Phẫu Thuật Tạo Hình (Tập 2): Phẫu Thuật Thẩm Mỹ – Neligan (Ấn bản 4)

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SECTION I
CHAPTER 12 • Neck rejuvenation
supraplatysmal fat represented 44% of the total neck fat,
subplatysmal fat contributed to 30.7%, and the submandibular
glands 24.5%; the contribution from the deep fat was <1%.
The platysma muscles are thin, bilateral structures that are
continuous with the SMAS in the face.11,12 The platysma is
vertically oriented in the neck extending from the clavicles
inferiorly and predominantly horizontal in the lower face. The
subSMAS plane.4 Both the lingual and hypoglossal nerves lie
deep to the submandibular gland. Therefore, intracapsular
resection of the gland minimizes the risk of bleeding and
nerve injury.
Although not a motor nerve, the most commonly injured
nerve in facelift/necklift surgery is the great auricular nerve
(GAN). The GAN is a purely sensory nerve that supplies the
earlobe, antitragus, scapha, helical crus, and lower posterior
auricle. Historically, the most common way of locating the
GAN, where it is most superficial and vulnerable to injury, is
at McKinney’s point, defined as a point 6.5 cm inferior to the
external auditory canal as it crosses the midbelly of the sterno­
cleidomastoid muscle.5 Since that time, other authors have
found a greater variation in the location of the GAN than
initially reported. In a cadaveric study, Ozturk described a
danger zone of injury for the GAN, which can be defined by
drawing a vertical line through the midlobule perpendicular
to the Frankfort’s horizontal, followed by a 30° angle con­
structed posteriorly from the midlobule.6 Ozturk found that
the superior course of the GAN fell within this triangle 100%
of the time (Fig. 12.3). Remaining in a superficial dissection
plane over this danger zone can greatly decrease incidence of
GAN injury.
Three important planes exist in the neck: the superficial
plane between the skin and the platysma; the intermediate
plane composed of the platysma and the interplatysmal fat;
and the deep plane containing the subplatysmal fat, the anterior
belly of the digastric muscles, and the submandibular glands.7
Several authors have looked more closely at the fat compart­
ments in the neck, specifically the anatomy of subplatysmal
fat.8,9 Rohrich et al. described central, medial, and lateral
compartments which form a V-shaped adipose tissue mass that
extends from the lateral third of the mandible to the thyroid
cartilage.10 In contrast, Larson et al. only identified central
and lateral compartments. Furthermore, they found that the
Fig. 12.1  Fresh cadaver dissection demonstrating the marginal mandibular nerve
(large arrows) coursing superficial to the facial vessels (small arrow) but deep to
the SMAS. It is here where the marginal mandibular nerve passes from deep to the
parotid masseteric fascia into the subSMAS cleavage plane and superficial to the
facial vessels that it is most prone to injury during facelift surgery. The dotted line
represents lower mandibular border. “A” represents the masseter muscle; “B”
represents platysma muscle reflected anteriorly; “C” represents the submandibular
gland. Rectangle seen at the lower mandibular border of the full face fresh cadaver
orients the reader to close-up view of cadaver dissection.
B
A
C
Fig. 12.2  The mandibular cutaneous ligament is located in the parasymphyseal
region 67.8 ± 3.3 mm from the horizontal line constructed from the gonial angle
along the inferior border of the mandible. (A) Horizontal ruler marks the lower
mandibular border (horizontal dimension), vertical ruler marks gonial angle and is
perpendicular to horizontal (vertical dimension). Facial artery (FA), marginal
mandibular nerve (MMN), mandibular osseocutaneous ligament (MOCL), and
platysma mandibular ligament (PML) are noted. (B) Cadaver dissection. The
mandibular osseocutaneous ligament (MOCL) and platysma mandibular ligament
(PML) are marked in green.
A
PML
FA
MOCL
MMN
B

377
Effects of aging/disease process
fascia. The platysmal edges then pull away from the underly­
ing structures, shorten, and form visible bands.
In addition to skin quality, soft tissue laxity, and fat mal­
distribution, developmental variations of the bony anatomy
will have a decided effect on the aging process. Specifically,
sagittal and vertical microgenia and/or a skeletal class II
appearance will have a negative impact on support of the
lower face and neck. Similarly, an obtuse gonial angle or
mandibular plane will negatively affect lower facial aging.
Conversely, correction of these skeletal deformities will
have a decidedly positive effect on the facial aging process
(Fig. 12.5).
The hallmark of a youthful face is a well-contoured neck.16–19
Several criteria of a youthful neck have been defined, includ­
ing a curving or blunt cervicomental angle of 105–120°, a
distinct inferior mandibular border, a slightly visible thyroid
cartilage, and a visible anterior sternocleidomastoid border
(Fig. 12.6).20,21 Knize grades the degree of neck deformity on
a I–IV scale. Grade I represents an ideal neck angle and
increasing numbers indicate increasing deformity. Using this
system, he documented consistent and significant long-term
neck correction following anterior lipectomy and platysma­
plasty.22,23 It is important to note, however, that an isolated
necklift in the presence of significant jowling and descent of
the neck–face junction will generally not produce a pleasing
aesthetic result.7
Effects of aging/disease process
In patients with facial aging, the neck and face are ideally
treated simultaneously. Therefore, a necklift is an important
component of virtually any facelift procedure. Similarly, it is
the rare patient who will be best treated by neck surgery
alone. While this chapter is devoted to the aging neck, the
maneuvers described should be considered as part of the
facelift technique. Virtually all techniques used for neck cor­
rection can be performed through the submental incision.
Aging in the lower face is due to varying degrees of laxity
that develops in the skin, retinaculum cutis, and cutaneous
ligaments of the face. Which component is most responsible
for facial aging dictates the type of face/necklift procedure
chosen. The importance of laxity in the lower masseteric-
cutaneous ligaments as a major factor in the development of
Fig. 12.3  Danger zone of injury for the great auricular nerve (GAN) can be defined
by drawing a vertical line through the midlobule perpendicular to the Frankfort’s
horizontal (parallel line shown in figure), followed by a 30° angle constructed
posteriorly from the midlobule. The transparent tracings of each individual cadaver
dissection were overlaid to document nerve location, as shown in this 70-year-old
female cadaver. All nerves lay within a 30° angle (black lines).
Fig. 12.4  Variations in platysma anatomy in the
submental region. Type I: interdigitation of the platysma
muscle 1–2 cm posterior to the mandibular symphysis.
Type II: interdigitation of the platysma muscles from
mandibular symphysis to the thyroid cartilage. Type III:
no interdigitation of the platysma muscles.
Type I
Occurs in 75% of cases (most common).
Demonstrates a limited decussation of
platysma muscles, extending 1 to 2 cm
below the mandibular symphysis.
Type II
Occurs in 15% of cases.
Demonstrates decussation of the
platysma from the mandibular
symphysis to the thyroid cartilage.
Type III
Occurs in 10% of cases.
Demonstrates no decussation
or interdigitations.
platysma has osseous connections to the mandible as it
ascends over the mandibular border. And while separate, the
platysma is intimately related to the mandibular septum, both
structures sending fibers to the mandibular border.13 Reece
et al. recently described the mandibular septum. They suggest
that the septum may act as a sling impeding fat descent below
the mandible, thus helping prevent jowl formation.13 Because
the platysma is continuous with the SMAS and has minimal
bone contact, laxity in the SMAS is transmitted to the
neck.2,11,12,14 There are three variations of platysmal anatomy
in the submental region:
Type I (75%): interdigitation of the platysmal muscles
1–2 cm posterior to the mandibular symphysis.
Type II (15%): interdigitation of the platysma muscles from
the mandibular symphysis to the thyroid cartilage.
Type III (10%): no interdigitation of the platysma muscles
(Fig. 12.4).15
With age, the retaining ligaments attenuate from the free
medial edges of the platysma muscle to the deep cervical

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SECTION I
CHAPTER 12 • Neck rejuvenation
In Chapters 6.2–6.10, facelift techniques are reviewed and
authors present their preferred method to manipulate the
deeper soft tissues of the face. Conceptually, techniques that
involve the SMAS are based on the premise that a major
component of facial aging is due to laxity in the SMAS and
the cutaneous ligaments. Not only do the SMAS procedures
correct this laxity, but the SMAS also acts as a vehicle for
repositioning lower face and submental fat. Whether SMAS
plication,25 SMAS excision and closure (lateral SMASectomy)26
or ligament release, SMAS advancement and reattachment
(extended SMAS procedures)16–19,27–30 is superior, is open to
question. Furthermore, certain techniques favor a vertical
advancement of the SMAS,16–18,27–33 while others utilize an
oblique vector.25,26
Laxity in the lower face is transmitted to the neck because
the SMAS and the platysma are located in the same plane with
minimal bony attachments. Therefore, tightening of the SMAS
has a decided effect on the platysma. In sequencing SMAS
manipulation in the face and platysmaplasty in the neck,
SMAS procedures should be performed first. Theoretically, if
the platysmaplasty is done first, this locks the platysma in
place and prevents repositioning of jowl and neck fat into the
face by SMAS elevation.34
In Chapter 6.4, the MACS lift principle, originally described
by Tonnard, is reviewed. In that technique, platysma tighten­
ing is accomplished along a mostly vertical vector utilizing
purse-string sutures in the cheek. Fogli borrows on and
extends this concept by relying on posterior–superior traction
on the neck platysma rather than anterior (medial) platysma
tightening. He believes that it is counterproductive to separate
skin from platysma. He addresses the platysma with a verti­
cally oblique vector, to Lore’s fascia (platysma auricular fascia,
or parotid cutaneous ligaments). Higher in the cheek, he uti­
lizes oblique vectors, suturing submalar fat to the malar bone
and a running suture continues as an oblique vector ending
at the anterior parotid fascia. His technique is predicated on
the concept of addressing laxity where the laxity is greatest.
Lax SMAS is sutured to immobile areas such as the malar
bone and parotid fascia.14
While soft-tissue changes associated with facial aging
have received widespread attention, the effect of facial aging
on the bony skeleton has not. Aside from the clear adverse
effect of tooth loss on the lower vertical facial height on the
the jowl has been established for some time.24 More recently,
this anatomy and its implications for aging have been further
clarified by Mendelson.2 This information is thoroughly
reviewed in Chapter 6.1. Mendelson’s “premasseteric space”
overlies the lower one-half of the masseteric muscle. The roof
of the space is the platysma, the posterior border of the mas­
seter represents its posterior border, the inferior border of the
mandible and mandibular septum its inferior border, the
anterior border of the masseter and the lower masseteric-
cutaneous ligaments its anterior border. Superiorly are the
stout upper masseteric-cutaneous ligaments. This is a poten­
tial space in youth, but becomes a true space with facial aging,
expanding and bulging onto the masseteric ligaments. This
results in stretching and jowl formation.
Fig. 12.6  Profile view demonstrates the attributes of a youthful neck including
(1) a cervicomental angle of approximately 105°; (2) a distinct inferior mandibular
border; (3) a slightly visible thyroid cartilage; and (4) a visible anterior border of
the sternocleidomastoid muscle.
Fig. 12.5  Preoperative photographs of a 58-year-old female with sagittal microgenia and facial aging: (A) profile view, (B) front view. Post-operative photographs of the
same patient 15 months following facelift, with extended SMAS and anatomic silicone chin implant: (C) front view, (D) profile view.
A
B
C
D

379
Preoperative assessment
relative excess of the skin envelope, chin ptosis, and an
adverse effect on the profile with aging.
Preoperative assessment
An analysis of facial proportions on the patient with facial
aging is a good starting point for patient assessment from
both a diagnostic and treatment standpoint. This can be done
rapidly during the patient examination in the office, as well
as from patient photographs after the initial interview. There
are a number of good methods of both frontal and profile
assessment. The analysis in Fig. 12.8 depicts ideal frontal
facial proportions; Fig. 12.9, the ideal transverse; and
maxilla and mandible, bony changes associated with facial
aging have been limited to the correction of developmental
abnormalities of the cheek and chin and infraorbital rim.35–38
However, certain dicta described in the orthognathic surgery
literature should be applied to the aging lower face and
neck.35,39–42 Rosen has demonstrated that just as expansion of
the soft-tissue envelope is desirable in the patient with facial
aging, expansion of the bony envelope with augmentation
techniques should be favored over reduction procedures in
the aging face, even when taken beyond normal cephalometric
bounds.43,44
Horizontal advancement genioplasty tightens suprahyoid
musculature, expands the skin envelope, and improves the
profile (Fig. 12.7), while chin reduction procedures lead to a
Fig. 12.7  Preoperative photographs of a 30-year-old female with sagittal and vertical microgenia: (A) front view, (B) profile view. One year following horizontal
advancement genioplasty: (C) front view, (D) profile view.
A
B
C
D
Fig. 12.8  Ideal facial proportion in frontal view. Distance from medial canthus to
top of the brow “A” is roughly equal to the vertical distance of the upper lip “C”;
medial canthus to alar base “B” is roughly equal to the vertical distance from
commissure to menton “D”.
Fig. 12.9  Transverse dimensions. The bitemporal distance is equal to the
bizygomatic distance, which is equal to the bigonial distance. This model is slightly
wider in the bizygomatic dimension.

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CHAPTER 12 • Neck rejuvenation
is due to (1) the unique ability of neck skin to contract once
released from the platysma and (2) more, not less skin, is
needed once the obtuse angle of the neck becomes more acute,
i.e., the hypotenuse of a triangle is less than its two sides
(Fig. 12.14).
The degree of platysmal banding should be assessed and,
when present, a determination made as to where the platysma
is most lax, i.e., medially. Skin tightening and necklift without
platysmaplasty will lead to early platysmal band correction.
However, if present and not addressed, platysmal bands will
invariably recur shortly after surgery.
In evaluating neck fat, assessment should be made both
above and below the platysma. While fat above the platysma
is generally readily apparent, the amount of fat deep to the
platysma is more difficult to gauge. The proper estimate of
subplatysmal fat often requires platysma opening for accurate
assessment. A reasonable maneuver at the time of the patient
exam is to ask the patient to grimace. Fat above the platysma
should remain within the examining fingers while subplatys­
mal fat will be less apparent.
In general, if there is a question as to the presence of sub­
platysmal fat, the platysma should be opened because of the
inaccuracy of preoperative assessment. With regard to neck
defatting, the trend is towards conservatism. The majority of
defatting is done centrally, over the jowl and posterior to the
gonial angle. Skin flaps should be left relatively thick in order
to avoid irregularities and an over-resected unnatural appear­
ance of the neck.
Non-surgical options
Some non-surgical treatments have been advocated for neck
rejuvenation. These include botulinum toxin,55 injectable
fillers,56,57 lasers,58 and intense pulsed light.59 Although these
alternatives have a role in the treatment of facial aging, either
as ancillary or stand-alone procedures, they do not exert the
same impact on facial aging that is seen with face/necklift
surgery.
More recently, microfocused ultrasound (MFU) has been
developed to help meet the growing public demand for
achieving more significant non-invasive skin tightening and
lifting of the lower face and neck. Transducers direct ultra­
sound energy to focal points within the dermal layers of the
skin and SMAS where temperatures can reach 65°C, causing
tissue coagulation and collagen contraction.60,61 A variety of
transducers are available to treat different tissue planes up to
5 mm deep. Paramount to MFU technology is the sparing of
the epidermal layers of skin to any thermal injury.
Approved by the US Food and Drug Administration (FDA)
in 2009, the Ultherapy device (Ultherapy, Ulthera Inc., Mesa,
AZ) combines MFU with high-resolution ultrasound imaging
(MFU-V), enabling visualization of tissue planes to a depth of
8 mm and allowing the user to see where the energy will be
applied.
The most commonly reported adverse event associated
with MFU-V was brief discomfort during the treatment
session.62 Pretreatment with oral acetaminophen or non-
steroidal anti-inflammatory drugs (NSAIDs) and the applica­
tion of topical lidocaine prior to the procedure is advised.
Other reported adverse events include transient erythema,
edema, and occasional bruising.62
Fig. 12.10, the ideal proportions in profile. Facial aging is
exacerbated by deficiencies in lower vertical facial height (Fig.
12.11) and by lower face sagittal deficiencies (see Fig. 12.5).
Vertical deficiency in the frontal plane is corrected at the time
of facelift/necklift surgery by vertical lengthening genioplasty.
Sagittal microgenia is corrected by horizontal genioplasty
or alloplastic chin augmentation (see Figs. 12.5 & 12.7,
respectively).
Midface weakness in the pyriform aperture area or the
submalar area results in premature aging, deepening of the
nasolabial folds, and a relative excess of the soft-tissue enve­
lope. Expansion of the soft-tissue envelope by soft-tissue
augmentation with fat injection or with a submalar implant
has a beneficial effect on facial aging (Fig. 12.12).
An attractive gonial angle may be masked by the fatty
neck. Conversely defatting just posterior to the ramus of the
mandible and inferior to the gonial angle will define and
enhance the lower face. When defatting is combined with
SMAS tightening, the surgical result is significantly enhanced
(Fig. 12.13).
In evaluating the neck proper, aging in the neck may be
due to skin excess, fat accumulation, platysma laxity, digastric
hypertrophy, submandibular gland abnormalities, or anatomic
variants such as a low hyoid bone (i.e., abnormalities in the
superficial, intermediate, or deep planes).7 Evaluation of the
skin is relatively straightforward. Marked laxity or excess skin
dictates the need for a pre- and postauricular incision for proper
skin redraping. Mild to moderate skin laxity may be treated
by a short scar facelift approach or submental incision and
skin undermining through the submental approach. Numer­
ous authors have stated that skin often need not be removed
from the neck during face/neck rejuvenation.20–23,35,36,45–54 This
Fig. 12.10  Ideal profile dimensions: Reidel’s line. A tangent is drawn from upper
lip to lower lip. Ideal chin position should fall on this line.

