Essentials of Aesthetic Surgery

922
Body Contouring
• The next bite of tissue should secure the lift to the rectus fascia just cephalad to the
pubic symphysis, between the external inguinal rings.

layer.
• At least three sutures in the row should be placed.
Rows two and three are placed from inferior to superior in similar fashion.

closure.
NOTE:

43
The remainder of the tissue is closed over a drain.
• Multiple attempts are made to prevent an abnormal, pulled appearance of the labia
majora, to minimize dimpling, and to achieve symmetry.
POSTOPERATIVE CARE
Ice packs and antibiotic ointment for postoperative days 1 and 2
Cephalexin prophylactically for 2-3 days7 (controversial)
Some advocate preoperative antibiotic prophylaxis only, thinking that postoperative
antibiotics only increase the risk of yeast vaginitis.41
Restrictions
• Exercise is restricted for 3 weeks.

• Sexual intercourse is restricted for 6 weeks.
80% of swelling will resolve within 6 weeks.

Moderate discomfort lasts for about 2 weeks.3
Absorbable suture irritation may occur.
COMPLICATIONS
Rare
LABIA MINORA
Alter6 central wedge with extension technique

• Stretching of labial scar in 4%
• Slight separation of the labial edge in 2% (most common issue)
7

7
most common with all techniques.3,38
Asymmetry of the minora and lateral clitoral hood
Stretched, widened, or painful scars
Revisions best delayed for a
• Allows time for healing and, more important, resolution of induration

923
Chapter 63 Female Genital Aesthetic Surgery
Persistent discomfort several months after treatment
• Can be treated with several-week course of a potent cortisone cream like clobetasol
0.05%
7
Hematoma
Infection
Skin retraction

10,36
Transient dyspareunia

LABIA MAJORA
Hematoma (rare, but more common with excessive fat removal)
of either skin or fat is most common7
• Can be adjusted in 6 months
Color issue or pain and sexual dysfunction rare
Most concerning7,22:
• Excessive skin excision leading to a gaping introitus



• Most often associated if medial thigh lift has been performed or will be performed
at the same time
7

thigh skin, pulling the labia majora, and opening the introitus

concomitant thigh lift
MONS PUBIS
Concavity with contour irregularities
Altered urinary stream
Skin necrosis
• Prevent by delaying majoraplasty
OUTCOMES
LABIAPLASTY
Alter study6
• 407-patient study


• Reoperation 2.9%
• Average patient satisfaction score
would undergo procedure again.
Minor complication rate 24%38
3,6,38,44-46

924
Body Contouring
MONS PUBIS
Appearance

Functional improvements
• 75% increase in ability to visualize the genitalia postoperatively




• Improvement in bladder incontinence
45
OTHER GENITAL PROCEDURES FOR MAINLY FUNCTIONAL
CONCERNS
Vaginal tightening
Hymenoplasty
Perineoplasty

TOP TAKEAWAYS

Although aesthetic and functional ideals are being established, it is critical to
review patient desires before surgery and point out how changes to one portion


The genital region is an aesthetic unit that must be viewed in total.

Reducing the labia minora alone in women with other complex genital issues,
regardless of the technique used, may result in an unnatural, imbalanced
appearance of the external genitalia.
17

A prominent clitoral hood, for instance, appearing proportional to enlarged labia
minora before reduction will become more prominent if not addressed.17

Surgeons should be familiar with reduction techniques of the labia minora from


Careful preoperative planning must include prior and planned procedures to
decrease postoperative complications.

Detailed postoperative expectations should be thoroughly reviewed with the

resolve in a few weeks but may persist for months.

Thorough review of activity restrictions postoperatively is critical.
REFERENCES
1. Hamori CA. Postoperative clitoral hood deformity after labiaplasty. Aesthet Surg J 33:1030,
2013.

Plast Surg 25:130, 2011.

925
Chapter 63 Female Genital Aesthetic Surgery
-
proach. Aesthet Surg J 31:551, 2011.

BMJ 325:1447, 2002.
6. Alter G. Female genital aesthetic surgery. In Nahai F, ed. The Art of Aesthetic Surgery: Principles
and Technique, ed 2. New York: Thieme Publishers, 2011.
7. Mirzabeigi JN, Jandali S, Mettel RK, et al. The nomenclature of “vaginal rejuvenation” and elec-
tive vulvovaginal plastic surgery. Aesthet Surg J 31:723, 2011.

9. Murariu D, Chun B, Jackowe DJ, et al. Comparison of mean labial width in patients requesting
labioplasty to a healthy control: an anatomical study. Plast Reconstr Surg 129:214e, 2012.
10. Munhoz AM, Filassi JR, Ricci MD, et al. Aesthetic labia minora reduction with inferior wedge


report. J Reprod Med 34:373, 1989.
12. Hodgkinson DJ, Hait G. Aesthetic vaginal labioplasty. Plast Reconstr Surg 74:414, 1984.
13. Capraro VJ. Congenital anomalies. Clin Obstet Gynecol 14:988, 1971.

reductions. Am J Obstet Gynecol 182:35, 2000.
15. Kato K, Kondo A, Gotoh M, et al. Hypertrophy of labia minora in myelodysplastic women.


labioplasty) [discussion]. Plast Reconstr Surg 105:423, 2000.

Aesthet Surg J 31:519, 2011.
-

19. Alter GJ. Pubic contouring after massive weight loss in men and women: correction of hidden
penis, mons ptosis, and labia majora enlargement. Plast Reconstr Surg 130:936, 2012.
20. Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended central wedge
resection. Plast Reconstr Surg 122:1780, 2008.
21. Gray H, Pick TP, Howden R, eds. Gray’s Anatomy (1901 Edition). Philadelphia: Rounding Press,
1974.

Wilkins, 1999.

hypertrophy of the labia minora pudenda in women. Acta Anat (Basel) 92:129, 1975.
24. Puppo V. Anatomy and physiology of the clitoris, vestibular bulbs, and labia minora with a re-
view of the female orgasm and the prevention of female sexual dysfunction. Clin Anat 26:134,
2013.

total absence. Ann Plast Surg 15:534, 1985.
26. Kelishadi SS, Elston JB, Rao AJ, et al. Posterior wedge resection: a more aesthetic labiaplasty.
Aesthet Surg J 33:847, 2013.
27. Radman HM. Hypertrophy of the labia minora. Obstet Gynecol 48(1 Suppl):78s, 1976.
28. Maas SM, Hage JJ. Functional and aesthetic labia minora reduction. Plast Reconstr Surg
105:1453, 2000.
29. Martin-Alguacil N, Schober JM, Sengelaub DR, et al. Clitoral sexual arousal: neuronal tracing
study from the clitoris through the spinal tracts. J Urol 180:1241, 2008.

926
Body Contouring
30. Martin-Alguacil N, de Gaspar I, Schober JM, et al. Somatosensation: end organs for tactile sen-

Springer, 2012.

aesthetic reduction of the labia minora. Plast Reconstr Surg 113:1820; discussion 1826, 2004.
32. Bloom JM, Kouwenberg EV, Davenport M, et al. Aesthetic and functional satisfaction after
monsplasty in the massive weight loss population. Aesthet Surg J 32:877, 2012.
33. Motakef S, Rodriguez-Feliz J, Chung MT, et al. Vaginal labiaplasty: current practices and a

34. Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia: Elsevier, 2009.

133:231e, 2014.
36. Hunter JG. Commentary on: Postoperative clitoral hood deformity after labiaplasty. Aesthet
Surg J 33:1037, 2013.
37. Maas SM, Hage JJ. Functional and aesthetic labia minora reduction. Plast Reconstr Surg
105:1453, 2000.

Adolesc Gynecol 23:352, 2010.

pacinian-like corpuscles in the labia minora of prepubertal girls. J Pediatr Adolesc Gynecol
23:352, 2010.
40. Choi HY, Kim KT. A new method for aesthetic reduction of labia minora (the deepithelialized
reduction labioplasty). Plast Reconstr Surg 105:419, 2000.
-
ous sensory receptors of the epithelium of the labia minor. Clin Anat 28:392, 2015.


2006.
44. Alter GJ. Management of the mons pubis and labia majora in the massive weight loss patient.
Aesthet Surg J 29:432, 2009.
45. Michaels J V, Friedman T, Coon D, et al. Mons rejuvenation in the massive weight loss patient

46. Goodman MP, Placik OJ, Benson RH III, et al. A large multicenter outcome study of female
genital plastic surgery. J Sex Med 7(4 Pt 1):1565, 2010.

