Master Techniques in Facial Rejuvenation 2

24  Facial and Cervical Lipectomy
319
fluid shifts typically seen with removal of large quantities
of adipose tissue. Furthermore, although bleeding can be
brisk in the face and neck, blood loss is usually of negligi­
ble consequence and certainly much less than in body lipo­
suction. Hematoma and seroma formation is rare (<1%)
and may usually be evacuated by needle aspiration fol­
lowed by application of pressure dressings [43]. A rapidly
expanding hematoma, however, requires exploration and
drainage in the operating room. Although primary infec­
tions occur in less than 1% of cases, infections occurring
in existing hematomas should be managed aggressively
[44]. Fortunately, most reported cases of facial nerve
neurapraxia are transient palsies arising from contusion
or stretch injuries and resolve within a few weeks [8,45].
The marginal mandibular nerve is the most commonly
may appear; these typically soften and dissipate over
time. Postoperative discomfort is usually minimal.
Patients with intraoral excision of the buccal fat pad
are instructed to use ice compresses, oral rinses, and
to consume a soft diet for a week. No dressing is used
for patients who only undergo buccal fat pad excision.
Patients should be counseled that postoperative edema
may take months to resolve completely.
COMPLICATIONS
Long-term experience with facial suction lipectomy has
shown it to be a safe surgical modality with relatively
few complications. Unlike whole-body liposuction, facial
liposuction does not have the capacity to produce major
A
B
Figure 24.21  After an incision is made through the mucosa, Schnidt
forceps are used to bluntly spread the buccinator muscle fibers and the
underlying, pale-yellow buccal fat pad can be seen (A). The forceps then
bluntly punctures the buccopharyngeal membrane and the buccal fat
pad can be gently expressed (B).
Figure 24.22  Typical appearance of buccal fat pad after excision.
Figure 24.23  The buccal fat pad is being excised during a rhytid­
ectomy after the sub–superficial musculoaponeurotic system flap has
been elevated and retracted. The inferior border of the zygomatic arch
is highlighted in purple.

320
MASTER TECHNIQUES IN FACIAL REJUVENATION
of 0.05 cc to 0.1 cc are injected into each site. Treatments
may need to be administered at 4 to 6 week intervals,
for 2 to 3 months. Overtreatment will result in dermal
atrophy and depression, as well as the formation of spider
telangiectasias.
Complications following buccal fat pad removal
include hematoma, infection, trismus, prolonged edema,
facial nerve injury, parotid duct injury, and contour irreg­
ularities and asymmetries. The most common complica­
tion is immediate postoperative edema, which may mimic
a hematoma.
FUTURE CONSIDERATIONS
Significant advances have been made in the art and science of
facial contouring. Although facial lipectomy remains an essen­
tial tool, the last decade has seen an explosion in noninvasive
methods of facial contouring. The use of injectable fillers has
added another dimension to facial sculpting, and at the time
of publication of this book, a new product, Kybella, was being
launched in the United States. Kybella is a noninvasive inject­
able derived from deoxycholic acid used to treat moderate-to-
severe convexity or fullness associated with submental fat in
adults. Deoxycholic acid, also known as ATX-101, is a natu­
rally occurring molecule in the body that aids in the breakdown
and absorption of dietary fat, and when it is injected into the
subcutaneous fat will cause the destruction of fat cells [46].
Kybella was approved by the United States Food and Drug
Administration in April 2015, and is injected into the subcuta­
neous submental fat. Patients typically benefit from a series of
treatments spaced 1 month apart, not to exceed six treatments.
At this point, the safety and efficacy of Kybella has not been
established outside the submental region, but the prospects
of application beyond the submental region is exciting. With
continued research, the science of facial contouring expand our
capabilities as artists and surgeons.
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of the facial nerve.
Other complications may result from overzealous lipo­
suction. In the neck, aggressive liposuction may expose
platysmal bands not previously apparent, creating a
“cobra” deformity (Fig. 24.24). This may require platys­
maplasty to correct. Conservative aspiration in the face
will reduce the risk of “skeletonizaton,” a phenomenon
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with advancing age and subsequent loss of facial volume.
When significant, the hollowed areas may be augmented
with autologous fat injections. Misguided aspiration of
the skin flap may result in dermal scarring with limited
options for correction.
Contour irregularities and asymmetries may manifest
once edema resolves. One study reported that 10% of
patients were undertreated, necessitating “touch-up”
treatments [2]. Touch-up liposuction may be performed
in the office under local anesthesia with microcannulas.
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is diluted to 5 mg/mL to 10 mg/mL, and small aliquots
Figure 24.24  Platysmal bands were unmasked in this patient after
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24  Facial and Cervical Lipectomy 320.e1
24. Matarasso A. Pseudoherniation of the buccal fat pad: a new clini­
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31. Dedo DD. Management of the platysma muscle after open and
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32. Morrison W, Salisbury M, Beckham P, et al. The minimal
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34. Klein JA. The tumescent technique for liposuction surgery. Am J
Cosmet Surg 1987;4:263–7.
35. Klein JA. Tumescent technique for regional anesthesia permits lido­
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36. Klein JA. The tumescent technique. Anesthesia and modified lipo­
suction technique. Dermatol Clin 1990;8(3):425–37.
37. Teimourian B, Kroll SS. Subcutaneous endoscopy in suction lipec­
tomy. Plast Reconstr Surg 1984;74(5):708–11.
38. Kesselring UK. Facial liposuction. Facial Plast Surg 1986;4(1):1–4.
39. Velazquez JM. Improving the labial commissurae and paralabial
folds with minimally invasive procedures: A useful method for
midfacial rejuvenation. Aesthet Surg J 2004;28(2):100–7.
40. Guyuron B, Michelow B. The nasolabial fold: a challenge, a solu­
tion. Plast Reconstr Surg 1994;93(3):522–9, discussion 530-2.
41. McKinney P, Cook JQ. Liposuction and the treatment of nasolabial
folds. Aesthet Surg J 1989;13(3):167–71.
42. Williams EF, Lam SM. Comprehensive facial rejuvenation. Phila­
delphia: Lippincott Williams & Wilkins; 2004.
43. Jasin ME. Submentoplasty as an isolated rejuvenative procedure
for the neck. Arch Facial Plast Surg 2003;5(2):180–3.
44. Kridel RWH, Pacella BL. Complications of liposuction. In: Eisele
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45. Tapia A, Ferreira B, Eng R. Liposuction in cervical rejuvenation.
Aesthet Surg J 1987;11(2):95–100.
46. Stryer L, editor. Biochemistry. 4th ed. New York, NY: WH Freeman
and Co.; 1995. p. 691–707.
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1. American Society for Aesthetic Plastic Surgery Statistics; 2014.
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unsuitable candidates. Plast Reconstr Surg 2003;112(5):1393–405,
discussion 1406-7.
3. Fattahi TT. Management of isolated neck deformity. Atlas Oral
Maxillofac Surg Clin North Am 2004;12(2):261–70.
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7. Goodstein WA. Superficial liposculpture of the face and neck. Plast
Reconstr Surg 1996;98(6):988–96, discussion 997-8.
8. Knize DM. Limited incision submental lipectomy and platysma­
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10. Fischer A, Fischer G. First surgical treatment for molding body’s
cellulite with three 5 mm. incisions. Bull Int Acad Cosmet Surg
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11. Fischer A, Fischer G. Revised techniques for cellulitis fat reduction
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12. Kesselring UK, Meyer R. A suction curette for removal of exces­
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1978;62(2):305–6.
13. Illouz YG. Body contouring by lipolysis: A 5-year experience with
over 3000 cases. Plast Reconstr Surg 1983;72(5):591–7.
14. Fournier PF. Why the syringe and not the suction machine? J Der­
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15. Flynn TC, Coleman WP II, Field LM, et al. History of liposuction.
Dermatol Surg 2000;26(6):515–20.
16. Fodor PB. Reflections on lipoplasty: history and personal experi­
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17. Knize DM. Limited incision submental lipectomy and platysma­
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19. Rohrich RJ, Pessa JE. The subplatysmal supramylohyoid fat. Plast
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20. Narasimhan K, Stuzin JM, Rohrich RJ. Five-step neck lift: inte­
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23. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and
clinical applications of the buccal fat pad. Plast Reconstr Surg
1990;85(1):29–37.

