64 396 Practical Plastic Surgery middle crura which continue from the most anterior portion of the medial crura towards the tip of the nose and begin the turn laterally to form part of the genu (i.e., curve) of the lower lateral cartilages. The lateral crura comprise the remainder of the genu by continuing laterally, posteriorly and slightly cephalically. It is important to note that as one traces the lateral crura from the tip posterolaterally, the crura project more cephalically (Fig. 64.1). Hence, the lateral crura provide structural support to the nasal rim predominantly at their medial portions, leaving the very lateral por- tions of the nasal alae devoid of cartilage. This portion of the nose is comprised of fibrofatty tissue covered by overlying skin. The nasal septum is composed of three structures: the perpendicular plate of the ethmoid posteriorly and cephalically, the vomer posteriorly and caudally and the quadrangular (i.e., cartilaginous) septum anteriorly. The septum functions as a sup- port structure for the mid-portion of the nose and it also comprises the medial component of the internal nasal valve (completed posteriorly by the nasal floor and laterally by the upper lateral cartilages). The average internal valve angle is 12˚. The arterial anatomy of the nose is important to consider for several reasons. While the blood supply to the nose is abundant making tissue necrosis a rare com- plication, the potential for clinically significant bleeding exists. Bleeding can be sig- nificant in that it can compromise tissue due to compression (e.g., septal hematoma) or compromise visualization during the rhinoplasty. Again, beginning cephalically, the blood supply to the dorsal nose is derived from the dorsal nasal artery and the external nasal branches of the anterior ethmoidal artery. The lateral nasal artery which arises from the angular artery supplies blood flow to the nasal sidewalls and the caudal nasal dorsum and tip. The columellar branches of the superior labial artery anastomose with the distal branches of the lateral nasal artery to supply the nasal tip from below. The blood supply to the septum comes from the anterior and posterior ethmoidal arteries, the sphenopalatine artery and the posterior septal ar- tery. The convergence of the anterior and posterior ethmoidal plexuses in the anterosuperior septum is known as Little’s area and is the most common site of injury causing epistaxis. Because of its location, the anterior ethmoidal artery is the most often injured in nasal trauma. The cutaneous nerve supply to the nose is important because adequate local analgesia can allow the plastic surgeon to perform a rhinoplasty without general anesthesia. Since the local anesthetics contain epinephrine, appropriate infiltration can also reduce blood loss. Furthermore, the local anesthetics can be used to hydrodissect delicate nasal tissues facilitating subsequent sharp dissection. For ex- ample, local anesthesia infiltrated submucosallly in the septal area, not only provides excellent hemostasis, but also separates the septal mucosa from the underlying carti- laginous septum. Beginning cephalically, the nasal branches of the supraorbital nerve are infiltrated to anesthetize the radix and proximal nasal dorsum. Sensation along the nasal sidewalls, alae and columella is blocked using local anesthesia on the nasal branches of the infraorbital nerve. The middle and distal thirds of the nasal dorsum as well as the tip of the nose are anesthetized by blocking the external nasal branches of the anterior ethmoidal nerve. The anterior septum is blocked by anesthetizing the medial and lateral branches of the anterior ethmoidal nerve. If a septoplasty will be performed in addition to the rhinoplasty, the nasopalatine and posterior nasal nerves, which supply sensation to the posterior septum medially and laterally, respectively, should be blocked. Once the nose is adequately blocked, the rhinoplasty procedure can begin. 64 397 Rhinoplasty Surgical Technique Whether to perform an open or a closed rhinoplasty remains a controversial topic. To be sure each technique has its advantages and disadvantages and these, along with the requests of the patient, should be used to guide the surgical ap- proach. The open rhinoplasty involves any of a variety of mid-columellar incisions to expose the nasal anatomy much like one would expose the engine of a car by opening the hood. Clearly, the advantages of this approach are the excellent visual- ization which facilitates the operative procedure and teaching. Disadvantages in- clude the external scars, the longer operative time and the increased postoperative swelling secondary to more aggressive manipulation