correct the hanging columella is set-back of the medial
crura on the overly long caudal septum. After dissecting
between the medial crura, the medial crura can be
sutured to the caudal septum with 5-0 clear nylon suture
to set tip projection and alar/columellar relationship.
POSTOPERATIVE CARE
Careful postoperative care is critical to achieve an optimal
result following rhinoplasty. In addition, patients should
be monitored closely during the immediate postoperative
period to ensure adequate oxygenation and hemostasis.
To avoid life-threatening complications, the cardiac and
pulmonary status of the patient should also be monitored.
Finally, if nasal packing is used, it should be removed
within 24 hours after surgery, with subsequent examination
of the septal flaps to evaluate for a septal hematoma.
Columellar sutures should be removed on the seventh
postoperative day. Postoperative edema that develops in
the supratip region can be treated with taping of the
supratip. On rare occasions, subdermal injections (0.1 to
0.2 mL) of triamcinolone acetonide (Kenalog, Westwood-
Squibb, Buffalo, NY, 10 mg/mL) can be placed into the
supratip. Such injections should only be used in patients
with thick skin. These injections may be administered
2 weeks after surgery, with no more than one injection
per month. Dermal atrophy may result from either
intradermal injections or frequent injections of higher
concentrations of Kenalog.
300
Ryan M. Greene • Dean M. Toriumi
Figure 18-11 Continued.
G
H
E
F
COMPLICATIONS
Because rhinoplasty is considered to be an elective
surgery, complications in the postoperative period can be
particularly distressing. It has been estimated that
complications occur in approximately 10% of cases.20
This figure may actually be much higher if sequelae such
as persistent swelling, ecchymoses, and skin discoloration
are considered. Postoperative sequelae and complications
of rhinoplasty generally fall into five major categories:
infection, trauma, necrosis, functional problems, and
iatrogenic difficulties.5
Rhinoplasty is considered by many to be the most
difficult facial plastic operation, largely due to the
intricate and highly variable anatomy. In addition, any
surgical modification is likely to change over the lifetime
of the patient, secondary to postoperative scar contracture
and healing. For these reasons, primary rhinoplasty is
often associated with a suboptimal outcome. It has been
estimated that 8% to 15% of primary rhinoplasty patients
eventually undergo revision surgery.21 There are a number
of nasal deformities that can result from primary
rhinoplasty, including middle vault collapse, supra-alar
pinching, and pollybeak deformity. Every surgeon should
become familiar with these deformities.
Future Considerations
The aging nose presents many unique challenges that
must be considered to achieve a desirable result. In
addition to addressing aesthetic changes, proper
preoperative diagnosis is critical to identify all existing
functional deficits. In this age group, aesthetic changes
should be conservative, with extensive discussion prior
to surgery. Because there is decreased structural support
in the older patient, excision of supportive cartilaginous
and bony structures should be minimized. Additional
support should instead be provided with structural grafts
to stabilize the nose and increase the likelihood of a
favorable functional and aesthetic outcome.
REFERENCES
1. Janeke JB, Wright WK: Studies on the support of the nasal tip.
Arch Otolaryngol 1971;93:458-464.
2. Krmpotic-Nemanic J, Kostovic I, Rudan P, et al:
Morphological and histological changes responsible for the
droop of the nasal tip in advanced age. Acta Otolaryngol
1971;71:278-281.
3. Patterson CN: The aging nose: Characteristics and correction.
Otolaryngol Clin North Am 1980;13:275-288.
4. Tardy ME: Rhinoplasty in midlife. Otolaryngol Clin North Am
1980;13:289-303.
5. Holt GR, Garner ET, McLarey D: Postoperative sequelae and
complications of rhinoplasty. Otolaryngol Clin North Am
1987;20:853-876.
6. Toriumi DM: Surgical correction of the aging nose. Facial
Plast Surg 1996;12:205-214.
7. Larrabee WF: Rhinoplasty in the aging patient. In Krause CJ,
Pastorek N, Mangat DS (eds): Aesthetic Facial Surgery.
Philadelphia: JB Lippincott, 1991, pp 361-384.
8. Johnson CM, Anderson JR: Nose lift operation: An adjunct to
aging face surgery. Arch Otolaryngol 1978;104:1-6.
9. Kabaker SS: An adjunctive technique to rhinoplasty of the
aging nose. Head Neck Surg 1980;2:276-281.
10. Toriumi DM, Johnson CM: Open structure rhinoplasty:
Featured technical points and long-term follow-up. Facial
Plast Surg Clin North Am 1993;1:1-22.
11. Anderson JR: Surgery of the nasal base. Arch Otolaryngol
1984;110:349-358.
