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832
Section 9
Plastic and Reconstructive Surgery
Back cut in
cartilage only
Figure 87-10. Septal pivot fl ap. To provide dorsal and caudal
support, the central cartilaginous/bony septum can be pivoted or
swung anteriorly. The blood supply of the septal pivot fl ap is centered
over the septal branches of the superior labial arteries.
A
B
Figure 87-11. Structural support of the nasal midline/dorsum. A, Costochondral graft carved into a “L” strut with alar battens. B, Cantilevered
cranial bone graft to be fi xed to the frontal skull with a miniplate.
period of ischemia during wound healing, the melano-
cytes of a skin graft may be injured and cause the fi nal
graft to appear hypopigmented or hyperpigmented.
Composite Chondrocutaneous Grafts
A composite chondrocutaneous graft can be an option
for reconstructing a nasal skeleton with defects that also
include nasal skin or inner nasal lining, or both. Com-
posite grafts can be harvested from the root of the helix
or from the conchal bowl (Figs. 87-13 and 87-14).9,18,19
Survival of the composite graft depends mainly on the
size of the graft and the vascularity of the recipient bed.
Diffusion from the recipient bed is the only source of
nutrients for the composite graft in the early postopera-
tive period. Several authors have reported complete
healing of composite grafts after partial necrosis.
In general, to minimize the possibility of necrosis,
graft size should not exceed 1.5 cm, and if possible,
composite grafts should be placed under or on
well-vascularized tissue. Grafts may be harvested as two
layers (skin-cartilage) or as three layers (skin-cartilage-
skin). Composite grafts are used mainly for reconstruc-
tion of the alae and columella.
Bilobed Flaps
The bilobed fl ap as described by Zitelli20 (Fig. 87-15) is
the most suitable method to repair small (<1.5 cm),
superfi cial defects of zone II (tip or ala, Fig. 87-16). It
moves the nasal defect from the zone of thick, immo-
bile skin (zone II) to the zone of thin, mobile skin (zone
area, nasolabial fold, and supraclavicular area. The
forehead has also been found to be an excellent site of
graft donor skin. Skin and a few millimeters of subcu-
taneous fat can be transferred from the forehead for
superfi cial defects of the alae and tip. A skin graft
should not be harvested from an area that is a possible
site for a forehead fl ap. Because of the temporary

Chapter 87
Nasal Reconstruction
833
Figure 87-12. Reconstruction of
cartilage support. If lining is created or
preserved, cartilage from numerous
sources (above: septum) can be tai-
lored to restore the nasal contour and
curvature. A cap graft or tip graft can
be used to promote lobule projection.
(From Burget GC, Menick FJ: Nasal recon-
struction: Seeking a fourth dimension. Plast
Reconstr Surg 78:145-157, 1986, with
permission.)
Conchal skin and
vertical wall cartilage
Anterior skin and
helical rim cartilage
Post-auricular skin
Conchal vertical
wall cartilage
Figure 87-13. Composite graft. The ear is
an ideal donor site for nasal reconstruction,
including full-thickness chondrocutaneous
grafts. Donor sites from the helical root or
posterior aspect of the ear can be closed pri-
marily with undermining. Anterior donor
sites from the conchal bowl may require a
skin graft for closure. (From Barton FE Jr: Aes-
thetic aspects of partial nasal reconstruction. Clin
Plast Surg 8:177-191, 1981, with permission.)

834
Section 9
Plastic and Reconstructive Surgery
A
B
C
D
E
Figure 87-14. Composite chondrocutaneous graft for nasal stenosis.
A, Bilateral nasal stenosis after necrosis of the nasal tip. B, Defect of the
ala and tip re-created. C, Harvest of a composite auricular graft. D, Inset
of the composite graft. E, Immediate postoperative appearance.
1). Fundamentals of this transposition fl ap are the
following:
1. The arc of rotation can vary between 90 and 180
degrees, but it is generally designed to be between
90 and 100 degrees. The radius will usually approxi-
mate 1.5 diameters of the defect.
2. The fi rst lobe should be the same size as the defect.
The second lobe is smaller and just narrow enough
to allow primary linear closure of the donor defect.
3. For medial defects, laterally based fl aps should be
designed.
4. Closure of secondary defects should not distort
normal landmarks, such as the lower eyelid.
Potential disadvantages of the bilobed fl ap are trap-
dooring (convex bulging) and obliteration of the alar
groove.
Nasolabial Flaps
Based either superiorly or inferiorly, the nasolabial fl ap
relies on a random blood supply derived from facial
artery perforators and takes advantage of the abun-
dance of mobile, non–hair-bearing skin in the medial
part of the cheek. Primary closure of the defect within
the nasolabial fold creates a minimal postoperative
deformity. Reconstruction involves fi rst tracing an
outline of the cutaneous defect on the donor site and
then elevating the fl ap in a subcutaneous plane (Fig.
87-17; also see Fig. 87-7).21-24 A superiorly based nasola-
bial fl ap is good for reconstruction of the entire alar
subunit, the inferior aspect of the nasal sidewall, and
the nasal platform on which the alar base rests. An
inferiorly based nasolabial fl ap is most useful for defects
of the upper lip, fl oor of the nose, and columella. A

Chapter 87
Nasal Reconstruction
835
b
b
a
a
A
b
b
a
a
B
Figure 87-15. Zitelli modifi cation of the bilobed fl ap. When
compared with the original design of a 180-degree arc of rota-
tion, which typically produces a dog-ear deformity at the rota-
tional point (A), the modifi ed transposition fl ap creates a
smaller defect by using a 90-degree arc of rotation and mini-
mizing dog-ear and trapdoor formation (B). (From Zitelli JA:
The bilobed fl ap for nasal reconstruction. Arch Dermatol 125:957-
959, 1989, with permission.)
nasolabial fl ap folded to create both internal and exter-
nal lining produces a bulky alar rim that will require
subsequent revision.
Forehead Flaps
A forehead fl ap transfers skin of ideal quality to recon-
struct the nasal skin defect in patients of all ages. The
forehead heals well with minimal scars even in donor
sites left to heal secondarily. Midline or paramedian
forehead fl aps can be raised on either the supratroch-
lear or supraorbital vessels.25 Most surgeons elevate a
paramedian fl ap based on an ipsilateral, supratrochlear
vascular pedicle that is located approximately 1.5 cm
from the midline. Doppler ultrasound can be used to
locate the pedicle, but even if no Doppler signal is
found, a fl ap with a pedicle based almost anywhere
along the midline of the forehead will probably survive.
To avoid strangulation caused by twisting of a wide
pedicle, the pedicle width of a paramedian fl ap should
be about 1.5 cm. To gain length for a paramedian
fl ap, one can extend the fl ap into the hair-bearing scalp
or extend the fl ap 1.5 cm below the orbital rim, or
both.
The pattern of the nasal defect should fi rst be
designed from the contralateral normal side of the
patient’s face as a model. If the contralateral side is also
injured, a plaster or clay model of an ideal nose can
serve as the template. Local anesthesia with epineph-
rine should not be injected into the forehead fl ap so
that the blood supply can be evaluated intraoperatively.
The forehead fl ap is elevated in a distal-to-proximal
direction with all layers of the scalp (skin, subcutaneous
tissue, and frontalis muscle) except periosteum. The
forehead fl ap is thinned only at the columellar inset
and along the alar rim. Closure of the donor site should
be done over the periosteum with subgaleal undermin-
ing of the forehead. Any gaps that cannot be closed
should be kept moist with antibiotic ointment, covered
with Vaseline gauze, and allowed to heal secondarily.
The pedicle of the paramedian forehead fl ap in
the glabellar region is typically covered with a split-
thickness skin graft to decrease bleeding and oozing.
Menick advises that only pristine, unexpanded fore-
head skin be transferred.26 An expanded forehead fl ap
can contract after the completion of nasal reconstruc-
tion and produce inferior aesthetic results. If necessary,

836
Section 9
Plastic and Reconstructive Surgery
B
A
C
Figure 87-16. Nasal tip defect reconstructed with a bilobed fl ap.
A, Bilobed fl ap design. B, Closure. C, Early postoperative appearance.
A
B
Figure 87-17. Superiorly based, single-stage nasolabial fl ap. A, Alar
defect. B, Nasolabial fl ap inset.
tissue expansion can be done secondarily after nasal
reconstruction to close the forehead donor site or to
perform forehead scar revision.
POSTOPERATIVE MANAGEMENT
Patients undergoing fi rst-stage nasal reconstruction
with a forehead fl ap should stay in the hospital over-
night. Any blanching of the fl ap or signs of venous
congestion can potentially be reversed with removal of
sutures or reinsetting of the fl ap. Doyle splints or intra-
nasal packs are not generally used unless there is
concern for the formation of synechiae. Because exter-
nal dressings may compromise fl ap circulation, they
are not placed on a fl ap used for nasal reconstruction.
Skin sutures, as well as any external bolster placed
on a skin graft, are removed 5 to 7 day after surgery.
Postoperative parenteral antibiotics are not routinely
prescribed.
PEARLS
• When designing a fl ap to reconstruct a defect or
subunit, one should use a template based on the
contralateral, uninjured side.
• If a forehead fl ap is to be used in a smoker, transfer
of the fl ap should be delayed for 3 weeks by incising
the perimeter without elevating the fl ap.

Chapter 87
Nasal Reconstruction
837
3. Burget GC, Menick FJ: The subunit principle in nasal reconstruc-
tion. Plast Reconstr Surg 76:239-247, 1985.
4. Singh DJ, Bartlett SP: Aesthetic considerations in nasal recon-
struction and the role of modifi ed nasal subunits. Plast Reconstr
Surg 111:639-648, discussion 649-651, 2003.
5. Rohrich RJ, Griffi n JR, Ansari M, et al: Nasal reconstruction—
beyond aesthetic subunits: A 15-year review of 1334 cases. Plast
Reconstr Surg 114:1405-1416, discussion 1417-1419, 2004.
6. Giugliano C, Andrades PR, Benitez S: Nasal reconstruction with
a forehead fl ap in children younger than 10 years of age. Plast
Reconstr Surg 114:316-325, discussion 326-328, 2004.
7. Shumrick KA, Campbell A, Becker FF, Papel ID: Modifi cation of
the subunit principle for reconstruction of nasal tip and dorsum
defects. Arch Facial Plast Surg 1:9-15, 1999.
8. Burget GC: Modifi cation of the subunit principle for reconstruc-
tion of nasal tip and dorsum defects [commentary]. Arch Facial
Plast Surg 1:16-18, 1999.
9. Burget GC, Menick FJ: Nasal support and lining: The marriage
of beauty and blood supply. Plast Reconstr Surg 84:189-202,
1989.
10. Barton FE Jr: Aesthetic aspects of partial nasal reconstruction.
Clin Plast Surg 8:177-191, 1981.
11. Menick FJ: A 10-year experience in nasal reconstruction with the
three-stage forehead fl ap. Plast Reconstr Surg 109:1839-1855, dis-
cussion 1856-1861, 2002.
12. Menick FJ: Nasal reconstruction: Forehead fl ap. Plast Reconstr
Surg 113(6):100E-111E, 2004.
13. Burget GC: Aesthetic restoration of the nose. Clin Plast Surg
12:463-480, 1985.
14. Moore EJ, Strome SA, Kasperbauer JL, et al: Vascularized radial
forearm free tissue transfer for lining in nasal reconstruction.
Laryngoscope 113:2078-2085, 2003.
15. Winslow CP, Cook TA, Burke A, Wax MK: Total nasal reconstruc-
tion: Utility of the free radial forearm fascial fl ap. Arch Facial
Plast Surg 5:159-163, 2003.
16. Walton RL, Burget GC, Beahm EK: Microsurgical reconstruction
of the nasal lining. Plast Reconstr Surg 115:1813-1829, 2005.
17. Burget GC, Menick FJ: Nasal reconstruction: Seeking a fourth
dimension. Plast Reconstr Surg 78:145-157, 1986.
18. Cervelli V, Bottini DJ, Gentile P, et al: Reconstruction of the nasal
dorsum with autologous rib cartilage. Ann Plast Surg 56:256-262,
2006.
19. Gloster HM Jr, Brodland DG: The use of perichondrial cutaneous
grafts to repair defects of the lower third of the nose. Br J Der-
matol 136:43-46, 1997.
20. Zitelli JA: The bilobed fl ap for nasal reconstruction. Arch Derma-
tol 125:957-959, 1989.
21. Barton FE Jr: Aesthetic aspects of nasal reconstruction. Clin Plast
Surg 15:155-166, 1988.
22. Guerrerosantos J, Dicksheet S: Nasolabial fl ap with simultaneous
cartilage graft in nasal alar reconstruction. Clin Plast Surg 8:599-
602, 1981.
23. Hollier HJ, Stucker FJ: Local fl aps for nasal reconstruction. Facial
Plast Surg 10:337-348, 1994.
24. Park SS, Cook TA: Reconstructive rhinoplasty. Facial Plast Surg
13:309-316, 1997.
25. Menick FJ: Aesthetic refi nements in use of forehead for nasal
reconstruction: The paramedian forehead fl ap. Clin Plast Surg
17:607-622, 1990.
26. Menick FJ: Facial reconstruction with local and distant tissue: The
interface of aesthetic and reconstructive surgery. Plast Reconstr
Surg 102:1424-1433, 1998.
• Reconstruction with a forehead fl ap should be done
in three stages, with secondary cartilage grafting
and fl ap thinning performed during the second
stage.
• Even though a normal alar lobule contains little
cartilage, a reconstructed ala should contain a
cartilage graft (i.e., in an nonanatomic position)
that spans the entire lobule to prevent soft tissue
contraction.
• Consideration of the subunit principle is useful only
for reconstruction of the convex subunits of the
nose (i.e., the tip, dorsum, alae, and columella)
with local fl aps because as a local fl ap heals, it
contracts centripetally and pulls the fl ap into a
convex shape.
PITFALLS
• If the fi rst step in nasal reconstruction is not
recreation of the defect (i.e., excising old scar
and contractions), the fi nal result will be a
reconstruction and fl ap design that are too small.
• If nasal reconstruction is done at the same time as
lip and cheek reconstruction, subsequent wound
settling can shift the lip-cheek platform and cause a
reciprocal shift in the position of the reconstructed
nose.
• Reconstruction of missing nasal lining with bulky
fl aps, such as a nasolabial or free fl ap, can lead to
nasal obstruction.
• When greater than 50% of a nasal convex subunit is
missing, patching the nasal defect with a local fl ap
without replacing the entire nasal subunit may
worsen the aesthetic outcome.
• In a child, delaying nasal reconstruction until nasal
growth is complete may lead to worsening
psychosocial concerns.
References
1. Rees TD, Liverett DM, Guy CL: The effect of cigarette smoking
on skin-fl ap survival in the face lift patient. Plast Reconstr Surg
73:911-915, 1984.
2. Bennett ME: Psychologic and social consequences of craniofacial
disfi gurement in children. Facial Plast Surg 11:76-81, 1995.

