Essentials of Aesthetic Surgery

622
Part VII Facial Surgery
History of trauma
Allergies
Cocaine/drug use
Screen for (see Chapter 1)




8,9
• BDD occurs in secondary rhinoplasty consultations in about 12% of cases, and in
2%-7% of all primary cosmetic patient consultations.8,9

addressing it are essential.
may be warranted.
CAUTION:

SENIOR AUTHOR TIP: It is crucial to make sure that the secondary rhinoplasty
patient’s concerns are real and match what the surgeon sees in severity. Exaggerated

of 1-10, 10 being the best. Disparity in rating beyond 3-4 points should be considered

COMPREHENSIVE NASAL AND FACIAL ANALYSIS
As described in the primary rhinoplasty chapter (Chapter 45), with special attention to
common secondary deformities:

• Excessive narrowing or convexity

alignment or splinting of bones
after osteotomy
• Irregularities/stairstep deformity

sites
• Rocker deformity (Fig. 46-1)

placement of medial osteotomy,
resulting in a wide upper dorsum

• Asymmetry of dorsal aesthetic lines
• Nasal deviation
• Inverted-V deformity (Fig. 46-2)



inadequate infracture of the nasal bones
Rocker
deformity
Preferred
superior
oblique
osteotomy
Rocker deformity.

623
Chapter 46 Secondary Rhinoplasty
Spreader graft
Septum
Collapse of
midvault . . .
. . . with narrowing
of internal valve
Widening of
internal valve
Upper lateral
cartilage
After
Before
Inverted-V deformity.
• Saddle nose deformity (Fig. 46-3)

secondary to overresection

• Polly beak deformity11


dorsum, underresection of the cartilaginous nasal dorsum
and/or excessive scar formation in the dead space of the
supratip area (Fig. 46-4)
12,13
• Bulbous or boxy tip deformity
• Pinched nasal tip deformity

crural support
Saddle
nose deformity.

secondary rhinoplasty patient with a supratip deformity caused
by both an underprojected tip and an underresected caudal
dorsum.

624
Part VII Facial Surgery


intercartilaginous attachments
• Overrotation



cartilage
• Infratip lobule





14

• Widened base
• Alar rim collapse resulting in impaired external
valve competency (Fig. 46-5)

framework at initial surgery

resistance of alae to gentle compressive force

established or predisposition to alar collapse.
• Alar retraction


• Notching

of previous incisions, scarring, and failure to
place supporting grafts

• Retraction, deviation, and/or inferior bowing

• Airway occlusion most common underdiagnosed and untreated deformity in
secondary rhinoplasty

revision
2
• Septum


• Turbinates
• Internal nasal valve competency

15
SENIOR AUTHOR TIP: History of septoplasty does not necessarily mean depletion of

cartilage in the septum.
Alar rim collapse.
Alar rim collapse caused by
lack of lower lateral cartilage
support.
Alar
pinching

625
Chapter 46 Secondary Rhinoplasty
FORMULATE TREATMENT PLAN
Surgical approach
Augmentation or resection
Correction of distortion/displacement/irregularities
Need for removal of prosthetic materials
Source and quantity of structural graft materials
• Rib cartilage
• Ear cartilage
• Septal cartilage
• Iliac/calvarial bone
• Alloplastic materials (controversial)
Delay any secondary surgery for at least
• Ensure maximal resolution of edema, scar maturation, and improved vascularity.
12 days postoperatively only if gross

16
Share preoperative analysis and treatment plan with patients.
• Use visual imagery: Photos, computer imaging, or onlay tracing
• Increases communication to establish realistic expectations and surgical goals
INFORMED CONSENT
NONSURGICAL TREATMENT
Observation

SURGICAL TREATMENT
Open versus closed rhinoplasty
TECHNIQUE
Reconstruction of the nasal osteocartilaginous framework is the foundation for
successful secondary rhinoplasty.

SENIOR AUTHOR TIP: The most common reason for a residual caudal deviation after
the primary and even secondary septorhinoplasty is failure to eliminate the redundant
overlapping dislodged portion of the caudal anterior septum to allow repositioning the
septum in the midline.
DISPLACED/DEVIATED ANATOMIC STRUCTURES

• Secondary osteotomies to reposition
• Occasional dorsal rasping to smooth contour
• Postoperative external splint to maintain position

626
Part VII Facial Surgery


support
• Cartilage scoring to disrupt curving tendencies

• Spreader grafts: Unilateral or bilateral to maintain septal alignment, support upper
lateral cartilages, and maintain integrity of internal nasal valve
• Septoplasty
Tip
• Pinched tip

17
• Bulbous or boxy tip


framework changes to obtain the desired results.



• Deviated tip


alignment.



needed


14: Medial crural sutures

asymmetry, consider partial resection of middle crus

UNDERRESECTION

• Component dorsal reduction (see Chapter 43)

• Overfullness or polly beak deformity
• A must be present to
have an appreciable supratip break for desirable results.
18
• Increase tip projection

627
Chapter 46 Secondary Rhinoplasty
18,19 (Fig. 46-6)



Septal extension grafts. A, Septal extension graft type I. B, Septal extension graft type
II. C, Spreader graft. D, Batten graft. E, Direct septal extension graft.
Type I
Type II
A
B
6 mm
45
Paired extended spreader grafts
C
Paired batten grafts
D
Direct extension graft
E





20
21,22
• Reduce dorsal septum further if the problem is an overprojected caudal dorsum.
• Excessive scar tissue in the supratip area may be excised conservatively, keeping in
mind potential vascular compromise.
• If the skin in the supratip area is thick, a supratip suture from the subcutaneous

11
Tip
• Persistent bulbous tip
• Cephalic trim
• Tip grafts

628
Part VII Facial Surgery
• Tip suturing



• Persistent hanging alae

• Marginal excision of soft tissue (controversial)

• Excessive bulk
• Debulking of tip, supratip, or alar soft tissues
SENIOR AUTHOR TIP: A columellar strut is used when the columella is short. A tip graft

to restore tip projection.
CAUTION:

OVERRESECTION

• Saddle nose or inverted-V deformity
• Minor overresection requiring <3 mm augmentation for correction

• Moderate to major overresection: Saddle nose or inverted-V deformity
• Dorsal augmentation



7


• Revision nasal osteotomies

• Internal nasal valve collapse and obstruction


Tip
• Short nose secondary to tip overrotation


18

• Overzealous cephalic resection of the lateral crus or excessive tip suturing
• Alar retraction


23 (Fig. 46-7)

629
Chapter 46 Secondary Rhinoplasty
Alar contour graft. A key element is proper placement and shape of the alar contour
graft immediately above the alar rim and spanning the alar notched area.
Alar spreader graft or lateral crural
strut graft17


is indicated for reconstruction of this
multilayer defect.


lengthen nasal sidewall as described by
Gruber et al
24 (Fig. 46-8)
15
• External nasal valve collapse: Secondary to weak


lateral crural strut graft
• Notching

or prevent notching
Intercartilaginous
graft. Insertion of a septal graft
into the gap between the upper
lateral cartilage and the lateral
crus element. The cephalic end
of it is sutured end-to-end to
the upper lateral cartilage. The
caudal end slips under (deep
to) the edge of the lateral crus
element.

630
Part VII Facial Surgery
SENIOR AUTHOR TIP: It is crucial to eliminate the dead space after removal of any

CONTOUR IRREGULARITIES
Rasp mild bony deformities
Secondary osteotomies for severe bony asymmetries
Remove or replace displaced or partially resorbed tip or other visible grafts.
• Onlay crushed cartilage for mild contour irregularities
Mild irregularities can be corrected with injection of hyaluronic acid or calcium


hyaluronidase if soft tissue ischemia occurs after injection.
25

irregularities in patients with thin skin.26
PROSTHETIC COMPLICATIONS

27

• Correction: Removal of implant and surrounding capsule (as much as possible
without damaging soft tissue envelope), correction of any untreated underlying
nasal deviation, and use of autologous grafting techniques

• Antibiotic therapy for cellulitis and early removal of implant if infection persists

• Commonly caused by implant extension into tip with no intervening layer between
implant and overlying soft tissue envelope
• Correction: Removal of implant and augmentation of tip with autologous tissue only

the prosthetic material.
• Removal of the implant will uncover substantial underlying cartilage and bony
atrophy.
Amount of autologous graft material necessary for correction of deformity should not
be underestimated.27
GRAFTS IN SECONDARY RHINOPLASTY
are preferred over alloplastic material because of the lower risk of
infection or extrusion.
To reconstruct the nasal osteocartilaginous framework, desirable grafts are those with
and
for autologous grafts in secondary rhinoplasty:
• Iliac bone graft

631
Chapter 46 Secondary Rhinoplasty
• Calvarial bone graft

• Auricular cartilage


28
• Septal cartilage

site morbidity, and harvest does not require a separate incision site.

