Atlas Phẫu Thuật Thẩm Mỹ (Tập 2) – Atlas of Cosmetic Surgery

461
Leg vein management  •  Chapter 26
Class 0 stockings are indicated in mild functional venous
insufficiency that results in minimal varicose veins with as­
sociated mild edema or leg fatigue. Chronic venous insuffi­
ciency and more severely symptomatic varicose veins should
be ­treated with either class I or II stockings. Class I or II stock­
ings are also indicated in the outpatient management of DVT
as they relieve pain and edema and enhance thrombus adhe­
sion. Leg ulcer treatment requires class II or III stockings in
­addition to local skin treatment. Alternatively, ulcerations may
be ­amenable to other types of compression treatment such as
multilayer bandages or inelastic bandages.
There is no consensus on the duration or degree of compres­
sion needed after surgery. Although one study has shown equal
efficacy between high- and low-pressure compression stockings
in minimizing incidence of bruising and thrombophlebitis after
varicose vein surgery, high-compression stockings are clearly
necessary after sclerotherapy. However, there appears to be no
difference between class I and class II compression stockings in
controlling the objective and subjective parameters of venous
insufficiency. Weiss et al. studied the duration of compres­
sion after sclerotherapy and found that subjects with the most
improvement used 3 weeks of compression, followed by the
group with 1 week of compression, followed by the group who
only used compression for 3 days.8 All treatment groups had
significant improvement compared to the control group that
did not receive compression. The 1-week and 3-week groups
also experienced less ­sclerotherapy-associated hyperpigmenta­
tion than the 3-day group and the control group. Table 26-3
lists the manufacturers of compression stockings.
Treatment of small vessel disease
Only after the reticular, varicose, and deep incompetent veins
have been treated should attention turn to treating the super­
ficial telangiectases with sclerotherapy or with laser or light-
based devices. In patients with only isolated telangiectases
without pressure problems in larger vessels, sclerotherapy or
laser/light therapy may be used primarily.
A
B
C
Fig. 26-8  Proper application of compression bandage post-
­sclerotherapy. Compression bandage is applied in the promixal
­direction, leaving no gaps. Ideally, 20–30 mm Hg of pressure should
be applied evenly throughout.
Table 26-2  Classes of compression stockings
Compression
class
Pressure
(mmHg)
Common
indications
0
10–20
Mild functional venous
insufficiency
I
20–30
Chronic venous insufficiency,
symptomatic varicose veins,
DVT
II
30–40
Symptomatic varicose veins,
DVT, venous ulcers
III
40–50
Venous ulcers
Table 26-1  Manufacturers of compression bandages
Manufacturer
Type
Adherence/Name
Se Pro Healthcare
Montgomery, PA
High Stretch
Nonhesive/Tubigrip
Beiersdorf
Norwalk, CT
Low Stretch
Nonhesive/Comprilan
Cohesive/Comprihaft
Adhesive/Elastoplast
Beiersdorf
High Stretch
Nonhesive/Eloflex
Cohesive/Elohaft

462
Chapter 26 
Cosmetic surgery procedures and techniques
Sclerotherapy
The goal of sclerotherapy is the intravascular infusion of a
chemical irritant to cause irreversible endothelial cellular
destruction, which leads to vascular fibrosis and oblitera­
tion. Virtually any foreign substance can be utilized to induce
venous endothelial damage, and several sclerosing solutions
are commercially available for this purpose (Table 26-4). The
selection of solution type, concentration, and quantity is
­dictated by the type and site of the varicosity.
Lasers and light sources
Sclerotherapy remains the gold standard for treatment of leg
veins and telangiectases. Public interest in laser and light treat­
ment of leg veins is high, and under the right circumstances
they can produce excellent results. As with all the other treat­
ment techniques, reverse pressure from associated reticular
or varicose veins must be recognized or treatment will be
doomed to failure. In many patients, a combination of treat­
ments is necessary, as lasers and light sources do not effectively
treat associated reticular and varicose veins.
Lasers have been used to treat leg veins since 1970s, al­
though laser surgeons did not achieve acceptable results until
the advent of the pulsed dye laser in the 1980s. In the 1990s,
the development of lasers with longer wavelengths and longer
pulse duration led to improved safety and efficacy, thus creat­
ing a niche for lasers in the treatment of leg veins.
Theoretical considerations  Basic requirements for a laser
or light source to treat leg veins are (1) a wavelength that is
proportionately better absorbed by the target (hemoglobin)
than surrounding chromophores, (2) penetration to the full
depth of the target blood vessel, (3) sufficient energy to dam­
age the vessel without damaging the overlying skin, and (4) an
exposure duration long enough to slowly coagulate the vessel
and its lining without damaging the surrounding tissue.
Ideal parameters, therefore, depend on wavelength, pulse
duration, and beam diameter. In general, longer-wavelength
visible light penetrates deeper into skin and should be chosen
to target deeper vessels (Fig. 26-9). Large-diameter segments
require a longer pulse duration to allow sufficient time for dif­
fusion of heat evenly throughout the cylindrical vessel lumen
(Table 26-5). Larger spot sizes penetrate deeper into tissue and
optimize fluence delivery to the target (Fig. 26-10).
The relative importance of the hemoglobulin absorption
peaks in green (541 nm) and red to infrared (800–1000 nm)
shifts as the depth and size of blood vessel changes (Fig. 26-11).
Absorption by hemoglobin in the long-visible to near-
­infrared range appears to become more important for vessels
over 0.5 mm in diameter and at least 0.5 mm below the skin
surface.9
Various laser and light devices have been utilized in an
­effort to enhance clinical efficacy and minimize the adverse se­
quelae of telangiectasia treatment. Unfortunately, most have
also been associated with adverse responses in excess of and
response rate far lower than those associated with sclerothera­
py. This is related both to insufficient vessel destruction and to
competition from overlying melanin and the lack of treatment
of hydrostatic pressure from the ‘feeding’ venous system.
The role of cooling  The concept of cooling the skin in an
effort to protect the epidermis during laser treatment of der­
mal targets was first studied by Gilchrest et al.10 with the use
of ice prior to argon laser treatment of port-wine stains. There
has been a recent resurgence of interest in skin cooling ­during
Table 26-3  Manufacturers of compression stockings
Brand
Location
Jobst
Charlotte, NC 704-554-9933
Sigvaris
Branford, CT 800-322-7744
JuZo
Cuyahoga Falls, OH 800-222-4999
Medi
Arlington Heights, IL 800-633-6334
Venosan
Asheboro, NC 910-672-6062
Table 26-4  Common sclerosing agents
Solution
Category
Advantages
Disadvantages
Brands
Sodium
tetradecyl
sulfate
Detergent
Painful only with
extravasation; capable
of sclerosing larger veins;
FDA approved
Necrosis if extravasation
>0.25%; pigmentation, matting
Sotradecol (Bioniche Life
Sciences Inc, Ontario,
Canada) Fibrovein (STD
Pharmaceuticals, Ltd.,
Hereford, England)
Polidocanol
Detergent
Always painless; rare
necrosis
Urticaria at injection site, no
pain to warn of arteriorlar
injection, not FDA approved
Aethoxysklerol Kreussler
Pharma, Germany
Hypertonic
saline
Hyperosmolar
solution
Nonallergenic;
FDA: off-label; painful injections,
necrosis, pigmentation, matting
None
Glycerin
Toxin
Rare matting,
pigmentation, necrosis
Too weak for large veins; more
viscous; possible allergy; not
FDA approved
Scleremo, Lab. Therica,
France

463
Leg vein management  •  Chapter 26
skin laser therapy in an effort not only to cool and protect
the epidermis and to prevent other collateral dermal ­damage
but also to reduce the discomfort associated with treatment.
Because high fluences are required to adequately damage
leg veins, cooling appears to be especially important in their
treatment in an effort to limit unwanted collateral injury.
Several approaches have been taken, including water-cooled
chambers applied directly to the skin, through which the laser
beam is directed (e.g. Chess Chamber, VersaPulse chill tip,
Lumenis; Photoderm chiller, Lumenis), cooling coupling gels,
and refrigerated spray cooling devices (e.g. Dynamic cooling
device, Candela; cryogen spray, CoolTouch). Cooling helps to
spare epidermal damage, allowing use of higher fluences, thus
yielding more damage of the targeted vessels, with a greater
degree of clearing per treatment.11,12
Treatment of large non-truncal varicose
veins
All varicosities result from excessive hemodynamic pressure.
To correct the problem, sources of high pressure must be
eliminated. Even though more distal and smaller veins may
be more cosmetically bothersome for the patient, proximal
high reflux points must be treated first to prevent immediate
recanalization of the finer vessels.
Foam sclerotherapy
In 1993, Dr. Juan Cabrera began using a microfoam prepa­
ration of sodium tetradecyl sulfate and polidocanol for scle­
rotherapy. This represented a revolution in the treatment of
venous diseases. The history of foam sclerotherapy actually
dates back to Orbach who in 1944 first proposed the use of
foam produced by the simple process of shaking a sclerosant
solution in a syringe also containing air. This produced large
Table 26-5  Ideal laser/light parameters for treatment of vascular
lesions
Wave­
length
(nm)
Pulse
duration
(ms)
Beam
diameter
(mm)
Vessels diameter
100  μm
580
1
300  μm
590
10
600  μm to 1 mm
600
20–100
Vessel depth
Less than 1  mm
>500
Small
Greater than 1  mm
>600
Larger
KTP
532 nm
PDL
585 nm
Alex
755 nm
Diode
800 nm
Nd:YAG
1064 nm
Stratum
corneum
Epidermis
Dermal
vessels
Fig. 26-9  Longer wavelength allows for deeper penetration.
Larger spot size
Smaller spot size
Epidermis
A
B
Fig. 26-10  Larger spot size (A) improves penetrance over smaller spot size (B).

464
Chapter 26 
Cosmetic surgery procedures and techniques
bubbles with a high air to liquid ratio, which proved to be
effective for smaller veins but not larger veins. Interest faded
for several decades, until Cabrera pioneered his newer foam
technique. Most recently, Frullini and Tessari have described
other variations. The Tessari method, which entails filling one
syringe with sclerosant and the other with air, and then pass­
ing the material back and forth through a three-way stopcock,
is now one of the most widely used techniques due its simplic­
ity, low cost, and ability to produce high-quality foam.
Advantages of foam  Foam sclerotherapy has several advan­
tages over traditional liquid sclerotherapy. Once a liquid is
injected, it mixes with the blood in the vein, thereby diluting
the concentration of the sclerosant. Foam, on the other hand,
will displace blood, allowing direct contact of the sclerosant
with the endothelium. As the efficacy of a given concentra­
tion of sclerosant is effectively increased when used as foam
instead of liquid, a lower concentration of a given sclerosant
can be used. Further, as a fixed volume of liquid can produce
up to 4–5 times that volume in foam, a lower total quantity
of sclerosant is required when it is delivered as foam. Both
these factors, lower concentrations and decreased quantities
of sclerosant, improve the safety of sclerotherapy. Moreover,
extravasated foam is much better tolerated than extravasated
liquid. Many phlebologists consider yet another advantage of
foam to be that the air contained in the foam is echogenic
as this dramatically increases visibility and accuracy when
performing duplex-guided sclerotherapy.
A ten-year, prospective, controlled, randomized trial in­
volving over 800 ­patients conducted by vascular surgeons in
Europe compared six treatment options for varicose veins:
liquid sclerotherapy, high-dose liquid sclerotherapy, multiple
ligations, stab avulsion, foam sclerotherapy, and ligation fol­
lowed by sclerotherapy. The report concluded that foam scle­
rotherapy appears to be more effective than standard-dose
liquid sclerotherapy, and results can be comparable to sur­
gery.13 Interestingly, this study also looked at lung scintigra­
phy in selected patients who received foam. The investigators
found no perfusion defects even after injections of up to 10 cc
of foam. Although foam sclerotherapy is effective for veins
of all sizes, some have noted slightly a higher rate of minor
side effects, such as pigmentation, inflammation, and mini­
mal necrosis, when this method is used to treat small reticular
veins and telangiectases.
Safety concerns  Some uncertainties remain regarding the
safety of the foam preparations. The stress that foam places
on the human respiratory system is still unclear, although
complication rates are exceedingly low. Frullini and Cavezzi
proposed a limit of 3 cc of foam per session of sclerotherapy,
although no major complications such as pulmonary embo­
lism, deep vein thrombosis, ischemic lesions, or anaphylac­
tic reaction were recorded. Others suggest less than 10 cc,
while some routinely use up to 40 cc without observing seri­
ous sequelae. However, when higher doses are used, there are
incidents of dry cough, chest discomfort, transient ischemic
attacks, and visual scotomas.
Ultrasound-guided sclerotherapy  The simplest method
of sclerotherapy injection is one based on clinical visuali­
zation, without the assistance of localization aids. This is
adequate for injection of clearly visible telangiectasia and
most reticular veins. However, the injection of deeper vari­
cose veins requires exquisite accuracy, which has led to
the introduction of duplex ultrasonography to guide scle­
rotherapy. Color flow duplex ultrasound has already been
immensely helpful in the diagnosis of venous reflux disease
and in aiding endovenous radiofrequency and laser ablation
techniques. It now enables experienced clinicians to per­
form sclerotherapy of deeper incompetent vessel or truncal
varicosities safely.
Doppler-guided sclerotherapy  While duplex ultrasound-
guided sclerotherapy has established a new safety standard for
sclerotherapy of varicose veins, the cost and operation of a
duplex ultrasound device is beyond the capacity of many der­
matologists. The introduction of continuous-wave Doppler
sclerotherapy in 1992 has made available a more simple and
cost-effective variation of the procedure. Doppler confirma­
tion lowers the risk of extravascular and intra-arterial injec­
tions, both of which can lead to necrosis of the skin or even
musculature. The advantage over duplex ultrasound is two­
fold. First, a Doppler transducer is much simpler and faster to
10000
1000
100
10
1
0.1
Dermis absorption
Dermis scattering
Wavelength (nm)
Oxyhemoglobin
Deoxyhemoglobin
400
500
600
700
800
900
1000
Fig. 26-11  The relative importance of the hemoglobulin absorption
peaks in green (541  nm) and red to infrared (800–1000  nm) shifts
as the depth and size of blood vessel change. (Courtesy Lumenis,
Santa Clara, CA.)

465
Leg vein management  •  Chapter 26
operate, and allows the physician to maintain visual contact
with the site of injection. Second, the Doppler is much less
costly to purchase.
Phlebectomy
History  Ambulatory phlebectomy is a surgical procedure
attributed to Swiss dermatologist Robert Muller.14,15 He first
performed the technique in an office setting in ­Neuchâtel,
Switzerland, in the late 1950s as an alternative to hospital-
based surgery and sclerotherapy. Acceptance of this tech­
nique was very slow. It became popular in the 1990s when
reduced time to resolution and longer-­lasting resolution
was realized. Importantly, new instruments became more
widely available.16
Phlebectomy is a safe and effective method for removing
nearly any incompetent vein below the saphenofemoral and
saphenopopliteal junction. The target veins can range from
the large truncal veins to their tributaries, perforators, and re­
ticular veins. In experienced hands, a vein can be removed
with minimal scarring through an incision as small as 1  mm.
Phlebectomy may be employed by itself, or in combination
with stripping and ligation, endovenous ablation, or sclero­
therapy. The veins most commonly treated by phlebectomy
are the accessory saphenous veins of the thigh, pudendal
veins, reticular varices in the popliteal folds, reticular veins on
the lateral thighs, veins in the ankles, and the dorsal venous
networks on the foot.
Indications  In younger patients with varicose veins, the walls
may be thicker, more muscular, and thus less susceptible to
penetration and injury by sclerosing solutions. These thicker
veins, particularly in athletic individuals, diminish the likeli­
hood that sclerotherapy will be effective. Other situations
more amenable to ambulatory phlebectomy include areas of
high flow such as large truncal or branch veins of the great­
er and lesser saphenous system. Phlebectomy leads to good
results except when significant reflux at the saphenofemoral
and saphenopopliteal junctions is present. In the case where
reflux at these junctions is present, the author recommends
ligation and short stripping or endovenous ablation techniques
using radiofrequency or lasers.
The decision to treat by ambulatory phlebectomy versus
sclerotherapy usually is determined by anatomic location, pa­
tient preference, and estimated thickness of vein wall. When a
‘blue’ vein is observed, this indicates a wall so thin that blood
may easily be visualized within it. Full-thickness damage by
sclerosing solutions is more likely, and these blue veins easily
shred when trying to hook them by ambulatory phlebectomy.
Therefore, flesh-colored veins are better treated by ambula­
tory phlebectomy.
Although usually more time-consuming than sclerotherapy,
ambulatory phlebectomy has several advantages, including
the avoidance of potential intra-arterial injection, extrava­
sation necrosis, and hyperpigmentation. Finally, unlike with
sclerotherapy, only one treatment is needed. Compared to
traditional surgery such as ligation, there is little or no scar.
The recurrence rate of large varicose veins is also reduced,
but only when the major source of reflux (if present) at the
saphenofemoral or saphenopopliteal junctions is eliminated
as well.
Treatment of perforating veins
Perforating veins (PV) join the superficial and deep veins and
channel blood flow from the superficial system to the deep
venous system (Fig. 26-12). There are numerous PVs in each
leg. Clinically and hemodynamically important perforating
veins are located at 4 sites – the thigh, the upper medal low­
er leg, the lower medial lower leg, and the knee (Fig. 26-13).
Although no strict criteria exist for the diagnosis of incompe­
tent PVs, most authors consider reflux of more than 0.5 s and
relative diameter of the vein as evidence of incompetence.
When the PV is primarily insufficient, likely the result of
an inherited weakness in the vein wall, direct treatment of the
PV can lead to clinical improvement. Likewise, when the in­
competent PV is associated with isolated deep venous reflux,
direct treatment may reduce symptoms. When a PV becomes
incompetent as a result of a proximal superficial venous insuf­
ficiency that places hemodynamic pressure on the distal veins,
treatment of this proximal superficial reflux should be the first
priority. This is the most common cause of incompetent PV.
Treatment of the PV when it is acts as a collateral pathway for
a deep venous obstruction is contraindicated.
The value of treating a PV alone is difficult to assess. It is
difficult to isolate the significance of an incompetent PV in
the context of coexisting venous insufficiency. In most cases,
an incompetent PV and superficial venous reflux are treat­
ed simultaneously to achieve clinical improvement. In fact,
whether PVs should be treated at all remains controversial,
but once a decision to eliminate incompetent PVs has been
made, several techniques are possible.
Subfascial endoscopic perforating surgery
Linton’s procedure, described in the 1930s, involves a long
skin incision to perform open ligation of the PVs. This pro­
cedure has now been largely abandoned due to unacceptable
level of morbidity. Instead, subfascial endoscopic perforating
surgery (SEPS) is now a widely accepted minimally invasive
surgical technique to eliminate incompetent PVs. In SEPS,
through a small incision in the upper calf, an endoscope is
introduced between the fascia and the underlying muscle.
With endoscopic visualization, an instrument is advanced
to intercept and eliminate all visible PVs. SEPS is associated
with much lower morbidity than the classic Linton procedure,
with the former method having wound complication rates
ranging from 4% to 6%.17 Usually performed in combina­
tion with ablation of the superficial venous reflux, SEPS in
both short-term and mid-term clinical series has been associ­
ated with high rates of healing of venous ulcerations and low
recurrence rates compared to compression bandaging alone.
However, the very long-term benefits and effects of SEPS are

466
Chapter 26 
Cosmetic surgery procedures and techniques
not yet known. Due to the advanced nature of the procedure,
the techniques will not be discussed in this chapter.
Sclerotherapy
The role of sclerotherapy in the treatment of incompetent PVs
has yet to be defined. Only a few studies have attempted to
characterize the efficacy of sclerotherapy, and using various
techniques and sclerosants, rates of successful occlusion ranging
from 20% to 90% have been reported.18 Sclerotherapy of per­
forating veins carries higher risk than sclerotherapy of smaller
telangiectasia since perforating arteries often accompany perfo­
rating veins. Inadvertent injection into arteries can lead to sig­
nificant tissue necrosis, with the further possibility of the sclero­
sant flowing into the deep venous system, causing deep venous
thrombosis. Other complications of sclerotherapy of incompe­
tent PVs, including hyperpigmentation, matting, and phlebitis,
are similar to those of sclerotherapy elsewhere. To minimize
arterial cannulation and subsequent ulceration during sclero­
therapy of PVs, ultrasound guidance may be enlisted.
Treatment of truncal incompetence
Sclerotherapy
Sclerotherapy of truncal veins (greater saphenous vein or lesser
saphenous vein) or their tributaries may be attempted with
concentrated sclerosant or foam sclerosant. To ensure maximal
contact of the sclerosant and the endothelium, and to reduce
the dilutional effect that occurs when sclerosant mixes with
blood, the physician may reduce the volume of the blood in the
veins to be injected by placing the patient in a supine or Tren­
delenburg position, or by elevating the leg. Examination of the
treated veins can be performed 2 weeks following the injection.
If closure has not been achieved, treatment can be repeated.
Stripping and ligation
Although recent advancements have allowed for minimally
invasive techniques, such as endovenous ablation techniques
or ultrasound-guided sclerotherapy, for eliminating truncal
reflux conventional surgical techniques are still useful in many
instances. The modern perforate-invaginate (PIN) technique
starts with ligation of the saphenofemoral junction and its
tributaries through a 2–3  cm incision in the groin. The greater
saphenous vein is then removed through this incision with the
help of a stripping tool that consists of a modified wire, which
is threaded through the GSV to the level of the upper calf,
where it is externalized. At this point, an acorn-shaped head
is attached to the proximal end of the stripper wire. As the
wire is pulled out in the distal direction, the vein invaginates
into itself, as it is pulled the entire length. The lesser saphen­
ous vein may be treated by the same method, but this carries
a high risk of nerve injury.
High ligation of the saphenofemoral junction without
concurrent saphenoectomy is associated with a high rate of
Superficial spider
veins (telangiectasias)
Reticular vein
Deep perforator
Deep venous
system
Dermis
Epidermis
Great saphenous vein
Superficial fascia
Varicose vein
Protuberant
varicosity
Indirect perforating vein
Deep fascia
Fig. 26-12  Cross-sectional view of the venous system of the lower extremity.

