Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

583
Chapter 35  Sclerotherapy of Varicose Veins
• known asymptomatic patent foramen ovale20
• high risk of thromboembolic events
• visual disturbances or neurological disturbances
following previous foam sclerotherapy.
In addition, it is important to adhere to the current prescrib-
ing information for the sclerosants used.23
Diagnosis before sclerotherapy
Successful sclerotherapy requires thorough planning. Sclero-
therapy is generally performed in sequential order of leakage
points, proceeding from the larger to the smaller varicose
veins. Therefore, a proper diagnostic evaluation should be
performed prior to treatment.2–4,19 Diagnostic evaluation
includes history taking, clinical examination, and Doppler
ultrasound investigation (Fig. 35.3). Additionally, functional
examinations (e.g. photoplethysmography, phlebodynamom-
etry, venous occlusion plethysmography) and imaging modali-
ties (e.g. duplex ultrasound, phlebography) may be considered.
Functional examinations make it possible to predict the
improvement in venous function that may be obtained by
removing varicosities. Diagnostic imaging is especially suitable
for identifying incompetent junctions within the deep venous
system and for locating pathological reflux, as well as for
clarifying post-thrombotic changes24,25 and for selecting the
most appropriate treatment option.
 TECHNICAL ASPECTS
Liquid sclerotherapy
Aethoxysklerol (BioForm Medical, Inc, San Mateo, CA) con-
tains the active ingredient polidocanol in concentrations of
0.25%, 0.5%, 1%, 2%, 3%, and 4% and is licensed in Germany
for liquid sclerotherapy of varicose veins. The maximum daily
dose of polidocanol is 2  mg/kg body weight.23 Table 35.1
provides recommendations for concentration and volume per
injection for liquid sclerotherapy.57
A smoothly functioning disposable or glass syringe is
required for liquid sclerotherapy as well as a cannula with a
Figure 35.3  Doppler
examination of the great
saphenous vein. (A) The
probe is held at a 30°–40°
angle to the surface of
the skin. (B) Reflux is
found after the release
of distal compression
denoting venous valvular
insufficiency. From Goldman
MP, Weiss RA, Sadick
NS: Sclerotherapy and
ambulatory phlebectomy.
In: Bolognia JL, Jorizzo JL,
Rapini RP. 2008; 2329–2343.
Femoral vein
Louder
Great saphenous vein
DOPPLER EXAMINATION OF THE GREAT SAPHENOUS VEIN
B
A
Table 35.1  Recommendations for concentration and volume per injection for sclero-
sants containing polidocanol used for liquid sclerotherapy
INDICATIONS
VOLUME/INJECTION (mL)
CONCENTRATION (%)
Spider veins
0.1–0.2
0.25–0.5
Central veins of spider veins
0.1–0.2
0.25–1
Reticular varicose veins
0.1–0.3
1
Small varicose veins
0.1–0.3
1
Medium-size varicose veins
0.5–2.0
2–3
Large varicose veins
1.0–2.0
3–4

584
Part 3  Aesthetic Surgical Procedures
small diameter. Cotton-wool rolls or pads and adhesive paper
tapes are used for local compression. The different tech-
niques vary considerably.26 The following principles apply to
liquid sclerotherapy:
• Puncture of the veins to be sclerosed can be performed
with the patient standing or lying down but the injection
is usually given with the patient lying down. After the
vein has been punctured with the free cannula or with
the syringe attached, the intravascular position is
checked.
• Intravascular injection of the sclerosant is performed
slowly, possibly in fractions. It is important to check
that the cannula is properly positioned inside the vein.
Severe pain during injection may be indicative of
perivascular injection.
• Immediately after injection of the sclerosant and
removal of the cannula, local compression is performed
along the course of the sclerosed vein.1,3,27,28
• When sclerosing spider veins, compression can be
performed using both a compression stocking and a
compression bandage.2,29,30
• Local compression can be removed the same evening or
the next day. Depending on the diameter and location
of the varicose vein, compression is performed for a
period of hours or may extend over several days and
weeks after injection of the sclerosant.4,19,31
• After a sclerotherapy session using the traditional
technique, the patient should walk around for a while
(physical thromboprophylaxis).
• A careful watch must be kept for any signs of allergic
reactions.
• Intensive sports activity, hot baths, saunas, and strong
UV radiation (solarium use) should be avoided in the
initial days after sclerotherapy.
Duplex ultrasound in liquid sclerotherapy
Duplex ultrasound-guided sclerotherapy has proved to be a
useful addition to the range of methods for sclerosing saphen-
ous junctions, truncal veins close to saphenous junctions, and
perforating veins.32–38 In this procedure, the vein to be scle-
rosed is visualized by duplex ultrasound with the patient lying
down and puncture is performed under visual control. The
needle is visible on the ultrasound image, and intravascular
injection can be monitored. Some authors use the ultrasound
transducer to apply intermittent pressure after injection.37,38
This enables the contraction of the injected venous segment
and assessment of the length of the sclerosed portion. This
technique is intended to offer greater control with fewer
complications and increased efficacy.
Foam sclerotherapy
For many years the literature has contained reports of scle-
rotherapy with foamed sclerosants.24,25,39–42 In recent years, as
the technology has improved, foam sclerotherapy has become
established particularly for the treatment of larger varicose
veins.36,43,44 Detergent-type sclerosants such as polidocanol
can be transformed into a fine-bubbled foam by special
techniques.
In the Monfreux technique,44 negative pressure is gener-
ated by drawing back the plunger of a glass syringe, the tip
of which is tightly closed. The resulting influx of air produces
a large-bubbled, fairly fluid foam.42 In the Tessari technique,
the foam generated is fine-bubbled and fluid at low concen-
trations and rather viscous at high concentrations, and it is
produced by the turbulent mixture of liquid and air in two
syringes connected via a three-way stopcock. The mixing
ratio for sclerosant plus air is 1 + 3 to 1 + 4.45 The double
syringe system (DSS) technique involves the turbulent
mixing of polidocanol with air in a sclerosant plus air ratio of
1 + 4 in two syringes linked via a connector. The resulting
product is a fine-bubbled, viscous foam.42,46
The standardized transformation of a licensed liquid scle-
rosant into a foam sclerosant and treatment with it is permis-
sible provided that the patient has been adequately informed
about the procedure and about the benefits and risks of the
method and consents to its use. Even if foam is used off-label,
the published evidence and data document the use as a stand-
ard procedure.
The Second European Consensus Conference on Foam
Sclerotherapy took place in Tegernsee, Germany in April
2006. On the basis of the experience of experts and the
available literature, foam sclerotherapy recommendations
were made.20 These recommendations are slightly modified
in the following text.
Puncture and injection
When treating the long saphenous vein (LSV) by direct punc-
ture, it is recommended that venous puncture be performed
in the proximal thigh area. If long catheters are used, the LSV
is accessed below the knee. When treating the short saphen-
ous vein (SSV) by direct puncture, it is recommended that
venous puncture be performed in the proximal or middle part
of the lower leg. When treating perforating veins, it is recom-
mended that the injection should not be made directly into
the affected vein.
Foam generation, concentrations, and volumes
The Tessari and Tessari/DSS methods are recommended for
the generation of foam sclerosant for all indications. Air is
accepted and/or proposed as the gas component for the gen-
eration of foam sclerosant for all indications. A mixture of
carbon dioxide and oxygen may also be used. The preferred
ratio of liquid sclerosant and gas for the generation of a foam
sclerosant is 1 + 4 (1 part liquid + 4 parts gas). Ratios
between 1 + 1 and 1 + 5 are used for reticular varicose veins
and spider veins, but the 1 + 4 ratio is used by the majority.
The recommended maximum foam volume per leg and
session (given in a single injection or in several injections) is
10 mL. The recommended foam volumes per venous punc-
ture are shown in Table 35.2 and the recommended concen-
trations are outlined in Table 35.3.
When treating large-caliber varicose veins, the foam sclero-
sant should be as viscous as possible.
Duplex ultrasound in foam sclerotherapy
The therapeutic effect of foam sclerotherapy on the patient
and on the patient’s leg should be assessed clinically and on
the basis of symptoms. The therapeutic effect of foam scle-
rotherapy on the LSV, SSV, collateral branches, recurrent
varicose veins, perforating veins, and on venous malforma-
tions additionally can be assessed using duplex ultrasound.
Duplex-guided ultrasound is an important technique that
enables puncture errors to be avoided when puncturing non-

585
Chapter 35  Sclerotherapy of Varicose Veins
Table 35.2  Foam volumes for venous injection
MEAN FOAM VOLUME PER
PUNCTURE (mL)
MAXIMUM FOAM VOLUME
PER PUNCTURE (mL)
Long saphenous vein
2–4
Up to 6
Short saphenous vein
2–4
Up to 4
Collateral veins
Up to 4
Up to 6
Recurrent varicose veins
Up to 4
Up to 8
Perforating veins
Up to 2
Up to 4
Reticular varicose veins
<0.5
<1
Spider veins
<0.5
<0.5
Venous malformations
2–6
<8
Table 35.3  Polidocanol concentrations refer to the liquid polidocanol solution from which foam is generated
LIQUID
0.25%
0.5%
1%
2%
3%
4%
Long saphenous vein
+
++
++
Short saphenous vein
+
++
+
Collateral veins
++
Recurrent varicose veins
(+)
++
++
+
Perforating veins
(+)
++
+
(+)
Reticular varicose veins
(+)
(+)
++
+
Spider veins*
++
(+)
(+)
Venous malformations
+
++
+
*Foam sclerotherapy is not the treatment of choice for vessels less than 1 mm in diameter. For sclerotherapy of spider veins, it is recommended that polidocanol in liquid form
be used initially. Where foam is used, small volumes of a 0.25% foam (possibly even of a 0.5% foam) should be injected.
visible varicose veins. Ultrasound visualization (preferably
duplex guided) is necessary for the direct puncture of non-
visible LSVs, SSVs, perforating veins, non-visible varicose
veins in the groin and popliteal fossa, and is recommended
for other non-visible varicose veins.
Duplex ultrasound is performed with the patient standing.
After treatment, the length of the occluded venous segment
must be compared with the length of the incompetent venous
segment that was to be occluded by sclerotherapy injection,
which means that the segment to be treated is defined prior
to injection. This is important for establishing whether the
‘whole vein’ is occluded after sclerotherapy. Reflux is assessed
during a Valsalva maneuver or during distal compression/
decompression.
When appropriate, more sophisticated and standardized
symptom scores such as the venous clinical severity score
(VCSS) may be used; otherwise visual analogue scales (VASs)
from 1 to 10 are helpful and simple to use. When appropriate,
more sophisticated and standardized clinical classifications
such as the clinical, etiologic, anatomic, and pathophysiologic
(CEAP) classification may be used. This classification is appli-
cable for all endovenous treatment methods (laser, radiofre-
quency, and sclerotherapy techniques) and should facilitate
comparison of techniques. When treatment is given simulta-
neously for medical and aesthetic reasons, two separate
assessment forms should be used. Details of the number of
treatments (injections and sessions) and the type of treat-
ment should be recorded.
Criteria for assessing the therapeutic effects of foam scle-
rotherapy are presented in Table 35.4.
Safety measures for foam sclerotherapy
Safety during foam sclerotherapy of the LSV and SSV can
be improved by:
• avoiding immediate compression of the injected areas
• using ultrasound to monitor foam distribution
• injecting a highly viscous foam
• ensuring there is no patient or leg movement for 2–5
minutes, no Valsalva maneuver, or other muscle
movement
• encouraging active muscle movement, for example
repeated foot flexion, if a larger volume of foam is
detected in the deep venous system.
 PITFALLS AND THEIR MANAGEMENT
Pitfalls and their management
 Allergic reactions are a rare complication in liquid and foam
sclerotherapy.
 Hyperpigmentation and induration occur more commonly after
foam sclerotherapy.
 Neurological disturbances, including migraine-like symptoms,
are more frequent after foam sclerotherapy.
 The maximum foam volume per session should be limited to
10 mL.
 After injection, the patient should rest supine for at least 5
minutes.
 History of symptomatic patent foramen ovale is a
contraindication for foam sclerotherapy.

586
Part 3  Aesthetic Surgical Procedures
Table 35.4  Assessment of treatment outcomes following foam sclerotherapy
GRADE
DUPLEX CRITERIA
CLINICAL CRITERIA
SYMPTOMS
2: Successful
No reflux
Complete disappearance of treated vein, or
‘fibrous cord’ (non-compressible, echogenic
cord at the site of the treated vein)
Complete occlusion (non-compressibility) of the
treated venous segment
Patency of the treated venous segment with
reduced diameter and antegrade blood flow
Normalized (i.e. no visible
varicose veins)
Absent or
improved
1: Partially
successful
Reflux <1 second
Partial non-compressibility
Partial occlusion of the treated venous segment
Diameter reduction
Normalized or improved
(i.e. varicose veins less
visible)
Absent or
improved
0: Unsuccessful
Reflux >1 second
or unchanged
Complete (or incomplete) patency and/or
diameter unchanged
No change or worse (i.e.
larger varicose veins or
deterioration in terms of
CEAP class)
No change or
worse
If performed properly, sclerotherapy is an efficient treatment
method with a low incidence of complications. However, a
number of adverse events may be encountered.2,47–50 In par-
ticular, these are:
• allergic reaction51–53
• skin necrosis32,54–56
• excessive sclerosing reaction (and thrombophlebitis)
• pigmentation56–58
• matting56
• nerve damage59–61
• scintillating scotomas47
• migraine-like symptoms62–64
• orthostatic collapse
• thromboembolism.48,65,66
Allergic skin reactions occur occasionally in the form of aller-
gic dermatitis, contact urticaria, or erythema. Anaphylactic
shock as well as inadvertent intra-arterial injection are
extremely rare complications constituting an emergency
situation.51–53,67
Transient migraine-like symptoms occur more commonly
after foam sclerotherapy than after liquid sclerotherapy.47 In
this context, it has been speculated whether a patent foramen
ovale, which is present in 15–25% of the population, might
be a factor here, allowing foam bubbles to pass into the arte-
rial circulation.68–71
Thromboembolic events (deep vein thrombosis, pulmonary
embolism, or stroke) occur in rare exceptional circumstances
after sclerotherapy. A higher risk is present when larger
volumes of sclerosant are used, particularly in the form of
foam,66,72,73 and in patients with a previous history of throm-
boembolism or known thrombophilia.22 In patients with these
risk factors, the indication for sclerotherapy must be defini-
tively, established and additional precautionary measures
must be observed.20
Skin necrosis has been described after perivascular injection
of sclerosants in higher concentrations and, rarely, after prop-
erly performed intravascular injection with sclerosants in
various concentrations, for example 0.5% polidocanol in
the treatment of spider veins.32,56 In the latter case, a mecha-
nism involving passage of the sclerosant into the arterial cir-
culation via arteriovenous anastomoses has been suggested.54
In individual cases, this has been described as embolia cutis
medicamentosa.74–76 Extensive necrosis may occur after inad-
vertent intra-arterial injection.32,56,67
Instances of hyperpigmentation have been reported with
frequencies ranging from 0.3% to 10%.58,77 In general, this
phenomenon regresses slowly. The incidence of hyperpig-
mentation is likely to be higher after foam sclerotherapy.47
Matting, fine telangiectasia in the area of a sclerosed vein,
is an unpredictable individual reaction of the patient and can
also occur after surgical removal of a varicose vein.56
Nerve damage has been reported experimentally after
perivascular injection.59–61 Local paresthesia after sclerother-
apy is very rare.
Other transitory phenomena after sclerotherapy include
intravascular clots, phlebitis, hematomas, disturbed sense of
taste, feeling of tightness in the chest, pain at the injection
site, swelling, induration, mild cardiovascular reactions, and
nausea. Additionally, complications may arise due to the
compressive bandage, such as blister formation (e.g. blisters
in the vicinity of an adhesive plaster).2,3 Intravascular clots
can be squeezed out after a stab incision to reduce the devel-
opment of hyperpigmentation.
The known presence of a patent foramen ovale is a relative
contraindication for foam sclerotherapy. In such patients, the
following is recommended:
• The patient should remain lying down for 8–30
minutes.
• Use only small volumes of foam (2 mL) or liquid
sclerotherapy
• Avoid Valsalva maneuvers.
• Elevate the patient’s leg by 30 cm.
Prior to foam sclerotherapy, it is not necessary to perform
specific investigations for patent foramen ovale.
A high risk of thromboembolism in the patient’s history and
known thrombophilia (especially in combination with a high
risk of thromboembolism) are relative contraindications for foam
sclerotherapy. In such patients, the following is recommended:
• Institute adequate low-molecular-weight heparin
prophy­laxis (in line with relevant guidelines/
recommendations).
• Implement physical prophylaxis.
• Use low sclerosant concentrations for foam generation.
• Use small volumes of foam.

587
Chapter 35  Sclerotherapy of Varicose Veins
• Decide on a case-by-case basis (perform a risk–benefit
assessment based on the particular indication).
Prior to foam sclerotherapy, it is not necessary to perform
specific investigations for thrombophilia.
Before sclerotherapy, patients should be informed about
risks and possible adverse effects. For foam sclerotherapy,
patients should also be advised that:
• there is a slightly higher risk of hyperpigmentation and
inflammation
• there is a risk of developing (transient) neurological
symptoms
• there is a risk of developing (transient) visual disturbances
• there is a risk of triggering migraine.
Patients should also be informed about the expected treat-
ment outcomes. For foam sclerotherapy, they should also be
told that:
• short-term outcomes are highly satisfactory
• further therapy is possible and may be necessary in some
cases, especially in treatment for large varicose veins
• foam sclerotherapy is more effective than liquid
sclerotherapy.
 SUMMARY
A wealth of published clinical series7,57,72,78–89 and controlled
clinical trials14–18,90–92 provide undoubted evidence to corrobo-
rate the elimination of intracutaneous and subcutaneous vari-
cose veins by sclerotherapy. The success rates of sclerotherapy
vary depending on technique, sclerosant (liquid or foam), and
venous caliber. Sclerotherapy is considered to be the standard
treatment for intracutaneous varicose veins (spider veins and
reticular veins), allowing improvement of up to 90% to be
achieved.54,84,93–96
Compression treatment with medical compression stock-
ings may improve the result of sclerotherapy for spider
veins.58,97–99 The incidence of pigmentation decreases signifi-
cantly.30,58 Local eccentric compression significantly increases
local pressure in the sclerosed area and improves the efficacy
of sclerotherapy.27
In older studies with liquid sclerotherapy, surgery was sig-
nificantly more effective in the treatment of truncal varices.9
In the sclerosis of truncal varicose veins, foam sclerotherapy
is significantly more effective than liquid sclerotherapy.15,17,18
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45. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new
sclerosing foam in the treatment of varicose veins. Dermatol Surg
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46. Breu FX, Guggenbichler S. European consensus meeting on foam sclero-
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30:709–717.
47. Guex JJ, Allaert F-A, Gillet J-L. Immediate and midterm complications
of sclerotherapy: report of a prospective multicenter registry of 12 173
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48. Hohlbaum G. Über iatrogene Schäden bei der Varizensklerosierung. In:
Staubesand J, Schöpf E (Hrsg.): Neuere Aspekte der Sklerosierung-
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49. Munavalli GS, Weiss RA. Complications of sclerotherapy. Semin Cutan
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50. Weiss RA, Weiss MA. Incidence of side effects in the treatment of tel-
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51. Feied CF, Jackson JJ, Bren TS, et al. Allergic reactions to polidocanol for
vein sclerosis. J Dermatol Surg Oncol 1994;20:466–468.
52. Feuerstein W. Schwere anaphylaktische Reaktion auf Hydroxypolyae-
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53. Pradalier A, Vincent D, Hentschel V, et al. Allergie aux sclérosants des
varices. Rev Fr Allergol 1995;35:440–443.
54. Bergan JJ, Weiss RA, Goldman MP. Extensive tissue necrosis following
high concentration sclerotherapy for varicose veins. Dermatol Surg
2000;26:535–542.
55. Duffy DM. Cutaneous necrosis following sclerotherapy. J Aesthet Der-
matol Cosmet Surg 1999;1:157–168.
56. Goldman MP, Sadick NS, Weiss RA. Cutaneous necrosis, telangiectatic
matting and hyperpigmentation following sclerotherapy. Dermatol Surg
1995;21:19–29.
57. Conrad P, Malouf GM, Stacey MC. The Australian polidocanol (Aethox-
ysklerol) study. Results at 2 years. Dermatol Surg 1995;21:334–336.
58. Weiss RA, Sadick NS, Goldman MP, et al. Post-sclerotherapy compres-
sion: controlled comparative study of duration of compression and its
effects on clinical outcome. Dermatol Surg 1999;25:105–108.
59. Seydewitz V, Staubesand J. Das ultrastrukturelle Substrat der Wirkung
paravasal und intraarteriell applizierter Sklerosierungsmittel: Ein experi-
menteller Beitrag zum Problem iatrogener Schäden nach Sklerotherapie.
In: Staubesand J, Schöpf E (Hrsg.). Neuere Aspekte der Sklerosierung-
stherapie. Heidelberg: Springer 1990; 40–65.
60. Van der Plas JPL, Lambers JC, van Wersch JW, et al. Reversible ischae-
mic neurological deficit after sclerotherapy of varicose veins. Lancet
1994;343:428.
61. Zipper SG. Nervus peronäus-Schaden nach Varizensklerosierung mit
Aethoxysklerol. Versicherungsmedizin 2000;4:185–187.
62. Benigni JP. Sclérothérapie à la mousse et migraines à aura. Phlébologie
2005;58:323–324.
63. Künzelberger B, Pieck C, Altmeyer P, et al. Migraine ophthalmique with
reversible scotomas after sclerotherapy with liquid 1% polidocanol. Der-
matol Surg 2006;32:1410.
64. Ratanahirana H, Benigni JP, Bousser MG. Injection of Polidocanol foam
(PF) in varicose veins as a trigger for attacks of migraine with visual aura.
Cephalalgia 2003;23:850–851.
65. Breu FX, Partsch B. Reversible neurologische Komplikationen bei der
Schaum-Sklerotherapie. Phlébologie 2006;3:115–116.
66. Forlee MV, Grouden M, Moore DJ, et al. Stroke after varicose vein foam
injection sclerotherapy. J Vasc Surg 2006;43:162–164.
67. Oesch A, Stirnemann P, Mahler F. The acute ischemic syndrome of the
foot after sclerotherapy of varicose veins. Schweiz Med Wochenschr
1984;114:1155–1158.
68. Fisher DC, Fisher EA, Budd JH, et al. The incidence of patent foramen
ovale in 1000 consecutive patients. Chest 1995;107:1504–1509.
69. Morrison N, Cavezzi A, Bergan J, et al. Regarding ‘stroke after varicose
vein foam injection sclerotherapy.’ J Vasc Surg 2006;44:224–225.
70. Passariello F. Sclerosing foam and patent foramen ovale. The final report.
In: Word Congress of the International Union of Phlebology, Jun 18–20
2007, Kyoto, Japan. Int Angiol 2007;26:87.
71. Wagdi P. Migräne und offenes Foramen Ovale: nur ein vorübergehender
Hoffnungsschimmer? Kardiovasc Med 2006;9:32–36.
72. Breu FX, Marshall M. Sklerotherapie mit Polidocanol in einer angiologisch-
phlebologischen Spezialpraxis. Prospektive und retrospektive Erhebung
über Ergebnisse und Komplikationen. Phlébologie 2003;32:76–80.
73. Wright D, Gobin JP, Bradbury AW, et al. Varisolve® polidocanol micro-
foam compared with surgery or sclerotherapy in the management of
varicose veins in the presence of trunk vein incompetence: European
randomized controlled trial. Phlebology 2006;21:180–190.
74. Geukens J, Rabe E, Bieber T. Embolia cutis medicamentosa of the foot
after sclerotherapy. Eur J Dermatol 1999;9:132–133.
75. Kersting E, Hornschuh B, Bröcker E-B. Embolia cutis medicamentosa
nach Varizensklerosierung mit Polidocanol. Phlébologie 1998;27:55–57.
76. Remy W, Vogt H-J, Borelli S. Embolia cutis medicamentosa – artige
Hautnekrosen nach Sklerosierungsbehandlung. Phlebol Proktol 1978;
7:67–72.
77. Georgiev M. Postsclerotherapy hyperpigmentations. J Dermatol Surg
Oncol 1993;19:649–652.
78. Barrett JM, Allen B, Ockelford A, et al. Microfoam ultrasound-guided
sclerotherapy of varicose veins in 100 legs. Dermatol Surg 2004;20:6–12.
79. Bergan JJ, Pascarella L, Mekenas L. Venous disorders: treatment with
sclerosant foam. J Cardiovasc Surg 2006;47:9–18.
80. Brodersen JP. Catheter-assisted vein sclerotherapy: a new approach for
sclerotherapy of the greater saphenous vein with a double-lumen balloon
catheter. Dermatol Surg 2007;33:469–475.
81. Cavezzi A, Frullini A, Ricci S, Tessari L. Treatment of varicose veins by
foam sclerotherapy: Two clinical series. Phlebology 2002;17:13–18.
82. Coleridge Smith PD. Chronic venous disease treated by ultrasound
guided foam sclerotherapy. Eur J Vasc Endovasc Surg 2006;32:
577–583.
83. Darke SG, Baker SJ. Ultrasound-guided foam sclerotherapy for the treat-
ment of varicose veins. Br J Surg 2006;8:969–974.
84. Hübner K. Ambulante Therapie der Stammvarikose mittels Krossekto-
mie und Sklerotherapie-ein Beitrag aus der Praxis des niedergelassenen
Phlebologen. Phlébologie 1991;20:104–108.
85. Kakkos SK, Bountouroglou DG, Azzam M, et al. Effectiveness and safety
of ultrasound-guided foam sclerotherapy for recurrent varicose veins:
immediate results. J Endovasc Ther 2006;13:357–364.
86. Milleret R, Garandeau C. Sclérose des grandes veines saphènes à la
mousse délivrée par cathéter écho-guidé sur veine vide: alpha-technique
– bilan des 1000 treatments. Phlébologie 2006;59:53–58.
87. Myers KA, Jolley D, Clough A, et al. Outcome of ultrasound-guided
sclerotherapy for varicose veins: medium-term results assessed by ultra-
sound surveillance. Eur J Vasc Endovasc Surg 2007;33:116–121.
88. Schadeck M. Sclérose de la petite veine saphène éviter les mauvais
résultats? Phlébologie 2004;2:165–169.
89. Wildenhues B. Endovenöse kathetergestützte Schaumsklerosierung.
Phlébologie 2005;34:165–170.
90. Alos J, Carreno P, Lopez JA, et al. Efficacy and safety of sclerotherapy
using Polidocanol foam: a controlled clinical trial. Eur J Vasc Endovasc
Surg 2006;31:101–107.
91. Kahle B, Leng K. Efficacy of sclerotherapy in varicose veins – a prospective,
blinded placebo controlled study. Dermatol Surg 2004;30:723–728.
92. Rao J, Wildemore JK, Goldmann MP. Double-blind prospective com-
parative trial between foamed and liquid polidocanol and sodium tetra-
decyl sulfate in the treatment of varicose and telangiectatic leg veins.
Dermatol Surg 2005;31:631–635.
93. Dover J, Sadick N, Goldman MP. The role of lasers and light sources in
the treatment of leg veins. Dermatol Surg 1999;25:328–336.
94. Kern P, Ramelet AA, Wütschert R, et al. Single-blind, randomized study
comparing chromated glycerin, polidocanol solution and polidocanol
foam for treatment of telangiectatic leg veins. Dermatol Surg 2004;
3:367–372.
95. McCoy S, Evans A, Spurrier N. Sclerotherapy for leg telangiectasia – a
blinded comparative trial of polidocanol and hypertonic saline. Dermatol
Surg 1999;25:381–386.
96. Norris MJ, Carlin MC, Ratz JL. Treatment of essential telangiectasia:
effects of increasing concentrations of polidocanol. J Am Acad Dermatol
1989;20:643–649.
97. Kern P, Ramelet AA, Wütschert R, et al. Compression after sclerotherapy
for telangiectasias and reticular leg veins. A randomized controlled study.
J Vasc Surg 2007;45:1212–1216.
98. Massay RA. Regarding the use of compression stockings after sclero-
therapy. Dermatol Surg 1999;25:517.
99. McDonagh B. Comments on the use of post-sclerotherapy compression.
Dermatol Surg 1999;25:519–521.