321
HISTORY
The history of autologous fat transfer stretches back over
an entire century. The first clinical case of fat transfer
was described by Neuber in 1893, who reported the
use of parcels of fat harvested from the upper extremity
to reconstruct a facial defect engendered by tuberculous
osteitis [1]. Two years later Czerny commented on filling
a breast deformity created by removal of a benign mass
with an excised lipoma [2]. In 1910 Lexer described fat
transplantation with larger pieces of fat and found that
doing so resulted in improved survival [3]. The following
year Bruning injected harvested fat into a postrhinoplasty
defect successfully [4] and Tuffier used fat placed into
the extrapleural space to manage pulmonary conditions
[5]. In 1932 Straatsma and Peer used fat to plug fistulas
that arose after frontal sinus surgery [6]. Two years later
Cotton finely morselized and inserted fat into various
defects. In 1956 Peer remarked that walnut-sized fat
transplanted fared better than smaller morselized grafts,
noting that free fat grafts lose almost half their weight
and volume after a year [7,8].
The rise of liposuction in 1974 stimulated renewed
interest in autologous fat transfer [9]. In 1982, Bircoll
reported using liposuctioned fat for contouring a range
of defects [10]. In the 1980s Illouz [11], Krulig [12], and
Newman [13], based on Pierre Fournier’s work, contin­
ued the trend of using aspirated fat for recontouring the
face and body. Despite these efforts at autologous fat
transfer, the question of viability remained and limited the
widespread adoption of this technique. Renewed interest
in fat grafting took root as reports of long-term viability
began to surface with the use of more gentle harvesting
techniques utilizing hand rather than machine suction,
and improvements in fat processing with the use of strain­
ing and centrifugation [14,15]. Despite older claims to the
contrary, injection of very small parcels of fat appeared
to improve survival, as the nourishment of each fat cell is
increased by the surrounding neighboring tissue.
Today, proponents of autologous fat transfer have
shown the long-term efficacy of fat transfer as well as its
importance in facial rejuvenation. Sydney Coleman revo­
lutionized the field of aesthetic facial surgery by putting
forth the idea that volume depletion and not gravitational
descent represents the primary mechanism of facial aging
[16]. He has demonstrated sustained 5- and 10-year facial
enhancement results after “lipostructure” fat grafting.
Roger Amar has meticulously analyzed the face in terms
of the intricate underlying musculature and has based his
fat-grafting method on using injections into the respective
muscle bellies to achieve aesthetic volume enhancement,
calling his unique protocol “fat autograft muscle injec­
tion” [17].
PERSONAL PHILOSOPHY
Volume restoration is no longer disputed as a principal
mechanism by which the face ages. Autologous fat trans­
fer along with injectable cosmetic fillers have become
recognized as important techniques to restore volume
in the aging face. Traditional rejuvenative procedures,
such as blepharoplasty and facelifts, have been predicated
on tissue excision. However, many of these efforts have
failed to truly rejuvenate the aging face, resulting in an
unnaturally pulled and lifted appearance. Furthermore,
traditional procedures may result in an exaggeration or
accentuation of age-related volume loss. A new paradigm
centered on volume restoration has supplemented rather
than eliminated the old paradigm visualizing only gravi­
tational descent of the face and neck. Accordingly, this
paradigm suggests that the aging face also suffers from
volume depletion over time like a grape that shrinks into
a raisin. Therefore, only removal of apparent skin and
tissue redundancy can unnaturally transform the face.
On the other hand, reinflation of the collapsed face with
much-needed volume can restore the face to its natural
and youthful form. Autologous fat transfer can play a
crucial role in facial rejuvenation as a standalone proce­
dure or in combination with traditional facial rejuvena­
tion procedures (Fig. 25.1) [18].
Like all rejuvenative procedures, the aim of facial fat
grafting is threefold: achieve a natural appearance by
restoring a youthful vibrancy, avoid complications, and
attain long-lasting aesthetic benefit. This chapter will
attempt to outline a systematic approach toward facial
fat enhancement that emphasizes simplicity, consistency,
and safety, and has been obtained through two decades of
clinical experience with ongoing technique refinements.
The use of fat grafting requires the surgeon to acquire
a new aesthetic appreciation of the aging process. A new
set of skills is required, including fat harvesting and infil­
tration, as well as management of unique complications.
Consequently, we advocate a conservative approach when
beginning to incorporate facial fat transfer in one’s prac­
tice. In our experience, the postoperative surgical morbid­
ity rate increases as one pushes the limits of fat transfer to
obtain ideal results, particularly in the periorbital region.
Additional fat transfer in cases of undercorrection is an
easier task when compared with the difficulty of manag­
ing complications such as visible contour irregularity or
C H A P T E R 25 
Complementary Fat Grafting
Robert A. Glasgold, MD, Mark J. Glasgold, MD, and Samuel M. Lam, MD

322
MASTER TECHNIQUES IN FACIAL REJUVENATION
an overcorrected face. Conservatism, particularly in the
periorbital region, should be the rule, especially for the
surgeon inexperienced with facial fat grafting. Since t
he writing of the first edition of this book, the advent of
micro disposable cannulas has allowed for very precise
placement of injectable office-based fillers. As a result of
these advances, injectable fillers can serve as a simple and
more accurate means of volume replacement to touch up
a fat-grafting procedure. Accordingly, today it is a far
more common practice to perform a primary fat grafting
followed by a touch up several months to a year later with
injectable fillers to improve the final result when needed.
The new aesthetic principles advocated in volume res­
toration mandate a different approach to the patient.
Rather than arbitrarily defining an aesthetic objective,
the surgeon should try to aim at regaining the patient’s
youthful appearance. Many surgeons today evaluate a
patient during consultation and attempt to define what
areas of the face require improvement without reference
to how the patient actually looked when younger. For
instance, browlifting is usually recommended when the
brow appears ptotic. However, a patient may never have
had a well-defined upper-eyelid sulcus or arched eyebrow
position. Overelevating a brow will often look unnatural
and may not return a patient to the way that he or she
looked when younger [19–21]. Volume restoration may
be all that is necessary for a patient who always had a
low-lying brow that has lost its fullness with age (Fig.
25.2). Patients are encouraged to bring in photographs
of themselves when they were younger. These photo­
graphs help the surgeon to learn more about the patient’s
youthful appearance and the patient to understand the
A
B
Figure 25.1  (A) Preoperatively this patient displays midfacial volume loss. (B) Postoperative photo 1 year after autologous fat transfer to the
superior and inferior orbital rims, cheek, submalar, and buccal regions in conjunction with upper-lid blepharoplasty and transconjunctival lower
lid blepharoplasty. (Courtesy of Robert Glasgold, MD. Reprinted with permission from Glasgold Group.)
A
B
C
Figure 25.2  (A) Patient photo from when she was in her twenties demonstrating a fuller and more youthful upper eyelid. (B). Preoperative photo
of this patient in her sixties demonstrating periorbital volume loss. The upper eyelid is characterized by an “A”-frame deformity with predominantly
medial volume loss. (C). One year postoperative photo following autologous fat transfer to the inferior and superior orbital rims and midface in
conjunction with upper eyelid blepharoplasty and facelift. (Courtesy of Robert Glasgold, MD. Reprinted with permission from Glasgold Group.)

25  Complementary Fat Grafting
323
pseudoherniated fat combined with fat grafting along
the hollow orbital rim provides the optimal balance of
safety and aesthetic benefit. In patients with considerable
pseudoherniated fat, the significant volume needed for fat
grafting can lead to patient dissatisfaction secondary to
increased likelihood for contour irregularity and overcor­
rection of the region. With ongoing clinical experience,
a surgeon will begin to perceive the complementary role
that volume enhancement can play in facial rejuvenation.
Although autologous fat has been used successfully to
manage hypoplastic lips and depressed facial lines (like
the nasolabial and labiomandibular folds), we strongly
believe that the rejuvenative benefit for these areas is
limited. Fat enhancement of the lips often requires signifi­
cant fat deposition with marked, prolonged ecchymosis
and edema with limited longevity. Similarly, augmenta­
tion of the deeper lines in the perioral region often fails
to achieve adequate patient satisfaction. We do infiltrate
fat into the nasolabial folds when performing fat augmen­
tation of the cheek to ensure that the newly augmented
cheek does not exaggerate the apparent depth of the
nasolabial folds. Patients whose primary goal is lip aug­
mentation or effacement of facial lines are best treated
with one of the many available injectable fillers.
ANATOMY
The understanding of facial topography is the most
important aspect of anatomy as it relates to fat graft­
ing. The soft-tissue loss that is associated with the aging
process is accentuated by the presence of facial retain­
ing ligaments, which create unfavorable depressions (Fig.
25.4). Hills and valleys develop across the surface of the
face, contrasting the convexity associated with a youthful
appearance.
The face is usually divided into thirds for better ana­
tomic understanding. The upper third comprises the
importance of volume loss in the aging process. Review­
ing a patient’s old photographs has particular relevance
and importance in order to appreciate the role of fat
grafting and help the surgeon conceptualize the surgical
plan.
Our approach for facial rejuvenation does not rely
solely on autologous fat transfer. We have entitled this
chapter “Complementary Fat Grafting” to emphasize the
complementary role that fat grafting plays in our clinical
practices (i.e., a patient’s aesthetic result and satisfac­
tion can be greatly enhanced by using a combination of
approaches such as fat grafting, facelifting, blepharo­
plasty, and even office-based procedures such as neuro­
modulators, injectable fillers, and laser/light therapies to
attain the desired level of improvement). Patients may be
considerably more pleased when each procedure adds to
the tally of aesthetic improvement (Fig. 25.3). Traditional
procedures and fat transfer need not be exclusive of one
another. We can embrace two ideologies: autologous fat
transfer for volume depletion and lifting procedures for
gravitational descent. It is also important, as alluded to,
not to forget about the third part of the triad for rejuve­
nation, that is, the importance of skin treatments such as
skin-care products, laser therapy, and neuromodulators.
Judicious use of fat grafting with select lifting procedures
can constitute a very potent mixture for correcting spe­
cific flaws of aging. For example, prominently descended
jowls and loose platysmal bands cannot be adequately
improved with fat grafting alone. Standard cervico­facial
rhytidectomy is often combined with fat grafting of the
prejowl sulcus to obtain the ideal aesthetic results. Com­
bining procedures can also diminish perioperative mor­
bidity; fat grafting alone in areas that could be more
easily targeted with facelift procedures requires consider­
able volume, adding to the already long recovery period
necessitated by fat grafting. The periorbital region is par­
ticularly unforgiving. Selective blepharoplasty to reduce
A
B
Figure 25.3  Preoperative (A) and 1-year postoperative (B) photos of a patient who underwent autologous fat transfer to the inferior and superior
orbital rims and midface in conjunction with upper eyelid blepharoplasty and facelift. (Courtesy of Robert Glasgold, MD. Reprinted with permis­
sion from Glasgold Group.)

