Facial Plastic and Reconstructive Surgery

FIGURE 3.1 Facial Fifths.

 (From Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology—Head and Neck Surgery. 6th ed. Philadelphia, PA: Saunders; 2015, fig. 19-7.)


FIGURE 3.2 Facial Thirds.

 (From Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology—Head and Neck Surgery. 6th ed. Philadelphia, PA: Saunders; 2015, fig. 19-8.)

• When measured from the nasion (frontonasal suture) to subnasale, midface should account for 43% of height when compared to 57% for lower face

Aesthetic Units of the Face

1. Forehead

2. Eyes

3. Nose

4. Lips

5. Chin

6. Ears

7. Neck

Glogau Photoaging Classification1

• Type 1: no wrinkles, mild pigmentary changes, and no keratoses, minimal wrinkles, and age in the 20s and 30s

• Type 2: hyperkinetic wrinkles, early solar lentigines and palpable keratoses, parallel smile lines, and age in the 40s

• Type 3: static wrinkles, dyschromia, telangiectasias, visible keratosis, and age in the 50s

• Type 4: only wrinkles, yellow-gray skin with neoplasia, and age in the 60s and older

Fitzpatrick Skin Pigmentation Classification2

• Based on first 60-minute unprotected exposure to midday sun at the beginning of spring

• Type 1: white, always burns, and never tans (typically redheaded)

• Type 2: white, usually burns, and tans with difficulty (typically blonde)

• Type 3: white, sometimes mildly burns, and on average, tans (typically brunette)

• Type 4: brown, rarely burns, and tans with ease (Mediterranean, Hispanic, East Asian)

• Type 5: dark brown, very rarely burns, tans very easily (South Asian)

• Type 6: black, never burns, tans very easily (African, Caribbean)

Norwood-Hamilton Male Hair-Loss Classification3

• Type 1: adolescent or juvenile hairline with no recession; rests at upper brow crease

• Type 2: minimal frontotemporal recession, ≤1.5 cm above the upper brow crease

Type 2A: additional recession in the central anterior region

• Type 3: deepening temporal recession, the first stage of balding

Type 3A: additional recession in the central anterior region

Type 3V: additional hair loss at the vertex

• Type 4: further frontotemporal recession with hair loss from the vertex; areas of recession are separated by a solid band of hair

Type 4A: frontotemporal hair loss beyond type 3A, but without loss at vertex

• Type 5: vertex loss is separated from the frontotemporal hairline by a narrow band of hair

Type 5A: severe thinning of the central anterior hairline in continuity with thinning at the vertex

Type 5V: additional loss at the vertex further thins the band separating it from the frontotemporal hairline

• Type 6: frontal and vertex regions of hair loss are joined, and hairline is relatively high temporally

• Type 7: a narrow band of hair remains in a horseshoe shape, connecting the sides and back of the scalp

Dedo Aging Neck Classification4

• Type 1: normal cervicomental angle, good muscle tone, and no submental fat

• Type 2: cervical skin laxity and obtuse cervicomental angle

• Type 3: submental adiposity; rejuvenation will require submental lipectomy

• Type 4: platysmal banding; rejuvenation will require imbrication or plication

• Type 5: retrognathia/microgenia; rejuvenation will require genioplasty or orthognathic surgery

• Type 6: low-lying hyoid; manage by setting appropriate expectations

Cervicomental angle: 80-95 degrees

Upper Lip Subunits

1. Philtrum dimple

2. Philtrum columns

3. Melolabial folds

4. Cupid’s bow

5. Vermilion border

Perioral Proportions

• Upper to lower-lip height 1:2

• Line drawn from the menton to the nasal tip: upper lip lies 4 mm posterior; lower lip lies 2 mm posterior

• Zero meridian of Gonzalez-Ulloa (perpendicular to the Frankfort plane; runs from the nasion to the pogonion): the mentolabial sulcus lies 4 mm posterior

Perioral Abnormalities

• Types of lip clefts

Bilateral and unilateral

Complete (through the nasal sill) and incomplete (Simonart’s band is intact at the sill)

