Anesthesiologist's Manual of Surgical Procedures, 4th ed.

Plastic and reconstructive surgery

Chapter 11.1

Facial Cosmetic Surgery

Angeline F. Lim MD


Lonny L. Ross MD, FRCSC


David M. Kahn MD


Tara Cornaby MD



Introduction to Cosmetic Facial Surgery

The presenting symptoms of the aging face are predictable, based on the effects of gravity, soft tissue atrophy, facial expression, ultraviolet radiation exposure, and connective tissue changes. Patients present with concerns about appearing tired, angry, or aged. They also may have functional difficulties, such as difficulty breathing or visual field obstruction due to drooping brows or eyelids. Other common complaints are wrinkles around the eyes and mouth, and a sagging or fatty chin and neck.

Cosmetic facial surgery aims to rejuvenate and restore the facial form by surgical manipulation of the hard and soft tissues. The techniques used involve any or all of the following: soft tissue release, resection, plication, and resuspension.

Facial aging takes place simultaneously in all areas of the face and neck; combined procedures are not uncommon. Generally in combined procedures, a browlift would precede a necklift, followed by a facelift. Blepharoplasty procedures can be performed at different times in the surgical scheme, because of their effect on eyelid tissue and brow posture. A rhinoplasty ideally is reserved for last, as it can cause bleeding and swelling that can obscure other facial surgical fields.

Facelift and Necklift

Surgical Considerations

Facelift (or Meloplasty or Rhytidectomy)

Description: Facelifts and midface lifts are procedures to rejuvenate the face by surgical manipulation of the soft tissues between the inferior orbital rim and the inferior border of the mandible. The lips and nose are generally unaffected. Many types of “facelift” procedures have been developed to address the diverse challenges of facial aging and rejuvenation. Traditional facelift procedures took place in the subcutaneous plane, with some skin resection. Today, three planes of dissection are used (Fig. 11.1-1). Subcutaneous dissection continues to be popular, traversing the adipose tissue below the skin and many of the vessels supplying the skin. The subSMAS technique develops the plane between the superficial musculoaponeurotic system of the face (SMAS) and the parotid gland. Finally, subperiosteal dissections (midface lifts) have become popular, due to the decreased risk of postoperative hematomas. Combinations of these dissection planes also have been described. More recently, greater attention has been paid to minimal access techniques. Surgeries such as the minimal access cranial suspension lift, as well as adjunctive procedures such as the barbed suture lift, are being performed more frequently.

Local anesthetics with epinephrine are injected presurgically for the various procedures. A number of subcutaneous infiltration mixtures may be used, including one described byKlein that consists of NS 1,000 mL with 1.0 mL epinephrine (1:1000) and 50 mL of 1% lidocaine ± 12.5 mL of 8.5% sodium bicarbonate solution. It has been shown that with the use of this mixture, 5–7 times the traditionally accepted maximum dose of lidocaine with epinephrine can be injected safely into the subcutaneous space. Not only does this solution provide hemostasis and hydrodissection, but decreased operative time and excellent perioperative analgesia also have been attributed to its use.

Traditional incisions typically are made in the preauricular region with temporal and postauricular scalp extensions. The approaches for the subcutaneous and SMAS techniques resemble those used for bilateral facial palsy and parotid gland operations. The midface procedures may be carried out through intraoral, temporal, and/or lower-lid incisions and may be combined with other facelift procedures.

A typical facelift may begin with subcutaneous dissection of the facial skin flap (Fig. 11.1-2) on one side, with meticulous hemostasis accomplished with bipolar electrocautery. The SMAS layer can then be mobilized and resuspended. Some surgeons continue on the same side with skin resection and closure before beginning on the other side, while others temporarily pack the first side and perform an identical procedure on the opposite side. In the latter case, a second look for bleeding is made on each side after a waiting period.



Figure 11.1-1. Anatomic layers of the face. Although the names vary, the arrangement persists, regardless of the area of the face. The facial nerve (CN VII) branches innervate their respective muscles of the SMAS layer via the deep surfaces. (Reproduced with permission from Thorne CHM, Aston SJ: Aesthetic surgery of the aging face. In Grabb & Smith's Plastic Surgery, 5th edition. Aston SJ, Beasley RW, Thorne CHM, eds. Lippincott-Raven: 1997.)

Hematoma is the most common complication of facelift surgery. Because hypertension is the most frequently encountered medical condition in the age group that typically presents for facelift, perioperative hypertension must be anticipated and treated pre-emptively to avoid development of hematoma. The risk is highest in male patients, perhaps due to increased perfusion of the bearded region, hormonal gender differences, or increased sebaceous gland density. Commonly used salicylates and other NSAIDS are contraindicated in the immediate preoperative period (i.e., within 10 days of surgery).

Smoking also has been shown to be detrimental to facelift results, especially with regard to skin flap survival. Ideally, patients should not smoke for two weeks before and after surgery.