• Rib cartilage
29


or
length and shape of cartilaginous portion

30


inframammary fold in female patients
DISADVANTAGES
Additional donor site incision
• In women the incision can be placed under the breast to be less conspicuous.
Postoperative pain
• Often relieved by injecting long-lasting local anesthetic into the donor site at the
end of the operation
• Some advocate using pain pumps.
Risk of pneumothorax
• Usually injury to parietal pleura only, not lung parenchyma
• If detected, place red rubber catheter into cavity, close incision in layers, and
remove catheter with suction while providing positive pressure ventilation.

Potential to warp
• K-wires may be placed through the graft to prevent distortion.

• Some advocate a limited CT scan to evaluate cartilage availability in these patients.


may be required.

Care is similar to that of primary rhinoplasty, with a few exceptions:
may take much


may be treated with in the subcutaneous
tissues, avoiding the dermis.

632
Part VII Facial Surgery
SURGICAL COMPLICATIONS
MAJOR
Devascularization of nasal tissue
Infection
Graft or implant resorption, loss, deviation, or extrusion
Airway obstruction secondary to internal or external nasal valve collapse
MINOR
Contour irregularity
Soft tissue scarring
INCIDENCE
Higher incidence of complications with increasing number of revision surgeries
COMMON TREATMENTS
Implant removal if persistent infection
• Autologous augmentation
After soft tissue recovery from surgery (up to a year), consider revision surgery using
previously described techniques.
• Counsel patients to set appropriate expectations.
• Use most supportive autologous cartilage available: rib cartilage.
TOP TAKEAWAYS

The key requirements for successful secondary rhinoplasty are adequate
preoperative evaluation and reconstruction of the nasal osseocartilaginous
framework.

Screen for BDD and avoid reoperating on these patients.

Delay secondary surgery for at least 12 months from the last surgery.

Five surgical obstacles in secondary rhinoplasty are scarring, framework
disruption, limited graft donor sites, excessively thin or thick skin, and
compromised vascularity.

External or open rhinoplasty is the preferred approach to secondary rhinoplasty.

Rib cartilage graft is the preferred donor material for secondary rhinoplasty.

Postoperatively, resolution of edema may take much longer than after a primary
rhinoplasty. Counsel patients accordingly.
REFERENCES
1. Constantian MB. Four common anatomic variants that predispose to unfavorable rhino-
plasty results: a study based on 150 consecutive secondary rhinoplasties. Plast Reconstr Surg
105:316; discussion 332, 2005.

maneuvers to correct them: a guide to reducing the revision rhinoplasty rate. Plast Reconstr
Surg 132:769, 2013.
3. Guyuron B, Bokhari F. Patient satisfaction following rhinoplasty. Aesthetic Plast Surg 20:153,
1996.

633
Chapter 46 Secondary Rhinoplasty
4. Gruber RP, Roberts C, Schooler W, et al. Preventing postsurgical dissatisfaction syndrome after
rhinoplasty with propranolol: a pilot study. Plast Reconstr Surg 123:1072, 2009.
5. Gubisch W, Eichhorn-Sens J. Overresection of the lower lateral cartilages: a common conceptual
mistake with functional and aesthetic consequences. Aesthetic Plast Surg 33:6, 2009.
6. Byrd HS, Constantian MB, Guyuron B, et al. Revision rhinoplasty. Aesthet Surg J 27:175, 2007.
7. Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg 80:161,
1987.
8. Constantian MB. Identify BDD patients prior to rhinoplasty. Cosmetic Surgery Times, June
2001.
9. Constantian MB. Emotional matters. Presented at the Rhinoplasty Symposium at the Annual
Meeting of the American Society for Aesthetic Plastic Surgery, New York, April 2007.
10. Sarwer DB, Wadden TA, Pertschuk MJ, et al. Body image dissatisfaction and body dysmorphic
disorder in 100 cosmetic surgery patients. Plast Reconstr Surg 101:1644, 1998.

2000.
12. Constantian MB. The boxy nasal tip, the ball tip, and alar cartilage malposition: variations on a
theme—a study in 200 consecutive primary and secondary rhinoplasty patients. Plast Reconstr
Surg 116:268, 2005.
13. Constantian MB. The two essential elements for planning tip surgery in primary and secondary
rhinoplasty: observations based on review of 100 consecutive patients. Plast Reconstr Surg
114:1571; discussion 1582, 2004.
-
malities and correction using an algorithmic approach. Plast Reconstr Surg 130:1148, 2012.
15. Guyuron B. Nasal osteotomy and airway changes. Plast Reconstr Surg 102:856, 1998.
16. Gruber RP. Early surgical intervention after rhinoplasty. Aesthet Surg J 21:549, 2001.
17. Gunter JP, Rohrich RJ. Correction of the pinched nasal tip with alar spreader grafts. Plast Re-
constr Surg 90:821, 1992.
18. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a method of controlling tip projec-
tion shape. Plast Reconstr Surg 100:999, 1997.
19. Ha RY, Byrd HS. Septal extension grafts revisited: 6-year experience in controlling nasal tip
projection and shape. Plast Reconstr Surg 112:1929, 2003.
20. Sheen JH. Tip graft: a 20-year retrospective. Plast Reconstr Surg 91:48, 1993.

22. Peck GC. The onlay graft for nasal tip projection. Plast Reconstr Surg 71:27, 1983.
23. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim
deformities in rhinoplasty. Plast Reconstr Surg 109:2495; discussion 2506, 2002.
24. Gruber RP, Kryger G, Chang D. The intercartilaginous graft for actual and potential alar retrac-
tion. Plast Reconstr Surg 121:288e, 2008.

2014.
26. Gryskiewicz JM, Rohrich RJ, Reagan BJ. The use of AlloDerm for the correction of nasal contour
deformities. Plast Reconstr Surg 107:561; discussion 571, 2001.
27. Won TB, Jin H. Revision rhinoplasty in Asians. Ann Plast Surg 65:379, 2010.

Otolaryngol 32:547, 2011.

Plast Reconstr Surg 121:1442, 2008.
30. Cochran CS, Gunter JP. Secondary rhinoplasty and the use of autogenous rib cartilage grafts.
Clin Plast Surg 37:371, 2010.

634
Rhinoplasty is becoming increasingly more common in nonwhite patients worldwide.
Most patients desire an improvement in their appearance, with preservation of certain
ethnic features.
• This is accomplished through a highly individualized approach involving recognition
of anatomic variations, familiarity with cultural aesthetics, an understanding of
patients’ preferences.

• Nasofacial harmony
• Symmetry of the brow-tip aesthetic line
• Appropriate dorsal line shape


• Functional breathing
PREOPERATIVE EVALUATION
Patient consultation with discussion of aesthetic preferences and cultural concerns.
Assess patient expectations and preferences, and determine whether the goal is for
versus

• Trauma or prior nasal or sinus surgery
• Previous alloplastic implant

• Functional complaints
Physical examination
• Palpation of cartilaginous and bony structure, dynamic inspiration, endoscopy
Standardized photography (frontal, lateral, three-quarter, basal views)1 (see Chapter 3)
Three-dimensional stereophotogrammetry facilitates objective comparison of
preoperative and postoperative results.
Digital image-morphing software2,3 allows direct communication of proposed changes
to all parameters (dorsal height, nasal length, tip rotation/projection, and base width).

635
Chapter 47 Ethnic Rhinoplasty
TIP: The use of a computer-imaging program can demonstrate potential changes
preoperatively and aid in communication between patients and surgeons regarding
expectations and possible outcomes.4
Facial analysis to assess for variation from the nonwhite aesthetic “norm.” Similar

• Recognition of each facial feature and how it relates to the nose is critical to achieve
nasofacial harmony.







INFORMED CONSENT


Possibility of banking unused cartilage behind the ear
Alternatives to surgery
Potential complications, including donor site morbidity and need for further surgery
PREPARATION
ANATOMIC VARIATIONS
Skin is usually more and relatively in ethnic patients.
Fibrofatty layer is also thicker (2-4 mm) and more prominent over the lower lateral


SENIOR AUTHOR TIP: Thick skin often requires making the nose larger (more

Thinning of the skin and soft tissue envelope is often necessary in ethnic patients. Fat
is evenly removed from the undersurface while taking care to preserve the subdermal
plexus.
Alar base usually has an increased base width with insertion lateral to the medial
lateral to
the alar-facial groove.
A wide spectrum of dorsal morphology exists (low height in black and Asian nose,
hump in Middle Eastern nose). Nasal bone length can also vary widely (Table 47-1).