• More common on the left than on the right, 2:1

• More common in males than in females

• Risk of second child with a cleft lip/palate after the first is affected: 4%

• Most common syndrome with cleft lip/palate: Van der Woude; characterized by lower-lip pits

Auricular Subunits

1. Helix

a. Crus helicis (divides the cymba and the cavum conchae)

2. Antihelix

a. Superior/posterior crus

b. Anterior/inferior crus

3. Darwin’s tubercle

4. Fossa triangularis (bounded by the antihelical crura and the helix)

5. Tragus

6. Antitragus

7. Intertragal incisura (divides the tragus and the antitragus)

8. Scapha (scaphoid fossa)

9. Conchal bowl

a. Cymba concha; superior to the crus helicis

b. Cavum concha; inferior to the crus helicis, contiguous with the external auditory meatus

10. Lobule

Auricular Proportions

• Ratio of auricular width to height: 1:2

• Auricular height 60-65 mm

Height roughly equal to nasal height

• Superior margin of the helical rim at the brow level

• Inferior margin of the lobule at the nasal ala level

• Superior pole rotated posteriorly 15 degrees

• Auriculocephalic angle, 20-30 degrees

10-12 mm from the helix to the mastoid at the superior pole

16-18 mm from the helix to the mastoid at the midauricle

20 mm from the lobule to the mastoid at the superior lobule

Auricular Abnormalities

1. Prominauris

a. “Lop ear” deformity resulting from antihelical-fold deficiency

b. “Cup ear” deformity because of conchal bowl excess

2. Stahl’s ear

a. Third, more superoposterior antihelical crus causes pointed, unfurled superior helix

3. Outstanding lobule

a. Prominent cauda helicis

4. Cryptotia

a. Superior aspect of auricular cartilage buried under skin

5. Microtia

a. Grade 1: most subunits present, although decreased in size

b. Grade 2: lobule and helical remnant is present

c. Grade 3: “Peanut ear,” with lobule and cartilage remnant present (most common)

d. Grade 4: anotia, no external structures present

e. Microtia more common on the right side

f. May be associated with hemifacial microsomia, Goldenhar syndrome

Eyelid Proportions

• Palpebral fissure width/intercanthal distance

Males: 26.5-38.7 mm

Females: 25.5-37.5 mm

• Palpebral fissure height

10-12 mm

• Margin-reflex distance (MRD)

MRD1 from light reflex to upper-lid margin: 4-5 mm

MRD2 from light reflex to lower-lid margin: 5-6 mm

• Tarsal crease 7-15 mm above the lash line; higher in females

• Upper lid should cover a small portion of the iris; inferior limbus should be within 1-2 mm of the lower lid

• Lateral canthus should be 2 mm higher than the medial canthus

Blepharoplasty Tests

• Schirmer test: strip of filter paper is inserted at the lower-eyelid margin (both eyes are measured at once) and left in place for 5 minutes with eyes closed; degree of wetting read as a linear measurement on the filter paper (normal ≥10 mm)

• Snap test: measures how quickly the lid margin snaps back against the globe after being distracted; longer than 1-2 seconds indicates lid margin laxity

Nasal Subunits

1. Tip

2. Columella

3. Dorsum

4. Sidewalls ×2

5. Alae ×2

6. Soft-tissue facets/triangles ×2

Nasal Surgery Considerations

1. Thickness of skin soft-tissue envelope

2. Straightness of dorsum: smooth brow-dorsum-tip aesthetic line is best assessed in a three-fourths view photograph

3. Tip support

4. Tip projection

5. Tip light reflex/symmetry of the nasal tip defining points

6. Tip tension with smile

7. Dynamic collapse

8. Modified Cottle maneuver to assess obstruction at the internal and external valves

9. Columellar show: 2-4 mm; differentiate hanging columella from alar retraction

10. Ala-to-tip ratio 1:1 when viewed from the side

11. Basal view should be triangular, not trapezoid; ratio of the infratip lobule length to the nostril length should be 1:2

