Operative Technique in Plastic Surgery – Kevin C.Chung

represents the level at which the inferior portion of the
gland will be excised. D. Intraoperative photo just prior
to partial gland excision. This should be performed in
such a manner that the portion protruding inferior to
the plane tangent to the ipsilateral anterior belly of the
digastric muscle and the ipsilateral mandibular border
will be resected incrementally with electrocautery. E.
Patient seen immediately after neck lift that included
submandibular reduction. The excised portions of the
glands are also demonstrated on both the right and
left sides.
■ Once the excision is complete, it is not necessary to oversew the cut edge of
the gland or close the gland capsule. It is also not necessary to overcauterize
the cut edge of the gland as this will result in more prolonged edema.
■ A drain should be placed in the subplatysmal space with this procedure and
left in place for several days. It is safest to perform the platysmaplasty before
drain placement and then to perforate the platysma and thread the drain into
place. This is to avoid the drain being caught with a suture during
platysmaplasty.
■ Partial Digastric Myectomy
■ Superficial, subtotal anterior digastric myectomy is performed under direct
vision through the submental incision after the subplatysmal space has been
opened, the platysma muscle has been mobilized, and subplatysmal fat and
protruding portions of the SMG have been excised as needed.
■ The redundant portion of the muscle can be excised by either a tangential
strip excision technique or by a partial division and excision technique.
Although both are reliable and effective, in most cases, tangential strip
excision provides the simplest method of reducing the muscle.
■ Tangential strip excision is performed by grasping the superficial redundant
portion of the muscle belly with a forceps and excising a strip of muscle
longitudinally with Metzenbaum scissors or cautery. Excision is begun near
the muscle origin at the mentum and continues toward the lateral hyoid. The

muscle is then reassessed and the action repeated until the protruding portion
is fully removed and optimal contour obtained.
■ In the partial division and excision technique, the excess muscle is gauged
and isolated on a tonsil forceps by pushing the tips of the instrument through
the midmuscle belly at the level of optimal contour and spreading to split the
muscle along the length of its fibers. The isolated muscle segment resting on
the instrument consisting of the superficial, protruding portion of it is then
excised with scissors or cautery by dividing it at the mentum and hyoid
(TECH FIG 3). Usually, this entails the excision of the superficial most half
or less of each muscle.
TECH FIG 3 • Partial division and excision technique
of digastric muscle reduction. A. Excess muscle
present is gauged and isolated on a tonsil forceps by
pushing the tips of the instrument through the
midmuscle belly at the level of optimal contour and
spreading to split the muscle along the length of its
fibers (view from patient’s right digastric muscle
through submental incision. Patient’s chin is at the left
upper corner of the photo and the neck is on the right).
B. The isolated muscle segment resting on the
instrument consisting of the superficial, protruding
portion of it is then excised with scissors or cautery by
dividing it near the mandible and the hyoid. The neck
is then re-examined and the maneuver repeated if
necessary until an improved contour is obtained.

■ Anterior Platysmaplasty and Myotomy
■ Platysmaplasty consists of suturing the medial muscle borders together from
mentum to thyroid cartilage in one or two layers. If redundant muscle is
present, it is excised medially before suturing is performed so that a smooth,
edge-to-edge approximation can be made (TECH FIG 4).
■ This is usually performed using simple interrupted sutures of 3-0 Vicryl or
Mersilene on a medium tapered needle. A running suture is not recommended
as this can cause a “purse string” effect potentially leading to the formation
of a midline band postoperatively. Once initial approximation is made with
interrupted sutures, the line of repair can be oversewn with a simple running
suture if desired. The repair should be snug but not tight.
■ When performing a face and neck lift together, cheek SMAS flaps should be
suspended prior to anterior platysmaplasty to allow optimal treatment of the
jowl. If postauricular transposition flaps are planned, this should be
performed after anterior platysmaplasty to prevent difficulty in joining the
medial borders of the platysma anteriorly.
■ Platysma myotomy should be performed after anterior platysmaplasty if
indicated (TECH FIG 5).
■ This should be done low in the neck at the level of the cricoid cartilage. At
this level, the muscle is thin and will bleed less, and the cut edges are less
likely to be visible postoperatively. In addition, a smooth transition across the
cervicomental angle is maintained and lower lip dysfunction is avoided.
■ Platysma myotomy is best begun through the submental incision just below
the inferiormost suture from the platysmaplasty. The medial muscle border is
grasped and lifted away from the deep cervical fascia with forceps. Myotomy
is then made by nibbling though the muscle in small increments with
Metzenbaum scissors. As the muscle is divided, it usually separates a
centimeter or more exposing the fascia beneath it. Gentle spreading with
scissor tips before each cut is made helps separate the muscle from the
underlying cervical fascia and facilitates dissection. The myotomy is
continued laterally and slightly superiorly.
■ If full-width division of the platysma is planned, the lateral most portion of
the transection is completed through the postauricular incision. The lateral
transection is complete when brought into continuity with the myotomy from
the anterior approach.

■ Prior to skin closure, usually one drain is placed in the subplatysmal space if
deep layer problems have been treated, and a second drain is placed
subcutaneously. If significant oozing is encountered at the end of the
procedure or in male patients, an additional drain can be considered for the
subcutaneous space.
TECH FIG 4 • Anterior platysmaplasty. Repair of
platysma diastasis from mentum to thyroid cartilage
(arrows) improves submental support and helps
consolidate the neck. It is not an adequate or effective
treatment of platysma bands, however.

TECH FIG 5 • Plan for “full-width” platysma
transection. Full-width myotomy not only corrects
anterior and lateral bands but provides improved
definition over the lateral mandibular border. However,
for patients with only anterior bands, a partial-width
transection beginning medially may be adequate. A.
Anterior neck after platysmaplasty but before full-width
platysma myotomy. B. After full-width platysma
myotomy (note: myotomy is most easily and
effectively performed after platysmaplasty has been
completed).
PEARLS AND PITFALLS