of the nasal tissues. During a closed rhinoplasty, no external incisions are made and access to the nasal framework is obtained via any number of internal incisions (e.g., inter-, intra- or infracartilage, or rim). Advantages with this technique are the lack of external scarring and the relative expeditiousness of the procedure. Its primary disadvantage is the limited visualization which therefore limits the manipulations than can be performed. This approach is best suited for patients requiring minor tip work, straight-forward re- section of a prominent dorsal hump, or those with a wide alar base. Dorsal Hump One of the most common complaints is a prominent dorsal hump. In consider- ation of the anatomy just reviewed, one can understand that this prominence can be caused either by projecting nasal bones, upper lateral cartilages, cephalic dorsal carti- laginous septum or some combination thereof. Resection of this dorsal hump can be performed either with the closed or open rhinoplasty technique. Once the overlying soft tissues have been dissected in the subcutaneous plane from the underlying bony and cartilaginous anatomy, the reason(s) for the projecting dorsum can be determined. While many techniques are used to achieve a more balanced nasal dorsum, the general principles are to sharply resect the cartilaginous components of the dorsal hump and to use either an osteotome or rasp to resect the bony dorsum. The rasp is generally used for more subtle bony adjustments. Two points about dorsal hump resection deserve emphasis. First, conservative resection is best. One can always resect more and as noted earlier, small changes often make pronounced differences in appearance. Secondly, it is important to avoid resection of the mucoperichondrium as this tissue layer provides support to the upper lateral cartilages and can lead to an inverted-V deformity. Tip Projection Under-projection of the nasal tip is another common problem. Tip projection can be enhanced in a number of ways. A transdomal suture bringing the genua closer together will add a mild degree of projection. Placement of an onlay tip graft can enhance tip projection as well as widen the nasolabial angle and increase lobular volume. Other ways of achieving the same effect are placement of a columellar strut graft and suturing the medial footplates together. In addition, lowering a dorsal hump will often give the impression of a cephalically oriented tip. Each of these techniques has its unique degree of tip enhancement and differing effects on sur- rounding nasal structures (e.g., columella, lobule, upper lip). The over-projecting tip (Pinocchio nose) is due to excess length of the medial and lateral crura. Resection of the medial or lateral crura or scoring of the dome-medial crura junction with or without resection of the lateral crura can be combined with a transfix- ion incision to reduce tip support to allow immediate posterior settling of the tip. 64 398 Practical Plastic Surgery Boxy Tip A boxy nasal tip is due to either an increased angle of divergence of the medial crura or a wide arc in the dome segment of the lateral crura This problem is com- monly treated by resection of the cephalic portion of the lateral alar cartilages and interdomal suturing. Widened Alar Base A wide alar base is a masculinizing feature. Since most patients seeking rhino- plasty are female, a wide alar base is a commonly encountered problem. The sim- plest way to narrow a wide alar base is through resection of a portion of the fibrofatty tissue making up the lateral-most portion of the alar rim (e.g., Weir excision). This technique has the disadvantage of placing visible (albeit small and well-hidden) scars on the external nasal skin. Transdomal sutures often used to augment tip projection can also pinch the lateral crura together thus slightly narrowing the alar width. Wide Nasal Bridge A wide nasal bridge is also a frequent complaint. This problem can be dealt with directly and indirectly. Clearly, nasal osteotomies will allow medialization of the upper and middle nasal vaults. These osteotomies can be performed via either open or closed approaches, using a continuous or perforated technique. This maneuver is often performed when a prominent dorsal hump has been resected, leaving the dor- sal edge of the nose with a widened, open roof, appearance. Preoperatively, the patient’s internal nasal valve angle must be evaluated because in-fracturing will narrow the nasal passage. If the internal nasal valve <12˚, the patient will have obstructed air- flow. Dorsal augmentation also gives the appearance of a narrower nose, again high- lighting the interplay of the various nasal components. Complications