12. Nasofacial relationships (Fig. 3.3)

Tip Projection Analysis Methods

1. Simons method: tip projection to upper-lip length 1:1 ratio

2. Goode method: tip projection to nasal length 0.55-0.6:1 ratio

3. Crumley method: tip projection, nasal height, and nasal length make a 3-4-5 triangle

Nasofacial Relationships (Fig. 3.3)

• Nasofrontal angle: 115-135 degrees

• Nasofacial angle: 30-40 degrees, ideally 36 degrees

• Nasolabial angle

Males: 90-95 degrees

Females: 95-110 degrees; greater rotation acceptable in shorter women

• Nasomental angle: 120-132 degrees

Craniomaxillofacial Trauma Primary Evaluation

1. Airway, breathing, circulation, disability, exposure

Orotracheal versus nasotracheal intubation versus tracheostomy

2. Vital signs

3. Neurological exam

Cranial nerves with visual acuity and tuning forks

Assess for intracranial injury

Cervical spine injury occurs in 10% of maxillofacial trauma cases

4. Inspect for lacerations, bleeding, and ecchymosis

Periorbital or postauricular ecchymosis may indicate skull-base fracture

5. Evaluate ears for hemotympanum, canal stepoffs, and clear or bloody otorrhea (cerebrospinal fluid [CSF] leak)

6. Evaluate the neck for tracheal deviation, subcutaneous emphysema, and bulging veins (tension pneumothorax or cardiac tamponade)

Craniomaxillofacial Trauma Secondary Evaluation (Top Down)

1. Upper face: scalp lacerations, skull deformities, frontal sinus/nasofrontal outflow tract injury, and CSF leak

2. Midface


• Periorbital edema and ecchymosis

• Bony stepoffs at orbital rim


FIGURE 3.3 Nasofacial relationships: (A) nasofrontal angle, (B) nasolabial angle in men and women, (C) nasofacial angle, and (D) nasomental angle. (From Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology—Head and Neck Surgery. 6th ed. Philadelphia, PA: Saunders; 2015, figs. 19-12, 19-16, 19-17, 19-18.)

• Assess pupillary response to light

• Marcus-Gunn pupil = afferent pupillary defect

• Assess extraocular muscle movement (forced ductions if patient is unresponsive)

• Assess for eyelid and lacrimal system injuries

• Ophthalmology consultation to rule out globe injury


• Assess for widening of the midface, trismus, and malar depression

• Infraorbital paresthesia common


• Assess for bony stepoffs and mobility of the palate or midface


• Most common facial fracture

• Assess for mobility, crepitus, tenderness, and swelling

• Check for clear or bloody rhinorrhea (CSF leak)

• Check for septal hematoma

• May cause septal necrosis and buckling or saddle deformity if untreated

• Incise and leave a drain

3. Lower face

Oral cavity: assess for dental injuries, lacerations, ecchymosis, and trismus

Occlusion: assess for open bite, crossbite, inability to close mouth, and missing teeth

• Angle dental occlusion classification5

• Class 1: the mesiobuccal cusp of the first maxillary molar fits in the buccal groove of the first mandibular molar

• Class 2 (overjet): the mesiobuccal cusp of the first maxillary molar contacts the mesial to the buccal groove of the first mandibular molar

• Class 3 (underjet): the mesiobuccal cusp of the first maxillary molar contacts the distal to the buccal groove of the first mandibular molar


• Assess for stepoffs and mobility of fractured segments

• Evaluate maximal incisal opening

• Assess for deviation of the mandible on opening, premature contact of the molars, loss of mandibular height, and anterior open bite

• All are signs of ipsilateral subcondylar fracture

• Look for floor-of-the-mouth hematoma

• Assess sensation of the mental nerve

Facial Resurfacing

Indications for Facial Resurfacing (See Cummings Otolaryngology, 6th ed., Chapter 26)

