Werner L. Mang · Manual of Aesthetic Surgery, 2nd Edition

Prof. Dr. Dr. Werner L. MangMedical Director of theBodenseeklinik, LindauClinic for Plastic and AestheticSurgeryGraf Lennart Bernadotte-Straße 188131 LindauTel.: 0049(0)8382-2 60 18-0Fax: 0049(0)8382-2 60 18-70www.bodenseeklinik.dewww.mangklinik.chE-mail: info@bodenseeklinik.de

APL-Professor at Klinikum rechts der Isar, Munich Technical University,Ismaningerstraße 22, 81675 Munich, GermanyPresident of the International Society for Aesthetic MedicineCEO of the Mang Medical One Clinic Group, Im Teelbruch 55,45219 Essen, Germany

Biography:– Consultant at 32– Post-doctoral qualification at 34– Medical Director of the Bodenseeklinik at 40– Founding President of the German Association for Aesthetic Surgery

and President of the International Society for Aesthetic Medicine– Honorary Professor of the University of St. Petersburg– Author of the most successful Handbook of Aesthetic Surgery– International recognition as a surgeon and guest speaker– Personally carried out more than 30,000 operations– Numerous contributions in print and TV media– 2003 At the peak of his surgical career, he achieved his vision:

he opened Europe’s largest beauty clinic: Bodenseeklinik– 2004 DVD Guide on Cosmetic Surgery– 2006 Ground-breaking ceremony for Mang Klinik Swiss– 2007 CEO of Mang Medical One Clinic Group (Berlin, Hamburg,

Dortmund, Düsseldorf, Wiesbaden, Hannover, Stuttgart, München,Lindau)

– 2008 Opening of Mang Klinik Swiss (www.mangklinik.ch)– 2009 Honorary Professor of the University of Jasi (ROM)– 2010 Publication of the new edition of the Manual of Aesthetic Surgery– 2010 Chairman of the International Congress for Aesthetic Surgery– Honorary member of many international societies

Werner L. Mang

MANUALOF AESTHETICSURGERY Second Edition

� Rhinoplasty

� Rhytidectomy

� Eyelid Surgery

� Otoplasty

� Breast Surgery

� Brachioplasty

� Abdominoplasty

� Thigh and Buttock Lift

� Liposuction

� Hair Transplantation

� Adjuvant Therapies,

Including Spacelift

� Photographic Documentation

in Aesthetic and Plastic

Surgery

� Informed Consent in Aesthetic

and Plastic Surgery

CoauthorsFrank Neidel · Marian Stefan Mackowski · Andrea Becker ·Jan-Thorsten Schantz · Ulrike Then-Schlagau

337 Medical Illustrations by Hans Jörg Schütze

28 Plates of Surgical Instruments and 184 Photographs

ISBN 978-3-540-78794-5 eISBN 978-3-540-78795-2

DOI 10.1007/978-3-540-78795-2

Springer Heidelberg Dordrecht London New York

Library of Congress Control Number 2010929103

ˇ Springer-Verlag Berlin Heidelberg 2010

This work is subject to copyright. All rights are reserved, whether the whole or part of thematerial is concerned, specifically the rights of translation, reprinting, reuse of illustra-tions, recitation, broadcasting, reproduction on microfilm or in any other way, and stor-age in data banks. Duplication of this publication or parts thereof is permitted only underthe provisions of the German Copyright Law of September 9, 1965, in its current version,and permission for use must always be obtained from Springer-Verlag. Violations areliable for prosecution under the German Copyright Law.

The use of general descriptive names, registered names, trademarks, etc. in this publicationdoes not imply, even in the absence of a specific statement, that such names are exemptfrom the relevant protective laws and regulations and therefore free for general use.

Product liability: The publishers cannot guarantee the accuracy of any information aboutdosage and application contained in this book. In every individual case the user mustcheck such information by consulting the relevant literature.

Cover-Design: eStudio Calamar, Figueres/BerlinDVD-Video: Video-Transfer, Groß-UmstadtPrinted on acid-free paperSpringer is a part of Springer Science + Business Media (www.springer.com)

Addresses

Professor Dr. med. Dr. habil. Werner L. MangMedical Director of the Bodenseeklinik, LindauClinic for Plastic and Aesthetic SurgeryGraf-Lennart-Bernadotte-Straße 188131 Lindau / GermanyTel. +49 (0) 83 82 – 26 01 80Fax +49 (0) 83 82 – 26 01 87 0email: info@Bodenseeklinik.deInternet: www.Bodenseeklinik.de

APL-Professor at Klinikum rechts der IsarMunich Technical UniversityIsmaninger Straße 2281675 München / Germany

Dr. med. Andrea BeckerPlastic and Aesthetic SurgeonBodenseeklinik LindauGraf-Lennart-Bernadotte-Straße 188131 Lindau / Germany

Dr. med. Marian Stefan MackowskiPlastic and Aesthetic Surgeon, General SurgeonBodenseeklinik LindauGraf-Lennart-Bernadotte-Straße 188131 Lindau / Germany

Dr. med. Jan-Thorsten SchantzBodenseeklinik LindauGraf-Lennart-Bernadotte-Straße 188131 Lindau / Germany

Dr. med. Ulrike Then-SchlagauPlastic and Aesthetic Surgeon, General SurgeonBodenseeklinik LindauGraf-Lennart-Bernadotte-Straße 188131 Lindau / Germany

This book is dedicated to my parents,Dr. Karl Mang (†) and Mrs Luise Mang

My thanks go to my wife, Sybille, and my children, Gloria and Thomas.

Without my wife’s strength over the last 30 years, I would not have beenable to achieve clinical and scientific prominence in the field of aestheticand plastic surgery in Europe. Only her understanding for my work gaveme the strength, in a 12-hour day with little holiday, to reach my goals.

PrefaceAt the request of Springer-Verlag, Heidelberg, I have written with prideand pleasure the new edition of the Manual of Aesthetic Surgery.Volumes 1 (head and neck region) and 2 (body) have been integratedinto one volume, which has been revised and extended with theaddition of the topics “Cosmetic Aesthetic Surgery,” “Breast Surgery,”“Mini Lift,” “Mini Abdomen,” “Buttock Lift,” and “Tumescence Lipo-suction with the MicroAire® System.”

The current trend is towards gentle surgical methods. The ‘MangSchool’ has as its motto: Less is more! You should not see cosmetic sur-gery. Aesthetic surgery is feel-good surgery and not altering surgery.That should be the philosophy of this book. The first editions of bothvolumes of the Manual of Aesthetic Surgery had high print runs andwere translated into many languages, including Spanish, Russian, andChinese.

The new edition bridges a few gaps, namely breast lifting and breastreduction. These operations are described in detail using illustrationsand videos, in order to provide also plastic and aesthetic surgeons withstandards.

Standards are of crucial importance in aesthetic surgery. Results mustbe reproducible. Every aesthetic surgeon will then be able to build onthis manual and refine his or her methods.

A lot has been going on in recent years and my zest for action has notwaned. As CEO of the Mang Medical One Clinic Group, I am respon-sible for 20 plastic surgeons performing expert aesthetic surgery in Ger-many every day. As a pioneer and visionary in this area in Germany, Isee it as my life’s work to train many young aesthetic surgeons, to givelectures worldwide and to offer good aesthetic surgery in Europe atacceptable prices.

I hope that the new edition of this book with its exciting additionsmeets with success and I wish happy reading to all of the interesteddoctors. The new handbook is a comprehensive work on aestheticsurgery and covers all procedures in the area of breast surgery, such assupramuscular or submuscular implantation, lifting, and reduction.Adjuvant treatments have also been brought up to date, even if not alldermatosurgical methods could be mentioned in their entirety.

The book contains many new tips and tricks, all collected during my20 years of experience as an aesthetic surgeon.

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This is therefore not just an entirely new edition of volumes 1 and 2,but it is an integrated volume with current and new surgical methodsand standards regarding surgery and adjuvant treatments.

Aesthetic surgery is an interdisciplinary specialist area.

This book is intended for all specialist disciplines which are relevantto aesthetic surgery: ENT, head/neck surgery, oral surgery, dermatol-ogy, ophthalmology, plastic surgery, surgery, gynecology, etc. There-fore, it is an interdisciplinary handbook for every interested doctor,specialist, or medical student.

Werner L. Mang

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Foreword by M. P. CeravoloEvery plastic surgeon’s desk is invaded daily by leaflets illustrating newbooks, manuals, and atlases of plastic surgery. It is impossible to buy orread all of them. Therefore, it is important to understand which text isvaluable and may enrich our knowledge and which may just representan ornamental object on our bookshelf. There are at least three goodreasons to have Professor Mang’s Manual of Aesthetic Surgery. The firstis its author – a physician who has dedicated his life to studying theperfection and diffusion of aesthetic surgery. His culture, based onmultidisciplinary experience, is enriched by a continuous innovativeanimus which has led him to create intermingling scientific relation-ships with the most experienced colleagues worldwide. This globalvision has allowed Professor Mang to create an opus which goesbeyond any frontier and represents a precious gem in the scientificworld. The second reason is the up-to-date quality of his opus. Eachsubject of aesthetic surgery, from rhytidectomy to laser resurfacing,from mammaplasty to botulinum toxin, is approached following themost recent theories and advancements. And last but not least, thethird reason is this book’s unique characteristic, its multimediaapproach: text, illustrations, and video on DVD. The clarity of thedescriptions combines with the precision of the drawings and the vividexplanatory imaging of the video. It is a book to read, to study, and toenjoy.

Mario Pelle CeravoloProfessor of Plastic SurgeryUniversity of Rio de Janeiro, BrazilMedical College, New York, USAand Rome, Italy

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Foreword by D. L. FeinendegenAesthetic surgery has experienced exceptionally rapid growth over thelast few years. There has been a continual increase in the number ofpeople requesting such operations and, alongside specialists in plasticsurgery, more and more doctors from other specialist surgical fields arenow working in this area. Until now, however, it has been possible toacquire sound training in aesthetic surgery within Europe in only a fewlarge hospitals. Doctors interested in this field, therefore, often have tomove abroad to obtain experience in aesthetic surgery.

