Master Techniques in Facial Rejuvenation 2

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INTRODUCTION
The basis for all facial rejuvenation is an appreciation
for normal aesthetic beauty and anatomy, the recogni­
tion of aging changes, and the knowledge to use various
techniques, procedures, and biomaterials to recreate a
more youthful face.
In the youthful face, roundness and volume abound
and the beauty in the midface is frequently referred to as
“apple cheeks.” This term pretty much says it all about
youth; roundness and fullness. In many senses, youth is
beauty and beauty is youth. As we age numerous changes
occur in the hard and soft tissues that contribute to the
aging face. Intrinsic factors such as heredity and extrinsic
factors such as sun exposure and smoking all have an
effect on how we look.
As early as the middle of the third decade, younger
patients begin to experience subtle midface volume loss.
As injectable facial fillers have become more common,
one of my most frequent treatments is filler midface aug­
mentation in patients in their 30s and 40s. Even patients
realize that they lose volume at an early age (Fig. 21.1).
Facial aging in many ways is a process of deflation
from volume loss. It was only several decades ago that
cosmetic facial surgeons simply pulled skin over a skel­
etonized face during facelift without restoring volume.
This created a situation where patients look tighter but
not younger. Over the past several decades facial reju­
venation has become more focused on creating natural
and youthful results by adding volume to facelift surgery.
Instead of just taking something away (skin and fat) we
are adding something back (implants, fat transfer, fillers)
to reinflate the aging face. Simply stated, contemporary
cosmetic facial surgeons realize the importance of volume
augmentation during rejuvenation.
One of the hardest things for the novice surgeon is
to make an accurate diagnosis of midfacial volume loss
and choose the proper treatment to correct it. Younger
surgeons have always had fillers as an option for cheek
enhancement, but those of us who have been practicing
for decades well remember the days where the only fillers
were collagen and they did nothing for the cheeks. In that
era, both facial implants and fat transfer were scientifi­
cally studied and refined into the mainstays in volume
enhancement they remain today.
Today’s facial surgeons can look at a patient with mid­
facial volume loss and decide on numerous treatments,
including injectable filler, fat transfer, midface lifting pro­
cedures, and silicone midface implants. Which is the best
option? That is a wide-open question and the true answer
is whatever works best in the hands of a specific surgeon
and provides a safe and natural patient result. Second­
ary to this broad answer, silicone implants have distinct
advantages over other therapies for numerous reasons.
Silicone implants are superior because:
• they are extremely biocompatible and inert
• they are permanent when anchored to the facial
skeleton with screws
• they are reversible (very few procedures are perma­
nent but reversible)
• they are adjustable as they can be trimmed, custom­
ized, or surgically exchanged for larger or smaller
sizes
• they come in a vast array of sizes and shapes
• they can be customized from computed tomography
(CT) scans
• they provide 3D augmentation
• they can be used in conjunction with other proce­
dures or as a standalone treatment
• they have an easy learning curve with low complica­
tion rates when properly performed.
In the consideration of the above list when comparing
other treatments:
• midface fillers are temporary
• fat transfer to the midface can be problematic in
longevity, mobility, and because it is placed in soft
tissues, will sag with age
• lifting procedures for the isolated midface, although
well described, have not made the impact that
implants have on facial rejuvenation and are not
permanent.
For all the above reasons I personally feel that midface
implants are the best available option for midface
rejuvenation.
DIAGNOSIS
Diagnosis of the aging midface is relatively straightfor­
ward, as it remains relatively constant in healthy indi­
viduals. The basis of a youthful midface is the malar fat
pad. This structure is triangular in shape, with the base
lying on the nasolabial fold and the apex lying on the
malar region in younger patients (Fig. 21.2).
As the hard and soft tissue aging progress, the fat pad
descends and atrophies. As this occurs the nasolabial fold
deepens and the tear trough region becomes more skel­
etal because of periorbital hard and soft tissue changes.
If you ask a patient with an atrophic midface to smile,
they look younger because the muscles elevate and fill the
midface. Having a patient with midface loss lay back in a
C H A P T E R 21 
Midface Implants
Joe Niamtu, MD, FACS

21  Midface Implants
271
chair and look in the mirror will also illustrate the aging
changes as well as show them a prediction how cheek
implant results will look. When gravity is removed from
the situation and the patient is supine, the jowls fall back
and fill the cheeks. This is how I show patients “surgical
predictions” (Fig. 21.3).
As stated, accurate analysis of the aging face requires
an understanding of the aging changes. My most basic
diagnostic tool is to keep a mental image of a youthful
midface and compare what is “missing” in the aging
patient. For the most part, the cheek region can be grossly
broken down into three regions (Fig. 21.4):
• the infraorbital region
• the malar/submalar region
• the zygomatic region.
It is important to point out that some patients merely
have developmentally deficient midface regions where the
maxillary and/or malar regions did not project to the
Figure 21.1  This image shows the author (JN), his father who is 27
years older, and his sons who are 4 and 6 years of age. The changes to
the midface across this time continuum show how the volume of youth
deflates and descends with age.
Figure 21.2  The malar fat pad provides the youthful volume in the
midface. With age it becomes atrophic and descends, which in part
contributes to the formation of the jowls.
Figure 21.3  Placing a patient in the supine position and having them
look in the mirror serves to illustrate midface reinflation because gravity
repositions the ptotic tissues to the midface. This position can also give
the patient and surgeon an idea of the anticipated result with implants.
Figure 21.4  The main areas of volume loss and subsequent augmenta­
tion are the infraorbital region (1), the malar/submalar region (2), and
the zygomatic region (3).

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MASTER TECHNIQUES IN FACIAL REJUVENATION
This type of implant is used for either patients with
developmental zygomaticomalar hypoplasia or patients
that want the “high cheekbone” look, which I per­
sonally feel is less contemporary than it was several
decades ago.
The third type of implant is the combined submalar
implant configuration. This type of implant is basically a
combination of the submalar and the malar shell styles,
and is used to treat a broader range of volume loss or
hypoplasia across the entire maxilla and lateral malar
region.
In my practice 95% of facial implants are submalar,
with the combined submalar making up the other 5%.
I may insert a malar shell type implant every several
years.
The Binder type II submalar implant is versatile, in
that even though the configuration is the same, using
different sizes can change the result (Fig. 21.6, left). This
implant has great submalar (and infraorbital) thickness
and then thins out to a less prominent but still significant
malar thickness, which finally totally feathers out for
minimal zygomatic augmentation. The average patient
(male or female) will use a medium-to-large implant.
Bigger patients, or those with more volume loss, may use
an extra-large submalar. In addition, all these implants
may be trimmed with scissors to further customize
the result.
The malar shell implant is used primarily for lateral
malar and zygomatic augmentation (Fig. 21.6, center).
The combined submalar implant runs larger than the
regular submalar configuration. Again, I use this for
patients that have more extreme volume loss or devel­
opmental maxillary and malar hypoplasia (Fig. 21.6,
right). I use a small-sized combined submalar implant
for most females or use a medium size and trim the edges.
Males may require a medium or large size. The large
size of the combined submalar implant is actually quite
large and few patients require that level of augmenta­
tion. One general rule of implant placement is when in
normal level. These patients have flat or hypovolumized
facial features even in youth.
It was not that long ago that custom implants did
not exist and surgeons had to fashion them manually by
carving a silicone block during the operation. Today’s
modern implants are produced on human skeletal models
and conform to the underlying anatomy much like a
store-bought shoe conforms to a foot.
The most common type of implant materials are porous
polyethylene and silicone. Although both materials can
produce a great result, there are numerous drawbacks of
using porous polyethylene material.
Silicone implants form a dense, fibrous capsule and
therefore do not integrate into the soft tissues. Porous
polyethylene implants, on the other hand, do integrate
with the soft tissues, and for this reason can be difficult
and sometimes impossible to remove. Porous polyeth­
ylene implants most commonly fragment upon removal
and are so attached to the soft tissue that muscle and peri­
neural tissue can adhere to the implant and be damaged.
Although there are many shapes and types of implants,
I have found over the three decades that I have been
placing facial implants that there are three main sizes that
will suffice in 99% of normal patients.
The most common type of aging change and con­
figuration of implant I place is the submalar type (Fig.
21.5). The Binder type II submalar silicone implant
() is my preferred implant
for most patients from the later third decade onwards.
This implant is available in the solid configuration or the
conform configuration, which has a cross-hatched poste­
rior surface. I do not use the conform configuration, as it
is overly flexible and I prefer the more rigid solid implant.
The advantage of the conform configuration is that if
it is not being screw fixated, the cross-hatched surface
provides increased stabilization during healing. Because
I fixate all implants it is of no benefit to me.
The malar shell–type implant is a configuration that I
seldom use, but it remains common with some surgeons.
Figure 21.5  This image shows the infraorbital, malar, and zygomatic regions that influence aging deflation and rejuvenative inflation. The patient
on the left has typical submalar deflation and is an excellent candidate for a submalar implant. The middle picture shows a patient with adequate
submalar volume but requiring malar augmentation and could be treated with a malar shell–type implant. The right image shows a patient with
both submalar and malar deficiency, who would be an excellent candidate for a combined submalar implant.

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SURGICAL TECHNIQUE
Cheek implant placement is a relatively simple and expe­
dient technique with a short learning curve for surgeons
who are familiar with the maxillofacial anatomy. Midface
implants can be placed with local anesthesia, but in my
practice virtually all surgery is performed with intra­
venous sedation or general anesthesia in an accredited
ambulatory surgery center. All patients are placed on a
cephalosporin for 1 week and given a prescription for
analgesic. An intraoperative dose of intravenous antibiot­
ics and steroid is given during the procedure.
The first step is local anesthetic infiltration at the peri­
osteal level across the maxilla and zygoma, and intra­
orally in the mucosa for hemostasis (Fig. 21.7).
After waiting sufficient time for the local anesthesia to
take effect, the incision is made on the first side. A 1-cm
incision is made just at the maxillary sulcus in the mobile
mucosa (Fig. 21.8). The oral mucosa is extremely pliable
and stretches to accommodate instruments, so large inci­
sions are not required. Larger incisions also produce
increased local bleeding and lead to larger dissections,
which are unnecessary and produce more morbidity.
The incision is made with scalpel, cautery, or radiowave
microneedle (my personal choice) through the mucosa
all the way through the periosteum to the bone. The first
rule of facial implants is that they must all be placed in
doubt, use a smaller implant. An implant that is a little
too small may look fine, but an overly large implant can
look very unnatural. Caution is also used with younger
patients seeking “celebrity” cheeks. I require these types
of patients to perform cheek filler first to make sure they
truly like their look. The actual size selection is more of
an art than a science and comes with experience. The use
of intraoperative sizer implants will be discussed later in
the chapter.
PRESURGICAL CONSIDERATIONS
When patients present or consult for cheek implants, the
entire dialog of diagnosis and treatment is presented.
Cheek implant placement is very foreign to some patients,
and having actual implants, models, figures, animations,
and so on is very helpful for education. Viewing actual
before and after pictures is also extremely useful.
A physical examination for any asymmetry or pathol­
ogy is completed, as well a comprehensive dental and
periodontal examination. Panoramic radiograph or cone
beam CT is performed to rule out any osseous, dental, or
sinus pathology that could affect the implants.
The sequelae and potential complications of implant
placement are discussed, including swelling, temporary
paresthesia, bleeding, infection, hardware rejection, over­
correction, undercorrection, and so on.
Figure 21.6  This image shows submalar, malar and combined submalar implants.
Figure 21.7  Local anesthesia is infiltrated at the periosteal level across the maxilla, malar, and zygomatic regions.

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MASTER TECHNIQUES IN FACIAL REJUVENATION
the subperiosteal plane without exception. There is no
significant anatomy to injure at the level of the incision.
Once the bone is encountered, a No. 9 Molt periosteal
elevator is inserted and the subperiosteal dissection is
continued in a superior direction but must stop short of
the infraorbital foramen and neurovascular bundle (Fig.
21.9). The infraorbital neurovascular bundle is the main
structure of significance during cheek implant placement
and must be protected at all times. Minor medial dis­
section is completed several millimeters away from the
piriform aperture.
After the short distance of vertical subperiosteal dis­
section, the periosteal elevator is angled in a superiolat­
eral direction across the maxilla and malar region (Fig.
21.10). The thumb and index finger are placed on either
side of the frontozygomatic suture to guide the dissection
and also to protect the orbit in the event that instrument
should slip (Fig. 21.11).
After the dissection is completed, the periosteal eleva­
tor is moved medially and laterally to make a sweeping
motion to perform the final dissection (Fig. 21.12). This
can also be performed with the index finger.
It is important to keep the dissection pocket as small
as possible. The actual pocket should be only slightly
larger than the implant to prevent dead space and implant
mobility (Fig. 21.13).
Hemostasis is performed with a small bipolar cautery.
Small submalar type implants will have the smallest
pockets and large combined submalar implants will have
the largest pockets. The combined submalar and malar
shell implants both require extended dissection over the
lateral malar and zygomatic regions. With larger inferi­
olateral dissections it is not uncommon to encounter the
Figure 21.8  A 1-cm incision is made to the bone level above the canine
tooth at the upper sulcus.
Figure 21.9  The subperiosteal dissection proceeds superiorly but stops below the level of the infraorbital nerve.

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proper size (Fig. 21.16). Although experienced implant
surgeons frequently know what type and size of implant
they will use, the sizers are very helpful in determining
the right implant.
The surgeon must remember that the intraoperative
outcome from the placement of sizers is only approxi­
mate because the flap is dissected, the lip elevators are
incised, and the tissues are engorged from the local anes­
thesia. Nevertheless, this gives the surgeon and the surgi­
cal team (from whom I always seek opinion) a general
ideal of result.
masseter tendon as it inserts on the zygoma and zygo­
matic arch (Fig. 21.14). There is no reason to dissect this
region deeply. The implant can lie over this soft tissue
without problem. The dissection needs to extend infe­
riorly and laterally enough to accommodate the specific
implant used.
After the subperiosteal pocket is successfully delin­
eated and dissected, the area is irrigated with antibiotic
solution (Fig. 21.15).
Implant sizers are available for all size implants and
can be quite useful for the surgical team to determine the
Figure 21.10  The vertical dissection is completed to a level below the infraorbital nerve and then is redirected superiolaterally over the malar
and zygomatic regions.
Figure 21.11  The lateral dissection proceeds toward the zygomatic region. The fingers are placed over the frontozygomatic region to guide the
dissection and protect the orbit.

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MASTER TECHNIQUES IN FACIAL REJUVENATION
occur as the tail is very thin. If this would occur, a notice­
able and palpable bump can occur on the lateral malar
region (Fig. 21.17).
Because these types of implants are anatomic, they
“find” their own position on the underlying bone. The
contour of the implant migrates to the contour of the
bone, which is usually close to the desired position
(Fig. 21.18).
Although the implants are anatomic, they will float
several millimeters in all directions and need to have
their position finalized before fixation. Once the implant
is placed, the soft tissues are manipulated by pushing on
the cheeks and pulling on the lips. If the implant extrudes,
it means it is too large and either the dissection needs to
be enlarged or the implant trimmed (Figs. 21.19–21.20).
My preference is to fixate midface implants internally.
An implant that is not fixated may heal well, but it may
also displace immediately or later. I have revised and
repositioned many implants placed by other surgeons
that were not fixated. I have never had a fixated implant
migrate. In addition, an infected implant that is screw
fixated can frequently be irrigated and salvaged, whereas
a mobile implant is a foreign body that must be removed
to treat an infection.
Once the correct size is determined, the sterile implant
is removed from the package and kept in the antibiotic
solution away from paper, surgical debris, glove powder,
and so on. The pocket is once again irrigated with antibi­
otic solution and the implant is placed. It is very impor­
tant to not fold the tail under the implant, which can
Figure 21.12  A sweeping motion is made with the periosteal elevator
to assist in dissection.
Figure 21.13  The implant pocket (illustrated here by the dotted line)
should be only slightly larger than the actual implant.
Z
Figure 21.14  This image shows the masseter tendon (white arrow) as
it attaches to the zygoma and zygomatic arch (Z).

