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

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Suture suspension lifts  •  Chapter 28
A
B
C
Fig. 28-22  (A) is preoperative, (B) is 6 months postoperative, and (C) is 1 year postoperative.
REFERENCES
  1. Kazinnikova OG, Adamian AA. Age-specific changes in facial and
cervical tissues: a review. Ann Plast Reconstr Aesthetic Surg 2000;
1:52–61.
  2. Sasaki GH, Cohen AT. Meloplication of the malar fat pads by
percutaneous cable-suture technique for midface rejuvenation: outcome
study (392 cases, 6 years’ experience). Plast Reconstr Surg 2002;
110:635–654.
  3. Keller GS, Namazie A, Blackwell K, et al. Elevation of the malar fat pad
with a percutaneous technique. Arch Facial Plast Surg 2002; 4(1):20–25.
  4. Owsley JQ, Fiala TG. Update: lifting the malar fat pad for correction of
prominent nasolabial folds. Plast Reconstr Surg 1997; 100(3):715–722.
  5. Giampapa VC, Di Bernardo BE. Neck recontouring with suture
suspension and liposuction: an alternative for the early rhytidectomy
candidate. Aesthetic Plast Surg 1995; 19:21–23.
  6. Beaty MM. Treatment of neck laxity with a Gore-Tex cervical sling for
patients with heavy neck tissues. Facial Plast Surg 2001; 17(2):117–122.
Patients should be instructed to sleep with their head el­
evated for the first few nights after surgery to minimize edema.
Ensure that all patients having received oral or intramuscular
sedation have safe transportation home. Evaluating patients
within 1 week of the procedure is important to monitor appro­
priate healing, verify resolution of side effects, adjust thread
tightness and ‘pull’ as needed, and manage patient concerns.
As some loss of cosmetic tightening is expected in nearly all
patients within 3 months, further follow-up is recommended
in this time frame to manage patient expectations and plan
adjuvant procedures as needed.
  7. Sulamanidze MA, Fournier PF, Paikidze TG, et al. Removal of facial
soft tissue ptosis with special threads. Dermatol Surg 2002;
28(5):365–371.
  8. Lycka B, Bazan C, Poletti E, et al. The emerging technique of antiptosis
subdermal suspension thread. Dermatol Surg 2004; 30(1):41–44.
  9. Lee S, Isse N. Barbed polypropylene sutures for midface elevation. Arch
Facial Plast Surg 2005; 7:55–61.
10. Khawaja HA, Hernandez-Perez E. Transcutaneous face-lift. Dermatol
Surg 2005; 31(4):453–458.
11. Vazquez GD. Facial percutaneous suspension. Plast Reconstr Surg 2005;
116(2):656–660.
12. Hernandez-Perez E, Khawaja HA. A percutaneous approach to
eyebrow lift: the Salvadorean option. Dermatol Surg 2003; 29(8):
852–855.
13. Silva-Siwady JG, Diaz-Garza C, Ocampo-Candiani J. A case of Aptos
thread migration and partial expulsion. Dermatol Surg 2005; 31(3):
356–358.
14. Jang HJ, Lee WS, Hwang K, et al. Effect of cog threads under rat skin.
Dermatol Surg 2005; 31:1639–1644.
15. Adamyan AA, Sulamanidze MA, Skuba ND, et al. Morphological
foundations of facelift using threads. A.V. Vishnevsky Institute of
Surgery, Russian Academy of Medical Sciences, Moscow, Russia.
Contour Threads monograph, provided by the manufacturer.
16. Eremia S, Willoughby MA. Novel face-lift suspension suture and
inserting instrument: use of large anchors knotted into a suture with
attached needle and inserting device allowing for single entry point
placement of suspension suture. Preliminary report of 20 cases with
6- to 12-month follow-up. Dermatol Surg 2006; 32:335–345.
17. DeLorenzi CL. Barbed sutures: rational and technique. Aesthetic Surg
J 2006; 26:223–229.
18. Horne DF, Kaminer MS. Reduction of face and neck laxity with
anchored barbed polypropylene sutures (Contour Threads™). Skin
Therapy Letter 2006; 11(1):5–7.

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Cosmetic surgery procedures and techniques
Appendix A
Contour Threads™ Consent Form
Patient Name: _____________________________________ Date: _______________Time: _______
Procedure:
Diagnosis:
Location: Eyebrows, Forehead, Midface, Neck
Dr. _________________________ and/or his/her staff have explained the nature of my condition, the nature of the procedure,
its alternative treatments, and the risks/benefits to be reasonably expected compared with alternative approaches. This document
is a written confirmation of this discussion.
By placing my initials next to the following items, I clearly understand and accept the following:
_______   1.  The goal of Contour Thread surgery, as in any other cosmetic procedure, is improvement, not perfection.
_______   2.  The final results may not be apparent for 6 to 12 months postoperatively.
_______   3.  In order to achieve the best possible result, in some cases additional surgery or Contour Thread placement
is necessary. There may be an additional fee for this extra surgery.
_______   4.  Some discomfort may be experienced during treatment. I give permission for the administration of anesthesia
when deemed appropriate by my physician or his/her designated staff.
_______   5.  Small insertion wounds are made for Contour Thread placement, which will take several days to heal. Small scars
may occur at the puncture site.
_______   6.  Strict adherence to the pre- and postoperative regimen is necessary in order to achieve the best possible results.
_______   7.  I have not taken any aspirin or aspirin-containing products, nonsteroidal antiinflammatory drugs (i.e. Advil/
Motrin or vitamin E) for 10 days prior to my surgery.
_______   8.  The surgical fee covers the operation itself and subsequent postoperative office visits. There is no guarantee that
the expected or anticipated results will be achieved.
_______   9.  I authorize the taking of photographs or films during the procedure and their use for teaching and research
purposes.
Although complications following Contour Thread placement are infrequent, by placing my initials next to the following,
I understand that they may occur:
_______   1. Skin irregularities, lumpiness, hardness and dimpling may appear postoperatively. Most of these problems
disappear with time, but localized irregularities may persist permanently. If loose skin is present in the treated area, it may
or may not shrink back to conform to my new contour.
_______   2. Deeper structures such as nerves, blood vessels, and muscles may be damaged during the course of surgery.
Although extremely uncommon, the potential for this to occur varies according to the site being treated. Injury to deeper
structures may be temporary or permanent.
_______   3. Infection is rare, but should it occur, treatment with antibiotics and/or surgical drainage may be required.
_______   4. Numbness or increased sensitivity of the skin over the treated areas may persist for months. It is possible that
localized areas of numbness or increased sensitivity could be permanent.
_______   5. Objectionable scarring is rare because of the small size of incisions used in Contour Thread surgery, but scar
formation is possible.
_______   6. In some cases, local allergies to tape, suture material, or topical preparations can occur. Systemic reactions may
result from the medication used during surgery, or from the use of oral antibiotics. Allergic reactions may require additional
treatment.
_______   7. Surgical bleeding is very rare, and theoretically could require hospitalization. It is possible that blood clots may
form under the skin and require subsequent surgical drainage.
_______   8. During the healing process, there is a possibility the skin will become either lighter or darker in the treated area.
This is usually temporary, but can be permanent.
_______   9. I have arranged for transportation home following surgery.
_______ 10. In addition to these possible complications, I am aware of the general risks inherent in all surgical procedures
and anesthetic administration.
_______ 11. Dr. _____________ requires assistants to perform the procedure, and they will be involved in all aspects of my care.

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_______ 12. I am aware that unexpected risks or complications may occur and that no guarantee or promises have been made
to me concerning the results of any procedure or treatment.
My signature certifies that I have read and discussed the previous material thoroughly with my physician and/or his/her staff;
and that I understand the goals, limitations and possible complications of Contour Thread surgery and I wish to proceed with
the operation.
I also consent to the administration of anesthesia i.v. sedation, or local to be applied by or under the direction of the operating
surgeon, and the use of such anesthetics as deemed advisable. I have received pre- and postoperative (before and after) instructions
both written and verbal. I was given a chance to ask questions and all of my questions have been answered to my satisfaction.
______________________________________
______________
Patient Signature 
Date
I have explained the above statements to the patient and answered all questions.
______________________________________
______________
Clinical Staff Signature 
Date
______________________________________
______________
Physician Signature 
Date
Appendix B
Preoperative Contour Treads™ Face-lift Instructions
Take all medication as prescribed:
• KEFLEX – one 500  mg tablet 2 times a day. Begin the day before surgery. (Or another antibiotic if allergic to Keflex
as prescribed by your doctor.)
• ATIVAN – you will be given an oral medication to relax you when you arrive at the office.
Preoperative precautions:
• DO NOT TAKE ASPIRIN- or ibuprofen-containing products for 2 WEEKS prior to surgery.
• Inform the staff if you are taking ANY medications (prescription or over-the-counter), or if you have any allergies to medications.
• PLEASE TRY NOT TO SMOKE for 2 weeks prior to surgery.
• DO NOT TAKE any oral VITAMIN E supplements for 2 WEEKS prior to surgery.
• DO NOT DRINK ANY WINE or ALCOHOL for 48 HOURS before surgery.
• Wear comfortable loose clothing the day of surgery. It is preferable to have clothing that you do not have to fit over your head
(buttons or zippers in the front), so as to make it easier to get dressed after the procedure.
• DO NOT plan to drive yourself home after surgery. YOU MUST arrange for transportation home after the procedure. If you will
be staying alone, please notify us in advance of your surgery date.
• If you have any questions, please feel free to call the office at _______.
Appendix C
Contour Threads™ Postoperative ­Instructions
Continue to take all medication as prescribed:
• Keflex (or other antibiotic if allergic to Keflex as prescribed by your doctor.)
• Tylenol for pain or Tylenol with Codeine for pain as directed. (Please read instructions on the bottle label ­carefully.)
• DO NOT TAKE ASPIRIN- OR IBUPROFEN-­containing products for three days after surgery.
• DO NOT DRINK ALCOHOL FOR 3 DAYS after ­surgery.
• PLEASE DO NOT SMOKE for 3 weeks after surgery.
• No strenuous activity for 1 week. Please ask at your follow up visits if you have questions regarding when you may resume
exercising.

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• It is IMPORTANT to avoid the following actions for 3 weeks after Contour Thread placement to ensure maximal results
from your procedure:

1. Don’t pull down on the sutures or massage/rub the treated areas.

2. Do not drink with straws or purse your lips.

3. Avoid straining.

4. If forehead was treated, hold brows up if coughing, sneezing, or crying.

5. BE EXTREMELY CAREFUL WITH SLEEPING:


• Try to sleep on your back.


• Do not apply pressure to your skin with the pillow.


• Use a cervical pillow (similar to pillow that fits around the neck to use on an airplane).
Additional instructions:

• Apply Bacitracin to injection sites.

• Do resume your regular diet and drink lots of fluids. Be cautious for the first 24 hours with solid foods.

• Apply ice to area for first 24 to 48 hours to reduce swelling and bruising.

• Sleep in an upright position for 24 hours to reduce swelling and bruising.

• If you have any questions or concerns at all, please feel free to call the center at _____________ during normal business hours
or have the doctor paged at _________________ at other times.
_________________________________________
Date___________________
Patient’s Signature
___________________________________________________________________
Patient (Print Name)

History and Science
Face-lift surgery (cervicofacial rhytidectomy) remains the ulti­
mate rejuvenative cosmetic procedure. Contemporary face-lift
surgery is a combination of art and science and requires signifi­
cant experience to become proficient. Many subtle, technique-
sensitive operative steps and nuances must be appreciated
by the surgeon to provide predictable results with few compli­
cations. The purpose of this chapter is to share some of the
pearls and pitfalls of face-lift surgery.
History
The scientific literature is replete with descriptions of early face-
lift techniques from the early twentieth century that primarily
detailed skin tightening and excision.1–11
Science
In 1973, Skoog presented a technique of elevating the platysma
muscle without detaching the skin.12 In 1976, Mitz and
Peyronie described the SMAS13 and later other authors de­
scribed techniques of SMAS plication and imbrication.14–16
By the late 1970s and mid-1980s a combination of complete­
platysmal muscle transaction, plication medial borders,­ and
pulling laterally was presented as the way to get the ‘best
result.­’17,18 Patient complaints, complications, and over­
operated necks occurred and many of these techniques were
abandoned.19 Deep plane and subperiosteal techniques have
been described by many authors20–22 as well as endoscopic
­approaches.23
Discussion
Many other techniques have been described and some surgeons
have gone as far as ‘inventing’ new techniques and patenting
catchy names to describe some minimally invasive face-lift
that is supposedly revolutionary. For the most part, these ‘new’
techniques are a rehashing of previously described techniques.
When reviewing the literature it should be kept in mind that
just because a technique has been published or promoted does
not mean it is better or safer. It will be mentioned many times
throughout this chapter that patient safety and outcome are
testament to ‘the best’ face-lift technique. Some techniques
may work well in the hands of a given surgeon and if they
provide safe procedures with great outcomes then they cannot
be criticized. For the novice surgeon, however, it is preferable
to begin with safe and predictable techniques before advancing
to more complex procedures. Walk before you run!
Procedures and Techniques
Preoperative clinical considerations
Face-lift anatomy
A basic review of pertinent anatomy is presented to under­
score salient features and danger zones. Any doctor attempt­
ing to perform face-lift surgery should devote significant time
and effort in studying this anatomy. This includes didactic and
cadaver dissection.
The first layer concerned in face-lift anatomy is obviously
the skin. The dermal plexus of blood vessels nourished the
skin (and face-lift flap) and must at all times be protected.
When dissecting a face-lift flap, several millimeters of fat are
left adherent to the dermal undersurface to protect this area
and enhance flap viability. The next layer is the subcutane­
ous layer (Fig. 29-1). This is the layer of fat that is intimate to
the dermis superiorly and also with the superficial musculo­
aponeurotic system (SMAS) inferiorly. The subcutaneous
layer is basically a safe layer in that the temples, neck, and
face can be undermined in the subcutaneous plane without
Face-lifts
Joseph Niamtu
C h a p t e r
29
P a r t 2

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Cosmetic surgery procedures and techniques
damage to significant anatomical structures. The third layer
is the SMAS layer. This layer separates the overlying subcu­
taneous fat from the underlying parotid-masseteric fascia and
facial nerve branches (Fig. 29-2). The SMAS layer is continu­
ous with the galea in the scalp, the temporal-parietal fascia
in the temples and the superior cervical fascia in the neck.
The SMAS invests the muscles of facial expression and vari­
ous authors contest each other in the finite description of
the SMAS and related layers. All motor nerves providing
­movement of the facial muscles are deep to this plane. The
forth surgical plane commonly involved in face-lift surgery is
the sub-SMAS plane (Fig. 29-3). This surgical plane contains
the facial nerve motor branches and the parotid duct. This
plane is best avoided for novice surgeons. Although the facial
nerve is usually protected by the parotid gland, the parotid-
masseteric fascia is a thin membrane that overlies the facial
nerve branches anterior to the parotid gland.
An entire chapter can easily be dedicated solely to face-lift
anatomy. The goal of this discussion is to familiarize the reader
with the most basic anatomy. Although it is of importance­ to
know all the structures, in the most basic form, it is merely
important to know how to stay away from them. For instance,
the external jugular vein can be vulnerable in some patients to
neck liposuction. The buccal nerve branches of the facial nerve
can be inadvertently injured by indiscretion when ­dissecting
anteriorly during flap elevation. The greater auricular nerve
is frequently encountered when performing the subcutane­
ous dissection over the sternocleidomastoid (SCM) muscle.
Continual­ review of pertinent face-lift anatomy should be an
ongoing pursuit of learning.
Instrumentation
Although many specialized instruments exist specifically for
rhytidectomy, in reality the procedure can be performed with
relatively basic surgical instruments that most doctors have
in their offices (Fig. 29-4). Specialized face-lift scissors are the
most important instrument in the face-lift procedure. This
author­ prefers Padgett ‘Gorney’ face-lift scissors (Padgett Inc.,
Kansas City, MO; Item #P-6831TC). Another indispensable
instrument is a versatile electrosurgery system. This is used all
throughout the face-lift procedure from incision to coagulation.
This author prefers the Ellman Radiowave Surgical System
Fig. 29-1  The subcutaneous plane is subdermal and is a ‘safe
plane’ in face-lift surgery, as the facial nerves lie inferior to the plane.
Fig. 29-2  The SMAS plane is a fascial plane that consists of the
galea (1) in the scalp, the SMAS (2) in the cheek and the superior
cervical fascia (3) in the neck.
• The facial nerves are generally protected while
dissecting in the subcutaneous plane.
• While any patient can have an exception, this
plane is considered safe for protecting the facial
nerve branches.
Pearls

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Face-lifts  •  Chapter 29
(Ellman International, Oceanside, NY) with microelectrodes for
incision and bipolar forceps and ball electrodes for coagulation.
Patient selection
There is no doubt that proper patient selection is the key to
successful face-lift results, especially for the novice surgeon.
There are a number of biopsychosocial variants that can
enhance­ or detract from the final result as well as increase or
decrease the stresses of dealing with the difficult patient. In
order to be a candidate for face-lift surgery, patients must pass
several basic tests (Table 29-1).
Number one, they have to be healthy enough for the proce­
dure and the anesthesia. In this day and age many patients are
living longer with multiple system disease supported by vari­
ous medications. We must remember that all cosmetic surgery
is elective and no one really ‘needs’ cosmetic surgery. For this
reason, the surgeon must never lose sight of the fact that no
patient should ever come out of a procedure in worse shape
than he or she entered. Most patients with controlled non-
life-threatening diseases such as hypertension, thyroid condi­
tions, diabetes, and minor pulmonary or cardiac conditions
can be successfully managed through face-lift surgery and
anesthesia. Patients on anticoagulants are a distinct problem
and one must consider all of the ancillary over-the-counter
medications that may affect coagulation. Aspirin and the 3 Gs
(ginkgo, garlic and ginseng) can alter coagulation as can other
herbs and mega-dose vitamins. Smoking is another problem
that affects both the surgery and the anesthesia. Although some
face-lift surgeons will refuse to operate on smokers, this author
has operated on scores of them without significant complica­
tions. It is important to be more conservative with this patient
population and perform a more complex preoperative work-
up. These patients are at risk not only for flap necrosis but for
intraoperative anesthetic and airway problems.
Face-lift patients are subject to a more intense preoperative
work-up. All face-lift patients are well served to have a physi­
cian history and physical at least 3 weeks before surgery as
well as CBC, coagulation panel, HIV, hepatitis C, and EKG.
If there is a significant smoking history a chest X-ray is indi­
cated. Routine preoperative screening will uncover cases of
undiagnosed disease such as diabetes, myocardial infarction,
thyroid disorders, and anemia.
The psychological status of the patient is also extremely
important for many factors including stress, the ability to be
happy, the ability to adequately follow instructions, and medi­
colegal reasons. Face-lift patients can display a wide range of
potential emotional problems. Most surgeons are very familiar­
with body dysmorphic disorder and should avoid patients
­exhibiting these signs or symptoms.
A large part of the happiness of a face-lift patient has to
do with communication and problems have to do with the
lack thereof. One problem is that the word ‘face-lift’ means
different things to different people. Some people think a
full face-lift involves other procedures such eyelid and brow
surgery­ along with the lower face surgery. As elemental as it
Fig. 29-3  The sub-SMAS layer contains the facial nerve branches
and the parotid duct. The thin membrane called the parotid-
masseteric fascia overlies the facial nerve branches anterior to the
parotid gland. 1, temporalis muscle; 2, masseter muscle; 3, sterno­
cleidomastoid muscle; 4, parotid gland; 5, external jugular vein;
6, greater auricular nerve.
Fig. 29-4  The author’s comprehensive face-lift instrumentation.
Table 29-1  General face-lift requirements
Adequate health history
Adequate recovery window
Adequate mental health
Adequate budget

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sounds, it is the duty of the surgeon to explain not only what
the face-lift is and will do, but also what it will not do. Expe­
rience has led this author to create a special form with the
surgical consent form. The form is entitled ‘What Your Face-
lift Won’t Do.’ This form explains that a face-lift by itself
is an operation for the lower face and will not improve the
other facial structures, generalized skin wrinkling, or ablate
the nasolabial folds. This form has become an integral part
of the consent process and has at times been reviewed with
a postoperative patient with aberrant expectations. A similar
form for smokers detailing the possible smoking-related com­
plications is also used.
To give patients an ideal of how they will look with a face-
lift, they are placed horizontal with the chin extended and given
a mirror to hold directly over the face, which in the author’s
experience is relatively accurate (Fig. 29-5).
Like most surgeons, this author provides multiple types
of face-lifts. Patients are given the option of a conservative
face-lift with a preauricular incision only. This limited-incision
face-lift can be performed with either SMASectomy or SMAS
plication. This procedure is for those patients with minor
aging, and addresses the jowls very efficiently but is less dra­
matic in neck tightening. It is reserved for younger patients or
those patients that demand conservative surgery. This limited-
incision technique can also be used with tumescent anesthesia
on a medically compromised patient who could not tolerate a
larger procedure or general anesthesia.
In terms of conventional face-lifts (pre- and postauricular
incisions) it is explained to the patient that face-lifts come in
small, medium, and large depending upon the amount of flap
dissection required. In a small face-lift a 2–3 cm flap is used,
while a large face-lift may require a flap of 7–8 cm. The longer
the flap (or when combining ancillary procedures), the longer
the recovery. Unlike many face-lift surgeons, this ­author does
not routinely perform midline platysmaplasty with face-lifts.
The posterior platysma is always plicated to the mastoid fas­
cia which generally provides an adequately tight neck. This
author has performed hundreds of face-lifts with and without
midline platysmaplasty and personally does not notice a sig­
nificant difference. On the contrary, many problems have been
seen from other offices from overtreating the central neck, es­
pecially if the area has been overliposuctioned. Finally, when
performing platysmaplasty, it is not uncommon to encounter
significant intraoperative bleeding in the midline. This can be
difficult to control and can lead to bilateral hematoma for­
mation. If a patient specifically addresses the platysma bands
or has significant bands at rest (most patients have bands on
animation), the midline platysmal may be addressed. Many
surgeons advocate and routinely perform midline platysma­
plasty but few of them have tried to omit the procedure and
compare results.
One of the most important prognosticators of face-
lift success­ lies in the patient’s anatomy. Obviously obese
patients with thick necks and retracted mandibles will be
more difficult than thin patients with normal jaw structure.
The author feels that one of the best means of making pa­
tients understand this concept­ is to show them the diagram
in Figure 29-6. The position of the hyoid bone and associ­
ated muscles can make a big difference in a surgical result.
Those patients with a retrognathic mandible and a low-set
hyoid bone (Fig. 29-6A) are difficult to correct to an acute
cervical-mandibular angle. Those patients with a normal
mandible anatomy and a high-positioned hyoid bone (and
associated muscles) are much easier­ on whom to produce
a tight 90-degree cervicomandibular­ ­ angle (Fig. 29-6B).
This exact diagram is kept in the consultation room and
this anatomical variant is shown to those patients­ with poor
neck esthetics. A chin implant can offset this retrognathic
chin and provide some lengthening to offset the low hyoid
position.
The day of the surgery
The patient arrives, and any final financial arrangements are
taken care of. Patients are instructed to arrive in lose cloth­
ing without pull over tops and to leave all jewelry at home.
When they arrive an additional set of digital photographs are
taken and they are marked for their surgery. The patient then
meets with the anesthesia personnel for a final examination.
A surgical marker is then used to mark the following structures
(Fig. 29-7).