467
Leg vein management  •  Chapter 26
­recurrence. Accessory veins, collateral veins, and tributaries
can dilate rapidly and reestablish the pattern of reflux. Liga­
tion of distal varicosities alone, as taught in vascular surgery
­programs in the 1970 and 1980s, is also inadequate because
the origin of reflux in the saphenous trunk remains unad­
dressed, and the point of high hemodynamic pressure persists.
Unsatisfied patients tend to return with recurrent varicosities.
The invasive nature of vein surgery still carries risk for ­various
complications (Table 26-6). The most serious of the complica­
tions is deep vein thrombosis leading to ­pulmonary embolism. To
avoid this potentially fatal outcome, ­postoperative compression
and ambulation are mandatory. Other undesired effects are
hematoma and wound infection, the incidence of which can
be minimized by good surgical technique. Inadvertent injury
to the sural and saphenous nerve can occur, and tends to be
very disconcerting to patients. Although annoying, telangiec­
tatic matting and hyperpigmentation are usually temporary
and amenable to treatment. Due to the advanced nature of the
procedure, the techniques will not be discussed in this chapter.
Endovenous ablation
Successful long-term treatment of truncal varicose veins
requires the elimination of both the highest point of reflux
and of the incompetent venous segment. Until recent years,
the standard for treatment of saphenous vein reflux has been
ligation with or without stripping, despite little evidence of
long-term success with ligation alone. Recurrences occur due
to re-anastamoses of previously ligated tributaries or failure
to ligate a functional tributary, which subsequently becomes
varicose. Furthermore, the traditional method of stripping
involves significant scars and a long, painful recovery period.
Sclerotherapy of truncal varicosities under ultrasound guid­
ance is an alternative, but an imperfect one, with a 10–42%
risk of recanalization in 1 year.19 With foam sclerotherapy, the
long-term success rate may increase, but the safety of the
­procedure is a consideration, as the sclerosant may flow
into the deep venous system.
A relatively recent technological innovation involves endo­
venous occlusion with radiofrequency (RF) energy. Under du­
plex ultrasound guidance, an RF catheter is inserted into the
greater saphenous vein and positioned at the base of the ter­
minal valve. The RF energy is then delivered while the cath­
eter is slowly withdrawn. This process enables shrinkage of
the vein wall without electrocoagulation of blood. At the con­
clusion of the procedure, there is no flow through the greater
saphenous vein. Over time, patient symptoms improve and
distal varicosities shrink (Fig. 26-14). Short-term advantages
of the RF procedure over traditional stripping and ligation
have been documented in prospective multicenter randomized
comparisons.20 In general, advantages of endovascular oblit­
eration of the GSV over conventional vein stripping include
a diminution of pain and shorter recovery time. Long-term
persistence of results has been quite favorable as well, with
2-year follow-up confirming elimination of GSV reflux in
more than 90% of treated limbs, with symptomatic improve­
ment in 95% of limbs.20
Alternatively, endovenous ablation can employ laser ­sources,
with the naked laser fiber inserted into the greater saphenous
Saphenofemoral junction
Hunterian perforator(s)
Dodd perforator(s)
Boyd’s perforator(s)
Cockett’s perforators
Fig. 26-13  Common location for perforating veins.
Table 26-6  Potential complications from vein surgery
Common
complications
Rare and/or serious
complications
Scarring
Deep vein thrombosis
Thrombophlebitis
Pulmonary embolism
Hyperpigmentation
Nerve injury
Telangiectatic matting
Postoperative wound infection

468
Chapter 26 
Cosmetic surgery procedures and techniques
vein and extracted during the laser-on period in the same man­
ner as with RF. Unlike RF ablation, laser ablation uses optically
generated thermal energy rather than radiofrequency-derived
thermal energy to damage the vein wall. In one study by Min
et al., over 400 varicose veins were successfully treated over a
3-year period with 810  nm diode laser energy delivered direct­
ly into the GSV.21 Long-term results in patients treated with
endovenous laser demonstrate a recurrence rate of less than
7% at 2-year follow-up. A single early study using the animal
model suggests that the 810  nm endovenous laser technique
may be at a higher risk compared to the RF technique for vein
perforations and may occasionally fail to cause significant col­
lagen shrinkage, which in theory may lead to early recanaliza­
tion and risk of recurrence; however, more recent human data
have not revealed such a risk of recurrence. Physician expe­
rience with endovenous laser ablation continues to increase,
and the available evidence indicates that the procedure is a safe
and effective technique, in the same general category as RF
ablation. The increased use of the 1320  nm Nd: YAG for laser
ablation promises to make this procedure even more well toler­
ated and effective. Due to the advanced nature of the proce­
dure, the techniques will not be discussed in this chapter.
PROCEDURES AND TECHNIQUES
Sclerothrapy
Preoperative clinical considerations
Patient selection
Before embarking on sclerotherapy, a pertinent medical his­
tory should be obtained. Specifically, history of lower extrem­
ity infections, diabetes, anaphylaxis, and severe asthma should
be elicited. Coagulopathies, pregnancy, history of recurrent
DVT, and inability to ambulate are contraindications for scle­
rotherapy. Laboratory tests are usually not necessary except
when hypercoagulable states are suspected. Diagnostic studies
such as duplex scanning should be reserved for patients with
symptomatic varicosities, varicose veins larger than 4  mm, or
large numbers of spider telangiectasia that are collectively
indicative of venous hypertension.
Prior to treatment, patients must understand the procedure
and its limitations (Boxes 26-2, 26-3). The patient must be told
that ‘perfect legs’ are not possible, although significant cos­
metic improvement is likely. The physician must never prom­
ise complete clearance of all the telangiectasia, and clarify
that in the best case, 3–6 treatments may provide about 80%
improvement. Treated veins may recur, and new telangiecta­
sia may appear in the future as well. Photographs are use­
ful for both the physician and the patient to document the
progress of the treatment. Photographs not only define the
pretreatment extent and the locations of varicose, reticular,
and telangiectatic veins, but they also document pre-existing
scarring or pigmentation.
The first treatment session is usually limited to a small
number of sites in order to observe the patient for any allergic
Box 26-2  Expected and minor sequelae of sclerotherapy
Hyperpigmentation
Edema
Matting
Pain with injection
Localized urticaria
Vasovagal reaction
Thrombophlebitis
Recurrence of treated vessels
Box 26-3  Rare and serious complications
from sclerotherapy
Deep vein thrombosis
Cutaneous necrosis
Anaphylaxis
Pulmonary emboli
Nerve damage
Fig. 26-14  (A) Before and (B) after ­
endovascular ­radiofrequency of GSV.
A
B

469
Leg vein management  •  Chapter 26
reactions and ability to tolerate the discomfort, and judge the
effectiveness of a particular concentration and class of scleros­
ing agent. It also serves to familiarize the patient with the treat­
ment, treating physician, clinic surroundings, and the sensation
of the fine needle. This allows more extensive treatment on the
second visit, as the patient is typically more relaxed. The test
site also complies with the suggestion in the package insert of
sodium tetradecyl sulfate, which states that a small area should
be treated initially to observe any signs of allergic reaction.
The patient returns in 4–6 weeks to evaluate the test site.
The patient is now familiar with the procedure, a response
to sclerosing solutions can be predicted, and more areas can
be treated with the patient less fearful and muscles relaxed.
The order of treatment is varicose veins, reticular veins, pur­
ple venulectases, telangiectatic webs or networks, and finally
treatment of the smallest and most isolated telangiectases.
Injection of telangiectases should not be undertaken until
larger-diameter reflux sources flowing back into the telangiec­
tatic area are eliminated. Reflux from larger vessels typically
originates proximally but rarely may originate distally.
Transillumination may help identify the sources of reticular
veins connected to telangiectatic webs (Fig. 26-15). When no
clear feeder vessel is identified by Doppler or transillumination,
then the point at which the telangiectases begin to branch out is
the site at which to begin injection. Whenever possible, it is best
to inject telangiectases during the visit when the reticular veins
are injected. Once sclerotherapy treatment sessions are com­
plete, the remaining vessels that are too small to cannulate with
a 30-gauge needle can be treated with laser or light sources.
Techniques
Injection of telangiectases  The typical sclerotherapy
tray setup includes: (1) 70% isopropyl alcohol for skin prep,
(2) 3  cc disposable syringes, (3) 30-gauge disposable ­transparent
hub needles, (4) sclerosants of various concentrations,
(5) ­cotton balls for compression, (6) Transpore or paper tape,
(7) ­three-way stopcock for foaming sclerosants, and (8) com­
pression bandages (Fig. 26-16). The following sclerosing
­solutions are used by the author:

1. Sodium tetradecyl sulfate (STS) (concentrations 0.1% to 0.5%)

2. Hypertonic saline (11.7% to 23.4%)

3. Glycerin, 72%
The patient is placed in either the prone or supine posi­
tion. Treatment sites may be wiped with gauze or cotton balls
saturated with 70% isopropyl alcohol, although cooling of the
skin may cause contraction of the reticular veins. It is sup­
posed that alcohol application reduces infection risk, but it
certainly helps to visualize vessels by increasing light transmis­
sion through otherwise reflective white scale on the epidermal
surface. Following complete evaporation of the alcohol, a 30-
gauge needle, bent to an angle of 10–30 degrees with the bevel
up, is placed on the skin so that the needle is parallel to the skin
surface. A 3  cc syringe filled with 1.5–2  mL of solution is held
between the index and middle fingers while the fourth and
fifth fingers support the syringe against the skin in a fixed posi­
tion facilitating accurate penetration of the vessel (Fig. 26-17).
Fig. 26-15  Transillumination of a reticular vein leading to a group
of telangiectases.
Fig. 26-16  Typical sclerotherapy tray setup.
Fig. 26-17  Correct hand position to facilitate injection.

470
Chapter 26 
Cosmetic surgery procedures and techniques
The nondominant hand is used to stretch the skin around the
needle and may offer additional support for the syringe.
Fastidious technique is crucial (Fig. 26-18). After visualiz­
ing the target vein, the firmly supported needle is then moved
slowly 1–2  mm forward, piercing the vein just sufficiently to
allow infusion of solution with the most minimal pressure on
the plunger to avoid extravasation. Magnifying lenses on the
order of 1.5× to 3× are often helpful to visualize cannulation
of the smallest telangiectases.
A very sharp needle is critical to cannulate small tel­
angiectases. The 30-gauge needle is changed often. Use of
32–33-gauge needles is not advised, as they veer off course
A
C
E
B
D
Fig. 26-18  (A) Visualization of the leg vein. (B) Two-point counterpressure applied to the injection site. (C) Placement of the needle into the
vein at 30 degrees. (D) Steady injection producing immediate blanching of vessel. (E) Immediate application of cotton ball and tape.

471
Leg vein management  •  Chapter 26
easily. Injection of a tiny bolus of air (0.05  mL) may be helpful
to establish that the needle is within the vein, as slight clear­
ing 1–3  mm ahead of the bevel can be seen. For small vessels,
0.5  cc of sclerosant per injection site is more than adequate to
sclerose the entire length of the vein without ‘blowing’ the ves­
sel, although larger vessels may require more volume. Imme­
diately after injection, cotton balls are applied over the length
of the vein with tape for compression. After all the target
­vessels are injected, compression bandages are applied.
Concentrations of sclerosants used for telangiectases are
less than those needed for reticular veins. The author rec­
ommends 0.1–0.2% STS, 11.7–23.4% hypertonic saline,
or 72% glycerin. Foam sclerotherapy is rarely necessary for
isolated small telangiectasia. The initial concentration is
typically the lowest concentration listed above. Unnecessary
high concentrations only increase the risks for matting and
pigmentation. The concentration may always be increased
at subsequent treatments if ineffective sclerosis occurs. In­
crease of sclerosant concentration is more effective than an
increased volume per injection. STS dissolves some of the
rubber of the syringe plunger, making it difficult to move
the plunger and contaminating the sclerosing solution with
­rubber breakdown products. For this reason, the author
strongly recommends the use of latex-free syringes (Terumo
Medical Corp., Somerset, NJ) to avoid allergic reactions due
to latex contamination of the sclerosant.
Sclerotherapy of reticular and varicose veins
The clinician should adhere to several principles in the sclero­
therapy of large varicose veins (Box 26-4). Sclerotherapy can
be effective for veins of any size, but the larger the vein, and
the higher the pressure at the point of injection, the more
the treatments and the higher the concentrations that will be
necessary, and the greater the likelihood of recurrence. Even
sclerotherapy of saphenofemoral junctions reflux is possible,
although the high concentration of sclerosant required and
the need for intraoperative ultrasound guidance may pre­
clude treatment by the novice clinician. For the ­inexperienced
practitioner, beginning with reticular veins and associated
telangiectases should be understood and practiced first before
embarking on the treatment of larger varicosities of the saphe­
nous system. Skills for larger veins are best learned at intensive
hands-on workshops.
Reticular veins  This procedure is similar to the injection
of telangiectases except that a much greater volume of solu­
tion is injected. A 3  cc syringe with a 30-gauge needle bent to
an angle of 10–30 degrees is inserted into the reticular vein,
which is usually superficial and visibly blue. When the sensa­
tion of piercing the vein is felt, the plunger is gently pulled
back with the thumb of the dominant hand until blood is seen
beginning to back up into the transparent plastic hub. If the
wall of the reticular vein is thin, the suction created by pull­
ing back on the syringe may cause the wall to adhere to the
needle bevel and prevent aspiration of blood. In this case one
can move the needle gently forward and backward, and if no
resistance is felt, the vein has probably been cannulated and
the injection may proceed cautiously.
Reticular veins undergo contraction following a cannula­
tion attempt or when the skin temperature is cool. If this
­occurs, another injection site along the reticular vein must be
sought. The cannulation of a reticular vein can be more dif­
ficult than protuberant venulectases or telangiectases. Usually,
the volume per injection site is no more than 0.5  mL, but the
capacity of long reticular veins may easily exceed 1  mL. The
progress of solution may be followed visually and the injection
stopped when the entire reticular vein has cleared of blood.
Until experience is gained in cannulating reticular veins, cau­
tious injection is the rule. Resistance to injection will be felt when
the reticular vein has not been properly cannulated and then will
be followed by a small hematoma. Necrosis is rare with extravas­
cular injection at this depth. After injection, all sites treated are
noted in anatomic diagrams in the patient’s record. Concentra­
tion and volumes of all sclerosing solutions are recorded.
The strength of sclerosants for treatment of reticular veins
are 0.2–0.5% sodium tetradecyl sulfate, (STS, Sotradecol) or
23.4% hypertonic saline. See Table 26-4 for a summary of
sclerosing solutions. When using foamed STS, the concen­
tration can be reduced by approximately half due to the in­
creased effectiveness. See Figure 26-19 for foam preparation.
Over time, the foam mixture tends to separate into its air
and liquid components. The stability of the foam is depend­
ent on the type of sclerosant, the concentration of sclerosant,
the air-to-sclerosant ratio, and the duration of mixing. The
type of stopcock connector, whether stainless steel, plastic,
• Wet surface with alcohol to increase light
transmission through skin.
• Bend needle to enter almost parallel to skin.
• Use minimal pressure on plunger.
• Proceed from largest to smallest veins.
• Consider foam sclerotherapy when appropriate.
Pearls
Box 26-4  Sclerotherapy of large veins
Identify and treat reflux points
Treat larger veins before smaller veins
Treat proximal before distal veins
Use maneuvers to empty veins of blood whenever possible
Compress immediately
• Patients must understand that multiple treat­
ments are needed, and that ‘perfect legs’ are not
possible.
• Use the lowest effective concentration possible
to avoid excessive tissue damage.
Pitfalls

472
Chapter 26 
Cosmetic surgery procedures and techniques
two-way, or three-way, appears not to be a significant factor in
the quality of the final ­product.
Varicose veins  Treatment of varicose veins is performed
on a recumbent patient. The patient’s veins are typically
marked with the patient standing prior to beginning treat­
ment, since the veins often collapse and become less visible
once the patient’s legs are elevated. One must be absolutely
positive of the intravascular positioning of the needle, since
higher volumes of higher-concentration sclerosants are used.
The needle is advanced while aspirating the syringe until dark
venous blood indicates penetration of the lumen. At this point
0.5–1.5  mL of concentrated sclerosant is injected at the site.
The needle is withdrawn and redirected to the next site. At
the conclusion of treatment the vein should visually appear
contracted. This is a rapid and efficacious technique that is
used by the majority of phlebologists treating large veins in
the United States today.
When this technique is used, it must be recognized that the
vessels being injected are not fully empty of blood; thus, the
sclerosant being injected must be more concentrated to allow
for dilution by the blood remaining in the vessel. The larg­
est vessels contain more blood and therefore require higher
concentrations of sclerosant and possibly higher volumes to
produce effective sclerosis after dilution. For this reason, we
recommend foam sclerotherapy for varicose veins. Sclerosing
solutions used are usually foamed 0.5% STS. Volumes per in­
jection site should not exceed 1mL. The clinician must remain
mindful of the maximum dosage of sclerosant when injecting
large veins (Table 26-7).
Postoperative clinical considerations
Compression
To decrease the incidence of thrombus formation, which may
lead to subsequent recanalization and post-sclerosis pigmenta­
tion, compression is also an essential adjunct to sclerotherapy
C
A
B
Fig. 26-19  (A) Tessari foam technique. Two syringes and a three-way stopcock are needed. One syringe is filled with a detergent sclerosant
and the other with air. The two syringes are connected using the stopcock. (B) By passing the material quickly back and forth through the stock
about 20 times, a foam is produced. (C) The foam must be quickly injected before it separates into its air and liquid components.

473
Leg vein management  •  Chapter 26
of large varicose veins. Direct apposition of vein walls due
to external compression increases the duration of sclerosant
contact with the endothelium, thus making the procedure
more effective. Lastly, the reduced thrombotic and subsequent
inflammatory phlebitic events may also minimize telangiec­
tatic matting. Some authors argue that telangiectasia less than
1  mm require no compression after injection, but there is
general agreement that sclerotherapy of larger telangiectasia,
venulectasia, reticular veins, and varicose veins must be
­followed by several days of compression therapy.
After massaging the injection site to distribute the sclerosant
more evenly, cotton balls are secured over the injection sites
by paper tape or Transpore tape. Graduated 20–30  mmHg
support hose are then applied, particularly in patients with
protuberant telangiectases or telangiectases in association
with reticular veins. Some physicians prefer to skip the cotton
balls and have the patients wear compression stockings. These
are best applied while the patient is still supine immediately
after the procedure has been completed. Having the patient
stand before putting on the stockings increases blood flow in
the sclerosed vessels and may decrease the effectiveness of the
treatment session.
The duration of compression needed after sclerotherapy
is still a matter of debate, although most recommend up to
2 weeks. The classic descriptions of sclerosis of varicose veins
described by Fegan, Hobbs, and Doran recommend compres­
sion for 6 weeks. A recent well-controlled study concluded that
3 weeks of compression may be ideal, but 1 week or 3 days
of compression is sufficient to improve results.22 In the United
States, few patients can tolerate 6 weeks of uninterrupted com­
pression, but most are able to comply with 2 weeks of compres­
sion stockings, and nearly all can tolerate a protocol that uses
relatively uninterrupted compression for the first 3 days.
Patients are encouraged to walk, and not restrict their ac­
tivities, with the exception of any exercise such as weightlifting
with sustained muscle contraction that results in a sharp rise
in venous pressure. Treatment intervals vary, but allowing 4–8
weeks between treatments helps to minimize the number of
necessary sessions. In the case of laser and pulsed light treat­
ment, waiting 8–12 weeks between treatments yields optimal
results. Often telangiectases will ultimately improve with at
least partial clearing after exhibiting no initial response with­
in the first 2 weeks. A typical patient undergoes three to five
treatments spaced 4–8 weeks apart. After the initial series of
treatments, a ‘rest’ period of 4–6 months allows pigmenta­
tion and matting to clear and allows remaining reticular veins
to ­establish ‘new’ routes of drainage. Approximately 80% of
vessels treated clear satisfactorily during the first course of
­treatment. The physician may then judge and re-evaluate any
remaining telangiectatic webs or new telangiectases for the
best approach for another round of sclerotherapy.
Hyperpigmentation
The incidence of hyperpigmentation depends on the scle­
rosing agent, the concentration, and the technique used. In
general, the incidence of hyperpigmentation is higher when a
stronger agent is used and when stronger concentrations of an
agent are used. Larger veins also have a higher incidence of
pigmentation, since more trapping of red blood cells occurs.
The cause of pigmentation is most likely a combination of
postinflammatory hyperpigmentation and direct ­hemosiderin
deposition. Hyperpigmentation is rare in vessels less than
1 mm in diameter.23
The rate of hyperpigmentation after sclerotherapy varies
from 10% to 80%. An incidence of 10–30% has been re­
ported for hypertonic saline and polidocanol24 but up to 80%
with 0.5% STS.25 The occurrence of pigmentation can be
reduced by using minimal concentrations of sclerosing solu­
tions, applying compression, and avoiding injection into sites
receiving reflux from larger associated varicosities. There is
no highly effective method for treating hemosiderin hyper­
pigmentation. Treatments that may have some value include
exfoliation, chelation, and short-pulsed pigment-specific laser
therapy, such as alexandrite or Nd:YAG laser. Most patients
will have spontaneous resolution of hyperpigmentation within
1 year, and watchful waiting with periodic photographic docu­
mentation of the pigmentation is satisfactory in most cases.
It is important to remind patients to return for drainage if
they notice any hyperpigmented firm or nodular areas after
treatment, as the duration of hyperpigmentation is lessened
by prompt drainage of coagula (preferably within 6 weeks).
Drainage of the coagula can be achieved with puncture of the
site using 18  g needle.
Matting
Telangiectatic matting refers to appearance of new red (occa­
sionally violaceous) ‘blush type’ regions containing large num­
bers of ‘new’ blood vessels less than 0.2  mm in diameter that
appear in patients after sclerotherapy or surgical removal of
varicose veins or venulectasia. The incidence of telangiectatic
matting is between 15% and 24%.26,27 Telangiectatic matting
may occasionally be associated with intolerable burning pain
and with leg edema; it usually resolves spontaneously in 3–12
months. Occasionally, telangiectatic matting can be perma­
nent, and patients should be informed prior to treatment.
It is widely believed, though unproven, that telangiectatic
matting is more common when higher infusion pressures,
larger volumes, and higher concentrations of sclerosant are
used. The author has observed that when infusion pressure is
increased, resulting in blanching of the entire capillary net­
work of the skin, telangiectatic matting is more likely to occur.
Table 26-7  Maximum dosage of sclerosants
Sclerosant
Maximum dosage
Sodium tetradecyl sulfate
10  cc of 3%
Polidocanol
20  cc of 3%
Sclerodex
20  cc per session
Hypertonic 23.4% saline
20  cc per session

