Review of Plastic Surgery – Donal W. Buck II

Basal Cell Carcinoma
239
24
Figure 24.3.  Clinical spectrum of nodular basal cell carcinoma (BCC). A, Translucent papulonodule with prominent telangiectasia on the
infraorbital cheek. B, Classic presentation with a pearly, rolled border and central, hemorrhagic crust. C, Dermoscopy of a pigmented BCC
demonstrating arborizing telangiectasia and multiple, bluish-gray, ovoid globules, pointing to the diagnosis of a small, nodular BCC; the one
large, bluish-brown structure resembles, but does not fulfill all the criteria for a large, bluish-gray, ovoid nest. D, Larger plaque with rolled
borders and multiple telangiectasia. E, Nodulo-ulcerative tumor of the preauricular region with translucent, rolled borders, most obvious at
the 12:00 location. (Reprinted from Bolognia, J.L., Jorizzo, J.L., Schaffer, J.V. [Eds.], 2012. Dermatology, 3rd ed. Elsevier, 1773–1793. A, Courtesy Stanley J Miller,
M.D.; C, courtesy Giuseppe Argenziano, M.D.)
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• Topical therapy
■ Imiquimod (Aldara): Approved for treatment of
superficial BCC, although typically reserved for lesions
that are not amenable to resection
• Radiation
■ Typically reserved for patients who cannot undergo
excision (e.g., elderly, significant comorbidities)
8. Gorlin syndrome (nevoid BCC syndrome)
• Rare, autosomal dominant disorder
• PTCH gene mutation
• Characterized by
■ Multiple or early-onset BCC
■ Odontogenic keratocysts
■ Palmar and plantar pits

Malignant Skin Conditions
240
■ Calcifications of the falx cerebri
■ Skeletal abnormalities
• Patients may also develop medulloblastomas,
meningiomas, and fibromas.
• BCCs typically appear after puberty but may occur in
childhood.
■ Exquisitely sensitive to radiation
• Diagnosis: Requires two major or one major and two
minor criteria (see Box 24.2)
BOX 24.2  DIAGNOSTIC CRITERIA FOR NEVOID BASAL
CELL CARCINOMA* SYNDROME
Major criteria
1. More than two BCCs or one BCC before the age of
20 years
2. Odontogenic keratocysts of the jaw (proven by
histology)
3. Three or more palmar or plantar pits
4. Bilamellar calcification of the falx cerebri
5. Bifid, fused, or markedly splayed ribs
6. First-degree relative with NBCC syndrome
Minor criteria
1. Macrocephaly (determined after adjustment for height)
2. Congenital malformations: Cleft lip or palate, frontal
bossing, “coarse face,” moderate or severe
hypertelorism
3. Other skeletal abnormalities: Sprengel deformity,**
marked pectus deformity, marked syndactyly of the
digits
4. Radiographic abnormalities: Bridging of the sella
turcica, vertebral anomalies such as hemivertebrae and
fusion or elongation of the vertebral bodies, modeling
defects of the hands and feet, flame-shaped lucencies
of the hands or feet
5. Bilateral ovarian fibroma
6. Medulloblastoma
**Unilateral elevation of smaller-sized scapula.
*The diagnosis of NBCC syndrome requires two major or one major
and two minor criteria.
Adapted from Kimonis, V.E., Goldstein, A.M., Pastakia, B., et al.,
1997. Clinical manifestations in 105 persons with nevoid basal cell
carcinoma syndrome. Am. J. Med. Genet. 69, 299–308.
BCC, Basal cell carcinoma; NBCC, Nevoid basal cell carcinoma.
• Treatment: Topical therapy, surgical excision, close
observation for development of neoplasms
Squamous Cell Carcinoma (SCC)
1. Second most common skin malignancy overall; most
common skin malignancy on the hand
2. Typically occurs on the face, hands, and forearms (sun-
exposed areas)
• ~60% of external ear tumors are SCC
• Frequently involves the lower lip
• Can also occur on the penis
3. SCC has an in situ variant and can develop from a precursor
lesion (actinic keratosis [AK]) and in association with human
papilloma virus (HPV) infection; also has the ability to
metastasize to lymph nodes and/or hematogenously
4. Risk factors for SCC the same as for BCC but also include
HPV infection, arsenic exposure, and chronic inflammatory
states (e.g., chronic wounds, burn scars)
5. Risk of recurrence, metastasis, and poor prognosis are
increased with poor differentiation, perineural invasion,
tumors >2 cm, rapid growth, and recurrence
6. Often characterized by raised, pink, plaque-like or scaly
papule, with occasional ulceration and ill-defined borders
7. Diagnosis: Similar to that of BCC
8. Histologic subtypes
• SCC in situ: Confined to the epidermis
• Bowen disease: “Erythroplasia of Queyrat” (SCC in situ) of
the penis
• Invasive SCC associated with AK
■ Located on sun-damaged/-exposed skin
■ Favorable prognosis with low risk of metastasis
• De novo invasive SCC (“Marjolin’s ulcer”)
■ High-risk variant with high rate of metastasis and poor
prognosis
■ Often occurs in immunocompromised patients and in
areas with chronic inflammation (e.g., burn scars, chronic
wounds, organ transplant patients; see Figure 24.4)
Figure 24.4.  Nodulo-ulcerative tumor. SCC on the sole that has
arisen from traumatic scars. (Reprinted from Neligan, P.C. [Ed.], 2013.
Plastic Surgery, vol. 1, 3rd ed. Elsevier, 707–742.)
• Keratocanthoma (see Figure 24.5)
■ Benign tumor that behaves like an SCC but is difficult to
differentiate histologically
■ Characterized by rapid growth with a central crater/
keratin plug
■ Can spontaneously regress
■ Treatment recommendation: Excision

Other Skin and Soft-Tissue Malignancies
241
24
• Adenoid SCC
■ Rare, ulcerated, nodular lesion on the face of elderly men
■ High rate of metastasis
9. Treatment options
• Mainstay is excision and staged reconstruction in defects
that cannot be closed primarily
■ Wide local excision with recommended 4-mm (low-risk)
or 6-mm (high-risk) margins for lesions <2 cm and up
to 1 cm in lesions >2 cm in diameter, on the hands, or
with aggressive histology (e.g., perineural invasion,
morpheaform subtype, Marjolin’s ulcer)
■ Mohs micrographic surgery (see below)
■ Amputation at the joint proximal to the lesion is
recommended for SCC that involves bone or the
nail bed.
• Sentinel lymph node (SNL) biopsy in SCC: Currently
controversial, although many advocate for SLN biopsy in
aggressive subtypes >2 cm in diameter.
• Cryotherapy and/or electrodesiccation and curettage
■ Typically reserved for multiple, low-risk, small,
superficial lesions
• Topical therapy
■ Imiquimod (Aldara): May be effective in treatment of
Bowen disease and invasive SCC, although typically
reserved for lesions that are not amenable to resection
■ Topical 5-fluorouracil (5FU): Effective in the treatment
of diffuse AK of the face
• Radiation
■ Typically reserved for patients who cannot undergo
excision (e.g., elderly, significant comorbidities), have
incompletely excised large lesions, and/or high-risk
tumors (e.g., deep SCC with perineural invasion)
Figure 24.5.  Keratoacanthoma on the nose. (Reprinted from Neligan,
P.C. [Ed.], 2013. Plastic Surgery, vol. 1, 3rd ed. Elsevier, 707–742.)
Other Skin and Soft-Tissue Malignancies
1. Merkel cell carcinoma
• Rare, highly aggressive cancer that develops just beneath
the skin and in hair follicles
• Frequently metastasizes to lymph nodes and other organs
(e.g., liver, bone, brain, lung, skin)
• Etiology: Merkel cell polyomavirus
• Characterized by a smooth, painless, nodular lesion on the
face, head, and neck
• Treatment: Wide local excision with 1- to 3-cm margins
and SLN biopsy in clinically negative nodes; adjuvant
radiation therapy is often recommended, along with
chemotherapy for distant metastases.
2. Angiosarcoma
• Malignant tumors of endothelial cells
• Aggressive tumors with a high rate of recurrence, frequent
metastases to distant sites, and poor prognosis
• Characterized by red, violaceous, nodular, or plaque-like
lesions on the face, trunk, or extremities
■ Stewart-Treves syndrome is a rare variant of
lymphangiosarcoma of the upper extremity that occurs
in postmastectomy patients.
■ Cutaneous angiosarcoma is commonly located on the
face and scalp of older men.
• Treatment: Surgical resection, radiation therapy,
chemotherapy, and immunotherapy with interleukin-2
3. Sebaceous carcinoma
• Arises from sebaceous glands and includes meibomian
gland carcinoma (eyelid), Zeis gland carcinoma, and
Montgomery gland carcinoma.
• Characterized by nodular/raised mass that can ulcerate
• High rate of lymph node metastases; thus, lymph node
biopsy/dissection is often recommended for large
lesions.
• Treatment: Wide local excision with at least 5-mm margins;
adjuvant radiation and/or chemotherapy may be useful.
4. Dermatofibrosarcoma protuberans (DFSP)
• Also known as giant cell fibroblastoma
• More than 90% associated with a chromosomal
translocation (17:22) affecting the collagen gene (COL1A1)
and the platelet-derived growth factor gene (PDGF).
• Characterized by multiple or solitary tumors that are
red, elevated, and often with a keloid appearance (see
Figure 24.6)
• Rarely metastasize but locally aggressive with high rate of
local recurrence
• Excision can be difficult because of tumor cell invasion of
local tissues with “tentacle-like” projections that appear
normal.
• Treatment: Wide resection with 5-cm margins; Mohs
micrographic surgery is useful for peripheral margin
mapping/clearance and reduces local recurrence rates;
adjuvant chemotherapy and radiation therapy may be
useful.

Malignant Skin Conditions
242
2. Advantages of Mohs
• Lower recurrence rates
• Higher cure rates
• Preservation of uninvolved skin in cosmetically sensitive
areas
• Same-day determination of margin clearance
3. General indications
• Tumors >2 cm
• Recurrent tumors or tumors in high-risk areas (e.g., eyelid,
nose, ear, lips, perineum, hands)
• Tumors with indistinct clinical margins (e.g.,
morpheaform) or aggressive features (e.g., perineural
invasion, poorly differentiated)
• Tumors in cosmetically sensitive areas
Suggested Readings
Ariyan, S., Berger, A., 2013. Chapter 31: Melanoma. In: Neligan, P.C. (Ed.),
Plastic Surgery, vol. 1, 3rd ed. Elsevier, pp. 743–785.
Arneja, J.S., Gosain, A.K., 2007. Giant congenital melanocytis nevi. Plast.
Reconstr. Surg. 120 (2), 26e–40e.
Buck, D.W., Kim, J.Y., Alam, M., et al., 2012. Multidisciplinary approach to
the management of dermatofibromasarcoma protuberans. J. Am. Acad.
Dermatol. 67 (5), 861–866.
Dzwierzynski, W.W., 2013. Managing malignant melanoma. Plast. Reconstr.
Surg. 132 (3), p. 446e–460e.
Garbe, C., Bauer, J., 2012. Chapter 113: Melanoma. In: Bolognia, J.L.,
Jorizzo, J.L., Schaffer, J.V. (Eds.), Dermatology, 3rd ed. Elsevier,
pp. 1885–1914.
Heitmann, C., Ingianni, G., 1999. Stewart-Treves syndrome:
lymphangiosarcoma following mastectomy. Ann. Plast. Surg. 44 (1),
72–75.
McMasters, K.M., Uris, M.M., 2012. Chapter 32: Melanoma and cutaneous
malignancies. In: Townsend, C.M., Beauchamp, R.D., Evers, B.M., et al.
(Eds.), Sabiston Textbook of Surgery, 19th ed. Elsevier, pp. 742–767.
Netscher, D.T., Leong, M. Orengo, I., et al., 2011. Cutaneous malignancies:
melanoma and nonmelanoma types. Plast. Reconstr. Surg. 127 (3),
37e–56e.
Ogawa, R., 2013. Chapter 30: Benign and malignant nonmelanocytic tumors
of the skin and soft tissue. In: Neligan, P.C. (Ed.), Plastic Surgery, vol. 1, 3rd
ed. Elsevier, pp. 707–742.
Soyer, H.P., Rigel, D.S., Wurm, E.M.T., 2012. Chapter 108: Actinic keratosis,
basal cell carcinoma and squamous cell carcinoma. In: Bolognia, J.L.,
Jorizzo, J.L., Schaffer, J.V. (Eds.), Dermatology, 3rd ed. Elsevier, pp.
1773–1793.
Figure 24.6.  Dermatofibrosarcoma protuberans on the abdomen.
(Reprinted from Neligan, P.C. [Ed.], 2013. Plastic Surgery, vol. 1, 3rd ed.
Elsevier, 707–742.)
5. Kaposi’s sarcoma
• Caused by human herpes virus 8 and associated with
human-immunodeficiency virus (HIV) and acquired
immune deficiency syndrome (AIDS)
• Characterized by red, purple, brown, or black nodules or
palpable blotches found on the skin
• Growth can be slow or rapid and can be associated with
significant mortality and morbidity.
• Treatment: Highly active antiretroviral therapy (HAART),
radiation therapy, cryotherapy, and chemotherapy; surgical
excision is not recommended and largely supportive
Mohs Micrographic Surgery
1. Mohs surgery can be performed for both BCC and SCC and
is more frequently being used for DFSP peripheral margin
mapping/clearance

Flaps and Microsurgery
Chapter
25 
Flap Definitions
1. Axial flap: Tissue that is based on the vascular territories of
named vascular pedicles with an axial alignment
2. Random flap: Tissue that is based off of an unnamed vascular
supply, whereby the primary vascularity is provided through
the subdermal plexus
3. Delayed flap: A flap that is incised and minimally or partially
elevated and then immediately placed back in its in situ
position to enhance flap circulation through the dilation of
choke vessels
4. Perforator flap: A flap that is designed and elevated based on
a perforating vessel within a known vascular territory,
whereby the perforator is dissected down to a known source
pedicle of sufficient length and diameter
5. Freestyle flap: A type of perforator flap that is designed
randomly off of an identified perforating vessel within a
specific region, whereby the perforator is dissected down to a
pedicle of sufficient length and diameter
6. Prelaminated flap: An axial flap that is modified with grafts
(e.g., mucosa, cartilage, or bone) to create composite tissue
structure at the donor site before flap transfer
7. Prefabricated flap (see Figure 25.1): A flap that is created by
introducing a vascular pedicle to a desired donor site that on
its own does not possess an axial blood supply. This induces
vascularization of the donor site from the pedicle before
transfer.
Figure 25.1.  1-4, Flap prefabrication technique. TE, Tissue expansion. (Reprinted from Wei, F.C., Mardini, S. [Eds.], 2009. Flaps and Reconstructive
Surgery. Elsevier, 103–116.)
Desired skin flap
1
Muscle
Deep vascular
pedicle
Pedicle with fascia
or small cuff of
muscle dissected out
Vascular pedicle
placed subcutaneously
on top of tissue expander
TE
TE
TE
Gore-Tex tubing around
proximal pedicle to
facilitate later
flap harvest
Gore-Tex
Gore-Tex
Gore-Tex
2
Expansion started
at 1 week and
continued for 8 weeks
• Tissue expanded
fully at 8 weeks
• Neovascularization
of skin and capsule
around tissue
expander
3
• Prefabricated flap is
raised off of the tissue
expander. The capsule
layer is included with
the flap
• Gore-Tex around
proximal pedicle
facilitates flap
dissection
4