589
36
Endovenous Ablation Techniques
with Ambulatory Phlebectomy
for Varicose Veins
Robert A Weiss MD and Mitchel P Goldman MD
Summary box
 Reflux from valvular incompetence in the great or small
saphenous vein must be eliminated along with treating distal
or branch varicose veins.
 Failure to treat proximal incompetence results in vein
recurrence.
 Endoluminal radiofrequency or infrared laser energy can
effectively seal and eliminate abnormal saphenous veins.
 Ambulatory phlebectomy may be performed on distal or
branch varicose veins in combination with endovenous
techniques.
 Tumescent anesthesia is effective and necessary for both
ambulatory phlebectomy and endoluminal radiofrequency
and laser closure.
 INTRODUCTION
Dermatologic surgery in the 21st century has evolved into a
minimally invasive subspecialty. Procedures once performed
under general anesthesia, those in which large incisions are
made to remove diseased tissue, are being replaced by tech-
niques that allow the treatment of damaged organ systems to
occur with small punctures under local or tumescent anesthe-
sia. This chapter discusses two methods whereby a patient’s
damaged and improperly functioning axial (saphenous) vein
is treated without requiring its removal – endovenous closure
through the thermal action of radiofrequency (RF) or a
number of infrared laser wavelengths.1
The first attempt to minimize surgery for varicose vein
disease was ligation of a great saphenous vein (GSV) and
distal varicose veins treated with either sclerotherapy or
ambulatory phlebectomy (AP). This simple technique was
demonstrated to result in a high degree of recurrence second-
ary to reanastomosis through hemodynamically significant
perforator veins present extending from the knee to the groin
which were not eliminated during the surgical procedure.1–5
Evidence has shown that for maximal improvement in abnor-
mal venous hemodynamics and resolution of symptoms, com-
plete removal of the GSV from the saphenofemoral junction
(SFJ) to the knee is required after ligating the SFJ.5 This
surgical procedure is most often performed under general
anesthesia with patients usually requiring up to 6 weeks to
return to normal activities.
Two methods for endovenous ablation have evolved to
replace ligation and stripping. The first utilizes RF energy
delivered through a specially designed endovenous electrode
(VNUS Medical, San Jose, CA) to accomplish controlled
heating of the vessel wall, causing vein shrinkage or occlusion
by contraction of venous wall collagen, to eliminate saphen-
ous venous reflux (also known as axial or truncal reflux). This
device was completely redesigned and released in 2007 with
replacement of fast clogging electrode tips with a system that
utilizes RF for simply heating a metal core. This 7-cm long
metal core is heated to 120°C and allowed to transmit heat
to the treated vessel for 20 seconds, which shrinks a vein
7 cm at a time to allow for faster vein ablation.
Following the development of RF closure, endoluminal
lasers were developed to close axial veins through dispersed
thermal energy, most typically from heat radiating from a
coagulum at the fiber tip (810–980 nm) to direct transfer to
water in vein walls (1320 nm). This leads to thermal damage
of collagen in vessel walls with subsequent resorption of the
damaged vein walls. Endovenous occlusion techniques over
the last decade have been uniformly accepted as less invasive
alternatives to saphenofemoral ligation and/or stripping.
Endovenous techniques are performed under local anesthesia
with patients returning to normal activities within 1–72
hours, depending on the technique and device utilized. AP or
foam sclerotherapy (see Chapter 35) may be required as an
adjunctive procedure to eliminate branch varicosities that do
not resolve with closure of the GSV alone.
Although the concept of endovenous elimination of reflux
is not new, previous approaches have relied on electrocoagu-
lation of blood. This resulted in thrombus occluding the vein
Historical vignette
 Ambulatory phlebectomy first described by Robert Muller
(dermatologic surgeon) in the 1950s.
 1966: Presented to the French Society of Phlebology by Dr
Muller with a negative reception.
 1990: Tumescent anesthesia introduced (Goldman & Weiss).
 1996: Added to American College of Phlebology core
curriculum.
 1998: Added to American Society for Dermatologic Surgery
curriculum.
 1998: First clinical trials of endoluminal radiofrequency
closure.
 1999: First clinical trials of endoluminal laser closure.

590
Part 3  Aesthetic Surgical Procedures
back to the transducer appear as white areas in the image.
Therefore, a needle placed in the vessel appears as bright
white. Vessel walls reflect ultrasound, while blood flowing
in a vessel absorbs and scatters ultrasound in all directions;
thus the normal vessel appears as a dark-filled white-walled
structure.
Reflux is diagnosed by placing the transducer over the
vessel in a longitudinal plane and observing the Doppler signal
in the vessels while (with the free hand) the distal leg is
momentarily compressed and released to increase the cepha-
lad movement of blood. Functional valves permit flow only
in the antegrade direction, but normal vessels can demon-
strate brief retrograde flow due to slow closing of valves.
Retrograde flow of duration greater than 1 second is consid-
ered pathologic reflux, and reflux that lasts more than 2
seconds is hemodynamically significant. The Valsalva maneu-
ver is a valuable way to demonstrate incompetence of the
terminal valve at the SFJ.
In the longitudinal view, the origin of the GSV is identified
as it courses off the common femoral vein. Two valves can
be visualized in the proximal GSV. The first is the terminal
valve, which lies at the vein origin. Distal augmentation or
Valsalva for Doppler flow reveals competence or incompe-
tence of this valve. The second valve, about 2 cm below the
subterminal valve, is examined in the same fashion. Major
tributaries that empty into the region of the SFJ can be iden-
tified here. These include the circumflex, pudendal, epigas-
tric, and others. Most commonly seen is the epigastric because
of its size and position in the same plane as the termination
of the greater saphenous vein. Once incompetence of the
GSV has been demonstrated with reverse flow, the patient
is a candidate for an endovenous ablation technique.
 TECHNIQUES AND
POSTOPERATIVE CARE
Radiofrequency
Directing RF energy to heat a catheter which then heat
damages vein walls is presently utilized to heat shrink vessels
by endovenous placement. The previous mechanism by which
with the potential for recanalization of thrombus being very
high. The concept of application of RF directly to tissue,
rather than blood, has been applied effectively for ablation of
abnormal conduction pathways for arrhythmias.1 This concept
was conceived for treatment of varicose veins as venous
occlusion with RF by the mechanism of venous blood coagu-
lation has been previously reported, but was not very success-
ful.6,7 Another technique which preceded the modern
application of RF to vein walls is endovascular diathermic
vessel occlusion, a technique in which a spider-shaped intra-
vascular electrode produced venous occlusion by electroco-
agulation with minimal perivascular damage.8
 PREOPERATIVE PREPARATION
Doppler ultrasound
Historically, the hand-held Doppler ultrasound is the main
tool used to detect reverse flow or reflux in the superficial
venous system. Smaller and less expensive duplex ultrasound
units have replaced hand-held Doppler units as the primary
tool. Optimal frequencies for examining superficial vessels
(1–2 cm below the skin) are 8–10 MHz, while deeper vessels
require a lower frequency of 4–5  MHz. Blood flow in the
venous system is very slow and intermittent; it is mainly
pulsed by calf muscle contraction. In order to generate an
audible signal of flow, a maneuver such as manual compres-
sion of the calf (simulating a muscle contraction) must be
performed by the examiner. When compression is released,
gravitational hydrostatic pressure causes reverse flow to cease
within 0.5–1.0 second when valves are competent, but a long
flow sound is audible when valves are incompetent.
The Doppler examination is usually performed with the
patient standing or sitting, because gravitational hydrostatic
pressure enhances the volume and velocity of retrograde flow
and makes it easier to detect. To perform this test, the non-
dominant hand gently squeezes the leg well below (distal
compression) or above (proximal compression) the point of
auscultation, while the dominant hand holds the Doppler
transducer lightly against the skin. Under normal circum-
stances, flow should be heard only during active distal com-
pression. Flow that is heard during proximal compression or
immediately after the release of distal compression is retro-
grade flow – a clear sign of incompetent valves. This tech-
nique is best demonstrated in a hands-on workshop and has
many limitations.
Duplex ultrasound
Small, relatively affordable, and very sharp image portable
devices have transformed duplex ultrasound into the tech-
nique which is used for venous flow diagnostics and treat-
ment. Duplex ultrasound consists of a dual-mode device that
allows a timed pulse echo to be superimposed with the con-
tinuous-wave Doppler. This allows one to ‘see’ the anatomy
in two dimensions while superimposing the Doppler flow
sounds as a visual color marker. Reflux can be shown visually
and very precisely compared to the hand-held Doppler. The
site of origin of reflux can be pinpointed. Duplex is very
useful to guide placement of access sheaths prior to endo­
venous treatment by direct visualization of the vein entry
point (Fig. 36.1).
Structures that absorb, transmit, or scatter ultrasonic waves
appear as dark areas, while structures that reflect the waves
Figure 36.1  Appearance of the saphenofemoral junction in
longitudinal view under duplex ultrasound. CFV, common
femoral vein.

591
Chapter 36  Endovenous Ablation Techniques with Ambulatory Phlebectomy for Varicose Veins
burn, resulting in an overall complication rate of 23%. They
concluded that reduction of complications is possible by lim-
iting treatment below the knee. They had a total of 88% of
patients with a totally occluded GSV. The probable reason
for the increase in adverse effects was their use of a spinal
anesthesia instead of the recommended tumescent anesthe-
sia. In addition they treated patients from the ankle proxi-
mally, which exposed the GSV within the calf to heat from
the RF catheter.
Another report describes two episodes of DVT in 29
patients treated with the VNUS Closure system.17 The sur-
geons treated the patients with a groin incision and passage
of the catheter from the groin downward. The authors do not
report the type of anesthesia used or the length of vein
treated. It is presumed that the patients were not ambulatory
and were treated under general anesthesia.
We conclude from these reports and our experience that
the most important factors in minimizing side effects are the
use of tumescent anesthesia and immediate ambulation.
General anesthesia is the most significant risk factor in devel-
oping DVT and the failure to use tumescent local anesthesia
is the major risk factor for developing skin burns. It is also
advisable to limit RF treatment to the GSV segment above
the knee to minimize the risk of paresthesia resulting from
injury to the saphenous nerve. In our experience of using
tumescent anesthesia in every case and using the technique
on non-sedated patients, only two patients have developed
focal numbness 4 cm in diameter on the lower medial leg.
These resolved within 6 months. No skin injury or thrombi
have been observed in any of our patients.
For clinical symptoms, the RF endovenous occlusion pro-
cedure rapidly reduces patient pain, fatigue, and aching, cor-
relating with a reduction in clinical, etiologic, anatomic, and
pathophysiologic (CEAP) class for symptoms and clinical
severity of disease (Table 36.1). When patients have had
surgical stripping on the opposite leg, the degree of pain,
tenderness, and bruising has been far greater on the leg
treated by stripping. Skin burns occurred prior to the tumes-
RF current heated tissue was resistive (or ohmic) heating of
a narrow rim (<1 mm) of tissue that was in direct contact
with the electrode. This is no longer the case. It was said that
if tissue is heated above 100°C, it begins to boil, so the
optimal target temperature is 70–90°C.9 We now understand
this to be incorrect as all of the endovenous techniques heat
the vessel at 120°C or beyond. The newest endovenous
design using RF heats the vessel to 120°C.
In the original RF catheter system, the catheter was pulled
through the vein while feedback-controlled with a thermo-
couple. With the new system, the catheter is held in place
while energy heats the catheter to a specified temperature of
120°C. This is believed to be a relatively safe process since
the temperature increase remains localized in a narrow rim
around the active electrode. The RF device requires close,
stable contact between the active electrode and the vessel
wall and requires tumescent anesthesia to allow contact of
the vein wall with the central 7-cm metal core. By controlling
temperatures, boiling, vaporization, and carbonization of the
tissues are avoided.10
With the previous-generation RF system, as shrinkage and
compaction of tissue occurred, there was a decrease in imped-
ance that decreased heat generation,11 but this is no longer
the case as only the temperature of the catheter metal core
is monitored. While previously the RF generator could be
programed to rapidly shut down when impedance rises, thus
assuring minimal heating of blood but efficient heating of the
vein wall, this is no longer the case.
Recent advances in design to simplify the electrical and
thermal effects applied to the venous system have been
implemented. The newest device is the ClosureFAST cath-
eter (VNUS Medical) (Fig. 36.2). The original animal exper-
iments with the earlier VNUS Closure catheter performed
by the authors demonstrated endothelial denudation along
with denaturation of media and intramural collagen with a
subsequent fibrotic seal of vein lumen (Fig. 36.3). Ten years
of clinical experience suggest that the VNUS Closure proce-
dure is highly effective at occluding saphenous veins and
abolishing reflux. The efficacy of the newest technology
remains to be seen, but initial results indicate that it is even
more effective than the previous generation. The newest
ClosureFAST technique, however, obeys the same principles
as the original.
Radiofrequency closure – standard technique
Several studies have detailed the outcome of RF endovenous
occlusion.12–15 In multicenter studies involving up to 324
patients with up to 2-year follow up, the vein occlusion rate
at 1-year examination was 91.6% from nine centers and
81.9% from 14 centers; 49 patients were followed up at 2
years with duplex scans and showed an 89.8% closure rate.
There was a 3% incidence of paresthesia as well as a 1.6%
rate when treatment was confined to the thigh. Two limbs
(0.8%) developed scarring from skin burns and three patients
developed a deep vein thromboisis (DVT) with one embo-
lism. The reason for the increase in adverse effects appears
to be the use of general anesthesia without tumescent
anesthesia by a majority of the surgeons.
Sybrandy & Wittens from Rotterdam reported 1-year
follow up of 26 patients treated with the VNUS Closure
catheter.16 They reported five patients with postoperative
paresthesia of the saphenous nerve and one with a cutaneous
Table 36.1  CEAP class description with findings after
endovenous radiofrequency occlusion prodedure
CEAP CLINICAL CLASS
DESCRIPTION
0
Asymptomatic
1
Telangiectasia
2
Varicose veins
3
Edema
4
Skin changes
5
Healed venous ulcer
6
Venous ulcer
Mean CEAP class of closure study population
PRE-TREATMENT
AT 6
WEEKS
AT 6
MONTHS
Total
2.0
0.5
0.5
3.0
0.5
0.3
4.0
2.3
1.4
2.4
0.8
0.6

592
Part 3  Aesthetic Surgical Procedures
Stationary during treatment
Slight overlap between treatments
7cm
1
2
3
4
5
6
0.5cm
Shaft markings for repositioning
Vein treated stepwise along the length
The newest radiofrequency catheter, ClosureFAST
Figure 36.2  The newest radiofrequency catheter, ClosureFAST.

593
Chapter 36  Endovenous Ablation Techniques with Ambulatory Phlebectomy for Varicose Veins
Varicose veins are marked, with the patient standing and
again with the patient lying down in the operative position,
using transillumination.19 After appropriate marking, the area
surrounding the GSV and distal tributaries to be treated is
infiltrated with 0.1% lidocaine tumescent anesthesia. The
amount of tumescent fluid ranges from 500 to 800 mL with
a typical lidocaine dose of 4–8  mg/kg. The GSV can be
accessed through a 2–3-mm incision in the medial mid-thigh
usually 20 cm inferior to the SFJ. The GSV is then treated
with an endovenous ablation technique and the varicose trib-
utaries removed with a standard ambulatory phlebectomy
technique. A ligature is placed on the exposed portion of the
greater saphenous vein. Ninety-five percent of all patients can
resume all preoperative activities within 1 week.
At the conclusion of the surgery, the entire leg is wrapped
in a short stretch compression bandage over copious padding
over the varicose veins removed through phlebectomy. The
tiny incisions are not sutured closed. The open 2-mm inci-
sions allow for drainage of the anesthetic solution over 24
hours, minimizing swelling and bruising. The patient is seen
the next day and the compression bandage is removed. The
leg is checked for hematoma or other adverse sequelae. All
incisions are covered with antibacterial ointment and a Band-
Aid (Johnson & Johnson Medical, Arlington, TX) and a 30–
40-mmHg graduated stocking is applied. The stocking is left
on 24 hours a day for 1 week.
Technique of closure using single puncture
under duplex guidance
Patients with reflux in the great or small saphenous vein
(SSV) are candidates, and it is best if the vein size does not
exceed 1.6 mm. A sample of the appropriate consent form
for the procedure is shown in Figure 36.4.
The procedure begins with the vein to be treated being
marked on the skin using duplex ultrasound. An appropriate
entry point that is easily cannulated per cutaneous is selected.
This is usually just below where reflux is no longer seen in
cent anesthesia technique in 2.5%, but this has not been seen
for almost a decade. Other side effects, virtually eliminated
by tumescent anesthesia, included clinical phlebitis at 6
weeks in 5.7%, and temporary quarter-sized areas of par-
esthesia in 18%, with most of these occurring immediately
above the knee and resolving within 6 months to a year.
Endovenous RF occlusion has replaced traditional surgery of
ligation and stripping of similar-size saphenous veins. Most
importantly for patients, side effects of DVT and nerve injury
are far lower than traditional ligation and stripping.
Our experience over 10 years indicates a 90% long-term
effectiveness rate. This is a more favorable outcome on vari-
cose veins than traditional surgery. Patients remain symptom
free and patent GSVs are not visible under duplex ultra-
sound. Furthermore, results observed at 6 months are indic-
ative of the long-term results. The superior epigastric vein
that continues to empty superiorly into the common femoral
vein is important to preserve, and endovenous techniques are
designed to preserve this vein. We have always believed that
there is a high margin of safety by maintaining flow through
this tributary. Among the many reasons, most importantly are
that the high flow rate appears to diminish the possibility of
extension of any thrombus (in the unlikely event that this
would occur) from the GSV, and normal venous drainage
from the lower abdomen is allowed to continue. In our per-
sonal experience, thrombus has not been observed.15
Radiofrequency closure with
ambulatory phlebectomy
The use of AP along with endovenous ablation techniques can
be very effective in eliminating saphenous reflux and varicose
tributaries. Our experience with over 500 patients with RF
combined with AP confirms this. Although very rarely prac-
ticed, a unique technique combining RF plus AP and ligation
is initiated by AP in the mid-thigh to expose the GSV.18 Most
physicians use the technique of duplex-guided puncture and
cannulation, described below.
A
B
Figure 36.3  Histology of radiofrequency
occlusion of sheep saphenous vein. (A)
Before treatment. (B) Acute histologic
features of radiofrequency occlusion.
Hematoxylin and eosin ×100.