474
Chapter 26 
Cosmetic surgery procedures and techniques
­Patient factors associated with an increased risk of ­telangiectatic
matting include excessive body weight, a family history of tel­
angiectases, and longer duration of spider veins.26
The most important first step in treating this complication
is to repeat the clinical evaluation of the patient, looking for
any previously unrecognized sources of hydrostatic pressure.
Transillumination may help locate a previously unseen re­
ticular vein. Much more information can be gained from a
duplex ultrasound examination. The duplex study should be
performed with the patient in the standing position, because
previously unrecognized high-pressure reflux from an inter­
mittently incompetent (clinically inapparent) saphenous vein
may be the culprit.
The patient is given a mild antiinflammatory cream to ap­
ply to the area, and photographs of the area are taken at 6–8-
week intervals until resolution occurs. Patients can be reas­
sured that even the worst matting can resolve completely over
time and are much more tolerant of this waiting period when
they have been suitably informed before start of treatment
that telangiectatic matting may occur.
Necrosis
To minimize skin necrosis, extravasation must be avoided. If
resistance to the easy injection of sclerosant or the beginning
of any ‘bleb’ at the injection site is noted, stop injecting imme­
diately. The physician needs to keep an eye on the injection
site at all times in order to notice the ‘bleb’ at the moment
of its occurrence. Some physicians keep a syringe containing
5–10  mL of normal saline nearby to flush and dilute any areas
of extravasation that may develop. If sclerosant extravasates,
it may also be diluted with 0.5–1% lidocaine without epine­
phrine. The benefit of dilution has not been proven but is
based on the theory that further dilution of a sclerosing solu­
tion will minimize the capacity for further tissue destruction.
A prolonged period of blanching following injection indicates
possible arteriolar compromise, and for this, immediate appli­
cation of topical nitroglycerine paste is recommended. Appli­
cation is made in small ‘dabs’ rubbed into the skin until a faint
blush replaces the blanch.
Sclerosing solutions vary in the degree of cellular necrosis
they produce. Hypertonic saline at 23.4% is a caustic scleros­
ing agent, and when an inexperienced practitioner uses this
agent, small spots of superficial epidermal damage often are
seen at points of injection where a small bleb of the solution
has escaped from the vein. The incidence of significant necro­
sis following sclerotherapy in experienced hands is estimated
at less than 1%.
Fortunately, when ulcerations do occur they are usually
fairly small, averaging 4  mm in diameter. At this size, primary
healing usually leaves an acceptable scar but will often result
in pigmentation changes on the skin lasting from months
to years. Occlusive or hydrocolloid dressings apparently
­decrease wound healing time. More importantly, occlusive
dressings decrease the pain associated with an open ulcer. Left
alone, ulcers may take 4–6 weeks to heal completely. If this
is unacceptable, excision and primary closure is a reasonable
alternative, depending on the anatomic location. Excision of
the ulcer with split- or full-thickness grafting usually leads to
a worse cosmetic result than healing by secondary intention.
A summary of complications, incidence, and means of pre­
vention is shown in Table 26-8.
Duplex ultrasound-guided sclerotherapy
Technique
The procedure (Box 26-5) begins with preoperative mapping
of the areas of superficial reflux. As always, deep vein throm­
bosis and deep vein incompetence should be ruled out. The
areas to be treated are identified, with the ultrasound trans­
ducer placed over the introduction site, which should be away
from important arteries and nerves. The site is first infiltrated
with local anesthesia, and the needle is inserted obliquely
toward the vessel. The needle should be visualizable on the
ultrasound display, and followed as it enters the vessel lumen.
The patient should be placed in Trendelenburg position to
reduce vessel size, and a syringe should be used to aspirate
blood to verify placement. Sclerosant of appropriate concen­
tration and volume for the vessel size can be either directly
infused through the needle or through a catheter that can be
placed into the vessel via a guidewire. The ultrasound should
show the sclerosant flowing into the vessel. The safety of the
technique is enhanced when foam is used instead of solution
since the echogenicity of foam dramatically increases visibil­
ity of the sclerosant and the physician is able to monitor the
movement of the sclerosant through the vein. Post-treatment
care follows the same protocol as conventional sclerotherapy,
with compression and limits on exercise.
The novice phlebologist should be aware that even with
­ultrasound-guided placement, this technique is not without
risk. Inadvertent intra-arterial placement or extravasation can
still occur, leading to severe tissue necrosis and nerve injury.
Indications
The advantage of ultrasound-guided sclerotherapy over
unaided, or blind, sclerotherapy is visual confirmation of pre­
cise placement of the sclerosant. Assisted injection is usually
not necessary when the vein is clearly visible from the skin
surface, but can be helpful when the vein is obscured. Treat­
ing tributaries of the saphenous vein is a particularly strong
indication for ultrasound guidance, but other special circum­
stances may also require this maneuver (Box 26-6).
Doppler-guided sclerotherapy
Technique
With the patient standing, the varicose vein is first marked by
palpation. Once the patient assumes a supine position, addi­
tional palpation confirms the absence of a rhythmic arterial

475
Leg vein management  •  Chapter 26
bruit, which when present indicates an artery in the area of
injection. The Doppler transducer is applied to the marked vein
at a 45-degree angle, and with a series of compressions of the
vein segment above and below the transducer, the transducer is
positioned such that each movement is clearly heard. With the
syringe in the other hand, the needle is inserted into the skin
2–3  cm away from the transducer, at a 45-degree angle facing
the transducer (Fig. 26-20.)
With slight aspiration during needle insertion, the
movement of venous blood into the syringe will be audi­
ble through the Doppler amplifier once the varicose vein is
punctured. Flow into the syringe hub provides visual confir­
mation. The sclerosant is finally injected, producing a liquid
flow sound.
Table 26-8  Common side effects and prevention
Side effect
Incidence (%)
Prevention
Telangiectatic
matting
10–50
Use minimal sclerosant concentrations
Limit blanching per injection to an area 1–2  cm in diameter
Use low injection pressures to avoid backup of solution into capillaries
Encourage weight loss prior to institution of therapy
Consider recommendation to discontinue oral contraceptives
Hyperpigmentation
11–80
Eliminate high-pressure reflux before treating smaller vessels
Minimize risks of vessel rupture
Avoid excessive syringe pressure
Minimize intravascular pressure by elevating leg during treatment
Select a sclerosant with the least inflammatory effects
Use a sclerosant concentration appropriate for vessel size
Apply compression immediately post-treatment
Remove post-sclerotherapy coagula as early as possible
Avoid concomitant use of minocycline
Direct treatment at the deepest site in a telangiectatic cluster
Avoid treating patients with known defects in iron transport
Necrosis
1–5
Use meticulous technique to avoid extravasation
Avoid prolonged blanching
Treat arteriolar spasm with vigorous local massage
Arteriolar spasm may be treated with 2% nitroglycerine ointment
If a small bleb of low concentration of solution is extravasated, massage for 1 minute
Use correctly sized compression garment and the right amount of compression
Box 26-5  Steps to ultrasound guided sclerotherapy
Preoperative mapping of area of reflux
Ultrasound visualization of placement of needle or catheter
Injection of sclerosant under direct visualization
Postoperative assessment of result with ultrasound
Box 26-6  Indications for duplex ultrasound guided
sclerotherapy
Greater saphenous vein without junctional incompetence
Lesser saphenous vein without junctional incompetence
Vulvar or scrotal varices
Varicosities in the obese patient
Extensive networks of varicosities
Large incompetent perforating veins
45º
Doppler transducer
Needle
Skin
surface
Vein
45º
Fig. 26-20  Continuous-wave Doppler localizes venous flow at the
needle tip. The wave beam and the needle are perpendicular.

476
Chapter 26 
Cosmetic surgery procedures and techniques
Indications
The indication for Doppler-guided sclerotherapy is based on
clinical presentation of the target varicose vein (Table 26-9).
When the vein is visible and palpable whether the patient is
standing or supine, sclerotherapy can proceed with only visual
inspection and palpation. But if the vein is palpable with the
patient standing but ceases to be palpable once the patient
assumes the supine position, the Doppler becomes helpful in
guiding the injection. Once the vein is not palpable in either
the standing or the supine position, only duplex ultrasound-
guided sclerotherapy should be attempted.
Ambulatory phlebectomy
Technique
Ambulatory phlebectomy (AP) requires only a sparse surgical
tray. Physicians vary regarding their preferred phlebectomy
hooks, with the most commonly used ones being the Muller,
the Oesch, the Varady, and the Ramelet (Fig. 26-21). The
various types have different tip sharpness, length, and handle
size. Most phlebologists use two or more types of different
sizes to accommodate veins of varying sizes and depths. The
Muller hook, available in four sizes, with a blunt tip, resem­
bles a crochet hook that elevates the vein from below. Oesch’s
hook, available in three sizes, is characterized by a massive
squared-off grip and is designed with a small barb at the tip
to pierce the vein from the lateral aspect and elevate it. Ram­
elet’s hook, available in two sizes, is a smaller, fine, sharp hook,
elevating the vein from above by lifting from adventitia. The
cylindrical shape of the grip permits a gentle rolling of the
hook between the fingers, diminishing wrist and hand stress
during the procedure.
Other necessary equipment includes a No. 11 scalpel or 18-
gauge needle to perform the incisions or punctures (Box 26-7).
A half dozen or more mosquito clamps or curved clamps
should be on the tray with the phlebectomy hooks. An operat­
ing table allowing rotation in the Trendelenburg position and
good overhead lighting is necessary. The presence of an assist­
ant to provide compression at sites of oozing is essential.
Sedation, if required, consists usually of an oral benzo­
diazepine. Varicose vein bulges are carefully delineated with
a skin marker pen on the standing patient. The patient is
then placed supine and the vein position is reexamined using
a transilluminator. Areas that are deeper and will be more dif­
ficult to hook are noted and marked. Local anesthesia using
a tumescent anesthesia technique requires a higher concen­
tration than tumescent anesthesia for liposuction. Typically,
0.2% lidocaine with 1:500  000 epinephrine in normal saline
is prepared. Injection is with a 22-gauge spinal needle that
dissects the tissue just under the varicose vein to be avulsed.
Usually no more than 200  mL is required for fairly long seg­
ments. Anesthesia of the leg often persists for 10 hours. Only
with work in the popliteal fossa may patients experience a
temporary foot drop from anesthesia of the peroneal nerve
and require assistance for ambulating and driving home.
Cutaneous incisions performed with No. 11 scalpel blade
or 18-gauge needle should be vertical along the thigh and low­
er leg and follow the skin lines at the knee or the ankle. The
distance between the incisions varies from 2  cm to 15 cm, but
is typically 3–4  cm. Once the ambulatory phlebectomy hook
is inserted into the puncture site, the targeted vein is gently
dissected by undermining with the shaft of the phlebectomy
hook. Attempts to pull the vein through the puncture site may
initially result in shreds of adventitial fibroadipose attach­
ments. Sometimes it is not until the third or fourth attempt
at lifting that a loosened vein segment can then be elevated
with the sharp tip of the hook. As the vein loop is exposed and
pulled through the small incision, mosquito forceps are then
used to clamp the vein loop. Traction is maintained by pulling
as far as the vein slides easily. Too much tension will result in
breakage. A gentle rolling motion accompanied by massage
can be helpful.
Novices are warned to avoid the popliteal fossa, dorsum
of the foot, peripatellar, or pretibial region, and recurrent
varicose veins after phlebitis or sclerotherapy. Hemostasis is
achieved with intraoperative and postoperative local compres­
sion and by Trendelenburg positioning of at least 10 degrees.
Venous ligation is not necessary, as stretching of the vein caus­
es rapid hemostasis most likely due to more exposed endothe­
lial sites for platelet aggregation. Avoiding ligation eliminates
all the additional complications of foreign material left just
below the skin.
A typical session lasts 30–60 minutes with the major ­portion
of a varicose vein extending from thigh to midcalf. Occasion­
ally, incision sites in the midthigh may stretch with removal
of large truncal veins and may require one 5-0 suture. Post­
operative pain seldom occurs because of long action of the
tumescent anesthesia, but some patients have reported a slight
Table 26-9  Indications for various sclerotherapy techniques
Varicose vein
Unguided
Doppler
Duplex ultrasound
Visible and palpable standing
and supine
Yes
Unnecessary
Unnecessary
Palpable standing but not
supine
No
Yes
Unnecessary
Impalpable standing or supine
No
No
Yes

477
Leg vein management  •  Chapter 26
burning at the site of incisions during the first postsurgical
night. Analgesia is easily achieved by acetaminophen. Imme­
diate ambulation reduces risks of deep venous thrombosis to a
negligible rate (Fig. 26-22).
Postoperative course
Hematoma and bleeding are the most likely complications of
ambulatory phlebectomy (Box 26-8). Therefore, meticulous
postoperative compression bandaging is required. The entire
course of the removed varicose vein is covered with four
layers of gauze pads or a single layer of ABD pads. These
are secured with a low-stretch bandage (such as Comprilan,
Beiersdorf-Jobst, Charlotte, NC) stretched to 80% of maximal
stretch to obtain a low resting pressure dressing. Hematomas
are minimized by placing compression at least 4  cm beyond
the most proximal incision. An elastic graduated compres­
sion stocking is also worn to obtain high resting pressure. The
patient walks for 10 minutes in the office and the dressing is
observed for any signs of bleeding. If the dressing remains dry,
the patient may drive home without assistance as long as local
anesthesia has not compromised motor function.
Dressings are changed after 24 hours, and the incision sites
are visually inspected. A less bulky dressing of gauze and in­
elastic compression is applied, and the compression stocking
is placed over this again. The inner dressing may be removed
at 48 hours, but daytime elastic graduated compression stock­
ings are mandatory for 7–14 days. Hematomas are barely
visible at 24 hours but become more prominent by 7 days.
A
B
C
D
Fig. 26-21  (A) Varady phlebectomy hooks. (B) Ramelet phlebectomy hooks. (C) Muller phlebectomy hooks. (D) Oesch phlebectomy hooks.

478
Chapter 26 
Cosmetic surgery procedures and techniques
Short showers are allowed 2–3 days postoperatively. Surgi­
cal puncture sites are usually totally invisible after 3–6 months
but may persist much longer in younger patients with tighter
skin. Hematomas rapidly disappear and pigmentation usu­
ally fades within 2–3 weeks. Long-term results are excellent as
long as the source of venous reflux has been correctly elimi­
nated. Since susceptibility to varicose veins is genetic, patients
need to be warned about recurrences or new varicosities in
the future even with definitive eradication by ambulatory
phlebectomy.
Laser and light-based devices
Preoperative clinical considerations
Depending on the size and location of the leg veins to be
treated, any one of a multitude of therapeutic options may be
appropriate. While selecting the correct treatment techniques
is important, management of patient expectations prior to
the treatment can be equally vital. A standard list of topics
should be discussed with every prospective patient (Box 26-9).
The patient must understand that although improvement is
expected, there is no guarantee regarding this or the degree
of improvement. Risks accompany any medical procedure,
and these must be discussed thoroughly. Once the physician
has conveyed the necessary information, the patient should
be encouraged to ask questions and should be provided with
a detailed explanation of concerns, as appropriate. If the
patient appears overly anxious, overly demanding, or simply
unable to understand the procedure, the patient may not be
an ideal candidate for intervention.
Skin
Vein
Mosquito
clamp
A
B
C
D
Fig. 26-22  (A) Puncture skin with 18-gauge needle or make
a small incision with #11 blade. (B) Introduction of hook through
incision and dissection of tissue around vein with stem of the hook.
(C) Hooking the vein upward through the incision. (D) Grasping and
extracting the vein using mosquito clamps.
Box 26-7  Phlebectomy supplies
Skin marking pen
Iodine prepping solution
Disposable face mask, sterile gloves
Local anesthetic, syringes, needles
Ambulatory phlebectomy hooks: Muller, Oesch, Ramelet,
Varady
Sterile 4×4 gauze pads
Needle 18 gauge, scalpel No. 11
Mosquito forceps
Absorbent dressings
Inelastic compression wrap
Elastic graduated compression stockings
• Delineate and mark vein locations with the
­patient standing.
• Consider vein size, vein location, and patient
tolerance while considering phlebectomy versus
sclerotherapy.
• Use combination of two or more types of vein
hooks to accommodate veins of different sizes
and depth.
Pearls
• Immediate postoperative ambulation reduces
the risk of deep vein thrombosis.
• Compression is essential to reduce hematoma.
• Saphenofemoral junction reflux should be
­investigated prior to phlebectomy.
Pitfalls

479
Leg vein management  •  Chapter 26
Laser selection
The challenge in laser treatment of leg veins is that the veins
vary widely in size and depth in the skin. Furthermore, the
superficial vessels are connected to deeper reticular veins,
which often require adjunctive treatment such as sclerotherapy.
The choice of wavelength and pulse duration is related to the
type and size of the vessels treated. In general, longer wave­
lengths allow for deeper penetration, and longer pulse dura­
tions are needed to slowly heat vessels with larger diameters.
Larger spot sizes are associated with reduced skin reflectance
and improved laser energy penetrance, resulting in greater
effective fluence delivery to the target.
Potassium titanyl phosphate (KTP) lasers  The earliest
successful treatment of leg veins utilized pulsed lasers and
light sources. Pulsed KTP, a 532  nm device, was initially
favored because the emitted wavelength was well absorbed by
hemoglobin and the KTP crystal in the laser hardware was
reliable and inexpensive. Although millisecond-domain KTP
devices proved valuable in treating facial telangiectases, early
experiences with small spot sizes and pulse durations of 10  ms
or less were disappointing. Outcomes were much more favora­
ble with the advent of larger spot sizes of 3–5  mm, and longer
pulse durations of 10–50  ms at fluences of 12–20  J/cm2.
The disadvantages of the KTP laser include the fact that
thick leg skin can pose a barrier to its limited penetrance,
and that the 532  nm wavelength is also heavily absorbed by
melanin. Consequently, patients with darker or tanned skin
are at high risk of dyspigmentation. Cooling is especially im­
portant in these cases to protect the epidermis. Given these
limitations, the pulsed KTP is best suited for small, superficial
telangiectases in patients with skin types I–III. Treatment is
technique-dependent, with multiple passes often needed to
achieve the clinical end points of vessel spasm or intravascular
coagulation, which are associated with better results. How­
ever, pulse stacking, or delivering repeated laser pulses to the
same site without pause, should be avoided, as this may lead
to ‘grooving’ or scarring.
Pulsed dye laser  The original pulsed dye laser (PDL) at
585  nm and 450  μs pulse duration was successful in treating
port-wine stains, which are composed of very superficial (aver­
age depth of 0.46  mm) and minute (100  μm diameter) vessels,
usually on the head and neck. However, PDL initially proved
to be unsatisfactory in treating leg veins since the short pulse
duration was ineffective for deeper and thicker vessels. Given
the implications of the theory of selective photothermolysis,
the ideal pulse duration for destruction of leg veins 0.1  mm to
several millimeters in diameter is in the range 1–50  ms. High
energy needs be delivered in a short interval to induce rup­
ture of the vessels with purpura and hemosiderin deposition,
seen clinically as long-term hyperpigmentation. The advent
of long-pulsed dye laser in the late 1990s enabled treatment
of this type. Currently, several devices using rhodamine dye
(Cynosure, Berkshire, UK: Photogenica, V-Star; Candela,
Wayland, MA: V-Beam) are capable of pulse durations rang­
ing from 1.5  ms to 40  ms and wavelengths from 585  nm to
600  nm, with the longer wavelengths permitting better pen­
etration to deeper vessels. However, even at these longer PDL
wavelengths, melanin absorption is still significant, and there
is a significant risk of postinflammatory hyperpigmentation if
epidermal cooling is insufficient.
Long-pulsed alexandrite laser  Several other pulsed lasers
have successfully exploited the small peak of hemoglobin
absorption in the 700–900  nm range. Specifically, the long-
pulsed alexandrite, diode, and Nd:YAG lasers are able to
treat larger-caliber veins; concurrently, their longer wave­
lengths permit them to penetrate deeper into skin with rela­
tively low levels of absorption by melanin. For example, the
755  nm alexandrite laser is capable of penetrating 2–3  mm
into the skin. Firing with pulse durations of up to 20  ms, this
laser can treat small- to medium-diameter vessels with some
success.
Diode lasers  Emitting at 800–930  nm, the diode lasers
are similar to alexandrite lasers in their ability to penetrate
deeper and target larger reticular veins, and to match the
tertiary hemoglobin absorption peak at approximately
900  nm while being absorbed relatively less intensely by
melanin.
Box 26-8  Complications of ambulatory phlebectomy
Frequent
Skin: transient pigmentation, vesicles from pressure dressing
Vascular: hematoma
Uncommon
Skin: contact dermatitis, infection, scar, tattoo from marking
pen, silicon (foreign body) granuloma
Vascular: postoperative bleeding, telangiectatic matting
Neurologic: postoperative pain, transitory sensory defect,
neuroma
Rare
Superficial thrombophlebitis
Lymphatic pseudocyst
Box 26-9  Pretreatment discussion topics
Patient expectations
Expected discomfort during treatment
Benefits of treatment
Possible complications of treatment
Treatment alternatives
Post-treatment care
Duration and nature of recovery phase