12. Tardy ME, Cheng E: Transdomal suture refinement of the
nasal tip. Facial Plast Surg 1987;4:317-326.
13. Toriumi DM, Tardy ME: Cartilage suturing techniques for
correction of nasal tip deformities. Op Tech Otolaryngol Head
Neck Surg 1995;6:265-273.
14. Johnson CM, Toriumi DM: Open Structure Rhinoplasty.
Philadelphia, WB Saunders, 1990.
15. Toriumi DM: Management of the middle nasal vault in
rhinoplasty. Op Tech Plast Reconstr Surg 1995;2:16-30.
16. Sheen JH: Spreader graft: A method of reconstructing the roof
of the middle nasal vault following rhinoplasty. Plast Reconstr
Surg 1984;73:230-237.
17. Tardy ME, Garner ET: Inspiratory nasal obstruction secondary
to alar and nasal valve collapse. Op Tech Otolaryngol Head
Neck Surg 1990;1:215-217.
18. Constantian MB: The incompetent external nasal valve:
Pathophysiology and treatment in primary and secondary
rhinoplasty. Plast Reconstr Surg 1994;93:919-931.
19. Toriumi DM: Caudal extension graft for correction of the
retracted columella. Op Tech Otolaryngol Head Neck Surg
1995;6:311-318.
20. Weimert TA, Yoder MG: Antibiotics and nasal surgery.
Laryngoscope 1980;90:667-672.
21. Byrd HS, Hobar PC: Rhinoplasty: A practical guide for
surgical planning. Plast Reconstr Surg 1993;91:642-656.
CHAPTER 18
Rhinoplasty in the Aging Patient
301
Asian blepharoplasty—cont’d
preoperative assessment for, 103–105
consultation and, 103–104
eyelid and facial aesthetics and,
104–105
surgical technique for, 105–115
full-incision, 112–115
for lower blepharoplasty, 101
partial-incision, 105–112
for upper blepharoplasty, 100–101
Asymmetry
following Asian blepharoplasty, 116–117
following mentoplasty, 225
with lipectomy, 243
Attractiveness, 1, 1f
Auricular nerve, greater, injury to, with
deep plane facelift, 141
Autologous fat transfer, 247–259
anatomy and, 249–251, 250f
of lower third of face, 250–251
of middle third of face, 250
of upper third of face, 250
complications of, 257–258, 258f
future considerations for, 259
historical background of, 247
philosophy for, 247–249, 248f,
249f
postoperative care for, 257
preoperative assessment for, 251
surgical technique for, 251–257
fat harvesting and, 251, 251f
general considerations and, 251
infiltration of fat and, 252–257
for lower third of face, 255–256,
256f, 257f
for middle third of face, 254–255,
255f, 256f
processing of fat and, 251–252,
253f, 254f
for upper third of face, 253–254,
254f
Autologous fat transfer—cont’d
for tridimensional endoscopic facelift,
188
Baker’s formula, for deep peels, 265
Baldness. See Alopecia.
Beauty concept
facial rejuvenation and, 3–4
historical background of, 1–3
in ancient Greece, 1–2, 2f
during Renaissance, 2f, 2–3, 3f
Beta hydroxy acid, for superficial peels,
265
Bichat’s fat pad excision, for tridimensional
endoscopic facelift, 187–188
Bitemporal fixation, for endoscopic
foreheadplasty, 52
Blepharoplasty, 8, 59–88
anatomy and, 60–63
of eyelid, 60f, 60–61
of eyelid skin, 61
of levator muscle, 62–63, 63f
of orbicularis muscle, 61, 61f
of orbital fat, 62, 62f
of orbital septum, 61, 62f
of tarsal plates, 62, 63f
Asian. See Asian blepharoplasty.
complications of, 8–9, 9f
future considerations for, 88
historical background of, 59
philosophy for, 59–60
postoperative care for, 80, 82–83, 83b
postoperative problems with, 83–87
aesthetic, 84–85
blindness as, 87
diplopia as, 87
fat pocket overcorrection as, 86
functional, 86–87
lid hematoma as, 86
of lower lid position, 85
nonresolvable, 84
Ablative laser resurfacing, 261, 263f,
263–264
Alopecia
with endoscopic foreheadplasty, 56
with open brow lift, 44
with tridimensional endoscopic facelift,
195
Alpha hydroxy acid, for superficial peels,
265
Aphrodite, 1, 2f
Artefill, 269–270, 270f
Asian blepharoplasty, 99–121
anatomy and, 101–103, 102f, 103f
complications of, 116–121
asymmetry as, 116–117
fold loss as, 117–118
infection as, 118–119
revision surgery and, 120–121
scarring as, 119–120
suture extrusion as, 118
full-incision method for, 112–115
general considerations for, 112–113,
113f–114f
operative technique and, 113–115,
115f–121f
future considerations for, 121
historical background of, 99
partial-incision method for, 105–112
general considerations for, 105, 105f
operative technique and, 105–112,
106f–113f
philosophy for, 99–101
aesthetics and cultural
considerations and, 99–100
lower blepharoplasty techniques
and, 101
upper blepharoplasty techniques
and, 100–101
with younger versus older patients,
101
postoperative care for, 115–116
303
Index
Note: page numbers followed by b indicate boxed material; those followed by f indicate
figures; those followed by t indicate tables.