594
Part 3  Aesthetic Surgical Procedures
Endovenous Ablation Consent Form

Patient Name
___________________________________________

Date ______________________


_____ A) AUTHORIZATION FOR VEIN SURGERY
I hereby authorize ______________________________to perform the Endovenous Ablation procedure on my veins for the
purpose of attempting to improve the symptomatology and/or appearance of my legs.
_____ B) ALTERNATIVES
I understand that alternative treatments for varicose veins exist, including conservative treatments (elastic stockings),
sclerotherapy (injection of sclerosing agents into diseased veins), ambulatory phlebectomy (pulling out a short segment of
vein) and stripping and vein ligation.
_____ C) RISKS
The nature of the procedure to be performed has been explained to me, and I understand that among the known risks are
bruising, swelling of the leg, and pain. I am aware that in addition to the minor risks specifically described above, there a re
other risks that may accompany any surgical procedure, such as loss of blood, infection, and inflammation in the venous
systems with formation of a thrombus (clot), postoperative bleeding, and nerve trauma that may lead to temporary
numbness.
_____ D) ANESTHESIA
I consent to the local anesthesia, to be administered by ________________________________. I am aware that risks are
involved with the administration of local anesthesia, such as allergic or toxic reactions to the anesthetic and cardiac arrest.
_____ E) PROPOSED TREATMENT RESULTS
I know that the practice of medicine and surgery is not an exact science, and, therefore, reputable practitioners cannot
guarantee results. No guarantee or assurance has been given by anyone as to the results that may be obtained. I have
had sufficient opportunity to discuss my condition and proposed treatment with the doctor, and all of my questions have
been answered to my satisfaction. I believe that I have adequate knowledge on which to base an informed consent to the
proposed treatment. I hereby authorize the doctor to perform any other treatment that may be deemed necessary should
he/she encounter an unhealthy or unforeseen condition during the course of the procedure. After the endovenous
ablation procedure, sclerotherapy can begin at your six week follow up visit. The cost of the endovenous ablation
procedure includes one sclerotherapy treatment of veins which are directly related to the vein that is treated with
endovenous ablation. Any further treatments or treatment of leg veins which are not related to the vein being treated with
endovenous ablation will be charged at the regular practice fee for sclerotherapy. Repeat endovenous ablation procedures
using modified parameters may need to be done at the discretion of the doctor.
_____ F) COOPERATION
I agree to keep the doctor and staff informed of any changes in my permanent address, and I agree to cooperate with them
in my after-care. I agree to keep my follow-up appointments at 1 week, 6 weeks, 6 months, and one year.
_____ G) PHOTOGRAPHS
I consent to be photographed before, during, and after the treatment. I understand that these photographs shall remain the
property of the doctor and may be published in scientific journals, presented in scientific meeting sessions and/or shown for
scientific reasons.
_____ H) INFORMED CONSENT
I certify that I have read and understand the above consent for surgery. It has been explained to me and I fully understand
the inherent potential risks, complications, and results of both the surgical procedure and the anesthetic to be
administered. I accept all responsibility for these or any other complications that may arise or result during the surgical
procedure(s) to be performed at my request according to this consent and surgical permit.
PLEASE INITIAL EACH PARAGRAPH AND SIGN BELOWS

Patient Signature ____________________________________________

Date ______________________

Witness __________________________________________________

Consent form for endovenous ablation procedure
Figure 36.4  Consent form for endovenous ablation procedure.

595
Chapter 36  Endovenous Ablation Techniques with Ambulatory Phlebectomy for Varicose Veins
The RF is then applied; the physician monitors the tem-
perature and impedance. Within 15 seconds, the target tem-
perature of 120°C should be reached. If this does not occur,
the catheter has been mistakenly advanced too far into the
common femoral vein. After target temperature is achieved,
the catheter is moved 7 cm down and the second application
of energy occurs. It is important to prevent application of
energy to the skin by making sure that markings on the cath-
eter for the final 7 cm of application are carefully observed.
At conclusion of the procedure, duplex ultrasound of the
SFJ should reveal no flow except for the superficial epigastric
emptying into the common femoral vein. The GSV should
be more echogenic with thicker-appearing walls.
Follow-up care
Class 2 compression hosiery is worn for 3 days with the
percutaneous closure technique and 7 days with the closure
plus phlebectomy technique. Patients will note some bruising
from the tumescent anesthesia but virtually none from RF
alone. Anesthesia of the treated portion of the leg may persist
for 8–24 hours. To gain experience, we recommend that for
the initial cases, the treated veins should be re-evaluated at
3 days by duplex ultrasound. This will allow correlation of
results with the pullback rate or any difficulty encountered
during the procedure. Once comfortable with the procedure,
the physician may want to see the patient for a duplex ultra-
sound follow-up study at 6 weeks. At that time, any open
segments can be treated by duplex-guided foam sclerother-
apy. It has been our experience that when closed at 6 weeks,
the GSV will remain closed, fibrosed, and almost indistin-
guishable from surrounding tissue at 6 months in all cases.
Symptom reduction is usually rapid with many patients expe-
riencing relief at 3 days, but some not until 6 weeks. Clinical
improvement in appearance of varicosities is also typically
seen within 6 weeks (Fig. 36.6). Although the patient instruc-
tions after the Closure technique are very straightforward,
including 3 days of compression, patients are still provided
with an instruction sheet (Fig. 36.7).
Endovenous laser ablation
Endovenous laser ablation (EVLA) allows delivery of laser
energy directly into the blood vessel lumen in order to produce
endothelial and vein wall damage with subsequent fibrosis. It
is presumed that destruction of the GSV with laser is a func-
tion of thermal destruction. The target for lasers with 810-,
940-, 980-, and 1064-nm wavelengths is intravascular red
blood cell absorption of laser energy. Only the 1320-nm
wavelength has allowed the targeting of water only. The
extent of thermal injury to tissue is strongly dependent on the
amount and duration of heat the tissue is exposed to. There-
fore, for the hemoglobin-dependent wavelengths, the amount
of residual blood in the vein following tumescent anesthesia
is important. It is impossible to standardize this, however.
Moritz & Henriques investigated the time–temperature
response for tissue exposed to up to 70°C.20 They found that
skin can withstand temperature rises for very short exposure
times and that the response appears to be logarithmic as the
exposure times become shorter. For example, an increase in
body temperature to 58°C will produce cell destruction if the
exposure is longer than 10 seconds. Tissues, however, can
withstand temperatures up to 70°C if the duration of the
exposure is maintained less than 1 second. Thus, any tissue
Figure 36.5  Duplex image of tumescent fluid around the
greater saphenous vein.
the GSV or SSV or where the vein becomes too small to
cannulate with an introducer set. For the majority of patients
in our series, this is at a point just above or below the knee
along the course of the GSV. Before proceeding, the patient’s
feet are wrapped in warm material or socks to minimize
vasoconstriction, a heating pad is placed under the thigh, and
a small amount of 2% nitroglycerin ointment (Nitro-Bid, E
Fougera & Co, Melville, NY) may be rubbed onto the intended
entry point to minimize vasoconstriction during the initial
cannulation process.
The patient is then prepped and draped, after which
0.1  mL of 1% lidocaine with or without epinephrine is
injected at the premarked site. It is important that the patient
experiences no pain during cannulation as the perception of
pain will cause an immediate and rapid contraction of the
saphenous vein. In order to place the sheath, a guidewire
must first be inserted through the initial needle puncture.
The guidewire is passed approximately 5 cm into the GSV.
The sheath is then threaded along the guidewire, piercing the
skin; its progress is followed by duplex until it is seen firmly
placed within the lumen of the GSV. After establishing the
intraluminal placement of the sheath, the guidewire is care-
fully withdrawn. Once the sealed sheath is placed into the
vein, the Closure catheter is then advanced. Others prefer
initializing entry via a venous cutdown or pulling of the vein
close to the surface with an ambulatory phlebectomy hook.
The Closure catheter, with a diluted heparin solution or
normal saline slowly running through a central lumen, is now
inserted through the sheath. Its progress up the GSV is
monitored by duplex. Once the catheter is in place, tumes-
cent anesthesia (consisting of 0.1% lidocaine neutralized to
pH 7 with sodium bicarbonate) is injected between the skin
and the cannulated GSV. This is for the purpose of providing
a heat sink, causing the vein to compress around the catheter
and to provide a painless experience for the patient. Duplex
monitoring of the anesthesia injection is not only recom-
mended but is essential to insure that the tumescent fluid is
injected into the perivenous space and that the fascial planes
are pushed away from the vein (Fig. 36.5).
The final check of the position of the catheter is made with
duplex ultrasound. The tip of the metal core of the 7-cm long
energy delivery tip is carefully placed 2 cm below the base
of the terminal valve cusps. The readout of temperature prior
to initiation of heating to 120°C should be substantially lower
than body temperature due to the perivenous tumescent
anesthesia. The starting temperature should be 25–28°C
instead of body temperature of 37°C if tumescent anesthesia
has been properly placed.

596
Part 3  Aesthetic Surgical Procedures
Figure 36.6  Two cases of right lower leg VNUS
Closure (before and after treatment).
injury from brief exposure to temperatures less than 50°C
would be expected to be reversible.
One in-vitro study model has predicted that thermal gas
production by laser heating of blood in a 6-mm tube results
in 6 mm of thermal damage.21 These authors used a 940-nm
diode laser with multiple 15-J, 1-second pulses to treat the
GSV. A median of 80 pulses (range 22–116) were applied
along the treated vein every 5–7 mm. Histologic examination
of one excised vein demonstrated thermal damage along the
entire treated vein with evidence of perforations at the point
of laser application, described as ‘explosive-like’ photodisrup-
tion of the vein wall. This produced the homogeneous throm-
botic occlusion of the vessel. Since a 940-nm laser beam can
only penetrate 0.3  mm in blood,22 the formation of steam
bubbles is the probable mechanism of action. The lack of
significant heating of perivenous tissues probably explains the
low complication rate.
Initial reports have shown this technique with an 810-nm
diode laser to have excellent short-term efficacy in the
treatment of the incompetent GSV, with 96% or higher occlu-
sion at 9 months with a less than 1% incidence of transient
paresthesia.23,24 Although most patients experience some
degree of postoperative ecchymosis and discomfort, no other
major or minor complications have been reported. Our obser-
vation has been that the incidence of postoperative pain and
ecchymosis is highest in hemoglobin-dependent wavelengths.
RF and 1320-nm laser, which transmit thermal energy more
directly to the vein wall, have very little postoperative dis-
comfort. Our patients treated with EVLA with an 810-nm
diode laser have shown a significant incidence of post-treat-
ment purpura and tenderness. Most of our patients treated
with 810-nm laser do not return to complete functional nor-
mality for 2–3 days as opposed to the 1-day downtime with
RF Closure or 1320-nm endovenous laser of the GSV. Since
the anesthetic and access techniques for the two procedures
are identical, we believe that non-specific perivascular thermal
damage is the probable cause for this increased tenderness.
Pulsed 810-nm diode laser treatment increases risk for per-

597
Chapter 36  Endovenous Ablation Techniques with Ambulatory Phlebectomy for Varicose Veins
importantly, treated vessels were not perforated even with a
fluence of 224 J/cm2. A diffusing fiber was also used to obtain
circumferential damage.
A clinical study using an endoluminal 1064-nm Nd:YAG
laser in the treatment of incompetent GSV in 151 men and
women with 252 treated limbs was also reported.28 Ligation
was also performed at the SFJ which did not allow for a
determination of the efficacy of GSV laser ablation. Spinal
anesthesia was used and the laser was used at 10–15 W of
energy with 10-second pulses and manual retraction of the
laser fiber at a rate of 10 seconds/cm. Skin overlying the
treated vein was cooled with cold water. The side effects
were notable with superficial burns in 4.8% of patients, par-
esthesia in 36.5%, superficial phlebitis is 1.6%, and localized
hematomas in 0.8%.
Using 1320 nm, tissue water is the target and the presence
of red blood cells and hemoglobin within the vessels is not
required as for the other wavelengths. We also utilize an
automated catheter drawback system at 1  mm/second to
provide uniform heating of the vessel. Studies in the porcine
GSV demonstrated full-thickness thermal damage at 5  W
with the 1320-nm laser and 20 W with the 1064-nm laser.29
Clinical studies have demonstrated 100% efficacy without
evidence of vessel perforation with use of the 1320-nm
foration of the vein as opposed to continuous treatment (Fig.
36.8).25 This has been proposed as a reason for the increased
symptoms with EVLA versus RF treatment.21 In our experi-
ence, attempts at modifications, including reduced fluence
and treating with continuous laser emission versus pulsed
laser emission, have not resulted in a reduction of postopera-
tive symptoms using the 810-nm diode laser (Fig. 36.9).
A longer wavelength, such as 940 nm, has been hypothe-
sized to penetrate deeper into the vein wall with resulting
increased efficacy. A report of 280 patients with 350 treated
limbs and 18-month follow up demonstrated complete
closure in 96%.26 Twenty vein segments were examined his-
tologically. When veins were treated with 1-second duration
pulses at 12  J, perforations were not present. When the
fluence was increased to 15 J with 1.2- and 1.3-second pulses,
microperforations did occur and were said to be self-sealing.
The author suggests that his use of tumescent anesthesia
as well as the above-mentioned laser parameters are respon-
sible for the lack of significant perforations and enhanced
efficacy.
Several studies have evaluated a 1064-nm neodymium:
yttrium-aluminum-garnet (Nd:YAG) endoluminal laser. In
one study, the lateral saphenous goat vein was used.27 Occlu-
sion was more likely when fluence exceeded 84 J/cm2. More
1. Keep bandage and stockings on until bedtime. If your toes turn blue or feel numb
loosen the bandage. If symptoms persist, call the doctor immediately.
2. You can resume normal activities today (walking is okay).
3. You can resume exercising in 3 days (no weights with the legs for 1 week).
4. You can take a shower tomorrow morning but no hot baths for 1 week.
5. Wear your support hose for 3 days, from first thing in the morning (ideally, take a
quick 5 minute shower and then put them on before doing the rest of your morning
ritual), until last thing at night.
6. Schedule the next follow-up visit in six weeks.
7. Bruising, local swelling and some tenderness are normal after surgery, but please
feel free to call the office if you have any questions.
VENOUS PROCEDURE POST-SURGERY INSTRUCTIONS
Postoperative patient instructions for endovenous ablation
Figure 36.7  Postoperative patient instructions for VNUS Closure.

598
Part 3  Aesthetic Surgical Procedures
A
perforation
B
vein
contrast leakage
Figure 36.8  Perforation caused by 810-nm diode laser in goat jugular vein. (A) Hematoxylin and eosin ×20. Perforation shown by
arrowhead. (B) Appearance under fluoroscopy intraoperative injection of contrast material showing leakage through multiple vein
perforations.
A
B
Figure 36.9  Clinical appearance at
postoperative day 1. (A) 810-nm diode
continuous laser application, not pulsed.
(B) 1320-nm neodymium:yttrium-
aluminum-garnet (Nd:YAG) continuous
laser application.
Nd:YAG intravascular laser in 24 patients with 6–12 months
of follow up.30 At 3–4-years of follow up, one author (MG)
is observing 10% recurrence of GSV incompetence but the
other author (RW) is not.
Weiss et  al.31 have compared 36 GSVs treated with the
810-nm diode laser to 42 GSVs treated with the 1320-nm
Nd:YAG laser and 174 GSVs treated with RF closure. They
found a 95% success rate with both RF and 1320-nm endo-
luminal treatment without adverse effects versus an 86%
success rate and a 52% incidence of adverse effects with the
810-nm diode laser. Adverse effects consisted of significant
pain with walking for 2–3 days in 99%, with significant bruis-
ing in 75% of treated legs. When compared to the 940-nm
diode laser, the 1320-nm Nd:YAG laser was seen to cause
fewer side effects in the endovenous treatment of the GSV.32
Clinical data showed that treatment-related pain and the use
of analgesics were significantly reduced when treated with
the 1320-nm Nd:YAG over the 940-nm diode laser.
Technique for closure using endoluminal laser
The patient is evaluated and marked. Anesthesia is delivered
along the vein and, for EVLA, a 600-µm laser fiber is inserted
into the vein. Modern systems no longer require a protective
sheath as novel fiber-optic tips have been developed that are
rounded and do not pose a hazard for perforating the vein.
(On the accompanying video using 810-nm, a protective
sheath is required to be placed before the fiber.) A helium–
neon (He:Ne) aiming beam that is continuously illuminated
when the laser is on ensures that the laser fiber is in the super-
ficial venous system and that the fiber tip for 810 nm extends
from the sheath. If the laser fiber retracts within the sheath,
thermal melting of the sheath occurs and plastic breakdown
products may be released into the vein (Fig. 36.10). A Steri-
Strip (3M Surgical Products, St Paul, MN) is placed on the
fiber to mark the length at which 1 cm of the laser fiber pro-
trudes from the sheath to prevent this from occurring.

599
Chapter 36  Endovenous Ablation Techniques with Ambulatory Phlebectomy for Varicose Veins
Correct placement of the laser fiber tip 2 cm distal to the
SFJ is confirmed through direct visualization with duplex
ultrasound and secondarily by laser fiber measurement and
viewing the He:Ne aiming beam through the skin. To attempt
to minimize risks of perforation and bruising, the 810-nm
laser is used in a continuous firing mode with withdrawal at
a rate of 1 cm/second. Typical fluence used is 12–14 J/cm2.
Endovenous laser treatment is stopped when the distal tip of
the fiber reaches a point 1–3 cm from the vein entry site.
This can be confirmed with direct visualization of the red
aiming beam through the skin or more typically by duplex
ultrasound. Total laser application time is recorded. Repeat
duplex ultrasound of the saphenous vein is performed con-
firming successful treatment, although it is typically difficult
to retreat the vein at this point and may require a subsequent
session if failure occurs. When the terminal portion of the
vein (immediately adjacent to the point of entry) is treated,
the catheter/sheath and the fiber are withdrawn and manual
pressure is applied to the puncture site. If clinically indicated,
ambulatory phlebectomy and/or sclerotherapy of tributaries
are performed.
 PITFALLS AND THEIR MANAGEMENT
Figure 36.10  Plastic sheath burned by 810-nm diode fiber
withdrawn while firing into the sheath.
Pitfalls and their management
 Proper preoperative diagnosis will direct appropriate care and
minimize adverse effects.
 Tumescent anesthesia placed around the veins requiring
treatment will minimize any postoperative complications.
 Immediate postoperative evaluation of the treated veins will
determine treatment efficacy and minimize recurrence.
lymphatic vessels. Prevention is by careful dissection of the
vein. Hematoma may occur if care is not taken to treat reflux-
ing venous segments first with either intraluminal laser or RF
closure or ligation.
Finally, scars from the surgical excision are always possible,
but usually only 2–3  mm in length and barely perceptible
after a few months.
 SUMMARY
A standard technique for endovenous occlusion using RF
ablation catheters or endoluminal laser delivered by fiber-
optics offers a less invasive alternative to ligation and strip-
ping. This has become the standard for treatment of
saphenous trunk reflux. Clinical experience in several thou-
sand patients shows a high degree of success with minimal
side effects, most of which can be prevented or minimized
with proper technique and wavelengths. The use of ambula-
tory phlebectomy for associated branch varicosities is an
option. With tens of thousands of endovenous procedures
performed with over a 90% success rate, these techniques
have been proven for over a decade and have replaced invasive
venous surgery.
 REFERENCES
1. McMullin GM, Coleridge Smith PD, Scurr JH. Objective assessment of
high ligation without stripping the long saphenous vein. Br J Surg
1991;78:1139–1142.
2. Jakobsen BH. The value of different forms of treatment for varicose
veins. Br J Surg 1979;66:182–184.
3. Munn SR, Morton JB, MacBeth WAAG, et al. To strip or not to strip
the long saphenous vein? A varicose vein trial. Br J Surg 1981;68:426–
428.
4. Rutherford RB, Sawyer JD, Jones DN. The fate of residual saphenous
vein after partial removal or ligation. J Vasc Surg 1990;12:422–428.
5. Sarin S, Scurr JH, Coleridge Smith PD. Assessment of stripping the long
saphenous vein in the treatment of primary varicose veins. Br J Surg 1992;
79:889–893.
6. Gradman WS. Venoscopic obliteration of variceal tributaries using
monopolar electrocautery. J Dermatol Surg Onc 1994;20:482–485.
7. Van Cleef JF. La ‘nouvelle electrocoagulation’ en phlébologie. Phlébolo-
gie 1987;40:423–426.
8. Cragg AH, Galliani CA, Rysavy JA, et al. Endovascular diathermic vessel
occlusion. Radiology 1982;144:303–308.
9. Haines DE. The biophysics of radiofrequency catheter ablation in the
heart: the importance of temperature monitoring. Pacing Clin Electro-
physiol 1993;16:586–591.
10. Haines DE, Verow AF. Observations on electrode–tissue interface
temperature and effect on electrical impedance during radiofre-
quency ablation of ventricular myocardium. Circulation 1990;82:1034–
1038.
11. Lavergne T, Sebag C, Ollitrault J, et al. [Radiofrequency ablation: phys-
ical bases and principles]. Arch Mal Coeur Vaiss 1996;89:57–63.
12. Chandler JG, Pichot O, Sessa C, et al. Defining the role of extended
saphenofemoral junction ligation: a prospective comparative study. J Vasc
Surg 2000;32:941–953.
13. Manfrini S, Gasbarro V, Danielsson G, et al. Endovenous management
of saphenous vein reflux. Endovenous Reflux Management Study Group.
J Vasc Surg 2000;32:330–342.
14. Merchant RF, Depalma RG, Kabnick LS. Endovascular obliteration of
saphenous reflux: a multicenter study. J Vasc Surg 2002;35:1190–1196.
15. Weiss RA, Weiss MA. Controlled radiofrequency endovenous occlusion
using a unique radiofrequency catheter under duplex guidance to elimi-
nate saphenous varicose vein reflux: a 2-year follow-up. Dermatol Surg
2002;28:38–42.
16. Sybrandy JE, Wittens CH. Initial experiences in endovenous treatment
of saphenous vein reflux. J Vasc Surg 2002;36:1207–1212.
17. Komenaka IK, Nguyen ET. Is there an increased risk for DVT with the
VNUS closure procedure? J Vasc Surg 2002;36:1311.
18. Goldman MP. Closure of the greater saphenous vein with endoluminal
radiofrequency thermal heating of the vein wall in combination with
The major pitfalls/complications of endovenous laser and RF
treatment and AP are temporary pigmentation over the
treated vein, temporary nerve damage, hematoma, localized
superficial thrombophlebitis, and temporary lymphocele. All
other adverse effects are extremely rare. A complete discus-
sion is found elsewhere.33
The adverse events previously mentioned are all prevented
by using proper technique described in the Techniques
section of this chapter as well as through proper diagnosis of
the refluxing veins. Allergic reactions may occur from lido-
caine used in the tumescent anesthesia but are extremely rare
and easily treated with epinephrine.
The most common adverse event that we have noticed is
lymphocele which occurs with AP disruption of superficial

