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Chapter 48
Mark the new Cupid’s bow peaks (usually 3-5 mm higher than the original) and the new
central portion (usually 2-3 mm higher than the original).
• Preserve and exaggerate the Cupid’s bow.
The tissue medial to the Cupid’s bow can be spared to make the scarring less
noticeable.
• This is essentially a corner mouthlift.
Continue the marking from the peaks laterally and parallel to the vermilion, tapering
down toward the lateral vermilion near the commissure.
Overcorrect the upper lip by 1 mm, because tissues will settle and descend ~ 1 mm by
6 months postoperatively.
Extension to or beyond the commissures can lead to lateral scars that are noticeable.
Excise the marked skin.
• Some surgeons excise down to muscle.
• Others advocate simply excising immediately subdermally, keeping as much
subcutaneous tissue as possible to preserve or create a natural ridge at the vermilion
border.
Some surgeons undermine 1-2 mm, whereas others do not.
Meticulous closure with 6-0 suture is crucial.
• Closing Cupid’s bow peak and trough points with vertical mattress sutures
promotes an everted edge.
• For the rest of the incision, a subcuticular suture can be run, and if further eversion
is desired, a simple running suture can be implemented.
Dermabrasion or laser resurfacing along incision decreases scar noticeability.
SENIOR AUTHOR TIP: Whereas lower lip advancement (i.e., excision of the lip skin at
the vermilion border all the way across the lip) is a tried and true technique in our hands,
we long ago abandoned the technique for the upper lip. The problem was stricture that
It is far safer to extend the corner mouthlift only to the peaks of Cupid’s bow and leave
the central lip skin intact. The central part of the lip can then be shortened by a liplift.
POSTOPERATIVE CARE
Same as that for augmentation with grafts
Early removal of sutures 5-7 days postoperatively
decrease scarring.
Use lipstick or cosmetic tattooing to cover scar.
COMPLICATIONS
Asymmetry, contour irregularities, obliteration of ski jump transition
Overcorrection
Undercorrection (6.25%-26%)
Hematoma
Asymmetry (5%-13%)
• Revisions done in ~ 10% of patients
Hypertrophic scarring (3%-27%)
Infection (~ 5%)
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Part VII Facial Surgery
CORNER MOUTHLIFT, ANGULOPLASTY
Similar to the direct liplift, but the excision stays lateral to the Cupid’s bow apices
ADVANTAGES
It can be used for downturned corners or combined with an indirect liplift (which lifts
centrally) to balance the mouth.
DISADVANTAGES
Similar to direct liplift
Can lead to permanent smirk if overcorrected
INFORMED CONSENT
Scar can be noticeable
Complications
EQUIPMENT
Same as that used for V-Y advancement
TECHNIQUE
Many marking patterns (see Fig. 48-10)
• The original technique involved marking a lentoid shape at the lateral lip, but
resulted in a scar that extended laterally past the commissure.
• A triangle pattern at the lateral lip is useful when the commissures are to be lifted
(eliminate frown).
• Spearhead and rhomboidal shapes similarly can tilt the commissures upward.
• A lentiform pattern can be used that extends laterally then inferiorly to incorporate
the marionette folds.
• A simple ellipse along the lateral lip is the most used pattern.
• Excise skin.
• Meticulous closure with 6-0 suture
POSTOPERATIVE CARE
• Similar to that for direct liplift
COMPLICATIONS
Scar hypertrophy and erythema occurred early postoperatively (18.8%), and all resolved
with time.
Misplaced scar above vermilion
• Treatment: Surgical revision with repositioning of scar along the vermilion border
Infection (~ 3.7%)
Undercorrection (4%)
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Chapter 48
Hypertrophic visible scar (15%)
makeup was applied.
Depressed scar (7%)
SENIOR AUTHOR TIP: Corner mouthlifts are extremely useful techniques when
sculpting senile vermilion. They have gone through three iterations in our practice:
scar mentioned above. It remains the most powerful lift of the three variants we use
frequently, but has the downside of a “whisker-like” scar that is present 20% of the time.
It is reserved for only the most downturned corners.
A wraparound corner mouthlift extends the incision around the commissure onto the
vermilion border of the lower lip for a distance long enough to eliminate the dog-ear.
It has medium power to lift, but can blunt the commissure.
A simple skin excision that stops at the commissure and tapers medially is our most
common corner mouthlift. Its downside is that it does not lift the commissure, but the
TOP TAKEAWAYS
Although perioral rejuvenation is scary in that many of the techniques involve
direct excisions that are “right out front,” it is crucial in achieving a harmonious
facial rejuvenation. Indirect approaches to the mouth (facelifts, midface lifts)
techniques described in this chapter is crucial.
The good news is that all of these techniques, although best done at the time
of a broader facial rejuvenation, can be done using local anesthesia in the
at minimal cost. This is a great advantage, because surgeons have already
developed a trusting rapport with their patients.
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2. Iblher N, Stark GB, Penna V. The aging perioral region—do we really know what is happening?
J Nutr Health Aging 16:581, 2012.
3. Klein AW. In search of the perfect lip: 2005. Dermatol Surg 31:1599, 2005.
Reconstr Surg 132:543, 2013.
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Part VII Facial Surgery
5. Guyuron B, Eriksson E, Persing J, eds. Plastic Surgery: Indications and Practice. Philadelphia:
Elsevier, 2009.
6. Ali MJ, Ende K, Maas CS. Perioral rejuvenation and lip augmentation. Facial Plast Surg Clin North
Am 15:491, 2007.
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Aesthet Surg J 27:632, 2007.
9. Hilinski JM, Cohen SR, eds. Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation
with Filler. Philadelphia: Elsevier, 2009.
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uronic acid for improvement of mouth corners. Dermatol Surg 31:276, 2005.
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Reconstr Surg 111:2176, 2003.
Devices 10:835, 2013.
16. Glogau R, Bank D, Brandt F, et al. A randomized, evaluator-blinded, controlled study of the
Surg 38:1180, 2012.
Surg J 33:862, 2013.
18. Clymer MA. Evolution in techniques: lip augmentation. Facial Plast Surg 23:21, 2007.
19. Truswell WH. Using permanent implant materials for cosmetic enhancement of the perioral
region. Facial Plast Surg 15:433, 2007.
Surg 20:327, 2012.
21. Narsete T, Ersek R, Narsete MP. Further experience with permafacial implants for lip augmenta-
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22. Niamtu J. Advanta ePTFE facial implants in cosmetic facial surgery. J Oral Maxillofac Surg
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Surg 27:550, 2011.
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ing in facial reconstructive surgery. Plast Reconstr Surg 124:471, 2009.
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treatments. Dermatol Surg 26:1150, 2000.
26. Churukian M. Red lip augmentation using fat injections. Clin Facial Plast Surg 5:61, 1997.
Plastic Surgery 23:36, 1999.
28. Rohrich RJ, Reagan BJ, Adams WP Jr, et al. Early results of vermilion lip augmentation using
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discussion 417, 2000.
29. Metzinger S, Parrish J, Guerra A, et al. Autologous fat grafting to the lower one-third of the
face. Facial Plast Surg 28:21, 2012.
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Chapter 48
30. Guyuron B, Majzoub RK. Facial augmentation with core fat graft: a preliminary report. Plast
Reconstr Surg 120:295, 2007.
31. Meyer R, Kesserling UK. Aesthetic surgery in the perioral region. Aesthet Plast Surg 1:61, 1976.
32. Cardoso AD, Sperli AE. Rhytidoplasty of the upper lip. In Hueston JT, ed. Transactions of the
Australia, Butterworhts, Sydney, Australia (1971).
33. Austin HW. The lip lift. Plast Reconstr Surg 77:990, 1986.
34. González-Ulloa M. The aging upper lip. D. Marchac, J.T. Hueston (Eds.), Transactions of the
sixth meeting of the international confederation for plastic and reconstructive surgery and
the international society of aesthetic plastic surgery, Masson, Paris (1975), pp. 443-446.
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36. Greenwald A. The lip lift. Plast Reconstr Surg 79:147, 1987.