Blepharoplasty
postoperative problems with—cont’d
orbital hematoma as, 87
slowly resolving, 83–84
of upper lid position, 85–86
preoperative evaluation for, 63–67
of eyelid anesthetic problem, 65–67,
66f, 67f
medical, 63–64
ophthalmologic examination in, 64f,
64–65, 65f
ophthalmologic history in, 64
psychological, 63, 64f
skin-only, for tridimensional
endoscopic facelift, 187
surgical technique for, 67–80
anesthesia of upper lid and, 68–70
for lower lid skin muscle flap
blepharoplasty, 71, 73, 75–78,
76f–82f, 80
skin marking in upper lid and,
67–68, 68f, 69f
for upper lid blepharoplasty, 70–71,
70f–75f
transconjunctival, lower. See
Transconjunctival lower
blepharoplasty.
Blepharoptosis, 8, 8f
following blepharoplasty, 85–86
Blindness, following blepharoplasty, 87
Botticelli, Sandro, 3
Botulinum toxin type A (Botox),
267–269, 268f
Branchial apparatus, embryology of,
17–18, 18f, 18t
Brow
anatomy of, 24–26, 34–35, 35f
innervation and, 25–26, 26f
lymphovascular, 26
myocutaneous and soft tissue,
24–25, 25f
skeletal, 24
in physical examination and facial
analysis, 6–7, 7f
treatment considerations for, 7
Brow ptosis, with endoscopic
foreheadplasty, 56
Buccal fat pad
age-related changes in, 124, 126f
deep plane facelift and, 134
Burning, of eyes, following
blepharoplasty, 83
Calcium hydroxylapatite, 270f, 270–271
Cannulas, for liposuction, 233, 233f,
234f
Canthal tendons, medial, anatomy of, 61,
61f
Canthoplasty. See Lateral canthoplasty.
Captique, 266
Cardiac toxicity, of phenol, 265
Caruncle, anatomy of, 90
Cervicofacial rhytidectomy, cervicoplasty
versus, for tridimensional
endoscopic facelift, 188
Cervicoplasty, for tridimensional
endoscopic facelift
anterior approach, 188–189
cervicofacial rhytidectomy versus,
188
Cheek
age-related changes in, 124, 125f
anatomy of, 28–30
innervation and, 29
lymphovascular, 29–30
myocutaneous and soft tissue,
28–29, 28f–30f
skeletal, 28
Chemical peels, 264–265
deep, 265
medium, 265
superficial, 265
Chin, anatomy of, 30–31, 218–219
innervation and, 31
lymphovascular, 31
myocutaneous and soft tissue, 30
skeletal, 30
Chin augmentation. See Mentoplasty.
Chin projection, 11, 11t
CO2 laser, for ablative resurfacing,
263–264
Collagen, as filler substance, 266
Columella, retracted, correction of,
297–300, 298f–300f
Columellar struts, for ptotic nasal tip,
287–288, 289f
Consultation, 4–13
history taking in, 4
morphing software for, 16
photography in, 13–14, 15f, 16
physical examination and facial
analysis in, 4t, 4–13, 5f, 6f
eyelids and periorbital region in,
7–9, 8f, 9f
forehead and brow complex in, 6–7,
7f
lower face and neck in, 10–11, 11t,
12f–13f, 13
midface in, 9–10, 10f
skin in, 4–6, 6t
Contact dermatitis, following
blepharoplasty, 83–84
Contact lenses, difficulties with, following
blepharoplasty, 83
Contour irregularities, with fat grafting,
257–258, 258f
Cool Touch laser, 264
Coronal incision, for open brow lift,
35–36, 36f, 37, 37f, 39
closure for, 41, 41f
Corrugator muscle, 35, 35f
Da Vinci, Leonardo, 3
Dedo neck classification, 11, 11t,
12f–13f, 13
Deep plane facelift, 123–141
anatomy and, 124, 125f, 126f,
126–127
complications of, 140–141
future considerations for, 141
historical background of, 123
philosophy for, 123–124
postoperative care for, 138–139
preoperative assessment for, 127
surgical technique for, 127–131,
128f–140f, 133–137
Dental occlusion, evaluation, 11, 11t
Depressor supercilii muscle, 35, 35f
Dermatitis, contact, following
blepharoplasty, 83–84
Digital photography, 13–14, 15f, 16
Diplopia, following blepharoplasty, 87
Double convexity deformity, 8, 8f
Dry eye syndrome, following
blepharoplasty, 86–87
Ear, external, embryology of, 18, 19f, 20
Ecchymosis, of eyelids, following
blepharoplasty, 83
Ectoderm, 17
Ectropion, 276
following blepharoplasty, 85
Elastic garment dressing, for midface
implants, 211, 214f
Embryogenesis, 17
Embryology, 17–21
of branchial/pharyngeal apparatus,
17–18, 18f, 18t
of external ear, 18, 19f, 20
of eye, 20
of face and nose, 20f, 20–21, 21f
of nasal cavity and paranasal sinuses,
21
of palate, 21
Endoderm, 17
Endoscopy. See Foreheadplasty,
endoscopic; Tridimensional
endoscopic facelift.
