Kỹ Thuật Bậc Thầy Trong Trẻ Hóa Khuôn Mặt

96
Harry Marshak • Steven C. Dresner
A
B
E
C
D
Figure 6-9 Lateral canthopexy. After the pinched skin is excised, a button-hole is made in the orbicularis muscle at the lateral aspect of the wound to
expose the lateral orbital rim (A). The retinaculum of the anterior crus of the lateral canthal tendon is identified (B and C). A 5-0 Vicryl suture (P-2 needle) is
passed through the retinaculum and the periosteum of the lateral orbital rim (D). This suture is tied temporarily while the tightness and contour of the lower
lid is examined. The extended skin incision is then closed (E).

conjunctival incision must be carried out lateral enough to
identify the lateral fat pad. After excising a moderate
amount of fat from the three pockets, the lower lid should
be examined from the skin side to ensure that there are no
bulges of fat remaining.
Damage to the inferior oblique muscle during the
dissection will generally lead to postoperative diplopia.
Mild trauma to the muscle often causes reversible
symptoms, but transection of the muscle will lead to a
permanent ocular motility disorder. The eye can sustain
injury during any eyelid procedure, but transconjunctival
surgery presents a larger risk. Trauma, including
penetration, can occur from ill-placed cautery, sutures, or
excessive pressure. Corneal abrasion can occur during any
manipulation of the eye, especially from the lid plate.
Corneal abrasions are extremely painful and can lead to
corneal ulcers. They must be treated with ophthalmic
antibiotic drops or ointment. If they persist more than
24 hours, ophthalmologic consultation is recommended.
Full-thickness globe penetration can occur from needles,
sutures, or cautery. This is a sight-threatening condition that
also requires immediate evaluation by an ophthalmologist.
The TCB must be performed in a precise manner.
Several pitfalls can occur during the surgical dissection.
An incision that is too low in the fornix will lead to poor
wound closure and scarring of the inferior cul-de-sac. If
the incision is extended too far medially and into the
caruncle, scarring can lead to entropion. A common error
involves carrying the dissection into the deep posterior
plane. A deep dissection can lead to retained anterior fat
CHAPTER 6
Transconjunctival Lower Blepharoplasty
97
A
B
Figure 6-10 Preoperative (A) and postoperative (B) views of a 58-year-old woman with dermatochalasis who underwent transconjunctival lower
blepharoplasty.
A
B
Figure 6-11 Preoperative (A) and postoperative (B) views of a 60-year-old woman with dermatochalasis and excess skin who underwent
transconjunctival and pinch lower blepharoplasty.

pockets in addition to risking trauma to the globe, inferior
oblique, and inferior rectus. Fat pads are in a sense
pyramids, and therefore, dissection and excision of fat too
close to the base of the pyramid may allow excess fat to
remain at the apex of the pyramid.
Future Considerations
The trend for conservative lower eyelid rejuvenation will
continue well into the future. TCB will continue to serve
as the workhorse of lower eyelid surgery as patients and
surgeons become more aware of poor aesthetic results
and postblepharoplasty eyelid malposition. The role of
midface rejuvenation and volume restoration will also
continue to gain acceptance as important adjunctive
procedure to enhance the overall results of lower
blepharoplasty. Noninvasive procedures may some day
replace the need for lower eyelid skin excision as newer
technologies provide safer results in all skin types.
REFERENCES
1. Katzen LB: The history of cosmetic blepharoplasty. Adv
Ophthalmic Plast Reconstr Surg 1986;5:89.
2. Bourguet J: Les hernies graisseuses de l’orbite. Notre
treitement chirugical. Bull Acad Med (Paris) 1924;92
(3 ser):1270.
3. Castanares S: Blepharoplasty for herniated intraorbital fat;
anatomical basis for a new approach. Plast Reconstr Surg
1951; 8(1):46.
4. Reidy JP: Swellings of eyelids. Br J Plast Surg 1960;13:256.
5. Edgerton MT Jr: Causes and prevention of lower lid ectropion
following blepharoplasty. Plast Reconstr Surg 1972;49(4):367.
6. Parkes M, Fein W, Brennan HG: Pinch technique for repair of
cosmetic eyelid deformities. Arch Ophthalmol 1973;
89(4):324.
7. Furnas DW: Festoons of orbicularis muscle as a cause of baggy
eyelids. Plast Reconstr Surg 1978; 61(4):540.
8. Tenzel RR: Complications of blepharoplasty. Orbital
hematoma, ectropion and scleral show. Clin Plast Surg 1981;
84(4):797–802.
9. McCord CD Jr, Shore JW: Avoidance of complications in lower
lid blepharoplasty. Ophthalmology 1983;90(9):1039.
10. Baylis HI, Long JA, Groth MJ: Transconjunctival lower eyelid
blepharoplasty. Technique and complications. Ophthalmology
1989;96(7):1027.
11. Hamra ST: Repositioning the orbicularis oculi muscle in the
composite rhytidectomy. Plast Reconstr Surg 1992; 90(1):14.
12. Zarem HA, Resnick JI.: Expanded applications for
transconjunctival lower lid blepharoplasty. Plast Reconstr Surg
1999;103(3):1041.
13. Doxanas MT: Minimally invasive lower eyelid blepharoplasty.
Ophthalmology 1994;101(8):1327.
14. Goldberg RA, Edelstein C, Balch K, et al: Fat repositioning in
lower eyelid blepharoplasty. Semin Ophthalmol
1998;13(3):103.
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Harry Marshak • Steven C. Dresner
A
B
Figure 6-12 Preoperative (A) and postoperative (B) views of a 53-year-old man with dermatochalasis, excess skin, and lower lid laxity who underwent
lateral canthopexy, transconjunctival and pinch lower blepharoplasty.

Asian blepharoplasty represents a unique topic in
aesthetic surgery. Successful surgery of the Asian upper
eyelid mandates a thorough knowledge of the divergent
anatomy, peculiar cultural predilections, aesthetic interests,
and precise operative techniques. Failure to understand
all of these important dimensions will undermine a
surgical endeavor. This chapter will help instruct novices
to experienced facial cosmetic surgeons on all of these
fundamental considerations to ensure uniform, consistent
surgeon and patient satisfaction. The discussion of operative
technique focuses on the limited, or partial-incision, as
well as the full-incision method of “double-eyelid” crease
formation that has served as the major methods on which
the authors have relied in several thousand clinical cases.
HISTORY
The first creation of a supratarsal crease can be traced
back to the late 19th century, when a Japanese surgeon
named Mikamo performed a suture-based procedure in
three reported clinical cases.1–3 Viewed within the cultural
context of the Meiji restoration, Mikamo’s seminal work
may be deemed simply as an expression of westernization
that was in vogue during that epoch of rapid assimilation
of Western ideals. However, Mikamo’s writings show that
his aesthetic references were for the most part internally
derived, that is, he claimed that 80% of the indigenous
Japanese people already had a double eyelid crease
naturally and that a single eyelid configuration imparted
a “monotonous and impassive” countenance that ran
counter to what “writers and painters have regarded as
an indicator of beauty.”2,3 He also commented on the
functional impairment that a single lid could impose by
way of “narrowed vision.”
After Mikamo, almost 30 years of silence passed before
another Japanese surgeon documented his experience
with the “double-eyelid” procedure. After World War II, a
burgeoning interest in Asian eyelid surgery arose owing to
the rise of intermarriage according to the Hawaiian surgeon
Leabert Fernandez in 1959.4 The Malayan surgeon Khoo
Boo-Chai popularized the suture technique for Asian
blepharoplasty in 1963 and claimed that the motivating
factors for surgery included the desire for socioeconomic
advancement by emulating a Western societal norm,
removing the stigma of distrustful-looking “beady” eyes,
and enhancing the prospect for marriage.5 Millard also
pioneered techniques in Asian blepharoplasty, advocating
orbital lipectomy to achieve the desired objective.6 Since
the 1980s, McCurdy has observed an undeniable trend
away from true “westernization” procedures in which high
Caucasian-looking folds and hollowed out eyelids from
overzealous lipectomy have given way toward conser-
vative, more natural-looking results that retain ethnicity.7
Asian blepharoplasty remains the most popular cosmetic
surgery for Asian patients today with a wide range of
surgical options available to attain a supratarsal fold as well
as to modulate related structures such as the epicanthus.
PERSONAL PHILOSOPHY
AESTHETICS AND CULTURAL CONSIDERATIONS
An ongoing debate that will not abate any time soon
concerns whether Asian eyelid surgery constitutes a
betrayal of native ethnicity in favor of Western ideals or
in fact represents a simple expression of Asian beauty
without external, Western references. Clearly, this chapter
does not seek to answer this very difficult question
definitively because the answer lies in subjectivity, bias,
and opinion. Nevertheless, as stated, true “westernization”
procedures that involved creation of a very high supratarsal
crease and hollowed eye appearance that closely
approximated a Western countenance have not been in
vogue for the past decade or more. Today, Asians who live
both abroad and in East Asia favor a natural-appearing
crease and eyelid shape that matches that of their native
peers and that can be found on their peers who never have
had surgery (i.e., that occurs as a natural trait). However,
the influence of Western media images and Caucasian
beauty on Asians living in the Occident or Orient alike
is undeniable. Globalization of a defined standard for
beauty has emerged in which racial boundaries have been
partly effaced by interracial marriage and increased use of
non-Caucasian models.
Understanding the cultural biases that influence a
decision for Asian eyelid surgery involves more than
Asian Blepharoplasty
Samuel M. Lam, MD • Young-Kyoon Kim, MD, PhD
99
C H A P T E R S E V E N

commentary about aesthetic ideals. Asians, particularly
those who live abroad in Asia or who have recently
emigrated to the West, often have very different, and what
may be construed as peculiar, attitudes and motivating
factors for cosmetic surgery that a Western surgeon
should consider during the consultation process. For
instance, beyond aesthetic interests, an Asian patient may
be seeking a change in his or her fortune, as dictated by
cultural folklore. A higher nose bridge, wider eyes, and
longer ear lobes are all associated with bringing a person
good luck and fortune. If the patient desires a cosmetic
procedure to ward off evil spirits and gain fortune, the
surgeon should be wary about pursuing surgery for the
obvious reason that the patient may be quite unsatisfied
afterward if the expected newfound luck does not
materialize.
Further, in the postoperative setting, Asian patients
can be highly critical of their cosmetic results and may be
susceptible to judgmental and negative commentary of
their family and friends regarding their decision to have
cosmetic surgery or the outcome. A supportive and
nurturing approach to the patient will help the surgeon to
satisfy and to cope with the demanding nature of many
Asian patients. Different ethnicities also tend to react
differently postoperatively, with Koreans who fall on one
extreme in their potential for vociferous and repeated
chimes of dissatisfaction compared to the reticent
Japanese who remain silent about what may trouble them
and instead decide to voice their discontent to another
surgical colleague. These broad generalizations are not
intended to denigrate any particular ethnicity but to
provide the Western surgeon unaccustomed to the
behavior and biases of Asian patients a framework with
which to address the patient in a constructive manner.7
TECHNIQUES FOR UPPER BLEPHAROPLASTY IN
ASIANS
Many surgical techniques exist for management of the
Asian upper eyelid, but for sake of academic clarity, they
can be classified into three main headings: full-incision,8
partial-incision,9 and suture-based methods.10 The vari-
ations and modifications of techniques for Asian blepharo-
plasty closely approximate the number of practitioners of
the art, as every surgeon performs a slightly different
technique based on experience and preference. Never-
theless, this proposed classification scheme provides an
insightful method to view the unique advantages and
disadvantages of each type of surgery so that the thoughtful
surgeon can find his or her own chosen method or choose
the right method for a particular patient.
The full-incision method provides the surgeon with
the ability to remove redundant skin and excess muscle as
well as fine tune the shape of the eyelid crease. Continuing
the full incision into the epicanthal region (or making a
separate incision in the epicanthus) permits modulation of
the epicanthus as part of the surgery. However, the full-
incision method is more labor intensive and may require
longer operative time. In addition, the chance for
scarring, especially medially near the epicanthus where
there is a biologic propensity toward cicatrix formation, is
increased. The recovery period during which time the
height and fullness of the created crease appears
unnatural is also the longest of all three major methods
and can last from several months to a full year. Revision
surgery can be the most demanding, as exploration and
correction at the level of the levator requires extreme care
and attention to prevent complication arising from
inadvertent levator injury. Despite these limitations, the
full-incision method remains the most ideal for the more
mature Asian patient who has concomitant derma-
tochalasis and who wants a double-eyelid created.
The suture-based method offers the benefits of quick
operative as well as recovery time. The patient will most
likely have a natural-looking lid-crease height in a matter
of days to weeks instead of months. Also, the surgeon does
not truly need to understand the intricacies of surgical
anatomy, as the suture is simply passed through from skin
to conjunctiva and back again. However, the suture
method also does not permit any removal of fat, which
can be problematic for two reasons. The fullness of the
upper eyelid is not truly addressed, and the adipose tissue
that becomes sandwiched between the levator and skin
may serve as a barrier for permanent adhesion that would
lead to early fold loss.11 Owing to these limitations, the
authors rarely rely on suture-based surgery, especially in
the older patient who may require some skin removal
along with double-eyelid creation.
The partial-incision method offers a balance between
the full-incision and suture-based methods. Through a
limited, 1.5-cm incision, the only adipose compartment
that contributes significantly to eyelid fullness can be
easily reduced and a significant levator-skin adhesion
established. The shorter incision minimizes the risk of
epicanthal webbing or scarring that may arise with the
full-incision method. Further, the recovery time falls
somewhat in between that of the suture-based and the
full-incision methods: approximately 3 to 4 months until
the lid-crease height should appear completely natural in
most cases. The fact that no skin is removed also permits
the overlying skin to redrape over the incision, thereby
camouflaging it during the healing process. The authors
argue that no skin needs to be removed (in the younger
age group), as the aesthetic deficit of the creaseless Asian
eyelid concerns the relatively low position of the central
adipose tissue and the lack of a supratarsal crease, both
conditions of which are addressed with the partial-
incision method. Revision surgery for the patient with a
partial incision is also considerably easier than with the
full incision. However, the more abbreviated incision may
be associated with a greater chance of eventual fold loss
than the full-incision method; but measures can be taken
100
Samuel M. Lam • Young-Kyoon Kim