324
MASTER TECHNIQUES IN FACIAL REJUVENATION
superior orbital rim, creating a softer appearance from
the presence of an infrabrow highlight (Fig. 25.5).
Advancing age manifests with volume loss of the orbit,
particularly in the superomedial aspect, due to bone
remodeling as well as fat loss [21,22]. The medial upper
lid has a ligamentous attachment to the orbital rim; as
a result, superomedial bone resorption causes a corre­
sponding cephalic retraction on the medial upper-lid fold,
manifesting as an A-frame deformity (see Fig. 25.2). The
bone and soft-tissue volume loss at the superior orbital
rim erodes the platform that supports the brow, resulting
in a relative brow descent and crowding of the upper lid.
Additionally, an infrabrow shadow will often appear and
interrupt the youthful continuum from upper-lid fold to
brow. Type I upper lids age with great variability, ranging
from primary skin redundancy without significant volume
loss to primary volume loss. The treatment strategy needs
to be tailored to the age-related changes apparent in the
individual being evaluated, balancing the need for skin-
removal blepharoplasty with volume-oriented strategies.
Aging in type II upper eyelids is dominated by volume
loss, with skin redundancy playing a much less significant
role.
The Middle Third
The middle third of the face is the most complex subunit
and perhaps the most important area for facial rejuvena­
tion with autologous fat grafting. This region encom­
passes the lower eyelid, the malar and submalar areas.
A youthful face is characterized by a confluence of the
lower eyelid and cheek regions, which becomes separated
into visually distinct regions during the aging process
(Fig. 25.5). The orbital rim is more clearly observed with
aging due to the orbital fat bulging superiorly and volume
recession along the inferior orbital rim. The voluminous
lateral cheek mound of youth dissipates to reveal the
brow and temple area, and the middle third corresponds
to the cheek and midface. The lower third constitutes the
chin, prejowl, jowl, and lateral mandible. This systematic
appraisal will provide a concrete formula for specific
volume enhancement based on each individual anatomic
territory. Clinically relevant regions of each anatomic
zone will be emphasized with pearls to guide surgical
strategy.
The Upper Third
The upper third of the face comprises three main con­
stituent elements: the brow, upper eyelid, and temple. A
youthful face displays a unified upper-lid–brow complex,
much the same way the youthful lower lid flows into
the cheek. A younger appearing upper eyelid will have a
uniform fullness, from medial to lateral, spanning from
the lid fold inferiorly to the brow superiorly; lacking an
immediate and pronounced infrabrow shadow typical of
an older eyelid [20,21]. A younger face will also dem­
onstrate a fuller temple, devoid of the shadows at the
temporal line and superior border of the zygoma that
develop with facial aging. Volume restoration is crucial
in minimizing the harsh and aging shadows of senescence
that manifest in the upper face.
Important to the analysis of the upper face is an under­
standing of the varied upper eyelid appearance and the
manner in which this affects both the aging process and
the techniques for rejuvenation. To simplify, youthful
upper eyelids can be broken down into two subtypes.
The more common, type I, is characterized by a fuller
upper lid with a minimal strip of visible pretarsal skin
between the lid fold and lash line. The less common, type
II, demonstrates a higher lid fold with a greater degree of
visible pretarsal skin, creating a more sculpted superior
orbital rim [20,21]. Regardless of subtype, youthful eyes
are characterized by soft-tissue volume camouflaging the
Midface depression/malar septum
Nasolabial fold
Malar mound
Labiomandibular fold
Prejowl sulcus
Infraorbital rim
Figure 25.4  The important anatomic landmarks for fat injections are depicted in this photograph. (Courtesy Lam S, Glasgold MJ, Glasgold RA.
Complementary fat grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)

25  Complementary Fat Grafting
325
fail to straighten the jawline if prejowl augmentation is
not performed. Volume deficiency in the lateral mandible,
posterior to the jowl, may be age related or congenitally
absent. The addition of volume to the lateral mandible
can help diminish the appearance of the jowl and restore
the youthful jaw contour.
PREOPERATIVE ASSESSMENT
The consultation for patients considering autologous fat
grafting is primarily based on sound facial analysis and
understanding the desires of the patient. Owing to the
complex and unconventional nature of autologous fat
grafting, patients may not entirely appreciate the benefits
of the procedure if they are more accustomed to tradi­
tional surgical procedures such as facelifts and blepharo­
plasty. Examining photographs from a patient’s youth can
significantly aid the surgeon in explaining the aesthetic
objectives of autologous fat grafting. Reviewing with the
patient each decade of change and showing the gradual
dissipation of soft-tissue volume can be informative to
most patients. Before and after photographs of other
patients who exhibit similar anatomy can also be quite
illuminating for a prospective patient. Digital morphing
technology often falls short of the intended mark, as it
is very difficult to convey volumetric changes. However,
three-dimensional imaging, for example, with Canfield’s
Vectra system, can provide a documented, quantitative
volume baseline that can be compared again in the future
when the patient returns, to determine the level of fat
retention [24].
After establishing realistic aesthetic objectives, the
surgeon must ensure that the patient fully comprehends
the benefits and limitations of the procedure. For instance,
fat grafting has proved to be less than ideal to manage
smaller, flatter contour of the malar bony eminence that
lacks any notable soft-tissue coverage. The anterior cheek
begins to lose volume, developing a linear depression
coursing from the nasojugal groove in a inferolateral
direction and corresponding with the underlying malar
septum ligamentous attachment [23]. Finally, the buccal
region can exhibit marked atrophy and should be recon­
stituted along with the anterior and lateral malar regions
to achieve better confluence and to avoid an exaggeration
of buccal hollowing following malar augmentation. As an
extension of the midface, the nasolabial fold should be
deemed part of midfacial volume enhancement.
Restoring midface volume is an important part of cre­
ating a more youthful appearance. Unfortunately, as we
have seen an increased acceptance and incorporation of
adding volume, there has been a corresponding increase
in putting too much emphasis on quantity of volume. In
particular, there appears an emphasis on overaugmen­
tation of the anterior cheek and the cheek highlight,
resulting in a unnatural appearance, especially when a
patient is smiling. As with many techniques, sometimes
the pendulum swings too far, and in that case it needs to
be reset to achieve the natural results we aim for.
The Lower Third
The lower third of the face is principally focused on
the labiomandibular fold, prejowl sulcus, labiomental
sulcus, and chin. The chin undergoes volume recession
as opposed to the volume gain that can be appreciated in
the jowl region. For very early jowling, volume enhance­
ment with autologous fat in the prejowl sulcus can be
sufficient to straighten the jawline. Even markedly con­
spicuous jowling is often accompanied by proportionate
volume contraction along the prejowl region. Accord­
ingly, facelifting to correct significant jowling can still
A
B
Figure 25.5  (A) Type I upper eyelid demonstrated in this 18-year-old woman. (B) Type II upper eyelid demonstrated in this 20-year-old woman.
(Reprinted with permission from Glasgold Group.)

326
MASTER TECHNIQUES IN FACIAL REJUVENATION
requiring patient repositioning for harvesting (Fig. 25.6).
With 10-mL Luer-Lok syringes outfitted with a harvest­
ing cannula, manual extraction of the fat should be per­
formed with only 1 to 2 mL of negative pressure held
on the plunger (Fig. 25.7). Entry sites for cannula inser­
tion through the skin are made with a 16-gauge Nokor
needle or a No. 11 blade in discreet areas such as the
umbilicus for the lower abdomen and the inguinal line
hypoplastic lips and deep nasolabial/labiomandibular
folds. In these areas, soft-tissue fillers may be a better
solution. Further, as mentioned previously, soft-tissue
fillers can be very helpful to touch up a fat-grafting pro­
cedure for optimal results.
SURGICAL TECHNIQUE
General Considerations
Autologous fat transfer can be undertaken with relatively
light intravenous sedation and infiltration of local anes­
thesia. Preoperatively the patient’s face should be marked
carefully to delineate the recipient sites for fat grafting.
Markings should be made with the patient in an upright
position so that dependent tissues can help accentuate
the highlights and shadows of the face. Determination
of the appropriate donor site should also be made in the
preoperative area. In deciding on the donor site, it is often
helpful to ask patients where they feel they accumulate
the most fat or which area has been the most recalcitrant
to fat loss despite exercise. Prior surgery, especially lipo­
suction, can preclude the harvesting of usable fat from an
area. Finally, the prohibitive presence of occult or visible
ventral hernias should be ascertained before embarking
on harvesting from the lower abdomen.
FAT HARVESTING
The areas that are typically available for fat harvest­
ing include the lower abdomen, inner thigh, outer thigh,
lower lateral buttock, lateral waist and lower back;
less commonly used, but possible harvest sites, include
the anterior thigh, inner knee, and triceps. The lower
abdomen and inner thigh have the advantage of not
A
B
Figure 25.6  The donor sites for fat transfer are shown. The most easily accessible areas are in the abdominal and inner thigh regions (A). Addi­
tional sites include the lateral thigh and flank areas (B). (Courtesy Lam S, Glasgold MJ, Glasgold RA. Complementary fat grafting. Philadelphia,
Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)
Figure 25.7  Fat-transfer instruments (Tulip Medical, Inc., CA, USA),
from top to bottom: The 0.9-mm injecting cannula (4-cm length) is
the cannula of choice for periorbital injections and is our primary
cannula used throughout the face. The 1.2-mm injecting cannula (6-cm
length) is an all-purpose cannula that can alternatively be used for injec­
tions outside the periorbital region. The 2.1-mm multiport harvesting
cannula (12-cm length) we have available as an alternative cannula for
thin patients. The 3.0-mm bullet-tip harvesting cannula (15-cm length)
is our primary harvesting cannula and can be used as one’s sole harvest­
ing cannula. (Courtesy Lam S, Glasgold MJ, Glasgold RA. Complemen­
tary fat grafting. Philadelphia, Lippincott Williams & Wilkins, 2007.
Copyright Lippincott Williams & Wilkins.)

25  Complementary Fat Grafting
327
A
C
B
D
Figure 25.8  (A) Harvested fat in a 10-mL syringe pre- (left) and post- (right) centrifugation. (B) The surgeon pours off supranatant (free fatty acids).
(C) The surgeon drains infranatant (primarily blood). (D) The fat is wicked with gauze to remove residual supranatant. (Courtesy Lam S, Glasgold
MJ, Glasgold RA. Complementary fat grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)
Solana Beach, CA) After each 10-mL syringe has been
filled from harvesting, it is sterilely passed to the surgical
assistant, who prepares that syringe for fat infiltration.
The assistant fastens a plug onto the Luer-Lok end of
the 10-mL syringe, removes the plunger with the syringe
in an upright position, and places a specialized cap into
the plunger side of the syringe. These caps and plugs
can be purchased from any reputable manufacturer, but
the original plunger and miniplastic Luer-Lok cover that
comes with the syringe should never be used for cen­
trifugation. After a balanced number of syringes have
been collected, they are inserted sterilely into the cen­
trifuge machine. Various types of systems are available,
each equipped with different inserts that can be steril­
ized. The centrifuge is turned on to rotate for approxi­
mately 3 minutes at 3000 rpm. A leeway of 1 minute and
1000 rpm can usually be permitted without compromis­
ing the fat processing.
After the fat has been centrifuged, the syringe is
removed sterilely and placed into a test-tube rack resting
on the sterile field. The processed syringe now appears
separated into three distinct layers: a supranatant consist­
ing principally of the oily residue of free fatty acids, the
central core of viable fat, and the infranatant composed
of blood and lidocaine (Fig. 25.8A). The cap from the
plunger side is always removed first to pour out the
for the inner thigh. A gentle motion should be carried out
to harvest the fat and the depth of the cannula should
be at the midlevel of the fat pad. If tenting of the skin
is noted, then the surgeon is most likely too superficial
and risks the potential for a contour irregularity at the
donor site. Passage of the cannula too deeply can elicit
significant discomfort, especially in the lower abdomen,
when the cannula abrades the rectus fascia. Harvesting
uniformly over the entire area can maximize fat yield
and minimize contour irregularities. Typically, owing to
the presence of lidocaine, blood, and lysed fat cells in the
preprocessed syringe, the amount of harvested fat should
be anticipated to be about half the collected volume, that
is, 5 mL of fat per 10-mL syringe. These estimates are
important when calculating how many milliliters of fat
are needed for transfer. The total volume of fat needed
for transplantation will depend on the surgeon’s clinical
judgment and should be modified for each patient. On
average, 30 to 50 mL of fat is a common amount for a
semiconservative full-face fat transfer, with over 60 mL
representing a more aggressive strategy.
Processing the Fat
Although numerous techniques for fat processing exist,
our preference is for either centrifugation (described
below) or Puregraft (a closed filtration system).(Puregraft;