One of the least desirable complications is injury to the facial nerve, which can produce a disastrous result following an elective cosmetic surgery. Many surgeons prefer that no paralytics be used during the procedure to allow for careful monitoring of facial nerve function.



Figure 11.1-2. Dissection of SMAS/platysma flap. If a composite rhytidectomy is performed, the same plane of dissection is used. If SMAS dissection extends to the zygomaticus major muscle, it is termed “extended.” (Reproduced with permission from Thorne CHM, Aston SJ: Aesthetic surgery of the aging face. In Grabb & Smith's Plastic Surgery, 5th edition. Aston SJ, Beasley RW, Thorne CHM, eds. Lippincott-Raven: 1997.)


Description: Necklift is the rejuvenation of the area from the inferior mandibular margin to the clavicles. This procedure often is combined with facelift procedures to sharpen the chin and smooth the anterior neck (i.e., improve the cervicomental angle). It usually is achieved by extending the facelift dissection inferiorly through the preauricular incision. A small submental incision may also be used to allow for submental liposuction, lipectomy, or platysma muscle modifications (plication, suspension, resection, or transection techniques).8 Some platysmal suspension techniques require the facelift incisions to remain open with continuity in the subcutaneous plane laterally.

Variant procedures or approaches: Laser resurfacing (see p. 1080 and p. 1512), especially in the perioral and periorbital regions; blepharoplasty and browlift (see p. 1071) are common adjunct procedures.

Usual preop diagnosis: Facelift: facial rhytids (wrinkles/creases); solar or senile elastosis; jowling; deep nasolabial folds; tear troughs; nasojugal folds; malar bags. Necklift: “turkey gobbler” neck; platysmal bands; cervical laxity; cervical rhytids


Summary of Procedures




Midface lift


Supine, reverse Trendelenburg


Preauricular, scalp

Extension of facelift incision + submental incision.

Intraoral ± subciliary or inferior lid

Special instrumentation

Infiltration equipment for super wet techniques; endoscopic equipment (more frequent with brow lifts)

⇐ ± liposuction instrumentation.

Unique considerations

Oral intubation; ability to move ETT side-to-side. Watch for: oculocardiac reflex (OCR), retrobulbar hematoma with periorbital approaches.
If laser is used:

·   Special fire-retardant ETT and drapes

·   Laser eye protection for all in room

·   Cannula-administered O2 should be far away from laser (fire safety).

·   Smoke evacuation system (See Facial Laser Resurfacing, p. 1080.)

Infiltration of large volumes of local with epinephrine in facelift and liposuction procedures.

Antibiotics + other meds

Cefazolin 1 g iv, (± methylprednisolone 125 mg iv). Antivirals periop if laser used (e.g., acyclovir 2,400 mg × 2 d preop and 14 d postop)

Surgical time

4–6 h

1–2 h

2–4 h

Closing considerations

Trendelenburg for final hemostasis ± drains
Some surgeons prefer gentle ↑ in BP during hemostasis.
Tissue thrombin agents may be used between the elevated flaps.
Sensory nerve blocks by surgeon
± Full head/face wrap before patient awakens
Gentle, nonagitated awakening to prevent sudden ↑ BP.


100–200 mL

Postop care

Monitor for hematoma: most common complaint is pain; therefore, r/o hematoma before increased analgesia or sedation.
Lightly compressive dressing, ± drains: both removed at 24 h.
2 wk no aspirin, moderate activity




Early hematoma:

Very rare

·   Large expanding: 1–15% (return to OR)

·   Small (> 30 mL): 10–15% (± aspiration in office)


Late hematoma (average = 9 d postop; 2° to exertion or aspirin use; from superficial temporal vessels)

Infection: 0–0.33%

Nerve injury:



·   Motor (temporal/marginal mandibular branches)


Very rare

·   Temporary: 0.1–2.6%


·   Permanent: 0–0.66%


·   Motor (spinal accessory nerve): Rare

Sensory injury:


·   Great auricular nerve →↓ sensation in lower of ear ± painful neuromas or paresthesias.



·   Lesser occipital nerve painful → neuroma.

Alopecia: 0.4% (most temporary, along the incision)

Skin slough: 14% (especially in retroauricular area) (12.5 × greater in smokers)


Dehiscence: 0.1–0.35%
Parotid cysts: Rare
Poor cosmetic result:

·   Hyperpigmentation

·   Telangiectasia (pre-existing lesions may worsen)

·   Hypertrophic scarring

·   Keloids: Very rare

·   “Pixie” (pulled-down earlobe) deformity (technique-dependent)

·   Hairline shifts

Ectropion (midface, approached via lid incisions only): Up to 3%

Pain score





Patient Population Characteristics

Age range

> 35 yr


1:9 to 1:5 (increased from 1:17 in the 1970s.)


104,055 facelift procedures in the United States (2006); sixth most common cosmetic plastic surgery procedure


Facial rhytids 2° solar elastosis, senile elastosis, facial expression

Associated conditions

Cancers of the skin (basal cell carcinoma, squamous cell carcinoma and precursors, and melanoma), in solar elastosis cases, especially fair-skinned patients

Anesthetic Considerations

See Anesthetic Considerations following Browlift and Blepharoplasty, p. 1075.

