Phẫu Thuật Trẻ Hóa Khuôn Mặt (Facial Rejuvenation Surgery)

CHAPTER 1: Endoscopic Browlift
98
toward the bone and the subperiosteal dissection
continued to the orbital margin, identifying the
supraorbital nerve (if this has not already been
achieved) (Fig. 3.1.20). The dissector is changed
to the surgeon’s left hand and a similar procedure
carried out on the left-hand side. In the midline,
using the same elevator, the subperiosteal dissec-
tion continues toward the nasion. It is important
to note that, very occasionally, this aspect of the
dissection can produce a vaso-vagal bradycardia,
which the anaesthetist should be aware of.
The dissector is now exchanged for the number
7 dissector which has an upward angled cutting
edge. This is initially inserted through the right
frontal port and used to split the periosteum
along the supraorbital margin. It is easiest to
begin this medially and a fi rm antero-superior
pressure is needed – the periosteum will usually
split relatively easily revealing the corrugator
musculature at the medial aspect of the orbit, the
supraorbital nerve as one moves more laterally,
fi nally dividing the periosteum into the temple so
that it is completely released (Fig. 3.1.21). Care
must be taken in the lateral aspect of this dissec-
tion to limit forward, i.e. anterior pressure, to
avoid neuropraxia of the frontal branch of VII.
The procedure is now repeated using the left
hand via the left frontal port on the left-hand
side.
At this point the depressor musculature is
divided. This is most easily accomplished using a
sharp punch, for a right-handed surgeon it is
easiest to begin using the right-handed instru-
ment beginning on the right side. The punch is
inserted through the right frontal port whilst
angling the endoscope slightly anteriorly to
provide good vision. It can be helpful to have the
assistant put gentle traction on the glabella skin
with a skin hook if visualization is diffi cult. The
corrugator muscle is incised using the punch. A
gentle closure of the punch with anterior
movement producing a tearing motion is most
effective and least likely to injure branches of
the supratrochlear nerve as they course through
the corrugator musculature (Figs. 3.1.22 and
Fig. 3.1.20 Identifi cation of supraorbital nerve.
Fig. 3.1.21 Division of supra-orbital periosteum.
Fig. 3.1.22 Division of corrugator muscle using
endoscopic punch.

Section 3
99
3.1.23). The depressor supercilii will be divided
by the same motion. The procerus muscles lie on
a more superfi cial plane and should be identifi ed
individually. They may then be divided using the
same sharp punch and it is helpful for the assis-
tant or scrub nurse to watch the skin overlying
the punch to be certain that it is not injured in
the division of the procerus (Fig. 3.1.24). The
same procedure for the corrugator, depressor and
procerus is repeated on the left-hand side which
is usually accomplished via the right lateral port
using the same right-handed instruments but on
occasion it may be necessary to use the left hand
punch and grasper via the left lateral port. Small
veins are usually identifi ed quite easily and can
be left uninjured. If bleeding does occur the
grasping forceps are used to secure the cut end
of the bleeding vessel and are touched by mono-
polar cautery to achieve haemostasis (Fig.
3.1.25). Suction may be necessary to clear dia-
thermy smoke from the optical cavity. If the
dissection is carried out with care the supraor-
bital and supratrochlear nerves should be well
protected throughout. At this point the endo-
scopic aspect of the surgery is complete.
Fixation is provided by suturing the frontal peri-
osteum through drill holes in the external table
of the skull. A 2.4 mm Rose head burr on a power
drill is most appropriate tool to make the holes
(Fig. 3.1.26). The fi xation points are created via
each lateral frontal port, whether left or right is
Fig. 3.1.23 Division of corrugator and preservation of
supratrochlear nerve.
Fig. 3.1.24 Corrugator and procerus muscles divided.
Fig. 3.1.25 Insulated endoscopic grasper as unipolar
cautery.
Fig. 3.1.26 A 2.4 mm Rose head burr and power drill.

CHAPTER 1: Endoscopic Browlift
100
done fi rst is immaterial. The assistant retracts
the edges of the wound with small retractors.
The surgeon holds the drill in his right hand
and the sucker in his left hand placing the drill
bit approximately 1 cm posterior to the anterior
extremity of the frontal port. The drill is angled
at approximately 60° to the frontal bone and
the hole drilled through the outer table. The
scrub nurse provides irrigation with saline to
cool the burr. Very little pressure is required
with the drilling hand and it is easy to feel the
diploe once it is reached (Fig. 3.1.27). The drill
is then removed and placed approximately 1 cm
posterior to the drill hole which has already been
made and again angled at approximately 60°
towards it (Fig. 3.1.28). Again, the surgeon holds
the drill in his right hand and in his left hand a
malleable (ribbon) retractor to protect the hair
from the drill. A drill hole is again made which
links up with the initial anterior drill hole and
once again, this is easy to feel. Confi rmation that
the two drill holes are continuous is made by
irrigating the drill holes which will also remove
any bone dust (Fig. 3.1.29). When both sides
have been drilled a 2/0 clear PDS suture is passed
through the anterolateral aspect of the frontal
port to gain a fi rm bite of the frontal periosteum
(Fig. 3.1.30). Tension is applied to ensure that
the suture is secure and the needle is then refash-
ioned slightly by digital pressure and passed from
Fig. 3.1.27 Anterior fi xation drill hole.
Fig. 3.1.28 Posterior fi xation drill hole.
Fig. 3.1.29 Irrigation of drill holes.
Fig. 3.1.30 PDS fi xation suture grasping frontal
periosteum.

Section 3
101
the anterior bony drill hole through to the pos-
terior (Fig. 3.1.31). The assistant then applies
tension to the posterior aspect of the lateral
frontal port with a skin hook whilst the surgeon
ties the suture through the drill holes (Fig.
3.1.32). This should provide secure fi xation of
the brow. Symmetry should be checked once
both sides have been tied.
A single microsuction drain is placed via the
central frontal port and should extend to the
glabella. The three frontal ports are closed using
interrupted sutures of 5/0 Caprosyn – particular
care must be taken to ensure that the anterior
aspect of each lateral frontal port is closed accu-
rately over the buried PDS suture. Each temporal
incision is then closed in turn – a 3/0 monocryl
horizontal mattress suture is used to support the
inferior cut edge of the TPF to the TF (Fig.
3.1.33). The cutaneous temporal wound is then
closed with a running 5/0 Caprosyn suture. If no
other surgery is contemplated then dressings are
unnecessary and the drain should be sutured in
position. One centimetre fl esh-toned micropore
tape is used to provide some pressure and support
the glabellar region (Fig. 3.1.34). The drapes are
removed and the hair washed, no other dressing
is necessary.
Fig. 3.1.31 Needle passed through drill holes.
Fig. 3.1.32 Retraction of lateral port with skin hook while
tying fi xation suture.
Fig. 3.1.33 Elevation of TPF and suture to TF.
Fig. 3.1.34 Procedure complete, dressing applied.

CHAPTER 1: Endoscopic Browlift
102
Post-operative Care
General care is as for other facial surgery – keeping
blood pressure stable and the head elevated above
the chest, particularly during the fi rst week. If
headache is a problem in the early post-operative
period it can usually be alleviated with a cox II
type non-steroidal anti-infl ammatory such as
celecoxib. If there is any question about adequacy
of eye closure then lubrication in the form
of simple eye ointment should be provided
and if necessary the eyes padded with damp eye
pads at night time. Review should take place at
approximately one week when the micropore
tape is removed and sound wound healing
checked.
Clinical pearls
The best candidates for endoscopic brow lift are
those with short fl at foreheads and a thick non
receding hairline whose skin has mild to moderate
rhytids and minimal real skin excess.
The success of this procedure depends on
adequate release of periosteum into the orbital
rim superiorly and laterally to the Z-F sutures
where there is a thickening within the periosteal
adhesion.
Keep the dissector fi rmly down onto the surface of
the temporalis fascia and underlying temporalis
muscle when breaking through the confl uence at
the level of the temporal crest in order to prevent
damage to the frontal branch of the facial nerve
that runs in the substance of the overlying
temporoparietal fascia.
Dissection into the orbital rim may lead to a
refl ex bradycardia due to manipulation of the
periorbita which the anaesthetist must be made
aware of.
Resecting glabellar musculature is best performed
using the punch rather than sharp dissection with
endoscopic scissors which risks more bleeding and
inadvertent damage to the supratrochlear nerves.
Care must also be taken not to remove any
subcutaneous fat particularly when treating the
more superfi cial procerus muscle which could lead
to a visible depression.
Points to note
• Pre-operative assessment with patient
standing upright.
• Ensure pupil-to-brow height <2.5 cm
and brow apex-to-frontal hairline
<7 cm.
• Mark glabellar furrows and vector of lift for
lateral brow with permanent marker.
• Prepare hair with gel and ribbons to isolate
scalp ports (midline as well as left and right
frontal over vectors of lift) and temporal ports
without cutting any hair.
• Tumescent infi ltration using 20 mL Luer lock
syringe and 23 gauge spinal needle.
• Incisions made in frontal region behind
hairline (midline, left and right frontal) and
temporal region.
• Subperiosteal dissection (without endoscope)
over frontal bone up to 1 cm above supraorbital
rim and laterally up to temporal crests.
• Temporal dissection (without endoscope)
made between temporoparietal fascia (TPF)
and temporalis fascia (TF).
• Dissect through the periosteal confl uence at
the temporal crest moving inferiorly to level
of zygomatico-frontal (Z-F) suture.
• Insert endoscope and release periosteum
along supra orbital rim and laterally to Z-F
sutures under direct vision.
• Release periorbita into orbital rim with down
cutting dissector under direct vision.
• Divide periosteum at orbital rim under direct
vision using upcutting dissector.