304
Index
Entropion, following transconjunctival
lower blepharoplasty, 95
Epiphora, following blepharoplasty, 87
Er:YAG laser, for ablative resurfacing,
263
External ear, embryology of, 18, 19f, 20
Eye(s)
burning of, following blepharoplasty,
83
dry, following blepharoplasty, 86–87
embryology of, 20
Eyelid(s). See also Asian blepharoplasty;
Blepharoplasty; Transconjunctival
lower blepharoplasty.
anatomy of, 22–24, 60f, 60–61
innervation and, 24
lymphovascular, 24
myocutaneous and soft tissue, 22f,
22–24, 23f
anesthesia for blepharoplasty and,
65–67, 66f, 67f
ecchymosis of, following
blepharoplasty, 83
hyposensitivity of, following
blepharoplasty, 83
inferior rotation of margin of,
following blepharoplasty, 85
lateral canthoplasty and. See Lateral
canthoplasty.
lower
changes in texture and appearance
of skin of, following
blepharoplasty, 83
testing tone of, 66, 66f
malposition of, following lateral
canthoplasty, 283
in physical examination and facial
analysis, 7–9, 8f, 9f
retraction of, 276
skin of, 61
treatment considerations for, 9
upper
anesthesia of, 68–70
inflammatory lesions of, following
blepharoplasty, 83
skin marking of, for blepharoplasty,
67–68, 68f, 69f
Facelifts. See Deep plane facelift; Lateral
SMASectomy facelift;
Rhytidectomy; Short-flap SMAS
rhytidectomy.
Facial analysis. See Physical examination
and facial analysis.
Facial anatomy, 21–31. See also specific
procedures.
Facial anatomy—cont’d
of eyelid and orbit, 22–24
innervation and, 24
lymphovascular, 24
myocutaneous and soft tissue, 22f,
22–24, 23f
skeletal, 22, 22f
of forehead and brow, 24–26
innervation and, 25–26, 26f
lymphovascular, 26
myocutaneous and soft tissue,
24–25, 25f
skeletal, 24
of lip and chin, 30–31
innervation and, 31
lymphovascular, 31
myocutaneous and soft tissue, 30
skeletal, 30
of lower third, 250–251
of middle third, 250
of midface and cheek, 28–30
innervation and, 29
lymphovascular, 29–30
myocutaneous and soft tissue,
28–29, 28f–30f
skeletal, 28
of neck, 31
innervation and, 31
lymphovascular, 31
myocutaneous and soft tissue, 31
skeletal, 31
of scalp and hair, 26–28
innervation and, 27
lymphovascular, 27f, 27–28
myocutaneous and soft tissue, 26–27
skeletal, 26
of upper third, 250
Facial angles, 4, 4t
Facial artery, transverse, anatomy of,
126–127
Facial embryology, 20f, 20–21, 21f
Facial landmarks, 4, 5f
Facial nerve injury
with deep plane facelift, 141
with liposuction, 243
with midface implants, 214
prevention of, in facelift surgery, 156,
156f
with tridimensional endoscopic facelift,
194–195
Facial rejuvenation, historical
background of, 3–4
Facial suction lipectomy, 227–243
anatomy and, 229f, 229–230, 230f
complications of, 242–243, 243f
future considerations for, 243
Facial suction lipectomy—cont’d
historical background of, 227
philosophy for, 227–229, 228f
postoperative care for, 242
preoperative assessment for, 230–232,
231f, 232f
surgical technique for, 232–242
anesthesia and, 234–235, 235f, 235t
equipment and, 232–233, 233f,
234f
markings and, 233–234, 234f
technique and, 235–239, 236f–242f,
241–242
Fat
harvesting of, for autologous fat
transfer, 251, 252f
infiltration of, for autologous fat
transfer, 252–257
orbital, anatomy of, 62, 62f
processing of, for autologous fat
transfer, 251–252, 253f, 254f
Fat grafting. See Autologous fat transfer.