Suggested Readings

  1. Alster TS, Apfelberg DB, eds: Cosmetic Laser Surgery: A Practitioner's Guide,2nd edition. Wiley-Liss, New York: 1999.
  2. American Society of Plastic Surgeons web site:
  3. Baker DC, Conley J: Avoiding facial nerve injuries in rhytidectomy. Plast Reconstr Surg1979; 64(6):781–95.
  4. Baker TJ, Gordon HL: Complications of rhytidectomy. Plast Reconstr Surg1967; 40(1):31–9.
  5. Brody GS: The tumescent technique for facelift. Plast Reconstr Surg1994; 94:563.
  6. Desnoyers Y, Custeau P, Berthiaume J: Anaesthesia for facial rhytidectomy. Can Anaesth Soc J1979; 26(3): 222–4.
  7. Dumanian GA, Bontempo FA, Johnson PC: Evaluation and treatment of the plastic surgical patient having a potential to bleed. Plast Reconstr Surg1995; 96(1):211–18.
  8. Feldman JJ: Corset platysmaplasty. Plast Reconstr Surg1990; 85(3):333–43.
  9. Goldwyn RM: Late bleeding after rhytidectomy from injury to the superficial temporal vessels. Plast Reconstr Surg1991; 88(3):443–5.
  10. Heinrichs HL, Kaidi AA: Subperiosteal face lift: A 200-case, 4-year review. Plast Reconst Surg1998; 102(3):843–55.
  11. Hester TR Jr, Codner MA, McCord CD, et al: Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience. Plast Reconstr Surg2000; 105(1):393–408.
  12. Hochman M: Midface barbed suture lift. Facial Plast Surg Clin N Am 2007; (15):201–7.
  13. Hoefflin SM: The extended supraplatysmal plane (ESP) face lift. Plast Reconstr Surg1998; 101(2):494–503.
  14. Kaye, BL: Complications of face-lift. Adv Plast Reconstr Surg1990; 6:125–76.
  15. Lemmon ML, Hamra ST: Skoog rhytidectomy: A five-year experience with 577 patients. Plast Reconstr Surg1980; 65(3): 283–97.
  16. Little JW: Three-dimensional rejuvenation of the midface: Volumetric resculpture by malar imbrication. Plast Reconstr Surg2000; 105(1):267–85.
  17. Mottura AA: The tumescent technique for face lifts? Plast Reconstr Surg1995; 96(1):231.
  18. Pitanguy I: Facial cosmetic surgery: A 30-year perspective. Plast Reconstr Surg2000; 105(4):1517–27.
  19. Rees TD, Lee YC, Coburn RJ: Expanding hematoma after rhytidectomy. Plast Reconstr Surg1973; 51(2):149–53.
  20. Schnur PL, Burkhardt BR, Tofield JJ: The second-look technique in face lifts: Does it work? Plast Reconstr Surg1980; 65(3):298–301.


  1. Schoen SA, Taylor CO, Owsley TG: Tumescent technique in cervicofacial rhytidectomy, J Oral Maxillofac Surg1994; 52: 344–7.
  2. Sullivan SA, Dailey RA: Endoscopic subperiosteal midface lift. Opthal Plast Reconstr Surg2002; 18(5):319–30.
  3. Tonnard P, Verpaele A, Monstrey S, et al: Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg 2002; 109(6):2074–86.

Browlift and Blepharoplasty

Surgical Considerations

Browlift (or Forehead Lift)

Description: Browlift is the resuspension of the brows and elimination of upper facial rhytids to restore the youthful appearance of the upper face. This procedure has a significant effect on the results of an upper blepharoplasty, with which it is frequently paired. Patients presenting for browlift usually have specific concerns about lateral brow hooding, forehead wrinkles, and glabellar creases that give them an angry appearance.

Like facelift procedures, browlifts have been performed in the subcutaneous plane, but the relatively avascular subgaleal and subperiosteal planes are more commonly used. The subgaleal and subperiosteal approaches have become more popular with the incorporation of endoscopic techniques. The incision may be a complete bicoronal or three to five small, interrupted access incisions along the hair line or within the hair-bearing scalp (Fig. 11.1-3). In the open technique, the bicoronal flap is dissected off the upper face (Fig. 11.1-4). The brows are elevated by scalp resuspension ± resection. Closure of the scalp helps maintain the resuspended position. The soft tissues may also be fixated directly to the cranium with screws or resorbable fixation devices and sutured to the temporal fascia to maintain


their new positions. Release of the periosteum along the superior orbital rims is a prerequisite to adequate resuspension when using a subperiosteal approach. Elimination of the upper facial rhytids (i.e., glabellar wrinkles) is achieved by resection of the medial brow musculature (corrugator and procerus) from beneath the elevated flap. Muscular bleeding is controlled with bipolar electrocautery.


