Video Atlas Phẫu Thuật Tạo Hình Thẩm Mỹ (Aesthetic Plastic Surgery Video Atlas)

Surgical Technique
287
Fig. 21.1 42 year old male with giant pannus (A and B). He had decreased his weight from 352 kg to 236 kg after gastric banding, but had
tremendous functional impairment from his pannus. Orthopedic pins are inserted through the edge of the pannus, held with traction bows,
and used to suspend the pannus above the patient (C and D). Large blood vessels are encountered and ligated (E). The pannus weighed 61 kg.
A
B
C
D
E
Monsplasty
Correction of mons ptosis and fullness is a necessary adjunct to
abdominal contouring in a high percentage of MWL patients. The
mons can be thinned to match the upper abdominal fl ap and elevated
using suture to restore a youthful contour. Failure to correct the mons
during an abdominoplasty or lower body lift can lead to an unsatisfac-
tory result, despite adequate correction of the abdomen, thighs, or
buttocks. During the abdominal-contouring procedure, the incision for
the lower margin of resection should be placed 6 cm above the anterior
vulvar commissure with the tissues on upward stretch (the line of
incision should come just above the pubic symphysis, and may need
to be marked slightly higher than 6 cm). This will help restore the
proper proportions for the pubic hairline. In order to properly reshape
this region, two specifi c steps are contemplated. One consideration is
for the suspension of tissues to the abdominal fascia. The second
consideration is reduction of the thickness of the mons. The authors
have found that liposuction, when used to thin the tissue of the mons,
results in prolonged edema and an unpredictable result. We have had
good success with direct defatting of the tissue of the mons. The thick-
ness of adipose tissue to be resected is estimated and marked. This is
based on the thickness of the abdominal fl ap in relation to the desired
thickness of the mons region. Next, the deep adipose tissue is retracted
with three Allis clamps and skin retractors placed on the anterior
surface. Using the electric cautery, a wedge resection of the adipose
tissue is performed with the dissection terminated at the pubic sym-
physis. Great care is taken to avoid entering the vaginal vault. This
technique results in a uniform thinning of the mons region. With or
without this initial reduction in thickness, the mons can then be
suspended to the abdominal wall fascia. Three to fi ve sutures are
placed from the deep layers of the mons superfi cial fascial system (SFS)
into the abdominal wall fascia using either 2–0 or 0–braided nylon.
This technique has resulted in durable results with a high degree of
patient satisfaction (Figs 21.6 & 21.7). We have encountered no inci-
dences of sexual dysfunction; quite the opposite in fact, patients are
so pleased to have this region rejuvenated that they report an

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
288
improvement in their sexual function. Patients are warned that the
angle of the urine stream may be changed temporarily because of the
pull on the mons tissues.
Lower-body lift
Correction of the abdomen alone is often not enough to restore appro-
priate contour for many MWL patients. Procedures have been devised
to correct the entire lower-body unit, including the lower-body lift, belt
lipectomy, and circumferential torsoplasty.18–21 Although the names
are different, the principle in theory is similar; to affect a circumfer-
ential correction of laxity in the buttocks, lateral thighs, and abdomen
with elimination of rolls and festoons.22 Lockwood popularized the
lower-body lift, and made many important contributions to this fi eld
including the repair of the superfi cial fascial system.23 Further enhance-
ments of outcomes have resulted from autologous augmentation of the
buttocks with lower-body lift procedures.24,25 Fat can be preserved from
the posterior resection based on gluteal artery perforators, deepithelial-
ized, and rotated into pockets over the gluteal muscles to give shape
to a region that otherwise becomes fl attened with routine lift proce-
dures. For the abdomen, the fl eur-de-lis can be added concomitantly
if laxity remains in the horizontal vector.
The circumferential body lift is a very powerful operation, allowing
correction of the abdomen, lateral thighs, and buttocks in a single
stage. The original description by Lockwood involved a correction of
the buttocks and lateral thighs with the anterior scars merging into
the groin crease. This procedure was later modifi ed by Lockwood to be
a combination of a thigh/buttock lift and an abdominoplasty. He then
referred to the earlier design as a Type I lift, and the circumferential
approach as a Type II lift. The latter version is used more commonly,
but one can still fi nd utility for the Type I lift. While Lockwood
described this operation as a three-position procedure (lateral decubi-
tus, contralateral decubitus, and then supine), the authors advocate a
two-position procedure. This operation starts with the patient in the
prone position and then turned to the supine position. While the
advantage of the original three positions of Lockwood’s operation was
that the hip could be fl exed to reduce tension on the closure, this
maneuver can also be accomplished with the patient in the prone
position.
In designing the operation, one must abandon the notion that the
markings will be based upon specifi c anatomic landmarks. Rather, the
following concept should be applied to each specifi c body type: a higher
(more superior) circumferential resection will directly excise fl ank rolls
and emphasize the waistline, while a lower (more inferior) resection
will effect a stronger elevation of the lateral thigh tissues and provide
a greater ability to contour the buttock region using autologous tissue
fl aps. It is the authors’ preference to keep the resection as low as pos-
sible to maximize the correction of saddlebag deformities and optimize
buttock shape. Abdominal-wall plication and vertical abdominal skin
resection, when indicated, provide adequate waist defi nition. The
markings begin with the patient in the supine position. With upward
stretch on the lower abdominal tissues, a mark is made in the midline
6 cm superior to the anterior vulvar commissure. This point should
rise just above the pubic symphysis on stretch, but may not in some
patients with a long torso. In such cases, this mark should be moved
superiorly by 1 or 2 cm until it as above the symphysis. The markings
A
B
C
D
Fig. 21.2 53 year old male with buried penis. The penis is retracted within his large pannus (A and B),
but can be manually extracted (C). Post-operative view demonstrates exposed genetalia (D).

Surgical Technique
289
A
B
C
Fig. 21.3 Surgical technique for Fleur-di-Lis (FDL) abdominoplasty.
Estimated resection is marked, and undermining commenced only to
those lines (A). Tissue is resected fi rst in the transverse axis, then
the vertical axis (B). Key is to preserve abdominal wall perforating
vessels and minimize undermining of abdominal fl aps (C).
A
B
Fig. 21.4 38-year-old woman following
50 kg weight loss. Pre and postoperative
views 12 months s/p FDL abdominoplasty,
including plication. An “hour glass” shape is
achieved.

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BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
290
continue with the patient in the standing position facing away from
the surgeon. The fi rst critical decision is to select the superior anchor
line. The superior anchor line will be the superior line of incision.
Once again, efforts should be made to keep this line as low as possible
in order to maximize the tension on the lateral thighs and the ability
to reshape the buttock. Once the superior anchor line is drawn in, this
will extend from approximately the mid axillary line to the posterior
midline bilaterally. Vertical reference marks are drawn in at six centi-
meter intervals. This will help guide symmetry in the markings as well
as help with re-approximating the tissues. Next, a pinch test is used
to draw the inferior tissues up to the anchor line and estimate the
amount of the resection. This involves rolling the inferior tissues
under the anchor line to most accurately estimate the amount of tissue
to be removed. As the lateral tissues are estimated, the patient is asked
to slightly abduct the legs. Each estimated point of resection is made
along the vertical hash marks. The inferior line of resection is then
drawn. The lateral margin of resection is then selected. This connects
the superior and inferior lines of incision. This is usually at the region
of the mid-axillary line, and will be a transition zone between the
posterior and anterior resections. At this point, estimation is made
about the amount of adipose tissue that will be preserved to shape the
buttock region. The overlying concept is that this operation is not
entirely a resection of tissue, but rather a repositioning of tissue in the
buttock region. To reach this goal, an area of adipose tissue is marked
that will be preserved. This can take the form of either an island of
adipose tissue, or an actual fasciocutaneous fl ap that will be under-
mined in its lateral region and transposed into the inferior buttock
region. The vertical reference lines are used to help insure symmetry
of these markings for this adipose tissue paddle. The patient is then
asked to turn and face the surgeon. With upward tension exerted on
the tissues on the patient’s right hip, a line is drawn from the lower
margin of resection and connected to the point above the mons. The
same maneuver is then repeated on the contralateral side. The line
just drawn will represent the line of incision for the abdominoplasty
part of the operation (Fig. 21.8). Once under anesthesia, the patient is
positioned prone to start. The foley catheter is inserted to monitor
urine output. Warming blankets and appropriate padding are placed
on the operative table. The legs are prepped in a circumferential
A
B
Fig. 21.5 44-year-old woman following 59 kg weight loss. Pre and postoperative views 6 months s/p FDL abdominoplasty, including
moderate plication. Epigastric skin laxity has been eliminated.
A
B
Fig. 21.6 Surgical technique for mons correction. Patient is marked for abdominoplasty with incision at 6 cm above the anterior vulvar
commissure (A).

Surgical Technique
291
C
D
E
F
G
H
Fig. 21.6, cont’d After fascial plication, a resection of the deep adipose tissue beneath the mons is marked to match the thickness of the
abdominoplasty fl ap and dissected with the cautery (B–D). This resection is wedge-shaped, extending to the pubic symphysis and avoiding
the vaginal vault. The deep surface of the mons is then suspended and secured to the abdominal wall fascia with 3-5 either 2-0 or 0 braided
nylon sutures (E,F). This results in reduction of the mons fullness and elimination of ptosis (G,H).

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
292
fashion. The calf compression boots are placed on each leg prior to
induction of anesthesia. The electric cautery grounding pad may be
placed on the calf beneath the compression boot. The authors generally
use two electric cauteries at one time so that the operation can be
performed in a team fashion. Two arm boards are placed at the lower
end of the table so the legs can be abducted. These arm boards are well
padded. Standard betadine prep is used. Epinephrine (1 : 100 000) is
mixed in the operating room (1 cc epinephrine 1 : 1000 per 100 cc
normal saline). This solution is injected into the dermis before incising
skin in order to control bleeding from the dermal edges. The region of
gluteal fat that was marked to be preserved is then stripped of epider-
mis using a sharp scalpel blade. A powered dermatome can also be
used for this step. Next, the adipose paddle that had been stripped of
epidermis is circumscribed and dissected down to the level of the
fascia. This is followed by removal of the skin and subcutaneous tissue
surrounding the paddle within the borders of the posterior resection.
The lateral margin of resection is also incised. The adipose tissue fat
is then undermined in its lateral region at the level of the muscle
fascia. This allows mobilization of the tissue fl ap inferiorly. A subcu-
taneous pocket is then undermined in the buttock region inferior to
the region of resection. The tissue fl aps can be mobilized into the
subcutaneous pocket and secured in this location with permanent
braded nylon sutures placed into the muscle fascia. Because the dermis
had been preserved on the tissue fl ap, this dermal surface area can be
plicated using either permanent or absorbable sutures to enhance
projection in the buttock region (Fig. 21.9). The Lockwood discon-
tinuous undermining device (Byron Medical, USA) is passed in the
subcutaneous tissue of the lateral thigh on both right and left sides.
This allows mobilization of the thigh tissues during closure. To facil-
itate the tension-free closure in the lateral aspects of the posterior
wound, the legs are abducted onto the extended arm boards that had
been placed in the lower region of the bed. As an alternative, a well-
padded sterile side table can be used (Fig. 21.10). The wound is secured
with towel clips to approximate the skin edges. Interrupted braded
sutures are placed in the subcutaneous tissues (superfi cial fascial
system). There is still controversy as to whether these sutures should
be permanent or absorbable. There is no clear scientifi c evidence on
which to fi rmly base this decision. The dermis is closed in two layers,
with interrupted deep dermal sutures followed by a running absorbable
monofi lament suture. The large lateral dog ears are simply stapled
shut. When the patient is turned supine, these dog ears will be resected.
Closed suction Jackson–Pratt drains are placed in the posterior wounds,
and taken out through the operative incision. Cyanoacrylate adhesive
is placed over the wound. This is followed by layered gauze dressings
and an occlusive plastic dressing so that the wound is protected during
the remainder of the procedure. The patient is then turned to the
supine position. The room is warmed during the fl ip, and care is taken
to keep all intravenous lines, catheters, and drain tubes, free of entan-
glement. The patient is prepped once again after the fl ip. The line
connecting the lower aspect of the lateral margin of resection with the
low transverse abdominoplasty incision is incised. At this point, the
procedure is essentially the same as any abdominoplasty. The degree
of undermining and plication of the abdominal wall muscles will be
dependent on the patient’s body type and surgeon preference. A fl eur-
de-lis resection may be safely combined with a body lift. Once the
abdominoplasty fl ap is ready to be resected, the operating table is fl exed
to facilitate this process. If the posterior resection is set low/inferior,
fl exing the waist in the supine position will not put much tension on
the posterior closure. If, however, the posterior resection is high/supe-
rior on the trunk, fl exing the waist may apply pull on the posterior
closure and a less aggressive resection should be planned. During the
fl ap resection, the lateral dog ears at the transition point between
anterior and posterior resections will be completely excised. Two closed
suction drains are placed in the abdomen. The abdominal closure
involves deep dermal interrupted sutures followed by a running mono-
fi lament absorbable suture. SFS sutures, using absorbable braided
suture are placed in the lateral high-tension areas. For postoperative
care, the patient is kept in a ‘beach chair’ position, fl exed at the waist.
The patient is instructed to be out of bed with assistance by the fol-
lowing morning or the same night, if possible. The average inpatient
stay is 2 nights for this procedure. An example of a body lift without
fl eur-de-lis abdominoplasty is shown in Figure 21.11. An important
adjunct to the lower body lift, especially in staged cases, is debulking
liposuction of the thighs. Figure 21.12 shows a patient, with signifi cant
adipose tissue on her thighs, who underwent bilateral circumferential
thigh liposuction concurrent with her abdominoplasty. This defl ates
the thigh tissues and facilitates a good aesthetic contour during a
second-stage vertical thighplasty. Some patients with previous abdom-
inoplasty may present for a lower body lift. In such cases, the conduct
of the operation is the same as described above, except that the ante-
rior incisions are merged into the previous abdominoplasty scars. This
may involve a secondary ‘tightening’ of the previous abdominoplasty.
In patients with or without a previous abdominoplasty, a Lockwood
Type I lower body lift can be employed (Fig. 21.13), with the anterior
scars veering into the groin crease bilaterally. This will provide a mod-
erate degree of pull on the medial thigh tissues. A key point is to keep
the scars very close to the mons region so that they do not descend
below the level of the groin crease.
Vertical thigh lift
The medial thighs present many technical challenges for the plastic
surgeon.26,27 On a practical level, patients with signifi cant skin laxity
on both medial and lateral thighs can rarely be treated satisfactorily
with a single procedure. The lower-body lift can provide a signifi cant
correction of lateral thigh laxity through superiorly directed traction,
but will have only a minimal impact on the medial thighs. Similarly,
a vertical thighplasty will impact the medial thighs and decrease leg
A
B
Fig. 21.7 49-year-old woman with signifi cant mons ptosis. Pre and postoperative views 6 months s/p abdominoplasty with mons
suspension.

Surgical Technique
293
circumference while leaving notable deformities on the lateral thighs
untouched. These concepts must be thoroughly conveyed to patients,
who often present with a complaint of ‘ugly thighs’ while clutching
the redundant skin on the medial thigh. There are well-selected
patients with reasonable tone on the lateral thigh and buttocks who
can benefi t from an isolated vertical thighplasty. However, a majority
of MWL patients will require both lower-body lift and vertical thigh-
plasty to achieve a complete aesthetic correction of the thighs. It is the
authors’ preference to stage lower-body lift and vertical thighplasty,
with the lower-body lift serving as the initial ‘cornerstone’ procedure.
This is benefi cial for the following reasons:
1. The lower-body lift, especially when done with the abdominoplasty,
will have a greater impact on the patient’s body shape and lead to
an immediate improvement in body image.
2. The lower-body lift will tend to relax over time, allowing the thigh
tissues to rotate inferiorly and medially. Staging the vertical resec-
tion compensates for this relaxation and achieves better contour,
while a revision could be necessary if the procedures are performed
concurrently.
3. The patient will have a much more arduous recovery if the proce-
dures are performed together.
A
B
C
D
E
F
Fig. 21.8 Examples of two patients marked for circumferential lower body lift. On the posterior views (A and D), the red hashed area
indicates the gluteal fat tissue that wil be preserved for buttock shape. Note that these patients have very different body types, but both
will benefi t from preserving gluteal fat. On the lateral views (B and E), the extent of lateral skin resection is noted. On the anterior views
(C and F), the low position of the transverse scar is observed. With the tissues on upward stretch (F), the fi nal scar location is suggested.
The second patient (D,E,F) is also marked for extensive debulking liposuction concurrent with the lower body lift. This will facilitate better
results for the second stage vertical thigh lift.

