The latest advances in liposuction provide patients with more effective results and a faster recovery time. These techniques include the tumescent technique, super-wet technique, ultrasound-assisted lipoplasty (UAL) and power-assisted liposuction.
The tumescent technique involves injecting areas of excess fat with a large amount of anesthetic liquid before proceeding with liposuction. The liquid causes the compartments of fat to become swollen and firm or “tumesced.” Since the fat compartments have expanded, they are easier to distinguish, allowing for smoother and more even results. The tumescent technique may last as long as 4 to 5 hours.
The super wet technique is similar to the tumescent technique, as it also requires the injection of anesthetic liquid. The difference is that significantly less volume is used – about a third as much. The surgery can be performed in about 1 to 2 hours.
During ultrasound-assisted lipoplasty, the cannula emits high frequency sound waves to liquefy fat cells and facilitate low-level aspiration. The use of ultrasonic energy allows for more precision in less fatty areas that have high amounts of muscles and tendons, as it acts primarily on the fat cells and has no effect on the vascular, nervous, or connective tissues. Surgery time is longer than traditional liposuction but is shorter than the tumescent technique.
Power-assisted liposuction uses a cannula that vibrates rather than one that is manually manipulated. This vibrating cannula whirs at a high enough speed to create a particularly high frequency vibration. This disrupts the fat cells, releasing them from the surrounding tissue and making them easier to suction out.
Power-assisted liposuction is generally associated with fewer complications, more precise sculpting, smaller incisions, shorter surgical times, and less trauma to the surrounding tissues. It is most useful for smaller areas that need minimal fat removed such as the chin, under the arms, the outer breasts, the belly, hips, flanks, and thighs.
There are some new procedures and techniques on the market called Smartlipo, laser lipo, vaser lipo, non-surgical liposuction, and others that are employed to reduce smaller areas of fat.
Liposuction is also known as lipectomy, lipoaspiration, liposculpture and lipoplasty. In Britain, there was a 41% increase in liposuction cases in 2013 (The British Association of Aesthetic Plastic Surgeons,
2014). In 2013, the American Association of Aesthetic Plastic Surgery reported liposuction as the most
popular surgical procedure, with an increase of 16% from the previous year. Initially, liposuction was
most popular in women, but over the years liposuction has become increasingly popular in the male
population and now tops the list of aesthetic surgical procedures for both sexes (ASAPS, 2014).
Liposuction is a surgical procedure that involves the use of specialised cannulas to infiltrate and suction
subcutaneous fat for the purpose of aesthetic body contouring and/or lipid transfer. Liposuction
has evolved over the years to provide an adjunct to several other areas of reconstruction, including the
breast, the head and neck area, and the upper and lower limbs.
In 1926, a French surgeon called Charles Dujarier agreed to operate on a young female model to sculpture
the lateral aspect of her calves. He used a sharp uterine curette. Unfortunately, this procedure ended
up damaging the patient’s femoral artery, resulting in gangrene and subsequent amputation (Flynn and
Coleman, 2000). Dujareir was sued for 200,000 Francs and died in the following months. The negative
impact on the patient resulted in any form of body sculpture being boycotted in plastic surgery circles
for decades (Glicenstein, 1989).
334 Textbook of Plastic and Reconstructi ve Surgery
Most of the literature attributes the innovation of liposuction to Dr Yves-Gerard Illouz, a French surgeon,
in the early 1980s. It was, however, first invented by Fischer, an Italian gynaecologist in the late
1970s (Flynn and Coleman, 2000). Illouz modified Fischer’s technique by infiltrating a small volume of
saline solution into the subcutaneous fat prior to suction. This technique was coined the ‘wet technique’;
Illouz was credited with the procedure, achieving global fame (Flynn and Coleman, 2000).
Later that decade, an American dermatologist, Jeffery Klein, introduced the ‘tumescent technique’
which involved infiltration of larger volumes of local anaesthesia and adrenaline before aspiration. This
reduced intra-operative blood loss and post-operative haematomas. A vast array of tools and techniques
such as power-assisted liposuction (PAL) and ultrasound-assisted liposuction (UAL) soon followed
(Iverson and Pao, 2008).
2.2. Patient selection
Liposuction is an elective procedure in patients who are generally healthy. Careful patient selection
is of utmost importance to achieve a satisfactory outcome. Other key factors include lifestyle changes
(smoking, alcohol, recreation drugs), regular exercise and a well-balanced diet (Rohrich et al., 2004).
Patients must be counselled so that they commit to these lifestyle changes, in addition to evaluating
and discussing any concerns. Those who adhere to these lifestyle changes have shown significant
improvements in their self-esteem and productivity (Stephan and Kenkel, 2010). Pregnancy, psychiatric
history or body dysmorphic disorder, morbid obesity, unattainable expectations, co-morbidities,
bleeding disorders and impaired wound healing should be addressed before the procedure is performed
(Kenkel and Stephan, 2013).
3. ANATOMY AND AREAS OF CONSIDERATION
Body contouring with liposuction requires a basic anatomical knowledge of subcutaneous fat and its
relation to the underlying fascia to provide optimal results. Subcutaneous fat is variable in density, thickness
and adherence throughout the body. It can be divided into three layers: the superficial, intermediate
and deep layers (Kenkel and Stephan, 2013). As a rule, the superficial layer is avoided because of the
higher risk of ecchymosis, bleeding, cutaneous trauma and body contour irregularities. Subcutaneous fat
is connected to its underlying tissue through fibrous attachments within the layers that are continuous
with the fascia inferiorly. Areas that have relatively thicker and denser attachments are responsible for
the natural shape and contours of the patient, and are termed the zones of adherence. These zones may
be traversed, but should not be directly suctioned.
Head and neck liposuction has gained in popularity in the past decade owing to the development of
appropriate techniques and safer equipment. Jowl and submental liposuction are the most popular in this
region, and have high overall satisfaction rates (Doerr, 2007). The trunk is by far the most popular area
for liposuction in men and women. Figure 15.1 shows the hypogastrium, flanks and lateral aspects of the
chest, which are common areas of liposuction in the trunk. Limb contouring is an important aesthetic
procedure in massive weight loss patients (Bruschi et al., 2009). Fat accumulates in the inferior aspect
of the proximal upper limb, often referred to as ‘bingo wings’. The medial and lateral aspects of the
upper thigh are frequently considered for liposuction. The surgeon should assess and advise the patient
on the suitability of the requested area for liposuction, with regards to safety and the aesthetic outcome.
Patients must be warned that formal surgical excision of the excess skin may be required after successful
liposuction. Figure 15.2 shows common areas for liposuction in the upper and lower limbs.
Figure 15.1. Common areas of liposuction on the trunk. A. Flank, B. chest and C. hypogastrium.
Figure 15.2. Common areas of liposuction on the upper and lower limbs. A. Proximal upper limb, B. medial
thigh and C. lateral thigh.
