Divided into equal fifths based on intercanthal distance, the distance between the medial canthi. This should equal the width of an eye in the average person. Intercanthal distance = eye width = distance from lateral canthus to lateral projection of ear (Fig. 6.1).

Equal thirds: trichion to glabella; glabella to subnasale; subnasale to menton.

Medially, it begins in the same vertical plane as the medial canthi about 1 cm superiorly.

The medial and lateral portions of the eyebrow should lie in the same horizontal plane.

The upper eyelids cover a small portion of the iris and the lower lid should be within 1–2 mm of the iris in neutral gaze.

Profile view, the cornea should be 12–16 mm anterior to the lateral orbital rim.

Radix should be 4–9 mm anterior to corneal plane.

Columellar show: 2–4 mm can be seen below the level of the alae when viewed in profile.

Malar projection is ideally located at a point 1 cm lateral and 1.5 cm inferior to the lateral canthus.

Thirds: upper lip (stomion superioris) to nasal base = , lower lip to chin =  (1:2 ratio).

Posture of lip can be procumbent (pushed out) or recumbent (pushed in).

Ideal chin projection:

0 Degree meridian: pogonion in vertical alignment with the nasion, perpendicular to the Frankfort horizontal line. Chin position should be within 2 mm ahead or behind this line.

Subnasale vertical: A line drawn perpendicular to Frankfort horizontal through subnasale. Chin position more than 6 mm behind this line is considered deficient. Chin position on or in front is considered excessive.

Position of hyoid is important in formation of the cervicomental angle that ideally is between 105 and 120°.

The first step is to identify the patient’s chief complaint. Are the expectations realistic? Is there a functional component in addition to an aesthetic component?

Standardized photographs are necessary for all rhinoplasty patients. Frontal, ¾, profile, and submental views are the minimum required photos.

Is there a history of previous nasal trauma, surgery, and/or sinus disease? Computed tomography might be helpful in these situations.

External valves are assessed by watching the patient breathe in and out forcefully. If the nostrils collapse during negative inspiration, then the lower lateral cartilages are weak and need augmentation during surgery.

Endoscopic- or speculum-assisted anterior rhinoscopy is undertaken to evaluate for any septal deviation, turbinate hypertrophy, and patency of the nasal airway.

The caudal edge of the septum sits along the nasal crest of maxilla and attaches to the anterior nasal spine (ANS). Deflection off this crest can cause nostril asymmetry.

Upper and lower lateral cartilages are attached to each other via the scroll area.

The internal nasal valve is made up of the septum medially, the caudal end of the upper lateral cartilage laterally, and the anterior end of the inferior turbinate inferolaterally. The valve is typically about 10–15° in most Caucasian noses.

The external nasal valves are the external perimeter of the nostrils (comprises LLC, nasal septum, and nasal floor). A weak LLC will cause collapse of the external valves upon forceful inspiration.

It is also important to note that the two medial crura are attached to each other by transdomal ligaments that attach the medial crura to the caudal edge of the septum (transdomal ligaments are a major structural support mechanism of the nasal tip) (Table 6.4).

If internal packing is used, systemic antibiotics must be administered for the duration of the intranasal packing. External dressing must be used in all cases in order to redrape the soft tissue envelope over the underlying cartilaginous and bony skeleton; this is a critical part of the procedure.

Postoperative systemic decongestants are helpful, although patients are asked not to blow their nose for 7–10 days. Saline nasal rinses can be used as often as necessary.

If an open structure rhinoplasty was performed, persistent tip edema occurs in all of the cases due to the transcolumellar incision; this edema will take months up to 1 year to resolve. Patients must be informed in advance about this.

Regarding residual asymmetries, minor asymmetries should not undergo revision surgery for several months (up to a year); minor issues usually resolve with time, massaging, or steroid injections. However, major asymmetries, or significant residual deviation of the nasal complex, should undergo revision within a few months; major deviations will not self-correct.

Residual Hump – very common occurrence; this is typically due to inadequate hump reduction. Requires revision surgery.

Pollybeak Deformity – fullness of the nasal supratip relative to the rest of the nose. Classified as cartilaginous (e.g., due to loss of nasal tip support) or soft tissue etiologies (e.g., scar tissue fills the supratip break). It is caused by inadequate dorsal septum removal and/or excessive bony dorsum removal, excessive dorsal septum resection, excessive alar cartilage removal, or excessive supratip scar removal. If soft tissue, may attempt intralesional steroid injection. Surgical revision dependent on etiology.

Saddle Nose Deformity – loss of septal support and saddling of the nose; could occur due to large septal perforations and loss of structural support. Requires major reconstruction of the nose, typically requiring large cartilage and/or bone grafting.

Open Roof Deformity – flat dorsum following large hump reduction due to failure to perform lateral osteotomy to close the “open roof.” Requires revision surgery via lateral osteotomy.

Rocker Deformity – green stick lateral osteotomy. This occurs when a lateral osteotomy is extended too cephalad along the medial canthal area where the bone can be quite thick. As an incomplete fracture occurs, the inferior aspect of the osteotomy “rocks” and the upper portion simply hinges or does not move at all. This deformity requires revision surgery in order to complete the cephalic portion of the lateral osteotomy.