Subcutaneous
fat
■ This layer of fat is essential to maintaining a soft smooth contour
to the neck. In most cases, very little subcutaneous fat needs to
be removed if proper attention is paid to deep layer problems.
Subplatysmal
fat
■ Aggressive treatment of subplatysmal fat can make
submandibular glands and digastric muscles much more visible;
thus, a surgeon should be prepared to treat all three problems in
such cases.
Submandibular
gland
reduction
■ It is critical to adequately mobilize the gland prior to resection.
This will greatly simplify both resection and control of any
significant bleeding.
Digastric
muscle
hypertrophy
■ In most cases, the decision to treat digastric muscles is made
intraoperatively after treating other deep layer problems.
Anterior
platysmaplasty
■ There is no need to suture the platysma under great tension when
deep layer problems are adequately addressed. A snug one-layer
edge-to-edge closure after excision of any redundant platysma is
adequate.
Recovery
■ Subplatysmal maneuvers will lead to a longer period of swelling
and induration, and surgeons using these techniques should be
prepared to counsel patients.
POSTOPERATIVE CARE
■ No dressings are required or used. They are arguably dangerous for tenuous
skin flaps and uncomfortable for patients and preclude inspection and
monitoring of the operative site.
■ All patients are instructed to sleep flat on their backs without a pillow or with
a small cylindrical neck roll. This posture assures an open cervicomental angle
and averts dangerous folding of the neck skin flap and obstruction of regional
cervical lymphatics. Patients are also shown an “elbow on knees” position that
accomplishes this open cervicomental angle while sitting.
■ Patients are allowed to take their usual diet after surgery but to avoid overly
sweet, salty, sour, or dry foods for several weeks. This in particular is important
if the SMGs have been treated.
■ The neck drains are usually left in place for 4 to 5 days. This will help speed
the overall resolution of edema, ecchymosis, and induration.
■ Patients are asked to set aside 7 to 10 days to recover depending on the extent

of their surgery, and additional time off is recommended if a face-lift or related
procedure is simultaneously performed.
OUTCOMES
■ See before and after examples (FIGS 8 to 10).
■ See case examples of before and after photos.
FIG 8 • Before and after surgery views of a woman, age
46 who has had no prior surgery. Note full neck, obtuse
cervicosubmental contour and “double chin”
appearance when the patient looks down in before
views. Palpation of the lateral submental triangle
revealed a firm mobile mass consistent with an
enlarged submandibular gland. Her preoperative
appearance suggests the presence of a “low hyoid.”
The same patient 11 months after face-lift, neck lift,
forehead lift, lower eyelift, and facial fat grafting. The
neck lift procedure included excision of subplatysmal
fat, submandibular gland reduction, superficial digastric
myectomy, anterior platysmaplasty, and full-width
platysma myotomy. Note attractive, youthful-appearing
neckline even when the patient looks down.
Comprehensive neck surgery has corrected problems
that are commonly misinterpreted as a low hyoid
position. The double chin deformity has also been

corrected. (Surgical procedures performed by Timonthy
J. Marten, MD, FACS.)
FIG 9 • Before and after surgery views of a woman age
55 who has had prior eyelifts and a perioral chemical
peel by another surgeon. Note full neck, obtuse
cervicosubmental contour and “double chin”
appearance. Palpation of the lateral submental triangle
revealed a firm mobile mass consistent with an
enlarged submandibular gland. Note paucity of
subcutaneous neck fat. The same patient 1 year and 4
months after face-lift, neck lift, forehead lift, upper and
lower eyelid lifts, perioral dermabrasion, and facial fat
grafting. The neck lift included excision of a large
amount of subplatysmal fat, submandibular gland
reduction, superficial digastric myectomy, anterior
platysmaplasty, and full-width platysma myotomy. Note
the youthful neckline. The double chin deformity has
been corrected by releasing the submental retaining
ligaments and blending the fat of the chin and the
submental area. (Surgical procedures performed by
Timonthy J. Marten, MD, FACS.)

FIG 10 • Before and after surgery views of a man, age
68 who has had no prior plastic surgery. Note poor
cervicosubmental contour and “double chin”
appearance when the patient looks down in before
views. An enlarged submandibular gland can be seen.
Note paucity of subcutaneous fat that is typical for
patients in older age groups. Platysmal bands are
visible in the anterior neck. The same patient 1 year
and 9 months after face-lift, neck lift, forehead lift, upper
and lower eyelifts, facial fat grafting, and ear lobe
reduction. The neck lift procedure included excision of a
large amount of subplatysmal fat, submandibular gland
reduction, superficial digastric myectomy, anterior
platysmaplasty, and full-width platysma myotomy. Note
well-defined jaw line and masculine-appearing neckline
even when he looks down.
COMPLICATIONS
■ Complications associated with subplatysmal neck lifting are similar to other
face and neck lift techniques (see High SMAS flap chapter).
■ Subplatysmal neck lifting in particular can lead to temporary platysmal
dysfunction likely related to injury to cervical branches. This will manifest as
asymmetric lip depressor function that should resolve within 3 months.
■ No major complications attributable to SMG excision, including seroma
formation, salivary fistula, or gustatory sweating, have been encountered in our

clinic over the last 20 years.
REFERENCES
1. Marten TJ. Treatment of the full, obtuse neck. Aesthet Surg J. 2005; 25(4
suppl):387-397.
2. Marten TJ. Cervical contouring in facelift. Aesthet Surg J. 2002; 22(6
suppl):541-548.

49
CHAPTER
Indications and Techniques
for Short-Scar Face-Lift
Steven M. Levine and Daniel C. Baker
DEFINITION
■ Surgery is the standard treatment to address descent and laxity in the aging
face.
■ Short-scar face-lift is defined as an incision that remains completely
preauricular.
■ Most also apply that definition to face-lift incisions the extend behind the lobe
and into the retroauricular sulcus, but that do not have a transverse component
or cross into the hairline at any point.
ANATOMY
■ Relevant anatomy is the earlobe and retroauricular sulcus.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Beyond usual history and physical findings to indicate a patient for a face-lift
and neck lift, the question is, “Does the patient have a significant amount of
cervical laxity?”
■ Short-scar face-lifts compromise on the ability to address neck laxity,
specifically, inferior neck laxity. Better stated, the short-scar face-lift is ideal
for a patient with minimal neck laxity who desires improvement along the
jawline and midface.
SURGICAL MANAGEMENT
■ Surgery should be performed in an accredited operating room.
■ A short-scar face-lift can be performed under local anesthesia with or without
sedation or general anesthesia.

Preoperative Planning
■ Consideration should be given as to whether the surgeon believes the patient
will be satisfied from the limited neck lift provided by the short-scar approach.
Positioning
■ The patient is supine on the procedure table.
■ Usually, the head of the bed is slightly elevated.
■ The authors prefer to sit for maximum stability.
Approach
■ An incision pattern is chosen, either preauricular or intratragal.
■ The skin is elevated in the subcutaneous plane after infiltration with local
anesthesia with epinephrine.
■ The superficial musculoaponeurotic system (SMAS) is addressed by any
number of acceptable means.
T E C H N I Q U E S
■ True Short-Scar Face-Lift
■ The skin incision stops at the base of the earlobe without separating the neck
skin from lobe.1
■ The skin flap is undermined (TECH FIG 1A).
■ The superficial musculoaponeurotic system (SMAS) is addressed via a flap,
SMASectomy, or plication procedure.
■ The skin flap is redraped, trimmed, and sewn under no tension (TECH FIG
1B).
■ The authors prefer to leave drains, but this understandably varies between
surgeons.