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Part 3  Aesthetic Surgical Procedures
ambulatory phlebectomy: preliminary 6-month follow-up. Dermatol Surg
2000;26:452–456.
19. Weiss RA, Goldman MP. Transillumination mapping prior to ambulatory
phlebectomy. Dermatol Surg 1998;24:447–450.
20. Moritz AR, Henriques EC. Studies of thermal injury II: the relative
importance of time and surface temperature in the causation of cutaneous
burns. Am J Pathol 1947;23:695–720.
21. Proebstle TM, Lehr HA, Kargl A, et al. Endovenous treatment of the
greater saphenous vein with a 940-nm diode laser: thrombotic occlusion
after endoluminal thermal damage by laser-generated steam bubbles.
J Vasc Surg 2002;35:729–736.
22. Roggan A, Friebel M, Dorschel K, et al. Optical properties of circulating
human blood in the wavelength range 400–2500  nm. J Biomed Opt
1999;50:523–529.
23. Min RJ, Zimmet SE, Isaacs MN, et al. Endovenous laser treatment of the
incompetent greater saphenous vein. J Vasc Interv Radiol 2001;12:1167–
1171.
24. Navarro L, Min RJ, Bone C. Endovenous laser: a new minimally invasive
method of treatment for varicose veins – preliminary observations using
an 810 nm diode laser. Dermatol Surg 2001;27:117–122.
25. Weiss RA. Comparison of endovenous radiofrequency versus 810  nm
diode laser occlusion of large veins in an animal model. Dermatol Surg
2002;28:56–61.
26. Bush RG. Regarding ‘Endovenous treatment of the greater saphenous
vein with a 940-nm diode laser: thrombolytic occlusion after endoluminal
thermal damage by laser-generated steam bubbles.’ J Vasc Surg
2003;37:242.
27. Parente EJ, Rosenblatt M. Endovenous laser treatment to promote
venous occlusion. Lasers Surg Med 2003;33:115–118.
28. Chang CJ, Chua JJ. Endovenous laser photocoagulation (EVLP) for
varicose veins. Lasers Surg Med 2002;31:257–262.
29. Goldman MP, Detwiler SP. Endovenous 1064-nm and 1320-nm Nd:YAG
laser treatment of the porcine greater saphenous vein. Cosmet Dermatol
2003;16:25–28.
30. Goldman MP, Mauricio M, Rao J. Intravascular 1320-nm laser closure of
the great saphenous vein: a 6- to 12-month follow-up study. Dermatol
Surg 2004;30:1380–1385.
31. Weiss RA, Munavalli G, Bellew SG, et al. Comparison of endovenous
saphenous vein obliteration techniques: 810 nm versus 1320 nm versus
radiofrequency. Lasers Surg Med 2005;17:34.
32. Proebstle TM, Moehler T, Gul D, et al. Endovenous treatment of the
great saphenous vein using a 1320 nm Nd:YAG laser causes fewer side
effects than using a 940 nm diode laser. Dermatol Surg 2005;31;1678–
1683.
33. Ricci S, Georgiev M, Goldman MP. Ambulatory phlebectomy, 2nd edn.
New York: Taylor & Francis; 2005.

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37
Minimum Incision Face Lift
Robert C Langdon MD
Summary box
 In most parts of the face and neck, a component of the
superficial musculoaponeurotic system (SMAS) lies just deep
to the subcutaneous fat.
 Superficial musculoaponeurotic system elevation by
plication or suspension with deep anchorage provides stable
correction of lower face and neck ptosis.
 Tumescent anesthesia greatly reduces postoperative
morbidity in face-lift surgery.
 The structure at greatest risk of injury in face-lift surgery is the
temporal branch of the facial nerve.
 Liposuction of the neck and jowls enhances the results of
face-lift surgery.
 Mid-face ptosis can be corrected by suture suspension of the
malar fat pads.
 INTRODUCTION
Facial aging occurs through three mechanisms: photoaging,
gravitational aging, and volumetric aging. Photoaging is the
result of sun damage and affects primarily the skin; it prob-
ably does not occur to a significant degree in tissues deeper
than the dermis. Gravitational aging is evidenced by stretch-
ing and sagging of soft tissues, especially those of the super-
ficial musculoaponeurotic system (SMAS). Volumetric aging
is manifested by atrophy of soft tissues (primarily fat and
muscle) and of bone. Soft tissue atrophy is most evident in
the anterior face and cheeks and can produce cheek hollow-
ing in the lateral maxillary area. Bone atrophy results in reces-
sion of the maxilla and mandible. Volumetric aging has an
unknown etiology.
The most direct solution to gravitational aging is lifting
surgery. The goal of a face lift (rhytidectomy) is to elevate
sagging soft tissue along vectors that reverse the effect of
gravity on those tissues. The most common surgical lifting
procedure (a SMAS lift) elevates the SMAS of the neck and
lower face.
This chapter will describe a minimum incision (short scar)
rhytidectomy that can be performed under tumescent local
anesthesia. First there will be a review of the anatomy of the
neck, lower face, and mid-face regions and a discussion of
how face-lift surgery can correct gravitational aging of these
structures. This will be followed by a discussion of the vari-
ations of face-lift surgery and how different techniques have
been devised to improve results, especially in the mid-face.
In the minimal incision technique preferred by the author,
tumescent local anesthetic solution is infused throughout the
operative field. The tumescent anesthetic solution can be
administered in a nearly painless fashion, which enables the
use of minimal perioperative sedation. The tumescent anes-
thetic facilitates surgical dissection in the subcutaneous plane
and also enhances hemostasis. The prolonged vasoconstriction
that results from the use of the tumescent anesthetic results
in reduced postoperative ecchymosis and edema, which
greatly accelerates the patient’s recovery.
Pre-excision of preauricular skin (in an ‘S’ configuration)
increases visibility of the operative field and facilitates under-
mining in the supra-SMAS plane. Undermining as far medial
as the malar fat pad enables use of a suspension suture to
elevate the pad. Malar fat pad suspension is a safe and effec-
tive way to improve mid-face aging, including correction of
deep nasolabial folds and of infraorbital hollowing. SMAS
plication is achieved with purse-string sutures that take mul-
tiple bites into the SMAS and are stably anchored to deeper
structures. The SMAS plication sutures are tied under sig-
nificant tension. Upon SMAS plication, the skin can be closed
in a predictable way using key sutures and minimizing the
need for additional skin removal and dog-ear repairs.
Anatomy relevant to face-lift surgery
Safe and effective face-lift surgery requires a thorough under-
standing of facial anatomy, especially that pertaining to the
SMAS and its retaining ligaments, the platysma and other
superficial muscles of expression, and motor nerve branches.
If dissections are successfully confined to supra-SMAS planes,
blood vessels and sensory nerves are less likely to be injured
during the surgery.
The SMAS is a complex mesenchymal tissue system that
is most broadly defined as the superficial muscles of facial
expression, fascial planes that are continuous with these
muscles, and myriad septal attachments between these fascial
planes and the dermis. Through the cutaneous attachments
of the superficial facial musculature and of the fascial planes
of the SMAS, contractions of the muscles are conveyed to
the skin, resulting in facial expression. In most parts of the
face and neck, a component of the SMAS lies just deep to
the subcutaneous fat. The SMAS includes the platysma
muscle in the neck and a robust fascia in the lateral cheek

602
Part 3  Aesthetic Surgical Procedures
facial nerve branches travel below the SMAS and innervate
the muscles of facial expression via the underside of the
muscles. In a typical SMAS lift, in which undermining is done
superficial to the SMAS, all of these lower branches of the
facial nerve are protected from injury by the SMAS itself.
The facial nerve branches at greatest risk during rhytidec-
tomy are the temporal branches, which lie within the super-
ficial temporal fascia at and cephalad to the zygomatic arch
(see Fig. 37.2). Great care must be taken to undermine at a
level superficial to this fascia (preferably within the subcuta-
neous fat) over and cephalad to the zygomatic arch. If the
zygomatic arch or deep temporal fascia are to be used as an
anchor point for SMAS or malar fat pad elevation, the distri-
bution of temporal branch rami as they cross the zygomatic
arch must be considered. In a study in which 35 cadaver
hemifaces were dissected, the most posterior ramus of the
facial nerve temporal branches crossed the zygomatic arch on
average at a point 1.8 cm anterior to the auricle.4 The most
anterior ramus of the temporal branch crossed the zygomatic
arch on average at a point 2.0 cm posterior to the anterior
origin of the arch.
Surgery that tightens the SMAS in a superior direction
results in an en bloc elevation of facial soft tissues at and
superficial to the SMAS. Elevated tissues include subcutane-
ous fat and skin, which are attached to the SMAS via myriad
septal attachments between SMAS and dermis.2 The robust
fascia of the lateral cheek SMAS can withstand significant
tension and is the ideal soft tissue layer for suture placement
to mediate lifting. In contrast, the dermis has much less
tensile strength and will stretch to produce a spread scar if
sutured under too much tension.
Variations on rhytidectomy
Four major variables characterize face-lift surgeries. These
are:
1. the anatomic plane(s) of dissection or undermining
2. the method of tightening the tissue plane(s) to be
lifted
3. the point of fixation or anchoring of the tightened tissue
plane(s)
4. the vectors along which the tissue planes are tightened.
Face-lift operations involve undermining along one or more
tissue planes and resuspension of tissue planes to reverse
gravitational sagging. Face lifts can be classified according to
the depth of the plane of dissection. The most superficial
plane is subcutaneous (supra-SMAS). The next level is sub-
SMAS; deeper still is subperiosteal dissection. The deeper-
level face lifts are designed to provide a greater degree of
structural lifting to fascia and superficial musculature. Deep-
plane dissection generally includes release of the deep retain-
ing ligaments that bind the SMAS to the underlying skeleton.
These are the zygomatic and mandibular ligaments.2 In
theory, releasing these deep attachments affords greater
mobility of the more anterior facial musculature and greater
improvement of the mid-face, especially the nasolabial folds.
There is considerable disagreement as to the long-term effi-
cacy of deeper-plane face lifts.5–8
Recent anatomic studies have shown that in the mid-face
(defined as the cheek medial to a line drawn from the malar
prominence to the modiolus (Fig. 37.3)), ptosis of the malar
fat pad is largely responsible for the stigmata of aging.9,10 The
area. The fascial components of the SMAS are continuous
with, or envelop, the superficial muscles of expression,
including the platysma, orbicularis oculi, risorius, and zygo-
matic muscles.
In the anterior face, the superficial fascia level is continuous
through the galea, frontalis, orbicularis oculi, SMAS, and
platysma. More posterior, in the temple region, the superfi-
cial fascia manifests as the superficial temporal fascia (also
called temporoparietal fascia). This superficial fascia merges
with deep temporal fascia at the zygomatic arch and is dis-
continuous with the SMAS of the cheek, which converges on
the zygomatic arch from below.1
The SMAS is attached to dermis above and to bone below
via two distinct retaining ligaments: the zygomatic (also
referred to as ‘McGregor’s patch’) and mandibular ligaments.2
In addition, there are several ligamentous attachments
between the SMAS and dermis, including those in the mas-
seteric and periauricular areas (Fig. 37.1).2,3 In a supra-SMAS
dissection for rhytidectomy, many of these retaining liga-
ments are encountered and divided. Many of them surround
perforating vessels and small sensory nerve branches. The
vessels frequently require bipolar cautery for hemostasis; as
a rule, the nerves regenerate postoperatively with restoration
of sensation in the cheek region.
The most important structure at risk of damage during
face-lift surgery is the facial nerve (Fig. 37.2). The nerve is
deep to the parotid gland at its foramen and begins its branch-
ing deep to the gland. Inferior to the zygomatic arch, the
Facial retaining ligaments
binding dermis to SMAS
Figure 37.1  Facial retaining ligaments. All of these ligaments
bind the dermis to the SMAS. The zygomatic and mandibular
ligaments also provide firm attachments between SMAS and
bone. Skin mobility is increased if the dermal attachments of
these ligaments are partially or completely severed during
rhytidectomy. (Adapted from Özdemir R, et al.
Anatomicohistologic study of the retaining ligaments of the face
and use in face lift: retaining ligament correction and SMAS
plication. Plast Reconstr Surg 2002;110:1134–1149 with
permission.)

603
Chapter 37  Minimum Incision Face Lift
superficial to the fascia remains attached to skin. Suspending
only this thick skin/fat flap (without the SMAS) is effective
in correcting ptosis of the central face and jowls.
In a SMAS lift, the SMAS layer can be tightened by either
plication, imbrication, or SMAS-ectomy. Plication is the sim-
plest method and is performed by suturing the SMAS to itself
or to a deeper tissue layer in order to shorten the expanse of
the SMAS. With plication, the SMAS is not incised. Suspen-
sion is a simple version of plication in which only two bites
are taken, one through the tissue (SMAS element) to be
suspended and one through the deeper anchoring tissue.
Imbrication involves incising and raising a SMAS flap by
undermining, then excising excess SMAS and suturing the
free edge to a less mobile structure in order to anchor it. In
SMAS-ectomy, the SMAS is excised without undermining;
the cut edges of the SMAS are then reapproximated by
suturing.
When the SMAS is mobilized by plication or suspension,
it must be anchored to a relatively immobile point of fixture
malar fat pad is a roughly triangular formation of subcutane-
ous fat that lies over the maxilla. Its superolateral corner
extends into the malar area and its lower apex is near the
modiolus. The malar fat pad is very fibrous and contains
myriad dense connective tissue septae that connect the
dermis to the underlying muscle fascia; it is therefore a com-
ponent of the SMAS (see earlier definition). Gravitational
descent of the malar fat pad results in deepening of the
nasolabial fold, infraorbital hollowing, and lowering and flat-
tening of the youthful convexity of the mid-face. Cadaver
dissection studies of the mid-face region have indicated that
suspension of superficial tissues (such as skin or subcutaneous
fat) affords superior correction of mid-face ptosis.9 The
fibrous nature of the fat pad enables the use of a suture placed
through the fat to suspend or elevate this tissue.11,12
Hoefflin advocates a supra-SMAS dissection that extends
widely enough to enable release of all retaining ligaments
between the SMAS and dermis.13 Undermining is immedi-
ately superficial to the platysma and SMAS so that all fat
Parotid gland
Marginal mandibular branch
Cervical branches
Buccal branches
Zygomatic branches
Temporal branches
Branches of the facial nerve
Figure 37.2  Branches of the
facial nerve. Caudal to the
zygomatic arch, all facial
nerve branches lie beneath
the parotid gland and SMAS,
and are protected from injury
if undermining is done
superficial to these
structures. Superficial to the
zygomatic arch and in the
temple region, the temporal
branches run within the
superficial temporal fascia.

604
Part 3  Aesthetic Surgical Procedures
 TECHNICAL ASPECTS
In the surgical technique described herein, tumescent local
anesthetic solution is instilled in the subcutaneous tissue of
the cheeks and neck. Complete anesthesia as well as signifi-
cant vasoconstriction are provided to the entire operative
field. If necessary, liposuction of the neck and jowls and
platysmaplasty are performed. Rhytidectomy begins with an
incision just within the hairline in the lower temple and side-
burn, continuing in the preauricular sulcus and into the
immediate postauricular area. Next, subcutaneous dissection
of the cheek and neck is performed at a level superficial to
the SMAS and platysma. Permanent or long-lasting absorb-
able sutures are used in four locations to plicate or suspend
the SMAS of the neck and cheeks. Each suture is anchored
to a stable fixation point. Finally, excess skin is trimmed and
the skin is closed.
After informed consent is obtained, preoperative photo-
graphs are taken with the patient sitting upright. Five poses
are used with the camera angle in the same horizontal plane
as the patient’s face: these include frontal, left and right
oblique, and left and right lateral views of the entire face and
neck. The oblique angle is standardized so that the anterior
nasion and inner canthus are aligned. Three additional low-
angle photos are taken from the frontal and oblique views.
Next, hair just behind the hairline in the lower temple and
sideburn area is shaved with a barber-style (electric) shaver.
Then, skin markings are made after the skin is degreased with
acetone (Fig. 37.4) A narrow strip of preauricular and imme-
diate infra-auricular skin (1.0–1.5 cm wide) is marked (solid
lines). This area of skin can be excised before undermining
of the cheek flap in order to increase visibility beneath the
flap during undermining. This skin moiety approximates the
amount of lateral cheek skin that will become redundant after
SMAS plication. Because most skin movement after SMAS
plication is vertical, only a conservative amount of skin should
be removed prior to undermining.
Skin markings (see Fig. 37.4) include demarcation of the
mandibular border and the medial border of the sternoclei-
domastoid muscles; these serve as guides for neck liposuction.
The jowl fat pad is delineated by the labial–mandibular sulcus
(marionette fold) medially and by the palpable edge of the
fat pad laterally. In the mid-face, the nasolabial and tear
trough furrows are marked. The latter structure denotes the
cutaneous attachment of the orbitomalar septum.19 This
structure lies between the periosteum of the arcus marginalis
(at the inferior orbital rim) and the dermis and is somewhat
impermeable to the passage of fluid. To avoid lower eyelid
edema, the orbitomalar septum should not be traversed
during surgery. The tear trough marking serves as an aid to
avoiding violation of the septum during mid-face surgery.
A horizontal dashed line indicates the level of the outer
canthus. A vertical hash denotes the palpable posterior
(outer) edge of the orbital rim. Just lateral to the orbital rim,
an anchor point in the deep temporal fascia will be used for
a suture that suspends the malar fat pad (the fourth SMAS
plication/suspension suture). A dotted line extends from this
anchor point toward the malar fat pad and indicates the
course of this suspension suture; the line terminates just
caudad to the end of the line delineating the orbitomalar
septum.
Solid horizontal lines denote the superior and inferior edges
of the zygomatic arch. An ‘X’ at a point 2 cm anterior to the
to maintain a stable tightening. In general, the SMAS itself
is relatively stable in the lateral cheek areas (preauricular and
infra-auricular). The mastoid periosteum is a stable fixation
point that can be used to secure platysma.14,15 Another fixa-
tion point for suspending the platysma is the auriculoplatys-
mal ligament, an immobile condensation of fascia in the
inferior preauricular area.2 Skeletal fixation can also be
achieved by suturing the SMAS to the periosteum of the
zygoma16 or of the posterior zygomatic arch.17 Deep temporal
fascia is another stable structure that can serve as an anchor
for SMAS plication.18
 PREOPERATIVE PREPARATION
As with any major surgery, patients must avoid any prescrip-
tion or over-the-counter medications that can predispose to
bleeding. Aspirin should be discontinued 2 weeks prior to
surgery. Vitamin E should be avoided starting 1 week before
surgery. Because several over-the-counter herbal preparations
can inhibit hemostasis, it is best to discontinue all herbal sup-
plements 1 week preoperatively.
Patients who smoke should discontinue smoking at least 2
weeks prior to surgery and not resume for at least 2 weeks
postoperatively. Smoking causes peripheral vasoconstriction,
which can compromise revascularization of the face-lift skin
flap and result in distal flap necrosis.
Preoperative laboratory evaluation should include bleeding
parameters such as prothrombin and partial thromboplastin
times, complete blood count (including platelets), and blood
chemistries.
The mid-face and the malar fat pad
Figure 37.3  The mid-face and the malar fat pad. The mid-face
region lies medial to a line drawn from the lateral edge of the
orbital rim to the modiolus (red line). Gravitational aging of this
region results from the descent of the malar fat pad, a roughly
triangular-shaped formation of relatively fibrous subcutaneous
fat. (Adapted from Owsley JQ, Zweifler M. Mid-face lift of the
malar fat pad; technical advances. Plast Reconstr Surg
2002;110:674–685 with permission.)

