Chapter 12: Cosmetic and Aesthetic Surgery

Rhinoplasty, blepharoplasty, rhytidectomy, injectable therapies, laser/energy devices, and medicolegal considerations for the OMS practice.

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Introduction

Cosmetic and aesthetic facial surgery is a natural extension of the OMS scope of practice, grounded in the surgeon's comprehensive training in facial anatomy, orthognathic surgery, and soft-tissue management. The AAOMS recognizes rhinoplasty, blepharoplasty, rhytidectomy, otoplasty, and injectable therapies as within-scope procedures for appropriately trained OMS surgeons (AAOMS Position Paper on Cosmetic Surgery, updated 2020). However, aesthetic surgery carries unique medicolegal and ethical considerations: the patient is elective, expectations may be unrealistic, and any complication carries disproportionate psychological impact.

This chapter addresses preoperative evaluation, surgical techniques for core aesthetic procedures, injectable and energy-based therapies, and the business and liability aspects of building an aesthetic practice within OMS.

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Patient Evaluation and Consultation

Facial Analysis

A systematic approach to facial analysis is the foundation of aesthetic treatment planning. The evaluation should proceed from macro (overall facial proportions) to micro (individual subunit analysis):

Frontal view:

• Facial thirds: upper (trichion to glabella), middle (glabella to subnasale), lower (subnasale to menton)
• Facial fifths: each one-fifth equals one eye width
• Facial symmetry assessment (note: mild asymmetry is normal and should be documented preoperatively)
• Nasal proportions: width at alar base should equal intercanthal distance

Lateral view:

• Nasolabial angle: 90-95 degrees (male), 95-105 degrees (female)
• Nasofrontal angle: 115-130 degrees
• Chin projection: Riedel line, Gonzalez-Ulloa meridian, or Legan line
• Cervicomental angle: ideally 90-105 degrees
• Lip projection: Ricketts E-line relationship

Oblique view:

• Malar prominence assessment
• Jawline definition
• Nasal dorsal aesthetic lines (Brow-Tip Aesthetic Lines)

Photography

Standardized medical photography is mandatory. The minimum series includes:

• Frontal (repose and smile)
• Right and left lateral
• Right and left oblique (45 degrees)
• Base/worm's-eye view (for nasal evaluation)
• Close-up views as indicated (eyelids, wrinkle patterns)

Technical standards: Consistent lighting (dual-flash or ring light), neutral background (blue or gray), reproducible patient positioning (Frankfort horizontal), calibrated focal length (85-105mm equivalent).

Psychological Screening

Critical Safety

Body dysmorphic disorder (BDD) affects an estimated 7-15% of cosmetic surgery candidates (Crerand et al., Plast Reconstr Surg, 2006). BDD patients have unrealistic expectations, fixate on perceived minimal defects, and are universally dissatisfied postoperatively. Red flags include: multiple prior cosmetic procedures, inability to specify the exact problem, bringing altered photographs, excessively detailed "wish lists," and hostility toward prior surgeons. A validated screening tool such as the BDDQ (Body Dysmorphic Disorder Questionnaire) should be part of the intake process.

Informed Consent

Cosmetic surgery consent must be exceptionally thorough:

• Document the elective nature of the procedure
• Specify expected and possible outcomes (avoid guarantees)
• Address all potential complications, including rare ones
• Use before/after photographs of representative outcomes (not "best cases" only)
• Document the patient's specific goals and what was discussed regarding achievability
• Allow a cooling-off period (minimum 2 weeks between consultation and surgery)
• Financial consent: clearly delineate surgical fees, facility fees, anesthesia fees, and revision policies

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Rhinoplasty

Preoperative Analysis

Nasal analysis follows a systematic evaluation of the nose from tip to dorsum to base:

Component	Assessment Parameters
Dorsum	Height, width, deviation, hump, saddle
Tip	Projection (Goode ratio: 0.55-0.60), rotation, definition, bifidity, bulbosity
Base	Alar width, columellar show, nostril shape, alar flaring
Septum	Deviation, spurs, perforations (internal exam)
Skin	Thickness (thin vs. thick), sebaceous quality
Internal	Valve competency, turbinate hypertrophy, septal pathology

Nasal valve assessment: The internal nasal valve (angle between the upper lateral cartilage and septum; normal >15 degrees) is assessed with the Cottle maneuver and modified Cottle test. Valve incompetence must be addressed surgically or the patient will have worse breathing postoperatively.