TECH FIG 1 • A. The pretragal incision and extent of
skin undermining. The incision may extend into the
retroauricular sulcus. In this patient, a SMASectomy is
planned. B. After the SMAS has been addressed, the
flap is rotated into position and excess skin is
trimmed.
Extended Short-Scar Face-Lift
■ The skin incision continues to the retroauricular sulcus.
■ This allows the neck to be addressed more adequately than with a true short-
scar procedure.
■ The skin flap is undermined.
■ The SMAS is addressed via a flap, SMASectomy, or plication procedure.
■ The skin flap is redraped, trimmed, and sewn under no tension.
■ When sewing the skin flap, a three-point stitch is placed from the lobe, the
neck skin, and deep to the fascia. This suture anchors the lobe in place to
prevent a pixie ear.
■ The traditional tension-bearing retroauricular suture at the cranial end of
the sulcus does not exist.
■ If there was neck laxity to address, the retroauricular closure will require
bunching or pleating of tissue (TECH FIG 2).
■ The wound should be closed carefully with interrupted suture.
■ This pleating settles out within 6 weeks.

■ The authors prefer to leave drains, but this understandably varies between
surgeons.
TECH FIG 2 • In a patient with mild to moderate
amounts of cervical skin laxity, there may be pleating
around the incisions; this will settle with time.
PEARLS AND PITFALLS
Approach
■ Do not hesitate to convert a short scar to a traditional scar for a better
result.
■ This needs to be discussed with patients preoperatively.
Flap
■ Do not overtrim the flap beneath the lobe. There should be no tension
on the skin beneath the earlobe. This is more important in a short-scar
operation than a traditional scar.
POSTOPERATIVE CARE
■ Cool packs are also used to reduce swelling.
■ Strict blood pressure control is enforced postoperatively.
■ Patients are instructed to do no lifting or bending for 2 weeks.

■ The authors prefer to place patients in a face and/or neck compressive dressing
for at least 4 to 6 hours after surgery, but up to 24 hours.
■ Drains are usually removed at 48 hours.
■ All patients are seen by the surgeon the following morning and then again
multiple times over the following week.
■ Sutures are usually removed at 1 week.
■ If needed, a low-dose steroid injection can be delivered to the subcutaneous
tissue behind the ear to help soften the pleated tissue.
OUTCOMES
■ Short-scar face-lifts in carefully selected patients can achieve excellent jawline
contour and midface elevation, as well as some neck tightening (FIG 1).
FIG 1 • Preoperative (A,B) and postoperative (C,D)
views of a patient who underwent a short-scar face-lift.
Note the improvement of the jowls and jawline.
COMPLICATIONS
■ Bruising and hematomas are the most common complications.
■ Hematomas in males are twice as common as they are in females.
■ Pixie ear creation is a problem if the flap is overtrimmed or inadequately
secured to the lobe and fascia.
REFERENCE
1. Baker DC. Lateral SMASectomy, plication and short scar facelifts: indications
and techniques. Clin Plast Surg. 2008;35(4):533–550, vi.
doi:10.1016/j.cps.2008.06.003.

50
CHAPTER
Indications and Techniques
for Buccal Fat Pad Excision
Alan Matarasso and Sammy Sinno
DEFINITION
■ The buccal fat pad is prominent in the infant face, where it contributes to the
suckling function of the cheek.1
■ Typically, as the face matures, the buccal fat pad becomes less noticeable, but
in some patients, it persists and serves as a primary contributor to a “round”
face.
■ An attractive, angular, and youthful appearing face is characterized by malar
convexity juxtaposed with submalar concavity.
■ Additionally, due to its intermuscular location, the buccal fat is typically
spared from atrophy.2
ANATOMY
■ The buccal fat pad is a stellate-shaped structure with four extensions.
■ It is located deep to the masseter muscle and superficial to the buccinators in
the buccopharyngeal membrane.
■ The parotid duct pierces the fat pad as it courses to the papilla across the
second maxillary molar (FIG 1).
■ The fat pad extends to the anterior edge of the masseter muscle; it is at this
location where the gland can protrude from overaggressive liposuction or
facelift dissection among other causes, a phenomenon known as buccal fat pad
pseudoherniation.3,4

FIG 1 • Anatomy surrounding the buccal fat pad.
■ Posteriorly, the fat pad extends deep to the angle of the mandible.
■ Superiorly, the fat pad extends to the temporalis muscle and deep to its fascia.
■ Another superior extension continues along the zygomatic bone’s contribution
to the lateral orbital wall.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The buccal fat pad can contribute to a “rounded” facial appearance,
obliterating submalar concavity in certain patients. This feature is seen most
prominently in the anterocaudal quadrant of the cheek, which is typically
targeted by excision of the gland.
■ The buccal fat pad is above the mandible and posterior to the nasolabial fold,
an area distinct from the jowl.
■ In contrast to a normally situated buccal fat pad, pseudoherniated fat can be
reduced with gentle pressure.
IMAGING
■ When attempting to palpate the buccal fat pad, a firm, pulsatile, or subtly

pigmented palpable mass warrants further workup with an MRI.
SURGICAL MANAGEMENT
Preoperative Planning
■ Patients undergoing buccal fat pad excision can have it as an isolated
procedure or more commonly undergo other facial surgical procedures
simultaneously.
■ Indications for excision include patients with a full, round face.
■ Excision is typically performed intraorally before other procedures (ie,
facelift) under nonsterile conditions, to decrease the incidence of infection and
risk of facial nerve injury.5
Positioning
■ The patient is placed in a supine position and the head positioned to gain
maximum exposure.
Approach
■ To avoid an external incision on the face or injury to the facial nerve, the
buccal fat pad is accessed through a minimal intraoral incision.
T E C H N I Q U E S
■ Buccal Fat Pad Excision
■ A total of 2 to 3 cc of 1% lidocaine with 1:100 000 epinephrine is injected
into the buccal mucosa across from the first and second maxillary molars
(TECH FIG 1A).
■ The cheek is retracted with a Caldwell-Luc retractor.
■ A 2.5-cm incision is made between the upper first and second maxillary
molar (TECH FIG 1B).
■ A cuff of mucosa below the gingivobuccal sulcus is maintained for adequate
wound closure (TECH FIG 1C).
■ Care is taken to visualize the papilla to avoid injury. The papilla with the
cheeks are retracted laterally.
■ External pressure is applied to guide the fat pad into the wound.