Professor Mang has been working to establish training in aestheticsurgery for many years. His greatest contribution has been to ensureinterdisciplinary cooperation between plastic surgeons, ENT specialists,oral surgeons, and other surgeons active in the field of aesthetic surgery.Professor Mang has already made these ideas a reality in his new clinic.

With this manual on aesthetic surgery, Professor Mang has created afoundation for training in aesthetic surgery. The first edition (originallypublished in two volumes) has already made a strong impression, withits clear structure and excellent, step-by-step diagrams that make evendifficult surgical techniques easy to understand. The manual appealsparticularly to young doctors who are having their first experience withaesthetic surgery. The additional option of audiovisual learning, pro-vided by the integrated DVDs, underlines Professor Mang’s modernteaching concept.

This new manual reflects Professor Mang’s tireless dedication to thetask of continuing to establish the field of aesthetic surgery. I myselfhave come to value Professor Mang as a teacher and wish him continuedsuccess in making his ideas a reality. I hope that as many doctors aspossible will be able to profit from these ideas, ultimately contributingto the welfare of patients.

Dr. med. Dominik L. FeinendegenPlastic, Reconstructive, and Aesthetic SurgeonZollikon, Switzerland

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Foreword by P. F. FournierIt is a great pleasure and a great honor for me to write a foreword to thesecond edition of Professor Werner L. Mang’s book.

Professor Mang and I have been acquainted for many years and haveattended many meetings together. He must be congratulated on havingpresented his great experience in aesthetic surgery in his book in adynamic way with a video included in a DVD. All experienced aestheticsurgeons or surgeons learning aesthetic surgery who have not had theprivilege to observe Professor Mang in his clinic at Lake Constance canbe informed about the latest and best procedures used by ProfessorMang. The text and illustrations are of exceptional quality and readingthe various chapters is a real pleasure.

All chapters have been written with great care and with the desire to beof the highest interest for the readers. There is no doubt that this secondedition will have the same deserved success as the first edition.

We are greatly indebted to Professor Mang for all the time he has spentin offering both seasoned and novice aesthetic surgeons eager to learnor refine a surgical procedure a true mine of precious and safe tech-niques. He is extending the horizons of our specialty by providing thereaders with his contributions and the improvements he has brought toconventional techniques. He emphasizes details that continue to makeour specialty creative and very practical at the same time. All suchprecise information is an incentive to read and learn more in order toachieve excellence in our daily work, in patient selection, in planning,and in performance.

Again, we should be very grateful to Professor Mang for sharing hisgreat knowledge, experience, creative mind, and insight.

I have known Prof. Mang for more than 20 years. Following his surgicaltraining, he gained an international reputation as a specialist in ENT andplastic surgery and, through the first edition of Manual of Aesthetic Sur-gery, he reached beyond the boundaries of Europe. In 1987, Prof. Mangfounded the German Society for Aesthetic Medicine and was a pioneer inthis field in Germany. I have frequently attended his wonderful confer-ences in Lindau on Lake Constance, listened to his excellent lectures, andbecome acquainted with interesting aesthetic surgeons from all over theworld. My wife and I have been pleased to accept private invitations fromthe Mang family and these have given us the pleasure of meeting Profes-sor Mang’s enchanting wife, Sibylle, and his children, Gloria and Thomas.

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Prof. Mang’s clinical activity and his services to society are remarkable.He is a workaholic and pursues his goals in aesthetic surgery deter-minedly, properly, and with a lot of self-sacrifice. In many discussionswith him, we wanted to find out what beauty really is. Cosmetic surgeonshave heavy responsibilities and must be creative.

For the Manual of Aesthetic Surgery, therefore, I have attempted todefine the term beauty:

Initially we are expected to believe that beauty has something to dowith proportion, balance, and symmetry. Thus, I would like to attemptto explain beauty objectively by looking back to the starting point ofthe ancient Egyptians, Greeks, and Romans.

What Is Beauty?

Beauty is a combination of form and proportion that brings us pleasureand that we can admire. The perception of beauty, however, variesbetween different cultures. Beauty is a balance between form andvolume. Beauty produces in us an aesthetic feeling, an admiration,by pleasing the eye. Some people even claim that beauty is a visualphenomenon.Beauty is a combination of qualities, such as form, proportion, thecolor of the human face (or other objects) that charm the gaze.

Over 200 years ago, David Hume (1711–1776), a Scottish philosopher,remarked, “Beauty is essentially a private and personal experience.Beauty is in the eye and mind of the beholder.” He also said, “Beauty isnot a quality of the thing itself but that which exists in the mind ofthose who contemplate it.” Beauty is an individual emotion.

A few philosophers have concluded, “Beauty is good, and what is good,is beautiful.”

A long time ago, the philosopher Sapphie said, “That which is beautifulis good and he who is good will soon become beautiful.”

Our early experiences influence how we judge now. Particularly becausebeauty does not captivate through detail but through the whole, whichis greater than the sum of the individual parts, our parents, partners,ex-partners, wives, and friends remind us of experiences. In the sameway, our current experiences will affect our feelings of tomorrow. Thehappy and unhappy phases of our lives leave behind traces that shapeour inclinations. Faces that we loved during our youth, which gave uswarmth and security, live on in our thoughts.

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Beauty does not only have to do with the face, the voice, the body, or acharming appearance. A person is beautiful because of their character,their personality, their ability to feel joy and give pleasure to others,and their capacity for love.

If we like a face, we like the mood which that person conveys. A personcan be attractive in many ways.

Beauty and charm are often confused. Cleopatra, George Sand, Louisade la Valliere and Theodora were famous for their beauty. In truth, theywere very beautiful but also had a lot of charm. Beauty is more an illu-sion than a reality.

Beauty exists not only for the eye but also for the mind.

A beautiful personality emphasizes the beauty of the face. There arenumerous ways of defining beauty and it is often associated withcharm. Charm, however, differs from beauty because it is permanent,whereas beauty fades. The English say, “Charm lasts! Beauty passes!”Ultimately, we can see that it is not only the eyes which judge whethersomeone is beautiful or not but the mind which plays a much greaterrole and judges the heart and inner beauty.

According to the American sociologist Frumkin, a woman is judged inrelation to her sexual charisma. Whether she is judged beautiful or notbeautiful depends not only on the symmetry of her proportions butalso on whether these attributes suggest potential sexual possibilities.

The sensual emotion is then transformed into an aesthetic feeling.

Following these classic explanations, we can conclude that the percep-tion of beauty differs among cultures and individuals and that it is notonly a question of form and symmetry. A person’s personality, charm,and inner beauty play an important part in giving a person a pleasingimage. The eyes alone do not make a judgment, but the head and theheart as well. The mind is influenced by our past experiences, whichaffect our judgment, just as our current experiences influence thefuture. One of Buddha’s teachings tells us, “Today is the son of yesterdayand the father of tomorrow.” Beauty is like an iceberg; only one smallpart is visible.

Konrad Lorenz, Nobel Prize Winner for Medicine and Physiology, hasmade a special contribution to our understanding of the biology ofbehavior. This has helped us to understand human beauty.

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When someone feels drawn to a face, this is because the face has child-like features. Everyone instinctively feels attracted to a childlike face.

The sight of a childlike face evokes an emotion that is automaticallylinked with a desire to protect. It is the same in both humans and ani-mals. Konrad Lorenz explained this in the following terms: the desire toprotect one’s offspring is prompted by something which the offspringsends out, a physical peculiarity, a sound, a smell. It is the same in man.There are signals which provoke protective instincts, sympathy, andtenderness. What are they, asks Konrad Lorenz? In infants, the signalscome from the head. The roundness and fullness, the prominent fore-head, the full cheeks, a small snub nose; all these infantile characteris-tics provoke a protective instinct. A child’s face is associated withpurity, friendliness, honesty, and vulnerability.

We know that women keep their curves, whereas men lose them.A good plastic surgeon should therefore ensure that, during surgery,he optimizes the characteristics which, as in a baby, provoke affection,tenderness, and a desire to protect.

Softness and roundness = tenderness.

Once again, to give the impression of beauty, it is of fundamentalimportance to be able to recognize childlike features in an adult’s face.Features, however, are not the sole cause of the protective reflex;expressions are also important. These at least have the advantage thatthey are within the reach of everyone. A few people know how helpfulexpressions can be in getting someone to do something or in pleasingsomeone.

The emotions which were elicited by Brigit Bardot’s childlike featureswere helped particularly by her famous “spoilt child”-like pouting.

Just as well known are the childlike expressions used, or abused, byMarilyn Monroe and Audrey Hepburn. It has even been rumored thatMarilyn Monroe deliberately made herself up badly to give the impres-sion that she was a small girl who still did not know how to get readyproperly and, even after long sessions at the hairdressers, immediatelyrumpled her hair to restore the disheveled appearance of a small girlwho had just come in from playing. Men have no desire to protectwomen who do not have a childlike appearance and want to dominatemen, and feel reminded more of their mother than their wife.

Women are more concerned with beauty than men and, consciously orsubconsciously, display this childlike behavior. They are consciously or

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subconsciously shy, fragile, weak, innocent, naıve, ignorant, tempera-mental, admiring, inquisitive, etc. A few women even emphasizeweaknesses to trigger the protective instinct. Have I already mentionedthat apparent weaknesses in women are also their strengths? All thisto strike a man directly in his heart. Napoleon said, “Women’s twoweapons are make-up (the significance of this will be discussed later)and the tears of a small, helpless child.”

It is easy to understand why childlike features in an adult can movesomeone, in the same way as freckles, full red cheeks, long eyelashes,blond curls, and well-defined and full lips. Among men, as we can seein a few of the great sex symbols, the side parting (Clark Gable, GaryCooper), an untidy mane of hair (Leonardo de Caprio), and dailyshaving can only be explained as the desire for a childlike appearance.It is not necessary, however, to have all these attributes; one is usuallysufficient.