Open vs. Closed Approach

Feature	Open (External)	Closed (Endonasal)
Incision	Transcolumellar + bilateral marginal	Bilateral marginal (intercartilaginous or delivery)
Visualization	Complete binocular exposure	Limited, requires experience
Tip work	Superior precision for complex tip surgery	Adequate for minor tip refinement
Edema	More prolonged tip edema (3-6 mo vs. 1-3 mo)	Less edema
Scar	Transcolumellar scar (typically imperceptible)	No external scar

Open approach preferred for: Major tip reconstruction, revision rhinoplasty, crooked nose, cleft rhinoplasty, dorsal augmentation with graft placement.

Key Surgical Maneuvers

Tip refinement:

• Cephalic trim: Removal of cephalic portion of lower lateral cartilage (preserve >6 mm to prevent alar collapse)
• Dome sutures (interdomal/transdomal): Narrow and define the tip; the interdomal suture creates tip symmetry, the transdomal suture narrows the domal angle
• Columellar strut: Cartilaginous graft placed between the medial crura to support tip projection
• Shield graft: Onlay cartilage graft for tip projection and definition (risks visibility in thin-skinned patients)
• Cap graft: Smaller onlay for subtle tip definition

Dorsal management:

• Hump reduction: Component approach (separate cartilaginous and bony hump removal) or en bloc resection
• Spreader grafts: Cartilaginous grafts placed between the dorsal septum and upper lateral cartilages to maintain/widen the internal nasal valve and create smooth dorsal aesthetic lines. Essential after hump reduction.
• Dorsal augmentation: Cartilage (diced cartilage in fascia [DCF], solid dorsal onlay) or alloplastic (ePTFE, silicone--higher complication rates)

Osteotomies:

• Lateral osteotomy: Closes the open roof after hump removal; performed low-to-low or low-to-high with a 2mm guarded osteotome or powered instruments
• Medial/intermediate osteotomy: For narrow bony vault or deviation
• Percutaneous technique: Reduced mucosal trauma, less edema

CPT: 30400 (rhinoplasty, lateral and alar cartilages and/or elevation of nasal tip), 30410 (including major septal repair), 30420 (including major septal repair, with or without cartilage scoring), 30430-30462 (secondary rhinoplasty)

Clinical Pearl

In the thick-skinned nose, aggressive cartilage reduction does not produce visible tip refinement--the thick skin envelope masks the underlying structural changes. Instead, focus on creating strong tip support (extended columellar strut or septal extension graft) that can push through the thick skin envelope. Consider defatting of the subcutaneous layer, but only conservatively to avoid vascular compromise.

Septoplasty Considerations

When rhinoplasty is performed with septoplasty for functional nasal obstruction, the procedure transitions from purely cosmetic to a combined functional-aesthetic case. Medical insurance typically covers the functional component.

CPT: 30520 (septoplasty), billed with modifier -51 when performed with rhinoplasty. 30465 (repair of nasal vestibular stenosis) for valve repair.

ICD-10: J34.2 (deviated nasal septum), J34.3 (hypertrophy of nasal turbinates)

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Blepharoplasty

Anatomy

The eyelid is a layered structure: skin, orbicularis oculi muscle, orbital septum, preaponeurotic fat, levator aponeurosis (upper lid) / capsulopalpebral fascia (lower lid), Muller's muscle (upper) / retractors (lower), tarsus, and conjunctiva. Understanding the relationship between the orbital septum and fat pads is essential:

• Upper lid: Two fat pads (medial/central preaponeurotic and medial/nasal). The lacrimal gland occupies the lateral space.
• Lower lid: Three fat pads (medial, central, lateral)

Upper Blepharoplasty

Indications: Dermatochalasis (excess skin causing visual field obstruction or cosmetic concern), steatoblepharon (fat prolapse), brow ptosis compensation.