1. Pre and postauricular incisions

2. The extent of the flap dissection

3. Inferior border of mandible

4. Outline of jowls

5. Outline of submental area to be liposuctioned

6. Outline of platysmal bands if they are to be addressed

7. Submental crease

8. Submalar areas if implants are planned

9. Blepharoplasty and or brow markings if upper facial
surgery is planned
Fig. 29-5  Placing the patient in a recumbent position negates
gravity and provides an idea of the face-lift result.

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Face-lifts  •  Chapter 29
Procedural techniques
Prep and drape
Small face-lifts (especially as stand-alone procedures) like other
minor cosmetic procedures can be performed in a ‘surgical
clean’ environment. The face and hair are washed with a sur­
gical­ prep and sterile towels are draped over the operating­ field.
The surgeon and staff wear sterile gloves, mask, and surgical­
cap. All instruments, of course, are sterile.
Larger face-lifts and those with multiple other procedures
are performed in a surgical sterile environment in the same
manner as in a hospital operating room. Although infections
are rare in the head and neck, the standard of care is to use
sterile technique. In addition, especially when performing
simultaneous brow-lift and other procedures, the procedure
can be relatively bloody. Using sterile technique with complete
gloves and gown and fully draping the patient’s entire body
protects not only the patient but also the surgeon and staff.
Anesthesia
The average surgeon can learn to be a good rhytidectomy sur­
geon. The limiting factor for many practitioners is frequently
the inability to use or procure i.v. or general anesthesia. In
most states a Certified Registered Nurse Anesthetist (CRNA)
or physician anesthesiologist can operate in private offices
and provide the sometimes necessary level of anesthesia for
larger procedures. There is no doubt that many face-lifts can
be performed with local and or tumescent anesthesia and
­dermatologists are the innovators of this technique. By the
same token, sometimes it is much faster and simpler for the
doctor and patient to utilize sedation or general anesthesia.
Anesthesia is a personal matter based on training, local stand­
ard of care, and doctor and patient preferences. Some practi­
tioners prefer tumescent techniques bolstered with minor oral
Fig. 29-7  Typical preoperative markings for face-lift and concomi­
tant procedures.
A
B
Fig. 29-6  (A) A normal mandibular posi­
tion with associated normal hyoid and floor
of mouth anatomy. (B) A retrognathic man­
dible with a low-set hyoid bone and floor of
the mouth. Facial morphology similar to (B)
is more difficult to normalize.

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sedation. Other practitioners favor monitored anesthesia care
(MAC) using i.v. sedation with full monitoring using room air
or supplemental oxygen. Other surgeons insist on full-blown,
intubated general anesthesia. There are many arguments for
and against each technique. The technique of choice is based
upon patient safety and surgeon preference.
A detailed discussion of anesthesia is beyond the scope
of this chapter. It is assumed that if a surgeon is qualified
to ­perform face-lift surgery, he or she can provide or obtain
­anesthesia support.
Local and tumescent anesthesia
Even when using general or i.v. anesthesia, local and tumes­
cent techniques are utilized for all face-lift surgery. This is
­invaluable for pain control, hemostasis, and tissue plane dis­
section and reduces the amount of anesthetic agents required.
As stated earlier, probably any face-lift could be performed
with local and tumescent anesthesia by experienced hands.
Tumescent solution (0.1% lidocaine with 1:1 000 000 epine­
phrine) is injected into the submental area. Generally, 50–80 cc
is injected into the area from the inferior border of the mandi­
ble to the thyroid cartilage extending to the sternocleidomas­
toid muscles on each side. This will correspond with the area
to be liposuctioned. Immediately after this injection, a similar
amount is injected into the pre- and postauricular areas on
the first side of the face-lift. Finally, the actual incision lines
are injected in front and behind the ear with about 8 cc of 2%
lidocaine with 1:100 000 epinephrine for added hemostasis.
It is very important to stay ‘several steps ahead’ with the tu­
mescent anesthesia as it takes about 15 minutes to be ­effective.
This means that one must inject the second side of the face-
lift about 15 minutes from finishing the first side. It is not
uncommon­ to operate outside of the anesthetized area and,
even with general­ anesthesia, the patient may react. It is prudent­
to reinject these areas to obtund the pain and settle the patient.
Chin implants
In this author’s experience about 50% of face-lift patients
will benefit from chin augmentation, especially those with
low hyoid position and retrogenia (recessive chin). Most face-
lift surgeons place chin implants from a submental crease
incision. This approach is done only if already performing
a midline platysmaplasty and hence already having an inci­
sion. Ninety percent of the author’s chin implants are placed
from an intraoral approach if no submental incision is be­
ing used for other purposes. The method of placement is of
personal preference. Using simple chin (and cheek) implants
are small procedures that can make a big difference in the
final result.
Midline platysmaplasty
The basic technique is relatively simple. The anterior neck
is infiltrated with about 75 cc of tumescent anesthesia and
local­ anesthesia is placed under the planned incision. A
3–4 cm incision­ is made approximately 2 mm inferior to the
submental­ crease and a routine submental liposuction is per­
formed. After adequate liposuction, the incision is extended to
about 3 cm and, using face-lift scissors, a subcutaneous flap is
dissected within the previously defined boundaries. The flap is
usually easily developed by spreading and pushing the face-lift
scissors. Care is taken not to blindly cut tissue under this flap,
as controlling bleeding in this area can be difficult. The author
prefers the Ellman radiofrequency system (Ellman Interna­
tional, Oceanside, NY) with a long bayonet bipolar forceps
to control bleeding in this area. If bleeding or oozing is left
unchecked, the blood can gravitate to both face-lift flaps caus­
ing bilateral hematomas. There are many described methods
to address the dehisced platysma muscle. Some techniques are
complex and involve inferior release or excision of the platysma.
These are best reserved for experienced surgeons. The most
common technique is the midline corset platysmaplasty.
The procedure is performed by using a large tonsil hemo­
stat to grab redundant tissue in the midline over the defatted
platysma. The excess tissue is secured with the hemostat and,
using the radiofrequency microneedle, the tissue at the base
of the hemostat is excised. This leaves a midline resection of
redundant tissue and the borders of the platysma muscle are
secured with 2-0 braided nylon suture and tied with a bur­
ied knot. Several sutures are placed above and below the first
­suture to secure the platysma edges in the midline (Fig. 29-8).
Again, the area is rechecked for any bleeding or oozing prior
to closing.­ The wound is closed in two layers with 5-0 gut
suture­ and 6-0 nylon­ suture for the skin. Many other platysma
techniques exist, including criss-cross platysma sutures that
are secured to the mastoid fascia.
Face-lift incision design
The design of the pre- and postauricular incisions is perhaps
the most critical step in successful face-lift surgery. A prop­
erly designed incision will preserve the natural hairline and
periauricular anatomy such as the tragus and earlobe. It will
camouflage the incision scars and be minimally perceptible by
the patient and observers. Every face-lift patient is a walking
advertisement; nothing is worse for marketing than unnatu­
ral scars, temporal baldness, pixie earlobes, or distorted ear
anatomy. One’s local hairdresser can attest to which surgeons
pay close attention to face-lift incisions!
Minimally invasive face-lifts may only utilize a preauricu­
lar incision, while most traditional face-lifts require incisions
in front and behind the ear. Many surgeons advocate mak­
ing a superior temporal extension that extends superiorly
from the helical attachment into the temporal hairline. There
is no doubt that this incision can simplify the face-lift proce­
dure, but it carries high liability of elevating the temporal tuft
of hair in the sideburn area (Fig. 29-9). Proponents of this
­vertical ­temporal extension will say that the pull in the face-lift
should not be such that one elevates the hairline, but elevated
hairlines remain a frequent complication from other offices.
This author prefers and exclusively uses a horizontal releasing
incision in the sideburn on all face-lift patients (Fig. 29-10).

523
Face-lifts  •  Chapter 29
The positive aspect of this is no elevation of the temporal tuft
and the release allows one more direct visual access to the
dissected flap. Having performed hundreds of face-lifts, the
author has personally experienced most common complica­
tions but has never experienced temporal baldness.
The design of this incision involves placing the incision just
into the natural hairline. The best way to describe it is to put
the incision ‘just superior to the real hairline.’ This means that
the incision is placed into the area where the hairline changes
density from the sparse, fine hairs to the actual denser hairline.­
A
B
Fig. 29-9  The vertical temporal extension
incision favored by some surgeons (A) and the
resultant temporal tuft elevation with unsightly
baldness that can result from that incision
design (B).
A
B
Fig. 29-8  A rendering of platysma dehis­
cence is shown with midline corset platysma­
plasty correction.

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If one pays attention to this area one will notice that the infe­
rior hairs are sparse and fine, and several millimeters into the
actual sideburn the hairs become denser and actually define
the sideburn. Beveling this incision will allow the sideburn
hairs to grow through the incision scar and further improve­
the cosmetic result.
After making the temporal tuft release, the incision is car­
ried to the helical attachment and proceeds inferior in a cur­
vilinear fashion along the helical attachment just superior to
the tragus. There is a natural crease between the cheek skin
and the helical ear skin in most patients. In addition, the skin
is frequently a different color and texture at the cheek–ear
junction.­ If this incision is placed in this crease or at this
natural­ junction the incision heals with minimal scarring. If
the incision is placed too anteriorly or posteriorly, the scar can
be quite noticeable.
The next and perhaps most critical part of the incision in­
volves the tragus. Most surgeons will use either a pretragal or
retrotragal (endaural) incision. There are advantages and dis­
advantages to both incisions. The retrotragal incision will bet­
ter hide the scar. It is technically more difficult to master and
requires much attention when cutting away and recontouring
excess skin. If attention to detail is not followed (and some­
times if it is) the tragus can become blunted and deformed.
This is infrequently noticed by patients as they rarely see it,
but is quite obvious to the surgeon and other observers. If a
surgeon can use this incision with predictable ­postoperative re­
sults it is a superior approach. In males with hair-bearing skin
that extends into this area, other problems can be encountered.
It is possible to pull the bearded skin onto the tragus and into
the auditory canal. This is a difficult area to shave and thus
presents a ‘daily’ problem. Some authors advocate using elec­
trosurgery to destroy the hair follicles on the dermal side of the
flap but the blood supply to the skin can be easily disrupted,
causing necrotic tissue loss and scarring of the tragus. In this
age of available laser hair removal, the patient can be treated
to destroy the hairs on the tragus. Finally, some patients do not
feel inconvenienced by shaving the tragal area. This author rou­
tinely uses a retrotragal incision in all females. It is frequently
used in males as well, unless there is an extremely well-defined
preauricular crease. Figure 29-10 illustrates both incisions.
As the incision progresses inferiorly the earlobe is encoun­
tered and the incision is made directly in the crease formed
by the lobe where it meets the cheek. Progressing to the pos­
terior surface of the earlobe the incision is kept in the crease
as it rounds the lobe. At this point the incision will be directed
superiorly, and multiple options exist. In females, place the
incision 4–5 mm posterior to the postauricular sulcus. This
means that the incision is placed superior to the crease sev­
eral millimeters onto the conchal cartilage. The theory in this
placement is that the scar will contract several millimeters and
postoperatively end up in the depth of the sulcus, thus hiding
the incision. In males with hair-bearing postauricular skin, the
incision is made directly in the sulcus. This is done to avoid
pulling bearded skin onto the mastoid or posterior ear skin
which is very difficult to shave. Figure 29-11 shows the alter­
native incision sites.
The incision must come off of the ear and enter the hair­
line. Again, much discourse exists concerning the best method
to finish the incision. Many surgeons chose to run the
posterior incision into the cervical hairline. There are some
advantages to this technique. Primarily, if the patient has sig­
nificant excess neck skin, a generous posterior excision will be
required to remove the excess. If the incision is placed in the
hairline it is possible that the posterior hairline will be pulled
so ­ superiorly that it can cause posterior auricular baldness
A
B
Fig. 29-10  (A) The temporal tuft release with the retrotragal incision design. (B) The temporal tuft release with the pretragal design.

525
Face-lifts  •  Chapter 29
by severe elevation of the hairline. An additional advantage
of the cervical hairline incision is that it is easier to trim the
excess skin. The incision design decreases dog-ears and hair­
line stepping. This incision also carries some significant prob­
lems. If there is too much tension placed on the flap or if the
incision breaks down, a large, hypopigmented and sometimes
hypertrophic scar is common in this area. It is a situation that
usually does not happen, but when it does, the scar can be
extremely problematic and difficult to improve. Even the best-
designed ­cervical hairline incisions frequently heal with a vis­
ible white line that is difficult to conceal and may preclude
the female patient from wearing her hair up or pulled back.
Figure 29-12 shows a cervical hairline postauricular face-lift
incision and one made more superior into the hair-bearing
scalp.
It is important to hide the incision as much as possible.
Having said this, the easiest place to hide the posterior incision
is at the greatest width of the pinna; in other words, the widest
portion of the ear. At this point, the distance of visible inci­
sion is minimal as the hairline is very close to the pinna. Mak­
ing the incision lower than this shows more skin between the
pinna and the hairline, thus a more visible scar. Making the
incision even lower, say in the mastoid area, produces a very
visible incision. These low incisions are easier to trim ­excess
skin and produce fewer dog-ears to deal with, but the trade-
off of a very visible scar, which is a poor exchange.
After extending the incision from the back of the ear at the
greatest width of the pinna, the incision changes from vertical
to horizontal with a 90-degree angle at this juncture. As the inci­
sion enters the hair-bearing scalp it traverses posteriorly and in­
feriorly in a gentle angle for 3–6 cm, as shown in Figure 29-13.
Flap dissection
After making the appropriate incision the lipocutaneous flap
is developed. This is frequently a difficult step for the begin­
ner. It is not infrequent for novice surgeons to dissect too su­
perficial or too deeply. This can endanger the flap viability or
Fig. 29-11  A typical posterior auricular incision in females (solid
line) which is made 3–5 mm above sulcus and the preferred place­
ment for males with bearded postauricular skin (dotted line) which is
made at the depth of the sulcus.
Fig. 29-12  The cervical hairline incision is made several millimeters
into the posterior hairline (dotted line) while the author’s preferred
posterior incision is made more superior into the hair-
bearing scalp (solid line).
• Unnatural hairlines are the sine que non of a bad
face-lift.
• Extreme attention needs to be paid to tech­
niques that potentially alter temporal or posterior
hairlines.
• Proper incisions should favor natural hair lines.
• In contemporary face-lift surgery there is no
excuse for temporal or postauricular baldness.
Pitfalls

526
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Cosmetic surgery procedures and techniques
disrupt neurovascular structures. It is imperative to perform a
smooth dissection of consistent depth and flap thickness. The
dissection should leave sufficient fat on the dermal surface of
the flap as well as on the underlying SMAS. If the dissected
flap is too thin, the dermal plexus of blood vessels of the frag­
ile skin flap can be compromised. If the flap is too thick, the
operator may invade the parotid gland or facial nerves. The
key is to dissect a lipocutaneous face-lift flap with several mil­
limeters of fat on the dermal surface of the skin and several
millimeters of fat over the deeper structures. A simple means
to facilitate this controlled dissection is to use generous tumes­
cent local anesthesia. The volume of subcutaneous tumescent
liquid will hydrodissect the flap and actually create a potential
space below the dermis and above the SMAS. Another simple
aid in maintaining the correct plane is to pretunnel the flap
prior to scissors dissection with a small liposuction cannula
that is not connected to a suction source. This helps further
define the correct surgical plane.
As stated above, there are many types of face-lift tech­
niques. Some involve only a skin dissection while others in­
volve deep-plane dissection. Novice face-lift surgeons should
concentrate on subcutaneous dissection with simple plication
techniques for the SMAS. ‘Long-flap’ face-lift dissection in­
volves dissecting very anterior in the face (6–10 cm anterior
to the ear), frequently to the nasolabial folds. This exten­
sive dissection is more technically difficult, is more prone to
complications, and requires extended healing. ‘Short-flap’
face-lift dissection involves a shorter dissection (2–6 cm ante­
rior to the ear) that stops at the malar region. This is a faster,
safer, quicker-healing technique. Many surgeons feel that ex­
tensive anterior techniques do not produce any significantly
better results than short-flap procedures. Figure 29-14 shows
a typical face-lift flap after subcutaneous dissection.
A
B
Fig. 29-14  A face-lift flap is shown after dissection (A) and lying passively without retraction (B).
Fig. 29-13  Placing the incision at the greatest width of the pinna
produces a short scar as indicated by the top arrow and placing it
lower produces a longer and more visible scar (lower arrow).

527
Face-lifts  •  Chapter 29
After the flap is adequately dissected close attention must
be paid to bleeding and oozing. Although minor bleeding can
be tolerated in some surgical procedures, it is imperative to
obtain extensive hemostasis in face-lift surgery. Postoperative
bleeding under the fragile face-lift flap can result in major
hematomas that can compromise the vascularity of the flap
and cause necrosis, tissue loss, and scarring. As with blepha­
roplasty surgery, bleeding with a face-lift can lead to horrific
complications. The best means of controlling hemostasis is
to stay ‘on top’ of all bleeding as it occurs. Never discount
a bleeding or oozing area. Instead, control the bleeding as
soon as it is encountered. This author uses three main meth­
ods of hemostasis, namely bipolar forceps, radiowave ball
electrodes, and radiowave conduction through a forceps. A
good 6-inch bayonet bipolar forceps in an absolute necessity
in face-lift surgery as it allows the surgeon to coagulate in
deep recesses. Figure 29-15 shows various methods of he­
mostasis.
C
A
B
Fig. 29-15  Absolute hemostasis is imperative in face-lift surgery. (A) A radiofrequency ball electrode. (B) A radiofrequency conduction with a
forceps. (C) A radiofrequency bipolar forceps. All of these techniques are effective.

