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278 Part VII&Facial Surgery
REFERENCES
1. Ramirez OM. Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg 2002;109:329
2. Isse NG. Endoscopic facial rejuvenation. Clin Plast Surg 1997;24:213
3. Ramirez OM. Endoscopic facial rejuvenation. Perspect Plast Surg 1995;9:22
SURGICAL COMPLICATIONS AND TREATMENT
10. After 2 days of completing a composite rhytidectomy with malar resuspension on a 58-year-old female, she
presents to the clinic with increasing pain and swelling of her left face. You suspect a hematoma. What could
have avoided this complication?
C. Strict blood pressure control and meticulous hemostasis.
Hematoma is a common complication of rhytidectomy, more often seen in men than women. Appropriate
blood pressure control perioperativelyand meticulous hemostasis are key to avoiding this issue. Use of cold
compresses and head elevation can help with edema. A temporary Frost suture postoperatively can help
prevent chemosis. Limited tension of skin closure can help prevent wound healing issues.
1
REFERENCE
1. CasonRW, AvashiaYJ, Shammas RL, Savetsky IL, Rohrich RJ. Perioperativeapproach to reducing hematomaduring
rhytidectomy: what does the evidence show? Plast Reconstr Surg 2021;147(6):1297–1309
SURGICAL COMPLICATIONS AND TREATMENT
11. A 60-year-old male presents with visible swelling of his conjunctiva and a foreign body sensation 5 days fol-
lowing midface rejuvenation. What is the best initial management plan?
A. Steroid eye drops.
This patient's presentation is concerning for chemosis. This is the most common nonsurgical complication
from a transpalpebral approach to the midface. It usually presents within 1 week from surgery and can last
up to 4 weeks or longer. Prevention is key, starting with lubrication of the eye during surgery and taking
care to prevent trauma during exposure. A temporary tarsorrhaphy can help reduce the rate of postoperative chemosis. Treatment is largely conservative with lubricating eye drops. Ophthalmic steroid drops can
be helpful. In severe or prolonged cases, conjunctivotomy can be considered.
1,2
REFERENCES
1. Weinfeld AB, Burke R, Codner MA. The comprehensive management of chemosis following cosmetic lower blepharoplasty. Plast Reconstr Surg 2008;122(2):579–586
2. Hester TR Jr, Douglas T, Szczerba S. Decreasing complications in lower lid and midface rejuvenation: the importance of orbital morphology,horizontallowerlid laxity, history of previous surgery, and minimizing trauma to the
orbital septum: a critical review of 269 consecutive cases. Plast Reconstr Surg 2009;123:1037
SURGICAL COMPLICATIONS AND TREATMENT
12. Your patient presents with mild lower eyelid malposition 3 weeks following midface rejuvenation. How
would you treat this patient?
D. Postoperative massage and eye lubrication.
Lower eyelid malposition is the most common surgical complication following a transpalpebral approach.
It is characterized by eyelid retraction, scleral show, and ectropion. It is caused by a vertical deficiency of
the anterior or posterior lamella in patients with laxity of the tarsus. Patients at increased risk include
those with lower eyelid laxity, prominent eyes, negative vector, negative canthal tilt, and/or preoperative
scleral show. Mild lower eyelid malposition is treated conservatively with postoperative massage, external
taping, and eye lubrication. If these treatments fail, the next options include surgical canthopexy or
canthoplasty. More severe cases may require drill hole canthal anchoring. Immediate surgical correction
may also be required to prevent keratopathy. It would be too early to start thinking about any filler or fat
grafting to support the lower eyelid in situations of inferior eyelid retraction. The underlying issue must be
a volumelossissue for this to be effective.
1,2
Chapter 40&Midface Rejuvenation 279
REFERENCES
1. Weinfeld AB, Burke R, Codner MA. The comprehensive management of chemosis following cosmetic lower blepharoplasty. Plast Reconstr Surg 2008;122(2):579–586
2. Hester TR Jr, Douglas T, Szczerba S. Decreasing complications in lower lid and midface rejuvenation: the importance of orbital morphology,horizontallowerlid laxity, history of previous surgery, and minimizing trauma to the
orbital septum: a critical review of 269 consecutive cases. Plast Reconstr Surg 2009;123:1037
41. Perioral Rejuvenation
Ira L. Savetsky, Anmol Chattha
See Essentials of Aesthetic Surgery, pp. 528–539
PREOPERATIVE EVALUATION
1. What is the typical size of the upper lip compared to total lip volume?
A. 1/5 of the total lip volume.
B. 1/4 of the total lip volume.
C. 1/3 of the total lip volume.
D. 1/2 of the total lip volume.
E. 2/3 of the total lip volume.
PATIENT EVALUATION
2. How many millimeters of upper incisor show in repose is considered aesthetically pleasing?
A. 0.5–1 mm.
B. 1–2 mm.
C. 2–3 mm.
D. 3–4 mm.
E. 4–5 mm.
PATIENT EVALUATION
3. A patient has perioral static lines without lip atrophy but with dyschromias. What is the optimal method of
perioral enhancement?
