Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Skin-only Lifts
Subcutaneous lifts rely on the undermining of the skin flap only to improve facial aging. They have been
used for over a century and have evolved from a limited undermining in the periauricular area to an
extensive skin undermining releasing the main retaining ligaments in a superficial plane. Skin traction
repositions the facial tissues and follows a superolateral vector of pull. Skin lifts are not universally
popular as most surgeons prefer SMAS manipulation because of the tension that is placed adjacent to or
in the suture line. 1,2
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SMAS Procedures
Dual-plane Approach
A dual-plane approach includes undermining of the skin flap and the superficial musculoaponeurotic
system (SMAS) separately. It facilitates SMAS and the skin modification in different vectors. The soft
tissue support of a dual plane approach is at the SMAS level rather than at the skin. The elevation vector
of the SMAS is usually superolateral, and the vector of the skin redraping is usually posterolateral. The
SMAS can be elevated as a flap (high SMAS technique), can be resected (SMASectomy), or can be plicated
with or without tissue stacking (Figure 51.6).
In the high SMAS technique, the SMAS flap is elevated at or above the zygomatic arch with medial
dissection with at least partial transection of the zygomatic and masseteric-cutaneous ligaments for full
mobilization of the cheek and jaw line. The platysma-cutaneous ligaments are preserved for proper
elevation and fixation of the SMAS and to prevent the lateral sweep deformity. The subcutaneous
undermining accompanies the SMAS undermining and extends anteriorly to include the area of the
mandibular ligaments and the neck 15,16 (Figure 51.7).
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FIGURE 51.6 The different vectors of traction of the SMAS flap during a high-SMAS facelift. Vertical vector is used for
elevation of midface, jowls, and neck. Lateral vector can be used for elevation of jowls and neck only.
The lateral SMASectomy technique was popularized by Baker and includes resection of a diagonal strip
of SMAS from the malar eminence to the angle of the mandible, parallel to the nasolabial fold with
posterior SMAS plication. The edges of the fix and mobile SMAS are brought together with sutures for
elevation of the jowls and cheek 17 (Figure 51.8).
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FIGURE 51.7 Preoperative (left) and 3-year follow-up (right) photos of a woman in her 60s who underwent a high SMAS face
and necklift with anterior platysmaplasty and partial platysma transection, upper and lower blepharoplasty, and lateral brow lift.
In the SMAS plication technique, there is no flap elevation or resection of SMAS. The edges of the fixed
and mobile SMAS are simply plicated together with sutures. The vectors can be diagonally oriented such
as in the lateral SMASectomy technique or vertically oriented, such as in the high SMAS technique,
depending on the desired outcome. The SMAS stacking procedure proposed by Rohrich includes a
limited lateral SMAS dissection and stacking of the SMAS during plication for volume increase in the
lateral cheek.
In the minimal access cranial suspension lift (MACS lift) developed by Tonnard, large purse-string suture
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loops are used to suspend the SMAS platysma in a cranial position instead of using the traditional
individual plication sutures placed parallel to the nasolabial fold. 18,19
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Deep Plane (Composite) Approach
The deep plane approach repositions the SMAS and skin as a single unit. The skin flap dissection in front
of the ear is limited and there the transition into a skin–SMAS flap starts laterally, over the deep parotid
fascia. 20 The skin–SMAS composite flap is suspended as a single structure in a superolateral vector. This
composite flap is thick and has robust vascularization, being a good option for patients with potential
would healing issues, such as smokers and diabetic patients. The critics of this technique point out that
the skin of the neck is usually shifted into the facial skin, and adjustments of the skin and SMAS flaps
cannot be performed independently and can cause artificial facial contour.
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FIGURE 51.8 Location of the lateral SMASectomy, which extends from the tail of the parotid to the lateral canthus.
In selected patients, other facial sub-SMAS procedures are needed to adjust facial volume and shape. 8
These include buccal fat pad excision or suspension and trimming of the parotid gland to reshape the
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face. Buccal fat pad may be approached through the mouth, through the temple, or through the sub-
SMAS dissection. There is a close relationship between the buccal fat pad and branches of the facial nerve
and the parotid duct.
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Fat Grafting
Fat grafting is used to improve facial appearance by volumetric enhancement of deflated areas. Fat
integrates well with facial tissues and when used in conjunction with a facelift, it can enhance the overall
results. The most common fat injection locations are the midface, temporal fossa, periocular and perioral
areas. Facial lines can also be treated with fat injections.
Facial fat grafting should be performed by avoiding bolus injections or the use of large particle sizes. The
most common fat grafting techniques and tools were developed by Coleman and Tonnard, and consist of
small size harvesting and injection cannulas. Harvesting cannulas vary from 2.1 to 2.4 mm in diameter,
and injection cannulas vary from 1.2 to 0.7 mm. 21,22
Microfat is a term that was coined by Tonnard and is defined as fat harvested in small particle sizes
utilizing tumescent infiltration and small gauge harvesting cannulas (2.0–2.4 mm). Microfat can be used
for facial volume restoration and is the preferred method used by the authors for volumization.
Nanofat is a fat grafting derivate from emulsification of microfat. There are no viable fat cells in the
nanofat solution. Adipose stromal cells are preserved in nanofat preparations and have been credited for
the restorative skin effects seen with the nanofat use. Nanofat should not be used for volume
enhancement, but as an adjuvant to skin quality improvement.
Preparation of the fat through decanting, straining, washing, or centrifugation procedures seems to be
equally effective for fat survival. Time from harvesting to injection seems to be the crucial point for
optimal fat intake. The quicker the fat injected after harvesting the better the result. 24 Exact fat grafting
survival is still uncertain, with reported rates of fat grafting survival varying from 40% to 80%. Therefore,
overcorrection is necessary for long results. The use of fat grafting can enhance results, but increase
operating room time, postoperative bruising, and swelling. Obtaining fat from multiple sites may be
needed for thin patients and may help prevent donor site deformities.
