Các Kỹ Thuật Phẫu Thuật Thẩm Mỹ (Aesthetic Surgery Techniques)

49
Summary
A
B
C
D
E
FIGURE 6.5  Avoid over-resection of muscle and fat.

50
SECTION 2    CHAPTER 6  •  Upper Blepharoplasty
A
B
FIGURE 6.6  On completing skin closure, there will usually be 2 to 3 mm of lagophthalmos.
A
B
FIGURE 6.7  Preoperative (A) and 4 months postoperative (B) views of the operative case.

51
Summary
References
1.
Seigel, R.J., 1992. Advanced upper lid blepharoplasty. Clin. Plast. Surg.
19, 319–328.
2.
Januszkiewicz, J.S., Nahai, F., 1999. Transconjunctival upper blepha­
roplasty. Plast. Reconstr. Surg. 103, 1015–1018.
3.
Niechajev, I.A., Ljungqvist, A., 1991. Central (third) fat pad of the
upper eyelid. Aesth. Plast. Surg. 15, 223–228.
4.
Lambros, V., 2007. Observations on periorbital and midface aging.
Plast. Reconstr. Surg. 120, 1367–1376.
5.
Fagien, S., 2010. The role of orbicularis oculi muscle and the eyelid
crease in optimizing results in aesthetic upper blepharoplasty: a new
A
B
C
FIGURE 6.8  Preoperative (A), 1 year postoperative (B) and 2 year postoperative (C) views of male cosmetic blepharoplasty with brow stabilization.
look at the surgical treatment of mild upper eyelid fissure and fold
asymmetries. Plast. Reconstr. Surg. 125, 653–666.
6.
Flowers, R., 1993. Upper blepharoplasty by eyelid invagination: anchor
blepharoplasty. Clin. Plast. Surg. 20, 193–207.
7.
Mendelson, B., Luo, D., 2015. Secondary upper lid blepharoplasty: a
clinical series using the tarsal fixation technique. Plast. Reconstr. Surg.
135, 508e–516e.
8.
Rohrich, R., Coberly, D.M., Fagien, S., Stuzin, J.M., 2004. Current
concepts in aesthetic upper blepharoplasty. Plast. Reconstr. Surg. 113,
32e–42e.

53
Surgical Preparation and Technique
53
7 
Asian Blepharoplasty
Takanori Yamawaki MD
Naoyuki Ohtake MD, PhD
Nobuyuki Shioya MD, FACS
The Clinical Problem
Synopsis
Upper eyelid blepharoplasty in Asians often refers to double-
eyelid plasty and epicanthoplasty because about half of Asians
lack an upper eyelid crease, so-called single eyelids. Many
procedures for double-eyelid plasty have been reported since the
suture technique was described by Mikamo1 in 1896. Although
the surgical principles are similar to those for occidental eyelids,
the surgical design and operative technique are different because
there are distinct anatomic differences in Asian eyelids.
The Aesthetic Problem
Asian upper eyelids are anatomically different from that of
white upper eyelids. Single eyelids are one of the most char­
acteristic features of Asians. There are many causes, such as
lower fusion point of the septum and levator, lack of levator
aponeurosis penetration into the pretarsal orbicularis oculi
muscle, and lower penetration of preaponeurotic fat into the
pretarsal area (Fig. 7.1).2,3
Epicanthus is another feature of the Asian eye. The epicanthus
covers the lacrimal lake and width of the interepicanthal
distance. Patients who have surgery for epicanthic folds and
desire concurrent double-eyelid surgery often develop aestheti­
cally unpleasant results.
Indications and Counseling
The indications for the upper eyelid blepharoplasty are as
follows:
1. Type of crease—lacking, low-set, incomplete, asymmetric,
multiple creases
2. Epicanthal fold
3. Entropion
4. Puffy eyelid without exophthalmos
5. Blepharoptosis
Creating a lid crease is not the most challenging operation
of Asian blepharoplasty. Creating a symmetric and natural
crease is more important but difficult to achieve. In the East
Asian individual, the natural crease typically parallels the lid
margin in the outer two-thirds of the eyelid, closing toward
the eyelid margin as it proceeds nasally. On the other hand,
there are some variations in the medial area. Medially, the
crease ends above the epicanthus, fuses with the epicanthus,
or dives beneath epicanthus.
The surgeon should evaluate the presence of blepharoptosis,
morphology of the upper eyelid crease, and eyebrow position,
then simulate the upper eyelid crease by pressing a bougie onto
the lid skin. Simulating several heights of the crease can help
both the surgeon and patient realize the ideal position of the
crease. The surgeon should ask about the patient’s desire for the
medial area. When the patient chooses the parallel type, medial
epicanthoplasty should be taken into consideration.
Some patients choose a semilunar crease. A semilunar crease
in an Asian face is quite unnatural, so the surgeon should not
agree with making a semilunar crease.4
Surgical Preparation and Technique
Buried Suture Method
The main purpose of this operation is to make an upper eyelid
crease without an incision scar. The indication for this operation
is the patient who does not have blepharoptosis, excessive
skin, and an excessive fat pad. Although many procedures of
a buried suture technique have been described, the principle
is to create a connection between the skin and tarsal palate or
levator aponeurosis.

54
SECTION 2    CHAPTER 7  •  Asian Blepharoplasty
height of the crease should be determined at the center of the
pupil by simulating several heights, from 6 to 8 mm. The line
of the crease is extended medially and laterally. The surgeon
can control the relationship between the crease and the epi­
canthus to some extent. Then, three points on the medial, middle,
and lateral sides of the designed crease line are marked with
dots (Fig. 7.2).
PROCEDURE
Three 2- to 3-mm incisions are made at the dots, designed as
described above. Then, 6-0 or 7-0 nylon sutures are passed
This technique has several advantages other than a no-scar
operation. The procedure is comparatively simple, the down
time is relatively short (usually a few days), and it can be reversed
by pulling out the suture(s) if the patient is not satisfied with
the result. On the other hand, this technique tends to relapse
more easily than incision techniques. Other complications are
asymmetry, skin or eye irritation, and a suture granuloma.
DESIGN
The appropriate height of upper eyelid crease is 6 to 8 mm
above the ciliary margin at the center of the pupil. First, the
FIGURE 7.1  Anatomic differences. There is a lower fusion point of the
septum and levator, lack of levator aponeurosis penetration into the pretarsal
orbicularis oculi muscle, and lower penetration of preaponeurotic fat into
the pretarsal area.
A
B
C
FIGURE 7.2  Simulation of the double eyelid. The height of the crease should be determined at the center of the pupil by simulating several heights, from 6 to 8 mm.

55
Incision Method
A
B
FIGURE 7.3  Examples of the buried suture technique. (A) Three 2- to
3-mm incisions are made at the dots, designed as described in the text;
6-0 or 7-0 nylon sutures are passed through the skin side to the
conjunctiva, slightly above the tarsal border. The needle reenters at the
exit point and goes through 2 mm horizontally at the level of the
aponeurosis. Then, the needle exits and reenters at the conjunctiva side
and goes through another edge of the skin incision point. The needle
reenters and goes through the dermal plane to the first entry point. (B)
Finally, the nylon sutures are buried.
Incision Method
Compared to the suture technique, the incision technique has
some advantages of an upper blepharoplasty, particularly
with the patient who has blepharoptosis, excessive skin, and a
puffy eyelid. Because this technique can make direct connection
through the skin side to the conjunctiva, slightly above the
tarsal border. The needle reenters at the exit point and goes
through 2 mm horizontally at the level of the aponeurosis.
Then, the needle exits and reenters at the conjunctiva side and
goes through another edge of the skin incision point. The needle
reenters and goes through the dermal plane to the first entry
point. Finally, the nylon sutures are buried (Figs. 7.3 and 7.4).
A
Before
After
C
D
B
FIGURE 7.4  Example of the buried suture technique. A 21-year-old woman consulted our clinic because of her narrow lid crease. She desired to have a wide upper lid
crease. A 7.5-mm eyelid crease at the center of the pupil was designed. (A,B) Before surgery. (C,D) After surgery.

56
SECTION 2    CHAPTER 7  •  Asian Blepharoplasty
of the skin to the tarsal palate or aponeurosis, the surgeon
can make the permanent upper eyelid crease. In addition,
this technique can add skin resection, levator advancement,
and fat pad resection. On the other hand, there are several
disadvantages of this technique. For example, it is relatively
difficult to expect the result intraoperatively because of the
swelling and the effect of the skin stitches.
DESIGN
First, the height of the crease should be determined at the
center of the pupil by simulating several heights, from 6 to
8 mm. If necessary, the line for resection of excessive skin should
be drawn.
If the crease is tapered nasally, mark the medial third of the
incision line to taper or beneath to the epicanthal fold. For the
parallel crease, the incision line should be parallel to the lid,
and an additional medial epicanthoplasty should be taken into
consideration.
PROCEDURE
The skin incision is made along the marking using no. 11 or
15 blade. If necessary, the excessive skin is resected. Then, the
FIGURE 7.5  Incision technique. The skin incision is made along the marking using a no. 11 or 15 blade. If necessary, the excessive skin is resected. Then, the pretarsal
orbicularis muscle is resected. At this point, the orbital septum can be recognized. After opening the septum, the preaponeurotic fat pads are identified. Usually, the orbital
septum may be only 2 to 3 mm above the tarsal border in Asian eye. Partial debulking of pretarsal fat for a puffy eyelid or levator advancement for blepharoptosis is taken
into consideration. To make a lid crease, a 6-0 Prolene suture is passed through the muscle and deepest dermis of the inferior edge and through the tarsal aponeurosis at
the center of the midpupillary level. When the suture is tied, the inferior skin should be slightly stretched. More sutures are made 6 mm medially and laterally to the first
suture. If the patient desires a parallel crease, a medial epicanthoplasty should be added at this time. After fixation of the crease, the skin is closed with 7-0 silk or nylon
sutures.
pretarsal orbicularis muscle is resected. At this point, the orbital
septum can be recognized. After opening the septum, the
preaponeurotic fat pads are identified. Usually, the orbital
septum may be only 2 to 3 mm above the tarsal border in the
Asian eye. Partial debulking of pretarsal fat for a puffy eyelid
or levator advancement for blepharoptosis is taken into con­
sideration. To make a lid crease, a 6-0 Prolene suture is passed
through the muscle and deepest dermis of the inferior edge,
through the tarsal aponeurosis at the center of the midpupillary
level. When the suture is tied, the inferior skin should be slightly
stretched. More sutures are made 6 mm medially and laterally
to the first suture. If the patient desires a parallel crease, a
medial epicanthoplasty should be added at this time. After
fixation of the crease, the skin is closed with 7-0 silk or nylon
sutures (Figs. 7.5 to 7.7).
Medial Epicanthoplasty
Although many medial epicanthoplasty procedures have
been reported, Z-plasty5 is suitable for an aesthetic medial
epicanthoplasty because this procedure leaves a minimal
scar. However, some patient cannot tolerate even the
smallest scar. Fig. 7.8 shows the design and intraoperative
procedure.

57
Incision Method
A
C
B
D
Before
After
FIGURE 7.6  Example of the incision technique. A 34-year-old woman consulted our clinic because of her narrow lid crease. A 6.0-mm crease at the center of the pupil
was designed, and excessive skin was resected. (A,B) Before surgery. (C,D) After surgery.

A
B
C
D
FIGURE 7.8  Example of an epicanthoplasty. (A,B) Design. (C) Excision of the skin. (D) Sutures.
A
C
B
Before
After
FIGURE 7.7  Incision technique and medial epicanthoplasty. (A,B) A
22-year-old woman had undergone surgery with buried sutures at another
clinic. (C) The incision technique and epicanthoplasty were carried out for
correction of the shape of the crease.