Chapter 88
Facial Reanimation
Barry M. Schaitkin
Rehabilitation of the patient with chronic facial paraly-
sis must take into account the loss of form and function.
When contemplating facial reanimation, the surgeon
should consider all variables that might infl uence the
choice of procedures, including the patient’s age, prog-
nosis, pathology, the extent of paralysis and functional
defi cit, the current status of the nerve and the likeli-
hood of spontaneous recovery, other neural defi cits,
comorbidities, and patient expectations. Reanimation
of the paralytic eyelid is usually required in addition to
the procedures described in this chapter.
PATIENT SELECTION
Although each patient presents unique needs and chal-
lenges, experience has led to guidelines for caring for
this group of patients.
1. The surgeon should reinnervate the facial muscles
as soon as possible.
2. The eye and face should be reanimated separately to
minimize mass movement.
3. A combination of static and dynamic procedures
usually provides the best result.
4. Each procedure is individualized to the patient’s
defi cit.
PREOPERATIVE PLANNING
Dynamic Reanimation Procedures
The dynamic procedures can be considered within four
broad categories. One can think of the facial nerve
nucleus as the proximal system and the facial nerve
musculature as the distal system and look at the proce-
dures based on what is surgically available. The proce-
dures are then dictated by the integrity of those systems
for use by the surgeon.
• Proximal system intact and distal system intact
• Proximal system intact and distal system not
available
• Proximal system not available and distal system
intact
• Neither system available
Patients with facial nerve disruption in the tempo-
ral bone are good examples of the proximal and distal
system intact. These patients are ideally suited for
having the facial nerve nucleus reconnected to the
facial musculature by either primary neurorrhaphy or
by use of a nerve graft. Reconstituting the nerve should
be performed as soon as possible for the best results.1
Patients with extensive facial nerve invasion by
cancer can create a situation without a distal nerve graft
site. Ideally, the viable proximal facial nerve can then
be used to innervate a microvascular free fl ap, or alter-
natively, these patients without a distal system can be
helped by muscle transposition.
Patients who have lost the facial nerve as part of
acoustic tumor surgery should have the nerve reconsti-
tuted immediately, if possible, by a nerve graft. However,
this frequently is not possible, and patients are often
reluctant to have a craniotomy for reestablishing nerve
continuity. These patients are dynamically innervated
by either a nerve substitution with a hypoglossal jump
graft or by use of a cross-facial nerve graft. The jump
graft works best if done in the fi rst year of paralysis. A
traditional hypoglossal to facial anastomosis causes a
unilateral tongue paralysis as a tradeoff, but can be
done as long as 2 years after facial nerve interruption
with good results.
Finally, for those lacking both systems, two dynamic
options are available: the temporalis muscle transposi-
tion and the innervated free fl ap based on another
cranial nerve (V, the contralateral cranial nerve VII, XI,
and XII have been used). This situation is characteristic
of the patient who has undergone radical surgery for
cancer of the parotid gland who presents years later for
reanimation.
In this situation, if the patient is a candidate for and
desirous of a dynamic procedure, and if that person
839

840
Section 9
Plastic and Reconstructive Surgery
understands the risks, options, and benefi ts, then
another cranial nerve should be used to innervate a
free muscle transfer. The free muscle (often the
gracilis) is anchored to the modiolus to give an active
smile. Some degree of static support should be pro-
vided at this setting to take away the gravitational effects.
This offers immediate improvement because the nerve
graft may not be completely functional before 18
months.
Static Procedures
These procedures can be combined with dynamic pro-
cedures or used independently depending on the
desired outcome. The most common procedures to
consider are the brow lift, nasal alar lateralization, sus-
pension of the oral commissure, and digastric muscle
transposition. Other minor static procedures for
improvement of lip position and for providing a bal-
anced smile can also be performed.
SURGICAL TECHNIQUE
Hypoglossal-Facial Jump Graft
Basic understanding of nerve repair is essential for
many of the planned procedures. The hypoglossal-facial
nerve jump graft will be described in detail to cover
microscopic neural techniques essential to all of the
procedures.
Surgical Principles
1. Neural repair, whether with a graft or directly, must
be tension free.
2. The endoneurial surface of each end must match.
3. The ideal graft not only has the proper length but
also a similar axon volume.
4. Nerve repair should always be performed under the
operating microscope.
The patient is prepped and draped as for a paroti-
dectomy, and a modifi ed Blair incision is used. A nerve
graft donor site must be prepped into the fi eld if the
preferred graft source, the greater auricular nerve, is
not available. Alternatively, the facial nerve can be
decompressed in the mastoid and transposed and
directly anastomosed into the hypoglossal nerve.2
The facial nerve is found in its normal location in
the parotid gland using the surgeon’s preferred ana-
tomic landmarks. The nerve may have undergone some
atrophy depending on how long the paralysis has been
present, but this does not make the nerve diffi cult to
fi nd.
If there has been previous parotid surgery and the
surgeon is looking for nerve branches in a previously
operated and/or irradiated bed, the surgery can be
extremely diffi cult. The surgeon in this case must be
comfortable fi nding the branches distal to the surgical
site and working proximally. Even this may be quite
diffi cult with the combination of nerve atrophy, scar
tissue, and the inability of the nerve to respond to elec-
trical stimulation.
Once the facial nerve is found, it is dissected to the
level of the pes and meticulous hemostasis is performed
to ease the microscopic nerve repair. The hypoglossal
nerve is dissected to expose it just distal to the ansa
cervicalis. In this way, the surgeon can be sure that vol-
untary tongue movement will stimulate all fi bers being
routed to the facial nerve.
The nerve graft is harvested and placed in a moist,
saline-soaked gauze sponge for later use. The distance
required is usually less than 8 cm, which is easily accom-
plished with the great auricular; alternatively, the medial
brachial cutaneous or sural nerve can be used.
The hypoglossal nerve is elevated into the surgeon’s
view under the operating microscope and above the
level of any blood by placing a Penrose drain under the
nerve and gently elevating it with a self-retaining retrac-
tor. The hypoglossal nerve is larger in diameter than
either the facial nerve or the great auricular nerve and
ideally only a portion is used. The procedure requires
less than half of the 11th nerve. Jack Kartush2 has sug-
gested passing an 8-0 nylon through a point represent-
ing one third of the neural diameter to allow the
surgeon to know when this limit is reached. Sectioning
the nerve under visual confi rmation of serial stimula-
tion with an electric stimulator also allows the surgeon
to work with decreased risk of permanent tongue weak-
ness. A beveled incision is made not more than one
third of the way through the hypoglossal nerve, partially
transecting the nerve and exposing a portion of the
proximal endoneurial surface. The proximal end of
the nerve graft is sutured to the proximal end of the
endoneurial surface created in the 11th nerve. Two or
three monofi lament 8-0 or smaller nylon sutures will
hold the graft in place. The Penrose drain is divided
with scissors and gently removed without disrupting the
graft.
Attention is then directed to the facial nerve site.
The surgeon divides the nerve down to the epineurium
on the posterior aspect. Preserving this epineurium will
prevent the nerve from retracting into the parotid gland
and greatly facilitates the repair. The nerve graft should
be placed with a gentle S-curve to assure no tension on
either anastomosis. Three 8-0 or 9-0 monofi lament
nylon sutures are adequate to prevent dehiscence.
Direct nerve repair and cross facial nerve repair is
done with similar principles. If the nerve is disrupted
intracranially, it is more diffi cult to repair because of
the pulsations, cerebrospinal fl uid, and lack of epineu-
rium, but similar principles apply. One or two sutures
are generally all that can be achieved.
The cross facial repair uses one or more branches
of the facial nerve. The surgeon fi nds the desired
branch, usually a distal midface branch, and with small
incisions about the nasal ala the nerve is bluntly tun-
neled out to the pretragal region on the paralyzed
side.
Static Procedures: Smile
Support of the modiolus is a valuable primary proce-
dure (Fig. 88-1) or can be a useful adjunct to a dynamic

Chapter 88
Facial Reanimation
841
procedure. Many materials have been used for this
purpose, including permanent suture, fascia lata, pal-
maris longus tendon, and a variety of cadaver and col-
lagen products. Autologous grafts have the disadvantage
of donor site morbidity, but are still superior because
of the decreased risk of infection, rejection, and
extrusion.
Measurements are taken from the zygomatic arch
to the modiolus. One half of the required length of
fascia lata is used as the incision length on the lateral
thigh. A 2.5-cm wide segment is taken and tunneled
from the oral incision, which can be either in the pro-
posed nasolabial fold or lip skin junction, to an incision
in the hairline. Preoperative planning determines the
vector of pull desired to mimic the contralateral side.
Incisions in the nasolabial fold work best in older
patients with deep folds on the normal side.
Static Procedures: Nasal Obstruction
Patients with loss of facial tone will shift the central
upper lip fi ltrum and collapse the ipsilateral nasal ala.
A portion of the suspension material used for the smile
can be used to lateralize the nasal ala through an alar
incision. If just the nasal ala is addressed, the procedure
through an alotomy can be used to suspend the nasal
ala to a lateral position of the front face of the maxilla
using a surgical anchor.
Static Procedures: Lower Lip
Static procedures on the lower lip vary depending on
the desired result and the presence of other facial nerve
defi cits. An isolated ramus mandibularis defect can be
treated with a lip plication or a digastric muscle trans-
position (Fig. 88-2).
The procedure is performed through multiple
small incisions in the neck to mobilize the digastric
muscle from its posterior aspect. Leaving the anterior
muscle belly fi fth nerve intact rarely provides dynamic
activity but does improve the missing inferior vector
present with a normal smile.
Patients who have a total facial paralysis should not
have a digastric muscle transposition because the infe-
rior pull may decrease oral competence. These patients
are best served with a lower lip wedge resection (Fig.
88-3). This procedure provides horizontal shortening
of the lip, allowing for improved oral competence and
speech as well as better symmetry from removal of the
area that takes on a “fat lip” appearance.3
Less than one third of the lip is removed to avoid
microstomia (Fig. 88-4).
POSTOPERATIVE CARE
Patients require very little specifi c postoperative care
after the majority of these procedures, and most are
Figure 88-1. Patient with static
suspension of nasolabial fold and
lower lip wedge.
A
B
Figure 88-2. Patient before (A) and after (B) digastric muscle transposition after ramus mandibularis paralysis during parotidectomy.

842
Section 9
Plastic and Reconstructive Surgery
C
A
B
Figure 88-3. Left lip wedge excision planning. (Reprinted with per-
mission from May M, Schaitkin BM: The Facial Nerve, May’s 2nd Edition.
New York, Thieme, 2000.)
Figure 88-4. A, Preoperatively, patient with complete right facial
paralysis demonstrating surgical planning. B, Patient at rest. C, Patient
smiling after lower lip wedge excision and fascia lata suspension only.
discharged on the day of surgery. However, there are a
few precautions one should take.
1. The patient with surgery that abuts the oral cavity
should be covered with prophylactic antibiotics.
2. Patients with muscular or facial attachments near the
modiolus should be placed on a soft diet to avoid
dehiscence.
3. No pressure dressings are used over nerve grafts or
muscle fl aps.
4. Lower extremity fascia and nerve graft sites are
treated with pressure dressings.
COMPLICATIONS
The main complication of the nerve graft procedures
is the lack of recovery of nerve function at all or to the
extent anticipated. Patients should be counseled about
the possibility of dehiscence of the nerve or failure of
the nerve to reach the target muscle. All patients who
have recovery from a neural procedure will have
synkinesis.

Chapter 88
Facial Reanimation
843
Likewise the static procedures are mostly subject to
the possible dehiscence of the tissues providing support.
Most of these issues are actually easier to remedy
through revision surgery because the scar from the fi rst
procedure provides a better means of attachment.
The use of foreign material for reanimation is
subject to the formation of granuloma, extrusion, and
infection.
PEARLS
• Great results begin with careful evaluation of the
patient’s history and desired outcome.
• Realistic expectations are necessary for patient
satisfaction. Preoperative and postoperative photos
from other patients are very helpful.
• Combined procedures with multiple levels of eye,
static, and dynamic reanimation provide the best
results.
• Hypoglossal jump grafting avoids tongue paralysis.
References
1. May M: Regional reanimation: Nose and mouth. In May M, Schait-
kin BM (eds): The Facial Nerve, May’s 2nd Edition. New York,
Thieme Medical, 2000, pp 775-796.
2. May M: Nerve substitution techniques. In May M, Schaitkin BM
(eds): The Facial Nerve, May’s 2nd Edition. New York, Thieme
Medical, 2000, pp 611-634.
3. Glenn MG, Goode RL: Surgical treatment of the “marginal man-
dibular lip” deformity. Otolaryngol Head Neck Surg 97:462-468,
1987.
PITFALLS
• Avoiding donor sites for graft material can lead to
long-term infection and extrusion.
• Pulling down a paralyzed lower lip for symmetry may
exacerbate oral competence problems.
• It is important to have a variety of procedures in
one’s armamentarium to avoid trying to place all
patients into the same procedure.

Chapter 89
Face Lift (Rhytidectomy)
Grant S. Gillman
Society places a high premium on a youthful appear-
ance, yet there is no way to stop the natural effects of
gravity, sun exposure, and dermal atrophy associated
with aging on one’s appearance. These facts have led
to a growing demand for reversal of the visible effects
of aging. Furthermore, these requests now come from
younger and younger patients—both male and female.
In addition, there is ever-increasing interest in preven-
tive measures, minimally invasive procedures, shorter
recovery times, reduced risk, and a more natural post-
operative appearance.
Although the fundamental goals of face-lift surgery
are similar in most patients, there exists a wide array of
surgical techniques and many procedural variations
among surgeons. Issues to be considered include place-
ment of the incision, the length of the incision (short
scar or limited incision face lift versus traditional inci-
sion face lift), the extent of skin undermining, the
depth of dissection, management of the superfi cial
musculoaponeurotic system (SMAS), treatment of the
neck and vector of the SMAS, and skin redraping, to
name a few. Indeed, if a single technique were clearly
superior, it would be adopted by all surgeons. In all
cases, preoperative analysis, clinical judgment, and indi-
vidualizing care based on the patient’s present state of
aging, expectations, and ability to tolerate and accept
each contemplated procedure and its postoperative
recovery and potential complications should be com-
bined to direct surgical choices.
PREOPERATIVE PLANNING
Preoperative evaluation begins by having patients high-
light their specifi c areas of concern and outlining for
the surgeon what bothers them most. In this way not
only can one begin to formulate a surgical plan, but
equally important, one can also begin to get a sense of
how realistic the patient’s expectations are, as well as
the motivation for having surgery. Proper patient selec-
tion cannot be overstated as an important determinant
of postoperative patient satisfaction.
A medical history is obtained and should cover all
past medical problems, with special emphasis on hyper-
tension, diabetes, thyroid disease, facial muscle weak-
ness, previous facial surgery, cardiovascular disorders,
smoking, and the use of any anticoagulant medications
(including products containing warfarin [Coumadin],
aspirin, or ibuprofen and any herbal products). A
general medical consultation is obtained if there is any
concern about the patient’s past or present state of
health. Smokers must be forewarned of the increased
risk of complications such as hematoma, skin slough-
ing, and poor healing. Ideally, they should stop smoking
at least 2 weeks before surgery and for 2 weeks
afterward.
A complete physical evaluation of the patient’s
entire head and neck is performed. For most patients
considering facial rejuvenation surgery, this will require
attention to forehead rhytides, brow position, and the
upper and lower eyelids, in addition to issues relevant
to face-lift surgery in particular.
For face-lift surgery, physical evaluation begins with
an overall assessment of the facial structure, shape, and
contour. Patients with good underlying bone structure,
prominent facial features, and a thin face are likely to
have more dramatic improvement and are therefore
better candidates for a face-lift than those with poor
facial skeletal structure and a rounder heavy face.
Skin texture—the quality, thickness, laxity, and
degree of wrinkling of the patient’s skin—is noted and
recorded. Older, thicker, less elastic skin with more
obvious actinic changes cannot be expected to hold the
contour as well as younger, thinner, more elastic skin
with less sun damage.
The examination continues with an evaluation of
the degree of sagging in the midface and cheek, jowls,
and submental region. The neck is examined for overall
contour, laxity of the platysma, and the presence or
845

846
Section 9
Plastic and Reconstructive Surgery
absence of platysmal bands. One should ask the patient
to clench the teeth tightly to accentuate the platysmal
bands. Chin position should be assessed as well because
relative microgenia may be an indication for chin aug-
mentation, which will help facilitate improvement in
overall neck defi nition.
The hairline is evaluated to enable decisions regard-
ing placement of incisions.1 Whereas a patient with a
low sideburn or temporal tuft may tolerate some supe-
rior shift of the hairline (and therefore a temporal
incision that extends upward from the helical root), a
patient with a high sideburn or temporal hairline will
not tolerate any hairline shift (and should therefore
have an incision that follows the temporal hairline).
Decisions also need to be made regarding a pretra-
gal or post-tragal incision. Although a post-tragal inci-
sion is better camoufl aged, it is balanced against the
risk of a tragus that then looks unnatural postopera-
tively. In patients with a deep preauricular crease, a
pretragal incision in front of the ear is a reasonable
option. In general, a pretragal incision is preferred in
men to avoid moving hair-bearing skin (the beard) all
the way back to the posterior edge of the tragus, as
would happen with a post-tragal incision. It is wise to
discuss all incision options and the rationale for the
various choices with the patient preoperatively and to
engage the patient in the decision-making process.
A thorough discussion with the patient should
follow regarding realistic expectations for outcome, the
typical intraoperative and postoperative course, and
potential complications and their relative frequency.
A complete set of photographs is important for
documentation and planning. At a minimum, frontal,
right and left oblique, and lateral views should be
included. Additional views that are frequently helpful
include three-quarter views from each side and a frontal
view with the patient’s teeth clenched to highlight pla-
tysmal banding.
Anesthesia
The patient and physician must decide together on the
most appropriate anesthesia for that particular patient.
Local anesthesia, supplemented by intravenous seda-
tion, is adequate for many aesthetic surgical procedures
on the face. The choice of intravenous sedation with
local anesthesia versus general anesthesia should take
into consideration the surgeon’s comfort level, the
patient’s preference, the anesthesiologist’s preference,
the duration of the procedure, and any tendency or
predisposition of the patient to obstruction of the airway
when sedated. Even with a general anesthetic, local
anesthesia with epinephrine is used for its hemostatic
effect and postoperative pain relief. Limiting the com-
bined operative procedures to be performed on the
same day to a maximum of 6 hours will lead to fewer
complications and will be better tolerated by the patient
and surgeon.
When intravenous sedation is chosen, in all circum-
stances it should be managed by the anesthesiologist/
nurse anesthetist rather than the operating surgeon to
maximize safety and allow the surgeon to focus only on
the procedure at hand. During infi ltration of the local
anesthetic the sedation is deepened, and then patients
can be allowed to “come up” from the sedation and it
can be titrated to a level at which they can respond to
commands, breathe on their own, and express any
discomfort.
Injections of local anesthetic are not performed
until all markings have been made. A mix of 50 mL of
1% lidocaine with 1 : 100,000 epinephrine combined
with 30 mL of 0.5% bupivacaine (Marcaine) with
1 : 200,000 epinephrine is used for the face and neck.
Typically, the neck is injected together with one side of
the face at the outset. The other side of the face is
injected when the fi rst operative side is being closed. In
this way one can distribute the total amount of lido-
caine and Marcaine injected over a longer interval to
avoid toxicity.
Markings
Skin markings are made with the patient in a semi-
upright or sitting position preoperatively. Markings
include those for skin incisions, the planned extent of
undermining, the topographic location of the facial
nerve (a line from 0.5 cm below the inferior attachment
of the earlobe to 1.5 cm above lateral brow), the infe-
rior border of the mandible, the angle of the mandible,
the specifi c location of the sagging jowls, and platysmal
banding when present.
In the temporal area, if the patient’s sideburn is low
enough to tolerate some hairline shift without looking
unnatural, the planned incision can extend superiorly
from the helical root in curvilinear fashion into the
temporal hair, where it will be well camoufl aged (Fig.
89-1). If any doubt exists about whether the patient can
tolerate a shift of the sideburn tuft or if the patient
already has a higher sideburn, the temporal incision is
designed to follow the hairline, several millimeters
within the hair, extends anteriorly from the helical root,
and then curves superiorly along the hairline for an
additional 1 to 2 cm (Fig. 89-2). By placing this incision
several millimeters within the hairline one can bevel the
incision to preserve the hair follicles below the incision.
Over time hair will then grow back through the incision
and render it less conspicuous.
A pretragal or post-tragal continuation of the inci-
sion is marked as determined preoperatively. A post-
tragal incision is made right along the free posterior
margin of the tragus. A pretragal incision follows the
crus of the helix into the incisura anteriorly before it
curves slightly forward in front of the tragus and travels
inferiorly in a natural skin crease to the base of the
earlobe.
In a female the incision is designed to curve around
the earlobe at its junction with the cheek, whereas in
males, a small cuff (several millimeters) of skin is main-
tained below the earlobe to prevent advancing bearded
skin right into the junction of the earlobe with the
cheek. The incision continues along the posterior
auricle, where it is carried 2 to 3 mm onto the posterior