Retracted Ala A retracted ala occurs in patients who have had overresection of the cephalic portions of the lateral crura in an attempt to improve tip definition. As healing progresses, wound contraction rotates the lateral crura cephalically and with it the alar rim. To avoid this pitfall, it is recommended that at least 6-9 mm of lateral crus remain after resection and that one make every attempt to leave as much vestibular mucosa as possible during the procedure. To fix this problem, a free cartilage graft can be used to augment the remaining lateral crura in minor cases. If a severe retrac- tion is encountered, composite grafts from the contralateral ear can be used to pro- vide, lining, coverage and support. Parrot Beak Deformity A parrot beak deformity refers to excessive supratip fullness following rhino- plasty. This problem can be caused by either underresection of the supratip dorsal hump or overresection of the nasal dorsum. If the cause is the former, further resec- tion to achieve a proper tip-to-supratip proportion is mandated. If the cause is the latter, a dorsal graft is appropriate. When the parrot beak deformity occurs in the early postoperative period it is attributed to edema and wound contraction. In this situation, a trial of conservative management with taping and steroid injection is appropriate. Careful technique with frequent assessments of the appearance of the nose during the procedure is the best way to avoid this problem. 64 399 Rhinoplasty Saddle-Nose Deformity The saddle-nose deformity appears as a disproportionately flattened dorsum, akin to a boxer’s nose. The most common cause is over-resection of the cartilaginous septum leaving less than 15 mm of support. Treatment in mild to moderate cases involves placing additional graft material over the depressed areas to restore the lateral and frontal profile. In severe cases, cantilevered bone grafts suspended from the frontal bone may be required. O pen Roof Deformity An open roof deformity occurs after resection of a dorsal hump without ad- equate in-fracture of the nasal bones. The dorsal bony edges become visible within a flattened area of the dorsum. Treatment is intuitive and consists of adequately in-fracturing the nasal bones. Inverted-V Deformity If the mucoperichondrium of the upper lateral cartilages is inadvertently resected, support to the upper lateral cartilages is lost. This problem causes the upper lateral cartilages to collapse inferomedially. On frontal view, the caudal edges of the nasal bones become visible. The best treatment is avoidance, but if it occurs, dorsal carti- lage grafting to restore dorsal nasal balance is the preferred treatment. Pearls and Pitfalls Each case has it own challenges and requires a careful estimation of the deformity preoperatively, a clear understanding of the techniques available, a proposed plan of action and sequence, and a meticulous, uncompromising surgical technique. Every operation has a risk for complication, and only the surgeon who does not operate has no complications. Under-correction and over-correction of a preexisting deformity may lead to either persistence of the deformity or the introduction of a new one. A new deformity may introduce functional deficits. Some deformities are illusory and correction can only follow accurate diagnosis. For example, when a patient requests dorsal reduction, first examine the nose in thirds. If the nasal radix is too low, augment it, don’t reduce the dorsum. The radix augmentation will give the illusion of a smaller nose. Furthermore, the nose must also be examined in relation to the face. For in- stance, a nose may appear large because the chin is small; a chin implant may be the best choice in some cases to achieve the illusion of facial harmony. Suggested Reading 1. Becker DG. Complications in rhinoplasty. In: Papel I, ed. Facial Plastic and Recon- structive Surgery. New York: Thieme, 2002:87-96. 2. Daniel RK. Rhinoplasty. In: Aston SJ, Beasley RW, Thorne CHM, eds. Plastic Sur- gery. Philadelphia: Lippincott-Raven, 1997:651-669. 3. Dingman RO, Natvig P. Surgical anatomy in aesthetic and corrective rhinoplasty. Clin Plast Surg 1977; 4:111. 4. Guyuron B. Dynamics in rhinoplasty. Plast Reconstr Surg 2000; 105:2257. 5. Rohrich RJ, Muzaffar AR. Primary rhinoplasty. Plastic Surgery: Indications, Opera- tions and Outcomes V. 2000:2631. 6. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St. Louis: Mosby, 1998:1-1440. 7. Sheen JH. Rhinoplasty: Personal evolution and milestones. Plast Reconstr Surg 2000; 105:1820. 