59
Complications
Complications
Although there are many complications and unfavorable results
associated with an upper blepharoplasty, most are attributable
to the preoperative consultation and intraoperative maneuvers.
Dissatisfaction with the height and shape of the crease often
result from a lack of communication during consultation. In
particular, if the surgeon makes too high a crease or semilunar
crease, correction of the height is difficult, and sometimes a
visible scar results. An asymmetric design or intraoperative
handling may result in an asymmetric crease. Other major
complications include multiple creases, sunken eye, relapse,
deep or shallow crease, ectropion, ptosis, ocular injury, milia,
cyst, and hypertrophic scar.
References
1.
Mikamo, K., 1896. A technique in the double-eyelid operation. J.
Chugaiijishinpo 17, 1197.
2.
Aston, S.J., et al., 2009. Aesthetic Plastic Surgery. Elsevier, Saunders,
pp. 367–392.
3.
Zide, B.M., Jelks, G.W., 1984. Surgical anatomy of the orbit. Plast.
Reconstr. Surg. 74, 301–305.
4.
Korn, B.S., Kikkawa, D., 2017. Video Atlas of Oculofacial Plastic and
Reconstructive Surgery, second ed. Elsevier, St. Louis, pp. 25–31.
5.
Park, J.I., Park, M.S., 2007. Park Z-epicanthoplasty. Facial Plast. Surg.
Clin. North Am. 15 (3), 343–352, vi.

61
Surgical Preparation and Technique
61
8 
Midface Descent and Malar Support
Ernesto J. Ruas MD, FACS
The Clinical Problem (Fig. 8.1)
Rejuvenation of the midface was formerly limited to a lower
lid blepharoplasty in conjunction with some form of a face lift.
Neither adequately addresses the nasojugal groove (also referred
to as the tear trough) or the nasolabial fold. Furthermore, a
traditional lower lid blepharoplasty would frequently include
resection of herniated lower lid fat, which in turn could produce
a gaunt, deflated lower lid that does not appear youthful.
Recently, more attention has been given to restoring a
youthful look to the midface by volumizing the face and
avoiding resection of lower lid fat as we have recognized the
loss of periorbital fat as part of the aging process.
The Aesthetic Problem
Our patients present complaining of “looking tired,” “bags
under my eyes,” or “dark circles under my eyes.” What they
are describing in popular terms are the classic aging changes
that are manifest in the lower lids and middle third of the face.
These include the following:
■ Loss of skin laxity, leading to excess lower eyelid skin
and fine wrinkles
■ Midface descent and ptosis of the malar soft tissues
■ The appearance of two aesthetic units—that is, the lower
lid and cheek are demarcated by the tear trough, where
there was only one in the person’s younger years
■ Increase in the vertical dimension of the lower lid—lid
margin to tear trough distance
■ Fat herniation
■ In its most severe form:
• Lateral canthal dystopia
• Scleral show
• Poor lower lid tone, ectropion
Management and Treatment Options
Our goal is to restore the youthful appearance to the midface
and should therefore ideally correct or at least improve the
problems noted above:
■ Resect redundant lower eyelid skin.
■ Resuspend the malar soft tissues.
■ Blunt or eliminate the tear trough, restoring a single
aesthetic unit.
■ Decrease the vertical dimension of the lower lid.
■ Preserve volume.
■ Correct canthal dystopia if present.
There are many options available to rejuvenate the midface.
A comprehensive historical review nicely outlines the various
techniques being used today.1
The transblepharoplasty subperiosteal cheek lift is my
preferred approach. Although it could be argued that it is
technically more demanding than a traditional lower lid
blepharoplasty, it successfully addresses the midface descent
and aims to blunt the tear trough, neither of which is adequately
corrected by a lower lid blepharoplasty alone.
Surgical Preparation and Technique
The procedure is performed under general anesthesia. A subcili­
ary incision is marked with brilliant green and infiltrated with
a solution of 1% xylocaine, with 1 : 100,000 epinephrine. The
cheek is also infiltrated but is not tumesced. Corneal protectors
are inserted with an ocular lubricant (e.g., Lacri-Lube) and/
or tobramycin and dexamethasone ophthalmic ointment (e.g.,
Tobradex). A 4-0 silk Frost suture is used for countertraction.
After allowing the vasoconstriction to take effect, the subciliary
incision is made and a skin muscle flap is developed in the
preseptal plane, all the way to the infraorbital rim. The arcus
marginalis is incised and a subperiosteal dissection of the entire

62
SECTION 2    CHAPTER 8  •  Midface Descent and Malar Support
Once the periosteum is redraped, the Frost suture is loosened,
and the lower lid margin is placed at 1.5 mm above the inferior
limbus. The skin muscle flap is redraped again in a superior-
temporal vector, and the excess skin and muscle are resected.
The greatest portion of the resection will be lateral, and it is
consistently more than what we are accustomed to in a tradi­
tional lower lid blepharoplasty. The subciliary incision is closed
by reapproximating the orbicularis lateral to the lateral com­
missure with 6-0 Vicryl sutures. The skin is closed with running
cheek is performed while protecting the infraorbital neurovas­
cular bundle. Dissection proceeds in a subperiosteal plane over
the nasomaxillary buttress, anterior maxillary wall, malar
eminence, and lateral orbital rim to the anterior third of the
zygomatic arch.
The periosteum is released inferiorly just above the buccal
sulcus as well as over the masseteric fascia, thus allowing
mobilization of the entire cheek in a superior temporal vector,
more or less perpendicular to the nasolabial fold. This maneuver
should produce a 5- to 8-mm (sometimes more) redundancy
of periosteum above the lateral portion of the infraorbital rim.
Four 1.1-mm drill holes are placed along the infraorbital
rim, as shown in Fig. 8.2. One drill hole is medial to the level
of the infraorbital foramen, and the other three are at the
midportion of the infraorbital rim, the lateral corner, and the
lateral canthal level.
Then, 3-0 Ethibond sutures (Ethicon, Somerville, NJ) are
used to suspend the periosteum along with the entire cheek
soft tissue envelope in a superior-temporal vector (Fig. 8.3).
Care must be taken not to overdo this suspension because it
can produce an unnatural appearance.
A lateral canthopexy is usually not performed unless the
patient requests that her or his lateral canthi be raised, or there
is significant lower lid ectropion and scleral show preoperatively
(i.e., failed snap test).
Once the periosteum has been resuspended, the orbital
septum is opened and the postseptal fat is redraped over the
infraorbital rim in an effort to blunt or eliminate the tear trough.
Rarely, and only in the most severe cases, is lower eyelid
fat resected. The redundant periosteum, which now lies above
the infraorbital rim, is used to cover the redraped fat and is
sutured with a few 7-0 Vicryl interrupted sutures to the orbital
septum while making sure that the Frost suture is retracting
the lower lid superiorly. This redundant periosteum reinforces
the orbital septum and adds volume to the lower lid (Fig. 8.4).
FIGURE 8.1  Frontal view showing the clinical problem.
FIGURE 8.2  Four 1.1-mm drill holes are placed along the infraorbital rim.
Frost suture
Suspension
suture
Released periosteum
along buccal sulcus
FIGURE 8.3  3-0 Ethibond sutures are used to suspend the periosteum along with
the entire cheek soft tissue envelope in a superior-temporal vector.

63
Complications
fuller, more youthful look to the middle third of the face. The
results are long-lasting, with more than a 10-year follow-up
continuing to show an improvement as compared to the
preoperative photographs (Fig. 8.8).
Complications
Previous studies have reported a relatively high incidence of
complications with the subperiosteal approach to the midface.
However, this has not been my experience.
The most common complication has been postoperative
chemosis, which usually resolves within 2 to 3 weeks, rarely
longer. Persistent chemosis lasting longer than 2 to 3 weeks is
treated with ophthalmic steroids.
Postoperative scleral show secondary to orbicularis hypotonia
(more often seen in older men) almost always resolves once
the orbicularis muscle regains its resting tone, generally 4 to
6 weeks postoperatively. Scleral show due to contracture and
scarring of the lamellae will frequently respond to triamcinolone
(Kenalog) injections and massage.
Box 8.1 lists complications and their incidence. No patient
has required reoperation for persistent scleral show.
If a patient has received onabotulinum toxin A (Botox) for
the treatment of crow’s feet, I wait 4 months for its effect to
wear off for fear of causing orbicularis hypotonia as a result
of its use. Similarly, we do not offer periorbital Botox for at
least 6 months postoperatively for the same reason.
and interrupted 6-0 Prolene sutures. The Frost suture is removed.
Bilateral infraorbital nerve blocks are administered with 0.25%
bupivacaine (Marcaine), with 1 : 200,000 epinephrine for
postoperative pain relief.
Postoperative Considerations
(Figs. 8.5 to 8.7)
The patient is given a silicone mask to be used for 36 hours
postoperatively to help reduce edema and protect the corneas.
The Prolene sutures are removed 5 to 7 days postoperatively.
Continued lubrication of the eyes is encouraged for 4 weeks,
particularly if an upper eyelid blepharoplasty was performed
as well.
Results
Figs. 8.5 to 8.7 show “pre” and late postoperative results. These
demonstrate a softening of the tear trough and an increase in
volume over the malar eminence, giving the appearance of a
Suspended
advanced
periosteum
Suture connecting edge
of inferior septum to
advanced lead edge
of periosteum
FIGURE 8.4  This redundant periosteum reinforces the orbital septum and adds
volume to the lower lid.
•
Short-term (resolution within 1–6 wks):
•
Chemosis: 38%
•
Scleral show: 21%
•
Lagopthalmos: 8%
•
Conjuctivitis: 5.1%
•
Ectropion: 2.9%
•
Conspicuous scar: 2.9%
•
Hypotonic lid: 0.7%
•
Long-term (resolution > 6 wks or that required reoperation):
•
Hematoma: 0.7% -> incision and drainage
•
Lateral scar revision: 0.7% -> z-plasty
•
Scleral show: 0.7% -> no reoperation
BOX 8.1  Complications

64
SECTION 2    CHAPTER 8  •  Midface Descent and Malar Support
A
B
C
D
FIGURE 8.5  Frontal views show early (A) and late postoperative results (B). Early (C) and late (D) profile views.

65
Complications
A
B
FIGURE 8.6  (A) A 55-year-old woman, 10 years after subperiosteal lower lid blepharoplasty by another practitioner. (B) 12 years later, she had a subperiosteal cheek lift at
the age of 67 years. Note the absence of a tear trough and the resection of a nevus on the lower lid following the cheek lift.
A
College yearbook photo
Pre-op
5 months post-op
6 years post-op
B
C
D
FIGURE 8.7  Composite images showing the patient as a younger woman (A) and preoperatively (B) and postoperatively (C,D).

66
SECTION 2    CHAPTER 8  •  Midface Descent and Malar Support
A
B
10 years post-op
10 years post-op
C
D
FIGURE 8.8  Front and profile views. The results are long-lasting, with more than a 10-year follow-up continuing to show improvement as compared to the preoperative
photographs.
References
1.
Paul, M.D., Calvert, J.W., Evans, G.R., 2006. The evolution of the midface
lift in aesthetic plastic surgery. Plast. Reconstr. Surg. 117, 1809–1827.
Further Reading
Gunter, J.P., Hackney, F.L., 1999. A simplified transblepharoplasty sub­
periosteal cheek lift. Plast. Reconstr. Surg. 103, 2029–2035.
Hester, T.R., Codner, M.A., McCord, C.D., 1996. The “centrofacial” approach
for correction of facial aging using the transblepharoplasty subperiosteal
cheek lift. Aesthet. Surg. J. 16, 51–58.
Hester, T.R., Codner, M.A., McCord, C.D., et al., 2000. Evolution of technique
of the direct transblepharoplasty approach for the correction of lower
lid and midfacial aging: maximizing results and minimizing complica­
tions in a 5-year experience. Plast. Reconstr. Surg. 105, 393–406.
Ortiz-Monasterio, F., 1991. Aesthetic surgery of the facial skeleton: the
forehead. Clin. Plast. Surg. 18, 19–27.
Tessier, P., 1979. Face Lifting and Frontal Rhytidectomy. Trans. VIIth Congr.
Plast. Reconstr. Surg., Brazil, p. 393.