A. Laser resurfacing with or without dermabrasion.
B. Fat injection.
C. Direct lip lift.
D. Indirect lip lift.
E. Maxillary lengthening.
PATIENT EVALUATION
4. A patient has lip hypoplasia with optimal incisor show. What is the optimal method of perioral enhancement?
A. Indirect lip lift.
B. Fat injection.
C. Direct lip lift.
D. Maxillary lengthening.
E. Neuromodulator “lip flip.”
PATIENT EVALUATION
5. A patient has lip hypoplasia with excessive incisor show. What is the optimal method of perioral
enhancement?
A. Indirect lip lift.
B. Direct lip lift.
C. Gingival shortening.
D. Maxillary lengthening.
E. Laser resurfacing.
Chapter 41&Perioral Rejuvenation 281
PATIENT EVALUATION
6. An old patient has lip hypoplasia, inadequate incisor show, a long lip, and an adequate nasolabial angle.
What is the optimal method of perioral enhancement?
A. Indirect lip lift.
B. Direct lip lift.
C. Lip augmentation.
D. Maxillary lengthening.
E. Laser resurfacing.
CHEMODENERVATION
7. A 67-year-old female is frustrated with the fact that she looks sad all the time and would like to know if there
is anything you can do for her downward-slanted oral commisures. What is the best product to use and which
of the following muscle is the main target to treat her condition?
A. Filler; oribicularis oris.
B. Filler; levator anguli oris.
C. Filler; depressor anguli oris.
D. Neuromodulator; mentalis.
E. Neuromodulator; depressor anguli oris.
CHEMODENERVATION
8. A 23-year-old girl has a “gummy smile” when she smiles and wants to know if there is a way to temporarily
treat this. Which of the following muscles are targeted with botulinum toxin to treat her condition?
A. Oribicularis oris.
B. Levator anguli oris.
C. Levator labii superioris.
D. Depressor anguli oris.
E. Mentalis.
SOFT TISSUE FILLERS
9. Which of the following soft tissue fillers is best used on patients with HIV lipoatrophy?
A. Hyaluronic acid based.
B. Poly-L-lactic acid.
C. Bovine collagen.
D. Human-based collagen.
E. Calcium hydroxyapatite.
SOFT TISSUE FILLERS
10. Which of the following soft tissue fillers requires skin testing prior to use?
A. Hyaluronic acid based.
B. Poly-L-lactic acid.
C. Bovine collagen.
D. Human-based collagen.
E. Calcium hydroxyapatite.
SOFT TISSUE FILLERS
11. Which of the following is a permanent soft tissue filler?
A. Polymethylmethacrylate.
B. Poly-L-lactic acid.
C. Bovine collagen.
D. Human-based collagen.
E. Calcium hydroxyapatite.
282 Part VII&Facial Surgery
SOFT TISSUE FILLERS
12. Which of the following soft tissue fillers should not be used for lip augmentation given the high incidence of
nodule formation?
A. Polymethylmethacrylate.
B. Autologous fat from knee.
C. Bovine collagen.
D. Human-based collagen.
E. Calcium hydroxyapatite.
SOFT TISSUE FILLERS
13. When correcting nasolabial folds with soft tissue filler, which of the following is the best technique to fill
this region?
A. Inject within the fold directly.
B. Inject slightly medial to the fold.
C. Inject slightly medial and lateral to the fold.
D. Inject slightly lateral to the fold.
E. Inject deep and caudally.
DERMABRASION
14. What is the most reliable indicator that the operator has reached the optimal depth in dermabrasion?
A. Erythema.
B. Frost effect.
C. Punctiform, superficial bleeding.
D. Pale yellow color.
E. Visualization of hair follicles.
LASER ABLATIVE RESURFACING
15. What is the clinical endpoint when performing laser ablative resurfacing with a carbon dioxide laser?
A. Erythema.
B. Frost effect.
C. Punctiform, superficial bleeding.
D. Pale yellow color.
E. Visualization of hair follicles.
Chapter 41&Perioral Rejuvenation 283
Answers
PREOPERATIVE EVALUATION
1. What is the typical size of the upper lip compared to total lip volume?
C. 1/3 of the total lip volume.
The upper lip is smaller than the lower lip and is a third of the total lip volume (Fig. 41.1).
