Dr. Pablo Vaquero
Back to homeWritten for colleagues

Surgical Notes

Technical notes on indication, surgical decision-making and perioperative management, written for colleagues.

53 chapters

Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.

Part I · Common to all facial surgery

Foundations

What applies to any operation, whatever the region: how skin heals, what impairs it, and how the patient is prepared before and after surgery.

Biology of repair

  1. Cutaneous wound healing — From the classic phases to reverse-engineering the scarThe phases and their mediators, the factors that derail healing, and why the fetus does not scar: the Engrailed-1 lineage, mechanotransduction, and what can already be blocked.
  2. Facial scar revision — Techniques, dermabrasion and lasersWhen and how to revise a facial scar: analysis, timing, excisional and irregularisation techniques, step-by-step dermabrasion — including use of the dental motor and bur selection — and which laser is indicated for each scar type.

Vascular basis of the flap

  1. Angiosomes and perforators — Designing the flap around the vesselTaylor and Palmer’s vascular map, the choke vessels that explain the delay phenomenon, and how to locate the perforator with Doppler to design the flap outward from the vessel.

Perioperative management

  1. Perioperative supplementation — What to stop, what to add, and on what evidenceThe list of supplements to withdraw before surgery and why, and what the evidence actually says about arnica, bromelain, vitamin C, zinc and vitamin A.
Part II · Rhinoseptoplasty

Nose

Applied anatomy and the method of facial analysis, then the nasal alterations one by one, each with its diagnosis and surgical plan.

Fundamentals

  1. Applied nasal anatomy — The layers, the framework, the ligaments and the valvesThe dissection plane and why it is always the same, the three vaults and the keystone area, the ligamentous system that supports the tip and the two valves on which breathing depends.
  2. Facial analysis — Lines, angles and proportions in each viewWhat is measured in each view, against what and in which order, the assessment by subunits and the cautions that keep numbers from replacing judgement.

Nasal alterations

  1. Nasal dorsum alterations — Diagnosis and surgical planningHump, kyphosis and pseudo-kyphosis, saddle nose, supratip, deviation, inverted V and axe-cut sign: what causes them, how to tell them apart and which manoeuvre corrects each.
  2. Nasal tip projection — Diagnosis and surgical planningOver-projected tip, tension nose, suspended tip and under-projected tip: which structure fails in each and which manoeuvre corrects it.
  3. Nasal tip rotation — Drooping tip and over-rotated tipWhy a tip droops, which manoeuvres rotate it, and how the shape of the resected caudal septal fragment determines the exact result.
  4. Nasal tip width and symmetry — Diagnosis and planningWide, bulbous or boxy tip and excessively narrow tip: the real causes, the manoeuvres that refine, and why width and projection always travel together.
  5. Alar cartilage malposition — Pinched, bulbous and boxy tipThe alteration to recognise before operating: why it causes valve collapse, how it looks on the frontal view, and what happens if a tip is refined without diagnosing it.
  6. Alar cartilage shape — Concavity, undulation and amorphous tipWhat shape a normal alar cartilage has, which shadows betray that it does not, and how each deformity is corrected: from suture to strut graft and turn-in flaps of the cartilage itself.
  7. Lobule, alar rim and nostrils — The lower third of the tipPinched infratip, discontinuous lobule and lobule-ala imbalance; unsupported rim, weak border and alar collapse; and why the nostrils are addressed last.
  8. Alar-columellar relationship — Hanging columella, alar retraction and their combinationsThe millimetres that define profile balance, Gunter’s six-type classification and what corrects each alteration, from the Levet manoeuvre to the chondrocutaneous graft.
  9. Skin envelope — The layer that decides how much of our work showsThick and thin skin as two different operations, the skin-thickness by cartilage-strength matrix, and the role of the musculature in the nasofrontal angle, projection and rotation.

Surgical technique

  1. Approach, choice of technique and undermining — The two prior decisions and their cost in supportThe choice between preservation and structural technique, the catalogue of incisions ordered by the support each costs, when the external approach is justified, undermining plane by plane and the general sequence of the operation.
  2. Septoplasty and the nasal valve — The structural pillar and the point that determines breathingThe septum as a structural pillar rather than a wall, the L-strut rule and what the evidence says about it, conservative techniques versus resection, and treatment of the internal and external valve with spreaders, autospreaders and alar grafts.
  3. Dorsum and osteotomies — Reducing the hump while preserving the aesthetic lines and the valveComponent reduction versus en bloc resection, the reference level and why the rhinion rules, the three osteotomies and their traps, closing the open roof and dorsal preservation techniques.
  4. The tip — Resection, sutures and support, in that orderThe tripod as a working model, cephalic resection and how much to leave, the complete catalogue of shaping sutures with their typical errors, the difference between columellar strut and septal extension, and deprojection techniques.
  5. Grafts and implants — Donor sites, preparation and the function of each graftThe hierarchy of donor sites and what each cartilage can do, how a graft is prepared so it does not warp, the catalogue by function, diced cartilage and fascia, and the slippery ground of alloplastic materials.
Part III · Rhytidectomy

Face and neck lift

The layered anatomy that decides which plane to operate in, the analysis of ageing, the choice of technique and the management of complications.

