The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

THE ART OF AESTHETIC SURGERY Principles & Techniques

The cover, frontispiece, and part opener artwork is adapted from “Nicole Series 03,” a unique sculpture
in welded steel, by artist William Salisbury. This image is used by permission of William Salisbury;


Foad Nahai, MD, FACS
EDITOR
Paces Plastic Surgery; Clinical Professor of Plastic Surgery,
Department of Surgery, Emory University,
Atlanta, Georgia
ILLUSTRATED BY
Brenda L. Bunch, MAMS
Amanda Yarberry Behr, MA, CMI
Quality Medical Publishing, Inc.
ST. LOUIS, MISSOURI
2011

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To
Shahnaz
My best friend and partner, whose beauty is only surpassed
by the loveliness that radiates from within. You are an inspiration
to us all, and your patience and understanding have made me
who I am. Thank you for enriching my life.

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Contributors
vii
William P. Adams, Jr., MD
Associate Clinical Professor of Plastic Surgery,
Department of Plastic Surgery, University of Texas
Southwestern Medical Center, Dallas, Texas
Neta Adler, MD
Attending Surgeon, Department of Plastic Surgery,
Hadassah Medical Center, Hebrew University School
of Medicine, Jerusalem, Israel
Jamil Ahmad, MD, FRCSC
Staff Plastic Surgeon, The Plastic Surgery Clinic,
Mississauga, Ontario, Canada
Gilbert C. Aiach, MD
Professor of Post-Graduate Education in Aesthetic
Surgery, International Society of Aesthetic Surgery;
Private Practice, Paris, France
Lisa Airan, MD
Assistant Clinical Professor, Department of
Dermatology, Mount Sinai Hospital, New York,
New York
Gary J. Alter, MD
Assistant Clinical Professor, Division of Plastic Surgery,
University of California–Los Angeles School of
Medicine, Los Angeles, California
Al S. Aly, MD, FACS
Clinical Professor of Plastic Surgery, The Aesthetic
& Plastic Surgery Institute, University of California–
Irvine, Orange, California; Iowa City Plastic Surgery,
Coralville, Iowa
Sérgio Fernando Dantas de Azevedo, MD
Resident Doctor, Dr. Ewaldo Bolivar de Souza Pinto
Plastic Surgery Department, São Paulo, Brazil
Daniel C. Baker, MD
Professor of Surgery, Institute of Reconstructive Plastic
Surgery, New York University Medical School,
New York, New York
James L. Baker, Jr., MD, FACS
Clinical Professor of Plastic Surgery, University of South
Florida; Chairman, Department of Plastic Surgery,
Florida Hospital System, Tampa, Florida
Guido Baroni, PhD
Assistant Professor, Department of Bioengineering,
Politecnico di Milano, Milan, Italy
Alfonso Barrera, MD, FACS
Clinical Assistant Professor, Department of Plastic
Surgery, Baylor College of Medicine, Houston, Texas
Fritz E. Barton, Jr., MD, FACS
Clinical Professor, Department of Plastic Surgery,
University of Texas Southwestern Medical Center,
Dallas, Texas
Bruce S. Bauer, MD, FACS, FAAP
Director, Pediatric Plastic and Reconstructive Surgery,
NorthShore University Health System, Highland Park,
Illinois; Clinical Professor of Surgery, University of
Chicago, Pritzker School of Medicine, Northbrook,
Illinois
Richard H. Bensimon, MD
Director of Plastic Surgery, Pearl Women’s Center,
Portland, Oregon
Andrew R. Berger
Vice President of Sales and Marketing, Quality Medical
Publishing, St. Louis, Missouri
Thomas M. Biggs, MD, FACS
Clinical Professor, Division of Plastic Surgery, Baylor
College of Medicine, Houston, Texas
Kristin A. Boehm, MD, FACS
Assistant Clinical Professor, Division of Plastic and
Reconstructive Surgery, Emory University; Paces Plastic
Surgery, Atlanta, Georgia

viii
Contributors
Inja Bogdan Allemann, MD
Department of Dermatology, Dermatologic Clinic,
University Hospital of Zurich, Zurich, Switzerland
Trevor M. Born, MD, FRCSC
Clinical Lecturer, Department of Plastic and
Reconstructive Surgery, Division of Surgery, University
of Toronto, Toronto, Ontario, Canada; Department
of Plastic Surgery, Lenox Hill Hospital, New York,
New York
Donald W. Buck II, MD
Resident Surgeon, Division of Plastic and Reconstructive
Surgery, Northwestern University, Chicago, Illinois
Joseph F. Capella, MD, FACS
Chief, Post-Bariatric Body Contouring, Division of
Plastic Surgery, Hackensack University Medical Center,
Hackensack, New Jersey
Carlos Casagrande, MD
Plastic Surgeon, Private Practice, Florianópolis, Santa
Catarina, Brazil
Kristoffer Ning Chang, MD
Associate Clinical Professor of Surgery, Department
of Surgery, University of California–San Francisco,
San Francisco, California
Stephen M. Chen, MD
Assistant Professor of Surgery, Division of Plastic
Surgery, Virginia Commonwealth University, Richmond,
Virginia
William P. Chen, MD, FACS
Clinical Professor of Ophthalmology, Department of
Ophthalmology, University of California–Los Angeles
School of Medicine, Los Angeles, California
Mark A. Codner, MD
Clinical Assistant Professor, Division of Plastic and
Reconstructive Surgery, Emory University, Atlanta,
Georgia
Sydney R. Coleman, MD
Assistant Clinical Professor, Department of Plastic
Surgery, New York University Medical Center, New York
University; TriBeCa Plastic Surgery, Centre for Aesthetic
Rejuvenation and Enhancement (Care Facility),
New York, New York
Gustavo A. Colon, MD, FACS
Section Head, Division of Plastic and Reconstruction,
Tulane Medical School, New Orleans, Louisiana
Albert E. Cram, MD, FACS
Professor Emeritus, Department of Surgery, University
of Iowa College of Medicine, Iowa City, Iowa
Anne Dancey, MBChB, MmedSci, FRCS (Plast)
Consultant, Department of Plastic and Reconstructive
Surgery, University Hospital Birmingham, Birmingham,
England
Emmanuel Delay, MD, PhD
Head, Department and Reconstructive Surgery, Centre
Léon Bérard; Private Practice, Clinique Charcot, Lyon,
France
Daniel A. Del Vecchio, MD, MBA
Consultant in Plastic Surgery, Department of Surgery,
Massachusetts General Hospital, Boston, Massachusetts
Barry E. DiBernardo, MD, FACS
Clinical Associate Professor, Department of Surgery,
Division of Plastic Surgery, University of Medicine and
Dentistry of New Jersey, Newark; Director, New Jersey
Plastic Surgery, Montclair, New Jersey
Jordan P. Farkas, MD
Department of Plastic Surgery, University of Texas
Southwestern Medical Center, Dallas, Texas
Joel J. Feldman, MD, FACS
Associate Clinical Professor of Surgery, Harvard Medical
School, Boston, Massachusetts
Julius W. Few, MD, FACS
Director, The Few Institute for Aesthetic Plastic Surgery;
Clinical Associate, Department of Plastic Surgery,
University of Chicago Pritzker School of Medicine,
Chicago, Illinois
Jack Fisher, MD
Associate Clinical Professor, Department of Plastic
Surgery, Vanderbilt University, Nashville, Tennessee
Vinícius Costa e Silva de Freitas, MD
Resident Doctor, Dr. Ewaldo Bolivar de Souza Pinto
Plastic Surgery Department, São Paulo, Brazil
Olivier F. Gerbault, MD
Private Practice, Paris; Director of Policlinique Esthétique
Marigny Vincennes, Vincennes, France
David J. Goldberg, MD
Clinical Professor of Dermatology; Director of Laser
Research, Department of Dermatology, Mount Sinai
School of Medicine, New York, New York