Fat pads, of lower eyelid, 90, 90f
Fat pockets, overcorrection of, following
blepharoplasty, 86
Fat pseudohernias, following
blepharoplasty, 84
Fat transfer. See Autologous fat transfer.
Fitzpatrick scale, 4, 6t, 262, 262t
Fold loss, following Asian blepharoplasty,
117–118
Forehead
anatomy of, 24–26
innervation and, 25–26, 26f
lymphovascular, 26
myocutaneous and soft tissue,
24–25, 25f
skeletal, 24
in physical examination and facial
analysis, 6–7, 7f
treatment considerations for, 7
Forehead lift, endoscopic, technique for,
175–178, 176f–179f
Foreheadplasty, endoscopic, 47–56
anatomy and, 48, 48f, 49f, 49t
complications of, 56
dissection of forehead and temporal
area and, 50
endoscopic equipment for, 48–49
fixation in, 52, 52f–55f, 56
frontal, temporal/lateral, 56
frontalis plication and, 56
glabellar, 56
historical background of, 47
incisions for, 49, 50f
optical cavity creation for, 49–50
Index
305
Foreheadplasty, endoscopic—cont’d
philosophy for, 47–48
postoperative care for, 56
preoperative assessment for, 48
with receding hairlines and baldness,
56
release of tissue attachments to bone
and deep fascia and, 50f, 50–51,
51f
surgical technique for, 49, 49b
tissue modifications for, 51f, 51–52
Frontalis muscles, 34–35, 35f
scoring of, for open brow lift, 41, 41f
Frontalis plication, in endoscopic
foreheadplasty, 56
Galea aponeurotica, 34, 35, 35f
Glabellar endoscopic foreheadplasty, 56
Glabellar muscle, exposure of, for open
brow lift, 40, 40f
Glogau classification, 263, 264t
Glycolic acid, for superficial peels, 265
Granulomas, with polymethyl
methacrylate treatment, 269–270
Greece
ancient, beauty and, 1–2, 2f
definition of beauty and, 1, 1f
Hair loss. See Alopecia.
Hairline, receding, endoscopic
foreheadplasty with, 56
Hematomas
following deep plane facelift, 140
of lids, following blepharoplasty, 86
with liposuction, 243
with open brow lift, 44
orbital, following blepharoplasty, 87
with tridimensional endoscopic facelift,
195
Hemorrhage, following blepharoplasty,
95
History taking, 4
Hyaluronic acid, stabilized, as filler
substance, 266, 267f
Hylaform, 266
Hyoid bone, position of, facial suction
lipectomy and, 231, 232f
Hyperpigmentation, following ablative
laser resurfacing, 264
Hypopigmentation, following ablative
laser resurfacing, 264
Implants, midface. See Midface implants.
Infection
following Asian blepharoplasty,
118–119
Infection—cont’d
with mentoplasty, 225
with midface implants, 214
with tridimensional endoscopic facelift,
195
Infraorbital nerve injury, with midface
implants, 214
Jowls, 126
analysis of, 11
Juvederm, 266
Lagophthalmos, following
blepharoplasty, 86
Lamellae, 275, 276f
of lower eyelid, 90, 90f
Laryngeal mask airway, for
transconjunctival lower
blepharoplasty, 91
Laser resurfacing
ablative, 261, 263f, 263–264
nonablative, 261, 264, 265f
Lateral canthoplasty, 275–283
anatomy and, 275–276, 276b, 276f
complications of, 283
historical background of, 275
philosophy for, 275, 275b
postoperative care for, 283
preoperative assessment for, 276–278,
277f, 278f
surgical techniques for, 278–283
with maximum lid repositioning,
278f–279f, 280
with minimal lid tightening, 281,
282f, 283
with moderate lid tightening,
280–281, 280f–281f
Lateral crural overlay technique, for
ptotic nasal tip, 288–289,
290f–294f
Lateral SMASectomy facelift, 145–152
complications of, 151–152, 152t
historical background of, 145
philosophy for, 145–146
postoperative care for, 150–151
surgical technique for, 146–150
anesthesia and, 146
defatting of neck and jowls and, 148
incisions and, 146f, 146–147, 147f
lateral SMASectomy including
platysma resection and, 148–149
open submental incision with medial
platysma approximation and, 148,
148f
skin closure and, 149–150, 150f,
151f
Lateral SMASectomy facelift
surgical technique for—cont’d
skin flap elevation and, 147–148
vectors and, 149, 149f
Levator palpebral superioris muscle,
anatomy of, 62–63, 63f
Lid distraction test, 8, 9, 9f
Lip(s), anatomy of, 30–31
innervation and, 31
lymphovascular, 31
myocutaneous and soft tissue, 30
skeletal, 30
Lip augmentation, silicone injection for,
271
Lipectomy
common cervicofacial regions for, 229,
229f
facial suction. See Facial suction
lipectomy.
