Operative Technique in Plastic Surgery – Kevin C.Chung

TECH FIG 9 • Incision sites and plan for injecting fat
into the nasojugal (“tear trough”) areas. Fat grafting of
the nasojugal “tear trough” area is typically performed
with a 4-cm 0.7-mm (22-gauge) injection cannula, and
fat is placed deep in a preperiosteal/suborbicularis
oculi plane. Typically, 0.5 to 1.5 cc of fat is placed on
each side depending on how far inferiorly and laterally
the “tear trough” extends onto the cheek. Level of
difficulty: advanced.
■ A 4-cm-long 0.7-mm (22-gauge) cannula is typically used, and fat is placed
deep in a preperiosteal/suborbicularis oculi plane—especially superiorly and
medially–where the skin is the thinnest. As experience is gained, and if care
is taken, fat can be placed safely more superficially, especially in the lower
more lateral part of the tear trough that is frequently seen to run down into
and onto the cheek.

TECH FIG 10 • Filling the “tear trough” with Fat. A.
Patient with hollow nasojugal groove (“tear trough”)
and an unnaturally hollow and elderly infra-orbital
appearance. B. Same patient seen after fat injections.
A healthier and youthful ocular appearance is noted
(procedure performed by Timothy Marten, MD, FACS
—Courtesy of Marten Clinic of Plastic Surgery).
■ Typically, 0.5 to 1.5 cc of fat is placed in the “tear trough” area, depending
on how far inferiorly and laterally it extends onto the cheek (TECH FIG 10).
Although ostensibly seeming simple to do, fat grafting the tear trough is
advanced in difficulty.
PEARLS AND PITFALLS
Fat harvest
■ The hip, waist, and outer thigh are the primary choice for fat harvest
sites in our practice.
■ They provide for abundant volume of fat, have less risk of surface
irregularities, and produce the best improvement in the patient’s
silhouette.
Fat
processing
■ The bottom 2 cc of fat in the centrifuged 10-cc syringe consists of
“stem cell”–rich fat.
■ This fat should be isolated and used for more critical areas like the
upper and lower orbits.
Instruments
■ Special fine blunt cannulas are required to safely perform periorbital
fat grafting.
■ Sharp needle injection increases the risk of embolization and should
be avoided.
Technique
■ Fat should be placed in very tiny aliquots with each pass in a
preperiosteal plane to produce optimal results and minimize
complications.
Ocular
injury
■ For both the upper and lower orbit, the surgeon must always keep
the nondominant index finger between the globe and the end of the
cannula to protect the globe at all times.

POSTOPERATIVE CARE
■ Regional fat grafting to the periorbital or more comprehensive facial fat
grafting is performed on an outpatient basis. Patients having a combined face-
lift with fat grafting are typically discharged to an aftercare specialist for the
first night after surgery.
■ Patients are asked to rest quietly and apply cool (but not ice or ice-cold)
compresses to their face for 15 to 20 minutes of every hour that they are awake
for the first 3 days after surgery.
■ Patients are advised to take a soft diet that is easy to chew and digest for 2
weeks after surgery and are encouraged to avoid salty foods.
■ When patients return to work or their social lives depends on how much fat is
injected, their individual swelling response, their occupation, and need for
secrecy. Patients are asked to set aside 2 to 3 weeks for recovery and 2 to 3
months prior to any major business presentation or important social function.
■ Most of the change in facial contour seen at 4 to 6 months is likely to consist
of living fat and represent a persistent improvement. Patients can be informed
that most of what they see is what they get at that point because swelling has
completely resolved.
OUTCOMES
■ See before and after examples (FIGS 4 to 6).
COMPLICATIONS
■ No major complications attributable to fat grafting, including infection,
embolization, tissue infarction, or blindness, have been encountered in our
clinic over the last 20 years.
■ Embolization leading to tissue infarction or blindness has been reported and
largely attributed to sharp needle injection.
■ Other complications are largely minor aesthetic problems and include lumps,
oil cysts, asymmetries, undercorrection, overcorrection, and donor-site
irregularities.
■ Though lumps or areas of overcorrection around the eyes have been
exceedingly rare in our practice, they are best treated by opening the eyelid and
removing the excess fat under direct vision.

FIG 4 • Periorbital fat grafting case example. A. Patient
with no previous surgery and hollow appearance
around the eyes. B. Same patient seen after facial fat
injections including the upper and lower orbit. A
healthier, more youthful appearance can be seen
(procedure performed by Timothy Marten, MD, FACS—
Courtesy of Marten Clinic of Plastic Surgery).
FIG 5 • Periorbital fat grafting case example. A. Patient
with no previous surgery and hollow appearance
around the eyes. B. Same patient seen after facial fat
injections including to the upper and lower orbit. A
healthier, more youthful appearance can be seen
(procedure performed by Timothy Marten, MD, FACS—
Courtesy of Marten Clinic of Plastic Surgery).

FIG 6 • Periorbital fat grafting case example. A. Patient
with previous upper and lower blepharoplasty and
hollow appearance around the eyes. B. Same patient
seen after facial fat injections including to the upper and
lower orbit along with face-lift and forehead lift. A
healthier, more youthful appearance can be seen
(procedure performed by Timothy Marten, MD, FACS—
Courtesy of Marten Clinic of Plastic Surgery).
REFERENCE
1. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219-
2227.

39
CHAPTER
Indications and Techniques
for Bridge of Bone
Canthopexy
Dev Vibhakar, Erez Dayan, and Michael J. Yaremchuk
DEFINITION
■ The positions of the lateral canthi are important functional and aesthetic facial
landmarks. Their position is a fundamental determinant of the shape of the
palpebral fissure.1
■ The terminology of lateral canthal surgery may be confusing. A lateral
canthopexy repositions the lateral canthal mechanism without violating the
commissure. Canthoplasty procedures, by design, alter the shape of the
palpebral fissure, because they disassemble and reassemble the lateral
commissure while often shortening the lower lid margin.2,3
■ Bridge of bone lateral canthopexy requires exposure of the lateral orbit and
mobilization of the lateral canthus soft tissue mechanism. Its efficacy is based
on the stable suture fixation point provided by drill holes placed relative to the
zygomaticofrontal suture in the bone of the lateral orbit. It is our preferred
technique for most surgical indications.
ANATOMY
■ The lateral canthus is more correctly termed a lateral retinaculum. The
retinaculum receives contributions from the lateral horn of the levator
aponeurosis, the lateral extension of the preseptal and pretarsal orbicularis oculi
muscle (lateral canthal tendon), the inferior suspensory ligament of the globe
(Lockwood ligament), and the check ligament of the lateral rectus muscle. It
has a broad attachment to the periosteum over the Whitnall tubercle (FIG 1).4
■ Variations of the point of attachment or length of the retinaculum will alter
eyelid shape, tension, and contour.5

■ The lateral canthal angle is normally superior to the medial canthal angle,
lying 4 ± 2 degrees or approximately 1.2 mm higher. This relationship is
important for effective tear film distribution, and lacrimal drainage and for an
aesthetically pleasing contour (FIG 2).1
FIG 1 • Position of the medial and lateral canthal
ligaments with respect to the bony orbit, tarsal plates,
and underlying ligamentous structures

