Aesthetic Oculofacial Rejuvenation

becomes thinner and its functions as a connective
and supportive tissue are reduced.
The facial fat compartments undergo a migration
in the caudal direction, leading to fat atrophy in
the orbital, frontal, buccal, temporal and perioral
regions, while the submental, lateral malar regions
of nasolabial fold will present an excess of redun-
dant and ptotic tissue (festoons). The superficial
musculoaponeurotic system (SMAS) becomes thin-
ner and longer. The zygomatic bones have horizontal
insertions in SMAS attachments; for this reason the
superior and inferomedial aspects of face do not
suffer all the gravity action. Atrophy of the malar
and maxilla bones, reduction of mandibular angle,
and reduction of the inferior orbit and chin projec-
tions
are
also
associated
with
facial
contour
alterations.
The first step in evaluating patients who are seek-
ing facial aesthetic enhancement is to discuss what
bothers them about their appearance. Good rapport
and open and uninhibited communication between
physician and patients are essential. Patients have
their own opinions about what they like and dislike
about their appearance, so before making treatment
recommendations it is a good idea to sit down and
look in the mirror with them, and listen to their
comments
about
their
appearance.
Encourage
patients to specify which flaws or deformities they
want to correct and then conduct a physical examin-
ation to identify the source of the patient’s comp-
laint. They usually notice that their eyes are not
the same1 and they notice bags, wrinkles, skin laxity
and eyebrow changes but they do not see behind
the symptoms the cardinal signs of the aging pro-
cess: volume displacement, loss of skin elasticity
and muscle hyperactivity. Some patients request
the surgeon to pull sinking brows and lids up and
out, unaware that this can exacerbate the effects
of volume loss, or worse leave them with an artifi-
cial tailored look. Any patient who does not have
gross dropping of the eyelids is a good candidate
for minimally invasive techniques.
Clinical evaluation begins by examining the posi-
tion and arching of the eyebrows, the muscle activ-
ity of the forehead, the heaviness of the upper
eyelids and the upper eyelid skin texture, checking
for drooping of the upper eyelid muscles and nar-
rowing of the palpebral apertures (ptosis), excessive
skin and prolapsing fat or prominent lacrimal glands.
The lower lids should be examined for position of
the lower lid margin-lower lid retraction or inferior
scleral show. They should also be checked for skin
texture as well as changes in pigmentation and
vascular pooling, creating dark circles, prolapsing
fat, creating shadows and contour irregularities, and
laxity of the lateral canthal tendons and lower eyelid
margin. The presence of extra folds of skin, muscle
or fat on the cheek is known as a ‘bag on a bag’
(a malar festoon).
Aging changes of the mid-face are manifest by
skin laxity, loss of bony contours, less prominent
cheek bones, soft tissue loss and deepening of naso-
labial folds.2 The lower face shows the presence of
more prominent jowls, deepening ‘marionette lines’
(melo-mental folds), submental skin redundancy
and fatty deposition, creating a double chin. The
lips lose volume and disappear, and the corners of
the mouth may droop (Figs 1.1 and 1.2, Table 1.1).
Once the source of the patient’s complaints has
been identified, the patient and physician must
decide what procedures are most appropriate for
the patient and what alterations are most compati-
ble with his or her face. They must agree on how
much downtime is acceptable and balance that with
how much improvement they will be satisfied with.
The objective is to achieve a natural look. Reviewing
old photographs can be helpful in tailoring the pro-
cedure to individual patients.
Patients should be informed of the available non-
surgical options for correcting or improving their
appearance, and presented with the pros and cons
of each approach. It is important that patients have
realistic expectations about the limitations of the
recommended procedures and what the outcomes
can be. They need to be made aware of the varia-
bility in healing and the important differences in
the tone and texture of each person’s skin. Patients
30 years
70 years
Fig. 1.1 Facial contour changes with age.
2
Aesthetic Oculofacial Rejuvenation

also need to understand that, although cosmetic
enhancement can make them look better and feel
better about themselves, it is unrealistic to expect
their lives to change dramatically.3,4
OVERVIEW OF NON-INVASIVE THERAPIES
As mentioned previously, the available non-surgical
aesthetic enhancement procedures are not stand-
alone therapies. The sum of their effects yields a
result that exceeds their individual effects. Currently
available therapies include intense pulsed light (and
enhanced effect with amino-levulinic acid and photo-
dynamic therapy), botulinum toxins, injectable soft
tissue fillers, chemical peeling agents, volumetric
radio frequency tissue heating instrumentation, and
non-ablative and fractionated lasers.
Intense pulsed light, first introduced in the mid-
1990s, is a well-recognized treatment modality for
improving the appearance of the photoaged face.
Photoaging refers to the clinical changes to facial
and other sun-exposed skin caused by chronic expo-
sure to ultraviolet light, including the appearance of
telangectasias (red lesions in the skin caused by per-
manent dilation of preexisting small blood vessels),
rough texture, fine and coarse wrinkles, yellow and
mottled pigmentation, brown age spots or ‘liver
spots’.1
Injections of botulinum toxin type A are the most
commonly used cosmetic enhancement procedures
in the USA, and are used to relax facial muscles
and diminish their secondary wrinkle-producing
effects. Understanding the anatomy and balance of
facial muscles will allow botulinum toxin, in addi-
tion to relaxing the dynamic rhytides, to be used
to achieve facial symmetry by elevating brows, com-
pensating for blepharoptosis and subtly adjusting a
downturned mouth. It works by binding to the
nerve endplate and blocking the release of acetyl-
choline. The bond is permanent until the nerve
develops a new endplate that begins releasing
acetylcholine again.2–5
Injectable fillers and volumizers are used to add
volume to the facial structure, filling in wrinkles
and
furrows,
replacing
lost
facial
volume
and
accentuating bony contours. Purified bovine colle-
gen and autogenous fat are two FDA-approved
fillers that have been successfully used in the USA
for more than 20 years. The ease of use and the lack
of adverse reactions and longer-lasting effect have
made hyaluronic acids the most widely used fillers.
They are available in an increasingly wide variety of
viscosities and differing characteristics.3,4
Chemical
peels
are
an
effective
therapeutic
option for reversing photoaging. They are recom-
mended for treating a variety of superficial condi-
tions
involving
the
epidermis
and
superficial
dermis, including mild sun damage, superficial
30 years
60 years
40 years
70 years
50 years
80 years
Fig. 1.2 Aging facial changes by decades of life.
Table 1.1
Histologic changes of human skin
due to intrinsic aging
Epidermal
Dermal
Cutaneous
adnexa
Flattening of the
dermo-epidermal
junction
Atrophy (loss
of dermal
volume)
Greying of hair
Reduction of
thickness
Few
fibroblasts
Hair loss
Different cellular
sizes and shapes
Fewer mast
cells
Change of
terminal and
vellus hair
Occasional
nuclear atypia
Reduced
vascularity
Abnormal nail
plate
Reduction of
melanocytes
Shorter
capillaries
Fewer glands
Fewer Langerhans
cells
Abnormal
nerve
endings
3
Overview of the Aesthetic Approach

wrinkling and pigmentary disorders, actinic kera-
toses (growths caused by excessive exposure to
the sun) and active acne. They are available in a
wide variety of strengths. Some strengths can be
used without any downtime. More potent varieties
require several days of healing.
Radiofrequency volumetric heating technology, or
thermage, uses high-frequency electrical current to
heat the deeper layers of the skin while cooling
the surface; this minimizes downtime and enhances
the effectiveness of the treatment. It is primarily a
lifting, tightening and contouring procedure.
Infrared volumetric heating technology (i.e. Titan
lasers and ALMA Lasers™) uses infrared properties
to heat the deep dermis and promote a lifting
effect.
Laser resurfacing is performed using a beam of
laser energy. Three types of lasers – ablative, non-
ablative and fractionated – are used for skin resurfa-
cing. Ablative lasers stimulate collagen regeneration
by removing the epidermis and heating the papillary
dermis. Non-ablative lasers are less intense and
require little or no healing time. They work by
treating the papillary dermis, causing the skin to
respond by regenerating as if repairing a wound.
Lasers that use chromophores (tissues that have a
color that attracts laser light of a specific wave-
length) are used for treating telangiectasias, heman-
giomas, vascular lesions, hair removal and abnormal
skin pigmentation. Fractionated lasers, which are
adaptations of ablative lasers, are designed to
improve skin texture with a minimum of downtime
and without anesthesia. They have the unique abi-
lity to create microthermal zones of tissue treatment
between untouched areas of skin. They are used to
improve skin texture, erase unwanted brown spots
and improve wrinkles around the eyes and mouth.6
Mesotherapy and carbon dioxide insufflation are
helpful tools for minimally invasive face and body
rejuvenation.
CONCLUSION
This textbook will summarize and address what is
available in the technologies of minimally invasive facial
and oculoplastic rejuvenation and how these tech-
nologies have enriched and revolutionized the field of
plastic surgery.
REFERENCES
1
Perkins SW, Batniji RK. Rejuventaion of the lower eyelid com-
plex. Facial Plast Surg. 2005;21(4):279–285.
2
Mandelson BC, Hartley W, Scott M, McNab A, Granzow JW.
Age related changes of the orbit and mid cheek and the implica-
tions for facial rejuvenation. Aesthetic Plast Surg. 2007;31(5):
419–423.
3
Glavas IP, Purewall BK. Non invasive techniques in periorbital
rejuvenation. Facial Plast Surg. 2007;23(3):162–167.
4
Finn JC, Cox S. Fillers in periorbital complex. Facial Plast Surg
Clin North Am. 2007;15(1):123–132, VII.
5
Lee CJ, Kim SG, Han JY. The results of periorbital rejuvenation
with botulinum toxin A using two different protocols. Aesthetic
Plast Surg. 2006;30(1):65–70.
6
Shook BA, Heuza GJ. Periorbital ablative and non ablative
resurfacing.
Facial
Plast
Surg
Clin
North
Am.
2005;13
(4):571–582, VII.
Economic impact of non-invasive technologies in
plastic surgery
Lydia Masako Ferreira, Marcel Vinicius de Aguiar Menezes
INTRODUCTION
Less or non-invasive technologies have been progres-
sively used and sought after in medical and surgical
procedures.1 Over the years they have gained popu-
larity in the surgical world, probably for being less
harmful to the organism or because of the technical
ease of their application.2 New technology develop-
ments in plastic surgery have followed this tendency,
which aims to shorten surgical time and downtime
as much as possible by employing procedures that
produce equivalent results to invasive procedures.
In some cases, they may even delay invasive plastic
surgeries.3
4
Aesthetic Oculofacial Rejuvenation

