The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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XIV Gender-Affirming Surgery
Table 112.1 WPATH Standards of Care guidelines
Procedure:
Trans masculine
Referrals
Documentation
Hormones
Age
Health status
Mastectomy and
creation of male chest
aOne referral (letter) by
a qualified mental health
professional
Persistent, well-
documented gender
dysphoria
Not a prerequisite
Age of majority
in given country
(18 in U.S.)
Significant medical
or mental health
concerns must be
reasonably well
controlled.
Hysterectomy and
oophorectomy
Two referrals (letters) by
qualified mental health
professionals; if one
letter is from therapist,
the other should be from
evaluator
Persistent, well-
documented gender
dysphoria
b12 continuous months
of hormone therapy as
appropriate to patient’s
gender goals; exception
if the patient has medical
or personal reasons not to
take hormones
Age of majority
in given country
(18 in U.S.)
Significant medical
or mental health
concerns must be well
controlled.
Metoidioplasty or
phalloplasty
Two referrals (letters) by
qualified mental health
professionals; if one
letter is from therapist,
the other should be from
evaluator
Persistent, well-
documented gender
dysphoria; must be living
12 continuous months
in gender role that is
congruent with gender
identity
12 continuous months
of hormone therapy as
appropriate to patient’s
gender goals; exception
if the patient has medical
or personal reasons not to
take hormones
Age of majority
in given country
(18 in U.S.)
Significant medical
or mental health
concerns must be well
controlled.
Trans feminine
Breast augmentation
(implants/lipofilling)
One referral (letter) by a
qualified mental health
professional
Persistent, well-
documented gender
dysphoria
Not an explicit criterion,
but recommended that
patients are 12 months
postfeminizing hormone
therapy
Age of majority
in given country
(18 in U.S.)
Significant medical
or mental health
concerns must be
reasonably well
controlled.
Orchiectomy
Two referrals (letters) by
qualified mental health
professionals
Persistent, well-
documented gender
dysphoria
b12 continuous months
of hormone therapy as
appropriate to patient’s
gender goals; exception
if the patient has medical
or personal reasons not to
take hormones
Age of majority
in given country
(18 in U.S.)
Significant medical
or mental health
concerns must be well
controlled.
Vaginoplasty
Two referrals (letters) by
qualified mental health
professionals
Persistent, well-
documented gender
dysphoria; must be living
12 continuous months
in gender role that is
congruent with gender
identity
12 continuous months
of hormone therapy as
appropriate to patient’s
gender goals; exception
if the patient has medical
or personal reasons not to
take hormones
Age of majority
in given country
(18 in U.S.)
Significant medical
or mental health
concerns must be well
controlled.
Adolescents
FtM chest surgery
Treatment decisions
should be made among
the adolescent, the
family, and the treatment
team
“Ample time” of living in
the desired gender role
One year of testosterone
treatment
(Below age 18)
Genital surgery
Must be living 12
continuous months
in gender role that is
congruent with gender
identity
dLegal age of
majority in
country
Abbreviations: FtM, female-to-male; WPATH, World Professional Association for Transgender Health.
aReferral letters should include:
1. Patient’s identifying characteristics
2. Diagnosis and other psychological evaluation results
3. Details of relationship to patient: duration of care, type of evaluation, type of counseling or treatment
4. Endorsing patient’s application and explaining how they fulfill criteria for surgery
5. Confirmation of informed consent
6. Confirmation of availability for coordination of care
7. Confirmation of adequately controlled mental health concerns
bTo introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes irreversible surgical intervention.
cThough it is not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional.
dThe age threshold should be seen as a minimum criterion and not an indication in and of itself for active intervention.

 Gender-Affirming Surgery 7RS Surgery
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112.3 FtM: Preoperative
Assessment
As noted previously, trans masculine patients presenting for
chest contouring should have a referral letter from a qualified
mental health provider that is in accordance with the WPATH-
SOC. Testosterone treatment is not a prerequisite for trans mas-
culine top surgery, except in adolescents (Table 112.1). Patient
evaluation should focus on general health, body mass index,
smoking history, medical comorbidities, and risk factors for
breast cancer. Any patient with a strong family history or other
breast cancer risk factors should undergo appropriate screening
preoperatively, including referral for possible genetic testing.
With the increasing recognition of the prevalence of gender dys-
phoria in adolescents, it is important to be aware that patients may
present for top surgery before the age of 18. The WPATH-SOC provide
guidance for gender-affirming surgery in adolescents, stating that
patients below the age of 18 may undergo FtM chest reconstruction
surgery with two additional requirements: the real-life experience,
which is a period of time living in the desired male sex role, and 1
year of testosterone treatment (Table 112.1). Assembling a multi-
disciplinary care team provides the highest degree of assurance for
proper patient selection in adolescent patients.
112.4 FtM: Examination of
3erWinenW %reDVW&KeVW
Anatomy
Three specific anatomic features determine the surgical proce-
dure of choice and should be carefully evaluated in each patient:
1. Size of the breast or breast parenchymal volume
2. Amount of excess skin, generally corresponding to the degree of
breast ptosis
3. Skin elasticity
Many trans masculine patients bind their breasts prior to sur-
gery to achieve the appearance of a flat chest, which often results
in ptotic, “pancake” breasts with poor skin elasticity (Fig. 112.1).
The size and position of the NAC should also be noted. The female
NAC size ranges more broadly than in anatomic males, but as a
general rule, it is widely accepted that the average female NAC
is larger than the male NAC and will need to be reduced in size
during the procedure. In addition, the nipple papule diameter and
projection is generally greater in females and should be noted and
included in the surgical plan. A full clinical breast examination is
mandatory for every patient.
Table 112.2 Gender-affirming top surgery procedure selection guideline
Trans masculine
Top surgery approaches:
BMI
Breast size
Skin quality
Ptosis
NAC
Patient goals
Liposuction with possible
peri-areolar incision
Fig. 112.2
< 25
< A cup
(small breasts)
Excellent
elasticity
Grade 0–I
Nipple does not
need to be resized
or repositioned.
Minimally invasive, patient
acknowledges higher chance
of nipple loss, redundant skin,
reoperation/revision rate, and
inability to resize nipple.
Concentric circular or
“donut mastopexy”
Fig. 112.3
< 25
< B cup
(small–medium
breasts)
Good elasticity
Grade 0–II
Nipple can be
reduced some but
does not need to be
repositioned.
Less scarring, minimally invasive,
patient okay with current
nipple positioning, patient
acknowledges higher chance of
secondary revisions and extra-
areola scarring.
Double incision
mastectomy with free
nipple grafting
Fig. 112.1, Fig. 112.4
> 25
> B cup
(medium-large
breasts)
Good–poor
elasticity
Grade II+
Nipple should
be resized and
repositioned to
more masculinizing
configuration.
Patient seeking flat chest with
minimal risk of reoperation/
revisions. Patient is satisfied with
long inframammary scarring.
Trans feminine
Top surgery approaches:
Breast size
Chest diameter
Implant volume
NAC
Considerations
Subglandular
A–C
Often tuberous
Wide
Maximum 550 mL
depending on
patient goals
and existing skin
envelope
Wide NAC–
NAC distance
poses difficulty
in achieving
postoperative
cleavage.
Subglandular implants may help
improve projection and minimal
distortion with muscle activation.
An implant width > breast width
may result in Snoopy-nose
deformity, requiring scoring of
breast parenchyma overlying
implant.
Submuscular or biplanar
placement
Fig. 112.5
A–C
Wide
Maximum 550 mL
depending on
patient goals
and existing skin
envelope
Cleavage is limited
as implants must be
centered under the
widely spaced NAC
and wide sternum.
There is less projection in
submuscular or biplanar
augmentations given a broad
pectoralis major muscle.
Implants may also be prone to
ride high in the pocket secondary
to muscle contracture.
Abbreviations: BMI, body mass index; NAC, nipple–areola complex.

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112.4.1 Choice of Surgical Procedure
A large number of individual surgical procedures have been
described for FtM gender-affirming surgery. This emphasizes that
no one procedure is optimal for all anatomic configurations, and
that there is considerable variation among surgeons in preferred
surgical approach. While top surgery is widely regarded as an
independent procedure, the objectives of creating a male chest
are generally analogous to treatment of gynecomastia. Several
systems or algorithms have been devised and are extensively
described in the literature to assist plastic surgeons in procedure
selection. To name a few, these include the Amsterdam expe-
rience, the Monstrey algorithm, and the McEvenue algorithm.
However, all current approaches can be classified or grouped into
three general strategies that will be effective across this entire
patient population:
1. Minimally invasive approach using liposuction, possibly com-
bined with periareolar incision, to reduce breast parenchyma
beneath the NAC and obliterate the IMF
2. Concentric circular or “donut mastopexy” approach with cir-
cumferential skin resection
3. Mastectomy through inframammary incisions with free nipple
grafting (referred to in the transgender community as double
incision free nipple grafting [DIFNG]).
Because of the expanding effects of chronic breast binding
on the skin envelope, the majority of patients, even those with
relatively small breasts, require DIFNG to achieve an aesthetically
satisfactory result. Table 112.2 gives the general guidelines
for selection of procedure type based on patient anatomy. It is
important to note that multiple other incision patterns have been
described and that procedure choice (even for identical anatomy)
is highly variable among surgeons. In addition, a patient’s desired
outcome may also play a role in procedure selection and incision
making, such as in cases of preserving chest tattoos or minimiz-
ing inframammary scar visibility. Table 112.2 represents our
recommended strategy and is intended as a general guide only.
The three approaches are not exclusive of each other; they are a
continuum of intervention that can be combined in different ways
when appropriate.
112.5 FtM: Preoperative
Preparation
When obtaining informed consent from a patient, the plastic
surgeon should explain the rationale for the choice of the specific
operative approach as well as the risks and likely outcomes.
Patients should be aware that for all FtM chest recontouring
procedures, the complication rate (Table 112.3) and revision rate
(Table 112.4) are relatively high, with concentric circular mastec-
tomy having the highest revision rate secondary to unfavorable
scarring. Patients should be optimized for surgery according to
accepted guidelines for nutritional status, smoking cessation,
diabetes control, antibiotic prophylaxis, and deep venous throm-
bosis prophylaxis. Despite the lack of compelling evidence, most
centers discontinue cross-sex testosterone treatment for several
weeks before and after surgery. This is now changing, with many
centers opting to continue testosterone treatment across the
surgical episode. Testosterone has not been definitively associ-
ated with wound healing delay, venous thromboembolism, or
bleeding in the postoperative period in studies of nontransgender
male patients. Procedures are most commonly performed as day
case procedures under general anesthesia.
112.6 )W0 SSeFiÀF 2SerDWiYe
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112.6.1 Liposuction and Periareolar
(“Keyhole”) Approach
Liposuction with possible periareolar incision is an appropriate
method for patients with small breast size, minimal skin excess,
adequate native NAC size, and excellent skin tone. Liposuction is
performed bilaterally to begin the procedure using tumescence
to help control bleeding. Three stab incisions may be used at
the medial IMF, the lateral IMF, and the axillary fold. Although
liposuction works best in fatty tissue, breast parenchyma can be
reduced with patience and effort. Liposuction should continue
across the IMF to weaken or obliterate that structure (one of the
four main objectives of FtM top surgery, mentioned previously).
Once the desired amount of breast volume has been removed
and an acceptable male chest contour has been achieved, a 3 to 9
o’clock incision is made at the periphery of the NAC, and breast
parenchyma is removed directly, especially from under the NAC.
The obvious advantage of this approach is the limited cutaneous
scarring. The skin and NAC will contract following removal of
the parenchyma secondary to elastic recoil. If it is necessary to
adjust the size of the NAC by more than 1 cm, a donut approach
may be preferable (Fig. 112.2).
112.6.2 Mastectomy with Circumareolar
Skin Excision
This approach is an appropriate choice for patients with modest
excess breast volume, a modest degree of skin excess, and good
skin tone. The procedure is planned by marking the reduction of
the NAC to a masculine dimension (2.4 × 2.0 cm). Following this, a
concentric circle is drawn around the initial reduced NAC mark-
ing, estimating the amount of skin that can be removed. The area
between these two concentric circles is de-epithelialized and an
incision is made from 4 to 8 o’clock in the de-epithelialized area.
This allows access to the breast parenchyma for direct excision.
Direct excision can be augmented with liposuction, especially
to feather the periphery and obliterate the IMF. Once suitable
reduction and contour have been achieved, the incision within
the de-epithelialized area is closed with an absorbable suture,
and the outer concentric circle is purse-stringed to the NAC
using a running suture in a spoke. We use a long-lasting absorb-
able polydioxanone suture (PDS), but many surgeons prefer a
permanent suture (e.g., Gore-Tex, W.L. Gore and Associates,
Flagstaff, A=) for the purse string. The advantage of this approach
is that the cutaneous scar is confined to the periphery of the
NAC. However, because of the limited access to the breast paren-
chyma, contour irregularities are relatively common. It is more
difficult to relocate the 1AC on the chest wall, and due to tension

 Gender-Affirming Surgery 7RS Surgery
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on the purse string, spreading of the scar at the periphery of the
NAC is frequently observed. Limited satisfactory options exist to
address this; therefore this approach is primarily reserved for
patients requiring a modest skin excision. If utilized, concentric
circular skin excision should be more conservative than aggres-
sive in nature (Fig. 112.3).
112.6.3 Double Incision Mastectomy
with Free Nipple Grafting
DIFNG is the most versatile of the techniques for FtM chest
reconstruction. It is suitable for patients with large breast vol-
umes, excess skin, and all skin qualities. Technically, the proce-
dure is straightforward, and wide exposure facilitates adequate
and precise breast tissue removal. Free nipple grafting allows
complete freedom to reduce the size and change the position of
the NAC.
Preoperatively, the IMF on each side is identified. Because this
mark may rise with excision and closure of the mastectomy, it is
best to mark incision 0.5 cm below the fold. Some surgeons prefer
an incision that curves up laterally along the lateral border of the
pectoralis, which works well in slim patients. In heavier patients,
the final scar location is more predictable in largely transverse
incisions.
The procedure begins by harvesting the NAC, 2.4 cm in diameter
on each side. The NAC grafts are defatted for later use. If papule
reduction is desired, a two-piece nipple graft may be performed
with separate grafts for the areola and papule to be placed one
inside the other. The inframammary incisions are made and dissec-
tion is carried to the level of the pectoralis fascia. The IMF is then
obliterated and scored, and the breasts are undermined superiorly
as a composite unit to the clavicles. The breast is redraped and
the amount of skin excision is estimated, typically just above the
upper pole of the NAC. The upper incision is made and the breast
is excised by raising a superiorly based flap superficial to the breast
capsule. Once the breasts are removed, the skin is redraped and
the amount excised is adjusted if necessary. The inframammary
incision is then closed, and with the patient in a sitting position
the position of the 1AC is confirmed. There are various methods for
determining the optimal male NAC position; we recommend avoid-
ing absolute measurements. Free-hand placement with sterile label
stickers ensuring symmetry from the midline and the sternal notch
generally works well. The site for the NAC is then de-epithelialized
(an oval shape more closely matches male appearance), and this
area can be now be used as an access point to perform liposuction
for tailoring and for obliterating the inframammary fold. The NAC
is then sewn in as a free graft with bolster dressings (Fig. 112.4).
The disadvantage of this approach is the long inframammary
scar. Despite this, the ability to precisely control tissue removal
and to contour the chest has resulted in a high satisfaction profile
and low revision rate for both complications and cosmetic revi-
sions. The specifics of inframammary incision design and method
for placement of the NAC vary among surgeons.
Fig. 112.1 (a–e) Effects of chest binding, preoperative double incision free nipple grafting gender-affirming surgery. (f–j) Effects of chest binding,
postoperative double incision free nipple grafting gender-affirming surgery.
Fig. 112.2 (a–d) Preoperative keyhole mastectomy. (e–h) Postoperative keyhole mastectomy.

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112.7 FtM: Postoperative Care
At the end of the procedure, patients will receive sterile dressings
and a prefitted compression vest. It is very important not to use
female surgical bras or breast binders in this patient population.
An Ace wrap (3M, St. Paul, MN) or abdominal binder is socially
more acceptable to these patients than anything resembling a
bra. The use of drains varies considerably among surgeons; we
prefer to place closed suction drains for the first 5 days postop-
eratively in patients undergoing concentric-circular or DIFNG
procedures. All of the usual precautions and instructions for
outpatient surgery should be in place through adequate preoper-
ative counseling regarding appropriate analgesic use, limitation
of strenuous activity, smoking cessation, and recognition of
complications. Patients are generally followed up 5 to 7 days
postoperatively when drains are removed, and the surgical sites
are inspected. For DIFNG patients, the NAC bolster is removed
and a nonstick dressing regime is instituted. Patients are advised
that they may engage in light activity and are seen again in 2 to
4 weeks. If wound healing is satisfactory, patients can have more
restrictions relieved and be advised that a late follow-up visit
at 4 to 6 months postoperatively will allow an accurate assess-
ment of final outcomes. Occurrence of complications naturally
warrants earlier and more frequent follow-up. It is mandatory
to inform patients that we do not have any data to guide sur-
veillance for breast disease in trans masculine patients. They
must inform their primary care physician of their transgender
status and their surgical history. Although there are no validated
recommendations, a yearly clinical breast exam is recommended
with additional imaging or screening for patients if warranted
(physical exam findings or significant breast cancer risk factors).
Further research will guide ongoing health maintenance recom-
mendations in the transgender population.
112.8 FtM: Complications and
Revisionary Procedures
Top surgery in trans masculine patients carries the same compli-
cation profile as breast surgery of this magnitude in natal females.
Reported complication rates vary widely in the literature (Table
112.3). Table 112.4 lists the most common complications and the
ranges of their relative frequency. Specific to DIF1G procedures,
incomplete take of the full-thickness NAC graft can occur. This
is best managed conservatively with dressings, often with a
satisfactory outcome without further intervention. In some
cases, NAC reconstructive operations and tattooing can be used
if needed. In cases where significant melanocyte content is lost
due to defatting of the NAC, tattooing of the nipple-areolar skin
can restore a more naturally pigmented appearance, especially
in darkly complected individuals.
Revision surgery to address contour irregularities, standing
cones, and skin irregularities are relatively common. The con-
centric circular carries the highest revision rate. Table 112.3 and
Table 112.4 summarize the reported complication and revision
rates for each of the three general approaches. It is recommended
Fig. 112.3 (a–e) Preoperative concentric mastectomy. (f–j) Postoperative concentric mastectomy.
Fig. 112.4 (a–e) Preoperative double incision free nipple grafting. (f–j) Postoperative double incision free nipple grafting.

 Gender-Affirming Surgery 7RS Surgery
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that ancillary procedures be delayed for a minimum of 6 months
after surgery to allow adequate scar maturation.
112.9 FtM: Outcomes
Transitioning by means of altering the body to match gender
identity by surgery has been repeatedly shown to improve quality
of life in transgender patients. Patient-reported outcome mea-
sures to assess subjective patient satisfaction with the cosmetic
outcome have also been used and described in the literature.
These included the use of a subjective Likert scale, visual analog
scale, Body Uneasiness Test, and BREAST-Q. Existing literature
on complication and revision rates, and on patient satisfaction,
demonstrates that FtM chest reconstruction surgery is overall a
very safe and effective procedure.
112.10 Male-to-Female Top Surgery
Breast augmentation in trans feminine patients is performed
much less frequently than chest recontouring in trans mascu-
line patients for a number of reasons. First, breast size in natal
females varies tremendously, and, therefore, having relatively
Table 112.3 Female-to-male top surgery complications in literature
Article
Author
Year
Study Design
N
Complication
Rate (%)
Complications
Creation of a male chest in female
transsexuals
Lindsay
1979
Case series
9
44
3 hematoma
Chest wall contouring for female-to-male
transsexuals: Amsterdam experience
Hage and Bloem
1995
Retrospective
cohort
70
20
7 hematoma
4 sloughing of areolar flaps
2 wound dehiscence
1 NAC graft loss
Circumareolar mastectomy in female-
to-male transsexuals and large
gynecomastias: a personal approach
Colić and Colić
2000
Case series
17
11.7
2 areolar necrosis
Chest wall contouring for female-to-male
transsexuals
Takayanagi and
Nakagawa
2006
Case series
29
27.6
3 partial NAC necrosis
1 hematoma
2 hemostasis
1 superficial skin necrosis of
areola
1 redundant skin with
periareolar wrinkles
Chest-wall contouring surgery in female-
to-male transsexuals: a new algorithm
Monstrey et al
2008
Retrospective
cohort
92
12.5
11 hematoma
5 wound dehiscence
5 partial NAC necrosis
2 abscess
Mastectomy in female-to-male
transsexuals
Namba et al
2009
Retrospective
cohort
132
7.6
6 hematoma
4 partial NAC necrosis
Subcutaneous mastectomy in female-to-
male transsexuals: a retrospective cohort-
analysis of 202 patients
Cregten-Escobar
et al
2012
Retrospective
cohort
202
5
Minor complications only
Female-to-male transgender chest
reconstruction: a large consecutive, single-
surgeon experience
Berry et al
2012
Retrospective
cohort
100
11
6 hematoma
3 infection
1 partial NAC loss
1 total NAC loss
Improved results after implementation
of the Ghent algorithm for subcutaneous
mastectomy in female-to-male
transsexuals
Bjerrome Ahlin et al
2014
Retrospective
cohort
30
71.4 (group 1)
25 (group 2)
Not specified
Sexual reassignment surgery in female-
to-male transsexuals: an algorithm for
subcutaneous mastectomy
Wolter et al
2015
Retrospective
cohort
173
11.8
32 hematoma
4 full NAC necrosis
3 partial NAC necrosis
2 seroma formation
Chest surgery in female to male
transgender individuals
Frederick et al
2017
Retrospective
cohort
88
33
Not specified
Female-to-male chest reconstruction: a
review of technique and outcomes
Donato et al
2017
Retrospective
cohort
130
24.5
21 minor (16%)
11 major complications (8.5%)
Surgical indications and outcomes of
mastectomy in transmen: a prospective
study of technical and self-reported
measures
van de Grift
et al
2017
Prospective
cohort
54
26
22
Concentric circular 26%
Mastectomy with FNG 22%
Abbreviations: FNG, free nipple graft; NAC, nipple–areola complex.

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XIV Gender-Affirming Surgery
small breasts is not necessarily problematic to be perceived as
female in public. Much like natal females, trans feminine patients
who receive estrogen therapy will experience variable degrees
of breast development, which may be adequate for the patient’s
self-image. In addition, breast augmentation is infrequently
covered by insurance, even when plans offer a gender surgery
benefit. Therefore, this is most often a self-pay procedure, and
a majority of patients are limited by personal costs. Although
fat grafting alone has been reported as an option for breast
augmentation, the vast majority of augmentation procedures in
trans feminine patients will involve breast implants. The latter
will therefore be the focus in the ensuing discussion.
112.11 MtF: Preoperative
Assessment
As for all gender expansive patients, sensitivity to preferred
names and pronouns is important, as is following the WPATH-
SOC (Table 112.2). Note that for trans feminine patients seeking
augmentation, the recommendation is that they first engage in
a full year of hormone therapy to allow maximum development
of their native breasts. Following this, the patient’s current
and desired breast size should be determined. The patient’s
general health status and risk factors for complications should
be assessed, including a mandatory, thorough assessment of the
risk factors for breast cancer in the future, including any family
history of breast disease.
Patients whose general health, motivations, and expectations
are realistic should be informed of the options and risks of
breast augmentation using alloplastic implants. A preoperative
mammogram is required in patients over 40 years old, as cancer
in trans feminine patients has been reported in the literature.
These choices and risks are discussed extensively in the chapters
on breast augmentation and include the relative advantages and
disadvantages of saline-filled and silicone gel–filled implants, the
relative merits of submuscular versus subglandular placement,
decreased visualization of breast tissue on mammography, choice
of incision, and a full discussion of the consequences of long-term
implantation of an alloplastic device. Patients should be fully
aware that an alloplastic device is likely to fail at some time in
the future, necessitating revision, removal, or replacement. All
the complications specific to breast implants should be reviewed,
including infection, capsular contracture, malposition, and,
although uncommon, breast implant–associated anaplastic large-
cell lymphoma (BIA-ALCL).
112.12 MtF: Examination of
3erWinenW %reDVW&KeVW
Anatomy
As discussed in the previous sections in this chapter, the male
chest is generally wider, with more widely placed and lower NAC
positions than in natal females. The IMF is also typically higher
and less rounded.
Breast base width should be measured bilaterally. Constricted
breasts, including tuberous breasts, may require scoring of the
parenchyma at the time of augmentation. These dimensions
should be carefully noted, and the patient should be informed
of its consequences for implant selection and placement. The
wide base diameter of the male chest often dictates large implant
volumes, and because the implant must be centered under the
1AC, the breasts will be relatively widely placed, with difficulty
achieving cleavage. Subpectoral placement of implants also limits
postoperative cleavage in bras and in clothing, depending on the
width of the patient’s sternum. Sizing of implants should be done
as for natal females, while wearing a bra they would like to fit into.
112.12.1 Choice of Surgical Procedure
As with natal females requesting breast augmentation, there
is no “standard” breast augmentation procedure for trans fem-
inine patients. This is due to the multiple options for implant
style, incision placement, implant placement (submuscular or
subglandular), and adjunctive maneuvers. Surgeon experience
and individual patient preference will guide the specifics of
each procedure more than the literature to date. Nonetheless, a
growing body of literature points out trends in trans feminine
augmentation (summarized in Table 112.1).
The most commonly performed cosmetic procedure world-
wide is likely a submuscular augmentation with smooth, round
implants (Fig. 112.5). A release of the pectoralis major muscle
Fig. 112.5 (a–e) Subpectoral breast augmentation with inframammary fold incisions, preoperative. (f–j) Subpectoral breast augmentation with
inframammary fold incisions, postoperative.

 Gender-Affirming Surgery 7RS Surgery
1631
inferiorly to the medial sternal origin with partial-thickness divi-
sion of the medial pectoralis muscle from the sternum is usually
recommended to allow better projection. A more recent trend is
toward subglandular placement, allowing for better projection
and minimal distortion with muscle activation.
Preoperative preparation for trans feminine chest surgery
requires the same detailed informed consent and attention to
mitigating risk factors as for trans masculine surgery. Although
there has been discussion to the contrary, we believe that existing
literature underscores the importance of stopping estrogen sev-
eral weeks preoperatively and resuming no sooner than several
weeks postoperatively.
112.13 0W) SSeFiÀF 2SerDWiYe
7eFKniTue Dnd
Postoperative Care
With the caveats already discussed, breast augmentation pro-
cedures in trans feminine patients are technically no different
than in natal women requesting breast augmentation. There is
wide variation among surgeons in the specific minor details of
the procedure, and there is no single, “correct” way to perform
the procedure.
Placement of an inframammary incision should be along the
final position of the IMF, as opposed to the preoperative position.
The desired implant size and profile will dictate the location on
the chest wall relative to the NAC. Lowering of the fold is common,
and often an underwire bra is used postoperatively to maintain
the new fold. Submuscular implants tend to ride high on the chest
wall, and a superior breast strap or binder may be used to lower
the implants in the first several weeks if necessary. The breast
parenchyma itself is often tuberous and fibrous. A Snoopy-nose
deformity may result if the implant base width, sized in relation
to the patient’s chest width, is larger than the breast base width.
Scoring of the parenchyma helps redrape the parenchyma over the
implant and provides a more natural-appearing breast mound. In
patients with small breast volume and wide chests, careful atten-
tion to implant selection must be made. Patient goals of very large
breasts must be countered by knowledge of an inadequate soft
tissue envelope. Limits of implant size are typically less than 500
mL in patients with minimal breast volume with resulting small
skin envelopes.
Postoperative care is the same as that for natal females request-
ing breast augmentation.
112.14 MtF: Complications and
Revisionary Procedures
Specific data in the literature are lacking, but there is no evidence
that there are unique complications specific to augmentation in
trans feminine patients. Relative frequency of “common” compli-
cations is assumed to be the same as for augmentation in natal
females. The rate of venous thromboembolism in trans feminine
patients on hormone therapy is much higher than for natal
women; therefore, it is our practice to stop estrogen therapy (spi-
ronolactone may continue) 3 weeks prior to surgery and restart
1 week after surgery. Expedient evaluation and workup of any
lower-extremity swelling, pain, fever, palpitations, or shortness
of breath must be performed to rule out deep venous thrombosis
and pulmonary embolism.
In addition to revisions for adjustment of size or implant
positioning, the inability to achieve cleavage with implants alone
likely leads to a higher frequency of revisionary fat grafting to
the medial breast in trans feminine patients compared to natal
women requesting augmentation.
112.15 MtF: Outcomes
There are few studies on patient satisfaction following breast
augmentation in trans feminine patients, but one study from
France demonstrates improvement in BREAST-Q scores 1 year
following surgery.
112.16 Transgender Chest
Reconstruction:
Concluding Thoughts
Overall, available evidence supports the safety and efficacy of
top surgery in transgender patients. FtM chest reconstruction
is commonly performed in trans masculine patients. A signifi-
cant volume of literature is instructive regarding procedural
choice, complications, and the positive health status effect.
Augmentation in trans feminine patients is less common due to
the effects of estrogen hormonal therapy and lack of insurance
coverage. Aside from some anatomic considerations discussed in
this chapter, augmentation procedures are no different in trans
feminine patients than in natal females requesting augmenta-
tion. Plastic surgeons performing these procedures should be
familiar with the special considerations when working with
transgender patients. It is essential that plastic surgeons adhere
to the WPATH-SOC when managing this patient population.
Clinical Caveats
• Surgeons should ensure that patients have met the WPATH-
SOC criteria before performing gender-confirming surgery of
any kind, including chest recontouring.
• Each patient’s familial and other risk factors for breast cancer
should be assessed, and a full clinical breast examination is
mandatory. Any patient with abnormal physical examination
findings or with a risk for breast disease above baseline should
have the appropriate, additional evaluation.
• Patients should be aware that revisionary surgery after chest
recontouring in trans masculine patients is common; rates
between 4 and 43% have been reported (Table 112.4).
• If the concentric circular approach for FtM chest reconstruc-
tion is chosen, the skin excision should be very conservative
to prevent problematic periareolar scars.
• Trans feminine patients undergoing breast augmentation
should be aware that the widely spaced male NACs will make
achieving midline cleavage difficult.