528
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Cosmetic surgery procedures and techniques
SMAS techniques
It should be pointed out that some surgeons will not address
the SMAS and only pull and remove excess skin. Experience
has shown that this is not a stable technique. Anyone who has
ever seen a tissue expander knows that skin readily stretches,
and longevity will be disappointing.
The SMAS is a controversial structure. Much has been
written about the SMAS; however, some very well-known
face-lift surgeons deny its existence. In broad terms, the
SMAS is fibrous connective tissue that invests the mimetic
muscles including the platysma. Again, it can be argued what
it is, where it is, what it does, etc. Whatever one believes, most
surgeons will agree that the SMAS is under the dermis and
above the parotid-masseteric fascia. It is not a separate dis­
cernible layer but rather closely associated with subcutane­
ous fat. When surgeons say they are grasping or incising the
SMAS, they are in reality speaking of fat, SMAS, and possibly
other connective tissue. This author believes that the SMAS
is a conglomeration of tissues rather than a separate identifi­
able structure.
Another example of terms of contention is the reference
to plication and imbrication. In reviewing five different well-
known face-lift texts, contradictory descriptions are seen. For
the purpose of this text the term plication will be used in
reference to grasping the SMAS and folding it over on itself
by means of a suture. The word ‘plica’ means fold and there
are many anatomic references to folded structures such as the
plica semilunaris in the eye. Plica refers to a fold. Imbrication
refers to overlapping, such as shingles on a roof. In order to
overlap there needs to be a cut or free edge. In SMAS imbrica­
tion, the SMAS is incised (and sometimes a portion resected)
and the borders are overlapped or sutured. SMAS flaps or
SMASectomies are considered imbrications in this chapter.
SMAS tightening is probably a more accurate description
with ‘open’ SMAS techniques referring to imbrication and
‘closed’ SMAS techniques referring to plication.
SMAS plication
SMAS plication is the best method for learning face-lift sur­
gery and for the novice face-lift surgeon. It involves grasping
the ptotic SMAS (and associated fat) with a pick-up and se­
curing it with a suture. The SMAS is then pulled in a posi­
tive vector (usually superior/laterally) and securing the tissue
to the SMAS (and fat) anterior to the tragal area. Although
there are many means to perform and describe this, the above
­description is very simple. This author prefers a 2-0 braided
nylon permanent suture with buried knots. The ptotic jowl
area (lateral to the corner of the mouth) is secured with the
suture and the tissue is pulled laterally and superiorly and,
as mentioned, stitched to the fixed SMAS (above the parotid)
near the tragus. The suture bite by the jowl is the distal suture­
and the suture bite near the tragus is the proximal suture. It
is imperative not to place these sutures too deep in the SMAS
as not to ensnare the facial nerve branches. Once the main
plication suture is placed the surgeon should see immediate
improvement of the ptotic jowl. At this point, several su­
tures are generally placed just above and just below the first
suture to bolster the suspension. Figure 29-16 shows SMAS
plication.
A
B
Fig. 29-16  (A) The ptotic jowl tissue (*A) secured with a 2-0 braided nylon suture and pulled in a positive vector and secured to the soft tissue
(*B) near the tragus. (B) The suture being clamped to prevent slack when tying.
• Absolute surgical hemostasis is a requisite
of intraoperative surgical face-lift technique.
• Postoperative bleeding can cause flap necrosis
with drastic consequences.
• Attempting to find and control a bleeder in the
middle of the night after a long day of surgery
is a frustrating and humbling experience.
• Stop it as soon as you see it!
Pearls

529
Face-lifts  •  Chapter 29
The next step in the plication procedure is to secure the
lateral (sometimes referred to as posterior) platysma border.
In theory, the lateral platysma border is isolated after the open
liposuction and the border is picked up with a tissue forceps
and secured with the same suture in a buried fashion. The
suture is then pulled in a positive vector (superior/lateral)
and secured to the dense mastoid fascia (Fig. 29-17A–C). A
deep suture bite can be performed in this area without dan­
ger of significant anatomical structures. Multiple sutures are
placed above and below the primary suture to reinforce the
suspension.
SMAS imbrication
As stated above, imbrication is a technique of overlapping­ the
cut edges of the SMAS. A SMAS flap is a type of imbrication­
technique. In this technique the SMAS is incised horizontally,­
several millimeters inferior to the zygomatic arch and ­vertically
several millimeters anterior to the skin incision margin as
shown in Figure 29-18.
The incision is made through the subcutaneous fat and
SMAS with care not to violate the parotid gland and/or the
paritod-masseteric fascia. After making the incision, the flap
is undermined several centimeters inferiorly and anteriorly to
release the SMAS. At this point, a skin cut-back is made in the
90-degree angle and the SMAS is pulled in a positive vector
(usually up and back) and secured with a suture. Cut-backs
are made on the excess vertical and horizontal tissues where
the retracted SMAS overlaps (Fig. 29-19). Multiple sutures are
then placed along the remainder of the incisions to reinforce
the suspension. The SMAS flap can be very dramatic in that
pulling on the corner can basically tighten the entire lower
face and neck in a single vector. If the SMAS is very thin or in
A
C
B
D
Fig. 29-17  (A) The approximate position of a ptotic lateral platysmal and (B) the intended suspension to the mastoid fascia. (C,D) The in vivo
lateral platysmal border (P) engaged and pulled upward and backwards where it is secured to the mastoid fascia (M) with a burred knot.
The dotted line in (C) indicates the inferior border of the mandible.

530
Chapter 29
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Cosmetic surgery procedures and techniques
patients with previous face-lifts, the SMAS may not be thick
enough to suspend.
SMASectomy
For the novice face-lift surgeon the thought of intention­
ally working around the facial nerve is intimidating. As one
gains experience, this technique is actually quite safe and very
effective.
The basis of SMASectomy is to excise a portion of SMAS
and bring the two incised edges together in a vector that
tightens the jowls and neck.19,24,25 Since the vector of pull is
perpendicular to the nasolabial fold, the SMASectomy tech­
nique can pull on and improve the nasolabial fold. The pro­
cedure is as follows. The nasolabial fold on the face is marked
with a surgical marker. A line is then marked on the SMAS
that is parallel to the nasolabial fold. This line runs from the
­malar area to the angle of the mandible and sometimes past
the mandible into the neck. Generally, a 2–3 cm width of
SMAS is removed. The crux of this procedure is to remove
the intended width of SMAS (and associated fat) but not to
violate the paritod-masseteric fascia which is just above the
facial nerve. Frequently, some SMAS and or fat tissue remains
after excising the SMAS, but in some patients the facial nerve
branches can be visualized. As with any SMAS technique, if
the SMAS is exceedingly thin or if the patient has had previ­
ous face-lift surgery the SMAS may not be substantial enough
to incise and suture.
A convenient means to facilitate the SMAS incision (and
excision) is to pick up the SMAS with a forceps, which cre­
ates a ‘tent’ effect. By tenting the SMAS, it is lifted off the
­underlying parotid-masseteric fascia, which facilitates dissec­
tion and protects the underlying nerves. This layer is very pli­
able and can be easily lifted of the deeper fascia. After the
width of SMAS is marked with a surgical marker, the proxi­
mal edge of the SMAS is incised with either a radiowave sur­
gical microelectrode or face-lift scissors. After the incision, the
tented SMAS is undermined with gentle scissor dissection as
performed in the skin undermining. When the undermining
intersects the distal portion of the marked SMAS, the entire
section of SMAS is removed.
The next step is to pull the distal SMASectomy incision
in a positive vector to lift the ptotic jowls and neck. The
SMASectomy border is grasped with two forceps at several
regions to determine the most favorable lift and a buried 2-0
braided ­nylon (or the surgeon’s preferred suture) is placed to
bring the distal incision edge to the proximal incision edge in
Fig. 29-18  The SMAS flap technique involves making
a 90-degree angle SMAS incision and undermining several centi­
meters. Pulling the flap in the correct vector (arrow) can improve
facial ptosis in several planes.
Fig. 29-19  The SMAS flap. The flap is pulled in a positive vector
and the excess (outside the dotted lines) SMAS is excised. The new
edges are then sutured with multiple sutures.

531
Face-lifts  •  Chapter 29
a ­positive vector. Next, five to eight more sutures are placed
from the malar­ area to mandibular angle area or even further
into the neck. The facial tightening seen with this maneuver is
impressive.­ Figures 29-20 to 29-22 illustrate the SMASectomy
technique.
Posterior platysma suspension
Depending on one’s nomenclature, the platysma border in
the lateral neck is termed the lateral or posterior platysma
border. This is the border shown in animation in Figure
29-23. By suspending the lateral platysma border, the neck
is subsequently tightened. Generally, the lateral platysma
border (and associated tissues) is secured with a suture and
the muscle is pulled in the correct vector and secured to the
mastoid fascia. Figures 29-17A and 29-17B shows the su­
tures in place from the lateral platysma border to the mas­
toid fascia.
A
B
Fig. 29-21  (A) The SMAS section being
removed off of the parotid-masseteric fascia
with the radiowave microsurgery needle. This
is generally undermined with face-lift scissors
before excision. Novice surgeons should use
only blunt dissection and not electrosurgery
to better protect the facial nerve. (B) The
SMASectomy defect after excision. Note the
reddish fibers of the masseter muscle at the
inferior portion of the excision site.
A
B
Fig. 29-20  (A) The outline of the section
of SMAS to be excised. This is parallel to the
nasolabial fold. (B) The outline of the area to
be excised after initial incision with radiowave
microneedle.
• The facial nerve branches lie deep to the
parotid-masseteric fascia and are vulnerable
when performing sub-SMAS dissection.
• Sub-SMAS techniques, although generally safe,
should not be attempted by novice surgeons.
Pitfalls

532
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Cosmetic surgery procedures and techniques
Addressing the skin
After the skin flaps are dissected and the ptotic deep tissues are
addressed the excess skin must be suspended and trimmed.
Again, before proceeding to the next step, hemostasis is
continually accessed, as after the skin is closed there is no con­
trol of bleeding.
Suspending the skin is a step that can make a face-lift ap­
pear natural or ‘done.’ The operated or wind tunnel look that
patients disdain is frequently caused by pulling the skin in an
incorrect vector. The general vector is superior/lateral, but
is actually somewhat different for each patient. If the side of
the face is viewed as a clock face, the general vector of pull is
about 2 o’clock on the left side and about 10 o’clock on the
right. It is of absolute importance to pull the skin flap within
a natural vector. Failure to do this will contribute to the un­
natural look or sometimes the ‘wind tunnel’ look, especially
when significant skin wrinkling is present. Figure 29-24 shows
the proper vector of pull for the preauricular skin flap. A sin­
gle skin cut-back is made that enables the anterior skin flap to
be pulled and suspended with a key suture (Fig. 29-25). The
key sutures carry the brunt of the tension of the flap and are
elemental in suspending the skin flaps. The goal is to have the
main tension on the key sutures and not the other skin inci­
sions. Tension on skin and scalp sutures can cause disfiguring
scarring. A tensionless skin closure should be something that
every face-lift surgeon keeps in mind with each suture. After
the initial skin cut-back is made, the flap is pulled into the
desired vector. This is an adjustable step as pulling more supe­
riorly or inferiorly will have different effects on the ptotic jowl
and neck skin. The flap is pulled into the basic vector and the
jowls and neck skin are examined for suspension. Simultane­
ously, the surgeon examines the ‘look’ of the suspended skin
to see if the vector of pull appears natural. This is especially
important in patients with skin wrinkling. If the wrinkles are
pulled in an incorrect vector the face takes on the unnatural
wind-blown look. Once the skin vector is correctly determined
the first key suture is placed. This author uses 4-0 Vicryl for
key sutures.
At this point the posterior skin flap is addressed. The primary­
skin cut-back is made (Fig. 29-25) similarly to the ­anterior flap.
It is extremely important to control the vector­ of this flap to
create a natural posterior hairline. If close ­ attention is not
paid to this vector a stepped hairline can result (Fig. 29-26).
Instead of merely pulling the posterior auricular skin flap
in a ‘two o’clock’ vector it is also slightly rotated toward the
­posterior ear to prevent a discontinuous step in the hairline
(Fig. 29-27).
After the anterior and posterior auricular flaps are cut
back and suspended with key sutures the remaining excess
skin is trimmed. Again, the goal is to have minimal tension
on the skin flaps. Since the excess skin is pulled over the in­
ferior ear, the lobe is covered and must be delivered from its
buried ­position. This is an extremely critical step in the face-
lift procedure, as failure to properly address the earlobe can
B
A
Fig. 29-22  (A) The closure of the SMAS
ectomy defect. Distal edge is sewn to the
proximal edge in a superior lateral vector
to elevate the ptotic jowl and related facial
tissues. (B) The SMASectomy specimen
overlying the cheek in the position of the
excision.
Fig. 29-23  A patient animating the platysma. The medial platysmal
bands (A) and the lateral (sometimes called posterior) platysmal
bands (B) are shown.

533
Face-lifts  •  Chapter 29
­result in a number of deformities, most notably the ‘pixie ear.’
A pixie earlobe is one that is stretched unnaturally and is
the sine que non of a bad face-lift. This deformity is usually
caused by ‘hanging the cheek on the earlobe.’ The most fre­
quent cause of the pixie ear is overzealous cut-back of the
inferior skin flap. If the cut-back is too long, closure becomes
difficult and the earlobe has to be stretched to achieve primary
closure and is thus deformed. The adage ‘measure twice, cut
once’ applies to the skin cut-back in the earlobe area. In small
flap face-lifts, sometimes only a few millimeters of skin need
to be cut back to accommodate the earlobe. In larger surgeries
a slightly longer incision is required. The key is not to overcut
the inferior flap and to pull the lobe through the minimal cut­
back. The inferior flap incision should rest in the crouch of
the earlobe. Only then should extremely cautious incision be
made to finalize the lobe/flap interface. Since the skin flap will
slightly retract, the lobe should be slightly tucked superiorly
and it will heal into a natural position. Figure 29-28 shows
various steps in delivering the earlobe through the inferior
face-lift flap.
C
A
B
Fig. 29-24  (A) An improper vector that is too vertical. (B) The correct vector. (C) An improper vector that is too lateral. Although generally
similar, each patient may need a different vector of directional pull.
A
B
Fig. 29-25  The skin cut-back and
key anchor sutures in the pre- and
­postauricular areas.

534
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Cosmetic surgery procedures and techniques
A
C
B
Fig. 29-28  (A) The earlobe hidden by the retracted excess skin. (B) The conservative release incision to deliver the lobe. It is imperative not
to overcut this incision to avoid a retracted lobe. (C) The earlobe delivered into a normal position through the flap.
A
B
Fig. 29-26  (A) The vector of the posterior flap
is slightly rotated towards the back of the ear.
(B) By doing this, the natural flow of the hairline
is preserved.
A
B
Fig. 29-27  (A) A naturally curving posterior
hairline from proper flap rotation. (B) A stepped
hairline from failure to rotate the flap slightly
anteriorly in addition to the posterior vector.

535
Face-lifts  •  Chapter 29
The excess skin is now removed on all aspects of the inci­
sion. The temporal tuft area should be beveled on both sides
of the incision to accommodate hair regrowth to hide the scar.
The skin cut-back in the temporal tuft area is trimmed while
stretching the incision with a skin hook to avoid puckering or
dog-ears (Fig. 29-29).
The next area addressed is the tragal area. If a pretragal
incision is used, this is a simple process but the trade-off is
a visible preauricular scar. When employing a retrotragal
­incision it is necessary to shape the new tragus from the ex­
cess skin flap. This can be challenging for the novice and
• An unnatural-appearing earlobe is a common
mistake that is easily avoided by conservative
surgical technique.
• Always utilize very conservative incisions when
delivering the earlobe and cut much less than
one thinks will be needed.
• It is always surprising how little an incision is
necessary to deliver the lobe. Overestimating
this cut will cause the earlobe to stretch, creating
a resultant pixie deformity.
Pearls
C
A
B
Fig. 29-29  (A) The excess skin flap to be excised. (B) The gaping of the curvilinear incision. (C) A skin hook being used to assist in control­
ling the incision closure. By retracting the incision with the skin hook the gaping incision can be managed to an aesthetic closure.

536
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Cosmetic surgery procedures and techniques
­requires patience and practice. A common mistake is to make
the ‘new’ tragus too small. Since the tissue in this area will
contract it is advisable to oversize the created tragus. Some
surgeons ­recommend defatting the flap by removing adipose
tissue from the dermal surface. In males with hair-bearing
skin some surgeons advocate destroying the base of the hair
follicles with electrosurgery. Care needs to be taken with this
delicate flap as the vascularity can easily be compromised. A
natural tragus is a protruding nub with an indentation above
and below. When trimming the tragus, this author places a
suture above and ­below the skin flap before it is trimmed. This
stabilizes the tissue and makes trimming easier. Trimming is
performed with face-lift scissors or with the Ellman radiowave
fine wire electrode on a pure cutting current to minimize
lateral­ tissue damage (Fig. 29-30). The key to forming the
new tragus is to define the supra- and infratragal indentations
and leaving sufficient excess tissue to allow for natural healing
contraction. Failure to reconstruct a natural tragus will result
in a very blunted tragus which is unsightly and difficult to
correct.­ If one cannot consistently reproduce a natural tragus,
a pretragal incision should be used to avoid the alternative of
a blunted tragus.
Finally, the posterior auricular scalp flap is trimmed. There
is frequently a dog-ear at the most distal extent of this flap.
Using a Burrow’s triangle or other dog-ear repair method
will correct the irregularity. After all cut-backs (Fig. 29-31) are
made 5-0 gut sutures are used by most (but not all) surgeons
in the subcutaneous regions. For final closure, 5-0 interrupted
gut sutures are used for the pre- and postauricular incision.
The temporal tuft incision is closed with 5-0 nylon sutures and
the posterior auricular incision is closed with skin staples or
5-0 gut suture (Fig. 29-32).
A
B
Fig. 29-30  (A) The Cupid’s bow outline
cut into the excess skin. (B) The newly cre­
ated tragus at final closure.
A
B
Fig. 29-31  Closure methods for the
various incisions. (A) 1, temporal tuft
incision closed with 5-0 nylon; 2, preau­
ricular incision closed with 5-0 or 6-0 fast
absorbing gut suture; (B) 3, posterior au­
ricular suture closed with 5-0 gut suture;
4, scalp incision closed with staples.

537
Face-lifts  •  Chapter 29
Concomitant or ancillary procedures
In the author’s practice it is rare to perform an isolated face-
lift without other simultaneous aesthetic procedures. Blepha­
roplasty, brow and forehead lift, chin or cheek implants, and
laser resurfacing are procedures commonly performed at the
same setting as face-lift surgery. These procedures are syner­
gistic in that the total is greater than the sum of the parts.
The scope of this chapter prohibits extended discussion on
these techniques but a serious face-lift surgeon must be able to
provide­ total facial rejuvenation.
Postoperative clinical ­considerations
Postoperative care
Immediately after the surgery and before the patient is awak­
ened, the hair is washed to clean blood and debris. This is
easily performed by double-bagging two large garbage bags
and placing the patient’s head in the center of the opening
(Fig. 29-33). While one assistant holds the garbage bag, the
other assistant washes the hair with sterile water and hydrogen
peroxide. Generally, one bottle of hydrogen peroxide and 2–3
liters of sterile water are used. Finally, a gentle hair condi­
tioner is used and the hair is combed with a large tooth comb
to untangle knotted or matted hair in preparation for the final
dressing.
Generally, by this time the anesthesia has ceased and emer­
gence is begun. It is important for the anesthetist to make this
a gentle and uneventful anesthetic emergence. Coughing,
bucking, and Valsalva maneuvers can increase blood pressure
and cause bleeding with resultant hematoma formation under
the flap. Gentle emergence is essential.
Most face-lift surgeons use large dressings to compress and
support the operated areas. Although a pressure dressing is
not a guarantee against hematoma, mild pressure on the oper­
ated areas is beneficial. Excessive pressure, on the other hand,
can compromise flap viability and in some cases compromise
the airway when coupled with postoperative edema. This au­
thor uses a light but bulky dressing as shown in Figures 29-34
and 29-35. A notch is cut in the submental area to prevent
airway constriction and choking sensation.
When the patient is fully awakened he or she is transferred
from the operating room to the recovery area and placed in
bed with a 45-degree elevation of the upper body. In most
cases, the patient recovers in the office for about 2 hours and
then is transported home with a responsible driver. The follow­
ing morning the patient is brought to the office and the dress­
ing removed. The flaps are closely inspected for hematoma or
A
C
B
Fig. 29-32  (A) The excess skin. (B) The trimming of that skin. (C) The final closure with appropriate sutures and staples.
Fig. 29-33  The patient’s hair is washed with hydrogen peroxide
and sterile water with a garbage bag to catch the rinse.

538
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Cosmetic surgery procedures and techniques
viability problems and the wounds are cleaned with hydrogen­
peroxide and triple antibiotic ointment is reapplied. The
patient is then dressed with a ‘jaw bra’-type elastic bandage
with Velcro attachments (Fig. 29-36). This dressing serves to
eliminate dead space from the dissected and liposuctioned ar­
eas as well as support the suture plications. It also serves as a
reminder for patients to be careful with their surgical sites.
Generally, the dressing is worn around the clock for the next
3–4 days and at night for several more days.
Patient is instructed to wash their hair on the second post­
operative day. It is important to warn patients that since they
will have temporary facial numbness they cannot feel the heat
generated from hair driers or curling irons. Full-thickness
­facial burns from the injudicious use of a hair dryer are well
documented. If staple closures were used, the patient is also
instructed to use care when combing hair in these areas. The
patient and/or caregiver are instructed on daily wound care
consisting of hydrogen peroxide and triple antibiotic oint­
ment. The patient returns to the office on day 10 to remove
the 5-0 nylon sutures in the temporal sideburn area and at
day 14 for removal of all remaining sutures and staples. The
patient is seen again at 1 month for preliminary postoperative
photographs and follow-up. Generally, the patient is seen on
a monthly basis, and final postoperative images are taken at
90 days.
Complications
One must differentiate sequelae from complications, and this
was hopefully addressed with the patient before surgery. The
saying is that ‘a problem that occurs after informed consent
is a sequela and a problem that occurs without informed
consent is a complication.’ This underlines the importance
of explaining potential or perceived problems before the
surgery. Postoperative hematoma remains the most feared
A
B
Fig. 29-34  (A) Xeroform gauze placed
circumferentially around the ear sutures.
(B) The gauze fluffs placed in the pre- and
postauricular skin flaps. It is important not to
make the dressing so tight as to compromise
the undermined flaps.
A
B
C
Fig. 29-35  (A) The surgical pad placed under the chin. (B) The Kling gauze dressing. (C) The Coban tape final covering.