336 Textbook of Plastic and Reconstructi ve Surgery
4. PRE-OPERATIVE ASSESSMENT
The pre-operative phase provides an opportunity to enhance rapport with the patient while obtaining
a thorough history and examination. The surgeon should document the patient’s medical history, current
medications, allergies, smoking, alcohol consumption, expectations and anaesthesia preferences.
Establishing realistic aims and committing to lifestyle changes is essential for long-term success. Patients
who present with symptoms of body dysmorphic disorder must be further evaluated. Success rates in
these patients are low and psychological support is advised (Glaser and Kaminer, 2005). Co-morbidities,
both past and present, should be thoroughly investigated because some conditions increase the chance
of deep vein thrombosis and can lead to suboptimal outcomes (Iverson and Pao, 2008). An American
Association of Anaesthesiologists (ASA) classification should be noted and, if necessary, followed by
an anaesthetic review.
Examination of the patient needs to be systematic and comprehensive (see Table 1.1). It is advisable
to have a member of the nursing team present during the examination to offer additional support to the
patient. Assessment of the aspirate estimation, skin laxity and fat deposition pattern is essential because
these factors determine the success of aesthetic surgical changes. The patient is asked to relax all muscles
for examination in a standing position, preferably in front of a mirror. This allows visualisation of the
shape of the patient’s body in its natural state and helps in examining muscular integrity. Any signs of cellulite,
asymmetry, scarring and dimples must be brought to the patient’s attention so as they are not attributed
to the procedure post-operatively. Hernias must be thoroughly looked for and addressed if necessary.
It is crucial to obtain formal medical photographs of the patient for record-keeping and future reference.
5. ANAESTHESIA OPTIONS
Anaesthesia options vary in each case and are critical in the pre-operative discussion and assessment of
the patient. Factors that influence the choice of anaesthesia include the patient’s general health (ASA
Table 15.1. List of patient parameters to note during a physical examination for liposuction.
Body Treatment area
Skin laxity and tone
Obvious musculoskeletal deformities
Fat distribution (local or diffuse)
Estimate volume of aspirate
classification), the surgeon’s/physician’s preference, the patient’s preference, the estimated volume of
aspiration, the optimal patient position, the length of operating time, intra-operative progress and the
available facilities. The three forms of anaesthesia used are local anaesthesia, intravenous sedation and
general anaesthesia. Lidocaine is usually the local anaesthetic of choice. It is preferable to bupivacaine
because of its safer profile and faster reversibility. The normal recommended dose of lidocaine is 7 mg/
kg but, owing to vasoconstriction and the aspirate containing lidocaine, up to 35 mg/kg is accepted
(Iverson and Pao, 2008). Lidocaine toxicity associated deaths are rare, but it is vital for the responsible
physician to identify lidocaine toxicity peri- and post-operatively.
Smaller volumes of aspirate are usually treated under local anaesthesia, intravenous sedation or a combination
of both. Intravenous sedation is used to provide patients a degree of comfort peri-operatively
and, for the physician, a conscious patient who is responsive to verbal and tactile stimuli.
Patients who plan to have multiple areas treated or have severe co-morbidities, other surgical procedures
planned, lengthy operations and estimated large aspirate volumes are more likely to receive
general anaesthesia. Procedures using general anaesthesia are more costly, require trained personnel and
warrant specific post-operative precautions.
Administering anaesthesia requires good comprehension of the changes in physiology that occur
during liposuction. An understanding of intra-operative fluid loss, its replacement, intra-operative physiological
monitoring and post-operative pain needs is vital prior to induction (Sood et al., 2011).
6. INVASIVE LIPOSUCTION TECHNIQUES
Various techniques are currently available for performing liposuction. Before choosing the appropriate
technique, several factors should be considered. These include the body areas involved, amount of
lipoaspirate, fibrous areas, possibility of revision liposuction and skin redundancy. The most commonly
used options include suction-assisted liposuction (SAL), PAL, UAL, VASER liposuction, water-assisted
liposuction (WAL) and laser-assisted liposuction (LAL) (Kenkel and Stephan, 2013). A new technique
called power WAL has also gained in popularity.
6.1. Suction-assisted liposuction
SAL was the first method described for liposuction and remains the one most commonly used (Ahmad
et al., 2011). It mechanically removes adipocytes along with other tissue. After the desired site is
injected with a wetting solution, a period of time is allowed for the infiltrate to take effect.
At markings made pre-operatively on the body, small incisions (3–4 mm) are made with a sharp
scalpel. The adipose tissue is then removed under negative pressure by a hollow cannula with a blunt
tip. It is recommended to start with a larger cannula in a deeper plane and then use a smaller diameter
cannula more superficially (Tabbal et al., 2013). The SAL technique is easy to use and a broad variety
of cannulas are available. One disadvantage is that it can be considerably laborious, particularly in
338 Textbook of Plastic and Reconstructi ve Surgery
6.2. Power-assisted liposuction
PAL uses an external power source as opposed to the surgeon. The cannula moves back and forth in
small oscillating motions. The small rapid vibrations break up the adiposites so they can be suctioned
out of the body. The power settings can be altered to control the rate. PAL is useful for large volumes,
fibrous areas and in revision liposuction.
6.3. Ultrasound-assisted liposuction
UAL delivers fat-liquefying ultrasonic energy which breaks down the adipose tissue. The emulsified
fat is then removed through a cannula. This is always a three-stage procedure because infiltration
must be used. The ultrasonic energy is dispersed from the superficial to the deep layers, and
there must be continuous movement to prevent thermal injury. The advantages of this technique are
improved contouring and its suitability for revision and for fibrous areas. On the negative side, the
equipment is more expensive, the operating time is longer and the risk of thermal injury is present if
not used correctly. A newer type of UAL called VASER liposuction uses less energy because of more
6.4. L aser-assisted liposuction
LAL is designed to achieve adipocyte removal and skin tightening from the thermal effect of the laser
on the dermis (Matarasso and Levine, 2013). A small laser fibre is inserted through an incision in the
skin. The four-stage procedure consists of infiltration, application of energy to the subcutaneous tissues,
evacuation and, finally, subdermal skin tightening.
6.5. Water-assisted liposuction
WAL is a technique in which instead of being destroyed, the adipocytes loosen, which facilitates a
gentler removal. The process comprises a single step, with simultaneous injection and removal. It is
considered to be gentle with less ecchymosis and a shorter recovery time due to less tissue trauma (see
7. APPLICATION OF WETTING SOLUTIONS
Liposuction was initially performed without any wetting solution, resulting in high rates of blood loss.
With the introduction of infiltrates, the operation is now performed with markedly less complications
and with the removal of larger volumes. They may also provide some peri-operative analgesia. Wetting
solutions are traditionally divided into four categories: dry, wet, superwet and tumescent (Sasaki, 2011).