927
PREOPERATIVE EVALUATION
History of weight loss and gain; type of exercise routine and current diet regimen, if any
History of skin laxity disorders and previous procedures
Physical examination: Pinch test, caliper measurement, skin laxity, body mass index,
visceral fat assessment
INFORMED CONSENT
Expectations of minor procedural discomfort and postprocedural erythema/edema

The potential for undercorrection or overcorrection of fat areas, possible contour
deformities, and overlying skin changes; no guarantee of aesthetic outcome
METHODS OF NONOPERATIVE TREATMENT
Cryolipolysis (e.g., CoolSculpting)


Radiofrequency energy (e.g., Vanquish)
CRYOLIPOLYSIS
Application of cooling panels to localized areas of adiposity resulting
1
Preclinical studies showed 2 with
maximal relative loss of nearly 1
A systematic review of human studies showed average reduction in caliper
measurement of and average reduction by ultrasound .3
SENIOR AUTHOR TIP: Changes seen as early as 3 weeks after treatment but most
dramatic results seen after 2 months.

Treatment of visible fat bulges of the submental area, upper arm, bra line fat, back fat,

<30

Pregnancy
History of cold-induced dermatologic syndromes (e.g., cryoglobulinemia, paroxysmal
cold hemoglobinuria, or cold urticaria)

928
Body Contouring

Patients with excessive skin laxity

Cooling applicator with attached mild vacuum
One- or two-panel devices can be used (Fig. 64-1).
Conduction gel applied between cooling device and treatment area

A, B, Concave applicator for

FLAT ONE-PANEL DEVICE
FOLDING TWO-PANEL DEVICE
Skin
Conduction gel
Fat
Tissue drawn toward
cooling panel by vacuum
Cooling
panel
A
B


Conduction gel is placed on the area to be treated.
Tissue is drawn into the cooling panel with the vacuum to create a seal (see Fig. 64-1).
Cooling panels are set to an energy extraction rate ~ 60-70 mW/cm 2 and held in place
for 30-60 minutes’ exposure time.
TIP: Temperature and time of application are both important to induce selective
cryolipolysis of fatty tissue.

Postoperative dressings are not needed but may be applied for patient comfort.
Topical and oral analgesics are used as needed.


• Minor discomfort during procedure4
• Temporary (several days) edema and/or erythema to treated area1,4
• Temporary (1-6 weeks) decreased light-touch sensitivity, temperature sensitivity,
pain sensitivity to treated area
4

• Paradoxical adipose hyperplasia (incidence: 0.52%).5

929
Chapter 64 Noninvasive Body Contouring
Incidence
• 100% of patients had erythema, which resolved within 1 week.


4

• Pain is adequately controlled with topical and oral analgesics.
• All minor complications are self-limited.
HIGH NTENSITY FOCUSED ULTRASOUND
High-intensity focused ultrasound is focused energy used to

HIFU increases the local temperature within the midlamellar fat layer leading to
coagulative necrosis of adipocytes and subsequent reduction of fat layer.
• Two case series have been reported of 282 and 85 patients treated with HIFU to the

respectively.
6,7
• A multicenter, randomized, sham-controlled, single-blinded trial of 180 patients
studying HIFU in trunk aesthetics showed a decrease of in the treatment
group compared with 1.2 cm in the sham group.
8
• A multicenter, randomized, nonblinded study of 118 patients treated with a
single HIFU treatment to the abdomen resulted in a decrease of in waist
circumference.
9
SENIOR AUTHOR TIP: Results typically seen 8-12 weeks after treatment.

Noninvasive waist circumference reduction

BMI <30 kg/m2

Pregnancy

<1 cm subcutaneous tissue at treatment area
Hernia at treatment area
Cancer
Implanted electrical stimulation devices


HIFU transducer device (see Fig. 64-2)


and are done in the standing position.
Patient is placed supine on the treatment table, exposing the area to be treated.
Topical anesthetic is applied to the treatment area.

930
Body Contouring
Focused ultrasound
therapeutic transducer
High-intensity
focused ultrasound
device (HIFU)
Low energy everywhere
except in the focal area
Ultrasound
imaging transducer
Fat
Skin
The HIFU transducer focally delivers the beam to the treatment nodes to thermally
ablate fat. The low-energy beams pass through skin over a wider area (with minimal damage) to
converge at a focal depth within the fat.
TIP: Marking a grid within the treatment area helps to guide duration of treatment

The HIFU transducer is aimed at the nodes of treatment and calibrated to deliver a total
energy dose of 100-150 J/cm2 at a focal depth of 1.1-1.6 cm (Fig. 64-2).
Multiple passes are made with the HIFU transducer to deliver the appropriate amount
of energy.
Treatment duration is typically <1 hour.
TIP: The focal depth is determined by the thickness of the adipose tissues being
treated.

Postoperative dressings are not needed but may be applied for patient comfort.
Topical and oral analgesics as needed


• Tenderness, edema, ecchymosis, and hard lumps to treated area that resolves over
1-2 weeks
8
Incidence
• 10%-15% that resolve within 1-2 weeks8

• Pain is adequately controlled with topical and oral analgesics.
All complications are self-limited.

931
Chapter 64 Noninvasive Body Contouring
LOW EVEL LASER THERAPY

reduction.
• The proposed mechanism is that

10

• Depth of penetration of laser light depends on wavelength, power output, and
biologic parameters of the target tissue

2.11,12
• No consistent observations of adipocyte disruption were observed in histologic or

preadipocytes, porcine Yucatan model, or lipoaspirates from human subjects with

12

circumference measurements.

dietary supplements permitted but use not recorded
13-15
• Six treatments over 2 weeks

in

treated control group (0.6 inches) at 2 weeks posttreatment (four combined
measurements).
13

sites demonstrated a total circumference reduction of 3.3 inches 1 week after

hips, and thighs (four combined measurements)
14



0.2 cm, respectively) at 2 weeks posttreatment.
15
• Six consecutive weekly treatments

utilizing measurements at the upper abdomen, waist, hip, and thighs, 1 week

16

Circumference reduction of upper arms, waist, hips, and thighs

Pregnancy
Cancer

932
Body Contouring


Patient is placed supine on the treatment table, exposing the area to be treated.
The laser diode modules are suspended ~ 15 cm above the anterior and then the
posterior aspect of the treatment area.
Transdermal delivery of the 635 nm laser
TIP:
on the device used.

Postoperative dressings are not needed but may be applied for patient comfort.
Topical and oral analgesics are given as needed.


ulceration
Incidence
Rare when laser-diode panel suspended ~ 15 cm above skin13,14,16

erythema progressed to skin ulceration (12%).17

• Most complications are self-limited or resolve with local wound care.
TOP TAKEAWAYS

An American Society of Plastic Surgeons report from 2010 states the number of
patients seeking minimally invasive aesthetic procedures increased from 5.5 to
11.5 million from 2000 to 2010.
18

Noninvasive body contouring modalities are not a replacement for liposuction,
healthy lifestyle, or a treatment to lose weight.


often requires multiple treatments to achieve modest results.

Noninvasive body contouring results are typically seen approximately 2 months
after treatment.
REFERENCES



results from a pig model. Dermatol Surg 35:1462, 2009.
3. Ingargiola MJ, Motakef S, Chung MT, et al. Cryolipolysis for fat reduction and body contouring:

933
Chapter 64 Noninvasive Body Contouring
5. Karcher C, Katz B, Sadick N. Paradoxical hyperplasia post cryolipolysis and management. Der-
matol Surg 43:467, 2017.

Med Surg 28:257, 2009.


Plast Surg 34:577, 2010.


Plast Reconstr Surg 128:253, 2011.
-
duction of subcutaneous adipose tissue using multiple treatment techniques. Dermatol Surg
40:641, 2014.

tissue. Plast Reconstr Surg 110:912; discussion 923, 2002.
11. Friedmann DP. A review of the aesthetic treatment of abdominal subcutaneous adipose tissue:
background, implications, and therapeutic options. Dermatol Surg 41:18, 2015.

before lipoplasty procedures. Plast Reconstr Surg 113:1796, 2004.


14. Jackson RF, Stern FA, Neira R, et al. Application of low-level laser therapy for noninvasive body

-
ference reduction. J Clin Aesthet Dermatol 5:42, 2012.
-
tive for reducing waist, hip, thigh, and upper abdomen circumference. J Clin Aesthet Dermatol
9:31, 2016.

subcutaneous adipose tissue by local adipocyte injury but rather by modulation of systemic

18. American Society of Plastic Surgeons. National Clearinghouse of Plastic Surgery Statistics: 2010

934
The World Professional Association for Transgender Health (WPATH) promotes a
multidisciplinary approach for the care of transgender patients.
According to the WPATH, transgender patients should be under the care of primary
care physicians, mental health services, and endocrinologist and surgical specialists.
Although hormone and nonsurgical interventions may help in the transition of


Surgeons who have received specialized training in transgender surgery may address
the unique aesthetic and functional concerns of transgender patients.
FACIAL FEMINIZATION

structures to soften masculine facial features.
A comprehensive history and physical examination are necessary to appropriately

standardized approach.
Goal is to use hidden approaches and protocolized surgical techniques to achieve a
natural and aesthetic result, alleviating gender dysphoria and facilitating transition.
AESTHETIC EVALUATION


• Frontonasal-orbital complex: Greatest determinant of facial gender

temporal ridges, and frontonasal transition

the eyelids


• The male nose is generally larger than the female nose because of increased volume
of bone and cartilage, most notable at .