1632
XIV Gender-Affirming Surgery
Table 112.4 FtM revisions: review of the literature
Article
Design
N
Age (yrs)
Medical
comorbidities
Breast
binding
Smoking
Follow-up
(months)
Complications
Revision procedures
Outcome
measurement
Lindsay (1979)
Case series
9
22–39
(average 25.4)
Not collected
Not
collected
Not
collected
7 patients for
5 months, 2
patients for 3
years
44% complication rate:
hematoma requiring
evacuation, 3 infection
and abscesses
Revision procedure
not required
Patient reported
satisfaction high;·
Rated as excellent:
2, Rated as good:
5, Rated as fair: 1
Hage and
Bloem (1995)
Retrospective
cohort
70
17–50
(average 27)
Not collected
Not
collected
Not
collected
6–96 (average
of 25)
20% complication rate:
Hematoma/seroma
formation: 7
Sloughing of areola
flaps: 4
NAC graft loss: 1
Wound dehiscence: 2
42.8% revision
rate. Overall
30 procedures,
including: 4
puncture evacuation
of hematoma, 3
repeat surgery
for hematoma,
3 skin grafting/
tattooing for areola
complications/NAC
loss, unspecified
number: planned
two-stage procedure
Satisfactory
cosmetic results
Colić and Colić
(2000)
Case series
17
23–34
(average 27.3)
Not collected
Not
collected
Not
collected
Unknown
11.7% complication rate:
2 NAC necrosis
5.9% revision rate:
1 skin graft for NAC
graft loss
Patient reported
satisfaction high+
Takayanagi
and Nakagawa
(2006)
Case series
29
Unknown
Not collected
Not
collected
Not
collected
Unknown
27.6% complication rate:
1 hematoma
2 burn scars
(due to hemostasis)
4 partial NAC necrosis
1 redundant skin with
periareolar wrinkles
17.2% revision
rate: 1 hematoma
evacuation
1 excision of
burn scar, 1
reoperation for
nipple flattening, 1
tattoo for superficial
skin necrosis, 1
skin excision for
redundant wrinkly
skin
Not measured
McGregor and
Whallett (2006)
Case series
15
Unknown
Not collected
Not
collected
Not
collected
60 months
Unknown
Minor revisions,
unspecified number
Patient reported
satisfaction high+
Continued

 Gender-Affirming Surgery 7RS Surgery
1633
Table 112.4 (continued) FtM revisions: review of the literature
Article
Design
N
Age (yrs)
Medical
comorbidities
Breast
binding
Smoking
Follow-up
(months)
Complications
Revision procedures
Outcome
measurement
Monstrey et al
(2008)
Retrospective
cohort
92
20–60 (mean
31)
Not collected
Not
collected
Not
collected
28 patients
(duration
unknown)
Total complications: 23
(12.5%)
approach 1: 21.8%
approach 2: 58.7%
approach 3: 19.5%
8 (4.3%) revision for
major complications
(hematoma
evacuation,
abscess drainage,
dehiscence)
59 (32.1%) revision
procedures
to improve
aesthetic outcome
(liposuction, scar
revision, nipple
reduction, nipple
reconstruction, skin
excision, dog-ear
correction)
Questionnaire,
Likert scale (1:
poor, 5: excellent)
patient reported
satisfaction high
Namba et al
(2009)
Retrospective
cohort
132
Mean age of
3 groups: 26,
31, 29
Not collected
Not
collected
Not
collected
Unknown
7.6% complication rate:
6 hematomas, 4 partial
necrosis of the NAC
6 hematoma
evacuations.
Unspecified
number of revision
procedures
Not measured
Cregten-
Escobar et al
(2012)
Retrospective
cohort
202
Average: 31
(± 10)
Not collected
Not
collected
Not
collected
Unknown
5% acute complication
rate, highest in approach
1 10.5%
0.05 total number of
acute reoperations
per breast secondary
corrections
for aesthetic
improvement
overall 40.4% (chest
contouring 17.8%,
scar revisions 12.6%,
NAC corrections
8.9%)
Not measured
Berry et al
(2012)
Retrospective
cohort
100
Median age:
28 (range
18–55)
17 medical:
asthma 12 (12%),
hypertension 1 (1%),
hypothyroidism (1%),
scimitar syndrome
(1%)
Not
collected
29 (29%)
Median: 7 (range
4–34)
11% complication
rate: 6 hematomas. 3
infections,
1 partial NAC loss 1 total
NAC loss
21% revision rate:
5 hematoma,
evacuations 10
axillary dog-
ear revisions, 2
nipple shavings,
1 liposuction, 1
scar revision, 2 flap
thinning/contouring
Linear analog
score: 1–5. Overall
patient- reported
satisfaction of
4.25. Median: 4,
range: 2–5
Antoszewski
et al (2012)
Retrospective
cohort
98
28.6 ± 1.7
Not collected
Not
collected
Not
collected
1–14 years after
surgery
Unknown
Unknown
Patient- reported:
good (59.2%)
satisfactory
(27.6%)
Continued on page 1634

1634
XIV Gender-Affirming Surgery
Table 112.4 (continued) FtM revisions: review of the literature
Article
Design
N
Age (yrs)
Medical
comorbidities
Breast
binding
Smoking
Follow-up
(months)
Complications
Revision procedures
Outcome
measurement
Bjerrome Ahlin
et al (2014)
Retrospective
cohort
30
Unknown
Not specified
Not
collected
Not
collected
Minimum: 12
group 1: Mean,
1.1 years
(1.0–1.3)
group 2: Mean
2.2 years
(1.0–3.8)
Group 1 ‡: 25% total
hematoma 6.3%
dehiscence 3.1% seroma
6.3% group 2 ‡: 50%
total after first op, 71.4%
total hematoma 7.1%
NAC necrosis 28.6%
dehiscence 14.3%
infection 32.1%
Mean number of
surgeries per breast:
group 1: 1.25 group
2: 2.5 (scar and
skin excision, NAC
reconstruction,
breast tissue
removal, liposuction)
Patient reported
satisfaction high+
Wolter et al
(2015)
Retrospective
cohort
173
Average: 28.6
(15–54)
Not collected
Not
collected
Not
collected
0.5, 3, 12
41 complications (11.8%
rate): minor (1.4%): 3
partial NAC necrosis
(0.9%), 2 seroma
formations (0.6%).
major (10.4%): 4 full
NAC necrosis (1.2%), 32
hematomas requiring
evacuation (9.2%)
31 revision
procedures (9%
revision rate): 5 scar
revisions (1.4%), 19
contour revisions
(5.5%), 7 NAC
revisions (2%)
Patient reported
satisfaction high:
77 (48.7%) “very
good,” 62 (39.3%)
“good”
Frederick et al
(2017)
Prospective
cohort
88
24 (range
15–71)
Not collected
Not
collected
Not
collected
1 week, 3 weeks,
3 months, and
1 year
8 hematomas
(< 30 days) (9%):
app 1: 6 (75% of all) app
3: 2 (25% of all) 21 long-
term (> 30 days) (24%):
app 1: 1 dog-ear (11%)
app 3: 7 dog-ears (78%)
12 hypertrophic scars
8 hematoma
evacuations
7 revision
procedures in 6
patients (6.8%),
hypertrophic scar
removal, dog-ear
revision, nipple
reduction. 1 patient
app 1 (17%) 5
patients app 3 (83%)
Majority
responded “very
satisfied” with
results (82.5%).
15.8% were
“satisfied” and 1
patient (1.8%)
was “very
unsatisfied”
Donato et al
(2017)
Retrospective
cohort
130
28 (range
14–56)
T2DM 2 (2%),
Asthma 16 (12%)
OSA 5(4%)
Not
collected
18 (14%)
Minimum
6 months
Total major: 11
complications (8.5%)
app 1: 3 (15%) app 3:
8 (7%) total minor: 21
complications (16%)
app 1: 4 (20%) app 3: 17
(15%) hematoma: app 1:
3(15%) app 3: 6(5%)
Total revision
procedures 13(10%)
app 1: 5 (25%) app 3:
8 (7%)
Not measured
Continued

 Gender-Affirming Surgery 7RS Surgery
1635
Table 112.4 (continued) FtM revisions: review of the literature
Article
Design
N
Age (yrs)
Medical
comorbidities
Breast
binding
Smoking
Follow-up
(months)
Complications
Revision procedures
Outcome
measurement
van de Grift
et al (2017)
Prospective
cohort
54
Average 25.8
(18–59)
Total co-occurring
physical diagnoses:
7 (13%)
Not
collected
Total
smoking:
12 (25%)
12 months
Approach 2: infection 2
(3.8%) seroma 9 (17.3%)
early hematoma 3 (5.8%)
late hematoma 5
(9.6%) dehiscence 6
(11.5%) NAC necrosis
3 (5.8%) asymmetry 8
(30.8%) skin irregular 5
(20.8%) skin surplus 5
(19.2%) app 3: infection
0 seroma 3 early
hematoma 4 (9.1%)
late hematoma 4 (9.1%)
dehiscence 1 (2.3%)
NAC necrosis 6 (13.6%)
asymmetry 4 (18.2%)
skin irregular 5 (30%)
skin surplus 7 (31.8%)
Approach 2: 10
(38.5%) app 3: 3
(13.6%) unspecified
Patient reported
satisfaction
good, better for
approach 3 overall
vs. 2
Bluebond-
Langner et al
(2017)
Retrospective
cohort
295
Total:
29.2 ± 8.9
approach 1:
27.7 ± 7.9
approach 3:
30.1 ± 9.4
Diabetes total 3 (1%)
approach 1: 0
approach 3: 3 (1.6%)
Not
collected
Total 31
(10.5%)
approach
1: 9 (8.3%)
approach
3: 22
(11.8%)
9.9 (1.4–9:8)
Total rate: 18% app 1:
21.1% app 3: 16.1%
app 1: infection 1
(0.9%) seroma 6 (5.5%)
hematoma 10 (9.2%)
NAC necrosis 5 (4.6%)
app 3: infection 4
(2.2%) seroma 9 (4.8%)
hematoma 10 (5.4%)
NAC necrosis 4 (2.2%)
Total rate: 39% app
1: 46.5% app 3:
34% app 1: direct
excision 17(23.9%)
liposuction 11
(15.5%) scar revision
2 (2.8%) conversion
1 (1.4%) NAC
revision 13 (18.3%)
app 3: direct excision
10 (10%)
liposuction 13 (13%)
scar revision 8 (8%)
NAC revision 11
(11%)
Not measured
McEvenue et al
(2017)
Retrospective
cohort
679
Total:
26.25 ± 9.0
(16–64)
approach
1: 22.8 ±
5.6 (16–46)
approach 3:
26.9 ± 9.3
(16–64)
Not collected
Total:
87.2%
approach
1: 100%
approach
3: 85.5%
Not
collected
5.5 (range,
0.05–92)
Total complication rate:
18.1% app 1: 33% app
3: 16% app 1: seroma
19 (18.3%) hematoma
11 (10.6%) infection
5 (4.8%) hypertrophic
scar 2 (1.9%) partial
NAC 0 (0%) dehiscence
0 (0%) app 3: Seroma
25 (4.3%) hematoma
22 (3.8%) infection 20
(3.5%) hypertrophic scar
17 (3.0%) partial NAC
3 (0.5%) dehiscence 3
(0.5%)
Total reoperation
rate: 11.2% app 1:
14.4% app 3: 10.6%
app 1: contour
revision 1 (1%)
nipple revision/
reduction 12 (11.5%)
hematoma with evac
2 (1.9%)
scar revision 0 (0%)
app 2:
contour revision
42 (7.3%) nipple
revision/ reduction
5 (0.9%) hematoma
with evac 9 (1.6%)
scar revision 10
(1.7%)
Aesthetic rating on
Likert scale: app 1:
4.6/5 app 3: 3.7/5
Abbreviations: app, approach; NAC, nipple–areola complex; T2DM, Type 2 diabetes mellitus

1636
XIV Gender-Affirming Surgery
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cations/icd10/browse/2016/en

 Gender-Affirming Surgery GeniWDO Surgery
1637
113 Gender-Affirming Surgery GeniWDO Surgery
David M. Whitehead and Loren S. Schechter
Abstract
Gender-confirmation surgery is a rapidly evolving field. In 2014,
the U.S. Department of Health and Human Services reversed a
Medicare ban on gender surgery, which it had previously considered
“experimental.” This ruling, along with increased awareness and
advocacy for the transgender and gender diverse communities,
has led to a dramatic increase in the number of individuals seeking
gender-confirming surgery. This chapter focuses on genital gen-
der-confirming procedures. For individuals designated male at birth,
vaginoplasty techniques, including both penile inversion and intes-
tinal approaches, are discussed. For individuals designated female at
birth, metoidioplasty and phalloplasty surgeries are reviewed.
Keywords
gender, gender confirmation, gender affirmation, surgery, geni-
tal, bottom, phalloplasty, vaginoplasty, penile inversion, urethral
lengthening
113.1 Indications and
Contraindications
Gender-confirmation surgery is the surgical treatment for gender
dysphoria, which is defined by the American Psychological
Association’s Diagnostic and Statistic Manual of Mental Disorders,
fifth edition (DSM-V) as dysphoria associated with “the distress
that may accompany the incongruence between one’s experi-
enced or expressed gender and one’s assigned gender.” Working
collaboratively with primary care providers, mental health pro-
fessionals, endocrinologists, and others, the surgeon is a member
of the multidisciplinary team. To this end, the World Professional
Association for Transgender Health (WPATH) publishes the
Standards of Care for the Health of Transsexual, Transgender, and
Gender Nonconforming People (V7, 2012). The Standards of Care
provide recommendations for the management of transgender
and gender-diverse persons, both medically and surgically. The
following recommendations are reproduced from that document.
Most individuals undergoing genital surgery are on cross-sex
hormones. The WPATH recommendations for initiating any medi-
cal treatment for gender dysphoria are as follows:
1. Persistent, well-documented gender dysphoria
2. Capacity to make a fully informed decision and to consent for
treatment
3. Age of majority in a given country (if younger, follow the guide-
lines in section VI of the Standards of Care, version 7)
4. If significant medical or mental health concerns are present,
they must be reasonably well controlled
Those wishing to undergo sterilizing procedures, such as orchi-
ectomy or hysterectomy must have, in addition to the foregoing
recommended criteria, the following:
5. Two referrals from a qualified mental health provider
6. Twelve continuous months of hormone therapy as appropriate
to the patient’s gender goals (unless the patient has a medical
contraindication or is otherwise unable or unwilling to take
hormones)
Finally, those wishing to undergo genital surgery—vaginoplasty,
metoidioplasty, or phalloplasty—have the following additional
recommended criterion:
7. Twelve continuous months of living in a gender role that is con-
gruent with the patient’s gender identity
The goal of these recommendations is to increase the likelihood
of a smooth and permanent transition, encouraging the patient to
deal with potential family, workplace, or other social issues prior
to having to do so while recovering from surgery.
It is important that the surgeon work with the patient’s mental
health and primary care professionals. Typically, the surgeon will
receive written mental health assessments containing the follow-
ing information:
1. The client’s general identifying characteristics
2. Results of the client’s psychosocial assessment, including any
diagnoses
3. The duration of the mental health professional’s relationship
with the client, including the type of evaluation and therapy or
counseling to date
4. An explanation that the criteria for surgery have been met, and
a brief description of the clinical rationale for supporting the
patient’s request for surgery
5. A statement about the fact that informed consent has been
obtained from the patient
6. A statement that the mental health professional is available for
coordination of care and welcomes a phone call to establish this
In addition, the surgeon should review relevant information as
well as the potential risks and benefits with the patient as part of
the informed consent discussion. If needed, the surgeon should
contact the mental health provider directly. As with any plastic
surgery procedure, the surgeon should understand the patient’s
expectations and feel comfortable that they are realistic and
achievable.
113.2 Preoperative Assessment
Prior to surgery, medical and mental health issues, if present,
should be well controlled.
113.2.1 2rFKieFWRmy9DginRSODVWy
For individuals undergoing orchiectomy, either in isolation or as
part of a vaginoplasty, it is vital to discuss that removal of the testes
will result in sterility. A discussion regarding fertility preserva-
tion may be warranted, with referral to appropriate specialists

1638
XIV Gender-Affirming Surgery
as needed. Additionally, for patients undergoing orchiectomy in
isolation, it is important to elicit whether the patient will plan on
subsequent vaginoplasty. If a future vaginoplasty is desired, the
patient should be made aware that the scrotal skin may atrophy
and reduce available local/regional tissue for creation of the
vagina. Physical examination includes evaluation of the testes for
abnormalities (e.g., masses), assessment for inguinal hernias, and
inspection of the penis for foreskin (i.e., history of circumcision).
For patients contemplating vaginoplasty, additional history
should be obtained, including a history of urinary complaints,
pelvic or prostatic radiation, and prior surgical procedures on
the genitalia or pelvis. A history of prostatitis or urinary tract
infections may increase the difficulty of dissection of the vaginal
cavity. Prior pelvic surgery or radiation (e.g., prostatectomy) may
be a contraindication for dissection of the vaginal cavity. In such
cases, a “zero-depth” vaginoplasty (i.e., external vulvoplasty) may
be a reasonable alternative. Prior hernia repair or orchiectomy via
inguinal incisions may interrupt the superficial external pudendal
artery, the primary blood supply to the neolabia majora. A history
of pubertal blockade/suppression is also important. These inter-
ventions limit growth of the genitalia and, as a result, may limit
the amount of tissue available for a penile inversion vaginoplasty.
If there is insufficient local donor tissue, alternative techniques
(e.g., skin graft from the flanks, tissue expanders, or intestinal
vaginoplasty) may be an option.
Patient goals and expectations should be assessed preopera-
tively. It is helpful to understand whether patients are sexually
active and/or capable of orgasm. This may help predict the
patient’s likelihood of achieving orgasm following surgery.
Additionally, patients should be asked whether they “tuck”—the
practice of placing the testes within the inguinal canal and folding
down the penis to reduce the appearance of the external genitalia
in clothing—as this may increase pelvic muscle tone, making
postoperative vaginal dilation more difficult. It is also important
to understand the postoperative goals regarding sexual activity,
and the anticipation regarding receptive vaginal intercourse. If the
patient plans on vaginal intercourse, the importance of postopera-
tive dilation should be reviewed.
Physical examination of the genitalia should include evaluation
of the penis for foreskin (i.e., history of circumcision), assessment
for testicular abnormalities, examination for inguinal hernias,
inspection for scars and prior incisions, and estimation of the
amount of skin available from the penis, scrotum, and perineum.
Inguinal hernias, if identified, should be addressed prior to
vaginoplasty.
113.2.2 0eWRidiRSODVWy3KDOORSODVWy
When discussing metoidioplasty and phalloplasty, the surgeon
should understand the patient’s goals, including (1) urination
while standing, (2) desire to engage in penetrative intercourse,
and (3) the goal of having the appearance of an anatomic phal-
lus. If the patient requests urination while standing, urethral
lengthening can be performed with either metoidioplasty or
phalloplasty. The most notable difference between a metoidio-
plasty and a phalloplasty is the size of the phallus created. The
metoidioplasty does not create a phallus of sufficient dimensions
to incorporate a penile prosthesis. As such, the ability to engage
in penetrative intercourse is unlikely.
Once the patient’s goals for genital surgery have been estab-
lished, a medical and surgical history should be obtained. This
includes the duration of testosterone treatment, history of
urinary issues (e.g., urinary tract infections, interstitial cystitis),
vaginal or vulvar pathology, smoking history, drug use, presence
of peripheral arterial disease, as well as reproductive history. If
hysterectomy/oophorectomy is planned, it is important to dis-
cuss the resulting sterility and, if interested, options for fertility
preservation. Referral to an appropriate fertility specialist can be
provided as needed. Body mass index (BMI) should be calculated,
although an elevated BMI may be a result of muscular hypertro-
phy. As obesity can increase the risk of complications and affect
surgical outcomes, the surgeon should consider body habitus
along with BMI. The physical exam should include inspection of
the genitalia to assess virilization, growth, and mobility of the
clitoris. The mons pubis should also be evaluated in reference to
the degree of subcutaneous fat and the presence of mons ptosis.
If a phalloplasty is planned, potential donor sites should be
discussed. The most common donor sites include the radial fore-
arm free flap (RFFF) and the anterolateral thigh flap (ALT). Less
common donor sites include the musculocutaneous latissimus
dorsi flap (MLD), abdomen (tubed abdominal flap), groin (superfi-
cial circumflex iliac artery flap, SCIP), or leg (osteocutaneous free
fibula flap).
In most patients, the RFFF allows for thin, supple tissue, which
can be readily folded into a tube-within-a-tube as first described
by Chang and Huang in 1984. It is sensate, with a robust cutaneous
nerve supply. The disadvantages include the requirement for micro-
surgery and the visibility of the forearm donor site. Preoperative
examination of the forearm should include an Allen’s test to assess
patency of the palmar arch, an assessment of any scarring (poten-
tially from “cutting”), and assessment of hair growth (both location
and density). If needed, hair removal (electrolysis or laser) should
be performed on the volar forearm, corresponding to the portion
of the flap that will be used to construct the urethra. Additionally,
in older patients, femoral pulse examination is recommended to
assess the quality of the recipient vessels.
The ALT has a less-conspicuous donor site and the possibility of
being transferred as a pedicle flap. However, in most individuals,
the thigh tissue is thick and limits the ability to perform a tube-
within-a-tube technique. Preoperative examination of the thigh
should include an assessment of the subcutaneous fat (total pinch
thickness should be less than or equal to 1 cm for a tube-within-
a-tube flap) and the location and density of hair growth. Typically,
hair removal is required prior to ALT phalloplasty.
113.3 Pertinent Anatomy
and Embryology
By developmental weeks 4 to 6, outgrowths of the coelomic epi-
thelium become the urogenital ridges, which subsequently form
the reproductive tracts, gonads, kidneys, and adrenal cortices.
During week 6, SRY, a transcription factor typically found on the
< chromosome, directs the undifferentiated gonad to become a
testis. In the absence of SRY, other transcription factors direct
the gonad to differentiate into an ovary.
:hile the wolffian and mllerian systems both develop ini-
tially, testosterone, secreted by the testis, promotes continued

 Gender-Affirming Surgery GeniWDO Surgery
1639
development of the wolffian system. This tissue becomes the
epididymis, vas deferens, seminal vesicle, and ejaculatory duct.
Testosterone also triggers descent of the testis into the scrotum.
Antimüllerian hormone, also secreted by the testis, causes
regression of the müllerian system. Peripheral conversion of tes-
tosterone to dihydrotestosterone leads to fusion of the urogenital
folds, forming the corpus spongiosum and pendulous urethra.
The corpora cavernosa forms from the genital tubercle, and
fusion of the labioscrotal folds forms the scrotum. In the absence
of antimüllerian hormone, the müllerian system becomes the
uterus and proximal vagina. In the absence of testosterone and
dihydrotestosterone, the genital tubercle develops into the
clitoris and corpora cavernosa, the urogenital folds become the
labia minora, the urogenital sinus develops into the urethra and
distal vagina, and the labioscrotal folds become the labia majora
(Fig. 113.1).
Penile inversion vaginoplasty rearranges the penoscrotal anat-
omy in a manner similar to its embryological origin: the glans
penis is used to create the clitoris, and the urethra is shortened
and spatulated to create the labia minora. Other portions of the
male urogenital system—the intrapelvic vas, the seminal vesicles,
and the prostate—are left in situ. Thus continued prostate sur-
veillance is recommended. Similarly, during urethral lengthening
procedures in trans men, embryologically derived female tissue,
including the labia minora, urethral plate, and/or vagina, is used
to construct a portion of the pars fixa of the urethra.
113.4 Preoperative Planning
and Markings
113.4.1 All Procedures
Patients are instructed to discontinue hormones for 2 weeks
prior to surgery. This recommendation is based primarily on
preoperative risk assessment models indicating a high risk of
venous thromboembolism (pelvic surgery, general anesthesia,
immobility, etc.). Patients are also instructed to discontinue
smoking and nicotine use prior to surgery. If the individual has a
recent history of smoking, or is an active smoker, a urine cotinine
test is performed, and surgery should be postponed if positive. A
bowel prep is also performed the day prior to surgery. A postop-
erative care plan, including who, if anyone, will be accompanying
and assisting the patient, is reviewed prior to surgery. Genital
surgery results in significant life changes, and it is essential that
a plan be in place for the patient to have adequate social and
physical support in the perioperative period.
113.4.2 Vaginoplasty
A bowel prep is performed the day prior to surgery. The patient is
positioned in lithotomy, and the abdomen, proximal thighs, and
perineum are prepped. The perineal body/central tendon is the
first landmark identified. This represents the convergence of the
anal sphincter, transverse perineal muscles, and bulbourethralis
muscles. A scrotoperineal flap, anywhere between 1 and 3 cm, is
marked, with its base located cephalad to the anus. The scrotal
skin graft is then marked, followed by the markings for penile
degloving (Fig. 113.2).
113.4.3 Metoidioplasty
A bowel prep is performed the day prior to surgery. The patient
is positioned in lithotomy, and the lower abdomen, proximal
thighs, and perineum are prepped. The metoidioplasty mark-
ings have four primary components: the vestibular lining
flap, the vaginal flap, the labia minora flaps, and the clitoral
degloving/circumcision incision. The proximal neourethra is
constructed with the vestibular and vaginal components, and
the distal neourethra is constructed with a combination of
an interposition buccal mucosal graft and overlapping labia
minora flaps (Fig. 113.3). Two parallel lines, approximately 2
cm apart, are marked on the vestibulum. These lines extend
from the level of the urethral meatus to the clitoris and are
connected orthogonally by a transverse line one-third of the
distance between the urethral meatus and the clitoris. This
transverse line represents the location at which the ventral
chordee is divided. The defect resulting from division of the
ventral chordee is later grafted with buccal mucosa. The labia
minora flaps are outlined. Typically, the inner aspect of the
left labium minus forms the ventral portion of the neourethra.
The left labium minus flap is used to reinforce the urethral
reconstruction, creating a layered closure of the neourethra.
The clitoral degloving/circumcision incision is designed at the
junction of the glans clitoridis and clitoral shaft skin. Finally,
the vaginal flap is marked. This flap is based at the distal vagina
and measures approximately 3 × 5 cm.
113.4.4 Phalloplasty
A bowel prep is completed the day prior to surgery. Markings
depend on flap selection. This section will focus on the two most
common phalloplasty techniques: RFFF and ALT.
3uEiF3erineDO 0DrNingV
An omega-shaped incision is designed over the mons pubis,
with one arm of the omega extending laterally and superiorly.
This line extends parallel to the inguinal crease for exposure
of the recipient vessels (femoral artery, saphenous vein). For
the RFFF phalloplasty, the recipient vessels are located on the
side contralateral to the forearm donor site (i.e., left RFFF, right
femoral artery/saphenous vein). For the ALT phalloplasty, the
flap is typically transferred as a pedicle flap. If pedicle length is
insufficient, the ALT flap may be transferred as a free flap. The
position of the femoral artery, femoral vein, and saphenous vein
and the location of the ilioinguinal nerve are marked (Fig. 113.4).
Forearm Markings
The RFFF encompasses most of the forearm tissue. A strip of skin
on the ulnar side of the forearm is preserved, including the basilic
vein, if possible. Preoperative markings are critical for proper
planning, and our practice is to use a transparent template to
design the flap. The dimensions of the forearm will determine
the length of the flap, with shorter forearms leading to a phallus
of shorter length. Increased thickness of the subcutaneous tis-
sues may require either a wider flap or skin grafting the ventral
penile shaft. Glansplasty, if desired, can usually be performed at
the same time.

1640
XIV Gender-Affirming Surgery
The urethral portion of the flap is marked over the less
hair-bearing portion of the forearm, located on the volar, ulnar
border. Depending on forearm dimensions, the urethral segment
of the flap is designed 3 to 4 cm in width by 15 to 18 cm in length.
The proximal urethral segment is widened to 4 to 5 cm, and a
zig-zag extension is designed into the antecubital fossa. The shaft
portion of the flap is designed approximately 13 to 14 cm in width
over the wrist, and 16 to 22 cm in width proximally. Flap length
is typically between 13 and 16 cm. Between the ulnar (urethra)
and radial (shaft) portions of the flap, a strip of skin measuring
approximately 1.25 cm in width is de-epithelialized. The excised
skin is used for later glansplasty, if desired. The glans is generally
Fig. 113.1 Embryology of the external genitalia. The male and female genitalia share common embryological precursors, which differentiate to form
the structures associated with each sex.

 Gender-Affirming Surgery GeniWDO Surgery
1641
formed by the distal 3 cm of the flap, with an additional 1 cm
portion used to construct the coronal ridge. The flap is dissected
under tourniquet control. However, the forearm is not exsangui-
nated so as to facilitate identification and dissection of superficial
veins. Fig. 113.5 provides forearm markings.
Thigh Markings
ALT flaps typically have greater subcutaneous fat than RFFF. This
may limit the ability to design the flap as a tube-within-a-tube.
Additionally, glansplasty, if desired, is deferred to a secondary
setting. A line between the anterior superior iliac spine and
the lateral border of the patella is marked. This line represents
the septum between the vastus lateralis and the rectus fem-
oris muscles. At the midpoint of this line, a circle with a 3 cm
radius is marked. This corresponds to the most likely location of
Fig. 113.4 Markings for the genital portion of phalloplasty. An ome-
ga-shaped incision is designed to inset the phallus. A linear extension
overlies the recipient neurovascular structures.
Fig. 113.5 (a,b) Markings for the radial forearm free flap phalloplasty.
The urethral portion of the flap is positioned along the ulnar border of
the ventral forearm and made longer than the shaft portion of the flap.
The intervening area between the urethra and shaft portions of the
flap is de-epithelialized.
Fig. 113.2 Markings for the penile inversion vaginoplasty. Most of the
scrotum is harvested as a skin graft to line the neovagina. A posteriorly
based scrotoperineal flap of variable dimension is designed and inset
into the penile flap.
Fig. 113.3 Markings for metoidioplasty. The proximal vestibulum acts
as the dorsal portion of the neourethra. A transverse incision allows
for division of the urethral plate. The subsequent defect is lined by a
buccal mucosal graft. The L flap is mobilized and folded over to create
the ventral portion of the neourethra (the L flap is de-epithelialized
externally); the R flap is de-epithelialized internally and transposed
over the L flap.