Nasolabial crease
Philtrum
Lateral commissure
Vermilion border
Fig. 41.1 The upper lip is smaller than the lower lip and is a third of the total lip volume. (Source: Anatomy. In:
Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
33%
66%
Cupid’s bow
Upper lip
Lower lip
1
REFERENCE
1. Agarwal A, Dejoseph L, Silver W, et al. Anatomy of the jawline, neck, and perioral area with clinical correlations.
Facial Plast Surg 2005;21:3
PATIENT EVALUATION
2. How many millimeters of upper incisor show in repose is considered aesthetically pleasing?
C. 2–3 mm.
Aesthetically, 2 to 3 mm of the upper incisors may show in repose, but the full length of the incisors should
show while smiling.
1
REFERENCE
1. Agarwal A, Dejoseph L, Silver W, et al. Anatomy of the jawline, neck, and perioral area with clinical correlations.
Facial Plast Surg 2005;21:3
PATIENT EVALUATION
3. A patient has perioral static lines without lip atrophy but with dyschromias. What is the optimal method of
perioral enhancement?
A. Laser resurfacing with or without dermabrasion.
Perioral lines can be a challenging problem. There are a variety of treatment modalities depending on the
type of lines present. In this patient with static lines (with dyschromias), laser resurfacing would be the best
option. Use of fat grafting would be the best option if the patient had concomitant atrophy of the lips. Lip lifts
or maxillary lengthening is the best for patients with lip hypoplasia or atrophy due to aging (Fig. 41.2).
1,2,3
284 Part VII&Facial Surgery
LINES
Strategies
STATIC DYNAMIC
• Without atrophy of lips
– Laser resurfacing with or
without dermabrasion
• With atrophy of lips
– Fat injection
(DYSCHROMIAS and
KERATOTIC CHANGES only)
Use laser resurfacing with or
wit hout derrnabrasion
• With dyschromias
– Laser resurfacing with or
without dermabrasion
• Without dyschromias
– Fat injection or string graft
Fig. 41.2 Algorithm for perioral enhancement. (DLL, Direct liplift; ILL, indirect liplift; NLA, nasolabial angle.)
(Source: Translated & reproduced by permission of Oxford University Press. Ponsky D, Guyuron B. Comprehensive surgical
aesthetic enhancement & rejuvenation of the perioral region. Aesthet Surg J 31:382, 2011.)
REFERENCES
1. Agarwal A, Dejoseph L, Silver W, et al. Anatomy of the jawline, neck, and perioral area with clinical correlations.
Facial Plast Surg 2005;21:3
2. CalhounKH. Lip anatomyand function. In: Calhoun KH, Stiernberg CM, eds. Surgery of the Lip. New York: Thieme
Publishers; 1992
3. Leveque JL, Goubanova E. Influence of age on the lips and perioral skin. Dermatology 2004;208:307
PATIENT EVALUATION
4. A patient has lip hypoplasia with optimal incisor show. What is the optimal method of perioral enhancement?
B. Fat injection.
In a patient with lip hypoplasia with optimal incisor show, the best method would be fat injection or filler
augmentation to improve volume. If the patient had inadequate incisor show and a long lip, then an indirect
or direct lip lift would be the ideal surgical decision. If the patient had a short lip, maxillary lengthening
would be the procedure of choice (Fig. 41.3).
1,2,3
LIP HYPOPLASIA
or AT ROPHY
YES
OPTIMAL incisor show EXCESSIVE incisor show
Strategies
• Conservative fat injection
• Conservative dermis fat graft
Long lip
If young, narrow NLA, use ILL
If older, optimal NLA, use DLL
INADEQUATE incisor show
Normal lip length
lip augmentation
Strategies
• Gingival shortening
• Dermis fat graft
• Fat injection
Short lip
Maxillary lengthening
lip augmentation
Fig. 41.3 Algorithm for perioral enhancement. (DLL, Direct liplift; ILL, indirect liplift; NLA, nasolabial angle.)