381
Surgical options
is younger with normal wound healing because the body’s
healing response to MFU-V is partially dependent on de novo
collagen synthesis.65 Additionally, MFU does not target
melanin and is, therefore, safe for all skin types. Patients with
severe neck laxity, platysmal banding, or significant amounts
of pre- and subplatysmal fat are not good candidates and
should be recommended for surgical correction.
Surgical options
The most effective approach to the aging face and neck is
through the facelift approach, either using a short scar
Oni et al. conducted the largest prospective non-randomized
clinical trial on 103 adults to study the effectiveness of Ulthe­
rapy on rejuvenation of the lower face. At day 90, they found
improvements reported by two-thirds of patients and by 60%
of blinded reviewers. They also observed better outcomes in
patients with a body mass index (BMI) of ≤30 kg/m2.63 In a
retrospective study evaluating results at 90 and 180 days after
treatment, Fabi reported more than 80% of subjects indicated
improvement in face and neck characteristics. Additionally,
there was no evidence of association between improvement
and age, Fitzpatrick skin type, alcohol intake, or major illness.64
MFU-V is most appropriate for patients with mild-to-
moderate laxity of the skin and soft tissues. The ideal patient
Fig. 12.11  (A) Preoperative frontal view
demonstrates less than ideal facial
proportions with eyebrow height significantly
less than the vertical height of the upper lip
(see Fig. 12.8). (B) The patient also
demonstrates ptosis of the chin in
preoperative profile view. (C) A 6-year
postoperative frontal view demonstrates
maintenance of corrected brow position
following endoscopic browlift and extended
SMAS facelift surgery. (D) A 6-year
postoperative profile view demonstrates
maintenance of soft-tissue chin correction.
A
B
C
D

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CHAPTER 12 • Neck rejuvenation
6. Alloplastic anatomic chin implant placement when
indicated.
Open surgical rejuvenation of the aging neck usually includes
some form of platysma modification. The platysma is
approached in the midline, opened, interplatysmal and sub­
platysmal fat removed, and the platysma is tightened by
closing it vertically. In addition, the muscle may be partially
divided in the horizontal direction low in the neck. This is
performed to allow the platysma to ride up superiorly, further
defining the cervicomental angle.
A wide variety of platysmaplasties have been described,
including lateral plication,68 varying degrees of low, horizon­
tal, partial transaction, either medially or laterally,16 simple
midline suturing,69,70 the corset platysmaplasty,45 and the
pants-over-vest platysma plication in the midline.71 Cruz et al.
more recently described the “platysma window”, an approach
that enables lateral platysma tightening, while minimizing the
technique for patients with minor neck laxity7,26,66,67 or using
a standard pre- and postauricular incision for those with
significant laxity in the neck. These techniques are reviewed
in Chapter 6. As mentioned earlier, when the SMAS is tight­
ened through a facelift approach, there is a decided benefit on
the neck platysma because there is minimal bony attachment
of the platysma to the mandible. Hence, SMAS tightening
above the mandible leads to platysma tightening below the
mandible. That being said, all other maneuvers used to
address the aging neck may be performed through the sub­
mental approach except for skin excision and horizontal
genioplasty. Direct neck procedures include the following:
1. Defatting superficial to the platysma
2. Subplatysmal and interplatysmal defatting
3. Medial platysmaplasty/platysma tightening
4. Platysma plication over the submandibular gland
5. Submandibular gland resection
Fig. 12.12  (A) Preoperative photograph of
a 38-year-old female with facial aging,
submalar hollow, and deep nasolabial folds.
(B) At 1 year following facelift with extended
SMAS and submalar implants.
A
B
Fig. 12.13  A 45-year-old female with facial aging, obtuse cervicomental angle, and loss of gonial angle: (A) front view, (B) profile view. At 1 year following extended
SMAS facelift, submental lipectomy and platysmaplasty and defatting of the gonial angle: (C) front view, (D) profile view.
A
B
C
D

383
Surgical options
risk of injury to the great auricular nerve at McKinney’s
point.72 In this technique, a 2-cm platysma flap is created one
finger breadth inferior to the angle of the mandible and
anterior to the anterior border of the sternocleidomastoid. The
platysma is tightened by placing two figure-of-eight spanning
sutures that extend from the plastysma window to the mastoid
fascia while sparing the nerve.72
Suspension sutures designed to improve the jawline and
neck–jaw angle were first described by Guerrerosantos73 and
then popularized by Giampapa.74 The principle is to create a
permanent artificial “ligament” under the mandible to correct
the deformities of the aging neck. Multiple variations of this
technique have been developed. Ramirez’s mattress suspen­
sion sutures utilizes a permanent suture (2-0 nylon, Gore-Tex)
from the submental area to mastoid and back, bilaterally.75
Feldman recently described a modification of the Ramirez
technique, called the “tuckster sutures”.76 After completing
the corset platysmaplasty, an absorbable suture is run from
the submental area to the mastoid fascia. Multiple bites are
taken in the platysma, below the mandibular border, address­
ing platysma laxity under the jawline and defining the lower
jaw border and gonial angle76 (Fig. 12.15). However, the long-
term efficacy of suture suspension techniques in improving
and masking abnormalities deep to the platysma has been
questioned by a number of authors.54,77 These authors prefer
muscle modification to suture suspension.
The submental approach to the neck can, therefore, be
considered either as an integral step to facial rejuvenation
or as a stand-alone procedure in selected individuals. In
Giampapa’s submental approach, liposuction was used to
defat the neck and for skin release. Medial platysmal bands
were resected when necessary and two interlocking sutures
from one digastric muscle to the opposite mastoid region
were placed.74,78,79 Since his description, a number of authors
have described a variety of submental approaches combin­
ing platysmaplasty with skin undermining.22,23,35,46–54,80–82
While each of these techniques varies to some degree, con­
ceptually they owe a good deal of their efficacy to lessons
learned from neck liposuction.83,84 We learned a number of
years ago that neck skin, unlike many other areas, has the
unique ability to contract when released from fibrous septae
Fig. 12.14  More, not less skin is needed in the neck once the obtuse
cervicomental angle is converted to a pleasing neckline, i.e., the hypotonuse of a
triangle is a shorter distance than the sum of its limbs.
and cutaneous ligaments. Knize’s22,23 anterior lipectomy and
platysmaplasty, which he practiced beginning in the early
1980s, utilizes a submental approach, medial platysmal plica­
tion, and submental undermining with excellent, long-term
results.
Recently, Feldman published an update of his necklift
techniques.45–52,85 His approach continues to consist of a
submental incision, defatting, a corset platysmaplasty, and
A
B
Fig. 12.15  The corset (Feldman) platysmaplasty. The platysma is opened in the
midline and subplatysmal modifications performed, including defatting, digastric
shave, or submandibular gland partial resection as indicated. The corset consists of
a running suture from chin to thyroid cartilage, re-approximating and tightening
medial playtsma edges. The suture is then run back up to the chin outside the first
suture line and halfway down again, progressively tightening the platysma corset
(A). Laterally, an absorbable “tuckster” suture is run from the submental area to the
mastoid fascia. Multiple bites are taken in the platysma, below the mandibular
border, addressing platysma laxity under the jawline and defining the lower jaw
border and gonial angle (B). (Adapted from Feldman J. Neck lift my way: an update.
Plast Reconstr Surg. 2014;134:1173–1183.)

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CHAPTER 12 • Neck rejuvenation
Fig. 12.16  A 40-year-old female with an obtuse cervicomental angle and submental fat. (A,B) Preoperatively. (C,D) At 13 months following liposuction using a submental
approach only.
A
B
C
D
varying degrees of undermining; however, he has reintro­
duced the use of lateral skin excision to manage lax skin.
He believes that by excising neck skin laxity through a
postauricular incision, rather than counting on skin contrac­
tion, more consistent contour improvement is observed.
Consequently, lateral neck skin excision is now applied in
the majority of his necklifts. Exceptions include patients
with (1) not enough hair to hide the postauricular scar;
(2) no interest of having additional incisions; and (3) good
skin tone.76
Ramirez has also described his anterior approach. Most
recently, he has added a horizontal plicating, submandibular
suture to his technique.86
The authors of the anterior approach to neck rejuvenation
are also in agreement on where to most effectively address
platysma tightening. They address it medially where it dem­
onstrates the most laxity. This is in direct contrast to Tonnard
and Fogli, who depend on a posterior vertical vector to effect
neck rejuvenation. Early on, Tonnard and Verpaele66 avoided
the anterior approach, although more recently, they and their
colleagues appear to be moving toward more medial platys­
mal plications in older individuals.14,67,87
Surgical approaches to neck rejuvenation include:
1. Liposuction
2. Anterior (submental) incision
3. Direct skin excision and Z-plasty.
Liposuction
Liposuction exerts its affect via a combination of subcutane­
ous fat removal and release of skin–muscle attachments.
Release of the skin from underlying platysma muscle allows
for avid skin contraction in young and middle-aged patients.
The ideal patient for neck liposuction is the relatively
young patient with good skin elasticity who has localized
submental and submandibular fat. In such patients, the tech­
nique is straightforward and uniformly excellent results
should be obtained. The result can be further enhanced in
patients with sagittal microgenia with the addition of a genio­
plasty. Correction of the skeletal deficiency combined with
submental liposuction can yield a dramatic result (Fig. 12.16).
The operation can be extended to treat patients with mark­
edly fat necks or patients with mild or moderate skin excess.
In such patients, submental and postauricular approaches are
used to minimize skin contour abnormalities. Wider skin
undermining should also be practiced to maximize skin
contraction (Fig. 12.17). While not ideal patients, this group
will demonstrate significant improvement.
Liposuction of the neck can either be undertaken with
suction-assisted lipectomy (SAL) or ultrasound-assisted
liposuction (UAL).
UAL emulsifies the supraplatysmal fat, which is then
evacuated. Ultrasonic energy causes an inflammatory reac­
tion, which some believe causes enhanced skin contraction.7
However, the use of UAL carries the potential risk of thermal
injury, dysesthesias, and marginal mandibular nerve palsy.88
UAL has, therefore, not been widely adopted in the submental
region because of its increased potential for complications,
complex and bulky instrumentation, and additional cost.
Newer technologies include VASER (vibration amplifica­
tion of sound energy at resonance) and SmartLipo (Cynosure,
Westford, MA). VASER is a fat pretreatment device based
on the emission of pulsed or continuous ultrasound energy
to emulsify fat before its aspiration. With thinner cannulas
and decreased use of ultrasonic energy, it is theoretically a
safer and more efficient process than standard ultrasonic
liposuction.89,90
SmartLipo uses an internal neodymium : yttrium-alumi­
num-garnet laser (1064 nm) to rupture fat cells. The laser
energy also interacts with the dermis, theoretically resulting
in collagen shrinkage, improving skin tightness and smooth­
ness on the neck.91 However, higher concentrations of free
fatty acids after laser-assisted lipoplasty may cause possible
hepatic and renal toxicity.92
Technique for liposuction of the neck
Liposuction of the neck can be performed readily under local
or general anesthesia. The patient is marked in the sitting
position prior to surgery, noting the location of submental
and/or submandibular fat and the extent of tunneling to
be performed. A large volume (50 cc) of 0.5% lidocaine
(Xylocaine; AstraZeneca, Wilmington, DE) and 1 : 2 000 000

385
Surgical options
is further improved by (1) subplatysmal and interplatysmal
fat removal; (2) the options of digastric muscle shave or plica­
tion; and (3) platysmaplasty and the resultant muscle tighten­
ing (Fig. 12.18).1,7
Proper patient selection is critical to surgical success. This
procedure is not an alternative to facelift, since no changes
will be noted above the lower mandibular border. Many
patients assume that the anterior approach will also correct
jowl formation, which it generally does not. In fact, there is
little change in the frontal view. Significant change will be
seen in profile only. To assure patient satisfaction, careful
explanation of the benefits and limitations of the procedure
are to be emphasized.
Patient selection is best guided by the degree of skin laxity.86
We, therefore, arbitrarily divide our patients into four groups
depending on their laxity of skin: grade I (no laxity); grade II
(mild); grade III (moderate); and grade IV (severe).54
These four patient grades fall relatively neatly into our
treatment paradigm: grade I patients (no skin laxity) may be
treated by liposuction alone through single or multiple inci­
sions. If, however, subplatysmal fat is suspected, at the comple­
tion of liposuction, the submental incision is opened and
subplatysmal and interplatysmal fat is sought out. Since it is
epinephrine is injected through the submental and postauricu­
lar approach. For maximum vasoconstriction effect, 15 min is
allowed to elapse.
A small caliber (2.4-mm) suction cannula with single or
multiple holes is used. Holes are directed toward the soft
tissue; liposuction is begun through the submental incision
using wall suction fanning out from the submental incision.
Additional postauricular stab incisions can be utilized to
cross-liposuction. Relatively little fat is generally removed
and overly aggressive liposuction is to be avoided to minimize
postoperative adverse sequelae such as contour irregularities,
banding, and skeletonization of the neck. Less is generally
more with this procedure. Normally, little change is seen on
the operating table. No drains are used. An elastic garment is
worn for 5 days postoperatively and for 2 weeks at night
only.53
Anterior (submental) incision
The anterior approach to neck rejuvenation (anterior lipec­
tomy and platysmaplasty, necklift without a preauricular
incision) improves upon the results of previous neck liposuc­
tion techniques. In addition to skin contraction, neck contour
Fig. 12.17  A 62-year-old female with submental fullness, moderate neck skin laxity: (A) front view, (B) profile view. Same patient 1 year postoperatively following
submental lipectomy, subplatysmal defatting, and platysmaplasty without a preauricular incision: (C) front view, (D) profile view.
A
B
C
D
Fig. 12.18  A 55-year-old female with mild skin laxity and an obtuse cervical angle secondary to fat: (A) front view, (B) profile view. Same patient 1 year following
submental lipectomy and medial platysmaplasty and subplatysmal fat removal: (C) front view, (D) profile view.
A
B
C
D

386
SECTION I
CHAPTER 12 • Neck rejuvenation
(Stryker, Portage, MI) is continued inferiorly. Fat distribution
in the subplatysmal and interplatysmal location is in the
shape of an inverted “T” extending laterally as dissection
extends inferiorly. Lymph nodes and anterior jugular branches
are routinely encountered. Nodes are removed and vessels
cauterized. Once defatting has extended down to the thyroid
cartilage, dissection is complete and the platysmaplasty of
choice is performed.
A postauricular sulcus incision is made on each side, and
through this incision the posterior dissection is completed.
If moderate laxity exists, the dissection extends over the
sternocleidomastoid. If not, a posterior sulcus incision is
made merely for ease of drain placement. The neck is drained
with a 7-mm J-Vac drain (Ethicon Inc., Somerville, NJ) in
all cases.
Direct excision of neck skin and Z-plasty
Although frowned upon by many, the direct excision of neck
skin and Z-plasty is a reasonable alternative in the elderly.
This generally applies to men in their mid- to late 70s or older
with significant submental skin excess, but on occasion can be
used in males or females as an adjunct to facelift surgery in
patients with massive weight loss. This procedure will appeal
to those elderly males who are unwilling to undergo a more
involved facelift procedure with its associated longer recovery,
added risk, and cost. However, the patient must understand
the location and extent of the neck scar before proceeding.
Photographs are particularly helpful in this regard (Fig. 12.20).
The procedure has the added benefit of being readily
performed under local anesthesia with or without seda­
tion. Skin excision tends to produce perhaps even a better
neckline than a standard facelift in this patient population,
once again, because skin excision is performed where laxity is
greatest (see Fig. 12.19). Although numerous techniques have
been described in the literature,94–98 we prefer the Gradinger
technique.99
Ideal candidates are non-obese elderly males with signifi­
cant skin excess. Diffusely fatty necks can be problematic as
smooth contour can be difficult to obtain.
Postoperatively, occasional mild hypertrophic scarring can
occur at 3 months, which readily resolves with dilute triam­
cinolone injections.
often difficult to determine whether subplatysmal fat is
present without opening the platysma, the platysma is opened
if there is any question. Grade II patients (mild skin laxity)
with an obtuse cervicomental angle are good candidates for
the anterior approach. Fat above the platysma, interplatysmal
fat, and subplatysmal fat are all readily treated through the
submental incision. The degree of skin undermining is dic­
tated by the degree of skin laxity. A good rule of thumb is that
the amount of undermining should be similar to the amount
one would do for that given patient if a standard facelift were
being performed. These patients with mild laxity will need
undermining to the anterior border of the sternocleidomas­
toid, while those with moderate laxity (grade III) will require
more extensive undermining over the sternocleidomastoid
muscle for adequate skin redraping (see Figs. 12.17 & 12.18).
Patients with marked skin excess (grade IV) are not candidates
for the anterior approach and will need standard facelift
techniques or a direct excision of neck skin and Z-plasty for
correction of facial aging (Fig. 12.19).53,93–96
While skin laxity is the most important factor in patient
selection, others come into play. Patients with diffusely fat
necks tend to be more difficult patients. Smooth contours are
more difficult to obtain and irregularities are more common.
Men tend to have less impressive results, presumably because
of thicker more sebaceous skin and less avid skin contraction.54
Technique for anterior lipectomy
and platysmaplasty (Video 12.1 )
As described for the patient undergoing neck liposuction, the
patient is marked preoperatively in the sitting position,
marking the submental fullness, the location of submandibu­
lar fat, the extent of planned undermining, and the submental
and posterior sulcus incisions. Infiltration with 50 cc of 0.5%
Xylocaine with 1 : 400 000 epinephrine, is similar to that
described for neck liposuction. A 3.5-cm submental incision is
made and superficial subcutaneous undermining is per­
formed. The extent of undermining is dictated by the degree
of skin laxity and excess. Once superficial undermining and
superficial defatting have been completed, the platysma is
opened in the midline, and interplatysmal and subplatysmal
fat removed. Fat is removed flush with the anterior belly of
the digastric muscles. Defatting using the Colorado needle
Fig. 12.19  A 67-year-old male with deep nasolabial folds and neck laxity due to skin excess and platysmal laxity: (A) front view, (B) profile view. Same patient 1 year
following direct excision of neck skin, Z-plasty, and direct excision of nasolabial folds: (C) front view, (D) profile view.
A
B
C
D

387
Complications
Management of the submandibular glands
Ptotic submandibular glands should be noted preoperatively,
as they will detract from the surgical result. Platysmaplasty,
direct plication over the gland, and submandibular gland
suspension will improve but not eliminate their visibility.
Indirectly re-establishing fascial support by SMAS plication
or platysmal suspension has also not proven to be effective in
the long term. Numerous authors have described suspension
or cable sutures from the submental or digastric muscle to the
mastoid process with reported success,74,80,81 while others
question these long-term results.77
While these authors do not remove submandibular glands
due to the possibility of significant complications, others
do.7,26,86,100,101
Technique for submandibular gland suspension
This technique is well described by Sullivan et al.102 The posi­
tion of the submandibular gland is marked preoperatively, the
neck is approached through a submental incision and the
platysma is opened. The capsule of the gland is found by
dissection underneath the platysma and lateral to the digastric
muscle. A 1.5-cm incision along the anterior surface of the
capsule parallel to the body of the mandible allows access to
the gland. Gentle dissection releases adhesions allowing
complete mobilization.
A hemostat is then used to create a subperiosteal tunnel
around the gland and along the lingual aspect of the man­
dibular body. A stab incision over the tip of the hemostat
establishes intraoral access. The end of a 2-0 suture is then
brought out through the neck incision.
A second pass lateral to the gland is performed. The peri­
osteal tunnel created for this suture is parallel but 3 cm
anterior to the initial one. The opposite end of the suture is
grasped and again pulled down into the neck. This creates a
suspension arc. The submandibular gland is then elevated
with gentle digital pressure and the knot secured. Finally, the
incised capsule is imbricated with a permanent suture and the
intraoral incision closed with chromic.102
Complications
Complications following neck rejuvenation surgery are similar
to those seen with standard facelift surgery.
Early complications
• Hematoma
• Seroma
• Sialoma
• Injury to the marginal mandibular branch of the facial
nerve
• Injury to the frontal branch of the facial nerve.
Late complications
• Contour irregularities
• Asymmetrical fat removal
• Inadequate reduction
• Overcorrection.
Postoperative care
Minimizing postoperative problems begins in the operating
room. Control of bleeding should be meticulous. The anesthe­
siologist should raise the blood pressure to the preoperative
blood pressure level as hemostasis is being gained. Relative
hypotension will mask bleeding. Raising the pressure toward
the end of the procedure will conversely minimize postopera­
tive hematoma. The recovery from anesthesia should be
smooth without coughing or retching. With the exception of
liposuction, patients are seen the morning following surgery.
At that time, the operative dressing and drain are removed.
Drains are used in all cases when there is significant neck
dissection. However, if drainage is significant, i.e., >30 cc in
24 h, the drain remains in place until the drainage has sub­
sided. Drainage is likely to be significant in fat necks or if
electrocautery is used to raise flaps. Therefore, scissor dissec­
tion is favored for skin flap elevation.
A chinstrap is worn continuously for 5 days and at night
for 2 weeks for those undergoing platysmaplasty and fat
resection. Patients are instructed to sleep with their heads
elevated and necks gently extended. A single pillow posi­
tioned behind the head should be avoided. Cervical flexion
can increase edema through venous obstruction, place excess
tension on mastoid region closures, and diminish adherence
of the skin to underlying structures.
There should be no heavy lifting or bending in the immedi­
ate postoperative period. NSAIDs and anticoagulants are best
avoided for at least 1 week after neck rejuvenation. Finally,
good communication between the surgeon and patient
increases cooperation and helps achieve a better surgical
outcome.
Fig. 12.20  Well-healed neck scar 1 year following direct excision of neck skin and
Z-plasty.