Chapter 89
Face Lift (Rhytidectomy)
847
surface of the conchal cartilage (i.e., lateral to the post-
auricular sulcus) because this incision will ultimately
generally settle into the sulcus rather than drift onto a
more visible area of postauricular skin. As with the
infralobular incision, in men the postauricular incision
is made either in or several millimeters behind the
postauricular sulcus to avoid drawing bearded skin up
onto the auricle.
The postauricular incision is drawn superiorly to a
point where the helical rim crosses the hairline (usually
1 to 1.5 cm above the level of the tragus) before turning
horizontally and posteriorly. From here the incision
may extend back into the occipital hair for several
centimeters (see Fig. 89-1) or may follow the hairline
inferiorly (several millimeters within the hairline) and
gently curve further into the hair for 1.5 to 2 cm at its
inferior extent (Fig. 89-2). The length of this incision
depends on the amount of redundant skin that is to be
excised; it must be long enough to allow the skin to
redrape without leaving a posterior scalp “dog-ear” or
a fold in the neck. Placing the incision along the hair-
line will make it easier to prevent any step-off deformity
along the postauricular hairline, particularly if one
anticipates removing a signifi cant amount of skin in this
region as the skin of the neck is lifted and redraped.
An example of intraoperative skin markings is pre-
sented in Figure 89-3.
It is not necessary to shave or cut the patient’s hair,
but after parting the hair, segments of twisted hair in
front and behind the planned incisions are wrapped
with rubber bands or paper tape. Lacri-Lube ointment
is combed into the hair on each side of the part to
further prevent hair from interfering with the wound
closure.
Once all markings are complete, injections of local
anesthetic are carried out with a 22- or 25-gauge spinal
needle in the subcutaneous dissection plane. Appropri-
Figure 89-1. Schematic of a face-lift incision extending superiorly
from the helical root into the temporal hair anteriorly. It can be used
in patients with a low temporal hairline tuft and extended posteriorly
behind the ear into the occipital hair.
Figure 89-2. Schematic of a face-lift incision extending anteriorly
within the temporal hairline. This incision is preferred in patients
with a low temporal hairline to prevent posterior shift of the hairline.
Posteriorly, an incision along the occipital hairline is illustrated.
ate infi ltration facilitates subsequent dissection. To
prevent injection of excessive amounts of lidocaine/
bupivacaine, only the fi rst region to be dissected is
injected at the outset of the operation, with each suc-
cessive region injected intraoperatively 10 to 15 minutes
before transitioning to that part of the surgery.
SURGICAL TECHNIQUE
As alluded to earlier, there are multiple variations on
face-lift surgery—a skin-only lift, skin dissection with
some modifi cation of the SMAS,2-6 deep-plane face-lifts,7
composite face-lifts,8 subperiosteal face-lifts,9 and
others.10,11 In general, the more extensive the dissection
or the deeper the plane of dissection, the greater the
risk of postoperative complications and facial nerve
injury. Furthermore, from surgeon to surgeon there
will be differences in incision preference, degree of
liposuction, extent of undermining, and methods of
treating the SMAS and platysma. With that in mind,
what is described herein is an outline of a safe,
basic, generic procedure with elaboration of some
variations.
Preoperative evaluation of the neck and platysmal
banding will help identify patients who will require
direct submental fat resection, liposuction, or medial
plication of the platysmal bands. In a patient with a
good cervicomental angle without excessive submental
fat or platysmal banding it may not be necessary to do
any direct submental dissection or fl ap elevation at all.
If it is thought that liposuction is warranted (a particu-
larly heavy neck with excessive subcutaneous fat) or
there are platysmal bands that need to be addressed,
this part of the surgery is done fi rst.
The operation begins with infi ltration of local anes-
thetic into the neck. The incision is placed in the sub-
mental area several millimeters behind (posterior to)

848
Section 9
Plastic and Reconstructive Surgery
tive irregularities or unevenness in the skin. The cannula
is then attached to suction and the liposuction is carried
out with care taken to maintain an even contour (to
palpation) across the entire area suctioned.
An alternative is to elevate the skin fl ap over the
neck fi rst with face-lift scissors and maintain an even 2-
to 3-mm cuff of fat on the undersurface of the skin.
“Open” liposuction is then conducted under more
direct vision. Boundaries for safe liposuction extend
from the inferior border of the mandible down to the
thyroid cartilage while remaining between the anterior
borders of the sternocleidomastoid muscles from either
side.
After using the 3- to 4-mm blunt cannula, a 5- to 6-
mm single-hole spatula-tipped cannula is passed over
the same area to smooth out, sculpt, and contour the
area. Care is taken to avoid overaggressive resection,
which may lead to cutaneous depressions and contour
irregularities postoperatively.
At this point it is helpful to inject local anesthetic
into the fi rst side of the face to be operated on. Next,
if not already done, the skin fl ap is elevated through
the submental incision over the neck (Fig. 89-5). Dis-
section across the entire neck is needed in patients who
require substantial fat excision or redraping of signifi -
cant excesses of skin. Plication of the medial borders of
the platysma is then carried out if indicated for platys-
mal banding. Either a lighted retractor is placed in the
submental incision or two Senn retractors can be used
with headlight illumination. The medial edge of the
platysma muscle from either side is identifi ed. The
medial edges are then sutured together from the level
of the thyroid notch up to the incision with buried 3-0
or 4-0 Vicryl or PDS suture. In selected cases in which
it is thought that there is a great redundancy of pla-
tysma muscle, it may be necessary to resect a strip of the
medial margin of muscle from either side before sutur-
ing the medial borders to one another. Hemostasis
should be ensured beneath the neck fl aps before
moving to the next step.
A
B
Figure 89-3. A, Preoperative skin markings along the temporal
hairline and post-tragally. The topographic location of the facial
nerve is outlined (dashed line), as is the extent of the proposed under-
mining, the angle, and inferior border of the mandible. B, The post-
auricular markings, which extend superiorly on the posterior auricle
several millimeters from the postauricular sulcus, traverse the scalp
above the level of the tragus, and extend inferiorly just within the
occipital hairline.
the submental crease (Fig. 89-4). This incision provides
the access necessary for submental liposuction if
planned or, alternatively, for elevation of neck skin
fl aps for better redraping or platysmal plication. Bear
in mind that the surgery will draw this incision anteri-
orly and superiorly, so consideration must be given to
ensuring that it remains well concealed in the submen-
tal region. If only liposuction is planned, a smaller
incision is suffi cient (0.5 to 1 cm), whereas if a skin
fl ap is to be elevated and the platysma plicated, a
slightly longer incision will be needed for optimal
visualization.
For liposuction, one can pretunnel with the lipo-
suction cannula off suction to initiate elevation of the
neck skin fl ap.12 A 3- or 4-mm three-hole blunt bullet-
tipped cannula is used initially while taking care at all
times to keep the aperture in the cannula directed
deep, away from the overlying skin, to prevent injury to
the dermis and minimize the potential for postopera-
Figure 89-4. The submental incision used for access to elevate the
neck skin fl ap.

Chapter 89
Face Lift (Rhytidectomy)
849
The postauricular and occipital incisions are then
made and the fl aps elevated with scalpel dissection for
the fi rst 2 to 3 cm (Fig. 89-6). Care is required initially
to maintain a thick fl ap over the mastoid region
(because this is some of the thinnest skin elevated in
the entire operation and therefore most at risk for
necrosis or skin sloughing). As one transitions down
into the neck below the mastoid, the fl ap must be super-
fi cial to the fascia overlying the sternocleidomastoid
muscle to protect the integrity of the greater auricular
nerve as it crosses the midportion of the muscle 6.5 cm
below the external auditory meatus. Once beyond the
mastoid region, further dissection is carried out with
face-lift scissors, and the fl ap is retracted with one or
two sharp double hooks and counter-traction provided
by the assistant distal to the point of elevation. The dis-
section is carried forward within the plane of the sub-
cutaneous fat until one joins the dissection of the neck
skin already elevated (Fig. 89-7).
Attention is then turned to elevation of the facial
skin fl aps. The incision is begun in the temporal region
along the predetermined markings and continues to
the base of the earlobe (Fig. 89-8). Dissection in the
temporal region can be either in the subcutaneous
plane or right on the deep temporal fascia—the former
being superfi cial to the frontal branch of the facial
nerve, the latter deep to the nerve. In either case, aware-
ness of the depth of dissection relative to the facial
nerve is critical to prevent injury.13
Having completed the incision with a no. 15 blade,
dissection along the deep temporal fascia can generally
be done quickly and bluntly with the back end of the
knife handle or even with fi nger dissection to the level
of the lateral orbital rim and the lateral aspect of the
forehead while always staying above the level of the
Figure 89-5. Elevation of the neck skin fl ap.
Figure 89-6. Initial sharp elevation of the postauricular skin fl ap.
Figure 89-7. Anterior extension of the postauricular dissection to
join the neck fl ap dissection.
Figure 89-8. The preauricular skin incision.

850
Section 9
Plastic and Reconstructive Surgery
zygomatic arch. It is important to recognize that a sub-
cutaneous soft tissue bridge or mesentery from the
deeper tissues up to the skin must be preserved at the
level of the zygomatic arch and lateral canthus to sepa-
rate the deeper temporal dissection from the subcuta-
neous dissection of the preauricular cheek skin fl ap
because the frontal branch of the facial nerve lies in this
soft tissue. When the temporal dissection is in the sub-
cutaneous plane (as opposed to being right on the deep
temporal fascia), it is contiguous with the plane in
which the facial skin is elevated and superfi cial to the
nerve at all levels. In this case it is not necessary to pre-
serve a soft tissue bridge at the level of the zygomatic
arch.
Subcutaneous dissection of the facial skin (and
temporal skin when that plane is chosen) is initiated
with either a no. 15 blade or sharp serrated iris scissors
and a sharp double-hook retractor for the fi rst 1 to 2 cm
because the deep tissues in this region are more adher-
ent to the overlying skin than the skin further forward
over the cheek.
Once the proper plane of dissection is identifi ed,
after the fi rst 1 to 2 cm, subsequent elevation of the
preauricular facial skin fl ap is performed with face-lift
scissors under direct vision (Fig. 89-9). The fl ap should
be elevated while leaving a thin, even layer of fat on the
undersurface of the skin to protect the subdermal
plexus. Having the assistant apply constant countertrac-
tion on the skin medially and using the operating room
lights to backlight or transilluminate the fl ap will help
one identify and maintain the proper plane of dissec-
tion and an even thickness of the skin fl ap. The fl ap is
undermined out to the limits that were marked preop-
eratively (usually about 5 to 6 cm). Preliminary hemo-
stasis is achieved at this point with bipolar cautery for
maximal safety. A moist sponge can then be placed
beneath the fl ap as attention is turned to the postau-
ricular area.
Once the preauricular cheek fl ap is elevated, the
dissection is connected with the postauricular skin fl ap
and continues into the neck to bring this fl ap into con-
tinuity with the neck skin previously undermined (Fig.
89-10). With the neck and cheek skin thus elevated,
hemostasis is once again addressed.
SMAS suspension is carried out next. Suspension
may be in the form of SMAS plication (suture suspen-
sion whereby the SMAS is folded on itself) or imbrica-
tion (either as a lateral SMAS-ectomy or by elevation
and trimming of a SMAS fl ap, with suture fi xation of
the margins of the excision). Because SMAS plication
can lead to bunching of soft tissue beneath the skin,
SMAS imbrication is favored and will be discussed
here.
One method of SMAS imbrication involves formal
SMAS fl ap elevation,2 redraping of the SMAS along a
superolateral vector, trimming of the excess, and sus-
pension with 3-0 PDS or Vicryl suture to reapproximate
the edges after excision of redundant SMAS. Alterna-
tively, SMAS imbrication can be carried out by way of a
lateral SMAS-ectomy (without actual elevation of the
SMAS fl ap).5,6,12 In the latter method, a J-shaped, 1.5- to
2-cm strip of SMAS is excised (the “SMAS-ectomy”) in
the preauricular area down to the parotid fascia (Fig.
89-11), with extension superiorly and anteriorly from
below the lobule of the ear up toward the malar emi-
nence (Fig. 89-12). The SMAS excision should not go
higher than the zygomatic arch to prevent injury to the
frontal branch of the facial nerve.
Approximation of the edges of the SMAS defect
that results from SMAS-ectomy will create the SMAS
suspension needed to elevate the jowl, neck, and naso-
labial fold. The direction of SMAS suspension is not
simply posterior, but rather primarily superior and
slightly posterior. Multiple 3-0 PDS or Vicryl sutures are
used to close the two exposed edges of the SMAS-ectomy
defect (Fig. 89-13).
The advantage of SMAS-ectomy over SMAS fl ap
dissection is that it can be done quickly and with less
risk to the facial nerve if one remains over the parotid
fascia. Furthermore, less tissue elevation/dissection
Figure 89-9. Elevation of the cheek fl ap with face-lift scissors.
Figure 89-10. Facial, occipital, and neck skin fl aps elevated and
joined in continuity.

Chapter 89
Face Lift (Rhytidectomy)
851
ricular incision extends straight back into the hair) to
enable one to realign the hairline and thus avoid any
step-off in that area. If the postauricular incision was
designed to follow the hairline, the skin fl ap can be
redraped in a more superior and posterior direction.
The fl ap is tailored with two key tension sutures.
The key sutures placed during closure of a face-lift
assume the greatest degree of tension on the closure
and also serve as guides for the direction of pull of the
facial skin. The anterior skin fl ap (preauricular cheek
skin) is fi rst “lifted” in a superior and posterior direc-
tion (Fig. 89-14). An incision is made in the fl ap down
to the helical root (Fig. 89-15). The fi rst tension or
tacking suture of 4-0 Prolene (or staple) is placed at this
point to effectively separate the temporal skin excess
from the preauricular skin excess (Fig. 89-16). The
excess temporal skin above the fi rst tension suture is
Figure 89-11. Initiation of the SMAS-ectomy by gently retracting
the SMAS while engaging the face-lift scissors to resect the SMAS
tissue down to the parotid fascia.
Figure 89-12. The completed SMAS-ectomy. Parotid fascia is visible
between the edges of the SMAS defect, which are being grasped with
forceps.
Figure 89-13. Initiation of imbrication of the edges of the SMAS
defect with 3-0 Vicryl. The tension placed on the SMAS closure
relieves the tension on the skin closure.
should theoretically help reduce the risk for postopera-
tive hematoma.
Once the SMAS suspension is complete, the redun-
dant skin will be overlapping the ear. Redraping and
excision of the excess skin follow. If there are any irreg-
ularities, dimpling, or bunching of skin as a result of
the SMAS suspension, further undermining of the skin
fl ap will resolve these problems and is carried out before
the skin excision.
For skin redraping, the anterior (preauricular) skin
fl ap is retracted along a superior and slightly posterior
vector while the posterior (postauricular) skin fl ap is
drawn superiorly and slightly anteriorly (if the postau-
Figure 89-14. Redraping of the cheek fl ap along a posterior supe-
rior vector.

852
Section 9
Plastic and Reconstructive Surgery
Figure 89-15. Incision in the facial fl ap down to the helical root.
Figure 89-16. Tacking suture placed to separate the temporal skin
excess from the cheek skin excess.
then excised. Skin closure in this area is achieved with
staples if in the hair or with 5-0 or 6-0 Prolene if along
the temporal hairline. If much tension is encountered,
a deep layer of 5-0 PDS sutures is used.
The postauricular skin fl ap is then redraped (Fig.
89-17). The second tension suture is next placed in the
postauricular incision at the level of the postauricular
hairline by cutting into the fl ap posteriorly at the point
where the hairline needs to be realigned. This effec-
tively separates the occipital portion of the skin fl ap
from the more immediate postauricular portion of the
fl ap.
The excess occipital skin behind the second tension
suture can then be excised and closure carried out in
a fashion similar to that in the temporal area—staples
if the occipital incision heads into the hair or running
5-0 or 6-0 Prolene or staples if the incision follows the
hairline (Fig. 89-18). A fl at closed suction drain is
brought out through a separate stab wound in the
occipital hair (behind the incision) and laid in the neck
before closing the occipital incision.
Moving from the hairline over the premastoid skin
to the superior aspect of the incision along the postau-
ricular sulcus, the redundant skin is trimmed and the
skin edges closed with 5-0 plain or fast-absorbing catgut
suture.
Skin now overlies the ear and only the trim around
the ear remains to be completed. Scissors are used to
cut the skin overlying the ear down toward the earlobe
along a line parallel to the auricular helix or postauricu-
lar sulcus (Fig. 89-19). The incision should not come
all the way down to the lower pole of the earlobe but
rather stop approximately 0.5 to 1 cm above the base of
Figure 89-17. The postauricular skin fl ap is redraped to facilitate
skin excision and closure without tension. In this case, because the
incision was just inside the hairline, the skin fl ap is retracted along a
posterior and superior vector. Note also that the anterior temporal
skin excess has been excised and sutured without tension.
Figure 89-18. Completion of the closure along the occipital hair-
line leaves only the skin excess that cradles the auricle.