Preoperative evaluation:

• Visual field testing (Humphrey or Goldmann) for insurance documentation
• Brow position assessment (true brow ptosis should be treated with brow lift, not aggressive upper blepharoplasty)
• Levator function testing (must rule out ptosis)
• Tear film assessment (Schirmer's test, tear break-up time)
• Bell's phenomenon (protective corneal reflex)

Technique:

1. Skin marking with the patient upright: inferior mark at the supratarsal crease (8-10 mm from lid margin), superior mark determined by pinch test (preserve at least 20 mm of skin between the superior mark and the brow to ensure adequate lid closure)
2. Local anesthesia (2% lidocaine with 1:100,000 epinephrine)
3. Skin excision (skin only or skin-muscle flap depending on the degree of orbicularis hypertrophy)
4. Orbital septum opened to expose preaponeurotic fat
5. Conservative fat sculpting (excision or repositioning of prolapsing fat)
6. Meticulous hemostasis (cautery of fat pad vessels to prevent retrobulbar hemorrhage)
7. Skin closure with 6-0 nylon or fast-absorbing gut

Critical Safety

Retrobulbar hemorrhage is the most feared complication of blepharoplasty, occurring in ~1:2,000 cases. It presents with proptosis, severe pain, decreased visual acuity, and a tense orbit within hours of surgery. Treatment is emergent: open the wound immediately at bedside, evacuate clot, apply ice and head elevation, administer IV mannitol (1-2 g/kg) and dexamethasone, perform lateral canthotomy and inferior cantholysis to decompress the orbit. Ophthalmology consultation is mandatory. Delay in treatment can result in permanent blindness (Hass et al., Ophthalmic Plast Reconstr Surg, 2004).

CPT: 15822 (upper blepharoplasty), 15823 (upper blepharoplasty with excessive skin weighting down lid)

Lower Blepharoplasty

Approaches:

• Transcutaneous (subciliary or subtarsal incision): Provides access for skin excision, fat repositioning, and orbicularis suspension. Higher risk of lid malposition (ectropion/scleral show).
• Transconjunctival: Incision through the conjunctiva; ideal for isolated fat removal/repositioning without skin excess. No external scar, lower ectropion risk.

Fat repositioning vs. removal: The modern paradigm favors fat repositioning (transposing orbital fat over the inferior orbital rim to fill the tear trough) rather than aggressive fat excision, which creates a hollow, aged appearance (Goldberg, Plast Reconstr Surg, 2000).

Adjunctive procedures:

• Chemical peel (TCA 15-25%) or CO2 laser resurfacing for fine wrinkle reduction
• Lateral canthopexy for lax lower lid (snap-back test positive)
• Midface lift for malar descent

CPT: 15820 (lower blepharoplasty), 15821 (with extensive herniated fat)

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Rhytidectomy (Facelift)

Patient Selection

The ideal facelift candidate presents with jowling, platysmal banding, submental fullness, and loss of the cervicomental angle, with relatively preserved skin quality. Heavy smokers should quit at least 4 weeks preoperatively due to markedly elevated flap necrosis risk (Grover et al., Ann Plast Surg, 2001).

Surgical Techniques

Skin-Only Facelift

The simplest technique: wide subcutaneous undermining, skin redraping, and excess skin excision. Largely abandoned as a standalone procedure due to high recurrence rates and unnatural appearance ("windblown" look).

SMAS (Superficial Musculoaponeurotic System) Techniques

The SMAS represents the fundamental plane of facial rejuvenation surgery. Options include:

• SMAS plication: Suture folding of the SMAS without undermining. Minimal risk to the facial nerve but limited lifting.
• SMAS imbrication (SMASectomy): Excision of a strip of SMAS followed by closure. More robust lift than plication.
• SMAS flap: Elevation and repositioning of a SMAS flap superficial to the parotid. Provides powerful vector correction.
• Extended SMAS (lateral SMASectomy): Greater dissection over the parotid with superior redraping of the midface.