539
Face-lifts  •  Chapter 29
­complication of face-lift surgery.26–28 Postoperative hemato­
mas can be classified as minor and major. Minor hemato­
mas are small collections of blood and/or serum (seromas)
that accumulate in gravity-dependent portions of the face-lift
flaps. These smaller ­collections generally do not compromise
flap viability but can organize to cause fibrous lumps or skin
pigmentation. These fluctuant collections are usually treated
by simple needle aspiration, which may need repeated. They
tend to heal without incident. Major hematomas, however,
present with significant morbidity and in rare cases possible
mortality. Major hematomas invariably result from unchecked
bleeding under the dissected flaps. They frequently manifest
as distinct arterial ‘pumpers’ or venous ‘oozers’ but can also
occur from multiple punctuate bleeding not specific to a lacer­
ated vessel. The true cure for postoperative major hematoma
is prevention as discussed throughout this chapter. It is a good
idea to return intraoperative blood pressure to normal prior
to final closure, as this sometimes shows bleeding points that
were not active with lower blood pressure. Since most ma­
jor post-face-lift hematomas occur within the first 24 hours
and more frequently in the first several hours after rhytid­
ectomy the immediate postoperative blood pressure should
be controlled. Essential hypertension is hopefully controlled
preoperatively but may need antihypertensive intervention
if significant. A 2.5 mg dose of Labatelol is used in the im­
mediate postanesthesia period and in the recovery period if
indicated. Perhaps the most important factor in prevention
of increased blood pressure is the level of patient postopera­
tive activity. Any activity, position, or maneuver that increase
blood pressure or produces a Valsalva effect is strictly avoided
for the first several days. This includes bending, lifting, strain­
ing, coughing, retching, vomiting, sneezing, and exertion.
Straining with constipation and intercourse has also been im­
plicated in postoperative face-lift bleeding. The author warns
patients about these potential dangers to the point of scaring
them. They are given written instructions and asked to be
bedridden the first day and a ‘couch potato’ for the next 48
hours. In addition, they are asked not to lift anything heavier
than 10 pounds for 1 week. Most patients can begin walk­
ing for exercise at about 1 week and begin treadmill or brisk
walking by 10 days. Extreme flexion and extension exercises
such as aerobics, weight training, and swimming are discour­
aged for 4–6 weeks.
In the event of a postoperative major face-lift hematoma,
immediate treatment is essential. As the hematoma expands
the pressure can provide stasis of the dermal plexus and
­devitalize the entire flap. In addition, extreme hematomas
can cause airway compromise. A witnessed postoperative he­
matoma can be initially treated with aspiration and pressure,
but if it reoccurs, the flap must be opened and explored. This
is common in the immediate postoperative period. More com­
monly, hematomas are insidious and progress slowly. They
are frequently manifested as severe, unilateral stabbing facial
pain. Sometimes patients are unable to bite the teeth together
due to the buccal cheek swelling. There may be significant
bleeding or oozing from the suture lines (Fig. 29-37) and the
patient may have a feeling of impending doom. If at all pos­
sible, the hematoma should be immediately decompressed to
prevent tissue death. This is feasible if the patient is still in the
office or hospital but not very feasible when he or she is home.
All surgeons who perform significant numbers of face-lifts will
at some time experience a major postoperative face-lift he­
matoma. This is a difficult time for the patient, the family, and
the surgeon as this signals a potential major complication and
can cause the patient to become very stressed and possibly lose
confidence in the surgeon. Compounding the stress is the fact
that hematomas frequently occur after hours while the pa­
tient is at home. This presents a need to return to the office or
­hospital for emergency hematoma evacuation. If the surgeon
has hospital privileges then the situation may be less stressful
as there is OR staff, anesthesia support, and sterile instrumen­
tation. If the surgeon needs to return to the office, however,
he or she may be blind-sided by unpreparedness. The first
time this author experienced this situation, the staff was dif­
ficult to locate, the instruments from that morning’s surgery
were cleaned but not sterilized, and the anesthetic drugs were
locked up. Circumventing all of this made the entire situation
Fig. 29-36  A lightweight compression is placed at the first
­postoperative day and is worn 24 hours for the next 3–4 days and
another week during sleep.

540
Chapter 29
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Cosmetic surgery procedures and techniques
much more stressful for all involved. Be prepared! An astute
surgeon and staff will anticipate the possibility of hematoma
or other postoperative emergencies and have a plan in place.
This should include a receptive staff that can be reached and
called to the facility, the presence of sterile instruments needed
to treat the problem, and the availability of anesthesia drugs,
equipment, and personnel.
As soon as the patient arrives at the office, an i.v. line
is started and the patient is lightly sedated. All sutures and
staples are removed from the offending side on both the
pre- and postauricular flaps. The clotted blood is evacuated
and the area is irrigated with saline to help visualize tissue
bleeding. Most frequently distinct arterial or venous bleeders
are isolated­ and coagulated with electrosurgery. Sometimes
no distinct vessels are seen but rather generalized oozing.
This is treated with electrosurgical cauterization and pres­
sure. Some surgeons use topical hemostatic agents such as
thrombin.
Six-inch bayonet bipolar forceps are invaluable for hemo­
stasis in tight spots under flaps. When the bleeding appears
to be controlled, iced saline gauze is packed in the flap pocket
and pressure applied for 10 minutes. The area is then in­
spected for another 5–10 minutes before reclosing. Generally,
the disruption to the suture line and reclosure do not cause
any aesthetic problem and the treated side heals the same as
the normal side. Bleeding from deep in the submental region
(as a result of midline platysmaplasty) can be especially chal­
lenging to control and can also cause bleeding that dissects
bilaterally and produces a hematoma on both sides as well as
in the neck. For this reason, special care is always directed to
each step when performing platysmaplasty.
Some surgeons use postsurgical drains and/or platelet-
rich plasma. The author has never used drains with face-lift
­surgery. Using a drain will not prevent a hematoma.
Nerve injuries
Post-face-lift paresthesia (altered sensation) in the preauricu­
lar areas and the ear and lobe are frequently normal seque­
lae of face-lift surgery. This generally results from disruption
of the transcutaneous nerve branches and most frequently
­returns within 90 days. The patient should be warned of this
preoperatively and informed that this is not a nerve injury per
se. Major motor nerve injury is rare as the facial nerve is ex­
tremely well protected within the body of the parotid gland
and then becomes more vulnerable as it exits the gland and
courses over the masseter muscle. The facial nerve branches
lie under the parotid-masseteric fascia which is below the
SMAS. Having said this, the facial nerve branches are fairly
well protected and unless deep-plane surgery is performed the
nerves should remain protected. A common means of nerve
injury is the novice surgeon who inadvertently makes too deep
a ­subcutaneous dissection as he or she progresses toward the
anterior face. One of the key factors of mastering face-lift sur­
gery is the ability to find the correct surgical plane and stay
in it. The subcutaneous plane is generally a very safe surgi­
cal plane and nerve injury would be quite rare in this plane.
For this reason, short flaps with plication procedures that
stay superficial to the parotid-masseteric fascia are the safest
methods for the novice surgeon to begin with.
Face-lift surgery, especially deep-plane techniques, put
multiple branches of the facial nerve at risk for injury.29 Nerve
injuries can manifest from multiple insults including, but not
limited to, transection, stretching, swelling, electrical or ther­
mal injury, and compression. The most frequent nerve injury
is to the greater auricular nerve (GAN) which is sensory to the
cheek and ear skin (see Fig. 29-3, number 6). This nerve runs
superficially over the body of the SCM muscle about 6.5 cm
inferior to the external auditory canal. Transection of this
A
B
Fig. 29-37  (A) A patient 30 hours post-face-
lift with a significant, compromising right sided
hematoma. (B) The ‘currant jelly’ clotted blood
under the flap.

541
Face-lifts  •  Chapter 29
nerve warrants immediate repair. Failure to recognize a GAN
injury can result in a painful postoperative neuroma. Lesser
injuries can also result in neuroma, and painful nodular swell­
ing in the area with shooting pain in the dermatome of the
GAN is pathognomonic for neuroma which needs resection
and repair.
The buccal and zygomatic branches of the facial nerve
provide motor function to the midface and upper lip and are
also frequently involved with nerve injury from face-lift sur­
gery. Fortunately, these nerves are very arborized and most
injuries in this area are temporary, and motor function re­
turns in weeks or months. Injury to the marginal mandibular
nerve, which provides motor function to the lower lip, can be
less forgiving. Great care must be exercised when working in
the area of this nerve. The nerve becomes superficial in the
area approximately 2 cm lateral to the oral commissures and
is more at risk in this area. Most blunt nerve injuries to the
marginal mandibular nerve resolve without problem but, like
any nerve injury, can be quite disconcerting to the patient.
Figure 29-38 shows the various nerves described and their
respective areas of vulnerability. Frontal and cervical branch
injuries are less common, but can and have occurred in face-
lift surgery.
Hairline problems
As mentioned above, failure to pay close attention to natural
hairline preservation is a dead giveaway to a bad face-lift. The
basis of learning face-lift surgery should center on a natural
temporal and posterior auricular hairlines. Temporal bald­
ness and unnatural or stepped posterior hairlines are easily
avoided.
Tissue necrosis
This subject was alluded to in the hematoma discussion.
Loss of flap viability, especially in the preauricular area, can
be ­catastrophic and is fortunately rare. It can occur for no
specific reason, but most frequently is caused by such factors
as rough handling of the flap, making the flap too thin, he­
matoma, pressure necrosis, excessive lateral tissue heat from
electrocautery, or overzealous retraction. Smokers are predis­
posed to tissue necrosis, as has been referenced many times in
this chapter. Generally, a flap that has lost viability will mani­
fest with a dusky or cyanotic appearance. The necrotic area
may blister and progressively becomes darker and begin to
slough. A scab will generally form and granulation tissue will
begin forming under the eschar. If one thinks that significant
loss of tissue viability is eminent in the preauricular area, hy­
perbaric oxygen therapy may be an immediate option. Con­
sultation with a wound management team is suggested. Some
surgeons advocate placing nitroglycerine paste on the flap but
this author is not aware of significant research supporting the
validity of this treatment.
Although significant tissue loss is rare in the preauricular
area, it happens with greater frequency on the posterior flap.
This is generally much less of a problem because this area
is less noticeable, especially in females with longer hair. In
addition, tissue loss in this area generally heals uneventfully.
The progression of dusky tissue with the appearance of tissue
slough and resultant scabbing should be treated conservatively
with conscientious wound care. Generally, hydrogen peroxide
lavage and soaks followed by Betadine wash and triple antibi­
otic ointment are usually adequate. The wounds appear very
necrotic at first but heal well over several months as shown in
Figure 29-39.
Postoperative infections
Post-aesthetic surgery wound infections of the head and neck
are rare due to the excellent blood supply to these areas.
­Localized wound care, systemic antibiotics, and culture and
sensitivity should be performed.
Conclusion
Face-lift surgery is the ultimate rejuvenative procedure
(Figs 29-40–29-46). It is a procedure that cannot be mastered
in a short time and volumes can be written about each as­
pect of the procedure. Like many procedures, there is much
­speculation and individual surgeon preference for various
Fig. 29-38  A simplified diagram of the main facial nerve branches
and areas of vulnerable with face-lift surgery.

542
Chapter 29
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Cosmetic surgery procedures and techniques
A
B
Fig. 29-40  This 56-year-old female was
treated with cervicofacial rhytidectomy, cervi­
cofacial liposuction, and periorbital CO2 laser
resurfacing; (A) before and (B) after.
A
B
Fig. 29-39  (A) A case of significant post
auricular necrosis in a smoker. (B) The same
area 5 months later.

543
Face-lifts  •  Chapter 29
A
B
Fig. 29-41  The same patient as Figure 29-40,
in the frontal view; (A) before and (B) after.
A
B
Fig. 29-42  This 54-year-old female smoker was treated with cervicofacial rhytidectomy with SMAS plication, cervicofacial liposuction, four-
quadrant blepharoplasty, subgaleal brow-lift, full-face CO2 laser resurfacing, and fat injection to cheeks and nasolabial folds; (A) before and
(B) after.

544
Chapter 29
������������������������������������������
Cosmetic surgery procedures and techniques
A
B
Fig. 29-44  This 56-year-old female underwent
cervicofacial rhytidectomy with SMAS plication,
cervicofacial liposuction, Gore-Tex chin implant,
four-quadrant blepharoplasty, and periorbital
CO2 laser resurfacing; (A) before and (B) after.
A
B
Fig. 29-43  This 74-year-old female was treated with cervicofacial rhytidectomy with SMASectomy, midline platysmaplasty, submalar cheek
implants, Gore-Tex chin implant, and full-face CO2 laser skin resurfacing (A) before and (B) after.

545
Face-lifts  •  Chapter 29
A
B
Fig. 29-45  This 73-year-old female underwent cervicofacial rhytidectomy with SMASectomy, upper blepharoplasty, and small Gore-Tex chin
implant; (A) before and (B) after.
A
B
Fig. 29-46  This 63-year-old male underwent cervicofacial rhytidectomy with SMASectomy, four-quadrant blepharoplasty, and full-face CO2
laser resurfacing. Note the mole on the right cheek and its change in position in the post­operative view; (A) before and (B) after.

546
Chapter 29
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Cosmetic surgery procedures and techniques
steps and techniques. This wide range of options can make
learning face-lift surgery confusing. As stated earlier, the most
important thing is to perform safe, predictable surgery with
satisfactory patient outcome. To that end, novice surgeons
should begin with safe and predictable methods that work
well in their hands. Someone once said that before one learns
the tricks of the trade, they must first learn the trade. This
adage is very applicable to face-lift surgery. Learn the basics
and ­experiment with advanced techniques as one’s experience
matures. Always put the patient first and do not get lured by
hyped procedures. The basic short-flap face-lift with SMAS
plication has been around for a long time and has satisfied
hundreds of thousands of surgeons and patients. Find out
what works and stick with it. Seek a mentor who has seen it
all come and go, and always be a teacher and always be a
student.
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  1. Lexer E. Zur gesichtsplastik. Arch Klin Chir 1910; 92:749.
  2. Joseph J. Plastic operation on protruding cheek. Stsch Med Wochenshr
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  3. Joseph J. Nasenplastikand sonstige gesichtsplastik negsteinen anhang
tiber mammaplastic. Leipaig: Curt Kabitzach; 1928:525–527.
  4. Joseph J. Verbesserung meiner hangemangenplastic (melomioplastic).
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  5. Passot R. La cheirurgie esthetique des rides du visage. Press Med 1919;
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  6. Passot R. La xhirurgie esthetique pure (technique et resultants). Paris:
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  7. Morestin H. La reduction graduelle des deformities tegumentaries. Bull
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  8. Brouguet J. La xhirurgie esthetique de la face. Concours Med 1921;
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  9. Lagarde M. Nouvelles techniques pour le traitement des rides de la face
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62–66.
11. Noel A. La chirurgie esthetique. Clearmont (Oise): Thiron et Cie; 1928.
12. Skoog T. Plastic surgery: new methods and refinements. Philadelphia:
WB Saunders; 1975.
13. Mitz V, Peyronie M. The superficial musculoaponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976; 58:
80–88.
14. Adamson JC, Horton CE, Crawford HH. The surgical correction of the
‘turkey gobbler’ deformity. Plast Reconstr Surg 1964; 34:598.
15. Rees TD, Aston S. Clinical evaluation of submusculoaponeurotic
dissection and fixation in face-lift surgery. Plast Reconstr Surg 1977;
60: 861–859.
16. Webster RC, Smith RC, Papsidero MJ, et al. Comparison of SMAS
plication with SMAS imbrication in face lifting. Laryngoscope 1982;
92(8 pt 1):901–912.
17. Connell B. Cervical lift: surgical correction of fat contour problems
combined with full width platysmal muscle flap. Aesthetic Plast Surg
1978; 1:355–365.
18. Connell BF. Contouring the neck in rhytidectomy by lipectomy and a
muscle sling. Plast Reconstr Surg 1978; 61:376–383.
19. Baker DC. Minimal incision rhytidectomy (short scar face-lift) with
lateral SMASectomy: evolution and application. Aesthetic Surg J 2001;
Jan/Feb:14–26.
20. Hamara ST. Composite rhytidectomy. St. Louis: Quality Publishing;
1993.
21. Tessier P. Subperiosteal face-lift [in French]. Ann Chir Plast Esthet
1989; 34:193–197.
22. Baker SR. Triplane rhytidectomy. Combining the best of all worlds.
Arch Otolaryngol Head Neck Surg 1997; 123(11):1167–1172.
23. Ramirez OM, Pozner JN. Subperiosteal minimally invasive laser
endoscopic rhytidectomy. St. Louis; the SMILE face-lift. Aesthetic Plast
Surg 1996; 20:463–470.
24. Baker DC. Lateral SMASectomy. Plast Reconstr Surg 1997; 100(2):
509–513.
25. Baker D. Rhytidectomy with lateral SMASectomy. Facial Plast Surg
2000; 16(3):209–213.
26. Niamtu J. Expanding hematoma in face-lift surgery: literature review,
case presentations, and caveats. Dermatol Surg 2005; 31:1134–1144.
27. Rees TD, Aston SJ. Complications of rhytidectomy. Clin Plast Surg
1978; 5(1):109–119.
28. Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg
1983; 10(3):543–562.
29. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy.
Anatomical variations and pitfalls. Plast Reconstr Surg 1979; 64(6):
781–795.
Table 29-2  American Society of Anesthesiology risk classification
ASA I
Patients are considered to be normal and
healthy.
ASA II
Patients have mild to moderate systemic
disease
ASA III
Patients have severe systemic disease that
limits activity, but is not incapacitating.
ASA IV
Patients have severe systemic disease that
limits activity and is a constant threat to life.
ASA V
Patients are moribund and are not expected
to survive more than 24 hours with or without
an operation.

Subject Index
A
abdomen
female tumescent liposuction see tumescent
liposuction
male tumescent liposuction, 357–358, 358
abdominal skin laxity, nonsurgical skin tightening,
221
abdominoplasty, tumescent liposuction with, 326
ablative fractional rejuvenation (AFR), 228
ablative skin resurfacing, 42–43, 225–247
ablative fractional rejuvenation (AFR), 228
adverse effects, 238–239, 240
analgesia, 233
carbon dioxide laser resurfacing, 225, 234
conditions, 232
drawbacks, 232
erbium:YAG combination, 230, 232
feathering, 234
as gold standard, 232
indications, 232
marking, 234
mechanism of action, 226
photodamage, 234
recovery, 237
rhytides, 229, 234
safety aspects, 234
scars, 230, 234
split-face comparison, 230
studies, 229, 229
consent form, 243
contraindications, 233
cosmetic improvements, 226–227
deep sedation, 234
erbium:YAG laser resurfacing, 234–235
carbon dioxide laser combination, 230, 232
collagen contraction, 227
conditions, 232
fractional, 228
mechanism of action, 227
recovery, 237
split-face comparison, 230
studies, 229, 230, 230
variable pulses, 227, 234
fractional deep dermal ablation (FDDA), 240
ablative skin resurfacing (Continued)
fractional photothermolysis see fractional
photothermolysis
fractional rejuvenating laser, 227, 227–228
general anesthesia, 234
history, 225–226, 226
mechanism of action, 226–229
patient information sheet, 243–244
patient selection, 233
plasma skin regeneration see plasma skin
regeneration (PSR)
postoperative considerations, 237–241
antibiotics, 238
antivirals, 238
closed wound care, 237, 239
melanin-containing microepidermal necrotic
debris (MENDS), 239
monitoring, 237, 238
open wound care, 237
recovery times, 239
wound care, 237–238
preoperative considerations, 233
pulsed carbon dioxide laser, 226
studies, 229–231
technique/procedure, 233–237
topical anesthesia, 233, 234
absorbable sutures, suture suspension lifts, 506
absorption spectra, melanin, 155–156, 156
acetaminophen
blepharoplasty, 501
postoperative pain management, 84, 84
acetylcholine release, botulinum type A toxin
therapy, 267–268
acne
incidence, 98
sebum, 95
acne flares, dermabrasion side effects, 454
acne scars, 400–401
boxcar, 400, 400, 445
development, 400
icepick, 400, 400, 445, 447
management see atrophic/acne scar management
rolling, 400, 400–401, 401, 447
subtypes, 400
see also specific types
actinic cheilitis, photodynamic therapy
see photodynamic therapy
actinic keratoses
dermabrasion, 444
glycolic acid/5-fluorouracil treatment,
123–124, 124
photodynamic therapy see photodynamic therapy
prevention, retinoids, 33
action spectrum
photoaging, 25–26
ultraviolet (UV) radiation, 24–26
active compression, leg vein management, 459
activity restriction, blepharoplasty, 501
adipose tissue, deposition of, 323
advancement flaps see skin flap(s)
aesthetic surgical closures, 419–441
allergic contact dermatitis, 423
cheek/chin, 432–434
concave vs. convex areas, 433
S-shaped primary closure, 432
wound contraction, 433
cosmetic unit junctions, 419, 420
definition, 422
ellipse closure, 419
eyelids, 424
forehead, 435, 437
hematomas, 422
high-tension wounds, 422
history, 419
linear closures, 422
medial canthal defects, 424
medication discontinuation, 423
M-plasty, 420, 420
perioral, 426
NEET areas, 419, 420
nose see nose reconstruction
patient education, 423
periocular, 424
persistent lymphedema, 424
perioral, 426–427
post-Moh’s micrographic surgery, 423, 425
postoperative considerations, 438–440
corticosteroids, 438
dermabrasion, 438
erythema, 439
Notes
Page numbers in italics refer to material in tables, figures or boxes.
To save space in the index, the following abbreviations have been used:
ALA - 5-aminolevulinic acid
KTP laser - potassium titanyl phosphate laser
SMAS - superficial musculoaponeurotic system
YAG - yttrium-aluminum-garnet