1. Advanced-to-severe skin damage with wrinkles at rest

2. Fine and deep rhytides

3. Uncontrollable acne

4. Acne scars

5. Ephelides

6. Lentigines

7. Actinic keratosis

8. Some skin cancers

Absolute Contraindications for Facial Resurfacing

1. Significant hepatorenal disease

2. Human immunodeficiency virus (HIV)

3. Immunosuppression

4. Emotional instability or mental illness

5. Ehlers-Danlos syndrome

6. Scleroderma or collagen vascular diseases

7. Recent isotretinoin treatment (within 6-12 months before)

Relative Contraindications for Facial Resurfacing

1. Darker skin type (Fitzpatrick IV, V, and VI)

2. History of keloid formation

3. History of cold sores

4. Cardiac abnormalities

5. History of previous facial irradiation

6. Unrealistic expectations

7. Physical inability to perform quality postoperative care

8. Anticipation of inadequate photo protection because of job, vocation, or recreation

Herpes Simplex Virus Prophylaxis Before Perioral or Full-Face Resurfacing6

• Valacyclovir 500 mg orally twice a day for 14 days, starting the day of the procedure.

Sequelae of Facial Resurfacing

• Pigmentary changes

Hyperpigmentation with darker-skinned patients, usually temporary (give 4-8% hydroquinone gel before surgery and sun protection factor [SPF] 30 sunblock after surgery, withhold systemic estrogens)

Hypopigmentation is most common; can be permanent

Depigmentation (rarely, and in isolated areas)

• Persistence of rhytides

• Prolonged erythema

• Persistent texture change of skin

• Hypertrophic subepidermal healing

• Milia

• Skin pore prominence

• Increased prominence of telangiectasias

• Darkening and growth of preexisting nevi

Complications of Facial Resurfacing

1. Skin infection

HSV outbreak

Pseudomonas, Staphylococcus, and Streptococcus


2. Lower-eyelid ectropion

3. Cardiac arrhythmias

4. Renal failure

5. Laryngeal edema

6. Toxic shock syndrome

7. Facial scarring

8. Telangiectasias

Topical Facial Resurfacing Therapies

• Retinoids (tretinoin)

• Bleaching agents (hydroquinone)

• Sunscreen

• Moisturizers

• Pretreat skin with the abovementioned products before resurfacing, which may improve resurfacing results; some patients will not need resurfacing after the topical regimen

Chemical Peels

• Superficial chemical peels act on the epidermis and have no effect on the dermis

Salicylic acid 5-15%

Glycolic acid 40-70%; must be rinsed off w/H2O or neutralized w/NaHCO3

Jessner solution (resorcinol, salicylic acid, lactic acid, and EtOH)

Trichloroacetic acid (TCA) 10-25%

• Medium peels penetrate down to the superficial reticular dermis

TCA 50% alone can cause scarring

TCA 35% in combination with dry ice pretreatment or Jessner or glycolic acid 70%

• Deep peels penetrate to the midreticular dermis and are often required for Glogau III-IV

Baker solution (phenol, septisol, croton oil, and distilled water); phenol penetrates further with decreasing concentrations


• Addresses deep scarring, deep rhytides, and acne-related pits/scars

• Variable depth of resurfacing

• Pinpoint bleeding in chamois-colored tissue indicates level of papillary dermis

• Use freezing spray before mechanical abrasion to decrease tissue spatter

• Good for decreasing height of thick scars

• Decreased postoperative erythema

• Microdermabrasion is more superficial and requires no anesthesia or physician

Laser Wave Characteristics

1. Collimated (parallel)

2. Monochromatic (same wavelength)

3. Coherent (in phase)

Ablative Lasers for Scar Revision and Skin Resurfacing

1. CO2 10,600 nm (far infrared), chromophore: H2O

2. Er:YAG (erbium-doped yttrium-aluminum-garnet) 2940 nm (near infrared), chromophore: collagen and dermal proteins

Either can be used as a fractionated treatment, which is safer for patients with darker skin

CO2 and Er:YAG can be used in sequence, with Er:YAG removing thermally necrotic tissue after CO2 treatment.