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
294
A
B
C
D
E
Fig. 21.9 Technique of shaping gluteal fat pads during lower body
lift. Based on preoperative markings (A), the red hashed area is
deepithelialized (B) and preserved full thickness while tissue lateral
to this region is excised to the level of the muscle fascia. The fat pad
is undermined laterally to allow rotation and a subcutaneous pocket
dissected inferiorly (C). The lateral aspect of the tissue fl ap is rotated
inferiorly into the subcutaneous pocket and secured to the deep
fascia with braided nylon suture. The dermal surface area can be
plicated to increase buttock projection (D). On table lateral/oblique
view shows buttock projection achieved.

Surgical Technique
295
4. Performing both procedures together can be taxing on the
surgeon.
A simple crescenteric transverse medial thigh excision is an operation
that should always be considered and discussed with patients when
addressing medial thigh deformities. This operation, however, is very
much underpowered, and can only provide enough upward pull to
improve laxity in the upper third of the medial thigh. Patients may
hold the misimpression that the force of pull can be transmitted all
the way to the knee. Because the vector of pull is directly vertical and
the thighs are constantly moving, the transverse scars are prone to
descent. This can be mitigated by keeping the scars close to the mons
(actually superior/medial to the groin crease) and anchoring the deep
SFS tissue to Colle’s fascia.28 This procedure also tends to result in a
lot of pleating along the transverse scar that takes time to resolve. This
operation does have its advantages. It avoids a visible longitudinal scar
and is of much less magnitude than the full vertical thighplasty. Addi-
tionally, this version of the thighplasty can be safely combined with a
lower-body lift. Achieving patient satisfaction with this procedure
depends upon selecting a patient with primarily proximal medial thigh
deformities and properly conveying the limitations of the operation.
Vertical thigh lift, like brachioplasty, involves a signifi cant visible
longitudinal scar on the extremity. The scar is placed on the medial
side of the upper thigh, and extends from the groin to the knee. A
transverse scar component in the groin crease is usually necessary;
however, this can usually be veered in one direction, either anterior or
posterior, to avoid a ‘t’ incision in certain cases. The markings begin
with the patient in the supine position, with the knees bent in a frog-
leg position (Fig. 21.14). The midline of the mons region is marked.
A distance of 4 cm lateral to this midline mark is then measured. This
will represent the border of the scar along the mons region. While this
may seem to be a short distance from the midline, the scar will move
laterally under tension. The line of incision is drawn along the groin
crease and extended into the gluteal fold. The length of this scar can
be variable based on the degree of skin laxity, and will represent the
transverse component of the scar for the vertical thigh lift. Next, the
extent of the vertical skin resection is estimated and marked with a
pinch test applied to move the thigh skin upward to meet the line of
incision just drawn in the groin crease. Next, the anterior anchor line
is drawn in on each leg. With posterior traction on the skin of the
thigh with the surgeon’s left hand, a straight line is drawn from the
level of the knee up to the groin crease. At the knee, the distal margin
of the incision should curve gently under the patella. The scar will
cross the knee in the mid-axial position and not interfere with ambu-
lation. Proximally, the line of incision should meet the groin crease
incision just posterior to the adductor muscle origin. The traction is
released from the tissues and applied in the opposite direction. With
the surgeon’s left hand, traction is placed in an anterior direction. A
similar line is drawn in exactly the same position along the thigh.
Under traction, that line will represent the position of the fi nal scar
on the medial thigh. Next, transverse reference marks are drawn in to
assist with tissue reapproximation. The same process is repeated on
the opposite leg. As a check for symmetry, the legs are pushed together
to observe the refl ection of the markings on each thigh. These should
essentially be mirror image markings. A cautionary note, however:
there may be some asymmetry of the thighs to start with.
In the operating room, the patient is positioned supine and the legs
prepped circumferentially. Calf compression boots are applied for
induction and sterile drapes wrapped around the calves covering the
sequential compression devices. This is done in a manner that would
allow the legs to be freely mobilized during the surgery. The incision
lines are infi ltrated with epinephrine (1 : 100 000) without lidocaine. If
an operating table with spreader bars is available, such as a urologic
cystoscopy table, this allows an operator to sit between the abducted
legs. The dissection begins with incising the anterior anchor line and
the groin crease incision (Figs 21.15 & 21.16). We do not commit to
the posterior margin of resection at this time. The entire anterior
anchor line is incised, as well as the anterior portion of the transverse
region of resection. The dissection over the femoral triangle is kept
very superfi cial to avoid injury to the underlying lymphatic structures.
Once the adductor tendon is reached proximally on the thigh, the dis-
section can be taken into a deeper plain. Distally, the dissection is
started in a plane that leaves some adipose tissue over the muscle
fascia. The saphenous vein is identifi ed distally and preserved during
the dissection. The plane of dissection is kept right above the saphe-
nous vein. An effort is made to preserve some adipose tissue around
the saphenous vein because the lymphatics run with this structure.
Tributories of the saphenous vein are controlled with surgical clips.
The tissues are undermined in a posterior direction until the estimated
mark of resection is reached. At this time, the actual posterior margin
of resection is rechecked using a fl ap marker or similar technique. The
authors often approach this resection in a manner similar to that of
the brachioplasty. In different points along the leg, the fl ap is incised
to the intended point of resection and secured with a towel clip. The
A
B
Fig. 21.10 Intraoperative views showing Lockwood undermining device (A) and abduction of the leg onto a sterile side table to take tension
off of lateral closure (B).

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
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A
B
C
D
E
F
Fig. 21.11 47-year-old woman following 52 kg weight loss and lower body lift. Pre and postoperative views shown at 1 year.
intervening segments of tissue are then removed. Once the tissue is
resected, a closed suction Jackson Pratt drain is placed from the groin
incision all the way to the distal point of resection at the knee. The
wound is then closed in layers, with running braded absorbable suture
in the SFS layer. Interrupted deep dermal sutures are placed along with
a running subcuticular suture of absorbable monofi lament material.
Three to fi ve braided permanent sutures are used to secure the SFS to
Colle’s fascia on both sides posterior to the adductor muscle tendon.
The transverse groin incision is closed with a running nylon suture.
For postoperative care, ace wraps are secured on the legs. The patient
is instructed to keep legs elevated in the early postoperative period,
and compressive hose are used for 2–4 weeks. Figure 21.17 demon-
strates the results of a vertical thighplasty in the absence of a lower-
body lift. Complications of leg swelling and temporary lymphedema
may be observed in the fi rst 2–6 weeks following surgery. Drains are
removed when output is <30 cc/24 hours. There are two variants of
this procedure worth noting. The transverse thigh lift without a verti-
cal component of resection was mentioned earlier, and only involves
the transverse crescent-shoped resection shown in the marking dia-
grams. Another variant to this procedure is a short vertical scar thigh
lift. This is similar to the vertical thighplasty described above, except
the scar is truncated in the mid thigh. While it is an appealing concept,
it is often diffi cult to achieve satisfactory results. There is often a
noticeable step-off in contour at the transition between the end of the
scar and the lower portion of the thigh. Candidates for this operation
tend to have good skin tone in the lower or distal thigh and obvious
festoons in the upper thigh that cannot be corrected with a transverse
thigh lift.

Surgical Technique
297
Brachioplasty
Aesthetic brachioplasty was described in the 1950s by Correa-Iturraspe
and Fernandez.29 Many variations exist for correction of excess skin of
the arms with regards to location of the incision either in the brachial
groove or more posteriorly. In addition, the axilla may be managed
with the inclusion of Z-plasties, W-plasties, or L-plasties to mitigate
scar contracture.30–33 Permanent sutures securing the superfi cial fascial
system to the axillary fascia may help to retain the axillary fold after
skin excision.34 The use of a single longitudinal elliptical pattern of
resection along the upper arm has been helpful in treating arm ptosis,
but does not address laxity of the axillary fold. To achieve a good aes-
thetic result, one must extend the resection into the axillary region.
Liposuction serves as a useful adjunct for thinning the posterior
aspect of the arms before brachioplasty excision; however, the surgeon
should be cautious of resultant swelling that may make skin closure
more diffi cult. One should infi ltrate with tumescent fl uid and move
immediately to aspiration to avoid edema. While some surgeons
commit to a pattern of excision based on pinch test, the authors
promote a more cautious step-by-step excision that allows concomi-
tant closure with resection. The inability to close an arm wound after
resecting for a brachioplasty is a much feared complication.
Brachioplasty best exemplifi es a trade off of skin for scar. The scar
from a brachioplasty is very prominent and visible. Moreover, this scar
can stay thick and red for many months before maturing and becom-
ing less noticeable. This element of preoperative counseling is vital
A
B
C
D
E
F
Fig. 21.12 39-year-old woman following 45 kg weight loss (A,B) and a fi rst stage lower body lift with 9 liter debulking liposuction of the
thighs (C,D). Six months later, the patient underwent a second stage vertical thighplasty (E,F).

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
298
A
B
C
D
E
F
G
H
I
Fig. 21.13 49-year-old woman s/p 36 kg weight loss with good skin tone on abdomen marked for bodylift without abdominoplasty
(Lockwood Type I bodylift). The red line is the estimated scar position, based on how far the superior incision will move under stretch.
Anteriorly, the scars extend parallel to the groin crease (A,B,C). Postoperative views at 8 months demonstrate that the operation can be
planned to position scars in a manner that accommodates a patient’s preference for clothing styles (D,E,F). The borders of the bathing suit
were marked fi rst. Note that the anterior scars come very close to the mons to prevent them from descending onto the anterior thigh (G,H,I).

Surgical Technique
299
A
B
C
D
E
F
Fig. 21.14 Markings for vertical thighplasty. (A) Line of incision drawn in groin crease starting 4cm lateral to midline of mons region; (B)
pinch test to estimate vertical component of skin resection; (C) Anterior line of resection drawn by placing posterior traction with left hand
and marking along mid-thigh. This will show estimated scar position; (D) Posterior line of resection drawn by applying anterior traction with
left hand and marking along mid-thigh; (E) Transverse reference lines drawn to aid in aligning tissues after resection; (F) Estimated margins
of resection checked by pinch test.

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
300
G
H
A
B
C
D
Fig. 21.15 Operative technique for vertical thighplasty. (A) Anterior line of resection has been incised and the fl ap undermined to the
posterior estimated line of resection; (B) saphenous vein has been identifi ed and preserved (course marked with vessel loops), with plane of
dissection just above the vein; (C and D) sharp towel clamp are used to hold the dissected fl ap and an everted towel clamp placed at the
edge of the anterior incision line used as a fl ap marker.
Fig. 21.14, cont’d (G) note that distal pattern of resection crosses knee in mid-axial position and curves under patella; (H) symmetry of
markings checked when legs are approximated-patterns should be mirror images if legs are symmetrical to start.

Surgical Technique
301
E
F
G
H
A
B
Fig. 21.16 (A) Intraoperative view of leg closed following resection; and (B) view of both legs demonstrating effect of thighplasty on right
leg compared with untreated left leg.
Fig. 21.15, cont’d (E and F) the fl ap is incised at intervals along the thigh and secured with sharp towel clamps; (G) after multiple
segmental incisions into the fl ap, the posterior line of resection is remarked between the towel clips and incised; (H) 3-5 braided nylon
sutures are used to approximate the SFS of the thigh tissues to Colle’s fascia on each thigh.

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
302
with brachioplasty candidates. Silicone sheeting or paper tape, along
with massage, can help with scar maturation. Patients should be well
informed about the possibility of poor scar formation and they should
be accepting of the scar location. While there is controversy over the
ideal location of the scar in brachioplasty procedures, the authors
prefer the bicipital groove. In this position, the scar is more diffi cult
to see in most situations. Patients who understand the fact that they
are trading redundant skin for a visible scar, and are also willing to be
patient while the scar matures, are likely to be satisfi ed with the
operation. Patients who are not well informed of this fact may be quite
dissatisfi ed with the results and may even seek litigation.
A brachioplasty may be performed as an isolated procedure,
although many MWL patients choose to combine brachioplasty with
other body-contouring procedures. Assessment of the brachioplasty
candidate begins with a careful evaluation of excess adipose tissue on
the arm as well as skin redundancy. The plastic surgeon will encoun-
ter a subset of arm-contouring patients with excess adipose tissue and
relatively good skin elasticity. These patients would be good candidates
for liposuction alone as a surgical option. Even if it is not completely
clear that liposuction alone can be performed without loosening of the
skin, patients who are reluctant to accept a scar may choose this option
as an initial procedure. This would be done with the understanding
that an excisional procedure could follow in the future if the patient
is unhappy with skin laxity. When skin laxity is present, an assess-
ment should be made as to the distribution and extent of the skin
laxity on the arm, axillary region, and lateral chest wall. It is very
important to correct the entire combined aesthetic unit of arm, axillary
fold, and lateral chest wall together. As mentioned, a simple elliptical
incision on the upper arm may correct circumferential skin laxity, but
will not correct the axillary fold descent. The surgical goals for correc-
tion of redundant skin on the arm include: proper scar placement,
elevation of the axillary fold, avoidance of uneven resection, avoidance
of over resection and correction of laxity on the lateral chest wall. The
authors advocate placement in the bicipital groove, and hold the
opinion that a posterior scar, while less visible to the patient, is quite
visible to other people. Elevation of the axillary fold is accomplished
with a fl ap of tissue brought high into the dome of the axilla. Avoid-
ance of uneven resection is best accomplished through a technique of
A
B
C
D
Fig. 21.17 (A) 52-year-old woman s/p
130 pound weight loss and previous
abdominoplasty. (B,C,D) Postoperative views
one year after revision abdominoplasty and
vertical medial thighplasty without having
had lower body lift.