To develop minimally invasive surgical proce-
dures, several
improved
techniques
have
been
incorporated into plastic surgery, such as pharma-
cology, cosmetology and diversified technologies,
for example fillers and volumizers, botulinum tox-
ins, lasers and radiofrequency tightening devices.3
Video-endoscopy was introduced to plastic surgery
in 1991 and quickly became popular as a less inva-
sive choice.4
Products and technologies in the plastic surgery
field associated with media influence or that are
perceived
as
being
straightforward
have
been
responsible for the explosion in aesthetic proce-
dures when compared to traditional plastic surgery
procedures.5,6 This growth is evident in the number
of aesthetic procedures taking place annually in the
USA:5–7 11.7 million in 20076 against 11.5 million
in 2006.7
The most commonly used non-invasive tech-
niques are currently botulinum toxin injections,
hyaluronic acid fillers, laser hair removal, facial
resurfacing and microdermabrasion.6,7
IMPACT OF MINIMALLY INVASIVE
PROCEDURES
According to the American Society of Aesthetic
Plastic Surgery (ASAPS), the four most common
cosmetic surgeries performed are liposuction, breast
augmentation, blepharoplasty and breast reduc-
tion.6,7 Liposuction is by far the most popular of
these, totaling 456 828 procedures in 2007, com-
pared with 176 863 in 1996.6,7
The popularity of plastic surgery and aesthetic
non-invasive procedures is rapidly increasing and
these aesthetic non-invasive procedures are gaining
acceptance, as indicated by comparing the number
of procedures performed in 1997 (1 126 177) with
that in 2006 (9 533 980) (Table 1.2).7 Botulinum
toxin injection was the non-invasive procedure
performed most often in 2007, with a total of
2 775 176 applications.7
NON-INVASIVE TECHNOLOGIES
IN PLASTIC SURGERY
Economic Impact
The intense growth in the use of new non-invasive
procedures has generated questions about their eco-
nomic impact, and if they delay, or even avoid, more
extensive surgical procedures.3,5,8 In North America,
US$13 billion was spent in aesthetic procedures
in 2007, of which US$8.3 billion was on surgical
procedures and US$4.7 billion was on non-surgical
ones.6
The use of botulinum toxin and facial fillers has
indirectly reduced the rate of growth in facial sur-
geries.9,10 Statistical data show a significant rise in
the number of treatments with botulinum toxin in
women when comparing data collected between
1997 and 2006, while procedures such as rhytido-
plasty and blepharoplasty, while still growing in
popularity, did so at a much slower pace in the
same period for the same group (40 and 30%,
respectively).7 However, it is well known that botu-
linum toxin and facial fillers, although efficient and
practical, are of a transient nature. For example, the
effect of botulinum toxin application is good for
6 months on average and then the procedure has
to be repeated. This option has an average cost of
US$500 per treatment (labor only, excluding the
cost of material) while a procedure like blepharo-
plasty
costs
only
US$2882.
Another
example
illustrating this discrepancy is lip augmentation
surgery, which has long-lasting results with a cost
around US$1726. Using filling substances such as
hyaluronic acid costs an average of US$512 per
treatment, but the temporary results last only 6 to
8 months.
Table 1.2
Procedures most frequently
performed in 2007
Procedure
Number performed
Surgical
Liposuction
456 828
Breast augmentation
399 440
Blepharoplasty
240 763
Abdominoplasty
185 335
Breast reduction
53 087
Non-surgical
Botulinum toxin
2 775 176
Hyaluronic acid injection
1 448 716
Laser hair removal
1 412 657
Microdermabrasion
829 658
Laser resurfacing
647 707
5
Overview of the Aesthetic Approach

As previously stated, the large number of non-
invasive procedures performed, because they are
simpler in nature and application, is delaying classi-
cal and invasive surgery (Table 1.3).11
The growth in the use of non-invasive technolo-
gies has attracted professionals from other medical
specialities, and they are now increasingly using
these procedures.12,13 In North America dermatolo-
gists (48%), plastic surgeons (38%), general surgery
professionals (>4%), otorhinolaryngologists (>3%),
ophthalmologists (>3%), family doctors (<1%),
pediatricians (<1%) and general clinicians (<1%)
are involved in these treatments.12 The profes-
sionals in these specialities are attracted by the
immediate results and the high financial returns
provided by less invasive technologies.12 However,
as a result unsatisfactory results are increasingly
being observed, which are related to technically
and scientifically unqualified medical or, even worse,
non-medical professionals.14
Botulinum Toxin
The application of botulinum toxin is the minimally
invasive procedure performed most often in the
USA.6,7,13 During 2007, it comprised 23.7% of all
cosmetic non-invasive procedures in that country.6
Botulinum toxin blocks the transmission of ner-
vous stimuli through muscle synapses, resulting in
a temporary, but reversible, paralysis.14 Clinically,
its effects last from 3 to 6 months and its use has
been expanded to various medical specialities, for
example the treatment of achalasia,14,15 blepharo-
spasm,
hyperidrosis,
spasmodic
dysphonia
and,
commonly, in the context of plastic surgery as an
aesthetic procedure.13,14,16
The rate of success in botulinum toxin therapy is
heavily dependent on a knowledge of anatomy, which
also minimizes the incidence of complications and
adverse side effects.14 Knowledge of the functional
facial musculature may make the difference between
two professional treatments when the toxin applica-
tion is performed by a skilled medical professional
or a just a technician or even by a medical professional
who is not skilled in cosmetics and facial balance.14
Botulinum toxin applications on the face are most
frequently done in the glabella, frontal and orbital
regions in the neck, nasolabial groove, peri-oral lines
and mentum.9,10,14 Facial rejuvenation using the
toxin requires new applications in programmed peri-
ods because of its temporary effects,10,13,14 therefore
to the initial cost of treatment the patient must add
the cost of future applications in order to ensure
durable results and prolonged effects.5,6,9,10,13,14
Economic Impact
As already stated, botulinum toxin has become very
popular, and in 2007 a total of 2 775 176 proce-
dures were performed in the USA, representing
23% of all non-invasive procedures and costing a
total of US$1 054 566 736.6
Lasers
Laser beams have several applications in plastic sur-
gery, for example hair removal, facial resurfacing, as
an adjuvant in post-surgery periods and in the
Table 1.3
Number of surgical and non-surgical procedures performed: 10-year comparison,
1997–2008
Number performed
Procedure
1997
2008
Liposuction (lipoplasty)
176 863
403 684
Breast augmentation
101 176
383 836
Eyelid surgery (blepharoplasty)
159 232
209 999
Botox
65 157
3 181 592
Chemical peel
481 227
338 432
Laser skin resurfacing
154 153
576 309
6
Aesthetic Oculofacial Rejuvenation

correction of unaesthetic scars.6,17 Laser technology
for facial resurfacing has been a valuable addition
to the techniques of therapeutic plastic surgery.
Its accuracy and broad spectrum allow different
depths of penetration to be achieved and it can be
tailored to treat a variety of skin types for the
removal of devitalized and aged tissue. A more nat-
ural tissue renewal is then possible with collagen
remodelling.18,19
Before the 1990s, lasers had only one wavelength
per machine, were highly selective for treatment
performance and besides being expensive were also
big, which made their indication, purchase, accom-
modation and maintenance difficult. They have
evolved into compact pieces of equipment and
intense pulsed light has extended the use of the
technology and reduced the cost. In addition, the
advent of multiple platforms or stations as bases
holding several types of lasers has made this tech-
nique more popular, widespread and accessible.
Economic Impact
The number of laser-based procedures in plastic
surgery has been increasing in recent years. In
1997 in the USA there were 154 000 applications
for facial resurfacing, while in 2007 this number
was up to 509 591, which is an increase of 230.8%
and is greater than the total number of liposuctions
performed in 2007. The revenue generated from
the use of lasers in facial resurfacing in 2006 was
over US$600 000, which, if added to the use of
laser for hair removal, reaches US$1 100 000.
Hyaluronic Acid
Hyaluronic acid is a polymer with viscous-elastic
properties that is safely used for facial fillings.20
Because of its characteristics, its popularity has
increased in recent years.6 It is a good option for
skin rejuvenation since it has low tissue reactivity
and shows longer-lasting results than injections of
at or collagen.21 However, like other non-invasive
procedures,
several
studies
have
shown
that
it
has limited duration and has to be reapplied every
3
to
6
months.
Although
in
some
cases
the
results may last for 12 months, there is still a cumula-
tive cost to users.20–22 The products available in
the market may have various origins, such as animal,
avian or bacterial fermentation. Each product has
properties that should be known by the professional
using it.22
Economic Impact
In 2007 1 448 715 applications of hyaluronic acid
were performed in the USA at a global cost of
US$834 460 585.6 The average application cost
was US$532 in 2006 and US$576 in 2007. Patients
using hyaluronic acid will need more applications
in the future, leading to a cumulative cost of
US$2500 dollars in 10 years if applications are
made every 2 years. If used for lip augmentation,
hyaluronic acid therapy is more expensive than con-
ventional surgery (around US$1776) over 10 years,
as the results of conventional surgery last much
longer.6,21
Microdermabrasion
This is a common procedure in plastic surgery,
consisting of a superficial skin abrasion to regain cuta-
neous youthfulness.23 It may be used for hyperchro-
mia clearing, facial scars and in facial rejuvenation in
cases of photo-induced injuries.23
The rejuvenation effect of cutaneous dermoabra-
sion is based on collagen remodeling, which decreases
small facial wrinkles.23
Economic Impact
A total of 829 638 microdermabrasion were per-
formed in the USA in 2007 at a total cost of US
$10 785 294. The average cost is US$130 per treat-
ment, making it the least expensive non-invasive
procedure.
CONCLUSION
It is obvious that the use of non-invasive technology
in plastic surgery is growing at an intensive rate.
Its popular appeal is notorious and the literature
documents its results very well. The economic
impact of these procedures may be high because in
many cases the applications must be periodically
renewed to obtain results comparable to those for
longer-lasting conventional surgery. Thus, in abso-
lute values, economic investment in this market is
favorable to non-invasive technologies when com-
pared to conventional surgeries.
It is highly possible that lower immediate costs
and rapid results attract more and more patients
to non-invasive procedures, although the relatively
short result durations do not mean less cost to the
patient if the treatment is evaluated as a long-term
7
Overview of the Aesthetic Approach