Ablative depth can be varied, typically deeper in fractionated treatments (150-300 μm)

Nonablative Lasers for Vascular Anomalies, Pigmented Lesions, and Tattoo and Hair Removal

1. KTP (potassium-titanyl-phosphate) 532 nm (green), chromophore: oxyhemoglobin and red tattoos

2. Pulsed-dye 585-595 nm (yellow), chromophore: oxyhemoglobin (may also be used for scar revision)

3. Alexandrite 755 nm (red), chromophore: melanin, blue, green, and black tattoos

4. Nd:YAG (neodymium-doped yttrium-aluminum-garnet) 1064 nm (near infrared), chromophore: oxyhemoglobin, melanin (in hair follicles), and blue and black tattoos

Laser only affects hair follicles in anagen

Takes 3-5 treatments, separated by 4-6 weeks, to ensure that all hair follicles are treated during the anagen phase

Works poorly on light-colored or vellus hair because of lack of chromophore for laser

5. Intense pulsed light/broadband light (515-1200 nm)—not a true laser—used for melasma, erythema and other hyperpigmentation, hair removal, and skin tightening

Requires multiple treatments, maintenance therapy


Dermal Filler Indications7

1. Static rhytides

2. May help fill in dynamic rhytides after chemodenervation

Dermal Fillers

1. Hyaluronic acid

Restylane, Perlane, Juvederm, and others

Inject into dermis

6-12 months’ duration

Hyaluronidase to correct excess injections

2. Calcium hydroxylapatite


Inject into dermis or subdermally

≥12 months’ duration

Do not inject into lips

3. Poly-L-lactic acid


Inject subdermally

Results take 4 weeks to appear, as new collagen forms

Lasts 12 months, but some permanent effect after normal course of two to three injections

Indicated for HIV lipoatrophy

4. Autologous fat

Harvested from the belly or thigh and centrifuged to concentrate adipocytes

Must be transferred atraumatically to improve cell viability

Inject at multiple levels, subdermally and deeper

5. Collagen

Zyderm and Zyplast

Rarely used anymore; requires allergy to bovine collagen testing before injection

Chemodenervation Characteristics

1. Most useful for dynamic rhytides

2. Takes 1-2 weeks to reach maximum effect

3. Lasts 3-4 months

4. Shorter duration of action and smaller effect may result from development of antibodies

5. With repeated facial cosmetic doses, patients often require less toxin or have a longer period between injections with the same effect

6. Acts by preventing release of acetylcholine in the neuromuscular junction

7. Recovery occurs first by development of new synapses, followed by recovery of function at the original synapse

Chemodenervation Agents

• Botulinum toxin comes in seven varieties: A-G

A and E cleave SNAP-25

B, D, and F cleave synaptobrevin (VAMP)

C cleaves syntaxin

• OnabotulinumtoxinA (Botox)

• AbobotulinumtoxinA (Dysport)

• IncobotulinumtoxinA (Xeomin)

• RimabotulinumtoxinB (Myobloc)

Brow Lift

Ideal Brow Position (Fig. 3.4)

• Women: begins medially at a vertical line from the ala of the nose; terminates at an oblique line drawn through the ala of the nose and extending past the lateral canthus; apex of brow arc between the lateral limbus and lateral canthus

• Men: lies at the supraorbital rim and does not arch as high as in women

Brow Lift Considerations

• Glabellar creases

Transverse creases caused by procerus, most superficial muscle of the glabella

Vertical creases caused by corrugator supercilii, superficial to frontalis, and deep to procerus

Division of the corrugator has a similar effect as permanent chemodenervation, but may lateralize the medial brows

• Frontal branch of the facial nerve

Within 2 mm of zygomaticotemporal “sentinel” vein between the superficial temporal fascia above and the deep temporal fascia below

Indications for Brow Lift

• Brow ptosis, especially when it contributes to an upper visual field deficit with dermatochalasis

• Corrugator and procerus hyperactivity are indications for endoscopic forehead lift

• Baldness is not a contraindication

Brow Lift Approaches

1. Endoscopic

2. Coronal

3. Midforehead

4. Direct


FIGURE 3.4 Ideal Brow Position.