Section 3
103
Points to note—cont’d
• Divide depressor musculature under direct
vision with an endoscopic punch
• Bony tunnels made in outer table of skull
using 2.4 mm rose burr to drill two opposing
holes at 60° degrees in the sagital plane
• Insertion of 2/0 PDS suture through frontal
periosteum and secured through the bony
tunnel.
• Sutures tied to fi x forehead at higher level
whilst traction placed on frontal scalp port
with skin hook.
• Temporal component of lift achieved by
advancing and suturing TPF to TF with 3/0
monocryl.
• Closure of skin incisions with dissolving
suture material in single layer.
Pre operative
Post operative
Pre & Post operative
&
Age 46 Endobrow, lower blepharoplasty, lateral canthoplasty

CHAPTER 1: Endoscopic Browlift
104
Pre operative
Post operative
Pre & Post operative
&
Age 63 Endobrow, upper blepharoplasty

Section 3
105
Pre operative
30 months post operative
Pre & Post operative
&
Age 43 Left unilateral endobrow, lower blepharoplasty – pre operative, 3 and 30 months post operative
3 months post operative

CHAPTER 1: Endoscopic Browlift
106
ANNOTATED BIBLIOGRAPHY
Elkwood A, Matarasso A, Rankin M, et al. National plastic
surgery survey: brow lifting techniques and
complications. Plastic and Reconstructive Surgery
2001;108:2143–50.
Large review of browlifting performed by members of the
ASPRS with data from 6951 patients (50% were performed
endoscopically). This is the largest series to date assessing
the outcome of forehead lifting. Complications rates were
low with the commonest being alopecia of usually a minor
degree (incidence 4%). Patient satisfaction was extremely
high (over 98%) emphasizing the popularity of this
procedure.
Jones BM, Grover R. Endoscopic browlift: a review of 538
patients and comparison of fi xation techniques. Plastic
and Reconstructive Surgery 2004;113:1242–1250.
A large consecutive series of browlifts performed using fi brin
glue fi xation and periosteal fi xation via bony tunnels with
quantitative assessment of outcome. Long term results
revealed that fi xation with bony tunnels maintained the
forhead lift signifi cantly better than fi brin glue. This
supports the need for periosteal fi xation for over one month
in order to maintain lift as a result of periosteal healing.
This is unlikely to be achieved with screw fi xation where
removal can be cumbersome and is usually performed at
about two weeks.
Isse NG. Endoscopic facial rejuvenation: Endoforhead, the
functional lift. Case reports. Aesthetic Plastic Surgery
1994;18:21–29.
A classic paper relating the authors description and early
experience with endoscopic forehead lift. The development of
the technique began in 1992 and was presented in a number
of meetings before publication.
McKinney P, Celetti S, Sweis I. An accurate technique for
fi xation in endoscopic browlift. Plastic and Reconstructive
Surgery 1996;97:824–827.
Description of periosteal fi xation of the forehead using
sutures through bony tunnels made in the outer table of the
skull via 60° opposing drill holes.

107
CHAPTER 2
Blepharoplasty
Indications
A number of facial features lead to patients enquire about eyelid
surgery. In the upper lid this usually relates to a degree of cutaneous
hooding concealing all or part of the upper eyelid itself in forward
gaze. In the lower eyelid it may relate to periorbital fat bulging behind
a weakened septum causing “bags”, as patients often term them, to
cutaneous wrinkling or some combination of these.
Patient Assessment
A thorough clinical history is essential to detect any pre-existing
ophthalmic disease or defect. In particular, it is important to know
whether the patient wears spectacles, contact lenses or both, has
pre-existing eye disease such as glaucoma, demonstrates evidence of
dry eyes in the form of excessive tearing, redness and or soreness,
particularly in the morning, and whether they have any medical con-
ditions that may affect the eyes such as diabetes and thyroid disease.
The family history may also be signifi cant insofar as puffy lower
eyelids are frequently familial and in such cases patients may seek
advice at a relatively young age.
Routine ophthalmological assessment is wise before any surgery is
carried out so that there is a baseline against which to judge any
alteration in visual acuity that may occur post-operatively. I have not
found a Schirmers test to be particularly helpful in predicting patients
at risk of developing dry eyes more accurately than with the clinical
history and examination.
The patient and examiner should be seated opposite each other with
their eyes at a similar height and the patient in direct forward gaze
S E C T I O N 3

CHAPTER 2: Blepharoplasty
108
(Fig. 3.2.1). General inspection should identify
orbital asymmetries (dystopia) and asymmetries
of eyebrow height that may, in turn, have an
effect on the apparent cutaneous excess in the
upper lid. The distance from pupil to upper lid
margin should be observed and any discrepancy
indicating upper lid ptosis noted. The position of
the supratarsal skin crease should be noted and
again any asymmetries, which may indicate dis-
insertion of the levator, identifi ed. The relative
position of medial and lateral canthus, i.e.,
whether they are at the same level or the lateral
canthus above or below the medial should be
noted – in a Caucasian female a slightly upward-
slanting palpebral fi ssure is generally thought
most attractive and a downward-slanting fi ssure
may indicate laxity in the lateral canthal
ligament.
The relative position of the lower lid in relation
to the iris should be identifi ed and any scleral
show noted (Fig. 3.2.2). The relationship of the
globe of the eye to the orbit, and in particular the
degree to which it protrudes in profi le view
beyond the inferior orbital margin is important.
Eyes that protrude beyond the inferior orbital
margin, known as a negative vector confi gura-
tion, are at signifi cantly greater risk of post-

Lower lid bulge
Upper lid ptosis
Lower lid retraction
Descent of brow
Midcheek groove
Palpebromalar
groove
Malar mound
Eyelid-cheek
junction
Lower lid crease
Canthal tilt
Lateral canthus
Nasojugal
groove
Medial
canthus
Upper lid
sulcus
Tear trough
deformity
Nasojugal
groove
Orbital fat
atrophy
Upper lid fold
Upper lid crease
EFFECT OF AGEING
NORMAL ANATOMY
Fig. 3.2.1 Patient examination – patient/surgeon
opposite each other with eyes at similar height.
Fig. 3.2.2 Features observed in clinical examination.

Section 3
109
blepharoplasty complication than those that are
protected by the inferior orbital margin, positive
vector (Fig. 3.2.3).
The distance from the pupil to eyebrow apex in
direct forward gaze should be measured using
callipers and also the distance from eyebrow peak
to anterior hairline (Fig. 3.2.4). This is helpful in
discriminating between lateral brow ptosis and
true dermatochalasis of the upper eyelid. An esti-
mate of the degree of skin excess in the upper
lid may be gained by pinching gently between
index fi nger and thumb and the position of any
fatty herniation is noted, particularly in the
medial and pre-aponeurotic compartments.
Bulging at the superolateral aspect of the upper
lid may indicate a prolapsed lacrimal gland.
Normal blink and eyelid closure should be noted.
Any pre-existing scars should be identifi ed. In the
lower eyelid the position and depth of the naso-
jugal furrow should be noted together with an
impression of the degree and site of any fatty
herniation above it. Skin quality should be
assessed and the degree of skin wrinkling particu-
larly at rest noted. The tension in the tarsal plate
and lateral canthal ligament is assessed using a
“snap test” (Fig. 3.2.5). The patient is instructed
> 21mm
Fig. 3.2.3 Orbit–globe relationship – positive/negative
vector.
Fig. 3.2.4 Pupil – brow (left) and
brow height measurement.
Fig. 3.2.5 Snap test. Note that after
release there is persisting scleral
show on the right, indicating a
degree of canthal laxity.

CHAPTER 2: Blepharoplasty
110
not to blink (this can be diffi cult to achieve) and,
whilst in direct forward gaze the eyelid is pulled
downward and laterally by the examiner’s thumb
or index fi nger. Tension is maintained for approx-
imately ten seconds, the patient is reminded not
to blink, and the tension is released. The eyelid
should return to its resting position more or less
immediately and any delay indicates lack of lower
lid support which must be taken into account
when planning surgery.
It is vital to show the patient their own image –
some asymmetry of soft tissue or bony landmarks
around the globe, eyelids, brow and orbit are
almost universal, but are often unappreciated
by the patient. If they are not pointed out pre-
operatively they certainly will be noticed after-
wards! The relative importance of upper lid and
brow surgery should be discussed when appropri-
ate and the limitations of upper lid surgery alone
in the presence of lateral brow ptosis empha-
sized. Above all, in any discussion about eyelid
surgery, it must be stressed that functional con-
siderations must always outweigh the aesthetic,
however important the latter may be. In simple
terms, from a patient’s perspective, this means
that the upper lid must close adequately and
comfortably to prevent lagophthalmos and dry
eyes and that the lower eyelid position must be
correct in relation to the globe. Patients will
often refer to blepharoplasty as “an eyelid lift” so
it is essential to stress that tension cannot be
placed on the lower eyelid and therefore that
some skin wrinkling particularly when smiling
will always be present. An easy analogy to use in
discussion of the lower eyelid is that of a washing
line, fi xed at either end, i.e., the canthi, but
unsupported in the centre so that if any tension
or weight is placed on it the line will bow down-
ward since it cannot pull the weight up (Fig.
3.2.6). If canthal reinforcement or support is
necessary in the form of canthopexy or cantho-
plasty, it must be explained and the conse-
quences, such as altering the cant of the palpebral
fi ssure and the potential for lower lid oedema
identifi ed.
The surgery itself should be discussed fully with
the patient. The siting of scars is pointed out and,
although they are generally well concealed, the
patient should be made aware that they may be
visible around the lateral canthus in the short or
medium term but can be covered with make-up
if need be. Specifi c risks and complications must
be fully outlined. Soreness of the eyes, a feeling
of grittiness and mild epiphora is common in the
fi rst few days post surgery and it may be helpful
to use lubricating ointment (simple eye oint-
ment) and, or, damp eye pads at night time.
Contact lenses generally should not be worn for
two weeks and long term contact lens wearers
should be warned that, for them, irritability of
the eyes is a more frequent occurrence than for
non-contact lens wearers. The incidence of
general complications is low – infection 0.01%,
haematoma approximately 1%. Although retro-
bulbar haematoma is extremely rare it must be
specifi cally discussed since its consequences, the
risk of damaging sight, are potentially cata-
strophic. In this regard the need for rest, particu-
larly in the fi rst three post-operative days, should
be stressed. The occasional occurrence of sub-
conjunctival oedema should be described and this
is more frequent when canthoplasty is used.
Ectropion and scleral show related to oedema or
mid-lamellar contracture and the appropriate
treatment when necessary are explained. It is of
Effect of skin removal
Effect of
lid tightening
Fig. 3.2.6 Washing line analogy.

Section 3
111
vital importance that patients are made aware
that eyelid surgery, particularly lower lid surgery,
is not necessarily as simple and straight-forward
as they may have been led to believe. Expecta-
tions must be pitched at a realistic level insofar
as some skin wrinkling in the lower lids will
always persist, particularly when smiling, and
surgery will have minimal infl uence on lateral
canthal furrows (laughter lines or crows feet).
Clarity of the upper lid may be restricted by a
degree of lateral brow ptosis that the patient may
not wish to treat, and again some skin wrinkling
is likely to persist if eye closure is to be adequate
post-operatively.
Surgical Technique
Positioning on the operating table, general patient
preparation and draping is as for other facial
surgical procedures (Section 2 Chapter1). It is
important to ensure that the head drape does not
place upward tension on the brows and so distort
the natural position of the upper lid. If multiple
procedures are planned then the best order to
proceed is endoscopic browlift, upper lid blepha-
roplasty, lower lid blepharoplasty, face/ neck lift.
Blepharoplasty alone may be carried out under
either local anaesthesia with intravenous sedation
or general anaesthesia. For all but the calmest of
patients I prefer general anaesthesia.
Upper lid blepharoplasty
The inferior incision line is usually marked at the
supratarsal skin fold which lies 10 mm–11 mm
above the ciliary margin. If the tarsal plate is
small and the skin fold therefore positioned very
inferiorly, it is preferable to mark the inferior
incision with its apex (at the centre of the lid)
10 mm above the ciliary margin and then paral-
leling the supratarsal fold toward the medial
canthus and laterally beyond the lateral canthus,
in a natural skin crease, for 4 mm–5 mm depend-
ing on the degree of skin excess (Fig. 3.2.7). The
site of the superior incision is gauged by pinching
the upper lid skin in fi ne-toothed or non-toothed
dissecting forceps, gathering the excess skin but
still permitting eyelid closure, or at the very most
the upper lid margin to lie at mid-pupillary level
(Fig. 3.2.8). The excision should not extend too
far medially toward the nose or bridging will
occur post-operatively with scar contracture
Fig. 3.2.7 Upper lid – inferior incision site.
Fig. 3.2.8 Upper lid – estimating skin to be excised.