8. Zide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg 1998; 101:840. Chapter 65 Practical Plastic Surgery, edited by Zol B. Kryger and Mark Sisco. ©2007 Landes Bioscience. Genioplasty, Chin and Malar Augmentation Jeffrey A. Hammoudeh, Christopher Low and Arnulf Baumann Introduction The chin provides harmony and character to the face. A strong chin or promi- nent jaw line is considered to be aesthetically pleasing, especially in males. When chin surgery is indicated, whether by anterior horizontal mandibular osteotomy (AHMO) or by alloplastic implant augmentation, it can create an aesthetically pleas- ing facial contour and establish proportionate facial height. In addition, the AHMO can improve obstructive sleep apnea by elevating the hyoid bone. Most genioplasty procedures are done to improve the mandibular profile in or- der to obtain a more natural profile. Genioplasty can shorten or lengthen the lower third of the face. Facial asymmetry may be corrected by rotation of the chin-point to coincide with the midline. The advantages of osseous genioplasty are versatility, reliability and consistency in correcting problems in the sagittal and vertical planes to achieve greater chin projection. In order to be able to make an appropriate recommendation, the correct preop- erative workup should be performed, including soft and hard tissue analyses. Ide- ally, cephalometrics and video cephalometric predictions would also be performed. Anatomy and Analyses It is important for the surgeon to be familiar with the classic soft tissue analysis and diagram of facial proportions. The size, shape and position of soft and hard tissue can enhance facial harmony and symmetry. The relationship between soft tissue and bone is important for planning the chin correction. For chin advance- ment, the bone to soft tissue proportion is 1:0.8, meaning that 1 mm of bony change is associated with 0.8 mm of soft tissue change. The face can be divided into upper, middle and lower thirds. The upper third of the face spans from the hairline to the glabella (G); the middle third from glabella to subnasale (Sn); and the lower third from subnasale to menton (Me). The lower third of the face can be further divided into an upper half (Sn to vermilion of the lower lip) and a lower half (Me to vermilion of the lower lip). The face is “balanced” when the three thirds are of similar height. Cephalometric analysis ensures that skeletal and occlusal disparities are identified and can be corrected before or at the same time as a genioplasty. Many patients that complain of a small chin truly do not have microgenia. They often have a true deficit of the mandible in the sagittal plane, which can be a class 2 malocclusion (retrognathia) or normo-occlusion (retrogenia). Retrognathia is ideally corrected with a bilateral sagittal split osteotomy (BSSO); however if the discrepancy is small, advancement genioplasty may sufficiently camouflage the facial profile into an orthognathic appearance. Retrogenia (chin point deficiency 65 401 Genioplasty, Chin and Malar Augmentation in the setting of a class I occlusion) and mild retrognathia (≤3 mm) are ideal cases for a genioplasty. It is important to understand the relationship of the dentition to the chin point. The boney chin point should be about 2 mm posterior to the labial surface of the mandibular incisors. This will help maintain a natural labio- mental fold. The position of the labiomental angle is paramount and profoundly influences the aesthetic outcome. Cephalometric analysis helps the surgeon to plan the operative procedure. The treatment plan is based on incorporation of these data into clinical assessment that will facilitate a postsurgical profile that is esthetically pleasing. Perceived Chin Abnormalities Due to Anomalies of the Maxilla When facial analysis identifies disharmony within a patient’s profile, the surgeon must determine whether there is an underlying occlusal and skeletal deformity or merely a poorly or over-projected mentum. True maxillomandibular discrepancies should be addressed with orthognathic surgery. In the case where occlusion is stable and a small mandibular deficiency exists (retrogenia), an isolated mandibular sagit- tal deficiency may be a candidate for an AHMO. To highlight the importance of the correct diagnosis, one can take the common occurrence of a patient complaining of a “small chin.” A recessed chin may be retrogenia or microgenia. An over projected chin may be macrogenia or prognathia. Micrognathia and macrognathia are rare. Prognathia and retrognathia more com- monly contribute to chin point abnormalities. In the setting of a patient complain- ing of a small chin, the lateral profile should be evaluated. Concavity or convexity in conjunction with the proportions of the middle and lower third of the face should be considered in the planning. The