548

Subject Index
aesthetic surgical closures (Continued)
preoperative considerations, 422
procedural techniques, 422–438
see also specific techniques
relaxed skin tension lines, 419, 420
secondary intention healing, temple, 437
side-to-side closure
forehead, 435
periocular, 424, 425
perioral, 426
temple, 437, 439
skin flaps see skin flap(s)
skin grafts see skin grafts
S-plasty, 419–420
temple, 437
side-to-side, 437, 439
topical antibiotics, 423
vertical mattress sutures, 422, 423
wound care compliance, 423–424
wound infection, 423
age/aging, 23–36, 38–43
atrophic suborbital aging, 310, 311
cheek mass, 39
extrinsic, 38, 101
facial expressions, 17
females, 40
frontalis muscle, 38
Glogau classification, 38
hair transplantation, 372
health, links to, 38
historical aspects, 38–39
hypertrophic suborbital aging, 310, 311
intrinsic (biological), 38
lower face, 38–39
males, 41
media influence, 38
muscular changes, 38–39
nonablative rejuvenation, 200
personal desires, 38–39
physiological changes, 38
SMAS, 39
midfacial, 489
studies, 38–40
subcutaneous fat changes, 39, 39, 310, 310
suborbital changes, 310, 311
sunscreens, 30
vertical rhytides, 39
Agency for Healthcare Policy and Research
(AHCPR), postoperative pain management
guidelines, 83–84
airway evaluation
Maliampati classification, 80
office-based sedation, 80, 80
airway management, office-based sedation, 81–82, 82
alar groove
nose reconstruction, 429, 433
rotation flaps, 429, 433
alexandrite laser therapy
hemangiomas, 146
long-pulse, 755nm laser
laser hair removal, 183, 184, 187
leg vein endovenous ablation, 479
Q-switched, pigmented lesion laser therapy
see pigmented lesions, laser therapy
vascular lesion therapy see vascular lesions,
laser therapy
allergic contact dermatitis, aesthetic surgical
closures, 423
allergic reactions
collagen tissue augmentation, 300
tattoo laser therapy, 167–168
allergic skin type, 99–100
alopecic spaces, hair transplantation repair, 391
alpha hydroxy acids (AHAs), as humectant, 97
alpha hydroxy acid treatment, 122–126
acne, 124
collagen, effects on, 122
conditions, 122
glycosaminoglycans, effects on, 122–123
hyaluronic acid, effects on, 122
with 13-cis-retinoic acid, 125
sun protection use, 125–126
techniques, 125–126
alpoecia reduction, hair transplantation, 375–376,
377
altitude, ultraviolet radiation, 28
ambulatory phlebectomy, 455, 476–478
complications, 479
equipment, 476, 478
large non truncal varicose veins, foam
sclerotherapy vs., 465
phlebectomy hooks, 476, 477
postoperative considerations, 477–478
sedation, 476
technique, 475–476, 478
American Society of Dermatologic Surgery
(ASDS), liposuction safety, 323–324
5-aminolevulinic acid (5-ALA)
history, 249
laser hair removal, 182, 189
methylated form, 251
topical, studies, 250–251
see also photodynamic therapy
anagen, hair follicle growth cycle, 180, 180
analgesia, 84, 84–85, 85
ablative skin resurfacing, 233
blepharoplasty, 501
hyaluronic acid tissue augmentation, 299
see also anesthesia
anatomy
face-lift patient selection, 520, 521
port-wine stain laser therapy, 143
see also specific body parts
androgenic alopecia, female patients, 373
android body shape, 323, 324
anesthesia, 59–76
autologous fat transplantation, 313, 415
calcium hydroxyapatite (Radiesse) soft tissue
augmentation, 306
dermabrasion, 444–445
face-lifts, 521–522
facial, 313
fat extraction, 312
hair transplantation see hair transplantation
historical background, 59–60
hyaluronic acid tissue augmentation
see hyaluronic acid tissue augmentation
hyperhidrosis botulinum type A toxin therapy,
281–282
laser therapy see laser therapy
local see local anesthesia
office-based see office-based sedation
anesthesia (Continued)
perioral aesthetic surgical closures, 426
procedures/techniques, 61–78
see also specific techniques
silicone soft tissue augmentation, 304
tattoo laser therapy, 173
topical see topical anesthesia
tumescent liposuction see tumescent liposuction
upper eyelid blepharoplasty, 495
see also office-based sedation; specific anesthetics
anger, facial expression, 15
angiomas, laser therapy, 145, 145
ankles, tumescent liposuction, 354
anterior fat pads, upper eyelids, 487
anterior upper arm, tumescent liposuction,
341–342
antibiotics
ablative skin resurfacing, 233, 238
autologous fat transplantation, 312, 415
hair transplantation, 377
laser surgery, 412
scar management, 401
topical, aesthetic surgical closures, 423
tumescent liposuction, 327, 359
antibody development, botulinum type A toxin
therapy, 268–269, 271
anticoagulant medication, face-lift patient selection,
519
antiemetic agents, postoperative nausea and
vomiting (PONV), 85–86, 86
antihistamines, postoperative pain management, 84
antioxidants
natural, 117
photoaging, 102
antiviral drugs
ablative skin resurfacing, 233, 238
dermabrasion, 411
laser surgery, 412
anxiolysis, definition, 78–79, 79
apnea, sedation, 81–82
aponeurotic ptosis, definition, 483
Aquaphor healing ointment, laser surgery, 403
aquaporin-3 (AQP-3), skin hydration, 94–95
Archives of Dermatology, photographic guidelines, 51
area preparation, hyaluronic acid tissue
augmentation, 293–294
arms, tumescent liposuction see tumescent
liposuction
arterial skin flaps, 420
Articulus™ suture, 511
aspirate monitoring, tumescent liposuction, 333, 334
aspirators, tumescent liposuction, 329, 330
aspirin, postoperative pain management, 84, 84
atrophic/acne scar management, 407, 407–416
alpha hydroxy acid treatment, 124
autologous fat transplantation, 415
dermabrasion, 410–411, 445–447, 446,
448–450
surgical excision, 408
dermasanding, 412
fillers, 415–416, 439
fractional photothermolysis, 230–231, 231
glycolic acid treatments, 124
laser therapy, 412–414
carbon dioxide laser, 412–413, 413
erbium:YAG laser, 413

Subject Index
549
atrophic/acne scar management (Continued)
nonablative lasers, 414
plasma skin resurfacing, 414
surgical excision, 408, 409, 439
photodynamic therapy see photodynamic
therapy
subcision, 409–410, 410, 411
surgical excision, 407–408, 408
laser therapy, 408, 409, 439
atrophic scars, 400–401
management see atrophic/acne scar
management
atrophic suborbital aging, 310, 311
audio recording, videography, 52
auricular skin flap trimming, posterior platysma
suspension, 536, 536
auriculotemporal nerve, 66, 72
autologous fat transplantation, 309–321, 320
anesthesia, 313
atrophic/acne scar management, 415
brow augmentation, 315, 315
complications, 319, 319–320
periorbital lumps, 319, 319–320
equipment, 312–313
extraction cannulae, 313
infiltration cannula, 314
syringes, 313
facial marking, 312, 312
fat freezing, 319, 319
forehead, 314, 314
history, 287, 309
iimmunocompromised mouse models, 309
jawline, 317, 317–318, 318
labiomental crease augmentation, 316–317,
317
lateral face augmentation, 317–318
malar augmentation, 316, 316
nasolabial crease augmentation,
316–317, 317
patient preparation, 312, 312
perioral augmentation, 316, 317
postoperative considerations, 318–320
dressings, 318
patient instructions, 319
swimming/bathing avoidance, 318
preoperative considerations, 309–310
principles, 313–314
hand placement, 313–314, 314
repeat procedures, 319
safety aspects, 320
suborbital augmentation, 315, 315, 316
techniques, 312–318
fat extraction, 312–313, 313
see also specific techniques
temples, 314, 315
axial flaps see skin flap(s)
axillae, hyperhidrosis botulinum type A toxin
therapy, 281
B
‘backfilling,’ autologous fat transplantation,
317–318, 318
back, lower, tumescent liposuction see tumescent
liposuction
‘banana roll,’ tumescent liposuction, 353
basal cell carcinoma (BCC), 26
epidemiology, 27
photodynamic therapy, 251, 259, 260
Bauman Skin Typing System, 102
Becker’s nevi, laser therapy, 161, 171
before-and-after pictures, 53
behavior, photoaging, 31, 31
benign tumors, vascular lesions, 135–136
benzocaine (Cetacaine), 60
benzodiazepines, postoperative pain management, 84
beta hydroxyacids (BHAs), as humectant, 97
bipolar radiofrequency/diode laser see nonsurgical
skin tightening
bleeding
ambulatory phlebectomy, 477
control see hemostasis
orbit, blepharoplasty complications, 490, 490
blepharochalasis, definition, 483
blepharoplasty, 483–503
adjunctive techniques, 484–485, 485
complications, 489, 489–491
diplopia, 490
hematomas, 490
incision irregularities, 491
lacrimal gland complications, 491
lagophthalmos, 490
lower lid malposition, 490–491, 491
orbital hemorrhage, 490, 490
over-/under-correction, 491
upper lid malposition, 490
vision loss, 490
webbing, 491
definitions, 483–503
history, 484–485
‘tear trough,’, 484, 485
lower eyelid see below
postoperative considerations, 501–502
preoperative considerations, 491–494, 494
cultural background, 493
gender, 493
medical history, 491
medication avoidance, 492, 492
ophthalmic history, 492
patient communication/counseling, 491–492
physical examination, 493
SMAS (superficial muscular aponeurotic
system) see SMAS (superficial muscular
aponeurotic system)
techniques, 494–500
upper eyelid see below
blepharoplasty, lower eyelid, 496–500
preoperative considerations, 493–494
‘hypertrophic’ orbicularis oculi muscle, 493,
493
results, 501
transconjunctival, 496–497, 497
transcutaneous, 497–499
fat repositioning, 499
hypertrophic orbicularis muscle removal, 498
incision and dissection, 498, 498
orbital fat removal, 498–499
skin closure, 499, 500
skin excision, 499
skin marking, 497
tear trough deformities, 499
tightening, 499
blepharoplasty, upper eyelid, 494–496, 495
anesthesia, 495
incision, 495, 495
lacrimal gland tissue, 496
preoperative considerations, 492–493
procedure, 495, 495–496, 496
removal estimation, 494–495
results, 500
ROOF sculpture, 496
skin marking, 494, 494–495
blistering, fractional photothermolysis, 240
blood loss, tumescent liposuction, 333
blood spatter, pigmented lesion laser therapy, 169
blood supply
follicular unit transplantation (FUT), 371
hair transplantation repair, 391
random-pattern flaps, 421, 421
body dysmorphic disorder (BDD), 4–5
incidence, 5
body image dissatisfaction, 4–5
body position, tumescent liposuction, 333
body shape, 323, 324
bothersome features, preoperative evaluation, 42
Botox see botulinum type A toxin therapy
botulinum type A toxin therapy, 20, 267–285
antibody development, 268–269, 271
brow lift, 276, 276, 277
clinical studies, 269–270
consent form, 285
depressor anguli oris, 279–280
dynamic rhytides, 43
emotional changes, 18
equipment, 272, 273
forehead, 276–279, 277, 278, 279
eyebrow depression, 276–277
frontalis muscle, 277
injection techniques, 278
‘Jack Nicholson look,’ 277–278, 278
lateral frontalis muscle fiber resistance, 278,
279
occipitalis muscle, 277
frontalis muscle, 273
forehead, 277
glabellar region, 273, 273–275
brow lift, 276
corrugator supercilii muscle, 273, 273, 274
depressor supercilii muscle, 273, 273
doses, 274
frontalis muscle, 273
gender differences, 274–275
injection sites, 273, 274, 275
injection techniques, 275
muscle activity persistence, 274
orbicularis oculi muscle, 273, 275, 275
procerus muscle, 273, 273, 274
proximal nose rhytides, 275
syringe position, 274
treatment requirements, 273, 274
headache therapy, 270
history, 267
hyperdynamic rhytides, 267
clinical studies, 269
dosage, 271
fillers, use with, 272
increase in use, 270
preoperative considerations, 271–272

550

Subject Index
botulinum type A toxin therapy (Continued)
resurfacing lasers, with, 272
see also specific anatomic locations
hyperhidrosis, 280–282
anesthesia, 281–282
axillae, 281
clinical studies, 269–270
cooling, 281
Frey’s syndrome, 270
gustatory sweating, 270
injection number, 281
injection techniques, 281
intradermal wheals, 280
Minor’s starch–iodine test, 280–281
palms, 281, 281
plantar foot, 281–282
preoperative considerations, 272
side effects, 283
topical therapy, with, 272
impact, 11
longevity, 282, 282
mechanism, 267–269, 268
acetylcholine release, 267–268
muscle weakness, 268
nerve ending regeneration, 268
neuromuscular junction, 267
SNARE protein, 267–268
mentalis, 279
muscle groups, 271
see also specific muscles
nasolabial fold, 280
neck, 280
platysmal banding, 280, 280
occipitalis muscle, forehead, 277
patient satisfaction, 283
periorbital region (lateral canthus/crow’s feet),
275–276, 276
injection techniques, 275
orbicularis oculi, 275–276, 276
postoperative considerations, 282–283
instructions, 282
preoperative considerations, 270–272
dilution options, 270–271, 271
dosage record, 271
pretreatment instructions, 271
reconstitution, 270–271, 271
storage, 271
side effects, 282–283
eyelid ptosis, 282, 282
sources, 269
techniques, 272–280
toxin structure, 268
upper lip, 279
vial contents/components, 269, 269
bovine collagen, soft tissue augmentation,
287
atrophic/acne scar management, 415
Bowman–Birk inhibitor (BBI), pigmentation
inhibition, 100
boxcar scars, acne, 400, 400, 445
brachioplasty, tumescent liposuction, 341
breast augmentation, mood disorders, 5
British Red Cross, camouflage makeup, 110
brow augmentation, autologous fat transplantation,
315, 315
‘brow blocks,’, 63, 70
brow lift, botulinum type A toxin therapy
see botulinum type A toxin therapy
brow ptosis, upper eyelid blepharoplasty, 493
bruising, hyaluronic acid tissue augmentation, 291
bupivacaine, local anesthesia, 60
buttocks, tumescent liposuction see tumescent
liposuction
C
cadaver-derived product, collagen tissue
augmentation, 300
café au lait macules, laser therapy, 160, 162, 171
calcium hydroxyapatite (Radiesse), soft tissue
augmentation, 306–307
calves, tumescent liposuction, 354
camouflage makeups (CMs), 107
benefits, 111
gender-specific importance, 112
history, 110
ideal characteristics, 111
indications, 111
limitations, 112, 112
paramedical therapists, 112–113
types of, 111
see also specific types
Camper’s fascia, abdominal tumescent liposuction,
344
cannulas
autologous fat transplantation, 314
tumescent liposuction see tumescent liposuction
capsule formation, suture suspension lifts, 506
capsulopalpebral fascia, lower eyelids, 486, 487,
488–489
capsulopalpebral head, lower eyelids, 488
Carbocaine, local anesthesia, 60
carbon dioxide laser therapy
ablative skin resurfacing see ablative skin
resurfacing
atrophic/acne scar management, 412–413,
413
blepharoplasty, 484
history, 225
keloid/hypertrophic scar management, 404
pigmented lesion laser therapy, 157
pulsed, 226
skin resurfacing see ablative skin resurfacing
carbon suspension-Q-switched Nd:YAG laser, laser
hair removal, 188
cartilage grafts, nose reconstruction, 427
catagen, hair follicle growth cycle, 180, 180
cell death, photodynamic therapy
mechanisms, 250
cell lifespan, photoaging, 26
cervical nerve, sensory innervation, 61
cervical plexus block, 70, 72
Chassaigne’s tubercle, 71, 72
scalp, 70, 71
cervical plexus, innervation, 70, 71
ear, 72
superficial branches, 71, 71
cervical tightening, Nd:YAG laser, 221
Cetacaine, 60
charge-coupled device (CCD), 51
Chassaigne’s tubercle, cervical plexus block,
71, 72
cheek(s)
aesthetic surgical closures see aesthetic surgical
closures
aging effects, 39
laxity, radiofrequency (RF) tissue tightening,
214, 218
poly L lactic acid (Sculptra), 303–304
rotation flaps, 433
skin grafts, 433
chemical depilatories, 181
chemical peels, 117–134
blepharoplasty, with, 485
choice of, 122
clinical studies, 119–121
depth of, 122
Fitzpatrick skin type, 121, 122
future work, 131
herpes simplex virus (HSV) infections, 121
history, 117–119
photoaging, 121
postoperative considerations, 121, 130–130
preoperative considerations, 121, 121–122
techniques, 121, 122–130
see also specific types
chemoprevention, photoaging, 32–33
cherry angiomas, 136, 136
laser therapy, 145
children
photoaging protection, 31, 31
sunscreens, 30
chilled air, laser hair removal cooling, 183
chin
aesthetic surgical closures see aesthetic surgical
closures
rotation flaps, 433
skin grafts, 433
chin implants, face-lifts, 522
chloroprocaine (Nesacaine), local anesthesia, 60
chromophores, cutaneous, absorption spectra, 137
chronologic aging, skin physiological changes, 23
cleansers, Oily–Dry skin care, 96
closed neck dissector, neck and jowl tumescent
liposuction, 339, 339
closed wound care, ablative skin resurfacing, 237,
239
Clostridium botulinum see botulinum type A toxin
therapy
clothing/apparel, photoaging, 30–31, 31
cocaine
historical background, 59–60
as local anesthesia, 60
collagen(s), 118
alpha hydroxy acid treatment, effects of, 122
biosynthesis, 118
contraction, erbium:YAG laser resurfacing,
227
denaturation, nonablative rejuvenation, 198
FACIT (Fibril-Associated Collagen with
Interrupted Triple helices), 118
Gly-X-Y sequence, 118
radiofrequency (RF) tissue tightening effects,
211
skin care, 97–98
tissue augmentation see below
type I, 118
dermal wound healing, 120

Subject Index
551
collagen(s) (Continued)
type III, 118
dermal wound healing, 120
type IV, 118
type VI, 118
type VII, 118
collagen tissue augmentation, 300–302
allergic reactions, 300
atrophic/acne scar management, 415
cadaver-derived product, 300
commercial products, 300
cross-linking effects, 300–301
glabella, 301
hands, 301–302
history, 300
human versions, 300
lips, 301, 301
marionette lines, 301
nasolabial creases, 301
zygomatic arch, 301–302
color correction, skin camouflage, 114
combined (multiple) wavelength lasers, vascular
lesion therapy, 140, 142
comedones, acne skin type, 98
compact cameras, photography, 46, 46
compression
leg vein management see leg vein management
sclerotherapy, 472–473
compression dressings
face-lifts, 537, 538
leg vein management, 459–460
compression stockings
leg vein management, 460–461, 461, 462
sclerotherapy, 460, 461
concomitant procedures, face-lifts, 537
consent see informed consent
consistency, imaging, 53
contact cooling, vascular lesion laser therapy, 138, 138
contact dermatitis, photodynamic therapy, 259
continuous wave lasers, pigmented lesion laser
therapy, 157
contour check, lower eyelid blepharoplasty, 493
contouring, skin camouflage, 114
Contour Threads™, 506, 507
convective cooling, vascular lesion laser therapy,
138, 138
cooling
epidermal, vascular lesion therapy
see vascular lesions, laser therapy
evaporative see evaporative cooling
hyaluronic acid tissue augmentation, 299–300
hyperhidrosis botulinum type A toxin therapy,
281
laser hair removal, 182–183, 193
port-wine stain laser therapy, 148
small vessel laser therapy, 462–463
vascular lesion laser therapy, 138, 138
corneal shields, laser therapy, 147
corrective camouflage see skin camouflage
corrugator muscles, emotion/expression
connection, 16–17, 18
corrugator supercilii muscle
botulinum type A toxin therapy, 273, 273, 274
emotion/expression connection, 16
facial expressions, 12
upper eyelids, 486
corticosteroids
aesthetic surgical closures, 438
hair transplantation, 393
keloid/hypertrophic scar management,
402–403, 403
cosmetic improvements
ablative skin resurfacing, 226–227
aesthetic surgical closures, 422
cosmetics see skin camouflage
cosmetic units
junctions, aesthetic surgical closures, 419, 420
tumescent liposuction, 333
Cosmoderm I, 300
Cosmoderm II, 300
cotton seed oil, phenol chemical peels, 130
counseling, skin camouflage, 113
Covermark, camouflage makeup, 110
COX-2 selective nonsteroidal antiinflammatory
drugs, postoperative pain management, 84
crow’s feet
botulinum type A toxin therapy see botulinum
type A toxin therapy
hyaluronic acid tissue augmentation, 298
crusting
dermal pigmented lesion laser therapy, 173
photodynamic therapy, 250
post-chemical peels, 130–131
cryoanesthesia, dermabrasion, 444
cryosurgery, keloid/hypertrophic scar management,
406, 406
culture
blepharoplasty, 493
facial expressions, 18
cutaneous cervical nerve, 70, 71
cutaneous chromophores, absorption spectra, 137,
137
cutaneous infections, laser hair removal, 190
cyclooxygenase (COX) inhibitiors
COX-2-specific, postoperative pain
management, 84
photoaging prevention, 32–33
D
Darwin, Charles, facial expressions, 11–12
decorin, in skin, 119
deep sedation
ablative skin resurfacing, 234
definition, 79, 79
deep vein thrombosis (DVT), tumescent
liposuction, 359
defect depth effects, skin grafts, 423
definition, hyaluronic acid lip augmentation, 296
degreasing agents, glycolic acid treatments, 126,
127
Demerol see meperidine (Demerol)
deoxyhemoglobin, absorption spectra, 137
depilatories, 181
depressor anguli oris, botulinum type A toxin
therapy, 279–280
depressor supercilii muscle
botulinum type A toxin therapy, 273, 273
upper eyelids, 486
depth of penetration, lasers, 137, 137
depth of tissue, radiofrequency (RF) tissue
tightening, 211
dermabrasion, 443–454
abrading end pieces, 443
anesthesia, 444–445
hand engine, 445, 445
herpes virus reactivation, 450–451, 453
history, 443
immunosuppressed patients, 453
indications, 444
aesthetic surgical closures, 438
atrophic/acne scar management
see atrophic/acne scar management
full-thickness skin graft improvement,
443–444
post-Moh’s partial-thickness defects, 447, 451
scar treatment, 444, 447, 452
tattoos, 447, 453
mechanism, 443
patient expectations, 453
postoperative considerations, 447, 450–451
dressings, 447, 453
erythema, 447, 450, 454
hyperpigmentation, 450, 454
infections, 447
triamcinolone acetonide, 447, 454
preoperative considerations, 444–445
hepatitis testing, 444, 453
HIV testing, 444, 453
procedural techniques, 445, 447–450
sedation, 444
side effects, 412
acne flares, 454
hyperpigmentation, 453
hypertrophic scars, 453
hypopigmentation, 454
pseudohypopigmentation, 454
skin type, 444
studies, 443–444
tretinoin cream, 444
dermal–epidermal junction (DEJ), extrinsic aging,
38
dermal lesions, laser therapy see pigmented lesions,
laser therapy
dermal photoaging, clinical studies, 119–120
dermal plexus, face-lift anatomy, 517
dermal wound healing, collagens, 120
dermasanding, atrophic/acne scar management, 412
dermatochalasis
definition, 483
radiofrequency (RF) tissue tightening, 219
Dermatologic Surgery, photographic guidelines, 51
dermis
anatomy, 117–118
cells of, 119
extracellular matrix (ECM), 117–118
fibroblasts, 119
wound healing, 120–121
dexamethasone, postoperative nausea and vomiting
(PONV), 86
diazepam
dermabrasion, 444
hair transplantation, 378
tumescent liposuction, 331
digital image catalogues, photography, 50
dilatations, vascular lesions, 136
dilution options, botulinum type A toxin therapy,
270–271, 271