CHAPTER 2: Blepharoplasty
112
(Fig. 3.2.9). The skin is infi ltrated with 1%
lignocaine and 1 : 200 000 adrenaline solution
(approximately 0.5 mL). Time is allowed for
the vasoconstrictor effect of adrenaline to occur
(Fig. 3.2.10).
I prefer to begin with the right eyelid so that if a
facelift is planned the surgeon is on the patient’s
left-hand side when the blepharoplasty is com-
plete. The assistant places an index fi nger on the
upper lid below the planned incision line and
exerts gentle inferior traction whilst the surgeon
exerts superior traction with his left hand (Fig.
3.2.11). The inferior incision line is made fi rst
using a number15 blade followed by the superior
incision. The assistant then exerts lateral traction,
the surgeon grasps the lateral aspect of the planned
skin excision in fi ne toothed forceps and removes
skin superfi cial to the orbicularis muscle with a
blade (Fig. 3.2.12). The lateral aspect of the
exposed orbicularis is then grasped in the forceps
and a narrow strip (2 mm–3 mm) excised across
Fig. 3.2.9 Upper lid skin markings complete.
Fig. 3.2.10 Upper lid – infi ltration.
Fig. 3.2.11 Upper lid skin traction to facilitate incision.
Fig. 3.2.12 Upper lid – excision of skin.

Section 3
113
the full width of the wound with tenotomy scis-
sors (Fig. 3.2.13). Haemostasis is achieved using
bipolar cautery. Gentle pressure on the globe will
confi rm the clinical impression of any excess
periorbital fat (Fig. 3.2.14). The medial fat pad
is exposed fi rst. The assistant places a skin
hook in the superomedial aspect of the wound
while the surgeon applies gentle pressure to the
globe to defi ne the location of the medial fat pad
which often lies further inferior than one might
expect (Fig. 3.2.15). A small incision is made
using scissors in the orbital septum over the fat
pad so that it may be exteriorised by gentle pres-
sure. Excess fat is clamped at its base with a hae-
mostat (Fig. 3.2.16) and then excised using
scissors.
Fig. 3.2.13 Upper lid – orbicularis strip excision.
Fig. 3.2.14 Upper lid – globe pressure to identify fat.
Fig. 3.2.15 Upper lid – identifi cation of medial fat pad.
Fig. 3.2.16 Medial fat pad clamped at base.

CHAPTER 2: Blepharoplasty
114
During excision it is best for the surgeon to hold
the haemostat in his left hand so as to be sure
that no traction is applied to the fat pad whilst
manipulating the scissors with his right hand
(Fig. 3.2.17). The base of the excised fat is coag-
ulated with bipolar cautery. Careful judgement
must be exercised in determining whether or not
it is necessary to excise pre-aponeurotic fat to
avoid creating a hollow orbit. When excess fat is
present, sometimes it may be in the centre of the
lid but on occasion it may extend to the lateral-
most part of the dissection. Again, it is exterior-
ized by an incision in the orbital septum and
gentle digital pressure on the globe. Care must
be taken not to over-resect fat and in addition
the underlying levator muscle and aponeurosis
must be protected. If any excess fat is identifi ed
it is clamped and excised as with the medial fat
pad (Fig. 3.2.18). If there is a defi ned lateral
bulge then it is essential to ensure that there is
not a prolapsed lachrymal gland – this is identi-
fi ed as a coral coloured structure distinct from
Fig. 3.2.17 Upper lid – excision of medial fat pad
(haemostat is beneath scissor).
Fig. 3.2.18 Upper lid – excision of pre aponeurotic fat.
the yellowish periorbital fat. When prolapsed it
may be reduced and retained in the lacrymal
fossa with 5/0 vicryl (Fig. 3.2.19). ROOF
(retro orbicularis occuli fat) fat lies deep to the
orbicularis but superior to the supra-orbital rim
Fig. 3.2.19 Upper lid – prolapsed lacrymal gland
(arrowed).

Section 3
115
(Fig. 3.2.20). In some patients, particularly
when endobrow is declined, reducing its bulk can
mask lateral brow ptosis to some extent but care
must be taken to protect the supraorbital nerve
and the frontal branch of the facial nerve
(Fig. 3.2.20).
If only upper lid blepharoplasty is being carried
out then the wound is now closed with a single
subcuticular 6/0 prolene suture (Fig. 3.2.21). If
lower lid blepharoplasty is also planned then this
is usually done before the upper lid is closed to
minimize the risk of corneal exposure.
Lower lid blepharoplasty
Treatment of the lower lid is much more contro-
versial than the upper. In general, I prefer fat
preserving techniques rather than fat excision
since these do, in the longer term, appear to give
more satisfactory results without the risk of pro-
ducing a hollow, aged eye. In the majority of
patients there is some cutaneous excess as well
as fatty herniation and so a transcutaneous, sub-
ciliary approach is used. When skin excess is non-
existent or minimal then a transconjunctival
approach may be preferred. In either event it is
possible to improve the aesthetics of the eyelid
without removing fat.
Transcutaneous approach
The incision is marked from a medial point just
below the lacrimal punctum continuing laterally,
just below the lashes, beyond the lateral canthus
into a natural smile line for approximately
4 mm–5 mm (Fig. 3.2.22). The surgical site is
infi ltrated with approximately 0.5 mL of 1% lig-
nocaine with 1 : 200 000 adrenaline solution. The
lateral most part of the incision is made fi rst using
a number15 blade held in the surgeon’s right
hand while he applies inferior traction to the
Fig. 3.2.20 Upper lid – ROOF fat (arrow).
Fig. 3.2.21 Upper lid – closure.
Fig. 3.2.22 Lower lid – marking of incision site (arrow).

CHAPTER 2: Blepharoplasty
116
cheek with his left, i.e., a right-handed surgeon
crosses his left hand over his right to achieve this
on the right side (Fig. 3.2.23). Stevens tenotomy
scissors are used to gently undermine the skin,
separating it from the underlying pre-tarsal orbi-
cularis occuli muscle along the planned length of
the incision and then to incise the skin taking
great care not to damage the eyelashes (Fig.
3.2.24). Upward traction is placed on the central
part of the lower lid either via a weighted suture
or the assistant holding a skin hook with its point
anteriorly, i.e., away from the globe (Fig. 3.2.25).
The surgeon grasps the supero-lateral aspect of
the skin incision in fi ne toothed forceps and sepa-
rates the skin from the orbicularis towards the
inferior margin of the orbit, beyond the junction
of the pre-tarsal and pre-septal musculature (Fig.
3.2.26). The junction of the pre-tarsal and pre-
septal orbicularis (which is usually apparent) is
incised and separated with tenotomy scissors
Fig. 3.2.23 Lower lid – lateral incision.
Fig. 3.2.24 Lower lid – subciliary incision.
Fig. 3.2.25 Lower lid – upward traction.
Fig. 3.2.26 Lower lid – separation of skin from orbicularis
muscle. The arrow marks the junction of the pre-tarsal
(above) and pre-septal portions.

Section 3
117
(Fig. 3.2.27). Haemostasis is achieved with
bipolar cautery. The assistant places a Desmarres
retractor in the lower aspect of the wound and
applies gentle inferior traction. A neurosurgical
linteen or similar non abrasive small swab is
placed on the pre-tarsal orbicularis under the
scissor points which are inclined downwards,
toward the inferior orbital margin. A blunt dis-
secting technique is used to separate the pre-
septal orbicularis from the underlying orbital
septum (Fig. 3.2.27). The inferior orbital margin,
and the arcus marginalis are identifi ed, the latter
as a sharp white layer running along the length of
the inferior orbital margin (Fig. 3.2.28). The
arcus marginalis is initially incised and then
released along the whole length of the inferior
orbital margin (Fig. 3.2.29). There may be some
small vessels to coagulate, which is most easily
achieved before they are cut, and medially care
must be taken not to injure the inferior oblique
muscle (Fig. 3.2.30). The release of the arcus
Fig. 3.2.27 Lower lid – incision between pre tarsal (above
arrowed) and pre septal (in forceps) orbicularis revealing
underlying septum orbitale (between scissor blades).
Fig. 3.2.28 Lower lid – identifi cation of arcus marginalis
(white structure, arrow).
Fig. 3.2.29 Lower lid – arcus marginalis release.
Fig. 3.2.30 Lower lid – inferior oblique muscle (arrow).

CHAPTER 2: Blepharoplasty
118
marginalis and therefore orbital septum will allow
periorbital fat to prolapse over the inferior orbital
margin.
A pocket is developed approximately 1 cm deep,
in a supraperiosteal plane, inferior to the inferior
orbital margin using blunt dissection with the
scissors (Fig. 3.2.31). The origin of the levator
labii superioris muscle may be seen (Fig. 3.2.32).
With the assistant providing superior traction on
the lid margin, the inferior edge of the orbital
septum is sutured into the pocket (the “septal
reset”), i.e., inferior to the inferior orbital margin,
using 5/0 vicryl sutures – usually fi ve or six will
suffi ce (Fig. 3.2.33). It is essential, through supe-
rior traction provided by the assistant, to ensure
that this manoeuvre does not displace the lid
margin inferiorly. Sometimes the septum may be
a little weak, particularly laterally where it may
be reinforced by sutures or gentle thermal septo-
plasty using the bipolar cautery. Haemostasis is
checked once more.
If an upper lid blepharoplasty has been carried
out the skin is closed at this point using a single
subcuticular 6/0 prolene suture. The lower lid
skin is then draped over the lid margin with a
lateral to medial vector (Fig. 3.2.34). Ensuring
Fig. 3.2.31 Lower lid – dissection of pocket inferior to
orbital rim.
Fig. 3.2.32 Lower lid – levator labii superioris muscle
origin (arrow).
Fig. 3.2.33 Lower lid – septal reset (inferior margin of
orbital septum, arrow).
Fig. 3.2.34 Lower lid – skin redraping supero-medial
vector (arrow).