388
SECTION I
CHAPTER 12 • Neck rejuvenation
The incidence of hematoma following facelift or the variety of
necklift procedures described in this chapter vary greatly,
from as low as 1% to significantly higher, depending upon the
study cited in the literature.103 The incidence of hematoma can
be minimized by performance of a careful history, making
certain that anticoagulants and antiplatelet medications are
avoided for 1–2 weeks preoperatively, and careful attention to
detail is carried out intraoperatively.
Other time-honored means of reducing incidence of hema­
toma include the avoidance of postoperative hypertension,
nausea, and vomiting. As mentioned earlier, attention to
blood pressure at the time of flap closure has been helpful in
our experience. Other adjuncts such as platelet-rich plasma104
and fibrin glue have been cited as effective in some hands,
while others have found these ancillary-type techniques
ineffective.105–107
There is no crime in getting a hematoma, but there certainly
is a crime in not recognizing one. Clearly, early evacuation of
both small and large hematomas minimize postoperative
morbidity. An expanding hematoma is a surgical emergency
due to the potential for airway compromise and skin flap
necrosis. Small hematomas, however, can also be troublesome
postoperatively. They are frequently missed because of facial
swelling and lead to long-term irregularities and patient
concerns. Large hematomas obviously need to be evacuated
in the operating room. However, small hematomas can often
be aspirated, milked out through the drains, or evacuated
with a suction cannula. If a small hematoma goes unrecog­
nized in the early postoperative period, it can be drained 7–14
days following surgery when the clot lyzes, and the hematoma
can be drained percutaneously.
Seromas are most frequent in the neck area and can also be
troublesome postoperatively. Unrecognized seromas lead to
neck contour irregularities, which are difficult or impossible
to correct. While it is not universally performed, most
surgeons drain the neck postoperatively. Our preference is to
use suction drains to obliterate dead space and minimize
seroma fluid collections. Drains are removed when output is
minimal. This may require drainage for 24 h or more. Should
a seroma occur in the neck following drain removal, repeat
aspiration is indicated until the seroma subsides.
Sialoma is a rare, but not unheard of, face/necklift compli­
cation. This may occur following subSMAS surgery or sub­
mandibular gland resection. It should be suspected when
clear fluid is found in the drain or by aspiration. The diagnosis
of parotid fistula is confirmed by measuring the amylase level
in the aspiration fluid. In the case of parotid fistulas, the
amylase level will be quite high. Suction drains that obliterate
dead space rather than repeated aspiration appears to be the
most effective means of resolving the fistula. In the absence
of distal obstruction, the fistula will close.
Facial nerve injury is also rare, most commonly involving
the marginal mandibular branch of the facial nerve, or the
frontal branch if a facelift approach is used. Most injuries are
relatively distal and resolve. However, marginal mandibular
nerve injury is more likely than frontal branch injury to be
permanent due to its peculiar anatomy. Re-exploration for
facial nerve injury is generally not indicated since injury is
most likely distal. The use of botulinum toxin A to weaken
the contralateral muscles is a reasonable temporizing approach
while waiting for the nerve injury to resolve.
Late complications of face and neck rejuvenation are gener­
ally aesthetic and include contour abnormalities due to the
irregular resection of fat, the unmasking of ptotic subman­
dibular glands, pixie ears, and abnormalities of scar forma­
tion. Neck banding due to over-resection of fat, unrecognized
seromas, or irregularities caused by platysma plication are
notoriously difficult to treat. Conservative defatting is the best
prevention.
2. Mendelson BC, Freeman ME, Wu W, et al. Surgical anatomy of the
lower face: the premasseter space, the jowl, and the labiomandibular
fold. Aesthetic Plast Surg. 2008;32:185–195. The areolar cleavage plane
overlying the lower masseter has specific boundaries and is a true space
named the “premasseter space”. This space is rhomboidal in shape, lined by
membrane, and reinforced by retaining ligaments. The masseter fascia lines
the floor and branches of the facial nerve pass under its deep surface. The
roof, lined by a thin transparent and adherent membrane on the underside
of the platysma, has a less dense collagen network and contains more
elastin. With aging, there is a significant reduction in the collagen density
of the roof. Expansion of the space with aging, secondary to weakness of the
anterior and inferior boundaries, results in formation of the jowl. Medial to
the premasseter space is the buccal fat in the masticator space, which
descends with aging and contributes to the labiomandibular fold and jowl.
The premasseter space should be considered as the preferred dissection plane
for lower (cervicofacial) facelifts because the space is a naturally occurring
cleavage plane and dissection is bloodless and safe as all the facial nerve
branches are outside of it.
7. Nahai F, ed. Neck lift. In: The Art of Aesthetic Surgery: Principles and
Techniques. Vol. 2. St. Louis, MO: Quality Medical Publishing;
2005:1239–1284.
14. Fogli AL. Skin and platysma muscle anchoring. Aesthetic Plast Surg.
2008;32:531–541.
24. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr
Surg. 1989;83:11–16.
26. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–
513. With the advent of liposuction in the 1980s, the author found that he
could obtain excellent neck contouring in many patients utilizing
liposuction combined with strong, lateral platysmal suturing. In a lateral
SMASectomy, a portion of the SMAS in the region directly overlying the
anterior edge of the parotid gland is removed. Because of this design, the
SMASectomy is performed at the interface of the superficial fascia fixed by
the retaining ligaments and the more mobile anterior superficial facial
fascia. On closure, this brings the mobile SMAS up to the junction of the
fixed SMAS, producing a durable elevation of both superficial fascia and
facial fat. The direction in which the SMASectomy is performed is
oriented so that the vectors of elevation following SMAS closure lie
perpendicular to the nasolabial fold, thereby producing improvement not
only of the nasolabial fold but also of the jowl and jawline.
33. Little JW. Three-dimensional rejuvenation of the midface:
volumetric resculpture by malar imbrication. Plast Reconstr Surg.
2000;105:267–269.
45. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg. 1990;85:333–
343. The corset platysmaplasty was developed to avoid producing necks
that display persistent or recurrent paramedian muscle bands, visible
submandibular gland bulges, and various contour irregularities. The two
medial edges of the platysma are joined together with a continuous suture
that runs down almost the full height of the neck to create a smooth, flat,
multilayered seam, leaving no free muscle edges. Progressive side-to-side
tightening along the midline defines the “waistline” of the neck.
Additional submandibular suturing may then be done to create strong,
Access the complete reference list online at

389
Complications
flat, vertical muscle pleats that correct submandibular gland bulging and
refine the jawline and anterolateral neck contours.
54. Zins JE, Menon N. Anterior approach to neck rejuvenation. Aesthet
Surg J. 2010;30:477–484. The anterior (submental) approach to neck
rejuvenation is one of the minimally invasive procedures with clear
documentation of long-term efficacy. The procedure improves upon
previous neck liposuction because in addition to skin contraction, the
results are enhanced by the removal of subplatysmal and interplatysmal
fat, the options of digastric muscle alterations and platysmal muscle
tightening. The technique is described in detail, potential complications
noted, and technical limitations of the procedure described.
66. Tonnard P, Verpaele A. The MACS-lift short scar rhytidectomy.
Aesthet Surg J. 2007;27:188–198.
67. Tonnard P, Verpaele A, Morrison C. MACS facelift. In: Aston SJ,
Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. New York,
NY: Saunders Elsevier; 2009:137–148.
76. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg.
2014;134:1173–1183.

389.e1
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labiomandibular fold. Aesthetic Plast Surg. 2008;32:185–195. The
areolar cleavage plane overlying the lower masseter has specific
boundaries and is a true space named the “premasseter space”. This
space is rhomboidal in shape, lined by membrane, and reinforced by
retaining ligaments. The masseter fascia lines the floor, and branches of
the facial nerve pass under its deep surface. The roof, lined by a thin
transparent and adherent membrane on the underside of the platysma,
has a less dense collagen network and contains more elastin. With aging,
there is a significant reduction in the collagen density of the roof.
Expansion of the space with aging, secondary to weakness of the anterior
and inferior boundaries, results in formation of the jowl. Medial to the
premasseter space is the buccal fat in the masticator space, which
descends with aging and contributes to the labiomandibular fold and
jowl. The premasseter space should be considered as the preferred
dissection plane for lower (cervicofacial) facelifts because the space is a
naturally occurring cleavage plane and dissection is bloodless and safe as
all the facial nerve branches are outside of it.
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509–513. With the advent of liposuction in the 1980s, the author
found that he could obtain excellent neck contouring in many patients
utilizing liposuction combined with strong, lateral platysmal suturing.
In a lateral SMASectomy, a portion of the SMAS in the region directly
overlying the anterior edge of the parotid gland is removed. Because of
this design, the SMASectomy is performed at the interface of the
superficial fascia fixed by the retaining ligaments and the more mobile
anterior superficial facial fascia. On closure, this brings the mobile
SMAS up to the junction of the fixed SMAS, producing a durable
elevation of both superficial fascia and facial fat. The direction in which
the SMASectomy is performed is oriented so that the vectors of elevation
following SMAS closure lie perpendicular to the nasolabial fold, thereby
producing improvement not only of the nasolabial fold but also of the
jowl and jawline.
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30. Owsley JQ. Mechanical properties and microstructure of the
superficial musculoaponeurotic system. Plast Reconstr Surg.
1996;98:59–73.
31. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg.
1992;90:1–13.
32. Hamra ST. Composite rhytidectomy. St. Louis, MO: Quality Medical
Publishing; 1993.
33. Little JW. Three-dimensional rejuvenation of the midface:
volumetric resculpture by malar imbrication. Plast Reconstr Surg.
2000;105:267–269.
34. Stuzin J, pers. comm. 2004.
35. Zins J, Morrison C. Aesthetic surgery of the aging face and neck.
In: Siemionow M, Eisenmann-Klein M, eds. Plastic and
Reconstructive Surgery. London: Springer; 2009:379–392.
36. Flowers RS. Tear trough implants for correction of tear trough
deformity. Clin Plast Surg. 1993;20:403–415.
37. Yaremchuk MJ. Infraorbital rim augmentation. Plast Reconstr Surg.
2001;107:1585–1595.
38. Yaremchuk MJ, Israeli D. Paranasal implants for correction of
midface concavity. Plast Reconstr Surg. 1998;102:1676–1685.
39. Bartlett SP, Grossman R, Whitaker LA. Age-related changes of the
craniofacial skeleton: an anthropometric and histologic analysis.
Plast Reconstr Surg. 1992;90:592–600.
40. Pessa JE, Zadoo VP, Mutimer KL, et al. Relative maxillary
retrusion as a natural consequence of aging: combining skeletal
and soft-tissue changes into an integrated model of midfacial
aging. Plast Reconstr Surg. 1998;102:205–212.
41. Whitaker LA. Biological boundaries: a concept in facial skeletal
restructuring. Clin Plast Surg. 1989;16:1–10.
42. Whitaker LA, Bartlett SP. Skeletal alterations as a basis for facial
rejuvenation. Clin Plast Surg. 1991;18:197–203.
43. Rosen HM. Surgical correction of the vertically deficient chin. Plast
Reconstr Surg. 1988;82:247–256.

389.e2
SECTION I
CHAPTER 12 • Neck rejuvenation
44. Rosen HM. Aesthetic guidelines in genioplasty: the role of facial
disproportion. Plast Reconstr Surg. 1995;95:463–472.
45. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg.
1990;85:333–343. The corset platysmaplasty was developed to avoid
producing necks that display persistent or recurrent paramedian muscle
bands, visible submandibular gland bulges, and various contour
irregularities. The two medial edges of the platysma are joined together
with a continuous suture that runs down almost the full height of the
neck to create a smooth, flat, multilayered seam, leaving no free muscle
edges. Progressive side-to-side tightening along the midline defines the
“waistline” of the neck. Additional submandibular suturing may then be
done to create strong, flat, vertical muscle pleats that correct
submandibular gland bulging and refine the jawline and anterolateral
neck contours.
46. Feldman JJ. Corset platysmaplasty. Clin Plast Surg. 1992;19:
369–382.
47. Feldman JJ. My Approach to Neck Lift. Denver, CO: Colorado
Society of Plastic Surgeons; 1995.
48. Feldman JJ Lesser lifts and ancillary procedures. Annual Meeting of
the American Society of Aesthetic Surgery; Orlando, FL, 1996.
49. Feldman JJ The isolated neck lift. Massachusetts General Hospital
Aesthetic Symposium; Vail, CO, 1996.
50. Feldman JJ Face or neck lift without a postauricular incision. 33rd
Annual Meeting of the American Society of Aesthetic Surgery;
Orlando FL, 2000.
51. Feldman JJ Approach to face-neck-brow-periorbital lift. Instructional
course. Annual Meeting of the American Society of Plastic
Surgeons; San Antonio, TX, 2002.
52. Feldman JJ Small incision necklift. Instructional course. Annual
Meeting of the American Society of Aesthetic Surgery; Vancouver,
Canada, 2004.
53. Zins JE, Fardo D. The “anterior-only” approach to neck
rejuvenation: an alternative to face lift surgery. Plast Reconstr Surg.
2005;115:1761–1768.
54. Zins JE, Menon N. Anterior approach to neck rejuvenation. Aesthet
Surg J. 2010;30:477–484. The anterior (submental) approach to neck
rejuvenation is one of the minimally invasive procedures with clear
documentation of long-term efficacy. The procedure improves upon
previous neck liposuction because in addition to skin contraction, the
results are enhanced by the removal of subplatysmal and interplatysmal
fat, the options of digastric muscle alterations and platysmal muscle
tightening. The technique is described in detail, potential complications
noted, and technical limitations of the procedure described.
55. Brandt FS, Boker A. Botulinum toxin for rejuvenation of the neck.
Clin Dermatol. 2003;21:513–520.
56. Agarwal A, Dejoseph L, Silver W. Anatomy of the jawline, neck,
and perioral area with clinical correlations. Facial Plast Surg.
2005;21:3–10.
57. Sclafani AP. Soft tissue fillers for management of the aging perioral
complex. Facial Plast Surg. 2005;21:74–78.
58. Goldman MP, Marchell NL. Laser resurfacing of the neck with the
combined CO2/Er:YAG laser. Dermatol Surg. 1999;25:923–925.
59. Weiss RA, Weiss MA, Beasley KL. Rejuvenation of photoaged skin:
5 years results with intense pulsed light of the face, neck, and
chest. Dermatol Surg. 2002;28:1115–1119.
60. Hayashi K, Thabit G 3rd, Massa KL, et al. The effect of thermal
heating on the length and histological properties of the
glenohumeral joint capsule. Am J Sports Med. 1997;25:107–112.
61. Ferraro GA, De Francesco F, Nicoletti G, et al. Histologic effects of
external ultrasound-assisted lipectomy on adipose tissue. Aesthetic
Plast Surg. 2008;32:111–115.
62. Fabi SG. Noninvasive skin tightening: focus on new ultrasound
techniques. Clin Cosmet Investig Dermatol. 2015;8:47–52.
63. Oni G, Hoxworth R, Teotia S, et al. Evaluation of a microfocused
ultrasound system for improving skin laxity and tightening in the
lower face. Aesthet Surg J. 2014;34:1099–1110.
64. Fabi SG, Goldman MP. Retrospective evaluation of micro-focused
ultrasound for lifting and tightening the face and neck. Dermatol
Surg. 2014;40:569–575.
65. MacGregor JL, Tanzi EL. Microfocused ultrasound for skin
tightening. Semin Cutan Med Surg. 2013;32:18–25.
66. Tonnard P, Verpaele A. The MACS-lift short scar rhytidectomy.
Aesthet Surg J. 2007;27:188–198.
67. Tonnard P, Verpaele A, Morrison C. MACS facelift. In: Aston SJ,
Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. New York,
NY: Saunders Elsevier; 2009:137–148.
68. Guerrerosantos J. Surgical correction of the fatty fallen neck. Ann
Plast Surg. 1979;2:389–396.
69. Castro CC. Transactions of the VIII International Congress of Plastic
and Reconstructive Surgery, Montreal, Canada, 1983.
70. Souther SG, Vistnes LM. Medial approximation of the platysma
muscle in the treatment of neck deformities. Plast Reconstr Surg.
1981;67:607–613.
71. Fuente del Campo A. Midline platysma muscular overlap for neck
restoration. Plast Reconstr Surg. 1998;102:1710–1715.
72. Cruz RS, O’Reilly EB, Rohrich RJ. The platysma window: an
anatomically safe, efficient, and easily reproducible approach to
neck contour in the face lift. Plast Reconstr Surg.
2012;129:1169–1172.
73. Guerrerosantos J, Sandoval M, Salazar J. Long-term study of
complications of neck lift. Clin Plast Surg. 1983;10:563–572.
74. Giampapa VC, Di Bernardo BE. Neck recontouring with suture
suspension and liposuction: an alternative for the early
rhytidectomy candidate. Aesthetic Plast Surg. 1995;19:217–223.
75. Ramirez OM. Advanced considerations determining procedure
selection in cervicoplasty. Part two: surgery. Clin Plast Surg.
2008;35:691–709, viii.
76. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg.
2014;134:1173–1183.
77. Nahai F. Reconsidering neck suspension sutures. Aesthet Surg J.
2004;24:365–367.
78. Giampapa V, Bitzos I, Ramirez O, et al. Suture suspension
platysmaplasty for neck rejuvenation revisited: technical fine
points for improving outcomes. Aesthetic Plast Surg.
2005;29:341–352.
79. Giampapa V, Bitzos I, Ramirez O, et al. Long-term results of suture
suspension platysmaplasty for neck rejuvenation: a 13-year
follow-up evaluation. Aesthetic Plast Surg. 2005;29:332–340.
80. Ramirez OM. Advanced considerations determining procedure
selection in cervicoplasty. Part two: surgery. Clin Plast Surg.
2008;35:691–709.
81. Ramirez OM. Advanced considerations determining procedure
selection in cervicoplasty. Part one: anatomy and aesthetics. Clin
Plast Surg. 2008;35:679–690.
82. Ramirez OM, Robertson KM. Comprehensive approach to
rejuvenation of the neck. Facial Plast Surg. 2001;17:129–140.
83. Courtiss EH. Suction lipectomy of the neck. Plast Reconstr Surg.
1985;76:882–889.
84. Goddio AS. Skin retraction following suction lipectomy by
treatment site: a study of 500 procedures in 458 selected subjects.
Plast Reconstr Surg. 1991;87:66–75.
85. Feldman J. Neck Lift. St. Louis, MO: Quality Medical Publishing;
2006.
86. Ramirez OM. Cervicoplasty: nonexcisional anterior approach. Plast
Reconstr Surg. 1997;99:1576–1585.
87. Tonnard P. Short-scar face lift: operative strategies and techniques, Vol.
II. St. Louis, MO: Quality Medical Publishing; 2007.
88. Grotting JC, Beckenstein MS. Cervicofacial rejuvenation using
ultrasound-assisted lipectomy. Plast Reconstr Surg.
2001;107:847–855.
89. de Souza Pinto EB, Abdala PC, Maciel CM, et al. Liposuction and
VASER. Clin Plast Surg. 2006;33:107–115.
90. Jewell ML, Fodor PB, de Souza Pinto EB, et al. Clinical application
of VASER-assisted lipoplasty: a pilot clinical study. Aesthet Surg J.
2002;22:131–146.
91. Collawn SS. Skin tightening with fractional lasers, radiofrequency,
Smartlipo. Ann Plast Surg. 2010;64:526–529.
92. Prado A, Andrades P, Danilla S, et al. A prospective, randomized,
double-blind, controlled clinical trial comparing laser-assisted
lipoplasty with suction-assisted lipoplasty. Plast Reconstr Surg.
2006;118:1032–1045.