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113:1828, 2004.
39. Echo A, Momoh AO, Yuksel E. The no-scar lip-lift: upper lip suspension technique. Aesthet Plast
Surg 35:617, 2011.
40. Greenwald A. The lip lift: cheiloplexy for cheiloptosis. Am J Cos Surg 2:16, 1985.
41. Austin HW. Rejuvenating the aging mouth Semin Plast Surg 8:27, 1994.
42. Perkins SW. The corner of the mouth lift and management of the oral commissure grooves.
Facial Plast Surg Clin N Am 15:471, 2007.
43. Ching S, Flowers RS. Perioral rejuvenation using the valentine anguloplasty. Paper presented
in American society for aesthetic plastic surgery annual meeting. 2005 Apr 28–May 3 (2005).
44. Parsa FD, Parsa NN, Murariu D. Surgical correction of the frowning mouth. Plast Reconstr Surg
125:667, 2010.
45. Borges AF. Sad pleats. Ann Plast Surg 22:74, 1989.
46. Delerm A, Elbaz JS. Cheiloplastie des lèvres minces. Proposition d'une technique. Am Chir Plast
20:243, 1975.
47. Aiache AE. Augmentation cheiloplasty. Plast Reconstr Surg 88:222, 1991.
49. Mutaf M. V-Y in V-Y procedure: new technique for augmentation and protrusion of the upper
lip. Ann Plast Surg 56:605, 2006.
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a systematic review of contemporary techniques and their outcomes. J Craniomaxillofac Surg
42:943, 2014.
52. Ponsky D, Guyuron B. Comprehensive Surgical Aesthetic Enhancement and Rejuvenation of
the Perioral Region. Aesthet Surg J 31:382, 2011.
lip. Arch Facial Plast Surg 13:332, 2011.
113:1836, 2004.
55. Yoskovitch A, Fanous N. Correction of thin lips: a 17-year follow-up of the original technique.
Plast Reconstr Surg 112:670, 2003.
excision approach to rejuvenating the aging mouth. Aesthet Surg J 29:83, 2009.
676
RELEVANT ANATOMY
MUSCLES
Mentalis
fossa to overlying skin
• Can cause wrinkling, and if
hyperdynamic, may be visible under
lower lip
chin dimple present
Depressor anguli oris
Quadratus (depressor) labii inferioris
Geniohyoid, genioglossus, mylohyoid, and
anterior belly of digastric
• Attach to lingual (posterior) aspect of
chin
BONY LANDMARKS
Mental foramen
Digastric fossa
Mental protuberance
Mental spines
Submandibular fossa
NERVE SUPPLY
and
(terminating branch exiting mental
foramen)
below mental foramen to prevent injury to
nerve branches or tooth apices.
Relevant muscular anatomy
for genioplasty.
Mentalis
muscle
Mylohyoid
muscle
Geniohyoid
muscle
Genioglossus
muscle
Orbicularis oris
muscle
Hyoglossus
muscle
A
Digastric muscle
(anterior belly)
Orbicularis oris
muscle
Mylohyoid
muscle
Mentalis muscle
Depressor labii
inferioris muscle
Depressor anguli
oris muscle
B
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Chapter 49 Genioplasty
NOTE:
BLOOD SUPPLY
(dominant supply) of facial artery
Inferior alveolar artery
SIGNIFICANT CEPHALOMETRIC POINTS
Most projecting portion of mandible. Denotes chin excess or
Columellar-labial junction
Deepest point between pogonion and incisor
Nasofrontal junction
( A-point; anterior nasal spine; articulaire;
B, B-point; Ba, basion; Frankfort horizontal plane;
gnathion; gonion; Me, menton; MP, mandibular plane;
nasion; OP, occlusal plane; Or, orbitale; posterior nasal spine;
Po, porion; Pog, pogonion; posterior nasal plane; sella.)
N
Or
ANS
A
PNS
OP
B
Pog
Gn
Me
Go
Ar
Po
S
FH
Ba
MP
INDICATIONS AND CONTRAINDICATIONS
OSSEOUS GENIOPLASTY
• Horizontal asymmetries of any magnitude
• Secondary cases after osseous or alloplastic genioplasty
• Adjunct to formal orthognathic surgery
or upper jaw surgery.
• Inadequate bone stock (i.e., elderly patients, bone pathology)
• Patient preference to not have osteotomy
More versatile procedure versus alloplastic augmentation
• Allows including reduction
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Part VII Facial Surgery
ALLOPLASTIC AUGMENTATION
• Need to increase only the labiomental fold depth
• Relative: Concomitant necklift/facelift
• Mandibular asymmetry
• Secondary cases with bony erosion
• Malocclusion: Orthognathic surgery required
TIP: Generally, alloplastic augmentation should be used only in patients with mild to
1-4
Caveat: Aesthetic surgery patients seem to prefer alloplastic augmentation, and tend to
shy away from osteotomies.
• Facelift/necklift procedures often include a submental incision that can easily be
used for placing a chin implant.
• Popular media has shown a bias toward alloplastic augmentation and present any
“cuts in the bone” as very “invasive.”
Malocclusion requires consideration of orthognathic surgery and a more extensive
workup (cephalometric analysis, occlusion models) and possible collaboration with an
oromaxillofacial surgeon.
implant can appear awkward.
PREOPERATIVE EVALUATION
• Diabetic and immunosuppressed patients: Not good candidates for alloplastic chin
implantation
• Age: Higher-age patients may have osteopenic bone—not good candidates for
osseous genioplasty
(Fig. 49-3)
).
(Fig. 49-3, B).
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Chapter 49 Genioplasty
surgery with maxillary and mandibular osteotomies.
C).
A
B
C
Occlusion types. A, Angle class I. B, Angle class II. C, Angle class III.
TIP: Obtaining previous orthodontic history is important; because occlusion may have
been corrected without addressing maxillary and mandibular disharmonies (deformity
becomes masked).
• Before 15 years of age, permanent dentition may not be fully erupted.
• Elderly patients may have retruded alveolar ridge (if edentulous), which contributes
to chin pad ptosis.
• Patients with or are for
any form of genioplasty until fully treated.
LIFE IZE PHOTOGRAPHS2
Bilateral sagittal view, frontal views, and bilateral oblique (three-quarter) views
MIDFACE HEIGHT
Especially important when accompanied by a deep
labiomental fold
• Patient better served by formal orthognathic correction, with or without a
genioplasty
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Part VII Facial Surgery
NOSE HIN IP EVALUATION
Nasofacial harmony is linked with chin dimensions and
vice versa.
Chin projection should be 3 mm posterior to nose-lip-
5
Nasal length: Two thirds of midfacial height and exactly
equal to chin vertical length5
Right-to-left asymmetries of the mandible and chin may
plate bending.
SOFT TISSUE ANALYSIS
Normally thick
Junction between upper and lower lip in repose
may deepen labiomental fold.4
• Indentation or crease between lower lip and lowest point of mandible (menton) best
seen on
• Fold aesthetics dependent on vertical proportion of mandible and facial length
3
3
• Evaluate for height (when stomion-to-menton is divided into thirds, fold often falls
at junction of upper and middle third).
4
• Depth
in
men and 4 mm in
6
augmentation may result in an
awkward exaggerated deep fold
and an overprojected chin
by vertical augmentation
A line drawn vertically down
facial plane on sagittal view, tangential
to anterior upper and lower lip (Fig.
49-5)
to upper lip projection.
• Pogonion should never project
beyond this line and should be
slightly posterior to it (or just
touching it).
Natural
horizontal
facial plane
Nose-chin-lip
evaluation.
Riedel plane
Riedel plane is a simple line that
connects the most prominent portion of the
upper and lower lip, which on a balanced face
should touch the pogonion.
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Chapter 49 Genioplasty
SENIOR AUTHOR TIP: The simplest and most useful means for assessing the chin
projection disharmony is Riedel line, which connects the upper to the lowermost
projected points and should touch the pogonion.
DYNAMIC AND STATIC CHIN PAD ANALYSIS4
A
prominence (i.e., native or from augmentation)
• Burr reduction or osteotomy setback may be required.