1642
XIV Gender-Affirming Surgery
perforating vessels. A handheld Doppler is used to confirm the
perforator position. The flap is then designed in a similar fashion
as the forearm flap (Fig. 113.6).
113.5 2YerYieZ RI 7eFKniTue
113.5.1 Vaginoplasty
As mentioned, penile inversion vaginoplasty relies on the homol-
ogous nature of female and male anatomy. At its core, the oper-
ation involves disassembly of the penis—skin (covering), glans
(neurosensory component), corpora cavernosa, and urethra. The
corpora cavernosa and testes are removed. The neovaginal cavity
is dissected and lined with penile skin and/or scrotal skin grafts,
the urethra is shortened, and the labia majora are formed from
the lateral scrotal tissue.
Preoperative antibiotics are administered, and 5,000 units of
unfractionated heparin are given subcutaneously. The patient is
positioned in lithotomy with sequential compression devices. A
warming device is placed over the chest and upper extremities.
The upper extremities are abducted on foam pads (< 90 degrees)
with the elbows in flexion. A rectal shield is placed to facilitate
digital rectal examination during dissection of the neovaginal
cavity. A Foley catheter is inserted on the sterile field.
The scrotal skin graft is harvested, defatted, depilated, and
sutured over a stent. The scrotoperineal flap is raised, incorporat-
ing the superficial fascia. The bulbospongiosus muscles, urethra,
and corpora cavernosa are exposed. Exposure is facilitated by
lateral retraction of the testes. A small Richardson retractor is
then placed under the ventral penile skin, and sharp dissection
is performed to elevate and deglove the penis. A circumferential
incision, approximately 1 cm proximal to the junction of the glans
and penile shaft skin, forms the subsequent preputial skin of the
neoclitoris and facilitates exposure of the dorsal neurovascular
bundle. The suspensory ligament of the penis is divided, and the
soft tissue of the pubis and lower abdomen is elevated off the
rectus sheath. This creates a subcutaneous pocket, which allows
placement and fixation of the neurovascular bundle of the neo-
clitoris (former glans penis). If possible, the superficial external
pudendal vessels are preserved. Bilateral orchiectomies, including
the spermatic cords, are performed at the level of the superficial
inguinal ring. The spermatic cord is suture ligated with 2–0 poly-
glactin (Vicryl, Johnson & Johnson, New Brunswick, NJ) sutures,
and the specimens are sent to pathology.
The perineal dissection is performed by dividing the central
tendon of the perineum. Following this, a Lowsley prostatic retrac-
tor replaces the Foley. This retractor assists with visualization of
the prostate and Denonvilliers’s fascia. Following division of the
rectourethralis muscle, dissection proceeds to Denonvilliers’s
fascia. Denonvilliers’s fascia, white in color and thus also known
as the “pearly gates” of the perineum, is divided. Denonvilliers’s
fascia may separate into an anterior and posterior layer. The
vaginal cavity is dissected anterior to Denonvilliers’s fascia when
possible. Once Denonvilliers’s fascia has been divided, dissection
can proceed bluntly. The Lowsley retractor is removed, and the
Foley catheter is replaced. The perineal cavity (i.e., neovagina)
may be widened, if needed, by dividing the levator ani muscles.
However, final vaginal width may be limited by the bony pelvis.
Upon completion of the perineal dissection, the bulbospongio-
sus muscles are removed, and the urethral bulb is resected and
oversewn.
The neoclitoris is fashioned from the dorsal glans penis. The
neurovascular structures are elevated off of the tunica albuginea,
incorporating Buck’s fascia. The glans of the neoclitoris is formed
by shaping and suturing the former glans penis into a cone. The
neoclitoral glans is fixed to the pubic tubercles on each side, and the
neurovascular pedicle is positioned and fixed in the subcutaneous
lower abdominal pocket. The urethra and corpora spongiosum are
separated from the overlying corpora cavernosa. Once the urethra
is mobilized, the corpora cavernosa are resected. The corpora cav-
ernosa may be completely resected, or, alternatively, a remnant of
the corporal bodies may be left at the level of the pubic tubercles.
This segment of retained corpora cavernosa may be used as a base
for fixation of the neoclitoris. A vertical incision is then made in
the penile skin flap, through which the urethra is transferred.
The full-thickness scrotal skin graft is sutured to the distal
penile skin flap to create the lining for the neovagina. The graft
and penile skin flap are sutured to each other with multiple
W-plasties so as to avoid a circular scar. The subcutaneous tissue
of the former scrotum (now labia majora) is fixed posteriorly to
the ischia on both sides. Two Penrose drains are placed in the
vaginal cavity, the penile skin and attached scrotal skin grafts are
inverted, and the labia majora are closed in a layered fashion. The
vagina is packed with vaginal packs impregnated with mafenide
acetate solution and water-soluble lubrication.
The urethra is then reflected upward, shortened, and incised
on its ventral side. A vertical incision is made in the dorsal wall
of the urethra to allow for insetting of the neoclitoris. The urethra
is sutured to the penile skin using a running locking suture. The
clitoris is inset into the urethra with interrupted sutures. This
configuration of urethra and neoclitoris provides an approxima-
tion of the labia minora. The Foley catheter is exchanged, and a
bulky dressing and mesh underwear are applied.
Representative images of vaginoplasty are shown in Fig. 113.7.
Fig. 113.6 Markings for the anterolateral thigh flap phalloplasty. The
urethral portion of the flap is marked longer than the shaft portion
of the flap, and the intervening area de-epithelialized. A proximal
de-epithelialized extension is designed to allow inclusion of a proximal
perforator (if needed), and the flap is designed distally enough to allow
for pedicle transfer to the groin.

 Gender-Affirming Surgery GeniWDO Surgery
1643
113.5.2 0RdiÀFDWiRn
Intestinal Vaginoplasty
The intestinal vaginoplasty technique is similar to the penile
inversion technique with the exception that a segment of intes-
tine, typically the sigmoid colon, is used to create the lining of
the vagina. This technique is primarily used for revision cases,
or for those individuals who lack sufficient genital tissue (e.g.,
individuals who transitioned prior to the completion of puberty).
When utilizing colon, patients undergo a preoperative colonos-
copy to assess for malignancy or polyps.
For intestinal vaginoplasty, a second team (either general or
colorectal surgery) performs the abdominal portion of the oper-
ation concurrent with the perineal dissection. During closure,
the pedicled intestinal segment, usually 12 to 15 cm in length, is
passed through the perineal defect.
Following surgery, patients dilate the vaginal introitus.
However, it is not uncommon to require release of the introital
scar. One potential advantage of the colon vaginoplasty is
mucus production potentially obviating the need for exogenous
lubrication. Additionally, patients require annual vaginal exam
and assessment for possible gastrointestinal malignancies in the
transferred vaginal segment.
113.5.3 Metoidioplasty
Metoidioplasty, developed from techniques used to treat severe
hypospadias, typically involves four components: clitoral release,
urethral lengthening, vaginectomy (performed as colpectomy/
colpoclesis—ablation and closure of the vaginal canal), and
scrotoplasty. This procedure is typically performed in stages and
in conjunction with urologic colleagues.
Preoperative antibiotics are administered, and 5,000 units of
unfractionated heparin are given subcutaneously. The patient is
positioned in lithotomy with sequential compression devices. A
warming device is placed over the chest and upper extremities.
The upper extremities are abducted on foam pads (< 90 degrees)
with the elbows in flexion. The urology team places a suprapubic
urinary catheter, and a Councill tip catheter is inserted into the
native urethra. Elastic hook retractors are placed to provide visu-
alization of the labia, introitus, and clitoris. Markings are placed
as described earlier.
Dissection begins with the vestibular incisions. These parallel
incisions are contiguous with both the vaginal flap and the cli-
toral degloving/circumcision incision. The incisions extend from
lateral to the urethral meatus to the lateral border of the clitoris.
Following this, the labia minora flaps are prepared. A rectangular
flap on the inner aspect of the left labium minus is designed and
elevated. The corresponding outer aspect of the left labium minus
is de-epithelialized, leaving a subcutaneous pedicle for the labial
flap. The inner aspect of the right labium minus flap is elevated and
will be subsequently discarded. This allows the outer, cutaneous
aspect of the right labium minus flap to serve as reinforcement for
the neourethra.
The clitoris is then degloved through a circumcision incision
located at the junction of the glans clitoridis and the clitoral shaft
skin. In elevating the skin, care is taken not to injure the dorsal
neurovascular bundle. The suspensory ligament of the clitoris is
identified and may be divided, either partially or fully, depending
on the degree of clitoral straightening and advancement needed.
The vestibulum is divided transversely at a point approximately
one-third of the way between the urethral meatus and the clitoris.
This allows for division of the ventral chordee with additional
straightening and advancement of the clitoris. The division of the
chordee creates a defect overlying the corporal bodies. An inter-
position buccal mucosa graft will span this defect. The vaginal flap
is elevated with dimensions approximating 3 ð 5 cm. The flap is
based at the distal vagina and elevated at the musculomucosal
layer.
The colpectomy/colpocleisis is performed by either resecting
or cauterizing the vaginal epithelium. Dilute epinephrine-soaked
gauze can be used to aid in hemostasis of the denuded vaginal
wall. Suture approximation of the lateral vaginal walls, including
the levator ani muscles, assists with obliteration of the vaginal
canal. The external opening of the vagina is then closed with pro-
gressive, layered suturing. A closed-suction drain may be placed.
Construction of the neourethra begins with placement of a
buccal mucosal graft over the defect created by division of the
ventral chordee. This graft is typically about 1.5 ð 6 cm and is fixed
to the underlying corporal bodies with multiple quilting sutures.
The proximal neourethra is created by suturing the vaginal flap
to the proximal vestibular lining flap. The left labium minus
lining flap is transposed over the Foley catheter and sutured to
the composite urethra (vestibular lining/vaginal flap and buccal
mucosa graft). The right labial flap is then transposed over the
neourethra, thereby reinforcing and providing a layered closure
of the neourethra. The right labial flap provides the external skin
cover of the ventral phallus. The skin is closed in a layered fashion.
Fig. 113.7 Vaginoplasty. (a) The scrotum is harvested as a
full-thickness skin graft, and the bulbospongiosus muscle and corpus
spongiosum are exposed. (b) The perineal dissection is completed, and
the corpora cavernosa excised. (c,d) Postoperative photos.

1644
XIV Gender-Affirming Surgery
A clitoral traction suture is placed to aid in monitoring of the
phallus postoperatively. A simple dressing is placed, with antibi-
otic ointment and gauze, and both the Foley and suprapubic cath-
eters are left in place. The drainage bag is affixed to the suprapubic
catheter to avoid traction on the phallus. A postoperative image of
metoidioplasty is demonstrated in Fig. 113.8.
113.5.4 Phalloplasty
The goals of phalloplasty include construction of an aesthetic,
sensate phallus capable of standing micturition and penetrative
intercourse. Preoperative antibiotics are administered, and 5,000
units of unfractionated heparin are given subcutaneously. The
patient is positioned in lithotomy with sequential compression
devices. A warming device is placed over the chest and nonoper-
ative upper extremity.
Genital Component
As with metoidioplasty, the urology team places a suprapubic
urinary catheter, and a Councill tip catheter is inserted into the
native urethra. Elastic hook retractors are placed to provide visu-
alization of the labia, introitus, and clitoris. Markings are placed
as described earlier.
The distally based vaginal flap is dissected first. Lidocaine with
epinephrine is injected into the anterior vaginal wall to assist
with hydrodissection and hemostasis. The flap is elevated at the
musculomucosal layer. Extending superiorly from the vaginal flap,
parallel vestibular incisions are made up to the lateral glans clito-
ridis. The clitoris is degloved as described in the metoidioplasty
section. However, in contrast to a metoidioplasty, the ventral
chordee is not divided.
Following elevation of the vaginal flap, the clitoris is mobilized,
and the proximal portion of the urethral reconstruction is per-
formed. The vaginal flap is sutured to the vestibular portion of the
urethra. Once the dorsal and ventral portions of the neourethra
are suture approximated, a transverse incision is made between
the glans clitoridis and the vestibulum for later anastomosis to
the penile (flap) urethra. The clitoris is de-epithelialized to allow
for later subcutaneous positioning at the base of the phallus. An
omega-shaped incision is made over the pubis. This incision is
contiguous with the perineal dissection and allows for transpo-
sition of the clitoral–neourethral construct. The clitoral–neoure-
thral construct is fixed to the pubis.
Colpectomy and colpocleisis are performed as described
for a metoidioplasty. The scrotum is constructed with medial
transposition of both labia majora, and a layered perineal closure
completes this portion of the procedure. The patient is reposi-
tioned from lithotomy to supine and reprepped. The recipient
vessel dissection (femoral artery and saphenous vein) for a radial
forearm phalloplasty or the procurement of an anterolateral thigh
flap then proceeds. Additionally, the ilioinguinal nerve, which acts
as the primary recipient sensory nerve for the flap, is isolated,
divided, and tagged.
RFFF Phalloplasty
The RFFF phalloplasty allows for creation of a sensate phallus
and urethra, which can accommodate subsequent placement of
a penile prosthesis. With a two-team approach, procurement of
the RFFF proceeds concurrent with the perineal portion of the
procedure.
The operative arm is positioned on an arm board, and a tourni-
quet is placed. Prior to tourniquet inflation, a radial artery cutdown
and Allen’s test are performed. After the Doppler signal to the
princeps pollicis artery is verified, the radial artery is ligated and
divided distally. The arm is then elevated but not exsanguinated,
and the tourniquet is activated. Dissection begins proximally with
identification of the cephalic vein, lateral antebrachial cutaneous
nerve, and the anterior branch of the medial antebrachial cuta-
neous nerve. Additional superficial veins draining the ulnar (ure-
thral) portion of the flap are maintained with the flap, if possible.
Typically, the basilic vein is left in situ to drain the retained skin on
the ulnar border of the forearm. Posterior cutaneous nerves may
also be identified and preserved with the flap. These cutaneous
nerves are divided proximally and tagged for later neurorrhaphy.
The segment of the flap between the urethral and shaft
skin is de-epithelialized, preserving the deep dermis. The de-
epithelialized skin is saved for later use during the glansplasty.
The flap is elevated in a suprafascial plane, and the sensory branch
of the radial nerve is identified and preserved. The radial artery
is dissected proximally to its takeoff from the brachial artery. The
venae comitantes of the radial artery are dissected proximally, and
the perforating branch between the vena comitantes and cephalic
vein is identified and preserved. This perforating branch allows
for drainage of both the superficial and deep venous systems
through a single venous anastomosis.
Once isolated on its neurovascular pedicle, the flap is shaped
in situ. The urethra is constructed in a layered fashion over a 16
French Councill tip catheter. The urethral closure is tested with
methylene blue so as to verify a watertight closure. The shaft skin
is then wrapped around the inner urethral tube and closed in a
layered fashion. If there is tension on the closure, a skin graft can
be applied on the ventral aspect of the phallus.
The urethral meatus is constructed by suturing the inner flap
(urethra) to the outer flap (shaft) with interrupted sutures. A
glansplasty is performed approximately 3 cm proximal to the
distal tip of the flap. The coronal ridge is fashioned by elevating a
distally based, partial-thickness flap. The flap is tapered on either
side of the suture line to simulate the appearance of a frenulum.
Fig. 113.8 Metoidioplasty. Postoperative photo.

 Gender-Affirming Surgery GeniWDO Surgery
1645
The de-epithelialized defect is then covered with the strip of skin
obtained from the de-epithelialized segment previously harvested
between the urethral and shaft portions of the flap.
Once the recipient vessels (femoral artery and saphenous vein)
are prepared, the flap is transferred to the pubis. The forearm
donor site is closed as the urethral and microsurgical anastomo-
ses are performed by the second team. The forearm muscles are
approximated over a closed-suction drain. We favor placement of
a bilaminate neodermis on the donor site. This is dressed with
negative pressure wound therapy for approximately 3 weeks.
Approximately 3 weeks later, the patient returns for split-thick-
ness skin grafting to the forearm and retrograde urethrogram.
RFFF phalloplasty photos are shown in Fig. 113.9.
ALT Phalloplasty
The ALT phalloplasty is performed following the perineal portion
of the operation (Fig. 113.10). The patient is taken out of lithot-
omy and placed in the supine position. Flap elevation proceeds
with the anterior incision. The rectus femoris muscle is retracted
to aid with identification of the descending branch of the lateral
femoral circumflex artery. Either musculocutaneous or septocu-
taneous perforators are identified and preserved. Ideally, distal
perforators are chosen, so as to effectively lengthen the vascular
pedicle. In order to create a sensate phallus, the lateral femoral
cutaneous nerve is identified and divided proximal to the flap
border. Following flap and pedicle dissection, a tunnel is devel-
oped under the rectus femoris and sartorius muscles, through
which the flap will be transferred.
Flap Inset
If microsurgery is to be performed, as with RFFF, the groin ves-
sels are prepared. In order to maximize flap (i.e., penile) length,
an arteriovenous loop is created by anastomosing the saphenous
vein to the superficial femoral artery in an end-to-side fashion.
The A-V loop is allowed to perfuse during the remainder of the
donor site preparation. Additional outflow veins, such as the
superficial inferior epigastric vein and superficial circumflex iliac
vein, are also isolated as needed. Prior to flap transfer, sutures
are pre-placed in the os of the reconstructed pars fixa of the ure-
thra. The flap is then transferred, and the urethral anastomosis
is performed by “parachuting” the sutures into place. The suture
line of the shaft is positioned ventrally.
The vascular anastomoses are performed between the arterial
limb of the A-V loop and the radial artery in an end-to-end
fashion, and the venous limb of the A-V loop to the cephalic
vein in an end-to-end fashion. Additional venous anastomoses
are performed as needed. Often, a coupling device is used for
the venous anastomoses. The flap is allowed to perfuse, and the
neurorrhaphies are performed by coapting the forearm nerves to
the ilioinguinal nerve. The dorsal clitoral nerves remain attached
to the de-epithelialized clitoris, which is buried subcutaneously at
the base of the phallus.
The flap is inset in a layered fashion, and a Penrose drain is
placed on each side of the groin donor site incisions. An antibiotic
patch is placed over the suprapubic catheter site, and the urinary
drainage bag is attached to the suprapubic catheter. The phallus is
positioned upright with gauze and/or towels. Additional support
is provided for the urethral Foley catheter to minimize pressure
on the urethral meatus. Antibiotic ointment with tribromophen-
ate gauze is applied to any areas of skin grafting. The patient is
monitored in the intensive care unit to assess flap perfusion.
113.6 Postoperative Care
113.6.1 Vaginoplasty
The typical length of stay is 7 days. Assisted ambulation begins
on the first postoperative day, and sequential compression
devices are maintained until discharge. A screening venous
duplex is performed on postoperative day 3 or 4. The vaginal
packing is typically removed on postoperative day 5 or 6, the
Foley catheter is typically removed on postoperative day 6 or 7,
and the patient is typically discharged on postoperative day 7
following urination.
Depending on the patient’s level of support, recuperation may
be at a rehabilitation facility for several days following discharge.
The patient is seen in the office between postoperative days 10
and 14 for dilation and douching instructions. A pelvic floor physi-
cal therapist may also provide assistance with pelvic relaxation so
as to facilitate vaginal dilation. Patients are asked to return to the
office 3 months following surgery, or sooner, if needed. Hormones
Fig. 113.9 (a,b) Radial forearm free flap phalloplasty. Postoperative
photos.
Fig. 113.10 (a,b) Anterolateral thigh flap phalloplasty. Postoperative
photos taken at 2 months.

1646
XIV Gender-Affirming Surgery
are resumed approximately 2 weeks following surgery, when the
patient is ambulatory.
Dilation protocols may vary based on individual circumstances.
The typical dilation schedule includes neovaginal dilation 3 times
daily for at least 3 months. The frequency of dilation may decrease
if patients are engaging in regular vaginal intercourse. Patients are
also instructed to douche daily with a dilute solution of either
povidone–iodine (Betadine) or vinegar and water, until healed.
Patients may begin vaginal intercourse at 8 weeks following
surgery if they are healing uneventfully.
113.6.2 Metoidioplasty
The typical length of stay is 3 days. Assisted ambulation begins
on postoperative day 1. Both sequential compression devices
and chemoprophylaxis are used, and perioperative antibiotics
are administered. The patient is discharged with both a supra-
pubic tube and penile Foley catheter. Patients are seen in the
office approximately 1 week following surgery. Testosterone is
resumed once the patient is ambulatory. Patients are encouraged
to wear loose-fitting clothing and avoid heavy lifting for 6 weeks
postoperatively. Drainage from the colpectomy/colpocleisis is
not uncommon and may require gauze pads.
Three weeks following surgery, a retrograde urethrogram is
performed. If the urethral anastomosis is intact, the Foley catheter
is removed. The suprapubic catheter remains in place until the
patient is effectively voiding, as measured by postvoid urinary
residuals. If a fistula is identified, the Foley catheter may be
exchanged and left in place for an additional 2 weeks.
113.6.3 Phalloplasty
Phalloplasty patients are monitored in the intensive care unit for
approximately 3 days following surgery. This allows assessment
of flap perfusion with handheld Doppler checks and clinical
examination. The phallus is elevated and free of compression, a
forced air warming blanket is placed, aspirin, chemoprophylaxis
with low-molecular-weight heparin, and prophylactic antibi-
otics are administered. For patients with an RFFF, occupational
therapy for range of motion on the forearm is initiated on
postoperative day 1, and the negative pressure wound therapy
dressing on the forearm is changed at 4- to 5-day intervals.
Assisted ambulation begins on postoperative day 4, at which
time the patient is transitioned to a regular floor. The patient is
typically discharged to a skilled facility on postoperative day 8.
Testosterone is restarted once the patient is ambulatory. Patients
are encouraged to wear loose-fitting clothing and avoid heavy
lifting for 6 weeks postoperatively.
At 3 weeks postoperatively, a retrograde urethrogram is per-
formed; if the two urethral anastomoses are intact, the Foley cath-
eter is removed, the patient begins voiding, and the suprapubic
catheter is left in place to allow monitoring of postvoid residuals.
If the patient is effectively voiding for 2 weeks, with less than 100
mL postvoid residual, the suprapubic catheter is removed. The
patient is encouraged to check in regularly with the office and to
return for a routine check at 2 to 3 months. The penile prosthesis
may be placed at 9 to 12 months following the phalloplasty if the
patient is healed and urinating well.
113.7 0RdiÀFDWiRnV Dnd
Ancillary Procedures
113.7.1 Vaginoplasty
In some individuals, there is insufficient penile and/or scrotal
tissue available for the penile inversion vaginoplasty. For these
individuals, additional full-thickness skin grafts can be harvested
from a hairless site on the flanks. If the entire vaginal canal is to
be lined with grafts, the grafts should measure approximately 15
cm in length by 10 cm in width (i.e., each flank site measuring 15
cm in length × 5 cm in width).
In individuals who have undergone previous prostate surgery
and/or radiation or do not desire or contemplate vaginal inter-
course, a “zero-depth” vaginoplasty (i.e., external vulvoplasty)
may be performed. This technique is similar to the penile inver-
sion procedure; however, the perineal dissection is deferred. A
vaginal “dimple” is created at the introitus.
Following vaginoplasty, some individuals may experience
urethral stream abnormalities (i.e., “spraying”) and/or an anterior
direction of the urine stream. In these circumstances, the position
of the urethral meatus may be surgically lowered or repositioned.
Additionally, following penile inversion vaginoplasty, the vaginal
introitus may have a vertical orientation, making vaginal inter-
course difficult. In these circumstances, the posterior introitus
can be divided, facilitating access to the vagina.
113.7.2 Metoidioplasty
In overweight individuals or individuals with significant skin
excess of the pubic region, a mons resection (aka mons lift or
monsplasty) can be performed so as to make the phallus more
visible. This is similar to correction of a buried penis in cis men.
In these cases, the soft tissue of the pubic region is resected, and
Scarpa’s fascia of the lower flap is affixed to the rectus sheath,
thereby assisting with exposure of the phallus. A mons lift is
commonly combined with a secondary scrotoplasty (Fig. 113.11).
During the secondary scrotoplasty, the former labia majora are
retrodisplaced using reverse V-< advancement flaps. This helps
position the scrotum anterior to (rather than in between) the
thighs.
113.7.3 Phalloplasty
Nine to twelve months following phalloplasty, provided the indi-
vidual has healed adequately and urinates well, penile and testic-
ular prostheses may be placed (Fig. 113.12). In general, hydraulic
penile prostheses are preferred so as to reduce the risk of implant
erosion. The available penile prostheses are not designed for
placement within a flap phalloplasty; they are designed to be
placed within the corporal bodies of cis men, wherein the tunica
albuginea acts as a thick connective tissue sheath. No such struc-
ture is present within a flap phalloplasty. In order to surgically

 Gender-Affirming Surgery GeniWDO Surgery
1647
construct corporal bodies, the implant cylinders are wrapped
within a sheath of acellular dermal matrix. This may help to rein-
force the local soft tissue, act as a barrier to implant migration,
and reduce shear forces on the overlying soft tissue.
Following cystoscopic placement of a Foley catheter, the penile
prostheses are placed via a suprapubic access incision. The pubic
symphysis is exposed, taking care not to injure the flap neuro-
vascular structures. Electrocautery is used to create two cortical
tunnels in the pubis, which will be used to anchor the penile
prosthesis. The tunnels for the cylinders are created in the flap
phalloplasty using blunt dissection with Hegar dilators. The base
of the cylinders is anchored to the pubis with permanent sutures.
For inflatable prostheses, the saline reservoir is placed retropubi-
cally. The cylinders are attached to the pump and reservoir, the
system is tested, and the pump placed within the hemiscrotum
contralateral to the vascular pedicle. A single testicular prosthesis
is then placed within the opposite hemiscrotum. The penile
prosthesis is left partially inflated for approximately 1 week. At 6
weeks following surgery, penetrative intercourse may be initiated.
113.8 5eVuOWV&RmSOiFDWiRnV
113.8.1 Vaginoplasty
One of the most significant complications following penile
inversion vaginoplasty is a rectovaginal fistula. The fistula may
result from an intraoperative rectal laceration, devascularization
of the rectum, or dilation injury, and patients may require fecal
diversion. In this circumstance, vaginal dilation may be delayed.
As such, the neovagina may stenose, and revision vaginoplasty
may be requested at a later date. This may be performed using
skin grafts, peritoneal flaps, or segments of intestine.
Bleeding can occur during the perineal dissection or postopera-
tively from the neoclitoris or urethra and vestibulum. In practice,
this bleeding, which typically occurs within the first 3 postop-
erative days, can be addressed on the hospital floor with silver
nitrate, hemostatic oxidized methylcellulose mesh dressing, and
direct pressure. Infection is rare after vaginoplasty, but wound
separation is not uncommon. Superficial separation of the poste-
rior incisions can typically be managed with local care consisting
of dilute Dakin’s solution twice daily and antibiotic ointment.
Other acute complications include vaginal prolapse, potentially
requiring operative intervention. Additional issues that may arise
following surgery include urethral stream abnormalities (i.e.,
spraying of urine). Most often, this resolves without intervention.
However, if persistent, urethral meatoplasty may be performed.
In order to maintain patency of the vaginal cavity, postoperative
dilation is required. Failure to dilate may result in stenosis of the
vaginal cavity, potentially requiring secondary procedures.
For a list of vaginoplasty-related complications, see Table 113.1.
113.8.2 Metoidioplasty
Complications following metoidioplasty generally fall into two
categories: urethral and healing related. Minor urinary issues
may include urinary spraying and postvoid dribbling. Postvoid
dribbling may be ameliorated with manual milking of the
urethra (posterior to anterior massage of the urethra to remove
retained urine). Urethral stricture and fistula remain two pri-
mary concerns. Some fistulas may heal without operative inter-
vention. Urethral stricture may require repair, either single- or
Fig. 113.11 Mons lift and scrotoplasty. A mons lift is performed
to increase visibility of the phallus created during metoidioplasty.
Retrodisplacement of the labia majora is performed with V-Y advance-
ment flaps to place the neoscrotum in a more anatomical position.
Fig. 113.12 Inflatable penile prosthesis insertion. Subcutaneous
tunnels are created to allow placement of the cylinders.