67
Anatomy
67
9 
Anatomic Relationship of SOOF and ROOF
in Eyelid Rejuvenation
Hazem M. Aly MBBCh, MSc, PhD
James D. Frame FRCS, FRCS (Plast)
The Clinical Problem: Prominent
Bulging Suborbicularis Oculi Fat Pad
and Retro-Orbicularis Oculi Fat Pad
(Fig. 9.1)
The aging lower eyelid can be a complex and difficult problem
to improve aesthetically. There is considerable risk of over-
resection of both fat and skin, with consequent pull-down
ectropion and permanent hollowness. An anatomic understand­
ing of the superficial and deep face fat compartments is crucial
when attempting to relocate, reduce, or augment the subor­
bicularis oculi fat pad (SOOF) or retro-orbicularis oculi fat pad
(ROOF) during periorbital rejuvenation.
Anatomy
Upper and Lower Eyelids
These are composed of an anterior lamella and posterior
lamella separated by the orbital septum. The anterior
lamella is formed by the skin and underlying orbicularis
oculi muscle. The orbital septum, originating from a band of
thickened periosteum at the orbital rim (the arcus marginalis),
separates both lamellae and is often referred to as the middle
lamella.
The posterior lamella is composed of the tarsal plate,
eyelid retractors, and conjunctiva. Fibers from the capsu­
lopalpebral fascia attach to the anterior lamella a few mil­
limeters below the tarsus to form the lower eyelid crease.
The forces imposed by the lower eyelid retractors and the
canthal ligaments determine the position of the lower eyelid
margin.
Orbit
The eyes are suspended in the orbital socket by the ocular
muscles, the optic nerve and blood vessels, and periorbital fat,
which often visibly bulge in the aging face. In the upper eyelid,
there are two medial fat pads communicating directly with
retro-ocular fat and one long lateral fat pad situated immediately
anterior to the levator palpebrae superioris in the supraorbital
sulcus. In the lower eyelid, there are three compartments, with
the medial and intermediate pads separated by the inferior
oblique muscle and the lateral pad held within its own fascial
compartment.
Infraorbital Region
This is divided into medial and lateral parts by the course of
the facial vein, typically coursing in a line 4 to 6 mm medial
to the midpupillary line. The medial part is formed of two
layers, the skin and the orbicularis oculi muscle, which is firmly
attached to the underlying bone.
In the lateral part of the infraorbital region, seven different
layers can be identified—the skin, subcutaneous fat layer,
orbicularis oculi muscle, SOOF, deep fascia (continuation of
the superficial lamina of the deep temporal fascia), prezygomatic
fat layer, and periosteum.
The orbicularis oculi muscle is attached to the orbital rim
by the orbicularis-retaining ligament. The zygomatic ligament
is a true osseocutaneous ligament that originates from the
periosteum of the zygoma and/or the zygomatic arch and
attaches to the overlying skin.
The malar fat pad is located in the superficial fat layer of
the midface, below the zygoma. This layer also comprises the
nasolabial fat and jowl fat pads. Reflection of this subcutaneous
fat layer and the orbicularis oculi muscle will expose the SOOF
superolaterally and deep cheek fat inferomedially.
The SOOF is a layer of periorbital fat that lies deep to the
superficial malar fat pad and the orbicularis muscle of the

68
SECTION 2    CHAPTER 9  •  Anatomic Relationship of SOOF and ROOF
lower eyelid, extending superiorly to the lateral canthus. The
tear trough forms the inferior boundary of the SOOF, and the
lateral orbital thickening forms the superior boundary. SOOF
has a horizontal medial component and a larger vertical lateral
component. Symmetric SOOF elevation is important when
considering a midface lift using a subciliary approach (Hamra).
The ROOF is analogous to the SOOF except that it is located
in the upper eyelid deep to the orbicularis oculi and above
the orbital fat pads in a separate layer. ROOF ptosis contributes
to eyebrow ptosis in the aging face. Brow elevation lifts the
ROOF; it is not a good idea to remove the ROOF (Figs. 9.2, 9.3
and 9.4).
Age-Related Changes
Age-related changes in the lower eyelid and midface affect all
tissues, including the skin, muscle, fat, and bone. Midface soft
tissue descent, demarcation of the nasojugal tear trough and
nasolabial folds, deflation of the facial soft tissues, and loss of
bone mass are all changes associated with aging. The midface
loses the uniformly rounded, full appearance due to laxity of
the suspensory attachment of the zygomatic ligaments and
shows an obliquely oriented Y shape grooving pattern. This
pattern is formed by the palpebromalar groove superolaterally,
the nasojugal groove medially, and the midcheek groove
inferolaterally. Atrophy of the SOOF and its adjacent deep fat
compartments in the midface are thought to be associated with
the development of malar bags with aging. The degeneration
and laxity of the superficial musculoaponeurotic system (SMAS)
elastin fibers also causes malar bags, in addition to eyelid
ectropion and orbital fat prolapse. Finally, the elongation of
the area between the orbicularis-retaining ligament and the
FIGURE 9.1  The clinical problem—prominent bulging suborbicularis oculi fat pad
(SOOF) and retro-orbicularis oculi fat pad (ROOF).
FIGURE 9.2  Preoperative frontal view of asymmetric eyebrow positioning in a 49
year old ex-boxer. There has been previous trauma to the right lateral eyebrow and a
clinician’s attempt to rebuild the brow using filler. This has resulted in a residual
lump. The brow ptosis and more significant eyelid hooding is over the untethered
left ROOF hence the asymmetry.
FIGURE 9.3  A perioperative view of the same patient, clearly demonstrating the
exposed right ROOF. The brow tissues are being easily manipulated upwards and
are sliding over the ROOF. The ROOF is a frictionless fat pad that allows free
movement and expression of overlying adjacent tissues, providing there is adjacent
motor activity of course.
eyelid margin leads to prolapse of orbital fat over the inferior
orbital rim and the appearance of eyelid bags. Weakness and
stretch of the orbital septum also lead to the projection of orbital
fat into the upper eyelid. Loss of elasticity leads to redundancy
of the skin of both eyelids.

69
Age-Related Changes
FIGURE 9.5  Frontal view of woman with prominent ROOF, deep orbital sulcus, and
ptotic SOOF.
FIGURE 9.4  A postoperative view of the same patient following a standard upper
eyelid blepharoplasty with ROOF preservation. The filler “lump” is still apparent.
Any attempt to remove it surgically would create a significant contour defect.
Case Study 1: Transconjunctival,
Skin-Preserving, Suborbicularis Oculi Fat
Pad Elevation (Figs. 9.5 to 9.9)
This 53-year-old woman presented with puffy lower eyelids,
asymmetric mild hooding of the upper eyelids, malar fat pad
ptosis, and prominent lower orbital sulci. There was no excess
of lower eyelid skin. A transconjunctival blepharoplasty
approach under general anesthesia was used to trim the lower
fat pad bulge and thus reduce the shadow of the orbital sulcus.
The postoperative pictures were taken 3 months after the
procedure. The SOOF layer has been marginally raised, which
helps elevate the superficial malar fat pad. The importance of
keeping facial proportions by limiting surgery is clearly
demonstrated in this case. If further elevation of the SOOF is
required, skin excision of the lower eyelid and compensatory
surgery elsewhere may be required.
Case Study 2: Suborbicularis Oculi Fat
Pad Elevation Via Subciliary Approach
(Figs. 9.10 to 9.15)
This 51-year-old woman was not happy with the look of her
eyes. She was a healthy nonsmoker, nondiabetic, and nonhy­
pertensive and did not take any medications.
On examination, the upper eyelid skin showed redundancy
with a large fold, not covering her pupils. Her lower eyelids
were asymmetric, with a deep tear trough on the left side and
prominent infraorbital rim in contrast to the right side, with
FIGURE 9.6  Postoperative view at 3 months showing periorbital volume reduction,
SOOF elevation, and less prominent orbital sulcus.
puffy lower eyelids and two or three folds at the lateral canthus
when smiling. The patient had good recoil of her lower eyelid
and a good moist eye, with no signs or symptoms of dry eye.
She agreed on an upper blepharoplasty procedure, including
skin excision to improve the supratarsal crease and a lower
blepharoplasty to treat the puffy eyelids and improve the tear
trough and lateral canthal area.

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SECTION 2    CHAPTER 9  •  Anatomic Relationship of SOOF and ROOF
FIGURE 9.7  Right lateral oblique view demonstrating ROOF and SOOF.
FIGURE 9.8  Postoperative lateral view at 3 months following periorbital volume
reduction and SOOF elevation.
FIGURE 9.9  Volume of fat resection from orbital fat pads obtained via
transconjunctival approach.
FIGURE 9.10  Case study 2: preoperative anterior face view showing puffy eyelids,
prominent orbital sulci, redundant skin, and asymmetric gaze.
Operative Technique: Suborbicularis Oculi Fat
Pad Elevation
A standard lower eyelid subciliary incision is used to expose
the orbicularis oculi; a skin muscle composite flap is dissected
down to the orbital rim, superficial to the orbital septum. The
SOOF is dissected off the periosteum on the infraorbital rim
and the zygomatic body. At this stage, manipulation and
elevation of the SOOF are used to correct the existing deformity
in the tear trough.
SOOF is repositioned at the area of the tear trough; this is
aided and augmented by allowing the intraorbital fat to herniate
through a small incision in the orbital septum. The desired
volume is then sutured onto the periosteum of the orbital rim
using absorbable Vicryl sutures. It can also be reattached by
suturing into a drill hole if there is no good periosteal purchase.
This restores the youthful appearance over the malar area.
Sometimes, excised periorbital fat can be used to augment
the malar area or smooth the crow’s feet. Excision of the
redundant lower eyelid skin and muscle is done by applying
traction on the flap laterally and determining the point of fixa­
tion of the flap at the lateral incision of the lateral canthus.
A lateral canthopexy using 4-0 Vicryl sutures prevents lateral
ectropion and exposure. The incision is closed with interrupted
sutures using 5-0 plain gut sutures. Taping of the malar area
in an upward direction and lower eyelid in a lateral direction
is done using Steri-Strips.
The ROOF rarely requires resection. It can be elevated during
correction of brow ptosis.

71
Age-Related Changes
FIGURE 9.11  Case study 2: skin markings over prominent fat pads.
FIGURE 9.12  Upper medial right orbital fat pad exposed under local anesthetic
prior to trim.
FIGURE 9.13  Right SOOF exposed to the orbital rim anterior to the orbital septum
by elevating a composite lower eyelid myocutaneous, orbicularis oculi skin flap.
FIGURE 9.14  After SOOF elevation and fixation, the orbicularis is resutured,
avoiding undue tension to the lateral canthus.
FIGURE 9.15  Skin laxity prior to excision is carefully assessed to avoid ectropion.
Postoperative Management
• Cool pads or hilotherapy
• Eye care
• Dexamethasone
• Tranexamic acid
Complications
• Dry eyes, discomfort
• Lower ectropion—better not to excise skin if in doubt
It is rare to see complications after upper eyelid surgery.
These are mainly the result of inadequate resection or not
appreciating the contribution of brow ptosis.
Further Reading
Aiache, A.E., Ramirez, O.H., 1995. The suborbicularis oculi fat pads: an
anatomic and clinical study. Plast. Reconstr. Surg. 95, 37–42.

72
SECTION 2    CHAPTER 9  •  Anatomic Relationship of SOOF and ROOF
Mendelson, B.C., Muzaffar, A.R., Adams, W.P., Jr., 2002. Surgical anatomy
of the midcheek and malar mounds. Plast. Reconstr. Surg. 110, 885–896.
Mendelson, B.C., Jacobson, S.R., 2008. Surgical anatomy of the midcheek:
facial layers, spaces, and the midcheek segments. Clin. Plast. Surg.
35, 395–404.
Owsley, J.Q., 1993. Lifting the malar fat pad for correction of prominent
nasolabial folds. Plast. Reconstr. Surg. 91, 463–474.
Rohrich, R.J., Arbique, G.M., Wong, C., et al., 2009. The anatomy of sub­
orbicularis fat: implications for periorbital rejuvenation. Plast. Reconstr.
Surg. 124, 946–951.
Tan, K.S., Oh, S.R., Priell, A., et al., 2011. Surgical anatomy of the forehead,
eyelids, and midface for the aesthetic surgeon. In: Massry, G.G., Murphy,
M.R., Azizzadeh, B. (Eds.), Master Techniques in Blepharoplasty and
Periorbital Rejuvenation. Springer, New York, pp. 11–24.
Cotofana, S., Schenck, T.L., Trevidic, P., et al., 2015. Midface: clinical anatomy
and regional approaches with injectable fillers. Plast. Reconstr. Surg.
136, 219S–234S.
Haddock, N.T., Saadeh, P.B., Boutros, S., Thorne, C.H., 2009. The tear
trough and lid/cheek junction: anatomy and implications for surgical
correction. Plast. Reconstr. Surg. 123, 1332–1340.
Hamara, S.T., 1992. Composite rhytidectomy. Plast. Reconstr. Surg. 90 (1),
1–13.
Kakizaki, H., Leibovitch, I., Selva, D., et al., 2009. Orbital septum attachment
on the levator aponeurosis in Asians: in vivo and cadaver study.
Ophthalmology 116, 2031–2035.
Kikkawa, D.O., Lemke, B.N., Dortzbach, R.K., 1996. Relations of the
superficial musculoaponeurotic system to the orbit and characterization
of the orbitomalar ligament. Ophthal. Plast. Reconstr. Surg. 12, 77–88.
Lucarelli, M.J., Khwarg, S.I., Lemke, B.N., et al., 2000. The anatomy of
midfacial ptosis. Ophthal. Plast. Reconstr. Surg. 16, 7–22.
May, J.W., Jr., Fearon, J., Zingarelli, P., 1990. Retro-orbicularis oculus fat
(ROOF) resection in aesthetic blepharoplasty: a 6-year study in 63
patients. Plast. Reconstr. Surg. 86, 682–689.