389.e3
References
93. Biggs TM. Excision of neck redundancy with single Z-plasty
closure. Plast Reconstr Surg. 1996;98:1113–1114.
94. Biggs TM, Koplin L. Direct alternatives for neck skin redundancy
in males. Clin Plast Surg. 1983;10:423–428.
95. Biggs TM, Koplin L. Concepts of neck lift. Clin Plast Surg.
1983;10:367–378.
96. Cronin TD, Biggs TM. The T-Z-plasty for the male “turkey
gobbler” neck. Plast Reconstr Surg. 1971;47:534–538.
97. Hamilton JM. Submental lipectomy with skin excision. Plast
Reconstr Surg. 1993;92:443–448.
98. Adamson JE, Horton CE, Crawford HH. The surgical correction of
the “turkey gobbler” deformity. Plast Reconstr Surg.
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99. Gradinger GP. Anterior cervicoplasty in the male patient. Plast
Reconstr Surg. 2000;106:1146–1155.
100. de Pina DP, Quinta WC. Aesthetic resection of the submandibular
salivary gland. Plast Reconstr Surg. 1991;88:779–788.
101. Singer DP, Sullivan PK. Submandibular gland I: an anatomic
evaluation and surgical approach to submandibular gland
resection for facial rejuvenation. Plast Reconstr Surg.
2003;112:1150–1156.
102. Sullivan PK, Freeman MB, Schmidt S. Contouring the aging neck
with submandibular gland suspension. Aesthet Surg J.
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platelet-rich plasma (platelet gel) and autologous platelet-poor
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107. Marchac D, Sandor G. Face lifts and sprayed fibrin glue: an
outcome analysis of 200 patients. Br J Plast Surg. 1994;47:306–309.

SECTION I • Aesthetic Surgery of the Face
13 
Structural fat grafting
Sydney R. Coleman and Alesia P. Saboeiro
SYNOPSIS
■ The concepts of rejuvenation are changing, placing more emphasis on
volume loss and volume restoration as well as improving the quality of
aging and sun damaged skin.
■ Fat grafting provides a long-lasting, minimally invasive means to
restore volume and rejuvenate the face, hands, or body.
■ Proper harvesting, refinement, and placement of the fat is essential for
consistent results.
■ The most forgiving area to learn structural fat grafting is the dorsum of
the hand, and the least forgiving area is the eyelid.
■ Fat grafting can be used to heal or replace tissue lost due to aging,
trauma, and/or disease, as well as to rejuvenate and dramatically alter
the contours of the face, hands, and/or body.
■ The future use of adipose-derived stem cells in regenerative medicine
and tissue engineering is promising.
■ Numerous aesthetic and reconstructive problems can be
addressed with structural fat grafting, but patient selection is
very important.
■ Fat must be harvested, refined, and placed with care to preserve its
natural architecture.
■ Predictable volume changes are more possible when fat is refined and
condensed by centrifugation and decanting.
■ Centrifugation at 1286 g is considered optimal. Condensation of
harvest fat through centrifugation may enhance fat graft take and
prevent long-term atrophy of the transplanted tissue.
■ Oil present after centrifugation can indicate adipocyte destruction
as well as the desired separation of oil from fatty
components.
■ Growth factors and stem cells have been isolated and appear to be
concentrated in the densest portions of centrifuged fat.
■ Fat should be grafted in very small aliquots using multiple passes of
the cannula and should not be molded after placement.
■ While technically considered minimally invasive, significant
and prolonged bruising and tissue edema can result from fat
grafting.
■ Continued research on the applications of adipose-derived stem cells
is of utmost importance.
Access the Historical Perspective section online at

Introduction
Basic science/disease process
Since the 1890s when fat grafting first began, there has been
controversy regarding the predictability and consistency of
results that may be obtained with fat grafting, with some
studies reporting up to a 70% rate of reabsorption. This is not
surprising, especially with the dramatic variations in tech­
nique that have been used to transplant and study fat.15 Ini­
tially, a reasonable explanation for this was based on Lyndon
Peer’s cell survival theory,16 whereby the number of viable
adipocytes transplanted correlates with the volume of grafted
fat that survives.
The future
An exciting new potential of fat grafts is in reparative and
regenerative medicine. Fatty tissue has been found to not only
contain adipocytes, but also a subpopulation of cells consist­
ing of adipose-derived stem cells (ADSCs), mesenchymal
stem cells (MSCs), endothelial cells and their progenitor cell
lines, smooth muscle cells and smooth muscle progenitor cell
lines, and numerous other stem cells that are multipotent and
have the potential to aid in tissue regeneration.18 ADSCs serve
a number of functions and may be induced to differentiate
into many different cell types in culture, including ectodermal,
mesodermal, and endodermal lineages. Additionally, ADSCs
have been shown to induce blood vessel formation, mitigate
fibrosis, and promote bone formation and wound healing. It
is now believed that this particular population of cells within
a fat graft may be a major contributor to the therapeutic
potential of the graft.19
  Access video and video lecture content for this chapter online at expertconsult.com

390.e1
Historical perspective
Historical perspective
The first report of fat grafting was in 1893 by German surgeon
Gustav Neuber1 when he transplanted adipose tissue har­
vested from the arm to correct a depressed facial scar that had
resulted from osteomyelitis. This was followed 2 years later
by Vincenz Czerny, who transferred a fist-sized lipoma from
the buttock to the breast.2 Even then, fat grafting was consid­
ered difficult, time consuming to perform, and somewhat
unpredictable; therefore, new solutions were sought.
The use of paraffin to correct deformities had been described
in 1830 by Baron Karl von Reichenbach. By the late 1800s,
Robert Gersuny and Leonard Corning were using paraffin,
either injected alone, with petroleum jelly, or with a combina­
tion of petroleum jelly and olive oil, into facial defects. Initially,
the paraffin and petroleum jelly filled in soft-tissue defects
nicely, providing a soft, natural-appearing contour. It appeared
to be an easy remedy for numerous deformities; but unfortu­
nately, after a time, complications such as paraffinomas, or
hard local swellings, began to emerge. Thus paraffin lost favor
within the medical community.
Looking for a solution to the problems caused by paraffin,
Eugene Holländer proposed the use of fat injected through a
cannula to correct deformities.3,4 He noted considerable reab­
sorption of the fat and therefore began mixing human fat with
fat from a ram in an attempt to stabilize it. This resulted in a
painful rash that lasted several days; however, a good cos­
metic result was obtained. Later, in 1919, Erich Lexer published
a two-volume book dedicated to the technique of fat grafting.5
In this book, he presented a wide variety of conditions such
as depressed scars, breast asymmetry, knee ankylosis, tendon
adhesions, and micrognathia and the successful results after
treatment with fat grafting. Charles Miller also described the
injection of transplanted fat for the correction of facial folds
and wrinkles in his 1926 publication, Cannula Implants and
Review of Implantation Technics in Esthetic Surgery.6 Despite
some favorable results from these pioneers, fat grafting was
still unpredictable and it thus fell out of favor.
It was not until the 1950s when Lyndon Peer studied the
gross and microscopic appearance of transplanted fat that we
began to understand and improve the predictability of fat
grafting.7 He discovered that adipose grafts lose approxi­
mately 45% of their weight and volume at 1 year due to cell
rupture and subsequent death. The fat cells that do not
rupture, however, will survive and volume will be maintained.
Improper handling of the fat prior to and during transplanta­
tion was also found to decrease the survival of the fat. Graft
size also appeared to play a role in survival. A graft the size
of a walnut was found to lose volume more rapidly than
multiple smaller grafts of similar weight, likely due to the
increased surface area of the smaller grafts. Revascularization,
as seen microscopically, was noted by Peer to be essential for
fat graft survival.
With the advent of liposuction in the 1980s by Fournier8
and Illouz,9 there was a renewed interest in fat grafting.
Results, however, were only partially successful, and the
thought at the time was that perhaps better preparation of the
fat was essential for its survival. Chajchir and Benzaquen10
took this advice and made some recommendations based on
their own favorable results, yet there was still great confusion
as to what really worked until the 1990s, when Coleman
standardized the technique. This technique, called Lipostruc­
ture, emphasizes gentle extraction of fat, centrifugation, and
micro-particle injections in multiple tissue planes. I have used
this technique since 1987 and have documented the longevity
and stability of fat grafting performed in this manner.11–14

391
Diagnosis, patient presentation, indications
merely the illusion of excess skin that disappears when the
volume is restored. The lower eyelids begin to deflate, making
the orbital rim more apparent and elongating the lid–cheek
junction. The tear trough extends diagonally into the anterior
cheek, breaking up the continuous line of cheek fullness and
accentuating the nasolabial folds.
The zygomatic arches lose their soft tissue covering to
reveal the bony outlines beneath and hollow buccal cheeks.
The vermillion of the lips becomes thinner and thinner with
time, and the lips begin to invert, which accentuates the length
of the cutaneous upper lip. The anterior chin becomes less
well defined and more rounded like one button instead of two
defined mounds with a central cleft. As volume and support
is lost along the posterior aspect of the jawline, the mandibular
border becomes less well defined and wavy, and the lower
face slides forward to accentuate the jowls and perimental
hollows/prejowl sulci.
Diagnosis, patient presentation,
indications
Patients who desire fat grafting to the face will present for
numerous different reasons. One of the most common reasons
is aging. These patients are generally over 40 years of age and
present with loss of facial fullness and a loss of elasticity and
thinning of the skin, resulting in skin laxity, wrinkles, or a
gaunt, skeletal appearance. As volume is restored to their face,
their appearance will begin to resemble their younger photo­
graphs by restoration of fullness and repair of the aging, often
sun damaged skin.
The younger patient who presents for facial fat grafting is
generally one who is unhappy about the shape or proportion
of a facial feature, such as the cheeks, chin, or jawline. These
patients can benefit from fat grafting to augment these defi­
cient structures in a manner similar to bone grafts or solid
implants. The facial proportions can be significantly altered
to create a more aesthetically pleasing balance.
Patients may also present for facial fat grafting for correc­
tive purposes. This includes patients with congenital defor­
mities such as hemifacial microsomia and Treacher Collins
syndrome. In addition, patients who have sustained previous
trauma resulting in significant scarring or tissue loss can often
benefit from fat grafting.22 Patients who have undergone pre­
vious facial cosmetic surgery often present with iatrogenic
deformities such as hollow upper and/or lower eyelids
and flattening of the posterior jawline. These areas can be
restored to a more youthful and natural appearance with fat
grafting.
Facial atrophy from etiologies other than aging23,24 have
been increasing over the last few decades, especially drug-
related lipodystrophy seen in patients taking antiretroviral
and protease inhibitor therapies. These patients often present
with a maldistribution of not only facial fat but also body fat.
While an excess of fat may appear as a dorsal hump on the
upper back/lower neck, the face usually appears hollow in
the temples and buccal cheeks, creating an appearance
pathognomonic for the drug-related lipoatrophy. Fat can be
removed from the dorsal hump by suctioning but should
probably not be used for grafting purposes, as it could have
an unusual growth pattern.
Rigotti et al. have used fat grafting in the irradiated breast
and consistently showed an improvement or complete healing
of the damaged tissues.20 As our understanding of fat and its
constituent cells improves, so will our ability to positively
affect other areas of medicine.
Aging and atrophy
What is the process by which we age?21 Our concepts of how
the face and body change with time are evolving, and the
traditional ways of thinking about the problems and their
solutions are being modified. We have been taught that over
time there is loss of elasticity of the tissues, which results in
descent and sagging of the skin. In the face, our historical and
traditional response to the descent has been to resuspend the
tissues and to remove the excess skin. What we have ignored
is the reason for the descent in the first place. While there are
obvious environmental and genetic components to aging, one
of the main reasons that the tissue starts to sag is lack of
support, or lack of volume beneath it. One component of this
volume is fat, but there are also components including colla­
gen, elastin, hyaluronic acid, etc., that are involved. The goal
then should be to replace the missing fullness and enhance
the quality of the skin. In most cases, the body supplies us
with a significant source of filling material to restore the
volume lost with aging in the form of fat. There are, of course,
limitations as to the ability of volume to support the overlying
tissues. If there is a tremendous amount of sagging or excess
skin, then manual resuspension and trimming may be
necessary.
The easiest way to analyze a face to determine how it has
changed is to study photographs of patients when they were
younger compared to their current state. Depending on the
degree of aging, one can often easily see that as the face ages,
typical patterns emerge. The aging portrait model shown in
Fig. 13.1 exemplifies the changes that occur, from left to right,
going from age 20 to 50 to 70 years.
The 20-year-old idealized drawing of a head (Fig. 13.1A,D)
has a full, smooth face. Her temples are flat and her brow and
glabella are unfurrowed. Her upper eyelids are full beneath
the brow and there is a short distance between the ciliary
margin and the lid crease. The lower eyelids are smooth and
there is minimal hollowing medially. Her cheeks are round
with the zygomatic arches well covered with soft tissue. There
is a slight hollowing in the buccal cheek, but she does not look
gaunt. She has minimal nasolabial folds compared with her
full cheeks, but she does not have deep folds or creases within
the folds. The lips are full, pouty, and everted, and the lower
lip is slightly larger than the upper lip. Her jawline and chin
are well-defined and smooth.
As we move from left to right in this model of aging, we
have a 20-year-old followed by a 50-year-old (Fig. 13.1B,E)
and finally a 70-year-old (Fig. 13.1C,F). As we go across, we
see hollowing of the temples with skeletonization of the area.
Wrinkles become more and more obvious in the forehead and
glabella secondary to loss of youthful fullness over areas of
muscular activity, especially in the glabella. The fullness that
was previously present beneath the brow is now diminished
and the upper eyelids appear to either collapse and fold
anteriorly or collapse posteriorly to reveal the hollow orbit.
There may be a real excess of skin, but there may also be

392
SECTION I
CHAPTER 13 • Structural fat grafting
of liposuction and variations of liposuction. These liposuction
deformities range from very slight irregularities that are
barely perceptible, to large indentations and even full-
thickness skin loss. The large and complex tissue deficiencies
often require several operative procedures, with the occasional
release of adhesions, to restore the necessary volume and
smoothness. In addition to large defects, there can also be
significant disturbances of body proportion, such as making
the feminine shape more boxy and masculine or creating an
unusually deep buttock crease that makes the buttock appear
droopy.
A new use of fat appears to come from its apparent healing
properties. Rigotti has grafted fat beneath tissue ulcerations
in the breast that occurred after radiation therapy, and has
noted remarkable restoration and healing of the involved
tissues.20 Radiated tissue that is stiff and non-compliant
What happens to the hands over time that will give away
the age of the patient if the face does not? Again, there is
a loss of volume or soft-tissue coverage over the veins and
tendons of the dorsal hand. The hands of a 20-year-old are
generally smooth and full, with the extensor tendons and
dorsal veins barely visible. There is naturally little fat over
the dorsum of the hands, but with thinning of the skin and
loss of interosseous muscle fullness, the hands can take on
a wasted appearance that can be reversed with fat graft­
ing. Fat grafting not only restores a subtle fullness to the
dorsal hand, but appears to thicken the skin as well, which
partially obscures the tendons and veins so obvious in
aging skin.25
As liposuction has become a more common procedure, and
with an increasing number of practitioners performing the
procedure, there are more deformities being created as a result
Fig. 13.1  Model of aging. From left to right in each row: (A,D) 20-year-old, (B,E) 50-year-old, and (C,F) 70-year-old.
A
B
C
D
E
F