21  Midface Implants
277
piriform bone or zygomatic buttress bone. Although
the screw can be placed through the maxilla into the
sinus without problem as commonly done in trauma
and reconstruction, I favor the thicker bone regions.
It is important to avoid the tooth roots when placing
hardware.
After the fixation is completed, the implant must be
inspected for proper placement, which includes the tail
being in the normal position and the implant sitting prop­
erly on the bone. It is imperative that the implant not
impinge on the infraorbital nerve. If the implant is too
close to the infraorbital foramen, a notch has to be made
with a scalpel to avoid nerve impingement (Fig. 21.23).
Any part of the silicone can be trimmed with scissors or
scalpel to customize the implant.
When the surgeon has completed one side, indexing is
performed to standardize the implant position so it can be
duplicated on the contralateral side. For superior/inferior
positioning, I measure the distance from the top of the
implant to the infraorbital foramen. For the lateral posi­
tion, I measure an imaginary line from the leading edge
of the implant to the position of the teeth below. This is
recorded and used to position the implant on the opposite
side (Fig. 21.24). The surgical site is once again irrigated
with antibiotic solution and closed with interrupted 4-0
gut suture. A running suture with water-tight closure is
not performed as it prevents drainage (Fig. 21.25).
After both implants are placed and fixated, the face is
examined for symmetry from various angles (Fig. 21.26).
The posterior view is especially useful for symmetry, as is
palpating the projection of both implants simultaneously.
The implants should not extend grossly below the
zygoma when placing a finger inside the mouth in the
maxillary sulcus. If the implants are grossly palpable into
the sulcus, they need to be repositioned superiorly, as this
low position will bother the patient as well as possibly
erode the mucosa. Several millimeters of palpable implant
in the upper sulcus is not a problem.
Once the implant position is finalized, it is fixated with
a single 2.0-mm titanium microscrew. The screws are self-
drilling and most companies will lend surgeons the kit on
a consignment basis where the screws are paid for as used
(Figs. 21.21–21.22). The screw is placed in the denser
Figure 21.15  Clindamycin antibiotic irrigation is performed several
times throughout the case.
Figure 21.16  This image shows an implant sizer on the face and inside the mouth.

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MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 21.17  It is important not to fold the thin tail above or below the implant body. If this occurs a noticeable bump will result, requiring
repositioning of the implant.
Figure 21.18  The left image shows the implant being inserted into the pocket and the right image shows the implant seating on the contour of
the malar region.
Figure 21.19  After this implant is in a passive position, the lips are manipulated and the cheeks are compressed to see if the implant displaces
from the pocket. If it does, the implant needs to be trimmed or the pocket enlarged.

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POSTOPERATIVE CARE
No dressing is generally used, although gauze placed
in the cheek between the teeth for several hours serves
to compress the region and keep oozing blood from
being swallowed. It is important to leave the gauze tails
outside the mouth to prevent aspiration or swallowing
of the gauze. Some surgeons use a compressive head
dressing.
Like any facial surgery, the patient is told to rest and
refrain from any medications that affect clotting. They
are advised to refrain from excessive facial animation and
to stay on a soft-food diet for 4 to 5 days.
Significant swelling can occur after midfacial implants
and patients are forewarned. A course of 60 mg of pred­
nisone once a day for 5 days without taper is very effective
Figure 21.20  If the implant is too large for the pocket it can be easily
trimmed.
Figure 21.21  Small fixation kits are available for office use on consign­
ment, where the surgeon only pays for the hardware used.
Figure 21.22  The left image shows a 6-mm titanium screw inserted to stabilize the implant and the right image shows the screw in place in the
piriform region.
for facial operations. All patients will experience pares­
thesia in the distribution of the infraorbital nerve, which
will improve over the ensuing weeks. Perioral animation
such as smile and pucker will be decreased because of
the disruption of the lip elevators and generalized edema.
This will usually improve back to normal within a few
weeks. Most patients are able to resume normal activities
7 to 10 days after surgery.

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MASTER TECHNIQUES IN FACIAL REJUVENATION
ION
Implant
Figure 21.23  The top images show a model of nerve impingement and the implant notched to relieve the impingement. The lower images show
the same situation clinically. ION, infraorbital nerve.
Figure 21.24  The left image shows a straight edge used to mark the medial edge of the implant to align with the corresponding tooth below it.
The right image shows the infraorbital foramina and the arrows indicate an example of the distance from the top of the implant. When the first
side is properly in place, these markings are used to replicate the correct implant position on the contralateral side.

21  Midface Implants
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CLINICAL CASES
Figs. 21.27 through 21.34 show before and after images
of silicone midfacial implants.
COMPLICATIONS
Complications after facelift surgery include:
• bleeding
• hematoma
• seroma
• infection
• overcorrection
• undercorrection
Figure 21.25  The incisions are closed with interrupted 4-0 gut sutures.
Gaps are intentionally left between the sutures to allow drainage.
Figure 21.26  The surgeon examines the symmetry from behind and
palpates the implant projection for symmetry.
Figure 21.27  This 45-year-old female underwent a mini facelift, upper blepharoplasty, and concomitant placement of medium type II submalar
implants. The before and after midface changes illustrate the need and utility of cheek augmentation when treating global facial aging changes.

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MASTER TECHNIQUES IN FACIAL REJUVENATION
the case. If blood or fluid expansion occurs in the pocket
it must be aspirated or drained by opening the incision.
Infection is rare and usually manifests early in the
postoperative period. If a significant infection occurs in
a nonfixated implant, it will probably require removal
as it becomes a mobile foreign body. In cases of infec­
tion where the implant is screw retained, the infection is
treated with incision and drainage, antibiotic irrigation,
• malposition
• asymmetry
• extended or permanent paresthesia
• implant mobility
• underlying bony resorption
• hardware problems.
Bleeding, hematoma, or seroma can occur but are rare
and best prevented by meticulous hemostasis throughout
Figure 21.28  This 66-year-old patient exhibited typical aging changes and was treated with comprehensive facelift, four-quadrant blepharoplasty,
full-face carbon dioxide laser resurfacing, and large type II submalar implants.
Figure 21.29  This 24-year-old male model requested a more distinct midface and cheeks. He was treated with large combined submalar shell
implants.

21  Midface Implants
283
has impinged on the infraorbital nerve. Although rare,
buccal or zygomatic nerve weakness can be seen after
implant placement. This is usually from nerve stretching
during the procedure and generally resolves spontane­
ously within 90 days.
A mobile implant can act as a foreign body and
needs to be stabilized. Failure to do so can contribute to
underlying bone resorption. If a surgeon feels that there
are underlying problems with any implant, it should be
explored.
and systemic antibiotics. I have successfully treated
several infections in this manner without removing the
implant.
Positional problems such as having implants that
are too large, too small, or asymmetric can be treated
by changing the side that the patient does not like. An
implant that has migrated needs to be repositioned and
fixated with a screw.
If a patient experiences extended dysesthesia or pares­
thesia, this can be explored surgically to see if the implant
Figure 21.30  This 57-year-old patient shows extreme mid and lower facial ptosis. She was treated with comprehensive facelift, lower blepharo­
plasty, full-face carbon dioxide laser resurfacing, and large combined submalar shell implants.
Figure 21.31  This 44-year-old female was treated with a mini facelift, upper blepharoplasty, and large submalar implants.

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MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 21.32  This 56-year-old male was treated with four-quadrant blepharoplasty, facelift, and medium combined submalar implants.
Figure 21.33  This 52-year-old female was treated with a mini facelift, carbon dioxide laser skin resurfacing, and large submalar cheek implants.

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3. Niamtu J 3rd. Essentials of cheek and midface implants. J Oral
Maxillofac Surg 2010;68:1420–9.
4. Yaremchuk MJ. Secondary malar implant surgery. Plast Reconstr
Surg 2008;121:620–8.
5. Niamtu J. Accurate and anatomic midface filler injection by using
cheek implants as an injection template. Dermatol Surg 2007;33:
1–4.
6. Roy D, Mangat DS. Facial implants. Dermatol Clin 2005;23:
541–7.
7. Binder WJ. Malar and submalar augmentation. Facial Plast Surg
Clin North Am 2008;16:11–32.
8. Terino E, Edwards MC. Alloplastic contouring for suborbital, max­
illary, zygomatic deficiencies. Facial Plast Surg Clin North Am 2008;
16:33–67.
9. Constantinides MS, Galli SK, Miller PJ, Adamson PA. Malar,
submalar, and midfacial implants. Facial Plast Surg 2000;16:
35–44.
10. Tantawi D, Eberlin S, Calvert J. Midface implants: surgical and
nonsurgical alternatives. Clin Plast Surg 2015;42:123–7.
CONCLUSION
Midface implants are a simple, safe, and effective means
for restoring midface volume loss from aging and devel­
opmental deficiency. No other midfacial treatments are
permanent and reversible, and offer such a wide array of
treatment choices. Midfacial implants occupy an impor­
tant place in the armamentarium of the contemporary
cosmetic surgeon.
S U G G E S T E D R E A D I N G
1. Yim HW, Nguyen A, Kim YK. Facial contouring surgery with
custom silicone implants based on a 3D prototype model and
CT-scan: a preliminary study. Aesthetic Plast Surg 2015;39:418–24.
2. Soares DJ, Silver WE. Midface skeletal enhancement. Facial Plast
Surg Clin North Am 2015;23:185–93.
Figure 21.34  This 58-year-old female was treated with facelift, upper blepharoplasty, carbon dioxide laser resurfacing, and large submalar cheek
implants.

286
HISTORY
Chin augmentation has been performed using autografts,
alloplastic materials, and mandibular advancement pro­
cedures. Autografts are complicated by the need for a
donor site, difficulty with shaping the grafts, and their
unpredictable pattern of resorption [1]. In contrast, allo­
plastic implants have proved to be an easy and reliable
means of augmentation. The most common method of
augmentation is with alloplastic implants, including Silas­
tic, Gore-Tex, Mersilene mesh, and Medpore implants
[2,3]. Silastic chin implants have the longest history of
continuous use of any of the alloplastic implants. They
have been safely used since the 1960s with a high degree
of satisfaction. Mandibular advancement procedures
require specialized equipment and add significant mor­
bidity to the procedure with little advantage.
The most significant evolution in mentoplasty has
been in implant design. The earliest Silastic implants
were carved individually by the surgeon. In 1966 Safian
and Dow Corning introduced the first preformed Silastic
implants [1]. These implants were equivalent to what
is now referred to as a curvilinear implant or a central
implant without a lateral component. Augmentation was
isolated to the central mentum and provided only anterior
projection. The next important advancement in implant
design was the introduction of the anatomic style of
implant by Toranto in 1982 [4]. These types of implants
have lateral tapering extensions, which wrap around the
mandible, providing anterior projection of the mentum,
filling of the prejowl sulcus, and an overall recontouring
of the mandible. The result is a more natural augmenta­
tion of the chin–jawline complex. These implants are
available as either anatomical chin implants (Spectrum
Designs Medical, Carpinteria, CA, USA) or extended
anatomical chin implants (Implantech, Ventura, CA,
USA). Realizing the importance of isolated prejowl aug­
mentation in certain patients, Mittleman introduced his
prejowl implant, which has a thin central portion and
provides bulk only in the lateral arms [5].
The surgical technique for mentoplasty using alloplas­
tic implants has not significantly changed in recent years.
The two common surgical approaches are an external
technique through a submental incision and an intraoral
technique through a gingivolabial sulcus incision. Both
approaches are commonly used today, generally deter­
mined by the preference of the individual surgeon.
PERSONAL PHILOSOPHY
An optimal facial skeletal structure serves as the founda­
tion for rhytidectomy and other facial rejuvenation pro­
cedures. Patients with poor skeletal foundations, as seen
with microgenia, will not only tend to show certain stig­
mata of aging earlier, such as poor necklines and jowling,
but will also obtain less than ideal results from a facelift.
In the appropriate patients, correction of microgenia is
a critical technique for facial rejuvenation, either as a
stand-alone procedure or in conjunction with facelifting
(Fig. 22.1).
Alloplastic implantation provides a safe, reliable, and
relatively simple means for chin augmentation. Ideally the
implant should have a very low incidence of infection or
rejection, provide predictable long-term results, and be
easy to remove if necessary. Silastic, a nonporous mate­
rial around which a fibrous capsule forms, meets all of
these criteria [6].
Our preferred implants are the extended anatomic (Im­
plantech), or anatomical (Spectrum Medical), implants;
for the purpose of this chapter we will be referring to
both as “anatomical chin implants.” These implants fill
the central mentum and have lateral arms that fill the
prejowl sulcus to produce a natural jawline. The lateral
arms on these implants also account for the lower in­
cidence of implant shifting relative to the central style
implants. The anatomical style implants are available
from each manufacturer in four sizes, providing between
5 and 9 mm of anterior projection. As the implant size
increases, so does the length and bulk of the implant’s
lateral arms.
Central implants do not have a lateral extension to fill
the prejowl sulcus. In patients with preexisting jowls, the
central implant will accentuate the prejowl sulcus, often
making the jowl appear more prominent. This is the
opposite effect of the extended anatomical chin implant,
which, by filling the prejowl sulcus, will reduce or cam­
ouflage the appearance of a jowl. In younger patients
without jowls, central implants also have the negative
effect of creating a more pointed appearing chin.
When performing mentoplasty we routinely have a
2-mm Silastic extension wafer available [7]. The wafer
provides a degree of intraoperative flexibility in terms
of implant sizing. On intraoperative assessment, if the
patient would benefit from further anterior projection,
a wafer can be placed under the central portion of the
C H A P T E R 22 
Mentoplasty
Robert A. Glasgold, MD, Mark J. Glasgold, MD, and Alvin I. Glasgold, MD

22  Mentoplasty
287
chin implant, increasing anterior central mentum projec­
tion by 2 mm.
We perform all mentoplasties through a submental
incision. The submental incision hides well and facilitates
accurate implant placement, particularly for anatomi­
cal chin implants, which require a lateral subperiosteal
pocket along the anterior-inferior mandibular border.
The submental approach also allows for suture fixation
of the implant to the mandibular periosteum, thereby pre­
venting implant shifting and vertical migration. Implants
placed through an intraoral approach are exposed to
oral contaminants and have a greater likelihood for
infection.
ANATOMY
The chin is composed of the overlying skin, subcutaneous
fat, muscles, and the mandible. The muscle components
of the chin are the mentalis, depressor labii inferioris,
and depressor anguli oris muscles, all of which are inner­
vated by the marginal mandibular branch of the facial
nerve. The mentalis muscle arises from the incisive fossa
on the mandible and inserts inferiorly into the dermis
of the chin. The mentalis muscle elevates the chin pad.
The depressor labii inferioris and depressor anguli oris
muscles arise from the oblique line of the mandible and
insert into the lip. Together they act to depress the lower
lip and corners of the mouth, respectively.
The portions of the mandible relevant to mentoplasty
are the symphysis, parasymphysis, and the body of the
mandible. The mental nerve exits the mental foramen,
and provides sensation to the chin and lower lip. The
mental foramen is generally found inferior to the second
premolar [8]. The mental foramen is approximately
2.5 cm lateral to the midline, and is located 1 cm above
the inferior border of the mandible. The foramen can also
been found at a point midway between the alveolar ridge
superiorly and the inferior edge of the mandible.
The anatomy of the chin-jawline complex changes
with age. Soft tissue and bone atrophy in the central
mentum can lead to, or exaggerate, the appearance of a
receding chin. Development or exaggeration of a prejowl
sulcus is also caused by atrophy of soft tissue and bone.
Age-related atrophy of the anterior mandibular groove,
located inferior to the mental foramen, contributes to the
prejowl sulcus [5]. Jowl formation, which exaggerates the
depth of the prejowl sulcus, results from ptosis of skin,
muscle, and subcutaneous fat.
PREOPERATIVE ASSESSMENT
Deficiencies of the chin are important to assess for both
the older patient seeking facial rejuvenation and the
younger patient desiring an improved facial appearance.
A receding chin produces an imbalance of the lower third
of the face and can be corrected with a chin implant.
Increasing chin projection will also improve the patient’s
appearance on front view, where a weak lower third can
give a rounded, less angular facial appearance.
The most common abnormality of the chin is micro­
genia (retrogenia), which refers to an underprojection of
the chin with normal occlusion. Patients with a receding
chin have a short hyoid-to-mentum distance, often asso­
ciated with an obtuse cervicomental angle. Chin aug­
mentation increases the distance from hyoid to mentum,
providing the appearance of a more acute cervicomental
angle (Fig. 22.2). In younger patients with submental
fullness and good skin tone, the addition of submental
liposuction can significantly enhance the result of chin
implantation (Fig. 22.3).
The simplest and most practical means to determine
appropriate chin projection on profile is by dropping a
line down from the lower vermilion, perpendicular to the
Frankfurt horizontal. Ideally, the pogonion (the anterior
most projection of the chin) should approach this line.
Patients whose projection falls behind this line should
A
B
Figure 22.1  (A) Preoperative and (B) 6-month postoperative views of a patient who underwent mentoplasty with a medium extended anatomical
chin implant and facelift.