Figure 11.1-3. Incisions for forehead/brow lifting. Consistent blepharoplasty results demand appropriate frontal lifting technique. A: Standard coronal incision. B: Male and female balding incision. Note the posterior displacement of the ascending incision for maximum camouflage. Hair perimeter incisions are rarely necessary. The central brow corrects nicely from only parietotemporal scalp excisions (after appropriate supraperiosteal release). (Reproduced with permission from Flowers RS, DuVal C: Blepharoplasty and periorbital aesthetic surgery. In Grabb & Smith's Plastic Surgery, 5th edition. Aston SJ, Beasley RW, Thorne CHM, eds. Lippincott-Raven: 1997.)


Figure 11.1-4. Exposure after subgaleal, supraperiosteal dissection of the forehead. The supraorbital nerves can be seen easily, but the supratrochlear nerves are more superficial and are hidden by the corrugator muscles. Scissors are used to tease through the corrugator muscles to locate the supratrochlear nerve branches. The muscle is then aggressively resected, preserving the sensory branches. (Reproduced with permission from Thorne CHM, Aston SJ: Aesthetic surgery of the aging face. In Grabb & Smith's Plastic Surgery, 5th edition. Aston SJ, Beasley RW, Thorne CHM, eds. Lippincott-Raven: 1997.)

Variant procedures or approaches: The browlift has become the facial plastic surgery procedure most adaptable to the techniques of endoscopy. Multiple smaller (1–1.5 inch) incisions are used within the scalp for access,




and small, elliptical excisions also may be used to achieve the desired effect. The muscle resection is accomplished endoscopically with very small biting forceps from beneath the flap.


Figure 11.1-5. Redraping the forehead/brow using “key” fixation sutures. Maximal tension is placed laterally to elevate the lateral brow to a greater extent than the medial brow. (Reproduced with permission from Thorne CHM, Aston SJ: Aesthetic surgery of the aging face. In Grabb & Smith's Plastic Surgery, 5th edition. Aston SJ, Beasley RW, Thorne CHM, eds. Lippincott-Raven: 1997.)

Summary of Procedures





Supine; table rotated 90 or 180°


Hairline, coronal; multiple scalp for endoscopic procedure

Upper: tarsal fold; lower: subciliary, transconjunctival

Special instrumentation

Fibrin glue, screws or resorbable fixation devices for suspension; endoscopic equipment

Bipolar electrocautery

Unique considerations

Local anesthetic with epinephrine

Retrobulbar hematoma; OCR; local anesthetic with epinephrine


Cefazolin 1 g iv ± methylprednisolone 125 mg iv

Surgical time

1–2 h

Closing considerations

Place dressing before arousing patient. Gentle arousal from anesthesia (↑ in BP or emesis → risk of hematoma)

No dressing (ointment)


50 mL


Postop care

PACU → room/home
Lightly compressive dressing
Head of bed elevated

Cool packs

Ophthalmic lubricant
Vision checks




Hematoma: Rare

Alopecia: Rare (more common with bicoronal approach)
Infection: < 1%
Frontalis paralysis: Rare (usually transient)
Poor cosmetic result
Sensory nerve dysfunction

Blindness: Extremely rare

Pain score



Patient Population Characteristics

Age range

Most ≥ 35 yr


Blepharoplasties: 1:4
Browlifts: 1:7.33


Blepharoplasties: 233,200 (fourth most common cosmetic procedure in the United States, 2006)
Browlifts: 55,525 (ninth most common cosmetic procedure in the United States, 2006)


Facial rhytids secondary to solar elastosis, senile elastosis, facial expression, and increased muscle resting tone; Asian eyelids

Associated conditions

Cancers of the skin (basal cell carcinoma, squamous cell carcinoma and precursors, and melanoma) in solar elastosis cases, especially fair-skinned patients


Figure 11.1-6. Traditional blepharoplasty technique. A: The caudal margin of the excision is marked and (B) the upper eyelid skin is pinched. Skin and muscle are excised (C, D, E); excess or herniated fat is removed from medial and lateral compartments (F, G, H); and the wound is closed (I). On the lower lid, the traditional approach is flap elevation, consisting of skin or skin with attached muscle (J, K). The skin is draped upward and outward so the surgeon can assess and remove excess skin (L, M). (Reproduced with permission from Flowers RS, DuVal C: Blepharoplasty and periorbital aesthetic surgery. In Grabb & Smith's Plastic Surgery, 5th edition. Aston SJ, Beasley RW, Thorne CHM, eds. Lippincott-Raven: 1997.)


Usual preop diagnosis: Brow ptosis; brow droop; upper facial rhytids (wrinkles or creases)

Blepharoplasty (or Lidlift)

Description: Blepharoplasty (Fig. 11.1-6), or lidlift, is the surgical rejuvenation of the periorbital region to eliminate the tired and aged appearance of the eyes. Westernizing the Asian eyelid also has become quite commonplace. Presenting complaints include excess lid skin, prominent periorbital fat, and absence of upper lid folds. Blepharoplasty can involve resection of skin, muscle (orbicularis oculi), and fat. Many patients presenting for this procedure will require a simultaneous browlift to re-establish the baseline position of the brows, revealing the true amount of upper-lid redundancy. Eyelid ptosis repair also can be achieved in the same surgery.