to minimize this chance, as will be explained in the
forthcoming section on surgical technique. The authors
reserve the full-incision method for those individuals over
40 years of age whose dermatochalasis would justify some
concomitant skin removal. If epicanthal advancement is
favored, a separate, limited incision can also be made
medially to address this area with the flexibility of
undertaking the epicanthoplasty at the same setting as
double-eyelid creation or at an earlier or later date given
the fact that the two incisions remain separate and distinct.
TECHNIQUES FOR LOWER BLEPHAROPLASTY IN
ASIANS
Blepharoplasty of the lower eyelid differs little from that
of the Caucasian: a transcutaneous or transconjunctival
approach may be used with good success. Accordingly, a
detailed step-by-step description of lower-lid blepharo-
plasty will not be described in this chapter. A trans-
conjunctival approach may be preferable in the Asian
patient for several reasons. Lower-eyelid dermatochalasis
is much less prevalent in the Asian patient; therefore, skin
removal is often unnecessary. Even if removal of skin
redundancy is required, a skin pinch technique can be
safely combined with the transconjunctival method. Also,
the predilection of the Asian skin toward hypertrophic
scarring and prolonged erythema may make a
transconjunctival approach better suited. Experience and
judgment will be important when deciding which method
to use. Lower-eyelid rhytidosis would typically be easily
treated in the fairer skin of Caucasians with 35%
trichloroacetic acid peel or ablative laser rejuvenation but
should be cautiously approached in Asians owing to the
risk of a protracted healing phase, including hyperpig-
mentation, hypopigmentation, prolonged erythema, and
scarring.
SUMMARY OF APPROACH: EVALUATION OF THE
YOUNGER VERSUS THE OLDER ASIAN PATIENT
For Asian upper blepharoplasty, the younger patient may
be easily addressed with the partial-incision method. This
relatively quick and straightforward method permits the
surgeon to address the aesthetic concerns of the majority
of younger patients. As the preponderance of double-
eyelid blepharoplasty procedures are performed in the
younger age group (teenage years through the 30s), the
partial-incision technique has remained the principal
method for Asian upper blepharoplasty in the authors’
practices.
Conversely, older patients (late 30s and beyond) may
have either already had a double eyelid created in the past
or do not desire this alteration in their appearance. For
older patients who request formation of a supratarsal
crease, the surgeon must exercise judgment as to which
method may be the most suitable for the patient. For early
brow descent/dermatochalasis, the partial incision may
still be used but with the incision placed slightly higher to
accommodate for the skin redundancy that will fall over
the incision. Because patients beyond the teenage years
and early 20s may not tolerate the lengthy time that the
full-incision method will render their appearance
unnatural, the partial-incision method may be favored for
the shorter healing time.
For the more mature patient with greater brow
descent/dermatochalasis, the full-incision method is
preferred so that skin redundancy can be addressed at the
same time. Preferably, a browlift should be performed
first at a minimum of 6 weeks antecedent to the double-
lid blepharoplasty, as almost every mature patient has
some degree of brow descent that would warrant
correction. However, many Asian patients may resist
undergoing a staged procedure because of the lengthened
recovery time, associated cost, and possible unfamiliarity
with browlifting. If a browlift is declined, the surgeon
should be careful not to remove so much upper-lid skin,
as to exacerbate brow ptosis or prevent a future browlift.
If an older patient requests upper facial rejuvenation and
would like to retain a single-eyelid configuration, the
surgeon can remove upper-eyelid skin by measuring an
arbitrary height (e.g., 5 to 7 mm above the ciliary margin)
on both upper eyelids using Castroviejo calipers. During
the blepharoplasty, the surgeon should avoid entry into
the postseptal fat in the central compartment, as fixation
of the skin to the underlying structures arising from
surgical dissection may result in unwanted crease
formation. Medial fat removal alone, however, rarely
leads to any measurable degree of crease fixation.
ANATOMY
The Asian upper eyelid has been characterized and
caricatured as uniquely different from that of other races,
specifically in the fullness of the lid appearance, absence
of a discernible supratarsal crease, a narrowed palpebral
fissure, webbing or downturn of a skinfold medially
(known as the epicanthus), and superior obliquity of the
eye at the lateral canthus. These characteristics are present
to a large extent in the Asian races, but by no means
should these anatomic traits be considered monolithically
universal in scope. Subtle and distinct variations exist
among the ethnic races (Koreans, Japanese, Chinese, etc.)
and differ markedly even within a particular ethnicity.
For instance, there is a higher observed frequency of a
single eyelid configuration in the Korean race, whereas
70% of southern Chinese possess a well-delineated
supratarsal fold. Overall, approximately 50% of East
Asians have a single, noncreased eyelid.12
The classification of the Asian upper eyelid into
creased and creaseless is not entirely accurate. In fact,
three morphologies of the Asian upper eyelid are present:
CHAPTER 7
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101

a defined supratarsal crease, a low eyelid fold, and a
complete absence of any fold (Figs. 7-1 and 7-2).13 The
type of eyelid crease is determined by the height at which
the levator aponeurosis inserts into the dermis. Many
investigative techniques—including magnetic resonance
imaging (MRI), scanning electron micrography, cadaveric
histologic analysis, and intraoperative surgical evaluation—
have explored the anatomic nature of levator insertion in
the Occidental versus the Oriental eyelid.14-16 The levator
has been found to insert into the dermis at variable
distances above the ciliary margin (or not at all) in the
Asian but overall at a lower height than in the Caucasian
(Fig. 7-3). It has also been reported that the levator
aponeurosis itself does not insert into the dermis, but
instead fine fibrous septae that extend from the tarsus
toward the dermis account for the formation of the
palpebral fold.
The puffiness of the Asian upper eyelid has been
attributed to an excess of preaponeurotic adipose tissue in
the single-eyelid configuration. Alternatively, it has been
proposed that the patient with a low or absent levator-to-
skin insertion also has a relatively low fusion of the orbital
septum with the levator aponeurosis (the so-called septo-
aponeurotic sling), allowing the fat to descend further
downward and thereby yield a fuller eyelid appearance.
Therefore, the Asian may in fact have the same amount of
preaponeurotic adipose tissue but exhibit greater fullness
only because of the relative lower descent of fat. Because
Asians tend to have lower eyelid creases than their
Western counterparts, even individuals with well-defined
creases still may have some greater degree of fullness
relative to Caucasians. Accordingly, this feature should
be surgically preserved, as a hollowed eyelid looks
particularly unnatural on an Asian compared with on a
Caucasian. The unrestricted descent of preaponeurotic fat
over the pretarsal region also contributes to a narrower
palpebral fissure, which may yield a ptotic appearance of
the upper eyelid (known as pseudoptosis orientalis).
The epicanthal fold that is present in 40% to 90% of
Asians may further narrow the palpebral aperture. The
epicanthal fold of skin curves downward along the medial
extent of the eyelid and can partially or completely
obscure the caruncle, or lacrimal lake. This anatomic
feature has been attributed to the vertical shortage and
102
Samuel M. Lam • Young-Kyoon Kim
Figure 7-1 This 23-year-old Chinese woman exhibits a rudimentary
supratarsal fold on her left side and an absence of a fold on her right side
(A). As evident, her right eyelid is fuller and lower than the left, because the
small, rudimentary left crease has retained her postseptal orbital fat in a
relatively higher position on the left side. A partial-incision technique was
performed at 8 mm above the ciliary margin to impart a more symmetrical
and defined supratarsal crease bilaterally (B).
Figure 7-2 This 32-year-old Vietnamese woman exhibits a well-
defined, but relatively low, supratarsal crease naturally. She did not have
eyelid surgery.
A
B

horizontal redundancy of the skin–orbicularis oculi complex
at the medial canthus. A broad and heavy epicanthal fold
may render the eye smaller and the nose broader and
flatter in appearance. Therefore, many surgical tech-
niques have been introduced to alter the epicanthus. The
position of the lateral canthus in the Asian has also been
recognized to differ from that in the Caucasian in its rela-
tive superior location vis-à-vis that of the medial canthus,
thus contributing to the observed “slant” of the eye.17
Surgical alteration of this area is fraught with difficulty,
including scarring, an unnatural appearance, and limited
aesthetic improvement.
Although the focus of this chapter is almost entirely
on the anatomy and surgery of the Asian upper eyelid, a
few salient differences in the lower eyelid of the Asian
patient should be mentioned for completeness. One
cadaveric study found limited to no adhesion of the
orbital septum and capsulopalpebral fascia at the lower
border of the tarsal plate.18 In a correlative study using
MRI, the orbital fat in the Asian lower eyelid was found to
extend further anteriorly with respect to the orbital rim.19
Second, the orbital fat tended to extend more superiorly
to the inferior border of the tarsus in those Asians who
did not have a well-defined upper-eyelid crease. The
suborbicularis oculi fat (SOOF), however, was found to be
similar in both Asians and Caucasians.
Besides eyelid anatomy, the brow constitutes a central
component for upper facial rejuvenation in the Asian
CHAPTER 7
Asian Blepharoplasty
103
patient. Brow anatomy in the Asian differs little from that
of the Caucasian. Generally, Asians tend to exhibit a
similar extent of brow descent as Caucasians and benefit
significantly from brow rejuvenation. Conversely, Asians
typically do not exhibit the same degree of lower facial
aging as Caucasians and may not require any lower facial
lifting procedure until they pass 60 years of age or older.
Browlift techniques for the Asian patient are the same as
for the Caucasian and lie beyond the scope of this chapter.
PREOPERATIVE ASSESSMENT
THE CONSULTATION
Before embarking on a careful physical examination, the
surgeon should open the consultation session with a
general inquiry as to the patient’s motivations, aesthetic
desires, fears, and other concerns. The salient points
regarding aesthetic and cultural opinions reviewed
previously should be kept in mind during the process.
Patients often bring in photographs of professional
models to help educate the surgeon as to precisely how
they would want to look. Although these photographs can
be instructive, they also can be deceptive, especially if the
patient is striving to look like the model rather than have
only the model’s specific eye shape. One author (SML)
shows his patients selected model photographs with very
Fat
Septum
Orbicularis m.
Levator aponeurosis
Tarsus
Fat
Septum
Orbicularis m.
Levator aponeurosis
Tarsus
A
B
Figure 7-3 The levator inserts into the dermis, which accounts for the presence of a supratarsal fold in the Caucasian as well as some Asians (A). The
levator does not insert into the dermis, which accounts for both the creaseless nature of the Asian eyelid as well as the puffiness due to the descent of orbital
fat more inferiorly than in the Western eyelid (B).

different facial features but with the same type of lid-
crease shape to help the patient understand the influence
that surrounding facial features can have on the aesthetic
judgment of the viewer regarding eye shape.
Perhaps the single most important factor in pre-
operative planning involves achieving a mutual under-
standing of desired lid-crease height. The easiest
classification scheme would be to offer the patient a low
(3 to 4 mm), medium (5 to 6 mm), or high crease (8 mm
or higher). The majority of patients today desire a low
crease height with a minority that express interest in a
medium crease and very few who desire a high
“westernized” crease. To provide the patient with a clear
understanding of a desired lid-crease height, several
methods can be used. As mentioned, photographs of
models can enhance dialogue with the stated caveats
recalled. Before-and-after photographs that represent
different lid-crease heights can be used for effective
communication and to provide concrete evidence of the
surgeon’s skills. Finally, placement of an open and
rounded paper clip, or similar device, pressed into the
patient’s eyelid to simulate a created lid crease can show
the patient in the mirror how a crease would look on his
or her face. The patient should always be reminded that
use of a paper clip never looks very natural and that the
device serves only as an aesthetic guideline for the patient.
EYELID AND FACIAL AESTHETICS
After the patient and surgeon have established a
preliminary dialogue about what concerns and desires the
patient may have regarding the procedure, the surgeon
can evaluate the precise dimensions of the patient’s anatomy
to determine what eyelid procedure(s) (e.g., partial- versus
full-incision, epicanthoplasty, lateral canthoplasty) and
related facial procedures (e.g., browlifting, lower-eyelid
blepharoplasty, augmentation rhinoplasty) could enhance
the result.
The fullness of the patient’s eyelid due to adipose
tissue should be carefully assessed. The main reason for
preoperative analysis of the adipose fullness is to help
guide the surgeon’s decision concerning how high to place
the incision. A patient with significant adipose tissue
would require greater removal of fat, which would in turn
allow the deflated skin postoperatively to redrape over the
incision, as no skin is removed with the limited-incision
technique, making the ultimate incision height slightly
lower than perhaps originally conceived. Accordingly, the
incision may be placed slightly higher (1 to 2 mm) to
accommodate the greater skin redrapage that would lower
the final postoperative height of the crease. Korean patients
tend to exhibit a greater amount of overall adipose
compared with other ethnic groups, such as Chinese or
Vietnamese.
The greater amount of skin dermatochalasis and
brow descent due to aging can make the partial-incision
technique less than ideal. The partial-incision method is
particularly well suited for younger patients without
evidence of eyelid aging for all the previously enumerated
benefits. As mentioned, the full-incision method may be
preferable for a more mature patient with evidence of
periocular aging to address the dermatochalasis that may
be present. However, the surgeon can still offer the patient
the partial-incision method in cases of early derma-
tochalasis by making the planned incision height again
slightly higher to accommodate the excess skin that will
redrape over the incision. Ideally, the aging eyelid/brow
complex should be addressed in a staged fashion, with
browlifting performed first to restore brow height
followed by a partial- to full-incision eyelid rejuvenation
at a minimum of 6 to 8 weeks after the procedure. The
edema and sedation required for a browlift make
concurrent double-eyelid blepharoplasty precarious, as
the risk of asymmetry is amplified. Convincing Asian
patients, especially those who live abroad in Asia or who
have recently emigrated to the West, that a staged
procedure would be the better solution is often difficult
owing to the popularity of double-eyelid surgery alone
without browlifting performed in Asia, lack of under-
standing of the benefits of a combined procedure, and
cost and time considerations. Based on the patient’s
anatomic findings and surgeon preference and judgment,
the proper eyelid and browlift techniques can be
determined. Clearly, in the aging Asian eyelid, the etiology
of tissue ptosis must be well delineated—pseudoptosis
orientalis (due to adipose fullness and a lack of a supratarsal
crease), blepharoptosis (due to levator dysfunction that
can often arise with age), and brow ptosis—to determine
the best procedure(s) for the patient.
Epicanthal shape and extent should also be con-
sidered in eyelid and facial analysis. A broad epicanthal
web can render the overall eye aperture smaller in
appearance and lead to an unbalanced appearance to the
eye shape if a double-eyelid procedure is done in isolation,
for the increased palpebral aperture that results from a
double-eyelid procedure done without epicanthal
modulation may render the eye shape overly vertical in
dimension and the eye width appear narrower in a
relative fashion. Epicanthal advancement can balance the
shape and contour of the eyelid in such patients. Because
the authors prefer a limited-incision epicanthoplasty, the
epicanthal portion of a procedure can be done concur-
rently or at a different time from double-eyelid formation.
This flexibility permits patients the luxury of choosing to
undergo a combined epicanthal advancement and double-
eyelid creation or do so during separate sessions. Also, a
strong epicanthal fold can make the eye shape appear too
narrow when judged by ideal facial proportions: the eye
width should be approximately one fifth the total
horizontal distance of the face from ear to ear, or more
simply, it should match the intercanthal distance. At
times, to achieve this desired objective, not only must the
104
Samuel M. Lam • Young-Kyoon Kim

