- •Foreword
- •Preface
- •Contributors
- •Reference
- •2 Evaluation of the Cosmetic Patient
- •The Eightfold Path to Patient Happiness
- •Listen to Your Patient Before Surgery (or you will surely have to listen to them after)
- •Document and Demonstrate
- •Ensure Appropriate Patient Motivation
- •Determine Realistic Surgical Goals
- •Conduct a Thorough Informed Consent
- •Create an Aesthetic Environment
- •Topical Ocular Anesthetics
- •Lidocaine
- •Bupivacaine
- •Epinephrine
- •EMLA
- •Other Topical Anesthetics
- •Bicarbonate
- •Benzyl Alcohol
- •References
- •Facial Nerve Blocks
- •Retrobulbar and Peribulbar Blocks
- •References
- •Sensory Nerve Blocks
- •Lacrimal Nerve Block
- •Frontal Nerve Block
- •Nasociliary Nerve Block
- •Infraorbital Nerve Block
- •Zygomaticofacial Nerve Block
- •Staff
- •Monitoring
- •Minimal Sedation
- •Moderate Sedation
- •Antagonists/Reversal Agents
- •References
- •Selection of Local Anesthesia
- •Selection of Oral Sedative Agent
- •Procedure
- •References
- •19 Keys to Success When Marking the Skin in Upper Blepharoplasty
- •26 Blepharoplasty Incisional Modalities: 4.0 Radiowave Surgery vs. CO2 Laser
- •Study
- •Results
- •References
- •27 Fat Preservation and Other Tips for Upper Blepharoplasty
- •28 Asian Blepharoplasty
- •29 Internal Brow Elevation with Corrugator Removal
- •41 Three-Step Technique for Lower Lid Blepharoplasty
- •Step 1: Transconjunctival Fat Removal
- •Step 3: Resuspension of the Anterior Lamella and Adjacent Malar Fat Pad to the Lateral Orbital Periosteum
- •Rationale for the Three-Step Procedure
- •Pearls
- •References
- •Divide Each Fat Pad Flush with the Orbital Rim—Nasal and Central Fat Pads
- •Divide Each Fat Pad Flush with the Orbital Rim—Lateral Fat Pad
- •Surgical Technique
- •Postoperative Care
- •Complications
- •Comments
- •References
- •54 Transconjunctival Lower Blepharoplasty with Intra-SOOF Fat Repositioning
- •Patient Selection
- •Procedure
- •Postoperative
- •Conclusion
- •References
- •56 Use of Tisseel in Lower Eyelid Blepharoplasty with Fat Repositioning
- •57 Lower Blepharoplasty with Fat Repositioning Without Sutures
- •Fat-Repositioning Procedure
- •References
- •Indications
- •Complications
- •Procedure
- •Stage 1
- •Stage 2
- •Conclusions
- •References
- •61 Treatment of Postblepharoplasty Lower Eyelid Retraction with Dermis Fat Spacer Grafting
- •Surgical Technique
- •References
- •Tumescent Technique
- •Avoiding Anesthetic Toxicity
- •Tumescent Technique
- •References
- •69 Incision Technique for Endoscopic Forehead Elevation
- •Central Incision
- •Paracentral Incisions
- •Temporal Incisions
- •Prevention of Alopecia
- •71 Endoscopic Midforehead Techniques: Improved Outcomes with Decreased Operative Time and Cost
- •Suggested Reading
- •Dissection of Central Forehead Space and Scalp
- •Dissection of Temporal Space
- •Release of Periosteum
- •77 Endosocopic Browlift with Deep Temporal Fixation Only*
- •Endoscopic Browlift with Deep Temporal Fixation Only
- •Temporal Lift
- •Surgical Technique
- •Incisions
- •Release of the Brow Depressor Muscles
- •Brow Elevation and Fixation
- •Results (Before and After Photographs)
- •Introduction
- •Surgical Technique
- •Conclusions
- •References
- •79 Scalp Fixation in Endoscopic Browlift
- •Suggested Reading
- •82 The Direct Browlift: Focus on the Tail
- •Patient Selection
- •Procedure
- •Postoperative
- •Complications
- •Conclusion
- •Introduction
- •Procedure
- •Conclusions
- •References
- •86 The Subperiosteal Mid-Face Lift Using Bioabsorbable Implants for Fixation*
- •References
- •88 Mid-Face Implants
- •105 Shaping of the Eyebrows with Botox