Flaps and Microsurgery
244
Flap Classification
1. Mathes-Nahai classification
• Type 1: Flap vascular supply via one major pedicle
• Type 2: Via one major and one minor pedicle
• Type 3: Via two major pedicles
• Type 4: Via segmental pedicles
• Type 5: Via one major and segmental pedicles (see
Figure 25.3 and Box 25.1-25.5)
8. Tubed flap: A flap that is rolled on itself to serve as a conduit
9. Reverse flow flap: A flap that is supplied through retrograde
flow
• Venous flow is possible through communicating vein
branches along the comitantes that allow reverse shunting
of flow to bypass valves.
10. Venous flap (see Figure 25.2): A flap of skin, subcutaneous,
tissue, and a venous plexus, whereby the inflow and outflow
of the flap is through veins.
• Considered for small dorsal or palmar defects, fingers, or
hand requiring simultaneous reconstruction of venous
outflow or arterial inflow
• Arterialized venous flaps: An arteriovenous fistula is
created by anastomosing the inflow vein to a recipient
artery and the outflow vein to a vein
• Arterialized venous “flow-through” flap: The proximal and
distal veins are anastomosed to a proximal and distal artery
to create a flow-through flap.
Figure 25.2.  Classification of venous flaps. A, Type I. B, Type II.
C, Type III. (Reprinted from Neligan, P.C., Gurtner, G.C. [Eds.], 2013. Principles
in Plastic Surgery, vol. 1, 3rd ed. Elsevier, 512–572.)
Cephalad vein
Type I
Cephalad vein
Caudal vein
Artery
Caudal vein
Cephalad vein
Artery
Type II
Type III
A
B
C
Reprinted from Neligan, P.C., Gurtner, G.C., (Eds.), 2013. Principles
in Plastic Surgery, vol. 1, 3rd ed. Elsevier, 512–572.
BOX 25.1  TYPE-I VASCULAR PATTERN MUSCLES
Abductor digiti minimi (hand)
Abductor pollicis brevis
Anconeus
Colon
Deep circumflex iliac artery
First dorsal interosseous
Gastrocnemius, medial and lateral
Genioglossus
Hyoglossus
Jejunum
Longitudinalis linguae
Styloglossus
Tensor fascia lata
Transversus and verticalis linguae
Vastus lateralis
Reprinted from Neligan, P.C., Gurtner, G.C. (Eds.), 2013. Principles
in Plastic Surgery, vol. 1, 3rd ed. Elsevier, 512–572.
BOX 25.2  TYPE-II VASCULAR PATTERN MUSCLES
Abductor digiti minimi (foot)
Abductor hallucis
Brachioradialis
Coracobrachialis
Flexor carpi ulnaris
Flexor digitorum brevis
Gracilis
Hamstring (biceps femoris)
Peroneus brevis
Peroneus longus
Platysma
Rectus femoris
Soleus
Sternocleidomastoid
Trapezius
Triceps
Vastus medialis

Common Local Flaps
245
25
Figure 25.3.  Mathes-Nahai classification of muscle and musculocutaneous flaps. (Reprinted from Neligan, P.C., Gurtner, G.C. [Eds.], 2013. Principles
in Plastic Surgery, vol. 1, 3rd ed. Elsevier, 512–572.)
Type I
Type II
Type III
Type IV
Type V
Tensor fascia lata
Gracilis
Gluteus maximus
Sartorius
Latissimus dorsi
Reprinted from Neligan, P.C., Gurtner, G.C. (Eds)., 2013. Principles
in Plastic Surgery, vol. 1, 3rd ed. Elsevier, 512–572.
BOX 25.3  TYPE-III VASCULAR PATTERN MUSCLES
Gluteus maximus
Intercostal
Omentum
Orbicularis oris
Pectoralis minor
Rectus abdominis
Serratus anterior
Temporalis
Reprinted from Neligan, P.C., Gurtner, G.C. (Eds.), 2013. Principles
in Plastic Surgery, vol. 1, 3rd ed. Elsevier, 512–572.
BOX 25.4  TYPE-IV VASCULAR PATTERN MUSCLES
Extensor digitorum longus
Extensor hallucis longus
External oblique
Flexor digitorum longus
Flexor hallucis longus
Sartorius
Tibialis anterior
Reprinted from Neligan, P.C., Gurtner, G.C. (Eds.), 2013. Principles
in Plastic Surgery, vol. 1, 3rd ed. Elsevier, 512–572.
BOX 25.5  TYPE-V VASCULAR PATTERN MUSCLES
Fibula
Internal oblique
Latissimus dorsi
Pectoralis major
Common Local Flaps
1. Z plasty: Useful for increasing length along a central limb
• Degree of angles dictates the amount gained in length
■ 30 degree angle leads to a 25% gain
■ 45 degree: angle leads to a 50% gain
■ 60 degree angle leads to a 75% gain
■ 75 degree angle leads to a 100% gain
■ 90 degree angle leads to a 120% gain (see Figure 25.4)
2. W plasty: Useful for scars that cross the relaxed skin tension
lines
• Requires undermining and removal of “healthy”
surrounding tissue for closure (see Figure 25.5)
3. Rhomboid flaps: A rotation flap based on a rhomboid skin
design that allows closure of the donor site primarily (see
Figure 25.6)

Flaps and Microsurgery
246
Figure 25.4.  Z-plasty technique. A, Central limb designed along the scar. Both limbs are equal in length, and angles A and B are 60
degrees. B, The flaps are transposed and sutured. Note that the original central limb has been lengthened and the scar is reoriented.
(Reprinted from McCarthy, J.G., Galiano, R.D., Boutros, S.G. [Eds.], 2006. Current Therapy in Plastic Surgery. Elsevier, 3–10.)
A
B
A
A′
B′
B
60°
60°
A
B
Figure 25.5.  W plasty. A,B, W plasty for repair of a straight scar.
Triangles become smaller at the end of the scar. A W plasty,
however, results in excision of nonscarred skin. (Reprinted from
McCarthy, J.G., Galiano, R.D., Boutros, S.G. [Eds.], 2006. Current Therapy in
Plastic Surgery. Elsevier, 3–10.)
A
B
Figure 25.6.  Rhomboid flap. (Reprinted from McCarthy, J.G., Galiano,
R.D., Boutros, S.G. [Eds.], 2006. Current Therapy in Plastic Surgery. Elsevier,
11–21.)
60°
60°
60°
60°
60°
60°

Common Local Flaps
247
25
4. Bilobed flaps (see Figure 25.7): A double transposition flap
that allows for movement of skin over a longer distance than
possible with a single transposition flap
• Useful for reconstruction of defects within the face and
nose
Figure 25.7.  Closure of nasal defect with bilobed flap. A, 1 × 1 cm skin defect of tip. B, Bilobe flap designed for repair. Anticipated
standing cutaneous deformity marked for excision in alar groove. Linear axis of each lobe designed 45° from each other, with primary lobe
axis positioned 45° from axis of defect. C, Transfer of flap requires complete undermining of entire nasal skin. D, Flap in place. E, 1 year
postoperative. No revision surgery performed. (Reprinted from Baker, S.R., 2007. Local Flaps in Facial Reconstruction, 2nd ed. Mosby.)
A
B
C
D
E

Flaps and Microsurgery
248
• Useful for coverage of tendons, exposed joints, or in areas
where a thin fascial flap is desired
4. Facial artery musculomucosal (FAMM) flap
• Vascular supply: Sacial a.
• Dissection includes buccinators muscle
• Can be used for oronasal defects of the palate, alveolus,
and nasal septum (see Figure 25.13)
5. Submental myocutaneous flap
• Vascular supply: Submental branch of the facial a.
• Flap should include the platysma muscle
• Advantages: Good contour, color, and texture for facial
defects
• Disadvantages: Donor site scar; pedicle reach often limits
use of this flap to the central and lower third of the face
(see Figure 25.14).
Common Flaps of the Trunk
1. Pectoralis major flap
• Vascular supply: Thoracoacromial a. (major); internal
mammary perforators (minor segmental)
• Advantages: Excellent flap for head and neck (central to
lower third), upper trunk, sternal defects; salvage flap for
free-flap failures.
• Disadvantages: Donor site morbidity; cannot use as a
turnover flap for sternal coverage if the internal mammary
a. has been used for a bypass procedure
2. Trapezius flap
• Vascular supply: Occipital a. (superior third); superficial
cervical a. (middle third); dorsal scapular a. (lower third).
■ 80% of flaps have a common trunk (the transverse
cervical a.), which then branches into the superficial
cervical and dorsal scapular arteries.
■ The transverse cervical a. is often divided during a
radical neck dissection.
• Advantages: Reliable musculocutaneous flap for posterior
head and neck defects; often a salvage flap for free-flap
failures.
• Disadvantages: Donor site, skin paddle can be thick and
difficult to shape, limited skin paddle availability (see
Figure 25.15)
3. Latissimus dorsi flap
• Vascular supply: Thoracodorsal a. (major); lumbar
intercostal perforators (minor segmental)
• Advantages: Reliable flap for provision of wide, pliable
muscle, skin, and occasionally bone (can be harvested with
portion of scapula in chimeric flap); workhorse muscle flap
for free tissue transfer to the extremities, scalp, and trunk;
workhorse pedicled flap option for breast reconstruction
• Disadvantages: Donor site, limited skin paddle availability,
relatively short pedicle (can be extended with interposition
grafts)
4. Serratus anterior flap
• Vascular supply: Thoracodorsal a. (inferior muscle slips);
lateral thoracic a. (superior muscle slips)
Common Flaps of the Head and Neck
1. Scalp flaps: Highly redundant blood supply allows for
multiflap variations based off of a vascular pedicle.
• Vascular supply (see Figure 25.8): Supratrochlear a. and
supraorbital a. (anterior scalp); superficial temporal a.
(temporal scalp); posterior auricular a. (parietal scalp);
occipital a. (occipital scalp)
Figure 25.8.  Arterial and nervous supply of the scalp. (Reprinted
from Neligan, P.C., Rodriguez, E.D. [Eds.], 2013. Plastic Surgery, vol. 3, 3rd ed.
Elsevier, 105–133.)
Supratrochlear nerve
Lesser occipital
nerve
Occipital artery
Posterior auricular
artery
Superficial temporal
artery
Supraorbital artery
Supratrochlear artery
Auriculotemporal
nerve
Supraorbital nerve
Greater occipital nerve
Third occipital nerve
• Primary closure often possible for defects <3 cm in
diameter
■ May require galeal scoring to enhance tissue stretch
• Scalp rotation flaps (e.g., orticochea) are useful for defects
with a maximum diameter of 6 cm or <50% total surface
area (TSA).
■ Tissue expansion can increase available soft tissue for
rotation and can be used for defects up to 50% of the
TSA without altering hair growth.
■ Dog ears created from rotation will most likely resolve
and should not be excised at the time of rotation.
■ In some instances, the donor site from the rotation can
be skin grafting as long as the pericranium is not
violated during flap elevation (see Figures 25.9
and 25.10).
2. Forehead flap
• Vascular supply: Supratrochlear a.
• Advantages: Excellent for resurfacing of nasal defects,
including the nasal tip; reliable vascular supply; excellent
donor site healing
• Disadvantages: Requires multiple stages; if flap extends into
hair-bearing region, can get persistent hair growth after
transfer (see Figures 25.11 and 25.12)
3. Temporoparietal fascia (TPF) flap
• Vascular supply: Superficial temporal a.
• Advantages: Thin flap, pliable

Common Flaps of the Trunk
249
25
Figure 25.9.  Local scalp flaps. A,B, Scalp rotation flaps; C, pinwheel flap; D, bipedicle advancement flaps; E, double opposing rotation
flaps; F, Y to T flap; G, bipedicled fronto-occipital flaps. (Reprinted from Marchac, D., 1990. Deformities of the forehead, scalp, and cranial vault. In:
McCarthy, J.G. [Ed.], Plastic surgery. WB Saunders, Philadelphia, 1538.)
A
B
C
D
E
G
F
• Advantages: Extremely versatile flap that can include
bone (scapula), relatively long pedicle with large
diameter; can be used as a functional muscle flap (long
thoracic n.)
• Disadvantages: Donor site, winged scapula (must preserve
superior 4 to 5 muscle slips).
5. Scapular/parascapular flap
• Vascular supply: Circumflex scapular a. (provides a
horizontal and vertical branch upon which flaps can be
designed)
• Advantages: Can provide multiple skin paddles with a
high degree of independent motion through use of the

Flaps and Microsurgery
250
Figure 25.10.  Orticochea three-flap technique. Two flaps based on the superficial temporal artery are used to reconstruct the defect. A
posterior-based flap based on the occipital vessels is used to fill the donor defect. (Reprinted from Arnold, P.G., Rangarathnam, C.S., 1982. Multiple
flap scalp reconstruction: orticochea revisited. Plast. Reconstr. Surg. 69, 607.)
Occipital vessel
s
Galea
Skin graft
Incisions
Pericranium
remains
Bone skull
1
1
1
1
1
2
2
2
2
2
3
3
3
3
Figure 25.11.  Arterial supply to the
paramedian forehead flap. (Reprinted
from Menick, F. [Ed.], 2009. Nasal
Reconstruction: Art and Practice. Elsevier,
109–154.)
Supratrochlear artery
Supraorbital artery
Dorsal nasal artery
Angular artery
Infraorbital artery
Transverse facial artery

Common Flaps of the Trunk
251
25
Figure 25.12.  Recommended dissection plane for the paramedian forehead flap. The paramedian forehead flap can be elevated in the
subcutaneous plane distally, with a transition proximally to the subperiosteal plane to include the supratrochlear artery. (Reprinted from
Menick, F. [Ed.], 2009. Nasal Reconstruction: Art and Practice. Elsevier, 109–155.)
Axial dermal
vessels preserved
Cut edge of frontalis muscle
Subcutaneous tissue
Frontalis muscle
Supratrochlear artery
Hairline
Cut edge of
frontalis muscle
Periosteum
Subcutaneous
tissue
Flap turned down with subcutaneous fat trimmed
preserving axial dermal vessels
Frontalis muscle
Corrugator muscle
Supratrochlear artery
transverse and descending cutaneous branches,
vascularized bone (lateral scapula border) for composite
flaps, and be used as a perforator flap for skin-only
reconstructions; useful for facial reconstruction (e.g.,
hemifacial microsomia, Romberg disease)
• Disadvantages: Donor site, relatively short pedicle
• Landmarks: “Quadrangular space” borders—triceps m.
(lateral border), teres minor (superior border), teres
major (inferior border), scapula (medial border) (see
Figure 25.16)
6. External oblique turnover flap
• Vascular supply: Intercostal a. (upper half); deep
circumflex iliac a. (DCIA) or iliolumbar a. (lower half;
DCIA most common)
• Advantages: Useful for large, midline, back defects without
other local options
7. Rectus abdominis flap
• Vascular supply: Deep inferior epigastric a. (off of external
iliac a.); superior epigastric a. (off of internal mammary a.)
• Advantages: Provides reliable muscle flap with good length;
workhorse as a musculocutaneous flap for breast, perineal,
and chest-wall reconstruction
• Disadvantages: Less reliable as a pedicled flap in instances
where ipsilateral internal mammary a. has been harvested
■ Flap based off of 8th intercostal a. in this instance
• Delay pedicled rectus myocutaneous flaps in patients with
the following risk factors: Obesity, active smoking, history
of radiation therapy, large volume requirements

Flaps and Microsurgery
252
3. Medial arm flap
• Vascular supply: Superior ulnar collateral a.
• Disadvantages: Less reliable, variable anatomy
4. Posterior interosseous a. flap
• Vascular supply: Posterior interosseus a.
• Advantages: Provides thin, pliable skin; useful for hand
reconstruction
• Most common complication after rectus flap
reconstruction for vaginal defects is vaginal stenosis
Common Flaps of the Upper Extremity
1. Brachioradialis flap
• Vascular supply: Radial recurrent a.
• Advantages: Useful for coverage of anterior elbow and
antecubital fossa defects, minimal donor site morbidity due
to redundancy of flexors
2. Lateral arm flap
• Vascular supply: Posterior radial collateral a. (PRCA)
• Advantages: Provides a thin, pliable fasciocutaneous flap
for coverage of the hand and other sensitive areas where
thin skin flaps are desired (e.g., floor of mouth, coverage of
joints); can be harvested with the posterior third of the
humerus as a composite flap
• Reverse lateral arm flap can be used for coverage of elbow
defects (vascular supply off of radial recurrent a.)
■ Disadvantages: Venous congestion with rotation ≥180
degrees (see Figure 25.17)
Figure 25.13.  A, Superiorly based facial artery musculomucosal
(FAMM) flap may be used for defects of the anterior palate,
alveolus, maxillary antrum, nose, upper lip, and orbit. B, Inferiorly
based FAMM flap may be used for defects of the posterior palate,
tonsillar fossa, alveolus, floor of mouth, and lower lip. (Reprinted
from Neligan, P.C., Rodriguez, E.D. [Eds.], 2013. Plastic Surgery, vol. 3, 3rd ed.
Elsevier, 461–472.)
$
%
1
1
2
2
3
3
Figure 25.14.  Prominent mandible angle: Mandible angle
ostectomy and external corticotomy with microfat graft in older
ages. (Reprinted from Neligan, P.C., Rodriguez, E.D. [Eds.], 2013. Plastic
Surgery, vol. 3, 3rd ed. Elsevier, 254–277.)
Facial artery
Submental branch
of facial artery
Figure 25.15.  Anatomic landmarks and flap markings. Typical
preoperative markings preparatory to a myocutaneous flap based
on the dorsal scapular artery (DSA). (Reprinted from Wei, F.C., Mardini, S.
[Eds.], 2009. Flaps and Reconstructive Surgery. Elsevier, 249–269.)