Every individual can display childlike features at any time. As regardsparticular features, if someone does not have these, he or she can usu-ally acquire them with the help of cosmetic surgery. Beauty is notmerely a completely natural phenomenon; instead, it has been a cul-tural phenomenon for a long time and this is the case particularly inthe present day. People try to improve themselves and women, to whombeauty is more important than it is to men (men tend to try to obtainpower), try to improve their beauty and charm with make-up andaccessories like spectacles, false eyelashes, earrings, hair styles, perma-nent make-up around the lips, eyelids and eyebrows, hats, necklaces,and the invisible accessory, perfume. A few modern accessories havebeen developed by beauty professionals to disguise beauty defects, e.g.,wide spectacle side pieces hide crow’s feet, a high frame emphasizesthe length of a nose that is too short and, conversely, a lower framedisguises a nose that is too long. All these strategies are discussed dis-creetly and in detail in women’s magazines. An old proverb describesthis perfectly: “Thirty percent of beauty is natural, seventy percent iscreated by vanity.” The disadvantage of this resource is that it is notpossible to look young and beautiful without it.

Make-up has always been around and if a face is to be beautified, itshould be made to look natural and the face should resemble a youngface. Lipstick, for example, creates the intense color of young red lips,which is a sign of a more rapid metabolism. Blusher is a reminder ofchildlike red cheeks and powder gives the face the pale, velvety skin ofyouth. Desmond Morris called this “over-stimulation.” Long false eye-

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lashes remind us of the long eyelashes of children. If applied badly,however, make-up can also ruin the beauty of a face. It can be bothfriend and foe. In ethnological books, we can read that in former times,witches improved the appearance of sick people so that the relativeswere not shocked when they saw them.

Childlike features and expressions are therefore important in provokingthe protective instinct, but the voice should also be soft and pleasant,like a child’s. A hard, metallic voice, such as smokers have, is notreminiscent of that of a child.

Clothing should be pleasing to the eye and mind and it should have agood cut. The mini skirt makes us think of the long legs of an adoles-cent. Colors remind us of childhood; light colors, like blue or pink, arealways chosen by older women. Naturally, black should be avoided.

In conclusion, all human senses should be stimulated: sight, hearing,smell (children do not have a smell – thus we use deodorant), andtouch. The firmness of the skin is also important.

Beauty institutes have understood this for a long time and apply itenthusiastically. Do we not read in women’s magazines: ladies havebeautiful breasts, a flat stomach, and good legs, but are they also firm?

The firmness and elasticity of tissue are fundamental qualities of achild’s skin and a part of their beauty. Beauty is costly. It is easy forwealthy people to get jewelry and beauty accessories, but these aremore difficult to acquire without money. This is one explanation of thepopularity of aesthetic medicine and surgery among the less well-offand among those who cannot please merely with their natural gifts orwith the artificial resources of the wealthy. As they are only able toplease with their body, the less wealthy will more pay readily for anoperation to remove acquired or existing supposed defects so that theycan continue to be admired.

The idea of using the child formula is well known. The heart should bereceptive to generosity, and this is used for reasons other than justnoble ones. Thus, for example, a child’s face next to the product in anadvertisement increases sales and turnover. Whether these are medi-cations or other products, if the consumers are sensitive, sales willincrease.

Naturally, a way to the heart is sought but also, and predominantly, away to the wallet. The child formula strategy is likewise used to directpublic attention to countries in need, to collect donations, and to fight

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poverty and suffering. A begging child will always get more moneythan an adult. The Disney films, of which audiences are so fond, useever smaller and ever more vulnerable animals; we always see theyoung mouse, the puppy or the fawn, never the fully grown animal.This also applies to toys. Usually, small animals and babies are used asdolls. As Saint Exupery said, “One can only see well with the heart.”

It is also important to know that a physical defect also provokes a pro-tective reflex. A few celebrated personalities and women involved inpolitics keep a slight squint, which could be easily corrected, to provokethis famous protective mechanism and thus strengthen their influenceand power of persuasion. They do not want an operation. It is just aswell known that if one part of the face is not perfect and other facialfeatures are consciously highlighted, then the defect is less striking, asthe eye is drawn to the emphasized features. If, for example, the eyesare beautiful and the nose is not, the eyes should be emphasized evenmore to disguise the unattractive nose. Make-up artists advise this eventhough they are not familiar with Konrad Lorenz’s theories and never-theless know how to beautify a face. A scar can deflect attention fromthe beauty of a face. To conceal public embarrassment, Passot says,“Give him a medal and he will be taken for a hero.”

Similarly, make-up artists do not know about the Muller-Lyer illusionof two lines of equal length with arrows pointing in different directionsat either end. Nevertheless, they know how to give eyes the appearanceof being closer together, by applying make-up to the inner corner or,conversely, increasing the distance between the eyes by applying make-up to the outer corner.

The same applies to cheek bones in a face that is either too long or tooshort. Blusher is applied either further apart or closer together asappropriate.

Why be beautiful? The reasons suggested are pride and a desire to beadmired and seen positively by others.

The cult of beauty is actually cultural. Humans are the only life formwho do not accept their fate but try to improve it. Preserving beautymeans improving the quality of life to beautify life. The progress of civi-lization in all areas has led to increased life expectancy. This does notseem to be sufficient; the quality of life must also be maintained and alife must be “beautiful” for longer. Some people say that medicine hasgiven a few more years to life; aesthetic medicine and surgery havegiven life to these years.

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Beauty and fashion are external signs of our inner need to express andredefine ourselves. Fashion is only a stylistic device in the work of artwhich is life.

Beauty does not last forever but everyone knows that, at the same time,beauty does not have an age. It is possible to look good at 20 but it isalso possible to remain irresistible for an entire lifetime, as Coco Chanelremarked.

Madame de Pompadour said, “The first requirement of a woman is toplease.” It is more and more difficult to fulfill this requirement withincreasing age. This reminds me of an old woman who came to me andasked for a facelift. When I showed that I had little interest in perform-ing this procedure because of her age, she said, in a quiet voice, “Whenone has ceased to please, one doesn’t have to displease for long.”

Ultimately, the desire to be beautiful is not a desire to be admired but adesire to be loved. In addition, this desire for love is ultimately the onlything that the followers of the cult of beauty want to communicate.

Konrad Lorenz acknowledges this, “Everyone loves children and wantsto protect them, this is hereditary.” Can you resent someone for want-ing to be like them in order to be loved more? There is no doubting thistheory. We should remember that the plastic surgeon should reconstructchildlike features in his work, if this is possible and desired, in order toprovoke positive feelings and admiration. We recognize the linkbetween beauty and admiration and the intense fluctuations of thespirit and the mind. Theodore Gautier summarized this well, “Toadmire is to love with the mind, to love is to admire with the heart.”

Konrad Lorenz’s theory is strengthened with details. To provoke aprotective instinct, an adult’s face must resemble that of a child; this isconsidered to be beautiful. The perception of beauty is subjective; thepersonality and qualities of the individual play a part. In those whoexperience this, this perception is influenced by earlier experiences.

Pierre F. Fournier, M.D.Honorary President of the French Societyof the Aesthetic Surgery (National Society)Paris, France

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Foreword by R. KaufmannIn the past few decades, aesthetic surgery has witnessed outstandingprogress. This has been mainly driven by a growing public demand forcorrective surgical procedures together with an increasing awarenessand the highest expectations for the best quality. Today’s understandingof aesthetic surgery, its technical and developmental stages, and thelevel of performance reflects the results of ongoing and combinedinputs made by leading physicians and pioneers from diverse subspe-cialties working in this field, including plastic surgeons, dermatologists,ENT specialists, maxillofacial surgeons, ophthalmologists, and others.However, although many procedures in the face are routinely performedwithin these subspecialties, major aspects of the art of cosmetic surgeryare usually not covered by subspecialty training alone. Professor Mang,one of the most experienced experts in aesthetic medicine and surgerytoday, has undertaken the challenge to provide colleagues interested inthis fascinating area with a modern state-of-the-art manual, showing astep-by-step approach to aesthetic surgical techniques. Chapters 3–6deal exclusively with facial procedures. The conceptual frame of thepresent manual promises the best and easiest access to this demandingfield by combining explanatory texts with video sequences on DVD andstepwise illustrations. I am convinced that Professor Mang’s work willbe of great value to colleagues from various subspecialties, and I hopethat it will have the success that it deserves.

Roland Kaufmann, MDProfessor and Chair of DermatologyJ.W. Goethe UniversityFrankfurt/MainGermany

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Foreword by S. MalakhovI first became acquainted with Prof. Mang in 2002 when he performedsurgery at the St. Petersburg Medical Academy at the invitation of Prof.Zapessotsky. Many plastic surgeons watched him doing this and werefascinated by his atraumatic operation technique. One of my assistantswent to Prof. Mang’s clinic at Lake Constance for further study andreported back on the friendly and excellent training received in Prof.Mang’s clinic.

On the occasion of his visit to St. Petersburg, Prof. Mang presented mewith the first volume of the first edition of Manual of Aesthetic Surgery.I was impressed by the clear and concise way in which cosmetic opera-tions were explained. This concept of audiovisual teaching was unknownat that time in Russia. All of my colleagues who have an interest in thesubject of aesthetic and plastic surgery were also impressed with thismanual.

The first volume dealt with cosmetic operations in the head/neck area,while the second volume described cosmetic operations in the trunkarea in a way that was equally clear and comprehensible. This secondedition, which combines the two volumes into one book, is an idealtextbook for learning about aesthetic surgery; this type of operationhas not previously been taught in this form, particularly in Russia.

I witnessed Prof. Mang’s hospitality on the occasion of the InternationalConference for Aesthetic Surgery in Lindau in July 2003. I wasimpressed not only with the scientific part of the conference in which600 people participated, but also with the social event on the occasionof the opening of Prof. Mang’s new clinic.

There are plans to further strengthen and intensify this relationshipbetween the clinic at Lake Constance and the Medical Academy inSt. Petersburg. I wish Prof. Mang much success for the new Manual ofAesthetic Surgery.