, giving them
prominent round cheeks, which are compatible with femininity.
• In males, the distance between the upper lip and nose is longer than in females.

• In males



Juan L. Rendon, Christopher J. Salgado

935
Chapter 65

facial third and gives greater vertical height.

transition between the chin and mandibular body.

The
In males, the trachea has a greater volume and diameter.
CAUTION:



1.
Patient ideas about her needs
2.
Clinical evaluation:


Hairline
Upper third
Forehead
Cheeks
Nose
Middle third
Upper lip




Neck
Adam's apple
3.
Complementary evaluation:
Three-dimensional CT scan, stereolithography, three-
dimensional models, virtual FFS
4.
Adjustment of patient expectations
5.

Evaluation and diagnosis protocol. (CT, Computed tomography; facial feminization
surgery.)

Include the hair and hairline shape, facial hair, skin texture, and the distribution and
volume of facial fat

androgenic alopecia1; females usually have rounded hairline that extends slightly higher
in the center than in men2 (Fig. 65-2).
Virtually all males have facial hair, which conditions skin to become thicker and rougher.

936
Body Contouring




Rounded
Type I: Ideal condition
Percentage: 22%
Treatment: None required
Type III: Naturally high
Percentage: 4%

M-shaped
Type II: Receding hairline
at temples
Percentage: 43%
Treatment: SHT

Type IV: Naturally high or
caused by alopecia
Percentage: 21%
Treatment: SHT*


Type V: Advanced
alopecia
Percentage: 10%
Treatment: SHT + DHT
or untreated
* SHT is performed only if a small advancement (up
to 1 cm) of the hairline is desired.
† This does not improve or correct recessions.
Hairline variations and possible treatments in male-to-female transgender patients.
Based on the hairline analysis of transgender patients treated to date (N = 492) for any facial
feminization procedure by our team. Both treatments, SHT (follicular unit strip surgery technique)

A DHT treatment (follicular unit strip surgery or follicular unit extraction technique) is performed
alone in a second session. ( Deferred hair transplant; hairline lowering surgery;
simultaneous hair transplant.)

937
Chapter 65

facial fat within the middle third of the face (cheek).3
Secondary features respond well to hormone therapy and should be addressed before
FFS.4
SURGICAL CONSIDERATION FOR FACIAL FEMINIZATION SURGERY
Facial CT with three-dimensional reconstructions should be obtained to assess
anatomic features that can be addressed.

adequate information.
Preoperative, intraoperative, and postoperative photographs (7 days, 6 months, and
1 year) should be maintained to provide an objective view of changes.



softens and feminizes the patient’s expression.
To reposition and remodel the forehead complex to soften frontal bossing,
supraorbital rims, frontomalar buttresses, and temporal ridges
Osteotomy and repositioning of the anterior wall of the frontal sinus
5 or
burring, depending on the anterior table thickness, to soften this region
• Can be combined with hair transplantation to achieve upper-third feminization in
one stage
6

and patient desires.

SENIOR AUTHOR TIP:
bone setback will often be required to achieve a good result.

• Hairline lowering surgery is recommended only in patients with a high hairline, and
non-hair-bearing scalp is excised during the lowering procedure.
SENIOR AUTHOR TIP:

lowering.

• Should be performed after androgenic alopecia stabilizes

density without active androgenic alopecia
To address the recessed corners of the hairline

• May be performed during forehead reconstruction or in a delayed fashion
6
: Follicles are obtained from a strip of scalp removed in a
small surgical procedure.
: Individual follicles are obtained, without the need
for a surgical procedure.

938
Body Contouring


• Fixed for augmentation, zygoma not commonly
reduced in FFS


• Autologous fat



Nose
• Standard rhinoplasty techniques are used to make nose smaller and compatible with
surrounding facial features.
• Reduction rhinoplasty is commonly performed immediately after forehead
reduction when done as a combined procedure.

• Reinforcement of nasal tip and dorsum with cartilage grafts to prevent collapse is
recommended.

To reduce the vertical dimension between the upper lip and nose

tissue without violating orbicularis oris
7




To modify width and height of the jaw, soften the jawline (including the
transition between the mandibular angle and symphysis), and modify the size,
shape, and position of the chin



third molar tooth roots and their relation to the mandibular angles

body and angles


chin bone resectioning and for redesigning mandibular angles


• Recommended in the region of the cervicomental fold to conceal scar and prevent
adhesions between thyroid cartilage and overlying soft tissues
• Incision should not exceed 2 cm.
Burring, rongeuring, or sharp resection with scalpel
• Must avoid sculpting near vocal cords

939
Chapter 65
SENIOR AUTHOR TIP: Marking should be performed with the patient facing the
surgeon; the surgeon should place the incision as cephalad as possible for maximal
concealment.
TOP SURGERY
For this refers to

• Top surgery in transgender females may require a mastopexy because of the
commonly low position of biologic male nipple on chest wall.
For this refers to
• A double-incision mastectomy (free-nipple grafts) is the most common top surgery
procedure for transgender males, with the most predictable results.
Top surgery remains one of the most commonly performed surgeries in gender

the patient for surgery should be obtained before performing the procedure in both
transgender males and transgender females.

congruent with their gender identity and is commonly performed before bottom
surgery (vaginoplasty or metoidioplasty/phalloplasty).
For some transgender people, top surgery will be the only surgical step during
transition.
INDICATIONS
Per WPATH8:
• A persistent, well-documented history of gender dysphoria
• The ability to make a fully informed decision and to give consent
• Age of majority in a given country

surgery must be well controlled.

patient undergo the procedure is required.
ADDITIONAL RECOMMENDATIONS
Transgender females should undergo feminizing hormone therapy for a
before breast augmentation surgery to maximize breast growth and obtain
superior aesthetic result.
Usually, only a half to a full cup size is obtained in breast growth in transgender females
on hormone therapy, and size will decrease if hormones are stopped.
MALE TO EMALE TOP SURGERY

Hormone therapy promotes mammogenesis, which follows a pattern similar to female
pubertal mammogenesis, resulting in a softly pointed breast, as seen in young girls, or
the small conical form found in young adolescents (Tanner stage 2 or 3).
9
dose dependent.

940
Body Contouring
Males tend to have a wider chest, stronger pectoral fascia, more developed pectoralis
muscles, and smaller nipple-areola complexes (NACs).

Even with large volume and a wide implant, preventing wide cleavage between breasts
is often not possible.
The NAC should always overlie the implant centrally.
Overly medial implant position can result in divergent nipple position and an
unacceptable aesthetic result.10


• Use of textured implants may reduce the potential for capsular contracture.

Incisions
• Axillary
• Inframammary: Should be placed lower than preoperative inframammary fold
because the inferior areolar margin and inframammary fold will expand after
augmentation


• Subglandar: Easier to perform; less pain with good aesthetic results in patients with
more subcutaneous and glandular tissue (Tanner stage 4 or 5)
• Subpectoral: More soft tissue coverage of implant, which is necessary in thin
patients; lower risk for capsular contracture

Good alternative to implants in patients with some breast volume from hormone
treatment
Can provide a small to moderate augmentation of the breast
Patients need to be informed that variable amounts of the injected fat will be resorbed.
• May require multiple grafting sessions to achieve desired volume
May also be used as an adjunct to implants
• Injected into subcutaneous plane
• Decreased implant visibility
• Helps to narrow wide cleavage between the breasts
FEMALE TO ALE TOP SURGERY
11,12

941
Chapter 65

transgender males.13
• SCM helps patient live in gender role that is congruent with their gender identity,
which is required before bottom surgery.
Relative to males, the female chest has excess skin and glandular tissue, as well as
abundant subcutaneous fat.

pectoralis marks the inferior margin of the chest.
During SCM, to achieve aesthetic
contouring.

• Removal of breast tissue and excess skin
• Reduction and proper positioning of the NAC
• Obliteration of the inframammary fold
• Minimization of chest wall scars to achieve aesthetically pleasing male chest

Many techniques are similar to those used in the surgical treatment of gynecomastia in
males (see Chapter 56).

