
Chapter 43 Nasolabial Fold
• Undercutting by the upper lip retractor muscles, particularly the levator labii
superioris. Yousif et al5 provided another perspective to the causes of the deepening
nasolabial fold.
• The nasolabial fold is the point of juncture between two skin territories.

thus is not supported by the muscles.
• Medial to the line of the nasolabial fold, the muscles insert on the skin and support
this area against gravity and laxity of aging skin.
• During aging, the “unsupported” skin and cheek mass lateral to the fold descends at
a much than the skin medial to the fold.
TIP: The discrepancy in the rate of descent of two adjacent skin territories creates and
accentuates the nasolabial fold.
Mendelson15 compared cheek and lip contours separated by the nasolabial fold and

• The contour of the youthful face becomes divided into a series of folds (convexities)
and furrows (concavities).
• In the midcheek, the round fullness of the youthful face is slowly lost, and hollowing
appears as an obliquely oriented
• The cheeks appear larger with aging, partly from the moving
medially toward the lip.
• Fullness and downward displacement of upper lip fold changes the commissure,
which appears deeper and longer and droops to become the

of the marionette furrow.
• Mental crease becomes deeper, longer, and downturned, as the
A
deepening of the nasolabial fold.16
• With aging, the cheek mass displaces and

• The relationship between the upper lip and fold remains constant.
• The lateral commissure moves laterally, while the apparent angle of the nasolabial
fold decreases.
TIP: Deepening of the nasolabial fold is caused by changes in the cheek mass and its
support.
In diseased states such as HIV lipodystrophy, overall facial fat atrophy deepens the
nasolabial fold.
• Atrophy of the fatty cheek above the fold

• Continued action of upper lip retractor muscles to further the deepening by
undercutting


• These changes are additive with those of the aging process of the skin and
subcutaneous tissue.

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Part VII Facial Surgery
ASSESSING THE NASOLABIAL FOLD
Upper lip levators
Modiolus (orbicularis oris)
Medial platysma jowl border
II
I
III
Functional zones of the nasolabial fold according to Barton.
BARTON CLASSIFICATION
Barton2 as related to assessing
rhytidectomy.

lip, particularly the levator labii superioris, levator anguli oris, zygomaticus minor, and
to a lesser extent, zygomaticus major

and indirectly by muscles acting on it (zygomaticus major, orbicularis oris, and
triangularis portion of depressor anguli oris)

attachments of platysma to the mandible
Each zone is an area of cutaneous wrinkling accentuated by actions of the underlying
muscles.
ZUFFEREY CLASSIFICATION
6,17 noted three types of nasolabial folds and correlated them with the underlying

Three types of fold:

lateral segments.
This angle varies.
NOTE:

NAHAI CLASSIFICATION
Nahai18

557
Chapter 43 Nasolabial Fold
Visible folds on animation
Visible folds at rest
Visible folds at rest and deepening of folds on animation
Deep folds at rest and deeper on animation
Overhanging folds
Grade I
Grade II
Grade III
Grade IV
Grade V

558
Part VII Facial Surgery
INFORMED CONSENT
Before initiating treatment, goals should be discussed with the patient, including the

Several treatment alternatives exist, from injection therapy to surgery, but not all
modalities will be ideal for a particular patient or even for a group of patients.

goals and expectations that can readily and safely be met.
MANAGEMENT OF THE NASOLABIAL FOLD
Treatment options for nasolabial folds and marionette grooves. A, Grade I. B, Grade II.
C, Grade III. D, Grade IV.
GRADE I
Visible folds on
animation
Intradermal
injection of less


2. Juvéderm Ultra
A
GRADE II
Visible folds at rest
Deeper injection of

1. Restylane
2. Juvéderm Ultra Plus
Toxins
B
GRADE III
Visible folds at rest
Deepening of folds
on animation
Deep injection of