The most commonly used wetting solutions combine a crystalloid with lidocaine, adrenaline and, not
infrequently, sodium bicarbonate. A common example is Klein’s formula, comprising 1000 ml normal
saline, 50 ml 1% lidocaine, 1 ml 1:1000 adrenaline and 12.5 ml 8.4% sodium bicarbonate. In a recent
study, Hatef et al. (2009) showed that varying doses of lidocaine did not affect intra- or post-operative
It is generally recommended not to use marcaine because of its possible cardiotoxicity, although
Failey et al. (2009) demonstrated no significant difference in the incidence of complications or length of
hospital stay when comparing bupivacaine and lidocaine.
Addition of adrenaline to the wetting solution adds a vasoconstrictive element which decreases
blood loss. The addition of adrenaline to lidocaine results in less systemic absorption of lidocaine. The
American Society of Plastic Surgeons has recommended that the total dose of adrenaline used in local
anaesthesia should not exceed 0.07 mg/kg to limit the systemic effects (Iverson et al., 2004).
Supplementing the wetting solution with sodium bicarbonate is known to decrease the painful sensation
that lidocaine can produce. This occurs through reducing the acidity of lidocaine, thus making the
pH more physiological.
As previously mentioned, wetting solutions reduce the amount of blood loss during liposuction. For a
dry technique, blood loss can typically be up to 50% of the final aspirate, whereas blood loss for the wet,
superwet and tumescent techniques is reported to be 10–30%, 1–4% and <1%, respectively (Iverson
et al., 2004).
Figure 15.3. Water-assisted liposuction.
340 Textbook of Plastic and Reconstructi ve Surgery
8. TECHNIQUES OF INFILTRATION
The dry technique uses no infiltrate and is now very uncommon. The wet method uses 200–300 ml/
area and the volume aspirated is to the desired effect. The superwet technique applies 1 ml infiltrate to
1 ml aspirate. The tumescent method involves infiltrating to skin turgor and aspirating 2–3 ml aspirate/
9. SURGICAL PLANNING
9.1. Pre-operative marking
Prior to surgery, the patient’s body is marked by the surgeon, ideally when the patient is in an upright
position in front of a mirror and with the patient’s involvement. The chosen areas for liposuction are
marked with circles. The known areas of adherence should be delineated. These are the zones in which
the more superficial structures adhere to the deeper structures (Figure 15.4).
Zones of Adherence Areas of liposuction
Figure 15.4. Zones of adherence.
Pre-operative data sheets may be used to document the areas of contouring. Skin tone, asymmetry,
cellulite and striae can also be included.
10. PATIENT POSITIONING
Most liposuction can be done with the patient in the prone position, and it is important to use adequate
padding for all pressure points pre-operatively. Repositioning to the supine position and re-preparation
should be performed with multiple staff to minimise the time taken. The upper chest, face, iliac crest,
bony prominences of the extremities and genitalia should be supported. Prevention of hypothermia is
important, as is the use of lower leg compression devices in the prevention of deep vein thrombosis.
The lateral decubitus position is not frequently used because it does not allow symmetrical comparison.
11. SURGICAL INSTRUMENTS
Liposuction is achieved with cannulas through small access incisions. The three important features for
determining the efficiency of a cannula are its tip, configuration and dimensions (diameter and length)
(Mathes and Hentz, 2006). The tip of the cannula influences the speed and the efficacy of liposuction;
most tips are blunt and have multiple openings. There are many different types of cannulas, which vary
in both length and diameter. Cannula sizes are available from 1.8 mm to 1 cm in size, and the most common
diameter is 2–5 mm (Kenkel and Stephan, 2013).
The length of the cannula varies from around 10 cm to 30 cm. Longer cannulas provide further access
but shorter cannulas enable more accurate control.
Cannulas used for SAL and PAL have multiple openings set back from the tip. One of the most
commonly used is the three-hole Mercedes-type cannula (see Figure 15.5). Cannulas used for PAL are
similar to those used for SAL. As described earlier, they oscillate in a plane parallel to the long axis
of the cannula. Power is provided by an electrical unit or a pneumatic hose (Mathes and Hentz, 2006).
UAL uses a hollow cannula or a solid probe. The VASER probes are solid with rings around them.
The tip of the ultrasonic apparatus oscillates 10 times faster than that used for PAL. These probes can
be solid or hollow. The hollow probe allows some fat to be extracted, although the openings are rather
small; therefore, further evacuation of the liquefied fat is needed.
Figure 15.5. Mercedes type cannula (three holes).
342 Textbook of Plastic and Reconstructi ve Surgery
12. COMPRESSION GARMENTS
Most patients should be able to go home within 24–48 hours, depending on the extent of the areas
involved and their general fitness. Large volume liposuction patients should stay in hospital overnight.
Compression stockings should be worn on the legs while in hospital to reduce the risk of thromboembolic
events. Wearing compression garments is standard post-liposuction. Compressive bandages are
often used in the first week if a customised garment is not available. Compression assists in contouring
and decreases bruising and oedema. The recommended length of time for garment use varies among
surgeons, but is usually a minimum of 6 weeks.
Possible complications from liposuction vary from minor to major, life-threatening events. They may
be divided into peri-operative (0–48 hours), early (1–7 days) and late (1 week to 3 months), as shown
in Table 1.2.
13.1. Peri-operative complications
In the peri-operative period, there may be complications related to the general anaesthesia, such as cardiac
events. It is therefore strongly recommended that patients are classified as ASA 1–2 and, if there
is any pre-existing cardiopulmonary disease, a medical review is warranted. Other anaesthesia complications
may include local effects of the tumescent infiltrate such as lidocaine toxicity or direct cardiac
effects of adrenaline.
Organ or intestinal perforation is rare but well documented in the literature. The abdomen, thorax and
retroperitoneum are all potentially affected areas, with perforations more commonly occurring through
previous scars or hernias (Haeck et al., 2009). The surgeon must always be aware of the location of the
tip of the cannula.
Table 15.2. Complications of liposuction.
Peri-operative Early Late
Anaesthetic complications Venous thromboembolism Late seroma
Perforation of organs Infection Oedema and ecchymosis
Volume shift Skin necrosis Paraesthesia
Bleeding Necrotising fasciitis Hyperpigmentation
Hypothermia Seroma Contour irregularities
Fat emboli syndrome
Fluid shifts can occur intra-operatively, especially during large volume liposuction. This may lead to
hypovolaemia or potentially pulmonary oedema. It is therefore important for both the anaesthetist and
the surgeon to document fluid input and output.
Bleeding during liposuction has become very rare after the introduction of wetting solutions.
The risk of hypothermia is higher in patients having multiple areas treated. It is associated with an
increased risk of bleeding, cardiac events and sepsis.