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Neck Contouring Techniques
Necklifts can be performed in isolation or combined with a facelift, and all facelift procedures will have
some effect on the neck (Table 51.1). The goal of neck rejuvenation is to modify and improve the
submental area and cervicomental angle. Depending on the patient’s anatomy and morphology, the
surgical options may include single or combined strategies that reduce the fat, remove skin, or modify the
muscles and deeper structures of the neck.
TABLE 51.1
Decision Making and Patient Selection for Treating the Aging Neck
Skin
Fat
Platysma Laxity ± 
 Subplatysma Volume
Treatment
Good elasticity
Yes
None
Liposuction
Good elasticity
Yes
Yes
Submental necklift
Laxity
Yes/no
Yes/no
Necklift
Anterior neck resection
The most common surgical techniques for neck rejuvenation are liposuction for superficial fat contouring,
platysmaplasty for muscle and fascia plication and reshaping, subplatysmal work for treatment of the
subplatysmal fat excess, digastric muscles and submandibular glands, lateral skin excision of the neck
flap, or direct anterior neck resection.
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Liposuction
The neck contains fat in the subcutaneous tissue between the skin and platysma muscle and in the deep
plane under the platysma, between the platysma medial borders, and above the digastric muscles. To
differentiate between subcutaneous fat and deep fat during the clinical exam, the submental fat is
pinched and the patient is asked to grimace to contract the platysma muscle. If the amount of fat does not
change with contraction, it indicates that most of the fat is subcutaneous and liposuction is a good option
for fat removal. If the fat pinch diminishes upon contraction, most of the fat is subplatysmal requiring an
open neck procedure to remove the fat.
The amount of fat in each plane varies according to patient’s weight and anatomy and is usually more
abundant in the central submental area.
Liposuction can be used to remove superficial fat between the skin and platysma. Used in isolation for
neck reshaping, it is ideal for patients who have good skin tone and elasticity. Liposuction is also
combined with necklift procedures. All liposuction modalities such as suction assisted liposuction (SAL),
power-assisted liposuction (PAL), ultrasound-assisted liposuction (UAL), and laser-assisted liposuction
(LAL) can be used. Small cannulas (size 2–3) are recommended to prevent excessive resection of fat and
surface irregularities.
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Platysmaplasty and Subplatysmal Procedures
The platysma is a pair of superficial muscle of the neck that originates from the pectoralis major muscle
fascia and inserts into the mentum and the inferior mandibular border. Its fibers ascend into the lower
face connecting to the depressor anguli oris and to the orbicularis oris. It is the extension of the SMAS in
the lower face and neck. Within the submental area, the anatomy and the level of midline decussation
between the muscles varies greatly from individual to individual. Cardoso de Castro classifies the
platysma decussation into Type 1, 2, and 3. Type 1 is the most common (75%) with limited submental
decussation. Type 2 (15%) shows decussation from the mandibular symphysis to the thyroid cartilage and
Type 3 (10%) shows no decussation.
Stuzin discussed the importance of the platysma retaining ligaments in the aging neck. These ligaments
are a series of fibrous bands connecting the mandibular symphysis to the thyroid and once attenuated
contribute to platysma descent, band formation, and the oblique cervical angle of the aging neck.
Platysma work is indicated in patients with neck laxity and the presence of platysma bands.
Submental necklifting consists in treatment of the central neck through a submental incision. The
submental necklift may be performed in isolation or in combination with a facelift. The submental
incision is placed just posterior to the submental crease, with subsequent flap elevation with scissors or
electrocautery, liposuction or direct resection of the subcutaneous fat if necessary, and a combination of
central platysma plication (anterior platysmaplasty) with or without transection of the medial platysma
borders. The extension of the transection usually depends on the thickness and location of the bands and
helps with neck reshaping. 20
Anterior platysmaplasty consists of suturing the medial platysma borders from the submental area to the
thyroid cartilage for tightening of the neck. The borders of the muscle can be simply approximated or
overlapped with or without transverse partial or complete platysma transection to weaken the platysma
bands. Transections usually start centrally at the level of the cricoid cartilage and extends laterally, but
this maneuver can also be performed from lateral to medial through the facelift incision. Absorbable and
permanent sutures may be used for plication through simple or continuous running sutures.
Other structures that influence the neck shape and aesthetics are located deep into the platysma muscle,
such as the subplatysmal fat, the anterior belly of the digastric muscles, and the submandibular glands.
The digastric muscles are paired and have an anterior and a posterior belly. The anterior bellies extend
from the posterior mandibular symphysis to the lesser cornu of the hyoid bone. The anterior belly and
posterior belly of each digastric muscle form two sides of the submental triangles. The submandibular
glands are located in the submental triangles and can produce a visible bulge in the lateral neck. The
facial artery and vein and the marginal mandibular branch of the facial nerve crosses the gland
superficially outside its capsule. The safest approach to the gland is intracapsular resection to avoid
neurovascular injury.
To access these deep structures, the surgeon should elevate the central platysma borders. Partial but not
complete subplatysmal fat is known to avoid submental depression. When prominent, the anterior belly
of the digastric can be partially or totally excised without noticeable loss of function. Enlarged
submandibular glands can be visualized laterally to the anterior belly of the digastric muscles. The
superficial lobe of the gland is exposed into the operating field by an Allis forceps or a strong suture
placement through the gland. The capsule is incised with needle-tip cautery, and the gland excess
resected piecemeal until ideal contour of the submandibular area is achieved. Thorough gland hemostasis
is important to avoid hematoma in this area and the risk of airway obstruction.
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Direct Anterior Neck Resection
Direct resection of the submental skin and fat excess with or without platysmaplasty is an option for neck
rejuvenation in selected patients. Good candidates for direct neck resection are usually males or older
patients of both genders who tolerate a central and more visible scar, who are not suitable for longer
operations or prefer a less extensive procedure. In an anterior neck, the superficial and deep planes of the
neck can be resected. Different incision designs have been proposed and straight resections are avoided to
prevent banding and scar contraction. Most incision patterns are variations of z-plasty in the midline.