Surgical Technique
303
on-table fl ap marking during the resection. This is done in a segmen-
tal fashion, which allows for accurate tailoring of the contour during
the procedure. Simply marking all margins of resection on a brachio-
plasty and excising can result in uneven resection that is quite notice-
able to the patients. Importantly, that strategy may also lead to over
resection of tissue and an inability to close the wound.
Brachioplasty markings are shown in Figure 21.18. The patient can
be sitting or standing with the arms bent at 90º at the elbow and 90º
abduction at the shoulder. The bicipital groove is marked fi rst, and will
represent the intended scar placement location. Next, a superior line
of incision is marked. This anchor line is determined by pulling
tension downward on the skin of the arm to estimate skin excursion
under stretch. In general, the superior line of incision is 2–3 cm supe-
rior to the bicipital groove mark. Under the tension of wound closure
after resection, the superior line of incision will be pulled downward
to the level of the bicipital groove. The distal extent of the resection
(Fig. 21.18A – point c) is usually at the level of the elbow. By placing
the resection along the bicipital groove, any scar will cross the elbow
in the midaxillary position relative to the joint. This allows one to
extend the incision distally without fear of joint contracture. With that
in mind, however, we do this only when necessary and tend to limit
extension of the scar onto the forearm because it can be very visible.
The proximal extent of the superior incision line (Fig. 21.18A – point
a) is set high into the dome of the axilla. Extending inferiorly from
point a and at a 90º angle from the superior line of incision, is the
extension of the incision onto the chest wall. The length of that inci-
sion (terminating at Fig. 21.18A – point b) is determined by the rela-
tive skin laxity on the lateral chest wall. As the skin laxity increases,
a greater extension is necessary. Next, a point in the axilla is selected
that will reach ‘point A’ under tension and will correct the descent of
the axillary fold. This mark, referred to as ‘point A prime’, is usually
4–5 cm from ‘point A’. A simple pinch test is used to estimate point
a prime. Next, the estimated inferior line of incision is determined by
a simple pinch test. This line is only an estimate and will not be
incised at the start of the procedure.
In the operating room, the arm is prepped distally to the elbow
with a sterile towel wrapped around the arm. Intravenous catheters
may be placed distal to the elbow. A blood-pressure cuff may be placed
on the forearm as necessary. The arm is prepped circumferentially and
the shoulder included in the sterile fi eld. If liposuction is to be per-
formed, a small amount of fl uid is infused into the posterior arm (1 cc
tumescent fl uid per each 1 cc of anticipated aspirate) and the fat tissue
is removed immediately through a port site at the elbow. The superior
line of incision and the line marking the extension onto the chest wall
are incised (Fig. 21.18). The soft tissue is dissected to a level just above
the brachial fascia. A fl ap consisting of skin and subcutaneous tissue
is then elevated away from the fascia and dissected inferiorly. Care is
taken to identify and preserve sensory nerves running through the fi eld
of dissection. The most notable of these is the medial antebrachial
cutaneous nerve (MABC). This is readily identifi ed in association with
the basilic vein at the distal upper arm. After dissecting distally to the
estimated inferior line of incision, the actual margin of resection will
be determined. An assistant grasps the forearm and elevates the arm
above the operating table so that the tissues of the posterior arm are
not tethered. A heavy forceps is used to transpose the superior margin
of resection beneath the dissected fl ap and estimate how much tissue
can be removed (fl ap marking technique). This is done at three points
along the upper arm. The fl ap is then divided with a scalpel at these
measured intervals and secured to the superior line of incision with a
sharp towel clip. This method of segmental marking and incising will
help establish an even contour of the arm. The tissue in the axilla is
then excised with a scalpel. A new line of inferior incision is marked
in between the towel clips and the remainder of the tissue is excised.
Next, the superfi cial fascia at point A′ is secured to a clavipectoral
fascia at point a with a permanent 0-braded nylon suture. This will
help keep the tissue suspended in the axilla. A closed suction drain is
placed in the wound extending out to the elbow and towel clips used
to secure the tissues and immediately replaced with staples. It is
important to align the skin edges as soon as possible after resection
so that edema does not increase and prevent closure of the wound.
The dermis is then closed in layers with absorbable suture. Following
wound closure, a sterile compressive wrap is placed on the arm. The
arm is unwrapped on the 3rd to 5th postoperative day and the wounds
checked. The patient is advised to avoid heavy lifting for at least 2
weeks. In addition, the patient is advised not to raise their arms and
abduct the shoulders above 90º for the fi rst week. Drains are discon-
tinued when output ≤30 cc/24 hours. After 2 weeks, the patient is
prescribed gentle active range-of-motion exercises to fully abduct the
shoulder. Figure 21.19 shows a representative case with maturation of
scar over time.
Specialized mastopexy technique in the
MWL patient, including upper-body lift
Breast deformities after massive weight loss are characterized by defl a-
tion and distortion. In particular, there is signifi cant volume loss,
elasticity loss, asymmetry, medialization of the nipples, and continu-
ation of laxity to the lateral chest wall and to rolls in the back. Tradi-
A
B
Fig. 21.18 Brachioplasty technique. (A) markings; (B) elevation of fl ap without to level of estimated margin of resection.

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
304
C
D
E
F
G
H
Fig. 21.18, cont’d (C) Medial Antebrachial Cutaneous nerve (MABC) adjacent to basilic vein at the elbow; (D) fl ap marking technique using
heavy forceps; (E) incision of fl ap to point of resection determined by fl ap marking; (F) multiple tissue segments isolated based on fl ap
marking at 3 intervals along upper arm; (G) new, more exact margin of resection drawn in between interval incisions; (H) tissue segments
removed to complete excision and wound approximated. Note offset angle of scars in axilla, which prevents scar contracture at the shoulder
joint similar to a Brunner incision on the hand.

Surgical Technique
305
tional techniques of breast reduction and mastopexy, especially with
short scars, tend to be insuffi cient solutions for this deformity. The
senior author has developed a technique using principles of dermal
suspension and total parenchymal reshaping to fundamentally create
an internal brassiere and provide lasting shape to the breast.34 A
modifi cation of the traditional Wise pattern provides control of the
skin envelope and a central dermoglandular pedicle is well-vascularized
and supports the nipple. Volume is maintained and autoaugmentation
using excess tissue from the side of the chest lateral to the breast
extending to the mid-axillary line can increase volume substantially
and reliably. Approaches to the breast should take into consideration
excess skin of the lateral chest wall as well as the back. If rolls are
prominent in a horizontal fashion on the back, their excision can be
incorporated into the mastopexy or brachioplasty for a complete upper-
body lift. Rolls that have a more vertical orientation can be excised
vertically along the mid-axillary line and may be in continuity with
brachioplasty scars. Improving the arms, breasts, and back can help
create a more harmonious appearance to the upper-body aesthetic
unit.
In marking the patient, the nipple position is referenced to the
inferior mammary fold, and moved to a more lateral position along a
symmetrically drawn breast meridian. The lateral portion of the Wise
pattern is extended posteriorly to encompass the axillary skin roll and
provide additional autologous tissue for breast volume. The Wise pattern
can be extended to the posterior axillary line and beyond, depending on
the extent of the lateral skin roll and the amount of tissue desired for
autologous breast augmentation (Figs 21.20 & 21.21). The robust blood
supply of the lateral thoracic region allows for a signifi cant amount of
tissue to be safely mobilized to the breast. We must make an important
point: the area of skin resection to alleviate the lateral skin roll may
extend beyond the portion of the Wise pattern to be de-epithelialized
(i.e. a portion of the lateral ‘wing’ of the Wise pattern may be de-epithe-
lialized and saved to assist in the reshaping and add volume, while the
remainder is simply excised to eliminate the skin roll). This fl exibility
in design allows the surgeon to control the skin envelope and titrate the
amount of lateral tissue to mobilize to the breast.
The entire region within the Wise pattern is deepithelialized. The
breast parenchyma is then completely degloved by raising a 1.5 cm
A
B
C
D
E
Fig. 21.19 44-year-old woman s/p 83 kg weight loss. Preoperative views (A and B), and postoperative views shown at 6 months (D and D)
and 2 years to demonstrate scar maturation (E).

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
306
thick fl ap overlying the breast capsule. Once the chest wall is reached,
undermining continues over the pectoralis major fascia to the level of
the clavicle. Medial and lateral fl aps of breast tissue are mobilized by
undermining over the chest wall. Care is taken to preserve signifi cant
perforating vessels that enter the tissue fl aps near the base. The lateral
fl ap is trimmed to the desired size, as necessary. The nipple survives
on a healthy central pedicle.
The next step is the suspension of the central dermal extension to
the chest wall. This is performed with a 0-braided permanent suture
in a mattress fashion. The dermis is fi rmly tacked to the periosteum
A
Wise pattern
B
The breast parenchyma is degloved
C
The lateral breast flap is elevated
D
The dermal edge of the medial breast flap is fixed to the chest
wall
Fig. 21.20 (A) The patient is marked with a Wise pattern that extends laterally to encompass the redundant axillary roll. The entire area of
the Wise pattern is deepithelialized, preserving an extensive dermal surface. (B) The breast parenchyma is degloved by raising a 1 cm-thick
fl ap and then continuing the dissection superiorly just superfi cial to the pectoralis fascia. Medial and lateral fl aps of dermis/breast tissue are
mobilized from the chest wall. The central dermal extension is elevated and secured to the chest wall (usually rib periosteum) using braided
nylon suture. (C) The lateral breast fl ap is elevated to create the lateral curvature of the breast mound, and the dermis secured to the chest
wall near the previous fi xation point. The lateral fl ap can be extended posteriorly on the chest wall to provide extra tissue for autologous
volume augmentation. (D) The dermal edge of the medial breast fl ap is fi xed to the chest wall. A running braided suture is used to
approximate the dermal edges of the lateral fl ap and central dermal extension. Dashed lines show the pattern of plication used. The pattern
of plication may be individualized to achieve the best breast shape in each patient. In general, there is a later component, a medial
component, and an inferior component that corrects the ‘bottomed out’ appearance and increases projection.

Surgical Technique
307
A
Running suture
B
The dermis along the lateral breast is secured to the lateral chest
fascia
C
The breast skin flap is redraped
D
The breast skin flap is closed with absorbable intradermal
sutures over a drain
Fig. 21.21 (A) The dermis of the medial breast fl ap is approximated to the central dermal extension using a running suture. The dermis on
the inferior pole of the breast is plicated with a running suture to shorten the distance between areola and inferior mammary fold to
approximately 5cm. (B) The dermis along the lateral breast is secured to the lateral chest fascia (not rib pereostium) with permanent sutures
to increase projection and accentuate the lateral curve of the breast. The breast parenchyma is now fi rmly secured to the chest wall, and
the shape has been adjusted using the plication sutures. (C and D) The breast skin fl ap is redraped and closed with absorbable intradermal
sutures over a drain. If the nipple is tethered and pointing in an inappropriate direction, the dermis adjacent to the nipple is scored to release
the tension. Because of the robust pedicle, scoring of the dermis can be safely performed along part of the circumference, if necessary.
of a selected rib along the breast meridian. This carefully placed suture
must pass through the pectoralis muscle and relies on palpation of the
rib with the non-dominant hand to guide the needle pass. The choice
of rib level for fi xation is made intraoperatively based on the distance
between the dermal edge and the nipple (i.e. how nipple areolar complex
position is affected by height of suspension). This is most often the
second rib. The suspension should raise the level of the nipple close to
the intended fi nal position. The lateral breast fl ap is then suspended
and secured to the chest wall by tacking to the rib periosteum in a
similar manner. The lateral fl ap dermal suspension suture will be very
close to the central suspension suture, although a lower rib level may
be selected to provide the desired shape. This will create a discrete
lateral curvature to the breast shape and replace the unsightly blending
of breast tissue with the lateral chest. The medial breast fl ap is then
suspended and secured to the chest wall. With the suspension points
established, control of the parenchymal shape is then gained. The

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
308
A
B
C
D
E
F
Fig. 21.22 57-year-old patient following 60 kg weight loss. Preoperative views (A and B) show severe ptosis with lateral roll. Intraoperative
views (C and D) demonstrate control of parenchymal shape with this technique, which is translated into restoration of aesthetic shape at 6
months post-operative (E and F).
A
B
C
D
E
F
Fig. 21.23 46-year-old patient treated with this mastopexy technique following 70 kg weight loss. Preoperative and 6 month post-operative
views are shown.

Surgical Technique
309
A
B
C
D
E
F
G
H
I
Fig. 21.24 56-year-old womn s/p 80 kg weight loss. (A and B) Initial preoperative views; (B and C) Patient shown 3 months following lower
body lift, mastopexy, and preliminary debulking liposuction of back rolls. She is marked for transverse upper body lift, with red line
indicating intended scar position and pattern of resection designed so that scars will merge with the mastopexy scars; (D,E,F) Patient
shown 7 months after upper body lift, with correction of back rolls and scar hidden by bra. Additionally, the lower body lift scars can be
seen in relation to the upper body lift scars; (G and I) intraoperative photographs showing defect on back after resection and closed wound.
broad surface area of dermis is meticulously plicated with running
absorbable sutures to adjust the shape. The process starts with approx-
imation of the dermis of the lateral fl ap to the central dermal extension.
This is followed by plication of the medial fl ap dermis to the central
dermal extension. The inferior pole of the breast is then plicated to
shorten the nipple to IMF distance and increase projection. The authors
have learned to carry out the suspension and plication steps simultane-
ously on both breasts, rather than completing one breast and moving
to another. This permits better symmetry. After initial placement of
plication sutures, a fi ne-tuning process follows in which additional
plication sutures are added. Sutures may be necessary to secure the
lateral breast fl ap to the lateral chest wall fascia. Constant redraping of
the skin fl ap during the shaping process helps guide both major and
minor adjustments to breast form. If the abdominal-wall tissues are
very loose, a decision may be made to secure the superfi cial fascial
system (SFS) layer of the dissected edge of the abdominal wall to the
periosteum of the 5th rib. This will restore IMF position.
For closure, the authors favor using a half-buried mattress suture
to secure the dermal edges at the ‘triple point’ along the IMF. Intra-
dermal sutures are then used to complete the closure, and suction
drains are placed in each lateral breast. A lightly compressive chest
wrap is then placed.
Restoration of breast shape and symmetry can be achieved in dif-
fi cult cases with this technique. Patient satisfaction has been high in
all cases. Pre and postoperative results are shown in Figures 21.22 and
21.23. The upper-body lift pattern of resection and results are shown
in Figure 21.24.
Specialized gynecomastia correction
technique in the MWL patient
The severe skin deformities of the male chest following massive weight
loss are diffi cult to correct without a major skin excision. Moreover,
periareolar techniques do not work well in this population. The authors

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
310
A
B
C
D
E
F
Fig. 21.25 44 year old male patient s/p 89 kg weight loss. (A and B) Inframmary fold marked, as well as anticipated nipple position and
superior extent of elliptical excision; (D and D) Results at 6 months, with scars still red and thick; (E and F) results at 1 year, with scars
matured.
A
B
Fig. 21.26 (A) Intraoperative photo of gynecomastia technique, showing thin broad dermal pedicle elevated; (B) Intraoperative photo (lateral
view) showing elliptical incision of skin. The superior tissues are undermined and the dermal pedicle is delivered through a new circular
incision at the desired nipple location.

Surgical Technique
311
A
B
C
D
E
F
G
H
I
Fig. 21.27 46-year-old woman s/p 95 kg weight loss, planned for 2 stage total body reconstruction. (A, B, C) Initial preoperative
photographs; (D,E,F) s/p fi rst stage circumferential lower body lift, vertical abdominal resection, and brachioplasty; (G,H,I) 6 months s/p
second stage upper body lift, mastopexy, and vertical thigh lift.