7,12 (Fig. 65-3).
Semicircular
Transareolar
Concentric
circular
Extended
concentric
Free-nipple graft
Good
No
Yes
Moderate to poor
Good
No
Yes
Moderate to poor
Moderate
Poor
Small
A cup, grade
1 ptosis
Elasticity
Nipple reduction
required?
Elasticity
Medium
B cup, grade
1 or 2 ptosis

C cup, grade
2 ptosis
Elasticity
Very large
Grade 2 or
3 ptosis
Will patient accept a
free-nipple graft?
Algorithm for choosing the appropriate subcutaneous mastectomy technique.

942
Body Contouring

be carefully assessed before surgery.

(Fig. 65-4).
The lateral extent of the inframammary fold incision should be carried along the lateral
border of the pectoralis major in a cephalad direction.
Hormone therapy should be stopped 2-3 weeks before surgery.
Monstrey’s schematic for choosing the appropriate SCM technique.

943
Chapter 65

• Not recommended at the anterior aspect of breast
• Good adjunct for addressing lateral excess fat
Incisions7,13
(Fig. 65-5)
Semicircular technique. Preoperative and postoperative images, with
incisions and scars shown.


nipple depression.

944
Body Contouring
(Fig. 65-6)
Transareolar technique. Preoperative and postoperative images, with
incisions and scars shown.

large, prominent nipples

of nipple (Fig. 65-7)

around the upper aspect of the nipple, with optional
extension medially and laterally. Approach is least
common.

window
Transareolar
technique incisions.
1
2
3
4

945
Chapter 65
(Fig. 65-8)

breast with poor skin elasticity

of deepithelialization.






medially and laterally
Concentric circular technique. Preoperative and postoperative images, with
incisions and scars shown.

946
Body Contouring
(Fig. 65-9)



cross midline.


pectoralis major to avoid dog-ear and to achieve superior aesthetic results.



intercostal segment), is recommended. Patient should always be positioned

7


and sensory changes.
SENIOR AUTHOR TIP: The lateralmost aspect of the incision should be brought in a
cephalad direction along the lateral aspect of the pectoralis major muscle.
Free-nipple technique. Preoperative and postoperative images, with
incisions and scars shown.

947
Chapter 65
COMPLICATIONS
Contour abnormalities: Breast, inframammary fold, nipple
NAC: Size, placement, viability
Skin redundancy
Poor scarring
• Total laparoscopic or robotic hysterectomy and bilateral salpingo-oophorectomy
may be safely performed in conjunction with SCM in female-to-male top
surgery.
14,15
Highest risk of complications for top surgery in transgender males is 10.5% using
periareolar approach; most commonly performed technique is the double-incision
mastectomy, which carries the lowest risk of complications, including hematoma.
16
TIPS FOR ACHIEVING AESTHETICALLY PLEASING SCM


and pectoralis fascia during dissection of glandular tissue from chest wall will prevent


and carefully incising the tight band of tissue that exists inferiorly.
The lateral incision should be carried cephalad along the pectoralis major muscle to
avoid a dog-ear and optimize the aesthetic result.

A circumferential elastic bandage or chest compressive garment should be applied
around the chest wall postoperative and worn for 4-6 weeks.

Before gender reassignment surgery, patients and surgeons must adhere to the WPATH
Standards of Care (SOC) documentation,8 which requires two letters (as opposed to
one for top surgery) from the patient’s mental health therapist recommending the
patient for surgery.
• The letters must include:





recommends the patient for transition surgery
To create a neovagina with satisfactory sexual function and aesthetic appearance,
alleviating gender dysphoria
• Neovagina must be of adequate depth and width.
Several techniques are available employing a variety of skin grafts, penile/scrotal skin
17,18

• Surgeon’s experience
• Skin elasticity and healing ability
• Previous surgery

948
Body Contouring
• Infection
• Nerve damage to neoclitoris during dissection of neurovascular pedicle
• Patient’s pelvic anatomy
Before surgery patients should undergo external genitalia examination (including
preoperative length of outstretched phallus to determine need for scrotal graft if using

7
AESTHETIC CONSIDERATIONS
Neoclitoris size and position
Hair growth over penile skin: Preoperative laser epilation is recommended to prevent
hairy neovagina if using penile skin inversion technique.
PENILE SKIN LAP VAGINOPLASTY APPROACH


Penile skin has less tendency to contract, may preserve local innervation
for sensibility of neovagina, can result in relatively hairless neovagina.

cavity, intravaginal hair growth, need for lubrication during intercourse, permanent
need for dilation



• Dissection of penile skin, neurovascular bundle for neoclitoris from glans penis
dorsally, in addition to urethra dissection ventrally
• Corpora cavernosa must be dissected and
removed at the level of attachment to the
pubic rami. Short remnants of the corpora
cavernosa are also destroyed to prevent
postoperative erection.







pedicle through which the urethra and
neoclitoris are passed either individually
or separately once the neovagina is inset.


subcutaneous layer intact; the urethral

sutured in place.

before placement of the neovagina in the
perineal space (Fig. 65-10).
Penile skin has been

inverted, preserving the dorsal
neurovascular pedicle, which
vascularizes the neoclitoris (not yet
dissected).

949
Chapter 65
• The urethra is separated from the remaining dorsal tissue, and blood supply is
maintained through preservation of the corpus spongiosum.







postoperatively.

• The neoclitoris is formed from the remaining dorsal
glans cap.


form a clitoral hood (Fig. 65-11).
• A tunnel is created in the perineal cavity between the
urethra, bladder, and rectum; the neovagina may be


of the urethral part of the vagina.

• Remaining penile skin is used to form the labia minora
and sutured to deepithelialized areas of the neoclitoris,
thus also creating a hood for the neoclitoris.
• Scrotal skin is fashioned to create the labia majora,
and the excess is removed.
POSTOPERATIVE MANAGEMENT
Drain care: Jackson-Pratt drain in perivaginal space for 3 days
Foley catheter: 10-14 days
Antibiotics: Cephalosporins and metronidazole for 5-7 days
Vaginal packing for 1 week, followed by vaginal stenting at night for 6 weeks, followed
by dilation
• Dilation of the neovagina once a day for 6 months; required unless daily vaginal
penetrative intercourse
• Five sizes


COLON VAGINOPLASTY APPROACH

and revision vaginal reconstruction.

shrink
Involvement of intestinal surgery and bowel anastomosis


• Transgender females who have failed primary vaginoplasty (primary vaginoplasty

Six months
after an inverted
penile skin technique
vaginoplasty, this
transgender female has
erogenous sensation and
successful penetrative
vaginal intercourse with
orgasm.

950
Body Contouring

• Intestinal malignancy

• Extensive abdominal surgery
• Smoking

2)
HIV positive patients must have adequate CD4 count and undetectable viral load to
avoid complications.
is most commonly used segment for vaginoplasty.
Gastrointestinal surgeon with


SENIOR AUTHOR TIP: Preference is given to a colon vaginoplasty in patients who
desire less vaginal dilation and vaginal penetration without lubrication and who have


Dissection of the neovaginal tunnel

to open into the perineal space
• The levator ani muscle is partially dissected using bipolar cautery to provide

• Blunt dissection above Denonvilliers fascia is carried up to the peritoneal fold where
gauze is placed for visualization by the laparoscopic surgeon.
The blood supply to the corpus spongiosum is ligated, and the corporeal body is
reduced.
Bilateral orchiectomy is performed.
The urethra is shortened and spatulated.

A neoclitoris and labia minora are designed from glans penis and penile skin.
• The neoclitoris is created similar to the method described in the penile inversion
technique.
The corpora cavernosa are dissected and rami ligated individually from the pubic bone.
Fixing the neoclitoris and spatulated urethra together on a “throne,” creates a pink,
natural-looking and aesthetic infundibulum.
The penile skin is inverted.

infundibulum, and urinary meatus.
Scrotal skin is trimmed to form the labia majora.
• Scars are placed in the inguinal fold.

A bowel prep is commonly performed before surgical intervention.
Sigmoid segment is mobilized from lateral peritoneal adhesions.

951
Chapter 65
To obtain a 6-inch segment of sigmoid colon, vasculature must be adequately
mobilized.
CAUTION:

TIP:
of vascular perfusion.
The mesosigmoid and sigmoid are divided using a linear bowel stapler/cutter just above
the rectum.

fully mobilize the sigmoid segment and achieve a tension-free perineal anastomosis.
In the pelvis, the peritoneal fold between the rectum and bladder is opened above
the level of Denonvilliers fascia to the level of the gauze placed during the perineal
component.
The patient is approached from the perineum and intraabdominally to adequately
connect and bring the sigmoid segment through.
The mobilized sigmoid is passed into the perineum, with care to avoid vascular tension.