investment. Finally, we would like to clarify that
these procedures are not substitutes for but may
delay and supplement conventional plastic surgery,
addressing
problems
that
conventional
invasive
techniques cannot.
REFERENCES
1 Wollina U, Goldman A, Berger U, Abdel-Naser MB. Esthetic and
cosmetic dermatology. Dermatol Ther. 2008;21(2):118–130.
2 Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM.
Percutaneous collagen induction therapy: an alternative treatment
for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008;
121:1421.
3 Grunwald T, Krummel T, Sherman R. Advanced technologies in
plastic surgery: how new innovations can improve our training
and practice. Plast Reconstr Surg. 2004;114:1556.
4 Vasconez LO, Monteroz AE. Histo´ria da cirurgia videoendos-
co´pica corporal. In: Videoendoscopia no Contorno Corporal e Proce-
dimentos Complementares. Rio de Janeiro: Edit Revinter; 2007:
P03, 5.
5 McCollough EG. Minimally invasive – minimally effective. Arch
Facial Plast Surg. 2007;9(4).
6 American Society for Aesthetic Plastic Surgery. Cosmetic Surgery
National Data Bank Statistics. extraı´do do site,
org; 2007. no dia 15/05/08.
7 American Society for Aesthetic Plastic Surgery. Cosmetic Surgery
National Data Bank Statistics. extraı´do do site,
org; 2006. no dia 28/02/08.
8 Lasalvia CG, Pereira LDES, Da Cunha MC, Kitadai SP. Costs and
efficacy of type A botulinum toxin for the treatment of essential
blepharospasm
and
hemifacial
spasm.
Arq
Bras
Oftalmol.
2006;69(5):701–705.
9 De Maio M. The minimal approach: an innovation in facial cos-
metic procedures. Aesth Plast Surg. 2004;28:295–300.
10 Ferreira LM, Ferreira LF, Blanes L. Toxina botulı´nica. In: Cirur-
gia Pla´stica: Guias de medicina ambulatorial e Hospitalar UNI-
FESP- Escola Paulista de Medicina. Sa˜o Paulo: Edit Manole;
2007:817, 822.
11 Alsarraf R, Alsarraf NW, Larrabee WF, Johnson Jr CM. Cosmetic
surgery procedures as luxury goods: measuring price and demand
in facial plastic surgery. Arch Facial Plast Surg. 2002;4:105–110.
12 Housman TS, Hancox JG, Mir MR. What specialties perform the
most common outpatient cosmetic procedures in the United
States?
Dermatol
Surg.
2008;34(1):1–8
doi:10.1111/j.1524-
4725.2007.34000.
13 Lee H, Saladi RN, Fox JL. Cohort study on patient response to
botulinum toxin cosmetic therapy. J Cosmet Dermatol. 2008;
7(1):39–42.
14 Kane MAC. Botulinum toxin. In: Grabb and Smith’s Plastic Sur-
gery. 6th ed. 2007:475.
15 Lake JM, Wong RK. Review article: the management of achalasia:
a comparison of different treatment modalities. Aliment Pharma-
col Ther. 2006;24(6):909–918.
16 Glaser DA, Hebert AA, Pariser DM, Solish N. Facial hyperhidro-
sis: best practice recommendations and special considerations.
Cutis. 2007;79(suppl 5):29–32.
17 Cavaliere CM. Lasers em cirurgia pla´stica. In: Livros Di, ed. Man-
ual de Cirurgia Pla´stica de Mishigan. vol. 10: Rio de Janeiro: Di
Livros; 2006:55.
18 Ferreira LM, Horibe EK, Haddad A, Zanata F. Cosmiatria. In:
Cirurgia Pla´stica: Guias de medicina ambulatorial e Hospitalar
UNIFESP – Escola Paulista de Medicina. Sa˜o Paulo: Edit Manole;
2007:783, 815.
19 Ruiz-Esparza J, Gomez JB. The medical face lift: a noninvasive,
nonsurgical approach to tissue tightening in facial skin using non-
ablative radiofrequency. Dermatol Surg. 2003;29(4)C¸:335.
20 Rohrich RJ, Ghavami A, Crosby MA. The role of hyaluronic acid
fillers (restylane) in facial cosmetic surgery: review and technical
considerations. Plast Reconstr Surg. 2007;120(suppl):41S.
21 Barbosa MVJ, Nahas FX, Ferreira LM. Cirurgia Pla´stica: Bioma-
teriais injeta´veis. In: Guias de medicina ambulatorial e Hospitalar
UNIFESP – Escola Paulista de Medicina. Sa˜o Paulo: Edit Manole;
2007:823–830.
22 Kurtz ES, Spencer JM. Approaches to document the efficacy and
safety of microdermabrasion procedure. Dermatol Surg. 2006;
32:1353–1357.
23 Karimipour DJ, Kangs Johnson TM, Orringer JS, Hamilton T,
Hammerbergc G, Fisher G. Microdermabrasion with and without
aluminum oxide crystal abrasion: A comparative molecularanalysis
of dermal remodeling. J Am Acad Dermatol. 2005;52:215–223.
8
Aesthetic Oculofacial Rejuvenation

Combining Non-Invasive Therapies
A step by step guide
Marian Cantisano-Zilkha, Alessandra Haddad
INTRODUCTION
A better comprehension of the facial aging process
and the introduction of safer, longer-lasting mate-
rials for restoring volume to facial structures has
given a new dimension to non-invasive facial rejuve-
nation. Since the introduction of injectable bovine
collagen for improving or eliminating facial wrinkles,
many new agents with safer and more effective
properties have been introduced. These newer
injectable fillers, when used in combination with
other minimally invasive therapies for the skin –
such as microdermabrasion, chemical peels, botul-
inum toxin and radiofrequency-based and light-
based treatments – have increased and prolonged
the degree of aesthetic results and the level of satis-
faction for patients and physicians. The appropriate
procedures, when skillfully performed, can dramat-
ically improve the patient’s appearance with little or
no downtime. Before considering the many options,
the physician has to be highly qualified and knowl-
edgeable about how to combine the different
resources to optimize the final result.
A multidimensional approach, using a combina-
tion of modalities, can improve facial skin texture,
pigmentation, tone, rhytidosis and facial contour.
It is important to understand that alterations can
be assessed in three levels: superficial, medium
and deep. Concerns at the deep level involve
muscular laxity or hyperactivity, fat migration, bone
reabsorption and deep dermal laxity. In general,
these alterations are considered a manifestation of
intrinsic aging because they are more related to
genetic inheritance than external ambiental factors.
Problems at the medium level include deterioration
of the integument marked by dermal atrophy, loss
of turgor and thickness, which is externally mani-
fested by wrinkles. Epidermal changes at the super-
ficial level include textural and vascular alterations,
mottled pigmentation and fine wrinkles. These
changes are usually related to photodamage or
ambiental influence into the skin (extrinsic aging).1
Non-invasive rejuvenation requires a three-dimen-
sional approach, always starting from the deeper
level to the superficial one.
The main purpose of this chapter is to suggest a
step-by-step guide to standardize the diagnostics
for individualizing patient needs and to propose a
logical sequence of procedures.
DEEP LEVEL
The options for facial rejuvenation at the deep level
include:
I. volume replacement
II. skin tightening
III. muscle relaxation (facial balance)
IV. surgery
2