ix
Contributors
Mark Gorney, MD, FACS
Medical Director, The Doctor’s Company, Napa,
California
Gilbert P. Gradinger, MD, FACS
Clinical Professor of Surgery, Department of Surgery,
Division of Plastic Surgery, University of California–
San Francisco, San Francisco, California
Ruth Maria Graf, MD, PhD
Professor, Department of Plastic Surgery, Federal
University of Paraná, Curitiba, Paraná, Brazil
James C. Grotting, MD, FACS
Clinical Professor, Division of Plastic Surgery,
Department of Surgery, University of Alabama at
Birmingham; Private Practice, Grotting Plastic Surgery,
Birmingham, Alabama; Clinical Professor, Division of
Plastic Surgery, University of Wisconsin, Madison,
Wisconsin
Dax Guenther, MD
Instructor, Division of Plastic Surgery, Brigham and
Women’s Hospital, Boston, Massachusetts
Jack P. Gunter, MD
Clinical Professor, Department of Plastic Surgery,
Department of Otolaryngology/ Head and Neck Surgery,
University of Texas Southwestern Medical School,
Dallas, Texas
Richard Y. Ha, MD
Clinical Instructor, Department of Plastic Surgery,
University of Texas Southwestern Medical Center; Dallas
Plastic Surgery Institute, Dallas, Texas
Elizabeth J. Hall-Findlay, MD, FRCSC
Private Practice, Banff Plastic Surgery, Banff, Alberta,
Canada
Moustapha Hamdi, MD, PhD, FCCP
Professor, Department of Plastic Surgery, Gent University
Hospital, Gent, Belgium; Professor, Department of
Plastic Surgery, Medical Institute Edith Cavell, Brussels,
Belgium
Dennis C. Hammond, MD
Clinical Assistant Professor, Department of Surgery,
Michigan State University College of Human Medicine,
East Lansing, Michigan; Associate Program Director,
Department of Plastic and Reconstructive Surgery,
Grand Rapids Medical Education and Research Center
for Health Professions, Grand Rapids, Michigan
T. Roderick Hester, Jr., MD, FACS
Clinical Professor, Department of Plastic Surgery, Emory
University School of Medicine; Paces Plastic Surgery,
Atlanta, Georgia
William Y. Hoffman, MD, FACS
Professor and Chief, Division of Plastic and
Reconstructive Surgery, University of California–
San Francisco, San Francisco, California
Jeffrey E. Janis, MD, FACS
Associate Professor and Program Director, Department
of Plastic Surgery, University of Texas Southwestern
Medical Center; Chief of Plastic Surgery, Parkland
Health and Hospital System, Dallas, Texas
Glyn Jones, MD, FACS
Professor of Surgery, Department of Surgery, University
of Illinois College of Medicine, Peoria, Illinois
†Martin H. Kelly, MD, FRCS
Consultant Plastic Surgeon, London Plastic Surgery
Associates, London, England
Jeffrey M. Kenkel, MD, FACS
Professor and Vice Chairman; Director, The Clinical
Center for Cosmetic Laser Treatment, Department of
Plastic Surgery, The University of Texas Southwestern
at Dallas, Dallas, Texas
Roger K. Khouri, MD, FACS
Chief Officer, Miami Breast Center, Key Biscayne,
Florida
Marie Czenko Kuechel, MA
Consultant, Founder, Czenko Kuechel Consulting,
Inverness, Illinois
Fábio Massaru Kuroyanagi, MD
Resident Doctor, Dr. Ewaldo Bolivar de Souza Pinto
Plastic Surgery Department, São Paulo, Brazil
Angela S. Landfair, MD, MPH
Resident, Department of Plastic Surgery, University of
Pittsburgh, Pittsburgh, Pennsylvania
Wendy Lewis
President, Wendy Lewis & Co. Ltd., New York,
New York
†Deceased.

x
Contributors
Michelle B. Locke, MBChB, FRACS
Honorary Lecturer, Department of Surgery, University
of Auckland, Auckland, New Zealand
William D. Losquadro, MD
Fellow and Clinical Instructor, Division of Facial
Plastic and Reconstructive Surgery, Department of
Otolaryngology–Head and Neck Surgery, University of
Illinois at Chicago, Chicago, Illinois
Alessandra Marchi, MD
Head of Breast Reconstruction Center, Department of
Plastic Surgery, Burns Unit, Ospedale Civile Maggiore
Borgo Trento–Azienda Ospedaliera Universitaria
Integrata, Verona, Italy; Consultant for Breast
Reconstruction, Department of General Surgery,
Ospedale Maggiore San Maurizio, Bolzano, Italy
Timothy J. Marten, MD, FACS
Founder and Director, Marten Clinic of Plastic Surgery,
San Francisco, California
Alan Matarasso, MD, FACS
Clinical Professor, Department of Surgery, Division of
Plastic Surgery, Albert Einstein College of Medicine,
New York, New York
Clinton D. McCord, Jr., MD
Associate Clinical Professor, Department of Plastic
Surgery, Emory University; Paces Plastic Surgery, Atlanta,
Georgia
J. Nicolas McLean, MD
Plastic Surgery Fellow, Department of Plastic and
Reconstructive Surgery, Emory University, Atlanta,
Georgia
Juan Diego Mejia, MD
Private Practice, Medellin, Colombia; Former Fellow,
Paces Plastic Surgery, Atlanta, Georgia
Constantino G. Mendieta, MD, FACS
Private Practice, Coconut Grove, Florida
Gabriele Cáceres Miotto, MD
Board-Certified Plastic Surgeon in Brazil, Florianópolis,
Brazil
Luis Humberto Uribe Morelli, MD
Resident Doctor, Department of Plastic Surgery,
Dr. Ewaldo Bolivar de Souza Pinto Plastic Surgery
Department, Santa Cecilia University, Santos, São Paulo,
Brazil
Dimitrios Motakis, MD, PhD, FRCSC
Plastic Surgeon, The Toronto Institute of Aesthetic Plastic
Surgery, Toronto, Ontario, Canada
Michel Moutran, MD, MSc
Department of Plastic and Reconstructive Surgery,
Centre Léon Bérard, Lyon, France
Girish S. Munavalli, MD
Assistant Professor, Department of Dermatology, Johns
Hopkins University School of Medicine, Baltimore,
Maryland; Medical Director, Dermatology, Laser, and
Vein Specialists of the Carolinas, Charlotte, North
Carolina
Thomas A. Mustoe, MD, FACS
Orion and Lucille Stuteville Professor of Plastic Surgery,
Division of Plastic Surgery, Northwestern University
Feinberg School of Medicine, Chicago, Illinois
Farzad R. Nahai, MD
Paces Plastic Surgery; Assistant Clinical Professor,
Division of Plastic and Reconstructive Surgery, Emory
University School of Medicine, Atlanta, Georgia
Foad Nahai, MD, FACS
Paces Plastic Surgery; Clinical Professor of Plastic Surgery,
Department of Surgery, Emory University, Atlanta,
Georgia
Maria Cecília Closs Ono, MD, MSc
Plastic Surgeon, Curitiba, Paraná, Brazil
Paolo Patete, MS
Department of Bioengineering, Politecnico di Milano,
Milan, Italy
Joel E. Pessa, MD
Assistant Professor of Plastic Surgery, Department of
Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, Texas
Byron D. Poindexter, MD
The Austin-Weston Center for Cosmetic Surgery, Reston,
Virginia
Jason N. Pozner, MD, FACS
Adjunct Clinical Faculty, Division of Plastic Surgery,
Cleveland Clinic Florida, Weston, Florida; Sanctuary
Plastic Surgery, Boca Raton, Florida
Dirk F. Richter, MD, PhD
Clinical Professor, Director and Chairman, Department
of Plastic Surgery, Dreifaltigkeits Hospital, Wesseling,
Germany

xi
Contributors
Gino Rigotti, MD
Director, Department of Plastic Surgery, Burns Unit,
Breast Reconstruction Center, Ospedale Civile Maggiore
Borgo Trento–Azienda Ospedaliera Universitaria
Integrata, Verona, Italy
Rod J. Rohrich, MD, FACS
Professor and Chairman, Crystal Charity Ball
Distinguished Chair in Plastic Surgery, Warren and Betty
Woodward Chair in Plastic and Reconstructive Surgery,
Department of Plastic Surgery, University of Texas
Southwestern Medical Center, Dallas, Texas
Lorne K. Rosenfield, MD, FACS
Clinical Professor, Department of Plastic Surgery,
Department of Surgery, University of California–
San Francisco; Adjunct Clinical Instructor, Department
of Surgery, Plastic Surgery, Stanford University Medical
Center, Stanford, California
J. Peter Rubin, MD, FACS
Director, Life After Weight Loss Body Contouring
Program, Associate Professor of Surgery, Division of
Plastic Surgery, University of Pittsburgh, Pittsburgh,
Pennsylvania
Anderson Saciloto, MD
Plastic Surgery Resident, Department of Plastic Surgery,
Ponitificia Universidade Catolica, Curitiba, Paraná,
Brazil
Cristianna Bonetto Saldanha, MD
Resident Doctor, Department of General Surgery, Santa
Casa of Santos Hospital, São Paulo, Brazil
Osvaldo Ribeiro Saldanha, MD
Chairman, Department of Plastic Surgery, Santa Cecília
University, Santos, São Paulo, Brazil
Osvaldo Ribeiro Saldanha Filho, MD
Resident Doctor, Department of General Surgery, Santa
Casa of Santos Hospital, Santos, São Paulo, Brazil
Renato Saltz, MD, FACS
Medical Director, Saltz Plastic Surgery and Spa Vitória,
Salt Lake City and Park City; Former Associate Professor
of Plastic Surgery, Department of Surgery, University of
Utah, Salt Lake City, Utah
Andrea Sbarbati, MD, PhD
Professor in Human Anatomy, Department of
Morphological and Biomedical Sciences, Anatomy and
Histology Section, University of Verona, Verona, Italy
David Shafer, MD
Attending Surgeon, Department of Plastic Surgery,
Manhattan Eye, Ear and Throat Hospital, New York,
New York
Robert K. Sigal, MD
Medical Director, The Austin-Weston Center for
Cosmetic Surgery, Reston, Virginia
Sirunya Silapunt, MD
Assistant Professor, Department of Dermatology,
University of Texas Medical School at Houston,
Houston, Texas
Phillip J. Stephan, MD, FACS
Clinical Instructor, Department of Plastic Surgery,
University of Texas Southwestern Medical Center,
Dallas, Texas
Alexander Stoff, MD, PhD
Department of Plastic and Reconstructive Surgery,
Dreifaltigkeits Hospital, Wesseling, Germany
James M. Stuzin, MD
Associate Professor of Surgery (Plastic) (Voluntary),
Department of Plastic Surgery, University of Miami
Leonard M. Miller School of Medicine, Miami, Florida
Edward O. Terino, MD, FACS
Medical Director, The Plastic Surgery Institute of
Southern California, Thousand Oaks, Los Angeles,
California
André Ricardo Dall’Oglio Tolazzi, MD, MSc
Plastic Surgeon and Post-Graduate in Surgery (PhD),
Department of Plastic Surgery, Federal University of
Paraná, Curitiba, Paraná, Brazil
Patrick L. Tonnard, MD
Assistant Clinical Professor, Department of Plastic
Surgery, Gent University Hospital; Director, Coupure
Centrum Voor Plastiche Chirurgie, Esthetisch Medisch
Centrum (E:MC2), Gent, Belgium
Dean M. Toriumi, MD
Professor, Division of Facial Plastic and Reconstructive
Surgery, Department of Otolaryngology–Head and Neck
Surgery, University of Illinois at Chicago, Chicago,
Illinois
Jonathan Toy, MD
Body Contouring Fellow and Clinical Instructor,
Department of Plastic Surgery, University of Pittsburgh
Medical Center, Pittsburgh, Pennsylvania