1. Autologous fat
2. Restylane
3. Radiesse
4. Juvéderm Ultra Plus
Marionette grooves
Depressor
anguli oris
Nasolabial folds

superioris

superioris
alaeque nasi
Toxins
C
GRADE IV
Visible folds at rest
Deeper folds on
animation
Midface lift
Deep injection
of viscous

subcutaneous tissue
1. Autologous fat
2. Restylane
3. Radiesse
4. Juvéderm Ultra Plus
Marionette grooves
Depressor
anguli oris
Nasolabial folds

superioris

superioris
alaeque nasi
Toxins
D

559
Chapter 43 Nasolabial Fold
Grade V.
or
Deep injection
of viscous

subcutaneous tissue
1. Autologous fat
2. Restylane
3. Radiesse
4. Juvéderm Ultra Plus
Marionette grooves
Depressor
anguli oris
Nasolabial folds

superioris

superioris
alaeque nasi
Toxins
E
Direct excision
Midface lift
GRADE V
Overhanging folds
Rejuvenation of the nasolabial fold begins with a careful assessment of the severity of
the fold.
Options range from “surface approaches” to “subsurface approaches”

• Subsurface approaches: lipectomy, excision, eversion, implantation, facelifts
INJECTIONS see C



Various choices are available, and materials are constantly evolving.
Examples include Restylane (Galderma), Juvéderm (Allergan), collagen, and fat
injections and have variable longevity and success.
Juvéderm Ultra Plus (Allergan) seems to correct nasolabial fold at least for 1 year.19

20
CAUTION:


as levator labii superioris or depressor anguli oris) and can serve to antagonize these
muscles, which “undercut” and exaggerate the nasolabial fold.

have variable longevity, typically result in incomplete and short-lived
correction, and may be best reserved for younger patients.
• Rohrich
21
technique.
• Marten
22 also reports excellent results with the combined technique; he describes a

at the piriform to address maxillary recession in the upper nasolabial fold.
SENIOR AUTHOR TIP:
small amounts, one side at a time, and have patient assess improvement and symmetry
as you go. This is a good gauge for postprocedure result and helps achieve patient
buy-in.

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Part VII Facial Surgery
DERMAL FAT GRAFTING see C
Adjunctive to a facelift and uses a dermal fat graft to smooth the nasolabial fold

Guyuron and Michelow23 described their approach and note lasting results:
1. Excess fat is debulked or repositioned in the nasolabial fold.
2. Skin is undermined medial to the nasolabial crease to separate dermal attachments
from underlying muscle and SMAS.
3. A soft, supple graft is interpositioned at the site of the nasolabial crease to create a
barrier to reattachment of muscle to dermis.
4. Excess skin is eliminated, and skin and SMAS are redraped to reduce ptosis of
subcutaneous structures.
NOTE:
Dermal grafts should have symmetry and smoothness before insertion to prevent
further palpable or visible irregularities.

dislodgement.
Graft should not be too bulky or scarring, and decreased absorption may contribute to
palpable or visible irregularities.
A
B
C
D
A Tulip Biomed pickle fork is used to undermine the skin through a nasal vestibule
incision. B, A Frasier suction cannula guides 4-0 plain suture percutaneously into the nose. C, The
SMAS graft is attached to the suture. D, The graft is fed into its subdermal position by traction on
the percutaneous suture.

561
Chapter 43 Nasolabial Fold
NASOLABIAL LIPECTOMY
Millard et al24presented their follow-up on nasolabial lipectomy through a facelift
approach.
The skin of the cheek is undermined in subcutaneous plane, with the scalpel turning
deeper in the nasolabial region.

The fold of the fat is further reduced with a right-angled scissors.
NOTE:

CAUTION:

FACELIFT see C


expertise and experience.
Understanding the surgical anatomy is critical, because this approach is complex and
carries the highest risk of complications if not used appropriately.
The attachment of the SMAS to the zygomatic muscles should be severed2,3 as one of


subcutaneous tissue to free it from the underlying tether of the SMAS.3
Thus, at the level of the
3

3 (Fig. 43-6).
Zygomaticus
major
Zygomaticus
major
SMAS


zygomatic muscles are encountered.
NOTE:


over the upper
third of the belly of the zygomatic major muscle, then passes to the deep surface of the
orbicularis oculi to provide innervations.
25 Thus

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Part VII Facial Surgery

2,15
The longevity of the improvement of the nasolabial fold using the surgical release
method is clearly established.2,15
PRIMARY EXCISION
This is the most direct method in eliminating
the nasolabial fold and usually a
In selected patients with overhanging
nasolabial folds uncorrected or
inappropriately corrected by procedures
discussed previously, or combinations, can
be managed by direct excision.
The amount of redundancy should be
substantial to justify the direct approach.
Direct liposuction or excision of the deep
fat through the facelift approach has failed
and inadequately corrected persistent
deformities.
Methods of excision vary, but the scar must
be placed for imperceptible healing.
One approach is to reshape and reposition
the ptotic cheek mass to smooth (not
obliterate) the nasolabial fold during skin excision.
26
This approach is best performed in 27 and is highly

