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

The zygomaticofacial nerve is a small nerve that emerges through a foramen 1 to
2 cm lateral to and below the lateral canthus. It is only at risk during subperiosteal
dissection of the periorbital area. Unlike the infraorbital nerve, the zygomaticofacial
nerve is very small and very easily divided. It is always accompanied by a small blood
vessel, and often the only indication that the nerve has been divided is the bleeding.
I make every attempt to identify and preserve this nerve during subperiosteal mid-
face lifts. Division of the nerve is of little consequence in terms of sensory loss, but
irritating discomfort in the area has been attributed to division of the nerve.
The mental nerve emerges through the mandible in the midpupillary line at the level
of the second premolar. This nerve is at risk during subperiosteal dissection for place-
ment of chin implants. Fortunately, it is a large nerve that is easily identified and not
easily injured with a periosteal elevator. Injury to the nerve results in debilitating sen-
sory loss in the lips and teeth.
Motor Nerve
One of the most devastating and long-lasting complications after facial rejuvenation
surgery is permanent injury of a branch of the facial nerve. Fortunately, the incidence
of facial nerve paralysis is fairly low. In a reported series of 6500 patients, facial
nerve paralysis was seen in 0.7%, with only 0.1% permanent. With endoscopic brow
lifts, the incidence of temporary paresis to the frontal branch of the facial nerve has
been consistently reported at 1%, with permanent injury of 0.1%. My personal ex-
perience parallels these reported series, but I have been fortunate enough not to have
permanent paralysis in any of my patients.
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Part VIII  Face Lift and Neck Lift
Lower buccal branch
Temporal branch
Zygomatic branch
Facial nerve
Marginal mandibular branch

The facial nerve branches most at risk include the buccal, frontal, and marginal
mandibular branches. Recently concern has been raised about the zygomatic branches
in association with complex periorbital procedures.
Most commonly reported injuries involve the buccal branches; however, because
these are multiple branches rather than a single nerve, recovery is usually seen within
3 to 4 months. The frontal branch is the next most frequently reported injured nerve,
and these are also multiple branches rather than a single nerve, and recovery is the
rule; however, recovery takes longer than after buccal branch injury. The marginal
mandibular branch is a single nerve, and complete recovery after injury is rare. For-
tunately, the resulting asymmetry of the mouth can be improved through the judi-
cious administration of botulinum toxin on the opposite side.
Buccal and Zygomatic Branches
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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
The buccal branches are multiple, and injury to all branches is rare. Dissection be-
low the SMAS, beyond the parotid gland, puts these nerves at risk. Therefore in any
face-lift procedure necessitating sub-SMAS dissection beyond the parotid gland, the
dissection should be performed bluntly and with caution. These branches are read-
ily visible, and injury is easily avoided. Blind or sharp dissection beyond the parotid
gland should be avoided. These branches all run deep to the zygomaticus major mus-
cle, so dissection beyond the zygomaticus major toward the nose and nasolabial fold
is safe as long as it is in a plane above the zygomaticus major.
Zygomatic and buccal branches
Marginal mandibular nerve
Lateral border of the zygomaticus major

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Part VIII  Face Lift and Neck Lift
Marginal
mandibular
nerve
Frontal
branches
The frontal branches of the facial nerve are at risk not only during forehead lifts
(coronal and endoscopic) but also with sub-SMAS face lifts, especially techniques
requiring a high-SMAS dissection. Classically the landmark for identifying the course
of this nerve has been a diagonal line drawn from a point 5 mm below the tragus to
a point 2 cm above the lateral brow. However, I have found that if the sentinel vein
is visible through the skin, a point 5 mm above the vein will usually mark the course
of the vein. I then draw a diagonal line toward the tragus and use this as the guide-
line. Because this nerve runs under the temporoparietal fascia above the zygoma and
very deep to the SMAS, below the zygoma, the surgeon can avoid injury to the nerve
by performing the temporal dissection of any forehead lift well below the tem-
poroparietal fascia. In fact, I make a point of placing all of my instruments directly
over the deep temporal fascia, pushing on the fascia as I dissect toward the zygoma
and orbital rim. Below the zygoma, injury is avoided by staying above the SMAS.
However, if high sub-SMAS dissection is undertaken, injury to the nerve is avoided
by dissecting just below the SMAS. Recent anatomic data demonstrate that the nerve
lies much deeper and closer to the periosteum of the zygoma rather than just below
the SMAS. During a combined temporal and facial dissection, the development and
maintenance of a “mesotemporalis” made up of the temporoparietal fascia and SMAS
will ensure the safety of this nerve.
Frontal Branches of the Facial Nerve

Marginal Mandibular Branch
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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
Marginal mandibular nerve
Marginal mandibular branch
of the facial nerve
Although the marginal mandibular branch is deep to the SMAS and the platysma
along all of its course, it is still susceptible to injury, especially as it courses over the
facial vessels at the level of the mandibular notch. The two factors contributing to
this area of risk are (1) the thinning of the SMAS and platysma in that area and (2)
the presence of perforating branches of the facial vessels. The thinning of the SMAS
and platysma puts the nerve at risk during blind dissection, where the scissors can
easily slip through the thin platysma and injure the nerve. The other mechanism of
injury is the use of electrocautery in an attempt to control bleeding from the perfo-
rating vessels. As a general rule, I prefer to use bipolar rather than the unipolar co-
agulating current for hemostasis during facial rejuvenation, because there is less elec-
trocautery current that can damage the nerve. In thin individuals I prefer to perform
the dissection along the mandibular border under direct vision to minimize the risk
of subplatysmal penetration.
When performing subplatysmal dissection of the neck, the surgeon must keep in
mind that the relationship of the marginal mandibular branch to the inferior border
of the mandible is variable; in fact, it can run 1 to 2 cm below the mandible along
its entire course, not just proximal to the facial vessels and the mandibular notch.

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Part VIII  Face Lift and Neck Lift
Although permanent injuries to the branches of the facial nerve are rare, it is vital
that the surgeon be familiar with the anatomy of these branches, their relationships
to the various layers of the face, their specific danger zones, and the risk afforded
each branch by the more complex and deeper dissections. Familiarity with specific
techniques is essential to minimize risk and avoid complications. I encourage any-
one performing facial rejuvenation to dissect the layers of the face and branches of
the facial nerve in the cadaver laboratory.
Spinal Accessory Nerve
Although extremely rare, injury to the spinal accessory nerve and a resultant shoul-
der drop have been reported. The nerve is most at risk during posterolateral dissec-
tion in the neck. The nerve emerges behind the posterior border of the sternocleido-
mastoid, almost at McKinney’s point or just above, coursing posteriorly and laterally
toward the trapezius.
Temporal branches of facial nerve
Greater auricular nerve
Supraorbital/
supratrochlear nerves
Zygomatic and buccal
branches of the
facial nerve
Infraorbital nerve
Marginal mandibular
branch of the
facial nerve
Mental nerve
FACIAL DANGER ZONES: MOTOR AND SENSORY NERVES

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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
Deep Venous Thrombosis
Venous thromboembolism (VTE) and its consequences, deep venous thrombosis
(DVT) and pulmonary thromboembolism (PE), are devastating, life-threatening, and
fortunately uncommon. The exact incidence of DVT in facial aesthetic surgery is not
known. Reinisch et al reported an incidence of 0.35% for DVT and 0.14% for PE
in face lifts. A 4-year review of 468 face lifts at Paces Plastic Surgery revealed two
patients with DVT, an incidence of 0.4%, with no PE. Our 0.4% compares to the
0.35% reported by the Reinisch group. Spring and Gutowski surveyed 3797 plastic
surgeons in the United States, who reported 15 DVT and PE events associated with
facial cosmetic procedures. Every precaution should be taken to minimize the risk
of DVT. Factors increasing the risk include the following:
 Age
 Family history
 Weight
 Use of oral contraceptives
 Length of procedure
 Type of anesthesia
Based on these factors, the dual task force of the American Society of Plastic Sur-
geons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS) as-
signed risk categories and made recommendations for patients undergoing plastic
surgery procedures according to the assigned risk category. These recommendations
were published in the November 1999 issue of Plastic and Reconstructive Surgery.
They are summarized in the table on p. 1778.
Internal jugular vein
Sternocleidomastoid
muscle
Site of injury
External
jugular vein
Great auricular nerve
Spinal accessory
nerve
Trapezius
muscle
External
jugular
vein
Great
auricular
nerve
Spinal accessory
nerve
Anterior border
of trapezius muscle