■ The buccopharyngeal membrane is pierced with a scalpel and then entered
with scissors.
■ The fat pad is grasped with Adson-Brown forceps and gently teased with a
hemostat (TECH FIG 1D).
■ The exposed portion of the fat pad is clamped with traction and the excess
excised. Only fat that protrudes easily is excised; overresection can cause
unattractive cheek hollowing. Extreme caution to avoid hollowing should be
exercised in patients with pseudoherniation.
■ Avoid excess traction that can distort the anatomy.
■ Care is taken to avoid accidental cautery injury to the lips by retracting with
a finger and electrocoagulating the stump.
■ The incision is packed with gauze soaked with lidocaine and epinephrine
while the same procedure is performed on the contralateral side.
■ Resections are performed on each side to maintain symmetry (TECH FIG
1E).
■ Electrocautery is used for hemostasis (TECH FIG 1F).
■ The incisions are closed with one interrupted 5-0 chromic suture.

TECH FIG 1 • A. Injection of local anesthesia. B.
Exposure and incision. C. Access for buccal fat pad
excision. D. Buccal fat pad retrieved from incision. E.
The specimens from each side are compared for
symmetry. F. Meticulous hemostasis is obtained.
PEARLS AND PITFALLS
Aesthetic
considerations
■ The buccal fat pad can contribute to a “rounded” facial
appearance, obliterating submalar concavity in certain patients.
■ In contrast to normally situated buccal fat pad, pseudoherniated
fat can be reduced with gentle pressure.
Operative
■ Excision is typically performed before other procedures (ie,

sequence
facelift) under nonsterile conditions, to decrease the incidence of
infection and risk of facial nerve injury.
Technical
considerations
■ Take care to avoid injury to the papilla; always keep this
landmark visualized.
■ Avoid over-resection because this will hollow the cheek area.
■ Excess traction while grasping the fat pad can distort local
anatomy. Avoid excess manipulation.
Untoward
sequelae
■ A small hematoma in the recess can result in an indurated cheek
mass that gradually resolves over time.
■ Prolonged cheek firmness and fullness can be caused by
excessive intraoperative manipulation, exploration, or hemostasis
(not a fluid collection or infection); this can be managed by
external massage and/or ultrasound treatments.
FIG 2 • (A,B) Preoperative and (C,D) postoperative
views of a patient who underwent buccal fat pat
excision.
POSTOPERATIVE CARE
■ The chromic sutures will dissolve.
■ Patients are encouraged to maintain adequate oral hygiene while incisions are
healing by rinsing with dilute hydrogen peroxide.
■ Excessive opening and closing of the mouth (“exercising”) is encouraged.
OUTCOMES
■ Buccal fat pad excision is a safe and effective technique that can restore
proportion to the midface (FIG 2).
■ It can complement other surgical procedures such as facelifting to restore a
more youthful aesthetic contour to the entire face.
■ Even as an isolated procedure, it can produce a more angular and sculpted

facial appearance.
COMPLICATIONS
■ Over-resection
■ Inadequate treatment
■ Injury to the papilla
■ Facial nerve injury
■ Wound dehiscence
REFERENCES
1. Matarasso A. Buccal fat pad excision: aesthetic improvement of the midface.
Ann Plast Surg. 1991;26(5):413-418.
2. Bansal V, Bansal A, Mowar A, Gupta S. Ultrasonography for the volumetric
analysis of the buccal fat pad as an interposition material for the management
of ankylosis of the temporomandibular joint in adolescent patients. Br J Oral
Maxillofac Surg. 2015;53(9):820-825.
3. Matarasso A. Pseudoherniation of the buccal fat pad: a new clinical syndrome.
Plast Reconstr Surg. 2003;112(6):1716-1718.
4. Matarasso A. Pseudoherniation of the buccal fat pad: a new clinical syndrome.
Plast Reconstr Surg. 1997;100(3):723-730.
5. Matarasso A. Managing the buccal fat pad. Aesthet Surg J. 2006;26(3):330-
336.

51
CHAPTER
Nonsurgical Neck
Contouring using
Deoxycholic Acid or
Microfocused Ultrasound
Lawrence S. Bass
DEFINITION
■ Submental fullness is the result of excess fat contributing to a convex surface
contour.
■ Skin laxity manifests as visible redundancy of skin.
■ Deoxycholic acid (DOCA) is a bile salt that destabilizes cell membranes and
emulsifies fat. A synthetically prepared DOCA is Food and Drug
Administration (FDA) approved for the reduction of submental fat and
fullness.1
■ Microfocused ultrasound (MFUS) is a technology that uses ultrasound to
image the target tissues (diagnostic ultrasound) mated with therapeutic
ultrasound that produces zones of coagulation. These zones are fractionated
spots of coagulation at a predetermined depth under the skin. Sound energy is
delivered in a beam that transits the skin at a low energy density converging at
a predetermined depth under the skin by creating a high energy density zone of
defined shape and size. A line of 25 fractional zones of coagulation is produced
each time the device is fired.
■ Ultrasound transducers of different frequencies are selected for the desired
depth of treatment. Total energy in each spot in the line can be varied on the
device.
ANATOMY
■ The submental area is bounded by the inferior border of the mandible

(mentum) anteriorly, the hyoid bone posteriorly, and the inferior border or the
mandibular bodies laterally.
■ Fat in this area can be subcutaneous or subplatysmal.
■ Aging changes in the neck include visible skin laxity or redundancy,
prominence of visible platysmal bands, and skin surface changes.
■ Laxity may manifest as a visible jowl, loss of jawline definition, and hanging
festoons of skin in the neck independent of any platysmal banding.
■ Transverse rhytides; crepey, rough skin texture; and solar elastosis are surface
aging changes that can be treated with MFUS.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Due to the focused nature of the results obtained with DOCA and MFUS, a
detailed history of aesthetic issues and goals is essential to ensure that the
correct therapies are selected.
■ Previous aesthetic therapies and surgeries should be carefully documented.
Although these treatments are frequently performed in individuals who have
previously undergone some form of treatment, safety and outcomes after
extensive or multiply recurrent treatments have not been formally studied or
reported at this time.
■ Examination should catalogue the location and magnitude of changes in each
clinically pertinent tissue layer.
■ The degree and location of skin laxity in the jowl, jawline, and submental area
are determined along with laxity changes inferior to the thyroid cartilage,
which must be addressed separately.
■ Presence of visible excesses in subcutaneous fat in the jowl and submental and
lateral neck areas should be recorded.
■ Platysmal diastasis is an important finding both for procedure selection and
patient counseling. The distance of separation and vertical extent of separation
should be noted.
■ Although it is not routinely possible to determine the amount of excess fat
present in the subplatysmal plane on physical examination, this may limit the
amount of improvement obtained with DOCA injection that addresses the
subcutaneous plane only.
IMAGING
■ Radiologic and diagnostic studies are not customarily used.