ALTERNATIVE, NOVEL, AND OTHER APPROACHES
Methods to correct the fold—at least noninvasive ones—will continue to evolve.
Pessa28 reported improvement of the medial nasolabial fold by selectively resecting the

muscles to smooth the fold.
Direct subcutaneous tissue that “forms the nasolabial fold” can be removed.29
Noninvasive technologies, involving application of variable degrees of external thermal
energy, exist and will continue to be explored and used as combination therapy
with other types of treatments. Although these technologies may seem promising,
most patient-reported and physician-reported improvement should be assessed
appropriately.
POSTOPERATIVE CARE AND TREATMENT
Injections with hyaluronic acids only need temporary topical treatment such as
application of ice.
although
other major procedures may be more suitable.

acetaminophen.
Surgical procedures with incisions will require more postoperative vigilance than those
using injectables.
Patient follow-up is crucial to assess longevity of the result and appraise it honestly.
If the nasolabial folds are very
deep, particularly if there is an overlap
of redundant skin, direct excision of the
nasolabial folds should be considered.

563
Chapter 43 Nasolabial Fold
SURGICAL COMPLICATIONS AND TREATMENT
Fillers causing visible and prominent asymmetry, when compared to the contralateral


with this treatment.
Minor asymmetry is expected; therefore asymmetry noted preoperatively should be
documented.
Infections are unlikely but need to be addressed with antibiotic therapy urgently to
prevent cellulitis.
Venous drainage of the central nasofacial triangle is toward the cavernous sinus, and a
very rare complication of can occur, which requires high
vigilance of diagnosis and treatment.

Scar improvement after direct excision can be enhanced by silicone tape; however,
compliance is poor, and liquid silicone–based products containing an SPF will generally


suggest necrosis, which is uncommon and needs to be addressed several months
after the procedure. Aggressive massage and pressure therapy are important early
postoperatively. Firmness should be expected early after the procedure.
TOP TAKEAWAYS


distinct anatomic zone, and not simply a crease or a simple fold.



No one treatment, surgical or nonsurgical, completely corrects age-related
deepening of the nasolabial fold.


appropriate for all types of fold. A combination of treatments may be necessary


Treatments may change during the course of a patient’s life.

When evaluating the various types of injectable materials to improve the nasolabial

term problem, while masking and perhaps distorting normal human anatomy.
REFERENCES

cheek area. Plast Reconstr Surg 58:80, 1976.
2. Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg 90:601, 1992.
3. Barton FE Jr. The SMAS and the nasolabial fold. Plast Reconstr Surg 89:1054, 1992.
4. Barton FE Jr, Gyimesi IM. Anatomy of the nasolabial fold. Plast Reconstr Surg 100:1276, 1997.
5. Yousif NJ, Gosain A, Matloub HS, et al. The nasolabial fold: an anatomic and histologic reap-
praisal. Plast Reconstr Surg 93:60, 1994.

232, 1992.

564
Part VII Facial Surgery

2017.

remarks about the panniculus adiposus. J Anat 60:1, 1925.
9. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for
cosmetic surgery. Plast Reconstr Surg 119:2219, 2007.
-
nism. Plast Reconstr Surg 83:1, 1989.

an anatomic study in cadavers. Plast Reconstr Surg 75:488, 1985.

Aesthetic Plast Surg 16:167, 1992.
13. Jackson IT. Anatomy of the nasolabial fold: the keystone of the smiling mechanism [discussion].
Plast Reconstr Surg 83:9, 1989.

Reconstr Surg 103:687; discussion 692, 1999.
15. Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with periosteal

16. Yousif NJ, Gosain A, Sanger JR, et al. The nasolabial fold: a photogrammetric analysis. Plast
Reconstr Surg 93:70, 1994.