(Source: Translated & reproduced by permission of Oxford University Press. Ponsky D, Guyuron B. Comprehensive surgical
aesthetic enhancement & rejuvenation of the perioral region. Aesthet Surg J 31:382, 2011.)
Chapter 41&Perioral Rejuvenation 285
REFERENCES
1. Agarwal A, Dejoseph L, Silver W, et al. Anatomy of the jawline, neck, and perioral area with clinical correlations.
Facial Plast Surg 2005;21:3
2. CalhounKH. Lip anatomyand function. In: Calhoun KH, Stiernberg CM, eds. Surgery of the Lip. New York: Thieme
Publishers; 1992
3. Leveque JL, Goubanova E. Influence of age on the lips and perioral skin. Dermatology 2004;208:307
PATIENT EVALUATION
5. A patient has lip hypoplasia with excessive incisor show. What is the optimal method of perioral enhancement?
C. Gingival shortening.
For a patient with lip hypoplasia with excessive incisor show, the best procedure of choice is gingival shortening, dermal fat grafting, or fat injection. A direct or indirect lip lift or maxillary lengthening would be a
good procedure for a patient with inadequate incisor show. Laser resurfacing would be a good option for a
patient with static lines and would not correct lip hypoplasia (Fig. 41.4).
LIP HYPOPLASIA
or AT ROPHY
YES
1,2,3
OPTIMAL incisor show EXCESSIVE incisor show
Strategies
• Conservative fat injection
• Conservative dermis fat graft
Long lip
If young, narrow NLA, use ILL
If older, optimal NLA, use DLL
INADEQUATE incisor show
Normal lip length
lip augmentation
Strategies
• Gingival shortening
• Dermis fat graft
• Fat injection
Short lip
Maxillary lengthening
lip augmentation
Fig. 41.4 Algorithm for perioral enhancement. (DLL, Direct liplift; ILL, indirect liplift; NLA, nasolabial angle.)
(Source: Translated & reproduced by permission of Oxford University Press. Ponsky D, Guyuron B. Comprehensive surgical
aesthetic enhancement & rejuvenation of the perioral region. Aesthet Surg J 31:382, 2011.)
REFERENCES
1. Agarwal A, Dejoseph L, Silver W, et al. Anatomy of the jawline, neck, and perioral area with clinical correlations.
Facial Plast Surg 2005;21:3
2. CalhounKH. Lip anatomyand function. In: Calhoun KH, Stiernberg CM, eds. Surgery of the Lip. New York: Thieme
Publishers; 1992
3. Leveque JL, Goubanova E. Influence of age on the lips and perioral skin. Dermatology 2004;208:307
PATIENT EVALUATION
6. An old patient has lip hypoplasia, inadequate incisor show, a long lip, and an adequate nasolabial angle.
What is the optimal method of perioral enhancement?
B. Direct lip lift.
In patients with lip atrophy with inadequate incisor show due to atrophy and ptosis, a direct lip lift is the procedure of choice. The other options would not be the ideal modality of treatment for this patient (Fig. 41.5).
1,2,3
286 Part VII&Facial Surgery
LIP HYPOPLASIA
or AT ROPHY
YES
OPTIMAL incisor show EXCESSIVE incisor show
Strategies
• Conservative fat injection
• Conservative dermis fat graft
Long lip
If young, narrow NLA, use ILL
If older, optimal NLA, use DLL
INADEQUATE incisor show
Normal lip length
lip augmentation
Strategies
• Gingival shortening
• Dermis fat graft
• Fat injection
Short lip
Maxillary lengthening
lip augmentation
Fig. 41.5 Algorithm for perioral enhancement. (DLL, Direct liplift; ILL, indirect liplift; NLA, nasolabial angle.)
(Source: Translated & reproduced by permission of Oxford University Press. Ponsky D, Guyuron B. Comprehensive surgical
aesthetic enhancement & rejuvenation of the perioral region. Aesthet Surg J 31:382, 2011.)
REFERENCES
1. Agarwal A, Dejoseph L, Silver W, et al. Anatomy of the jawline, neck, and perioral area with clinical correlations.
Facial Plast Surg 2005;21:3
2. CalhounKH. Lip anatomyand function. In: Calhoun KH, Stiernberg CM, eds. Surgery of the Lip. New York: Thieme
Publishers; 1992
3. Leveque JL, Goubanova E. Influence of age on the lips and perioral skin. Dermatology 2004;208:307
CHEMODENERVATION
7. A 67-year-old female is frustrated with the fact that she looks sad all the time and would like to know if there
is anything you can do for her downward-slanted oral commisures. What is the best product to use and which
of the following muscle is the main target to treat her condition?