1648
XIV Gender-Affirming Surgery
two-stage urethroplasty depending on the location and length
of the stricture
For a list of metoidioplasty-related complications, see Table
113.2.
113.8.3 Phalloplasty
Donor Site
Donor site scarring can be of concern to the patient, especially
in regard to the forearm. A compression sleeve, incorporating
the hand, is worn starting 3 weeks following skin grafting to
help reduce scar hypertrophy and hand swelling. Patients are
advised to delay tattoo of the forearm donor site for at least 1
year following surgery, and to avoid a tattoo over the anatomic
location of the sensory branch of the radial nerve. Following
surgery, range of motion and occupational therapy are instituted
on postoperative day 1.
Flap Complications
Flaps are monitored postoperatively using a handheld Doppler
and clinical examination with attention to flap turgor, color, tem-
perature, and Doppler pulses. A low threshold for re-exploration
and anastomotic revision should be maintained. :hile total flap
failure is uncommon, partial flap loss may occur. Most often,
areas of epidermolysis or partial flap loss are managed with
local wound care. Additionally, incisional dehiscence between
the ventral penile shaft and surrounding pubic skin may occur,
necessitating delayed primary closure. The flap should be sup-
ported during ambulation for up to 6 weeks following surgery.
Perineal Complications
Drainage from the colpectomy/colpocleisis site is not uncommon.
This is most often managed with local care.
Urethral Complications
Urethral stricture and fistula may occur independently or in
tandem. :hile small fistulas may heal without intervention,
they may also be a sign of distal stricture. While a full discus-
sion of treatment of urethral strictures is beyond the scope of
this chapter, either single- or two-stage urethroplasty may be
required. In general, treatment depends upon the length and
location of the stricture.
Penile and Testicular Prosthesis Complications
As discussed earlier, potential concerns regarding testicular and
penile prostheses include erosion, displacement, infection, and
mechanical failure.
A list of phalloplasty-related complications is provided in Table
113.3.
113.9 Closing Thoughts—
D 7eDm (̵RrW
Gender confirmation is a multidisciplinary effort. A team
approach of surgeons, primary care providers, and mental health
professionals is recommended. Additional providers, including
physical therapists, social workers, and case managers, is also
helpful in managing a wide range of clinical and administrative
issues. It is helpful to have a working relationship with local
mental health professionals who are well versed in gender-related
issues, both for assistance in interpretation of letters of referral,
as well as for assistance in helping manage social, emotional,
and mental health needs. Social workers are helpful in assessing
an individual’s support system and identifying potential areas
Table 113.1 Vaginoplasty complications
Penile inversion
Rectovaginal fistula
0.6–17%
Urethrovaginal fistula
1.7%
Neovaginal prolapse
1–10%
Stricture
- Introital
2.5–12%
- Neovaginal
3.2–15%
Meatal stenosis
5–9.7%
Urinary tract infection
4.4–32%
Postoperative bleeding
3.2–10%
Wound dehiscence
12–33%
Urinary spraying
9.5%
Intestinal
Rectovaginal fistula
2–20%
Stenosis/stricture
9–16%
Prolapse
1–8%
- Mucosa only
6.5%
Malodor
9.0%
Excessive discharge
0.7%
Table 113.2 Metoidioplasty complications
Stricture
3.8–9.1%
Fistula
5.0–16.9%
Diverticulum
1.3%
Testicular implant revision
3.8%
Table 113.3 Phalloplasty complications
Complete flap loss
0.9%
Partial flap loss
7.2%
Vascular anastomotic revision
7.8–11.3%
Fistula
15–70%
Stricture
6–52%
Meatal stenosis
14%
Prosthesis related
Need for revision
34.7–41%
Inability to have intercourse
16.3–20%

 Gender-Affirming Surgery GeniWDO Surgery
1649
of concern, easing transitions from inpatient to outpatient, and
helping to avoid potential impediments to care. An institutional
commitment to the program is helpful in cultivating culturally
competent care. In closing, surgeons interested in performing
gender-confirmation surgery should be appropriately trained.
For those considering genital surgery, this is best accomplished
by participating in a fellowship program.
113.10 Conclusion
Gender-confirmation surgery is a growing field. Our patients will
benefit from our shared knowledge and experience during this
exciting time.
Clinical Caveats
• Genital surgery for gender confirmation is a multidisciplinary
field; the surgeon should work collaboratively with specialists
in mental health, medicine, endocrinology, urology, social
work, and physical therapy as needed to provide optimum
care.
• Review the surgical referrals from mental health providers;
when in doubt, contact the provider directly.
• Discontinuing hormone therapy 2 weeks prior to surgery is
recommended. It can be resumed following surgery, once the
patient is reliably ambulatory.
• Smoking cessation is recommended prior to surgery.
• Patients undergoing perineal dissection or colpectomy/colp-
oclesis receive a bowel prep the day prior to surgery.
• In patients with a history of prostatectomy or pelvic radiation
consider a zero-depth vaginoplasty (i.e., “vulvoplasty”).
• A Lowsley retractor can facilitate exposure of the prostate
and Denonvilliers’s fascia during perineal dissection.
• Gender confirmation surgery requires a commitment on the
part of the patient and surgeon. Additionally, phalloplasty
and metoidioplasty patients must be counseled as to the risk
of urinary and healing complications.
Suggested Reading
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complications, and sexual function. J Sex Med 2014;11(7):1835–1847
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[4] Chang TS, Hwang :<. Forearm flap in one-stage reconstruction of the penis.
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[5] Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of
transsexual, transgender, and gender-nonconforming people, version 7. Int J
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[6] Djordjevic ML, Bizic M, Stanojevic D, et al. Urethral lengthening in metoidioplas-
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and labia minora flap. Urology 2009;74(2):349–353
[7] Doornaert M, Hoebeke P, Ceulemans P, T’Sjoen G, Heylens G, Monstrey S. Penile
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[9] Felici 1, Felici A. A new phalloplasty technique: the free anterolateral thigh flap
phalloplasty. J Plast Reconstr Aesthet Surg 2006;59(2):153–157
[10] Frey JD, Poudrier G, Chiodo MV, Hazen A. A systematic review of metoidioplasty
and radial forearm flap phalloplasty in female-to-male transgender genital
reconstruction: is the “ideal” neophallus an achievable goal? Plast Reconstr Surg
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Index
I-1
Index
Note: b indicates a box; f, a figure; t, a table.
A
Abdominal aesthetic surgery in men, 1474–1482
anatomy, 1475–1476, 1476f
ancillary procedures, 1480
autologous BodyBanking abdominal contour-
ing techniques, 1478–1479, 1478f, 1479f
BodyBanking, 1474–1475, 1475f, 1476f
indications and contraindications, 1474–1475,
1475f, 1476f
outcomes/results, 1480–1481
BodyBanking with liposuction and autolo-
gous fat grafting, 1480–1481
silicone six-pack abdominal implant
placement, 1481
postoperative care, 1480
preoperative assessment, 1476–1477
preoperative planning, including markings,
1477–1478, 1477f
silicone six-pack abdominal augmentation,
1479–1480, 1480f, 1481f
Abdominoplasty, 1409–1443, 1409f
anatomy, 1409–1413
blood supply, 1411–1412f
fat, 1410, 1410
muscle and fascia, 1410, 1411f
nerves, 1413
skin, 1410
soft tissue layers, abdominal wall, 1410
umbilicus, 1412
combination procedures, 1415–1416
complications, 1440, 1442
abdominal wall relaxation, 1442
delayed wound healing, 1440
dog-ear formation, 1440
fat necrosis, 1442
recurrent soft tissue ptosis, 1442
scarring, 1440, 1442
seroma, 1440
umbilical necrosis, 1442
evaluation, 1413
abdominal wall, 1413, 1415f
fat, 1413, 1414f
skin, 1413, 1413f
preoperative considerations, 1414–1415
body habitus, 1414
deep venous thrombosis, 1415
future pregnancies, 1415
general health, 1414
smoking history, 1414
procedures, 1417–1440
circumferential abdominoplasty,
1428–1432, 1431f, 1432f, 1433f
extended abdominoplasty, 1425–1428,
1428f, 1429f, 1430f
fleur-de-lis abdominoplasty, 1432–1434,
1434f, 1435f
full abdominoplasty, 1417–1425, 1419f, 1421f,
1422f, 1423f, 1425f, 1426f, 1427f
isolated abdominal wall rejuvenation,
1439–1440, 1441f
male abdominoplasty, 1436–1437, 1437f,
1438f
mini-abdominoplasty, 1434–1436, 1436f,
1437f
panniculectomy, 1437, 1439, 1439f
technique overview, 1416–1417
abdominal wall management, 1416–1417,
1418f
excess fat management, 1416, 1417f
excess skin management, 1416, 1416f
umbilicus management, 1418
Abductor group, 1308f, 1309
Ablative fractional lasers, 199
Ablative full-field lasers, 196–197, 197t, 198f
Ablative lasers, 232
Abnormally low hairline, 275, 277f
Acne, 122f, 123–124
Acquired age-related ptosis, 398–399, 399f
Acquired third-nerve palsy, 400, 401f
Actinic damage to skin, 68
Adipose tissue, 521–522, 522f
Adipose tissue and fat grafting, 1346–1349,
1349f
donor site and harvesting, 1347
fat grafting technique, 1347
graft processing, 1347–1349
lipoinjection technique, 1349, 1350f
Adjuvant procedure for breast reconstruction,
1070
Advanced practice registered nurse (APRN) and
MedSpa law, 76
Aesthetic eyelid surgery clinical decision
making, 357–373
evaluation, 357–361, 357f, 358f
canthal position, 359, 360f
decision-making factors, 358b
eye prominence and Hertel Measurement,
359, 359f, 360f
fat, 359
lid tone, 359
muscle, 359
scleral triangles, 359–360, 360f
skin, 359
upper lid ptosis, 359
lower eyelid rejuvenation, 364–368, 365b,
365f, 366f, 373f
fillers, 365
lid retraction causes, 366b
orbicularis flap, 368, 368f
pinch blepharoplasty, 365, 365f, 366f
transconjunctival approach, 366, 366t
transcutaneous approach, 366–367, 367f
preoperative planning, 361–368
fat management options, 361–362, 361b,
361f, 362f, 363f, 364f
lower eyelid rejuvenation, 364–368, 365b,
365f, 366f
transpalperbral midface lift, 368
upper eyelid rejuvenation, 362, 364, 363b,
364t
results, 368–372
long-term results, 371, 371f, 372f
short-term results, 368–370, 369f, 370f, 371f
upper eyelid rejuvenation, 362, 364, 363b,
364t, 373f
skin excision, 364
skin-muscle excision, 364
transconjunctival approach, 364, 364f
Aesthetic eyelid surgery complications, avoid-
ance, and treatment, 458–469
aesthetic problems, 466–469
change in eyelid shape, 466–467
eyelash loss, 469
eyelid asymmetry, 467, 486f
fat injection complications, 467–468, 468f
scar, 467
skin texture problems, 468
functional problems, 458–466
chemosis, 466, 467f
diplopia, 463, 464f
dry eye and epiphora, 464–466, 465f, 466f
ectropion, 460–463, 462f, 463f
infection, 458, 458t
lagophthalmos and corneal exposure,
458–460, 459f, 460f, 461f
lid retraction and lateral canthal rounding,
460, 461f
midriasis, 463
orbital hemorrhage and hematoma, 458,
459f
paresthesias of eyelid, 464, 465f
ptosis of upper eyelid, 463
refractive changes, 464
trichasis and entropion, 463
Aesthetic indications and contraindications for
botulinum toxin injection, 139–140
Aesthetic medicine in aesthetic surgical
practice, 63–66
patient acquisition, 64
economy and, 64
subscription aesthetic services model,
64–65
patient conversion, 65–66
patient education, 65
patient optimization, 65
laser therapy, 65
noninvasive technologies, 65
scar management, 65
patient retention, 64–65
Aesthetic problems, eyelid surgery, 466–469
change in eyelid shape, 466–467
eyelash loss, 469
eyelid asymmetry, 467, 486f
fat injection complications, 467–468, 468f
scar, 467
skin texture problems, 468
Aesthetic services subscription model, 64–65,
71–72
customer data, 72
expansion of practice, 72

Index
I-2
future revenue stream, 72
loyalty, 72
millennials and, 73
monthly payments, ease of, 72
retention, 72
satisfaction, 72
Aesthetic upper eyelid blepharoplasty, 374–375
African descent proportions, rhinoplasty, 924,
925f
African rhinoplasty, 989–994
Age as risk factor, 40
Aging and midface recontouring, 478f, 479–482,
479f, 480f
Aging changes of the face, 634–635
Aging face and need for fat injections, 687–688
Aging forehead and brow evaluation, 283–284,
284f, 285f
brow position evaluation, 283–284, 284f
rhytids, crows’ feet, and lateral orbital area
evaluation, 284
skin evaluation, 284, 285f
Aging herniated patient and lower eyelid pinch
blepharoplasty, 455
Aging mouth rejuvenation, 863–870
alloplastic fillers, 870
ancillary surgical procedures, 869–870
alloplastic implants, 869
dermis graft, 869
fat grafting, 869
mucosal advancement flaps, 869
perioral resurfacing, 869–870
anatomy, 863, 863f
postoperative care, 868–869
preoperative assessment, 864
surgical procedures, 864–868
corner mouth lift, 865–867, 866f, 867f
direct incision, 867–868, 868f, 869f
lip lift, 864–826, 863f, 864f
vermilion advancement, 867, 868f
Aging patient and lower eyelid pinch blepharo-
plasty, 453, 453f
Aging skin, 127–130
Airway management, 53t
Alar base reduction, Asian rhinoplasty, 975
Alar-columellar relationship correcting,
937–938, 938f, 939f, 940f
Alar rims, 936, 937f
Alloplastic chin augmentation, 887, 887f
Alloplastic graft materials for rhinoplasty
revision, 1015
Alloplastic fillers, 870
Alloplastic implants, 869
Alpha-hydroxy and beta-hydroxy acids for
exfoliation and cell renewal, 113
ALT phalloplasty, 1645, 1645f
American Society for Aesthetic and Plastic
Surgery top ten procedures, 222t
American Society of Anesthesiologists status,
41, 41t, 52t
Anaplastic large-cell lymphoma, breast
implant-associated, 1042
Anatomical correlation of boundaries between
topographic planes, 521, 521f
Anatomic fat compartments, 525
Anatomic spaces, 527–528, 528f
Anesthesia methods, 53–57
airway management, 53t
general anesthesia, 53
local anesthesia, 54–57, 55t, 56t
monitored anesthesia care, 53
office-based anesthesia, 56–57
sedation, 53–54, 54t
tumescence solutions, 55–56
Anesthetic considerations, 48–50. See also
Sedation and anesthesia
local anesthetic systemic toxicity, 48–50, 49f
nil per os, 48
postoperative nausea and vomiting, 48
Anterior and posterior vaginoplasty, 1576–1577
Anterior neck MACS lift short-scar rhytidectomy
with fat grafting, 585
Anterior thigh telangiectasias, 219–220, 219f,
220f
Anxiety, 53
Aperture, 23–24, 23f
Asian rhinoplasty, 970–982
anatomy, 970
indications and contraindications, 970
operative techniques, 971–975
alar base reduction, 975
auricular cartilage harvest, 972–973, 973f
costal cartilage harvest, 971–972
dorsal augmentation, 973–974, 973f, 974f
skin flap evaluation, 973
tip contouring, 974–975, 975f
preoperative assessment, 970–971
preoperative planning, 971
problems and complications, 975–976
results, 976–982, 976f, 977f, 978f, 979f, 980f,
981f, 982f
Asian upper eyelid anatomy variations, 349f, 350
Asymmetrical breasts, 1069–1070, 1069f
Asymmetric hypoplasia, 1275
Augmentation blepharoplasty MACS lift short-
scar rhytidectomy with fat grafting,
587, 587f
Augmentation mammoplasty, 1617
Auricular cartilage harvest, Asian rhinoplasty,
972–973, 973f
Autogenous facial implant material, 729–730
bone, 729
fat, 730
hydroxyapatite, 731
polyethylene, 731
polysiloxane (silicone), 731
polytetrafluorethylene (PTFE), 731
Autologous fat, 887–889, 890f, 891f
Autospreader flaps, 933, 934f
B
Bauman Skin Type (BST) test, 119, 120f
Benzodiazepine or opioid overdose, 58
Biceps, 1305–1306, 1305f
Bilateral breast augmentation or lipoaugmenta-
tion, 1067–1068, 1069f
Biocell surface (texture) for breast implants,
1041, 1042f
Bipolar RF devices, 203
Blepharoplasty questionnaire, 6f
Blood and lymphatic supply to upper eyelid,
378, 378f
Blue rubber bleb nevus syndrome, 217–218, 218f
Bodybanking, 1474–1475, 1475f, 1476f
autologous BodyBanking abdominal contour-
ing techniques, 1478–1479, 1478f, 1479f
BodyBanking with liposuction and autologous
fat grafting, 1480–1481
Body contouring applied anatomy, 1293–1315
anatomical milestones, 1298–1310
art and anatomy, 1293–1294, 1295f
body sculpting basis, 1310
body sculpting techniques, 1310–1312
fat distribution, 1310, 1311f
human form, 1295–1296, 1296f, 1297f
lower leg, 1309–1310
gastrocnemius, 1309–1310, 1310f
soleus, 1310
sculpt and carve, 1312–1314, 1313f, 1314f
shoulder and arm, 1304–1306
biceps, 1305–1306, 1305f
brachialis, 1305f, 1306
deltoid, 1304–1305, 1304f, 1305f
triceps, 1304f, 1305, 1305f
symmetry and proportions, 1296–1298, 1298f
thighs and hips, 1306–1309
abductor group, 1308f, 1309
gluteus maximus, 1306–1307, 1306f, 1307f
gluteus medius, 1307
hamstrings, 1308–1309, 1308f, 1309f
iliopsoas, 1307
quadriceps, 1307–1308, 1308f, 1309f
sartorius, 1308f, 1309
trunk muscles, 1298–1304, 1298–1299, 1299f,
1300f
erector spinae, 1303–1304, 1304f
external oblique, 1300f, 1301f, 1302
latissimus dorsi, 1303, 1304f
multifidus, 1304
pectoralis major, 1302–1303, 1303f
rectus abdominis, 1299, 1302, 1300f, 1301f
serratus anterior, 1300f, 1301f, 1302
Body contouring clinical decision making,
1316–1326
abdominal contouring, 1818–1317
abdominal exam and assessment, 1317–1321
adjacent areas, 1321
fat, 1317
intra-abdominal fat, 1317, 1320f
myofascial laxity, 1317, 1319f
skin quality, 1317, 1317f, 1318f
causes of abdomen fullness, 1316b
patient evaluation and counseling, 1316
patient profiles, 1321–1323
excess abdominal wall fat, 1321, 1321f
massive-weight-loss patients, 1322–1323,
1323f
normal quality skin, minimal to moderate
fat, 1321, 1322f
severe amounts of excess skin, 1321–1322,
1322f
safety issues, 1323
thigh lift, 1323, 1324f, 1325f
upper arms, 1323
Body contouring, noninvasive and minimally
invasive, 1327–1340
energy-assisted liposuction, 1327–1332
laser-assisted liposuction, 1328–1329, 1328f,
1329f, 1330f
ultrasound-assisted liposuction, 1329–1332,
1331f
noninvasive modalities, 1332–1339
cryolipolysis, 1332, 1334, 1333f, 1334f
high-intensity focused ultrasound,
1334–1335
multipolar radiofrequency, 1337–1338
muscle bulking with electromagnetic
pulsed energy, 1339
noninvasive laser lipolysis, 1335–1337,
1336f, 1337f
pharmacologic adipocytolysis injection
therapy, 1339
Body contouring questionnaire, 7f
Body dysmorphic disorder, 17–19, 833–834
body image dissatisfaction and body dysmor-
phic disorder, 18–19
motivations and expectations, 18
Body image and self-worth, 16–17
Body image dissatisfaction and body dysmor-
phic disorder, 18–19

Index
I-3
Body lift, 1396–1408
anatomy, 1397–1398
blood supply, 1397
nerves, 1397
superficial fascial system, 1397–1398, 1399f
ancillary procedures, 1404–1406
buttock lift, 1405–1406, 1406f
vertical abdominoplasty, 1404–1405, 1405f
complications, 1406–1407
indications and contraindications, 1396–1397
massive-weight-loss patients, 1396, 1397f
non-massive-weight-loss patients,
1396–1397, 1398f
male considerations, preoperative assessment,
1403–1404, 1404f
operative technique, 1400, 1402–1404, 1402f,
1403f, 1404f
outcomes, 1408
postoperative care, 1406
preoperative assessment, 1398–1399
medical history, 1398
nutrition, 1399
physical exam, 1398–1399
preoperative planning, 1399–1400, 1401f,
1402f
Body mass index as risk factor, 40–41, 41f
Bone grafting for rhinoplasty revision, 1014
Botulinum toxin injection for facial rejuvena-
tion, 135–149
aesthetic indications and contraindications,
139–140
anatomy, 140, 141f
chronology of clinical use, 136, 137t
combination/ancillary treatments, 143
complications, 144–145
inadvertent muscle paralysis, 144
local complications from injection, 144
therapeutic failures, 144–145
dilution/storage, 138–139
ideal patient, 140
injection technique, 141, 142f
neurotoxins/fundamentals, 136–138
mechanism of action, 138
product preparation, 136–138
nonaesthetic uses, 136, 137t
outcomes and patient results, 145–149, 146f,
147f, 148f
posttreatment care, 144
pretreatment planning, 141
nonsurgical skin rejuvenation, 135–136
target-specific dosing, 141–143
crow’s feet, 142–143
depressor anguli oris, 143
dimpled chin, 143
glabellar lines, 142
horizontal forehead lines, 143
lips, 143
lower eyelid, 142–143
platysmal bands, 143
upper eyelid, 143
toxicity, 138
Bounce and ring flash, 35, 37
Bowel preparation protocol for transfeminiza-
tion, 1611
Brachialis, 1305f, 1306
Brachioplasty, 1372–1386, 1373f
anatomy, 1373, 1374f
ancillary procedures, 1380, 1380f
indications and contraindications, 1372
operative technique, 1377–1380, 1378f, 1379f,
1380f
outcomes, 1381, 1383, 1381f, 1381t, 1382f,
1383f
postoperative care, 1380–1381, 1381f
preoperative assessment, 1373–1376
extensive brachioplasty, 1375f, 1376
minimal incision brachioplasty, 1374–1376,
1375f
standard brachioplasty, 1375f, 1376
thoracobrachioplasty, 1375f, 1376
preoperative planning and markings,
1376–1377, 1377f
minimal incision brachioplasty, 1376–1377,
1377f
standard, extensive, and thoracobrachio-
plasty, 1377, 1377f
results, 1384f, 1385f, 1386f
Brand perception, 96
Breast anatomy, 1023–1035
blood supply, 1029–1031, 1030f, 1031f
breast fascial system, 1025–1027, 1028f, 1029f
embryology, 1023–1024, 1023f, 1024f, 1025f
glandular anatomy, 1025, 1026f, 1027f
hormonal regulation, 1028–1029
innervation, 1031–1032, 1032f
lymphatic drainage, 1032–1033, 1033f
microscopic anatomy, 1028
muscle and inframammary fold, 1033–1034
surface anatomy, 1024–1025, 1025f, 1026f
Breast augmentation, 1051–1065
body proportions and analysis, 1052
breast beauty and the ideal breast, 1052–1054,
1053t
breast beauty template in planning process,
1054
breast shape analysis, 1052–1053
history, 1051–1052
ICE principle, 1054–1055
ICE principle and problem solving, 1059, 1059f
measurement principles, 1055–1058, 1055f
ICE principle analysis, 1056
implant positioning, 1055–1056, 1056f,
1057f, 1058f, 1059f
results, 1060, 1061f, 1062f, 1063f, 1064f
round versus anatomical implants,
1059–1060, 1060f
Breast augmentation, composite primary and
revision, 1084–1097
ADM and scaffold, 1085–1086, 1086f
anatomy, 1088–1089
composite breast augmentation, 1084–1085,
1085f
fat grafting, 1094–1095
fat harvesting and injection technique,
1095–1096
harvest small parcels, 1095–1096
maximize fat “take,” 1096
placement technique, 1096
pocket exploration for inadvertent place-
ment of fat, 1096
indications and contraindications, 1086–1087,
1086f, 1087f, 1088f, 1089f
operative technique, 1090–1094
bring incision lines straight down, 1091,
1092f
double-hand-in-glove fit, 1092, 1093f
imbrication and stabilization of scaffold to
anterior skin flaps, 1094, 1095f
immobilize ADM or scaffold properly, 1094,
1095f
immobilize the breast, 1094, 1095f
insert scaffold off the incision line or nipple,
1093–1094, 1094f
limit surgical lint, 1091, 1092f
protect implant with nipple shields, funnels,
1091, 1092f
thick flaps of tissue recommended, 1094,
1095f
treat scaffolds and ADMs like implants,
1090–1091, 1092f
use abdominal tab, 1091–1092, 1093f
use three-dimensional templating, 1093,
1093f
postoperative care, 1096
preoperative planning and marking,
1089–1090, 1091f
results and outcomes, 1096
secondary or breast revision patients,
1087–1088, 1087f, 1088f, 1089f, 1090f,
1091f
Breast augmentation process, 1036–1040
patient education, 1036
postsurgical regimen, 1037, 1039t
refined surgical technique/fast-track recovery,
1037
subprocesses, 1036, 1037f
tissue-based planning, 1036–1037, 1038f
Breast base width (BBW) tissue-based planning
for breast implants, 1045, 1046f
Breast conservative treatment sequelae
correction, 1070
Breast fat grafting, 1066–1088
aesthetic surgery indications, 1067–1068
additional procedure to mastopexy, 1068
bilateral breast augmentation or lipoaug-
mentation, 1067–1068, 1069f
complication management with residual
sequelae, 1068, 1069f
composite breast augmentation (implant +
fat transfer), 1068
ancillary procedures, 1073–1074
fibrous strings and adhesions release, 1074
inframammary fold definition, 1073–1074
inframammary fold liposuction, 1073
processed fat grafting with enrichment
procedures, 1074
complications, 1074–1075
contraindications, 1070
controversy, 1066–1067
operative technique, 1071–1072
anesthesia, 1071
fat harvesting, 1071, 1071f
fat preparation, 1071, 1072f
fat transfer, 1071–1072, 1073f
incision placement, 1071
outcomes, 1075
clinical, 1075
oncologic, 1075
radiologic, 1075
postoperative care, 1074
breast, 1074
harvest site, 1074
preoperative assessment, 1070
preoperative planning and markings, 1071
reconstructive surgery indications, 1068–1070
adjuvant procedure for breast reconstruc-
tion, 1070
asymmetrical breasts, 1069–1070, 1069f
breast conservative treatment sequelae
correction, 1070
breast reconstruction conversion from
prosthesis to autologous, 1070
breast reconstruction with RAVA, 1070
pectus excavatum, 1068–1069
Poland’s syndrome, 1068, 1069f
reverse expansion, 1070
total breast reconstruction with fat grafting,
1070
tuberous breasts, 1069

Index
I-4
results, 1077–1078, 1077f, 1078f, 1079f, 1080f,
1081f, 1082f
success rate evaluation, 1075–1077
clinical evaluation, 1075–1076
interferometry, 1076–1077
Breast implant choices, 1041–1050
anatomically shaped, 1044–1045, 1045f
combination, 1043–1044
gel properties, 1043, 1043f
implant selection variation, 1047–1048, 1048f
lower breast footplate, 1047
narrow/wide breast distance, 1047
poor soft tissue coverage, 1048
short nipple to inframammary fold, 1048
patient desires, 1049
round, 1044, 1044f
saline, 1042–1043
shell, 1044
silicone, 1043
surface (texture), 1041–1042
Biocell, 1041, 1042f
implant-associated anaplastic large-cell
lymphoma, 1042
Sientra Texture, 1042, 1042f
Siltex, 1041, 1042f
texture shortcomings, 1042
three-dimensional imaging, 1048–1049
tissue-based planning, 1045–1047
breast base width (BBW), 1045, 1046f
lower pole skin pinch thickness, 1046–1047,
1047f
nipple to inframammary fold, 1046, 1046f,
1047f
skin stretch, 1047, 1048f
sternal to nipple, 1045, 1046f
Breast reconstruction conversion from prosthe-
sis to autologous, 1070
Breast reconstruction effects, 1281, 1281f
Breast reconstruction with RAVA, 1070
Breast reduction, alternative approaches,
1209–1234
anatomy, 1210–1213, 1211f, 1212f, 1213f, 1214f
indications and contraindications, 1209–1210,
1210f
markings, 1216–1217
areolar opening, 1217
ideal breast meridian, 1216
new nipple position, 1216–1217
skin resection pattern, 1217, 1217f
upper breast border and inframammary
fold, 1216, 1216f
operative technique, 1218–1232
free nipple graft, 1221–1222, 1224–1225,
1230f
inferior pedicle, inverted T-breast, 1221,
1225f, 1226f, 1227f, 1228f
infiltration, 1218
liposuction only, 1218, 1220, 1221f, 1222f,
1223f
long superior pedicle, 1225, 1232, 1232f
no vertical scar, 1221, 1229f
parenchymal resection only, 1218, 1219f,
1220f
outcomes and results, 1233
preoperative assessment, 1214, 1216
Breast reduction and mastopexy clinical
decision making, 1134–1151
breast aesthetics principles, 1134
scars, 1134
shape and size, 1134
symmetry, 1134
breast reduction, 1134–1141, 1135f, 1136f
breast-shaping techniques, 1139–1140, 1140f
liposuction-only, 1136
pedicles, 1136–1139, 1137f, 1138f, 1139f
skin, 1141, 1144, 1141f, 1142f, 1143f, 1144f,
1145f, 1146t
mastopexy, 1144–1151, 1144t, 1146f, 1147f
augmentation, 1151, 1151t
patient profiles, 1146, 1147f
ptotic breast evaluation, 1145–1146
shape restoration, 1146, 1148
skin removal, 1148, 1149f, 1150f
volume restoration, nipple-areolar position
restoration, 1148
Breast reduction: lateral pedicle technique,
1182–1194, 1183f, 1184f
anatomy, 1184–1186, 1185f
indications and contraindications, 1182–1184,
1185f
operative technique, 1188, 1190f
postoperative care, 1188, 1190
preoperative assessment and planning,
1186–1188, 1186f, 1187f, 119f
problems and complications, 1190, 1190t
results, 1191, 1191f, 1192f, 1193f
Breast surgery questionnaire, 7f
Breast symmetry management, 1274–1283
anatomy, 1274
breast reconstruction effects, 1281, 1281f
causes, 1274
iatrogenic causes of asymmetry, 1277–1278
asymmetric breast reduction, 1277
asymmetry induced during augmentation,
1277–1278, 1278f, 1279f, 1280f
asymmetry resulting from capsular
contracture, 1278
outcomes, 1282
postoperative care, 1282
preoperative assessment, 1274–1275
preoperative planning and operative tech-
niques, 1275–1277
asymmetric hypoplasia, 1275
gynecomastia, 1276–179
Poland’s syndrome, 1276
tuberous breast deformity, 1275–1276,
1276f
unilateral hypomastia with normal contra-
lateral breast, 1269
problems and complications, 1282
radiation after breast conservation,
1281–1282, 1282f
Broad-based inferior pedicle technique,
1485–1486, 1485f, 1487f
Brow lifting options, 289, 290t, 334–340
coronal brow lift, 334–336, 335f, 336f, 337f
direct brow lift, 336–338, 336f, 337f, 338f
transpalpebral browpexy, 338–340, 340f
Brow position for aging forehead and brow
evaluation, 283–284, 284f
Brow rejuvenation, 283–291
aging forehead and brow evaluation, 283–284,
284f, 285f
brow position evaluation, 283–284, 284f
rhytids, crows’ feet, and lateral orbital area
evaluation, 284
skin evaluation, 284, 285f
anatomic features, 283, 283f
brow lifting options, 289, 290t
forehead rejuvenation options, 285–288, 282t,
283f
ancillary procedures, 288–289, 289f
direct approach, 288, 288f
endoscopic forehead lift, 285–287, 287f, 287t
injection of toxins, 288, 289f
lateral temporal brow lift, 287–288, 287f
open coronal forehead lift, 285, 286f
transpalpebral browpexy, 288, 288f
transpalpebral excision of corrugator and
procerus muscles, 288, 288f, 289f
Bulbocavernosus muscle, 1501, 1501f
Bundled prices, 98–99
Burn alopecia treatment, 255–256, 256f
Business considerations in nonsurgical practice,
67–73
aesthetic subscription and benefits, 71–73
customer data, 72
expansion of practice, 72
future revenue stream, 72
loyalty, 72
millennials and, 73
monthly payments, ease of, 72
retention, 72
satisfaction, 72
consultation, 67–68
full correction goal, 69
full-service bank, 69
long-term treatment plan, 69
offering of comprehensive aesthetic plan,
68–69
intense pulsed-light device, 69
photographic analysis, 69
patient retention, 70–71, 71f, 71t
skin aging, 68
actinic damage, 68
dynamic lines, 68
gravity, 68
volume loss, 68
Buttock lift, 1405–1406, 1406f
C
Calcium hydroxyapatite, 155, 155f
Camera selection, 32–33
Camouflaging scalp scars, 254, 254f, 255f
Canthal position evaluation in aesthetic eyelid
surgery, 359, 360f
Capsular contracture, 1098–1105
current science, 1098–1099, 1100f
management, 1101–1103
nonsurgical, 1101
surgical, 1101–1103
prevention, 1099–1101
site change versus no site change, 1102–1103,
1103f, 1104f
total capsulectomy verses partial capsulec-
tomy versus capsulotomy, 1101, 1102f
Cardiovascular condition as risk factor, 42
Carotenoids for photoprotection, 115
Cartilaginous framework, 872
Castilian rhinoplasty, 997
Central wedge labiaplasty and clitoral hood
reduction, 1536–1543
anatomy, 1536
clitoral hood reduction, 1540–1541, 1541f
indications and contraindications, 1536
operative techniques, 1538–1540, 1538f,
1539f, 1540f
outcomes, 1542
postoperative care, 1541–1542
preoperative assessment, 1536–1537
preoperative planning, 1537f, 1538, 1538f
results, 1543, 1543f
Centrofacial rejuvenation, 480–482, 481f
Cephalic trim, 932, 933f
Change in eyelid shape as aesthetic problems,
eyelid surgery, 466–467
Chemical and physical sun protection factor,
113–114
Chemical peels, 173–195, 819, 820f