21
BODYLIFTS AND POST MASSIVE WEIGHT LOSS BODY CONTOURING
312
advocate an elliptical excision of chest skin with preservation of the
nipple on a thinned broad-based dermal pedicle. The scar position is
in the inframmary fold. Figures 21.25 and 21.26 show the results of
technique and the dissection of the pedicle.
Multiple procedures and staging
Multiple procedures may be combined, providing safety is the overrid-
ing principle and the operative-setting appropriate (e.g. inpatient facil-
ity). When combining procedures, the authors avoid combinations that
will result in opposing vectors of pull. An example would be combining
lower-body lift and upper-body lift. Additionally, both the magnitude
of recovery, given the patient’s age and medical condition, should be
considered. The experience of the operative team, number of operating
surgeons, and potential for surgeon fatigue should also be taken into
account. In general, the authors will do as much as a circumferential
lower-body lift and one upper-body procedure in a single operative
setting for well-selected patients. When planning staged procedures,
the authors allow at least 3 months between stages. Well-planned
stages can result in a safe total body contouring (Fig. 21.27).
COMPLICATIONS INHERENT TO BODY
CONTOURING AFTER MWL
An overwhelming majority of complications with body-contouring pro-
cedures consist of wound-healing complications (mainly dehiscence)
and seroma. One notable phenomenon in this population is recurrent
skin laxity. Despite the surgeon’s best effort to tighten skin at the time
of surgery, many patients will encounter relaxation of the skin in the
weeks to months following surgery. This can be severe enough to
require revision. A host of less common complications are seen in this
population, including infection, bleeding, skin necrosis, and throm-
botic complications.
REFERENCES
1. Livingston EH. Preface: bariatric surgery. Surg Clin N Am 2005;
85:xiii–xvii.
2. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical
procedures. JAMA 2005; 294(15):1909–1917.
3. Davis MM, Slish K, Chao C et al. National trends in bariatric surgery,
1996–2002. Arch Surg 2006; 141:71–74.
4. Nguyen NT, Goldman C, Rosenquist CJ et al. Laparoscopic versus open
gastric bypass: a randomized study of outcomes, quality of life, and
costs. Ann Surg 2001; 234:279–289.
5. Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization
and in-hospital outcomes of bariatric surgery. J Gastrointest Surg 2002;
6:855–861.
6. Buckwald H, Avidor Y, Braunwald E et al. Bariatric surgery: a systematic
review and meta-analysis. JAMA 2004; 292:1724–1737.
7. Safadi BY. Trends in insurance coverage for bariatric surgery and the
impact of evidence-based reviews. Surg Clin N Am 2005;
85:665–680.
8. American Society of Plastic Surgeons Statistics, 2006. wwww.
plasticsurgery.org.
9. Song AY, Jean RD, Hurwitz DJ et al. A classifi cation of weight loss
deformities: the Pittsburgh Rating Scale. Plast Reconstr Surg 2005;
116:1534–1554.
10. Matory WE, O’Sullivan J, Fudem G et al. Abdominal surgery in patients
with severe morbid obesity. Plast Reconstr Surg 1994; 94:976–987.
11. Vastine VL, Morgan RF, Williams GS. Wound complications of
abdominoplasty in obese patients. Ann Plast Surg 1999; 42:33–35.
12. Shermak MA. Hernia repair and abdominoplasty in gastric bypass
patients. Plast Reconstr Surg 2006; 117:1145–1150.
13. Kelly HA. Excision of the fat of the abdominal wall lipectomy. Surg
Gynecol Obstet 1910; 10:299.
14. Lockwood T. High-lateral-tension abdominoplasty with superfi cial fascial
suspension. Plast Reconstr Surg 1995; 96:603–615.
15. Matarasso A. Abdominoplasty. A system of classifi cation and treatment
for combined abdominoplasty and suction-assisted lipectomy. Aesthetic
Plast Surg 1991; 15:111–121.
16. Dellon AL. Fleur-de-lis abdominoplasty. Aesth Plast Surg 1985; 9:27–32.
17. Persichetti P, Simone P, Scuderi N. Anchor-line abdominoplasty: A
comprehensive approach to abdominal wall reconstruction and body
contouring. Plast Reconstr Surg 2005; 116:289–294.
18. Mühlbauer W. Radical abdominoplasty, including body shaping:
representative cases. Aesth Plast Surg 1989; 13:105–110.
19. Aly AS, Cram AE, Chao M et al. Belt lipectomy for cicumferential
truncal excess: The University of Iowa experience. Plast Reconstr Surg
2003; 111:398–413.
20. Lockwood TE. Lower-body lift. Aesthetic Surg J 2001; 21:355.
21. Van Geertruyden JP, Vandeweyer E, de Fontaine S et al. Circumferential
torsoplasty. Br J Plast Surg 1999; 52:623–628.
22. Hurwitz DJ, Rubin JP, Risen M et al. Correcting the saddlebag deformity
in the massive weight loss patient. Plast Reconstr Surg 2002; 8:87–95.
23. Lockwood TE. Lower body lift with superfi cial fascial suspension. Plast
Reconstr Surg 1993; 92:1112–1122.
24. Sozer SO, Agullo FJ, Wolf C. Autoprosthesis buttock augmentation
during lower body lift. Aesth Plast Surg 2005; 29(3):133–137.
25. Centeno RF. Autologous gluteal augmentation with circumferential body
lift in the massive weight loss and aesthetic patient. 2006; 33(3):479–
496.
26. Lewis JR. The thigh lift. J Int Coll Surg 1957; 27(3):330–334.
27. Shultz RC, Feinberg LA. Medial thigh lift. Ann Plast Surg 1979;
2:404–410.
28. Lockwood T. Fascial anchoring technique in medial thigh lifts. Plast
Reconstr Surg 1988; 82:299–304.
29. Correa-Inturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa
Med Argent 1954; 34:24.
30. Aly A. Brachioplasty in the patient with massive weight loss. Aesthetic
Surg J 2006; 26:76–84.
31. Hurwitz DJ, Holland SW. The L brachioplasty: an innovative approach
to correct excess tissue of the upper arm, axilla, and lateral chest. Plast
Reconstr Surg 2006; 117(2):403–411.
32. Strauch B, Linetskaya D, Baum T et al. Brachioplasty and axillary
restoration. Aesthetic Surg J 2004; 24:486–488.
33. Lockwood T. Brachioplasty with superfi cial fascial system suspension.
Plast Reconstr Surg 1995; 96(4):912–920.
34. Rubin JP. Mastopexy after massive weight loss: dermal suspension and
total parenchymal reshaping. Aesthetic Surg J 2006; 26:214–222.

313
CHAPTER 22
Surgical Management of Migraine Headaches
Bahman Guyuron and Devra Becker
INDICATIONS AND CONTRAINDICATIONS
Indications:
1.
Failure of conservative treatment.
2.
Corrugator supercilii hypertrophy.
3.
More than two severe migraine headaches a month.
4.
Response to botulinum toxin A with complete or >50%
reduction of headaches.
Contraindications:
1.
Medical condition simulating migraine headaches.
2.
Unacceptable surgical risk.
3.
Pregnancy or lactation.
INTRODUCTION
Migraine headaches (MH) are a signifi cant cause of morbidity, affect-
ing over 28 million Americans, with a lifetime prevalence estimated
to be between 11% and 32% across several countries.1–6 MH are ranked
as #19 among all diseases worldwide causing disability.7–9 The cost of
medical treatment of MH in the USA has been estimated at 14 billion
US dollars.10 There is an additional burden of 13 billion US dollars for
loss of work. There are two subtypes of migraine: without aura, and
with aura. Auras develop over 5–20 minutes, but last for less than 60
minutes, and are followed by a migraine. One out of three patients
with MH experience aura.
MH are usually frontotemporal, typically unilateral, and are char-
acterized by recurrent attacks of pulsating, intense pain associated with
nausea and photophobia. The diagnostic criteria of migraines are
shown in Table 22.1. Traditional, nonsurgical treatment of migraines
can be nonpharmacologic or pharmacologic. Nonpharmacologic treat-
ment of migraines consists of avoidance of triggers, usually caffeine,
alcohol, or tobacco. Pharmacologic treatment can be further subdivided
into acute analgesic, acute abortive, and prophylactic treatment. Acute
analgesic treatment consists of pain control, acetaminophen, non-ste-
roidal anti-infl ammatory drugs (NSAIDS), analgesics, benzodiazepines,
opioids, and barbituates. First-line acute abortive treatment is triptans,
although IV antiemetics and ergotamine can be used as well. Prophy-
lactic treatment consists of beta blockers, tricyclic antidepressants, and
valproic acid.11
Though tension headaches can be confused with migraine without
aura, it is possible to distinguish them from migraine, because tension
headaches are not associated with nausea and are not affected by
activity. Another group of headaches to be separated from MH are
cluster headaches. Cluster headaches are marked by severe pain and
Summary
1. Migraine headaches affl ict 12% of the population
(28 million people) and is three times more common in
women.
2. Many of the patients are in the age group commonly
seeking aesthetic surgery, and it is very common for
patients seeking aesthetic surgery to have headache
complaints.
3. Migraine headaches unresponsive, or poorly responsive, to
medical management can be treated surgically.
4. All migraine patients should undergo evaluation by a
headache specialist for initial diagnosis and medical
management.
5. Plastic surgeons managing migraine headaches are advised to
evaluate patients for potential trigger sites by injection with
botulinum toxin A or nerve block.
6. All patients with retrobulbar migraine headaches should have
intranasal examination and CT scan for examination of
septal spurs or deviation, contact points, and turbinate
hypertrophy.
7. The trigger sites can be identifi ed by the location of the
symptoms at the onset of the migraine cascade, detection of
tender or hypersensitive points, or sites on which pressure can
abort the headache, response to injection of botulinum toxin A
in that site, and pathology found on CT.
8. Glabellar trigger sites are treated with resection of the
corrugator and depressor supercilii and partial procerus
removal.
9. Temporal trigger sites are treated with avulsion of the
zygomaticotemporal branch of the trigeminal nerve.
10. Occipital trigger sites are treated with removal of a segment of
the semispinalis capitus muscle and replacement with fatty
tissue.
11. Intranasal trigger sites are treated with septoplasty and
reduction of the inferior turbinate.
12. Unilateral surgery may unmask contralateral symptoms.
13. Approximately 1 in 5 female patients undergoing cosmetic
surgery suffer from migraine headaches.

22
SURGICAL MANAGEMENT OF MIGRAINE HEADACHES
314
affect the orbital, supraorbital, or temporal regions exclusively.12 They
are 15–180 minutes in duration, and are associated with unilateral
autonomic disturbances, such as conjunctival injection, lacrimation,
nasal congestion, rhinorrhea, forehead and facial sweating, miosis,
ptosis, and eyelid edema. During an attack, the headaches occur once
every other day up to eight times a day. In contrast to MH, patients
with cluster headaches are typically restless and agitated.
Nonpharmacologic treatment of cluster headache consists of avoid-
ance of ethanol, histamine, nitroglycerine, or tobacco. Abortive treat-
ment consists of 100% oxygen, triptans, cafergot, and dihydroergotamine.
Prophylactic treatment consists of verapamil, lithium, methysergide,
ergotamine tartrate, and prednisone taper.13
PATHOPHYSIOLOGY
Pathophysiology of MH
Though migraine pathophysiology has not been completely elucidated,
there are several plausible and experimentally substantiated theories.
Importantly, these explanations incorporate both central and periph-
eral nervous-system activity, and these factors interact and lead to
MH. There are four mechanisms in the pathogenesis of MH.15 First,
patients with MH have some experimental evidence of interictal corti-
cal derangements, specifi cally hyperexcitability of cortical neurons.
Second, periaqueductal gray matter (PAG), which is an antinociceptive
modulator, becomes progressively dysfunctional in MH. Burstein14
provided evidence that the sensitization of nociceptors causes an
increase in neuronal discharges, which causes an increase in sensitiv-
ity to all stimuli. In other words, the central nervous system is ramped
up, compared to normal, in response to both normal and painful
stimuli. Third, auras are caused by cortical spreading depression, and
the cortical spreading depression itself might cause irritation of the
trigeminal nerve nucleus caudus.15 Finally, trigeminal nerve irritation
causes release of substance P, calcitonin gene-related peptide, and
neurokinin A in the cell bodies of the trigeminal nerve.15–17 The sub-
stances then travel along the nerve and produce a localized meningitis,
and dilation of large vessels and dura mater innervated by the
trigeminal nerve.1,2,15,18,19 Although this dilation is thought to cause
MH, in our view it is the consequence of infl ammation.
What causes the initial trigeminal nerve irritation is not exactly
known. The anatomic relationship between trigeminal nerve branches
and head and neck musculature provides the basis of the trigger site
hypothesis of trigeminal nerve irritation in our opinion. Triggers sites
are where nerves are irritated either by traversing the muscle or due
to contact with it. This concept is borne out by anatomic studies. The
trunk of the supratrochlear nerve, and branches of the supraorbital,
which are both branches of the ophthalmic division of the trigeminal
nerve, pierce the corrugator and depressor supercilii. The fact that
many patients with MH have evidence of corrugator hypertrophy pro-
vides support for this hypothesis, which is further reinforced by the
benefi cial effects attained from injection with botulinum toxin A.
Branches of the ZMTBTN pierce the temporalis muscle. The greater
occipital nerve pierces the semispinalis capitus muscle.20,21 In some
ways, this is analogous to piriformis syndrome, in which contraction
of the piriformis muscle results in sciatic nerve irritation.22,23
Like MH, the pathophysiology of cluster headaches is not well
understood. What is known is that pain in cluster headaches is medi-
ated by the fi rst division of the trigeminal nerve, while autonomic
activation is mediated by cranial parasympathetic outfl ow from the
facial nerve. There is no brainstem activation in cluster headaches,
which distinguishes it pathophysiologically from MH.24
SURGICAL TREATMENT
Rationale for surgical treatment
In 1931, Walter Dandy removed the inferior cervical and fi rst thoracic
sympathetic ganglions in two patients, hypothesizing that migraine
pain had a clinical profi le consistent with nerve involvement.25 In
1946, Gardner reported on the resection of the greater superfi cial
petrosal nerve in 26 patients. Though he reported some success in
migraine patients, he noted complications including nasal dryness,
decreased tear production, and corneal ulcerations.26 Slightly more
than two decades later, Murillo described temporal neurovascular
bundle resection in 34 patients for treatment of migraine headaches.27
Shortly after, Murphy reported greater occipital neurectomy for occip-
ital migraine.28 Murillo and Murphy both had shortcomings in the
length of follow-up of their studies, and there was a sequela of
numbness resulting from these procedures. These radical surgeries
with morbid sequelae led to unacceptable surgical outcomes, but the
idea that surgery has potential in the treatment of headaches has
persisted.
Recent observations have supported new, safer, surgical protocols.
In the senior author’s practice the fortuitous discovery that several
patients who had undergone forehead rejuvenation procedures had
resolution of their MH led to the development of surgical protocols to
treat refractory headaches.
The understanding that the glabellar muscle group (GMG, includ-
ing the corrugator, depressor supercilii, and procerus) itself may con-
tribute to the pathophysiology, means that resection of these muscles
makes intuitive sense. Not only do these patients benefi t functionally
from the surgery, they also observe some aesthetic improvement. Fur-
thermore, the involvement of the ZMTBTN, which is sometimes
resected in facial rejuvenation procedures,2 makes transection of that
nerve justifi able for the treatment of headaches, since temporalis
muscle resection may result in a depression and may also be of some,
although minor, functional consequence.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
With the type of headache in mind, the ideal candidate for surgery
must be identifi ed. Studies have traditionally evaluated patients by the
following criteria: proper diagnosis of headache (by headache question-
naire and evaluation by a physician trained in evaluating the headache
patient), corrugator supercilii hypertrophy (Fig. 22.1), absence of
medical or neurological conditions likely to cause headache, and the
absence of unacceptable surgical risk. Pregnant and nursing women
are also typically excluded from surgical consideration.
The constellation of symptoms leads the examiner to suspect the
potential trigger sites,1–4 which is further validated by a nasal exam.
The nasal exam includes direct and indirect endoscopic examination
– which must be performed to detect septal deviation, turbinate hyper-
trophy, and concha bullosa – and fi ndings are confi rmed using a CT
scan (Fig. 22.2).
Table 22.1 Migraine headache diagnostic criteria
A. At least fi ve attacks meeting B–D
B. Headaches lasting 4–72 hours (untreated or unsuccessfully
treated)
C. Headaches have at least two of the following characteristics:
unilateral location, pulsating quality, moderate or severe pain
intensity, aggravation by or causing avoidance of routine
physical activity (for example walking or climbing stairs)
D. During headache at least one of the following: nausea and/or
vomiting, photophobia and phonophobia
E. Not attributable to any other disorder
(Adapted from International Headache Society. The International Classifi cation of
Headache Disorders. 2nd edn. Cephalalgia 2004; 24(Suppl 1):9–160).

315
Operative Approach for Migraine Headaches
OPERATIVE APPROACH FOR
MIGRAINE HEADACHES
Trigger sites
Currently, there are four common trigger sites: frontal triggers, where
glabellar muscles irritate the supratrochlear and supraorbital nerves
and cause frontal headaches; temporal triggers, where contraction of
the temporalis muscle causes infl ammation of the ZTBTN and causes
temporal headaches; occipital triggers, where the semispinatus capitus
stimulates the occipital nerve and causes occipital headaches; and
septonasal triggers, where intranasal structures compress the tri-
geminal end branches and cause paranasal and retrobulbar head-
aches.20,21,29 There are several less common trigger sites, most of which
are at intersections of nerves and arteries, such as the superfi cial
temporal artery and the auriculotemporal nerve, or the greater occip-
ital nerve and occipital arteries. The constellation of the symptoms
that aid in detection of the trigger sites have been outlined in Table
22.2.
The role of botulinum toxin A
A headache journal, which patients keep daily, is invaluable in
assessing response to botulinum toxin A, confi rming candidacy for
surgery, and evaluating outcomes of surgery.
Botulinum toxin A (Botox, Allergan, Irvine, California) blocks the
release of acetylcholine at the neuromuscular junction; a deadly neu-
rotoxin produced by Clostridium botulinum, its clinical utility for in
MH has only been recently discovered.30,31. Clostridium botulinum
actually produces seven subtypes of the neurotoxin-labeled A, B, C, D,
E, F, and G, each of which has its own cellular substrate and target
cleavage site.
Fig. 22.1 Example of corrugator supercilii hypertrophy.
A
B
C
Fig. 22.2 CT fi ndings in MH with intranasal triggers. Note the left-ward septal deviation and bony spur in A and B. Panel C demonstrates
septal deviation and a bony spur coming into contact with the middle turbinate on the left. Contact points such as this can act as triggers in
MH.
Table 22.2 The constellation of symptoms that aid in the
diagnosis of migraine headache trigger sites
Frontal headache
Occipital headache
Frontal pain
Upper neck/occipital pain
Late afternoon
Stress
Stress
Heavy-exercise related
Strong frowning muscles
Muscle tightness
Eyebrow/eyelid ptosis
Trigger point tenderness
Tenderness
Response to Botox
Temporal headache
Rhinogenic headaches
Temporal pain
Pain behind the eyes
Morning
Early am
Stress
Weather-related
Clenching/grinding
Allergy-related
Trigger point tenderness
Hormone-related
TMJ pain
Rhinorrhea
Cyclic

22
SURGICAL MANAGEMENT OF MIGRAINE HEADACHES
316
It was fi rst introduced over three decades ago as a treatment for
strabismus,32–35 and since has been used in many neuromuscular con-
ditions, including oromandibular dystonia, laryngeal dystonia, cervical
dystonia, writer’s cramp, and hemifacial spasm.35
At the time of this writing, the use of botulinum toxin A for
clinical treatment of migraines is investigational and still controver-
sial.36–38 We use botulinum toxin A to confi rm suspected trigger sites.
The trigger points are injected systematically, starting with the
most common and severe trigger site based on the patient’s reported
symptoms and physical examination. This is most often the corruga-
tor supercilii muscle. First, 12.5 U of botulinum toxin A are injected
with a long 30-gauge needle into the glabellar muscle sites. Trigger
sites are injected 1 month apart, up to a maximum of 3. Patients then
keep a headache diary, and refrain from taking prophylactic migraine
medication. Those patients with trigger sites that respond, either com-
pletely or partially (defi ned as a 50% reduction of headache intensity
or frequency from baseline for 4 weeks), to botulinum toxin A are
considered for surgical intervention2 (Fig. 22.3). Nerve blocks could be
used similarly.
The primary complication of botulinum toxin A injected into the
temporal area is atrophy of the temporal muscles.39 This disuse atrophy
is temporary, and patients should be counseled appropriately. Eyelid
ptosis is the second most common complication. Some patients
have developed antibodies to botulinum toxin A, rendering it relatively
ineffective. This has been estimated to occur in over 7% of treated
patients.35,40 The use of non-A botulinum toxins for patients resistant
to type A is currently being investigated.35 It should be noted that
while the lethal dose is estimated to be very high in humans (the
LD50 parenteral dose is 3000 U), the maximum recommended dose
is 300–400 U per 3-month period, which minimizes the risk of
resistance.35
Frontal triggers
Frontal triggers include any of the glabellar muscles: corrugator super-
cilii, depressor supercilii, and procerus. The goal of surgery is to prevent
further muscular irritation of the supraorbital and supratrochlear
nerves, and complete resection is necessary for a favorable outcome.41
The approach can be either transpalpebral42,43 or endoscopic. The
endoscopic approach can be valuable because a corrugator resection,
temporal release, and ZMTBTN resection can all be performed through
this approach.
A & C & ST
A & ST
SD & ET
SD & ET
Inject site C
Inject site C
B
Elimination
No change
Improvement
A & C
Elimination
No change
Improvement
C & ST
ST
SD & ET
SD & ET
C
Elimination
No change
Improvement
B & C & ST
B & ST
SD & ET
SD & ET
B & C
Elimination
No change
Improvement
A & B & C & ST
A & B & ST
SD & ET
SD & ET
A & B & C
Elimination
No change
Improvement
Inject site C
Inject site C
A & B
Elimination
No change
Improvement
Inject site B
Inject site B
A
Elimination
No change
A = Most common trigger site
B = Next most common trigger site
C = 3rd most common trigger site
SD = Septal deviation
ET = Enlarged turbinates
S&T = Septum & Turbinates
= Identified trigger site(s)
Improvement
Inject site A
Diagnosis of MH using botulinum toxin
Fig. 22.3 Algorithm for diagnosis of MH using botulinum toxin. Trigger sites are injected with 12.5 U of botulinum toxin with a 1 inch long
30-gauge needle. Improvement is operationally defi ned as a 50% reduction of headache intensity or frequency from the baseline for 4 weeks.
(Redrawn from Guyuron B, Kriegler JS, Davis J, et al. Comprehensive Surgical Treatment of Migraine Headaches. Plast Reconstr Surg
115(1):1-9, 2005.)

317
Operative Approach for Migraine Headaches
Transpalpebral approach
Potential pitfall: Irregular resection of the corrugator supercilii
muscle can cause contour deformities and recurrence of MH; fat
grafting the corrugator site minimizes this risk.
Under intravenous sedation, the patient is prepped and draped. The
upper tarsal crease is marked on each eyelid, with an incision length
of approximately 1 inch. Local anesthesia (0.5% lidocaine with
1 : 100 000 epinephrine) is infi ltrated into the eyelid. A skin incision
is made with a 10c blade, and is extended through the orbicularis
muscle. The plane between the orbicularis muscle and the septum is
identifi ed, and dissection continues cephalad, in that plane, with baby
Metzenbaum scissors. The depressor supercilii muscle comes into
view fi rst. The muscle is lighter in color than the corrugator supercilii
and it is less friable. The muscle is then removed as thoroughly as
possible. The corrugator supercilii muscle is identifi ed by its position
over the supraorbital rim, as well as its darker color compared with
the orbicularis oculi and depressor supercilii muscles. The corrugator
muscle is undermined. A small communicating vein is often seen
between the suprorbital and supratrochlear vessels. The corrugator
supercilii muscle is removed in a lateral and medial fashion, using
electrocautery, while the supraorbital and supratrochlear nerves are
preserved. Then, attention is turned to the medial aspect of the upper
eyelid. Fat is harvested from the medial compartment and grafted to
the site of resected muscle. The fat graft serves three purposes: it
minimizes contour deformity resulting from muscle resection, it pro-
tects the exposed nerve branches, and it also minimizes the current
function. The graft is sutured with 6–0 polygalactin (Vicryl), and the
skin incision is sutured with 6–0 plain catgut.1,43
Postoperatively, the patient is allowed to resume light activities on
day one, regular activities on day seven, and heavy activity after 3
weeks.
It should be noted that this procedure is very similar to aesthetic
rejuvenation of the forehead, as described in Chapter 109 (Forehead
rejuvenation).
Complications of this approach
The most common complication of this approach is paresthesias of
the forehead and frontoparietal scalp. These paresthesias nearly always
resolve if the nerves have been preserved. There is a risk of asymmetry
as well, if the muscle is not removed thoroughly and evenly on both
sides.
Endoscopic approach
After proper preparation of the face under sedation, the incision sites
are marked. There are fi ve total incisions: one midline incision and
two on either temple, all placed within the hair-bearing skin. Xylocaine
containing 1 : 100 000 epinephrine is injected in the non-hair-bearing
skin and xylocaine containing 1 : 200 000 epinephrine is injected in the
hair-bearing skin. The dissection is performed in the subperiosteal
plane to the supraorbital rim and lateral orbital rim, and zygomatic
and malar arches. The procedure for the ZMTBTN is described below,
and requires exposure of the zygomatic and malar arches. For corruga-
tor resection, attention is concentrated in the glabellar area. The
supraorbital nerves and corrugator muscle are exposed, and the peri-
osteum is then released laterally leaving the central portion intact over
the mid-glabellar area to prevent too much resection in the medial
eyebrows. The corrugator muscle is removed, and fat harvested from
the temporal region is grafted to the corrugator site. Fascial sutures of
3–0 polydioxanone are placed laterally for resuspension. A suction
drain is placed in the incision and is fi xed with 5–0 plain catgut.
Incisions are repaired with 5–0 polygalactin (Vicryl) and 5–0 plain
catgut1 (Fig. 22.4) (see Chapter 7, Forehead rejuvenation).
Complications
Alopecia can occur at port sites. Temporal or scalp paresthesias or
anesthesia can result from this approach, as well as inadequate resec-
tion of muscle. Eyebrow elevation can be affected (resulting in either
too much or too little elevation uni- or bi-laterally), and dimpling can
occur on animation.44 The temporal branch of the facial nerve is vul-
nerable to injury during the dissection, which can result in frontalis
paralysis. These complications are rare.
Temporal triggers
The endoscopic approach is useful because it provides access to
both the temporal trigger site and the frontal trigger sites, which
are commonly active in the same patient.
Temporal headaches are triggered primarily by contraction the tempo-
ral muscle around the ZMTBTN.
After appropriate preparation of the head and face, fi ve 1.5 cm
incisions are marked – one midline incision, and two on either temple,
7 cm and 10 cm from the midline. The forehead, temple, and malar
regions are then injected with 1% lidocaine with 1 : 100 000 epineph-
rine; the scalp is injected with 0.5% lidocaine with 1 : 200 000 epineph-
rine. After the incisions are made with a 15 scalpel, they are deepened
with spreading effects of baby Metzenbaum scissors to the deep tem-
poral fascia. The dissection continues using a periosteal elevator until
the endoscopic access device (EAD) (Applied Medical Technology,
Cleveland, Ohio) is inserted to allow for the endoscope to be intro-
duced. The periosteal elevator then raises periosteum posteriorly and
A
B
Fig. 22.4 Endoscopic view of the ZMTBTN.
The dissection is performed using a
periosteal elevator (A). The nerve can be seen
superfi cial to the deep temporal fascia just
under the grasping forceps (B).

22
SURGICAL MANAGEMENT OF MIGRAINE HEADACHES
318
cephalically. Once dissection is completed for the right side, the same
is done on the left side. A subperiosteal dissection is then carried under
endoscopic visualization to the supraorbital rim, lateral orbital rim,
zygomatic, and malar arches. The dissection is continued immediately
superfi cial to the deep temporal fascia and the ZMTBTN is exposed.
Grasping forceps are used to hold it while it is avulsed. It is important
that as much length of the nerve as possible is transected to prevent
re-coaptation, and we usually remove approximately 3 cm. Any bleed-
ing vessels are coagulated and the proximal nerve end is allowed to
retract into temporalis muscle to reduce the risk of neuroma forma-
tion. The periosteum and arcus marginalis are released in the lateral
orbital and supraorbital regions for transposing and fi xing the soft
tissues.1 The endoscopic devices are removed, and a single hook is
placed on either side of the caudal portion of the incision. A 3–0 PDS
suture is used to fi x the superfi cial and intermediate temporal fascia
to the deep temporal fascia laterally. A #10 TLS drain is placed, and
the skin incisions are repaired with 5–0 poliglecaprone 25 (Monocryl)
and 5–0 plain catgut interrupted stitches.
The drain is removed on postoperative day two and the patient is
allowed to return to light activities the next day, to regular activities
within 7 days, and to heavy activities within 3 weeks.
Complications
Paresthesia and anesthesia are the most common adverse conse-
quences of the surgery. Fortunately, both of these are temporary.
Alopecia around the incisions can occur, which often is temporary.
Patchy alopecia, perhaps related to the injection of epinephrine-
containing local anesthetic is a possibility. This type of alopecia is also
often temporary. Injury to the temporal branch of the facial nerve may
cause paralysis of the frontalis muscle. This complication is commonly
short-lasting as well.
Occipital triggers
A 4-cm midline incision is designed in hair-bearing caudal occipital
region while the patient is seated. After induction of anesthesia, the
patient is placed in the prone position with the shoulders raised by a
gel roll and the neck fl exed. The area around the incision is shaved to
approximately 2 cm width. The incision site is then infi ltrated with
1% lidocaine with 1 : 100 000 epinephrine. The skin incision is made
with a 10 scalpel and hemostasis is achieved with coagulation cautery.
The incision is taken to the midline raphe, and the trapezius fascia
is incised about 0.5 cm to the right of midline. The semispinalis
capitus muscle fi bers are identifi ed by their vertical orientation and
their location directly underneath the fascia; the trapezius muscle,
which rarely reaches the midline, has obliquely oriented fi bers, and if
encountered it is divided and retracted laterally. The semispinalis
muscle is then further exposed using retraction, and dissection con-
tinues under the trapezius fascia and muscle laterally. The trunk of
the greater occipital nerve is located approximately 1.5 cm from the
midline and 3 cm caudal to the occipital protuberance (Point A).
Munion clamps are used to isolate the nerve. A full-thickness, 1 inch
length of muscle is dissected medially to the nerve, and is transected
superiorly and inferiorly using cautery at the coagulation mode. The
muscle resection is considered complete when no muscle fi bers remain
medial to the nerve.
A small portion of the trapezius fascia and muscle immediately
overlying the nerve are then removed. The nerve is then isolated with
a vessel loop and traced back, ensuring no fascial bands remain. Occa-
sionally, the nerve bifurcates. In this case, it is necessary to remove
muscle fi bers between the two branches.
A 2 × 2-cm subcutaneously fl ap based caudally is elevated and passed
under the nerve and is sutured to the midline raphe. A drain is placed,
and the wound is closed with 5–0 polygalactin (Vicryl) and 5–0 plain
catgut. This procedure is then repeated on the other side (Fig. 22.5).
The drain is removed in 2 days. The patient is allowed to return
to light activity the next day, to routine activity within 1 week, and to
heavy activity within 3 weeks.
Septonasal triggers
Septonasal triggers must be considered when injection of botulinum
toxin A in other trigger sites results in no change, improvement
without resolution, or when the pain is mostly behind the eyes and
commonly triggered by weather changes.
The face is prepped and draped after the induction of general anes-
thesia. The nose is packed with cocaine-soaked gauze and is infi ltrated
with 0.5% lidocaine with 1 : 200 000 epinephrine initially and 0.5%
lidocaine containing 1 : 100 000 epinephrine after a few minutes. An
L-shaped incision is made on the left side of the septum, and the
mucoperiosteum is elevated. The opposite mucoperiosteum is accessed
through an incision in the cartilage and is elevated. The deviated
portion of the cartilaginous septum and bone is removed, and a straight
piece is replaced. It is crucial to remove any existing spurs and elimi-
nate any contact points between the turbinates and the septum. The
mucoperiosteal fl aps are sutured back into place with 5–0 chromic
running quilting sutures. Doyle splints are placed and fi xated with
5–0 prolene sutures.
The Doyle stents are removed in 2 weeks. The patient may resume
light activities on postoperative day one and heavy activities on post-
operative day seven.
In some cases, the inferior turbinates are enlarged and require
resection. The inferior turbinates are infi ltrated with 0.5% lidocaine
containing 1 : 200 000 epinephrine, and 0.5% lidocaine containing
1 : 100 000 epinephrine after a few minutes. Turbinate scissors are
used to resect the inferior turbinates conservatively. A partial infrac-
ture is performed and the area is cauterized. A patient who has
concha bullosa or signifi cant enlargement of the middle turbinates will
require partial or complete resection of the middle turbinates. Using
the sharp end of the septal elevator, the mucosa overlying the turbinate
is incised and is peeled off over the medial half of the turbinate. The
medial wall of the concha bullosa is resected and Doyle stents are
inserted.
Complications
Temporary dryness of the nose occurs in 12% of our patients.
Synechiae and sinus infection are rare.
OPERATIVE APPROACH FOR
CLUSTER HEADACHES
Early surgery for cluster headaches consisted of partial or complete
transection of the trigeminal nerve.45 This turned out to be a procedure
with many complications, including dysesthesias, corneal numbness,
and masseter weakness. Simply transecting the ZMTBTN is a safer
alternative.
We prefer the endoscopic approach, as described above, and have
had a good deal of success, specifi cally when the septum and turbinate
surgery was included.
CONCLUSION
The decision-making and treatment algorithm is shown in Figure 22.2.
A patient who presents for surgical treatment for headaches should
have a thorough headache evaluation. Once the headaches are identi-
fi ed as either MH or cluster headaches, careful documentation of
current and past medications is made. For MH, trigger sites are then
identifi ed by systematically injecting 12.5 U of botulinum toxin A in
frontal, temporal, and occipital trigger sites. For frontal trigger sites,
corrugator resection is performed. For temporal trigger sites, the zygo-
maticotemporal branch of the trigeminal nerve is resected. For occipi-
tal trigger sites, we resect the semispinalis capitus muscle medial to
the greater occipital nerve. Septal and turbinate surgery is performed
for patients who have evidence of septal deviation and enlarged turbi-
nates, and whose clinical profi le suggests septal and turbinate triggers.

Conclusion
319
A
B
C
D
Fig. 22.5 Surgical technique for release of the occipital nerve for occipital migraines. The 4-cm incision is designed in the caudal occipital
region (A). The incision is taken to the midline raphe (B) and the trapezius fascia is incised slightly away from the midline (C); the
semispinalis muscle fi bers can be identifi ed by their vertical orientation. Dissection continues subfascially and superfi cial to the muscle, and
the trunk of the occipital nerve will be seen approximately 1.5 cm lateral to the midline and 3 cm caudal to the occipital protuberance (D).