epicanthal skin be advanced but the medial canthal
ligament may require shortening as well. A broad
epicanthal fold can also accentuate a very flat nasal
dorsum. Concomitant augmentation rhinoplasty can help
restore balance to the eye and nose region with or without
epicanthoplasty. As mentioned before, lateral canthoplasty
provides limited perceived aesthetic benefit and should
only be considered when combined with an epicanthoplasty
to attain sufficient opening of the eye aperture in a
horizontal dimension.
SURGICAL TECHNIQUE
THE PARTIAL-INCISION METHOD
General Considerations
The first step in surgery is confirmation of the appropriate
lid-crease height, especially if some time has elapsed
between the initial consultation and procedure. In most
circumstances, a crease measured at 8 mm above the
ciliary margin will yield a low to medium crease, whereas
a l0-mm marking will produce a medium to high crease.
Some variability obviously exists, depending on the amount
of adipose tissue the patient has—with a greater amount
of adipose removal leading to a lower resulting crease—
and the amount of extra skin redundancy, which is
principally a factor of age, a greater amount of extra skin
leading to a lower resulting crease as well. The patient
should have the marking performed precisely with
Castroviejo calipers and with the eyelid skin stretched
taut until incipient eyelash eversion is noted. Generally
speaking, a measured crease marking will result in a final
crease-fold height of about half of the measured distance;
thus, a crease marked at 8 mm will give the patient
approximately a 4-mm crease height after all edema has
resolved (typically 3 months postoperatively). The patient
should clearly understand that the exact lid-crease height
cannot be determined with absolute precision given the
preceding inconsistent anatomic factors, such as the
amount of lid skin redundancy and degree of adipose
tissue. Of note, the patient should be shown the proposed
marking in the seated position using the previously
described paper clip, as the skin that folds back over will
only do so in the upright posture and not while supine
(Fig. 7-4). Also as an aside, the older patient (late 30s and
beyond) who exhibits greater skin redundancy should
either have a full-incision performed or have the lid crease
marking raised to 10 to 12 mm in order to yield a lower
final crease height, depending on the degree of brow
ptosis and dermatochalasis present.
During the procedure, the patient should have
minimal to no sedation because the patient’s cooperation
with eye opening and closing is a vital component to the
success of the operation. The authors prefer no sedation
for any phase of the procedure to ensure optimal patient
compliance. Because the infiltration of anesthesia is quite
limited with the partial-incision method, patient dis-
comfort is similarly kept to an acceptable minimum, as
compared with the full-incision technique.
Operative Technique
After the patient has corroborated the proposed lid-crease
height, the surgeon may begin the marking and execution
phase of the procedure. The patient is placed in the supine
position, and the surgeon is seated above the patient’s
head in the midline looking downward for the entire
duration of the procedure. The Castroviejo calipers, or a
similar measuring device, are used to mark the crease
height at the midpupil on each side while the patient’s
skin is stretched until incipient eyelash eversion (Fig.
7-5). A very fine-tipped, gentian violet surgical marking
pen or, alternatively, a fine toothpick dipped in gentian
violet should be used for all lid markings. A standard
gentian violet marking pen has too broad a nib that
leads to imprecision in crease marking and thereby
commensurate imprecision when making the incision.
CHAPTER 7
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105
Figure 7-4 The patient shows the characteristic upper eyelid fullness
and narrow palpebral aperture on the right side, and the proposed crease
formation is shown by using a paper clip pressed into the left upper eyelid
as an instructive tool. Given the patient’s relatively young age, a partial-
incision method has been selected for eyelid crease creation.

The proposed marking is extended for a total length
of 1.5 cm on each eyelid with the medial extent starting
approximately at the medial limbus (Figs. 7-5 and 7-6).
The Castroviejo calipers should be used to confirm
symmetry in three respects: (1) uniform height of the lid
crease from the ciliary margin along the entire length, (2)
same length of incision (1.5 cm) for both eyelids, and (3)
same distance from the medial canthus to the medial
limbus, the latter of which again represents the medial
extent of the incision line.
When both markings are deemed acceptable (Fig.
7-7), the surgeon may proceed with the infiltration
of local anesthesia; 2% lidocaine mixed with 1:50,000
epinephrine is preferred, and a 1-mL syringe outfitted
with a 30-gauge needle is used for delivery. The needle is
carefully placed in the midline of each marking and
precisely 0.3 mL of anesthetic is delivered to each eyelid:
the needle is not threaded under the skin but held
stationary in the midline, and the anesthetic is slowly
infiltrated subcutaneously as a wheal (Fig. 7-8). This
method minimizes patient discomfort and the risk of
hematoma and ecchymosis. The eyelid skin is then gently
pinched and rolled between the index and thumb above
and below the proposed incision in order to ensure
uniform distribution of the anesthetic across the entire
length of the incision (Fig. 7-9). After several minutes, the
30-gauge needle can be used to test for adequate
anesthesia across the entire length of each proposed
incision. If any additional anesthetic is required, the same
amount and location of injection should be performed on
both eyelids in order to maintain the ability to estimate
106
Samuel M. Lam • Young-Kyoon Kim
Figure 7-5 The nondominant hand stretches the upper eyelid skin until
the eyelashes evert to a perpendicular orientation to the skin. A gentian
violet marking pen is then used to indicate a point at this height at the
midpupil.
Figure 7-6 This schematic illustration shows the recommended length
(1.5 cm) and location (starting at the medial limbus medially and extending
laterally from there) of the incision used for the partial-incision method.
1.5 cm
8 –10 mm
Equidistant
with contralateral
side
Incision commences
along medial limbus
A
B
Figure 7-7 These photographs show symmetrical markings completed
that conform to the specifications outlined in Figure 7-6 with the skin
unstretched (A) and stretched (B).

crease symmetry between the two sides: an excessive
amount of anesthetic placed on one side will lead to a
falsely higher appearance of that lid crease, which will in
turn impair the surgeon’s ability to judge symmetry.
Povidone-iodine solution is applied topically across
both upper eyelids to encompass the forehead and the
midface/cheek region, with care taken not to use an
excessive amount that would contact the globe and
engender conjunctival irritation. The remainder of the
face is then covered with sterile drapes following standard
operative protocol.
After 10 minutes are allowed to transpire since injection
of the anesthetic, the skin incision can be undertaken
using a Bard-Parker No.15 blade (Fig. 7-10). Surgery
progresses in a symmetrical fashion with incision of each
eyelid performed and each step undertaken in tandem, as
will be explained. When making each incision, care
should be taken to ensure that the marked line is followed
precisely in terms of length and height so as to ensure
symmetry, which can be facilitated with the upper-eyelid
skin placed under tension using the nondominant hand or
with the aid of the surgical assistant during the incision.
Both incisions should be carried out through the
dermis and muscle. Fine bipolar forceps, needle-point
cautery, or customized fine-tip forceps (designed by YKK)
to which monopolar cautery is applied can be used to
achieve hemostasis before continuing (Fig. 7-11).
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Asian Blepharoplasty
107
Figure 7-9 After the local anesthesia is infiltrated, the anesthetic is
evenly distributed across the entire incision by gently pinching and rolling
the incision between the index finger and thumb.
Figure 7-8 Local anesthesia consisting of 2% lidocaine with 1:50,000
epinephrine is infiltrated with a 30-gauge needle and a 1-mL syringe for a
total of precisely 0.3 mL by placing the needle in the midline of the incision
and raising a wheal.
Figure 7-10 The skin and muscle are incised with a No.15 blade.
Figure 7-11 As the orbicularis is transected, the orbital septum will
become exposed, and additional hemostasis is required before continuing.

The orbicularis oculi is then gently transected on each
eyelid with the No.15 blade, and additional cautery is
used to attain adequate hemostasis. (The reader is
reminded again that both eyelids are operated on in an
alternating fashion.)
At this point the orbital septum is encountered; the
surgeon should then excise a small wedge of orbital
septum laterally to expose the underlying preaponeurotic
adipose pocket (Fig. 7-12). Of note, the orbital septum
should also be excised as superiorly along the wound edge
as possible to avoid injury to the underlying levator and
to approach the fat pad more directly. If the adipose tissue
does not become immediately apparent, gentle downward
pressure on the globe can be applied above and below the
wound edges to compel the adipose tissue to herniate
through the fenestrated orbital septum. If the adipose
tissue is still restricted from full view, then an additional
amount of orbital septum may need to be removed. Gentle
pressure can again be applied to expose the underlying fat
pad. When the fat pad becomes visible through the defect,
a pair of forceps can be used to tease the remaining fat out
through the fenestration (Fig. 7-13).
A fine pair of straight scissors is then passed with the
tines closed through the surgical fenestration from lateral
to medial to ensure that there is unrestricted passage of
the scissors between the orbital septum above and the
adipose tissue below (Fig. 7-14). Then, the remaining
orbital septum can be safely transected laterally to
medially to permit the remaining adipose tissue to be
exposed along the entire incision length (Fig. 7-15).
A cotton-tipped applicator should be used to sweep
the adipose tissue away from the underlying levator
complex until the glistening white levator aponeurosis is
fully in view. At times a thin, filmy layer may remain
between the adipose tissue and the true levator, and this
attenuated layer must be transected to provide complete
and unrestricted access to the levator (Fig. 7-16). If the
surgeon is uncertain as to which layer he or she has
arrived at, the surgeon should grasp that layer with
forceps and ask the patient to open his or her eyes. If the
patient cannot open his or her eyes, then the surgeon most
likely has grasped the levator and has therefore arrived at
the correct depth. Judicious and careful dissection will
limit the risk of inadvertent levator injury.
With the adipose tissue and the levator in view, the
surgeon should progress to the contralateral side until
both structures are similarly exposed. A symmetrical
amount (0.1 to 0.2 mL) of 2% plain lidocaine should be
108
Samuel M. Lam • Young-Kyoon Kim
Figure 7-13 When the orbital fat becomes visible, a pair of forceps is
used to tease the fat through the orbital-septal fenestration.
Figure 7-12 Fine scissors should be used to excise a wedge of orbital
septum laterally and superiorly along the wound to expose the underlying
orbital fat.
Figure 7-14 The scissors are then passed with tines closed under the
remaining orbital septum to ensure that there is a clear plane between the
orbital fat and the levator aponeurosis so that inadvertent transection of the
levator does not occur. The photograph shows the overlying orbital fat and
the glistening white levator below with scissor tips entering immediately
below the remaining, untransected orbital septum.

infiltrated into each fat pad before resection in order to
enhance patient comfort (Fig. 7-17). The surgeon should
be careful not to allow any of the lidocaine to trickle onto
the underlying levator, which can in turn become anes-
thetized and not function properly, albeit temporarily.
With a temporarily paralyzed levator, determination of
symmetry can be quite problematic, and the levator may
remain dysfunctional for several weeks postoperatively.
After adequate infiltration of anesthesia directly into
the fat pads, the adipose tissue on one side should be
clamped with a fine mosquito clamp so that 1 cm of
adipose tissue remains under the clamp (Fig. 7-18). The
overlying adipose tissue is then removed sharply with
scissors (Fig. 7-19), leaving a small cuff of adipose tissue
above the clamp to be cauterized (Fig. 7-20). The clamp
is removed, and the remaining adipose tissue is carefully
observed for hemostasis. The same technique for adipose
resection is then undertaken on the contralateral side. Of
note, a symmetrical amount of fat should be retained in
situ, whereas it is inconsequential if an asymmetrical
amount is removed.
A single levator-to-skin fixation suture is then placed
in the central aspect of the incision using a 7-0 nylon (or
8-0 Dexon) in a buried fashion. At first, the needle should
pass superiorly to inferiorly (i.e., backhanded) through
the inferior wound edge, capturing a full thickness of
dermis along with 0.2 to 0.3 mm of the epidermal edge.
The surgeon’s nondominant index finger should be used
to roll out, or evert, the wound edge so that the full
thickness of dermis and a small amount of epidermis can
be more easily and accurately captured: Purchase of a
small bite of epidermis is a critical component to ensure
CHAPTER 7
Asian Blepharoplasty
109
Figure 7-16 Some remaining fibers must be transected in order to
attain unrestricted access to the levator aponeurosis.
Figure 7-15 The remaining orbital septum can be safely transected
laterally to medially to permit the remaining adipose tissue to be exposed
along the entire incision length.
Figure 7-17 After the same technique has been used to expose the
contralateral fat pad, both fat pads are anesthetized with 2% plain lidocaine
(approximately 0.1 to 0.2 mL).
Figure 7-18 The adipose tissue is clamped to permit 1 cm of adipose
tissue to remain in situ under the clamp.