Common Flaps of the Lower Extremity
253
25
• Disadvantages: Donor site defect, neuroma (superficial
branch of the radial nerve), venous congestion (often
harvest skin paddle with cephalic vein for outflow to
reduce risk for venous congestion)
• Landmarks
■ Proximal radial a. found deep to brachioradialis
■ Distal radial a. found within the intermuscular septum
between the brachioradialis and flexor carpi radialis (see
Figure 25.18)
Common Flaps of the Lower Extremity
1. Iliac crest osteocutaneous flap
• Vascular supply: Deep circumflex iliac a.
• Advantages: Can be harvested with a skin paddle up to
12 × 6 cm and an iliac crest bone segment of up to 8 cm;
good contour for mandible reconstruction
• Disadvantages: Thick and bulky cutaneous portion that is
insensate and difficult to inset; risk of hernia formation at
donor site
2. Groin flap
• Vascular supply: Superficial circumflex iliac a.
• Advantages: Provides thin soft-tissue coverage of the hand,
wrist, and distal forearm; can be used as a free flap
• Landmark
■ Arises from the common femoral a. or superficial
femoral a.; travels parallel to, 1 cm deep, and 2 to 3 cm
inferior to the inguinal ligament (see Figure 25.19)
3. Shaw flap
• Vascular supply: Superficial inferior epigastric a.
• Advantages: Useful for coverage of hand and forearm
defects with better elbow position than traditional groin
flap (located higher, so elbow can remain flexed)
• Landmark
■ Pedicle found at the intersection of the inguinal
ligament and femoral a. and courses to the anterior
axillary line
4. Gluteal a. flap
• Vascular supply: Superior gluteal a. (SGA) and inferior
gluteal a. (IGA) off of internal iliac a.
• Advantages: Useful for coverage of sacral wounds, defects
of lumbar spine; can be harvested off of perforators as
fasciocutaneous flaps for breast reconstruction
• Disadvantages: Tedious dissection when used as free flaps;
requires position change if using as free flap for anterior
defects/reconstruction
• Landmarks
■ The SGA exits lateral and deep to the sacrum above
the piriformis, whereas the IGA exits below the
piriformis.
○ The piriformis can be outlined by a line drawn from
the greater trochanter to the midpoint between the
posterior superior iliac spine (PSIS) and the coccyx.
○ The SGA will often emerge at the junction of the
medial and middle thirds of a line drawn from the
PSIS to the greater trochanter.
• Disadvantages: Limited reach for distal hand/finger defects,
high incidence of partial flap loss
• Landmarks
■ Pivot point is located 2 cm proximal to ulnar styloid
■ Flap should be centered on a line drawn from the lateral
epicondyle to the distal radioulnar joint.
5. Radial forearm flap
• Vascular supply: Septocutaneous perforators from the
radial a.
• Advantages: Thin fasciocutaneous flap; useful for defects
where thin, pliable tissue is desired (hemiglossectomy
defects, floor of mouth, cheek, hand, etc.); can be harvested
with bone as a composite flap
■ Radius should be harvested from radial aspect and be no
greater than 40% of the cross-sectional area to reduce
the risk of distal radius fracture.
■ Vascular supply to radius is via fascioperiosteal
perforators within the intermuscular septum.
Figure 25.16.  Anatomic landmarks and markings. ELAF, Extended
lateral arm flap; LAF, lateral arm flap. (Reprinted from Standring, S. [Ed.],
2005. Gray’s Anatomy: The Anatomic Basis of Clinical Practice, 39th ed.
Churchill Livingstone.)
LAF
ELAF
Combination

Flaps and Microsurgery
254
6. Sartorius flap
• Vascular supply: Segmental perforators from the superficial
femoral a.
• Advantages: Useful for coverage of groin defects and
femoral vessels
• Disadvantages: Relatively unreliable because of segmental
blood supply
• Landmarks
■ Most proximal pedicle located ~8 cm from anterior
superior iliac spine
7. Rectus femoris flap
• Vascular supply: Lateral circumflex femoral a.
• Advantages: Reliable myofascial flap; useful for coverage of
abdominal, groin, and hip defects
• Disadvantages: Harvest results in 15-degree extensor lag of
knee.
• Expanded rectus femoris flap can be used to cover massive
abdominal wall defects and reach the xyphoid.
Figure 25.17.  A,B, Mathes-Nahai classification of fascia/fasciocutaneous flaps. (Reprinted from Wei, F.C., Mardini, S. [Eds.], 2009. Flaps and
Reconstructive Surgery. Elsevier, 305–319.)
1
2
3
4
5
7
6
1
2
3
4
1. External occipital protuberance
2. Trapezius
3. Inferior angle of scapula
4. Latissimus dorsi
5. Erector spinae
6. Posterior superior iliac spine underlying sacral dimple
7. Rectal cleft
1. Median furrow
2. Lateral border of erector spinae
3. Gluteus maximus
4. Gluteal fold
Black: scapular flap
Blue: ascending vertical flap
Red: parascapular
Green: imecc flap
A
B
5. Gracilis
• Vascular supply: Medial circumflex femoral a. (profunda
femoris a.)
• Advantages: Reliable myofascial flap; provides thin, pliable
muscle coverage; useful for groin/medial thigh defects;
can be used as a functional m. for fascial reanimation
(obturator n.)
• Disadvantages: Vertical skin paddle unreliable (especially
over distal third)
• Landmarks
■ Pedicle enters the muscle 8 to10 cm below the pubic
tubercle.
■ The gracilis m. is the most superficial m. in the medial
thigh (between the adductor longus and brevis m.),
is triangular shaped, and coalesces into a tendon
distally.
• TUG flap: Transverse upper gracilis myocutaneous flap for
use in autologous breast reconstruction (see Figure 25.20)

Common Flaps of the Lower Extremity
255
25
8. Anterolateral thigh flap
• Vascular supply: Perforators from the descending branch
of the lateral circumflex femoral a.
• Advantages: Reliable fasciocutaneous flap that has become
a workhorse free flap for reconstruction of the extremities,
head and neck, glossectomy defects, and trunk; can be
harvested with vastus lateralis m. for bulk
• Disadvantages: Tedious dissection for intramuscular
perforators; subcutaneous tissue can be thick, resulting in a
bulky flap.
• Landmarks
■ Main pedicle lies within the septum between the rectus
femoris m. and the vastus lateralis m.
■ Perforators to skin can typically be found within a 3-cm
radius at the midpoint of a line from the ASIS to the
superolateral patella (see Figure 25.21).
9. Medial femoral condyle flap
• Vascular supply: Descending geniculate a.
• Advantages: Provides reliable, small-segment vascularized
bone graft
10. Gastrocnemius flap
• Vascular supply: Medial and lateral sural a. (off of the
popliteal a.)
• Advantages: Workhorse local flap for coverage of complex
knee wounds and proximal-third lower leg wounds; can be
harvested with skin
• Disadvantages: Limited reach
• Medial head is larger and more preferred than lateral head.
Figure 25.18.  Radial forearm flap. A, Standard arc to antecubital fossa. B, Reverse arc to palmar surface of hand. (Reprinted from Neligan,
P.C., Gurtner, G.C. [Eds.], 2013. Principles in Plastic Surgery, vol. 1. Elsevier, 512–572.)
A
B
11. Soleus flap
• Vascular supply: Proximal supply via posterior tibial,
popliteal, and peroneal a.; distal supply via posterior tibial
a. (medial) and peroneal a. (lateral)
• Advantages: Useful coverage for middle-third lower leg
defects.
• Reversed hemisoleus flap can occasionally be used for
proximal lower-third leg defects (based medially off of
perforators from posterior tibial a.)
12. Peroneal a. perforator flap
• Vascular supply: Perforators from the peroneal a.
• Can be used as a propeller fasciocutaneous flap for lower
leg defects
13. Reverse sural a. flap
• Vascular supply: Septocutaneous perforators from the
peroneal a.
• Can be used for distal-third leg defects
• Improved flap survival when the saphenous vein and
median cutaneous sural n. are included in the flap
• Disadvantages: Venous congestion, partial flap loss (see
Figure 25.22)
14. Free fibula flap
• Vascular supply: Peroneal a.
• Advantages: Reliable vascularized bone flap; useful for
mandible reconstruction; can provide up to 25 cm of bone;
be harvested with skin based off of peroneal perforators in
the posterior intermuscular septum; include soleus m. and/
or flexor halluces longus m. to provide bulk

Flaps and Microsurgery
256
Figure 25.19.  Groin flap elevation. A, The dominant pedicle is the superficial circumflex iliac artery; B, venae comitantes and superficial
circumflex iliac vein. (Reprinted from Neligan, P.C., 2013. Plastic Surgery, 3rd ed. Elsevier, 127–150.)
Inguinal ligament
Superficial
circumflex
iliac artery
Sartorius
Saphenous vein
Superficial
circumflex
iliac artery
and vein
Sartorius
fascia
$
%
• Disadvantages: Donor site morbidity, claw toes, ankle/knee
instability, nerve injury
■ Must leave 6 cm of proximal fibula and distal fibula for
stability of the knee and ankle joints, proximal and distal
6 cm of bone for stability
15. Medial plantar a. flap
• Vascular supply: Medial plantar a. (off of posterior tibial
a.)
• Advantages: Useful for coverage of heel or distal foot
defects
• Disadvantages: Limited arc or rotation and reach, usually
requires skin graft of donor site
16. Lateral calcaneal flap
• Vascular supply: Lateral calcaneal a. (off of
peroneal a.)
• Advantages: Useful for coverage of lateral ankle defects;
very reliable
• Disadvantages: Limited arc of rotation and reach; typically
requires skin graft of donor site
17. Great toe flap
• Vascular supply: 1st dorsal metatarsal a. (off of dorsalis
pedis in 2/3rds and deep plantar a. or plantar arch
in 1/3rd)
• Advantages: Useful for thumb reconstruction

Common Flaps of the Lower Extremity
257
25
Figure 25.20.  Gracilis muscle flap elevation. It is a type-II circulation pattern (the dominant pedicle is the terminal branch of the medial
circumflex femoral artery, and one or two minor pedicles arise as branches of the superficial femoral artery) and can reach to cover the
abdomen, ischium, groin, and perineum as a muscle or musculocutaneous flap. (Reprinted from Neligan, P.C., 2013. Plastic Surgery, 3rd ed. Elsevier,
127–150.)
Medial femoral
circumflex artery
Adductor longus
Adductor brevis
Branch from
obturator nerve
Abductor magnus
Sartorius
Semimembranosus
Gracilis
Gracilis
tendon (cut)
Figure 25.21.  The anterolateral thigh flap. Numerous perforators are found along the region of intermuscular septum between the vastus
lateralis and rectus femoris. These perforators usually drain into the descending branch of the lateral femoral circumflex artery, proceed
proximally to the lateral circumflex artery, and then on to the profunda femoris artery. (Reprinted from Neligan, P.C., 2013. Plastic Surgery, 3rd ed.
Elsevier, 127–150.)
Anterolateral thigh
flap isolated on lateral
branch of descending
lateral femoral circumflex
artery and lateral femoral
cutaneous nerve

Flaps and Microsurgery
258
General Microsurgery Considerations
1. Factors that can affect anastomosis patency include surgical
precision, vessel size, vessel size mismatch, blood flow,
tension, kinking, and the use of anticoagulants/
antithrombotics.
• Most influential factor on anastomotic patency is surgical
precision.
• No evidence for benefit of anticoagulation, type of
anastomosis, or suture technique
• Adequate fluid resuscitation is paramount.
■ Euvolemia is preferred because hypovolemia and volume
overload can have detrimental effects on flap perfusion.
• Although anastomotic couplers have been used for arterial
anastomoses, their use is contraindicated in the setting of
vessel calcification.
2. Anastomotic thrombosis
• Most occur within the first 24 hours (~90%)
■ In head and neck cases, it is most likely to occur within
12 hours of the anastomosis
• Venous thrombosis is more common than arterial
thrombosis.
■ Signs of venous thrombosis: Flap congestion, brisk
capillary refill, brisk dark bleeding from skin paddle
when scratched
■ Signs of arterial thrombosis: Pale, cool flap; delayed
capillary refill; no return of bright red bleeding when
skin paddle is scratched; loss of Doppler signal
■ Any concern for thrombosis warrants an immediate
return to the operating room with exploration of the
anastomosis.
○ Rapid return to the operating room yields higher
salvage rates.
• Management of thrombosis
■ Thrombectomy and revision of the anastomosis
+/− intraflap thrombolytics
■ Thrombolytics
○ Tissue plasminogen activator (tPA)
♦ Mechanism of action: Activated in the presence of
fibrin and catalyzes the conversion of plasminogen
to plasmin
♦ Preferred thrombolytic; more specific than
urokinase or streptokinase
♦ Disadvantages: Bleeding
○ Dextran
♦ Formerly used as a thrombolytic; no longer used
in the United States
♦ Mechanism of action: Decreases factor VIII and
von Willebrand (vWF) factor, which results in
decreased platelet function and aggregation and
increased susceptibility of fibrin to degrade
♦ Disadvantages: Risk of anaphylaxis, flash
pulmonary edema, acute respirator distress
syndrome (ARDS), acute renal failure (toxic to
glomeruli)
Common Visceral Flaps
1. Omental flap
• Vascular supply: Right and left gastroepiploic a.
• Advantages: Reliable, thin, pliable flap; useful for defects
of the sternum/trunk, perineum, abdomen, groin, and
intrathoracic region
• Disadvantages: Donor site morbidity, hernia formation;
requires skin graft
2. Jejunal flap
• Vascular supply: Jejunal a. (from the superior
mesenteric a.)
• Advantages: Useful for esophageal/pharyngeal
reconstruction
• Disadvantages: Donor site morbidity
Figure 25.22.  The reverse sural artery flap is a fasciocutaneous
flap based on the median superficial sural artery and its
communication with the perforating branch of the peroneal artery
situated in the region of the lateral malleolar gutter. Reverse flow is
established after elevation of the flap and with division of the sural
artery and the nerve proximally. (Reprinted from Neligan, P.C., 2013.
Plastic Surgery, 3rd ed. Elsevier, 127–150.)