maxilla should be evaluated. If the maxilla is set appropriately in the sagittal plane and there is mild retrognathia (≤3 mm) or retrogenia, then a genioplasty is appropriate. However, if a maxillary developmental dysplasia is present, a formal orthognathic work-up should be done. In contrast, patients complaining of a “prominent chin” often have pseudomacrogenia. These individuals may have maxillary sagittal hypoplasia, which manifests with a retruded upper lip, a midfacial concavity or deficiency, and a chin that may appear prominent in the sagittal plane. Since the true etiology is maxillary hypoplasia, the corrective procedure would be a Le Fort I osteotomy to advance the maxilla anteriorly to coincide with the chin point. A pitfall would be for a novice surgeon to perform a genioplasty to set the chin point back to coin- cide with the maxilla. In maxillary vertical deficiency, the patient presents with pseudomacrogenia due to the counterclockwise rotation of the mandible. In this case, the chin is accentu- ated and appears larger than normal. Patients with this condition have a short lower third facial height and present with poor maxillary tooth show at rest and when smiling. When the mandible is placed in the normal centric relation, the chin point increases in the sagittal plane. Maxillary vertical height correction will allow for a more natural position of the chin and only then can a decision be made on the need for genioplasty. Maxillary vertical excess may manifest as pseudomicrogenia due to the exces- sive downward growth of the maxilla causing a clockwise rotation of the man- dible. In such cases, the rotation of the mandible results in the appearance of a small chin due to poor projection of the chin in the sagittal plane. The patient will likely have excess gingival show, a long lower third facial height and mentalis 65 402 Practical Plastic Surgery muscle strain from the forces needed to close the interlabial gap. The treatment for this type of facial anomaly may be to reposition the maxilla superiorly, particu- larly in the posterior area. Maxillary sagittal hyperplasia is extremely rare. Patients may complain of a small chin as well. Once again, this is most likely a case of pseudomicrogenia, where the chin appears relatively small due to the prominence of the maxilla in the sagittal plane. These patients will have a convex facial profile associated with maxillary pro- trusion and an acute nasolabial angle. This form of microgenia can be corrected with repositioning of the maxilla, after which a decision can be made on the need for an adjunct genioplasty. Evaluation of the Mandible After a thorough investigation to rule out any maxillary discrepancies, the next step is to evaluate the mandible. For a patient with mandibular hypoplasia with either gross malocclusion or severe hypoplasia (greater than 4 mm), a formal orthognathic work-up is necessary. The risks of advancing or augmenting a chin greater than 5-6 mm include an unnatural appearance, a deep labiomental angle, and the risk of advancing the chin point past the lower central incisor. Severe man- dibular sagittal hypoplasia is corrected with a BSSO, and genioplasty should be viewed as an adjunct procedure. Prognathia in the setting of class 3 malocclusion should be corrected by a setback with a BSSO. Isolated true macrogenia in the presence of a normal class 1 occlusion can easily be treated with a genioplasty, set- ting the chin point back and even reducing chin height if needed. Indications for Isolated Genioplasty After careful scrutiny of the skeletal, dental and soft tissue structures, there exist certain cases that are amenable to isolated genioplasty. An isolated genioplasty can be considered if functional occlusion is present and the lower third profile has mild hypoplasia or hyperplasia in the sagittal or vertical plane. A sagittal hypoplasia (3-4 mm) in the setting of functional normo-occlusion with acceptable facial propor- tions is an ideal candidate for AHMO with advancement. A variation of the stan- dard sliding genioplasty is the “jumping” genioplasty. The “jumping” genioplasty is ideal for sagittal advancement when vertical reduction is needed. Patients who are considered for isolated genioplasty should have a good overall profile and occlusion. The surgical goals for these patients include creating an aes- thetically pleasing facial contour and establishing proportionate facial height. Ideal candidates for a genioplasty are: (1) retrogenia, i.e., recessed chin point with class I occlusion; (2) mild retrognathia (≤4 mm) with a functional occlusion; and (3) macrogenia. For example, in a patient that may have a long lower third of the face, a