that a foreign-body reaction occurs and a more
permanent lid crease is attained (Fig. 7-21). A second
bite is then taken superiorly to inferiorly through the
portion of levator that lies superiorly above the initial
dermoepidermal bite (Fig. 7-22). The knot is then tied
down once (Fig. 7-23A); and the patient is asked to open
his or her eyes to ensure that the crease height appears
adequate and the eyelashes begin to evert (i.e., the
eyelashes should be oriented perpendicular, or 90 degrees,
to the skin surface) (Fig. 7-23B). Conversely, overly or
underly everted eyelashes will compromise the surgical
outcome. If the foregoing criteria are met, then the suture
is tied down with a total of four square knots, and both
suture ends are cut with a long tail.
A central fixation suture is then placed in the exact
same manner for the other eyelid. If both eyelid creases
appear to be symmetrical (Fig. 7-24), then the long
suture tails can be trimmed down to the knot to leave no
discernible suture tail. Needle holders that have built-in
scissors to allow expeditious and precise trimming of the
suture tails. As these sutures remain permanently, it is
important that an excessive number of knot throws or
long suture tails not be present that would predispose
toward suture extrusion over time. If the crease heights do
not appear symmetrical, the surgeon should press gently
inferiorly on the brow to ensure that the skin above the
created creases fold adequately over the crease. If the
result still appears asymmetrical, the lower crease can be
raised by placing the central suture more superiorly along
the levator, or the side with too high a crease, conversely,
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Samuel M. Lam • Young-Kyoon Kim
Figure 7-19 The overlying, excess adipose tissue is then sharply
removed with scissors.
Figure 7-20 Cautery is applied to the clamp before freeing the fat from
the clamp.
Figure 7-21 A single 7-0 nylon suture is passed through the middle of
the incision to capture the full thickness of the dermis by everting the
wound edge with the nondominant index finger (A). In addition, the suture
must also capture 0.2 to 0.3 mm of epidermis as well (B). Capturing a small
amount of epidermis will help engender a foreign-body reaction and
thereby lead to a more tenacious adhesion, which is critical when
performing fixation through a limited incision.
A
B

lowered by placing the suture more inferiorly along the
levator.
After the first levator-to-skin fixation suture has been
successfully placed on each side, the remaining fixation
sutures can be easily undertaken. The presence of the first
fixation suture creates a fanning gullwing-shaped fold in
the levator that permits easy placement of the remaining
levator sutures through this fold (Fig. 7-25). If the fold is
not visible, then an adequate levator-to-skin fixation most
likely has not been established, and the first fixation
suture should be redone. The manner in which the
remaining sutures are placed follows the same method
described for the first fixation suture (Figs. 7-26 and
7-27). Each fixation suture should be placed in an
alternating fashion between eyelids, and crease height,
confirmed by having the patient open his or her eyes after
each fixation suture is placed. A total of approximately
five to seven sutures should be placed along the entire
length of each incision. It is important not to be tempted
to place fewer than this recommended number of sutures,
as with fewer sutures, the risk of crease loss over time is
amplified.
After all the fixation sutures have been secured, the
skin is then closed with three interrupted 7-0 nylon
sutures distributed evenly across the wound length and
positioned between the fixation sutures (Fig. 7-28).
If asymmetry is noted after skin closure, the levator
can be found between the skin sutures and additional
CHAPTER 7
Asian Blepharoplasty
111
Figure 7-22 The second bite is taken superiorly to inferiorly through
the mid-height of the exposed levator directly superior to the skin bite
described in Figure 7-21.
A
Figure 7-24 The same central suture is placed on the contralateral side,
and symmetry is inspected.
Figure 7-23 The suture is then tied down with a single knot (A). The patient is asked to open his or her eyes to determine proper crease height and the
perpendicular orientation of the eyelashes (B). If the eyelashes appear overly or underly everted, the suture position of the levator bite should be lowered
or raised, respectively.
B

fixation sutures can be placed to adjust the lid-crease
height: if the surgeon would like to raise a low crease, the
surgeon can place new fixation sutures between the upper
wound edge and the levator until the height of the crease
approximates the contralateral side. However, if excessive
eyelash eversion arises, then the incision should be opened
and the levator-skin fixation sutures replaced.
At the close of the procedure, the patient’s face is then
cleaned with hydrogen peroxide solution, and the
incisions are dressed with Bacitracin ointment. The
patient confirms the symmetry of the lid creases in the
mirror before ice packs are placed over both eyes to
minimize postoperative edema.
THE FULL-INCISION METHOD
General Considerations
The full-incision method that will be described herein
follows the principles of levator fixation enumerated in
the partial-incision section, including fixation of only the
central 15 to 20 mm, as in the partial-incision method.
As with the partial-incision method, marking the
appropriate crease height for the patient is an important
first step. With the patient sitting upright, the surgeon
places a paper clip, or similar device, into the fold to
create a natural-appearing crease that appears acceptable
to the patient and surgeon alike (Fig. 7-29). The patient
112
Samuel M. Lam • Young-Kyoon Kim
A
B
Gullwing shape
A
B
Figure 7-25 A properly placed first levator–skin fixation suture will create a gullwing crease configuration in the levator aponeurosis that will guide the
remaining fixation sutures (A). This schematic illustration shows the gullwing shape that the levator should assume after the first fixation suture is placed (B).
Figure 7-27 The second bite of the next fixation suture should then
pass through the gullwing fold in the levator, as diagrammed in Figure
7-25B. A total of five to seven fixation sutures should be placed on each
eyelid in an alternating fashion between each side, so the surgeon can verify
symmetry with each suture.
Figure 7-26 The next fixation suture should be placed through the skin
for the first bite exactly in the same manner prescribed for the first fixation
suture, as described in Figure 7-21.

is then asked to close the eyes with the paper clip left in
place, and a surgical marking pen is used to place a dot at
the height of the paper clip in the midpupillary line
(Fig. 7-30). The patient is asked to open the eyes again
and a second dot is placed where the overlapping skin
folds over with the paper clip in place at the midpupillary
line (Fig. 7-31). The patient is asked to close the eyes
again, and the surgeon then places a third dot with the
marking pen halfway between the two previous dots
(Fig. 7-32). The lower dot marks the lower limb of the
incision, which is then tapered inferiorly laterally and
medially: the incision should end approximately at the
lateral canthus laterally and extend to about 5 mm medial
to the medial canthus. The superior limb of the incision
should follow the third marked dot, the one that lies
halfway between the first two marked dots. Medially, the
superior limb should taper to meet the medial point of the
inferior limb; laterally, the superior limb should extend to
the orbital rim, which is then connected to the lateral
extent of the inferior limb with a straight line (Fig. 7-33).
The same technique is repeated on the contralateral side
and the two sides are compared for symmetry. Castroviejo
calipers can be used to verify precise symmetry before
continuing.
Operative Technique
After both eyelids are marked appropriately, the patient is
administered local anesthesia with a total of 1 mL of 2%
lidocaine mixed with 1:50,000 epinephrine on each side
from a 1-mL syringe outfitted with a 30-gauge needle. To
CHAPTER 7
Asian Blepharoplasty
113
Figure 7-29 The first step in the full-incision method (like in the partial-
incision method) for Asian blepharoplasty is placement of an open paper
clip, or similar device, into the eyelid to create an eyelid fold.
Figure 7-28 After all fixation sutures have been placed, the skin is
closed with three interrupted 7-0 nylon sutures. Care should be taken not
to transect the fixation sutures with the skin-closure needle, as placement of
the skin sutures should be situated between the fixation sutures.
Figure 7-30 The patient is then asked to close his or her eyes with the
paper clip left in place, and a surgical marking pen is then used to place a
dot at the height of the paper clip in the midpupillary line.
Figure 7-31 The patient is asked to open his or her eyes again and a
second dot is placed where the overlapping skin folds over with the paper
clip in place at the midpupillary line.

minimize ecchymosis and patient discomfort, the same
technique of raising a subcutaneous wheal (as opposed to
tunneling) can be used as described previously in the
section on the partial-incision method (Fig. 7-34A and B)
After 10 minutes are allowed to transpire for optimal
hemostasis and anesthesia, a No.15 blade is used
to incise through the skin and orbicularis muscle (Fig.
7-35). The island of skin and muscle is then dissected free
from the underlying orbital septum using tenotomy
scissors and then discarded (Fig. 7-36).
Meticulous hemostasis is necessary along the cut
edges of the orbicularis muscle in order to minimize
postoperative ecchymosis and to permit ease of further
dissection (Fig. 7-37). A small fenestration in the lateral
third of the orbital septum is then created by excising a
tiny wedge, as described above in the partial-incision
method (Fig. 7-38). The fat compartment is then teased
out (Fig. 7-39A and B), the orbital septum is incised
(Figs. 7-40A and B and 7-41), and the fat is clamped and
excised in the same manner prescribed for the partial-
incision method. Generally speaking, only the middle
third of the levator need be exposed and only the central
fat compartment removed, just as described in the partial-
incision method. Fixation of the levator proceeds in the
114
Samuel M. Lam • Young-Kyoon Kim
Figure 7-32 The patient is asked to close both eyes again: the two marked dots are shown (A). The surgeon then places a third dot with the marking
pen halfway between the two previous dots (B).
Figure 7-33 The lower dot marks the lower limb of the incision, which is then tapered inferiorly laterally and medially: The incision should end
approximately at the lateral canthus laterally and extend to about 5 mm medial to the medial canthus (A). The superior limb of the incision should follow the
third marked dot, that is, the one that lies halfway between the first two marked dots. Medially, the superior limb should taper to meet the medial point of
the inferior limb; laterally, the superior limb should extend to the orbital rim, which is then connected to the lateral extent of the inferior limb with a straight
line. The markings are shown to the patient for the full-incision method (B).
A
B
A
B

exact manner as described for the partial-incision
method—only the central 15 to 20 mm of levator need be
fixated for a durable adhesion (Figs. 7-42 to 7-44). After
symmetry is confirmed, the skin incisions are closed with
a running 7-0 nylon suture that should carefully avoid
disturbing any of the fixation sutures (Fig. 7-45).
Meticulous surgical execution and attention to symmetry
will yield consistently superior aesthetic results (Figs. 7-46
to 7-49).
POSTOPERATIVE CARE
Postoperative care remains essentially the same for the
patient undergoing either the partial- or full-incision
method. Before the patient is discharged from the
operating theater, he or she is reminded that the lid-crease
height will appear unnaturally high for several weeks to
months (longer with the full-incision method). In
addition, symmetry is difficult to assess for the first 2
postoperative weeks owing to resolving edema. The
patient is informed as well that he or she may also
experience an unusual sensation when opening the eyes
for the first few postoperative days, because of suture
fixation of the levator. The patient is informed that edema
will worsen considerably on the second or third
postoperative day and then will begin to dissipate rapidly
thereafter. Contact lens use should be restricted for the
first 2 postoperative weeks in order to avoid shearing the
wound edges open during eyelid manipulation; eyeglasses
should be worn instead. All these precautions are
preferably declared in the preoperative setting so that the
CHAPTER 7
Asian Blepharoplasty
115
A
B
Figure 7-34 Subcutaneous wheals are raised with local anesthesia in order to minimize ecchymosis associated with the threading technique (A and B).
Figure 7-35 After 10 minutes are allowed to transpire for optimal
hemostasis and anesthesia, a No.15 blade is used to incise through the skin
and orbicularis muscle.
Figure 7-36 The island of skin and muscle is dissected free from the
underlying orbital septum using tenotomy scissors and then discarded.

patient can be comfortable in advance with the post-
operative recovery period and plan his or her social/
professional calendar accordingly.
The most important aspect for the patient to follow
postoperatively is strict adherence to liberal ice appli-
cation to the surgical site during the first 2 postoperative
days; following this policy will expedite resolution of
edema. Cold ice packs should be replaced with those that
become warm about every 20 to 30 minutes as tolerated,
and stressful viewing activity should be kept to a
minimum. Ice application thereafter is superfluous, and
warm packs should never be used. Perioperative
antibiotic usage is not necessary and follows the surgeon’s
philosophy and preference. Narcotic medication for
discomfort is rarely indicated, and significant pain should
alarm the surgeon to the evolution of a hematoma.
For the first postoperative week, the patient should
gently clean the incision with hydrogen peroxide using
a cotton-tipped applicator twice daily followed by
application of Bacitracin ointment. Desiccated wounds
heal poorly so a generous amount of Bacitracin should be
used unless the patient should experience an allergic
reaction to the product. Any petroleum-based ointment,
such as Aquaphor, can be used as a substitute as needed.
It is important that the patient cease all peroxide and
Bacitracin application after the first postoperative week,
as continued usage only serves to impair wound healing
and may lead to wound dehiscence. Skin sutures may be
removed from 3 to 7 days postoperatively. On the 10th
postoperative day, the patient is encouraged to apply
topical vitamin E oil to the incision site twice daily for
2 weeks in order to minimize the risk of scar formation.
Thereafter, the patient is free from any postoperative care
regimen.
COMPLICATIONS
ASYMMETRY
Perhaps the most common complication following
double-eyelid surgery is asymmetry between the created
lid creases. Even 1 mm of difference between the eyelids
can be glaringly noticeable for the surgeon and patient
alike. Therefore, accumulated experience and meticulous
surgery will help reduce the incidence of this particular
complication. Following the partial-incision method, if
asymmetry is noted during the first 2 weeks, no treatment
is required, as edema may be accountable for the
asymmetry, especially if a small hematoma arose on one
side or greater dissection was required on one eyelid. After
116
Samuel M. Lam • Young-Kyoon Kim
Figure 7-37 Meticulous hemostasis is necessary along the cut edges of
the orbicularis muscle in order to minimize postoperative ecchymosis and
to permit ease of further dissection.
Figure 7-38 A small fenestration in the lateral third of the orbital
septum is then created by excising a tiny wedge of orbital septum (A).
Additional septum is excised until the fat becomes visible through the defect
(B).
A
B