73
Surgical Preparation and Technique
73
10 
Nonsurgical Rejuvenation of the Periorbital Area
Patrick J. Treacy, MBBCh, LRCSI, MICGP, MBCAM, H Dip Derm, BSc (Hons)
The Clinical Problem
A variety of differing aesthetic treatments and procedures are
presently available for nonsurgical periorbital rejuvenation.
Although less invasive treatments will not replace surgery, a
growing patient population is seeking results through low-risk
procedures with associated minimal downtime. These tech­
niques are largely based on wound healing and collagen
generation and continue to improve as new technologies become
available. Many devices target the injury deep in the underlying
tissue, leaving no visible external signs of trauma and an
increased ability to deliver energy safely to deeper tissue planes.
Each of these techniques has its own relative benefits and risks,
and a combination of treatments is steadily gaining a
foothold.
Synopsis
Nonsurgical periorbital rejuvenation techniques include the
following:
■ Botulinum toxin injections
■ Hyaluronic acid and/or other type of dermal fillers
■ Monopolar, bipolar radiofrequency (RF) energy
■ Microneedling collagen induction therapy
■ Microfocused high-intensity ultrasound
■ Platelet-rich plasma (PRP, or plasma therapy)
■ Bidirectional suspension sutures
■ Chemical peels
■ Nonablative and ablative lasers
■ Combination nonsurgical techniques, DUBLiN lift
The Aesthetic Problem (Fig. 10.1)
The periorbital area consists of the eyelids and surrounding
areas, including the eyebrows, bony eye socket and rims, cheeks,
and forehead. It is often the first area to show signs of aging
because of multidimensional and multifactorial reasons. The
demand for minimally invasive skin-tightening procedures has
been rising as patients seek effective alternatives to aesthetic
surgical procedures of the area.
The face, and more especially the eyes, is the area for which
most patients seek cosmetic rejuvenation. The periorbital area
is very important in contact between humans because it provides
a window to the rest of society regarding a patient’s level of
health, tiredness, emotional status, and interest in others.
The eyes and eyelids are very complex and delicate areas
and, as such, need to be approached and treated with care.
Recent studies have shown that changes occur in the bony
structure surrounding the eye and have a substantial impact
on the aging process, especially with respect to volumetric
changes.1 The periorbital aging process is complex; it is a
three-dimensional process that affects not only the skin, but
also constantly interacts with the underlying layers— adipose
tissue, muscles, and bones. The aesthetically attractive lower
eyelid should display a relatively smooth transition between
the preseptal and orbital portions of the orbicularis oculi muscle
and continue into the upper malar region without a definable
transition point.2
Periorbital aging can hence be attributed to the following:
• Gravity and its effect
• Decrease in collagen and elastin
• Laxity and ptosis of subcutaneous tissues
• Atrophy and hypertrophy of adipose tissues
• Bone reabsorption
Surgical Preparation and Technique
Neuromodulators
The periorbital anatomy is particularly well suited for botulinum
toxin A (Botox) treatments and is the most frequent site to

74
SECTION 2    CHAPTER 10  •  Nonsurgical Rejuvenation of the Periorbital Area
• Crow’s feet (periorbital)
• Eyebrows (arched, horizontal, gullwing). It also permits
the lifting of the eyebrow
Botox was used to weaken the orbicularis oculi muscle and
allow the frontalis to cause a minimal elevation and open up
the eye area. This technique can also become useful before or
after periorbital laser resurfacing augments the effects of the
laser and helps maintain the improved appearance of wrinkles,5
as can be seen in the next case.
Chemical Peels
Chemical peels are one of the most common procedures used
for skin rejuvenation. The process involves applying a caustic
substance to the skin to produce a controlled, partial-thickness
injury. Peels are categorized as affecting the superficial, medium,
and deep levels. Superficial peels penetrate the epidermis
down to the dermal-epidermal junction. These peels include
Jessner’s solution, which is a combination of resorcinol,
salicylic acid, and lactic acid in an alcohol solution. Glycolic
acid at concentrations of 20% to 70% is a more popular agent
used for superficial chemical peeling. Trichloroacetic acid is
a versatile peeling agent because the concentration may be
adjusted to achieve the desired depth of peel. Deep chemical
peeling entails longer healing times and increased potential for
complications. Baker’s formula is the most commonly used deep
chemical peel.
benefit from the cosmetic application of the toxin. Therapy is
aimed at paralyzing specific muscles to reverse their effects
on the overlying skin. Dermatologic use of Botox has tradition­
ally been applied to the treatment of glabellar furrows and
forehead and periorbital rhytids.3,4 Cosmetic benefits of Botox
treatment include smoother, line-free skin, improved brow
contour, and optimal postsurgical healing in certain circum­
stances. Botox therapy is simple, effective, and forgiving, making
it very popular among physicians and patients alike.
Case 1 (Fig. 10.2)
A 33-year-old patient wished to have a smoother forehead,
improved brow contour, and reduction in the periorbital rhytids,
which resulted from both photoaging and contraction of the
orbicularis oculi muscles.
Case 2 (Fig. 10.3)
A 42-year-old patient wished to have improved brow contour
and reduction in periorbital rhytids. Botox can be used in the
following areas:
• Forehead (horizontal lines)
• Frown lines (vertical)
Orbicularis
oculi muscle
Orbital fat
Orbital fat
Maxillary
bone
Youthful eye
Aging eye
Orbital
septum
Lower
eyelid
Upper
eyelid
FIGURE 10.1  Tear trough deformity. (Adapted from original artwork by Kevin February, with permission.)

75
Surgical Preparation and Technique
A
C
B
FIGURE 10.2  A 33-year-old patient before (A,B) and after (C) treatment
with botulinum toxin 2 weeks later.
A
C
B
FIGURE 10.3  A 42-year-old patient showing evidence of brow elevation
after injecting the orbicularis oculi muscle in three areas, before (A) and
after (B,C) treatment 2 weeks later.
Nonablative and Ablative Lasers
Advances in laser technology in recent decades have increased
the options for the treatment of dermatologic conditions of
the eye and eyelid. The recent advent of fractionated laser
technology has resulted in dramatically decreased healing
times for periocular skin resurfacing and fewer adverse
effects. Fractionated laser resurfacing has now nearly sup­
planted traditional full-field laser resurfacing, and safe treat­
ment of rhytids on the thin skin of the eyelids is possible.6 It
has also been adapted for the removal of periorbital lesion,
such as syringomas, xanthelasma, milia, and seborrheic
keratosis.
Case 3 (Fig. 10.4)
A 43-year-old patient wanted a technique that would reverse
her periorbital rhytids more permanently than botulinum alone.
She also wanted to address the issues of photoaging, including
skin laxity and pigmentation.
Coarse wrinkles in the periorbital area showed good improve­
ment in the regions submitted to a double-pass, nonsequential,
fractional ultrapulsed CO2 light treatment (Active FX, Lumenis,
San Diego, CA), which is considered an excellent treatment
for photodamaged facial skin. I have also used the SmartXide
DOT (Deka M.E.L.A. Calenzano (FI), Italy) and the Syneron

76
SECTION 2    CHAPTER 10  •  Nonsurgical Rejuvenation of the Periorbital Area
A
C
B
FIGURE 10.4  A 43-year-old patient showing evidence of rhytid reduction
after CO2 fractionalized resurfacing and injection of the orbicularis oculi
muscle prior to the procedure.
CO2RE (Syneron Candela, Irvine, CA), with good results in
this area.
Case 4 (Fig. 10.5)
A 55-year-old male patient with coarse periorbital rhytids and
lateral brow ptosis wanted something more beneficial than
Botox infraorbital and anterior to the zygomatic area. He had
been receiving botulinum toxin for 4 years.
However, these ablative treatments are accompanied by
significant downtime, along with the risk of possible infection
or hyperpigmentation. Some physicians prefer nonablative
fractionalized resurfacing (Fraxel, Reliant Technologies, Moun­
tain View, CA) as a treatment that has a lower therapeutic and
side effect profile. However, this does not also consider
chronologic aging problems, such as volume deficits resulting
from the loss and repositioning of facial fat, which is addressed
by combination techniques such as the DUBLiN lift.7
Filler Augmentation
Many authors have published comprehensive treatment of the
periorbital region with hyaluronic acid.1 The tear trough or
infraorbital hollow is a challenging area to treat, and only a
few fillers are suitable for this delicate area. Several forms of
hyaluronic acid are available (e.g., benzyl esters of hyaluronic
acid, HYAFF) that have differing degradation profiles and have
been used periorbitally. Calcium hydroxyapatite (CaHA;
Radiesse, Merz, Raleigh, NC), composed of synthetic CaHA
microspheres, has been used to restore infraorbital malar volume
and had an aesthetic effect in patients.8
Case 5 (Fig. 10.6)
A 57-year-old woman had a prominent tear trough deformity
that caused a sunken appearance of her eye. She complained
of a dark shadow over the lower eyelid, giving her a fatigued
appearance, despite adequate rest.
The term tear trough deformity was coined by Flowers.
In his opinion, descent of the cheek, loss of facial volume,
underdevelopment of the infraorbital malar complex, and a
muscular defect between the orbicularis muscle and angular
head of the quadratus labii superioris muscle were all
responsible for the development of a tear trough deformity.9
Dark circles are often a result of a tear trough deformity.
However, the causes of dark circles can be multifactorial.
Changes in skin thickness, laxity, hyperpigmentation, and
actinic changes also play a role. Thin skin or prominent
subcutaneous venous pooling accentuates the periorbital
darkening.10
Case 6 (Fig. 10.7)
A 58-year-old woman presented with infraorbital rhytids
and a loss of volume in her nasojugal groove and malar
area. The patient complained that the sagging of the lower
eyelid caused her to have an aged and tired appearance to
her face.
Tear trough deformity is refractory to attempts at cosmetic
concealment. It is a natural consequence of the anatomic
attachments of the periorbital tissues. Traditional techniques
relied on surgical excision of skin, muscle, and fat, as well as
chemical peels. Treatment now uses replacement of volume
with dermal fillers.
Bidirectional Thread Lifts
For bidirectional thread lifts, local anesthetic injections are
administered, and a small entry point is made with an 18-gauge
needle. The thread is then inserted 5 mm under the skin into
the thin fat layer, following the vector that was predetermined
to obtain the best result. This is a technical innovation and is
a simple and noninvasive technique.11

77
Surgical Preparation and Technique
A
C
D
B
FIGURE 10.5  (A–C) A 55-year-old patient showing evidence of deeper rhytid reduction after double-passed CO2 fractionalized resurfacing and injection of the orbicularis
oculi muscle prior to the procedure. (D) The histopathology shows collagen formation at a depth of 700 nm.
B
A
FIGURE 10.6  A 38-year-old patient showing evidence of tear trough deformity (A) that was restored aesthetically with hyaluronic acid fillers (B).
A
B
FIGURE 10.7  A 58-year-old patient treated with calcium hydroxyapatite to the nasojugal groove and the malar area to restore loss of volume.

