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© Springer Nature Switzerland AG 2021

R. Reti, D. Findlay (eds.)Oral Board Review for Oral and Maxillofacial

6. Cosmetic Surgery

Ryan M. Diepenbrock1  , Tirbod Fattahi2, Salam Omar Salman3, Anthony S. Alessi4, John B. Holds5, Krishna Priya Kalyam6, Michael G. Niemkin7, Jaclyn A. Tomsic8  , Zach Farhood9 and Manik S. Bedi10

Diepenbrock Facial Cosmetic Surgery, Oral and Maxillofacial Surgery Associates, Fort Wayne, IN, USA

University of Florida College of Medicine, Jacksonville, OMFS, Jacksonville, FL, USA

University of Florida Health – Jacksonville, Department of Oral and Maxillofacial Surgery, Jacksonville, FL, USA

Westchester Medical Center, Oral Maxillofacial Surgery, Vallhalla, NY, USA

Departments of Ophthalmology and Otolaryngology/Head & Neck Surgery, St. Louis University School of Medicine, Ophthalmic Plastic & Cosmetic Surgery, Inc., St. Louis, MO, USA

Washington University, St. Louis, Department of Ophthalmology, St. Louis, MO, USA

Ophthalmic Plastic and Cosmetic Surgery, LLC, Atlanta, GA, USA

University Hospitals, Department of Surgery, Cleveland, OH, USA

Saint Louis University, Otolaryngology – Head & Neck Surgery, St. Louis, MO, USA

Tampa Surgical Arts, Odessa, FL, USA
Ryan M. Diepenbrock (Corresponding author)
Jaclyn A. Tomsic

Glogau scaleFitzpatrick scaleDedo classificationRhinoplastyRhytidectomyPlatysmaplastyNegative vectorOpen roof deformityBotulinum toxinSMASBlepharoplastyTumescent anesthesiaSchirmer’s testPolly beak deformityPixie ear deformityMcKinney’s pointMcGregor’s patchSaddle nose deformityKeel deformityCobra neck deformityMarginal reflex distance (MRD1 and MRD2)DermatochalasisGlobe distraction testSnap back testBrow liftConnell’s signOtoplastyDavis techniqueMustardé suturesTelephone ear deformityCauliflower earTretinoinGlycolic acidHydroquinoneChemical peelLaser resurfacingHyperpigmentationHypopigmentationMiliaEr:YAG laserCO2 laserDysportCrow’s feetBunny linesHyaluronic acidMarionette linesTyndall effect

Facial Analysis

General Esthetics

Transverse Facial Fifths

  • 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).

Fig. 6.1

Facial proportions. (Reprinted with permission from Azizzadeh B, Murphy MR, Johnson CM. Master Techniques in Facial Rejuvenation. WB Saunders Company; 2006)

Vertical Facial Thirds

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


  • Communicates with scalp.

    • 5 layers: Skin, Cutaneous tissue, galea Aponeurotica, Loose areolar tissue, and Pericranium.

  • Four muscles contribute to its motion: frontalis, procerus, corrugator supercilii, and orbicularis oculi.

    • These contribute to the dynamic wrinkles in the forehead often treated with neuromodulators (e.g., botulinum toxin).


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

  • Apex should lie on a vertical line drawn on the lateral limbus.

    • The most lateral portions of the eyebrows meet in tandem with an oblique line drawn from the alar base to the lateral canthus (Fig. 6.2).

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

Fig. 6.2

Ideal female eyebrow position. (Reprinted with permission from Azizzadeh B, Murphy MR, Johnson CM. Master Techniques in Facial Rejuvenation. W B Saunders Company; 2006)


  • 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.


  • Ideal anatomic relationships:

    • Nasofrontal angle: 115–135°.

    • Nasolabial angle: 95–110° in females, 90–95° in males.

    • Nasofacial angle: 30–40° (Fig. 6.3a). Angle formed from a vertical tangent to the glabella through the pogonion and intersecting the line formed through the nasal tip.

    • Nasomental angle: 120–132° (Fig. 6.3b). The angle formed by the tangent line from nasion to the nasal tip and the nasal tip to pogonion.

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

  • Nasal projection:

    • Simons’ method: length of the upper lip from the vermillion border to columella, and columella to tip ratio should be 1:1. (Fig. 6.4a) [1].

    • Goode method: ratio of radix-nasal tip (RT) and the line drawn from RT to the alar groove should be 0.55–0.6 RT. Retains nasofacial angle from 36 to 40° (Fig. 6.4b).