Special Flap Considerations
259
25
■ Platelet aggregation test or enzyme-linked
immunosorbent assay (ELISA)
• Treatment: Stop heparin and switch to an alternative
anticoagulant (e.g., argatroban, lepirudin, danaparoid)
until platelet levels return to baseline.
■ Remember to discontinue heparin flushes of all
intravenous lines.
Suggested Readings
Chuang, D.C.C., 2009. Chapter 29: Gracilis flap. In: Wei, F.C., Mardini, S.
(Eds.), Flaps and Reconstructive Surgery. Elsevier, pp. 397–410.
Colohan, S., Saint-Cyr, M., 2013. Chapter 2: Management of lower extremity
trauma. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 63–91.
Dumanian, G.A., Heckler, F.R., Bernard, S.L., 2003. The external oblique
turnover muscle flap. Plast. Reconstr. Surg. 111 (7), 2344–2348.
Guo, L., Pribaz, J.J., 2009. Chapter 11: Prefabrication and prelamination. In:
Wei, F.C., Mardini, S. (Eds.), Flaps and Reconstructive Surgery. Elsevier, pp.
103–116.
Guo, L., Pribaz, J.J., 2009. Clinical flap prefabrication. Plast. Reconstr. Surg.
124 (Suppl. 6), e340–e350.
Hallock, G.G., 2009. Chapter 2: Classification of flaps. In: Wei, F.C., Mardini,
S. (Eds.), Flaps and Reconstructive Surgery. Elsevier, pp. 7–15.
Hansen, S.L., Young, D.M., Lang, P., et al., 2013. Chapter 24: Flap
classification and applications. In: Neligan, P.C., Gurtner, G.C. (Eds.),
Principles in Plastic Surgery, vol. 1. Elsevier, pp. 512–572.
Hong, J.P., 2013. Chapter 5: Reconstructive surgery: lower extremity coverage.
In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 127–150.
Jackson, I.T. (Ed.), 2007, Local Flaps in Head and Neck Reconstruction, 2nd
ed. QMP, pp. 1–611.
Jackson, I.T., 2013. Chapter 18: Local flaps for facial coverage. In: Neligan,
P.C., Rodriguez, E.D. (Eds.), Plastic Surgery, vol. 2, 3rd ed. Elsevier, pp.
440–460.
Jones, N.F., Lister, G.D., 2011. Chapter 51: Free skin and composite flaps. In:
Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.), Green’s Operative
Hand Surgery, 6th ed. Elsevier, pp. 1721–1756.
Kim, S., Chung, K.C., 2009. Chapter 95: Free tissue transfer. In: Guyuron, B.,
Eriksson, E., Persing, J.A. (Eds.), Plastic Surgery Indications and Practice.
Elsevier, pp. 1225–1237.
McCarthy, J.G., Galiano, R.D., Boutros, S.G., 2006. Chapter 1: Plastic surgery
strategies. In: McCarthy, J.G., Galiano, R.D., Boutros, S.G. (Eds.), Current
Therapy in Plastic Surgery. Elsevier, pp. 3–10.
Menick, F., 2009. Chapter 6: A modern approach to nasal reconstruction with
a forehead flap. In: Menick, F. (Ed.), Nasal Reconstruction: Art and Practice.
Elsevier, pp. 109–0154.
Morris, S.F., Maciel-Miranda, A., Hallock, G.G., 2013. Chapter 1: History of
perforator flap surgery. In: Blondeel, P.N., Morris, S.F., Hallock, G.G., et al.
(Eds.), Perforator Flaps, 2nd ed. QMP, pp. 3–24.
Morris, S.F., Taylor, G.I., 2013. Chapter 23: Vascular territories. In: Neligan,
P.C., Gurtner, G.C., (Eds.), Principles in Plastic Surgery, vol. 1. Elsevier, pp.
479–511.
Neligan, P.C., 2013. Chapter 10: Cheek and lip reconstruction. In: Neligan,
P.C., Rodriguez, E.D. (Eds.), Plastic Surgery, vol. 2, 3rd ed. Elsevier, pp.
254–277.
Pang, C.Y., Neligan, P.C., 2013. Chapter 25: Flap pathophysiology and
pharmacology. In: Neligan, P.C., Gurtner, G.C. (Eds.), Principles in Plastic
Surgery, vol. 1, 3rd ed. Elsevier, pp. 573–586.
Pederson, W.C., 2011. Chapter 50: Nonmicrosurgical coverage of the upper
extremity. In: Wolfe, S.W., Hotchkiss, R.N., Pederson, W.C., et al. (Eds.),
Green’s Operative Hand Surgery, 6th ed. Elsevier, pp. 1645–1720.
Pribaz, J.J., Chan, R.K., 2013. Chapter 19: Secondary facial reconstruction. In:
Neligan, P.C., Rodriguez, E.D. (Eds.), Plastic Surgery, vol. 2, 3rd ed. Elsevier,
pp. 461–472.
Spector, J.A., Levine, J.P., 2006. Chapter 2: Cutaneous defects: flaps, grafts,
and expansion. In: McCarthy, J.G., Galiano, R,D., Boutros, S.G. (Eds.),
Current Therapy in Plastic Surgery. Elsevier, pp. 11–21.
Wei, F.C., Mardini, S. (Eds.), 2009. Flaps and Reconstructive Surgery. Elsevier.
Wei, F.C., Tay, S.K.L., 2013. Chapter 26: Principles and techniques of
microvascular surgery. In: Neligan, P.C., Gurtner, G.C. (Eds.), Principles in
Plastic Surgery, vol. 1, 3rd ed. Elsevier, pp. 587–621.
Wells, M.D., Skytta, C., 2013. Chapter 5: Scalp and forehead reconstruction.
In: Neligan, P.C., Rodriguez, E.D. (Eds.), Plastic Surgery, vol. 2, 3rd ed.
Elsevier, pp. 105–133.
3. Flap monitoring
• Clinical exam
■ Temperature
■ Color
■ Turgor
■ Capillary refill
■ Scratch test
○ Skin paddle scratched with an 18-gauge needle or
scalpel to evaluate for bleeding
• Doppler
■ Pencil doppler: Useful for monitoring flaps with arterial
perforator signals found within the transferred skin
paddle
■ Implantable venous doppler: Doppler probe is wrapped
around the pedicle vessel just distal to the anastomosis.
○ Effective for monitoring, especially for flaps without a
skin paddle or buried flaps in which clinical exam is
difficult
○ Newer implantable dopplers are integrated within the
anastomotic coupler device
• Tissue oxygenation
■ Use of spectroscopy to detect tissue oxygenation with
the flap skin paddle
■ Trends of tissue oxygenation, and subsequent changes in
those trends, can be used to detect flap compromise.
■ Absolute tissue oxygenation <30% suggests flap
ischemia.
Special Flap Considerations
1. Venous congestion
• Delayed or persistent venous congestion of flaps, not
related to a venous thrombus, can be treated with leeches.
■ Advantages: Leech application will provide decongestion
of flap through action of hirudin.
■ Disadvantages: Risk of infection that can progress from
cellulitis to sepsis, caused by Aeromonas hydrophila
○ Prevention via prophylactic treatment with a
fluoroquinolone (e.g., ciprofloxacin) and/or
aminoglycoside
○ Continue treatment until the wound is fully healed
because of possibility of a delayed infection.
2. Heparin-induced thrombocytopenia (HIT)
• An immune-mediated thrombocytopenia that can occur in
patients exposed to heparin, especially those who have had
prior exposure within 3 months, which can result in
thrombotic events, limb ischemia, and death
• Mechanism: Antibody binding to heparin and platelet
factor 4, resulting in platelet activation, aggregation, and
increase in thrombin generation
• Diagnosis
■ A 30% decrease in baseline platelet count combined with
any thrombotic event

SECTION 6: Aesthetic
Eyelid Anatomy,
Reconstruction, and
Blepharoplasty
Chapter
26 
General Anatomy (see Figure 26.1)
1. Upper eyelid layers (superficial to deep)
• Skin → orbicularis oculi muscle → retro-orbicularis oculi
fat (ROOF) → orbital septum → orbital fat (central and
medial) → levator palpebrae superioris m. → Müller’s
muscle → conjunctiva
2. Lower eyelid layers (superficial to deep)
• Skin → orbicularis oculi muscle → suborbicularis oculi fat
(SOOF) → orbital septum → orbital fat (lateral, central,
and medial) → levator palpebrae superioris m. → Müller’s
muscle → conjunctiva
3. Orbital fat
• Upper eyelid
■ Two compartments: Medial and central
■ Medial fat is pale in color.
■ No lateral compartment, because the lacrimal gland
occupies the lateral portion
• Lower eyelid
■ Three compartments: Medial, central, and lateral
■ Medial fat is pale in color.
■ Medial and central compartments separated by the
inferior oblique m.
4. Vascular supply of the eyelids (see Figure 26.2)
• Branches of the ophthalmic a. (medially) and lacrimal a.
(laterally) via the internal carotid artery
■ Form the medial and lateral palpebral a., which
anastomose to create the arterial arcades of the lid
■ The upper eyelid has two arterial arcades.
○ Marginal arcade runs along the surface of the tarsal
plate, 2 to 3 mm above the eyelid margin
○ Peripheral arcade runs parallel to the marginal
arcade, superior to the tarsal plate, and in between
the levator m. and Müller’s m.
■ The lower eyelid has only one well-developed marginal
arcade.
• Also receive arterial supply from branches of the facial a.,
superficial temporal a., and infraorbital a. via the external
carotid a.
Figure 26.1.  Eyelid anatomy. Each eyelid consists of an anterior
lamella of skin and orbicularis muscle and a posterior lamella of
tarsus and conjunctiva. The orbital septum forms the anterior
border of the orbital fat. (Reprinted from Neligan, P.C., Buck, D.W. [Eds.],
2013. Core Procedures in Plastic Surgery. Elsevier, 1–22.)
Orbicularis oculi
Upper tarsal plate
Capsulopalpebral fascia
Lockwood’s ligament
Müller’s muscle
Inferior rectus
Superior rectus
Levator palpebrae
Dorsal nasal artery
Lateral nasal artery
Inferior palpebral artery
Angular artery
Supraorbital artery
Infraorbital artery
Superficial temporal
artery
Lacrimal artery
Zygomaticofacial artery
Transverse facial artery
Facial artery
Supratrochlear artery
Medial palpebral artery (superior)
1. Peripheral arcade
2. Marginal arcade
Medial palpebral artery
(inferior)
Figure 26.2.  Arterial supply to the periorbital region. (Reprinted from
Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery.
Elsevier, 1–22.)

General Anatomy 26
261
5. Sensory innervation of the eyelids (see Figure 26.3): Via
the ophthalmic (V1) and maxillary (V2) divisions of the
trigeminal n.
• Supraorbital n.: Upper eyelid and forehead skin
■ Exits the orbit through the supraorbital notch or
supraorbital foramen
• Supratrochlear n.: Central forehead skin and medial upper
eyelid
■ Courses superiorly through the corrugator m. and is
vulnerable to injury during transpalpebral resection of
medial brow depressors
• Infratrochlear n.: Medial upper and lower eyelid and
medial canthal tendon
• Lacrimal n.: Lacrimal gland, conjunctiva, and lateral
portion of the upper eyelid
• Zygomaticofacial n.: Lateral fat pad of the lower eyelid and
lateral skin of the lower eyelid
• Infraorbital n.: Lower eyelid, cheek, and upper lip
7. Orbital septum
• A connective tissue structure that functions to contain the
orbital contents
• Attaches peripherally at the orbital rim via the arcus
marginalis (the periosteal extension of the septum) and
fuses centrally with the lid retractors at tarsal plates at the
lid margins
■ A transconjunctival approach to the lid/orbit can be
performed in a pre- or postseptal plane.
8. Eyelid retractors
• Levator complex
■ Originates at the orbital apex from the lesser wing of the
sphenoid and travels horizontally until it reaches the
Whitnall ligament, where it then changes to a more
vertical direction before inserting onto the upper eyelid
tarsal plate, orbital septum, and dermis via an
aponeurosis
○ Above the level of the tarsus, the orbital septum lies
anterior to the levator, and preaponeurotic fat lies
posterior to the orbital septum.
○ Müller’s muscle lies directly posterior to the levator
m., superior to the tarsus.
■ Motor innervation via the oculomotor n. (cranial n.
[CN] III).
• Müller’s muscle
■ Sympathetic smooth muscle of the upper eyelid
■ Arises from the levator complex and inserts directly on
the tarsus
Figure 26.3.  Sensory nerves of the eyelids. (Reprinted from Neligan,
P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier,
1–22.)
Infraorbital nerve
Infratrochlear nerve
Supratrochlear nerve
Supraorbital nerve
Lacrimal nerve
Zygomaticofacial
nerve
Zygomaticotemporal
nerve
6. Orbicularis oculi m. (see Figure 26.4)
• Superficial muscle of facial expression, innervated by the
facial n. (frontal and zygomatic branches)
• Divided into three anatomical portions: Orbital, preseptal,
and pretarsal
■ The orbital orbicularis m. is used in forced eyelid
closure.
■ The preseptal and pretarsal orbicularis fibers are critical
for blinking and voluntary winking and originate
medially from a superficial and deep head associated
with the medial canthal tendon.
■ The pretarsal orbicularis fibers run horizontally, anterior
to the tarsus, and insert into the lateral orbital tubercle
(Whitnall’s tubercle) via the lateral canthal tendon.
■ Avoid injury to the pretarsal orbicularis.
Figure 26.4.  Fascial muscles of the orbital region. Note that the
preseptal and pretarsal orbicularis muscles fuse with the medial
and lateral canthal tendons. (Reprinted from Neligan, P.C., Buck, D.W.
[Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier, 1–22.)
Superciliary corrugator
Procerus
Frontalis
Orbicularis oculi
Pretarsal
orbicularis
Preseptal
orbicularis

Eyelid Anatomy, Reconstruction, and Blepharoplasty
262
■ Positioned posterior to the levator m., directly superior
to the tarsus
■ Resection of Müller’s m. can provide 2 mm of eyelid
elevation.
• Capsulopalpebral fascia
■ Makes up the anteriosuperior portion of the lower eyelid
retractors distal to the Lockwood ligament
■ Inserts on the inferior border of the tarsus and functions
akin to the levator m. in the upper eyelid
■ Divided during the transconjunctival incision
9. Inferior oblique muscle
• Located between the medial and central fat compartments
of the lower eyelid, deep to the periosteum
• Vulnerable to injury when performing fat excision or fat
compartment manipulation during lower blepharoplasty
or via inadvertent resection, cauterization, scarring,
hemorrhage, edema, or suture injury while repairing the
septum
■ Depending on the extent of injury, symptoms, including
diplopia, can be transient or permanent.
10. Orbitomalar ligament/orbicularis retaining ligament (see
Figure 26.5)
• Attaches the orbicularis oculi muscle of the eye to the
orbital rim, separating the lower eyelid from the midface
• Contributes to the lateral canthal ligament
• Release is required to obtain access to the midface when
approaching it from the lower eyelid.
11. Whitnall ligament
• Fascial thickening of the upper eyelid that surrounds the
levator m. and tarsus to provide structural support to the
lid and aids the levator m. in elevating the lid superiorly by
changing the functional orientation of the m. fibers
• Attaches laterally to the orbit at Whitnall’s tubercle (lateral
orbital tubercle)
12. Lockwood ligament
• A fascial thickening of the lower eyelid that surrounds the
inferior rectus and inferior oblique muscles and fuses with
the capsulopalpebral fascia to support the globe
• Analogous to the Whitnall ligament in the upper eyelid
13. Canthal tendons (see Figures 26.6 and 26.7)
• Medial canthal tendon (or medial palpebral ligament)
■ Fibrous band that is continuous with the tarsal plates
and attaches the lid to the orbital rim
■ Three limbs: Anterior, posterior, and superior
○ Posterior, or deep limb, attaches to the posterior
lacrimal crest
■ Intimately related to the pretarsal and preseptal orbicular
oculi m. and lacrimal system
• Lateral canthal tendon (or lateral palpebral ligament)
■ Attaches the upper and lower tarsal plates to Whitnall’s
tubercle inside the lateral orbital rim and deep to the
septum
Figure 26.5.  The orbicularis muscle fascia attaches to the
skeleton along the orbital rim by the lateral orbital thickening (LOT)
in continuity with the orbicularis retaining ligament (ORL). (Adapted
from Ghavami, A., Pessa, J.E., Janis, J., et al., 2008. The orbicularis retaining
ligament of the medial orbit: closing the circle. Plast. Reconstr. Surg. 121 [3],
994–1001.)
Orbicularis oculi
Orbicularis retaining
ligament
Nasal bone
Maxilla bone
Frontal bone
Zygomatic bone
Orbicularis retaining ligament
Lateral orbital thickening
Corrugator supercilii
Figure 26.6.  The lateral canthal tendon inserts securely into the
thickened periosteum overlying Whitnall’s tubercle. The tarsal strap
is a distinct anatomic structure that suspends the tarsus medial
and inferior to the lateral canthal tendon to the lateral orbital wall,
approximately 4 to 5 mm from the orbital rim. (Reprinted from Neligan,
P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier,
1–22.)
Tarsus
“Tarsal strap”
Whitnall’s tubercle
Lateral canthal tendon
Orbital septum