Deep Plane Facelift

Developed by Hamra (1990), the deep plane technique releases the SMAS-platysma from the underlying parotid masseteric fascia and zygomatic ligaments as a composite flap:

• The plane of dissection transitions from subcutaneous (temporal/preauricular) to sub-SMAS (over the cheek)
• Releases key retaining ligaments: zygomatic ligament, masseteric ligament
• Allows powerful repositioning of the midface without tension on the skin
• Longer-lasting results; lower skin-flap necrosis rate (no tension on skin closure)
• Requires advanced surgical skill and anatomic knowledge to protect the facial nerve

Surgical Caution

The facial nerve is at greatest risk during deep plane dissection, particularly the marginal mandibular and buccal branches. The marginal mandibular nerve courses deep to the platysma below the mandibular border (within 1-2 cm of the border in 80% of patients). Maintaining dissection superficial to the deep investing fascia of the parotid protects the main trunk. Nerve monitoring is a useful adjunct (Wormald & Fritz, Facial Plast Surg, 2021).

Neck Lift / Platysmaplasty

Addressed in conjunction with or independently from rhytidectomy:

• Submental liposuction: Pre-platysmal fat (and sub-platysmal fat via direct excision)
• Anterior platysmaplasty: Midline plication of the platysma bands via a submental incision
• Lateral platysma imbrication: Part of the facelift SMAS technique
• Submandibular gland reduction: For ptotic submandibular glands contributing to fullness (partial excision via submental approach; risk to marginal mandibular nerve and lingual nerve)

CPT: 15828 (rhytidectomy, forehead), 15829 (superficial musculoaponeurotic system [SMAS] flap)

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Chin and Malar Augmentation

Chin Augmentation (Mentoplasty)

Evaluation: Chin deficiency is assessed relative to the lower lip (Gonzalez-Ulloa: chin should reach the zero meridian, a vertical line perpendicular to Frankfort horizontal at nasion) and in the context of overall facial proportions.

Options:

Method	Advantages	Disadvantages
Alloplastic implant (silicone, Medpor, ePTFE)	Simple, predictable, reversible (silicone)	Infection (1-3%), bone resorption, malposition, capsular contracture
Sliding genioplasty	Autogenous, precise 3D movement, permanent	More invasive, requires osteotomy, possible mental nerve injury
Injectable filler (CaHA, PLLA)	Nonsurgical, no downtime	Temporary, expensive over time, limited projection

Implant placement (intraoral approach):

1. Mentalis muscle identification and sharp incision (preserve muscle origin for proper lip competence)
2. Subperiosteal pocket creation (precise; avoid excessive lateral dissection to prevent implant migration)
3. Implant placement and fixation (screw fixation reduces migration risk)
4. Layered closure with mentalis muscle resuspension

CPT: 21120 (genioplasty, augmentation; prosthetic material), 21121 (sliding osteotomy, single piece), 21122 (sliding osteotomy, two or more osteotomies)

Clinical Pearl

Always assess the occlusion before recommending chin augmentation. A Class II malocclusion with mandibular retrusion may be better addressed with orthognathic surgery (BSSO advancement) rather than an implant that masks the underlying skeletal discrepancy. A sliding genioplasty provides more versatility (vertical, horizontal, and transverse correction) than an alloplastic implant.

Malar Augmentation

Implant options: Silicone, Medpor (porous polyethylene), or custom PEEK implants placed via intraoral (sublabial), subciliary, or preauricular approaches.

Submalar vs. malar implants: Submalar implants address midface hollowing; malar implants augment the zygomatic body and arch. Combined designs (malar-submalar) are available.

Fixation: Screw fixation to the malar eminence is recommended to prevent migration.

CPT: 21270 (malar augmentation, prosthetic material)

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Otoplasty

Indications

Prominent ears (>20 mm from mastoid to helical rim) caused by:

• Underdeveloped antihelical fold
• Conchal excess (deep conchal bowl)
• Combination of both

Techniques

Mustarde sutures: Horizontal mattress sutures placed through the posterior cartilage to create the antihelical fold. The gold standard for antihelical fold recreation.

Conchal reduction: Excision of conchal cartilage (via anterior or posterior approach) or suturing the concha to the mastoid periosteum (conchal setback).

Scoring/rasping techniques (anterior scoring): Weakening the anterior cartilage surface to allow cartilage remodeling. Less predictable than suture techniques.

EarFold implant: A percutaneous metallic implant (Earfold, Allergan) that folds the antihelical cartilage. Minimally invasive, performed under local anesthesia. Suitable for select patients with isolated antihelical fold deficiency.

Timing: Otoplasty can be performed as early as age 5-6 (when the ear has reached ~85% of adult size), but the majority of cases in OMS practice are adult patients.