Chapter 89
Face Lift (Rhytidectomy)
853
the earlobe. This preserves more skin below the earlobe
to cradle the earlobe at closure rather than risking
closure under tension and inferior retraction of the
earlobe with healing. The earlobe is then sutured in
place (Fig. 89-20), and any excess skin overlying the
postauricular sulcus incision line is trimmed. Postau-
ricular closure is with 5-0 plain or fast-absorbing
catgut.
The excess preauricular skin is then tailored to
facilitate an exacting tension-free closure (Fig. 89-21)
with running 6-0 Prolene (Fig. 89-22).
Ten to fi fteen minutes before completing closure
on the fi rst side, the second side of the face should be
injected with local anesthetic. The second side of the
face-lift proceeds in the same way as the fi rst side. The
submental incision is closed at the completion of surgery
with either 5-0 fast-absorbing gut or 6-0 Prolene
suture.
Dressings
The end of the operation is the best time to comfortably
clean the patient’s hair. Saline and a large-toothed
comb are used to remove all loose hair, dried blood,
and debris. Bacitracin ointment is next applied to all
incisions, which are then covered with either Xeroform
gauze or a nonadherent dressing (Telfa).
A lightly compressive dressing of open fl uffed 4 ×
4-inch gauze is applied to provide padding over the
periauricular area, around the lower part of the face,
and over the neck. The dressing is then secured with a
3- or 4-inch Kerlix gauze wrap and either an elastic
bandage or a 3-inch roll of Coban self-adhesive tape to
hold the dressing in place. The goal is a snug but com-
fortable dressing.
Figure 89-19. Skin is incised along the line of the auricular helix
toward the lower pole of the ear; the incision stops 0.5 to 1 cm above
the base of the earlobe to allow the skin to be tucked under the
earlobe without any inferior pull or tension at closure.
Figure 89-20. The earlobe position has been secured and the
excess skin along the postauricular sulcus excised and closed.
Figure 89-21. Excision of the anterior (cheek) skin redundancy.
Figure 89-22. Appearance on completion of skin closure.

854
Section 9
Plastic and Reconstructive Surgery
POSTOPERATIVE MANAGEMENT
The patient is instructed to keep the head of the bed
elevated 30 degrees, avoid bending over, and not under-
take strenuous activities for the fi rst week. Most patients
are kept overnight in a unit capable of caring for face-
lift patients unless they have made appropriate arrange-
ments for home care. Ice-cool compresses are applied
to the face during the fi rst 24 to 48 hours. Many patients
have found small bags of frozen peas to be an excellent
source of cool compresses over these moist dressings.
The peas are in plastic bags, conform well to the face
and eyes, and hold the cool temperature for a pro-
longed period. In addition, they can be refrozen and
reused for this purpose. Patients are told preoperatively
that they will swell and bruise during the fi rst few post-
operative days.
Patients are evaluated on the fi rst postoperative
morning for any evidence of hematoma and to test the
integrity of the facial nerve. The drains are removed,
and a clean, lighter dressing is secured. Patients are told
to remove the dressing the following day (postoperative
day 2) and may then begin to gently wash their hair and
care for their own face. They are instructed to be careful
with the temperature of the water and their blow dryer
because of temporary alterations in scalp and facial
sensation. In addition, patients should wait 3 to 4 weeks
before undergoing hair coloring or a permanent. A
nylon or spandex elasticized facial support dressing is
supplied to the patient, who wears it full-time (aside
from bathing) for the fi rst week. Patients are told to
gently clean the visible incisions with hydrogen perox-
ide and then reapply an antibacterial ointment three
times daily.
The preauricular sutures are removed on the fi fth
or sixth postoperative day. Scalp staples are removed 7
to 10 days postoperatively. The absorbable postauricu-
lar sulcus stitch is allowed to dissolve.
Representative preoperative and postoperative
patient photos are seen in Figure 89-23.
A
B
C
D
Figure 89-23. A and B, Preoperative frontal and lateral views of a patient before a face-lift and blepharoplasty. C and D, Postoperative frontal
and lateral views of the patient who underwent a face-lift and blepharoplasty.

Chapter 89
Face Lift (Rhytidectomy)
855
COMPLICATIONS14-16
Hematoma
Small hematomas are one of the most common and
troublesome complications. If identifi ed immediately
postoperatively, they can often be aspirated with an 18-
gauge needle. However, when a small hematoma is
camoufl aged by swelling, one must wait 7 to 14 days
before the hematoma will liquefy and allow removal by
aspiration. Residual hematomas may cause some dim-
pling and fi rmness beneath the facial skin. Larger
hematomas (incidence of approximately 3% in females
and up to 9% in males) are generally apparent
within the fi rst 24 hours and mandate return to the
operating room for evacuation, hemostasis, and reclo-
sure. Failure to identify or address a more substantial
hematoma puts the patient at increased risk for skin
necrosis, infection, and dimpling or irregularities in the
overlying skin.
Facial Nerve Injury
Most immediate postoperative facial nerve paralysis
will resolve spontaneously within 6 weeks and is due
to the effects of the local anesthetic, stretch, local
crush injury, infl ammation, or compression by a sup-
port suture. Occasionally, permanent paralysis will
occur as a result of complete transection of the frontal,
marginal mandibular, or buccal branch or injury
induced by electrocautery. If the injury is identifi ed
intraoperatively,
immediate
repair
is
indicated;
otherwise, treatment is expectant in the hope that
the defi cit will resolve or diminish. Ultimately, pre-
vention of such injuries is paramount, and if the dis-
section is maintained in the proper plane and the
surgeon is cognizant of the depth of the facial nerve
relative to the depth of dissection, facial nerve injuries
are avoidable.
Skin Necrosis
The incidence of signifi cant skin necrosis is between
1% and 3%. It is most common in the mastoid region
because the skin fl ap is the thinnest there, tension is
greatest, and it is farthest away from the blood supply.
The usual causes of more extensive skin necrosis are
some combination of the following: delayed recogni-
tion of a signifi cant hematoma, excess tension on the
closure, excessive superfi cial dissection (overly thin skin
fl aps), a history of impaired circulation secondary to
smoking or diabetes, excessive pressure from the dress-
ing, infection, or traumatic handling of tissues. All
sloughing should be treated by observation, reassur-
ance, and wound care. A lot of personal attention is
required to help these patients deal psychologically
with this unexpected sequela. An eschar will eventually
form at sites with full-thickness skin loss, and the scars
are usually satisfactory. Scars that heal unacceptably can
be revised later.
References
1. Kridel RW, Liu ES: Techniques for creating inconspicuous face-
lift scars: Avoiding visible incisions and loss of temporal hair. Arch
Facial Plast Surg 5:325-333, 2003.
2. Stuzin JM, Baker TJ, Baker TM: Refi nements in face lifting:
Enhancing facial contour using Vicryl mesh incorporated into
SMAS fi xation. Plast Reconstr Surg 105:290-301, 2000.
3. McCullough EG, Perkins SW, Langsdon PR: SASMAS suspension
rhytidectomy: Rationale and long term experience. Arch Otolar-
yngol Head Neck Surg 115:228-234, 1989.
4. Mittleman H, Newman J: SMASectomy and imbrication in face
lift surgery. Facial Plast Surg Clin N Am 8:173-182, 2000.
5. Baker DC: Lateral SMASectomy. Plast Reconstr Surg 100:509-513,
1997.
6. Baker DC: Minimal incision rhytidectomy (short scar face lift)
with lateral SMASectomy: Evolution and application. Aesthetic
Surg J 21:14-26, 2001.
7. Hamra ST: The deep-plane rhytidectomy. Plast Reconstr Surg
86:53-61, 1990.
8. Hamra ST: Composite rhytidectomy. Plast Reconstr Surg 90:1-13,
1992.
PEARLS
• Attention to detail in the preoperative evaluation
will help establish realistic patient expectations and
guide decisions to optimize surgical results.
• Careful consideration should be paid to the position
of the hairline, and incisions should be chosen to
avoid excessive shift or misalignment of the hairline,
which can result in telltale signs of surgery.
• Incisions in males should be modifi ed to avoid
shifting bearded skin all the way back to the
posterior margin of the tragus or right up to the
attachment of the earlobe.
• The surgeon should always be conscious of the
location and depth of the facial nerve relative to the
plane of dissection to avoid inadvertent injury.
• Suspension of the SMAS, whether by plication,
imbrication, or SMAS-ectomy, is fundamental to
minimize skin closure tension and improve the
longevity of the face-lift.
PITFALLS
• Tobacco smokers are at much higher risk for
complications and must be counseled appropriately
preoperatively; heavy smokers should not be
considered candidates for this procedure.
• Dissection deep to the fascia overlying the
sternocleidomastoid muscle in the neck may injure
the greater auricular nerve.
• Overaggressive surgery must be avoided to prevent
an unnatural, pulled, “surgical” look.
• Excessive tension on the skin closure will increase the
risk for skin necrosis and widened scars, both of
which are largely preventable.
• Disproportionate, particularly unilateral facial pain
may be indicative of a hematoma and mandates
immediate examination of the patient.

856
Section 9
Plastic and Reconstructive Surgery
9. Psillakis JM, Rumley TO, Camargos A: Subperiosteal approach as
an improved concept for correction of the aging face. Plast
Reconstr Surg 82:383-392, 1988.
10. Baker SR: Triplane rhytidectomy: Combining the best of all
worlds. Arch Otolaryngol Head Neck Surg 123:1167-1172, 1997.
11. Saylan Z: The S-lift for facial rejuvenation. Int J Cosmetic Surg
7:18-24, 1999.
12. Williams EF, Lam SM: Lower facial rejuvenation. In Williams EF,
Lam SM (eds): Comprehensive Facial Rejuvenation. Philadel-
phia, Lippincott Williams & Wilkins, 2004, pp 105-151.
13. Larrabee WF Jr, Makielski KH, Cupp C: Facelift anatomy. Facial
Plast Surg Clin N Am 1:135-152, 1993.
14. Ahn MS, Kabaker SS: Complications of face lifting. Facial Plast
Surg Clin N Am 8:211-221, 2000.
15. Adamson PA, Moran ML: Complications of cervicofacial rhyti-
dectomy. Facial Plast Surg Clin N Am 1:257-271, 1993.
16. Baker DC: Complications of cervicofacial rhytidectomy. Clin Plast
Surg 10:543-562, 1983.

Chapter 90
Blepharoplasty
Grant S. Gillman
As our population continues to grow older, society’s
emphasis on a more youthful appearance continues to
increase and has led to rising interest in reversing the
visible signs of aging. The periorbital region is usually
the fi rst area of the face to show signifi cant signs of
aging. Correction of this imperfection can signifi cantly
“turn back the clock” of aging and has thus led to the
popularity of aesthetic surgery on the eyelids.
PATIENT SELECTION
Appropriate candidates for upper eyelid blepharoplasty
are patients who objectively have redundant skin of
the upper eyelids (dermatochalasis). Although in most
cases the motivation is purely cosmetic, other patients
with more signifi cant excess skin and hooding of the
upper lids may have functional visual fi eld restriction.
In the latter patients, automated visual fi eld testing is
necessary for proper documentation to justify the
medical necessity so that reimbursement by third-party
payers is facilitated.
Appropriate candidates for lower eyelid blepharo-
plasty will generally have pseudoherniation of the
orbital fat (“bags”), either with or without a vertical
excess of skin.
In all cases patients must be well motivated and
have realistic expectations regarding the surgical
outcome.
PREOPERATIVE PLANNING
All patients are asked to describe their particular area
of concern. A thorough history of any ocular problems
is then elicited, including any history of periorbital
surgery, previous blepharoplasty, visual diffi culties,
glaucoma, and “dry eye” symptoms such as frequent
blinking, tearing, dryness, red eyes, itching, burning, or
crusting of the lid margins.
A medical history is obtained and should cover
all past medical problems with special emphasis on
hypertension, diabetes, thyroid disease, facial muscle
weakness, cardiovascular disorders, and the use of any
anticoagulant medications (including aspirin products,
warfarin, nonsteroidal anti-infl ammatory drugs, vitamin
E, multivitamins, and over-the-counter oral herbal
preparations). If the surgeon has any concerns regard-
ing other ophthalmic conditions (e.g., dry eyes,
glaucoma, ptosis), the patient should be evaluated
preoperatively by an ophthalmologist for clearance
before making plans for surgery.
Whether one is planning upper or lower eyelid
surgery, the surgeon must be familiar with the anatomy
of the eyelid and periorbital area1 to make the best
preoperative decisions, in addition to performing well-
executed surgery.
In assessing the upper eyelid area, the position of
the brow is fi rst evaluated to determine the extent to
which brow ptosis might be contributing to the appar-
ent skin excess of the upper eyelids. In men, a youthful
brow position rests at the level of the superior orbital
rim, whereas in women, the brow should rest at a level
about 1 cm above the orbital rim. Signifi cant brow
ptosis should prompt a conversation with the patient
about the merits of a brow-lift or a combination of brow-
lift and blepharoplasty.
The size, shape, and confi guration of the bony
orbit, as well as the size, shape, and symmetry of the
palpebral aperture, are then evaluated. Complete eye
closure preoperatively is naturally critical—any pre-
existing lagophthalmos is a defi nite contraindication to
upper eyelid blepharoplasty because it will undoubtedly
increase if upper lid surgery is performed. It is
857

858
Section 9
Plastic and Reconstructive Surgery
important to look at the position and symmetry of the
upper lid folds and supratarsal creases, the amount of
scleral show, and the position of the globe in the orbit.
Any asymmetry should be pointed out to the patient
preoperatively. A patient with eyelid ptosis must under-
stand that blepharoplasty alone will not correct eyelid
ptosis and that ptosis repair is necessary in addition.
The appearance of aging in the periorbital area can
be due to an excess of periorbital skin, protuberant fat,
and hypertrophic orbicularis muscle. It is important to
correctly diagnose and record the contribution of each
to the patient’s deformity. One should record the
degree of excess skin in each eyelid and fat in each fat
compartment (upper medial and central; lower medial,
central, and lateral). Any orbicularis oculi muscle hyper-
trophy is also recorded.
The patient is asked to look straight at the surgeon
with the eyes open, then with the eyes closed, and fi nally
in upward gaze without moving the head. During these
maneuvers, the upper and lower eyelids are closely
evaluated for the relative amount of excess skin and fat.
The excess fat in the lower lid compartments is high-
lighted in the upward gaze position. Applying pressure
to the patient’s globe while the eyelids are closed helps
exaggerate and delineate the locations of excess fat in
both the upper and lower eyelid compartments.
Lower eyelid tone is assessed with a “snap test” (also
called the lid distraction test) whereby the lid is drawn
anteriorly outward from the globe with the thumb and
forefi nger. More than 10-mm movement of the lid
margin is considered abnormally lax. In addition, one
watches how long it takes for the lower lid to return to
its pretest position. A normal, youthful lid will snap
back immediately. In the lid retraction test, the lower
lid is drawn inferiorly toward the orbital rim, and once
again one observes for abnormally slow return of the
lid to its normal position. Poor lower lid tone should
lead the surgeon to consider alternative techniques to
standard skin-muscle lower lid blepharoplasty or a con-
comitant canthoplasty or canthopexy.
Finally, the visual acuity of each eye should be
tested individually with an eye chart or by having the
patient read fi ne print with one eye.
Preoperative photographs are important for docu-
mentation and planning. A complete set would include
a full facial view (vertically oriented, 1:7 or 1:8 ratio)
and close-up (1:4 ratio, horizontally oriented) frontal,
oblique, and lateral views of the eyes. The close-up
frontal view should include a photo with the eyes closed
and one with the eyes gazing upward. Consistent pre-
operative and postoperative focal length, lighting, back-
ground, patient positioning, and subject-to-lens distance
are essential.
The patient and physician must decide together on
the most appropriate anesthetic for each patient. Local
anesthesia, supplemented by intravenous sedation, is
usually adequate for all aesthetic surgical procedures
on the eyelids. Patients who require only resection of
skin of the upper eyelids often do well with local anes-
thesia alone. In some cases the patient or anesthesiolo-
gist may feel most comfortable with general anesthesia.
Patient comfort should be the ultimate goal for maximal
surgical safety.
SURGICAL TECHNIQUES
Upper Lid Blepharoplasty
For upper eyelid blepharoplasty, the amount of skin
resected depends on the amount of excess as deter-
mined by preoperative examination.2 It is again empha-
sized that one should ensure that the brow is not ptotic
and that it is held in correct position during marking
of the upper eyelid resection.
Markings
The incisions are marked preoperatively with the patient
in the sitting position and the brow held in proper posi-
tion before injection of local anesthetic. The level of
the inferior incision is usually between 8 and 12 mm
from the lash line in the midpupillary line and 5 to
6 mm above the medial and lateral canthi. The inferior
incision is generally marked in the patient’s natural
upper eyelid crease, which lies at the upper edge of the
tarsal plate, unless the crease is less than 8 mm from the
lash line centrally. In such cases the central marking
should be measured to lie 8 to 10 mm above the lashes.
The incision is planned such that it lies in the upper
eyelid crease and the skin resected is from the preseptal
region, not the pretarsal area. The natural supratarsal
crease may or may not be symmetrical from one side to
another. One can choose to use the patient’s natural
crease regardless or adjust one side to ensure sym -
metry. This decision is best made with the patient
preoperatively.
At the lateral canthus the marking should sweep
gently laterally and upward toward the tail of the brow,
as much as needed to excise the skin that accounts for
any lateral hooding. It rarely needs to extend beyond
the lateral aspect of the lateral orbital rim. Medially, the
incision marking should not extend more than 1 to
2 mm beyond the punctum of the eyelid. Extending the
incision too far nasally into the concavity at the medial
orbit increases the risk of creating a webbed scar across
this area. In patients with signifi cant excess skin, the
medial extension is curved upward in a W pattern to
avoid a dog-ear and keep the scar from coinciding with
the epicanthal fold.
It is important to hold the patient’s brow in its
correct anatomic position when determining the
amount of skin to be resected from the upper lid. A
“skin pinch” technique is then used to determine the
amount of excess skin to be resected. Conservatism is
always recommended. The middle of the excess skin is
gently grasped with fi ne forceps and lifted until slight
eversion of the lashes occurs. The upper incision is
marked at the point where the lower incision meets the
upper limit of the excess skin. This is done in at least
four positions across the upper eyelid. The marks are
then connected to outline the upper incision line (Fig.
90-1). This resection is tested at multiple levels by pinch-
ing the upper and lower incision lines together (before