• If tension persists, further dissection of vascular structures is warranted.
The distal suture line of the sigmoid segment is opened and secured to the external
neovagina.
The length of the neovagina may be determined by introducing a vaginal dilator
into the sigmoid from the perineal opening and visualizing the desired length under
transillumination.
• A second linear stapler is used to transect at the appropriate level, usually 6 inches
from the introitus.


future prolapse.
The proximal sigmoid and rectum are anastomosed using a stapled anastomosis.

Neovaginal stenosis

Neovaginal prolapse
Colon cancer risk
Bowel adhesions
Bowel leakage
Prolonged ileus
Intraabdominal infection

Traditionally, bottom surgery for transgender males was relatively uncommon,
compared with bottom surgery for transgender females and top surgery for
transgender males.

952
Body Contouring
As more private insurers increase coverage for transgender patients, bottom surgery
for transgender males is increasing.

• Male-appearing external genitalia and standing micturition
• Ability to penetrate during sexual intercourse and have orgasm
AESTHETIC AND FUNCTIONAL CONSIDERATIONS
Patient’s primary concern for pursuing surgery:

• Desire to complete their transition to male
Additional patient considerations:
• Desire to retain receptive penetration (anal penetration option or metoidioplasty
with vaginal canal preservation)
• Single-stage surgery versus multistage surgeries
Patient expectations will help to guide appropriate surgery: Metoidioplasty versus
phalloplasty, with or without hysterectomy and salpingo-oophorectomy, vaginectomy
and/or scrotoplasty
METOIDIOPLASTY
Single-stage alternative to phalloplasty
May be performed with or without vaginectomy, depending on desire for urethral
lengthening and/or scrotoplasty
Neophallus: 3-8 cm in length
Aesthetically, provides a realistic-appearing microphallus capable of engorgement with
erotic sensation
Functionally, standing micturition is possible.



adiposity

the clitoris to allow surgical straightening of the hypertrophied clitoris.
• The chordae are divided, releasing the corpora bodies from their attachment to the
labia minora.
• Urethral extension may be employed to elongate the short urethral plate when
buccal mucosa is used.


• Associated with minimal recovery
• Based on transverse release of the chordae without manipulation of the urethra

• May be combined with a vaginectomy
• Residual mucosa and Skene glands can result in persistent secretions after
vaginectomy.
• Complications: Malunion or malrotation of incisional closure

953
Chapter 65

• Involves release of chordae plus extension of the urethral plate
• Standing micturition possible in some but not all patients
• Associated with high sexual satisfaction rate

diminished orgasmic function
• Reoperation rate: 30%
• If desired, scrotoplasty can be performed in second stage.

• Single-stage surgery to achieve removal of the vaginal mucosa, metoidioplasty, and
creation of neourethra and scrotum
• Standing micturition is possible in all patients.
• Associated with high satisfaction in quality of erection, sensation of neophallus, and
sexual arousal
• Vaginectomy: Total removal of the vaginal mucosa, except for anterior vaginal wall
adjacent to the urethra, which is used for urethral reconstruction

• Scrotoplasty includes implantation of testicular implants or fat grafting.

Hematoma, wound infections, skin necrosis, urinary tract infections,

management.

testicular implant displacement. Operative management is required.
Urethral extension facilitates standing micturition.19
• Various methods to elongate the urethra



• The distal urethra
• The ventral portions
PHALLOPLASTY
s: To create a functional and aesthetic phallus to alleviate gender dysphoria
• Normal, standing micturition
• Phallic rigidity for penetration during sexual intercourse
The preferred approach for patients desiring to live fully as a male


regarding the patient’s desired goals from surgery, including the length and
circumference of the neophallus, is required to guide surgical approach.


• A reduction in dysphoria is expected, and having an orgasm after surgery will


and may be performed using either a prelaminated urethra or a tube within a tube
technique.
20

954
Body Contouring

• Superior to other techniques because it meets the goal of creating an aesthetically
pleasing and sensate neophallus with a functioning neourethra
• Provides thin, malleable, and sensate tissue (at least two sensory nerves can be





• Requires advanced microsurgical techniques
• Noticeable donor site morbidity
• Multistage procedure
• Frequent urethral complications

procedure at 5 years because of implant malfunction, extrusion, or infection.

For the tube within a tube technique, preoperative laser depilation is recommended on


necessary.
The mons region of a transgender male has abundant hair from exogenous
testosterone therapy.
• An abrupt transition from a mons full of hair to a hairless penile shaft may lead to a
poor aesthetic outcome.
• Superior aesthetic results may be achieved with depilation of the mons and penile
shaft postoperatively.

• Patient refusal to accept donor site scar on their body
• Patient refusal to accept transfer of the nondominant hand forearm tattoo to the
neophallus
SENIOR AUTHOR TIP:

COMMON SURGICAL SEQUENCING
Mastectomy
Hysterectomy and oophorectomy, vaginectomy, scrotoplasty, and
reconstruction of the lengthened part of the urethra (similar to a metoidioplasty),
prelamination of radial forearm with skin or mucosa
Phalloplasty
COMPLICATIONS


Anorgasmia/dyspareunia
Urinary complications (41%-80%)21 -
22) or urinary stricture

955
Chapter 65

screws used on radius)
Bone or implant extrusion, implant infection
TESTICULAR AND ERECTILE IMPLANTS
Testicular implants are usually the last stage of reconstruction.
• Typically performed at least 12 months after phalloplasty to allow vascular
integration of the phallus and to decrease the risk of vascular compromise during
implantation
Testicular implants

sizes.


implant may be needed.
Erectile implants
• Readily available in many formats, lengths, and sizes
• In transgender males, erectile implants are placed in fatty tissue with low blood
supply and without the protection of corporeal bodies found in biologic men.

• A plastic surgeon should be present during implant placement to facilitate surgery.
TOP TAKEAWAYS

A suprapubic tube is strongly recommended during microsurgical phalloplasty.

A pericatheter retrograde cystourethrogram approximately 2-3 months after

catheter removal and a voiding trial.





Surgeons performing phalloplasty must ensure female reproductive organs have
been removed, because they are often forgotten and can be carcinogenic.

If performing neural anastomosis to clitoral nerve end to end, only one clitoral
nerve should be used. Sensory nerves can be used for the remaining donor
nerve anastomosis.


tissue may be used for coronaplasty skin.
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Table 15-1 Data from Fitzpatrick TB. The
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Table 20-1 Data from Fitzpatrick TB. The
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Table 20-2 Data from Glogau RG. Aesthetic
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Table 26-1 Data from V-Loc™ Wound
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Fig. 30-7 Data from Moss JC, Mendelson
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Table 31-1 Data from Fitzpatrick TB. The
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Table 31-2 Data from Glogau RG. Aesthetic
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Semin Cutan Med Surg 15:134, 1996.
Chapter 32
Figs. 32-1, 32-4, 32-6, 32-7 From Barrera
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Figs. 34-2 through 34-4 and 34-6 From
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Fig. 34-5 From Codner MA, McCord CD Jr,
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Fig. 34-11 From Rohrich RJ, Coberly
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Figs. 35-4 through 35-6 From Barton FE.
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Chapter 36
Figs. 36-1; 36-4, C, D; 36-10 From Pu
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Fig. 36-7 From Codner MA, McCord CD Jr,
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Chapter 37
Fig. 37-2 From Nahai F, ed. The Art
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Figs. 37-3 and 37-4 From Barton FE.
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Table 37-1 Data from Barton FE, Ha R,
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Chapter 38
Figs. 38-3, 38-5, 38-6 From Barton FE.
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Chapter 39
Figs. 39-1 and 39-6 From Codner MA,
McCord CD Jr, eds. Eyelid & Periorbital
Surgery, ed 2. New York: Thieme
Publishers, 2016.
Fig. 39-3 From Bentz ML, Bauer BS,
Zuker RM, eds. Principles and Practice of
Pediatric Plastic Surgery, ed 2. New York:
Thieme Publishers, 2016.
Table 39-3 Data from Liu MT, Totonchi
A, Katira K, et al. Outcomes of mild to
moderate upper eyelid ptosis correction
using Müller’s muscle-conjunctival
resection. Plast Reconstr Surg 130:799e,
2012.
Chapter 40
Fig. 40-2 Data from Moss JC, Mendelson
BC, Taylor GI. Surgical anatomy of the
ligamentous attachments in the temple
and periorbital regions. Plast Reconstr
Surg 105:1475, 2000.
Figs. 40-3 and 40-9 From Codner MA,
McCord CD Jr, eds. Eyelid & Periorbital
Surgery, ed 2. New York: Thieme
Publishers, 2016.
Fig. 40-4 From Blondeel PN, Morris SF,
Hallock GG, Neligan PC, eds. Perforator
Flaps: Anatomy, Technique, and Clinical
Applications, ed 2. New York: Thieme
Publishers, 2013.
Fig. 40-7 From Nahai F, ed. The Art
of Aesthetic Surgery: Principles &
Techniques, ed 2. New York: Thieme
Publishers, 2011.
Chapter 41
Fig. 41-2 From Ponsky D, Guyuron
B. Comprehensive surgical aesthetic
enhancement and rejuvenation of the
perioral region. Aesthet Surg J 31:382,
2011.
Fig. 41-3 From Pu LLQ, Chen YR, Li QF, et
al, eds. Aesthetic Plastic Surgery in Asians:
Principles and Techniques. New York:
Thieme Publishers, 2015.
Fig. 41-5 From Tonnard PL, Verpaele
AM, Bensimon RH, eds. Centrofacial
Rejuvenation. New York: Thieme
Publishers, 2018.
Fig. 41-6 From Barton FE. Facial
Rejuvenation. New York: Thieme
Publishers, 2008.
Chapter 42
Fig. 42-1 From Tonnard PL, Verpaele
AM, Bensimon RH, eds. Centrofacial
Rejuvenation. New York: Thieme
Publishers, 2018.
Chapter 43
Figs. 43-3 and 43-4 From Nahai F, ed.
The Art of Aesthetic Surgery: Principles
& Techniques, ed 2. New York: Thieme
Publishers, 2011.
Figs. 43-5 and 43-7 From Barton FE.
Facial Rejuvenation. New York: Thieme
Publishers, 2008.