FIG 2 • Dimensions of the palpebral fissure measured in
young Caucasian women. The mean height of the
palpebral fissure measured from the upper lid (Ps) to
lower lid (Pi) margin at the midpupil was 10.8 ± 1.2 mm
(n = 200). The mean length of the eye fissure measured
from medial commissure to lateral commissure was
30.7 ± 1.2 mm (n = 200). The mean inclination of the
eye fissure was 4.1 ± 2.2 degrees.
PATHOGENESIS
■ Medial and inferior canthal malposition changes the width and shape of the
palpebral fissure as well as the position of lower eyelid resulting in the round
eye deformity.1
■ Inferior displacement of the lower eyelid may cause lagophthalmos leading to
inadequate globe protection and exposure keratitis. Epiphora secondary to a
displaced lower punctum and impaired tear drainage may also occur.
■ The etiology of canthal malposition may be hereditary, senile, paralytic,
traumatic, or iatrogenic.4
■ Malposition of the lateral canthus most often occurs secondary to surgical
access to the orbit and lower lid structures.2,3
PATIENT HISTORY AND PHYSICAL FINDINGS
■ History and physical examination are the most important elements of

preoperative assessment and planning for both reconstructive and cosmetic
procedures. Standard preoperative photographs are taken and reviewed with the
patient.
■ History of recent eye surgery, dry eye, or visual acuity changes should be
specifically elicited.
■ Physical examination findings for lower eyelid malposition include canthal tilt,
lid snapback test, lid distraction test, vector analysis, scleral show, and the
presence of chemosis or keratoconjunctivitis. Other patient-directed
examination includes visual acuity testing, Schirmer test for lacrimation, and
slit-lamp evaluation.
IMAGING
■ Whereas preoperative radiologic examination is uncommon for purely
aesthetic surgery, computerized tomographic (CT) evaluation is almost routine
for reconstructive procedures. CT scans provide the ability to view anatomic
features in different planes and in three dimensions.
SURGICAL MANAGEMENT
Preoperative Planning
■ Informed consent should include intrinsic risk of canthal malposition and
potential for temporary postoperative chemosis.
■ The patient’s desired canthal position should be determined in aesthetic-
focused procedures.
■ This procedure may be performed under local or general anesthesia.
Positioning
■ The patient is placed supine on the operating room table at a 90-degree
perpendicular position relative to the anesthesiologist for maximal exposure.
T E C H N I Q U E S
■ Preoperative Preparation
■ Prior to antiseptic preparation and draping, a dilute solution of Marcaine and
epinephrine (1:200 000) is infiltrated into the operative site for postoperative

pain control and intraoperative hemostasis.
■ Intravenous antibiotic prophylaxis is administered approximately 30 minutes
preoperatively.
■ Operative Approach
■ Bridge of bone lateral canthopexy requires access to the lateral orbital rim
from the level of the Whitnall tubercle to the zygomaticofrontal suture. This
can be accomplished through the lateral extent of an upper blepharoplasty
incision. Most often, the lateral extent of both upper and lower
blepharoplasty incisions is used (TECH FIG 1).
■ The lower blepharoplasty incision provides superior visualization of the
lateral canthal tissue.
■ This anatomy may also be approached from the access provided by a
bicoronal incision during exposure of traumatic fractures or aesthetic brow
lift.
TECH FIG 1 • Through the lateral extent of the lower
lid blepharoplasty incision, the lateral canthus is
identified and released from the Whitnall tubercle by

subperiosteal dissection.
■ Figure-of-8 Suture Fixation of Lateral Canthus
■ When only 1 or 2 mm of superior or lateral movement of the lateral canthus
and adjacent lid margin are desired, one or both limbs of the lateral canthus
may be purchased with a figure-of-8 suture without freeing of the lateral
retinacular structures from the lateral orbit (TECH FIG 2). The amount of
commissure movement will be limited by the length of the ligament, the
point of suture purchase relative to the lateral commissure, and the position
of the lateral orbit drill holes. This approach is most appropriate when there is
minimal commissure malposition and no local scarring from previous lid
surgery.
■ When more significant movements of the lateral commissure and lid margin
are desired, complete subperiosteal freeing of the lateral retinacular structures
is required before figure-of-8 suture purchase of both limbs of the ligament.
■ Through the lateral extent of the lower blepharoplasty incision, the lateral
retinaculum is identified and dissected, and both limbs of the lateral canthus
are purchased with a figure-of-8 nonabsorbable suture or 30- or 32-gauge
titanium wire suture.

TECH FIG 2 • The lateral canthus is purchased by a
figure-of-8 suture or 30-gauge titanium wire suture.
■ If scarring from previous lower lid surgery restricts canthal movement, the
lateral third of the middle lamellae is incised with needle-tip electrocautery to
allow for sufficient mobility.
■ Drill Holes and Positioning of Lateral Canthus
■ Through the upper access approach, the zygomaticofrontal suture is
identified. This suture provides a landmark to allow symmetric placement of
drill holes made in the lateral orbital rim.
■ Using the zygomaticofrontal suture as a landmark, two drill holes are placed
in the lateral orbital rim (TECH FIG 3A). The position of the lower drill hole
is key, because it determines the maximum upward movement of the canthus.
The upper drill hole is necessary to create the “bridge of bone”—a stable
fixation point.
■ The lateral canthal position and aperture shape are determined by the
position of the drill holes, which should be 2 to 3 mm above the medial
canthal plane to give the intercanthal axis a slight upward tilt. The drill holes
should also be placed in the internal orbit about 3 to 4 mm posterior to the
anterior margin of the lateral orbital rim so the lateral lid will not be drawn
away from the globe.
■ To determine the ideal position of the drill holes, one can grasp the lateral
canthus and tuck it against the lateral orbital rim until the desired canthal and
lower lid position is obtained. The positions are marked and drill holes are
made at that point. Most often, they are positioned just at, and 2 mm below,
the zygomaticofrontal suture.
■ The suture is then delivered in a subcutaneous plane from the lower to the
upper incision (TECH FIG 3B).
■ Each end of the suture is then passed from within the orbit through the drill
holes to the lateral orbital rim. This is accomplished by bending a 28- or 30-
gauge wire on itself and passing the bent end through the drill hole into the
orbit (TECH FIG 3C).

TECH FIG 3 • A. Using the zygomaticofrontal suture
as a landmark, two drill holes are placed in the lateral
orbital rim. B. Suture is then delivered in a
subcutaneous plane from the lower to the upper
incision. C. Each end of the suture is then passed
from within the orbit through the drill holes to the
lateral orbital rim. D. One end of the canthopexy stitch
is placed into the “passing wire” loop to be pulled from
inside the orbit through the drill hole to outside the
orbit. E. The suture ends are then tied over the bridge
of bone between the two holes. F. Tension on the
sutures during their tying or tension on the wires
during their twisting will determine canthal movement.
■ One end of the canthopexy stitch is placed into the “passing wire” loop to be
pulled from inside the orbit through the drill hole to outside the orbit (TECH
FIG 3D).
■ The suture ends are then tied over the bridge of bone between the two holes
(TECH FIG 3E).
■ Tension on the sutures during their tying or tension on the wires during their
twisting will determine canthal movement (TECH FIG 3F). The location of
the lower drill hole dictates the limit of movement.
■ Passage of the canthopexy sutures must occur from within the orbit to the

outside. This allows tying the sutures over the bridge of bone (TECH FIG
4A) and allowing the lower lid to be applied to the globe (TECH FIG 4B).
TECH FIG 4 • Passage of the canthopexy sutures
must occur from within the orbit to the outside. This
allows tying the sutures over the bridge of bone (A)
and allowing the lower lid to be applied to the globe
(B).
■ When wire fixation is used (most often for reconstructive cases), the wire
ends are left approximately 5 mm long. This length of twisted wire has two
advantages. First, it allows intraoperative (or postoperative) adjustment of the
canthal position by simply twisting or untwisting the wires without repeating
the suturing process. In addition, this length allows the ends to be placed into
one of the drill holes or into the orbit. This maneuver avoids postoperative
visibility or palpability of the wire ends.