Visible scars, hypertrophic scars, and long lasting scar erythema are some of the downsides of this
approach.
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Postoperative Management
The use of drains under the skin flap is a common practice for neck and facelift. Small size Jackson-Pratt
drains to bulb suction are usually left on each side of the face for 24 h after surgery. Drains have not
shown to prevent hematomas or seromas but are advocated by many authors to help decrease the
amount of swelling and bruising after a facelift and help the patient return quickly to social activities. 15
Facial dressings and head wrapping are commonly used after face and necklifts and removed 24 h after
surgery. After this, a compressive, nonbinding chin strap or garment is recommended for a couple of
weeks. Head elevation during sleep can help with swelling, as well as low salt intake in the postoperative
period.
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Complications
Face and necklifts are considered safe procedures with a low overall complication rates. According to a
2016 large prospective cohort study by Gupta et al., the incidence of facelift complications that need
hospitalization within 30 days of surgery is 1.8%. Hematoma (1.1%) and infection (0.3%) were most
common. The same study found male gender an independent factor for hematoma. Body mass index >=
25 and combined procedures increased the infection risk. 25
Hematoma is the most common early complication of a face and necklift and it usually occurs in the first
24 to 48 h after surgery. The overall incidence of all (minor-large) postoperative hematoma is variable due
to lack of consistent classification, usually reported to be 4% to 8% for men and 1% to 3% for women.
Minor hematoma is defined as a collection of blood that does not require surgical evacuation but is
amenable to treatment by bedside aspiration, with volumes under 30 cc. An expanding hematoma is a
serious complication with an incidence of 1.8% that requires immediate recognition and treatment due to
impending risk of skin necrosis, airway obstruction, and death. Minor hematomas can lead to persistent
face and neck edema, nerve compression, skin necrosis, and unpleasant aesthetic results.
Several strategies have been proposed to decrease the incidence of post facelift hematoma. Strict blood
pressure control in the operating room (SBP < 150 mm Hg) is a widely recognized preventive
intervention. Antihypertensive clonidine has been used successfully in the postoperative period to keep
SBP under 140 mm Hg. The use of fibrin glue, absence of epinephrine in the local anesthetic solutions,
and compressive dressings have been reported to be beneficial but are not completely effective in
preventing hematomas. A few recent studies have demonstrated that the use of quilting sutures is a
promising strategy in prevention of hematoma in the face by reducing the rate of hematoma to zero in the
published series. 26
Injuries to motor and sensory facial nerves are also acute complications of face and necklift. The great
auricular nerve is the most commonly injured nerve and will lead to numbness of the lower part of the
ear and earlobe. Its superficial location on the sternocleidomastoid muscle surface places the nerve at risk
of transection during the neck flap dissection. Nerve compression by sutures during platysma suspension
can also cause numbness and chronic pain. 7
Injury to the marginal mandibular branch of the facial nerve results in weakness of the ipsilateral lower
lip depressors (denervation of the depressor anguli oris). It also affects the ipsilateral mentalis muscle.
Neurapraxia is more common than complete nerve transection in this area, and can return within a few
days to 3 to 6 months. Another common cause of nerve dysfunction in the immediate postoperative
period is temporary paralysis of the facial nerves due to injection of local anesthetic in the dissected areas.
It usually takes a few hours for the local anesthetic to wear off.
Smoking can increase the chance of skin necrosis and poor wound healing after cosmetic surgery. 27-29
Rees found that the incidence of skin slough after facelift was 7.5% in smokers compared to 2.5% in
nonsmokers. A recent systematic review and meta-analysis by Rohrich shows that at least 4 weeks of
abstinence from smoking reduces respiratory and wound-healing complications. Skin necrosis is initially
managed with local wound care. They can heal as wide or hypertrophic scars, and further treatments
with steroid injections or excision of the scars and flap readvancement are common treatments.
Poor wound healing can be a consequence of poorly planned incisions, too much tension placed on the
skin during closure, or poor healing characteristics related to ethnicity (Asians, African Americans).
The “pixie ear” deformity is a known tell-tale sign of previous facelift. It is caused by tethering and
forward rotation of the base of the lobule due to excessive tension during wound closure and distortion of
natural axis of rotation of the lobule. Other tell-tale signs of previous facelifts are “joker lines”, “lateral
sweep”, postauricular banding, facial deformities related to abnormal SMAS and skin traction, suturing
points, or noncorrection of facial deflation.
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Secondary facelifts have similar complications to a primary procedure, and the timing for a secondary
facelift is in average a decade after the first procedure. Secondary facelift patients are older and usually
have thinner tissues. Ancillary procedures such as skin resurfacing and fat grafting are often added to
secondary facelifts to improve outcomes. Beale at al proposed the “five Rs” or tenets for performing a
sound secondary rhytidectomy: (1) resect skin/scar, (2) release abnormal vectors, (3) refill by fat grafting,
(4) reshape with SMAS procedures, and (5) redrape skin. 30
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Questions
1. A 62-year-old healthy woman comes to the office for her preoperative visit in preparation for her
facelift surgery in 2 weeks. You explain the risks and benefits of the surgery, and she asks what the
most common complication of a facelift is. What do you answer?
a. Facial nerve injury
b. Skin necrosis
c. Seroma
d. Hematoma
e. Infection
2. A 59-year-old woman comes back to the office for follow-up 3 months after surgery. She is pleased
with the aesthetic results but refers complete numbness of the left earlobe. Which nerve was most
likely injured during the surgical procedure?
a. Posterior auricular nerve
b. Spinal accessory nerve
c. Cervical branch of the facial nerve
d. Great auricular nerve
e
Mandibular branch of the facial nerve
3. During the 2-week follow-up visit of a patient submitted to a high SMAS face and necklift, you
noticed a 3 × 4 cm dark patch of skin in the left postrauricular area adjacent the retroauricular suture
line. There is no redness or secretion in the area. Which of the following is the most appropriate next
step to manage this patient?