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Part VIII  Face Lift and Neck Lift
DVT Prophylaxis
Risk Factors
Recommendations
Low Risk
41 years of age
Comfortable position on operating table
No oral contraceptives/hormones
Slight knee flexion
No chronic disease, infections, malignancy
Avoid extremity compression or constriction
No personal or family history of DVT, PE, etc.
No history of venous insufficiency
Short operative procedure
Moderate Risk
41 years of age
Comfortable position on operating table
Current oral contraceptives/hormones
Slight knee flexion
Chronic disease, infections, malignancy
Avoid extremity compression or constriction
Personal or family history of DVT, PE, etc.
Intermittent pneumatic compression
Short operative procedure
Frequent alteration of operating table position
High Risk
41 years of age
Comfortable position on operating table
Longer procedure (1 hr)
Slight knee flexion
Current oral contraceptives/hormones
Avoid extremity compression or constriction
Chronic disease, infections, malignancy
Consider preoperative hematology consultation
Personal or family history of DVT, PE, etc.
Consider preoperative and postoperative
anticoagulants
Intermittent pneumatic compression
From McDevitt NB. Deep vein thrombosis prophylaxis. American Society of Plastic and Reconstructive Surgeons. Plast
Reconstr Surg 104:1923-1928, 1999.
Standard pneumatic pressure garments extending from knee to ankle
PlexiPulse intermittent pneumatic compression devices (Kinetic Concepts, Inc., San Antonio, TX) placed on feet

In my practice almost all patients undergoing facial rejuvenation fall into the high-risk
category. All of these patients are operated on under general anesthesia; support is
placed behind their knees, and intermittent pneumatic compression garments are
used in all of them. Stuzin et al have reported zero incidence of DVT in over 10,000
face lifts spanning 30 years, all of which were performed under local anesthesia with
sedation. They comment that patients operated on with intravenous sedation moved
during the procedure thus reducing the tendency of venous stasis and DVT.
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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
Venous Thromboembolism Risk Factors for Plastic Surgeons to Consider
Solid, consistent evidence that these are the most important risk factors*
Prior history of VTE (DVT or PE)
Malignancy (active or in patient history)
Thrombophilia disorders (inherited or acquired)
Factor V Leiden mutation (makes factor V resistant to activated protein C)
Prothrombin 20210A mutation (found exclusively in whites)
Antithrombin deficiency
Protein S and protein C deficiency
High levels of fibrinogen or plasminogen, factor VIII, factor IX, factor XI, thrombin
activatable fibrinolysis inhibitor (TAFI), or protein C inhibitor
Low levels of tissue factor pathway inhibitor (TFPI)
Hyperhomocysteinemia (plasma homocysteine level 18.5 mmol/L)
Dysfibrinogenemia and polycythemia vera
Antiphospholipid antibodies (lupus anticoagulant and anticardiolipin)
Obesity (risk may be highest for those 40 years of age)
Use of oral contraceptives, tamoxifen, hormone replacement therapy, or other estrogen-
containing drugs
Known to be risk factors but probably not in the top tier; do not disregard
as unimportant
Age  40 years (risk rises as age rises)
General anesthesia (risk rises with each hour in surgery, regardless of procedure)
Varicose veins
Inflammatory disease (inflammatory bowel disease, rheumatologic diseases, especially
systemic lupus erythematosus)
Abdominal surgery (carries higher risk than most other types of surgery)
Pregnancy, abortion, or miscarriage within 3 months
Smoking
Recent hip or knee replacement or hip fracture
Recent surgery of any kind
Prolonged travel by air, train, or car
Recent physical trauma
*Important risk factors that are rarely encountered in plastic surgery practices include prolonged immobilization, isch-
emic stroke, heart failure, chronic lung disease, respiratory failure, serious infection, pneumonia, central venous catheter-
ization, paralysis, spinal cord injury. Some risk factors are permanent (such as a history of VTE or cancer, chronic disease,
thrombophilia, age) and some are transient (such as surgery, travel, estrogen use, pregnancy).

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Part VIII  Face Lift and Neck Lift
Craftsmanship Issues
Some postoperative concerns are not true complications; I prefer to call them issues
of finesse, quality, or craftsmanship. But they are the issues that make all the differ-
ence in the patient’s perception of the quality of the result. In this category I include
the following:
 Scar placement and scar quality
 Ear distortion
 Hair loss and hairline distortion
 Contour irregularities
Scar Placement and Scar Quality
I regularly talk to patients to explain where the incisions and scars will be. Occa-
sionally the patient looks back at me and comments, “Well, there won’t be any scars,
will there? This is plastic surgery, after all.” I reply that all incisions leave scars and
that the best I can offer them is to place the scars where they will be imperceptible
or at least less noticeable, and that I will make every effort to ensure the quality of the
scars, although this will depend as much on the location and tension as well as on
the patient’s biology as it will on surgical technique.
Avoiding Undesirable Scars
The key to avoiding undesirable scars is to manage tension appropriately. Special at-
tention is required in those who are prone to hypertrophic scarring, especially red-
headed individuals with a ruddy complexion and patients who are keloid prone.
This man underwent a MACS-lift elsewhere and has hypertrophic scars in front and
behind his ear, most likely related to tension. Note that the horizontal scar below
has sideburn has healed well. Incisions are planned so that they will be inconspicu-
ous and allow appropriate distribution of tension. Meticulous closure under mini-

mal tension and aggressive early management of scar problems are important. Inci-
sions in the hair are made parallel to the hair roots; the use of cautery is judicious
and limited to preserve hair roots. Closure must avoid excessive tension, which dam-
ages the hair roots. Incisions along the hairline are also made in the direction of the
hair roots to preserve and encourage hair growth through the resulting scar.
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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
The preauricular incision should never be a straight line. It should be broken up
above and below the tragus. I prefer the intratragal incision whenever possible.
This incision is made in such a way that the tragus has a beginning and an end. Far
too often this is not done, and the tragus blends into the lower face with a telltale
sign of a face lift. The incision behind the ear is placed either within the sulcus or
1 to 2 mm on the posterior surface of the ear. My preference is to make it on the ear
rather than within the sulcus.
This woman underwent a face lift by a nonsurgeon who left her with a hypertrophic
straight-line scar in front of her ear and little in the way of facial rejuvenation. I saw
her in consultation and performed a secondary face lift with appropriate lacement
of the incisions. Seven years later, the tragus appears natural and there is no hyper-
trophic scarring or distortion. In the intervening 7 years she has colored her hair.

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Part VIII  Face Lift and Neck Lift
Distribution of tension during the closure defines the quality of the resultant scar.
Tension should usually be placed at the level of the concha, behind the earlobe, and
behind the ear, never in the preauricular or tragal area or the earlobe. Once the skin
tension has been appropriately distributed, the excess skin along the pre auricular
area and behind the ear is excised and closed in two layers under no tension. Usu-
ally this closure will not require a suture any larger than a 6-0. If sutures stronger
than 6-0 are required for this closure, then there is too much tension and the scar
will widen unacceptably.
This patient, who had a face lift with the full classic incision including preauricular
intratragal incisions, is seen preoperatively and in early postoperative and late post-
operative views.