2 weeks, however, if asymmetry persists, the surgeon
should consider elective revision surgery. At this time,
revision surgery is quite straightforward, as simple
spreading with scissors—after the initial incision is
made—will expose the levator quickly. Asymmetry that is
noted after that time will require more extensive surgery
but remains still relatively less labor intensive than if a
full-incision method was undertaken. With the full-
incision method, asymmetry may persist for several more
weeks and may be entirely accounted for by edema.
Therefore, a minimum of 1 month, if not longer, should
be taken to attend the resolution of the asymmetry. If
asymmetry persists beyond 3 months, the asymmetry
most likely is not related to edema but to technical error.
Regardless of surgical technique, the golden rule is to never
operate on one single eyelid no matter how tempting, as
symmetry is impossible to gauge with unilateral,
corrective surgery.
FOLD LOSS
With the partial-incision method, fold loss is higher as
compared with the full-incision method because of the
more limited distance of fixation, but still less than with
the suture-based technique. Fold loss may be due to the
technical error of not fixating a small amount of the
epidermal edge (as explained before), insufficient number
of fixation sutures (five to seven per side), or suture
fixation of the false layer above the true levator, among
other factors. Careful review of the surgical technique
expounded earlier will limit this problem from arising. If
fold loss does occur, revision surgery is mandated: Again,
CHAPTER 7
Asian Blepharoplasty
117
Figure 7-39 The fat compartment is teased out through the defect to expose the levator aponeurosis (A and B).
Figure 7-40 The orbital septum is incised with a pair of tenotomy scissors to expose the remaining levator (A and B).
A
A
B
B

both eyelids must be operated on in order to ensure
symmetry.
SUTURE EXTRUSION
As the authors favor permanent internal fixation sutures,
suture extrusion may occur. Burying the knot and
minimizing knot throws as outlined in the surgical
procedure will help reduce the likelihood of suture
extrusion. With either the partial- or full-incision method
explained herein, if one or two sutures are lost during the
first 3 months, fold loss most likely will not occur.
Nevertheless, if a suture becomes exposed during the
initial few months, the surgeon should admonish the
patient not to remove the uncovered suture or expect
the surgeon to do so in order to minimize the potential for
fold loss. After the first 3 months, fold fixation should be
more tenacious with the partial-incision method, and
removal of any exposed sutures can be safely pursued.
INFECTION
Infection is rare with or without the use of perioperative
antibiotics. Typically, if an infection occurs, the situation
118
Samuel M. Lam • Young-Kyoon Kim
Figure 7-41 The fat and levator are fully exposed after incision of the
orbital septum.
Figure 7-42 After the excess fat of the central compartment is excised with a 1-cm cuff left in situ, the first levator to skin fixation suture can be established
(A). Just like the manner described for the partial-incision method, the full thickness dermis and a small amount of epidermis is taken in the first bite (the skin
bite). The second bite is taken through the midportion of the levator (B).
Figure 7-43 The first fixation suture is tied down, and the patient is
asked to open the eyes to ensure that the eyelashes appear perpendicularly
oriented to the skin.
A
B

arises due to a suture abscess, which mandates immediate
removal of the offending suture followed by topical and
oral antibiotics until the condition fully resolves. Culture
and sensitivity evaluation should be routinely performed,
although the causative organism tends to be a constituent
of skin flora.
SCARRING
Scarring is quite rare with the partial-incision method, as
the incision length is limited and no wound tension is
present, and no skin is removed. Hypertrophic scar is
most notably problematic along the medial epicanthal
region, as may be observed with the full-incision method.
Direct, intralesional steroid injection with triamcinolone
acetonide (10 mg/mL) can be used to reduce any scar
formation. Unless exuberant in nature, the scar should be
CHAPTER 7
Asian Blepharoplasty
119
Figure 7-44 The second fixation suture is placed in the same manner (A). Of note, like in the partial incision method, a gullwing shape should appear
in the levator to guide the remaining fixation sutures along this fold in the levator. Like the partial-incision method, fixation sutures can be placed simply along
the central 15 to 20 mm of the exposed levator for adequate crease formation (B).
A
B
Figure 7-45 After symmetry is confirmed, the skin incisions are closed
with a running 7-0 nylon suture that should carefully avoid disturbing any of
the fixation sutures.
A
B
Figure 7-46 Preoperative (A) and postoperative (B) views taken of a
41-year-old Japanese woman with the full-incision double-eyelid creation.

left alone for the first few months in order to avoid
loosening of the fixation suture during this critical period.
REVISION SURGERY
Fold loss and obvious asymmetry call for revision surgery.
As mentioned, during the first 2 postoperative weeks,
wound strength is quite low; therefore, revision surgery is
relatively facile. Thereafter, dissection through the scarred
surgical bed must always be approached carefully and
meticulously: first and foremost, levator injury must be
avoided. After the initial incision through the skin, gentle
spreading with fine scissors should be undertaken until
the levator is exposed. Finding the remaining
preaponeurotic fat pad superiorly will help protect the
surgeon from inadvertent levator injury, as the levator is
always found immediately deep to the adipose tissue.
Discovery of any previously placed fixation sutures will
also guide the surgeon as to the correct depth. If the
surgeon is uncertain, he or she should always verify that
120
Samuel M. Lam • Young-Kyoon Kim
Figure 7-47 Preoperative (A) and postoperative (B) views taken of a 21-year-old Korean woman with the partial-incision double-eyelid creation.
A
B
Figure 7-48 Preoperative (A) and postoperative (B) views taken of a 46-year-old woman with the full-incision technique.
A
B

the levator has not been arrived at by grasping the tissue
to see whether the patient can open and close the eyes;
again, if the patient cannot open the eyes, the surgeon
most likely has the levator in his or her grasp.
Future Considerations
Perhaps a look back will help the reader envision what
will come. Over the past century, the original suture-
based technique has met with the rise of many variations
of incisional surgery. Permutations of both major
techniques, like the one described herein, are continuing
to evolve, and hybrids of suture and incision-based
methods have also been explored. Different
epicanthoplasty and lateral canthoplasty methods have
been introduced as adjunctive measures to the creation
of the double eyelid. Surgical techniques that modulate
the crease and epicanthus will continue to evolve in the
future (as, in fact, the authors are at this time completing
work on an original technique for epicanthal
advancement). However, no clear trend has arisen, and it
is doubtful it will arise, as surgeons will most likely
continue to adhere to their own favored method(s).
The past decade has witnessed quite a change in
aesthetic opinion, moving from the desire for a true
“westernization” eyelid appearance to now a low,
natural-appearing crease. As the popularity of interracial
unions continues to rise and certain cultural boundaries
are effaced, a universal aesthetic may propel (or
conversely hinder) acceptance of the procedure.
Controversy will always surround whether double-eyelid
creation represents a denial of one’s ethnicity or in fact
stems from motivation to emulate a more ideal beauty
that is derived from one’s own native peers. As notions of
fashion, style, and beauty are constantly in flux, the
creation of the double eyelid will no doubt be subjected
to the same cultural forces.
REFERENCES
1. Lam SM: Mikamo’s double-eyelid blepharoplasty and
the westernization of Japan. Arch Facial Plast Surg
2002;4:201-202.
2. Mikamo M: Plastic operation of the eyelid. J Chugaii-jishimpo
1896;17:1197.
3. Mikamo M: Mikamo’s double-eyelid operation: The advent of
Japanese aesthetic surgery: 1896. Plast Reconstr Surg
1997;99:664-669.
4. Fernandez LR: Double eyelid operation in the Oriental in
Hawaii. Plast Reconstr Surg 1960;25:257-264.
5. Boo-Chai K: Plastic construction of the superior palpebral
fold. Plast Reconstr Surg 1963;31:74-78.
6. Millard DR Jr: The Oriental eyelid and its surgical revision.
Am J Opthalmol 1964;57:646-649.
CHAPTER 7
Asian Blepharoplasty
121
A
B
Figure 7-49 Preoperative (A) and postoperative (B) views taken of a 45-year old woman full-incision technique.

7. McCurdy JA Jr, Lam SM: Cosmetic Surgery of the Asian Face,
2nd ed. New York: Thieme, 2005.
8.
McCurdy JA Jr: Upper blepharoplasty in the Asian patient:
The “double eyelid” operation. Facial Plast Surg Clin North
Am 2002;10:351-368.
9. Lam SM, Kim YK: Partial-incision technique for creation of
the double eyelid. Aesthet Surg J 2003;23:170-176.
10. Choi AK: Oriental blepharoplasty: Nonincisional suture
technique versus conventional incisional technique. Facial
Plast Surg 1994;10:67-83.
11. Homma K, Mutou H, Ezoe K, Fujita T: Intradermal stitch
blepharoplasty for Orientals: Does it disappear? Aesthet Plast
Surg 2000;24:289-291.
12. McCurdy JA Jr: Cosmetic Surgery of the Asian Face. New
York: Thieme, 1990.
13. Jeong S, Lemke BN, Dortzbach RK, et al: The Asian upper
eyelid: An anatomical study with comparison to the Caucasian
eyelid. Arch Ophthalmol 1999;117:907-912.
14. Hwang K, Kim DJ, Chung RS, et al: An anatomical study of
the junction of the orbital septum and the levator aponeurosis
in Orientals. Br J Plast Surg 1998;51:594-598.
15. Yuzuriha S, Matsuo K, Kushima H: An anatomical structure
which results in puffiness of the upper eyelid and a narrow
palpebral fissure in the Mongoloid eye. Br J Plast Surg
2000;53:466-472.
16. Morikawa K, Yamamoto H, Uchinuma E, Yamashina S:
Scanning electron microscopic study on double and single
eyelids in Orientals. Aesthet Plast Surg 2001;25:20-24.
17. Hanada AL, de Souza EN Jr, Moribe I, Cruz AA: Comparison
of palpebral fissure obliquity in three different racial groups.
Ophthal Plast Reconstr Surg 2001;17:423-426.
18. Lim WK, Rajendran K, Choo CT: Microscopic anatomy of the
lower eyelid in Asians. Ophthal Plast Reconstr Surg
2004;20:207-211.
19. Carter SR, Seiff SR, Grant PE, Vigneron DB: The Asian lower
eyelid: A comparative anatomic study using high-resolution
magnetic resonance imaging. Ophthal Plast Reconstr Surg
1998;14:227-234.
122
Samuel M. Lam • Young-Kyoon Kim

HISTORY
The signature operation of facial rejuvenation is the
rhytidectomy. Of all the procedures designed to remedy
the effects of aging, the rhytidectomy has the most
profound ability to improve the patient’s appearance. The
first recorded efforts to surgically rejuvenate the face
appeared early in the 20th century.1-3 The first 50 years of
the 20th century saw little advance, burdened by the risks
of anesthesia and the lack of medications, such as
antibiotics, surgeons were forced to move forward with
great trepidation. As technologic advances erupted in the
latter half of the 20th century, surgical advances soon
followed. In the last 30 years of the century these tech-
nologic advances enabled surgeons to provide excellent
surgical results to their patients. And the popularity of
facial rejuvenation has since exploded. Today, an attrac-
tive outward appearance is a sign of strength and health
instead of vanity.4
The original techniques employed short skin flaps
and minimal, if any, manipulation of the underlying soft
tissues for fear of damaging the facial nerve. With greater
anatomic understanding, the techniques progressed
deeper into the ptotic tissues of the aging face. The skin
flaps gradually became longer and the manipulations of
the underlying soft tissue, the superficial musculoaponeu-
rotic system (SMS), became more aggressive. With these
advances new frontiers were crossed and new compli-
cations arose. In addition, physicians working in this
field have now gained a much greater knowledge and
appreciation for other factors that historically had been
neglected, especially in regard to lifestyle choices, such as
smoking and alcohol intake, and in medications, such as
antiplatelet agents.
The field has undergone a fascinating 30-year
evolution since the groundbreaking work of Dr. Skoog in
the 1970s.5 Skoog was the first to perform what can be
called the deep plane technique; Hamra advanced the
concept to include the soft tissues of the midface with his
deep plane and composite techniques.6-9 Today, there is
great controversy as to the appropriate technique and
plane of dissection for optimal rejuvenation.4 With the
advent of the deep plane facelift technique, rhytidectomy
took a quantum leap forward. For decades, the rhytidec-
tomy provided the patient with a benefit that often
pleased the patient but left the surgeon wanting more.
This exciting new technique enabled the surgeon to
provide a more lasting, natural result. We propose our
techniques described herein not as an answer to these
dilemmas but as a proven method to safe, excellent,
reproducible results in facial rejuvenation.
PERSONAL PHILOSOPHY
The evolution of our technique was based on several
criteria. First, the result with the deep plane technique
was superior to that of the SMAS lift plication and
imbrication techniques. With a more thorough under-
mining of the ptotic soft tissues of the face a better
postoperative result soon followed, as would be expected.
Although the SMAS procedure is excellent for short-term
gains in reducing skin laxity and mild improvement of
soft tissue ptosis, the majority of the ptotic soft tissue
remains fallen. We agree with the previously published
viewpoint that “minilifts” or subcutaneous facelift
procedures have only dealt with laxity of the skin and do
not completely address the ptotic soft tissues of the face.6,7
Second, once experience had been gained with this
technique the long-term results became evident. In
addition, the occurrence of the pulled or “operated look”
decreased rapidly with the increased use of this technique.
We also believe that with the shorter skin flap and
superior blood supply of the deep plane technique, the
catastrophic issues of skin loss and poor scar appearance
are greatly diminished. With its strict adherence to
physiologically sound principles, the effect of the deep
plane technique is maintained for a longer period than
that of the skin flap techniques. This is due to the
composite flap maintaining the viscoelastic properties of
the SMAS.10 Though others have not agreed with these
opinions, we maintain our results have improved greatly
since the transformation of techniques.11,12
Much excitement has been generated over the
“weekend” or “mini-facelifts.” With the promise of smaller
incisions and less downtime, these procedures have
received significant attention over the last several years as
the popularity of plastic surgery has flourished. These
The Deep Plane Facelift
Calvin M. Johnson Jr., MD • Mark R. Murphy, MD
123
C H A P T E R E I G H T