393
Patient selection
Patients with facial lipoatrophy are also excellent candi­
dates for fat grafting, regardless of the cause of their disease
process. Like Treacher Collins syndrome patients (see Fig.
13.6), these patients have specific soft-tissue defects, making
fat an ideal long-lasting filler. A temporary filler could theo­
retically be used in a patient such as this, but the volume of
product that would be needed on a regular basis would likely
be cost-prohibitive (Fig. 13.7).
There are very few options to rejuvenate the aging hand.
If there is a problem of pigmentation, lasers can be helpful in
removing the spots. Topical treatments can also be of some
help; however, it is impossible to lessen the prominence of
obvious tendons and veins without the addition of some
volume. The patient in Fig. 13.8 demonstrates the loss of
volume in the dorsum of the hand due to aging. The hand
has a somewhat wasted appearance, with poor quality skin.
After fat grafting to the dorsum of the hand, the veins and
can be restored to a more normal consistency and texture
and allows filling of contour deformities. In addition,
anecdotal reports have been made regarding the improve­
ment of the appearance of scars and skin quality after fat
grafting.19,22
Patient selection
There are few contraindications to fat grafting to the face and
body. The first contraindication is true for all procedures,
which is poor patient health prohibiting anesthesia. Small
areas of fat grafting can often be performed under local
anesthesia, but anything involving more than a few milliliters
of fat usually requires sedation. In addition, patients with
unrealistic expectations are not good candidates for this or
any other procedure. A contraindication specific for fat graft­
ing is the extremely thin patient who does not have sufficient
fat for transfer. Since large volumes of fat are generally not
needed for the face, enough fat can usually be harvested in
all but the most anorexic patient or muscle-bound body
builder. For fat grafting to the hands, breasts, or body, signifi­
cantly more fat is usually needed, and often there is a limit as
to the correction that can be made given the paucity of fat in
some patients. Asking the patient to gain weight prior to the
procedure only makes sense if the patient is willing and able
to maintain that weight afterwards.
In aging patients with a tremendous amount of loose,
excess skin, fat grafting can be disappointing. These patients
are either left with residual skin excess or if completely filled,
may have an unusual appearance to their face. In these cases,
it is usually advisable to first tighten the skin with a more
traditional facelift and then to add volume with fat. The aging
patient in Fig. 13.2 represents a typical patient that might
present for a facelift. She is instead an excellent candidate for
fat grafting to the face, particularly along the jawline and chin,
where there is an apparent slight excess of skin secondary to
deflation. The jowls and irregular jawline that are present and
this degree of laxity in the neck can be improved significantly
with fat grafting without any cutting or suspension techniques.
By adding volume back into the face, the contours are
improved and the skin is effectively tightened and lifted by
radial expansion.
Younger patients usually do not have as much facial
atrophy and subsequent sagging of the skin, but the overall
appearance of the face can be changed drastically with a shift
in facial proportions. The patient in Fig. 13.3 is an example of
how a more balanced upper and lower lip and more defined
chin can make the face look more balanced and attractive. The
patient in Fig. 13.4 is an example of a chin augmentation in a
younger patient to improve the overall facial proportions. The
patient in Fig. 13.5 is an example of an upper and lower
lip augmentation. Filling the lips gives her a much softer
appearance.
Patients with more severe deformities such as those seen
in Treacher Collins syndrome are excellent candidates for fat
grafting. This is true despite the fact that the condition is
complex, with both bony and soft-tissue abnormalities. The
unusual facial contours present in Fig. 13.6 would be very
difficult to address with anything other than fat, as different
volumes can be tailored to the specific defects to create a more
normal appearance.
Fig. 13.2  (A) The patient preoperatively. (B) Rejuvenation of the jawline and neck
was accomplished with placement of structural fat along the border of the mandible
back to the angle of the mandible and forward into the chin. Significant
augmentation of the lower lip also adds to her improved proportion and
rejuvenation.
A
B

394
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CHAPTER 13 • Structural fat grafting
Fig. 13.3  The patient (A) before and (B) 6
years after fat grafting to the lower face:
17 cc to chin; 12.5 cc to the left border of
the mandible; and 8 cc to the lower lip.
Please note that no fat was placed into the
upper lip, so the size of the upper lip can
be used as a meter to evaluate the degree
of change present.
A
B
Fig. 13.4  (A,B) This young woman presented for improved balance of her lower face; 5 cc of fat was placed into her anterior and inferior chin to elongate it. Note that the
natural dimple was preserved.
A
B
Fig. 13.5  This 50-year-old woman had fat grafting to her upper and lower lips in three stages to minimize the postoperative swelling. (A) The patient before and (B) 15
months after her last fat grafting procedure.
A
B

395
Patient selection
Fig. 13.6  This 22-year-old woman presented after multiple reconstructive attempts at treating her Treacher Collins syndrome. (A) She presented with not only
malproportion of her face, but also impending extrusion of hardware in her zygoma. (B) Diffuse fat grafting from the lateral lower eyelids extending out to the zygomatic arch
not only reinforced the thin lateral eyelid skin, but also covered the obvious hardware visible through the thin cheek skin.
A
B
Fig. 13.7  (A) This patient presented with idiopathic facial atrophy with the primary involvement on the left side of the face. At her first procedure, 13 cc was placed into
the left cheek and 4 cc into the right. At the second procedure, an additional 12.2 cc was placed diffusely over the left cheek and nothing further was done on the right.
(B) Shows the patient 15 months after the second procedure.
A
B
Fig. 13.8  (A) This 46-year-old woman presented complaining of visible tendons and ropey veins on her hand and wrist. (B) She had 40 cc of fat diffusely infiltrated over
the dorsal surface from the distal forearm to the proximal interphalangeal joints.
A
B

396
SECTION I
CHAPTER 13 • Structural fat grafting
tendons are less visible and the quality of the skin appears
improved.
Patients presenting with post-liposuction deformities are
excellent candidates for fat grafting. The patient in Fig. 13.9
has irregularities created by liposuction. Grafted fat is really
the only option to correct areas of significant deficiency,
Fig. 13.9  This 50-year-old woman
presented after liposuction to her thighs
and lateral buttock, followed by an
attempted fat grafting (A); 69 cc was
grafted to the hip and 156 cc to the lateral
buttock and thigh. Ten months later, an
additional 20 cc was grafted to the lateral
thigh. She returned 1 year after the second
procedure (B).
A
B
A
B
Fig. 13.10  This patient presented after resection of a non-secreting pituitary
adenoma through a craniotomy incision, followed by a 6-week course of
radiation. The craniotomy left her with a significant depression in her temple,
which extended into her temporal–parietal scalp. (A) Cranioplasty was
attempted 5 years after the radiation, but it “fell in”, making the condition
worse than before the procedure. She presented with the above depression
extending from her temple and into her scalp, which also had some alopecia.
(B) Her appearance 26 months after 9 cc was placed into the visible temple
depression and another 17 cc into the scalp behind her hairline. Not only was
the contour deformity completely corrected, but the patient felt that the quality
of her skin was improved, as well as her alopecia (although it was difficult to
photograph the improved hair growth).
whereas small depressions can occasionally be corrected with
temporary fillers.
The patient in Fig. 13.10 is an example of atrophy that has
occurred in the temple secondary to radiation therapy. After
grafting fat to the region, the area is not only filled in but it is
also of a more normal texture and consistency.

397
Treatment/surgical technique
Treatment/surgical technique
(Video 13.1 )
The Coleman method of fat grafting is essentially unchanged
since its original inception more than two decades ago.11 The
process involves harvesting the fat gently to preserve the
delicate architecture, refining the fat with centrifugation to
remove non-viable components and provide a predictable
volume,26 and placement of the fat in small aliquots to increase
the surface area and ensure a blood supply to the grafted
tissue.27 When these principles are adhered to, structural fat
grafting can be a relatively predictable and safe procedure.
Recent histologic studies have shown that this method of
harvesting and refinement with centrifugation yields fat with
a high percentage of survival and near-normal adipose cel­
lular enzyme activity.17
Harvesting
The choice of donor site for fat grafting is dependent on the
desires of the patient and accessibility of the fat, as no conclu­
sive differences in viability or “graft take” have been demon­
strated from one site to another in scientific studies. In general,
the love handle, posterior hip, back, and lateral thighs are more
forgiving and do not have as much potential to wrinkle as the
abdomen and medial thighs. Incisions are hidden in creases,
scars, stretch marks, or hair-bearing areas, if possible. Through
these incisions, local anesthetic solution is infiltrated using
a blunt Lamis infiltration cannula. For straight local cases,
the local anesthetic solution consists of 0.5% lidocaine with
1 : 200 000 epinephrine; however, for general anesthesia cases,
where larger volumes of fat are harvested, a solution contain­
ing 0.2% lidocaine with 1 : 400 000 epinephrine is used. The
amount of solution infiltrated is essentially equal to the amount
of fat removed.
Fat is then harvested using a two-hole Coleman harvesting
cannula attached to a 10-cc syringe. This harvesting cannula
is designed to harvest intact fatty tissue parcels that are large
enough to survive, but small enough to pass through the
standard infiltration cannula (17 gauge). The plunger of the
10-cc syringe is pulled back only a few milliliters during
suctioning, so as not to create too much negative pressure and
rupture the fat cells. Incisions are closed with interrupted
nylon sutures (Figs. 13.11 & 13.12).
Refinement
As fat is harvested, the first few syringes occasionally have
more local anesthetic present than later. As the suctioning
continues, many of the later syringes contain less infiltrate
and more blood. After the 10-cc syringe is full, the cannula is
disconnected from the syringe and a Luer-Lok plug is used to
cap the syringe. The plunger is then removed, and the syringe
is placed into the centrifuge. To maintain sterility during the
centrifugation process, a centrifuge with a sterilizable central
rotor and sleeves that are sterilizable is essential. Centrifuga­
tion at 1286 g for 2 min concentrates the fat so that the aqueous
components (the local anesthetic and blood) can be removed
and discarded by releasing the Luer-Lok plug. In addition,
any ruptured fat cells that release their oil can be decanted off
the top and/or wicked away with Telfa pads (Fig. 13.13).
Fig. 13.11  Harvesting cannulas.
Fig. 13.12  “Bucket handle” tip of harvesting cannulas.
The fat is then transferred to a 1-cc syringe for placement
into the face and hands or a 3-cc syringe for placement into
the breasts or body. This process yields relatively pure fat for
grafting, providing a much more predictable volume of tissue
than a sample with excess liquid and/or oil might. Allow­
ing the syringe of harvested fat to sit on end and sediment
will separate the fat from the oil and aqueous component to
some extent, but it is more time consuming and has less of
a concentrating effect than centrifugation. The uncentrifuged
sample will initially appear to provide the proper correction,
but in a short period of time, much of it will be reabsorbed
and the procedure will have been considered a failure
(Fig. 13.14).
Placement
Planned incision sites are anesthetized with 0.5% lidocaine
with 1 : 200 000 epinephrine, and small stab incisions are made
for the placement of fat through one of three Coleman can­
nulas (Figs. 13.15 & 13.16).
Small amounts of 0.5% lidocaine with 1 : 200 000 epineph­
rine are usually infiltrated into the face for vasoconstriction
of the vessels prior to placement of the fat. This not only helps
to reduce bruising, but also decreases the chance of accidental
intravascular embolization of the fat. The success of the fat
grafting procedure depends not only on the harvesting and
refinement, but also on the placement of the fat in a manner

398
SECTION I
CHAPTER 13 • Structural fat grafting
placement, as the surface must be smooth before you leave
the operating room. The stab incisions used to place the fat
are closed with single interrupted nylon sutures.
Postoperative care
Care of the patient after fat grafting has evolved over time.
Initially, all areas of the face, except the upper eyelids, were
covered with Microfoam tape, forming a sort of mask. Now
occasionally, we will use Tegaderm, which is more flexible,
tolerable, and socially acceptable. Around the eyes, dressings
must be applied carefully so as not to pull the lower eyelids
down. In areas of the face that were suctioned, 12-inch Reston
foam is usually applied, followed by Tegaderm or Microfoam
tape to compress the foam. In addition, cold therapy is usually
recommended for up to 72 h postoperatively.
The hands are generally still dressed with Microfoam tape,
and the donor sites are dressed with a compression garment
or abdominal binder. The dressings are usually left in place
for 3–4 days, at which time the patient is seen in the office,
the dressings are removed, and the facial sutures are removed.
Body sutures at the donor sites and on the hands are usually
removed at 5–7 days. Lymphatic drainage techniques using a
very light touch can be performed on the face and/or body,
but deep massage is to be avoided during the first month.
Outcomes, prognosis, complications
In addition to the obvious volumetric changes that can occur
with fat grafting, it has been noted by many to also improve
the quality of the overlying skin. Rigotti has grafted fat
beneath irradiated, ulcerated breast skin and has noted
healing and normalization of the affected skin. Mojallal et al.
have also demonstrated improvement in adherent scars, skin
texture, skin suppleness, skin color, and scar quality in their
patients.22 This group has demonstrated similar findings his­
tologically in the nude mouse.
The most common complications, or side effects, of fat
grafting to the face, hands, or body are aesthetic. There is
generally considerable swelling and bruising that occurs with
the multiple passes of the cannula used to place the fat. Bruis­
ing generally resolves in 2–3 weeks, but there have been a few
cases of prolonged subcutaneous pigmentation that is easily
visible through the thin skin of the lower eyelids. This has the
appearance of “tea staining” and can take many months to
resolve.
More problematic is the potential for subcutaneous irregu­
larities visible through the skin, which can occur in both the
recipient and donor sites. In the recipient sites, excess grafted
fat will appear as a lump beneath the skin. This can be the
result of placement of a volume that was too large just beneath
thin skin, particularly in the periorbital region. These bits of
unwanted fat can be difficult to remove; therefore caution
should be employed when grafting into this area (Fig. 13.19).
Potential remedies for irregularities caused by excess fat
include suctioning of the fat using the same cannula used for
infiltration,28 direct excision of the fat under visualization,29
and Lipodissolve,30 which is not approved by the Food and
Drug Administration in the United States. Irregularities in the
donor sites can also be problematic, particularly if too much
fat is removed.
that increases its chance for survival and graft “take”. This
means maximizing the contact surface area of the fatty parcel
with the surrounding tissue, such that a blood supply can be
conferred to the newly grafted fat (Fig. 13.17).
Transferring large globules of fat can result in central
necrosis of the mass with subsequent resorption and loss of
volume, or possibly even cyst formation (Fig. 13.18).
The fat is placed gently during the withdrawal of a blunt
Coleman infiltration cannula. Fat can be placed at different
levels to accomplish different effects. For instance, grafting fat
immediately beneath the dermis can improve the quality of
the skin, decreasing wrinkles, decreasing pore size, and even
reducing scarring. Special care must be taken, however, when
placing fat superficially, as irregularities are more apt to be
apparent in this plane. This is especially true in areas that
have thin skin, such as the lower eyelid. To make changes in
the shape of the face or body that relate to the underlying
bony skeleton, fat can be placed above the periosteum. The
structure should be purposefully built up with tiny aliquots
of fat rather than attempting to insert larger aliquots and then
mold the tissue after it is placed. Molding may displace the
fat or cause necrosis of some or all of the fat in an area,
resulting in uneven contours. The only time molding should
be considered is if an irregularity is noted at the time of
Fig. 13.13  Appearance of a syringe after centrifugation. Note the small oil layer at
the top; the large volume of fat in the midportion, and the small layer of local
anesthetic/blood at the bottom.

399
Outcomes, prognosis, complications
Fig. 13.14  The Coleman refinement and transfer process.
Harvest
Centrifuge fat
Decant
less-dense
oil layer
Release
dense aqueous
component
Wick
Transfer to
smaller syringe
Oil back to
harvest site to
lubricate incision
Fig. 13.15  Placement cannulas.
Fig. 13.16  Various placement cannula tips, from the most blunt to the least blunt.

400
SECTION I
CHAPTER 13 • Structural fat grafting
encouraged to have the procedure performed when they are
at their ideal body weight and to maintain that weight, if
possible.
Secondary procedures
With fat grafting, secondary procedures, or touch-up proce­
dures, are possible if the correct volume of fat was not placed
initially. Due to the difficulty in the lower eyelid of removing
fat, it is far better to undercorrect the area and return to the
The most catastrophic potential complication is an intra­
vascular embolization, which fortunately is extremely rare.
Such an event can occur when fat is inadvertently injected
under pressure into a small artery, with retrograde filling
of the vessel. With the next pump of the heart, this intra-
arterial fat can embolize to an end arteriole resulting in tissue
ischemia. This has never been reported when using a blunt
cannula; therefore, sharp needles are discouraged except
when placing fat directly into the dermis. For similar reasons,
the injection of large boluses of fat and injection guns are not
recommended.31
Infections in the recipient or donor site are also extremely
rare, but if they do occur, they can result in resorption of
the grafted fat and loss of the desired correction. Strict
sterile technique should be employed during fat grafting,
and cannulas that penetrate the oral mucosa should be con­
sidered contaminated. Lip augmentation, therefore, should
be performed last if fat grafting is performed elsewhere on
the face.
Significant changes in weight can result in concomitant
changes in the size of the area grafted; therefore, patients are
Fig. 13.17  Placement of fat into the recipient site. Note that placement is
performed during the withdrawal of the cannula and is placed in different layers to
build up the structure.
Fig. 13.18  Injection of a large mass of fat and the central necrosis that can occur
when this is done.
Fig. 13.19  This 48-year-old man presented with large protuberant masses on his
lower eyelids after fat grafting to the lower eyelids and cheeks. The surgeon had
attempted to correct the problem with the injection of catabolic steroids into the
transplanted fat. According to the patient, the steroids made his irregularities more
visible as the skin appeared thinner.