Section 3
119
that the lid is in the neutral position, excess skin
is marked. The superolateral corner of the lower
lid skin is grasped with fi ne toothed forceps and
the skin excess excised – it is wise to cut above
the marked line initially, check that the lid skin
lies correctly and if necessary excise a little more
rather than risk excising too much (Fig. 3.2.35).
Haemostasis is checked once more. On occasion
it may be necessary to excise a little of the supe-
rior margin of the pre-septal orbicularis muscle if
it creates a bulge. This will usually cause some
bleeding requiring cautery. A single 6/0 prolene
suture is placed at the lateral canthus to orientate
the lid skin and the remainder is closed with a
similar, running, subcuticular stitch (Fig. 3.2.36).
Steristrips are used to secure the sutures, support
the wounds and apply superior traction to the
lower eyelid (Fig. 3.2.37). I avoid bandaging or
other application of pressure to the globe because
patients dislike it, and moreover it will conceal
rather than prevent any untoward swelling or
haematoma post operatively.
Transconjunctival lower lid blepharoplasty
This is a useful approach when there is little
or no skin excess in the lower eyelid, either
alone or in combination with resurfacing of the
lid skin.
A traction suture of 5/0 prolene is inserted into
the grey line of the lower lid margin. As the
assistant applies gentle anterior traction to this
suture, the surgeon grasps the conjunctiva at
the inferior fornix and inserts a second stay
suture here. A vascular arcade can be identifi ed
in the conjunctiva approximately 5 mm inferior
Fig. 3.2.35 Lower lid – excision of excess skin.
Fig. 3.2.36 Lower lid – closure.
Fig. 3.2.37 Upper and lower lid blepharoplasty complete
steristrips support the suture lines.

CHAPTER 2: Blepharoplasty
120
to the lid margin which is the site for the incision
(Fig. 3.2.38). This is infi ltrated with approxi-
mately 0.2 mL of 2% lignocaine with 1 : 80 000
adrenaline solution. A corneal protector is
inserted (Fig. 3.2.39).
The superior stay suture, attached to a haemost-
sat, is allowed to act as a retractor under its own
weight with gentle inferior traction being applied
to the lid margin suture. The initial incision
(Fig. 3.2.40) is best accomplished using a Colo-
rado micro needle cautery (Fig. 3.2.41). It is
important that the settings are low, i.e., approxi-
mately cut 10, coagulation 10, blend 1. Having
made the incision, a blunt dissection is performed
using Stevens tenotomy scissors between the
orbicularis and the septum until the arcus margi-
nalis is reached at the inferior orbital rim – the
assistant retracts the lower lid and orbicularis
using a Desmarres retractor (Fig. 3.2.42). Very
Fig. 3.2.38 Conjunctival traction sutures. The incision site
is indicated by the arrow.
Fig. 3.2.39 Corneal protection shield inserted.
Fig. 3.2.40 Conjunctival incision along vascular arcade.
Fig. 3.2.41 Colorado microneedle.
Fig. 3.2.42 Conjunctiva retracted with Desmarres
retractor, septum (arrow), with underlying peri-orbital fat
exposed.

Section 3
121
little bleeding is usually encountered and once
the arcus marginalis has been identifi ed (Fig.
3.2.43) it is released from the orbital rim using
scissors exposing the underlying periorbital fat
(Fig. 3.2.44). A pocket is developed in the supra-
periosteal plane inferior to the inferior orbital
margin, over the anterior maxilla, for about 1 cm
much as with transcutaneous blepharoplasty
(Fig. 3.2.45). It is diffi cult to carry out a septal
reset in the same way but it is possible to secure
periorbital fat over the inferior orbital margin so
as to reduce fat bulging and efface the nasojugal
fold. This is best accomplished using 4/0 novafi l
sutures double armed with straight taper needles
(Fig. 3.2.46). Two sutures are generally used,
Fig. 3.2.43 Arcus marginalis identifi ed (white structure,
arrow).
Fig. 3.2.44 Arcus marginalis released, peri-orbital fat
exposed.
Fig. 3.2.45 Dissected pocket over anterior maxilla.
Fig. 3.2.46 4/0 Novafi l suture double armed taper
needles.

CHAPTER 2: Blepharoplasty
122
passed transversely through periorbital fat (Fig.
3.2.47) and then transcutaneously through the
cheek. The surgeon passes the needle through
from the deep to the superfi cial surface of the
cheek using a malleable retractor to protect the
globe whilst the assistant applies gentle pressure
with a haemostat on the cheek skin to encourage
the needle to pierce it (Fig. 3.2.48). Gentle trac-
tion on the sutures will secure the periorbital fat
over the inferior orbital margin (Fig. 3.2.49).
The operative fi eld is irrigated using balanced
saline solution, the stay sutures removed and the
lid replaced in the neutral position. The proce-
dure is repeated on the left side. At the end of
the operation the conjunctival incision is not
closed, the transcutaneous Novafi l sutures are
secured using steristrips under gentle tension and
the lid is supported using fl esh toned micropore
tape. The sutures are removed on the fi fth or
sixth day along with the tape.
Canthal support
Lateral canthal support in the form of cantho-
plasty or canthopexy may be required for a func-
tional purpose, i.e., to reduce the risk of the
scleral show or ectropion after lower lid blepha-
roplasty, for an aesthetic purpose, i.e., to elevate
the lateral canthus and therefore change the ori-
entation of the palpebral fi ssure, or for both.
Many techniques are available but in general I
prefer an orbicularis muscle sling, a transcanthal
canthopexy or formal lateral canthoplasty
depending the individual patient’s needs. Which-
ever technique is used (when combined with
blepharoplasty) it should be done when both the
upper and lower lid blepharoplasty are complete
Fig. 3.2.47 Novafi l passed through orbital fat.
Fig. 3.2.48 Transcutaneous passage of sutures to secure
orbital fat– retractor protects the globe.
Fig. 3.2.49 Gentle traction on transcutaneous sutures to
secure orbital fat below orbital rim.

Section 3
123
but before any skin is excised from the lower
eyelid.
Orbicularis muscle sling
A segment of the pre-septal orbicularis oculi may
be used to support the lower eyelid and is particu-
larly useful when there are heavy malar bags, since
it will provide some elevation of the lateral cheek
also. Once the lower lid septal reset has been
carried out, but before any skin is trimmed, the
assistant places a skin hook in the superolateral
corner of the lower lid skin and applies gentle
upward traction. The surgeon grasps the superolat-
eral edge of pre-septal orbicularis muscle, beneath
the skin fl ap, and dissects it from the skin for
approximately 1 cm inferior to the margin of the
incision and medially to approximately the mid-
pupillary line (Fig. 3.2.50). If there has been an
upper lid blepharoplasty then the lateral aspect of
this is used to access the lateral orbital rim, if not
a 1 cm incision is made in the lateral supratarsal
crease. By blunt dissection with tenotomy scissors
the superolateral periorbital rim periosteum is
identifi ed (Fig. 3.2.51). This will form the anchor
point for the canthoplasty and it is important to
identify the periosteum (a white layer) as it folds
over the lateral orbital rim so that there is, effec-
tively, a double layer to suture to. The skin bridge
between upper and lower lid blepharoplasty is
undermined deep to the orbicularis oculi. A hae-
mostat is passed beneath which grasps the superior
corner of the dissected lower lid pre-septal orbicu-
laris (Fig. 3.2.52). The muscle fl ap is then
pulled superiorly beneath the skin bridge
Fig. 3.2.50 Dissection of pre-septal orbicularis muscle
fl ap (arrow).
Fig. 3.2.51 Dissection of lateral orbital rim (arrow).
Fig. 3.2.52 Haemostat grasps muscle fl ap (arrow) via the
upper lid.

CHAPTER 2: Blepharoplasty
124
(Fig. 3.2.53). A 5/0 PDS suture is used to secure
the orbicularis fl ap to the lateral orbital rim with a
mattress stitch in such a way that the muscle lies
on the lateral, i.e., external, surface of the orbit.
The suture is passed through the muscle fi rst then
the lateral orbital rim from lateral to medial through
the periosteum in the opposite direction, i.e., from
medial to lateral, through the muscle again and
then tied (Fig. 3.2.54). Tension must be judged in
such a way as to provide support to the lower lid
but not to be so tight as to cause unreasonable
restriction to lymphatic fl ow post-operatively.
Once the muscle has been secured redundant
lower lid skin is excised (see Fig. 3.2.35).
Transcanthal canthopexy
This is a simple means of providing lateral canthal
reinforcement without signifi cantly altering the
position of the canthus or risking asymmetry
post-operatively. The lateral orbital wall peri-
osteum is dissected via the upper lid (see Fig.
3.2.51). A skin hook is placed in the lateral upper
lid margin and gentle lateral traction applied.
Using a number 15 blade a tiny incision is made
over the lateral canthus (Figs. 3.2.55 and 3.2.56).
Fig. 3.2.53 Muscle fl ap (arrow) passed superiorly.
Fig. 3.2.54 Suture of muscle fl ap (arrowed) to orbital rim.
Fig. 3.2.55 Incision at lateral canthus.
Fig. 3.2.56 Incision (arrow) at lateral canthus.

Section 3
125
A double-armed 5/0 prolene suture on round
bodied “visiblack” needles is used for the cantho-
pexy passing each needle in turn through the
incision over the lateral canthus in the direction
of the canthal ligament and emerging through the
upper lid incision (Figs. 3.2.57 and 3.2.58). Each
needle is then passed through the lateral orbital
wall periosteum in a medial to lateral direction
so that the knot is tied on the external surface of
the orbit reinforcing and shortening the ligament
at its natural point of insertion on the medial
aspect of the orbit (Fig. 3.2.59). At this point
excess skin may be trimmed from the lower
eyelid (see Fig. 3.2.35).
Lateral canthoplasty
This procedure will elevate the lateral canthus
and so change the orientation of the palpebral
fi ssure.
The
lateral
orbital
wall
periosteum
is
dissected via the upper lid or a small incision
in the lateral supratarsal crease if no blepharo-
plasty has been done (Figs. 3.2.60 and
Fig. 3.2.57 Passage of double armed prolene suture
through lateral canthal incision.
Fig. 3.2.58 Suture passed through lateral canthal
incision.
Fig. 3.2.59 Canthal fi xation to lateral orbital rim (arrow).
Fig. 3.2.60 Canthoplasty incision marked.

CHAPTER 2: Blepharoplasty
126
3.2.61). The lateral canthal ligament is grasped
via the upper lid incision at the lateral canthus
with fi ne-toothed forceps and drawn laterally
which places it under tension (Figs. 3.2.62 and
3.2.63). Holding the forcep in the surgeon’s left
hand, a Stevens tenotomy scissor is slid along the
lateral orbital margin in the right hand. The liga-
ment can be felt as a tight band and is divided
using the scissor (Fig. 3.2.64). When the division
is complete it is obvious since.the lateral canthus
becomes mobile in the forcep (Fig. 3.2.65). A
Fig. 3.2.61 Identifi cation of lateral orbital wall
periosteum.
Fig. 3.2.62 Identifi cation of lateral canthal ligament.
Fig. 3.2.63 Lateral canthal ligament placed under
tension.
Fig. 3.2.64 Forceps place lateral canthal ligament under
tension while scissors divide it.
Fig. 3.2.65 Canthal ligament moblile.

