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Surgical Anatomy and Physiology of the Nose

Rhinoplasty surgery requires a robust understanding of the surgical anatomy and physiology of the nose and nasal airway. Only by building on this solid foundation can a rhinoplasty surgeon adjust and tailor surgical techniques to fit unique individual patient needs. By balancing the patient's concerns with the surgeon's diagnosis after a complete examination, the surgeon can determine which set of techniques are most suitable to accomplish…

A History of Modern-Day Rhinoplasty

Introduction From the Edwin Smith Surgical Papyrus to the Sushruta legacy to early nasal surgery techniques, the roots of modern-day rhinoplasty stem from the early beginnings of nasal reconstruction. Early on, it was recognized that the nose was a complex structure, a prominent and central feature of the face that was susceptible to disfigurement by trauma, infection, tumors, and even punishment. For this reason, mutilation, deformity,…

Rhinoplasty in the Aging Patient

Personal Philosophy Rhinoplasty at any age is a complex operation that requires precise preoperative diagnosis to select the appropriate surgical technique. Owing to variations in nasal anatomy and aesthetic expectations, no single technique is appropriate for all patients. Each rhinoplasty patient presents the surgeon with a diversity of nasal anatomy, contours, and proportions that requires a series of organized maneuvers tailored to the patient's functional and…

Complementary Fat Grafting

History The history of autologous fat transfer stretches back over an entire century. The first clinical case of fat transfer was described by Neuber in 1893, who reported the use of parcels of fat harvested from the upper extremity to reconstruct a facial defect engendered by tuberculous osteitis . Two years later Czerny commented on filling a breast deformity created by removal of a benign mass…

Facial and Cervical Lipectomy

History Cervicofacial lipectomy, performed by liposuction or direct fat excision, is a powerful tool in lower face and neck rejuvenation. Lipectomy may be useful in younger and older patients to remove unwanted deposits of fat, contour the corpulent face, and as an adjunctive treatment of the aging face. Since its introduction into the United States in the early 1980s, liposuction has become the most commonly performed…

Orthognathic Aesthetic Facial Surgery

Introduction The secret of a beautiful face lies behind a well-balanced proportion of facial features and is a composite of all of the anatomical elements, including skin, subcutaneous tissues, muscle, bone, and teeth. Facial plastic surgeons strive daily with the achievement of this harmonious balance. Dentofacial deformities affect approximately 20% of the population, out of which 5% have major skeletal deformities . Orthodontic and surgical treatment…

Mentoplasty

History Chin augmentation has been performed using autografts, alloplastic materials, and mandibular advancement procedures. Autografts are complicated by the need for a donor site, difficulty with shaping the grafts, and their unpredictable pattern of resorption . In contrast, alloplastic implants have proved to be an easy and reliable means of augmentation. The most common method of augmentation is with alloplastic implants, including Silastic, Gore-Tex, Mersilene mesh,…

Midface Implants

Introduction The basis for all facial rejuvenation is an appreciation for normal aesthetic beauty and anatomy, the recognition of aging changes, and the knowledge to use various techniques, procedures, and biomaterials to recreate a more youthful face. In the youthful face, roundness and volume abound and the beauty in the midface is frequently referred to as “apple cheeks.” This term pretty much says it all about…

Tridimensional Endoscopic Facelift

History The tridimensional endoscopic facelift is based upon the construct of the subperiosteal facelift technique initially described by Tessier .Tessier conceived that this “orthomorphic” subperiosteal facelift would be an innovative way to provide facial rejuvenation in young and middle-age patients . Subsequently, Psillakis et al. published their modifications to the subperiosteal approach, demonstrating that extensive lateral periorbital dissection could provide improved rejuvenation of the cheek region. Soon…

Reshaping Rhytidectomy

History The history of facial rejuvenation has mainly focused on addressing cervicofacial laxity. In 1919 Bettman and Bourget simultaneously presented their experience with subcutaneous rhytidectomy . In 1960 Aufricht was the first to describe plication of the tissue deep to the superficial fat plane . Webster and other facelift surgeons used similar techniques of suturing the “deeper layers” to improve their results . During the same…