Fat embolism syndrome (FES) is a rare complication of liposuction, in which fat becomes lodged
in the small vessels of the lungs. The diagnostic criteria are at least two of the following: respiratory
distress, cerebral involvement and petechial rash within 48 hours of the procedure. Hypoxia is often the
first sign; others include fever, tachypnoea and bilateral X-ray changes. Treatment is mainly supportive.
It is important to differentiate between a pulmonary embolism and FES.
13.2. E arly complications
The incidence of venous thromboembolism in liposuction is thought to be relatively low, with a risk of
<1%. It is important to review all pre-operative risk factors. The use of elastic compression stockings,
intermittent pneumatic devices and low molecular weight heparin is recommended when necessary.
Signs include lower extremity swelling, Homan’s sign, tachypnoea and/or chest pain. Prompt treatment
with anticoagulation for deep vein thrombosis and possible thrombectomy or thrombolysis for pulmonary
embolism is indicated.
Small infections may occur within haematomas. Systemic infection is thought to be more likely in
smokers, diabetics and immunocompromised patients. Local infection and fulminant necrotising fasciitis
are well documented in liposuction. It is common practice to give one dose of antibiotic pre-operatively
and to closely monitor and treat any post-operative fever and cellulitis. A large study of major and lethal
complications of liposuction by Lehnhardt et al. (2008) showed that the most frequent complications
were bacterial infection such as necrotising fasciitis, gas gangrene and other forms of sepsis.
Skin necrosis appears to be more common in smokers and in patients who undergo superficial
13.3. L ate complications
Seromas appear to be more frequent in the lower abdominal area and usually become more noticeable at
around 1 week post-operatively. They are thought to be more likely if adequate pressure garments have
not been used and in patients with a high body mass index. Some studies have suggested there is a higher
risk of seromas with UAL. They appear to be more common in overtreated areas.
Oedema and ecchymosis are reduced with the use of compression garments for 4–6 weeks. There
may be more swelling after UAL, and ecchymosis tends to be more frequently present in smokers or in
patients on anticoagulants.
344 Textbook of Plastic and Reconstructi ve Surgery
Post-operative aesthesia or dysaesthesia usually regresses within 10 weeks, but may infrequently last
up to a year. Occasionally neurological pain may be associated with neuroma formation or damage to
underlying fascia or muscle.
Contour irregularities are the most common late complication. Surgical treatment consists of corrective
liposuction or lipofilling.
14. NON-INVASIVE LIPOSUCTION
The technologies used for non-invasive liposuction include ultrasound, laser, cryotherapy and injection
mesotherapy. Mesotherapy involves a series of injections containing multiple ingredients which act in
two ways: lipolytic agents stimulate lipolysis and ablative chemicals destroy adipocytes. This process
is thought to increase blood and lymphatic flow in the mesoderm. The cells shrink, dissolve and are
extracted (Rohrich, 2005).
Maintenance of a healthy diet and exercise in conjunction with liposuction can enable patients to achieve
their desired body shape and contour. To achieve a satisfactory outcome, it is paramount that patients
adhere to the recommended diet and level of physical activity. Liposuction is under continuous development
with regards to technology and instrumentation. It is deemed safe and effective but, as with all
invasive surgery, is not without side effects. Diligent patient selection and realistic expectations will give
the most rewarding results.
American Society for Aesthetic Plastic Surgery (ASAPS). 2014. Cosmetic Surgery National Data Bank: Statistics 2013.
Aesthet Surg J, 34, 1–20.
Ahmad, J., Eaves, F. F., 3rd, Rohrich, R. J. & Kenkel, J. M. 2011. The American Society for Aesthetic Plastic Surgery
(ASAPS) survey: Current trends in liposuction. Aesthet Surg J, 31, 214–24.
Bruschi, S., Datta, G., Bocchiotti, M. A., Boriani, F., Obbialero, F. D. & Fraccalvieri, M. 2009. Limb contouring after
massive weight loss: Functional rather than aesthetic improvement. Obes Surg, 19, 407–11.
Doerr, T. D. 2007. Lipoplasty of the face and neck. Curr Opin Otolaryngol Head Neck Surg, 15, 228–32.
Failey, C. L., Vemula, R., Borah, G. L. & Hsia, H. C. Intraoperative use of bupivacaine for tumescent liposuction: The
Robert Wood Johnson experience. Plast Reconstr Surg, 124(4), 1304–11.
Flynn, T. C., Coleman, W. P., 2nd, Field, L. M., Klein, J. A. & Hanke, C. W. 2000. History of liposuction. Dermatol Surg,
Glaser, D. A. & Kaminer, M. S. 2005. Body dysmorphic disorder and the liposuction patient. Dermatol Surg, 31, 559–60;
Glicenstein, J. 1989. Dujarier’s case [in French]. Ann Chir Plast Esthet, 34, 290–2.
Haeck, P. C., Swanson, J. A., Iverson, R. E., Schechter, L. S., Singer, R., Basu, C. B., Damitz, L. A., Glasberg, S. B.,
Glassman, L. S., Mcguire, M. F. & Committee, A. P. S. 2009. Evidence-based patient safety advisory: Patient selection
and procedures in ambulatory surgery. Plast Reconstr Surg, 124, 6S–27S.
Hatef, D. A., Brown, S. A., Lipschitz, A. H. & Kenkel, J. M. 2009. Efficacy of lidocaine for pain control in subcutaneous
infiltration during liposuction. Aesthet Surg J, 29, 122–8.
Iverson, R. E., Lynch, D. J. & American Society of Plastic Surgeons Committee On Patient Safety. 2004. Practice advisory
on liposuction. Plast Reconstr Surg, 113, 1478–90; discussion 1491–5.
Iverson, R. E. & Pao, V. S. 2008. MOC-PS(SM) CME article: Liposuction. Plast Reconstr Surg, 121, 1–11.
Kenkel J. M., Stephan P. J. 2013. Liposuction: A comprehensive review of techniques and safety. In: Warren, R. J. (ed.)
Plastic Surgery. China: Elsevier.
Lehnhardt, M., Homann, H. H., Daigeler, A., Hauser, J., Palka, P. & Steinau, H. U. 2008. Major and lethal complications
of liposuction: A review of 72 cases in Germany between 1998 and 2002. Plast Reconstr Surg, 121, 396e–403e.
Matarasso, A. & Levine, S. M. 2013. Evidence-based medicine: Liposuction. Plast Reconstr Surg, 132, 1697–705.
Mathes S. J., Hentz V. R. 2006. Plastic Surgery, Michigan, Saunders Elsevier.
Rohrich, R. J. 2005. Mesotherapy: What is it? Does it work? Plast Reconstr Surg, 115, 1425.
Rohrich, R. J., Broughton, G., 2nd, Horton, B., Lipschitz, A., Kenkel, J. M. & Brown, S. A. 2004. The key to long-term
success in liposuction: A guide for plastic surgeons and patients. Plast Reconstr Surg, 114, 1945–52; discussion 1953.
