Aesthetic Plastic Surgery E-Book


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Aesthetic Plastic Surgery - edited by Sherrell J. Aston, MD, Douglas S. Steinbrech, MD and Jennifer L. Walden, MD - brings you the masterful expertise you need to achieve breathtaking outcomes for every cosmetic surgery procedure, including MACS lift, endoscopic mid and lower face rejuvenation, lid/cheek blending - the tear trough, cohesive gel breast augmentation, lipoabdominoplasty, and many more. A "who's who" of international authorities in plastic surgery explain their signature techniques, giving you all the know-how you need deliver the exceptional results your patients demand. Operative videos on DVD let you observe these techniques being performed in real time; and Expert Consult online access enables you to reference the text, download the images, and watch the videos from any computer.
  • Coverage of hot topics includes MACS lift, endoscopic mid and lower face rejuvenation, lid/cheek blending - the tear trough, the newest rhinoplasty techniques, cohesive gel breast augmentation, fat grafting techniques, details of the latest injectables and fillers, and many other highly sought-after procedures.
  • Operative videos - on DVD and online - let you see how leading experts perform more than 50 important techniques, including extended SMAS face lift, traditional inverted-T breast augmentation, and lipoabdominoplasty.
  • Nearly 1600 full-color photographs and illustrations demonstrate what to look for and what results you will achieve.
  • A consistent, extremely user-friendly organization guides you through history, evaluation, anatomy, technical steps, post-operative care, complications, and pearls and pitfalls for each procedure - giving you all the advice you need to make informed, effective decisions and avoid complications and disappointing results.
  • Expert Consult online access allows you to reference the complete contents, perform rapid searches, download the images, and watch the operative videos from any computer.
Your purchase entitles you to access the web site until the next edition is published, or until the current edition is no longer offered for sale by Elsevier, whichever occurs first. If the next edition is published less than one year after your purchase, you will be entitled to online access for one year from your date of purchase. Elsevier reserves the right to offer a suitable replacement product (such as a downloadable or CD-ROM-based electronic version) should online access to the web site be discontinued.


United States of America
Miastenia gravis
Surgical incision
Breast surgery
Wedge resection
Surgical suture
Incision and drainage
Ptosis (eyelid)
Breast implant
Reconstructive surgery
Nasal septum deviation
Postoperative nausea and vomiting
Submandibular gland
Breast reduction
Caucasian race
Adipose tissue
Weight loss
Soft tissue
Cleft lip and palate
Internal medicine
List of surgical procedures
Medical ultrasonography
Sodium chloride
Plastic surgery
Simplified molecular input line entry specification
General surgery


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Published 14 October 2012
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Aesthetic Plastic Surgery
Expert Consult
Sherrell J. Aston, MD, FACS
Professor of Surgery (Plastic), New York University School of
Medicine, Chairman of the Department of Plastic Surgery,
Manhattan Eye, Ear & Throat Hospital, New York, New York,
Douglas S. Steinbrech, MD, FACS
Clinical Associate Professor of Surgery (Plastic), New York
University School of Medicine, Attending Physician, Plastic
Surgery, Manhattan Eye, Ear & Throat Hospital, New York,
New York, USA
Jennifer L. Walden, MD, FACS
Attending Surgeon, Program Director, Plastic Surgery,
Manhattan Eye, Ear & Throat Hospital, New York, New York,
S a u n d e r sTable of Contents
Instructions for online access
Cover image
Title page
List of Contributors
Section 1: Office organization
Chapter 1: Office practice of plastic surgery
Part 1: Introduction of the practice needs
Part 2: Marketing and practice enhancement
Chapter 2: Clinical photography for the aesthetic patient
Breast images
Body contouring views
Integrity in photography
The future of clinical photography
Section 2: Anesthesia
Chapter 3: Anesthesia in aesthetic surgery
History of ambulatory anesthesia
Preoperative evaluation – patient safety
Preoperative medications
Methods of anesthesia
Office-based anesthesia
Intraoperative considerations
Postoperative considerations
ComplicationsChapter 4: Postoperative nausea and vomiting
The “big little problem”
Risk factors for PONV
Prophylactic treatment
Common medications
Ineffective medications
Non-medical interventions
Intractable nausea and vomiting
Post-discharge nausea and vomiting
Chapter 5: Patient safety in aesthetic surgery
The process of patient safety
How to create a culture of safety and quality (steps you do with your staff)
Specific “problematic” topics in patient safety
Section 3: Facelift
Chapter 6: Facelift anatomy, SMAS, retaining ligaments and facial
Functional evolution of the face
Regions of the face
Layers of the face
Anatomy over the cavities in the skeleton
Anatomy and aging of the face
Application of anatomy to surgical technique
Chapter 7: Facelift with SMAS technique and FAME
Physical evaluation
Technical steps
Postoperative care
Chapter 8: The SMAS facelift – restoring facial shape in facelifting
Physical evaluation – patient planning
Anatomic considerations
Extended SMAS technique
SMAS elevationPostoperative care
Chapter 9: Short scar facelift
Physical evaluation
Technical steps
Postoperative care
Complications of the short scar facelift
Chapter 10: Foundation facelift
Patient evaluation
Technical steps
Postoperative care
Chapter 11: The “High SMAS” facelift technique
Physical evaluation
Technical steps
Postoperative care
Chapter 12: MACS facelift
Introduction/key points
Physical evaluation
Technical steps
Postoperative care
Chapter 13: The multi-vectored rhytidoplasty
Chapter 14: The male facelift
Physical evaluation
Technical stepsPostoperative care
Chapter 15: Endoscopic mid and lower face rejuvenation
Physical evaluation
Technical steps
Postoperative care
Chapter 16: Endoscopic facial rejuvenation
Physical evaluation
Technical steps
Postoperative care
Clinical case example
Chapter 17: Facial rejuvenation in non-Caucasians
Anatomy and physiology of aging
Aging in the African-American and Hispanic
Facial rejuvenation
Chapter 18: Aesthetic facial microsurgery
Physical evaluation
Technical steps
Postoperative care
Chapter 19: Midface lift
Physical evaluation
Technical steps
Postoperative careComplications
Section 4: The neck
Chapter 20: Deep plane procedures in the neck
Physical evaluation
Technical steps
Postoperative care
Chapter 21: Treatment of the male neck
Physical evaluation
Technical steps
Postoperative care
Chapter 22: Managing submandibular glands
Physical evaluation
Technical steps
Postoperative care
Section 5: Browlift
Chapter 23: Non-endoscopic limited incision browlift
Physical evaluation
Technical steps
Postoperative care
Chapter 24: Coronal browlift
Physical evaluation
Technical steps
Postoperative careComplications
Chapter 25: Endoscopic browlift with internal fixation
Physical evaluation
Technical steps
Postoperative care
Chapter 26: Transblepharoplasty browlift
Physical evaluation
Technical steps
Postoperative care
Section 6: Suture suspension
Chapter 27: Suture suspension for face and neck
Physical evaluation
Technical steps
Postoperative care
Chapter 28: Suture suspension for brow and upper face
Physical evaluation
Technical steps
Postoperative care
Section 7: Blepharoplasty
Chapter 29: Conventional upper and lower blepharoplasty
Physical examination
Technical steps
Postoperative careComplications
Chapter 30: Lateral canthal suspension techniques
Physical evaluation
Technical steps
Postoperative care
Chapter 31: Lid–cheek blending: the tear trough deformity
Physical evaluation
Technical steps
Postoperative care
Chapter 32: Tarsal strip canthoplasty
Physical evaluation
Technical steps
Postoperative care
Chapter 33: Blepharoplasty in the East Asian patient
The history of Asian periorbital surgery
Anatomy and physical evaluation
Technical steps
Postoperative care
Chapter 34: Treatment of blepharoplasty complications
Complications in the early postoperative period (1st week)
Complications in the intermediate post-operative period (1st–6th week)
Complications in the late postoperative period (7th week and beyond)
Section 8: Malar, chin and mandibular contouring
Chapter 35: Autologous contouring the lower faceHistory
Physical evaluation
Technical steps
Postoperative care
Chapter 36: Alloplastic chin augmentation
Physical evaluation
Technical steps
Postoperative care
Section 9: Rhinoplasty
Chapter 37: Primary closed rhinoplasty
Physical evaluation
Technical steps
Postoperative care
Chapter 38: Primary open rhinoplasty
Physical evaluation
Technical steps
Postoperative care
Chapter 39: Secondary rhinoplasty
Patient evaluation
Technical steps
Postoperative care
Chapter 40: Nasal tip grafting with an “anatomic tip graft” and sizersHistory
Physical evaluation
Technical steps
Postoperative care
Chapter 41: Anatomic approach for tip problems
Preoperative evaluation
Technical steps
Postoperative care
Chapter 42: Correction of the deviated septum
Physical evaluation
Technical steps
Postoperative care
Chapter 43: The ethnic rhinoplasty
Middle Eastern
Chapter 44: The Asian rhinoplasty
Physical evaluation
Technical steps
Postoperative care
Chapter 45: Correcting the cleft lip nose
Physical evaluation
Technical stepsPostoperative care
Section 10: Ear
Chapter 46: Primary otoplasty and reconstruction
Physical evaluation
Technical steps
Postoperative care
Section 11: The breast
Chapter 47: Traditional inverted-T breast reduction
History and introduction
Physical evaluation
Technical steps
Postoperative care
Chapter 48: Mastopexy with and without augmentation
Physical evaluation
Technical steps
Preoperative assessment
Postoperative care
Chapter 49: Pitanguy breast reduction
Physical evaluation
The classic Pitanguy breast reduction technique
The rhomboid Pitanguy breast reduction technique
Postoperative care
Chapter 50: Medial pedicle vertical mammaplasty
HistoryPhysical evaluation
Technical steps
Postoperative care
Chapter 51: Periareolar Benelli mastopexy and reduction: The “Round
Physical evaluation
Technical steps
Chapter 52: Breast implants: background, safety and general
History/implant development
Safety and efficacy
Physical evaluation
Chapter 53: Breast augmentation
Physical evaluation
Technical steps
Postoperative care
Chapter 54: The dual plane approach to breast augmentation
Physical evaluation
Technical steps
Postoperative care
Chapter 55: Cohesive gel breast augmentationHistory
Physical evaluation
Technical steps
Postoperative care
Patient examples
Chapter 56: Difficult breast augmentations
Tuberous breast deformity
Anterior thoracic hypoplasia
Poland’s syndrome
Chapter 57: Breast reconstruction
Physical evaluation
Technical steps
Postoperative care
Chapter 58: Nipple–areola reconstruction
Physical evaluation
Technical steps
Postoperative care
Section 12: Body contouring/bariatric massive weight loss
Chapter 59: Pure aspiration lipoplasty
Physical evaluation
Technical steps
Postoperative care
Chapter 60: Complications and corrections of lipoplasty
Local complications
Chapter 61: New concepts in fat grafting
Histology of the fat tissue
Technical steps
Histological evaluation
Chapter 62: Lipoabdominoplasty: Saldanha’s technique
Physical evaluation
Technical steps
Postoperative care
Chapter 63: Lipoabdominoplasty: Advanced techniques and technologies
Safety concerns over combining lipoplasty and excisional surgery
Innovations in abdominoplasty
VASER® ultrasonic lipoplasty combined with excision
Ultrasonic cutting devices
Technical considerations for Ethicon EndoSurgery Synergy® ultrasonic
scalpel in lipoabdominoplasty
Steps for lipoabdominoplasty
Chapter 64: Non-surgical ultrasonic lipoplasty
Physical evaluation
Technical steps
Postoperative care
Aesthetic results
Chapter 65: Ultrasound assisted liposuctionHistory
Physical evaluation
Technical steps
Postoperative care
Chapter 66: Abdominoplasty techniques
Physical evaluation
Anatomy of the abdominal wall
Technical steps
Postoperative care
Chapter 67: Brachioplasty
Physical evaluation
Technical steps
The operation
Postoperative care
Chapter 68: Belt lipectomy: Lower body lift
Physical evaluation
Technical steps
Postoperative care
Chapter 69: High lateral tension abdominoplasty
Physical evaluation
Technical steps
Postoperative care
Chapter 70: Gluteal augmentation
HistoryPhysical evaluation
Technical steps
Postoperative care
Section 13: Skin and facial resurfacing
Chapter 71: Botox® for face, neck and brow
Physical evaluation
Technical steps
Post-treatment care
Chapter 72: Lip augmentation
Physical evaluation
Anatomy and architecture of the lip
Technical steps
Postoperative care
Chapter 73: Structural fat augmentation of the face and hands
Technical steps
Postoperative care
Chapter 74: Hyaluronic acid injectable filler
Physical evaluation
Technical steps
Postoperative care
Chapter 75: Non-hyaluronic acid fillers for facial augmentation
Classification of fillers
Physical evaluationTechnical steps
Postoperative care
Chapter 76: Laser resurfacing
Physical evaluation
Technical steps
Postoperative care
Chapter 77: Fractional resurfacing
Physical evaluation
Anatomy for procedure
Technical steps
Postoperative care
Chapter 78: Total facial alloplastic augmentation
Historical background
The evaluation
Applied anatomy for total alloplastic facial augmentation
Technical steps of alloplastic facial augmentation
Postoperative care
Chapter 79: Chemical peels and dermabrasion
Physical evaluation
Technical steps
Postoperative care
SAUNDERS is an imprint of Elsevier Limited
© 2009, Elsevier Limited. All rights reserved.
First published 2009
© Robert S. Flowers – Chapter 33 artwork
The right of Sherrell J Aston, Douglas Steinbrech and Jennifer Walden to be
identi, ed as author/s of this work has been asserted by him/her/them in
accordance with the Copyright, Designs and Patents Act 1988.
No part of this publication may be reproduced or transmitted in any form or
by any means, electronic or mechanical, including photocopying, recording, or any
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publisher. Permissions may be sought directly from Elsevier’s Rights Department:
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ISBN: 978-0-7020-3168-7
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Medical knowledge is constantly changing. Standard safety precautions must be
followed, but as new research and clinical experience broaden our knowledge,
changes in treatment and drug therapy may become necessary or appropriate.
Readers are advised to check the most current product information provided by the
manufacturer of each drug to be administered to verify the recommended dose, the
method and duration of administration, and contraindications. It is the
responsibility of the practitioner, relying on experience and knowledge of the
patient, to determine dosages and the best treatment for each individual patient.
Neither the Publisher nor the author assume any liability for any injury and/or
damage to persons or property arising from this publication.
The Publisher
Printed in ChinaLast digit is the print number: 9 8 7 6 5 4 3 2 1 )