Contributors
xii
Matthew J. Trovato, MD
Fellow, Department of Surgery, Division of Plastic and
Reconstructive Surgery, UMDNJ–New Jersey Medical
School, Newark, New Jersey
Carlos Oscar Uebel, MD, PhD
Associate Professor, Division of Plastic Surgery,
Pontificia Universidade Catolica do Rio Grande do Sul;
Full Member, the Brazilian Society of Plastic Surgery,
Porto Alegre, Brazil
Alexis M. Verpaele, MD
Assistant Clinical Professor, Department of Plastic
Surgery, Gent University Hospital; Director, Coupure
Centrum Voor Plastiche Chirurgie, Esthetisch Medisch
Centrum (E:MC2), Gent, Belgium
William J. Vinyard, MD
Vinyard Institute of Plastic Surgery, Guntersville,
Alabama
Simeon Wall, Jr., MD, FACS
Assistant Clinical Professor, Department of Surgery,
Louisiana State University Health Sciences Center;
Private Practice, The Wall Center for Plastic Surgery,
Shreveport, Louisiana
Robert A. Weiss, MD, FAAD
Associate Professor, Department of Dermatology,
Johns Hopkins University School of Medicine,
Baltimore, Maryland; Director, The Maryland Laser
Skin and Vein Institute, Hunt Valley, Maryland
George W. Weston, MD
The Austin-Weston Center for Cosmetic Surgery, Reston,
Virginia
Scott Woehrle, PA-C
Physician Assistant, Capella Plastic Surgery, Ramsey,
New Jersey
V. Leroy Young, MD, FACS
President, BodyAesthetic Research Center, St. Louis,
Missouri

Preface
xiii
I
t is hard to believe that 6 years have passed since the first edition of The Art of
Aesthetic Surgery was published. This was an immense undertaking for me, but
it was also a rewarding and educational one. It was written to address the enormous
demand for and interest in cosmetic surgery and the need for comprehensive infor-
mation on that topic. I had not anticipated the warm reception that the book would
receive from colleagues throughout the world and have been delighted, humbled,
and gratified to witness its continued popularity and enthusiastic readership. Recent
translations into Korean and Russian attest to the ongoing global need for educa-
tion in aesthetic surgery.
Why then a second edition? Surely once was enough for a project of this magnitude.
The answer is obvious: this is a dynamic field that is experiencing significant growth,
with numerous exciting new developments. Interest in this topic has not abated over
the years; in fact, it has grown stronger and more vibrant. While many of the proce-
dures touted 6 years ago are still being performed, others have been replaced by new,
less-invasive approaches or techniques that emphasize volume replacement to en-
hance rejuvenation procedures. Furthermore, new technology, noninvasive techniques,
and a number of new devices, fillers, and products have enhanced our ability to pro-
vide our patients with a broader spectrum of options and improved outcomes.
Clearly, there was a need for a revision of the book to reflect these dramatic and on-
going changes.
Today nonsurgical cosmetic treatments such as injectables continue to gain in pop-
ularity, while we have seen a decline in some surgical approaches to facial rejuvena-
tion. Nowhere is this change more dramatic than in the area of brow rejuvenation.
Another important trend has been the emphasis on volume enhancement in perior-
bital and facial rejuvenation. In keeping with these trends, we have increased cover-
age of nonsurgical treatments and injectables and have added new sections and chap-
ters dealing with volume and its role in facial rejuvenation.
In contrast to the reduction in the number of invasive surgical procedures for facial
rejuvenation being performed today, there has been a dramatic increase in breast and
body-contouring procedures, in normal-weight patients as well as in individuals who
have lost massive amounts of weight. Accompanying this burgeoning interest and
demand have been advances, the development of new procedures, and refinements
of existing techniques

I did not approach the task of this revision lightly. As with the first edition, it in-
volved many late nights and weekends spent writing and editing. A busy practice,
numerous academic and societal commitments, a journal editorship, and an effort
to bring more balance into my own life were all forces working against such an un-
dertaking. Then why did I feel this was the right time to take on the responsibilities
and make the time commitment for editing a second edition? Obviously, there was
more than one reason.
My commitment to learning and teaching was a primary motivator. From my ear-
liest writings on muscle and musculocutaneous flaps to the editing of this three-
volume work on aesthetic surgery, I have always felt an obligation to contribute to
the literature and to help advance our specialty. This book represents a continuation
of my lifelong dedication to this process. It has been a wonderful way to reach out
to young and experienced surgeons alike and to offer them insight into the remark-
able contributions made by leading experts worldwide. During academic travels and
interactions with plastic surgeons and trainees all over the world, I have witnessed
their interest in aesthetic surgery and their desire to master the basics of aesthetic
surgery and to learn about the latest techniques. This new edition has been written to
address that need and to provide information on current advances that emphasize
safe and best practices to all aesthetic surgeons.
Every chapter has been revised with new material added. Thirty-nine new chapters,
reflecting the growth and diversity of our specialty, have been included. The number
of DVDs has also grown, with more than 20 operative videos now included in this edi-
tion. It is with great pleasure that I welcome 65 new contributors who, along with our
previous contributors, bring valuable insights and considerable expertise to this new
edition. These contributors have graciously succumbed to my gentle arm-twisting
and have provided us with outstanding chapters on a diverse range of topics. They
have all distinguished themselves as educators and innovators.
The positive feedback we have received on the clinical decision-making chapters
prompted the expansion of existing chapters and the inclusion of new ones. The ad-
ditions reflect the increase in the number of options now available for each patient.
These chapters reflect my own daily decision-making process, not only in the oper-
ating room but also in the clinic when I evaluate new patients and care for them af-
ter the operation.
My personal interest and fascination with human anatomy dates back to my first
year in medical school. I recall one of my teachers telling the class, “You will learn
anatomy three times and forget it three times.” He went on to say that unlike other
knowledge we would acquire over the years, anatomy would never change. Of course,
he was right; anatomy does not change. However, it is important to note that we
change, and our understanding of anatomy evolves and deepens with experience.
xiv
Preface

Back then, I never imagined that one day as a practicing plastic surgeon not only
would I remember all the anatomy I learned, but also I would learn intricate details
that were unimaginable then. Little did I know that in some modest way I would
even contribute to that knowledge base. Interest in anatomic detail as it applies to
aesthetic surgery continues with further clarification of facial anatomy, such as the fat
compartments and more detailed descriptions of anatomy of the trunk and breast
relating to emerging body-contouring procedures. In keeping with these new find-
ings, all anatomy chapters have been appropriately updated.
The topic of patient safety also assumes a more prominent position in this edition,
with a major chapter on safety considerations in aesthetic surgery as well as specific
chapters on problems and complications in different anatomic regions.
The third volume, which focuses on breast surgery and body contouring, has been
greatly expanded with more than 20 new chapters and many new contributing au-
thors. We now have chapters on fat grafting to the breast, the medial and lateral pedi-
cles in breast reduction, mastopexy and breast reduction in massive-weight-loss pa-
tients, and mastopexy-augmentation. The section on body contouring provides
information on innovative liposuction techniques and on different approaches to
body contouring, with new topics ranging from patient screening to brachioplasty,
back and lateral fold contouring, lipoabdominoplasty, gluteal augmentation, female
genital surgery, and correction of iatrogenic deformities.
We have updated all of the artwork and redesigned the look of the book to make it
more modern. This includes the cover: although we have retained the theme of the
“Three Graces,” which symbolizes all aspects of beauty in aesthetic surgery, our
graces have now been transformed from the classic Renaissance look of the first edi-
tion to modern-day abstraction.
It is my wish that readers will receive this second edition with enthusiasm equal to
that of the first publication. I hope that it will provide a source of new information,
stimulate thought, and foster innovation. As with any writing project, this book has
been a major undertaking, but it has also been a labor of love. I have learned as much
as I have taught, and I continue to marvel at the outstanding work being done by
my colleagues throughout the world. I am gratified to be able to share it with you in
these pages. My goal for this book is to provide trainees as well as experienced prac-
titioners with a solid foundation for learning basic principles and techniques in aes-
thetic surgery to enable them to build on this foundation and to forge new solutions
to ongoing problems and challenges.
Foad Nahai
xv
Preface