605
Chapter 37  Minimum Incision Face Lift
Tumescent local anesthetic solution containing lidocaine,
epinephrine, and sodium bicarbonate (Table 37.1) is admin-
istered subcutaneously throughout the anterior neck
extending to 3  cm lateral to the medial border of the
sternocleidomastoid muscle. Included in the area of anesthe-
sia are the mastoid and postauricular areas and the jowls. The
medial jowl, including the area of the mandibular ligament,
is anesthetized (see Figs 37.1 and 37.4).
Liposuction of the anterior neck and jowls is performed
using five incisions.20,21 From a single submental and two
infralobular incisions, the neck is liposuctioned using first a
14-gauge Capistrano microcannula, then a 3-mm accelerator
(triport) cannula. The jowls are suctioned manually using a
10-mL syringe and a 14-gauge accelerator (triport) microcan-
nula from an infralobular and an ipsilateral infrajowl incision.
This area is treated conservatively in order to avoid over-
resection. The aspirate is allowed to separate in the syringe
to enable quantitation of supernatant fat and to assure
consistency of aspirate volume between the left and right
jowls.
auricle and 1 cm superior to the zygomatic arch indicates one
of the anchor points for SMAS plication. At this point a
suture (the third SMAS plication/suspension suture) will be
anchored in the deep temporal fascia and used to plicate
cheek SMAS along the vector denoted by the dotted line that
runs toward the jowl; this plication suture will improve
sagging of the jowl. A radial mark approximately 7 cm from
the tragus denotes the approximate extent of subcutaneous
undermining on the cheek and neck. A solid line denotes the
initial skin incision. This line is drawn just behind the tem-
poral hairline, along the lower sideburn, into the hairless area
between sideburn and ear, and caudal within the preauricular
sulcus. This line terminates immediately posterior to the
lobule.
Blood pressure is checked. If systolic pressure is above
110 mmHg and/or diastolic pressure is greater than 70 mmHg,
a single dose of clonidine 0.1 mg is given orally. Next, seda-
tion is administered with midazolam 2.5–5.0 mg and hydroxy­
zine 25 mg, both intramuscularly. Arterial oxygen saturation
is monitored by pulse oximetry.
A
B
Figure 37.4  Presurgical markings. (A) Patient marked for liposuction of neck and jowls and minimum incision face lift. (B) The
S-form moiety that denotes skin to be excised from the preauricular area is marked with a solid line. A curvilinear extension from this
marking, within the lower sideburn and lower temple hairline, indicates where the zig-zag incision will be made. Two solid lines
indicate the palpable edges of the zygomatic arch. The solid line on the cheek and neck marks a 7-cm radius from the tragus and is
used as a guide for the extent of subcutaneous undermining. Dashed lines denote anatomic features including the tear trough, the
nasolabial fold, the labiomandibular fold (pre-jowl sulcus), the inferior border of the mandible, and the anterior border of the
sternocleidomastoid muscle. The tear trough line indicates the cutaneous insertion of the orbitomalar septum. Two dashed lines
indicate the vectors for malar fat pad suspension and superolateral SMAS plication. A dashed line marks the level of the lateral
canthus; the vertical hash denotes the palpable edge of the orbital rim at this level.
Table 37.1  Composition of tumescent anesthetic solution. To a 500 mL bag of normal saline are added the indicated volumes
of stock solutions of lidocaine HCl, epinephrine, and sodium bicarbonate
INGREDIENT
STOCK CONCENTRATION
VOLUME (mL)
AMOUNT
FINAL CONCENTRATION
Sodium chloride (normal saline)
0.9%
500
–
–
Lidocaine HCl
2%
50
1000 mg
0.18%
Epinephrine
1 mg/mL (1 : 1000)
2
2 mg
3.6 mg/L (1 : 278 500)
Sodium bicarbonate
8.4% (1 mEq/mL)
5
5 mEq
9 mEq/L
Reprinted with permission from Langdon RC. The S-lift. In: Moy RL, Fincher EF, eds. Procedures in cosmetic dermatology series: advanced face lifting. Philadelphia: Elsevier
Saunders; 2006.

606
Part 3  Aesthetic Surgical Procedures
and will facilitate later skin closure. The transected hair fol-
licles will result in hair growth within and caudal to the final
scar, thus minimizing the scar’s visibility. The incision is
extended into the preauricular area where it follows the
supratragal notch and descends just anterior to the tragus in
the preauricular sulcus (see Fig. 37.4). In most patients, the
preauricular incision is made within an existing skin fold. The
skin incision is carried through the skin into the subcutaneous
fat. At this time, the preauricular strip of skin can be excised.
Subcutaneous undermining of the lateral cheek/lateral neck
skin flap is accomplished using 12.7-cm and 17.8-cm Metzen-
baum scissors. Over the parotid gland, the undermining is
done deep to the subcutaneous fat, directly superficial to the
SMAS. Deep undermining in the lateral part of the flap pro-
duces a thick flap that includes the subcutaneous fat. A
If midline platysma plication is necessary, an incision
(approximately 3 cm long) is made in the submental crease.
Under direct headlight visualization, a dissection is carried
out onto the anterior neck in the supraplatysmal plane to a
distance of 6–8 cm from the incision. Undermining is per-
formed using Metzenbaum scissors. Most septal attachments
between platysma and skin are divided. Larger blood vessels
are avoided and small bleeding vessels are coagulated by
bipolar cautery. The anterior platysma borders are plicated
using the corset technique.22 A running suture of 3-0 Ethi-
bond (Ethicon, Somerville, NJ) is used to approximate the
two muscle edges, beginning just caudal to the incision and
continuing to a distance of 4 cm down the neck. Bites into
the muscle are taken approximately 3–4 mm from the medial
edge. The running suture is continued in the reverse (cepha-
lad) direction with larger bites (approximately 6–8 mm on
each side) in order to increase the medial pull on the platysma
muscles. The running suture terminates at its origin near the
submental incision. The knot is buried on the underside of
the approximated muscle edges. After complete hemostasis
of the undermined tissue is confirmed, the skin is closed in
a bilayered interrupted fashion with buried dermal sutures of
5-0 Vicryl (Ethicon) and surface sutures of 5-0 Prolene
(Ethicon).
Next, additional tumescent anesthetic solution is instilled
in the cheek and temple areas. A 10-mL syringe with a
25-gauge needle is used to inject the anesthetic solution. The
immediate subcutaneous fat layer of the cheeks and temple
is gently tumesced with care taken to include the entire
subcutaneous space. (Discontinuous distribution of tumes-
cent solution within the operative field will result in incom-
plete anesthesia.) Usually, greater than 100 mL is used per
side. The upper border of the operative field is the level of
the tail of the eyebrow in the temple. Additional anesthesia
to the maxillary area can be provided by a nerve block of the
infraorbital nerve using 0.5% bupivacaine with epinephrine
1 : 200 000.
Rhytidectomy is performed beginning with the initial skin
incision 3–4 mm within the hairline of the lower temple and
sideburn. This incision is made in a zig-zag pattern (Fig. 37.5)
with the blade angled perpendicular to the hair follicles (Fig.
37.6). The zig-zag pattern lengthens the incision in this area
Figure 37.5  Zig-zag skin incision within hairline of lower
sideburn. This curvilinear incision is angled so that it transects
hair follicles.
A
B
Figure 37.6  Angle of incision within lower sideburn. The hair
follicles in the sideburn slant downward (caudad). The incision
should be made within the hairline and should transect the
lowermost hair follicles. Hair will regrow from the transected
follicles and will help obscure the scar. (Adapted from Langdon
RC. The S-lift. In Moy RL, Fincher EF, eds. Procedures in
cosmetic dermatology series: advanced face lifting.
Philadelphia: Elsevier Saunders; 2006.)

607
Chapter 37  Minimum Incision Face Lift
nocleidomastoid muscle (Fig. 37.7), or to the marginal man-
dibular nerve (see Fig. 37.2). Both of these nerves lie deep
to the platysma. Subcutaneous undermining in the lateral
neck should extend only slightly posterior to the ear lobule.
Undermining of the cheek should extend to approximately
7 cm from the tragus, and in the temple as far cephalad as
the level of the tail of the eyebrow and anterior to just beyond
the temporal edge of the orbital rim. Undermining should
include the lower temple area cephalad to the zygomatic arch
thicker distal flap will be better vascularized, decreasing the
risk of vascular compromise (and subsequent flap necrosis)
postoperatively. In the lateral neck area, the undermining is
done immediately superficial to the platysma. If liposuction
of the neck was performed, the lateral neck dissection will
connect with the ‘tunnels’ created by liposuction. Care must
be taken to assure that the neck undermining is done super-
ficial to the platysma in order to avoid damage to the great
auricular nerve, which lies directly on the belly of the ster-
Marginal mandibular branch
of facial nerve
From ophthalmic division
of trigeminal nerve [V1]
From maxillary division
of trigeminal nerve [V1]
From mandibular division
of trigeminal nerve [V1]
Zygomaticotemporal
nerves
Supraorbital nerve
Supratrochlear nerve
External nasal nerve
Infratrochlear nerve
Zygomaticofacial
nerve
Infraorbital nerve
Buccal nerve
Mental nerve
Third occipital nerve
(C3)
From fourth, fifth, sixth,
seventh, and eighth
cervical nerves
Lesser occipital nerve
(C2,3)
Great auricular nerve
(C2,3)
Medial branches of
dorsal rami of cervical
spinal nerves
Branches from
cervical plexus
Greater occipital nerve
(C2)
Transverse cervical nerves
(C2,3)
Supraclavicular nerves
(C3,4)
Auriculotemporal
nerve
Cutaneous nerves of the head and neck
Figure 37.7  Sensory nerves of the neck and cheek. The great auricular nerve lies on the sternocleidomastoid muscle, and is at risk
of injury if undermining in the lateral neck is done deep to the platysma. (Adapted from Standring S, et al. Gray’s anatomy, 39th
edn. Edinburgh: Churchill Livingstone; 2005.)

608
Part 3  Aesthetic Surgical Procedures
in order to facilitate placement of the third SMAS plication/
suspension suture (see SMAS plication below). Increased
difficulty will be encountered when dissecting through the
facial retaining ligaments (see Fig. 37.1). These retaining
ligaments attach the SMAS to the overlying dermis and are
composed of relatively thick connective tissue. Frequently,
bleeding is encountered when these ligaments are divided
because they usually surround communicating blood vessels.
This bleeding may necessitate bipolar cautery to achieve
hemostasis. Medial to the parotid gland, the distal branches
of the facial nerve are no longer protected by the overlying
gland, and extra care should be taken to undermine superficial
to the SMAS. If liposuction of the jowl area was previously
performed, the medial dissection will communicate with the
‘tunnels’ created earlier. Hemostasis should be periodically
reassessed by direct visualization of the undermined flap,
with bipolar cautery used as necessary.
After dissection of the cheek flap is complete, a periosteal
elevator can be used to partially release the mandibular
retaining ligament (see Fig. 37.1). Release of this ligament
(between the SMAS and dermis) will improve mobility of
the overlying skin in the jowl area.
SMAS plication
Four high-tensile-strength sutures are used to plicate or
suspend the SMAS (Fig. 37.8). In each case a non-absorbable
suture material (2-0 Ethibond) is used. Alternatively, an
absorbable material (such as 0 PDS) may be used. The first
suture is anchored in the auriculoplatysmal ligament, the
relatively immobile fascia (a SMAS component) between the
ear lobule and the platysma.2 The suture should be placed
1–1.5 cm inferomedial to the ear lobule. A superficial bite of
the needle should be placed through the fascia at this anchor
point. If a deeper bite is taken through this fascia, there is a
risk of the suture impinging on a branch of the great auricu-
lar nerve, which becomes more superficial in this area (see
Fig. 37.7). After verifying that its placement is secure, this
suspension suture is then placed through the platysma at a
point caudal to the mandibular border, usually 4–5 cm from
the anchor point. One or two bites are taken through the
platysma in a direction perpendicular to the axis of the sus-
pension suture (Fig. 37.9). The suture is tied under maximal
tension, which provides a superolateral suspension of the
platysma. This suspension improves platysmal laxity and will
smooth most mild-to-moderate platysmal bands (obviating
the need for platysmaplasty).
The second SMAS plication/suspension suture is anchored
in the dense connective tissue superficial to and including the
periosteum of the posterior zygomatic arch. Before placement
of this suture, 1–2  mL of tumescent anesthetic solution is
injected just superficial to the bone. The needle is inserted
1.5 cm anterior to the tragus and is directed deeply and at a
45° angle posteroinferior. If this bite is done horizontally,
there is a risk of the needle lacerating the superficial temporal
vessels near the ear. After placement of this plication suture,
its integrity should be tested by pulling up on both ends; the
suture should hold when tension sufficient to move the
patient’s head is applied. The suture is placed in a purse-string
fashion in which multiple bites (approximately 1.5 cm apart)
are taken through the SMAS. This SMAS plication suture is
run directly caudal toward the lateral neck and will pass over
the first suture that was used to suspend the platysma; the
4
3
2
1
The four SMAS plication/suspension sutures
used in the minimum incision face lift
Figure 37.8  The four SMAS plication/suspension sutures used
in the minimum incision face lift. The placement of each suture
including its anchor point, orientation, and approximate length
and width is shown. The first suture is anchored in the
auriculoplatysmal ligament and suspends the platysma in a
superolateral direction. The second suture (a purse string) is
anchored in the periosteum of the posterior zygomatic arch and
plicates the lateral cheek SMAS and the lateral platysma in a
vertical direction. The third suture (also a purse string) is
anchored in deep temporal fascia and plicates the cheek SMAS
in a superolateral direction. The fourth suture is anchored in
deep temporal fascia and suspends the malar fat pad in a
superolateral direction.
Figure 37.9  Placement of the first SMAS plication/suspension
suture (patient’s left side). The suture has been anchored in the
auriculoplatysmal ligament (foreground); the needle is passing
through the platysma. The view is into the undermined lateral neck;
the ear lobule is in the foreground with cotton ball in the canal.

609
Chapter 37  Minimum Incision Face Lift
1.5 cm apart) in a relatively wide pattern (see Fig. 37.8) to
create a purse-string pattern. The central axis of this purse
string should follow or parallel the dotted line directed
toward the jowl that was drawn in the surgical markings (see
Fig. 37.4). The purse string should extend to approximately
6 cm from its anchor point.23 The bites into the SMAS should
each be tested to verify that the fascia has been engaged.
Deep bites should be avoided because the temporal branches
of the facial nerve run deep to the SMAS in this area (caudal
to the zygomatic arch). In its final bite through the SMAS,
the needle should enter the buttonhole, where the suture is
tied to its other end under maximal tension, as described for
the second plication suture. The resulting knot can be buried
in the buttonhole.
The fourth suture is used to suspend the malar fat pad. A
buttonhole is created a few millimeters posterior (lateral) to
the orbital rim (the outer edge of the orbital rim was previ-
ously marked with a vertical hash; see Fig. 37.4). The bony
edge of the orbital rim is palpated and a buttonhole (as was
used for the third plication suture) is created through the
orbicularis oculi to expose the deep temporal fascia (Fig.
37.11). The suspension suture is anchored in deep temporal
fascia by placing its needle into the buttonhole (oriented
caudally) to take a bite through the deep fascia and SMAS
(orbicularis oculi). The integrity of this anchoring bite is then
tested. The needle is then used to take a bite into the supe-
rolateral corner of the fibrous malar fat pad at a deep level in
the fat. The integrity of this bite is tested by pulling on both
ends of the suture. One should see satisfactory cephalad
suspension of the mid-face region with movement of the
malar fat pad. If the bite into the fat pad is placed too super-
ficially, puckering (dimpling) of the skin may be created when
tension is applied to the suture ends (necessitating replace-
ment of the suture). If malar fat pad suspension is satisfac-
tory, the suspension loop can be completed by placing the
low point of this suture should be approximately 4 cm below
the caudal edge of the tragus (measured with a ruler or scalpel
handle). At its nadir, a horizontal bite is taken through the
platysma and the suture is carried in an anterior direction so
that it is slightly flared at its base (see Fig. 37.8). The suture
continues in a cephalad direction toward its origin, with the
final bite taken approximately 4 mm from the suture origin.
This plication suture is then tied with a high degree of tension,
providing vertical lift to the lateral platysma. To tie a knot
with this suture under high tension, after the first overhand
throw, an assistant should clamp down on the knot using a
smooth (non-serrated) needle holder. The surgeon then com-
pletes the second throw of the knot in the opposite direction
to complete a square knot, which is tightened simultaneously
with the assistant’s release and withdrawal of the needle
holder. Three additional throws in alternating opposite direc-
tions are made to further secure the knot.
The third suture used to plicate the SMAS is anchored to
deep temporal fascia at a point 2 cm anterior to the auricle
and 1  cm cephalad to the zygomatic arch. This relatively
anterior and cephalad anchor point provides a somewhat ver-
tical vector to plication of cheek SMAS and optimizes lift of
the jowl area.23 The anchor point in the deep fascia is accessed
by preparing a ‘buttonhole’ through the superficial temporal
fascia (SMAS). The sharp tips of iris scissors are used to
puncture and spread apart the superficial tissue layers until
the characteristic striated appearance of deep temporal fascia
is seen several millimeters deep to the SMAS (Fig. 37.10).
The plication suture is anchored in deep temporal fascia by
inserting its needle through the buttonhole in order to take
a bite of the deep fascia and the overlying SMAS. The needle
is oriented toward the tragus as this bite is taken. The integ-
rity of the anchored suture should be tested by pulling on
both of its ends to verify that it holds. Next, the SMAS of
the lateral cheek is plicated by taking multiple bites (1–
Figure 37.10  Anchor point for the third SMAS plication/
suspension suture. A ‘buttonhole’ was created in the superficial
temporal fascia at a point 2 cm anterior to the auricle and 1 cm
cephalad to the zygomatic arch. The soft tissue was gently
spread using the tips of iris scissors to the level of deep
temporal fascia. The needle to place the suture will be run
through the deep temporal fascia in the direction of the tragus.
(Reprinted with permission from Langdon RC. The S-lift. In: Moy
RL, Fincher EF, eds. Procedures in cosmetic dermatology series:
advanced face lifting. Philadelphia: Elsevier Saunders; 2006.)
Figure 37.11  View of the second, third, and fourth SMAS
plication/suspension sutures (patient’s left side). The cephalad
edge of the undermined cheek flap is retracted. The two
purse-string sutures have been tied. The buttonhole for the
fourth suture, with deep temporal fascia at its base, is seen to
the left. This suture will suspend the malar fat pad; it has been
placed in the fat pad, but has not yet been tied. The patient’s
ear (with cotton ball inserted) lies to the right; her nose is in the
upper left corner. Note the zig-zag skin incision in the
foreground.

610
Part 3  Aesthetic Surgical Procedures
The posterior edge of the flap is then sutured to the preau-
ricular incision. The flap edge is trimmed (rounded) to better
match the tragus and supratragal notch (Fig. 37.16). Buried
dermal sutures (3-0 Vicryl) and surface sutures (5-0 Prolene)
are placed. Generally it is not necessary to trim excess skin
from the infra-auricular or postauricular areas (Fig. 37.17).
 OPTIMIZING OUTCOMES
The great majority of patients benefit from liposuction of the
neck and jowls performed at the time of face lift. Thorough
liposuction of the neck will result in skin contraction that syn-
ergizes with lateral platysma tightening from face lift. Turning
the cannula ports ‘upward’ toward the underside of the dermis
can aid in assessing evenness of fat removal from the central
neck (submental) region. An aggressive ‘window wiper’ trans-
verse motion of the cannula, in order to sever all attachments
between the dermis and platysma, should be avoided.21 Even
those patients with moderate amounts of submental fat will
have improved results if neck liposuction is performed along
needle through the orbicularis and into the buttonhole. The
suture is tied under moderate tension and the knot is buried
in the buttonhole.
After all four SMAS plication/suspension sutures have been
placed, attention is directed toward skin closure. Because the
second and third plication sutures are of a purse-string design,
subcutaneous fat may ‘bunch up’ within the tightened purse
strings. This excess fat can be carefully trimmed with Metzen-
baum scissors. A final check for hemostasis should be done
prior to skin closure.
The undermined cheek flap should be conveyed by plica-
tion of underlying SMAS in a cephalad and slightly posterior
direction. Prior to final closure, redundant skin is trimmed
from the cephalad part of the flap as the flap is stretched
under mild to moderate tension (Fig. 37.12). A Pitanguy flap
demarcator (Fig. 37.13) can be used to estimate the amount
of flap skin that can be safely trimmed. A curvilinear incision
(made at an angle matching that used to transect hair follicles
in the original zig-zag incision) is made using supercut iris
scissors. The mobilized cheek flap is then sutured at the
original zig-zag incision in the lower temple/sideburn area.
The zig-zag creates increased linear length to better match
the (longer) curvilinear cut edge of the flap (Fig. 37.14).
Buried dermal sutures (3-0 Vicryl) are used to approximate
the edges (Fig. 37.15).
Figure 37.12  The cephalad edge of the cheek flap is pulled
with a skin hook and is measured for skin trimming with a
Pitanguy flap demarcator (see Fig. 37.13).
Figure 37.13  Pitanguy flap demarcator. This instrument is
useful for estimating the amount of additional skin to be
trimmed from the cheek flap on skin closure.
Figure 37.14  The cheek flap after trimming of excess skin. The
zig-zag incision provides increased linear length to better match
that of the cut edge of the cheek flap.
Figure 37.15  Buried sutures have been placed to approximate
the cephalad edge of the trimmed cheek flap to the zig-zag
incision.

611
Chapter 37  Minimum Incision Face Lift
free skin flap can be directed independent of the SMAS in
order to avoid distortion.
Also standardized are the radii of the two purse-string
SMAS plication sutures (the second and third plication/sus-
pension sutures). These radii should be measured so that they
are similar on both sides of the face. The main variable that
determines the actual degree of plication is the tension under
which the sutures are tied. Although this tension is appreci-
ated subjectively, equal amounts should be applied on oppo-
site sides of the face. Robust purse-string plication of the
SMAS can result in significant bunching of the fascia. To
smooth the contour, excess fat can be trimmed off the fascia
using Metzenbaum scissors. Such trimming should be done
cautiously in the area near the zygomatic arch because of the
presence of facial nerve branches within the fascia.
The fourth SMAS plication/suspension suture, which is
used to suspend the malar fat pad, is not necessary in all cases.
Patients with a very thin malar fat pad or who lack significant
infraorbital hollowing or nasolabial folds do not require this
suspension. When this suture is used, it should be tied under
moderate tension. Too much tension can produce bunching
of the skin of the lower eyelid, a problem that may necessi-
tate skin removal with a pinch blepharoplasty technique.24
If the vertical vector of SMAS plication is excessive, bunch-
ing of skin may occur in the lower temple region. The excision
of excess skin from the cephalad edge of the cheek flap prior
to skin closure may not correct all of this skin excess. A
temple lift may be necessary to convey excess skin into the
upper temple/parietal scalp area.25
 POSTOPERATIVE CARE
Generally, no drain is needed. Parenteral corticosteroids to
reduce postoperative edema are generally not necessary. A
head wrap (Design Veronique, Richmond, CA), as is used
after cervical liposuction, is placed. Gauze squares of 7.6 ×
7.6 cm are placed between the secured skin flap and the head
wrap to increase compression over the flap (Fig. 37.18). The
level of compression should be mild to moderate so as not to
compromise vascular sufficiency of the flap. Postoperative
medications include an oral antibiotic (usually cephalexin
500 mg twice daily for 5 days) and an analgesic to be used if
needed (e.g. Vicodin). The head wrap dressing should be left
on overnight. The patient is generally seen 1 day after surgery
and at 7 days for suture removal.
 PITFALLS AND THEIR MANAGEMENT
with face lift. Liposuction of the jowls will reduce the convex-
ity of the jowl but should be done conservatively to avoid a
postoperative depression. For most patients, 5 mL or less of
supernatant fat should be removed from each jowl.21
Platysma plication via corset platysmaplasty should be con-
sidered in any patient who has prominent platysmal bands
and in patients with less conspicuous bands but who also
demonstrate visible animation of the medial platysma while
talking or making facial expressions. Cinching the platysma
muscles in the midline via platysmaplasty can enhance the
tightening of the neck by face lift via a hammock or sling
effect conveyed by the superolateral pull of the SMAS/
platysma plication.
In those patients with chin recession, augmentation can be
provided by a chin implant. Through a submental skin inci-
sion, an alloplastic implant can be placed subperiosteally
along the anterior surface of the lower edge of the mandible.
Several features of the described face-lift procedure are
standardized. One such feature is the extent of subcutaneous
undermining (approximately 7 cm from the tragus). This dis-
tance can be increased as needed to enable better access to
the mid-face. Moderately extensive skin undermining allows
for more vigorous platysma and SMAS plication because the
Figure 37.16  The lateral edge of the cheek flap has been
trimmed to accommodate the tragus and supratragal notch.
Figure 37.17  Final skin closure.
Pitfalls and their management
 Be conservative with initial skin removal to avoid problems
with skin reapproximation.
 Stay superficial to the platysma to avoid injury to the great
auricular or marginal mandibular nerves.
 Use bipolar cautery to secure hemostasis.
 Warn smokers to cease smoking for 2 weeks before and after
surgery because of the danger of flap necrosis.
 Take care to avoid disrupting the orbitomalar septum, which
may result in significant postoperative edema.
 Exercise caution when trimming excess skin upon closure to
avoid undue skin tension, which may result in wide scars or
‘pixie ear.’