a. Placement of a negative pressure treatment
b. Wide debridement
c. Debridement and full thickness skin graft
d. Local wound care
e. Oral antibiotics for a week
4. Hematoma is a common complication of facelift surgery. Which of the follow options is a known
risk factor for this complication?
a. Operation performed in an office-based facility
b. Hyperthyroidism
c. Loose surgical dressing
d. History of previous hematoma
e. Male gender
5. Six months after a primary facelift with SMASectomy, a 70-year-old man comes back for follow-
up. He was overweight and has lost 15 lb since surgery. Now he complains of midface hollowing,
depressed temporal area and visible marionette lines. On examination, there is deflation of temples,
midface, and perioral area with good tension on the skin. What is an appropriate option for
improving this patient’s concerns?
a. SMAS plication procedure
b. Chemical peels
c. Placement of cheek implants
d. Laser resurfacing
e. Fat grafting to the face
1. Answer: d. The most common complication of a facelift is a hematoma, with an incidence that
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varies from 1% to 8% in most series. Hematoma that requires surgical evacuation in the operating
room has an incidence of 1.8% according to a large prospective study from Gupta et al. Minor
hematomas can be drained at the bedside and are likely underreported. Facial nerve injury, skin
necrosis, seroma, and infection are not the most common complications of a facelift. Infection is the
second most common complication that requires hospital admission within 30 days of surgery. 1,25
2. Answer: d. The overall incidence of nerve injury in facelift surgery is low. Transection of the great
auricular nerve is the most frequent nerve injury of facelift surgery, with an estimated incidence of
up to 2.6%. Common symptoms associated with great auricular nerve injury are numbness of the
earlobe, concha, and posterior auricle or focal pain in case of nerve entrapment from suture
placement around the nerve or from neuroma formation. The nerve is located about 6.5 cm inferior to
the external auditory canal on the surface of the sternocleidomastoid muscle. 6,7
3. Answer: d. Minor wound issues are known complications of facelifts. The initial treatment is daily
local wound care without debridement. In the absence of infection, the eschar will act as a biological
dressing and reepithelialization occurs with minor consequences, most commonly wide or
hypertrophic scars. Unfavorable scars can be further treated with steroid injections, local resection, or
flap readvancement to improve tension upon closure. 1,2
4. Answer: e. According to a 2016 large prospective cohort study by Gupta et al., the incidence of
facelift complications that need hospitalization within 30 days of surgery is 1.8%. Hematoma (1.1%)
and infection (0.3%) were most common. This same study found male gender an independent factor
for hematoma. The same study showed that operations performed in an office-based facility have
less risk of hematoma and infection. Surgical dressing, use of drains, and a history of previous
hematoma are not risk factors for hematoma after facelift. 1,2,25
5. Answer: e. Facial aging, weight loss, and systemic diseases can cause facial deflation. When there
is minimal or no skin laxity associated with facial deflation as in this case, fat grafting is a good
option to improve facial deflation by itself. It can be used in combination with a facelift (lift and fill
technique). The most common fat injection locations are the midface, the temporal fossa, the
periocular, and the perioral areas. Facial lines can also be treated with fat injections. Facial fat
grafting should be performed with a proper technique, avoiding bolus injections or the use of large
particle sizes. Synthetic fillers such as hyaluronic acid fillers can also be used to improve facial
deflation. 5,9,21,22
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References
Mustoe, T, Park, E. Evidence-based medicine face lift. Plast Reconstr Surg. 2014;
 133:1206.
Wan, D, Small, KH, Barton, FE. Face Lift. Plast Reconstr Surg. 2015;136:676e-689e.
Alghoul, M, Codner, MA. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthet Surg J. 2013;33(6):769–782.
Mitz, V, Peyronie, M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58:80–88.
Rohrich, R, Pessa, J. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments.
Plast Reconstr Surg. 2008;121(5):1804–1809.
Roostaeian, J, Rohrich, RJ, Stuzin, JM. Anatomical considerations to prevent facial nerve injury. Plast Reconstr Surg. 2015;135(5):1318–1327.
Rohrich, RJ, Taylor, NS, Ahmad, J, Lu, A, Pessa, JE. Great auricular nerve injury, the “subauricular band” phenomenon, and the periauricular
adipose compartments. Plast Reconstr Surg. 2011;127(2):835–843.
Seckel, BR. Facial danger zones: avoiding nerve injury in facial plastic surgery. Can J Plast Surg. 1994;2(2):59–66.
Rohrich, RJ, Pessa, JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg.
2007;119(7):2219–2212.
Fitzpatrick, TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124(6):869–871.
Nahas, FX, Sterman, S, Gemperli, R, Ferreira, MC. The role of plastic surgery in congenital cutis laxa: a 10-year follow-up. Plast Reconstr Surg.
1999;104(4):1174–1178; discussion 1179.
Practice advisory for preanesthesia evaluation: an updated report by the american society of anesthesiologists task force on preanesthesia
evaluation. Anesthesiology. 2012;116(3):522–538.
Wilkins, EG, Pannucci, CJ, Bailey, SH, et al. Preliminary report on the PSEF Venous Thromboembolism Prevention Study(VTEPS): validation
of the Caprini Risk Assessment Model in plastic and reconstructive surgery patients. Plast Reconstruc Surg. 2011;126(4):107.
Baker, DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J.
2001;21:14–26.
Marten, TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek and midface. Clin Plast Surg. 2008;35(4):569–603.
Trussler, AP, Stephan, P, Hatef, D, Schaverien, M, Meade, R, Barton, FE. The frontal branch of the facial nerve across the zygomatic arch:
anatomical relevance of the high-SMAS technique. Plast Reconstr Surg. 2010;125:1221–1229.
Baker, DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–513.
Saylan, Z. The S-lift for facial rejuvenation. Int J Cosmet Surg. 1999;7:18–23.