Sasaki, G. H. 2011. Water-assisted liposuction for body contouring and lipoharvesting: Safety and efficacy in 41 consecutive
patients. Aesthet Surg J, 31, 76–88.
Sood, J., Jayaraman, L. & Sethi, N. 2011. Liposuction: Anaesthesia challenges. Indian J Anaesth, 55, 220–7.
Stephan, P. J. & Kenkel, J. M. 2010. Updates and advances in liposuction. Aesthet Surg J, 30, 83–97.
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uk/about-us/press-releases/1833-britain-sucks [Accessed 31 October 2014].
Facial Aesthetic Surgery
Muholan Kanapathy, Niall Kirkpatrick
1. PATIENT SELECTION
Facial aesthetic procedures have been rapidly growing in number across the globe over the past few
decades. Globalisation and social media have played a major role in encouraging patients to undergo
these procedures (The American Society for Aesthetic Plastic Surgery, 2010). Surgeons therefore have
a greater responsibility to appropriately educate patients and use careful patient selection criteria to
choose the appropriate candidates for the treatment.
Considerations regarding patient selection and pre-operative counselling for aesthetic surgery include
a clear understanding of the patient’s perception of their problem and their expectations of surgery as
well as knowledge of a wide range of surgical techniques and their risks.
While most patients have clearly identifiable concerns and appropriate expectations, care should be
taken with patients that are overly expectant and demanding, those requesting multiple interventions
(i.e. ‘the surgiholic’ patients), those with marital breakdown or job loss, those pushed into surgery by
others, those with body dysmorphic disorder, and those with whom the surgeon feels incompatible
(Gorney, 2010). Careful patient selection will avoid disappointment for those who may not have understood
the procedure or have underestimated the limitations of surgery.
2. SURGICAL ANATOMY OF THE FACE
A comprehensive description of facial anatomy is beyond the scope of this text. However, key anatomical
points relating to facial aesthetic procedures will be emphasised.
Facial Aesthetic Surgery 347
2.1. Soft tissue layer
The soft tissue of the face consists of five basic layers which are arranged concentrically (Figure 16.1).
Specific age-related changes occur in each facial layer; procedures to reposition tissues form the basis
of facial rejuvenation surgery.
In the skin, flattening of the dermoepidermal layer coupled with a reduction in the levels of collagens
III, IV and VII, chondroitin sulphate, elastin, oxytalan fibres, melanocytes and Langerhans cells determine
susceptibility to age-related changes (Gilchrest, 1989; Contet-Audonneau et al., 1999).
Subcutaneous tissue consists of two important components: the subcutaneous fat and retinacular
cutis. The retinacular cutis is part of the retaining ligaments that pass through the subcutaneous tissue to
provide support. In areas with a thick subcutaneous layer, the retinacular cutis fibres are susceptible to
weakening and distension with age.
The superficial musculoaponeurotic system (SMAS) layer contains the mimetic muscles that are
involved in facial expression. The SMAS is continuous with the platysma, temporoparietal fascia, frontalis
and galea aponeurotica. Manipulation of the SMAS, as described by Mitz and Peyronie in 1976,
has become a popular means of rejuvenating the face, with many later variations described (Mitz and
Peyronie, 1976). In facelift procedures, greater tension can be applied to the SMAS than to the skin, and
the SMAS may act as a carrier for other tissues such as muscle and fat pads. In addition, it forms a key
landmark in facial nerve anatomy: below the zygomatic arch, all branches of the facial nerve are deep
1) Skin 2
3) Musculo aponeurotic
4) Retaining ligament and space
5) Periosteum and deep fascia
Figure 16.1. Soft tissue layers of the face.
348 Textbook of Plastic and Reconstructi ve Surgery
to the SMAS (Mendelson and Wong, 2013). Only the mentalis, levator anguli oris and buccinator muscles
are innervated on their superficial surface. All other muscles are innervated on their deep surface.
Therefore, dissection in the plane superficial to these muscles is considered relatively safe.
The face also has a fibrous support system of retaining ligaments that prevents repositioning and
fixation of facial soft tissues if not released. The retaining ligaments and soft tissue spaces make up
the loose areolar tissue. This is an avascular potential space that allows the superficial layers to glide,
enabling facial expression. This layer is safe for dissection because no structures cross within it. The
retaining ligaments comprise both osteocutaneous ligaments and musculocutaneous ligaments. The
osteocutaneous ligaments include the zygomatic ligament, which extends from the zygomatic arch and
body (McGregor’s patch) through the malar fat pad to the dermis, and the mandibular ligament, which
extends from the parasymphyseal region to the dermis. The parotid and masseteric cutaneous ligaments,
formed by union of the superficial and deep facial fascia, attach these structures to the overlying dermis.
2.2. Nerve anatomy
The greater auricular nerve, a branch of the cervical plexus, is the symptomatic nerve most commonly
injured during facelift surgery. The superior course of the greater auricular nerve falls within a 30° angle
constructed using the vertical limb perpendicular to the Frankfurt horizontal and a second limb drawn
posteriorly from the midlobule (Ozturk et al., 2014). Division of this nerve leads to numbness of the
earlobe and lateral pinna and also a potential for problematic neuroma if not repaired.
The midface receives sensory innervation from the zygomaticofacial, infraorbital and posterior maxillary
nerves and motor innervation from the facial nerve. These nerves are at risk of injury during surgery.
The facial nerve emerges from the stylomastoid foramen and passes through the parotid gland, dividing
into five main branches which provide motor innervations to mimetic muscles. The temporal
branch courses superficially after crossing the zygomatic arch, in the plane deep to the temporoparietal
fascia. It travels along a trajectory known as the Pitanguy line from the tragus to a point approximately Plastic Surgery Dubai FAQs
1.5 cm superior to the lateral brow (Pitanguy and Ramos, 1966). The buccal and zygomatic
branches form multiple interconnections which may conceal injury to the buccal branch, the branch
most commonly injured during facelift surgery. The marginal mandibular branch courses approximately
1–2 cm below the border of the mandible before crossing the facial vessels, in the plane deep
The marginal mandibular and temporal branches are the most vulnerable to long-term dysfunction if
Facial Aesthetic Surgery 349
3. AGEING FACE
Facial ageing is a dynamic, complex and multidimensional process whereby a complex interplay of
several factors contributes to changes in each anatomical layer. The ageing process may vary dramatically
between individuals and is thus influenced by genetic factors. When assessing the ageing face, it
is important to consider the skeletal architecture, the soft tissue layers including anterior fat pads, the
retaining ligament anchors and, finally, the overlying skin.