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Acknowledgments
xvii
T
his book is intended as a testament to all of the surgical pioneers who laid the
foundation for modern aesthetic surgery, as well as a tribute to current con-
tributors whose ingenuity and skill are paving the way for future developments. While
acknowledging my mentors, I also credit the young surgeons in whose training I have
been privileged to participate. Their enthusiasm and quest for knowledge continues
to stimulate me.
This work would never have been completed without the support and encourage-
ment of my family, my partners, those with whom I work on a daily basis at Paces
Plastic Surgery, and my friends at Quality Medical Publishing. I would be remiss if
I didn’t mention all of them by name. My wife, Shahnaz, has been a support and a
part of my professional life for 41 years. She, more than anyone, has put up with my
unusual hours and weekends away from home. My son, Farzad, in practice with me
now, and daughter, Fariba, have always been interested in what I do and have en-
couraged me in my efforts. My partners, Rod Hester, Sonny McCord, Farzad Na-
hai, and Kristin Boehm, not only contributed to the book but also provided encour -
agement, advice, and most of all, support in looking after my patients while I was
away working on the book. Linda Neal, my personal assistant and right hand for
many years, and my new assistant, Lori Meeks, as well as Mary Popp, RN, and An-
gela Evans, RN, FA, spent endless hours gathering information and putting case his-
tories together. Lester Robertson, who has worked with us as a physician assistant
and a professional photographer for 28 years, worked tirelessly to put digital images
together for all of us at Paces Plastic Surgery.
I am indebted to all at QMP, notably Brenda Bunch and Amanda Behr, whose tal-
ents as medical illustrators are only surpassed by their professionalism and their will-
ingness to revise and rework until I was satisfied. Michelle Berger and Amy Debrecht
not only encouraged but also managed to have all the contributors (and the editor
as well) submit their manuscripts and videos in a somewhat timely manner. Taira
Keele and Olivia Ayes provided the follow-up needed to process the chapters, check
on missing items, and keep everything in order and on target. Brett Stone, with the
able assistance of Thuy Khuu, did an amazing job of working with the images and the
pages, providing color correction, sizing adjustments, and quality control. Suzanne
Wakefield’s skills as an editor not only took care of my errors but also taught me
that my command of English grammar may not be all I thought it was. The intuitive,

graceful layouts and attention to detail of Susan Trail and Elaine Kitsis transformed
ordinary manuscripts into a visually appealing book. Sandra Hanley scoured every
corner of the pages for correctness and consistency, and Carol Hollett corrected er-
rors and incorporated contributors’ changes. With unwavering determination, Carolyn
Reich shepherded the three volumes to timely publication. Andrew Berger has led
the marketing and sales effort; his unique knowledge of the book’s contents is in-
valuable in informing surgeons about its benefits and helping residents understand
its value. He has ensured that this book will, along with QMP’s other publications,
receive unprecedented exposure through a vibrant marketing campaign and atten-
dance at more than 30 annual plastic surgery meetings worldwide.
Most of all, I am indebted to Karen Berger, not only for her friendship of more than
30 years, but also for her encouraging me to undertake this project—and her tenac-
ity to see it to fruition. Without exaggeration, this project may never have been com-
pleted without her assistance and hard work.
I acknowledge the outstanding contributors to the book, not only the original con-
tributors who updated and in some cases totally rewrote their chapters, but also the
new authors whose contributions have filled in any deficiencies that may have ex-
isted in the first edition. I am most grateful to them for generously and so readily
sharing their expertise with us.
xviii
Acknowledgments

Contents
xix
Volume I
Part I  Fundamentals
1
The Patient 3
Foad Nahai
2
Patient Safety in Aesthetic Surgery 35
V. Leroy Young
3
Sedation and Anesthesia for Aesthetic Surgery 71
Donald W. Buck II, Thomas A. Mustoe
4
Facial Aesthetic Surgery in Skin of Color 87
Julius W. Few
4-1 African American rhinoplasty, 104
Few
5
Photographic Essentials in Aesthetic Surgery 115
Farzad R. Nahai, William Y. Hoffman
Part II  Business Basics
6
The Practice: Models, Management, and Marketing 151
Foad Nahai, Gustavo A. Colon, Wendy Lewis, Marie Czenko Kuechel,
Andrew R. Berger
7
The Practice: Staffing, Services, and Financial Planning 193
Marie Czenko Kuechel
8
Aesthetic Surgery and the Law 223
Mark Gorney
Part III  Nonsurgical Cosmetic Treatments
9
Clinical Decision-Making for Nonsurgical Cosmetic Treatments 245
Foad Nahai
1

10 Skin Care and Dermatologic Treatments 261
Inja Bogdan Allemann, David J. Goldberg
11 Botulinum Toxin Injections for Facial Rejuvenation 295
Alan Matarasso, David Shafer
11-1 Botox Cosmetic and Dysport: anatomy, supplies, techniques, and results, 312
Matarasso, Shafer
12 Soft Tissue Fillers in Aesthetic Facial Surgery 329
Trevor M. Born, Lisa Airan, Dimitrios Motakis, Foad Nahai
13 Structural Fat Grafting: Basics and Clinical Applications in the Hand,
Face, and Nose 395
Sydney R. Coleman
14 Dermabrasion 475
James L. Baker, Jr.
15 Chemical Peels 493
Richard H. Bensimon, Michelle B. Locke, Foad Nahai
15-1 Croton oil peel, 514
Bensimon
16 Lasers and Devices in Plastic Surgery 537
Jason N. Pozner, Barry E. DiBernardo, David J. Goldberg
17 Sclerotherapy and Laser Vein Treatment 561
Girish S. Munavalli, Sirunya Silapunt, Robert A. Weiss
Part IV  Hair Transplantation
18 Applied Anatomy in Hair Transplantation 595
Alfonso Barrera
19 Clinical Decision-Making in Hair Transplantation 605
Alfonso Barrera
19-1 Hair transplantation with micrografts and minigrafts, 618
Barrera
20 Micrograft and Minigraft Megasessions in Hair Transplantation:
Current Techniques and Future Directions 635
Carlos Oscar Uebel
21 Reoperation, Refinement, and Treatment of Complications
After Hair Transplantation 691
Jack Fisher
xx
Contents
1
1
1

Part V  Brow Lift
22 Clinical Decision-Making in Brow Lift 717
Foad Nahai
23 Temporal Brow Lift 735
Foad Nahai
24 Endoscopic Brow Lift: The Three-Portal Approach 749
Foad Nahai
25 Other Approaches to Brow Lift 789
Foad Nahai
Part VI  Eyelid Surgery
26 Applied Anatomy of the Eyelids and Orbit 807
Mark A. Codner, Michelle B. Locke
27 Clinical Decision-Making in Aesthetic Eyelid Surgery 831
Foad Nahai
27-1 Upper and lower blepharoplasty and midface cheek lift, 838
Nahai
28 Upper Eyelid Blepharoplasty 863
Mark A. Codner, Juan Diego Mejia
29 Upper Blepharoplasty in the Asian Patient 893
William P. Chen
29-1 Upper blepharoplasty in the Asian patient, 897
Chen
30 Lower Eyelid Blepharoplasty 907
Mark A. Codner, Juan Diego Mejia
31 Transconjunctival Blepharoplasty 941
Foad Nahai
32 Lower Eyelid Pinch Blepharoplasty 969
Lorne K. Rosenfield
32-1 Pinch blepharoplasty, 979
Rosenfield
33 Ptosis Surgery in the Blepharoplasty Patient 995
Clinton D. McCord, Jr., Foad Nahai
34 Avoidance and Treatment of Complications of Aesthetic
Eyelid Surgery 1019
Clinton D. McCord, Jr., Foad Nahai
xxi
Contents
1
2
2

Volume II
Part VII  Midfacial Rejuvenation
35 Clinical Decision-Making in the Midface 1071
Foad Nahai
36 Cheek Lift 1079
Joel J. Feldman
37 Midface Recontouring 1137
T. Roderick Hester, Jr., J. Nicolas McLean
38 Endoscopic Rejuvenation of the Midface 1159
Renato Saltz, Carlos Casagrande, Anderson Saciloto, Gabriele Cáceres Miotto
39 Alloplastic Facial Contouring 1191
Edward O. Terino
Part VIII  Face Lift and Neck Lift
40 Applied Anatomy of the Face and Neck 1273
Foad Nahai, Juan Diego Mejia, Farzad R. Nahai
41 Clinical Decision-Making in Face Lift and Neck Lift 1347
Foad Nahai
42 The MACS-Lift Short-Scar Rhytidectomy With Fat Grafting 1377
Patrick L. Tonnard, Alexis M. Verpaele
43 Short-Scar Rhytidectomy 1435
Daniel C. Baker
44 Extended SMAS Technique in Facial Rejuvenation 1471
James M. Stuzin
44-1 Face lift with extended SMAS Vicryl mesh fixation, 1488
Stuzin
45 High SMAS Face Lift With Orbicularis Redraping and Septal Reset 1511
Fritz E. Barton, Jr.
46 Lamellar High SMAS Face and Midface Lift: A Comprehensive
Technique for Natural-Appearing Rejuvenation of the Face 1525
Timothy J. Marten
47 Combined Face Lift and Facial Fat Grafting 1621
Timothy J. Marten
xxii
Contents
3