636
Part VII Facial Surgery
TIP:
healing. This highlights the importance in creating strong support for long-term results.



Black nose
Short nasal bones
Wide nose

Wide bimalar distance
Horizontally oriented nostrils, wide base


Asian nose
Thick sebaceous skin

Weak lower lateral cartilage


Wide nasal base
Retracted columella
Middle Eastern nose



Hanging columella
Septal deviation
Hispanic nose
(types described
by Daniel
10)
Normal radix height, high bridge, normal tip projection

normal bridge, dependent tip
Broad base, thick skin, wide tip


GRAFTING MATERIAL see C
Nasal septum, auricular cartilage
Costal cartilage11 is stronger; therefore it can be cut thinner with less bulk in the nose. It
has a lower vascular demand making it less likely to resorb. Surgeons are able to harvest
a larger volume of material. Pain at donor site is decreased (compared to the ear)
because less cautery is used.
TIP: Disadvantages to costal cartilage harvest (increased operative time, warping, and
donor site morbidity) are minimized with experience.
Bone grafts include iliac bone and split calvarial grafts.
Irradiated rib may also be an option.

637
Chapter 47 Ethnic Rhinoplasty
Types of allografts include: Silicone, ePTFE, and porous polyethylene.









TIP:
patient during the initial consultation.
TECHNIQUE
PREOPERATIVE PLANNING
General anesthesia with oral endotracheal intubation for airway protection from blood
and secretions; also allows costal cartilage harvest if indicated

and draping. This allows ample time for vasoconstriction. Injection also creates

amount of available bony and septal cartilage by needle palpation at this time.

or auricular cartilage to be harvested. The entire face and intranasal area are prepared
with dilute povidone-iodine, and the patient is draped to maintain sterility throughout
the procedure. If cartilage is to be harvested, surgeons must change gloves to prevent
contamination.
OPENING THE NOSE
Columellar (inverted-V, stairstep) incision
made with a No. 11 blade. If deprojection
is planned, incision is placed closer to tip
lobule (below top of nostrils) (Fig. 47-1).
For patients requiring increased projection,
incision should be slightly below mid-
columellar level and not close to the upper
lip.
Bilateral marginal incisions made with a
No. 15 blade and connected to the
extension of the columellar incision
Tip exposure with sharp dissection
(Converse scissors).

Three-point retraction with sharp two-prong
retractors is used to aid in dissection over the lower lateral cartilages.
Dorsal exposure and elevation of periosteum over the nasal bones using a Joseph
elevator. The extent depends on plan for augmentation/reduction/osteotomies.
Varying inverted-V columellar
incision. Placed closer than normal to the
tip lobule as the surgeon plans to deproject
the nose.

638
Part VII Facial Surgery
Septal exposure can be through a separate Killian incision or through lateral retraction

important.
Septal cartilage harvested after the upper third of the nose is addressed to prevent
is preserved to ensure
adequate support.
SENIOR AUTHOR TIP: Sharp dissection while opening the nose helps to preserve the
subdermal plexus and prevent excessive swelling that occurs with tearing of the tissue
during blunt dissection.
By limiting blunt dissection over the nasal dorsum, a tight subperiosteal pocket is
preserved in anticipation of a secure dorsal augmentation graft.
Once the nose is open, the surgeon should evaluate the structural and contour

MANAGEMENT OF THE BONY VAULT
Osteotomies are used to narrow the dorsum or to correct deviations or dorsal hump.4
They are performed medial to lateral. Osteotomies should be avoided if major dorsal

appearance and narrow-to-narrow look of the dorsum.
MANAGEMENT OF THE MIDDLE THIRD
Spreader grafts increase the area of the internal nasal valve and provide foundation to
prevent saddling and postoperative rotation/shortening. They also work to lengthen a
short nose or retracted columella. Unilateral placement of a spreader graft is used to
straighten the nose.
Extended spreader grafts are typically 20-40 mm long, 4-6 mm wide, and 1-3 mm


They are placed between the divided upper lateral cartilages and the septum. They can
also go in submucosal pockets in cases where the midvault is not opened. This helps to
increase the internal nasal valve angle.
To correct a concave midvault sidewall, surgeons may use multiple spreader grafts,
batten grafts, or an onlay graft.
TIP: If curvature of the proposed spreader graft is a concern, place the concave sides
toward the septum to prevent future asymmetry.
Upper lateral cartilages must be secured to septum to prevent inverted-V deformity
and pinching of the internal valve. Placement of a clocking suture can adjust for tilt in a
crooked nose.

639
Chapter 47 Ethnic Rhinoplasty
MANAGEMENT OF THE NASAL BASE
Symmetry is evaluated from the head of the bed.
The caudal septum is reset to midline with swinging-door maneuver or by shifting the
nasal spine. This can be achieved with a 5 mm straight osteotome placed at a slight angle
toward desired position. Once engaged, the osteotome acts as a lever to shift the spine.

Monitoring for change in dorsal line and projection after this maneuver is essential.

or a caudal septal extension graft (Fig. 47-2, ).
• Caudal septal extension grafts increase tip projection to stretch amorphous skin and
lengthen the short nose/retracted columella.

12,13 extended
spreader grafts, slivers of cartilage, or 0.25 mm perforated PDS plates (Fig. 47-2, B
and C).
• Caudal septal replacement grafts also increase tip projection to stretch amorphous
skin and often use less cartilage than when attempting to straighten a severely

14 (Fig. 47-2, D).
A
B
C
D
Caudal septal extension graft. B, Graft secured with extended spreader grafts
and slivers of cartilage. C, Graft secured with 0.25 mm perforated PDS plates. D, Caudal septal
replacement graft.
TIP: Caudal septal extension/replacement grafts are the only cartilage grafts in
structure rhinoplasty that must be straight. Septal cartilage may be preferred over
costal cartilage in this case.
TIP: Caudal septal extension grafts or caudal septal replacement grafts are preferred,
because they minimize postoperative loss of tip projection and help to control rotation
and length.

640
Part VII Facial Surgery
DORSAL GRAFTING
The dictates grafting material used. Septal cartilage is used

is less favorable because of contour irregularities and potential to resorb.
Serial carving with repeated soaking and drying will allow curvature to declare itself.
TIP:
the cartilage to warp. Grafts should be placed concave side down (Fig. 47-3). Smoothing
all edges of the graft and tapering cartilage for seamless transition at radix and supratip


performed after the tip position has been
set. A tight pocket at the cephalic edge of
the dissection cavity (over nasal dorsum)
is created. The cortical bone of the nasal
dorsum is “roughened” while a segment
of perichondrium is interposed between
it and the cartilage graft to create an
ossifying scar, accomplished through one
of two methods:
• To roughen the cortical bone and
expose cancellous bone, 8-10 vertical
perforations are made in the nasal bones
using a 2 mm straight osteotome or the
dorsum is rasped slightly.
5-0 PDS suture is placed bilaterally through
the lower lateral aspect of the graft to the
upper lateral cartilage as the second and

TIP CONTOURING
The medial crura are secured to the septal
replacement or extension graft with a
4-0 plain gut suture on a straight (SC-1)
needle. Several 5-0 PDS sutures are used to

crura to the septal extension graft. The
medial crura are widely dissected to release
and advance anteriorly on the caudal septal
extension graft to create a more obtuse
nasolabial angle and increase nasal tip
projection.
A shield graft is used to increase projection
in thick-skinned patients for appropriate

augments the infratip and changes
projection. Soft tissue can be placed over

and prevent visibility (Fig. 47-4).
Dorsal graft orientation.
Placed with concave side down. If concave
side is up, warping can occur resulting in
fullness in the radix and supratip.
A
B

shield graft, sutured in place. B, Perichon-

641
Chapter 47 Ethnic Rhinoplasty
Tip onlay grafts are used when no change to the infratip is needed. Change in position

is preferred to prevent tip bossae.

prevent visibility of the shield graft. The surgeon bevels the cartilage at 45 degrees and
attaches it to the posterior edge of the shield graft.
Tip bulbosity can be corrected through alteration of the dome and the use of lateral
crural strut grafts.

further narrowing.

from the undersurface of lateral crura and creates a pocket extending toward the
piriform aperture in same vector as the lateral crura. The medial edge of graft is
beveled at 45 degrees and tucked into the dome apex. The graft is placed along
cephalic edge of lower lateral cartilage. The concave side faces the airway to prevent
nasal obstruction as a result of delayed warping. Graft dimensions are usually
25-30 mm by 4-5 mm by 1-2 mm.
Malpositioned lateral crura and alar retraction are corrected through repositioning of
asymmetrical or cephalically oriented lateral crura16 (Fig. 47-5). Dissection of the lateral
crura is the same as that mentioned previously, but the surgeon divides the lateral
aspect of lower lateral cartilage at the areas of the sesamoid cartilage. Pockets are
created in the most favorable vector for the patient.
A
B
B, New, favorable orientation.
The external valve is stabilized with alar batten grafts and alar rim grafts.
Batten grafts strengthen the sidewall, especially if the lateral crura are repositioned.
They also serve to improve asymmetries in the brow-tip aesthetic line.
Alar rim grafts are used to smooth the transition between the tip lobule and alar
lobule. They prevent valve collapse and pinching of the tip over time. They are placed
by creating a small pocket immediately caudal to the marginal incision. The surgeon
should taper the ends of the graft to prevent visibility (Fig. 47-6).