- •Modifying the Position of the Medial Eyebrows
- •Modifying the Position of the Lateral Eyebrows
- •Arching and Lifting the Eyebrows
- •Lowering and Flattening the Eyebrows
- •Treating Eyebrow Asymmetry
- •Pitfalls
- •Conclusion
- •References
- •109 Botox Injection to the Lacrimal Gland for the Treatment of Epiphora
- •113 Optimizing Outcome from Facial Cosmetic Injections and Promoting Realistic Expectations
- •Preparations
- •Posttreatment
- •Expectations
- •115 List of Fillers
- •Consultation
- •Anesthesia
- •Choice of Filler
- •Anatomic Guidelines
- •Technique
- •Summary
- •References
- •121 Liquid Injectable Silicone for the Upper Third of the Face
- •References
- •122 Periocular Injectables with Hyaluronic Acid and Calcium Hydroxyapatite
- •General Principles
- •Hyaluronic Acid (HA)
- •Calcium Hydroxyapatite
- •References
- •125 Pearls for Periorbital Fat Transfer
- •129 Retinoids for the Cosmetic Patient
- •Background
- •Suggested Reading
- •Patient Selection
- •Infrared vs. Pulsed Dye
- •Postoperative Care
- •Choosing a Device
- •KTP or Frequency-Doubled Nd:YAG laser (532 nm)
- •Pulsed-Dye Laser (585 nm, 595 nm)
- •Intense-Pulsed Light Device (500–1200 nm)
- •Long-Pulsed Nd:YAG laser (1064 nm)
- •Fractional Resurfacing Lasers
- •Low Intensity Sources
- •Laser and Light Sources for Skin Rejuvenation
- •Patient Evaluation
- •Surgical Planning
- •Anesthetic Techniques
- •Surgical Procedure
- •Postoperative Care
- •Background
- •Technology
- •Patient Selection
- •Treatment
- •Conclusion
- •Key Elements of Procedure
- •Patient Selection and Preparation
- •Procedure
- •Postoperative
- •Conclusion
- •References
- •145 Repair of the Torn Earlobe
- •Questions to Ask the Patient
- •Basic Principles
- •Surgical Technique for Complete Earlobe Tears
- •Surgical Repair for Partial Torn Earlobes
- •References
- •Introduction
- •Preoperative Markings
- •Technique
- •Discussion
- •Conclusion
- •Reference
- •147 SMAS Malar Fat Pad Lift with Short Scar Face Lift
- •148 Ten Tips for a Reliable and Predictable Deep Plane Facial Rhytidectomy
- •Introduction
- •Tip 1. Marking (Figure 148.1)
- •Tip 2. Skin Flap Dissection (Figure 148.2)
- •Tip 3. Marking the Zygomatic Arch (Figure 148.3)
- •Tip 4. SMAS Flap Creation (Figure 148.4)
- •Tip 5. Creating the SMAS Flap (Figure 148.5 and 148.6)
- •Tip 6. SMAS Flap Fixation (Figure 148.7)
- •Tip 7. Skin Flap Fixation (Figure 148.8)
- •Tip 8. Addressing the Earlobe (Figure 148.9)
- •Tip 9. Skin Excision Tips (Figure 148.10)
- •Tip 10. Addressing the Neck (Figure 148.11)
- •References
- •153 Adjustable Suture Technique for Levator Surgery
- •Surgical Technique
- •Reference
- •154 Tarsal Switch Levator Resection for the Treatment of Myopathic Blepharoptosis
- •Surgical Technique
- •Suggested Reading
- •156 Minimally Invasive Ptosis Repair
- •Mini-invasive Ptosis Surgery
- •Suggested Reading
- •Further Reading
- •158 Ptosis Repair by a Single-Stitch Levator Advancement
- •Reference
- •References
- •171 Medial Canthorraphy
- •Index
10 R.Z. Silkiss
It is important it remind patients that form follows function, and that a maximally aesthetic result will follow from the appropriate management of the target tissue. These tissues should not be overcorrected. Aesthetic results are always relative to age and native configuration. Patients and surgeons need to keep the correction in context to the patient’s age, ethnicity, and natural appearance in youth.
Create an Aesthetic Environment
As an aesthetic surgeon, it is beneficial to create an environment in the of ce which expresses your ability to understand the nature of aesthetics.