A may increase submental soft tissue fullness and worsen the cervicomental
angle if bony setback performed
WITCH S HIN DEFORMITY
Ptosis of soft tissue caudal to menton and an exaggerated submental crease
Correction requires soft tissue/muscle resection and/or repositioning.
Augmentation can exaggerate deformity.
TIP:
to prevent ptosis recurrence.7
CERVICOMENTAL ANGLE
Angle between chin and neck on sagittal view should not be very obtuse or acute
Adjunct neck soft tissue contouring techniques: Submental lipectomy, platysmaplasty,
anterior digastric resection, and/or submandibular gland resection or suspension can
further enhance chin aesthetics.
IMAGING
Cephalograms and/or Panorex
• Always indicated for secondary cases
• Required: If maxillary/mandibular imbalance or malocclusion suspected
• Obtain Panorex if any concern for nerve malposition or uncertain apical teeth
location and/or dental pathology
SOFT TISSUE RESPONSE/OSSEOUS
MOVEMENT RATIO
0.8-0.9:1.0
0.25-0.50:1.0
CLASSIFICATION OF CHIN
DEFORMITY
Small chin
Normal
Microgenia
Macrogenia
Long retrogenia
Chin deformity.
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Part VII Facial Surgery
Short or long macrogenia/microgenia
8 can serve as a guide for operative
planning (Table 49-1).
Type
Class I
Macrogenia
Horizontal: Osteotomy with setback or osteotomy
Vertical: Osteotomy and resection
Both horizontal and vertical: Osteotomy, resection, and setback
Class II
Microgenia
Horizontal: Osteotomy with advancement, autogenous or
alloplastic augmentation
Vertical: Osteotomy and lengthening, with or without graft
Both horizontal and vertical: Osteotomy, lengthening, and
advancement, with or without graft
Class III
Combined
Horizontal macrogenia with vertical microgenia: Osteotomy
with lengthening and setback
Horizontal microgenia with vertical macrogenia: Osteotomy
with resection of horizontal segment and advancement
Class IV
Aysmmetrical
Short anterior lower face: Addition of wedge of bone to short side
Normal lower facial height: Removal of wedge of bone from long
side; add to short side
long side
Class V
Witch’s-chin
Soft tissue correction
Class VI
Pseudomacrogenia
Soft tissue adjustment (not predictable)
Class VII
Pseudomicrogenia
Maxillary osteotomy
INFORMED CONSENT
Should include, but not be limited to, the following:
Possible injury to nerves in the area with subsequent temporary versus permanent
changes in sensation
• Neurosensory changes in chin and lips
Malunion, nonunion, plate/hardware extrusion and need for later removal (for osseous
genioplasty)
Implant malposition, extrusion (exposure), palpability, need for later removal, and the
possibility of bone resorption under the implant should be described (for alloplastic
augmentation genioplasty)
Overcorrection versus undercorrection
TIP: Preoperative asymmetries should be pointed out to patients, but guarantees of
their corrections should not be made.
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Chapter 49 Genioplasty
EQUIPMENT AND IMPLANT MATERIAL
ALLOPLASTIC CHIN AUGMENTATION: GENERAL EQUIPMENT
or clear nylon suture (3-0 to 4-0 caliber) that is passed through the implant is
recommended.
• Many implants have preplaced holes; silicone implants allow suture to easily pass
through the implant.
and to
either bone or periosteum.
• Craniofacial screws (and therefore drills and appropriate screw applicators) can be
used to directly screw in the implant and is best indicated for polyethylene implants,
Colorado needletip cautery and 9 mm periosteal elevator for pocket dissection
(alloplastic and osseous techniques)
ALLOPLASTIC IMPLANT TYPES
Available in smooth or textured
10,11
10,11: Developed system based
on zonal anatomy with chin implants
that have lateral tapered edges, which
can also augment the mandibular body
jawline (Fig. 49-7)
Easy to sterilize by steam or
irradiation, easy to carve, can be stabilized
with screw or sutures (Mitek Bone Anchor
System), allergic reaction extremely rare, no
ingrowth, which allows easy removal
Causes resorption
in underlying bone (increased with
malposition), potential for migration,
visibility if thin skin
Contains
ingrowth, and incorporation of implant versus
encapsulation (as with silicone and nonporous
implants)
Firm consistency but
malleable and carvable, infection rate may
be lower than silicone-based implants
(perhaps because of vascular ingrowth),
premandibular jawline aesthetic
facial segment. (CM, Central
mentum; ML, midlateral; PL,
posterolateral; PM, premaxilla;
submandibular.)
LOWER THIRD
PL
ML
CM
SM
PM
PM
CM
SM
PL
ML
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Part VII Facial Surgery
sutures
prosthesis, usually has large dimensions and requires trimming/customizing
intraoperatively
• Custom-made (silicone- or polyethylene-based) implants based on three-
dimensional modeling (perhaps, more useful if multiple facial implants required) are
available.
BIOLOGIC CHIN AUGMENTATION
Autologous cranial bone
Rib or conchal cartilage grafts
Irradiated cartilage sources
OSSEOUS GENIOPLASTY: SPECIAL EQUIPMENT
A limited orthognathic or genioplasty tray with reciprocating sagittal saw (side-cutting)
is preferred.
Two plates sometimes needed if correcting horizontal asymmetry or performing a
jumping genioplasty
SURGICAL TECHNIQUES: OSSEOUS GENIOPLASTY
Common types of osseous genioplasty. A, Reduction genioplasty. B, Sliding genioplasty.
C, Jumping genioplasty.
A
B
C
TIP: Excess inferior/posterior stripping may devascularize the lower bone segment
after an osteotomy is performed. Only lateral exposure is required to visualize mental
nerves.
SENIOR AUTHOR TIP: Regarding patients with long face deformity and horizontal
microgenia, it is crucial to realize that should the patient not undergo a maxillary vertical
reduction advancement of the chin to an optimal position, this may result in a longer
appearing face and in major potential patient dissatisfaction. Under this condition, the
chin advancement should be conservative.
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Chapter 49 Genioplasty
REDUCTION GENIOPLASTY
To correct increased vertical height or sagittal excess
11 have developed an evaluation system that does not require cephalometrics.
• Highlights of the preoperative evaluation and technique include:
with patient smiling. Thinner-padded
patients may reveal exaggerated chin prominence when smiling. This requires a
more aggressive reduction.
A higher chin pad percentage means greater chin size
appearance and a greater reduction is needed.
Chins with similar bony
reduction.
Angling osteotomy inferiorly will produce a vertical reduction.
NOTE:
Ostectomy
TIP: Genioplasty results can be enhanced with submental soft tissue procedures:
liposuction, lipectomy, and/or platysmaplasty.
SLIDING GENIOPLASTY
Standard operation for
Two segments advanced anteriorly
TIP: Dissection that is carried obliquely and anteriorly or at a right angle to bone will
when closing.
JUMPING GENIOPLASTY
Very minor chin height excess
Inferior fragment “jumped” over superior segment as an onlay
INTERPOSITIONAL BONE GRAFTS OR HYDROXYAPATITE
To add more vertical length
Added to osteotomy segment that has been angled superiorly
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Part VII Facial Surgery
CENTRALIZING GENIOPLASTY
To correct asymmetries
Wedges of autologous bone graft or hydroxyapatite often needed
CORRECTION OF LONG, NONPROJECTING CHIN12
Presents a unique challenge and can be successfully treated with both a one-cut in situ
contoured jumping genioplasty and extraoral vertical reduction/sagittal augmentation
genioplasty, which:
• Reduce excess chin height, control sagittal advancement, provide pogonion
projection, and prevent the risks of a standard wedge ostectomy.
SENIOR AUTHOR TIP:
the cephalic portion of the lip incision facilitates reattachment of the soft tissues and
reduces the potential for the lip ptosis.