642
Part VII Facial Surgery
Alar rim grafts before placement. B,
the marginal incision.
A
B
TIP: An individualized approach is crucial to tip management in ethnic patients.

convex lower lateral cartilages in Middle Eastern patients but may worsen the
appearance in Asian patients with weak lower lateral cartilages and hanging alar lobules.
CLOSURE
A single subcuticular 6-0 Monocryl suture in the midline of the collumelar incision is
placed to relieve tension and align the skin/soft tissue envelope. This is followed by
interrupted 7-0 nylon vertical mattress suture in at least seven places along the incision
for slight eversion of the skin edges. The skin edge is further approximated with simple
interrupted 6-0 fast-absorbing gut suture.
TIP: In darker-skinned patients, the use of absorbable sutures will result in prolonged
erythema and possible suture tracking.
Marginal incisions are reapproximated with interrupted 5-0 chromic gut sutures.
Ensuring the suture does not alter the alar margin is critical. If notching occurs, the


straight septal needle in running mattress fashion.
Radiopaque 0.25 mm septal splints are placed if turbinate work is performed to prevent
synechiae formation.
17 are placed if lateral crural strut grafts were used to ensure
redraping of vestibular mucosa. They are fashioned from 0.25 mm bivalve splints.
Tape is applied to the external nose before placement of a cast to protect skin.
SENIOR AUTHOR TIP: I place a thermoplastic splint. This allows placement of adhesive
remover through holes before removal.

643
Chapter 47 Ethnic Rhinoplasty
BASE REDUCTIONS
Performed after closure is complete. This provides the greatest potential to leave
irreversible deformity if not done correctly.
Types include internal alar base reduction used for treatment of the overlying large
nostril and excessive nostril sill. External alar base reduction is needed in patients with


suture is placed as an adjunctive maneuver in patients with persistent alar base width.

• Plan incision slightly adjacent to alar/facial or alar/vestibular junction.
• Forego injecting local anesthetic, because it may deform anatomy.
• Avoid all cautery.
• Slightly bevel incisions to promote eversion of skin edges.
• Close incisions meticulously.
TIP: If performing a base reduction is questionable, the surgeon should defer this
irreversible technique. The decision to forgo base reduction and possibly return at a
later date should not be faulted.
POSTOPERATIVE CARE
Oral second-generation cephalosporin is prescribed for 1 week and antibiotic soaks for
2 weeks postoperatively.
Pain control is primarily with acetaminophen with narcotic prescription given for
breakthrough pain. Patients are instructed to avoid aspirin- and ibuprofen-containing
medications to decrease risk of epistaxis.
Cast, splints, tape, and columellar sutures are removed about 1 week postoperatively. If
base reduction is performed, sutures remain in place until postoperative day 10-14.
Discharge instructions include: maintaining head elevation, consuming a low salt
diet, using incentive spirometry if costal cartilage was harvested, and refraining from
strenuous activity and heavy lifting for 1 month postoperatively.

future change and to determine whether further intervention is indicated.
COMPLICATIONS
Infection is managed aggressively to prevent graft resorption. These patients usually
return to the operating room for washout and placement of drains. Broad-spectrum
antibiotic coverage is crucial.
Scarring is a potential complication. History of keloid formation should be determined.
They are less likely to form on the face and are managed with massage and steroids.

This highlights the importance of the dermal suture at columellar incision.
Visible grafts and warping should be managed during the initial procedure. Surgeons
can determine the direction of warping with serial carving of the graft material and
by allowing cartilage to soak and dry several times throughout the case for natural
curvature to declare itself. Surgeons should be familiar with and
to minimize future warping.
Asymmetry can occur after base reduction.

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Part VII Facial Surgery
TOP TAKEAWAYS


successful ethnic rhinoplasty.

Patients’ cosmetic concerns should be addressed while maintaining racial
congruencies, if desired.

Strong tip support mechanisms are established to increase projection while
controlling rotation and length.

Tip contouring techniques in ethnic patients vary from those used in whites.

Costal cartilage harvest is often required for appropriate augmentation of the
dorsum and tip.
REFERENCES
1. Afrooz PN, Amirlak B. Digital imaging and standardized photography. In Rohrich RJ, Adams WP
Jr, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters, ed 3. New York: Thieme
Publishers, 2014.
2. Dixon TK, Caughlin BP, Manaretto N, Toriumi DM. Three-dimensional evaluation of unilateral
cleft rhinoplasty results. Facial Plast Surg 29:106, 2013.
3. Toriumi DM, Dixon TK. Assessment of rhinoplasty techniques by overlay of before-and-after
3D images. Facial Plast Surg Clin North Am 19:711, 2011.
4. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg 37:335, 2010.

111:1322; discussion 1340, 2013.
6. Kontis TC, Papel ID. Rhinoplasty on the African-American nose. Aesthetic Plast Surg 26(Suppl
1):S12, 2002.
7. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg 123:1343,
2009.
8. Bizrah MB. Rhinoplasty for Middle Eastern patients. Facial Plast Surg Clin North Am 10:381,
2002.
9. Beheri GE. Rhinoplasty in Egyptians. Aesthetic Plast Surg 8:145, 1984.
10. Daniel RK. Hispanic rhinoplasty in the United States, with emphasis on the Mexican American
nose. Plast Reconstr Surg 112:244; discussion 257, 2003.
11. Toriumi DM, Asher SA. Primary rhinoplasty techniques: use of costal cartilage. In Cobo R, ed.
Ethnic Considerations in Facial Plastic Surgery. New York: Thieme Publishers, 2015.
12. Park JH, Jin HR. Use of autologous costal cartilage in Asian rhinoplasty. Plast Reconstr Surg
130:1338, 2013.
-
plications. Arch Facial Plast Surg 9:285, 2007.
14. Toriumi DM. Subtotal septal reconstruction: an update. Facial Plast Surg 29:492, 2013.
15. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 8:42, 2006.
-
plasty. Plast Reconstr Surg 99:943; discussion 953, 1997.

28:218, 2012.

645
DEFINITION OF PROBLEM
THE AGING LIP
Collagen framework loosens, dermis thins, orbicularis oris thins and loses curve,
redistribution of volume, cumulative solar damage
Contrary to previous teaching, there is a loss of volume but
1,2
Resultant stigmata


• Decreased pout
• Cheiloptosis (elongated cutaneous upper lip)
• Inverted vermilion (results in thin vermilion)
• Minimal dental show
• Attenuation and loss of Cupid’s bow curvature
• Downward tilt of oral commissures
• Perioral wrinkle
Congenital variations
• Hypoplastic lip, long cutaneous upper lip, short cutaneous upper lip with excessive
incisor or gum show, lack of ideal vermilion contours, asymmetries
GOALS OF TREATMENT
RESTORATION OR CREATION OF AESTHETIC LIP CHARACTERISTICS
Projection of lips (upper lip in line with or in front of lower), central pout
Shape:
vermilion border3
Upper cutaneous lip/upper vermilion ratio <3 (ideal 1.1-2.3), upper/lower
vermilion ratio of 1:1.6 (see Fig. 48-1)
INDICATIONS AND CONTRAINDICATIONS TO TREATMENT
INDICATIONS
Enhance lip volume, shape, balance
• Improve self-image
CONTRAINDICATIONS
Body dysmorphic disorder
Emotional/psychological instability
Unrealistic expectations
Patient demands guarantees
Pregnant or lactating

646
Part VII Facial Surgery
Immunosuppression
Bleeding disorders
PREOPERATIVE EVALUATION
PATIENT HISTORY
Assess patient desires and expectations.
• Ask patients to provide photos of their lips from when they were happy with them.
Has the patient undergone prior lip augmentation?