480
Chapter 26 
Cosmetic surgery procedures and techniques
Long-pulsed Nd:YAG 1064  nm laser  The development
of long-pulsed Nd:YAG lasers was an exciting milestone in
the treatment of leg veins. The 1064  nm wavelength, longer
than the alexandrite and diode lasers, affords even deeper
penetration into the skin to target deep, relatively large-cal­
iber vessels. The Nd:YAG laser has a maximum penetration
depth of 3  mm, which makes it ideal for destruction of large
vessels in the mid-dermis. The scant absorption by melanin
also decreases the potential for epidermal damage, even in
darker skin types. However, the high fluence needed for deep
penetration increases the risk for collateral damage as heat
is dissipated to the tissue surrounding the target vessels. Fur­
thermore, treatment with the long-pulsed 1064  nm laser is
relatively painful, requiring vigorous epidermal cooling and
topical anesthesia. Whereas a complete treatment with other
lasers may entail several passes at lower fluences, multiple
passes with the high-fluence Nd:YAG laser should be performed
with extreme caution. Larger-caliber vessels with diameters
of 0.5–3  mm respond best. As with other lasers, the treatment
goal is to achieve blanching of the vessels without burning the
overlying skin.
Intense pulsed light  The intense pulsed light (IPL) device
is typically a noncoherent, 515–1200  nm, flashlamp-pumped
light source (Palomar, Burlington, MA: Estelux, Medilux,
Starlux; Syneron, Ontario, Canada: Aurora, Polaris, Lumenis,
Santa Clara, CA: One, Quantum, VascuLight) Unique to IPL
is the ability to use filters to remove shorter wavelengths in
order to increase selectivity. Multiple low-pass filters, rated
at 560–755  nm, can be used in this manner. Most useful for
vascular lesions are 550  nm and 570  nm filters that deliver
primarily the yellow and red wavelengths with some infrared
irradiation.
Broadband IPL takes advantage of the dynamic opti­
cal properties of hemoglobin. As vessel size increases from
0.1  mm to 1  mm, and depth increases from 0.3  mm to 1  mm,
the peak absorption of hemoglobin shifts from 600  nm to ap­
proximately 900  nm. Therefore, a broadband source of 515–
1200  nm allows the physician to target the smaller, superficial
vessels and the larger, deeper vessels simultaneously. Another
practical advantage of the IPL is the relatively larger spot size
that facilitates treatment.
Patient selection  Surgical interventions, endovenous abla­
tive techniques, and sclerotherapy remain the primary choices
for varicose veins and reticular veins 3  mm or larger. Lasers
and light sources can be considered when telangiectases 3  mm
or smaller are present. Patients best suited for treatment with
light-based devices are those: (1) in whom sclerosants are
medically contraindicated; (2) who are needle-phobic; (3) who
have failed sclerotherapy; (4) whose vessels are too small for
cannulation (less than 0.3  mm); and (5) with foot or ankle ves­
sels that are difficult to treat with sclerotherapy. Since sclero­
therapy is heavily technique-dependent, physicians who are
unfamiliar with sclerotherapy may find more use for lasers. If
sclerotherapy is undertaken, treatment should be from largest-
to smallest-caliber vessels, starting with varicosities, incompe­
tent perforators, reticular veins, and finally ending with fine
telangiectases.
Patients should also understand that treatment of leg veins
does not culminate in instant improvement. For laser and light
devices, 8–12 weeks may be the optimal interval between
treatments. Often, telangiectases will ultimately improve
despite no signs of change within the initial 2 weeks.
A primary indication for lasers and light sources is tel­
angiectatic matting. Matting refers to multiple tiny new tel­
angiectases that appear in patients, often after sclerotherapy.
Usually, matting presents as a confluent, clustered patch of
numerous vessels less than 0.2  mm in diameter at the site
of treatment. The incidence of matting after sclerotherapy
is between 15% and 24%, and although it usually resolves
spontaneously in 3–12 months, it can lead to dissatisfaction
if patients are not counseled appropriately of the risk before
treatment.
Technique
Technique for laser (1064  nm) direct contact method
It is critical to wear protective glasses when using the 1064  nm
wavelength, as it is one of the most penetrating and damaging
to the eyes. Treatment with long-pulsed 1064  nm lasers is quite
painful. Cooling and either topical anesthesia or local anesthe­
sia are necessary when treating all but the smallest veins. Many
of the long-pulsed 1064  nm devices available are based on a
fiber delivery system with contact or dynamic cooling. For
the contact cooling devices, water-based gel is placed directly
on the skin and the crystal or spacing device is held directly
against the skin. Minimal pressure is placed against the skin,
since the target may be compressed with excessive hand pres­
sure. In some cases in which a larger reticular vein is targeted
for 1064  nm laser, slight pressure may be used to minimize the
total diameter of the vein to allow greater penetration and less
total heat accumulation by virtue of less hemoglobin heated.
This may make the treatment slightly less painful. During
treatment of small-caliber vessels, immediate disappearance is
often seen, but during treatment of larger-caliber vessels, there
is often no visible change in the treated vessel.
Dynamic cooling technique
Some devices allow an integrated cryogen spray to be timed
and synchronized with the laser pulse. For smaller vessels, the
cryogen is typically sprayed before the laser pulse. For larger
leg veins, the cryogen spray may be delivered immediately
after the laser pulse, reducing damage from dissipated heat. It
is thus possible to have a dynamic cooling spray both before
and after the laser pulse for increased patient comfort and
increased safety of the epidermis. Higher fluences can thus be
delivered. The main advantage of the dynamic cooling lasers
for leg veins is excellent visibility during treatment; the main
disadvantage is accumulated cold injury should too many
pulses be delivered in the identical spot. The key to safety and

481
Leg vein management  •  Chapter 26
increased patient comfort is to allow each pulse to be sepa­
rated by at least 2–3  mm and to keep the cumulative cryogen
time to less than 60  ms.
IPL technique
A thick layer of gel must be placed onto the crystal and abso­
lutely no pressure applied as the crystal is placed over the target
area, floating the crystal in gel. Compressing this 2–3  mm layer
of gel against the skin will result in crystal placement too close
to the skin, thus greatly increasing the risks of epidermal injury.
Plastic spacers are available to increase the uniformity of dis­
tance of crystal and thickness of gel, although most users sim­
ply float the crystal, holding the weight of the IPL head in their
hands. Newer head designs have taken this into account; they
have become much more lightweight and have incorporated
integral Peltier cooling devices to keep the crystals at 1°C. For
skin types I to untanned III with very fine red telangiectases,
acceptable results can usually be obtained; when large areas are
involved, the large spot size of the IPL allows rapid treatment.
To minimize rectangular footprinting, a 10% overlap of pulse
placement is used, or alternatively a second pass oriented 90
degrees from the original direction may be made. No EMLA
cream is used before treatment, as there is a high incidence
of vasoconstriction produced by the prilocaine component of
EMLA. ELA-Max 4% lidocaine (Ferndale Labs, Ferndale, MI)
is a better choice but is usually not necessary with cooling.
REFERENCES
  1. Engel A, Johnson ML, Haynes SG. Health effects of sunlight exposure
in the United States: results from the first national health and nutrition
examination survey, 1971–1974. Arch Dermatol 1988; 124:72–79.
  2. Weiss RA, Weiss MA. Resolution of pain associated with varicose and
telangiectatic leg veins after compression sclerotherapy. J Dermatol Surg
Oncol 1990; 16:333–336.
  3. Thibault P, Bray A, Wlodarczyk J, et al. Cosmetic leg veins: evaluation
using duplex venous imaging. J Dermatol Surg Oncol 1990; 16:612–618.
  4. Somjen GM, Ziegenbein R, Johnston AH, et al. Anatomical
examination of leg telangiectases with duplex scanning [see comments].
J Dermatol Surg Oncol 1993; 19:940–945.
  5. Weiss RA, Weiss MA. Doppler ultrasound findings in reticular veins
of the thigh: subdermic lateral venous system and implications for
sclerotherapy. J Dermatol Surg Oncol 1993; 19:947–951.
  6. Partsch H. Primary Varikose der Vena Saphena Magna und Parva.
In: Kriessman A, Bollinger A, Keller H, eds. Praxis der Doppler
Sonographie. Stuttgart: Thieme; 1982:101–103.
  7. Weiss RA. Evaluation of the venous system by Doppler ultrasound
and photoplethysmography or light reflection rheography before
sclerotherapy. Semin Dermatol 1993; 12:78–87.
  8. Weiss RA, Sadick NS, Goldman MP, et al. Post-sclerotherapy
compression: controlled comparative study of duration of compression
and its effects on clinical outcome. Dermatol Surg 1999; 25:105–108.
  9. Smithies DJ, Butler PH. Modelling the distribution of laser light in
port-wine stains with the Monte Carlo method. Phys Med Biol 1995;
40:701–731.
10. Gilchrest BA, Rosen S, Noe JM. Chilling port wine stains improves the
response to argon laser therapy. Plast Reconstr Surg 1982; 69:278–283.
11. Chess C, Chess Q. Cool laser optics treatment of large telangiectasia of
the lower extremities. J Dermatol Surg Oncol 1993; 19:74–80.
12. Waldorf HA, Alster TS, McMillan K, et al. Effect of dynamic cooling
on 585-nm pulsed dye laser treatment of port-wine stain birthmarks
[see comments]. Dermatol Surg 1997; 23:657–662.
13. Belcaro G, Cesarone MR, Di Renzo A, et al. Foam-sclerotherapy,
surgery, sclerotherapy, and combined treatment for varicose veins: a
10-year, prospective, randomized, controlled, trial (VEDICO trial).
Angiology 2003; 54(3):307–315.
14. Muller R. Ambulatory phlebectomy. Ther Umsch 1992; 49:447–450.
15. Muller R. Traitement des varices par la phlebectomie ambulatoire. Bull
Soc Franc Phlebologie 1966; 19:277–279.
16. Ramelet AA. Muller phlebectomy: a new phlebectomy hook.
J Dermatol Surg Oncol 1991; 17:814–816.
17. Stuart WP, Adam DJ, Bradbury AW, et al. Subfascial endoscopic
perforator surgery is associated with significantly less morbidity and
shorter hospital stay than open operation (Linton’s procedure). Br J Surg
1997; 84(10):1364–1365.
18. van Neer PA, Veraart JC, Neumann HA. Venae perforantes: a clinical
review. Dermatol Surg. 2003; 29(9):931–942.
19. Yamaki T, Nozaki M, Iwasaka S. Comparative study of duplex-guided
foam sclerotherapy and duplex-guided liquid sclerotherapy for the
treatment of superficial venous insufficiency. Dermatol Surg 2004;
30(5):718–722; discussion 722.
20. Weiss RA, Munavalli G. Endovenous ablation of truncal veins. Semin
Cutan Med Surg 2005; 24(4):193–199.
21. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of
saphenous vein reflux: long-term results. J Vasc Interv Radiol 2003;
14(8):991–996.
22. Weiss RA, Sadick NS, Goldman MP. Post-sclerotherapy compression:
controlled comparative study of duration of compression and its effects
on clinical outcome. Dermatol Surg 1999; 25:105–108.
23. Weiss RA, Weiss MA. Incidence of side effects in the treatment of
telangiectasias by compression sclerotherapy: hypertonic saline vs.
polidocanol. J Dermatol Surg Oncol 1990; 16:800–804.
24. Duffy DM. Small vessel sclerotherapy: an overview. Adv Dermatol 1988;
3:221–242.
25. Weiss RA, Goldman MP. Advances in sclerotherapy. Dermatol Clin
1995; 13:431–445.
26. Davis LT, Duffy DM. Determination of incidence and risk factors
for postsclerotherapy telangiectatic matting of the lower extremity: a
retrospective analysis. J Dermatol Surg Oncol 1990; 16:327–330.
27. Norris MJ, Carlin MC, Ratz JL. Treatment of essential telangiectasia:
effects of increasing concentrations of polidocanol. J Am Acad
Dermatol 1989; 20:683–689.
• Consider wavelength, pulse duration, fluence,
and beam diameter for the target veins.
• Large beam diameter and longer wavelengths
allow deeper tissue penetration.
• Use long-pulsed 1064  nm laser for the treatment
of larger-caliber veins.
Pearls
• Cutaneous lasers cannot effectively treat large
reticular veins and varicose veins.
• Beware of competing melanin absorption
­leading to collateral tissue damage.
• Patients must understand the results may not be
immediately visible.
Pitfalls

Blepharoplasty
Brian Biesman
C h a p t e r
27
History and Science
Definitions and normal eyelid position
Blepharoplasty refers to the surgical contouring of the eyelids
performed for functional or cosmetic reasons. The procedure
is designed to improve conditions such as steatochalasis, or steato­
blepharon, referring to prominence of periocular fatty tissue, or
dermatochalasis, a term describing age-associated development
of excess eyelid skin. Dermatochalasis should be differentiated
from blepharochalasis, a familial, idiopathic condition character­
ized by recurrent, transient episodes of eyelid edema. This
rare condition, occurring more often in younger women, may
lead to dermatochalasis if the lid skin becomes stretched and
redundant following repeated bouts of edema. Blepharoptosis,
or ptosis, refers to an abnormally low upper eyelid position rel­
ative to the superior edge of the cornea (corneoscleral limbus)
when the eye is in a straight-ahead position (primary gaze).
Normally, the upper eyelid margin rests approximately 2 mm
below the superior corneal limbus. Ptosis is classified by onset
(congenital or acquired) and by etiologies: myogenic (affecting
levator muscle and superior tarsal, or Müller’s muscle), aponeu­
rotic (such as dehiscence of the levator muscle aponeurosis),
neurogenic (conditions such as myasthenia gravis, abnormali­
ties of the sympathetic nerves to Müller’s muscle or of the
oculomotor nerve to levator muscle), mechanical (neoplasms
may weigh down the lid), or traumatic (injury to the levator
muscle or tendon).
The lower lid margin normally rests at or 1 mm above the
inferior corneal limbus and protects the inferior ocular surface
when the eyes are in primary gaze. Inferior scleral show refers
to the condition where the white sclera is visible between the
­inferior limbus and the lower eyelid margin. Such a finding
suggests the presence of horizontal lid laxity, orbicularis ­muscle
Key Points
n Periorbital rejuvenation should not only involve
­removal of fat, but instead should redistribute
orbital fat into the tear trough region.
n A combination of procedures may be necessary to
achieve a more comprehensive facial rejuvenation
effect, and incisional eyelid surgery establishes the
‘foundation’ in creating structural improvements.
n The difference in appearance between ­Occidental
and Asian eyelids is primarily a reflection of
­anatomic differences in the relationship of the
orbital septum to the levator aponeurosis, as
well as the location and distribution of fat.
n Each structure found in the upper eyelid has
a counterpart in the lower eyelid.
n In patients with an underlying dry eye ­condition,
blepharoplasty should be approached
­conservatively with judicious removal of skin and
orbicularis muscle so as to minimize impairment
of eyelid closure.
n A patient’s gender and cultural background must
be considered when planning eyelid surgery.
n For upper lid blepharoplasty, the inferior border of
the incision should be placed at the desired height
of the eyelid crease.
n The goal of lower eyelid surgery is to eliminate the
fatty tissue prominence while avoiding a ‘hollow’
appearance.
p a r t 2

484
Chapter 27
Cosmetic surgery procedures and techniques
denervation (as in facial nerve paresis), prominent globes, shal­
low orbits, or internal eyelid scarring and ­contraction due to
trauma or prior surgery. This condition should be differenti­
ated from ectropion, a term used to refer to the rotation of
the lid margin away from the globe. Ectropion may occur as a
result of involutional horizontal eyelid laxity, contraction from
postsurgical scarring, excessive resection of lower eyelid skin,
injury to the zygomatic branch of the facial nerve, as well as
other etiologies.
Blepharoplasty historical ­considerations
Eyelid surgery has been described for centuries and continues
to evolve.1,2 The 1970s were noted for the awareness of poten­
tial complications associated with blepharoplasty, including
dry eye syndrome and lower eyelid malposition. Techniques
incorporating concurrent horizontal lower lid tightening and
later transconjunctival approaches were introduced subse­
quently.
Laser and other technologies versus
cold steel
Carbon dioxide laser technology has also been applied to
blepharoplasty since 1980.3 The prevailing opinion in the
1980s was that CO2 lasers produced too much thermal dam­
age to be useful in cutaneous surgical procedures.4 Interest in
laser-assisted blepharoplasty was restored with the introduc­
tion of newer lasers in the 1990s. Surgery could be performed
quickly and efficiently and yielded equally satisfactory results,
leading to more widespread acceptance of laser incisional sur­
gery as a viable technique in certain clinical settings. With the
availability of a variety of incisional devices, such as cold steel,
radiofrequency knife, monopolar cautery, and CO2 ­laser, the
instrumentation becomes a personal choice made by each
­surgeon.
One of the most important questions is whether using la­
sers to perform incisional procedures benefits the surgeon, the
patient, both, or neither. The literature is decidedly unclear in
attempts to answer this question. Anecdotal reports and small
unmasked studies offer conflicting conclusions as to the benefit
of lasers in blepharoplasty, the aesthetic procedure performed
most often with lasers rather than traditional instrumenta­
tion.5–8 Some authors report that the CO2 laser offers little ad­
vantage over the scalpel9 while a survey comparing scalpel ver­
sus CO2 laser blepharoplasty indicated benefits of using a laser
including quicker recovery time to usual activities (6.3 vs. 9.1
days), and shorter operating times (four eyelid blepharoplasty
times of 58 vs. 94 minutes).10 Biesman, Buerger, ­Flaherty and
colleagues have performed the only prospective, multicenter,
double-masked study to address this issue. Ophthalmic plas­
tic surgeons experienced in both laser-assisted and traditional
techniques (at least 100 cases of each over the preceding 2
years) performed blepharoplasty procedures on 35 patients
using laser on one side and cold steel on the other. The side
treated with laser was randomly selected and the patients were
blinded to the surgeon’s choice. Patients were examined 1, 2,
and 4 weeks after surgery. Results were assessed by patient
questionnaire and by evaluation of photographs by a skilled,
masked observer. Two weeks after surgery there was no sig­
nificant difference in the amount of swelling, discoloration, or
wound appearance. This study did not evaluate surgical times
(Biesman BS, Buerger DE, Yeatts, et al., unpublished data).
Proponents of laser incisional surgery find that soft tissue
surgery may be performed more efficiently and, in some cases,
more effectively with lasers than with standard techniques.
There are several reasons for this. First, when used properly,
the laser handpiece acts as three instruments: a cutting tool,
a cautery, and a blunt dissection device. The intraoperative
transfer of instruments and therefore total operating time is
thus decreased. Second, intraoperative efficiency is increased
further by the near absolute hemostasis that is often achieved
when working in areas such as the periorbital region where
most blood vessels have an internal diameter of 0.5 mm or
less. For this reason, the CO2 laser has found its greatest inci­
sional applications in the periorbital region. Third, dissection
with the CO2 laser in the eyelids and periorbital region al­
lows surgery to be performed on delicate vascular structures
such as the levator palpebrae superioris and the superior tarsal
(Müller’s) muscle with a lower risk of tissue distortion, func­
tional impairment, or hematoma formation. Consequently,
the use of lasers may allow certain incisional procedures such
as blepharoptosis repair or correction of eyelid retraction to
be performed with greater precision.
To remove or redistribute fat
Until recently, blepharoplasty was characterized as a subtrac­
tive surgery, consisting primarily of removing skin, muscle,
and/or fat. A greater emphasis on fat preservation and the
conceptualization of the eyelid as an integral part of the up­
perface or midface are part of the newest trends in blepharo­
plasty techniques.11,12 The underlying concept is that, with ag­
ing, we do not actually develop excess quantities of fat; rather,
existing orbital fat becomes more prominent with descent of
the malar fat pads and subsequent deepening of the nasojugal
groove (also known as the ‘tear trough’) (Fig. 27-1). By this
reasoning, then, periorbital rejuvenation should not involve
removal of fat but instead should redistribute orbital fat into
the tear trough region medially and the infraorbital sulcus cre­
ated by stretching of the orbitomalar ligament. Infraorbital fat
redistribution may be performed alone or in conjunction with
midface lifting or rhytidectomy. Intraoperative times and post­
operative swelling are both prolonged when fat redistribution
is performed. The decision as to how to approach the orbital
fat should be made on a case-by-case basis.
The role of adjunctive techniques
with blepharoplasty
The role of CO2 laser resurfacing as an adjunct to blepha­
roplasty was first introduced in 1994 by Weinstein.13 This
underscored the concept that a combination of procedures