328
MASTER TECHNIQUES IN FACIAL REJUVENATION
from an entry point just above the brow (Fig. 25.10).
The depth of fat placement is deep to the orbicularis
muscle, often just above the periosteum. The cannula
passes perpendicular to the superior orbital rim and fat
is primarily placed just inferior to the superior orbital rim
so as to fill the infrabrow shadow and help restore the
brow’s platform. In almost every situation medial volume
is needed; in contrast, there is much greater variability
on the need for lateral volume. For the medial upper lid
1 cc of fat is usually adequate, with an additional 1 cc
of fat for the lateral upper lid if needed. For much more
volume-deficient upper lids, especially type II lids, you
may add an additional 1 cc, for a total of 3 cc. This is
an area where people are pleased with less, not more, so
it is best to start with more conservative volumes.
Fat transfer to the temple presents certain challenges
in that there tends to be a lower percent of fat survival
in this area and the overlying thin skin could predis­
pose to contour irregularity. Both of these problems are
more related to superficial placement in a subcutaneous
plane. To overcome these issues, we use an approach
supranatant (see Fig. 25.8B). Then, the plug is unscrewed
from the Luer-Lok side and the infranatant is allowed to
drain from below (see Fig. 25.8C). The syringe is returned
to the test-tube rack without cap or plug and with the
plunger side facing upward so that the fat does not spill.
Additional supranatant is wicked away by placing an
unfurled 4 × 4 cotton gauze into the exposed plunger
side of the syringe to make contact with the column of
fat (see Fig. 25.8D). It is very important that the 4 × 4
gauze pad not be trimmed so as to prevent introduc­
tion of particles of shorn cotton into the mixture of fat
intended for infiltration. After a few minutes have trans­
pired, the wicks are removed and the fat is transferred
into the back end of a 20-mL syringe to facilitate trans­
fer into the 1-mL infiltration syringes (Fig. 25.9A). The
plunger of the 20-mL syringe is gently reinserted, and a
transfer hub is used to join the 20-mL syringe with the
1-mL syringe via a Luer-Lok connection (see Fig. 25.9B).
The fat is then transferred to each 1-mL syringe, one at
a time. Generally, only four 1-mL syringes are required;
as the surgeon constantly infiltrates fat, the assistant can
reload the next syringe.
Infiltrating the Fat
The fat is always infiltrated with a 1-mL Luer-Lok syringe
so as to ensure placement of a very limited parcel of fat
per each passage of the cannula. Differential placement of
fat will optimize its viability and minimize complications.
In areas that are less forgiving, such as the periorbital
region, 0.03 to 0.05 mL is injected per pass. In more
robust regions, such as the prejowl sulcus and midface,
0.1-mL injections can be performed in each pass. Only
blunt injection cannulas should be used in order to mini­
mize the chance of nerve or vessel damage during infiltra­
tion (see Fig. 25.7). A standard 20-gauge needle is used
to create the puncture site in the skin through which
the cannula tip is introduced. If considerable resistance
on the plunger is met when infiltrating fat, the cannula
should be withdrawn from the patient and cleared to
prevent inadvertent injection of a large bolus of fat.
Upper Third
Our approach to the upper eyelid/superior orbital rim
has evolved where we now generally approach this region
A
B
Figure 25.9  Processed fat is poured into a 20-mL syringe (A). The fat is then transferred to 1-mL Luer-Lok syringes through the attached transfer
hub (B). (Courtesy Lam S, Glasgold MJ, Glasgold RA. Complementary fat grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright
Lippincott Williams & Wilkins.)
Figure 25.10  Placement of fat under the superior orbital rim. (Cour­
tesy Glasgold RA, Lam SM, Glasgold MJ. Periorbital fat grafting. In:
Massry G, Azzizadeh B, Murphy M, editors. Master techniques in
blepharoplasty and peri-orbital rejuvenation. New York, NY: Springer.
2011.)

25  Complementary Fat Grafting
329
be judiciously used in the more volume-deficient patients,
with additional fat placed in a more superficial plane.
The lateral and anterior cheeks are easier areas to
augment. The cheeks can tolerate a more generous
amount of fat (0.1 mL per pass) in more superficial planes
without risking contour irregularities. The skeletonized
lateral cheek should be augmented to restore a youthful,
full, rounded contour that blends well with a full, ante­
rior cheek. The anterior cheek is typically divided by a
linear depression running from the superomedial nasoju­
gal groove inferolaterally to the buccal region. Placement
of fat into the anterior cheek should be principally situ­
ated into the greatest areas of tissue loss, the depression
at the malar septum and the region inferomedial to the
malar septum. Passage of the cannula to reach the ante­
rior cheek can be made from a lateral cheek entry site,
and the cannula often must be forcefully pushed through
the fibrous malar septum to breach it (Fig. 25.12). At
times, the malar septum does not pose much resistance
and can be easily traversed.
Patients should be evaluated for the presence of a malar
mound, which appears as a protuberance at the junction
of the anterior and lateral cheek lying just lateral to the
upper portion of the malar septum. When this feature is
present, the surgeon should attempt to avoid placement of
excessive fat under the already prominent malar mound.
Gentle contouring around the malar mound can help
soften the appearance of the malar protuberance while
at the same time rebuilding lost volume of the cheek.
If patients note a history of fluctuating, cyclic edema of
the malar mound, placement of fat immediately below
this structure may only worsen the condition and lead to
protracted swelling in this area for several months.
In the thin patient, the buccal and submalar regions
are often hollow and can tolerate a generous amount of
fat with minimal concern of contour irregularity. Place­
ment of fat into the subcutaneous tissue and somewhat
more deeply will soften a gaunt appearance and provide a
better transition between the malar and submalar regions.
Finally, the precanine fossa (the triangular depression cir­
cumscribed by the nasal ala medially and the upper extent
where the cannula is introduced and the fat placed into
a deeper plane below the temporalis fascia and even into
the temporalis muscle. The fat is placed into a recipient
area that tends to allow for greater take of the fat graft
and, by nature of the depth of injection, is less likely to
cause contour irregularity. The amount of fat needed
will depend greatly on the degree of concavity in the
temporal fossa. Again, a conservative approach is best; a
small residual concavity is preferable to an overfilled and
unnatural appearance.
Middle Third
Volume loss in the midface results in visible breakpoints
along the malar septum and between the lower lid and
cheek, imparting an aged and tired appearance. Often,
the midface is the most important region of the face to
augment with fat. Reestablishing a uniform and seamless
contour between the lower eyelid and cheek should be
the principal objective in many cases. Although infiltra­
tion of fat into the precanine fossa and nasolabial fold
is unlikely to efface a deep nasolabial fold, it can create
a better transition between the newly augmented cheek
and the upper lip.
The inferior orbital rim is one of the more difficult
areas of the face to enhance with fat and constitutes a
region where the majority of complications arise. Large-
volume fat injection (greater than the recommended 0.03
to 0.05 mL per cannula pass) or placement of fat in a
superficial plane can increase the chance of a notice­
able irregularity postoperatively. Our complication rates
have dramatically reduced by approaching this region
from an inferior-based entry site (Fig. 25.11). Using this
approach, the cannula tip passes perpendicularly to the
inferior orbital rim. This maneuver should be performed
with the index finger of the surgeon’s nondominant hand
placed on the superior aspect of the inferior orbital rim
in order to protect the globe. As one begins incorporat­
ing fat transfer, it is recommended that a conservative
amount of fat be placed along the inferior orbital rim (a
total of 2 mL per side) in the supraperiosteal plane so as
to minimize contour problems. Larger volumes of fat can
B
A
Figure 25.11  (A) Placement of fat along the inferior orbital rim; the index finger of the surgeon’s nondominant hand protects the globe. (B) An
intraoperative view of fat placement along the inferior orbital rim. (Courtesy Lam S, Glasgold MJ, Glasgold RA. Complementary fat grafting.
Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)

330
MASTER TECHNIQUES IN FACIAL REJUVENATION
the anterior and inferior aspects of the mandibular
body in order to achieve a three-dimensional, cylindri­
cal reshaping of the prejowl depression (Fig. 25.14). If
the chin appears to benefit from mild projection, fat
can also be placed along the anterior chin to achieve
the effect of an augmentation mentoplasty. The lateral
mandible is augmented as needed, with placement of fat
posterior to the jowl so as not to accentuate the full­
ness. If a concurrent rhytidectomy is planned, fat should
not be distributed along the lateral mandible, as this
area will be undermined regardless of the type of facelift
performed.
POSTOPERATIVE CARE
At the end of the procedure, the patient does not require
any sutures, bandages, or drains of any kind unless a
concurrent lifting procedure was performed. The patient
is discharged after the appropriate interval of postanes­
thesia observance. Although some surgeons who practice
fat transfer do not believe in immediate postoperative
of the nasolabial fold laterally) and the nasolabial fold
are augmented not with the expectation of effacement
of the fold, but rather to achieve an improved transi­
tion between the newly augmented anterior cheek and
the upper lip. A generous amount of fat can be placed
into the precanine fossa deeply into the supraperiosteal
plane to improve the hollowness in this area. The entire
nasolabial fold including the precanine fossa can then be
augmented from a perpendicular direction (i.e., from the
lateral cheek) into a more superficial subcutaneous plane.
Lower Third
The principal areas of the lower face that benefit from
fat augmentation are the prejowl sulcus, labiomandibular
recess, labiomental sulcus, lateral jawline, and anterior
central mentum. Of these five areas, the prejowl sulcus
can be considered the most important for enhancement
in order to provide maximal straightening of a descended
jawline (Fig. 25.13). A generous amount of fat can be
placed into the prejowl sulcus without risking contour
deformity. Placement of fat should be made along both
A
B
Figure 25.12  (A) The location and trajectory of the anterior cheek injection. (B) The intraoperative injection is performed. ([A] Courtesy Lam
S, Glasgold MJ, Glasgold RA. Complementary fat grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams
& Wilkins.)
A
B
Figure 25.13  This patient had a facelift 7 years ago and is unhappy with her jawline (A). Her primary issue is volume loss in the prejowl sulcus.
(B) The results 1 year after isolated volume augmentation to the prejowl sulcus. (Courtesy Lam S, Glasgold MJ, Glasgold RA. Complementary fat
grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)