    • 3-4-5 triangle by Crumley and Lanswer. Hypotenuse is a line from nasion to nasal tip, projection is the smallest length (Alar crease to nasal tip). Nasal projection is 60% of nasal length (3:5) [1].

  • 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.

Fig. 6.3

(a) Nasofacial angle (b) Nasomental angle. (Reprinted with permission from Zimbler M. Cummings Otolaryngology 6th edition. Elsevier Books; 2015)

Fig. 6.4

Nasal tip projection. (a) Simons method (b) Goode method. (Reprinted with permission from Zimbler M. Cummings Otolaryngology 6th edition. Elsevier Books; 2015)

Mouth/Chin (Lower Facial Third)

  • Thirds: upper lip (stomion superioris) to nasal base = $$ \raisebox{1ex}{$1$}\!\left/ \!\raisebox{-1ex}{$3$}\right. $$, lower lip to chin = $$ \raisebox{1ex}{$2$}\!\left/ \!\raisebox{-1ex}{$3$}\right. $$ (1:2 ratio).

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

  • Lip position:

    • Determined from line drawn from subnasale to soft tissue pogonion. Upper lip should be 3.5 mm anterior and lower lip 2.2 mm anterior to this line.

    • E-line: A line between nasal tip and pogonion. Upper lip should be 4 mm and lower lip 2 mm behind this line.

  • 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.

Skin Evaluation

Wrinkles (Rhytids)

  • Dynamic – due to repetitive muscle movement

    • E.g., between eyebrows, forehead wrinkles, crow’s feet

    • Rx: Neuromodulators (Botox)

  • Static – due to skin elasticity loss

    • Nasolabial folds, mentolabial sulcus, along the cheeks, under the eyelids, and neck wrinkles

    • Rx: dermal fillers, chemical peels, lasers, and rhytidectomy

Glogau Classification of Photoaging  – assesses patient’s level of photoaging and categorizes the amount of wrinkling and discoloration into four categories (Table 6.1) [2].

Table 6.1

Glogau classification of photoaging










No age spots

Mild pigment changes

Little or no makeup use

No keratoses




During movement

Early brown “age spots”

Skin pores more prominent

Early skin texture changes

Usually wears some foundation

Keratoses palpable but not visible




At rest

Telangiectasias and some dyschromia

Visible brown “age spots”

Prominent, small blood vessels

Heavy foundation worn

Advanced photoaging





Yellow-gray skin tone

Prior skin cancers

Actinic keratoses“Caked on” makeup, cannot wear makeup as it cakes

and cracks

Fitzpatrick Scale of Sun-Reactive Skin Type  – evaluation of skin response to UV light and thus susceptibility to burn (Table 6.2).

Table 6.2

Fitzpatrick scale of sun-reactive skin type [2]

Skin type

Skin color

Response to ultraviolet light


White (very fair)

Always burns, never tans


White (fair)

Usually burns, tans with difficulty


White/olive (most common)

Occasional mild burn, tans on average


White (light brown)

Rarely burns, tans easily


Dark brown

Very rarely burns, tans very easily



Never burns

Dedo Classification of Cervical Anomalies  – classifies aging neck abnormalities based on the anatomic layers of the neck (Fig. 6.5a, b and Table 6.3) [3, 4].

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

Fig. 6.5

Dedo neck classification system. (Reprinted with permission from Azizzadeh B, Murphy MR, Johnson CM. Master Techniques in Facial Rejuvenation. W B Saunders Company; 2006)

Table 6.3

Dedo classification of cervical anomalies



area involved





Minimal deformity

Well-defined cervicomental angle, good muscle tone, nominal submental fat




Lax skin – begins to hang like a curtain. No fat accumulation. No platysma weakness

Treatment: Cervicofacial rhytidectomy




Excessive submandibular/submental adipose

Treatment: submental lipectomy/liposuction +/− cervicofacial rhytidectomy



Anterior platysmal


Have patient grimace with teeth clenched to evaluate

Treatment: resect platysma/suture together +/− cervicofacial rhytidectomy




Treatment: consider chin implant or bony genioplasty vs orthognathic surgery +/− cervicofacial rhytidectomy



Low hyoid bone

Normal hyoid position is C3-C4

Lowered position precludes optimal outcome/requires more aggressive surgery

Inform patient of limitations



  • 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.

  • Characteristics of the soft tissue envelope of the nose.

    • Thick sebaceous overlying skin can make a rhinoplasty quite challenging by obscuring the underlying anatomical structures.