 (From Flint PW, Haughey BH, Lund VJ, et al. Cummings Otolaryngology—Head and Neck Surgery. 6th ed. Philadelphia, PA: Saunders; 2015, fig. 19-13.)

Endoscopic Brow Lift8

• Patients with short foreheads (<6 cm from brow to hairline), brow ptosis, or corrugator and procerus hyperactivity

• Subperiosteal dissection

• Avoid supratrochlear and supraorbital neurovascular bundles when releasing the periosteum from the supraorbital rim

• Release the periosteum all along the lateral orbital rim to permit temporal lifting and relief of lateral periocular hooding

• 1.5 cm longitudinal incisions placed behind the hairline in median and paramedian positions (superior to the lateral limbus), and longer incisions placed behind the temporal hair tufts

• Periosteum secured in the elevated position with absorbable anchors, or sutures through bone bridges placed under paramedian incisions, or with fibrin glue

• Decreased scarring, alopecia, and numbness of the scalp compared with an open procedure

Coronal Approach to Brow Lift

• Subgaleal dissection

• May elevate hairline; pretrichial or trichophytic (just behind hairline) approaches minimize hairline elevation

• Scar may become visible with time as hair thins, particularly in male patients

• Male pattern baldness best predicted by hair pattern of maternal grandfather

Midforehead Approach to Brow Lift

• Excise and elevate via an incision in a transverse forehead rhytid

• More common approach in men

Direct Approach to Brow Lift

• Incisions made along the superior margin of brows

• Most effective for correcting lateral brow ptosis and hooding

Brow Lift Complications

1. Forehead itching (25%)

2. Diffuse alopecia (5%)

3. Patchy areas of permanent numbness (1%)

4. Excessive brow elevation (0.3%)


Eyelid Anatomy (See Cummings Otolaryngology, 6th ed., Chapter 29)

• Orbicularis oculi forms the transition from the brow into the upper eyelid and surrounds the eye

Orbital portion overlies the bony orbit

Palpebral portion overlies the eyelid: pretarsal and preseptal portions

Tarsal plate and orbital septum lie deep to palpebral orbicularis

• Orbital septum divides the lid into the anterior and posterior lamellae

Anterior lamella: skin and orbicularis oculi

Posterior lamella: conjunctiva, eyelid retractor, and upper or lower tarsal plate

Orbital septum and tarsal plate constitute “middle lamella”

Septum originates at the arcus marginalis, a confluence of the periosteum of the facial skeleton and the periorbita at the bony orbital rims

In the upper lid, the septum does not extend over the upper surface of the tarsal plate, but is found as a thin membrane 10 mm or more above the lid margin, inserting on the upper lid retractors

In the lower lid, the septum is attached to the inferior edge of the tarsal plate

Tarsal plate is 8-10-mm tall in the upper lid

Tarsal plate is 4-5-mm tall in the lower lid

Preaponeurotic Fat

• Deep to the septum, superficial to the levator aponeurosis

• Dissection through the septum more superiorly avoids injury to the levator aponeurosis and Müller’s muscle, which will result in ptosis

• Upper lid has two fat pads

Nasal (medial) and middle (largest), with the temporal (lateral) compartment being occupied by the lacrimal gland

• Lower lid has three fat pads

Medial (nasal), central, and lateral (temporal)

Inferior oblique muscle separates the medial and central compartments

• Medial compartment in both the upper and lower lids contains denser, whiter fat

Lid Retractors

• Upper eyelid

Retracted by levator palpebrae superioris and Müller’s muscle

Primary retractor is the levator muscle, originating in the orbital apex; lies immediately superior to the superior rectus; at the orbital aperture, it is supported by Whitnall’s ligament