Index
I-5
anatomy, 177
depth of peeling, 177, 177f
histologic changes with chemical peels, 177
comprehensive facial rejuvenation goal, 173
facial aging process, 173
indications and contraindications, 175–177
Fitzpatrick classification of skin type, 175,
175t, 176f
Glogau classification of photoaging,
175–177, 176t
pharmacology, chemical peeling agents,
174–175
outcomes and results, 190–192, 191f, 192f,
193f, 194f
croton oil, 175
Jessner’s solution, 174
phenol, 174–175, 175t
trichloroacetic acid, 174
posttreatment care, 186–187, 186f, 187f, 188f,
189f
prepeel preparation, 177–178
pretreatment planning, 178–180
croton oil, 178–179, 179t
medications, 178
pretreatment routine, 179–180
solution preparation, 178
problems and complications, 187–190
treatment, 180–186
application routine, 180, 180f
croton oil peel, 182–186, 184f, 185f, 185t
TCA peel, 180–182, 181f, 181t, 182f, 183f
treatment evolution, 173–174
variations, 186, 186f, 187f
Chemosis as functional problems, eyelid
surgery, 466, 467f
Chemosis for lower eyelid blepharoplasty, 421,
421f
Chin rejuvenation, 882–895
complications, 891–893
nonsurgical techniques, 891–892, 893t
surgical techniques, 891
dermal fillers as nonsurgical approach,
889–890, 891f, 892f
genioplasty, 882
preoperative assessment, 882–884, 883f
dental morphology, 882–883
skeletal evaluation, 883–884
soft tissue analysis, 883–884, 884f
surgical techniques, 885–889
alloplastic chin augmentation, 887, 887f
autologous fat, 887–889, 890f, 891f
osseous genioplasty, 885–886, 886f
treatment approach, 884–885
Chronic progressive external ophthalmoplegia,
400, 400f
Circumferential abdominoplasty, 1428–1432,
1431f, 1432f, 1433f
Classical thigh lift, 1493–1494, 1495f
Classic medial thigh lift, 1491–1492
Cleansers, 130–131
Clinical photographic standards, 33–37
bounce and ring flash, 35, 37
intraoperative photography, 37, 37f, 38f
standard flash, 35
standard views for regions of interest, 33–35,
34f, 35f, 36f
studio effect photography, 37, 37f
Clitoral frenulum thickening, 1509, 1511f
Clitoral hood prominence, 1515, 1515f, 1516f
Clitoral hood reduction, 1540–1541, 1541f
Clitoral hood surgical alteration, 1507,
1544–1549
anatomy, 1544–1545, 1545f
causes, prevention, and preoperative informa-
tion for patient, 1546–1547
frequency, 1547
presentation and clinical examination of
surgical alterations, 1545, 1546f
treatment, 1547–1548, 1547f, 1548f
Clitoris/clitoral hood, 1502, 1503f
Coleman technique for hand and fat structural
fat grafting, 551–558
harvesting, 551–552
harvesting instruments, 552–553, 553f
instruments, 557, 557f, 558f
placement, 555–558, 555f, 556f, 557f
refinement and transfer, 553–555, 553f, 554f
Collagen and dermal repair, 115–116
copper, 115–116
peptides, 115
Color line revision techniques, 1593
Combining aesthetic procedures, 44–45
Communication failures, 46
Complications and problems management, 12
Complications of botulinum toxin injection,
144–145
local complications from injection, 144
inadvertent muscle paralysis, 144
therapeutic failures, 144–145
Composite breast augmentation (implant + fat
transfer), 1068
Compressed vs. uncompressed vs. raw format,
29–30, 29f, 30f
Congenitally herniated patient and lower eyelid
pinch blepharoplasty, 455
Congenital ptosis, 401–403, 402f
Conjunctiva and upper eyelid blepharoplasty, 378
Continuous surgical technique in the Asian
patient, 393, 393f
Conventional (visual) and duplex-guided
sclerotherapy, 211–213, 213t
CoolSculpting application, 226f
Copper for collagen and dermal repair, 115–116
Corner mouth lift, 865–867, 866f, 867f
Cornrow plugs, 275–278, 275f
Coronal brow lift, 334–336, 335f, 336f, 337f
Cosmeceuticals, 119–134
Bauman Skin Type (BST) test, 119, 120f
matching ingredients to skin type, 120–130,
121f, 122f
acne, 122f, 123–124
aging skin, 127–130
dry skin, 121–122, 122t
oily skin, 120–121
pigmented skin, 126–127
products to avoid, 122–123, 122f
rosacea-type sensitive skin, 124–125
sensitive skin, 123–125
stinging skin, 125–126, 125t, 126t
postprocedure cosmeceuticals, 132–133
preprocedure cosmeceuticals, 132
procedure techniques, 132–133
injectables, 133
microneedling, 132–133
skin care regimen design, 130–132, 131f
cleansers, 130–131
evening retinoids, 132
eye products, 131
moisturizers, 131
morning sunscreen, 131
treatment products, 131
skin cell aging reversal, 129–130
skin types diagnosis, 120
Skin Type Solutions (STS) system, 119
Costal cartilage grafting for rhinoplasty
revision, 1014
Costal cartilage harvest, 956–957
Costal cartilage harvest, Asian rhinoplasty,
971–972
Crease, 519
Crease fixation and upper eyelid blepharoplasty,
383–384, 383f, 384f
Crew resources management and checklists,
46, 47f
Croton oil, 175, 178–179, 179t
Crow’s feet and botulinum toxin injection,
142–143
Cryolipolysis, 224–226, 225f, 225t, 226f, 1332,
1334, 1333f, 1334f
Customer data, 72
D
Danger zones in face and neck clinical anatomy,
525, 525f, 526f
Debulking revision surgery, 1598–1599, 1600f
Deep fascia of the face, 523, 524f
Deep venous thrombosis, 1415
Defatting neck and jowls, 604–605
Delta facelift, 828
Deltoid, 1304–1305, 1304f, 1305f
Dental morphology, 882–883
Deoxycholic acid, 223–224, 222f
Depilatory procedures for transfeminization,
1611
Depressor anguli oris and botulinum toxin
injection, 143
Depth of field, 25, 25f, 26f
Dermabrasion, 161–165, 818–819, 819f
equipment, 162–163
example, 165, 166f
patient selection and contraindications,
161–162, 162t
postoperative considerations, 164
preprocedural preparation, 162
problems and complications, 164–165, 165f
skin changes and treatment efficacy, 164
technique, 163–164, 163f, 164f, 165t
Dermis graft, 869
Descent and radial expansion of facial fat, 621,
621f
Deviated nose correction, 931, 931b
Diabetes mellitus as risk factor, 41, 42f
Differential vectors for redraping SMAS dissec-
tion and skin flap, 625–632, 625f
extended SMAS dissection, 625–626
facial asymmetry, 628, 628f
incisions, 631–632, 631f
platysma bands and cervical obliquity
correction, 629–630, 629f
SMAS elevation, 626–627, 626f
SMAS fixation, 628, 629f
SMAS fixation versus platysmaplasty,
630–631, 630f, 631f
Digital photography, 30–34
camera selection, 32–33
dynamic range, 31–32, 32f
file storage and backup, 32
protected information and HIPAA compliance,
33
resolution, 31
sensor size, 30–31, 31f
Dilation exercises for transfeminization, 1611
Dimpled chin and botulinum toxin injection,
143
Diplopia as functional problems, eyelid surgery,
463, 464f
Direct approach for forehead rejuvenation, 288,
288f
Direct brow lift, 336–338, 336f, 337f, 338f

Index
I-6
Direct incision, 867–868, 868f, 869f
Dissatisfied patients, 13–14
Documentation, 11–12
postoperative, 12
preoperative, 12
Dog-ears revision techniques, 1593
Donor ellipse harvest for female pattern alope-
cia treatment, 261–262, 261f
Donor ellipse harvest for male pattern baldness
treatment, 261–262, 261f
Donor site harvesting for hair transplantation,
253–254, 254f, 255f
Donor site scar, 278, 278f
Dorsal augmentation, Asian rhinoplasty,
973–974, 973f, 974f
Dorsal hand veins, 216–217, 217f
Double folds, 1509, 1511f, 1514, 1514f, 1515f
Dry eye and epiphora as functional problems,
eyelid surgery, 464–466, 465f, 466f
Dry skin, 121–122, 122t
Dynamic lines in skin, 68
Dynamic range, 31–32, 32f
E
Earlobe, 539
Earlobe rejuvenation, 831
Eating disorders, 17
Ectropion as functional problems, eyelid
surgery, 460–463, 462f, 463f
Edge and non-wedge surgical techniques
review, 1523–1526 1526f
Edge shave revision techniques, 1593
Elderly patient and lower eyelid pinch blepharo-
plasty, 453
Emollients for skin moisturizing, and barrier
repair, 113
Emulsified intradermal fat grafting, 819
Endoscopic brow lift, 298–316, 317–333
anatomy, 299–302, 319
glabellar muscles, 300, 301f
periorbital septa and adhesions, 300, 301f
sentinel vein, 299–300, 300f
supratrochlear and supraorbital nerves,
300, 302f
temporalis muscle and temporal crest, 300,
300f
ancillary procedures, 313–314, 313f, 314f,
330–331
eyelid, 330–331
myomodulators, 331
advantages and disadvantages, 299
brow aesthetics, 319, 319f
brow and periorbital aging, early signs, 298,
298f
endoscopic-assisted brow lift operative
technique, 323–330
central fixation, 327–330, 329f, 330f, 331f
central portal and subperiosteal dissection,
323–324, 323f, 324f, 325f, 326f
temporal fixation, 327, 327f, 328f
temporal incisions, 325–327, 325f, 326f, 327f
indications and contraindications, 299, 299f
operative techniques, 305–313
central access incision, 306, 308, 308f, 309f
closure, 310, 312, 312f
drain placement, 310, 311f
fixation choices, 312–313, 313t
hair preparation, 305, 306f
infiltration, 305
muscle modification, 308, 310f, 311f
periosteum division, 308, 309f
temporal incisions and dissection, 305–306,
306f, 307f, 308f
outcomes and results, 314–315, 314f, 315f
patient selection, 317, 317f, 318f
postoperative care, 314, 331
preoperative assessment, 302, 319–320, 320f
patient evaluation, 319–320, 320f
preoperative planning, 302–303, 303f
injections, 321, 322f, 323f
markings, 303, 304f, 320–322, 321f, 322f
operative sequence, 303
patient positioning, 303, 305f
team preparation, 302
youthful brow, 298f
results and outcomes, 331–332
brow lift alone, 331, 332f
brow lift and upper blepharoplasty, 331,
332f
Endoscopic forehead lift for forehead rejuvena-
tion, 285–287, 287f, 287t
Energy-assisted liposuction for body contouring,
1327–1332
laser-assisted liposuction, 1328–1329, 1328f,
1329f, 1330f
ultrasound-assisted liposuction, 1329–1332,
1331f
Erector spinae, 1303–1304, 1304f
Estheticians and MedSpa law, 76–77
Ethnic rhinoplasty, 983–1001
African, 989–994
case example, 994
preoperative evaluation and anatomic
assessment, 990–993, 991f, 992f
technical steps, 993
Hispanic, 994–998
case examples, 998
preoperative evaluation and anatomic
assessment, 995–998, 1000f, 999f
technical steps, Castilian, 997
technical steps, Mestizo, 998
technical steps, Mexican-American, 997
Middle Eastern, 983–989
characteristics of nose, 984, 985f
preoperative evaluation and anatomic
assessment, 984
technical steps, 985–989, 985f, 986f, 987f,
988f
postoperative care, 998–1000
Evening retinoids, 132
Exfoliation and cell renewal, 113
alpha-hydroxy and beta-hydroxy acids, 113
retinoids, 113
Expansion Vibration Lipofilling (EVL), 1462
Exposure, 24–25, 24f
Extended abdominoplasty, 1425–1428, 1428f,
1429f, 1430f
Extended MACS lift facelift incisions, 474, 476f
Extended MACS lift (X-MAC), 574
Extended SMAS concept, 638–639, 639f
Extended SMAS dissection, 625–626
External genitalia/vulva, 1501, 1501f, 1502–1504
clitoris/clitoral hood, 1502, 1503f
labia majora, 1503–1504, 1504f
labia minora, 1502–1503
External genitals and vagina, nonsurgical
rejuvenation, 1508
External oblique, 1300f, 1301f, 1302
Eyebrow, mustache, and beard restoration, 255,
255f, 256f
Eyelash loss as aesthetic problems, eyelid
surgery, 469
Eyelash reconstruction and augmentation,
256–257, 257f
Eyelid anatomy, 347–352, 347f, 348f, 350f
Eyelid and periorbital anatomy, 343–356
Asian upper eyelid anatomy variations, 349f,
350
eyelid anatomy, 347–352, 347f, 348f, 350f
forehead, 346, 346f
lower eyelid, 350–351, 350f
midface anatomy, 352–355, 353f, 354f, 355f
innervation, 354–355, 355f
vasculature, 355
venous and lymphatic drainage, 355
neurovascular supply of eyelids, 351–352
arterial supply, 351, 352f
eyelid innervation, 351–352, 352f
venous and lymphatic drainage, 351
temple, 344–345, 344f, 345f
temple and brow, 343–346, 343f
upper eyelid, 348–350, 348f
Eyelid asymmetry as aesthetic problems, eyelid
surgery, 467, 486f
Eye products, 131
Eye prominence and Hertel Measurement
evaluation in aesthetic eyelid surgery,
359, 359f, 360f
Eye prominence and lower eyelid blepharo-
plasty, 411–412, 411f
Eye protection mechanisms and lower eyelid
blepharoplasty, 411, 411f
F
Face and facial rejuvenation nonsurgical
cosmetic treatments, 104
Face and neck clinical anatomy, 574–583
adipose tissue, 521–522, 522f
anatomical correlation of boundaries between
topographic planes, 521, 521f
anatomic spaces, 527–528, 528f
compartmentalization of facial adipose tissue,
525, 526f, 527f
danger zones, 525, 525f, 526f
deep fascia of the face, 523, 524f
face design, 519, 520f
facial muscles, 526–527, 527f
retaining ligaments, 523–525, 524f, 525f
superficial fascia, 522–523, 523f
terminology
anatomic fat compartments, 525
crease, 519
facet, 521
fat compartments, 525
rhytid (wrinkle), 519
superficial fat, 521
wrinkles, crow’s feet, and laugh lines,
519–520, 520f
Facebook, 80, 81–82
Face design, 519, 520f
Face incisions, 535, 536f, 537f
Facelift and facial fat grafting simultaneously,
687–724
aging face and need for fat injections, 687–688
case examples, 718–723, 718f, 719f, 720f, 721f,
722f
complications, 716
concerns, 716–718
fat duration, 716, 717f
fat lumpiness, 716–717, 717f
weight gain or loss, 717–718
fat injection and aging, 688–689
fat injection drawbacks, 688
facelift and fat injection rationale, 688, 688f
volumetric rejuvenation, tissue integration,
and stem cell effect, 688
fat injection sequencing, 689–690
fat injection technique, 690–699
anesthesia, 690–691

Index
I-7
donor site, 690–691
equipment, 690, 690f, 691t
fat and platelet-rich plasma, 694
harvesting fat, 692–693, 692f, 693f
informed consent, 690
logistics, 690
marking, 691
patients with previous filler use, 694–695
planes of fat placement, 698–699
processing harvested fat, 693–694, 694f,
695f
injecting fat, 695–699, 696f
determining volume, 695–696, 697t, 698f
technique, 696, 698, 698f
nomenclature, 688
postoperative care, 713, 715
recovery and healing, 715
retreatment, 715
site treatment particulars, 699–715
buccal recess area, 707, 708f
cheek, 699, 700f, 701f
chin, 701, 701f
documentation, 713, 714f
geniomandibular groove, 699, 699f, 700f
jawline, 705–706, 706f
learning fat injection procedure, 713, 715t
lips, 703–704, 703f, 704f, 705f
lower orbit/lower eyelid area, 709–710, 710f,
711f
microliposuction, 712, 713f
midface, 699–701
nasolabial injection, 701–703, 702f, 703
perioral area, 704–705, 705f
secondary facelift patients, 711, 712f
tear trough, 710–711, 711f, 712f
temple area, 706–707, 707f
upper orbit/upper eyelid area, 707–708, 709f
Facelift and neck lift clinical decision making,
529–550
evaluation, 529–534, 529f, 530f, 531f
facial adhesions and retaining ligaments,
533–534, 534f
facial skin, 531, 531f
neck zone, 532, 532b, 533f
perioral zone, 532, 532b
periorbital zone, 531–532, 532b
neck treatment options, 545–550
deep plane, 547–548, 548f, 549f
incisions, 545–546, 545f, 546f, 546t
intermediate plane, 546–547, 547f
neck planes, 546b
plication sutures, 550
skin undermining, 548, 549t
superficial plane, 546, 547f
suspension sutures, 549, 549f
vectors, 549, 549f
treatment options, 534–545
ancillary procedures, 544
earlobe, 539
face incisions, 535, 536f, 537f
preauricular incision, 539, 539f, 540f, 541f
resurfacing, 544–545
retroauricular incision, 539, 541, 541f, 541t
subcutaneous dissection, 541, 542f
subfacial dissection, 541, 542f
subperiosteal dissection, 542, 543f
suspension sutures, 543, 544f
temple incisions, 535, 538f
vectors, 543, 543f, 544f, 544t
volume management, 543–544, 545f
Facelift incisions, 474, 476
extended MACS lift, 474, 476f
high-SMAS technique, 474, 476f
SMASectomy, 476, 476f
Facelift, lamellar high-SMAS, 634–686
anesthesia, 653–655, 654f
case studies, 680–685, 681f, 682f, 683f, 684f,
685f
facial rejuvenation concepts, 634–641
aging changes of the face, 634–635
ancillary procedures, misapplication of,
640–641
extended SMAS concept, 638–639, 639f
high SMAS, rationale for use, 638, 638f, 639f
lamellar dissection and bidirectional tissue
shifts, 639–640, 640f
lateral sweep, 640, 641f
panfacial rejuvenation, 635
SMAS and midface, 637–638, 637f
SMAS flap, rationale for use, 636–637
SMAS, rationale for use, 635–636
incision planning, 641–651
conchomastoid portion incision, 646–647
occipital portion incision, 647–650, 647f,
648f, 649f
perilobular incision, 645–646, 677f
postauricular height, 650, 650f
postauricular incision, 646, 646f
preauricular incision, 643–645, 643f, 644f,
645f, 646f
short-scar facelift, 650–651, 650t, 651f
temple incision, 641–643, 642f, 643f
transmastoid portion incision, 647
Marten Clinic of Plastic Surgery facelift tray,
686
postoperative care, 679–680
preoperative preparations, 651–653
chemical treatment of hair, 653
infection prophylaxis, 653
operating room time allocation, 653
smokers and former smokers, 652
ultrasonic and radiofrequency skin-shrink-
ing treatments, 652–653
SMAS and platymsa planning modification,
651
surgical technique, 655–679, 656t
cheek and neck skin flap elevation, 657–660,
658f, 660f, 661f, 662f, 663f
completion of concurrently planned
procedures, 678
drain placement, 670
dressings, 678–679
lateral platysma border suspension,
669–670, 671f
local anesthesia, 655, 657, 657f
making incisions, 657
positioning, 655
prepping and draping, 655
skin flap repositioning and anchoring suture
placement, 670–672, 672f
skin flap trimming and closure, 672–678,
672f, 673f, 674f, 675f, 676f, 677f, 678f
SMAS dissection, 661–664, 663f, 664f
SMAS flap dissection completeness
assessment, 665
SMAS flap elevation technique, 664–665
SMAS suspension and proper SMAS vector,
665–669, 665f, 666f, 667f, 668f, 669f
temple dissection, 660–661, 661f, 663f
Facelift longevity, 609, 609f, 610f
Facet, 521
Facial adhesions and retaining ligaments,
533–534, 534f
Facial adipose tissue, 525, 526f, 527f
Facial aesthetic surgery avoidance and manage-
ment of complications, 844–859
craftsmanship issues, 852–858
contour irregularities, 857–858, 857f
ear distortion, 856, 856f
hairline loss and hairline distortion,
856–857, 856f, 857f
motion distortion, 858
scar placement and scar quality, 853–854,
856, 852f, 853f, 854f, 855f, 856f
deep vein thrombosis, 852, 852f, 853t
hematoma, 844–847, 845f
intermediate postoperative measures, 845,
847f
intraoperative procedures, 845
management, 845, 847, 847b, 847f
preoperative measures, 844–845, 845f, 846f
sequential or repeat hematomas, 845
nerve injuries, 848–852
accessory nerve, 852, 852f
buccal branches, 850, 851f
facial nerve, 850–852, 850f
marginal mandibular branch, 851–852, 851f,
852f
sensory nerves, 848–850, 849f
temporal and zygomatic branches of facial
nerve, 850–851, 851f
rare complications, 858
skin slough, 847–848, 848f
skin slough avoidance, 848
skin slough treatment, 848, 848f
Facial aging process, 173
Facial asymmetry, 628, 628f
Facial contouring, 499, 499f, 500f, 501f
Facial feminization procedures, 1620–1622
forehead contouring and hairline advance-
ment, 1620–1621, 1621f
genioplasty, 1621
lip lift, 1621
rhinoplasty, 1621
tracheal shave, 1621, 1621f
Facial feminization surgery, 1610
Facial implant augmentation, 725–748
autogenous implant material, 729–730
bone, 729
fat, 730
hydroxyapatite, 731
polyethylene, 731
polysiloxane (silicone), 731
polytetrafluorethylene (PTFE), 731
complications, 731
bone erosion, 731
implant malposition, 731
infection, 731
evaluation and planning, 727–729
facial measurements, 728–729, 730f
radiologic exam, 728, 729f
sexual dimorphism, 729, 730f
indications, 725–727
balance and definition, 725, 725f
deficiency, 725–727, 726f, 727f, 728f
rejuvenation, 727, 728f
lower face, 738–747
chin, 738–743, 740f, 741f, 742f, 743f, 744f
mandible angle, 743–746, 745f, 746f, 747f
midface implants, 733–738
cheek (malar eminence), 734–735, 735f
infraorbital rim, 735–738, 736f, 737f, 738f,
739f
piriform aperture, 733, 733f, 734f
operative technique, 731–733
hemostasis, 733
implant selection, 732
incisions, 732, 732f
preparation, 731–732, 732f

Index
I-8
screw fixation, 732–733
Facial masculinization procedures, 1622
other procedures, 1622
thyroid cartilage augmentation, 1622
Facial masculinization surgery, 1611
Facial muscles, 526–527, 527f
Facial nerve danger zones, 619–620, 619f
frontal branch, 619
marginal and cervical branches, 619–620, 620f
zygomatic branch, 619, 620f
Facial rejuvenation concepts, 634–641
aging changes of the face, 634–635
ancillary procedures, misapplication of,
640–641
extended SMAS concept, 638–639, 639f
high SMAS, rationale for use, 638, 638f, 639f
lamellar dissection and bidirectional tissue
shifts, 639–640, 640f
lateral sweep, 640, 641f
panfacial rejuvenation, 635
SMAS and midface, 637–638, 637f
SMAS flap, rationale for use, 636–637
SMAS, rationale for use, 635–636
Facial rejuvenation, extended SMAS technique,
612–633
aesthetic analysis and treatment planning,
620–625
descent and radial expansion of facial fat,
621, 621f
volume loss and facial deflation, 621–623,
621f, 622f
anatomy, 612–620, 613f
anatomic consistency, 676
anatomic facial units, 613
deep facial fat compartments, 617, 617f
facial fascia, 613–614, 615f
facial fat compartments, 614–615
muscle layers, 613, 614f
retaining ligaments, 617–619, 617f, 618f
SMAS thickness, 613
superficial fat compartments, 615–616, 616f
differential vectors for redraping SMAS
dissection and skin flap, 625–632, 625f
extended SMAS dissection, 625–626
facial asymmetry, 628, 628f
incisions, 631–632, 631f
platysma bands and cervical obliquity
correction, 629–630, 629f
SMAS elevation, 626–627, 626f
SMAS fixation, 628, 629f
SMAS fixation versus platysmaplasty,
630–631, 630f, 631f
facial nerve danger zones, 619–620, 619f
frontal branch, 619
marginal and cervical branches, 619–620,
620f
zygomatic branch, 619, 620f
skeletal support, role in formulating surgical
treatment plan, 623–625
convexity of malar region, 624–625, 624f
facial length and relative vertical heights,
623–624, 624f
facial width, bizygomatic diameter, and
malar volume, 623, 623f
vertical height of mandibular ramus, 625
Facial skin, 531, 531f
Fat compartments, 525
Fat embolism and fat embolism syndrome, 1455
Fat evaluation in aesthetic eyelid surgery, 359
Fat grafting, facial rejuvenation, 869
Fat grafting, hand rejuvenation, 558–561
aesthetic and anatomic considerations, 558,
558f
indications and patient selection, 558
technical approach, 559–561, 559f, 560f, 561f
Fat injection and aging, 688–689
Fat injection complications as aesthetic prob-
lems, eyelid surgery, 467–468, 468f
Fat management options for eyelid rejuvenation,
361–362, 361b, 361f, 362f, 363f, 364f
Fat necrosis and cysts, 1458
Fat option for vaginal tightening, 1573–1574
FDA-approved fillers, 151t
Female androgenic alopecia, 248f, 249, 249f
Female genital rejuvenation, applied anatomy,
1501–1505
bulbocavernosus muscle, 1501, 1501f
external genitalia/vulva, 1501, 1501f,
1502–1504
clitoris/clitoral hood, 1502, 1503f
labia majora, 1503–1504, 1504f
labia minora, 1502–1503
internal genitalia, 1505
introitus, 1505
vagina, 1505
mons pubis, 1502, 1503f
perineum, 1504
Female genital rejuvenation clinical decision
making, 1506–1508
clitoral hood alteration, 1507
complaints and concerns, 1506
external genitals and vagina, nonsurgical
rejuvenation, 1508
labia major alteration, 1507
labia minora alteration, 1506–1507
labiaplasty revision, 1508
mons pubis alteration, 1507
patient evaluation, 1506
vagina surgical rejuvenation, 1508
Female genital rejuvenation, surgical and
non-surgical, 1509–1517
anatomical structures, 1511, 1512f
anatomical variation management, 1512–1516
clitoral hood prominence, 1515, 1515f, 1516f
double fold, 1514, 1514f, 1515f
labia minor thickening, 1512, 1513f
pigmentation, 1516, 1516f
thin atrophic labia minor, 1512, 1513f, 1514f
clitoral frenulum thickening, 1509, 1511f
double folds, 1509, 1511f
irregular pigmentation, 1509, 1512f
labia minora, 1509, 1510f, 1511f
labiaplasty, 1509, 1510f
patient satisfaction with outcomes,
1520–1522
posterior fourchette, 1509, 1511f
psychological motivations, 1518–1519
psychological predictors of outcomes,
1519–1520
Female pattern alopecia treatment, 261–264
anesthesia and preparation, 261, 261f
donor ellipse harvest, 261–262, 261f
graft dissection, 262–263, 262f
graft insertion, 263, 263f, 264f
postoperative care, 263–264, 266f, 267f
Female-to-male procedure-specific evaluations,
1617, 1617t
mastectomy, 1617
phalloplasty, 1617
Feminizing procedures, 1610–1611
facial feminization surgery, 1610
transfeminine genital surgery, 1610–1611, 1611f
ancillary procedures, 1611
bowel preparation protocol, 1611
depilatory procedures, 1611
dilation exercises, 1611
neovaginal depth and diameter, 1611
oncologic screening, 1611
thromboprophylaxis, 1611
vaginoplasty, 1610, 1611f
Festooned patient and lower eyelid pinch
blepharoplasty, 453, 453f’
Festoons revision techniques, 1593, 1593f
Fibrous strings and adhesions release in breasts,
1074
File storage and backup, 32
Fillers, lower eyelid rejuvenation, 365
Financial responsibilities, 10–11
First consultation, 3–7
blepharoplasty questionnaire, 6f
body contouring questionnaire, 7f
breast surgery questionnaire, 7f
follow-up letter to prospective breast surgery
patient, 8f
general intake information, 6f
nurse or patient coordinator contact, 5
patient letter, 5f
personal history questionnaire, 5f
receptionist contact, 4–5
surgeon contact, 5–7
telephone contact, 4–7
Fitzpatrick classification of skin type, 175, 175t,
176f
Flaps revision surgery, 1597, 1598f, 1599f
Fleur-de-lis abdominoplasty, 1432–1434, 1434f,
1435f
Fluid management with sedation and anesthe-
sia, 57
Foamed sodium tetradecyl sulfate or polidoca-
nol sclerotherapy, 215, 216f
Focal length, 21–22
Follow-up letter to prospective breast surgery
patient, 8f
Forehead anatomy, 346, 346f
Forehead contouring and hairline advancement,
1620–1621, 1621f
Forehead MACS lift short-scar rhytidectomy
with fat grafting, 585
Forehead rejuvenation options, 285–288, 282t,
283f
ancillary procedures, 288–289, 289f
direct approach, 288, 288f
endoscopic forehead lift, 285–287, 287f, 287t
injection of toxins, 288, 289f
lateral temporal brow lift, 287–288, 287f
open coronal forehead lift, 285, 286f
transpalpebral browpexy, 288, 288f
transpalpebral excision of corrugator and
procerus muscles, 288, 288f, 289f
Fractional photothermolysis, 233
Free-nipple graft technique, 1485, 1486f
Full abdominoplasty, 1417–1425, 1419f, 1421f,
1422f, 1423f, 1425f, 1426f, 1427f
Full-field and fractional resurfacing devices,
196–199
ablative fractional lasers, 199
ablative full-field lasers, 196–197, 197t, 198f
nonablative fractional laser, 198–199
nonablative nonfractional lasers, 197–198
Functional problems, eyelid surgery, 458–466
chemosis, 466, 467f
diplopia, 463, 464f
dry eye and epiphora, 464–466, 465f, 466f
ectropion, 460–463, 462f, 463f
infection, 458, 458t
lagophthalmos and corneal exposure,
458–460, 459f, 460f, 461f
lid retraction and lateral canthal rounding,
460, 461f