    • Thin skin will expose every underlying characteristics and flaws.

  • Nasal complex:

    • Deviated, wide/narrow, does the nose look too big or too small (over-/under-rotated, over-/under-projected, etc.)?

    • Nasal tip: bulbous, round, triangular, trapezoidal, boxy, amorphous.

    • Nasal dorsum: C-shaped, reverse C-shaped, twisted, deviated, deflected, wide/narrow, inverted-V deformity.

    • Nasal complex deviation is often indicative of septal deviations. Asymmetrical nostrils are also telltale signs of caudal septal deviation. Any underlying cartilaginous or bony irregularities are noted.

  • Cottle’s test is performed in order to assess the integrity of the internal nasal valve. The test is performed by occluding one nostril and having the patient breathe in and out of the other nostril. After assessing patency, the cheek tissue is pulled laterally on the same side as the breathing nostril. If breathing significantly improves, the test is positive denoting collapse of the internal nasal valve.

    • A more reliable clinical diagnostic procedure is a modified Cottle’s test. In the modified test, the wooden end of a cotton tip applicator is placed at the junction of the dorsal septum and upper lateral cartilages to stent out or expand the internal nasal valve angle.

  • 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.

Pertinent Anatomy (Fig. 6.6)

It is imperative to use appropriate language when describing the topography of the nasal complex. Due to its orientation on the face, phrases such as anterior or posterior are not as descriptive; rather, terms such as cephalad, dorsal, or caudal are much more useful. A nose that is “up turned,” similar to a Miss Piggy appearance, is called an over-rotated nose. A nose whose tip is ptotic and pointing toward the floor is called under-rotated. Conversely, a nose that is “too big,” and projecting off the face, is called an over-projected nose. The cartoon character of Pinocchio has an over-projected nose.

Fig. 6.6

Nasal anatomy. (Reprinted with permission from Bagheri S and Khan A. Clinical Review of Oral and Maxillofacial Surgery. Elsevier; 2014)

There are four different tissue types in the nasal cavity: skin, mucosa, cartilage, and bone. The soft tissue envelope is thickest at nasal bridge and nasal tip and thinnest along the mid-dorsum region. There are two major components of the nose: the bony vault and the cartilaginous vault, components of which are listed below:

  • Bony Vault

    • Paired nasal bones

    • Bony septum: vomer inferior, ethmoid superior

  • Cartilaginous Vault

    • Cartilaginous septum

    • Paired upper lateral cartilages (ULC)

    • Paired lower lateral cartilages (LLC)

      • Lateral crura of LLC

      • Medial crura of LLC

  • 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).

Table 6.4

Support mechanisms

Major tip support mechanisms

Minor tip support mechanisms

Size, shape, resilience of the medial and lateral crura

Attachment of the medial crural footplates to the caudal

margin of the quadrangular cartilage

Connective tissue attachment of the upper and lower

lateral cartilages (scroll region)

Interdomal ligament

Dorsal cartilaginous septum

Membranous septum

Sesamoid complex

Skin and subcutaneous fibrofatty tissue

Nasal spine

Surgical Technique

There are essentially two methods to approach the nasal complex: open structure rhinoplasty and endonasal. There are inherent advantages and disadvantages to each technique (Table 6.5).

Table 6.5

Open vs. endonasal technique

Open technique

Endonasal technique

Longer operation

Longer recovery

External scar

Prolonged tip swelling (due to transcolumellar incision)

Greater access and visualization

Shorter procedure

Shorter recovery

No external scar

Limited access, especially for structural grafting

Preferred for “touch-up” revision surgery

Open Technique

  1. 1.
    Open structure rhinoplasty should begin with harvest of the septum. First, the nose is approached through a marginal incision that is connected to an inverted “V” transcolumellar incision. Once the nose is degloved in a subperichondrial and subperiosteal fashion, attention is directed to the septum. Submucosal resection of the septum involves removal of cartilaginous septum for grafting purposes and to remove nasal deviation.

    • Must retain a 1 cm “L” strut to maintain support of the nasal complex (1 cm dorsal and 1 cm caudal septum).

    • Septum can be approached through the dorsal approach, Killian incision, and/or hemi- or complete transfixion approach. Once the septum is harvested, attention is directed back to the nose.

  2. 2.

    If a dorsal hump reduction is needed, removal of the cartilaginous and bony components must be performed incrementally to prevent over-resection.

  3. 3.