552

Subject Index
dimethylhydrinate, postoperative nausea and
vomiting (PONV), 86
dimpling, suture suspension lifts, 510
diode lasers
bipolar radiofrequency combination
see nonsurgical skin tightening
laser hair removal, 184, 187
leg vein endovenous ablation, 479
nonablative rejuvenation, 198, 201, 205
radiofrequency combination, 205
vascular lesions, 140, 142
diplopia
blepharoplasty complications, 490
botulinum type A toxin therapy side effects,
282
direct contact laser therapy, leg vein endovenous
ablation, 480
discharge, office-based sedation, 86, 92
discomfort monitoring, radiofrequency (RF) tissue
tightening, 217–218
dispigmentation, photodynamic therapy, 259
DNA damage, ultraviolet (UV) radiation, 25
dolasetron, postoperative nausea and vomiting
(PONV), 86
donor area harvesting, hair transplantation
see hair transplantation
Doppler ultrasound
guided foam sclerotherapy, 464–465
guided sclerotherapy see sclerotherapy
leg vein management, 456, 457, 458
dorsal (external) nasal nerve block, 63, 65
nose local anesthesia, 72
dosage(s), botulinum type A toxin therapy, 271, 274
dosage record, botulinum type A toxin therapy, 271
drainage quantity, tumescent liposuction, 358
dressings
ambulatory phlebectomy, 477–478
autologous fat transplantation, 318
dermabrasion, 411, 447, 453
hair transplantation, 393
drug interactions, hair transplantation, 376–377,
396–398
dry (D) skin category, 93–95
dry-resistant (DR) skin types, sebum, 95
Duchenne smile, 14, 16
Duplex ultrasound
greater saphenous vein (GSV), 458, 459
guided sclerotherapy see sclerotherapy
leg vein management, 457–458
Duranest (etidocaine), local anesthesia, 60
dynamic cooling laser therapy, leg vein endovenous
ablation, 480–481
dynamic rhytides, botulinum toxin therapy, 43
dysthesia, tumescent liposuction, 359
E
ear
local anesthesia, 72, 72
reconstruction see below
earlobe
face-lift incision design, 524, 525, 526
posterior platysma suspension, 533, 534
ear reconstruction
full-thickness skin grafts (FTSGs), 431, 438
skin flaps see skin flap(s)
eating disorders, 5
ecchymoses
botulinum type A toxin therapy side effects,
282
skin camouflage, 109
edema
blepharoplasty, 501
intense pulsed light (IPL) sources, 204
laser hair removal, 193, 193, 194
nonablative rejuvenation, 207
nonsurgical skin tightening, 221, 222
suture suspension lifts, 510
tumescent liposuction, 359
EEG see electroencephalography (EEG)
eflornithine cream, laser hair removal, 194
elastic fibers, skin, 118–119
elastin, in skin, 118
electroencephalography (EEG)
emotion/expression connection, 16–17
facial feedback testing, 13
electrolysis, hair removal, 181
electromyography (EMG)
emotion/expression connection, 16–17
facial feedback testing, 13–14
electro-opical synergy (ELOS) technology, laser
hair removal, 187, 188
ellipse closure, aesthetic surgical closures, 419
ELOS (electro-opical synergy) technology, laser
hair removal, 187, 188
embryonal fusion plate, hyaluronic acid nasolabial
crease augmentation, 295
emergencies, office-based sedation, 90
emergency equipment, sedation, 88
EMG see electromyography (EMG)
emollients
post-chemical peels, 130
skin care, 97
emotion
facial expression connection
see facial expressions
health link, 18–19
emotional contagion, facial expression, 16–17
endogenous chromophore lasers, laser hair
removal, 183, 187–189
endovenous ablation, truncal leg vein
incompetence, 467–468, 468
end-point determination, tumescent liposuction
anesthesia, 332, 332
entry site scars, tumescent liposuction, 359
environmental influences, photoaging,
28–29
ephelides (freckles)
laser hair removal, 195
laser therapy, 160, 163
epidermis
anatomy, 117
cooling, vascular lesion therapy
see vascular lesions, laser therapy
damage to, laser hair removal, 194, 194
erbium:YAG laser resurfacing, 234
hydration, plasma skin regeneration
(PSR), 236
lesions, laser therapy see pigmented lesions,
laser therapy
photodamage, 117
pigment change, photoaging, 25
epinephrine
poly L lactic acid (Sculptra), 302
tumescent anesthesia, 74
tumescent liposuction, 325, 330
erbium:glass lasers, nonablative rejuvenation, 198,
201–202
erbium:YAG lasers
ablative skin resurfacing see ablative skin
resurfacing
atrophic/acne scar management, 413
fractional resurfacing, 228
history, 225–226
pigmented lesion laser therapy, 157
erythema
aesthetic surgical closures, 439
dermabrasion, 447, 450, 454
dermal pigmented lesion laser therapy, 173
intense pulsed light (IPL) devices, 151, 204
laser hair removal, 193, 193, 194
nonablative rejuvenation, 207
nonsurgical skin tightening, 221, 222
photodynamic therapy, 250, 254, 258
post-chemical peels, 131
skin camouflage, 109
erythematous nodules, nonsurgical skin tightening,
221, 222
essential hypertension, face-lift complications, 539
etidocaine (Duranest), local anesthesia, 60
eumelanin, skin pigmentation, 100
evaluation, preoperative see preoperative evaluation
evaporative cooling
laser hair removal cooling, 183
vascular lesion laser therapy, 138, 138
excised specimens, photography, 55
exogenous chromophores, laser hair removal,
188–189
expectations see patient expectations
extracellular matrix (ECM)
dermis, 117–118
photoaging, 26
extraction cannulae, autologous fat transplantation,
313
extrinsic aging, 38, 101
eyebrow depression, botulinum type A toxin
therapy, 276–277
eyelid(s), 483–484
aesthetic surgical closures, 424
blepharoplasty complications, 490
ptosis, botulinum type A toxin therapy side
effects, 282, 282
eyelid(s), lower, 488–489
blepharoplasty complications, 490–491, 491
capsulopalpebral fascia, 486, 487, 488–489
inferior oblique muscle, 487
inferior orbital fat pads, 486, 488–489
Lockwood’s suspensory ligament, 487, 488
eyelid(s), upper, 485–488, 486, 487
anterior fat pads, 487
Asian, 488, 488
corrugator supracilii muscle, 486
depressor supercilii muscle, 486
lacrimal gland, 487
lateral canthal tendon, 486
levator aponeurosis, 486
levator muscle, 486
levator palpabrae superioris muscle, 487

Subject Index
553
eyelid(s), upper (Continued)
medial canthal tendon, 486
Müller’s muscle, 486–487
muscles, 486
occidental, 488, 488
occipitofrontalis muscle, 486
orbicularis oculi muscle, 485, 486
orbital septum, 485, 486
preaponeurotic (central) fat pedicle, 485, 487
procerus muscle, 486
retro-orbicularis fat (ROOF), 485–486
superior transverse (Withnall’s) ligament, 487
eye protection
laser surgery, 147, 169, 403
hair removal, 193
photoaging prevention, 31
F
face
aging, 38–39
total local anesthesia, 75, 75
face-lifts, 517–546
anatomy, 517–518
SMAS, 517–518, 518
subcutaneous plane, 518
sub-SMAS plane, 518, 519
anesthesia, 521–522
chin implants, 522
complications, 538–541
essential hypertension, 539
facial nerve injuries, 541
greater auricular nerve (GAN) injury,
540–541
hairline problems, 541
hematoma, 538–540, 540
infections, 541
nerve injuries, 540–541, 541
suture bleeding, 539, 540
tissue necrosis, 541, 542
concomitant procedures, 537
flap dissection, 525–527, 526
hemostasis, 527, 527
long vs. short, 526
thickness importance, 525–526
history, 517
incision design, 522–525, 523
earlobe, 524, 525, 526
horizontal-releasing incision, 522–523, 524
minimally-invasive, 522–523
retrotragal incision, 524, 524
tragus, 524
instrumentation, 518–519, 519
limited-incision method, 520
midline platysmaplasty, 522, 523
patient expectations, 519–520, 520
patient selection, 519, 519–520
anatomy, 520, 521
posterior platysma suspension, 531–537
auricular skin flap trimming, 536, 536
border, 531, 532
earlobe delivery, 533, 534
hemostasis, 532
incision closure, 536, 536, 537
skin flap, 532, 533
skin removal, 535, 535
face-lifts (Continued)
skin suspension, 532
stepped hairline, 532, 534
tension minimization, 532–533
tragal area, 535–536, 536
vector importance, 533
postoperative considerations, 537–541
compression dressings, 537, 538
hair washing, 537, 537, 538
‘jaw-bra’-type dressing, 538, 539
patient activity, 538
preoperative considerations, 517–520
prep and drape, 521
procedural technique, 521–525
see also specific stages
results, 542, 543, 544, 545
risk classification, 546
skin marking, 520–521, 521
SMAS techniques, 528–531
SMASectomy, 520, 530–531, 531, 532
SMAS imbrication, 529–530, 530
SMASplication, 520, 528, 528–529, 529
Facial Action Coding System (FACS), 13
facial anesthesia, autologous fat transplantation, 313
facial expressions, 11–22
aging, 17
anger, 15
Duchenne smile, 14, 16
emotion connection, 14–17
emotional contagion, 16–17
facial mimicry, 16–17
group cohesion, 17
initiation/modulation, 15, 15, 16, 16
measurement of, 16–17
studies, 14–16
facial muscles, 39, 39
fear, 13
fear/surprise, 14
intense fear, 13
negative emotion curtailment, 19–20, 20
positive emotion accentuation, 18–19
subpopulations, 17–18
upper facial muscles, 12, 12
facial feedback hypothesis, 11–12, 19
criticism of, 17
study conclusions, 17
testing of, 13–14
facial fillers, 43
facial mimicry, 16–17
facial muscles, facial expression, 12, 12, 39, 39
facial nerve injuries, face-lift complications, 541
facial photography, 53–54
facial ptosis, hyaluronic acid nasolabial crease
augmentation, 295
FACIT (Fibril-Associated Collagen with
Interrupted Triple helices), collagens, 118
fair skin, photodynamic therapy, 256
fanning, atrophic/acne scar management, 410
fasciocutaneous flaps see skin flap(s)
fat extraction, autologous fat transplantation,
312–313, 313
fat freezing, autologous fat transplantation, 319,
319
fat replacement, tumescent liposuction, 360
fat repositioning, transcutaneous lower eyelid
blepharoplasty, 499
fear, facial expression, 13, 14
intense, 13
feathering
carbon dioxide laser resurfacing, 234
plasma skin regeneration (PSR), 237
female(s)
aging, 40
breast tumescent liposuction see tumescent
liposuction
hair transplantation see hair transplantation
female pattern hair loss (FPHL), 365
hair loss patterns, 366, 368
fentanyl, 91
postoperative pain management, 84
fibrin clots, dermal wound healing, 120
fibroblasts, in dermis, 119
fibronectin, in skin, 119
fillers
atrophic/acne scar management, 415–416,
439
botulinum type A toxin therapy, use with, 272
see also soft tissue augmentation
finasteride, hair loss therapy, 367–368, 370, 373
Fitzpatrick skin type
chemical peels, 121, 122
dermabrasion patient selection, 444, 450–451
epidermal lesion laser therapy, 170
laser surgery, 403
Fitzpatrick wrinkle score, radiofrequency (RF)
tissue tightening, 213
flaps see skin flap(s)
flashlamp pulsed-dye laser, nonablative
rejuvenation, 198
flash, photography, 47–48
flumazenil (Romazicon), 91
5-fluorouracil
glycolic acid treatments, 123–124
intralesional injections, keloid/hypertrophic
scar management, 402–403
foam sclerotherapy
advantages, 464
clinical trials, 464
Doppler-guided, 464–465
foam preparation, 471–472, 472
large non truncal varicose veins, 463–465
ambulatory phlebectomy vs., 465
reticular veins, 471–472
safety concerns, 464
ultrasound-guided, 464
follicular unit(s), 382
follicular unit extraction (FUE), 372
follicular unit transplantation (FUT), 365, 368–371,
372, 384–386
advantage, 385
blood supply integrity, 371
density, 370
hair counts, 369
hairline, 386, 387
hair survival rates, 370, 371, 373
multi-unit grafts, with, 384, 387–388
hair survival, 387–388, 388, 389
results, 385
terminology, 371
vertex area, 388, 390
timing of, 390
folliculitis, laser hair removal, 194–195

554

Subject Index
forehead
advancement flaps, 435
aesthetic surgical closures see aesthetic surgical
closures
autologous fat transplantation, 314, 314
botulinum type A toxin therapy see botulinum
type A toxin therapy
local anesthetic techniques, 62–75, 63
see also specific techniques
fractional deep dermal ablation (FDDA), 240
fractional erbium:YAG laser resurfacing, 228
fractional photothermolysis, 235–236
conditions, 233
acne scars, 230–231, 231
consent form, 244–245
depth of injury effects, 236
history, 226
patient information sheet, 245
side effects, 239–240
studies, 230
technique, 235–236, 236
topical anesthetic, 235
fractional rejuvenating laser see ablative skin
resurfacing
freckles see ephelides (freckles)
Frey’s syndrome, hyperhidrosis botulinum type A
toxin therapy, 270
frontal (F) area, hair transplantation, 384
frontalis muscle
aging, 38
anatomy, 277, 277
facial expressions, 12
frontal nerve, 61, 62, 62
full-thickness skin grafts (FTSGs), 421–422
dermabrasion, 443–444
ear reconstruction, 431, 438
medial canthal defects, 424
nose reconstruction, 430, 434
philtrum repair, 427
G
Gasparotti’s point, tumescent liposuction, 350,
350, 351
gender
blepharoplasty, 493
botulinum type A toxin therapy, 274–275
camouflage makeup importance, 112
facial expressions, 17
hyaluronic acid nasolabial crease
augmentation, 295–296
tumescent liposuction, 333
tumescent liposuction anesthesia, 332
general anesthesia
ablative skin resurfacing, 234
clinical studies, 79
definition, 79, 79
risks of, 79, 79
techniques, 81
glabellar region
advancement flaps, 435, 437
aesthetic surgical closures, 435
botulinum type A toxin therapy see botulinum
type A toxin therapy
calcium hydroxyapatite (Radiesse) soft tissue
augmentation, 307
glabellar region (Continued)
collagen tissue augmentation, 301
hyaluronic acid tissue augmentation see
hyaluronic acid tissue augmentation
silicone soft tissue augmentation, 305–306
Glogau classification, aging, 38
glycerin
as humectant, 97
sclerotherapy, 462
glycolic acid treatments, 122–126
acne, 124
actinic keratoses, 123–124, 124
complications, 125
degreasing agents, 126, 127
with 5-fluorouracil, 123–124, 124
photodamage, 123
skin preparation, 126
techniques, 125–126
tretinoin use, 126
glycosaminoglycans (GAGs)
alpha hydroxy acid treatment, effects of,
122–123
in skin, 119
see also specific types
Gly-X-Y sequence, collagens, 118
graft preparation/insertion, hair transplantation
see hair transplantation
granisetron, postoperative nausea and vomiting
(PONV), 86
granulation tissue, dermal wound healing, 120
greater auricular nerve (GAN), 70
ear innervation, 72
injury, face-lift complications, 540–541
neuropathy, suture suspension lifts, 510, 511
greater occipital nerve
anatomy, 70, 70
nerve block, 70
greater saphenous vein (GSV), 455, 456
Duplex ultrasound, 458, 459
‘grenz,’ 120
gridding, radiofrequency (RF) tissue tightening,
217, 217
group cohesion, expression/emotion, 17
growth cycle, hair follicle growth cycle, anagen, 180
gustatory sweating, hyperhidrosis botulinum type A
toxin therapy, 270
gynecoid body shape, 323, 324
H
hair-bearing flaps, 181
hair color, 180
hair transplantation, 372
laser hair removal, 191
hair counts, follicular unit transplantation (FUT),
369
hair, excessive, 180–181
laser therapy see laser hair removal
traditional treatment methods, 181
see also specific methods
hair follicles, 179–180, 180
growth cycle, 179–180, 180
stem cells, 180
hairline
assessment, 375, 375, 376
face-lift complications, 541
hairline (Continued)
follicular unit transplantation (FUT), 386, 387
hair transplantation repair, 391
hair loss patterns, 366, 367–368, 369
hair shaft caliber, hair transplantation, 372
hair survival, follicular unit transplantation, 370,
371, 373
with multi-unit grafts, 387–388, 388, 389
hair transplantation, 365–398
alpoecia reduction, 375–376, 377
anesthesia, 378–379
lidocaine/epinephrine, 378, 378
donor area harvesting, 379–380
‘safe’ areas, 379, 379
scars, 379–380, 381
female patients, 373–374, 374
follicular unit extraction (FUE), 372
graft preparation/insertion, 380–384
area marking, 383, 384
follicular units, 382
multi-unit grafts, 383–384
scoring grafts, 383
sectioning, 380, 382
storage/hydration, 382, 382–383
survival rates, 380, 382
hairline assessment, 375, 375, 376
hairline results, 386–387, 388
history, 366
male patients, 373, 374
multi-unit grafting (MUG) see multi-unit grafts
(MUGs)
patient assessment, 372–376
patient objectives, 372
postoperative care, 393
preoperative considerations, 376–377
antibiotics, 377
drug interactions, 376–377, 396–398
hair washing, 377
patient instructions, 377, 395–396
prednisolone, 377
viral infections, 377
procedures, 378–392
see also specific procedures
recipient area, 384–392
area limitation, 384
frontal (F), 384
midscalp (M), 384
peripheral vertex transplantation, 384
vertex (V), 384
into scar tissue, 392, 392
stem cell therapy, 372
studies, 366–372
hair loss patterns, 366, 367–368, 369
medical treatment, 367–368
transplant repair, 390, 390–392, 391
alopecic spaces, 391
blood supply, 391
donor area, 391
hairline, 391
vertex area, 388, 390
see also follicular unit transplantation (FUT)
hair trimming, hair transplantation, 379
hair washing
face-lifts, 537, 537, 538
hair transplantation, 377
hair wave/curl, hair transplantation, 372