Preoperative and 4-year postoperative views of a patient who underwent a short-
scar face lift with a preauricular intratragal incision ending at the earlobe.
Closure of the retroauricular incision requires as much attention to detail or perhaps
even more than the preauricular incision. It is very unusual to see hypertrophic scar-
ring in front of the ear; however, it is not so uncommon to see it behind the ear.
I think this is related to excessive tension and overresection of retroauricular skin.
Another problem is scar migration in an outward direction from the retroauricular
sulcus. This is avoided by anchoring the posterior ear skin and the face-lift flap skin
to the mastoid fascia with every bite or every other bite when closing the retroau-
ricular portion of the incision.
Treatment of undesirable scars includes intralesional injection of steroid medications
and the application of topical creams or silicone gels. Scar revision may also be an
appropriate treatment.
Ear Distortion
Very often, close observation of the tragus and earlobe will reveal telltale signs of a
face lift. It is not only the appearance of the scar but distortions of the tragus and
earlobe that attract the eye and scream out: “Yes, I have had a face lift!”
The tragus must have a beginning and an end, and must project outward from the
face and external auditory meatus with a gentle posterior tilt. Forward displacement
renders the external auditory meatus more visible, creating the impression that it has
been enlarged. This is a result of excessive tension with no break above or below the
tragus. An extreme example is the ablation of the tragus. This is avoided by deepen-
ing the pretragal sulcus, especially in secondary face lifts and, if necessary, suturing
the pretragal skin into the sulcus.
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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery

1784
Part VIII  Face Lift and Neck Lift
This patient who has had a previous face lift demonstrates near complete ablation
of her tragus with wide open external auditory meatus. Her earring conceals the
pixie ear deformity. On the right, her ear is seen on the operating table before a sec-
ondary face lift.
Earlobe problems are related to improper closure around the earlobe. I prefer to leave
the earlobe hanging free rather than suturing it to the skin flap. This allows the nat-
ural “angle of the dangle” described by Connell. Suturing the earlobe leads to pixie
earlobe deformity and a migration of the earlobe into the neck, another telltale sign
of a face lift.
Another finesse issue with the earlobe is the concomitant reduction of the earlobe
at the time of a rhytidectomy. This is especially important in older patients who have
large, pendulous, creased earlobes. The addition of autologous fat or filler into the
aging earlobe will eliminate the creases and render a more youthful appearance.
Hair Loss and Hairline Distortion
Hairline distortion is one of the most common stigmata of a face lift. Possible dis-
tortions include the following: elevation or elimination of the sideburns, irregular or
a step-off in the retroauricular hairline, and frontal hairline elevation. The most com-
mon problem, however, is scar alopecia. This is also the simplest problem to resolve.
Sideburn elevation or elimination is avoided by appropriate placement of the inci-
sion. In a primary face lift in patients with a short sideburn, I will make a prehairline
incision, and in all patients undergoing secondary face lifts I will also make a pre-
hairline incision. This affords ample exposure for the face lift without any change in
sideburn position. An alternative is to continue the preauricular incision into the
temporal area and to take out the skin triangle below the sideburns. This will also
maintain sideburn length.

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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
Preoperative and postoperative views are shown of a patient who had a secondary
face lift. Hairline distortion and sideburn shortening was avoided through a prehair-
line incision extending into the preauricular, intratragal, and retroauricular areas.
Retroauricular hairline step-offs and distortion are avoided by aligning the occipi-
tal hairline first and then resecting the excess retroauricular skin and scalp. A certain
amount of tailoring is needed in patients with excess or loose neck skin.
The high-forehead hairline is seen more commonly with coronal rather than endo-
scopic brow lifts, although brow elevation is also seen with the endoscopic approach.
This problem is best avoided by techniques that allow shortening of the forehead;
all of these techniques entail an incision in the frontal hairline, an incision that some
patients are not willing to accept.
Scar Alopecia
Hair loss is avoided through minimization of tension and with gentle tissue handling.
Overuse of the electrocautery, tight sutures, and staples will damage hair roots. The
After a previous face lift, this woman had eleva-
tion of the hairline, with elimination of sideburns
and a wide, depigmented preauricular scar.

most common scar alopecia that I have encountered has been at the external screw fix-
ation site associated with the endoscopic forehead lift. All of these problems are rela-
tively easy to correct through simple excision of the bald spots under local anesthesia.
Very rarely, after facial aesthetic surgery and brow lift (notably endoscopic brow lift),
there may be partial or full alopecia of the entire scalp. Fortunately, most of these
are self-limiting. Topical use of Rogaine and steroids may accelerate the recovery. In
patients with thinning hair, as a preventive measure I encourage the preoperative and
postoperative use of Rogaine on the scalp.
Contour Irregularities
Contour irregularities result from improper defatting, SMAS plication, and mis-
managed hematoma.
Oversuction or suction too close to the dermis, especially in the neck, will lead to
banding and skin adhesion to the platysma. This is best avoided by leaving 3 to 5 mm
of fat on the deep surface of the skin, keeping the suction cannula hole pointed away
from the dermis, and limiting the number of passes in each tunnel.
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Part VIII  Face Lift and Neck Lift
Excessive fat removal in the subcutaneous plane to mask or correct problems deep
to the platysma is a common error that is often difficult to reverse as is seen in this
woman. Overaggressive fat removal from her neck and submental area has unmasked
platysma bands and prominent digastric muscles.

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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
SMAS plication with or without SMAS resection can lead to contour irregularities.
Multiple sutures should be placed to ensure that the plication and suture lines are
smooth without any discernible irregularities. These are best avoided by inspecting
and ensuring a smooth subcutaneous contour before closure.
Even the smallest hematoma, if inadequately drained, will lead to prolonged swell ing,
subcutaneous scarring, and irregularities. These irregularities are best treated through
lymphatic drainage and skin massage. I have also found external ultrasound useful,
especially with the banding in the neck. Steroid injections may also be helpful. Re-
operation is also an option.
Some patients refer to these contour irregularities as “waves.” There are some pa-
tients, however, in whom the waves are seen only on animation, representing what
I think is an imbalance of the mimetic muscles of the cheek after deep and subperi-
osteal procedures. These are difficult problems to correct and may be related to dis-
ruption and reattachment of muscle origins and partial denervation.
Motion Distortion
One of the more difficult problems to correct following a face lift is the distortion
observed on animation, especially in the cheek area. The cause of such distortions
is not fully understood, which makes the problem difficult to correct. It is thought
to be related to a change in the relationship of the muscles of facial expression with
the overlying soft tissues and/or the underlying bony skeleton.
Infections
Infections after facial aesthetic surgery are extremely rare, because the face has a
plentiful blood supply. However, the sequelae of infection can be serious and include
skin slough and scarring. All patients undergoing facial aesthetic surgery should have
their faces washed and hair shampooed with antiseptic hair shampoo on the day of
the procedure. The face and hair should be prepared and draped as with any other
surgical procedure. Although controversial, I still use perioperative antibiotics on all
patients undergoing facial aesthetic surgery.
Very rarely, Pseudomonas infection of the face is seen in swimmers who harbor
Pseudomonas organisms in their auditory canals. As a precaution, we always soak
the earplugs in povidone-iodine solution (Betadine) before placing them in the ex-
ternal auditory meatus.

Other Rare Complications
Although perforation of the parotid gland capsule or even the gland itself is en-
countered with sub-SMAS dissections, such violations of the gland and its capsule
are very rarely of any consequence. However, a few cases of parotid fistula and even
parotid cysts have been reported after rhytidectomy. If encountered, these problems
are usually self-limiting and will resolve spontaneously. However, it is important to
ensure that the parotid duct is intact. If the problem does not resolve spontaneously,
exploration and open drainage will be required. The drug somatostatin (Sandostatin),
which decreases salivary secretion, may be helpful in managing this problem. How-
ever, the side effects may not be acceptable. Injections of botulinum toxin A into the
parotid gland will reduce its secretions and is preferred over somatostatin.
Concluding Thoughts
The results of a face lift are at best temporary. The consequences of
complications may be permanent.
CLAUDIO CARDOSO DE CASTRO
Although complications cannot be totally eliminated, careful patient selection and
preparation, attention to surgical and anesthesia detail, and attentive postoperative
management by an experienced team will significantly reduce complications. Unlike
any other field of surgery or even other areas in aesthetic surgery, complications and
unfavorable results affecting the face and neck cannot be concealed or otherwise pro-
tected from public view. The problems are out there not only for you and the patient
to see, but for the entire world! This is especially true for the patient’s family and
close friends and her hairdresser. It is vital to understand that regardless of how mi-
nor or inconsequential the problem may seem to the surgeon, these problems are sig-
nificant for the patient. The patient’s concerns must be openly discussed, the patient
must be reassured, and every attempt should be made to rectify the problem as ex-
peditiously as possible with minimum or no expense to the patient. After evacuation
and closure of facial hematomas, I routinely reassure the patient that the hematoma
will in no way affect the quality of their result but may delay their recovery, espe-
cially the resolution of the ecchymosis. Patients with temporary facial nerve paresis
are reassured that in all likelihood the weakness is temporary and that permanent
facial nerve weakness is extremely rare. None of us is happy about complications,
least of all me. I make every attempt to personally see and take care of all my pa-
tients whenever possible. This becomes even more important with patients who have
a complication. It is their own surgeon they want to see, not the surgeon’s partner,
assistant, or nurse. Their own surgeon should see them on every visit, and it is im-
1788
Part VIII  Face Lift and Neck Lift