    Spreader grafts are indicated for augmentation of the internal valve, or if trying to straighten a crooked nose. Spreader grafts are harvested usually from the septum and placed between ULC and dorsal septum. For revision rhinoplasties with previously harvested septal cartilage, allograft rib cartilage or autologous rib/ear may be used. After placement of spreader grafts, lateral and medial osteotomies are frequently performed.

  4. 4.

    Lateral osteotomies involve fracturing of the frontal processes of maxilla and portions of the nasal bones in order to reduce nasal width, straighten a deviated nasal complex, or close minor open roof deformities. Medial osteotomy requires fracturing of the nasal bones in order to further narrow a nose or to prevent a “rocker deformity.”

  5. 5.
    Nasal tip: Once the cephalad portion of the nose is addressed, attention is directed toward the tip.

    • A columellar strut graft is placed between the medial crura to provide tip support.

    • Alar batten grafts can be placed along the dorsal aspect of lateral crura to provide stability, especially in cases of external valve collapse.

    • Cephalic trim, if necessary, requires removal of cephalic portion of lateral crura to debulk the tip and rotate the nasal tip; it is imperative to leave about 7–8 mm of native lateral crus in place to maintain tip support.

    • Transdomal and intradomal suturing are performed to narrow the nasal tip and provide support.

    • Shield grafts, named for their “shield”-like shape, are secured to the dome in four corners for enhanced tip definition, to provide an increase or decrease in apparent tip rotation, and to increase tip projection (Table 6.6).

Table 6.6

Nasal tip augmentation


Cephalic Trim











Medial Crura



Septal Resection

Increased tip




Decreased tip




Narrow nasal tip



Decrease tip




Increased tip




Postoperative Management

  • 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.

Common Complications

  • 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.

Pearls of Wisdom

  • 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.

Rhytidectomy (Face Lift)

A surgical procedure to rejuvenate the appearance of the face by the removal of excess skin and may include manipulation of the SMAS (superficial musculoaponeurotic system).


There are five layers of the face that includes the skin, subcutaneous tissue (superficial fat layer/superficial fascia/deep fat or areolar layer), musculoaponeurotic layer, retaining ligaments and spaces, and the deep fascia in the midface and periosteum in the scalp.

  • The SMAS is the superficial fascia and incorporates muscle and fat of the face, temples, forehead, and neck.

    • Separates the superficial fat layer from the underlying deep fat and fascia.

    • Superficial to the facial nerve in the surgical area.

    • Over the parotid gland, it is thick and aponeurotic.

    • Over the facial mimetic muscles, it is thin and layered.

  • Retaining ligaments of the face are osteocutaneous (tether skin to bone) and fasciocutaneous (SMAS to deep fascia).

    • Osteocutaneous ligaments: zygomatic, infraorbital, and mandibular ligaments.

    • Fasciocutaneous ligaments: parotid cutaneous and masseteric cutaneous ligaments.

  • McKinney’s point – where the greater auricular nerve passes over the center of the sternocleidomastoid muscle.

    • It is 6.5 cm inferior to the caudal most point of the bony external auditory meatus with the head turned 45 degrees in the opposite direction.

  • 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.

  • All muscles of facial expression are innervated on their deep surfaces except:

    • Levator anguli oris

    • Buccinator

    • Mentalis


  • 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.

Superficial Plane Versus Deep Plane Face Lifts

  • Superficial plane facelift

    • Substantially faster to perform; however, the appearance isn’t as natural and has a limited duration.

    • Skin only, mini-lifts, SMAS plication, SMAS imbrication, SMASectomy, and thread lifts.

  • Deep plane facelift

    • Deeper plane facelifts use the facial SMAS to achieve and maintain a consistent, predictable, natural, stable, and youthful appearance to the middle and lower thirds of the face.

    • Surgery takes longer to perform and care has to be taken when elevating the SMAS off the facial nerve.

Surgical Technique

  • 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.


(a) Mini lifts: skin only. (b) Thread lift. (Courtesy of Dr. William T Evans DDS, MD, FACS)

Fig. 6.8

Imbrication vs. plication facelift. (Reprinted with permission from Fisher E. Rhytidectomy. Oral and Maxillofacial Surgery, Third Edition. Elsevier; 2017)

Types of Facelifts

Superficial Plane Facelifts

  • 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.

Deeper Plane Facelifts

  • 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.

Combined Procedures

  • 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.

Postoperative Care

  • 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.

Post-op Complications and Management of Face Lift Surgery

  • 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.

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Jul 23, 2021 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Surgery
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