485
Blepharoplasty  •  Chapter 27
may be necessary to achieve a more comprehensive facial
­rejuvenation effect and that incisional surgery established the
‘foundation’ in creating structural improvements. Chemical
peeling and laser resurfacing achieve skin quality improve­
ments that cannot otherwise be attained with surgery alone.
Chemical peels and laser resurfacing techniques are reviewed
elsewhere in this book. Other adjunctive treatments that en­
hance the outcome of blepharoplasty surgery include injection
of botulinum toxin into the ‘crow’s feet’ and orbicularis oculi
muscle below the temporal eyebrow, injection of fillers such
as hyaluronic acid into the tear trough and infraorbital sulcus,
and newer resurfacing techniques such as plasma skin resur­
facing and fractional resurfacing. Monopolar radiofrequency
can be used to tighten the eyelid skin, reducing ‘hooding’ and
improving skin texture. This technique is most useful for those
individuals who either have minimal changes and thus are not
surgical candidates or who have already undergone blepharo­
plasty in the past, are resistant to additional surgery, and have
only moderate cutaneous eyelid laxity. Fractional and plasma
skin resurfacing may also be used concurrently with and ­after
blepharoplasty to reduce the appearance of fine lines and
­surgical scars (Box 27-1).
Surgical anatomy of the upper eyelids
The upper eyelid skin is the thinnest in the body and overlies a
minimal layer of subcutaneous tissue. Deep to this is found the
orbicularis oculi muscle, a strong, circular sphincter with con­
centrically arranged fibers whose primary function is to close
the eyelids. The orbicularis muscle is divided into three re­
gions: orbital, preseptal, and pretarsal. Superiorly, the orbital
portion blends with the frontalis, procerus, and corrugator
supraciliaris muscles (Fig. 27-2). Laterally, the orbicularis
overlies the superficial temporalis fascia. Inferiorly, the fibers
cover the origins of the muscles that elevate the nasal ala and
upper lip. Medially the orbital orbicularis fibers arise from
the ­superomedial orbital rim and nasal bones. The preseptal
orbicularis fibers originate from the medial canthal tendon
and arc laterally, overlying the orbital septum in the upper
and lower eyelids before joining to form the lateral canthal
tendon. The pretarsal orbicularis muscle is located imme­
diately anterior to the tarsal plate, a firm structure formed
by compressed collagen fibers. The eyelids are suspended by
derivatives of the orbicularis muscle, the medial and ­lateral
canthal tendons. Disruption or marked laxity of either of
these structures will result in eyelid malposition and/or
­canthal deformities.14,15
The orbital septum, a firm, fibrous structure found deep to
the preseptal orbicularis oculi muscle, arises from a thickened
region of the orbital rim periosteum known as the ­arcus mar­
ginalis and extends towards the tarsal plates where it fuses with
the levator aponeurosis (Fig. 27-3). The location of this fu­
sion varies between Asian and Occidental eyelids. The orbital
septum acts as a divider between intraorbital and extraorbital
structures. Laterally, the septum is contiguous with the lateral
canthal tendon and the lateral horn of the levator aponeu­
rosis. The septum ordinarily serves as a barrier that keeps
the orbital fat in a posterior position relative to the orbital
rim. The surgical importance of the septum is that it should
be distinguished from the levator aponeurosis in the upper lid.
If opened surgically or found to be naturally dehisced, the
orbital septum should not be sutured closed. Trapping the
­orbital septum into a wound can lead to vertical contraction
and restriction of eyelid excursion.16
Immediately posterior to the orbital septum in the upper
eyelid lies the central or preaponeurotic fat pocket, one of two
upper eyelid fat pads. This fat pocket is an extremely useful
landmark in eyelid surgery as it always lies anterior to the leva­
tor muscle and its aponeurosis. The anterior–posterior sepa­
ration between the orbital septum and the levator aponeurosis
is greatest just below the superior orbital rim and it is at this
location that the septum should be opened during eyelid sur­
gery if the risk of injury to deeper structures is to be mini­
mized. The preaponeurotic fat pad (located posterior to the
orbital septum) should be distinguished from fat found anterior
to the septum (submuscular fat) in Asians or retro-orbicularis
fat (ROOF) descended into the eyelid, an involutional change.
The yellow preaponeurotic fat is separated from the pale
­yellow or white colored nasal fat by the interpad septum. The
nasal fat pad is located medial and inferior to the trochlea of
Fig. 27-1  A 40-year-old female with a prominent nasojugal tear
trough deformity.
Box 27-1  Techniques important in periorbital rejuvenation
Blepharoplasty
Botulinum toxin injection
Fillers
Ablative resurfacing
Chemical peels
Plasma skin resurfacing
Fractional skin resurfacing

486
Chapter 27
Cosmetic surgery procedures and techniques
the superior oblique muscle, and care should be taken when
dissecting in this portion of the eyelid (Fig. 27-4).
The levator muscle arises from the greater wing of the
sphenoid and, through its tendinous aponeurosis, is the pri­
mary retractor of the upper eyelid (Fig. 27-5). Damage to or
dehiscence of the levator tendon will result in ptosis. The leva­
tor complex exerts its effect via two insertions, a broad band
that fuses onto the anterior-superior third of the upper eyelid
tarsal plate, and a series of fine leaflets extending through the
orbicularis oculi muscle that insert onto the skin approximately
8–10 mm above the eyelid margin. These attachments result
in close approximation of the skin to the tarsal plate and form
a clearly visible line known as the upper eyelid crease. This is
the usual position of the inferior border of a blepharoplasty
incision. The tarsal plates themselves are collagenous struc­
tures that serve to provide mechanical support to the eyelids.
The upper lid tarsus has a greater vertical dimension than
its lower lid counterpart (10 vs. 4 mm). Müller’s muscle is a
Orbital septum
Orbital septum
Levator aponeurosis
Lateral canthal tendon
Medial canthal tendon
Capsulopalpebral fascia
Fig. 27-3  Anatomy of the orbital septum. Note that the septum fuses with the levator aponeurosis in the upper eyelid and the capsulopalpe­
bral fascia in the lower eyelid.
Occipitofrontalis m.
Corrugator supracilii m.
Orbicularis oculi m.
(preseptal portion)
Orbicularis oculi m.
(pretaral portion)
Procerus m.
Orbicularis oculi m.
(orbital portion)
Depressor
supercilii m.
Fig. 27-2  Muscles controlling eyebrow movements. These muscles may be modified during blepharoplasty or brow lift surgery.

487
Blepharoplasty  •  Chapter 27
­sympathetically innervated smooth muscle that originates high
in the orbit beneath the levator aponeurosis and inserts onto
the superior tarsal border. It is a secondary elevator of the eye­
lid whose effect can be most easily appreciated in patients with
Horner’s syndrome in which the sympathetic ­innervation to
the orbit is interrupted due to a lesion in the superior ­cervical
spine, apex of the lung, or the neck. The upper and lower
eyelids are lined by a thin, transparent membranous ­structure
known as the conjunctiva. The conjunctiva functions to
­protect, lubricate, and support the ocular surface.17
Medial fat pad
Lacrimal sac
Medial canthal
tendon
Valley of the
inferior oblique m.
Central (preaponeurotic)
fat pad
Lateral canthal tendon
Lateral fat pad
Central fat pad
Medial fat pad
Fig. 27-4  Distribution of the anterior orbital fat pads. There are two pads in the upper eyelid and three in the lower lid.
Superior transverse
(Whitnall’s) ligament
Lacrimal gland
Capsulopalpebral
fascia
Arcuate expanse of the
inferior oblique m.
Levator palpabrae
superioris m.
Lockwood’s suspensory
ligament
Fig. 27-5  Anatomy of the primary upper and lower eyelid retractors and their suspensory ligaments.

488
Chapter 27
Cosmetic surgery procedures and techniques
The difference in appearance between Occidental and
Asian eyelids is primarily a reflection of anatomic differences
between the orbital septum and its relationship to the levator
aponeurosis and the location and distribution of fat. These dif­
ferences between the Asian and Caucasian upper eyelids can
be appreciated in cross-section. In the Asian lid, the orbital
septum fuses with the levator aponeurosis at a location often
well below the superior tarsal border and anterior to the tarsal
plate (Fig. 27-6). It is for this reason that some Asian lids have
low or even absent eyelid creases.18 Necessarily following from
the low fusion of the septum and levator, the preaponeurotic
fat pad lies nearer the lid margin in the Asian lid, imparting
an appearance of greater fullness.19 Further contributing to
this ‘thickened’ appearance is a submuscular fat pad that ­often
spans the upper lid above the superior tarsal border. This fat
pad is not found in Occidental lids and is well known as a
source of confusion to surgeons not accustomed to operating
on Asian lids.
Surgical anatomy of the lower eyelids
The upper and lower eyelids are analogous structures. That
is to say, each structure found in the upper eyelid has a coun­
terpart in the lower eyelid. For example, Müller’s muscle in
the upper eyelid is analogous to a sympathetically innervated
smooth muscle in the lower lid known as the inferior tarsal
muscle. Similarly, the levator complex is the primary elevator
of the upper eyelid and has as it lower lid counterpart the
capsulopalpebral fascia (CPF), a thick fibrous tissue that is the
primary lower eyelid retractor (see Fig. 27-5).
As the levator aponeurosis and orbital septum fuse before
inserting into the tarsal plate on the upper eyelid, the CPF and
septum fuse prior to inserting into the lower lid tarsus.
The capsulopalpebral head emanates from the inferior rectus
muscle and divides to envelop the inferior oblique muscle.
­After rejoining anteriorly as Lockwood’s suspensory ligament
further extension anteriorly and superiorly from this point is
known as the capsulopalpebral fascia. Lockwood’s ligament is
attached to the medial orbital wall and to the lateral orbital
wall, where it forms part of the lateral retinaculum, consisting
of the lateral horn of the levator aponeurosis, lateral canthal
tendon, Lockwood’s ligament, and the check ligament of the
lateral rectus muscle. A portion of the capsulopalpebral fascia
inserts onto the inferior tarsal border and the conjunctival for­
nix (suspensory ligament of the fornix), and at a level ranging
from 3 to 5 mm inferior to the tarsus, is fused with the ­orbital
septum. The inferior tarsal muscle is found between the
capsulopalpebral fascia and conjunctiva.
The inferior orbital fat pads appear clinically to be three
distinct pads, a white or light-colored nasal pad, and more
typical yellow-colored central and lateral fat pockets (see Fig.
27-4). In fact, the lateral fat pocket seems to be subdivided
into two pads, one adjacent to the central fat and the other lo­
cated more posterior and lateral to the first. Interestingly, dye
injection studies fail to demonstrate these divisions and sug­
gest that anatomically the inferior orbital fat lies in one large
compartment.20 The inferior oblique muscle separates medial
and central fat pads. This muscle originates from the anterior
medial orbital floor, just posterior to the lacrimal sac fossa and
passes laterally and posteriorly to insert onto the inferolateral
Orbital orbicularis
Orbital septum
Preseptal orbicularis
Occidental
fusion point
Occidental
lid crease
Pretarsal orbicularis
Preaponeurotic
fat
Levator m.
Conjunctiva
Levator
aponeurosis
Muller’s m.
Tarsus
Meibomian
gland orifice
Grey line
Arcus marginalis
Asian fusion point
Tarsus
Levator
aponeurosis
Asian upper lid
crease
Preaponeurotic fat
A
B
Fig. 27-6  (A) Sagittal view of an occidental upper eyelid. Note position of Müller’s muscle and the anteriorly directed leaflets of the levator
aponeurosis that insert into the skin to form the upper eyelid crease. (B) Sagittal view of an Asian upper eyelid. Note the low position at which
the orbital septum fuses with the levator aponeurosis, the preaponeurotic fat anterior to the tarsus, and the low position of the eyelid crease.

489
Blepharoplasty  •  Chapter 27
globe. The arcuate expansion of the inferior oblique muscle
is a fascial band extending from the inferior oblique muscle to
the inferolateral orbital rim and appears to separate the cen­
tral from the lateral fat areas. This structure may be surgically
divided during transconjunctival lower lid blepharoplasty to
facilitate exposure of the lateral fat compartments. The ­lateral
fat pad is thought to consist of a more obvious anterior ­portion
and another slightly posterior and lateral fat pad.21
Midfacial region superficial muscular
aponeurotic system
The midfacial region is bordered above by the inferior orbital
rim and below by the mouth.22 The superficial muscular
aponeurotic system (SMAS), a distinct fibromuscular layer
contiguous throughout the head and neck, is thought to
transmit contractions of the facial muscles to the skin, thus
facilitating facial expression. The SMAS is stabilized by its at­
tachments to the orbital rim superiorly and the body of the zy­
goma and the zygomatic arch laterally.23 Inferiorly, the SMAS
is continuous with the platysma muscle and in the medial por­
tion of the midface it is less well defined.24,25 Attenuation of
the SMAS itself and/or the connections between the SMAS
and its overlying skin are believed to account for some of the
involutional changes occurring in the aging face.
The malar and nasojugal folds have been described indi­
cating a region where a fascial extension attaches the orbital
rim through the orbicularis muscle to the skin.26 The orbito­
malar ligament represents the collagen and elastin fiber attach­
ments extending from periosteum along the inferior orbital
rim, through the submuscular fat and orbicularis oculi muscle,
and inserting into the skin.23,27 The orbitomalar ligament has
been noted to elongate with age, contributing to the sagging
appearance of malar folds commonly known as festoons with
advancing age. In addition, the descent of midfacial soft tissue
exposes the contour of inferior orbital rim leading to a naso­
jugal ‘tear trough’ deformity.
Subcutaneous fat is found both anterior and posterior to the
SMAS (Fig. 27-7). The pre-SMAS fat is more prominent in the
buccal and malar regions and less thick in the forehead. The
malar fat pad is an area of thickened subcutaneous (pre-SMAS)
fat shaped like a triangle with its base along the nasolabial fold
and the apex pointing toward the zygoma.28 This fat pad is
­adherent to the overlying skin and underlying SMAS in youth.
The sub-SMAS adipose tissue is also pronounced in the malar
region. Of note, anatomic studies have demonstrated continu­
ity of sub-SMAS fat such that the ROOF and SOOF (see
below) are site-specific terms for a contiguous anatomic layer.23
Age-related changes in the lower eyelid and midfacial regions
have been described by various terms suggesting downward
migration including festoons, mounds, and bags.29 With the
effects of time and gravity, elastic fibers in both the dermis and
the SMAS degenerate and weaken. The malar fat pad remains
more closely adherent to the overlying skin and thus ­descends
in a plane anterior to and independent of the SMAS.30 A simi­
lar phenomenon occurs in a deeper, sub-SMAS fat layer known
as the suborbicularis oculi fat pads (SOOF).31 Both the SMAS and
SOOF attach to the inferior border of the orbicularis oculi
muscle and when they migrate inferiorly the orbicularis mus­
cle is stretched inferotemporally, resulting in a redundant fold
below the inferior orbital rim known as a malar festoon or malar
bag.32 Festoons must be differentiated from prominence of the
orbital fat, as these conditions often coexist. When viewed sag­
ittally, orbital fat produces a bulge above the inferior orbital
rim while malar festoons create a bulge below the rim. When
these findings are present simultaneously, a ‘double convexity’
deformity results.29 Involutional changes in the midface must
be recognized and addressed so as to permit adequate rejuve­
nation at the time of blepharoplasty surgery.
Complications of blepharoplasty
Understanding the potential complications associated with
blepharoplasty will allow the surgeon to more effectively re­
duce the risk of adverse sequelae. A more comprehensive dis­
cussion of such complications is published in review ­articles.33
The following is a summary of the important problems and
the mechanisms by which they exert their effect (Box 27-2).
Orbital septum
Skin and subcutaneous fat
Preseptal orbicularis m.
Suborbicularis fat
Malar fat
Zygomaticus
minor m.
Buccal fat pad
Periosteum of orbital rim
Fig. 27-7  Schematic drawing of midfacial anatomy.
Box 27-2  Blepharoplasty complications
Blindness due to hemorrhage or direct ocular injury
Bleeding
Infection
Diplopia
Asymmetry
Over-resection of skin/muscle/fat
Scarring
Lacrimal gland injury
Dissatisfaction with outcome

490
Chapter 27
Cosmetic surgery procedures and techniques
Vision loss
Surgeons should be aware of the catastrophic potential for
vision loss following blepharoplasty surgery. While one survey
estimated this complication to occur in 0.04% of all blepha­
roplasties,34 the exact frequency in not known. In the English
language literature, more than 75 cases of post-blepharoplasty
blindness, mostly associated with lower lid surgeries, have been
reported.33
The mechanism for vision loss is often related to orbital he­
morrhage (Fig. 27-8). The compressive effect of ­hemorrhage in
the orbit causes increased intraorbital and intraocular pressure
which compromises the vascular supply to the eye, ­specifically
the retina, and optic nerve. The source of the hemorrhage is
controversial and is traditionally believed to be due to excessive
manipulation of anterior orbital fat with subsequent transmis­
sion of force to posterior orbital vessels.35 Systemic risk factors
for uncontrolled hemorrhage include hypertension, atheroscle­
rosis, use of anticoagulants or aspirin, and bleeding dyscrasias.
Postoperative hematomas develop usually within 24 hours of
surgery.36 Activity restrictions should be emphasized especially
during the immediate postoperative period. Patients may note
significant pain, asymmetric swelling, proptosis, and visual dim­
ming. Vision loss from hemorrhage is an ophthalmic emergency
and warrants urgent referral for ophthalmic intervention.
Mechanisms of visual injury other than hemorrhage include
excessive vasospasm from epinephrine in the local ­anesthetic
injection,37 inadvertent globe injury while administering local
anesthesia38 or during laser-assisted surgery.39
Diplopia
Diplopia, or double vision, may be a transient or persistent
complication resulting from interference with extraocular mus­
cle function. The occurrence is rare, estimated to be 0.03% in
one study40 and should be avoidable. Temporary diplopia may
be caused by edema or local anesthetic injection effects on the
extraocular muscles.41,42 Improvement is often spontaneous
and should be monitored by an ophthalmologist.
Persistent motility disturbances may result from direct or
indirect injury to extraocular muscles or their innervation.
The inferior oblique40,43 is the muscle most frequently injured
during blepharoplasty as it courses between the nasal and cen­
tral fat compartments in the anterior orbit. By identifying the
muscle, dissection and fat removal can be performed safely.44
Damage to the superior oblique muscle, tendon, or trochlea
may occur during aggressive liposculpting of the nasal fat pad
in upper lid blepharoplasty.43,45,46 Less common is surgical
trauma to the inferior rectus muscle.47
Upper lid malposition
Temporary ptosis may result from postoperative edema. Per­
sistent ptosis as a direct result of surgery is infrequent and may
involve injury to the levator tendon,48 levator muscle anesthetic
toxicity,41 or internal scarring which restricts lid mobility. If
significant ptosis develops immediately after upper blepharo­
plasty, the wound should be explored and the levator muscle
and its aponeurosis should be carefully inspected for disinser­
tion or transection.
Lagophthalmos, or incomplete eyelid closure, can be a tem­
porary or permanent sequela of blepharoplasty. When related
to postoperative edema or decline in orbicularis muscle tone
the condition should improve spontaneously within the first
1–2 weeks after surgery. The mechanism involved in persist­
ent lagophthalmos may be vertical shortening from excess skin
removal, inadvertent trapping of the orbital septum into the
wound, or septal adhesions, all of which can limit eyelid excur­
sion. As a result of the poor eyelid closure, the cornea and eye
surface may become dry. Symptoms may include foreign body
sensation, blurred vision, and tearing, which may accompany
clinical findings of ocular injection or lid swelling. Topical ar­
tificial tear supplements in drop, gel, or ointment form may
be necessary to protect the cornea. Massage or forced orbicu­
laris closure may reduce mild postoperative lagophthalmos.
Severe conditions may require surgical intervention, such as
skin grafting or midface lifting.
Lower lid malposition
Malposition of the lower eyelid is one of the most common
post-blepharoplasty complications (Fig. 27-9).33 Findings may
range from downward bowing with inferior scleral show to
frank ectropion. Ectropion after blepharoplasty surgery only
occurs when a transcutaneous approach has been employed.
The most common etiology of post-blepharoplasty lower
eyelid ectropion is over-resection of skin such that the down­
ward vector created overrides the ability of the horizontal
force vectors generated at the canthi to maintain an appro­
priate eyelid position.49 This problem can largely be avoided
by resecting eyelid skin only when the patient gazes upward
with the mouth open, thus placing the lower lid skin on
maximum stretch. Other etiologies include closure of the or­
bital septum within the wound, excessive cauterization of the
Fig. 27-8  Orbital hemorrhage after blepharoplasty surgery. Vision
was not lost. (Photograph courtesy Dr. Sterling Baker.)