25  Complementary Fat Grafting
331
(“lumps” or “bulges”) and overcorrection or undercor­
rection. A systematic appraisal of the problem and tar­
geted correction for each individual problem should be
undertaken in every case.
“Lumps” present as small discrete areas of excessive
fat, and are most likely to occur in the periorbital region.
Conservative placement of fat in the periorbital region is
an important step in avoiding this problem. When a lump
does occur, treatment begins with steroid injections into
the area of concern. If this fails to correct the problem,
and there appears to be a relatively discrete lump of fat,
directly excising this can alleviate the contour deformity
(Fig. 25.15).
“Bulges” are wider areas of elevation and may repre­
sent persistent edema or induration, or in some cases a
large uneven placement of fat. Bulges present as thick­
ened areas, which can be palpated and seen along the
inferior orbital rim. Injection with conservative amounts
of triamcinolone acetonide in increasing strengths from
10 mg/mL to 40 mg/mL have proven beneficial in most
circumstances, but must be repeated every 1 to 2 months
until resolution. In our experience, direct liposuction of
these areas has not been successful.
Overcorrection implies that a generalized region has
been overly inflated beyond the patient’s expectations. As
mentioned, the first several weeks to months are marked
by ongoing resolution of tissue edema. Therefore, a con­
servative, expectant approach is advocated. If failure of
timely resolution of the problem is encountered, then
microliposuction with an 18-gauge Klein Capistrano
cannula can be performed to reduce volume.
Undercorrection remains the most favorable complica­
tion, as it represents the most easily correctable condi­
tion. Additional fat harvesting and infiltration can be
accomplished relatively quickly and without difficulty
under local anesthesia or limited intravenous sedation.
FUTURE CONSIDERATIONS
We are standing at the crossroads of a major paradigm
shift from excision-based surgery to volume enhancement.
Whether or not there will be an increasing shift away from
excisional surgery in favor of volume correction is yet to
icing of transplanted regions owing to the risk of reduc­
ing fat cell viability, we believe that doing so does not
compromise the aesthetic result and can also expedite
the recovery. We advocate icing intermittently for at least
the first 48 to 72 hours postoperatively. Head elevation
is stressed for the first several nights after surgery as it
can reduce the extent of postoperative edema. Although
heavy exercise, especially with increased intra-abdominal
pressure and bending over, should be avoided; a light
isometric weight-lifting regimen with one-half to one-
third the typical weight and lighter cardiovascular exer­
cise can be undertaken once the swelling has begun to
recede, usually by the fourth or fifth postoperative day.
Besides these restrictions, there are no limitations per se
that prevent exercising areas of the body that were used
for donor harvesting. Finally, limiting salt intake may
minimize and assist in the resolution of postoperative
edema.
Although postoperative care is relatively simple and
straightforward, management of postoperative expecta­
tions may be more involved. Patients may perceive that
their face appears too inflated for their liking in the first
several postoperative weeks and regard this outcome as
an unintended result. Although the expected course of
recovery is explained in detail preoperatively, constant
reassurance should be proffered, with patients return­
ing as often as necessary. Ecchymosis and edema that
accompany fat grafting can be more pronounced than in
traditional surgical procedures, resulting in a social and
professional encumbrance for a longer period of time.
The periorbital region may be the most afflicted area with
bruising and soreness. In contrast to the face, where the
patient generally experiences very little discomfort, the
fat-harvesting sites are generally more painful for the first
several days to weeks after surgery.
COMPLICATIONS
The complications that arise after fat grafting are rela­
tively unique compared with those that may arise after
traditional lifting procedures. Injuries to nerves or vascu­
lar structures are extremely rare. The more common prob­
lems with fat transfer arise from contour irregularities
A
B
Figure 25.14  (A) The location and trajectory of the prejowl injection. (B) The intraoperative injection is performed. ([A] Courtesy Lam S, Glasgold
MJ, Glasgold RA. Complementary fat grafting. Philadelphia, Lippincott Williams & Wilkins, 2007. Copyright Lippincott Williams & Wilkins.)

332
MASTER TECHNIQUES IN FACIAL REJUVENATION
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be determined. We advocate a combination approach
that requires judicious selection of lifting procedures and
fat grafting tailored to each individual. Whatever the
outcome, it appears that fat grafting and facial volume
enhancement represent the present and future of facial
rejuvenation, as we see it from the narrow vantage of
today’s prism.
As we still have yet to find the perfect facial filler, the
field of synthetic facial injectables continues to advance
at a dizzying pace. Today, we have a multitude of choices
that continue to grow, as United States Food and Drug
Administration approval marches forward. Every type
of filler carries specific characteristics that make it more
ideal for a certain clinical application and also drawbacks
that may hinder implementation. The continuing change
in the landscape of facial fillers offers the possibility for
volume-augmentation procedures with less downtime and
without the need for harvesting fat. The rise of disposable
micro cannulas in particular, several years ago, permits
very advanced in-office facial sculpting with injectable
fillers that today can provide an alternative or supplement
to a fat-grafting procedure.
We predict that volume enhancement will continue to
play an increasing role as both a complementary and a
standalone procedure in facial rejuvenation.
R E F E R E N C E S
1. Neuber F. Fettransplantation. Chir Kongr Verh Dtsch Ges Chir
1893;22:66.
2. Czerny M. Plastischer ersatz der brusterlruse durch ein lipom. Verh
Dtsch Ges Chir Zbl Chir 1985;27:72–5.
3. Lexer E. Freie Fettransplantation. Dtsch Med Wochenschr
1910;36:640.
4. Bruning P. Cited by Broeckaert TJ, Steinhaus J: Contribution a
l’étude des greffes adipueses. Bull Acad R Med Belg 1914;28:440.
5. Tuffier T. Abces gangreneux du pouman ouvert dans les bronches:
hemoptysies repetee operation par decollement pleuro-parietal;
guerison. Bull Mem Soc Chir Paris 1911;37:134.
6. Straatsma CR, Peer LA. Repair of postauricular fistula by means
of a free fat graft. Arch Otolaryngol 1932;15:620–1.
A
B
C
Figure 25.15  (A) Preoperative view of a patient who underwent fat transfer to the inferior orbital rim and cheek. Six months postoperatively,
the patient has good malar augmentation but persistent visible lumps at the central inferior orbital rim (B). This patient was also unhappy with
persistent lower lateral fat that had not been removed. After correction of these problems with direct excision of redundant lower lid skin and
excess fat through an incision placed in the crease following the inferior orbital rim (C). The lateral fat pad was reduced through a transconjunc­
tival approach. (Courtesy Lam S, Glasgold MJ, Glasgold RA. Complementary fat grafting. Philadelphia, Lippincott Williams & Wilkins, 2007.
Copyright Lippincott Williams & Wilkins.)

333
PERSONAL PHILOSOPHY
Rhinoplasty at any age is a complex operation that
requires precise preoperative diagnosis to select the
appropriate surgical technique. Owing to variations
in nasal anatomy and aesthetic expectations, no single
technique is appropriate for all patients. Each rhino­
plasty patient presents the surgeon with a diversity of
nasal anatomy, contours, and proportions that requires
a series of organized maneuvers tailored to the patient’s
functional and aesthetic needs. In addition, the surgeon
must also be skilled at manipulating and controlling the
dynamics of postoperative healing to attain an optimal
long-term result.
NASAL ANALYSIS
Over time the nasal structure and external contour are
influenced by a multitude of genetic and environmental
factors. Children typically have a convex nasal dorsum
that progresses to a straight dorsal line. In the aging
patient, the nasal dorsum may become increasingly
convex. In combination with general lengthening of the
nose, there may be relative lengthening from ptosis of
the nasal tip or exaggeration of an existing dorsal hump
[1]. In addition, nasal function in the aging patient may
also decline, with compromise of the nasal airway at both
internal and external nasal valves.
The nasal bones may become brittle and more readily
fractured with aging [2]. Dorsal hump reduction must
be executed with precision to minimize irregularities that
may be visible through the thinner skin of the aging
patient [2]. Judicious and precise osteotomies are required
to avoid excessive narrowing of the bony vault or commi­
nuted fractures of the nasal bones. Wide periosteal eleva­
tion is not recommended in the aging patient. To avoid
loss of periosteal support, periosteal elevation should not
extend to the site of intended lateral osteotomies [2].
As the most significant changes over time occur in the
upper and lower lateral cartilages, careful preoperative
evaluation of the size, shape, angulation, and orientation
of each cartilaginous component of the nose is essential in
surgical planning for aesthetic and functional rhinoplasty.
The scroll region is a fibrous union at the cephalic margin
of the lower lateral crura, which connects these lateral
cartilages [1]. With aging, the upper and lower lateral
cartilages begin to separate and fragment [3,4]. This may
result in the collapse of the internal nasal valve and lateral
wall. As one ages, the middle nasal vault will tend to col­
lapse as the upper lateral cartilages move inferomedially.
Loss of support of the medial crura and stretching of the
fibrous attachments from the posterior septal angle and
nasal spine to the medial crural footplates result in their
posterior movement and retraction of the columella [4].
This retraction may be further compounded by resorp­
tion of the fat pad of the medial crura and premaxilla in
the aging patient [3].
The lower lateral cartilages provide the main support
for the nasal tip. The caudal margin of the lateral crura
should be oriented slightly superior to the cephalic margin.
Loss of this relationship may lead to a poorly defined
nasal tip and pinched ala. In addition, the external nasal
valve may be compromised due to loss of lateral wall
support [5]. Diminished support of the lateral and medial
crura as well as disunion of the upper lateral cartilages
may ultimately create a ptotic nasal tip and increasingly
acute nasolabial angle [5]. Preoperative assessment of
the base view of the medial crural footplates is essential
in evaluating the stability of the nasal base. Long and
strong medial crural footplates that extend to the nasal
spine will provide significant support and minimize loss
of projection in the long-term result [5].
The aging patient is also subject to changes in the
properties of the skin. Loss of elasticity and dehydration
of the skin diminishes the skin’s pliability. Furthermore,
resorption of subcutaneous fat deposits and soft-tissue
atrophy contribute to skeletonization of nasal bone step-
offs or sharp angulations of the lower lateral cartilages
[6]. In the aging patient, the skin’s ability to contract and
redrape over a reduced bony and cartilaginous structure
is diminished. On rare occasions direct excision of skin
from the nasal dorsum or supratip can be performed to
aid redraping. In this patient population external inci­
sions can be performed with less likelihood of unfavor­
able scar [7].
PREOPERATIVE ASSESSMENT
As with any facial aesthetic surgery patient, preopera­
tive assessment must address anatomic, functional, and
psychological factors [2]. The surgeon must discuss moti­
vation and aesthetic goals with the patient. Not infre­
quently, older patients do not wish to look dramatically
different and elect for more conservative changes. The
aging patient has developed a self-image over many years
and must be counseled on the proposed changes.
Reviewing standard preoperative photographs with
the patient is critical during surgical consultation. This
may aid in eliciting the patient’s preferences, which may
stem from an established self-image or from a cultural
C H A P T E R 26 
Rhinoplasty in the Aging Patient
Victor Chung, MD, Neela Rao, MD and Dean M. Toriumi, MD