Levator palpebrae superioris splits into the levator aponeurosis anteriorly and Müller’s muscle posteriorly

Müller’s muscle travels inferiorly, closely adherent to the conjunctiva, and inserts on top of the tarsal plate

Levator aponeurosis inserts laterally and medially into the canthal tendons, and fuses with the orbital septum and dermis at the upper-eyelid crease; inferiorly, fibers travel anteriorly and posteriorly, attaching to the orbicularis oculi and tarsal plate, respectively

• Lower eyelid

Capsulopalpebral fascia of the lower eyelid is analogous to the levator aponeurosis of the upper lid, an extension of the inferior rectus muscle, which depresses the lower lid on downward gaze

Densely adherent to the conjunctiva and is routinely transected in lower-lid transconjunctival approaches


• Rare variant of angioedema

• Recurrent, painless periorbital edema leading to chronic changes in eyelid skin elasticity, atrophy, hyperpigmentation, and upper lid ptosis

• Can lead to lacrimal gland and fat prolapse


• Redundancy and draping of the eyelid skin in the aged face

• Called “pseudoptosis” when it progresses to the point that skin drapes over the upper eyelashes and causes visual field defects


• Redundant folds of lax skin and orbicularis muscle

• Usually on the lower lid

Upper-Lid Incision Considerations

• When deciding how much skin to take, pinch with forceps until slight lid eversion is evident; this will lead to slight postoperative lagophthalmos, which will resolve

• Plan to leave ≥15 mm of skin between the lash margin and the inferior aspect of the brow

• Do not carry the incision medially to the medial canthus or webbing may ensue

• Do not excise orbicularis oculi muscle in patients with history of dry eyes

Lower-Lid Blepharoplasty Approaches

1. Transconjunctival

2. Subciliary skin flap

3. Subciliary skin pinch excision

Transconjunctival Approach to Lower-Lid Blepharoplasty Considerations

• For older patients w/pseudoherniation of orbital fat, limited amount of skin excess

• Young patients w/familial hereditary pseudoherniation of orbital fat and no excess skin

• Revision blepharoplasty patients, patients who do not want to have an external scar or have a history of keloid or dark-skinned individuals because of the possibility of hypopigmentation of an external scar

• Does not disrupt the orbicularis oculi, minimizing the incidence of ectropion

• Avoid damage to the inferior oblique muscle

• Do not pull fat out of the orbit; coax it out gently and cauterize carefully to avoid intraorbital hematoma

Preseptal Approach to Transconjunctival Blepharoplasty

• Conjunctival incision made 2 mm posterior to the inferior border of the inferior tarsal plate

• Dissect along the anterior face of the septum and then open the septum to access orbital fat

• Preferred approach for orbital floor fractures; allows elevation of the orbital floor periosteum

Postseptal Approach to Transconjunctival Blepharoplasty

• Conjunctival incision made 4 mm posterior to the inferior border of the inferior tarsal plate

• Accesses orbital fat compartments directly

• Septum remains intact; decreased risk of ectropion

Subciliary Approach to Lower-Lid Blepharoplasty

• For large amounts of excess skin and orbicularis oculi

• Safely and easily dissect in a relatively avascular submuscular plane

• Ability to remove redundant lower-eyelid skin

• Additional tightening of skin and muscle with lateral suspension sutures

• Do not carry incision past the inferior punctum

• Skin-muscle flap procedure: subciliary incision with elevation of skin-muscle flap, fat resection, and skin-muscle flap resection

• May be combined with transconjunctival approach to address skin, muscle, and fat

Asian Eyelid Considerations

• Defined by the epicanthal fold and absence of upper-eyelid tarsal crease

• 50% of Asians have a tarsal crease (“double eyelid”)

• If the crease is absent, the orbital septum and levator aponeurosis attach to the skin farther inferiorly, anterior to tarsal plate

• Orbital fat prolapses anteriorly, preventing the formation of a prominent upper-eyelid crease and creating fullness of the upper eyelid