Although a seemingly benign procedure, the manipulation of periorbital fat can have very serious consequences. Retrobulbar hematoma and blindness can occur postoperatively, and the oculocardiac reflex (OCR) can complicate the intraoperative course with bradycardia and hypotension. This generally resolves with elimination of the stimulus.

Blepharoplasty, as an isolated procedure, is often performed with local anesthetic and intravenous sedation so that patients can open and close their eyes during the surgery. This helps to achieve a good result and decreases the risk of lagophthalmos, which is especially important if a ptosis repair is also planned.

Variant Procedures or Approaches: CO2 laser blepharoplasty techniques have proven effective, but must be done under the safety parameters of eye protection and fire and burn prevention (see p. 1080). With this technique, the fat and skin resections are achieved with a laser, replacing the use of a scalpel. Using the laser to gain some of the skin tightening associated with blepharoplasty has also been described.

Usual preop diagnosis: Blepharochalasis; periorbital fat; blepharoptosis; dermatochalasis; supratarsal fold absence; Asian eyelid

Suggested Readings

  1. American Society of Plastic Surgeons web site:
  2. Berkowitz RL, Jacobs DI, Gorman PJ: Brow fixation with the Endotine Forehead device in endoscopic brow lift. Plast Reconstr Surg2005; 116(6):1761–7.
  3. Flowers RS, Caputy GC, Flowers SS: The biomechanics of brow and frontalis function and its effect on blepharoplasty. Clin Plast Surg1993; 20(2):255–68.
  4. Flowers RS: The art of eyelid and orbital aesthetics: multiracial surgical considerations. Clin Plast Surg1987; 14(4):703–21.
  5. Matarasso A: The oculocardiac reflex in blepharoplasty surgery. Plast Reconstr Surg1989; 83(2):243–50.
  6. Mittelman H, Apfelberg DB: Carbon dioxide laser blepharoplasty—advantages and disadvantages. Ann Plast Surg1990; 24(1):1–6.
  7. Ortiz-Monasterio F, Barrera G, Olmedo A: The coronal incision in rhytidectomy—the brow lift. Clin Plast Surg1978; 5(1):167–79.
  8. Ramirez OM: Endoscopic techniques in facial rejuvenation: an overview. Part 1. Aesth Plast Surg1994; 18:141–7.
  9. Ramirez OM: Endoscopically assisted biplanar forehead lift. Plast Reconstr Surg1995; 96(2):323–33.
  10. Sacks SH, Lawson W, Edelstein D, et al: Surgical treatment of blindness secondary to intraorbital hemorrhage. Arch Otolaryngol Head Neck Surg1988; 114:801–3.
  11. Stasior OG, Ballitch HA II: Ptosis repair in aesthetic blepharoplasty. Clin Plast Surg1993; 20(2):269–73.
  12. Steinsapir KD, Shorr N, Hoenig J, et al: The endoscopic forehead lift. Opthal Plast Reconstr Surg1998; 14(2):107–18.
  13. Wolfe SA, Baird WL: The subcutaneous forehead lift. Plast Reconstr Surg1989; 83(2):251–6.

Anesthetic Considerations

(Procedures covered: facelift, necklift; browlift, blepharoplasty)


Cosmetic facial surgery is elective and should be performed preferably on ASA I or II patients. Often, several cosmetic procedures (including facial laser resurfacing) are performed during the same surgical session. A preop discussion


with the surgical team is important to help define the anesthetic plan. The above procedures are predominantly done under GA in the hospital, but can also be done under MAC with local anesthesia.


A careful inspection of the airway should be performed. Surgeon may request intraop manipulation of the oral ETT from side-to-side.


A thorough cardiovascular evaluation should be performed, because HTN is the most common medical condition in this patient population. Many procedures involve the use of significant amounts of local anesthetic with epinephrine, placing the patient at higher risk for HTN, dysrhythmias, and coronary artery spasm. Additionally, consider patient suitability for the use of controlled, mild controlled ↓ BP (particularly the facelift patient).
Tests: ECG, if indicated from H&P.


[check mark] for recent aspirin/NSAID use.
Tests: CBC, if indicated from H&P.


Others tests as indicated from H&P.


Preop sedation with clonidine (adjunctive hypnotic and antihypertensive agent) or midazolam usually is appropriate. Preop steroids (dexamethasone 4–8 mg) also may be used to reduce postop pain and PONV, as well as swelling.


Anesthetic technique: Cases are predominantly done under GA, using an ETT or LMA, as appropriate. Several authors describe the use of a propofol/ketamine MAC or “dissociative anesthetic” in the office-based setting. There are varying descriptions of this technique, generally involving a propofol infusion with incremental ketamine boluses or infusion, resulting in elimination or significant reduction in the administration of iv opiates.