ultrasonic, 239, 242
Lipoplasty, of neck and jowls, in lateral
SMASectomy facelift, 148
Liposuction, syringe, handheld, 233
Lower face
anatomy of, of lower third, 250–251
in physical examination and facial
analysis, 10–11, 11t, 12f–13f,
13
treatment considerations for, 11
Malar bags, following blepharoplasty, 84
Malar deficiency, 201, 201t, 202f
Malar eminence
anatomy of, 200–201
dissection of, 206, 206f–208f
Malar shell implants, 208, 209f
Malar wrinkling, following
blepharoplasty, 84
Malar-submalar deficiency, 201t,
202–203, 205f
Malar-submalar implants, 208
Mandibular matrix system, 189–192
implant placement for, 190–192,
190f–194f
implant system for, 189–190
button chin implant as, 190
extended wrap-around chin implant
as, 189
mandibular angle implant as, 189
prejowl implant as, 190
Mandibular nerve, marginal, anatomy of,
229
Margin reflex distance, 8, 8f
Masseteric ligaments, anatomy of,
126
Mentocervical angle, 4t
306
Index
Mentopexy, for tridimensional endoscopic
facelift, 181–182, 184–185,
184f–188f, 187
Mentoplasty, 217–225
anatomy and, 218–219
complications of, 225
future considerations for, 225
historical background of, 217
philosophy for, 217–218, 218f
postoperative care for, 224–225
preoperative assessment for, 219f,
219–220, 221f, 222f
with submental liposuction, 239,
240f
surgical technique for, 220, 222f–225f,
223–224
Mesoderm, 17
Midface
aging of, 124, 125f, 126, 199–200
anatomy of, 28–30, 250
innervation and, 29
lymphovascular, 29–30
myocutaneous and soft tissue,
28–29, 28f–30f
skeletal, 28
deformity of, patterns of, 201t,
201–203, 202f–205f
in physical examination and facial
analysis, 9–10, 10f
treatment considerations for, 10
Midface implants, 197–214
anatomy and, 199–201, 201f
complications of, 214
future directions for, 214
historical background of, 197
philosophy for, 197–199, 198f–200f
postoperative care for, 211, 214
preoperative analysis for, 201t,
201–203, 202f–205f
surgical technique for, 202–211
exposure of submalar triangle and
creation of implant pocket and,
206, 208, 208f
general guidelines for, 202–205
implant insertion and, 208–210,
209f, 210f
incision and dissection of malar
eminence and, 206, 206f–208f
preparation for surgery and,
205–206, 206f
securing implants and, 210–211,
211f–213f
wound closure and dressing and,
211, 214f
Midface lift, endoscopic, technique for,
178–181
Milia, incisional, following
blepharoplasty, 85
Morphing software, 16
Nasal cavity, embryology of, 21
Nasal profile alignment, 294–295,
296f–297f
Nasal tip, ptotic, correction of, 287–289,
288f–295f, 292
Nasal valve collapse, 295–297, 298f
Nasal vault, middle, narrowed, 293–294
Nasofacial angle, 4t
Nasofrontal angle, 4t
Nasolabial angle, 4t
acute, correction of, 297–300, 298f–300f
Nasolabial fold, age-related changes in,
124, 126
Nasomental angle, 4t
Neck
analysis of, 11, 11t, 12f–13f, 13
anatomy of, 31
innervation and, 31
lymphovascular, 31
myocutaneous and soft tissue, 31
skeletal, 31
in physical examination and facial
analysis, 10–11, 11t, 12f–13f, 13
youthful-appearing, criteria for,
229–230, 230f
Nefertiti, 1, 1f
N-lite laser, 264
Nonablative laser resurfacing, 261, 264,
265f
Noninvasive facial rejuvenation, 261–272
ablative laser resurfacing as, 261,
263f, 263–264
anatomy and, 261–262, 263f
chemical peels as, 264–265
deep, 265
medium, 265
superficial, 265
future considerations for, 272
historical background of, 261
injectable substances for, 261,
265–272, 266b, 267f
botulinum toxin type A as, 267–269,
268f, 269f
calcium hydroxylapatite as, 270f,
270–271
collagen as, 266
poly-L-lactic acid as, 271–272
polymethyl methacrylate as,
269–270, 271f
silicone as, 271
stabilized hyaluronic acid as, 266,
267f
Noninvasive facial rejuvenation—cont’d
nonablative laser resurfacing as, 261,
264, 265f
philosophy for, 261
preoperative assessment for, 262t,
262–263, 263b
Nose. See also Nasal entries; Rhinoplasty.