Lacrimal/Eyelid Physiology
263
26
2. Eyelids open
• The lacrimal puncta are open and in contact with the
lacrimal lake at the medial aspect of the lower eyelid
• The lacrimal sac is collapsed and empty, and the canaliculi
are patent.
Lacrimal/Eyelid Physiology
1. The lacrimal drainage system (see Figure 26.8)
• Consists of the lacrima gland, punctum, ampulla,
canaliculi, lacrimal sac, and nasolacrimal duct
Figure 26.7.  The medial canthal tendon envelops the lacrimal sac.
It is tripartite, with anterior, posterior, and superior limbs. Like the
lateral canthal tendon, its limbs are continuous with tarsal plates.
The components of this tendon along with its lateral counterpart
are enveloped by deep and superficial aspects of the orbicularis
muscle. (Adapted from Spinelli, H.M., 2004. Atlas of Aesthetic Eyelid and
Periocular Surgery. Saunders, Philadelphia, 13.)
Superior limb, medial canthal tendon
Posterior limb, medial canthal tendon
Anterior limb, medial canthal tendon
Anterior and posterior lacrimal crests
Lacrimal fossa
Lacrimal gland
(orbital lobe)
Lacrimal gland
(palpebral lobe)
Lateral horn of
the levator
aponeurosis
Ductules
Nasolacrimal duct
Inferior meatus
Canaliculus
Ampulla
Punctum
Inferior
turbinate
Lacrimal sac
Middle
turbinate
Middle
meatus
Figure 26.8.  Cross section of the lower eyelid. (Reprinted from Nerad,
J.A., 2009. Techniques in Ophthalmic Plastic Surgery: A Personal Tutorial, 1st
ed. Elsevier Health Sciences, Philadelphia, 43.)
3. Eyelids closed
• The lacrimal puncta are closed.
4. Normal tear flow
• Opening the eyelids
■ The canaliculi open to allow collection of tears.
■ The lacrimal diaphragm returns to its resting position
because the sphincter action of the oribularis is released.
■ Relaxation of the lacrimal diaphragm creates sufficient
pressure to propel the tears from the lacrimal sac into
the nasolacrimal duct.
• Closing the eyelids
■ Tears are milked lateral to medial
■ The deep heads of the preseptal muscles contract,
which
○ Shortens the canaliculi and closes their ampullae.
○ Pulls the lacrimal diaphragm laterally, creating
negative pressure that opens the lacrimal sac, causing
it to fill with tears
5. Lacrimal pump failure can be caused by anatomic obstruction
and/or functional failure.
• Functional failure may be due to a displaced punctum,
eyelid laxity, weak orbicular muscle of the eye, or CN-VII
palsy.
• Anatomical obstruction may occur at any point along the
lacrimal drainage pathway and may be congenital or
acquired.
■ Primary acquired lacrimal duct obstruction: Occurs in
elderly patients secondary to fibrosis
■ Secondary acquired obstruction may be caused by
tumors, trauma, or mechanical obstruction.
6. Testing lacrimal function
• Jones tests: Two tests used to evaluate for and discern
among functional and obstructive etiologies of poor
tear flow
■ Jones-I test: Fluorescein dye is injected into the
punctum, and the examiner looks for presence of
fluorescein dye drainage from the nose.
○ A positive test means that there is drainage.
○ A negative test means that there is no drainage and
suggests an obstruction; requires a Jones-II test.
■ Jones-II test: Performed after a negative Jones-I test and
involves cannulation of the punctum and irrigation with
1 mL of saline
○ If fluorescein-dye-stained fluid is now visualized at
the inferior turbinate, there is partial obstruction of
the lower canalicular system (most likely at the level
of the nasolacrimal duct).
○ If fluorescein-dye-stained fluid is found flowing
retrograde within the tear sac, this suggests total
obstruction of the nasolacrimal duct.
7. Treatment options for lacrimal pump failure
• Can perform nasolacrimal duct dilation or stent placement
in cases of distal functional pump failure.
■ Contraindicated in cases of complete obstruction
• Conjunctivodacryocystorhinostomy (CDCR): Performed in
cases of flaccid canaliculi, paralysis of the lacrimal pump,

Eyelid Anatomy, Reconstruction, and Blepharoplasty
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and when the site of obstruction is proximal (punctum,
canaliculi, lacrimal sac)
■ CDCR is not required when these structures are intact.
• Dacryocystorhinostomy (DCR): Performed in cases of
distal obstruction (nasolacrimal duct)
Eyelid Evaluation
1. Visual acuity
• Superior or lateral visual field loss suggests functional
ptosis or pseudoptosis.
• If superior visual field loss is present, test with the lid taped
and untaped and document any improvement.
2. External examination
• Should include examination of extra-ocular movements,
pupil evaluation, signs of asymmetry, skin lesions, dry eye,
conjunctivitis, and brow ptosis
■ Compensated brow ptosis: Constant frontalis m.
contraction to elevate the ptotic brow
○ Important to consider because blepharoplasty alone
in these patients could worsen the brow ptosis.
○ Diagnosed by evaluating the change in brow position
with the patient in downward and frontal gaze
3. Eyelid ptosis: Defined by how much the upper limbus is
covered by the lid margin at rest and forward gaze
• Normal: 1 to 2 mm
• Mild ptosis: 2 mm
• Moderate: 3 mm
• Severe: ≥4 mm
4. Eyelid laxity: Defined by relative relaxation of lid support
structures and resting tone of the lid
• Laxity determined by distance lid can be distracted away
from the globe.
■ Mild: 1 to 2 mm
■ Moderate: 2 to 6 mm
■ Severe: >6 mm
• Lid tone determined and graded according to the snap-
back test
■ Snap-back test: Lid is distracted away from globe, held
for a few seconds, and released. Measure the amount of
time from release to the lid assuming its resting position,
correlated with the degree of laxity and loss of muscle
tone.
○ Grade 0 (normal): Lid returns to position
immediately upon release
○ Grade I: Lid returns to position after ~2 to 3 seconds
○ Grade II: Lid returns to position after ~4 to 5 seconds
○ Grade III: >5 seconds for lid to return to position, or
only occurs after blinking
○ Grade IV (severe): Lid never returns to position
5. Globe position: Determined by the position of anterior
border of the globe relative to the most anterior point of the
lateral orbital rim
• Can be objectively measured using a Hertel
exophthalmometer
■ Enophthalmos: <14 mm
■ Normal: 15 to 18 mm
■ Exophthalmos/proptosis: >18 mm
6. Levator function: Defined as the distance that the upper lid
retracts when the globe moves from inferior gaze to upward
gaze
• Normal/excellent: 12 to 15 mm
• Good: 8 to 12 mm
• Fair: 5 to 7 mm
• Poor: 2 to 4 mm
• None: 0 mm
7. Tear production: Can elicit risk for postoperative dry eye
• Schirmer test: After applying topical anesthetic, place filter
paper strips in the lateral third of the lower eyelid, and the
level of filter paper moisture is measured over time.
■ After 5 minutes, normal tear production should be
>15 mm.
■ 5 to 10 mm indicates borderline tear production.
■ <5 mm indicates hyposecretion.
Blepharoptosis
1. Many etiologies
• Congenital ptosis (see Figure 26.9)
■ Occurs in young patients
■ Defined by
○ Moderate-to-severe ptosis
○ Absent eyelid crease
○ Poor levator function
■ A child with progressive or acute symptoms suggests a
possible tumor etiology (e.g., rhabdomyosarcoma); thus,
magnetic resonance imaging (MRI) is indicated.
■ Treatment options
○ Observation can be tried for mild cases.
○ Frontalis sling performed for moderate-to-severe
cases and in mild cases with persistent symptoms, to
prevent amblyopia or other visual disturbances
Figure 26.9.  Unilateral congenital ptosis. (Reprinted from
Philandrianos, C., Galinier, P., Salazard, B., et al., 2009. J. Plast. Reconstr.
Aesthet. Surg. 63 [5], 782–786.)

Lower Eyelid Blepharoplasty
265
26
■ Diagnosed by frontalis contraction and eyebrow
elevation when the patient opens her eyes from the
closed position
Upper Eyelid Procedures
1. Skin-only upper blepharoplasty: Excision of excess eyelid
skin, with or without resection of orbicularis muscle, and/or
manipulation of orbital fat
• Generally indicated for patients with excess skin
(dermatochalasis), normal ptosis, and normal levator
function
• Can be combined with levator techniques below in setting
of ptosis
2. Blepharoptosis repair: Technique often determined by degree
of ptosis and levator function
• Fasanella-Servat: Full-thickness excision of conjunctiva,
superior 3 mm of tarsus, and Müller’s muscle
■ Indicated in patients with mild ptosis and good-to-
excellent levator function
○ Disadvantage: Does not address excess external skin
• Müller’s muscle resection: Full-thickness excision of the
conjunctiva and Müller’s muscle, with sparing of the tarsus
■ Indicated in patients with mild ptosis and fair-to-good
levator function
■ Leads to approximately 2 mm of lid elevation
■ Do not perform deep excision because levator muscle
lies deep to Müller’s muscle in this location.
○ Disadvantage: Does not address excess external skin
• Levator aponeurosis reinsertion/advancement: Levator
aponeurosis is advanced/resuspended to the tarsus
■ Indicated in patients with moderate ptosis and fair
levator function
• Frontalis suspension: The upper lid is connected to the
brow using different sling materials (including fascia or
synthetic materials) to allow frontalis m. contraction to aid
in elevating the upper lid.
■ Indicated in patients with severe ptosis and poor levator
function
Lower Eyelid Blepharoplasty
1. Can be approached through subciliary incision or
transconjunctival incision
• Subciliary incision allows removal of excess external skin.
• Transconjunctival approach can be pre- or postseptal.
■ Often used for repositioning or manipulation of orbital
fat compartments and release of arcus marginalis
2. Preoperative lower lid tone and laxity is important for
determining additional necessary procedures.
• Moderate-to-severe laxity (>6 mm distraction) and poor
tone on snap-back test: Options include lateral
canthoplasty and tarsal strip canthoplasty.
• Mild-moderate laxity (>2 mm distraction) and poor-
moderate tone: Options include horizontal wedge excision
and orbicularis m. repositioning.
• Senile/involutional ptosis
■ Occurs in elderly patients
■ Most commonly related to dehiscence or attenuation of
the levator aponeurosis from the tarsal plate
■ Defined by
○ Upper eyelid ptosis
○ Superior migration of the upper eyelid crease
○ Abnormal levator function depending on severity of
attenuation/dehiscence
♦ The degree of levator function determines
corrective options.
➔ Levator plication (shortening)
➔ Poor levator function: Frontalis suspension
➔ Moderate function: Requires levator resection
versus plication
➔ Normal/excellent levator function: Levator
aponeurosis reinsertion or plication, Fasanella-
Servat procedure, or Müller’s muscle resection
(if only mild ptosis)
 Fasanella does not address excess external
skin.
• Horner syndrome
■ Occurs with disruption of sympathetic nerve action
within the superior cervical ganglion
■ Defined by
○ Ptosis
○ Miosis
○ Anhidrosis
○ Normal eyelid crease position
• Myasthenia gravis
■ Occurs in young women or elderly men
■ Autoimmune disease caused by antibodies to the
acetylcholine receptor at the postsynaptic neuromuscular
junction
■ Defined by
○ Unilateral or bilateral ptosis that is exaggerated with
fatigue
○ Diplopia with extraocular muscle involvement
■ Diagnosed by muscle fatigability on examination or
pharmacologic testing (edrophonium test)
■ Treatment options
○ Acetylcholinesterase inhibitors (e.g., Neostigmine)
○ Immunosuppressants (e.g., prednisone,
cyclosporine)
○ Thymectomy (high incidence of thymoma)
• Inadvertent chemodenervation of upper eyelid retractors
■ Can occur after Botox injection for glabellar rhytids
secondary to medication diffusion
○ Treatment options
♦ Observation
♦ α-Adrenergic agonists (e.g., apraclonidine)
➔ Stimulates Müller’s muscle
• Compensated eyelid ptosis
■ Occurs when the frontalis muscles are used to elevate the
eyebrows, resulting in functional improvement in visual
fields and ptosis

Eyelid Anatomy, Reconstruction, and Blepharoplasty
266
2. Thyroid ophthalmopathy
• Most common cause of proptosis and diplopia in adults
• Symptoms include eyelid edema, conjunctival injection, lid
lag, and proptosis.
• Treatment is focused on management of underlying
thyroid disorder.
3. Blepharospasm: Uncontrolled muscle contraction of the
eyelid
• Many causes, although etiology of many cases is unknown
(idiopathic)
• Botulinum toxin injection is the preferred treatment
method for most patients.
4. Dry eye syndrome (dysfunctional tear syndrome)
• Occurs as a result of deficient tear production leading to
corneal irritation and can progress to corneal scarring
• Can develop after eyelid surgery
■ Risk factors
○ Preoperative dry eye
○ Injury to orbicular oculi m.
○ Combined upper and lower blepharoplasty
procedures
○ Hormone replacement therapy
○ Laser vision correction (Lasik) within 6 months of
blepharoplasty
♦ Affects tear production and corneal sensation
■ Consider eye lubrication pre- and postoperatively
5. Asian eyelids
• No supratarsal crease secondary to a general lack of levator
aponeurosis insertion into the dermis
• Narrow pretarsal segment of the supratarsal lid fold when
present secondary to a more caudal fusion of the orbital
septum to the levator aponeurosis
• More ROOF and SOOF fat when compared to the
Caucasian eyelid
• More likely to have epicanthal folds
• If very minimal laxity, can consider temporary
tarsorrhaphy for corneal protection
3. Complications
• Lower eyelid malposition: Most common complication
■ Etiologies
○ Excessive scarring
○ Over-resection of skin
○ Over-resection of orbital fat
○ Imbrication of orbital septum
○ Orbicularis m. palsy
○ Edema
○ Hematoma
■ Risk factors
○ Malar hypoplasia
○ Proptosis
○ High myopia
○ Lower lid laxity
○ Thyroid ophthalmopathy
■ Treatment options
○ Early postoperative period: Downward massage,
aggressive lubrication to protect the cornea
○ Persistent malposition may require secondary surgical
intervention, depending on the cause.
• Ectropion
■ Often secondary to lower lid laxity or lamellar scarring
■ In early postoperative period, can be managed with scar
massage
■ If it persists after 6 to 9 months, consider surgical
intervention depending on the likely cause.
○ For lower lid laxity: Consider canthoplasty
○ For cicatricial ectropion: Consider a scar release and
skin graft
○ For midlamellar scarring: Consider lysis of adhesions
and an interposition graft
○ For paralytic ectropion: Consider a tarsoligamentous
sling that supports the medial and lateral canthus
Miscellaneous Eyelid Conditions
1. Epiblepharon (see Figure 26.10)
• Most commonly occurs in the lower eyelids; may be
congenital
• More common in patients of Asian descent
• Defined by
■ Excess pretarsal skin and orbicular muscle at the lower
eyelid margin
■ Cilia inversion with contact against the globe
■ Accentuated in downward gaze
• Treatment options
■ Observation in congenital cases because most resolve
with facial growth
■ Surgical intervention indicated when the inverted
eyelashes cause corneal injury and irritation
○ Surgery consists of resection of excess skin and
orbicularis m., with placement of sutures between
the tarsal plate and subcutaneous tissue to create
adhesions.
Figure 26.10.  A 3-year-old male with lower lid epiblepharon.
Note how the lower lid eyelashes are touching the cornea and
conjunctiva. (Reprinted from Kim, C., Shin, Y.J., Kim, N.J., et al., 2007.
Conjunctival epithelial changes induced by Cilia in patients with epiblepharon
or entropion. Am. J. Ophthalmol. 144 [4], 564–569.)