Fundamentals

  1. The layers of the face — Organisation, continuities and the plane of dissectionThe concentric five-layer arrangement and its constancy throughout the cervicofacial territory, the differential behaviour of fixed and mobile SMAS, the anatomical revision of the deep layers and the plane of dissection that follows from it.
  2. Fat compartments and retaining ligaments — The anatomical origin of the facial sulciThe compartmentalisation of facial fat and the ligamentous system that delimits it, the mechanism by which both generate the sulci, the dissection line the ligaments describe and the recent reclassification of the mandibular ligament.
  3. Nerves and vascular supply — The structures that delimit the dissectionThe course of the facial nerve branch by branch and its relation to the fasciae and ligaments, the safety principle that follows, the anatomy of the great auricular nerve and the vascular basis of the skin flap.
  4. Facial ageing and preoperative assessment — What descends, what atrophies and whom to operateThe four processes that compose cervicofacial ageing, the operative definition of a suitable candidate, assessment of the midface and of the orbital vector, cervical examination and the preoperative record.

Surgical technique

  1. Choosing the technique — Which layer is mobilised and in which direction it is repositionedThe spectrum of techniques ordered by the layer they mobilise, plication versus imbrication, the abandonment of the biplanar technique, the orientation of the vector and its adaptation to glandular ptosis.
  2. Deep-plane facelift, step by step — From marking to closureThe complete deep-plane sequence: marking with the patient seated, incision design, subcutaneous undermining, SMAS elevation and ligamentous release, repositioning and closure.
  3. Facial fat grafting — Processing, plane of infiltration and contraindicated territoriesThe four products obtained according to processing, the line separating the lifting from the volumising effect, the plane corresponding to each region, the two contraindicated territories and the biological basis of resorption.

Complications

  1. Complications of facelift surgery — Haematoma, flap compromise and nerve injuryThe most frequent complication and its prevention, the distinction between flap compromise and necrosis with their respective treatments, the actual incidence of nerve injury and the postoperative schedule.
Part IV · Cervical contour

Neck

The layered anatomy of the neck, the platysma and its variants, the fat compartments and the deep structures that determine the cervicomental angle, with their technical translation.

Anatomy and assessment

  1. Cervical anatomy — The layers and the five elements that define the contourThe layered organisation of the neck, the anatomy of the platysma and its variants, the supra- and subplatysmal fat compartments, and the five anatomical elements that determine the cervicomental angle.

Surgical technique

  1. Platysmaplasty and cervical contour — Management of the subplatysmal planeThe restricted indication for cervical liposuction, management of the subplatysmal plane, medial and lateral platysmaplasty step by step, and the three manoeuvres that open the cervicomental angle.
Part V · Oculoplasty

Eyelids and periocular region

Upper and lower blepharoplasty, from assessment to complication management, and eyelid reconstruction after oncological resection or trauma.

Aesthetic eyelid surgery

  1. Upper blepharoplasty — Marking, technique and variantsWhat defines a youthful upper lid, how to rule out ptosis and brow descent before marking, millimetre-by-millimetre marking and the full surgical sequence with its variants.
  2. Lower blepharoplasty I — Assessment and decision algorithmApplied anatomy, examination of the four components and the complete algorithm that decides approach and associated manoeuvres.
  3. Lower blepharoplasty II — Step-by-step technique and rationaleRetroseptal transconjunctival, preseptal fat transposition and subciliary approach: full sequence, instruments and the reason behind each step.
  4. Lower blepharoplasty III — Perioperative care and complicationsPreoperative assessment, postoperative regimen and management of the two complications you must know how to solve: retroseptal haematoma and ectropion.

Reconstruction

  1. Eyelid reconstruction — Principles and defect-based algorithmThe two lamellae and the blood-supply rule, the algorithm by defect size and site, and the named flaps that solve each scenario.
Part VI · Otoplasty

Ear

The ear is a folded plate of cartilage, and almost everything operated on there is a fold that is missing or an angle that is excessive. Here are the anatomy and measurements that localise the defect, the families of techniques that correct it and the complications that define the long-term result.

Fundamentals

  1. Auricular anatomy and analysis — The measurements that localise the defectThe subunits and where they hide scars, the anthropometry that defines normality, the three angles that decide whether an ear is prominent, the anatomical causes of prominence and the catalogue of auricular deformities.

Prominent ears

  1. Prominent ear otoplasty — The concha first, the antihelix secondThe graduated approach starting with the concha, the exact sequence of conchomastoid and Mustardé sutures with their measurements, the four families of techniques and what comparative evidence says about recurrence and complications.

Complications

  1. Otoplasty complications — Those to treat today and those seen at six monthsThe difference between surgical complication and aesthetic sequela, haematoma and chondritis as emergencies, suture problems by material, the dysaesthesias nobody asks about, and the catalogue of preventable deformities with their mechanisms.
Part VII · Diagnosis and reanimation

Facial palsy

The face that has stopped moving: how it is diagnosed and graded, what time window exists before the muscle is no longer salvageable, where motor input comes from when the facial nerve no longer serves, and what to do with the eye and the asymmetry when movement does not fully return.