portant that the visits become more frequent. Anything short of this will lead pa-
tients to believe that at best their surgeon is avoiding them and at worst that their
surgeon has abandoned them.
Complications and patient dissatisfaction with results test not only the established
doctor-patient relationship but also our abilities as physicians and compassionate
human beings. The confidence and trust of the patients gained over a period of weeks,
months, or even years is threatened or lost very easily if the situation is not handled
sensitively.
Do not hesitate to consult partners or colleagues when dealing with complications,
especially in patients who express anger or even undue concern that their problems
have not been as self-limiting as you have indicated. In patients who will need ex-
tensive revisions, it is important to seek the advice of partners and other colleagues
and to resolve financial issues up front and as soon as possible.
The best way to deal with complications is to avoid them. If we cannot avoid them,
we must remedy them expeditiously and effectively.
Clinical Caveats
 Preoperatively, patients should be given a list of medications, herbal remedies, and
dietary supplements to avoid.
 Appropriate blood pressure management should be initiated before, during, and
after the operation to reduce the risk of hematoma.
 The perioperative use of clonidine should be considered.
 Pain, anxiety, nausea, and blood pressure elevation must be treated aggressively
in the recovery room.
 An expanding hematoma must immediately be decompressed; it is a potential dis-
aster.
 Excessive tension on the skin should be avoided.
 The surgeon should be familiar with the anatomy of the sensory and motor nerves
at risk.
 Sub-SMAS dissection beyond the parotid gland should be done under direct vision.
 Blunt instruments are best for sub-SMAS dissection beyond the parotid gland.
 If possible, bipolar is preferred over unipolar coagulation of bleeders below the SMAS.
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Chapter 50  Avoiding Complications in Facial Aesthetic Surgery
Continued

1790
Part VIII  Face Lift and Neck Lift
Clinical Caveats—cont’d
 Preventive measures should be taken to avoid DVT in all patients.
 The surgeon should be a craftsman, taking the time necessary to produce a satis-
factory result.
 The sideburns and hairline should be respected, keeping changes minimal.
 A natural-appearing tragus and earlobe should be maintained.
 The surgeon should be kind to the hair roots.
 Avoid oversuction of neck fat should be avoided.
 A smooth facial contour must be under the skin flap.
 Complications must be treated expeditiously.
 It is important to remember that the patient’s facial complication is on view all
the time.
Annotated Bibliography
Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: anatomic variations and
pitfalls. Plast Reconstr Surg 64:781-795, 1979.
The authors discuss the detailed anatomy of the muscular branches of the facial nerve,
how to prevent injuries to them during rhytidectomy, and how to manage injuries when
they do occur.
Jones BM, Grover R. Avoiding hematoma in cervical rhytidectomy: a personal 8-year quest.
Reviewing 910 patients. Plast Reconstr Surg 113:381-387; discussion 388-390, 2004.
Hematoma remains the most common complication of rhytidectomy and can lead to
prolonged facial edema and skin necrosis. The authors discuss the effects of ancillary
procedures and the effect of epinephrine to reduce hematoma occurrence.
Jones BM, Grover R. Reducing complications in cervicofacial rhytidectomy by tumescent
infiltration: a comparative trial evaluating 678 consecutive face lifts. Plast Reconstr Surg
113:398-403, 2004.
This is the first comparative study of tumescent infiltration in facial rejuvenation sur-
gery. The authors present the results of their study, which investigated the long-term
outcome in a large series of consecutive face lifts performed with (229 cases) and with-
out (449 cases) tumescence. They discuss the spectrum of techniques used in the study
and compare complications between the groups. The surgical technique and aesthetic
implications for rejuvenation surgery are also discussed.

Keyes GR, Singer R, Iverson RE, et al. Analysis of outpatient surgery center safety using an
internet-based quality improvement and peer review program. Plast Reconstr Surg
113:1760-1770, 2004.
Assessing the quality of care delivered in office-based outpatient surgery centers is dif-
ficult, because formerly there was no central data collection system. The authors discuss
the new Internet-based quality improvement and peer review program developed by the
American Association for Accreditation of Ambulatory Surgery Facilities, which ana-
lyzes outcomes for the surgery centers it accredits. Both inpatient and outpatient se-
quelae are presented and compared.
McDevitt NB. Deep vein thrombosis prophylaxis. American Society of Plastic and Recon-
structive Surgeons. Plast Reconstr Surg 104:1923-1928, 1999.
In October 1998, at the annual meeting of the American Society of Plastic and Recon-
structive Surgeons, the board of directors convened the Task Force on Deep Vein Throm-
bosis to address concerns that had been identified through the research of the Lipoplasty
Task Force. This article represents an extensive review of the literature and critical analy-
sis of clinical experience.
McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidec-
tomy. Plast Reconstr Surg 66:675-679, 1980.
The great auricular nerve is the one most commonly injured during rhytidectomy. The
authors discuss a technique that uses fixed anatomic landmarks to help the surgeon
avoid injury to the great auricular nerve and the jugular vein.
Rees TD, Lee YC, Coburn RJ. Expanding haematoma after rhytidectomy: a retrospective
study. Plast Reconstr Surg 51:149-153, 1973.
Preoperative identification of patients who might be prone to hematomas, factors as-
sociated with hematomas, and measures that might be effective in their prevention are
discussed.
Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap survival in the
face lift patient. Plast Reconstr Surg 73:911-915, 1984.
The authors present data demonstrating that a significant number of skin sloughs ob-
served after face-lift surgery are attributed to patients’ cigarette smoking. Implications in
terms of patient selection and preoperative counseling are also discussed.
Suggested Readings
Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas. Plast Re-
constr Surg 115:2119-2122, 2005.
Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical evac-
uation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg
116:1973-1985; discussion 1986-1987, 2005.
Baker TJ, Gordon HL. Complications of rhytidectomy. Plast Reconstr Surg 40:31-39, 1967.
Baker TJ, Gordon HL, Mosienko P. Rhytidectomy: a statistical analysis. Plast Reconstr Surg
59:24-30, 1977.
1791
Chapter 50  Avoiding Complications in Facial Aesthetic Surgery

de Chailain T, Nahai F. Amputation neuromas of the great auricular nerve after rhytidec-
tomy. Ann Plast Surg 35:297-299, 1995.
Connell BF. Correcting deformities of the aged earlobe. Aesthet Surg J 25:194-196, 2005.
DDAVP official FDA information, side effects and uses. Available at

Ellenbogen R. Pseudo-paralysis of the mandibular branch of the facial nerve after platysmal
face-lift operation. Plast Reconstr Surg 63:364-368, 1979.
Freilinger G, Gruber H, Happak W, et al. Surgical anatomy of the mimic muscle system and
the facial nerve: importance for reconstructive and aesthetic surgery. Plast Reconstr Surg
80:686-690, 1987.
Grover R, Jones BM, Waterhouse N. The prevention of haematoma following rhytidectomy:
a review of 1078 consecutive facelifts. Br J Plast Surg 54:481-486, 2001.
Keyes GR, Singer R, Iverson RE, et al. Mortality in outpatient surgery. Plast Reconstr Surg
122:245-250; discussion 251-253, 2008.
Lawrence WT, Murphy RC, Robson MC, et al. The detrimental effect of cigarette smoking on
flap survival: an experimental study in the rat. Br J Plast Surg 37:216-219, 1984.
Patronella CK, Ruiz-Razura A, Newall G, et al. Thromboembolism in high-risk aesthetic
surgery: experience with 17 patients in a review of 3871 consecutive cases. Aesthet Surg
J 28:648-655, 2008.
Peterson R, Johnston D. Facile identification of the facial nerve branches. Clin Plast Surg
14:785-788, 1987.
Rees TD, Barone CM, Valauri FA, et al. Hematomas requiring surgical evacuation follow-
ing face lift surgery. Plast Reconstr Surg 93:1185-1190, 1994.
Reinisch JF, Bresnick SD, Walker JW, et al. Deep venous thrombosis and pulmonary em-
bolus after face lift: a study of incidence and prophylaxis. Plast Reconstr Surg 107:1570-
1575; discussion 1576-1577, 2001.
Schwember G, Rodriguez A. Anatomic surgical dissection of the extraparotid portion of the
facial nerve. Plast Reconstr Surg 81:183-188, 1988.
Spring MA, Gutowski KA. Venous thromboembolism in plastic surgery patients: survey re-
sults of plastic surgeons. Aesthet Surg J 26:522-529, 2006.
Stuzin J, Wagstrom L, Kawamoto HK, et al. Anatomy of the frontal branch of the facial
nerve: the significance of the temporal fat pad. Plast Reconstr Surg 83:265-271, 1989.
Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an important reference point for sur-
gery in the temporal region. Plast Reconstr Surg 101:27-32, 1998.
Young VL, Botney R. Patient Safety in Plastic Surgery. St Louis: Quality Medical Publishing,
2009.
Young VL, Watson ME. The need for venous thromboembolism (VTE) prophylaxis in plas-
tic surgery. Aesthet Surg J 26:157-175, 2006.
1792
Part VIII  Face Lift and Neck Lift