■ Closure
■ If local incisions are used for access, an ellipse of skin and muscle is
removed from the lateral aspect of the upper lid to remove the lid redundancy
caused by the upward movement of the canthus.
■ The wounds are closed in layers.
■ A temporary tarsorrhaphy stitch is often placed to avoid or minimize
chemosis.
■ Postoperative Care
■ Postoperatively, keep the patients head in a raised position to minimize
edema and pain. Ice packs are applied to counteract swelling.
■ Analgesia (narcotic and/or NSAIDs) as necessary for pain control.
■ A single dose of IV antibiotics is given 30 to 60 minutes prior to incision.
Oral antibiotics are continued no longer than 24 hours after surgery.
■ Sutures are removed at 1 week after surgery.
■ When extensive dissection is performed, postoperative chemosis is common.
In addition to ophthalmic lubricants, a temporary tarsorrhaphy stitch is left in
place for 5 to 7 days. The tarsorrhaphy is performed by placing a single 5-0
nylon suture through the upper and lower lid margins and adjacent skin
approximately 2 to 3 mm lateral to the lateral limbus.
■ Outcomes
■ Appropriate patient selection and sound surgical technique provide a vast
majority of patients with satisfactory aesthetic outcomes (FIGS 3 and 4).
FIG 4 • A. Brow lift reversal was performed using a
hairline incision in this patient who preoperatively had
a high forehead. B. The patient also underwent

infraorbital rim augmentation, subperiosteal midface
lift, and bridge of bone lateral canthopexy as well as
brow lift reversal.
■ When canthopexy is performed in heavily scarred tissues, wound contraction
and contracture usually result in some loss of long-term canthal position.
When bridge of bone canthopexy is performed in a nontraumatized field,
canthal reposition is stable.
FIG 3 • A 27-year-old woman without any previous
orbital surgery desired upward movement of her
lateral canthus. A. Preoperative frontal view. B. Six-
month postoperative view.
■ Complications
■ Complications are infrequent after bridge of bone canthopexy.
■ Temporary chemosis is an anticipated short-term sequela. Some relapse may
be anticipated when surgery is performed in heavily scarred fields.
REFERENCES
1. Yaremchuk MJ. Restoring palpebral fissure shape after previous lower
blepharoplasty. Plast Reconstr Surg. 2003;111(1 suppl):441-450.
2. Fagien S. Lower-eyelid rejuvenation via transconjunctival blepharoplasty and
lateral retinacular suspension: a simplified suture canthopexy and algorithm for
treatment of the anterior lower eyelid lamella. Oper Tech Plast Reconstr Surg.
1998;5:121.
3. Fagien S. Algorithm for canthoplasty: the lateral retinacular suspension: a
simplified suture canthopexy. Plast Reconstr Surg. 1999;103(7 suppl):2042-
2053.
4. Gioia VM, Linberg JV, McCormick SA. The anatomy of the lateral canthal

tendon. Arch Ophthalmol. 1987;105(4 suppl):529-532.
5. Glat PM, Jelks GW, Jelks EB, et al. Evolution of the lateral canthoplasty:
techniques and indications. Plast Reconstr Surg. 1997;100(6 suppl):1396-1405.

40
CHAPTER
Indications and Techniques
for Palatal Spacer Grafts
Dev Vibhakar, Erez Dayan, and Michael J. Yaremchuk
DEFINITION
■ Retraction of the lower eyelid is a consequence of various surgical and
medical conditions affecting the periorbital and midface region.
■ Craniofacial trauma, tumors, facial paralysis, thyroid eye disease, and
cosmetic blepharoplasty can alter the position of the normal lower eyelid.
■ The clinical manifestation of this is inferior scleral show, lagophthalmos, and
exposure keratitis. This can lead to dry eye syndrome, ocular discomfort,
excessive tearing, photophobia, and blurred vision, as well as a cosmetically
unappealing sad-eyed appearance.1
■ Placement of a graft of palatal mucosa between the tarsal plate and lower lid
retractors can elevate the lower lid margin.2,3
ANATOMY
■ The normal lower eyelid lies at or just above the inferior corneal limbus.
■ It is tethered medially and laterally by the canthal tendons.
■ The lateral canthal angle is approximately 4.1 degrees or 1.2 mm higher than
the medial canthal angle.
■ It is considered a trilamellar structure—the anterior lamella (skin and
orbicularis oculi muscle), the middle lamella (orbital septum), and the posterior
lamella (lower eyelid retractors and conjunctiva (FIG 1A).
■ The hard palate is composed of keratinized stratified squamous epithelium.
■ There is no sex difference in mucosal thickness, and it increases with greater
distance from the marginal gingiva, the mucosa being thinnest near the first
molar.
■ The bones of the hard palate are the palatine processes of the maxilla

anteriorly and the horizontal plates of the palatine bones posteriorly.
■ The greater palatine neurovascular bundles emerge bilaterally from the greater
palatine foramina most commonly found medial to the upper second molar.
■ They pass anteriorly along grooves in the palate to enter the incisive foramina
(FIG 1B).
PATHOGENESIS
■ Lower lid retraction can result from shortening of any of the lower eyelid
lamella.
■ This results in vertical contracture of the lower lid and is most commonly seen
because of trauma or aggressive lower lid blepharoplasty.
■ Patients with thyroid eye disease have a relative lower eyelid deficiency due to
its inferior displacement caused by globe prominence.
■ When lower lid malposition is caused by middle and posterior lamella
inadequacy, grafts of palatal mucosa placed beneath the tarsal plate provide
increase height and stiffness to support and elevate the lower lid margin (FIG
2).

FIG 1 • A. Lower eyelid anatomy demonstrating the
anterior lamella (skin and orbicularis oculi muscle), the
middle lamella (orbital septum), and the posterior
lamella (lower eyelid retractors and conjunctiva). B.
Relevant palatal neurovascular anatomy for donor-site
harvest.

FIG 2 • A,B. Lower lid malposition secondary to vertical
contracture of scarred septum. C–E. Hard palate
mucosal graft used as a spacer between the lower
tarsal plate and the recessed conjunctiva, lower eyelid
retractors, and orbital septum.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The underlying cause (previous surgery, metabolic disease, trauma, skeletal
morphology) of lower eyelid retraction is determined.
■ A thorough ophthalmologic examination is performed.
■ Measuring the inferior scleral show assesses the degree of lower lid
displacement.
■ The status of the lower lid lamellae, skeletal morphology, and cheek
prominence is assessed.
■ Deficiencies of the middle and posterior lamellae are indications for the use of

spacer grafts.
SURGICAL MANAGEMENT
Preoperative Planning
■ Informed consent should include intrinsic risks and benefits of donor-site–
related and lower lid complications. These include the possibility of infection,
displacement, asymmetry, deformation, hematoma, seroma, motor/sensory
nerve injury, donor-site discomfort, and palatal fistula.
■ Prior to the induction of anesthesia, the amount of vertical height required to
correct scleral show is measured medially and laterally with the patient in a
sitting position.
■ The authors’ preference is to use general endotracheal or nasotracheal
anesthesia. This allows optimal preparation of the donor site, operative site,
and control of the airway.
■ 0.12% chlorhexidine gluconate oral rinse is prescribed for daily use beginning
3 days preoperatively and including the day of surgery.
Positioning
■ Intravenous cephalosporin or ciprofloxacin antibiotic prophylaxis is
administered approximately 30 minutes preoperatively.
■ Patients are placed supine on the operating room table at a 90-degree
perpendicular position relative to the anesthesiologist to allow for maximal
exposure.
T E C H N I Q U E S
■ Harvesting the Hard Palate Mucosa
■ A side bite block is placed to facilitate exposure.
■ A throat pack is placed.
■ On average, a 25 × 10 mm graft is measured for harvesting. In cases of
bilateral lid retraction, either one large central graft is taken and divided, or
two separate grafts are taken from opposite sides of the palate.
■ The junction of the hard and soft palate is identified laterally with forceps.
The second molar is identified to assess the location of the greater palatine

foramen.
■ The graft is harvested in the canine-premolar region toward midline, where
the palatal mucosa is thickest (TECH FIG 1A).
■ The palate is then infiltrated with 1% lidocaine with epinephrine 1:100 000.
■ A 15-blade scalpel is used to incise the mucosa and submucosa leaving the
periosteum intact. A small layer of fat is harvested with the graft.
■ Once the graft is harvested (TECH FIG 1B), bipolar cautery is used for
selective hemostasis.
■ The resulting defect is then covered with Surgicel (Johnson & Johnson, New
Brunswick, NJ) that is secured in place with 4-0 chromic gut sutures.
■ The graft is trimmed to remove all fatty tissue, mucosal glands, and
submucosa from its undersurface (TECH FIG 1C).
■ It is stored in saline-soaked gauze until ready for transfer to the eyelid.
TECH FIG 1 • A. Graft harvest site. B. Average palatal
graft is about 25 × 4 mm. C. Trimmed graft.