612
Part 3  Aesthetic Surgical Procedures
considerable subcutaneous fibrosis in this area. This fibrosis
can increase the difficulty of undermining and also increase
the risk of inadvertently entering the subplatysmal plane.
Over the sternocleidomastoid muscle, the great auricular
nerve is vulnerable to injury if the plane of dissection goes
deep to the platysma. Similarly, the marginal mandibular
nerve may be injured by sub-SMAS dissection in the vicinity
of the inferior jowl.
The most feared complication of face-lift surgery is hema­
toma. The vasoconstriction afforded by tumescent anesthesia
greatly reduces intraoperative bleeding, but meticulous
hemostasis is required to prevent postoperative bleeding.
Bipolar cautery is essential to achieve adequate hemostasis.
Non-stick bipolar forceps will stay clean of debris (Table 37.2).
At the end of surgery, the patient should be inspected for
evidence of active bleeding. Localized swelling with bruising
mandates removal of sutures, identification of the bleeding
vessel, and bipolar cautery. In patients with increased intra-
operative bleeding and in whom hemostasis requires above-
average effort, a drain should be placed until the first
postoperative day.
Patients who smoke are at significant risk of flap necrosis
postoperatively. If a smoker fails to adhere to the admonition
of discontinuing smoking for 2 weeks prior to and after
surgery, the vasoconstrictive and toxic effects of cigarette
smoke may cause necrosis of the distal part of the flap.
Incipient necrosis manifests as a dusky color near the suture
line. A healthy flap is pink in color and refills quickly after
pressure diascopy. If examination suggests poor revasculariza-
tion, topical nitroglycerin may be of help as a vasodilator and
may forestall necrosis.26 Oral pentoxifylline may also be
helpful.26 Necrosis will likely result in a wide scar adjacent to
the suture line. This scar can be removed by simple linear
excision at a later date.
Undermining in the infraorbital area should be done caudal
to the orbitomalar septum.12 Disrupting this septum can
result in significant postoperative edema in the lower eyelid
area. The dermal attachment of the septum is denoted by the
tear trough (see Fig. 37.4); the inferolateral extent of the
septum is generally at a point 2.5 cm caudal to the lateral
canthus.12,19
Upon skin closure, excess skin should be trimmed cau-
tiously to avoid removing too much. Tension on the dermal
The preoperative marking of the preauricular S-form skin
excision should be conservatively done. The amount of SMAS
laxity should be assessed to aid in determining the width of
this marking. In patients undergoing secondary rhytidectomy,
no skin should be excised prior to final skin closure. After
SMAS plication, the skin edges should be largely approxi-
mated so that dermal sutures can be placed under only mild
tension. If too much skin is excised initially, it may be diffi-
cult to reapproximate the skin edges after SMAS plication.
It is best to be conservative with the initial skin removal;
excess skin can always be trimmed at the time of skin closure.
While undermining onto the neck, one must take care to
stay superficial to the platysma. Patients who have undergone
liposuction of the neck on a previous date may present with
Figure 37.18  Cervicofacial head wrap. This elastic band is
placed postoperatively and is worn at least 23 hours per day for
3 days. The wrap provides gentle compression.
Table 37.2  Instruments used in minimum incision face lift
ITEM
SOURCE
COMMENTS
SuperCut iris scissors
SSR, Inc, Oyster Bay, NY
Useful for excising and trimming skin
Metzenbaum scissors (5 inch, 7 inch)
Miltex, Inc, York, PA
Used for undermining
Converse blade retractors (sizes 3 and 4)
Miltex, Inc, York, PA
Used for retracting face-lift flap
Mini rake retractor (4 prong)
Van Sickle Surgical
Instruments, Bedford, TX
Used for retracting face-lift flap
Periosteal elevators (4 mm, 6 mm, 10 mm)
Implantech, Ventura, CA
Used for release of mandibular ligament; also useful for
subperiosteal undermining in endoscopic forehead lift and for
placement of chin implants
Non-stick bipolar forceps
Silverglide Surgical
Technologies, Boulder, CO
Resistant to accumulating tissue debris during use
Pitanguy flap demarcator
SSR, Inc, Oyster Bay, NY
Used to mark excess skin for excision from distal edge of a
skin flap
Surgitel Odyssey LED head-light
General Scientific Corp, Ann
Arbor, MI
Lightweight, provides very good illumination of surgical field

613
Chapter 37  Minimum Incision Face Lift
used to release the mandibular ligament without the need to
extend subcutaneous undermining to this area. Release of the
mandibular ligament weakens the cutaneous attachment
medial to the jowl and improves the mobility of the jowl upon
SMAS plication and skin closure. Ptosis of the malar fat pad,
the primary cause of gravitational aging of the mid-face, can
be lessened by suspension sutures placed in the fat pad and
anchored in the deep temporal fascia posterior to the orbital
rim at the level of the lateral canthus.
Superior plication of the lateral platysma and superolateral
plication of lateral cheek SMAS can be achieved with purse-
string sutures through these structures that are anchored in
deeper tissues. These anchors are very stable and allow for
the application of significant tension to these plication sutures.
Enough tension can be applied to provide appreciable lift
without the need for release of deep retaining ligaments
between bone and SMAS.
The patient depicted in Figure 37.19 demonstrates the
results of the minimum incision face lift described in this
chapter.
sutures should be mild. Too much tension can result in a wide
scar or, at the caudal border of the ear lobule, a ‘pixie ear’
deformity in which downward tension obliterates the normal
sulcus between the lobule and the skin of the mastoid area.
 SUMMARY
The minimal incision rhytidectomy described herein can
result in significant improvement in gravitational facial aging,
especially if combined with liposuction of the neck and jowls,
platysmaplasty, and suspension of the malar fat pads. Tumes-
cent local anesthesia, if properly administered, enables the
use of very-low-dose perioperative sedation. Vasoconstriction
provided by the tumescent anesthetic provides excellent
hemostasis and reduces postoperative bruising and swelling,
thus speeding patients’ recovery.
Pre-excision of preauricular skin improves visibility beneath
the cheek flap during undermining. Undermining to a moder-
ate distance onto the cheek allows redraping of the skin flap
independently of the SMAS. A periosteal elevator can be
A
B
Figure 37.19  This 61-year-old patient is
shown (A) before and (B) after liposuction
of the neck and jowls and minimum
incision face lift with suture suspension of
malar fat pads.

614
Part 3  Aesthetic Surgical Procedures
 REFERENCES
1. Gosain AK, Yousif NJ, Madiedo G, et al. Surgical anatomy of the SMAS:
a reinvestigation. Plast Reconstr Surg 1993;92:1254–1263.
2. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg
1989;83:11–16.
3. Özdemir R, Kilinç H, Ünlü E, et al. Anatomicohistologic study of the
retaining ligaments of the face and use in face lift: retaining ligament
correction and SMAS plication. Plast Reconstr Surg 2002;110:1134–1149.
4. Bernstein L, Nelson RH. Surgical anatomy of the extraparotid distribu-
tion of the facial nerve. Arch Otolaryngol 1984;110:177–183.
5. Hamra ST. A study of the long-term effect of malar fat repositioning in
face-lift surgery: short-term success but long-term failure. Plast Reconstr
Surg 2002;110:940–951.
6. Mendelson BC. A study of the long-term effect of malar fat repositioning
in face-lift surgery: short-term success but long-term failure. Plast Recon-
str Surg 2002;110:952–955 (discussion).
7. Hester TR. A study of the long-term effect of malar fat repositioning in
face-lift surgery: short-term success but long-term failure. Plast Reconstr
Surg 2002;110:956–959 (discussion).
8. Becker FF, Bassichis BA. Deep plane face-lift vs superficial musculo-
aponeurotic system plication face-lift. Arch Facial Plast Surg 2004;6:8–
13.
9. Yousif NJ, Gosain A, Matloub HS, et al. The nasolabial fold: an anatomic
and histologic reappraisal. Plast Reconstr Surg 1994;93:60–69.
10. Gosain AK, Amarante MTJ, Hyde JS, et al. A dynamic analysis of changes
in the nasolabial fold using magnetic resonance imaging: implications for
facial rejuvenation and facial animation surgery. Plast Reconstr Surg
1996;98:622–636.
11. Sasaki GH, Cohen AT. Meloplication of the malar fat pads by percutane-
ous cable-suture technique for mid-face rejuvenation: outcome study 392
cases, 6 years’ experience. Plast Reconstr Surg 2002;110:635–654.
12. Owsley JQ, Zweifler M. Mid-face lift of the malar fat pad: technical
advances. Plast Reconstr Surg 2002;110:674–685.
13. Hoefflin SM. The extended supraplatysmal plane (ESP) face lift. Plast
Reconstr Surg 1998;101:494–503.
14. Baker DC. Lateral SMAS-ectomy. Plast Reconstr Surg 1997;100:509–
513.
15. Baker DC. Minimal incision rhytidectomy (short scar face lift) with
lateral SMAS-ectomy: evolution and application. Aesth Surg J 2001;21:
14–26.
16. Mendelson, BC. SMAS fixation to the facial skeleton: rationale and
results. Plast Reconstr Surg 1997;100:1834–1842.
17. Saylan Z. Purse string-formed plication of the SMAS with fixation to the
zygomatic bone. Plast Reconstr Surg 2002;110:667–671.
18. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspen-
sion lift: a modified S-lift. Plast Reconstr Surg 2002;109:2074–2086.
19. Pessa JE, Garza JR. The malar septum: the anatomic basis of malar
mounds and malar edema. Aesth Surg J 1997;17:11–17.
20. Langdon RC. Liposuction of neck and jowls: five-incision method com-
bining machine-assisted and syringe aspiration. Dermatol Surg 2000;26:
388–391.
21. Langdon RC. Liposuction of neck and jowls. In: Hanke CW, Sattler G,
eds. Procedures in cosmetic dermatology series: liposuction. Philadelphia:
Saunders; 2005.
22. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg 1990;85:333–
343.
23. Langdon RC. The S-lift. In: Moy RL, Fincher EF, eds. Procedures in
cosmetic dermatology series: advanced face lifting. Philadelphia: Elsevier
Saunders; 2006.
24. Tonnard PL, Verpaele AM. The MACS-lift short-scar rhytidectomy. St.
Louis: Quality Medical Publishing; 2004.
25. Verpaele AM, Tonnard P. Combining the MACS-lift with the temporal
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1999;120:272–274.

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38
Vertical Vector Face Lift
with Local Anesthesia
Rafael A Schulze MD, Brian Somoano MD, and Greg S Morganroth MD
Summary box
 As facial soft tissue ptosis develops with advancing age, the
vector of descent is primarily downward with gravity.
 The vertical vector face lift removes excess adipose tissue of
the neck and jawline, reverses the gravity-associated descent
of the SMAS, and restores a youthful balance to the aging
face.
 The vertical vector of SMAS plication and fixation of platysma
to mastoid fascia results in minimal periauricular skin excision
and provides a tension-free skin closure without inferior
displacement of the earlobe or distortion of the hairline.
 Tumescent anesthesia utilizing 0.3% lidocaine solution with
1 : 500 000 epinephrine followed by neck liposuction and
suctionless undermining of the pre- and postauricular flaps
allows for pre-undermined skin to facilitate flap creation.
 This technique minimizes common complications such as
pixie ear deformity, misalignment of hairline, and nerve injury.
 INTRODUCTION
Over the past 6 years, face-lifting procedures have evolved
towards less aggressive techniques that provide more natural
aesthetic outcomes. Dermatologic surgeons have been at the
forefront of the evolution by developing and refining mini-
mally invasive face lifts with local anesthesia alone. Patients
who never considered face-lift surgery and those patients
originally planning on having traditional face lifts under
general anesthesia have been extremely receptive to these
safer, less invasive, and faster healing techniques. The vertical
vector face lift, described by Dr Morganroth in 2003,1 is an
office-based, local anesthesia face-lift procedure that can be
performed with or without oral and intramuscular sedation.
The key surgical component of this face lift is the primarily
vertical vector of soft tissue movement to reverse gravita-
tional aging. As facial soft tissue ptosis develops with advanc-
ing age, the vector of descent is primarily and most importantly
downward with gravity. The vertical vector face lift seeks to
reverse this descent through surgical manipulation of the
superficial musculoaponeurotic system (SMAS). In contrast,
many traditional face lifts that utilize a horizontal vector for
tightening of the SMAS do not provide the necessary vertical
lift and lead to either inadequate rejuvenation or unnatural
lines of tension that are accentuated as the patient ages. Ver-
tical lifts do not typically cause the overstretched appearance
with flattened nasolabial folds characteristic of the traditional
lift techniques – the so-called ‘wind-swept’ appearance.
This chapter will describe the vertical vector face lift per-
formed under tumescent local anesthesia. The important
components of this procedure include the use of a short-scar
technique that involves both a pre- and postauricular incision,
the latter of which is usually made to extend up to 3–4 cm
into the occipital scalp to allow for a broader zone of under-
mining of the neck. The vertical vector of SMAS plication
and elevation of the platysma to the mastoid fascia results in
less periauricular skin excision and provides a tension-free
skin closure without inferior displacement of the earlobe or
distortion of the temporal or retroauricular hairlines. Neck
liposuction combined with suctionless undermining of the
pre- and postauricular flap with the liposuction cannula allows
for customized sculpting of excess adipose tissue and a pre-
undermined skin to facilitate flap creation and minimize
untoward complications.
Anatomy
Face and neck anatomy is discussed in detail in Chapters 1
and 37. The relevant aesthetic considerations for face-lift
surgery and the pertinent anatomy will be succinctly sum-
marized.
The foundation of Western facial analysis is based on pro-
portion. Vertically, the face is divided into thirds. Though the
eyes are included in discussions about the upper face, ana-
tomically the upper third of the face is defined superiorly by
the hairline, and by the inferior extent of the eyebrow. The
mid-face extends from this level to the nasal sill. The lower
third is bounded by the base of the nose (nasal sill) and the
chin. Each third is equal in height (Fig. 38.1). A weak chin
or microgenia is the most common cause of loss of facial
proportions and is easily corrected by a chin implant. Chin
augmentation with an implant is frequently performed at the
same time as a face lift.
The two major anatomic structures that influence the
appearance of the lower face are the SMAS and the platysma.
The SMAS is fascia that invests the facial mimetic muscula-
ture, and is intimately related to the skin by ligamentous
attachments. It connects with the galea superiorly and infe-
riorly with the platysma.
The platysma is the shield-like thin muscle that originates
from the pectoralis fascia, extends to the neck, interdigitates

616
Part 3  Aesthetic Surgical Procedures
the lower portion of the auricle. The lesser occipital nerve
emerges from behind the posterior border of the sternoclei-
domastoid muscle superior to the greater auricular nerve and
courses upward to innervate the neck and the scalp skin
posterior to the ear. The general area of emergence of the
greater auricular, transverse cervical, and lesser occipital
nerves from behind the sternocleidomastoid has been desig-
nated Erb’s point. Its importance is underscored by the fact
that the spinal accessory cranial nerve (XI), the motor inner-
vation to the trapezius muscle, also emerges within this vicin-
ity. Erb’s point is located by connecting a line from the angle
of the jaw to the mastoid process. From the midpoint of this
line, a vertical line is dropped 6  cm until it intersects the
sternocleidomastoid muscle (see Fig. 1.33). These sensory
nerves are vulnerable during undermining of the postauricular
flap over the SCM muscle.
The facial nerve supplies motor innervations to the face.
The temporal branch innervates the frontalis muscle and
courses most superficially at the zygomatic arch. The marginal
mandibular branch innervates the lip depressor muscles. It
runs slightly inferior to the mandible before traveling more
superficially as it reaches the oral commissures. While the
zygomatic and buccal branches are less susceptible to injury
during subcutaneous dissection, there are many anastomoses
between them, so that functional impairment if traumatized
is usually minimal and transient. In the neck, the platysma is
innervated by the cervical branch of the facial nerve. The
spinal accessory nerve is found in the posterior triangle, but
runs across the body of the sternocleidomastoid muscle, and
is susceptible to injury. Injuries to facial motor nerves during
a vertical vector face lift are avoided by proper marking of
the flap extent and ensuring undermining remains in the
subcutaneous plane.
The blood supply of the lower face consists of branches of
the facial arteries. There is an analogous venous system,
which has many perforators. Branches from the external
carotid supply the majority of the neck.
Facial aesthetics and goals of the vertical
vector face lift
Many factors contribute to the structural changes of the aging
face. For many years, it was felt that gravity played the
dominant role in the aged face. While it certainly is a signifi-
cant contributor, photodamage, loss and redistribution of fat,
muscle atrophy and hypertrophy, bony reabsorption, and
genetics play important roles in facial sagging and jowling.
Solar elastosis and collagen damage in the skin create rhytides
and a superficial flaccidity. Loss of fat in the periorbital
region, malar region, and lower cheeks causes a hollowness
and volumetric decrease that contributes to sagging. Fat accu-
mulation in the upper neck blunts the cervicomental angle.
Muscle atrophy, particularly in the temporal region, leads to
volumetric changes, decreasing anchoring points, and conse-
quently increases the sagging of the more superficial tissues.
Hypertrophy as well as separation of the platysma produces
bands that disrupt the cervicomental angle and the smooth
neck contour. Over time, the face’s bony foundation, which
provides buttresses for the soft tissues, reabsorbs. This reab-
sorption is particularly apparent in the lower face. Notably,
resorption of the mid-lateral mandible and chin leads to more
volume depletion and hollowing to create the pre-jowl sulcus
that accentuates the sagging of the jowls.
with the SMAS, and attaches to the risorius muscle. In most
individuals, the platysma decussates/intertwines at the midline.
Yet, in a significant minority, 39% in one study, the platysma
divides at the midline.2 Combined with concomitant hyper-
trophy from years of lower facial expression, platysmal
banding results in a gobbler-like appearance of the neck.
The relationship of the face to the neck can be measured
in several ways. The classic method is to determine the angle
between the vertical neck and the submandibular plane. This
cervicomental angle should be less than 120°. Ellenbogen &
Karlin referred to the angle bound by the submentum and
the sternocleidomastoid muscle because it was easier to visu-
ally assess.3 The submentum–sternocleidomastoid angle
should be 90° to provide a youthful look.
The lower face is bounded superiorly by an imaginary hor-
izontal line from the earlobe, traversing across the cheek to
the base of the columella, and extending across the contra­
lateral cheek and earlobe. The inferior border of the lower
face is demarcated by the mandibular line. The superior
portion of the neck extends from the mandibular line to the
thyroid notch. In the lower face, the soft tissue envelope
includes skin, subcutaneous fat, SMAS, and muscle. In the
upper neck, the layers are similar, though the platysma is
continuous with the SMAS. A subplatysmal fat pad is located
in the midline. Other structures include the submandibular
glands that are located in the fascial plane at the anterior
aspect of the mandible bilaterally, and the hyoid bone, which
is located in the anterior neck deep to the strap musculature.
The vertical vector face lift is a subcutaneous procedure
that is designed to avoid injury to the motor or sensory nerves
of the face and neck; however, an understanding of the nerve
anatomy of the face and neck is important. The sensory
innervation of the lower face is provided by the third branch
of the trigeminal nerve. In the postauricular region, C2 and
C3 contribute to the greater auricular nerve, which innervates
Ideal facial balance
Trichion
Upper third
Middle third
Lower third
Glabella
Subnasale
Menton
Figure 38.1  The face is divided into equal thirds for the ideal
facial balance.