I Volume Replacement
Although we will describe fillers for deep level vol-
umetric correction, changing the presentation of the
product and the level of application allows its use
for the intermediate level of correction.
Filling in the convex and concave areas of the
face, which reflect light and shadows, can lead to a
notable rejuvenating effect. The volume replace-
ment is usually performed with fillers, implants or
autologus fat. Prior to the advent of modern soft
tissue fillers, the anatomical changes of the aging
face were primarily surgically addressed (rhytidec-
tomy, brow lift and mid-facelift) or by using ablative
(carbon dioxide, CO2) lasers or peelings (fenol).
Although these more invasive techniques are asso-
ciated with an increased morbidity (infection, bleed-
ing and increased downtime), they are still valuable
tools in the cosmetic surgeon’s armamentarium
for advanced facial antiaging. Combination therapies
using soft tissue fillers, chemo-denervation, non-
ablative laser and light sources provide a more
appealing option to patients and surgeons, and
can address many of the mild to moderate signs of
aging.2
There are many classifications of fillers, but they
can be categorized based on their source as follows:
v autogenic: fat (see Chapter 10), autologous
plasma (see Chapter 13), autologous collagen
(see Chapter 9)
v allogenic: cadaveric collagen, human fibroblast
cell culture
v xenogenic: collagen, mostly from bovine or
porcine sources, and hyaluronic acid products
from rooster combs or bacterial fermentation
v synthetic: silicone products,
polymethylmethacrylate (PMMA),
hydroxylapatite, poly-L-lactic acid,
polyacrylamide.
They can also be classified according to their
durability after being injected in biodegradables
and non-biodegradables (see Chapter 9). Some
authors classify them according to their fibroblastic
properties (poly-L-lactic acid, hydroxylapatite and,
in a lower scale, hyaluronic acid fillers)3 if they are
just passive fillers (collagen) or if they are perma-
nent (silicone, PMMA). Pathologists do not always
agree with this classification because it is their
belief that every time a foreign body is introduced
into the dermis it causes some degree of inflamma-
tory reaction. That reaction can be mild or almost
imperceptible (e.g. collagen) or moderate, with con-
sequent fibroblastic activity associated (e.g. poly-L-
lactic acid, hydroxylapatite or hyaluronic acid)3 or
severe inflammatory response, generally related to
clinical problems such as foreign body granuloma-
tous reaction or even true troublesome tuberculoid
granulomas.
II Skin Tightening
The development of CO2 lasers demonstrated that
heat can promote long-term collagen remodeling.4,5
Because of the long healing time and since patient
selection is limited to fair skin types, the technology
had to develop in another direction. The advent of
radiofrequency (RF) technology opened up a new
path for skin tightening without epidermal damage.
Radiofrequency energy is different from optical
energy because it depends on the electrical properties
of the skin, rather than on the levels of pigmentation,
for the selective thermal destruction of targeted areas,
which is known as electro-thermolysis. In 2004 the
FDA approved RF dermal heating with simultaneous
epidermal cooling as a tool to stimulate new collagen
formation and, consequently, improve skin laxity.
Thermage® (Thermage Inc., CA) was the first RF
device launched, and today many devices promise to
tighten the skin in a non-ablative way.6
Systems using RF current alone, have achieved
good results for skin tightening, with comparable
efficacy to laser resurfacing and potentially more
rapid healing. However, because of the high depth
of penetration, the procedure can be more painful.
A technology that integrates RF energy with optical
energy – using a lower intensity of both – has also
shown efficacy in hair removal and wrinkle reduc-
tion for all hair colors and skin types. In addition,
these dual systems may reduce the risk of the side
effects associated with either RF or optical treat-
ments alone.7
RF technology, using high frequency current in
the range of 0.3 to 10 megahertz (MHz), produces
a pure thermal effect on biological tissue that has
made it useful for both electrosurgery and various
dermatologic applications. Electrical conductivity
relies on the frequency of electrical current, and
the type and temperature of tissue. The distribution
of electrical current depends on how the electrodes
are configured. Typical configurations used in med-
icine are unipolar and bipolar. Although they differ
in the way the RF current is controlled and directed
at the target tissue, there is no difference in the
final tissue effect at the same RF frequency.8
One of the problems with RF technology is that
some of the devices do not produce enough heat
10
Aesthetic Oculofacial Rejuvenation

to cause collagen remodeling. Achieving a true skin-
tightening effect in the dermal level (1 to 3 mm
under the surface) requires a sustained volumetric
dermal heating in one area, for a prescribed amount
of time,9 without exposing fat, cartilage and nerves
to residual heat. Inappropriate use of RF can para-
doxically reduce fat in that area.
Another FDA-approved RF device for treating
wrinkles and rhytids is the Accent XL® (Alma
Lasers, Caesarea, Israel). It combines two RF modes
in a single device. Each proprietary mode – bipolar
and unipolar – is delivered by a discrete handpiece
to distribute therapeutic heat at different tissue
depths within the body. The bipolar handpiece
creates local, superficial dermal heating on delicate
areas, such as the face. The unipolar and larger
handpieces provide deep dermal and subdermal
heating of larger areas.
The latest application, currently in the final 544
Investigational Protocol FDA process, is able to pen-
etrate to a depth of 100 mm. This device, the Lipo-
tron® (RevecoMED International, Anaheim, CA),
unlike its predecessors, will be used not only for
wrinkle reduction, rejuvenation of the face and cel-
lulite smoothing, but also for body contouring. The
most significant feature of the Lipotron®, with its
depth of heat penetration, is that it affects the vis-
ceral fat as well as the subcutaneous fat. It operates
at 0.5 MHz and feels like a warm massage to the
patient.
Other
modalities,
such
as
infrared
devices
(Titan®, Cutera Inc., CA) and ST Near Infrared
handpiece (Alma Laser, Caesarea, Israel) are being
used worldwide with a high level of patient satisfac-
tion and few reports of collateral effects. Good can-
didates for these procedures are patients with light
to moderate laxity, hidden mandibular arch, sub-
mental laxity, prominent nasolabial fold due to skin
laxity and suborbicularis oculi fat (SOOF) pad
descend (more than due to dermal atrophy), ptosis
of eyebrow secondary to skin laxity of the upper
third of the face, and thin skin, with little or no sub-
cutaneous fat deposit, below the targeted area.
When using skin-tightening devices, perhaps the
most critical point is making sure that the patient
has realistic expectations of the limited potential
of these non-invasive techniques. They should
understand that they will not achieve the same
results as with plastic surgery but they will have less
risk, no scars or recovery time, and no interruption
of their social or work activities. The key is to iden-
tify the critical areas that will elicit a pull or a lifting
effect, distally to the vector force of the areas, and
treat them in the same direction as in a facelift.
Some practitioners even re-treat the area with mul-
tiple passes over the ‘anchoring points’ along the
frontal hairline, zygomatic bone and pre auricular
sulcus areas or any area where the skin is barely
movable over the deep structures.
III Muscle Relaxation and Facial Balance
Botulinum toxin injection is the most widely per-
formed non-invasive procedure. It is the ‘gold stan-
dard’ treatment, especially for the upper third of
the face. Botulinum toxin type A is a protein com-
plex that is produced by the bacterium Clostridium
botulinum,
a
powerful
neurotoxin
that
causes
muscle paralysis. In a medical setting, small doses
of an injectable form of sterile, purified botulinum
toxin are used to block the release of acetylcholine,
which signals muscle contractions in the face. By
selectively blocking the muscles’ ability to contract,
botulinum toxin can soften the vertical frown lines
between the eyebrows (glabellar lines) that tend to
make individuals look tired, angry or old.10
In 1989, the FDA approved botulinum toxin
type A (Botox®) to treat two eye muscle disorders:
blepharospasm (uncontrollable blinking) and strabis-
mus (misaligned eyes). The toxin was subsequently
approved to treat certain types of dystonia, a neuro-
logical disorder that causes severe contractions of
the muscles, and hyperhidrosis, severe sweating
of the armpits. During the course of these treat-
ments, physicians noticed that Botox® softened
the glabellar lines. In April 2002, after placebo-
controlled, multicenter, randomized clinical studies
demonstrated
that
botulinum
toxin
markedly
improved these frown lines, the FDA approved
Botox® for cosmetic use to temporarily improve the
appearance of moderate to severe glabellar lines.
The cosmetic uses of the botulinum toxin are
thoroughly discussed in Chapter 8.
Botox® in Combination Therapy
There are a number of areas where combining
botulinum toxin with other modalities produces
improved and longer-lasting results. In patients with
deep glabellar frown lines that persist even at rest,
using an injectable soft tissue filler gives an imme-
diate improvement that is accentuated after the
botulinum
toxin
effect
is
apparent,
and
this
improvement lasts longer than when either modal-
ity is used alone.11,12 Although injectable fillers
11
Combining Non-Invasive Therapies

can improve marionette lines and oral commissures,
the patient and physician often view the improve-
ment as unsatisfactory. The outcome can be greatly
improved by injecting the depressor anguli oris mus-
cle with botulinum toxin to raise the corners of the
mouth and reduce the muscular ridge descending
from the corner of the mouth.13
Botulinum injections are also used as pretreat-
ment for intense pulsed light (IPL), non-ablative
laser and photomodulation therapies. Using IPL
not only improves skin texture, but also makes the
effect of botulinum toxin treatment more striking.
In addition, botulinum toxin seems to enhance the
skin texture improvement achieved with non-abla-
tive lasers and may also augment the effects of
non-thermal, non-ablative photomodulation using
light-emitting diodes.
Botulinum toxin injection is a standard pretreat-
ment procedure for laser resurfacing and its effect
is crucial during the period of collagen remodel-
ing.14 Ideally, patients are treated 2 weeks prior to
the laser resurfacing procedure. This allows suffi-
cient time for additional touch-up injections when
needed.
Botulinum
toxin
pretreatment
also
improves the effect of facial RF technology.15
Botulinum toxin injection is a non-invasive ther-
apy that has dramatically and safely changed the
process of facial rejuvenation. Table 2.1 summarizes
the benefits of combining several aesthetic enhance-
ment treatments.16
IV The Surgical Approach
Although it is not the intention of this book to dis-
cuss surgical alternatives, the surgical approach has
also changed dramatically because of the evolution
and awareness of the physiology of the skin and
the aging process. For many years, the classic surgi-
cal facelift with large incisions – eye, neck and brow
lifts, bi-coronal pre- and retroauricular incisions –
has been the only option for treating wrinkles asso-
ciated with the skin’s loss of elasticity. Society’s
growing interest in maintaining a youthful appear-
ance has resulted in a greater awareness of the
physiology of the skin and how to treat it in a more
efficient way. Consequently, the incision size has
decreased, sutures can be more effectively placed
and the endoscopic approach is a reality. For peri-
ocular
rejuvenation,
the
gold
standard
surgical
approach is the transcutaneous approach to the
Table 2.1
Benefits of specific combination therapies
Combination therapy
Benefits
Botulinum toxin and fillers
Combines the treatment of dynamic and static wrinkles for a
more complete and long-lasting effect than either treatment by
itself
Botulinum toxin and IPL
Improves the surface of the skin while addressing the dynamic
cause of many facial wrinkles and enhancing the effects of IPL
treatment
IPL and microdermabrasion
Work together to superficially resurface and tone the outer
layers of skin with minimal downtime and risk. If the skin is not
too sensitive, using microdermabrasion the day after a
superficial IPL treatment speeds up the clearing of mottled
pigmentation
Microdermabrasion and peels
Both therapies address the outer layers of skin, using different
techniques – chemical and mechanical – to improve the skin’s
appearance. Performing microdermabrasion first enhances the
depth of the peel but does not address wrinkles caused by
volume loss or facial expression
Skincare, microdermabrasion, chemical peels,
botulinum toxin, injectable soft fillers, IPL, CO2 laser
A good skincare regimen at home is essential for maximizing
the effects of aesthetic enhancement procedures. The better
the condition of the skin, the greater the effect of other non-
invasive therapies
Fillers and IPL
Fillers restore volume to the face, and IPL tones and refines the
texture of the outer layers of skin and improves its appearance
Cantisano-Zilkha, M. Contemporary Aesthetic Enhancement. Handbooks in Health Care Company, 2008.
12
Aesthetic Oculofacial Rejuvenation