962
Credits
Chapter 44
Fig. 44-2 Data from Rohrich RJ, Rios
JL, Smith PD, et al. Neck rejuvenation
revisited. Plast Reconstr Surg 118:1251,
2006.
Fig. 44-3 From Barton FE. Facial
Rejuvenation. New York: Thieme
Publishers, 2008.
Figs. 44-4 through 44-7 From Nahai F, ed.
The Art of Aesthetic Surgery: Principles
& Techniques, ed 2. New York: Thieme
Publishers, 2011.
Chapter 45
Figs. 45-1, 45-2, 45-5, 45-8 through
45-21, 45-23, 45-24, D; 45-27, 45-29,
45-31 through 45-33, 45-37 From Rohrich
RJ, Adams WP Jr, Ahmad J, Gunter JP,
eds. Dallas Rhinoplasty: Nasal Surgery
by the Masters, ed 3. New York: Thieme
Publishers, 2014.
Chapter 46
Fig. 46-1 From Rohrich RJ, Adams
WP Jr, Ahmad J, Gunter JP, eds. Dallas
Rhinoplasty: Nasal Surgery by the Masters,
ed 3. New York: Thieme Publishers, 2014.
Fig. 46-3 From Nahai F, ed. The Art
of Aesthetic Surgery: Principles &
Techniques, ed 2. New York: Thieme
Publishers, 2011.
Figs. 46-4 through 46-7 From Rohrich
RJ, Adams WP Jr, Ahmad J, Gunter JP,
eds. Dallas Rhinoplasty: Nasal Surgery
by the Masters, ed 3. New York: Thieme
Publishers, 2014.
Chapter 48
Fig. 48-9, B From Ozturk CN, Li Y, Tung R,
et al. Complications following injection of

2013.
Chapter 49
Figs. 49-1 and 49-8 Data from Cohen
SR. Genioplasty. In Achauer BH, Eriksson
E, Guyuron B, et al, eds. Plastic Surgery:
Indications, Operations, and Outcomes,
vol 5. St Louis: Mosby-Elsevier, 2000.
Figs. 49-4 and 49-7 From Nahai F, ed.
The Art of Aesthetic Surgery: Principles
& Techniques, ed 2. New York: Thieme
Publishers, 2011.
Table 49-1 Data from Guyuron B, Michelow

deformities. Aesthetic Plast Surg 19:257,
1995.
Chapter 50
Fig. 50-4 From Bentz ML, Bauer BS,
Zuker RM, eds. Principles and Practice of
Pediatric Plastic Surgery, ed 2. New York:
Thieme Publishers, 2016.
Chapter 51
Figs. 51-1, 51-3, 51-8 From Hall-Findlay
EJ. Aesthetic Breast Surgery: Concepts &
Techniques New York: Thieme Publishers,
2010.
Figs. 51-5 and 51-6 From Jones GE.
Bostwick’s Plastic & Reconstructive
Breast Surgery, ed 3. New York: Thieme
Publishers, 2010.
Chapter 52
Fig. 52-1 Data from Kirwan L.
Augmentation of the ptotic breast:
simultaneous periareolar mastopexy/
breast augmentation. Aesthet Surg J
19:34, 1999.
Fig. 52-3 From Fisher J, Handel N, eds.
Problems in Breast Surgery: A Repair
Manual. New York: Thieme Publishers,
2014.
Table 52-1 From Adams WP Jr, Mallucci P.
Breast augmentation. Plast Reconstr Surg
130:598e, 2012.

963
Credits
Table 52-2 From Hidalgo DA. Breast
augmentation: choosing the optimal
incision, implant, and pocket plane. Plast
Reconstr Surg 105:2202, 2000.
Chapter 53
Fig. 53-1 Data from Kirwan L.
Augmentation of the ptotic breast:
simultaneous periareolar mastopexy/
breast augmentation. Aesthet Surg J
19:34, 1999.
Fig. 53-4 Data from Rohrich RJ, Thornton
JF, Jakubietz RG, et al. The limited scar
mastopexy: current concepts and
approaches to correct breast ptosis. Plast
Reconstr Surg 114:1622, 2004.
Table 53-1 Data from Rohrich RJ, Beran SJ,
Restifo RJ, et al. Aesthetic management
of the breast following explanation:
evaluation and mastopexy options. Plast
Reconstr Surg 101:827, 1998.
Chapter 54
Fig. 54-2 From Hall-Findlay EJ. Aesthetic
Breast Surgery: Concepts & Techniques
New York: Thieme Publishers, 2010.
Table 54-1 Data from Stevens WG,
Freeman ME, Stoker DA, et al. One-stage
mastopexy with breast augmentation:
a review of 321 patients. Plast Reconstr
Surg 120:1674, 2007; and Calobrace
MB, Herdt DR, Cothron KJ. Simultaneous
augmentation/mastopexy: a retrospective
5-year review of 332 consecutive cases.
Plast Reconstr Surg 131:156, 2013.
Table 54-2 Data from Lee MR, Unger JG,
Adams WP Jr. The tissue-based triad:
a process approach to augmentation
mastopexy. Plast Reconstr Surg. 134:215,
2014.
Chapter 55
Fig. 55-4 From Nahai F, ed. The Art
of Aesthetic Surgery: Principles &
Techniques, ed 2. New York: Thieme
Publishers, 2011.
Chapter 57
Fig. 57-1 From Nahai F, ed. The Art
of Aesthetic Surgery: Principles &
Techniques, ed 2. New York: Thieme
Publishers, 2011.
Fig. 57-3 Data from Rohrich RJ, Smith
PD, Marcantonio DR, Kenkel JM. The
Zones of Adherence: Role in Minimizing
and Preventing Contour Deformities in
Liposuction. Plast Reconstr Surg 107:1562,
2001.
Chapter 58
Fig. 58-2 From Appelt EA, Janis JE, Rohrich
RJ. An algorithmic approach to upper arm
contouring. Plast Reconstr Surg 118:237,
2006.
Fig. 58-7 From Aly A, ed. Body Contouring
After Massive Weight Loss. New York:
Thieme Publishers, 2006.
Table 58-1 From Rohrich RJ, Beran SJ,
Kenkel JM, eds. Ultrasound-Assisted
Liposuction. New York: Thieme Publishers,
1998.
Chapter 59
Fig. 59-1 From Aly A, ed. Body Contouring
After Massive Weight Loss. New York:
Thieme Publishers, 2006.
Figs. 59-3 and 59-4 From Mendieta CG.
The Art of Gluteal Sculpting. New York:
Thieme Publishers, 2011.
Chapter 60
Fig. 60-7 From Pollock H, Pollock T.
Progressive tension sutures: a technique
to reduce local complications in
abdominoplasty. Plast Reconstr Surg
105:2583; discussion 2587, 2000.
Fig. 60-8 Data from Heller JB, Teng E, Knoll
BI, et al. Outcome analysis of combined
lipoabdominoplasty versus conventional
abdominoplasty. Plast Reconstr Surg
121:1821, 2008.