288
MASTER TECHNIQUES IN FACIAL REJUVENATION
to evaluate the depth of the prejowl sulcus to determine
if it will be completely effaced by a facelift. In the setting
of more advanced prejowl sulcus volume loss, a rhytid­
ectomy alone may fail to produce the desired jawline.
These patients should be considered for prejowl sulcus
augmentation with or without central mentum projec­
tion, depending on their chin projection on profile.
Analysis of a patient with a receding and aged chin may
reveal volume deficiencies outside of the areas adequately
addressed with an implant. Chin implant placement, and
therefore its area of augmentation, is limited superiorly
by the mental nerve. Individuals with thin faces and more
significant microgenia commonly have a deep labiomen­
tal sulcus. If ignored at the time of surgery, isolated place­
ment of an alloplastic chin implant may exaggerate the
depth of the labiomental sulcus. Proper identification and
be considered for augmentation mentoplasty. Patients
should also be evaluated while smiling, as smiling may
increase projection to a degree that may influence the
choice of implant. The ideal anterior projection is gender
specific. In women, several millimeters of underprojection
is acceptable, whereas men can tolerate slight overprojec­
tion, providing a stronger chin. Malocclusions should be
noted and, if present, referred for orthognathic evaluation.
Development of a prejowl sulcus is a characteristic
sign of aging. In a patient with minimal jowl, filling the
prejowl sulcus with an implant may give a jawline com­
parable to that achieved with a facelift. In patients with
a greater degree of jowling, isolated prejowl sulcus aug­
mentation will be inadequate; in these patients a facelift
is needed to get the optimal jawline rejuvenation. Before
rhytidectomy for correction of the jowl, it is important
A
B
Figure 22.2  Preoperative view of a patient with microgenia, displaying (A) a short hyoid-to-mentum distance and a deep prejowl sulcus and (B)
6-month postoperative view following mentoplasty with a medium extended anatomical chin implant.
A
B
Figure 22.3  (A) Preoperative profile view of a patient with microgenia, a poorly defined jawline, and a prejowl sulcus. (B) One-year postoperative
profile view after correction with mentoplasty with an extra-large extended anatomical chin implant and submental liposuction.

22  Mentoplasty
289
injection (Fig. 22.5). The addition of Botox treatment of
the mentalis muscle will further enhance the contour by
reducing the hyperdynamic nature of this muscle.
Digital photography with computer imaging is helpful
in the evaluation and consultation. Reviewing a patient’s
photograph, particularly on profile, will often help the
patient understand the importance of chin augmenta­
tion for obtaining an optimal result. Computer imaging
allows patients to visualize the effect of augmenting the
chin and filling the prejowl sulcus. For patients who are
more comfortable with a nonsurgical option, hyaluronic
acid–based fillers provide an effective means of doing
this. Patients are counseled that as a long-term solution,
a preformed alloplastic implant is a more cost-effective
option and does not require yearly injections.
SURGICAL TECHNIQUE
Preoperatively all patients receive intravenous prophylac­
tic cefazolin or clindamycin, if allergic to penicillin. The
implant is prepared by placing a guide suture through
each end of the implant to facilitate its placement and
prevent the tail of the implant from folding upon itself
(Fig. 22.6). A 2-0 silk suture threaded onto a Keith needle
is passed through the lateral end of the implant, approxi­
mately 3 mm from the distal edge. This is then repeated
with a second 2-0 silk suture and Keith needle for the
contralateral side. Each of the free ends of the 2-0 silk
are rethreaded onto the Keith needle. The implant is
then soaked in a clindamycin-saline solution until its
placement.
A submental incision, approximately 2 cm in length, is
designed with its central portion just anterior to the sub­
mental crease and gently curving posteriorly to the crease
at the lateral aspects. The superior skin edge is retracted
treatment of this deficiency will optimize both the aes­
thetic result and the patient’s satisfaction. Autologous
fat transfer can be performed concurrently with mento­
plasty to help soften the sulcus. Alternatively, injectable
fillers can be used postoperatively to address this deficit
(Fig. 22.4).
Patients undergoing mentoplasty should be evalu­
ated for certain preexisting conditions, any of which,
if present, should be reviewed with the patient so that
they are aware of these preoperatively. These conditions
include hypesthesia of the chin and lip region, marginal
mandibular nerve weakness, asymmetries of the chin and
jawline, and contour irregularities of the chin. Superfi­
cial skin contour irregularities are quite common with
advancing age, and if not addressed in the consultation,
their persistence postoperatively may be a source of
patient dissatisfaction. The irregular contour (or “peau
d’orange” appearance) is caused by the dynamic nature
of the mentalis muscle, loss of overlying subcutaneous
fat, and decreased skin elasticity. Although increasing
pogonion projection with an implant will have an overall
benefit on the appearance of a receding chin, it will not
correct the irregular skin contour because the implant
sits deep to all of the anatomical structures contribut­
ing to these superficial changes. If the patient desires
improvement in the superficial skin contour, attention
should be focused on a combination of reducing men­
talis muscle hyperactivity and restoring the overlying
tissue buffer (i.e., subcutaneous fat and skin) that cam­
ouflages the muscle. Treatment involves filling superfi­
cial to the mentalis muscle to create a smoother surface.
Injectable hyaluronic acid–based fillers work very well to
smooth contour by injecting into the deep dermis. Deeper
placement of the filler can improve contour, but not to
the degree that can be achieved with more superficial
A
B
Figure 22.4  (A) Preoperatively this patient was displeased with the prominent appearance of the region below her lower lip, which was second­
ary to a combination of microgenia and volume deficiency across the labiomental sulcus. (B) Postoperative appearance following placement of an
extended anatomical chin implant in conjunction with autologous fat transfer across the labiomental sulcus. Midface fat transfer was performed
concurrently. (Photo courtesy Robert Glasgold, MD; reprinted with permission from Glasgold Group, 2014.)

290
MASTER TECHNIQUES IN FACIAL REJUVENATION
The lateral subperiosteal pocket is initiated with elec­
trocautery, hugging the inferior border of the mandible.
A Joseph elevator is introduced to elevate the subperi­
osteal pocket (Fig. 22.7). External palpation with the
contralateral hand will help to guide the subperiosteal
dissection, ensuring that the pocket remains along the
anterior-inferior border of the mandible to avoid trauma
to the mental nerve. Once the pocket is elevated, an
Aufricht retractor (8 × 45 mm) is placed into the pocket
(Fig. 22.8). A Joseph elevator is then inserted into the
pocket under the Aufricht retractor and the subperiosteal
pocket is gently stretched to ensure the implant will fit
comfortably into the pocket. The subperiosteal pocket is
upward while dissection is carried down through the
soft tissue and muscle. The periosteum is incised at the
inferior portion of the anterior surface of the mandible.
A cuff of periosteum is preserved at the inferior border of
the mandible, to which the implant is eventually sutured.
A subperiosteal pocket is elevated centrally, creating a
pocket that is large enough to accommodate the implant.
We prefer to elevate the central subperiosteal pocket
using electrocautery.
A
B
Figure 22.5  (A) This patient presented with superficial irregular contour (“peau d’orange”) and microgenia. Her primary goal was correction of
the contour and she also desired nonsurgical augmentation of the chin. (B) Both the overall contour and projection were addressed by the use of
hyaluronic acid (HA)–based injectable fillers. HA fillers were used in the central mentum, prejowl sulcus, and labiomandibular fold. The superficial
contour was corrected by filling the dermis of the anterior chin with HA fillers, without the use of Botox. (Photo courtesy Robert Glasgold, MD;
reprinted with permission from Glasgold Group, 2014.)
Figure 22.6  Extended anatomical chin implant prepared for place­
ment with a 2-0 silk suture threaded through each of its lateral ends
and onto Keith needles.
Figure 22.7  The lateral subperiosteal pocket is elevated along the
inferior border of the mandible with a Joseph elevator.

22  Mentoplasty
291
then elevated on the contralateral side prior to placing
the implant.
After bilateral subperiosteal dissection is completed,
the Aufricht retractor is used to hold open the pocket.
The Keith needle with guide suture is passed through the
subperiosteal pocket under the retractor, aiming toward
the angle of the mandible, and is passed out through the
skin (Fig. 22.9). The guide suture is grasped by an assis­
tant and gentle traction is provided to guide insertion of
the implant as it is fed into the pocket with a straight
clamp. The guide suture ensures proper placement of the
lateral tail of the implant, and prevents the thin tail from
folding on itself. Once the implant is inserted and the
Aufricht retractor removed, continued traction is placed
on the guide suture to maintain its position during inser­
tion of the contralateral side (Fig. 22.10). The Aufricht
is now placed in the contralateral side and the implant
inserted in the same manner as the first side (Fig. 22.11).
Once the implant is inserted, its position should be
evaluated both by manual palpation and visual inspec­
tion. Central placement is confirmed by aligning the
central blue mark on the implant with the junction of
Figure 22.8  The lateral subperiosteal pocket is exposed with the
Aufricht retractor.
Figure 22.9  Keith needle, with guide suture, being passed through
lateral pocket and out through the skin at the angle of the mandible.
Figure 22.10  After the implant is fed into the pocket on the right,
traction is maintained on the guide suture to prevent displacement while
inserting the contralateral side.
Figure 22.11  Chin implant placed within the subperiosteal pockets.
the upper central incisors. Manually palpate the implant
to confirm it lies flat against the mandible and is sitting
along the inferior border of the mandible. The degree
of anterior projection is then evaluated. It is important
to remember that the intraoperative appearance can be
affected by swelling from both local anesthetic injection
and surgical manipulation. With the patient in a supine
position mandibular recession is exaggerated; the surgeon
should correct for this while visually assessing projection
by holding the jaw in its proper anatomic position.
If further augmentation is deemed necessary after
implant placement, an extension wafer (Glasgold Wafer,
Implantech, Ventura, CA, USA) can be placed to provide
2 mm of additional anterior projection (Fig. 22.12). The
extension wafer does not have a central mark; making
a nick at its central point on the inferior edge will help
ensure proper alignment. The wafer is then simply
inserted under the central portion of the implant (Fig.
22.13). Once correctly positioned it is sutured to the chin

292
MASTER TECHNIQUES IN FACIAL REJUVENATION
(Fig. 22.15). The muscle is reapproximated over the
implant with interrupted 4-0 PDS sutures. The subcu­
taneous tissues are reapproximated with several inter­
rupted 4-0 PDS sutures. The skin incision is closed with
a running 6-0 Prolene suture.
If chin implantation is performed in conjunction with
a facelift, the mentoplasty is performed first. Once the
chin implant is placed and sutured in, the muscle is closed
prior to proceeding with the subcutaneous submental
dissection to address the submental fat and platysma. If
liposuction is performed, it is done first through a small
incision in the center of the planned submental incision
before extending the incision for the mentoplasty.
In some patients, isolated prejowl augmentation is
needed to achieve a straight jawline. Although preformed
implants for prejowl augmentation are available, we
prefer injection augmentation with either autologous fat
or a synthetic filling material. When patients undergoing
a facelift need prejowl augmentation, the fat is harvested
and injected into the prejowl sulcus prior to proceeding
with the facelift at the same setting.
POSTOPERATIVE CARE
Patients receive a total of 2 days of antibiotic prophy­
laxis. The first dose is given intravenously the morning
of surgery, followed by one dose of oral cefadroxil that
evening and two more doses on the first postoperative
day. If allergic to penicillin, the patient will receive two
additional doses of oral clindamycin the days of surgery
implant with two 4-0 polydioxanone (PDS) sutures, each
placed approximately 1 cm lateral to the midline.
After it has been confirmed that the implant is appro­
priately placed, the implant is sutured to the inferiorly
based cuff of periosteum with two 4-0 PDS sutures (Fig.
22.14). These sutures are placed approximately 1 cm
lateral to the midline. If an extension wafer is used,
the 4-0 PDS suture is placed through the periosteal cuff
and then through both the wafer and overlying implant
Figure 22.12  Extension wafer (Glasgold wafer) for use with anatomic
or extended anatomic chin implants to provide an additional 2 mm of
central anterior projection.
Figure 22.13  In cases in which the need for further projection is deter­
mined intraoperatively after implant placement, an extension wafer
can be placed under the central portion of the implant to provide an
additional 2 mm of projection.
Figure 22.14  The implant is secured inferiorly to the mandibular
periosteum with two 4-0 PDS sutures.

22  Mentoplasty
293
30 years of experience we have had to remove an implant
secondary to infection on only a few occasions. If an
implant is removed because of infection, we will generally
wait a period of 6 months before reimplantation. This
allows sufficient time for swelling to resolve and scar to
form so that sizing for another implant will be accurate.
If the chin appears mildly overprojected during the
postoperative period, the patient should be reassured and
observed over a period of at least 3 months to allow swell­
ing to subside before deciding to downsize the implant.
In the case of undercorrection, an extension wafer can
be placed under the existing implant as described previ­
ously; alternatively, the implant can be replaced with a
larger one.
Asymmetries following augmentation are most com­
monly from preexisting mandibular asymmetries, which
if significant, would ideally have been reviewed with the
patient preoperatively. Implant shifting can occur, and
would most commonly be in the cephalad direction.
Shifting is prevented by using the submental approach,
which allows suture fixation of the implant to the man­
dibular periosteum.
Numbness and paresthesias in the distribution of the
mental nerve are secondary to traction on the nerve during
surgery and are almost universally self-limited, lasting
from weeks to months. Marginal mandibular weakness is
a very rare temporary complication secondary to traction
on the nerve while the implant pocket is being created.
Bone resorption of the central mandible following
alloplastic chin implants has been described. In practice
this has not been a significant issue [4,9]. To minimize
resorption, the implant should be placed on the more firm
cortical bone of the lower border of the mandible [10].
Placement of the implant in a sub- or superperiosteal
position has not been shown to significantly affect the
incidence of bone resorption [10].
R E F E R E N C E S
1. Safian J. Progress in nasal and chin augmentation. Plast Reconstr
Surg 1966;37:446–52.
2. Adams J. Facial augmentation with solid alloplastic implants. In:
Glasgold AI, Silver FH, editors. Applications of biomaterials in
facial plastic surgery. Boca Raton: CRC Press; 1991.
3. Binder W, Kamer F, Parkes M. Mentoplasty—a clinical analysis of
alloplastic implants. Laryngoscope 1981;91:383–91.
4. Toranto I. Mentoplasty: a new approach. Plast Reconstr Surg
1982;69:875–8.
5. Mittleman H. The anatomy of the aging mandible and its importance
to facelift surgery. Facial Plast Surg Clin North Am 1994;2:301–9.
6. Silver FH, Maas CS. Biology of synthetic facial implant materials.
Facial Plast Surg Clin North Am 1994;2:241–53.
7. Glasgold A, Glasgold M. Intraoperative custom contouring of the
mandible. Arch Otolaryngol Head Neck Surg 1994;120:180–4.
8. Mittelman H. Augmentation of the chin and pre-jowl sulcus. In:
Terino EO, Flowers RS, editors. The art of alloplastic facial con­
touring. St. Louis: CV Mosby; 2000.
9. Friedland JA, Coccaro PJ, Converse JM. Retrospective cephalomet­
ric analysis of mandibular bone resorption under silicone rubber
chin implants. Plast Reconstr Surg 1976;57:144–51.
10. Pearson DC, Sherris DA. Resorption beneath Silastic mandibular
implants. Effects of placement and pressure. Arch Facial Plast Surg
1999;1:261–4.
and three more doses on the first postoperative day. No
dressing is used for patients undergoing mentoplasty.
Patients are instructed to apply ice to the surgical site. It
is not uncommon for patients to complain of postopera­
tive pain; the larger the implant the greater the tendency
for patients to experience discomfort. Patients are seen
on postoperative day 7, at which time the skin sutures
are removed.
COMPLICATIONS
Complications following mentoplasty with alloplastic
implants include infection, over- or undercorrection,
asymmetry, numbness in the distribution of the mental
nerve, marginal mandibular nerve weakness, and man­
dibular resorption. Infection is very rare, especially with a
submental approach. It can occur in the immediate post­
operative period as well as months to years later. Infection
usually presents as increasing pain, tenderness, or swell­
ing. Once the infection is identified, treatment includes
a course of oral antibiotics. If infection is not resolving
with antibiotics, the implant should be removed. In over
Figure 22.15  When an extension wafer is used, the wafer and implant
are first sutured together (the medial sutures). Then the implant and
wafer are secured as a single unit to the mandibular periosteum inferi­
orly with two 4-0 PDS sutures.