■ Lower Eyelid Surgery
■ After markings are made (TECH FIG 2A), the lower lid is infiltrated with
1% lidocaine with epinephrine 1:100 000.
■ Double skin hooks are used to expose the posterior lamella and identify the
inferior border of the tarsal plate. A cotton-tipped applicator can facilitate
palpating the transition.
■ A 5-0 nylon suture is placed through the central portion of the lower fornix
and retracted posteriorly over the eye to protect it and provide
countertraction.
■ A transconjunctival incision is made extending from below the punctum to
the lateral canthus.
■ Dissection is performed sharply to create a space between the inferior border
of the tarsus and the superior edge of the recessed conjunctiva and lower lid
retractors (TECH FIG 2B).
■ The graft is placed within this space with the mucosal surface toward the
globe (TECH FIG 2C).
■ The inferior border of the graft is sutured to the recessed retractors and
conjunctiva. The superior border of the graft is sutured to the inferior border
of the tarsal plate.
■ This is performed with double-armed 5-0 chromic sutures. The needles are
passed full thickness through the lid, exiting the skin surface. Simple
interrupted stitches are placed to ensure a flat transition and prevent any
ridges.
■ Each suture is then tied on the skin surface, ensuring that the knots are not
secured tightly (TECH FIG 2D).
■ A temporary tarsorrhaphy suture of 5-0 nylon is placed laterally if chemosis
is a concern (TECH FIG 2E).

TECH FIG 2 • A. Patient markings. B.
Transconjunctival exposure of the posterior lamella to
identify the inferior border of the tarsal plate. C.
Palatal graft is secured between the inferior border of
the tarsus (black arrow) and the superior edge of the
retracted conjunctiva (white arrow) and lower lid
retractors with the mucosal surface toward the globe.
D. The graft-securing sutures are tied on the skin
surface. E. Immediate postoperative results.

PEARLS AND PITFALLS
Patient
selection
■ Many cases of lower lid retraction involve a multifactorial process
requiring adjunct procedures such as a lateral canthopexy/canthoplasty,
release of middle lamellar scarring, midface suspension, or infraorbital
rim augmentation.
Surgical
approach
■ In the anterior palatal region, the neurovascular bundle runs toward the
midline incisive canal and may be damaged if graft harvesting is not
limited to the canine-premolar region.2,3
■ The donor site often oozes; it is important to not damage the periosteum
or apply excessive electrocautery as this may cause necrosis of the
underlying bone resulting in an oronasal fistula.
■ Donor site granulates and heals completely within 2 to 3 weeks.
■ The donor graft is typically trimmed medially. The majority of vertical
height is required from the central lower limbus to the lateral canthus.
Donor-
site
selection
■ Hard palate mucosa closely approximates lower lid tarsus in terms of
contour, thickness, and stiffness.
■ It is abundant and easily obtained.
■ As an autograft, it is not at risk for rejection. It may undergo only
minimal shrinkage following grafting for predictability in lid elevation.
■ It has a mucosal surface and is well tolerated when grafted into the
lower lid.
POSTOPERATIVE CARE
■ Oral antibiotics are prescribed for 7 days after surgery (cephalexin 500 mg
q8h).
■ Patients are asked to eat a soft diet for 7 days postoperatively.
■ Frequent mouthwashes are advised as well as careful tooth brushing.
■ Ocular lubricant ointment is applied every 12 hours.
■ Patients are instructed to refrain from strenuous exercise for 2 to 3 weeks
postoperatively.
■ The patients are instructed to apply ice for 48 to 72 hours and sleep with head
of bed elevated greater than 30 degrees or with three or four pillows.
■ Follow up is at 1-, 2-, and 4-week intervals. Thereafter, long-term follow-up is

at 6 months and 1 year.
■ The external lower lid chromic sutures are trimmed at 1 week’s time.
OUTCOMES
■ Appropriate patient selection and sound surgical technique provides a vast
majority of patients with satisfactory aesthetic outcomes (FIG 3).
■ The improvement in scleral show and resolution of symptoms are noted once
the swelling has resolved.
COMPLICATIONS
■ Donor site
■ Palatal fistula is typically self-limiting and allowed to granulate over time. A
palatal splint or obturator can be made to provide symptomatic relief.
■ Oral candidiasis will result in compromised healing. This resolves with oral
antifungal treatment.
■ Lower lid
FIG 3 • A. A 45-year-old woman presented with lid
descent after lower lid blepharoplasty with tarsal strip in
negative vector patient. B. One year after infraorbital
rim augmentation, subperiosteal midface lift, and palatal
spacer graft. C. A 49-year-old man with lower lid
descent after lower lid blepharoplasty and tarsal strip.
D. Six months after subperiosteal midface lift and

palatal graft placement.
■ Corneal irritation can occur from hard palate suture grafts, but this is limited
by placing the suture knots on the external skin surface.
■ Ocular discharge is not uncommon in the initial postoperative period. The
keratin layer of the hard palate graft continues to accumulate. Over time
metaplasia to nonkeratinized mucosa occurs.
REFERENCES
1. Patel Munjal P, Shapiro Michael D, Spinelli Henry M. Combined hard palate
spacer graft, midface suspension, and lateral canthoplasty for lower eyelid
retraction: a tripartite approach. Plast Reconstr Surg. 2005;115(7):2105-2114.
2. Kersten RC, Kulwin DR, Levartovsky S, et al. Management of lower lid
retraction with hard palate mucosa graft. Arch Ophthalmol. 1990;108:1339.
3. Wearne MJ, Sandy C, Rose GE, et al. Autogenous hard palate mucosa: the
ideal lower eyelid spacer? Br J Ophthalmol. 2001;85:1183.
4. Mommaerts MY, DeRui G. Prevention of lid retraction after lower lid
blepharoplasties: an overview. J Craniomaxillofac Surg. 2000; 28:189.
5. Patipa M. The evaluation and management of lower eyelid retraction
following cosmetic surgery. Plast Reconstr Surg. 2000;106:438.
6. Patipa M. Complications of lower eyelid blepharoplasty. Semin Ophthalmol.
1996;11:183.
7. Spinelli HM, Jelks GW. Periocular reconstruction: a systematic approach.
Plast Reconstr Surg. 1993;91:1017.

41
CHAPTER
Section X: Facelifting and
Necklifting
Indication and Technique for
Skin-Only Face and Neck
Lifting
James Zins and Gehan D’Souza
DEFINITION
■ Modern face and neck rejuvenation no longer focuses only on skin tightening
but also may include fat contouring and volume restoration.
■ Skin-only face-lift techniques avoid superficial musculoaponeurotic system
(SMAS) manipulation. When combined with the release of major ligaments of
the face, a skin-only face-lift may produce results equal to a more invasive
technique.
■ Knowledge of anatomical planes, three-dimensional relationship of the facial
nerves, and location of the retaining ligaments is imperative.
■ Procedures range from skin-only manipulation to alterations of the SMAS
including minimal access cranial suspension (MACS) lift, lateral
SMASectomy, extended SMAS, and the composite rhytidectomy.
ANATOMY
■ Skin/fascial relationship
■ The facial soft tissue architecture can be described as being arranged in a
series of concentric layers: skin, subcutaneous fat, superficial fascia, mimetic
muscle, deep facial fascia (parotidomasseteric fascia), and the plane
containing the facial nerve, parotid duct, and buccal fat pad.