964
Credits
Fig. 60-12 Reprinted from Disease of the
Month, Vol. 51, Caprini JA, Thrombosis risk
assessment as a guide to quality patient
care, 2005, with permission from Elsevier.
Box 60-1 Data from Rosenberger LH,
Politano AD, Sawyer RG. The surgical care
improvement project and prevention of
post-operative infection, including surgical
site infection. Surg Infect (Larchmt)
12:163, 2011.
Chapter 61
Table 61-3 From Song AY, O'Toole JP,

deformities after massive weight loss:
application of the Pittsburgh rating scale.
Semin Plast Surg 20:24, 2006.
Chapter 62
Fig. 62-7 From Aly A, ed. Body Contouring
After Massive Weight Loss New York:
Thieme Publishers, 2006.
Fig. 62-8 From Rubin JP, Toy J. Mastopexy
and breast reduction in massive-
weight-loss patients. In Nahai F, ed. The
Art of Aesthetic Surgery: Principles &
Techniques, 2nd ed. New York: Thieme
Publishers, 2011.
Fig. 62-9 From Nahai F, ed. The Art of
Aesthetic Surgery: Principles & Techniques,
ed 2. New York: Thieme Publishers, 2011.
Table 62-1 Data from National Institutes

obesity by bmi, waist circumference, and
associated disease risks.
Chapter 63
Figs. 63-1 and 63-14 through 63-17 From
Nahai F, ed. The Art of Aesthetic Surgery:
Principles & Techniques, ed 2. New York:
Thieme Publishers, 2011.
Table 63-1 Data from Mirzabeigi JN, Jandali
S, Mettel RK, et al. The nomenclature
of “vaginal rejuvenation” and elective
vulvovaginal plastic surgery. Aesthet Surg J
31:723, 2011.
Table 63-2 Data from Felicio Y. Labial
surgery. Aesthet Surg J 27:322, 2007.
Chapter 65
Fig. 65-1 From Salgado CJ, Monstrey

Medical and Surgical Perspectives. New
York: Thieme Publishers, 2017.
Fig. 65-2 From Capitán L, Simon D, Meyer
T, et al. Facial feminization surgery:
simultaneous hair transplant during
forehead reconstruction. Plast Reconstr
Surg 139:573, 2017.
Figs. 65-3 through 65-9; Table 65-1 From
Monstrey SJ, Ceulemans P, Hoebeke P.
Sex reassignment surgery in the female-
to-male transsexual. Semin Plast Surg 25:
229, 2011.
Several Figs. and Chapters 31, 39 and 54
were previously published in Janis JE, ed.
Essentials of Plastic Surgery, ed 2. New
York: Thieme Publishers, 2014.

Index
965
A
Abdominal wall, anatomy of, 837-840
Abdominoplasty
aesthetic aspects of, 840
after massive weight loss, 874-876
anesthesia guidelines for, 98-100
common malpractice claims and, 53
complications of, 852-853
contraindications for, 841
indications for, 840-841
infection and, 177
informed consent for, 844-845
postoperative care after, 851-852
preoperative evaluation for, 842-843
relevant anatomy for, 837-840
techniques for

high-lateral-tension abdominoplasty,
849-850
lipoabdominoplasty, 848
miniabdominoplasty, 848-849
progressive tension sutures, 847
reverse abdominoplasty, 851
traditional abdominoplasty, 845-847
using progressive tension sutures, 344
and venous thromboembolism, 99, 162,
164, 165
Ablative laser resurfacing
anesthesia for, 214-216
complications of, 218-220
general characteristics of, 206
goals of, 212
markings for, 214
postoperative care after, 217-218
for rejuvenation of perioral region, 535-536
safety, 214
using carbon dioxide laser
physics, 212-213
technique, 216
using erbium:yttrium aluminum garnet
laser
physics, 213
technique, 216-217
using fractional laser, 213-214
Abrading tips, 262-263
diamond fraise, 262
serrated wheel, 263
wire brush, 263
Absorption, lasers and, 206
Accupoint electrostimulation, as antiemetic
therapy, 79
Acellular dermal graft, micronized, 648
Acetaminophen, for analgesia, 111-112
Acetone, as a degreasing agent, 242
Acid aspiration prophylaxis, 67
Acne
after carbon dioxide laser therapy,
220
treatment, 199
Acneiform eruptions, after chemical peels,
255
Acrocordon, 188
Actinic keratosis, 187
Adipocyte transplantation, complications
of, 311-312
Adnexal structures of skin, 181
Aesthetic evaluation
of Asian eyelid, 466
of breast, 719-721
for facial feminization, 934-937
of lower eyelid, 452
of upper eyelid, 438-440
Aesthetic medicine, goals of, 13
Aesthetic surgeon, role of, 3


Aging skin, causes of, 191
AHAs; see Alpha-hydroxy acids
AICD; see Automated implantable cardio-

Airway management, general principles,
71-72
Alar base, correction of, 610-612
Alar rim deformities, correction of, 611-
612
Alcohol, and surgical complications, 148
All-trans-retinoic acid, 240
Alloderm, 338

966
Index
Allogeneic materials
bilaminate neodermal natrix, 338
general characteristic of, 337
homologous bone, 337
homologous cartilage, 337
homologous dermis, 338
lyophilized fascia, 337
Alloplasts

341

high-density porous polyethylene,
339
hydroxyapatite, 339-340
metals, 338-339
polydioxanone, 342
polyglactin 910, 342
polylactic acid derivatives, 341
silicone, 340-341
Aloe vera, 195
Alopecia, 73, 402
Alpha-hydroxy acids, 193-194, 250
Ambulation, and venous thromboembolism
prophylaxis, 153-154
Ambulatory surgery centers
accreditation of, 174
and cosmetic procedures, 176

federal regulations for, 175
and Medicare, 175
patient selection, 177
standards for, 175
state regulations for, 175-176
Ambulatory surgery, decision-making for,
88-91
American Society for Aesthetic Plastic
Surgery logo, 14
American Society of Anesthesiologists

121-122
American Society of Plastic Surgeons seal,
18
Aminolevulinic acid, as treatment for skin
cancer, 187
Anagen, 182, 402
Analgesia; see Multimodal analgesia; opioids
analgesic options for, 111-112
Anchor blepharoplasty, 444
and total intravenous anesthesia, 60
Anesthesia
ablative laser therapy and, 214-215
airway management for, 71-72
American Society of Anesthesiologists

65-66
for blepharoptosis repair, 502-503
for chemical peel procedures, 241
considerations with administration of, 61
critical preoperative patient information,
62
fasting guidelines for, 66-67
functional status and metabolic equiva-
lents, 67-68
general principles of, 59-61
identifying risk factors for, 62-63
-
ers, 650
malignant hyperthermia and, 79-81
for massive-weight-loss patients, 883-
884
model of provider(s), 61
monitored anesthesia care, 68-71
nonablative laser therapy and, 225
postanesthesia recovery unit care, 81
patient selection for, 61-62
perioperative considerations for
ambulatory surgery, 88-91
cardiovascular diseases, 85-86
herbal supplements, 91-92
hypothermia, 74-76
obstructive sleep apnea, 87-88
pulmonary diseases, 86-87
positioning for, 73-74
postoperative and postdischarge nausea
and vomiting, 76-79
preoperative evaluation for, 61-62
preoperative screening for, 61-62
preoperative testing for, 63-65

abdominal procedures, 98-100
body contouring after massive weight
loss, 98-100
botulinum toxin injection, 272
breast procedures, 98-100
facial laser resurfacing, 97-98
facial plastic surgery, 95-97
fat grafting, 299, 304, 305, 307
hair transplantation, 405

967
Index
indications for, 764
outcomes of, 765, 767
postoperative care after, 767
surgical planning and treatment, 765-
767
techniques for
single-stage procedure, 764-765
two-stage procedure, 765
Augmentation; see Augmentation-
mastopexy; breast augmentation;
lip augmentation
Autoaugmentation, 833
Autografts
bone, 336
cartilage, 336

Autologous fat augmentation, 833-834
-
brillator, 85

Avobenzone, 189
Azelaic acid, 199
B

743
Balanced technique, for general anesthesia,
60
Baldness, patterns of, 403-404
Bariatric surgery, techniques for, 870-871
Barr, Mark, 15

Basal cell cancer, 186
BCC; see Basal cell cancer
Beam shape, lasers and, 206
Beauty
ancient concepts, 13-14
classical concepts, 17-18
golden ratio, 14-15
Vitruvian Man, 16-17
Belotero products, 287
Belt lipectomy, 874-876
Benzodiazepine reversal, 71
Beta-lipohydroxy acid, 239
BIA-ALCL; see Breast implant-associated ana-
plastic large cell lymphoma
Bilopancreatic diversion, 871
Biomaterials, nonbreast
allogeneic materials, 337-338
alloplastic materials, 338-341
liposuction, 98-100

upper blepharoplasty, 442
pulmonary aspiration prevention, 66-67
Angiomas, 188
Anguloplasty, 672-673
Anterior jugular vein, 382
Anterior triangle of neck, 387
Antibiotic prophylaxis, for methicillin-
resistant Staphylococcus aureus,
149
Anticoagulation, and laser therapy, 210
Antiemetic therapy, for postoperative nau-
sea and vomiting, 78-79
drugs most commonly used for, 79
Antifungals, laser therapy and, 210

healing, 185

healing, 185
Antioxidants, 193, 194
Antivirals, laser therapy and, 210
Aortic stenosis, perioperative anesthesia
considerations for, 85