Thomas D. Rees, MD, FACS
At last, this book makes available a single volume text of aesthetic surgery
that is truly of the 21st century that not only presents each subject in an organized
and very readable format, but also provides for continuous, ongoing updating
through the electronic miracles of the internet and the computer so that the reader
does not have to wait for a period of years for another edition to keep current on
any given topic by which time the rst edition may be well out of date and behind
the curve on new techniques and information.
The availability of DVDs made in real time of actual surgical procedures, and
videos add enormously to the appeal of this book. In the past, the best we could do
to make the contents, both verbal and visual of the symposia that Dr. Aston and I
put together was to result in a monograph of the proceedings and to make
available tapes and DVDs of the operations performed in conjunction with the
meetings; however, these were separate issues and not always coordinated to
represent the e orts of the faculties drawn from experts from all over the world.
Monographs evolving from meetings and symposia are di cult to bring to
fruition. Faculty members are usually very busy professionals who resent giving
the time to prepare their presentations in monograph form, and it is di cult and
often presumptuous for the editors to rework the manuscripts to arrive at a
common format. The contributing authors to this book were challenged by the
continuous updating features as well as the accompanying DVDs and videos which
really made their writing e orts live almost in real time, and avoided the often
odious and unpopular task of having to rewrite their chapters in a few years time
for yet another edition.
I found the uniform format of each chapter in this volume to be most
appealing and reader friendly, especially the absence of redundancy, i.e. history
and personal philosophy. It is di cult to teach aesthetic surgery only by the
written word. Aesthetic surgery expertise only comes with hands on experience.
“Aesthetic Plastic Surgery” comes as close to reproducing an actual operating
room environment as one can expect. At the very least the book is a practical
companion to the real thing.@
For the past twenty-nine years Dr. Thomas D. Rees and I co-chaired the
Manhattan Eye, Ear & Throat Hospital Aesthetic Surgery Symposium, which
brought together a multidisciplinary faculty of experts in just about every facet of
aesthetic surgery. Attendees and patients from around the world have bene ted
from the carefully prepared presentations of the latest advances and tried and true
aesthetic surgery techniques. The highly organized program format and, for the
most part, rigidly controlled presentation times forced the faculty members to
present ‘just the meat’ of their topic. There was no time for exhaustive historical
reviews or philosophical discussions. The audience over the years has
overwhelmingly given high reviews to this format. Dr. Rees and I discussed on
numerous occasions various ways to harness the tremendous amount of material
presented during these four- or ve-day symposia (i.e. a monograph of the yearly
meeting, videos, CDs or audio tapes). It was not done for various reasons. However,
Dr. Rees did publish three textbooks that achieved worldwide success: (1) Cosmetic
Facial Surgery by Dr. Thomas D. Rees and Dr. Donald Wood-Smith 1973 (2)
Aesthetic Plastic Surgery 1980 to which I was a contributor and (3) Aesthetic
Plastic Surgery, 1994 co-edited by Dr. Thomas D. Rees and Dr. Gregory S.
Shortly after the 2005 MEETH symposium, one of my co-authors/editors Dr.
Douglas S. Steinbrech proposed to me the idea of putting together a textbook based
on the subject matter of the recently concluded meeting. After all, we had covered
just about the entire eld of aesthetic surgery. At rst I was tepid to the idea;
however, two weeks later Dr. Steinbrech showed up at my o ce with an outline for
the book and ideas about how it could be produced e ciently. My associate Dr.
Jennifer L. Walden was enthusiastic about the project and agreed to be one of the
co-authors/editors. After several meetings we agreed on the book content (which
was signi cantly diBerent from the 2005 symposium), book format, style, authors
and ‘nuts and bolts’. That product is what we have here.
Drs. Steinbrech and Walden are wise and capable beyond their years. They are
publishing, lecturing and operating. Most of the good ideas associated with this
project should be credited to them. Dr. Douglas S. Steinbrech is a product of the
New York University general surgery and plastic surgery residency programs. He is
a busy member of the plastic surgery staB at MEETH and Lenox Hill Hospitals and
is a favorite of our plastic surgery residents and fellows in teaching and
demonstrating surgical techniques. Dr. Jennifer L. Walden, a native Texan, trained
in the integrated plastic surgery program at the University of Texas Medical Branch
and came to MEETH as an aesthetic surgery fellow in 2003. In addition to her busy
private practice, she is the Program Director of our resident and fellows’ teaching
program at MEETH and anyone who has ever met her knows she is a natural
This book is a multi-authored single volume text covering most areas of
aesthetic surgery. It is not intended to be an encyclopedia of aesthetic surgery
techniques but a select accumulation of contemporary procedures that are in
frequent use by the authors. The authors are for the most part well known and/or
with considerable experience in their topic. We are indebted to all of the authors as'
they gave of their time and work to make this book a reality. I hope that they will
feel a sense of pride in contributing to this book and sharing their experience and
The chapters in this book were submitted online through a software program
we had designed for this project. The authors con gured their chapters to the
template so as to provide to the reader the core material. The template provided to
the authors stated the need for:
1). Two concise paragraphs about the history surrounding this procedure.
2). Physical evaluation.
3 ) . Three to ve concise paragraphs about the anatomy relevant to this
4). Seven to twelve paragraphs describing the technical steps for this procedure.
5 ) . One paragraph describing the post-operative care associated with this
6). One paragraph describing the complications associated with this procedure
and how you treat them.
7). In bullet form list five Pearls and five Pitfalls.
8). Summarize your procedure in ten to twenty precise steps.
9). List no more than 10 of the most important references.
With the leap forward in internet and computer technology, we have some
exciting new additions to this textbook which include: an on-line virtual
companion textbook with monthly updates of new material, hypertext links that
allow jumping from one topic to another with just a click of the mouse, and a full
complement of DVD and downloadable videos for viewing on a laptop.
We also wanted this book to be analogous to Cameron’s Current Surgical
Therapy for surgery residents, a useful book of pertinent and relevant topics that
could easily be carried in one hand and taken on call or on rounds.
The intended reader is any plastic surgeon interested in aesthetic surgery. We
hope that young surgeons nd it organized so as to provide concise details of the
procedures and techniques contained and to add to their knowledge base. For some
who are in the midst of their training this book may be their rst exposure to some
of the speci c topics; however, we are con dent that more experienced surgeons
will also nd it useful. All surgeons must constantly update their knowledge of
contemporary procedures and strive for improved results. We hope this book helps
with that process.
Sherrell J. Aston, MD, FACS
2009List of Contributors
William P. Adams, Jr., MD
Associate Clinical Professor, Department of Plastic
Surgery, UT Southwestern Medical Center, Dallas, TX, USA
Alexander C. Allori, MD, MPH
Post-Doctoral Research Fellow, Institute of
Reconstructive Plastic Surgery Laboratories, New York
University Medical Center, New York, NY, USA
Al S. Aly, MD
Assistant Professor of Surgery, University of Iowa
College of Medicine, Coralville, IA, USA
Sherrell J. Aston, MD, FACS
Professor of Surgery (Plastic), New York University
School of Medicine, Chairman of the Department of Plastic
Surgery, Manhattan Eye, Ear & Throat Hospital, Past
President, American Society for Aesthetic Plastic Surgery,
New York, NY, USA
Bruce W. Ayers, BA, CCRA
Clinical Research Coordinator, Minimally Invasive
Aesthetics, LLC, Beverly Hills, CA, USA
Daniel C. Baker, MD
Professor of Plastic Surgery, New York University,
Institute of Reconstructive Plastic Surgery, New York, NY,
Thomas J. Baker, MD
Clinical Professor of Plastic Surgery at the University of
Texas Medical Branch, Educational Foundation Professor
for the International Society of Aesthetic Plastic Surgery
(ISAPS), Voluntary Professor of Plastic Surgery, Universityof Miami School of Medicine, Miami, FL, USA
Fritz E. Barton, Jr., MD, FACS
Clinical Professor, Department of Plastic Surgery,
University of Texas Southwestern Medical Center, Past
President of the American Society for Aesthetic Plastic
Surgery, Dallas Plastic Surgery Institute, Dallas Day Surgery
Center, Dallas, TX, USA
Louis C. Benelli, MD
Plastic and Reconstructive Surgery, Department of
Surgery, Bichat Hospital, University of Paris, Paris, France
Thomas M. Biggs, MD
Clinical Profesor of Plastic Surgery, Baylor College of
Medicine, Houston, TX, USA
Michael A. Bogdan, MD
Private Practice, Southlake, TX, USA
Ewaldo Bolivar de Souza Pinto, MD, PhD
Santa Celília University, Santos, São Paulo, Brazil
Fredric S. Brandt, MD
Private Practice Coral Gables, FL and Manhattan, NY,
Principal Investigator, Dermatology Research Institute,
LLC, Coral Gables, FL, USA
Kevin Brenner, MD
Roxbury Clinic and Surgery Center, Beverley Hills, CA,
A. Jay Burns, MD
Clinical Assistant Professor, Department of Plastic
Surgery, University of Texas Southwestern Medical Center,
Dallas, TX, USA
John L. Burns, MDClinical Instructor, Department of Plastic Surgery,
University of Texas Southwestern Medical Center, Dallas,
Steven Byrd, MD
Professor of Plastic Surgery, The University of Texas
Southwestern Medical Center, Chief of Plastic Surgery
Department, Children’s Hospital, Director/Managing
Partner, Dallas Day Surgery Center, Partner, Dallas Plastic
Surgery Institute, Dallas, TX, USA
Claudio Cardoso de Castro, MD
Chief & Professor, Plastic Surgery Service, University of
the State of Rio de Janeiro, Rio de Janeiro, Brazil
Paulo Roberto Gomes Carneiro, MD
Resident Doctor, Dr. Ewaldo Bolivar de Souza Pinto
Plastic Surgery Service, Santos, São Paulo, Brazil
Alex Cazzaniga, BS, MBA
Director of Clinical Research, Dermatology Research
Institute, LLC, Coral Gables, FL, USA
Daniel J. Ceradini, MD
Resident, Department of Plastic Surgery, New York
University Medical Center, New York, NY, USA
Mark A. Checcone, MD
Assistant Professor, Head & Neck Surgery: Division of
Facial Plastic Surgery, Washington University West County
Office, Creve Coeur, MO, USA
Ernest S. Chiu, MD, FACS
Associate Professor of Surgery, Director of Plastic
Surgery Research, Division of Plastic and Reconstructive
Surgery, School of Medicine, Tulane University, New
Orleans, LA, USA
C. Spencer Cochran, MDClinical Assistant Professor, Department of
Otolaryngology-Head & Neck Surgery, University of Texas
Southwestern Medical Center at Dallas Gunter Center for
Aesthetics & Cosmetic Surgery, Dallas, TX, USA
Mark A. Codner, MD
Clinical Assistant Professor, Department of Plastic
Surgery, Emory University, Private Practice, Paces Plastic
Surgery, Atlanta, GA, USA
Sydney R. Coleman, MD
Assistant Clinical Professor, New York University
Medical Center, Director, TriBeCa Plastic Surgery, New
York, NY, USA
Gustavo A. Colon, MD
Clinical Professor, Tulane University, Metairie, LA, USA
Albert E. Cram, MD, FACS
Iowa City Plastic Surgery, Coralville, IA, USA
Court Cutting, MD
Professor of Surgery (Plastic Surgery), New York
University Medical Center, New York, NY, USA
Rollin K. Daniel, MD, FACS
Clinical Professor of Plastic Surgery, University of
California Irvine, Professor of Surgery, McGill University,
Chief of Plastic Surgery, Royal Victoria Hospital, Newport
Beach, CA, USA
Leonora d’Ascensão Mansur, MD
Member of the Brazilian Society of Plastic Surgery, Santa
Helena, MG, Brazil
Wojciech Dec, MD
Resident, Department of Plastic Surgery, New York
University Medical Center, New York, NY, USAJosé Abel de la Peña, MD
Hospital Angeles de las Lomas, Mexico City, Mexico
José Luis Martín del Yerro Coca, MD
Head of the Departament of Plastic, Reconstructive and
Asthetic Surgery, Hospital Quirón, Madrid, Spain
Maurício Doi, MD
Titular member of the Brazilian College of Surgeons,
Associated Aspirant Member of the Brazilian Society of
Plastic Surgery, Resident Doctor, “Dr. Ewaldo Bolivar de
Souza Pinto” Plastic Surgery Service, Unisanta, São Paulo,
Michael Edwards, PhD
Plastic Surgery Insitute of Southern California, Thousand
Oaks, CA, USA
Rodrigo Federico, MD
Resident Doctor, Dr. Ewaldo Bolivar de Souza Pinto
Plastic Surgery Service, Rio de Janeiro, RJ, Brazil
Roberto L. Flores, M.D.
Assistant Professor of Surgery, Riley Hospital for
Children, Indiana Univeristy Medical Center, Indianapolis,
Robert S. Flowers, MD
The Flowers Clinic, Honolulu, HI, USA
Peter Fodor, MD, FACS
Past President, American Society for Aesthetic Plastic
Surgery, Associate Clinical Professor, Dept of Plastic
Surgery, UCLA Medical Center, Los Angeles, CA, USA
Brandon Freeman, MD
Aesthetic Fellow, Department of Plastic Surgery,
University of Texas-Southwestern, Dallas, TX, USAJack A. Friedland, MD, FACS
Associate Professor of Plastic Surgery, Department of
Plastic Surgery, Mayo Medical School, Past President,
American Society for Aesthetic Plastic Surgery, Scottsdale,
Allen Gabriel, MD
Staff Physician, Clinical Research Director, Department
of Plastic Surgery, Loma Linda University School of
Medicine, Loma Linda, CA, USA
Roy G. Geronemus, MD
Clinical Professor of Dermatology, New York University,
Director, Laser & Skin Surgery Center of NY, New York,
Ashkan Ghavami, MD
Private Practice, Beverly Hills, CA, USA
Mary K. Gingrass, MD
Assistant Clinical Professor, Vanderbilt University School
of Medicine, The Plastic Surgery Center of Nashville,
Nashville, TN, USA
Ronald P. Gruber, MD
Clinical Assistant Professor, University of California,
Adjunct Clinical Assistant Professor, Stanford University,
East Bay Aesthetic Plastic Surgery Center, Oakland, CA,
Jack P. Gunter, MD
Clinical Professor, Department of Plastic Surgery &
Clinical Professor, Department of Otorhinolaryngology,
The University of Texas Southwestern Medical Center,
Dallas, TX, USA
Bahman Guyuron, MD, FACS
Kiehn-DesPrez Professor and Chair, Department of
Plastic Surgery, Case Western ReserveUniversity/University Hospitals Case Medical Center,
Lyndhurst, OH, USA
Elizabeth J. Hall-Findlay, MD, FRCSC
Plastic Surgeon, Banff Plastic Surgery, Banff, Alberta,
Haideh Hirmand, MD, FACS
Clinical Assistant Professor of Surgery, Cornell Medical
College, New York, NY, USA
Erik A. Hoy, MD
Resident, Department of Plastic Surgery, Brown
University, Providence, RI, USA
Dennis J. Hurwitz, MD, FACS
Director, Hurwitz Center for Plastic Surgery, Clinical
Professor of Plastic Surgery, University of Pittsburgh,
Pittsburgh, PA, USA
Nicanor G. Isse, MD
The Isse Institute of Cosmetic Surgery, Inc., Newport
Beach, CA, USA
Elizabeth B. Jelks, MD
Department of Ophthalmology, New York University
School of Medicine, New York, NY, USA
Glenn W. Jelks, MD, FACS
Associate Professor of Surgery (Plastic Surgery),
Associate Professor of Ophthalmology, New York
University School of Medicine, New York, NY, USA
Mark Jewell
Past President, American Society for Aesthetic Plastic
Surgery, Assistant Clinical Professor Oregon Health
Science University, Portland, OR, USANolan S. Karp, MD
Associate Professor of Plastic Surgery, New York
University School of Medicine, Chief, Plastic Surgery
Service, Tisch Hospital, New York, NY, USA
Arnold W. Klein, MD
Professor of Medicine and Dermatology, David Geffen
School of Medicine, University of California, Los Angeles,
Los Angeles, CA, USA
Gil Kryger, MD
Kryger Institute of Plastic Surgery, Thousand Oaks, CA,
Val Lambros, MD, FACS
Clinical Instructor in Surgery, University of California,
Irvine, Newport Beach, CA, USA
Walter Lampeter, CSA, RNFA
Surgical Assistant, Department of Plastic Surgery,
Manhattan Eye, Ear & Throat Hospital, New York, NY, USA
Gary J. Lelli, Jr., MD
Assistant Professor of Oculoplastic Surgery, Department
of Ophthalmology, New York Presbyterian Hospital, Weill
Cornell Medical Center, New York, NY, USA
Oren Z. Lerman, MD
Resident, The Institute of Reconstructive Plastic Surgery,
New York University Medical Center, New York, NY, USA
Richard D. Lisman, MD, FACS
Clinical Professor of Ophthalmology, New York
University School of Medicine, Director of Ophthalmic
Plastic Surgery Services, New York University Medical
Center and Manhattan Eye, Ear & Throat Hospital, New
York, NY, USA
Montien Lueprapai, MDPlastic Surgeon, Lerdsin Hospital, Bangkok, Thailand
Vincent P. Marin, MD
Clinical Instructor, Department of Plastic Surgery,
University of Texas Southwestern Medical Center, Dallas,
W. Jason Martin, MD
Director, Aspen Institute of Plastic and Reconstructive
Surgery, Aspen Valley Hospital, Aspen, CO, USA
G. Patrick Maxwell, MD, FACS
Clinical Professor of Surgery, Department Plastic
Surgery, Loma Linda University Medical Center, Loma
Linda, CA, USA
Joseph G. McCarthy, MD
Professor of Surgery (Plastic), Institute of Reconstructive
Plastic Surgery, New York University Medical Center, New
York, NY, USA
Ricardo A. Meade, MD
Clinical Instructor, University of Texas Southwestern
Medical Center, Private Practice, Dallas Plastic Surgery
Institute, Dallas, TX, USA
Bryan Mendelson, FRCSE, FRACS, FACS
President of the International Society of Aesthetic
Plastic Surgery, Toorak, Victoria, Australia
Joseph Michaels, V MD
Body Contouring Fellow, Clinical Professor of Surgery,
Division of Plastic Surgery, University of Pittsburgh Medical
Centre, Pittsburgh, PA, USA
Colin M. Morrison, MSc, FRCS(Plast)
Department of Plastic Surgery, Addenbrooke’s Hospital,
Cambridge University Hospitals NHS Foundation Trust,
Cambridge, UKNewton Moscoe, MD
Private Practice, Austin, TX, USA
Foad Nahai, MD, FACS
Paces Plastic Surgery, Atlanta, GA, USA
Timothy Neavin, MD
Aesthetic Surgery Fellow of Richard Ellenbogen, Los
Angeles, CA, USA
Carlos G.L. Neves, MD
Specialist Member of the Brazilian Society of Plastic
Surgery, SBCP, Titular Member of the Brazilian College of
Surgeons, TCBC, Rio de Janeiro, RJ, Brazil
Michael K. Newman, MD
Clinical Instructor, Department of Plastic Surgery,
Georgetown University Hospital, Washington, DC, USA
Ferdinand A. Ofodile, MD, FACS
Clinical Professor of Surgery, Columbia University, Chief
of Plastic Surgery, Harlem Hospital Center, New York, NY,
Sheldon Opperman, MD
Site Director, Department of Anesthesiology, Manhattan
Eye, Ear & Throat Hospital, New York, NY, USA
Salvatore Pacella, MD, MBA
Attending Surgeon, Division of Plastic Surgery, Scripps
Clinic Medical Group, La Jolla, CA, USA
Keyian Paydar, MD
Resident, Division of Plastic and Reconstructive Surgery,
University of California, Irvine, Irvine, CA, USA
John A. Perrotti, MDClinical Assistant Professor of Surgery, New York
Medical College, Attending Surgeon, Manhattan Eye, Ear &
Throat Hospital, New York, NY, USA
Ivo Pitanguy, MD
Professor of Plastic Surgery, Pontifical Catholic
University of Rio de Janeiro and the Carlos Chagas
Institute of Post-Graduate Medical Studies, Rio de Janeiro,
RJ, Brazil
Gerald H. Pitman, MD
Clinical Professor of Surgery (Plastic Surgery), Institute
for Reconstructive Plastic Surgery, New York University
School of Medicine, New York, NY, USA
Ronaldo Pontes, MD
Chairman of the Clinic, Professor of Surgery, Fluminense
Federal University, Niterói, RJ, Brazil
Henrique N. Radwanski, MD
Assistant Professor of Plastic Surgery, The Pontifical
Catholic University of Rio de Janeiro and the Carlos
Chagas Post-Graduate Medical Institute, Rio de Janeiro, RJ,
Oscar M. Ramirez, MD
Director of Esthetique Internationale, “The Center for
Cosmetic Plastic Surgery Enhancement”, Clinical Assistant
Professor, Plastic Surgery, The Johns Hopkins University,
Timonium, MD, USA
Emily Ridgway
Resident, Harvard Division of Plastic Surgery, Boston,
Rod Rohrich, MD, FACS
Professor and Chairman; Crystal Charity Ball
Distinguished Chair in Plastic Surgery and the Betty and
Warren Chair in Plastic and Reconstructive Surgery,Department of Plastic Surgery, The University of Texas
Southwestern Medical Center, Dallas, TX, USA
David J. Rowe, MD
Assistant Professor of Plastic Surgery, Department of
Plastic Surgery, University Hospitals Case Medical Center,
Cleveland, OH, USA
Gregory L. Ruff, MD
Private Practice, Chapel Hill, NC, USA
Pierre Saadeh, MD
Program Director, Plastic Surgery, New York University
School of Medicine, New York, NY, USA
Alesia P. Saboeiro, MD
Private Practice, Tribeca Plastic Surgery, New York, NY,
Osvaldo Saldanha, MD
Head of Plastic Surgery Service – UNISANTA, Santos,
São Paulo, Brazil
Narayana Pauline Serpa, MD
Clinica Fluminense, Rio de Janeiro, RJ, Brazil
David Michael Shafer, MD
Aesthetic Surgery Fellow, Manhattan Eye, Ear & Throat
Hospital, New York, NY, USA
John W. Siebert, MD
Professor of Surgery, University of Wisconsin School of
Medicine Madison, WI, Adjunct Professor (Plastic Surgery),
New York University Medical Center, New York, NY, USA
Scott Lawrence Spear, MD
Chairman and Professor, Deparment of Plastic Surgery,
Georgetown Universtiy Hospital, Washington, DC, USADouglas S. Steinbrech, MD, FACS
Clinical Associate Professor of Surgery (Plastic), New
York University School of Medicine, Attending Physician,
Plastic Surgery, Manhattan Eye, Ear & Throat Hospital,
New York, NY, USA
David Stoker, MD, FACS
Clinical Assistant Professor of Surgery, Division of
Plastic and Reconstructive Surgery, Keck School of
Medicine of the University of Southern California, Marina
del Rey, CA, USA
James M. Stuzin, MD
Assistant Professor of Surgery, Department of Plastic
Surgery, University of Miami, School of Medicine, Miami,
Sean A. Sukal, MD, PhD
Director, Sukal Skin Institute, Boca Raton, FL, USA
Patrick K. Sullivan, MD
Associate Professor, Plastic Surgery, Brown University,
Providence, RI, USA
Nicolas Tabbal, MD, FACS
Clinical Associate Professor of Surgery, Institute for
Reconstructive Plastic Surgery, New York University School
of Medicine, New York, NY, USA
Michèle Tardif
Chirurgie plastique, Hôpital Maisonneuve-Rosemont,
Montréal, QC, Canada
Steven Teitelbaum, MD, FACS
Assistant Clinical Professor of Plastic Surgery, David
Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Oren M. Tepper, MD
Resident, The Institute of Reconstructive Plastic Surgery,New York University Medical Center, New York, NY, USA
Edward O. Terino, MD
Medical Director, Plastic Surgery Institute of Southern
California, Thousand Oaks, CA, USA
Charles H. Thorne, MD
Associate Attending Surgeon, Manhattan Eye, Ear &
Throat Hospital, Associate Professor of Plastic Surgery,
New York University School of Medicine, New York, NY,
Patrick L. Tonnard, MD
Coupure Centrum Voor Plastische Chirurgie, Ghent,
Dean M. Toriumi, MD
Professor, Division of Facial Plastic and Reconstructive
Surgery, Department of Otolaryngology – Head and Neck
Surgery, University of Illinois at Chicago, Chicago, IL, USA
Andrew P. Trussler, MD
Assistant Professor, Department of Plastic Surgery,
University of Texas – Southwestern, Dallas, TX, USA
Andrey Van Ass Malheiros, MD
Resident Doctor, Dr. Ewaldo Bolivar de Souza Pinto
Plastic Surgery Service, Rio de Janeiro, RJ, Brazil
Alexis M. Verpaele, MD
Coupure Centrum Voor Plastische Chirurgie, Ghent,
Jennifer Walden, MD, FACS
Attending Surgeon and Program Director, Plastic Surgery,
Manhattan Eye, Ear & Throat Hospital, New York, NY, USA
Richard Warren, MD, FRCS(C)Clinical Professor, Division of Plastic Surgery, University
of British Columbia, Vancouver, BC, Canada
Stephen M. Warren, MD
Associate Professor of Surgery (Plastic), Institute of
Reconstructive Plastic Surgery, New York University
Medical Center, New York, NY, USA
Adam Bryce Weinfeld, MD
Attending Plastic Surgeon, University Medical Center,
Brackenridge Dell Children’s Medical Center of Central
Texas, Temple, TX, USA
Michael Zelman
Anesthesiologist, Lennox Hill Anesthesiology, New York,
D e d i c a t i o n
This book is dedicated to my wife Mu e, whose patience and support are
endless, and our daughters Ashleigh and Bracie as most of my time for this project
was stolen from them on nights and weekends.
Sherrell J. Aston, MD, FACS
For Edward and Narge, Steinbrech and Jeffrey Sharp for all their support.
Douglas S. Steinbrech, MD, FACS
I dedicate this book to my parents, Dr. Richard and Shirley Walden, who have
never once questioned my aspirations and dreams.
Jennifer L. Walden, MD, FACS%
We would like to acknowledge and thank Dr. Thomas D. Rees for writing the
Foreword of this book. He set the standards for teaching aesthetic surgery.
The current generation of aesthetic surgeons and those to follow are indebted to
him. We are honored that he wrote the first page of this book.
We would like to acknowledge Mr. Walter Lampeter, Certi ed Surgical
Assistant, for his untiring e ort as the technical editor of this book. When this project
was in the early stages of development Dr. Steinbrech, Dr. Walden and I knew that
our schedules would not permit either of us to be the point person as the day to day
recipient of chapters submitted online. Needless to say most chapters required
signi cant e ort to process, coordinate the parts and then pass them online to us for
the initial edits before being sent to Elsevier. Walter was essential to getting this
book published. We will always be grateful for his hard work, easy going personality
and coolness under pressure.
We are also grateful to Sue Hodgson Publishing Director at Elsevier who was so
helpful in making this book come to fruition. Her advice and guidance was superb.
Her willingness to make this book be the way we wanted was inspiring and much
appreciated. Elsevier is fortunate to have Sue represent their plastic surgery books
Sherrell J. Aston, MD, FACS
I would like to acknowledge my parents, Edward and Narge Steinbrech, and my
entire family for their un- inching support over the years of my schooling and
I also must pay tribute to mentors in- uential in my academic development: Dr.
Frank C. Spencer, NYU, Chief Emeritus of the Department of General Surgery, Dr.
Steven A. Rosenberg, Chief of the Surgery Branch of the National Cancer Institute at
the National Institutes of Health, and Dr. Michael T. Longaker. They have all
supported and inspired me throughout my training and research.
Also, I have to thank Dr. Joseph G. McCarthy, my Chief at the NYU Institute of
Reconstructive Plastic Surgery, who embodies the true spirit of the academic leader
and has always said, “for a surgeon: research and writing only happens at night and
on weekends.” Once again, he was correct.
I am deeply grateful to Mr. Je rey W. Sharp and Dr. W. Rodney Sharp, whose
words of encouragement have boosted this project forward from its very inception.
Also, I am indebted to colleague and good friend, Dr. Pierre B. Saadeh, who must be
given credit for being particularly instrumental in the genesis of this textbook.
And, of course, special thanks are due to the indefatigable Dr. Sherrell J. Aston,
whose talent may only be equalled by his sheer drive, and who didn’t need to edit
another textbook, but took on this challenge with unbridled enthusiasm and stalwart
Douglas S. Steinbrech, MD, FACS
I would like to acknowledge my mentors who have helped me to become the
surgeon that I am today. To Dr. Linda Phillips, who has served as a role model and
mentor for me for the past twelve years; someone who makes being the chairman of"
the American Board of Plastic Surgery, dean of the medical school, chief of plastic
surgery, and mother of four children look easy.
And nally, Dr. Sherrell Aston, my senior associate and co-editor of this
textbook; he is a gifted surgeon who has been an unwavering source of support and
inspiration in my fellowship and private practice of aesthetic plastic surgery in New
York. I would not be here today were it not for these people.
Jennifer L. Walden, MD, FACS
*******General Acknowledgement**********
Dr. Aston, Steinbrech, and Walden would also like to thank all of the authors of
this textbook for devoting hundreds of hours toward the preparation of their
chapters. The quality of this textbook is directly related to their experienced insight
and hard work.Section 1
Office organization'

Office practice of plastic surgery
Gustavo A. Colon
Part 1: Introduction of the practice needs
Initial steps
Before establishing a practice, you have to decide where it is that you want to live.
However, deciding on an urban, suburban, or rural area may be somewhat
di cult. The rst thing that one has to evaluate is the number of plastic surgeons
who are practicing within the community. It would be very di cult to establish
yourself in an area where there are multiple plastic surgeons who already have
appropriate referral sources, and it is best to look for a community in which there is
a de nite need for a plastic surgeon, either with a group or in solo practice or even
in academic medicine.
The location
Before you nish training, you should investigate the area in which you are
interested. Look at demographics, population growths, median incomes, growth of
the city and/or community, and evaluate the statistics of the metropolitan areas,
particularly where there is the greatest density of plastic surgeons. Speak to plastic
surgeons in the community to get their opinions, concepts and ideas, which
sometimes may be negative since they may not welcome a new, young,
welltrained plastic surgeon. Our sources for potential practice locales are the American
Medical Association, which o ers a market area pro le (MAPS) that includes
information about community demographics, or the local Chamber of Commerce in
the area in which you are considering relocating. The hospitals in the area can be
of great assistance in getting and interpreting whatever data you may need, for
example, hospitals will tell you the number of plastic surgeons on sta , then you
can evaluate which plastic surgeons are servicing that health community, what the
referral sources are and whether there is a need for a younger plastic surgeon.
The practice
The next decision you have to make is the type of practice that you would like to
join, a multi-specialty group with a large number of di erent types of specialties,
i.e. a Mayo Clinic or Cleveland Clinic type of setup, a group practice of plastic
surgeons practicing together. Alternatively, you may share space with another
plastic surgeon, to help him or her decrease their overheads and at the same time
have full advantage of their established plastic surgical sta . You may prefer an
academic position, in a teaching institution or a sponsored or salaried position in a
hospital that allows you a private practice, but where you are dependent upon
referrals from and to that speci c entity. Finally, there is the independent model or
solo practice.