SURGICAL TECHNIQUE: GENIOPLASTY
3-4 cm transverse incision (needletip electrocautery) in anterior gingivobuccal sulcus
Mucosa incised and dissection carried oblique anterior or at right angle to bone,
Subperiosteal dissection of symphysis, only inferior enough to do osteotomy (excess
inferior/posterior stripping may devascularize lower bone segment after osteotomy
performed); exposure continued laterally to posterior dissection inferior
to molar roots
Burr or saw is used to make midline vertical hash mark as a reference
Reciprocating osteotomy saw used to make horizontal osteotomy, at least 5-6 mm
inferior to mental foramen, cut posteriorly
• Orientation/angle of cut (oblique) guides direction of mobility and degree of
correction (see previous TIP)
Mobilization of segment (digastric muscle disinsertion may be needed) assessed
intraoperatively with measurements obtained previously for amount of advancement,
side-to-side repositioning or reduction needed
if required
: Single plate in midline. Asymmetry correction, multisegments, or jumping
genioplasty requires two plates. (Some surgeons prefer biodegradable screw/plate
systems.)
Irrigation, muscle repair
prevent soft tissue ptosis recurrence.
7
Mucosal closure (with 4-0 chromic gut) with incorporation of muscle layer or,
preferably, closure of muscle layer with 4-0 Vicryl or 4-0 clear nylon suture and 1-inch
Microfoam tape compression dressing and/or a chin strap garment
SENIOR AUTHOR TIP: The osteotomy plane should be 5 mm below the mental
foramen to reduce the potential injury to the nerve.
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Chapter 49 Genioplasty
SURGICAL TECHNIQUE: IMPLANT GENIOPLASTY
APPROACH: ADVANTAGES AND DISADVANTAGES
• Submental exposure allows more precise placement.
• Possibly fewer cases of malposition and mental nerve injury
• Soft tissue/muscle closure should be strong to prevent soft tissue ptosis.
• Relatively indicated with concomitant facelift and/or necklift
• No visible scars
• Similar infection rate
• Improper implant position (often too superior)—no direct visualization of pocket
• May have higher chance of plate/screw extrusion
FIXATION
• Screws13
• Sutures,4,7,14 Mitek
and soft tissue approximation becomes even
more important
TIP: Securing the implant is well worth the time. Bone holes are not needed. By
3-0/4-0 clear nylon or 3-0/4-0 PDS is adequate.
IMPLANT POSITION
Directly over is
Superior positioning
• Can increase bone and/or tooth root resorption/erosion, movement, and
asymmetries
• Implant may be visible, palpable, and show irregularities.
• Place subperiosteally
• Polyethylene (Porex) may be more likely to show.
TIP: Creating too large a pocket can increase malposition rates. A larger pocket is
SENIOR AUTHOR TIP:
malpositioned and it is closer to the alveolar ridge.
IMPLANT REMOVAL/SECONDARY CASES
Will often require:
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Part VII Facial Surgery
• Soft tissue/muscle manipulations (resection, repositioning) to prevent:
botulinum toxin A injections
7
in both
primary and secondary cases.15
about implant movement/malposition, patients do not want silicone prosthesis
Replacement after malposition and/or bony erosion,
patients do not want osteotomy
precise pocket
POSTOPERATIVE CARE
DRESSING
Microfoam tape (if used) removed in 3-4 days, along with the chin strap, to examine
contour and incision
5-7 days and then at night for the next 1-2 weeks
POSITION AND ACTIVITY
Patients instructed to limit activity that increases heart rate for 5-7 days
Head of bed up (45 degrees) for 3-5 days
Sleep supine as much as possible for the next 1-2 weeks.
DIET
Can resume previous diet as tolerated
early
Rinse mouth after each meal with water and/or Peridex.
PROPHYLACTIC ANTIBIOTICS
continuation for 3-5 days every 8 hours is all that is needed.
If intraoral approach used, a 3-day regimen of Peridex oral rinse solution is helpful,
scheduled every 8 hours and as a rinse after each meal
STEROIDS
Recommended to decrease edema
IV dose should be given perioperatively.
A steroid taper regimen is recommended postoperatively (i.e., Solu-Medrol 5-day taper)
HERBS, OTHER POSTOPERATIVE MEDICATION
(high-dose pineapple extract).
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Chapter 49 Genioplasty
COMPLICATIONS
AESTHETIC RESULTS
• However, dissatisfaction rate is very low.
16:
90%-95%
85%-90%
Overcorrection: More common in women; may result in overprojection and
masculinization
: Very controversial with limited reports
• One study showed slightly higher satisfaction and self-esteem improvement rates
with osseous genioplasty.
16
Related to technique of improper soft tissue/muscle (mentalis) dissection
• Bony asymmetries with osseous genioplasty: Increase chance if osteotomy not
posterior enough
HEMATOMA
Rare; commonly at lateral osteotomy site
INFECTION
Uncommon (<5% for implants (Proplast, Vitek), approximately 3% for osseous)1,16
More likely with hematomas in osseous techniques
Overall may be more common in alloplastic implantation (may require implant
removal)
Some surgeons report no infections.13
Implant extrusion: Very rare, related to infection and high placement
MALPOSITION
More common with intraoral implant placement
bone resorption rates
May be best treated with a textured secured implant or osseous technique
BONE RESORPTION
Seen most often with malposition and a nonsecured smooth silicone implant
Treat with textured secured implant
Osseous procedures usually not adequate because of inadequate bone stock
NERVE INJURY
Often a retraction injury and resolves in 2-6 weeks
• Permanent: Extremely rare and probably results from direct transection or avulsion
during dissection or unrecognized implant pressure directly on the mental nerve
then must
TIP:
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Part VII Facial Surgery
5%-6% rate
implant.
and damage of inferior alveolar nerve as it courses caudally
TOP TAKEAWAYS
The inferior alveolar nerve can be absent or distorted in patients with hemifacial
macrosomia or other facial deformities.
Some patients have an imbalance in chin projection, height, and/or asymmetry
relative to other facial features.
Generally, alloplastic augmentation should be used only in patients with mild to
1-4
Preoperative asymmetries should be pointed out to patients, but guarantees of
their corrections should not be made.
REFERENCES
1. Cohen SR. Genioplasty. In Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indica-
3. Rosen HM. Osseous genioplasty. In Aston SJ, Beasley RW, Thorne CN, eds. Grabb and Smith’s
Plast Reconstr Surg 104:1843, 1999.
5. Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg
91:642, 1993.
6. Michelow BJ, Guyuron B. The chin: skeletal and soft tissue components. Plast Reconstr Surg
95:473, 1995.
Surg 19:257, 1995.
9. Yaremchuk MJ. Facial skeletal augmentation. In Mathes SJ, Hentz VR, eds. Plastic Surgery: The
Head and Neck, ed 2. Philadelphia: Saunders Elsevier, 2006.
10. Terino EO. Alloplastic facial contouring by zonal principles of skeletal anatomy. Clin Plast Surg
19:487, 1992.
chin reduction. Plast Reconstr Surg 120:530, 2007.
Plast Reconstr Surg 120:760, 2007.
13. Yaremchuk MJ. Improving aesthetic outcomes after alloplastic chin augmentation. Plast Re-
constr Surg 112:1422, 2003.
Reconstr Surg 104:1854, 1999.
success. Plast Reconstr Surg 120:1378, 2007.
genioplasty. Aesthetic Plast Surg 14:199, 1990.
691
NORMAL EAR ANATOMY AND DEVELOPMENT
The ear is of its adult size by the year of life.
Average length of 10-year-old male ear is 60 mm.
Neonatal cartilage is malleable and softer.
Scapha
Crura of antihelix
Concha
Helix
Antihelix
Posterior sulcus
Crus of helix
Tragus
Intertragic
notch
Antitragus
Anatomy of the external ear.
TIP: Good outcomes have been achieved by molding techniques if implemented
EMBRYOLOGY
Ear begins to protrude approximately 3-4 months of gestation.
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Part VII Facial Surgery
VASCULARITY
• Posterior auricular artery
Posterior
auricular
artery
Superficial
temporal
artery
Vascularity of the external ear.