Fundamentals

  1. Facial palsy — Diagnosis, causes and the clock that starts tickingHow to separate a central from a peripheral palsy in thirty seconds, the real distribution of causes with figures, Bell’s palsy and what the evidence says about its treatment, the red flags that force reconsideration, and the time window that decides which surgery is possible.

Reanimation

  1. Reanimation of recent palsy — Where to find the motor inputQuantitative and qualitative motor sources and why none suffices alone, the surgical anatomy of the masseteric nerve with its millimetric landmarks, masseteric-to-facial anastomosis and the logic of triple innervation.

Eye and symmetrisation

  1. The paralytic eye and symmetrisation — What must be solved before movement returnsLagophthalmos and the lid weight with the weight correction almost nobody applies, ectropion and lower lid suspension, and botulinum toxin for contralateral hyperkinesis and synkinesis, with doses by muscle.
Part VIII · Forehead, brows and lips

Upper third and perioral

The two ends of the face, read before any other region and which in surgery tend to trail behind the facelift. Above, the bony contour of the forehead, brow position and the hairline; below, lip length and what shows of the incisor.

Forehead and brows

  1. Forehead, temple and hairline — The upper third begins at the boneThe three determinants of the upper third and what corrects each, classification of the supraorbital ridge according to the frontal sinus, cranioplasty with its mandatory preoperative measurement, hairline management and temporal hollowing.
  2. Brow lift — Why the tail falls, where the nerve runs and which approach to chooseThe anatomy explaining why the brow falls laterally, the frontotemporal branch layer by layer, the three resuspension vectors and the three approaches — temporal, frontotemporal and direct — with their indications.

Lips and perioral

  1. Lip lift and corner lift — The three levels, heights by point, and what exposes the incisorWhat shortens the lip and what exposes the incisor — not the same thing — the three-level design with its four points, recommended heights, suspension to the piriform ligament and when to add the corner lift.
Part IX · Chin, contour and harmonisation

Facial skeleton

Beneath everything operated on in the face lies a skeleton that defines the proportions, and no soft-tissue surgery corrects a structural problem. Here is the chin as the piece that orders the lower third, and the logic of moving the skeleton with an aesthetic rather than a purely occlusal goal.

Chin and jawline

  1. Genioplasty — The chin moves in three dimensions, not oneClassification of chin deformities in three planes, the trap of using genioplasty for what is a mandibular position problem, the basal osteotomy step by step with all its movements, hemigenioplasty for asymmetry and the bone versus implant debate.

Orthofacial surgery

  1. Orthofacial surgery — Moving the skeleton with an aesthetic goal, not only an occlusal oneThe shift from orthognathic to orthofacial surgery, the three levels of intervention on skeleton and soft tissue, fully digital planning, and the procedures combined in the same operation: rhinoplasty, mandibular contouring, lipofilling and rejuvenation.
Part X · Functional anatomy, toxin and fillers

Facial animation

The muscles that give the face its expression, one by one: where they lie, in which layer, what they do and where their nerve reaches them. It is the shared basis of facial palsy, botulinum toxin and filler, and the map explaining why one same feature is corrected in three different ways.

Anatomy of facial animation

  1. Principles of facial animation — Layers, innervation and why it matters when injectingWhat sets a mimetic muscle apart, the four muscular planes and their three innervation exceptions, functional grouping, facial nerve territories, and what all this implies for palsy, toxin and filler.
  2. Upper third musculature — One elevator against four depressorsFrontalis, corrugator, procerus, depressor supercilii and orbicularis: origin, insertion, layer and innervation of each, the wrinkle each produces, and the exact translation into point, depth and dose.
  3. Middle third musculature — The lip elevators and the most dangerous area of the faceNasalis, lip elevators, zygomatics and risorius across their four planes, the vascular map that makes this the highest-risk area, and filler volumes and planes by region.
  4. Lower third and neck musculature — The modiolus, mentalis and platysmaOrbicularis oris, depressors, mentalis, buccinator, masseter and platysma: where they lie, what they do, and the doses and depths that separate a good result from an asymmetric smile.

Botulinum toxin

  1. Botulinum toxin in facial palsy — Symmetrising by weakening, not stimulatingWhy weakening the healthy side improves the paralysed face, how to assess before injecting, which muscle to treat on each side at what dose and depth, and what EMG or ultrasound guidance adds.
  2. Aesthetic botulinum toxin — Product, equipment, marking and technique area by areaWhich product and how to reconstitute it, the equipment needed, the pre-treatment record, technique and doses for each facial area, and the errors producing a dropped brow, startled look or asymmetric smile.

Fillers

  1. Fillers and vascular complication — Danger anatomy, prevention and what to do when it happensWhich territories link the face to the retina, which measures really reduce embolism risk, how an occlusion is recognised in its first minutes, and the high-dose pulsed hyaluronidase protocol.