Lateral SMASectomy Facelift

History The senior author's first experience with rhytidectomy was during residency in the late 1970s. At that time, the emphasis was on extensive defatting of the neck with complete platysma muscle transection, plicating medial borders and pulling laterally. However, several years of patient complaints, complications, and overoperated necks led to a modification of this technique. With the advent of liposuction in the 1980s, the author found…

Deep Plane Rhytidectomy Modifications

Introduction The gradual transformation of the aging face culminates in predictable changes in the surface topography and anatomical relationships of facial subunits. The morphogenesis affects individuals on a variable time course, as each person has a unique underlying bone structure and genetic predisposition. The progression of facial aging is therefore best evaluated on an individual basis, irrespective of chronological age. There are innumerable findings associated with…

The Deep Plane Facelift

History The signature operation of facial rejuvenation is the rhytidectomy. Of all the procedures designed to remedy the effects of aging, the rhytidectomy has the most profound ability to improve the patient's appearance. The first recorded efforts to surgically rejuvenate the face appeared early in the 20th century . The first 50 years of the 20th century saw little advance; burdened by the risks of anesthesia…

Aesthetic Rejuvenation in the Patient of Asian Ancestry

Introduction Asia is the largest and most populous continent and encompasses a myriad of cultures and ethnicities. As such, “Asian aesthetics” also encompass diverse issues and vary significantly throughout the continent. For the purposes of this chapter, we will discuss aesthetics as it relates to people of East and Southeast Asian heritage. Although certain aesthetic concerns are nearly universal across ethnicities, patients of Asian ancestry seeking…

The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty

Introduction Traditional lower blepharoplasty consists of an open approach, transcutaneous procedure in which variable amounts of skin, muscle, and fat are excised. Inherent to this technique is a predilection for rounding of the canthal angle and lower eyelid retraction , noted to occur in 6% to 20% of such cases . In the authors' experience these are very difficult problems to address and cause tremendous dissatisfaction…

Transcutaneous Lower Blepharoplasty

Introduction The transcutaneous skin-muscle flap blepharoplasty has a long history in the field of cosmetic eyelid surgery. As with any surgical approach, it has distinct advantages and disadvantages. The chief advantage of the transcutaneous approach is the capacity to treat excess skin and orbicularis muscle that requires redraping for adequate lid recontouring and superior lower eyelid rejuvenation, the major limitation of the transconjunctival approach. The transcutaneous…

Transconjunctival Lower Blepharoplasty With and Without Fat Repositioning

Introduction Lower blepharoplasty has evolved significantly since its early descriptions . Traditional surgery involved an open transcutaneous approach that allowed the excision of skin, muscle, and fat sequentially through the same subciliary incision . Although still a common approach to lower blepharoplasty today, the transcutaneous route can be associated with an increased incidence of lower eyelid malposition and rounding of the canthal angle . The addition…

Ptosis Repair and Blepharoplasty

History The evolution of ptosis surgery can be studied and categorized from an anatomical point of view. These categories include skin excision, frontalis suspension, resection of tarsus and/or Müller's muscle, and levator resection. Each technique has undergone periods of transformation, falling in and out of favor over time . The origin of ptosis surgery focusing on advancing the levator muscle complex is credited to Bowman in…

Minimally Invasive Complementary Adjuncts to Upper Blepharoplasty

Introduction Upper blepharoplasty has evolved significantly since its early descriptions focused on rudimentary techniques of skin excision only . In the 20th century, the first detailed description of internal upper eyelid anatomy emphasizing the presence of distinct fat compartments within the eyelid was published . As, on first glance, aged eyelids appear associated with skin, muscle, and fat excess, the trend in surgery was to aggressively…

Nonsurgical Brow and Eyelid Rejuvenation

Introduction The shift towards less nonsurgical techniques to rejuvenate the periorbital area continues, and patient requests for procedures involving minimal downtime with less “surgical” results increase each year. The American Society of Aesthetic Plastic Surgeons reported that patients received a total of 8.9 million cosmetic nonsurgical procedures, including 5.5 million injectable treatments and 2.1 million skin rejuvenation treatments . Understanding the underlying anatomy and aging changes…