334
MASTER TECHNIQUES IN FACIAL REJUVENATION
background. Computer imaging has become an increas­
ingly common tool to facilitate discussion between the
surgeon and patient about aesthetic goals and surgically
feasible results. It is important to remind the patient that
the computer-enhanced images are not a guarantee of the
exact postoperative result, but provide the surgeon with
a better understanding of the patient’s aesthetic goals.
A thorough medical history and physical examina­
tion are necessary in the aging patient, as they are more
likely to have co-morbid medical conditions. Collabora­
tion with the primary care physician is a prerequisite
prior to surgical scheduling. Medications that interfere
with hemostasis should be discontinued at least 2 weeks
prior to surgery.
SURGICAL TECHNIQUE
Preoperative Considerations
Selection of the surgical approach must take into consid­
eration both the operative objectives and the surgeon’s
experience. If the patient requires only conservative
volume reduction of the lateral crura or dorsal hump
reduction, a nondelivery approach with cartilage splitting
or a retrograde approach will suffice. However, when
more complex nasal tip work or middle-vault recon­
struction is required, an external approach or delivery
of bilateral chondrocutaneous flaps is preferred. The
surgeon should select the least invasive approach pos­
sible to avoid disruption of the nasal support mechanisms
and maximize the functional and aesthetic result for each
individual nose.
The technical approach for the aging nose is in a top-
down fashion: setting the dorsal height first, aligning the
nasal bones, addressing the middle vault, securing the
nasal base, and contouring the tip last. These structural
changes should be both conservative and in harmony
with the aging patient’s other facial features.
The External Approach
The patient is first injected with 1% lidocaine with
1 : 100,000 epinephrine in the nasal tip, between the
domes, down to the columella, at the planned marginal
incision sites, and along the lateral walls of the nose.
Additional injections to the nasal septum facilitate iden­
tification of the amount of cartilaginous septum available
for grafting material. An inverted V columellar incision
is then marked midway between the base of the nose
and the top of the nostrils. A transcolumellar incision
is executed with a No. 11 blade. Care must be taken to
avoid damaging the caudal margin of the medial crura.
Marginal incisions are then made along the caudal border
of the lateral crura. Columellar incision extensions are
created bilaterally with a No. 15 blade.
Once the incisions are complete, angled Converse scis­
sors are used to sharply elevate the skin off the medial
crura. Sharp dissection preserves the subdermal plexus,
which improves hemostasis and minimizes postoperative
edema. It is important to keep particular attention to
preserve the soft tissue triangles and maintain a cuff of
tissue separating the marginal incision from the alar rim.
Using three-point retraction, the surgeon continues to
raise the skin envelope sharply, advancing the dissection
laterally to expose the lateral crura. In the aging patient,
subcutaneous fat and muscle should be preserved in order
to avoid noticeable irregularities of the underlying bone
and cartilage through the thinner skin of the aging nose.
The anterior septal angle is identified, with exposure of
the middle nasal vault in the midline. Sharp dissection
is continued to the rhinion, which may be followed by
blunt subperiosteal dissection of the skin off the nasal
dorsum up to the nasion if profile alignment is necessary.
If a radix graft is planned, then a narrow pocket should
be dissected in the midline over the radix. This narrow
pocket will prevent shifting of a radix graft.
After completing the dissection of the nasal frame­
work, the surgeon surveys the nose and plans the antici­
pated grafts necessary to structurally support the nose for
the anticipated result.
Profile Alignment and Narrowing the Nose
Successful management of the bony nasal vault of the
aging patient involves conservative dorsal hump reduc­
tion, avoidance of dorsal irregularities, and alignment of
the nasal bones without excessive narrowing. Because the
nasal bones in the aging patient can be thin and brittle,
careful manipulation of the bony vault must be exercised
in order to avoid comminuted fractures or excessive nar­
rowing of the bony vault. Green-stick fractures of the
nasal bones are acceptable in the aging patient, as this
type of fracture is less likely to comminute or become
excessively displaced medially.
For dorsal hump reductions, a Rubin osteotome can be
used to address 80% of the hump. The residual hump can
be managed with a fine rasp. With larger dorsal humps,
wide undermining of the overlying skin soft-tissue enve­
lope is necessary to accommodate for reduced skin elas­
ticity and less rapid shrinkage and redraping. In patients
with a deep nasofrontal angle, small crushed cartilage
and soft-tissue radix grafts can be placed above a dorsal
hump to create a straight profile. The nasal starting point
should be located at the level of the superior palpebral
fold in female patients, with a slightly higher location in
male patients. In some cases, dorsal hump reduction can
be avoided if the profile can be improved with a combina­
tion of radix grafting and appropriate increase in nasal
tip projection.
Following profile alignment in the aging patient, lateral
osteotomies can be performed to address excess width or
deviation of the nasal bones. Using the smallest osteo­
tome (2 or 3 mm) minimizes trauma and bleeding when
fracturing the thin bone. In most aging patients, medial
osteotomies can be avoided as the bones are readily frac­
tured. Because the thinner skin of older patients show the
smallest dorsal irregularity, special care must be taken to
ensure a smooth dorsum. Additional rasping or soft tissue
onlay may be required to prevent visible irregularities.
Septal Surgery
The goals of septal surgery in the aging patient is similar
to other patients: correction of deviation obstructing the
nasal airway and harvest of grafting material. The septum
may be accessed via multiple approaches. When taking

26  Rhinoplasty in the Aging Patient
335
middle nasal vault width is set and inferomedial collapse
of the upper lateral cartilages is avoided. Care must be
taken to not create excess width to the middle vault.
Patients with short nasal bones are at higher risk of col­
lapse and will need thicker and longer spreader grafts.
If possible, the surgeon should try to avoid dividing the
upper lateral cartilages from the septum in order to pre­
serve native middle-vault support in the older patient.
Thus, if dorsal hump reduction is not needed in the
aging patient, the spreader grafts may be placed into
submucosal tunnels with preservation of the attachment
of the upper lateral cartilages to the septum regardless of
approach. In many older patients with a functional deficit
at the internal nasal valve and lateral wall, spreader grafts
will be insufficient and additional valve-supporting grafts
should be used.
Ptotic Nasal Tip
As the nose ages, the nasal tip frequently droops, creating
a ptotic nasal tip (Fig. 26.2). This change in nasal contour
gives an elongated appearance. Patients that have shorter
medial crura are likely to develop tip ptosis due to a lack
of tip support. Patients with long medial crura that wrap
around the nasal spine and caudal septum are less likely
to develop tip ptosis (Fig. 26.3). Severe ptosis of the nasal
tip can also result in nasal airway compromise by altering
the pathway of inspiratory air currents [3]. Correction of
the ptotic nasal tip generally involves increasing nasal tip
rotation and projection. As demonstrated by the tripod
concept described by Anderson [12], ptosis of the nasal
a less invasive approach, a Killian incision is preferred
because of its excellent exposure without compromise
of the support attachments between the medial crural
footplates and the caudal septum. A hemitransfixion inci­
sion can be used if exposure of both sides of the caudal
septum is required. The hemitransfixion or full trans­
fixion incision can sometimes lead to a loss of support
due to disruption of some of the attachments between
the medial crura and caudal septum. In some patients,
it may be necessary to dissect between the medial crura
to access the caudal septum. Patients with a deviated
caudal septum may benefit from this approach to allow
correction of the deformity. Other patients with poor tip
support could benefit from stabilization of the nasal base
through this approach.
When performing septal surgery in the aging patient,
dissection of the mucosal flaps should be limited because
the mucoperichondrium is thinner and susceptible to
dryness. The correct plane of dissection, deep to the peri­
chondrium, is critical to flap integrity. It may be prefer­
able to raise a mucoperichondrial flap on only one side
of the septum to preserve the vascular supply of the
contralateral side. A substantial L-shaped septal strut
should be preserved to support the lower two-thirds of
the nose. We prefer to leave at least a 1.5-cm caudal and
dorsal strut for support. Extra cartilage should be left at
the osseocartilaginous junction to avoid loss of dorsal
septal support and disruption of the dorsal septum from
the ethmoid bone at the “keystone” area. The surgeon
should be aware that the septal cartilage may be partially
calcified in the aging patient, which leaves the surgeon
with less cartilage for grafting. After completion of the
septal surgery, a running 4-0 plain gut mattress suture
is used to approximate the mucoperichondrial flaps and
prevent fluid collection and hematoma formation.
Narrowed Middle Vault
In some older patients, an excessively narrow middle
nasal vault can result when weak upper lateral cartilages
collapse inferomedially. Significant cartilage migration
may also result in collapse of the internal nasal valve.
These patients experience improvement in their nasal
airway obstruction while performing the Cottle maneu­
ver or with lateralization of the lateral nasal wall with
an instrument. To correct this deformity, the surgeon
can apply bilateral spreader grafts between the dorsal
margin of the nasal septum and the upper lateral carti­
lages [8–10]. These grafts are rectangular in shape and
measure approximately 5 to 15 mm in length, 3 to 5 mm
in width, and 1 to 2 mm in thickness.
Spreader grafts can be applied via an endonasal
approach into precise submucosal tunnels [8] or may be
applied directly between the upper lateral cartilages and
the nasal septum via the external rhinoplasty approach
[10,11]. In the external rhinoplasty approach, the upper
lateral cartilages are freed from the nasal septum after the
middle nasal vault is exposed. The rectangular spreader
grafts are then applied between the upper lateral cartilages
and septum, and sutured into place with 5-0 polydioxa­
none (PDS) mattress suture (Fig. 26.1). With incorpora­
tion of the upper lateral cartilages into the suture, the
Figure 26.1  Bilateral spreader grafts applied to the dorsal septum.