Reconstruction
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26
6. Involutional entropion versus involutional ectropion
• Difficult to discern in the static state because of the
associated lower eyelid laxity in both cases
• Diagnosis can be made on animation of the orbicularis m.,
because the lower eyelid inverts on attempted eyelid
closure in cases of involutional entropion.
7. Hyphema is a traumatic hemorrhage of the anterior chamber
of the eye.
8. Blepharochalasis: Inflammation of the eyelid characterized by
recurrent episodic painless eyelid swelling
• Over time, can progress to thin, atrophic eyelid skin,
levator aponeurosis attenuation, and ptosis
Reconstruction
1. Reconstructive options are generally selected based on the
lamellar components missing and the overall size of the
defect.
• Anterior lamellar defects (skin and orbicularis oculi m.)
■ Depending on size, options include
○ Secondary intent
○ Primary closure
○ Full-thickness skin grafts
○ Local flaps (e.g., cheek advancement, transposition
flaps)
• Posterior lamella defects
■ Conjunctival replacement
○ Mucosa graft (buccal mucosa, hard palate mucosa)
○ Conjunctival graft
■ Tarsal defects
○ Auricular or nasal septal cartilage grafts
• Composite defects/eyelid margin defects
■ <25% (33% for upper lid): Direct layered closure
■ 25% to 50%: Lateral cantholysis with direct closure
versus Hughes tarsoconjunctival flap
■ 50% to 75%: Tenzel flap, Hughes tarsoconjunctival flap
■ >75%: Cheek advancement flap with septal/auricular
cartilage graft and lining graft.
2. Hughes tarsoconjunctival flap (see Figure 26.11)
• A pedicled tarsoconjunctival flap from the upper eyelid is
elevated and advanced to the lower lid defect to replace the
posterior lamella and tarsus.
■ Take care to leave 3 to 4 mm of the upper tarsus intact
to prevent loss of upper lid support.
■ Can reconstruct the anterior lamella by a cheek
advancement flap or other local skin/muscle flap.
■ The flap pedicled is divided at 6 weeks.
Figure 26.11.  A, Tarsoconjunctival advancement flap for lower lid
reconstruction (Hughes): This superiorly based advancement flap
provides a conjunctival lining and tarsal support (posterior lamella)
for the lower lid defect. B, The anterior lamella is reconstructed
with a skin graft or flap. (Reprinted from Herford, A.S., Cicciu, M., Clark, A.,
2009. Traumatic eyelid defects: a review of reconstructive options. J. Oral
Maxillofac. Surg. 67 [1], 3–9.)
B
A

Eyelid Anatomy, Reconstruction, and Blepharoplasty
268
4. Cutler-Beard flap
• Indicated for large central defects of the upper eyelid
• Uses a full-thickness segment of the lower eyelid that is
pedicled and passed under an intact lower lid margin
bridge and inset into the defect
• The flap pedicle is divided at 6 to 8 weeks.
Suggested Readings
Alghoul, M., Pacella, S.J., McClellan, T.W., et al., 2013. Eyelid reconstruction.
Plast. Reconstr. Surg. 132 (2), 288e–302e.
Azurin, D.J., Versaci, A.D., 2010. Chapter 58: Eyelid reconstruction. In:
Weinzweig, J. (Ed.), Plastic Surgery Secrets Plus, 2nd ed. Mosby, pp.
388–394.
Bashour, M., Vistnes, L.M. Upper eyelid reconstruction procedures, treatment,
& Management. Found at:
treatment. Accessed on 8/14/14.
Bashour, M., Vistnes, L.M., Lower Lid Ectropion Blepharoplasty Workup.
Found at: Accessed
on 8/14/14.
Dudas, J.R., Hurst, E.A., 2014. Chapter 8: Eyelid (cancer and reconstruction).
In: Woo, A.S., Shahzad, F., Synder-Warwick, A.K. (Eds.), Plastic Surgery Case
Review: Oral Board Study Guide. Thieme, pp. 33–36.
Few, J., Ellis, M.E., 2013. Chapter 8: Blepharoplasty. In: Neligan, P.C. (Ed.),
Plastic Surgery, 3rd ed. Elsevier, pp. 108–137.
Flowers, R.S., Smith, E.M., 2010. Chapter 75: Blepharoplasty. In: Weinzweig,
J. (Ed.), Plastic Surgery Secrets Plus, 2nd ed. Mosby, pp. 487–497.
Gangopadhyay, N., Woo, A.S., 2014. Chapter 18: Lower lid ectropion (senile
or paralytic). In: Woo, A.S., Shahzad, F., Synder-Warwick, A.K. (Eds.), Plastic
Surgery Case Review: Oral Board Study Guide. Thieme, pp. 77–80.
Ge, N.N., McGuire, F., Dyson, S., et al., 2009. Nonmelanoma skin cancer
of the head and neck II: surgical treatment and reconstruction. Am. J.
Otolaryngol. 30 (3), 181–192.
Green, J.P., Charonis, G.C., Goldberg, R.A., 2013. Chapter 12: 11: Eyelid
trauma and reconstruction techniques. In: Yanoff, M., Duker, J.S. (Eds.),
Ophthalmology, 4th ed. Saunders, pp. 1312–1317.
Herford, A.S., Cicciu, M., Clark, A., 2009. Traumatic eyelid defects: a review
of reconstructive options. J. Oral Maxillofac. Surg. 67 (1), 3–9.
Koh, K.S., Choi, J.W., Ishii, C.H., 2013. Chapter 10: Asian facial cosmetic
surgery. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 163–183.
Leedy, J.E., 2007. Chapter 78: Blepharoplasty. In: Janis, J.E. (Ed.), Essentials of
Plastic Surgery, 1st ed. Quality Medical Publishing, pp. 795–807.
Lin, L.K., 2013. Chapter 2:
Eyelid Anatomy and Function. In: Holland, E.J.,
Mannis, M.J., Lee, W.B. (Eds.). Ocular Surface Disease: Cornea, Conjunctiva,
and Tear Film. Saunders, pp. 11–115.
Lisman, R.D., Lelli, G.J., 2009. Chapter 34: Treatment of blepharoplasty
complications. In: Aston, S.J., Steinbrech, D.S., Walden, J.L. (Eds.), Aesthetic
Plastic Surgery. Elsevier, pp. 393–408.
Neligan, P.C., Buck, D.W. (Eds.), 2013. Chapter 1: Blepharoplasty. In: Core
Procedures in Plastic Surgery. Elsevier, pp. 1–22.
Nicoson, M.C., Myckatyn, T.M., 2014. Chapter 17: Lower lid ectropion
(cicatricial). In: Woo, A.S., Shahzad, F., Synder-Warwick, A.K. (Eds.), Plastic
Surgery Case Review: Oral Board Study Guide. Thieme, pp. 73–76.
Philandrianos, C., Galinier, P., Salazard, B., et al., 2009. Congenital ptosis:
long-term outcome of frontalis suspension using autogenous temporal fascia
or fascia lata in children. J. Plast. Reconstr. Aesthet. Surg. 63 (5), 782–786.
Potter, J.K., 2007. Chapter 30: Eyelid reconstruction. In: Janis, J.E. (Ed.),
Essentials of Plastic Surgery, 1st ed. Quality Medical Publishing,
pp. 287–294.
Sachanandani, N.S., Tenenbaum, M., 2014. Chapter 16: Aging upper face
(brows and lids). In: Woo, A.S., Shahzad, F., Synder-Warwick, A.K. (Eds.),
Plastic Surgery Case Review: Oral Board Study Guide. Thieme, pp. 69–72.
Trussler, A.P., Rohrich, R.J., 2008. Blepharoplasty. Plast. Reconstr. Surg. 121
(S1), 1–10.
3. Tenzel semicircular flap (see Figure 26.12)
• A semicircular rotation advancement musculocutaneous
flap beginning at the level of the lateral canthus
• Uses lateral orbit skin redundancy to advance into defect
Figure 26.12.  Repair of a lower eyelid defect with the Tenzel
myocutaneous flap. (Reprinted from Yanoff, M., Duker, J.S. [Eds.], 2014.
Ophthalmology, 4th ed. Elsevier, 1312–1317.)
TENZEL MYOCUTANEOUS FLAP
Traumatic and surgical defect
Temporal incision line

Rhinoplasty and
Nasal Reconstruction
Chapter
27 
Anatomy of the Nose
1. The nose is a system of two closely related layers.
• Outer layer: Soft, elastic sleeve that slides over the semirigid
inner framework
■ Skin/soft tissue: Thinner and more loosely attached over
the cartilaginous and bony framework and thicker and
more adherent over the nasal tip
■ Lower lateral cartilages (LLCs): Paired “alar cartilages”
that contain medial, middle, and lateral crura that
support the nasal tip and play a significant role in
determining tip shape, size, and projection
• Inner layer: Semirigid framework
■ Nasal bones make up the upper bony vault of the nasal
dorsum and articulate with the upper lateral cartilages
(ULCs) inferiorly and the nasal septum to form the
“keystone area.”
■ ULCs make up the cartilaginous midvault, articulate
with the cephalic margin of the LLCs at the “scroll area,”
and contribute to the internal nasal valve (INV) (see
below).
■ Septum: Formed by the perpendicular plate of the
ethmoid bone; vomer, maxillary crest, crest of the
palatine bone; and the septal or “quadrangular”
cartilage; provides structural support to the nose and
divides the airway
■ Nasal lining: Mucosal inner layer (see Figure 27.1)
2. Muscles of the nose: Crucial to dynamic function of the nasal
valve and airway
• Facial paralysis (cranial nerve [CN] VII) can cause nasal
airway obstruction on side of lesion
• Levator labii superioris: Dilates the nares; paralysis of this
muscle shows collapse of the external valve.
• Depressor septi nasi: Depresses nasal tip (see Figure 27.2)
3. Nasal valves
• INV (between septum and ULC): 10 to 15 degrees; if <10 =
spreader grafts.
■ Cottle maneuver positive
■ Contributes the most to nasal air-flow resistance
• External nasal valve (ENV; at genu of LLC and nares):
Often from over-resection of LLC; treatment: Alar batten
grafts (see Figure 27.3)
4. Vascular supply to the nose
• Nasal tip: Columellar artery (superior labial a. → facial a.
→ external carotid a.), lateral nasal a. (angular a. → facial
a. → external carotid a.)
■ Limited dissection above the alar groove will spare injury
to the lateral branch of the angular a., which could
contribute to tissue loss if injured.
• Nasal sidewall, dorsum: Angular a. and lateral nasal a.
■ The lateral nasal a. also perfuses the nasal tip during
open rhinoplasty.
• Posterior nasal septum: Sphenopalatine a.
• Upper/central nasal septum: Posterior ethmoid a. (see
Figure 27.4).
5. Sensory innervation of the nose
• External branch of the anterior ethmoidal nerve: Nasal
tip; vulnerable to damage during endonasal rhinoplasty
procedures
■ Emanates from between the nasal bone and the lateral
nasal cartilage, supplying sensation to the skin at the
distal nasal dorsum and tip
• Infraorbital nerve: Lower lateral half of the nose and
columellar skin
• Infratrochlear nerve: Cephalic portion of the nasal
sidewalls and the skin overlying the radix
• Supraorbital nerve also innervates the skin of the radix.
• Supratrochlear nerve supplies sensation to the forehead
skin.
• Nasopalatine nerve branches from the pterygopalatine
ganglion to innervate the inferior septum and travels
through the incisive foramen to join the greater palatine
nerve from the palate.
6. Nasal subunits
• The nose is made up of 9 esthetic subunits.
■ Nasal sidewall (2)
■ Nasal dorsum
■ Nasal ala (2)
■ Soft triangle (2)
■ Columella
■ Nasal tip (see Figure 27.5)

Rhinoplasty and Nasal Reconstruction
270
septal deviation, trauma, nasal valve collapse, turbinate
hypertrophy, intranasal masses)
■ INV incompetence and/or collapse thought to be the
most common cause
• In cases of rhinitis and turbinate hypertrophy, preoperative
medical treatment is recommended.
■ Viral rhinitis: Oral/topical decongestants
■ Allergic rhinitis: Decongestants, 2nd-generation
antihistamines, cromolyn sodium nasal spray (mast cell
stabilizer), nasal topical corticosteroids, ipratropium
bromide nasal spray (anticholinergic), and corticosteroid
injection of the inferior turbinate
Nasal Physiology
1. Nasal functions
• Conduit for oxygenated air to enter the lungs
• Reservoir for warming and humidifying inspired air
• Provides sense of smell
• Filters air and provides first-line immune defense against
pathogens
2. Nasal airway obstruction
• The middle meatus marks the path of primary air flow
within the nasal cavity.
• Causes of obstruction include any abnormality that results
in increased nasal resistance and decreased air flow (e.g.,
Figure 27.1.  Diagrams of the cartilaginous and bony nose and septum. (Reprinted from Aston, S.J., Steinbrech, D.S., Walden, J.L. [Eds.], 2009. Aesthetic
Plastic Surgery. Saunders, 437–472.)
Sella turcica
Sphenoid sinus
Vomer
Crest of
palatine bone
Crest of maxillary bone
Perpendicular plate
of ethmoid bone
Anterior
septal angle
Anterior
nasal spine
Premaxilla
bone
Nasal bones
Nasal bone
Upper lateral
cartilage
Upper lateral
cartilage
Piriform
aperture
Lateral crus
Medial crus
Septum
Anterior nasal spine
Maxillary crest
Lower lateral
cartilage
Quadrangular
septal cartilage
A
B
C

Nasal Physiology
271
27
Figure 27.2.  Profile view illustration depicting the nasal
musculature. (Reprinted from Guyuron, B. [Ed.], 2012. Rhinoplasty. Elsevier,
1–26.)
Procerus
Nasalis
Levator labii
superioris
alaeque nasi
Depressor septi
Figure 27.3.  The nasal valves. The internal valves are formed by the articulation of the upper lateral cartilages with the anterior (dorsal)
septal edge; the external valves are formed by the alar cartilage lateral crura and their associated, investing, soft-tissue cover. (Reprinted
from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier, 46–70.)
Internal valve
External valve
Figure 27.4.  Nasal arterial anatomy. (Reprinted from Aston, S.J.,
Steinbrech, D.S., Walden, J.L. [Eds.], 2009. Aesthetic Plastic Surgery. Saunders,
507–521.)
Arcades
Lateral
nasal artery
Columellar
branches
Superior
labial artery
Facial
artery
Angular
artery