Finally, I would like to complete my foreword by providing a little infor-mation on the history of plastic surgery in Russia:

Plastic and Aesthetic Surgery in Russia – the Past and the Future

The development of plastic surgery in Russia is closely associated withthe name of the great Russian surgeon, N.I. Pirogov. It was he who firstpaid attention to the aesthetic results of surgery on open areas of thehuman body. In his famous book, Basis of General War Field Surgery,

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he touched on the topics repeatedly. One of his followers wrote the thesison rhinoplasty. In 1865, another brilliant follower, Y.K. Shimanovskii,published the first manual in the world for practical surgeons, HumanBody Surface Surgery, for which he was awarded the I. Bush prize. Thisunique book contains more than 150 drafts and schemes of plasticsurgery procedures made with the author’s own hand, many of themstill relevant.

A little later in 1869, the young Russian surgeons, S.M. Yanovich-Chainski,A.S. Yatsenko, and P.Ya. Pyasetskii, took up the idea of J. Reverdin con-cerning free transplantation of autodermal microflaps for closing wounddefects and implemented their experience in Russia. In 1898, K.P. Sus-lov worked out the original method for the elimination of nose defectsby transplantation of free skin–cartilage transplants from the ear.

Unfortunately, during the first decades of the twentieth century, therewere three revolutions and the First World War, which did not favor thedevelopment of plastic surgery in Russia. Nevertheless, in 1916 theworldwide recognized work by V.P. Filatov was published. The workwas dedicated to the results of using round fat-dermal flaps developedby V.P. Filatov. This method was the only possibility for tissue complextransplantation right up to the second half of the twentieth centurywhen flaps with axial blood supply came into use. Other famous Russiansurgeons who played an important role in plastic surgery developmentinclude: P.I. Diakonov, N.A. Bogoraz, A.A. Limberg, A.E. Rauer, B.I.Vozchek, B.S. Preobrazhenskii, I.M. Mikhelson, among many others.

After World War II, a special system was organized for the treatment ofburn patients; this played a particular role in the formation and devel-opment of plastic surgery in Russia. During this research and organiza-tion work, several generations of plastic surgeons grew up, who have agood knowledge of the most up-to-date methods of free and local skinplastic surgery procedures, including those using microsurgery.

The methods of skin reconstruction by means of different variants ofcombined autoallodermaplastics were developed and implemented.

The most significant names in this field were Y.Y. Dzhanelidze, T.Y.Ariev, M.I. Shraiber, N.I. Atiasov, B.S. Vihriev, among others.

In 1930, in Moscow increasing interest in plastic surgery led to thecreation of the Institute of Beauty, which is now called the Institute forPlastic Surgery and Cosmetology. In 1961, a similar clinic was openedin Leningrad. In the following decades this trend developed rapidly,

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and there are now hundreds of centers working in the field of beautysurgery in Russia.

At the end of the last century, many specialists understood that plasticsurgery is an independent and complex specialty that requires the long-term education of individual surgeons. That is why, at the end of the1980s and the beginning of the 1990s, the first structure for the trainingand retraining of plastic surgeons was included in the system of contin-uous medical education in Moscow. In 1997, at the Saint PetersburgMedical Academy of Postgraduate Studies, the first special departmentand clinic for plastic and aesthetic surgery was created. Specialists inthis department have experience in all methods of plastic surgery andeducational work. The department provides long-term programs forthe basic training of young specialists (3–5 years) and short-term pro-grams for continuing medical education. The intensive research workof the departmental staff allows training programs to be refreshed andongoing improvement of the surgery procedures.

All of the above means that the education of plastic surgeons is contin-uous and that their professional level is constantly renewed.

The following events have favored the development of plastic surgery inRussia: creation of the All-Russian Society of Plastic, Reconstructiveand Aesthetic surgeons; publishing of several periodicals; organizationand holding of scientific conferences, seminars, and master-classes indifferent regions of Russia; constant contact with international societiesof plastic surgeons.

My colleagues and I believe that aesthetic surgery in Russia has a greatfuture.

Professor S. MalakhovHead of the Clinic for Plasticand Aesthetic SurgerySaint Petersburg Medical Academyof Postgraduate Studies, Russia

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Foreword by H. MassihaAesthetic plastic surgery is perhaps the fastest growing area in the fieldof surgery. As more and more surgeons spend more time performingaesthetic operations, it becomes increasingly evident that authoritativeinstructions are needed to extend the competence of the surgeon.

Although it looks simple, aesthetic surgery is very demanding techni-cally and artistically. The task of becoming a good aesthetic surgeoncould be greatly eased by observing and working with masters in thefield. Since the option of working with these experts is not practical formost surgeons, reading their works and becoming familiar with theirideas becomes even more important. A major advantage of this book isnot only the large number of elegant diagrams, but also the inclusion ofa video presentation.

Professor Mang has undertaken the monumental task of bringingtogether the most advanced and practical techniques of aesthetic sur-geons in the Manual of Aesthetic Surgery. This book is the result of longyears of research, observation, and hard work in the pursuit of excel-lence in aesthetic plastic surgery. In addition to his extensive educationin the field of head and neck surgery, Professor Mang has traveled allover the world to visit, observe, and exchange ideas with the greatestaesthetic surgeons. On numerous occasions he has invited these author-ities to his clinic to share his ideas and perfect his concepts and tech-niques through creative interactions and exchanges. The purpose of thebook is not only to teach young aesthetic surgeons about basic opera-tions and how to avoid pitfalls and complications, but also to empha-size what is currently the state of the art in aesthetic surgery.

This book will satisfy all types of aesthetic surgeons and will help toimprove their results with the ultimate beneficiary being “the all-important patient”. I highly recommend this wonderful book of aes-thetic surgery to all surgeons who seek the opportunity to improvetheir results. I congratulate Professor Mang in providing this vital ser-vice to the field of aesthetic surgery and to the young aesthetic surgeon.

Hamid Massiha, MD, FACSProfessor of Plastic SurgeryNew Orleans, Louisiana, USA

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Foreword by D. MillesiAesthetic surgery has developed with enormous velocity over the pastdecade. Owing to the growing number of patients undergoing aestheticsurgery, it is not only more and more accepted in a wider range of ourpopulation, but also has to fulfill the growing expectations of verycritical patients.

Many new techniques are at our disposal and the number is constantlygrowing. Apart from basic techniques, detailed technical points becomemore and more important for successful outcomes.

It is nearly impossible to provide a complete survey of all techniquesavailable today in a single textbook, not to mention the variety oftechnical details that are frequently not described. It is to W. L. Mang’scredit that he elected the forum of a manual instead of a large textbookto present his great personal experience. His techniques and tricks arepresented in the form of very instructive sketches, and any surgeonwho wants to enter the field of aesthetic surgery can do this easily fol-lowing the impressive illustrations. Now the new edition of the Manualof Aesthetic Surgery is available. It covers liposuction, breast implants,hair transplantation, aesthetic surgery of the extremities, and abdomi-nal plastic surgery. These chapters on surgical techniques are comple-mented by a chapter on adjuvant therapies, including lipotransfer. Thenew edition is designed according to the same principles as the firstedition. Again, the main focus is on the illustrations, which are easy tofollow and help the reader to understand the individual surgical steps.In addition to the excellent optical presentations, a DVD is included,providing audiovisual presentations. I personally have profited enor-mously from the brilliant images, and I am sure that this new editionwill help beginners in this field in the same way. It would be advanta-geous if all prominent surgeons in aesthetic surgery would present theirprofessional experience in a way similar to W.L. Mang.

Prim. Dr. med. Dagmar MillesiFachärztin für plastische und ästhetische ChirurgieVienna, Austria

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Foreword by I. PitanguyIn his Manual of Aesthetic Surgery, Professor Mang provides a clearlywritten and comprehensible book that can be read by all physicianswho may have an interest in the field of aesthetic plastic surgery.Prof. Mang shares with us his vast experience in aesthetic surgery andpresents the techniques that have proven useful in his hands.

Together with his team of collaborators at the clinic at Lake Constance,Prof. Mang describes operations clearly and explicitly. Especially for theyounger surgeon, the book offers the opportunity to becomeacquainted with aspects of surgery of the abdominal and breastregions, as well as the upper and lower limbs.

When Prof. Mang first visited me in Brazil in 1972, he impressed me asa particularly hard-working colleague, eager for knowledge. Throughhis numerous visits to my clinic in Rio, and during my own visits toGermany, I have grown to know Prof. Mang and his delightful familywell and to value the friendship that we have developed, which is char-acterized by that special charm all Germans are capable of giving.

With the completion of his clinic at Lake Constance, Prof. Mang ful-filled his life’s dream. I wish both his clinic and this book much success.

Prof. Ivo Pitanguy, FACS, FICSHead Professor of the Post-Graduate Coursesin Plastic Surgery of the PontificalCatholic University of Rio de Janeiroand the Carlos Chagas Post-Graduate Medical Institute.Member of the Brazilian Society of Plastic Surgery,the Brazilian National Academy of Medicine,and the Brazilian Academy of Letters

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Foreword by R. SchmelzleThe Manual of Aesthetic Surgery, written by Professor W.L. Mang fromLindau, presents aesthetic and plastic surgery from the perspective ofone of the leading practitioners in the field. Although the manual isintended for young physicians and representatives of many differentmedical specialties, it is also an important reference work for membersof the field of aesthetic surgery itself.

The excellent illustrations provided by a graphic artist from Springer-Verlag are accompanied by brief explanatory texts. Together they allowthe entire field of aesthetic surgery to unfold in a clear and easy-to-understand manner. A point worthy of special mention is the audiovi-sual character of this textbook, which presents the most importantoperations in the head and neck area via text, illustrations, and video.

This second edition will also serve as a guide in the area of “qualityassurance,” a goal which is frequently cited today.

I hope that the Manual of Aesthetic Surgery will reach a large audience.

Dr. Dr. Rainer SchmelzleProfessor of Maxillo-facial Plastic SurgeryUniversity of HamburgGermany

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Foreword by H. U. SteinauThis new textbook of Werner L. Mang’s Manual of Aesthetic Surgerybrings together his group of experienced plastic surgeons and special-ized ENT and maxillofacial colleagues to share their profound personalknowledge in treating the most common aesthetic problem areas.

Anatomical landmarks and potential pitfalls are clearly depicted anddiscussed. The publisher has provided coloured pictures of excellentquality with accompanying schematic drawings.