DIFFERENTIAL DIAGNOSIS
■ Skin laxity
■ Excess subcutaneous fat
■ Excess subplatysmal fat
■ Platysmal diastasis
■ Dermal rhytids
SURGICAL MANAGEMENT
■ Excess fat in the neck, in the absence of skin redundancy, has traditionally
been treated with suction-assisted lipectomy. Increasingly, energy-based
devices have been mated with the liposuction procedure to amplify skin
tightening or lifting in patients with mild laxity resulting from aging changes.
■ For more advanced aging changes with skin laxity in the jowl and neck area,
surgical lifting procedures such as facialplasty, neck lift, and submentalplasty
are the standard for providing the most complete correction, albeit with greater
incisions, recovery time, and cost.
■ More recently, minimally invasive treatments utilizing sutures that suspend
facial and neck tissues and stimulate neocollagenesis are occasionally utilized.
NONSURGICAL MANAGEMENT
■ DOCA injection is indicated for the treatment of subcutaneous fat in the
submental area. Treatment of fat in the neck inferior to the mandible and
anterior to the sternocleidomastoid muscle is also commonly performed.
■ Two to six treatments are required depending on the degree of excess fat. Each
treatment has up to 50 injections of a fixed dose of medicine placed at a fixed
distance apart.
■ The amount of fat present determines the number of treatments required.
Retreatment is performed at interval of at least 1 month between treatments.
■ Although larger necks can be treated, the ideal patient has modest to moderate
amounts of fat and is typically treated in two to three sessions of 20 injections
each.
■ Treatment of jowl fat is specifically contraindicated due to concerns of injury
to the marginal mandibular branch of the facial nerve. Theoretically, this may
not be rational on an anatomic basis given the typical submandibular location
of the nerve as it courses past the jowl area and due to the subplatysmal
location of the nerve. But as of this writing, there is no published clinical

experience demonstrating the safety or lack thereof for treatment of the jowl.
■ MFUS has a specific FDA indication for the noninvasive lifting of skin in the
jowl and neck region. Surface features such as transverse neck rhytides and
laxity below the level of the thyroid cartilage can also be addressed.
■ The ideal patient has good skin quality with only modest skin excess and is not
substantially overweight.
■ A single treatment is performed to produce neocollagenesis and skin lifting
over a 3- to 6-month period, although repeat treatments may be performed for
more improvement if the patient is a responder.
■ The combination of DOCA injection and MFUS may provide a noninvasive
means to correct many of the changes seen in the aging neck if they are mild to
moderate in severity. There is currently no published literature reporting results
using this combined approach.
Preoperative Planning
■ The size of the treatment area for DOCA injection must be determined so the
amount of medicine needed can be calculated and the patient advised of
treatment cost. The patient also should be advised of the likely number of
treatments to provide a complete or near-complete correction.
■ Patient counseling about expected recovery after DOCA injections is essential
to avoid unexpected disruption of work and social activities.
■ MFUS treatment planning involves assessment of the area requiring treatment
at each depth and the amount of treatment at each depth (number of lines to be
placed). Although there is a theoretical standard 3-mm advancement of the
transducer between lines, in practice, most providers will put a greater or fewer
number of lines in a given area depending on the severity of the features being
treated.
Positioning
■ Patients are typically treated on a conventional examination table or chair in an
examination room in the supine or partially reclining or upright position
depending on provider preference. Treatment of the submental area in the
upright position can be difficult with MFUS due to runoff of the fluid within
the transducer when it is upside down.
Approach
■ DOCA is injected in the midlevel of the subcutaneous fat with a 30-gauge

needle.
■ MFUS is delivered transcutaneously using ultrasound gel to couple the energy
efficiently into the skin.
T E C H N I Q U E S
■ Deoxycholic Acid Injection
■ Marking starts with an outline of the inferior border of the mandible. A
boundary marking is placed one centimeter below the inferior border of the
mandible to keep the treatment away from the marginal mandibular branch of
the facial nerve. The anterior border of the sternocleidomastoid muscle may
be marked. Next, the thyroid cartilage is palpated and marked followed by
the location of the hyoid bone. The submental crease is outlined. These are
all simple anatomic landmarks (TECH FIG 1).
■ The fat is again palpated and lateral markings are made to delimit the
intended treatment zone.
■ The anterosuperior border of the treatment zone will be the submental
crease. The posteroinferior border will be the hyoid bone. Assessment and
selection of the lateral border markings is an important judgment for the
clinician, ensuring a complete treatment in an efficient fashion.
■ Local anesthesia is injected into the subcutaneous fat of the treatment area to
minimize patient discomfort during and immediately after the treatment.
Typically, 5 mL of 1% lidocaine with epinephrine or less is required.
■ A temporary marking grid is applied to guide appropriate spacing of
injections. After removing the protective plastic backing, the sheet is held
against the skin and moistened. Following 15 seconds of continuous gentle
pressure, the application sheet is removed leaving the treatment grid
markings on the skin. Use of the grid is essential to ensure appropriate dosing
and density that would be difficult to produce freehand.
■ Unwanted injection dots are removed with isopropyl alcohol for clarity
during treatment. The remaining dots can be counted and the necessary
amount of medication drawn up.
■ Each 1-mL syringe holds 5 injections. Using a 30-gauge needle, 0.2 mL is
injected at each point just adjacent to the grid dot to avoid tattooing the skin.

The medication is placed in the center of the subcutaneous fat, not
intradermal or subplatysmal. Pinching up the skin at each injection site prior
to insertion of the needle facilitates accurate placement of the medication.
■ Once all treatment dots have been injected, the grid is removed with
isopropyl alcohol and a cool compress applied.
TECH FIG 1 • A diagrammatic illustration of typical
pretreatment markings for DOCA injection.
■ Microfocused Ultrasound
■ Columns of treatment are designed to cover the treatment area. These
columns can be marked for clarity during the treatment.
■ Ultrasound gel is placed on the selected treatment transducer. The deepest
focal point transducer is used first, followed by successively more superficial
transducers.
■ The transducer is placed at one end of a treatment column and the ultrasound

image reviewed. The image must confirm adequate contact. The firing line
indicates where energy will be delivered that must be aligned with
appropriate target tissues such as SMAS, platysma, or deep dermis (TECH
FIG 2).
■ Once appropriate positioning and contact is confirmed, the transducer is
fired, delivering the therapeutic ultrasound and placing a line of microthermal
zones (MTZ) at the selected depth.
■ The transducer is then advanced 3 mm or the desired distance to place the
next line. This process is continued until the column of treatment is
completed followed by treatment of any adjacent columns.
■ After exposure of the full treatment area with the first transducer, the process
is completed again with the next (more superficial) transducer. Treatments
are typically bilayer and occasionally trilayer. Skin is lifted using exposures
at the SMAS/platysma level with 4.5-mm focal point depth transducers and at
the dermal subcutaneous junction using 3-mm focal point depth transducers.
More superficial features, like transverse neck lines, can be treated using the
1.5-mm transducers.