Tonnard, P, Verpaele, A, Monstrey, S, et al. Minimal access cranial suspension lift: 
 a modified S-lift. Plast Reconstr Surg. 2002;109:2074–2086.
Stuzin, JM, Feldman, JJ, Baker, DC, Marten, TJ. Cervical contouring in face lift. Aesthet Surg J. 2002;22(6):541–548.
Coleman, SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 suppl):108s–120s.
Tonnard, P, Verpaele, A, Peeters, G, et al. Nanofat grafting: basic research and clinical application. Plast Reconstr Surg. 2013;132(4):1017–1026.
Sinno, S, Wilson, S, Brownstone, N, Levine, SM. Current thoughts on fat grafting: using the evidence to determine fact or fiction. Plast
Reconstr Surg. 2016;137(3):818–824.
Rohrich, RJ, Ghavami, A, Constantine, FC, Unger, J, Mojallal, A. Lift-and-fill face lift: integrating the fat compartments. Plast Reconstr Surg.
2014;133:756e-767e.
Gupta v, Winocour J, Shi H, Shack RB, Grotting JC, Higdon KK. Preoperative risk factors and complication rates in facelift: analysis of 11,300
patients. Aesthet Surg J. 2016;36(1):1–13.
Neto, JC, Rodriguez, DE, Boles, FM. Reducing the incidence of hematomas in cervicofacial rhytidectomy: new external quilting sutures and
other ancillary procedures. Aesthet Plast Surg. 2013;37(5):1034–1039.
Krueger, JK, Rohrich, RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery. Plast Reconstr Surg.
2001;108:1063-1073; discussion 1074–1077.
Rees, TD, Liverett, DM, Guy, CL. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg.
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Wong, J, Lam, DP, Abrishami, A, Chan, MT, Chung, F. Short-term preoperative smoking cessation and postoperative complications: a
systematic review and meta-analysis. Can J Anaesth. 2012;59(3):268–279.
Beale, EW, Rasko, Y, Rohrich, RJ. A 20-year experience with secondary rhytidectomy: a review of technique, longevity, and outcomes. Plast
Reconstr Surg. 2013;131(3):625-634.
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Seminal articles
Mitz, V, Peyronie, M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. 1976. Plast Reconstr Surg. 58:80–88.
The first detailed anatomic description of the superficial facial fascia. The authors called it the superficial musculo-aponeurotic system,
stablishing the acronym SMAS in facial surgery
Alghoul, M, Codner, MA. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthet Surg J. 2013;33(6):769–
782.Review article that clarifies the anatomy and nomenclature of the retaining ligaments of the face and its importance in facial
rejuvenation surgery.
Marten, TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek and midface. Clin Plast Surg. 2008;35(4):569–603.
Comprehensive description of the high-SMAS flap surgical anatomy and technique for face and neck rejuvenation.
Gupta, v, Winocour, J, Shi, H, Shack, RB, Grotting, JC, Higdon, KK. Preoperative risk factors and complication rates in facelift: analysis of
11,300 patients. Aesthet Surg J. 2016;36(1):1–13. Large prospective study with current data evaluating risk factors and complication in face
lift patients.
Rohrich, RJ, Pessa, JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg.
2007;119(7):2219–2212. Facial deflation is an important feature of facial aging. The authors describe the fat compartments of the face and
its implications in facial rejuvenation surgery.
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C H A P T E R 5 2
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Rhinoplasty
Robert H. Gilman and Jeremy Warner
Key Points
Nasal surgery requires accurate evaluation, assessment, and treatment of both aesthetic and
functional components.
Rhinoplasty surgery can be approached through both open and closed approaches, and there are a
number of factors that will direct the surgeon on the most appropriate approach.
Thorough knowledge of the functional aspects of nasal surgery is critical to prevent postoperative
functional airway issues.
There is a range of technical maneuvers available, from basic to complex, for safe and effective
rhinoplasty, septorhinoplasty, and revision rhinoplasty.
The rhinoplasty surgeon will need to have knowledge of both short-term and long-term facets of the
healing process.
Although rhinoplasty and revision rhinoplasty share many commonalities, there are specific issues
with revision rhinoplasty surgery that the surgeon must be aware of.
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Terminology
Table 52.1 contains terms associated with rhinoplasty.
TABLE 52.1
Terminology Associated with Rhinoplasty
Alae/ala: The outer skin of the nostrils from the nostril margin to the skin overlying the alar cartilage making up the lateral surface of the
external nose and composed of fibrofatty tissue
Alar groove: The transition between the alae and the lateral nasal sidewalls, defined by a shadow or crease
Anatomic dome: The area of transition between the medial and lateral crura of the alar/lower lateral cartilage. The anatomic dome usually
but not always corresponds to the most projecting point of the nasal tip (the clinical dome).
Anterior septal angle: The junction of the caudal septum and the dorsal septum
Anterior: Toward the forward surfaces on lateral view
Cartilage-splitting incision: Intranasal incision within the body of the lower lateral cartilage
Caudal septum: The caudal most portion of the cartilaginous septum
Caudal: Toward the nostrils or the same as inferior when referring to the nose
Cephalic: Toward the root or radix of the nose for the same as superior when referring to the nose
Clinical dome: The apparent point(s) of maximum projection of the tip
Columella: The anatomic columnar structure of the nose that includes the paired lower medial crura of the lower lateral cartilages and its
surrounding soft tissues.
Columellar labial angle: Formed by the angle between the columella and the upper lip. This angle is not dependent on the nasal base
position, as in the nasolabial angle.
Columellar lobular angle: The angle formed at the junction of the columella and the infratip lobule. The angle is usually 35°–45° in females
and 0°–35° in males.
Dorsal aesthetic lines: Imaginary lines starting at the medial edge of the brows and tracing a gentle curve down the lateral side of the
dorsum to the tip-defining points.