Let’s talk primarily about solo or group practices. Group practices, of course,
provide economic security and a source of patients. All usually include built-in
coverage for vacations and weekends, hopefully a congenial atmosphere of other
plastic surgeons with whom you can discuss cases with access to appropriate
equipment, and opportunities to pursue the area of specialization in which you are
interested. Also, by practicing in an established geographic area with an
established group you have instant name recognition.
However, group practice may be somewhat di cult because there may be
frustration at the loss of autonomy, dissatisfaction with the inability to make
independent decisions, con4icts with associates and di culty with nancial
matters, which may not have been properly addressed during the initial interviews
and contract. Other certain points need to be established prior to going into a
group practice:
• Make sure that the philosophy of the group is the same as your philosophy, not
only in the ethics of practice, but also in appropriate nancial sharing of costs,
billing, and remuneration.
• Meet all the doctors you are working with and make sure that there is an aura
of compatibility; understand what di erences and competition may exist
within the practice.
• Speak to the youngest plastic surgeon or the last one who joined the group
because they will be able to tell you what their frustrations and/or bene ts are
of being in a group practice.
• Check the reputation of the group practice within the community, that the
practice is viable, growing and that it does need another plastic surgeon.
• Make sure that your spouse or signi cant other will be compatible with the
spouses or signi cant others of the group. If the spouses are working in the
same group practice, make sure that they will not be the controllers of your
practice, otherwise this may cause a difficult professional and social situation.
• All written contracts should be reviewed by an attorney and/or consultant who
is looking after your bene t, not theirs. Never start work without a written
contract, have it reviewed, make sure that it ts your philosophy of practice
and that it is beneficial to both parties; it must be a win–win situation.
You must have advisors to help you manage a successful practice. First of all you
need to have an accountant or a CPA who will handle all your nancial needs, help
you set up initial o ce accounting systems and handle tax matters, prepare
monthly income and expense statements and counsel you on investments. You will
need an attorney who will review all your contracts, a banker who will loan or give
you the credit line to start out initially, an insurance broker for liability needs and a
real-estate broker to nd you a new home or help you locate an o ce if you are
going into solo practice. Perhaps ultimately you might need a management
consultant to evaluate and manage your practice, but not initially. Management
consultants usually come in after an established practice needs tweaking or perhaps
some rearranging.
Solo practice

If you are starting out in an independent practice, you will need to obtain the
appropriate state occupational licenses and you really need to apply early for
privileges at the speci c hospitals where you wish to practice. Once you have
decided on the community in which you wish to practice, you need to look for
o ce space. You have to decide whether you want to purchase or lease. Initially I
think it is easier to lease than to purchase, to avoid excessive overheads. Find a
house in a community which you think would be adequate for your family; your
spouse and your children will follow you wherever you go, but choose a community
which will be adaptable and comfortable for them.
Once you decide on the area in which you wish to practice, you will have to
begin to draw up an income and expenditure projection so that you can borrow the
monies that you will need to start a practice and use as income for the initial
months. Apply to the appropriate managed care programs and/or insurances which
service the community, arrange for your liability, o ce insurance, o ce overhead,
o ce liability, business interruption insurance, employee delity bonds, major
medical insurance for you and your employees, disability, life and ultimately
automobile insurance. Acquire an answering service, get a beeper, cell phone, print
business cards and announcements, and arrange for accepting credit cards within
your practice. From a social, professional standpoint, you need to meet referring
physicians and interview prospective janitorial services and o ce personnel. Study
your CPT codes and use appropriate billing of your services for the area.
Office space
There are certain rules for nding and designing your o ce space. You have to
maintain privacy according to the HIPPA regulations. There has to be absolute
privacy for the patients coming into your o ce. The waiting room has to be
comfortable, and sizable to allow patients to sit comfortably. The secretarial sta
should have an appropriate view of the waiting room to be able to welcome the
patients, as well as keep an eye out as to what is going on in the waiting area. They
should also be able to prevent any undue occurrences or pilfering of the material
and/or furniture in the waiting area. Remember, the waiting room is the rst
contact that the patient has with your office. Your décor should make the statement
that you want to make in your practice. Use the décor that is appropriate for your
practice and which re4ects you. Exam rooms should be practical, clinical, usable
and comfortable for both the doctor and the patient. Please remember that rst
impressions are made in seven seconds, and you don’t get a second chance so the
first impression of your office should be one that gives them a sense of trust.
Supplies and equipment are something that will be di cult to evaluate. I think
that all of us need to purchase the appropriate supplies for o ce management. You
do not need to buy every piece of equipment that you see at a meeting or exhibit,
but have appropriate equipment to handle any type of emergency. I would
recommend that every o ce have an emergency CPR kit, computerize your o ce
early. It is much easier to run a practice with computers. There are enough
computer programs which are directed speci cally to plastic surgery to make your
life and that of your staff very easy, and in some instances paperless.
How much money do you need to establish a practice? Once again, it depends on

your personal style, how extravagant do you want to be and how much you want
to spend in your practice; middle of the road is always the best approach. As
previously stated, you need to borrow money in order to support yourself for
several months, so you have to establish a credit line and relationship with a bank.
Will you get a better deal because you are a doctor? The answer is “no”. In the
past, doctors were favored banking customers and could get loans at low interest
with real 4exible terms. I do not think that is the case at the present time. You will
get a credit line knowing full well that the bank hopes that you will be a long-term
customer. When borrowing money, certain things are required: past tax returns, a
pro forma, which is a statement that projects the sources of income for the
immediate future and that you will have an income to repay this loan over a period
of time. At the same time, it will project your fees for expected surgical procedures,
and the amount of income you expect to have over the next several months. They
will also ask you for your estimated expenses, a nancial statement and so bear in
mind the ve Cs which a bank will require: collateral for the loan, your capacity to
pay the loan, capital that you have available, your character and any conditions
for the loan.
Once you have established a practice and have opened your o ce, initially it is
better that you keep it small if you are in solo practice. At the same time, if you are
in a group practice it might be better to maintain a low professional pro le rather
than trying to go out and “corner the market” because this may create antagonism
among your older colleagues who think you are nothing but a young upstart
without experience, and they may not back you in di cult situations. Keep your
sta small, good, reliable and make sure that they follow your principles and
philosophy of practice. As far as your equipment is concerned, buy what you need,
keep your office open at appropriate hours and be available.
There are three things that make a doctor successful: ability, a ordability, but
above all availability. However, make sure that you charge patients for your
services. Bill promptly; remember cheaper is not better. Do not practice to make
money, just be a good physician and appropriate nancial remunerations will
follow. Do not commit fraud, do not lie to insurance companies, be honest about
who you are and what you do and in your billing, and you will have a long
successful practice. Do not do unnecessary surgery. Be honest to your patients and
yourself, particularly when you are beginning; say that you are still learning but
that you are a well-trained surgeon and that you can handle the complexities of
any surgical procedure for which you were trained. Read and understand all
managed care contracts. Do not negotiate with your patients and remember that
maintaining a practice is dependent upon three things: reputation, reputation and
reputation. Maintenance of the practice will depend on physician referrals, patient
referrals, area of specialization, good results and constant monitoring. Do not
create gimmicks to attract patients; do your job well enough to be an expert and
the patients will come.
The staff
Employee empowerment

Your sta should generate enthusiasm, teamwork and pride in their work, but with
responsibility to you and your structured organization. The patient will choose you
for surgery if you can accommodate them surgically and nancially, and if they
like you and your sta . Your sta must meet the patient’s needs by customization
and individualization of care and services. The sta should follow this simple
1. Do the little things right.
2. Go the extra mile.
3. Always exceed the customer’s expectations.
The aim of your sta is to encourage prospective patients to convert from
might to want to will, and to create a service that will expand your market share.
Therefore, when trying to bring a new plastic surgical service to the community,
the goal is market expansion and revenue increase.
Business development of plastic surgical services
You need to use business tactics to accomplish the expansion objectives by:
1. Developing a new product or service (plastic surgery).
2. Raising or lowering prices to make financing more available.
3. Creating a new promotion with advertising or internal marketing.
4. Establishing a definite public relations effort through your staff.
5. Developing new channels of distribution through your own patient population
or other services (i.e. skincare line of products).
6. Establishing plans and timelines to evaluate and track the service.
Hence you have to develop a situation analysis in which you:
• Analyze market trends and the needs of the service being introduced.
• Determine the domestic, local, and international needs of the service.
• Study the implications of new trends. (Is this something that is going to last or is
it something that is going to come and go?)
• Weigh the nancial opportunities for this product or service. (Is it a product or
service that only you are going to deliver or is the product or service so
available that it is diluted?)
• Evaluate the competition. What are they doing and how are they marketing?
• Determine the risks of your endeavor.
The service has to be visible, be convenient, and it must have a simple
organizational layout with friendly and professional assistance. It must be priced
fairly, be consistent and constant. Remember that in plastic surgery it is not a
product that you are selling, it is a biological technical service, which is not
returnable and not guaranteed with many variables. Besides product, the other
three “Ps” of plastic surgery are:
• Positioning, which is dependent on your reputation.
• Price has never been a factor, because the consumer may equate expensive with

better and cheaper with inexperience.
• Promotion is the only element that can be used to expose the public to plastic
surgery. Maintaining a practice depends on three things: reputation, reputation
and reputation.
So, be caring, concerned and available at all times for your patients. You want
to be the plastic surgeon who will be in your prospective patient’s mind when and
if they change the might to want to will. It takes about ten years to establish a good
elective type practice, but it is good results and reputation that keep you
Tips for a successful practice
1. All patients should be appropriately billed; patients should know exactly what
kind of service they are getting even if the service is free. When you do not
charge, give the patient a bill with the appropriate discount so that they know
how much you have discounted or not charged for the operative procedure.
2. Treat patients very well and be their con dant and trustful physician, but do
not make patients friends; maintain a social distance from your patient
population. This does not mean that your friends cannot be patients, but do
not try to socialize within your patient population.
3. Patients will sue you for three things: because they do not like you, they do not
like the bill and they do not like the surgery, or a combination of all three. So
do not be surprised; it happens to all of us, just document accordingly.
4. Do not fool around with patients, you can lose your license and it certainly is
not appropriate ethically or morally.
5. The o ce is like a confessional; nothing is ever discussed outside the o ce by
you or your staff.
6 . Your specialty is plastic and reconstructive surgery, not cosmetic surgery,
which is just part of our specialty.
7 . Don’t take yourself too seriously. Do not let life pass you by. Nobody is
indispensable and plastic surgery is what you do for a living; it is not what you
live for.
Style, substance and communication
What really attracts and maintains patients in your practice may not only be your
surgical expertise, but your ability to communicate. So when you communicate,
you have to project likeability, integrity, competence and sincerity. In other words,
the patient has to like you to ultimately trust you for surgery.
Improve your communication skills by the following:
1. Listen to the patient, attentively.
2. Make eye contact with the patient and sit down, be at their eye level to speak
to them.
3. Be positive in how you talk, but always speak the truth. Do not get defensive;
once you get defensive with a patient, whether it is preoperative or
postoperative, you are going to get into the guilt, hostility, arrogance cycle.

4 . Give useful information, be honest, concise, positive, truthful, reliable,
memorable but factual and keep it simple.
5 . Your demeanor should be pleasant and sincere; smile appropriately and
genuinely with patients.
6. Have a friendly, open face, no frown or distant stare.
7 . Be interested in what the patient’s problem is. You should absolutely give
them your full attention. Do not be in a rush to leave. Make them feel that in
the few minutes that you are there, you have no other interests.
8 . Your body language should be cordial with appropriate gestures. In
consultations, sit, touch the patient with professional concern, always make
the e ort to make contact with the patient physically as well as emotionally
and mentally.
9 . Dress neatly and always talk calmly to the patient, in a warm distinct,
deliberate tone with normal pitch and rate, using understandable language.
Never be condescending or arrogant; remember communication is an
intellectual act of love.
Part 2: Marketing and practice enhancement
How I market an aesthetic practice
Marketing may enhance your practice, but it is reputation that makes the
di erence. In managing my practice, one of the things that I put rst is my
personal family life. I try always to remember that plastic surgery is a profession,
not a lifestyle, and that you have to put things in perspective with de nite
priorities. At the same time, you have to be yourself and not try to imitate or be
any other plastic surgeon. The priorities are basically simple: if you are satis ed
professionally, growing and nancially stable, doing what you like to do, why
Several years ago, I began to evaluate my practice, how it had grown, and to
look at the external factors and inherent factors that had pushed my practice to the
point where I was. I found several things. I found out from questionnaires and
focus groups among the patients and sta that I was a personable, caring
physician, and a known factor in the plastic surgical community with a reputation,
but that I was a bit quick with patients and seemed to have too many other things
on my mind, and that I really needed to spend more time with the patients.
Therefore, I began to formulate my practice into a much more patient-oriented
centre, so that patients could obtain more information about aesthetic plastic
surgery, not just from me, but from my sta . I hired a patient coordinator and
began to evaluate the patient and track the results. We investigated why patients
were scheduling, and the numbers of patients that were scheduled versus the
number of new patients who were being seen. We began to instruct the patients
during the initial consultation for a longer period of time, giving them a lot more
information with videotapes, brochures, etc., and we began to evaluate the practice
on a quarterly basis.
All these things have put the practice into more focus so that it is more
business-like, e cient and better organized. My philosophy was never planned. It
just evolved over the years as an extension of my personal principles:


My philosophy
1 . To identify my personal professional goals and to continue at a productive
2. To emphasize the positive aspects of the practice.
3. To realize my limitations and be happy in what you are and what you have
achieved and try to plan for the future.
4. To remember “ain’t nobody indispensable.”
The following section integrates my personal concepts and philosophies for
creating a continuous and successful plastic surgical practice.
Why do patients come to you?
Primarily they come because you are new and available. You are new in private
practice and patients may feel that they can get a better nancial deal, not because
of your expertise. However, your surgical services are judged on the same standards
of care of any other plastic surgeon, not only in your community, but nationwide.
• Referrals. These usually come from physicians, patients, family, friends and
sta , but they mostly come without much knowledge of plastic surgery or you.
So make patients feel comfortable with you and trust you.
• Do not sell surgery. The patient comes to you for one procedure, but don’t
suggest that they have another operative procedure simply because you need
experience. Occasionally, two operative procedures may go together such as a
chin implant and a rhinoplasty, or rather than having a breast augmentation,
the patient may need to have a mastopexy; but do not sell an operative
procedure that they are not seeking. Patients need to feel that you are honest,
sincere, truthful and dependable.
• Be honest as to who you are. You are new in practice but well trained,
available and competent.
• When seeing another doctor’s patient: Do not accept a patient from another
physician without calling him rst and nding out the other side of the story.
It is important to understand that what one patient tells you about another
doctor may not be the entire truth.
The initial consultation
Cosmetic patients are nervous, guilty and feel sometimes that they are taking up
your time in asking for silly elective procedures when you could be doing more
“important” surgery. Patients are usually out of their element when they talk to
you. The rst consultation with a plastic surgeon is always the most di cult one.
Put them at their ease.
• Introduce yourself honestly, who you are and what you are. Address the patient
with simplicity but respect.
• Tell them of your experience or inexperience with surgery. If you are dishonest,
it will come back to haunt you. If it is the rst time that you are doing an
operation, tell the patient it is the rst time that you are doing such an
operative procedure, but then tell them that you are a trained surgeon and this
is a surgical procedure that should not be di cult to do, or that somebody will
be there who has more experience to help you.
• Never say don’t worry, because they are always worried and anxious. Just talk
honestly and reassure the patient.
• Never say everything will be okay, because it may not be and it may not turn
out to be perfect.
• Examine the patient thoroughly and vocalize all of your findings to them.
• Explain your surgical plan to them and tell them it is only a plan, not a
blueprint and that things can change during the operation.
• Inform the patient thoroughly and honestly of common complications and
problems that can occur, and even discuss complications that are not common.
• In this day and age, it is important to be absolutely thorough in your discussion
with the patient.
• Do not get talked into or do surgeries that are not necessary.
• Do not say money is not an object, because to them it may be. If things go
wrong, it is what they are going to sue you for, money.
• Do not sell or talk surgery in social situations. Discourage o -the-cu
First impressions:
• They are made in seven seconds.
• Your whole practice and you will be evaluated by the patient in how and what
you say, what your staff says, and how they and you are perceived by them.
• Good service leaves permanent good impressions and maintains a reputation.
Patient characteristics
• The driver. With these patients, it’s a quick consultation and a quick decision.
They do not have time to be there for a long period of time. They want
something done right away and a decision is made quickly. That patient will
usually decide not to have the surgery as quickly as they make the decision to
have the surgery. It is important that you spend some time with these patients
and evaluate them. This type of patient is usually the high driving executive or
the society matron who really does not have much time to spend with you. You
are just another service person to them.
• The talker. This patient comes in and takes time and wants multiple consults
during the initial consultation. They usually have ten single-spaced typewritten
pages of questions to discuss with you. You have to evaluate these patients
immediately as to what their needs are and spend some time with them,
making sure that they are realistic in their expectations, within a reasonable
consultative period.
• The planner. This one has his or her operation planned, and usually has
decided how they want to have the surgery or what they don’t want to have in
their surgery. They want to see if you and the surgery fit into their plan.
• The thinker. One who asks few questions, wants you to make decisions and
doesn’t talk much during the consultation. They have been thinking about the
surgery and now want to think about you and consider what you have to say.
This is the patient who will say, “You are the doctor; you tell me what I need!”
• The shopper. Has seen other plastic surgeons and is comparing price, sta
surgical availability, etc. Be yourself and don’t compete with other surgeons.
Treat them with caution but without great expectations.
Handling the patient postop
Remember, it’s not over till it’s over. Patients are yours forever when you’re in
practice. You never go o the service. If you lose a patient or they go some place
else, you lost because that’s an unhappy patient.
Postoperative handling of a patient is as technically important as the surgery.
If there is a complication or problem, reassure the patient that “you and she/he will
get through it together.”
Things to do
1. You change the dressings, you remove the sutures, or be there when somebody
in your sta is going to do it, or explain to the patient why you won’t be there.
Make sure that the patient sees you and feels that you are as concerned about
their postoperative treatment as you were about getting them to the operating
2 . See the patient frequently whether they need it or not. They really need
reassurance in the postoperative period, because many of them will get a
postoperative depression.
3 . Be supportive of any patient. Answer their questions honestly, quickly and
thoroughly. Many of them are undergoing a surgical procedure for the rst
time, and while for you it may be a routine postoperative situation, for them it
is not.
4. Be honest. If you see a problem, explain to the patient what it is. Tell them if
there is a problem or complication, and explain your proposed plan of action.
Remember, “just a little swelling” can get you just so far. Don’t blame a
complication on a patient. Most problems that result between doctors and
patients could have been resolved during the postoperative period. This is a
golden period. They can love you or hate you in the immediate postoperative
The difficult and unhappy patient
Patients may be one of the following:
• The demanding patient. I want the surgery when I want it and how I want it.
That’s what I’m paying you for, and if you don’t do it the way I want you to do
it, I won’t pay you.
• The apologetic patient. This is a patient who comes in apologizing all the
time for bothering you, apologizing for wasting your time when you have so
many other important patients to see and sick patients to take care of. This is a
patient who needs hand-holding. They need reassurance because they are very
insecure about their situation and if you let them down, they may get

• The . irtatious patient is a patient who says, “Oh, I’ve heard so much about
you. You’re the most wonderful doctor in the world,” but usually is shopping
around for a reduced fee.
• The hostile patient. “I’m not happy with my surgery.” “I’m not happy with
you or your bill.” Your sta will tell you about the hostile patient, because
they will have been extremely hostile to the sta a few visits before they get
hostile with you.
• The angry patient is a patient who is not happy with surgery. “I am not going
to pay you.” “If you try to bill me, I will sue you.” Usually somebody has told
them that the surgery was inappropriate and poorly done.
• The negotiating patient is the patient who comes in and says, “I have a lot of
friends waiting to have surgery. They want to see how I turn out. Couldn’t you
please give me a discount?” Do not negotiate; make your fee appropriate for
your services.
• The fraudulent patient is the one who says, “Couldn’t we just call it something
else and see if my insurance will pay for it?”
Dealing with complications
Complications happen.
1. Try to identify the high-risk patient surgically and emotionally.
2. Deformity vs. concern in a patient. If the concern is so much greater than the
deformity or if the deformity is so much greater than the concern, you have a
loaded situation and these patients need to have a reality check. You need to
sit down and talk to them about exactly how they feel about themselves and
how they see themselves and their self-images. They may have BDS (body
dysmorphic syndrome).
3. The multi-surgeon or multiple surgery patient. This is a very di cult patient.
The patient has had multiple operative procedures and has visited multiple
other surgeons. It is imperative that you speak to each of the surgeons who
have operated on these patients, get their operative reports, and never accept a
patient who won’t let you talk to the doctor (with appropriate consent) who
operated on them beforehand. There are two sides to every story and that
doctor may just very well tell you what you need to know, so that you don’t
take this patient on as a problem case. You never want to be the last of a long
list of problem surgeries.
4. If a patient has a real or imagined surgical problem, it is important for you to
be there for them. You must be their anchor. You must be their rock and make
them realize that the problem is minimal and does not require surgery.
Otherwise, they are going to go someplace else. Be supportive, positive, but
5. Talk to the family and patient and be careful how you phrase things. Also,
when you speak to anybody other than the patient, make sure you have the
patient’s permission. If you don’t, you may be violating the con dentiality of
the doctor/patient relationship.
6 . Deal with the patient’s problems, not with your anxieties or fears. All
complications get resolved. What doesn’t get resolved is your attitude toward

Avoid the guilt/hostility/arrogance/counter hostility cycle!
If you get into this cycle with a patient, you have really lost the game with
them, because the patient will make you feel guilty, then you’ll feel hostile to the
way they are reacting to their problem, and you are going to get arrogant with this
patient and stop answering their phone calls. Ultimately you are going to get
counter hostility from the patient towards you, and this generally creates a litigious
Effective internal marketing techniques for plastic surgery
Plastic surgery is one of the most visual and media expectant specialties in
medicine today. Credibility in plastic surgery is tenuous and di cult to achieve,
even without marketing, but with the amount of external marketing that we see
today, it is even more di cult to maintain any degree of professionalism within the
medical community.
Let us explore the acceptable internal marketing techniques that can be used
e ectively to promote plastic surgery, and even look at the methods that have been
ine ective, counterproductive and cost prohibitive. The best marketing strategy for
a plastic surgeon is to maintain patient loyalty and patient awareness in the
specialty of plastic surgery.
General overview
Plastic surgery, unlike many other specialties, is enjoying an increasing growth and
demand for services. Since the 1970s to the present, there has been a huge increase
in plastic surgeries nationally; however, the increased competition from many other
specialists who also do plastic surgery is increasing at an alarming rate. We
compete for the upscale young, middle-aged men and women with discretionary
income who are willing to pay for elective plastic surgical procedures.
The faces of competition
The competition, particularly in aesthetic surgery, is increasing. There is an
increasing amount of marketing for plastic surgical patients from “marketeers”,
hospitals and so-called “cosmetic surgery centers”. They all use media marketing
and distribute patients among provider participants. However this high-pro le
marketing, which is supposed to attract patients with high to middle incomes for
elective procedures, may not be as pro table because of the high cost of promotion
and since the procedures are not paid for by third-party payers. So, there are large
out of pocket costs to the patient, generating high fees, but necessary low
reimbursements to outpatient facilities.
The many “marketing programs” that attempt to generate patients for select
plastic surgeons or “cosmetic surgeons” through generic marketing e orts, have
diluted the quality of plastic surgery and perhaps put in jeopardy the quality of
surgeons who may be marketing with a corporate entity.
What is marketing?