age-related changes in, 285
embryology of, 20f, 20–21, 21f
narrowing of, 294–295, 296f–297f
Numbness
with endoscopic foreheadplasty, 56
following mentoplasty, 225
Oblique muscle, inferior, damage to, with
transconjunctival lower
blepharoplasty, 97
Open browlift, 33–44
anatomy and, 34–35, 35f
author’s philosophy for, 33–34
complications of, 43–44
historical background of, 33
postoperative care for, 33–43
preoperative assessment for, 35f,
35–36
technique for, 36–42, 36f–43f
Ophthalmologic examination, for
blepharoplasty, 64f, 64–65, 65f
Ophthalmologic history, blepharoplasty
and, 64
Orbicularis muscle, anatomy of, 61, 61f
Orbicularis ridge, beneath lower lid
incision, prominent, following
blepharoplasty, 84–85
Orbit, anatomy of, 22–24
innervation and, 24
lymphovascular, 24
myocutaneous and soft tissue, 22–24,
23f
skeletal, 22, 22f
Orbital fat, anatomy of, 62, 62f
Orbital septum, anatomy of, 61, 62f
Palate, embryology of, 21
Palpebral sulcus, superior, anatomy of,
60f, 60–61
Paramedian fixation, for endoscopic
foreheadplasty, 52
Paranasal sinuses, embryology of, 21
Paresthesia
following mentoplasty, 225
with open brow lift, 44
Periorbital region
in physical examination and facial
analysis, 7–9, 8f, 9f
treatment considerations for, 9
Index
307
Perlane, 266
Pharyngeal apparatus, embryology of,
17–18, 18f, 18t
Phenol peels, 265
Photography, 13–14, 15f, 16
Physical examination and facial analysis,
4t, 4–13, 5f, 6f
eyelids and periorbital region in, 7–9,
8f, 9f
forehead and brow complex in, 6–7, 7f
lower face and neck in, 10–11, 11t,
12f–13f, 13
midface in, 9–10, 10f
skin in, 4–6, 6t
Platysma muscle
approximation of, open submental
incision with, for lateral
SMASectomy facelift, 148, 148f
resection of, lateral SMASectomy
facelift including, 148–149
Platysmal bands, exposure during
lipectomy, 243, 243f
Platysmaplasty
with liposuction, 238–239
in short-flap SMAS rhytidectomy, 158
Polyclitus, 2
Poly-L-lactic acid, injectable, 271–272
Polymethyl methacrylate, 269–270,
271f
Praxiteles, 1, 2f
Pre-embryonic period, 17
Pressure dressings, following facial
suction lipectomy, 239, 242f
Pretarsal muscle, anatomy of, 61, 61f
Pretrichial incision, for open brow lift,
35–39, 37f, 38f
closure for, 41–42, 42f
Procerus muscle, 35, 35f
scoring of, for open brow lift, 40f,
40–41, 41f
Prud’hon, Pierre-Paul, 3, 3f
Pruritus, with open brow lift, 44
Pseudohernias, fat, following
blepharoplasty, 84
Psychological evaluation, for
blepharoplasty, 63, 64f
Radiesse, 270, 271f
Renaissance, beauty concept during, 2f,
2–3, 3f
Renal toxicity, of phenol, 265
Restylane, 266
Revision surgery
following Asian blepharoplasty,
120–121
following rhinoplasty, 301
Rhinoplasty, 285–301
anatomy and, 285
complications of, 301
future considerations for, 301
historical background of, 285
philosophy for, 285
postoperative care for, 300
preoperative assessment for, 286
surgical technique for, 286–300
for acute nasolabial angle or
retracted columella, 297–300,
298f–300f
external approach for, 286
for external nasal valve collapse,
295–297, 298f
for narrowed middle nasal vault,
293–294
preoperative considerations and,
286, 287f
profile alignment and narrowing of
nose and, 294–295, 296f–297f
for ptotic nasal tip, 287–289,
288f–295f, 292
for septal surgery, 287
Rhytidectomy. See also Deep plane
facelift; Lateral SMASectomy
facelift; Short-flap SMAS
rhytidectomy.