MAC with local anesthetic also is an option and may be advantageous for certain patients (e.g., with Hx of PONV) or for cases that benefit from a patient's intraop ability to follow commands (e.g., ptosis repair).


For those procedures done under GETA, a standard induction (see p. B-2) is appropriate. An oral RAE ETT may be used to minimize intrusion into the surgical field. For cases involving a laser, a shielded ETT manufactured for laser surgery should be used and the cuff filled with NS and methylene blue, rather than air. (Note: no cuffed ETT is 100% laser-proof; always use standard precautions.)


Standard maintenance (see p. B-2) with volatile anesthetic ± propofol infusion is appropriate in most cases. Muscle relaxation should be avoided in cases with facial nerve monitoring. Mild, controlled ↓ BP may be requested and used to facilitate hemostasis. HTN should be avoided and treated immediately if it occurs. Maintain anesthesia during application of head/face wrap.


Antiemetic prophylaxis (e.g., ondansetron 4 mg iv) is recommended, as postop emesis greatly increases the likelihood of hematoma formation. Perform thorough oropharyngeal suctioning and ensure that all throat packing has been removed. A smooth emergence with no notable increase in BP is preferred.

Blood and fluid requirements

Blood loss generally minimal
IV: 18 ga × 1
NS/LR @ 2–4 mL/kg/h


Standard monitors (see p. B-1)

Control of blood loss

Local infiltration with epinephrine
Surgical hemostasis
Mild degree of ↓ BP


[check mark] and pad pressure points.
Rotate OR table 90–180°.

Scleral shields ± ophthalmic ointment



Local anesthetic toxicity
Retrobulbar hematoma

Remove inciting stimulus. Consider atropine 0.5 mcg and deepening anesthetic.






Vigorous treatment of nausea is important.

Pain management

Local infiltration + iv/po narcotics, if needed

R/O expanding hematoma as cause of increasing pain.

Suggested Readings

  1. Aasboe V, Raeder JC, Groegaard B: Betamethasone reduces postoperative pain and nausea after ambulatory surgery. Anesth Analg1998; 87:319–23.
  2. Friedberg BL: Propofol ketamine anesthesia for cosmetic surgery in the office suite. Int Anesthesiol Clin2003; 41(2):39–50.
  3. Richard MJ, Skues MA, Jarvis AP, et al: Total iv anesthesia with propofol and alfentanil: dose requirements for propranolol and the effect of premedication with clonidine. Br J Anaesth1990; 65:157–63.
  4. Yoho RA, Romaine JJ, O'Neil D: Review of the liposuction, abdominoplasty, and face-lift mortality and morbidity risk literature. Dermatol Surg2005; 31:733–43; Erratum in:Dermatol Surg 2005; 31(9 Pt 1):1158.


Surgical Considerations

Description: Rhinoplasty, one of the greatest challenges of plastic surgery, is the surgical manipulation of the nasal form for aesthetic and/or functional improvement. In combination with nasal septal surgery, it is called septorhinoplasty. Common patient requests are for dorsal hump reduction and improved tip definition. Cosmetic surgery of the nose can be divided into four major types: tip rhinoplasty, dorsal rhinoplasty, alarplasty, and septoplasty, in addition to other ancillary procedures to enhance airway function.

Tip and dorsal procedures may be accomplished by either reduction or augmentation. Augmentation can be achieved with synthetic materials such as silicone, expanded fibrillated polytetrafluoroethylene polymer (Gore-Tex), porous polyethylene implants (Medpore), and hydroxyapatite. Cadaveric or autologous tissue (cartilage, bone, fascia, or dermis) also are utilized. Common donor sites for cartilage are the ear concha (via an anterior or posterior approach), the nasal septum (internal nasal approach), and the ribs. Bone harvest sites may include the outer table of cranium, the iliac crest, and the ribs. Dermal graft is commonly harvested from the groin and fascial graft harvest is often taken from the temporoparietal region. (Table 11.1-1 shows the range of open and closed rhinoplasty techniques.)

A throat pack is useful to prevent aspiration or ingestion of blood, as significant blood pooling can occur in the naso/oropharynx area, especially with nasal osteotomies used to narrow or straighten the nasal dorsum. Cases where such pooling is expected are safer under GA with a throat pack. Often rhinoplasties are done with local or regional (nasociliary and infraorbital blocks) anesthesia with sedation. Vasoconstrictor-soaked nasal packs (cocaine vs epinephrine vs oxymetazoline) are placed before the first incision.

The decision of open versus closed technique is based on patient requirements and surgeon preference. An open approach will utilize a transcolumellar incision to allow elevation of a nasal skin flap and degloving of the lower alar cartilages for direct and wide exposure of the nasal framework. Closed approaches use intercartilaginous, intracartilaginous, infracartilaginous, rim, hemitransfixion, and transfixion incisions (all hidden within the nose).