■ Superficial fascial system invests mimetic muscles of facial expression,
whereas deep fascial system covers and protects the facial nerve branches.1
■ Ligaments and zones of adhesion
■ Retaining ligaments buttress the facial soft tissues against downward forces.
These ligaments are in a constant location in relation to the facial nerve
branches.2,3
■ Ligaments act as sentinels to the facial nerve branches.
• True ligaments such as zygomatic and mandibular ligaments fixate the bone
to the dermis and pass through SMAS.
• False ligaments such as parotid and masseteric ligaments fixate fascial
layers to superficial soft tissue.
■ Recent writings have emphasized the concept of adhesions rather than
retaining ligaments. Adhesions such as the masseteric temporal and
supraorbital ligaments are fibrous or fibrofatty attachments between
superficial and deep tissue.
■ Neck
■ Factors that provide a youthful and aesthetically pleasing neck include
distinct mandibular border, subhyoid depression, thyroid bulge, a distinct
border to the sternocleidomastoid muscle, and a cervicomental angle of 105 to
120 degrees.
■ Facial nerve—five groups of branches are identified
■ Frontal (temporal) branches: Pitanguy delineated the course that extends
from 0.5 cm below the tragus to 1.5 cm above the lateral eyebrow.4 At the
level of the zygomatic arch, the branches run 1.8 cm anterior to the helical
crus, and 2 cm posterior to the lateral orbital rim deep to the SMAS and
parotid masseteric fascia. Superior to the arch, the nerves travel in the
innominate fascia—a fusion plane between superficial and deep fascia. One
should remain superficial to the superficial layer of the deep temporal fascia
or deep to the layer.4
■ Zygomatic and buccal branches: Interconnections between these branches
account for natural recovery. The most commonly injured facial nerve is the
buccal ramus.
■ Mandibular branches: The mandibular branch consists of a single nerve with
few interconnections with other facial nerves that results in a risk of
permanent injury. Posterior to the facial vessels, the mandibular rami travel
within 1 cm cephalad to the mandibular border. Anterior to the facial vessels,

the branches are always cranial to the border. The nerve travels deep to the
parotid masseteric fascia and under the platysma by crossing superficial to the
facial vessels.
■ Cervical branches: The nerve travels in close proximity to the gonial angle at
the 1.74 mm inferior to the mandibular border.
PATHOGENESIS
■ There is controversy between descent of soft tissue and volume loss in relation
to facial aging. One camp suggests laxity of malar soft tissues as an etiology.
The other side suggests that volume loss is the key factor leading toward facial
aging.1,5
■ Malar soft tissue migrates distal to the zygomatic cutaneous ligaments. This
leads to soft tissue ptosis directly adjacent to the fixation of the nasolabial fold.
■ Masseteric cutaneous ligaments support the cheek soft tissues that migrate
downward inferior to the mandibular border to forming jowls.
■ Jowling and loss of mandibular definition occurs by laxity of masseteric
ligaments or deflation of the fat compartments of the face (submandibular).
NATURAL HISTORY
Upper third
■ Aging is associated with
■ Eyebrow ptosis
■ Transverse forehead rhytides
■ Vertical glabellar lines
■ Hairline recession
Middle third
■ Aging is associated with
■ Blepharochalasis
■ Ptosis of malar soft tissue
■ Laxity of lateral canthus and lid lead to rounding of palpebral fissure and
ectropion
■ Lower lid fat bulge
■ Crow’s feet
■ Tear trough deformity
■ Palpebromalar groove
■ Malar mound
The lower third and neck

■ Aging is associated with
■ Bulge superior to the nasolabial crease
■ Nasolabial crease deepening
■ Marionette lines
■ Exaggeration of the labiomental fold
■ Perioral wrinkles
■ Loss of the cervicomental angle secondary to skin ptosis, fat accumulation,
and muscling banding
■ Platysmal bands
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients with medical comorbidities including cardiac and respiratory
conditions should be excluded from surgery. Screening of bleeding
complications should be undertaken.
■ Antiplatelet medication must be ceased 2 weeks prior to surgery.
■ Smoking must be stopped at least 4 weeks prior to operation.
■ Patients with body dysmorphic disorder, unrealistic expectations, or
psychiatric illness should also be excluded.
■ Elderly patients (older than 65 years) are not at higher risk for complications
compared to those younger than 65 years old when properly screened.
IMAGING
■ No imaging is necessary prior to procedure.
NONOPERATIVE MANAGEMENT
■ Nonsurgical interventions include botulinum toxin and soft tissue fillers. Skin
resurfacing procedures include chemical peels, Ulthera, deoxycholic acid, and
light amplification by stimulated emission of radiation (LASER) therapy such
as fractionated CO2 or erbium laser. Fat grafting is used for volume
augmentation.
SURGICAL MANAGEMENT
■ In the cheek a skin-only dissection can lead to good or excellent results when
subcutaneous dissection is extensive by freeing the zygomatic cutaneous
ligament, mandibular cutaneous ligament, and masseteric cutaneous ligament.
■ Operative intervention for face-lift by elevating, advancing, and redraping of
the skin.

■ When aging affects the neck, one must proceed with fat removal and platysma
tightening.
Preoperative Planning
■ Soft tissue and skeletal cephalometrics may be helpful for assessment of facial
aging. One should assess symmetry and proportions of regions of the face and
identify differences between soft tissue and skeletal muscle pathology that
cause facial aging.
■ Assessment should begin with the head in straightforward gaze with the
Frankfort horizontal parallel to the ground and the lips and eyebrows in a
relaxed position.
■ When assessing the face, it can be divided into three horizontal thirds. The
horizontal thirds are produced by lines drawn adjacent to the menton, nasal
base, brows at the supraorbital notch level, and hairline.
■ The lower third can be divided into the upper third and the lower two-thirds
by a line drawn through the oral commissures.
■ The lower third can be divided into halves by a horizontal line adjacent to the
lowest pint of the lower lip vermilion.
Positioning
■ The endotracheal tube is secured. Stainless steel dental wire (26 gauge) is used
to affix the endotracheal tube to the first bicuspid.
■ Face and hair are prepped entirely.
■ Reinforced endotracheal tube is used and brought over the head rather than
down toward the chin. The tube is attached to the anesthesia machine using a
straight connector and extension tubing, which rests on a “Christmas tree”
holder (Mainline Medical, Norcross, Georgia).
■ Sterile stockinet is applied over the tubing and the “Christmas tree” connector.
■ When eyelids and upper face access is required, the Christmas tree is removed
from under the stockinet; the tube is directly placed onto the patient’s draped
torso and clipped to the drapes.
Approach
■ Preauricular incision
■ Incision in the preauricular region has been shown to decrease scarring.
■ Incision should be carried out in a retrotragal or pretragal fashion (FIG 1).