Section 3
127
5/0 prolene suture double armed with round
bodied “Visiblack” needles is used for canthal
support – both needles are passed through the
ligament at the point at which it is grasped by
the forceps (Fig. 3.2.66). They are then passed
back through the suture loop to gain a secure
grasp of the ligament (Fig. 3.2.67). The site for
ligamentous re-insertion must be carefully chosen
and usually lies at approximately the level of the
pupil or at most 1 mm–2 mm above it. Both
needles are passed through the lateral orbital wall
periosteum from medial to lateral so that the
knot lies on the external surface but the ligament
is secured in its natural position on the medial
aspect of the lateral orbital wall (Fig. 3.2.68).
Once the canthoplasty is secure (Fig. 3.2.69)
Fig. 3.2.66 Double-armed prolene suture passed
through proximal lateral canthal ligament stump.
Fig. 3.2.67 Suture “locked” and suspending lateral
canthal ligament.
Fig. 3.2.68 Suture tied.
Fig. 3.2.69 Canthoplasty complete.

CHAPTER 2: Blepharoplasty
128
the canthal elevation is obvious when compared
to the un-operated side (Fig. 3.2.70). The inci-
sions should not be closed, and if a lower blepha-
roplasty has been done redundant skin should not
be excised, until both canthoplasties are com-
plete in order to ensure symmetry.
Clinical pearls
Pre-operative recognition of the high risk patient
is crucial to success in blepharoplasty. Important
elements are symptoms of dryness and
examination to establish prominence of the globe,
i.e., negative vector or positive vector eyes, as well
as laxity of the lower lid itself by the snap test and
measurement of how far the lower lid can be
distracted from the globe (more or less than
6 mm).
Avoid placing the lower limb of the upper
blepharoplasty incision more than 10 mm above
the lid margin in women and more than 8 mm in
men in order to avoid an unnatural appearance of
the supratarsal crease.
Avoid over-resection of fat in the upper lid to
avoid developing a hollow and skeletal
appearance which can be very ageing. Additional
care must be taken in the upper lid to diff erentiate
between fat herniation and ptosis of the lachrymal
gland which should be repositioned below the
orbital rim and never resected.
In transconjunctival lower lid blepharoplasty it is
important to remember that the inferior oblique
muscle separates the medial and central fat
compartments. This muscle can be brought into
the operative fi eld and therefore damaged
inadvertently by excessive traction on the fat
compartments during mobilisation.
Rejuvenation of the lower lid with the septal reset
will help to blend the lid-cheek junction as the
lower orbital rim is covered by fat to reduce its
prominence. However care must be taken to
provide upward traction on the lower lid when
suturing the septal reset in order to prevent lid
malposition. If severe descent of the lid cheek
junction has occurred this is likely to involve mid
facial ptosis and rejuvenation of the midface will
be needed in addition to rejuvenate the lid cheek
junction correctly.
Measurement of lower lid distraction from
the globe is helpful in deciding when to
perform canthopexy or canthoplasty. A poor
snap test indicating lower lid laxity suggests the
need for canthal support but a distraction test of
greater than 6 mm would favour the use of
canthoplasty over canthopexy in order to shorten
the lower lid.
Fig. 3.2.70 Canthoplasty complete on right side only.
Note the elevation of the lower lid margin and the lateral
canthus.

Section 3
129
Points to note
Upper Blepharoplasty
• Mark lower incision of upper blepharoplasty
about 10 mm above ciliary margin.
• Upper incision marked at limit of upper lid
closure when the two incision lines are
approximated with forceps.
• Inferior incision line of upper blepharoplasty
performed fi rst.
• Skin excision followed by muscle excision.
• Fat removal performed by perforating orbital
septum and resecting medial then central fad
pads with meticulous haemostasis after clamp
removal.
Lower Blepharoplasty
• Incision in lower lid from lacrimal punctum
below lashes and beyond lateral canthus for
4 mm–5 mm.
• Tenotomy scissors used to undermine skin
over pre-tarsal orbicularis and incise skin.
• Orbicularis incised at junction of pretarsal and
preseptal orbicularis and separated from the
orbital septum by blunt dissection to level of
arcus marginalis.
• Release of arcus marginalis to allow orbital fat
to prolapse over orbital rim which is secured
with septal reset.
• Excess skin removed from lower lid
ensuring lid margin remains in neutral
position.
Transconjunctival Blepharoplasty
• Prolene stay suture applied to grey line of
lid margin and inferior fornix of
conjunctiva.
• Corneal protector inserted.
• Incision in conjunctiva made with Colorado
needle followed by blunt dissection to level of
arcus marginalis.
• Release of arcus marginalis to allow prolapse
of orbital fat over orbital rim.
• Sutures used to secure the prolapsed fat and
positioned to eff ace the nasojugal fold.
Orbicularis Sling
• Orbicularis sling performed after lower
blepharoplasty septal reset has been
performed but before skin resection in
lower lid.
• Orbicularis muscle dissected from overlying
skin in lateral corner for 1 cm inferiorly and up
to level of mid pupillary line.
• Periosteum of lateral orbital rim identifi ed
either via upper blepharoplasty incision or via
incision in supratarsal crease over lateral orbit.
• Preseptal orbicularis which has been
dissected free is passed superiorly to lateral
orbital rim and sutured to the periosteum to
provide lateral support.
• Lateral wall periosteum is dissected via upper
lid incision.
Lateral Canthopexy
• Incision made over lateral canthus.
• Double-ended prolene sutures passed from
canthal incision to orbital rim under upper lid
incision.
• Sutures tied through periosteum of orbital
rim to shorten lateral canthal ligament
• Skin excess removed from lower lid after
canthopexy performed.

Pre operative
Post operative
Pre & Post operative
&
Age 55 Upper and lower blepharoplasty

Section 3
131
Pre operative
Post operative
Pre & Post operative
&
Age 63 Upper and lower blepharoplasty

CHAPTER 2: Blepharoplasty
132
Pre operative
Post operative
Pre & Post operative
&
Age 49 Upper and lower blepharoplasty

Section 3
133
ANNOTATED BIBLIOGRAPHY
Hamra ST. Arcus marginalis release and orbital fat
preservation in midface rejuvenation. Plastic and
Reconstructive Surgery 1995;96:354–362.
With aging, the periorbital area reveals progressive exposure
of underlying skeletal anatomy as compared with the lower
areas of the face, whose thicker soft tissues continue to
cover underlying bony landmarks. Conventional lower
blepharoplasty techniques that remove lower eyelid fat can
create a concave contour deformity of the lower eyelids
that causes the “operated” appearance. The author reviews
the results of 152 patients treated to preserve the lower
eyelid fat and to advance it beyond the infraorbital rim. An
arcus marginalis release was accomplished, and the
subseptal fat was advanced and sutured beyond the entire
infraorbital rim and under the repositioned orbicularis
muscle.
Hamra ST. The role of the septal reset in creating a youthful
eyelid-cheek complex in facial rejuvenation. Plastic and
Reconstructive Surgery 2004;113:2124–2141.
Following on from the concept of orbital fat preservation and
repositioning the author describes the concept of the septal
reset which has distinct advantages over transposition of
orbital fat alone, as it creates a fi rmer under surface for the
lower eyelid. This manoeuvre creates a more youthful lower
eyelid-cheek complex, as the normal concave aging
skeletonization of the periorbital area is transformed to a
more convex contour seen in youth. The effectiveness of this
operation is demonstrated in this paper with clinical
examples.
McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring.
Plastic and Reconstructive Surgery 2003:113:222–237.
Appropriate canthal anchoring is effective in preventing
postoperative lower-lid malposition, in ensuring eyelid
closure, and in improving or maintaining proper eye shape.
In many patients, a canthopexy (non-lysis canthal
anchoring) is effective. However, in patients with signifi cant
horizontal laxity, cantholysis with appropriate lid support is
required. It should be remembered that canthal anchoring,
no matter how well performed, will not prevent severe lower-
lid complications in cases of over-resection of lower-lid skin
and of poorly performed midface procedures that do not
support the lower lid and cheek. An thorough review of
canthal support and tightening is presented by the authors.
McKinney P, Byun M. The value of tear fi lm breakup and
Schirmer’s test in preoperative Blepharoplasty evaluation.
Plastic and Reconstructive Surgery 1999;104:566–569.
The authors published their original article on the value of
tear fi lm breakup and Schirmer’s tests in preoperative
blepharoplasty evaluation in 1989. The purpose of this
update was to expand the original article. It was concluded
that the abnormal tear fi lm breakup and Schirmer’s tests
were not good predictors of possible post-blepharoplasty dry
eye complications. In contrast it was concluded in the review
that the anatomy and the history including scleral show,
lagophtholmus, negative vector, snap test, previous surgery,
increased blinking, dryness, grittiness and pain were more
important predictors of postoperative dry eye problems than
the ocular tests.
Mendelson BC, Muzaff ar AR, Adams WP Jr. Surgical anatomy
of the midcheek and malar mounds. Plastic and
Reconstructive Surgery 2002;110: 885–896.
This paper combines anatomical dissection with operative
anatomy to appraise the mid face and lid cheek junction.
This study located a glide plane space overlying the body of
the zygoma. The space functions to allow mobility of the
orbicularis oculi, where it overlies the zygoma and the
origins of the elevator muscles to the upper lip. The space is
a cleft between the sub-orbicularis oculi fat and the
preperiosteal fat and is lined by a fi ne membrane. The
anatomic boundaries are clearly defi ned by retaining
ligaments, which correlate with the triangularity of the
space. The relevance of this to surgical rejuvenation of the
midface and lid cheek junction are documented clinically by
the authors.
Rizk SS, Matarasso A. Lower eyelid blepharoplasty: analysis of
indications and the treatment of 100 patients. Plastic and
Reconstructive Surgery 2003;111:1299–1306.
A retrospective review of data for 100 consecutive
patients (ranging in age from 30 to 80 years)
who underwent lower eyelid procedures during a
12-month period was presented. Procedures were categorized
as follows: lower lid blepharoplasty,; lower lid
transconjunctival blepharoplasty, lower lid transconjunctival
blepharoplasty with laser resurfacing and lower lid laser
resurfacing alone. Two complications of retained fat pads
(one medial and one lateral) were encountered and were
addressed with a secondary operation using a
transconjunctival blepharoplasty approach. The paper
provides an algorithm to help in decision making for lower
lid blepharoplasty.