Marketing and advertising are not interchangeable terms. Marketing is a process of
learning who your customers are, what they need, and what they want from your
organization, thus allowing you to access that information (research) to make
policy, service and programmatic decisions (planning), to implement new policies,
services and programs. Then feedback is requested (testing, tracking) to let your
customers (patients) know that you have responded to their needs and concerns
(communications). Customer satisfaction is the ultimate goal of any marketing
program. Marketing is the soul of commerce. It is a fundamental principle of
commercial activity and has become a recognized modality in the health care
delivery system in the United States.
Definition of terms in marketing
Basically, marketing is an activity which places the producer (physician) of a
product (medical service, surgical or otherwise) into a mutually bene cial
relationship with the potential customer (patient) of that product. The concept of
marketing traditionally addresses the four Ps:
1. The product or service, which is to be sold.
2. The positioning of the produce in the marketplace.
3. The price or cost of the product or service.
4. The promotion of the product.
We are going to concern ourselves with the last element, the appropriate,
ethical, and nancially e cient way of promoting our products, which are plastic
surgical services.
External marketing and advertising
Because advertising combines creativity with marketing strategy, it does hopefully
attempt to gain the best results for one’s dollar. Paid advertising, of course, allows
one to control the timely placement of message and message content, and hopefully
with careful planning and exposure, to create widespread awareness and ultimately
increase patient 4ow into a physician’s o ce. With a good advertising campaign, a
plastic surgeon can accomplish a successful public relations program that will
create awareness, educate, be of generate interest, and hopefully enhance
Unfortunately, such a creative advertising and marketing program from an
external approach does cost a lot of money. This does not work as well as medical
marketing companies would lead us to believe. Plastic surgeons who have
approached their marketing strategies by heavy media advertising have found that
it almost becomes cost prohibitive and that the dollar return may not ultimately
generate the expected bottom line. While public advertising may be a part of a
general marketing program, it certainly cannot be the only means of attracting
patients who we wish to have in our practice. The question is, is it easier for a
plastic surgeon to attract prospective patients by advertising only, or is it more
e ective to attract and retain new patients from one’s own practice and physician
referrals by using other marketing techniques?
Internal marketing




The cost of promotion to bring in new patients to the practice can be signi cantly
diminished if internal marketing programs are in place and e ectively used. Very
simply put, what one does is deputize patients, friends, relatives, and hopefully
physicians to refer to your practice. It is important, therefore, in internal marketing
to have a large or growing base of patients who will be interested in elective plastic
surgical procedures, and at the same time approach groups outside your immediate
practice circle through some e ective cost-e cient external marketing techniques
other than mass media advertising.
Therefore, you must evaluate your practice:
• Find out if your practice is enjoying a fair market share of existing patients.
• Identify the most promising potential consumers of elective plastic surgical
services for your practice and hopefully create new market sectors where
patients can be tapped (aesthetic surgery, pediatric plastic surgery outpatient
facility, skin care, etc.).
• Are there new operative procedures that you can learn and put into practice so
that your practice has an ever-expanding armamentarium of procedures for
your patient population (microsurgery, craniofacial surgery, hand surgery)?
The basic steps of developing a plan and strategy are:
• Scrutinize your practice.
• Find out what are its strengths and its weaknesses.
• Define the service that you are providing.
• Find who else you could employ to provide them.
• Keep track of your competition and nd out what they do right, what they do
wrong, who they are, and why you are better or worse.
Examine what promotional e orts you have had in the past. If you have not
had any, then begin to develop some within your practice. You have to create a
program that will enhance your image as an ethical, professional plastic surgeon
and maintain a professional atmosphere that patients will be attracted to. The
bottom line is that you have to be able to produce and the product is good results
in plastic surgery. You can package your image any way that you want, but if you
cannot produce a nal result of good ethical quality plastic surgery, you will not
survive, no matter how much marketing you create. Remember, reputation is the
Things that you can do immediately to improve your practice
Well-trained staff
The best internal marketing tool is a well-trained sta . The sta person who
answers your phone makes the rst impression with prospective patients. As
obvious as this seems, I have noticed that many doctors are probably not aware of
how their phone is being answered. Patients should feel, from the very rst phone
call that their needs are your most important concern. They should also perceive
that your appointment schedule and other aspects of your o ce management are
handled in a highly e cient manner. These impressions can be easily conveyed if



the person answering the phone uses appropriate language and a bright pleasant
tone of voice. I advise against using an answering service or machine during
normal business hours, including lunchtime; however, if you do, make sure that the
service is coached in the proper way to handle your calls and that they identify
your o ce and do not just say, “Doctor’s o ce.” Have a human being answer the
phone, not a machine.
Initial office visit
The next step in creating a positive impression is the initial o ce visit. O ce décor
should be consistent with your practice and comfortably appealing. Avoid
ostentatiousness as this may very well have a negative psychological e ect on
patients who may automatically assume they cannot afford you.
Flow of patients
The 4ow of patients in the o ce should be smooth; try to keep appointments with
prospective patients comfortably separate from postop patients. We have all had
those occasional patients who want to argue over fees or make other complaints; as
minor as they may be, they are surely disconcerting to new patients. Remember,
the patients want their doctor’s o ce to be well organized for psychological
reasons as well as practical ones. After all, if a doctor’s o ce is chaotic, might not
his operating room be similarly haphazard? You do not want such thoughts ever to
enter a patient’s mind.
Probably the best thing that I have done in my practice is to hire a patient
coordinator. Typically, the patient coordinator will meet with the patient, either
before or after his/her appointment. She will show the patient any videos, photos
or computer images relative to the procedure of interest, discuss the patient’s
history, expectations and answer questions, and put the patient at ease. It also
helps the doctor compile a more complete pro le of the patient than would be
possible through a typically time-constrained consultation. Remember, it is vital
that all sta members who deal with the patients are consistent in their approach;
be sure you adequately prepare them through a comprehensive sta training
program. You always want your sta to express your philosophy, plans and
procedures, not their own personal ideas.
Small touches
Small touches are important. No patient ever visits our o ce without receiving a
thank you note mailed out the next day. We also make a point of sending thank
you’s to referring patients and physicians. Keep in touch with past patients, even if
it is only a once-a-year mailing of a newsletter, practice brochure or patient
questionnaire. People enjoy receiving information on new techniques in aesthetic
surgery or being updated on changes within your practice. If you send out any kind
of literature, invest the time and money to make the piece attractive. A poorly
designed newsletter or brochure will not achieve positive results for your practice.
Track patients through a computer system to make periodic mailings a
relatively easy task. On a monthly basis, track potential surgical patients against
new patients seen in consultation. At least once or twice a year compile and check
this ratio. If the ratio is less than 50% of new patients actually scheduling for
surgery, try to nd out what is happening to the rest of your prospects. Consult'


your records for clues. This review is likely to suggest changes that you might make
in your practice management and your personal style and/or your sta ’s approach
to patients. Use personal public relations rather than advertising to boost your
image in the community. This will keep your promotional costs down. O er
seminars on aesthetic surgery or plan an open house in your o ce. Especially if
you have an o ce surgical center, prepare your sta adequately for these kinds of
professional or social interactions in or outside of your office.
Personal contact
In any patient contact, be personal. Show the patient through eye contact and brief
touch that he or she has your respect. Jot down in your notes personal items, which
the patient mentions such as a new job, an upcoming vacation, the wedding of a
son or a daughter, etc. The next time you see your patient, ask her how the new job
is or how the vacation to Bermuda went. The patient will be amazed at your
memory and such inquiries will help convey genuine interest and maintain your
concern in the patient. It is that kind of friendly professionalism which earns trust
and shows that you are a caring physician.
Happy and informed
Remember, your most receptive audience are your patients. Keep them happy and
informed. Remember, a happy patient, on average, will tell three or four other
prospective patients about you, but an unhappy patient will spread the bad news to
20 or more patients. Remember, a professional, ethical reputation is the key.
Steps in creating an internal marketing program
In structuring practice enhancement, you must:
1. Evaluate the needs of your practice.
2. Plan a budget.
3. Look critically at your practice.
4. Look outside your practice.
5. Plan and outline a program that fits you personally.
Let’s look at these areas individually:
1. Evaluate your practice
A. Are you satisfied?
B. Are you financially viable?
C. Do you have a good patient mix?
D. Are you growing?
E. Where do you want to go with your practice?
If the answer is “yes” to A–D then you need to go no further, but if the answer
is “no” to any of them, then you need to proceed with a customized marketing
program that fits your personal image.

2. Plan a budget
A. 10–15% of revenue to start.
B. 5–7% of revenue to expand.
C. 7–10% of revenue for new ventures.
D. 3–5% of revenue to continue as you are after you have established a program.
These percentages are estimates; budget what you can afford.
3. Look at your practice
A. Who are your patients?
B. Who are your referrals?
C. How good is your staff?
D. What is your image?
This is a real test of your ability to assess your present practice honestly, so
that you can address the areas in your office that need tweaking.
4. Look outside your practice
A. Who is your competition?
B. How is your location?
C. Do you need to promote yourself?
D. How does your practice measure up to others in your community?
The bottom line of structuring is a practice enhancement program; after you
have established such a program it is important that you evaluate and track your
practice’s nances on a quarterly basis. You should only commit the monies that
you can spare into any program. It takes at least 6–12 months to see any results of
any marketing program. The results are never direct, but will show up in the
number of patients that you see, the turnover of new patients to surgeries and
obviously your pro t and loss statement. Remember, you can do it yourself with
minimal outside help. You know your practice better and plastic surgery better
than anybody else. Just take the time to look at your practice. Remember that
advertising is like a drug habit; once you start, you cannot stop it because that may
be your source of new patients. And finally, do not let your overheads bury you!
Strategic plan
A strategic plan is nothing more than future plans based on progressive ideas
solidly backed by concrete facts and concepts. Remember, while one cannot
predict the future, all new concepts and ideas come from somebody’s dream of
what he/she would like to do or be. We have to see where we are today, where we
want to go and where we would like to be realistically in the future. Hopefully,
with organized planning, we will take all the right steps and do all the right things
to achieve the proposed concepts.
But to achieve a strategic plan, one has to sit down and formulate an overall
concept, and certain questions need to be answered before formulating a plan.
1. What do you want to do? (MISSION).
2. What are you today? (CURRENT STATE).
3. What do you want to be? (VISION/FUTURE STATE).
4. What do you have to do? (AREAS OF FOCUS).
5. How do you get there? (STRATEGIES).
6. How will you know when you are doing these things well? (TRACKING).
Then create a stepwise overview project to organize the steps in putting any
program into effect.
Step I: Project organization. (Decide where you want to go with your practice.)
Step II: Information collection.
Step III: Situational assessment. (What do you need to change to achieve these
Step IV: Strategy development. (Develop a place with some professional
assistance if needed.)
Step V: Implementation. (Implement a reasonable approach which fits you.)
Different plans for implementation
Phase I
1. Evaluate your practice.
2. Evaluate your patient population.
3. Evaluate your surgical mix.
4. Create identifying images (logo).
5. Streamline your office patient care.
6. Discuss your new patient approach with staff.
7. Develop brochures or use them more efficiently.
8. Develop a newsletter. (May not give direct results and is very expensive and
occasionally overdone.)
9. Develop patient acknowledgment letters, cards and thank you notes.
10. Develop patient follow-up letters.
11. Develop representative programs for plastic surgery to prospective patient
groups in or outside your office complex.
12. Directory advertising. (Is just another yellow paper ad – unless you are rst,
e.g. AAAA Plastic Surgery.)
13. Patient coordinator program in office.
14. Use hospital marketing director to market plastic surgery.


15. Direct media advertising.
16. Tracking system for patients.
17. Evaluate the costs of any program versus the bottom line.
18. Abandon any program if results do not justify the expense.
Phase II
1. Paper trail of informational booklets, i.e. pre and postoperative instructions on
all procedures.
2. Personalized all-purpose book on plastic or aesthetic surgery.
3. Elegant, stylish brochure about your practice.
4. Personalized videotapes of procedures.
5. Personalized informed consent and brochures.
6. Website (important).
7. Office surgery.
8. A postoperative extended care facility.
Phase III
1. Open house for patients, public and physicians.
2. Contracts with managed care programs (HMOs, PPOs, etc.).
3. Financing for non-covered surgical services.
4 . To referral sources o er more than a letter of thank you or a Christmas
a. to patients; offer discounts
b. to doctors; offer discount to their patients and/or free consultations.
5. Gifts to patients, i.e. 4owers, scrub shirts, scarf, pocket calendar, cosmetics,
6. Amenities: facials, body massages, a day of luxury.
7. Skincare/spa or service with cosmetics with logo (creams, lotions, anti-wrinkle
creams, etc. – expensive investment).
Marketing is like a tree. It must be planted, allowed to take root, to grow and to
leaf out before you can expect it to bear fruit. Before you begin any marketing
program, take a hard and thorough look at where you are in relation to where you
want to be. Look at your life-long goals and assess your areas of strength and areas
in which you need to improve, not only in your practice, but in your own personal
life and nd out if professional marketing is something that you can feel
comfortable with, that you can live with and that will t into your overall nancial
strategies. To be successful, you have to communicate e ectively that you can
satisfy the patient’s needs as well as your personal needs. You have to choose the
types of communication that are in line with your own comfort level, and follow
those activities that you feel are appropriate for you as a surgeon and as an
individual.Further reading
Albrecht K, Zemks R. Service American – doing business in the new economy.
Homewood, IL: Dow Jones-Irwin; 1989.
Antin HB, Antin A. Secrets from the lost art of marketing. New Orleans: The Antin
Marketing Group; 1992.
Baum N. Marketing your clinical practice. Gaithersburg, MD, 1992
Beckaham JD. Marketing your practice – a practical guide for physicians. Arlington
Heights, IL: Health Market, Inc; 1993.
Brown S, Nelson AM, Branhesh S, Wood S. Patient satisfaction pays. GaithersburgMD:
Aspen Publications; 1995.
Brown SW, Morley AP. Marketing strategies for physicians. A guide to practice growth.
Oradell, NJ: Medical Economics Books; 1996.
Colon GA, Church JM. Office surgery – old concept modernized. J Louisiana State Med
Soc. 1982;134(5):7–9.
Colon GA. Office surgery. Current Therapy in Plastic and Reconstructive Surgery. J
Louisiana State Med Soc. 1988:416–419.
Hillestad SG, Berkowitz E. Health care marketing plans: from strategy to action.
Homewood, IL: Dow Jones-Irwin.
Jewell M, Jewell M. Practice management. Newport Beach, CA: ASAPS; 1998.
LeBoeuf M. How to get and keep the customer for life. New York: Putnam; 1997.
McCormack M. What they Don’t Teach Your at the Harvard Business School. New York,
NY: Bantam Books; 1997.
Naisbitt J. Megatrends – ten new directions transforming our lives. New York, NY:
Warner Books; 1997.
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Practice development for residents. Chicago, IL: ASPRS, 1992.
Quick J. A short book on the subject of speaking. New York, NY: McGraw Hill.
Ramirez LD, Lowder JD, Lowder BL. Practice growth through effective patient relations
(proven techniques for plastic surgeons to increase cosmetic surgery). Salt Lake City,
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Sachs L. Do-it-yourself marketing for the professional practice. Englewood Cliffs, NJ:
Starr P. The social transformation of American medicine. New York, NY: Basic Books;


Clinical photography for the aesthetic patient
Val Lambros
The world is lled with forms: objects, people and other things that we look at,
identify, enjoy, de ne, interact with, and make judgments about. When we look at
these we are not seeing the things themselves, we are seeing how they interrelate
with the light that they are seen in.
The word “photography” means “light writing”. The old saying that “a picture
is worth a thousand words” is simply not true; a picture contains more and
di erent information than words could possibly express. The goal of clinical
photography is to observe conditions on the body, record them and record changes
that happen to them. These recordings may be made for any number of reasons,
but for a plastic surgeon the usual aim is to identify pre-existing conditions, modify
them and to see how the modi cations worked. Pictures are invaluable in the
record of patient care for both the surgeon and the patient. They are referred to on
each patient visit. They may show the steps to a surgical triumph. At worst they
may need to provide a defense in a court of law.
The body exhibits highly complex curvatures and shapes. Though not
perceptual psychologists, we are amazed at how selective, limited and evanescent
visual memory can be. It is common in our practice to have a patient say that a
certain wrinkle “just appeared”, when wrinkles typically take years to emerge. We
have noticed this in our own mirror. Many patients, insisting that they know every
pore on their faces, for example, will be surprised when a fairly large feature is
pointed out to them. With astonishing rapidity, sometimes within days, patients
forget how they used to look, after an operation. The surgeon’s visual memory is
frequently not much better.
A surgeon’s analytic focus may be on a particular structure while not noticing
an adjacent area a centimeter away, and a certain structure or con guration may
be present before treatment and not noticed until afterwards. This latter situation is
frustrating to patient and surgeon alike as the patient is convinced that there is a
“new” problem as a result of surgery. The surgeon cannot prove otherwise without
a good visual record. Similarly, areas remote to the surgery may be problematic
and without photos there is no good way to analyze them.
The desiderata of clinical photography are straightforward. One must be able
to see the conditions present on a print or a screen, and one must see them in the
same way at some future time. The images must be consistent over time in lighting
and in position. Though simple in concept these are difficult to achieve in practice.
Digital photography has advanced quickly to become the main tool used by
plastic surgeons for clinical documentation. Digital imaging is less expensive, more
exible and easier to archive than lm, though backup becomes an issue. The
resolution of the images continues to improve. Early in the evolution of digital
photography, digital point and shoot cameras were popular; however the image
1quality with small zoom lenses and small image sensors left much to be desired./


Plastic surgery is a professional endeavor with high standards for record
keeping. We prefer the use of digital SLRs (single lens re ex cameras) which use
interchangeable lenses with more sophisticated ashes. Though a detailed
explanation of CCD sensors, pixel dimensions and print size, and printed dots is
beyond the scope of this chapter, we would note that for practical purposes the
horizontal resolution (number of pixels of width of a certain image) times the
vertical resolution (same) will give the pixel size of the image, usually measured in
megapixels. Most commercial printers print at 300 pixels per inch for photographic
quality. Thus a camera that has a resolution of 8 megapixels will be able to print at
about 8 × 10 inches. Larger prints may be made with some reduction in quality.
We think that a 4–5 megapixel range is a reasonable minimum for professional
The use of digital technology allows the taking of large numbers of images
with essentially no unit increase in costs. At the time of this writing memory storage
costs have plummeted, thus making storage and backup much less expensive than
even a few years ago. Patient images may be stored in specialized programs that
provide archiving with other functions. An example is the Mirror System from
Canfield Scientific.
Digital photography is a continuation of traditional photography, and the rules of
exposure, lighting and composition are the same as they have been for the last 170
The exploration of light, shadow, form and position has been one of the
triumphs of western art. Highly talented people have devoted careers to
understanding these relationships and there is a sizeable literature on photography
for these ends. Unlike portraiture, where the intent is to capture a face or body in a
attering way, or to reveal an essential truth about someone or something, the
goals of clinical photography are not artistic. They should be an unremittingly
2honest designation of what is there. It is a visual transcription.
What de nes facial and bodily features in the world of daily life is the light
one sees them in, or more properly the interplay of light and shadows that visually
de nes them. Tangential light shows wrinkles, contours and shapes in a very
di erent way than hard anterior light or soft “wrap around” light, which atten
and minimize them (Fig. 2.1). "