The chapters explain the selection of optimal surgical strategies anddetails are given on their basic instrumental supplementation, surgicalprinciples, and potential problems. Advanced planning and selection ofsafe solutions are followed by various anesthetic regimens includingtumescence techniques, which are now used routinely in ambulatorysurgery.

Taken as a whole, this second edition represents a valuable contributionthat will provide novices during residency with a broad-based trainingprogram. Its interesting case collections and methodologies affordexperienced aesthetic surgeons the opportunity to critically comparetheir preferred treatment options with convincing “second opinions.”

Professor Mang and his multidisciplinary team are to be commendedfor their continuous educational efforts and outstanding didacticaccomplishments.

Professor Dr. med. Hans U. SteinauDepartment of Plastic Surgery and BurnsBG-University Hospital “Bergmannsheil”RU-Bochum, Germany

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IntroductionAesthetic surgery is an interdisciplinary specialty. Its members arerecruited from the fields of surgery, gynecology, orthopedics, otolaryn-gology (ENT), maxillofacial surgery, plastic surgery, ophthalmology,and dermatology. In most cases, they are specialists who have becomeinterested in practicing aesthetic surgery after completing their special-ist training.

Aesthetic surgery is not synonymous with plastic surgery. During theirtraining in aesthetic surgery, aspiring aesthetic surgeons have to learnspecial surgical techniques, which are unfortunately not adequatelydescribed in the postgraduate training catalogues.

This manual has been prepared as an audiovisual medium. It presentsthe most important standard operations in the field of aesthetic surgeryin a clearly understandable style. We hope that the manual will helpyoung surgeons to learn the techniques of aesthetic surgery and –equally important – to avoid mistakes and complications.

The manual is primarily aimed at specialists in aesthetic surgery. How-ever, it is also suitable for physicians who become interested in aes-thetic surgery after finishing medical school who would like to find outabout the field, as well as for the natural target group of physicians whowant to learn the techniques of aesthetic surgery after completing theirspecialist training.

In line with the author’s didactic concept, the manual is accompaniedby a DVD containing a video film of each operation and by a surgicalatlas with 337 color illustrations. In the surgical atlas, the individualsteps are shown again and explained in detail in the accompanying text.This structure allows the physician to reproduce each surgical stepprecisely and to master the associated techniques.

There are obviously several variations of each surgical technique. Theauthor has deliberately concentrated on the standard operations as hiscontribution toward “demystifying” the field of aesthetic surgery. Thisreflects his conviction that aesthetic surgery, like any other kind ofsurgery, is a reproducible discipline which can be learned.

The manual is designed to serve two purposes: the education of youngsurgeons and quality assurance in the field of aesthetic surgery. It is theonly work of its kind available internationally.

The manual is intended to be a basic tool and is not for professionalsand doctors who have been practicing in this specialty for a long time.

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It is intended to be a textbook for doctors who are starting out in thisfield and want to learn about it.

Naturally, it was not possible to mention all the tricks, subtleties, andlatest operation methods, suture materials, implants, etc. in this book.Every aesthetic surgeon must learn these through further training andconferences. However, for every surgical technique in trauma orabdominal surgery, the basics of the operation must be standardized.

This was achieved well with the first edition of the manual. It has beenthe most successful book of its kind for Springer-Verlag, Heidelberg,and has been published in Spanish, Russian, and Chinese because ofthe enormous interest it received. The same format and approach hasbeen adopted in this second edition.

I had never thought that this book would be so well accepted. It hasbecome an interdisciplinary textbook for surgeons, ENT and dentalsurgeons, plastic surgeons, dermatologists, gynecologists, orthopedists,and urologists and has a place in many hospital libraries throughoutthe world.

After the first edition was published, I received invitations to givelectures and surgical courses and take up chairmanships from almosteverywhere in the world. I have been accredited as an honorary profes-sor at foreign universities and see my life’s task in plastic and aestheticsurgery as being to bring together all specialties that teach and researchthe field of aesthetic surgery in order to ensure excellent quality assur-ance in relation to patient care.

As a result of my lectures to the most varied specialist societies onevery continent, I have discovered again and again that there is compe-tition between ENT surgeons, dental surgeons, and plastic surgeons inalmost every country, even though all three specialties performextremely valuable work in the field of aesthetic surgery.

The leading plastic surgeons of the past, Diefenbach, von Gräfe, Joseph,and Lexer were either ENT surgeons or general surgeons. We mustnever forget our history and the disciplines from which the specialty ofaesthetic and plastic surgery has developed.

Anyone who has had sound surgical training and has an interest in thefield of aesthetic surgery will value this book as a benchmark. It can helpin allowing the specialty of aesthetic surgery to be taught in an interdis-ciplinary way, so that the specialties concerned can mutually exchangeknowledge and thus contribute to further progress in this field.

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Aesthetic surgery can only achieve a serious basis in the long-termthrough constant training, the exchange of ideas, attendance at confer-ences, and the opening up of all specialties that perform valuable workin this field. Neither plastic surgery nor ENT and dental surgery canclaim this specialty for themselves alone, as there is too much overlapboth historically and in the specialist further-training guidelines. Forthis reason, work is carried out in an interdisciplinary way at the clinicat Lake Constance with the departments ENT and plastic surgery, plas-tic and reconstructive surgery, maxillofacial surgery, aesthetic dentalsurgery, dermatology, and venous, hair, and laser surgery. This is theonly way a large clinic can cover the entire spectrum. The same appliesto a well-trained aesthetic surgeon. He will always have main areaswithin his field of work and will be unable to cover all operations pro-fessionally alone. This is why the model of the clinic at Lake Constancewill be successful in the long term, as in this clinic different groups ofspecialists are unified and offer interdisciplinary aesthetic surgery. Thisis the clinic of the future.

Every year approximately 3,000 operations are carried out at the clinicat Lake Constance, which has five operating theaters and 50 beds.

The Manual of Aesthetic Surgery should be seen as the symbiosis of mylifetime work with the Bodenseeklinik. It has been published to coincidewith the building of the new clinic (completion 2003). All physicianswith an interest in aesthetic surgery can build on this and refine theirsurgical techniques during the course of their life. The basic principlesmust be standardized, so that dangers and risks can be reduced. Rhino-plasty should not be performed differently in London and Rome, andliposuction techniques should be the same in New York and Tokyo.

Just as in abdominal surgery, there are basic principles that must beobserved so that the operations and results can be reproduced andserious treatment errors can be avoided.

Naturally, there are variations in the operations, whether the procedureis rhinoplasty, otoplasty, breast implants, or liposuction. The sameapplies to operations on the appendix or tonsils. The basic surgicaltechnique used, however, is always the same. The anatomy never lies. Itis therefore essential that the basic operations are standardized, partic-ularly in aesthetic surgery, which I consider to be the most difficulttype of surgery, as the surgeon must not only be well trained, but mustalso be a psychologist and artist.

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This manual was written at the urgent request of many of the numerousphysicians who come to the author’s clinic every day as observers. Theobjective of the manual is to give a large number of physicians a solid,broad, and interdisciplinary foundation in aesthetic surgery. This is evi-dent at many points in the manual and especially in the words of intro-duction written by the following authors:

– Mario Ceravolo, MD, University Professor, General Plastic Surgery,Rome, Italy

– Dominik L. Feinendegen, Plastic, Reconstructive and Aesthetic Sur-geon, Zollikon, Switzerland

– Pierre F. Fournier, M.D., Honorary President of the French Society ofthe Aesthetic Surgery (National Society), Paris, France

– Roland Kaufmann, MD, University Professor, Dermatology, Frank-furt, Germany

– S. Malakhov, Professor, Head of the Clinic for Plastic and AestheticSurgery, Saint Petersburg Medical Academy of Postgraduate, Russia

– Hamid Massiha, MD, University Professor, Plastic Surgery, New Orle-ans, Louisiana, USA

– Dagmar Millesi, Prim. Dr. med., Plastic Surgery, Vienna, Austria– Ivo Pitanguy, MD, University Professor, Plastic Surgery, Rio de

Janeiro, Brazil– Rainer Schmelzle, MD, University Professor, Maxillofacial Plastic

Surgery, Hamburg, Germany– Hans U. Steinau, Professor Dr. med., Department of Plastic Surgery

and Burns, BG-University Hosptial “Bergmannsheil”, RU-Bochum,Germany

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A General RemarkIf I may be permitted another remark here:

The author’s philosophy and the philosophy of the Bodenseeklinik isinterdisciplinary cooperation, instruction and further training of youngdoctors, cooperation with all professional societies for the promotionof good patient care, and further development in the field of aestheticsurgery.

The Manual of Aesthetic Surgery has thus come about through tirelesswork. My clinic at Lake Constance is the largest clinic of its kind inEurope, a training clinic with interdisciplinary cooperation between allspecialties that provide a stimulus for aesthetic surgery. Doctors fromthe disciplines of plastic surgery, ENT and dental surgery, dermatology,aesthetic dentistry, and anti-aging medicine all work in the clinic atLake Constance. There are also dietary assistants, specialist beauticians,hairstylists, color consultants, and psychologists.

Long-term success can only be achieved when aesthetic surgery is seento be holistic medicine and the correct indications are available. Manypatients have serious psychological problems that cannot be solvedeven by the best cosmetic surgery. These patients are then dissatisfiedwith the surgeon and try to find a cure from other surgeons. If thesesurgeons do not then cooperate with the surgeon who carried out theprevious operation, the patient will complain. Medicolegal problemshave an important role in aesthetic surgery throughout the world.

The specialty can only have a long-term future if doctors are well-trained, act as good colleagues towards one another, and do not want tomake their name at the cost of others. I would therefore like to pass onthis message to all the surgeons in the world: be considerate and fair tocolleagues, regardless of their specialty. The Hippocratic Oath shouldapply to cosmetic surgeons, too.

The philosophy of the Mang school is naturalness. Less is more.

Health before beauty. Cosmetic surgery is not “alteration surgery” butrather “well-being surgery.”

The aim of every operation, whether it is a facelift, rhinoplasty, or abreast implant, should be a natural result. The patient should feel goodand the surgery should not be conspicuous. Faces that are perfectlysmooth, unnaturally augmented lips, and huge breasts are no longerthe trend of the twenty-first century. The manual therefore presentssurgical techniques that provide natural and normal results.