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SECTION 2    CHAPTER 10  •  Nonsurgical Rejuvenation of the Periorbital Area
Case 7 (Fig. 10.8)
A 53-year-old woman presented with a left lateral brow ptosis
following a minifrontal craniotomy for an aneurysm repair.
This procedure had resulted in a frontotemporal defect, and
the patient complained that the sagging of the upper eyelid
caused her to have an aged, sad, and tired appearance to her
face.
The patient denied any functional sequelae of her brow
ptosis, such as headaches or ocular fatigue, although she did
describe a small deficit in her visual field. Her visual acuity,
pupillary examination, and extraocular motility were normal.
There was no loss of sensation in the area of the resultant scar
because the supratrochlear and supraorbital sensory nerves
innervate the central and lateral forehead, as well as portions
of the anterior scalp.
Autologous Platelet-Rich Plasma Injections
PRP is a highly concentrated autologous solution of plasma
prepared from the patient’s own blood. PRP contains platelets
that are purported to release numerous growth factors, which
may be valuable for numerous dermatologic applications. Five
major growth factors—transforming growth factor (TGF),
insulin-like growth factor (IGF), platelet-derived growth factor
(PDGF), epidermal growth factor (EGF), and vascular endo­
thelial growth factor (VEGF)—are known to be related to the
wound-healing processes. These growth factors are released
D
B
C
A
FIGURE 10.8  A 53-year-old patient showing elevation of lateral brow ptosis after placement of a bidirectional thread lift to the frontalis area.
from platelets, and the production of collagen of fibroblasts is
stimulated by IGF, EGF, interleukin-1 (IL-1), and tumor necrosis
factor alpha (TNF-α).
Red Light Phototherapy: Low-Level Laser (Light) Therapy
(LLLT)
It is known that red light is absorbed by an intracellular enzyme,
cytochrome c, responsible for stimulating fibroblasts by regulat­
ing gene activity and apoptosis. Many different studies have
been done to determine the efficacy of this wavelength in
collagen production and skin rejuvenation.12
Collagen Induction Therapy
Collagen induction therapy (CIT) is an aesthetic medical
procedure that involves puncturing the skin repeatedly with
tiny sterile needles. Typically, this is done with a specialized
instrument called a microneedling device. CIT appears to be
a safe method for treating the periorbital region without
destroying the epidermis. The procedure can be repeated safely
and is also applicable in regions where laser treatments and
deep peels are of limited use.
Case 8 (Fig. 10.9)
A 37-year-old woman presented with infraorbital rhytids and
a loss of volume in her nasojugal groove and malar area. She

79
Surgical Preparation and Technique
A
B
FIGURE 10.9  A 37-year-old patient treated with a combination of CO2 laser, botulinum toxin, plasma-rich protein, and 633-nm red light to restore sagging of the lower
eyelid and infraorbital rhytids (DUBLiN lift).
A
B
FIGURE 10.10  A 33-year-old patient with a dilated tortuous facial reticular vein treated with radiofrequency (Syneron Polaris LV 100f).
complained that the sagging of the lower eyelid caused her to
have an aged and tired appearance to her face.
Nonsurgical techniques, in general, do not attend to chrono­
logic aging problems such as volume deficits resulting from
the loss and repositioning of facial fat. For this patient, it was
decided to combine five established therapies in an attempt
to address these deficits. The facial rejuvenating therapies
included microneedling, low-dose Ultralase laser, PRP growth
factors, Omnilux 633 light, and neurotoxins. The technique is
called the DUBLiN face lift as an acronym of the procedures
involved:
D Dermaroller
U Ultralase laser
B Blood growth factors
Li Light (near-red, 633 nm)
N Neurotoxin
Radiofrequency and Infrared
Over the past decade, RF and infrared (IR) laser devices have
been popularized owing to their ability to deliver controlled
heat to the dermis, stimulate neocollagenesis, and produce
modest tissue tightening, with minimal recovery time. These
devices use RF energy and electrical energy to deliver a con­
trolled thermal injury to heat skin.
Case 9 (Fig. 10.10)
A 33-year-old woman patient presented with a dilated, tortuous,
facial reticular vein that was causing her some emotional
distress. The prominent vessel was totally asymptomatic but
was a rather deep shade of blue. The patient had already been
refused sclerotherapy and surgical removal in a hospital and
a private clinic.
RF entered the realm of periorbital skin rejuvenation in 2002
when the US Food and Drug Administration (FDA) approved
the use of Thermage (Solta, Hayward, CA) for facial skin
tightening. Since then, many different variants of RF devices,
including the monopolar Pellevé (Cynosure, Westford, MA)
have been developed and approved by the FDA. These devices
deliver continuous monopolar RF energy, rather than pulsed
heating, and repeatedly bring the skin to therapeutic tempera­
tures until maximal contraction is obtained.
Another effective bipolar RF device for the periorbital area
is the Syneron Polaris, based on electro-optical synergy using
conducted RF in combination with a high-power diode laser.
It has multiple applications, including wrinkle and skin texture
treatment. The superposition of RF and light creates strong
heating of the deep dermis, with minimal risk of side effects,
and the electrode design allows high-energy delivery to a depth

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4.
Guerrissi, J., Sarkissian, P., 1997. Local injection into mimetic muscles
of botulinum toxin A for the treatment of facial lines. Ann. Plast.
Surg. 39, 447–453.
5.
West, T.B., Alster, T.S., 1999. Effect of botulinum toxin type A on
movement-associated rhytids following cutaneous CO2 laser resurfac­
ing. Lasers Surg. Med. 25, 259–261.
6.
Clementoni, M.T., Gilardino, P., Muti, G.F., et al., 2007. Non-sequential
fractional ultrapulsed CO2 resurfacing of photoaged skin. J. Cosmet.
Laser Ther. 9, 218–225.
7.
Treacy, P., 2012. Combining therapies for the ageing face: the DUBLiN
lift. Prime International. 2:7, 20–31.
8.
Bravo, B.S., Rocha, C.R., Bastos, J.T., Silva, P.M., 2015. Comprehensive
treatment of periorbital region with hyaluronic acid. Clin. Aesthet.
Dermatol. 8, 30–35.
9.
Flowers, R.S., 1993. Tear trough implants for correction of tear trough
deformity. Clin. Plast. Surg. 20, 403–415.
10.
Sadick, N.S., Bosniak, S.L., Cantisano-Zilkha, M., et al., 2007. Definition
of the tear trough and the tear trough rating scale. Cosmet. Dermatol.
6, 218–222.
11.
De Benito, J., Pizzamiglio, R., Theodorou, D., Arvas, L., 2011. Facial
rejuvenation and improvement of malar projection using sutures
with absorbable cones: surgical technique and case series. Aesthetic
Plast. Surg. 35, 248–253.
12.
Bhat, J., Birch, J., Whitehurst, C., Lanigan, S.W., 2005. A single-blinded
randomized controlled study to determine the efficacy of Omnilux
Revive facial treatment in skin rejuvenation. Lasers Med. Sci. 20,
6–10.
Further Reading
Sclafani, A.P., 2009. Applications of platelet-rich fibrin matrix in facial
plastic surgery. Facial Plast. Surg. 25, 270–276.
of 2.5 mm. IR laser skin tightening is a minimally invasive
way to tighten periorbital skin without surgery and helps
reverse some of the signs of aging. Devices used for this purpose
include the Titan (Cutera, Brisbane, CA).
Microfocused Ultrasound
Microfocused ultrasound (MFU) has been recently developed
to meet the public demand for periorbital skin lifting and
tightening. This noninvasive device is called Ulthera; the
treatment is known as Ultherapy (Ulthera, Mesa, AZ). It causes
fractional thermal injury to a precisely set depth using ultra­
sound technology, with minimal discomfort and transient
erythema. It can be focused on subcutaneous tissue, producing
small (<1 mm) thermal coagulation points to a depth of up to
5 mm within the mid to deep reticular layers of the dermis
and subdermis. The application of heat at these thermal coagula­
tion points causes collagen fibers in the facial planes to become
denatured, contracting and stimulating de novo collagen.
References
1.
Moran, M.L., 2013. Office-based periorbital rejuvenation. Facial Plast.
Surg. 29, 58–63.
2.
Glaser, D.A., Patel, U.J., 2010. Enhancing the eyes: use of minimally
invasive techniques for periorbital rejuvenation. Drugs Dermatol. 9,
s118–s128.
3.
Carruthers, A., Caruthers, J., 1997. Cosmetic uses of botulinum A
exotoxin. Adv. Dermatol. 12, 325–347.

81
Surgical Preparation and Technique
81
11 
High SMAS Face Lift
Bud S. Alpert MD
The Clinical Problem (Fig. 11.1)
The patient looks in the mirror and at recent photographs and
thinks that he or she looks old and tired. She or he comments,
“how I feel is much younger then how I look” and may state
that the work environment is competitive and many cohorts
look much younger. An associated loss of self-confidence may
be claimed.
Synopsis
■ Changes of facial aging of the cheeks, jowls, and neck are
characterized by anterior and inferior descent of soft
tissues over the facial skeleton.
■ The challenge is to restore a natural youthful appearance
by moving the descended soft tissues in a superior and
posterior vector without distortion of the patient’s
original appearance (i.e., looking pulled, stretched, or
different.)
■ A high superficial musculoaponeurotic system (SMAS)
platysmal flap is used as the primary vehicle for restoring
soft tissues to a youthful position.
■ Neck defatting, combined with a full-width
platysma transection, is effective for girth reduction
of the neck.
■ A sub–SMAS-platysma dissection extends until easy
movement of the overlying skin and subcutaneous
tissues, from cheeks to neck, is obtained by traction on
the flap.
■ The skin is redraped in a custom fashion for the
individual’s face and closed without tension.
■ A great majority of patients are comfortable in
public after 2 weeks. The procedure entails extremely
low morbidity and high patient and surgeon
satisfaction.
The Aesthetic Problem
Facial aging is characterized by a change in appearance associ­
ated with the obligatory descent of the soft tissues of the face
over the facial skeleton. Progressive loss of elasticity, combined
with gravitational impact over time, produces this descent.
There is an associated decrease in fullness over the cheek bones
and an associated prominence of the nasolabial folds, jowls,
and neck laxity, together with redundant soft tissues and
platysmal banding to varying degrees.
The vectors of soft tissue descent are anterior and inferior.
There are true and perceived alterations in facial shape and
volume, with a progressive change from the heart-shaped face
of youth to a vertically rectangular (boxy) shape of aging. There
is a loss of definition of the cheek bone and jaw line, with
angularity replaced by obliquity (Fig. 11.2).
The surgical challenge is to restore the soft tissues to their
place of origin and accomplish this without altering the patient’s
native appearance. In my experience, most patients desire to
“look like myself.”
Surgical Preparation and Technique
Facial aging issues addressed are the cheeks, jowls, and neck.
The eyes and forehead are not subjects of this discussion. Much
has been written about the plane(s) of dissection in face lifting,
with advocates for subcutaneous, SMAS, subperiosteal, and
combinations (e.g., deep plane, composite, zygo-orbicular) of
these demonstrating excellent results. The addition of fat grafting
as a modality useful in face lifting has become well established,
and is commonly used in conjunction with all the aforemen­
tioned techniques. The SMAS has been used in various fashions
(e.g., imbrication, SMASectomy with plication, elevation,
and transposition, with or without the platysma) and has
remained a time-tested vehicle as a prime force for tissue
repositioning.
SECTION 3  •  Face Lift
James D. Frame

82
SECTION 3    CHAPTER 11  •  High SMAS Face Lift
The flap described is broad, allowing excellent exposure in
the dissection required for elevation and transposition. The
size of the flap allows for its use as the prime tissue mover
with variations of SMAS and platysma thickness, as well as
for the occurrence of buttonholing. This approach also has the
benefit of tension distribution over a large area, as opposed
to techniques that rely on a minimal number of tension points.
I find the use of one flap (high SMAS-platysma), dissected
in one plane, to be an extremely useful and reproducible method
of approaching the correction of the cheeks, jowls, and neck
changes of aging. This avoids changing planes as one moves
across the face, which can result in smaller flaps, with associated
potential decreased strength and utility, and difficulties with
exposure and visualization.
A
B
FIGURE 11.1  A 57-year-old woman who thinks she looks older than her age and doesn’t like her heavy neck.
A
B
FIGURE 11.2  A 64-year-old woman with changes of facial aging (see text).