Dorsal: Along and toward the bridge of the nose, either on anterior-posterior or anterior on a lateral view
External nasal valve: Corresponds to the support of the nostril with deep inspiration. A competent valve will keep the nostril open during
deep inspiration
Hemitransfixion incision: An incision along one side of the caudal septum, not going through and through only
Infratip lobule: Transition area between the tip (domes) and the columella
Intercartilaginous incision: Intranasal incision between the upper and lower lateral cartilages
Internal nasal valve: Supportive functional opening within the nasal cavity at the junction of the lower lateral and upper lateral cartilages
(scroll area), the angle of which is defined by the septum and the upper lateral cartilage as it diverges from the septum. An angle of less
than 15° may contribute to a greater tendency for valvular insufficiency on inspiration.
Keystone area: The area where the bone structures meets the cartilage structures along the dorsum of the nose
Lateral alar crus (crura): Lateral wing of the alar cartilage
Lower lateral cartilages: Paired cartilage structure of the nasal tip also known as the alar cartilage and composed of the medial and lateral
crura and dome. It gives support to the nostrils and the external nasal valve and gives rise the tip shape
Marginal incision: An incision caudal to the lower lateral cartilage
Medial alar crus (crura): medial wing of the alar cartilage
Menton: The most inferior point of the mandible/chin as seen on lateral view of a cephalogram
Nasal horizontal facial plane: Corresponds to the Frankfort Horizontal line, the plane defined by a 90° plane from the vertical facial plane,
with the line drawn from the inferior portion of the external auditory canal to the bony inferior orbital rim
Nasal pyramid: Corresponds to the bony structure of the upper nose, pyramidal in shape
Nasal septum: The anatomic structure that separates the nasal airway into two separate nasal cavities, with a portion being cartilaginous
and a portion being bony
Nasal turbinate: Intranasal mass structures consisting of mucosa, erectile tissue, and thin bone, which helps to humidify and control the
flow of air as it passes through the nose. Of the three turbinates located on each side, the inferior turbinate is the most important.
Nasolabial angle: Formed by a line drawn through the anterior and posterior ends of the nostril and vertical facial plane. The angle is
usually 95°–100° in females and 90°–95° in males.
Pogonion: The most anterior projection of the mandible as seen on a cephalogram
Pyriform aperture: Area of the bony midface that corresponds to the nasal cavity opening
Radix: The area deepest point of transition of the bony forehead to the bony upper nose
Scroll area: The area where the cephalic edge of the lower lateral cartilage interlocks with the caudal edge of the upper lateral cartilage.
Sesamoid cartilages: Accessory lateral cartilage structures lying between just lateral to the lower lateral cartilages and the pyriform aperture.
Soft triangle/facet: On basal view, the area of transition between the columella and the nostril rim, corresponding to the area just caudal to
the domes where there is no cartilaginous structure
Stomion: Midpoint of the oral fissure with the lips closed
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Supratip: The area just above the tip or the transition area between the dorsum and tip
Tip: Includes the paired alar cartilages (lower lateral cartilages), tip complex, columella, and nostrils
Tip-defining points: Refers to the light reflex on the outer skin corresponding to the structural paired cartilaginous domes. Ideally, they are
paired, symmetrical, and distinct.
Tip projection: Refers to how far the nasal tip projects from the face. There are multiple ways to determine tip projection. One of the more
common ways is to measure two lines: (A) the length from the nasal base crease to the tip on lateral view and (B) the length of nose on
lateral view from radix to nasal tip. Line A should be about 0.67 the length of B (B divided by A = 0.67).
Tip rotation: Refers to the angle of rotation of the nasal tip. There are multiple ways to measure tip rotation. One of the more common ways
is to draw a line from the alar base crease to the nasal tip and compare this angle to the vertical facial plane.
Transcolumellar incision: Incision used in an open rhinoplasty approach, along the mid columella, to allow nasal flap elevation. Most
surgeons use either a “stairstep” or an “inverted V”
Transfixion incision: A through-and-through incision that is made along both sides of the caudal septum
Upper lateral cartilages: Paired cartilages along the middle third of the structural nose, extending from the septum medially to the pyriform
bones laterally and from the cephalic border of the lower lateral cartilage to the nasal bone. The nasal bone overlaps the cephalic edge of
the upper lateral cartilage.
Vertical facial plane: Defined by a 90° plane from the Frankfort horizontal
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Nasal Anatomy (Figure 52.1)
FIGURE 52.1 Nasal anatomy. A. Nasal septum. B. Lateral view. C. Anterior-posterior view. D. Internal side wall.
Skin: Thicker over the upper and lower third of the nose and thinner over the middle third muscle-
osseocartilaginous framework
Bones: Nasal, frontonasal process, and palatal crest of the maxilla, nasal process of the frontal,
perpendicular plate of the ethmoid, vomer
Cartilage: Upper lateral and lower lateral, accessory, sesamoid, quadrangular
Arterial blood supply (Figure 52.2)
External nose
Internal carotid-ophthalmic-anterior ethmoid-external nasal branch of anterior ethmoid
Lateral nasal
External carotid-facial-angular-lateral nasal
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Superior labial-columellar
External carotid-maxillary-infraorbital
Internal nose
Internal carotid-ophthalmic-anterior and posterior ethmoid
External carotid-sphenopalatine and greater palatine
Angular and labial
Venous blood supply
Generally follows the arterial supply
The nasal veins do not have valves
The nasal venous system has direct communication to the cavernous sinus, thus making nasal
infections potentially a life-threatening event
Nerve supply (Figure 52.3)
Trigeminal-ophthalmic-nasociliary-anterior ethmoid: supplies the anterior half of nasal cavity
External branch of the anterior ethmoid: supplies the nasal skin from rhinion to tip
Posterior ethmoid: supplies the superior half of nasal cavity
Infratrochlear: supplies the nasion and bony dorsum
Mucosa
The vestibule is lined by hair-bearing squamous epithelium up to the level of the caudal margin
of the alar cartilage, where it transitions to pseudostratified ciliated columnar respiratory
epithelium with abundant seromucinous glands
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FIGURE 52.2 Nasal arterial supply.