18. Nahai F. Clinical decision-making for nonsurgical cosmetic treatments. In Nahai F, ed. The Art


treatment of severe nasolabial folds. Plast Reconstr Surg 121:289, 2008.
-

2):S222, 2007.
-
ments. Plast Reconstr Surg 133:756e, 2014.
22. Marten TJ, Elyassnia D. Fat grafting in facial rejuvenation. Clin Plast Surg 42:219, 2015.
23. Guyuron B, Michelow B. The nasolabial fold: a challenge, a solution. Plast Reconstr Surg 93:522,
1994.
24. Millard DR, Mullin WR, Hunsaker RH. Evaluation of a technique designed to correct nasolabial
folds. Plast Reconstr Surg 89:356, 1992.
25. Freilinger G, Gruber H, Happak W, et al. Surgical anatomy of the mimetic muscle system and
the facial nerve: importance for reconstructive and aesthetic surgery. Plast Reconstr Surg
80:686, 1987.
26. Sen C, Cek DI, Reis M. Direct skin excision fat reshaping and repositioning for correction of
prominent nasolabial fold. Aesthetic Plast Surg 28:307, 2004.
27. Rudkin G, Miller TA. Aging nasolabial fold and treatment by direct excision. Plast Reconstr Surg
104:1502, 1999.
28. Pessa JE. Improving the acute nasolabial angle and medial nasolabial fold by levator alae muscle
resection. Ann Plast Surg 29:23, 1992.
29. Arrunategui C. Observations on a new concept for correction of the nasolabial fold in rhyti-
dectomy. Aesthetic Plast Surg 24:97, 2000.

565
VISUAL CRITERIA FOR A YOUTHFUL NECK1
A distinct inferior mandibular border
A visible subhyoid depression
A visible thyroid cartilage bulge
A visible anterior border of the sternocleidomastoid muscle
A cervicomental angle of 105-120 degrees
Distinct
mandibular
border
Cervicomental
angle
105-120 degrees
<3 mm

Distinct
mandibular
border
<3 mm

Subhyoid
depression
Thyroid
bulge
Distinct SCM border
Visual criteria for a youthful neck. ( Nose-lip-chin plane; sternocleidomastoid.)
SENIOR AUTHOR TIP: Neck recontouring is an integral part of necklifting and often
is all that is required.
Thus, a corollary to a youthful neck comprises the visual criteria for an aging neck.
VISUAL CRITERIA FOR AN AGING NECK2
An obtuse cervicomental angle, caused by:

• Excess subplatysmal fat
• Excess preplatysmal fat

Cervical spinal compression changes related to age
An aging chin
An aging lower face


Sumeet Sorel Teotia, Foad Nahai

566

SENIOR AUTHOR TIP:



PREOPERATIVE EVALUATION3


SKIN
Skin quality,
SENIOR AUTHOR TIP:
Apparent excess skin



Real excess skin







Skin quality is inversely related to the length of the incision required.
TIP:


FAT

subcutaneous
(preplatysmal) deep
(subplatysmal)

• Submental

rest.
• Preplatysmal
subplatysmal


contraction.
Fig. 44-2

567
Chapter 44 Necklift

to the muscle, and an to the neck is needed.

PLATYSMA4
or platysmal banding is evaluated.
SENIOR AUTHOR TIP: I look for and make a note of the central and lateral platysmal
bands.
Imperfections in the neck and jaw shadows are noted.
Skin excess often accompanies platysmal banding.
The neck and face interface is assessed, because platysma decussates above the
youthful jawline.
The location, direction, and distance between platsymal bands are noted.
is controversial.5-7
• A contracted platysma creates a hammock between the jawline and clavicle.

neck.

• Age-related changes to the fascia allow contents of platysma (fat and other
structures) to “bulge,” creating bands (Fig. 44-3).
Superficial
layer of cervical
investing fascia
Fascia is weak
in the midline
Cervical fascia
is dense and
strong laterally
Platysmal banding.

568
Part VII Facial Surgery
DIGASTRIC MUSCLES
In a fatty neck, digastric muscles are not easily evaluated.
In a thin neck, they can bulge below the inferior border of the mandible, creating a
subtle but important irregular contour.
A persistent bulge after submental fat excision can be caused by prominence of the
digastric muscles.
The status of digastric muscles is best evaluated intraoperatively, after removal of
subcutaneous fat.
SUBMANDIBULAR GLAND
Prominence of the gland below the mandibular rim within the submandibular triangle is
evaluated.
In a fatty neck, this is often not possible.
Intraoperative evaluation is necessary in most cases.
Flexing a patient’s neck may help to accentuate a locally bulging deformity from the
gland.
MANDIBULOCUTANEOUS LIGAMENT
Jowls may result from tethering of the relaxing facial tissues at this ligament.
The volume of jowling is evaluated with the patient in a supine position.