Inverted V – collapse of the upper lateral cartilages. Caudal edges of nasal bone can be seen through the non-supported skin. Treated most often with spreader grafts.

Keel Deformity – the dorsum in cross section comes to a point rather than a rounded dome. Often treated with spread grafts and nasal osteotomies.

A minimum of 7–8 mm of lower lateral cartilage should remain after a cephalic trim to prevent pinching, alar retraction, external nasal valve collapse, and/or tip asymmetry.

The supratip break is formed from the junction of the caudal edge of the lower lateral cartilages and the dorsal septum (anterior septal angle). For significant reduction of the cartilaginous septum, one should use the anterior septal angle as the starting point for hump reduction.

There should be roughly 2–4 mm of the columella shown from the profile view. The amount of columella show is related to the amount of “hooding or retraction” of the alar rim or the amount of “hanging or retraction” of the columella.

Tip defining points of the nose: supratip break, infratip break, domes of the lower lateral cartilages.

Relative over projection of the nasal tip may be due to microgenia or midface deficiency. A rhinoplasty evaluation must also include consideration of the chin projection and midface projection.

McGregor’s patch – zygomatic cutaneous ligaments found in the malar area, difficult area of dissection due to fibrous attachment and thickening of the subcutaneous layer. Risk of bleeding due to perforating branch of transverse facial artery.

What is the patient’s chief complaint?

Complete medical history to include social and psychological evaluation. Past facial surgery/cosmetic surgery? Multiple cosmetic surgeries should raise concern for body dysmorphic disorder.

Medications and supplements should be reviewed. It is important to identify products that can increase bleeding such as antiplatelet agents, anticoagulants, NSAIDS, high dose vitamin E, fish oil, ginseng, ginkgo biloba, and St. John’s wort.

Smoking/nicotine history? Recommended to stop using nicotine products 6 weeks before and 4 weeks after any surgery to reduce necrosis risk (3× incidence versus non-smokers). As nicotine supplements aids are widely available over the counter, question patients on such aids as patches and gums. Medications such as bupropion SR (Zyban ®) or varenicline tartrate (Chantix ®) can help aid in quitting prior to surgery.

Realistic expectations? Will not erase all signs of aging. Will address lower third of face including neck laxity, jowling, mesolabial folds, and some nasolabial folds. Will not address wrinkles around mouth.

Upper, middle, lower face evaluation. Platysmal dehiscence, jowling, descent of the malar fat pads, nasolabial folds, marionette lines, etc.? Skeletal profile, e.g., retrognathia? Microgenia?

Clinical photos (both smiling and at repose): frontal, right and left ¾ view, right and left profile views, submental vertex.

The exact locations, extensions, and depth vary from doctor to doctor and type of facelift (Fig. 6.7a, b).

The typical incision design consists of a temporal hair tuft sparing incision, 45° hockey stick, or vertical incision design.

The incision rests in the preauricular sulcus until the tragus of the ear is reached. At this point either an endaural incision (females) is made or one may choose to stay in the preauricular fold (men). The preauricular fold is preferred for men to prevent hair growth on the tragus.

The inferior extension goes under the earlobe (a 2 mm cuff to prevent a pixie ear deformity) and then extends to the posterior auricular sulcus. Some surgeons prefer to carry the incision onto the conchal cartilage to prevent migration of the scar.

At the point of the greatest width of the pinna, the incision turns posteriorly into the hair-bearing region of the scalp. The incisions in the hair are beveled as much as possible to allow ingrowth of hair into the scar.

Short scar facelifts may only have a pretragal incision with minimal extension.

Dissection and management of the SMAS varies depending on the type of facelift performed (Fig. 6.8). SMAS plication: The SMAS is folded on itself and sutured. Includes the preauricular and possibly the infrazygomatic SMAS.

SMAS imbrication: The SMAS is incised, overlapped, and sutured.

SMASectomy: A portion of the SMAS is excised from the malar eminence to the mandibular angle and the edges are sutured together.

Skin lift: Utilizes a short flap or an extensive long flap and only a subcutaneous dissection is performed. Redundant soft tissues are repositioned by traction of the skin only. Looks tight, pulled, and unnatural. Rarely used.

Mini lifts (S-lift, Feather Lift) (Fig. 6.7a): Redundant preauricular soft tissue is excised and incision edges are undermined for closure. Minimal undermining may be performed. The facial SMAS is plicated, purse stringed, or barbed sutures are utilized for elevation.

Threadlift (Lifestyle lift, Quicklift, Lunchtime lift, etc.) (Fig. 6.7b): Redundant SMAS is elevated by sutures that are typically fixed to the preauricular deep temporal fascia.

SubSMAS: First a subcutaneous dissection is performed. Then infrazygomatic, preauricular, and infra-auricular platysmal incisions are made through the facial SMAS. The SMAS is then undermined to the anterior border of the parotid gland. Traction is placed on the SMAS and the excess is excised or folded, then sutured.