Index
I-9
midriasis, 463
orbital hemorrhage and hematoma, 458, 459f
paresthesias of eyelid, 464, 465f
ptosis of upper eyelid, 463
refractive changes, 464
trichasis and entropion, 463
Functional upper eyelid blepharoplasty, 374, 374f
Functional vs. cosmetic upper eyelid blepharo-
plasty, 380, 380f
G
Gastrocnemius, 1309–1310, 1310f
Gender-affirming surgery and patient selection,
1615–1619
common gender-affirming procedures, 1615t
female-to-male procedure-specific evalua-
tions, 1617, 1617t
mastectomy, 1617
phalloplasty, 1617
male-to-female procedure-specific evalua-
tions, 1617–1618, 1617t
augmentation mammoplasty, 1617
vaginoplasty, 1617–1618
preoperative considerations, 1618
insurance issues, 1618
patient education, 1618
social support, 1618
preoperative evaluation, 1616, 1617t
WPATH guidelines, 1616
Gender-affirming surgery clinical decision
making, 1607–1614
feminizing procedures, 1610–1611
facial feminization surgery, 1610
transfeminine genital surgery, 1610–1611,
1611f
gender dysphoria and diagnosis, 1607, 1608t
masculinizing procedures, 1611–1613
facial masculinization surgery, 1611
metoidioplasty, 1612
phalloplasty, 1613
transmasculine bottom surgery, 1612
transmasculine top surgery, 1612, 1612f
preoperative evaluation, 1609–1610, 1609f,
1609t
psychotherapy, counseling, and hormone
therapy, 1607
feminizing hormone therapy, 1617
masculinizing hormone therapy, 1608
transfeminine genital surgery, 1610–1611
ancillary procedures, 1611
bowel preparation protocol, 1611
depilatory procedures, 1611
dilation exercises, 1611
neovaginal depth and diameter, 1611
oncologic screening, 1611
thromboprophylaxis, 1611
vaginoplasty, 1610, 1611f
Gender-affirming surgery: facial surgery,
1620–1622
facial feminization procedures, 1620–1622
forehead contouring and hairline advance-
ment, 1620–1621, 1621f
genioplasty, 1621
lip lift, 1621
rhinoplasty, 1621
tracheal shave, 1621, 1621f
facial masculinization procedures, 1622
other procedures, 1622
thyroid cartilage augmentation, 1622
male and female face, 1620
preoperative considerations, 1620
Gender-affirming surgery: genital surgery,
1637–1649
anatomy, 1638–1639, 1640f
indications and contraindications, 1637
modifications and ancillary procedures,
1646–1647
metoidioplasty, 1646, 1647f
phalloplasty, 1646–1647, 1647f
vaginoplasty, 1646
postoperative care, 1645–1646
metoidioplasty, 1646
phalloplasty, 1646
vaginoplasty, 1645–1646
preoperative assessment, 1637–1638
metoidioplasty/phalloplasty, 1638
orchiectomy/vaginoplasty, 1637–1638
preoperative planning and markings,
1639–1642
metoidioplasty, 1639, 1641f
phalloplasty, 1639–1642, 1641f, 1642f
vaginoplasty, 1639, 1641f
results/complications, 1647–1648
metoidioplasty, 1647–1648, 1648t
phalloplasty, 1648
vaginoplasty, 1647, 1648t
technique overview, 1642–1645
ALT phalloplasty, 1645, 1645f
intestinal vaginoplasty, 1643
metoidioplasty, 1643–1644, 1644f
phalloplasty, 1644–1645, 1645f
RFFF phalloplasty, 1644–1645
vaginoplasty operative technique, 1642,
1643f
Gender-affirming surgery: top surgery,
1623–1636
complications and revisionary care, female-
to-male, 1628–1629, 1629t, 1632–1635t
indications and contraindications, 1623
operative techniques, female-to-male,
1626–1629
double incision mastectomy with free
nipple grafting, 1627, 1628f
liposuction and periareolar approach, 1626,
1627f
mastectomy with circumareolar skin
excision, 1626–1627, 1628f
postoperative care, female-to-male, 1628
top surgery, female-to-male, 1623–, 1624t
breast/chest anatomy, 1624, 1627f
preoperative assessment, 1624, 1625t
preoperative preparation, 1626, 1629t,
1632–1635t
surgical procedure choices, 1626
top surgery, male-to-female, 1629–1630
complications and revisionary procedures,
1631
examination of breast/chest anatomy, 1630
operative technique and postoperative care,
1631
outcomes, 1631
preoperative assessment, 1630
surgical procedure choices, 1630–1631,
1630f
Gender as risk factor, 40
General anesthesia, 53
General intake information, 6f
Genioplasty, 882, 1621
Glabellar lines and botulinum toxin injection,
142
Glogau classification of photoaging, 175–177,
176t
Gluteal augmentation with fat transfer,
1444–1460, 1445f
anatomy, 1446–1448
danger zones, 1448
ligamentous anatomy, 1446–1448, 1447f,
1448f
muscular anatomy, 1446, 1446f
neurovascular anatomy, 1446
zones of adherence, 1448
complications, 1455, 1457–1459
asymmetry and contour abnormalities, 1458
fat embolism and fat embolism syndrome,
1455
fat necrosis and cysts, 1458
infection, 1458–1459, 1458f
poor fat survival, 1455, 1457
seroma, 1459
indications and contraindications, 1445
operative technique, 1451–1453
closure, 1453
fat injection, 1451–1453
fat preparation, 1451, 1452f
lipoaspiration, 1451
preprocedural protocol, 1451
postoperative care, 1453
preoperative assessment, 1448–1449, 1449f
preoperative planning and markings,
1449–1450, 1450f
results, 1453–1464, 1454f, 1455f, 1456f, 1457f
Gluteus maximus, 1306–1307, 1306f, 1307f
Gluteus medius, 1307
Glycerin sclerotherapy, 215
Góes periareolar technique with mesh support,
1238–1240, 1240f, 1241f
Gold standard for facial rejuvenation, 610
Graft dissection for female pattern alopecia
treatment, 262–263, 262f
Graft dissection for male pattern baldness
treatment, 262–263, 262f
Graft insertion for female pattern alopecia
treatment, 263, 263f, 264f
Graft insertion for male pattern baldness
treatment, 263, 263f, 264f
Gravity and effect on skin, 68
Groove revision related to improper suture
technique, 1600–1601, 1601f, 1602f
Guidelines, ethical social media use, 84f
Gynecomastia, 1276–179
classification, 1484, 1484t
Gynecomastia treatment, 1284–1289
anatomy, 1284–1285, 1285f
indications and contraindications, 1284
markings, 1286, 1286f
operative technique, 1286–1287
emulsification, 1286
extraction, 1286
fat grafting, 1286–1287, 1287f
infiltration, 1286
pull-through technique, 1286, 1287f
outcomes, 1288, 1288f
postoperative care, 1287–1288, 1288f, 1289f
compression, 1288
drainage, 1287–1288
preoperative assessment, 1285–1286
Gynecomastoid appearance, 1483
H
Hair growth cycle, 243–244, 246f
Hairline design, 243, 245f
Hairline distortion, 833, 834f
Hair loss patterns, 248–252
female androgenic alopecia, 248f, 249, 249f
male pattern baldness, 248–249, 248f, 248t,
249f
transplantation, 250, 250f, 251f, 252f
Hair transplantation applied anatomy, 243–247,
248–259

Index
I-10
applied anatomy, 245–246, 245f, 246f
growth cycle, 243–244, 246f
hairline design, 243, 245f
hair loss patterns, 248–252
female androgenic alopecia, 248f, 249, 249f
male pattern baldness, 248–249, 248f, 248t,
249f
transplantation, 250, 250f, 251f, 252f
histology, 243, 244f, 245f
preoperative planning, 252–257
aesthetic considerations, 252–253, 252f
burn alopecia treatment, 255–256, 256f
camouflaging scalp scars, 254, 254f, 255f
donor site harvesting, 253–254, 254f, 255f
eyebrow, mustache, and beard restoration,
255, 255f, 256f
eyelash reconstruction and augmentation,
256–257, 257f
sideburn corrections, 255, 255f
Hair transplantation complications, 265,
267–268, 270–281, 270f
indications and contraindications, 272
ingrown hairs and cysts, 267
keloids, 268
patient examples, 275–279
abnormally low hairline, 275, 277f
cornrow plugs, 275–278, 275f
donor site scar, 278, 278f
high hairline, 278
isolated frontal forelock, 275, 275f
straight hairline, 278
temporal alley defect, 275, 276f
traumatic hair loss, 279, 279f
postoperative care, 279
preoperative assessment, 272–273, 273f
preoperative planning, 273, 274f
avoiding donor site problems, 274
preoperative hair transplantation options,
273–274, 274f, 275f
problems requiring reoperation, 270–271, 271f
technique evolution, 271–272
widening of donor scar site, 267
Hair transplantation, follicular unit micrograft-
ing and minigrafting, 259–270
complications, 265, 267–268
ingrown hairs and cysts, 267
keloids, 268
widening of donor scar site, 267
historic review of hair transplantation,
259–260
natural result essentials, 260–261, 260f
treatment technique, male pattern baldness
and female pattern alopecia, 261–264
anesthesia and preparation, 261, 261f
donor ellipse harvest, 261–262, 261f
graft dissection, 262–263, 262f
graft insertion, 263, 263f, 264f
postoperative care, 263–264, 266f, 267f
scar alopecia correction secondary to facelift
procedure, 265, 266f, 267f
Halo Hybrid Fractional Laser, 236, 236f, 237f
Hamstrings, 1308–1309, 1308f, 1309f
Hand and fat structural fat grafting, 551–572
Coleman technique, 551–558
harvesting, 551–552
harvesting instruments, 552–553, 553f
instruments, 557, 557f, 558f
placement, 555–558, 555f, 556f, 557f
refinement and transfer, 553–555, 553f, 554f
fat grafting, hand rejuvenation, 558–560
aesthetic and anatomic considerations, 558,
558f
indications and patient selection, 558
technical approach, 559–561, 559f, 560f,
561f
lip rejuvenation, 561–566
aesthetic and anatomic considerations, 561,
562f
indications and patient selection, 561
technical approach, 561–566, 562f, 562f,
563f, 564f, 565f, 566f
nasolabial folds and marionette grooves,
567–571
aesthetic and anatomic considerations, 567,
567f
indications and patient selection, 567–568
technical approach, 568–571, 568f, 569f,
570f, 571f
Health Insurance Portability and Accountability
Act (HIPAA), 77–78
Hematoma, 43
Hemostatic net, 829
Herniated fat pads and lower eyelid blepharo-
plasty, 412–413, 412f
High hairline, 278
High-intensity focused ultrasound, 1334–1335
High SMAS, rationale for use, 638, 638f, 639f
High-SMAS technique for facelift incisions, 474,
476f
Hispanic rhinoplasty, 994–998
Castilian, 997
Mestizo, 998
Mexican-American, 997
Hoarseness, cough (airway irritation), 57
Horizontal forehead lines and botulinum toxin
injection, 143
Horner’s syndrome, 400, 400f
Hyaluronic acid-based fillers, 154–155, 155f
Hydrators/humectants for skin moisturizing,
and barrier repair, 112
Hydroquinone for pigment reduction, 116
Hypertension, 53
I
Iatrogenic deformities treatment and evalua-
tion, 1461–1473
complications, 1471–1472
considerations, 1464–1465
dose-responsive curves, 1461f
Expansion Vibration Lipofilling (EVL), 1462
fibrosis from thermal liposuction, 1462f
indications, 1463–1464f, 1465f
liposuction options comparison, 1465–1466
markings, 1466–1467
postoperative care, 1470–1471, 1470f
results, 1471, 1471fi, 1474f
SAFELipo, 1462, 1463f
subcutaneous anatomy, 1466, 1467f
technical steps, 1467–1470, 1468f, 1469f, 1470f
Iliopsoas, 1307
Implant selection variation, 1047–1048, 1048f
lower breast footplate, 1047
narrow/wide breast distance, 1047
poor soft tissue coverage, 1048
short nipple to inframammary fold, 1048
Inadvertent muscle paralysis from botulinum
toxin injection, 144
Incisional surgical techniques in the Asian
patient, 393–394, 393f, 394f, 395f
Infection as functional problems, eyelid surgery,
458, 458t
Inferior turbinoplasty, 931–932, 932f
Inflammation, redness, and scar reduction,
135–136
licorice extract, 117
oatmeal, 117
topical and oral polyphenols, 116–117
Inframammary fold definition, 1073–1074
Inframammary fold liposuction, 1073
Injectables, 133
Injection of toxins for forehead rejuvenation,
288, 289f
Ingrown hairs and cysts, 267
Instagram, 80, 82–83
Insurance issues for gender-affirming surgery,
1618
Intense pulsed-light device, 69
Internal genitalia, 1505
introitus, 1505
vagina, 1505
Interrupted surgical technique in the Asian
patient, 392, 392f
Intestinal vaginoplasty, 1643
Intraoperative photography, 37, 37f, 38f
Introital gaping revision surgery, 1601
Introital gaping secondary to lateral tension,
1593–1594
Introital suture minor separation, 1593
Introitus, 1505
Invasiveness, increasing degree of nonsurgical
cosmetic treatments, 103t
Irregular pigmentation, 1509, 1512f
Isolated abdominal wall rejuvenation,
1439–1440, 1441f
Isolated frontal forelock, 275, 275f
J
Jessner’s solution, 174
K
Keloids, 268
Kojic acid for pigment reduction, 116
Kybaella injections, 224f
L
Labial amputation revision, 1596–1597, 1597f,
1598f, 1599f
Labia majora, 1503–1504, 1504f
Labial majora and mons pubis surgical alter-
ation, 1550–1557
anatomy, 1550–1551
labia majora, 1550, 1551f
mons pubis, 1550–1551, 1552f
ancillary procedures, 1555
indications and contraindications, 1550
labia majora, 1550
mons pubis, 1550
operative techniques and surgical markings,
1552–1555
labia majora, 1552, 1553f, 1554f
mons pubis, 1556f, 1557
perioperative considerations, postoperative
care, and complications, 1555–1557
outcomes and results, 1557
labia majora, 1555
mons pubis, 1550
preoperative assessment and planning,
1551–1553
labia majora, 1551–1552, 1552f
mons pubis, 1553, 1555, 1555f, 1556f
Labia majora surgical alteration, 1507,
1550–1557
Labia minora, 1502–1503
Labia minora alteration, 1506–1507
Labia minora reduction surgery, 1523–1535
anatomy, 1526, 1526f, 1527f
ancillary procedures, 1530
edge and non-wedge surgical techniques
review, 1523–1526 1526f

Index
I-11
gynecologic history, 1528b
indications and contraindications, 1524–1526
operative technique, 1528, 1529f, 1530
outcomes, 1530–1532
complications, 1531–1532
patient satisfaction, 1530–1531
sexual function, 1531
postoperative care, 1530
preoperative assessment, 1527–1528
preoperative planning, including markings,
1528, 1529f
results, 1532, 1532f, 1533f, 1534f
Labia minora revision surgery, 1589–1603
circumstances resulting in patient request for
revision, 1589–1590
patient factors, 1590
physician factors, 1590
surgical and postoperative factors, 1589
factors in seeking revision, 1590, 1592
major revision, 1590, 1592
minor revision, 1590
major revision, 1594–1602
debulking, 1598–1599, 1600f
flaps, 1597, 1598f, 1599f
groove revision related to improper suture
technique, 1600–1601, 1601f, 1602f
introital gaping revision, 1601
labial amputation revision, 1596–1597,
1597f, 1598f, 1599f
mini-wedges and linear resection, 1600,
1601f
silicone lip implant reconstruction,
1597–1598, 1600f
sinus track revision, 1595–1596
V-wedge revision separation, 1594–1595,
1594f, 1595f, 1595f, 1596f
minor revision techniques, 1593–1594
color line, 1593
dog-ears, 1593
edge shave, 1593
festoons, 1593, 1593f
introital gaping secondary to lateral tension,
1593–1594
introital suture minor separation, 1593
minor fistula(e) following V-wedge
labiaplasty, 1594
prominent frenular fold edge revision, 1594
side-to-side dissymmetry, 1593
negotiation with patient, 1590, 1591f
paperwork, 1592
procedure, equipment, setup, anesthesia,
venue, 1592
rules, 1592
surgeon, 1592
timing, 1592
Labia minora thickening, 1512, 1513f
Labiaplasty, 1509, 1510f
buyer’s remorse: undereducated consumer,
1579
complications, 1583–1587
appearance, 1583, 1584f
asymmetry, 1583
bruising and excessive edema, 1583–1584
cautery-induced skin burn, 1585
delayed postoperative bleeding, 1584–1585
hematoma formation, 1584
hypo- and hyperesthesias, including clitoral
nerve damage, 1587
incision line grooves, 1585–1586
infection, 1585
pain during recovery, 1586
postoperative sexual and vulvar pain,
1586–1587
suture rejection/fistula formation, 1587
suture removal, 1585
dissatisfied patient, 1587
expectations, 1579, 1580f
inadequate reduction, 1583
linear labiaplasty rules, 1582, 1581f
unwanted clitoral prominence, 1583
V-wedge-type labiaplasty rules, 1582
wound dehiscence management, 1582–1583
Labiaplasty and hood reduction complication
avoidance and treatment, 1579–1588
Labiaplasty revision, 1508
Lacrimal apparatus and upper eyelid blepharo-
plasty, 378
Lacrimal gland resuspension and upper eyelid
blepharoplasty, 384–385, 385f, 386f
Lagophthalmos and corneal exposure as
functional problems, eyelid surgery,
458–460, 459f, 460f, 461f
Lamellar dissection and bidirectional tissue
shifts, 639–640, 640f
Laser-assisted liposuction, 1328–1329, 1328f,
1329f, 1330f
Laser CO2–erbium option for vaginal tightening,
1574
Laser resurfacing, 232–237, 819, 819f
ablative lasers, 232
fractional photothermolysis, 233
Halo Hybrid Fractional Laser, 236, 236f, 237f
nonablative lasers, 232
Lasers and light-based devices in plastic surgery,
196–205
full-field and fractional resurfacing devices,
196–199
ablative fractional lasers, 199
ablative full-field lasers, 196–197, 197t, 198f
nonablative fractional laser, 198–199
nonablative nonfractional lasers, 197–198
noninvasive skin tightening, 201–203
microfocused ultrasound, 202–203
radiofrequency devices, 203–204
pulsed-light devices, 201, 202f
vascular laser devices, 199–201
near-infrared devices, 200–201
potassium titanyl phosphate, 200, 200f
pulsed dye laser, 199–200
vascular treatment selection, 229t
Laser therapy, 65
Laser treatment of reticular vessels and telagiec-
tasias, 213–214
Lateral brow proxy and upper eyelid blepharo-
plasty, 386, 387f
Lateral canthal support for lower eyelid blepha-
roplasty, 417, 418f
Lateral crural strut grafts, 936, 937f
Lateral SMAS plication, 606, 606f, 607f
Lateral SMASectomy, 594, 595f
Lateral SMASectomy, advantages and disadvan-
tages, 596
Lateral sweep, 640, 641f, 832, 833f
Lateral temporal brow lift for forehead rejuvena-
tion, 287–288, 287f
Lateral thigh telangietasias, 215, 215f, 215t
Latissimus dorsi, 1303, 1304f
Lens selection, 22
Levator and Müller’s muscle and upper eyelid
blepharoplasty, 377–378, 373f
Levator function, 398, 398f
Licorice extract for inflammation, redness, and
scar reduction, 117
Lid retraction and lateral canthal rounding as
functional problems, eyelid surgery,
460, 461f
Lid retraction causes, lower eyelid rejuvenation,
366b
Lid tone evaluation in aesthetic eyelid surgery,
359
Lighting and flash, 25–26, 27f
Linear labiaplasty rules, 1582, 1581f
LinkedIn, 81
Lip lift, 493–495, 494f, 495f, 496f, 502–503, 503f,
864–826, 863f, 864f, 1621
Lip microfat grafting, 493, 493f, 494f
Lipoaspiration, 1451
Lipofilling/lipocontouring, 818
Liposuction and high-definition liposculpture,
techniques and safety, 1341–1360
adipose tissue and fat grafting, 1346–1349,
1349f
donor site and harvesting, 1347
fat grafting technique, 1347
graft processing, 1347–1349
lipoinjection technique, 1349, 1350f
complications, general liposuction, 1352–1356
bleeding, 1355
fat embolism, 1356
infection, 1355
lidocaine toxicity, 1356
necrosis, 1355, 1355f
perforation, 1356
pulmonary edema, 1356
seroma, 1355
thromboembolism, 1355–1356
complications, specific high-definition
liposculpture, 1356–1358
asymmetry, 1357
burns, 1356–1357, 1357f
contour irregularities, 1357, 1357f
loose skin, 1358, 1359f
scars, 1358
skin retraction, 1357, 1358f
unnatural appearance, 1357, 1358f
outcomes, 1351–1352, 1351f, 1352f, 1353f,
1354f
postoperative care, 1349–1351
general effects, 1350
sequence control, 1350–1351
target of therapy, 1350
types of postoperative procedures, 1350
VASER technique for body sculpting,
1342–1345, 1343f, 1344f, 1345f, 1346f,
1347f
Liposuction options comparison, 1465–1466
Lip rejuvenation and enhancement, 492–493,
492f, 492t
Lip rejuvenation, fat grafting, 561–566
aesthetic and anatomic considerations, 561,
562f
indications and patient selection, 561
technical approach, 561–566, 562f, 562f, 563f,
564f, 565f, 566f
Lip resurfacing, 497–498, 498f, 503
Lips and botulinum toxin injection, 143
Local anesthesia, 54–57, 55t, 56t
Local anesthetic systemic toxicity, 48–50, 49f,
57–58
Local complications from botulinum toxin
injection, 144
Long-pulse laser therapy, 218–219, 219f
Lower breast footplate, implant selection
variation, 1047
Lower extremity sclerotherapy and laser vein
treatment, 206–208, 207f, 207t
Lower eyelid anatomy, 350–351, 350f
Lower eyelid and alar rejuvenation, 485–487,
486f, 487f

Index
I-12
Lower eyelid and botulinum toxin injection,
142–143
Lower eyelid blepharoplasty, 410–424
complications, 420–422
chemosis, 421, 421f
lower lid malposition, 420–421, 421f, 421b
visual changes, 421
indications, 410
operative techniques, 415–419
adjunctive technique, 419, 420f
anesthesia, 415
lateral canthal support, 417, 418f
lower lid blepharoplasty, 415–419, 417f,
418f, 419f
markings, 414, 416f
tear trough deformity, 419–420, 420f
outcomes, 430
periorbital classification, 414t
postoperative care, 419–470, 470f
preoperative assessment, 410–414
conditions and risk of complications from,
410b
eye prominence, 411–412, 411f
eye protection mechanisms, 411, 411f
herniated fat pads, 412–413, 412f
lower lid evaluation, 412, 412f
malar eminence, 414
medical history and evaluation, 410
midface, 413–414
skin pigmentation, 413
tear trough deformity, 413, 413f
preoperative planning, 414
results, 422f, 423f
Lower eyelid pinch blepharoplasty, 439–457,
439f, 440f
aesthetic advantages, 442
anatomy, 443
ancillary procedures, 449–450
history and evolution of technique, 440–441
indications and contraindications, 442–443,
443f
postoperative care, 450
preoperative assessment, 443–445
photography, 444–445, 444f, 445f, 446f
physical exam, 443–444, 443b
principles of technique, 441, 441f, 442f
problems and complications, 451
procedure, 446–450
markings, 446, 447f
pinch skin plasty, 448–449, 448f, 449f, 450f
prophylactic canthopexy, 447
stitch canthopexy, 447–448, 448f
therapeutic pexy, 447
transconjunctival surgery, 447
upper blepharoplasty, 446–447
results, 451–453
aging herniated patient, 455
aging patient, 453, 453f
congenitally herniated patient, 455
elderly patient, 453
festooned patient, 453, 453f
male patient with poor morphology, 455,
morphologically compromised patient, 455,
455f
older congenital scleral show patient, 455
orbitally grooved dark circled patient,
453–454, 454f
repinch patient, 455, 456fi
thick-skinned patient, 455
two-day prime patient, 455
younger congenital scleral show patient,
454, 454f
younger patient, 453
Lower eyelid rejuvenation, 364–368, 365b, 365f,
366f, 373f
fillers, 365
lid retraction causes, 366b
orbicularis flap, 368, 368f
pinch blepharoplasty, 365, 365f, 366f
transconjunctival approach, 366, 366t
transcutaneous approach, 366–367, 367f
Lower eyelids transconjunctival blepharoplasty,
429–435
anatomy, 429
operative technique, 432–434
orbital fat pads, 429–430, 430f
postseptal approach, 431, 431f
preoperative planning, 431–432, 432–433,
432f, 433–434, 434f, 435f
preseptal approach, 431, 431f
results, 434–435, 435f, 436f
transconjunctival approaches, 430, 430b, 431f
Lower face implants, 738–747
chin, 738–743, 740f, 741f, 742f, 743f, 744f
mandible angle, 743–746, 745f, 746f, 747f
Lower lateral crural turnover flap, 932–933, 933f
Lower leg anatomy, 1309–1310
gastrocnemius, 1309–1310, 1310f
soleus, 1310
Lower lid evaluation, 412, 412f
Lower lid malposition in lower eyelid blepharo-
plasty, 420–421, 421f, 421b
Lower pole skin pinch thickness tissue-based
planning for breast implants,
1046–1047, 1047f
Lymphocele/lymphedema, 1496
M
MACS lift short-scar rhytidectomy with fat
grafting, 573–593, 573f
ancillary procedures, 585–550
anterior neck, 585
augmentation blepharoplasty, 587, 587f
forehead, 585
microfat grafting, 586–587, 586f
nanofat, 588–590, 588f, 589f, 590f
posterior neck, 585
sharp-needle intradermal fat grafting,
587–588, 588f
short-scar temporal lift, 585–586, 586f
case study, 590–592, 590f, 591f, 592f
MACS lift, 574–585, 574f
anatomy, 575, 576f
indications and contraindications, 575, 575f,
576f
preoperative planning and assessment,
575–577, 576f
operative technique, 577–582
flap creation, 580, 580f
incision, 579, 579f, 580f
markings and incisions, 577–579, 578f
oblique loop, 581, 582f
results, 583, 584f
skin redraping and resection, 581–582, 582f,
583f
vertical loop, 580–581, 581f, 582f
postoperative care, 584–585
problems and complications, 584–585
technique overview, 573–574
extended MACS lift (X_MAC), 574
simple MACS lift (S-MAC), 573–574
Malar eminence and lower eyelid blepharo-
plasty, 414
Male abdominoplasty, 1436–1437, 1437f, 1438f
Male massive weight loss chest excision,
1483–1489
anatomy, 1483
ancillary procedures, 1488
gynecomastoid appearance, 1483
indications and contraindications, 1483
operative technique, 1485–1488
broad-based inferior pedicle technique,
1485–1486, 1487f
free-nipple graft technique, 1486–1487
outcomes and results, 1488
postoperative care, 1488
preoperative assessment, 1484
preoperative planning, including markings,
1484–1485
broad-based inferior pedicle technique,
1485, 1485f
free-nipple graft technique, 1485, 1486f
gynecomastia classification, 1484, 1484t
procedure choices, 1484–1485
pseudogynecomastia, 1483
Male patient with poor morphology and lower
eyelid pinch blepharoplasty, 455,
Male pattern baldness, 248–249, 248f, 248t, 249f
Male pattern baldness treatment, 261–264
anesthesia and preparation, 261, 261f
donor ellipse harvest, 261–262, 261f
graft dissection, 262–263, 262f
graft insertion, 263, 263f, 264f
postoperative care, 263–264, 266f, 267f
Male-to-female procedure-specific evaluations,
1617–1618, 1617t
augmentation mammoplasty, 1617
vaginoplasty, 1617–1618
Malignant hyperthermia management, 47–48,
58
Mallampati classification, 51t
Management services organization (MSO) model
and MedSpa law, 74, 75f
Marginal reflex distance, 398, 398f
Masculinizing procedures, 1611–1613
facial masculinization surgery, 1611
metoidioplasty, 1612
phalloplasty, 1613
transmasculine bottom surgery, 1612
transmasculine top surgery, 1612, 1612f
Massive-weight-loss patient screening and
safety issues, 1361–1371, 1361f, 1362t
intraoperative strategies, 1368–1369
anesthesia considerations, 1368
calculations, 1369
circumferential body prep, 1368
fluid management, 1368–1369
normothermia maintenance, 1368
operating room logistics, 1368
seroma prevention, 1369
surgical technique, 1369
laboratory workup, 1365
macronutrients, 1364
medication review, 1365
micronutrients, 1365
nicotine cessation, 1365–1366
nutritional assessment, 1363–1364, 1364f
perioperative DVT chemoprophylaxis, 1366,
1366t
preoperative optimization, 1362–1363
perioperative planning, 1366–1367
postoperative infection prevention, 1367
staging strategies and setting priorities,
1367
total procedure time, 1366–1367
postoperative care strategies, 1369–1370
analgesia, 1370
Mass media and entertainment industries, 15
Mastectomy, 1617