REJUVENATION OF THE
CHEEKS,CHIN,LIPS,
AND EARS
PART IX

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Rejuvenation of the Aging Mouth

ROBERT K. SIGAL, BYRON D. POINDEXTER,
GEORGE W. WESTON
CHAPTER 51

T
he mouth can be a difficult area to rejuvenate. In younger patients with mini-
mal facial aging, the surgeon can frequently leave the mouth untouched and
still produce a harmonious result with standard lifting and augmentation techniques.
In these patients, often in their late thirties and their forties, the focus is the midface
and jawline, where well-hidden incisions under the eyes and around the ears allow
re-creation of youthful contours. The surgeon may choose to fill thinning lips, rhytids,
and creases or perhaps resurface the perioral skin, but often that is all that is needed.
In younger patients, more is not necessarily better.
In older patients, however, ignoring the mouth often leads to facial disharmony. An
old mouth in the center of an otherwise rejuvenated face does not leave the patient
looking young or old—it leaves the patient looking odd. The surgeon can be left in a
difficult position, with an unhappy patient and the question, “What do we do now?”
There is a tendency to look back and think that if a portion of the operation had
been performed “better,” the result would be different. One may wonder whether
pulling harder on the midface tissues or switching to a deeper plane for the face lift
might have created a better aesthetic result on a long, aging lip or loose nasolabial
fold. Perhaps if more fat or filler had been added, the effect might be more natural. Al-
though these are worthy considerations, experience suggests the result would still
probably be inadequate.
Two factors conspire to defeat our efforts to rejuvenate the perioral region indirectly
from the well-hidden scars around the ears or under the eyes. First is the elasticity
of the facial soft tissues. Lifting techniques in any plane above the periosteum lose
power the farther they are from “the pull.” Pulling the skin and SMAS a centimeter
at the ear ultimately moves the nasolabial fold only millimeters. Second is the nature
of the deeper tissue to which the skin is attached around the mouth. With no sub-
cutaneous fat beneath it, the skin inside the nasolabial folds is particularly resistant
to remote pull. The intimate relationship of the perioral skin to the underlying mus-
cle tends to keep it in place. The rejuvenative efforts inside the nasolabial lines are
reduced to those that are easily done; that is, erasing the wrinkles and filling the lips.
Although “lipstick wrinkles” and a thin vermilion certainly deserve attention, there
is often more work to be done.
This is where the utility of a direct approach to perioral aging and aesthetics is evi-
dent. Plastic surgeons are comfortable with hidden incisions on the face, and com-
fortable with obvious scars on other parts of the body (such as from mastopexy and
abdominoplasty), but we are uncomfortable with incisions on parts of the face that
might be obvious. Surgeons justifiably fear creating scars that will be visible and ir-
reparable, a permanent reminder of the surgeon’s hand. Yet most of plastic surgery
requires acknowledging and making the trade-off of a particular scar for a change
in shape. As long as that trade-off is worthwhile in the vast majority of cases, a tech-
nique makes it into the arsenal of “approved” plastic surgery procedures.
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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

Although the idea of directly excising tissue around the mouth can be daunting, we
have found that direct excisions around the mouth, when placed in natural creases,
are actually less noticeable than most other scars. After performing more than 3000
such direct excisions, we are convinced that they have a significant role in rejuve-
nating the aging mouth. In this chapter we will attempt to define our approach to
restoring a youthful appearance in this difficult region.
THE AGING MOUTH
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Chapter 51  Rejuvenation of the Aging Mouth
At the extremes, the differences between young and old mouths are obvious. With
age, the upper lip lengthens so that the upper incisal show of youth is hidden. The
lower lip attenuates and involutes, revealing the lower incisal show of age. The tis-
sue around the oral commissure deflates and descends medially around it, produc-
ing a saddened appearance. Soft, subtle rolls are erased and replaced with angular
peaks and creased valleys. The chin pad drops, and the loose tissue around the naso-
labial folds becomes so excessive that it is difficult to pull flat, even in the most expe-
ri enced hands. That an indirect approach to these issues is inadequate is underscored
by these images: the woman on the right has already had a face lift. We will address
each of these distinct signs of perioral aging with strategies for their correction.
Long Upper Lip
With age, the distance lengthens between the nostril sill and the vermilion. The up-
per lip thins, widens, and hangs like a curtain over the upper teeth. A youthful mouth
in repose should have at least 3 to 4 mm of incisal show with the lips parted. How-
ever, recognizing the problem and fixing it are two different issues. Indirect ap-
proaches have been frustratingly unsuccessful in our hands; although some plastic
surgeons claim that a midface lift will indirectly shorten the upper lip, we have been
unable to duplicate their results. We have found that fat grafting alone will give a
sense of lip elevation because the fuller lip now recreates a bit of an arc. Although
useful, this solution is restricted to correction of a minimal problem.
3
51-1 Rejuvenation
of the aging mouth

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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
One approach we tried briefly was to directly excise the skin adjacent to the vermil-
ion in a continuous strip. This “upper lip advancement” appeals in theory, because
it affords maximal control over the shape of the vermilion border and the contour
of the Cupid’s bow. We tried this approach for a time almost 25 years ago and quickly
abandoned it because of its nearly 30% contracture rate. Further, when that scar
contracts, it is extremely difficult to make an aesthetic surgical revision. In the ap-
propriate patient, we have found it far better to extend a corner mouth lift medially
to each apex of the Cupid’s bow and elevate the central lip through a small lip lift.
Lip Lift
We have found an excision under the nostril sill to be a more predictable and con-
trollable solution to a long upper lip. Our founding partner, Harvey Austin, devel-
oped the lip lift independently and presented 83 cases in 1986, although others had
previously reported it. This lip lift, as we have described it, will shorten the central
upper lip and slightly evert it. The procedure was originally designed as a wavy skin
excision that leaves the scar in the crease below the nostril sill.
There is no mathematical formula for determining how much to shorten the lip; how-
ever, two points are worth making. First, a residual lip length that is shorter than 10
to 12 mm from the nostril sill to the vermilion border will make the lip appear too
short. Second, one should overcorrect by a third to allow for postoperative relax-
ation. Given these caveats, our resections average 5 to 7 mm.

We have performed all of the variations of this excision, and all have utility. Two
bear special mention. The first is the one with the central component (top row, cen-
ter). If it takes a certain measure of surgical fortitude to put a scar under the nose,
it takes an order of magnitude more to put a scar down the middle of an unscarred
upper lip.
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Chapter 51  Rejuvenation of the Aging Mouth
Yet this scar heals beautifully, and the subtle narrowing this excision imparts to the
upper lip and its enhancement of the Cupid’s bow warrant its consideration in the
appropriate patient. We have run that central component varying distances down
from the labiocolumellar fold, often all the way to the vermilion.
The second variation involves intranasal extensions (top of page, bottom row, left).
On occasion, a lip lift may give the sense of widening the alar bases. Patients who
have real or perceived widening may find their result objectionable for this reason
alone. Narrowing the alar verge by simply adding a full-thickness excision intranasally
manages this issue.