One should develop a clean, comfortable space with current décor.
There should be health and fashion magazines in the patient lounge.
Although the medical profession may receive its cosmetic information from peer-reviewed scientific journals, your patients are receiving their information and misinformation from mass media. The surgeon should be somewhat familiar with the current “lore or buzz” in the media.
The aesthetic environment should extend to the operating room. Here, the surgeon should provide for a calm, controlled, relaxing experience. “Handesthesia” goes a long way to reassuring an anxious patient during a procedure.
Patients always like to receive something more than expected. Send your patients home with sunglasses, gel packs, ointment, etc. Make the postoperative period easy. Send patients home with their postoperative medication or prescriptions, a postoperative appointment, and easy to read, explicit instructions. Ensure comfortable suture removal. In the event of a need for revision, be explicit about your revision policy. Make certain this is well known to the staff in advance to avoid unnecessary confusion or conflict. Finally, and above all, be available, affable, and able to follow through in resolving patient issues before and after a procedure.
The ultimate secret to a happy patient is communication, expectation management, and informed surgical and procedural judgment. Perhaps
“The Eightfold Path to Patient Happiness” can help guide your way.
3
Preoperative Patient Counseling for Cosmetic Blepharoplasty
William P.D. Chen
Cosmetic blepharoplasty is one of the most popular forms of aesthetic surgery of the face. The surgical outcome is intimately related to the interaction of the upper eyelids with the forehead and brows, as well as the lower eyelids, lateral canthi, and the mid-face and cheek’s topography. Therefore, in any discussion and examination of a patient with regard to this form of surgery, an astute clinician should be attentive to the entire face and not confine his or her attention to the superficial upper and lower eyelid skin layers. This awareness of surrounding as well as deeper structures will ultimately yield much better surgical outcome and a happier patient.
In my first of ce consultation with new patients, I listen first to their complaints, and mentally classify the complaints into relative orders (or wish list) including those that can be improved upon versus transient improvement or no improvement at all. I then assess from their personality and temperament what degree of enthusiasm or tolerance to surgery they possess. Ultimately, the surgeon and the patient need to mutually agree on what is comfortable, beneficial, and worthwhile for the patient to undertake. This may include financial matters, time commitment as to postoperative healing course, as well as overall general medical conditions that may have a bearing on the type of surgery and anesthesia recommended.
I always try to encourage patients to speak their mind, even if they may be embarrassed, and I try to facilitate this in an environment free of stress. Very often patients may be overly self-conscious about an issue that matters very little to anyone they interact with, or one may need to point out an extreme condition that needs to be corrected before the aesthetic outcome can be achieved, for example, involutional ptosis in conjunction with upper eyelid hooding. It is important to customize individual aspects of your particular technique for that patient. For example, I have not performed two exactly identical procedures among any of my patients who came to me to have Asian blepharoplasty.
After an adequate prioritization of goals with the patient, I then explain what the procedure involves before, during and after the surgery and what is expected of the patient.
11
12 W.P.D. Chen
In the office chart for the patient, I jot down particular aspects of their facial structure (like ptosis, ectropion, entropion, lateral canthal dehiscence, thinning of levator and aponeurosis, forehead brow overaction, prominent sulcus), what was mentioned to them (for example, one upper lid margin is half a millimeter lower than the other, one eye is more sunken and shows a more prominent sulsus), what were the patient’s response and preferences (high crease, low crease, shape of crease line selected as well as skin texture and preexistent thining of lower lid skin and telangiectatic blood vessels observed) as well as whether I told the patient that despite their stated preference, whether it can be achieved. If a patient has thick dry skin, an oily complexion, superficial furuncles, or rosacea—these are all noted onto my plan of management for this patient.
If a patient seems extremely nervous, I usually try to call them the night before the procedure to make sure all is well. On the day of surgery in the preoperative area, I greet the patient again and reiterate the goal(s) of the surgery. If there is any discrepancy between what I told them and what they think and expect of the surgery, I will always defer the surgery until another day, although this is extremely rare.
Reprinted with permission from: Chen WPD, Khan JA, McCord, Jr, CD. Color Atlas of Cosmetic Oculofacial Sugery. Philadelphia: Butterworth Heinemann/ Elsevier, 2004.
Part II
Anesthesia