upper lids and transconjunctival for the lower lids
(CO2 laser-assisted or not) combined with resurfa-
cing techniques (ablative, fractional lasers or chemi-
cal peels). The need for plastic surgery still exists,
but non-invasive alternatives can complement sur-
gery and often allow the patient to postpone surgery
and bring longer-lasting results.
SUPERFICIAL AND MEDIUM LEVELS
The overall appearance of aging skin is primarily
related to the effects of sun exposure over time.
Signs of photoaging are becoming evident in youn-
ger people, especially those who regularly partici-
pate in outdoor activities that expose them to
increasingly high levels of UV radiation. When epi-
dermal damage, or photodamage, is predominant,
the treatment must include cosmeceuticals, micro-
dermabrasion, IPL photorejuvenation and, in more
severe cases where precancerous lesions such as
actinic keratosis are present, the use of photody-
namic therapy and fractionated lasers. These thera-
pies are discussed in Chapter 4.
The Glogau Wrinkle Scale (Table 2.2), developed
by Richard G. Glogau, MD, a clinical professor of
dermatology at the University of California, San
Francisco, USA, provides a method for physicians
to quickly categorize patients’ faces, based on photo-
aging, and match them to the appropriate therapy.16
The following therapies are used to treat super-
ficial
and
medium-depth,
age-related
changes.
Table 2.3 suggests therapies for photodamaged skin,
based on the Glogau photodamage scale.16
I Chemical Peels
Alpha-hydroxyl Acid Peels
Alpha-hydroxyl acid peels are useful in the manage-
ment of mild rhytidosis and dyspigmentation. They
are available in varying strengths. We usually begin
with a 50% glycolic buffered solution applied for a
maximum of 10 minutes. A 70% buffered solution
is much more potent. The strength of the peel is
increased during subsequent sessions according to
patient’s tolerance and therapeutical response.1
Trichloracetic Acid Peels
Trichloracetic acid peels are useful in the manage-
ment of mild-to-moderate rhytidosis and dyspig-
mentation. Trichloracetic acid (TCA) can be used
as a superficial (20 or 25%) or medium (30 or
35%) depth peel depending on the concentration
used and the number of layers applied.1
II Microdermabrasion
This procedure should not be confused with the
classic dermabrasion. It is a superficial technique
for
minor
skin
problems
that
is
effective
in
smoothing out mild skin blemishes, such as fine
wrinkles, age spots and light acne scars. In addi-
tion, it stimulates the body to produce new skin
cells and increased collagen, which improves the
skin’s elasticity and makes it look fresher. Because
of its simplicity, microdermabrasion has become
one of the most popular cosmetic treatments in
the USA.
Microdermabrasion gradually removes the upper
layers of skin using a tool that rapidly sprays tiny
aluminum oxide crystals at the skin’s surface,
removing one layer at a time. A vacuum device,
which is used simultaneously, takes away the sepa-
rated skin and blasting particles. To achieve the
desired effect, a series of 5 to 12 microdermabra-
sion treatments, spaced a few weeks apart, are
usually needed. Periodic treatments every few
months can maintain the appearance of the rejuve-
nated skin. Although the treatment process is long,
each treatment is fairly quick and painless, and the
recovery is undemanding. This type of treatment is
generally performed by a well-trained aesthetician,
and does not require a physician. Care should be
taken in patients with rosacea, diffuse red back-
ground pigmentation of the face or telangiectasias,
since it could worsen the condition.
III Dermabrasion and Dermaplaning
When dermabrasion was first developed more than
100 years ago, it was primarily used to improve
scars caused by acne, chicken pox, accidents or dis-
eases. Over the last few decades, this resurfacing
technique has been refined and grown in popularity.
Today, dermabrasion is most often used to treat
other skin conditions, including defects in pigmen-
tation, fine facial wrinkles, sun damage, liver spots
and certain types of skin lesions (e.g. precancerous
growths), and for tattoo removal. Dermaplaning is
most commonly used to treat deep acne scars.
Dermabrasion and dermaplaning help to renew
the skin’s top layers using different methods of con-
troled scraping. Both procedures can be performed
on the entire face or on selected small anatomic
13
Combining Non-Invasive Therapies

Table 2.2
Glogau photoaging classification
Skin type
Approximate age
Findings
I. ‘No wrinkles’ (Fig. 2.1)
20s to 30s
• Mild pigmentary changes
• No keratoses
• Minimal wrinkles
• Patient wears minimal or no make-up
II. ‘Wrinkles in motion’
(Fig. 2.2)
Late 30s or 40s
• Visible early senile lentigines
• Palpable but not visible keratoses
• Parallel smile lines beginning to appear lateral to mouth
• Patient usually wears some foundation
III. ‘Wrinkles at rest’
(Fig. 2.3)
50s or older
• Obvious dyschromia and telangiectasias
• Visible keratoses
• Wrinkles even when not moving facial muscles
• Patient always wears heavy foundation
IV. ‘Only wrinkles’ (Fig. 2.4)
60s or 70s
• Yellow-gray skin color
• Prior skin malignancies
• Wrinkled throughout; no normal skin
• Patient cannot wear make-up because it ‘cakes’ or
‘cracks’
Cantisano-Zilkha, M. Contemporary Aesthetic Enhancement. Handbooks in Health Care Company, 2008.

subunits. With dermabrasion, the outer layer of skin
is scraped away with a rough wire brush, a burr or a
fraise containing diamond particles and attached to
a motorized handle. The surgeon continues scraping
until the safest level that will make the scar or wrin-
kle less visible is reached. With dermaplaning, the
surgeon uses a hand-held instrument resembling an
electric razor (dermatome) with an oscillating blade
that moves back and forth to evenly remove the sur-
face layers of skin that surround the facial defect
until the lowest point of the scar becomes more
level with the surrounding skin. Depending on the
size of the area of skin that is to be treated, the pro-
cedure can take from a few minutes to an hour and
a half to perform. In cases where scarring is deep or
a large area of skin is involved, the procedure may
be performed in stages or more than once.
IV Intense Pulsed Light
IPL is administered by a flash lamp device emitting
light of multiple wavelengths. Cutoff filters are
used to enhance the preferential absorption by
blood vessels or pigment.17 IPL is an increasingly
popular non-ablative light modality. Unlike lasers,
it is a non-collimated, non-coherent light source
that penetrates the dermis to generate collagen
and cause skin to contract and tighten. IPL emits a
spectrum of wavelengths in the 515 to 1200 nm
range, and allows for variation of pulse length and
mode, delay between pulses and change in the
amount of power delivered. Because cutoff filters
eliminate the lower range of wavelength of light
emitted, patients with darker skin types (Fitzpa-
trick III to IV) can be safely treated. IPL has been
successfully used to treat unwanted and ingrown
hair, rosacea, telangiectasias (permanently dilated
facial blood vessels), freckles and skin darkening,
sun damage, wrinkles, scars, acne and tattoos. It is
also used in combination with photodynamic ther-
apy (PDT) as the light source to activate the photo-
sensitizing agent in the tissue to be treated.
V Photodynamic Therapy
PDT dates from 1400BC, when a variety of botani-
cals where used to improve phototherapy.17 It is
defined as the selective destruction of malignant
or fast-growing cells by light activation of a photo-
sensitizing agent, in the presence of oxygen. It treats
specific areas of the skin without damaging sur-
rounding tissue. In the early 1960s, Lipson and
Schwartz, at the Mayo Clinic, injected hematopor-
phyrins into a patient undergoing surgery and they
noted a fluorescence in the neoplastic tumor that
demonstrated the localization of photosensitizing
agent into the tumors. Although used in dermato-
logy to treat basal cell carcinoma, multiple actinic
keratoses (AKs) and sebaceous disorders, such as
acne and sebaceous hyperplasia, PDT has been
found to have a variety of cosmetic benefits and
has become one of the ideal treatment options to
treat patients with signs of chronic aging, such as
wrinkling,
irregular
thinning
of
the
epidermis,
blotchy hyperpigmentation, telangectasias and pre-
malignant AKs with little downtime.
Clinicians should be aware of the bright future of
this non-invasive modality and should be ready for
Table 2.3
Suggested combination treatments
for photoaging skin based on the Glogau scale
Goglau
wrinkle
scale
Treatments
Level I
• Light moisturizers
• Sunscreen
• Topical and internal antioxidants
Level II
• Sunscreen
• Moisturizers
• Sensitive clarifying lotion with
Kojic acid* and retinoids
• Retinoids
• AHA peels
• Prophylactic botulinum toxin to
prevent progression of dynamic
wrinkling
• IPL
Level III
• Sunscreen
• Moisturizers
• Clarifying lotion with
hydroquinone* and retinoids
• AHA peels
• IPL series or PDT
• TCA peel
• Erbium laser peel
• Fractional devices
Level IV
• Sunscreen
• Moisturizers
• Nourishing cream
• Clarifying lotion with extra-
strength retinoids and extra-
strength hydroquinone
• PDT or TCA peel
• Phenol peel
• CO2 laser resurfacing
*A skin-lightening agent. AHA, alpha-hydroxy acid; TCA,
trichloroacetic.
15
Combining Non-Invasive Therapies