Outcome and Complications
We have performed more than 1000 lip lifts since 1980, mostly in combination with
corner mouth lifts. It has been an extremely reliable procedure with a high rate of
patient satisfaction. When problems occur, they usually involve wound healing, asym-
metry, or undercorrection. The first two categories are usually handled by revision. We
have seen a handful of scars widen beneath the nostril sill. These are usually easily
corrected: the tension placed on the skin edges after excising many millimeters of lip
skin is now replaced with the slighter tension produced by excising a few millime-
ters of widened scar. We have seen only a handful of hypertrophic scars (all in Viet-
namese patients), and these responded well to injection. Our preferred injection for
hypertrophic scars on the face is Kenalog 40 mixed 1:1 with 5-FU. Minor issues with
asymmetry often stem from unnoticed preexisting asymmetries and can also be han-
dled with revision.
Although it is straightforward to excise more skin in patients who consider their lips
to be undercorrected, overcorrection is more problematic. Of the few we have en-
countered, most lips have relaxed over time, and the patients have grown comfort-
able with the result. Time heals many things. Keeping to the excisional parameters
outlined earlier and erring on the conservative side in resections should yield excel-
lent results.
Anatomic Variations
Five anatomic variations merit caution:
1. A short upper lip with lack of incisal show
Lengthening the incisors through cosmetic dentistry may be a better solution
than further lip shortening.
2. A long upper lip with significant incisal show
Shortening this lip may expose too much incisor.
3. A highly arched lip in which a lip lift could exaggerate the central arch and
make the corners appear to turn down
An extended corner lift (discussed later) might be a better solution.
4. A rounded nostril sill that would hide a scar poorly
We have on occasion taken down the nasal spine to make the labiocolumel-
lar angle more acute.
5. A mouth with downturned corners, where a lip lift can further emphasize the
downturn
In this instance, it may be better to perform a corner mouth lift concomi-
tantly, or to forego the lip lift altogether.
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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

Downturned Mouth
Around the oral commissure, aging perioral tissues descend and wrap medially, cre-
ating a spectrum of anatomic variants of aging over time. The aging mouth can de-
velop an unhappy or even bitter appearance as the lateral lip lengthens, the vermilion
rolls inward, marionette grooves form, and the commissure itself eventually descends.
Inside the nasolabial folds, indirect approaches to the correction of what we call the
downturned mouth are remarkably ineffective. Although one might be tempted to
elevate this tissue from either a face-lift incision or from the lower lid, we have found
any correction to be short lived.
Midface Elevation
Our experience with elevating the midface in an attempt to correct the downturned
mouth has been particularly disappointing. Over the years, we have tried different
iterations of the procedure (including various combinations of temporal, intraoral,
and subciliary incisions). All seem to have some effect on the downturned mouth
early after surgery, but as the lift imparted relaxes over time, the ultimate correction
is not as pronounced as what might be achieved with a simple corner mouth lift.
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Chapter 51  Rejuvenation of the Aging Mouth
This 45-year-old woman came to us unhappy with her angry, tired appearance. She
underwent facial rejuvenation that included midface elevation. The downturned
mouth corners appear corrected 1 week postoperatively; however, at 3 months those
tissues have relaxed significantly and approximate her preoperative appearance.
Preoperative
1 week postoperatively
3 months postoperatively

Corner Mouth Lift
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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
A short upper lip can exaggerate an already downturned mouth. An attempt to solve
this problem (in the context of a postcleft whistle deformity) led to the first corner
mouth lift by Austin in 1985. His use of a Z-plasty elevated the downturned corners
but left rotated tissue below the commissure as an unnatural bulge. Excising this
bulge led to its correction and the realization that it was unnecessary. Thus the sec-
ond iteration of the original corner mouth lift (hereafter referred to simply as a cor-
ner mouth lift) was developed—a triangular excision of skin designed to rotate the
mouth corners cephalad.
To design a corner mouth lift, a mark is first placed at the commissure precisely at
the junction of the skin with the vermilion. A line is extended medially along the ver-
milion border for 10 to 16 mm. If one looks closely, there is often a subtle transition
of the three-dimensional curve of the vermilion in this region. If this transition is
present, it makes a good place to stop the medial extension.
A second line is then drawn from the commissural mark toward the top of the ear,
stopping short of the nasolabial fold.

The ends of the two lines are connected with a third line, the shape of which can be
varied to modify the lift of the lateral upper lip vermilion. A slight arc imparted to
this third line will evert the lateral lip vermilion more than a straight or concave line
will. Most of the third lines have a slight arc to them.
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Chapter 51  Rejuvenation of the Aging Mouth
The lift imparted to the corner of the mouth depends on the amount of skin excised.
Measured from the commissural mark to the point directly above it on the third line,
we have found that 5 to 7 mm of excised skin is our average, 3 to 5 mm gives a small
lift, and 7 to 10 mm corrects a more significant downturn.
Wraparound Corner Mouth Lift
One of the disadvantages of the corner mouth lift is the scar. The part of the scar ly-
ing along the vermilion border is well concealed, but the portion that lies lateral to
the commissure extends onto virgin lip skin and is, to some extent, at the mercy of
the vagaries of the healing process. In fact, it is visible in the previous patient’s post-
operative photo.
To avoid problems encountered with this lateral aspect of the scar, Weston devised
the “wraparound” corner mouth lift in 1994. This subtle but important alteration
of the corner mouth lift keeps the scar along the vermilion border by wrapping it
around the commissure onto the lower lip margin.

1804
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
Design of the wraparound corner lift begins with the same commissural mark and me-
dially directed line, as described earlier. The second line, however, is directed more ver-
tically than before, toward the lateral canthus rather than toward the tip of the ear.
The third line connects the ends of the other two, as previously described, but now
a fourth line is added, running from the commissural mark medially along the lower
lip’s vermilion border. This fourth line is approximately half as long as its counterpart
along the upper lip vermilion, and, with some undermining of the subjacent lip skin,
allows the commissural mark to rotate into the apex of the excised triangle of skin.
We have found a deep stitch of 5-0 or 6-0 polyglactin with significant purchase of
“perimodiolar” tissue crucial to minimizing the closure tension and ultimate scar,
as can be seen in this patient at 3 months postoperatively.

Vermilion Roll-Out
When the commissures require lifting, the wraparound corner mouth lift is an ex-
cellent procedure, but it can leave some minor irregularity along the lower lip mar-
gin where the excess tissue is worked in. Poindexter realized in 2005 that if the com-
missure itself does not need lifting (and most do not), a simple excision of skin along
the vermilion of the upper lip that stops at the commissure works nicely.
1805
Chapter 51  Rejuvenation of the Aging Mouth
The design of this excision is simpler than that of the other corner mouth lifts. It be-
gins with the same first line (commissural mark to medial endpoint along the ver-
milion border). The second line then becomes an arc connecting the ends of the first
line. This arc ascends sharply from the commissure toward the medial canthus, then
falls back gradually to meet the medial endpoint of the first line.
Over the past 23 years, we have performed more than 1500 corner mouth lifts and
have found it to be one of our most valuable rejuvenative techniques. It has the ca-
pacity, more than almost any other single procedure, to alter the overall facial coun-
tenance. At its best, it changes sad and angry to almost angelic. Three technical con-
siderations bear mention:
1. The surgeon should err on the conservative side (excisions less than 7 mm).
Taking more tissue can lead to secondary effects that become difficult to man-
age—bulges lateral to the commissure, for example. Keeping resections to this
limit also minimizes the problematic depressed scar. Although Juvéderm (Al-
lergan, Santa Barbara, CA) has proved to be a reliable temporary solution,
revision has occasionally been necessary.