Chapter 90
Blepharoplasty
859
injecting the local anesthetic) and checking for excess
eversion of the lid margin.
Infi ltration of the local anesthetic is accomplished
with a 30-gauge, 11–2 -inch needle (Fig. 90-2). Injecting
just below the skin and superfi cial to the underlying
orbicularis oculi will minimize hematoma formation.
Total volume per lid is generally about 1 to 1.5 mL.
After allowing adequate time for the hemostatic effect
of the local anesthetic to commence, the skin is incised
along the markings (Fig. 90-3). A skin-only resection is
fi rst performed with either a no. 15 scalpel, a needle-
tipped cautery, or sharp scissors (Fig. 90-4). Hemostasis
is obtained with a needle-tipped electrocautery (Fig.
90-5).
In patients in whom the supratarsal crease needs to
be accentuated, excision of a 3-mm strip of orbicularis
muscle is done separately with fi ne forceps and fi ne,
Figure 90-1. Outline of an upper eyelid blepharoplasty incision.
Figure 90-2. Injection of local anesthetic.
Figure 90-3. Skin incision with a no. 15 blade for upper eyelid
blepharoplasty.
Figure 90-4. Skin excision with scissors undermining superfi cial to
the orbicularis oculi.
Figure 90-5. Hemostasis achieved after skin excision.

860
Section 9
Plastic and Reconstructive Surgery
sharp, curved scissors in the midportion of the wound
(Fig. 90-6).
If it was determined preoperatively that excision of
orbital fat is necessary, one proceeds with that step at
this time. Preoperative evaluation of each compartment
will help one determine the amount of excess fat to be
excised and avoid under-resection. With fi nger pressure
on the globe, the excess fat in the orbital compartments
can be seen bulging through the orbital septum. A
small opening is made through the orbital septum over
the top of the fat compartments to be addressed (Fig.
90-7). The excess fat is then teased through the opening
in the septum with fi ne forceps and a cotton swab (Fig.
90-8).
Before fat excision, a small amount of local anes-
thetic should be injected into the base of the fat pedicle
because the excision can be uncomfortable for the
patient. A small, curved hemostat is then placed at the
base of the excess fat to be removed. To avoid over-
resection, excess traction is not placed on the fat, and
only the fat that is easily delivered through the orbital
septum is resected. Small, curved scissors are used to
excise the fat while leaving a small cuff above the hemo-
stat. The cut edge is cauterized before releasing the
hemostat. As an alternative, one can slowly cauterize
across the base of the fat (bipolar cautery) without
clamping across the base of the pedicle (Fig. 90-9),
thereby minimizing the risk of excess traction on the
posterior orbital vessels that might result from manipu-
lation of the hemostat.
Simple interrupted sutures can be placed in the
incision lateral to the lateral canthus (Fig. 90-10) to
better manage tension at the closure line in this part of
the wound. The remainder of the upper lid incision is
closed with running 6-0 monofi lament pullout subcu-
ticular suture (Fig. 90-11). Any gaps in the closure
should be addressed with an additional simple stitch of
interrupted 6-0 fast-absorbing gut suture. Mastisol and
small Steri-Strips are used to anchor the medial and
lateral extent of the suture.
Figure 90-6. Excision of a thin strip of orbicularis oculi muscle in
the midportion of the upper eyelid wound.
Figure 90-7. Opening of the orbital septum over the medial upper
eyelid fat compartment.
Figure 90-8. Teasing orbital fat through the orbital septum (upper
eyelid lateral compartment).
Figure 90-9. Bipolar cautery (seen at the corner of the photo) is
used to cauterize across the base of the fat pad, which is then carefully
excised.

Chapter 90
Blepharoplasty
861
The subcuticular suture is removed at a follow-up
appointment about 5 days postoperatively. A represen-
tative preoperative patient photo and postoperative
result are seen in Figure 90-12.
Lower Lid Blepharoplasty
Preoperative evaluation of the lower lids is essential in
determining the type of operation most appropriate for
each patient. One should evaluate and record the
amount of excess fat in each of the lower lid compart-
ments (medial, central, and lateral), the amount of
excess skin of the lower lids, the presence or absence
of orbicularis hypertrophy, the extent of fi ne skin wrin-
kling, and the degree of lower lid laxity.
In patients with minimal excess skin, the transcon-
junctival approach3 to the lower lids is preferred. The
transconjunctival approach eliminates the “rounding”
deformity often found in the lateral aspect of the lower
lid after the traditional transcutaneous approach. It also
minimizes the chance of lower eyelid retraction devel-
oping (scleral show and frank ectropion). A mild tri-
chloroacetic acid (TCA) chemical peel can be used
as an adjunct to transconjunctival blepharoplasty. In
patients with signifi cant excess skin of the lower lid or
those who already have lower lid deformities secondary
to lid laxity that require correction, a transcutaneous
approach4 is used with a subciliary incision and eleva-
tion of a skin-muscle fl ap.
Figure 90-10. Interrupted stitches are used to close the wound
lateral to the lateral canthus.
Figure 90-11. Closure of the remaining incision with a subcuticu-
lar stitch.
Postoperative Management
The patient applies ice-cool compresses to the eyes
during the fi rst 24 to 48 hours. Many patients have
found small bags of frozen peas to be an excellent
source of cool compresses. The frozen peas are in
plastic bags, they conform well to the face and eyes, and
they hold the cool temperature for a prolonged period.
In addition, they can be refrozen and reused for this
purpose.
Patients are told preoperatively that their eyes will
swell and bruise during the fi rst few days postopera-
tively. Liquid tears are used for daytime dryness of the
eyes if needed, and Lacri-Lube ointment can likewise
be used for nighttime protection if required. An oph-
thalmic antibiotic ointment is applied over the incisions
three times daily after gently cleaning the incisions with
a cotton swab soaked in hydrogen peroxide.
A
B
Figure 90-12. Preoperative (A) and postoperative (B) views of an
upper eyelid blepharoplasty patient.

862
Section 9
Plastic and Reconstructive Surgery
Transconjunctival Approach
Although this operation can be done under general
anesthesia, it is typically performed under local anesthe-
sia with intravenous sedation. Once the depth of seda-
tion is adequate, the conjunctivae are anesthetized with
0.5% topical ophthalmic tetracaine or proparacaine
hydrochloride solution, and corneal shields (green con-
tacts) are lubricated with ophthalmic ointment and
used to protect the cornea.
Lidocaine (1%) with 1 : 100,000 epinephrine is
injected via a 27- or 30-gauge needle in the conjunctiva
beneath the planned incision (Fig. 90-13) and percuta-
neously deep to the orbicularis overlying the orbital
septum of the lower lid to anesthetize and hydrodissect
the plane of dissection.
A wide double hook is then used to retract the
lower lid margin (Fig. 90-14). A conjunctival incision is
made with a needle-tipped cautery at a level 1 to 2 mm
below the tarsal plate (Fig. 90-15) and deepened to
divide the attachment of the lower lid retractors to the
inferior tarsus. Medially, the incision should stop short
of the punctum of the lacrimal duct to avoid inadver-
tent injury to the lacrimal canaliculi, and laterally the
incision is carried as far as necessary to provide ade-
quate exposure of the lower lid fat compartments.
A 5-0 silk or nylon traction suture is then placed
through the inferior conjunctival incision margin, with
a hemostat on the free ends of the suture. The hemostat
is passed over the patient’s forehead to retract the con-
junctiva and inferior retractors up over the cornea. This
provides countertraction for the dissection and protects
the underlying cornea as well. An assistant then uses a
wide double hook or a Desmarres retractor to retract
the lid side of the conjunctival incision (the superior
incision margin). Preseptal dissection (Fig. 90-16) is
then carried out to elevate the overlying skin and muscle
off the orbital septum down to the orbital rim with a
combination of sharp and blunt dissection. The orbicu-
laris can easily be separated from the septum by pushing
the muscle anteriorly and inferiorly with a cotton
swab. The dissection should be relatively quick and
avascular.
Once the fl ap is elevated, orbital fat should
be readily apparent behind the orbital septum (Fig.
90-17). Pressure on the globe will cause the orbital
fat to bulge forward; a small opening is then made in
the septum overlying the fat compartments to be
addressed.
The fat from each compartment is dealt with sepa-
rately. The fat is teased free from the surrounding fascia
and attachments with fi ne forceps in one hand and a
cotton-tipped swab in the other (Figs. 90-18 and 90-19;
lateral fat dissection not shown). Once the orbital fat
has been mobilized, one can resect the excess fat. As
with upper lid fat removal, a small amount of local
anesthetic should be injected into the base of the fat
pedicle before excision.
Figure 90-13. Injection of the lower eyelid conjunctiva (right
eye).
Figure 90-14. Eversion of the lower eyelid with a blunt double
hook to expose the conjunctiva before making an incision (right
eye).
Figure 90-15. Conjunctival incision (with needle-tipped electro-
cautery) just below the inferior edge of the tarsal plate (left eye). Note
the corneal protector in place.

Chapter 90
Blepharoplasty
863
extends above the plane of the inferior orbital rim
without traction; at this level one minimizes the risk of
injuring the inferior oblique muscle, which lies between
the medial and central fat compartments.
It is important to address each compartment indi-
vidually to avoid missing any of the fat pads. The medial
fat pad is distinguished from central or lateral fat by its
paler color. After adequate resection has been per-
formed, one should evaluate the resection by replacing
the lower lid in its anatomic position and examining
the lower lid with and without pressure on the globe. It
is important to re-explore any area that continues to
look prominent and to pay particular attention to bilat-
eral symmetry. With the patient in the supine position,
a slight concavity of the overall contour of the lid will
generally ensure a good result.
It is not absolutely necessary to close the conjunc-
tival incision. It will heal without problem even if left
unsutured. Alternatively, a single suture can be placed
Orbital fat
Tarsus
Conjunctiva
Orbicularis
oculi
Skin
Orbital
rim
Figure 90-16. Sagittal schematic view of the plane of dissection for
preseptal transconjunctival blepharoplasty. The arrow indicates the
level of the conjunctival incision, just below the inferior edge of the
tarsal plate. The dissection then proceeds (dashed line) toward
the inferior orbital rim in the plane between the orbicularis oculi and
the orbital septum overlying the orbital fat compartments.
Figure 90-17. After preseptal dissection in the plane between the
orbicularis oculi and the orbital septum, a Desmarres retractor placed
deep to the muscle exposes the orbital septum, through which one
can see the underlying orbital fat compartments (right eye). A bridle
suture is in place to retract the conjunctiva superiorly for corneal
protection.
Figure 90-18. Central compartment fat being teased though an
opening in the orbital septum with the aid of a cotton-tipped applica-
tor (right eye).
Figure 90-19. Medial compartment fat teased through an opening
in the orbital septum before removal (right eye).
A fi ne curved hemostat is placed at the base of the
mobilized fat, and small curved scissors are used for
sharp resection while leaving a small cuff of fat above
the hemostat. A cautery device is then used to coagulate
the cut edge of the fat. Alternatively, one can use bipolar
cautery across the base of the fat without a hemostat
and fi ne scissors to incise the cauterized stump and
excise the fat. With this technique one works slowly and
incrementally across the base of the fat to maximize
control and minimize the risk of bleeding. Adequate
resection is achieved by removing only the fat that

864
Section 9
Plastic and Reconstructive Surgery
in the incision to properly align the conjunctival wound,
but it should be placed lateral or medial to the corneal
limbus (corneal-scleral junction) to avoid any direct
corneal irritation from the suture. Fast-absorbing 6-0
catgut suture is used with an inverted buried knot. Pre-
operative and postoperative photos of a lower eyelid
transconjunctival blepharoplasty patient are seen in
Figure 90-20.
As one becomes more comfortable with the proce-
dure, small amounts of excess skin can be removed by
subciliary “pinch” excision at the same time if only a
minor amount of skin resection is needed, or a mild
35% TCA peel of the periorbital area can be used to
treat fi ne wrinkles.
Transcutaneous Approach
Transcutaneous lower lid blepharoplasty is reserved for
patients with large amounts of excess skin or hypertro-
phy of the orbicularis muscle that needs to be addressed,
as well as those with lower lid deformities secondary to
laxity that would benefi t from a lower lid suspension
procedure.
In patients with a signifi cant disparity in the amount
of excess skin and muscle, separate skin and muscle
fl aps are raised to the level of the infraorbital rims, and
the appropriate excesses are dealt with individually.
This is less common and probably accounts for no more
than 2% to 3% of all blepharoplasty patients. All other
transcutaneous blepharoplasty patients are treated with
B
A
Figure 90-20. Preoperative (A) and postoperative (B) views of a
lower eyelid transconjunctival blepharoplasty patient.
the standard skin-muscle fl ap technique that is described
later.
Markings
The lower eyelid incision parallels the lash line and is
placed 1.5 to 2 mm below it (Fig. 90-21). Adequate
access can often be achieved with an incision extending
medially only as far as the medial limbus of the cornea
and lengthening the incision further only if need be.
Beyond the lateral canthus, the incision angles slightly
downward and lateral, parallel to or in a lateral perior-
bital skin crease (crow’s foot), and extends about 5 to
7 mm. It is important to make this extension only as
long as needed to remove the redundant skin. The dis-
tance between the designed lateral extents of the upper
and lower incisions should be at least 5 to 7 mm.
Procedure
Although this operation can be done under general
anesthesia, it is typically performed under local anesthe-
sia with intravenous sedation. Once the depth of seda-
tion is adequate, the eyes are lubricated with ophthalmic
ointment. Lidocaine (1%) with 1:100,000 epinephrine
is injected along the proposed incision, as well as deep
to the preseptal orbicularis oculi, with a 27-gauge, 11/2-
inch needle.
A no. 15 blade is then used to incise through the
skin of the small extension beyond the lateral canthus
or along the entire subciliary incision, through skin
only. The incision lateral to the canthus is next deep-
ened to a submuscular (preseptal) plane (Fig. 90-22).
One can then blindly predissect or elevate inferiorly
and medially down to the orbital rim deep to the muscle
to separate the muscle from the septum beneath it with
fi ne scissors in a blunt spreading motion (Fig. 90-23).
Figure 90-21. The subciliary incision is marked approximately
2 mm below the lash margin and extends 5 to 7 mm beyond the
lateral canthus.

Chapter 90
Blepharoplasty
865
Small, sharp curved scissors are then tunneled medially
under the skin in the pretarsal area, superfi cial to the
orbicularis oculi, and the subciliary incision is com-
pleted through skin only.
At this point the dissection has involved skin only
in the pretarsal area, and the pretarsal orbicularis
muscle is left intact and not elevated. It is important to
leave the pretarsal orbicularis muscle intact to act as a
hammock and help support the lower lid to decrease
the likelihood of ectropion. The dissection in the pre-
septal area has thus far been deep to the orbicularis.
The planes of the skin-only elevation (pretarsal)
and the skin-muscle fl ap dissection (preseptal) are then
connected by incising the muscle below the tarsus,
approximately 3 to 5 mm from the lash line (Fig. 90-
24). A bridle suture is placed through the superior
incision margin or the gray line to retract the conjunc-
tiva cephalically for corneal protection (Fig. 90-25).
The skin-muscle fl ap is then elevated down to the level
of the infraorbital rim, and the entire orbital septum is
exposed. The fl ap can be retracted by an assistant with
a wide blunt double-ball hook (Fig. 90-26).
Small openings are made through the orbital
septum to facilitate dissection of fat from each compart-
ment (central, medial, and lateral) as needed (Figs.
90-27 and 90-28 show removal of fat from the central
and medial compartments, respectively). Fat removal
proceeds as previously described for preseptal transcon-
junctival lower lid blepharoplasty.
The skin-muscle fl ap is then redraped over the
lower lid lashes in an upward and slightly lateral direc-
tion (Fig. 90-29). If suffi ciently responsive at this point,
the patient is asked to open the mouth and to look
toward the top of the head. A cut is then made in the
Figure 90-22. On completion of the subciliary skin-only incision,
the segment beyond the lateral canthus is deepened to a submuscular
plane.
Figure 90-23. The initial blind submuscular dissection should
proceed easily, without encountering any resistance, through the
relatively avascular plane between the orbicularis oculi and the orbital
septum deep to it. The dissection is carried toward the inferior orbital
rim.
Figure 90-24. The muscle is incised below the level of the subcili-
ary incision with a “blade-in, blade-out” maneuver to connect the
skin-only pretarsal dissection with the submuscular elevation below
the tarsus.
Figure 90-25. A bridle suture is placed to retract the tarsus and
conjunctiva superiorly for corneal protection.