History of:
• Bleeding disorders or immunosuppression
• Allergies or history of anaphylaxis

• Hypersensitivities or excessive scarring with previous allogeneics
• Counsel patients to stop taking aspirin, NSAIDs, vitamin E, herbal supplements, and
other anticoagulants or antiplatelets (if possible) at least 2 weeks before procedure
to minimize bleeding and swelling.
• Pregnancy or lactation
• Smoking

permanent cessation is best.


after procedure)
PHYSICAL EXAMINATION
Patient positioning: Upright and in repose
Exclude a current perioral infection.
Measure lip dimensions.
4
Frontal view (Fig. 48-1)
• The length of the lips should equal
the distance from one medial corneal
limbus to the other.
• Ratio of upper/lower vermilion show
should be 1:1.6 (golden ratio) (see
Chapter 2).
• Upper cutaneous lip/upper vermilion
ratio <3 (ideal 1.1-2.3)
• Interpupillary line and stomion
(commissural line) should be parallel
and horizontal.
Aging leads to downward tilt of
commissures (frown in repose).
• Subnasale-stomion distance should be
half of stomion-menton distance.
1
1.6
Subnasale
Stomion
Menton
1x
2x
Frontal lip view.

647
Chapter 48


open bite, or muscular dystrophy.
• With lips slightly parted, incisor show should be about 2 mm.
• When smiling, gum show should be minimal.

(necessitating gingivectomy), hypoplastic upper lip, or overactive muscles.
• Cupid’s bow forms a “gentle M” shape, the stomion forms a “lazy M,” and the lower
lip vermilion forms a “gentle W” with its peaks 2-3 mm lateral to the corresponding
M peaks of the upper lip.
• Three thickenings of the upper lip: A central tubercle and lateral thickenings, which
are separated from the central tubercle by arches
• Two paramedian thickenings of the lower lip, which correspond to and contour to
the upper arches
5 (Fig. 48-2)
• Nasolabial angle should be 85-105 degrees.
• Slight eversion at the vermilion border with a
projected “ski jump” transition
3

subnasale and pogonion.
• Upper lip either in vertical plane with lower lip,
or slightly anterior (~ 2 mm)

pogonion
• Upper lip, lower lip, and chin should touch an
imaginary line (Riedel line).
• Chin should be within 1 mm of a vertical
line drawn down from lower lip vermilion-
cutaneous border (Frankfort plane).
• Mid-nares to chin (Steiner line) should touch
upper lip.

Note asymmetries and contour irregularities.
Evaluate perioral region.
• Assess vertical lip lines, nasolabial fold, labiomandibular fold (marionette lines), and
prejowl sulcus.
• Assess quality of rhytids (dynamic versus static).
• Consider adjuvants for perioral rejuvenation (see Chapter 41) such as botulinum

Assess structural/bony loss, dentition, and soft tissue volume loss.


improvement (see Chapter 3).
PATIENT COUNSELING AND OPERATIVE PLANNING
Outline aesthetic goals.
Discuss various procedures and options (discussed later in the chapter).
• There are many approaches to augmenting and enhancing the lips.
• Whenever many techniques to solve a problem exist, a universally optimal solution
is probably not available.

The red line depicts the Riedel line,
connecting upper lip, lower lip, and
chin.

648
Part VII Facial Surgery
• Each option has advantages and disadvantages in various situations.
• Develop an individualized plan with the patient.
Manage expectations, emphasizing realistic aesthetic outcomes.
If a surgical intervention will be performed, inform patient of the risk of hypertrophic or
depressed scarring.
Patients are often concerned about pain.
• Explain what they can expect during the procedure and the plan to minimize pain.
Explain the postoperative plan.
AUGMENTATION USING INJECTABLE FILLERS
ADVANTAGES
Minimally invasive
Reversible

before committing to an intermediate-duration or permanent treatment.
DISADVANTAGES
Good for volume needs, but not high-volume needs
Results are suboptimal in the aged, inelastic, ptotic lip.
Does not correct an elongated upper cutaneous lip.
• Can produce “duck bill” or “trout pout” lips in such patients
Should not be used in patients with a history of anaphylaxis, multiple severe allergies,
or allergies to bacterial proteins
EXAMPLES

Bovine

(Cosmoderm and Cosmoplast, Allergan): No hypersensitivity reactions


• No skin testing is required, but do not use it in patients with a history of
anaphylactic or recurrent allergic reactions.
It has been reported to cause nodule formation.
Collagen injectables, in general, have a short duration (3-6 months).
Because of low viscosity, they are good for and the


Short duration (3 months)
Rarely used



Native human HA lasts only days, so synthesized products are for
increased stability and longevity.

649
Chapter 48
Rare complications

Softer gels (Juvéderm) might be better for the lips, where the skin is thin.


High viscosity and elasticity

Used for and
Some experts use it along the vermilion
border; however, many experts say to avoid its
use in lips.
• The lips are highly dynamic and can cause

• This leads to lumps and nodules that are
hard to treat when long-term or permanent

SENIOR AUTHOR TIP: Do not inject Radiesse into the lip vermilion. Fig. 48-3 shows
an example of the white clumps that often form after injection. These take a long time

far better alternatives.
L
Injected into deep dermis and subcutaneous space


Requires multiple treatments to achieve desired augmentation



Permanent
Contraindicated in thin skin


PMMA microspheres suspended in 3.5% bovine collagen
• Therefore skin testing for sensitivity is needed before use.
Bovine collagen absorbed in 1-3 months, but the PMMA microspheres are surrounded

Permanent
Can form nodules or granulomas
• However, newer preparations have lower complication rates, ~ 0.01%.
Successfully used in nasolabial fold, radial lip lines, and white roll
Proper injection technique is vital.
• Injected into deep dermis using linear tunneling method with constant pressure
through a 26-gauge needle
Visible nodules after
Radiesse injection into the lip vermilion.

650
Part VII Facial Surgery
Not intended for use in the vermilion lip
• Many experts warn that it should not be used in this location because of a high risk
of lump and nodule formation.
INFORMED CONSENT
Needle marking, swelling, redness, ecchymosis, pain, itching

• These are usually self-limited.
Asymmetries and contour irregularities
Undercorrection or overcorrection
Complications (as listed later in the chapter)
EQUIPMENT
Good overhead lighting
Very small needle, 30- to 32-gauge for low-viscosity products, or slightly larger
(~ 27-gauge) for high-viscosity products
Anesthetic


TECHNIQUE
The technique for HA or collagen injections is described here.
Perform postprocedure massage (pinch and roll) if blending is needed.

There are several viable approaches.
Apply ice or a cold compress to the site before injection.
Must apply 45-60 minutes before injection


• Inject along the vermilion border and areas to be augmented.
• Swelling should dissipate after 10 minutes.


0.5 ml of 1% lidocaine can be injected along the upper and 0.5 ml along the
lower gingival sulci.
• Alternatively, topical benzocaine can be applied along the mucosal sulci using either
a cotton-tipped applicator or a 2 × 2 gauze.
• Because of the rapid absorption through mucosal surfaces, the anesthetic only

Inject ~ 0.25 ml at both the infraorbital and the mental foramina.
• This can prevent normal motion of the lips, compromising aesthetic outcome.
• Some think that this allows too-aggressive injections.


makeup, prepare the injection site with antiseptic, and do not breach the mucosa.

651
Chapter 48

Anterograde linear threading, retrograde linear threading, radial
fanning, serial puncture, and cross-hatching9 (Fig. 48-4).
A
B
C
D
Injection techniques. A,
is advanced (anterograde) or withdrawn (retrograde). B, Serial puncture. Filler is deposited in
multiple, adjacent injections. C, Radial fanning. Filler is injected by linear threading but is redirected
and advanced in a new radial direction before the needle is completely withdrawn. D, Cross-
hatching. Filler is injected by linear threading along multiple parallel and perpendicular passes.
• Anterograde and retrograde linear threading and serial puncture are the techniques
most used for lip augmentation.

advancing needle.

The needle is advanced to the desired location, then,

The needle is inserted, and a small depot is deposited until
resistance is met. The needle is withdrawn and then reinserted a short distance
farther, and another small depot is deposited.



Inject vermilion lip, vermilion border, and philtral columns as needed for individualized
enhancement, seeking to accentuate patient’s anatomy.
• A slow (<0.3 ml/minute) and gentle injection technique causes less pain. It also

652
Part VII Facial Surgery

• Be conservative with the philtral columns. Minor alterations are visible.
• Preserve the Cupid’s bow. Small alterations are noticeable and can be distorting.
• Avoid creating fullness above upper vermilion. This blunts the vermilion border and

• Accentuate the three upper lip and two lower lip thickenings.