FIG 1 • The course of the preauricular and postauricular
incision.
■ Temporal incision
■ Temporal hairline incision is used when lateral canthus to temple distance is
more than 5 cm.
■ When distance is less than 5 cm, temple scalp extension incision is made.
■ Postauricular incision
■ Incision in the postauricular sulcus and crosses the region of postauricular
skin where the helix and postauricular hairline join
■ This continues into the occipital scalp or follows the hairline.
■ Submental incision
■ A 3 to 4 cm incision is centered over midline 5 mm caudal to the submental
crease.5

T E C H N I Q U E S
■ Skin-Only Face and Neck Lifting
■ Subcutaneous dissection (TECH FIG 1)
■ Local anesthetic
• Infiltrate incision sites with 0.5% lidocaine with epinephrine (1:200 000).
Regions of subcutaneous undermining are infiltrated with 0.5% lidocaine
with epinephrine (1:200 000).
• Inject each ipsilateral facial region prior to undermining to maintain
tumescence and local block effect.
■ Subcutaneous undermining
■ Skin flaps should be elevated under direct vision.
■ Preauricular dissection
• Dissect anterior to the helix beginning in a superficial subcutaneous plane
to avoid injury to the superficial temporal vessels. Care should be taken to
avoid injury to tragal cartilage. In the area of the cheek, dissection should
preserve fat on skin flap to provide for a robust flap. This plane should be
consistent in the area of the upper neck and inferior mandibular border.
• Dissect anteriorly to incise platysma-cutaneous ligaments and mandibular
cutaneous ligaments when indicated.
■ Postauricular dissection
• Elevate skin superficial to the sternocleidomastoid taking care to preserve
fascia protecting the great auricular nerve (GAN).
• Note: GAN location has been described (GAN fall within a 30-degree
angle constructed using the vertical limb perpendicular to the Frankfort
horizontal and a second limb drawn posteriorly from the midlobule).
■ Temporal region
• Dissect in a plane superficial to the superficial temporal fascia and bevel
blade parallel to the hair follicles.
• Identify the orbicularis oculi and remain in a superficial plane to this
muscle.
■ Neck dissection
■ Local anesthetic is administered if general anesthetic is used.

• Infiltrate incision site with 0.5% lidocaine with epinephrine (1:200 000).
Regions of subcutaneous undermining are infiltrated with 0.5% lidocaine
with epinephrine (1:200 000).
■ Incise the skin through 3.5 mm submental incision 5 mm caudal to the
submental crease previously marked.
■ Use Bovie cautery or scissors to begin undermining in subcutaneous tissue
to connect lateral dissection subcutaneous planes with that of the lower
face.
■ Defat submental region above the platysma in the midline.
■ Incise platysma in midline to level of the thyroid cartilage.
■ Remove interplatysmal and subplatysmal fat.
■ Fat is resected flush with the anterior bellies of the digastric muscles.
• Subplatysmal fat is excised flush with the digastric muscles to avoid
creation of a cavity between the muscles.
• Digastric muscles may be plicated in the midline or partially resected if
bulging prominent.
■ Dissection extends inferiorly to the thyroid cartilage inferiorly and laterally
to the anterior belly of the digastric. Lateral dissection is strictly in a
preplatysmal plane.
■ Platysmaplasty
• 3-0 PDS suture used in running fashion to sew cut edges of platysma to
midline from chin to thyroid cartilage and back to the chin (corset
platysmaplasty).
■ Close incision with subdermal 4-0 Monocryl suture and running 5-0
subcutaneous fast-absorbing suture.
TECH FIG 1 • A. Skin flaps elevated. B. Extent of

cheek and neck dissection
■ Skin redraping
■ Goal: Skin shifted along vector perpendicular to the nasolabial fold. In
postauricular region, skin should be shifted along vector parallel to
mandibular border for optimal improvement of the anterior neck.
■ Suspend skin flap first at the cranial most aspect of the helix with vector
perpendicular to nasolabial fold.
■ Use a face-lift marker and incise in a T-shaped incision in flap.
■ Suspend flap with a 4-0 Prolene suture.
■ A third suture is placed high in the postauricular region.
■ Second point of suspension is at the lobular region where 4-0 Monocryl
suture suspends flap at inferior lobule.
■ Flap is divided at the lobule and exteriorized.
■ Skin flap tailoring
■ Preauricular trimming/closure
• Mark skin flap redundancy and trim skin flap. Preauricular portion of flap
is trimmed to match preauricular curves.
• Care must be taken over tragal region to avoid tragal retraction from
tension on skin flap and tragus.
• Defat pretragal portion of skin flap for pleasing contour.
• Affix skin flap to cranial preauricular skin with 4-0 Monocryl subdermal
sutures.
• Run 6-0 fast-absorbing sutures for preauricular closure taking care to evert
skin edges.
■ Postauricular trimming/closure
• Trim anterior border of the postauricular skin flap to match curve of
incision in auriculomastoid sulcus.
• Excise skin along posterior border of the postauricular skin flap using
face-lift marker as guide. Wound edges should touch one another without
gaps (ie, no tension on postauricular skin flaps).
• Run 5-0 fast-absorbing gut suture for single-layer closure.
PEARLS AND PITFALLS

Tension
■ Preauricular incision under moderate tension. Postauricular incision
should be under no tension. Tension in the postauricular region leads
to a hypertrophic scar at best or skin slough at the worst.
Release of
ligaments
■ Subcutaneous dissection over the cheek over the region of the major
zygomatic ligament must be done carefully as nerve injury can occur
in a deep dissection.
Dissection
plane
■ In the cheek, the dissection of the skin-only face-lift is more
superficial than the deeper dissection over the platysma.
Excellent
results
■ Excellent results in skin-only face-lift are predicated on the release of
mandibular ligaments, zygomatic ligaments, and masseteric ligaments.
Neck
■ Patients with platysmal banding require an anterior neck approach
platysmaplasty in addition to the skin-only face-lift.
Cautery
■ Bipolar cautery use rather than unipolar cautery use reduces both the
incidence of neuropraxia and neck drainage.
POSTOPERATIVE CARE
■ Patient discharged form postoperative unit after procedure.
■ A head dressing is not essential, but a soft dressing prevents unsightly blood
leakage and is removed the following morning.
■ Patients are provided with analgesics only.
■ Patients are examined 1 day after surgery with care to examine suture lines
and skin flaps.
■ Patient drains are removed 1 day after surgery regardless of output unless
drainage is significant, ie, greater than 30 cc.
■ Patients begin showering 1 day after surgery following removal of dressings.
■ Residual sutures are removed 7 days after surgery.
OUTCOMES
■ See FIGS 2 and 3.

FIG 2 • A–C. Preoperative. D–F. Postoperative 1 year—
Skin-only face-lift with neck lift
FIG 3 • A–C. Preoperative. D–F. Postoperative 1 year—
Skin-only face-lift and neck lift
COMPLICATIONS
■ Early complications
■ Hematoma: The incidence of hematoma formation is variable ranging from
1% to 10%. One should maintain blood pressure at preoperative levels during
closure to detect bleeding once epinephrine effect wanes. Small hematomas
are dealt with in a conservative fashion. Large hematomas must be drained in
the operating room and cleared through (milking out through drains or
aspirated with needle).
■ Seromas: Occur in the neck region and lower face. If seroma forms after
drain removal, aspirations with a needle and syringe in clinic are required.
Undrained seromas lead to neck irregularities that can be difficult or
impossible to correct.
■ Sialoma: Rarely occur, caused by parotid gland injury. This is diagnosed with
high amylase levels. Leaks resolve with conservative treatment in the absence
of distal obstruction.
■ Facial nerve injury: Permanent injury incidence is 0.4% to 2.6%. Most
common branches injured are injuries include buccal branches. Buccal
branch injury is not apparent as there are many interconnections between the
buccal branch and other facial nerve branches. Marginal mandibular nerve
injury is the second most common but is apparent due to it being single nerve
without interconnections with other branches. Early nerve defects are
neuropraxic rather than axonotmesis and usually resolve. The marginal
mandibular and cervical nerves are differentiated as the marginal mandibular
gives innervation to the mentalis, which results in the lack of lip eversion

when injured.
■ Late complications
■ Contour irregularities: Occur as a result of asymmetric fat excision
■ Pixie ears: Caused by tension on the lobule during closure
■ Unsatisfactory scars: Widened misplaced scars, hypertrophic scars, or skin
slough
■ Alopecia
■ Loss of tragal definition
REFERENCES
1. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep
facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg.
1992;89(3):441-449.
2. Huettner F, Rueda S, Ozturk CN, et al. The relationship of the marginal
mandibular nerve to the mandibular osseocutaneous ligament and lesser
ligaments of the lower face. Aesthet Surg J. 2015;35(2):111-120.
3. Alghoul M, Bitik O, McBride J, Zins JE. Relationship of the zygomatic facial
nerve to the retaining ligaments of the face: the Sub-SMAS danger zone. Plast
Reconstr Surg. 2013;131:245e-252e.
4. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance
of its variations in face lifting. Plast Reconstr Surg. 1966;38(4):352-356.
5. Lambros V. Observations on periorbital and midface aging. Plast Reconstr
Surg. 2007;120(5):1367-1376.