491
Blepharoplasty  •  Chapter 27
septum or eyelid, hypertrophic scarring, and injury to the fa­
cial nerve. Temporary lower lid displacement may result from
edema, hematoma, or reduced orbicularis muscle tone.49,50
Conservative measures such as lid massage, orbicularis
­contraction exercises,51 and artificial tear supplements and
­lubricants can be instituted. If the lids do not close completely
and the eye is exposed, an ophthalmologist should monitor the
patient and determine the need for corrective interventions.
If the lower eyelid does become ectropic after blepharo­
plasty surgery, it should be assessed for the presence of hori­
zontal laxity. If present, the lid can usually be repaired by a
simple tightening procedure performed at the lateral canthus.
If the lid is not horizontally lax, then vertical lengthening of
the lid will be required. Identifying the need for horizontal lid
tightening and performing prophylactic measures before or
at the time of blepharoplasty should reduce the risk of these
secondary complications.
Incision irregularities, webbing
Eyelid crease asymmetries or improper placement of the
incision are unsatisfactory results of blepharoplasty that
should be avoided with careful preoperative planning. Web­
bing in the medial canthal region resembles an epicanthal
fold and results from excessive medial skin excision or from
vertical cicatrix if the upper lid incision extends too far
inferomedially. In the lateral canthal region, webbing is the
result of inadequate separation between the upper and lower
­blepharoplasty incisions. If the conditions do not improve
spontaneously or with conservative measures, then surgical
intervention is indicated.
Incision line suture tracts or hypertrophic scarring may be
avoided by careful skin closure using monofilament sutures and
by removing sutures 3–5 days after surgery. Tissue adhesives,
such as autologous fibrin glue52or N-butyl-2-cyanoacrylate,53
may also reduce development of incision irregularities by
­eliminating the need for sutures. While this concept is appeal­
ing, tissue glue is not practical in most cases of ­cosmetic blepha­
roplasty due to discomfort, wound dehiscence, and possible
failure to evert the wound edges. Suture milia are cystic eleva­
tions at the sites where suture passes into the skin that emerge
1 week postsurgery and often remit spontaneously over a pe­
riod of months.54 Milia can occur with most sutures, ­including
silk, mild chromic gut, and polypropylene. Subcuticular ­closure
or early suture removal may reduce the occurrences.
Overcorrection and undercorrection
Aggressive removal of orbital fat in the upper lid may lead to a
sunken superior sulcus. This is particularly undesirable in males
as it imparts a feminine look. When fat is unevenly sculpted,
the sulcus may have an irregular contour. Excessive excision
of fat from the lower lids may result in undesirable lower lid
concavity and can exaggerate visible contour of the orbital rim
and nasojugal tear trough deformities. Free fat grafts have been
used to correct the volume deficit, but a variable degree of fat
absorption is common. Overcorrection of dermatochalasis by
excessive skin or muscle removal was discussed earlier.
While possibly disappointing to the patient, undercorrec­
tion (referring to inadequate skin, muscle, or fat removal) has
far fewer adverse sequelae and may be improved with care­
fully planned ‘touch-up’ surgery. If there is apparent under­
correction of steatoblepharon, it is advisable to wait at least
3 months for complete resolution of tissue edema before pro­
ceeding with revisions.
Lacrimal gland prolapse and injury
An estimated 10–15% of young individuals undergoing
blepharoplasty have symmetrically or asymmetrically dis­
placed lacrimal glands, although prolapse is considered an
involutional process.55 If a prolapsed lacrimal gland is not
repositioned during upper lid blepharoplasty, residual lateral
lid fullness will produce an unsatisfactory result. While a few
surgeons routinely resect the prolapsed portion of the lacrimal
gland, this practice should be avoided to reduce the risk of
producing a pathologically dry eye.15
Procedures and Techniques
Preoperative clinical considerations
Patient communication and counseling
As is true for any aesthetic surgical procedure, preoperative
counseling and setting of appropriate expectations is criti­
cally important prior to blepharoplasty surgery. A general
medical history should be taken with particular attention paid
to symptoms of Graves’ disease or other thyroid conditions,
environmental allergies, or episodic eyelid swelling that may
Fig. 27-9  Lower eyelid retraction and inferior scleral show ­following
lower transcutaneous blepharoplasty.

492
Chapter 27
Cosmetic surgery procedures and techniques
suggest blepharochalasis, a variant of hereditary angioedema.56
Recurrent bouts may result in stretching and wrinkling of skin
that ultimately leads to dermatochalasis. A history of rheuma­
toid arthritis or autoimmune disease may be associated with
coexisting dry eye syndrome.
Every patient should be questioned about bleeding disor­
ders or tendencies, use of aspirin, nonsteroidal antiinflamma­
tory agents, anticoagulants, chronic oral steroids, vitamin E,
St. John’s wort, or garlic supplements in order to assess the rel­
ative risk for excessive intraoperative or postoperative bleed­
ing (Table 27-1). The decision to discontinue blood-thinning
agents at least 11–14 days preoperatively through the early
postoperative period should be made in conjunction with the
prescribing physician.
Preoperative ophthalmic history
and screening
Surgical candidates should be questioned about pre-existing
ocular diseases and the use of ophthalmic medications. In­
dividuals with visual complaints (blurred vision, diplopia)
or any ocular symptoms (including foreign body sensation,
pain, itching, dryness, discharge) should be referred to an
ophthalmologist before considering periocular surgery. In
patients with an underlying dry eye condition, blepharo­
plasty should be approached conservatively with judicious
removal of skin and orbicularis muscle so as to minimize
impairment of eyelid closure. Patients should be warned of
possible exacerbation of dry eye symptoms and temporary
contact lens intolerance that may occur after any blepharo­
plasty procedure.57
Even in the absence of symptoms, basic assessment of
­vision (with a pocket eye chart), pupils (for size, reaction,
and ­ symmetry), and eye movement should be included for
all ­patients. Certain findings should alert the surgeon to the
potential for postoperative ocular complications. Redness or
crusting of eyelid margins may indicate infection or inflam­
mation and should be controlled preoperatively. Abnormali­
ties in blink frequency or completeness of lid closure may
increase the risk of corneal exposure problems after blepha­
roplasty surgery.
Preoperative examination and considerations in upper
eyelid blepharoplasty
The rigorous and systematic examination in preparation for
upper eyelid blepharoplasty should include studying the fore­
head, orbital rim, brows, sub-brow fat, lacrimal gland, fatty
prolapse, upper lid crease, and upper lid position. The ob­
jective is to identify any features or abnormalities that may
predispose an individual to unsatisfactory outcome. Such pre-
existing conditions may need to be addressed in order to safely
and effectively proceed with blepharoplasty. Surgical plan
should be formulated in the preoperative ­evaluation.
Table 27-1  Aspirin and aspirin-like agents to be avoided preoperatively
A.P.C.
Ascriptin
Bufferin
Advil
Aspirin Suppositories
Butalbital
Aleve
Bayer Aspirin
Butazolidin
Alka Seltzer
BC Powders
Cama-Inlay Tabs
Anacin
Buff-A-Comp
Ceracol Capsules
Ascodeen-30
Buffadyne
Clinoril
Congespirin
Measurin
Robaxisal
Cope
Meclomen
Sine-Off
Coricidin
Midol
Sk-65 Compound Caps
Darvon Compound
Monacet & Codeine
St John’s wort
Dolobid
Motrin
Stendin
Dristan
Nalfon
Stero-Darvon & A.S.A.
Duragesic
Naprosyn
Supac
Ecotrin
Norgesic
Synalgos Capsules
Emprazil
Nuprin
Synalgos D.C.
Equagesic
Orudis
Tolectin
Excedrin
Pabirin Buffered Tabs
Triaminicin
Feldene
Panalgesic
Vanquish
Fiorinal
Percodan
Vitamin E
Garlic Supplements
Persantine
Voltaren
Indocin
Persistine
Zomac

493
Blepharoplasty  •  Chapter 27
Upper face and lid examination
The forehead, brows, and upper lids are assessed as a unit with
the patient sitting upright. Particular attention should be di­
rected to brow position, symmetry, and presence of ­horizontal
forehead dynamic rhytides or frontalis muscle weakness. Old
photographs of the patient may reveal acquired involutional
changes that will be helpful in selecting the appropriateness
of brow lifting. When assessing the forehead–brow area, the
frontalis muscle should be relaxed to determine the resting
height of the brows; compensatory brow recruitment, mani­
fested by forehead furrowing from frontalis muscle contrac­
tion, may mask an underlying brow ptosis, dermatochalasis,
or upper eyelid ptosis.
To determine the amount of brow ptosis that may need
to be corrected, the brow is held at a desired position and
the distance the brow falls to its relaxed level is measured.
The brow position is not usually altered by blepharoplasty,58
although postoperative brow relaxation may occur. If there
is pre-existing brow ptosis and the blepharoplasty candidate
does not desire brow correction, a conservative skin and
muscle excision should be performed to avoid downward
traction of the brow towards the eyelid crease. If a brow ele­
vation is necessary to optimize the blepharoplasty results, the
brow lift should be conducted first, before or at the time of
blepharoplasty.
Lateral brow fullness due to excessive bony orbital rim
projection may be altered by surgically reducing the bony
contour. Fullness from soft tissue thickening from ROOF
prominence is sculpted through the upper lid blepharo­
plasty incision. ­ Superotemporal eyelid fullness inferior to
the ROOF may represent dermatochalasis from lateral brow
ptosis or involutional lacrimal gland prolapse. A prolapsed
lacrimal gland presents as a palpable, discreet, somewhat
mobile mass located just below the superotemporal orbital
rim. If gland repositioning is overlooked at the time of
blepharoplasty, there will remain undesirable residual lateral
lid fullness. Diffuse lid edema should be differentiated from
steatochalasis. Orbital fat will protrude when pressure is gen­
tly applied against closed eyelids or when eyes are directed to
the sides or upwards. In contrast, the fullness from lid edema
will appear stable with these maneuvers. Lid edema may be
a response to ocular allergies or systemic abnormalities such
as thyroid disease.
A patient’s gender and cultural background must be
­considered when planning eyelid surgery. For example, a
strategy that effectively achieves the impression of reju­
venation for a female may not be appropriate for a male.
­Likewise, aesthetically pleasing features of the Occidental
eyelid may not be desirable to an Asian individual. Eld­
erly patients with generalized signs of facial aging may
not wish to have aggressive blepharoplasty and seek only
age-appropriate improvements. The preoperative discus­
sion must include clear communication of anticipated ana­
tomic modifications in a manner that reduces ambiguity of
­expectations.
Preoperative clinical considerations for lower lid
blepharoplasty
Planning lower eyelid blepharoplasty requires recognition of
various anatomic associations and of the typical involutional
changes that occur in the midface. The evaluation should be
attentive to lower lid skin quality, quantity and pigmentation,
contour of the eyelid relative to the globe and midface, lower
lid margin position, and horizontal laxity.
Skin and orbicularis oculi muscle
Hypertrophy of the orbicularis oculi muscle will cause a
bunching effect that is particularly prominent when an indi­
vidual smiles. The lower lid should thus be evaluated in both
the relaxed state and with a forced smile in order to determine
the relative contributions of skin, muscle, and fat to the eye­
lid’s overall appearance. This maneuver also helps determine
if excess skin is present in the lids and provides valuable infor­
mation about the skin’s elasticity (Fig. 27-10).
Lower lid contour and midfacial anatomy
It is important to assess the bony support of the lower eyelid
prior to performing lower blepharoplasty. If the lower lid does
not have adequate bony support, following blepharoplasty
the lid may ‘slide down’ the globe, producing an aesthetically
and possibly a functionally unsatisfactory result. A helpful test
to evaluate the bony support for the lower lid is to view the
patients in profile as the head is held level and gaze straight
ahead. An imaginary coronal plane is drawn through the most
anterior projection of the malar eminence, and the position
of the globe relative to this plane is noted (Fig. 27-11). If the
plane passes anterior to the cornea, the lid has adequate sup­
port; if the plane passes through the globe itself, midfacial
elevation, cheek implants, or other maneuvers may be consid­
ered at the time of blepharoplasty surgery.
Lower lid laxity and position
If a transcutaneous approach is being considered, the lower
lid position and degree of horizontal laxity must be assessed.
Pre-existing lower lid retraction, scleral show, or laxity may re­
quire correction prior to or in conjunction with blepharoplasty
to avoid postoperative lid malpositions and corneal exposure
complications. The snap test is performed by pulling the lower
Fig. 27-10  ‘Hypertrophic’ orbicularis oculi muscle.

494
Chapter 27
Cosmetic surgery procedures and techniques
lid inferiorly and observing for a normal quick resumption of
its position against the globe prior to the next blink. A lid that
fails to return to position briskly demonstrates lower lid laxity
and the snap test is interpreted to be positive. The distraction test
is performed by gently grasping the lower lid skin horizontally
and pulling away from the globe to determine how far the lid
can be stretched. If this distance is greater than 6 mm, there is
laxity and the test is considered positive.57
If lower lid laxity is identified, skin removal should be con­
servative and concurrent lower lid tightening measures should
be performed. Involutional eyelid laxity results more often from
weakness of the lateral canthal tendon rather than medial can­
thal weakening or tarsal lengthening.58–62 The surgical correc­
tion usually entails lateral tightening procedures (Box 27-3).
Procedural techniques
Upper lid blepharoplasty
Skin marking
Marking of the skin incisions is perhaps the most important
step in blepharoplasty surgery; if the initial marking is not per­
formed well, the ultimate surgical outcome will be suboptimal.
Skin markings may be made with the patient in an upright or
supine position. If the initial markings are made with the pa­
tient supine, it is helpful to recheck the marks with the patient
upright to assess changes that may occur due to gravitational
effects on the eyelid or eyebrow. Calipers or a ruler are use­
ful for achieving greater symmetry. One can use a fine-point
marking pen, a standard surgical marking pen sharpened to
a point with a #15 blade, or a toothpick dipped in dye such
as brilliant green or methylene blue. Eyelid marking is usu­
ally performed in the holding area prior to administration of
sedative agents.
The inferior border of the blepharoplasty incision should
be placed at the desired height of the eyelid crease. In Cau­
casian patients the central portion of the crease is highest
while the temporal and nasal ends are lower. In the Asian
lid, the crease is more often less arched.63 Nasally, the inci­
sion should extend no closer than 5 mm from the superior
punctum and, in general, should not extend more medially
than an imaginary line drawn vertically through the upper
punctum. Extending the incision too far nasally can induce
cicatricial band formation, or ‘webbing.’ The lateral portion
of the upper eyelid incision is flared temporally and usually
does not extend beyond the tail of the brow (the most lat­
eral portion of the brow cilia). If concurrent transcutane­
ous lower blepharoplasty is planned, the upper and lower
­eyelid incisions should be separated by at least 5 mm so as
to ­diminish the risk of lateral canthal webbing and chronic
lymphedema.64–66
To estimate the amount of eyelid skin to be removed, with
the eyes gently closed, one arm of a smooth forceps is placed
in the eyelid crease while the other pinches the redundant skin
until the eyelashes just begin to rotate. This marks the maxi­
mum amount of skin that may be safely removed. In males,
skin excision is often performed more conservatively than in
females as lids with minimal folds may appear ‘feminized.’ In
A
B
Fig. 27-11  (A) A coronal plane drawn through the most anterior projection of the zygoma passes anterior to the cornea. There is adequate
bony support for the eyelid. (B) The same plane passes through the eye indicating insufficient bony support for the lower eyelid.
Box 27-3  Preoperative evaluation of blepharoplasty
patients
Take ophthalmic history
Measure visual acuity
Note eyebrow position
Note eyelid position, closure
Note lower eyelid tone
Note of globe relative to lower eyelid

495
Blepharoplasty  •  Chapter 27
general, the superior border of the incision should pass no
closer than 1 cm from the inferior border of the eyebrow cilia
(Fig. 27-12). This approximates the zone where the thicker
skin of the eyebrow transitions into the thinner skin of the
eyelid.
If brow ptosis is present and is not to be corrected at the
time of blepharoplasty, the brow may be manually elevated to
an appropriate position when the eyelids are marked. Failure
to do this may result in resection of an excessive amount of
skin such that if the patient subsequently decides to undergo
brow-lifting, lagophthalmos will result.67
Anesthesia
Blepharoplasty may be performed under local anesthesia
alone or in combination with intravenous sedation or, if in
conjunction with larger or more extensive surgical proce­
dures, under general anesthesia. When relying on anesthetic
injection for both anesthesia and hemostasis, a 1:1 mixture of
2% lidocaine with epinephrine 1:100 000 mixed with 0.5%
bupivacaine is prepared in a 9:1 ratio with hyaluronidase. The
hyaluronidase helps the anesthetic solution diffuse through the
tissues and minimizes distortion.
Surgical procedure
One drop of topical anesthetic (such as proparacaine 0.5%) is
instilled in each eye and protective plastic scleral shells lubri­
cated with ophthalmic ointment are placed behind the lids.
A No. 15 Bard Parker blade is used to incise along the skin
markings. Hemostasis is achieved and a skin-muscle flap is
then elevated, taking care to stay in the plane deep to the
orbicularis muscle, as failure to do so will result in excessive
bleeding. Sharp dissection of skin and muscle in the plane an­
terior to the septum is facilitated by countertraction. Once the
skin and muscle flap is removed, the orbital septum should be
visible (Fig. 27-13). The preaponeurotic fat pad, a useful land­
mark, should be visualized beneath the septum as it will pro­
trude anteriorly when pressure is gently applied to the globe.
If there is still uncertainty as to the septum’s identity, the edge
of the tissue should be grasped with a forceps to verify the sep­
tum’s firm attachment to the orbital rim, thus distinguishing it
from the levator aponeurosis which moves freely.
The septum is opened horizontally in the area overlying
the orbital fat, allowing the fat to prolapse into the wound
(Fig. 27-14). The preaponeurotic fat is yellow in color and the
nasal fat has a whiter appearance. The nasal fat pad may be
divided into two seemingly separate pockets by a fibrous sep­
tum.68 Therefore, this area should be dissected carefully yet
thoroughly. Traction on the fat pads should be avoided to pre­
vent rupturing of deeper orbital blood vessels. It is ­preferable
to allow the fatty tissue to emerge into view by gently applying
pressure to the globe with a cotton-tipped ­applicator. ­Bipolar
cauterization is used to maintain hemostasis. Fat ­ removal
­requires exquisite control of bleeding. Fat lobules can be
cauterized or clamped in advance of cutting. The removed
fat may be set aside for comparison with quantity anticipated
preoperatively and for comparison between the left and right
lids. Undercorrection is far easier to correct than the ­hollow
deformities resulting from excessive fat removal. While sculpt­
ing the nasal fat pad, it is imperative to avoid injury to the
­medial canthal tendon and the trochlea of the superior
­oblique muscle.
Fig. 27-12  Typical appearance of upper blepharoplasty incision.
Orbicularis oculi m.
Orbital septum
Fig. 27-13  Upper blepharoplasty. A skin-muscle flap is elevated,
exposing the underlying orbital septum. Care is taken not to dissect
within the muscle itself.

496
Chapter 27
Cosmetic surgery procedures and techniques
Lacrimal gland tissue is normally firm and whitish in color
as opposed to the soft texture and yellow color of the fat of the
central fat pad. A prolapsed gland should be suspended and re­
positioned behind the orbital rim using 5-0 monofilament per­
manent suture. Abnormal lacrimal gland appearance or friable
texture of the adjacent periosteum is an indication for biopsy.
If the ROOF is to be sculpted, dissection in the suborbicu­
laris muscle plane extends 10–15 mm above the lateral portion
of the superior rim, avoiding injury to the lacrimal nerve. The
fat pad is reduced in the lateral third to half of the brow in
an en bloc fashion, tapering the perimeters to avoid abrupt
disparities in thickness. The dissection should not extend
medial to the central brow to avoid damaging the supraorbital
neurovascular complex. A layer of fat should be preserved
between the orbicularis oculi muscle and rim periosteum, as
excision of the entire ROOF complex may result in surface
irregularities, skin adhesions producing brow immobility, or a
combination of these problems.
Excess orbicularis or septum in the wound may be trimmed
to further improve lid contour. If the lid crease is to be
reformed, a maneuver known as supratarsal fixation may be
performed. With this maneuver, the wound edges are sutured
to the superior tarsal border. Supratarsal fixation may be
­performed with interrupted or running sutures. Alternating
superficial skin closure and deep passes to engage the levator
aponeurosis can also be used to define the new lid crease. When
the wound is aligned in preparation for skin closure and excess
skin is encountered at the medial end of the wound, a Bur­
row’s triangle can be excised. The resultant wound should be
closed with interrupted sutures. Cold compresses are applied
immediately after surgery. Occlusive dressings are avoided,
so abrupt vision changes or excessive bleeding from the wound
will be apparent.
Lower lid blepharoplasty
Selecting the approach to lower lid blepharoplasty depends
upon whether there is excess skin, excess orbicularis mus­
cle, excess herniated fat, or malar descent. When there is fat
herniation in the absence of excessive lower lid skin, then a
transconjunctival approach is favored. When there is moderately
excessive lower lid skin, herniated orbital fat, or hypertro­
phy of the orbicularis muscle, a skin-muscle flap approach
is used.
Transconjunctival blepharoplasty
Areas of prominent fat protrusion should be marked with the
patient sitting upright; when in a supine position the fat falls
posteriorly into the orbit and is difficult to assess. Topical an­
esthetic is administered and scleral shields lubricated with an
ophthalmic ointment are inserted to protect the eye. Local an­
esthetic is injected subconjunctivally into the fatty tissue com­
partments (posterior to the rim where the septum originates)
and along the inferior orbital rim, near the infraorbital nerve.
If anesthetic is injected into the inferior oblique muscle, tem­
porary pupillary dilation and diplopia may result. The lower
lid is retracted inferiorly using a Desmarres retractor which
should rest against the maxilla anterior to the inferior orbital
rim. A lid plate or malleable retractor is placed in the fornix
and over the protected globe to ballot the eye so as to induce
protrusion of orbital fat. The incision is created horizontally
through conjunctiva and lid retractors overlying the area of
fat herniation, usually half way between the inferior fornix
and inferior tarsal border. Since the lower lid retractors may
fuse with the orbital septum as low as 2–3 mm below the in­
ferior tarsal border, the orbital fat does not extend superiorly
beyond this point and the incision should be made below this
level. A battery-operated disposable hot cautery, Colorado
needle, radiofrequency device, or CO2 laser may be used to
achieve hemostatic cutting. Once the conjunctiva and lower
eyelid retractors have been divided, the anterior orbital fat
becomes visible within its fibrous sheath (Fig. 27-15). While
the wound edges are retracted with scleral hooks, dissection is
• Pay attention to the position of the eyelid crease
when making the incision.
• Beware of inherent upper eyelid asymmetry.
• Distinguish between true dermatochalasis and
upper eyelid fullness due to eyebrow ptosis.
Pearls
Preaponeurotic fat
Fig. 27-14  Upper blepharoplasty. The preaponeurotic fat pad is
prolapsed into the surgical field after the orbital septum is opened
near the superior orbital rim.
• Do not resect too much upper eyelid skin as this
may induce eyebrow ptosis or lagophthalmos.
• Do not confuse the preaponeurotic fat pad
with fatty degeneration within the levator
­aponeurosis.
• The eyelids can be most unforgiving; err on the
side of being conservative.
Pitfalls