48 Neck Lift 1675
Foad Nahai
49 Reoperative Rhytidectomy 1717
James C. Grotting, William J. Vinyard
50 Avoiding Complications in Facial Aesthetic Surgery 1761
Foad Nahai
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
51 Rejuvenation of the Aging Mouth 1795
Robert K. Sigal, Byron D. Poindexter, George W. Weston
51-1 Rejuvenation of the aging mouth, 1797
Sigal, Poindexter, Weston
52 Refinements in Otoplasty Techniques 1823
Bruce S. Bauer, Neta Adler
52-1 Otoplasty, 1830
Bauer
Part X  Rhinoplasty
53 Applied Anatomy of the Nose 1859
Rod J. Rohrich, William P. Adams, Jr., Joel E. Pessa, Jack P. Gunter
54 Clinical Decision-Making in Rhinoplasty 1875
Jeffrey E. Janis, Jamil Ahmad, Rod J. Rohrich
55 Primary Rhinoplasty 1895
Jeffrey E. Janis, Jamil Ahmad, Rod J. Rohrich
55-1 Open approach to primary rhinoplasty, 1924
Rohrich
56 Tip Grafting for Nasal Contouring 1975
William D. Losquadro, Dean M. Toriumi
57 Secondary Rhinoplasty 2023
Gilbert C. Aiach, Olivier F. Gerbault, Martin H. Kelly
58 Ethnic Rhinoplasty 2101
William D. Losquadro, Dean M. Toriumi
58-1 Nasal dorsal augmentation, 2113
Toriumi
58-2 Dorsal hump reduction: high horizontal dorsal osteotomy for more
precise control, 2113
Toriumi
xxiii
Contents
3
3
4
4
4

xxiv
Contents
Volume III
Part XI  Breast Surgery
59 Applied Anatomy of the Breast 2151
Kristin A. Boehm, Foad Nahai
60 Clinical Decision-Making in Breast Surgery 2167
Foad Nahai
61 Choosing the Right Breast Implant 2205
Dennis C. Hammond
62 Breast Augmentation 2233
Glyn Jones
63 Fat Grafting to the Breast 2279
Emmanuel Delay, Michel Moutran
64 Breast Augmentation With External Expansion and Megavolume
Autologous Fat Grafting 2309
Roger K. Khouri, Daniel A. Del Vecchio
65 Fat Grafting to Treat Capsular Contracture 2343
Gino Rigotti, Alessandra Marchi, Guido Baroni, Paolo Patete, Andrea Sbarbati
66 Augmentation Mastopexy 2363
Dennis C. Hammond
67 Control and Precision in Mastopexy 2395
James C. Grotting, Stephen M. Chen
68 Breast Reduction: The Medial Pedicle Technique 2443
Elizabeth J. Hall-Findlay
69 Breast Reduction: The Lateral Pedicle Technique 2483
Moustapha Hamdi, Anne Dancey
69-1 Septum-based lateral mammaplasty, 2500
Hamdi
70 Short-Scar Mammaplasty With a Pectoralis Loop 2513
Ruth Maria Graf, André Ricardo Dall’Oglio Tolazzi, Maria Cecília Closs Ono,
Thomas M. Biggs
70-1 Vertical mammaplasty, 2517
Graf
5
5

71 Alternative Approaches to Breast Reduction 2531
Elizabeth J. Hall-Findlay, Foad Nahai
71-1 Free nipple graft technique, 2542
Jones
72 Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
2597
J. Peter Rubin, Jonathan Toy
72-1 Dermal suspension mastopexy, 2607
Rubin
73 Management of Breast Asymmetry 2623
Glyn Jones
73-1 SPAIR mammaplasty technique, 2633
Hammond
74 Treatment of Gynecomastia 2647
Dax Guenther, Richard Y. Ha, Rod J. Rohrich, Jeffrey M. Kenkel
Part XII  Body Contouring
75 Applied Anatomy in Body Contouring 2679
Angela S. Landfair, J. Peter Rubin
76 Clinical Decision-Making in Body Contouring 2709
Foad Nahai
77 Noninvasive and Minimally Invasive Body Contouring 2725
Jason N. Pozner, Barry E. DiBernardo
77-1 Laser liposuction, 2737
DiBernardo
78 Liposuction: Basic Techniques and Safety Considerations 2745
Jordan P. Farkas, Phillip J. Stephan, Jeffrey M. Kenkel
79 Screening and Safety Issues in the Massive-Weight-Loss Patient 2797
Joseph F. Capella, Matthew J. Trovato, Scott Woehrle
80 Brachioplasty 2819
Joseph F. Capella, Matthew J. Trovato, Scott Woehrle
80-1 Brachioplasty, 2840
Capella
81 Back and Lateral Fold Contouring 2853
Dirk F. Richter, Alexander Stoff
81-1 Upper lateral thoracic lift, 2866
Richter
xxv
Contents
5
5
5
5
6
6

82 Body Lift: Belt Lipectomy 2885
Al S. Aly, Albert E. Cram
82-1 Belt lipectomy, 2905
Aly
83 Abdominoplasty 2935
Gilbert P. Gradinger, Lorne K. Rosenfield, Farzad R. Nahai
83-1 Comprehensive abdominoplasty, 2966
Rosenfield
84 Lipoabdominoplasty 3027
Osvaldo Ribeiro Saldanha, Sérgio Fernando Dantas de Azevedo,
Fábio Massaru Kuroyanagi, Vinícius Costa e Silva de Freitas,
Osvaldo Ribeiro Saldanha Filho, Cristianna Bonetto Saldanha,
Luis Humberto Uribe Morelli
84-1 Lipoabdominoplasty with selective undermining, 3033
Saldanha
85 Gluteal Augmentation 3051
Constantino G. Mendieta
86 Female Aesthetic Genital Surgery 3097
Gary J. Alter
87 Evaluation and Treatment of Iatrogenic Deformities 3125
Sydney R. Coleman
88 Correction of Contour Deformities After Liposuction 3139
Kristoffer Ning Chang
89 Special Problems in Reoperative Body Contouring 3169
Joseph F. Capella
Part XIII  Final Thoughts
90 Reflections on the Art of Aesthetic Surgery 3183
Foad Nahai
Credits C-1
Index I-1
xxvi
Contents
6
7
7

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FUNDAMENTALS
PART I

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The Patient

FOAD NAHAI
CHAPTER 1
Spring, Teodor Axentowicz

A well-informed patient is a happy patient.
O
ur patients are bombarded with information about cosmetic medicine and sur-
gery; it is a pervasive theme in our youth-oriented society, appearing in print,
electronic, broadcast, and social media. Although some of the information obtained
from these sources may be helpful, much of it is intended to entice rather than en-
lighten. Advertising for aesthetic surgery is calculated to bring patients into the sur-
geon’s office, often by promising more than can be delivered while minimizing risks,
complications, and the possibility of unfavorable or suboptimal results. Websites and
social media devoted to cosmetic medicine and aesthetic surgery often overload pa-
tients with information promoting one procedure over another. Although the infor-
mation in itself is not detrimental, it can be confusing. Patients may not have the
medical background, experience, or sophistication to sort through this material to
make an informed decision. The more conflicting information they receive, the more
confusing it becomes, and often the more unrealistic their expectations. It is the sur-
geon’s responsibility to educate the patient by presenting the facts in an unbiased
manner. Even then, patients may not be able to reach a decision and may rely on the
surgeon’s recommendations, trusting his or her knowledge and abilities.
It is this basic concept of trust that is being eroded through the blatant marketing
of aesthetic procedures and materials to the public. The implication from this pro-
motional activity is that aesthetic surgeons are mere vendors of a commodity. Hav-
ing a breast augmentation is not like buying a bra or lingerie, and a face lift is not
like purchasing a high-end luxury automobile, where one shops for the most con-
venient dealership or the best discounts. Nothing could be further from the truth.
We are not selling a product; we are providing a service—a service that is personal
and customized to each patient, one that carries risks unlike those encountered at
the beauty salon or spa. This is a high-end service that encompasses the entire pa-
tient experience. This experience begins with the initial telephone inquiry. It pro-
gresses through encounters with the receptionist, patient coordinator, nurse, and sur-
geon, culminating in the surgical procedure. The success of this experience is strongly
dependent on the surgeon’s skill, experience, and judgment.
Not all surgeons have the same experience, medical knowledge, training, surgical
expertise, or technical ability. The well-informed patient should choose a surgeon
based on trust, not on hype or cost.
4
Part I  Fundamentals

5
Chapter 1  The Patient
The First Consultation
The decision to seek cosmetic treatments or aesthetic surgery is usually not a spon-
taneous one. Most likely the patient has been contemplating this possibility for
months, if not years, before picking up the phone to make an appointment with a
plastic surgeon. Some patients may have extensively researched the procedure, the
surgeon, and the surgeon’s practice through the Internet and in particular the sur-
geon’s website. Others rely solely on the recommendations of friends and family.
These recommendations are best when they are based on personal experience. Sat-
isfied patients are the ideal source of referrals, and far more valuable than any ad-
vertising, promotions, or even marketing that money could buy.
The initial consultation does not necessarily begin with the first phone call to sched-
ule an appointment. Most likely the prospective patient has already visited the prac-
tice’s website, and the first contact may have been through the website. The website
and the first telephone contact leave a lasting impression with the patient; if those
contacts are unfavorable, the patient may decide against making an appointment or
fail to keep it. Prompt responses to the patient’s inquiry through the website and
proper telephone etiquette are of utmost importance. The phone should be answered
after a maximum of five rings, and the voice that greets the caller should be cheer-
ful and inviting, announcing the name of the practice and the name of the person
answering, followed by, “How may I help you?” This greeting should be spoken in a
clear, understandable voice. Such an encounter will leave the caller with a positive
impression. Conversely, an unfavorable impression may be left when the phone is an-
swered by a programmed voice reeling off a list of options, each requiring a separate
button to be pushed, until the irritated caller is either disconnected or put in touch
with the appropriate person. This type of impersonal answering system can alienate
potential patients. By the time the annoyed caller actually reaches a live person, he
or she is not in any mood to discuss aesthetic surgery. In any high-end service, im-
mediate contact with a caring individual is essential.
In most offices, the caller is first connected with the person responsible for schedul-
ing appointments. This person needs to understand the importance of flexibility, even
for surgeons who are fortunate enough to have large practices with few immediate
openings for new patients. Impressive as it may sound to inform a patient that there
are no openings because the surgeon is fully booked for 18 months or longer, in most
cases rather than impressing the patient, this will only encourage him or her to look
elsewhere. We live in a world where everyone is busy. Most of our patients value their
time as we do and only have specific days and times when they can afford to miss
work for a doctor’s appointment. This is particularly true for those seeking aesthetic
surgery, who do not wish to ask for sick time or announce to their supervisor that
they are going to see a plastic surgeon.