401
Secondary procedures
goal of the first procedure is to fill in large deficits with sig­
nificant amounts of fat and later to come back and refine the
area.
operating room for a second stage, if necessary, at a later date.
In complicated liposuction-deformity cases, a second stage is
often part of the original plan, as it can be very difficult to
make an area smooth enough in one procedure. Generally, the
11. Coleman SR. The technique of periorbital lipoinfiltration. Oper Tech
Plast Reconstr Surg. 1994;1:20–26. This article was the first published on
the Coleman technique of fat grafting.
13. Coleman SR. Structural Fat Grafting. 1st ed. St. Louis, MO: Quality
Medical Publishing; 2004. This is a comprehensive text on fat grafting.
17. Pu LL, Coleman SR, Cui X, et al. Autologous fat grafts harvested
and refined by the Coleman technique: a comparative study. Plast
Reconstr Surg. 2008;122:932–937.
18. Zuk PA, Zhu M, Mizuno H, et al. Multilineage cells from human
adipose tissue: implications for cell-based therapies. Tissue Eng.
2001;7:211–228. This is the first clear description of the presence of stem
cells in fat grafts. This article had four plastic surgeons among the
authors.
19. Coleman SR. Structural fat grafting: more than a permanent filler.
Plast Reconstr Surg. 2006;118(3 suppl):108S–120S. This article is the
first article to clearly spell out the healing effect of fat grafting on the
surrounding tissues.
20. Rigotti G, Marchi A, Galie M, et al. Clinical treatment of
radiotherapy tissue damage by lipoaspirate transplant: a healing
process mediated by adipose-derived adult stem cells. Plast Reconstr
Surg. 2007;119:1409–1424.
21. Coleman SR, Grover R. The anatomy of the aging face: volume loss
and changes in 3-dimensional topography. Aesthet Surg J. 2006;26:
S4–S9.
22. Mojallal A, Lequeux C, Shipkov C, et al. Improvement of skin
quality after fat grafting: clinical observation and an animal study.
Plast Reconstr Surg. 2009;124:765–774.
25. Coleman SR. Hand rejuvenation with structural fat grafting. Plast
Reconstr Surg. 2002;110:1731–1743.
31. Coleman SR. Avoidance of arterial occlusion from injection of soft
tissue fillers. Aesthet Surg J. 2002;22:555–557. The avoidance of
intravascular embolization should be always on the mind of anyone
injecting fat.
Access the complete reference list online at

401.e1
References
References
1. Neuber F. Fettransplantation. Bericht über die verhandlungen der
Deutschen gesellschaft für chirurgie. Zbl Chir. 1893;22:66.
2. Czerny V. Plastischer erzats der brustdruse durch ein lipom. Zentral
Chir. 1895;27:72.
3. Holländer E. Berliner Klinischer Wochenschrift. 1909;18.
4. Holländer E. Die kosmetische chirurgie (S.669–712, 45 Abb.). In:
Joseph M, ed. Handbuch der Kosmetik. Leipzig: Verlag van Veit;
1912:690–691.
5. Lexer E. Die Freien Transplantationen. Stuttgart: Ferdinand Enke;
1919.
6. Miller C. Cannula Implants and Review of Implantation Technics in
Esthetic Surgery. Chicago, IL: Oak Press; 1926.
7. Peer LA. The neglected free fat graft, its behavior and clinical use.
Am J Surg. 1956;92:40–47.
8. Fournier PF. Reduction syringe liposculpturing. Dermatol Clin.
1990;8:539–551.
9. Illouz YG. The fat cell “graft”: a new technique to fill depressions.
Plast Reconstr Surg. 1986;78:122–123.
10. Chajchir A, Benzaquen I. Fat-grafting injection for soft-tissue
augmentation. Plast Reconstr Surg. 1989;84:921–935.
11. Coleman SR. The technique of periorbital lipoinfiltration. Oper Tech
Plast Reconstr Surg. 1994;1:20–26. This article was the first published on
the Coleman technique of fat grafting.
12. Coleman SR. Lipoinfiltration of the upper lip white roll. Aesthet
Surg J. 1994;14:231–234.
13. Coleman SR. Structural Fat Grafting. 1st ed. St. Louis, MO: Quality
Medical Publishing; 2004. This is a comprehensive text on fat grafting.
14. Coleman SR. Long-term survival of fat transplants: controlled
demonstrations. Aesthetic Plast Surg. 1995;19:421–425.
15. Ersek RA. Transplantation of purified autologous fat: a 3-year
follow-up is disappointing. Plast Reconstr Surg. 1991;87:219–227.
16. Peer LA. Cell survival theory versus replacement theory. Plast
Reconstr Surg. 1955;16:161–168.
17. Pu LL, Coleman SR, Cui X, et al. Autologous fat grafts harvested
and refined by the Coleman technique: a comparative study. Plast
Reconstr Surg. 2008;122:932–937.
18. Zuk PA, Zhu M, Mizuno H, et al. Multilineage cells from human
adipose tissue: implications for cell-based therapies. Tissue Eng.
2001;7:211–228. This is the first clear description of the presence of stem
cells in fat grafts. This article had four plastic surgeons among the
authors.
19. Coleman SR. Structural fat grafting: more than a permanent filler.
Plast Reconstr Surg. 2006;118(3 suppl):108S–120S. This article is the
first article to clearly spell out the healing effect of fat grafting on the
surrounding tissues.
20. Rigotti G, Marchi A, Galie M, et al. Clinical treatment of
radiotherapy tissue damage by lipoaspirate transplant: a healing
process mediated by adipose-derived adult stem cells. Plast Reconstr
Surg. 2007;119:1409–1424.
21. Coleman SR, Grover R. The anatomy of the aging face: volume loss
and changes in 3-dimensional topography. Aesthet Surg J.
2006;26:S4–S9.
22. Mojallal A, Lequeux C, Shipkov C, et al. Improvement of skin
quality after fat grafting: clinical observation and an animal study.
Plast Reconstr Surg. 2009;124:765–774.
23. Ascher B, Coleman S, Alster T, et al. Full scope of effect of facial
lipoatrophy: a framework of disease understanding. Dermatol Surg.
2006;32:1058–1069.
24. Burnouf M, Buffet M, Schwarzinger M, et al. Evaluation of
Coleman lipostructure for treatment of facial lipoatrophy in patients
with human immunodeficiency virus and parameters associated
with the efficiency of this technique. Arch Dermatol. 2005;141:
1220–1224.
25. Coleman SR. Hand rejuvenation with structural fat grafting. Plast
Reconstr Surg. 2002;110:1731–1743.
26. Coleman SR. Harvesting, refinement and transfer. In: Structural Fat
Grafting. St. Louis, MO: Quality Medical Publishing; 2004:29–51.
27. Coleman SR. Overview of placement techniques. In: Structural Fat
Grafting. St. Louis, MO: Quality Medical Publishing; 2004:70–71.
28. Coleman SR. Lower lid deformity secondary to autogenous fat
transfer: a cautionary tale. Aesthetic Plast Surg. 2008;32:415–417.
29. Spector JA, Draper L, Aston SJ. Lower lid deformity secondary to
autogenous fat transfer: a cautionary tale. Aesthetic Plast Surg.
2008;32:411–414.
30. Duncan DI, Chubaty R. Clinical safety data and standards of
practice for injection lipolysis: a retrospective study. Aesthet Surg J.
2006;26:575–585.
31. Coleman SR. Avoidance of arterial occlusion from injection of soft
tissue fillers. Aesthet Surg J. 2002;22:555–557. The avoidance of
intravascular embolization should be always on the mind of anyone
injecting fat.

SECTION I • Aesthetic Surgery of the Face
14 
Skeletal augmentation
Alan Yan and Michael J. Yaremchuk
SYNOPSIS
■ The underlying skeleton is the fundamental determinant of facial
appearance.
■ Facial skeletal augmentation can add angularity, definition, or balance
to a face of normal dimensions.
■ Given acceptable occlusion, implant surgery can be an alternative or
adjunct to orthognathic surgery in disproportioned faces.
■ All faces are asymmetric. Facial asymmetries should be discussed
with patients preoperatively.
■ Most skeletal augmentation is done with alloplastic implants.
■ Solid silicone and porous polyethylene are the most commonly used
materials for facial skeletal augmentation.
■ Facial skeletal augmentation with custom implants using computer-
assisted design, computer-assisted manufactured (CAD-CAM)
technology allows precise preoperative analysis, surgical planning,
better fit, and more predictable postoperative facial contour than stock
implants.
■ Incisions should be placed remote from implant placement.
■ The subperiosteal plane is preferred for implant placement.
■ Gaps between the implant and the skeleton result in unanticipated
increases in augmentation.
■ Screw fixation of the implant prevents implant movement as well as
gaps between the implant and the skeleton.
Introduction
• The size and shape of the facial skeleton are fundamental
determinants of facial appearance.
• Small asymmetries in skeletal morphology can be
noticeable.
• Small changes through surgical intervention can be
powerful.
• Augmentation is the predominant means of aesthetic
contouring of the facial skeleton in non-Asian
populations.
• Although the use of autogenous bone as an onlay graft is
conceptually appealing, it is limited by donor site
morbidity and unpredictability of the result.
• Most facial skeletal augmentation is performed with
alloplastic implants.
Access the Historical Perspective section online at

Basic science/disease process
Most often, facial skeletal deficiencies are perceived in disease-
free individuals whose dimensions fall within the normal
range. These patients desire more definition, angularity, or
balance to their facial dimensions.
Craniofacial deformities which are disfiguring and of
functional consequence usually require skeletal osteotomy
and rearrangement as primary treatment. Alloplastic aug­
mentation of the skeleton is often adjunctive in the treatment
of the aesthetic sequelae of these diseases.
In less severe deformities, for example, midface or man­
dibular hypoplasia with normal or compensated occlusion,
alloplastic augmentation may be a preferable alternative to
osteotomy.
Recently studies in senescent changes in the facial skeleton
revealed retrusion of the midface and mandibular skeleton
over time. This supports the concept of alloplastic augmenta­
tion of the facial skeleton as part of the algorithm for facial
rejuvenation and enhancement.1
Patient selection
Patients with normal, deficient, surgically altered, or trau­
matically deformed anatomy may all benefit from implant
augmentation of their craniofacial skeleton.
  Access video content for this chapter online at expertconsult.com

402.e1
Historical perspective
Historical perspective
The use of alloplastic implants to restore or improve contour
of the facial skeleton was introduced in the 1960s and 1970s
when surgeons used alloplastic materials such as silastic
sponges and solid polyethylene to reconstruct post-traumatic,
postablative, and congenital defects. Since they were often
used in compromised soft-tissue environments, visibility,
extrusion, and infection were not uncommon. Meanwhile,
craniofacial techniques which advocated extensive osteoto­
mies and the liberal use of autogenous bone as both
interposition and onlay grafts were being developed and
popularized. In the 1970s and 1980s, Ed Terino, Bob Flowers,
and Linton Whitaker saw the potential of skeletal augmenta­
tion with alloplastic materials as an important element of
aesthetic facial enhancement. Using remote incisions to place
biocompatible materials under well-vascularized soft tissues,
they developed techniques to alter the contours of the facial
skeleton reliably. In the 1990s, the senior author, with a back­
ground in craniofacial surgery, employed the concepts of
wide exposure and rigid fixation in the use of alloplastic
implants to enhance the facial skeleton.

403
Patient selection
Fig. 14.1  (A) Illustration of midface concavity and
compensated occlusion. (B) Multiple midface
implants provide visual effect of LeFort III osteotomy
and advancement but do not alter occlusion.
A
B
Fig. 14.2  (A) Mandibular deficiency with
compensated occlusion. (B) The visual effect of
sagittal split osteotomy and horizontal osteotomy of
the chin with advancement has been simulated with
mandible and chin implants. Note that the class I
occlusion is unchanged. Notice also that the border
regularities inherent with skeletal osteotomies are
avoided when implants are used.
A
B
Skeletal enhancement
Most often, facial skeletal augmentation is performed to
enhance facial appearance in patients whose skeletal relation­
ships are considered within the normal range but prefer more
definition and angularity to their appearance. Other patients
desire to “balance” their facial dimensions.
Alternative to orthognathic surgery
Midface and mandibular hypoplasia are common facial
skeletal variants. These patients have normal occlusion or
have been compensated by orthodontics, with no respiratory
or ocular compromise. Skeletal repositioning would require
additional
orthodontic
tooth
movement.
Such
time-
consuming, costly, and potentially morbid treatment plan is
appealing to few patients. In these patients, the appearance
of skeletal osteotomies and rearrangements can be simulated
through the use of facial implants. Diagrammatic representa­
tions of how implant surgery can mimic the appearance of
skeletal osteotomies are shown in Figs. 14.1 and 14.2.
Adjunct to orthognathic surgery
Alloplastic implants can enhance the results of certain orthog­
nathic surgery procedures, including the LeFort I maxillary

404
SECTION I
CHAPTER 14 • Skeletal augmentation
Fig. 14.3  Infraorbital rim implants create upper midface convexity to compensate
for lower midface advancement. Posterior mandible implants can camouflage
osteotomy-induced irregularities along the mandibular border as well as
malpositions of the mandibular angles. Chin implants can correct mandible border
contour irregularities after sliding genioplasty.
Fig. 14.4  Illustration showing how the placement of infraorbital rim implant on an aged orbit creates contours that mimic a youthful orbit. (A) CT scan of a youthful face
and orbit. (B) CT scan of an aged orbit. (C) Implant augmentation of the infraorbital rim restores a youthful orbital contour.
A
B
C
advancement, the sagittal split mandibular osteotomy, and
the sliding genioplasty.2
The LeFort I advancement may fulfill its functional role by
creating appropriate occlusal relations, but it inadequately
treats midface hypoplasia since only the lower half of the
midface is advanced. Patients in whom the infraorbital and
malar region were deficient before LeFort I osteotomy will
continue to be deficient postoperatively. The rim deficiency
in the parasagittal plane may be accentuated by the more
advanced position of the tooth-bearing segment. This results
in a convexity confined to the lower half of the midface. Allo­
plastic augmentation of the infraorbital rim with or without
malar implants can create a more aesthetic, convex midface.
Posterior mandible implants can camouflage osteotomy-
induced irregularities along the mandibular border as well as
malpositions of the mandibular angles after bilateral sagittal
split osteotomy. Chin implants with lateral extensions or
specially designed and strategically placed implants can
correct mandibular border contour irregularities after sliding
genioplasty (Fig. 14.3).
Graves ophthalmopathy
Graves ophthalmopathy is a chronic autoimmune condition
that usually affects both orbits and involves all orbital tissue
compartments, including the extraocular muscles, periorbital
connective fatty tissue, and lacrimal gland. The clinical signs
and symptoms of Graves ophthalmopathy reflect the mechani­
cal consequences of increased orbital tissue volume and
pressure within the orbit. These consequences lead to an
abnormal and symptomatic protrusion of the globes. Clinical
findings include proptosis, impaired ocular motility, diplopia,
lid retraction, and impaired visual acuity due to optic neu­
ropathy, with menacing blindness. In cases of moderate to
severe proptosis, favoring severity (when the relationship of
the anteriormost point of the cornea to the malar eminence is
of a significant negative vector), an infraorbital rim augmenta­
tion combined with a subperiosteal midface lift at the malar
eminence effectively increase orbital volume and globe lid
coverage (reversing the negative vector), which prove to be
of substantial symptomatic relief and improved periorbital
aesthetics.3
Rejuvenation
Traditional concepts of periorbital and midface aging and
rejuvenation focus on the soft tissues only. Recently, senescent
changes in the supporting facial skeleton have been investi­
gated. Findings in these studies revealed retrusion of the
midface skeleton and mandible (Fig. 14.4). This diminution in
projection would hasten the gravitational-induced descent of
their overlying and now less supported soft-tissue envelope.4
Alloplastic skeletal augmentation can both restore skeletal
contours and support the overlying soft-tissue envelope.1
Provision of these functions supports the concept of selec­
tive alloplastic augmentation of the facial skeleton as part of
the algorithm for facial rejuvenation and enhancement.
Selective augmentation of the infraorbital rim, malar, and
pyriform aperture in the aging midface skeleton can mimic
the contours of its youthful counterpart. Selective augmenta­
tion of the chin and mandible can restore youthful contours
of the lower jaw.

405
Treatment/surgical technique
do not account for facial dimensions that are known to differ
with gender and age. Most of these canons of proportion (e.g.,
the width of the upper face is equal to five eye-widths) are
interesting but hold for few individuals and cannot be
obtained surgically or, if obtainable, only with extremely
sophisticated craniofacial procedures. For these reasons, we
have found it more useful to use the anthropometric measure­
ments of normal individuals to guide our selection of implants
for facial skeletal augmentation15 (see Ch. 28 – Cleft and cra­
niofacial Orthognathic Surgery). Normal-dimensioned faces
are intrinsically balanced; that is, the relations between various
areas of the face relate to one another in a way that is not
distracting to the observer. By comparing a patient’s dimen­
sions to the average, the surgeon has some objective basis as
to what anatomic area may be amenable to augmentation, and
by how much.
Radiology
In general, the decision of the size and position of the implant
is mostly an aesthetic judgment, and most procedures are
done without preoperative radiology assessment. Cephalo­
metric X-rays are most often used for planning chin and
mandible augmentation surgery. These studies define skeletal
dimensions and asymmetries as well as the thickness of the
chin pad. With the advent of patient-specific custom implants
using computer-assisted design (CAD) and computer-assisted
manufacturing technology (CAM), preoperative medical
computer tomography (CT) or office-based cone beam CT
(CBCT) is obtained for each patient to reconstruct a virtual
three-dimensional model of the facial skeleton. This allows for
millimeter assessment of the contour deformity: symmetry,
height, width, projection, and its relationship to the entire
facial skeleton. Applying knowledge of the normal skeletal
relationship and aesthetic criteria, virtual surgery can be
performed, and patient-specific custom implants are designed
to provide the optimal surgical result.
Treatment/surgical technique
Anesthesia and preparation
Facial skeletal augmentation is routinely performed on an
outpatient basis under either local anesthesia supplemented
with sedation or general anesthesia. General anesthesia with
nasotracheal or endotracheal intubation assures protection of
the airway and the best possible antiseptic preparation of the
oral cavity. Patient positioning and exposure for implant
placement are also optimized when the airway is controlled.
Prior to preparation and draping, a dilute solution of bupiva­
caine with epinephrine is infiltrated into the operative site for
postoperative pain control and intraoperative hemostasis.
Cephalosporins are administered perioperatively. Chlorhexi­
dine gluconate oral rinse (0.12%) is prescribed for daily use
beginning 3 days before surgery.
Incisions
Incisions for skeletal access and implant placement are adopted
from craniofacial and aesthetic surgery. Transconjunctival
retroseptal incisions, often combined with lateral canthotomy,
are routinely used to access the infraorbital rim and internal
Skeletal versus soft-tissue augmentation
Both the soft tissues and the skeleton contribute to facial
contour, and are impacted by the aging process. Hence, soft-
tissue and skeletal augmentation can be appropriate to restore
youthful facial contours. However, these modalities are not
equivalent in their impact on facial appearance. Free fat graft­
ing and the injection of various fillers are intuitive for the
restoration of soft-tissue volume loss due to senile atrophy.
However, they have limited role in simulating the effect of an
increase in skeletal projection. Whereas augmenting the facial
skeleton results in increase in the projection of the skeleton,
augmenting the soft-tissue volume results in inflation of the
soft-tissue envelope and blunting of the skeletal contours.
Overly aggressive augmentation of either component brings
home the point. If excessively large implants were placed on
the skeleton, the appearance would be too defined and, ulti­
mately, skeletal. If too much fat were placed in the soft-tissue
envelope, an increasingly spherical and otherwise undefined
shape would result.
Diagnosis/patient presentation
For patients presenting with reconstructive problems, implant
surgery is performed to return the involved area to its original
appearance or, if that is not possible, to create a face that is sym­
metric and accepted as normal. For patients presenting for aes­
thetic enhancement, the surgical goal is more arbitrary. Because
implant augmentation of the facial skeleton results in measur­
able changes in facial dimensions and proportions, it is intuitively
advisable and appropriate to use facial measurement and pro­
portion to evaluate the face and to help guide surgery.
Physical examination
Physical examination remains the most important element of
preoperative assessment and planning. Reviewing life-size
photographs with the patient can be helpful when discussing
aesthetic concerns and goals as well as demonstrating the
asymmetries common to all faces. The recognition of facial
asymmetries is important to the surgeon in preoperative plan­
ning and to the patient in anticipating the postoperative
result. It is important to recognize that facial asymmetries are
more complex than relative skeletal deficiencies or excess;
rather, they reflect three-dimensional differences that are most
easily conceptualized as “twists” of the facial skeleton that
can only be partially compensated for with surgery.
Neoclassical canons and facial
anthropometries
For the purposes of painting and sculpture, Renaissance
scholars and artists formulated ideal proportions and rela­
tions of the head and face based largely on classical Greek
canons. Although frequently referenced in discussion of facial
skeletal augmentation, these idealized neoclassical canons
have a limited role in surgical evaluation and planning. When
the dimensions of normal males and females were evaluated
and compared to these artistic ideals, it was found that some
theoretic proportions are never found, and others are one of
many variations found in healthy normal people, or those
deemed more attractive than normal.5 The neoclassical canons