Aphrodite of Milo; see Venus de Milo
Apnea-hypopnea index, 87

Applicators, for chemical peel agents, 242
approach for proper management of,
110-111
Arbutin, 199
Arcuate expansion, 363
Arms, photographic series for, 34
Arnica montana, 146, 294, 446
ASCs; see Ambulatory surgery centers
Aspiration prophylaxis medications, 67
Aspirin, for venous thromboembolism pro-
phylaxis, 165
Asthma, perioperative anesthesia consider-
ations for, 86

294
Atypical melanocytic nevi, 188
Aufricht, Gustave, 18
Augmentation-mastopexy
special considerations for, 759
algorithm for selecting, 766
alternatives to, 764
complications of, 767

968
Index
Blood glucose, preoperative testing for, 64
Blood loss, recommendations based on an-
ticipated amount of, 123
BMI; see Body mass index
Body contouring
after massive weight loss
anesthesia guidelines for, 100-102
for back, 877-878
for breasts, 879-881
for buttocks, 877
complications of, 884-885
for face and neck, 882-883
liposuction, 871
medial thigh lift technique, 862-863
for medial thighs, 878-879
preoperative evaluation for, 872, 873
safety concerns for, 883-884
staging considerations for, 873
for trunk/abdomen, 874-876
for upper arms, 882
for waist and lateral thighs, 876
noninvasive techniques for
cryolipolysis, 927-929
high-intensity focused ultrasound,
929-930
low-level laser therapy, 931
Body dysmorphic disorder
characteristics of, 7
incidence of, 7
medicolegal considerations, 45
recognizing patients with, 3
Body language, medicolegal considerations
and, 47
Body mass index

liposuction and, 124
obesity and, 90-91, 869

postbariatric body contouring and, 132,
133
Body, photographic series for
for massive weight loss, 35-36
standard male series, 34-35
standard series, 32-33
supplemental views, 33-34
Bone graft, 336, 337
Botanicals, 194
Bottom surgery
female-to-male surgery
metoidioplasty, 952-953
phalloplasty, 953-955
testicular and erectile implants, 955
Biomaterials, nonbreast—cont’d
autografts, 336
biologic reactions to, 335

ideal properties of, 335
resorbable types of, 341-342
Bioocclusive dressings, 217
Bispectral index, 60

Blepharoplasty
Asian
complications of, 479-480
preoperative evaluation for, 466-468
techniques, 468-471
common malpractice claims and, 52
comparison of Asian and white eyelids,
462-466
of lower eyelid
anatomy, 451-453
complications, 458
for correction of tear trough deformity,
487-488
postoperative care, 458
techniques, 454-457
of upper eyelid
anatomy, 429-435
equipment, 441
indications, 429-435
informed consent, 440-441
postoperative care, 445-449
preoperative evaluation, 436-440
techniques, 441-445
Blepharoptosis
anesthesia for, 502-503

etiologic factors for
acquired ptosis, 500
congenital ptosis, 499-500
pseudoptosis, 499
true ptosis, 499
preoperative evaluation for, 501
algorithm for procedure selection, 503
relevant anatomy for, 498-499
techniques for
external levator resection, 506-507
Fasanella-Servat procedure, 503-504
frontalis suspension, 507
levator aponeurosis advancement,
504-506
levator reinsertion, 507
Müller muscle-conjunctival resection,
504

969
Index
examination of, 720-721
photographic views, 721
footprint, 720
hypertrophy of, 769
innervation of, 714-715
lymphatic drainage of, 718-719
muscles of, 717-718
shape and aesthetics of, 719-720
skin and parenchyma of, 716, 751
venous drainage of, 714
Breast augmentation
complications of, 739-745
contraindications for, 724
history of implants, 723-724

implant shape/dimension, 729-730
implant size, 730
implant texture, 729
implant volume, 728
indications for, 724
informed consent for, 726-727
instrumentation for, 727
photographic series for, 38
postoperative care after, 739-740
and postoperative pain, nausea, and vom-
iting, 177
preoperative evaluation for, 724-726
technical point, 738-739
techniques for
incision location, 735-738
markings, 730
pocket position, 731-734
Breast implant-associated anaplastic large
cell lymphoma, 746-747
Breast reduction
in adolescents, 777
after irradiation, 779
common malpractice claims and, 52
complications of, 783-785
and free-nipple grafting, 782-783
indications for, 769-770

informed consent for, 771
outcomes, 782
and pedicle transection, 779
photographic series for, 39
postoperative care after, 783
postoperative drains for, 781
preoperative evaluation for, 770-771
preoperative mammography for, 782
secondary surgery, 777-778

male-to-female surgery
colon vaginoplasty approach, 949-951

948-949
Bottoming out, 742
Botulinum toxin, injection of
anesthesia for, 272
complications of, 278
contraindications to, 270

history of, 269-270
immunogenicity, 272-273
indications for, 270
informed consent for, 271-272
patient evaluation for, 271
physiology, 269-270
postoperative care after injection of, 277
precautions for using, 270-271
reconstitution of, 272
storage of, 272
syringe and needles for using, 272
technique, 273
for chin, 276-277
for forehead, 274-275
for glabellar complex, 273-274
for lateral periorbital region, 275
for masseter, 277
for nasal region, 274
for necklift, 569
for perioral region, 275-276
Boxy nasal tip, types of, 610
Brachioplasty
after massive weight loss, 882
equipment for, 821
indications for, 818
informed consent for, 820-821
operative procedure for, 824-825
postoperative care after, 826
preoperative evaluation for, 819-820
relevant anatomy for, 818-819
techniques for
liposuction, 825-826
markings, 821-822
two-ellipse technique, 823
Brag books, 53
Breast
arterial supply to, 713-714
development of, 711-712



embryology of, 711

970
Index
Cannulas
for fat grafting, 298, 302
for liposuction, 804
Canons, neoclassical, 18-19, 391
Caprini risk assessment model for venous
thromboembolism, 160-162,
853

Capsular contracture, 742-745
Capsulopalpebral fascia, 362
Carac, 187, 189
Carbon dioxide laser
equipment, 212-213
for perioral rejuvenation, 535
postoperative care after, 217-218
Cardiac arrhythmias, as complication of
chemical peels, 254
Cardiac implantable electronic device, 85

Cardiovascular testing, advanced preopera-
tive, 65
Carotenoids, 194
Cartilage graft, 336, 337
Catagen, 182, 402
Cavernous sinus thrombus, 563
Cellulite, 800-801
Centralizing genioplasty, 686
Cephalometric points, for genioplasty,
677
Cerebrovascular disease, perioperative an-
esthetic considerations for, 85
Cervical spinal nerves, 377-378
Cervicomental angle, 681
Chamomile, 195
Characteristics of aesthetic surgery
patients, 3
Cheek
assessment of, 399, 542
fat compartment of, 373
Chemical peel
agents
beta-lipohydroxy acid, 239
croton oil, 237-238
glycolic acid, 235-236
Jessner solution, 236
Phenol-croton oil and TCA, 238
salicylic acid, 238-239
trichloroacetic acid, 237

241
choice of applicator, 242
Breast reduction—cont’d
techniques for
excisional reduction, 772-777
suction lipectomy, 771-772
Breast-feeding, after breast reduction, 784
Broadband light, 224
Bromelain, 146, 294, 446
Brow
assessment of, 394

innervation of, 366
photographic series for, 27-28
Browlift
complications of, 426-427
alopecia, 427
contour deformities, 427
facial nerve injury, 427
overelevation, 427

423
goals of, 418

patient evaluation for, 416-418
postoperative care after, 426
preoperative planning for, 418
techniques for
custom coronal incisions, 416, 417

incision options, 418-422
progressive tension sutures, 345
Browpexy, direct, 444
Buttock augmentation
complications of, 834-835
contraindications for, 828
equipment for
autologous fat grafting, 830
silicone implants, 830
indications for, 828
informed consent for, 830
postoperative care after, 834
preoperative evaluation for, 829
techniques for
autologous fat augmentation, 833-834
autologous fat grafting, 830-832
silicone implants, 832-833
C

Cancer detection, preoperative and postop-
erative, 747
Cancer, of skin, 186-187