INNERVATION
• Innervates tragus and crus helicis
• Divides into anterior and posterior branches
• Innervates remaining scapha and lobule
• External acoustic meatus and medial conchal bowl
CARTILAGINOUS ANATOMY
Sulcus antihelicis transversus
Eminentia conchae
Ponticulus
Cauda helicis
Cartilage of meatus
Spina helicis
Cartilaginous anatomy (posterior view).
693
Chapter 50 Otoplasty
Posterior surface has two important landmarks:
is the site of attachment to the auricularis posterior muscle.
• Must be dissected and removed before conchamastoid sutures (Furnas technique)
serves as possible transition point from posterior dissection to an
anterior dissection in the subperichondrial plane without violating the lateral skin
envelope.
NORMAL PROPORTIONS OF THE AESTHETIC EAR
The long axis of the ear inclines posteriorly approximately 20 degrees from vertical.
The ear axis does not normally parallel the bridge of the nose.
The ear is positioned approximately one ear length (5.5-7 cm) posterior to the lateral
orbital rim between horizontal planes that intersect the eyebrow and columella.
The width is approximately 50%-60% of the length.
• Width 3-4.5 cm
The anterolateral aspect of the helix protrudes at a 21-30 degree angle from the scalp.
The anterolateral aspect of the helix is approximately 1.5-2 cm from the scalp.
• There is a large amount of racial and gender variation.
The lobule and antihelical fold lie in a parallel plane at an acute angle to the mastoid
process.
The helix should project 2-5 mm more laterally than the antihelix in frontal view.
Proportions of the ear. A, The normal ear and its parts. B, The ear’s critical proportions.
.10
.5
.33
.23
.43
.5
15°-20°
8°
37°
Helix
Superior (posterior) crus
Otobasion superioris
Fossa triangularis
Root of helix
Tragus
Intertragic notch
Otobasion inferioris
Inferior (anterior) crus
Cymbum conchae
Antihelix
Cavum conchae
Antitragus
Lobule
Scapha
A
B
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Part VII Facial Surgery
EPIDEMIOLOGY/PATHOLOGY
Autosomal dominant trait
Incidence in whites is about 5%.
1.
of ear.
2.
10 or obtuse conchamastoid angle
3.
Multiple studies5,6,11,12 indicate protruding ears may lead to teasing and bullying that
can result in emotional and behavioral problems in the long term.
Recent literature emphasize that, performed in the correct patients, otoplasty can
GOALS OF SURGICAL TREATMENT
All upper-third ear protrusion must be corrected.
The helix of both ears should be visible beyond (lateral to) the antihelix from an anterior
view.
The helix should have a smooth and regular contour along its course.
When viewed from behind, the contour of the helical rim should be a straight line.
The postauricular sulcus should not be markedly decreased or distorted.
The helix-to-mastoid distance should be in the normal range of in the upper
third, in the middle third, and in the lower third.
The position of the lateral ear border to the head should match within at any
point between the two ears.
PREOPERATIVE EVALUATION
A thorough history should be obtained.
• The history should include the motivations and desires of the patient, as well as any
indication of psychological stress.
Examination should focus on the following:
• Degree of antihelical folding
• Depth of the conchal bowl
• Plane of the lobule and deformity, if present
• Angle between the helical rim and the mastoid plane
• Quality and spring of the auricular cartilage
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Chapter 50 Otoplasty
SENIOR AUTHOR TIP: First question: Are the protruding ears of normal shape or are
they protruding AND of abnormal shape (e.g., constricted ear, Stahl ear).
Preoperative photographs should be obtained. Spira14 recommended taking two
• Worm’s-eye view helps to determine the degree of the deformity that may
otherwise be masked by lighting/shadows.
SENIOR AUTHOR TIP: I think the posterior view is critical and perhaps more important
than some of the views mentioned previously.
INDICATIONS/CONTRAINDICATIONS
as elevated circulating estrogen levels keep auricular cartilage malleable and
responsive to molding casts.
The ear is nearly fully developed by at which time surgery should be
considered in appropriate candidates.
NOTE:
• Balogh and Millesi
15 have shown that auricular growth was not halted after a 7-year
mean follow-up in 76 patients who underwent cartilage excision otoplasty for
prominent ears.
• Patients with prominent ears generally do not care if a little growth inhibition results
from the surgery.
INFORMED CONSENT
essential.
Although the goal of this surgery is to improve self-image through correction of the
deformity, it does not guarantee a “better life.”
Risks include undercorrection, overcorrection, unnatural or sharp contours, hematoma,
infection, chondritis, recurrent deformity (early and/or late), persistent asymmetry with
the contralateral ear, and protrusion of permanent sutures through the medial skin.
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Part VII Facial Surgery
EQUIPMENT
A Dingman otoabrader or half of an Adson-Brown Tissue forceps may be used for
cartilage scoring.
Aside from this, no special equipment is required for this surgery.
Methylene blue is a useful tool for transposing landmarks on the anterolateral surface
of the ear to the cranial surface through the use with a 25-gauge needle.
SURGICAL TECHNIQUES
16: Cartilage shaping
17: Cartilage shaping
18: Cartilage breaking
19: Cartilage scoring
20: Cartilage scoring
NOTE:
21,22
TIP:
intraoperative assessment for symmetry is encouraged. To prevent asymmetry after
the procedure, performing an otoplasty on both ears should be considered, even if only
one appears particularly prominent.
Younger patients should undergo general anesthesia in an appropriate facility.
setting. Adults can almost always undergo the procedure under local anesthesia.
MUSTARDÉ TECHNIQUE
Used to correct upper-third deformities
almost always performed in combination with
other maneuvers
697
Chapter 50 Otoplasty
The Mustardé technique. A, Several pairs of ink marks are made on the concha and
outer aspect of the antihelix. B, Several 25-gauge needles dipped in ink are used to transfer the ink
marks to the postauricular skin. C, The skin excision is carried down to cartilage. After hemostasis
is obtained, several sutures are placed through the full thickness of cartilage. Usually only two or
three well-placed sutures are required. D, The sutures are tied simultaneously. A subcuticular 4-0
nylon suture is used for closure.
Poorly defined
antihelical
fold
Ink marks
Press medially
on ear
Incision
Ink marks
A
B
Mattress suture
Subcuticular
suture
Mattress suture
Mastoid bone
Mastoid bone
C
D
• Press medially on the scapha to create the proposed antihelical fold and superior
crus.
the ear.
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Part VII Facial Surgery
TIP: Scratching the needle with a Bovie pad may help to remove the outer silicone
layer of the needle and allow a better hold of the methylene blue and leave more
pronounced markings.
• On the cranial surface of the ear, mark the postauricular skin excision as an ellipse
between the tattooed markings.
SENIOR AUTHOR TIP: Excising skin may not be needed in some cases.
hydrodissection in the subperichondrial plane.
• Undermine in a subperichondrial plane using sharp dissection.
(see Fig. 50-3) to the cephalicmost portion of the scapha.
obtained by dissecting a window between the cauda helicis and the conchal
cartilage. This is done with sharp dissecting scissors.
elevator.
TIP: Undermine only the area intended for cartilage scoring, because this will minimize
the dead space on the anterior surface of the auricle.
• Place permanent mattress sutures (4-0 clear nylon or 4-0 Mersilene) full thickness
through the cartilage along the tattooed marks, making sure to capture the anterior
perchondrium without piercing anterior skin. When each half of the Mustardé
mattress suture is placed, the lateral skin should be examined to rule out a full-
thickness bite, for the next bite.
NOTE:
TIP: The placement of the mattress sutures in the scapha should be wider than the
placement in the concha. These should span like spokes on a wheel, unlike parallel
mattress sutures (see Fig. 50-5). This will create a more curvilinear, natural-appearing
antihelix.23
• Place all mattress sutures before tying (four to six mattress sutures are usually
required).
• The skin is then approximated with interrupted 5-0 plain gut.