22
SURGICAL MANAGEMENT OF MIGRAINE HEADACHES
320
E
F
G
H
Fig. 22.5, cont’d A 1 inch length of muscle is dissected medial to the nerve, and transected (E–G).

Conclusion
321
I
J
K
L
Fig. 22.5, cont’d A fl ap is designed to be placed under the nerve (H–L). This protects the nerve.

22
SURGICAL MANAGEMENT OF MIGRAINE HEADACHES
322
M
N
O
Fig. 22.5, cont’d The fl ap is sutured to the midline raphe (M), and a
drain is placed (N). The incision is closed in layers while attaching
the subcutaneous fl ap to the midline raphe (O).

References
323
For patients with cluster headaches, partial or complete transection of
the trigeminal nerve can be performed.
REFERENCES
1. Guyuron B, Tucker T, Davis J. Surgical treatment of migraine
headaches. Plast Reconstr Surg 2002; 109(7):2183–2189.
2. Guyuron B, Kriegler JS, Davis J, Amini SB. Comprehensive surgical
treatment of migraine headaches. Plast Reconstr Surg 2005;
115(1):1–9.
3. Henry P, Auray JP, Gaudin AF et al. Prevalence and clinical
characteristics of migraine in France. Neurology 2002; 59(2):232–237.
4. Patel NV, Bigal ME, Kolodner KB, Leotta C, Lafata JE, Lipton RB.
Prevalence and impact of migraine and probable migraine in a health
plan. Neurology 2004; 63(8):1432–1438.
5. Adeney KL, Flores JL, Perez JC, Sanchez SE, Williams MA. Prevalence
and correlates of migraine among women attending a prenatal care
clinic in Lima, Peru. Cephalalgia 2006; 26(9):1089–1096.
6. Mattsson P, Svardsudd K, Lundberg PO, Westerberg CE. The prevalence
of migraine in women aged 40–74 years: a population-based study.
Cephalalgia 2000; 20(10):893–899.
7. Leonardi M, Mathers C. Summary of methods and data sources, global
burden of disease. Geneva: World Health Organization; 2000.
8. Leonardi M, Steiner TJ, Scher AT, Lipton RB. The global burden of
migraine: measuring disability in headache disorders with WHO’s
Classifi cation of Functioning, Disability and Health (ICF). J Headache
Pain 2005; 6(6):429–440.
9. WHO. Reducing risks, promoting healthy life. Geneva: World Health
Organization; 2002.
10. Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of
migraine in the United States: disability and economic costs. Arch
Intern Med 1999; 159(8):813–818.
11. Lim C. Headache, migraine. In: Ferri F (ed.) Ferri’s clinical advisor
2007: instant diagnosis and treatment. 9th edn. Philadelphia: Mosby
Elsevier; 2007.
12. International Headache Society. The International Classifi cation of
Headache Disorders. 2nd edn. Cephalalgia 2004; 24(Suppl 1):9–160.
13. Lim C. Headache, cluster. In: Ferri F (ed.) Ferri’s clinical advisor 2007:
instant diagnosis and treatment. 9th ed. Philadelphia: Mosby Elsevier;
2007.
14. Burstein R, Cutrer MF, Yarnitsky D. The development of cutaneous
allodynia during a migraine attack clinical evidence for the sequential
recruitment of spinal and supraspinal nociceptive neurons in migraine.
Brain 2000; 123(Pt 8):1703–1709.
15. Welch KM. Contemporary concepts of migraine pathogenesis. Neurology
2003; 61(8 Suppl 4):S2–S8.
16. Goetz C. Textbook of clinical neurology. 3rd edn. Philadelphia:
Saunders; 2007.
17. Moskowitz MA. The neurobiology of vascular head pain. Ann Neurol
1984; 16(2):157–168.
18. Novak VJ, Makek M. Pathogenesis and surgical treatment of migraine
and neurovascular headaches with rhinogenic trigger. Head Neck 1992;
14(6):467–472.
19. Feindel W, Penfi eld W, Mc NF. The tentorial nerves and localization of
intracranial pain in man. Neurology 1960; 10:555–563.
20. Mosser SW, Guyuron B, Janis JE, Rohrich RJ. The anatomy of the
greater occipital nerve: implications for the etiology of migraine headaches.
Plast Reconstr Surg 2004; 113(2):693–697; discussion 698–700.
21. Dash KS, Janis JE, Guyuron B. The lesser and third occipital nerves and
migraine headaches. Plast Reconstr Surg 2005; 115(6):1752–1758;
discussion 1759–1760.
22. Benzon HT, Katz JA, Benzon HA, Iqbal MS. Piriformis syndrome:
anatomic considerations, a new injection technique, and a review of the
literature. Anesthesiology 2003; 98(6):1442–1448.
23. Kuncewicz E, Gajewska E, Sobieska M, Samborski W. Piriformis muscle
syndrome. Ann Acad Med Stetin 2006; 52(3):99–101; discussion 101.
24. Leone M, Proietti Cecchini A, Mea E et al. Functional neuroimaging
and headache pathophysiology: new fi ndings and new prospects. Neurol
Sci 2007; 28(Suppl 2):S108–S113.
25. Dandy WE. Treatment of hemicrania (migraine) by removal of the
inferior cervical and fi rst thoracic sympathetic ganglion. Johns Hopkins
University Bulletin 1931; 48:357–361.
26. Gardner WJ, Stowell A, Dutlinger R. Resection of the greater superfi cial
petrosal nerve in the treatment of unilateral headache. J Neurol 1947;
4:105–114.
27. Murillo CA. Resection of the temporal neurovascular bundle for control
of migraine headache. Headache 1968; 8(3):112–117.
28. Murphy JP. Occipital neurectomy in the treatment of headache. Results
in 30 cases. Md State Med J 1969; 18(6):62–66.
29. Guyuron B, Tucker T, Kriegler J. Botulinum toxin A and migraine surgery.
Plast Reconstr Surg 2003; 112(5 Suppl):171S–173S; discussion 174S–176S.
30. Evers S. Status on the use of botulinum toxin for headache disorders.
Curr Opin Neurol 2006; 19(3):310–315.
31. Argoff CE. The use of botulinum toxins for chronic pain and headaches.
Curr Treat Options Neurol 2003; 5(6):483–492.
32. Scott AB, Rosenbaum A, Collins CC. Pharmacologic weakening of
extraocular muscles. Invest Ophthalmol 1973; 12(12):924–927.
33. Scott AB. Botulinum toxin injection into extraocular muscles as an
alternative to strabismus surgery. J Pediatr Ophthalmol Strabismus
1980; 17(1):21–25.
34. Scott AB. Botulinum toxin injection of eye muscles to correct
strabismus. Trans Am Ophthalmol Soc 1981; 79:734–770.
35. Brin MF. Botulinum toxin: chemistry, pharmacology, toxicity, and
immunology. Muscle Nerve Suppl 1997; 6:S146–S168.
36. Smuts JA, Schultz D, Barnard A. Mechanism of action of botulinum
toxin type A in migraine prevention: a pilot study. Headache 2004;
44(8):801–805.
37. Welch KM. Botulinum toxin type A for the treatment of headache: con.
Headache 2004; 44(8):831–833.
38. Blumenfeld A. Botulinum toxin type A for the treatment of headache:
pro. Headache 2004; 44(8):825–830.
39. Guyuron B, Rose K, Kriegler JS, Tucker T. Hourglass deformity after
botulinum toxin type A injection. Headache 2004; 44(3):262–264.
40. Greene P, Fahn S, Diamond B. Development of resistance to botulinum
toxin type A in patients with torticollis. Mov Disord 1994; 9(2):213–217.
41. Guyuron B, Varghai A, Michelow BJ, Thomas T, Davis J. Corrugator
supercilii muscle resection and migraine headaches. Plast Reconstr Surg
2000; 106(2):429–434; discussion 435–437.
42. Guyuron B, Michelow BJ, Thomas T. Corrugator supercilii muscle
resection through blepharoplasty incision. Plast Reconstr Surg 1995;
95(4):691–696.
43. Guyuron B, Knize DM. Corrugator supercilii resection through
blepharoplasty incision. Plast Reconstr Surg 2001; 107(2):604–607.
44. Guyuron B. Endoscopic forehead rejuvenation: limitations, fl aws, and
rewards [reply]. Plast Reconstr Surg 2007; 119:1116–1119.
45. Maxwell RE. Surgical control of chronic migrainous neuralgia by
trigeminal ganglio-rhizolysis. J Neurosurg 1982; 57(4):459–466.

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325
A
Abdominal perforation, liposculpture, 264
Abdominal wall
laxity, 270, 270
layers, 271, 271
musculature, 270, 270–1
sensory innervation, 271
vascular zones, 271, 271
Abdominoplasty, 267–83, 280–3
complications, 277–9
contour irregularity, 278–9
counselling, 270
deep vein thrombosis/pulmonary embolus, 279
hematoma, 277
high lateral tension, 268, 269, 276
indications, 267–9
infection, 277
lipo-, 268, 269, 276–7
markings, 272
mini-, 268, 269, 275–6, 276
operative approach, 270–7
operative techniques, 272–5, 273–5
paresthesia, 279
physical examination, 269–70, 270
postoperative care, 279
preoperative considerations, 269–70
preoperative photographs, 270
previous abdominal scars, 268–9
relevant anatomy, 270–2, 270–2
scarring, 279
seroma, 277–8
tissue necrosis, 278
types of, 278
umbilical deformity, 279
variations for the weight-loss patient, 286, 287–90
wound dehiscence, 277
Acellular dermal matrix (ADM) see Alloderm
Adipose tissue
considerations in liposculpture, 259
preparation in liposculpture, 260
Aesthetic surgery see specifi c procedure
Age
effects on neck, 131–2
soft tissue loss, 21–2
Aging
face, 213–14, 214
Airway
rhinoplasty, 164, 167–8
Allergies to facial fi llers, 30–1
Alloderm, 257
Alloplastic material
facial skeletal augmentation, 204
Alopecia
after coronal forehead lift, 77
after endoscopic forehead rejuvenation, 76
classifi cation, 51
female, 50
male androgenic, 50
management see Hair transplantation
Anagen hair growth phase, 51, 52
Androgenic alopecia, 50
Anesthesia
facial fi llers, 27–8
facial skeletal augmentation, 200
hair transplantation, 58–60, 60
laser resurfacing, 45
liposculpture, 260
Anthropometrics
facial, 200, 203
Antibiotics
breast augmentation, 230
breast reduction, 241
laser resurfacing, 45
Antihelix
aesthetics, 7
Appendectomy scar, 268
Aquamid, 27
Arcus marginalis, 73, 74
Artecoll, 27
ArteFill, 27
Avobenzone, 17, 18
Axillary approach, breast augmentation, 227–8
B
Bell’s phenomenon, 6, 6, 87, 87
Blepharochalasis, 85, 86
Blepharodermachalasia, 4
Blepharoplasty
asymmetry, 101
blindness, 100
cosmetic, 5, 5
laser, 46–7
lower
skin/muscle, 93–6, 93–6
using skin-fl ap technique, 97, 98
transconjunctival lower, 96–7, 96–8
upper lid, 90–3, 90–3
Blepharoptosis, 86
Blindness
after fat injection, 69
blepharoplasty, 100
periorbital rejuvenation, 85
Blinking, 87, 90
Body dysmorphic disorder (BDD), 1–2, 2, 168
Body mass index (BMI)
abdominoplasty, 269
bodylifts, 286
Bodylifts, 285–312
brachioplasty, 297–303, 303–5
complications, 309–12
contraindications, 286
gynecomastia correction, 309, 310
lower-body lift, 288–92, 293–8
mastopexy including upper-body lift, 303–7,
306–9
monsplasty, 287–8, 290–2
multiple procedures and staging, 311, 312
patient evaluation, 285–6
surgical technique, 286–309
variations of abdominoplasty, 286–90
vertical thigh lift, 292–6, 299–302
Bone
resorption, genioplasty, 195
Bony nasal vault, 146, 146
Bottoming out, breast reduction, 247
Botulinum toxin A, 35–42
brow elevation, 37–8, 39
complications, 36, 42
contraindications, 36
crow’s feet, 37, 38
dosage, 36
forehead, 37
functional anatomy, 36
glabella, 36–7
hyperhidrosis, 36
indications, 35–6, 67
lower eyelid, 37
lower face, 40, 41
migraine, 315–16, 316
nasolabial fold, 39–40, 40
neck, 39, 40
postoperative care, 42
preoperative history and considerations, 36
Bouquet deformity, 65
Brachioplasty, 297–303, 303–5
Breast asymmetry
after breast augmentation, 229
after breast reduction, 246–7
Breast augmentation, 219–32
complications and side effects, 229–30,
229–32
implant insertion, 228
incision closure, 228, 228
incisional approach, 225–8, 227
indications and contraindications, 219–20
operative technique, 222–9
patient and implant selection, 220–2, 220–3
postoperative care, 230–1
preoperative history, 221–2
preoperative markings, 224–5, 224–5
psychological considerations, 221–2
relevant surgical anatomy, 222–4
saline implants see Saline breast implants
silicone implants see Silicone, breast implants
sub-muscular versus sub-glandular implant
placement, 225, 226
transareolar/periareolar approach, 228
Breast implants
dimensions, 221
insertion, 228
malposition, 229
rupture, 230, 231
saline see Saline breast implants
selection, 220, 220–1
silicone see Silicone, breast implants
tilt test, 220, 220
visibility, 229
see also Breast augmentation
Breast ptosis, 249
minor, 250, 255
moderate, 250, 253, 255, 256
recurrent, 256
Regnault classifi cation of, 249, 250
severe, 250–1, 253, 256, 257
see also Mastopexy
Index
Note: Page numbers in bold refer to fi gures and tables.