A typical closed rhinoplasty (Fig. 11.1-7) begins with dorsal work through intercartilaginous incisions. The dorsum may be reduced using a scalpel and/or rasps beneath the undermined dorsal skin and periosteum. The septum is addressed as necessary through a hemitransfixion incision (± cartilage harvest). Tip reduction by scalpel or scissor resection of the lower alar cartilage ± tip suture is next. Nasal osteotomies with an osteotome and mallet begin at the base of the nasal bones along the piriform aperture. Digital manipulation completes the fractures, and this is when most of the blood loss occurs. Dorsal and tip grafts are applied as necessary, with alar modifications made last. Alar reduction entails wedge resection of the lateral alar base and primary closure.


Table 11.1-1. Rhinoplasty Techniques




Incisions/skin flap elevation

Tip analysis/cephalic crura excision

Extramucosal tunnels

Dorsal modification

Caudal septum/anterior nasal spine



Graft preparation

Definitive dorsum/spreader grafts

Tip: Columella strut/tip sutures


Alar base modification

Dressing/postop management


Skin elevation/extramucosal tunnels

Rasp bony hump/
excise cartilaginous hump

Radix reduction

Check profile line/septal angle

Caudal septum/anterior nasal spine

transcolumellar incisions

Tip exposure and analysis

Septal correction/harvest


Definitive dorsum/spreader grafts

Tip/columellar modification (excision/sutures/grafts)


Alar base modification


transfixion incision

Skin elevation/extramucosal tunnels

Rasp bony hump/
excise cartilage hump

Radix reduction

Check profile line/septal angle

Caudal septum/anterior nasal spine


Infracartilaginous incisions

Alar cartilage delivery





Alar base modifications


Note: Only those steps appropriate for the individual case are performed.

Depending on the type of rhinoplasty performed, different dressings will be applied at the end of the procedure. When nasal bone osteotomies are used, the patient will require a dorsal nasal splint ± bilateral nasal packing. Nasal packing is generally removed at 24–72 hours postoperatively. When septal manipulation is needed, nasal packing or some sort of septal splint may be placed. The packs are generally removed within three days, but the splints can be maintained much longer and the nasal airways kept patent with vasoconstrictor nasal sprays.

Variant procedures or approaches: Placement of a columellar strut (cartilage graft) and release of the tip depressor muscle often are achieved via intraoral vestibular incisions (behind the upper lip).

Usual preop diagnosis: Posttraumatic nasal deformity (including disordered breathing, “saddle nose,” crooked nose, septal deviation); developmental nasal deformities (bulbous tip, flat tip, drooping tip, broad dorsum, dorsal hump, alar widening, “Pinocchio nose”); congenital nasal malformation (cleft nasal deformities)


Summary of Procedures


Supine, table may be rotated 180°. If GA: oral ETT toward foot of bed, shoulder roll, neck extended, scleral lubricant, shields


External vs internal nasal incisions

Special instrumentation


Unique considerations

Throat pack for expected nasopharyngeal bleeding. Intranasal vasoconstrictors.


Cefazolin 1 g iv

Surgical time

1–2.5 h

Closing considerations

Suction stomach via OG tube at the end of surgery. Remove throat pack prior to extubation. Internal and/or external nasal splints are placed for dressings.


Tip rhinoplasty: 20 mL
Dorsum with osteotomies: 75–150 mL
Septoplasty: + 50 mL

Postop care

PACU → room (most patients are home the same day). Ensure minimal PONV; elevate head of bed; no pressure on nose (e.g., O2 mask).




Infection: > 1%
Adverse cosmetic result:
   Alar notching
   Alar collapse
   Dorsal irregularity
   Tip droop
   Adverse functional result (i.e., poor airway)
   Septal perforation

Pain Score

3 (4 with osteotomies)


Figure 11.1-7. Closed rhinoplasty. A: Transcartilaginous approach using an intracartilaginous incision. B: Delivery approach, using a high intercartilaginous incision and a marginal incision to facilitate delivery of the lateral crura. (Reproduced with permission from Daniel RK: Rhinoplasty. In Grabb & Smith's Plastic Surgery, 5th edition. Aston SJ, Beasley RW, Thorne CHM, eds. Lippincott-Raven: 1997.)



Patient Population Characteristics

Age Range

Most ≥ 15 yr




307,258 (third most common cosmetic procedure in the United States, 2006)


Developmental; acquired (post-traumatic); congenital (see Secondary Cleft Lip and Nasal Surgery, p. 1418).

Associated conditions

Breathing difficulties; psychosocial issues (body dysmorphic disorder)

Anesthetic Considerations

See Anesthetic Considerations for Nasal and Sinus Surgery, p. 245.