2. Beware of patients with deep marionette grooves. In these patients, wrapping
the corner mouth lift can accentuate these depressions, particularly if the
fourth line or lower lip counterincision is not long enough. We have tried un-
dermining and filling the marionette grooves, with varying degrees of success.
Their significant presence is one of the indications we still have for a tradi-
tional corner mouth lift, and if the grooves are severe enough, they can be im-
proved with a combination of modalities.
3. The skin excision for any version of the corner mouth lift can be extended
medially up to the peak of the Cupid’s bow without becoming visible. We
again caution not to extend the incision to the area between the apexes of the
Cupid’s bow (as in a full upper lip advancement). At best, this can leave a vis-
ible scar with an unnatural, obviously surgical shape. At worst, it can leave a
tight band across the central lip. We have found that a better choice is to per-
form a lip lift to elevate the central lip and a corner mouth lift to elevate the
downturned corners.
Nasolabial Region
As an individual ages, the smooth, uncomplicated nasolabial region becomes in-
creasingly complex and difficult to rejuvenate. Initial signs of aging, creases that de-
lineate the fold, serve as tethers for the overlying cheek skin. Tissues thicken and thin
around the creases, leading to folds over them and depressions both above (piriform
aperture) and below (in the region of the mandibular ligament). How we deal with
this area depends on the extent to which the aging process has affected it.
Simple creases in a younger patient often lend themselves to filling alone. We say “of-
ten,” because filling creases without somehow exerting a pulling force on them can
lead to unpredictable irregularity in the healing process. Patients whom it affects—
younger patients who are not quite ready for a face lift, whose adjacent nasolabial
skin is otherwise slightly loose and fairly smooth—are often least able to tolerate this
irregularity. These caveats are true for fat injection more than for dermal fillers.
Augmentation of the Nasolabial Folds With Fillers
Nevertheless, filling the creases of the nasolabial fold is a fine technique in many
younger patients and in combination with a face lift in older ones. Available sub-
stances run the gamut from autologous to alloplastic, from long lasting to short term.
As a generalization, it seems to us that the material to be used for any augmentation
should as much as possible mirror the tissue into which it is being placed. (The main
exception to this rule seems to be the lips, where fat remains our filler of choice.) Fat
seems to survive best in fat, dermis/collagen seems to distort skin less than other sub-
stances, and silicone or Gore-Tex implants seem to do best placed deep, near the
1806
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

bone. Thus our preferred filler for directly beneath the nasolabial creases is Juvéderm
for short-term correction, and strips of fascia for longer-term correction. One ben-
efit of Juvéderm is that hyaluronidase can quickly and easily “erase” overcorrection.
The technique for placement of the latter is straightforward and has been previously
described.
Direct Fold Excision
1807
Chapter 51  Rejuvenation of the Aging Mouth
As the aging process continues, the looseness around the nasolabial fold increases
until filler is no longer effective. Using it in the volumes necessary is financially cum-
bersome and can be aesthetically undesirable. Some of these patients consider them-
selves too young for face lifts. In this group we consider performing direct excision
of the nasolabial fold, trading the uniformly thin scar that is barely perceptible at
conversational distance for the looseness that is visible from across the room.
Combining this direct excision with a lifting procedure is safe and allows a slightly
less aggressive face lift, leaving the patient with a more natural appearance.

1808
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
Our technique for determining the design follows. Placement of the scars is critical:
they should be just medial to the nasolabial furrow and extend no farther than is
necessary to excise the laxity.
The variations of our different excisional markings illustrated here are determined
by the anatomy of the individual.
 In 75% of patients, only the lower nasolabial fold is excised.
 In 25%, the inferior aspect of that incision is run laterally (as in the blade of a
hockey stick).
 Less than 5% of the time, the full length of the nasolabial fold is excised, and
on rare occasion folds are excised horizontally.

Key Principles
1809
Chapter 51  Rejuvenation of the Aging Mouth
The nasolabial crease is marked for the length to be excised, trying to leave both
ends in depressions so that subtle dog-ears will be masked. The pen is placed over
the area of most laxity (usually near the center of the drawn crease line), and the
skin is pulled medially without moving the pen.
A dot is placed that will mark the lateralmost border of the excision. This medial
pull is repeated a couple of times, with marks as needed to help define the arc of ex-
cision before connecting them. In this case, the patient’s anatomy suggested we draw
the lateral (hockey stick) extension.
The pen is placed back over the crease, and this time the skin of the cheek is pulled
laterally, again without moving the pen. There will be less movement in this direc-
tion. Again a dot is placed, this time marking the medial extent of the excision. The
medial dots are connected to form the outline of the total resection.

1810
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
Direct Fold Excision With Face Lift
Until a surgeon becomes familiar with the operation, it is prudent to perform the di-
rect excision as a secondary procedure. It is easily done with the use of local anes-
thesia in an examination room if the nasolabial excess remains problematic after a
face lift. However, if on preoperative examination the nasolabial region remains lax
while the surgeon simulates a face lift by lateralizing the cheeks with the fingers, we
often propose combining the two procedures.
A full-length nasolabial excision is shown. When this is performed in combination
with a face lift, the nasolabial fold is excised first. If the nasolabial tissue excision is
delayed until after the face lift, the residual swelling associated with the face lift may
make it appear that the direct excision is unnecessary. Our experience shows, how-
ever, that when the swelling and tightness relax after a few days, the need for direct
excision again becomes apparent. Note how the intraoperative tightness has relaxed
in the photo on the right, taken 1 week postoperatively.
Over the past 25 years we have performed more than 600 direct excisions of the na-
solabial folds. It is difficult to recall patients who have ultimately been dissatisfied
during that period, although many are concerned during the first 3 months. Once
the redness and firmness fade, however, the scars are almost imperceptible. Even mi-
nor irregularities are rare and can almost always be adjusted in the office with the
patient under local anesthesia.

Nasal Corner
The upper portion of the nasolabial fold is so rarely excised because it usually shows
up as a depression on examination rather than looseness or tissue excess. As people
age, the soft tissue overlying the piriform aperture thins until the skin at the corner
of the nostril feels like it rests almost on bone. Filling in this vacant nasal corner is
an extraordinarily easy and useful adjunct to almost any rejuvenation. It can be per-
formed in many different ways.
Filling the Nasal Corner
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Chapter 51  Rejuvenation of the Aging Mouth
The simplest way to fill the nasal corner is to inject the area with autologous fat or
perhaps fascia. Our preference is for the former, usually injecting from 1 to 2 cc, as
was done for this patient. A second method is to insert an equivalent volume of SMAS
or mastoid fascia into that region through a stab incision usually made just inside
the nostril verge. Through that incision a Joseph elevator is used to create a small
pocket into which the tissue is inserted. An alloplastic option is to place a small tri-
angle of silicone carved from either a cheek or chin implant along the bone from an
incision in the upper buccal sulcus or from the nostril verge. Brink implants (Im-
plantech, Ventura, CA), with or without the connection overlying the nasal spine,
are quite useful in this regard.

Resurfacing Procedures
Resurfacing the perioral area is both old and new. Modalities such as dermabrasion,
peels, and lasers have been in use long enough to be well understood by most expe-
rienced surgeons. However, integrating resurfacing into a comprehensive plan to re-
juvenate a harmonious face is something with which we continue to struggle.
Young faces are not wrinkled and are evenly pigmented. Nothing symbolizes an old
face more than wrinkles. Rhytids vary from fine to coarse and can either be confined
to one area (initially perioral or periocular) or can be distributed more globally. Al-
though often only the perioral area is resurfaced with facial rejuvenation, in a glob-
ally wrinkled aged face, consideration must be given to resurfacing the entire face.
In the end, the quality of skin in all areas of the face should be consistent.
For fine wrinkling confined to the perioral region, we primarily rely on dermabra-
sion and the tunable erbium laser (Sciton, Palo Alto, CA). For the former, painting
the skin with a light coat of methylene blue and removing it with a coarse diamond
fraise (cleaning it frequently with a toothbrush dipped in peroxide to prevent clog-
ging the fraise’s interstices) provides a nice margin of safety.
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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
As the rhytids become coarser, dermabrasion and the Sciton laser remain our main-
stays. In addition, we almost always undercut the deeper rhytids with an 18-gauge
needle and fill that undercut with a drop of autologous fat.

The settings for the Sciton laser vary, but we have found a single pass with 40 mi-
crons of ablation will almost universally induce a light peel. As the skin peels, much
of the solar dyschromia comes off with it, and at this fluence, this laser appears safe
for undermined skin. This becomes important in integrating any deeper central laser
treatment (perioral, nasal, and forehead) in one stage with a face lift. By going deeper
in the central (not undermined) regions of the face with the laser tuned for coagu-
lation, we are able to erase most fine to moderate wrinkling and still blend the color
change in that central area with the rest of the face in one session.
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Chapter 51  Rejuvenation of the Aging Mouth
This 64-year-old patient demonstrates this principle. Of note here is the use of fat
grafting as an adjunctive modality for treating wrinkles. When the wrinkles are fine
and radially oriented, adding fat beneath the vermilion will sometimes stretch the
vermilion border enough to obviate the need for resurfacing. Certainly, it is a good
adjunct procedure. Botulinum toxin, 2 to 4 units placed intermittently along the up-
per lip, is also useful in the short term and can be done adjunctively with fat injections.
Deeper resurfacing always runs the risk of hypopigmentation, and every surgeon
must perform his or her own calculus. Recently, ours has erred on the side of leav-
ing rhytids rather than risking an uncorrectable skin discoloration. One can always
perform a secondary wrinkle procedure.
We reserve the use of phenol for the deepest rhytids, which in our practice are rela-
tively rare. Deep resurfacing poses the problem of combining a very powerful resur-
facing modality with lifting procedures in one stage. We have used all manner of
lasers (CO2, tunable, regular erbium, fractionated) and 35% trichloroacetic acid dur-
ing face lifts and have used them to resurface flaps at the same time. We have yet to
resurface an undermined flap with phenol and cannot envision a situation in which
we would attempt it. We have therefore used phenol centrally (brow, nose, and mouth)
and combined it with other resurfacing agents on the flap, or we simply stage the
lifting procedures with a full-face phenol peel.