INDEX
326
Breast reduction, 233–47
asymmetry, 246–7
bottoming out, 247
central pedicle, 234–5
choice of operation, 237–8
complications and side effects, 245–7, 245–7
free nipple grafts, 235
hematoma, 246, 247
history of development of different techniques,
233
indications, 237–8
infection, 245–6, 245–6
inferior pedicle, 234, 234
inverted T, inferior pedicle, 234, 234, 237, 238,
243, 243–5, 244
operative approach, 243–4
operative technique, 244
postoperative care, 244
preoperative markings, 243, 243–4
lateral pedicle, 235
liposuction-only, 237
medial pedicle vertical, 234, 235, 238–43, 242
operative approach, 238–41
operative technique, 240–1
postoperative care, 241–3
preoperative markings, 238–40, 239–40
nipple-areola necrosis, 246, 246
periareolar technique, 237
preoperative considerations, 238
principles behind techniques, 233–5, 234, 236
pseudoptosis, 247
puckers, 247
seroma, 246
skin fl ap necrosis, 246
superior pedicle, 235
unanswered questions, 235–7
under-resection, 247
vertical approach, 237
wound healing, 245–6
Breast(s)
anatomy, 222–4
blood supply, 233–5
lift see Mastopexy
Burr reduction genioplasty, 186–7, 189
C
Calcium hydroxylapatite (CaHA), 26, 26
Canthopexy, 94
Capsular contracture
breast augmentation, 230
genioplasty, 195–6
Carbon dioxide (CO2) laser, 44
Carbon dioxide slush peel, 15
Carotenoid pigments, 17
Carotid arteries, 89
Cartilage grafts
conchal, 172
costal see Costal cartilage graft
Catagen hair growth phase, 51, 52
Caudal dorsum adjustment, 172–3, 173
Cephalic trim, 153, 153
Cervical obliquity, 131
Cervicosubmental lipectomy, 134
Cheek
augmentation with fat, 213, 214
Chemical peeling 11–19
complications and side effects, 15–16
contraindications, 11
deep, 12, 15
indications, 11–13
medium-depth, 12, 13, 15, 15
operative approach, 13–15, 14, 15
optimizing outcomes, 15
postoperative care, 16, 16–19, 18
preoperative history and considerations, 13
superfi cial, 12, 13, 13–14, 14
technique comparisons, 13
Chemosis, blepharoplasty, 101
Chin
aesthetics, 8, 8
anatomy, 179, 181
asymmetries, 182, 184, 188, 191–2
augmentation with fat, 214
deformity classifi cation, 182, 182–5, 183–8
facial proportions, 179
harmony, 180–2
muscles, 181
sensory nerves, 179, 181
symmetry, 182
see also Genioplasty; Macrogenia; Microgenia
Cholecystectomy scar, 268
Cleansers, skin, 16, 16
Cluster headaches, 213–14, 322
Coleman technique of fat grafting, 216
Columella
correction of protruding, 173
hanging, 169–70, 170
Columellar strut, 156, 156–7, 157, 173, 175
Combar, 16, 16
Compact horny layer, 17
Composite facelift, 106, 107
Compression
vertical thigh lift, 295
Computed tomography (CT)
facial skeletal augmentation, 199–200
Computerized pattern generator (CPG), 44
Conchal cartilage grafts, 172
Conjunctivitis, 46
Cooper’s ligaments, 249
Corneocytes, 11
Coronal forehead lift, 76–7, 77, 82
Corrugator muscle, 68
Corrugator supercilii muscle, 70
hypertrophy, 314, 315
Cortical spreading depression, 314
Costal cartilage graft
harvesting, 172
Counselling
abdominoplasty, 270
rhinoplasty, 144
Craniofacial skeleton, aesthetic contouring,
199–211
alloplastic implants, 200, 204
anesthesia, 200
complications, 210
facial anthropometries, 200, 203
incisions, 200
indications, 199
mandible implants, 207–10, 210–11
midface implants, 204–7, 209
infraorbital rim, 205, 206, 207
malar, 206–7, 209
pyriform aperture, 205–6, 208
mimicking facial osteotomies, 201–2
neoclassical canons, 200
physical examination, 199
preoperative evaluation, 199–200
radiology, 199–200
requisites of implant shape, positioning
and immobilization, 204, 205
surgical planning, 200
Crow’s feet, 37, 38
D
DDAVP (desmopressin), 100
Deep plane facelift, 106, 107
Deep venous thrombosis (DVT), 268, 279
Dental roots
exposure, genioplasty, 191
Depressor anguli oris, 41
Depressor septi nasi, 145, 145, 163, 164
Depressor supercilii muscle, 68
Dermabrasion, 48
Dermatochalasis, 86
Dermis, 11
Desmopressin (DDAVP), 100
Diabetes mellitus
aesthetic surgery, 3
Digastric muscle
resection, 134
Dihydrotestosterone (DHT), 50
Dimethicone, 17
Diplopia, 100
Diver’s test, 270, 270
Dog ears
abdominoplasty, 278
breast reduction, 238
rhytidectomy, 126
Dorsal defi ciency, nose, 171, 171–2
Dorsal hump, nose, 171, 175
Double bubble deformity, 229–30
Drains
breast augmentation, 230
rhytidectomy, 125, 128
Dressings
breast augmentation, 230–1
Dyspigmentation, 13, 13
E
Ear(s)
aesthetics, 7
Ecchymosis, 100
Ectropion
laser resurfacing, 46
Edema
around the eyes, 5, 5
liposculpture, 265
Embolism
fat, 263–4
intravascular, 216–17
pulmonary, 263, 268, 279
EMLA cream, 28
Endoscopic facelift, 108, 108
Endoscopic forehead rejuvenation, 72–6, 76, 82
complications, 75–6
indications, 67
operative technique, 72–5, 73–5
postoperative care, 75
relevant surgical anatomy, 72
Epicranial layer, 68
Epidermal DNA excision repair, 17
Epidermis, 11
Erbium laser, 47
Estrogen
replacement therapy, 13
Exercise
after breast augmentation, 231
Exophthalmus, 5, 5
Extended SMAS facelift, 106, 107
External nasal valve, 148
Extrusion, genioplasty, 192
Eyebrow(s)
elevation, botulinum toxin A, 37–8, 39
elevation after coronal forehead lift, 77
ptosis, 3, 4, 4, 67, 68, 86
Eyelashes, 88
Eyelid(s)
aesthetics, 5–6, 6
anatomy, 88–90, 88–90
blepharoplasty see Blepharoplasty
blood supply, 89, 89
ectropion see Ectropion
excursion, 86–7
facial fi llers, 29–30
lower
augmentation with fat, 213–14
bags, 86, 86
botulinum toxin A, 37
laser resurfacing, 97
nerve supply, 88, 88, 89–90, 90
ptosis, 3, 68, 85, 86
retraction, 100
upper
fat compartments, 85
ptosis, 86
Eye(s)
aesthetics, 5–6, 6
dry, 86, 100–1
edema around, 5, 5
protection in laser resurfacing, 45
F
Face
aesthetics see Facial analysis
lower, botulinum toxin A, 40, 41

Index
327
mid see Midface
see also entries beginning Craniofacial; entries
beginning Facial
Facelift see Rhytidectomy
Facial analysis, 3–9
basilar view, 8–9
cervical region, 8, 8
internal nose examination, 9
lower zone
front view, 7–8
profi le view, 8, 8
middle zone
front view, 4–7, 5–7
profi le view, 7
overhead view, 9
rhinoplasty, 139–42
upper zone
front view, 3, 4
profi le view, 3–4, 4
Facial artery, 146, 146
Facial fi llers see Fillers, facial
Facial framing, 52–3
Facial lipoatrophy scale, 23, 24
Facial nerve, 70–1
damage during endoscopic forehead rejuvenation,
76
and SMAS-rhytidectomy, 131–2
see also Facial reanimation
Facial pigmentation, 13
Facial skeletal augmentation see Craniofacial
skeleton, aesthetic contouring
Facial structure augmentation with autologous
fat, 213–17
for change in facial proportion, 214, 214
complications, 216–17
contraindications, 215
for facial rejuvenation, 213–14, 214
harvesting, 216
indications and contraindications, 213
for lipoatrophy, 215, 215
placement, 216
postoperative care, 217
preoperative history and considerations, 215–16
for reconstruction, 214, 215
refi nement, 216
technique, 216
Fan technique, facial fi llers, 28, 29
Fat embolism, 263
Fat grafts, 69–70, 70
facial structures see Facial structure augmentation
with autologous fat
Fat injection, 68–9, 69
complications, 69
indications, 67
operative approach, 68–9
optimizing outcomes, 69
postoperative care, 69
relevant surgical anatomy, 68, 68
technique, 69
Female hair loss, 50
Fillers, facial, 21–32
anatomical considerations, 28
anesthesia, 28
asymmetry, 30, 31
clinical examples, 31–2
complications and side effects, 30–1
contraindications, 24
forehead, 67
glabellar lines, 28–9
indications, 22–4
injectable, 25–7, 25–7
lips, 30, 30
lower eyelids, 29–30
marionette lines, 28
nasolabial folds, 28
operative approach, 28–30, 29
paramental crease, 28
postoperative care, 32
preoperative history and consideration, 24
soft tissue loss
in the aging patient, 21, 22
in disease conditions, 21–2
Fitzpatrick skin types, 12
Flap necrosis
breast reduction, 246
Fleur-de-Lis abdominoplasty (FDL), 289
Food products having deleterious effects on surgery, 2
Footplates, nasal, 173
Forehead
aesthetics, 8–9
botulinum toxin A, 37
lift, coronal see Coronal forehead lift
wrinkles, 3, 4
Forehead elongation shortening, 67, 68, 80–2
complications, 81
operative technique, 80, 80–1, 81
postoperative care, 81
Forehead rejuvenation, 67–82
coronal forehead lift, 76–7, 77
endoscopic, 72–6, 73–6
fat graft, 69–70
fat injection, 68–9, 69
indications, 67
preoperative history and considerations, 68
rhytidectomy with pretrichial incision, 78, 78–80,
79
shortening of the elongated forehead, 80, 80–2, 81
summary of the armamentarium, 82
transpalpebral corrugated resection, 70–2, 70–2
Fractionated laser, 47–8
Frontal bossing, 3, 4
Frontal nerve, 89–90
Frontalis muscle
botulinum toxin A, 37
eyebrow and eyelid ptosis, 68
forehead lines, 68
in transpalpebral corrugator resection, 70
Frontotemporal recession, 49
Frown lines, 68
Frowning, 36–7
G
Galea aponeurotica, 68
Genioplasty, 179–96
anatomy, 179, 181–2
augmentation techniques, 179, 187–90, 192–5,
193
classifi cation of chin deformity, 182–4, 182–7
complications and side effects, 190–6, 194
indications and contraindications, 179–80
operative approach, 184–90, 189–93
osseous see Osseous genioplasty
osteotomy with caudal segment repositioning, 187
postoperative care, 196, 196
preoperative history and considerations, 180–2
using augmentation techniques, 192–6
Giant pannus, 286, 287
Glabella, 36–7
Glabellar lines, facial fi llers, 28–9
Glands of Moll, 90
Glands of Zeis, 90
Globe-orbital rim relationships, 205, 206
Glycolic acid chemical peel, 13, 13–14
Goblet cells, 90
Gynecomastia
correction, 309, 310
H
Hair
anatomy, 52, 55–6
follicles, 55, 55
growth, 51, 52
loss see Alopecia; Hair transplantation
type, 51
Hair transplantation, 49–66
before and after photos, 54–5
anesthesia, 58–60, 60
classifi cation of alopecia, 51, 53
female hair loss, 50
goals of, 51–3
hair type, 51, 54
importance of type of graft and natural hairline
design, 49
indications, 49–51
male androgenic alopecia, 50
operative approach, 55–62
patient selection, 50–1
preoperative history and considerations, 51–5
prevention of complications, 55
primary, case studies, 62–3, 63, 64
scalp excisions, 60–1, 61
secondary, case studies, 63–6, 65
special cases, 55
surgical anatomy, 55, 55–6
surgical technique, 56–8, 56–9
tissue expansion, 61, 62
unsatisfactory, 50
Hairline, 52–3, 54
Hamilton’s classifi cation of alopecia, 51
Helix
aesthetics, 7
Hematoma
abdominoplasty, 277
blepharoplasty, 100
breast augmentation, 229
breast reduction, 246, 247
endoscopic forehead rejuvenation, 76
facial fi llers, 30
genioplasty, 191
mastopexy, 254
neck rejuvenation, 136
retrobulbar, 100
Hemoglobin, 43
Hemorrhage
blepharoplasty, 100
retrobulbar, 100
rhinoplasty, 164
Herbal medications having deleterious effects
on surgery, 2
Hernias
bodylifts, 286
High lateral tension abdominoplasty (HLTA)
indications, 268, 269
technique, 276
High SMAS facelift, 104, 106–7, 107–8, 119, 121,
122, 124
HIV patients, loss of peripheral fat in, 22
Hormone supplementation, 13
Horner’s tensor tarsi muscle, 89
Humectants, 16–17
Hyaluronic acid
facial fi llers, 25, 25–6, 30, 30–1
Hydrocolloids, 16–17
Hydroquinone, 45
Hyoid bone malposition, 8, 8
Hyperhidrosis, 36
Hyperpigmentation
laser resurfacing, 46
Hypertelorism, 5
Hypertension
aesthetic surgery, 3
blepharoplasty, 100
Hypoglossal nerve
injury, 136
Hypotonic fl uids, 260
I
Implants
breast see Breast implants
chin see Genioplasty, augmentation techniques
facial see Craniofacial skeleton, aesthetic
contouring
Inclusion cysts, 46
Infection
abdominoplasty, 277
after endoscopic forehead rejuvenation, 76
breast augmentation, 229
breast reduction, 245, 245–6, 246
fat grafting, 217
genioplasty, 191, 195
laser resurfacing, 46
liposculpture, 265
rhinoplasty, 164
Inframammary fold (IMF), 250
Infraorbital rim implants, 205, 207
Infratrochlear nerve, 90

INDEX
328
Intense pulsed light (IPL), 44, 47
Intercellular lipids, 11, 12
Interdomal sutures, 155, 155, 156
Interictal cortical derangements, 314
Internal nasal valve, 147–8, 148
Intra-abdominal pressure, 268
Intranasal exam, 142–4
Intravascular embolization, 216–17
Inverted V-deformity, nose, 172, 172
Isolated frontal forelock, 55
Isotretinoin, 168
Itching after endoscopic forehead rejuvenation, 76
J
Jessner’s peel, 15
K
Keratinocyte melanin, 17
Keratoconjunctivitis sicca, 100–1
Keratopathy, exposure, 100–1
Krause’ glands, 90
L
Labiomental groove, 8, 181
Lacrimal secretory system, 90
Lagophthalmos, 86, 100
Lambert-Eaton syndrome, 36
Lamellar SMAS dissection and bidirectional facelift,
104, 106
Laser-assisted liposuction, 261
Laser blepharoplasty, 46–7
Laser resurfacing, 42–3, 43–8, 46
complications and sequelae, 46
future of, 48
indications and contraindications, 44–5
lower eyelid, 97
methods, 44
operative approach, 45
postoperative care, 45–6
preoperative considerations, 45
Lateral canthus, 88
Lateral crura strut, 173
Lemperle scale, 22–3, 23
Levator aponeurosis, 89
advancement operation, 97–8
Levator labii alaeque nasi, 145, 145
Levator muscle function, 86
Levator palpebrae muscle, 89
Lidocaine
toxicity, 264
Lip-chin relationship, 139, 140
Lipids, skin, 11, 12
Lipoabdominoplasty
indications, 268, 269
technique, 276–7
theoretical advantages of, 269
Lipoatrophy, fat grafting, 215, 215
Lipodystrophy, 21–2
Liposculpture, 259–66
anesthesia and preoperative preparation, 260
complications, 262–5
considerations about the adipose tissue, 259
indications, 259–60
limits, 265
materials used to perform liposuction, 260
preparation of the adipose tissue to be aspirated, 260
results, 261, 261–5
surgical techniques, 260–1
Liposuction
breast reduction, 237
techniques, 260–1
ultrasound assisted, 260, 261
see also Liposculpture
Lip(s)
aesthetics, 7–8
augmentation with fat, 214
cleft see Cleft lip
facial fi llers, 30, 30
incompetence, 7
lower, retraction in genioplasty, 192, 196
Lower-body lift, 288–92, 293–8
Lower cartilaginous nasal vault, 147, 147
Lower ventral curvature (LVC), 224, 224, 225
Ludwig’s classifi cation of alopecia, 51
M
Macrogenia, 182, 182–3, 184–5
combined horizontal and vertical, 185
horizontal, 180
vertical, 184
MACS (minimal access cranial suspension) lift, 104,
109–10
Malar bags, 86, 86
Malar bones
aesthetics, 9
augmentation, 206–7, 209
Malar grooves management, 97
Male androgenic alopecia, 50
Mandible
augmentation with fat, 214, 214
implants, 207–10, 210–11
Mandibulosacral dysplasia, 22
Margin refl ex distance (MRD), 86, 87
Marginal mandibular nerve, 135
Marionette lines, 28
Massive weight loss body contouring see Bodylifts
Mastopexy, 249–57
complications and side-effects, 254–6
implant selection and placement, 251–4, 253, 256
including upper-body lift, 303–7, 306–9
indication, 249
minor ptosis, 250, 255
moderate ptosis, 250, 253, 255
operative approach, 251–4
optimizing outcomes, 254
patient assessment, 250
patient marking, 250, 250–1, 251, 252
periareolar purse string, 254
postoperative care, 256
preoperative history and considerations, 249–51,
251
purse string, 252
Regnault approach, 250, 251
severe ptosis, 250–1, 253, 256, 257
see also Breast augmentation; Gynecomastia
Medial antebrachial cutaneous nerve (MABC),
303, 304
Medial canthal tendon, 89
Medial crural septal sutures, 155, 155
Medial crural sutures, 154, 154–5
Medications
having deleterious effects on surgery, 2
Meibomian glands, 90
Mental foramina, 586, 179, 181
Mental nerve, 179, 181
Mentalis, 41
Meradimate, 17–18, 18
Microgenia, 181, 182, 183, 195
combined horizontal and vertical, 186, 194
horizontal, 180, 185, 194
vertical, 186
Midface
implants, 204–7, 209
infraorbital rim, 205, 206, 207
malar, 206–7, 209
pyriform aperture, 205–6, 208
lift, 104, 108–9
Migraine, 313–23
diagnostic criteria, 314
frontal triggers, 316–17, 317
indications and contraindications, 313
occipital triggers, 318
operative approaches, 315–22
for cluster headaches, 318
pathophysiology, 314
preoperative history and considerations, 314
role of botulinum toxin A, 315–16, 316
septonasal triggers, 318
surgical treatment, 314
temporal triggers, 317–18, 319–22
trigger sites, 315, 315
Milia, laser resurfacing, 46
Mini-abdominoplasty
indications, 268, 269
technique, 275–6, 276
Mini-lift (face), 104, 110
Minimal access cranial suspension (MACS) lift, 104,
109–10
Moisturizers, skin, 16–17, 17
Mons pubis, 278–9, 287–8, 290–2
Monsplasty, 287–8, 290–2
Mouth see Oral cavity
Müller muscle-conjunctival resection, 98–9, 99–100
Müller’s muscle, 89
Muscle of Riolan, 89
Muscle(s)
chin, 181
nasal, 145–6
Myasthenia gravis, 36
N
Nasal alae
aesthetics, 7, 7
alar-columellar relationship, 142, 143, 144,
157–60, 159–60
assessment, 139, 140
base abnormalities, 174, 174–6
base surgery, 162–3, 164
correction of retracted rim, 174
fl aring, 162–3, 164
Nasal bones
asymmetry, 168–9, 169
osteotomy, 171
Nasal collapse, 172
Nasal dorsum, 139, 141, 143
Nasal fl aws, 167–8
Nasal tip
abnormalities, 169, 169
grafts, 157, 157, 158, 173, 174
modifi cation, 153–7, 154–8
projection, 141, 142, 157
refi nement, 173
rotation, 142, 143, 157
Nasal vaults, 146, 146–7, 147
Nasojugal groove
facial fi llers, 29–30
management, 97
Nasolabial angle, 333–4, 336, 169
Nasolabial folds, 808
botulinum toxin A, 39–40, 40
facial fi llers, 22–3, 23, 28
Neck
aesthetics, 8, 8
botulinum toxin A, 39, 40
Neck rejuvenation, 131–6
anatomy and effects of ageing, 131
complications and side-effects, 136
contraindications, 132
indications, 131–2
postoperative care, 136
preoperative history and considerations, 132
SMAS suspension and platysmal plication, 133,
133
submandibular gland suspension and resection,
134–5, 135, 135, 136
subplatysmal fat resection, 133–4, 134
Necrotizing fasciitis, 265
Neoclassical cannons, 200
Nerve transfers see Neurotization
Nerve(s)
scalp, 58, 60
Neurosensory loss, genioplasty, 191
Nipple
free grafts, 235
necrosis, 235, 246, 246
placement errors, 255
Nipple areola complex (NAC)
breast augmentation, 224, 224
necrosis, 246, 246, 255
Norwood classifi cation of alopecia, 51, 53, 55
Nose
aesthetics, 6–7, 7, 9
anatomy, 139–44, 139–44
deviation, 139