497
Blepharoplasty  •  Chapter 27
extended through the capsulopalpebral fascia until the central
fat pad is visualized. The incision is extended laterally to the
lateral canthal angle and medially to a point just lateral to the
plica semilunaris.
The amount of anticipated fat removal is determined
in the preoperative evaluation, the goal being to eliminate
the fatty tissue prominence while avoiding a ‘hollow’ ap­
pearance. A Desmarres retractor can be placed within the
wound to retract and expose the orbital fat. If the fat is not
transected with a hemostatic device, it should be carefully
clamped with a hemostat prior to division. If a CO2 laser is
used to transect the fat, clamping is not necessary. Fat exci­
sion should proceed in a systematic fashion and only that fat
herniating anterior to the level of the orbital rim is removed.
Care must be taken to avoid injury to the inferior oblique
muscle when working in the medial and central portions of
the lower eyelid (Fig. 27-16). The lateral fat pad is usually
divided into two compartments, one adjacent to the central
fat pad and another located more posteriorly and laterally.69
To adequately expose these lateral fat lobules, the arcuate
expanse of the inferior oblique may be divided. The inferior
oblique muscle divides the central and nasal fat compart­
ments and should be recognized by its horizontal orientation
in the anterior-inferior orbit. Injury to this muscle or its sheath
may result in double vision. The presence of prominent ves­
sels associated with the medial fat compartment should be
anticipated. Medial fat repositioning can be performed with
the transconjunctival approach. The orbital septum remains
intact and the periosteum can be incised at the arcus mar­
ginalis in order to access the subperiosteal space (see below).
If redistributing orbital fat, ensure both the transposition of
fat as well as the release of the orbicularis oculi muscle at its
insertion site.
The patient may be assisted to the sitting position to assess
symmetry and effectiveness of the fat reduction. The wounds
are irrigated and hemostasis is ascertained. The conjunctival
incision is under little tension and may be left to close spon­
taneously. The retractors do not require closure. The scleral
shells are removed and a combination antibiotic-steroid drop
(such as Tobradex® Alcon, TX) is instilled. Due to the fre­
quency of adverse reactions, products containing neomycin
should be avoided.
Transcutaneous lower lid blepharoplasty
with or without fat repositioning
Skin marking and anesthesia  Preoperative markings should
be drawn with the patient sitting upright. It is helpful to delin­
eate the nasojugal tear trough, specific location and severity
of fatty prolapse, and the extent of orbicularis muscle hyper­
trophy when applicable. Using forceps to gently pinch the
lower lid, determine the maximum amount of skin that can be
removed from the subciliary area without inducing downward
lower lid margin bowing. This mark will remind the surgeon
of the upper limit of vertical shortening when skin is actu­
ally removed in subsequent steps. Preoperative photographs
are useful for intraoperative reference. Topical anesthetic is
instilled into both eyes and protective scleral shields lubri­
cated with artificial tear ointment are placed behind the lids.
The local anesthetic described above is injected subcutane­
ously over the entire lower eyelid and into the lateral canthal
region.
Fig. 27-15  Lower eyelid transconjunctival blepharoplasty,
­surgeon’s view. The dashed line indicates the recommended
­placement of the incision.
Conjunctiva and
lower eyelid
retractors
Jaeger plate
protecting the eye
Fibrous capsule
surrounding
anterior orbital fat
Fig. 27-16  Lower eyelid transconjunctival blepharoplasty, right
eye, surgeon’s view. The inferior oblique muscle passes between
the nasal and central fat pads. It should be identified but not
manipulated during blepharoplasty surgery. The fat pads may be
conservatively resected or repositioned.

498
Chapter 27
Cosmetic surgery procedures and techniques
Incision and dissection  A standard subciliary incision placed
1.5 mm below the cilia can be initiated laterally with a No. 15
Bard Parker blade (Fig. 27-17). The incision is ­extended me­
dially to within 2 mm of the lacrimal punctum using sharp
Wescott scissors or with a No. 15 Bard Parker blade. Lateral
to the lateral canthal angle, the incision is directed infero­
temporally along a natural laugh line. This lateral portion of
the lower lid incision is extended if more skin needs to be
­removed, but initially the length need only facilitate skin and
muscle dissection inferiorly. A traction suture placed partial
thickness through the tarsus centrally and just at the subciliary
incision (avoiding skin puncture) is useful for providing coun­
tertraction.
Generally, a combined skin and muscle flap method is
used. However, it may be advantageous to elevate skin only
in the pretarsal orbicularis area, since keeping the muscle
layer undisturbed may decrease the chance of developing a
depressed subciliary scar (Fig. 27-18). Once the orbicularis
muscle has been exposed, a blunt-tipped scissors is used to
buttonhole the preseptal muscle (Fig. 27-19). The muscle is
then opened across the full extent of the wound and dissection
is performed inferiorly in the suborbicularis oculi plane until
the inferior orbital rim is exposed. Meticulous hemostasis is
maintained during this dissection.
Removal of hypertrophic orbicularis muscle  When orbicu­
laris muscle hypertrophy is present, a skin flap can be dis­
sected to expose the muscular bulge. The superior edge of
prominent orbicularis mounding often begins 3–5 mm below
the lash line and is accentuated with smiling. The muscle is
reduced by partially and superficially excising muscle tissue
layers along the orientation of the fibers, decreasing the ante­
rior to posterior prominence. Bleeding is anticipated but easily
controlled in this region. An alternative method uses electro­
surgical modification and ablation of the orbicularis muscle to
reduce the muscle prominence.70
Removal of orbital fat  In contrast to the transconjunctival
approach, when the transcutaneous approach is utilized the
orbital fat cannot be exposed without opening the orbital
Orbicularis oculi m.
Forceps applying
upward traction
Fig. 27-19  Transcutaneous lower blepharoplasty. The preseptal
orbicularis oculi muscle is opened with traction superiorly on the
eyelid margin and on the inferior border of the wound.
Fig. 27-17  Transcutaneous lower blepharoplasty. Typical skin
incision.
Fig. 27-18  Transcutaneous lower blepharoplasty. Some surgeons
prefer to leave the pretarsal orbicularis oculi muscle intact to help
decrease the risk of postoperative ectropion.

499
Blepharoplasty  •  Chapter 27
­septum. The entire width of the septum may be incised at a
point just above the arcus marginalis in order to expose the
medial, central, and lateral fat compartments. The fat may
then be transposed or excised conservatively. Alternatively,
small buttonholes can be made in the septum to allow access
to the fat. Gentle pressure applied to the orbit through the lids
will accentuate fat herniation. When the first lateral fat pad is
removed, balloting the globe can expose a second more pos­
terior fat pad.71 This fat may also need to be sculpted to avoid
residual temporal lower eyelid fullness. Next, the central and
nasal fat pads are addressed. Fat that protrudes anterior to the
rim can safely be removed using techniques described ­earlier.
Sitting a patient upright during surgery will allow ­ better
­judgment of the adequacy of liposculpting. Care should be
taken not to excise too much fat. Fat repositioning into a tear
trough defect will produce a more youthful appearance than
will overaggressive fat resection.
Fat repositioning
Traditional blepharoplasty techniques emphasizing fat re­
moval alone are now recognized to be too limited a strategy
in rejuvenative surgery. In the presence of significant cheek fat
descent, rejuvenation may additionally require a midface lift,
a discussion of which is beyond the scope of this ­chapter.72
Tear trough deformities without significant malar descent can
be corrected by fat preservation and repositioning. In this ­setting,
nasal fat removal would worsen a sunken lid ­appearance. The
inferomedial orbital rim is palpated and the septum is ­incised at
the arcus marginalis, near the origin of the levator labii ­superioris
alaeque nasi muscle. A periosteal elevator is used to create a
­subperiosteal pocket 10 mm distal to the incision ­spanning the
length of the trough to be filled. Damage to the infraorbital
­foramen located 7–10 mm inferior to the rim at the junction of
the medial third and lateral third of the eyelid is avoided.
The medial fat capsule is incised to liberate the fat lobules
and allow fat to be advanced anteriorly without creating trac­
tion. The fat is fashioned into a mallet-shaped fat flap with a
5–7 mm diameter pedicle and positioned into the subperiosteal
pocket. If properly performed, there should be no tendency for
the fat to recoil posteriorly and extraocular motility should not
be restricted. The fat can be secured using a 6-0 polygalactin
or nylon horizontal mattress stitch that loosely engages the an­
terior edge of periosteum and part of the fat pedicle. Alterna­
tively, the fat may be positioned into a pocket fashioned in the
preperiosteal plane. The fat pedicle may be imbricated with a
7-0 polypropylene suture which is brought through the skin and
tied to maintain adequate positioning of the fat pad. The su­
ture is removed approximately 1 week postoperatively. Patients
undergoing fat repositioning should be advised that postopera­
tive swelling may persist several weeks or months.
Skin excision
The skin-muscle flap is draped without traction over the
subciliary incision (Fig. 27-20). The amount of skin to be
removed is determined with the patient gazing upward and
opening the mouth. Excess skin extending above the sub­
ciliary incision is excised with sharp Westcott scissors. The
primary lid skin tightening effect is achieved by horizontal
shortening at the laugh line, rather than by shortening verti­
cally. Therefore, conservative amounts of skin are removed
from the subciliary region. Aggressive vertical shortening is al­
most guaranteed to cause lower lid malposition. The excised
subciliary skin is a horizontally oriented triangle with apex
pointing medially with maximal widths usually ranging from
1 mm to 4 mm.
As mentioned, skin tightening should be accomplished
in the horizontal vector. The edge of the skin-muscle flap is
draped laterally along the curvature of the lower lid with a
gentle amount of traction and the overlap is excised to reduce
skin redundancy. The extra ‘dog-ear’ of tissue is eliminated
by a combination of extending the original laugh line incision
(usually not more than 15 mm) and excising a triangle of the
skin-muscle flap with apex at the inferior extent of the lateral
incision.
Lower eyelid tightening
Laxity of the lateral canthal tendon and/or inferior retinacu­
lum is extremely important in lower eyelid rejuvenation. Fail­
ure to tighten a lax lower eyelid during lower blepharoplasty
will result in postoperative ectropion, inferior scleral show,
and tearing. When tightening the lower eyelid, it is important
to maintain the general shape of the eye. Conversion of an
‘almond-shaped’ eye to a ‘round’ shape will certainly produce
an unhappy patient.
Skin closure  The subciliary portion of the wound should not
be under tension and can be closed using 7-0 chromic gut, silk,
or nylon sutures in a running fashion from medially to laterally.
The lateral wound extent is closed in an interrupted fashion
to maximally align the closure and distribute tension. Sutures
are removed in 5 days, although in laser-assisted ­incisions, the
­sutures should remain for 7–10 days (Figs 27-21, 27-22).
• Be aware of the inferior oblique muscle and do
not manipulate it.
• Tightening the inferior retinaculum is an
­important part of lower blepharoplasty.
• If resecting lower eyelid skin, place the skin on
maximal stretch to avoid inducing an ectropion.
Pearls
•  Do not over-resect orbital fat.
•  If performing transconjunctival blepharoplasty,
do not let the lower eyelid curl back on itself
as this can lead to an inadvertent full-thickness
eyelid incision.
• The eyelids can be most unforgiving; err on the
side of being conservative.
Pitfalls

500
Chapter 27
Cosmetic surgery procedures and techniques
A
B
A
B
C
Fig. 27-20  (A) Transcutaneous lower blepharoplasty. The skin-muscle flap is draped without traction over the incision while the patient gazes
superiorly and opens the mouth, placing the lower eyelid on maximum stretch. The dashes indicate the proposed line of skin excision.
(B) Transcutaneous lower blepharoplasty. A ‘dog-ear’ of tissue should be excised laterally to reduce skin redundancy. (C) Transcutaneous
lower blepharoplasty. Correct appearance of wound as it is closed.
Fig. 27-21  Clinical photographs
(A) before and (B) 1 month after
upper blepharoplasty.

501
Blepharoplasty  •  Chapter 27
Postoperative clinical considerations
Written postoperative instructions should include information
on activity restrictions, wound care, and expected wound ap­
pearance. It is difficult to list every specific restriction or con­
traindication; therefore, an explanation of why the limitations
are recommended will allow the patient to extrapolate and
employ good judgment. The patient should be informed of
signs or symptoms that warrant medical attention and then
urged to maintain a low threshold for seeking your medical
advice. It is important to indicate whom to contact in the
event of an ocular emergency.
Wound care and appearance
Patients are instructed to apply ice compresses as often as pos­
sible for the first 48–72 hours in order to reduce eyelid swell­
ing and improve comfort level. Crushed ice or frozen peas
can be placed in resealable plastic bags. Direct application of
compresses to the skin has been known to cause frostbite and
can be avoided by placing a moistened gauze or towel on the
lids to buffer the intense cold of the ice pack. On the day
of surgery, applications initially of 30 minutes duration each
hour are suggested, with decreasing intensity over the subse­
quent 2 days after surgery. Beyond this, ice has limited efficacy
and warm compresses are recommended for improved subjec­
tive comfort. The patient is instructed to keep the head and
neck elevated 30–45 degrees with 2–3 stacked pillows during
sleep to further reduce periocular accumulation of depend­
ent edema for at least the first 3 days. A combination antibi­
otic-steroid ointment is applied to the suture line three to four
times per day to reduce tissue reaction to sutures.
Patients should be prepared to expect eyelid swelling and
bruising beginning on the first postoperative day. The edema is
expected to diminish 2–3 weeks after surgery. Consumption of
salty foods or a systemic state of fluid retention may aggravate
eyelid swelling. Darkening of the skin in the early postoperative
period may represent deposition of hemosiderin and resolves
spontaneously. Persistent pigmentation may occur as a result of
sun exposure while lids are ecchymotic.73 Patients are thus in­
structed to avoid such exposure by wearing sunglasses or a hat.
Activity restrictions
To avoid bleeding induced by positive pressure to the orbital
or eyelid vasculature during the first postoperative week,
­patients should refrain from heavy lifting or exertion, ­lowering
the head beneath the heart, or other activities that result in a
Valsalva maneuver. If patients live a significant distance from
a medical facility, they should arrange to stay nearby for the
first night after surgery. Patients should be contacted by tel­
ephone on the evening of surgery and the following day. If a
patient reports persistent bleeding, swelling, significant pain,
decreased vision, erythema, or discharge from the wound,
prompt examination is required. If there are no unanticipated
concerns, the patients are then seen again on postoperative
day 5–10 for suture removal.
Analgesia
Satisfactory postoperative analgesia is usually achieved with
acetaminophen alone, although some patients require nar­
cotics such as propoxyphene or codeine. Nonsteroidal anti­
inflammatory agents and aspirin must be avoided for at least
1 week after surgery to diminish bleeding risks. Application
of ice compresses often provides additional comfort and may
reduce swelling and ecchymosis.
Anticipated recovery
Low-exertion exercise may be resumed after 1 week, and
more vigorous activities after 2 weeks. Contact lens wear may
be resumed 1–2 weeks after surgery, but the patient must be
reminded to limit lid manipulation as the wounds are subject
to dehiscence in the early postoperative period. This antici­
pated postoperative contact lens wear abstinence should be
discussed with patients preoperatively so they may be pre­
pared to wear glasses during the early postoperative period.
Patients are told to expect 80% of the swelling to resolve over
2 weeks, while the remaining 20% may take 3–6 months or
A
B
Fig. 27-22  Clinical photographs (A) before and (B) 1 month after transconjunctival lower blepharoplasty.

502
Chapter 27
Cosmetic surgery procedures and techniques
longer to completely resolve. Makeup may be applied to the
upper eyelids 1–2 days after the sutures have been removed.
Concealer may be applied to the eyelids remote from inci­
sion lines to cover ecchymosis soon after surgery; however, the
patients must exercise caution in removing the cosmetics to
avoid excessive periocular manipulation.
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Norman Publishing; 1994:4–6 .
  2. Katzen LB. The history of cosmetic oculoplastic surgery; in cosmetic
oculoplastic surgery, 3rd edn. Philadelphia: WB Saunders; 1999:3–10.
  3. Baker SS, Muenzler WS, Small RG, et al. Carbon dioxide laser
blepharoplasty. Ophthalmology 1984; 91:238–243.
  4. Wesley RE, Bond JB. Carbon dioxide laser in ophthalmic plastic and
orbital surgery. Ophthalmic Surg 1985; 16:631–33.
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10. Glassberg E, Babapour R, Lask G. Current trends in laser
blepharoplasty. Results of a survey. Dermatol Surg 1995; 2:1060–1063.
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eyelid blepharoplasty. Semin Ophthalmol 1998; 13:103–106.
12. Hamra ST. The role of orbital fat preservation in facial aesthetic
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13. Weinstein C. Ultrapulse carbon dioxide laser removal of periocular
wrinkles in association with laser blepharoplasty. J Clin Laser Med Surg
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14. MT Doxanas, RL Anderson. Oriental eyelids: an anatomic study. Arch
Ophthalmol 1984; 102:1232–1235.
15. Lemke BN, Lucarelli MJ. Anatomy of the ocular adnexa, orbit, and
related facial structures. In: Nesi FA, Lisman RD, Levine MR, eds.
Smith’s ophthalmic plastic and reconstructive surgery, 2nd edn.
St. Louis: Mosby; 1997:1–75.
16. Meyer DR, Linberg JV, Wobig JL, et al. Anatomy of the orbital septum
and associated eyelid connective tissues. Ophthal Plast Reconstr Surg
1991; 7:104–113.
17. Doxanas MT, Anderson RL. Eyebrows, eyelids, and anterior orbit. In:
Clinical orbital anatomy. Baltimore: Willimas & Wilkins; 1984:57–88.
18. Hisatomi C, Fujino T. Anatomical considerations concerning
blepharoplasty in the Oriental patient. Adv Ophthalm Plast Reconstr
Surg 1983; 2:151–165.
19. Liu D, Hsu WM. Oriental eyelids: anatomic difference and surgical
consideration. Ophthalm Plast Reconstr Surg 1986; 2:59–64.
20. Barker DE. Dye injection studies of intraorbital fat components. Plast
Reconstr Surg 1977; 59:82–85.
21. Putterman AM. The mysterious second temporal fat pad. Ophthalm
Plast Reconstr Surg 1985; 1:83–86.
22. Hoenig JA, Shorr N, Shorr J. The suborbicularis oculi fat in aesthetic
and reconstructive surgery. Int Ophthalm Clin 1997; 37:179–191.
23. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial
musculoaponeurotic system to the orbit and characterization of the
orbitomalar ligament. 1996; 12:77–88.
24. Mitz V, Peyronie M. The superficial musculoaponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg 1986;
58:80–88.
25. Reuss W, Owsley JQ. The anatomy of the skin and fascial layers of the
face in aesthetic surgery. Clin Plast Surg 1987; 14:677–682.
26. Hargiss JL. Surgical anatomy of the eyelids. Trans Pac Coast
Otolaryngol Ophthalmol Soc 1963; 44:193–202.
27. Lucarelli MJ, Khwarg SI, Lemke BN, et al. The anatomy of midfacial
ptosis. Ophthalm Plast Reconstr Surg 2000; 16:7–22.
28. Owsley JQ. Lifting the malar fat pad for correction of prominent
nasolabial folds. Plast Reconstr Surg 1993; 91:463–474.
29. Furnas DW. Festoons, mounds, and bags of the eyelids and cheek. Clin
Plast Surg 1993; 20:367–385.
30. Owsley JQ. Anatomy of the head and neck for aesthetic surgery. In:
Owsley JQ, ed. Aesthetic facial surgery, Philadelphia; WB Saunders;
1994:7–24.
31. Aiache AE, Ramirez OH. The suborbicularis oculi fat pads: an
anatomic and clinical study. Plast Reconstr Surg 1995; 95:37–42.
32. Hamra ST. Repositioning the orbicularis oculi muscle in composite
rhytidectomy. Plast Reconstr Surg 1992; 90:14–22.
33. Lowry JC, Bartley GB. Complications of blepharoplasty. Surv
Ophthalmol 1994; 38:327–350.
34. DeMere M, Wood T, Austin W. Eye complications with blepharoplasty
or other eyelid surgery: a national survery. Plast Reconstr Surg 1974;
53:634–637.
35. Koorneef L. The architecture of the musculo-fibrous apparatus in the
human orbit. Acta Morphol Neerl Scand 1977; 15:35–64.
36. Neuhaus RW. Complications of blepharoplasty. Am Acad Ophthalmol
Focal Points. 1990; 8(3):1–12.
37. Mahaffey PJ, Wallace AF. Blindness following cosmetic blepharoplasty –
a review. Br J Plast Surg 1986; 39:213–221.
38. Schechter RJ. Management of inadvertent intraocular injections. Ann
Ophthalmol 1985; 17:771–775.
39. Nelson CC, Passyk KA, Dootz GL. Eye shield for patients undergoing
laser treatment. Am J Ophthalmol 1990; 110:39–43.
40. Hayworth RS, Lisman RD, Muchnick RS, et al. Diplopia following
blepharoplasty. Ann Ophthalmol 1984; 16:448–451.
41. Rainin EA, Carlson BM. Postoperative diplopia and ptosis: a clinical
hypothesis based on the myotoxicity of local anesthetics. Arch
Ophthalmol 1985; 103:1337–1339.
42. Perlman JP, Conn H. Transient internal ophthalmoplegia during
blepharoplasty: a report of three cases. Ophthalm Plast Reconstr Surg
1991; 7:141–143.
43. Harley RD, Nelson LB, Flanagan JC, et al. Ocular motility disturbances
following cosmetic blepharoplasty. Arch Ophthalmol 1986; 104:542–544.
44. Jordan DR, Anderson RL, Thiese SM. Avoiding inferior oblique injury
during lower blepharoplasty. Arch Ophthalmol 1989; 107:1382–1383.
45. Levine MR, Boynton J, Tenzel RR, et al. Complications of
blepharoplasty. Ophthalm Surg 1975; 6:53–57.
46. Wesley RE, Pollard ZF, McCord CD Jr. Superior oblique paresis after
blepharoplasty. Plast Reconstr Surg 1980; 66:283–286.
47. Alfonso E, Levada AJ, Flynn JT. Inferior rectus paresis after secondary
blepharoplasty. Br J Ophthalmol 1984; 68:535–537.
48. Baylis HI, Sutcliffe T, Fett DR. Levator injury during blepharoplasty.
Arch Ophthalmol 1984; 102:570–571.
49. Carraway JH, Mellow CG. The prevention and treatment of lower lid
ectropion following blepharoplasty. Plast Reconstr Surg 1990; 85:830.
50. Edgerton MT Jr. Causes and prevention of lower lid ectropion following
blepharoplasty. Plast Reconstr Surg 1972; 49:42–52.
51. Kamer FM, Mikaelian AJ. Preexcision blepharoplasty. Arch Otolaryngol
Head Neck Surg 1991; 117:995–999.
52. Mandel MA. Closure of blepharoplasty incisions with autologous fibrin
glue. Arch Opthalmol 1990; 108:842–844.
53. Kosko PI. Upper lid blepharoplasty: skin closure achieved with butyl-2-
cyanoacrylate. Ophthalmic Surg 1981; 12:424–425.
54. Baylis HI, Goldberg RA, Wilson MC. Complications of upper
blepharoplasty. In: Cosmetic oculoplastic surgery. Putterman AM,
Warren LA, eds. Philadelphia; WB Saunders; 1999:411–428.