Fig. 2.1 On the left the patient is illuminated with an on-camera detachable ash;
on the right a twin umbrella set up. These are both commonly used light sources.
The on-camera ash is harsher and the sides of the face are not well-exposed. The
tear troughs are better visualized however. Care has been taken here to slightly
underexpose the images. With overexposure both images would be unrealistically
without skin shadows.
A recurring problem in the lighting of patient images is that certain details and
contours are washed out or attened so much by the light that they are not visible.
Body cellulite or certain facial wrinkles are frequently not seen in anterior ( ash)
light, but highly visible in everyday vertical light.
In general skin irregularities are best seen in tangential light. Shapes such as
breasts, or body contours are best seen in slightly shaded light. Di erent light
shows di erent things and there is no single light that will show everything, so
compromises have to be made. The more attractive a particular lighting setup
make the person look, the less likely it is to show the issues of skin and shape that
are of interest to patients and surgeons.
Lighting schemes
Many plastic surgery lighting designs have been developed. They vary from on
camera ashes of di erent complexities to external lights in di erent
con gurations. Portrait lighting is usually asymmetrical, i.e. the sides of the face or
2body are lit di erently for purposes of interpretation of the subject. In general/


clinical lighting should be symmetrical. If time, space, and temperament of the
surgeon allow, we like the use of small silver twin umbrellas, mounted higher than
the patient’s eye level. This light is somewhat forgiving, but shows reasonable skin
detail and by shifting the lights up or down one can see greater degrees of skin
detail. The disadvantage of this lighting is that it casts shadows across the
nasolabial fold (NLF) and tends to overexpose the tear troughs (Fig. 2.1).
However this lighting scheme is versatile and has enough spread to show body
contours well. Even without a dedicated photo room, small slaved ash units with
di users may be attached to the wall. More vertical light gives very accurate body
skin rendition, and so the lights may be elevated or bounced o the ceiling to show
skin irregularities for body shots. Light boxes may be used, though we nd this
light overly attering. All of these light sources have been used successfully in
di erent oE ces and all have adherents. The clinical examples shown here use twin
1umbrella lighting.
The assumptions made for the purposes of this chapter are that many surgeons
do not have the room and inclination to set up external lights and most will use an
on-camera flash.
We prefer the use of a separate on-camera ash. This separates ash from the
lens enough to add a tangential quality to the light (the built in ash in many
digital cameras is so close to the axis of the lens that the light is attened and
details in the center of the frame tend to be washed out).
If the camera is turned vertically, the lighting will fade slightly on the side of
the subject opposite the ash. This is not necessarily a problem, though detail may
be lost on the darker side. When a vertical orientation of the camera and ash are
used it is important to have the ash pointing from anteriorly, i.e. in an oblique or
lateral view the ash should be on the side of the face that the nose is pointing to,
otherwise a shadow will be cast across the face.
A small diffuser on the flash may remove some of the harshness and contrast of
this kind of light. As with all aspects of practice some experimentation is necessary.
Reproducibility of lighting is easy with this method. All the pictures are taken the
same way. Though this style of lighting does not necessarily give the prettiest
images it can be highly accurate (see figures).
Other on-camera lighting systems are available and are useful for specialized
3applications. We do not think that a ring light is very useful for clinical
photography of body parts other than close-ups of the skin itself. The light that it
casts is co-axial with the camera lens and is at and shadowless by design. These
attributes make the ring light useful in fashion photography, but it hides too many
relevant skin contours to be recommended for clinical photography other than to
illuminate deep into cavities, under flaps or for dermatologic reasons.
Perspective changes occur when a three dimensional object is portrayed in two
dimensions. In plastic surgery the classic example is a face taken full frame with a
wide-angle lens (the distance from the subject to the camera is short) and a longer
lens (the distance from the camera to the subject is greater). In the rst case the
central, closer part of the face will seem to bulge and the ears will seem to recede.
In the second case the face will look atter, the nose will get smaller and the ears
will widen out (Fig. 2.2). This e ect is commonly ascribed to the lens, but is in
reality solely a function of camera to lens distance. For body and face, a taking
distance of 4–6 feet is adequate. We will use a lens of 105 mm (or 105 mm
equivalence for most digital cameras) at a distance of about 5 feet for the face and4a lens of 50 mm (or equivalent) for body.


Fig. 2.2 Perspective changes are very clear here. The image on the left was taken
at 5 feet, the image below at 2 feet and the image on the right at about 14 inches.
The focal length of the lens is only material in the distance it takes to ll the frame
from ear to ear. This e ect is actually evident if one looks closely in a mirror at
similar distances.
Though highly sophisticated metering is available for modern cameras and is
commonly used, for the purposes of lighting in a known room at a known distance
we favor the use of manual exposures. The light and shutter speed are always the
same, and the distances are constant. We think that an f-stop of a least 11–16 is
necessary for enough depth of eld to assure that the back and the front of the
subject are in focus. For facial images we focus on the eyes.
Standardization is easy when it comes to exposure and camera to subject distance.
Standardization of position is very diE cult. As with anything that is diE cult, many
attempts have been made to achieve similarity in position. For most clinical
purposes we nd that simply paying close attention to the preoperative position
and carefully trying to match it by comparing photo to patient works well for the
typical clinical situation. In attempting to match a patient to a photograph the
tendency is to exaggerate the rotation. Rotation is usually easier to match than
vertical position.
Clinical pictures should have a strong element of ritual to them and should
always be taken the same way. We put the patient on a rotating stool and once the
AP is taken have her rotate without tuning the neck. For both face and body
photography we nd it helpful to place numbered cards or markers on the wall at
545 degree increments to help the patient face the appropriate direction.
For faces we prefer ve basic images: AP right and left obliques, and both laterals.
These views contain most of the necessary information about the face. We repeat
this basic sequence as necessary for follow-up photos. Because the face is a mobile
structure and because patients will animate in their mirrors and misremember how
they looked in the past, we take smiling views in the AP obliques and lateral. These
are valuable for general purposes and to show smiling induced chin ptosis. We will
include as many dynamic images as necessary to show preoperative nerve function.
We also take an AP of the neck from below with the platysma in repose and in
animation and any other special views that the case may call for (Fig. 2.3).

Fig. 2.3 One half of the face series is shown. We like to take the oblique with the
nasal tip at the mid-pupillary line. A smiling image is taken in each of the cardinal
positions (not shown). Platysma views are taken as shown in repose and with
animation and close-up views are taken of any other area of interest. Any other
animation views are included as desired. Ears should be visible in pre- and
postoperative images. Though it is frequently diE cult to persuade patients to
remove makeup, most can be convinced into clipping their hair back. These
pictures should be ritualistic in their position.
Eyelids are taken with the face pictures and in close-up in the AP in superior
gaze as well as laterals (Fig. 2.4).

Fig. 2.4 A–C, Eyelid close-ups are illustrated.
Photography of the nose is contained in the facial series. Anteroposterior
images are taken (ensuring that the ears are equally visible to control rotation),
obliques and lateral. In addition smiling views are taken of the AP and the lateral
images to demonstrate the e ect of the lip on the nose. In addition basilar views
are taken, one looking directly up the dorsum and one with more head uptilt for a
3,6–8true basilar view. Camera viewfinders with grids are useful to align the eyes or
ears for uniformity in position (Fig. 2.5).

Fig. 2.5 The nose series is contained in the face series, with AP oblique and
lateral images. Smiling images are included in the AP and lateral. The only
di erent view is the two basilar views of the nose, one looking up the dorsum and
one more angled to look at the nasal base./
Breast images
These are simply AP obliques and laterals. We also include a relaxed and pectoralis
contracting view such as pushing the hands on the hips, in the case of breast
implants. Sometimes a forward leaning view is useful to demonstrate asymmetry
(Fig. 2.6A–D).

Fig. 2.6 A–D, Half of a breast series. The forward leaning view is helpful to show
Body contouring views
Here is where some exibility with lighting can be helpful. The overall shape of the
body is best seen in even light, but the quality of the skin is best seen with more
vertical light. Umbrellas with slaved strobe light are very useful here as they may
be elevated and lowered to show the desired contours.
Additional detail images are taken of the knees, medial thighs and arms as
necessary. We have the patient stand on a designated spot and then face markers
on the wall of the room at 45 degrees apart for consistency of position. In some
patients with excess skin a “diver’s view” is helpful to look at redundant skin. We
think that the arms should be included in the pictures as arm position can influence
the way the skin drapes on the torso and the torso may be made to look arti cially
good if the arms are elevated out of the picture area (Fig. 2.7).


Fig. 2.7 The skin contours can be most accurately judged if the lights can be
elevated in a series like this. The pictures are taken in 45-degree increments with
the patient facing markers on the walls of the room. In this case the breasts were
imaged as well as the body. We nd it helpful to take pictures of the knees and
inner thigh separately. The arm position should be visible in the images.
Arms are photographed in abduction with the elbow exed vertically. When
the arm is photographed end on from and below the elbow any redundancy in the
skin is instantly visible. Focus is at the mid-arm (Fig. 2.8).

Fig. 2.8 The arms are taken in AP and PA views. The non-standard lateral view
shows much more detail of the curvature of the inferior skin than the standard
Standardization of color is diE cult in digital photography. Even with correct
exposure the images may be at muddy or o color as they are downloaded from
the camera.
If we are using images for publication or presentation we will modify color and
contrast to make the images look the same. Since as surgeons, we are usually
looking at contours and not colors we try to make the skin tone as realistic as
possible. As a point of photographic integrity we never change morphogenic pixels.
There are numbers of programs that will allow editing of photos. The industry
standard is Adobe Photoshop (Adobe Systems, San Jose, CA), a large complex
program. A useful program at the time of this writing is Adobe Photoshop
Elements, which is less expensive yet has all the functionality necessary for routine
editing of images.
Integrity in photography"