294
INTRODUCTION
The secret of a beautiful face lies behind a well-balanced
proportion of facial features and is a composite of all of
the anatomical elements, including skin, subcutaneous
tissues, muscle, bone, and teeth. Facial plastic surgeons
strive daily with the achievement of this harmonious
balance.
Dentofacial deformities affect approximately 20% of
the population, out of which 5% have major skeletal
deformities [1]. Orthodontic and surgical treatment of
dentofacial deformities can produce a high degree of sat­
isfaction for the patient and surgeon. However, presurgi­
cal treatment planning and execution remain challenging.
The adage “form follows function” is applied, as a sig­
nificant overlap occurs between occlusal function and
facial aesthetics. Ideally the goals of orthognathic surgery
should be (1) to correct any masticatory dysfunction and
establish a functional masticatory system; (2) to enhance
aesthetics of the patient’s face and profile; (3) to prevent
further degeneration of any mechanical problem; and (4)
to stabilize the occlusion in a patient with temporoman­
dibular joint (TMJ) disease.
Although surgery of the nose mainly involves cor­
rection of skeletal and cartilage abnormalities, aesthetic
surgery on the remainder of the face is often concerned
with soft tissue deformities. In many instances, surgery
of the soft tissues is sufficient; however, attention must
often be paid to underlying skeletal deformities to correct
many congenital or traumatic reconstructive problems.
In order to achieve an aesthetic ideal, the surgeon must
have a clear concept of proportion, a method to analyze
deformities, and the ability to apply specific techniques to
a given deformity. Evaluation of facial deformities should
include skeletal and soft tissue analysis. Soft tissue analy­
sis can be done in an unstructured way through focused
observation or by careful study of consistent frontal and
lateral photographs. Generally, skeletal analysis involves
evaluation of the facial bones and is easier to quantify
by determining the patient’s dental occlusion and through
the use of cephalometric radiography.
After careful skeletal and soft tissue analysis, a detailed,
systematic treatment plan is established. This involves
using 3D imaging and dental and bony models, and is
often the product of multidisciplinary teamwork. Surgical
correction is then performed with the aim of establishing
or enhancing facial harmony.
AESTHETIC FACIAL ANALYSIS
Dental Analysis and Occlusion
Dental analysis and treatment directly address the rela­
tionship of the maxillary and mandibular teeth. Since the
introduction of the Angle classification system in 1899
[2], orthodontists and surgeons have used this system
to describe normal and abnormal dental occlusion. The
reference point in the Angle classification is the rela­
tionship of the maxillary to the mandibular first molar
teeth. In class I occlusion, the mesiobuccal cusp of the
first maxillary molar fits in the groove on the lateral or
buccal surface of the first mandibular molar tooth (Fig.
23.1). This description represents the ideal relationship
of the molar teeth only. When the remainder of the teeth
interdigitate perfectly, the occlusal relationship is said to
be normal. However, malocclusion can exist when the
molar relationship is class I. In class II malocclusion, the
mesiobuccal cusp of the first maxillary molar is mesial
or in front of the first mandibular molar (Fig. 23.2).
Class II malocclusion may arise from the lack of man­
dibular development or from an abnormally protuberant
maxilla. The resulting posteriorly positioned mandible
is termed retrognathia. Retrognathia may be associated
with airway compromise in infants and obstructive apnea
in adults. In class III malocclusion the mesiobuccal cusp
of the first maxillary molar is positioned distal to the ideal
position. This type of malocclusion is primarily skeletally
based and is characterized by a large protrusive mandible
(prognathism) or by an underdeveloped retrusive maxilla
(Fig. 23.3). Prognathism is a horizontal excess and can
be present in the mandible or maxilla. With dentoskeletal
deformities, the teeth are often crowded or tipped in a
manner that may mask a given deformity. The patient
with mandibular prognathism often exhibits a lingual
tipping of the mandibular incisors. This tendency of the
lip to attempt to “normalize” the situation is called a
dental compensation [3].
In mandibular micrognathia or retrognathia, there
is a decrease in horizontal growth of the mandible. This
deformity often results in a “Sunday bite,” in which the
patient is functioning anteriorly of centric relation. This
type of bite increases the chance of TMJ disease and
myofascial pain dysfunction. If the patient and physi­
cian are not aware of a Sunday bite, the treatment plan
may be incorrect and result in a poorly functioning or
less than optimal aesthetic result. If the mandible is in
C H A P T E R 23 
Orthognathic Aesthetic Facial
Surgery
Jonathan M. Sykes, MD and Gustavo A. Suárez, MD

23  Orthognathic Aesthetic Facial Surgery
295
When observing a patient with VME at rest, at least two-
thirds of the crown of the upper incisor is often visible
(Fig. 23.4).
Skeletal Analysis
Dimension and proportion are two key elements in diag­
nosing structural facial disharmony. Skeletal analysis
demonstrates the relationship of the facial bones and
illustrates any deformity in this relationship.
The cephalometric radiograph allows objective evalu­
ation of bony and soft tissue morphology, and provides
objective data that assist in the diagnosis and treatment
of facial skeletal deformities. Cephalograms were orig­
inally introduced into orthodontics during the 1930s.
Strikingly, it has been only until the late 1960s that this
imaging tool has gained widespread acceptance for prac­
tical application [5].
Several methods have been developed for the produc­
tion of standardized cephalometric radiographs, such as
A
B
Figure 23.1  Angle classification: class I occlusion. (A) Schematic
diagram of class I occlusion. (B) Diagram of class I occlusion and rela­
tion to overlying skin - soft tissue envelope.
A
B
Figure 23.2  Angle classification: class II occlusion. (A) Schematic
diagram of class II occlusion. (B) Diagram of class II occlusion and
relation to overlying skin - soft tissue envelope.
A
B
Figure 23.3  Angle classification: class III occlusion. (A) Schematic
diagram of class III occlusion. (B) Diagram of class III occlusion and
relation to overlying skin - soft tissue envelope.
Figure 23.4  A patient with vertical maxillary excess (VME). VME is
often associated with excess incisor show and gummy smile.
the correct position but the chin is deficient, a condi­
tion termed microgenia is present. This deformity is best
treated either with bony genioplasty or chin augmenta­
tion with an alloplast.
When the maxillary and mandibular teeth do not
contact, the term apertognathia or open bite is used.
Apertognathia is most often secondary to vertical excess
of the posterior mandible or maxilla. An open bite also
may be caused by abnormal tongue habits, abnormal
speech habits, or other intraoral defects. Often, patients
with apertognathia have TMJ disease and have difficulty
bringing their lips together. Vertical maxillary excess
(VME) is a condition in which there is vertical excess
of the midface. VME is often associated with excess
incisor show (gummy) smile with lip incompetence [4].

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MASTER TECHNIQUES IN FACIAL REJUVENATION
ANB is greater than 4 degrees and SNA is greater than
normal, the class II malocclusion is most likely secondary
to maxillary protrusion. If ANB is greater than 4 degrees
and SNA is less than normal, mandibular retrognathia
probably exists.
Other important angles exist (Table 23.1). The Frank­
fort mandibular plane angle is created by the intersection
of the Frankfort horizontal plane and the mandibular
plane (from gonion to menton). The mandibular plane
angle as defined by Tweed is the inclination of the man­
dibular plane [8]. The saddle angle is the angle between
the anterior and posterior cranial bases. The articular
angle (S–Ar–Go) can be affected by orthodontic treat­
ment and it is reduced in all cases of mandibular prog­
nathism. The gonial angle (Ar–Go–Me) plays a role in
growth prognosis of the mandible and is affected by
the relationship between the body and the ramus of the
mandible. The gonial angle indicates the direction of
mandibular growth, with a large gonial angle indicating
posterior condylar growth.
Various linear distances have also been described
(Table 23.2). These lines are measured by identifying the
two connecting points on the cephalometric radiograph.
The mandibular base is determined by measuring the dis­
tance between the gonion (Go) and pogonion (Pog) when
projected onto the mandibular plane. The maxillary base
is measured from the posterior nasal spine (PNS) to point
A. The distance from the sella (S) to the nasion (N) is the
anteroposterior extent of the anterior cranial base.
those presented by Hofrath and Broadbent in 1931 [6,
7]. Using a cephalostat, stabilization of the head in a
fixed and reproducible position is achieved. In order to
further standardize the radiograph, a consistent subject-
to-film distance and x-ray target-to-subject distance must
be used. The use of a soft tissue technique helps to clearly
demonstrate the relationship between the soft tissues and
the facial skeleton. A true lateral view, with no head
rotation in the sagittal plane, is then taken. This cepha­
lometric radiograph provides a two-dimensional outline
of the lateral aspect of the craniofacial skeleton on which
various analyses may be performed. To effectively use the
lateral cephalometric tracing, standardized bony land­
mark points are used. These skeletal points allow linear
and angular measurements to be performed. These mea­
surements can be compared with normative reference
values in order to quantify the skeletal abnormality.
The line connecting the nasion (N) and sella (S) is
midline and is often used as the reference plane on which
most cephalometric analysis is based (Fig. 23.5). Angles
SNA (anteroposterior position of maxilla), SNB (antero­
posterior position of mandible), and ANB (difference
between SNA and SNB) are relatively simple to derive
and provide valuable basic information in analyzing the
relationship of the maxilla and mandible to the skull
base. If the angle ANB is greater than 4 degrees, a skel­
etal class II malocclusion is present. The maxillary versus
mandibular contribution to this malocclusion may be
determined by measuring the angles SNA and SNB. If
Figure 23.5  Lateral cephalometric radiograph analysis.

23  Orthognathic Aesthetic Facial Surgery
297
TABLE 23.1  Cephalometric Angular Measurements
Points of
the Angle
Definition
Mean Value
(Degrees)
N–S–Ar
Saddle angle
123
S–Ar–Go
Articular angle
143
Ar–Go–Me
Gonial angle
128
Ar–Go–N
Upper gonial angle
52–55
N–Go–Me
Lower gonial angle
70–75
SNA
Anteroposterior position of maxilla
82
SNB
Anteroposterior position of mandible
80
ANB
Difference between SNA and SNB
22
SN–MP
Angle between SN and mandibular
plane
35
Pal–MP
Angle between palatal and
mandibular plane
25
O–P
Intersecting Frankfort mandibular
plane angle
20–29
Cd-A maxillary length; Cd-B mandibular length; Cd-Go length
of mandibular ramus; FH Frankfort horizonal -from Porion to
Orbitale; Go-Gn extent of mandibular base; Go-Me extent of
point A N-B naison-point B; Me-Go length of mandibular base;
N-A naison-height; N-Go naison-gonion line, for analysis of the
gonial angle; N-Id naison-infradentale; N-Pog naison-poignon;
N-Pr naison prosthion; Pal palatal plane; P-O Frankfort line
(plane)–plane should be parallel to ground; S-Gn, Y axis.
From Rakowski T. An atlas and manual of cephalometry radiography.
Philadelphia: Lea & Febiger; 1982.
A variety of analyses using the previously mentioned
skeletal points, lines, and angles have been described [9].
In all instances, these analyses represent an attempt to
describe the normal relationship of the facial skeleton.
Soft Tissue Analysis
The successful correction of dentofacial deformities also
requires careful preoperative assessment of soft tissues
and an accurate prediction of their response to skeletal
surgery. Consequently, dental and skeletal analyses alone
are inadequate in evaluating and predicting facial form.
TABLE 23.2  Cephalometric Linear Measurements
Distance
Definition
Mean Value (mm)
S–N
Anteroposterior extent of
anterior cranial base
71
S–Ar
Extent of lateral cranial base
48
S–Go
Posterior facial height
87
N–Me
Anterior facial height
114
PNS–Point A
Maxillary base
48
Go–Po
Mandibular base
78
S-Ar Lateral extent of the cranial base; S-Go posterior facial
mandibular base; S-N sella-naison–anteriorposterior extent of
anterior cranial base.
From Rakowski T. An atlas and manual of cephalometry radiography.
Philadelphia: Lea & Febiger; 1982.
Soft tissue analysis is the final determinant in evalu­
ating the overall attractiveness of the face. As used by
the casual observer, this method is subjective, less easily
quantified, and more importantly, it can vary among dif­
ferent cultures and ethnic backgrounds [9–11].
Although the soft tissues are more difficult to stan­
dardize than dental or skeletal parameters, analysis may
be performed by using fixed soft tissue reference points,
as described in Fig. 23.5. These points are often directly
correlated with associated bony reference points, e.g., (n)
soft tissue nasion correlating to the skeletal nasion (N) or
(pog) soft tissue with skeletal pogonion (Pog). However,
some soft tissue points are variable in location and have
no associated skeletal points, e.g., the trichion (tr) or
hairline. It is the variable thickness of the soft tissues such
as the lips or nose and the relative position of nonfixed
points such as the trichion that determine the overall
facial structure and appearance.
Finally, to accurately correct facial deformities, the
facial plastic surgeon must understand the amount of soft
tissue change gained by a given bony alteration [12,13].
The soft tissue response to skeletal surgery varies in dif­
ferent regions of the face. In portions of the face where
the overlying soft tissues are relatively thin, larger, and
more predictable, soft tissue changes are usually obtained
for a given bony alteration (Table 23.3). The accurate
prediction of these responses determines the final aes­
thetic result.
Photographic Analysis
Consistent and reproducible photographs are essential
when planning surgical correction of any facial deformity.
Photographs function as useful teaching aids for patients,
residents, and surgeons. They also provide accurate pre­
operative and postoperative medico-legal documentation.
Photographs also give the surgeon a macroscopic view
of the relationship between the individual’s facial skel­
eton and the overlying soft tissues. More importantly,
however, photographs provide the surgeon with a visual
record that can be retrospectively analyzed. It is through
such periodic critical assessment that surgical procedures
are modified.
Consistency is the most important aspect in medical
photography. A macro lens in the focal length range of
80 to 110 mm is recommended. The Frankfort horizontal
plane in which a line is drawn from the porion (superior
border of the tragal cartilage) to the infraorbitale (inferior
orbital rim is parallel to the ground) must be used as a
guideline when taking full-face portrait views [9]. At least
five full-face portrait views should be obtained. These
include a posteroanterior, two lateral, and two oblique
views. In addition, a submental-vertex (basal) view and
close-up views of the occlusion from the posteroanterior
and lateral orientation should be obtained.
TREATMENT PHILOSOPHY
Diagnosis and treatment of the patient with dento­
facial deformities must occur in a systematic fashion.
First, a careful medical and dental history and physical
examination must be performed. Facial trauma and any

298
MASTER TECHNIQUES IN FACIAL REJUVENATION
management plans for dentofacial deformities involve
complex and lengthy treatment, requiring significant
patient cooperation and commitment.
Dental Treatment
As a general rule, all routine dental care should be com­
pleted before initiating orthodontic treatment or orthog­
nathic surgery, because most orthodontic treatments place
relatively high demands on the teeth and periodontal
tissues. Consequently, periodontal disease, caries, dental
fillings, and extractions should be treated or completed
before orthodontic therapy.
Treatment of TMJ dysfunction is usually performed
before any orthodontic treatment. This may include anal­
gesics, anti-inflammatory medication, or dental splints,
with the aim of decreasing pain and muscular spasm.
Pretreatment of these problems allows a better evaluation
of the patient’s occlusion and facilitates more accurate
treatment planning.
Preoperative Orthodontic Treatment
In most clinical situations, preoperative orthodontic
treatment is necessary to align the dental arches and to
maximize the dental occlusion [9]. The goals of orth­
odontic therapy are to level and align the dental arches
and to relieve all unnecessary dental crowding (Figs.
23.7–23.8). Preoperative orthodontic therapy usually
requires a period lasting between 6 and 18 months after
initial diagnosis.
Once the orthodontic goal is achieved, a new set of
mounted dental models is made. The patient is reevalu­
ated and model surgery is performed on the dental models.
Generally, the cephalometric evaluation is repeated, and
this is typically done with computer imaging on the ceph­
alometric radiograph in order to predict the eventual
facial profile as a result of the planned bony movements.
orthodontic therapy should be included in the medical
history. The patient’s needs and expectations should be
established, and specific attention should be placed on
the relative importance of the functional versus cosmetic
correction expected by the patient [14]. After completion
of the basic examination, photographic and 3D radio­
graphic analyses are performed. Dental study models may
be constructed. These models allows for analysis of the
relationship between the maxillary and mandibular teeth
(Fig. 23.6).
After a thorough dental, skeletal, and soft tissue analy­
sis is performed, a full problem list is compiled. This
list must be prioritized according to the severity of each
deformity and the patient’s needs and expectations. At
this point, it is paramount that the risks, benefits, and
limitations of potential treatment options are fully dis­
cussed with the patient. This is crucial because most
TABLE 23.3  Soft Tissue Changes After
Maxillofacial Surgery
Procedure
Response Ratio of Soft Tissue to Bone
Mandible Setback
Pogonion
1 : 1
Inferior labial sulcus
0.9 : 1
Labrale inferius
0.8 : 1
Labrale superius
0.2 : 1
Mandible Advancement
Pogonion
1 : 1
Labrale inferius
0.8 : 1
Labrale superius
Variable
Chin Advancement Alone
Pogonion
0.8 : 1
Chin Advancement With Mandibular Advancement
Pogonion
0.4 : 1
Chin Setback Alone
Pogonion
0.25 : 1
Menton
0.33 : 1
Maxilla Setback
Subnasale
0.5 : 1
Labrale superius
0.5 : 1
Maxilla Advancement
Subnasale
0.5 : 1
Labrale superius
0.5 : 1
Maxilla: Superior Repositioning
Lip length shortened
0.2 : 1
Maxilla: Inferior Repositioning
Lip lengthened
Variable
From Lehman JA. Soft tissue manifestations of aesthetic detects of the
jaws: diagnosis and treatment. Clin Plast Surg 1987;14:767–83.
Figure 23.6  Dental study model.