6
Part I  Fundamentals
Your website is the face of your practice to the world.

Although we may not always be able to accommodate every patient’s scheduling
needs for every office visit, it is important to do so for the initial consultation. For
this reason, some practices offer evening and Saturday office hours. Patients should
be asked how soon they would like to schedule the appointment. Then every effort
should be made to schedule the appointment as close to that date as possible, with-
out overcommitting the surgeon, yet leaving sufficient time for the initial consulta-
tion. (In my practice, at least 1 hour is allotted.) Although patients assume that doc-
tors are never on time, patients still make every effort to arrive as scheduled. It is a
matter of common courtesy, whenever feasible, to see patients at the appointed time.
Obviously, this is not always possible. It is good practice, however, to notify patients
if you are running late either before they arrive, if possible, or on their arrival.
The scheduler should record the caller’s name, address, and contact information. It
is also important to inquire about the reason for the consultation. Some individuals
may be reluctant to disclose this information to a stranger on the phone. The sched-
uler should explain that while patient privacy is of the utmost importance, these
questions are being posed to determine whether the practice offers the procedure
that the patient is seeking. It also provides valuable information for the surgeon to
help prepare for the patient’s initial consultation and to ensure that sufficient time
is allotted for that appointment. Patients seeking removal of a skin lesion may not
require as much time at the initial visit as someone seeking facial rejuvenation. Once
the appointment is made, patients are told that a package will be mailed to them or
can be downloaded from the website. Most practices now offer patients the option of
filling out their initial paperwork online, thus eliminating the need to do so in the
doctor’s waiting room during the initial visit.
Some patients may not want to receive mail, phone calls, faxes, emails, or other com-
munications that are identified as coming from a plastic surgeon’s office. Special care
should be taken to cater to these needs. The scheduler should ask where the patient
would like to receive correspondence from the office. Some thought should be given
to using envelopes and fax cover sheets without any indication that this is coming
from a plastic surgeon’s office; envelopes should have a street address without a prac-
tice name or logo. In the interest of patient confidentiality, the scheduler should also
specifically ask patients how they wish to be contacted by the practice, for example,
home, cell, or office phone, or by email.
Next, an information package is sent from the office that includes general informa-
tion about the practice, maps and directions, specific information about the surgeon,
his or her qualifications and practice philosophy, a letter detailing what will happen
during the initial consultation, and a brochure on the procedure the patient is seek-
ing. Most, if not all, of this information is probably already available on the sur-
geon’s practice website. However, it is important to remember that not all patients
are Internet savvy, and some may prefer a hard copy; therefore the printed material
serves as a reliable resource for all patients regardless of their technical know-how.
7
Chapter 1  The Patient

Maps and directions to the surgeon’s office should be sufficiently detailed to allow
patients to easily locate the office. Parking should be ample and convenient. Any spe-
cial parking instructions should be detailed in the information package. Even though
a patient is looking forward to the visit with the plastic surgeon, this initial consul-
tation is a stressful event; getting lost or frustrated over finding a parking space will
merely add to patient anxiety.
On the next page is an example of the type of patient letter that is sent with our prac-
tice information package.
The patient’s first face-to-face encounter in the surgeon’s office will be with the re-
ceptionist, who should greet the patient and notify the patient coordinator or nurse
of the patient’s arrival. It is disconcerting for a patient to walk into the surgeon’s of-
fice for the first time, only to find that no one is there to greet her or him; even worse
is when two or three staff members are engrossed in conversation or occupied on
the telephone, and the patient is ignored. It is also essential that we respect the pa-
tient’s privacy during this sign-in process; several points merit particular attention.
Privacy and HIPAA Regulations
 Sign-in lists where the patient signs his or her name under the name of the previ-
ous patient should be avoided.
 The receptionist should sit in an enclosed space, preferably in a glass-enclosed area
to maintain privacy yet allow the receptionist to have full view of the waiting room.
 The receptionist or nurse should refrain from loudly announcing the patient’s name
in the waiting room.
 Under no circumstances should the patient be greeted with the words, “You are
here to see Dr. Nahai about your breast enlargement?”
 In most states in the United States and in some other countries, the practice is re-
quired to display a Patient’s Bill of Rights and the privacy statement.
Once a patient has signed in, he or she should be told when to expect to be taken to
the consultation room to meet with the patient coordinator. If there is a delay, the
patient is given an estimate of the waiting time, and coffee or a soft drink can be of-
fered. Whenever possible, an explanation is provided for the delay. If the delay is in-
ordinate or unacceptable, the patient is offered the choice of rescheduling or wait-
ing. If I am running unacceptably late—a half hour or more—the fee for the initial
consultation will be waived and the patient’s parking charges paid as a gesture of
goodwill.
The patient is then escorted to one of the examination rooms. In my practice, the
nurse meets with the patient first. A history is taken and the completed health ques-
tionnaire, which has been downloaded from the website or mailed out to the patient
before the initial office visit, is reviewed.
8
Part I  Fundamentals
Text continued on p. 15

9
Chapter 1  The Patient
Dear Patient:
I am looking forward to meeting you when you come in for your initial consultation with Dr. _________.
A map and directions to our location are enclosed for your convenience. Parking is available, as
indicated on the map.
We are located in the ________________ building on the _______ floor. Elevators are located in the
lobby of the main entrance to our building and on level _______ of the parking deck.
We realize your time is valuable; please allow 11⁄2 to 2 hours for your consultation. This will permit
ample time for your consultation with Dr. _____________, for photography and video imaging, and
for consultation with our aesthetician, as appropriate. I will also meet with you to discuss the surgical
fees and scheduling, and to answer any questions you might have. Most of all, you will be able to
familiarize yourself with our practice, our facility, and the staff, without time constraints.
We look forward to seeing you soon. In the meantime, if you have any questions or if you need further
information, please feel free to contact me at any time.
Sincerely,
___________________________
Patient Coordinator

10
Part I  Fundamentals
PERSONAL HISTORY QUESTIONNAIRE
This information is confidential and will not be released without your authorization.
Date__________________
Name________________________________________________________________ DOB___________ Age_______
LAST
FIRST
MIDDLE
Ht___________ Wt___________ Sex: M F Marital status:  Single  Married  Widowed  Divorced
Date of last physical exam___________ Doctor_____________________ Referring Doctor_____________________
Phone_________________ Purpose of this consultation__________________________________________________
PAST MEDICAL HISTORY: Do you have or have you had? (If yes, give date of occurrence.)
AIDS or HIV
N Y__________
Bleeding tendencies
N Y__________
Asthma
N Y__________
Thyroid
N Y__________
Blood pressure
N Y__________
Lupus
N Y__________
Heart
N Y__________
Lungs
N Y__________
Cancer
N Y__________
Kidneys
N Y__________
Nervous problems
N Y__________
Fibromyalgia
N Y__________
Gallbladder
N Y__________
Bleeding problems
N Y__________
Arthritis
N Y__________
Stomach
N Y__________
Diabetes
N Y__________
Scleroderma
N Y__________
Hepatitis
N Y__________
Other serious illnesses you have had__________________________________
Do you regularly smoke? Y N How much per day?________________
Do you regularly drink over 3 cups of coffee per day? Y N
Do you regularly drink alcohol or beer? Y N How much per week?________________
MEDICATIONS: Are you presently taking any of the following? (Circle.)
Aspirin/Anacin
Cough medicine
Antibiotics
Phenobarbital
Dilantin
Bufferin
Thyroid pills
Blood pressure pills
Blood thinners
Iron
Motrin
Hormones
Insulin/diabetic pills
Digitalis
Sleeping pills
Ibuprofen
Birth control pills
Arthritis medication
Cortisone
Water pills
Other medication not listed_______________________________________________________________________
Do you take herbal supplements? Y N If yes, what are they?_________________________________________
Aspirin and aspirin type products can cause excessive bleeding during surgery.
DRUGS OR SUBSTANCES TO WHICH YOU ARE ALLERGIC___________________________________________
FAMILY HISTORY: Have blood relatives had? (Please circle and give reason.)
High blood pressure_________________ Arthritis______________________ Asthma______________________
Diabetes__________________________ Stroke_______________________ Goiter_______________________
Bleeding disorders__________________ Breast cancer_________________ Other cancer__________________
SERIOUS ILLNESSES OR INJURIES: Please list any serious illnesses or injuries and dates.
Illness/Injury________________________ Year_______
Illness/Injury________________________ Year_______
Illness/Injury________________________ Year_______
Illness/Injury________________________ Year_______
OPERATIONS: Please list operations and year.
Operation__________________________ Year_______
Operation__________________________ Year_______
Operation__________________________ Year_______
Operation__________________________ Year_______
WOMEN ONLY
Is there a chance you may be pregnant? Y N Regular menses? Y N Date of last menstrual period__________
Any complications with pregnancies?_______________________________________________________________
How many pregnancies?_______ How many children?_______ Did you breastfeed? Y N How many?_______
Date of last mammogram_________  Normal  Abnormal
Specify abnormality_____________________________________________________________________________
Breast cancer:
L R Date_____________
Mastectomy________________ Date_____________
Breast biopsy:
L R Date_____________
Oncologist____________________________________
Surgeon for breast biopsy_______________________
Address______________________________________
Address_____________________________________