Index
I-13
Mastopexy and breast reduction in massive-
weight-loss patients, 1258–1273
advantages and disadvantages, 1258b
anatomy, 1259–1261, 1260t, 1261f
breast reduction in massive-weight-loss
patients, 1270, 1272, 1271f, 1272f
combined procedures, 1267–1268
goals, 1259
indications and contraindications, 1259
operative technique, 1263–1265, 1264f, 1265f,
1266f
patient profiles, 1259, 1259f, 1260f
postoperative care, 1265, 1267
preoperative assessment, 1261–1262
preoperative planning, 1262–1263
adequate breast volume, 1262
excessive breast volume, 1262
inadequate breast volume, 1262
markings, 1262–1263, 1263f
technique choice, 1262
problems and complications, 1268
results, 1268–1270, 1268f, 1269f, 1270f
Mastopexy control and precision, 1235–1257,
1235f
biologics versus standard meshes, 1245, 1246f
breast ptosis classification, 1236, 1236f
breast-shape deformity causes, 1235–1236
implant use with mastopexy, 1244–1245
liposuction, 1245–1246, 1247f
mastopexy to correct overaugmented breast,
1246–1247
operative technique, 1237–1238
selection, 1237
skin incision and scar shape versus
dermoglandular pedicle, 1238
outcomes and complications, 1247–1248,
1248f
patient evaluation, 1236–1237, 1237f
periareolar techniques, 1238–1244
Góes periareolar technique with mesh
support, 1238–1240, 1240f, 1241f
periaerolar mastopexy without parenchy-
mal reshaping, 1238, 1239f
vertical mastopexy without implants,
1240–1244, 1242f, 1243f, 1244f
postoperative care, 1247
results, 1248–1249, 1253–1255, 1249f, 1250f,
1251f, 1252f, 1253f, 1254f
Wise vertical scar with long horizontal scar,
1245
Mastoplexy primary and revision augmentation,
1106–1133
anatomy, 1108–1109, 1109f, 1110f
ancillary procedures, 1121, 1124f, 1125f
basic concepts and assessment, 1122, 1123
fat grafting, 1120–1121, 1123f
indications and contraindications, 1106
mastopexy pattern selection, 1112–1113, 1112f
circumareolar mastopexy, 1113, 1113f, 1114f
crescent lift, 1112, 1112f
inverted-T scar, 1113, 1116f
vertical mastopexy, 1113, 1115f
new implant selection in revision surgery,
114, 1126f
operative techniques, 1115–1118
circumareolar mastopexy, 1115, 1117–1118,
1119f, 1120f
crescent lift, 1115
inverted T-scar mastopexy, 1118, 1122f
vertical mastopexy, 1118, 1120f
outcomes and complications, 1122
pocket control, 1125–1126, 1127f
postoperative care, 1121–1122
preoperative assessment and management of
expectations, 1106, 1108, 1107f, 1108f
preoperative planning, 1109–1115
implant incision, 1111, 1111f
implant selection, 1109–1111, 1111t
preoperative planning, universal markings,
1113, 1113f, 1115f, 1117f
results, 1129, 1130f, 1131, 1131f, 1132f
skin envelope adjustment, 1129
skin removal and incisions, 1118, 1120, 1123f
soft tissue coverage, 1126, 1128f, 1129
tissue reinforcement, 1129, 1129f
Matching ingredients to skin type, 120–130,
121f, 122f
acne, 122f, 123–124
aging skin, 127–130
dry skin, 121–122, 122t
oily skin, 120–121
pigmented skin, 126–127
products to avoid, 122–123, 122f
rosacea-type sensitive skin, 124–125
sensitive skin, 123–125
stinging skin, 125–126, 125t, 126t
Mechanical ptosis, 400, 401f
Medial pedicle vertical breast reduction,
1152–1181, 1152f, 1153f, 1153t
anatomy, 1154–1156, 1155f, 1157f, 1158f, 1159f
complications, 1175–1177
dehiscence, 1176, 1178f
fat necrosis, 1176–1177
hematoma, 1175, 1177f
infection, 1175–1176, 1177f
nipple necrosis, 1177, 1178f
seroma, 1175
wound healing problems, 1176, 1177f
indications and contraindications, 1153–1154,
1154f, 1155f
operative technique, 1165–1170
infiltration, 1167, 1168f
parenchymal resection, 1167–1170, 1168f,
1169f, 1170f, 1171f, 1172f
pedicle creation, 1167
positioning, 1165, 1167
postoperative care, 1170–1171, 1173f, 1174f,
1175f
preoperative assessment, 1156–1157, 1159,
1161–1162, 1159f, 1160f, 1161f, 1162f
preoperative planning, 1162–1166
areolar opening markings, 1164, 1164f
ideal breast meridian markings, 1162, 1163f
liposuction area markings, 1165, 1167f
new nipple position markings, 1163–1164,
1164f
skin resection pattern markings, 1164, 1165f
superomedially based pedicle markings,
1164–1165, 1165f, 1166f
upper breast border and inframammary fold
markings, 1162, 1163f
problems and complications, 1171–1173
results, 1178–1179, 1179f, 1180f
revisions, 1173, 1175
inferior breast pucker correction, 1173, 1175f
re-reduction, 1173, 1176f
Medical assistants and MedSpa law, 77
MedSpas and the law, 74–79
compliance issues, 77–78
Health Insurance Portability and
Accountability Act (HIPAA), 77–78
payment of commissions, 77
diagnosis, 76, 76t
advanced practice registered nurse (APRN),
76
nurse practitioner (NP), 76
physician assistants (PAs), 76
market growth data, 74
ownership, 74–75
management services organization (MSO)
model, 74, 75f
requirements, 75
treatment providers, 76–77
estheticians, 76–77
medical assistants, 77
registered nurses, 76
trends in the industry, 78–79
autonomy of nurse practitioners, 78
private equity, 78
tax reform, 79
Mestizo rhinoplasty, 998
Metering, 26–28, 28f
Metoidioplasty, 1612, 1639, 1641f, 1643–1644,
1644f, 1646, 1646, 1647f
Metoidioplasty/phalloplasty, 1638
Mexican-American rhinoplasty, 997
Microdermabrasion, 165–167
equipment, 167
mechanism of action, 165–166
patient selection and contraindications, 166
postoperative considerations, 167
preprocedural preparation, 166
problems and complications, 167
skin changes and treatment efficacy, 167
technique, 167
Microfat grafting and midface recontouring,
482–483, 482f, 483f, 483t
Microfat grafting MACS lift short-scar rhytidec-
tomy with fat grafting, 586–587, 586f
Microfocused ultrasound, 202–203, 227–228,
227f, 228f
Microneedling, 132–133, 168–170, 168t, 164f
equipment, 169
mechanism of action, 168
patient selection and contraindications, 168
postoperative considerations, 170
preprocedural preparation, 168–169
problems and complications, 170
skin changes and treatment efficacy, 170
technique, 169–170
Middle Eastern descent proportions, rhino-
plasty, 925–926, 925f
Middle Eastern rhinoplasty, 983–989
Midface anatomy, 352–355, 353f, 354f, 355f
innervation, 354–355, 355f
vasculature, 355
venous and lymphatic drainage, 355
Midface and lower eyelid blepharoplasty,
413–414
Midface clinical decision making, 473–477, 473f
facelift incisions, 474, 476
extended MACS lift, 474, 476f
high-SMAS technique, 474, 476f
SMASectomy, 476, 476f
temporal approach, 474
transpalpebral approach, 474, 474f, 475f
Midface endoscopic rejuvenation, 505–516
anatomy, 505, 506f
indications and contraindications, 505
operative technique, 507–512
closure, 512
direct needle fixation, 510–511, 510f
dissection, 509–510, 509f, 510f
endotine fixation, 511, 512f
incisions, 508, 509f
infiltration, 508
instruments, 507–508, 508f
operating room setup and patient position-
ing, 508, 508f

Index
I-14
outcomes and results, 512–513, 513f, 514f, 515f
postoperative care, 512
preoperative assessment, 506
preoperative planning and marking zones,
506–507, 507f
Midface implants, 733–738
cheek (malar eminence), 734–735, 735f
infraorbital rim, 735–738, 736f, 737f, 738f,
739f
piriform aperture, 733, 733f, 734f
Midface recontouring, 478–504
aging, 478f, 479–482, 479f, 480f
centrofacial rejuvenation, 480–482, 481f
facial contouring, 499, 499f, 500f, 501f
microfat grafting, 482–483, 482f, 483f, 483t
perioral rejuvenation, 490–499, 490f
lip lift, 493–495, 494f, 495f, 496f
lip microfat grafting, 493, 493f, 494f
lip rejuvenation and enhancement,
492–493, 492f, 492t
lip resurfacing, 497–498, 498f
nasolabial fold correction, 490–491, 492f
perioral nanofat treatment, 496–498, 498f
perioral sharp-needle intradermal fat
injection, 495–496, 496f, 497f
results and outcomes, 498–499, 499f
periorbital rejuvenation, 483–490, 483f, 484f
lower eyelid and alar rejuvenation, 485–487,
486f, 487f
nanofat treatment for dark circles, 487–488,
488f
results and outcomes, 488–490, 489f
upper eyelid rejuvenation, 484–487, 487f
problems and complications, 500–503
lip lift, 502–503, 503f
lip resurfacing, 503
perioral fat grafting, 502
periorbital fat grafting, 500, 502, 502f
Midriasis as functional problems, eyelid surgery,
463
Millennials and aesthetic surgery, 73
Mini-abdominoplasty, 1434–1436, 1436f, 1437f
Mini-wedges and linear resection revision
surgery, 1600, 1601f
Minor fistula(e) following V-wedge labiaplasty,
1594
Moisturizers, 131
Monetization of social media, 82
Monitored anesthesia care, 53
Mons pubis, 1502, 1503f
Mons pubis surgical alteration, 1507, 1550–1557
Morning sunscreen, 131
Morphologically compromised patient and
lower eyelid pinch blepharoplasty,
455, 455f
Motivation for surgery, 7, 18
Mucosal advancement flaps, 869
Müllerectomy, 406, 407f
Multipolar RF devices, 203, 231–232
Muscle evaluation in aesthetic eyelid surgery,
359
Multifidus, 1304
Multipolar radiofrequency, 1337–1338
Muscle bulking with electromagnetic pulsed
energy, 1339
N
N-acetylcysteine for photoprotection, 115
N-acetylglucosamine for photoprotection, 115
Nanofat MACS lift short-scar rhytidectomy with
fat grafting, 588–590, 588f, 589f, 590f
Nanofat treatment for dark circles, 487–488,
488f
Narrow/wide breast distance, implant selection
variation, 1047
Nasal base stabilization, 957, 958f
Nasal contouring tip grafting, 953–969
anatomy, 954, 954f
indications and contraindications, 953
operative techniques, 956–963
closure, 962–963
costal cartilage harvest, 956–957
incision and dissection, 956
nasal base stabilization, 957, 958f
nostril reshaping, 962, 963f
septal cartilage harvest, 956, 957f
tip projection, 957, 959, 959f, 960f
tip refinement, 959–960, 962, 961f, 962f
tip rotation, 959
patient history, 955
photography and imaging, 955
physical examination, 955
postoperative care, 964
preoperative assessment, 954–955
preoperative planning, including markings,
955, 956f
problems and complications, 964
results, 964–967, 965f, 966f, 967f, 968f, 969f
Nasal dorsum, 930, 930f, 931f
Nasal vaults, 900–901, 900f
bony vault, 900, 901f
lower lateral cartilaginous vault, 900–901,
902f
upper cartilaginous vault, 900, 901f, 902f
Nasolabial fold correction, 490–491, 492f
Nasolabial folds and marionette grooves, fat
grafting, 567–571
aesthetic and anatomic considerations, 567,
567f
indications and patient selection, 567–568
technical approach, 568–571, 568f, 569f, 570f,
571f
Nasolabial folds and marionette grooves non-
surgical cosmetic treatments, 107–108,
107f, 108f
Near-infrared devices, 200–201
Neck lift, 749–770, 828
anatomy, 750–753
clinical corrections, 752–753, 753f
digastric muscle, 751, 752f
fat, 750, 750f, 751f
platysma muscle, 751, 751f
submandibular gland, 752, 752f
components of a neck lift, 749b
operative techniques, 755–768
endoscopic or limited-incision neck lift,
761, 762f
full-scar face and neck lift, 762–768, 763f,
764f, 765f, 766f, 767f, 768f
liposuction, 755–758, 756f, 757f, 758f, 759f
short scar face and neck lift, 761–762, 762f,
763f, 764f
submental neck lift, 758–761, 759f, 760f,
761f
preoperative assessment, 753–755
fat, 753, 754f
muscle and submandibular gland, 754, 754f
neck evaluation, 753b
neck-face interface, 754
planes of intervention, 755
skin, 754, 755f
vectors, 754
preoperative planning and decision making,
755
problems and complications, 768–769, 768f,
769f
surgical options, 749–750, 749b, 750f
Neck lift, secondary, 771–815, 772f
anesthesia techniques, 791–792
anterior platysmaplasty, 802–803, 802f, 803f
considerations, 791
intraoperative sedation method, 792
lateral platysmal border management,
803–805, 803f, 804f, 805f
monitoring patient, 792
preferred technique, 791–792, 791f
preop medications, 792
transverse platysma myotomy, 805–806,
806f
case examples, 811, 812f, 813f, 814f
operative sequence for skin flap elevation,
793–809
cervical lipectomy, 795–798, 796f, 797f
drain placement, 807–808
dressings, 809
final contouring of cervicofacial fat, 807
incision closure, 808–809
partial digastric myectomy, 800–802, 801f
partial platysma myectomy, 806–807, 807f
preservation of existing subcutaneous fat,
793
skin flap elevation, 794, 795f
submandibular gland reduction, 798–800,
798f, 799f
submental incision placement, 793–794
postoperative care, 809–810
after-surgery activity, 810
cool compresses, 809
diet after surgery, 810
drain removal, 810
medications, 810
return to work, 810
sleeping and head position, 809
suture removal, 810
wound care, 810
preoperative preparations and care, 790
operating room time allocation, 790
smokers and former smokers, 790
ultrasonic and radiofrequency skin-shrink-
ing treatments, 790
strategies, 772–777
inappropriate placement of chin implants,
775–776, 776f
neck lift with facelift, 777, 779f
residual skin excess and shifts, 776–777,
777f, 778f, 779f
short-scar limitations, 775
short-scar neck lift (submental incision
only), 773–775, 774f, 775f
submental liposuction, 772–773, 773f
surgical planning, 777–794
large submandibular gland planning
treatment, 787–789, 788f, 789f
platysma treatment planning, 781–785,
782f, 783f, 784f
prominent anterior belly of digastric
muscle, 789–790, 790f
submental incision, witch’s chin and double
chin correction, 777–781, 780f, 781f
submental region evaluation and assess-
ment, 785–787, 786f, 787f, 788f
surgical techniques, 792–793
local anesthesia administration, 793, 793f
positioning, 792
prepping and draping, 792
Neck nonsurgical cosmetic treatments, 108–110,
109f
Neck planes, 546b
Neck zone, 532, 532b, 533f

Index
I-15
Neovaginal depth and diameter for transfemini-
zation, 1611
Neurotoxins/fundamentals, 136–138, 821
mechanism of action, 138
product preparation, 136–138
Neurovascular supply of eyelids, 351–352
arterial supply, 351, 352f
eyelid innervation, 351–352, 352f
venous and lymphatic drainage, 351
Niacinamide for pigment reduction, 116
Nil per os, 48
Nipple to inframammary fold tissue-based
planning for breast implants, 1046,
1046f, 1047f
Nonablative lasers, 232
Nonablative nonfractional lasers, 197–199
Noncandidates for surgical procedures, 7–9
Nonincisional surgical techniques in the Asian
patient, 391–392
Noninvasive laser lipolysis, 1335–1337, 1336f,
1337f
Noninvasive modalities of body contouring,
1332–1339
cryolipolysis, 1332, 1334, 1333f, 1334f
high-intensity focused ultrasound, 1334–1335
multipolar radiofrequency, 1337–1338
muscle bulking with electromagnetic pulsed
energy, 1339
noninvasive laser lipolysis, 1335–1337, 1336f,
1337f
pharmacologic adipocytolysis injection
therapy, 1339
Noninvasive skin tightening, 201–203
microfocused ultrasound, 202–203
radiofrequency devices, 203–204
bipolar RF, 203
monopolar RF, 203
multipolar RF, 231–232
picosecond lasers, 204
unipolar RF, 203
Non-light-based skin resurfacing, 159–172
anatomy, 160–161
dermabrasion, 161–165
equipment, 162–163
example, 165, 166f
patient selection and contraindications,
161–162, 162t
postoperative considerations, 164
preprocedural preparation, 162
problems and complications, 164–165, 165f
skin changes and treatment efficacy, 164
technique, 163–164, 163f, 164f, 165t
evolution of techniques, 159–160, 160f
microdermabrasion, 165–167
equipment, 167
mechanism of action, 165–166
patient selection and contraindications, 166
postoperative considerations, 167
preprocedural preparation, 166
problems and complications, 167
skin changes and treatment efficacy, 167
technique, 167
microneedling, 168–170, 168t, 164f
equipment, 169
mechanism of action, 168
patient selection and contraindications, 168
postoperative considerations, 170
preprocedural preparation, 168–169
problems and complications, 170
skin changes and treatment efficacy, 170
technique, 169–170
Nonsurgical cosmetic treatments clinical
decision making, 103–110
face and facial rejuvenation, 104
invasiveness, increasing degree of, 103t
nasolabial folds and marionette groves,
107–108, 107f, 108f
neck, 108–110, 109f
options of office-based vs. surgical proce-
dures, 104, 104f, 105f
rhytids, 104–107, 105t, 106f, 107f
Nonsurgical skin rejuvenation, 135–136
Nonsurgical treatment of face and neck,
222–240
American Society for Aesthetic and Plastic
Surgery top ten procedures, 222t
laser resurfacing, 232–237
ablative lasers, 232
fractional photothermolysis, 233
Halo Hybrid Fractional Laser, 236, 236f, 237f
nonablative lasers, 232
ptotic skin, 226–232
CoolSculpting application, 226f
microfocused ultrasound, 227–228, 227f,
228f
radiofrequency, 228–231, 229f, 231f
Silhouette InstaLift, 232f, 233f, 234f, 235f
ThermiTight application, 228f
thread lifting, 232, 232f, 233f, 234f, 235f,
236f
stackable therapies, 237, 238f
volume reduction, 222–226
cryolipolysis, 224–226, 225f, 225t, 226f
deoxycholic acid, 223–224, 222f
Kybaella injections, 224f
Normal venous anatomy of lower anatomy,
208–209, 208f, 209f
Normothermia, 47
Nose anatomy, 897–904
blood supply, 898, 899f, 900f
muscles, 898, 898f, 899f
nasal function, 901–903, 903f
nasal vaults, 900–901, 900f
bony vault, 900, 901f
lower lateral cartilaginous vault, 900–901,
902f
upper cartilaginous vault, 900, 901f, 902f
rhinoplasty anatomic sequence, 897–898, 897f
Nostril reshaping, 962, 963f
Nurse or patient coordinator contact, 5
Nurse practitioners (NPs) and MedSpa law, 76,
78
O
Oatmeal for inflammation, redness, and scar
reduction, 117
Obstructive sleep apnea and obstructive lung
disease as risk factor, 41–42
Obvious scars, 833, 836f
Occlusives for skin moisturizing, and barrier
repair, 112–113
Oculopharyngeal muscular dystrophy, 400, 401f
Office-based anesthesia, 56–57
Office-based procedures, 45–46
Oily skin, 120–121
Older congenital scleral show patient and lower
eyelid pinch blepharoplasty, 455
Oncologic screening in transfeminization, 1611
Open coronal forehead lift for forehead rejuve-
nation, 285, 286f
Open submental incision with medial platysma
approximation, 605, 605f
Optical distortion, 22, 22f
Options of office-based vs. surgical procedures,
104, 104f, 105f
Oral tranexamic acid for pigment reduction, 116
Orbicularis flap, lower eyelid rejuvenation, 368,
368f
Orbicularis oculi muscle and upper eyelid
blepharoplasty, 375–376, 376f
Orbital hemorrhage and hematoma as
functional problems, eyelid surgery,
458, 459f
Orbitally grooved dark circled patient and lower
eyelid pinch blepharoplasty, 453–454,
454f
Orbital pathology, 401
Orbital septum and lacrimal gland and upper
eyelid blepharoplasty, 377, 377f
Orchiectomy/vaginoplasty, 1637–1638
Osseous genioplasty, 885–886, 886f
Osteotomies, 938–942, 941f, 942f, 943t, 944f
Otoplasty techniques refinement, 871–881
anatomy, 872–873, 872f
cartilaginous framework, 872
postauricular fascia, 872–873, 873f
ancillary procedures, 877
dressings and postoperative care, 877–879
indications and contraindications, 871–872
outcomes and results, 879, 879f, 880f, 881f
postauricular fascia operative technique,
874–877, 876f, 877f, 878f
preoperative assessment, 873
preoperative planning, 873–874
access incision, 874, 875f
hair preparation, 874
head positioning, 874, 874f
Overcorrection of ptosis, 407–408, 408f
Over-the-counter skin care and nutraceutical
basics, 111–118
collagen and dermal repair, 115–116
copper, 115–116
peptides, 115
exfoliation and cell renewal, 113
alpha-hydroxy and beta-hydroxy acids, 113
retinoids, 113
inflammation, redness, and scar reduction,
135–136
licorice extract, 117
oatmeal, 117
topical and oral polyphenols, 116–117
photoprotection, 113–115
carotenoids, 115
chemical and physical sun protection factor,
113–114
N-acetylcysteine, 115
N-acetylglucosamine, 115
selenium, 114
vitamin C, 114
vitamin E, 114
zinc, 114–115
pigment reduction, 116
hydroquinone, 116
kojic acid, 116
niacinamide, 116
oral tranexamic acid, 116
skin cleansing, 111–112
skin moisturizing, and barrier repair, 112–113
emollients, 113
hydrators/humectants, 112
occlusives, 112–113
P
Palpebral fissure, 397–398, 397f
Panfacial rejuvenation, 635
Panniculectomy, 1437, 1439, 1439f
Paresthesias of eyelid as functional problems,
eyelid surgery, 464, 465f
Partial resection of submandibular glands, 829

Index
I-16
Patient, 3–14
colleague, friends, and family discount
services, 11, 11f
complications and problems management, 12
dissatisfied patient, 13–14
documentation, 11–12
postoperative, 12
preoperative, 12
financial responsibilities, 10–11
first consultation, 3–7
blepharoplasty questionnaire, 6f
body contouring questionnaire, 7f
breast surgery questionnaire, 7f
follow-up letter to prospective breast
surgery patient, 8f
general intake information, 6f
nurse or patient coordinator contact, 5
patient letter, 5f
personal history questionnaire, 5f
receptionist contact, 4–5
surgeon contact, 5–7
telephone contact, 4–7
motivation for surgery, 7
noncandidates for surgical procedures, 7–9
patient education, 10–11
postoperative visits, 12–13
surgeon shopping, 9
Patient care coordinator (PCC), 85–94
final candidate assessment, 90–92, 90f
background check, 92
essential skill assessment, 91
offer letter, 91, 91b
reference and social site check, 91
workstyle analysis, 90–91
hiring process, 86–90, 87b
advertising, 87–88, 88b
interview, 89–90, 89b
phone screening, 88–89
position description development, 86–87,
86b
résumé reviews, 88
second interview, 90
measuring and rewarding success, 93–94, 94b
orientation and training, 92–93, 92b, 93b
skills, 85–86, 86b
compassion, 85
genuineness, 85
internet and social media savvy, 86
intuitiveness, 85
keyboarding, 86
organizational and project management
abilities, 86
rapport building, 85
sales skills, 85–86
Patient education, 10–11
Patient letter, 5f
Patient positioning for surgery, 46
Patient positioning with sedation and anesthe-
sia, 57
Patient retention, 70–71, 71f, 71t, 72
Pectoralis major, 1302–1303, 1303f
Pectus excavatum, 1068–1069
Peptides for collagen and dermal repair, 115
Perforating veins sclerotherapy and laser vein
treatment, 209, 210f
Perineum, 1504
Perineoplasty, 1574–1575, 1575f
Perineoplasty and vaginal rejuvenation, 1566,
1566f
Perioperative considerations, 46–48
communication failures, 46
crew resources management and checklists,
46, 47f
malignant hyperthermia management, 47–48
normothermia, 47
patient positioning, 46
skin preparation/scrub, 46–47
Perioral fat grafting, 502
Perioral nanofat treatment, 496–498, 498f
Perioral rejuvenation, 490–499, 490f, 830–831,
831f, 832f
lip lift, 493–495, 494f, 495f, 496f
lip microfat grafting, 493, 493f, 494f
lip rejuvenation and enhancement, 492–493,
492f, 492t
lip resurfacing, 497–498, 498f
nasolabial fold correction, 490–491, 492f
perioral nanofat treatment, 496–498, 498f
perioral sharp-needle intradermal fat
injection, 495–496, 496f, 497f
results and outcomes, 498–499, 499f
Perioral resurfacing, 869–870
Perioral sharp-needle intradermal fat injection,
495–496, 496f, 497f
Perioral zone, 532, 532b
Periorbital classification for lower eyelid
blepharoplasty, 414t
Periorbital fat grafting, 500, 502, 502f
Periorbital rejuvenation, 483–490, 483f, 484f,
829–830, 830f, 831f
lower eyelid and alar rejuvenation, 485–487,
486f, 487f
nanofat treatment for dark circles, 487–488,
488f
results and outcomes, 488–490, 489f
upper eyelid rejuvenation, 484–487, 487f
Periorbital septa and adhesions, 300, 301f
Periorbital zone, 531–532, 532b
Personal history questionnaire, 5f
Perspective distortion, 2, 22f
Phalloplasty for transfeminization, 1613, 1617,
1639–1642, 1641f, 1642f, 1644–1645,
1645f, 1646–1647, 1647f,
Pharmacologic adipocytolysis injection therapy,
1339
Phenol, 174–175, 175t
Photographic essentials in aesthetic surgery,
21–38
aperture, 23–24, 23f
clinical photographic standards, 33–37
bounce and ring flash, 35, 37
intraoperative photography, 37, 37f, 38f
standard flash, 35
standard views for regions of interest,
33–35, 34f, 35f, 36f
studio effect photography, 37, 37f
compressed vs. uncompressed vs. raw format,
29–30, 29f, 30f
depth of field, 25, 25f, 26f
digital photography, 30–34
camera selection, 32–33
dynamic range, 31–32, 32f
file storage and backup, 32
protected information and HIPAA compli-
ance, 33
resolution, 31
sensor size, 30–31, 31f
exposure, 24–25, 24f
focal length, 21–22
lens selection, 22
lighting and flash, 25–26, 27f
metering, 26–28, 28f
optical distortion, 22, 22f
perspective distortion, 2, 22f
postprocessing, 28–29, 29f
sensitivity (ISO speed), 24
shutter speed, 23
Photoprotection, 113–115
carotenoids, 115
chemical and physical sun protection factor,
113–114
N-acetylcysteine, 115
N-acetylglucosamine, 115
selenium, 114
vitamin C, 114
vitamin E, 114
zinc, 114–115
Physician assistants (PAs) and MedSpa law, 76
Picosecond lasers devices, 204
Pigmented skin, 126–127
Pigment reduction, 116
hydroquinone, 116
kojic acid, 116
niacinamide, 116
oral tranexamic acid, 116
Pinch blepharoplasty, lower eyelid rejuvenation,
365, 365f, 366f
Pinch skin plasty, 448–449, 448f, 449f, 450f
Pinterest, 81
Pittsburg grades 1–3 for breast reduction, 1262
Pixie ear and earlobe scar migration, 833, 834f
Platysma bands and cervical obliquity correc-
tion, 629–630, 629f
Platysmal bands and botulinum toxin injection,
143
Platysmal transection and lateral platymaplasty,
829
Poland’s syndrome, 1068, 1069f, 1276
Poly-L-lactic acid, 155
Polymethylmethacrylate, 155–156,
Popliteal fossa bulging reticular veins, 216, 216f
Postauricular fascia, 872–873, 873f
Posterior neck MACS lift short-scar rhytidec-
tomy with fat grafting, 585
Posterior vaginal wall rejuvenation, 1565–1566,
1565f, 1566f
Posterior vaginoplasty, 1575–1576, 1576f, 1577f
Postoperative complications, 42
Postoperative dissatisfaction, 1495
Postoperative documentation, 12
Postoperative management and complications
of sedation and anesthesia, 57–58
benzodiazepine or opioid overdose, 58
hoarseness, cough (airway irritation), 57
local anesthetic systemic toxicity, 57–58
malignant hyperthermia, 58
postoperative nausea and vomiting, 57
Postoperative nausea and vomiting, 48, 52, 52t,
57
Postoperative visits, 12–13
Postprocedure cosmeceuticals, 132–133
Postprocessing, 28–29, 29f
Postsurgery psychological status, 18
Potassium titanyl phosphate, 200, 200f
Power of nine in pricing, 99
Preauricular incision, 539, 539f, 540f, 541f
Preoperative documentation, 12
Preoperative evaluation for sedation and
anesthesia, 51–53
American Society of Anesthesiologists
classification of patients, 52t
anxiety, 53
hypertension, 53
Mallampati classification, 51t
postoperative nausea and vomiting, 52, 52t
preoperative home medication management,
52
prophylaxis and anxiolysis, 52–53
Preoperative home medication management, 52

Index
I-17
Preoperative planning for hair transplantation,
252–257
aesthetic considerations, 252–253, 252f
burn alopecia treatment, 255–256, 256f
camouflaging scalp scars, 254, 254f, 255f
donor site harvesting, 253–254, 254f, 255f
eyebrow, mustache, and beard restoration,
255, 255f, 256f
eyelash reconstruction and augmentation,
256–257, 257f
sideburn corrections, 255, 255f
Preprocedure cosmeceuticals, 132
Pricing strategies, 95–99
brand perception, 96
bundled prices, 98–99
power of nine, 99
special offers, 98
premium pricing, 95–96, 96b
pricing power, 96
strategic discounting, 96–97, 97b, 97t
reactionary discounting, 96
transactional buyers, 96–97, 97b
Unique Service Proposition (USP), 95
value proposition, 96
Procedure techniques, 132–133
injectables, 133
microneedling, 132–133
Processed fat grafting with enrichment proce-
dures, 1074
Prominent frenular fold edge revision, 1594
Prophylactic cantopexy, 447
Prophylaxis and anxiolysis, 52–53
Protected information and HIPAA compliance,
33
Pseudogynecomastia, 1483
Pseudoptosis, 401, 402f
Psychiatric status and history, 19
Psychological considerations in aesthetic
surgery, 15–20
body image and self-worth, 16–17
characteristics of aesthetic surgery patients,
16
mass media and entertainment industries, 15
medical advances, 15
postsurgery psychological status, 18
psychiatric status and history, 19
psychopathology, aesthetic surgery patients,
17–18
body dysmorphic disorder, 17
depression and suicide, 17–18
eating disorders, 17
psychosocial functioning, 18–19
body image dissatisfaction and body
dysmorphic disorder, 18–19
motivations and expectations, 18
Psychopathology, aesthetic surgery patients,
17–18
body dysmorphic disorder, 17
depression and suicide, 17–18
eating disorders, 17
Psychosocial functioning, 18–19
Ptosis of upper eyelid as functional problems,
eyelid surgery, 463
Ptosis surgery in the blepharoplasty patient,
397–409
anatomy, 397
ancillary procedures, 406–408
overcorrection of ptosis, 407–408, 408f
undercorrected ptosis, 408
indications and contraindications, 397
operative technique, 403–406
anatomic method, 405–406
Müllerectomy, 406, 407f
surgery in the awake patient, 403–405,
404f, 405f, 406f
surgery with general anesthesia, 405–406
preoperative assessment, 397–403
acquired age related ptosis, 398–399, 399f
acquired third-nerve palsy, 400, 401f
chronic progressive external ophthalmople-
gia, 400, 400f
congenital ptosis, 401–403, 402f
Horner’s syndrome, 400, 400f
levator function, 398, 398f
marginal reflex distance, 398, 398f
mechanical ptosis, 400, 401f
myasthenia gravis, 399–400, 400f
oculopharyngeal muscular dystrophy, 400,
401f
orbital pathology, 401
palpebral fissure, 397–398, 397f
pseudoptosis, 401, 402f
traumatic ptosis, 400–401, 401f
preoperative planning, including markings,
403
results, 409, 409f
Ptotic skin, 226–232
CoolSculpting application, 226f
microfocused ultrasound, 227–228, 227f, 228f
radiofrequency, 228–231, 229f, 231f
Silhouette InstaLift, 232f, 233f, 234f, 235f
ThermiTight application, 228f
thread lifting, 232, 232f, 233f, 234f, 235f, 236f
Pulsed dye laser, 199–200
Pulsed-light devices, 201, 202f
Q
Quadriceps, 1307–1308, 1308f, 1309f
R
Radiation after breast conservation, 1281–1282,
1282f
Radiofrequency devices, 203–204
bipolar RF, 203
monopolar RF, 203
multipolar RF, 231–232
picosecond lasers, 204
unipolar RF, 203
Radiofrequency energy-based skin tightening,
819–821
Radiofrequency monopolar-multipolar option
for vaginal tightening, 1574
Radiofrequency treatments, 228–231, 229f, 231f
Reactionary discounting, 96
Receptionist contact, 4–5
Reconstructive breast surgery indications,
1068–1070
adjuvant procedure for breast reconstruction,
1070
asymmetrical breasts, 1069–1070, 1069f
breast conservative treatment sequelae
correction, 1070
breast reconstruction conversion from
prosthesis to autologous, 1070
breast reconstruction with RAVA, 1070
pectus excavatum, 1068–1069
Poland’s syndrome, 1068, 1069f
reverse expansion, 1070
total breast reconstruction with fat grafting,
1070
tuberous breasts, 1069
Rectus abdominis, 1299, 1302, 1300f, 1301f
Reddit, 81
Refractive changes as functional problems,
eyelid surgery, 464
Registered nurses (RNs) and MedSpa law, 76
Regnault’s classification of breast ptosis, 1236
Reoperative rhytidectomy, 817–843
aesthetic evaluation, 822, 824, 826–827
facial nerve risk with re-elevation of SMAS,
824, 826, 827f
failure of skin redistribution and contour-
ing, 827
hairline, 822
inadequate correction of hypertrophic
or ptotic deep neck structures,
826–827, 828f
persistent buccal fat pseudoherniation, 826,
827f
previous SMAS elevation, 824
primary facelift suture material use, 826
skin and scars, 824, 826f
subcutaneous tissue, 824, 826f
ancillary treatment of facial aesthetic
subunits, 829–831
earlobe rejuvenation, 831
perioral rejuvenation, 830–831, 831f, 832f
periorbital rejuvenation, 829–830, 830f, 831f
categories of patients requiring reoperation,
817
complication management, 834–841
dysphagia, 840
emotional issues, 841
hematoma, 834–836, 837f
infection, 838, 839f
nerve injury, 840, 840f, 841f
parotid fistula, 838–839
salivary gland problems, 838–841
skin slough, 837–839, 838f
submandibular gland sialoma, 839–840
indications for surgery, 821–822
adjunctive procedures to enhance previous
results, 821–822, 823f
continued signs of aging, 821, 822f
dissatisfaction with previous results, 822
planned staged intervention, 822, 823f, 825
maintaining results, 818–821
chemical peels, 819, 820f
dermabrasion, 818–819, 819f
duration, 818
emulsified intradermal fat grafting, 819
laser resurfacing, 819, 819f
lipofilling/lipocontouring, 818
neurotoxin, 821
radiofrequency energy-based skin tighten-
ing, 819–821
skin care, 821
skin texture improvement and rhytids,
818–819
soft tissue refillers, 818
volume manipulation, 818
preventing and correcting overoperated look,
832–834
body dysmorphic disorder, 833–834
hairline distortion, 833, 834f
know when to say no, 832
lateral sweep, 832, 833f
obvious scars, 833, 836f
pixie ear and earlobe scar migration, 833,
834f
tragal distortion, 832, 833f
surgical options, 827–834, 827b
delta facelift, 828
hemostatic net, 829
neck lift, 828
partial resection of submandibular glands,
829
platysmal transection and lateral platyma-
plasty, 829