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FIGURE 52.3 Nasal nerve supply.
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Functional Nasal Conditions
Physiologic: airway obstruction caused by nonanatomic, nonmechanical conditions
Allergy
External irritants
Tobacco
Medications
Vasomotor rhinitis
Rhinitis medicamentosa
Nasal sinus disease
Sexual or emotional stimulation
Hyperthyroidism
Pregnancy
Anatomic: airway obstruction caused by mechanical or anatomic impingement on the physical airway
Congenital or acquired nasal septal deviation
Congenital or acquired nasal bony deviation
Congenital or acquired nasal cartilage weakness
Internal valve collapse
External valve collapse
Nasal turbinate bone and/or mucosal hypertrophy
Nasal polyps
Synechiae
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Patient History and Examination
Patient Concerns and Goals
It is very important to determine exactly why patients seek a consultation for potential nasal surgery.
The patient is asked to look at a mirror and describe exactly what they see, what bothers them, and
specifically as possible in what ways they would change their nasal appearance.
The patient is told that for the purposes of the exam they can assume that anything that they might
want changed can be done but they are also told that in reality it may not be possible.
It is incumbent upon the surgeon to assess that the patient’s goals are indeed realistic. A patient with
a concern that is disproportionate to the actual degree of deformity that is present should be
approached with great caution. 1-3
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Aesthetic Nasal History
History and nature of any nasal trauma
Pretrauma photos when available
Emergency department (ED) notes and radiologic exam records when available. Note whether
closed reduction or surgical intervention was attempted
Operative reports when available
Presence of nasal obstructive symptoms related to trauma or disease
Constant
Intermittent
Epistaxis and or rhinorrhea
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History of Previous Nasal Surgery
Copy of operative notes when available
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Psychological History
Consider psychologic consultation and clearance
Be aware of body dysmorphic disease
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Current Medications
Medications that can increase nasal obstruction
Negative medication interactions
Feedback from prescribing medical doctor regarding medication stops for surgery
Adequate control of unrelated systemic medical conditions
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History of Bleeding Disorders or Difficulties With Previous Surgeries
Hematology consultation when necessary
Anesthesia consultation when necessary
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Current Employment
Need to factor in recovery time off work
Physical labor versus desk job
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Current Physical Activities
Time away from vigorous exercise, gym, working out, or running
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Health History
Epistaxis
Rhinorrhea
Allergies
Work and home environmental assessment (exposure history)
Chronicity, seasonality
Medications
Previous surgery
History of cocaine abuse
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Physical Examination
External evaluation
Cottle testing
Anterior rhinoscopy before and after vasoconstriction
Nasoendoscopy (if available)
Rhinomanometry (if available)
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Diagnostic Testing
CT scanning
MRI
Allergy testing
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Focused Nasal Examination
External Examination
Apparent length and projection of the nose
Dorsal profile
Symmetry of the external nose, including deviations
Width of the alar and bony bases
Visible and/or palpable bony and/or cartilaginous irregularities
Condition of the nasal skin and its thickness or thinness
Presence or absence of nasal scars and skin lesions
Size, shape, and width of the nostrils
Presence of prominent medial crural footplates
Degree of columellar show
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Internal Examination
Cottle tests for both internal and external valve dysfunction first without and then with
vasoconstrictor 4
Anterior rhinoscopy with evaluation of the nasal mucosa, its moisture, and color
The presence or absence of discharge
The presence or absence of nasal polyps
The shape and alignment of the caudal nasal septum and caudal aspect of the nasal turbinates
particularly inferior turbinate
The presence of any nasal septal perforations
The presence of scars or scar contracture along with signs of previous nasal surgery
If the patient has had previous nasal surgery palpation of the nasal septum with a Q-stick can
identify whether cartilage has been previously removed. If available, nasoendoscopy can be
performed under topical anesthesia to better visualize the posterior aspects of the nasal airway
including the posterior septum and turbinates.
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Computer Imaging
The use of computer imaging can help to determine the types of changes that can reasonably be made,
and it is a visual way of demonstrating the surgeon’s concept of the change in the patient’s nose directly
to that patient. It is important to stress to the patient that computer-imaged results cannot be construed as
a guarantee of that exact result. The computer image is a tool that allows the patient and the surgeon to
view the same proposed result at the same time. 5,6
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Nasal Analysis
Much has been previously published regarding the ideal nasal aesthetics. 7-9 Byrd analysis looks at
idealized relationships between nasal landmarks. Comparison of these idealized measurements with the
patient’s actual measurements suggests quantifiable changes that can be made in that patient’s nose.
Computer image analysis uses the surgeon’s aesthetic eye to draw the planned change in the patient’s
nose and then figure what maneuvers are needed to achieve those changes. At this time, the projection or
lack thereof of the chin can be analyzed on the lateral photographs by using either Byrd analysis or
computer-imaged change. This is one of the few areas where a procedure not directly mentioned by the
patient may be legitimately proposed. The use of computer imaging can be very helpful in this situation
to demonstrate the change that can be made by genioplasty. General analytic guidelines have limitations
based on variability of ideals presented by racial, age, and gender differences. 10-12
The facial thirds (Figure 52.4A): Transverse lines drawn tangent to the hairline, brow at the level of the
supraorbital notch, nasal base, and at the chin (menton) roughly divide the face into thirds. The
forehead third shows significant variability because of the differences in forehead height as
determined by hairline. The lower third of the face can be subdivided into thirds by adding a
horizontal line at 
 the level of the oral commissures (stomion). The upper third defines the upper lip
including the Vermillion while the lower two thirds define the lower lip and chin. Attention to these
measurements helps the surgeon to assess overall maxillofacial harmony. Underlying facial
disharmony should be discussed with patients prior to any facial aesthetic surgery (not just
rhinoplasty) to ensure that the patient understands what is beyond the scope of the planned surgery.