reduc- tion genioplasty is performed to reduce the vertical dimension of the chin. Verti- cal reduction is done by performing a second horizontal osteotomy that is parallel to the first osteotomy, and a segment of bone is removed. Another indication for an isolated genioplasty may be a mild asymmetry, when the chin does not coin- cide with facial midline. An oblique triangular wedge of bone can be removed from one side and transplanted to the other side to correct chin asymmetry. In all cases, the chin has to be rigidly fixed by miniplates, wire or screws. A variety of genioplasty is the “jumping” genioplasty. This type of procedure allows the sur- geon to both increase the chin projection and shorten the vertical dimension of 65 403 Genioplasty, Chin and Malar Augmentation the chin simultaneously. After the osteotomy is completed, the basilar segment is elevated on top of the upper symphysis. Surgical Technique Genioplasty can be performed under local anesthesia with IV sedation or under general anesthesia. General anesthesia is more commonly used with this procedure. Lidocaine with epinephrine is infiltrated along the depth of the buccal vestibule. An incision is made in the buccal vestibule, initially perpendicular to the mucosa then perpendicularly to the muscle and bone. The dissection is continued in the subperi- osteal plane to identify the mental foramen on both sides. After identification of the mental foramen, the mental nerves should be protected from both direct and trac- tion injury. The osteotomy is done under the apices of the teeth and the mental nerve. Upon completion of the osteotomy, the chin is then rigidly fixated. A step-off (sharp edge) at the posterior part of the genioplasty should be avoided. The contour of the mandible should be smooth. There are a variety of techniques used for fixa- tion of the chin including wires, resorbable or titanium bone plates. Closure should be done in multiple layers. The mentalis muscle must be reapproximated. The muscle layer can also be reattached to the chin using Mitek anchors. We prefer using two Mitek anchors to secure the mentalis muscle to bone. Alternatively, simple reapproximation with two horizontal mattress sutures is acceptable. This prevents ptosis of the mentalis muscle. Nonfixation may result in a “witches chin.” A com- pressive chin dressing is worn for 5 days postoperatively. The oral mucosa is closed with a running 3-0 chromic suture. The advantage of this procedure is its versatility, reliability and reproducible correction of chin point discrepencies. The disadvan- tages, when compared to alloplastic augmentation, include increased operative time, bleeding and incidence of mental nerve hypoesthesia. Chin Augmentation Using an Alloplastic Implant An alternative to genioplasty in correcting chin hypoplasia is the use of a chin implant. The use of implantable biomaterials and devices plays a potential role in most forms of reconstructive surgery. The common locations for alloplastic aug- mentation are the chin and malar regions. There are numerous synthetic implant- able materials that can be classified as carbon based polymers, noncarbon-based polymers, metals and ceramics. This wide selection allows the surgeon to choose a material tailored to the individual needs of the patient. Silicone (silastic), a noncarbon-based polymer, was one of the first materials used in facial implants. Silicone is resistant to degradation and when fixed against a bony surface its long term stability is very high. Carbon-based polymers include polytetrafluoroethylene (PTFE), polyethylene (PE) and aliphatic polyesters. PE is currently being used in its high density form (HDPE), which allows for contouring by the surgeon. The solid implantable form of HDPE (Medpor®) allows for increased fibrous ingrowth lead- ing to long-term stabilization of the implant. Alloplastic chin augmentation is a well-accepted technique used in the correc- tion of mild retrognathia or true retrogenia. The advantages of alloplastic augmen- tation include the material being readily available without donor morbidity, shorter operating time and less blood loss. The disadvantages include bone resorption, infection, extrusion and displacement. When an implant is used, either an intraoral or extraoral approach can be used. With the extraoral approach, the incision placement is in a natural crease location. 