CPT: 69300 (otoplasty, protruding ear, with or without size reduction)

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Scar Revision

Principles

Scar revision does not erase scars; it replaces an unfavorable scar with a more favorable one. Key principles include:

• Realignment: Reorient the scar to lie within or parallel to relaxed skin tension lines (RSTL)
• Irregularization: Break up a linear scar to reduce visual conspicuity
• Tension reduction: Minimize wound closure tension
• Camouflage: Place the scar within aesthetic unit boundaries

Techniques

Technique	Indication
Elliptical excision with layered closure	Simple linear scar with adequate surrounding tissue
Z-plasty	Reorientation of scar direction; lengthening of contracted scar
W-plasty	Irregularization of a long linear scar across an aesthetic unit
Geometric broken line closure (GBLC)	Random irregularization for long scars
Serial excision	Wide scars that cannot be excised in a single stage
Tissue expansion	Large scars requiring local tissue recruitment

Adjunctive therapies:

• Steroid injection (triamcinolone 10-40 mg/mL): For hypertrophic scars and keloids
• 5-Fluorouracil injection: Adjunct to steroids for recalcitrant keloids
• Silicone sheeting/gel: First-line prophylaxis for hypertrophic scarring
• Laser: Pulsed dye laser (595 nm) for erythematous scars; fractional CO2 for textural irregularity
• Radiation: Low-dose superficial radiation (12-20 Gy) for keloid excision sites to prevent recurrence (Ogawa et al., Plast Reconstr Surg, 2009)

CPT: 13100-13160 (complex repair of face); 14040-14302 (local flaps); 15002-15004 (wound preparation for skin graft)

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Injectable Therapies

Botulinum Toxin

Mechanism: Inhibits acetylcholine release at the neuromuscular junction by cleaving SNARE proteins, producing temporary muscle paralysis (onset 3-7 days, duration 3-4 months).

FDA-approved products (all onabotulinumtoxinA or its variants):

• Botox (onabotulinumtoxinA, Allergan)
• Dysport (abobotulinumtoxinA, Galderma) -- conversion ratio ~2.5:1 relative to Botox
• Xeomin (incobotulinumtoxinA, Merz) -- no complexing proteins
• Jeuveau (prabotulinumtoxinA, Evolus)
• Daxxify (daxibotulinumtoxinA, Revance) -- longer duration (~6 months)

Common treatment areas and dosing (onabotulinumtoxinA):

Area	Typical Dose	Injection Points
Glabellar complex	20-25 U	5 points (1 procerus, 4 corrugators)
Frontalis	10-20 U	4-8 points across forehead
Lateral canthal lines (crow's feet)	12-16 U per side	3-4 points per side
Mentalis (chin dimpling)	4-6 U	2 points
Platysmal bands	10-20 U per band	Every 1.5 cm along band
Masseter (masseter hypertrophy / TMD)	25-50 U per side	3 points in masseter bulk
Gummy smile (LLSAN muscle)	2-4 U per side	At yoke of LLSAN

Clinical Pearl

For the OMS practice, masseter botulinum toxin injection serves dual aesthetic and therapeutic purposes: it slims the lower face and reduces bruxism/TMD symptoms. Inject deep into the masseter bulk at 3 points, avoiding the superficial portion to prevent visible hollowing of the buccal fat pad and inadvertent risorius/zygomaticus paralysis.

Dermal Fillers

Categories:

Type	Product Examples	Duration	Reversibility
Hyaluronic acid (HA)	Juvederm (Vycross), Restylane (NASHA/OBT)	6-18 mo	Hyaluronidase
Calcium hydroxylapatite (CaHA)	Radiesse	12-18 mo	Not directly reversible
Poly-L-lactic acid (PLLA)	Sculptra	18-24 mo	Not reversible
Polymethylmethacrylate (PMMA)	Bellafill	Permanent	Not reversible

Injection techniques:

• Linear threading: Retrograde injection while withdrawing the needle/cannula
• Serial puncture: Multiple small aliquots in a row
• Fanning: Multiple linear threads from a single entry point
• Cross-hatching: Grid pattern for volumetric filling
• Bolus injection: Deep depot injection for projection (e.g., chin, malar)