Blepharoplasty Complications

1. Milia

2. Hematoma/blindness

3. Lagopthalmos

4. Ectropion: eversion from excessive lower-lid skin or muscle excision, lid contracture, or lateral laxity

5. Ptosis

6. Epiphoria

7. Diplopia

8. Conjunctival chemosis/ecchymosis

Ectropion Management

• Lower-lip tape splinting or forceful eye closure

• Gentle massage + corneal protection

• Surgical correction after 3 months

Full-thickness skin graft (FTSG) from the upper lid

If from lateral lid laxity

• Horizontal lid shortening

• Z-plasty

• Muscle suspension

Face Lift

Midface Lift Considerations (See Cummings Otolaryngology, 6th ed., Chapter 27)

• Elevates malar fat pad and suborbicularis oculi fat (SOOF)

• Effaces deep nasolabial folds

• Often combined with lower-lid blepharoplasty to avoid redundant lower-lid skin after lift

SOOF may be transferred inferiorly to augment malar eminence

May augment effect with fillers and/or cheek implants

Midface Lift Approaches

• Endoscopic access

Similar to the lateral aspect of the endoscopic brow lift but periosteal elevation and release are carried around the infraorbital rim

Periosteum suture is suspended to the temporalis fascia

• Intraoral access

Subperiosteal dissection of midface via a gingivobuccal sulcus incision

Absorbable implant suspends the midface periosteum to the temporalis fascia

Implant anchored to the temporalis fascia via a temporal hair-tuft incision

Rhytidectomy Anatomy by Layers (See Cummings Otolaryngology, 6th ed., Chapter 27)

1. Skin

2. Subcutaneous fat contains hair follicles

3. Galea aponeurotica/frontalis muscle/temporoparietal fascia (TPF) superiorly, contiguous with superficial musculoaponeurotic system (SMAS) in the mid and lower face and then platysma in the lower face and neck9

4. Parotidomasseteric fascia surrounds the parotid posteriorly and the masseter anteriorly, contiguous with the periosteum of zygomatic arch and temporalis fascia

Rhytidectomy Incisions

• Female: typically posttragal to break up the scar

• Male: typically preauricular to avoid pulling hair-bearing beard skin closer to the auricle or onto the tragus; there is usually a <1-cm-wide vertical band of non–hair-bearing skin anterior to the auricle that should remain intact

Rhytidectomy Approaches

1. Subcutaneous lift

2. SMAS lift

3. Deep-plane lift

4. Composite lift

5. Minimal-access cranial-suspension (MACS) lift

Subcutaneous Lift

• Original facelift operation

• Short-lived results

• No longer performed

Smas Lift

• Subcutaneous flap raised in the face and neck

• SMAS incised overlying parotid and plicated to bear tension of the lift

• Facial nerve branches are not ordinarily visualized

Deep-Plane Lift10

• Subcutaneous flap raised until the line between the zygoma and the angle of mandible is reached; SMAS is incised, and dissection is carried anteriorly along the plane of the zygomaticus major muscle, elevating the malar fat pad into the flap

• Facial nerve branches visualized and avoided

• Entire flap bears tension; excellent vascularity medially because of the thickness of the flap

• Neck is addressed as for SMAS flap rhytidectomy, leaving face and neck dissections in different planes, separated by the platysmal insertion at the level of the mandible

• May help efface nasolabial folds

Composite Lift

• Deep-plane lift with repositioning of SOOF via transconjunctival lower-lid blepharoplasty

Minimal-Access Cranial-Suspension Lift

• Three purse-string loops of suture plicate SMAS to elevate the face in a vertical vector

Vertical loop elevates the neck

Oblique loop elevates the jowl

Malar loop elevates the midface

• Short incision with no postauricular component


• Addresses platysmal banding

• Done with submental liposuction and/or direct lipectomy

• Medial borders of the platysma are sutured together down to the hyoid level

• May also divide platysma transversely

Jul 9, 2018 | Posted by in OTOLARYNGOLOGY | Comments Off on Facial Plastic and Reconstructive Surgery

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