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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
This middle-aged woman underwent a phenol peel to resurface her perioral region.
There is persistent redness following the procedure, which is typical of the prolonged
recovery from the deeper peels.
Nasolabial Variants and the Marionette Groove
Folds of tissue around the nasolabial crease can be massed primarily either medial
or lateral to the crease itself, the former commonly known as the marionette groove.
The clinical implication of this distinction is that lateral tissue can be expected to re-
spond better to all modalities (face lifts, skin-tightening resurfacing, and direct exci-
sions) than will medial tissue.

This patient demonstrates both variants; she underwent a face lift with deep central
Sciton laser resurfacing and fat grafting. Three months postoperatively, it can be seen
that the modalities had less effect on the patient’s right side in effacing the marionette
groove.
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Chapter 51  Rejuvenation of the Aging Mouth
Temporary correction of the marionette groove can be achieved nicely with Juvé-
derm (less than 1 cc) and/or botulinum toxin (4 to 6 units) placed into the depres-
sor anguli oris (identified by asking the patient to exaggerate the marionette groove
while the surgeon palpates the area for muscle contraction).

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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
More permanent correction is often best achieved by combining direct excision (or
skin tightening laser) of any lateral nasolabial excess with subcision of the marionette
groove. For this we use a 14-guage needle and then inject fat. A horizontal mattress
suture of 6-0 Prolene can be used to elevate the subcised tissue during the early phase
of healing. Four units of botulinum toxin may be useful during healing.
The Vermilion: Restoring Shape and Volume
The lips thin and roll inward as we age, and the vermilion can virtually disappear,
making one look old and bitter. Although the lip lift and corner mouth lift both ex-
pose more vermilion, the primary goals of those techniques are to correct a long up-
per lip and drooping mouth corner, not to correct thin lips or contour the lower lip
vermilion. Restoring volume to the lips not only helps re-create the plumpness of
youth but also helps to subtly rejuvenate the complex anatomy around the commis-
sures. Advancing the lower lip vermilion is also indicated on occasion, usually in the
older patient or aged face.

Fat Grafts
For moderately thin lips, we prefer fat grafting. Although we have found the lips to be
one of the places on the face with the most variable “take,” grafting fat remains a
workhorse, because of its low cost, availability, and ease of use. The technique can
be as accurate as threading tissue grafts; the survival rate in our hands varies from
0% to 70%. We have begun freezing fat for later injection with the patient under lo-
cal anesthesia. Although cell culture techniques suggest that these cells do not sur-
vive without a special culture medium, we suspect additional volume may be achieved
through the scarring process.
Alloplastic Fillers
Alloplastic materials are a nice fallback should fat resorb completely or be found ob-
jectionable by the patient. Hyaluronic acids have been our favorites. Collagen has a
long history, and its strengths and weaknesses are well known. Autologen was a nice
idea but was financially impractical and is of historical interest. AlloDerm may have
utility, but it is expensive, and we have no experience with its use in the lips. We have
found Radiance disastrously lumpy. We have essentially abandoned implanting Gore-
Tex in the lips, because too many unnatural results warranted its removal.
Lip Advancement
In aged lips, when the lower lip is very thin or has rolled inward significantly, tissue
grafts for volume may be inadequate, and lip advancement should be considered. As
mentioned earlier, upper lip vermilion advancements done by excision of a contin-
uous strip of upper lip skin, including the prolabial portion between the peaks of
the Cupid’s bow, are risky, because they can sometimes contract and flatten the Cu-
pid’s bow. Even the best of scars in this area are fairly noticeable.
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Chapter 51  Rejuvenation of the Aging Mouth
As discussed earlier, a better solution is to extend the corner mouth lift up to the ip-
silateral peak of the Cupid’s bow and perform a small central lip lift, as was done
for this patient. (Fat was also grafted to the lips.)

The lower lip architecture is less complex than that of the upper lip, and lower lip
advancement is a reliable way to expose more lower lip vermilion. A strip of subja-
cent skin is excised from corner to corner, twice as wide as the amount of advance-
ment desired. The scar lands at the vermilion border and is usually imperceptible,
even from inches away. When combined with the corner mouth lift, a small gap
should be left between the incisions at the commissure to prevent the possibility of
scar contraction.
Mucosal Advancement Flaps
Mucosal advancement flaps can also be used to increase mucosal volume and change
the shape of the vermilion. We now rarely use them because they lengthen the upper
lip, and patients complain about how the mucosal scars feel. We prefer the other pro-
cedures described earlier.
Ancillary Procedures
Correction of a Witch’s Chin
We have tried many ways to correct a ptotic chin pad, or witch’s chin, and have found
the following technique to be a straightforward and reliable way to go about it.
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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

Through a submental incision, the fat pad of the chin is isolated on a superior pedi-
cle by separating it from the skin above and periosteum below. This dissection must
be generous enough, particularly laterally, to allow for the free rotation of the fat
flap up under itself. Attaching a “leading” stitch to the apex of the flap and direct-
ing that stitch along the periosteum and out the labiomental fold easily accomplishes
that rotation. Taping the stitch in place fixes the flap.
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Chapter 51  Rejuvenation of the Aging Mouth
This 62-year-old woman was unhappy with her aging face but was particularly fo-
cused on her ptotic witch’s chin. She underwent a facial rejuvenation that included
correction of her ptotic chin pad by rotation of the superiorly based fat flap. Results
are shown at 4 months postoperatively. She is delighted with the improvement.
Reshaping the Philtral Columns
A smooth, round, simian upper lip is simply not youthful. We have discussed ways
of recreating vermilion contour (lip lifts and fat grafts) but have only alluded to recre-
ating the subtle anatomy around the philtral columns; a lip lift with a central com-
ponent will often suggest columns by creating a philtral dimple and, if extended far
enough, a “pouty” apex to the Cupid’s bow.

Hills are often hills because they are next to valleys. Creating a philtral dimple is
sometimes enough to rejuvenate the philtral region. This can be accomplished by the
lip lift with a central component, or by simply undermining the lip lift and taking a
partial-thickness “scoop” of orbicularis oris muscle. The resultant cleft mimics the
philtral dimple.
The actual creation of philtral columns is a bit more difficult. We have used fat graft-
ing without great success. Fat seems to live poorly in this tight, mobile area. Juvé-
derm works well, but its effects are relatively short lived. Fascial strips seem to be a
good option and are currently our preferred choice when the patient desires a more
permanent solution. They are placed by attaching a leading stitch onto the end of
the strip, then into a 14-gauge needle that is placed under the skin in the desired lo-
cation of the philtral column. Austin had found it useful to wrap these strips in
polyglactin.
Concluding Thoughts
We have found that surgical rejuvenation of the aging mouth often requires a more
direct approach than most plastic surgeons are routinely comfortable with. Our usual
trade-off of scar for shape takes on new meaning when the scar might lie along the
vermilion border, on the nostril sill, or along what was a nasolabial crease. Never-
theless, in more than 80 combined years of practice and in more than 3000 patients,
we have found that trade-off not only worthwhile but a wonderful adjunctive solu-
tion to difficult rejuvenative problems.
Clinical Caveats
 At least 10 to 12 mm of upper lip should be left after a lip lift.
 It is better on the conservative side for corner lifts; lip lift excisions should be less
than 7 mm.
 If the commissure itself is in good position and does not need lifting, a vermilion
roll-out should be considered.
 The surgeon should beware of a patient with deep marionette grooves. In these
patients, wrapping the corner mouth lift can accentuate these depressions, par-
ticularly if the fourth line or lower lip counterincision is not made long enough.
 Caution should be exercised when combining a lip lift with an open rhinoplasty.
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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears