Aesthetic Surgery Techniques

153
Surgical Preparation and Technique
153
20 
Male Rhinoplasty
Clifford Clark MD
Jared Troy MD
The Clinical Problem (Fig. 20.1)
Rhinoplasty remains the most common aesthetic procedure in
men, with 55,000 performed in 2014 alone.1 Male anatomic
variation, frequent posttraumatic pathology, desired aesthetic
differences, and the resultant technical nuances make a male
rhinoplasty a different and unique challenge. Additionally,
there is a negative connotation of the male rhinoplasty patient;
it has been suggested they are difficult to satisfy and have the
potential for psychological pathology (Box 20.1).2 The reports
of male rhinoplasty patients’ violent encounters with their
surgeons and other perceived male psychological issues have
led to the development of screening recommendations from
Gunter (Box 20.2).3
While caution should always be applied in patient selection,
current literature and the authors’ experience do not support
the higher prevalence of body dysmorphic disorder, decreased
satisfaction, or more violent encounters with men.
Surgical Preparation and Technique
Preoperative Evaluation
An initial intake questionnaire allows a relaxed way to inquire
about medical, psychiatric, and social history. The surgeon’s
initial discussion with the patient should raise these simple
questions:
1. What bothers you about your nose (aesthetic and/or
functional concerns)?
2. What do you like about your nose?
3. What would you like your nose to look like?
4. What are the desired male nasal aesthetics (Box 20.3)?
Operative Plan
The ideal nasal length is calculated from the stomion-menton
distance (STM) or the midfacial height (MFH). Disproportion
between MFH and lower facial height (LFH) should alert the
surgeon that non-nasal abnormalities should be considered.
The ideal nasal length is 0.67 × MFH, or STM, whichever is
closest to the patient’s measured nasal length. If the calculated
nasal length is off, adjustment of the radix height should be
considered first. Changing the tip rotation should next be
considered to create the ideal nasal length.4,5
NONOPERATIVE TECHNIQUE
In patients for whom operative intervention is questionable
because of previous surgery, unobtainable expectations,
or concerns of a body dysmorphic disorder (BDD) variant,
nasal contouring with injectable fillers has been extremely
successful.
OPERATIVE TECHNIQUE
The closed approach is used when a moderate dorsal reduc­
tion without spreader grafts and minimal tip work is planned.
An open rhinoplasty is mainly performed when multiple
maneuvers are needed, including spreader grafts and complex
tip work.
An open rhinoplasty is performed with a stair-step columellar
incision at the narrowest part of the columella. The soft tissue
is separated from the alar in the subperichondrial plane until
the tip is degloved. The dorsum is mobilized with a periosteal
elevator. A cephalic trim is often performed first, leaving an
appropriate width of lateral alar cartilage to provide strong
support.

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SECTION 4    CHAPTER 20  •  Male Rhinoplasty
mucosal injury before the cartilaginous dorsum is
resected with angled septal scissors and rasping of the
bony dorsum.
The options for dorsal nasal augmentation are as follows:
1. Temporalis fascia graft for 1 mm of augmentation or to
disguise the dorsum in the case of extremely thin skin
2. Septal cartilage onlay for 1 to 2 mm that includes the
need for definition temporal fascia and
3. Crushed cartilage (auricular) sausage technique for
2 to 4 mm
4. Rib cartilage when structural support is needed or
more than 4 mm is desired
5. Fascia is well suited for radix grafts because multiple
layers may be used to obtain the desired thickness
The resultant open roof defect from dorsal reduction is closed
using an external 2-mm osteotome low to high or low to low
medial oblique osteotomy. A medial oblique osteotomy is first
performed using a 3-mm osteotome. This results in a more
predictable osteotomy closure in the male nose.
A
B
C
FIGURE 20.1  The clinical problem. (A) Posttraumatic nasal deviation and dorsal hump. (B) Nasal and septal deviation, dorsal hump with internal valve collapse. (C)
Posttraumatic loss of nasal dorsum.
Single
Immature
Male
Overly expectant
Narcissistic
BOX 20.1  SIMON Mnemonic2
1. Minimal disfigurement
2. Delusional distortion of body image
3. Identity problem or sexual ambivalence
4. Confused or vague motives
5. Unrealistic expectations for changes in life situation as a
result of surgical treatment
6. Poorly established social or emotional relationships
7. Unresolved grief or crisis situation
8. Blaming of misfortune on physical appearance
9. Excessive concern about aging
10. Sudden anatomic dislike
11. Hostile attitude toward authority
12. History of physician dissatisfaction
13. Paranoid thoughts
BOX 20.2  Screening Recommendations: 13 Danger Signs3
•
Straight, strong dorsum
•
Strong dorsal aesthetic lines
•
Less tip rotation: 90–95 degrees
•
Nasofrontal angle: 138 degrees
•
Nasofacial angle: 38 degrees
•
Thick skin, wider tip
•
Nasal bones wider: 80% of intercanthal distance to 2 mm <
intercanthal distance
•
Smaller columella-lobular angle: 10–30 degrees for men vs. 45
degrees for women
BOX 20.3  Male Nasal Aesthetics
The options for dorsal reduction are as follows:
1. Modest dorsal reduction (<1 mm) only requires
rasping of the bone and sharp shaving of the
cartilaginous dorsum.
2. Reductions of more than 2 mm first require separating
the upper lateral cartilage from the septum to prevent

155
Surgical Preparation and Technique
deviated as a C-shaped deformity to the right. The nasal bones
were wider and more concave on the right and more convex
left. The tip was broad and not well defined. On lateral view,
the radix was at the lash level. There was a moderate dorsal
hump. His nasal length was 51 mm and tip projection was
38 mm. The ideal nasal length is 47 mm (MFL × 0.67), ideal
tip projection (ideal nasal length × 0.67) is 32 mm, and nasolabial
angle is 90 degrees.
An open rhinoplasty was performed using the described
technique, including a Peck-type graft.
Case 20.2 (Fig. 20.3)
A 20-year-old college student presented with the chief complaint
of improving his large dorsum. He additionally was concerned
about difficulty breathing through the left airway. The physical
examination demonstrated a midfacial and lower facial length
of 67 mm. His nose deviated to the left. On lateral view, his
radix height was at the superciliary crease, nasal length was
49 mm, and nasal projection was 40 mm. His ideal nasal length
was calculated to be 45 mm and ideal projection 30 mm. His
labial-columellar angle was indistinct. He had microgenia and
a class I occlusion. The internal examination demonstrated
narrowed internal nasal valves bilaterally, with a severely
deviated septum on the left that was nearly occluding the
airway.
Prior to rhinoplasty, an alloplastic genioplasty was performed
through a submental incision with an anatomic silicone implant
placed in a subperiosteal plane. An open rhinoplasty was
performed using the described technique, with spreader grafts
and tip sutures.
Case 20.3 (Fig. 20.4)
A 22-year-old desired improvement in his nasal aesthetics. He
disliked the “dip” on his nose. His past history included
significant trauma to his face and nose in a motor vehicle
accident that was followed by an unknown operative interven­
tion. He denied breathing difficulties.
The physical examination demonstrated a midfacial length
of 60 mm, lower facial length of 62 mm, washout of his dorsal
aesthetic lines, and telecanthus. The tip was bulbous and the
alar base was wide. The internal examination demonstrated
some limitation of the left airway at the septum–maxillary
crest interface.
On lateral view, the radix was inferiorly placed at the lower
border of the limbus. The glabella demonstrated increased
projection, accentuating a marked concavity of the nasal dorsum.
The radix was 8 mm from the corneal plan and 10 mm inferior
to the glabella. The nasal length was 38 mm, and the tip was
23 mm. The ideal nasal length was calculated to be 40 mm
(0.67 × MFL), and the ideal tip projection was calculated as
27 mm (0.67 × ideal nasal length). The ideal radix position was
calculated as 11.2 mm (0.28 × ideal nasal length). The nasolabial
angle was 92 degrees.
An open rhinoplasty was performed using the described
techniques, with the desired goal of dorsal volume augmentation
of 4 to 5 mm, raising the radix to the supratarsal crease. A
seventh rib cartilage graft was used to augment the dorsal
defect.
The middle vault is then reconstructed:
1. The redundant upper lateral cartilages are often folded
medially and sutured to the septum with 5-0 PDS
sutures to reconstruct the nasal dorsum.
2. Spreader grafts are liberally used to reconstruct the
internal nasal valve, straighten the nose, and/or
achieve strong dorsal aesthetic lines.
Finally, the lower third is addressed. The intention is to
establish well-supported and symmetric lower lateral cartilages,
tip rotation of 90 to 95 degrees, and columellar-lobular angle
of 10 to 45 degrees. Projection is achieved in a stepwise fashion,
first with suture stabilization of the medial lower lateral car­
tilage, with or without a floating columellar strut if maintenance
of the tip projection is desired. A transdomal mattress suture
is used if up to 2 mm of additional projection is needed. A
columellar strut reaching the nasal spine or dorsal extension
graft is used if significant projection is needed. Finally, onlay
grafts are occasionally necessary for increased tip projection
or definition, but are avoided, if possible, to prevent the well-
known risk of graft visualization.
Skin thickness plays a key role in which maneuvers are
performed to create a masculine nose. Less aggressive tip sutures
are needed in thin-skinned patients, whereas thick-skinned
patients may not even show the most aggressive suture work.
Suture techniques with tip-defining transdomal sutures and
interdomal sutures are performed last and assessed with
periodic skin redraping to determine progress. A tip dorsal
measurement of 7 to 11 mm is desired and measured with
calipers prior to closing. Less than 7 mm can be necessary
when no supratip break is necessary, and more than 7 mm is
necessary in a scarred or thick soft tissue envelope.
Closure is started by precise alignment of the stair-step
incision with 6-0 nylon sutures and carried laterally to the
skin-mucosal junction. The mucosa is then closed with 5-0
chromic simple interrupted sutures. Redundant mucosa is
trimmed as needed.
The nose is protected with Steri-Strips and an Aquaplast
dressing. An internal Doyle splint is used if the septum is
altered; it is always secured transseptally with 3-0 silk
sutures.
Postoperative Care
The splints and sutures are removed in 5 to 7 days. Taping
can be useful postoperatively, but most male patients may
prefer to do without this.
Nasal massage and lymphatic drainage begin after 2 weeks.
Steroid injection (0.5 mL of 10 mg/mL triamcinolone [Kenalog]
with 0.5 mL 2% lidocaine) is begun after 3 months if the supratip
is firm and induration is present. Injections continue every
third month until resolution.
Case 20.1 (Fig. 20.2)
A 22-year-old college athlete presented for a cosmetic rhi­
noplasty. His chief complaints were his dorsal hump and
deviation. His history included a nasal fracture 7 years prior to
presentation.
The physical examination demonstrated a midfacial length
(MFL) of 71 mm and a lower facial length of 74 mm; his nose

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SECTION 4    CHAPTER 20  •  Male Rhinoplasty
A
C
E
F
D
B
FIGURE 20.2  Case study 20.1. (A,C,E) Preoperative photographs. Complaint of nasal deviation and dorsal hump: rightward C-shaped deformity, nasal bone asymmetry,
broad and poorly defined nasal tip, moderate dorsal hump. (B,D,F) Postoperative photographs. After open septorhinoplasty with dorsal hump reduction, left multilevel
osteotomy spreader grafts, trans- and intradomal sutures, and Peck onlay graft.

157
Surgical Preparation and Technique
A
C
E
F
D
B
F
FIGURE 20.3  Case study 20.2. (A,C,E) Preoperative photographs. Complaint of large nasal dorsum, nasal airway obstruction, and microgenia: nasal deviation to left,
narrow internal nasal valves, indistinct labial/columellar angle, prominent nasal dorsum. (B,D,E) Postoperative photographs. After open septorhinoplasty-dorsal hump
reduction, asymmetric spreader grafts (two on the right which closed the open roof), floating columellar strut for stabilization, cephalic trim with transdomal sutures.

158
SECTION 4    CHAPTER 20  •  Male Rhinoplasty
D
E
C
A
B
FIGURE 20.4  Case study 20.3. (A,C,E) Preoperative photographs. Complaint of loss of dorsal height: inferiorly displaced radix, loss of dorsal aesthetic lines, bulbous tip,
wide alar base. (B,D) Postoperative photographs. After open septorhinoplasty with rib cartilage dorsal onlay graft, cephalic trim, columelar strut and tip defining sutures.

159
Surgical Preparation and Technique
American Society of Plastic Surgeons: 2016 Plastic Surgery Statistics.
<>.
Crerand, C.E., Franklin, M.E., Sarwer, D.B., 2006. Body dysmorphic disorder
and cosmetic surgery. Plast. Reconstr. Surg. 118, 167e–180e.
Crerand, C.E., Phillips, K.A., Menard, W., Fay, C., 2005. Nonpsychiatric
medical treatment of body dysmorphic disorder. Psychosomatics 46,
549–555.
Herruer, J.M., Prins, J.B., van Heerbeek, N., et al., 2015. Negative predictors
for satisfaction in patients seeking facial cosmetic surgery: a systematic
review. Plast. Reconstr. Surg. 135, 1596–1605.
Hinderer, U.T., 1978. Dr. Vazquez Añón’s last lesson. Aesthetic Plast. Surg.
2, 375–382.
Phillips, K.A., Grant, J., Siniscalchi, J., et al., 2001. Surgical and nonpsychiatric
medical treatment of patients with body dysmorphic disorder. Psy­
chosomatics 42, 504–510.
Picavet, V.A., Prokopakis, E.P., Gabriëls, L., et al., 2011. High prevalence
of body dysmorphic disorder symptoms in patients seeking rhinoplasty.
Plast. Reconstr. Surg. 128, 509–517.
Sarwer, D.B., 2002. Awareness and identification of body dysmorphic
disorder by aesthetic surgeons: results of a survey of american American
Society for Aesthetic Plastic Surgery members. Aesthetic Surg. J. 22,
531–535.
Veale, D., De Haro, L., Lambrou, C., 2003. Cosmetic rhinoplasty in body
dysmorphic disorder. Br. J. Plast. Surg. 56, 546–551.
References
1.
American Society of Plastic Surgeons: 2014 Plastic Surgery Statistics.
< tics?s
ub=2014+Plastic+Surgery+Statistics Report/>.
2.
Gorney, M., 2003. Criteria for patient selection: an ounce of prevention.
Presented at the Residents and Fellows Forum, Aesthetic Plastic Surgery
Annual Meeting, Boston, MA, May 16, 2003.
3.
Gunter, J.P., 1990. Rhinoplasty. In: Courtiss, E.H. (Ed.), Male Aesthetic
Surgery, second ed. Mosby, St. Louis.
4.
Daniel, R., 1991. Rhinoplasty and the male patient. Clin. Plast. Surg.
15, 751–761.
5.
Rohrich, R., Janis, J., Kenkel, J., 2003. CME: Male Rhinoplasty. Plast.
Reconstr. Surg. 112, 1071–1085.
Further Reading
American Psychiatric Association, 2000. Diagnostic and Statistical Manual
of Mental Disorders, fourth ed, Text Revision. American Psychiatric
Association Press, Washington, DC, pp. 505–511.

161
Botulinum Toxin
161
21 
Medical Rhinoplasty
Christopher M.E. Rowland Payne MB, BS, MRCP
The Clinical Problem (Fig. 21.1)
Increased nose self-awareness translates into increased patient
concern and increased demand for relatively small changes in
nasal contour. Medical rhinoplasty is especially well suited to
many of these patients. The pretreatment consultation should
include a psychological assessment. Patients with body dys­
morphic disorder (BDD) need special consideration.1
Prior to treatment, it is helpful to demonstrate any asym­
metries to the patient. The risk of bruising is reduced by asking
the patient to avoid aspirin and other nonsteroidal antiinflam­
matory drugs for 14 days prior to treatment.
Botulinum Toxin
Multi-mini Botulinum Toxin
The technique of precision placement of multiple minidose
injections of botulinum toxin (BTX) i.e., more injections, each
of a much lower dose, has been described as multi-mini BTX
(M-M BTX).2 In M-M BTX, the target muscles are carefully
observed and palpated; the points of maximum movement
are identified and injected. Compared with standard BTX
protocols advocated by manufacturers, M-M BTX has the
advantages of being more controlled and predictable in its
action, more natural in its effects, more economical in the
quantities of BTX used, and possibly marginally longer in its
duration of action (patients are typically booked for their next
treatment 5.5 months after the last one).
Nasal Muscle Function and Anatomy
The muscles of the nose serve to open and close the nostrils,
also known as the nares. Hence, there are dilator muscles and
constrictor muscles. The main function of the dilators is to
ensure that the nostrils do not become sucked flat on inspiration,
especially on deep inspiration. Indeed, the commencement of
deep inspiration is immediately preceded by dilation of the
nostrils. The dilators are more developed in certain ethnic
groups, and this is apparent as flared nostrils and/or arched
nasal side walls. In all races and ethnic groups, flaring of the
nostrils is a manifestation of anger.
The function of the contractor muscles is less clear, but it
has been noted that some free divers can teach themselves to
close their nares when submerged. Presumably, the increased
external barometric pressure of the deep water assists with
this.
The surface anatomy of the nose is outlined in Fig. 21.2.
The principal nostril dilators and nasal tip depressors are listed
in Box 21.1.
Increasing the Nasofrontal Angle
At the sellion, the procerus muscle and other soft tissues that
lie anterior to the nasal bone are drawn posteriorly by the
medial fibers of the orbicularis oculi. Relaxation of this drawing
back of the sellion allows the procerus and other soft tissues
to prolapse anteriorly by 1 mm, which serves to lessen the
depth of the sellion and widen the bridge of the nose. To do
this, BTX is injected laterally to the sellion, over the most anterior
part of the lateral facing aspect of the nasal bone (0.25 neurotoxin
units [ntu] each side; Fig. 21.3).
Bunny Lines
The nasalis pars transversa is partly responsible for so-called
bunny lines. The patient is asked to make a bunny nose (i.e.,
wrinkle the nose). The nasalis pars transversa is injected
subdermally with BTX, 0.5 ntu (Fig. 21.4).

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SECTION 4    CHAPTER 21  •  Medical Rhinoplasty
There are three methods to treat dilator naris posterior (Fig.
21.6). In the first method to treat dilator naris posterior (DNP-
Rx1), the operator’s finger pads are placed in the patient’s ala
nasi fossae, pointing toward the tip of the nose. The patient
is asked to flare the nostrils. At the point of maximum muscle
movement beneath the operator’s finger pads, an intradermal-
subdermal injection of BTX, 0.5 to 1.0 ntu, is made on each
side.
A second method to treat the dilator naris posterior (DNP-
Rx2) is that of Perez.3 The lateral nasal sulcus is observed. The
patient is asked to sniff sharply. The part of the sulcus that is
most drawn in by the sniff, usually at the posterolateral end
of the sulcus, is the point chosen for the injection. At this site
BTX, 0.5 ntu, is injected.
Reducing Nostril Flare
Nostril flare and the high arched nostril are in large part due
to contraction of the dilator naris anterior and dilator naris
posterior (Fig. 21.5). To treat the dilator naris anterior, the skin,
7 to 9 mm superior to the top of the arch of the free edge of
the nostril, is observed. The patient is asked to flare the nostrils.
The point of maximum movement usually lies 7 mm superior
to the free edge of the nostril, at a point just anterior to the
top of the arch. At this site, BTX, 0.5 ntu, is injected.
A
B
FIGURE 21.1  The clinical problem. (From Verner, I., Rowland Payne, C.M.E., 2009. Fillers. In: Baran, R., Maibach, H., Shai, A. [Eds.] Handbook of Cosmetic Skin Care,
2nd ed. Informa Healthcare, London, pp. 193–200, with permission.)
G
S/R
R
ST
PN
SN
FIGURE 21.2  Surface anatomy of the nose. G, Glabella; S/R, sellion/radix/root;
R, rhinion; ST, supratip; PN, pronasale/tip; SN, subnasale.
Nostril dilators
Dilator naris anterior
Dilator naris posterior
Depressor septi nasi
Levator labii superioris alaeque nasi (LLSAN)
Anomalous nasi
Nasal tip depressors
Depressor septi nasi
Dilator naris posterior
Compressor narium minor
LLSAN
Dilator naris anterior
Compressor naris
BOX 21.1  Principal Nostril Dilators and Nasal Tip Depressors

163
Botulinum Toxin
FIGURE 21.3  To flatten the sellion angle, part of the orbicularis oculi may be
treated with BTX, 0.25 ntu, on each side.
FIGURE 21.4  To treat bunny lines, the nasalis pars transversa is treated by
injecting BTX, 0.5 ntu, on each side.
FIGURE 21.6  There are three methods to treat the dilator naris posterior—
inferiorly (DNP-Rx1), anteriorly (DNP-Rx2), and superiorly (DNP-Rx3). See text for
details.
FIGURE 21.5  To treat nostril flaring, the dilator naris anterior and dilator naris
posterior are treated by injecting BTX, 0.5 ntu, at each point. The anterior point
treats the dilator naris anterior and the posterior point treats the dilator naris
posterior.

164
SECTION 4    CHAPTER 21  •  Medical Rhinoplasty
by injecting BTX, 0.5 ntu, 5 mm lateral to the midline, at the
level of the pronasale.
LLSAN may be treated. The clinician’s index and middle
fingers should be placed, one each side of the patient’s nose,
just superior to the ala nasi fossa, on the inferior slope of where
the prominence of the cheek joins the side of the nose. The
patient is asked to screw up the face. The clinician’s fingertips
can detect the point of maximum muscular contraction; the
muscle lies relatively deep to the skin. At this site, BTX, 0.5
ntu, is injected perpendicularly to the skin on each side of the
nose. Treating LLSAN with BTX will allow the nasal tip to rise
a little, and treatment of LLSAN is even more helpful to lessen
ala nasi shadowing, bunny lines of the nose, or a gummy
smile.
Fillers
Types of Filler
Hyaluronic acid (HA) is an example of an inert filler.4 Subcision,
silicone, and polylactic acid are fibrogeneic fillers. Calcium
hydroxylapatite is a combination gel with features of both
inert and fibrogeneic fillers.
With an inert filler, the filling effect is primarily related to
the amount of filler substance introduced. With fibrogeneic
fillers, the filling effect is related more to the vigor of the patient’s
foreign body granuloma reaction.
Inert fillers, such as HA, may be injected into the soft tissues,
usually into the subcutaneous tissue. The result is immediate;
the inert fillers are biodegradable. They mostly have the
advantage of a high safety profile. If a problem arises after
injection (e.g., an inflammatory nodule or the patient is dis­
satisfied with the result), the problem will resolve spontaneously
because the filler is biodegraded effortlessly over a matter of
months—and, in the case of HA, much more quickly if hyal­
uronidase is used. Inert fillers seldom stimulate a host reaction,
so unwanted granulomas are rare with inert fillers, unless they
become microbiologically contaminated. Inert fillers have the
commensurate disadvantage of a temporary result. The effect
of an inert filler injection is apparent as soon as the injection
has been made.
Fibrogeneic fillers, on the other hand, have the advantage
of long durability but carry a greater risk of long-lasting
problems, such as granulomatous inflammatory nodules, and
misplaced injections, which will not disappear effortlessly in
6 to 12 months.
Fibrogeneic fillers are usually administered over a series of
visits. The desired result is achieved gradually. The archetypal
fibrogeneic filler is silicone, which is administered as serial
microdroplet silicone (SMDS). SMDS is usually an intradermal
injection. It is the equivalent of putting a grain of sand into
an oyster and then allowing the oyster to make a pearl. Because
silicone microdroplets may be seeded with great precision,
even in the tightly bound tissue of a scar, SMDS may be used
to repair scars that would not be amenable to HA, such as
postsurgical or post–cleft lip repair scars or deep V notch rhytids.
Because only tiny amounts of SMDS are injected in each
microdroplet (≈0.003 mL/intradermal needle puncture), SMDS
does not run the risk of inducing vascular occlusion or embo­
lism, which is a potential problem with HA. Using silicone as
In the third method to treat the dilator naris posterior (DNP-
Rx3), the operator’s index fingers are placed on each side of
the nose, along the osseocartilaginous junction. The patient is
asked to dilate the nose so as to push the operator’s fingers
laterally. At the point of maximum muscle movement beneath
each of the operator’s finger pads, an intradermal-subdermal
injection, BTX, 0.5 to 1.0 ntu, is made on each side.
In some patients with very large nostrils, it may be helpful
to treat the dilator naris posterior by all three methods and
also to treat the depressor septi nasi and levator labii superioris
alaeque nasi (LLSAN) muscles with small doses (e.g., BTX, 0.5
ntu, at each point).
Elevating the Nasal Tip
The slightly upturned nasal tip of youth is subject to gravity
and the depressor effects of several muscles, especially depressor
septi nasi and dilator naris posterior (Box 21.1) but also the
LLSAN, dilator naris anterior, compressor narium minor, and
other smile muscles. Gradually, as the nasal tip turns downward
with the passage of years, the supratip angle evolves from
acute to obtuse. These muscles may be treated by BTX
(Fig. 21.7).
To treat depressor septi nasi, the operator’s finger is placed
on one philtral ridge. The patient is encouraged to contract
the depressor septi nasi. The point of maximum movement
will be felt under the operator’s finger. It is often 0.25 cm lateral
to the superior part of the philtral ridge, just inferior to the
nasal sill. An injection of BTX, 0.5 to 1 ntu, is made at this
point. This is a deep injection made at an oblique angle to the
skin, with the needle directed superiorly and medially.
The dilator naris posterior is injected with BTX, 0.5 ntu, as
described above. The dilator naris anterior may also be injected
with BTX, 0.5 ntu. The compressor narium minor may be treated
FIGURE 21.7  Treatment of nasal tip depression. Start at the nasal tip with
compressor narium minor and proceed clockwise to depressor septi nasi, dilator
naris posterior, levator labii superioris alaeque nasi (LLSAN) and dilator naris
anterior and inject BTX, 0.5 ntu, at each site on each side of the nose.

165
Fillers
Nasal Tip
The young nose has an elevated tip, which falls with age.
Unwanted downturning of the nasal tip can be reversed by
filler injection. The tip can be lifted by a filler injection in the
subcutis of the columella. A point is selected that is two-thirds
of the distance from the nasolabial angle (subnasale) to the tip
of the nose (pronasale). Pointing tipward, the needle is inserted.
As it is advanced subdermally 2 to 4 mm in a tipward direction,
HA (0.05 mL) is injected in antegrade. When the needle reaches
the pronasale, further filler continues to be injected (0.05 mL)
into the subcutaneous tissue of the nose, between the pronasale
and supratip.
This injection increases anterior projection and thus effaces
ptosis. Increased anterior projection also somewhat reduces
lateral projection—that is, when the nasal tip is elevated in
this way, the tip will become somewhat narrower because as
the anterior projection increases, the lateral projection is reduced.
This injection therefore not only corrects nasal tip ptosis but
SMDS—and not as a bolus injection—entirely removes the risk
of the development of fibrotically encased silicone lakes that
migrate (e.g., as might occur after rupture of a silicone breast
implant).
Retro Ala Nasi Injection
Volume for volume, there is no other filler injection that is
more effective in treating the aging midface than the retro ala
nasi injection.5 Consequently, it is often the best starting point
for filler treatment of the face or nose.
In the retro ala nasi injection, the needle enters the skin
1 cm lateral to the lateral border of the ala nasi and runs in a
superomedial direction. The needle passes easily through the
subcutis into a space that lies just deep to the ala nasi—posterior
to the alar cartilage rather than posterior to the alar nasi fossa).
Having aspirated first, 0.05 to 1 mL of HA is injected. The
technique is repeated on the contralateral side (Fig. 21.8).
Saddle Nose Correction
Filler at the radix (sellion) will help correct a saddle deformity
of the nose. HA filler is suitable. The filler may be introduced
subdermally by needle or cannula. A cannula is safer and
therefore preferred, if possible, but use of a needle is more
precise. When a needle is used, aspiration prior to injection is
essential to avoid an accidental intravascular injection with all
its attendant hazards. A saddle nose may be attenuated by
0.2 to 0.5 mL HA filler (Fig. 21.9).
Nasal Hump Reduction
The nasal hump is called the rhinion. The nasal hump can
only be reduced surgically. However, in most cases, the per­
ceived disability is not so much the rhinion itself as the rhinion
angle. This angle may be softened by a very small amount of
filler at the sellion. This will help attenuate the appearance of
an exaggerated nasal hump. The appearance of a prominent
hump, in some patients, may be further improved by HA filler
(0.02–0.05 mL) injected subdermally by cannula along the ridge
of the cartilaginous part of the nose, from the supratip to the
rhinion. This is a vascular area and, if a needle is used, caution
should be exercised to avoid accidental intravascular injection
of filler.
A
B
FIGURE 21.8  Retro ala nasi injection. (A) Before retro ala nasi injection. Note the alar nasi shadowing. (B) After retro ala nasi injections (0.05 mL hyaluronic acid) on each
side. Note the effacement of both ala nasi shadowing and nasolabial groove. No filler was injected into the nasolabial groove. (From Verner, I., Payne, C.R., 2009. Fillers. In:
Baran, R., Maibach, H., Shai, A. [Eds.] Handbook of Cosmetic Skin Care, 2nd ed. Informa Healthcare, London, pp. 193–200, with permission.)
A
B
FIGURE 21.9  Posttraumatic saddle nose. (A) Before hyaluronic acid (HA) filler. (B)
After HA filler. (From Verner, I., Payne, C.R., 2009. Fillers. In: Baran, R., Maibach,
H., Shai, A. [Eds.] Handbook of Cosmetic Skin Care, 2nd ed. Informa Healthcare,
London, pp. 193–200, with permission.)

166
SECTION 4    CHAPTER 21  •  Medical Rhinoplasty
References
1.
Rowland Payne, C.M.E., 2016. The aesthetic consultation. In: Andre,
P., Haneke, E., Marini, L., et al. (Eds.), Textbook of Aesthetic and
Cosmetic Dermatology. CRC Press, London, pp. 67–74.
2.
Rowland Payne, C.M.E., 2012. Multi-mini botulinum. In: Redaelli, A.,
Braccini, F. (Eds.), Botulinum Toxin A in Aesthetic Medicine. Officina
Editoriale Oltrarno Srl Firenze, pp. 185–198.
3.
Perez, F., 2014. Personal communication.
4.
Rowland Payne, C.M.E., Verner, I., 2015. Fillers and soft tissue augmenta­
tion. In: Lotti, T., Katsambas, A. (Eds.), European Handbook of Der­
matological Treatments. Springer, London, pp. 1191–1216.
5.
Rowland Payne, C.M.E., 2002. Tissue augmentation. Presented at the
Eleventh Annual Congress of the European Academy of Dermatology
and Venereology, Prague.
Further Reading
De Maio, M., Rzany, B., 2007. Botulinum Toxin in Aesthetic Medicine.
Springer-Verlag, Berlin.
De Maio, M., Rzany, B., 2009. The Male Patient in Aesthetic Medicine.
Springer-Verlag, Berlin, p. V.
Rowland Payne, C.M.E., Philipp-Dormston, W., 2016. Botulinum toxin.
In: Andre, P., Haneke, E., Marini, L., Rowland Payne, C.M.E. (Eds.),
Textbook of Aesthetic and Cosmetic Dermatology. CRC Press, London,
pp. 577–580.
can also slightly reduce bulbosity of the nasal tip. On the other
hand, the needle may be used in a fan-like fashion, between
the pronasale and supratip, to soften a nasal tip that is too
pointed.
Nasal Asymmetries
Small irregularities can be corrected by HA filler.
Nostril Free Edge
The free edge of the nostril is called the alar rim. If it is judged
to be too arched, this can be improved with filler. Subdermal
filler is all that is required, perhaps needing only 0.02 mL of
HA. This is precise work and painful unless a cream containing
lidocaine 7% plus tetracaine 7% (Pliaglis) is first applied for
10 minutes. When the injection has been carried out once or
twice, at 6- to 12-month intervals, and to the patient’s satisfac­
tion, it may be followed by three to five sessions of SMDS at
4- to 6-week intervals to provide a lasting solution.
Nostril Sill
Any injection of the nostril sill is unlikely to be simply a cosmetic
enhancement. It is much more likely to be a repair of a rhino­
plasty scar or a scar following trauma or cancer surgery or,
most often, a cleft lip repair scar. This is precise work, and
painful, unless lidocaine 7% plus tetracaine cream (Pliaglis) is
first applied for 10 minutes. It is best achieved with three to
five sessions of SMDS at 4- to 6-week intervals.

169
Surgical Preparation and Technique
169
22 
Aesthetic Orthognathic Surgery
Michael Miloro MD, DMD, FACS
Michael R. Markiewicz MD, DDS, MPH
The Clinical Problem
Dentofacial (dentoskeletal) deformities are characterized by
an abnormal position of the maxilla and/or mandible and
associated teeth that affect jaw function and facial aesthetics.
These deformities are as follows (Fig. 22.1):
• Class I—normal skeletal pattern, maxilla and mandible
in an orthognathic relationship
Occlusal relationships are characterized by the mesiobuccal
cusp of the maxillary first molar occluding with the mesiobuccal
groove of the mandibular first molar; the maxillary canine
occludes with the distal half of the mandibular canine and the
mesial half of the mandibular first premolar.
• Class II—skeletal deformity characterized by a
deficient mandible
• Class III—skeletal deformity characterized by a
prognathic mandible
Class II and III occlusal relationships are characterized by
the mesiobuccal cusps of the maxillary first molar being mesial
and distal to the buccal groove of the mandibular first molar,
respectively, as well as the distal surface of the mandibular
canine being distal and mesial to the mesial surface of the
maxillary canine, respectively.
In addition to anteroposterior jaw discrepancies, there are
transverse jaw discrepancies, open bite or deep bite discrepan­
cies, vertical (excess or deficient) deformities, and chin
deformities—retrusive (retrogenia) or protrusive (progenia).
The Aesthetic Problem
Dentofacial deformities of the maxilla, mandible, and chin
include overgrowth (hyperplasia), undergrowth (hypoplasia),
and asymmetries. Facial aesthetics are compromised by the
abnormal position of the maxilla, mandible, and chin.
Patients may appear to have an upper or lower jaw or chin
that is too large or too small, which manifests within the
dentition as a malocclusion (e.g., class I, II, III). There may be
a lip incompetence, mentalis strain, gummy smile, underbite,
overbite, poor neck-chin-throat morphology, sagging skin,
submental redundancy, lack of malar projection, scleral show,
ptotic nasal tip, everted lower lip, thin upper lip, and other
facial aesthetic problems.
Surgical Preparation and Technique
Management and Treatment Options
A thorough cephalometric analysis assists the clinical and
radiographic diagnostic evaluation and treatment of the maloc­
clusion and skeletal deformity. The operative plan should be
clinically driven with the aid of three-dimensional treatment
planning and virtual surgical planning (VSP) considering
functional and aesthetic concerns (Fig. 22.2).
Surgical therapy is aimed at the correction of the specific
individual patient deformity, with correction of the maloc­
clusion, functional deficiency, and unaesthetic appearance.
Surgical procedures include a maxillary Le Fort osteotomy
(Fig. 22.3), malar augmentation, mandibular sagittal split osteotomy
(Fig. 22.4), vertical ramus osteotomy, various other forms of
ramus osteotomies (e.g., inverted L osteotomy), chin genioplasty
procedures (Fig. 22.5), and malar augmentation (Fig. 22.6).
Treatment and Operative Techniques
MAXILLARY SURGERY: LE FORT I OSTEOTOMY
Using a proper surgical drape, with a nasal endotracheal tube
secured while avoiding excessive alar pressure, a K-wire is
placed at the soft tissue nasion as an external vertical reference
point. Calipers are used to measure and record the vertical

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CHAPTER 22  •  Aesthetic Orthognathic Surgery
Class I
Class II
Class III
FIGURE 22.1  Class I, II, and II dentofacial and skeletal relationships.
Preoperative position
Intermediate position
Final position
FIGURE 22.2  Virtual surgical planning (VSP) of an orthognathic surgical case.

171
Surgical Preparation and Technique
osteotome separates the lateral nasal wall posteriorly toward
the pyramidal process of the palatine bone.
For segmental maxillary surgery, interdental osteotomies
are made with a saw. Next, the maxilla is downfractured. Tessier
elevators are placed behind the posterior maxilla for
mobilization.
The occlusal splint—intermediate (two-jaw surgery) or final
(single-jaw surgery)—is used. The maxillomandibular complex
is then passively positioned in a posterior-superior direction,
seating the mandibular condyles. Anterior and posterior bony
interferences are identified and reduced until the desired vertical
dimension is achieved.
Rigid fixation is applied to the nasomaxillary and zygomatic-
maxillary buttresses. Maxillomandibular fixation is released
and, in single-jaw surgery, the occlusion is assessed for reproduc­
ibility. In the case of double-jaw surgery, the intermediate
occlusion should be verified prior to mandibular surgery. An
FIGURE 22.3  Le Fort I maxillary osteotomy procedure.
FIGURE 22.4  Bilateral sagittal split mandibular osteotomy procedure.
FIGURE 22.5  Genioplasty procedure.
FIGURE 22.6  Alloplastic malarplasty (malar augmentation) procedure.
distance between the K-wire and orthodontic brackets at the
central incisor.
A circumvestibular incision is made from the first molar to
the first molar above the mucogingival junction. Subperiosteal
dissection exposes the lateral maxilla, lateral nasal walls, piri­
form aperture, anterior nasal spine, infraorbital foramen,
zygomatic-maxillary buttress, and posterior maxilla.
A reciprocating saw is used to create an osteotomy of the
anterior maxillary wall. A straight osteotome completes the
posterior osteotomy to the pterygoid plates, and a curved
osteotome is used to separate the maxilla from the pterygoid
plates. A nasal osteotome separates the nasal septum and vomer
from the nasal crest of the maxilla. A single-guarded nasal

172
CHAPTER 22  •  Aesthetic Orthognathic Surgery
such as eliminating dental compensations and managing the
transverse tooth size (Bolton analysis) and curve of Spee
discrepancies.
Maxillary Surgery
In multipiece maxillary surgery, damage to tooth roots may
occur. This is prevented with proper orthodontic divergence
of roots and osteotomy site planning prior to surgery. A much
less common complication is blindness, which is attributed to
propagation of a fracture from the pyramidal process of the
palatine bone or pterygomaxillary junction.
Mandibular Surgery
Specific surgery complications related to the bilateral sagittal
split osteotomy are often prevented with proper technique,
including use of the so-called Dal Pont and Hunsuck modifica­
tions, which include extending the anterior ramus osteotomy
to the body of the mandible and limiting the posterior extent
of the medial to the retrolingual fovea. In addition, a critical
component often overlooked by the novice is failure to osteoto­
mize the inferior border of the mandible appropriately, which
will result in a buccal plate fracture. Neurosensory disturbance
of the inferior alveolar nerve is a complication that increases in
prevalence with the age of a patient. Management of a nerve
transection, when identified intraoperatively, should include
immediate neurorrhaphy. Failure to seat the proximal segment
properly in centric relation at the time of fixation will usually
result in an ipsilateral open bite.
Genioplasty
The most common complications after a horizontal osteotomy
of the mandibular symphysis is asymmetry, sectioning of the
apices of mandibular teeth and damage to the mental nerve,
and notching at the mandibular body, which can be prevented
by placing the osteotomy level with the occlusal plane and as
distally as possible.
Case Examples (Figs. 22.7 to 22.12)
■ Class II skeletal deformity, vertical maxillary excess,
mandibular hypoplasia, retrogenia
• Surgery: Le Fort osteotomy with impaction, bilateral
sagittal split osteotomy with advancement,
advancement genioplasty (see Fig. 22.7)
■ Class III skeletal deformity, maxillary hypoplasia,
mandibular hyperplasia
• Surgery: Le Fort osteotomy with advancement and
impaction, bilateral sagittal split osteotomy with
setback (see Fig. 22.8)
■ Class II skeletal asymmetry, asymmetric maxillary
hypoplasia, asymmetric mandibular hyperplasia
• Surgery: Le Fort osteotomy with asymmetric
advancement, bilateral sagittal split osteotomy with
asymmetric setback (see Fig. 22.9)
■ Class III skeletal deformity, maxillary hypoplasia,
mandibular hypoplasia, malar hypoplasia
• Surgery: Le Fort osteotomy with advancement,
bilateral sagittal split osteotomy with setback, malar
alar cinch suture may be applied to control the width of the
alar base, and a V-Y (or double V-Y) advancement may be
performed to increase lip prominence and provide lip support.
MANDIBULAR SURGERY—BILATERAL SAGITTAL
SPLIT OSTEOTOMY
A mucosal incision is made from the first molar to midway
up the ascending ramus. Following subperiosteal dissection
to the medial ramus and protection of the inferior alveolar
neurovascular bundle, the medial osteotomy is made with a
drill or saw and continued anteriorly along the ascending
ramus, just medial to the mandibular buccal cortex to the
external oblique ridge (first or second molar region).
The vertical osteotomy is made where the external oblique
ridge blends with the body of the mandible, usually just between
the first and second molar regions. The saw or drill cuts through
the inferior border. Osteotomes are used to complete the
mandibular split.
The interocclusal splint is inserted, and maxillomandibular
fixation is applied. The condyle is seated passively into centric
relation and fixation is applied. The occlusion is assessed for
accuracy and reproducibility.
GENIOPLASTY
A labial mucosal incision is made below the mucogingival
junction between the canine teeth. The mentalis muscles are
incised, leaving an adequate cuff for closure. Subperiosteal
dissection to the inferior border of the mandible is carried out,
identifying the mental nerves bilaterally.
After scoring the symphyseal midline, a reciprocating saw
is used to cut through the anterior mandible. The osteotomy
is completed.
Vertical augmentation by wedge ostectomy or vertical
augmentation by bone grafting may be performed. The distal
segment is positioned and rigid fixation is applied using
bicortical screws or prebent plates.
The position of the chin is then reassessed. The wound is
irrigated and closed in layers, and a postoperative chin dressing
is applied.
Postoperative Regimen
Guiding interocclusal elastics should be placed to assist patients
in finding their new bite, as well as to correct for any minor
occlusal discrepancies. Neurosensory disturbances may last
for 3 to 12 months. Infection is uncommon but, when identified,
should be managed expectantly. Aggressive use of antiemetics,
corticosteroids, propofol anesthesia, and aggressive fluid
management is advocated to avoid nausea and emesis.
A nonchew diet is suggested for 5 to 6 weeks, but patients
should begin mobilizing their jaws shortly after surgery. Swell­
ing can be partially reduced by the use of corticosteroids
intraoperatively and postoperatively.
Complications
The most common complication following orthognathic surgery
is relapse. Prevention includes proper orthodontic preparation,

173
Case Examples
A
B
C
D
E
F
FIGURE 22.7  (A) Class II skeletal deformity, vertical maxillary excess, mandibular hypoplasia, retrogenia. (B–D) Surgery—Le Fort osteotomy with impaction, bilateral
sagittal split osteotomy with advancement, advancement genioplasty. (E,F) Results of surgery.

174
CHAPTER 22  •  Aesthetic Orthognathic Surgery
A
B
D
E
C
FIGURE 22.8  (A,B) Class III skeletal deformity, maxillary hypoplasia, mandibular hyperplasia. (C) Surgery—Le Fort osteotomy with advancement and impaction, bilateral
sagittal split osteotomy with setback. (D,E) Results of surgery.

175
Case Examples
A
B
C
FIGURE 22.9  (A–C) Class II skeletal asymmetry, asymmetric maxillary hypoplasia, asymmetric mandibular hyperplasia.
Continued
augmentation with alloplastic cheek implants (see
Fig. 22.10)
■ Class II skeletal deformity, vertical maxillary excess,
mandibular hypoplasia, retrogenia
• Surgery: Le Fort osteotomy with impaction, bilateral
sagittal split osteotomy with setback, advancement
genioplasty (see Fig. 22.11)
■ Class III skeletal asymmetry, maxillary hypoplasia,
mandibular hyperplasia, malar hypoplasia
• Surgery: Le Fort osteotomy with advancement,
bilateral sagittal split osteotomy with setback, malar
augmentation with alloplastic cheek implants (see
Fig. 22.12)
Text continued on p. 183

176
CHAPTER 22  •  Aesthetic Orthognathic Surgery
E
G
F
Preoperative position
Intermediate position
Final position
D
(D) Surgery—Le Fort osteotomy with asymmetric advancement, bilateral sagittal split osteotomy with asymmetric setback. (E–G) Results of surgery.
FIGURE 22.9 cont’d

177
Case Examples
A
C
B
Preoperative position
Intermediate position
D
Final position
FIGURE 22.10  (A–C) Class III skeletal deformity, maxillary hypoplasia, mandibular hypoplasia, malar hypoplasia. (D) Surgery—Le Fort osteotomy with advancement,
bilateral sagittal split osteotomy with setback, malar augmentation with alloplastic cheek implants.
Continued

178
CHAPTER 22  •  Aesthetic Orthognathic Surgery
E
[H]
F
G
H
(E–H) Results of surgery.
FIGURE 22.10 cont’d

179
Case Examples
A
C
D
B
Preoperative position
Intermediate position
Final position
FIGURE 22.11  (A–C) Class II skeletal deformity, vertical maxillary excess, mandibular hypoplasia, retrogenia. (D) Surgery—Le Fort osteotomy with impaction, bilateral
sagittal split osteotomy with setback, advancement genioplasty.
Continued

180
CHAPTER 22  •  Aesthetic Orthognathic Surgery
E
F
H
G
(E–H) Results of surgery.
FIGURE 22.11 cont’d

181
Case Examples
A
C
B
Preoperative position
Intermediate position
Final position
FIGURE 22.12  (A,B) Class III skeletal asymmetry, maxillary hypoplasia, mandibular hyperplasia, malar hypoplasia. (C) Surgery—Le Fort osteotomy with advancement,
bilateral sagittal split osteotomy with setback, malar augmentation with alloplastic cheek implants.
Continued

182
CHAPTER 22  •  Aesthetic Orthognathic Surgery
D
E
Preoperative position
Final position
F
G
(D–G) Results of surgery.
FIGURE 22.12 cont’d

183
Case Examples
Hunsuck, E.E., 1968. A modified intraoral sagittal splitting technic for
correction of mandibular prognathism. J. Oral Surg. 26, 250–253.
Proffit, W.R., Turvey, T.A., Phillips, C., 1996. Orthognathic surgery: a
hierarchy of stability. Int. J. Adult Orthodon. Orthognath. Surg. 11,
191–204.
Ruckman, P., Schlieve, T., Borba, A.M., Miloro, M., 2016. External reference
nasal pin for orthognathic maxillary positioning: what is the proper
method of placement? J. Oral Maxillofac. Surg. 74, e391–e399.
Trauner, R., Obwegeser, H., 1957. The surgical correction of mandibular
prognathism and retrognathia with consideration of genioplasty. II.
Operating methods for microgenia and distoclusion. Oral Surg. Oral
Med. Oral Pathol. 10, 899–909.
Further Reading
Bell, W.H., 1975. Le Forte I osteotomy for correction of maxillary deformities.
J. Oral Surg. 33, 412–426.
Borba, A.M., Ribeiro-Junior, O., Brozoski, M.A., et al., 2014. Accuracy of
perioperative mandibular positions in orthognathic surgery. Int. J.
Oral Maxillofac. Surg. 43, 972–979.
Dal Pont, G., 1961. Retromolar osteotomy for the correction of prognathism.
J. Oral Surg. Anesth. Hosp. Dent. Serv. 19, 42–47.
Epker, B.N., 1977. Modifications in the sagittal osteotomy of the mandible.
J. Oral Surg. 35, 157–159.
Hamilton, T., Markiewicz, M.R., Jarman, J., Bell, R.B., 2012. Dental outcomes
in computer-assisted orthognathic surgery. J. Craniofac. Surg. 23,
e223–e226.
Hsu, S.S., Gateno, J., Bell, R.B., et al., 2013. Accuracy of a computer-aided
surgical simulation protocol for orthognathic surgery: a prospective
multicenter study. J. Oral Maxillofac. Surg. 71, 128–142.

185
Surgical Preparation and Technique
185
23 
Implantology
Edward R. Schlissel DDS, MS
The Clinical Problem (Fig. 23.1)
Synopsis
■ The patient, a 20-year-old woman, suffered an injury to
the anterior maxilla in a motor vehicle accident. There
were no injuries to her lips or other perioral structures.
■ Emergency care was provided immediately, and
reconstruction commenced 3 months later.
■ Treatment, over a period of 18 months, included two
surgical procedures and dental rehabilitation, including
gingival surgery.
■ Treatment was provided by a team, which included a
maxillofacial surgeon, restorative dentist, and dental
technical laboratory.
The Aesthetic Problem (Fig. 23.2)
Following this injury, the patient was left with a significant
dentofacial injury, which made her extremely self-conscious
about her smile. She was also unable to speak clearly and
could not eat satisfactorily. She believed that she could not
continue with her education and that her chances for employ­
ment were diminished. These prospects made her emotionally
depressed. She avoided social contacts and became
withdrawn.
At the time of examination, after emergency care, the fol­
lowing conditions were noted:
• The maxillary central incisors, associated alveolar
bone, and soft tissue had been avulsed.
• The maxillary left lateral incisor was fractured,
devitalizing the dental pulp.
• Primary closure of the wound, without grafting,
resulted in location of the labial frenulum at the crest
of the alveolar ridge.
• There was significant deficiency in the volume of bone
and soft tissue, including a lack of keratinized
connective tissue.
• Lacking incisor teeth, the patient was unable to make
all speech sounds clearly, would not smile without
hiding her face behind her hand, and was in emotional
distress.
A panoramic radiograph was made at the time of examination
(see Fig. 23.2). Note the teeth missing at the maxillary midline
and the impacted third molars.
The goal of treatment was to replace the missing teeth and
tissue and restore the damaged teeth to appear and function
in a manner consistent with long-term health. The plan of
treatment that was selected included augmentation of bone
and soft tissue, placement of two dental implants, and placement
of dental restorations on the four maxillary incisor teeth. The
procedures selected offered the best outcome, with the least
compromise to remaining dental structures.
The alternative treatments were a removable partial denture
or fixed partial denture. The location of the maxillary frenulum
would have interfered with either type of restoration. Addition­
ally, the patient rejected a removable prosthesis as an alternative.
A fixed partial denture was not possible because of the damage
to the adjacent teeth and the poor long-term prognosis in a
young patient.
Surgical Preparation and Technique
Treatment
This reconstruction was accomplished in four stages—surgical
restoration of bone and soft tissue with grafting, placement of
dental implants, development of soft tissue contour for tooth
replacement, and restoration of damaged and missing teeth.

186
    CHAPTER 23  •  Implantology
with the surrounding bone and were suitable for dental
restoration.
One week later, provisional dental restorations were made
and placed on the implants. The provisional restorations were
made of polyether ether ketone (PEEK) and dental composite
resin. They were secured to the implants by a titanium screw,
tightened to 20 Ncm. Soft tissue healing was evaluated at
6 weeks (Fig. 23.4). It was noted that contour was not aestheti­
cally pleasing. Small modifications were made with a low-energy
diode laser (2 W, 808 Ncm; Fig. 23.5).
After 4 weeks, healing was reevaluated (Fig. 23.6). It was
determined that tissue healing was acceptable. The socket areas
surrounding the dental implants had also healed (Fig. 23.7).
Note the triangular shape of the recesses, which mimic the
natural shape around maxillary central incisors.
The time for healing and maturation of tissue in between stages
was critical to the outcome of the procedures.
Bone augmentation was accomplished by reflection of the
tissue and placement of a combination autogenous bone and
allograft material, protected by a resorbable membrane. The
autogenous bone was obtained during the surgical removal
of the impacted maxillary and mandibular third molars. The
flap was advanced, and the labial frenulum was repositioned
to a location suitable for dental restorations. Healing after this
procedure was 6 months.
After 6 months, the tissue was reflected minimally, and two
dental implants were placed (Fig. 23.3). The implants, which
are made of chemically pure titanium and had chemically
prepared surfaces, were placed into osteotomy sites prepared
with low-speed rotary instrumentation under continuous
irrigation. Under these circumstances, it is predictable that the
implant will be colonized by bone and will achieve osseointegra­
tion. This interface can withstand the force of occlusal function
and can support gingival tissues.
After 4 months, the implants were exposed, and their status
was evaluated. Reverse torque testing at 35 Newton centimeter
(Ncm) demonstrated that the implants were firmly integrated
FIGURE 23.1  Conditions present at the initial examination.
L
FIGURE 23.2  Panoramic radiograph made at the time of the initial examination.
L
FIGURE 23.3  Panoramic radiograph made after placement of the dental implants.
FIGURE 23.4  Provisional restorations, 6 weeks after placement.
FIGURE 23.5  Provisional restorations, immediately after recontouring with laser.

187
Postoperative Program
self-conscious about her injury. The teeth and the soft tissue
contours appear natural (Fig. 23.11).
Postoperative Program
The patient did not require any special posttreatment care.
Routine dental visits were satisfactory.
FIGURE 23.6  Provisional restorations, 4 weeks after recontouring with laser.
FIGURE 23.7  Socket areas around implants. The lateral incisors have been
prepared for crown restorations.
FIGURE 23.8  Ceramic crown restorations before placement.
FIGURE 23.9  Titanium abutments seated on implants, before placement of crown
restorations.
FIGURE 23.10  Radiograph of implants, screws, abutments, and crown
restorations.
FIGURE 23.11  Clinical condition 6 months after placement of restorations.
Dental restorations were made of lithium disilicate ceramic
(Fig. 23.8). The shade used matches the remaining teeth, and
the contours are aesthetically pleasing.
Custom posts for the implants were made with computer-
aided design and Computer Assisted Manufacturing (CAM)
technology. They are composed of commercially pure titanium,
which was plated with titanium nitride. This gold-hued surface
appears more natural under restorations and through translucent
tissue than dark grey titanium (Fig. 23.9).
The abutments were secured with gold plated titanium
screws tightened to a torque level of 20 Ncm. The restorations
were placed on the natural teeth and titanium abutments with
dental adhesive cement. The radiograph shown in Fig. 23.10
of the area shows the implants with the abutments, screws
and restorations.
The patient was pleased with the outcome and had full
function restored. Her aesthetic concerns were resolved, she
was able to speak and chew properly and was no longer

188
    CHAPTER 23  •  Implantology
These complications may be avoided by using a team
approach to treatment and by following accepted protocols
for surgical and restorative dental procedures.
Further Reading
Elian, N., Jalbout, Z., Cho, S., et al., 2003. Realities and limitations in the
management of the interdental papilla between implants: Three case
reports. Pract. Proced. Aesthet. Dent. 15 (10), 737–744.
Tarnow, D., Elian, N., Fletcher, P., et al., 2003. Vertical distance from the
crest of bone to the height of the interproximal papilla between adjacent
implants. J. Periodontol. 74 (12), 1785–1788.
Tarnow, D.P., Magner, A.W., Fletcher, P., 1992. The effect of the distance
from the contact point to the crest of bone on the presence or absence
of the interproximal dental papilla. J. Periodontol. 63 (12), 995–996.
Complications
Restoration of this defect by the team could have been com­
plicated by any of the following errors:
■ Inadequate replacement of missing hard and soft tissues
■ Improper location of the labial frenulum
■ Incorrect selection or location of dental implants
■ Poor surgical technique, leading to failure of the dental
implants to integrate with the surrounding bone
■ Poorly contoured provisional restorations that did not
lead to the desired outcome
■ Dental restorations with poor contour or color matching,
resulting in patient dissatisfaction of unacceptable
function

189
The Clinical Problem (Figs. 24.1A, 24.2A, 24.3A, 24.4A, 24.5A, and 24.6A)
189
24 
Aesthetic Dentistry of the Smile Line
Arun Nayyar DMD, MS
The Clinical Problem (Figs. 24.1A,
24.2A, 24.3A, 24.4A, 24.5A,
and 24.6A)
1. Bleaching of discolored teeth
2. Improving tooth length to enhance the smile line
3. Surgical correction of hard and soft tissue to correct
anatomic disparities and subsequent dental procedure
4. Restoring worn and missing spaces with crowns, veneers,
and implants
5. Treating a single tooth space with an implant, eliminating
the need for a bridge, which involves a reduction of two
adjacent teeth
Denture wearers have an improved quality of life with an
implant-supported fixed prosthesis. In facial cosmetic plastic
surgery, the smile line plays a dominant role in a successful
outcome. A plastic surgeon provides appearance-related facial
surgery. The combined efforts of a plastic surgeon and dentist
experienced in smile management result in a detailed pretreat­
ment plan, with predictable outcomes.
Presurgical analysis by the dentist helps develop critically
needed information for the surgeon, including a comprehensive
analysis of the skeletal abnormalities of the upper and lower
arches. These findings can assist the surgeon with treatment
options related to management of a protruding maxilla or a
retruded mandible. Detailed information can be obtained with
regard to smile analysis, high lip line, and related issues, which
can be corrected during surgery.
The role of the dentist in appearance-related dentistry and
enhancement of a smile line has been well documented.
Examples are presented in this chapter to help understand the
synergy between the surgical skills of a plastic surgeon and
the treatment that results in further enhancement rendered by
a dentist. Sometimes, the dentistry is completed prior to surgery.
In such situations, the dental work provides comprehensive
details and landmarks that the plastic surgeon can use as refer­
ences for the final surgical outcome.
Issues that detract from a pleasing smile include the
following:
1. Crooked broken teeth, spacing, or disparity in gum
height
2. Discolored teeth
3. Disproportionate facial growth
4. Bite collapse due to grinding, decay, or poor oral
habits
5. Facial collapse due to tooth and bone loss
6. Poor smile due to missing spaces
7. Facial collapse due to bone loss from extractions
Dental treatment options that enhance the appearance of
an individual include the following:
1. Space management with orthodontics, veneers,
crowns, and implants
2. Tooth whitening
3. Oral maxillofacial surgery, including hard and soft
tissue reduction
Overgrown gums (gummy smile) can be improved with
recontouring of the soft and hard tissue.
4. Worn and broken teeth, as well as missing spaces,
restored with veneers, crowns, and implant-supported
restorations
5. Single missing tooth space restored with
implant-supported crown
6. Rehabilitation of patients with no teeth with implants
and fixed prosthesis, resulting in excellent facial
support and long-term benefits
Examples of dental treatments that can lead to excellent
outcomes are presented here for a better understanding of the

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    CHAPTER 24  •  Aesthetic Dentistry of the Smile Line
Case 24.2: Smile Enhancement With Tooth
Whitening (Fig. 24.2)
Bleaching material can be safely used to whiten discolored
teeth. The technique is well proven and does not harm the
underlined tooth structure. Home bleaching is the norm, and
some patients may prefer in-office power bleaching. The
bleaching material removes microscopic stains embedded within
the body of enamel structure, resulting in a whiter, brighter
smile.
Case 24.3: Skeletal Asymmetry (Fig. 24.3)
The patient presented with excessive maxillary bone, resulting
in a high lip line. The retruded mandible also affects the patient’s
facial features. A comprehensive treatment plan developed
with the team effort of an orthodontist, surgeon, and dentist
resulted in a positive outcome. Treatment phase consisted of
an orthodontic procedure followed by Le Fort I maxillary
correction and mandibular recontouring.
role of the dentist in appearance-related plastic surgery
procedures.
Case 24.1: Resolving Space and Gummy
Smile (Fig. 24.1)
The patient presented with an uneven and gummy smile, drifted
teeth, and spaces present, which resulted in an unappealing
smile. Soft and hard tissue recontouring was completed, fol­
lowed by 10 porcelain veneers. The even coloration and gingival
contour complements the smile and is well expressed in the
patient’s eyes.
A conservative approach to treatment of discolored teeth
is conservative tooth shaping with ceramic veneers bonded to
the teeth. This approach is minimally invasive, and the clinical
outcome is very predictable. The dentist can control the size,
shape, and color. In these situations, a higher quality of smile
aesthetics is achieved by veneering a minimum of 10 teeth
from premolar to premolar. A patient with a very wide smile
may require coverage of the molars. Note that the buccal
corridors are well filled and complement the lip line.
A
B
FIGURE 24.1  (A) The aesthetic problem—short teeth, disparity in gums, and tipped teeth in the buckle corners. (B) Treatment technique—orthodontic tooth movement,
with surgical soft and hard tissue shaping. (Courtesy of Dr. Gerald Benjamin.)
A
B
FIGURE 24.2  (A) The aesthetic problem—patient presented with a discolored tooth due to injury. (B) Treatment technique—included root canal and internal bleaching.
This approach eliminates the need for a full crown. (Courtesy of Dr. Yogesh Virmani.)

191
The Clinical Problem (Figs. 24.1A, 24.2A, 24.3A, 24.4A, 24.5A, and 24.6A)
three implants to restore the upper left quadrant; veneers and
crowns were cemented over the teeth and implant abutments.
Case 24.5: Missing Teeth and Implants
(Fig. 24.5)
The traditional technique of restoring a missing space with a
three-unit bridge has now been replaced with a single implant
in place and restored with a crown. The longevity of implants
is three to five times longer than a bridge. The preferred
technique is an implant and crown. This technique is minimally
invasive, and the adjacent teeth do not have to be included in
the restoration, as has to be done when a bridge is made.
Case 24.4: Oral Reconstruction for Broken,
Discolored, and Missing Teeth With a Poor
Smile and Facial Collapse (Fig. 24.4)
Good preventive care can prolong the clinical health of dental
tooth structures. However, many older patients present with
worn teeth, discoloration, drifted spacing, and bite collapse.
These patients require a comprehensive full-mouth reconstruc­
tion. A detailed treatment plan includes diagnostic analysis,
interim treatment, and final restorations.
Implant-supported fixed restorations have replaced the use
of a removable partial denture in many clinical situations. For
this patient, a full mouth reconstruction was completed, including
A
B
FIGURE 24.3  (A) The aesthetic problem—smile line of the patient is compromised due to disproportionate growth of the upper and lower jaws and display of excessive
gums. (B) Treatment technique—surgical correction included a Le Fort procedure and chin reduction, followed by orthodontic treatment. To enhance the lip line further, the
patient elected to have veneers. This approach eliminated excessive gum visibility and improved the smile line. (Courtesy of Dr. Sandesh Mayekar.)
A
B
FIGURE 24.4  (A) The aesthetic problem—a comprehensive oral reconstruction is indicated for a patient with a poor smile line due to discolored or worn teeth, old
restorations, and missing spaces. (B) Treatment technique—a detailed analysis is needed to establish a treatment protocol. Soft and hard tissues are surgically contoured
for an aesthetic smile line. Implants placed in missing spaces eliminate the need for a partial denture. Full mouth reconstruction was completed with veneers, crowns, and
implant-supported restorations. (Courtesy of Dr. John Highsmith.)

192
    CHAPTER 24  •  Aesthetic Dentistry of the Smile Line
The patient can function in the same manner as when she or
he had natural teeth. Patients can enjoy the benefit of a fixed
prosthesis that does not have to be removed every night.
Patients with missing teeth were traditionally condemned
to wear removable dentures, which caused discomfort and
long-term bone loss. Today, patients have the option of restoring
their mouths with mini or conventional implant-supported,
removable, complete dentures.
The best clinical option today is an implant-supported, screw
retained fixed prosthesis. At least four or more implants are
placed in each arch, over which a metal framework is fitted.
This framework is covered with gingival color resin and
appropriate resin teeth. The entire assembly is then put into
place with screws. This prosthesis is fixed to the implants and
is the best treatment of choice.
Case 24.6: Screw-Retained Fixed
Teeth Over Implants—The Best
Choice (Fig. 24.6)
With over two decades of proven success, implant-supported
fixed restorations are the treatment of choice to replace missing
teeth. This is applicable for single and multiple missing spaces,
and has been found to be the best method of treatment for
patients with no teeth. Implant-supported full arch rehabilitation
is accomplished with teeth attached to the implants with screws.
The technique and excellent outcome are described below.
The screw-retained prosthesis provides facial support and
an aesthetic smile, stimulates bone, and prevents bone loss.
A
B
FIGURE 24.5  (A) The aesthetic problem—the traditional technique of restoring a missing space has been a three-unit bridge that requires the reduction of adjacent teeth.
A single-unit implant is a good treatment option. (B) Treatment technique—a single-unit implant restored with a custom-made abutment and well-contoured crown is a
successful long-term treatment of choice. (Courtesy of Dr. John Highsmith.)
A
B
FIGURE 24.6  (A) The aesthetic problem—the management of an edentulous arch was a removable denture. A fixed prosthesis retained with screws to implants integrated
in the bone eliminates the problems associated with removable dentures. (B) Treatment technique—four to six implants surgically placed in selective sites in the bone.
Excellent osseointegration is observed. The implants provide excellent support for a screw-retained prosthesis. These restorations are greatly preferred by the patient and
have universal acceptance. This technique replaces the use of removable dentures. (Courtesy of Dr. Larry Holt.)

195
Surgical Preparation and Technique
195
25 
The Small Breast
Henrique P.L. Cintra MD
The Clinical Problem (Fig. 25.1)
Hypomastia is usually a developmental issue but may also be
seen after pregnancy, breastfeeding, or major weight loss. It is
well known how negatively the size, shape, and symmetry of
a woman’s breast may affect her mental and physical
well-being.
Women with severe developmental hypomastia should not
expect significant breast augmentation but aim to have more
normal-looking breasts. This more conservative approach is
intended to improve their negative self-image perception and
their fear of very noticeable changes.
In contrast, women with involutional hypomastia are in
their 30s, may have already breast-fed, and are disappointed
with the loss of skin elasticity volume and consistency of residual
breast tissue. Their aesthetic perception is linked to previous
size or to the increased breast size seen in pregnancy. It is not
uncommon to see a patient who carries a picture of her breast­
feeding period showing this as the desired size.
Surgical Preparation and Technique
Management and Treatment Options
Smooth, round, silicone elastomer–containing silicone gel
implants have been available since the beginning of modern
breast augmentation surgery, when they were introduced in
1962 by Cronin and Gerow,1 but capsular contracture has always
been of greatest concern in the years following. To lower
capsular contracture rates, a coat of polyurethane foam was
first applied to the implant’s surfaces in 1969 by Ashley2; since
then, it has been reported as the most successful device to
avoid periprosthetic capsular contracture.
Later on, in an attempt to reproduce the surface appearance
of polyurethane, textured implants were developed. However,
polyurethane implants, as compared to smooth and textured
implants, remain the best option for the treatment of recalci­
trant capsular contracture, although thicker shells and a more
cohesive gel can also contribute to lowering the rate of this
complication.
With the biodimensional concept, cohesive gel stable form
implants, with different shapes and projections, became available
to assist a wide spectrum of anatomic variations. Interestingly,
Ashley’s first polyurethane implants were an anatomic teardrop
shape. Round implants, containing less cohesive gel and placed
in submuscular pockets, will assume a teardrop shape when
the patient is standing.
A round implant has, on average, 15% more gel than an
anatomic one with the same base and projection, making it
heavier and leading to greater distention of the lower pole of
the breast. This bottoming out is associated with an early relapse
of breast ptosis after mastopexy with breast augmentation or
with implant-induced breast ptosis.
As a general rule, the ideal implant should be as light as
possible. Its volume distribution should be customized to
individual anatomic variants and the patient’s preference.
Assessment of Problem: Anatomic
Description
The breast parenchymal base width may not be adequate to
hide the implant’s edges perfectly. Also, young patients may
have very firm skin, which limits the available projection of
the breast mound.
It must be stressed to the patient that selection of the ideal
implant is based on biodimensional analysis and not on its
volume, because obviously the same size of implant will look
different in different body types. To customize breast augmenta­
tion, the width and height of the parenchyma footplate, the

196
    CHAPTER 25  •  The Small Breast
• Breast parenchyma footplate
• Height of the breast in the chest wall
• Chest width
In addition to these measurements, breast parenchyma
distribution and mobility must be evaluated, together with
estimating skin elasticity. A pinch test is used to evaluate the
thickness of the tissues in the upper pole. In my opinion, a
pinch test of less than 2 cm will often indicate the need for
subpectoral placement of the implant. If polyurethane implants
are chosen for very thin patients with poor tissue coverage,
it is preferable to use the split muscle technique (Fig. 25.3).
This is a dual-plane approach from a subglandular dissec­
tion of the lower breast, followed by blunt division of the
pectoralis major muscle fibers at the nipple areola complex
level, entering a submuscular plane between the pectoralis
major and minor. The retropectoral technique, as described
by Tebbets,3 is better indicated for smooth and textured
implants.
distances between the suprasternal notch to the nipple, between
the nipples, and from the nipple to the inframammary sulcus,
and the intermammary distance are measured.
Key landmarks are as follows (Fig. 25.2):
• Suprasternal notch
• Nipple areola complex
• Inframammary fold
FIGURE 25.1  The clinical problem.
S
N
IMF
FIGURE 25.2  Key landmarks for morphometric analysis. The intramammary
distance is indicated by the green arrow; the nipple to nipple distance is indicated
by the red arrow; the nipple (N) to inframammary fold (IMF) distance is indicated
by the blue arrow; the suprasternal notch (S) to nipple distance is indicated by the
yellow arrows; dotted lines indicate the parenchyma footplate.
A
B
FIGURE 25.3  (A) Split muscle technique. Pectoralis major muscle fibers are
divided at the level of the nipple areola complex to maximize tissue coverage
in patients with less than 2-cm pinch test in the upper pole of the breast. Due
to the strong adherence of polyurethane implants, it can be predicted that the
muscle will not slip on the implant, ensuring proper coverage. (B) The
retropectoralis plane, as described by Tebbets,3 is better indicated for textured or
smooth implants.

197
Surgical Preparation and Technique
short to fit the lower pole of the implant, the sulcus has to be
lowered; otherwise, the incision will be visible when the implant
settles down in the chest.
The disadvantages may be troublesome scars.
Infra-areolar
This incision is placed in the bottom half of the areola and,
although the scar is in a visible place, it fades very well.
Disadvantages are as follows:
• A small areolar perimeter is not suitable for larger
implants.
• Transection of mammary ducts contaminated by
Staphylococcus epidermidis can lead to the formation of
biofilm.
Axillary
The axillary incision is ideal when no scar is desired in the
breast, and hypertrophic scars are a major concern. It is best
suited for small breasts with little or no ptosis.
Disadvantages include the following:
• There may be difficulty with hemostasis from this
remote access port.
• Dissection of the lower breast is hampered, especially
in constricted lower pole breast tissue.
• Placing the implant in a proper position may be
difficult if anatomic implants are being used.
PLANE OF DISSECTION
Subglandular Plane
In my opinion, subglandular implants will more effectively
restore breast shape and correct ptosis than submuscular
implants. When considering prepectoral implantation, adequacy
of soft tissue cover of the implant is critical, because rippling
and waving deformities may arise.
Subfascial Plane
An additional pocket, which has been introduced more recently
and advocated by some, is the subpectoral fascial pocket. Some
studies have noted that this thin layer of tough tissue offers
the advantage of subglandular placement, with a thicker soft
tissue cover. For lower pole expansion, the pocket can be
extrafascial inferiorly and subfascial superiorly for better results.
Submuscular Plane
The pectoral muscle can be horizontally divided at various
levels, described as dual-plane maneuvers, to allow varying
degrees of submuscular to subglandular implant coverage.
The advantages of submuscular implantation are as follows:
1. Lower incidence of capsular contracture
2. Improved breast contour, because the edges of the
implant are blunted by the muscle
3. Less exposure of the prosthesis to bacterial contaminants
from glandular tissue
4. A plane of dissection that is less vascular than with
retroglandular implant placement
5. Maximal preservation of nipple sensation
Implant Selection
■ Tight skin and gland envelope—select implants with low
to moderate projection.
■ Involutional hypomastia in patients with more elastic
skin and gland envelope—select high-profile implants.
■ A constricted lower breast needs more filling in the lower
breast than in the upper breast—select an anatomically
shaped implant.
■ A deflated breast with a flattened central mound needs
more projection—select a round or polyurethane-coated
conical implant.
■ If a patient requires a fuller décolleté—select a round
implant.
Treatment and Operative Technique
ANESTHESIA
Use local infiltrative and intravenous sedation, thoracic
epidural blockade, and intravenous sedation, or use general
anesthesia.
INCISIONS
Inframammary (Fig. 25.4)
This permits complete visualization of the prepectoral or
subglandular pockets and allows precise placement of virtually
all implants. The limits of the inframammary incision are the
midline of the breast and anterior axillary line; its length is
from 4 to 6 cm. This more lateral placement of the incision
helps hide it under the breast.
The incision must be placed at the ideal position of the
sulcus. If the distance from the areola to the real sulcus is too
FIGURE 25.4  An inframammary incision is made between the midbreast line and
anterior axillary line, exactly at the placement of inframammary fold. In this case, it
was lowered to increase the base of a constricted breast.

198
    CHAPTER 25  •  The Small Breast
Polyurethane-coated implants adhere well in the surgical
pouch, and no massage is necessary. The breasts are firmer in
the first year, and the upper pole may be a little bit fuller.
After this, softness will continuously improve, and it will take
more than 10 years to notice the first signs of capsular
contracture.
Case Studies
See Figs. 25.6–25.9.
Complications
Perioperative Complications
Hematoma: immediate evacuation is recommended.
Nonoperative management of small hematoma is
possible but there is an increased risk of late capsular
contracture
Seroma: usually are resorbed after a week.
Infection: Staphylococcus epidermidis is the most frequent
pathogen. A significant number of infections respond
to antibiotics if therapy is initiated in the early phase
of the infection. If infection progresses then the
implant must be removed.
Mondor’s disease is a superficial thrombophlebitis
affecting the veins along the inferior aspect of the
breast and chest wall. It is a self-limiting process that
resolves after a few weeks.
Implant exposure and extrusion may occur after an infection
or wound dehiscence. The implant may be preserved in the
surgical pouch, but has to be removed if infection
progresses.
When malpositioning occurs with a polyurethane implant,
the solution is surgical revision in the first 3 weeks, because
after this the implant will not be mobilized in the surgical
pouch. If smooth or textured implants are malpositioned,
applying elastic straps and bandage with continuous pressure
may help until the periprosthetic capsule contracts and stabilizes
the implant position.
Delayed Complications
Chronic Seroma.  A late seroma may arise after a low-grade
infection or just from the continuous movements of a rough
surface, which have originated from an inflammatory response.
Recalcitrant seroma must be investigated because breast implant
associated anaplastic large cell lymphoma (BIA-ALCL) has to
be ruled out by cytology studies. Chronic seroma requires
capsulectomy, with or without implant replacement.
Capsular Contracture.  Capsules classified as Baker grades 3
and 4 require explantation with partial or complete capsulec­
tomy. If the implant is retroglandular, a change of plane is
advised.
Rotation and Displacement.  This is more often observed with
anatomically textured implants but will rarely happen with
polyurethane-coated implants. However, if delamination of
the polyurethane coat occurs, the elastomer will not adhere to
the periprosthetic capsule and may rotate. Reoperation is
☛ Tips and Tricks
To make the manipulation of the implant as sterile as possible,
a strict ritual should be followed, in which, before the introduc­
tion of the implant, the patient’s skin is renewed with antisepsis,
and gloves are changed (Fig. 25.5). Only then can the implant
be manipulated, which is transferred via a sterile sleeve into
the surgical cavity.
Drains are placed through a stab incision in the armpit and
left for at least 6 hours. The average drainage volume is 150 mL
of hemoserous fluid. This is mainly composed of the local
anesthetic infiltrate that leaks from the parenchyma into the
surgical cavity once the implant is inserted and compresses
the surrounding tissues.
Although controversial, in my experience, the use of drains
avoids the disappointment of the patient seeing a large breast
that deflates when the fluid is reabsorbed after 1 week. In
addition to this emotional issue, if polyurethane implants are
used, it is paramount to have a very dry operative field, because
any fluid entrapped between the glandular surface and poly­
urethane foam will prevent the formation of a good capsule.
Postoperative Care
Because the surface of the implant interferes with healing,
specific aftercare for each type of implant is adopted. Smooth
implants have a higher propensity to capsular contracture, so
the surgical pouches are made larger, and implants must be
mobilized after 3 days.
Textured implants are usually placed in the retropectoralis
muscle plane and may be displaced upward with muscle
contraction. To avoid this superior displacement, a circumfer­
ential elastic strap is placed around the upper chest in the
early postoperative period. Surgical pockets are tightly adjusted
to the implant to avoid rotation and displacement. Extreme
physical activities should be avoided for 1 month.
FIGURE 25.5  No-touch technique. The surgeon’s gloves are changed before
handling the implant, which is wrapped in a sterile sleeve to minimize biofilm
formation.
Text continued on p. 203

199
Postoperative Care
A
B
C
D
FIGURE 25.6  (A) Preoperative frontal view of a patient with a constricted lower breast. (B) Postoperative frontal view of breast augmentation with a 275-mL anatomic
polyurethane implant. The inframammary fold was lowered, and the constriction of the lower breast was released with radial incisions. (C) Preoperative lateral view.
(D) Postoperative lateral view.

200
    CHAPTER 25  •  The Small Breast
A
B
C
D
FIGURE 25.7  (A) Preoperative frontal view of a very thin patient with developmental hypomastia. The nipple to inframammary fold was too short, and the upper breast
pinch test was less than 2 cm. (B) Postoperative frontal view after breast augmentation with a 235-mL anatomic polyurethane implant. The inframammary sulcus was
lowered to increase the lower ventral curvature. (C) Preoperative lateral view. (D) Postoperative lateral view. The split muscle technique allows a smooth transition between
the chest wall and the upper pole of the implant.

201
Postoperative Care
B
A
C
D
FIGURE 25.8  (A) This patient has postpregnancy involutional hypomastia. The whole breast is deflated and saggy. (B) Postoperative frontal view after breast augmentation
with a 300-mL conical implant, with a moderate profile. (C) Preoperative lateral view. (D) Postoperative lateral view.

202
    CHAPTER 25  •  The Small Breast
A
C
D
B
FIGURE 25.9  (A) Preoperative front view of a very tall and thin young lady. The upper chest was longer than large, with inadequate tissue coverage. (B) Postoperative
front view after split muscle technique for breast augmentation with a 280-mL anatomic polyurethane implant with moderate profile. (C) Preoperative lateral view.
(D) Postoperative lateral view.

203
Postoperative Care
References
1.
Cronin, T.D., Gerow, F.J., 1963. Augmentation mammaplasty: a new
“natural feel” prosthesis. In: Transactions of the Third International
Congress of Plastic and Reconstructive Surgery. Excerpta Medica.
2.
Ashley, F.L., 1970. A new type of breast prosthesis; preliminary report.
Plast. Reconstr. Surg. 45, 421–424.
3.
Tebbets, J.B., 2002. A system for breast implant selection based on
patient tissue characteristics and implant soft tissue dynamics. Plast.
Reconstr. Surg. 109, 1396–1409.
Further Reading
Hester, T.R., Jr., Nahai, F., Bostwick, J., Cukic, J., 1988. A 5-year experience
with polyurethane-covered mammary prostheses for treatment of
capsular contracture, primary augmentation and breast reconstruction.
Clin. Plast. Surg. 15, 569–585.
Handel, N., Silverstein, M.J., Jensen, J.A., et al., 1991. Comparative experience
with smooth and polyurethane breast implants using the Kaplan-Meier
method of survival analysis. Plast. Reconstr. Surg. 88, 475–481.
Hedén, P., Jernbeck, J., Hober, M., 2001. Breast augmentation with anatomical
cohesive breast implants. Clin. Plast. Surg. 28, 531–552.
Sabino Neto, M., Abla, L.E.P., Lemos, A.L., et al., 2012. The impact of
surgical treatment on the self-esteem of patients with breast hypertrophy,
hypomastia, or breast asymmetry. Aesthetic Plast. Surg. 36, 223–225.
Wang, T.Y., Albornoz, C., Hu, Q., et al., 2014. Abstract 9: a 10-year experience
of routine MRI screening for silicon implant rupture: are FDA recom­
mendations supported by evidence? Plast. Reconstr. Surg. 133, 978.
required to change the implant and to adjust the surgical pouch
with sutures or capsuloplasty. For polyurethane implants, simple
replacement is enough.
Implant-Induced Ptosis.  The weight of a large breast implant
applied over thinning tissues that are progressively stretched
for years may lead to a lengthening of the lower breast. This
may require mastopexy and replacement with a smaller implant.
Rippling and Waving.  When the dimensions of the patient’s
soft tissue do not match the implant size, skin wrinkling and
implant palpability arise from folding of the implant shell.
Because inadequate coverage is the main cause of this deformity,
initial implant size selection is critical. If the implant is retro­
glandular, and the upper breast is too thin, placement must
be changed into a submuscular plane, maximizing the coverage
stitching of the upper halves of the capsule to each other and
using microfat injection superficial to the capsule in the upper
breast to minimize the risk of intracapsular injection.
Implant Extrusion.  Progressive thinning of the lower breast
under the pressure of a hard edge may lead to ischemic necrosis
and exposure of the implant. After removing the implant, it
is advisable to wait for healing and reorganization of the lower
breast tissue before replacement.
Implant Rupture.  This is one of the most serious complications
and concerns of patients. Silent rupture may occur without
any clinical sign being noticed by the patient or physician;
therefore, magnetic resonance imaging is recommended for
evaluating breast implant integrity if a suspicion arises.

205
Surgical Preparation and Technique
205
26 
The Clinical Problem
Breast hypertrophy is a frequent condition in women. It may
occur due to excessive development of glandular tissue during
puberty, secondary to weight gain or as a result of naturally
occurring fat deposition of breast tissue that takes place with
aging.
In this chapter, based on a case report, we will discuss clinical
findings, expectations, surgical techniques, postoperative
evolution, and possible complications.
During puberty, RB saw her breasts develop rapidly. Her
clothes wouldn’t fit right—she would often have to buy larger
garments for her upper body—her brassiere would hurt her
shoulders, and she could not adequately cushion her breasts
during sports activities.
Secondary to the increase in volume and weight of her
breasts, the skin of her breasts stretched, along with all of
their support system (Cooper’s ligaments), which led to breast
ptosis that resulted in both caudal and lateral placement
of the nipple-areola complex. She started to frequently feel
pain in her back and cervical region, which led her to seek
medical help.
At physical examination, the patient presented with large-
based breasts that were bulkier in their lower pole, with a loss
in cleavage volume (at the projection of upper quadrants; Fig.
26.1). Her inframammary folds showed signs of dermatitis
caused by the folding of the breasts over the abdomen, and
her shoulders had visible sites of skin depression caused by
the brassiere straps. Undoubtedly, there was an indication for
surgical treatment of her breasts.
Surgical Preparation and Technique
Management and Treatment Options
Treatment for breast hypertrophy is surgical, through breast
reduction. Surgery has three main objectives:
1. Reducing the amount of breast tissue (glandular or
fatty)
2. Correcting the shape of breasts
3. Cranially repositioning the nipple-areola complex (NAC),
thus bringing a more aesthetic shape for breasts
During the preoperative evaluation, it is important to do
the following:
• Evaluate the patient’s weight.
• Get adequate imaging (ultrasound [US],
mammography, magnetic resonance imaging [MRI])
under the guidance of a breast disease specialist.
• Inform the patient about placement and size of
surgery scars.
• Inform the patient about the possible impact on
breastfeeding, and discuss all other possible
complications.
Many techniques have been developed,1–3 with modifications
performed mainly on the incisions and pedicles used.
Techniques using periareolar incisions, with a vertical exten­
sion, lateral extension (L), and Wise pattern (anchor) have been
developed and are used according to the preferences of the
patient and surgeon. The Wise pattern is drawn with the junction
Breast Reduction: Superomedial Pedicle
Wise-Pattern Approach
Alexandre S.F. Fonseca MD, PhD
Guilherme Flosi Stocchero MD
Gustavo Flosi Stocchero MD

206
    CHAPTER 26  •  Breast Reduction: Superomedial Pedicle Wise-Pattern Approach
8. En bloc resection
9. Cranial rotation of the superomedial pedicle
10. Closure of the breast pillars with 3-0 polyamide sutures
(Fig. 26.4)
11. Skin closure of points BCD with 4-0 polyamide sutures
12. Skin closure of the vertical incision 6 cm above the point
BCD with 4-0 polyamide sutures, determining the
inferior limit of the areola
13. Demarcation of the areola aperture with an areola
marker
14. Trimming of the areola aperture through
de-epithelialization of the demarcated area
15. Closure of incisions using interrupted subdermal 3-0
absorbable sutures and running subcuticular 4-0
absorbable sutures
of two ellipses, one horizontal and another one vertical, which
allow for skin redraping over the breasts in a tridimensional
fashion, thus helping the reshaping and aesthetic projection
of the breasts.
Although surgery for reduction of large breasts will fre­
quently result in extensive scars, patients will usually accept
them in exchange for the reduction in their weight and volume
and the more adequate reshaping and replacement of the breasts.
Improvements in self-esteem and well-being have already been
proven by scientific studies.
Among the most frequently used pedicles in breast reduction,
the inferior and the superomedial pedicles stand out due to their
versatility and possibility of being used even for gigantomastia
patients. The superomedial pedicle is our preferred choice.
The choice of the superomedial pedicle presents some
advantages, among them the ability of safely lifting the NAC
for many centimeters because of the presence of branches from
the perforator vessels of the second intercostal space (ICS).
Another advantage is the possibility of shaping the pedicle
with a smaller thickness (2 cm), thus allowing for greater
mobility of the NAC and allowing for resection of breast tissue
in all quadrants.4 It is also important to note that the supero­
medial pedicle preserves the cleavage (projection of the upper
medial quadrants) better than the inferior pedicle.5
Even so, in situations in which the distance between the
NAC and suprasternal notch is much greater than the distance
between the NAC and inframammary fold (IMF), use of the
inferior pedicle should be considered.
Treatment and Operative Technique
This involves the following factors:
1. Preoperative markings using the Wise pattern (Fig. 26.2)
2. Incision over the IMF
3. Subglandular undermining of the entire breast
4. Demarcation of the areolar incision using an areola marker
5. De-epithelialization of the pedicle
6. Shaping of the full-thickness pedicle with a scalpel,
perpendicular to the markings (Fig. 26.3)
7. Incision over the remaining markings (AC, CC′, BB′).
A
B
C
FIGURE 26.1  (A) Preoperative frontal view. (B) Preoperative right oblique view. (C) Preoperative right lateral view.
C’
A
A
B
B
11cm
11cm
C
C
C’
B’
D
D
B’
FIGURE 26.2  Preoperative markings.

207
Postoperative Plan
brassieres must be used for 30 days. The patient must avoid
exercising for 60 days.
The patient discussed in this chapter showed a good outcome,
with no complications. Excised breast tissue amounted to 680 g
from the left breast and 650 g from the right breast. The results
achieved were quite satisfactory, according to the surgeon and
patient’s opinions. The patient related experiencing great relief
from her former symptoms (Fig. 26.5). Breast reduction has
brought greater harmony and better shape of breasts (Fig. 26.6)
with the correction of ptosis and a better distribution of breast
parenchyma among the quadrants (Fig. 26.7).
Postoperative Plan
The patient must avoid moving her arms above her shoulders
for 72 hours and avoid lying down in a ventral or lateral position.
Analgesics should be prescribed according to the patient’s
demand. Prophylactic antibiotics should be used for 24 hours.
Dressings should not be wet for 2 to 3 days. After that, the
surgeon will replace them with microporous adhesive for 7 to
10 days. Drains may be used according to the surgeon’s prefer­
ence. Carrying heavy objects must be avoided. Surgical
A
B
FIGURE 26.3  (A) Superomedial pedicle. (B) En bloc mammary resection.
A
B
6cm
11cm
FIGURE 26.4  (A) Areolar repositioning, 6 cm above the inframammary fold. (B) Closing sutures.

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    CHAPTER 26  •  Breast Reduction: Superomedial Pedicle Wise-Pattern Approach
A
B
C
FIGURE 26.5  (A) Postoperative frontal view. (B) Postoperative right oblique view. (C) Postoperative right lateral view.
A
D
E
F
B
C
FIGURE 26.6  Preoperative and postoperative comparisons. (A) Preoperative frontal view. (B) Preoperative right oblique view. (C) Preoperative right lateral view.
(D) Postoperative frontal view. (E) Postoperative right oblique view. (F) Postoperative right lateral view.