Key facial zones and filler selection:

• Lips: Soft, low-G' HA fillers (Juvederm Ultra, Restylane Kysse)
• Nasolabial folds: Medium-viscosity HA (Juvederm Vollure, Restylane Defyne)
• Cheeks/midface: High-G' HA (Juvederm Voluma, Restylane Lyft) or CaHA (Radiesse)
• Temples: HA (Voluma) or CaHA
• Jawline/chin: High-G' HA or CaHA
• Tear trough: Use extreme caution; low-viscosity HA only (e.g., Restylane-L) with cannula technique

Critical Safety

Vascular occlusion is the most serious complication of dermal filler injection, potentially causing tissue necrosis or blindness. High-risk zones include the glabella (supratrochlear artery), nasal dorsum (dorsal nasal artery), nasolabial fold (angular artery/facial artery), and temple (superficial temporal artery). Vision loss occurs from retrograde arterial embolization to the ophthalmic artery. Immediate management: Stop injection, apply warm compresses, inject hyaluronidase (150-300 U) into and around the affected area, administer aspirin 325 mg, apply nitroglycerin paste, and obtain urgent ophthalmology consultation if vision symptoms present (DeLorenzi, Aesthet Surg J, 2014).

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Laser and Energy-Based Devices

Classification

Modality	Mechanism	Applications
Ablative CO2 laser (10,600 nm)	Vaporizes water in tissue; controlled thermal injury	Full-face resurfacing, deep wrinkles, acne scars
Ablative Er:YAG (2,940 nm)	Higher water absorption; less thermal injury	Moderate resurfacing, less downtime than CO2
Fractional CO2 / Er:YAG	Microthermal zones of ablation with intact skip areas	Moderate resurfacing with reduced downtime
Non-ablative fractional (1550 nm)	Dermal collagen remodeling without epidermal disruption	Mild wrinkles, textural improvement
IPL (broadband light)	Chromophore-targeted (melanin, hemoglobin)	Dyspigmentation, telangiectasias, rosacea
Pulsed dye laser (595 nm)	Selective photothermolysis of hemoglobin	Vascular lesions, erythematous scars
Nd:YAG (1064 nm)	Deep dermal heating	Hair removal, vascular lesions, skin tightening
Radiofrequency (RF)	Volumetric tissue heating via electrical current	Skin tightening, subdermal remodeling
Ultrasound (HIFU)	Focused thermal injury at depth	Skin tightening (Ultherapy)

Ablative Resurfacing Protocols

Full-face ablative CO2 laser resurfacing remains the gold standard for severe photodamage and perioral rhytids, but requires:

• Antiviral prophylaxis (valacyclovir 500 mg BID, starting 1 day pre-procedure, continuing 10-14 days)
• Strict sun avoidance for 3-6 months
• Assessment for Fitzpatrick skin type (Types IV-VI at high risk for post-inflammatory hyperpigmentation; consider fractional or non-ablative alternatives)
• Downtime: 7-14 days for ablative; 3-5 days for fractional

CPT: 15780 (dermabrasion, total face), 15781 (dermabrasion, segmental), 15786-15787 (abrasion, lesion), 17999 (unlisted dermatologic procedure, used for laser resurfacing by some payers)

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Fat Grafting

Structural Fat Grafting (Coleman Technique)

Autologous fat transfer provides a permanent, biocompatible volumizer:

Harvesting: Low-pressure liposuction (manual syringe aspiration preferred) from the abdomen, thighs, or flanks. Tumescent anesthesia at the donor site.

Processing: Centrifugation (3,000 rpm x 3 minutes, Coleman protocol), gravity decanting, or filtration (Telfa rolling). Goal: separate oil, aqueous layer, and concentrated fat.

Injection: Small aliquots (0.1-0.3 mL per pass) injected in multiple planes and tunnels to maximize graft-to-recipient contact and vascularization. Overcorrection of 20-30% is typical to account for resorption.

Applications in facial rejuvenation:

• Temporal hollowing
• Infraorbital/tear trough volume loss
• Malar volume loss
• Nasolabial fold effacement
• Lip augmentation
• Jawline and chin augmentation
• Perioral rejuvenation

Survival rates: Published graft survival ranges from 40-80%, depending on technique, processing, and injection site. The face has generally favorable outcomes due to rich vascularity.