Suggested Readings

  1. American Society of Plastic Surgeons web site:, 444 East Algonquin Rd, Arlington Heights, IL 60005-4664.
  2. Becker DG, McLaughlin RB, Loevner LA, et al: The lateral osteotomy in rhinoplasty: clinical and radiographic rationale for osteotome selection. Plast Reconstr Surg2000; 105(5): 1806–19.
  3. Byrd HS, Salomon J, Flood J: Correction of the crooked nose. Plast Reconstr Surg1998; 102(6):2148–57.
  4. Eppley BL: Alloplastic implantation. Plast Reconstr Surg1999; 104(6):1761–83.
  5. Gruber RP, Friedman GD: Suture algorithm for broad or bulbous nasal tip. Plast Reconstr Surg2002; 110(7):1752–68.
  6. Gruber RP: Lengthening the short nose. Plast Reconstr Surg1993; 91(7):1252–8.
  7. Gunter JP, Rohrich RJ: Correction of pinched nasal tip with alar spreader grafts. Plast Reconstr Surg1992; 90(5):821–9.
  8. Guyuron B: Nasal osteotomies and airway changes. Plast Reconstr Surg1998; 102:856.
  9. Molliex S, Navez M, Baylot D, et al: Regional anaesthesia for outpatient nasal surgery. Br J Anaesthesia1996; 76:151–3.
  10. Niechajev I, Haraldsson PO: Two methods of anesthesia for rhinoplasty in outpatient setting. Aesth Plast Surg1996; 20: 159–63.
  11. Owsley TG, Taylor CO: The use of Gore-Tex for nasal augmentation: A retrospective analysis of 106 patients. Plast Reconstr Surg1994; 94(2):241–50.
  12. Sheen JH: Adjunctive techniques in rhinoplasty: harvesting cranial bone for nasal grafts. In Video Perspectives in Plastic Surgery. Quality Medical Publishing, St. Louis: 1989, 1–32.
  13. Tebbetts JB: Shaping and positioning the nasal tip without structural disruption: A new, systematic approach. Plast Reconstr Surg1994; 94(l):61–77.

Also see References for Secondary Cleft Lip/Nasal Surgery, p. 1421.


See Chapter 12.8 Surgery for Craniofacial Malformations, Otoplasty, p. 1423.

Facial Laser Resurfacing

Description: Laser resurfacing is a technique by which a controlled burn is administered to the skin of the face with laser technology, creating a healing process which reduces the signs of aging or acne. CO2 laser resurfacing is commonly used with facial cosmetic procedures. It is used widely for the periorbital and perioral creases and wrinkles not addressed by previously described facial cosmetic surgical techniques. Nerve blocks, local anesthesia, intravenous sedation, and GA are all possibilities for laser treatment. The choice of anesthetic depends more on the specific surgical procedures to be performed first, as the laser procedure is usually adjunctive and added at the end. Facial laser resurfacing is done frequently in an office-based setting (see Chapter 14.0 Office-Based Procedures, p. 1512). Because laser resurfacing is usually an adjunct to another facial cosmetic procedure, the following discussion pertains primarily to the unique set of safety issues that must be addressed in the OR.


Ocular Hazards: These include direct and reflected injury to the eye. Everyone present, including the patient and all medical personnel, requires laser-specific (i.e., wavelength-specific) safety eyewear. Laser-specific scleral shields must be available for the patient in cases where the patient's eyewear would be in the operative field. Protective eyewear must be undamaged and have:

  • Permanent labels with wavelength and optical density tolerance
  • Side shields
  • Damage threshold of > 10 sec
  • No surface reflection
  • Good fit
  • Approval from the laser safety officer

Fire and reflectivity hazards: Many items used in the OR (e.g., drapes, sponges, plastic cannulas, etc.) are made of materials that can be fire hazards if not kept from interacting with the laser beam. Protection from fire and reflectivity is provided by:

  • Having fire-retardant or moist draping
  • Having water basin available
  • Having a fire extinguisher readily available
  • Avoiding all alcohol-containing prep solutions
  • Avoiding use of plastic and rubber instruments (may melt or ignite)
  • Using special fire-resistant ETTs or wet sponge protection for plastic ETTs to decrease the possibility of tube breach or ignition
  • Avoiding open sources of O2(nasal cannulas, etc.)
  • Avoiding metal or other reflective materials

Airborne contaminants: The laser destruction of cells releases carbon particles, microbials, DNA, and toxic fumes. Protection for the patient and medical personnel is provided by:

  • Utilizing a smoke evacuation system 2 cm from created plume
  • Wearing high-filtration masks. Note that these masks become less effective if moistened from perspiration during a long case; if the laser is to be used at the end of a case, changing masks before using the laser may be prudent.

Anesthetic Considerations

See Anesthetic Considerations following Browlift and Blepharoplasty, p. 1075, or Office-Based Laser Skin Resurfacing, p. 1513.

Suggested Readings

  1. Alster TS, Apfelberg DB, eds: Cosmetic Laser Surgery: A Practitioner's Guide,2nd edition. Wiley-Liss, New York: 1999.
  2. Blakeley KR, Klein KW, White PF, et al: A total intravenous technique for outpatient facial laser resurfacing. Anesth Analg1998; 87:827–9.