65 404 Practical Plastic Surgery The extraoral approach has a lower rate of infection although it is more difficult to achieve precise placement of the implant. The intraoral technique introduces oral flora into the pocket of dissection, increasing the risk of infection and extrusion. Malar Augmentation The malar prominences contribute to aesthetic balance and beauty. Deficiencies or asymmetry in the malar region are usually secondary to trauma, congenital anomalies, such as Treacher Collins syndrome, cancer, or aging. Malar augmentation can be used in either aesthetic or reconstructive practices to achieve symmetry and balance of the face. For example, patients that have undergone repair of a cleft lip and palate may require a LeFort I osteotomy to correct midface deficiency and malocclusion. Correc- tion of the occlusion can be done with the LeFort I osteotomy. The concave profile can be enhanced by malar augmentation (or doing a high osteotomy) to help reestab- lish overall facial harmony and proportions. In the aging patient, the face may have a tired appearance due to resorption of the maxilla and descent of the malar fat over the zygoma. Malar augmentation may help to create a more youthful appearance. Preoperative assessment of the deficient or asymmetric malar region is impor- tant prior to any augmentation. The facial skeleton can be analyzed using three-dimensional CT generated models from which custom-made implants can be fabricated. Any asymmetries found should be pointed out to the patient and docu- mented. Malar augmentation can be done with autologous bone or with alloplastic implants. Technique A number of approaches have been described, including the lower eyelid, coro- nal, temple and preauricular incisions. However, the most popular approach is by an intraoral incision. This approach leaves no visible scar and allows the procedure to be performed under local anesthesia if desired. The intraoral approach is done through an upper buccal sulcus incision followed by subperiosteal dissection of a pocket in the malar region. It is important to identify the infraorbital nerve and protect it. The implant is contoured and placed after creation of an adequate pocket. It should remain “uncontaminated “during its placement in order to decrease the risk of infection. In the no touch technique, the implant does not come in contact with gloved hands, skin, or oral mucosa in hopes to decrease any bacterial contami- nation load. Finally, the implant should be secured with either screws, nonabsorb- able sutures, or held in place by a tight pocket of periosteum. Pearls and Pitfalls Over the long-term, genioplasty is much more durable than alloplastic augmen- tation of the chin. At some point, most implants will require replacement due to malposition, extrusion, infection or overlying soft tissue changes. Osseous genio- plasty, however, can last a lifetime. It is important to discuss this with the patient. When designing the proposed osteotomy for genioplasty, one has to pay particu- lar attention to the apices of the teeth and the mental nerve. The intraoral approach provides a simple access without a visible scar. The mental foramen lies on the same vertical plane defined by the second bicuspid tooth, infraorbital foramen and pupil. The mental nerve should be dissected out, retracted superiorly and protected during the osteotomy. The three branches of the mental nerve exit the mental foramen and 65 405 Genioplasty, Chin and Malar Augmentation supply general sensation to the chin point. The osteotomy line should be about 3 mm below the mental canal to avoid the route of the inferior alveolar nerve. Genioplasty by AHMO has also found a functional role in patients with ob- structive sleep apnea. Advancement of the genioglossal muscle leads to indirect el- evation of the hyoid, thus serving as an adjunct to bimaxillary surgery. A long distance (>15 mm) from the hyoid to the mandibular plane angle can contribute to a de- crease in the posterior airway space. By advancing the genial tubercle and muscles, this will indirectly pull the hyoid closer to the mandibular plane and away from the posterior airway. Suggested Reading 1. Chang EW, Lam SM, Karen M et al. Sliding genioplasty for correction of chin abnor- malities. Arch Facial Plast Surg 2001; 3(1):8. 2. Constantinides MS, Galli SK, Miller PJ et al. Malar, submalar and midfacial implants. Facial Plast Surg 2000; 16(1):35. 3. Millard DR. Chin implants. Plast Reconstr Surg 1954; 13(1):70. 4. Spear SL, Kassan M. Genioplasty. Clin Plast Surg 1989; 16(4):695. 5. Spear SL, Mausner ME, Kawamoto Jr HK. Sliding genioplasty as a local anesthetic outpatient procedure: A prospective two-center trial. Plast Reconstr Surg 1987; 80(1):55. 6. Wolfe SA. Chin advancement as an aid in correction of deformities of the mental and submental regions. Plast Reconstr Surg 1981; 67:5. 7. Yaremchuk MJ. Facial skeletal reconstruction using porous polyethylene implants. Plast Reconstr Surg 2003; 111(6):1818. [...]... 