406
SECTION I
CHAPTER 14 • Skeletal augmentation
terial porosity between 125–250 µm, which allows fibrous
tissue growth into the implant surface. This porous character­
istic has both advantages and disadvantages. Soft-tissue
ingrowth reduces the tendency for the implant to migrate and
to erode underlying bone. Porosity also allows some flexibility
and adaptability of the implant. However, porosity causes soft
tissue to adhere to the implant, making placement more dif­
ficult and requiring a larger pocket to be dissected than with
smooth implants. The soft-tissue ingrowth also makes implant
removal more difficult.
The firm consistency of porous polyethylene allows it to be
easily fixed with screws and contoured with a scalpel or
power equipment without fragmenting.
Requisites of implant shape,
positioning, and immobilization
Shape
The external shape of the implant should mimic the desired
shape of the bone it is augmenting. Its posterior surface should
mold to the bone to which it is applied. The implant margins
must taper imperceptibly into the native skeleton so that they
are neither visible nor palpable.
Positioning
Although some surgeons prefer to place implants in a soft-
tissue pocket, clinical experience has led us to adopt a sub­
periosteal approach, which involves a relatively bloodless
dissection that is also safe to peripheral nerves. It allows
visualization and, therefore, more precise augmentation of the
skeletal contour. The size of the pocket will be determined by
the type of implant used and its method of immobilization.
The long-standing teaching using smooth silicone implants
is to make a pocket just large enough to accommodate the
implant and, therefore, guarantee its position. Porous implants
require a larger pocket because they adhere to the soft tissues
during their placement. The senior author, whether using
smooth or porous implants, dissects widely to visualize the
complex three-dimensional topography of the skeletal
anatomy being augmented. This panoramic exposure allows
a more precise and symmetric implant positioning.
Immobilization
Facial implants should be immobilized. While it is common
practice to stabilize the implant by suturing it to surrounding
soft tissues or by using temporary transcutaneous pull-out
sutures, screw fixation of the implant to the facial skeleton is
preferred. Screw fixation prevents any movement of the
implant and assures application of the implant to the surface
of the bone. Because each facial skeleton has a unique and
varying surface topography, a nonconforming implant will
leave gaps between the implant and the skeleton. Gaps are
problematic for two reasons. The space between the implant
and the skeleton is equivalent to additional augmentation.
This can lead to unanticipated increased augmentation and
asymmetry. Gaps are also potential dead space for hematoma
and seroma formation. Screw fixation allows for final contour­
ing with the implant in position. This is particularly important
orbit. The lateral extent of the lower lid blepharoplasty inci­
sion provides access to the lateral orbit and zygomatic arch.
This small cutaneous incision leaves an inconspicuous scar.
Skin or skin muscle flap lower lid incisions provide alternative
approaches to the periorbital area. Intraoral sulcus incisions
are used to augment the midface as well as the mandibular
body and ramus. These incisions are made with a generous
labial cuff to allow watertight mucosal closure. Chin augmen­
tation is performed through submental or intraoral incisions.
Placement of incisions directly over implants is avoided.
Implant materials
Implant materials used for facial skeletal augmentation are
biocompatible – that is, there is an acceptable reaction between
the material and the host. In general, the host has little or no
enzymatic ability to degrade the implant with the result that
the implant tends to maintain its volume and shape. Likewise,
the implant has a small and predictable effect on the host
tissues that surround it. This type of relationship has an
advantage over the use of autogenous bone or cartilage which,
when revascularized, will be remodeled to varying degrees,
thereby changing volume and shape. The alloplastic implants
presently used for facial reconstruction have not been shown
to have any toxic effect on the host.6 The host responds to
these materials by isolating the implant in the form of a fibrous
capsule around the implant. The most important implant
property that determines the nature of the encapsulation is
the implant’s surface characteristics. Smooth implants result
in the formation of smooth-walled capsules. Porous implants
allow varying degrees of soft-tissue ingrowth that result in a
less dense and less defined capsule. It is a clinical impression
that porous implants, as a result of fibrous incorporation
rather than encapsulation, have a lower tendency to erode
underlying bone or migrate due to soft-tissue mechanical
forces and, perhaps, are less susceptible to infection when
challenged with an inoculum of bacteria. The most commonly
used, commercially available materials for facial skeletal
augmentation are solid silicone, which has a smooth surface,
and porous polyethylene (MEDPOR, Stryker Corporation,
Kalamazoo, MI; OMNIPORE, Matrix Surgical, Atlanta, GA).
Silicone
Solid silicone or silicone rubber used for facial implants is a
vulcanized form of polysiloxane, a polymer created from
interlinking silicone and oxygen with methyl side groups.
Silicone implants have the following advantages: they are
easily sterilized by steam or irradiation; they can be carved
with either scissors or scalpel; and they can be stabilized with
a screw or suture. There are no known clinical or allergic
reactions to silicone implants. Because they have a smooth
surface, there is no soft-tissue ingrowth, allowing them to be
easily removed. Disadvantages to silicone implants include
the tendency to cause resorption of underlying bone, the
potential to migrate if not fixed to the underlying skeleton,
and the likelihood of its fibrous capsule to be visible when
placed under a thin soft-tissue envelope.
Polyethylene
Polyethylene is a simple carbon chain of ethylene monomer.
Polyethylene used for facial implants is porous with intrama­

407
Midface implants
Hints and tips
Screw fixation of implants not only prevents implant movement
but also obliterates gaps between the implant and the native
skeleton. Gaps result in unanticipated increases in
augmentation.
Hints and tips
A suction drain placed at the site of augmentation aids in
detection and management of postoperative hematoma.
where the implant interfaces with the skeleton. Any step-off
between the implant and the skeleton will be palpable and
visible in patients with thin soft-tissue cover.
Preventing hematoma
The
adequacy
of
hemostasis
shortens
convalescence
and minimizes morbidity. Moreover, hematomas are associ­
ated with most postoperative infections. Strategies to mini­
mize hemostasis include infiltrating the soft tissues with
epinephrine-containing solution, packing the operative field
with epinephrine-soaked neuropaddies until the wound is
closed, routine use of suction drains, and application of a
mildly compressive tape dressing at the completion of each
procedure.
Midface implants
Virtually all aesthetic augmentation is performed on the
middle and lower thirds of the facial skeleton. The midface is
best conceptualized as having three zones amenable to aug­
mentation (alone or in combination). Implants are designed
to augment these three areas: the infraorbital rim, the malar,
and the pyriform aperture.
Infraorbital rim
Because the infraorbital rim and upper midface skeleton
support the lower eyelids and the cheek soft tissues, their
projection impacts lid and cheek position. Patients with
retrusive upper midface skeletons are more likely to undergo
premature lower lid and cheek descent with aging. Rees and
LaTrenta warned that this lack of skeletal support makes these
patients “morphologically prone” to lower lid malposition
after blepharoplasty.7 Lack of skeletal support also limits the
efficacy and longevity of midface lifting procedures.
Jelks and Jelks8 categorized globe–orbital rim relationships
and the tendency for the development of lower lid malposi­
tion after blepharoplasty. On sagittal view, a line or vector is
placed between the most anterior projection of the globe and
the malar eminence and lid margin. They defined a positive
vector relationship as one which exists when the most anterior
projection of the globe is posterior to the lid margin and the
malar eminence. A negative vector relationship exists when
the most anterior projection of the globe lies anterior to the
lower lid and the malar eminence. Patients with a negative
vector relationship are prone to lid malposition after lower
blepharoplasty. Augmentation of the infraorbital rim in
patients with a retruded infraorbital rim can bring it into a
better relationship with the globe, thereby “reversing the
negative vector” (Fig. 14.5).9,10 Infraorbital rim augmentation
is part of the strategy for normalizing the appearance of
patients who are “morphologically prone”. It can be adapted
for morphologically prone patients who are first seeking
improvement in their periorbital appearance or for those
whose lid malposition and round-eye appearance have been
exaggerated by previous lower blepharoplasty.9
Surgical technique
The infraorbital rim and adjacent anatomy must be exposed
sufficiently to assure ideal implant placement, imperceptible
implant–facial skeleton transition, and screw fixation. Direct,
subciliary skin or skin muscle flap incisions can provide this
exposure. A transconjunctival, retroseptal incision may require
lengthening with a lateral canthotomy. The arcus marginalis,
the orbicularis oculi, and the origins of the lip elevators are
separated from the underlying skeleton in the subperiosteal
plane to expose the infraorbital rim.
It is important to identify the infraorbital nerve as it exits
from the infraorbital foramen, which is located about 1 cm
below the margin of the orbit in the midpupillary line.11
We prefer to use a transconjunctival incision together with
an intraoral sulcus incision to expose the entire midface
skeleton in the subperiosteal plane.
Implants are designed to increase the sagittal projection of
the infraorbital rim. Their lateral aspect provides medial
malar augmentation. The implants are carved to fit the specific
needs of the patient. Segmenting the implant may allow better
adaptation of the implant to the contour of the underlying
skeleton and also facilitate placement of the implant through
limited skeletal access. The implant is fixed to the skeleton
with titanium screws. The cheek soft-tissue mass is often
resuspended by sutures tied to the rim implant (subperiosteal
midface lift). This technique is summarized in Fig. 14.6. A
clinical example is shown in Fig. 14.7. (See Ch. 6.8 – Facelift
– Subperiosteal midface facelift).
Malar
Prominent malar bones are considered attractive. Hence, the
malar area is frequently augmented with implants. The lack
of anthropometric and cephalometric landmarks precludes
the availability of normative data, making analysis and aug­
mentation of the malar area highly subjective. Malar deficiency
is often part of a generalized midface deficiency for which
malar augmentation alone may be inadequate or even inap­
propriate treatment. Clinical experience has shown that when
malar projection is deemed inadequate, malar augmentation
is most effective when it recreates the contours of a normal
skeleton with prominent anterior projection.
Malar implant augmentation is often performed because
full cheeks are associated with a youthful look. This may
provide an aesthetic benefit if there is relative malar hypopla­
sia or if the implants are of modest size and projection. Malar
augmentation is not equivalent to soft-tissue augmentation or

408
SECTION I
CHAPTER 14 • Skeletal augmentation
Fig. 14.5  Jelks and Jelks8 categorized globe–orbital rim relationships by placing a line or “vector” between the most anterior projection of the globe and the malar
eminence and lid margin. (A) Positive vector relationship. In the youthful face with normal globe-to-skeletal rim relations, the cheek mass supported by the infraorbital rim
lies anterior to the surface of the cornea. The position of the cheek prominence beyond the anterior surface of the cornea is termed a positive vector. (B) Negative vector
relationship. In patients with maxillary hypoplasia, the cheek mass lies posterior to the surface of the cornea. The position of the cheek prominence beyond the anterior
surface of the cornea is termed a negative vector. (C) “Reversed” negative vector relationship. Alloplastic augmentation of the infraorbital rim can reverse the negative
vector. (Redrawn after Yaremchuk MJ. Restoring palpebral fissure shape after previous lower blepharoplasty. Plast Reconst Surg. 2003;111:441–450. © 2003, with
permission of Lippincott Williams and Wilkins.)
Positive vector
A
Negative vector
B
"Reversed" negative vector
Implant
C
Fig. 14.6  Overview of operation to increase projection of infraorbital rim and
“reverse the negative vector” in patients with upper midface skeletal deficiency. I
prefer a transconjunctival retroseptal incision (broken line) and, if necessary, the
lateral extent of a lower lid blepharoplasty incision (solid line) to expose the
infraorbital rim. This approach preserves the integrity of the lateral canthus, and
hence, the palpebral fissure. Transcutaneous blepharoplasty or transconjunctival
with lateral canthotomy incisions are alternative approaches which provide greater
exposure but are accompanied by a greater risk of palpebral fissure distortion. An
intraoral incision is used to access the lower midface skeleton and to identify and
protect the infraorbital nerve. The lower lid and midface soft tissues are freed by
subperiosteal dissection. The implant is immobilized with titanium screws.
resuspension, and it impacts poorly on surface irregularities
such as lower-eyelid wrinkles or secondary bags. Too often,
when performed under these reasons, malar augmentation
may detract from periorbital aesthetics by contributing to
lower lid malposition, particularly when placed through an
eyelid approach.12
Surgical technique (Video 14.3 )
Asymmetry is the most frequent complaint after malar implant
augmentation12; adequate surgical site exposure is therefore
crucial for accurate implant placement. Malar augmentation
can be performed through intraoral, coronal, eyelid incisions,
or combinations thereof. It is the senior author’s preference to
access the malar midface through an intraoral approach. An
upper buccal sulcus incision is made far enough from the apex
of the sulcus so that sufficient labial tissue is available on
either side for secure incision closure. Transconjunctival and
crow’s feet incisions are often performed to assure proper
placement of the superior aspect of the implant. Care is taken
to identify the infraorbital nerve. Subperiosteal dissection is
carried over the malar eminence, onto the zygomatic arch,
and up to almost the zygomaticotemporal suture. The pocket
size should allow precise insertion of the implant to the area
of the skeleton desired for augmentation. Extending a malar
implant onto the zygomatic arch has a profound impact on
midfacial width. Although implants with greater projection
are available, we rarely perform more than 4 mm of augmen­
tation at the point of maximum projection. Larger implants
may become obvious with time as the overlying soft tissues
atrophy and descend. The capsule formation that accompanies
smooth-surfaced implants further exaggerates the tendency
towards implant visibility. In the senior author’s experience,
implants with large surface areas do not mimic natural skel­
etal topography and cause unnatural implant-dictated

409
Mandible implants
contours. More recent implant designs include registration
tabs that rest on the lateral aspect of the infraorbital rim and
superior aspect of the zygomatic arch. Placement of the
implants on fixed anatomic landmarks lessens the likelihood
of asymmetric implant placement. The intraoperative position
of both smooth and porous implants can be stabilized with
screw fixation of the implant to the skeleton (Fig. 14.8).
A clinical example is shown in Fig. 14.9.
Fig 14.9 appears
online only.
Patient-specific custom malar–infraorbital
rim implants
Patients with midface hypoplasia often require augmentation
of both the infraorbital rim and malar eminence. Custom
implants using CAD-CAM technology allow precise preop­
erative planning, better fit, and more predictable postopera­
tive facial contour than stock implants. A clinical example is
shown in Fig. 14.10.
Pyriform aperture
The average Caucasian face is convex. A relative deficiency in
lower midface projection may be congenital or acquired,
particularly after cleft surgery and trauma. Patients with
satisfactory occlusion and lower midface concavity can have
their aesthetic goals realized with skeletal augmentation.
Implantation of alloplastic material in the paranasal area can
simulate the visual effect of LeFort I advancement and other
skeletal manipulations. Pyriform aperture augmentation
increases the projection of the nasal base and, therefore, opens
the nasolabial angle.13 It also tends to lessen the depth of the
nasolabial fold by effacing it from below (Fig. 14.11).
Surgical technique
Paranasal augmentation is done through an intraoral incision
made approximately 1 cm above the sulcus, with the medial
extent just lateral to the piriform aperture to avoid placing
incisions directly over the implant. Subperiosteal dissection
exposes the area to be augmented, and the infraorbital nerve
is identified and preserved. The patient’s anatomy will deter­
mine whether the entire crescent, or just the horizontal or
Fig. 14.7  A 52-year-old woman had undergone previous browlift, rhytidectomy, and upper and lower lid blepharoplasty. Lower lid retraction was treated by multiple
canthopexies, spacer grafts, and full-thickness skin grafts. Dry-eye symptoms persisted. Infraorbital rim augmentation, midfacelift, and lateral canthopexy resolved her
symptoms. Her brows and hairline were repositioned. (A) Preoperative frontal view. (B) Postoperative frontal view. (C) Preoperative lateral view. (D) Postoperative lateral
view. Note the vertical line defining globe–rim relations. The procedure transformed the preoperative negative vector to a positive vector globe–rim relationship.
A
B
C
D
vertical limb of the crescent-shape implant, will be utilized.
The root of the canine should be avoided if the implant is
immobilized with screws. The implant may compromise the
nasal airway if positioned over the pyriform aperture.
The technique is illustrated in Fig. 14.12.
A patient who underwent aesthetic rhinoplasty and aug­
mentation of the pyriform aperture area is shown in Fig. 14.13.
Fig 14.13 appears online only.
Mandible implants
Each of the anatomic areas of the mandible – chin, body, angle,
and ramus – may be deficient and is amenable to augmenta­
tion with alloplastic materials.
Chin
There is consensus that the ideal profile relation portrays a
convex face with the upper lip projecting approximately
2 mm beyond the lower lip and the lower lip projecting
approximately 2 mm beyond the chin.12 On average, men tend
to have larger, more projecting chins than women.14
Hints and tips
Placing a large chin implant in a woman may masculinize her
lower face.
Early implant designs augmented the mentum only and, if
prominent, often created a stuck-on appearance due to failure
of the lateral aspect of the implant to merge with the anterior
aspect of the mandibular body (Fig. 14.14). “Extended” chin
implants with tapered lateral extensions were later designed
to allow the chin implant to merge better with more lateral
mandibular contours.15 However, as implants become larger
with more complex three-dimensional configurations, they
are often less likely to fit the needs of a given patient. A
one-piece chin implant with lateral extensions is unlikely to
have an arc, projection, and inclination appropriate for every
mandible. Furthermore, with one-piece implants, asymmetry
in horizontal positioning increases as one proceeds laterally.