techniques are similar to standard SMAS facelifts and
thus are an option for certain patients.
Generally speaking, patients for whom these pro-
cedures are devised suffer from lax skin, especially in the
lower face. Often, in our practice, these concerns are minor
and handled with reassurance. When a patient considers
facial cosmetic surgery, we feel the first operation should
be the definitive procedure. If the patient has had a “less
invasive” procedure in the past, the tissue planes are
forever altered, thus making further surgery, when the
aging process has come to fruition, much more difficult.
This is obviously a matter of personal preference, and
some patients will persist in having work done regardless
of the surgeon’s preferences. This is a matter for each
individual practice. For ours, all primary facelifts are
done via the deep plane techniques.
A variety of midfacial approaches have been proposed
over the last 15 years. The point of origin for most of
these procedures is from the work of Tessier.13 Several
variations of this approach have been proposed.14-26
We favor the deep plane technique over the sub-
periosteal midface approach for several reasons. The first
is the direct nature in which the deep plane technique
addresses the fallen tissue. The focus of midfacial reju-
venation is the suspension of the soft tissues of the
midface that have fallen with time. In the deep plane
technique, the surgeon may directly manipulate this tissue
to the desired location. To state the issue directly, deep
plane surgery “works at the level at which mobility and
aging laxity are occurring.”27 The tissue to be repositioned
in the midface is the cheek fat that rests on the zygo-
maticus musculature. With elevating the soft tissues off of
the zygomatic musculature, the surgeon may now address
the nasolabial fold and the descent of the soft tissues in
a manner not possible before. A SMAS correction is
inherently more effective than a subperiosteal approach
in the midcheek because it is closer to the tissue to be
repositioned.28
In addition, the nerves that innervate the facial mus-
culature enter from below. Thus, it stands to reason that
dissection techniques that leave the nervous structures
between the plane of dissection and the target tissue leave
the nerves at risk from either direct trauma through
inadvertent movements of the dissector or, more commonly,
through traction neuropraxia. The subperiosteal technique
has been reported to have a high rate of facial nerve
injuries, implying a steep learning curve.14
Edema from periosteal manipulations is significant,
and for it to persist for weeks, if not months, is not
uncommon.29-31 To patients who are expecting a “minimally
invasive” procedure, this may prove to be a difficult
issue. In the subperisoteal approach, the zygomaticus
musculature is repositioned to a place it never was before,
the intermalar distance is necessarily increased, and fre-
quently manipulation of the lateral canthus is required.32
Not only is the lateral canthus often altered, but the
resetting of the zygomaticus musculature may also lead to
an unwanted alteration of the patient’s appearance.33 One
must be concerned about the potential for distortion of
the palpebral fissure with many of these procedures.34-38
When an open lower lid blepharoplasty approach is
incorporated into the subperiosteal midfacial techniques,
the lower lid malposition rate has been reported to be as
high as 50%.36
Our approach to facelifting, as with our overall
practice approach, is the attainment of a natural, lasting
result via conservative means. We seek to provide the
patient with rejuvenation where the observer cannot
detect that an operation has occurred. The deep plane
technique may not be considered conservative in some
quarters, but with the technique performed as described
herein, we feel it to be exceedingly safe and well tolerated
by the patient.
ANATOMY
The facelift surgeon must be fully versed in the complex
anatomy of the face. A complete discussion of the
anatomic relationships is beyond the scope of this chapter
and the reader is advised to refer to excellent published
reports on this challenging territory.39-41 There are several
anatomic keys to the aging face, and specific areas of
concern are discussed. As we age, some of the most
profound effects are noted in the midface. A key to the
deep plane technique is the anatomy of the midcheek and
malar region.
The cheek mass descends with age and causes a
deepened nasolabial fold inferiorly while creating a
depression at the infraorbital rim (Fig. 8-1).42 The malar
fat pad atrophies and descends with age leading to a
deepened nasolabial fold, a crescent-shaped hollowness at
the lid-cheek interface and nasojugal groove, and lack of
cheek prominence, giving a sunken, tired appearance.43
The effects of gravity are more pronounced on superficial
tissues.29,42
Another feature of midfacial aging is the buccal fat
pad. It provides fullness to the cheek in youth and
diminishes, relatively, in size as the patient ages.44 This fat
pad has four major components with the buccal being the
largest. On the lateral aspect of the masseter lies this
parotid-masseteric fascia, a key structure in the deep
plane technique. This fascia layer is found between the
overlying SMAS and the underlying branches of the facial
nerve (Figs. 8-2 and 8-3). Fortunately, this fascia binds
the branches of the facial nerve down, a key factor when
placing extreme traction on the SMAS to expose the deep
plane. As this fascia continues anteriorly, it shifts
superiorly to envelop the buccal fat pad, parotid duct, and
buccal branches of the facial nerve.44-46
Another important area of the midface is the
nasolabial fold.47-49 The nasolabial fold is a true anatomic
124
Calvin M. Johnson Jr. • Mark R. Murphy

CHAPTER 8
The Deep Plane Facelift
125
A
C
B
Figure 8-1 The graduated stages of the aging face.

boundary between the fatty cheek above and the upper lip
below.47 As the tissues of the midface become ptotic with
age the nasolabial fold deepens and becomes of greater
concern to the patient.
The lower aspect of the face is dominated by jowling
and submental fat. The jowling that so troubles the aging
population results from the descent of the platysma
muscle in the neck and face with the associated fat and
skin along the mandibular line. The platysma has been
described as having a graded aging process.50,51 The
history of submental fat resection is often attributed to the
work of Millard and others.52,53
The SMAS merits specific discussion. First described
by Mitz and Peyronie, the SMAS layer and manipulations
thereof have intrigued facial plastic surgeons for 30
years.54 This layer has been seen as an extension of
the platysma into the face (see Figs. 8-2 and 8-3). The
SMAS is considered to be a fibromuscular structure that
lies in continuity with the platysma and has no bony
attachments.54-60 The layer is thought to consist of
connective tissue and muscle. The SMAS has fibrous
extensions that connect it to the skin.61,62 The SMAS is
thicker in its lateral aspect over the parotid and tapers as
it travels medially.61 Our experience concurs with this
report. There has also been controversy over the relation-
ship of the SMAS to the parotid fascia as to whether they
are separate layers or one and the same.55-59,63,64 Whether
they are one and the same or distinct layers means little to
the surgeon. The key point is that there is a fascia layer to
be raised in this region and its thickness varies from
patient to patient. We have found the SMAS to taper as
the deep plane dissection is carried medially.
The SMAS is noted to be muscular in its inferior
component where the platysma rises into the face and
more fibrous as the surgeon goes further cephalad as the
platysma tapers. In the more muscular, inferior portion of
the SMAS, facial nerve branches are commonly seen
traversing the masseter muscle on the floor of the dis-
section as the deep plane is raised (see Figs. 8-2 and 8-3).
Also of note during our dissection technique are the
retaining ligaments of the face. The key ligaments for our
procedure are the zygomatic ligament and the masseteric
ligaments.65 The zygomatic ligament may be released as
the dissection proceeds to the origin of the zygomaticus
major at the anterior aspect of the zygomatic arch. Care
should be taken in this area, as it is closely associated with
the facial nerve. The masseteric ligaments pose a
challenge for the surgeon in that they closely resemble
peripheral branches of the facial nerve. When dissecting
in the correct plane these ligaments may be safely
released.
The vascularity of the deep plane technique is an
important concept. Schuster and associates described
three concentric vascular arcades.66,67 The most lateral
arcade is drawn from the zygomatico-orbital and trans-
verse facial arteries. The middle arcade consists of the
infraorbital and facial artery connected by the middle and
posterior jugal branches, and the medial arcade contains
the angular artery, superior and inferior labial arteries,
and a branch of the ophthalmic artery. When raising a
126
Calvin M. Johnson Jr. • Mark R. Murphy
Zygomaticus major m.
Superficial parotid gland
Buccal fat pad
Figure 8-2 A comprehensive view of the important landmarks for the
deep plane technique.
Figure 8-3 The elevated SMAS and its relationship to adjacent
structures; note the platysma is continuous with the face as it extends
superiorly into the face, a key dissection plane for the deep plane lift. The
superior aspect of the anatomic planes is for illustrative purposes alone and
is not a component of the deep plane technique
Temporoparietal
fascia
Galea
Zygoma
Stensen’s duct
Facial n.
Masseter m.
Buccal fat
Platysma

skin flap in the SMAS or skin-only facelift this outermost
arcade is traumatized as a random flap is created. As this
flap is developed blood must pass through a choke zone as
it traverses one arcade to another. The further medial this
dissection is carried, the more tenuous the blood supply
becomes as the blood must now pass through two choke
zones. The deep plane technique avoids this vascular
compromise.
There is great concern for the temporal branch and
the marginal mandibular branch, due to their respective
lack of anastomotic connections, during deep plane
rhytidectomy.68 There are usually four rami of the nerve
that cross the zygomatic arch, though this number varies,
of course. The most anterior ramus is an average of
2.0 cm posterior to the anterior end of the zygomatic arch.
The danger zone is located in a region overlying the
zygomatic arch approximately 2.0 cm anterior to the
superior attachment of the auricle and 2.0 cm posterior to
the bony orbital rim. It is in this area that the nerve is just
beneath the subcutaneous fat and directly overlying the
bony prominence of the zygoma.68 When employing the
deep plane technique, the surgeon must also be cognizant
of the marginal mandibular branch anatomy. As the
surgeon aggressively attempts to rid the patient of jowling
with an anterior dissection in the lower face he or she
must note that the marginal branch is located deep to the
platsyma until approximately 2.0 cm lateral to the corner
of the mouth. At this point, the nerve takes a more
superficial trajectory along the undersurface of the facial
mimetic muscles. The facial artery can also be used as a
guide. Posterior to the vessels the nerve is generally not in
the dissection; however, anterior to the vessels the surgeon
must proceed with caution.69 The most commonly injured
nerve in rhytidectomy is the greater auricular. This
structure is located approximately 6.5 cm inferior to the
bony auditory canal.70
PREOPERATIVE ASSESSMENT
Prior to the analysis of the patient’s cosmetic desires and
possibilities, a thorough history and physical examination
must be performed. This is especially true for aesthetic
surgery. As an elective procedure there can be no excuse
for an overlooked medical issue that can compromise the
outcome. General issues that should be investigated
include previous surgeries, medications, smoking and
alcohol intake, and any coexisting medical conditions.
Specific issues to facial rejuvenation surgery such as the
use of aspirin and other nonsteroidal anti-inflammatory
medications, hypertension, and smoking history should be
thoroughly explored and explained to the patient. In
addition, there are several medical diseases the facial
plastic surgeon must respect. Obviously, any blood
dyscrasia must be evaluated with a hematologist. Also,
several connective tissue disorders, such as Ehlers-Danlos
CHAPTER 8
The Deep Plane Facelift
127
syndrome, may compromise the result of an otherwise
good operation.
Perhaps of equal importance in the preoperative
assessment is the evaluation of the patient’s psyche by
the surgeon. We make a point to ascertain the patient’s
motivation for the proposed procedure(s). This is a highly
individualized approach that each surgeon must discover
for himself or herself. We cannot stress enough the
importance of this evaluation. No matter what the
technique nor how well it is executed, a psychologically
impaired patient will not be pleased.
The surgeon should then evaluate the nature of the
skin. Sun damage, smoking history, and Fitzpatrick type
are but a few of the skin features that must be assessed
during the preoperative consultation process. Fair skin
with a moderate amount of sun damage usually heals
best, but darker skin types necessitate more caution on
the part of the surgeon. The patient should be questioned
as to his or her healing history and any preexisting
medical conditions or medications that might hinder the
healing process.
After the initial examination of the skin we prefer to
examine the overall appearance of the face. The patient’s
ethnicity, body habitus, and age all play a role in this
initial assessment. The general proportions of the face
should be considered. The face is generally broken down
into fifths vertically, based on the width of an eye; and
thirds horizontally, as measured from the hairline to the
glabella, from the glabella to the subnasale and from the
subnasale to the menton. Any facial asymmetries should
be noted at this time. All faces have some level of
asymmetry. This is normal and should be conveyed to the
patient, preoperatively.
The surgeon should then proceed to examine the
patient’s bony infrastructure. This is the scaffolding on
which the soft tissues of the face are suspended. The
malar prominence, mandible, and hyoid positions are all
examined and palpated. A strong bony structure to the
face is obviously the favorable situation.
The soft tissue components of the face are the final
facet of the examination. Jowling, buccal fat, the sagging
midface and nasolabial fold, infraorbital hollowness, and
the aging neck are the focal points of the soft tissue
examination. The scope of this chapter is not to elaborate
on these components as they are described in other
portions of the text.
SURGICAL TECHNIQUE
Nearly all of our deep plane facelifts are performed under
general anesthesia. Usually, these procedures are combined
with a series of other facial rejuvenation procedures
(browlifts, blepharoplasties, etc.). It is certainly acceptable
to perform the procedures under local anesthesia with
sedation. Our preference for general anesthesia is based

on patient comfort and safety, in addition to surgeon
preference. We believe that intubation is the safest form of
airway management during these long cases when a
significant amount of sedation and analgesic agents are
administered. It is also an optimal environment for the
surgeon, having been relieved of a moving, sometimes
talkative, and restless patient. Relieved of the need to
constantly monitor the airway and patient comfort, the
surgeon may focus on the task at hand.
After administration of the anesthetic the patient is
prepped. The first step in our preparation is a minor
shaving of hair in the pre- and postauricular areas. The
preauricular area is shaved to enable the “bird’s beak”
incision, which extends horizontally to the temporal hair
tuft through the sideburn.71 The postauricular shaving is
performed by noting the superior aspect of the conchal
bowl and drawing a straight line in an inferoposterior
vector from this point (Fig. 8-4). Regular masking tape is
then applied to tuck the remaining hair out of the field.
A thorough injection of local anesthetic (an equal
mixture of 0.5% lidocaine with 1:200,000 epinephrine
and 0.5% bupivacaine with 1:200,000 epinephrine) is
then performed in the subdermal planes of dissection
bilaterally. The surgeon should note the character of the
skin and dermis during the injection, especially in revision
procedures. When performed in conjunction with other
procedures, the facelift is always performed last to ensure
that a compressive dressing may be placed at the
termination of the case. The face and neck are then
prepped and draped in standard surgical fashion and
the head is wrapped with a sterile towel and clamped. The
endotracheal tube is draped in a sterile stocking.
Our incision placement is dictated by the desire to
preserve hair and create the optimal vectors for lifting the
tissue in a natural manner. Thus, we choose to bring the
anterior and superior aspect of the incision forward,
through the sideburn hair with a gentle curve as it
progresses anteriorly (Fig. 8-5). Care is taken to maintain
an adequate amount of sideburn hair that will grow over
and thus mask the scar. In order to maintain a normal
hair pattern the preauricular tuft must not be advanced
over the level of the supraauricular sulcus.72 By employ-
ing a frontotemporal hairline incision the surgeon may
place the vector of lift more superiorly than lateral. It is
not a pure vector but we feel it minimizes untoward
sequelae.33,73-75 We agree with others that the classic
incision beginning at the superior attachment of the
auricle and tracing superior and posterior inherently
shifts the hair in unnatural fashion and can be a stigma of
facelift surgery.72,76,77
The postauricular incision is marked by bisecting the
superior aspect of the shaved hair, as noted from the
superior conchal bowl vector, to the inferior aspect of the
native hairline. The preauricular incision is marked
horizontally from the temporal hair tuft, through the
sideburn, now shaved, to the bird’s beak above the ear.
The incision then traverses inferiorly in a native preau-
ricular crease in a pretragal fashion. The preauricular
incision then gradually wraps around the lobular attach-
128
Calvin M. Johnson Jr. • Mark R. Murphy
Figure 8-4 The markings begin at the temporal hair tuft and through
the sideburn to the bird’s beak. The planned incision then traverses the
preauricular area, around the lobule, and onto the posterior surface of the
auricle. The incision terminates in the postauricular hair-bearing area that has
been bisected as shown.
Figure 8-5 The anterosuperior aspect of the incision is made. This
incision is beveled, consistent with hair-saving principles.