82(6):98 3-9 3 2 Grazer FM, Goldwyn RM Abdominoplsty assessed by survey with emphasis on complications Plast Reconstr Surg 59(4) :51 3 -7 3 Greminger RF The mini-abdominoplasty Plast Reconstr Surg 19 87; 79 (3) :35 6-6 5 4 Hester Jr TR, Baird W, Bostwick IIIrd J et al Abdominoplasty combined with other major surgical procedures: Safe or sorry? Plast Reconstr Surg 1989; 83(6):99 7- 1 004 5 Lockwood TE High-lateral-tension... system suspension Plast Reconstr Surg 1995; 96(3):60 3-1 5 6 Lockwood TE Maximizing aesthetics in lateral-tension abdominoplasty and body lifts Clin Plast Surg 2004; 31(4):52 3-3 7 7 Pitanguy I Abdominal lipectomy Clin Plast Surg 1 975 ; 2(3):40 1-1 0 Chapter 70 Liposuction Zol B Kryger Indications Liposuction, or suction-assisted lipectomy, is the most common plastic surgical procedure performed in the U.S It... Inc., 2000:23 9-3 69 2 Salomon JA, Barton JR FE Augmentation mammaplasty Selected Readings in Plastic Surgery 2004; 28(8): 1-3 4 3 Spear SL, Elmaraghy M, Hess C Textured-surface saline-filled breast implants for augmentation mammaplasty Plast Reconstr Surg 2000; 105:154 2-1 552 4 Tebbetts JB A surgical perspective from two decades of breast augmentation Clin Plast Surg 2001; 28(3):42 5-4 34 Chapter 67 Gynecomastia... for the actions of peripheral aromatase (cirrhosis, thyroid excess, adrenal disease and starvation) Practical Plastic Surgery, edited by Zol B Kryger and Mark Sisco ©20 07 Landes Bioscience 414 Practical Plastic Surgery Drugs that interfere with estrogen-testosterone balance include: estrogens, estrogen-like compounds (marijuana, heroin), gonadotropins, inhibitors of testosterone (spironolactone, cimetidine... mastopexy Finally, women with a high risk of breast cancer should be evaluated carefully since surgery may alter the architecture of breast tissue making detection and treatment of cancer difficult Practical Plastic Surgery, edited by Zol B Kryger and Mark Sisco ©20 07 Landes Bioscience 418 Practical Plastic Surgery Preoperative Considerations Judicious care should be taken during patient assessment... Grabb and Smith’s Plastic Surgery 5th ed Lippincott-Raven Publishers, 19 97 6 Weinzweig J Augmentation mammaplasty Plastic Surgery Secrets Philadelphia: Hanley, 1999:238 68 Chapter 69 Abdominoplasty Amir H Taghinia and Bohdan Pomahac Classification and Choice of Procedure Procedures used to change the shape of the anterior abdomen include liposuction (suction-assisted lipectomy), mini-abdominoplasty (infraumbilical... Kahn S Classification and surgical correction of gynecomastia Plast Reconstr Surg 1 973 ; 51:48 5 Spear SL, Little IIIrd JW Gynecomastia Grabb and Smith’s Plastic Surgery 5th ed Lippincott-Raven Publishers, 19 97 6 Wilson JD Gynecomastia Harrison’s Principles of Internal Medicine 11th ed New York: McGraw-Hill Book Co., 19 87 Chapter 68 Mastopexy Richard J Brown and John Y.S Kim Introduction Mastopexy, or... panniculitis These patients have poor vascularity of the abdominal wall tissue; therefore even limited flap undermining can lead to complications Practical Plastic Surgery, edited by Zol B Kryger and Mark Sisco ©20 07 Landes Bioscience 424 Practical Plastic Surgery Patients with excess abdominal wall fat usually benefit from weight loss prior to an operation Successful preoperative weight loss heralds... technique used for marking is Practical Plastic Surgery, edited by Zol B Kryger and Mark Sisco ©20 07 Landes Bioscience Liposuction 431 to use to use a topographical map-like sytem in which the area to be suctioned is marked with concentric rings An increasing number of rings indicates a greater thickness of fat to be suctioned The areas to be avoided are marked as well Prior to 70 surgery, an intravenous... whereas others prefer a V-shaped incision (Fig 69.8) Figure 69.6 Gauging excess tissue Once the flap is fully raised, the patient’s hips are flexed and the flap is pulled inferiorly to assess the amount of excess tissue to be excised 69 428 Practical Plastic Surgery Figure 69 .7 Gauging excess tissue The lower flap can be cut in half to provide better visualization of excess tissue-especially in the midline . Facial Plastic and Recon- structive Surgery. New York: Thieme, 2002:8 7- 9 6. 2. Daniel RK. Rhinoplasty. In: Aston SJ, Beasley RW, Thorne CHM, eds. Plastic Sur- gery. Philadelphia: Lippincott-Raven,. Readings in Plastic Surgery. 2004; 28(8): 1-3 4. 3. Spear SL, Elmaraghy M, Hess C. Textured-surface saline-filled breast implants for augmentation mammaplasty. Plast Reconstr Surg 2000; 105:154 2-1 552. 4 breast augmentation. Clin Plast Surg 2001; 28(3):42 5-4 34. Chapter 67 Practical Plastic Surgery, edited by Zol B. Kryger and Mark Sisco. ©20 07 Landes Bioscience. Gynecomastia Reduction Richard