Rhinoplasty and Nasal Reconstruction
272
4. Base width: Equal to intercanthal distance
5. Angle of divergence refers to middle crura of LLC; the angle
between R and L middle crus while looking at the nose from
anterioposterior (AP) view.
• Ideal angle: 30 to 60 degrees; >60 = boxy tip, <30 = narrow
tip (see Figure 27.8)
6. The nostrils should have a teardrop configuration, with the
diameter of the base slightly larger than the diameter of the
apex.
• The long axis of each nostril points in a slight medial
direction (see Table 27.1).
Preoperative Considerations
1. Perform a full and thorough nasal history, examination, and
analysis and address areas of concern accordingly.
2. The aging nose is characterized by a drooping, elongated tip
complex and is primarily related to loss of intrinsic LLC
support.
3. The Asian nose is characterized by alar flare, a bulbous nasal
tip, a short retracted columella (i.e., no columellar show),
thick subcutaneous tissue, and a wide, flat nasal dorsum.
• Basilar view shows a flat columella-alar triangle with
hanging ala and a poorly projecting nasal tip.
• Asian rhinoplasty generally focuses on augmentation of the
nasal dorsum with an alloplastic implant.
■ Silicone implants are especially popular throughout Asia.
■ When performing nasal augmentation with an implant,
consider thickness of the overlying soft tissues to reduce
the risk for implant extrusion.
Ideal Nasal Analysis (see Figure 27.6)
Figure 27.5.  Illustration of the sensory innervation of the nose
from cranial nerve (CN) V. (Reprinted from Guyuron, B. [Ed.], 2012.
Rhinoplasty. Elsevier, 1–26.)
Supraorbital nerve
Supratrochlear
nerve
Infratrochlear nerve
Infraorbital nerve
External nasal
branch of anterior
ethmoidal nerve
Figure 27.6.  Important nasal landmarks in profile view. (Reprinted
from Aston, S.J., Steinbrech, D.S., Walden, J.L. [Eds.], 2009. Aesthetic Plastic
Surgery. Saunders, 437–472.)
Nasolabial angle
Tip defining points
Supratip break
Nasofrontal angle
1. Nasofrontal angle: Males, 120 to 130 degrees; females, 115 to
125 degrees
2. Nasolabial angle: Males, 90 to 95 degrees; females, 100 to 105
degrees
3. Tip projection: Equal to base width; 2/3 length of nose (see
Figure 27.7)
Figure 27.7.  Byrd method of determining tip projection based on
ideal nasal length. Using this method, the patient’s nasal projection
should be 23 their nasal length. (Reprinted from Aston, S.J., Steinbrech,
D.S., Walden, J.L. [Eds.], 2009. Aesthetic Plastic Surgery. Saunders, 507–521.)
0.67
1.0

Preoperative Considerations
273
27
5. Esthetic septorhinoplasty carries a high incidence of
postoperative patient dissatisfaction.
• Patient selection is critical.
• Most common reasons for dissatisfaction
■ Unsatisfactory results, irregularity of scar, continued
nasal obstruction, asymmetry, emotional distress, and
cost
■ Risk factors
○ Patients with unrealistic expectations or excessive
demands
○ Patients who are indecisive, immature, secretive,
motivated by others, or unstable
4. Hanging columella
• Caused by prominence of the caudal septum or convexity
of the caudal margin of the medial crura
• Treatment options: Resection of the caudal margin of the
medial crura
Figure 27.8.  Variations in tip shape. (Reprinted from Aston, S.J.,
Steinbrech, D.S., Walden, J.L. [Eds.], 2009. Aesthetic Plastic Surgery. Saunders,
507–521.)
Normal tip
30˚
Bulbous tip
Boxy tip
A
B
C
Table 27.1  External Nasal Analysis
Frontal View
Facial proportions
Skin type/quality
Fitzpatrick type, thin or thick, sebaceous
Symmetry and nasal
deviation
Midline, C-, reverse C-, S-, or S-shaped
deviation
Bony vault
Narrow or wide, asymmetrical, short or long
nasal bones
Midvault
Narrow or wide, collapse, inverted-V
deformity
Dorsal esthetic lines
Straight, symmetrical or asymmetrical, well
or ill defined, narrow or wide
Nasal tip
Ideal/bulbous/boxy/pinched, supratip,
tip-defining points, infratip lobule
Alar rims
Gull shaped, facets, notching, retraction
Alar base
Width
Upper lip
Long or short, dynamic depressor septi
muscles, upper lip crease
Lateral View
Nasofrontal angle
Acute or obtuse, high or low radix
Nasal length
Long or short
Dorsum
Smooth, hump, scooped out
Supratip
Break, fullness, pollybeak
Tip projection
Over- or underprojected
Tip rotation
Over- or under-rotated
Alar-columellar
relationship
Hanging or retracted alae, hanging or
retracted columella
Periapical hypoplasia
Maxillary or soft-tissue deficiency
Lip-chin relationship
Normal, deficient
Basal View
Nasal projection
Over- or underprojected, columellar-lobular
ratio
Nostril
Symmetrical or asymmetrical, long or short
Columella
Septal tilt, flaring of medial crura
Alar base
Width
Alar flaring
Present or absent
Reprinted from Neligan, P.C., Buck, D.W. (Eds.), 2013. Core
Procedures in Plastic Surgery. Elsevier, 46–70.

Rhinoplasty and Nasal Reconstruction
274
Rhinoplasty Techniques
1. Closed rhinoplasty
• Performed through infracartilaginous or intercartilaginous
incisions without an “external” incision
• Advantages: Minimal scar visibility, less disruption of
soft-tissue vascularity
• Disadvantages: Limited exposure and assessment of nasal
structures in their “resting state”
2. Open rhinoplasty
• Performed through a columellar incision that extends into
an infracartilaginous incision to “open” the nose
• Advantages: Maximal visibility and assessment of nasal
structures in their “resting state,” greatest degree of control
over techniques
• Disadvantages: External scar burden, disrupts soft-tissue
vascularity
3. Osteotomies (see Figure 27.9)
• Often performed to narrow and/or straighten the dorsum
or correct an open roof deformity
• Can be performed externally or internally
■ An external osteotomy is performed at the nasofacial
junction and has potential to injure the angular a.
• Infracturing of the nasal bones can result in nasal airway
obstruction by inadvertently narrowing the INV (<10 to 15
degrees).
○ Patients with body dysmorphic disorder (BDD)
○ Patients who “doctor shop”
• Management of the dissatisfied patient: Frequent
communication and follow-up
6. BDD
• Affects 7% to 15% of all plastic surgery patients
• Characterized by the degree of concern being much greater
than the degree of deformity; patients are generally
unaware that concerns are excessive.
■ The patient is preoccupied with appearance so much so
that a significant amount of time is spent trying to
camouflage or change the outward appearance with
makeup.
• Most patients with BDD are single (70% never married)
and up to 50% have suicidal ideation.
• Treatment recommendation: Refer to a psychiatrist to
provide useful psychotherapy and pharmacotherapy.
7. Photographic documentation
• Critical for planning, demonstration of results, and patient
education
• Lighting, patient positioning, and obtaining standard views
are paramount for best photographic results.
■ Standard views include frontal, oblique, lateral, basilar,
cephalic, and smiling lateral
■ Optimal orientation of the camera: Hold camera laterally
and flash from the same side as the nose (e.g., in lateral
and oblique views).
Figure 27.9.  Percutaneous discontinuous lateral nasal osteotomies. A, Low to high; B, low to low; C, double level (right). (Reprinted from
Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier, 46–70.)
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&

Rhinoplasty Techniques
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27
4. Septoplasty
• Often performed for deviated septum and nasal airway
obstruction
• Approached through an incision in the mucosa along the
septal wall
■ Hemitransfixion incision: Performed on one side
■ Full-transfixion incision: Performed on both sides of the
nasal wall
○ A full-transfixion incision can lead to decreased tip
projection and loss of nasal tip support. In cases
using a full-transfixion incision, a columellar strut
graft is recommended to add tip support.
• When removing the septum, take care to preserve a 1-cm
“L strut” (1 cm of caudal septum and 1 cm of dorsal
septum) to preserve strength.
■ If less than 1 cm is preserved, there is a risk of dorsal
collapse and saddle nose deformity (see Figure 27.10).
5. Cephalic trim (see Figure 27.11)
• The cephalic portion of the LLC can be trimmed to
■ De-rotate the nasal tip.
■ Reduce tip width.
■ Decrease tip fullness.
■ Increase the definition of the tip-defining points.
• Over-resection of the LLC can lead to ENV obstruction.
Figure 27.10.  Submucoperichondrial dissection. (Reprinted from
Neligan PC, Buck DW, [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier,
46–70.)
Figure 27.11.  Cephalic trim. A, Lateral and middle crura; B, lateral crus (right). (Reprinted from Neligan, P.C., Buck, D.W., [Eds.], 2013. Core
Procedures in Plastic Surgery. Elsevier, 46–70.)
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Rhinoplasty and Nasal Reconstruction
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6. Altering tip projection: Tip projection can be increased or
decreased through varying techniques.
• To increase tip projection
■ Cartilage tip graft
■ Medial crura sutures
■ Columellar strut graft
■ Resection of the caudal margin of the septum and
cephalic alar rim can rotate the nasal tip and increase
projection subtly.
• To decrease tip projection
■ Resection of the lateral and medial crura
■ Resection of the nasal spine
■ Full-transfixion incision (through weakened tip
support)
Figure 27.12.  A, The alar batten onlay graft provides strength to the lower lateral crus and the external nasal valve. B, The alar batten
onlay graft can be placed superiorly over the scroll area to increase crural strength and decrease internal nasal valve collapse. (Reprinted
from Ansari, K., Asaria, J., Hilger, P., et al., 2008. Op. Tech. Otolaryn. Head Neck Surg. 19 [1], 42–58.)
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%
Common Grafts and Sutures Used
in Rhinoplasty
1. Alar batten grafts: Cartilage placed as an only over the LLC
and the “scroll area”
• Useful to support the ENV, provide tip support, or
de-rotate the tip (see Figure 27.12)
2. Alar rim grafts: Cartilage placed caudal to the LLC
• Useful to correct alar retraction and/or asymmetry and
support the ENV (see Figure 27.13)
3. Spreader grafts: Cartilage interposed between the ULC and
septum
• Useful to open the INV (increase INV angle) and
straighten the dorsal esthetic line (see Figure 27.14)

Common Grafts and Sutures Used in Rhinoplasty
277
27
Figure 27.13.  Alar contour grafts. (Reprinted from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier, 46–70.)
Figure 27.14.  Dorsal spreader grafts. (Reprinted from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier, 46–70.)
Spreader grafts

Rhinoplasty and Nasal Reconstruction
278
Figure 27.15.  A, Floating and B, fixed columellar strut grafts.
(Reprinted from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in
Plastic Surgery. Elsevier, 46–70.)
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%
4. Columellar strut graft: Cartilage placed between the medial
crura of the LLC
• Useful to maintain or increase tip projection, unify the
nasal tip, and provide tip support (see Figure 27.15)
5. Lateral crural strut graft: Cartilage graft inserted between the
vestibular lining and the lateral crus of the LLC
• Useful to stent open a collapsed ENV (see Figure 27.16)
6. Transdomal sutures: Horizontal mattress sutures placed at the
dome or in the lateral crus of the LLC
• Useful to narrow the domes or the convexity of the lateral
crura
• May increase tip projection slightly (see Figure 27.17)
7. Interdomal sutures: Sutures between the domes
• Useful to alter columellar projection and tip projection (see
Figure 27.18)
8. Medial crural sutures: Sutures between the paired medial
crura of the LLCs.
• Useful to correct medial crura asymmetry, reduce flaring,
narrow the columella, and stabilize a columellar strut (see
Figure 27.19)
9. The columella-septal suture: Suture between the caudal
septum and medial crura
• Useful to rotate and strengthen the tip (see Figure 27.20)
Figure 27.16.  Lateral crural strut grafts. (Reprinted from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier, 46–70.)

Postoperative Nasal Deformities
279
27
• Treatment: Often requires use of autografts (e.g., auricular
cartilage, rib) or synthetic grafts
2. Open roof deformity
• Causes: Aggressive dorsal hump reduction resulting in
separation between the nasal sidewalls and the septum
• Treatment: Nasal osteotomies with infracturing or
placement of spreader grafts
3. Pollybeak deformity
• Causes: Inadequate resection of the lower dorsal septum or
excess scar formation in the supratip region
• Characterized by fullness in the supratip area that pushes
down and under; projects the nasal tip
• Treatment
■ If <3 months since primary rhinoplasty, corticosteroid
injection
■ If >3 months since primary rhinoplasty, nasal tip grafts
4. Rocker deformity
• Causes: Medial osteotomy that goes beyond the thick radix
bone, resulting in “rocking” of the fragment during
manipulation
• Characterized by contour deformity
• Treatment: Repositioning of the cephalic fracture lower on
the nasal bone
5. Inverted V deformity
• Causes: Avulsion of the ULCs or excessive removal of the
transverse portion of the ULC during dorsal septal resection
• Treatment: Placement of spreader grafts
Figure 27.17.  Nasal tip suturing technique (transdomal). (Reprinted
from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery.
Elsevier, 46–70.)
Figure 27.18.  Nasal tip suturing technique (interdomal). (Reprinted
from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery.
Elsevier, 46–70.)
Figure 27.19.  Nasal tip suturing technique (Medial crural).
(Reprinted from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in
Plastic Surgery. Elsevier, 46–70.)
Figure 27.20.  Intercrural septal suture. (Reprinted from Neligan, P.C.,
Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier, 46–70.)
Postoperative Nasal Deformities
1. Saddle nose deformity
• Causes: Excessive resection of the nasal dorsum leading to
a loss of dorsal support, septal hematoma, excessive
resection of the septum, fracture of the perpendicular plate
of the ethmoid, or comminution of the nasal bones during
infracture

Rhinoplasty and Nasal Reconstruction
280
■ Bilobed flap (see Figure 27.22)
○ Useful option for nasal tip and alar defects <1.5 cm in
size
6. Minor contour deformities
• If minor, and along the nasal dorsum and/or sidewalls,
consider correction with soft-tissue fillers.
• Inject filler into the subsuperficial musculoaponeurotic
(sub-SMAS) plane just above the periosteum.
Other Postoperative Considerations
1. Anosmia
• Some smell disturbance can occur after rhinoplasty.
• This disturbance will not inhibit ability to smell irritants
(e.g., ammonia), because this input travels through the
trigeminal n., which is not injured during rhinoplasty.
• If a patient complains of anosmia following rhinoplasty,
including irritants, consider malingering.
2. Acute periostitis
• Characterized by acute erythema of the nasal dorsum after
dorsal hump reduction
• Caused by retained shavings after dorsal rasping or saw
osteotomy that act as a nidus for infection
• Treatment: Oral antibiotics
■ After the erythema resolves, any residual dorsal
prominence can be excised (typically wait 8 to 12 months
after the initial operation).
3. Edema
• Postoperative edema is common and can persist for several
months
• Perioperative steroid administration has been shown to
decrease postoperative edema and ecchymosis.
■ Extended dosing is better than one-time dosing.
Nasal Reconstruction
1. Reconstructive options are dependent on the defect location
and depth.
• Focus analysis of the defect on location, cover, lining, and
support
• Some surgeons advocate subunit reconstruction when the
defect covers ≥50% of a particular subunit.
2. Superficial, small defects (intact cartilage framework)
• Upper 2/3rds of the nose is characterized by thin skin and
is amenable to full-thickness grafts.
• Small wounds of the sidewall or medial canthal region can
be allowed to heal by secondary intent (e.g., wounds
<0.5 cm in size).
• Local flaps may also be used (especially for wounds <1.5 cm
in size).
■ Dorsal nasal flap (see Figure 27.21)
○ Vascular supply: Angular a.
○ Useful option for defects of the dorsal midline (up to
2 cm in size)
○ May elevate the nasal tip and alter tip rotation
Figure 27.21.  The dorsal nasal flap is based on an axial vessel
and may cover defects up to 2 cm in diameter. (Reprinted from Burget,
G.C., Menick, F.J., 1994. Aesthetic Reconstruction of the Nose. Mosby, St Louis;
with permission.)
Skin only elevated
Ideal flap border
Actual flap border
Figure 27.22.  Bilobed flap. A,B, Zitelli’s design removes the
burrows triangle initially to improve the ease of flap rotation and
minimize donor site contour deformities. The first lobe for rotation
is set at the same size as the defect, in order to avoid distortion.
The second limb is designed such that its central portion or axis
represents an arc of rotation from 90 to 100 degrees. The bilobed
flap is best used in defects <1.5 cm in diameter. (A,B, Reprinted
from Burget, G.C., Menick, F.J., 1994. Aesthetic Reconstruction of the Nose.
Mosby, St Louis; Beahm, E.K., Walton, R.L., Burget, G.C., Concepts in nasal
reconstruction. In: Butler, C.E., Fine, N.A. [Eds.], 2008. Principles of Cancer
Reconstructive Surgery. Springer, New York; with permission.)
Excise
triangle first
First lobe same
size as defect
Limits of
submuscular
undermining
Trim flap last
90–100 degrees
Pivot point
= Radius of
defect
A
B