617
Chapter 38  Vertical Vector Face Lift with Local Anesthesia
Once it is determined that the patient is a good candidate
for surgery, the surgeon must work to align the patient’s
expectations for the outcome with his/her expected results
from their procedure. The surgeon should be concerned if
the patient seems to be a perfectionist who will be intolerant
of any flaw, is overly demanding, or has dissatisfaction with
a prior surgery that appears to have been performed well with
a good result. Often, difficult patients are first noticed by
receptionists, nurses, or cosmetic consultants. While some
practitioners employ a questionnaire, others use their judg-
ment and experience rather than a formal process. The prac-
titioner should also examine the patient’s motivations.
Obviously, the patient should not desire facial rejuvenation
in order to please someone else. Nor will the face lift make
the individual appear as they were three decades younger or
dramatically change the person’s lifestyle or status. Patients
who are not considered suitable candidates for surgery are
encouraged to seek a second or third opinion.
It is also important to address the patient’s subjective con-
cerns. If the concern is limited to wrinkling, then a lifting
procedure alone will not provide a satisfactory result. A resur-
facing procedure alone or in combination with a lift would
provide a better result. If the patient’s concern is primarily
with prominent nasolabial folds, it should be explained that
fillers will need to be used with or without a face lift.
If a rhytidectomy is indicated, the procedure including the
preoperative preparation and the postoperative course should
be summarized. Some practitioners use a computer program
to simulate a postoperative result;5 however, the authors feel
that these computer simulations may be an inaccurate por-
trayal of results. The risks of the procedure as well as the
surgeon’s own complication profile should also be discussed
to ensure that the patient understands that complications
have occurred in the past and may occur in the future. The
patient’s medical history is reviewed and relative contraindi-
cations may include: overall poor health status; uncontrolled
hypertension; cardiac disease; thyroid disease; bleeding dis-
order or chronic anticoagulation; history of keloids; immuno-
suppression; unstable psychiatric illness; or unrealistic
expectations. Chronic illnesses are often easily identified,
assuming that the patient does not seek to intentionally
mislead the surgeon. Because the authors perform the face
lift under local anesthesia versus general anesthesia, the risks
are less for most patients and more patients will be able to
receive medical clearance.
If the patient genuinely wants to address lower face and
neck laxity, the integrated process of the cosmetic consultant
and aesthetic surgeon should result in the scheduling of the
surgery. While some surgeons prefer to discuss the fee, the
authors prefer to leave this to the cosmetic consultant in
order to preserve the doctor–patient relationship and focus
on medical and surgical components of the procedure. After
the physician leaves the room, the consultant will discuss the
fee, answer additional questions, provide the patient with the
opportunity to contact previous face-lift patients, and sched-
ule the preoperative and day of surgery appointment. The
cosmetic consultant will serve as the liaison between the
doctor and patient for the remainder of this relationship.
Once the patient has placed a deposit and a date has been
reserved, a preoperative appointment is scheduled. The
standard preoperative work-up includes a medical clearance
from the patient’s primary care physician, electrocardiogram,
a complete blood count/platelets, prothrombin time/partial
The vertical vector face lift is designed to remove excess
adipose tissue of the neck and jawline, reverse the gravity-
associated descent of the SMAS, and restore a youthful
balance to the aging face. The addition of an extended chin
implant in patients with chin recession provides a synergistic
outcome by adding volume and restoring youthful facial pro-
portions. Skin resurfacing with fractional or ultrapulsed
carbon dioxide lasers provides wrinkle reduction to comple-
ment the improved neck and jawline from the vertical vector
lift. Blepharoplasty or brow-lift surgery is easily incorporated
in the face-lift procedure. Lastly, volumetric enhancement
with fillers is best performed at least 3 months following the
vertical vector face lift to allow resolution of surgical swelling
and determine the best volume to enhance the residual
volume loss uncorrected by the lift.
Patient selection
In the past, face lifts were reserved for those patients in
their sixth decade or older who generally had severe skin
laxity. The vast majority of these patients were women.
With newer, less aggressive, and safer techniques that have
minimal downtime, younger patients seeking to correct the
aging face have more options for facial rejuvenation surgery.
As long as a patient can tolerate the procedure and has no
underlying medical contraindication, age should not be a
major factor, especially since this procedure is performed
with local anesthesia.4 With the aging baby-boomer genera-
tion, there is also an increasing number of men undergoing
face-lifting procedures, and the patient selection criteria are
no different. However, as will be discussed below, the
anesthesia, incision, and occasionally the postoperative care
may be modified.
The key indication for a vertical vector face lift is soft tissue
laxity and vertical descent of the face and neck that is easily
corrected by pulling upward in the preauricular cheek to
simulate the vertical vector of SMAS tightening. The degree
of flaccidity is a result of gravity-induced ptosis, but is also
impacted by a combination of genetic, Fitzpatrick skin type,
and sun exposure/protection factors. A fair-skinned 40-year-
old woman, who has not protected herself from the sun, with
mild to moderate laxity of the lower face, may be an excellent
candidate for a vertical vector face lift.
Cosmetic consultation and preoperative
appointment
The initial patient consultation should take place in a quiet,
well-appointed room that contains patient education bro-
chures, before-and-after photos, patient testimonials, infor-
mation regarding the surgeon’s credentials, and any relevant
publications authored by the surgeon. While a staff member
cosmetic consultant is not absolutely necessary, this staff
member can improve patient care and service by creating
a bond with the patient to facilitate communication and
serve as a liaison to the end of the postoperative phase.
This cosmetic consultant interviews the patient initially to
understand the patient’s cosmetic concerns and discuss
the various options for treatment. The cosmetic consultant
will summarize the patient’s concerns to the physician so that
he/she can focus on the issues that are important to the
patient. The cosmetic consultant can also provide a separate
opinion regarding the patient’s emotional and mental
stability.

618
Part 3  Aesthetic Surgical Procedures
anterior neck skin off of the platysma muscle (Fig. 38.6). A
strip of adipose tissue is excised with scissors to reveal the
edges of the platysmal bands and subplatysmal fat is debulked,
if necessary (Fig. 38.7). Excess muscle from platysma bands
is excised and hemostasis is achieved with electrosurgery. If
indicated, a subperiosteal chin–jowl or jowl implant is placed
through the same incision. The submental incision is closed
in a multilayered linear closure with 4-0 Vicryl (Ethicon,
Somerville, NJ) and 5-0 nylon sutures or cyanoacrylate tissue
adhesive.
The patient is then positioned with the left face down.
Gentian violet is used to remark the incisions and undermin-
ing zones. Using a #15 blade, the anterior incision is created
with great care to follow the natural curve of the ear, along
the edge of the tragus, within the anterior and inferior earlobe
crease, directly within the postauricular crease (not over
conchal bowl cartilage), and with a trichophytic incision to
preserve hair follicles of the occipital scalp. A cutback is
created at the end of the incision with a 60° angle (Fig. 38.8)
to eliminate the need to chase a dog ear into the occipital
scalp.
The anterior flap is undermined first in the subcutaneous
plane with Gorney scissors until the anterior pocket matches
the preoperative markings in extent and shape (Fig. 38.9).
Elevation of the flap is facilitated by a combination of trans­
illumination, direct fiber-optic illumination, and countertrac-
tion by surgical staff. The posterior incision is in the adipose
plane just below the hair follicles and stays superficial through
the fibrous fascia over the sternocleidomastoid to avoid injur-
ing the lesser occipital and great auricular nerves. A combina-
tion of vertical and horizontal undermining is continued until
entering the neck liposuction plane, where resistance to
undermining dramatically decreases due to the prior liposuc-
tion tunnels. Care is taken to undermine the entire neck with
curved Gorney scissors across the midline within the adipose
layer (Fig. 38.10). Meticulous hemostasis is obtained with
direct visualization with a fiber-optic headlamp and electro-
coagulation with or without suction.
thromboplastin time, HIV and hepatitis screening, and blood
chemistry. The preoperative appointment takes place a few
weeks before surgery and the consultant reviews the pre-,
intra-, and postoperative phases of the procedure, reviews the
laboratory tests with the physician, has the patient sign all
consent forms, and receives full payment for the procedure.
 TECHNICAL ASPECTS
The surgical technique starts with preoperative marking of
the areas of neck liposuction and undermining. The zones of
neck liposuction are defined by the anterior border of the
sternocleidomastoid muscle and the inferior border of the
neck above the sternal notch. Next, the zones of pre- and
postauricular flap and neck undermining are marked. First, a
horizontal line is drawn on the anterior neck below the zone
of wrinkling. This line is extended bilaterally posterosuperi-
orly over the sternocleidomastoid muscle and into the occip-
ital scalp in a curvilinear manner to end approximately 3–4 cm
posterolateral to the inferior border of the top third of the
helix. Platysmal bands, if present, are outlined and the sub-
mental incision planned just anterior to the submental crease.
The anterior face-lift incision is drawn, starting at the medial
third of the sideburn parallel to the top of the helix and
extending inferiorly along the preauricular crease, along the
edge of the tragus, around the earlobe, and in the postau-
ricular crease to the junction of the middle and top third of
the ear. Unlike the common practice of placing the incision
over the back of the conchal bowl in anticipation of stretch
back into the postauricular crease, this incision is placed in
the postauricular crease to allow for anchor sutures to mastoid
fascia that inhibit any stretch back of the incision. The inci-
sion is then extended posterolaterally into the scalp to meet
with the vertical line extending along the inferior border of
the elastotic neck skin approximately 3–4 cm from the post­
auricular crease. At the end of the postauricular incision, a
60° cutback is created to preplan the angle of vertical lift of
the skin and eliminate redundant scalp skin requiring standing
cutaneous cone revision. The anterior flap undermining line
of demarcation is created in a semicircular manner approxi-
mately 5–7 cm medially, and is connected to the neck flap
inferiorly (Fig. 38.2). The skin is then prepared with Hibi-
clens soap (Molnlycke Health Care, Inc, Norcross, GA).
The face-lift and submental incision lines are infiltrated
with 1% lidocaine with 1 : 100 000 epinephrine. A #11
blade is used to create a 2-mm stab incision in the submental
crease, sideburn incision, postauricular horizontal incision,
and inferior earlobe crease. A 0.3% tumescent lidocaine solu-
tion with 1 : 500 000 epinephrine is infiltrated with a Klein
pump in the subcutaneous plane. Typically 250–350 mL of
anesthetic are required for the face and neck anesthesia
(Fig. 38.3).
After allowing 20 minutes for adequate anesthesia and
vasoconstriction, the neck liposuction is performed via the
submental and infra-auricular crease stab incisions with 2-
and 3-mm spatula cannulae. The extent of liposuction is
determined by the individual patient’s adipose deposits. The
suction is turned off and a 2-mm spatula cannula is used via
the sideburn and postauricular stab incisions to undermine
the anterior and posterior skin flaps and connect them to the
neck liposuction plane (Figs 38.4 and 38.5).
The submental stab incision is extended approximately
1  cm bilaterally. Gorney scissors are used to elevate the
Figure 38.2  Infiltration of anesthesia and undermining of skin
are performed via superior-based punctures (white circles)
whereas liposuction and infiltration of anesthesia are performed
via inferior-based puncture sites (green circles). Liposuction is
first performed in the yellow shaded zone followed by
undermining in the subcutaneous plane in the white shaded
zone. (Courtesy of Dr G Morganroth.)

619
Chapter 38  Vertical Vector Face Lift with Local Anesthesia
A
B
C
Figure 38.3  Infiltration of tumescent anesthetic with a Klein
pump for postauricular flap (A), neck (B), and preauricular flap
(C) anesthesia. (Courtesy of Dr G Morganroth.)
A
B
Figure 38.4  Liposuction of the anterior neck (A) and lateral
neck, jawline, and lower face (B) with a 3-mm spatula cannula.
(Courtesy of Dr G Morganroth.)
The SMAS plication is performed with 3-0 nylon buried,
interrupted sutures and begins in the preauricular region.
Multiple sutures are placed for the direct vertical plication
parallel to the preauricular incision. Typically, five to seven
sutures are placed anteriorly (Fig. 38.11). The postauricular
plication involves a vertical elevation that is not possible in a
solo neck lift, which has a more lateral vector than the verti-
cal vector lift. Every suture that is placed sequentially creates
an increasingly upward vector. The six to eight buried neck
plication sutures anchor the edge of the SMAS and platysma
muscle, located anterior to the sternocleidomastoid muscle,
to the tough mastoid fascia (Fig. 38.12). Following neck
plication, additional undermining is required to release teth-
ered skin in both anterior and posterior flaps created by
elevation. Meticulous hemostasis is confirmed throughout the
anterior and posterior flaps. Jackson–Pratt drains are placed
via the postauricular flap and extend across the midline of the
neck.
The anterior and posterior skin is then retracted superolat­
erally at the same time. For the anterior flap, the lateral and
superior retraction is balanced to prevent distortion of the
lateral canthus and minimize redundant tissue at the sideburn

620
Part 3  Aesthetic Surgical Procedures
postauricular incision is closed with at least 10 sutures of 3-0
Vicryl that are first passed through the mastoid fascia in the
postauricular crease to lock the flap edge deep in the postau-
ricular crease to the residual ear skin (Fig. 38.16). Each of
the anterior and posterior periauricular sutures is placed with
the flap bite approximated 5 mm inferior to the anchor bite
of fascia or cartilage. The pre- and postauricular Vicryl anchor
sutures allow for complete closure of the earlobe portion of
the incision without any visible tension on the lobe (Fig.
38.17) and will prevent downward displacement of the
earlobe (pixie ear deformity)6 with relaxation of the skin. The
skin edges are already approximated by the numerous buried
sutures; however, additional 5-0 nylon running and inter-
rupted sutures or cyanoacrylate tissue adhesive are placed for
additional support (Fig. 38.18).
Prior to beginning the contralateral side, the patient is
positioned with two compression bandages over the pre- and
postauricular regions to prevent intraoperative hematomas.
area (Fig. 38.13). 4-0 Prolene sutures are used to anchor the
skin flap at the superior aspect of the preauricular incision
and central tragus (Fig. 38.14). Before retracting postauricu-
lar skin, a 1-cm incision is made in the flap overlying the
earlobe to allow the earlobe to project anterior to the pre- and
postauricular flaps. The postauricular skin is then stretched
in a vertical direction to provide natural neck rejuvenation
without lateral lines of tension. While pulling the postauricu-
lar flap, the vector is then directed upward perpendicular to
the postauricular crease to provide reapposition of the skin
edges of the cutback at the end of the postauricular incision.
4-0 Prolene sutures anchor the skin flap to the occipital scalp
at the cutback and the flap to the superior aspect of the
postauricular crease. The excess skin is then excised to create
a smooth flap edge corresponding to the original incision
pathway and shape of the ear (Fig. 38.15). The anterior inci-
sion is closed with 12–15 buried suteares of 4-0 Vicryl. The
A
B
Figure 38.5  Undermining of preauricular flap (A) and postauricular flap (B) with a 2-mm spatula cannula without suction. (Courtesy
of Dr G Morganroth.)
Figure 38.6  Undermining of midline neck prior to debulking
platysmal fat with Gorney scissors. (Courtesy of Dr G
Morganroth.)
Figure 38.7  Excision of submental fat to visualize edge of
platysmal muscle. (Courtesy of Dr G Morganroth.)

621
Chapter 38  Vertical Vector Face Lift with Local Anesthesia
Figure 38.8  Postauricular incision includes a cutback to
eliminate redundant tissue at the posterolateral aspect of the
incision. (Courtesy of Dr G Morganroth.)
Figure 38.9  Undermining is started in the preauricular flap in
the subcutaneous plane. (Courtesy of Dr G Morganroth.)
Figure 38.10  Undermining is continued in the subcutaneous
plane in the postauricular zone and across the midline of the
neck. (Courtesy of Dr G Morganroth.)
Figure 38.11  3-0 Nylon sutures are placed first in the
preauricular region to plicate the SMAS in a vertical upward
direction. (Courtesy of Dr G Morganroth.)
Figure 38.12  Postauricular plication sutures are placed from
the mastoid fascia to the edge of the platysma muscle and are
directed in a vertical upward direction. (Courtesy of Dr G
Morganroth.)
Figure 38.13  The skin is gently retracted in a superoposterior
direction without causing tension on the lateral canthus.
(Courtesy of Dr G Morganroth.)

622
Part 3  Aesthetic Surgical Procedures
 POSTOPERATIVE CARE
All incisions are dressed with antibiotic ointment such as
bacitracin, non-stick bandages, and 4 × 4 gauze. Standard neck
liposuction compression garments are placed followed by a
cervical collar to prevent neck flexion and formation of abnor-
mal skin folds. The compression garment and cervical collar
are worn for 3 days. The patient returns the next day for a
wound check and drain removal. If sutures are placed, the
anterior flap and submental sutures are removed at 7 days and
the postauricular flap sutures are removed at 10 days. If the
superficial skin closure is achieved with cyanoacrylate tissue
adhesive, the patient is seen 1 week postoperatively for a
wound check. Most patients experience only moderate post-
operative postauricular discomfort, lasting for a few days. The
bruising and edema in these lifting procedures typically
resolve over 5–10 days and most patients return to work after
1 week. Numbness, mild edema, and evolving fibrosis will be
present in variable amounts for up to 8–10 weeks. Frequent
gentle daily massage is useful to accelerate healing. A signifi-
Figure 38.14  4-0 Prolene sutures are placed in the sideburn,
tragus, and postauricular crease to anchor the skin flap prior to
trimming. (Courtesy of Dr G Morganroth.)
Figure 38.15  Excess skin is excised carefully to create minimal
tension on the incision. (Courtesy of Dr G Morganroth.)
Figure 38.16  The postauricular flap is anchored into place with
multiple 3-0 Vicryl sutures from the skin edge, through the
mastoid fascia, and back through the skin to lock the flap into
the postauricular crease. (Courtesy of Dr G Morganroth.)
Figure 38.17  The incision is first closed with 3-0 and 4-0 Vicryl
interrupted, buried sutures. The pre- and postauricular sutures
are anchored to the fascia to remove tension from the earlobe.
(Courtesy of Dr G Morganroth.)
Figure 38.18  The skin incision is closed with cyanoacrylate
tissue adhesive. Note the alignment of the postauricular hairline.

623
Chapter 38  Vertical Vector Face Lift with Local Anesthesia
cant number of patients experience temporary swelling and
discomfort that requires reassurance during the first few weeks.
All patients are seen every 4 weeks until all swelling resolves.
The patients are reassured from the preoperative consultation
and through the postoperative course of a 1-year or longer
duration for complete healing (Figs 38.19 and 38.20).
 PITFALLS AND THEIR MANAGEMENT
Pitfalls and their management
 Preoperatively, ensure the patient’s expectations are aligned
with his/her expected results from the rhytidectomy.
Figure 38.19  (A) Before a vertical vector
face lift, periorbital carbon dioxide laser
resurfacing, and a 35% trichloroacetic acid
peal to the rest of the face. (B) Six months
after surgery. Note the lack of a ‘wind-
swept’ appearance of the cheeks and
orbital region. The contour of the nasolabial
folds is preserved.
Figure 38.20  (A) Lateral view before
surgery. (B) Six months after surgery. The
lateral view demonstrate the remarkable
improvement in the neck and jawline.
A
B
A
B
 Prevent hematomas by ensuring patient compliance with
stopping aspirin and other predisposing medications,
maintaining meticulous intraoperative hemostasis, placing
drains, and using postoperative pressure garments.
 Avoid injuring the major motor or sensory nerves by
dissecting in the adipose layer superficial to the
sternocleidomastoid muscle and avoid a sub-SMAS dissection
anteriorly.
 Trim flaps precisely, utilize layered closure, and use select
anchoring bites into deeper stable tissues to ensure
tensionless closures.
 Use non-resorbable sutures for SMAS plication.

624
Part 3  Aesthetic Surgical Procedures
would be the corrective treatment of choice. The marginal
mandibular branch runs along the inferior border of the man-
dible and is most susceptible to injury near the lateral com-
missure of the lip, usually a result of overly aggressive
liposuction in this region or traumatizing the nerve with the
cannula as it crosses the mandible. Given its innervations of
the lower lip depressors, injury results in smile asymmetry
and possibly even impaired speech. The buccal branches can
also be injured, particularly in the preparotid region, but the
risk is less than the risk to temporal or marginal mandibular
nerves. The orbicularis oris, buccinators, and risorius muscles
are innervated by the buccal branches of the facial nerve.
Injury to a single branch may not have obvious consequences
as this nerve has several interconnected branches and receives
multiple anastomoses from the zygomatic branches. Less
commonly, the spinal accessory nerve can also be injured
while undermining in the neck region. Since it innervates the
sternocleidomastoid and trapezius muscles in the neck and
back, shoulder droop and the classic ‘winged scapula’ appear-
ance may result. If transected, nerve reanastomosis should be
strongly considered and a consultation with a neurosurgeon is
indicated. Prevention by way of dissecting superficially and
minimizing trauma at high-risk sites cannot be overemphasized.
Other potential pitfalls can be significantly reduced through
the execution of a tensionless closure.13 Not only can excess
tension compromise flap vascularity, increasing the risk of
skin slough or even frank necrosis but also it predisposes to
widened or hypertrophic scars. The combination of precise
flap trimming, layered closure, and the use of select anchor-
ing bites into deeper stable tissues can all help to prevent
these suboptimal outcomes. Buttonhole, or full-thickness
penetration of the flap skin, can be avoided by careful under-
mining and transillumination to be sure that the proper plane
is maintained.
Skin surface irregularities may be a consequence of plica-
tion sutures placed too superficially or with variable tension,
insufficient undermining, overly aggressive liposuction, or a
persistent hematoma or seroma. Massage can sometimes
assist in rectifying the contour. Premature sagging may occur
if plication sutures fail to support the SMAS until fibrosis sets
in. This can be prevented by taking adequate bites of the
SMAS with multiple, securely tied, interrupted sutures that
are non-resorbable. Although the robust vascularity of the
head and neck and the sterile conditions of the procedure
make infection relatively uncommon, broad-spectrum antibi-
otics are used in the perioperative period to potentially min-
imize this risk. A select portion of the population will also
develop contact dermatitis, usually to the topical antibiotic
or tape used in the postoperative period. Discontinuation of
the causative agent and the use of a weak topical corticoster-
oid can help to aid in its resolution. Seromas are relatively
uncommon and avoiding manipulation of the parotid gland
can help prevent this complication.
 SUMMARY
Patient preference for facial rejuvenation with decreased
complications and less downtime has helped to propel the
evolution of face-lifting techniques over the past decade.
Dermatologic surgeons have made significant contributions in
this regard, helping not only to spearhead the use of local
anesthesia for these procedures but also describing numerous
modifications in technique with more conservative incision
The judicious surgeon with proper patient selection can
employ the vertical vector face-lift technique and expect
aesthetically pleasing, predictable, and lasting results while
limiting risks and avoiding complications.
Most complications are minimized by careful preoperative
counseling, ensuring a sterile environment, meticulous hemo­
stasis, detailed suturing of the skin, and careful execution of
the subcutaneous dissection. By localizing the dissection to
the adipose layer superficial to the sternocleidomastoid muscle
and avoiding a sub-SMAS dissection anteriorly, the operation
can be carried out safely without injuring the major motor or
sensory nerves. Once the surgeon and the team are experi-
enced, this procedure is accomplished in less than 1.5 hours
with minimal complications. However, even the most experi-
enced dermatologic surgeon is bound to encounter adverse
events if enough rhytidectomies are performed. Although
meticulous surgical technique and appropriate patient educa-
tion regarding pre- and postoperative instructions can actively
help prevent complications, it is important to be able to rec-
ognize and initiate treatment when these are encountered.
Hematomas are the most common complication of rhyti­
dectomy. Incidence has been estimated around 4% though
published reports have ranged from 1% to 9%.7,8 Males are
known to be at greater risk.9 Nearly all will occur during the
first 24 hours after surgery, though hematomas even over a
week later have been reported.10 Inappropriate postoperative
pressure or pain may be the most reliable presenting sign,
although a frank enlarging mass or purpura should clearly also
raise suspicion. Early identification and management are
important as hematomas can predispose to secondary infec-
tion, puckering and other flap contour irregularities, neuro-
praxia, or even epidermal slough or necrosis by hindering flap
perfusion. One can attempt to evacuate small and stable
hematomas by needle or liposuction aspiration and compres-
sion bandages, performed daily to ensure resolution. Larger or
expanding hematomas often require taking down a portion of
the flap to locate and coagulate the culprit vessel, and repeated
saline irrigation helps to ensure complete clot removal. Strict
compliance in stopping aspirin and other predisposing medi-
cations, well-controlled blood pressure, meticulous intraop-
erative hemostasis and an effective postoperative pressure
bandage can all aid in preventing bleeding and its sequelae.7
Nerve injury, especially motor nerve injury, is an unwel-
come and potentially devastating complication of face lifts.
The great auricular nerve is the most frequently affected
nerve, which may be damaged in up to 7% of procedures.11,12
It runs superiorly along the sternocleidomastoid, and is prone
to injury while elevating the facial flap in the postauricular
region. Given that it supplies sensation to the ear lobule,
injury can be especially distressing for females as the resulting
numbness can make putting on earrings a challenge. The lesser
occipital nerve may also be injured during rhytidectomy,
though less frequently. Transection of the lesser occipital
nerve can result in numbness in the postauricular scalp skin.
In supra-SMAS rhytidectomies, it is estimated that motor
nerve injury occurs in up to 3.1% of patients.12 Among the
motor nerves, the temporal branch of the facial nerve is the
most commonly injured during rhytidectomy. It is most
superficial and susceptible to injury as it crosses over the
zygomatic arch, where it lies just inferior to a thin layer of
SMAS that can be easily penetrated. Injury results in ipsilat-
eral eyebrow ptosis, and patients may describe lid heaviness
and limited peripheral vision. Direct or endoscopic brow lift