TECH FIG 2 • Application of sound energy in a clinical
MFUS treatment.
PEARLS AND PITFALLS
Injection technique
■ The needle should be placed into the middle of the
subcutaneous fat. This minimizes the risk of exposure of
skin or deep anatomy to effects of the medication.
Pinching up the skin in the fingers of the noninjection
hand facilitates precision in needle placement at the
appropriate depth.

Lateral jawline
■ Injection to fat in the lateral portion of the neck must
avoid exposure of the marginal mandibular branch of the
facial nerve. A buffer zone of 1 cm from the inferior
border of the mandible is commonly used.
■ Patients who have undergone previous surgery such as
facialplasty deserve extra caution due to the greater
potential variation in nerve position.
Jowl
■ Although direct injection of the jowl fat is tempting,
product labeling forbids injection due to concern over the
marginal mandibular branch. Of course, the injection is
supposed to be superficial to the platysma, and it is
unclear how often the nerve even transits the jowl area en
route to its muscular insertions. As of this writing, it is
unknown whether this is a real or merely theoretical
concern.
Injection spacing
■ DOCA should be injected using the manufacturer
supplied marking grid to insure proper spacing of doses.
Closer spacing can result in tissue necrosis, and wider
spacing can result in loss of efficacy.2
Medication dilution
■ DOCA should be injected as supplied (10 mg/mL)
without adulteration or dilution. 0.2 mL (2 mg) should be
injected at each injection site. An attempt to “stretch” the
medication by diluting or underdosing will result in loss
of efficacy.
MFUS skin prep
■ To facilitate gliding the handpiece, avoid heavy makeup.
Men should be close shaved.
Pattern planning
■ Modify standardized templates to adjust for size of the
patient’s face. Select number of lines based on severity of
findings.
Transducer selection
■ Transducers are selected for the anatomic structures
requiring correction. Usually, this is a bilayer treatment
with 3-mm and 4.5-mm depth transducers to target the
dermal/subcutaneous junction and the SMAS and
platysma, respectively.
Number of treatment
lines
■ To create observable lifting, treatments usually deliver
400 to 700 lines to the cheek and neck areas. 200 to 300
line treatments are sometimes employed for maintenance
or follow-up treatments.
Maintaining/restoring
gel contact
■ Moderate pressure avoids excess thinning of the gel layer
between the transducer and skin. Reapplication of gel to

the transducer is usually more expedient than
manipulation of the transducer against the skin in an effort
to restore contact.
Convexities
■ Convex areas such as just medial to the
sternocleidomastoid muscle are particularly prone to loss
of transducer contact with the skin resulting in blistering
and potential scarring.
Periocular area
■ Treatment should not be delivered within the orbital rim
to avoid unintended exposure and damage to the globe.
POSTOPERATIVE CARE
■ Both treatments benefit from cool compresses and nonsteroidal anti-
inflammatory drugs (NSAIDs) to help minimize discomfort on the day of
treatment.
■ In an attempt to minimize the pronounced edema after DOCA injection,
antihistamines, NSAIDs, and compression garments have been used, but
formal study of this did not demonstrate any benefit.3
OUTCOMES
■ Improvement in submental contour can be seen with a typical 20-injection
DOCA treatment (FIG 1). In patients with a larger collection of submental fat,
a greater number of treatments with more injections covering a larger area can
be used. This provides a greater degree of improvement with durable results
(FIG 2). Although skin laxity is generally no worse after treatment, occasional
significant reduction in laxity is seen. This has not been formally studied
making the degree and consistency of improvement unknown at this time (FIG
3).
■ Fifty-five percent of subjects in one study reported a one-grade improvement
in submental contour after two DOCA treatments and 75% after four
treatments.4 Marginal mandibular paresis was reported in 4.3%, which can take
several months to resolve.

FIG 1 • A 52-year-old woman who underwent a single
DOCA treatment of 20 injections. A. Pretreatment. B. 2
months post treatment.

FIG 2 • A 54-year-old woman who underwent 6 DOCA
treatments at monthly intervals with a total of 254
injections. A,B. Lateral and anteroposterior views
pretreatment. C,D. Lateral and anteroposterior views 6
months post last treatment. E,F. Lateral and
anteroposterior views 32 months post last treatment.
■ MFUS typically reduces laxity in the neck area and sharpens the contour of the
jowl/jawline area (FIG 4). In patients who are responders, additional
treatments can be used to obtain additional improvement or to maintain the
result (FIG 5).
■ A prospective study of 93 patients treated with MFUS using the original
treatment protocols (approximately 250 to 300 lines) using objective and
subjective measures of response showed laxity improvement in 63.6% and
58.1% of patients at 90 days. More than half of the patients with a BMI greater
than 30 did not respond.5

FIG 3 • A 64-year-old woman who underwent 6 DOCA
treatments at monthly intervals with a total of 139
injections. A. Lateral view pretreatment. B. Lateral view
6 months post last treatment. C. Lateral view 32 months
post last treatment.
■ In another study, 67% of subjects showed improvement at 180 days post
MFUS treatment. This nonresponder rate seems consistent across the available
studies to date.6
COMPLICATIONS
DOCA
■ Ecchymosis
■ Edema
■ Pain
■ Numbness

■ Erythema
FIG 4 • A 41-year-old woman. A. Pretreatment. B.
Thirteen months post a single MFUS treatment.

FIG 5 • A 53-year-old woman. A. Pretreatment age 53.
B. Thirty months after first and 16 months after second
MFUS treatment, now age 55.
■ Induration
■ Paresthesia
■ Nodule
■ Pruritus
■ Dysphagia
■ Facial nerve injury
■ Skin loss
■ Scarring
■ Induration
■ Nodule formation
■ Facial nerve injury

MFUS
■ Erythema
■ Ecchymosis
■ White or red wheals
■ Blistering
■ Scarring
■ Numbness
■ Facial nerve injury
REFERENCES
1. Rotunda AM. Injectable treatments for adipose tissue: terminology,
mechanism, and tissue interaction. Lasers Surg Med. 2009;41:714-720.
2. Dayan SH, Humphrey S, Jones DH, et al. Overview of ATX0191
(deoxycholic acid injection): a nonsurgical approach for reduction of
submental fat. Dermatol Surg. 2016;42:S263-S270.
3. Dover JS, Kenkel JM, Carruthers A, et al. Management of patient experience
with ATX-101 (deoxycholic acid injection) for reduction of submental fat.
Dermatol Surg. 2016;42:S288-S299.
4. Jones DH, Carruthers J, Joseph JH, et al. Refine-1, a multicenter, randomized,
double-blind, placebo-controlled, phase 3 trial with ATX-101, an injectable
drug for submental fat reduction. Dermatol Surg. 2016;42:38-49.
5. Oni G, Hoxworth R, Teotia S, et al. Evaluation of a microfocused ultrasound
system for improving skin laxity and tightening in the lower face. Aesthet Surg
J. 2014;34:1099-1110.
6. Fabi SG, Goldman MP. Retrospective evaluation of micro-focused ultrasound
for lifting and tightening the face and neck. Dermatol Surg. 2014;40:569-575.