42
CHAPTER
Indications and Techniques
for Face-Lifting and Neck
Lifting
David A. Hidalgo and Sammy Sinno
GENERAL CONCEPTS
■ Facial aging is a result of progressive degenerative changes in the skin, deeper
soft tissues, and underlying skeletal structures, often occurring independently
and each to variable degrees.
■ Although new nonsurgical techniques that attempt to restore a more youthful
facial appearance continue to develop, surgical rejuvenation remains the most
powerful approach.
■ Face-lifting and neck lifting involves dissection and manipulation of facial
skin and deeper soft tissues to create an aesthetically rejuvenated facial
appearance and youthful contour in the neck.
■ The superficial musculoaponeurotic system (SMAS) layer of the face can be
manipulated independent of facial skin in several ways to provide more natural
and long-lasting results.
■ SMAS technique options include SMAS flap, SMASectomy, and SMAS
plication.1–3 Facial contour, skin quality, soft tissue volume, and bone structure
all influence the choice of technique.
■ There are various strategies applicable to treating aging changes in the neck
that address visible muscle banding, skin laxity, and general neck contour.
■ Adjunctive procedures involving periorbital surgery, regional resurfacing, soft
tissue volume augmentation, skeletal augmentation, and others enhance the
results of face-lifting and neck lifting.
ANATOMY
■ The face is a lamellar structure that, from superficial to deep, consists of skin,

subcutaneous fat, SMAS, deep fascia (parotidomasseteric fascia), the mimetic
muscles, facial nerve branches and the parotid gland, muscles of mastication,
deep fat compartments, and bone.
■ The facial nerve innervates most muscles of facial expression on their deep
surface and is protected in the area over the parotid by the parotidomasseteric
fascia.4
■ The SMAS is contiguous with the platysma muscle inferiorly and the galea
aponeurotica superiorly.5 Tightening of this layer repositions ptotic facial
tissues and is a key component of restoring youthful facial contour.
■ The platysma muscle in the neck typically develops ligamentous laxity with
aging. This commonly results in the development of visible medial muscle
edges (bands) anteriorly that exhibit variable thickness, length, and spacing
between them. Excess subcutaneous fat superficial to the muscle can also
contribute to the appearance of an aging neck.
■ Structures deep to the platysma including subplatysmal fat, submandibular
glands, digastric muscles, and the hyoid bone can also contribute to contour
problems independent of the aging process, as can skeletal conditions such as
microgenia.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients typically present for surgical rejuvenation of the face and neck over
the age of 50, but some seeking correction of minimal deformities can present
in their early 40s.
■ Patients presenting for the first time in their 70s are also reasonable candidates
provided there are no prohibitive medical conditions.
■ The best candidates for surgery are those with significant aging changes who
are motivated for the right reasons; good candidates should be psychologically
stable and have realistic expectations.
■ Characteristic signs of facial aging include deepening of the nasolabial folds
with associated midface ptosis and deflation; progressive actinic skin damage
and laxity; subcutaneous atrophy; development of jowls, “marionette lines,”
and adjacent prejowl hollowing; and platysma laxity leading to anterior bands
and an obtuse cervicomental angle laterally.
■ Smoking increases the risk of wound complications, particularly in the setting
of wide skin undermining. Therefore, complete cessation of smoking is
required for at least 3 weeks prior to surgery. Nicotine substitutes of all types
are also prohibited.

■ Strategies to minimize complications when uncertainty exists regarding
compliance include avoiding retrotragal incisions, limiting the extent of the
retroauricular incision design (short-scar option if appropriate), avoiding
opening the anterior neck, and limiting skin undermining.
■ Patients with a BMI over 30 and significant medical conditions such as
obstructive sleep apnea, severe diabetes, or cardiovascular disease are
unfavorable candidates for surgery in an office-based setting. Men with a
history of obstructive urinary symptoms should have a urology consultation
prior to surgery.
IMAGING
■ Although 3D scanning is available today, it does not significantly enhance
communication between the surgeon and patient beyond what high-quality
facial photographs and mirror examination can achieve.
SURGICAL MANAGEMENT
Preoperative Planning
■ Skin quality is assessed including thickness, elasticity, and degree of actinic
damage.
■ Many patients will benefit from simultaneous regional skin resurfacing with a
chemical peel such as 30% trichloroacetic acid for the thinner periorbital skin
or dermabrasion for the thicker perioral skin.
■ Lasers are an alternative resurfacing modality, perhaps best suited to full face
treatment with fractionated laser-based technology subsequent to surgery.
■ Patients with high sideburns are advised that their hairline may move slightly
or that a subsideburn incision may be necessary to prevent excessive
movement. The latter is more common in secondary or tertiary cases.
■ Pretrichial temporal incisions are another option but can cause variable scar
quality and generally are not well accepted by patients.
■ The choice between a pretragal and retrotragal incision is influenced by tragal
anatomy, its overlying skin quality, and adjacent preauricular skin thickness
and texture.
■ Retrotragal incisions effectively break up the continuity of the preauricular
incision but must be carefully crafted to avoid an unnatural-appearing tragus.
■ Women who have a large, projecting tragus with thin, delicate overlying skin
and adjacent thick cheek skin are better suited to a pretragal incision.

■ Most men are also good candidates for pretragal incisions to avoid the
transposition of thicker, hair-bearing skin over the tragus and to avoid a more
feminized appearance in this area.
■ Women under 60 years with minimal neck changes seeking improvement for
early jowls and nascent lateral check laxity are often good candidates for a
posterior incision pattern limited to the postauricular sulcus (short-scar
technique).6 This is particularly advantageous in those who habitually expose
this area due to hairstyle preferences.
■ Nevertheless, well-designed and expertly executed full postauricular scar
patterns are preferred to a more limited incision approach that fails to correct
cervical skin laxity.
■ Most women and even men with complete alopecia are best served with a
complete postauricular scar pattern.
■ Individual bone structure, soft tissue volume, and surgical timing (primary or
secondary, tertiary) are all influential in selecting the optimal SMAS technique
for each patient. Those with strong mandibular or maxillary bone contours
generally require less SMAS manipulation, as do those with lighter soft tissue
volumes. The opposite scenarios argue for more extensive SMAS
manipulation.
■ For patients with prominent facial bone structure and light or medium
thickness soft tissues, a SMASectomy is indicated.
■ For patients with normal or small facial bone structure who require more
extensive repositioning of heavier facial soft tissues, an extended SMAS flap
is more effective.
■ For patients with thin, minimally ptotic soft tissues, or in secondary or
tertiary cases, a SMAS plication is appropriate.
■ Facial fat volume and distribution are assessed.
■ If significant hollowing in the prejowl sulcus or deflation of the malar
compartment is observed, adjunctive fat grafting of these areas should be
considered at the time of the primary procedure.
■ Prominent lateral cheek hollowing, seen less commonly, is best treated with
a separate fat grafting procedure at a later procedure.
■ The extent of cervical skin laxity and the underlying neck contour are
evaluated.
■ Older patients with very loose skin of poor quality that extends to the base of
the neck are always counseled that they may need a limited secondary