83
Surgical Preparation and Technique
Treatment and Operative Technique
Preoperatively, the patient is marked in the sitting position,
noting the cardinal landmarks of the jaw line, platysma bands,
and estimated skin undermining of the face and neck
(Fig. 11.3). The patients all receive the antiemetic agent apre­
pitant (Emend) preoperatively.
The procedure is performed under general anesthesia with
endotracheal intubation, and 0.25% xylocaine plus 1/200,000
epinephrine is infiltrated into all areas to be operated on. The
anterior neck is addressed first. Preoperatively, a decision is
made about whether or not to open the neck. I have three
indications to open the neck through a submental incision:
1. Presence of bilateral, very anterior, long platysmal
bands
2. Excessive fat (preplatysmal and/or subplatysmal)
so that I think I can manage better directly from
the front
3. Extreme neck obliquity so that I think I can manage all
potential contributory factors better from the front
(e.g., preplatysmal and subplatysmal fat, platysma
muscle, anterior belly digastric muscle, submandibular
gland)
If the anterior neck is to be managed closed, undermining
with or without liposuction is indicated using wall suction
and 1.8- and 2.4-mm, three-hole cannulae.
A standard preauricular and postauricular rhytidectomy
incision are used. Anteriorly, most are post-tragal, with the
exception being some men who select a pretragal incision
preoperatively. Temporal and occipital variations for individual
hairlines are selected, taking into account anatomic requirements
and what the patient desires, as is practicable. Subcutaneous
dissection proceeds in the neck to communicate anteriorly
with the area undermined (if opened) or that dissected with
Direct apposition suturing of tissue to tissue avoids relying
on the suspension sutures used in other techniques. The flap
is extremely strong, absorbing all of the work of the procedure
and allowing no tension to be placed on the skin, a potential
cause of a pulled or done look.
This approach maintains the surgeon’s choice of a vector
for skin movement to be different than that of the SMAS-
platysma flap, which is primarily vertical. Skin undermining
for redraping can be tailored to the requirements of the patient’s
anatomy independently from the primary SMAS-platysma
movement. In the technique described here, the high SMAS-
platysma flap is associated with a full-thickness platysma
transection. The benefits of this are related both to the facility
of flap rotation and to a reduction in neck girth when compared
to that at the jaw line level. In patients with heavy necks
associated with excess subcutaneous fat, a more pleasing neck
contour may be achieved by the combination of fat removal
with full-thickness platysma transection.
In addition, platysma transection helps decrease the severity
of transverse lines in the neck, heretofore infrequently addressed
or successfully corrected. These lines, which are perpendicular
to platysma contractions, are the analogues of the transverse
forehead lines associated with frontalis muscle action and of
the crow’s feet lines in relation to the dynamics of the vertically
oriented fibers of the orbicularis oculi at the lateral orbit.
Primary risks associated with the high SMAS-platysma flap
relate to delamination in a plane in proximity to the facial
nerve. A secure knowledge of the anatomy, along with the
broad exposure afforded by the flap breadth, allows the dis­
section to be performed safely. Similarly, the full-thickness
platysma transection must be performed with sound anatomic
knowledge to avoid injury to the marginal mandibular branch
of the facial nerve as well as deeper structures. With such care,
this procedure may be performed safely and with minimal
difficulty.
A
B
FIGURE 11.3  Preoperative markings on a patient.

84
SECTION 3    CHAPTER 11  •  High SMAS Face Lift
the helical inset, and is carried forward under direct vision
until the vertically oriented lateral fibers of the orbicularis
oculi are encountered (see Fig. 11.5B and C). At the level of
the helical inset, the frontal branch of the facial nerve crosses
the zygomatic arch approximately 4 cm anterior to the helix
and is deep to the SMAS crossing the zygoma (Fig. 11.6). An
anterior branch of the superficial temporal artery may be
encountered in this dissection and can be cauterized without
difficulty. The lateral orbicularis oculi fibers encountered here
are responsible for crow’s feet and may be divided or resected
as a rectangle to diminish these lines (Fig. 11.7).
The posterior end of the high SMAS transverse incision is
then connected to the platysma transverse incision by a vertical
preauricular incision through the SMAS. The sub–SMAS-
platysma dissection proceeds in a cephalocaudal or reverse
direction, depending on the surgeon’s preference (e.g. dominant
handedness and which side of the face is being dissected).
Care is taken to remain as far beneath the SMAS-platysma
layer and above the parotid fascia as is possible because there
are individual variations in the thickness of these layers. But­
tonholes tend not to be problems because a benefit of the large
size of the flap is that it may be used effectively, despite these.
As the dissection proceeds anteriorly on the cheek, several
points are noted. Maintaining a broad front of dissection is
the liposuction cannulae. Lateral preplatysmal defatting is
accomplished under direct vision using a flat liposuction
cannula. Direct trimming refinements are done as needed. The
lateral border of the platysma is easily identified and carefully
elevated approximately 5 cm below the mandibular border.
The external jugular vein lies immediately beneath in most
cases. Anatomic variations may exist, with double-barreled,
angular branching, or anterior jugular veins all being possibili­
ties. The dissection proceeds under direct vision beneath the
platysma at this level, with sequential division of the muscle
using electrocautery until the anterior border has been transected
and the subcutaneous plane is encountered anteriorly. In patients
with extremely thick platysma muscles, it may be beneficial
to resect approximately 1 cm from the caudal muscle edge
under direct vision to assist in thinning the neck at this level.
The benefit in girth reduction of this semicircular defatting
and platysma division, with or without resection, can be
significant (Fig. 11.4).
Preauricular subcutaneous cheek undermining is then
accomplished according to preoperative markings, which
initially may appear abbreviated and can be subsequently
extended to allow customization of skin redraping without
tension or irregularities (Fig. 11.5A). An incision is made through
the SMAS at the cephalic margin of the zygoma, anterior to
A
C
B
2-4 cm
FIGURE 11.4  (A,B) Lateral border of platysma identified 5 cm below the mandible, external jugular vein beneath, and scissors beneath the platysma. (C) Platysma totally
divided—borders are now 2 to 4 cm apart and preplatysmal defatting has been accomplished.

85
Surgical Preparation and Technique
A
C
B
FIGURE 11.5  (A) Preauricular incision has been made; cephalic and caudal borders of zygomatic arch are noted. (B,C) An incision is made through the superficial
musculoaponeurotic system at the cephalic margin of the zygoma, anterior to the helical inset. This is carried forward under direct vision until the vertically oriented lateral
fibers of the orbicularis oculi are encountered.
4 cm
2 cm
FIGURE 11.6  Cadaver dissection demonstrating frontal branch of the facial nerve
crossing the zygoma deep to the superficial musculoaponeurotic system.
FIGURE 11.7  Lateral orbicularis oculi fibers responsible for crow’s feet.

86
SECTION 3    CHAPTER 11  •  High SMAS Face Lift
area for caution is at and just below the mandibular border as
the dissection proceeds anterior to the edge of the parotid.
This is where the marginal mandibular branch of the facial
nerve resides, underneath the superficial layer of the deep
cervical fascia. As the large flap is dissected and ligaments are
lysed, traction on the flap will demonstrate progressively easier
movement of the nasolabial fold, jowl, labiomandibular fold,
and anterior neck skin. This one large flap will be the entire
vehicle required for the proper repositioning of the facial soft
tissues (Fig. 11.9).
Once adequate mobility has been attained, fixation is
accomplished by direct apposition of the SMAS to SMAS and
beneficial because visualization and exposure are maximized,
allowing structures to be identified. The vertically oriented
facial ligaments are sequentially lysed, allowing progressively
increased flap mobility. The mobile SMAS (a term coined by
Fritz Barton, roughly from the level of the mandible to below
the tragus) is easily dissected, facilitating increased exposure
and flap movement.
As the anterior dissection proceeds at the cephalic aspect,
the zygomaticus major muscle is identified caudal to the area
of the division of the lateral orbicularis fibers. Just inferior to
the zygomaticus is an area for caution because this is where
facial nerve branches may be exposed (Fig. 11.8). A second
A
B
FIGURE 11.8  Large superficial musculoaponeurotic system–platysma flap elevated. The scissors tip identifies the zygomaticus major.
A
B
FIGURE 11.9  Traction on the flap allows easy movement after the facial ligaments are lysed.

87
Complications
agents are used as indicated. Antinausea agents are used as
necessary (e.g., promethazine, ondansetron). Dressings are
changed, drains are removed, and patients are discharged the
day following surgery. On the second postoperative morning,
they are instructed to remove the dressings, shower, and wash
their hair with their usual soap and shampoo. Sutures are
removed on postoperative days 6 to 10. The overwhelming
majority are comfortable in public at 2 weeks postoperatively.
The procedure is associated with a very high rate of patient
satisfaction, with the majority of patients extremely pleased
with their outcome. A review of long-term results at 10 years
postoperatively has consistently revealed that patients have
not yet returned to their original preoperative status regarding
the degree of facial aging (Figs. 11.11 and 11.12).
Complications
In 15 years of performing high SMAS-platysma face lifts in
over 1000 patients, the hematoma rate has been just under 2%.
There have been no infections or nerve deficits. There have
been cases of delayed healing, primarily in the high postau­
ricular region, and approximately a 5% incidence of scars (e.g.,
postauricular, submental) requiring intralesional steroid injection
or revision. It is my impression that the drastic reduction of
smoking in the general population, along with attention to
perioperative blood pressure control and nausea and vomiting
prevention, have led to a decrease in the morbidity of these
procedures.
platysma to sternocleidomastoid and mastoid fascia in a primar­
ily vertical vector, with interrupted sutures. I use approximately
half 4-0 Ethibond and half 5-0 Vicryl sutures. At the cephalic
transverse incision at the top of the zygoma, the fixation points
go from the helical inset at the temporalis fascia anteriorly to
a point behind the 4 cm distance previously mentioned as the
crossing point of the frontal branch. A counterincision in
the flap at the ear lobule is used as needed, depending on the
specific vertical rotation and the patient’s anatomy. Subsequent
repositioning of the facial skin and subcutaneous tissues from
the top of the cheek, including cephalic elevation of the lower
lid-cheek junction to and including the neck, is immediately
evident after SMAS-platysma flap fixation. The skin is then
redraped with appropriate vector adjustment and additional
undermining, if required, for contouring and smoothness and
closed without tension (5-0 Vicryl, 6-0 Prolene; Fig. 11.10). A
10-mm fluted round drain is placed into the neck and brought
out through a postauricular stab wound to closed via reservoir
suction. A thin layer of Arista, an absorbable hemostatic agent
consisting of polysaccharide spheres produced from plant
starch, is sprinkled on the dissected field prior to closure. A
bulky cotton head wrap is placed.
Postoperative Considerations
Patients spend the night of surgery in the hospital. Pain is
usually minimal, with appropriate control provided. Blood pres­
sure is monitored, and beta blockers and other antihypertensive
A
B
FIGURE 11.10  One flap may reposition the entire cheek, jowl, and neck complex.

88
SECTION 3    CHAPTER 11  •  High SMAS Face Lift
A
C
D
B
FIGURE 11.11  (A,C) Preoperative views. (B,D) Postoperative views, 1 year.