625
Chapter 38  Vertical Vector Face Lift with Local Anesthesia
lengths and extent of undermining. These mini and short-scar
face lifts, as described in Chapter 37, have indeed been
shown to be effective in the younger patient with lower face
laxity, but minimal loose and elastotic neck skin.
The vertical vector face lift with local anesthesia incorpo-
rates both an anterior and posterior approach, with an incision
length between the mini and more traditional lifts. The more
extensive zone of undermining of the neck, in combination
with submentoplasty and liposuction of the face and neck,
allows for long-lasting full face-lift-like results but with lower
risk, less recovery time, and avoidance of extra costs associ-
ated with general anesthesia. In addition to re-establishing a
more acute cervicomental angle, even in those with promi-
nent jowling, the lack of a horizontal vector for SMAS tight-
ening avoids the dreaded ‘wind-blown’ appearance. When
indicated, upper and lower blepharoplasty, chin implants, and
full-face laser resurfacing can be combined to provide a syn-
ergistic result.
 REFERENCES
1. Morganroth GS. The facial lipo-lift: the dermatologic surgeon’s alterna-
tive to the traditional face lift. The American Society for Dermatologic
Surgery. New Orleans, Louisiana, October 10, 2003.
2. Vistnes LM, Souther SG. The anatomical basis for common cosmetic
anterior neck deformities. Ann Plast Surg 1979;2:381–388.
3. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youth-
ful neck. Plast Reconstr Surg 1980;66:826–837.
4. Becker FF, Castellano RD. Safety of face-lifts in the older patient. Arch
Facial Plast Surg 2004;6:311–314.
5. Ramirez OM. High-tech facelift. Aesthetic Plast Surg 1998;22:318–
328.
6. Kridel RW, Liu ES. Techniques for creating inconspicuous face-lift scars:
avoiding visible incisions and loss of temporal hair. Arch Facial Plast Surg
2003;5:325–333.
7. Grover R, Jones BM, Waterhouse N. The prevention of haematoma fol-
lowing rhytidectomy: a review of 1078 consecutive face lifts. Br J Plast
Surg 2001;54:481–486.
8. Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy:
a personal 8-year quest. Reviewing 910 patients. Plast Reconstr Surg
2004;113:381–387, discussion 388–390.
9. Lawson W, Naidu RK. The male face lift. An analysis of 115 cases.
Arch Otolaryngol Head Neck Surg 1993;119:535–539, discussion 540–
531.
10. Goldwyn RM. Late bleeding after rhytidectomy from injury to the super-
ficial temporal vessels. Plast Reconstr Surg 1991;88:443–445.
11. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy.
Anatomical variations and pitfalls. Plast Reconstr Surg 1979;64:781–
795.
12. Morganroth GS, Gladstone HB, Neuhaus IM. Complications of face
lifting procedures. In: Gloster HM, ed. Complications in cutaneous
surgery. New York: Springer 2008; 224–237.
13. Knize DM. Periauricular face lift incisions and the auricular anchor. Plast
Reconstr Surg 1999;104:1508–1520, discussion 1521–1503.

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627
39
Blepharoplasty and Brow Lifting
Alina Fratila MD and Brent R Moody MD
Summary box
 The goals of blepharoplasty and brow lifting are to restore the
youthful appearance of the eyelid–eyebrow unit with a perfect
functional result and an optimal facial aesthetic appeal.
 Today’s aesthetic eyelid surgery rejuvenates by contouring
and repositioning the orbital fat, restoring the convexity of
the lid–brow junction, and elevating the brow whenever brow
ptosis is present.
 Profound knowledge of the anatomy and all operating
procedures necessary to rejuvenate the orbital unit, as well as
appropriate preoperative evaluation, enhances the likelihood
of a perfect outcome.
 Upper and lower eyelid blepharoplasty can be performed
as distinct procedures or can be combined in the same
surgical setting. Brow lifting can be performed concomitantly,
if necessary. If blepharoplasty and brow lifting are to be
combined, first brow lifting should be performed and then the
upper eyelid skin excision should be reevaluated in order to
prevent removal of excessive skin.
 Blepharoplasty and brow lifting should be customized to the
individual patient to achieve maximum aesthetic improvement
with long-term effects.
 Aesthetic surgery of the orbital unit is neither simple nor
should it be construed as only skin excision.
 The advantages of using the laser beam of the UltraPulse®
EncoreTM CO2 (UPCO2) laser (Lumenis Ltd, Yokneam, Israel)
for laser-assisted blepharoplasty are: minimal intraoperative
bleeding with improved recognition of the eyelid anatomy,
shorter operating time, and reduced postoperative bruising
and swelling. Laser-assisted blepharoplasty requires
intravenous sedation or general anesthesia.
 INTRODUCTION
Blepharoplasty and brow lifting are popular aesthetic surgical
procedures performed by surgeons with various specialties:
dermatologic, oculoplastic, ear, nose and throat, maxillofa-
cial, general, and plastic surgeons. The goal of this chapter is
to provide the reader with a thorough understanding of the
surgical anatomy and principles involved with eyelid and
eyebrow surgery. Both the aesthetic and functional aspects
of eyelid surgery should be taken into consideration in order
to restore a full visual field for the patient with extreme
dermatochalasis. Excess upper eyelid skin may serve as a
donor site for full-thickness skin grafts. While no single stand-
ard or cookbook approach exists for any surgical procedure,
certain concepts and techniques have withstood the test of
time and are generally accepted.
Historical vignette
Blepharoplasty (Greek blepharon, meaning eyelid, and plastos,
meaning created) has a more than 1000-year-old history.1
Aesthetic eyelid surgery is the result of a continuous develop-
ment and refinement of surgical techniques and instruments
regarding excision of skin, degenerated muscles, herniated
orbital fat, and creation of the upper eyelid crease, as well as
restoring the supporting structural deficiencies.
Blepharoplasty began in 1818 with von Graefe writing
about eyelid reconstruction that he used in 1809.1,2 This
procedure remained the standard practice for the next 150
years. Publications in Germany in the late 1800s surfaced
regarding the excess fold of the upper eyelid.1 Fuchs was the
first to point out the meaning of the weakening of the levator
aponeurosis in the metamorphosis of the excessive skin.
Many view Fuchs as the first to correctly evaluate the rec-
reation of the eyelid crease and recognize its aesthetic value.3
Fox was the first to utilize the word dermatochalasis in 1952
to accurately associate excess eyelid skin with aging.4
Aesthetic eyelid surgery began its main and most important
development at the beginning of the 20th century in the USA,
with Miller’s publication of the first photograph in medical
history to show the crescent-shaped incision for eliminating
excessive lower eyelid skin.5 In 1924, Bourguet described the
transconjunctival removal of herniated orbital fat in lower
eyelid blepharoplasty and, 5 years later, the two separate fat
pockets of the upper lid, which he recommended excising.6 In
1931, Joseph recognized the benefits of correcting brow ptosis
for aesthetic reasons and described hairline and forehead
crease incisions to elevate the brows.7 In 1961, Pang, who
came from the Far East, promoted the supratarsal fixation,8
while Sheen introduced this terminology in 1974 to the West.9
In 1982, the Putterman textbook on cosmetic oculoplastic
surgery described the full-thickness resection at the margin of
the lower eyelid along with upper eyelid blepharoplasty.10
The role of the UPCO2 laser as a superior incisional instru-
ment to perform blepharoplasty was first demonstrated by
Baker in 198311 and published 1 year later in the Yearbook of
Ophthalmology. The dermatologist Lawrence David was the
first to use the UPCO2 laser for transconjunctival blepharo-
plasty.12 There is no doubt today, despite much controversy,

628
Part 3  Aesthetic Surgical Procedures
that laser-assisted blepharoplasty of the lower eyelids
transconjunctivally in combination with laser skin resurfacing
of the periorbital skin is the state-of-the-art technique in
aesthetic eyelid rejuvenation.13
Key anatomic considerations
The eyelid skin lies on a thin layer of subcutaneous tissue over
the orbicularis oculi muscle (Fig. 39.1). This orbicularis oculi
muscle, innervated by the zygomatic branch of the facial
nerve (Fig. 39.2), is divided into three regions: the pretarsal,
the preseptal (the palpebral portion), and the orbital portion.
Originating at the medial canthus, the orbital portion closes
the eyes. Under the orbital orbicularis muscle, the retro-
orbicularis oculi fat pad (ROOF) in the upper eyelid and the
suborbicularis oculi fat pad (SOOF) in the lower eyelid
connect at their lateral ends overlying the orbital rim and
lateral canthal tendon. The ROOF and SOOF are separated
from the orbital fat pads by the orbital septum and, in the
lower lid, also by the layers of the superficial musculoapone-
urotic system (SMAS).14 The ROOF lies between the ante-
Figure 39.1  Superficial periocular anatomy.
Bulbar conjunctiva
Punctum
Punctum
Caruncule
Posterior margin of eyelid
Anterior margin of eyelid
Orifices of tarsal glands
Palpebral conjunctiva
Tarsal glands beneath conjunctiva
Inferior fornix of conjunctiva
Iris
Lateral
canthus
Medial
canthus
Lateral or
malar sulcus
Inferior palpebral sulcus
Superior palpebral sulcus
Nasojugal
sulcus
Eyelashes
Tarsal part of upper lid
Orbital part of upper lid
Pupil
Surface anatomy of the eye
rior and posterior layers of the deep galea aponeurotica and,
with age, it may hypertrophy, causing fullness in the brow
and lateral half of the upper lid14 (Fig. 39.3). Beneath the
palpebral orbicularis muscle lies the orbital septum, dividing
the orbit into an anterior and posterior compartment. On the
upper eyelid, the orbital septum extends from the perios-
teum of the orbital rim down to the levator aponeurosis. In
the lower eyelid, the orbital septum joins the fascia capsu-
lopalpebralis. On the upper as well as on the lower eyelid,
the septum does not reach the proximal border of the tarsal
plate but fuses with the upper and lower lid retractors,
2–4 mm from the tarsal plate.14 In the upper eyelid, there
are two fat pads, a smaller medial (white in color) and a larger
central one (more yellow). Lateral to this preaponeurotic fat
lies the lacrimal gland, in the lacrimal fossa. In the lower lid,
the fat pads divide into three compartments: medial, central,
and lateral. Between the medial and the central fat pads in
the lower eyelid lies the inferior oblique muscle, which
should not be damaged during fat pad reduction at the time
of blepharoplasty. Likewise, the trochlea and superior oblique
muscle tendon should not be injured during upper blepha-
roplasty.15 Figure 39.4 shows the locations of the fat pads
that are frequently modified during cosmetic blepharo-
plasty, as well as the canthal tendons and inferior oblique
muscle.
The levator palpebrae superioris muscle runs in a horizontal
direction anteriorly in the orbit and changes at the Whitnall’s
ligament level to a vertical direction, the so-called levator
aponeurosis. The fibers of the Whitnall’s ligament connect to
the trochlea medially, and laterally they extend to join the
capsule of the lacrimal gland. Whitnall’s ligament divides the
lacrimal gland into a palpebral and an orbital lobe (Fig. 39.5).
The arterial supply to the eyelids and the venous drainage
illustrated in Figure 39.6 should also be noted and avoided in
eyelid surgery.14
Initial consultation and patient selection
Patients seek out a surgeon desiring either a cosmetic enhance-
ment or a functional improvement in their eyelids and/or
brow region. The preoperative evaluation should include a
thorough discussion of the risks and benefits of the planned
procedure. Choose patients with realistic expectations and
thoroughly evaluate them preoperatively while also referring
them to an ophthalmologist for a visual acuity examination
and to exclude any eye disorders. When interviewing and
evaluating patients, it may be best to use open-ended ques-
tions such as ‘What do you wish to improve?’ This interview
process is optimized when patients contemplate and articu-
late their own goals for surgery. Ask patients to bring old
photos; these may help the surgeon determine what they
want the postoperative result to resemble. A hand-held
mirror allows patients to look at their face as a cotton-tipped
applicator is used to hold up excess skin. The surgeon should
be wary of the patient who asks what should be done. The
surgeon may advise what can be done with an acceptable
probability of success. Ultimately, patients must decide if
what is possible is congruent with their aesthetic goals.
After the patient’s goals for surgery have been clarified,
the obligation of the surgeon is to thoroughly evaluate the
patient. A safe procedure is recommended, and the patient
is informed about additional procedures which may be
necessary.

629
Chapter 39  Blepharoplasty and Brow Lifting
Figure 39.2  Periorbital and eyelid muscles and their relationship with local nerves. (From Tyers AG, Collins JR. Colour Atlas of
Ophthalmic Plastic Surgery, 3rd edn. Oxford: Butterworth-Heinemann; 2008.)
Procerus
Frontalis
Frontal branch,
facial nerve
Zygomaticus major
Zygomatic branches,
facial nerve
Galea aponeurotica
Superficial branches,
supraorbital nerve
Corrugator supercilii
Deep branch,
supraorbital nerve
Temporal crest
Superficial and
deep branches,
supratrochlear nerve
Periorbital and eyelid muscles and their relationship with local nerves
Blepharoplasty
Tests for lower lid laxity are paramount in the preoperative
evaluation because scleral show or frank ectropion are pos-
sible after lower lid blepharoplasty. Two tests that should
be routinely performed are the distraction test and the snap
test. The distraction test, or so-called pinch test, is performed
by pulling the lower lid anteriorly away from the globe. If
greater than 7–8 mm of lid excursion occurs, lower lid hori-
zontal laxity is present. In the snap test, the lower lid is pulled
inferiorly. If the lid does not spontaneously return to the
normal position prior to the next blink, the test is positive,
indicating lower lid laxity. The lower lid laxity is due
mainly to laxity in one or both canthal tendons, alone or
in combination with laxity in the orbicularis musle. Lower
lid laxity and/or lateral canthal tendon laxity are not con-
traindications to surgery, but rather an indication that a lid-
tightening procedure may be needed (lower eyelid horizontal
shortening resection or tarsal strip procedure, or a lateral
canthal tendon tuck procedure, canthopexy, or cantho-
plasty).3 Figure 39.7 illustrates the snap and distraction tests.
Lower scleral show may also be an indication of lower lid
laxity.
A patient with significant lid ptosis will not be well served
if only a blepharoplasty is performed and the underlying
ptotic lid is not addressed. In a patient with significant der-
matochalasis and mild ptosis, simply pointing out the droop-
ing of the eyelid preoperatively will be important. The
preferred test for ptosis is measurement of the marginal
reflex distance (MRD). The MRD describes the position of
the eyelids relative to the midpupillary line. MRD can be
performed by measuring the relationship in millimeters from
the margin of the upper eyelid to a penlight reflex in the
pupil. A normal MRD is 4 mm. While an exact measurement
is not necessary, the relationship of the light reflex to the
lower eyelid is important to note. It should be symmetric
between the eyelids and may be an indication of globe mal-
position if asymmetric. The patient with globe malposition
should be evaluated by an ophthalmic surgeon as this condi-
tion may be associated with an orbital tumor or thyroid
ophthalmopathy. Analyzing the globe position in relation to
the orbital rim from a lateral view, a positive vector relation-
ship between ocular globe, lower lid, and malar eminence is
a normal and favorable anatomic situation. On the other
hand, a negative vector relationship indicates a higher risk of
lower eyelid retraction and scleral show when performing
additional laser skin resurfacing for rejuvenating wrinkled,
sun-damaged skin. Mild ptosis is manifested by an upper
MRD of 1.5–2 mm; moderate ptosis by an MRD of 0.5 mm;
and severe ptosis by an MRD of 0–0.5  mm. Figure 39.8
illustrates the MRD and palpebral fissure measurements.
An assessment of levator function is also required. Levator
function can be tested by measuring upper eyelid excursion
when the patient moves the eyes from maximal downgaze to
maximal upgaze with a fixed brow position. A full discussion
of the evaluation and management of ptosis may be found in
various references.14 Blepharoplasty surgeons should be famil-
iar with the etiology of adult ptosis. The surgeon may also

630
Part 3  Aesthetic Surgical Procedures
tion questionnaires (Fig. 39.9). A sample physician template
is presented in Figure 39.10. The use of the template requires
the surgeon to demonstrate conscious consideration of each
aspect of the evaluation and avoid omissions.
Particular attention is paid to signs or symptoms of thyroid
ophthalmopathy, dry eyes (Schirmer’s test), previous oph-
thalmic surgery (wait at least 6 months after LASIK surgery
or, if the patient plans to have LASIK, it is best to recom-
mend having blepharoplasty first), recurrent eyelid and peri-
orbital edema, allergies, sensitive skin, history of poor hearing,
and keloid formation or hyperpigmentation.
Standard laboratory evaluation includes hematologic and
coagulation profiles (complete blood count with platelets,
prothrombin and partial thromboplastin times), a blood
chemistry profile, and a thyroid panel. As discussed later,
bleeding is a rare but serious complication of blepharoplasty.
All anticoagulants must be stopped prior to surgery. If a
patient has a medical condition that requires uninterrupted
anticoagulants, proceeding with surgery should be seriously
reconsidered. Herbal supplements and some vitamins may
increase the tendency for bleeding and many common over-
the-counter medications contain aspirin or non-steroidal anti-
consider consultation from an ophthalmologist. The amount
of ptosis and the function of the levator aponeurosis are key
factors in determining the usual causes of ptosis and in choos-
ing the appropriate operation (levator aponeurosis repair or
levator resection). Most cases of adult acquired ptosis are
involutional and can be corrected with levator aponeurosis
repair at the time of blepharoplasty.16,17
Mild ptosis (so called pseudoptosis) can be improved by
simply performing blepharoplasty. When analyzing the upper
eyelid, the surgeon should differentiate between skin laxity
alone or in combination with prolapsed preaponeurotic fat
pads, prolapsed lacrimal glands, hypertrophy of the ROOF,
brow ptosis, and deficiency of the levator aponeurosis. Excess
lower lid skin, so-called festoons, dominates the eyelid’s
pathology, and fat pad removal transconjunctivally was
unnecessary in this patient. Such a patient is best served when
both the upper and lower eyelids are operated on together.
The excision of a significant amount of lower eyelid skin, in
combination with lower lid laxity, requires a transcutaneous
skin–muscle flap reduction with a small orbicularis oculi
muscle flap anchored to the orbital rim of the upper eyelid.
It is helpful to develop standardized preoperative evalua-
Figure 39.3  Cross-sectional anatomy of
upper and lower eyelids.
Superficial galea
Deep galea
Anterior and posterior deep galea
Sub-brow fat pad (ROOF)
Frontalis muscle
Preaponeurotic fat
Orbital septum
Orbital septum
Orbital fat
Orbitomalar ligament
Preseptal fat
Orbicularis oculi muscle
Suborbicularis oculi fat (SOOF)
Orbicularis muscle
Müller's muscle
Levator aponeurosis
Levator muscle
Superior tarsus
Inferior tarsus
Inferior tarsal muscle
Inferior oblique muscle
Conjunctiva
Capsulopalpebral fascia
Malar fat pad
Superior rectus muscle
Cross-sectional anatomy of upper and lower eyelids

631
Chapter 39  Blepharoplasty and Brow Lifting
Figure 39.4  Upper and lower eyelid fat pads and tendons.
Central fat pad
(preaponeurotic fat)
Trochlea
Nasal fat pad
Medial canthal tendon
Medial fat pad
Central fat pad
Lateral fat pad
Lateral canthal tendon
Inferior oblique muscle
Lacrimal gland
Upper and lower eyelid fat
pads and tendons
Figure 39.5  The canthal tendons. (From Spinelli HM. Atlas of
Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders;
2004.)
The canthal tendons and tarsal plates,
the upper and lower eyelid retractors
inflammatory drugs. Blepharoplasty surgeons should maintain
an updated list of such products.18 Blood pressure under good
control helps to minimize bleeding complications. Using the
UPCO2 laser beam as a cutting tool, the risk of bleeding can
also be reduced.
Brow lifting
The shape and configuration of the eyebrows and the eyelid–
eyebrow complex, as well as the fullness of the ROOF,
should always be analyzed before surgery. Special attention
should be paid to the brow position in relationship to the
Figure 39.6  The blood supply to the eyelids. (From Tyers AG, Collins JR. Colour atlas of ophthalmic plastic surgery, 3rd edn.
Oxford: Butterworth-Heinemann; 2008.)
The blood supply to the eyelids
Supratrochlear artery
Medial palpebral artery
Angular artery and vein
Facial artery and vein
Supraorbital artery and vein
Tarsal arcades upper lid
Lateral palpebral artery
Superficial temporal
artery and vein
Transvers facial artery
Tarsal arcade lower lid
Infraorbital artery and vein
Dorsal nasal
artery and vein