23  Orthognathic Aesthetic Facial Surgery
299
movement. If two-jaw surgery is to be performed (i.e.,
surgery on the maxilla and mandible), two splints are
fabricated before surgery. The first splint (intermediate) is
placed to indicate the position of the maxilla after maxil­
lary osteotomy and movement before mandibular oste­
otomy. The second splint is used to identify the occlusion
and jaw position after both the maxillary and mandibular
osteotomies and their movements are accomplished. This
final splint remains in place after repositioning of the
entire maxillomandibular complex. The patient is usually
placed in maxillomandibular fixation with a wafer splint
in position.
SURGICAL PROCEDURES
Le Fort I Osteotomy
The Le Fort I maxillary osteotomy is the most common
surgical procedure to correct dentofacial deformities
involving the maxilla. This versatile procedure allows
horizontal advancement of the maxilla, vertical impac­
tion or shortening of the maxilla, or vertical lengthening
of the maxilla with down grafting (Fig. 23.9).
Additionally, the maxilla can be widened by perform­
ing a parasagittal split. The correction of transverse max­
illary deficiency requires preoperative surgical planning
and involves performance of the horizontal Le Fort oste­
otomy and paramidline osteotomy to achieve transverse
widening.
The Le Fort I maxillary osteotomy is performed with
nasal intubation. Xylocaine 1% with 1 : 100,000 epi­
nephrine (6 mL) is injected into the sublabial sulcus for
vasoconstriction. A mucosal incision is made 5 to 6 mm
above the mucogingival junction from the right maxillary
first molar to the left maxillary first molar. The incision
is carried down through the periosteum with monopolar
cautery, and elevation of the periosteum is done in order
Preoperative Work-Up and Dental Model Surgery
After maximal preoperative occlusal relationships are
obtained, the plaster dental models are mounted and the
amount of surgical correction is determined. An acrylic
interocclusal wafer splint is fabricated for use during
surgery. This splint provides an exact template on which
the maxillary and mandibular dental arches may fit
intraoperatively.
The interdental wafer splint is constructed to indi­
cate the new horizontal (anteroposterior) and transverse
position of both jaws after osteotomy and repositioning.
The interdental splint does not dictate the new verti­
cal (superior-inferior) position of the jaws. The vertical
dimension is determined during presurgical planning and
accomplished by ostectomy (for shortening) and bone
grafting (for lengthening) before final bony movement.
If the patient has maxillary transverse constriction and
requires intraoperative widening, a splint with full palatal
coverage is constructed. The full palatal coverage splint
enhances stability after bony osteotomy and paramedian
palatal split.
If single-jaw surgery is to be performed, a single inter­
dental wafer splint is placed at the conclusion of jaw
Figure 23.8  Dental crowding corrected after orthodontic treatment.
Figure 23.9  Le Fort I maxillary osteotomy.
Figure 23.7  Dental crowding prior to orthodontic treatment.

300
MASTER TECHNIQUES IN FACIAL REJUVENATION
movement of the maxilla is achieved. The maxilla can
then be repositioned, and miniplates are coapted to fit the
new position of the maxilla and the prefabricated dental
wafer splint establishes the new maxillary position.
If vertical shortening is desired, ostectomy is performed
before down fracture. If lengthening is desired, bone
grafting is performed at this time. Four L-shaped plates
are placed to secure the maxilla into its new position
after using the prefabricated dental splint and wiring it
into position. The maxillomandibular complex is rotated
superiorly using Dawson’s technique to prevent disloca­
tion of the mandibular condyles. After rigid fixation is
achieved, the preplanned occlusion is verified clinically
and the mucosal incision is then closed with running
locking 3-0 chromic catgut sutures. A bunching suture
of 3-0 braided absorbable material is usually used to
narrow the nasal base. If the lip was thin or short preop­
eratively, V-to-Y advancement and closure of the mucosa
may be performed. The individual displayed in Figures
23.13–23.17 is a 32 year-old female with class III maloc­
clusion and maxillary cross bite. She underwent Le Fort
I maxillary osteotomy and advancement of 6 mm with
rotation to correct her cross bite.
The LeFort I osteotomy has a long list of potential
complications, all of which underscore the technical chal­
lenges encountered with maxillary surgery (Box 23.1)
[15–20].
Sagittal Split Mandibular Osteotomy
The bilateral sagittal split mandibular ramus osteotomy
(BSSRO) of the mandible is one the most versatile surgi­
cal procedures for the correction of mandibular deformi­
ties. It can be used for advancement and retrusion of the
mandible (Fig. 23.11). The BSSRO is especially satisfac­
tory when used in prognathic patients with an open-bite
deformity.
to isolate and identify the infraorbital nerve. The nasal
mucosa is reflected with a curved elevator along the bony
nasal floor and onto the lateral wall of the nose. Next,
a reciprocating saw is used to make an osteotomy along
the lateral maxillary wall from the maxillary buttress to
the region of the piriform rim. This osteotomy should be
performed at least 5 mm above the root of the cuspid
tooth. The bony prominence of the cuspid tooth can
usually be visualized and easily palpated. The recipro­
cating saw is then placed into the bony cut and into the
maxillary sinus, with the cutting edge facing laterally
to complete the lateral osteotomy to the junction of the
pterygomaxillary fissure.
After the initial osteotomy is completed, any amount
of planned vertical shortening (impaction) is marked
above the initial osteotomy with a caliper (Fig. 23.10). If
anterior impaction is to be performed, the second oste­
otomy is performed at this time. Identical bony cuts are
made on the opposite side of the maxilla. A thin straight
osteotome is placed through the facial osteotomy, and a
greenstick fracture is performed on the medial wall of the
maxillary sinus or lateral wall of the nose, extending from
the piriform rim to the posterior area of the lateral wall
of the nose. At this point, the nasal septum is separated
with a forked osteotome. A gloved finger can be placed
inside the mouth to the posterior nasal spine to guide the
osteotomy and palpate to avoid mucosal perforation of
the soft palate.
After the horizontal osteotomies are completed,
a curved osteotome is placed in the pterygomaxillary
fissure in a vertical orientation. A pterygoid chisel is
used to separate the posterior maxilla from the pterygoid
plates. Once the pterygoid plates are separated, they can
be moved easily. After all bony cuts have been performed,
the maxilla is down fractured with gentle digital pressure
anteriorly. As the maxilla is down fractured, the nasal
mucosa is reflected superiorly off of the nasal floor; care
is taken to preserve the palatine neurovascular bundles.
A Rowe disimpaction forceps can be used in a rocking
motion to free the maxilla and facilitate down fracturing.
Next, all posterior bony interferences are removed care­
fully with a large, round-cutting burr until unobstructed
Figure 23.10  Planned vertical shortening (impaction) is marked above
the initial osteotomy with a caliper.
Box 23.1  LeFort I Osteotomy Complications
Malpositioning
Bleeding
Infraorbital nerve traction injury
Vascular compromise
Periodontal defects
Devitalized teeth
Nerve injury
Ophthalmic artery injury
Nasolacrimal injury
Oronasal and oroantral fistulas
Nasal septal deviations
Maxillary sinusitis
Poor aesthetic soft tissue changes
Injury to the parotid duct
Unfavorable fractures (pterygoid plate, sphenoid bone, middle
cranial fossa)
Nonunion
Eustachian tube dysfunction
Velopharyngeal incompetence
Arteriovenous fistulas (carotid cavernous sinus)
Dysphagia
Transverse relapse
From Capone RB, Sykes JM. Complications in facial plastic surgery.
New York: Thieme; 2012.

23  Orthognathic Aesthetic Facial Surgery
301
alveolar nerve to the medial border of the mandible. Once
this nerve is identified, a thin retractor is placed above the
nerve and the nerve is gently pulled medially.
A horizontal osteotomy is performed on the medial
cortex of the mandible above the entrance of the inferior
alveolar nerve from the anterior border of the ramus to
the fovea area of the mandibular condyle. The osteotomy
is carried along the anterior border of the ramus and
along the external oblique line to the distal first molar
region. A vertical osteotomy is then performed on the
buccal surface of the mandible from the inferior border
of the mandible to join to the external oblique osteotomy.
The inferior border of the mandible must be completely
cut through both cortices to achieve a favorable split of
the mandible.
Once the osteotomies are performed bilaterally, the
mandible is split bilaterally by placing a Smith spreader in
the retromolar area. As the mandible is split, the inferior
alveolar nerve is visualized and may need to be teased
gently out of the posteromedial aspect of the proximal
segment of the mandible. If the inferior alveolar nerve is
injured, an epineural repair is attempted.
After the mandibular split is completed bilaterally, the
patient is placed into the preplanned occlusion as deter­
mined by the fabricated final dental splint and placed into
maxillomandibular fixation. Rigid fixation of the mandi­
ble is accomplished by making a small stab incision in the
region of the antigonial notch parallel to the branches of
the facial nerve. A blunt trocar is placed through the stab
incision, and the mandible is seated with digital pressure
inferiorly and anteriorly to place the mandibular condyle
into the glenoid fossae. Rigid fixation is accomplished
with three 2.7-mm screws. Care should be taken to not
injure the tooth roots or the inferior alveolar nerve when
placing the screws. Compression of the osteotomized seg­
ments should not be performed to avoid causing the bony
segments to flare out laterally.
Conversely, if a mandibular setback is performed, and
the segments are compressed, the proximal segment will
turn medially. Any overcompression with screw fixation
can cause outward rotation of the condyle with subse­
quent TMJ dysfunction. If the condyles are compressed
posteriorly or superiorly, late resorption of the condyles
can develop, with a resultant open bite.
One of the risks of the sagittal split osteotomy is inferior
alveolar nerve injury. The incidence nerve injury can be as
high as 80% to 90%. The mechanism of nerve injury can
be stretching (excessive medial retraction), direct trauma
(i.e., a difficult mandibular split), or chisel placement.
Visualization of the course of the inferior alveolar nerve
after the split is completed and transcribing this course on
the distal segment may be helpful during screw placement
in an attempt to avoid injury to the nerve. BSSRO is also
associated with avascular necrosis of the proximal bony
segment. The teeth adjacent to the sagittal fracture line
may also be compromised.
Bony Genioplasty
Horizontal osteotomy of the bony mentum is a versatile
procedure that can be performed simultaneously with
maxillary and mandibular osteotomies. The procedure
Sagittal split ramus osteotomy is performed intraorally
with a mucosal incision similar to that used in vertical
subcondylar mandibular osteotomy. Xylocaine 1% with
1 : 100,000 epinephrine (6 mL) is placed on the medial
and lateral aspects of the ramus of the mandible. After
adequate time for hemostasis is allowed, monopolar
cautery is used to make an incision midway along the
ramus of the mandible at the depth of the anterior ramus
inferiorly to continue onto the external oblique line. The
periosteum is incised and a Hargis periosteal stripper is
used to elevate the tissues on the anterior border of the
mandible up to the coronoid tip. After these tissues are
retracted, a periosteal elevator is used to strip any fibers
of the temporalis muscle off of the anterior border of the
mandible. A large curved clamp is then placed on the
coronoid tip to retract these tissues superiorly.
A small elevator is used to reflect medial tissues in a
subperiosteal direction at the level of the sigmoid notch
of the mandible. The subperiosteal dissection is carried
out carefully to identify the entrance of the inferior
Figure 23.11  Sagittal split mandibular ramus osteotomy (BSSRO).

302
MASTER TECHNIQUES IN FACIAL REJUVENATION
is performed through an intraoral incision and allows
three-dimensional correction of any chin deformity. The
operation permits advancement or retrusion of the bony
mentum in a horizontal direction, shortening or length­
ening in a vertical direction, or correction of transverse
discrepancies secondary to chin asymmetry (Fig. 23.12).
Xylocaine 1% with 1 : 100,000 epinephrine (4 mL) is
placed in the mucolabial fold for hemostasis. An inci­
sion is made 5 to 6 mm below the mucogingival junc­
tion from left to right cuspid. The incision is made with
monopolar cautery and carried down through the perios­
teum. A subperiosteal dissection is carried out inferiorly,
leaving a small amount of soft tissue attached to the bony
pogonion.
The mental nerves are identified and preserved bilater­
ally. The midline of the bony mentum is identified and
marked with a side-cutting burr, which facilitates align­
ment of the segments after osteotomy and movement.
The osteotomy is measured with calipers for symmetry
and inscribed with a reciprocating saw. After the anterior
aspect of the bony mentum is scored with the saw, a
second osteotomy is performed if vertical reduction is to
be performed. The osteotomy is then completed with a
reciprocating saw, and the bony mentum is down frac­
tured. Facial and lingual cortices must be cut cleanly to
Figure 23.12  Genioplasty of the bony mentum.
A
B
Figure 23.13  Before and proposed after dental study models. The maxilla has been advanced 6 mm and rotated to create the ideal class I occlusion.
A
B
Figure 23.14  Preoperative and postoperative occlusal photographs of the patient.