Taking a conservative approach, undercorrecting initially with gradual shaping over
time, will lead to a more natural look.

Submucosal, just above orbicularis oris
Needle in potential space between red and white lip


Mid-dermis9 (Fig. 48-5)
Injection pattern. A, Young lips. B, Aging lips.
Nasolabial
fold
Vermilion
border
A
Nasal base
Philtral column
B
Inject caudal half of philtrum,

vermilion lips.
Inject full philtrum and across
entire vermilion lips.
Some vermilion eversion and shortening of
the cutaneous upper lip can be obtained by
injecting submucosally in the wet vermilion.
If using collagen, overcorrect by 10%-20%.
Apply ice intermittently for swelling and
cryoanalgesia.

Numerous generic augmentation
approaches exist. Two are included here:


3,10,11 (Fig. 48-6)

position.

technique. Inject vermilion from lateral
to medial, inject corner of lips to create
“supportive buttresses” from mandibular
to lower lateral lip.

653
Chapter 48

view.


groove).

Redirect it at 20-degree angle from lip.



upper lip connect, thereby elevating the corner of lip and decreasing the
labiomandibular groove.


buttresses” to reestablish vertical height (lost secondary to bone resorption).


and buttresses.

12 (Fig. 48-7)


Pinch
philtral column with nondominant hand
while injecting in retrograde threading
fashion in dermis. Repeat procedure in other
philtral column.
Insert needle at the
base of the philtral columns and advance
down to the wet-dry margin. Inject in a
retrograde threading fashion, creating a strut
for each Cupid’s bow apex.

Inject a thread along
the vermilion-cutaneous junction from the
apex of Cupid’s bow laterally and halfway to
the oral commissure. Repeat procedure on
the other side.
With patient everting lower lip, insert
needle into the wet-dry margin at about a third of the way from the midline
to the commissure. Deposit 0.1 cc into the orbicularis oris muscle. Repeat
procedure on the other side.
Inject in the lateral lower cutaneous lip,
just below the oral commissure. Repeat procedure on the other side.
Inject superiorly in the nasolabial folds. This allegedly
helps to evert the lip.
2
2
1
3
1
3
4
4
5
5
6
6
Six-step technique.

Cupid’s bow.
of the vermilion-cutaneous
junction.
tubercles. Support the oral
commissures. Nasolabial fold.

654
Part VII Facial Surgery
SENIOR AUTHOR TIP:
13 The blunt tip of a 25-gauge
microcannula introduced from each commissure and extending medially allows bruise-
free volumization (Fig. 48-8, and B). Philtral augmentation needs to be done sharply,
however.
Numbing the sensitive vermilion is trivial and should be done with serial submucosal
injections of lidocaine 1% with epinephrine at the sulcus. To make these relatively painless
injections completely pain free, paint a topical anesthetic onto the mucosa 1-2 minutes
before injections (Fig. 48-8, C and D). We use a combination of lidocaine 10%, prilocaine
10%, and tetracaine 4%. This technique prevents the problem of distorting the anatomy
by direct injection of anesthetic into the lips.
A
B
C
D
and B, The blunt tip of a 25-gauge microcannula introduced from each commissure
and extending medially allows bruise-free volumization. C and D, Topical followed by local
anesthetic for painless injections.
POSTPROCEDURE CARE
Schedule next appointment (possibly for touch-ups in 2-4 weeks) to ensure patient
retention.

Continue intermittent ice application for the next few hours.
Avoid massaging perioral region, and minimize facial movements for the short-term.
Sleep with head elevated for 1 night.
Resume skin care and makeup application after 24 hours.
Take postprocedure photos at follow-up visits.
COMPLICATIONS
Complications for HA and collagen injections are listed (Fig. 48-9).

655
Chapter 48


Erythema
Ecchymosis
Edema
Cold compresses
Apply pressure
Observe
Clumping


Massage

Hyaluronidase
(for HA)
Excision
Erythematous
nodule
Infection
Fluctuant
abscess


Culture
Antibiotics
Empiric antibiotics
Recovery
No improvement
Telangiectasias


Hyaluronidase (for
HA)
Migration
Excision
Hyaluronidase (for
HA)
Hypertrophic scar
Intralesional steroid

Granuloma
Massage
Intralesional steroid
Hyaluronidase (for HA)
Excision
Recovery

Consider factitious
lesion
Culture (3 weeks)
Two-drug
antibiotic therapy
Hyaluronidase
5-FU
Excision
Prevent contact
with lesion
Topical wound care
Surgical
debridement
Reculture
Change antibiotics
No improvement
Complications and treatment algorithm for hyaluronic acid and collagen injections.
( hyaluronic acid; incision and drainage; intense pulsed light.)
© Oxford University Press.

656
Part VII Facial Surgery

Swelling (~ 73%-89% of cases), ecchymosis (~ 10%-61% of cases), erythema (~ 40%-93%
of cases). These are self-limited, usually resolving within 7 days.
Transient hyperpigmentation
Infection (as high as 5%)
• Treatment: Antibiotics
Telangiectasias
• Treatment: Pulsed dye laser







(start with 150 IU and titrate up) and massage the area. This will dissolve the HA.

12-24 hours, because these are often caused by swelling from needle entry.
Delayed nodules


protective matrix
•


5-FU, intralesional laser therapy.




Hypersensitivity reactions, local or systemic (angioedema, anaphylaxis)
• Occurs in 3%-5% of cases with bovine collagen, and in <0.5% with HA



• Granulomas






Very rare, estimated to be <0.001% of cases
Vascular occlusion

657
Chapter 48
• Patients usually present with pain on injection, then develop blanching, duskiness,
or ecchymosis.
• Delayed presentation can also occur, possibly from the volume of HA compressing
vessels.
• Symptoms evolve over the next 1-2 days (erythema, edema, discoloration, constant
pain)





and associated pressure


A result of untreated vascular occlusion


• Antibiotics
• Debridement
AUGMENTATION WITH IMPLANTS
ADVANTAGES
Permanent
Biocompatible: They have been used in medical devices for years.
Reliable amount of bulk with little shrinkage
Reversible
DISADVANTAGES
Does not fully integrate: Possibility of migration or extrusion
Does not treat a long cutaneous upper lip

Although advertised as soft and pliable, many think that they have an unnatural feel.
• This probably depends on which product is used.
Some think they inhibit natural lip motion (in upper lip more than in lower).
Expensive
SENIOR AUTHOR TIP: Implants to the lips are almost never a good idea. Objects
placed into this highly mobile area, whether they integrate or not, are likely to distort
the anatomy and become visible—most notably at extremes of expression. Because little
or no shrinkage occurs over time, what might look proportional at 50 years of age will
look overdone at 70 years of age. Finally, removing them is often not trivial. Integrating

integrate often leave capsules that are problematic in their own right.

658
Part VII Facial Surgery
EXAMPLES

Earlier products (Gore-Tex, SoftForm, UltraSoft; Tissue Technologies) had low porosity,
which did not allow adequate cellular ingrowth.
• Surgeons and patients reported poor results, including hardening, palpability, and
visibility of the implants.
18
Newer, dual-porosity products (Advanta, Atrium Medical) allow more cellular ingrowth
and have a softer, more natural feel, and allow more natural lip movements.
• These are reportedly three times softer than older constructs.
Patient satisfaction with Advantra was 90% when implants were placed into nasolabial
fold or lips.19
Various shapes (round, oval) and diameters (1.8-5.0 mm); 15 cm length
With or without preattached trocar

The shell is composed of two membranes: An outer ePTFE shell and an inner silicone
shell.
• This supposedly allows some cellular ingrowth (to minimize migration) but is limited
(to minimize hardening).
Possibly softer than ePTFE



No cellular ingrowth
Possibly softer than ePTFE products
Three diameters (3, 4, and 5 mm) and lengths (55, 60, and 65 mm)
INFORMED CONSENT
Palpability, migration, and extrusion of implant
Infection, with need for implant removal
Contour irregularities, asymmetries
Alterations in sensation, speech competence, oral competence; usually temporary
Overcorrection or undercorrection: ~ 4% of patients require size adjustment.
Swelling can take weeks to fully resolve.
Expect ecchymosis, decreased motion of lips, and dysesthesia for weeks to months.
Complications
EQUIPMENT
Good overhead lighting
1% lidocaine with epinephrine
Tenotomy scissors
Bunnell tendon passer
No. 11 or No. 15 blade
Ruler
Suture

659
Chapter 48
TECHNIQUE
Measure the length of the lips while they are stretched or with the patient’s mouth
wide open.
Choose appropriate implant size.
Give anesthesia.
• Usually a combination of blocks (infraorbital and mental), local anesthesia for
vasoconstriction and hemostasis, and oral or IV sedation with agents (i.e., ketamine
and valium) for patient comfort
Preoperative and postoperative antibiotics
• Some surgeons soak the implant in antibiotic solution before implantation.
Make 3-5 mm stab incisions bilaterally a few millimeters medial to the oral commissures
on the upper lip.
NOTE:

Using tenotomy scissors or a Bunnell tendon passer, create a submucosal or
intramuscular tunnel across the vermilion.
• Some perform this along the course of the wet and dry lip margin, whereas others
place the tunnel at the vermilion border.
• If an implant is placed too high, it can cause a ridge or blunt the vermilion-
cutaneous junction, whereas if placed too low, it can cause a retracted appearance.

intramuscular, or submuscular.