ment and slightly onto the posterior aspect of the conchal
bowl as it rises to reach the posterior take-off near
the superior aspect of the conchal bowl (Fig. 8-6).
Occasionally, the anterior aspect of the incision must be
extended into the temple region when the surgeon
anticipates that a significant amount of skin will be
removed. It is vital to place this extension within a natural
rhytid emanating from the lateral orbital skin (Fig.
8-7).78,79 This extension is commonly used in revision
procedures and in older patients who have extremely lax
skin with multiple fine rhytids.
The lengths of the anterior and posterior components
of the incisions are dictated by the anticipated amount of
skin mobilization and resection. The function of these
incisions is primarily to manage the dog-ears that occur
with the advancement of the flap. The lift is basically a
posterior and anterior rotation flap with a central
advancement component.80
All incisions are made with a No. 10 blade. We prefer
the use of these larger blades because with their increased
surface area the knife stays sharper for longer periods, an
important factor when performing extensive incisions.
The incision begins at the anterior/superior aspect and
traverses the preauricular portion, around the lobule, and
onto the postauricular portion, where it terminates in the
hairline. The initial portion of the incision, through the
sideburn, should be performed with a beveled blade
parallel to the follicles to ensure masking hair growth
during the recovery period. The incision is beveled in
accordance with accepted hair-saving principles.81
Once the incisions have been performed the skin is
then elevated. The bird’s beak area is grasped with an
Adson forceps and using a sharp, fine scissors, the skin
elevation is begun. We prefer to use a transillumination
technique to ensure proper depth of dissection. The plane
of dissection is subdermal, just inferior to the hair
follicles. With the transillumination technique the
assistant places the overhead lights onto the skin while the
operative field has no direct light (Fig. 8-8). This is in
direct opposition to the commonly used technique of
bright illumination from behind the surgeon’s head and
onto the field. Once adequate skin has been raised, several
different instruments can be used to retract the skin. A
thimble with a double prong, a variety of rake retractors,
and our preference, the Anderson bear claw, are all
acceptable retractors. The skin elevation, as with almost
all our dissection maneuvers, requires an excellent
assistant to provide countertraction. Other technical
CHAPTER 8
The Deep Plane Facelift
129
Figure 8-6 The postauricular incision is made slightly onto the
posterior aspect of the conchal bowl, out of the sulcus. This position is due
to the forward traction placed on the auricle. When released, the incision
will rest in the sulcus. The surgeon should not disrupt the perichondrium.
Figure 8-7 The anterior extension may be added in revision cases or
in those in whom excess of skin is to be removed. This is generally
performed in older patients with an abundance of lines to mask the incision.
Figure 8-8 The transillumination technique ensures proper depth of
dissection.

aspects worthy of mention include the dissection over the
sternocleidomastoid musculature. The fascia in this area
can be very adherent leading to injury of the great
auricular nerve if care is not taken (Fig. 8-9).82 After
discerning the plane, we change scissors from sharp-
tipped to dull. Many surgeons will perform a blunt
dissection of the subdermal plane, which is definitely
acceptable. But in this day and age of minimal downtimes
and the need for expedient recoveries, we have found our
technique to be less traumatic to the tissues and thus our
postoperative edema is considerably less than if we
employed the blunt dissection techniques.
The subdermal elevation is continued for approxi-
mately 5 to 6 cm from the incision points (Figs. 8-10 and
8-11). This dissection may be carried slightly more
anterior in the region of the malar eminence, where the
dissection turns deeper as the deep plane is raised.
In the inferior aspect of the dissection, the subdermal
plane is raised until the surgeon reaches the angle of
the mandible. At this point, a lighted retractor is used
to dissect the posterolateral portion of the platysma (Fig.
8-12). The overhead lights used for transillumination are
now removed from the field. The subdermal dissection
should be relatively bloodless as long as adequate local
has been injected and sufficient time has transpired.
Once the edge of the platysma has been identified, the
plane can be rapidly developed with broad spreading
movements of the dissecting scissors. The preplatysma
dissection may require the use of extra long scissors to
dissect to the midline. We try to lift all of the subdermal
fat off the muscle, leaving a clean plane of muscle at the
floor of the dissection.
We infrequently perform liposuction of the neck,
though it is a viable option in select cases. We prefer direct
excision of fat. We concur with other authors that lipo-
suction can lead to several postoperative issues that are
exceedingly difficult to remedy. As with many other issues
in plastic surgery, it is best to underdo this portion of the
procedure than to try to attain the “perfect” result, which
can lead to drastic, difficult postoperative issues.83,84
After completely elevating the skin and subcutaneous
tissue from the platysma, the surgeon pays attention to
the deep plane. We prefer to enter this plane 2 to 3 cm
anterior and slightly superior to the angle of the mandible
130
Calvin M. Johnson Jr. • Mark R. Murphy
Figure 8-10 The extent of skin dissection using the transillumination
technique.
Figure 8-11 The shaded area depicts the extent of the subcutaneous
dissection.
Figure 8-9 The postauricular skin is raised, displaying the thin flap and
adherent fascia overlying the sternocleidomastoid muscle.

inferiorly (Figs. 8-13 and 8-14). A line may be marked
for the incision into the deep plane from just above the
angle of the mandible to the junction of the zygomatic
arch and body. This incision, as with all others in the deep
plane technique, is performed with the No. 10 blade. The
incision into the deep plane is generally placed near the
anterior aspect of the parotid gland. By placing the
incision this far forward with a curve at the superior
aspect, the frontal branch of the facial nerve is avoided in
the dissection because it is posterior and superior to the
incision into the deep plane (Fig. 8-15).
The lighted retractor, preferably with nonlacerating
teeth, is used to gain a purchase of the SMAS and the
surgeon’s wrist is turned to place the SMAS under tension.
The assistant provides countertraction similar to that
provided when raising the skin flap. This can be awkward
for the surgeon and assistant until the move is learned.
Patience is encouraged in attaining the proper balance of
retraction between surgeon and assistant.
With the SMAS held taut by the lighted retractor
and the countertraction provided by the assistant the
plane is incised with the No. 10 blade (Fig. 8-16). Almost
immediately after opening this plane, the surgeon will
note the SMAS lifted up with the retractor at the roof of
the dissection while the masseteric fascia falls to the floor,
broadly displaying the deep plane (Figs. 8-17 and 8-18).
Occasionally, facial nerve branches can be seen traversing
this fascia (Fig. 8-19). The surgeon can take great
comfort in that as long as the masseteric fascia is seen, the
facial nerve branches are intact. Once opened, the plane
can be developed with either a scissors in a spreading
fashion or with the No. 10 blade in a pushing motion. We
prefer to use the No. 10 blade to push down the
connective tissue attachments from the undersurface of
the flap (Fig. 8-20). The muscle fibers of the platysma are
usually seen on the undersurface of the flap and are used
as guide for the dissection. The blade should be positioned
so as to peel fibers from the undersurface as opposed to
using the knife from the floor of the dissection and
pushing the fibers up to the undersurface of the platysma.
The surgeon must be mindful of the position of the
mandible as the dissection continues anteriorly and
inferiorly so as not to risk injury to the marginal
mandibular nerve.
After mobilization of the inferior aspect of the flap,
attention is then directed to the superior portion of the
CHAPTER 8
The Deep Plane Facelift
131
Figure 8-12 The lateral aspect of the platysma is dissected. The red
muscle is seen on the floor of this dissection.
Figure 8-13 The inferior portion of the deep plane is entered over the
masseter muscle approximately 2 to 3 cm anterior and slightly superior to
the angle of the mandible.
Figure 8-14 The deep plane incised. The outlined portion illustrates
the amount of tissue excised when the flap is suspended.

132
Calvin M. Johnson Jr. • Mark R. Murphy
Figure 8-15 The trajectory of the frontal branch of the facial nerve is
depicted. Note that the placement of the incision into the deep plane is
anterior to these rami and thus protects the nerve from injury.
Figure 8-17 The deep plane has been exposed and tension, with the
lighted retractor, must be utilized to further dissect the plane. The retractor
is placed immediately superficial to the incision and elevated away from the
face. The assistant provides vital countertraction (note the fingers of the
assistant) and the plane is dissected.
Figure 8-18 With adequate traction, and countertraction, the plane
immediately shows itself.
Figure 8-19 The masseteric fascia ensures the underlying facial nerve
branches are intact.
Figure 8-16 The superior aspect of the incision is made and the flap is
raised. Note the near pure anterior vector of the incision over the zygoma,
as the incision is directly over the bone.

dissection. With a finger, the surgeon palpates the
zygomatic arch to ascertain the location of the notch on
the inferior aspect of this bone. With the No. 10 blade, he
or she makes an incision approximately 1 to 2 cm in front
of this landmark.
The zygomatic major muscle is the key structure to be
identified (Figs. 8-21 to 8-23). Often, a small, perforating
branch of the transverse facial artery will be encountered
before the zygomaticus is completely identified. This is
carefully addressed with bipolar cautery. Discerning the
zygomaticus from the lateral, inferior aspect of the
orbicularis is often difficult, and the surgeon should
consider the depth of the dissection to ensure proper
identification, the orbicularis being the more superficial of
the two muscles.
Once free, the zygomaticus provides an excellent
landmark as the surgeon continues freeing the soft tissues
of the midface anteriorly while safeguarding the facial
nerve branches deep to the muscle.46 It is often necessary to
incise the tissue anterior to this muscle to completely
mobilize it. Superior dissection is generally avoided
secondary to the persistent edema that results from
surgical manipulation in this region. This edema persists
CHAPTER 8
The Deep Plane Facelift
133
Figure 8-20 The blade is angled superficially and the connective tissue
is pushed down from the undersurface of the flap.
Figure 8-21 Once incised the upper portion of the deep plane is
dissected to the origin of the zygomaticus major medially.
Figure 8-22 The origin of the zygomaticus major is seen as the red
muscle in the distal aspect of the dissection
Figure 8-23 The key anatomic relationships of the deep plane
dissection are depicted. The superior aspect of the dissection is at the
superior segment of the zygomaticus major. The zygomaticus serves as a
safe guide for the dissection as it progresses anteriorly. The inferior aspect
of the deep plane is anterior to the mandible, at the posterior end of the
platysma.

longer than any other in the deep plane facelift and can
be most troublesome to patients. Thus, we have diverged
from the composite technique as described by
Hamra.7,32,85,86 We prefer to perform our periorbital
dissection in the blepharoplasty component of our facial
rejuvenation. This is in contrast to others favoring the
deep plane technique, where the periorbital rejuvenation
is incorporated into the facelift component of the
rejuvenation. Our preference to avoid dissection in the
periorbital area is shared by others.87 Our rationale is
similar, to avoid excessive postoperative edema and
recovery periods and the difficult issues that often arise
with periorbital manipulation. Grounded in the excellent
anatomic work of Pessa, we do not dissect superior to the
caudal margin of the orbicularis oculi so as not to disrupt
the malar septum.40,41
When this dissection is complete the surgeon will
have the flap raised in two sections with an intervening
ridge of adherent tissue between two well-developed
planes (Fig. 8-24). The ligamentous attachments in this
area are densely adherent. With the two well-developed
portions of the plane as a guide, the surgeon may
confidently use the No. 10 blade in a pushing fashion
similar to that done with the inferior and superior aspects
of the flap (Fig. 8-25). It is not recommended to dissect
only the superior or inferior portion of the flap and then
free this area. After dissecting the inferior plane the
surgeon may be tempted to continue the dissection
superiorly. The surgeon should avoid this temptation
because it is easy to be led deep to the zygomaticus
musculature and into the facial nerve branches. It is by
connecting the tunnels that the surgeon may move
forward with the dissection in a safe manner.
As the plane elevation continues the lighted retractor
must be advanced with the advancing dissection to
maintain appropriate tension at the point of dissection.
The surgeon must retain focus on elevating the flap at the
appropriate depth. It is common to migrate superficially
as the flap is dissected anteriorly. This risks perforating
the flap and limiting the tension that may be placed upon
it when suspending the fallen tissues. There is no
definitive anterior limit to the dissection. We generally try
to free the flap to within 1 to 2 cm of the nasolabial fold.
Once raised, the surgeon may address the buccal fat
pad if necessary. We generally do not perform resection of
the buccal fat pad, but it is in the center of the field at the
end of this dissection if the surgeon chooses to alter it.
Care should be exercised here as this is deeper than the
plane of dissection and the facial nerve branches are at
greater risk.
The submental region poses unique challenges. Some
patients may require no intervention in this region, others
need submental liposuction, and yet others benefit from
a submental incision with direct fat excision and
platysmaplasty or platysmaplasty without fat excision.78
When performing liposuction without platysmaplasty we
create two small, 1-cm incisions within a native crease.
When combining platysmaplasty either with direct
submental fat excision or liposuction the approach is via
a 2- to 3-cm incision in a natural submental crease. The
planned incision is injected with local anesthetic and
the incision is made. A small subcutaneous dissection is
performed until the medial aspects of the paired platysma
muscles are defined (Fig. 8-26). The medial edges of these
muscles, or bands, are completely freed and the dissection
is carried laterally to meet with the previously
undermined skin in the neck. This dissection is performed
with a headlight. There are a variety of rakes and retractors
that can be utilized for this step of the procedure. We
prefer a small fine rake followed by a malleable retractor.
Again, the use of countertraction by the assistant greatly
facilitates this dissection.
134
Calvin M. Johnson Jr. • Mark R. Murphy
Figure 8-24 The intervening bridge of tissue separating the superior
and inferior portions of the deep plane is dissected using the push-down
technique.
Figure 8-25 The medial aspect of the deep plane is raised using sharp
dissection. Please note that the suspensory ligaments shown here must be
released for a maximum lift.