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Aesthetic surgery is not beauty surgery. It is instead high-tech surgerywith the highest surgical standards. As with every other surgical proce-dure, the risks mean that specialist surgical personnel, anesthesia,recovery rooms, and inpatient monitoring are essential. Surgery on aday-case basis is only advisable for minor procedures carried out underlocal anesthesia, such as eyelid corrections, spacelifts, hair transplanta-tions, and laser operations. Otherwise, an inpatient stay is necessary, asmost complications, e.g., severe bleeding, occur within the first 24 hafter the operation.

The current worldwide problem of medicolegal issues in cosmeticsurgery procedures should be combated with extensive expert activity.

In addition to providing accurate oral and written information in thepresence of witnesses and photographic documentation, use of the cor-rect surgical techniques and postoperative monitoring are extremelyimportant in avoiding the possibility of becoming liable for compensa-tion. More and more patients are happy to take legal action and thismeans that good training, quality assurance, good relationshipsbetween colleagues, and professional interaction with patients are evenmore essential.

The Standard Procedures

The standard procedures are clear and can be easily and safely learnedfollowing good basic surgical training. Similar basic surgical rulesapply to brachioplasty, abdominoplasty, thigh lift, and buttock lifts. Inprinciple, these procedures entail cleanly lifting a cutaneous/fatty flapfrom the fascia and tightening the skin appropriately, using a largecutaneous resection and positioning the incisions in such a way thatthey are preferably not visible. The surgeon’s talent is estimating thecorrect cutaneous resection, so that not too much and not too little isremoved, and accurate surgical planning of the incisions so that theywill preferably be in a non-visible area. The intracutaneous suturingtechnique with Monocryl, a suture which is not removed, is now stan-dard and provides the best results. In certain cases, the skin may alsobe adapted with overcast cutaneous suturing with thin nylon, followingsubcutaneous, tension-free skin closure. When these continuoussutures are removed in time, the cosmetic results of the suturing are nodifferent than for intracutaneous suturing.

For all operations associated with large scars, follow-up treatment isvery important. A compression dressing should be worn for approxi-

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mately 4 weeks and follow-up treatment for the scar should be carriedout with a silicone plaster. Scars resulting from brachioplasty, abdomi-noplasty, and thigh and buttock lifts in particular are often unpredict-able and must be discussed in detail with the patient when the proce-dure is explained so that there is no disagreement later.

The standardized surgical procedures described in detail in the manualare presented in abridged form below.

Rhinoplasty

About 70% of all functional-aesthetic rhinoplasties are performed toreshape long noses with a bump. For this reason, the manual presentsa reproducible and simple technique for correcting this type of nosedeformity. In addition, several variations are briefly described.

During aesthetic nasal tip correction using the eversion method, amucosal epithelial layer inevitably remains following the removal oflarge portions of the alar cartilage. The more the tip is reduced, themore excess skin there will be. This so-called Mang‘s triangle isresected following suturing in order to achieve nonirritable healing ofthe skin inside the nasal wings without step formation.

Strictures and stenoses can be avoided by taking pains to leave themucosa intact during the removal of alar cartilage. Furthermore, theremoval of equal-sized triangles on both sides facilitates aesthetic shap-ing of the nasal wings.

Rhytidectomy Using the Tumescence Technique – Mini Lift

The manual presents a standardized surgical facelift operation usingthe tumescence technique. This procedure involves simple and gentledissection with transection of the osteodermal ligaments, as describedby Hoefflin (extended supraplatysma plane facelift, referred to as ESPlift). Dissection of the superficial musculo-aponeurotic system (SMAS)is not necessary, since the sagging caused by the aging process is aproblem of lipocutaneous tissue and – similar to breast ptosis – is notattributable to fascia and muscle layers at deeper levels. The methodpresented is standardized, easy to reproduce, and gentle to the tissue. Inaddition, it involves very little loss of blood and yields excellent long-term results. The tumescence facelift technique presented here for thefirst time facilitates dissection and is therefore an especially goodapproach for newcomers to aesthetic surgery. This method of face lift-ing produces the best long-term results.

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Upper Eyelid Surgery

Following the surgical steps shown in the manual, even an inexperi-enced aesthetic surgeon can perform upper eyelid blepharoplasty with-out any difficulty. The manual shows exactly how the excess skin isremoved symmetrically on both sides after the surgical area has beenmarked. In addition, it demonstrates the pointwise medial and inter-mediate separation of the orbital septum in preparation for liposuction.

Upper eyelid blepharoplasty is one of the most frequently performedoperations in the field of aesthetic surgery; it is performed on an outpa-tient basis under local anesthesia. This procedure achieves a dramaticaesthetic effect with a modest investment of surgical effort; moreover,it enjoys a high degree of acceptance among patients.

Lower Eyelid Surgery

Lower eyelid blepharoplasty requires substantial surgical skill andexperience. Whereas skin can be removed in the upper eyelid regionwithout any difficulty, the resection of excess skin in the lower eyelidarea requires great circumspection and restraint. The surgical techniquepresented takes account of all the important steps, such as surgicalplanning, liposuction, and skin resection. In addition, it providesprecise instructions on how to prevent complications so that even abeginner will not make any serious mistakes.

The operation can be carried out under local anesthesia or with a larynxmask.

The most important points to observe here are the exact liposuction(of “baggy eyes”), proper hemostasis, and gentle skin resection. Aninexperienced surgeon should initially remove too little rather than toomuch skin.

Otoplasty

Out of the large number of otoplasty (anthelix plasty) proceduresdescribed in the literature, the manual presents a surgical proceduredeveloped by the author which successfully combines the converse andStenström operations.

This operation is carried out in easily understandable anatomical steps.The auricle is repositioned without any tension at a 30° angle; as aresult of the removal of the concha, modest ear reduction is achieved.

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This operation is suitable for patients aged 6 or older; it can be per-formed on an outpatient basis under local anesthesia.

Breast Augmentation

This procedure is requested very frequently. The incision line andaccess are decisive factors in the success of the operation. In the manualand video, we present the simplest and safest type of access. Thisinvolves making a small incision in the inframammary fold and, withsupramuscular insertion, clean dissection between the fascia and thegland.

With submuscular access, the implant is inserted below the pectoralmuscle, after this has been carefully detached at the medial and caudalattachment.

One video shows supramuscular access, as this is the easiest surgicaltechnique for novices and provides an aesthetically pleasing result if theskin condition is good. The other video shows the submuscular access.

In a clinical study on our patients, we were able to establish that there isno significant difference in the rate of fibrosis in submuscular and insupramuscular access. The rate of fibrosis among our patients was lessthan 4% for both these methods.

The choice of implant is also important. Only licensed implants shouldbe used. We would advise against using cheap implants and implantsthat have not undergone long-term testing.

The concept of breast augmentation described in the manual can beused as a basis. Experience is very important, particularly in breastsurgery, as regards the shape of the implant (round, low profile, highprofile, anatomical, etc.) and the best position (sub- or suprapectoral).

In addition to an access incision in the inframammary fold, naturallythe incision can also be made above the nipple or via the axilla.

This requires additional experience and practice. The wound is suturedintracutaneously with 4.0 Monocryl. The sutures are not tightened andthe incision can be treated with a silicone plaster 4 weeks after theoperation for 2 months. Usually, there is no residual visible scar.

The procedure is performed under conventional anesthesia and withantibiotic cover. The patient should wear a specially fitted sports bra for4 weeks after the operation.

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Breast Lifting and Breast Reduction

We have attempted to standardize and clearly represent breast liftingand breast reduction. There are already innumerable methods formastopexy. The success of an operation lies in its systematization.

The text, images and film have been arranged so clearly and logicallythat every interested doctor can learn these methods. That is the aim ofthis handbook, to produce extensive and accurate instructions in orderthat risks can be avoided and results are reproducible.

Particularly in breast lifting and breast reduction surgery, preoperativeplanning and marking are very important. We present the caudal stalktechnique according to Robbins, which ensures good blood supply to thenipple. The procedure can be learnt logically and in a clear manner. Ofcourse, each aesthetic surgeon who masters these standard procedurescan develop further with other methods; however, the basics of aestheticsurgery must be correct first. This can then be usefully built upon.

Brachioplasty

An important factor in brachioplasty, as with all major tightening oper-ations on the torso, is that there may be residual scars if the suturingtechnique and wound healing are poor. This must be made clear to thepatient before the operation.An important preoperative stage in the operation is to mark the surplusskin to be resected precisely on the patient, who should be standing.

The size of the resection is also a decisive factor in the successful out-come. If too little is resected, this will result in folds in the medial areaof the upper arm. If too much is resected, hypertrophic scars may form.

The surgical technique is simple. It basically consists of dissection of acutaneous/fatty flap from the fascia of the upper arm, step-by-stepresection, and wound closure in three layers. As the patient is oftenworried about a large caudal scar extending to the epicondyle of theupper arm, we have developed a modified technique: the “fish mouth”technique. With this technique, the tightening is not performed verti-cally and primarily on the upper arm, but horizontally and on the skinof the axilla. With this type of incision, the incision on the inside of theupper arm does not extend beyond the proximal third. Postoperativescar care is also important with this type of incision. The patient mustbe monitored for 24 h after the operation, and the special compressiondressing can be removed after 8 days.

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Abdominoplasty – Mini Abdominoplasty

The art of a good aesthetic surgeon is in choosing the right indication.He needs many years of experience to do this. It is possible to achievegood results without making large incisions with the new method oftumescence liposuction, particularly with collections of fat in the abdo-men/hip area. If, however, there is a lot of surplus skin and the patienthas lost more than 30 kg in weight, or pregnancies have severelystretched the upper abdomen and periumbilical region, abdominopla-sty is indicated.

If it is necessary to tighten only the lower abdomen, it may be possibleto avoid moving the navel. However, it is usually necessary to make anincision around the navel and reimplant this in the correct position.