866
Section 9
Plastic and Reconstructive Surgery
skin-muscle fl ap at the level of the lateral canthus to the
point at which the excess skin meets the cut edge of the
infraciliary margin. That point is sutured with 6-0
Prolene, and the excess skin is effectively divided into
two triangles of excess skin—one medial and one lateral
to the canthus (Fig. 90-30). The surgeon next excises
the extra skin, fi rst the lateral triangle (Fig. 90-31) and
then the medial triangle (Fig. 90-32), so that there is
no tension on the skin closure. It is imperative that the
surgeon be conservative with skin excision from the
lower eyelid to minimize the risk of lid malposition. A
strip of orbicularis (several millimeters) is then excised
from beneath the upper margin of the skin-muscle fl ap
(Fig. 90-33)—failure to do so would result in overlap-
Figure 90-26. The skin-muscle fl ap is elevated and retracted toward
the inferior orbital rim to expose the orbital septum and the underly-
ing orbital fat compartments.
Figure 90-27. Delivery of fat from the central compartment.
Figure 90-28. Delivery of fat from the medial compartment.
Figure 90-29. The skin-muscle fl ap is redraped over the infraciliary
incision.
Figure 90-30. An incision is made in the fl ap at the lateral canthus
as far as the edge of the infraciliary incision, and that point is secured
with 6-0 Prolene suture, thereby effectively dividing the skin excess
into two separate triangles—one medial and one lateral to the
canthus.

Chapter 90
Blepharoplasty
867
ping of this muscle over the pretarsal orbicularis that
was not elevated.
After hemostasis is verifi ed, a fl ap suspension suture
of 5-0 PDS is placed to support the position of the lower
lid through the healing period.5 The orbicularis under
the skin-muscle fl ap is grasped medial to and below the
lateral orbital tubercle (Whitnall’s tubercle) and sus-
pended with a buried inverted suture to the periosteum
at the lateral orbital tubercle. It is important to get a
good bite of periosteum and also to ensure suffi cient
purchase on the muscle without dimpling the overlying
skin. The skin edges at this point should lie in easy
approximation (Fig. 90-34) to allow closure without
tension. The wounds are then closed with interrupted
7-0 Prolene suture lateral to the canthal angle and inter-
Figure 90-31. Excision of excess skin lateral to the lateral
canthus.
Figure 90-32. Excision of the excess triangular skin medially.
Figure 90-33. Excision of a thin strip of orbicularis muscle from
beneath the skin-muscle fl ap edge to prevent muscle beneath the fl ap
from overlapping the pretarsal muscle, which was preserved.
Figure 90-34. Skin-muscle fl ap blepharoplasty, just before skin
closure with easy tension-free approximation of skin edges.
rupted or running 6-0 fast-absorbing gut suture along
the subciliary portion of the incision. Preoperative and
4-month postoperative photos of a patient who under-
went a lower eyelid skin-muscle fl ap blepharoplasty are
seen in Figure 90-35.
Postoperative Management
Postoperative management of a patient after lower lid
blepharoplasty is similar whether done via the transcon-
junctival or the transcutaneous approach and not unlike
that of the upper lids. The only difference is that if a
transconjunctival approach is used for the lower lids, an
ophthalmic antibiotic drop with steroid (e.g., Tobra-
Dex) is applied for the fi rst 5 days postoperatively.
Patients are instructed to not wear contact lenses for at
least 1 week after surgery.

868
Section 9
Plastic and Reconstructive Surgery
A
B
Figure 90-35. Preoperative (A) and postoperative (B) views of a
lower eyelid skin-muscle fl ap blepharoplasty patient.
COMPLICATIONS6
Corneal Injury
The best treatment of corneal injuries is prevention.
Lubrication should be placed in the eyes to prevent
desiccation during surgery. Shields can be worn during
blepharoplasty to protect the cornea, and the surgeon
should be cautious about the use of abrasive gauze near
the cornea.
Pain in the eye is a warning sign of a corneal injury.
If any concern exists postoperatively regarding possible
corneal injury, evaluation by an ophthalmologist is rec-
ommended. Fluorescein staining can be used for diag-
nosis, and treatment includes ophthalmic antibiotic
ointment and maintenance of the eye at rest with an
occlusive dressing until healing is complete.
Wound Separation
Sutures are typically removed on or before the fi fth
postoperative day. Infrequently, the lateral aspect of the
wound may begin to separate, and this should be cor-
rected with Steri-Strips or the wound should be resu-
tured if necessary.
Asymmetries
Not uncommonly, postoperative asymmetries will refl ect
unrecognized preoperative asymmetries in excess lid
skin or asymmetric preoperative brow position. Noting
such asymmetries and discussing them with the patient
preoperatively will often make minor postoperative asym-
metries acceptable. If a brow procedure is not indi-
cated, asymmetric skin excision may be necessary in an
attempt to avoid postoperative differences between the
two sides. Asymmetry in fat excision can also be appar-
ent postoperatively. Again, attention to detail intraop-
eratively will help avoid such problems. If asymmetry
persists after several months postoperatively, revision
surgery will be necessary.
Dry Eyes
Possible causes of dry eyes include an unrecognized
preoperative condition, injury to the lacrimal gland
(uncommon), excessive skin resection, and edema. By
far postoperative edema is the most common cause and
should settle over a 1- to 3-week period postoperatively.
The interim use of artifi cial tears and lubricating oint-
ments is important to help prevent keratitis. Excessive
skin resection will ultimately require repair with a full-
thickness skin graft replacement.
Epiphora
Excess tearing from the eyes is common during the
fi rst 48 hours postoperatively. It is usually due to edema
of the skin or temporary muscular atony, which can
then impair the function of the tear drainage system.
The epiphora usually resolves as the swelling subsides.
Intermittent episodes may persist with changes in
weather. Other possible causes include eversion of
the punctum (secondary to either edema or ectro-
pion—see later) or, less commonly, injury to the
canaliculus.
Lagophthalmos
Patients are often unable to completely close their eyes
because of edema in the immediate postoperative
period. Most commonly, lagophthalmos is due to imme-
diate postoperative edema. It is treated with lubricating
ointments and time. If this condition is secondary to
over-resection of upper lid skin, desiccation can lead to
corneal injury. In such cases, release of the upper lid
along with skin grafting must be considered. Again, the
best treatment is prevention, which is why it is impera-
tive to measure the amount of skin to be resected (via
the aforementioned pinch technique) several times
before making any skin incisions.
Ptosis
Temporary “pseudoptosis” secondary to swelling is not
uncommon in the fi rst postoperative week. Persistent
ptosis suggests injury to the levator expansion during
opening of the orbital septum. The levator apparatus is
most at risk in the inferior portion of the wound where
the surgeon is closest to the upper border of the tarsal
plate, the point at which the levator fuses with the
orbital septum. Any excision of muscle or opening of
the septum is safest if one stays away from the lower
portion of the wound after excision of skin. Persistent

Chapter 90
Blepharoplasty
869
ptosis should be corrected by reinsertion of the levator
into the tarsus or dermis.
Extraocular Muscle Injury
The inferior oblique muscle lies in a vulnerable posi-
tion between the medial and central fat compartments
of the lower lid. It should be looked for in every case,
although it is not always seen. Being alert to the location
of the muscle, however, will help avoid inadvertent
injury. Care must be taken to avoid clamp, Bovie, or
sharp injury to this muscle during fat dissection and
resection. If immediately identifi ed, the transected ends
should be approximated. Diplopia on upward lateral
gaze is indicative of injury to the muscle. Persistent
postoperative diplopia that lasts longer than 1 or 2
weeks should be evaluated by an oculoplastic surgeon
for appropriate care.
Lower Lid Malposition
Temporary excess “scleral show” in the immediate post-
operative period may be due to edema and temporary
paresis of the orbicularis oculi muscle. It will often
resolve in the perioperative period as the edema lessens
and the muscle reinnervates. Treatment of any chemo-
sis includes topical steroids and prevention of exposure
keratitis. Massage of the lower lid in an upward and
outward direction will also help. Often, tape support of
the lower lid during the early postoperative period will
lessen the degree of scleral show.
Unrecognized preoperative lower lid laxity may
also contribute to postoperative ectropion. In such
cases, secondary canthopexy or canthoplasty may be
required. If the ectropion is due to overaggressive skin
resection, secondary surgery to correct the deformity
with scar release and full-thickness skin grafting may be
necessary after several months of observation and con-
servative management.
The best means of treatment is prevention. The
transconjunctival approach avoids the contraction asso-
ciated with healing of the skin and muscle incisions
used for the infraciliary approach. In addition, patients
with any degree of laxity who require skin excision via
an infraciliary approach should be considered for pro-
phylactic lateral canthopexy.
Retrobulbar Hematoma/Visual Loss
Retrobulbar hematoma is the most feared complication
after routine blepharoplasty. The most likely cause is a
vascular injury with retraction of the bleeding vessel
into the retrobulbar space. The eye becomes fi rm,
chemotic, and progressively more proptotic. The lids
cannot close as the globe continues to bulge outward.
Progressively increasing intraocular pressure can lead
to ophthalmoplegia, ischemia of the optic nerve, and
visual loss. A retrobulbar hematoma generally develops
within the fi rst 4 to 6 hours postoperatively, and prompt
diagnosis and management are critical to prevent per-
manent visual loss.
Initial treatment involves opening of incisions; iced
saline compresses; 20% mannitol (2 g/kg) as an osmotic
agent to decrease intraocular pressure; acetazolamide
(Diamox)
500 mg
intravenously;
dexamethasone
(Decadron) 10 mg intravenously; control of hyperten-
sion (if present); head elevation; and correction of
any coagulopathies. Visual acuity should be evaluated
frequently.
Any deterioration in visual acuity is an urgent sign
and, when coupled with elevated intraocular pressure,
signifi es potential optic nerve ischemia. In this situa-
tion, in addition to removal of all external sutures,
lateral canthotomy and inferior cantholysis are
indicated on an emergency basis to facilitate orbital
decompression. Emergency ophthalmic consultation
is necessary but should not delay performance of
canthotomy and cantholysis if faced with visual
compromise.
PEARLS
• A well-considered preoperative evaluation of the
upper and lower eyelids, including assessment of
orbital fat, skin, lid laxity/tone, and brow position,
and a general medical and ophthalmic history are
essential for guiding decisions regarding the surgical
approach and extent of surgery.
• Conservatism is always warranted with eyelid
surgery. It is always easier to do more at a later date
if necessary, but complications resulting from
overaggressive eyelid surgery can be very diffi cult to
correct.
• For upper eyelid surgery, preoperative skin markings
should be checked and rechecked to avoid excessive
excision of skin.
• Absolute hemostasis is necessary to minimize the
possibility of postoperative retrobulbar hematoma.
• The risk of lower eyelid malposition is much lower
with a transconjunctival approach.
PITFALLS
• Failure to consider brow position as it relates to any
apparent excess of upper eyelid skin may still leave
patients with a somewhat hooded appearance or
“crowded” upper periorbital region. In patients in
whom the primary problem is brow ptosis, it should
be addressed either instead of or in addition to
upper blepharoplasty.
• Opening the orbital septum low toward the tarsal
plate in the upper eyelid increases the risk for injury
to the levator aponeurosis and iatrogenic ptosis.
• Overaggressive surgery or fat removal, whether from
the upper or lower eyelids, can create a hollowed,
gaunt appearance in addition to functional
complications such as lagophthalmos and eyelid
malposition.

870
Section 9
Plastic and Reconstructive Surgery
References
1. Kontis TC, Papel ID, Larrabee WF: Surgical anatomy of the eyelids.
Facial Plast Surg 10:1-5, 1994.
2. Pastorek N: Upper lid blepharoplasty. Facial Plast Surg Clin N Am
3:143-157, 1995.
3. Perkins SW: Transconjunctival lower lid blepharoplasty. Facial
Plast Surg Clin N Am 3:175-187, 1995.
4. Smullen SM, Mangat DS: Cosmetic lower eyelid surgery: Transcu-
taneous approach. Facial Plast Surg Clin N Am 3:167-174, 1995.
5. Pastorek NJ: Blepharoplasty update. Facial Plast Surg Clin N Am
10:23-27, 2002.
6. Adamson PA, Constantinides MS: Complications of blepharo-
plasty. Facial Plast Surg Clin N Am 3:211-221, 1995.
• Patients with a very prominent, protrusive globe
(“pseudoproptosis”) in which the corneal plane lies
anterior to the inferior orbital rim on lateral view—
the so-called negative vector—are at high risk for
postoperative eyelid malposition with lower lid
transcutaneous approaches.
• Lack of attention to hemostasis through every step
of the operation may result in injury to important
structures (e.g., levator aponeurosis, lacrimal gland,
tarsal plate, inferior oblique muscle) or worse,
retrobulbar hematoma.

Chapter 91
Soft Tissue Trauma
Bernard J. Costello and John F. Caccamese, Jr.
Facial injuries account for a signifi cant number of
emergency department visits each year, with 50% to
70% of these injuries having a soft tissue component.1,2
Repair plus reconstruction of facial injuries is a highly
specialized endeavor best treated by those with experi-
ence and a comprehensive understanding of the mech-
anism of injury, the complex anatomy of the region,
and the physiologic and psychosocial impact that some
injuries have. Most patients have a high level of expecta-
tion that after treatment their appearance will be largely
unchanged from their preinjury state. Unfortunately,
regardless of the skill of the surgeon, this is sometimes
not the case because of the severity of the injury. A
recent survey prioritized cosmetic outcome, more so
than function, as the single most important factor to
patients with facial lacerations.3 This chapter reviews
the basic concepts important in the repair and recon-
struction of soft tissue injuries of the face.
EVALUATION
Evaluation of soft tissue injuries of the face begins much
the same as for any injured state. The primary and sec-
ondary surveys are performed, at which time other inju-
ries might be recognized. At times, airway protection is
needed because of the complexity of the injury or
massive bleeding involving the airway. Tracheotomy or
cricothyrotomy is considered for patients with severe
injuries that prohibit intubation or when extensive
edema is anticipated, such as with severe avulsion or
blast injuries of the oral cavity.
Initial stabilization occasionally requires control of
hemorrhage. In the facial region, pressure dressings
usually suffi ce for such purposes; however, larger vessel
and arterial bleeding will require ligation. Blind appli-
cation of clamps is discouraged because there are mul-
tiple structures of importance, such as the facial nerve,
within the deep tissues.
After stabilization, a detailed examination of the
craniofacial skeleton and soft tissues is performed. In
addition, the superfi cial structures of the face (e.g.,
eyelids, nose, ears), deep structures such as the parotid
gland and duct, facial nerves, and the lacrimal gland
and its drainage system must be carefully examined in
a systematic fashion. Imaging is then used to further
delineate the injuries, because facial fractures are
common in patients who have sustained soft tissue
trauma to the face. Injuries may then be managed
defi nitively, as in simple lacerations, or expectantly, as
in crush and blast injuries. Severe crush or blast injuries
are often subject to further soft tissue necrosis and leave
a more signifi cant wound than that seen at initial
examination.
PREPARATION
Preparing the sites for repair and reconstruction is
important for both defi ning the extent of injury and
preventing complications. Most facial wounds should
be closed within 24 hours to avoid an increased risk for
infection. The rich vascular supply of the region affords
the surgeon some latitude in the management of these
injuries that is not seen with extremity wounds or other
less vascularized regions. Perioperative intravenous
antibiotics should be considered for contaminated
wounds and those exposed to sinus and oral fl ora.
In preparation for closure, wounds should be thor-
oughly cleansed with sterile saline, and pulsatile irriga-
tion systems should be considered if the wound is grossly
contaminated with debris. Most wounds will be clean or
clean-contaminated with little chance for infection if
irrigated appropriately and empirical perioperative
antibiotics are selected according to the expected con-
taminants. However, for grossly contaminated wounds,
consideration should be given to a prolonged course of
antibiotics.
After thorough preparation, the wound should be
rendered hemostatic, again using local measures, suture
ligation, and electrocautery when appropriate. Bipolar
cautery is helpful in areas where motor nerves may be
871