Integrity in photography
In the increasingly competitive world of cosmetic surgery where surgeons are trying
to in uence future patients, or in presentations for peers, or for other reasons, there
is and has always been the temptation to alter photographs to make the results look
better than they really are. Clinical photography is not designed to atter the
patient (or the doctor). It is a legal document designed to be a part of a medical
record and show the conditions that existed at one or more points in time.
Di erent light shows di erent things. Wrinkles hollows and other imperfection
on the face and body are de ned by the shadows that they cast. In the absence of
shadows, wrinkles disappear and results can look miraculous. It is very possible to
make the skin and other contours look far better than they really do by altering the
direction, quality and brightness of the light, a practice sometimes seen in books,
journals and presentations, where on occasion most of the clinical result is from the
di erence in photography. This may sometimes be a naïve mistake, but in fact
most of the un attering images are seen in the preoperative pictures and the better
ones in the postoperative ones.
It is not uncommon to see eyelid surgery presented with the light coming more
vertically in the preoperative picture accentuating the upper lid shadow and tear
trough and the postoperative lights coming from straight anterior, attening these
9shadows. Strangely both patients and doctors continue to be fooled by elementary
tricks like this and be impressed with the results that they purport to show. The
lighting and position should be the same. The ability of photo editing programs to
alter images is a frightening part of the brave new digital world.
Cosmetic surgery is still surgery, its practitioners went to medical school and
did internships residencies and fellowships. They should be expected to maintain
the ethical standards that they learned there. The light that is used for the
preoperative photos should be used for the postoperative ones, and digital
modifications to images should not include changing any morphogenic elements.
The future of clinical photography
The next step in fusing digital photography, computers and the patient will
probably be in the use of 3-D cameras. These are highly sophisticated devices
which capture the points that comprise the surface of an object and can reproduce
them in any position and orientation. Changes can be made in perspective to match
a 3-D to a 2-D image. Currently, accuracy of the surface image of such cameras is
about a millimeter. Measurements can be taken along the surface of an image or
point to point. In some applications volume di erences may be measured. Clearly
the quality and range of results that will be documented will be remarkable.
1. Galdino GM, Vogel JE, Vander K, Craig A. Standardizing digital photography: it’s
not all in the eye of the beholder. Plast Reconstr Surg. 2001;108(5):1334–1344.
2. Upton B, Upton J. Photography. Boston: Scott, Foresman and Company; 1989.
3. Galdino GM, DaSilva D, Gunter JP. Digital photography for rhinoplasty. Plast
Reconstr Surg. 2002;109(4):1421–1434.
4. Dickason WL, Hanna DC. Pitfalls of comparative photography in plastic andreconstructive surgery. Plast Reconstr Surg. 1976;58:166.
5. DiBernardo BE, Adams RL, Krause J, et al. Photographic standards in plastic
surgery. Plast Reconstr Surg. 1998;102(2):559–568.
6. Rohrich R, personal communication, February 2008.
7. Daniel R, personal communication, February 2008.
8. Guyuron B, personal communication, February 2008.
9. Sommer DD, Mendelsohn MMD. Pitfalls of nonstandardized photography in facial
plastic surgery patients. Plast Reconstr Surg. 2004;114(1):10–14.Section 2
AnesthesiaCHAPTER 3
Anesthesia in aesthetic surgery
Michael Zelman, Daniel J. Ceradini
History of ambulatory anesthesia
The origins of anesthesia began with a series of events in the mid 1800s. While training in New
York City, Crawford Long experienced the recreational use of ether and nitrous oxide during
student parties: the so-called “ether frolics”. After starting his practice, he applied the use of
diethyl ether to anesthetize a patient during removal of two small tumors from a man’s neck in
1842. He did not publish his methods until 1849, several years after the use of nitrous oxide was
reported by Horace Wells and the /rst successful public demonstration of nitrous oxide by William
T.G. Morton in 1846. These pioneers set the stage for the rapid integration of anesthesia into
surgical practice, which proceeded over the latter half of that century.
Shortly after World War I, with increasing popularity of o5 ce-based surgery, the utilization of
a dedicated anesthesiologist in the o5 ce setting was /rst described by Ralph Waters in 1919. He
described his experiences administering anesthesia in the surgeon’s o5 ce, where his responsibilities
included supplying the operating room, recovery room, and his private doctor’s “loa/ng and
smoking room”. He recognized the /nancial potential of his situation, and noted that success was
1intimately tied to the satisfaction of the surgeon.
Later in the mid-20th century, with rising costs and ine5 ciency of inpatient care and
increasing shortage of hospital beds, there was signi/cant transition to outpatient surgery. In an
e7ort to maximize patient throughput, cut costs, and maximize reimbursement, John Ford and
Wallace Reed designed the /rst freestanding ambulatory surgicenter in Phoenix, Arizona in 1969.
Most cases in this facility were performed under general anesthesia. Based on their drive for
e5 ciency, this stimulated the development of anesthetic regimens and postoperative medications
that would allow patients to return home sooner. These techniques continue to evolve today.
Over 60% of all surgical procedures performed in the US are in an ambulatory setting. In
aesthetic surgery, the vast majority of procedures are performed in the outpatient or o5 ce setting.
Functional knowledge about of the practice of anesthesia and how it can be applied to the
aesthetic surgeon’s practice is vital to success.
Preoperative evaluation – patient safety
Ambulatory anesthesia has evolved as a means of convenience, e5 ciency, and cost cutting to
surgical practice. However, a critical determinant in these bene/ts is patient selection and safety.
The objective of preoperative evaluation is to manage risk – to identify patients who are at low
risk, and to reduce these risks at the time of surgery. In some cases the risk of anesthesia is equal to
or greater than the surgical procedure at hand. There is no consistent classi/cation of preoperative
risk, but particular attention to details of the patient’s history, physical exam, and other diagnostic
screening tools can determine whether surgery should be deferred while pre-existing medical
conditions are addressed.
The objective of anesthesia is to maintain a state of physiologic homeostasis during the stress
of surgery. The physiologic response to surgery is similar to the “/ght or Bight” response, altering
blood Bow from non-vital organs to the brain and heart. In order to maintain homeostasis,
preoperative determination of cardiac reserve, ability to exchange oxygen, and patient factors
which may negatively impact these processes must be known. To this end, the Rule of Threes can
simplify the approach to preoperative screening and focus practitioners on the aspects of the
history and physical exam which inBuence patient outcomes in the perioperative period (Table
23.1). Exercise tolerance approximates cardiac reserve, and can be approximated using metabolic
equivalents (METs). Several studies have demonstrated that the ability to do four or more METs
correlates to improved perioperative outcomes. Walking /ve city blocks, climbing two Bights ofstairs, running over short distances, and participating in moderate recreational activity (i.e.
dancing or golf) without the need to stop for rest is the equivalent of four METs.
Table 3.1 The Rule of Threes
Acute history 1. Exercise tolerance
2. History of present illness and its treatments
3. When the patient last visited with his or her primary care physician
Chronic history 1. Medications and causes for their use and allergies
2. Social history including drug, alcohol, and tobacco use and cessation
3. Family history and history of prior illnesses and operations
Physical 1. Airway
2. Cardiovascular
3. Lung, plus those aspects specific to the patient’s condition or planned
From Miller RD. Miller’s anesthesia, 6th edn. New York: Elsevier/Churchill Livingstone, 2005.
As there is no reliable classi/cation system of preoperative risk, a standardized approach to
data collection in the preoperative period can facilitate decision making throughout the patient’s
course. The initial collection should happen shortly after the decision to proceed with surgery in
the surgeon’s o5 ce. In addition to medical history pertinent to the speci/c surgical procedure, a
standard set of questions designed to identify risk factors should be answered, such as those found
2in the Preoperative and Preprocedure Assessment Clinic (PPAC) Form. The physical exam should
be similarly structured and standardized with some notable additions. Airway assessment is
performed according to the Mallampati airway classi/cation based on observations of oral
structures visible with tongue maximally protruded, which correlates to ease of intubation (Table
3.2). Additional factors to consider which may limit airway visualization are a short neck, limited
cervical spine mobility, poorly mobile or retruded mandible.
Table 3.2 Mallampati airway classification system
I Faucial pillars, soft palate, uvula, tonsillar pillars visualized
II Faucial pillars and soft palate visualized, uvula visualized
III Soft palate, base of uvula visualized
IV Soft palate only
Based on the history and physical, patients are broadly classi/ed according to their medical
/tness. The current classi/cation system endorsed by the American Society of Anesthesiology
(ASA) is a modi/cation of the Saklad classi/cation developed in the 1940s. Useful more as a global
assessment of preop status rather than a measure of risk, the ASA system classi/es patients based
on the presence of medical illness (Table 3.3).
Table 3.3 ASA classification systemASA Medical conditions Common examples
I Healthy, no co-existing medical illness
II Mild systemic disease with no Asthma, hypertension, mild obesity, diabetes
functional limitation (well controlled)
III Severe systemic disease with functional Poorly controlled DM, stable angina,
limitation coronary artery disease
IV Severe systemic disease that is a CHF, unstable angina
constant threat to life
V Moribund with death expected within
24 hours
Following a focused history and physical intake, surgeons must then determine the need for
additional preoperative screening tests. The tendency of surgeons is to order a large range of
ancillary tests, some of which are not necessarily indicated, in an e7ort to have any conceivable
test result available to the anesthesiologist on the morning of surgery. This poses several potential
problems. Testing not indicated by medical history may lead to treatment of borderline
abnormalities, which may result in patient harm and distress. In addition, since most preoperative
abnormalities are not documented in the chart, the failure to investigate abnormal tests is a greater
risk of medico-legal liability than the failure to detect it in the /rst place. Therefore, the guidelines
published by the American Society of Anesthesiologists (ASA) summarized in Table 3.4 should be
utilized to determine the need for additional preoperative screening tests. In addition, preoperative
evaluation should include tests relevant to the type of surgery being performed. For instance, if
intraoperative and postoperative bleeding is a signi/cant risk, then a baseline hematocrit should be
included in the preoperative work-up.
Table 3.4 Guidelines for preoperative screening tests (based on ASA standards)
Preoperative test Indicated Not necessarily indicated
Electrocardiogram Age >50 with cardiac risk Age >50 with no cardiac risk factors
Pre-existing cardiac or
peripheral vascular disease
Diabetes mellitus
Metabolic disease
Chest radiograph Pre-existing cardiac or Smoking, advanced age, stable cardiac
respiratory disease disease, stable COPD, recent URI
COPD or reactive airway
Complete blood History of anemia Routine use not indicated
Hematologic disorder Liver disease
More invasive procedures
Coagulation History of bleeding diathesis Routine use not indicated
Anticoagulant therapy Regional anesthesia (insufficient data)
Liver disease
Serum chemistries Endocrine disease Routine use not indicated
Renal or liver dysfunction
Medications affecting
serum/urine electrolytes
Urinalysis Only select procedures Routine use not indicated
(genitourinary procedures)
Pregnancy testing Consider in all women of
childbearing age
Uncertain pregnancy history
Adapted from American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation: a report
by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology
Based on current practice, patient assessment by the anesthesiologist frequently occurs on the
morning of surgery. While adequate for the majority of patients without signi/cant medical
comorbidity or risk factors, there is a select group of patients with signi/cant medical problems or
preoperative risk that would bene/t from an evaluation well before surgery. It is the role of the
surgeon to identify these patients and ensure they receive a focused assessment by an
anesthesiologist to minimize their operative risk prior to the morning of surgery (Table 3.5). Failure
to do so may result in case cancellation which is frustrating for all parties involved.
Table 3.5 Indications for preoperative anesthesia evaluation prior to day of surgery (based on ASA
General Medical condition prohibits daily activity or necessitates continual assistance
Hospital admission within 2 months for acute or exacerbation of chronic
Morbid obesity (BMI >30)
Cardiovascular Angina, coronary artery disease, history of myocardial infarction
Symptomatic arrhythmias
Poorly controlled hypertension (DBP >110, SBP >160)
Congestive heart failure
Respiratory COPD or reactive airway disease requiring chronic medication
Recent COPD or reactive airway disease exacerbation
History of airway surgery or unusual airway anatomyEndocrine Diabetes mellitus
Adrenal disease
Thyroid disease
Hepatobiliary disease
Neurological Seizure disorder
CNS disease
Adapted from American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation: a report
by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology
2002;96:485–496 and Pasternak LR. Preoperative screening for ambulatory patients. Anesthesiol Clin North
America 2003;21:229–242, vii.
Finally, the decision is made on the method of anesthesia to use. There are a number of factors
that inBuence this decision including medical history, nature of the procedure, length of surgery,
facility resources, surgeon’s expertise, anesthesiologist’s expertise, and to some extent, patient
The specific features of each method for anesthesia will be discussed later in this chapter.
Preoperative medications
Preoperative medication management is an important concept in optimizing patient physiology
before they enter the operating theater. Conceptually, this can be viewed as a therapeutic
opportunity to minimize preventable risk in an e7ort to improve patient outcomes. Speci/cally, the
management of medical co-morbidities, patient anxiety, and predictable side e7ects of surgery
and/or anesthetic agents should be addressed to ensure patient comfort throughout the
perioperative period and minimize preventable complications.
Maintenance medications
In general, patients undergoing pharmacologic treatment for medical illness should continue taking
most of their preoperative medications on the morning of surgery to maintain their steady-state
physiology. Examples of such medications include anti-hypertensives, thyroid replacement,
medications for symptomatic gastroesophageal reBux, and medications required to optimize
pulmonary function (i.e. steroids). Notable exceptions to this guideline are anticoagulants and
antiplatelet agents due to the increased risk of bleeding complications as well as oral hypoglycemic
medications and insulin which should be adjusted according to blood glucose levels. In patients
with more complex medical problems, consultation with a primary care provider is advised to
individualize the patient’s needs perioperatively. Herbal supplements should be discontinued, often
several days prior to surgery, as many have been shown to a7ect platelet function. Antidepressants
or antianxiety medications can be continued with the exception of monoamine oxidase inhibitors,
such as phenelzine (Nardil).
Patient anxiety is a signi/cant consideration to address preoperatively for several reasons. The /rst
is physiological. The anxiety associated with the anticipation of surgery, injection of local agents,
and being aware of the surroundings during surgery can all have signi/cant hemodynamic e7ects,
which may a7ect the intraoperative anesthetic medications given during surgery. This potentially
increases the incidence of postoperative complications, particularly nausea, vomiting, and blood
pressure control. The second consideration is psychological. Anticipation of surgery often evokes
psychological symptoms due to alterations in body image, previous traumatic experiences,
unrealistic expectations about outcomes, and fear of pain or discomfort. A simple phone call from
the surgeon or anesthesiologist on the evening prior to surgery has been shown to reduce this
anxiety. Further, psychiatric disorders are not uncommon in the aesthetic population, and the risk
of postoperative psychological complications (anxiety, post-traumatic stress, panic attacks) is
predicted by their presence preoperatively. In this instance, premedication with an appropriate
anxiolytic facilitates a more even psychological state throughout the perioperative period. Notably,in patients with pre-existing psychological disorders, anxiolytics are often continued in the
postoperative period. The more common preparations of preoperative anxiolytics include oral
valium taken on the morning of surgery (10–20 mg) and Versed IV/IM (2–4 mg) used immediately
prior to entering the operating room.
Postoperative nausea and vomiting (PONV) is a signi/cant problem a7ecting approximately 30%
of patients undergoing surgery with anesthesia, and results in delayed discharge, unplanned
hospital admissions, and increased medical cost. In more severe cases, PONV can lead to wound
dehiscence, aspiration, hematoma, and severe electrolyte disturbances. Prophylaxis is commonly
used to reduce the risk of PONV, and includes the use of serotonin receptor antagonists (i.e.
ondansetron), steroids, anticholinergics, benzamides (i.e. reglan), and butyphenones (i.e.
droperidol). The speci/c management of PONV is the subject of a subsequent chapter and will not
be discussed here.
While relatively hypotensive anesthesia is preferred by many surgical subspecialties, it is of
particular importance in aesthetic surgery. Considering the elective and aesthetic nature of this
type of surgery, hematoma is a dreaded complication of most procedures and is often correlated to
the presence of pre-, intra-, or postoperative hypertension. Antihypertensive agents are used
preemptively as the stress of surgery, in/ltration, and awareness all may increase blood pressure
signi/cantly. Clonidine is a useful drug in this respect, as it reduces sympathetic outBow from the
central nervous system, suppresses the peripheral e7erent sympathetic pathways, lowers peripheral
vascular resistance, and may have sedative e7ects. Transdermal forms of clonidine are very useful
in the postoperative period to prevent hypertension in healthy patients. Alternatively,
chlorpromazine (Thorazine) is a major tranquilizer which has a sedative e7ect while acting to
lower blood pressure due to its potent α-antagonist activity.
Methods of anesthesia
Selecting the method of anesthesia is dependent on a number of factors including safety, efficiency,
cost, patient preference, surgical expertise, availability of regional or local options, skill of the
anesthesiologist, and capability of the facility. Ideally, the method chosen should have a relatively
rapid onset, provide adequate amnesia and analgesia to facilitate performing the surgical
procedure safely, and have a relatively short and complication-free recovery period. Although
general anesthesia remains one of the most common techniques, there is an increasing popularity
of local and nerve blocks combined with intravenous sedation (monitored anesthesia care) in the
ambulatory setting.
General anesthesia
General anesthesia induces a state of unconsciousness and analgesia through the use of intravenous
and inhaled agents, necessitating de/nitive airway management. It is not simply de/ned by the
presence of an endotracheal tube. Use of general anesthesia in the ambulatory setting must be
e5 cient and cost-e7ective. Although there is a higher incidence of anesthesia-related side e7ects
when compared to other methods, general anesthesia remains the most widely utilized technique.
This requires that specialized equipment, anesthesia machines, and medications are readily
available in the facility.
Airway management in general anesthesia is performed using either endotracheal intubation
or the laryngeal mask airway (LMA). Endotracheal intubation is the most invasive method and
o7ers the greatest control of the airway, particularly when there are changes in patient positioning
intraoperatively. However, aside from these particular instances, there are speci/c criteria for
intubation including airway protection (i.e. in patients at risk for aspiration), maintenance of
airway patency, pulmonary toilet, and speci/c needs to maintain oxygenation (positive pressure
ventilation, positive end-expiratory pressure). Endotracheal intubation is associated with a high
incidence of postoperative patient complaints including sore throat, cough, and hoarseness.
The alternative is the laryngeal mask airway (LMA), which is halfway between endotrachealintubation and mask anesthesia. The LMA causes minimal cardiovascular responses during
insertion, is well tolerated during maintenance anesthesia, provides a relatively secure airway, and
results in half as many airway-related complaints postoperatively. The device can also be re-used,
frequently in the outpatient setting making it a cost-e7ective airway solution. However, the LMA
does not protect the airway from aspiration, GERD, and upper airway bleeding, so its use is
cautioned in patients at risk for these issues. Many anesthesiologists utilize the LMA during
rhinoplasty because it acts as a mechanical barrier for blood, preventing it from entering the
stomach during surgery which can lead to nausea and vomiting in the postoperative period.
Monitored anesthesia care
Monitored anesthesia care (MAC) is de/ned as the presence of an anesthesiologist to monitor vital
parameters or administer supplemental drugs to patients receiving local anesthesia for surgical
procedures. Up to 50% of outpatient procedures could be performed with MAC, reducing the cost
of perioperative care up to 80% compared to general anesthesia. The preoperative workup for MAC
should be as rigorous as general anesthesia because in a very small fraction of cases, emergent
intubation may be required. In general, patients suitable for MAC are cooperative patients who
understand that they may be aware during the surgical procedure. These patients should have a
favorable airway and are undergoing relatively short procedures (<_3c2a0_h29_. contingent=""
on="" these="" parameters="" is="" the="" ability="" of="" surgeon="" to="" provide=""
excellent="" local="" _anesthesia2c_="" either="" via="" /eld="" blocks="" or="" speci/c=""
nerve="" blockade.="" mac="" associated="" with="" fewer="" post-anesthesia="" side=""
e7ects="" and="" more="" rapid="" recovery="" discharge.="" main="" disadvantage=""
lack="" airway="" _control2c_="" requires="" anesthesiologist="" carefully="" titrate=""
medications="" maintain="" spontaneous="" respiration="" while="" keeping="" patient="">
Local anesthesia
Local anesthesia is perhaps the most powerful method of anesthesia, and in skilled hands, is often
the only method of anesthesia used. Local agents block nerve conduction by altering sodium
conductance in neuron. Precision of placement (nerve blocks) and total dose (/eld blocks and
in/ltration) are important determinants in anesthetic e7ect. Central nervous system and
cardiovascular toxicity are the most common serious adverse e7ects of local anesthetics and are
directly related to dose and circulating plasma levels. The more common local agents and their
clinical characteristics are listed in Table 3.6.
Table 3.6 Local anesthetic agents
Considering the large percentage of plastic surgery procedures that involve the face, mastery
of local anesthesia in the face is critical to facilitate patient comfort during a variety of o5 ce-based
3cases. Described eloquently by Zide in 1998, complete sensory blockade of the face can be
accomplished using eight precisely placed regional nerve blocks (Fig. 3.1) with a minimal volume
of anesthetic.Fig. 3.1 Regional nerve blocks in the face. Using eight precisely placed nerve blocks, the face can
be completely anesthetized. Circles indicate the entry point of the needle, and arrows indicate the
direction of insertion and infiltration.
1. Infraorbital nerve
The infraorbital foramen opens downward and medially, approximately 5–9 mm below the inferior
orbital rim in the vertical plane of the medial limbus in forward gaze. This block is approached
from in intraoral or percutaneous route between the alar base and nasolabial fold. The needle is
inserted pointing towards the medial limbus and advanced until the foramen is entered directly or
bony contact is made, at which time the needle is “walked” up the face of the maxilla injecting
local anesthetic at points of contact until the foramen is found. Only 1–2 mL of local anesthetic is
necessary for complete blockade of the infraorbital nerve. The nasal sidewall, lower lid, cheek, and
upper lip (up to but often not including the commissure) are anesthetized using this technique.
2. Mental nerve
The mental nerve exits the foramen below the second mandibular bicuspid as a group of 2–3
fascicles, which arborize quickly to innervate the lower lip, vermillion, and chin. Frequently,
manually distracting the lip over the second bicuspid at the level of the gingivobuccal sulcus
visually exposes the mental nerve in its submucosal course, allowing for precise intraoral
placement of 1–2 mL of local anesthetic. This anesthetizes the lower lip and upper chin, but often
does not adequately a7ect the lower chin due to the deeper course of the lower mental nerve
branches and sensory myohyoid nerve. To completely anesthetize the chin, the needle is almost
completely withdrawn, redirected in a plane parallel with the face of the anterior mandible, and
advanced in a supraperiosteal plane to just beyond the lower border of the mandible. Local
anesthesia is deposited (2–3 mL) as the needle is withdrawn, anesthetizing the lower chin.
Positioning behind the head of the patient facilitates this maneuver.
3. Supraorbital and supratrochlear nerves
The supraorbital and supratrochlear nerves are blocked using one approach based on their
anatomic proximity. While palpating the supraorbital notch with one /nger, the brow is distracted
laterally with the thumb and the needle is inserted in the middle third of the eyebrow pointedtowards the supraorbital notch beneath the corrugator muscles. Local anesthesia is deposited 1 cm
prior to the notch, just above the notch, and medially at the nasal bone to include the
infratrochlear nerve. The forehead and frontoparietal scalp from the temporal line of fusion to near
midline and the medial half of the upper eyelid skin are anesthetized using this technique. It is
important to counsel patients prior to this block that some degree of periorbital ecchymosis may
4. Dorsal nasal nerve
The dorsal nasal nerve is a terminal branch of the anterior ethmoid division of the nasociliary
nerve supplying the anterior septal mucosa, lateral nasal wall, ala, vestibule, and tip. It exits the
nasal vault at the lower border of the nasal bone 5–10 mm lateral to the midline plane. While
palating the distal ends of the nasal bones between the thumb and index /nger, 1–2 mL of local
anesthesia is injected 5–10 mm lateral to midline on both sides.
5. Zygomaticotemporal nerve
One of two distal branches of the zygomatic nerve, the zygomaticotemporal nerve exits a foramen
posterior to the lateral orbital rim at or below the level of the lateral canthus to innervate an area
posterior to the lateral orbital wall above the level of the canthus back to the hairline and up to the
temporal line superiorly. While palpating the zygomaticofrontal suture, the needle is inserted
approximately 5 mm inferior to this landmark and is advanced behind the lateral orbital rim to a
point 10 mm below the level of the lateral canthus. Local anesthetic is deposited throughout the
course of the needle during withdrawal.
6. Zygomaticofacial nerve
The second distal branch of the zygomatic nerve is the zygomaticofacial nerve, which exits via one
or several foramina on the anterior surface of the zygoma. After locating the junction of the
infraorbital and lateral orbital rim by palpation, 2 mL of local anesthetic is deposited 1–2 cm
lateral to this landmark in a supraperiosteal plane anesthetizing a triangular area centered on the
cheek prominence with the apex oriented inferiorly ending at the lower border of the anterior
ramus of the mandible.
7. Great auricular nerve
The great auricular nerve emerges from behind the sternocleidomastoid muscle and continues
superiorly along its surface to innervate the lower half of the ear, postauricular skin, and variable
regions overlying the mandibular angle up to the tragus. The landmark for injection is located
along a line 6.5 cm inferior from the external acoustic meatus that intersects the mid-axis of the
sternocleidomastoid muscle. Local anesthetic is deposited on the anterior fascial surface of the
8. Mandibular division of the trigeminal nerve (V3)
The mandibular division of the trigeminal nerve innervates the majority of the cheek and pretragal
regions, and is accessed via spinal needle through the sigmoid notch 1 cm posterior to the
pterygoid plate. The sigmoid notch is palpated externally approximately 2.5 cm anterior to the
tragus as the patient opens and closes the mouth. A small amount of super/cial anesthetic is
deposited here to account for a larger needle. Next, a 22-gauge spinal needle is inserted through
the anesthetized area in a plane perpendicular to the face and advanced until contact with the
pterygoid plate, taking note of how deep the needle has been advanced (usually around 4 cm, a
plastic slide is useful in this capacity). The needle is then almost completely withdrawn, redirected
to a point 1 cm posterior to the initial point of contact, and then advanced to the same depth
measured previously. Following aspiration, 3–4 mL of local is deposited to numb the cheek area.
Office-based anesthesia
The concept of a surgeon operating from an o5 ce setting has been routinely practiced over several
decades, but the recognition of o5 ce-based anesthesia (OBA) as a subspecialty of anesthesia is
only a recent development. OBA is technically de/ned as the administration of anesthesia in a
facility not licensed as an ambulatory surgery center, which operates and is integrated into thedaily operations of a surgeon’s o5 ce. Practically speaking, there is a broad range of procedures
which utilize OBA, from very minor surgical procedures, to much more invasive procedures. The
level of surgical complexity that can be performed in this setting are highly dependent on the
surgeon’s skill and level of comfort with the procedure. Regardless, patient selection is a critical
factor in maintaining the efficiency, convenience, and cost-effectiveness of office-based procedures,
and the standards of our specialty are outlined in a task force statement from the American Society
4of Plastic Surgeons (ASPS). The basic clinical requirements for safe OBA can be summarized using
5the pneumonic POSEMED (Table 3.7).
Table 3.7 Requirements for safe office-based anesthesia
Positive pressure ventilation Small anesthesia machine or bag-mask apparatus
Oxygen Gas line or cylinders
Suction One unit with a backup
Emergency equipment Airway supplies, defibrillator, crash cart
Monitors Electrocardiogram, blood pressure, pulse oxymetry
Drugs ACLS/resuscitative agents, anesthetic agents, dantrolene
According to the ASPS, plastic surgery performed under anesthesia other than minor local with
minimal oral tranquilization should be performed in a facility that is accredited by a national or
state-recognized agency (such as the American Association for Accreditation of Ambulatory
Surgery Facilities (AAAASF), the Accreditation Association for Ambulatory Health Care (AAAHC),
or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)), certi/ed to
participate in the Medicare program under Title XVIII, or licensed by the state the facility is
6located in. Accreditation in OBS a7ords several advantages to surgeons, including facility fee
acquisition, regulation compliance, and a marketing advantage to patients familiar with o5
cebased surgery. ReBecting the growing popularity of OBA, each accrediting agency has begun to
tailor their criteria to smaller facilities to reduce the cost and administrative burden of
Intraoperative considerations
Positioning and padding the patient in the operating room is often overlooked in the busy
perioperative period. Anesthetized patients lack the normal defense mechanisms from
pressureinduced injury, and are at risk for nerve, vessel, joint, and skin injury. Particularly in body
contouring and breast procedures where several position changes are characteristic, attention to
detail in orienting and padding the patient are required. According to the ASA Closed Claims
Database (1970–1995), nerve damage (16%) was second only to death (32%) in the nature of
liability claims settled with ulnar neuropathy and brachial plexus injuries being the most
7frequent. As a result the ASA issued a practice advisory for the prevention of perioperative
neuropathies, detailing the speci/c recommendations related to upper extremity, lower extremity,
2and padding (see summary in Miller ).
Maintenance of thermal steady state requires that dissipative heat loss is balanced by heat
production. During surgery, excessive heat loss and redistribution of heat from the core to
peripheral tissues contributes to mild core hypothermia. Even mild levels of hypothermia (up to
3°C) can contribute signi/cantly to surgical outcomes, increasing morbidity of cardiac outcomes,
decreased resistance to surgical wound infections, impaired coagulation, and decreased
postoperative comfort. Prospective randomized studies have demonstrated that mild intraoperativehypothermia is associated with delayed wound healing, prolonged hospitalization, and a 3-fold
8increase in the incidence of wound infection.
Thus, in order to maintain steady state during surgery accurate core thermal monitoring must
be used to identify thermal losses, while making an e7ort to minimize dissipative heat losses and
supplementing heat production. Examples of heat supplementation include heated airway
humidi/ers, forced air warmers and blankets, and passive heat and moisture exchangers. For
surgical procedures less than 60–90 minutes in length, forced warming devices are not likely to be
cost-effective measures.
Fluid management
Optimizing cardiac function and oxygen delivery as well as maintaining electrolyte balance are the
primary goals of intraoperative Buid management. For many aesthetic procedures, Buid
management is relatively straight forward, balancing maintenance requirements with pre-existing,
surgical, and insensible losses. However, there are several procedures where Buid management
becomes more complicated. Liposuction is one such instance where large Buid volumes are instilled
subcutaneously, allowed to dwell, then partially aspirated along with subcutaneous fat. Based on
the volume of aspirate, there are speci/c resuscitation guidelines which should guide surgeons to
maintain euvolemia in the perioperative period.
Postoperative considerations
Postoperative recovery is de/ned by three overlapping phases: early, immediate, and late recovery.
Early recovery (phase I) describes the patient during emergence from anesthesia which begins with
the discontinuation of anesthetic agents. During this phase, patients regain protective airway
reBexes and motor function. Throughout early recovery, patients are assessed for criteria for
discharge from the recovery room according to the Aldrete scoring system, which incorporates
9voluntary movement, respiration, circulation, consciousness, and oxygen saturation. After
attaining an adequate score, patients can be moved out of the recovery room to intermediate
recovery (phase II), where they are prepared for discharge. With the development of shorter acting
anesthetic regimens, the concept of “fast tracking” has emerged as a cost e7ective means of
recovery. Typically, these patients achieve an adequate Aldrete score upon entering the recovery
room, and can safely be moved to phase II saving valuable recovery room resources. However, the
Aldrete scoring system does not account for postoperative emesis and pain, the two main
contributors to delayed discharge. As a result, White proposed a modi/ed scoring system to
10determine a patient’s eligibility for fast-track status. Late recovery (phase III) occurs after
discharge from the facility when patients return to their preoperative physiologic state.
During phase II, the evaluation of patient suitability for discharge often is passed from the
anesthesiologist to the practitioners sta5 ng the unit. Standardized criteria are used to ensure
patient safety and determine home readiness, and include vital signs, ambulation, nausea and
vomiting, pain, and surgical bleeding. On average, patients meet these criteria within 1–2 hours of
11surgery. The ability to tolerate oral intake is not a requirement for discharge, and patients should
not be forced to drink liquids postoperatively; oral intake has not been shown to inBuence the
incidence of nausea and vomiting. Routinely requiring patients to void postoperatively should also
be avoided, unless the ability to void is an integral part of the surgical procedure.
The most frequent post-anesthetic complications such as nausea, vomiting, pain, and
cardiovascular instability should be anticipated and addressed in the pre- and intraoperative
periods to minimize the risk of patients developing issues in the recovery phase. Other common
complications related to airway irritation (hoarseness, cough) are minor and will resolve
Malignant hyperthermia (MH) is a potentially life-threatening complication of anesthesia that
requires the availability of speci/c pharmacologic agents to treat a severe crisis. MH is a
subclinical myopathy triggered by volatile inhalational agents or succinylcholine which manifests
as a hypermetabolic state of tachycardia, hypercarbia, acidosis, rigidity and fever. Geneticallylinked to mutations in the RYR1 gene, MH can occur in patients with a family history or with no
history at all. Onset can be rapid, occurring intraoperatively or in the postoperative period and
should be rapidly identi/ed and treated with dantrolene. Because of the potentially fatal outcomes
of MH, all o5 ce and ambulatory centers that utilize inhalational agents or succinylcholine should
be equipped with an adequate supply dantrolene to treat a fulminant malignant hyperthermic
Pearls & pitfalls
• The objective of anesthesia is to maintain a state of physiologic homeostasis during the stress
of surgery.
• Several studies have demonstrated that the ability to do four or more metabolic equivalents
(METs) correlates to improved perioperative outcomes.
• Preoperative medication management is an important concept in optimizing patient
physiology before they enter the operating theater.
• While relatively hypotensive anesthesia is preferred by many surgical subspecialties, it is of
particular importance in aesthetic surgery.
• Although general anesthesia remains one of the most common techniques, there is an
increasing popularity of local and nerve blocks combined with intravenous sedation
(monitored anesthesia care) in the ambulatory setting.
• Local anesthesia is perhaps the most powerful method of anesthesia, and in skilled hands, is
often the only method of anesthesia used.
• Complete sensory blockade of the face can be accomplished using eight precisely placed
regional nerve blocks with a minimal volume of anesthetic.
• The recognition of o5 ce-based anesthesia (OBA) as a subspecialty of anesthesia is a recent
• Preoperative evaluation is to manage risk – to identify patients who are at low risk, and to
reduce these risks at the time of surgery. In some cases the risk of anesthesia is equal to or
greater than the surgical procedure at hand.
• Preop testing not indicated by medical history may lead to treatment of borderline
abnormalities, which may result in patient harm and distress.
• There is a select group of patients with signi/ cant medical problems or preoperative risk that
would benefit from an evaluation well before surgery.
• Postoperative nausea and vomiting (PONV) is a signi/ cant problem a7ecting approximately
30% of patients undergoing surgery with anesthesia.
• The laryngeal mask airway (LMA) does not protect the airway from aspiration, GERD, and
upper airway bleeding, so its use is cautioned in patients at risk for these issues.
• Malignant hyperthermia (MH) is a potentially life-threatening complication of anesthesia that
requires the availability of specific pharmacologic agents to treat a severe crisis.
1. Waters R. The downtown anesthesia clinic. Am J Surg. 1919;33(Suppl):71–73.
2. Miller RD. Miller’s anesthesia, 6th edn. New York: Elsevier/Churchill Livingstone; 2005.
3. Zide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg. 1998;101:840–851.
4. Iverson RE, Lynch DJ. Patient safety in office-based surgery facilities: II. Patient selection. Plast
Reconstr Surg. 2002;110:1785–1790. discussion 1791–1792 –
5. Koch ME, Dayan S, Barinholtz D. Office-based anesthesia: an overview. Anesthesiol Clin North
America. 2003;21:417–443.
6. Iverson RE. Patient safety in office-based surgery facilities: I. Procedures in the office-basedsurgery setting. Plast Reconstr Surg. 2002;110:1337–1342. discussion 1343–1346 –
7. Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve injury associated with anesthesia: a closed
claims analysis. Anesthesiology. 1999;90:1062–1069.
8. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of
surgicalwound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.
N Engl J Med. 1996;334:1209–1215.
9. Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth. 1995;7:89–91.
10. White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with
the modified Aldrete’s scoring system. Anesth Analg. 1999;88:1069–1072.
11. Chung F, Chan VW, Ong D. A post-anesthetic discharge scoring system for home readiness after
ambulatory surgery. J Clin Anesth. 1995;7:500–506.
12. American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation: a report by
the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology.
13. Pasternak LR. Preoperative screening for ambulatory patients. Anesthesiol Clin North America.
2003;21:229–242. vii$
Postoperative nausea and vomiting
David M. Shafer, Sheldon Opperman
The “big little problem”
The estimated incidence of postoperative nausea and vomiting (PONV) in the
general surgical population ranges from 20% to 30% and up to 70% to 80% in
high-risk patients. This adds signi cantly to the healthcare burden in terms of cost
(extended hospital stay) and patient morbidity (prolonged disability). In fact, many
patients rank PONV as the most distressing aspect of their hospital stay, reporting
that PONV is a greater concern than postoperative pain. A recent survey found that
patients are even willing to incur increased personal medical costs in an e, ort to
reduce or prevent PONV.
PONV is an important, but often disregarded, complication of the patient’s
surgical experience. Plastic surgery procedures have the highest incidence of PONV
(Table 4.1). In fact, breast augmentation has a reported 8–10× higher incidence of
PONV than other plastic surgery cases, with 42% immediate PONV and 43%
incidence 24 hours after surgery. The rami cations range from physical (increased
blood pressure potentiating postoperative bleeding, ecchymosis and edema) to
psychological (unpleasant and uncomfortable experience for the patient). PONV is
an often preventable cause of unanticipated hospital admissions, which leads to
increased labor and material costs and disruption of patient 2ow through an
already overburdened healthcare system. As the rate of elective outpatient
procedures continues to grow, any e, ective e, ort to reduce or prevent
unanticipated costs is certainly valuable.
Table 4.1 Type of surgery as a risk factor for PONV. Plastic surgery has the highest
odds ratio for PONV
Risk factors for PONVTargeted prevention of PONV
• Assessing patient risk factors (Table 4.2)
– patient characteristics
– type of anesthesia
– type and length of surgery (Table 4.1 and Fig. 4.1)
• Risk factor reduction
• Aggressive prophylaxis/combination treatment (Fig. 4.2)
– moderate-risk adults: 1 to 2 interventions
– high-risk adults: 2 or more interventions
– children: combination therapy
• Salvage treatment if prophylaxis fails.
Table 4.2 PONV risk factors
Patient-specific Anesthetic-related Surgically-related
Age Volatile anesthetics Duration of surgery
Female Nitrous oxide Type of surgery
Non-smoker Intraoperative opioids
History of PONV Postoperative opioids
History of motion sickness
Young age
Factors separated by patient-specific, anesthesia-related, and surgery-related.
Fig. 4.1 Duration of surgery as a risk factor for PONV. As the duration of surgery
increases up to 3 hours, the risk of PONV increases.$
Fig. 4.2 Patient management algorithm for PONV. Single or multiple
interventions are used depending on risk factors.
Prophylactic treatment
Nausea and subsequent vomiting are controlled by two centers in the brain, the
chemoreceptor trigger zone (CTZ) and the emetic center (EC). The CTZ is located
in the area postrema and has ve di, erent receptors which lead to activation.
These receptors also serve as targets for anti-emetic medications. Neuronal
pathways connect the CTZ to the EC, which is located in the reticular formation.
The EC is activated through these neural pathways from the CTZ or directly by the
vagus nerve resulting from gastric distension.
Known risk factors are the primary indication for PONV prophylaxis. As the
number of risk factors increases, the risk of PONV increases. In fact, a patient with
no risk factors has a PONV risk of 10%, while one risk factor gives a 20% risk. For
each additional risk factor, the risk of PONV increases by 20% (Fig. 4.3).
Fig. 4.3 Compounding risk factors for PONV. The risk of PONV is directly
proportional to the number of risk factors.
Many risk factors cannot be changed (female gender, history of PONV), while
other factors can potentially be addressed to reduce the risk of PONV. Speci cally,
if the surgical procedure can be performed under regional or local, rather than
general anesthesia, there is a potential for signi cant reduction in PONV.
Additionally, the approach to general anesthesia can be addressed to reduce PONV.As volatile anesthetics and nitrous oxide are known to be major contributors to
PONV, their use should be minimized. On the other hand, total IV anesthesia
(TIVA) utilizing propofol (Diprovan, AstraZeneca) has been shown to reduce PONV
by up to 25%. Additionally, the use of opioids, both intraoperatively and
postoperatively, is also a major risk factor for PONV. Substitution with non-opioid
pain relievers, such as non-steroidal anti-in2ammatory drugs (NSAIDs) can help
prevent PONV. Finally, high-dose use of neostigmine has been shown to exacerbate
PONV. However, this e, ect is dose-dependent and minimizing the dose decreases
the risk for PONV.
The individual patient risk factors should be considered when formulating a
treatment plan. While prophylaxis is not required for low-risk patients (<1 risk=""
_factor29_2c_="" those="" patients="" with="" moderate="" _28_1e28093_2=""
_factors29_="" require="" a="" targeted="" prophylaxis.="" prophylaxis=""
involves="" the="" use="" of="" one="" or="" more="" drugs="" from=""
different="" classes="" medications="">Table 4.3).
Table 4.3 PONV medications
Medication Class/mechanism
Ondansetron (Zofran, 5-HT -receptor antagonists3
Dolasetron (Anzemet,
Granisetron (Kytril, Roche)
Tropisetron (Navoban,
Dexamethasone (Decadron, Glucocorticoid
Droperidol (Inapsine, Akorn Butyrophenones, antagonizes dopamine and
Inc) alpha adrenergic receptors
Haloperidol (Haldol,
OrthoMcNeil Pharmaceutical)
Dimenhydrinate (Dramamine, Anticholinergic
Scopolamine (Transderm-Scop, Anticholinergic
Aprepitant (Emend, Merck) Substance P/NK1 receptor antagonist
Promethazine (Phenergan, Peripheral H -receptor antagonist1
Medications are separated by class and mechanism. Generic name (trade name,
Combination therapy is superior to monotherapy. Moderate risk patients
should be treated with medications of di, erent classes to optimize PONV
management. Common combinations include droperidol and dexamethasone or
ondansetron and dexamethasone.
High risk patients (more than two risk factors) may require triple therapy
involving ondansetron, droperidol and dexamethasone. Additionally, every e, ort
should be made to minimize anesthesia-related (regional or TIVA anesthesia
instead of general anesthesia) and surgical-related (surgical duration) risk factors.
Of note, since the most common antiemetic medications (droperidol,
dexamethasone, and ondansetron) are all low cost, highly e, ective, and safe
medications, many advocate aggressive prophylactic treatment with these
medications regardless of patient risk profile.
Common medications
See Fig. 4.2.
5-HT -receptor antagonists3
This class of drug includes ondansetron (Zofran, GlaxoSmithKline), dolasetron
(Anzemet, Sano -Aventis), granisetron (Kytril, Roche), and tropisetron (Navoban,
Novartis), which block serotonin 5-HT3 receptors. The action occurs both centrally
and peripherally, with the main action on the medulla oblongata. This class of drug
is considered quite safe, as much higher doses are typically used in the prevention
of chemotherapy-related nausea and vomiting. The recommended prophylactic dose
of ondansetron (Zofran) is 4 mg IV administered at the conclusion of surgery.
H1-receptor antagonist
Promethazine (Phenergan, Baxter) is a phenothiazine derivative that competitively
blocks H -receptors producing an antihistamine and antiemetic e, ects. The dosing1
range of promethazine (Phenergan) is 12.5 to 25 mg given either PO, IM, or IV every
four to six hours.
Dexamethasone (Decadron, Merck) is a high-potency, synthetic glucocorticoid with
anti-in2ammatory and immunosuppressant properties. When given at the
beginning of a surgical procedure, dexamethasone has been show to prevent PONV.
The initial recommended dose of dexamethasone (Decadron) is 4 to 5 mg. One study
showed a similar e, ect of 4 mg dexamethasone versus 4 mg ondansetron.
However, both medications are often used in combination therapy.
This class of drug is used as an antipsychotic and as an antiemetic, which
antagonizes dopamine and alpha adrenergic receptors. Droperidol (Inapsine, Akorn
Inc), haloperidol (Haldol, Ortho-McNeil Pharmaceutical) are the most commonly
used. Droperidol (Inapsine) is usually given at a dose of 0.625 to 1.25 mg IV at the*
conclusion of surgery. However, recent concern was raised due to the FDA advisory
for potential cardiovascular risks at higher doses. Droperidol and ondansetron have
been shown to have similar eN cacy. Haloperidol (Haldol), administered 0.5 to 2 mg
IV, is also e ective at the prevention of PONV without the side e, ects seen in the
treatment of psychiatric disorders at higher does. Haloperidol does have a risk for
QTc prolongation, so it is not a first-line recommendation.
This class of drug exhibits its anticholinergic e, ects through the inhibition of
vestibular stimulation. Dimenhydrinate (Dramamine, P, zer) is administered at a dose
of 1 mg/kg IV. Optimal timing of dosing is not established.
Transdermal scopolamine
Scopolamine (Transderm-Scop, Baxter) is an anticholinergic medication which is
administered via a transdermal patch. Ideal application of scopolamine is 4 hours
prior to the surgical procedure, due to the slow onset of action. Each patch contains
1.5 mg scopolamine.
Substance P/NK receptor antagonists1
Substance P is an important neuropeptide released from primary nerve endings in
the CNS and peripheral nervous system. It belongs to the tachykinin family of
neurotransmitters and has a strong aN nity for NK receptors, which are highly1
concentrated in the brainstem vomiting center. Aprepitant (Emend, Merck) is a
Substance P/NK1 receptor antagonist available in both oral (40 mg given prior to
induction of anesthesia) and IV forms (Fosaprepitant, Merck).
Ineffective medications
Several medications have been shown to be ine, ective in the treatment of PONV.
These include metoclopramide (Reglan, Baxter), ginger root, and cannabinoids
such as nabilone (Cesamet, Valeant Pharmaceuticals International) and
Non-medical interventions
While this chapter concentrates on the medical prevention and therapy for PONV,
one must also consider non-medical, complimentary approaches. Patient education
about PONV should be included in preoperative counseling. Additionally,
approaches such as acupressure (Sea-Band or Relief-Band) and meditation may be
useful for those patients that are motivated by non-traditional methods.
Intractable nausea and vomiting
In the event that prophylactic measures to prevent PONV fails (PONV within 6
hours of administration of antiemetic or PONV without prophylaxis), aggressive
salvage treatment must be initiated to prevent further worsening of PONV. The
initial medication should be chosen from a class di, erent than that used for
prophylaxis. If no PONV prophylaxis was used, then the 5-HT -receptor antagonists3$
(ondansetron/Zofran) are the , rst-line treatment. However, lower doses may be just
as e, ective (1 mg IV ondansetron versus 4 mg IV). An additional recovery regime
includes 2 to 4 mg IV or dexamethasone, 0.625 mg of IV droperidol, and 6.25 mg
IV of promethazine. Finally, under monitored conditions, 20 mg IV of propofol
(Diprivan, AstraZeneca) can be administered for rescue therapy. If PONV returns
more than six hours after first administration of antiemetic, then a repeat dose from
the same class of medication is acceptable. Finally, inhaled isopropyl alcohol in the
rst 24 postoperative hours has been shown to be an e, ective intervention for
Post-discharge nausea and vomiting
While the major focus is on PONV in the in-patient and monitored setting,
postdischarge nausea and vomiting (PDNV) presents a considerable obstacle. Nearly
80% of PONV occurs within 48 hours of surgery. However, 65% of patients do not
experience PONV symptoms until after leaving the recovery room. With the
increasing shift to ambulatory or out-patient, oN ce-based surgery, PDNV
prevention and treatment require greater attention. Prophylactic, combination
therapy employed prior to, during, and after the procedure is most e, ective.
Additionally, the oral disintegrating form of ondansetron (Zofran ODT,
GlaxoSmithKline) is available in 4 mg and 8 mg doses for post-procedure treatment
and scopolamine (Transderm-Scop, Baxter) patches are useful for continued
postprocedure treatment.
Pearls & pitfalls
• Identify patient risk factors for PONV
• Reduce baseline risk factors
• Prophylactic measures are effective
• Utilize combination therapy
• Inhaled isopropyl alcohol is an effective postoperative intervention
• Carefully identify risk factors
• Recognize failed prophylaxis
• Switch class of medication if same class already failed
• Employ aggressive salvage therapy if needed
• Be aware of delayed or post-discharge nausea and vomiting
1. PONV presents a common but often preventable phase of postsurgical care.
2 . One must rst identify patients at highest risk for PONV (females,
nonsmokers, and previous history of PONV) and aggressively employ prophylacticmeasures.
3. Single agent prophylaxis may be adequate for patients with no risk factors or
a single risk factor.
4 . Combination therapy with multiple medications from di, erent chemical
classes is superior to mono-therapy when approaching patients with multiple
risk factors.
5 . Salvage therapy employs additional medications from additional chemical
Further reading
American Society of PeriAnesthesia Nurses. ASPAN’s Evidence-Based Clinical Practice
Guideline for the Prevention and/or Management of PONV/PDNV. J PeriAnesthes
Nurs. 2006;21(4):230–250.
Apfel C. Postdischarge nausea and vomiting: risk assessment and treatment
strategies. Anesthesiology News January. 2008:1–7.
Cotton JW, Rowell LR, Hood RR, et al. A comparative analysis of isopropyl alcohol
and ondansetron in the treatment of postoperative nausea and vomiting from the
hospital setting to the home. AANA. 2007;75(1):21–26.
Gan TJ, Consensus Guidelines for the Management of PONV. Littleton, CO: Medical
Education Resources and Applied Clinic Education, 1 January 2008.
Glass PS. Practice Guidelines for the Management of Postoperative Nausea and
Vomiting: Past, Present, and Future. Internat Aesthes Res Soc. 2007;105(6):1228–
Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia Guidelines for
the Management of Postoperative Nausea and Vomiting. Ambulat Anesthesiol.
Gan TJ, Sloan F, Dear Gde, et al. How much are patients willing to pay to avoid
postoperative nausea and vomiting? Anesth Analg. 2001;92:393–400.
Sinclair DR, Chung F, Mezei G. Can postoperative nausea and vomiting be
predicted? Anesthesiology. 1999;91:109–118.&
Patient safety in aesthetic surgery
Mark Jewell
Much of my inspiration to write and teach about patient safety comes from Lucian
Leape MD, my professor of pediatric surgery at the University of Kansas. Dr Leape
ultimately left Kansas and went to Harvard School of Public Health, where he
focused on patient safety and the ways that mistakes and errors in healthcare
delivery could be minimized. Dr Leape was also one of the authors of Crossing the
1Quality Chasm book which de ned key quality issues in healthcare delivery. My
thinking has been in uenced by Steve Spear PhD and Mark Graban, who have
2gone beyond Dr Leape’s Institute of Medicine book, To Err is Human by applying
aspects of the Toyota Production System and Lean Manufacturing to healthcare
3,4delivery. While immediate focus has been on how to make the delivery of
healthcare safer, there are other widespread defects of dignity, comfort, satisfaction
and wasteful allocation of precious resources that will take longer to improve.
In writing this chapter, I also looked to other areas where there have been
remarkable advances in safety and de ned processes to accomplish outcomes.
When one looks at the data, as of January 2009, there has not been a fatality in
United States domestic air carriers due to an accident for the preceding 24 months.
This accomplishment relates to the application of CRM (crew resource
management) processes for safety. This is centered around pre- ight
brie ngs/debrie ngs, working with checklists, and dealing with errors. The recent
e8ectiveness of CRM was proven in a crash of US Airways ight 1549 (January
2009) into New York’s Hudson River in which all passengers and crew survived,
largely on the ability of the pilot and crew to manage the scenario of power loss at
takeoff due to bird strikes.
Whether it is a manufacturing (Toyota Production System, Lean
Manufacturing) or aviation-based (CRM) process for the development of a patient
safety, there are two di8erent, yet e8ective processes that can be adapted to
produce excellent programs that will make a di8erence in your clinic and surgical
The process of patient safety
While we are concerned about serious episodes in healthcare delivery that involve
harm to patients, the e8ective remedy is not to browbeat those who deliver care by
demanding that they give safer care. What is needed is a fundamental redesign of
the process and ways to cross as the book mentions, the “quality chasm” in
delivering both quality and safety.
If one looks for comparisons in other areas of American industry, large
hospitals compare nicely with the likes of General Motors and Ford. Quality
improvement in both GM/Ford and large hospitals is an episodic adventure, goal-$
oriented, and too often, a “special campaign” that lacks support from the workers.
Although, progress has been made in some areas, there seems to be sometimes a
greater focus on the “look what we have done” instead of this is how we do
something well, time and time again. The presence of an unknown individual with
a clipboard on the surgical unit usually heralds yet another ill-conceived quality or
safety initiative.
There are divergent approaches to quality improvement and patient safety in
medical care. For individuals who work in hospitals, there is a distinct Joint
Commission of the Accreditation of Healthcare Organizations (JCAHO)
“JCAHOmindset“ regarding policies, processes, and procedures about patient safety that
seem to interfere with how surgeons function and how sta8 thinks that an
operating room should function in the real world. For individuals who work in out
of hospital environments, including oC ce based surgery units, there seems to be
less preoccupation with a “JCAHO boogeyman” and more on how patient safety
and care quality can be improved with each patient interaction. Currently, a
majority of patient care is rendered in facilities that are outside of a
“JCAHOblessed” workplace. Published reports in the literature substantiate that outcomes
are as good or better in out-of-hospital surgical facilities that are accredited by
5other organizations.
Too often in the JCAHO, approach to providing solutions for patient safety,
important components of safety and quality are overlooked. For instance, the
xation with the “time out” exercise before starting surgery only covers a single
dimension of a “surgical destination,” that says what procedure is being performed
and the surgical site. What’s missing here is the really important stu8, like a status
check of the patient in terms of “being ready for surgery.” I cannot think of a
surgeon or the captain of an airliner ready for takeo8 who would be angered if a
subordinate gave them a status report that covered the requisites of prophylactic
antibiotics having been administered, DVT prophylaxis, warming blanket to
prevent hypothermia, and the implants that you speci ed are in the room.
Otherwise, the “time out” does not allow for e8ective communication in a
team6oriented workplace.
There is literally no way in large hospital settings to stop a faulty process once
it has been placed in motion. On the other hand, there is a reliance on alternative
processes called “work-arounds” to remedy a faulty process. We all have been in
the uncomfortable position of having a surgery underway and discover that needed
items such as implants are nowhere to be found, or that the patient did not receive
prophylactic antibiotics. If this occurred in a Japanese factory, a worker would pull
the Andon cord to stop the production line when a defect was noted in order to
stop the line and prevent defective work from occurring.
All plastic surgeons want to avoid the downward spiral of complications,
dis gurement, disability, re-operations, emotional distress, claims for professional
liability, and increased regulatory oversight. If we look to other industries, namely
aviation and Toyota automotive, there have been developed surprisingly e8ective
processes to improve quality, minimize mistakes, and change a culture of workers.
Achievement of a superior surgical outcome should always be followed by
re ection on what went right and what mistakes were avoided as a means of
learning how to repeat such results consistently. Conversely, when failures occur,
progress toward improvement is often impeded when we engage in unscienti c
analysis or resort to naïve investigations, reprisals, and secretive behavior that is$
7often seen in institutions.
For example, the problem of deep vein thrombosis with ensuing pulmonary
embolism remains a vexing safety issue in all surgical patients, yet simplistic
responses by state regulatory agencies to limit oC ce-based surgery do not prevent
its occurrence or morbidity/mortality in other venues. What is needed here is for
the real problem to be addressed through scienti c inquiry that will provide
solutions. Directed research by plastic surgery foundations would be a good starting
Various approaches to reducing patient injuries, improving outcomes, and
decreasing the cost of healthcare delivery have been suggested by organizations
concerned with improvements in patient safety. Some represent Band-Aid patches
to problems; others – such as careful hand-washing and safe-site surgery – are
simply common sense. Ill-conceived patient safety initiatives can impair the
credibility of better-conceived attempts to improve patient safety.
At the time of this writing, physicians lack e8ective knowledge-management
programs with which to capture and promulgate the lessons learned from both
successful and unsuccessful surgical initiatives. If organizations within plastic
surgery choose to raise the performance bar to improve patient safety, it is
imperative that a structured framework of research and educational initiatives be
set in place that will provide a comprehensive curriculum for our community of
caregivers. Ideally such initiatives will take advantage of Internet-based technology
and other electronic information resources so that meaningful data can be made
available quickly and easily.
How to create a culture of safety and quality (steps you do
with your staff)
1 . Identify areas where improvement is needed, i.e. your reoperation rate in
breast augmentation.
2. Establish a goal, i.e. making elective surgery safer by lowering the re-operation
3. Defining (map) the process that needs improvement.
4. Develop documents and tools that enable the process to be de ned better for
patients and staff (Cycle of Care) concept.
5. Minimize mistakes and errors that can occur in the process.
6. Eliminate work-arounds in the process.
7. Measure your progress against benchmark values.
8. Institutionalize your progress and use it as a way to start other quality and
safety programs.
Here are some additional thoughts on how to develop a systematic approach to
• Put patient at center of process
– Increase awareness and accountability for their own safety and clinical
• Safety is a management and leadership priority
– Empower staff to troubleshoot and innovate$
– Communicate and verify safety practices
– Help each other achieve safe outcomes
• Staff accountability
– Recognize and deal with staff underperformance
– Non-punitive error reporting.
Delivery of operational excellence requires that work-arounds are eliminated
and ambiguities regarding decision areas in planning, care delivery, and patient
3management. As Steven Spear wrote in his Harvard Business Review article,
“People confront the same problems, encountered every day, for years, manifested
as irritations, ineC ciencies, and occasionally catastrophes.” Poor designed systems
are set ups for failure and trying harder by working around the problem is not the
correct way to solve it. It is only through the e8orts of all involved that a better
design evolves to avoid defective work or unsafe care. When caregivers are
involved in the solution to a problem, there is generally improvement of a process,
versus top-down management.
At ASAPS, a dedicated group of physicians, led by James Matas MD,
8undertook a project to develop the “Cycle of Care” product. This was the rst time
that the entire cycle of care was looked at from the rst interaction with a patient
until their chart was put back in the record room at the end of the care cycle. By
de ning a process and the critical in ection points, care could be improved. From
an information systems perspective, the amount of information available to make a
determination that a patient meets criteria for safe surgery helps make this a simple
yes or no decision. Forms and check lists are useful for surgical planning and to
document what has been accomplished in preparing for surgery (Box 5.1).
Aftercare teaching is equally important regarding wounds, drains, nausea, and
danger signs.
Box 5.1
Forms and check lists for surgical planning. The Cycle of Care was envisioned as a “backbone” that could be customized
by the end user as a way to lay out the roadmap of what happens during the care
of a patient. It is an e8ective way to help understand what has been accomplished
in preparing a patient for surgery and documents the quality of care delivered. This
also helps minimize mistakes in planning for surgery, aftercare, and medications
(Fig. 5.1).$
Fig. 5.1 ASAPS Cycle of Care.
In addition to the Cycle of Care concept, other areas of patient safety deserve
attention. These represent signi cant areas where improvements can be made to
prevent a majority of problems:
1. Timely administration of IV antibiotics before surgery.
2. Avoidance of hypothermia during and after surgery.
3. DVT prophylaxis (foot pumps and fractionated heparin).
4. Avoidance of dry eyes during deep sedation or general anesthesia.
5 . E8ective management of lidocaine-containing wetting solutions along with
volumes of lipoaspirate during lipoplasty.
6. Documentation of allergies, currently used prescription and over-the-counter
medications, herbal/dietary supplements, and smoking status during the
preoperative planning for surgery.
7. Placing the patient at the center of the process by having increased awareness
and accountability for their own safety and clinical decisions.
Specific “problematic” topics in patient safety
Methycillin-resistant Staphylococcus aureus (MRSA)
The matter of MRSA whether community-acquired or hospital-acquired is
9problematic even in a practice that is oriented towards aesthetic surgery . It
requires a di8erent mindset for all caregivers in terms of meticulous hand washing,
use of alcohol or alcohol-chlorhexidine hand sanitizers, protective gloves, disposal$
of medical waste, and sanitation of the patient care areas and surfaces. MRSA can
be brought into the office by something as innocuous as a stitch abscess or impetigo
on a child who is accompanying their parent during an oC ce visit. Suspected
infections in patients should be cultured and MRSA-e8ective drugs administered, if
a Gram-stain is positive for cocci, pending culture and sensitivities to con rm
Smoking and nicotine use
10Smoking remains an area of risk in aesthetic surgery. Rees, in 1984, described a
13-fold increase in skin necrosis in smokers undergoing rhytidectomy. Other reports
show increased risk for other procedures involving aps. Nicotine remains a very
addictive drug, with a high rate of recidivism in those trying to stop its use. I have
found it necessary to give patients enough time to successfully stop smoking before
surgery of 6 weeks versus shorter periods of time. There still is no consensus on
what is the minimum amount of time that a patient has to be 100% smoke-free to
be safe from nicotine-induced skin necrosis. It is useful in the preoperative
examination to have a patient attest to their smoking and nicotine status. If there is
concern regarding compliance, a dipstick urinary continine test can be performed. I
have found it helpful not to do the testing on the day or surgery, but two weeks
before the scheduled date in order to have time to ll the time, if the test is positive
11and surgery cannot be performed.
Deep vein thrombosis (DVT)
Even in aesthetic surgery, DVT can occur. Reinisch studied DVT during
rhytidectomy and noted 84% of the DVT and pulmonary embolisms were
12associated with general anesthesia. The take-home message here is that e8ective
measures such as foot pumps or sequential compression stockings must be used to
minimize risk. Chemoprophylaxis with low molecular weight heparin, interestingly
13added the risk of a 16% hematoma complication.
Abdominoplasty remains a situation with increased morbidity and mortality as
compared to other aesthetic procedures. There has been surprisingly no research
14into why abdominoplasty is 20 times more lethal than lipoplasty. DVT
prophylaxis, early mobility, and the avoidance of Foley catheters and bedpans
15appear to be successful in diminishing the risk of complications.
The matter of estrogen supplements and oral contraceptives still lacks
consensus regarding management in the perioperative period. If you elect to have a
policy on the discontinuation of oral contraceptives by patients undergoing elective
surgery on grounds that you are trying to diminish risk of DVT, be certain to
recommend alternative forms of birth control.
Lipid emulsions for the treatment of lidocaine/bupivicaine toxicity
The use of Intralipid as a means to resuscitate asystole and CNS toxicity is a novel
16approach to treat lidocaine and bupivicaine toxicity. Additional information may
be found at
Beta-blockers in patients undergoing elective surgery$
The use of beta-blockers in patients with documented coronary artery disease has
been shown to decrease mortality. While most aesthetic surgery patients are ASA I–
II classi cation, there are individuals that are ASA III, with stabilized systemic
disease, hypertension, coronary artery disease, who seek aesthetic and
reconstructive procedures. The use of beta-blockers to mitigate perioperative
17myocardial infarction and arrhythmia is a consideration.
Plavix®/aspirin withdrawal in patients who have cardiac stents
The use of stent devices for the treatment of coronary artery disease is
commonplace. Besides the use of drug-eluting stents to limit restenosis, adjunctive
®treatment includes anti-platelet drugs such as aspirin and Plavix (clopidogrel).
Decisions to withdraw stent patients from the anti-platelet therapy deserve
forethought and discussion with the patient’s cardiologist. Informed consent
discussions in stent patients is essential to cover the potential for myocardial
infarction and stent occlusion. Late stent thrombosis can occur in situations where
18patients have completed the recommended 12 months of anti-platelet therapy.
As a surgeon, you are in the best position to de ne a culture of safety and quality
both in the oC ce and your surgical unit. Much progress can be made in quality
and safety if you look at the cycle of care and determine where improvement is
needed. If problems occur, take the time to analyze the mistakes that were made
and improve the process versus making the same mistake twice. The ASAPS Cycle
of Care product is an excellent starting point for you to develop a process of safety
and quality.
1. Institute of Medicine. Crossing the quality chasm. National Academies Press; July
2001. 337 pp
2. Corrigan J, Kohn L, Donaldson M. To err is human: building a safer health system,
1st edn. National Academies Press; 15 April 2000. 287 pp
3. Spear S. Fixing healthcare from the inside, today. Harvard Business Review.
September 2005.
4. Graban M. Lean Hospitals: Improving quality, patient safety, and employee
satisfaction, 1st edn, Productivity Press, University Park, IL
5. Jewell M. Medical errors in aesthetic plastic surgery. Aesthet Plast Surg.
6. Keyes G, Singer R, Iverson R, McGuire M, Yates J, Gold, Thompson D. Analysis of
outpatient surgery center safety using an internet-based quality improvement and
peer review program. Plastic Reconstr Surg. 2004;113(6):1760–1770.
7. Jewell M. Patient safety data: how it can improve our performance. Aesthet Surg J.
8. The American Society for Aesthetic Plastic Surgery. Cycle of Care Workbook.
ASAPS. 2006.
9. Chambers H. Community acquired MRSA-resistance and virulence converge.
NEJM. 2005;352:1485–1487.10. Rees T, Liverett D, Guy C. The effect of cigarette smoking on skin-flap survival in
the face lift patient. Plastic Reconstr Surg. 1984;73(6):911–915.
11. Jewell M. Smoking in plastic surgery. In: ASPS Patient Consultation Resource Book.
The American Society of Plastic Surgeons; 2006.
12. Reinisch J, Bresnick S, Walker J, Rosso R. Deep venous thrombosis and
pulmonary embolus after face lift: a study of incidence and prophylaxis. Plastic
Reconstr Surg. 2001;107(6):1570–1575.
13. Durnig P, Jungwirth W. Low-molecular-weight heparin and postoperative
bleeding in rhytidectomy. Plast Reconstr Surg. 2006;118(2):502–507.
14. Hughes C. Reduction of lipoplasty risks and mortality: An ASAPS survey. Aesthet
Surg J. 2001;21:120–127.
15. Stevens WG, Vath S, Stoker D. “Extreme” cosmetic surgery: a retrospective study
of morbidity in patients undergoing combined procedures. Aesthet Surg J.
16. Weinberg G. Lipid rescue resuscitation from local anaesthetic cardiac toxicity.
Toxicol Rev. 2006;25(3):139–145. [Review] –
17. Poldermans D, Boermsa E. Beta-blocker therapy in non-cardiac Surgery. NEJM
Editorial. 2005;353:412–414.
18. Vaknin-Assa H, Assali A, Ukabi S, Lev EI, Kornowski R. Stent thrombosis
following drug-eluting stent implantation. A single-center experience. Cardiovasc
Revasc Med. 2007;8(4):243–247.Section 3