In the video, the basic abdominoplasty technique is described clearly,concisely, and simply so that every experienced surgeon will be able toperform this procedure. As with all tightening operations on the body,the procedure consists of an operation on the thick cutaneous/fatty flapalong the abdominal fascia. It is essential that the surgeon makes pre-cise markings on the torso while the patient is standing and carefullyplans the surgery prior to the operation. The level of the incision mustbe defined precisely so that it will always be possible to avoid a verticalincision. The more surplus skin there is, the more caudally the incisionmay be placed. During abdominoplasty it must also be taken intoaccount that the mons pubis is usually included in the tightening.

Dissection is carried out along the abdominal fascia as far as the costalarch. The entire cutaneous/fatty flap is then pulled downward andresected in stages, with the upper body slightly flexed, so that laterneither too little skin (bulging) nor too much skin (risk of necrosis) isresected.

A preoperative autologous blood donation is advisable for very obesepatients. Ultrasound investigation for umbilical and abdominal wallhernias is also recommended. Intraoperative and postoperative throm-bosis and infection prophylaxis is given for 10 days after the operation.The 4.0 Monocryl sutures must not be tight. A silicone plaster isapplied after 4 weeks for 2 months. Care of the scar is essential. This isthe mark of a good abdominoplasty. Similarly, the reconstruction of thenavel must appear natural and there should be no “dog ears” at thesides in the caudal area of the incision.

The procedure is performed under general anesthesia during an inpatientstay. A special girdle should be worn for 4 weeks after the operation.

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Thigh and Buttock Lift – New Methods

The technique for a thigh lift is similar to that for brachioplasty.Deep, subcutaneous dissection of the fascia and step-by-step resectionof the skin, previously marked precisely, are performed.

An operation on the medial side of the thigh is one of the most unsatis-factory operations an aesthetic and plastic surgeon can perform.

The patient’s expectations of the procedure are usually too great andhe/she is then disappointed by the result. The patient should thereforebe given an extremely detailed explanation prior to the thigh and but-tock lift. The indication should be considered carefully and if thepatient expects too much, they should preferably be turned away.

The extent of the resection should be defined carefully the day beforethe operation. If the skin on the inner side of the thigh is loose, the but-tock region is usually also loose, so these operations can be combinedwell.

The incision line in the buttock area should not extend beyond thelateral buttock fold, as otherwise there may be residual aestheticallydispleasing scars, which often disturb patients more than hanging skin.

With extremely slack skin in the area of the medial thigh, vertical tight-ening extending to the medial side of the knee can be performed inaddition to horizontal tightening in the groin and buttock region. Thisallows extremely intense tightening of the entire medial thigh, but theresidual scar should be drawn to the patient’s attention and explained.

The video shows the most frequently requested operation for horizon-tal thigh and buttock lifting. In contrast to brachioplasty, it is importantthat the thick cutaneous/fatty flap be secured at two points to achieve alonger-lasting result and better scar formation, owing to gravity in thethigh area. The points for fixation are the periosteum of the pubic boneand the inguinal ligament. The extent of the resection is defined withkey sutures, and the area is resected in stages so that not too much andnot too little skin is removed. The operation is performed under gen-eral anesthesia on an inpatient basis. Thrombosis and infection pro-phylaxis is started. A special girdle must be worn for 3 weeks after theoperation, followed by care of the scar with a silicone plaster.

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Because of the many requests, hair transplantation, Prof. Mang’s space-lift, and a few brief descriptions of adjuvant therapies have also beenincluded.

Adjuvant therapies are being continually developed and newly pub-lished, mainly within the field of dermatology. For this reason, only theessential features of the adjuvant therapies are described very briefly inthis manual, with no claim to completeness.

The new edition retains the essential texts on biological implants (colla-gen), lipotransfer, botulinum toxin, dermabrasion, ultrapulse CO2 laser,erbium: YAG laser, coblation, and chemical peeling. In addition, wehave filmed short videos on biological implants (collagen, hyaluronicacid), botulinum toxin, dermabrasion, erbium: YAG laser, and chemicalpeeling. For space reasons, these films have been kept very short andshould show that adjuvant therapies should also be included in therepertoire of an experienced aesthetic surgeon.

Two of these treatments have been described in detail in the video andthe text.

Liposuction – Removal of Fat with the Tumescence Technique

(Mang’s Solution) – MicroAire® System

Liposuction is one of the most frequently performed operations in aes-thetic and plastic surgery. In men, liposuction is primarily requestedfor the abdominal/hip area; in women, it is for the lateral and medialthigh, buttocks, and hips (“saddle area”).

Dry suction under general anesthesia does not merely put a strain onthe cardiovascular system with an increased risk of thrombosis andembolism, but also causes blood loss, including a drop in hemoglobinto under 8 g %, as well as destroying the infrastructural supporting tis-sue (IST).

This infrastructural supporting tissue is maintained when the tumes-cence technique is used, so that there is no “chewing gum effect”following liposuction, i.e., the skin does not have depressions in it butinstead is tightened.

The tumescence technique was first published at the beginning of the1990s by Jeff Klein. Lidocaine was used as local anesthesia. In view ofthe toxicity, we carried out a large study that showed that the aestheticand plastic surgical tumescence technique with lower doses of prilo-

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caine solution (Mang’s solution) produces the same results with a lowerincidence of complications:

) Mang’s solution = 0.9 % saline solution (NaCl) 3000 ml) 1 % prilocaine 1500 mg (= 150 ml)) Epinephrine 3 mg) 8.4 % NaHCO3 30 mEq) Triamcinolone acetonide 30 mg

As high doses of prilocaine may cause methemoglobinemia, no morethan 6000 ml of this tumescence solution should be injected per sessioneither manually or with a pump. The results are very good if the correctindications are given. There is no blood loss, the risk of thrombosis andembolism is significantly reduced, and there is protection from infection.The patient is mobile on the first day after the operation.

The patient should be monitored for 24 h after the operation. He/shemay leave the hospital with a special girdle, which must be worn for3 weeks. The injection sites may be treated with scar ointment for3 weeks after the operation. Then the region treated by liposuctionshould be exercised in a gym under supervision.

In the video, the manual tumescence liposuction technique with Mang’ssolution is presented as a basic technique. Auxiliary devices of whatevertype (MicroAire®, ultrasound, reciprocator, etc.) may be useful andreduce the liposuction time, although the same results can be achievedperfectly with the manual technique. This technique is simple, can beperformed without any large instruments, and there are no significantrisks if it is carried out by a specialist.

Similarly, the tumescence injection can be given manually or mechani-cally with a pump. The manual technique, however, is very time-con-suming and it is necessary for the surgeon to have a lot of stamina, soat our clinic we apply the tumescence solution quickly (without toomuch pressure and over at least 45 min) and homogeneously with asix-cannula pump system. Following local tumescence anesthesia, youshould wait 30 min and then begin liposuction.

If performed by an experienced surgeon, manual liposuction may takeup to 90 min and up to 45 min with the MicroAire® system. The patientmust be prepared for the total liposuction procedure with tumescenceto last approximately 2.5 h.

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Hair Transplantation

Hair transplantation is a procedure frequently performed in men. Wehave an experienced transplantation team, managed by Dr. Frank Nei-del. Depending on the indication, we work with both slit and micro-punch techniques, manually or with laser assistance. Precise surgicalplanning, the correct technique, and the schedule of the hair transplan-tation team, which is made up of the surgeon and three assistants whoprepare the hair roots, are all important factors.Approximately 3000 hair roots are transplanted per session. The proce-dure is performed on an outpatient basis under local anesthesia. Thepatient is then given antibiotic cover and hair hygiene is strict.

The hair should be washed on the fourth day after the operation with amild chamomile shampoo.

Spacelift

The name spacelift was chosen by Prof. Mang and protected by patent(German Patent Office, Patent and Logogram No: 303 23891), as three-dimensional fat droplets of 0.1–0.3 mm are injected via the purifiedautologous fat cells into the space between the cutaneous and adiposetissue of the face, virtually as if in a honeycomb. As these fat dropletsare not injected in a bolus dose but by using microinjections, they donot die but retain a vascular association and are transformed into fibro-blasts, or rather connective tissue cells, and thus stabilize the aging pro-cess. Fat cells are thus injected into the space between the cutaneousand adipose tissue, particularly at those sites where the collagen andelastin fibers break down with age, i.e., in the nasolabial, mouth, fore-head, lateral eye, and cheek regions.

The spacelift should be seen as a prophylaxis against aging after the35th year of life. If there is surplus skin in the area of the neck/cheeksor eyelids, conventional tightening or lifting must be performed.

A spacelift cannot replace a facelift.

The procedure is carried out on an outpatient basis under local anes-thesia. Cooling and lymph drainage are then necessary for 3 days, alongwith antibiotic cover.

Adjuvant Therapies

Adjuvant forms of therapy administered during or after surgical proce-dures – or as a single form of therapy – play a very important role in

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the area of aesthetic facial surgery. However, it is very important thatthe correct form of therapy should be selected for each type of skinaging. The manual presents a critical assessment of each individualmethod along with practical instructions enabling the surgeon to per-form them independently. In the chapter on laser therapy and adjuvanttherapies, a great deal of attention has been devoted to tricks, tech-niques, mistakes, and risks. As a result, even an inexperienced physi-cian can quickly obtain an overview of the most important proceduresin aesthetic surgery currently performed on an outpatient basis.

This manual has been created to put aesthetic surgery on a serious pro-fessional foundation equal to that of the other surgical specialties andto offer standard techniques.

Conscientious patient instruction, correct evaluation of the indicationfor surgery, and quality-oriented and standardized surgical techniques,together with good follow-up care, guarantee satisfied patients.

Werner L. Mang

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AcknowledgementsAs aesthetic surgeons, we are often unable to define beauty, and weshould not be swayed by fashion. What is said to be beautiful in themedia today may be different again in a few years’ time. The aestheticsurgeon must therefore impart timeless beauty through his creativework. The patient must feel good. Less is often more and overly aggres-sive aesthetic surgery is not my style.

During the 1980s and 1990s, I spent a lot of time at conferences in theUSA and Brazil, but in the last few years I have been more active inRussia and China. I often receive invitations from these countriesbecause of my Manual of Aesthetic Surgery as aesthetic surgery is onlyjust being developed there, and any knowledge in this field is extremelywelcome. I have become acquainted with many competent plasticsurgeons who are very interested in the field of aesthetics, particularlyin Russia. The demand is also increasing in these countries.