52
CHAPTER
Section XI: Rhinoplasty
Indications and Technique
for Closed Rhinoplasty in
Patients With Dorsal Hump
and Wide Tip
Barış Çakır and Ali Teoman Tellioğlu
DEFINITION
■ The reason for a wide nasal tip is that the dome and lateral crura are wider than
normal.
■ The distance between the nostrils and the lateral crura is generally narrow.
■ An excessively enlarged dorsal cartilage and nasal bone result in a nose with a
prominent bridge that is aesthetically unacceptable.
ANATOMY
■ The nose consists of mobile and immobile areas.
■ The mobile part of the tip consists of the lower lateral cartilages.
■ The immobile part of the nose consists of the septum, the upper lateral
cartilages, the maxilla, and the nasal bones (FIG 1).
■ The mobile nose tip is connected to the septum and the upper lateral cartilages
by means of the Pitanguy and scroll ligaments. The nose tip moves up and
down along these ligaments.
■ The scroll and Pitanguy ligaments are formed by a thickening of the
superficial musculoaponeurotic system (SMAS) at the supratip; they are
functionally significant because they constitute a part of the SMAS.
■ Protection and repair of these ligaments are crucial for the projection, mobility

and definition of the nose.
FIG 1 • The nose consists of mobile and immobile
areas. The mobile part of the tip consists of the lower
lateral cartilage. The immobile part of the nose consists
of the septum, the upper lateral cartilages, the maxilla,
and the nasal bones.
PATHOGENESIS
■ The cartilages and bones that form the skeleton of the nose stand in close
relation to each other.
■ Many patients present with a history of trauma to the nose. Generally, one can
observe a large and deviated vomer.
■ Our theory is that a greatly enlarged septum pushes the upper lateral cartilages
anteriorly and the medial crura caudally.
■ The upper lateral cartilages pull the cephalic edge of the lateral crus anteriorly
and therefore distort the resting angle of the lateral crura.
■ A septal cartilage that projects anterocaudally results in the domes being
formed more caudal than normal.

■ The lobule is formed short, while the lateral crura are long. The nasal tip
widens because the lateral crura become more dominant in the tip area.
■ The convex nature of the lateral crura and the distorted reclining angle of the
lateral crura result in the tip appearing wide and round (FIG 2).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Noses that are not in harmony with the face and have flawed internal
proportions may disturb patients from an aesthetic viewpoint.
■ Patients generally complain that their nasal tip is big and that they find the
bridge disturbing.
■ Inspection: A visual examination is most important; problems are clearly
diagnosed with the help of photographs.
■ The nasal tip is wide.
■ The lobule is generally short.
■ The lateral crura are generally convex, long and wide.
■ The cephalic edge of the lateral crus is more anteriorly located than the
caudal edge.
■ The dorsal septum and the nasal bones are hypertrophic.
■ Because the septum pushes the tip forward, the more than normally
projecting nasal tip is likely to be pulled downward when the patient laughs.
■ Palpation
■ Skin thickness directly influences the results. Strong cartilages and thin skin
respond better to rhinoplasty surgery. By touching the nasal skin and
examining the inside of the nasal tip with the help of a light source, we can
gain valuable information about the soft tissue and cartilages.
IMAGING
■ Front, base, top, lateral, and oblique photographs are standard procedure. A
lateral photograph of the patient smiling gives clues about the dynamics of the
nasal tip.

FIG 2 • A–H. The lobule is formed short, the lateral
crura long. Because the lateral crura become more
dominant in the tip area, the nasal tip widens. The
lateral crura’s convex nature and the distorted reclining
angle of the lateral crura result in the tip appearing wide
and round.
■ An SLR camera of medium quality is sufficient. One can obtain a detailed and
standard photographic archive with a 100- or 105-mm fixed macro lens.
■ On close-up photographs, the nasal tip appears wider. In order to objectively
depict the changes in the nasal tip, the camera’s focal length has to remain the
same.
■ A black or blue background is preferable. A black background prevents a black
shadow and looks better but may render the hair invisible. Blue is a color more
appropriate for scientific purposes.
■ Lighting changes the photographic results. The double softbox system is
standard. To obtain standardized photographs, patient, the doctor and the
lighting need to remain in the same location. It is advisable to draw a circle on
the floor about 1 to 2 m in front of the background curtain.

■ Lighting: To understand the lighting technique, one has to look at the eyes
first. If the light reflection is not the same between the preoperative and
postoperative photographs, it is difficult to make a comparison.
■ Fish-eye effect: If the before photograph is taken with a fish-eye effect, the
ears will not be visible. It is not possible to draw a meaningful comparison
between two photographs with unequal focal distances.
SURGICAL MANAGEMENT
■ Rhinoplasty surgery began in the form of closed reduction; however, a more
controlled resection and reconstruction with an open rhinoplasty technique
have become more popular.
■ Closed surgery based on an intracartilaginous approach, where the surgeons
could not see the tip cartilages, has quickly lost popularity. Because control is
difficult to achieve, more inexperienced surgeons do not prefer this technique
because it is difficult to achieve control.
■ Because it is easy to learn and perform open rhinoplasty, this technique has
gained great popularity in recent years.
■ Although open rhinoplasty allows for more control, side effects such as
rigidity and numbness are quite bothersome.
■ In an effort to combine the control of open rhinoplasty techniques with the fast
healing of the closed rhinoplasty, “open rhinoplasty with endonasal approach”
has become an alternative approach. We named this philosophy as the
“preservation rhinoplasty.”
Preoperative Planning
■ It is important to do the imaging work on a lateral photograph before the
surgery.
■ By doing the imaging work together with the patient, we can learn about the
patient’s expectations.
Approach
■ Make a transfixion incision on one side (if the surgeon is left handed, on the
left side; if right handed, on the right).
■ Enter under the dorsal perichondrium from the septal angle and dissect as far
as under the dorsal bone. In this area, the Daniel-Cakir blunt perichondrium
elevator is particularly useful.
■ Enter under the upper lateral perichondrium and dissect caudally as far as the