23  Orthognathic Aesthetic Facial Surgery
303
procedures. The complications most often associated
with genioplasty are listed in Box 23.2 [21–23]. Careful
dissection of the mental nerve, reinsertion of the men­
talis muscle fibers (with two-layer closure), stepped soft
tissue incision (soft tissue incision at one level and muscle
dissection at a lower level in the chin), and careful sub­
periosteal dissection plane will limit these complications.
SUMMARY
The goals in the treatment of dentofacial deformities
are to maximize form and function. The facial plastic
A
B
Figure 23.15  Preoperative and 6 month postoperative views of the patient before and after Le Fort I osteotomy with advancement and rotation
of the maxilla.
A
B
Figure 23.16  Preoperative and 6 month postoperative views of the patient before and after Le Fort I osteotomy with advancement and rotation
of the maxilla.
prevent an asymmetric or unfavorable fracture. Careful
attention is given to the mental nerve region in an attempt
to avoid injury to the nerves with the reciprocating saw.
After the inferior bony segment is down fractured,
any irregular bone areas are removed with a round burr.
The preplanned surgical correction is performed, and
the mobile bony segment is repositioned into the desired
three-dimensional postoperative position. The bone is
then stabilized with miniplates or lag screws.
Genioplasty is a versatile technique that is useful in iso­
lated cases of horizontal or vertical mandibular discrep­
ancies, as well as in combination with other orthognathic

304
MASTER TECHNIQUES IN FACIAL REJUVENATION
R E F E R E N C E S
1. Proffit WR, Fields HW Jr, Moray LJ. Prevalence of malocclusion
and orthodontic treatment need in the United States: estimates from
the NHANES III survey. Int J Adult Orthodon Orthognath Surg
1998;13:97–106.
2. Angle EH. Classification of malocclusion. Dent Cosmos 1899;
41:248.
9. Sykes JM. Orthognathic surgery. In: Papel ID. Facial plastic and
reconstructive surgery. New York: Thieme; 2009.
10. Thomas JR. Multicultural issues in facial plastic surgery. Facial
Plast Surg Clin North Am 2014;22(3):ix.
11. Rowe-Jones JM. Facial aesthetic surgical goals in patients of differ­
ent cultures. Facial Plast Surg Clin North Am 2014;22(3):343–8.
12. Park JY, Kim MJ, Hwang SJ. Soft tissue profile changes after
setback genioplasty in orthognathic surgery patients. J Craniomax­
illofac Surg 2013;41(7):657–64.
13. Aydil B, Özer N, Marşan G. Bimaxillary surgery in Class III mal­
occlusion: soft and hard tissue changes. J Craniomaxillofac Surg
2013;41(3):254–7.
15. Lanigan DT, Hey JH, West RA. Major vascular complications of
orthognathic surgery: hemorrhage associated with Le Fort I oste­
otomies. J Oral Maxillofac Surg 1990;48(6):561–73.
21. Lindquist CC, Obeid G. Complications of genioplasty done alone
or in combination with sagittal split-ramus osteotomy. Oral Surg
Oral Med Oral Pathol 1988;66(1):13–16.
22. O’Ryan F. Complications of orthognathic surgery. Oral Maxillofac
Surg Clin North Am 1990;2:593–4.
surgeon has the challenging task of optimizing the rela­
tionship of the maxillary and mandibular teeth, treating
any mechanical problems with the TMJ, and balancing
facial proportions. Evaluation of dentofacial deformities
should occur in a careful systematic fashion and include
dental, skeletal, and soft tissue analysis. Comprehensive
care involves integration of the general dentist, ortho­
dontist, and facial plastic surgeon in the treatment. When
careful treatment planning is performed, the simultane­
ous goals of improving dental occlusion and maximizing
facial aesthetics can be achieved.
References available online at expertconsult.com.
A
B
Figure 23.17  Preoperative and 6 month postoperative views of the patient before and after Le Fort I osteotomy with advancement and rotation
of the maxilla.
Box 23.2  Genioplasty Complications
Nerve injury (mental nerve)
Inferior mandibular border contour irregularity and unaesthetic
contours
Chin ptosis and deepening of the labiomental sulcus
Gingival recession
Mandibular sulcus scarring
From Capone RB, Sykes JM. Complications in facial plastic surgery.
New York: Thieme; 2012.

23  Orthognathic Aesthetic Facial Surgery 304.e1
13. Aydil B, Özer N, Marşan G. Bimaxillary surgery in Class III mal­
occlusion: soft and hard tissue changes. J Craniomaxillofac Surg
2013;41(3):254–7.
14. Alanko OM, Svedström-Oristo AL, Tuomisto MT. Patients’ per­
ceptions of orthognathic treatment, well-being, and psychological
or psychiatric status: a systematic review. Acta Odontol Scand
2010;68(5):249–60.
15. Lanigan DT, Hey JH, West RA. Major vascular complications of
orthognathic surgery: hemorrhage associated with Le Fort I oste­
otomies. J Oral Maxillofac Surg 1990;48(6):561–73.
16. Shoshani Y, Samet N, Ardekian L, Taicher S. Nasolacrimal
duct injury after LeFort I osteotomy. J Oral Maxillofac Surg
1994;52(4):406–7.
17. Reiner S, Willoughby JH. Transient abducens nerve palsy following
a Le Fort I maxillary osteotomy: report of a case. J Oral Maxillofac
Surg 1988;46(8):699–701.
18. Vedtofte P, Nattestad A. Pulp sensibility and pulp necrosis after Le
Fort I osteotomy. J Craniomaxillofac Surg 1989;17(4):167–71.
19. Bell WH, You ZH, Finn RA, Fields RT. Wound healing after mul­
tisegmental Le Fort I osteotomy and transection of the descend­
ing palatine vessels. J Oral Maxillofac Surg 1995;53(12):1425–33,
discussion 1433–4.
20. Sher MR. Treatment of oro-antral-nasal fistula after anterior maxil­
lary osteotomy. J Oral Surg 1980;38(3):212–14.
21. Lindquist CC, Obeid G. Complications of genioplasty done alone
or in combination with sagittal split-ramus osteotomy. Oral Surg
Oral Med Oral Pathol 1988;66(1):13–16.
22. O’Ryan F. Complications of orthognathic surgery. Oral Maxillofac
Surg Clin North Am 1990;2:593–4.
23. Park HS, Ellis E III, Fonseca RJ, et al. A retrospective study
of advancement genioplasty. Oral Surg Oral Med Oral Pathol
1989;67(5):481–9.
R E F E R E N C E S
1. Proffit WR, Fields HW Jr, Moray LJ. Prevalence of malocclusion
and orthodontic treatment need in the United States: estimates from
the NHANES III survey. Int J Adult Orthodon Orthognath Surg
1998;13:97–106.
2. Angle
EH.
Classification of malocclusion. Dent Cosmos
1899;41:248.
3. Andrews LF. The six keys to normal occlusion. Am J Orthod
1972;62:296–309.
4. Burstone CJ. Lip posture and its significance in treatment planning.
Am J Orthod 1967;53:262–84.
5. Khouw FE, Proffit WR, White RP. Cephalometric evaluation of
patients with dentofacial disharmonies requiring surgical correc­
tion. Oral Surg Oral Med Oral Pathol 1970;29(6):789–98.
6. Hofrath H. Die Bedeutung der Röntgenfern- und Abstandsauf­
nahme für die Diagnostik der Kieferanomalien. Fortschr Kieferor­
thop 1931;1:232–58.
7. Broadbent BH. A new X ray technique and its application to ortho­
dontics. Angle Orthod 1931;1:45–66.
8. Tweed CH. The Frankfort-mandibular plane angle in orthodontic
diagnosis, classification, treatment planning, and prognosis. Ameri­
can Journal of Orthodontics and Oral Surgery 1946;32(4):175–230.
9. Sykes JM. Orthognathic surgery. In: Papel ID. Facial plastic and
reconstructive surgery. New York: Thieme; 2009.
10. Thomas JR. Multicultural issues in facial plastic surgery. Facial
Plast Surg Clin North Am 2014;22(3):337–486.
11. Rowe-Jones JM. Facial aesthetic surgical goals in patients of differ­
ent cultures. Facial Plast Surg Clin North Am 2014;22(3):343–8.
12. Park JY, Kim MJ, Hwang SJ. Soft tissue profile changes after
setback genioplasty in orthognathic surgery patients. J Craniomax­
illofac Surg 2013;41(7):657–64.

305
HISTORY
Cervicofacial lipectomy, performed by liposuction or
direct fat excision, is a powerful tool in lower face and
neck rejuvenation. Lipectomy may be useful in younger
and older patients to remove unwanted deposits of fat,
contour the corpulent face, and as an adjunctive treat­
ment of the aging face. Since its introduction into the
United States in the early 1980s, liposuction has become
the most commonly performed aesthetic procedure [1].
Liposuction has been used from head to toe with repro­
ducible results and minimal complications. Although
the initial experience stemmed from its applications in
body sculpting, suction lipectomy has become a powerful
method to remove undesirable adipose tissue and contour
the cervicofacial region. There is a wealth of literature
documenting advances in techniques and instrumentation
used in liposuction, and a review of the history of this
technique is important to understand its fundamental
principles and provide a context for evolving applica­
tions [2–8].
The earliest references to adipose tissue removal date
to the 1920s in France [9]. In 1921 Dujarrier removed
fatty tissue from a ballerina’s leg using a uterine curette;
this resulted in amputation secondary to vascular injury
and gangrene. Initial catastrophic results such as this
discouraged further attempts at lipoextraction for several
decades. A more practical approach to lipoextraction
was developed in the mid-1970s by Fischer and Fischer,
who designed a cannula attached to a suction device to
facilitate tissue removal [10,11]. A similar approach was
independently developed by Kesselring, who advocated
suction-assisted lipectomy [12].
Although the addition of a suction device proved to
be a major advance, problems with sharp-edged curet­
tage instruments and large cavities created by wide
tissue undermining persisted. Most of these problems
were solved with the advent of the blunt technique, still
in use today. Inspired by the Fischers’ work, Illouz in
Paris reported his 5-year, 3000-case experience with
suction-assisted lipolysis using a new blunt-tipped suction
cannula [13]. His “wet” technique included injection of
the aspiration site with a hypotonic saline solution, theo­
retically to rupture the adipocytes. The blunt-tipped can­
nulas were connected to a high-power suction machine
and were used to create tunnels in a fan-shaped manner
to aspirate fat.
Fournier made further technical refinements on Illouz’s
technique [14]. He advocated a “dry” technique without
preinfiltration of hypotonic solution as he did not believe
that infiltration with hypotonic solution was necessary.
Furthermore, Fournier proposed taping the suctioned
areas to collapse the aspiration tunnels and advocated
the idea of syringe liposuction as an alternative to suction
pumps.
American surgeons visited France and learned the
techniques of liposuction. In 1977 the first American
to visit France was Field, a dermatologic surgeon [15].
Other American surgeons followed, and in 1980 Martin,
an otolaryngologist, visited Illouz and began to perform
liposuction in Los Angeles in 1981. Soon, symposia and
training courses were held to disseminate the techniques
of liposuction. The American Society of Plastic and
Reconstructive Surgeons was primarily under the tutelage
of Illouz, whereas Fournier was largely responsible for
encouraging participation and teaching physicians from
all specialties. The first American course in liposuction
was given by Newman, an otolaryngologist and cosmetic
surgeon, and Dolsky, a plastic surgeon, in Philadelphia
in 1982. Since that time, there has been great intellectual
dialogue and innovation, leading to significant advances
in cannula instrumentation, aspiration methods, and
anesthetic techniques [16].
With advances in understanding of facial and cervical
anatomy, surgeons have expanded on classical techniques
and engaged in direct excision of submuscular fat pre­
viously thought to be inaccessible by liposuction. His­
torically, fat removal deep to the platysma was avoided
because of concerns regarding neurovascular complica­
tions [17]. More recently, however, Feldman and others
have emphasized the importance of submuscular fat
removal in appropriate patients to optimize results fol­
lowing necklifts [18–20]. Still, most surgeons agree that
subplatysmal fat is not conducive to liposuction, and if
removal is warranted, should be approached with caution
under direct visualization.
The buccal fat pad is another submuscular location
that is best treated with direct excision. In 1732 Heister
first described the buccal fat pad as a glandular unit, and
in 1802 Bichat was the first to recognize that this glandu­
lar unit was predominantly fatty [21,22]. The buccal fat
pad was further described as having multiple extensions,
and in 1997 Matarasso described pseudoherniation of
the buccal fat pad as a new clinical entity [23,24]. In
addition, it is important to recognize that similar to peri­
orbital and subplatysmal fat, the buccal fat pad behaves
differently to subcutaneous fat and persists through times
of emaciation. Indeed, following significant weight loss
and reduction in subcutaneous fat, people will commonly
have persistent buccal fat [25].
C H A P T E R 24 
Facial and Cervical Lipectomy
Jeannie H. Chung, MD and Edwin F. Williams III, MD, FACS

306
MASTER TECHNIQUES IN FACIAL REJUVENATION
In the last two decades, facial sculpting techniques
have allowed surgeons to contour both subcutaneous and
submuscular fat with efficacy and minimal complications.
PERSONAL PHILOSOPHY
Liposculpture has revolutionized aesthetic surgery of
the face and neck by allowing surgeons to contour and
improve anatomic regions not adequately addressed by
lifting and redraping procedures; indeed, cervicofacial
lipectomy has become an integral technique in the suc­
cessful rejuvenation of the face and neck. The authors rec­
ognize that many excellent surgeons differ in the nuances
of their lipectomy techniques. This chapter does not
attempt to provide an impartial treatise on cervicofacial
lipectomy, but rather provides a practical strategy born of
significant clinical experience to produce optimal results.
Within the overall population, the authors find that
only a select group of patients benefit from primary cer­
vicofacial liposuction alone. Such primary liposuction
procedures are reserved for younger patients with local­
ized adipose tissue and good skin tone, which allow for
adequate skin contracture and redraping. In the authors’
practices, liposuction is frequently used in conjunction
with other rejuvenation procedures of the face and neck
(e.g., mentoplasty, plastysmaplasty, or rhytidectomy),
and is most effective in recreating an acute cervicomen­
tal angle and helping to delineate a smoother jawline.
The authors use both the tunneling technique to remove
adipose collections in the submental region as well as the
“layer” technique, in which a skin flap is elevated before
aspiration (Fig. 24.1). The authors find that the layering
technique facilitates skin redraping without the risk of
dimpling and skin irregularities from septal attachments
inherent in the tunneling technique.
In the last decade the authors have noted a shift from
the classic techniques and have engaged in more direct
excisional lipectomy procedures in select patients to
provide improved facial reshaping. This is in part based
on sound anatomic studies, advances in surgical tech­
nique, and time-proven efficacy and safety. With this
increased understanding and experience, the boundaries
have expanded to allow optimal results in cervicofacial
contouring. We advocate that a judicious mixture of both
liposuction and direct fat excision in appropriate patients
may be necessary for optimal results.
C
D
B
A
Figure 24.1  Schematic representation of the layer technique for liposuction. The skin is widely undermined in the subcutaneous plane (A), which
allows for uniform retraction of the skin after liposuction (B). With the tunneling method, random passes are created with the aspiration cannula
(C), creating a greater risk of dimpling and uneven skin contours as the skin retracts (D).

24  Facial and Cervical Lipectomy
307
angle of the mouth. The posterior and superior borders
extend in continuity with the superficial musculoapo­
neurotic system (SMAS). Significant variation may exist
in the midline of the platysma, from the mentum to the
hyoid bone. In some patients, the muscle fibers decussate
across the midline, creating a muscular sling. In others,
the absence of decussation may lead to a diastasis that
worsens over time. Rejuvenation of the neck requires
manipulation of one or more of these structures. It is
important to note that optimal results following liposuc­
tion depend as much upon the resiliency and elasticity of
the overlying skin as the amount of fat removed.
The marginal mandibular branch of the facial nerve
is at risk when liposuction is directed over the mandible.
The marginal mandibular nerve courses inferiorly, ante­
rior to the angle of the mandible, 1 to 2 cm below the
inferior margin of the mandible into the submandibu­
lar triangle. The nerve then ascends over the mandible
to innervate the depressor muscles of the mouth 2 cm
lateral to the oral commissure. Although the marginal
mandibular nerve lies under the cover of the platysma,
some patients may have attenuated muscle fibers; aggres­
sive suctioning for jowls and mandibular contouring may
place this nerve at risk of inadvertent injury.
Liposuction is usually performed in the adipose layer
superficial to the platysma in the neck, an extremely safe
region devoid of vital neurovascular structures. However,
the surgeon will occasionally need to remove deeper layers
of adipose tissue or dissect deep to the platysma to mobi­
lize its medial ends for a platysmaplasty. Subplatysmal fat
In all surgical endeavors, the authors strive for straight­
forward and safe techniques. For many aesthetic proce­
dures, new instruments, equipment, and technology are
being introduced to facilitate use, improve results, and
minimize complications. However, these advancements
need to be evaluated with a critical eye. At its most
fundamental level, suction lipectomy involves a rigid
cannula connected to a suction device and direct lipec­
tomy involves a thorough understanding of cervicofacial
anatomy with a discerning eye for facial contouring. We
are in an exciting time in aesthetic medicine where there
are many tools available for cervicofacial contouring. The
authors believe in a multimodal approach using volume
augmentation, soft-tissue redraping, and liposculpting for
the best and most natural-appearing results. This chapter
provides preoperative guidelines for proper patient selec­
tion, reviews options for anesthesia, highlights necessary
equipment, and outlines salient technical points.
ANATOMY
A thorough understanding of facial anatomy is critical
to the successful application of lipectomy techniques. A
comprehensive review of the head and neck is beyond
the scope of this chapter, but it is important to highlight
the anatomic structures relevant to facial liposculpture.
Fat in the area of the jowls and neck is highly compart­
mentalized [20]. Fascial borders are encountered between
the different zones of fat, and these borders originate in
the superficial fascia and insert in the dermis of the skin
[26]. Dye injection studies have distinguished discrete
superior and inferior subcutaneous fat compartments of
the mandible [27]. The superior jowl compartment is an
inferior extension of the nasolabial folds and is bounded
anteriorly by the oral commissure, whereas the inferior
jowl is located lateral and inferior to the superior jowl
fat. This inferior jowl pad is separated from the sub­
mandibular fat compartment by the mandibular septum,
which inserts 1 cm superior to the mandibular border to
the skin. The mandibular septum extends laterally to the
angle of the mandible. Jowling is limited inferiorly by
the septum and may occur with septal laxity (Fig. 24.2).
Although various facial regions have been addressed
with liposuction, the most commonly treated area remains
the neck. Cervical anatomy has many variations, and the
specific anatomic features pertinent to aesthetic appear­
ance merit special attention. These considerations are
critical in performing appropriate preoperative evalua­
tion and tailoring the ultimate surgical approach.
The portion of the neck that is best addressed by
liposuction is the central subunit, which is bounded supe­
riorly by the inferior border of the mandible, posteriorly
by the anterior border of the sternocleidomastoid muscle,
and inferiorly by the thyroid cartilage. Beneath the skin
lies a variable amount of fat. The quality of this fat varies
from patient to patient as well as from one anatomic
region to another. The adipose layer lies superficial to
the platysma, a thin, broad-based muscle that originates
from the superficial fascia over the pectoral and deltoid
muscles, ascends over the clavicle, and inserts on the
mandible below the oblique line and the skin at the lateral
Mandibular
ligament
A
B
C
D
Mandibular
septum
Figure 24.2  The anatomy of jowling includes the superior jowl fat
(A), inferior jowl fat (B), submandibular and submental triangles (C),
and the lateral neck (D).