872
Section 9
Plastic and Reconstructive Surgery
present. Débridement of the wound is accomplished
when necessary, and hemostasis is achieved again.
Removal of debris that is both large and small is impor-
tant for healing, as well as for cosmesis of the area. Fine
particles left embedded in the epidermis and dermal
layers may cause tattooing, which is more diffi cult to
manage secondarily. Aggressive removal of these parti-
cles with a nail brush, individually with a no. 11 blade,
or by primary dermabrasion is recommended in most
cases because secondary removal tends to be less suc-
cessful and may be more damaging.
CLASSIFICATION OF INJURY AND
MANAGEMENT TECHNIQUES
Types of Injury
Lacerations
Lacerations of the superfi cial and deep soft tissues of
the face occur in an assortment of patterns and with
varying complexity. The term laceration implies that all
tissues are present but disrupted, so primary closure is
usually uncomplicated. However, lacerations vary
greatly, depending on the mechanism of injury. The
shearing action involved in a dog bite injures the tissues
in a much different manner than does the clean cut of
a sharp blade. Moreover, the mechanism and severity
of injury have implications with regard to the fi nal aes-
thetic result. Planning closure of the laceration requires
consideration of the patient’s healing capabilities, tissue
quality, and orientation of the laceration in relation to
the relaxing skin tension lines (RSTLs).
Simple linear lacerations are easily repaired if par-
ticular attention is paid to reapproximation of the deep
layers, obliteration of dead space, and orientation of
the wound to the RSTLs. In simple lacerations, revision
is not usually necessary unless excessive scarring occurs
or if the wound directly opposes the RSTLs, which may
benefi t from reorientation. Stellate lacerations are gen-
erally the result of shearing, blunt, or explosive forces
that crush and break the skin in multiple directions and
thus naturally violate the RSTLs with multiple fl aps of
varying depth and irregularity. The force often results
in contused and necrotic wound edges, which at times
culminates in further tissue loss. A combination of
blood, clot, edema, and elastic retraction of the skin
edges often gives the appearance of an avulsion injury.
However, after meticulous cleansing the true extent of
the wound can be appreciated. Débridement of these
wounds should be sparing but complete because the
vascular supply is generally good and aesthetic results
are best with minimal débridement.
Repair of lacerations requires precision and atten-
tion to detail when they are present in such a conspicu-
ous place as the face. A variety of techniques are used
when closing lacerations of the facial tissues (Fig. 91-1).
Several basic concepts warrant discussion when consid-
ering selection of the repair technique:
1. Tension-free closure. A tension-free closure minimizes
scarring and is achieved by ensuring that the deeper
layers of the closure provide enough tensile strength
to allow reapproximation of the epidermis without
undue tension. Suture marks are more likely to
occur when a wound is closed under tension at the
epidermal level. Precisely placed sutures are helpful
in preventing this problem. A well-performed deep
closure will also allow early removal of skin sutures,
thereby further preventing epithelialization of the
suture tract, which leads to suture marks.
2. Wound eversion. Placement of sutures to evert the
superfi cial layers is important in obtaining an aes-
thetic result. Eversion should be explained to patients
so that they will understand that fl attening should
occur with time. Repairs that are neutral or inverted
have a tendency to contract and invert further during
the initial healing phases. Scarring that is depressed
is much more noticeable.
3. Anatomic placement of sutures. Attention to anatomic
layers with symmetry and precise placement contrib-
utes to a wound that heals in a more predictable and
aesthetic manner.
Contusions
Contusions exhibit bruising and swelling, as well as
hematoma formation when subcutaneous vessels
rupture. Contusions may indicate an underlying
fracture, such as on the chin (e.g., subcondylar mandi-
ble fractures), and spectacle hematomas of the perior-
bital tissues (e.g., orbitozygomatic fractures). Most
contusions require no treatment other than for symp-
tomatic relief of pain and swelling, such as the applica-
tion of ice, elevated head positioning, and analgesics.
However, severely contused laceration edges should
also be sharply débrided if it is likely that these areas
may break down later because of the extent of the
trauma.
Abrasions
Abrasions are superfi cial wounds of the skin and mucosa
and involve loss of superfi cial epithelium with exposure
of the underlying dermis or submucosa. Injuries of
greater depth tend to be grouped with avulsions.
Healing occurs by rapid re-epithelialization (0.5 mm/
day) and typically requires only supportive care. Initial
débridement and tissue cleansing may be of benefi t
when the skin is embedded with road debris or has been
subject to powder burns. Failure to cleanse the wound
may potentiate traumatic tattooing, which occurs when
wound healing takes place with embedded debris.
Thorough cleansing with a brush usually accomplishes
this quite well, but primary or secondary dermabrasion
is sometimes necessary. Other adjuvant materials can be
used to facilitate the healing process and prevent the
accumulation of fi brinous plaque, such as antibiotic
ointments, nonadherent dressings, and silicone gel
sheeting. It should be noted that to date, few data have
demonstrated signifi cant aesthetic improvement with
the use of these materials; however, in the author’s
experience, for large abrasions, these dressings decrease
crusting and make wound care less painful.

Chapter 91
Soft Tissue Trauma
873
A
B
C
D
Figure 91-1. A, Simple interrupted sutures should be placed evenly and far enough
away from the laceration edge that eversion of the skin edge is achieved. B, A simple
continuous suture may be used for lacerations that are easily approximated. C, Hori-
zontal mattress sutures are rarely used on skin but may be used for wounds that require
extra strength, such as avulsions or gunshot wounds, and are expected to require revi-
sion. The surgeon must remember to avoid tying the sutures too tight or the blood
supply to the margins of the laceration will be constricted. D, Running subcuticular
sutures may be used in wounds that are well approximated and cleanly lacerated. A very
aesthetic closure can be achieved if the wound edges are everted appropriately. (Redrawn
from Laskin DM [ed]: Oral and Maxillofacial Surgery, vol 1. St Louis, CV Mosby, 1980, pp
277-280.)
Burns
Facial burns range from superfi cial to full thickness,
depending on the cause and duration of the exposure.
Facial burns occur in approximately one half of all
patients admitted to the burn unit. Although most facial
burns are superfi cial, deep partial-thickness or full-
thickness burns do occur, and the facial anatomy is
inexorably altered. Primary reconstructive efforts are
focused on preservation of function with the under-
standing that achieving an aesthetic preinjury result is
challenging. Large areas of skin loss are sometimes
replaced with split-thickness skin, but it is a poor sub-
stitute for facial skin and specialized structures such as
the eyelids and lips. Serial excision, local fl aps, and free
tissue transfer are also options, depending on the burn
site.4
Trapdoor and Circular/Pedicled Lacerations
“Trapdoor” lacerations result in a soft tissue fl ap that pre-
sents healing dilemmas because of the beveled nature of
the fl ap, which then results in a pincushion deformity.
The traumatic event creates varied wound depth that
often requires additional undermining of the opposing
side of the laceration to properly layer the closure and
evert the edges. Freshening of the edges is also com-
monly needed to provide opposing parallel surfaces in
the same tissue plane to better distribute contractile
force during the healing period. Small Z-plasties along
the circumference of a trapdoor wound may be helpful
in avoiding less than ideal contraction, scarring, and
contour deformities; however, this technique should be
attempted only when one is sure that the injury does not
have a signifi cant contusive element.

874
Section 9
Plastic and Reconstructive Surgery
Bite Wounds
Treatment of bite wounds merits separate discussion
because they are often complex wounds with features
of lacerations, avulsions, and contusions concomitant
with polymicrobial contamination. The crushing force
delivered by the dog’s jaw often results in widespread
tissue injury that is grossly contaminated with up to 64
species of bacteria.5 Antibiotics are always considered in
the management of bite wounds because the contami-
nation is usually polymicrobial in nature. Penicillins
and cephalosporins are generally effective in treating
the predominantly gram-positive fl ora.
Children younger than 10 years are most frequently
the victims of facial dog bites, largely because dogs have
easy access to a child’s face.6,7 The lips, nose, and cheeks
are the most commonly injured structures and some the
most challenging to reconstruct.8,9 Conservative débride-
ment and aggressive cleansing should be undertaken
promptly, followed by primary closure when appropri-
ate. Defi nitive reconstruction with local or distant tissue
can be carried out once the zone of necrosis has become
evident and the wound is suffi ciently clean (Fig. 91-2).
Puncture wounds are often left unclosed.
Though uncommonly encountered in the United
States, rabies must always be considered with animal
bites, especially with unprovoked attacks or bites from
high-risk animals. Raccoons and bats carry the disease
with the greatest frequency in the United States,
although foxes, skunks, and wild dogs are also consid-
ered high risk. Human rabies immune globulin and
vaccine are recommended for bites and exposures, irre-
spective of the time between exposure and treatment,
unless the individual has previously been vaccinated
and rabies antibodies can be detected. The vaccine
takes 7 to 10 days to induce an immune response, and
immunity lasts approximately 2 years. The vaccine is
injected into the deltoid region at a dose of 1 mL
on days 0, 3, 7, 14, and 28. Rabies immune globulin
(20 IU/kg) is administered with as much of the dose as
possible infi ltrated in and around the wound (location
permitting) and the rest given intramuscularly in the
gluteal region with a needle of suffi cient length to
ensure intramuscular injection. The syringes and
needles used for vaccine and immune globulin should
be different. The tetanus vaccination status of the
patient should also be ascertained, and appropriate
administration of either tetanus vaccine or tetanus
immune globulin should be completed (Table 91-1).10
Avulsions
Avulsions occur as a result of a high-energy or shearing
injury, such as motor vehicle trauma, a gunshot, or an
animal bite. For small wounds, adjacent tissue can be
mobilized and advanced for primary closure. However,
these injuries can be some of the greatest challenges to
the facial trauma surgeon. Flaps that can be revascular-
ized should be replanted when possible. When tissue
loss is imminent because of the severity of trauma or
delay in treatment, avulsive injuries may benefi t from a
period of observation with serial débridement and
dressing changes to ensure adjacent tissue viability
before defi nitive reconstruction. Typically, wound
necrosis is evident within a few days to weeks and recon-
struction can then be completed. Avulsion of special
structures such as the ear and scalp may require salvage
with microvascular replantation techniques. Other
large defects may call for the recruitment of distant
pedicled or microvascular fl aps after a period of obser-
vation and expectant wound management (Fig. 91-3).
Finally, primary skin grafting, followed by secondary
revision (i.e., tissue expansion with local fl ap rotation,
serial graft excision, free fl ap reconstruction), contin-
ues to remain a good option in many complex wounds
rather than depending on healing by secondary inten-
tion, which can lead to extensive scar contraction.
Gunshot Wounds
Firearm injuries are common in countries that do not
have strict gun control laws. A detailed discussion of the
complexities of gunshot wounds is beyond the scope of
this chapter, but the basic concepts presented here are
important to recognize. A variety of injury patterns can
be expected depending on the type of projectile. Low-
velocity weapons such as pellet guns may cause limited
local damage, whereas high-velocity projectiles may
disrupt tissue along a defi ned vector. Various projectiles
are designed with differing degrees of soft and hard
tissue damage capability. Most of these injuries depend
on how the projectile passes through tissue, including
tumble, yaw, and other physical properties. Projectiles
with higher velocity and a propensity to twist, fragment,
and turn through tissue will produce more signifi cant
damage. Additionally, bone and tooth fragments
become secondary projectiles that tend to increase the
fi eld of injury. The blast injury that occurs with the
initial trauma varies according to these projectile char-
acteristics but is often not apparent for days after the
injury. The greater the injury capability of the projec-
tile, the longer the surgeon should wait to consider
defi nitive reconstruction. A certain degree of additional
tissue necrosis will occur in a delayed fashion, depend-
ing on these characteristics, and expectant wound man-
agement is advisable. The ultra high-velocity weapons
used in combat may cause particularly devastating injury
to the facial soft tissues and skeleton. Reconstruction
may include local, regional, or free tissue fl aps, depend-
ing on the degree of injury. Revision may be expected
in more signifi cant injury.
Several key concepts are important to remember
when closing complex wounds such as gunshot
wounds:
• Layered closure prevents tension on the wound at the
epidermal level, which will decrease scarring poten-
tial. All dead space should be closed with an anatomi-
cally layered closure. This is particularly important
for the random-pattern fl aps that may be developed
as rotation or advancement fl aps for local closure of
small to medium-sized defects.
• Débridement is important for successful healing of
the wound, but the surgeon should remember that

Chapter 91
Soft Tissue Trauma
875
A
C
D
E
B
Figure 91-2. A, Clinical photo showing a young girl after being bitten multiple times
by her dog. B, Magnifi ed view showing that 50% of the superfi cial lip was avulsed to the
commissure. C, Layered closure yields an aesthetic repair by closing muscle, mucosa, and
skin independently. D and E, One year after the injury.
because the face is very vascular, aggressive débride-
ment is often not necessary. Tissues that are mini-
mally contused do not generally need to be débrided.
Small irregular edges should be excised and simpli-
fi ed in most cases.
• RSTLs are helpful in planning local fl ap recruitment.
A more aesthetic result is obtained when the fl aps can
be designed to allow incisions, backcuts, and dog-ear
repairs to fall within the RSTLs.
Anesthesia
In most instances, local anesthesia, when appropriately
applied, is suffi cient to allow complete closure of the
wounds typically seen in the emergency department.

876
Section 9
Plastic and Reconstructive Surgery
Particularly complicated wounds or wounds in small
children will often require sedation or general anesthe-
sia. The benefi ts of general anesthesia in the operating
room are evident when caring for complicated wounds
because better instrumentation and lighting are readily
available.
It is helpful to be profi cient in local anesthetic
blocks of the trigeminal system when repairing wounds
of the face. Frequently, large areas can be profoundly
anesthetized when blocking the region with a precisely
placed local anesthetic. Generally, 1% lidocaine with
1:100,000 epinephrine is used and provides profound
anesthesia in the area of repair. One must consider the
maximal allowable dose in individuals who require
other procedures concurrently or have extensive lacera-
tions requiring multiple injections. Such consideration
is particularly important in small children because it is
not diffi cult to reach the maximal allowable dose with
what seems to be a small volume of anesthetic. Nerve
blocks can be helpful in these patients inasmuch as less
volume is required to achieve profound anesthesia.
One must also make sure that facial nerve function has
been thoroughly evaluated when anesthetizing lateral
face wounds, because exploration and primary repair
may be warranted before wound closure.
Suture Materials
A variety of sophisticated materials are available to the
surgeon for repair and reconstruction of soft tissue
injury, and understanding their capabilities and han-
dling characteristics is important (Table 91-2). Both
nonresorbable and resorbable materials are available in
a variety of sizes and with a variety of needle types.
Deeper layers are best reapproximated with longer-
lasting resorbable suture that is braided. Suture strength
and the rate of degradation should anticipate forces
placed on the wound particular to the anatomic locale
and provide enough tensile strength to support the
wound and allow complete healing. Subcutaneous and
deep dermal sutures are best placed with the knot buried
and the use of resorbable suture. Skin is best reapproxi-
mated with nonresorbable monofi lament suture at least
5-0 or smaller in size. It is often convenient to consider
resorbable material in pediatric patients because they
may require an additional anesthetic or involuntary
restraint to remove simple sutures. These materials may
have slightly more reactivity and cause additional infl am-
mation at the healing site. Staples may be used in less
cosmetic areas such as scalp wounds.
Needles come in a variety of shapes and sizes as
well. The skin is best sutured with a cutting needle to
minimize trauma to skin during placement. Most deep
tissues and mucosa are best approximated with tapered
or combination needles to minimize trauma to tissues.
Keratinized mucosa such as the palate or gingiva may
be closed with a cutting needle.
Figure 91-3. Massive facial avulsion involving the eyelids, nasal
complex, upper and lower lips, and check after a motor vehicle crash
in which this young child was not restrained. It is important to note
damage to the globe, lacrimal system, facial nerve, salivary glands, and
nasal drainage system for the sinuses in such complex injuries. Com-
posite soft tissue grafting with microvascular techniques can be used
either immediately or as a staged procedure.
Table 91-1
PROTOCOL FOR PROPHYLAXIS OF WOUNDS FOR TETANUS
Tetanus Toxoid Vaccination Status
Clean and Minor Wounds
All Other Wounds
Td
TIG
Td
TIG
Unknown or less than 3 doses
Yes
No
Yes
Yes
3 or more doses
No*
No
No†
No
*Yes if more than 10 years since the last dose.
†Yes if more than 5 years since the last dose.
Td, tetanus and diphtheria toxoids; TIG, tetanus immune globulin.
Adapted from Diphtheria, tetanus, and pertussis: Recommendations for vaccine use and other preventive measures. Recommendations
of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep 40(RR-10):1-28, 1991.