336
MASTER TECHNIQUES IN FACIAL REJUVENATION
We typically use a graduated approach for correction
of the ptotic nasal tip by initially considering placing
a sutured-in-place columellar strut between the medial
crura. We have found this to be particularly effective
if the dependent lobule is caused by buckling of the
medial or intermediate crura. A sutured-in-place columel­
lar strut both provides support and straightens buckled
medial and intermediate crura. A straight rectangular
piece of septal cartilage is placed in a precise pocket
created between the medial and intermediate crura [9].
The columellar strut is fixed into position using a 5-0
plain catgut suture on a straight septal needle. The strut
is easily applied using the external rhinoplasty approach,
which allows maximal visualization, precise placement,
and suture fixation of the graft. These struts can also
be applied using a small endonasal incision placed just
caudal to the caudal margin of the medial crura. Once
the incision is made, a precise pocket is made between
the medial crura for graft placement and suture fixation.
In many patients, a columellar strut will not provide
sufficient support to the nasal base. These patients will
require more significant structural support. The caudal
septal extension graft is a versatile technique for tip sta­
bilization that may also allow alteration of the nasolabial
angle and precise tip positioning. The caudal extension
graft may be created with a longer inferior margin to
blunt an acute nasolabial angle (Fig. 26.4). Likewise, an
over-rotated nose with a short dorsal length may be cor­
rected with a caudal septal extension graft with a longer
superior margin to provide counter-rotation and length.
Furthermore, the caudal septal extension graft sta­
bilizes the medial crura to the anterior septum. This
approach is appropriate in a patient with a short or
normal length of the caudal septum. A straight segment
of cartilage is necessary and this should be secured in an
end-to-end relationship with the existing caudal septum
and stabilized with bilateral extended spreader grafts and/
or thin splinting cartilage grafts (Fig. 26.5). It is critical
tip can usually be corrected by supporting the medial
and intermediate crura or by shortening the lateral crura.
The nasal base provides a foundation for the lower
third of the nose and it is critical in maintaining tip
projection postoperatively. The choice of technique for
stabilizing the nasal base varies upon the patient’s specific
structural deficiencies and the surgical goals.
Figure 26.2  Patient with ptotic nasal tip and acute nasolabial angle.
A
B
C
Figure 26.3  Relationship between medial crura and footplates to the caudal septum. Long strong medial crura extend to the base of the nose
near the posterior septal angle and wrap around the caudal septum (A). This relationship provides excellent nasal tip support. Short medial crura
do not extend to the nasal base and provide less tip support (B). Short caudal septum with separation of medial crura away from caudal septum
results in loss of tip support (C).

26  Rhinoplasty in the Aging Patient
337
intermediate and medial crura are further secured to the
caudal septal extension graft or native caudal strut with
5-0 PDS suture.
If stabilizing the nasal base does not adequately correct
the ptotic nasal tip, then additional surgical maneuvers
must be used to increase tip rotation. The mechanism
of these maneuvers is to project and rotate the nasal
tip by recruiting the lateral crura medially. Placement of
a transdomal suture is one method to accomplish this
goal [13,14]. Without violating the underlying vestibular
skin, a 5-0 PDS suture is placed in a horizontal mattress
fashion across each dome. To recruit the lateral crura
medially, the lateral bite of the suture extends lateral to
the anatomic dome. This suture narrows the nasal tip
by approximating the domes and creating a more acute
domal angle, in addition to increasing tip projection and
rotation. In some cases, the transdomal suture can further
compromise the nasal airway by creating internal recur­
vature of the lateral crura that protrude. Such obstruc­
tion can be avoided by using a lateral crural strut graft
to lateralize the offending lateral segment of the lateral
crus. If the transdomal suture does not correct the ptotic
nasal tip, it may be necessary to perform a more aggres­
sive maneuver to shorten the lateral crura.
The lateral crural overlay technique is a procedure that
increases tip rotation by shortening the lateral crura. In
this technique, the lateral crura are incised at the midpoint,
and the medial segment is dissected from the underlying
vestibular skin (Fig. 26.7). The cut ends of cartilage are
then overlapped (3 mm or 4 mm) and resutured with two
5-0 PDS mattress sutures to reconstitute the lateral crural
segments into their shortened configuration. The degree
of tip rotation is directly proportional to the degree of
overlap (shortening) of the lateral crura. Symmetric align­
ment of the lateral crura must be achieved to avoid tip
or alar margin asymmetry (Fig. 26.8). Another option is
to dissect the lateral crura from the underlying vestibular
skin out to the sesamoid cartilages (lateral crural release)
and then place a lateral crural strut graft on the undersur­
face of the lateral crura. The domes are moved laterally
to increase nasal tip projection and rotation (Fig. 26.9). If
this technique is used, it is critical that the caudal septal
extension graft is sufficiently projected to allow advance­
ment of the intermediate crura anteriorly [15].
Acute Nasolabial Angle and Retracted Columella
Owing to posterior positioning of the feet of the medial
crura, the aging patient frequently has an acute naso­
labial angle. Correction of this deformity adds support
to the medial crural component of the tripod complex
and improves the aesthetic appearance on lateral view.
For minor augmentation, 1- to 2-mm pieces of cartilage
(preferably with attached soft tissue) can be placed into
a small pocket between the feet of the medial crura. This
serves to support the lower lateral cartilages, preserve
tip projection, and correct an acute nasolabial angle.
With more significant deficiency of the medial crura,
more aggressive maneuvers may be necessary. In most
patients, a caudal septal extension graft will be necessary
to support the nasal base and open the nasolabial angle.
As described for stabilizing the nasal base in the aging
to ensure the nasal tip is positioned in the midline [5].
Preoperatively, the aging patient should be counseled that
when a caudal septal extension graft is utilized, the nasal
tip will be stiffer and have less recoil, and that they may
have a crease in their upper lip when they smile.
The aging patient with a hanging columella and promi­
nent caudal septum will benefit from setting back the
medial crura onto the caudal septum. First, the septum
is exposed by dissecting between the medial crura and
raising bilateral mucoperichondrial flaps. The caudal
septum must then be carefully assessed to ensure it is
positioned in the midline to avoid tip deviation. If neces­
sary the caudal septum can be shortened to adequately
lift the nasal tip. After wide dissection around the caudal
septum and nasal spine, the medial crura can be moved
onto the caudal septum to rotate the nasal tip (Fig. 26.6).
The medial crura are then sutured to the caudal septum
using 4-0 plain gut suture on a straight septal needle. The
suture must be placed through the cephalic margin of the
medial crura to avoid retraction of the columella [5]. The
A
B
Figure 26.4  Caudal septal extension graft that is oriented with longer
segment inferiorly based to provide augmentation to the nasolabial
angle and to enhance nasal tip rotation.

338
MASTER TECHNIQUES IN FACIAL REJUVENATION
Nasal Tip Contour
Once the rotation has been set in the aging patient’s
nose, tip projection and contour may be addressed. The
complexities of nasal tip contouring cannot be adequately
described in this chapter; however, general concepts will
be described. In the aging patient, lateral crural strut
patient with tip ptosis, this technique can simultaneously
address an acute nasolabial angle in the aging patient.
When utilizing this technique, the aging patient needs to
be made aware preoperatively that this graft may alter
the length of the upper lip, which could change the upper
lip posture during smiling, forming a horizontal crease.
A
B
Figure 26.5  (A) Extended spreader grafts extending beyond the dorsal septum and stabilizing a caudal septal extension graft. (B) Splinting grafts
used to stabilize the inferior margin of the extension graft.
A
B
C
Figure 26.6  (A) Wide dissection around the caudal septum to release the medial crura. (B) Positioning the medial crura on the caudal septum to
shorten the nose and rotate the tip. (C) Suture used to stabilize the medial crura onto the caudal septum.

26  Rhinoplasty in the Aging Patient
339
G
H
I
J
K
A
E
C
B
D
F
Figure 26.7  Lateral crural overlay technique. (A) The overly long lower lateral cartilages. (B) Overly long lateral crura are seen intraoperatively.
(C, D) The cartilages are marked for excision. (E) Lateral crura overlap is depicted. (F) Intraoperative photo of cartilage dissected from underlying
vestibular skin. (G, H) Lateral crural ends are resutured. (I) Excessive caudal margins of the overlapped cartilage are trimmed. (J, K) Lateral crura
are realigned, symmetrical, and stable.

340
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
D
E
F
G
H
B
C
Figure 26.8  Patient with ptotic nasal tip. The lateral crural overlay technique was used to shorten the lateral crura and rotate the nasal tip. Pre­
operative (A, C, E, G) and postoperative (B, D, F, H) views.