Nasal Reconstruction
281
27
■ Nasolabial flap (see Figure 27.23)
○ Vascular supply: Perforators from the facial and
angular arteries
○ Donor site closure occurs within the nasolabial fold.
○ Can be staged with pedicle division
○ Useful for defects of the lateral nose, ala, and total
alar reconstruction
■ Forehead flap (particularly for defects >1.5 cm in size,
defects of the nasal tip, and composite defects)
○ Vascular supply: Supratrochlear vessels
○ Workhorse flap for large nasal tip defects and total
nasal reconstruction
○ Can be extended and folded to provide nasal lining
○ Staged reconstruction requiring a separate pedicle
division (typically 3 weeks)
○ For composite reconstruction, requires additional
stages including flap thinning and cartilage graft
placement before pedicle division (see Figure 27.24)
3. Small (<1.5 cm) full-thickness defects of the alar rim
• Classic wound for composite graft from the helical root
4. Composite/full-thickness defects require reconstruction of the
nasal lining, support, and skin.
• Options for nasal lining reconstruction
■ Mucoperichondrial flap from the nasal septum
○ Vascular supply: Superior labial arteries
○ Can be used as a composite graft by including septal
cartilage (“septal pivot flap”) (see Figure 27.25)
Figure 27.23.  Subunit nasolabial two-stage flap. A,B, Initial flap elevation and inset. C, Flap pedicle division. (Reprinted from Burget, G.C.,
Menick, F.J., 1994. Aesthetic Reconstruction of the Nose. Mosby, St Louis; with permission.)
Tail of pedicle
thinned, trimmed,
and inset
Remnant of alar
subunit excised
Undermined
area
Subcutaneous
pedicle based
superiorly
Tapered
skin pedicle
Dog ear
exicsed
A
C
B
■ Folded forehead flap or skin-grafted forehead flap
■ Cutaneous turnover flaps from adjacent skin
■ Nasolabial flap
■ Facial artery myomucosal (FAMM) flap
■ Radial forearm free flap
• Options for support
■ Septal cartilage
■ Auricular cartilage (e.g., concha)
■ Rib cartilage or osteochondral rib grafts
• Options for skin
■ As above; forehead flap is the workhorse.
5. Rhinophyma
• Localized nasal soft-tissue swelling secondary to fibrosis,
sebaceous hyperplasia, and lymphedema
• May develop spontaneously or in patients with a history of
acne rosacea
• Male predilection
• Occasionally degenerates into a skin malignancy
• Treatment options: Tangential surgical excision and/or
laser ablation and electrosurgical excision

Rhinoplasty and Nasal Reconstruction
282
Figure 27.25.  Variations of the septal intranasal lining flaps. (Reprinted from Burget, G.C., Menick, F.J., 1994. Aesthetic Reconstruction of the Nose.
Mosby, St Louis; with permission.)
1
2
6
7
Whole septal composite
Septal plus middle vault lining
Angled composite
3
4
Long composite
Bipartite
Bipedicle
Ipsilateral
5
Figure 27.24.  Three ways to gain length for a paramedian forehead flap: 1, Extend the flap into the hair-bearing scalp and depilate the flap;
2, extend the flap 1.5 cm over the orbital rim, lifting the eyebrow with the flap, if necessary; and 3, score only the frontalis muscle at 1-cm
intervals, allowing the flap to expand up to 1.5 cm longitudinally. (Reprinted from Mathes, S. [Ed.], 2006. Plastic Surgery, 2nd ed. WB Saunders,
Philadelphia.)
Release of frontalis m.
at 1-cm intervals
Extend flap into
hair-bearing scalp
Extend base of
flap across
supraorbital rim
1
2
3

Nasal Reconstruction
283
27
Guyuron, B., Rowe, D.J., 2009. Chapter 42: Correction of the deviated
septum. In: Aston, S.J., Steinbrech, D.S., Walden, J.L. (Eds.), Aesthetic Plastic
Surgery. Saunders, pp. 523–530.
Hong Roy, W., Menick, F., 2010. Chapter 57: Nasal reconstruction.
In: Weinzweig, J. (Ed.), Plastic Surgery Secrets Plus, 2nd ed. Mosby,
pp. 381–387.
Janis, J.E., Ahmad, J., Rohrich, R.J., 2011. Chapter 55: Primary rhinoplasty.
In: Nahai, F. (Ed.), The Art of Aesthetic Surgery, 2nd ed. Quality Medical
Publishing, pp. 1895–1974.
Marin, V.P., Cochran, C.S., Gunter, J.P., 2009. Chapter 41: Anatomic
approach for tip problems. In: Aston, S.J., Steinbrech, D.S., Walden, J.L.
(Eds.), Aesthetic Plastic Surgery. Saunders, pp. 507–521.
Rohrich, R.J., Adams, W.P., Pessa, J.E., et al., 2011. Chapter 53: Applied
anatomy of the nose. In: Nahai, F. (Ed.), The Art of Aesthetic Surgery:
Principles and Techniques, 2nd ed. QMP, pp. 1859–1873.
Sandel, H.D., Meyers, A.R., Polly Beak Deformity in Rhinoplasy. Emedicine.
com. Found at:
Accessed on: September 12, 2014.
Tabbal, N., Bogdan, M., 2009. Chapter 38: Primary open rhinoplasty. In:
Aston, S.J., Steinbrech, D.S., Walden, J.L. (Eds.), Aesthetic Plastic Surgery.
Saunders, pp. 473–479.
Tebbets, J.B., 2006. Open and closed rhinoplasty (minus the “versus”):
analyzing processes. Aesthet. Surg. J. 26 (4), 456–459.
Toriumi, D.M., Checcone, M., 2009. Chapter 44: The Asian rhinoplasty. In:
Aston, S.J., Steinbrech, D.S., Walden, J.L. (Eds.), Aesthetic Plastic Surgery.
Saunders, pp. 555–571.
Suggested Readings
Ansari, K., Asaria, J., Hilger, P., et al., 2008. Grafts and implants in
rhinoplasty: techniques and long-term results. Op. Tech. Otolaryn. Head
Neck Surg. 19 (1), 42–58.
Aston, S.J., Martin, J., 2009. Chapter 37: Primary closed rhinoplasty. In: Aston,
S.J., Steinbrech, D.S., Walden, J.L. (Eds.), Aesthetic Plastic Surgery. Saunders,
pp. 437–472.
Beahm, E., Walton, R.L., 2009. Chapter 4: Nasal reconstruction. In: Butler,
C.E. (Ed.), Nasal Reconstruction. Elsevier, pp. 73–126.
Berth-Johns, J., 2014. Chapter 211: Rhinophyma. In: Lebwohl, M.G.,
Heymann, W.R., Berth-Jones, J., et al. (Eds.), Treatment of Skin Disease:
Comprehensive Therapeutic Strategies, 4th ed. Elsevier, pp. 677–678.
Chapter 3: Rhinoplasty. In: Neligan, P.C., Buck, D.W. (Eds.), 2013. Core
Procedures in Plastic Surgery. Elsevier, pp. 46–70.
Daniel, R.K., Brenner, K.A., 2009. Chapter 39: Secondary rhinoplasty. In:
Aston, S.J., Steinbrech, D.S., Walden, J.L. (Eds.), Aesthetic Plastic Surgery.
Saunders, pp. 481–494
DeRosa, J., Toriumi, D., 2010. Chapter 78: Rhinoplasty. In: Weinzweig, J.
(Ed.), Plastic Surgery Secrets Plus, 2nd ed. Mosby, pp. 516–525.
Fernandes, S.V., Meyers, A., medicine.com. Found at:
.medscape.com/article/843439-overview#a17. Accessed on: September 12,
2014.
Galdino, G.M., DaSilva, D., Gunter, J.P., 2001. Digital photography for
rhinoplasty. Plast. Reconstr. Surg. 109 (4), 1421–1434.
Guyuron, B., 2012. Rhinoplasty. Saunders, pp. 1–448.

Rhytidectomy and
Neck Rejuvenation
Chapter
28 
Essential Facial Anatomy
1. Continuous facial layers (see Figure 28.1)
2. Nerves
• Motor nerve innervation of the muscles of facial expression
(see Table 28.1 and Figure 28.2)
• Sensory innervation of the face and neck (see Figure 28.3)
3. Anatomy of the aging face (see Figure 28.4)
Rhytidectomy
1. Techniques (see Table 28.2 and Figures 28.5-28.10)
2. Preoperative considerations
• Blood pressure control
• Stop all antiplatelet and anticoagulant medications at least
7 to 10 days preoperatively.
• Smoking cessation at least 3 to 4 weeks before surgery
and after surgery to reduce the risk of facial skin flap
necrosis
3. Complications
• Hematoma
■ The most common facelift complication (reported
to occur in 2% to 3% of women and up to 8%
of men)
■ Symptoms: Unrelenting, asymmetric ear and facial
pain
■ Risk factors
○ Hypertension
○ Male gender
■ Treatment
○ Early: Operative evacuation
○ Late (days after surgery with no skin compromise):
Attempt aspiration.
• Skin loss
■ Risk factors: Excess tension, thin flaps, hematoma, tight
dressings, smoking
■ Frequently occurs in the retroauricular location
■ Treatment: In general, treat skin loss conservatively (e.g.,
antibiotic ointment, silver sulfadiazine), with possible
scar revision at a later date. If infection is present,
debridement may be necessary and large areas may
require skin grafting.
• Alopecia
■ Etiology: Excess tension at the incision, direct injury to
follicles
○ Beveling during incision placement within the hair
will reduce the risk of alopecia by promoting hair
growth within the scar.
■ Secondary facelifts have a high risk for causing greater
distortion of the hairline; thus, use a new incision for
these procedures.
■ Large areas of alopecia may require hair transplantation,
scalp rotation flaps, or even scalp expansion at a later
date.
• Nerve injury
■ In general, nerve palsy following facelift procedures is
managed with initial observation unless known direct
nerve injury has occurred.
■ If direct injury occurs during surgery, primary
repair of the nerve and/or primary grafting is
recommended.
• Infection
■ Treat infections with antibiotics to reduce the risk of
subsequent skin loss and scarring.
■ Rarely, pseudomonas infection can occur, particularly in
patients who are colonized with pseudomonas species
within the ear canal (e.g., swimmers).
○ For these patients, add ciprofloxacin for
coverage.
• Malar hollowing secondary to malar fat pad resorption
■ Secondary to interruption of the angular a. during
dissection
Necklift
1. Preoperative considerations
• Degree of skin laxity
• Cervicomental angle
• Platysmal banding
• Presence of excess submental fat
• Chin position
• Submandibular glands
• Hyoid bone, thyroid cartilage (see Figures 28.11-28.13)
Text continued on page 292

Necklift
285
28
Figure 28.1.  The facial layers of the scalp, face, and neck. SMAS, Superficial muscular aponeurotic system. (Reprinted from Neligan, P.C.,
Rodriguez, E.D. [Eds.], 2013. Plastic Surgery, vol. 3, 3rd ed. Elsevier, 1–22.)
Deep temporal fascia
Deep facial fascia
Deep
cervical fascia
Zygomatic
arch
Coronoid
process
Parotid gland
Mandible
Temporalis
Temporal bone
Periosteum
Skin
Galea
Superficial facial fascia,
enclosing mimetic
muscles of face (SMAS)
Superficial cervical fascia
(enclosing platysma)
Subcutaneous
fat
Superficial temporal
(temporoparietal) fascia

Rhytidectomy and Neck Rejuvenation
286
Table 28.1  Extratemporal Facial Nerve Branches
NERVE BRANCH
LOCATION
INNERVATED MUSCLES
BRANCH INJURY
NOTES
Temporal/frontal
Pitanguy’s line (0.5 cm below
tragus to 1 cm above and lateral
to brow); often travels with
“sentinel vein”; deep to SMAS
at level of the zygoma and deep
to temporoparietal fascia above
zygoma
Frontalis muscle,
orbicularis oculi
Inability to elevate the
brow, weak eyelid
closure
Often neurapraxia injury
from stretch; susceptible
to injury at level of the
zygoma with sub-SMAS
techniques; neuropraxia
Zygomatic
Pierce the deep
parotidomasseteric fascia 4 cm
anterior to the tragus and travel
toward lower lid and midcheek
Lower orbicularis oculi
(primarily); also some
innervation of zygomaticus
major, buccinator,
orbicularis oris, levator labii
Often asymptomatic
because of arborization
with buccal branch
Buccal
Pierce deep parotidomasseteric
fascia at anterior border of
masseter
Orbicularis oculi,
zygomaticus major and
minor, levator labii
superioris, buccinator,
orbicularis oris
Often asymptomatic
because of arborization
with buccal branch;
occasional inability to
compress cheeks
Most common motor
nerve injury with facelift
Marginal
mandibular
Deep to platysma, can travel up
to 3 to 4 cm below the
mandibular border
Lower lip depressors,
mentalis, orbicularis
Inability to depress lower
lip (injured side higher
during smile) or to purse
lips
Treatment: Observation
unless known direct injury;
Botox to uninjured side
can improve symmetry
Cervical
Deep to platysma, below
mandibular border
Platysma
Inability to depress lower
lip (pseudoparalysis of
marginal mandibular n.)
Treatment: Observation
SMAS, Superficial muscular aponeurotic system.
Figure 28.2.  The facial nerves. (Reprinted from Neligan, P.C., Rodriguez, E.D. [Eds.], 2013. Plastic Surgery, vol. 3, 3rd ed. Elsevier, 1–22.)
Parotid gland
Posterior
auricular nerve
Zygomaticotemporal division
Cervicofacial division
Marginal mandibular
branches
Cervical branch
Buccal branches
Zygomatic branches
Temporal branches

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28
Figure 28.3.  The sensory supply of the face. (Reprinted from Neligan, P.C., Rodriguez, E.D. [Eds.], 2013. Plastic Surgery, vol. 3, 3rd ed. Elsevier, 1–22.)
A1
A1 - External nasal
B1
B1 - Infraorbital
C1
C1 - Mental
A3
A3 - Supratrochlear
B3
B3 - Zygomaticotemporal
C3
C3 - Auriculotemporal
A2
A2 - Infratrochlear
B2
B2 - Zygomaticofacial
C2
C2 - Buccal
GAN
GON - Greater occipital nerve
LON
LON - Lesser occipital nerve
GON
GAN - Greater auricular nerve
A4
A4 - Supraorbital
Figure 28.4.  The aging face exhibits changes in the skin, superficial wrinkles, deeper folds, soft-tissue ptosis, loss of volume in the upper
third and middle third, and increased volume in the lower third. (Reprinted from Neligan, P.C., Warren, R.J. [Eds.], 2013. Plastic Surgery, vol. 2, 3rd ed.
Elsevier, 184–207.)
Perioral wrinkles
Buccal fat pad ptosis
Expansion and ptosis of jowl fat
Elongating upper lip
Excess preplatysmal and
subplatysmal fat
Platysma muscle laxity
Malar fat descent
Frontalis contraction
Lateral brow ptosis
Temporal fat pad atrophy
Upper lid sulcus hollowing
Orbicularis oculi laxity
Orbicularis contracture
Lower lid laxity
Loss of midface fat
Transverse forehead creases
Temporal wasting
Crow’s feet
Tear trough
Cheek descent
Midface flattening
Nasolabial folds
Thinning lips
Marionette lines
Jowls
Transverse neck folds
Platysma bands
Vertical neck pleats