11
Chapter 1  The Patient
GENERAL INTAKE INFORMATION
Date_________________
Name__________________________________________________________________ Age__________
LAST
FIRST
MIDDLE
Referring Physician______________________________________ Phone_________________________
CHIEF COMPLAINT _________________________________
REVIEW OF SYSTEMS
___________________________________________________
__________________________________________________
__________________________________________________
PRESENT ILLNESS _________________________________
___________________________________________________
__________________________________________________
__________________________________________________
PAST HISTORY
1. Serious illnesses __________________________________
_______________________________________________
_______________________________________________
2. Operations _______________________________________
Cigarette smoking / amount?
Y N
_______________________________________________
________________________________
_______________________________________________
DVT history? Y N
3. Other hospitalizations ______________________________
________________________________
_______________________________________________
_______________________________________________
4. Allergies / medications _____________________________
Bleeding disorders? Y N
_______________________________________________
________________________________
_______________________________________________
Medications affecting bleeding:
Latex allergy? Y N
ASA
5. Present medications _______________________________
Vitamin E
_______________________________________________
Ibuprofen
_______________________________________________
Dietary / herbal supplements
_______________________________________________
________________________________
________________________________
FAMILY HISTORY ___________________________________
________________________________
___________________________________________________
________________________________
___________________________________________________
___________________________________________________

12
Part I  Fundamentals
BLEPHAROPLASTY
Date_________________
Name__________________________________________________________________ Age__________
LAST
FIRST
MIDDLE
HISTORY
Yes
No
Have you had any eye problems?
_____
_____
Do you wear glasses?
_____
_____
contacts?
_____
_____
Do you have dry eyes?
_____
_____
Do you have glaucoma?
_____
_____
Do you have a family history of glaucoma?
_____
_____
Do you have high blood pressure?
_____
_____
EXAMINATION
Visual acuity: Right________ Left________
Herthel measurements (eye prominence)
Ptosis
Eyelid position
Lateral canthus
Medial canthus
Fat
Skin
Muscle
Laxity
Snap test
Distraction test
Periorbital
Brow
Crow’s-feet
Glabella
Tear trough
Lid-cheek junction
Slit lamp if needed

13
Chapter 1  The Patient
BREAST SURGERY
Name_____________________________________________________________ Date_______________
LAST
FIRST
MIDDLE
Reason for consultation___________________________________________________________________
Goals_________________________________________________________________________________
Age________ Dominant hand________ Height_________ Weight_________ Weight stable? Y N
Children_______ Breastfeed_______________________ Maximum cup size during pregnancy_______
History of breast disease__________________________________________________________________
Family history___________________________________________________________________________
Last mammogram_______________________________________________________________________
PHYSICAL EXAMINATION
Bra size_________
Skin: Quality_______________________________ Quantity________________________________
Breasts: Fatty______________________________ Fibrous_________________________________
Ptosis: Right: I II III Left: I II III
Asymmetry__________________________________________________________________________
Lumps/masses_______________________________________________________________________
Nipple sensation: R L
Current implants: Saline____________ Silicone____________
Capsular contractures: R L
Submuscular____________ Subglandular____________
BW
R_______ L_______
BT
R_______ L_______
SSN:N
R_______ L_______
N:IMF
R_______ L_______
PLAN
Augment: Saline_________ Gel_________ Moderate/HP_________ Smooth/textured_________
Size(s): Submuscular__________________ Subglandular__________________
Mastopexy: Periareolar__________________ Vertical__________________

14
Part I  Fundamentals
BODY CONTOURING
Name_____________________________________________________________ Date_______________
LAST
FIRST
MIDDLE
Reason for consultation___________________________________________________________________
Goals_________________________________________________________________________________
Age________ Sex: F M
Height________ Weight________ Weight loss/gain (last 12 months): Loss______lb Gain_______lb
Dress size__________ Pants size__________ Bra size__________
Pregnancy?____________ Weight of child(ren) at birth________________________________________
Exercise frequency:  Sporadic (1/wk)  Occasional (2-3/wk)  Regular (4-6/wk)  Daily
PHYSICAL EXAMINATION
Diastasis
Hernia
SKIN EXAMINATION
Left
Right
Skin tone:
Normal
_____
_____
Flaccid
_____
_____
Asymmetry
_____
_____
Dimpling
_____
_____
Striae
_____
_____
Telangiectasia
_____
_____
Varicose veins
_____
_____
PROPOSED PROCEDURE

At this time the patient usually discusses the reason for the consultation with the
nurse. This takes from 10 to 20 minutes, depending on the patient, the nurse, and
the procedure. I then review this information before meeting with the patient. I greet
the patient and introduce myself and immediately ask, “What can I do for you?” We
then discuss the patient’s goals and what he or she hopes to accomplish through aes-
thetic surgery. Next we review the patient’s history, including pertinent information
on general health and specific information concerning previous aesthetic treatments,
procedures, and skin care. Procedure-specific information is discussed in detail. For
example, any woman desiring breast surgery is asked specifically about her family
history of breast disease, including cancer, history of breast masses and biopsies,
mammography, and childbearing history. If the patient is contemplating liposuction
or body-contouring procedures, we discuss lifestyle, exercise, nutrition, and weight
control. For abdominal procedures, we discuss previous abdominal operations, includ -
ing liposuction and hernia surgery. For facial rejuvenation procedures, I ask whether
patients are currently smoking, but I am also interested in their smoking history—
that is, if they have ever smoked, for how long, how heavily, and when did they stop?
I question all patients about a history of phlebitis or deep venous thrombosis.
Once the history has been reviewed, I return to the reason for the consultation.
Throughout this consultation, I know that the patient is assessing me as a person, a
physician, and a surgeon. Clearly, he or she has no way of realistically evaluating my
knowledge of aesthetic surgery or my technical abilities. In all likelihood, patients
will base their decisions on my demeanor and how warm, caring, and attentive I ap-
pear. Meanwhile, I am assessing the patient. Are his or her goals realistic? Will I be
able to meet these goals? Do I like the individual? If we have a complication, will I be
able to maintain patient confidence while we resolve the problem? I am particularly
attentive to the patient’s body language, eye contact, tone of voice, and most of all,
his or her enthusiasm and interest during the consultation. I observe the patient’s
appearance, hairstyle, makeup, clothing, and accessories. These not only reflect the pa-
tient’s tastes but also attention to detail and how exacting the individual will be as
a patient. I am concerned when an individual who is sloppily dressed and poorly
groomed comes in seeking aesthetic surgery. In a similar manner, the appearance and
grooming of the surgeon leaves an important impression about the surgeon’s atten-
tion to detail and the care, attention, and meticulous surgical technique that he or
she offers to each patient. I certainly would be hesitant to let any sloppily dressed or
poorly groomed physician or nurse take care of me!
It is not unusual for patients to come in having researched the procedure on the
Internet or on other physicians’ websites. In all likelihood they have sought con-
sultation elsewhere as well. They may have been given conflicting advice and in-
formation, which they may or may not share with me. Close to the end of our con-
sultation, I now ask them if I have told them anything that they were not aware of
or anything that conflicts with information they may have been given elsewhere.
15
Chapter 1  The Patient

Dear Patient:
It was nice to meet you at __________________ Plastic Surgery on __________. As we discussed,
you are a good candidate for breast enlargement. With this operation, we plan to place a saline im-
plant (filled with saltwater) under the muscle of your chest through an incision in the crease below
each of your breasts. I am aware of your desires for final breast size and will do my best to address
them. However, please remember that we will select your implants based on the dimensions of your
breasts rather than the volume of the implants. The operation will be performed in our operating rooms
as an outpatient procedure.
It is important to understand that breast augmentation is not maintenance free; the implants are not
permanent, will eventually fail, and have to be changed. There is always the risk of capsular contrac-
ture (hardening of the breast), which may also necessitate reoperation and implant change. I would
be happy to meet with you again to go over this and the other risks and complications that we have
discussed before you make a final decision. In the meantime, if you need any more information or
if we can assist you in any way, please don’t hesitate to call.
Best wishes.
Sincerely,
___________________________, MD
(Physician Name)
16
Part I  Fundamentals