Extended SubSMAS: Purported to improve facelift results in the area of the nasolabial fold. First a subcutaneous dissection is performed. Then infrazygomatic, preauricular, and infra-auricular platysmal incisions are made through the facial and neck SMAS. The SMAS is then undermined further than the subSMAS facelift, enough for passive mobilization. The retaining ligaments are interrupted. Traction is again placed on the SMAS and the excess is excised or folded, then sutured. A cervicoplasty is usually performed.

Deep Plane: An extended SubSMAS facelift that has minimal subcutaneous dissection. The SMAS incision is from the malar eminence to the mandibular angle. Extreme traction is placed on the SMAS-skin flap in a superolateral direction, then sutured to the preparotid SMAS. A subcutaneous neck dissection is performed.

Composite: A deep plane facelift with a subSMAS dissection below the central part of the malar fat pad that includes the pre-zygomatic SMAS and orbicularis oculi muscle.

Extended Multiplanar Multivector: An extended subSMAS deeper plane facelift that includes a suborbicularis oculi muscle and sub SOOF dissection in order to interrupt the infraorbital osteocutaneous ligaments. In addition, a wedge of the orbital portion of the orbicularis oculi muscle is excised.

The ideal age for a facelift patient is between 45 and 65. The patient’s age can vary significantly depending upon genetics, environmental exposure, smoking, injury etc. The younger the patient, the quicker they will recover and longer they will benefit from the procedure. A facelift only addresses the midface and lower face.

Multiple additional procedures may be performed simultaneously including brow lifts, upper and lower lid blepharoplasties, fat transfer, facial implants, and rhinoplasty.

Laser skin resurfacing can only be performed simultaneously if the skin flap is of sufficient thickness to withstand the insult; however, this is reserved for experienced surgeons.

Facelift dressing for first 48 hrs then nightly for 1 week.

See after 24 hours for correct wound drape and rule out hematoma.

Ice for first 24–48 hours.

Hydrogen peroxide to clean wounds daily.

Appropriate pain medication.

Appropriate antibiotics (topical and oral).

Avoid aspirin, ibuprofen, vitamin E, herbal and homeopathic medications.

No alcohol for a minimum of 7 days postoperatively.

No smoking during healing process.

Sleep on back with two pillows for 2 weeks.

Shampoo hair after 48 hours.

Soft foods initially for comfort.

Sunblock SPF ≥ 30.

Hematoma – two types: major and minor, both pose a risk for skin necrosis. Minor hematoma is usually less than 10 cc and is often not appreciated until bandages are removed. Treatment requires needle aspiration or manual expression. Excessive facial pain and excessive edema are major signs of a major (expanding) hematoma. Major hematomas require operative setting to identify causative vessel.

Pixie Ear Deformity – inferior traction of earlobe due to pull of skin. Avoided by leaving cuff of tissue around earlobe. Surgical treatments include undermining the skin and reinforcing the SMAS or a triangular wedge (V-Y closure) is removed and the lobe is reattached in a superior and posterior position.

Necrosis – most affected areas are the mastoid and post-auricular regions due to thin skin thickness and distance from vascular supply. Cleanse area with hydrogen peroxide and maintain moisture, e.g., trolamine salicylate (Biafine ®). Some clinicians recommend nitropaste to encourage vasodilatation. Hyperbaric oxygen may be used to encourage wound healing and revascularization in large affected areas.

Unaesthetic Scar – steroid injections such as triamcinolone 3 mg every 6 weeks for 3 months. Overuse may cause dermal atrophy, depression, and spider telangiectasia. Carbon dioxide laser resurfacing and microneedling may help reduce visibility of scar. Scar revision surgery may also be considered.

Facial Nerve Damage – temporal and marginal mandibular branch (most common motor nerve damaged) can be affected. Most commonly this is transient and only a matter of time until nerve function returns. May also consider neurotoxin to the unaffected side (to help mask difference in animation) or referral for facial reanimation consultation. Damage to frontal branch may impair orbicularis oculi and require globe protection such as eye patches, temporary tarsorrhaphy, or gold weight implantation to upper eyelid.

Sensory Nerve Damage – greater auricular nerve (most common nerve injured) injury reported around 1–7%. Most injuries resolve in 6 months. Patient may complain of anesthesia, paresthesia, or dysesthesia in the inferior portions of the ear lobule, ear, and the sternocleidomastoid region. If neuroma, suspected MRI may help identify for early intervention. Gabapentin and tricyclic antidepressant therapy may help alleviate pain.

Infection – incision and drainage with cultures and sensitivities.

Hair Loss – tension alopecia can be avoided by adequate wound support without excessive tension. May be due to telogen effluvium, reversible hair loss due to stress, allow 6 months for observation and consider steroid injections. Permanent alopecia may be treated with topical minoxidil (Rogaine ®), hair follicle transplant, PRP injections, local flap, or resection with primary closure.

Hyperpigmentation – usually resolves in 6 months . Patient may apply 4% hydroquinone or kojic acid cream to the affected area.