3.1. Assessment of facial ageingPlastic Surgery Dubai FAQs
Surgical correction of facial ageing attempts to reverse gravitational changes to soft tissues and restore
In the context of the surgical management of facial ageing, the face can be usefully separated into
three anatomical areas:
1. The upper face, including the forehead, upper eyelids and eyebrows.
2. The midface, including the anterior cheek and lower eyelids.
3. The lower and lateral face, neck and perioral regions.
The upper face extends from the hairline down to the upper eyelids. Surgical procedures targeting
the upper face include forehead and brow lifts, temporal lift, upper blepharoplasty and fat grafting to
The midface is a triangular area below the eyelid bounded medially by the nasofacial angle, inferiorly
by the nasolabial fold and corner of the mouth, and superiorly by the lower eyelid and tear trough and
the lateral canthus at the superolateral aspect (Mendelson and Wong, 2012). Key elements of midfacial
ageing are gradual ptosis of the cheek skin below the infraorbital rim, creating infraorbital hollowness,
descent of the malar fat pad with loss of malar prominence, deepening of the tear trough and associated
exaggeration of the nasolabial fold (Owsley, 1993; Stuzin et al., 1995; Hester, 2001; Paul et al., 2006;
Saltz and Ohana, 2012).
Surgical procedures directed at the midface may be approached via the temporal region or lower
eyelid. It is important to emphasise that these procedures are complicated and involve dissection of the
face at deep levels close to neurovascular structures (Hachach-Haram and Kirkpatrick, 2013). They may
involve long downtimes and prolonged swelling for patients. Given the significant complication profile,
these procedures should only be attempted by surgeons with a clear understanding of and thorough
training in this area.
Most commonly, facial rejuvenation is directed at the lateral cheek and lower third of the face and
encompasses many modern facelift techniques and neck procedures. To achieve harmony in facial rejuvenation
surgery, procedures to correct ageing within different zones may be performed simultaneously
or in a staged fashion.
350 Textbook of Plastic and Reconstructi ve Surgery
3.1.1. Soft tissue changes in ageing face
Ageing of the soft tissues of the midface is multifactorial and attributed to a combination of increased
laxity of the orbicularis oculi muscle and orbital septum, horizontal laxity of the tarsal plate component
of the lower lid, laxity of the zygomaticus muscles and elevators of the upper lip with subsequent
deepening of the nasolabial fold, and fat atrophy. Most significantly, attenuation of the osseocutaneous
ligaments, including the orbitomalar and orbicularis-retaining ligament, with descent and inferior
migration of the soft tissues, including the malar and other fat pads, into the anterior maxillary hollow
inferomedially, results in an apparent volume loss in the anterior cheek with visible lengthening of the
lower eyelids, giving the face a more squared, vertical appearance (Owsley, 1993; Krastinova-Lolov,
1989; Nahai, 2005; Mendelson and Wong, 2012).
In youth, the upper anterior cheek skin is firmly supported by the orbitomalar septum that allows
little or no downward migration (Mendelson et al., 2007). Facial septa extending from the SMAS
through the malar fat pad to the overlying dermis further support the malar fat pad (Owsley, 1993).
The repeated movements of animation, as well as repeated zygomaticus and levator muscle contraction
and shortening, result in pressure within the overlying cheek and prominence of the nasolabial fold
Over time, the supporting fat pad facial septa stretch and weaken, resulting in downward migration Plastic Surgery Dubai FAQs
of the malar fat pad and the appearance of infraorbital flattening or hollowing, and permanent prominence
of the nasolabial fold (Figure 16.2). The fat pads, which include suborbicularis oculi fat (SOOF),
temporal fat, malar fat pad and the buccal fat pad, form an important part of the facial architecture.
They are partitioned into discrete compartments. Variance in ageing suggests that ageing of these fat
pads is not entirely confluent but is instead characterised by how these compartments independently
change with age (Krastinova-Lolov, 1989; Owsley, 1993; Rohrich and Pessa, 2007; McCollough et al.,
2009). Disruption of the lower eyelid–cheek complex due to inferior migration of the malar fat pad and
the SOOF results in a ‘double-contour’ deformity of the midface (Rohrich and Pessa, 2007; Ransom
et al., 2012).
The midface receives sensory innervation from the zygomaticofacial, infraorbital and posterior maxillary
nerves and motor innervation from the facial nerve. These nerves are at risk of injury during midfacial
dissection. Finally, skin changes and collagen degradation add to the ageing process by affecting
the facial surface and skin thinning.
3.1.2. Skeletal architecture in the ageing face
The inferior orbital rim is composed of the zygoma, the lacrimal bone and the anterior maxilla; projection
of these structures determines the vector of the midface and the skeletal support available for the
soft tissues of the midface. It is important to recognise that the anterior maxilla is significantly concave.
Skeletal resorption, at both the periorbital level and maxillary level, has been attributed to the decreased
Facial Aesthetic Surgery 351
malar projection and increased orbital aperture seen in ageing. This can have significant consequences
on the projection and prominence of the maxilla and on the location of facial ligament attachments
(Nahai, 2005; Mendelson et al., 2007). The maxilla may undergo significant skeletal resorption, with
up to a 10° loss in the maxillary angle contributing to the typical ageing cheek stigmata associated with
loss of maxillary projection and resulting in the development of a lid–cheek continuum deformity and a
prominent nasolabial fold (Mendelson and Wong, 2012).
Several factors accelerate the ageing process in the skin. Cumulative exposure to ultraviolet irradiation
is an important factor that influences skin ageing. Clinical signs of photoaging include freckles, rhytides,
telangiectasia, loss of elasticity and a sallow colour.
The Glogau classification of photoaging is most commonly used to describe skin changes due to
photodamage and aging (Table 16.1) (Nguyen et al., 2012). The Glogau scale is useful for estimating
the overall amount of facial ageing and assists discussion of the potential outcome of cosmetic
Loss of fat
Figure 16.2. Features of the ageing face.
352 Textbook of Plastic and Reconstructi ve Surgery
4. SURGICAL AESTHETIC TREATMENT
The youthful face is often defined by malar and lateral cheek fullness with associated submalar concavity,
giving a smooth contour coupled with an aesthetically pleasing convex lower eyelid–cheek continuum
(Hachach-Haram and Kirkpatrick, 2013). The lower mandibular jawline is even and smoothly
defined, and the eyebrow convex and situated on or above the supraorbital margin, with the eyelid having
a well-defined crease.
Facelift surgery started as early as 1901, and has evolved significantly since then (Warren, 2013).
Since the mid-1990s, there has been increasing interest in the midface lift as a sophisticated component
of facial rejuvenation, with the development of techniques other than the traditional pre- and
post-auricular approaches (Berkowitz et al., 2005). Newer approaches are based on the principle of lifting
in a more vertical or superolateral vector (Berkowitz et al., 2005).
4.1.1. Operative techniques of facelift
126.96.36.199. Subcutaneous facelift
The subcutaneous facelift evolved from the first facelift involving a simple skin incision at the temporal
hairline and pre-auricular region to a more extensive subcutaneous dissection with skin repositioned in
a superolateral vector (Warren, 2013). The skin flap is created by dissecting in the plane immediately
superficial to the SMAS, thus preserving the subdermal plexus for vascular supply (Hoefflin, 1998).