After the medial aspects of the muscles are freed, the
flaccid medial components, bands, are grasped with an
Allis clamp. A Kelly clamp is then placed parallel to the
excess musculature being retracted by the Allis. This
excess tissue is then sharply excised and the clamp is
released. Care should be exercised so as not to pull on the
tissues excessively with the Allis to make sure that an
excess of platysma is not removed. There is little need for
hemostasis as the clamp is released. After the excess
platysma is removed, the free ends are then bound with
buried 3-0 Prolene (Fig. 8-27). This closure should be
tensionless so that when the tissue is suspended in the
superolateral vector the bound platysma muscles do not
shred. The surgeon must be cautious not to remove too
much platysma, as the actual mechanism of tightening
the neck is from the superolateral movement of the deep
plane and skin, not the midline binding of the muscle.
The bound muscles act as a sling to lift the submental
region.
After completing the platysmal portion of the pro-
cedure, fat may then be directly excised from the under-
surface of the skin and subcutaneous flap with standard
facelift scissors or by meticulous liposuction under direct
visualization. We use both direct and submental lipo-
suction to remove excess fat in this area depending on the
severity of the amount of fat. We prefer, as do others,
direct lipectomy for removal of significant amounts of fat.
With the direct exposure the surgeon may comfortably
remove adequate fat while maintaining the masking
properties of this fat layer.88
The surgeon should display extreme caution in this
aspect of the case. This is not a fat removal procedure.
Although there is a strong temptation to aggressively
utilize this technique many patients may develop
profound anterior banding because the cushioning
padding of fat has been removed. At the far end of this
spectrum is the “cobra” deformity which manifests as a
deep submental concavity as a result of oversuctioned
fat.83,88 Once this deformity is created it is exceedingly
difficult to remedy.
The surgeon can sculpt the preexisting fat but should
avoid operating on patients with an excessive amount of
fat in the submental area. It is recommended to have the
patient lose the excess weight prior to any surgical
manipulation. Before closure, the surgeon should reassess
the area to make sure a smooth contour surface exists
with no irregularities. A suction drain is then placed in the
preplatysmal plane and suspension of the flaps is begun.
The drain serves two purposes. The first is to limit
postoperative hematoma formation. Although no drain
prevents, or resolves, a true hematoma, a drain can mini-
mize the extent of the complication. The other purpose of
the drain is to evacuate normal fluid that accumulates
under the flap and prolongs the healing process. While
these collections are generally physiologically benign, in
this era a premium is placed on a speedy recovery and
return to normal activity. With the drain, this recovery is
hastened.
At this point, the lateral aspect of the deep plane flap
is grasped and pulled in a superolateral vector and
sutured in the preauricular area (Fig. 8-28). The surgeon
should attempt to move the flap as superior as possible
and avoid a lateral pull as that leads to the “operated
CHAPTER 8
The Deep Plane Facelift
135
Figure 8-26 The medial aspects of the paired platysma muscles are
dissected via a submental incision in a natural skin crease.
Figure 8-27 The medial edges of the trimmed platysma muscles are
bound with permanent suture.

look” dreaded by surgeon and patient alike. When
suspending the deep plane, the surgeon should minimize
tension. If not, the SMAS will elongate over time and the
improvement will be gradually lost.89
As desirable as a purely vertical vector is in
facelifting, when oblique traction is applied to the lateral
face the distortions that are produced with a purely
vertical lift are minimized, such as crowding of tissue at
the lateral orbital rim.27 The superior vector is usually
limited with a dog-ear of the deep plane and skin flaps
anteriorly. The flap is then sutured in place with buried
3-0 Prolene sutures. We choose Prolene less for its
permanent effect than for its excellent biocompatibility
and inert nature. We have rarely had any of our deep
Prolene sutures spit.
Infrequently, we need to incise the posterior aspect of
the deep plane flap to redrape it behind the ear to the
mastoid tip. The suture suspensions track from the
mastoid tip to the superoanterior aspect of the flap near
the zygomatic arch (Fig. 8-29). In the region of the
zygomatic arch we often use a smaller caliber suture, 4-0
or 5-0 Prolene, depending on the nature of the flap and
overlying skin. If the tissue lying between the sutures is
rough and will be palpable through the overlying skin, we
will run a 4-0 or 5-0 caliber suture through these areas to
smooth them. When suspending the inferior aspects of the
flap, near the lateral edge of the platysma, the surgeon
should take care not to place excessive tension on one side
of the flap. This is to avoid difficulties in suspending the
contralateral, lower region of the flap. Here the surgeon is
basically pulling against himself or herself.
When the flap suspension is complete, the surgeon
will more often note puckering at the interface of the skin
flap and deep plane. With a sharp scissors, he or she
should free these regions with caution. It is possible to
perforate the deep plane flap when performing this
tailoring if the surgeon migrates deeply. This can be fixed
with a 4-0 Prolene, but it is obviously best to avoid this
problem with a careful dissection technique.
The skin flap is then tailored and sutured into place.
The first step in this process is to grasp the flap and
redrape it along a superolateral vector and secure it to the
region immediately above the ear. With the tissue firmly
held with an Adson forceps, a No. 11 blade is then used
to incise the skin at the point of approximation between
the flap and area superior to the auricular root. As with
draping of the deep plane flap, the primary vector should
be superior and limited by the amount of dog-ear
formation anteriorly. The anterior aspect of our incision is
a more favorable vector for tissue suspension.75
Once incised, a key suture is placed to reapproximate
the opposing edges (Fig. 8-30). At this point the surgeon
will have a dog-ear anteriorly between the suture and the
most anterior component of the incision, near the anterior
portion of the sideburn. This dog-ear is marked and
136
Calvin M. Johnson Jr. • Mark R. Murphy
Figure 8-28 The deep plane flap is grasped near the angle of the
mandible and using a near vertical vector is suspended superiorly with a
buried 3-0 Prolene suture.
Figure 8-29 The last of several suspension sutures is placed.
Figure 8-30 The first skin suspension suture is placed. The skin flap is
suspended in a superolateral vector. The flap is incised with a No. 11 blade
as it is held in the desired location with an Adson forceps.

excised and the opposing skin edges are stapled (Figs.
8-31 and 8-32). We prefer stapling rather than suturing
in this area because the staples are masked by the hair
and we believe the staples cause less constriction of the
blood vessels, thus maximizing blood supply to the
regenerating hair follicles.
The next key suture is the postauricular tacking
stitch. The skin flap is grasped in the postauricular region
and draped in an almost direct superior vector. As
opposed to the preauricular tacking suture a No. 11 blade
is not needed to incise the flap. In actuality, the surgeon is
grasping tissue that previously lay at the level near the
lobule and advancing it to the turnoff point of the postau-
ricular incision as it turns posterior into the hairline. This
will leave a dog-ear in the hair-bearing area. This is
marked, excised, and stapled in an identical fashion to the
preauricular dog-ear (Fig. 8-33).
At this juncture the fashioning of the preauricular
incision is performed. The surgeon should grasp the skin
with an Adson forceps in front of the ear, and using the
inferior conchal bowl as a guide the surgeon cuts the skin
with a scissors to the area immediately inferior to the
tragus. The preauricular skin is then tailored, with this
mark as a guide (Fig. 8-34). When excising the excess skin
the surgeon should leave a 2- to 3-mm gap between the
opposing skin edges (Fig. 8-35) to compensate for the
inherent residual laxity that causes a sheared appearance
to the scar as it heals. Obviously care must also be taken
to avoid leaving too large a gap and thus creating a
situation of extreme tension at the closure site, especially
at the lobule where a satyr’s ear may result. The skin
closure is performed with 5-0 Prolene in a running,
locking fashion that is begun at the lobular attachment
with a vertical mattress suture (Fig. 8-36). Another
vertical mattress suture is placed adjacent to this one and
a running, locking suture is performed on the posterior
aspect of the closure (Figs. 8-37 and 8-38). If a
submental approach was performed, this incision is closed
with interrupted vertical mattress sutures.
After closure is complete, the wounds are coated with
antibiotic ointment and a nonadherent Telfa dressing is
placed over the incisions. The wounds are then dressed in
a light compressive dressing of fluffed cotton and Kerlix.
Figures 8-39 and 8-40 demonstrate preoperative and
postoperative photographs of individuals who have
undergone deep plane facelift procedures.
CHAPTER 8
The Deep Plane Facelift
137
Figure 8-31 The anterior dog-ear is excised.
Figure 8-32 The anterior aspect of the incision is closed with staples.
Figure 8-33 The posterior dog-ear is excised. This area is closed in a
similar fashion to the anterior dog-ear.

POSTOPERATIVE CARE
The patient undergoing facial rejuvenation is very
concerned about the night of his or her surgery. By
keeping the patient within our facility, with our personnel,
the patient is reassured of attendant care in a manner not
possible in a hospital. And even though it is certainly
acceptable to send the patient home, or to a hotel, on the
night of the procedure with trained personnel, if a
138
Calvin M. Johnson Jr. • Mark R. Murphy
Figure 8-37 The complete closure. The postauricular incision is closed
in an identical manner to the preauricular portion, starting with a vertical
mattress and completed in a running, locking fashion.
Figure 8-38 The complete closure is shown with the deeper
suspension sutures.
Figure 8-34 The preauricular excess skin is removed. Note the guiding
cut at the inferior aspect of the tragus.
Figure 8-35 A 2- to 3-mm gap is ideal to compensate for post-
operative skin laxity.
Figure 8-36 The preauricular closure is begun with a vertical mattress
suture and completed in a running, locking fashion.

problem arises it is optimal to have the facilities to deal
with such an issue immediately.
The following morning all drains are removed and a
lighter compression dressing is placed. This lighter
dressing is removed by the patient, at home, on the
following day. The patient is instructed to maintain
meticulous care of the incisions with 50% hydrogen
peroxide and antibiotic ointment. On postoperative day 3
or 4 the preauricular and submental sutures are removed
and the incisions are immediately taped with flesh tone
tape after the application of an adhesive. The postau-
ricular sutures and staples are removed 1 week after the
surgery, followed by the application of tape and adhesive.
The tape remains on the incisions 24 hours a day for
1 week. After this period, depending on the patient’s
healing, we continue taping only at night for up to a month.
We advise patients that they can return to nonstrenuous
work within 1 week, though most patients choose to take
2 weeks off. The patient is also instructed that he or she
may comfortably go out in public within 10 to 14 days.
Strenuous activity may slowly commence 3 to 4 weeks
from the procedure.
CHAPTER 8
The Deep Plane Facelift
139
A
B
Figure 8-39 Preoperative frontal (A) and
lateral (C) views of a 67-year-old woman.
Postoperative frontal (B) and lateral (D) views of
a 67-year-old woman after a tricophytic browlift,
upper lid blepharoplasty, transconjunctival lower
lid blepharoplasty with skin pinch, and deep
plane facelift.
C
D

COMPLICATIONS
The most common risk with this technique, as with all
facelifts, is hematoma formation. Hematomas predomi-
nantly occur within the first 6 to 12 hours after the
procedure; thus our preference for keeping our patients
within our facility. The only factor proved to increase the
incidence of hematoma is preoperative hypertension.90
The incidence of hematomas in facelift surgery has been
reported between 0.3% and 15% with a variety of
operative techniques.90-96 For deep plane techniques, the
incidence has been reported at 2.2% for major hematomas
and 6.65% for minor hematomas. It should be noted that
none of the hematomas in this report were in the deep
plane, thus confirming the premise that this is a relatively
avascular plane.96 Left untreated, a facial hematoma can
have catastrophic consequences.97 The damage incurred
with hematomas is greatly lessened when the issue is
promptly noted and treated.
Other, less common issues may also occur. Skin loss is
exceedingly rare with the enhanced vascularity seen with
140
Calvin M. Johnson Jr. • Mark R. Murphy
Figure 8-40 Preoperative frontal (A) and lateral
(C) views of a 48-year-old woman. Postoperative
frontal (B) and lateral (D) views of a 48-year-old
woman after a coronal browlift, upper lid blepharo-
plasty, transconjunctival lower lid blepharoplasty with
skin pinch, and deep plane facelift.
A
B
C
D

our technique. Infection is also very rare secondary to
the excellent vascular supply to the face as a whole.
Hypertrophic scarring in our practice is most commonly
seen in the postauricular region and is managed with
monthly Kenalog-10 injections and massage. These scars
usually resolve given the appropriate time.
The most feared complication of the deep plane
technique is facial nerve paralysis. In the senior author’s
practice of a decade with the technique described herein
no permanent nerve injuries have occurred (unpublished
data). Kamer has recently reported no facial nerve
injuries in over 2600 cases with a similar deep plane
technique.98 Reports in the literature range from 0.4% to
2.6% for various techniques.46,93,99-102 Although it seems
counterintuitive, we feel that dissecting in a deeper plane
is safer than other procedures. The surgical planes are
very well delineated using our technique. It is not
uncommon to notice a mild paresis within the first
6 hours after surgery. Calm should be maintained as this
is most likely secondary to the use of local anesthesia. If
the paresis exists beyond this time, patience must be
practiced by both the physician and the patient, as the
issue will likely resolve, albeit slowly.
The most common nerve injury is iatrogenic trauma
to the greater auricular nerve.103 Of the motor branches of
the facial nerve, the frontal and marginal branches are at
the greatest risk for a functional deficit. This is due to the
lack of a significant anastomotic network.46 For the deep
plane and subsequent composite techniques, the reported
rates of facial nerve injuries were 0.99% and zero percent,
respectively, with no permanent weakness.67
Future Considerations
Long-standing improvement in the midface continues to
be an elusive goal for the facial cosmetic surgeon. It has
been found that after 12 years the improvement in the
jawline is superior to that found in midface, as noted by
improvement in the nasolabial fold. It should be noted in
this report that the sample size was small, 20 patients,
and that all patients were pleased with their results.
Within this field of surgery patient satisfaction must be
recognized and honored.104, 105
We would suggest that this is not a technical fault, but
merely that the patient does continue to age and that
different components of the face age differently. An
improvement that lasts for years should not be dismissed
in this realm of surgery, especially with patients’
understanding that they will continue to age and that we
have an arsenal of techniques to deal with aging after the
original procedure. We feel our techniques minimize the
common sequelae of the standard facelift.33,74
To minimize the “lateral sweep,” we prefer a prehairline
incision in the temple region to make the vector more
vertical.29,74
We have discussed the subperiosteal and composite
techniques previously in this chapter. The benefits of
approaching the midface through the lower lid must be
weighed against the morbidity incurred.106
Our approach to facelifting, as with our overall practice
approach, is the attainment of a natural result via
conservative means. We seek to provide the patient with
a lasting, natural result where the observer cannot detect
that an operation has occurred. The deep plane
technique may not be considered conservative in some
quarters but with the technique performed as described
herein we feel it to be exceedingly safe and well
tolerated by the patient.
Various modalities have been recommended to address,
and complement, trouble areas of facial rejuvenation
such as the nasolabial folds. Fat grafting, soft tissue fillers,
and alloplastic implants are all adjunctive methods that
may be utilized by the surgeon to attain the optimal
result. It is beyond the scope of this chapter to discuss, in
detail, each of these methods. Each has its own strengths
and weaknesses. Fat grafting is highly variable and there
are donor site issues that must be considered. Soft tissue
fillers do not have donor site considerations but there is
the question of longevity, infection, and injection
technique, which can be painful even with regional
blocks. The more permanent tissue fillers can potentially
cause palpable abnormalities. Alloplastic implants are a
consideration, but unless the original issue was a
hypoplastic malar eminence on retrognathia the surgeon
must question what he or she is treating.
We have followed with great interest the progress of
the invasive, minimally invasive, and endoscopic
approaches to midfacial rejuvenation.34,107-109 We feel, as
do others, that an ideal midfacial rejuvenation procedure
has yet to be determined (see Figs. 8-39 and 8-40).
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