I have a close relationship with the University of St. Petersburg throughProf. Malakhov, whose human qualities I admire just as much as hissurgical skills.

Within Europe, our task is also to share our knowledge in aestheticsurgery. In doing this, doctors will make a substantial contribution tointernational understanding. The same applies to China where there isa great demand for knowledge in aesthetic surgery. Young doctors fromthis country have demonstrated their technical skill in my clinic.

I have already mentioned all of my medical colleagues with whom Ihave been working since 1975 and have had the privilege to learn from,as well as everyone who has helped me on the way. In addition to these,I would also like to mention my long friendship with Prof. Ivo Pitanguy.I first visited Prof. Pitanguy at his clinic in Rio de Janeiro in 1972. Sincethen, Prof. Ivo Pitanguy has often taken part in conferences in Lindauand is always a very welcome guest in our home. His professional com-petence, his charm, his gentlemanly nature, his warm-heartedness andhis ability to get things done, as well as his pioneering spirit and hislove for aesthetic and plastic surgery have perhaps encouraged me tocontinue resolutely in this specialty and to pass on my knowledge toyoung colleagues. This young team of enthusiastic aesthetic and plasticsurgeons at my clinic has also helped me to complete the manual. Forthis, I would like to give particular thanks to my plastic surgery consul-tants, Dr. med. A Becker and Dr. med. Marian Stefan Mackowski fortheir assistance, Dr. med. Frank Neidel for compiling the hair trans-

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plantation chapter, Dr. J.T. Schantz for the photographic documentationand his marvelous care of patients on the ward. Particular thanks alsogo to Dr. med. Ulrike Then-Schlagau (plastic and general surgeon) forher tireless and enthusiastic work on this book and whose excellentqualifications have been a positive asset to this second edition. Mysincere thanks for this. I would also like to thank Ms Annemarie Anzen-bacher and Ms Karina Engelhardt for the clerical work and organizationand my entire surgical and inpatient team who likewise gave up muchtime to compile the films and photographs.

My particular thanks naturally go to Springer-Verlag and, in particular,Ms Gabriele Schröder, who has always been very patient with me andhas not pressed me too much, despite my delays. I would like to thankMartha Berg and Joachim W. Schmidt for the wonderful production ofthe manual and, last but not least, Mr Klaus Peter Prieur, who recordedthe films in the operating room and edited and set them in the studiowith much patience, skill, and originality.

The Manual of Aesthetic Surgery is brought to life by the excellentillustrations. Mr Hans Jörg Schütze created these in an ingenious way.He was present at the operations and drew every important stage.I offer him my warmest thanks for this.

Werner L. Mang

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History – VitaWhereas aesthetic surgery has enjoyed widespread acceptance in theUSA and Brazil since the 1970s, it is only during the last 20 years thatthis field has become established in Germany and Europe.

At the age of 14 – way back in 1964 – I already knew that I wanted tobecome a facial surgeon. I was absolutely fascinated by plastic surgery,and spent my free time making models of faces and noses. From thestart, my father, Dr. Karl Mang, supported my wish to study medicineand to specialize in plastic surgery. During my first year of medicalschool, I traveled to Brazil to meet Prof. Ivo Pitanguy, my most impor-tant role model at that time.

Starting in 1972, I made regular visits to Professor Pitanguy’s clinicduring the summer and semester breaks. Over the years our mentor-student relationship grew into a deep friendship, and we now see eachother regularly at congresses all over the world.

Without the generosity with which Professor Pitanguy shared hisknowledge and experience, and the intellectual and professional fasci-nation he exerted on me, I would perhaps not have had the strength toraise the field of aesthetic surgery to its present level in Germany. In1987, I founded the German Society of Aesthetic Surgery, of which Iwas President for 12 years and I am now President of the InternationalSociety for Aesthetic Medicine (IGÄM e.V.). False modesty aside, I feelthat it is fair to say that I have had a decisive influence on the develop-ment of aesthetic surgery in Germany.

At congresses in Germany, surgeons with international reputations areoften invited as guest speakers. When I accept such invitations, myobjective is always to promote quality assurance and advances inaesthetic and plastic operations.

After studying medicine, I underwent postgraduate training in surgery,with guest residencies in Australia, England, and the USA. I realizedearly on that training in otolaryngology (ENT medicine) is indispens-able to a surgeon planning to work in the area of facial plastic surgery.During this part of my postgraduate training (1975–1980), I receivedenormous clinical and scientific support from Professor Volker Jahnke.

After gaining this additional qualification as an ENT specialist andperforming a number of plastic operations, I worked on the staff of theKlinikum rechts der Isar in Munich run by Professor Werner Schwab.Professor Schwab deserves a large amount of the credit for encouraging

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my scientific work and allowing me to pursue an independent course asan aesthetic surgeon. Without his tolerant support, I would perhapsnever have founded the German Society of Aesthetic Surgery or com-pleted the work required to achieve professorial status.

I have always viewed aesthetic surgery as an interdisciplinary field ofstudy. It is evident from the forewords in this manual, written by prom-inent representatives of several medical specialties, that the variousmedical specialties have a lot to learn from each other. Dermatology isone of the fields related to aesthetic surgery. Professor Roland Kauf-mann is a dermatologist who has accompanied us along much of ourjourney.

In the field of oromaxillofacial surgery, I would like to express my spe-cial gratitude to Professor Rainer Schmelzle, whose motto is “coopera-tion instead of confrontation.” Professor Schmelzle shares my view thatmedical specialties have a lot to learn from each other and that qualityassurance and continued education are of central importance in thefield of aesthetic surgery.

During the 1990s, I was very involved in collaborating with aestheticsurgeons in the USA and in setting up international training pro-grams. I have had a good relationship – a friendship in fact – withDr. George Brennan for many years. I visited Dr. Brennan for the firsttime in 1983 and was immediately fascinated by his facelift technique.In 1998, I asked him if he would like to become vice president of theWorld Society of Aesthetic Surgery (WASS). The WASS would like toset up an annual exchange program in aesthetic surgery betweenEurope and the USA. We have already held highly successful wintermeetings in St. Moritz and Aspen and summer meetings in Lindauand Newport Beach.

I would like to take this opportunity, moreover, to thank Dr. MarioCeravolo, who participated actively in the development of aesthetic sur-gery. This colleague has always encouraged and supported me in theview that physicians attending professional conferences should not con-centrate exclusively on scientific topics but should seize the opportunityto make invaluable personal contacts offered by conferences, meetings,publications, and professional societies. Another person deserving ofspecial mention is Dr. Bruce Connell, an outstanding aesthetic surgeonwho has taught me a lot. During my visits to the USA – and his visits toGermany – we have spent many memorable times together. I have thehighest respect for his work and am very pleased that he is taking such

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an active role in the WASS – and now in the International Society ofAesthetic Medicine (ISAM e.V.).

These acknowledgements would not be complete without a mention ofDr. Hamid Massiha from New Orleans, whose excellent blepharoplastytechniques and outstanding human qualities inspire my deep respect.

Finally, I would like to thank all of the colleagues who agreed to write aforeword to the Manual of Aesthetic Surgery. These people are not justgood plastic and aesthetic surgeons but I also count them as friends.

Werner L. Mang

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Ten RulesDuring the past 20 years, the author has performed more than 30,000surgical procedures with the aim of improving patients’ appearance.

During this time, he has developed a professional philosophy which canbe summed up in ten rules:

1. Your conduct toward your colleagues should be characterized byfairness. Cooperation not confrontation is the most importantthing.

2. Health takes precedence over beauty. Aesthetic surgeons, like allother physicians, are bound by the Hippocratic Oath.

3. Genuine beauty cannot be purchased.

4. Healthy nutrition, sports, and a positive lifestyle often do more fora person’s look than aesthetic surgery.

5. A patient should never incur debts for aesthetic surgery.

6. Patients should be given comprehensive information about thecosts and risks of the operation. Cooperation with a trained cosme-tician is a vital part of preoperative and postoperative treatment.

7. There are limits to what can be achieved by aesthetic surgery. Eventhe best aesthetic surgeon has dissatisfied patients.

8. Beware of poorly trained physicians, emotionally disturbedpatients, and cranks.

9. Neither the doctor nor the patient stands to profit from long-drawn-out litigation; the only “winners” are the lawyers.

10. A patient should never make a rash decision to undergo aestheticsurgery. If he or she has any doubts at all, it is best to obtain asecond opinion from another surgeon before going ahead with thesurgery.

The decisive factors for the success of aesthetic surgery are the consci-entious instruction of patients, state-of-the-art surgical methods, andprofessional follow-up care. As a result of the large number of casestreated there over the years, the Lake Constance Clinic has an impres-sive photographic archive.

The manual has been designed as an audiovisual medium and isaccompanied by a surgical atlas. The surgical techniques are explainedconcisely, objectively, and vividly to a target audience, including physi-

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cians from all medical specialties. The aim of the authors is to improvesurgical results and prevent complications. It is intended less for spe-cialists in aesthetic surgery than for physicians who want to take upaesthetic surgery. The manual is therefore also suitable for interestedstudents, interns, and residents. The surgical methods described havebeen applied in a large number of cases (more than 1000 for eachtechnique); over the years, a sizable body of clinical and scientificdocumentation has been amassed for each method. The methods haveproven themselves from the point of view of surgical outcome, riskminimization, and long-term results.

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Contents1 Photographic Documentation in Aesthetic and Plastic Surgery 1

2 Informed Consent in Aesthetic and Plastic Surgery 7

3 Rhinoplasty 13

4 Rhytidectomy 65

5 Eyelid Surgery – Blepharoplasty 165

6 Otoplasty 227

7 Breast Surgery 263

8 Brachioplasty 349

9 Abdominoplasty 379

10 Thigh and Buttock Lift 433

11 Liposuction 475

12 Hair Transplantation 519

13 Adjuvant Therapies, Including Laser Surgery 541

14 Aesthetic Surgery: Quo Vadis? 629

15 Bibliography 631

16 Subject Index 649

17 List of Suppliers 656

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