CHIN
The chin should be evaluated in reference to facial proportions.

Demineralization of the lower jaw and teeth from age or pathological causes can



An alloplastic chin implant or an osseous genioplasty may complement anterior neck
contour.
SENIOR AUTHOR TIP:
chin).
INFORMED CONSENT

are discussed with the patient. An intervention is chosen only after an honest conversation

A thorough knowledge of anatomy of the neck will help to prevent complications (see
Chapter 30).
OPTIONS FOR NECK REJUVENATION
Developing an algorithm based on anatomy and clinical evaluation will help to improve
neck contour. A logical, “layered” approach can help to plan steps in an operation and
address each component of the neck.

569
Chapter 44 Necklift

• Skin
• Subcutaneous fat
Platysmal muscle and banding

• Anterior belly of digastric muscles
• Submandibular gland
• Suprahyoid fascia
• Subplatysmal fat pad
NONSURGICAL OPTIONS FOR NECK REJUVENATION

particularly in primary neck rejuvenation. It may be reserved for secondary corrections.
SENIOR AUTHOR TIP: Currently, injectables have a limited role as do nonsurgical
skin-tightening technologies.
BOTULINUM TOXIN
Use of has been suggested.10-12
May delay eventual surgical procedure
May be useful supplement to surgery and for postsurgical defects of persistent banding
Platysmal bands are injected with botulinum toxin.
Technique involves grasping bands and distracting them away from the neck.
Usual starting dose is 10-30 units in women, 10-40 units in men and women receive
2-12 injections per band and men receive 3-12 injections.
A total of approximately 40-100 units is used (Botox).
SENIOR AUTHOR TIP: The relatively large number of units required makes treatment
with toxins very expensive, especially in the long term.


Not to be used in older patients with passive platysmal banding

Complications include dysphagia (rare).
ULTRASOUND SYSTEM
A (Ulthera System, Merz) for improved skin laxity
and tightening of the lower face has been reported13:
Employs microfocused ultrasound to cause discrete focal heating of the dermis
Stimulates neocollagenesis and elastin remodeling

• At day 90, improvements reported by two thirds of patients and nearly 60% of
blinded reviews
• Better outcomes in patients with BMI <30

Technology requires judicial use in highly selected patients.

570
Part VII Facial Surgery
MEDICATION
In April 2015, the FDA approved an injectable drug (Kybella, Allergan) for treatment of
submental fullness (also known as a double chin):
given as an injection
A naturally occurring molecule in the body that aids in breakdown and absorption of
dietary fat
Indicated for improving the appearance of moderate to severe convexity or fullness
associated with submental fat in adults
CAUTION:


Causes injection site hematoma/bruising in most people (72% in clinical trials)
The formulation is nonhuman and nonanimal.
Causes destruction of fat cells when injected and cannot accumulate afterward

fullness
Sold in Canada under the name Belkyra

• Injections are 2 mg/cm2 per dose.
• A single treatment consists of up to a maximum of 50 injections.
• Each injection is 0.2 ml (up to a total of 10 ml), spaced 1 cm apart.

• In clinical trials, 68% responded to improvement with Kybella compared with
placebo, based on validated physician and patient measurements.
SURGICAL OPTIONS FOR NECK REJUVENATION
Several isolated and combination procedures are available, and each is best suited
according to anatomy and clinical presentation.
LIPOSUCTION

• Best for isolated, younger patients (generally 20-30 years of age)
• Normal skin and subcutaneous quality with good tone

• Not indicated for patients with subplastysmal fat (too deep for liposuction)
• Skin and subcutaneous pinch test is best assessment for selecting candidates.
• Should be no platysmal bands present at rest
• Isolated method, and can improve a short, fatty neck
• Can be combined with an open neck technique to ease subsequent surgical
dissection

• General anesthesia is suggested, although local may be acceptable with caution.
• Patient must be supine, with neck extended.
• Incisions are in submental neck and/or (usually) behind earlobes.