409.e1
Midface implants
Fig. 14.9  A 24-year-old woman underwent malar augmentation, chin augmentation, and submental lipectomy. (A,B) Preoperative frontal and oblique views.
(C,D) Postoperative frontal and oblique views.
A
B
C
D

409.e2
SECTION I
CHAPTER 14 • Skeletal augmentation
Fig. 14.13  A 20-year-old woman underwent rhinoplasty and paranasal augmentation. Note how the skeletal augmentation increased the nasolabial angle. Since midface
concavity tends to increase the relative projection of the nose, creating midface convexity tends to lessen the relative projection of the nose. A–C Preoperative frontal,
lateral, and oblique views. D–F Postoperative frontal, lateral, and oblique views.
A
B
C
D
E
F

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CHAPTER 14 • Skeletal augmentation
Fig. 14.8  Overview of the operative technique for malar augmentation. The upper
sulcus incision is at least 1 cm above the apex so that sufficient tissue is available for
closure. Transconjunctival and crow’s feet incisions are also performed to assure proper
placement of the superior aspect of the implant. Taking care to identify the infraorbital
nerve, the subperiosteal dissection is carried over the malar eminence and on to the
zygomatic arch just beyond the zygomaticotemporal suture. Registration tabs on the
implant rest on the lateral aspect of the infraorbital rim and superior aspect of the
zygomatic arch and lessen the likelihood of asymmetric implant placement. Implants are
fixed with titanium screws for immobilization, and for obliteration of the dead space
between the posterior surface of the implant and the anterior surface of the facial
skeleton. The implants are contoured so that they are identical in size and shape, are
appropriate for the area to be augmented, and merge imperceptibly with the native
skeleton. A trochar-attached suction drain is placed. It exits through temporal hair-
bearing scalp or the postauricular area. The colored area denotes the area of
subperiosteal dissection. The implant usually extends from the temporozygomatic suture
on the zygomatic arch to just below the foramen of the infraorbital nerve.
Fig. 14.10  Patient with midface hypoplasia.
(A) Preoperative three-dimensional image of facial
skeleton. (B) Design of custom malar–infraorbital
rim implant using CAD-CAM technology.
A
B

411
Mandible implants
Fig. 14.11  Diagram shows impact of implant relative to profile and nasolabial
angle.
Fig. 14.12  Diagrammatic overview of paranasal implant surgery. The green area
indicates the area of subperiosteal dissection. Note proximity of infraorbital nerve.
Note that the root of the canine tooth lies below the area to be augmented. It must
be avoided during screw immobilization of the implant.
Subperiosteal
dissection
Canine root
Incision in
buccal mucosa
Fig. 14.14  (A,B) Illustration and clinical example of a large button chin implant
resulting in a poor implant mandible transition with a stuck-on appearance.
Button implant
A
B
It is not uncommon to find one end of an extended silicone
implant impinging on the mental nerve, while the other end
extends beyond the edge of the mandibular border (Fig.
14.15). A two-piece chin implant allows adaptation of each of
these parameters for a given mandible (Fig. 14.16).16
Technique (Video 14.1 )
The midline of the chin is marked as a reference point. The
chin is accessed through either a submental or intraoral inci­
sion. An intraoral incision should be placed 1 cm above the
sulcus to provide adequate tissue inferiorly for ease and
security of closure. This incision also avoids pooling of saliva
over the suture line, which risks implant contamination if the
closure is not secure. The technique of intraoral placement of
chin implants avoids a cutaneous scar but provides limited
exposure to the menton while compromising the mentalis
muscle. As a result, the intraoral approach can be associated
with superior malposition of implants and lower lip dysfunc­
tion resulting from mentalis muscle division or detachment.17
After reviewing his series of more than 100 cases of postopera­
tive chin problems, Zide noted that almost all chin implant
problems that he had encountered were caused by implants
placed intraorally.18 The submental approach and extended
dissection avoid damage to the mentalis muscle and allow
better visualization of the mental nerve.

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CHAPTER 14 • Skeletal augmentation
Fig. 14.15  Malpositioned one-piece extended implant. (A) When placed through
an intraoral approach it is common for one end to extend beyond the mandibular
border while the other end impinges upon the mental nerve. (B) Clinical example:
extended one-piece implant protruding beyond the mandibular border.
III-adapting and mobile one piece implant
A
B
Fig. 14.16  Illustration of a two-piece chin implant placed in a subperiosteal
pocket. Note two-piece design, which allows the lateral extension of the implant to
follow the inclination of the mandibular border. Because the contour of the posterior
surface of the implant does not mimic the contour of the anterior surface of the
mandible, there is a gap between the mandible and the implant.
Gap before fixation
Two-piece implant
Hints and tips
Many chin implant problems are caused by intraoral
placement.
Subperiosteal dissection should extend approximately
1 cm beyond the area of augmentation to provide a panoramic
view of the complex and varying contours of the mandible,
thereby allowing precise implant placement. Porous polyeth­
ylene implants consisting of two half pieces connected by a
tab insert allow the inferior border of the implant to mimic
the inclination of the inferior border of the mandible. In
certain implant designs, symmetric placement is aided by
registration tabs to the inferior border of the mandible. The
implant is immobilized with titanium screws (Fig. 14.17).
Clinical examples of alloplastic augmentation of the chin
are shown in Fig. 14.18.
Implant augmentation versus sliding genioplasty
In most clinical situations, we prefer to augment the sagittal
projection of the chin with alloplastic implants rather than
with horizontal osteotomy and advancement genioplasty.
While chin point advancement after osteotomy has the advan­
tage of stretching the attached suprahyoid muscles, decreas­
ing submental fullness, and improving submental contour, it
also results in unnatural bony and border contours with a
poor transition, resulting in a stuck-on appearance of the chin,
much like a large button chin implant. There are also step-offs
at the osteotomy sites along the mandibular body which are
detrimental to those who have an existing pre-jowl sulcus.
Extending the osteotomy to the second molar can minimize
both of these deformities but may exaggerate mandible asym­
metry after advancement.
Horizontal osteotomy of the chin with inferior reposition­
ing of the chin point is a key procedure to increase the vertical
height of the severely deficient chin. Stock implants have a
more limited impact on increasing chin height. Implants
placed on the inferior border of the chin can effect small
increases in chin height. Unlike stock implants, CAD-CAM
chin implants can be manufactured with an inferior border
which uniquely wraps around the inferior chin edge, thereby
allowing vertical elongation of the chin.
Ramus, angle, and body
Aside from chin augmentation, there are three patient popula­
tions who may benefit from other mandibular augmentation
procedures. One group has mandibular dimensions that relate
poorly to the upper and middle thirds of the face but are
within normal range. These patients perceive a wider lower
face as an enhancement to their appearance. Patients in this
treatment group often present with a desire to have a defined,
angular lower face. They benefit from implants designed to
augment the ramus and posterior body of the mandible and,
in so doing, increase the bigonial distance or lower facial
width.

413
Mandible implants
Fig. 14.17  Screw fixation of the implant to the mandible prevents implant
movement and obliterates gaps between the implant and anterior surface of the
mandible. Screw fixation also allows in-place contouring of the implant to ensure
desired contour and an imperceptible implant–skeleton transition. (A) Illustration
showing “in-place” contouring of the implant fixed to the mandible with titanium
screws. (B) Clinical example of screw-fixed two-piece porous polyethylene chin
implant exposed through a submental incision.
Contouring distal transition
Screw fixation
A
B
Fig. 14.18  A 35-year-old woman with microgenia underwent chin augmentation with an alloplastic implant. (A) Pre- and (B) 1 year postoperative frontal views.
(C) Pre- and (D) 1 year postoperative lateral views.
A
B
C
D
Fig. 14.19  Configuration of implant used to augment the deficient mandible.
Because it extends beyond the posterior border of the ramus and inferior edge of
the ramus and body, it closes the mandible angle and levels the plane of the
mandible border. Screw fixation guarantees position and ensures application
of implant to skeleton. Typical implant dimensions: A = 80 mm; B = 30 mm;
C = 10 mm; D = 5–10 mm; E = 5–10 mm; F = 5 mm.
A
C
B
D
F
E
B
Patients with mandibular deficiency who have had their
malocclusion treated with orthodontics may benefit from
mandible implants. Implants are designed to correct the
obtuse mandibular angle with steep mandibular plane, as
well as the decreased vertical and transverse ramus dimen­
sions (Fig. 14.19). The addition of an extended chin implant
will camouflage the poorly projecting chin.
Patients who have undergone orthognathic surgery
often have contour irregularities after skeletal osteotomy and
rearrangement. Posterior mandible implants can camouflage
osteotomy-induced irregularities along the mandibular border
as well as malposition irregularities after sliding genioplasty.
These post-orthognathic surgery-induced asymmetries are
best managed with CAD-CAM implants.
Technique (Video 14.2 )
An intraoral incision is made to expose the ramus and body
of the mandible. It is made at least 1 cm above the sulcus on

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CHAPTER 14 • Skeletal augmentation
mandible with titanium screws placed intraorally. Clamps
which stabilize the implant in the desired position simplify
screw fixation through the limited intraoral exposure. Screw
fixation can also be performed transcutaneously with stab
incisions placed beneath the mandibular border and tele­
scoped cephalad. Screws are placed to avoid the anticipated
path of the inferior alveolar nerve prior to its exit from the
mental foramen.
It is crucial to soften any transitions between the implant
and the mandible, especially where the implant extends
beyond the inferior edge of the anterior mandibular border.
Any step-offs between the implant and the mandible in this
area may be visible in thin patients. Screw fixation of the
implants allows final implant contouring with scalpel or
mechanical burr. A small suction drain is placed at the opera­
tive site and exits through the skin behind the ear. The incision
is closed in two layers with absorbable sutures.19
A clinical example is shown in Fig. 14.21.
its labial side. The anterior ramus and body of the mandible
are freed in the subperiosteal plane from their overlying soft
tissues (Fig. 14.20). If the mental area is also being augmented,
a submental incision is made for access and exposure of the
anterior mandible. The mental nerve is visualized as it exits
its foramen to avoid injury. It is important to free both the
inferior and posterior borders of the mandible off of soft-
tissue attachments to allow implant placement. When freeing
the inferior border of the posterior mandible it is important
to maintain the integrity of the pterygomasseteric sling. Dis­
ruption of this sling allows the masseter to ascend, resulting
in contour irregularity which is exaggerated with masseter
contraction.
To assure proper placement of the implant and its applica­
tion to the surface of the mandible, the implant is fixed to the
Fig. 14.20  An intraoral mucosal incision is made along the ramus and posterior
body of mandible. It is made approximately 1 cm above the sulcus on its labial
side. A subperiosteal pocket is created for placement of the mandible implant.
Fig. 14.21  A 28-year-old woman with micrognathia underwent horizontal osteotomy of the chin with lengthening as well as placement of chin and mandible implants.
(A,B) Preoperative frontal and oblique views. (C,D) Postoperative frontal and oblique views.
A
B
C
D
Hints and tips
Make the intraoral incision at least 1 cm above the sulcus on
the labial side to provide adequate soft tissue for two-layer
closure and to avoid saliva pooling over the suture line in the
early postoperative period.
Custom mandibular angle–body–chin implant
It is not uncommon for patients who underwent bilateral
sagittal split osteotomy to present with concomitant asym­
metry at the mandibular angle, step-offs at the body, and
deformity at the chin. They are ideal candidates for custom
mandibular angle–body–chin implant using CAD-CAM
technology. A clinical example is shown in Fig. 14.22.
Postoperative care
A suction drain is routinely placed at the operative site.
The drain is routinely removed the next morning after
midface and chin procedures, and within 24–72 hours after
placement of mandible implants. A supportive tape dressing
placed at the completion of surgery is usually removed the
next morning. Oral antibiotics are prescribed for 7 days
postoperatively.
When intraoral incisions are used, patients are asked to
remain on a soft diet for the first 72 hours after surgery. They
are also instructed to refrain from strenuous exercise for 2–3
weeks postoperatively.

415
Outcomes, prognosis, and complications
implant site. The accumulation of these clinical data provide
some useful information on risk factors that contribute to
morbidity with implants. For example, the quality of the soft-
tissue coverage is clearly related to morbidity. Complication
rates are lowest in the chin and malar region where the soft-
tissue cover is relatively thick, and highest in the nose and ear,
where the soft-tissue cover is thin and often under tension
from the underlying device. The surface characteristic of an
implant may also be important. Porous implants allow a
certain ingrowth of tissue which may allow the presence of
host defenses within the implant to decrease the risk of infec­
tion. Given that several biomaterials are well tolerated in the
human body, the actual chemical structure of an implant is
important only to the degree that it influences the consistency
and surface characteristics of the device.
Outcomes, prognosis, and
complications
The literature supports the biocompatibility of the currently
used implant materials.6 No cases of cancer have been reported
in association with a polymer craniofacial implant. True
hypersensitivity reactions to prefabricated polymer implants
are extremely rare. There are no truly scientific data that
document the surgical complication rate related to facial
skeletal augmentation. Prospective studies that control for
surgical technique, implant site, patient selection, and
follow-up time do not exist. We reviewed almost 200 reports
in the literature that provided sufficient data to compare
complication rates related to both implant material and
Fig. 14.22  A 36-year-old male with a history of
micrognathia presented with contour deformity of
the mandible after LeFort I advancement, bilateral
sagittal split osteotomy, and sliding genioplasty.
A CAD-CAM custom chin–mandible implant was
designed to correct the mandibular contour
deformity and to improve the projection of his chin.
(A) Preoperative frontal and sagittal views.
(B) Preoperative three-dimensional image of the
facial skeleton. (C) Design of custom chin–
mandible implant using CAD-CAM technology.
(D) Postoperative frontal and sagittal views.
A
B
C
D

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CHAPTER 14 • Skeletal augmentation
implants is often cited as a complication of implant surgery,
the process is rarely clinically significant unless a chin implant
that overrides the lower incisor tooth roots creates symptoms.
Wide subperiosteal exposure of the area to be augmented
optimizes implant placement, screw fixation prevents implant
movement, and visualization of the infraorbital and mental
nerves before and after implant placement avoids problems
with nerve compression.
Secondary procedures
The most common indication for secondary surgery is visibil­
ity of facial implants. Since it is inevitable that the volume of
soft tissues changes with time but that of alloplastic implants
does not, large implants placed under a thin soft-tissue cover
will become visible in time. This phenomenon is exaggerated
when smooth-surface implants which elicit a vigorous capsule
response are used. Patients with thin soft tissue are advised
preoperatively that soft-tissue augmentation with fillers or fat
injections may later be appropriate.
In 2003, the senior author reported his personal experience
with porous implants used for facial skeletal reconstruction.20
This study was based on experiences with 162 patients who
were operated on over an 11-year period (1990–2001). In this
series there were no implant migration, extrusion, formation
of clinically apparent capsules, and symptoms attributable to
bioincompatibility. Infection rate was 3%. Since that report no
subsequent patient has presented with late infection, that is,
after 6 to 8 weeks postoperatively. We believe these late pre­
sentations reflect small bacterial contaminations during
surgery that were initially suppressed by perioperative anti­
biotic administration. The rate of complications, most signifi­
cantly infection, has decreased in facial implant procedures
with the senior author’s subsequent clinical experience.
In animal models, the presence of a foreign body decreases
the minimal infecting dose of Staphylococcus aureus due to
impaired bacterial clearance. If microorganisms are not elimi­
nated rapidly from an implant surface they will adhere to the
implant initially by nonspecific physical forces and then by
the formation of biofilms characterized by cells clustering
together in an extracellular matrix attached to the implant.
Biofilms protect bacteria from host defenses and antibiotics.
Only aggressive debridement and long-term suppressive
therapy have been effective in treating orthopedic implant-
related infections.21 This approach is usually not appropriate
for facial implant patients as both debridement and chronic
infection may be deforming in this appearance-conscious
population. Since antibiotic treatment alone is rarely success­
ful, facial implant-related infections are treated with implant
removal, antibiotics, and appropriate wound care. Implants
may be replaced in 6–12 months.
Common causes for patient dissatisfaction after facial
implant surgery include malposition, asymmetry, and sensory
nerve dysfunction. Although bone resorption beneath facial
Bonus images for this chapter can be found online at

Fig. 14.9 A 24-year-old woman underwent malar augmentation, chin
augmentation, and submental lipectomy. (A,B) Preoperative frontal and oblique
views. (C,D) Postoperative frontal and oblique views.
Fig. 14.13 A 20-year-old woman underwent rhinoplasty and paranasal
augmentation. Note how the skeletal augmentation increased the nasolabial
angle. Since midface concavity tends to increase the relative projection of the
nose, creating midface convexity tends to lessen the relative projection of the
nose. A–C Preoperative frontal, lateral, and oblique views. D–F Postoperative
frontal, lateral, and oblique views.
1. Yaremchuk MJ, Kahn DM. Periorbital skeletal augmentation to
improve blepharoplasty and midfacial results. Plast Reconstr Surg.
2009;124:2151–2160. Describes the impact of the projection of the skeleton
on the soft-tissue envelope and periorbital appearance.
8. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on
the palpebral aperture. Clin Plast Surg. 1991;18:183–195. Emphasizes
the importance of globe rim relations and morbidity in lower lid
blepharoplasty.
10. Yaremchuk MJ. Restoring palpebral fissure shape after previous
lower blepharoplasty. Plast Reconstr Surg. 2003;111:441–450,
discussion 451–452. Introduces the concept of negative-vector reversal
with implants.
12. Yaremchuk MJ. Secondary malar implant surgery. Plast Reconstr
Surg. 2008;121:620–628. Avoidance and correction of malar implant-
related problems.
18. Zide BM, McCarthy J. The mentalis muscle: an essential
component of chin and lower lip position. Plast Reconstr Surg.
1989;83:413–420. Warns of potential damage to the mentalis muscle with
the intraoral approach to chin augmentation and presents techniques for
repair.
20. Yaremchuk MJ. Facial skeletal reconstruction using porous
polyethylene implants. Plast Reconstr Surg. 2003;111:1818–
1827. Reports the senior author’s clinical experience.
Access the complete reference list online at