Despite being a relatively safe procedure, the subcutaneous facelift is rarely performed today because it
relies on skin tension to produce the desired lift; this often leads to widened scars and early recurrence
Table 16.1. Glogau classification of photoageing.
Group Age (years) Findings
1 20–30 No wrinkles
Change in homogeneity of colour
2 30–40 Wrinkles on animation as expression lines
2 50–60 Wrinkles at rest
Make-up provides homogeneity of colour but accentuates the wrinkles
4 60 or older Severe wrinkling
Actinic keratosis and skin cancers
Make-up creates ‘cracked mud’ appearance
Facial Aesthetic Surgery 353
and an unnatural ‘pulled’ appearance. However, this technique may be useful in selected patients such
as those with pseudoxanthoma elasticum or with multiple previous facelifts.
188.8.131.52. Subcutaneous facelift with SMAS manipulation
Upon raising a subcutaneous skin flap, several different techniques can be used to manipulate the SMAS
to restore volume to the malar region, thus creating a more youthful appearance. Plication uses sutures
to fold the SMAS and reposition fat from the lower face. SMAS imbrication requires incision and overlapping
of the SMAS with suture fixation. The SMAS is advanced in a different vector from the skin,
thereby avoiding the use of skin tension alone. However, recurrence of facial ptosis may occur if sutures
pull through the skin.
The minimal access cranial suspension (MACS) lift, popularised by Tonnard and Verpaele (2007),
uses permanent purse string sutures anchored to the deep temporal fascia to achieve superolateral suspension Plastic Surgery Dubai FAQs
of the SMAS–platysma layer. Multiple small bites are taken during suture placement to create
micro-imbrications of fat and SMAS. In the simple MACS lift, two purse string sutures are used
to address the neck and lower third of the face. An additional third suture is included in the extended
MACS lift to suspend the malar fat pad. The main disadvantage of the MACS lift is its reduced longevity
of effect. MACS is most effective in younger patients who require minimal skin redraping.
184.108.40.206. Subcutaneous facelift with a separate SMAS flap (plus variations)
Elevating separate skin and SMAS flaps provides greater flexibility in the direction and tension applied
to each flap. The SMAS flap is usually advanced in a more vertical direction with firm suture fixation to
immobile tissues, while the skin flap is redraped under minimal tension in a superolateral vector. This is
crucial to avoid the ‘lateral sweep’ effect.
220.127.116.11. Skoog facelift
In 1974, Skoog described raising the skin, subcutaneous fat and SMAS as a single unit (Skoog, 1974).
Modifications of the technique have evolved to overcome tethering of the SMAS attachment to the lip
elevators and thus improve the nasolabial fold (Barton and Hunt, 2003).
18.104.22.168. Lateral SMASectomy
The lateral SMASectomy, as described by Baker, excises a strip of SMAS (obliquely from the angle of
mandible to the lateral malar eminence) along with the overlying fat (Baker, 1997). The width of SMAS
resection depends on the extent of laxity. The vector of elevation (perpendicular to the nasolabial fold)
is not ideal and can produce an unnatural or ‘pulled’ appearance, otherwise known as ‘lateral sweep’ or
‘Nike swoosh’. Flattening, with loss of volume in the lateral cheek element, may also occur.
354 Textbook of Plastic and Reconstructi ve Surgery
SMAS procedures can rejuvenate the middle third of the face by elevating tissues over the malar
eminence with slight effacement of the nasolabial fold. The points of fixation for the most vertically
elevated SMAS flap lie lateral to the orbit along the line of the zygoma and zygomatic arch. These techniques
can address the jowls and produce an excellent jawline, as well as correcting laxity in the neck
and the lateral cheek. However, these procedures do not address well the volume changes below the
eyes and the problem of malar and anterior fat repositioning in its entirety. Consequently, they do not
rejuvenate the true midface and their results on the midface are unpredictable. Enhancement of malar
volume may therefore be achieved without adequately restoring the lower lid–cheek continuum. SMAS
procedures may well produce acceptable results with a high satisfaction rate in younger patients, but in
the older patient or those with more complex problems, SMAS procedures alone will generally fall short
of ideal. Moreover, SMAS lifts can exacerbate the problem of the concavity and hollow appearance of
the lower lid, giving a typical ‘lateral sweep facelift’ appearance. In contrast, re-elevating the midface
using the orbicularis oculi flap as the primary vehicle, with or without subperiosteal dissection and
re-suspension, can restore a more youthful convexity to the lower lid–cheek continuum; this is usually
best seen in photographic three-quarter views.
The recent development of volume-enhancing minimally invasive techniques such as autologous
fat transfer has led some surgeons to opt for simpler techniques with minimal post-operative oedema.
Filling midface contour defects enables a quick return to normal life. However, the fundamental problem
of midface descent is not addressed and may even be made worse by further weighting of the tissues.
Irregularity of the tissues may also become apparent once post-surgical oedema resolves; often,
these results are not forgiving. These patients may subsequently benefit from corrective midface surgery.
Although midface lifting techniques are more complex to perform and require careful patient assessment
and choice of procedure, they can address ageing of the anterior cheek better than conventional
facelift techniques. When performed either in isolation or in conjunction with other facelift or periorbital
procedures, they produce harmonious and natural rejuvenation for patients. Furthermore, they can be
used as powerful reconstructive tools for patients with soft tissue midface deficiencies.
22.214.171.124. Subperiosteal facelift
Tessier advanced the subperiosteal approach for middle third facial rejuvenation and also highlighted
the use of the coronal approach to achieve adequate lifting of the temporal and lateral canthal areas
(Tessier, 1979). In the 1980s, Santana described the importance of subperiosteal dissection to allow
traction of the deeper structures to improve the nasolabial fold and recommended resection of Bichat’s
fat pad (buccal fat) to produce a more prominent malar appearance (Barton, 2002).
Mendelson described the use of extended SMAS dissection and periosteal fixation that refined the
process of elevating the ptotic malar fat pad, resulting in effacement of the nasolabial fold (Stuzin et al.,
1995; Barton and Hunt, 2003).
Ramirez et al., Ortiz-Monasterio, and Tapia et al., were concerned with the risk of neurapraxia;
they independently demonstrated that careful subperiosteal dissection using multiple subperiosteal
Facial Aesthetic Surgery 355
pockets minimises these risks (Barton, 2002). Furthermore, by dissecting beneath both layers of the
temporal fascia, midface rejuvenation was achievable (Guerrerosantos, 1983; Feldman, 1990; Jones and
Subperiosteal dissection can be performed via lower eyelid incisions, limited temporal incisions
(often in combination with intraoral sulcus incisions) and the coronal ‘mask lift’ approach. The decision
regarding which approach to use largely depends on the need to control the lateral canthus and brow
complex. Some patients will also require release of the parotid–masseteric ligaments because these can
restrict midfacial elevation. Subperiosteal dissection along the zygomatic arch with inferior dissection
on the superior surface of the masseter muscle allows the release of these ligaments.