135
CHAPTER 1
Complications and How to Avoid Them
Complications in facial aesthetic surgery are, fortunately, uncommon
and when they do occur tend to be temporary nuisances rather than
permanent disasters. Many can be avoided by careful patient selec-
tion, operative planning and surgical technique, but however careful
the surgeon, as with all medical endeavour, complications will occur
from time to time. Careful analysis of outcome has produced a risk
management strategy to keep the incidence of complications at a
minimum.
Facelift
The commonest complication in face lift surgery is haematoma, most
studies quoting an incidence of between 2–9% (Table 4.1.1). It is
distressing for both the patient and the surgeon, may damage skin
viability and, if bilateral, can cause respiratory obstruction. The aeti-
ology of haematoma is multi-factorial and therefore requires multi-
variate analysis to investigate it. In a study of 1078 consecutive
patients operated on by two experienced surgeons we found a total
incidence of haematoma of 4.2%.1 Of these, 76% occurred within
the fi rst 24 hours of surgery. Risks were analyzed using an odds ratio
that revealed that that anterior, open platysmaplasty, pre-operative
systolic hypertension, male gender, intake of aspirin or non-steroidal
anti-infl ammatory drugs and smoking caused a signifi cant increase in
the risk of haematoma (Table 4.1.2). The type of facelift, whether
the surgery was primary or secondary, the pre-existence of cardio-
vascular or pulmonary disease, the use of fi brin glue to seal skin fl aps,
the specifi c surgeon carrying out the operation and the age of the
patient had no infl uence on the incidence of haematoma.
Some had suggested that tumescent infi ltration would reduce the
incidence of haematoma,2 but in another large study we found that
this was not the case.3 Analyzing 678 patients operated on consecu-
tively by the senior author (BMJ) between January 1994 and July
S E C T I O N 4

CHAPTER 1: Complications and How to Avoid Them
136
2000 it was also possible to confi rm that neither
fi brin glue, the use of dressings or drains had
any impact on the incidence of haematoma
(Table 4.1.3).
Adrenaline is widely used in this type of surgery
in subcutaneous infi ltration solutions to reduce
bleeding at surgery but it is possible that reactive
vasodilatation in the post-perative period may
predispose to haematoma. We studied two large
patient groups operated on consecutively by the
senior author in successive 18 month periods.4 In
229 patients operated on between January 1999
and June 2000, adrenaline was included in the
tumescent solution whilst in 232 patients oper-
ated on between July 2000 and January 2002, it
was excluded. All of the surgery was carried out
by the same surgeon (BMJ), the procedures were
similar, no fi brin glue was used and light dressings
were applied for twelve hours in each case
together with minivac suction drains. Excluding
adrenaline reduced the incidence of major hae-
matoma (needing return to the operating room
for evacuation) from 4.8% to 0% and of minor
haematoma (needing aspiration only) from 2.6%
to 0.4% (Table 4.1.4). From July 2000 to date
(December 2006) we have seen no expanding
haematomas in over 1000 consecutive facelift
patients. Excluding adrenaline had no effect on
the incidence of other complications such as skin
necrosis, wound dehiscence, alopecia, motor or
sensory nerve injury, the occurrence of hypertro-
phic scars or the need for scar revision. It is likely
that, when adrenaline is used, the risk of reactive
vasodilatation causing haematoma increases with
the effi ciency (speed) of surgery.5
Table 4.1.1. Published incidence of haematoma in facelift
procedures.
Author and date of
Number of
Haematoma
publication
patients
incidence (%)
Jones 1995
137
3.6
Marchac & Sandor 1994
200
2–9
Rees et al 1994
1236
1.86
Leist et al 1977
324
3.4
Rees et al 1973
806
3.26
Table 4.1.2. Predisposing factors to haematoma formation.
Risk factor
Increase in risk

(odds ratio)
Anterior platysmaplasty
4.3
Pre-operative blood pressure >150
3.6
Male gender
2.8
Aspirin/NSAI intake
2.3
Smoking
2.1
Table 4.1.3. Potential factors that could infl uence
haematoma formation (678 patients, from January 1994
through to July 2000).
Procedure
Incidence
p
Tumescence
11/229 (4.8%)
>0.5
No tumescence
14/449 (4.2%)
Fibrin glue
17/412 (4.1%)
>0.6
No fi brin glue
13/266 (4.9%)
Dressings
14/331 (4.2%)
>0.5
No dressings
16/347 (4.6%)
Drains
11/229 (4.8%)
>0.4
No drains
19/449 (4.2%)
Table 4.1.4. The infl uence of adrenaline on haematoma
formation.
Complication
Adrenaline
Adrenaline

included
excluded
Major haematoma
11 (4.8%)
0
Minor haematoma
6 (2.6%)
1 (0.4%)
Skin necrosis
1 (0.4%)
2 (0.8%)
Wound dehiscence
0
0
Alopecia transient
1 (0.4%)
0
Motor injury
0
0
Sensory injury
0
0
Hypertrophic scar
1 (0.4%)
1 (0.4%)
Scar revision
1 (0.4%)
0

Section 4
137
Although tumescent infi ltration did not reduce
the incidence of haematoma in facelift surgery,
it was felt that it may have other benefi cial
effects. It is used extensively in liposuction to
reduce bleeding and facilitate dissection and
there is evidence from ophthalmology that topical
steroids limit scar production. In 1992 Hoeffl in6
had suggested that a topical steroid spray would
reduce swelling in facelift and in 1994 Owsley7
suggested that it would ease the dissection.
Hoeffl in later described his “super wet” tech-
nique and suggested that this reduced swelling.8
It is impossible to assess swelling in any meaning-
ful way in aesthetic surgery but in craniofacial
surgery there is an easy marker, i.e. the patient’s
ability to open their eyes after operation. A study
was carried out in 20 children undergoing uni-
sutural craniosynostosis surgery.9 The children
were divided into two groups of ten: in the fi rst
no tumescent infi ltration was used whilst in the
second a weight adjusted tumescent soft tissue
infi ltration was introduced before beginning
surgery (Table 4.1.5). The effect of tumescence
on swelling was dramatic; in the group in which
no tumescence was used, 9 out of 10 children
could not open their eyes at 48 hours post-opera-
tively, whilst in the second group where tumes-
cent infi ltration was used 9 out of 10 could open
their eyes at 48 hours (Fig. 4.1.1). Based on this
study tumescent infi ltration (containing adrena-
line) was incorporated into the senior author’s
surgical technique for facelift. We analysed 678
patients operated on between 1994 and 2000 to
assess its effects.3 In 449 patients no tumescence
was used whilst in 229, 200 mL of tumescent
solution was infi ltrated subcutaneously to each
side of the face before beginning the surgery.
There was a statistically demonstrable reduction
in the incidence of skin necrosis, wound dehis-
cence, temporary alopecia, scar hypertrophy,
stretched scars and consequently the need for
scar revision (Table 4.1.6). Subjectively, it made
Table 4.1.5. Composition of tumescent solution with
adrenaline (volume weight adjusted for children).
• 500 mL Ringer lactate
• 25 mL 0.25% bupivicaine
• 25 mL 0.5% lignocaine with 1 : 200 000 adrenaline
• 0.5 mL 1 : 1000 adrenaline
• 1.25 mL triamcinolone 40 mg/mL
• 1500 U hyaluronidase
Table 4.1.6. The eff ect of tumescent infi ltration in facelift
surgery.
Complication
No tumescent
Tumescent
p

infi ltration
infi ltration
Skin necrosis
14 (3.1%)
1 (0.4%)
0.03
Wound
2 (0.4%)
0
dehiscence
Alopecia
19 (4.2%)

0.006
(temporary)
Scar hypertrophy
25 (5.6%)
1 (0.4%)
0.001
Scar stretched
21 (4.7%)
1 (0.4%)
0.003
Scar revision
29 (6.5%)
1 (0.4%)
0.001
Fig. 4.1.1 Eff ect of tumescent
infi ltration on swelling in
craniosynostosis surgery.

CHAPTER 1: Complications and How to Avoid Them
138
the dissection easier, particularly over the pla-
tysma muscle and post-operative swelling
appeared to be reduced (Fig. 4.1.2). It is inter-
esting to speculate on why tumescent infi ltration
may have such a positive effect on scars and
wound healing. Although it is hard to produce
evidence, it seems likely that it is related to intra-
operative tissue expansion or “creep”, the fact
that reducing swelling will in turn reduce tension
on wounds post-operatively and perhaps that
there is some direct action of the incorporated
steroid.
Drains are used routinely by many surgeons in
this kind of surgery, although often without any
particular rationale. Recent studies have sug-
gested that drains confer no benefi t in breast
reduction or abdominoplasty. It is known that
they may cause haematoma when removed and
so we questioned whether they were necessary
in facelift surgery. We randomized 50 patients so
that two minivac suction drains were used in one
side of the facelift only – the patients thus acting
as their own controls. Two hundred millilitres of
tumescent solution without adrenaline was used
per side in each patient and independent asses-
sors scored for haematoma, oedema and bruising,
one day and one week post surgery according to
a published protocol (Table 4.1.7).10 The patients
also scored themselves for swelling, discomfort
and bruising at one week. Any drainage was
recorded. The independent assessors found no
difference in haematoma or oedema either on
day one or day seven, but a signifi cant reduction
in bruising at day seven on the drained side (Table
4.1.8). This fi nding was refl ected in the patient’s
own assessment of themselves which found no
Table 4.1.7. Scoring system used to assess the
eff ectiveness of drains.
Haematoma
Grade 1: Nil
0
Grade 2: Micro, not clinically signifi cant
1
Grade 3: Small, best evacuated by manual expression or
2
aspiration
Grade 4: Signifi cant, requiring formal surgical drainage
3
Oedema
Grade 1: Nil
0
Grade 2: Minor
1
Grade 3: Moderate
2
Grade 4: Marked, unusual amount
3
Bruising
Grade 1: Barely perceivable to nil
0
Grade 2: Present, but minimal
1
Grade 3: Moderate, some tracking at distance
2
Grade 4: Extensive, marked tracings
3
Fig. 4.1.2 Patient 5 days post
endoscopic browlift, lower
blepharoplasty and volumetric
facelift.