26  Rhinoplasty in the Aging Patient
341
width, supratip break, and overall refinement of the tip
(Fig. 26.10).
Nasal Valve Collapse
Older patients often present to the surgeon with com­
plaints of nasal airway obstruction located primar­
ily at the nostril margin. The nostrils may collapse on
moderate-to-deep inspiration, with inadequate support of
the lateral nasal walls and alae secondary to weak lower
lateral cartilages. In some cases, the lateral crura are in
a cephalic position and provide little support to the alar
side walls [10,16,17]. This deficiency has been described
as external nasal valve collapse and can be diagnosed
by observing alar collapse on deep inspiration. These
patients will characteristically experience improved nasal
airflow if the alae are supported during nasal breathing
with the Cottle maneuver.
Internal or external nasal valve collapse in the aging
patient can be surgically corrected by applying bilateral
alar batten grafts at the site of maximal lateral nasal
wall collapse or near the nostril margin, respectively
[10,16,17]. Alar battens can be fashioned from curved
cartilage of the nasal septum or of the cavum or cymba
conchae of the ear. The concave surface of the batten graft
is oriented medially to support the collapsing segment of
the nostril in external valve collapse or the lateral nasal
wall in internal valve collapse. To correct external valve
collapse, the grafts are typically placed just caudal to the
grafts are useful for simultaneously refining the nasal tip
contour and preventing lateral wall collapse.
When performing lateral crural strut grafts in the aging
patient, the first step is to dissect the tightly adherent ves­
tibular skin off of the undersurface of the native lateral
crura. Hydrodissection with 1% lidocaine and 1 : 100,000
epinephrine will make the appropriate plane of dissection
more evident. The dissection is continued laterally in this
plane toward the pyriform aperture, creating a pocket for
the grafts. Women require shorter grafts than men. Grafts
are sutured in place with 5-0 PDS suture to the underside
of the native lateral crura. Oblique dome sutures are
placed to flatten the domes and orient the lateral crura
with the caudal edge higher than the cephalic edge.
Repositioning of the lower lateral cartilages involves
fully mobilizing the lateral aspects of the lateral
crura. The lateral crural strut grafts are performed as
described earlier, except for lateral pockets designed to
correct asymmetry of the ala. A neutral or horizontal
pocket is created for the lower alar lobule and a down­
ward oriented pocket is created for the retracted alar
lobule.
Tip augmentation creates additional projection and
refinement in the nasal tip of the aging patient. This can
be accomplished with a rectangular, horizontally oriented
tip onlay graft (preferably soft cartilage with attached soft
tissue) secured with 6-0 monocryl suture. Variation in the
size and placement of the graft can set the projection, tip
A
B
C
Figure 26.9  (A) Lower lateral cartilages released from vestibular skin. Blue mark shows location of previous domes. (B) The lateral crura are
advanced medially on the caudal septal extension graft to increase tip projection and rotation. (C) Lateral crural strut grafts are placed to stabilize
the lateral crura and provide adequate length to the lateral crura.

342
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
B
C
D
G
H
E
F
Figure 26.10  Patient with thick skin and bulbous nasal tip. In this patient a tip graft was applied to increase tip projection. A caudal septal exten­
sion graft was used to support the nasal base. Preoperative (A, C, E, G) and postoperative (B, D, F, H) views.

26  Rhinoplasty in the Aging Patient
343
Figure 26.11  Alar batten graft applied into pocket caudal to existing
lateral crura to support lateral wall.
vigilant postoperative monitoring for adequate oxy­
genation, hemostasis, and cardiopulmonary sequelae is
warranted.
Columellar sutures should be removed on the seventh
postoperative day. Postoperative edema that develops in
the supratip region can be treated with taping of the
supratip or, less commonly, with subdermal injection with
0.1- to 0.2-mL triamcinolone acetonide (Kenalog, 10 mg/
mL; Westwood-Squib, NY, USA). Such injections should
only be used in patients with thick skin. These injections
may be administered 2 weeks after surgery, with no more
than one injection per month. Dermal atrophy may result
from either intradermal injection or frequent injections of
higher concentrations of Kenalog.
COMPLICATIONS
Because rhinoplasty is considered to be an elective
surgery, complications in the postoperative period can
be particularly distressing. Postoperative sequelae and
complications of rhinoplasty generally fall into five major
categories: infection, trauma, necrosis, functional deficits,
and iatrogenic difficulties. It has been estimated that com­
plications occur in approximately 10% of cases [4]. This
figure may actually be much higher if sequelae such as
persistent swelling, ecchymoses, and skin discoloration
are considered. Particularly in the aging patient, medical
comorbidities may significantly increase the risk of peri­
operative complications.
Rhinoplasty is considered by many to be the most dif­
ficult facial plastic operation, largely due to the intricate
and highly variable anatomy and lifelong postoperative
changes secondary to postoperative scar contracture and
healing. For these reasons, primary rhinoplasty is often
associated with a suboptimal outcome. It has been esti­
mated that 8% to 15% of primary rhinoplasty patients
eventually undergo revision surgery [18]. There are a
number of nasal deformities associated with primary
rhinoplasty, including middle-vault collapse, supra-alar
pinching, and pollybeak deformity. Every surgeon should
become familiar with these deformities.
CONCLUSION
The aging nose presents many unique challenges that
must be considered to achieve a desirable result. In addi­
tion to addressing aesthetic changes, proper preoperative
diagnosis is critical to identify all existing functional defi­
cits. In this age group, aesthetic changes should be conser­
vative, with extensive discussion prior to surgery. Because
there is decreased structural support in the older patients,
excision of supportive cartilaginous and bony structures
should be minimized. Additional support should instead
be provided in the form of structural grafts that stabilize
the nose of the aging patient and increase the likeli­
hood of a favorable and lasting functional and aesthetic
outcome.
lateral crura and extend from the pyriform aperture to
the lateral aspects of the lateral crura (Fig. 26.11). For
internal valve collapse, the grafts are placed at the point
of maximal lateral nasal wall collapse, usually at the
point of the supra-alar groove. When performing lateral
crural strut grafts with repositioning, a batten graft pro­
vides support at the site vacated by the cephalically ori­
ented lower lateral crura. As with spreader grafts, these
grafts can be applied through either an endonasal incision
or via the external rhinoplasty approach. Once the graft
is in position there should be an immediate improvement
in support of the alar side walls as well as diminution of
alar collapse during inspiration.
Materials for Grafting
The first choice of materials for grafting in most patients
is septal cartilage. Auricular cartilage is an option as well.
In some aging patients costal cartilage may be needed
due to the lack of sufficient septal cartilage and auricu­
lar cartilage may be too weak. If costal cartilage is to
be harvested in the older patient, their cartilage may be
calcified. In most patients over 55 years of age the degree
of calcification can be significant, with large islands of
calcified rib. The cartilage can be assessed for calcifica­
tion by placing a needle into the rib and mapping out the
ossified areas. Care must be taken to avoid going between
the ribs or through the ribs, as this can result in a pneu­
mothorax. In many older patients the partially calcified
cartilage can be used with precise carving and care not to
fracture the cartilage. When carving the older cartilage it
is preferable to keep the fibrous outer cortex as it is more
resilient and resistant to fracturing. The costal cartilage
is abundant and has great utility in structural grafting in
the aging nose (Fig. 26.12).
POSTOPERATIVE CARE
Careful postoperative care is critical to achieve an op­
timal result following rhinoplasty. In the aging patient,

344
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
B
C
D
E
F
G
H
Figure 26.12  Aging patient with ptotic tip and septal perforation. She underwent previous septoplasty, resulting in septal perforation. (A) Pre­
operative frontal view showing bulbous nasal tip and narrowed middle nasal vault. (B) Lateral view showing ptotic nasal tip. (C) Preoperative
endoscopic view of the septal perforation. (D) Harvested costal cartilage from sixth rib showing some calcification. (E) Conservative dorsal hump
reduction. (F) Costal cartilage used to stabilize damaged caudal septum and also act as an extension graft. (G) Lateral crural strut grafts sutured to
the undersurface of the lateral crural remnants. (H) Lateral crura with lateral crural strut grafts positioned in lateral wall pockets.

26  Rhinoplasty in the Aging Patient
345
I
K
L
M
N
O
P
Q
R
S
J
(I) Soft tissue placed over the tip cartilages. (J) Intraoperative endoscopic view of the closed septal perforation after
closing with bipedicled septal mucosal flaps and a costal perichondrium interpositional graft. One flap was recruited from the floor and the other
side recruited from the superior septum. (K) Preoperative frontal view. (L) Three-year postoperative frontal view. (M) Preoperative right lateral
view. (N) Postoperative right lateral view. (O) Preoperative right oblique view. (P) Postoperative right oblique view. (Q) Preoperative base view.
(R) Postoperative base view. (S) Postoperative endoscopic view of successfully closed septal perforation.
Figure 26.12, cont’d

346
MASTER TECHNIQUES IN FACIAL REJUVENATION
5. Toriumi DM. New concepts in nasal tip contouring. Arch Facial
Plast Surg 2006;8:156–85.
6. Janeke JB, Wright WK. Studies on the support of the nasal tip. Arch
Otolaryngol 1971;3(5):458–64.
7. Kabaker SS. An adjunctive technique to rhinoplasty of the aging
nose. Head Neck Surg 1980;2:276–81.
8. Sheen JH. Spreader graft: a method of reconstructing the roof of
the middle nasal vault following rhinoplasty. Plast Reconstruct Surg
1984;73(2):230–7.
9. Johnson CM, Toriumi DM, Daniel RK. Open structure rhinoplasty.
Plast Reconstruct Surg 1990;86(3):594.
11. Toriumi DM. Surgical correction of the aging nose. Facial Plast
Surg 1996;12(2):205.
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1980;13(2):289–303.
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laryngol Clin North Am 1980;13(2):275–88.
4. Krmpotic-Nemanic J, Kostovic I, Rudan P, et al. Morphological
and histological changes responsible for the droop of the nasal tip
in advanced age. Acta Otolaryngol 1971;71(1-6):278–81.

26  Rhinoplasty in the Aging Patient 346.e1
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R E F E R E N C E S
1. Cochran CS, Ducic Y, DeFatta RJ. Restorative rhinoplasty in the
aging patient. Laryngoscope 2007;117(5):803–7.
2. Tardy ME. Rhinoplasty in midlife. Otolaryngol Clin N Am
1980;13(2):289–303.
3. Patterson CN. The aging nose: characteristics and correction. Oto­
laryngol Clin North Am 1980;13(2):275–88.
4. Krmpotic-Nemanic J, Kostovic I, Rudan P, et al. Morphological
and histological changes responsible for the droop of the nasal tip
in advanced age. Acta Otolaryngol 1971;71(1-6):278–81.
5. Toriumi DM. New concepts in nasal tip contouring. Arch Facial
Plast Surg 2006;8:156–85.
6. Janeke JB, Wright WK. Studies on the support of the nasal tip. Arch
Otolaryngol 1971;3(5):458–64.
7. Kabaker SS. An adjunctive technique to rhinoplasty of the aging
nose. Head Neck Surg 1980;2:276–81.
8. Sheen JH. Spreader graft: a method of reconstructing the roof of
the middle nasal vault following rhinoplasty. Plast Reconstruct Surg
1984;73(2):230–7.
9. Johnson CM, Toriumi DM, Daniel RK. Open structure rhinoplasty.
Plast Reconstruct Surg 1990;86(3):594.
10. Toriumi DM. Management of the middle nasal vault in rhinoplasty.
Operat Tech Plast Reconstruct Surg 1995;2(1):16–30.