Both subciliary and transconjunctival lower eyelid incisions can be used to elevate the midface in the
subperiosteal plane alone. The subciliary approach is required to elevate the midface in the submuscular
plane, allowing fashioning of the orbicularis flap as described by Hamra. This approach also allows separate
subperiosteal dissection and elevation in a biplanar technique.
The temporal approach utilises a short incision and careful dissection deep to the frontal branch of the
facial nerve to avoid injury. Temporal supraperiosteal dissection using an endoscopic method has also
been described (Byrd and Andochick, 1996).
Berkowitz et al. described the use of the Endotine device (Coapt Systems, Palo Alto, CA, USA)
for midface lifting (Berkowitz et al., 2005). Endotine devices are biodegradeable polylactide polymer
devices that provide simultaneous elevation and fixation of tissue (Barton and Hunt, 2003). They are
an excellent method of fixation for subperiosteal dissection because they provide a wide platform for
purchase of these tissues, thus providing controlled and reliable fixation. These devices can be anchored
either to the deep temporal fascia superiorly with sutures or with screw fixation to the inferolateral
orbital rim and can be augmented with suture fixation to the inferior orbital rim where indicated.
Among the advantages of subperiosteal face lift are en bloc mobilisation of soft tissue, which provides
better exposure and better visibility, a low risk of facial nerve injury, and exposure of the bony
skeleton, allowing skeletal contouring such as insertion of facial implants and synchronous lifting of the
midface and brow (Warren, 2013). Its disadvantages include the requirement for additional equipment,
a longer post-operative recovery period and minimal effects on facial skin.
4.1.2. Complications of facelift procedures
Haematoma is the most common post-operative facelift complication, with an incidence of 3–4% in
women, increasing to 8% in men. Development of haematoma is most likely to occur in the first 24
hours after surgery and requires urgent surgical evacuation. Prevention of haematoma may be facilitated
by strict monitoring of blood pressure during the peri-operative period, with smooth awakening from
anaesthesia avoiding valsalva manoeuvre.
356 Textbook of Plastic and Reconstructi ve Surgery
126.96.36.199. Nerve injury
188.8.131.52.1. Motor nerves
Damage to the facial nerve is one of the most feared complications of facelift surgery. In the first few
hours post-operatively, paralysis may be due to the effects of local anaesthesia. Subsequently, nerve
injury may be related to cautery, traction, suture injury or division.
184.108.40.206.2. Sensory nerves
The great auricular nerve is the one most commonly injured. Interruption of smaller, cutaneous sensory
nerves may lead to self-limiting alterations in sensory innervation.
220.127.116.11. Skin necrosis
Skin necrosis may occur in the central cheek or at the posterior edge of the skin flap. A watershed area is
described in the central cheek between the zones supplied by the facial and superficial temporal arteries
and may contribute to skin necrosis in this area. Other risk factors include haematoma, infection, thin
skin flaps, excessive tension and smoking. Conservative management of skin loss is usually adopted.
18.104.22.168. Facelift stigmata
Complications include distortion of the tragus and lobule, displacement of the hairline and bearded skin
in men, the ‘lateral sweep’ effect and contour irregularities (as discussed previously). There are risks of
asymmetry and lower eyelid inferior malposition.
22.214.171.124. Other complications
Less common complications include infection (1%), hypertrophic scars, numbness, pigmentary changes,
alopecia (up to 8.4%), parotid fistulae, and prolonged oedema or facial pain (Baker et al., 1977; LeRoy
et al., 1994).
4.2. Upper third rejuvenation
Age-related changes in the upper third of the face can falsely project an appearance of tiredness, sadness,
anger or lack of interest (O’Doherty and Joshi, 2013). Evaluation of the upper eyelid must include
the eyebrow, and it is important to tailor upper eyelid blepharoplasty and brow rejuvenation to the
Facial Aesthetic Surgery 357
The eye is perhaps the most important aesthetic unit of the face because it plays a major role in determining
Blepharoplasty refers to excision of excess eyelid skin and muscles with or without the excision and
manipulation of orbital fat for functional or aesthetic purpose (Biesman and Iwamoto, 2002).
126.96.36.199. Upper blepharoplasty
188.8.131.52.1. Relevant surgical anatomy for upper blepharoplasty
The two main goals for upper lid blepharoplasty include restoration of a naturally sharp and crisp tarsal
fold and a pretarsal show (O’Doherty and Joshi, 2013).
In aesthetically attractive eyes, the pretarsal eyelid show is often only 2–3 mm (Figure 16.3)
(O’Doherty and Joshi, 2013). The upper eyelid can be divided into tarsal and orbital portions at the level
of the supratarsal fold. In Caucasians, this skin crease is located about 7–10 mm from the palpebral margin,
which results from fusion of the levator aponeurosis, orbital septum and fascia of the orbicularis
oculi into the dermis (Figure 16.4).
In the ageing eyelid, orbicularis muscle becomes hypotonic and descends, accentuating the palpebromalar
crease. Ageing leads to a higher fold, with or without upper lid ptosis and/or skin laxity of the lid
(O’Doherty and Joshi, 2013). Loss of crease attachments may cause the skin to rest toward or beyond
the upper eyelid–eyelash margin, which may cause interference with upper outer visual fields. This is
accompanied by elongation of the lower eyelid and descent of the lateral canthus. Orbital septum laxity
causes the fat to herniate anteriorly, leading to formation of prominent eye bags.
184.108.40.206.2. Clinical evaluation
Prior to carrying out any procedure, the surgeon should obtain a good history from the patient. Medical
conditions such as hypothyroidism and bleeding disorders need to be excluded. The upper eyelid margin
usually rests 2 mm below the superior corneal limbus. Ptosis is the condition in which the upper eyelid
drops further down. Ptosis can have a myogenic (affecting the levator or Müller muscle), neurogenic
(myasthenia gravis), or mechanical or traumatic cause. The lower eyelid margin usually rests about
1 mm above the inferior corneal limbus. Visibility of white sclera below the inferior limbus is known as
inferior scleral show. This inferior scleral show is normal in some populations.
Evaluation of the upper eyelid must include evaluation of the eyebrow. Brow ptosis, which may be
compensated by frontalis contraction, should be corrected to achieve repositioning of heavy eyebrow
skin. Ageing also causes the eyebrow fat to descend over the upper lid, giving it a full appearance. Eyelid
skin resection may cause worsening of the brow ptosis because elevation by frontalis muscle is no
longer needed for the visual field. Plastic Surgery Dubai FAQs