Chapter 91
Soft Tissue Trauma
877
Adequate instrumentation and lighting are essen-
tial for accurate surgical closure. Delicate needle holders
and fi ne pickups are helpful to approximate tissue in a
detailed and atraumatic fashion. Fastidious tissue han-
dling is also crucial for an aesthetic closure. Excessive
epidermal handling with tissue forceps can result in
crush injury to the skin edges. Picking up tissue in the
deep and subcutaneous planes minimizes trauma to
the epidermis and improves superfi cial healing. The
surgeon should be comfortable with all forms of hand
and instrument ties, as well as suture-placing techniques.
Mastering these techniques is essential to providing a
superior closure.
Cyanoacrylate Tissue Adhesives
When applied carefully, the use of tissue adhesives for
closure of wounds is both cost-effective and effi cient.
Their effi cacy for strength of closure and cosmesis has
been demonstrated in the literature.11,12 Two main cya-
noacrylate-based tissue adhesives are available for trau-
matic wound closure, butyl-2-cyanoacrylate (Histoacryl,
Braun, Germany) and 2-octylcyanoacrylate (Derma-
bond, Ethicon, Somerville, NJ). The 2-octyl polymer
was created to avert some of the shortcomings of its
predecessor. Butyl-2-cyanoacrylate maintains only 10%
to 15% of the wound strength of 5-0 monofi lament on
closure day 1; however, its strength was equivalent on
days 5 to 7. 2-Octylcyanoacrylate, in contrast, has roughly
three times the three-dimensional breaking strength of
butyl-2-cyanoacrylate, which compares more favorably
with conventional wound closure.
Cyanoacrylate tissue adhesive can be used topically
to close skin lacerations on its own, or it can be used
along with deep sutures. Deep dermal sutures can be
placed to obtain proper wound edge eversion. As with
suture techniques, everting the wound edges is essential
to the cosmetic success of skin closure with tissue adhe-
sives, because eversion helps alleviate the effects of scar
widening. Skin apposition should be maintained with
forceps or fi ngers regardless of whether deep sutures
are used during the application. For optimal results,
multiple thin layers should be applied over the epider-
mis and allowed to dry for approximately 10 to 30
seconds. This technique prevents pooling and running
of the tissue adhesive, which can lead to signifi cant
complications in certain areas of the face (i.e., eyes,
ears), and it also diminishes the heat transferred to
tissues during polymerization.12-14 It should be noted
that this material is not recommended around the
eyelid tissues because unintended adhesion of the
eyelid or other critical structures has occurred. Tissue
adhesive materials are not viscous and tend to run quite
easily. For this reason, moist gauze should be present
to remove excess when necessary.
Postoperative Wound Care
A carefully crafted dressing is important both for pro-
tection of the wound from contaminants and for care
of the wound. In most instances, a minimal dressing is
used that may consist of small bandage strips or antibi-
otic ointment placed several times a day for 1 week.
Complex wounds may require extensive dressings,
retention sutures, or temporary bolsters. Pressure dress-
ings may be helpful in certain types of scalp wounds to
avoid hematoma formation, or drains may be used in
areas of potential dead space. Ear lacerations often
require the placement of bolster dressings to help avoid
hematoma formation. Tarsorrhaphy and Frost sutures
may be placed in eyelids to prevent unwanted contrac-
tion and disruption of certain repairs.
After the acute healing phase has passed and a
small amount of intrinsic strength has developed in the
wound, early suture removal is possible, and meticulous
Table 91-2
COMMONLY USED SUTURE MATERIALS FOR FACIAL REPAIR AND RECONSTRUCTION WITH
SOME OF THEIR IMPORTANT CHARACTERISTICS
Suture
Absorbable
Common Site of Use
Pearls
Polyglycolic
acid
Yes
Deep layers of closure
such as fascia
Excellent handing characteristics because it is a braided
suture; moderate reactivity; offered with antibiotic treatment;
smaller suture may lose tensile strength at about 2 weeks;
bury the knots
Polyglecaprone
Yes
Deep and subcuticular
closure; fi ne suture
may be used for skin
Good handing characteristics for a monofi lament suture;
moderate reactivity; very small sizes such as 5-0 can be used
for key sutures on skin because resorption is rather quick
Chromic gut
Yes
Mucosal repair; very
fi ne suture may be
used for skin closure
More reactivity and less desirable handing characteristics;
monofi lament suture; very useful for mucosal closure because
it is resorbed quickly
Nylon
No
Skin closure or
subcuticular pull-out
suture
Monofi lament suture that requires removal; minimal
reactivity; easily seen for removal because of its black color
Polypropylene
No
Skin closure or
subcuticular pull-out
suture
Monofi lament suture that requires removal; excellent
handing characteristics; minimal reactivity; easily seen for
removal because of its blue color

878
Section 9
Plastic and Reconstructive Surgery
care of the wound continues. Sutures can generally be
removed in 5 to 7 days for most facial wounds. Early
removal prevents hatchmarking, although wounds that
are under some tension may require a longer retention
period. Alternatively, every other suture can be removed
at an early visit. Additional adhesive bandaging may be
used to reinforce and protect the wound for an addi-
tional week or two. Once the sutures are removed, the
wound may be gently massaged several times daily to
help hasten maturation and soften any hypertrophic or
uneven subcutaneous scarring. Supplemental material
such as vitamins, silicone gels, or lotions may help
improve scarring in some instances, but positive
outcome data are lacking. Use of sunblock is encour-
aged because excessive exposure to ultraviolet radiation
can alter the pigmentation and leave the scar more
visible. Sunblock that is nonirritating to the eyes is
important for upper facial wounds.
Revision
Secondary reconstruction of soft tissue injuries of the
face is beyond the scope of this chapter, but it is impor-
tant to discuss the likelihood of secondary surgery with
patients who have endured trauma. Scar revision is
inevitable in some patients who either do not exhibit
optimal healing or have scarring as a result of a more
severe injury. In general, most revisions are best per-
formed after 1 year unless extremely unfavorable aes-
thetics or functional concerns are present. Scar
maturation continues beyond the initial months of
healing and will continue to improve the appearance
of many scars without signifi cant intervention in the
fi rst year. A long-term follow-up schedule should be
discussed with patients to ensure the best result, as well
as their own personal satisfaction.
SPECIAL CONSIDERATIONS
Periocular Injury
When evaluating periocular soft tissue trauma, one
must fi rst exclude underlying globe injury and cranio-
orbital fractures. In addition, when evaluating the upper
and lower eyelids, one should consider the location,
depth, tissue loss, function, and presence of foreign
bodies. Measurements of canthal distances and sym-
metry are important to assess medial or lateral canthus
detachment. Primary reconstruction of these special-
ized orbital injuries is usually more successful than sec-
ondary reconstruction.
If the injury is linear in nature, repair consists of
anatomic reapproximation of the tissue layers. The
eyelid margin, the eyelash line, the gray line, and the
meibomian glands are conventionally used as land-
marks to direct the operative repair. The fi rst sutures
are placed along the lid margin or gray line to initiate
proper alignment, as well as to provide traction for the
remainder of the closure. Size 6-0 silk or nylon is used
for this purpose, with the ends cut long and tied down
under adjacent skin sutures to avoid corneal abrasion.
The tarsal plate and pretarsal muscles are closed with
6-0 Vicryl, and the skin is closed with 6-0 nylon. The
conjunctiva may be left unclosed if the wound edges are
well apposed. It is essential to ensure proper alignment
of the tarsus and eversion of the lid margin to avoid a
notched appearance of the lid.
Complex lacerations and eyelid avulsion injuries
may appear to have what seems to be signifi cant tissue
loss; however, once cleaned and thoroughly evaluated,
they can usually be closed primarily. Should the cornea
become exposed, immediate attention is required to
keep it moist until defi nitive lid repair has been accom-
plished (Fig. 91-4). It is important to reposition the
injured tissues so that the canthi, orbital septum, and
levator aponeurosis are restored to the best positions
possible (Fig. 91-5). When tissue loss has occurred,
every effort should be made to preserve existing struc-
tures, even when their appearance is marginal. Avulsed
tissues can often be used as composite or full-thickness
grafts for the reconstruction of partial-thickness defects.
Full-thickness defects of up to one half the eyelid may
be closed primarily with the use of releasing incisions.
Tissue loss of greater than one half the eyelid may
require a cheek advancement fl ap, lid switch proce-
dure, or skin graft.
Any disturbance in the lacrimal system can lead to
an excess or defi cit of tear availability, which may then
result in corneal damage or visual changes. Both the
secretory and excretory aspects of the lacrimal system
are vulnerable to injury. The secretory component con-
sists of the lacrimal gland, the conjunctiva, and the
minor glands of the eyelid. A tear fi lm is produced and
distributed over the cornea primarily by the action of
the eyelids and then drains medially. Drainage occurs
via the lacrimal canalicular system, the lacrimal sac, and
the nasolacrimal duct. The canaliculi are absolutely
crucial for normal tear drainage and are the most fre-
quently injured structures of the lacrimal system.15
Injury to the lacrimal canaliculi should be suspected
with any laceration medial to the puncta. The wound
should be evaluated by direct inspection, probing, or
direct or indirect instillation of visible fl uids into the
canalicular system. This should allow thorough evalua-
tion of the patency and continuity of the canaliculi by
the presence or absence of injected fl uid in the wound
versus the nose. Fluorescein is most commonly used for
this purpose.
Injuries to the superior canaliculus rarely cause
epiphora; however, most transections of the inferior
system should be repaired, because the inferior cana-
liculus is responsible for the majority of normal tear
drainage. Primary repair of canalicular injuries includes
careful probing and intubation of the canaliculi under
magnifi cation. The proximal canaliculus is often diffi -
cult to identify and may be localized by probing the
uninjured punctum and then passing the probe medi-
ally. The probe can then be passed through the wound
into the distal aspect of the canaliculus and through the
injured punctum. Intubation is frequently performed
with either a monocanalicular or bicanalicular silicon
tube, which is left in place for 3 months until re-epithe-
lialization of the canaliculus has occurred and the peri-

Chapter 91
Soft Tissue Trauma
879
canalicular infl ammation has resolved.15,16 Once this is
complete, pericanalicular sutures are placed and the lid
margin is closed.
Facial Nerve Injury
Traumatic injury to the extracranial facial nerve should
be suspected when lateral facial lacerations and parotid
injuries are recognized. When possible, it is important
to obtain an accurate examination of the cranial nerves
before the administration of local anesthetic, sedative
medications, or paralytics. Unfortunately, this may be
diffi cult in patients who have suffered multisystem
trauma or signifi cant neurologic injury. Focal defi cits
in facial tone and expression may help localize the
damaged segment. This also facilitates appropriate
exploration at the time of wound closure. As a general
rule, facial nerve injuries distal to a vertical line dropped
from the lateral canthus of the eye are not repaired
because they are too small for successful coaptation.
Microsurgical repair of the nerve can be successfully
performed within 2 to 3 weeks of the original injury.
However, immediate repair may be easier for the
surgeon because stimulation of the distal axons before
wallerian degeneration aids in identifi cation of the
nerves. Should the repair be delayed as a result of severe
systemic injuries, the nerve endings should be marked
with suture at the time of débridement (Fig. 91-6).
Options for repair of extracranial facial nerve injury
include primary neurorrhaphy, graft neurorrhaphy,
and nerve transposition. Occasionally, superfi cial parot-
idectomy must be performed to adequately mobilize
the proximal and distal nerve branches for an optimal
tension-free repair. Concomitant gland and duct inju-
ries should be addressed at this time to avoid the forma-
tion of a sialocele, tissue infl ammation, and impaired
healing, which may adversely affect the outcome of the
nerve repair. Regardless of the procedure chosen, the
repair is best performed under magnifi cation. In prepa-
ration for the repair, excision of the proximal and distal
nerve stumps to provide healthy fascicles should be
undertaken.
Common nerve donor sites for reconstruction of
the facial nerve include the great auricular nerve, the
sural nerve, and the median antebrachial cutaneous
nerve. Selection of the donor site should be based on
the graft dimensions needed for the particular repair
and the patient’s acceptance of the notion that anesthe-
sia will be experienced at the donor site. Finally, nerve
transposition of the hypoglossal nerve or an intact
branch of the ipsilateral facial nerve has proved useful
in select cases. One drawback of this technique includes
mass movement of the face rather than detailed indi-
vidual muscle group movement.17,18
Parotid Gland and Duct Injuries
Lacerations of the gland parenchyma are managed
by layered closure (to include the capsule of the
gland) whenever possible. Sialocele is an infrequent
A
C
D
E
B
Figure 91-4. A to C, Clinical photos of a young girl who was struck by a fi re hose that
had become dislodged from a moving fi re truck with disruption of the periorbital tissues
and an avulsed zygomaticomaxillary complex (ZMC) fracture. After plating the ZMC on
the back table, the wound was closed and all the periorbital structures were repositioned
with minimal débridement. D and E, Three months after the repair, the wound has the
typical erythema associated with ongoing tissue remodeling, and all her orbital and peri-
orbital structures are functioning well.

880
Section 9
Plastic and Reconstructive Surgery
A
C
D
B
Figure 91-5. A and B, Preoperative
photos of an Amish boy with a chain-
saw injury to the right upper lid and
brow. The orbital musculature and
septum are disrupted, the tarsus is
intact, and there is minimal tissue
loss. C and D, Primary débridement
and closure are achieved with ana-
tomic repositioning of the compo-
nents of the upper eyelid. Prompt
lubrication is important to keep the
cornea moist and avoid abrasion.
A
B
C
D
Figure 91-6. A, A stab injury has
severed the superior division of the
facial nerve. B and C, Isolation of the
nerve under high-power magnifi ca-
tion allows excellent visualization of
the proximal and distal stumps and
primary repair of the nerve. D,
Closure over a suction drain helps
avoid hematoma, seroma, and sialo-
cele formation.

Chapter 91
Soft Tissue Trauma
881
complication, especially when the drainage mechanism
of the gland is intact. Persistent sialocele should alert
one to the possibility of a missed duct injury and war-
rants re-exploration. In addition to the facial nerve, the
parotid gland and Stenson’s duct are particularly sus-
ceptible to lateral facial injuries and present special
management challenges. Causes of parotid injury are
numerous but frequently involve slash or stab wounds
to the cheek, glass injuries from bottle fragments or
automobile windows, and avulsive and blast injuries.
Failure to recognize and appropriately manage signifi -
cant gland and duct injuries may result in a sialocele or
salivary-cutaneous fi stula.
The anatomic course of the duct can be approxi-
mated externally by a line extending from the tragus of
the ear to the midpoint of a vertical line drawn from
the alar base of the nose to the vermilion of the upper
lip. Thorough exploration should be undertaken and
both ends of the severed duct identifi ed. Retrograde
cannulation of the duct may confi rm the presence of
injury, as well as identify the distal stump. The proximal
portion may be identifi ed by milking saliva from the
gland. The proximal duct is large, thus making it ame-
nable to identifi cation with loupe magnifi cation. When
possible, the duct should be repaired primarily over a
stent. The stent is then left in place for several weeks to
encourage re-epithelialization. Should there be a con-
tinuity defect involving the duct, a vein graft may be
used in an attempt to re-establish continuity. Another
approach is to divert the remaining proximal duct pos-
teriorly in the oropharynx to develop a new drainage
site. Alternatively, the proximal stump may be tied off
in the hope that the gland will eventually atrophy. Pres-
sure dressings and antisialagogue medications may be
useful as adjuncts.
External Ear Injury
The ear is highly vascular and will often survive on a
narrow pedicle despite severe trauma. Therefore, the
surgeon should be conservative when débriding tissue
in this area. For simple lacerations, the ear has the
advantage of well-defi ned landmarks that are easily
reapproximated (Fig. 91-7). Layered closure with fi ne,
undyed, slowly resorbable suture to approximate and
support the cartilage framework and with fi ne mono-
fi lament suture to close skin is appropriate in this situ-
ation. Auricular hematomas secondary to blunt trauma
are commonplace and should be drained acutely lest
the patient be left with a “caulifl ower ear” deformity.
The incision for drainage should be placed in a recessed
portion of the pinna over the hematomas. A bolster
dressing is placed with transauricular sutures to obliter-
ate the resultant dead space and assist in redraping the
soft tissue.
Avulsed segments that are no greater than 1.5 cm
may be suitable as composite grafts. If the segment is
not available, wedge excision and primary closure may
be performed. Avulsions of the entire ear may be reat-
tached with the use of an operative microscope if the
time until replantation is short and the vessels are mini-
mally damaged. Alternatively, the cartilage can be de-
epithelialized and buried within the dermis to preserve
the tissue for secondary reconstruction. Rarely do
buried cartilage replantations or total auricular recon-
structions live up to the cosmetic expectations of the
patient, except in the hands of exceptionally skilled
A
C
B
Figure 91-7. A, Slash injury with disruption of the facial, ear, and scalp tissues. Only
the superfi cial layers were affected. No parotid duct or facial nerve injury occurred. B,
Primary repair of the laceration in anatomic layers. C, One week after repair once the
sutures were removed. (Courtesy of Domenick Coletti, DDS, MD, Baltimore, MD.)

882
Section 9
Plastic and Reconstructive Surgery
surgeons with considerable experience. Implant-sup-
ported prostheses are very aesthetic but may induce
chronic irritation associated with the abutment-skin
interface.
Nasal Injuries
Injuries to the nose range from simple lacerations to
avulsions and may involve the underlying bone, carti-
lage, and mucosa. The injury frequently occurs at the
junction of the bony and cartilaginous skeleton and is
often much more extensive than apparent on the
surface. As with other structures of the face, tissues that
appear somewhat questionable should be preserved
and used as pedicled fl aps or composite grafts. Signifi -
cant partial nasal avulsions may survive, provided that
one of the multiple vascular pedicles remains intact
(Fig. 91-8). Mucosa should be closed when possible,
and nasal cartilage should be carefully repositioned and
sutured to preserve the tip projection and support. The
skin envelope is closed to protect the underlying carti-
lage. For avulsion injuries and full-thickness nasal skin
injuries, composite grafts and full-thickness skin grafts
from the ear and periauricular skin may be considered.
Before entertaining primary reconstruction (e.g., local
fl aps and grafts), one must ensure a clean viable wound
bed with minimal risk of infection.
Scalp Injuries
The scalp encompasses the area from the supraorbital
rims anteriorly to the occiput posteriorly and is com-
posed of fi ve distinct layers. The total area of the scalp
is quite substantial and the tissue highly vascular. Sig-
nifi cant blood loss can occur in association with scalp
injuries and should be replaced aggressively with iso-
tonic fl uids or blood products. Hemostasis is often of
primary concern when managing scalp wounds and can
largely be achieved with the judicious use of clamps and
hemostatic sutures. Acutely, digital pressure and large-
volume sterile saline injection directly applied to the
wound can achieve temporary hemostasis until the
proper instrumentation is available for defi nitive surgi-
cal control.
Primary closure of the scalp is easily accomplished
when there is no signifi cant tissue loss. The scalp should
A
C
D
B
E
F
Figure 91-8. A to C, Preoperative
views of a young boy who sustained a
dog bite injury to the nasal complex
with near avulsion of the external
nose and upper lip. The upper lip is
pedicled on the superior labial arter-
ies and the injury has penetrated
through the oral cavity to the maxil-
lary vestibule. D, After reconstruc-
tion. E and F, Three weeks after the
repair, the child is shown with the
typical erythema of the wounds and
excellent healing.