89
Complications
A
C
D
B
FIGURE 11.12  (A,C) Preoperative views. (B,D) Postoperative views, 1 year.

91
)
91
12 
Management of the Neck
Gregory P. Mueller MD, FACS
Nicholas R. Nikolov MD, FACS
The Clinical Problem (Fig. 12.1)
Synopsis
Neck shape is determined by the following:
■ Mandible anatomy—chin hypoplasia
■ Skin turgor, texture, tone
■ Fat deposition location and volume
■ Platysma anatomy and physiology
■ Submandibular gland size and position
■ Digastric muscle size
■ Hyoid position
■ Thyroid cartilage prominence
The Aesthetic Problem
Neck contours are determined by the interplay of multiple
factors. Because the face and neck are visualized as one region
of the human form, it is important to understand the importance
of maintaining a balanced appearance. In a study by Ellenbogen
and Karlin,1 attractive features of the youthful neck were
described (Fig. 12.2) as follows:
1. Cervicomental angle, 105 to 120 degrees;
submental-sternocleidomastoid angle, 90 degrees
2. Visible border of sternocleidomastoid muscle
3. Visible thyroid cartilage
4. Subhyoid depression
5. Well-defined mandibular border
Patients are distressed by a lack or loss of neck contours
that is genetically inherited or acquired through the aging
process. Sculpted neck contours relay an image of youth and
fitness, whereas poorly defined necklines make a person appear
older and less fit or overweight. These perceptions commonly
affect how we view ourselves or how we view others. Under­
standing each patient’s concerns, goals, and desires is paramount
when determining the optimal approach to rejuvenate and
refine the neck. Involving the patient in the decision-making
process by presenting various options allows formulating a
realistic treatment plan that will address the specific problem
areas. It also creates a platform to present realistic expectations.
The ability to review similar patients with similar neck
problems—showing before and after images—is one of the
most effective ways to educate potential patients regarding
what to expect. Skin quality and texture are also important
factors. Patients do not like the wrinkles that develop in the
neck skin as a result of sun exposure and aging. Patients are
also concerned about the unattractive appearance of features
such as platysma banding, which occurs with movement.
A complete medical history should be taken to determine
suitability for any treatment. The presence of congenital and
autoimmune disorders of the skin needs to be researched to
determine if surgical or other treatment modalities are safe,
with predictable outcomes. A history of trauma, malignancy,
and/or prior procedures that may have altered the neck anatomy
and physiology are important to discuss. Determining the
patient’s impression of prior surgical procedures and their
success or failure will give the surgeon a great deal of important
information regarding how the patient will perceive the outcome
determined by a recommended treatment plan. Risk factors
such as prior complications, poor wound healing, excessive
scarring, and a history of smoking need to be identified and
considered. Most importantly, a thorough understanding of
the patient’s concerns needs to be coupled with a viable treat­
ment plan that will deliver results to satisfy the patient. The
success of satisfying a patient is based on the ability to com­
municate realistic expectations of the outcome.
It is important to understand the various anatomic features
that define what is considered attractive. Surgically altering
the neck without attention to the face may draw attention
because of the loss of harmony.

92
SECTION 3    CHAPTER 12  •  Management of the Neck
be considered. Genetically, a person may have an obtuse angle
that results from a low position of the hyoid, which may give
the appearance of excessive submental fat. Thyroid cartilage
position and prominence are noted and are important to consider
in female patients for whom a platysma myotomy is planned.
In these cases, it is recommended to keep the myotomy at
least 2 cm below the thyroid cartilage. The slight visibility and
prominence of the thyroid cartilage are considered attractive in
females, and the unmasking of a prominent thyroid cartilage is
not desirable. When evaluating the neck, it is important to point
out findings to the patient so that she or he may understand
that certain features may become more apparent following fat
removal and/or modification of the deeper structures of the
neck. In addition, large submandibular glands, fat deposits, and
prominent digastric muscles need to be assessed and treated, as
indicated, to improve outcomes. Age-related changes that need
to be addressed include increased fat deposits, visible platysma
bands at rest or with movement, ptosis of the submandibular
glands, and skin laxity. All these factors contribute to the loss of
youthful and attractive neck contours. During the consultation,
all these anatomic features need to be addressed and discussed
with the patient.
Surgical Preparation and Technique
Clinical Findings (Box 12.1)
Patients are aware of the various minimally invasive or non­
invasive technologies available. Most patients will choose a
less invasive, less risky approach if there is one available.
Patients almost always ask if there is laser or other technology
that will tighten skin because they do not want incisions that
Visual inspection of the front of the neck and the lateral view
is helpful to identify platysma bands and assess the cervico­
mental angle. Assessing the bony structure of the mandible
is the initial step in evaluation. The width of the mandible
and the lateral and anterior projections of the chin must
Ptotic
submandibular
glands
Fat deposition
Skin rhytids
A
B
Sagging
digastric
muscles
Chin
projection
Platysma
bands
Loss of
jawline
definition
Jowls
Neck skin laxity
FIGURE 12.1  Aging neck features. (A) Front view. (B) Oblique view. (© 2016 Andrea Charest and Karina Metcalf, with permission.)
Nose-
lip-chin
plane
(NLCP)
Distinct
mandibular
border
Subhyoid
depression
Thyroid bulge
Distinct
sternocleidomastoid
(SCM) border
<3mm
Cervicomental angle
105° to 120°
FIGURE 12.2  Ideal youthful neck lines, as described by Ellenbogen and Karlin.1
(© 2016 Andrea Charest and Karina Metcalf, with permission.)

93
Surgical Preparation and Technique
will leave scars. As long as a procedure is effective, patients
will almost always choose the less invasive, less risky option.
The shape and form of the neck can be altered by various
maneuvers that reposition, modify, and remove certain key
components. The level of invasiveness increases with the depth
of the modification. Altering superficial components of the
neck, such as the skin and subcutaneous fat, is less invasive
and risky than surgical modification of deeper structures, such
as the submandibular glands. In patients with the early signs
of aging that have affected skin tone and texture, options of
using laser or energy-based technologies are available to tighten
and tone the skin. If patients are complaining of excess skin
that is significant, a skin excision is indicated to remove excess
skin folds that make the person appear old. This requires
incisions around the ear that leave scars. With skin excision,
there is an increased risk of wound healing problems. The
risk-benefit ratio is acceptable in this group because current
technology will not tighten redundant skin.
•
Chin projection ± chin augmentation vs. genioplasty
•
Hyoid position—inform patient regarding expectations
•
Thyroid cartilage ± prominence
•
Skin laxity minimal + energy-based tightening (e.g.,
radiofrequency, laser, ultrasound)
•
Skin laxity—moderate to severe + excision
•
Fat deposits + excision
•
Platysma banding + platysmaplasty, percutaneous vs. open;
consider platysma band division
•
Ptotic submandibular glands + suspension vs. partial resection
•
Digastric muscle + partial excision
BOX 12.1  Clinical Findings
A
B
FIGURE 12.3  Platysma muscle flexion showing banding and fatty layer over the platysma before (A) and after (B) percutaneous division of the bands and liposuction of the
neck.
In most cases, subcutaneous fat deposits are present that
add to the loss of refined contours of the neck. It is important
to localize the fat deposits preoperatively so that fat removal
can be performed accurately. This can be determined by observ­
ing the patient as he or she flexes the neck musculature and
platysma muscle (Fig. 12.3).
Visualizing the fatty layer and its thickness is easy as conceal­
ing of the platysma muscle is visualized underneath thicker
areas of fat deposits. Regardless of the amount of fat identified
and localized in the neck, it is always important to leave a thin
blanket of fat (3–5 mm) on the undersurface of the skin to
maintain the smoothness of the neck skin and prevent dermal
tethering.
Four structures make up the foundation that supports the
overlying neck skin. The presence of prominent subplatysmal
fat requires direct excision or placement of the trampoline
platysmaplasty (TPP) lacing over the surface of the platysma
muscle to elevate the fat deposit and smooth neck contours.
If direct excision is performed, it is critical to approximate the
medial platysmal borders to prevent contour irregularities.
Underlying enlarged or ptotic salivary glands can also contribute
to the aged appearance of the neck. In addition, if subcutaneous
fat is removed, the glands are uncovered and can become visible.
If these are drooping or enlarged, suspension or partial resection
may be considered. Procedures to remove part of the gland
carry the risk of injury to the marginal mandibular nerve, as
well as excessive bleeding. Suspension of the glands, as
described by Guerrosantos2 and Feldman,3 is less invasive and
does not risk injury to the nerve.
Muscle anatomy and activity are also factors that need to
be assessed. For patients with large anterior digastric muscles,
partial resection may need to be considered. For patients with
platysmal banding that is present at rest or with movement,
modification of the muscle is indicated. Feldman’s corset
platysmaplasty3 is one option, as is the percutaneous TPP
as described by Mueller et al.4 In addition, back cuts can be

94
SECTION 3    CHAPTER 12  •  Management of the Neck
puncture device, dermal clearing device, LED light source,
and one stainless steel rod (Sutorod) with a fiberoptic core.
The “Suturod” (Implicitcare LLC, Newport Beach California,
USA) has a 100-inch, 4-0 braided polyester suture that attaches
to the center of the rod. Placement of the suture matrix on the
surface of the platysma muscle is critical to obtaining successful
results with the TPP and NDS. Light illuminating from the
tip of the rod with the attached suture allows the surgeon
to determine the depth and direction of travel accurately,
thereby enabling successful construction of the suspension
systems in the plane between the neck skin and underlying
platysma.
made in the anterior border of the platysma muscle, thus
lengthening the edge and smoothing out the front surface
of the neck. These cuts can be placed under direct visual­
ization or using the percutaneous approach with a suture
ligature.
Treatment and Operative Technique
PERCUTANEOUS TRAMPOLINE PLATYSMAPLASTY AND
NECK-DEFINING SUTURE
With this technique, two nonabsorbable suture matrices are
constructed in the subcutaneous space and positioned on the
surface of the platysma muscle. The TPP and neck-defining
suture (NDS) are the two suspension systems that support and
shape the entire area underneath the jawline (Fig. 12.4).
The NDS suture loop is placed at the back portion of the
neck to support and elevate the cervicomental angle and
submandibular glands in a manner very similar to the Giampapa
suture suspension. The percutaneous suture loop is anchored
in the dense retaining ligaments behind each ear overlying the
mastoid fascia (Fig. 12.5).
The TPP suture strands are introduced through several small
punctures along the lateral jawline and underneath the chin,
yielding a framework similar to a shoelace that functions like
a trampoline. The retaining ligaments along the lateral aspect
of the mandible provide the anchoring aspect of the TPP matrix
(Fig. 12.6). These retaining ligaments include the platysma
auricular ligaments, masseteric ligaments, and mandibular
ligaments (Fig. 12.7).
The method of delivering suture strands and anchoring
them by passing the suture around the retaining ligaments
along the lateral ramus of the mandible is accomplished with
a specialized light-emitting diode (LED) instrument system
(ICLED, formerly called iGuide; ImplicitCare, Newport Beach,
CA). This light-guided system includes a marking tape,
1 24
22
23
21
168
14
13
12
11
20
17 9
4
3
18
10
2
7
15
5
6
19
FIGURE 12.4  Trampoline platysmaplasty suture framework to support the area
from the mentum to the cervicomental angle.
FIGURE 12.5  Neck-defining suture framework to support the back of the neck,
including the submandibular glands and cervicomental angle. The suspension
sutures also help shape the angle of the mandible.
TPP
TPP
TPP
NDS
NDS
NDS
FIGURE 12.6  Anchor points along the lateral mandible for the trampoline
platysmaplasty (TPP) area supported and shaped with the neck-defining suture
(NDS).

95
Postoperative Considerations
Case Study (Figs. 12.8 and 12.9)
A 50-year-old woman had an early onset of an aging neck. She
has requested neck rejuvenation and refinement to restore a
more sculpted, youthful neckline. On examination, she was
Platysma
auricular
ligaments
Masseteric
ligaments
Mandibular
ligaments
FIGURE 12.7  Retaining ligaments along the lateral jawline are used as anchors for
the trampoline platysmaplasty. (© 2016 Andrea Charest and Karina Metcalf, with
permission.)
A
B
FIGURE 12.8  A 50-year-old woman before (A) and after (B) trampoline platysmaplasty and neck-defining suture to shape and rejuvenate the neck lines.
found to have mild actinic damage, with mild skin laxity. She
has developed an obtuse cervicomental angle with platysma
banding and submandibular gland ptosis. She also had fat
deposition of the neck extending to the ramus of the mandible.
The patient underwent percutaneous division of the platysma
bands, SmartLipo laser liposuction (Hologic, Inc., Marlborough,
MA, USA) treatment to the skin of the lower face and neck,
suction-assisted lipectomy of the neck, and placement of the
TPP and NDS.
Postoperative Considerations
Percutaneous Platysmaplasty and
Neck-Defining Suture
Patients are instructed to remove the chin strap on the first
day and to wear it afterward continuously while not icing or
when sleeping for a total of 3 days. Additional postoperative
instructions include cold compresses applied as often as possible
for the first 3 days during waking hours. Patients typically
experience minor bruising that can be concealed with makeup.
During the first 3 weeks, most patients have limitations in
opening the mouth widely and often observe visible dimpling
at the anchor points with wide mouth opening. At 3 weeks,
patients are released to full activity, with little evidence of
visible postoperative swelling and bruising (Figs. 12.10 to 12.12;
Video 12.1).
This patient had restoration of her youthful jawline with a
much more sculpted appearance. She progressed well post­
operatively, with her bruising resolving after 10 days. Using
the SmartLipo laser to treat the dermis allowed tightening of
the skin envelope around her newly shaped and supported
neckline.