the way it may not only change how certain malig-
nant or premalignant conditions of the skin and acne
conditions are treated, but also open up another
level in skin rejuvenation.
Lasers and non-lasers, such as blue light, IPL
(560–590 filters) or pulsed dye lasers, can be suc-
cessfully used in PDT for dermatologic conditions.17
VI Non-ablative Lasers
Non-ablative lasers include the 1064-nm neodymium:
yttrium–aluminum garnet (Nd:YAG) laser, which is
useful for vessel ablation and hair removal (Cool
Glide®), and the 1320-nm Nd:Yag (Cool Touch®)
laser, which is used for collagen stimulation.
VII Fractionated Laser Devices
Fractional resurfacing, or fractional laser therapy
(FLT) represents a technology that seeks to address
the limitations of both ablative resurfacing and non-
ablative treatments. Many companies now offer
versions of fractionated erbium or carbon dioxide
lasers. The Fraxel™and the Pixel™lasers are both
adaptations of the erbium laser that were designed
to improve skin texture with a minimum of down-
time and without anesthesia. Both of these lasers
have the unique ability to create microthermal
zones of tissue treatment between untouched areas
of skin. Side effects are generally limited to a sun-
burn-like redness, which disappears in a few days.17
More recently, CO2 fractionated lasers, such as
Ellipse Juvia® (Ellipse A/S H
rsholm, Denmark)
and Pixel CO2 Omnifit® (Alma Lasers, Caesarea,
Israel), have also been developed and approved.
They are supposed to have the ideal wavelength
for treating wrinkles, poor skin texture, large pores,
sun spots, brown spots, scars and uneven pigmenta-
tion. Multiple treatments are required for a desir-
able result, but discomfort is minimal and there is
little healing downtime.
CONCLUSIONS
Non-invasive approaches for improving facial skin
texture and contours are becoming increasingly pop-
ular, but physicians and patients must understand
that one treatment modality alone is not the
answer. Non-invasive facial rejuvenation is an effec-
tive modality with few complications and little
recovery time. Our patients have experienced sig-
nificant improvement with combined approaches
to rejuvenation. When multiple therapies are used
in combination, the outcome can exceed the expec-
tations, and the final result can be more than the
sum of the individual components (see Table 2.4).
Table 2.4
Recommended techniques by
facial area
Forehead and eyebrows
Skin-tightening techniques
Botulinum toxin
IPL/PDT/chemical peels
Micropigmentation for eyebrows
Glabella
Botulinum toxin
Avoid fillers; if needed, carefully fill residual depressions
using serial puncture or linear threading techniques
Upper eyelids
Botulinum toxin for retraction
Skin tightening devices
Micropigmentation for cosmetic purposes
Lower eyelids
Relax and flatten the pretarsal orbicularis muscle with
one to two units of Botox
For rhytids, use fractional devices, resurfacing
techniques, peels
For laxity and/or retraction, perform lateral canthal
tendon plication
Malar eminences
Skin-tightening devices
IPL/PDT/chemical peels
Volumetric replacement with high-density hyaluronic
acid, Sculptra, Radiesse
Nasolabial folds
Fillers
Skin-tightening devices
Melomental folds
Botulinum toxin at depressor angulii oris muscles
Skin-tightening devices
Fillers
Lower facial contours
Skin-tightening devices
Platysma treatment with Botulinum toxin
Lips
Fillers
Neuromodulation
Resurfacing, peels or fractional devices
Micropigmentation
16
Aesthetic Oculofacial Rejuvenation

REFERENCES
1 Cantisano-Zilkha M. Patient home care regimens. Ophthalmol
Clin N Am. 2005.
2 Bosniak S, Cantisano-Zilkha M, Glavas IP. Injectable fillers. In:
Minimally
Invasive
Techniques
of
Oculofacial
Rejuvenation.
Theime Publishers; 2005:41–53.
3 Carruthers J, Carruthers A. Soft Tissue Augmentation. 2nd ed.,
Vol. 7. Elsevier Inc; 2008:84–87.
4 Kirsch KM, Zelickson BD, Zachary CB, et al. Ultrastructure of
collagen thermally denatured by microsecond domain pulsed CO2
laser. Paper presented at the 17th Annual Meeting of the Ameri-
can Society of Lasers in Medicine and Surgery, Phoenix, April
1997.
5 Fitzpatrick RE, Rostan EF, Marchell N. Collagen tighetening
induced by carbon dioxide laser versus erbium:YAG laser. Lasers
Surg Med. 2000;27(5):395–4003.
6 Zelickson BD, Kist D, Bernstein E, et al. Histological and ultra-
structural evaluation of the effects of a radiofrequency-based
nonablative
dermal
remodeling
device.
Arch
Dermatol.
2004;140:204–209.
7 Bitter Jr R, Mulholland S. Report of a new technique for
enhanced non-invasive skin rejuvenation using a dual mode pulsed
light and radio-frequency energy source: Selective radiothermoly-
sis. J Cosmet Dermatol. 2002;1:142–143.
8 Sadick NS. Selective electro-thermolysis in aesthetic medicine:
a review. Lasers Surg Med. 2004;34:91–97.
9 Narins RS, Tope WD, Pope K, Ross EV. Effects associated with a
radiofrequency tissue tightening device: rare, preventable, and
correctable with subcision and autologous fat transfer. Dermatol
Surg. 2006;32:115–121.
10 Bosniak S, Cantisano-Zilkha M. Neuromodulation and manage-
ment of facial rhytidosis. In: Minimally Invasive Techniques of
Oculofacial Rejuvenation. New York, NY: Thieme; 2005.
11 Bosniak S, Cantisano-Zilkha M. Hyaluronic acid gel injections for
facial rejuvenation: a 3-year clinical experience. Operative Techni-
ques
in
Oculoplastic,
Orbital,
and
Reconstructive
Surgery.
1999;2:177–181.
12 Carruthers J, Carruthers A. A prospective randomized, parallel
group study analyzing the effect of BTX-A (Botox) and nonanimal
sources hyaluronic acid (NASHA, Restylane) in combination
compared with NASHA (Restylane) alone in severe glabellar rhy-
tides in adult female subjects: treatment of severe glabellar rhy-
tides
with
hyaluronic
acid
derivative
compared
with
the
derivative and BTX-A. Dermatol Surg. 2003;29:802–809.
13 Bosniak S, Cantisano-Zilkha M, Rinaldi P, et al. Lip and perioral
rejuventation: a multidisciplinary approach. Operative Techniques
in
Oculoplastic,
Orbital,
and
Reconstructive
Surgery.
2001;4:104–108.
14 Bosniak S, Cantisano-Zilkha M. Cosmetic Blepharoplasty and
Facial Rejuvenation. Philadelphia: Lippincott-Raven Publishers;
1999.
15 Bosniak S, Cantisano-Zilkha M. Neuromodulation and manage-
ment of facial rhytidosis. In: Minimally Invasive Techniques of
Oculofacial Rejuvenation. New York, NY: Thieme; 2005.
16 Cantisano-Zilkha M. Combining aesthetic enhancement therapies.
In: Contemporary Aesthetic Enhancement. Handbooks in Health
Care Company. 2008.
17 Cantisano-Zilkha M. Understanding skin resurfacing-mechanical
devices, lasers and other modalities. Contemporary Aesthetic
Enhancement. Handbooks in Health Care Company. www.
hhcbooks.com; 2008.
Anatomy of the periorbital area
Ioannis P Glavas
INTRODUCTION
The upper and lower eyelids are two complex and
thin flaps covering the eye. Knowledge of their anat-
omy is important for the cosmetic surgeon for sev-
eral reasons. The eyelids protect the eyes from the
outside world and play an important role in the pro-
duction, distribution and drainage of the tears (eye-
lid lacrimal pump mechanism). From an aesthetic
aspect, it is the anatomic characteristics of the eye-
lids and their relationship with the surrounding tis-
sues (orbital fat and suborbicularis oculi fat) and
structures (brows and midface) that define the eth-
nic identity of a person. They also contribute to the
appearance of the ‘eye’ that people perceive as
beautiful or not. The level and shape of the eyelid
margin and crease, the amount and position of
orbital fat, the degree of skin rhytidosis and the
underlying vascularity are factors that contribute
to the appearance of the eyelids and may be modi-
fied using surgical or non-surgical procedures.
Gender and ethnic variations should be taken
into account when evaluating the eyelids. Male
upper eyelids are fuller and their crease is lower
17
Combining Non-Invasive Therapies

than in the female. The eyebrows are lower and flat.
The female upper lids have more defined superior
sulcus and the brow has a more arched shape.1
Asian eyelids are fuller and have a lower lid crease.
The lower lids are also relatively full and their con-
tour is flat (removing excessive orbital fat results in
the occidental appearance of the Asian eyelid).
STRUCTURE OF THE EYELIDS
The eyelids can be divided into structural layers:2
v the skin and subcutaneous tissue
v muscles of protraction
v muscles of retraction
v orbital septum
v orbital fat
v tarsal plates
v conjunctiva.
There are four distinct eyelid layers at the level
of the tarsal plates. From the anterior to the poste-
rior direction they are the skin, orbicularis oculi
muscle,
tarsal
plate
and
palbebral
conjunctiva.
Beyond the tarsal plate (superior in the upper eyelid
and inferior in the lower) the eyelids are composed
of the skin, orbicularis muscle, orbital septum,
orbital fat, retractor muscles (levator and lower lid
retractors) and conjunctiva.
The anterior lamella of the eyelid is composed of
the eyelid skin and orbicularis oculi muscle. Exces-
sive removal of this layer results in eyelid retraction
and possibly ectropion. The middle lamellae is com-
posed of the tarsus and orbital septum. Excessive
use of electrocautery during surgery may result in
eyelid retraction and lagophthalmos.
The average palpebral fissure is 9–10 mm verti-
cally when the lids are open and about 30 mm hori-
zontally.3 The two medial canthi are separated by
one horizontal palpebral width. The margin of the
upper eyelid is positioned about 1–2 mm inferior
to the superior limbus. The margin of the lower
lid is normally positioned at the lower limbus. The
highest point of the upper lid is located medial to
the pupil.
The skin of the eyelids is the thinnest in the
body. It has no subcutaneous fat. Translucency of
the thin skin of the lower lids contributes to the
appearance of dark circles under the eyes. Known
causes of dark circles are prominent vascularity of
the lower lids, sun damage, shadow from prolapsing
orbital fat and tear trough abnormality.
The skin crease of the upper eyelid is formed by
the attachment of the levator aponeurosis at the
superior tarsal border and skin. The level of the
crease in the Caucasian eye is 10–12 mm in females
and 7–8 mm in males. The level of the crease in
Asian eyelids is significantly lower or absent. This
is explained by the lower position of preaponeurotic
fat on the upper eyelid. Modification of the Asian
eyelid fold is based on the removal, repositioning
or preservation of the preaponeurotic fat during
blepharoplasty. The folds of the skin around the
medial canthus extending to the lower or upper
eyelids form the epiblepharon seen in Asian eyelids.
The upper eyelids have approximately 100 eye-
lashes that originate from the anterior eyelid margin
and are arranged in two or three irregular rows. The
lower lid has about 40–44 lashes that are also thin-
ner. Eyelash transplantation can restore eyelids with
sectoral or total madarosis. It is performed using the
single follicle transplantation technique. The grafts
from the scalp are placed in three irregular rows.
The orbicularis muscle is the main protractor of
the eyelid.2 This muscle is innervated by the cranial
nerve VII and its action narrows the palpebral fis-
sure and closes the eye. It is divided into three
parts: the pretarsal, preseptal and orbital. The pre-
tarsal and preseptal divisions are involved in invol-
untary blinking while the orbital part is more
involved in the forceful closure of the eyelid. The
orbucularis
oculi
action
is
also
important
for
the physiologic function of the lacrimal pump. The
lateral and medial canthal tendons are bands of
connective tissue attached to the tarsal plates. The
suborbital orbicularis oculi fat (SOOF) is located
posterior to the orbital section of the orbicularis
muscle. This is a useful anatomic relationship since
the entire cheek may be mobilized by elevating
the SOOF at the level of the inferior orbital rim.4
The tarsal plates and septum form the layer imme-
diately posterior to the orbicularis muscle. The tarsal
plates serve as the ‘skeleton’ of the eyelids. They are
composed of dense connective tissue. The upper tar-
sal plate is 10–12 mm vertically (in the center of the
eyelid). The lower tarsal plate measures 4 mm verti-
cally. The two plates are attached firmly at the medial
and lateral canthi. Meibomian glands are located in
the tarsus and provide lubrication to the eye and a
protective mucus layer over the aqueous component
of the tear film. Aging results in stretching of the tar-
sal plates and eyelid malpositions. Repositioning or
shortening of the tarsal plates using tarsal strip proce-
dure or canthal plication can restore the eyelid
contour and level. The septum is a thin layer of
connective fibrous tissue and originates from the
orbital rim at the arcus marginalis. Attenuation of
18
Aesthetic Oculofacial Rejuvenation