Facelift anatomy, SMAS, retaining ligaments and
facial spaces
Bryan Mendelson
Anatomically correct facial rejuvenation surgery is the basis for obtaining natural
appearing and lasting results. The complexity of the anatomy of the face, and especially
that of the midcheek, accounts for the formidable reputation of facial surgery. This is to
the extent that many surgeons design their rejuvenation procedures around an avoidance
of anatomical structures, and thereby limit the intent to camou aging of the aging
The purpose of this chapter is to establish a foundation for the advancement of facial
rejuvenation surgery by de ning clear general principles as the basis for a sound
conceptualization of the facial structure.
A proper anatomical understanding is fundamental to mastery in facial rejuvenation
for several reasons. The pathogenesis of facial aging is explained on an anatomical basis,
and particularly the variations in individual patients. This is the basis of preoperative
assessment from which follows a rational plan for the correction of the changes. The
anatomy explains the di erences between the many procedures available and the
apparent similarities in their results. An accurate intraoperative map of the anatomy is
essential for the surgeon for e cient and safe operating with minimal morbidity, and
specifically addressing appropriate concern for the facial nerve.
Functional evolution of the face
The anatomy of the face is more readily understood when considered from the
perspective of its evolution and the function of its components (Fig. 6.1). Located at the
front of the head, the face provides the mouth and masticatory apparatus at the entrance
to the embryonic foregut, as well as being the location for the receptor organs of the
special senses: eyes, nose and ears. The skeleton of the face incorporates a bony cavity for
each of these four structures. Those for the special senses have a well-de ned bony rim,
in contrast to the articulated broad opening of the jaws covered by the oral cavity. The
soft tissues of the face, integral to facial beauty and attraction, are in reality, dedicated
entirely to their functions.