Index
329
differences between male and female, 142, 145
function, 147–8
history, 138–9
length, 139
vascular supply, 146, 146
see also Rhinoplasty; entries beginning Intranasal;
entries beginning Nasal
Nostrils
aesthetics, 9
short, 174
O
Obese patients
abdominoplasty, 268
breast reduction, 238
Occipital incision, facelift, 115–18, 115–18
Occipital nerve
release, 318–21
Occlusives, 16–17
Octinoxate, 18, 19
Octisalate homosalate, 18
Ophthalmic artery, 146, 146
Oral cavity
aesthetics, 7–8
Oral commissures, 7
Oral contraceptives, 11
Orbicularis oculi muscle, 88, 88–9, 90
botulinum toxin A, 38, 41
hypertrophic, 86
in transpalpebral corrugator resection, 70
Orbital fi ssure slant, 5, 5
Orbital septum, 89
Osseous genioplasty, 185–9
Ostectomy, 186
Osteotomies
with caudal segment repositioning, 187, 189–92
nasal bone, 171
rhinoplasty, 160–1, 160–3
Oxybenzone, 17, 18
P
Packing, rhinoplasty, 174
Panfacial rejuvenation, 111
Panniculectomy, 286, 287
Pannus, giant, 286, 287
Paramental crease, 28
Paresthesia, abdominoplasty, 279
Patient assessment
aesthetic surgery, 1–9
bodylifts, 285–6
forehead rejuvenation, 68
mastopexy, 250
rhinoplasty, 167–8
Patient counselling see Counselling
Patient expectations
breast augmentation, 220
cosmetic surgery, 1
rhinoplasty, 138
Pectoralis major muscle, breast augmentation, 222–3,
230
Penis
buried, 286, 288
Periaqueductal grey matter (PAG), 314
Periareolar purse string mastopexy, 254
Perilobular incision, facelift, 114
Periorbita, 73
Periorbital rejuvenation, 85–101
anatomy, 88–90, 88–90
complications and side effects, 100–1
deep nasojugal or malar grooves, 97
indications and contraindications, 85
laser resurfacing of the lower eyelid, 97
levator aponeurosis advancement operation, 97–8
lower blepharoplasty using skin-fl ap technique, 97,
98
Müller muscle-conjunctival resection, 98–9, 99–100
operative approach, 88–91
patient evaluation, 86–7, 86–8
pitfalls, 101
postoperative care, 101
skin/muscle lower blepharoplasty, 93–6, 93–6
transconjunctival lower blepharoplasty, 96–7, 96–7
upper lid blepharoplasty, 90–3, 90–3
Petrolatum, 17
Phenylephrine test, 88
Photoaging, 44–5
Photoprotection, 18, 18
Pigmentation
facial, 13
Pin-wheel technique, 253, 256
Pittsburgh Weight Loss Deformity Scale, 286
Platysma, 131
plication, 133, 133
Platysmal bands, 39, 40
Poly-L-lactic acid (PLA), 26–7, 27
Polyacrylamide gel, 27
Polymethylmethacrylate (PMMA) beads, 27
Polysiloxane see Silicone
Porous polyethylene, 204
Port-wine stain, 43, 44
Postauricular incision, facelift, 115
Power-assisted liposuction, 260–1
Preadipocytes, 259
Preauricular incision, facelift, 113–14, 113–15
Pretrichial forehead rejuvenation, 78–80, 82
complications, 80
operative technique, 78, 78–9, 79
optimizing outcomes, 80
Procerus muscle, 68, 70–1
Pseudomacrogenia, 182, 183
Pseudomicrogenia, 182, 183–4
Pseudoptosis, breast reduction, 247
Puckers, breast reduction, 247
Pulmonary embolism
abdominoplasty, 268, 279
liposculpture, 263
Purse string mastopexy, 252
Pyriform aperture augmentation, 205–6, 208
R
Radiologic evaluation
facial skeletal augmentation, 199–200
Radix
alteration, 170–1, 171
under-resected, 168, 168
Rectus muscle, 271
Regnault classifi cation of breast ptosis, 249, 250
Reidel’s plane, 8, 8, 181, 183
Retinoids, 13
Retrobulbar hematoma, 100
Retrobulbar hemorrhage, 100
Retrograde approach, rhinoplasty, 150, 150
Retroorbicularis oculi fat (ROOF), 87, 89, 92
Rhinoplasty
cosmetic, 5 (see also Rhinoplasty, primary)
primary, 137–65
alar base surgery, 162–3, 164
closure, 161–2, 163
complications and side effects, 164–5
depressor septi translocation, 163, 164
incisional approaches, 148–9, 149
indications, 137–8
operative technique, 149–60
cephalic trim, 153, 153
correcting the alar-columellar relationship,
157–60, 158–60
incision, 149–51, 150–2
inferior turbinoplasty, 153
preparation for surgery, 149
reducing the osteocartilaginous hump, 152–3
septal reconstruction/cartilage graft harvest, 153
skin envelope dissection, 152, 152
spreader grafts, 153, 154
tip modifi cation, 153–7, 154–8
osteotomy techniques, 160–1, 160–3
patient selection, 138, 138
postoperative care, 165
preoperative history and considerations, 138–44
anatomic features, 139–44, 139–44
nasal history, 138–9
patient counseling, 144
patient factors, 138
psychological issues, 138
relevant anatomy, 144–8, 145–8
secondary, 167–77
adjustment of the caudal dorsum, 172–3, 173
alar base abnormalities, 174
alteration of the radix, 170–1, 171
correcting the dorsal defi ciency, 171, 171–2
correction of inverted V-deformity and nasal
collapse, 172, 172
correction of protruding columellar, 173
correction of retracted alar rim, 174
defi nition of nasal fl aws, 167–8
dorsal hump, 171, 176
footplates, 173–4
harvesting conchal cartilage graft, 172
harvesting costal cartilage graft, 172
incision, 170
indications and contraindications, 170
lateral crura strut, 173
nasal bone osteotomy, 171
patient assessment, 167–8
physical examination, 168–70, 168–70
placement of columellar strut, 173, 175
short nostril, 174
splint and packing, 174
surgical techniques, 170–7
tip graft, 173, 174
tip refi nement, 173
Rhytidectomy, 103–29
advantages and disadvantages of different types, 105
complications, 128
composite, 104, 106
deep plane, 104, 106
drain placement, 125
drain removal, 128
endoscopic, 104, 108
extended SMAS, 104, 106
facelift techniques, 103–5
forehead, with pretrichial incision, 78–80, 81
complications, 80
operative technique, 78, 78–80, 79
optimizing outcomes, 80
high SMAS, 104, 106–7, 107, 108, 121, 128
incising the SMAS and fl ap elevation, 121–3, 122
indications, 110–11
lamellar SMAS dissection and bidirectional, 104,
106
MACS, 104, 109–10
medication, 128
midface, 104, 108–9
mini-lift, 104, 110
with neck lift, 133
occipital incision, 115–17, 116–17
operative approach, 118–28, 119–27
pan-facial rejuvenation, 153
perilobular incision, 114–15
postauricular incision, 115
postoperative care, 128–9
preauricular incision, 113–14, 114–15
preoperative history and considerations, 111–18,
111–19
short scar, 104, 110
skin fl ap elevation, 118–19, 120
skin fl ap repositioning and suspension suture
placement, 125–8, 125–7
skin only, 104, 105
SMAS, 105
SMAS plication, 104, 105
SMAS suspension, 123–4, 123–4
SMASectomy, 104, 105
subcutaneous forehead, indications, 67
submental incision, 117–19, 118–19
subperiosteal, 104, 107–8
suture suspension, 104, 109
temple incision and fl ap dissection, 119–21, 120–1
temporal incision, 111–13, 111–13
Rhytids, 13, 13
architecture of, 22
botulinum toxin A see Botulinum toxin A
eyelid, 86
facial fi llers, 22–3
forehead, 3, 4
location in the aging face, 22
Rocker deformity, 161, 163

INDEX
330
S
Salicylates, 19
Salicylic acid chemical peel, 13, 13–14
Saline breast implants, 220–1
Scalp
excision, hair transplantation, 60–1
Scalp advancement for elongated forehead, 67,
68, 80–2
complications, 81
operative technique, 80, 80–81, 81
postoperative care, 81
Scarpa’s fascia, 271
Scars
abdominoplasty, 279
mastopexy, 249
previous abdominal in abdominoplasty, 268–9
Schirmer’s test, 88
Selective photothermolysis (SPTL), 43–4
Septic shock, 229
Septum, 147, 147
deviation, 169, 169
Seroma
abdominoplasty, 278
breast augmentation, 229
breast reduction, 247
Short scar facelift, 104, 110
Silicone
breast implants, 220
facial fi llers, 27
facial implants, 204
mask in laser resurfacing, 46
SIMON acronym, 138
Skin
assessment for aesthetic surgery, 2
cleansers, 16, 16
examination in abdominoplasty, 269
nasal, 139, 145
types, 12
repair see Wound healing
Skin care, 11–19
complications and side effects, 15–16
contraindications, 11
indications, 11–13
operative approach, 13–15, 14, 15
postoperative care, 16–19, 16, 17, 18
preoperative history and considerations, 13
technique comparisons, 13
Skin-only facelifts, 104
SMAS see Superfi cial musculoaponeurotic system
(SMAS)
Smile patterns, 36
Smoking
abdominoplasty, 268
aesthetic surgery, 1
breast reduction, 238
and forehead rhytidectomy, 78, 80
Snap back test, 87
Soap, 16, 16
Soft tissue
expansion see Tissue expansion
loss
in the aging patient, 21
in disease, 21–2
ptosis, genioplasty, 191
SPF (sun protection factor), 19, 19
Splints
rhinoplasty, 174
Spreader grafts, rhinoplasty, 153, 154, 172, 172
Staphylococcus aureus
liposculpture, 263
Stratum corneum, 11, 12, 17
Sub-mammary fold incision, 225–7
Subcutaneous fat, 269, 271
Subcutaneous forehead rhytidectomy, 67
Submandibular glands
approach to, 135
ptosis, 131
resection, 131, 134–5, 135, 136
suspension, 131, 134–6, 135
Submental incision, facelift, 117, 118, 119
Subperiosteal facelift, 104, 107–8
Subplatysmal fat resection, 133–4, 134
Suction assisted liposuction, 261
Suction drains
abdominoplasty, 278
Sunscreens, 17–19
classifi cation, 17
formulations, 18
ingredients, 18, 19
natural cutaneous UV protective mechanisms, 17
SPF and photoprotection, 19
Superfi cial musculoaponeurotic system (SMAS),
107, 131
facelifts see under Rhytidectomy
modifi cation, 118
plication, 104, 105
ptosis, 7
SMASectomy, 104, 105
suspension and platysmal plication, 133, 133
Superior transverse ligament of Whitnall, 89
Superoxide dismutase, 17
Supraorbital nerve, 67, 71
Supratarsal crease, 88
Supratip break, 141
Supratrochlear nerve, 67, 71, 90
Suture suspension facelift, 104, 109, 125–8
Sutures
breast augmentation, 228
interdomal, 155, 155
medial crural, 155, 154–5
medial crural septal, 155, 155
rhinoplasty, 154, 154, 161–2
transdomal, 155–6, 156
Syndet, 16, 16
Synthetic detergent, 16, 16
Systemic retinoids, 13
T
Tarsal plates, 89
Tear tough region, facial fi llers, 29–30
Tears, 88, 90
Telecanthus, 5
Telogen hair growth phase, 108, 51, 52
Temporal alley, 61, 62
Temporal incision, facelift, 111–13, 111–13, 117,
117–18
Tension headaches, 133
Thermal relaxation time, 43–4
Thighplasty, 292–6, 299–302
Thrombosis, 268, 279
Tissue expansion
hair transplantation, 61, 62
Tissue necrosis, abdominoplasty, 278
Titanium dioxide, 18, 19
Tobacco smoking see Smoking
Tooth
aesthetics, 8
devitalization, genioplasty, 191
Topical retinoids, 13
Toxic shock syndrome, 277
Transareolar/periareolar approach, breast
augmentation, 228
Transcartilaginous incision, rhinoplasty, 150, 150
Transconjunctival lower blepharoplasty, 96–7, 96–7,
98
Transdomal sutures, 155–6, 155–6
Transpalpebral corrugator resection, 70, 70–2, 82
complications, 72
indications, 67
operative technique, 71–2, 71–2
optimizing outcomes, 72
relevant surgical anatomy, 70–1
Tretinoin, 45, 168
Trichloroacetic acid chemical peel, 13, 15
Trigeminal nerve, 90
irritation, 314
Turbinates, 147, 148
Turbinoplasty, inferior, 153
U
UltraPulse laser, 44
Ultrasound assisted liposuction (UAL), 261, 262
Umbilical deformity, 279
Umbilicoplasty, 274–5, 275
Upper-body lift, 303–7, 306–9
Upper cartilaginous nasal vault, 146–7
Urocanic acid, 17
UVA sunscreen ingredients, 17–19
UVB sunscreen ingredients, 19
V
Vertical thigh lift, 292–6, 299–302
Visual fi eld examination, 87–8
W
Wagon-wheel technique, 253
Webster’s triangle, 160, 161
Weight loss body contouring see Bodylifts
Whitnall’s ligament, 89
Wise pattern mastopexy, 305–6, 306
Witch’s chin deformity, 182, 184
Wolfring’s glands, 90
Wound closure
rhinoplasty, 161–2, 163
Wound dehiscence
abdominoplasty, 277
genioplasty, 191, 192
Wound healing
breast reduction, 245–6
Wrinkles see Rhytids
X
Xerostomia, 136
Z
Zinc oxide, 18, 19
ZMTBTN, 314, 317