the orbital septum results in prolapse and herniation
of orbital fat. The septum acts as a barrier between
the eyelid and orbit. It protects the orbital space from
the spread of infection or hemorrhage.
The orbital fat is located immediately posterior
to the orbital septum. It is a significant anatomic
landmark. The superior orbital fat is divided into
two distinct parts. The preaponeurotic fat pad is
located centrally posterior to the orbital septum
and anterior to the levator aponeurosis. The lateral
portion is located very close to the lacrimal gland.
Inadvertent excision of lacrimal gland tissue during
blepharoplasty results in significant bleeding and
increases the risk of retrobulbar hemorrhage. The
medial or nasal fat pad is pale yellow in color. It is
positioned close to the infratrochlear nerve and
the tendon of the superior oblique muscle (troch-
lea). The lower fat pad is divided into three parts.
The inferior oblique muscle separates the medial
from the central fat pads. The arcuate expansion
of the inferior oblique muscle separates the central
from the lateral fat pads. It is important to be able
to recognize and avoid these important anatomic
landmarks during blepharoplasty or permanent and
serious complications of ocular motility and diplopia
may arise. Hemostasis is of equal importance when
excising orbital fat to avoid the possibility of retro-
bulbar hemorrhage and blindness.5
The retractors of the eyelids are the levator and
Muller’s muscles for the upper lid and the lower
lid retractors for the lower lid. The levator aponeu-
rosis is the distal end of the levator muscle and pro-
jects into anterior and posterior portions at the level
of the upper tarsal plate. The anterior portion
inserts into the skin and orbicularis muscle forming
the superior eyelid crease.
The palpebral conjunctiva is the most posterior
layer of the eyelid. It contains goblet cells and the
accessory lacrimal glands of Kause and Wolfring.
These are mostly located in the upper eyelid and
are responsible for baseline tear secretions of the
eye. The lacrimal gland is mostly responsible for
reflex tearing triggered by the parasympathetic ner-
vous system. Postsurgical dry eye after blepharo-
plasty
may
be
attributed
to
the
temporary
malfunction of these accessory lacrimal glands dur-
ing the immediate postoperative period.
Vessels
Blood supply to the eyelids is provided by the inter-
nal and external carotid arteries. The internal carotid
artery provides the supraorbital, nasal, supratrochlear
and lacrimal arteries. The external carotid provides
the angular and temporal arteries. Multiple anasto-
moses are present between the two vascular net-
works. There are two vascular arcades on the upper
eyelid and usually only one on the lower.
The marginal arterial arcade of the upper eyelid
is located about 2 mm above the eyelid margin and
is anterior to the plate. The lower lid has one arte-
rial arcade located at the inferior tarsal border.
Lymphatic Drainage
Lymphatic drainage of the eyelids is directed to the
preauricular and submandibular lymph nodes. Ver-
tical incisions of the canthi may result in significant
and chronic eyelid lymphedema.
Nerves
The first and second divisions of the V cranial nerve
give sensory innervations to the eyelids. The supra-
orbital nerve (V1) innervates the forehead and lateral
periocular area. The maxillary nerve (V2) innervates
the lower eyelid and cheek. Motor nerve supply is
provided by cranial nerves III and VII, and the sym-
pathetic nerves. The areas prone to injury during sur-
gery are the supraorbital nerve in the region of the
eyebrow fat, the facial nerve in the lateral eyebrow
and lateral upper eyelid, and the infraorbital nerve
in the medial aspect of the inferior orbital rim.
The eyelids are complex and delicate structures
protecting the eye from the environment and defin-
ing the ethnic identity of the eyes. Knowledge of
the anatomy of the periocular area and respect of
the anatomic landmarks of the eyelids is useful for
preoperative planning and to avoid severe postoper-
ative complications.
REFERENCES
1
Bosniak S. Minimally Invasive Eyelid Rejuvenation. In: Bosniak S,
Cantisano-Zilkha M, eds. Minimally Invasive Techniques of
Oculofacial
Rejuvenation.
New
York:
Thieme;
2005:75–89
[Chapter 9].
2
American Academy of Ophthalmology. Anatomy. In: Orbit, Eye-
lids, and Lacrimal System, 2006–2007. San Francisco, CA: Amer-
ican Academy of Ophthalmology; 2006:135–147 [Chapter 9].
3
Bergin DJ. Anatomy of the eyelids, lacrimal system, and orbit. In:
McCord CD, Tanenbaum M, eds. Oculoplastic Surgery. 2nd ed.
New York: Raven Press; 1987.
4
Shorr N, Perry JD. Lower blepharoplasty and midface descent.
In: Chen WPD, ed. Oculoplastic Surgery: The Essentials. New
York: Thieme; 2001:147–164 [Chapter 11].
5
Kikkawa DO, Vasani SN. Ophthalmic Facial Anatomy. In:
Chen WPD, ed. Oculoplastic Surgery: The Essentials. New York:
Thieme; 2001:1–19 [Chapter 1].
19
Combining Non-Invasive Therapies

Skincare
Eckart Haneke
INTRODUCTION
The skin, our biggest organ, is the outer layer of the
body and protects us against noxious influences from
our environment. It also has very important immuno-
logic and defense functions and is our largest sensory
organ. It maintains the body’s external shape and
exhibits important direct and indirect social func-
tions. Genetic and hormonal factors, sex, lifestyle
and gender characteristics are responsible for deter-
mining differing tolerances of exogenous factors and
for influencing skin structure and function.
The skin is made up of three layers:
v the epidermis
v the dermis
v the subcutis.
The epidermis is the outermost layer of our skin.
It is made up of:
v the basal layer, with cells in continuous division
to allow lifelong renewal
v the spinous layer, the thickest of the epidermal
layers
v the granular layer, which prepares the epidermis
for cornification (or keratinization)
v the outermost stratum corneum or horny layer.
The stratum corneum is functionally the most
important layer as it prevents the skin and thus
the body from losing its water content. Without this
layer, which is just a few microns thick but consists
of many layers of horn cells, we would not be able
to live outside an aqueous environment. The stra-
tum corneum is also very important in controling
the penetration of substances into the skin, includ-
ing drugs and cosmetics.
Hair and nails are derived from the epidermis, as
are sweat and apocrine glands.
Melanocytes populate the basal layer. Female
hormones have an influence on the biochemical
composition of the horny layer and improve its
quality.1 Skin pigmentation is lighter in women than
in
men,2
but
is
subject
to
female
hormonal
influences.
The dermis is the carrier layer of the epidermis
and is a tough and resistant layer of connective
tissue. It is made up of collagen and elastic fibers
embedded in the so-called ground substance of gly-
cosaminoglycans, of which the most important is
hyaluronic acid. Hyaluronic acid is able to bind
water, and functions both as a lubricant for the col-
lagen and elastic fibers and as a volume-giving sub-
stance for the skin.
The skin is less thick in women than in men,3 and
that discrepancy increases noticeably with age. Estro-
gen therapy over a 12-month period leads to a thick-
ening of the dermis.4
The subcutaneous fat is both a mechanical and
thermal insulator, as well as an energy storage organ.
Its distribution over the body is determined by
gender-specific hormonal influences and by genetic
factors. Its total amount depends greatly on the cal-
ories consumed and used every day. Although most
people do not like fat in their bodies, it is important
for thermal insulation and for the shape of the face
and the rest of the body. However, once the body
has accumulated excess adipose tissue it tends not
to lose it again. This tendency is what makes weight
loss so difficult. Fat is unique and contains approxi-
mately 5000 stem cells per gram, and since it can be
easily grafted from a donor site of the body to a
receptor site, fat transplantation is probably also a
‘stem cell transfer’.5
The cutaneous fat layer is thicker in women than
in men6 and it has architectural differences, parti-
cularly where it is the thickest – so-called cellulite.7
The difference in fat distribution is the probable
reason that women’s tolerance to cold is superior
to men’s.8
All three skin layers are equally important for
good shape and health. There are many myths about
skincare that are supposed to guarantee beautiful
skin. Although beautiful skin is healthy skin, the
3