FURNAS TECHNIQUE
Used to correct deformities of the middle third by addressing conchal excess
almost always performed in combination with
other maneuvers such as Mustardé sutures and correction of lobular prominence; may
be combined with other techniques (e.g., Mustardé technique for correcting an absent
antihelical fold)
699
Chapter 50 Otoplasty
The Furnas technique. A, The Furnas technique is best used for patients with prominence
of the superior two thirds of the ear. B, The deeply cupped and enlarged conchal cartilage of the
prominent ear is contrasted with normal conchal cartilage in cross section. C, An ellipse of skin is
excised in the postauricular sulcus, exposing the posterior auricular muscles and ligaments. These
are divided and resected. D and E, Several mattress sutures are used to attach conchal cartilage to
the mastoid fascia. The mattress sutures should be placed through the full thickness of the conchal
cartilage. The sutures are tied simultaneously.
Enlarged
conchal
cartilage
Incision
Normal
Prominent
Mattress suture
Subcuticular
suture
Mattress suture
Mastoid bone
Mastoid bone
Mastoid bone
A
B
C
D
E
• Take care to extend the dissection medially across the auriculocephalic angle onto
the mastoid fascia.
• Dissection should extend medially along the conchal cartilage until the ponticulus is
conchamastoid sutures.
allows accentuation of the setback.
24
700
Part VII Facial Surgery
CAUTION:
• Dissection should also extend to ~ 2 cm over the mastoid region.
• A segment of mastoid fascia is resected to expose the underlying perichondrium.
Mastoid fascia is preserved intact so that sutures can be placed into it.
• One or two permanent mattress sutures (4-0 clear nylon or 4-0 Mersilene) are then
placed.
posterior cartilaginous surface and the anterior perichondrium, while sparing the
anterior skin.
pull-through.
TIP: In cases of excessively large conchae, anterior displacement of the medial aspect
of the concha may narrow the external auditory canal (Fig. 50-7). In this situation,
elevated and sutured to the mastoid region to obtain similar results (Fig. 50-8).14
• The skin may be approximated with a running 5-0 chromic gut suture.
Narrowing of the external auditory canal from anterior displacement of the medial
aspect of the concha.
Mastoid
process
External
auditory canal
Concha
701
Chapter 50 Otoplasty
Perichondrium and underlying cartilage elevated and sutured to the mastoid region.
CONVERSE
OOD MITH TECHNIQUE
A rather than cartilage-molding technique, as in the
previously discussed examples
Useful for correcting very severe prominent ear deformities (when the entire ear is
involved)
antihelix and superior crus that may leave a “postoperative” appearance
18
• Press medially on the auricle to create an antihelical fold in the desired location, in a
fashion similar to that described for the Mustardé technique.
• Mark the superior rim of the triangular fossa, the upper border of the superior crus,
and the junction of the helix and scapha.
• Mark the full length of the conchal rim.
• Transpose these markings with a 25-gauge needle, mark an ellipse of skin to be
the fashion described for the Mustardé technique.
• Incise cartilage full thickness with a scalpel, sparing the lateral skin.
• Create the antihelix by placing full-thickness mattress sutures with permanent
• Estimate the amount of conchal excess by pressing inward on the newly created
antihelix, and excise the appropriate amount.
• Approximate the newly cut edges of the concha and antihelix with permanent
suture.
TIP: Avoid everting the edges, because doing so will cause permanent ridging.
• The skin may be approximated with a running 5-0 chromic gut suture.
702
Part VII Facial Surgery
A
B
C
D
E
F
G
The Converse–Wood-Smith technique. A,
crus of the antihelix, as well as the crural junction. B, The anterior and posterior borders of the
antihelix, the superior border of the superior crus, and the conchal rim are outlined with ink. C and
D, The planned cartilaginous incisions. E,
applied to the scapha. F and G, The center line of the superior crus and antihelix is marked by
25-gauge needles. An ellipse of skin is fashioned to incorporate these and excised.
703
Chapter 50 Otoplasty
H
I
J
J
K
L
M
N
N
The skin is undermined in a subperichondrial plane and the cartilaginous
segments marked with needles. The cartilage is incised full thickness, without merging the incisions.
I, If necessary, a wire brush may be used to thin thick and rigid cartilage. J, Mattress sutures are placed
to form the superior crus and body of the antihelix. K, The conchal rim is incised. L, Digital pressure is
used to assess the amount of conchal excess. M and N, The appropriate amount of conchal cartilage
is excised, and the antihelix and conchal rim are approximated with a single suture.
704
Part VII Facial Surgery
CORRECTION OF LOBULE PROMINENCE OWER THIRD
Corrected using the (Wood-Smith)25
A, A V extension of
the posterior auricular incision is drawn on the posterior surface of the lobule. B, While the ink is still
wet, the lobule is pressed against the mastoid skin. C, The mirror impression of the V is transposed
D, Closure
is performed with a running 4-0 nylon suture.
A
A
B
C
D
• Mark a “V extension” from the inferior aspect of the postauricular incision used for
correction of prominent ear deformity (e.g., Furnas or Mustardé).
• Transpose the marking to the mastoid skin while the ink is still fresh, forming a
• Approximate skin.
705
Chapter 50 Otoplasty
CORRECTION OF A PROMINENT HELICAL ROOT
A prominent helical root that overprojects laterally may be addressed with a
(Fig. 50-11).
• An incision is made in the sulcus where the root of the helix abuts the scalp with a
No. 15 blade scalpel.
• The skin is undermined medially to the deep temporal fascia and laterally to the
cartilage of the root of the helix.
• A permanent (4-0 clear nylon or 4-0 Mersilene) mattress suture is placed between
Temporalis fascia
The Hatch suture. An incision is made down to cartilage and deep temporal fascia.
ADJUNCTIVE TECHNIQUES FOR SPECIFIC FINDINGS
A pointed thickening at the junction of the upper and middle third
of the helix in approximately 10% of all patients. Full-thickness excision of the excess
skin and cartilage can be performed so that scar is inconspicuous at the transition
from lateroanterior to medioposterior. Helical contour is improved, and apparent
prominence is further reduced (Fig. 50-12).
The presence of the third and/or horizontal superior crus with a pointed
upper helix. Results in upper- and middle-third prominence. A variety of techniques
exist, including combination approaches.
26 Because of high relapse rate, the upper pole
prominence at a minimum should be addressed.
Soft tissue between the concha and mastoid can be resected
Alternatively, a burr can be used to carefully remove mastoid cortical bone.
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Part VII Facial Surgery
Darwin
tubercle
Incision
on edge of
Darwin
tubercle
Cartilage
incision
edge of
helical rim
Skin incision
of helical rim
Skin incision
of helical rim
Darwin tubercle.
POSTOPERATIVE CARE
Postoperative care usually involves a bulky, protective dressing.
Spira14
hematoma, extreme pain, and general well-being.
• The dressings are removed at 7-10 days and the incisions cleaned with dilute
peroxide.
• Spira has patients take a 5-day regimen of oral antibiotic (usually cephalexin).
• The external sutures dissolve spontaneously.
COMPLICATIONS
HEMATOMA
Sudden onset of persistent, unilateral pain should alert surgeons of a possible
hematoma.
Management
• Dressing removal
• Suture removal
• Evacuation of clot
• Reapplication of dressings with mild compression
Should be done in operating room for reexploration and hemostasis if active bleeding
encountered
707
Chapter 50 Otoplasty
INFECTION
Uncommon
• Suspect if sudden increased unilateral pain on postoperative day 3 or 4
Usually from or occasionally
useful in preventing spread of infection and chondritis
Some advocate liberal use of hospital admission and IV antibiotics after culture and
sensitivity for purulent infection to prevent progression to chondritis.14
CHONDRITIS
cartilage
LATE DEFORMITY
Usually manifests within 6 months of surgery
• Recurrence after 1 year is rare.
More often operator dependent than technique dependent
Tan27 found:
• 24% of patients undergoing the Mustardé technique require “reoperation.”
• 10% of patients undergoing the Stenstroem technique required “reoperation.”
of cases.
more “sharp edges” and “contour irregularities” than do noncartilage-breaking
techniques (e.g., Mustardé and Stenstroem).
TIP: Surgeons need to “break the ring of cartilage” to prevent telephone ear deformity.