96
SECTION 3    CHAPTER 12  •  Management of the Neck
Prevention of Complications
■ Avoid over-resection of fat; preserve 3 to 5 mm of fat on
the cervical skin flaps.
■ Recognize and treat hypertrophy of the digastric muscles
and ptosis of the submandibular glands.
■ Use meticulous hemostasis and careful dissection.
Complications
Chronic complications are aesthetic in nature and include
contour irregularities that are usually secondary to over-resection
of fat in the superficial plane. Acute complications include
hematoma, seroma, and marginal mandibular nerve injury.
A
B
FIGURE 12.9  A 50-year-old woman flexing her neck before (A) and after (B) trampoline platysmaplasty and neck-defining suture showing the support underneath the chin
and at the cervicomental angle.
A
B
FIGURE 12.10  A 52-year-old woman before (A) and after (B) neck lift with skin excision and corset platysmaplasty.

97
Complications
References
1. Ellenbogen, R., Karlin, J.V., 1980. Visual criteria for success in restoring
the youthful neck. Plast. Reconstr. Surg. 66, 826–837.
2. Guerrerosantos, J., 1978. The role of the platysma muscle in rhytido­
plasty. Clin. Plast. Surg. 5, 29–49.
3. Feldman, J., 1990. Corset platysmaplasty. Plast. Reconstr. Surg. 85,
333–343.
Management of Complications
■ Contour irregularities—fat grafting and redraping of skin
■ Hematoma and seroma—recognition and draining
■ Marginal mandibular nerve palsy—see patients
frequently, provide reassurance; allow several weeks to
3 months to resolve
A
B
FIGURE 12.11  Front views of a 55-year-old man before (A) and after (B) neck lift with skin excision, digastric muscle excision, and corset platysmaplasty.
A
B
FIGURE 12.12  Side views of a 55-year-old man before (A) and after (B) neck lift with skin excision, digastric muscle excision, and corset platysmaplasty.

98
SECTION 3    CHAPTER 12  •  Management of the Neck
fine points for improving outcomes. Aesthetic Plast. Surg. 29,
341–350.
Giampapa, V.C., Di Bernardo, B., 1995. Neck recontouring with suture
suspension and liposuction: an alternative for the early rhytidectomy
candidate. Aesthetic Plast. Surg. 19, 217–223.
Guerrerosantos, J., 2005. Suture suspension platysmaplasty for neck
rejuvenation revisited: technical fine points for improving outcomes.
Aesthetic Plast. Surg. 29, 351–352.
Guerrerosantos, J., Espaillat, L., Morales, F., 1974. Muscular lift in cervical
rhytidoplasty. Plast. Reconstr. Surg. 54, 127–131.
McKinney, P., 2003. Cervicoplasty: nonexcisional anterior approach: a
10-year follow-up. Plast. Reconstr. Surg. 111, 1346–1347.
Mendelson, B., Freeman, W., Huggins, R., 2008. Surgical anatomy of the
lower face: the premasseter space, the jowl, and the labiomandibular
fold. Aesthetic Plast. Surg. 32, 185–195.
Ramirez, O.M., 1997. Cervicoplasty: nonexcisional anterior approach.
Plast. Reconstr. Surg. 99, 1576–1585.
Ramirez, O.M., 2003. Cervicoplasty: nonexcisional anterior approach: a
10-year follow-up. Plast. Reconstr. Surg. 111, 1342–1345.
4. Mueller, G.P., Leaf, N.L., Aston, S.J., 2012. The percutaneous trampoline
platysmaplasty: technique and experience with 105 consecutive patients.
Aesthet. Surg. J. 32, 11–24.
Further Reading
Aston, S.J., 1983. Platysma-SMAS cervicofacial rhytidoplasty. Clin. Plast.
Surg. 10, 507–520.
Furnas, D.W., 1989. The retaining ligaments of the cheek. Plast. Reconstr.
Surg. 83, 11–16.
Giampapa, V.C., Bitzos, I., Ramirez, O.M., Granick, M., 2005. Long-term
results of suture suspension platysmaplasty for neck rejuvenation: a
13-year follow-up evaluation. Aesthetic Plast. Surg. 29, 332–340.
Giampapa, V.C., Bitzos, I., Ramirez, O.M., Granick, M., 2005. Suture
suspension platysmaplasty for neck rejuvenation revisited: technical

99
The Clinical Problem
99
13 
The Turkey Neck: Surgical Management
Darryl J. Hodgkinson MBB (Hons), FRCS (C), FACS, FACCS
The Clinical Problem
Aging in white individuals is accompanied by jowls, submental
laxity, or fullness and laxity, with banding of the platysma
muscles. This combination is often referred to as a turkey neck.
Along with these changes, which begin in the early 40s, are
skin laxity and horizontal creasing. There is a progressive
downward and forward cascade of skin, fat, and muscles,
obliterating the cervicomental angle and causing deep oblique
horizontal creases. The laxity extends onto the chest, and there
is an expressed dissatisfaction by the patient, especially when
she or he notices the view in an oblique downward gaze or
by lateral observation. The derogatory term of turkey neck or
chook neck accompanies the patient’s dissatisfaction with appear­
ance (Fig. 13.1).
In the overall approach that I have adopted to correct turkey
neck, the contributory platysma muscle bands are relocated
laterally, inferiorly, and anteriorly.1,2 The lateral approach and
suspension alone are inadequate if the bands are thick and
redundant. For that reason, I assess the thickness, descent of
the bands, and distance between the bands in relaxation and
movement. I quantitate these and then determine whether a
direct submental anterior approach will be needed to eradicate
the bands (Fig. 13.2). The treatment of turkey neck aims to
reestablish the cervicomental angle, reduce skin laxity, expose
the sternomastoid throughout its height, and firm and tone
the neck skin from the clavicle to the mandible, complying
with Ellenbogen and Karlin’s3 classic description of the youthful
neck.
Case Study 1
The patient shown here, TR (Fig. 13.3), was a 56-year-old, former
first-class international flight attendant, height 169 cm,
weight 60 kg, and nonsmoker, with moderate social alcohol
consumption. Her complaint in consultation was mainly her
lax neck and jowls. She demonstrated her desire for rejuvenation
with a finger lift, displacing the facial and neck tissues upward
and obliquely. She was an attractive woman who was popular
and always had an authoritative role, but her confidence was
waning. Her only previous cosmetic treatments had been
botulinum toxin A (Botox) injections, mainly to the forehead,
and one Thermage (Solta Medical, Hayward, CA) treatment
to the neck and jowls.
Clinical Examination and Planning
The key to assessing the neck is a thorough clinical evaluation
of the fat, skin, and platysma muscles and evaluation of how
each component contributes to the neck deformity. The patient
is asked to contract her or his platysma muscles and grimace;
the tone in the platysma is assessed by palpation. This can be
difficult in the more obese patient.
Neck skin laxity is assessed, together with observation of
the horizontal creases and how the jowls contribute to the loss
of definition of the mandible. The overall projection of the
forehead, nose, lips, and chin in profile should be well balanced
(Fig. 13.4).
Surgical Procedure
The procedure is performed under general anesthesia using a
total intravenous (IV) anesthetic (propofol) technique (TIVA)
and local infiltration with 20 mL xylocaine with 1 : 100,000
adrenaline and then a more tumescent infusion into the face
and neck with 200 mL of xylocaine, 0.25%, and 1 : 400,000
adrenaline.
Standard face lift flaps are undermined vertically into the
neck, just beyond the first major transverse horizontal neck
crease and across toward the jowl on the face. A strip of parotid
fascia 1 cm wide is excised from the inferior border of the
tragus, down over the sternomastoid, incorporating the platysma
auricular ligament. A lighted retractor is used to dissect a
2-cm-wide space deep to the platysma muscle, which exposes

100
SECTION 3    CHAPTER 13  •  The Turkey Neck: Surgical Management
At this point, the platysma bands are sharply excised (Video
13.4). In the case described here, these bands were widely
separated, and resection only was carried out. However, more
recently, I have been tacking the cut edges of the platysma
back down to the hyoid bone and to the digastric muscles.
After meticulous hemostasis in the submental area, the wound
is closed with subcutaneous absorbable sutures and running
5-0 Prolene sutures.
The face is revisited, and the extra skin is trimmed under
modest tension. The subcutaneous tissues are closed with
absorbable 4-0 and 3-0 PDS sutures; 3-0 nylon half-buried
sutures were placed in the hair-bearing area, and the preau­
ricular skin was closed with 5-0 Prolene simple running sutures.
The earlobe is left mobile, without suturing to the flaps.
Postoperative Management
Ice-soaked gauze was placed on the eyes, and a firm bandage
was checked for comfort when the patient was awake and
alert. In the postoperative period, blood pressure was controlled
with clonidine, 100 to 200 mg.
After approximately 2 to 3 hours, the patient was then
transferred with a clinic nurse to a local boutique hotel close
to the outpatient facility. The patient was nursed overnight
with a private nurse and then came to the office the next day,
where she was reviewed and the bandage removed.
The patient was seen throughout the course of the next 2
weeks for suture removal, reassurance, and wound management.
Her result is seen in Fig. 13.6 at 10 days and 4 months
postoperatively.
Case Study 2
The second patient is a 49-year-old woman, GH (Figs. 13.7 and
13.8). In addition to a turkey neck, the patient had significant
laxity around the periorbital region. In this case, the patient
had upper and lower lid blepharoplasties, a brow lift, and
a face and neck lift. The result shows a soft contouring of
the entire neck, and the periorbital rejuvenation adds to the
overall satisfaction of the patient and surgeon (Fig. 13.9). The
importance of considering the balance of the whole face is
emphasized.
Potential Complications
The submental approach has been associated with a greater
incidence of hematoma by some authors.7 However, this has
not been my experience in over 500 cases.
Increased morbidity from my approach is due to the extra
dissection, cauterization, and mobilization of the muscles to
achieve an obliteration of the turkey neck. In particular, there
are numerous bleeders encountered between the platysma
muscles and lymph nodes. If lymph nodes are found to be
enlarged, they are removed.
In regard to infection, I have had one case of a very large
abscess in the submental area, which required drainage. The
patient’s skin suffered and required steroid injections to reduce
hypertrophic and subcutaneous scarring. Generally speaking,
the skin retraction is adequate but often is not as complete as
one would desire.
Palpability of the permanent, triple-cable sutures has not
been a problem because, for many years, I have used the added
the underside of the platysma and its white glistening fascia
(Video 13.1).
Three passes of a 2/0 Tevdek suture on a round-bodied
needle are carefully passed through the tunnel underneath the
platysma muscle. This triple cable is attached to Lore’s fascia
behind the angle of the mandible (Video 13.2).
Then, using a rocking technique and cinching up the neck
with the suture, the suture is tied under tension to give a tight
neck, extending from the décolletage to the base of the skull
(Video 13.3). By adjusting the tension and observing the tone
of the neck, an appropriate elevation is usually about 3 cm.
NOTE: It is important that the positioning of the suture is
behind the angle of the mandible, not across it; occasionally,
the suture has to be reinserted in a more vertical posterior
aspect. Closure of the strip excision edges of the superficial
musculoaponeurotic system (SMAS) creates a further vertical
tensioning and also covers the triple-cable Tevdek sutures.
These key maneuvers on the platysma influence the whole
neck (Fig. 13.5).
Fat trimming is then necessary around the angle of the
mandible and over the sternomastoid. Figure-of-eight, 4-0
absorbable Maxon sutures are inserted to plicate the jowl area
and extended up to the zygoma.4 Occasionally, a SMASectomy,
similar to that described by Baker, is performed.5
Submental Platysmaplasty
I have adapted the submental approach described by Fogli6,9
to prevent anterior platysmal rebanding.
A 4-cm incision is made 2 mm anterior to the submental
crease. A subcutaneous dissection proceeds down to the trachea,
passing over the hyoid bone and the thyroid cartilage
(Video 13.4).
Fat is trimmed from the anterior platysma, which exposes
the platysmal bands. A modest amount of fat is also removed
from the interplatysmal and subplatysmal areas.
FIGURE 13.1  Stigmata of the turkey neck. (Courtesy of Robin Franklin.)