scroll area (FIG 3).
■ If there exists a caudal excess of the lateral crus, make an intracartilaginous
incision in such a way that 2 to 3 mm of the caudal edge of the lateral crus is
left in the skin. The cartilage left in the skin is called an auto-rim flap.1
FIG 3 • Enter under the upper lateral perichondrium and
dissect caudally as far as the scroll area.
FIG 4 • A–C. Beginning from the turning point of the
lateral crus, dissect the lower lateral cartilage by means
of a subperichondrial dissection.
■ Make an infracartilaginous incision to the dome and medial crus.
■ Beginning from the turning point of the lateral crus, dissect the lower lateral
cartilage by means of a subperichondrial dissection (FIG 4).
■ Pulling the domes laterally with a hook, dissect the domes. Dissect the medial
crura subperichondrially to the level of the footplates. In this area, the Daniel-
Cakir sharp perichondrium elevator is particularly useful (FIG 5).
■ Join the two dissections in the scroll region and expose the caudal edge of the

bones.
■ Enter under the periosteum by scratching the caudal edge of the bones with an
elevator.
■ Dissect the nasal and maxillary bones subperiosteally. In this area, the Daniel-
Cakir periosteum elevator is particularly useful.
■ Carefully join the subperiosteal dissection planes in the midline.
■ Beginning from the upper lateral caudal edge, dissect the internal valve
mucosa subperichondrially.
FIG 5 • A,B. Pull the domes laterally with a hook and
dissect the domes. Dissect the medial crura
subperichondrially until the footplate. In this area, the
Daniel-Cakir sharp perichondrium elevator is
particularly useful.
T E C H N I Q U E S
■ Dorsal Resection
■ Resect the cartilage hump as a composite (TECH FIG 1A,B).
■ Resect the exposed right and left nasal bone with bone scissors (TECH FIG
1C,D).
■ If the radix is high, rasp the radix. Reduce the radix in a controlled way
without causing the glabella to swell.
■ File down any asymmetries of the bony surface to create a symmetrical

appearance. A bone file, mastoid bur or rasp can be used for this purpose.
■ Medialize the bone flaps with the help of lateral osteotomy, or lateral
osteoectomy and median oblique and transverse osteotomies (TECH FIG
1E,F). Performing this procedure after tip surgery reduces swelling.
Tip Surgery
■ Extract the domes from each nostril by dissecting the superficial
musculoaponeurotic system (SMAS) from the deep SMAS.
■ Determine the correct length of the lateral crus by stealing from the lateral
crus.
■ Shape the new domes with a cephalic dome suture1 (TECH FIG 2A,B).
■ Extract both domes through the nostril closer to you and let the assistant
hold the dome farther away from you at the midline with the help of a hook.
■ Join the domes by suturing the soft tissue between the domes. This suture
will assist with equalizing the domes (TECH FIG 2C,D).
■ Equalize the domes with a figure-of-8 suture.
■ Place the strut graft between the medial and middle crura with sutures.
Stabilize the tip of the strut cartilage graft with a U suture passing through the
domes, stabilize the tip of the strut cartilage graft.
■ Reconstruct the columellar break point, the lobule and the columella with a
6-0 PDS suture (TECH FIG 2E).
■ Place the lower lateral cartilages in such a way that the superficial SMAS fits
into the gap between the medial and middle crura.
Dorsal Reconstruction
■ Shape the cartilage that has been resected as a composite and place it as a
spreader graft (TECH FIG 3A–D).
■ Repair the scroll ligaments (TECH FIG 3E,F).
■ Close the mucosa with a 6-0 Monocryl.
For more detail, see the handbook on Aesthetic Septorhinoplasty.

TECH FIG 1 • A,B. Resect the cartilage hump as a
composite. C,D. Resect the exposed right and left
nasal bone with bone scissors. E,F. Medialize the
bone flaps with the help of lateral osteotomy, or lateral
osteoectomy and median oblique and transverse
osteotomies.
TECH FIG 2 • A,B. Shape the new domes with a
cephalic dome suture. C,D. Join the domes by

suturing the soft tissue between the domes. This
suture will assist with equalizing the domes. E.
Reconstruct the columellar break point, the lobule and
the columella with a 6-0 PDS.
TECH FIG 3 • A–D. Shape the cartilage that has been
resected as a composite and place it as a spreader
graft. E,F. Repair the scroll ligaments.
PEARLS AND PITFALLS
Osteotomy
contraindications
■ When performing a wide dissection to the dorsum, an
osteotomy with a lateral osteotome is contraindicated. The
bones may collapse. If you perform an osteotomy, do so by
entering from the cut on the skin or the rim incision with a 2-
mm chisel.
Dissection
■ Subperichondrial dissection decreases the risk of damage and
progressive thinning of the soft tissue, and it helps to protect
the scroll ligament. It is easy to enter the subperichondrial
plane where the cartilage is thick. A good dissection is the best
camouflage.

Pitanguy midline
ligament
■ A closed approach does not interfere with the Pitanguy
ligament next to the columellar system. This is very beneficial
to control the supratip skin.
Bruising,
swelling
■ Insert an intravenous tube splinted with a scalpel next to the
nasal bone to decrease swelling.
Imaging
■ We can plan rotation, projection, and resection with the help
of the imaging work. Increasing the tip rotation and projection
as well as filling the deep radix reduces the amount of dorsal
resection. Imaging prevents us from over-resection.
Head lamp
■ For closed surgery, a headlight is absolutely necessary. In
order to be able to see the deepest areas of the dissection,
surgeons should align the lamp with their own radix.
POSTOPERATIVE CARE
■ Carefully tape the nose without squeezing the tip. If the tape pinches the nose
tip caudally, the positioning of the tip cartilages can be damaged.
■ Because thermoplastic plaster is water resistant, the patient may shower every
day.
■ Applying tape underneath the eyes decreases swelling and bruising.
■ The patient can be discharged after 3 to 4 hours.
■ In case of swelling, a cold compress can be applied. Cold compresses are not
routinely used after wide dissection and inserting drains.
■ The patient rests in bed with the head elevated.
■ Paracetamol with codeine is sufficient for pain management.
■ To treat bone edema, diclofenac potassium can be prescribed from day 5 to 10.
■ After the preoperative prophylaxis, there is no need for antibiotics after
preoperative prophylaxis.
■ Saltwater irrigation can be done for 10 days.
■ Internal silicone dolly splints can be removed after 2 to 4 days.
■ After 10 days, the cast is removed. Generally, no more tape is used.