E. Neuromodulator; depressor anguli oris.
Neuromodulator to the depressor anguli oris is the target muscle to treat this patient's condition. On each
side, 2 to 5 units are used. The needle is inserted into peak of the Cupid's bow, 2 to 3 mm above the vermilion
border. Injection of the depressor anguli oris muscle will cause elevation of the oral commissure. This muscle
can be found by asking the patient to depress the lower lip or frown. The bulk of the muscle is palpable
inferolateral to the oral commissure at the level of the mandible.
1
REFERENCE
1. Loos BM, Maas CS. Relevant anatomy for botulinum toxin facial rejuvenation. Facial Plast Surg Clin North Am
2003;11:439
CHEMODENERVATION
8. A 23-year-old girl has a “gummy smile” when she smiles and wants to know if there is a way to temporarily
treat this. Which of the following muscles are targeted with botulinum toxin to treat her condition?
C. Levator labii superioris.
Injecting 1 unit of botulinum toxin into the levator labii superioris muscle at its origin on the maxilla (superolateral to the ala) creates a weakness of the central aspect of the upper lip during smile which helps
eliminates gingival show.
1
Chapter 41&Perioral Rejuvenation 287
REFERENCE
1. Loos BM, Maas CS. Relevant anatomy for botulinum toxin facial rejuvenation. Facial Plast Surg Clin North Am
2003;11:439
SOFT TISSUE FILLERS
9. Which of the following soft tissue fillers is best used on patients with HIV lipoatrophy?
B. Poly-L-lactic acid.
Poly-L-lactic acid (PLLA) f illers, often marketed under the brand name Sculptra, are commonly used for
patients with HIV lipoatrophy. Lipoatrophy is a condition characterized by the loss of fat tissue, and it
can be a side effect of certain HIV medications. PLLA fillers are biocompatible and can help stimulate collagen
production, leading to a gradual increase in volume over time. They are particularly well-suited for
addressing the facial volume loss associated with HIV lipoatrophy.
1
REFERENCE
1. Monhian N, Ahn MS, Maas CS. Injectable and implantable materials for facial wrinkles. In: Papel ID, ed. Facial
Plastic and Reconstructive Surgery. 2nd ed. New York: Thieme Publishers; 2002
SOFT TISSUE FILLERS
10. Which of the following soft tissue fillers requires skin testing prior to use?
C. Bovine collagen.
Collagen fillers (bovine collagen), which are derived from either human or bovine sources, used to require
skin testing prior to use. This testing was done to check for potential allergic reactions or sensitivities to the
collagen product. However, it is important to note that many modern fillers no longer require skin testing
due to advancements in filler formulations.
1
REFERENCE
1. Monhian N, Ahn MS, Maas CS. Injectable and implantable materials for facial wrinkles. In: Papel ID, ed. Facial
Plastic and Reconstructive Surgery. 2nd ed. New York: Thieme Publishers; 2002
SOFT TISSUE FILLERS
11. Which of the following is a permanent soft tissue filler?
A. Polymethylmethacrylate.
Polymethylmeth acrylate(PMMA )fillers are considered permanent soft tissuefillers. PMMA is a synthetic material that is not absorbed by the body over time, providing long-lasting results. Thesefillers are oftenused for deep
wrinkles and facial volume loss. However, it is important to note that while PMMA fillers are considered permanent, they may still require touch-up treatments over the years as natural aging processes continue.
1
REFERENCE
1. Monhian N, Ahn MS, Maas CS. Injectable and implantable materials for facial wrinkles. In: Papel ID, ed. Facial
Plastic and Reconstructive Surgery. 2nd ed. New York: Thieme Publishers; 2002
SOFT TISSUE FILLERS
12. Which of the following soft tissue fillers should not be used for lip augmentation given the high incidence of
nodule formation?
E. Calcium hydroxyapatite.
Calcium hydroxyapatite (Radiesse) and poly-L-lactic acid (Sculptra) should not be used for lip augmentation because of their high incidence of nodule formation.
1
REFERENCE
1. Monhian N, Ahn MS, Maas CS. Injectable and implantable materials for facial wrinkles. In: Papel ID, ed. Facial
Plastic and Reconstructive Surgery. 2nd ed. New York: Thieme Publishers; 2002