Most patients respond that they were aware of some but not all of the information
that we provided. In my experience, this new information is almost always related
to expected outcomes and complications. It amazes me that even today I see patients
who have researched breast augmentation on the Internet and have had consulta-
tions elsewhere, but may not be aware that breast implants are not permanent.
I never pressure patients to make a decision during the initial visit. In fact, I en-
courage them to ask questions, take home the materials we provide, and to return
for a second visit, which is complimentary, before making a final decision. However,
we do arrange for our patient coordinator to quote fees and discuss scheduling dur-
ing this first visit.
I follow up every new consultation with a personal letter rather than a form letter,
summarizing our discussion and a brief description of my recommendations; I re-
mind patients that I would be happy to meet with them again before they make a
decision or schedule a procedure.
Motivation
A well-motivated patient is a happy patient.
Understanding patient motivation is an essential goal of the initial consultation.
Questions probe the reasons for seeking surgery. For whom is the patient pursuing the
operation—is it to please someone else? Does the patient think that this will change
his or her life? The best patients are those who are seeking surgery for themselves so
they can look better. The best motivation is self-improvement. With most patients,
I am able to understand what motivates them after a few minutes. Sometimes I will
ask patients whether they hope that the aesthetic surgery will change anything in
their lives and inquire as to whose idea it was for them to have this procedure.
Almost always, teenagers seeking rhinoplasty or other aesthetic procedures suitable
for their age are accompanied by a parent. I make it a point to address the teenagers
directly and have them, rather than the parent, tell me what they would like. I usu-
ally tell them that they will have to live with the result, not their parents or their sur-
geon, so they need to carefully consider what they are requesting. Although I will al-
low the parents to express their opinions, I make it clear to the patients that they
should make the final decision.
Patients often have hidden agendas—secret and personal reasons for seeking this pro-
cedure. They are reluctant to share this with the surgeon or the staff, and even with
their family and friends. These hidden agendas may include attracting the opposite
sex, seeking a promotion, or simply a life-altering event. Beware of this hidden
17
Chapter 1  The Patient

agenda, because despite an excellent result, these patients will never be happy unless
the requirements of the hidden agenda have been fulfilled.
When to Say No
Not every person I see is a candidate for a surgical procedure. I classify noncandi-
dates into six general categories, as follows:
1. Those seeking the procedure before they are ready for it
For example, breast augmentation for teenagers, face lifts in women who do
not need one or who will see little difference, or rhinoplasty in 12-year-olds
2. Those with unrealistic expectations
For example, those patients who believe that aesthetic surgery will “change
their lives,” save a marriage, or make them look like swimsuit models or movie
stars
3. Patients on whom I would prefer not to operate
For example, those who are overly demanding, noncompliant, abusive to of-
fice staff, or “aesthetic surgery junkies”
4. Another surgeon’s unhappy patient who has a reasonable result but remains
extremely critical of the original surgeon
5. Patients who are psychologically unstable
6. Those who are seeking to improve on problem areas or imperfections that
are not readily recognized by others; these individuals may well have body
dysmorphic disorder (BDD)
Patients in group 1 are counseled that it is too early for the procedure they are seek-
ing. I explain to these patients that I would like them to be my patients and that
I will operate on them at the appropriate time. A woman seeking a face lift before she
is truly ready will be offered skin care, other ancillary procedures, and injectables,
if appropriate, until they are ready for a surgical procedure. I explain to teenagers
seeking augmentation that it is best to wait until their breasts have stopped grow-
ing. I will make an exception for teenagers with significant breast asymmetry and
promise the 12-year-old that as soon as her nose is fully grown, we will take care of it.
I explain to patients in group 2 that I do not believe I can provide them with the re-
sult they are looking for or meet their expectations. I also let them know that I am
concerned that they will be unhappy or displeased with me.
Patients in group 3 require special tact. I tell these demanding patients that I do not
believe that our office will be able to provide them with the level of service that they
are seeking. To the abusive patient I explain that the office staff and I are a team and
because the patient has already indicated an unwillingness to work with my office
staff, I cannot care for this individual because I will not work without my colleagues.
Finally, to the patient who has an insatiable desire for plastic surgery, I say you have
had it all and it is too early to have any more.
18
Part I  Fundamentals

19
Chapter 1  The Patient
Dissatisfied or unhappy patients in group 4 are told that they have had a reasonable
result, that they are being unduly tough on their previous surgeon, and that I doubt
I can significantly improve on what has been done. My major concern is that a patient
with an average result who is trashing the original surgeon will one day say the same
about me, regardless of the result. Any patient who walks in and unjustifiably claims
that they were “butchered” or “mutilated” is an immediate noncandidate.
Group 5 includes psychologically unstable patients whose instability is not always
readily discernible. I advise them to seek counseling and treatment before consider-
ing aesthetic surgery. In fact, anyone under psychiatric care at the time of consulta-
tion, regardless of my own personal impression of his or her suitability, is referred
back to the psychologist or psychiatrist for clearance before scheduling. It is not un-
common today to see patients who are taking antidepressants such as fluoxetine
(Prozac) or bupropion (Wellbutrin). This by itself does not disqualify them, as long
as they are stable individuals. Most of the time the antidepressants have been pre-
scribed by their internist or family physician for mild depression rather than for any
severe psychiatric condition. Most of these individuals are suitable candidates for
aesthetic surgery.
Group 6 individuals may appear normal to the untrained; however, their insistence
that a small blemish or minimal deviation from the norm is a major deformity that
is ruining their lives and incapacitating them is an indication of BDD. These indi-
viduals should be referred for counseling. Surgical or other procedures on these pa-
tients lead to further dissatisfaction, disappointment, and anger. Extreme caution
should be exercised in handling this group.
I discuss the options available to the patient and make my recommendations. I ex-
plain that I prefer to operate in our own office-based surgical center, which is certi-
fied and inspected by the American Association for Accreditation of Ambulatory Sur-
gery Facilities (AAAASF) and the state of Georgia. I tell patients that anesthesia will
be provided under the supervision of a board-certified anesthesiologist and that
I personally will perform the entire operation. I explain that they will be charged for
the consultation that day, and if I operate on them, they will be expected to prepay
for the surgery. All follow-up visits before and after the operation are included in the
charges for the surgery. I do not discuss specific fees and charges; our patient coor-
dinator does that. I do, however, explain to patients that I will perform revisions, if
needed, at no additional charge. Although rare, should a complication necessitate
the services of other physicians or hospitalization, those expenses would be the pa-
tient’s responsibility. Years ago, Dr. Gil Gradinger shared with me a letter that he
gave to his patients on this subject. I still use a modified version (p. 20) that patients
are asked to read and sign before surgery.
However, my no-charge policy for revisions does not always apply to liposuction pa-
tients, who often return seeking revisions and repeat liposuction after weight gain,

To My Patients:
Prior to surgery, you will have paid my fee as well as other costs. Although it is very unusual,
compli cations requiring additional surgery, consultation, hospitalization, or other services can occur.
There will be no additional charges for any service performed by me or the staff. However, any other
doctor, hospital, or related expenses will be your responsibility.
Healing after an operation is usually a predictable process leading to a good result. However,
occasionally a surgical revision is necessary to help achieve this result. In this situation there will be
no charge for my services, but there may be a small facility charge.
______________________________________, MD
(Physician Name)
I understand and accept the above statements.
______________________________________
_______________________
(Patient Signature)
(Date)
20
Part I  Fundamentals

To My Liposuction Patients:
Approximately two to three weeks after the operation, you will notice some decrease in your weight.
The actual weight loss will of course depend on the volume of fat that was removed. Following the
operation, it is important that you maintain your weight and avoid any weight gain. Maintaining your
weight, or better still, losing weight postoperatively will only enhance your result. In contrast, any
weight gain will have the opposite effect.
Normally, there is no charge for a revision or touch-up of liposuction if done within one year of the
original surgery, provided your weight has remained the same. However, if there has been a weight
gain of 10 pounds or more postoperatively, there will be a fee for any revision.
In order to maintain your good result following liposuction, I encourage you to maintain your weight!
______________________________________, MD
(Physician Name)
I understand and accept the above statements.
______________________________________
_______________________
(Patient Signature)
(Date)
21
Chapter 1  The Patient

thereby obviating the results of the original procedure. To avoid future misunder-
standings, we talk to these patients preoperatively about the impact of weight gain
on long-term liposuction results. Liposuction patients are asked to read and sign an
additional form regarding weight gain and repeat procedures (p. 21) so that they
fully understand that additional liposuction after a substantial weight gain (10 pounds
or more) will not be considered a revision but a new procedure.
Surgeon Shopping
Currently the public is being advised to seek two if not more consultations before
selecting a plastic surgeon, so most patients will see another surgeon before pro-
ceeding. Although a second or third opinion is not unusual today, I would be wary
of patients who have seen numerous plastic surgeons. Occasionally a patient comes
in with an information package and video images from another practice and a file
full of information and images downloaded from the Internet. Sometimes the pa-
tient tells me that a different procedure was recommended by others. This in itself is
not a red flag to me, but it requires extra time and discussion. I explain that each
surgeon will recommend an operation that, in his or her hands, comes as close as
possible to the patient’s desired goal. I assure the patient that I have done the same.
The fact that my recommendation differs from that of the other surgeon (or sur-
geons) does not necessarily mean that I am correct and the other surgeons are not;
it simply means that I have recommended a procedure that, in my hands, would give
the patient the best result.
I tell patients who have seen other surgeons that they should not base their choice
of physician on price, on who has the fanciest or sparsest office, or on convenience
of location. Rather, the choice should be based on the overall impression of the physi-
cian and the office staff, rapport with them, and most of all, confidence and trust.
I explain to patients that even in the best of hands complications are possible, and
that they should have enough confidence and trust in the surgeon they choose to al-
low him or her to handle any problems through to resolution. Patients often make
the mistake of going to another physician once they have developed a complication,
even though the original surgeon would be equally capable of dealing with it. These
patients often blame themselves and are convinced that they made the wrong choice.
I tell them that if they choose me, they should have enough confidence to allow me
to handle any complication unless I recommend that they see someone else.
Patient Education
I discuss outcomes, risks, and complications with the patient during the initial con-
sultation. All patients are informed that all procedures carry risks and that cosmetic
treatments and aesthetic surgery are no exception. I explain that the risk of a life-
threatening complication is not as small as the risk of flying—and significantly less
than driving around Atlanta. Once the patient is reassured in terms of general risks,
22
Part I  Fundamentals