Subject Index
555
Hamilton–Norwood hair loss pattern classification,
366, 367–368
hand engine, dermabrasion, 445, 445
hand placement, autologous fat transplantation,
313–314, 314
hands, collagen tissue augmentation, 301–302
Hatchet flaps, nose reconstruction, 430, 435
hats, photoaging prevention, 31
headaches, botulinum type A toxin therapy, 270
head, sensory anatomy, 61, 61
see also specific nerves
health
emotion links, 18–19
preoperative evaluation, 42
helical advancement flaps, ear reconstruction, 431
hemangiomas, 135–136, 146
laser therapy, 146
pulsed-dye lasers, 146, 149
hematomas
aesthetic surgical closures, 422
ambulatory phlebectomy, 477
blepharoplasty complications, 490
face-lift complications, 538–540
tumescent liposuction, 359
hematoporphyrin derivative (HPD), photodynamic
therapy, 250
hemoglobin absorbance, small vessel laser therapy,
464
hemorrhage see bleeding
hemostasis
face-lift flap dissection, 527, 527
hair transplantation, 379, 386
posterior platysma suspension, 532
hepatitis testing, dermabrasion, 444, 453
herpes simplex virus (HSV) infections
chemical peels, 121
photodynamic therapy preoperative
considerations, 255
reactivation
ablative skin resurfacing, 239
dermabrasion, 450–451, 453
high definition (HD) video camera, 51
high-tension wounds, aesthetic surgical closures, 422
hips, tumescent liposuction see tumescent
liposuction
hirsuitism, 180
HIV infection, laser therapy risks, 169
HIV testing, dermabrasion, 444, 453
horizontal-releasing incision, face-lift incision
design, 522–523, 524
humectants, skin care, 96–97
Hunter’s canal, tumescent liposuction, 353
hyaluronic acids
alpha hydroxy acid treatment, effects of, 122
dermal wound healing, 120
in skin, 119
structure, 287–288
hyaluronic acid tissue augmentation, 287–300, 288
anesthesia, 291–292
lip augmentation, 292–293, 296, 296
nasolabial crease augmentation, 293
atrophic/acne scar management, 415
bruising, 291
contraindications, 290
flow/stiffness, 289
future work, 300
hyaluronic acid tissue augmentation (Continued)
glabella, 297–298, 298
hands, 299
topical anesthetic, 299
volumes needed, 299
Hylacross™, 288, 289
Hylaform, 288, 289
indications for, 289–290
informed consent, 292
Juvederm, 288, 289
lips, 296–297
anesthetics, 292–293, 296, 296
rolled border, 296, 296
volume, 296–297, 297
marionette lines/oral commissures, 297
nasolabial creases, 290, 294, 294–296, 295
amount needed, 295
anesthetics, 293
embryonal fusion plate, 295
facial ptosis, 295
gender differences, 295–296
particle size, 289
periorbital area, 298
post-treatment considerations, 299–300
pretreatment considerations, 290–291
implanted devices, 291–292
infections, 290
medications, 290, 291
patient schedule, 290
procedural techniques, 292, 293–299
area preparation, 293–294
injection depth, 292, 292
injection techniques, 292, 293
product selection, 292–293
see also specific anatomical areas
Restylane™, 288, 289
swelling, 299
zygomatic arch, 298–299
anesthetics, 293
hydrocool dressings, tattoo laser therapy, 174, 174
hydromorphone, postoperative pain management, 84
hydroxyacids, as humectant, 97
hydroxyzine hydrochloride (Vistaril), tumescent
liposuction, 331
Hylacross™, 288, 289
Hylaform, 288, 289
hyoid bone position, neck and jowl tumescent
liposuction, 336–337, 337, 340
hyperdynamic rhytides, botulinum type A toxin
therapy see botulinum type A toxin therapy
hyperhidrosis, botulinum type A toxin therapy
see botulinum type A toxin therapy
hyperpigmentation
ablative skin resurfacing, 239, 240
dermabrasion, 450, 453, 454
infraorbital, laser therapy, 165
laser hair removal, 194
nonablative rejuvenation side effect, 200
pigmented lesion laser therapy, 173
post-chemical peels, 128, 130, 131
post-laser therapy, 164, 165–166
sclerotherapy, 473, 475
hypertension, essential, face-lift complications, 539
hypertonic saline, sclerotherapy, 462
hypertrichosis, 180–181
laser hair removal, 195
hypertrophic orbicularis oculi muscle, lower eyelid
blepharoplasty, 493, 493
transcutaneous, 498
hypertrophic scars, 399–400
characteristics, 401
dermabrasion side effects, 453
laser hair removal, 190
management see keloid/hypertrophic scar
management
post ablative skin resurfacing, 239
hypertrophic suborbital aging, 310, 311
hypodermoclysis, tumescent liposuction, 325
hypopigmentation
dermabrasion side effects, 454
intense pulsed light (IPL) sources, 204, 204
keloid/hypertrophic scar management, 404
laser hair removal, 194, 194
phenol chemical peel side effect, 130, 130
hypoventilation, sedation, 81–82
I
ibuprofen, postoperative pain management, 84
ice packs
laser surgery, 413
suture suspension lifts, 511
icepick scars, 400, 400, 445, 447
iimmunocompromised mouse models, autologous
fat transplantation, 309
imaging, 45–55
consent forms, 52
consistency, 53
historical aspects, 45
staff training, 53
studio space, 53
trial and error, 53
tumescent liposuction, 327
see also photography; videography
imiquimod, topical, 407
immunosuppression
dermabrasion, 453
photodynamic therapy preoperative
considerations, 255
implanted devices
hyaluronic acid tissue augmentation, 291–292
nonsurgical skin tightening, 217
incision(s)
closure, posterior platysma suspension, 536,
536, 537
and dissection, transcutaneous lower eyelid
blepharoplasty, 498, 498
face-lifts see face-lifts
irregularities, blepharoplasty complications,
491
scars, aesthetic surgical closures, 422
upper eyelid blepharoplasty, 495, 495
incisional/excisional surgery, keloid/hypertrophic
scar management, 404–405, 405
incision sites, tumescent liposuction
anesthesia, 331
drainage, 358
indomethacin, postoperative pain management, 84
infections
ablative skin resurfacing, 239
dermabrasion, 447
face-lift complications, 541

556

Subject Index
infections (Continued)
hyaluronic acid tissue augmentation, 290
tumescent liposuction, 359
inferior alveolar nerve, 66
inferior alveolar nerve block, 68, 68–69
inferior oblique muscle, lower eyelids, 487
inferior orbital fat pads, lower eyelids, 486,
488–489
inferior palpebral nerve, anatomy, 62
inferior scleral show, definition, 483
infiltration cannula, autologous fat transplantation,
314
inflammation, photoaging, 101–102
informed consent
hyaluronic acid tissue augmentation, 292
nonsurgical skin tightening, 217
informed consent forms
ablative skin resurfacing, 243
botulinum type A toxin therapy, 285
fractional photothermolysis, 244–245
imaging, 52
photodynamic therapy, 263–265
plasma skin regeneration (PSR), 246
suture suspension lifts, 514–515
tumescent liposuction, 363–364
infraoral nerve blocks, hyaluronic acid tissue
augmentation, 293
infraorbital hyperpigmentation, laser therapy, 165
infraorbital nerve block, 62–64
facial approach, 63, 64
intraoral approach, 63, 64
nose local anesthesia, 72
infraorbital tissue laxity, radiofrequency (RF) tissue
tightening, 218
infrared skin tightening, 43
infratrochlear nerve block, 63
nose local anesthesia, 72
initiation, expression/emotion, 15, 15, 16
injection depth, hyaluronic acid tissue
augmentation, 292, 292
injection techniques, hyaluronic acid tissue
augmentation, 292, 293
inorganic agents, sunscreens, 29
intense fear, facial expression, 13
intense pulsed light (IPL)
broadband, laser hair removal, 186, 187–188
leg vein endovenous ablation, 480, 481
nonablative rejuvenation, 198–199,
203–204
pigmented lesion laser therapy, 159
vascular lesion laser therapy see vascular
lesions, laser therapy
interferon-γ, keloid/hypertrophic scar
management, 406–407
intradermal wheals, hyperhidrosis botulinum type
A toxin therapy, 280
intralesional corticosteroid injections, keloid/
hypertrophic scar management, 402–403,
403
intralesional 5-fluorouracil injections, keloid/
hypertrophic scar management,
402–403
intraocular retinal hemorrhage therapy, silicone
soft tissue augmentation, 304
intravenous access, sedation, 89
intrinsic (biological) aging, 38
J
‘Jack Nicholson look,’ botulinum type A toxin
therapy, 277–278, 278
James, William, facial expressions, 11–12
‘jaw-bra’-type dressing, face-lifts, 538, 539
jawline
aging changes, 310, 311
autologous fat transplantation, 317, 317–318,
318
Jessner’s solution, 130
salicylic acid chemical peels, 126
trichloroacetic acid (TCA) chemical peels, 128
Journal of the American Academy of Dermatology,
photographic guidelines, 51
jowels
nonablative rejuvenation, 200
tumescent liposuction see tumescent liposuction
Juvederm, 288, 289
K
keloid scars, 399–400
characteristics, 401
laser hair removal, 190
management see keloid/hypertrophic scar
management
keloid/hypertrophic scar management, 402–407
cryosurgery, 406
side effects, 406
incisional/excisional surgery, 404–405, 405
interferon-γ, 406–407
intralesional corticosteroid injections, 402–403,
403
intralesional 5-fluorouracil injections,
402–403
laser surgery, 403–404
nonablative rejuvenation, 203
pressure, 405–406
rapamycin, 407
silicone gel sheeting, 406
tacrolimus, 407
topical imiquimod, 407
topical retinoic acid, 407
verapamil, 407
keratinocytes, dermal wound healing, 120
ketamine, hair transplantation, 378–379
ketorolac (Toradol)
hair transplantation, 378
postoperative pain management, 84
Klein tumescent fluid, fat extraction, 312, 313
knees, tumescent liposuction see tumescent
liposuction
Koebner phenomenon, laser hair removal, 195
KTP laser
leg vein endovenous ablation, 479
millisecond-pulsed 532 nm
port-wine stains, 149–150
spider angiomas, 150
millisecond-pulsed, 532, vascular lesions, 139,
149–150
Nd:YAG laser combination, nonablative
rejuvenation, 202
nonablative rejuvenation, 202, 203
pigmented lesion therapy, 157
Q-switched 532nm, telangiectasias, 144
L
labial melanotic macules, laser therapy, 160
labiomental crease augmentation, autologous fat
transplantation, 316–317, 317
laboratory studies, tumescent liposuction, 327
lacrimal gland, 487
blepharoplasty complications, 491
upper eyelid blepharoplasty, 496
lactic acid, as humectant, 97
lagophthalmos, blepharoplasty complications, 490
lamellar ichthyosis, alpha hydroxy acid treatment,
123
lancing, atrophic/acne scar management, 410, 411
large non truncal varicose veins, 463–465
laryngeal mask airway (LMA), 82, 82
laser(s), 136–138
depth of penetration, 137, 137
fluence, 138, 170, 173, 234
pulsed-dye laser see pulsed-dye lasers
pulse duration, 137–138
pulse width, 182
selective photothermolysis, 136
spot sizes, 139, 193, 234, 462, 463
tissue interaction in pigmented skin, 155–156
wavelength, 136–137
see also laser therapy; specific lasers
laser hair removal, 179–196, 195
clinical studies, 189
cooling, 182–183, 193
ELOS (electro-opical synergy) technology,
187, 188
exogenous chromophores, 188–189
expected efficacy, 191, 191–192
history, 179
indications, 191
intense pulsed broadband light source, 186,
187–188
laser types, 181, 183–188, 184–187
carbon suspension-Q-switched Nd:YAG
laser, 188
diode lasers, 184, 187
endogenous chromophore lasers, 183,
187–189
long-pulse alexandrite 755nm laser, 183,
184, 187
long-pulsed Nd:YAG laser, 185
long-pulse ruby 694nm lasers, 183, 184
Q-switched lasers, 182
Q-switched Nd:YAG laser, 184, 187
mechanisms, 181, 181–182
see also specific mechanisms
meladine, 188–189
patient selection, 190–192
cutaneous infections, 190
expectations, 191
hair color, 191
history, 190, 190
hypertrophic scarring, 190
keloids, 190
medications, 190
previous hair removal, 190–191
skin diseases, 190
skin pigmentation, 190
photochemical destruction, 182
photodermal destruction, 181–182

Subject Index
557
laser hair removal (Continued)
with photodynamic therapy, 189
photomechanical destruction, 182
postoperative considerations, 193–196
preoperative considerations, 189–192
pretreatment instructions, 192
procedural techniques, 192–193
safety, 193
side effects, 194–195
small pulsed light hair removal systems, 188
‘softlight’ technique, 182
spot size, 193
test spots, 193
treatment numbers, 192, 194
Lasers in Surgery and Medicine, photographic
guidelines, 51
laser-susceptible pigments, tattoo laser therapy, 166
laser therapy
ablative skin resurfacing see ablative skin
resurfacing
anesthesia, 403
atrophic/acne scar management, 412
pigmented lesions, 169
vascular lesions, 147
assisted liposuction, 329, 334–335
atrophic/acne scar management
see atrophic/acne scar management
botulinum type A toxin therapy, with, 272
direct contact, 480
eye protection, 169
hair-removal see laser hair removal
keloid/hypertrophic scar management see
keloid/hypertrophic scar management
nonablative rejuvenation see nonablative
rejuvenation
pigmented lesions see pigmented lesions, laser
therapy
resurfacing with blepharoplasty, 485
small vessel disease see small vessel laser therapy
vascular lesions see vascular lesions, laser
therapy; specific lesions
lateral canthus
botulinum type A toxin therapy see botulinum
type A toxin therapy
tendon, upper eyelids, 486
lateral face augmentation, autologous fat
transplantation, 317–318
lateral nasal nerve, anatomy, 62
lateral palpebral nerve, anatomy, 62
lateral retinaculum, lower eyelids, 488
lateral subdermic venous system (LSV), 455, 457
legs
telangiectasias, sclerotherapy see sclerotherapy
tumescent liposuction see tumescent liposuction
venous system, 455–456, 456, 457
see also leg vein management; specific veins
leg vein laser therapy, 467–468, 478–481
diode lasers, 479
direct contact method, 480
dynamic cooling method, 480–481
intense pulsed light, 480, 481
laser selection, 479
long-pulsed alexandrite laser, 479
long-pulsed Nd:YAG, 480
patient selection, 480
potassium titanyl phosphate (KTP) laser, 479
leg vein laser therapy (Continued)
preoperative considerations, 478–479, 479
pulsed-dye lasers, 479
leg vein management, 455–481
ambulatory phlebectomy see ambulatory
phlebectomy
compression, 459–461, 460
active, 459
bandages, 459–460
compression stockings, 460–461, 461, 462
indications, 459
manufacturers, 461
passive, 459
diagnosis, 455–456
Doppler ultrasound, 456, 457, 458
Duplex ultrasound, 457–458
photoplethysmography (PPG), 457
physical examination, 457
reflux diagnosis, 457–458, 459
history, 455
large non truncal varicose veins, 463–465
foam sclerotherapy see foam sclerotherapy
phlebectomy, 465
laser therapy see leg vein laser therapy
perforating veins, 465–466, 466, 467
small vessel disease, 461–463
laser therapy see laser therapy
sclerotherapy, 462
telangiectasia, 455
treatment algorithm, 456–468, 458
truncal incompetence, 466–468
endovenous ablation, 467–468, 468
sclerotherapy, 466
stripping and ligation, 466–467, 467
leg vein visualization, sclerotherapy, 470
lenses, photography, 46–47
lentigenes
laser therapy, 160, 160, 161, 171
nonablative rejuvenation, 200
lentigo, laser therapy, 171
lentigo maligna, laser therapy, 164
lesion size, port-wine stain laser therapy, 143
lesser occipital nerve, 70
ear innervation, 72
lesser saphenous vein (LSV), 455, 456
leukotrichia, laser hair removal, 195
levator aponeurosis, upper eyelids, 486
levator muscle, upper eyelids, 486
levator palpabrae superioris muscle, upper eyelids,
487
lid laxity/position, lower eyelid blepharoplasty,
493–494
lidocaine (Xylocaine)
drug interactions, 324
epinephrine with, 378, 378
historical background, 60
local anesthesia, 60
mechanisms, 324
tumescent liposuction, 324
lidocaine toxicity, 324, 325
tumescent liposuction, 359
lifestyle, preoperative evaluation, 42
light emitting diodes, nonablative rejuvenation,
199, 199, 206
lighting, videography, 52
limited-incision method, face-lifts, 520
linear closures, aesthetic surgical closures, 422
linearity, suture suspension lifts, 510
line of view, videography, 51
Linton’s procedure, 465–466
lip(s)
collagen tissue augmentation, 301, 301
hyaluronic acid tissue augmentation see
hyaluronic acid tissue augmentation
local anesthesia, 73, 73
silicone soft tissue augmentation, 306
upper, botulinum type A toxin therapy, 279
lipocytic dermal augmentation, atrophic/acne scar
management, 415
liposculpture, tumescent liposuction, 332
liposuction, tumescent anesthesia, 73
lip restoration, 43
lip shielding, photodynamic therapy, 257
liquid makeup, 111
local anesthesia
agents, 60, 60
see also specific local anesthetics
dermabrasion, 411, 444
face-lifts, 522
laser therapy, 147
mechanism of action, 60
perioral aesthetic surgical closures, 427
suture suspension lifts, 506
local phototoxicity, photodynamic therapy, 259
Lockwood’s suspensory ligament, 487, 488
long-pulsed Nd:YAG laser see Nd:YAG laser
long-pulse ruby 694nm laser, laser hair removal,
183, 184
long-stretch compression bandages, 459–460
long wavelength noncoherent infrared light,
nonablative rejuvenation, 206
lorazepam, tumescent liposuction, 331
love handles, male tumescent liposuction, 357–358,
358
lower back, tumescent liposuction see tumescent
liposuction
lower face, aging, 38–39
lymphedema, periocular closure, 424
M
macro lenses, 47, 48
macrophages, in dermis, 119
magnetic resonance imaging (MRI), emotion/
expression connection, 17
make-up see skin camouflage
malar folds
autologous fat transplantation, 316, 316
midfacial SMAS, 489
male breasts, tumescent liposuction see tumescent
liposuction
male pattern baldness (MPB)
classification, 369
finasteride therapy, 373
hair transplantation, 366
incidence, 370
patterns, 370
see also hair transplantation
males, aging, 41
malformations, vascular lesions, 135
Maliampati airway classification, 80
malignant melanoma see melanoma