Clinical Pearl

Nanofat (emulsified fat filtered through a 0.5 mm connector) can be injected superficially for skin quality improvement. The regenerative component (adipose-derived stem cells and growth factors) improves skin texture, elasticity, and fine wrinkle appearance independently of volume effect (Tonnard et al., Plast Reconstr Surg, 2013).

CPT: 15771 (grafting of autologous fat, harvested by liposuction; first 50 cc), 15772 (each additional 50 cc), 15773-15774 (grafting to face)

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Marketing and Liability Considerations

Building an Aesthetic Practice

Marketing: Aesthetic surgery marketing is subject to state dental board and medical board regulations:

• All advertising must be truthful, non-deceptive, and verifiable
• Before/after photographs must not be digitally altered (beyond standard image processing)
• Disclaimers should accompany any outcome representations ("Results may vary")
• Social media content should not create unreasonable expectations
• HIPAA compliance is mandatory for any patient photographs used in marketing (written consent with specific media authorization)

Practice structure considerations:

• Aesthetic procedures are typically performed in an office-based surgical suite with appropriate accreditation (AAAHC, AAAASF, or state equivalent)
• Separate aesthetic consultation space with appropriate lighting, privacy, and photography setup
• Dedicated aesthetic coordinator for scheduling, follow-up, and patient communication
• Financial policies for cosmetic (non-insurance) procedures: clear fee structures, payment plans, cancellation policies

Liability

Cosmetic surgery carries heightened malpractice risk:

• Higher patient expectations: Any outcome short of perfection may be perceived as failure
• Elective nature: Juries have less sympathy for complications from elective procedures
• Documentation: Exhaustive preoperative documentation is the single best defense against litigation
• Revision policies: Many OMS practices offer one complimentary revision for rhinoplasty and rhytidectomy within the first year; this must be clearly delineated in the consent

Surgical Caution

Maintain a separate cosmetic surgery malpractice rider on your professional liability insurance. Not all OMS malpractice policies cover the full spectrum of aesthetic procedures. Verify coverage limits and specific procedure coverage with your carrier annually.

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Coding Summary

Procedure	CPT Code(s)
Rhinoplasty (primary)	30400-30420
Rhinoplasty (secondary)	30430-30462
Septoplasty	30520
Upper blepharoplasty	15822-15823
Lower blepharoplasty	15820-15821
Rhytidectomy	15828-15829
Chin augmentation (implant)	21120
Genioplasty (sliding)	21121-21122
Malar augmentation	21270
Otoplasty	69300
Fat grafting	15771-15774
Dermabrasion	15780-15781
Scar revision (complex repair)	13100-13160
Local flap	14040-14302

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Key References

1. Gunter JP, Rohrich RJ, Adams WP. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3^rd ed. CRC Press; 2014.
2. Fisher DM, Sommerlad BC. Cleft lip, cleft palate, and velopharyngeal insufficiency. Plast Reconstr Surg. 2011;128(4):342e-360e.
3. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86(1):53-61.
4. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 Suppl):108S-120S.
5. DeLorenzi C. New high dose pulsed hyaluronidase protocol for hyaluronic acid filler vascular adverse events. Aesthet Surg J. 2017;37(7):814-825.
6. Tonnard P, Verpaele A, Peeters G, et al. Nanofat grafting: basic research and clinical applications. Plast Reconstr Surg. 2013;132(4):1017-1026.
7. Goldberg RA, Edelstein C, Shorr N. Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour. Facial Plast Surg. 2000;16(4):317-321.
8. Crerand CE, Phillips KA, Menard W, Fay C. Nonpsychiatric medical treatment of body dysmorphic disorder. Psychosomatics. 2005;46(6):549-555.
9. AAOMS. Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (ParCare 6^th ed). 2017.
10. AAOMS Position Paper: The Role of the Oral and Maxillofacial Surgeon in Facial Cosmetic Surgery. 2020.
11. Ogawa R, Akaishi S, Kuribayashi S, Miyashita T. Keloid and hypertrophic scars are the result of chronic inflammation in the reticular dermis. Int J Mol Sci. 2017;18(3):606.