TOP TAKEAWAYS
The endpoint of a procedure is a straight helical contour when the ear is viewed
from behind. A straight contour ensures harmonious setback of the upper,
middle, and lower thirds of the ear.
Do not excise skin, except for the triangle behind the lobule, for lobule
repositioning.
Make absolutely sure that no sutures have penetrated the lateral skin. They will
REFERENCES
1. Allison GR. Anatomy of the external ear. Clin Plast Surg 5:419, 1978.
auricular anomalies. Ann Plast Surg 38:263, 1997.
3. Tan ST, Shibu M, Gault DT. A splint for correction of congenital ear deformities. Br J Plast Surg
47:575, 1994.
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Part VII Facial Surgery
-
niofac J 29:324, 1992.
5. Adamson JE, Horton CE, Crawford HH. The growth pattern of the external ear. Plast Reconstr
Surg 36:466, 1965.
6. Macgregor FC. Ear deformities: social and psychological implications. Clin Plast Surg 5:347,
1978.
7. Hao W, Chorney JM, Bezuhly M, et al. Analysis of health-related quality-of-life outcomes and
their predictive factors in pediatric patients who undergo otoplasty. Plast Reconstr Surg
132:811e, 2013.
outcome after otoplasty using suture techniques in 62 children and adults. Plast Reconstr Surg
126:2115, 2010.
9. McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr Surg 41:17, 1968.
10. Campobasso P, Belloli G. [Protruding ears: the indications for surgical treatment] Pediatr Med
Chir 15:151, 1993.
11. Bradbury ET, Hewison J, Timmons MJ. Psychological and social outcome of prominent ear
correction in children. Br J Plast Surg 45:97, 1992.
Reconstr Surg 124(1 Suppl):27e, 2009.
14. Spira M. Otoplasty: what I do now—a 30-year perspective. Plast Reconstr Surg 104:834, 1999.
15. Balogh B, Millesi H. Are growth alterations a consequence of surgery for prominent ears? Plast
Reconstr Surg 89:623, 1992.
16. Mustardé JC. The correction of prominent ears using mattress sutures. Br J Plast Surg 16:170,
1963.
17. Furnas DW. Correction of prominent ears by conchamastoid sutures. Plast Reconstr Surg
42:189, 1968.
18. Converse JM, Wood-Smith D. Technical details in the surgical correction of the lop ear defor-
mity. Plast Reconstr Surg 31:118, 1963.
19. Stenstroem SJ. A “natural” technique for correction of congenitally prominent ears. Plast Re-
constr Surg 32:509, 1963.
20. Chongchet V. A method of antihelix reconstruction. Br J Plast Surg 19:276, 1966.
21. Gibson T, Davis W. The distortion of autogenous cartilage grafts: its cause and prevention. Br
J Plast Surg 10:257, 1958.
22. Fry HJ. Interlocked stresses in human nasal septal cartilage. Br J Plast Surg 19:276, 1966.
23. Thorne C, Wilkes G. Ear deformities, otoplasty, and ear reconstruction. Plast Reconstr Surg
129:701e, 2012.
24. Elliott RA. Complications in the treatment of prominent ears. Clin Plast Surg 5:479, 1978.
25. Wood-Smith D. Otoplasty. In Rees T, ed. Aesthetic Plastic Surgery. Philadelphia: Saunders, 1980.
26. Weinfeld AB. Stahl’s ear correction: synergistic use of cartilage abrading, strategic Mustarde
suture placement, and anterior anticonvexity suture. J Craniofac Surg 23:901, 2012.
Surg 39:270, 1986.
PART VIII
Breast Surgery
(Trang không có chữ)
711
EMBRYOLOGY, DEVELOPMENT, AND PHYSIOLOGY
EMBRYOLOGY
The breast is
From week 8-10 of embryologic development, breast growth begins with
In week 6, milk ridge develops extending from axilla to groin.
From week 7 of gestation to birth, mammary anlage on chest wall develops into an
water, fat, and cellular debris may be secreted from the neonatal breast, stimulated by
maternal hormones.
Normal breast development in anterolateral pectoral region at level of fourth
intercostal space
Supernumerary breasts and nipples can occur along milk ridge.
• Most common location for polymastia is wall below the
inframammary crease.
is the occurring in of the
population.
Abnormal regression of milk line can lead to underdevelopment of breasts (hypoplasia).
Complete absence of breast (amastia) usually associated with hypoplasia of ipsilateral
pectoralis musculature and chest wall (Poland syndrome).
DEVELOPMENT
Puberty begins at 10-12 years of age as a result of hypothalamic gonadotropin-
releasing hormones secreted into the hypothalamic-pituitary portal venous system.
Anterior pituitary secretes follicle stimulating hormone (FSH) and luteinizing hormone
FSH causes ovarian follicles to mature and secrete estrogens.
Estrogens stimulate longitudinal growth of breast ductal epithelium.
As ovarian follicles become mature and ovulatory, the corpus luteum releases
progesterone, which, in conjunction with estrogen, leads to complete mammary
development.
1:
• Stage 1: Preadolescent elevation of nipple only; no palpable glandular tissue or
areolar pigmentation
• Stage 2: Presence of glandular tissue in the subareolar region; nipple and breast
project as single mound
• Stage 3: Further increase in glandular tissue with enlargement of breast and nipple
but continued contour of nipple and breast in single plane
Melissa A. Crosby, Glyn Jones
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Part VIII Breast Surgery
• Stage 4: Enlargement of areola and increased areolar pigmentation with secondary
mound formed by nipple and areola above level of breast
• Stage 5: Final adolescent development of a smooth contour with no projection of
the areola and nipple
of puberty or skeletal maturation
endocrine abnormality
for abnormal gonadotropin levels
MENSTRUAL CYCLE
Premenstrual: Estrogen peak, breast engorgement, breast sensitivity
Follicular phase (days 4-14): Mitosis and proliferation of breast epithelial cells
Luteal phase (days 5-28): Progesterone levels rise, mammary ducts dilate, and alveolar
Menstruation: Breast involution and decrease in circulating hormones
Breast engorgement and tenderness (at a minimum 5-7 days after menstruation):
Palpation is most sensitive for detecting masses and most comfortable for patient at
this time.
PREGNANCY AND LACTATION
progesterone, placental lactogen, prolactin, and chorionic gonadotropin.
First trimester:
complex (NAC) increases.
Second trimester:
colostrum collects within the lobular alveoli.
Third trimester: By parturition, breast size triples from vascular engorgement, epithelial
proliferation, and colostrum accumulation.
Withdrawal of placental lactogen and sex hormones with delivery results in breast
being
713
Chapter 51 Breast Anatomy
pituitary secretion of
pituitary secretion of leads to breast myoepithelial contraction and
milk ejection.
Prolactin and oxytocin secretion is stimulated by nursing infant’s tactile stimulation of
nipple.
Postlactational involution occurs during the 3 months after cessation of nursing;
regression of extralobular stroma is a primary feature.
MENOPAUSE
Involves loss of glandular tissue and
Some lobules remain, but postmenopausal breast consists mainly of fat, connective
tissue, and mammary ducts.
VASCULAR SUPPLY2
ARTERIAL SUPPLY
• Receives blood supply from
subdermal plexus, which
communicates through
perforators with underlying
deeper vessels supplying
the breast parenchyma.
• Supplied by:
Subclavian artery
Thoracoacromial
artery
Axillary artery
Internal
thoracic artery
Lateral
thoracic artery
Medial intercostal perforators
Thoracodorsal
artery
Internal thoracic
perforating branches
Anterolateral
intercostal
perforators
Pectoralis major muscle
Pectoralis minor muscle
Deep fascia
Deep layer of enveloping breast fascia
Internal intercostal muscle
External intercostal muscle
Fourth deep branches of internal
mammary vein and artery
Würinger septum
Rib
branch of internal
mammary artery
enveloping breast
fascia
branch of internal
mammary artery
Cooper
ligaments
Duct
Gland
2
3
4
5
6
Vascular supply of breast.