The facial fifths (Figure 52.4B yellow lines): Vertical lines are drawn tangential to the periphery of the
ears on both sides, the lateral canthi on both sides, and the medial canthi on both sides. Ideally, each
segment to the face defined by these vertical lines should be of equal width.
Midline facial vertical (Figure 52.4B, black line): A line drawn from the midglabella to the menton. This
line can be used to help determine nasal symmetry in the anterior-posterior view
Dorsal aesthetic lines (Figure 52.5A): These are curved and opposing lines traced from the super orbital
ridges curving in toward the keystone area and then flaring slightly as they curve outward toward
the tip-defining points.
Alar base width (Figure 52.5B): This distance should be roughly equal to the distance between the
medial canthi, as in lines labeled a.
Bony base width (Figure 52.5B): This distance should be roughly 80% of the distance between the
medial canthi, as in lines labeled b.
Alar rim orientation (Figure 52.5C): The alar rims should be symmetrical and flare slightly in it
inferolateral direction anterior tip assessment: the supratip break, tip-defining points, and columellar
lobular angle are used to define two opposing triangles over the tip of the nose. The intersecting
bases of these triangles form a horizontal line through the tip-defining points. These triangles should
be roughly symmetrical.
Gull wing line (Figure 52.5D): A line drawn along the superior border of the ala from one side curving
around the columellar to the other side should describe a gentle curve similar to the sweep of a
seagull in flight.
Opposing equilateral triangles (Figure 52.5E): Draw two equilateral triangles with their bases opposed
to one another. The corners of the diamond thus formed are the two tip-defining points—the
supratip break and the columellar lobular angle. These structures should ideally be symmetrical.
Base view triangle (Figure 52.6): In the worm’s eye view, a triangle is drawn with its base horizontally
through the alar bases and its sides, tangent to the lateral nasal walls. This should form an equilateral
triangle.
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Lobular to nostril ratio (Figure 52.6): The nostril should be two thirds and the lobule one third of the
nasal height in the worm’s eye view.
Nostril shape (Figure 52.6): The nostrils should be roughly teardrop shaped with the base wider than
the apex and with the axis oriented in a slight medial direction from based apex.
Nasal length (Figure 52.7): The apparent length of the nose from radix to tip. This should be
approximately the same as the distance from the stomion to the menton.
Perceived nasal length: The apparent length of the nose can be changed by changing the position of the
nasal frontal angle or the tip-defining point. Decreasing the rotation of the tip and/or elevating the
area of the radix thus moving the nasal frontal angle cephalad will give the perception of a longer
nose while increasing tip rotation and/or lowering the radix thus moving the nasal frontal angle
caudad will give the appearance of shortening the nose. In addition, a more anterior position of the
nasal frontal angle can make the nasal tip look less projecting while a more posterior or deeper
position for the nasal frontal angle can make the nasal tip look relatively more projecting.
Horizontal ideal chin position (Figure 52.8A): A vertical line can be drawn from a point that is one-half
the distance between the radix and the nasal tip and tangent to the anterior most projection of the
upper lip. The anterior most projection of the lower lip should be about 2 mm posterior to this line. A
parallel line dropped from the anterior most projection of the lower lip should be anterior to the
anterior projection of the chin in women and should be tangent to the anterior projection of the chin
in men.
Nasolabial angle (Figure 52.8B): The angle that is formed between the facial vertical line and the line
drawn through the most anterior and posterior edges of the nostril. The degree of rotation of the
nasal tip is assessed by evaluating the nasolabial angle. The angle is usually 95° to 100° in women
and 90° to 95° in men.
Nasofrontal angle (Figure 52.8C): This is determined by the angle of intersection of a line from the tip
to the radix corresponding the dorsal plane of the nose and a line along the plane of the brows.
Analysis of aesthetically pleasing noses reveals angles ranging from 128° to 140° with the ideal for
females being 134° and for males being 130°.
Columellar lobular angle (Figure 52.8D): This is the angle formed by the intersection of a line drawn
tangential to the columella and to the infratip lobule. This angle is ideally 30° to 45°.
Supratip break (see Figure 52.8C): A pleasing appearance particularly for the female nose is the
presence of a supratip break. This is a slightly greater dorsal angulation between the plane of the
nasal dorsum and the plane from the cephalic edge of the dome to the tip-defining point.
Tip projection (Figure 52.9): The degree to which the nasal tip extends from the face. This can be
measured by drawing a line from the alar cheek junction to the nasal tip, and the distance between
these two points should be approximately equal to the distance of the alar base width and should be
approximately 0.67 times the radix-to-tip distance or the nasal length (Figure 52.9A). Another
measure of tip projection states that 50% to 60% of a line drawn from the alar cheek junction to the
tip should lie anterior to a line drawn tangent to the most projecting portion of the upper lip (Figure
52.9B). Finally, the tip projection as measured from the alar base should equal the alar base width
(Figure 52.9C).
The alar-columellar relationship (Figure 52.10): Two lines are drawn, one through the long axis of the
nostril and the other from the alar rim to the columellar rim at the midpoint of the first line. The
distance from the alar rim to the first line should be the same as the distance from the columellar rim
to the first line. Increase in either of those distances may represent alar retraction or columellar show.
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FIGURE 52.4 A. Facial thirds. B. Facial fifths (yellow lines) and midline facial vertical for symmetry (black line).
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FIGURE 52.5 A. Dorsal aesthetic lines. B. Alar base width (a) and bony base width (b). C. Alar rim orientation. D. Gull wing
line. E. Opposing equilateral triangles.
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FIGURE 52.6 Base view/worm’s eye view showing triangle, lobular to nostril ratio, and nostril shape.
FIGURE 52.7 Nasal length. Ideal nasal length is equivalent to the stomiom-to-menton distance. A, ala; M, menton; R, radix; S,
stoma; T, tip.
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FIGURE 52.8 A. Ideal chin position. B. Nasolabial angle. C. Nasofrontal angle, dorsal line. D. Columellar lobular angle.
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