308
MASTER TECHNIQUES IN FACIAL REJUVENATION
The buccal fat pad is usually located between the ver­
tical masseter and horizontal buccinator, and is closely
associated with the parotid duct and the facial nerve
(Fig. 24.4). Enveloped by the parotidomasseteric fascia,
the buccal fat pad has been described as tubular in form
with a main body and four extensions: the buccal, ptery­
goid, superficial, and deep temporal [23]. The body and
the buccal extensions are the most superficial segments
and impart fullness to the cheeks and are clinically rel­
evant for aesthetic surgery. Fifty percent of the volume
of the buccal fat pad is within the body and buccal
extension. The body rests centrally along the posterior
maxilla and upper fibers of the buccinator. The buccal
extension enters the cheek below the parotid duct and
extends along the anterior border of the masseter, overly­
ing the main portion of the buccinator. The parotid duct
lies superficial to the fat pad and then penetrates the fat
pad and the buccinator to enter the oral cavity oppo­
site the maxillary second molar. Usually, directly beneath
the parotid duct, lie several small branches of the facial
nerve, including a large buccal branch. Its anterior limit
is bounded by the facial vessels, which are in the same
plane as the buccal fat pad. The buccal fat is enclosed by
an extension of the parotid-masseteric fascia. This fascia
encases the lateral surface of the masseter muscle and the
branches of the fascial nerve. As it extends into the cheek
beyond the anterior border of the masseter muscle, the
fascia becomes more superficial and overlies the buccal
is also compartmentalized into the central fat (between
the medial heads of the digastric muscle), medial fat
(underlying the platysma), and lateral fat [19]. Central
fat is dark yellow, whereas the medial and lateral
compartments are pale yellow, similar to buccal fat.
Excision of subplatysmal fat warrants extreme caution
given the risk of injury to the deep neurovascular struc­
tures. The anterior jugular veins and perforating branches
of the submental vascular plexus lie deep to the platysma,
near its midline. If violated, these vessels may be dif­
ficult to control, particularly with limited exposure and
visualization.
In 1980 Ellenbogen described five visual criteria that
create the appearance of a youthful neck [28]. These cri­
teria are (1) a distinct mandibular border without jowl
overhang; (2) a subhyoid depression, which gives the
appearance of a long and thin neck; (3) a visible thyroid
cartilage contour; (4) a visible anterior border of the ster­
nocleidomastoid muscle; and (5) a cervicomental angle
measuring between 105 and 120 degrees (Fig. 24.3).
These criteria were initially used to assess the results of
platysma cervical lifts, but they are also applicable in the
more global assessment of the neck. Not all of these crite­
ria may be attainable with facial lipectomy, but they serve
as useful guidelines for the goals of surgical treatment.
Figure 24.3  Five visual criteria for a youthful neck as described by
Ellenbogen: distinct mandibular line (1), subhyoid depression (2),
thyroid cartilage bulge (3), anterior border of the sternocleidomastoid
muscle (4), and a cervicomental angle between 105 and 120 degrees (5).
(From Ellenbogen R, Karlin JV. Visual criteria for success in restoring
the youthful neck. Plast Reconstr Surg 1980;66(6):826–37.)
Parotid
gland
Masseter m.
Parotid
duct
Buccal extension
of buccal fat pad
Temporal extension
of buccal fat pad
Figure 24.4  The buccal fat pad sits between the masseter and buccina­
tor muscles. The buccal extension is the most superficial component and
contributes to the fullness of the cheeks. The parotid duct is superficial
to the buccal fat pad before it penetrates the buccinator muscle. m.,
Muscle.

24  Facial and Cervical Lipectomy
309
in predicting outcomes [30,31]. Skin with elastic
integrity will more effectively redrape over the
underlying liposculpted contour. Although it has
been suggested that skin contractility may be sub­
optimal in patients older than 40 years [30], all
patients need to be evaluated on an individual basis
(Fig. 24.5). Furthermore, crepe paper appearance of
the skin is a preoperative predictor of failure from
isolated liposuction without rhytidectomy [2,31].
2. Amount and location of fat. The surgeon should
assess the location and amount of fat by palpation.
This is best accomplished with the pinch and roll
technique [2,3]. The skin should be palpated or
rolled between two fingers to determine the thick­
ness of the skin and fat. In the cervical region, the
presence of preplatysmal fat should be differenti­
ated from subplatysmal fat. With palpation, subpla­
tysmal fat is generally firmer owing to its connective
tissue and fibrous content [2].
3. Integrity of the platysma. The surgeon should eval­
uate the thickness and laxity of the platysma. The
presence of platysmal bands at rest indicate that
some form of platysmaplasty should be performed
for proper rejuvenation of the neck [3,8]. Further­
more, cervical liposuction may expose occult bands
[32]. This may be assessed by having patients strain
their neck with their teeth clenched while making a
grimace; with this provocative test, platysmal bands
caused by laxity of the muscular anterior borders
may be revealed.
4. Condition of the surrounding skeletal framework.
Deficiencies in the surrounding skeletal framework
of the cervicofacial region may significantly affect
the results of liposuction. Both Dedo and Kamer
devised classification systems evaluating cervical
abnormalities to guide preoperative evaluation and
fat pad, parotid duct, and the buccal branches of the
facial nerve [23,29].
PREOPERATIVE ASSESSMENT
As with any cosmetic procedure, success depends on
patient selection and careful preoperative evaluation. A
full medical history should also be assessed to evaluate
the appropriateness of surgical intervention and identify
risk factors for suboptimal results. Comorbidities such as
hypertension, coagulopathies, diabetes, and smoking may
complicate healing in the postoperative period. Patients
with significant weight gain are not good candidates
for local lipectomy, as it is not a cure for overall obesity.
However, lipectomy is effective for patients who are
plagued with unwanted local deposits of fat, which may
be a result of hereditary predisposition, poor dietary and
exercise habits, age, medications, hormones, or weight
gain. Even when weight loss regimens are implemented,
facial areas such as the submental region are difficult to
change. Although exercise programs help to tone muscles
throughout the body, it is difficult to strengthen muscles
of the face and neck; in addition, toned muscles do not
necessarily reduce the amount of superficial adipose tissue.
A critical anatomic and aesthetic evaluation is essen­
tial. A systematic approach will prevent the surgeon
from overlooking any critical anatomic features and
from making an erroneous assessment of the locus of
concern. Evaluation should start with an assessment of
the patient’s overall body habitus. Patients of short and
stocky stature with wide necks will not achieve a thin,
contoured neck even with significant liposuction.
The surgeon must then assess the following:
1. Skin condition. Skin should be evaluated for flex­
ibility, elasticity, firmness, and adherence to the
underlying tissues, all of which play a critical role
A
B
Figure 24.5  Preoperative profile (A) of a 65-year-old patient with submental and submandibular fullness. Although atypical of older patients, this
patient’s skin contractility allowed for satisfactory improvement in the cervicomental angle with liposuction alone (B).

310
MASTER TECHNIQUES IN FACIAL REJUVENATION
most benefit. Obviously, the surgeon should make rec­
ommendations in light of the patient’s area of concern.
For example, augmentation mentoplasty is a wonderful
adjunct to cervical liposuction in creating the appear­
ance of an acute cervicomental angle. However, most
patients do not seek consultation with a surgeon for a
chin implant; rather, they ask for improvement in their
neck contour, and it is only when the advantage of an
implant is pointed out that patients realize the benefits.
Older patients need to be counseled that liposuction alone
will not improve the appearance of aging skin or facial
wrinkles. These patients may benefit from other rejuvena­
tive procedures such as rhytidectomy or skin resurfacing.
SURGICAL TECHNIQUE
The goals of cervicofacial lipectomy are to remove
unwanted deposits of fat and to create a smooth contour.
These goals are accomplished through liposuction of
subcutaneous fat or by direct excision of undesirable
submuscular fat. These procedures may be performed
in isolation or in combination with other adjuvant thera­
pies. Several technical nuances need to be appreciated to
avoid complications and to optimize surgical results.
Equipment
A reliable aspiration device is essential to successful lipo­
suction. Multiple suction devices are commercially avail­
able, but the most effective and efficient machines share
several characteristic features. Although perfect vacuums
(1 atm, 760 mm Hg [29.92 inches Hg]) are difficult to
achieve in the clinical setting, suction devices are able to
achieve vacuums close to 736 mm Hg (29 inches Hg).
Low noise output (<55 dBA scale) and high flow rate
(>100 L/min) are also desired features [30]. In the cer­
vicofacial region, vacuum pressures of 559 mm Hg to
selection of the most appropriate surgical option
[31,33]. Dedo proposed that patients with either
a short mandible-to-hyoid distance or low-lying
hyoid have an obtuse cervicomental angle, limiting
the effects of submental surgery (Fig. 24.6). Correct
projection of the mentum will give the impression
of an acute cervicomental angle. To better assess
this, the surgeon may drop a plumb-line down from
the lower lip. In women, the mentum should be at
or slightly behind this line when viewed from the
lateral aspect. In men, the mentum should be on
or slightly anterior to this line. In some patients,
placement of a chin implant would accentuate the
results of submental lipectomy; in others, the place­
ment of cheek augmentation with volumizers or an
implant will accentuate the results of buccal fat pad
removal.
5. Prominence of surrounding soft-tissue structures.
The surgeon should assess for ptotic submandibular
or large parotid glands. Liposuction in the subman­
dibular region may enhance the appearance of the
submandibular glands [2,32]. Similarly, liposuction
of cheek fat may enhance the anterior border of an
enlarged parotid gland. Furthermore, patients with
heavy masseter musculature may not benefit from
facial liposuction.
After a thorough physical evaluation has been performed,
the surgeon determines if a patient is an appropriate
candidate for isolated lipectomy. The ideal patient for
isolated lipectomy has good skin elasticity, is of stable and
average weight, and has a localized adipose collection out
of proportion to the rest of the body.
Some patients are not good candidates for isolated
lipectomy but may benefit from adjunctive procedures.
Without offending patient sensibilities, the surgeon
must recommend the procedure(s) likely to provide the
B
A
Figure 24.6  The hyoid bone should ideally rest cephalad and posterior to the mentum for a youthful neckline (A). A low-lying anterior hyoid
bone limits the results of submental liposuction and cervical rejuvenation (B).

24  Facial and Cervical Lipectomy
311
Finally, Luer-Lok microcannulas may be attached to small
syringes and are useful in autologous fat injection.
Markings
It is prudent in the preoperative holding area to mark
the patient while in the upright position, as the soft
tissue contours may become distorted when the patient
lies supine. Important anatomic structures, such as the
inferior border of the mandible, anterior and posterior
borders of the sternocleidomastoid muscle, superior
584 mm Hg (22 to 23 inches Hg) are usually adequate for
smooth and continuous suction. The surgeon should check
the suction pressure before the start of any procedure to
ensure that the pressure is within the desired range. Hand-
held syringe liposuction, popularized by Fournier, is also a
safe and efficient alternative to suction pump fat removal
[14]. Fournier believed this method minimized blood loss
and provided the surgeon with accurate measurements of
the amount of fat removed. Syringe liposuction is also an
excellent backup should there be mechanical or electrical
problems with a suction pump.
In addition to a reliable suction source, appropriate
cannulas should be chosen. An abundance of cannu­
las are currently available (Fig. 24.7). The surgeon will
typically become familiar with three or four cannulas
that he or she will use routinely, depending on the loca­
tion and phase of liposuction (e.g., active fat removal,
sculpting, or feathering). In the cervicofacial region, the
most frequently used cannulas range in size from 1 mm
(microcannulas) to 6 mm in diameter. Larger cannulas
have the capacity to remove greater volumes of fat and
are appropriate for areas such as the submental triangle.
However, microcannulas are useful for fine sculpting and
contouring, particularly in areas near vital neurovascu­
lar structures, such as the marginal mandibular nerve.
Microcannulas are frequently used to contour the jowls,
cheeks, and nasolabial folds.
Cannulas with blunt tips are preferable in the cervi­
cofacial region. Blunt cannulas have openings located a
few millimeters away from the tip and are gentler on the
tissues than those designed with end openings. Cannulas
with the opening at the tip may act as a shaver when
passed over tissue and may function more as a curette
than a gentle suction device. The spatula-shaped tip is
useful for undermining skin flaps in the preplatysmal fat,
as its shape facilitates the surgeon to stay superficial to
the platysma.
Cannulas are manufactured with varying numbers of
apertures (Fig. 24.8). Those with more openings allow
fat to be suctioned more rapidly. We prefer a cannula
with a single suction aperture for active fat removal,
although multiple apertures are useful on the microcan­
nulas to facilitate fat removal through a smaller diameter
lumen. There are also cannulas that may be attached to
the handle via a Luer-Lok connection, which are more
economical than those permanently attached to handles
(Fig. 24.9). The Luer-Lok system also allows cannulas to
be attached to aspiration syringes for syringe liposuction.
Figure 24.7  Liposuction cannulas are available in a variety of lengths,
diameters, and tip specifications.
Figure 24.8  Aspiration cannulas with different tip shapes, aperture
sizes, and numbers allow versatility in their function and in the areas
to receive suction lipectomy. The cannula on the far right is suitable
for infiltration, whereas the spatula tip cannula (second from right) is
useful on the adipose tissue overlying the parotid and buccal regions.
The cannula on the far left has its opening at the tip of the cannula
rather than the side, which allows it to remove fat through a shaving
mechanism.
B
A
Figure 24.9  The Luer-Lok mechanism allows an interchangeable
system whereby various aspiration cannulas may be used with a single
handle. With a typical Luer-Lok handle (A), the cannulas attach at one
end (left) and the suction tubing at the other (right). The same Luer-
Lok cannulas may be attached to a syringe for syringe liposuction (B).