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55. Smith B, Lisman RD. Dacryoadenopexy as recognized factor in upper
lid blepharoplasty. Plast Reconstr Surg 1983; 71:629–632.
56. Collin JRO. Blepharochalasis. A review of 30 cases. Ophthalm Plast
Reconstr Surg 1991; 7:153–157.
57. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty
patient: bypassing the pitfalls. Clin Plast Surg 1993; 20:213–223.
58. Hill JC. An analysis of senile changes in the palpebral fissure.
Can J Ophthalmol 1975; 10:32–35.
59. Shagets FW, Shore JW. The management of eyelid laxity during
lower eyelid blepharoplasty. Arch Otolaryngol Head Neck Surg 1986;
112:729–732.
60. Hill JC. The role of the lateral canthal tendon in lower eyelid laxity
(commentary). Plast Reconstr Surg 1982; 69:623.
61. Neuhaus RW. Anatomic basis of ‘senile’ ectropion. Ophthalm Plast
Surg 1985; 1:87–89.
62. Ousterhout DK, Weil RB. The role of the lateral canthal tendon in
lower eyelid laxity. Plast Reconstr Surg 1982; 69:620–622.
63. Chen WPD. Comparative anatomy of the eyelids. In: Chen WPD, ed.
Asian blepharoplasty: a surgical atlas. Boston: Butterworth-Heinemann;
1995:1–19.
64. Smith B, Nesi FA. The complications of cosmetic blepharoplasty.
Ophthalmology 1978; 85:726–729.
65. Tenzel RR. Treatment of lagophthalmos of the lower lid. Arch
Ophthalmol 1969; 81:366–368.
66. Wolfley DE. Blepharoplasty: the ophthalmologist’s view. Otolaryngol
Clin North Am 1980; 13:327–363.
67. Frankel AS, Kamer FM. The effect of blepharoplasty on eyebrow
position. Arch Otolaryngol Head Neck Surg 1997; 123:393–396.
68. Ullmann Y, Levi Y, Ben-Izhak O, et al. The surgical anatomy of the
fat in the upper eyelid medial compartment. Plast Reconstr Surg 1997;
99(3):658–661.
69. Putterman AM. The mysterious second temporal fat pad. Ophthalm
Plast Reconstr Surg 1985; 1:83–86.
70. Weber PJ, Wulc AE, Moody BR, et al. Electrosurgical modification of
orbicularis oculi hypertrophy. Ophthalm Plast Reconstr Surg 2000;
16(6):407–416.
71. Putterman AM. Simultaneous treatment of lower eyelid
dermatochalasis and abnormal-appearing skin. Am J Ophthalmol
1983; 96:6–9.
72. Putterman AM. Cheek and midface lift combined with full-thickness
temporal lower eyelid resection. Cosmetic oculoplastic surgery: eyelid,
forehead, and facial techniques, 3rd edn. Philadelphia; WB Saunders;
1999: 235–247.
73. Adams BJS, Fuerstein SS. Complications of blepharoplasty. Ears Nose
Throat J 1986; 65(1):6–18.

History and Science
Background and history
Intrinsic aging of the face and neck combined with extrinsic
insults such as cigarette smoke and ultraviolet radiation cause
predictable ptosis of soft tissues and the appearance of more
prominent facial lines.1 Traditional surgical procedures for
face and neck lifting usually involve general anesthesia, skin ex­
cision with resulting scars, extensive undermining, the risk of
significant perioperative complications, and extended recovery
Suture Suspension Lifts
David Horne and
Michael S. Kaminer
C h a p t e r
28
p a r t 2
Key Points
n Many patients are willing to trade decreased
cosmetic improvement for the lower morbidity and
recovery times associated with minimally invasive
procedures.
n There are several potential advantages of this
­implant compared to earlier suspension sutures:
More secure anchoring by tying with a paired
suture to underlying fascia,
Unidirectional barbs limiting motion to one vector,
Clear suture for low visibility or invisibility under
thin or transparent skin.
n Durability of cosmetic effect with suspension
­sutures when used as monotherapy may be limited.
periods. These procedures are being increasingly ­supplanted
by new noninvasive or minimally invasive techniques. While
the cosmetic benefit of these new procedures may not be
as dramatic, many patients are clearly willing to trade some
­degree of efficacy for decreased morbidity and recovery time.
The utility of internal sutures for lifting soft tissue has
been well demonstrated. Internal sutures have been used as
adjuncts to traditional open face-lifts for years. Sasaki and Co­
hen and others have demonstrated efficacy of this technique
in lifting the relatively fibrous malar fat pad in the context
of open face-lifts.2–4 Other nonabsorbable sutures have been
used as adjuncts to liposuction in the lower face and neck by
Giampapa and Di Bernardo and others.5,6
As surgeons increasingly experimented with less invasive
procedures, the use of internal suspension sutures as stand-
alone procedures was inevitable. Essentially ‘incisionless’ face
lifting has been suggested by multiple authors using such im­
plants.7–12 Many of these studies are uncontrolled and limited
in their follow-up.
The durability and effect of some of these approaches
may be limited by impermanent anchoring or undesirable
tissue tension vectors. The concept of increasing the holding
capacity of these sutures by adding barbs was introduced by
Sulamanidze et al.7 At least three proprietary sutures have
emerged as the result of this early work: the Aptos Thread,
the Isse Endo Progressive Facelift Suture (KMI Inc., Anaheim,
CA) and Contour Threads (Surgical Specialties, Reading,
PA). Limitations of these implants have included protrusion
of sutures through the skinm7,13 asymmetry of cosmetic
­effect,2,7,8 poor durability of effect,8,and the need to place sub­
sequent sutures to maintain symmetry or correct ­asymmetry.7
Basic science/clinical studies
The rationale for adding barbs to suspension sutures is to dis­
tribute tension more uniformly over the length of the suture;
hundreds of barbs will catch on hundreds of fibrous septae in

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Chapter 28
Cosmetic surgery procedures and techniques
the subcutis. This theoretically reduces tension on proximal
and distal ends of nonbarbed loops.
Jang et al. demonstrated formation of a capsule around
barbed suture in rat skin consisting of collagen, fibroblasts,
blood vessels, and inflammatory cells. This fibrous capsule
formed sooner and thicker around cogged sutures than around
noncogged sutures in the rat model.14 Nonpeer-reviewed data
from the manufacturer of Contour Threads similarly suggests
that the presence of barbs along the suture may increase fi­
broblast activity and resulting fibrosis around the scar. In an
animal model, this fibrous capsule was well incorporated into
the surrounding dermis and subcutis in several months.15 It is
not clear if this translates clinically into improved long-term
performance of the suture.
Eremia and Willoughby discuss the use of absorbable an­
chored suture similarly anchored to the temporal fascia. As an
adjunct to open face-lifts, the small series suggested that the
sutures were beneficial in terms of extending the duration of
lifting with open conservative lifts and improving the appear­
ance of postoperative preauricular scars and earlobe position.
In the same series, for closed procedures without skin excision
or undermining, excellent results were reported for the first
6 months. However, the authors report essentially complete
loss of tightening at 12 months’ follow-up.16
Translocation of ptotic skin away from the central and lower
face towards the hairline results in predictable bunching of
the skin. This redundant skin resolves within 2–3 weeks even
in patients with relatively inelastic skin. The process by which
this occurs is unclear. DeLorenzi posits an apoptotic process,
‘the biological opposite of tissue expansion.’17 The increased
presence of myofibroblasts, as demonstrated by Jang et al.,
may allude to the role of cellular remodeling.14
Discussion
The durability of cosmetic tightening and lifting with pure
subdermal suture suspension is unclear. A small series initially
reported retention of up to 90% of face and neck tightening
at 4 months in patients treated with Contour Threads.18 How­
ever, the authors’ experience is that further loss of tightening
can be seen for up 12 months postoperatively. It appears that
the majority of relaxation occurs in the first 3–4 months after
the procedure, and in most patients subsequent loss of effect
is minimal. Maintenance of cosmetic effect is greatest in the
midface and poorest along the jawline and neck. The utiliza­
tion of additional sutures in these poor-performing areas may
alleviate some of this predictable loss.
A larger series showed predictable loss of tissue lifting at
6 months with complete loss of tightening at 12 months with
a similar, though absorbable suture.16 However, this report
showed improvement of cosmetic outcome when this suture
was used as an adjunct to open face-lift.
The use of barbed sutures appears to be a viable strategy
for lifting and repositioning of facial tissue, at least temporar­
ily. Contour Threads may provide advantages to the surgeon
and patient that other thread systems do not. Longer and
larger follow-up studies are essential.
The optimal techniques for placement and removal of su­
tures, the consequences of long-term subdermal polypropylene
placement, and the potential for revision and retightening of
extant sutures should be the subjects of future ­investigation.
Procedures and Techniques
Preoperative clinical considerations
Patient selection
Patients should be counseled that the cosmetic results are not
as dramatic or long-lasting as those which could be achieved
with a surgical rhytidectomy. Patients are typically in their
30s to 60s. The skin of older patients, or patients with severe
dermatoheliosis or elastosis, may not retract or remodel as ef­
fectively. Similarly, patients with significant smoking histories,
diabetes, immunocompromised, or other factors that could
retard healing should be carefully considered. Patients with
bleeding disorders or on medications that inhibit clotting
should be counseled regarding the increased risk of hematoma
and ecchymosis. Patients unwilling or unlikely to comply
with the extended postoperative instructions to avoid stress or
trauma to the lifted soft tissues are not ideal candidates.
A sample informed consent form and a sample of preop­
erative instructions given to patients are provided in Appendix
A and Appendix B, respectively.
Other considerations
Though the entire procedure may be completed under local
anesthesia, many patients will benefit from oral or muscular
sedation or anxiolysis. Infiltration of relatively large amounts
of local anesthetic may otherwise be uncomfortable for the
patient at the beginning of the procedure. Similarly, mild
sedation may make the relatively long procedure time (usu­
ally at least 2 hours) more bearable. The goal is to keep the
patient awake and alert yet comfortable. The patient must
be able to turn his/her head and move according to the
­surgeon’s instructions during instrumentation. Patient input
is also critical to ensure correct plane of placement and to
determine the final degree of tightening at the end of the
procedure.
The patient should be prepped and draped in the usual
sterile fashion as for any surgical procedure. Hibiclens or
benzalkonium chloride (Zephiran, Sanofi-Synthlabo, NY)
are good choices as antiseptics as they do not obscure pre­
operative markings. A surgical tray prepared for a standard
excision is usually adequate. A surgical table or chair that can
be moved easily from a seated to a supine position is essential.
The threads are most easily placed with the patient supine.

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Suture suspension lifts  •  Chapter 28
For final contouring, the patient will need to return to the
seated position while maintaining sterile technique.
Procedural techniques
See Figures 28-1 through Figure 28-22 for a graphic presenta­
tion of the procedure.
• Hibiclens or Zephiran provide adequate
­antisepsis without obscuring or altering
­preoperative surgical markings.
• Mupirocin cream applied to hair surrounding the
insertion sites helps keep hair from catching on
the barbs and being pulled into the skin.
• Once all threads are placed, some initial
­tightening can be done with the patient supine.
Final contouring should be done with the patient
in a natural, seated position.
• Leaving the distal end of the threads exposed
for up to 1–3 days postoperatively may allow
­immediate postoperative swelling to subside
prior to final contouring.
• A travel or airplane pillow that fits closely around
the neck can be used by patients at night to limit
motion and trauma to the face while sleeping.
Pearls
Fig. 28-1  The Contour Thread™ is supplied as a 25 cm
­polypropylene suture with a barbed middle portion. It is attached
to a 7-inch straight insertion needle distally and a 26 mm half-circle
taper needle proximally.
Fig. 28-2  The patient immediately before the procedure.
Fig. 28-3  With the patient in a seated position, the course and
number of Contour Threads to be used are marked out with a surgi­
cal marker. Local anesthesia is infiltrated along these lines (0.5–1%
lidocaine with 1:100 000 to 1:200 000 epinephrine).

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Cosmetic surgery procedures and techniques
Fig. 28-4  For lifting of the brow, middle, and lower face, placement
of the insertion needle occurs posterior to the frontal and temporal
hairline. A small area of hair may be trimmed away in preparation.
This area should be infiltrated with local anesthesia with epinephrine
for improved hemostasis.
Fig. 28-5  A 3–4 mm incision is made at the proximal end of each
thread track to facilitate placement of the insertion needle.
Fig. 28-6  For each pair of sutures, a third incision is made 1–2 cm
posterior to the insertion incisions. The anchoring knot will be tied
and seated into this third incision.
Fig. 28-7  Surgical scissors are used to create a pocket over the
temporal fascia for seating of the anchoring knot.
Fig. 28-8  For most anatomic locations, it is advantageous to bend
the needle to allow it to follow more easily the curves of the face.
Fig. 28-9  The prepared insertion needle after curving by the
surgeon prior to insertion.

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Suture suspension lifts  •  Chapter 28
Fig. 28-10  To place an individual thread, the surgeon guides the
insertion needle through the distal incision and into the subcutane­
ous plane. The needle is advanced in this plane in a zigzag move­
ment (approximately 25–30 per thread) along the marked trajectory.
Once anchored, this zigzag placement of the suture limits retrograde
motion along the suture and results in an implanted suture that is
longer than the drawn trajectory. This maximizes the number of
barbs in the subcutis and theoretically provides more stability of the
translocated skin.
Fig. 28-11  Movement of the needle and suture through the
subcutis is generally well tolerated by patients. If the straight needle
moves superficial to this plane it is immediately apparent as linear
dimpling of the overlying skin. If the needle enters the deep subcutis
or approaches the muscle fascia or periosteum, the patient will report
the sensation of pain or pressure. As illustrated, the ­needle may be
lifted to ensure uniformity of placement. At any point, the insertion
needle may be partially or completely removed and ­repositioned.
Fig. 28-12  The insertion needle exits the skin at the medial cheek.
A cotton-tipped applicator aids in stabilizing the skin over the exiting
needle.
Fig. 28-13  The insertion needle is cut from the thread after pulling
the attached suture through the skin. This leaves the barbed portion
of the thread buried in the subcutis with the free ends extending from
the proximal insertion point and the distal medial face exit point.
Postoperative considerations
A sample of the postoperative instructions given to patient is
provided in Appendix C.
Possible complications
Because the Contour Thread barbs may be released with in­
tense pressure, patients must initially avoid strenuous exercise
or movements that could dislodge the tightened skin from the
hundreds of barbs along the sutures.
Fig. 28-14  The curved needle on the proximal end of the suture is
then used to anchor the suture near its insertion to the underlying fas­
cia or periosteum. The incision 1–2 cm posterior to the insertion points
serves as an exit point for the curved needle after this deep suturing.

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Chapter 28
Cosmetic surgery procedures and techniques
Fig. 28-15  Greater security of this anchor point is achieved by
tying this suture at its proximal end with its paired suture running
a similar parallel course in the skin. It is recommended to tie this
square knot with four throws. It is useful to tie the knot onto a scissor
or similar instrument to facilitate the proper square knot architecture
and tension. The resulting knot is seated in the previously created
suprafascial pocket through the posterior incision by gentle traction
on the distal ends of the paired sutures.
Fig. 28-16; Fig. 28-17  When all planned threads have been
placed and anchored, the patient returns to the seated position.
The distal ends of the threads extend from the patient’s medial face.
Holding the distal end of the suture with one hand, the surgeon’s
other hand pushes the lax skin overlying the suture towards the an­
choring point. The unidirectional barbs catch on the fibrous septae
of the subcutis, preventing retrograde movement.
The distal end of the suture may protrude against the der­
mis at rest or with certain movements of the head and neck.
This may be appreciated subjectively by the patient or may
be visible or palpable on examination. Though this complaint
may resolve with time as fibrosis forms around the distal su­
ture, the distal end may need to be located, moved extracuta­
neously, and cut shorter.
The large amount of subdermal instrumentation predict­
ably results in at least moderate edema and ecchymosis. Swell­
ing can persist, especially in the infraorbital area, for up to
3 weeks. The relatively thin skin of the neck is most susceptible
to bruising where it may persist for the same time period.
­Immediate postoperative edema may be significant enough to
interfere with contouring at the end of the procedure. It may
be necessary to leave the distal ends of the sutures exposed
and have the patient return several days postoperatively for
final contouring.
The subjective sensation of ‘tightness’ of the translocated
skin is nearly universal. Patients understand that this is a cor­
relate of cosmetic tightening and readily acclimate to this
sensation. Pain and tenderness at rest and with mastication
are common, typically at anchoring points over the tempo­
ralis. These symptoms are usually mild but may require oral
analgesia.
Transient neuropathy of the greater auricular nerve may
occur when using the sternocleidomastoid muscle fascia as an
anchoring point on the lateral neck. Using the new Articulus
modification (see Fig. 28-20) or leaving the knotted proximal
ends of the paired sutures unanchored in the subcutis may
limit this complication.
Acute loss of tightening along one or multiple sutures may
occur with trauma. Violent coughing, yawning, and crypto­
genic, nocturnal trauma have all been associated with abrupt
loss of tightening. This may be associated with rupture of the
anchoring site or loss of suspension along a majority of barbs
along the length of the suture. Compliance with postoperative
instructions should minimize this poor outcome. Insertion of
more threads in the traumatized area may be necessary.

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Suture suspension lifts  •  Chapter 28
Linearity or dimpling may be noticeable under the rela­
tively thin skin of the temples and neck. This may resolve with
time. Ensuring that the thread is placed in an adequately deep
tissue plane is essential to avoid this complication.
Asymmetry of cosmetic tightening, dimpling or linearity,
or the sensation of the distal end of the suture may all be
addressed immediately, as well. Firmly applied retrograde
pressure along a suture will result in the focal release of sev­
eral underlying barbs from their attachment to fibrous septae.
This can be appreciated as a clicking sensation under the sur­
geon’s finger. In the authors’ experience, threads have been
successfully released in this manner up to 9 weeks postopera­
tively, though this becomes increasingly difficult after the third
week.
Other considerations
Mild pressure and ice packs will help minimize immediate
postoperative pain, swelling, and bleeding. Patients should
clearly understand that too much pressure may dislodge the
newly place threads and result in loss of cosmetic correction.
It may be useful to demonstrate to patients exactly how much
pressure is appropriate and which areas should be avoided.
Any remaining postoperative pain should be managed with
oral analgesics containing acetaminophen with or without
a mild opioid. Remind patients to avoid oral analgesics such as
aspirin or ibuprofen that would increase the risk of hematoma
and ecchymosis.
Fig. 28-19  The distal end of the suture extending from the medial
face is cut at its exit point and retracts under the skin. Incisions used
for insertion of the straight needle and anchoring heal rapidly by
secondary intention.
Fig. 28-20  A modification of this suture, marketed as ‘Articu­
lus,’ is supplied as a longer barbed suture with straight needles
­attached at both ends. Insertion at paired, side-by-side entry points
­(approximately 1–2 cm apart) leaves the paired sutures attached by
a nonbarbed segment which straddles the underlying fascia. This
modification may eliminate the need for tying the paired sutures in
some locations.
Fig. 28-18  The patient after tightening of all sutures. Translocation
of the skin along the suture causes the lax skin of the face and neck
to accumulate at the hairline and lateral neck. This may be camou­
flaged with anterior combing of the hair. The resulting folds of skin
are quickly and almost completely remodeled or redistributed to the
scalp and neck in several days to weeks.