Fig. 6.1 Functional evolution of the facial skeleton, from the primordial vertebrate, sh
through to the primate chimpanzee (center) and to the human. The facial skeleton
supports four bony cavities whose size and location relate to their speci c function. The
eyes move to the front for stereoscopic binocular vision, while the nasal aperture is
reduced, due to the lesser importance of olfaction. The ear remains in its original location,
at the back of the face. The location of the orbits alters subsequent to cranial growth,
which creates a new upper third of the face.
The soft tissue overlying each cavity undergoes modi cations to form the cheeks,
including the lips, the eyelids, the nose, and the ears. For each there is a full thickness
penetration through the soft tissue, around which super cial facial muscles are located
for control of the aperture of the functioning shutter. This is most evident for the lids and
lips in the human. While the primary function of the sphincteric shutters is to protect the
contents of the cavities, they are further adapted to a higher level of functioning for the
additional roles of expression and communication. The degree of precision required for
this important secondary function requires the muscles to be more nely tuned and the
soft tissue xation modi ed, to allow mobility. The balance between these two opposing
functions, movement and stability, is integral to the facial structure. Aging brings with it
a change of the youthful balance, leading to an altered expression on activity and at rest.
It is a major surgical challenge to restore the youthful balance following rejuvenation
surgery and to have normal dynamic appearance.
The combination of continued movement and delicate xation of the tissues is the basis
for the ligamentous laxity that predisposes to the characteristic sagging changes of the
aging face.
Regions of the face
The traditional approach to the face in thirds (upper, middle and lower) while useful,
limits conceptualization, as it is not based on the evolving structure. The signi cant
muscles of facial expression are all located on the front of the face (anterior aspect)
predominantly around the eyes and mouth, where their e ect is seen in communication.
For these functional reasons the anterior aspect of the face contains the more delicate
expressive areas, which are prone to developing aging changes (Fig. 6.2).

Fig. 6.2 Regions of the face. The xed lateral face (shaded) overlies the masticatory
structures and is separated from the mobile anterior face by the vertical line of facial
ligaments (red). These ligaments are, from above: temporal, lateral orbital, zygomatic,
masseteric and mandibular. The muscles of facial expression are within the anterior face.
The midcheek is split obliquely into two separate functional parts in relation to the two
adjacent cavities. The periorbital part above, (blue) and the perioral part below (yellow),
share the midcheek and meet at the midcheek groove (oblique dotted line).
In contrast, the lateral face is relatively immobile as it passively overlies the
structures to do with mastication, which are all deep to the investing deep fascia. These
are the temporalis and masseter on either side of the zygomatic arch, along with the
parotid and its duct. The only super cial muscle in the lateral face is the platysma in the
lower third, which reaches no higher than the oral commissure. Internally, a distinct
boundary separates the mobile anterior face from the lateral face. The vertically oriented
line of retaining ligaments attached to the facial skeleton forms this boundary (Fig. 6.2).
The anterior aspect is the region of the face requiring rejuvenation.
From the perspective of priorities in rejuvenation surgery, the midcheek is the most
important area of the face, because of its prominent central location between the two
facial expression centers, the eyes and the mouth. The periorbital and the perioral parts

overlap in the midcheek (Fig. 6.2). The periorbital part overlies the body and orbital
process of the zygoma, while the perioral part overlies the maxilla, a bone of dental
origin. The functional parts are inherently mobile and meet at the relatively immobile
boundary that extends in an oblique line across the midcheek. This is the midcheek
1groove formed by the dermal extensions of the zygomatic ligaments (Fig. 6.3).
Fig. 6.3 The internal structure of the midcheek is revealed by its surface anatomy when
aging changes are present. The two functional parts of the midcheek relate to the
underlying cavities and are separated by the oblique line of the midcheek groove (3)
which overlies the skeleton. The midcheek has three segments. The lid–cheek segment
(blue) and the malar segment (green) are within the periorbital part and are adjacent to
the nasolabial segment (yellow) in the perioral part, which overlies the vestibule of the
oral cavity. The three grooves de ning the boundaries of the three segments interconnect
like the italic letter Y. The palpebromalar groove (1) overlies the inferolateral orbital rim
and the nasojugal groove (2) overlies the inferomedial orbital rim, then continues into the
midcheek groove (3). Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek:
facial layers, spaces, and the midcheek segments Clin Plast Surg 2008;35:395–404.
The soft tissue of the anterior face is further subdivided according to: where it
overlies the skeleton and: where it overlies a bony cavity. The soft tissue is modi ed
where it forms the lid and the mobile cheek because there is no underlying deep fascia.
The transitions that de ne the part of the cheek overlying bone (the malar segment), and
the mobile extensions (lower lid and the mobile cheek, nasolabial segment) are not visible
in youth due to the shape of the youthful midcheek, which has a compacted rounded
fullness. Subsequently, these transitions do become visible due to aging laxity in the
The facial nerve in relation to regions of the face

The level in which the facial nerve branches travel relates to the region of the face (Fig.
6.4). In the lateral face below the zygomatic arch the branches remain deep to the
investing deep fascia. In the anterior face (and above the lower border of the zygoma) the
branches are more super cial in relation to their muscles. The transition in levels occurs
at the retaining ligament boundary, which is the last position of stability before the
mobile anterior face. The nerves are protected here as they course outward to their nal
Fig. 6.4 The layers of the face. The ve layers of the scalp are a prototype of facial
anatomy and the simpler basis for the more complex structure elsewhere on the face.
Layer 4 is the most changed layer, consisting of alternating spaces and ligaments. The
course of the facial nerve changes level at the ligamentous boundary transition from the
lateral to the anterior face. Mendelson BC, Jacobson SR. Surgical anatomy of the
midcheek: facial layers, spaces, and the midcheek segments; Clin in Plast Surg
Layers of the face
The principles of facial structure can be summarized quite simply:
1. The scalp is the basic prototype for understanding facial anatomy, as it is the least
differentiated part of the face (Fig. 6.4).
2. The face is constructed of concentric soft tissue layers over the bony skeleton.
3. The ve layers of the scalp are: (i) skin; (ii) subcutaneous; (iii) musculo-aponeurotic;
(iv) areola tissue; (v) deep fascia.
4. The layers are not homogenous over the face proper, as they are modi ed in areas of
5. The key areas of function overlie the bony cavities, especially the eyelids and the
cheeks and mouth.
6 . A multilinked brous support system supports the dermis to the skeleton (Fig.
26.5). The components of the system pass through all layers.
7. At the transition between that over the skeleton to that overlying the cavities (eyelids

and mouth) there is a modification of the anatomy.
8. The complexity of the facial structure results from the balance required between
mobility and stability (ligamentous support).
Fig. 6.5 The ligaments of the multi-link brous support system of the face can be
likened to a tree. This system attaches the soft tissues to the facial skeleton; it links all
layers of the face. The retaining ligaments are attached to the periosteum and deep
muscle fascia and fan out via a series of branches into and through the SMAS. In the outer
part of the subcutaneous layer, the increased number of progressively ner retinacular
cutis fibers securely grasp the dermis.
It should be remembered that the complexity of the facial structure is entirely due to
the bony cavities and their functional requirements. Transitional anatomy occurs at the
boundary of the cavities, as in the scalp where the complexity of the glabella occurs
where the forehead adjoins the orbital and nasal cavities. Here, the deeper facial muscles
and related retaining ligaments attach to the skeleton.
Details of the layers
Layer one – skin
The structural collagen of the dermis is the outermost part of the brous support system
and is intrinsically linked, both embryologically and structurally, with the collagenous
tissue of the deeper layers. The thickness of the dermal collagen relates to its function,
and tends to be in inverse proportion to its mobility. The dermis is thinnest on the eyelids
and thickest on the forehead and nasal tip. The thinner, more mobile dermis is
susceptible to an increased tendency for aging changes.
Layer two – subcutaneous
The subcutaneous layer has two components: (i) the subcutaneous fat, which provides
volume and mobility, is supported by (ii) the brous retinacular cutis that connects the
dermis with the underlying SMAS. Both components vary in amount, proportion and
arrangement according to the specific region of the face.
In the scalp, the subcutaneous layer has a uniform thickness and consistency of!




xation to the overlying dermis, whereas, over the face proper, the subcutaneous layer
has considerable variation in thickness and attachment. In the high function mobile areas
bordering an aperture such as the pretarsal part of the eyelid and the lips, this layer is
compacted and subcutaneous fat is not present, so that the layer appears to be
Each of the three midcheek segments has a distinctly di erent thickness of
subcutaneous fat. The subcutaneous layer is thinnest in the lid–cheek segment adjacent to
the lid proper. In the malar segment the layer is moderately thick and uniform, whereas it
is markedly thicker in the nasolabial segment, which has the thickest layer of
subcutaneous fat of the face. Where the subcutaneous fat is thicker, the retinaculum
bers are lengthened and more prone to weakness and distension. The thick
subcutaneous fat in the nasolabial segment is named the malar fat pad, which is
confusing terminology given that its position is predominately medial to the prominence
3,4of the zygoma in the perioral part of the midcheek (Fig. 6.2).
Within the subcutaneous layer, the attachment to the overlying dermis is stronger
than on its deep surface, due to the tree-like arrangement of the retinacular cutis bers
(Fig. 6.5). In super cial, i.e. subdermal, dissection of the subcutaneous layer, many ne
retinacula cutis bers are encountered. At the interface with the underlying layer 3, there
are fewer, though larger bers and less subcutaneous fat, which appears not to descend
fully to the interface where it overlies the super cial muscles, orbicularis oculi and
This explains why surgically the subcutaneous layer can be more easily dissected o
the outer surface of the underlying muscle layer (orbicularis oculi and platysma) than
over other parts of layer 3.
The retinacular bers are not uniform across the face, but vary in their orientation
and arrangement according to the region. This variation mirrors the anatomy of the
underlying 4th layer. As will be more apparent when the 4th layer is discussed, the line of
retaining ligaments continue vertically through the subcutaneous layer to form septae,
5that form boundaries which compartmentalize between more mobile areas. Accordingly,
where the subcutaneous layer overlies spaces (in the 4th layer) there are no vertically
oriented subcutaneous ligaments extending through. In contrast, the retinacular bers
overlying the spaces have a predominantly horizontal orientation, being in strata-like
layers that are less restrictive to underlying movement.
Clinical correlation
The variation in the arrangement of the retinacular cutis bers accounts for the
variability in ease of subcutaneous dissection between di erent parts of the face. Where
the subcutaneous dissection overlies a space and the retinacular cutis bers are more
horizontal, the subcutaneous layer tends to separate relatively easily, often with simple
blunt dissection. Where the subcutaneous dissection directly overlies a facial ligament,
the vertical septae are responsible for a rmer adhesion between the SMAS and the
dermis. Sharp dissection is usually required for release here.
Layer three – musculo-aponeurotic
To ful ll its functional role, the face contains skeletal muscle within its soft tissue
structure. These ‘intrinsic’ muscles of facial expression are fundamentally di erent to
skeletal muscles beneath the deep fascia, which move bones, because they move the soft
tissues of which they are a part. All the muscles of the face are within this layer, enclosed
to a varying degree within a fascial covering and lining. The muscles are all derived from
the embryonic second branchial arch. The muscle precursors migrated into the facial soft
tissues in a series of laminae, each lamina being innervated by its own branch of the
facial nerve. While the de nitive muscles have subsequently lost continuity with their