Section 4
139
difference in swelling or discomfort but a signifi -
cant reduction in bruising on the drained side
at one week (Table 4.1.9 and Fig. 4.1.3).
In summary, this fi rst prospective randomized
control trial of the use of drains in facelift surgery
found that they had no effect on post-operative
complications or oedema but they did reduce
bruising both clinically and subjectively and so
accelerated the patient’s return to normal
activities.11
We would recommend the use of tumescent
infi ltration, without adrenaline, and small bore,
low suction drains to reduce complications in
facelift surgery. Serious problems such as sensory
(great auricular nerve) or motor (facial nerve)
nerve damage should be minimised by thorough
anatomical knowledge. Careful placement of
incisions will limit the visibility of scars. The use
of graded compression stockings and/or intermit-
tent compression boots will keep the already low
risk of deep vein thrombosis to a minimum.
Endoscopic Browlift
Complications following endobrow are very rare.
In the short term, headache is relatively frequent,
occurring in approximately 30% of patients. This
usually lasts no more than 12 hours and can be
relieved with a cox II type inhibitor such as Cele-
coxib. We have seen no haematomas in over 1000
endoscopic browlift procedures carried out over
a 12 year period. There has been one infection.
When the technique was fi rst introduced and
Table 4.1.8. The eff ect of drainage (by independent
assessors) – comparison of drained versus undrained sites.
Haematoma
Day 1
ns

Day 7
ns
Oedema
Day 1
ns

Day 7
ns
Bruising
Day 1
ns

Day 7
p = 0.005
ns, not signifi cant.
Table 4.1.9. The eff ect of drainage (by patient assessment)
– comparison of drained versus undrained sites after one
week.
Swelling
ns
Discomfort
ns
Bruising
p = 0.002
ns, not signifi cant.
Fig. 4.1.3 Patient after facelift,
tranconjunctival lower
blepharoplasty and TCA peel – left
side only drained. Note the
increased bruising on the right non-
drained side at one week.

CHAPTER 1: Complications and How to Avoid Them
140
undermining was carried out posteriorly, toward
the vertex, temporary alopecia did occur on occa-
sion (0.90% of our initial series) but since aban-
doning any posterior undermining in 1996 no
alopecia has been seen. We have seen one palsy
of the frontal branch of the facial nerve, again
early on in the series. Providing the dissection
plane is on the superfi cial layer of the temporalis
fascia, i.e., deep to the temporoparietal fascia,
this nerve should be safe. Particular care should
be taken with retraction in the temporal region
and in secondary procedures where normal tissue
planes may be obliterated. In our experience the
drill hole fi xation technique is secure and relapse
has not occurred.12
It is important to guard against the potential for
lagophthalmos when endobrow is carried out at
the same time as upper lid blepharoplasty and to
avoid this, the brow should always be done before
the blepharoplasty. Care should also be taken in
patients who have had an upper lid blepharo-
plasty in the past and a careful pre-operative
assessment, elevating the brow with a fi nger to
check that eye closure is adequate, should prevent
mishap.
Blepharoplasty
Infection following blepharoplasty is unusual,
the incidence being in the region of 0.01%. The
haematoma risk is approximately 1%, generally
occurring very soon after the surgery and usually
superfi cial. Retrobulbar haematoma, whilst extre-
mely rare, is a most worrying complication of
which patients should be warned. It is essential
to reinforce the importance of simple measures
to reduce venous blood pressure in the head and
neck, i.e., keeping the head above the chest at all
times, sleeping with extra pillows and avoiding
any strenuous activity, particularly for the fi rst
3–5 days after surgery.
Upper lid surgery is generally straightforward
though it is important to avoid excess excision of
skin or fat. Lagophthalmos should not occur if
these judgements are made carefully. By contrast
irritating complications after lower lid surgery are
relatively frequent. Risks can be mitigated by
careful pre-operative assessment, in particular
taking note of the lid position in relation to the
globe, the globe position in relation to the orbit
and the tension in the lateral canthal ligament /
tarsal plate (see Section 1 Chapter 2). Excision
of fat from the lower eyelid will frequently result
in a progressively “hollow eye” over a period of
time and so generally we prefer the fat preserv-
ing, septal reset technique described by
Hamra.13 To limit the risk of scleral show it is
important to ensure that an assistant places
upward traction on the lower lid margin during
the septal reset and to avoid excessive use of the
cautery to reduce the risk of middle lamella con-
tracture. Irrigation of the orbital septum with
triamcinolone may further limit this complica-
tion.14 In patients at particular risk of developing
chemosis (negative vector eye) or if chemosis is
seen at the termination of the procedure then a
temporary lateral tarsorrhapy can be a very effec-
tive technique to resolve it. Massage during the
post-operative phase (once the sutures have been
removed) in which the lower lid margin is pushed
upwards with an index fi nger whilst looking down
and repeated ten times or so, two or three times
a day, may be useful in maintaining suppleness in
the lower eyelid. Secure taping upwards of the
lower lid with steristrips or micropore tape assist
in maintaining its position during the early post-
operative phase. Canthopexies and canthoplas-
ties may reinforce a slack lateral canthal ligament
or tarsal plate and are of assistance when used
judiciously. Particular care must be taken in any
patient with pre-existing dry eye symptoms
and, especially contact lens wearers. If dry eye
symptoms (soreness, grittiness) do occur post-
operatively, particularly in the short term, lubri-
cation with “simple” eye ointment at night time
combined with the use of Hypromellose drops
during the day and possibly padding the eyes
closed at night can assist greatly and, generally,
these symptoms are self-limiting. If a facelift is
planned following blepharoplasty, or in a patient

Section 4
141
who has previously undergone blepharoplasty, a
temporary tarsorrhaphy for the duration of the
operation will prevent corneal drying and conse-
quent soreness.
Serious complications are rare and can mostly be
mitigated by careful surgical assessment and
judgement. Scleral show and ectropion should be
avoided by the measures outlined above. Aware-
ness of the position of the inferior oblique muscle
and its proximity to the lower lid dissection,
particularly during release of the arcus margina-
lis, will avoid damaging it and causing diplopia.15
If bandages or other occlusive dressings are used
there is a risk of masking the development of a
haematoma post-operatively and so they are best
avoided.
Revisional Procedures
Fortunately, it is unusual for facial rejuvenation
techniques to require surgical revision. Haema-
toma should be evacuated promptly and, most,
are best returned to the operating room to be
formally irrigated either under anaesthesia or
sedation. Simple aspiration, whilst appearing ade-
quate at the time, can result in post-operative
fi brosis and a prolonged recovery period. On the
rare occasions that infection does occur it should
be treated aggressively with appropriate antibiot-
ics combined, if necessary, with surgical irriga-
tion. Whether antibiotics are necessary as a routine
prophylaxis is debatable. We favour cefuroxime
given intravenously at induction followed by fi ve
days oral treatment. If infection does occur it is
worth bearing in mind that pseudomonas is a
potential pathogen (probably introduced from
the ear) which is usually sensitive to ciprofl oxa-
cin. We do not feel it is justifi able to use
this drug as a fi rst line prophylaxis. Minor scar
revisions may be necessary from time to time
but should be left until maturity, i.e., 9–12 months
post-operatively. Keloid scars are a rare occur-
rence (one in our experience) and are best guarded
against by careful enquiry pre-operatively of indi-
viduals with predisposing skin types and avoiding
excessive tension on the scar.
Occasionally, in patients with a very heavy neck
or excessive slack skin, it may be wise to warn
pre-operatively that two surgical procedures may
be necessary to achieve the desired end result.
REFERENCES
1. Grover R, Jones BM, Waterhouse N. The prevention of
haematoma following rhytidectomy: a review of 1,078
consecutive facelifts. British Journal of Plastic Surgery
2001;54:481–486.
Analysis of risk factors infl uencing haematoma in a large
series of patients undergoing rhytidectomy using
multivariate analysis. A scoring system was developed to
predict the likelihood of haematoma preoperatively and to
help in decision making in order to reduce risk.
2. Brody GS. The tumescent technique for facelift. Plastic
and Reconstructive Surgery 1994;94:407.
Initial report using tumescence to reduce haematoma risk
in small retrospective series.
3. Jones BM, Grover R. Reducing complications in cervicofa-
cial rhytidectomy by tumescent infi ltration: a compara-
tive trial evaluating 678 consecutive facelifts. Plastic and
Reconstructive Surgery 2004;113:398–403.
Detailed description of the use of tumescent infi ltration in
facelifting comparing outcome in a large series with and
without tumescence. There was signifi cant reduction in
problems of wound healing as well as hypertrophy and
stretched scars using tumescence. Improvement was seen in
dissection of the skin fl aps particularly in the neck although
no change in haematoma risk was seen.
4. Jones BM, Grover R. Avoiding haematoma in cervicofa-
cial rhytidectomy: a personal eight year quest reviewing
910 patients. Plastic and Reconstructive Surgery.
2004;113:381–387.
Analysis of a large series of patients undergoing
rhytidectomy with specifi c investigation into the effects of
omitting adrenaline from the tumescent infi ltrate. By
avoiding adrenaline there was a dramatic reduction in the
haematoma incidence. No reduction was seen with the use
of fi brin glue.
5. Knize DM. Avoiding haematoma in cervicofacial
rhytidectomy: a personal eight year quest reviewing 910
patients – Discussion. Plastic and Reconstructive Surgery
2004;113:388–389.
Commentary on the above paper suggesting that avoiding
adrenaline may be particularly important when surgery is
performed effi ciently. In some patients there may be
rebound bleeding when the effect of the adrenaline wears