• Some think that when placed intramuscularly, the implants tend to migrate.
Ensure uniform depth of the tunnel across the lip.
Insert the implant using a tendon passer.
Touch-free technique: Avoid touching the implant or allowing it to touch mucosa (oral

If one implant is used to span the entire upper lip, bow-stringing or abnormal motion
on animation can result.
• Using two implants in series (one for each hemilip) can lead to more natural lip
motion.
• The lower lip can be spanned with one implant.
Repeat procedure for the lower lip.
Multiple implants can be added for more volume.
Some implants (Advanta) are preloaded with a trocar and placed percutaneously.
Some implants come tapered; others should be cut so that the ends taper.

Suture the stab wounds.
POSTPROCEDURE CARE
Antibiotics for 5-7 days


laughing, puckering) for 1-2 weeks.

660
Part VII Facial Surgery
Sleep with head elevated for several days.
Avoid strenuous activity for 1-2 weeks.
Good oral hygiene
Vaseline or lip moisturizer
COMPLICATIONS
Bleeding, hematoma
Infection (0.2%-4.2%)
• Treatment: Antibiotics
• Removal of implant
Shrinkage (0.2%-3% of cases with newer products, ~ 16% for older products)

• 1.5%-10% revision rate, except VeraFil revision rates have been reported as high
as 25%
• 0.8%-7.5% of patients request removal of an implant. Rates of removal of older
products (Gore-Tex, SoftForm, UltraSoft) are much higher, with some reports as
high as 100%.
Numbness
• Usually self-limited
Allergic reaction (very rare)
Granuloma: Rare
Ulcers
Extrusion (~ 1%)
AUGMENTATION WITH GRAFTS
ADVANTAGES
Biocompatibility
Full integration
Quite natural feel
If complicated by an infection, the graft does not usually need to be removed.
DISADVANTAGES
Variable rates of resorption, results not completely predictable

EXAMPLES


Biosystems), human collagen matrix (Dermalogen, Collagenesis), porcine collagen
matrix (Surgisis)
Acceptable longevity 1-3 years: ~ 80% survival at 1 year
No need for donor site
Must document allergies preoperatively, because many of these products are antibiotic
impregnated

661
Chapter 48
Very expensive
~ 4% complication rate

Inexpensive if harvested during a concurrent procedure (e.g., blepharoplasty, facelift,
liposuction); otherwise, expensive in OR costs and materials, and leaves an additional
scar
SENIOR AUTHOR TIP:
Varying resorption rates
Various autografts can be used:

temporalis fascia, postauricular fascia, galea, palmaris longus, sternocleidomastoid


Fat injections and core fat grafts
• Natural feel
• The lips are the worst recipient site compared with other facial subunits. Nondynamic
recipient areas are better.
24

25 showed total resorption at 8-9 months regardless of multiple
treatments.

26
27 reported <20% resorption when injected intramuscularly into orbicularis
oris.

• Dermal-fat graft


(e.g., lower abdomen; subiliac crest; or suprapubic, gluteal, or inframammary
folds)
SENIOR AUTHOR TIP: Dermal-fat grafts are a wonderful way to restore volume to lips
that need more than just fat grafting. When harvesting a strip of dermis, make sure to

the amount needed if harvesting from the abdomen, and if working near the pubis, be
careful of engrafting hair follicles.
Remove as much fat as possible from the underside of the dermis before threading
between the commissural incisions. (I like to weight each end of the dermis with a

the dermis is passed through the lip, center it and then pull the lip away from the face
to maximize its length. This maneuver will pull as much dermis as possible into the lip.
Trim the excess, but leave 2 mm to insert into the incision at closure. I use 5-0 chromic
gut, making sure to capture the dermal edge into the commissural closure to anchor
the dermis in place.

662
Part VII Facial Surgery
INFORMED CONSENT
Undercorrection or overcorrection

Contour irregularities, asymmetries
Need for multiple treatments to approach permanency
Secondary procedures to correct imperfections or increase volume
Expect ecchymosis, decreased motion of lips, and dysesthesia for weeks to months.
Complications
EQUIPMENT
Same as equipment used for implant augmentation (see previous description)
Fine-tipped coagulator/cautery
TECHNIQUE
• Measure length of lips while they are stretched.



Harvest graft from donor site. Ensure hemostasis.
• If using a dermal-fat graft, deepithelialize the graft.

lips.28
• Rehydrate product as per instructions, if necessary.
Trim the graft to the desired size and shape.

• Some experts simply make strips rather than contouring the graft, because they
think such contouring leads to asymmetries and surface irregularities.

strips.
Some advocate two grafts for the upper lip (one for each hemilip) with ~ 3 mm of
overlap, thereby enhancing or creating the natural central tubercle.
Insert graft into a submucosal or intramuscular tunnel with a tendon passer in a similar
manner as for implants.

A 14- or 16-gauge angiocatheter is inserted into the vermilion border just medial to the
oral commissure, tunneled submucosally, and brought out at the midline.
A stylet from a 5 Fr suction device is passed through the catheter, hooked to the graft,
and withdrawn back through the tunnel to properly seat the graft.
This is repeated on the other side.
The lower lip can be augmented with one pass extending from one side to the other.

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Chapter 48

See Chapter 23 for greater detail.
29
• Fat is harvested using dry or tumescent technique.

or thigh.
• Atraumatic harvesting technique is employed.

cannula.
• The aspirate can be processed with centrifugation or gravity separation.

• Using an injecting cannula, fat is injected into the lips, either intramuscularly or into
the submucosal tissue.
• To decrease the risk of complications (e.g., vascular occlusion, fat emboli,
hematoma), epinephrine, deposition of small aliquots, and large blunt cannulas are
employed.
• Small aliquots (0.1-0.2 ml) of fat are injected as the cannula is withdrawn to
decrease the force needed for deposition and thereby minimize adipocyte trauma.
• Multiple passes, making new tracts each time, are performed.
• Typical injection volumes: 1-2 ml into the upper lip and 1.5-3 ml into the lower lip

30

0.5% lidocaine hydrochloride with epinephrine 1:100,000.

• A 5 mm incision is made at the donor site.
• The oblique end of the syringe is inserted into the subcutaneous fat using a boring
motion (rotation and advancement), while simultaneously gently pulling back on
the syringe piston to make room in syringe for the fat core.

• The syringe is inserted into a deep mucosal lip tunnel, and while the syringe is
withdrawn, the piston is gently pushed to insert the fat core into the tunnel.
• The lips should be overcorrected by ~ 10%-15%.
POSTPROCEDURE CARE
Similar to augmentation with implant
Antibiotics are not needed.
• Antimicrobial ointment can be applied over the incisions.
COMPLICATIONS
Hematoma
Infection
• Treatment: Antibiotics
• Usually do not need to remove graft

664
Part VII Facial Surgery

Graft exposure
Fat necrosis (fat grafting or dermal-fat graft)
Epidermal cysts (dermal-fat graft)


platelet-rich plasma (PRP) is added to the fat graft.
Arterial occlusion (fat injection)

• Fat embolization with resultant stroke or blindness (two known case reports from
fat injections into lower third of face)

ADVANTAGES
Augmentation with one’s own tissue (no concern for hypersensitivity reactions)
Permanent
Nonvisible scars
DISADVANTAGES
Can have unwanted philtral protrusion
Does not change cutaneous upper lip length
Advancements can lead to poor lip motion postoperatively.
Can have poor results with thin, aged lips
• Results are better in people <40 years of age with good elastic tissues.
Steep learning curve for mastery
INFORMED CONSENT
Expect lip dryness
Asymmetry
Paresthesia
Philtral protrusion

Complications
EQUIPMENT
Good overhead lighting
1% lidocaine with epinephrine
No. 15 blade
Tenotomy scissors
Ruler
Suture
TECHNIQUE
Apply anesthesia.
One of the many V-Y advancement patterns is chosen (Fig. 48-10).
A wide V pattern is incised with the base of the V facing the labial
sulcus and the tips pointing toward the wet-dry margin.