cervicofacial, cervicoplasty versus,
for tridimensional endoscopic
facelift, 188
liposuction with, 239, 241f
Rubens, Peter Paul, 2, 2f
Scalp, anatomy of, 26–28
innervation and, 27
lymphovascular, 27f, 27–28
myocutaneous and soft tissue, 26–27
skeletal, 26
Scarring
following Asian blepharoplasty,
119–120
following blepharoplasty, 85
following ptotic nasal tip correction,
292
Schirmer test, 9
Scleral show, following blepharoplasty,
85
Sculptra, 271–272
Septal surgery, 287
Short-flap SMAS rhytidectomy, 153–170
anatomy and, 154–156, 155f, 156f
complications of, 166, 166b
future considerations for, 166
historical background of, 153
philosophy for, 153–154
Short-flap SMAS rhytidectomy—cont’d
postoperative care for, 166, 167f–170f
preoperative assessment for, 156, 157b
surgical technique for, 156–160, 157b,
157f–165f, 158b, 162–163, 166
Silicone, injectable, 270–271
Skin
contact dermatitis and, following
blepharoplasty, 83–84
loss of, following deep plane facelift,
140–151
in physical examination and facial
analysis, 4–6, 6t
redundant, persistence following
blepharoplasty
in lower lid, 84
in upper lid, 84
SMAS rhytidectomy, short-flap. See
Short-flap SMAS rhytidectomy.
Snap test, 8–9, 9f
of lower eyelid tone, 66, 66f
Software, morphing, 16
Spreader grafts, for narrowed middle
nasal vault, 293–294
Submalar deficiency, 201t, 201–202,
203f, 204f
Submalar implants, 208
Submalar triangle
anatomy of, 201, 201f
exposure of, 206, 208, 208f
Submental incision, open, with medial
platysma approximation, for
lateral SMASectomy facelift, 148,
148f
Superficial musculoaponeurotic system.
See also Lateral SMASectomy
facelift; Short-flap SMAS
rhytidectomy.
anatomy of, 126
Supraorbital nerve, 35
Supratrochlear nerve, 35
“Surprised look,” with open brow lift, 44
Suture fixation, for midface implants
direct, external, 211, 212f–213f
indirect, lateral, 211, 211f
Suture marks, following blepharoplasty,
85
Suture tunnels, following blepharoplasty,
85
Syringe liposuction, handheld, 233
Tarsal plates, anatomy of, 62, 63f
Tearing, following blepharoplasty, 83
Teeth, dental occlusion and, evaluation,
11, 11t
“Telephone formation,” 51
308
Index
Temporal fixation, for endoscopic
foreheadplasty, 52, 53f–55f
Temporal/lateral frontal Glabellar
endoscopic foreheadplasty, 56
Tightness, sensation of, following
blepharoplasty, 83
Transconjunctival lower blepharoplasty,
89–98
anatomy and, 90, 90f
complications of, 95, 97–98
future considerations for, 98
historical background of, 89
philosophy for, 89–90
postoperative care for, 95
preoperative analysis for, 90–91, 91f
surgical technique for, 91, 92f–98f, 93,
95
Transillumination technique, for deep
plane facelift, 129, 129f
Triamcinolone acetonide, for bulges
following fat grafting, 258
Trichiphytic incision, for open brow lift,
35–39, 37f, 38f
closure for, 41–42, 42f
Trichloroacetic acid, for medium peels,
265
Tridimensional endoscopic facelift,
173–195
anatomy of facial aging and, 175
Tridimensional endoscopic facelift—
cont’d
central oval of face and, 175
complications of, 194–195
future considerations for, 195
historical background of, 173
mandibular matrix system and,
189–192
implant placement for, 190–192,
190f–194f
implant system for, 189–190
philosophy for, 173, 174f
photographic documentation for,
175
postoperative care for, 192–194
preoperative assessment for, 175
surgical technique for, 175–189
anterior approach cervicoplasty and,
188–189
Bichat’s fat pad excision and,
187–188
cervicoplasty versus cervicofacial
rhytidectomy and, 188
fat grafting and, 188
forehead lift procedure and,
175–178, 176f–179f
mentopexy and, 181–182, 184–185,
184f–188f, 187
midface lift procedure and, 178–181
Tridimensional endoscopic facelift
surgical technique for—cont’d
peripheral hemicircle of face and,
188–189
skin-only blepharoplasty and, 187
Tunneling method, for liposuction, 235
Ultrapulse CO2 laser, 264
Ultrasonic lipectomy, 239, 242
Venus, 3, 3f
Vision, diplopia and, following
blepharoplasty, 87
Vision loss, following blepharoplasty,
87
Vitruvius, Pollios, 2–3
Wound closure, for midface implants,
211
Wound problems, following
blepharoplasty, 83
Zyderm, 266
Zygomatic ligament, anatomy of, 126
Zygomatic major muscle, deep plane
facelift and, 133, 133f
Zygomatico-orbital artery, anatomy of,
126–127
Zyplast, 266
Index
309