procedure at 1 year to obtain an optimal, durable result. This also applies to
younger patients having a single strong midline submental skin band.
■ It is important to discuss this preoperatively with those having either of these
characteristics.
■ Anterior neck surgery is indicated for platysmal bands that are prominent and
generally no further apart than 2.5 cm. Patients are advised that a 2.5- to 3-cm
submental incision will be necessary to accomplish this.
■ Subplatysmal fat excision is a helpful adjunct for improving an obtuse
cervicomental angle and can be an indication alone for opening the neck in
the absence of platysmal bands.
■ Partial excision of the submandibular glands and digastric muscles is a much
more aggressive and controversial approach for contour improvement and is
not routinely recommended.
■ Patients are counseled on the option of having a chin implant placed when
microgenia is present. Even in subtle cases, an extra small implant is often
beneficial.
■ Ptotic chin pads (witch’s chin deformity) and more subtle chin/neck junction
depressions should be noted and addressed in the surgical plan.
■ Perioral resurfacing is often indicated in conjunction with face-lifting and neck
lifting.
■ Upper lip rhytides are usually the first to appear and tend to be the deepest.
The oral commissures, prejowl sulcus, and chin are also affected to variable
degrees but usually much less than the upper lip.
■ Chemical peels, laser resurfacing, and mechanical dermabrasion are all
effective at improving rhytides but also can cause depigmentation of the
treated areas.
■ Nevertheless, even conservative rhytide ablation significantly enhances the
overall result of surgery. Dermabrasion, perhaps the least technically
sophisticated and oldest tool, allows precise depth control of treatment in
experienced hands.
■ Simultaneous periorbital rejuvenation is frequently requested and discussed
and, less commonly, a nasal tip plasty to address concerns regarding a bulbous
or drooping tip.
■ Earlobe reductions or repair of elongated or lacerated earlobe piercings are
also sometimes requested during the preoperative evaluation.
Patient Preparation

■ All patients have standardized multiview facial photographs taken, with
additional views of areas where adjunctive treatment is planned.
■ These photographs are used for preoperative planning and communication,
intraoperative reference, and postoperative outcome discussions.
■ Medical clearance is routinely obtained in patients over 60 or in younger
patients with specific medical conditions of concern.
■ Patients taking blood-thinning medications for cardiac stents or arrhythmias
must be evaluated by their cardiologist to determine the safety of
discontinuance for a suitable interval both before and after surgery. The same
applies to patients on prophylactic low-dose aspirin.
■ Strict blood pressure control is necessary perioperatively to facilitate surgery
and minimize the potential for a postoperative hematoma. Therefore, patients
with hypertension must optimize their medical regimen for blood pressure
control prior to surgery.
■ Clonidine can be administered from either an oral or transdermal route
immediately prior to surgery to manage blood pressure that remains refractory
to tight control.
■ Hospital employees, such as anesthesiologists and nurses, or others with a
prior history of MRSA should be screened with a nasal swab culture.
■ Patients who test positive should be treated with Bactroban (mupirocin) prior
to surgery to eliminate their carrier status.
■ The benefits of perioperative homeopathic use such as Arnica montana for
ecchymosis and bromelain for edema are unproven but can be safely employed
at the surgeon’s discretion.
■ Excessive doses of Arnica may increase the risk of hemorrhage.
■ Patients are instructed to wash their face and hair thoroughly the night before
surgery, remain nothing by mouth (NPO) after midnight, and take their blood
pressure medication on the morning of surgery.
Patient Positioning
■ The patient is positioned supine on the operative table with the knees slightly
bent to optimize lower extremity venous return.
■ The arms are carefully immobilized and a warming blanket is placed.
■ A triangular headpiece facilitates performing the procedure.
■ Anesthesia is induced, either an oral airway or laryngeal mask airway (LMA)
placed, and the patient typically maintained on propofol for the duration of the

procedure.
■ Normotensive anesthesia is preferred throughout the procedure in order to
minimize the prospect of hematoma development.
■ Consideration should be given for placement of a urinary catheter for long
procedures and for men with a history of obstructive symptoms.
■ One preoperative dose of cephalosporin is administered.
■ If the patient is a hospital employee or has a history of MRSA, vancomycin is
given instead.
■ The incisions and key reference points are marked, the sites of injection
prepped with Betadine swabs, and the areas of dissection infiltrated with a
dilute lidocaine and epinephrine solution (100-cc normal saline, 100 cc 1%
lidocaine, 1 cc of epinephrine).
■ Tumescent technique is not necessary, and typically 200-cc total is used for
the face and neck.
■ The face is then prepped with Zephiran Chloride (benzalkonium chloride) and
a head drape applied.
T E C H N I Q U E S
■ Incisions
■ Incisions are all made using a no. 10 blade scalpel.
■ Temporal incisions within the scalp angle back approximately 20 to 30
degrees above the ear to avoid the course of the superficial temporal artery
(TECH FIG 1A).
■ Pretrichial incisions are avoided in the temporal area due to their
inconsistent healing quality.
■ Subsideburn incisions are positioned at the root of the helix and extend
transversely for no more than 2 cm when needed.
■ A commitment for making subsideburn incisions is generally not necessary
until skin redraping at the time of closure.
■ The retrotragal incision is positioned slightly posterior to the free edge of the
tragus and defines its superior and inferior borders. The inferior portion of
the incision then extends anterior to the tragus for several millimeters before
making a sharp angle to parallel the attached portion of lobule (see TECH

FIG 1A).
■ Pretragal incisions parallel the curve of the helix to its root and then inflect
downward with a short mirror image curve that then straightens to parallel
the tragus down to the lobule (TECH FIG 1B).
■ Short-scar postauricular design can use the full length of the sulcus to allow
for even skin distribution when closing, thereby minimizing the potential for
significant pleat formation (TECH FIG 1C).
■ Full postauricular incisions reflect posteriorly high in the sulcus, cross the
mastoid skin with a gentle upward curve, and then continue into the
occipital scalp parallel to and just inside the hairline, cut on a bevel to
preserve hair shafts (TECH FIG 1D).
■ The submental incision is 2.5 to 3 cm in length and can be placed either in
the natural crease or slightly posterior to it, depending on surgeon preference.
■ Creation of a “mesotemporalis” by deep dissection in the temporal area is
not recommended as this maneuver predisposes to late (10 to 14 days)
massive superficial temporal artery hemorrhage. This complication occurs
suddenly and is associated with challenging patient management issues.
TECH FIG 1 • Incisions. A. The temporal scalp

incision is angled backward approximately 30 degrees
to avoid the superficial temporal artery. A small
amount of scalp skin can be pre-excised as shown by
the design. The retrotragal portion of the skin incision
lies posterior to the free edge of the tragus. The
incision then turns a right angle at the lower border of
the tragus to parallel the lower ear and lobule. Avoid
pretrichial incisions (red line) when possible. B.
Pretragal incision design in a male. C. Short-scar
postauricular incision design can use the whole length
of the sulcus to facilitate an even distribution of skin
during closure. D. Typical postauricular skin incision
design. The incision reflects from the postauricular
sulcus high on the mastoid bare skin before
transitioning into the occipital scalp.
■ Skin Flap Elevation
■ Once all incisions have been made, the no. 10 blade is used to begin the skin
flap elevation 1.5 to 2 cm anteriorly in the preauricular area (TECH FIG
2A,B). Care is taken to maintain proper thickness when starting the flap with
the knife.
■ The postauricular and upper neck skin is then raised sharply off the
mastoid and origin of the sternomastoid muscle (TECH FIG 2C).
Hemostasis is obtained in all areas raised so far.
■ In the case of retrotragal incisions, soft tissue is sharply undermined at the
base of the tragus and folded over anteriorly (TECH FIG 3).
■ It is sutured to the SMAS with a continuous 4-0 Vicryl suture.
■ This maneuver creates a “hill and valley” effect just anterior to the tragus.
As the skin follows this contour during closure, tragal definition is
enhanced.