558

Subject Index
mandibular nerve (V3), 61, 61
anatomy, 66
nerve block, 69, 69
Marcaine, local anesthesia, 60
marionette lines
calcium hydroxyapatite (Radiesse) soft tissue
augmentation, 307
collagen tissue augmentation, 301
hyaluronic acid tissue augmentation, 297
mast cells, in dermis, 119
matching, skin camouflage, 113
matting, sclerotherapy, 473–474, 475
Max Factor, camouflage makeup, 110
maxillary nerve (V2), 61, 61
anatomy, 62
maxillary nerve block, 62–66
nose anesthesia, 72–73
total second division nerve block, 65–66, 67
Maximally Descriptive Facial Movement Coding
System, 13
mechanical ptosis, 483
media influence, aging, 38
medial canthal defects, 424, 426
medial canthal tendon, upper eyelids, 486
medical history
blepharoplasty, 491
dermabrasion, 444
scar management, 401
tumescent liposuction, 326
medication avoidance/discontinuation
aesthetic surgical closures, 423
blepharoplasty, 492, 492
hyaluronic acid tissue augmentation,
290, 291
laser hair removal, 190
photodynamic therapy, 255
megapixels, photography, 49
meladine, laser hair removal, 188–189
melanin
absorption spectra, 137, 155–156, 156, 181–182
hair color, 180
melanin-containing microepidermal necrotic,
ablative skin resurfacing, 239
melanocytes, skin pigmentation, 100
melanocytic nevi, laser therapy, 163–164, 165
melanoma, 26
epidemiology, 27–28
incidence, 27–28
sunscreen use, 27
ultraviolet (UV) radiation, 27
melanotic macules, laser therapy, 160
melasma
glycolic acid treatments, 124
laser therapy, 164
skin camouflage, 107, 108
mental health referrals, preoperative psychological
evaluation, 6–7
mental health status, preoperative psychological
evaluation, 5–6
mentalis, botulinum type A toxin therapy, 279
mental nerve block, 67, 67–68
anesthetized area, 67, 68
meperidine (Demerol)
dermabrasion, 444
postoperative pain management, 84
tumescent liposuction, 331
mepivacaine (Polocaine/Carbocaine), local
anesthesia, 60
methemoglobin, absorption spectra, 137
methyl-ALA/red light see photodynamic therapy
microablative skin resurfacing, 225–247
microdroplet techniques, silicone soft tissue
augmentation, 304
microepidermal necrotic debris (MNDs), 228
microscopic treatment zones, fractional
rejuvenating laser, 227, 227
midazolam (Versed), 91
tumescent liposuction, 331
midfacial SMAS see SMAS (superficial muscular
aponeurotic system)
mid-infrared lasers, nonablative rejuvenation
see nonablative rejuvenation
midline platysmaplasty, face-lifts, 522, 523
midscalp (M) area, hair transplantation, 384
milia en plaque, dermabrasion, 444
mineral makeup, 111
techniques, 114, 114
minocycline-induced pigmentation, laser therapy,
165
Minor’s starch–iodine test, hyperhidrosis detection,
280–281
minoxidil, hair transplantation, 393
moderate sedation
clinical studies, 78–79
definition, 79, 79
risks of, 79, 79
techniques, 81
modulation, expression/emotion, 15, 15, 16
Moh’s micrographic surgery, postoperative
correction see post-Moh’s micrographic
surgery
moisturizers, post-chemical peels, 130–131
monitored anesthesia care (MAC), 522
monitoring
ablative skin resurfacing, 237, 238
office-based sedation, 90–91
sedation, 88
monopolar radiofrequency, blepharoplasty, with,
485
mood disorders, 5–6
morphine, postoperative pain management, 84
motivation
for cosmetic surgery, 40, 42–43
preoperative psychological evaluation, 4
mouth corner elevation, 279
M-plasty see aesthetic surgical closures
Muller phlebectomy hooks, 476
Müller’s muscle, 486–487
contraction, botulinum type A toxin therapy
side effects, 283
multicolored tattoos, laser therapy, 173
multilayer compression bandages, 460
multimodal pain management, 84
multiple treatments, port-wine stain laser therapy,
142
multi-unit grafts (MUGs), 383–384
cosmetic result, 385
follicular unit transplantation, with see follicular
unit transplantation (FUT)
graft preparation/insertion, 383–384
muscle weakness, botulinum type A toxin therapy,
268
muscular changes, aging, 38–39
musculocutaneous flaps see skin flap(s)
myocutaneous island pedicle flaps see skin flap(s)
myogenic ptosis, definition, 483
N
naloxone (Narcan), 91
naproxen, postoperative pain management, 84
Narcan (naloxone), 91
nasociliary nerve, 61
nasojugal fold, midfacial SMAS, 489
nasolabial crease
autologous fat transplantation, 316–317, 317
calcium hydroxyapatite (Radiesse) soft tissue
augmentation, 306–307, 307
collagen tissue augmentation, 301
hyaluronic acid tissue augmentation
see hyaluronic acid tissue augmentation
poly L lactic acid (Sculptra), 303
silicone soft tissue augmentation, 305, 305
nasolabial fold, botulinum type A toxin therapy,
280
nasum dorsum, aesthetic surgical closures, 429
natural antioxidants, skin, 117
natural moisturizing factor (NMF), skin hydration,
94
Nd:YAG laser
1064nm
nonablative rejuvenation, 200–201
nonsurgical skin tightening see nonsurgical
skin tightening
1320nm, nonablative rejuvenation, 201
long-pulsed
laser hair removal, 185
leg vein endovenous ablation, 480
nonablative rejuvenation, 198
Q-switched
laser hair removal, 184, 187
pigmented lesion laser therapy, 157, 159
vascular lesion laser therapy see vascular
lesions, laser therapy
neck
botulinum type A toxin therapy see botulinum
type A toxin therapy
sensory anatomy, 70, 72
tumescent liposuction see tumescent liposuction
neck and jowls, tumescent liposuction, 335–340
necrosis, sclerotherapy, 474, 475
NEET areas, aesthetic surgical closures, 419, 420
negative emotion curtailment, facial expression,
19–20, 20
neodymium:yttrium-aluminum-garnet (Nd:YAG)
lasers see Nd:YAG laser
nerve blocks
cocaine, 60
see also specific nerve blocks
nerve ending regeneration, botulinum type A toxin
therapy, 268
nerve injuries, face-lift complications, 540–541, 541
Nesacaine (chloroprocaine), 60
neuromuscular junctions, botulinum type A toxin
therapy, 267
Nevi spilus, laser therapy, 161
nevus of Ota, laser therapy, 162–163, 164, 171
nevus spilus, laser therapy, 171

Subject Index
559
nonablative lasers, atrophic/acne scar
management, 414
nonablative rejuvenation, 197–206
age-related complaints, 200
basic science, 198–199
clinical complaints, 200
see also specific complaints
cooling systems, 199–200
depth, 198
efficacy, 198
future work, 207
history, 197–198, 210
hypertrophic scarring, 203
intense pulsed light (IPL), 198–199, 203–204
laser therapy
diode lasers, 198, 201, 205
Er:glass lasers, 198, 201–202
flashlamp pulsed-dye laser, 198
KTP laser, 202, 203
mid-infrared lasers, 200–202
Nd:YAG laser, 198, 200–201, 202
pulsed-dye laser, 202, 202–203
radiofrequency/diode laser, 205
light emitting diodes, 199, 199, 206
limited benefits, 207
long wavelength noncoherent infrared light, 206
noncoherent light sources, 203–206
see also specific types
patient expectations, 200
postoperative considerations, 207
preoperative considerations, 199–200
radiofrequency/laser/light combination, 204,
204–206
assessments, 205–206
rhytides, 205
rhytides, 200, 203, 205
skin pigmentation, 199
therapeutic ultrasound, 206
treatment course, 198
visible light devices, 202, 202–203
see also specific devices
see also specific lasers/techniques
non-life threatening disease, face-lift patient
selection, 519
non-opioid analgesics, postoperative pain
management, 84, 85
nonpigmented (N) skin category, 100–101
nonsteroidal antiinflammatory drugs (NSAIDs), 84
hyaluronic acid tissue augmentation, 299
nonsurgical skin tightening, 210–224
bipolar radiofrequency/diode laser, 211, 219,
220
clinical trials, 215
equipment, 213
mechanism of action, 213
periorbital skin laxity, 220
rhytides, 215, 220
side effects, 222
wrinkles, 215
broadband infrared light source, 212, 219–220,
220
abdominal skin laxity, 221
clinical trials, 216
parameters, 220
side effects, 222
ultrastructural analysis, 212
nonsurgical skin tightening (Continued)
clinical trials, 213–216
equipment, 210, 210
history, 210–211
Nd:YAG laser 1064nm, 212–213, 220–221
cervical tightening, 221
clinical trials, 216
side effects, 222
postoperative considerations, 221–222
post-treatment instructions, 221–222
preoperative considerations, 216–217
side effects, 222
see also radiofrequency (RF) tissue tightening
nose reconstruction
aesthetic surgical closures, 427–431, 430
alar groove, 429, 433
area functionality, 427
cartilage grafts, 427
different areas, 427, 430
nasum dorsum, 429
primary closure, 429
second intention healing, 427, 429, 432
bilobed flaps, 430, 436
full-thickness skin grafts (FTSGs), 430, 434
Hatchet flaps, 430, 435
laterally based crescentic advancement flaps,
430
local anesthesia, 72–73
myocutaneous island pedicle flaps, 430, 435
nasolabial (melolabial) transposition flaps,
430–431, 437
rhombic transposition flaps, 430
rotation flaps, 430, 435
skin grafts, 427
transposition flaps, 430
Novocain see procaine (Novocain)
O
occipitofrontalis muscle, upper eyelids, 486
occlusives, skin care, 96
Oesch phlebectomy hooks, 476
office-based sedation, 78–92
airway evaluation, 80, 80
airway management, 81–82, 82
discharge, 86, 92
emergencies, 90
guidelines, 89–90
history, 78
monitoring, 90–91
patient selection, 80, 90
perioperative care, 90
postoperative considerations, 81–86
pain management, 79
postoperative nausea and vomiting see
postoperative nausea and vomiting (PONV)
preoperative considerations, 80
procedure guidelines/standards, 80–81
quality of care guidelines, 89
recovery care, 86
risk management, 81–82
office behavior, preoperative psychological
evaluation, 6
oily (O) skin category, 93–95
Olsen hair loss pattern classification, 369
Omnia positioning system, photography, 54
ondansetron, postoperative nausea and vomiting
(PONV), 86
open wound care, ablative skin resurfacing, 237
operating suite, photography, 55
ophthalmic history, blepharoplasty, 492
ophthalmic nerve (V1), 61, 61
opioids
postoperative nausea and vomiting (PONV),
84
postoperative pain management, 84, 84
optical tracking, fractional photothermolysis, 236
oral commissures, hyaluronic acid tissue
augmentation, 297
orbicularis oculi muscle
botulinum type A toxin therapy, 273, 275, 275,
275–276, 276
upper eyelids, 485, 486
orbital fat removal, transcutaneous lower eyelid
blepharoplasty, 498–499
orbital hemorrhage, blepharoplasty complications,
490, 490
orbital septum, upper eyelids, 485, 486
orbitomalar ligament, midfacial SMAS, 489
organic agents, sunscreens, 29
oxycodone, postoperative pain management, 84
oxygen saturation, office-based sedation, 81–82
oxygen, sedation, 89
oxyhemoglobin, absorption spectra, 137,
137, 156
oxytalan, in skin, 118
ozone layer, ultraviolet radiation, 28
P
pain
ambulatory phlebectomy, 476–477
botulinum type A toxin therapy side effects,
282
suture suspension lifts, 510
pain management, 81–85
Agency for Healthcare Policy and Research
(AHCPR) guidelines, 83, 83–84
analgesics, 84, 84–85, 85
see also specific analgesics
postoperative care, 79
tumescent liposuction, 358
see also analgesia
palms, hyperhidrosis botulinum type A toxin
therapy, 281, 281
papules, acne skin type, 98
paracetamol see acetaminophen
paraffin injections, soft tissue augmentation, 287
paramedian forehead flap, skin flaps, 420
paramedical camouflage makeup therapists,
112–113
particle size, hyaluronic acid tissue augmentation,
289
passive compression, leg vein management, 459
paste makeup, 111
techniques, 114, 114
patient activity, post-face-lifts, 538
patient characteristics, aesthetic surgical closures,
422
patient communication/counseling, blepharoplasty,
491–492
patient education, aesthetic surgical closures, 423

560

Subject Index
patient expectations
dermabrasion, 453
face-lifts, 519–520, 520
hair transplantation, 372
nonablative rejuvenation, 200
pigmented lesion laser therapy, 170
preoperative evaluation, 4
preoperative psychological evaluation, 4
sclerotherapy, 468
tumescent liposuction, 326
unrealistic expectations, 42
patient information
ablative skin resurfacing, 243–244
fractional photothermolysis, 245
hyaluronic acid tissue augmentation, 299
plasma skin regeneration (PSR), 246–247
patient instructions
autologous fat transplantation, 319
hair transplantation, 377, 395–396
photodynamic therapy, 263
suture suspension lifts, 515–516
patient motives, 3–9
patient preparation
autologous fat transplantation, 312, 312
tumescent liposuction, 327–328
patient satisfaction/dissatisfaction
botulinum type A toxin therapy, 283
tumescent liposuction, 341, 359–360
patient schedule, hyaluronic acid tissue
augmentation, 290
patient selection
dermabrasion, 444
face-lifts see face-lifts
female breast tumescent liposuction, 354–355
hair transplantation, 372–376
leg tumescent liposuction, 348
leg vein laser endovenous ablation, 480
neck and jowl tumescent liposuction, 335, 336
office-based sedation, 80, 90
photodynamic therapy, 255
pigmented lesion laser therapy, 169–170
sclerotherapy, 468–469
sedation, 88
suture suspension lifts, 506
tumescent liposuction, 325–326
‘PDT reaction,’ photodynamic therapy, 256
pedicle width
random-pattern flaps, 421
skin flaps, 421
perforate–invaginate (PIN) technique, truncal leg
vein incompetence, 466
perforating veins see leg vein management
perinasal ring block, dermabrasion, 444–445
periocular area, aesthetic surgical closures, 424
perioperative care, office-based sedation, 90
perioral area
advancement flaps, 426–427, 428
aesthetic surgical closures, 426–427
rotation flaps, 428
perioral augmentation, autologous fat
transplantation, 316, 317
periorbital area
botulinum type A toxin therapy see botulinum
type A toxin therapy
hyaluronic acid tissue augmentation, 298
skin laxity, 220
periorbital lumps, autologous fat transplantation,
319, 319–320
personnel training, sedation, 88
petroleum-based emollients, post-chemical peels,
130
Phenergan see promethazine (Phenergan)
phenol chemical peels, 130
philtrum repair, 427
phlebectomy
ambulatory see ambulatory phlebectomy
compression stockings, 460
large non truncal varicose veins, 465
phlebectomy hooks, ambulatory phlebectomy, 476,
477
photoaging, 23–36, 24, 38, 101
action spectrum, 25–26
antioxidants, 102
behavior, 31, 31
chemical peels, 121
chemoprevention, 32–33
children protection, 31, 31
clinical features, 23, 23
clinical studies, 26–33
clothing/apparel, 30–31, 31
definition, 23
depth of, 122
environmental influences, 28–29
epidermal pigment change, 25
microscopic changes, 120, 120
molecular mechanisms, 26
nonablative rejuvenation, 199
public policy, 31–32
rhytide development, 101
skin care, 96
skin type, 23
smoking, 28
sun beds, 28–29
sunscreens see sunscreens
tanning, 28–29
telomere length, 26
see also skin cancer; ultraviolet (UV) radiation
photochemical destruction, laser hair removal, 182
photodamage
carbon dioxide laser resurfacing, 234
epidermis, 117
glycolic acid treatments, 123
photodynamic therapy see photodynamic
therapy
radiofrequency (RF) tissue tightening, 214
photodermal destruction, laser hair removal,
181–182
photodynamic therapy, 249–265
acne, 260
ALA/blue light, 256
postoperative considerations, 260
preoperative considerations, 255
topical ALA/intense pulsed light, 254,
258–259
topical ALA/long-pulsed pulsed-dye laser,
252–253, 253, 258
actinic cheilitis, 260
postoperative considerations, 260
preoperative considerations, 255
topical ALA/long-pulsed pulsed-dye laser,
252, 253, 257
actinic keratoses, 260
photodynamic therapy (Continued)
ALA/blue light, 255–256
history, 249
methyl-ALA/red light, 259
postoperative considerations, 260
preoperative considerations, 254–255
topical ALA/intense pulsed light, 254, 258
topical ALA/long-pulsed pulsed-dye laser,
252, 252, 257
topical photosensitizer/broad-spectrum light
source, 251
topical photosensitizer/red/blue lasers, 251
ALA-induced PPIX fluorescence, 251
basal cell carcinoma, 251, 259, 260
clinical studies, 250–254
consent form, 263–265
fair skin, 256
hematoporphyrin derivative (HPD), 250
history, 249–250
laser hair removal, 189
mechanisms, 250
methyl-ALA/red light, 259–260
patient instructions, 263
‘PDT reaction,’ 256
photodamage repair, 260
ALA/blue light, 255–256
postoperative considerations, 260
preoperative considerations, 254–255
topical ALA/intense pulsed light, 254, 258
topical ALA/long-pulsed pulsed-dye laser,
252, 257
photorejuvenation
phototoxicity, 260
postoperative considerations, 260
preoperative considerations, 255
topical ALA/intense pulsed light, 254
postoperative considerations, 260
sunlight avoidance, 255, 256, 260
preoperative considerations, 254–255
side effects, 250
squamous cell carcinoma, 251
systemic photosensitizer/broad-spectrum light
source, 250
systemic photosensitizer/red/blue lasers, 251
topical ALA/blue light, 255–256
topical ALA/intense pulsed light, 253–254,
258–259
acne, 254, 258–259
actinic keratoses, 254, 258
dispigmentation, 259
photodamage, 254, 258
photorejuvenation, 254
topical ALA/long-pulsed pulsed-dye laser,
251–253, 257–258
acne, 252–253, 253, 258
actinic cheilitis, 252, 253, 257
actinic keratoses, 252, 252, 257
erythema, 258
lip shielding, 257
photodamage, 252, 257
postoperative course, 258
PPIX, 251
topical photosensitizer/broad-spectrum light
source, 250–251
topical photosensitizer/red/blue lasers, 251
photographic records, skin camouflage, 113

Subject Index
561
photography, 52–53
compact cameras, 46, 46
digital image catalogues, 50
equipment, 46
excised specimens, 55
facial, 53–54
flash, 47–48
lenses, 46–47
megapixels, 49
Omnia positioning system, 54
in operating suite, 55
positioning, 53, 54, 54
PowerPoint™ presentations, 50
for publication, 49–50, 51
resolution, 49–50
single lens reflex cameras, 46, 46
standard views, 53–54, 54
white balance, 48–49, 49
photomechanical destruction, laser hair removal,
182
photon recycling, intense pulsed light (IPL) sources,
203
photoplethysmography (PPG), leg vein
management, 457
photorejuvenation, photodynamic therapy see
photodynamic therapy
photothermolysis
fractional see fractional photothermolysis
selective, 136
phototoxicity, photodynamic therapy, 260
local, 259
phrenic nerve, cervical plexus block, 72
physical examination
blepharoplasty, 493
leg vein management, 457
office-based sedation, 80
preoperative evaluation, 42
upper eyelid blepharoplasty, 493
pigment alteration
chemical peels, 121
glycolic acid treatments, 124
pigmented (P) skin category, 100–101
pigmented lesions, laser therapy, 155–177
anesthesia, 169
dermal lesions, 172
epidermal lesions, 170
complications, 173
dermal lesions, 159, 161–168, 172–173
epidermal lesions, 159, 159–161, 170–172
anesthesia, 170
Fitzpatrick skin type, 170
intense pulsed light (IPL), 170
laser fluence, 170
postoperative changes, 171–172
skin pigmentation, 170
history of, 155–177
intense pulsed light (IPL), 159
epidermal lesions, 170
laser types, 156–157, 158
long-pulsed lasers, 157–158
pigmented lesion pulsed-dye laser, 157, 158
pulsed-dye lasers, 159
pulsed lasers, 156–159, 164
Q-switched alexandrite laser, 157, 158, 159
Q-switched lasers, 156–159, 157
Q-switched neodymium:YAG laser, 157, 159
pigmented lesions, laser therapy (Continued)
Q-switched ruby laser (QSRL), 155,
157–158, 159
preoperative considerations, 168–170
patient evaluation, 169–170
safety procedures, 168–169
skin pigmentation, dermal lesions,
172–173
tattoos see tattoos
see also specific lesions
pixels per inch, resolution, 49
plantar foot, hyperhidrosis botulinum type A toxin
therapy, 281–282
plasma skin regeneration (PSR), 228–229,
236–237, 237
atrophic/acne scar management, 414
conditions, 233
rhytides, 231–232, 232
consent form, 246
epidermal hydration, 236
equipment, 229
hand piece, 228
feathering, 237
mechanism of action, 229
patient information sheet, 246–247
postoperative considerations, 240–241
PSR1 protocol, 237
PSR2 protocol, 237
PSR3 protocol, 237
side effects, 240–241
studies, 230, 231–232
topical anesthetic, 237
platysmal banding, botulinum type A toxin therapy,
280, 280
platysma location, neck and jowl tumescent
liposuction, 335
platysma repair, neck and jowl tumescent
liposuction, 339–340, 340
pneumatic skin flattening (PSF), laser hair removal
cooling, 183
polidocanol, sclerotherapy, 462
Polocaine, local anesthesia, 60
polycystic ovary disease, hirsuitism, 180
poly L lactic acid (Sculptra), 302–304
amounts needed, 303
cheeks, 303–304
duration, 302
epinephrine, 302
equipment, 303
mechanism, 302
nasolabial creases, 303
postoperative care, 303
zygomatic arch, 303
polypeptides, skin care, 97–98
port-wine stains (PWS), 135, 136
laser therapy, 142, 142–143, 155
cooling, 148
millisecond-pulsed 532 nm KTP lasers,
149–150
pulsed-dye lasers, 147–148
purpura, 148, 148, 150
resistant, 142, 143
skin pigmentation, 143
positive emotion accentuation, facial expression,
18–19
positive-pressure ventilation, 82, 82
positron emission tomography (PET), emotion/
expression connection, 17
posterior platysma suspension see face-lifts
postinflammatory hyperpigmentation, laser
therapy, 164
post-laser therapy hyperpigmentation, 165–166
post-Moh’s micrographic surgery
aesthetic surgical closures, 423, 425
dermabrasion, 447, 451
postoperative considerations, 7
chemical peels, 121, 130–130
neck and jowl tumescent liposuction, 340
office-based sedation, 81–86
sedation, 79
postoperative consultations, skin camouflage, 113
postoperative nausea and vomiting (PONV), 79,
85–86
antiemetic agents, 85–86, 86
opioids, 84
postoperative packing, female breast tumescent
liposuction, 356
potassium titanyl phosphate (KTP) laser see KTP
laser
powered cannulas, tumescent liposuction,
329, 330
PowerPoint™ presentations, 50
PPIX, topical ALA/long-pulsed pulsed-dye laser,
251
practice guidelines, sedation, 88–89
preaponeurotic (central) fat pedicle, upper eyelids,
485, 487
prednisolone, hair transplantation, 377
preoperative considerations
chemical peels, 121, 121–122
office-based sedation, 80
sedation, 88
see also specific procedures
preoperative evaluation, 3–7
body dysmorphic disorder, 4–5
body image dissatisfaction, 4–5
bothersome features, 42
expectations, 4
health, 42
lifestyle, 42
mental health referrals, 6–7
mental health status, 5–6
motivation, 4
office behavior, 6
physical examination, 42
psychiatric history, 5
questions, 9
see also specific procedures
prep and drape, face-lifts, 521
pressure dressings
atrophic/acne scar management, 415
keloid/hypertrophic scar management,
404
pressure, keloid/hypertrophic scar management,
405–406
pretreatment instructions, botulinum type A toxin
therapy, 271
prilocaine, local anesthesia, 60
primary closure, nose reconstruction, 429
procaine (Novocain)
historical background, 60
local anesthesia, 60