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Part VIII Breast Surgery
• Receives both parenchymal and subdermal blood supply
VENOUS DRAINAGE
Follows the arterial supply
INNERVATION2
Dermatomal in nature
Derived from the anterolateral and anteromedial branches of the thoracic intercostal
nerves T3-5
the upper and lateral portions of the breast.
Nipple-areolar sensation is derived from the anteromedial and anterolateral T4
intercostal nerve.
Intercostal brachial nerve courses across axilla to supply upper medial arm and is often
injured during axillary dissection, resulting in anesthesia and paresthesia.
Cervical plexus
3
4
5
Anteromedial
intercostal
nerves
3
4
5
6
Anterolateral
intercostal
nerves
Intercostobrachial nerve
Innervation to breast.
ANATOMIC STUDIES
3
• 28 unilateral breast dissections in female cadavers
of the nipple in 93%.
source 79% of the time.
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Chapter 51 Breast Anatomy
NAC.
4,5
• 28 anatomic dissections and 14 arterial injection studies of female cadavers
(medially)
(Fig. 51-3).
found within septum.
Breast tissue
Würinger septum
Perforating branch
of the fourth deep
branch of the internal
mammary artery and vein
Pectoralis major
muscle
Fifth rib
Würinger septum.
6
• Injection study of seven female cadavers with arterial distribution patterns mapped
for 14 breasts
thoracic (zone 2)
regularity to the NAC
• Concluded that pedicles with a or component may be
strictly based on regularity of arterial anatomy
• Study did not account for added safety with greater breast width.
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Part VIII Breast Surgery
SKIN AND PARENCHYMA2
Adult breast extends from
the second to the seventh rib
in the midclavicular line and
from the sternocostal junction
medially to the midaxillary line
laterally.
• Also extends into the axilla,
providing breast teardrop
shape (axillary tail of
Spence)
Adult mammary gland
comprises multiple lobules
connected and drained by
16-24 main lactiferous ducts.
is the functional unit of
breast.
• Each lobule is composed of
hundreds of
secretory potential and
is connected to the lactiferous ducts by its own interlobular ducts.
Each main lactiferous duct dilates as it approaches the nipple, forming a sinus
which functions as reservoir for milk
storage.
bacteria.
are elevations formed by openings of ducts of
and are located near periphery of areola.
Montgomery glands are large sebaceous glands capable of secreting milk; they
represent an intermediate stage between sweat and mammary glands.
• Montgomery glands also act to lubricate the areola during lactation.
Fat content varies but is responsible for most of bulk, contour, softness, consistency,
and shape of breast.
• Fat content increases as glandular component subsides, i.e., after lactation or during
menopause.
Breast is supported by layers of
distinguish unless patient is thin.
—on deep surface of breast: A loose areolar plane
exists between this layer and deep fascial layer that overlies underlying musculature.
Cooper ligaments
dermis; ptosis results from attenuation of these attachments.
The inframammary fold (IMF) is the lower border of the breast and is a distinct
anatomic structure that should be preserved whenever possible.
the skin in place (similar to the gluteal fold).
7
Nipple duct
Central
collecting duct
Lactiferous
duct
Breast lobule
Superficial layer
of superficial fascia
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Chapter 51 Breast Anatomy
UNDERLYING MUSCULATURE
Cut pectoralis
major muscle
Serratus
anterior
muscle
External
oblique
muscle
Rectus
abdominis
muscle
Pectoralis
minor muscle
Pectoralis
major muscle
Deltoid muscle
Serratus
anterior
muscle
Clavicular head
External
oblique
muscle
Rectus
abdominis
muscle
Sternal head
Underlying musculature.
PECTORALIS MAJOR
The medial clavicle, sternum, anterior ribs (second through sixth), external
oblique, and rectus abdominis fascia
Upper humerus 10 cm from humeral head on lateral side of intertubercular
sulcus
Adduction and medial rotation of arm
Internal mammary perforators, thoracoacromial, intercostal perforators,
lateral thoracic artery
Medial (sternal portion) and lateral (clavicular portion) pectoral nerves
Upper medial portion of breast located over pectoralis major
Absence of sternal head of pectoralis major seen in Poland syndrome
PECTORALIS MINOR
Enterolateral surface of third through sixth ribs
Coracoid process of scapula
Draws scapula down and forward
Pectoral branch of thoracoacromial, lateral thoracic artery, direct branch
of axillary artery
Medial pectoral nerve
TIP: The pectoralis minor serves as a landmark during axillary dissection, because the
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Part VIII Breast Surgery
SERRATUS ANTERIOR
Anterolateral aspects of upper eight ribs
Anterior surface of medial aspect of scapula
Stabilizes scapula against chest wall during abduction and elevation of arm in
horizontal direction; pulls scapula forward and laterally
RECTUS ABDOMINIS MUSCLE
Pubic base
Third through seventh costal cartilages
Flexes the vertebral column and tenses the abdominal wall
Superior and inferior epigastric artery and vein, subcostal and intercostal
perforators
Segmental motor nerves from seventh through twelfth intercostal nerves
EXTERNAL OBLIQUE
External surface of lower anterior and lateral ribs
Iliac crest and medial abdominal fascial aponeurosis
Compression of abdominal contents
Inferior eight intercostal arteries
Seventh through twelfth intercostal nerves
LYMPHATIC DRAINAGE2
Subclavicular nodes
Sentinel lymph nodes
Supraclavicular nodes
Level III
Level I
Internal
mammary
nodes
Pectoralis minor
muscle
Level II
External
mammary nodes
Extensive lymphatic network of both and deep lymphatic drainage
originates from periareolar lymphatic plexus that
accompanies venous drainage.
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Chapter 51 Breast Anatomy
begins as individual lymphatics that drain each lactiferous
duct and lobule and then penetrate through the deep fascia of the underlying
musculature.
deep pectoral nodes or directly to subscapular nodes.
nodes to supraclavicular nodes.
Medial lymphatic channels run with internal mammary perforating vessels and drain to
parasternal nodes.
• Level I:
• Level II: Behind pectoralis minor and below axillary vein
• Level III: Medial to medial border of pectoralis minor
Rotter nodes: Between pectoralis major and minor
BREAST SHAPE AND AESTHETICS
19 to 21 cm
7 to 8 cm
Acromion
MHP
INP
epicondyle
MCP
SN
21 cm
21 cm
21 cm
6.9 cm
21 cm
IMF
Ideal breast measurements. ( Inframammary fold; ideal nipple plane; MCP,
midclavicular point; midhumeral plane; sternal notch.)
Ideally in harmony with proportions of the chest, torso, and buttocks
NAC: 19-21 cm from the sternal notch, 9-11 cm from midline, and 7-8 cm from IMF
Medial cleavage: Function of medial origin of the pectoralis major and the medialmost
extent of the breast parenchyma
Ideally symmetrical in size, shape, volume, and ptosis
Ptosis: Nipple position relative to IMF and breast parenchyma (see Chapter 53)
TIP: Perfect symmetry is rare and should be noted and documented preoperatively.
Women desiring full medial cleavage without bra support are often disappointed with
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Part VIII Breast Surgery
BREAST FOOTPRINT
Upper breast border
Medial breast border
Inferior breast border
Breast footprint.
The breast footprint on the chest wall consists of four landmarks:
1. Upper breast border
2. Inframammary fold
3. Medial breast border
BREAST EXAMINATION
Patient medical history, including prior breast problems, surgery, routine screening,
family history, menstrual history, and reproductive history important
Examination is easiest to perform when tenderness and
engorgement are minimal.
Begin with palpation of supraclavicular and anterior and posterior cervical lymph node
chains.
Next, inspect and compare breasts.
• Observe for skin changes, dimpling, or nipple abnormalities.
• Abnormalities in lower quadrants may be accentuated by patient raising arms or
contracting pectoralis muscle.
important.
Breasts should be palpated while patient is in and positions, including
palpation of and
TIP: Placement of patient’s ipsilateral hand behind head while supine allows pull of the
lateral quadrants and tail of the breast into the chest wall for easier and more complete
examination.