Index
I-18
subplatysmal excision, 829
supraplatysmal fat liposuction, 828
tangential excision or plication of anterior
bellies of digastric muscles, 829
Repinch patient and lower eyelid pinch blepha-
roplasty, 455, 456fi
Resection of brow fat and upper eyelid blepha-
roplasty, 385, 386f
Resolution, 31
Results of lower eyelid pinch blepharoplasty
aging herniated patient, 455
aging patient, 453, 453f
congenitally herniated patient, 455
elderly patient, 453
festooned patient, 453, 453f’
male patient with poor morphology, 455,
morphologically compromised patient, 455,
455f
older congenital scleral show patient, 455
orbitally grooved dark circled patient,
453–454, 454f
repinch patient, 455, 456f
thick-skinned patient, 455
two-day prime patient, 455
younger congenital scleral show patient, 454,
454f
younger patient, 453
Resurfacing, 544–545
Retaining ligaments in face and neck clinical
anatomy, 523–525, 524f, 525f
Retinoids for exfoliation and cell renewal, 113
Retroauricular incision, 539, 541, 541f, 541t
Reverse expansion, 1070
RFFF phalloplasty, 1644–1645
Rhinoplasty anatomic sequence, 897–898, 897f
Rhinoplasty clinical decision making, 905–912
case examples, 910–912, 911f, 912f
digital imaging, 906–907, 908f
initial consultation, 905–906
initial conversation with patient, 906
nose anatomy, 905
plan formulation, 907, 909, 909f
procedure, 909–910, 910f
red flag patient, 907, 909f
surgical planning and analysis, 905, 905f
Rhinoplasty for feminization, 1621
Rhinoplasty, primary, 913–952
anatomy, 914–918
blood supply, 915, 916f
muscle, 915, 915f
nasal function, 916–918, 917f
nasal vaults, 915–916, 916f, 917f
skin, 914–915, 915f
indications and contraindications, 913–914
open versus endonasal approach, 914, 914t
operative technique, 927–943
alar-columellar relationship correcting,
937–938, 938f, 939f, 940f
alar rims, 936, 937f
autospreader flaps, 933, 934f
cephalic trim, 932, 933f
deviated nose correction, 931, 931b
incision: endonasal approach, 927–928, 928f
incision: open approach, 928–929, 929f
inferior turbinoplasty, 931–932, 932f
lateral crural strut grafts, 936, 937f
lower lateral crural turnover flap, 932–933,
933f
nasal dorsum, 930, 930f, 931f
osteotomies, 938–942, 941f, 942f, 943t, 944f
septal reconstruction/cartilage graft
harvest, 930–931, 931f, 932f
skin envelope dissection, 929, 929f
spreader grafts, 933, 934f
tip modification, 934–936, 935f, 936f
outcomes, 944–945
results, 945–949, 945f, 946f, 947f, 948f, 949f,
950f, 951f
postoperative management, 943–944
preoperative assessment, 918–926
African descent proportions, 924, 925f
facial analysis, 918–925, 919f, 920f, 921f,
922f, 923f, 924f
initial consultation, 918, 918f
intranasal examination, 926, 927f
male patient proportions, 924
Middle Eastern descent proportions,
925–926, 925f
preoperative planning, 926–927, 926b, 927t
technique evolution, 913
Rhinoplasty, revision, 1002–1019
anatomy, 1003–1004, 1004f
ancillary procedures, 1011, 1014–1015
alloplastic graft materials, 1015
bone grafting, 1014
costal cartilage grafting, 1014
septal and auricular cartilage, 1011, 1014
indications and contraindications, 1002–1003,
1002f, 1003f
operative techniques, 1006–1011, 1007f, 1008f,
1009f, 1010f, 1011f, 1012f, 1013f
outcomes, 1015
postoperative care, 1015
preoperative placement and markings, 1005,
1006f
preoperative assessment and planning,
1004–1005
results, 1015–1018
surgical plan and steps, 1015–1016, 1016f,
1017f, 1018f, 1019f
Rhytids, crows’ feet, and lateral orbital area for
aging forehead and brow evaluation,
284, 519
Rhytids nonsurgical cosmetic treatments,
104–107, 105t, 106f, 107f
Risk factors, 39–41, 40t
age, 40
American Society of Anesthesiologists status,
41, 41t
body mass index, 40–41, 41f
cardiovascular condition, 42
diabetes mellitus, 41, 42f
gender, 40
obstructive sleep apnea and obstructive lung
disease, 41–42
smoking, 41
Risk management, 39
Rosacea-type sensitive skin, 124–125
Round versus anatomical implants, 1059–1060,
1060f
S
SAFELipo, 1462, 1463f
Safety, 39–50
anesthetic considerations, 48–50
local anesthetic systemic toxicity, 48–50, 49f
nil per os, 48
postoperative nausea and vomiting, 48
combining aesthetic procedures, 44–45
office-based procedures, 45–46
perioperative considerations, 46–48
communication failures, 46
crew resources management and checklists,
46, 47f
malignant hyperthermia management,
47–48
normothermia, 47
patient positioning, 46
skin preparation/scrub, 46–47
postoperative complications, 42
risk factors, 39–41, 40t
age, 40
American Society of Anesthesiologists
status, 41, 41t
body mass index, 40–41, 41f
cardiovascular condition, 42
diabetes mellitus, 41, 42f
gender, 40
obstructive sleep apnea and obstructive
lung disease, 41–42
smoking, 41
risk management, 39
surgical site infection, 42–44, 43t
hematoma, 43
venous thromboembolism, 43–44, 44f, 445f,
46f
Sartorius, 1308f, 1309
Scar alopecia correction secondary to facelift
procedure, 265, 266f, 267f
Scar as aesthetic problems, eyelid surgery, 467
Scar management, 65
Scleral triangles evaluation in aesthetic eyelid
surgery, 359–360, 360f
Sclerotherapy and laser vein treatment, 206–221
pretreatment assessment, 206–211
lower extremity, 206–208, 207f, 207t
normal venous anatomy of lower anatomy,
208–209, 208f, 209f
perforating veins, 209, 210f
telangiectatic leg veins, 209–211, 210f, 211f,
211t
upper extremity, 210–211, 212f
vessel classification, 211t
treatment options, 211–214
conventional (visual) and duplex-guided
sclerotherapy, 211–213, 213t
laser treatment of reticular vessels and
telagiectasias, 213–214
treatment regimen, 214–220, 214t
anterior thigh telangietasias, 219–220, 219f,
220f
blue rubber bleb nevus syndrome, 217–218,
218f
dorsal hand veins, 216–217, 217f
foamed sodium tetradecyl sulfate or polido-
canol sclerotherapy, 215, 216f
glycerin sclerotherapy, 215
lateral thigh telangietasias, 215, 215f, 215t
long-pulse laser therapy, 218–219, 219f
patient education, 214–215
popliteal fossa bulging reticular veins, 216,
216f
Sedation, 53–54, 54t
Sedation and anesthesia, 51–59
anesthesia methods, 53–57
airway management, 53t
general anesthesia, 53
local anesthesia, 54–57, 55t, 56t
monitored anesthesia care, 53
office-based anesthesia, 56–57
sedation, 53–54, 54t
tumescence solutions, 55–56
postoperative management and complica-
tions, 57–58
benzodiazepine or opioid overdose, 58
hoarseness, cough (airway irritation), 57
local anesthetic systemic toxicity, 57–58
malignant hyperthermia, 58
postoperative nausea and vomiting, 57

Index
I-19
preoperative evaluation, 51–53
American Society of Anesthesiologists
classification of patients, 52t
anxiety, 53
hypertension, 53
Mallampati classification, 51t
postoperative nausea and vomiting, 52, 52t
preoperative home medication manage-
ment, 52
prophylaxis and anxiolysis, 52–53
technical considerations, 57
fluid management, 57
patient positioning, 57
thermoregulation, 57
Selenium for photoprotection, 114
Sensitive skin, 123–125
Sensitivity (ISO speed), 24
Sensor size, 30–31, 31f
Sentinel vein, 299–300, 300f
Septal and auricular cartilage for rhinoplasty
revision, 1011, 1014
Septal cartilage harvest, 956, 957f
Septal reconstruction/cartilage graft harvest,
930–931, 931f, 932f
Seratus anterior, 1300f, 1301f, 1302
Sexual dysfunction and prolapse, 1560
Sharp-needle intradermal fat grafting MACS
lift short-scar rhytidectomy with fat
grafting, 587–588, 588f
Short nipple to inframammary fold, implant
selection variation, 1048
Short-scar mammaplasty with pectoralis loop,
1195–1208
anatomy, 1195–1196, 1196f
indications and contraindications, 1195
operative technique, 1197–1199, 1198f, 1199f,
1200f, 1201f, 1202f
outcomes, 1203, 1203f, 1204f, 1205f, 1206f,
1207f
postoperative care, 1199, 1202
preoperative assessment, 1196
preoperative planning, 1196, 1196f
problems and complications, 1202
Short-scar rhytidectomy, 594–611
complications, 607–608, 608t
facelift longevity, 609, 609f, 610f
gold standard for facial rejuvenation, 610
lateral SMASectomy, advantages and disad-
vantages, 596
neck correction as biggest challenge, 609
operative technique, 603–607
defatting neck and jowls, 604–605
incisions, 603, 603f
lateral SMAS plication, 606, 606f, 607f
open submental incision with medial
platysma approximation, 605, 605f
skin closure, temporal fascia, and earlobe
dog-ears, 607
skin flap elevation, 603–604, 604f
vectors, 606–607
outcomes, 608–609, 608f
patient profiles, 597–602
fair candidate, 599, 601, 600f, 601f
good candidate, 597, 599, 598f, 599f
ideal candidate, 597, 598f
poor candidate, 601, 602f
short-scar facelift, advantages and disadvan-
tages, 596–597, 597t
technique evolution, 594–596
lateral SMASectomy, 594, 595f
less invasive techniques, 594–595
short-scar rhytidectomy, 595–596, 596f
SMAS, 594
unnatural results, 609–610
Short-scar temporal lift MACS lift short-scar
rhytidectomy with fat grafting,
585–586, 586f
Shoulder and arm anatomy, 1304–1306
biceps, 1305–1306, 1305f
brachialis, 1305f, 1306
deltoid, 1304–1305, 1304f, 1305f
triceps, 1304f, 1305, 1305f
Shutter speed, 23
Sideburn corrections, 255, 255f
Side-to-side dissymmetry revision techniques,
1593
Sientra Texture surface (texture), 1042, 1042f
Silhouette InstaLift, 232f, 233f, 234f, 235f
Silicone lip implant reconstruction revision
surgery, 1597–1598, 1600f
Silicone six-pack abdominal augmentation,
1479–1480, 1480f, 1481f
Silicone six-pack abdominal implant placement,
1481
Siltex surface (texture), 1041, 1042f
Simple MACS lift (S-MAC), 573–574
Sinus track revision surgery, 1595–1596
Skin aging, 68
actinic damage, 68
dynamic lines, 68
gravity, 68
volume loss, 68
Skin and crease/fold complex and upper eyelid
blepharoplasty, 375, 376f
Skin care regimen design, 130–132, 131f, 821
cleansers, 130–131
evening retinoids, 132
eye products, 131
moisturizers, 131
morning sunscreen, 131
treatment products, 131
Skin cell aging reversal, 129–130
Skin cleansing, 111–112
Skin closure and upper eyelid blepharoplasty,
384
Skin closure, temporal fascia, and earlobe
dog-ears, 607
Skin envelope dissection, 929, 929f
Skin evaluation in aesthetic eyelid surgery, 359
Skin excision, upper eyelid rejuvenation, 364
Skin flap elevation, 603–604, 604f
Skin flap evaluation, Asian rhinoplasty, 973
Skin for aging forehead and brow evaluation,
284, 285f
Skin moisturizing, and barrier repair, 112–113
emolients, 113
hydrators/humectants, 112
occlusives, 112–113
Skin-muscle excision, upper eyelid rejuvenation,
364
Skin, orbicularis, and fat resection and upper
eyelid blepharoplasty, 382, 382f, 383f
Skin pigmentation lower eyelid blepharoplasty,
413
Skin preparation/scrub, 46–47
Skin products to avoid, 122–123, 122f
Skin stretch tissue-based planning for breast
implants, 1047, 1048f
Skin texture improvement and rhytids, 818–819
Skin texture problems as aesthetic problems,
eyelid surgery, 468
Skin treatment products, 131
Skin type diagnosis, 120
Skin Type Solutions (STS) system, 119
SMAS, 594
SMAS and midface, 637–638, 637f
SMAS dissection, 661–664, 663f, 664f
SMAS elevation, 626–627, 626f
SMAS fixation, 628, 629f
SMAS fixation versus platysmaplasty, 630–631,
630f, 631f
SMAS flap dissection completeness assessment,
665
SMAS flap elevation technique, 664–665
SMAS flap, rationale for use, 636–637
SMAS suspension and proper SMAS vector,
665–669, 665f, 666f, 667f, 668f, 669f
SMASectomy for facelift incisions, 476, 476f
Smoking as risk factor, 41, 1414
Snapchat, 81, 83
Social media, 80–84
Facebook, 80, 81–82
guidelines, 84f
Instagram, 80, 82–83
LinkedIn, 81
monetization, 82
Pinterest, 81
Reddit, 81
Snapchat, 81, 83
Twitter, 81, 83
YouTube, 80, 82–83
Social support for gender-affirming surgery,
1618
Soft tissue fillers, 150–158
complications, 156–157, 157f
FDA-approved fillers, 151t
patient assessment, 150
rheologic considerations, 152, 154
techniques, 152, 152f, 152t, 153f
types of fillers, 154–156
calcium hydroxyapatite, 155, 155f
hyaluronic acid-based fillers, 154–155, 155f
poly-L-lactic acid, 155
polymethylmethacrylate, 155–156,
Soft tissue refillers, 818
Soleus, 1310
Spas. See MedSpas and the law
Special offers as pricing strategy, 98
Spreader grafts, 933, 934f
Stackable therapies, 237, 238fi
Standard flash, 35
Standard views for regions of interest, 33–35,
34f, 35f, 36f
Sternal to nipple tissue-based planning for
breast implants, 1045, 1046f
Stitch canthopexy, 447–448, 448f
Straight hairline, 278
Strategic discounting, 96–97, 97b, 97t
reactionary discounting, 96
transactional buyers, 96–97, 97b
Stinging skin, 125–126, 125t, 126t
Studio effect photography, 37, 37f
Subcutaneous dissection, 541, 542f
Subfacial dissection, 541, 542f
Subperiosteal dissection, 542, 543f
Subplatysmal excision, 829
Superficial fascia, 522–523, 523f
Superficial fat, 521
Supraplatysmal fat liposuction, 828
Supratrochlear and supraorbital nerves, 300,
302f
Surface (texture) for breast implant choices,
1041–1042
Biocell, 1041, 1042f
implant-associated anaplastic large-cell
lymphoma, 1042
Sientra Texture, 1042, 1042f
Siltex, 1041, 1042f
texture shortcomings, 1042

Index
I-20
Surgeon contact, 5–7
Surgeon shopping, 9
Surgical site infection, 42–44, 43t
hematoma, 43
venous thromboembolism, 43–44, 44f, 445f,
46f
Suspension sutures, 543, 544f
T
Tangential excision or plication of anterior
bellies of digastric muscles, 829
Target-specific dosing of botulinum toxin
injection, 141–143
crow’s feet, 142–143
depressor anguli oris, 143
dimpled chin, 143
glabellar lines, 142
horizontal forehead lines, 143
lips, 143
lower eyelid, 142–143
platysmal bands, 143
upper eyelid, 143
Tarsal plate and upper eyelid blepharoplasty,
376–377, 377f
Tear trough deformity in lower eyelid blepharo-
plasty, 413, 413f, 419–420, 420f
Technical considerations in sedation and
anesthesia, 57
fluid management, 57
patient positioning, 57
thermoregulation, 57
Telangiectatic leg veins sclerotherapy and laser
vein treatment, 209–211, 210f, 211f,
211t
Telephone contact, 4–7
Temple anatomy, 344–345, 344f, 345f
Temple and brow anatomy, 343–346, 343f
Temple incisions, 535, 538f
Temporal alley defect, 275, 276f
Temporal approach for midface clinical decision
making, 474
Temporal brow lift, 291–297
indications and contraindications, 291
operative techniques, 291–296
anesthesia, 291–292
lateral temporal brow lift, 292, 293f, 294f
transpalpebral glabellar muscle modifica-
tion, 293–296, 294f, 295f, 296f
preoperative planning, 291
brow markings, 291, 292f
eyelid markings, 291, 293f
results, 296, 297f
Temporalis muscle and temporal crest, 300, 300f
Therapeutic failures of botulinum toxin
injection, 144–145
Therapeutic pexy, 447
ThermiTight application, 228f
Thermoregulation with sedation and anesthesia,
57
Thick-skinned patient and lower eyelid pinch
blepharoplasty, 455
Thighplasty, 1490–500
anatomy, 1490, 1491f, 1492f
ancillary procedures, 1495
indications and contraindications, 1490
operative technique, 1492–1495
classical thigh lift, 1493–1494, 1495f
patient positioning, 1492–1493, 1494f
vertical thigh lift, 1494–1495
postoperative care, 1495–1496
lymphocele/lymphedema, 1496
postoperative dissatisfaction, 1495
venous thromboembolism, 1496
wound dehiscence/delayed wound healing,
1495–1496
preoperative assessment, 1490–1491, 1493f
preoperative planning and markings,
1491–1492
classic medial thigh lift, 1491–1492
vertical medial thigh lift, 1492
results, 1496f, 1497f
Thighs and hips anatomy, 1306–1309
abductor group, 1308f, 1309
gluteus maximus, 1306–1307, 1306f, 1307f
gluteus medius, 1307
hamstrings, 1308–1309, 1308f, 1309f
iliopsoas, 1307
quadriceps, 1307–1308, 1308f, 1309f
sartorius, 1308f, 1309
Thin atrophic labia minor, 1512, 1513f, 1514f
Thread lifting, 232, 232f, 233f, 234f, 235f, 236f
Thromboprophylaxis for transfeminization,
1611
Thyroid cartilage augmentation, 1622
Tip contouring, Asian rhinoplasty, 974–975, 975f
Tip modification, 934–936, 935f, 936f
Tip projection, 957, 959, 959f, 960f
Tip refinement, 959–960, 962, 961f, 962f
Tip rotation, 959
Tissue-based planning for breast implants,
1045–1047
breast base width (BBW), 1045, 1046f
lower pole skin pinch thickness, 1046–1047,
1047f
nipple to inframammary fold, 1046, 1046f,
1047f
skin stretch, 1047, 1048f
sternal to nipple, 1045, 1046f
Topical and oral polyphenols for inflammation,
redness, and scar reduction, 116–117
Top surgery, female-to-male, 1623–, 1624t
breast/chest anatomy, 1624, 1627f
preoperative assessment, 1624, 1625t
preoperative preparation, 1626, 1629t,
1632–1635t
surgical procedure choices, 1626
Top surgery, male-to-female, 1629–1630
complications and revisionary procedures,
1631
examination of breast/chest anatomy, 1630
operative technique and postoperative care,
1631
outcomes, 1631
preoperative assessment, 1630
surgical procedure choices, 1630–1631, 1630f
Total breast reconstruction with fat grafting,
1070
Toxicity of botulinum toxin injection, 138
Tracheal shave, 1621, 1621f
Traditional vaginal posterior repair, 1565, 1565f
Tragal distortion, 832, 833f
Transactional buyers, 96–97, 97b
Transconjunctival approach, lower eyelid
rejuvenation, 366, 366t
Transconjunctival approach, upper eyelid
rejuvenation, 364, 364f
Transconjunctival blepharoplasty, 425–436
fat in eyelid management, 425–426
indications, 426, 426f
lower eyelids, 429–435
anatomy, 429
operative technique, 432–434
orbital fat pads, 429–430, 430f
postseptal approach, 431, 431f
preoperative planning, 431–432, 432–433,
432f, 433–434, 434f, 435f
preseptal approach, 431, 431f
results, 434–435, 435f, 436f
transconjunctival approaches, 430, 430b,
431f
preoperative assessment, 426
technique evolution, 425, 425t
upper eyelid, 426–429
operative technique, 428–429, 429f
pertinent anatomy, 426–427, 427f, 428f
preoperative planning, 428
results, 429, 429f
transconjunctival approaches, 427
Transconjunctival surgery, 447
Transcutaneous approach, lower eyelid rejuve-
nation, 366–367, 367f
Transmasculine bottom surgery, 1612
Transmasculine top surgery, 1612, 1612f
Transpalpebral approach for midface clinical
decision making, 474, 474f, 475f
Transpalpebral browpexy anatomy, 338–340,
340f
Transpalpebral browpexy for forehead rejuvena-
tion, 288, 288f
Transpalpebral excision of corrugator and
procerus muscles for forehead
rejuvenation, 288, 288f, 289f
Transpalperbral midface lift, 368
Transfeminine genital surgery, 1610, 1611f
ancillary procedures, 1611
bowel preparation protocol, 1611
depilatory procedures, 1611
dilation exercises, 1611
neovaginal depth and diameter, 1611
oncologic screening, 1611
thromboprophylaxis, 1611
vaginoplasty, 1610, 1611f
Traumatic hair loss, 279, 279f
Traumatic ptosis, 400–401, 401f
Triceps, 1304f, 1305, 1305f
Trichasis and entropion as functional problems,
eyelid surgery, 463
Trichloroacetic acid, 174
Trochlea and superior oblique muscle and upper
eyelid blepharoplasty, 378, 378f
Trunk muscles, 1298–1304, 1298–1299, 1299f,
1300f
erector spinae, 1303–1304, 1304f
external oblique, 1300f, 1301f, 1302
latissimus dorsi, 1303, 1304f
multifidus, 1304
pectoralis major, 1302–1303, 1303f
rectus abdominis, 1299, 1302, 1300f, 1301f
serratus anterior, 1300f, 1301f, 1302
Tuberous breast deformity, 1275–1276, 1276f
Tuberous breasts, 1069
Tumescence solutions, 55–56
Twitter, 81, 83
Two-day prime patient and lower eyelid pinch
blepharoplasty, 455
U
Ultrasound-assisted liposuction, 1329–1332,
1331f
Undercorrected ptosis, 408
Unilateral hypomastia with normal contralat-
eral breast, 1269
Unipolar RF devices, 203
Unique Service Proposition (USP), 95
Unwanted clitoral prominence, 1583
Upper back contouring, 1387–1395
anatomy, 1387, 1388f, 1389f
ancillary procedures, 1391, 1392f
indications and contraindications, 1387

Index
I-21
operative techniques, 1390–1391, 1390f, 1391f
outcomes, 1391–1393
postoperative care, 1391
preoperative assessment, 1387–1389, 1389t
preoperative planning and markings,
1389–1390, 1389f
results, 1393f, 1394f, 1395f
Upper blepharoplasty, 446–447
Upper blepharoplasty in the Asian patient,
389–396
anatomy, 389, 389f, 390f
complications, 394
physical examination, 390–391, 391f
preoperative evaluation, 389–390
surgical techniques, 391–394
continuous technique, 393, 393f
incisional techniques, 393–394, 393f, 394f,
395f
interrupted technique, 392, 392f
nonincisional techniques, 391–392
Upper extremity sclerotherapy and laser vein
treatment, 210–211, 212f
Upper eyelid anatomy, 348–350, 348f
Upper eyelid and botulinum toxin injection, 143
Upper eyelid blepharoplasty, 374–388
anatomy, 375–378
blood and lymphatic supply to upper eyelid,
378, 378f
conjunctiva, 378
lacrimal apparatus, 378
levator and Müller’s muscle, 377–378, 373f
orbicularis oculi muscle, 375–376, 376f
orbital septum and lacrimal gland, 377, 377f
skin and crease/fold complex, 375, 376f
tarsal plate, 376–377, 377f
trochlea and superior oblique muscle, 378,
378f
ancillary procedures, 384–386
lacrimal gland resuspension, 384–385, 385f,
386f
lateral brow proxy, 386, 387f
resection of brow fat, 385, 386f
indications and contraindications, 374–375
aesthetic upper eyelid blepharoplasty,
374–375
functional upper eyelid blepharoplasty,
374, 374f
general considerations, 375
operative technique, 382–384
crease fixation, 383–384, 383f, 384f
skin closure, 384
skin, orbicularis, and fat resection, 382,
382f, 383f
postoperative care, 386–387
preoperative assessment, 378–380
documentation of functional vs. cosmetic,
380, 380f
past medical and ophthalmic history,
378–379
physical examination, 379–380, 379f, 38f
preoperative planning, including markings,
381–382, 381f
results, 387, 387f, 388f
Upper eyelid rejuvenation, 362, 364, 363b, 364t,
373f, 484–487, 487f
skin excision, 364
skin-muscle excision, 364
transconjunctival approach, 364, 364f
Upper eyelid transconjunctival blepharoplasty,
426–429
operative technique, 428–429, 429f
pertinent anatomy, 426–427, 427f, 428f
preoperative planning, 428
results, 429, 429f
transconjunctival approaches, 427
Upper lid ptosis evaluation in aesthetic eyelid
surgery, 359
V
Vagina, 1505
Vaginal rejuvenation and perineoplasty,
1558–1571
anatomy, 1560–1561, 1561f, 1562t,
1563–1564t
ancillary surgical procedures, 1566–1567, 1567f
operative techniques, 1564–1566
perineoplasty and vaginal rejuvenation,
1566, 1566f
posterior vaginal wall rejuvenation,
1565–1566, 1565f, 1566f
traditional posterior repair, 1565, 1565f
outcomes/risks/complications, 1567
postoperative care, 1567
preoperative assessment, 1561–1562
preoperative planning, 1562, 1564
results: sexual function after vaginal rejuve-
nation, 1567–1568, 1569t
vaginal rejuvenation, 1558–1560, 1559f
indications and contraindications, 1560
sexual dysfunction and prolapse, 1560
Vaginal tightening, 1572–1578
anatomy, 1572
G-spot enhancers fillers: plasma, 1573
indications and contraindications, 1572
nonsurgical vaginal tightening options,
1573–1574
fat, 1573–1574
laser CO2–erbium, 1574
radiofrequency monopolar-multipolar, 1574
pretreatment assessment, 1572–1573
pretreatment planning, 1573
surgical approach, 1574–1577
anterior and posterior vaginoplasty,
1576–1577
perineoplasty, 1574–1575, 1575f
posterior vaginoplasty, 1575–1576, 1576f,
1577f
Vagina surgical rejuvenation, 1508
Vaginoplasty, 1610, 1611f, 1617–1618, 1639,
1641f, 1642, 1643f, 1645–1646, 1647,
1648t
Value proposition in pricing, 96
Vascular laser devices, 199–201
near-infrared devices, 200–201
potassium titanyl phosphate, 200, 200f
pulsed dye laser, 199–200
Vascular treatment selection, 229t
VASER technique for body sculpting, 1342–1345,
1343f, 1344f, 1345f, 1346f, 1347f
Venous thromboembolism, 43–44, 44f, 45f, 46f,
1496
Vermilion advancement, 867, 868f
Vertical abdominoplasty, 1404–1405, 1405f
Vertical medial thigh lift, 1492
Vertical thigh lift, 1494–1495
Vessel classification, sclerotherapy and laser
vein treatment, 211t
Vitamin C for photoprotection, 114
Vitamin E for photoprotection, 114
Volume loss and facial deflation, 621–623, 621f,
622f
Volume loss and skin, 68
Volume manipulation, 818
Volume reduction, 222–226
cryolipolysis, 224–226, 225f, 225t, 226f
deoxycholic acid, 223–224, 222f

Kybaella injections, 224f
V-wedge revision separation revision surgery,
1594–1595, 1594f, 1595f, 1595f, 1596f
V-wedge-type labiaplasty rules, 1582
W
Widening of donor scar site, 267
Wise vertical scar with long horizontal scar,
1245
Wound dehiscence/delayed wound healing,
1495–1496
Wound dehiscence management, 1582–1583
Wrinkles, crow’s feet, and laugh lines, 519–520,
520f
Y
Younger congenital scleral show patient and
lower eyelid pinch blepharoplasty,
454, 454f
Younger patient and lower eyelid pinch blepha-
roplasty, 453
YouTube, 80, 82–83
Z
Zinc for photoprotection, 114–115