CHAPTER 1: Complications and How to Avoid Them
142
off which would be missed if the fl aps are closed at an
effi ciently early stage. Avoiding adrenaline allows this
bleeding to be visualised from the start and controlled
appropriately.
6. Hoeffl in SM. Decreasing prolonged swelling and pain
associated with deep plane facelifts. Plastic and
Reconstructive Surgery 1992;90:1125.
This report suggested spraying a mixture of triamcinolone,
bupivacaine and adrenaline beneath facelift skin fl aps and
stated that this “appeared to decrease swelling” in the post
operative period.
7. Owsley JQ, Weibel TJ, Adams WA. Does steroid medica-
tion reduce facial oedema following facelift surgery? A
prospective, randomised study of 30 consecutive
patients. Plastic and Reconstructive Surgery 1996;
98:1–6.
Investigation into the effects of steroids on outcome
following rhytidectomy (intravenous methyl prednisolone
and topical triamcinolone). Patient photographs were
assessed by independent plastic surgeons and the steroid
treated group showed no observed benefi t.
8. Hoeffl in SM. The extended supraplatysmal plane (ESP)
facelift. Plastic and Reconstructive Surgery
1998;101:494–503.
Surgical description of the ESP facelift which is raised in a
deep subcutaneous plane. The use of tumescence was used
and thought to reduce swelling post operatively.
9. Neil-Dwyer JG, Evans RD, Jones BM, Hayward RD.
Tumescent steroid infi ltration to reduce post operative
swelling after craniofacial surgery. British Journal of
Plastic Surgery 2001;54:565–569.
Prospective trial of tumescence in paediatric craniofacial
surgery with highly signifi cant reduction in postoperative
swelling as judged by its effect on eye closure.
10. Marchac D, Greensmith AL. Early postoperative
effi cacy of fi brin glue in facelifts: a prospective random-
ized trial. Plastic and Reconstructive Surgery
2005;115:911–916.
Investigation into the use of fi brin glue in rhytidectomy
with scoring system to objectively evaluate bruising and
oedema following surgery. No signifi cant reduction in
expanding haematoma was found with fi brin glue in
contrast to the previous fi ndings of Marchac in 1994
11. Jones BM, Grover R, Hamilton S. The effi cacy of surgical
drainage in cervico-facial rhytidectomy: A prospective,
randomized controlled trial. Plastic and Reconstructive
Surgery 2007; In Press.
Prospective randomised trial of the use of surgical drainage
following rhytidectomy with patients acting as their own
control. Clear benefi t was found for small bore concertina
drains in reducing bruising at one week post operatively.
They had no effect on swelling, haematoma or pain.
12. Jones BM, Grover R. Endoscopic browlift: a review of 538
patients and comparison of fi xation techniques. Plastic
and Reconstructive Surgery 2004;113:1242–1250.
Study of 538 consecutive endoscopic browlifts performed by
a single surgeon comparing the effi cacy of fi brin glue
against 2/0 PDS sutures secured through bone tunnels in
maintaining brow position post operatively. At one week
there was no difference, but at longterm follow up (greater
then 3 months) the bone tunnels were signifi cantly more
stable.
13. Hamra ST. Arcus marginalis release and orbital fat
preservation in midface rejuvenation. Plastic and
Reconstructive Surgery 1995;96:354–362.
Description of lower lid rejuvenation with fat preservation
by detaching the orbital septum from the arcus marginalis
and then reattaching it below the lower orbital rim in order
to reduce the frontal herniation of orbital fat and also to
blend the lid cheek junction.
14. Barton FE, Ha R, Awada M. Fat extrusion and septal reset
in patients with the tear trough triad: a critical appraisal.
Plastic and Reconstructive Surgery 2004;113:2115–2121.
A review of the septal reset technique in 71 selected
patients.
15. de Castro CC. A critical analysis of the current surgical
concepts for lower blepharoplasty. Plastic and Recon-
structive Surgery 2004;114:785–793.
Critical analysis of 100 consecutive blepharoplasties in
order to ascertain factors which infl uence aesthetic outcome
and strategies to reduce complication and unfavourable
outcome.

143
CHAPTER 2
Avoiding Litigation
Litigation is becoming an evermore-common feature of life in the 21st
century. A culture which encourages the thought that every event
must be somebody’s “fault” (usually somebody else’s!) encourages
“blame” and so recourse to law. This is refl ected in attitudes to
medico-legal litigation in general but perhaps particularly in aesthetic
surgery where expectations are high and tolerance of a defect, per-
ceived or real, low. It is important that patients do have access to
the law when there has been genuine clinical negligence but these
form a relatively small proportion of the total claims relating to aes-
thetic surgery.
Simple precautions, most of which are outlined in Section 1 Chapters
1 and 2, can help prevent misunderstanding and spurious claims.
Patient selection is key, beginning before any consultation has taken
place. Advertising and marketing have become an integral part of
aesthetic surgical practice, but widespread advertising to the public
at large or overly aggressive marketing is likely to attract patients who
may not be suitable for surgery. The most reliable, secure and stable
source of referral is from professional colleagues and by word of
mouth. To build a practice via this route is likely to take longer than
a more commercial approach but will certainly be more durable.
A thorough initial consultation is mandatory at which it is vital to
listen to the patient in order to build as complete a picture as possible
of them and their life. They should be thoroughly informed of the
limitations of any surgical procedure and also of potential risks and
complications so that if they do choose to proceed consent will be
truly “informed”. It is well recognized that patients retain only a
proportion of what they are told so the consultation should be rein-
forced with comprehensive written information. No pressure should
be put on patients to proceed to an operation and indeed it is wise,
in any written information provided, to encourage them to take as
much time as they feel necessary to consider the matter before reach-
ing a decision. Patients should be discouraged from proceeding
S E C T I O N 4

CHAPTER 2: Avoiding Litigation
144
precipitately to an operation. A second consulta-
tion can be extremely helpful both to patient and
surgeon in clarifying any concerns which remain
unclear.
Comprehensive medical records, both written
and photographic, are of immeasurable impor-
tance. Medico-legal claims may arise at a time
remote from any intervention and the written
account will be the only available evidence. The
more comprehensive it is the more likely a claim
will be defensible. The records can also prevent
or defl ect a criticism, this being particularly true
of photographs. Patients will often, quite genu-
inely, not have noticed asymmetries in their facial
features that predate any operation. Hopefully
these will be pointed out at the initial consulta-
tion with good medical photography but if not,
the photographs are of immense help in any dis-
cussions, which may occur after the event.
Communication is perhaps the most vital factor
in avoiding confl ict. The patient must feel com-
fortable that the surgeon is caring and motivated
by their best interests, not his wallet. A compre-
hensive system of support is necessary within the
practice (secretary, nurse, etc.) and effective and
adequate medical cover must be provided when-
ever the surgeon is unavailable. Advice should be
easily accessed during the post-operative period,
the patient being seen at any time that it is neces-
sary. Very often concerns arising after an opera-
tion can be simply resolved if the patient is seen
whereas if they do not have access to the surgeon
or his staff resentment may build up. There should
be no charge for any post-operative visit or con-
sultation and it is wise also not to charge for visits
after the initial consultation, but before an opera-
tion. In general, revisional procedures relating
directly to an operation should also incur no cost
to the patient, particularly if they are within a
year of the intervention. After this the surgeon
should use his discretion but again, in many cases,
it is wisest not to make any charge even if it may
seem reasonable to do so. When patients do have
a genuine problem post-operatively, be honest
about its cause and prognosis (if known), see
them as often as they think necessary and give
them as much time as they need.
In general, aesthetic surgery should be absorbing
and rewarding for both the surgeon and the
patient. It is vital to analyze one’s results scien-
tifi cally and remain, above all, a good doctor and
an honest individual. This is neither an exercise
in self promotion nor an extension of the current
vogue for celebrity but a genuine attempt to
improve the quality of life.

145
Index
A
Adrenaline, 136
Ageing, 22
Anaesthesia, 11–16
choice of anaesthetic, 12–15
pre-operative assessment, 11–12
recovery care, 15–16
Anatomy, 17–33
facial muscles, 24–7
facial nerve, 27–32, 33
retaining ligaments, 18–22, 32
sensory supply, 30–2, 33
subcutaneous layer, 17–18, 32
superfi cial musculo aponeurotic
system, 22–4, 32
Anxiolysis, 12
B
Blepharoplasty, 107–33
complications, 140–1
indications, 107
patient assessment, 107–11
surgical technique, 111–28
lower lid blepharoplasty, 115–29
upper lid blepharoplasty, 111–15
Bonney’s blue ink, 39, 40, 61
Brow height, 6
Buccal-maxillary ligaments, 21
C
Cannulae, 10
Clinical records, 2, 3
Clonidine, 14
Communication, 144
Complications, 135–41
blepharoplasty, 140–1
endoscopic browlift, 139–40
facelift, 135–9
COX-2 inhibitors, 16
D
Deep venous thrombosis, 13
Drapes, 37
Dressings, 37–8
limited scar technique, 67
SMASectomy, 51
subperiosteal/volumetric
procedures, 83
E
Endoscopic browlift, 91–106
complications, 139–40
informed consent, 92
instrumentation, 93
post-operative care, 102
pre-operative preparation, 92
results, 103–5
surgical technique, 93–101
F
Facial muscles, 24–7
periocular, 24–5
perioral and neck, 25–7
Facial nerve, 27–32, 33
Forceps, 10
G
General anaesthesia, 12, 13–15
H
Haematoma, 135–6
Hair, preparation for surgery, 35, 36
Head drapes, 9–10
Hibiscrub, 35
Hypertension, 11–12
I
Infi ltration, 40
Initial consultation, 5–8
Instrumentation, 10
endoscopic browlift, 93
see also individual techniques
L
Laryneal mask airway, 14
Lateral canthoplasty, 125–8
Limited scar technique, 59–71
dressings, 67
pre-operative preparation, 60–1
results, 69–70
skin closure, 66–7
surgical technique, 61–4
trimming of skin fl aps, 64–6
Litigation, avoidance of, 143–4
Local anaesthesia, 12–13
Locking slip knots, 81
M
McGregor’s patch, 63
Minimal access cranial suspension lift,
60
Mustarde suturing forceps, 10
N
Nasopharyngeal airway, 14
Nausea and vomiting, post-operative,
16
Neck muscles, 25–7
Non-steroidal anti-infl ammatory
drugs, 16
O
Offi ce organization, 2
Operating theatre, 9–10
Operative procedures, order of, 37
Orbicularis muscle sling, 123–4
P
Parecoxib, 16
Patients
comfort in operating theatre, 9
expectations, 8
Periocular muscles, 24–5, 32
Perioral muscles, 25–7, 33
Photographic records, 2, 4
Physical examination, 6
Pixie ear deformity, 66
Platysma-auricular ligaments, 21
Post-anaesthesia care, 15–16
Post-operative care, 37–8
SMASectomy, 51

Index
146
Pre-operative assessment, 11–12
Pre-operative marking, 36
Pre-operative preparation, 35–8
endoscopic browlift, 92
limited scar technique, 60–1
subperiosteal/volumetric
procedures, 73–4
Propofol, 13
Pseudo-marginal mandibular palsy,
30
Pupil-brow distance, 6, 91, 109
R
Records, 144
clinical, 2, 3
photographic, 2, 4
Recovery care, 15–16
Remifentanil, 14
Retaining ligaments, 18–22, 32
false, 20–1
functional anatomy, 22
true, 19–20
Retractors, 10
Revisional procedures, 141
S
Scissors, 10
Sedation, 11–16
deep, 12
minimal, 12
moderate (conscious), 12
Sensory supply, 30–2, 33
Skin closure, 50–1
Skin fl aps
limited scar technique, 64–6
SMASectomy, 48–9
Skin hooks, 10
SMASectomy, 39–58
dressings, 51
incisions, 42–5
infi ltration, 40
platysma dissection, 45–7
post-operative care, 51
results, 53–7
skin closure, 50–1
suction lipectomy, 40–2
surgical technique, 39–40
trimming of skin fl aps, 48–9
Smoking, 35
Snap test, 6–7, 109
Subcutaneous layer, 17–18, 32
Subperiosteal/volumetric procedures,
73–89
dressings, 83
incisions, 75–83
pre-operative preparation, 73–4
results, 85–8
surgical techniques, 74–5
Suction lipectomy, 40–2
Superfi cial musculo aponeurotic
system, 22–4, 32
Surgical equipment, 9–10
Surgical technique, 37
T
Total intravenous anaesthesia, 14
Transcanthal canthopexy, 124–5
Tumescent infi ltration, 137–8
V
Volumetric procedures see
Subperiosteal/volumetric
procedures