665
Chapter 48
V-Y advancement patterns. The areas shaded red indicate incisions or areas to
be resected. (CML, Corner of the mouthlift; DLL, direct liplift; indirect liplift; V-Y lip
augmentation.)
DLL, upper and lower
lip31
ILL, bullhorn subnasal
liplift32
ILL, philtrum stretching,
variation #133
ILL, philtrum stretching,
variation #233
ILL,
lift34
ILL, bullhorn subnasal
liplift32,35
ILL, Greenwald
incision36
ILL, double duck
suspension37
ILL, Italian technique38
ILL, nonscar suspension
technique39
CML, lentoid incision40
CML, triangular
incision41
CML, rhomboidal
incision42
CML, Valentine
anguloplasty43
CML, extended
incision44
CML, lentoid excision

pleats’45
VYLA, tranverse Y-V
incision46
VYLA, double V-Y
incision47
VYLA, W-shaped
incision48
VYLA, V-Y in V-Y
incision49

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Part VII Facial Surgery
A large V is incised spanning nearly the entire width of the
lip, with the base of the V pointing to the labial sulcus and the tips near the wet-dry
vermilion margin.

but its width just covers the middle third of the lip.


One or two W patterns are incised in the wet mucosa with bases pointing
toward labial sulcus and tips toward wet-dry margin.

Three Vs are incised on the upper lip and two can be incised
on the lower lip.

fullness; namely, the central tubercle and the lateral thickenings.

50: A horizontal V is incised laterally in the wet mucosa with its base
pointing toward the commissure and the tips pointing medially.

fullness.

In the wet mucosa, a central 12-15 mm horizontal incision is
made with V-shaped branches extending toward the commissures at each end.




undermined, advanced, and closed in a single layer.
The orbicularis oris can be plicated for added thickness.
POSTOPERATIVE CARE
Similar to that for augmentation with grafts
Antiseptic mouthwash
COMPLICATIONS

Asymmetry (2.8%-25%)
Undercorrection (4%-21%)
Overcorrection (3%)
Paresthesia (12%)
Infection
Dehiscence (6%)
SENIOR AUTHOR TIP: The learning curve for V-Y mucosal advancements is steep,
and there is very little call for them in senile (thin, long) lips. We rarely do them in our
practice, their place taken by combinations of volumization and direct skin excisions.

667
Chapter 48
ADJUVANT SURGERIES

• However, one aspect of senescent lips remains—the elongated cutaneous upper lip.
• Imaging studies have given evidence that the senescent lip is not actually volume
depleted, but that the

52


making a comeback.

ADVANTAGES
Decrease the length of the cutaneous upper lip by resecting a portion of the upper lip
just below the nose.
Accentuate pout.
The scar can be well hidden and is least noticeable in patients with a wide nostril base,

DISADVANTAGES
Shorten the upper lip mainly centrally.
• Can be combined with a corner mouthlift to balance the lip
Overcorrection results in excessive upper incisor show.
INFORMED CONSENT
Risk of noticeable scar
Expect ecchymosis and dysesthesia for weeks to months.
Overcorrection or undercorrection
Complications
EQUIPMENT
Same as that used for V-Y advancement
TECHNIQUE
Give anesthesia.
• Often done under a regional (infraorbital nerve) block with local anesthetic for
vasoconstriction
• Sedation can be added, based on patient comfort.

nasal crease below the nostril sill (see Fig. 48-10 for variations).
• The incision can be extended inferolaterally along the nasolabial fold to reduce
droopy nasolabial fold.
• The skin below the columella can be spared.

668
Part VII Facial Surgery


SENIOR AUTHOR TIP:
and it is best left to only the most experienced surgeons.
NOTE:
• The medial aspect of the incision can be extended inferiorly along philtral columns
to accentuate or create the Cupid’s bow.
• A midline triangular or a wide vertical excision can be added to either narrow a wide
philtrum or treat an absent Cupid’s bow.
• The incision can be made to stairstep up into the nasal sill.
The height of the skin to be excised should be ~ 3-5 mm.
• Ensure that the height from nasal base to Cupid’s bow is at least 12 mm, regardless
of incisor show, or else the lip will look too short.
The skin and subcutaneous tissue down to the orbicularis oris fascia are excised.
Either no undermining, or wide undermining of the upper cutaneous lip almost down
to vermilion border can be performed.
• Not undermining will shorten the upper lip more.
• Wide undermining will decrease cutaneous lip/vermilion ratio more (increases
vermilion height).
Meticulous two-layer closure with 6-0 suture
SENIOR AUTHOR TIP: Patient selection is critical for any direct excision around the
mouth, but particularly for liplifts. Particular attention should be paid to the acuity of
the labiocolumellar angle (the sharper the better), the ratio of the width of the nose
to the width of the mouth (the larger the better), and to the individual anatomy at the
nostril sill. Some sills lend themselves to bullhorn excisions (e.g., the lip skin seems to
move into the nostril), and others are more linear with an abrupt change from nostril
to labial skin at the sill.
Vertical components added to the liplift are powerful ways to narrow a wide, simian
senile upper lip. The vertical component can be taken down all the way to the vermilion,
if necessary, where the dog-ear can help to re-create the pout at the center of Cupid’s
bow.
Be very cautious in undermining the upper lip skin. Any postoperative bleeding (in this

at worst turn the lip to “concrete” for an extended period.
POSTOPERATIVE CARE
Same as that for augmentation with grafts
Early removal of sutures 5-7 days postoperatively
COMPLICATIONS

Undercorrection (2.4%)

669
Chapter 48
Infection (1.6%-2.1%)
Hypertrophic scarring (5.3%), or scar needing correction with dermabrasion (20%)
LIP SUSPENSION
ADVANTAGES
No visible scar
Increases nasal tip projection
Minimal operative time
Easily reversed by removing the suspension suture
DISADVANTAGES
Possibly unwanted changes to nasal tip
INFORMED CONSENT
Can have ecchymosis, decreased motion of lips, and dysesthesia for a period of time
Complications
EQUIPMENT
No. 15 blade
Tenotomy scissors
Fine-tipped cautery

TECHNIQUE


intercartilaginous incision (separating lower lateral from upper lateral cartilages).
• This is done bilaterally.

oris.
• This extends horizontally the width of the base of the nose, and inferiorly halfway to
the vermilion-cutaneous border.
Through the intercartilaginous aspect of the incision, the nasal tip and dorsum are
undermined so that the columella and lower lateral cartilages move freely as a subunit.

resected.
A 3-0 suspension suture is passed through the inferior portion of the incision and down
halfway to the vermilion-cutaneous border.
• The suture is passed through orbicularis oris muscle and fascia and brought back up
and secured to the anterior nasal spine.
The upper lip skin is pulled up as the suture is tightened, redistributing the skin into the
nasal vestibule (where excess tissue can be excised), as well as up through the columella
and nasal tip, which rotates and projects the tip.
A tip rhinoplasty can be done for patients with excessive nasal tip projection.

columella.
The columella is sutured to the septum, and the incision is closed.

670
Part VII Facial Surgery
SENIOR AUTHOR TIP: We have no experience with this technique and would urge
caution when depending on long, permanent sutures—especially mobile ones—to

POSTOPERATIVE CARE
Same as that for augmentation with grafts
Early removal of sutures 5-7 days postoperatively
COMPLICATIONS
Synechia
Nasal stenosis

Suture abscess (2%)
Paresthesias
Undercorrection
• Only 85% of patients had shortened total lip height.
• 79% had increased sagittal projection pout.
• 74% had increased incisor show, and 25% had increased vermilion show.

ADVANTAGES
Allow optimal control of the desired vermilion placement by incising along the
vermilion and directly advancing it
Shortens the cutaneous upper lip and increases vermilion height
DISADVANTAGES
Risk of losing the white roll
The scar usually fades to become less noticeable, but this can take years.

young skin.
INFORMED CONSENT
Scar will likely be quite noticeable for months.

Expect ecchymosis, dry lips, decreased motion of lips, and dysesthesia for weeks to
months.
Complications
EQUIPMENT
Same as that used for V-Y advancement
TECHNIQUE

line.
Trace vermilion border (or ~ 0.25 mm above white roll).