312
MASTER TECHNIQUES IN FACIAL REJUVENATION
mixed with 1 : 100,000 epinephrine, and a microcannula
used for infiltration is placed through a small incision.
The microcannula is subsequently connected to an IV
bag containing the tumescent fluid (Fig. 24.10). In this
fashion, the microcannula may be used to simultane­
ously create tunnels in the adipose tissue and deliver the
tumescent fluid. Once the requisite 15 minutes has passed
to allow for adequate vasoconstriction and anesthesia,
liposuction may be performed.
Although tumescent anesthesia has a strong follow­
ing among those with office-based practices, many sur­
geons prefer IV sedation for facial contouring. Although
proponents feel that tumescence facilitates dissection in
the proper tissue planes, others find the resultant tissue
distortion makes assessment difficult and hinders precise
facial contouring.
Technique
Suction Lipectomy
Primary liposuction may used to contour the submentum,
lateral neck, jawline, melolabial folds, jowls, and midface,
and these areas may be accessed through a combination
of small incisions. The choice of incisions depends on the
site(s) to be treated. These incisions are well hidden and
well tolerated by the patient.
In our experience, the majority of patients who
benefit from isolated liposuction seek improvement in
the appearance of their necks. The ideal patient for sub­
mental liposuction is the younger patient with localized
fat and resilient skin, devoid of platysmal pathology (Fig.
24.11). Optimal results depend as much on the ability of
the skin to rebound and redrape as on the amount of fat
that is removed. The tunneling method initially developed
by the Fischers is used by many facial plastic surgeons.
The tunneling technique for the submental region is out­
lined here.
Submental liposuction begins with an incision that is
made 1 mm posterior to the submental crease. Proper
border of the thyroid cartilage, course of the marginal
mandibular nerve, and external jugular veins, are marked.
Furthermore, submental fat, jowl pads, and other fat
deposits are also marked. One approach utilized alternat­
ing cross-hatches to distinguish between the main areas
to be treated versus the adjacent areas to be feathered.
Markings for any planned adjunctive procedures may
also be placed at this time. Even with careful preoperative
marking, tissues may become distorted on the operating
table with changes in position, edema, and local infiltra­
tion; for this reason, it may be useful to have preoperative
photographs available during the procedure. If the buccal
fat pad is to be removed through the intraoral approach,
Stensen’s duct as well as the white fibrous bite line are
also marked on the buccal mucosa.
Anesthesia
Several options for anesthesia are available, depending
on physician and patient preference. For isolated facial
suction lipectomy, oral sedation with local anesthesia or
IV sedation usually suffices. Local nerve blocks to the
infraorbital, mental, and transverse cervical nerves may
be used to provide peri- and postoperative anesthesia.
When adjunctive procedures such as rhytidectomy are
performed, general anesthesia may be used.
Our dermatology colleagues have advanced the fron­
tier of office-based procedures using local anesthetic
techniques. In 1987 Klein introduced the tumescent tech­
nique, allowing the safe administration of larger doses of
lidocaine [34]. The recommended maximum dose of lido­
caine was 7 mg per kilogram of body weight when given
with epinephrine. Klein showed that lidocaine could be
safely given up to 35 mg/kg if diluted in large volumes of
hypotonic fluid (Table 24.1), as decreasing the concentra­
tion of lidocaine resulted in slower peak plasma levels.
Another advantage with tumescence is decreased blood
loss [35,36]. The tissue bed is bathed in the tumescent
fluid for at least 15 minutes, allowing prolonged vascular
exposure to epinephrine.
For office-based liposuction with tumescence, patients
may be given 1 mg of oral lorazepam and 25 mg of intra­
muscular meperidine before the procedure. Proper car­
diovascular monitoring is necessary. The entry site for the
liposuction cannula is then infiltrated with 1% lidocaine
TABLE 24.1  Klein’s Tumescent Formula
for Liposuctiona
Component
Amount
Lidocaine
50 mL of 1% lidocaine
solution (500 mg)
Epinephrine
1 mL of 1 : 1000 solution of
epinephrine solution (1 mg)
Sodium bicarbonate
12.5 mL of 8.4% NaH2CO3
solution
Normal saline
1 L of 0.9% NaCl solution
aFor cervical liposuction, a 500-mL bag of normal saline suffices. The
amount of the components must be adjusted accordingly.
From Klein JA. Tumescent technique for liposuction surgery. Am J
Cosmet Surg 1987;4:263–7.
Figure 24.10  A model of a tumescent infusion pump with adjustable
flow rates and a foot pedal (not shown), which allows the surgeon to
control infiltration.

24  Facial and Cervical Lipectomy
313
vessels and nerves, and their preservation ensures con­
tinued vascular and nervous supply to the skin [37].
Furthermore, these attachments are believed to aid in the
contracture of overlying skin. Although many surgeons
espouse the tunneling technique, contracture of the septal
attachments between the tunnels may result in dimpling
and skin irregularities. Besides the tunneling technique,
the authors also use the layer technique for the submental
region to minimize the possibility of uneven skin contours
[38]. The initial steps are identical to those outlined pre­
viously. Once the area around the submental incision is
dissected in the proper plane, wide double-hook retrac­
tors are used to retract the superior and inferior skin flaps
for proper tensioning. The right-handed surgeon typically
stands at the head of the bed and holds the inferior retrac­
tor with the left hand. The assistant stands on the right
side of the bed while holding the inferior retractor. Rather
than creating dry tunnels with a cannula, the surgeon
widely undermines the submental region to the anatomic
borders mentioned earlier with Metzenbaum scissors
(Fig. 24.13). Undermining should not proceed over the
mandible in efforts to prevent injury to the marginal
mandibular nerve. At least 3 to 4 mm of adipose tissue
should be left on the underside of the skin flap to prevent
an uneven contour and to preserve the skin’s vascularity.
Wide undermining also allows excellent redraping of skin
without tethering from septal attachments and the con­
sequent skin irregularities. Once the skin flaps have been
widely elevated, liposuction proceeds as with the tunnel­
ing technique, with the nondominant hand folding the
skin over the cannula tip, constantly assessing the depth
of adipose tissue (Fig. 24.14). Care should be taken with
liposuction in the submental region as the fascia over­
lying the platysma is thin and inadvertent entry into the
subplatysmal plane is possible. To prevent a demarcation
between the treated and untreated areas, undermining
should extend beyond the aspiration site and feathering
should be performed at the perimeters and the submental
compartment should not be skeletonized.
The jowls, lateral neck, and submandibular regions
may also be approached in a similar fashion from postau­
ricular or infralobular incisions (Fig. 24.15). The authors
have also utilized incisions directly along the jawline for
incision placement is essential to prevent deepening of
this crease with subsequent scar contracture, a defor­
mity that is likened to a “witch’s chin.” The incision is
typically 1 cm in length to accommodate a 4- to 6-mm
cannula. The incision should be large enough to accom­
modate the cannula, with additional space to prevent fric­
tion burn on the wound edges from the back-and-forth
motion of the cannula. The incision is carried through
the skin and subcutaneous adipose tissue, and 1 to 2 cm
of the surrounding skin is elevated sharply using small
iris or tenotomy scissors. This creates a tissue pocket
that facilitates placement of the cannula tip in the appro­
priate subdermal plane. The cannula is then introduced
with the aperture directed toward the adipose tissue and
away from the skin flap. During cannula insertion, the
suction should be off to prevent inadvertent injury to the
adjacent skin.
Once the cannula tip has been safely introduced
beneath the skin, interconnecting tunnels are created
radially from the mentum to the anterior borders of the
sterno­cleidomastoid muscle laterally and the thyroid notch
inferiorly, similar to spokes radiating from the hub of a
bicycle wheel (Fig. 24.12). After the tunnels are created in
the region of the planned liposuction, suction is applied
and multiple passes are re-executed in the same spoke-
like fashion. The right-handed surgeon should control the
cannula with the right hand while the left hand constantly
folds the skin over the cannula. This maneuver will help
to assess the depth of the cannula tip as well as the thick­
ness of the adipose layer. Throughout the procedure, the
surgeon pauses and palpates the neck and target areas to
ensure a smooth, even contour. Bulges and irregularities
indicate uneven liposuction; dimpling connotes tethering
of the septal attachments, which should be released. As
the submentum lies in the center of the “spokes,” care
should be taken to ensure even aspiration. Hollowing and
a submental depression may occur if too much liposuc­
tion is performed in this region. The tunnels created by
this method allow the superficial tissues to compress into
the newly created dead space.
Another proposed advantage of this technique is the
preservation of septal attachments from the subcutaneous
tissue to the dermis above. These septa contain blood
A
B
Figure 24.11  An ideal candidate for isolated submental and submandibular liposuction with localized fat, and resilient, elastic skin (A). Notable
improvement could be seen in the neck contour 3 months following submental and submandibular liposuction (B).

314
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 24.13  In the layer technique, the skin flap is widely undermined
with Metzenbaum scissors across the submental region to just inferior
(1–2 cm) to the jawline. Dissection is carried in a subcutaneous plane
to the anterior borders of the sternocleidomastoid muscle and thyroid
notch, with the tip of the scissors tenting the skin upward to prevent
injury to the deeper structures of the neck. Sharp dissection should not
be carried directly over the mandible to protect the marginal mandibu­
lar nerve. Placement of a double hook at the incision provides counter-
retraction on the skin flap.
Figure 24.14  The surgeon drapes the skin over the cannula aperture
with his or her nondominant hand to guide the passage of the cannula
as well as to constantly assess the depth of adipose tissue. The cannula
aperture should be directed away from the skin flap to prevent dermal
scarring and contour irregularities. The cannula tip also helps tent the
skin flap to prevent inadvertent injury to deeper structures.
B
A
Figure 24.12  Submental liposuction is performed in a systematic
fashion from a submental incision (A and B). The submentum serves
as a fulcrum from which the cannula is advanced in a radial fashion,
like the spokes of a wheel, to the anterior borders of the sternocleido­
mastoid muscle laterally and the thyroid notch inferiorly. Caution must
be exercised not to advance the tip of the cannula deep to the platysma
muscle to prevent inadvertent injury to the deep structures of the neck.

24  Facial and Cervical Lipectomy
315
cannula is placed through the incision, and tunnels are
created in an arc-like fashion from the prominence of
the fold to the antral fat. The incisions may be closed
with a 6-0 fast-absorbing plain gut. The authors do
not routinely treat the melolabial folds primarily with
liposuction, as the results are variable and often tran­
sient [39,40]. However, when performed to complement
another procedure, such as rhytidectomy, liposuction of
the melolabial fold may add to the overall improvement
of the face [41].
Concomitant chin augmentation may significantly
enhance the results of submental liposuction in some
patients (Fig. 24.16). The chin implant places anterior
stretch on the cervical skin, creating a tighter cervico­
mental angle. In the preoperative assessment, patients
with microgenia should be identified, and the benefits
of a chin implant discussed. The chin implant should be
placed after submental liposuction has been completed to
accurately assess the projection of the implant. Implanta­
tion may be performed using the same submental incision
described earlier.
Lipocontouring may also be combined with rhytidec­
tomy to optimize aesthetic results (Fig. 24.17). Submental
liposuction and platysmaplasty are such integral compo­
nents of lower facial rejuvenation that they are practically
considered part of complete rhytidectomy in cases with
favorable platysmal anatomy [42]. Submental liposuction
and platysmaplasty usually precedes rhytidectomy. After
liposuction, direct assessment and treatment of the pla­
tysma is possible. Lipocontouring may also be performed
through the rhytidectomy incision. Skin flaps are elevated
and facial liposuction is performed after treatment of
the SMAS. A 4-mm spatula-tip cannula may be used to
aspirate fat from the pretragal region, jowl, and midface
under direct vision (Fig. 24.18). In this manner, “cross-
hatching” may be performed evenly to prevent overtreat­
ment of any one area. A small 1-mm cannula is used for
fine contouring over the jowl. Through the rhytidectomy
incision, the lateral neck and the submandibular region
may also be aspirated. This provides overlap with the
central neck areas treated from the submental incision
and promotes a smooth, overall contour. A “cobra”
deformity, which may arise if the central neck receives
aggressive liposuction, may thus be avoided.
Direct Excision
Although suction lipectomy has been performed for sub­
platysmal fat, the authors do not advocate this prac­
tice, as the subplatysmal plane is replete with submental
vessels and the risk of bleeding is significant. Bleeding in
the subplatysmal plane may be brisk; obtaining control
of bleeding with limited visualization using electrocautery
places the marginal mandibular nerve at risk. Subplatys­
mal fat is best treated by direct surgical lipectomy.
Subplatysmal fat excision is usually performed as part
of a necklift as the medial bands of the platysma need to
be addressed after the subplatysmal fat excision. A full
description of the necklift procedure will be addressed
elsewhere in this text, but the salient points of subpla­
tysmal fat excision are described here. After the admin­
istration of local anesthetic to the neck, a 2- to 2.5-cm
Figure 24.15  Cervicofacial liposuction may be achieved through
a limited number of incisions. The submental incision allows excel­
lent access to the central neck. The lateral neck and jowls may be
approached from the infra- or retroauricular incisions, and the preau­
ricular incision allows liposuction over the parotid bed and midface
region. An incision in the nasal vestibule or nasolabial groove is used
for the melolabial folds.
closer and direct access to the jowls. A 16-gauge Nokor
needle is used to make the tiny incision, which heals
imperceptibly. As the jowl is an unforgiving area for
contour irregularities and is in close proximity to the
mandibular branch of the facial nerve, smaller cannulas
(1 to 2 mm) are used for gentle sculpting and creation
of a gentle contour with the nonaspirated regions. It
is crucial to be aware of the location of the tip of the
cannula and to keep the cannula tip in the subcutaneous
layer. Suction should be released upon withdrawal from
the jowl to prevent inadvertent aspiration of tissue in the
posterior facial tissue and creation of an unsightly divot.
If a small volume of fat is to be removed, occasional
release of the vacuum allows the fat to reach the col­
lection canister. In this way the surgeon may accurately
assess the amount of fat that has been removed. The
postauricular or infralobular incisions also provide access
to the jowls and excellent access to the submandibular
area, and allow overlap with the areas aspirated via the
submental approach.
The prominent melolabial fold continues to be a chal­
lenge. Liposuction can be used to contour this region and
begins with a small incision placed in the nasal vestibule,
nasolabial groove, or near the oral commissure. A 1-mm

316
MASTER TECHNIQUES IN FACIAL REJUVENATION
D
C
B
A
Figure 24.16  Preoperative (A) and 6-month postoperative (B) lateral, and preoperative (C) and 6-month postoperative (D) oblique views of a
25-year-old patient with submental fullness, microgenia, and elastic skin who underwent submental liposuction and Gore-Tex chin augmentation.
The chin implant serves as an excellent adjunct to submental liposuction by placing anterior stretch on the skin, resulting in a tighter cervicomental
angle.

24  Facial and Cervical Lipectomy
317
used to evert the edges of the platysma muscle. Using the
needle-tip cautery, the central subplatysmal fat is removed
layer by layer to achieve the desired contour. The authors
advocate a conservative removal in this area, but have
removed the fat to the level of the digastric muscle in
selected patients. The subplatysmal fat is highly vascu­
larized; thus use of Bovie cautery is recommended. The
medial bands of the platysma are then plicated in a corset
fashion to fill in some of the void created by fat removal.
If the medial bands of the platysma are not plicated after
excision of the central subplatysmal fat, an over-resected
“cobra” deformity will result. Release of the mandibular
septum may be necessary for proper redraping of the skin
and fat at the mandibular border, and direct excision of
the inferior jowls may be needed [20].
Patients who seek contouring of full cheeks may benefit
from a buccal pad removal (Fig. 24.19). This procedure
may be performed in an office setting with oral sedation
(2 mg of oral lorazepam) and local anesthesia, or under
IV sedation. Patients are prophylactically treated with
clindamycin. A marking pen is used to mark Stensen’s
duct and the white bite line. The planned incision is
halfway between these landmarks, parallel to the bite line
starting opposite the second molar (Fig. 24.20). A half
mixture of 1% lidocaine with 1 : 100,000 epinephrine
and 0.5% bupivacaine is used for local anesthesia. A
30-gauge, 1-inch needle is used to infiltrate the mucosa
only, as infiltration into the buccinator may cause unnec­
essary distortion of the tissues. A needle tip electrocautery
on a cutting setting is used to incise the mucosa only and
a 2.5-cm incision is made. A long, fine Schnidt hemostat
is used to spread the fibers of the buccinator, pointing
the tips of the forceps towards the helix. As the muscle
fibers are spread, the glistening yellow fat is seen under
submental incision is made 1 mm posterior to the submen­
tal crease. Excess subcutaneous fat is usually addressed
by liposuction as described earlier in this chapter, and
this allows the platysma to be seen. Using the needle-tip
Bovie cautery, the medial edge of the platysmal muscle is
freed off the underlying fat and right-angle hemostats are
A
B
C
D
Figure 24.17  Preoperative (A, B) and postoperative (C, D) views of a patient following a facelift and necklift with subcutaneous liposuction,
platysmaplasty, and subplatysmal lipectomy.
Figure 24.18  Liposuction over the parotid bed, jowls, and midface
region may be facilitated under direct vision through the facelift inci­
sion. The authors prefer to elevate the rhytidectomy skin flaps in the
traditional manner with sharp dissection, followed by liposuction.
However, pretunneling may be performed initially with or without
suction to facilitate skin flap elevation.