reverse is not always true. When the epidermis is not
healthy it may become red, rough, sallow, dry, scaly,
spotty or lose its luster and smooth texture. It devel-
ops large pores and dilated blood vessels, and a
variety of benign and precancerous lesions as well
as cancers. When the dermis gets old and/or sun-
damaged, it loses its turgor and elasticity, takes on a
yellowish color and develops wrinkles and folds.
BASIC SKINCARE
Beautiful skin has a smooth and shiny surface, is
evenly pigmented and has a silky touch – it is like
babies’ skin. Traditional knowledge tells us that pre-
vention is better than treatment. The best protec-
tion from the harmful effects of ultraviolet (UV)
rays are UV-proof clothes (hats, shirts, trousers),
avoidance of direct sun exposure (applying sun-
screen 30 minutes before exposure) and perhaps
the use of oral and topical application of vitamins
C, E, A, other antioxidants and scavengers of reac-
tive oxygen species.
The stratum corneum, as the outermost layer, has
to be kept moist since it becomes scaly and loses its
elasticity when dry (Fig. 3.1). Unfortunately, moisture
cannot be easily added to the skin; in fact, what moist-
urizers do is to help the skin to keep its own moisture.
Contrary to common belief, oil-in-water emulsions
may even impair the barrier function of the stratum
corneum.9 Glycerol may reverse this harmful effect
on the horny layer. Glycerol-containing hand creams
have proven to be effective, and facial skincare may
also benefit from glycerol as an ingredient. Urea is
another natural moisturizer with unique properties
since it can penetrate the horny layer and keep
moisture in the skin. The addition of ammonium lac-
tate may enhance this effect.10 However, topical pre-
parations that contain higher urea concentrations tend
to itch when applied to the dry skin of atopic indivi-
duals.
Dexpanthenol
is
another
substance
that
improves stratum corneum hydration (Fig. 3.2).11
The stratum corneum is also able to store fat-
soluble substances. Many lipophilic drugs and cos-
meceuticals are retained in it and slowly released.
This property is used in dermatology for many
creams and ointments that only require a daily
application. Simple emollients provide a protective
film of fat, preventing transcutaneous water loss
and therefore keeping the skin moist. It is not a
paradox that the higher the content of fat in the
skincare product, the better it maintains skin mois-
ture. This applies to all skin areas, from the very
thin eyelid skin to the far more oily and thicker
forehead skin.
It is not only the active ingredients of skincare
products that are important. The art of making pro-
ducts that are well tolerated, easily applied, non-
allergenic, non-toxic or otherwise harmful and feel
comfortable on the skin must be supplemented by
optimizing existing delivery systems and developing
new application systems. A number of stable carrier
systems have been developed that allow controlled
release of the incorporated ingredients. These systems
include liposomes, sphyngosomes, niosomes, multiple
emulsions, microemulsions, microsponge delivery
systems and thalaspheres, as well as solid lipid
nanoparticles and nanostructured lipid carriers.12 In
particular, solid lipid nanoparticles have good physical
long-term stability, protect incorporated labile sub-
stances against degradation, ensure controlled release
A
B
Fig. 3.1 Effect of a simple emollient on skin roughness. A, Before treatment; B, after 6 weeks of once-daily application.
22
Aesthetic Oculofacial Rejuvenation

of incorporated ingredients, prolong the release of per-
fumes and repellents, enrich active ingredients in cer-
tain skin regions, increase skin hydration and protect
against UV light.
More than 80% of the visible aging of facial skin
is due to UV exposure. Smoking and other exoge-
nous influences are also important. Avoiding UV
exposure and not smoking are the most important
factors for beautiful skin.
Whereas UVA is relatively low in energy, it
penetrates into the dermis where it causes connective
tissue damage, a process erroneously called ‘photoag-
ing’, although it is in fact photodamage. It causes solar
elastosis, a peculiar type of connective tissue damage,
blotchy hypo- and hyperpigmentation, and sun-burst
vessels. On either side of the neck, a multicolored
aspect, called poikiloderma of Civatte, may appear.
It is therefore logical to add potent sun-protective
substances to daycare products, particularly during
the sunny season. High-energy UVB does not pene-
trate so deeply and is mainly absorbed by the DNA
of the epidermis, where it is responsible for tanning,
a defense mechanism of the skin against sun exposure.
In the long term, however, UVB is responsible for
precancerous lesions and skin carcinomas. It dries
the epidermis out, causing scaling, rough hyperkerato-
tic areas and pigment spots. Sunscreens containing
UVB-absorbing substances can be effective in pre-
venting skin cancer development. However, sun-
screens protecting against both UVA and UVB have
the best spectrum of action, protecting against photo-
aging and also considerably reducing UV-induced
immunosuppression.
Washing and cleansing of the skin are important
daily skincare measures. There is no scientific proof
that washing the face once daily with a mild soap is
harmful and makes the skin dry. It is self-evident that
the use of soaps should never be overdone and
depends on the degree of soiling. Whether or not
common alkaline soaps are more harmful than non-
alkaline synthetic detergents and skin cleansers
remains unproven since these substances are more
aggressive degreasing agents than normal soaps. Many
people claim that they do not tolerate perfumed soaps
or detergents. It is therefore logical for these people
to abandon them and not to try one soap after the
other. Tolerability and cleansing properties do not
depend on the price of the product.
For people who really cannot use soaps or deter-
gents, a well-tolerated emulsion may be used
instead. In fact, it is the ability of the soap or deter-
gent to dissolve or emulsify fat that is responsible
for the cleaning action. The oily part of the emul-
sion dissolves the debris and allows it to be removed
from the skin surface.
Skin irritation is more frequent in women than in
men,13 and apparently Asian females complain more
readily about skin irritation and intolerance of cos-
metics than Causasians. However, skin irritability is
very difficult to quantify and remains mostly a sub-
jective impression of the individual.
COSMETIC SKINCARE
Cosmetics are defined as articles without therapeutic
function (US Federal Food, Drug and Cosmetic Act,
1938). EU legislation forbids cosmetic preparations
from containing active ingredients (EU 76/768).
Usually, they are substances with immediate effects
A
B
Fig. 3.2 Dex-panthenol containing cream. A, Before treatment; B, skin-smoothing effect is better than that achieved with
an emollient.
23
Skincare

on skin physiology to clean, protect, maintain and
regenerate the skin. Topicals with active ingredients
are considered drugs.
Two major classes of cosmetics are distinguished:
v decorative cosmetics, which may also have a
minor effect on skin physiology
v substitutive-regenerative cosmetics, which have
a marked effect on the condition of skin,
mucous membranes and their appendages, such
as the hair, nails, sweat and apocrine glands, teeth
and minor salivary glands.
Decorative cosmetics are effective for ‘camou-
flage’, but have no effect on photodamage. One
example is the self-tanning agents that are based
on dihydroxyacetone, which reacts with free amino
groups of keratin to produce a decorative brown
color. Although this is not harmful to the skin it
has no UV-protective action.
Regenerative-substitutive cosmetics are applied
to regenerate, maintain or improve good skin condi-
tion. By law, they must not have a systemic effect.
A third class of substances called cosmeceuticals
has recently been introduced. These are cosmetic
agents with improved and/or enhanced action, a
proven benefit, but a low risk. Fruit acids, a-
hydroxy acids, vitamin A and vitamin E are now
considered cosmeceuticals when applied topically.
They may also exhibit adverse side effects. Nutri-
ceuticals, substances with similar actions, may be
useful as absorption from the skin is often limited.
There is a great deal of advertising of products
that can prevent cutaneous aging and improve photo-
aged skin. Many of these products have demon-
strated either antioxidant or repairing activities in
in-vitro experiments, but most have not been tested
according to the stringent rules of good dermatologic
practice and science. Some of the most important
and effective cosmetics are sunscreens. They prevent
not only sunburn, but also more harmful conse-
quences that are not immediately seen, such as
immunosuppression, DNA damage and elastotic
degeneration of the connective tissue. It is important
to keep in mind that even if these products are cor-
rectly used, consumers cannot remain in the sun for
longer periods. The skin needs to be protected from
carcinogenic UVB and the less energetic UVA.
Ultraviolet light also induces release of iron into the
tissues, which in turn promotes the generation of
free radicals and connective tissue damage. Topical
iron chelators – substances that are able to bind iron
– have been shown to be protective.14
Oxygen radical scavengers – a-tocopherol (vita-
min E), ascorbic acid (vitamin C), propyl gallate
and a number of antiinflammatory agents such as
ibuprofene, naproxene or hydrocortisone – prevent
UV-mediated DNA damage and squamous cell car-
cinoma. Just as sunscreens may often contain these
products, cosmetic preparations for outdoor use
should also contain UV filters.
COSMOCEUTICALS
Vitamin A
Vitamin A is all-trans-retinol. It restores the horny
layer
by
stimulation
of
keratinocyte
renewal,
reduces desiccation of the skin, stabilizes cell mem-
branes and controls membrane permeability. Retinal
is all-trans-retin aldehyde. Its action is very similar
to that of vitamin A. Atmospheric oxygen oxidizes
it to vitamin A acid (VAA; also known as tretinoin,
all-trans retinoic acid or Retin A™), thus exhibiting
similar, but milder, VAA effects. It is a physiologi-
cal metabolite of vitamin A and is produced in the
liver. Even though there is very little absorption into
the blood stream, retinoic acid is a drug, not a cos-
meceutical, and therefore is not allowed in cosmetic
preparations. It is used topically in 0.025–0.1% con-
centration for acne treatment and rejuvenation, and
systemically in promyelocytic leukemia. It is there-
fore the only substance that can turn the biological
clock back. Combinations with hydroquinone or
azelaic acid are potent skin depigmenting agents
used for treatment of melasma. Since melasma is
often provoked or exacerbated by previous inflam-
mation, mild cortisone cream is often also added.
Vitamin A is an animal product, whereas the pro-
vitamin carotenoids occur mainly in red vegetables
and fruit, such as carrots, tomatoes (containing lyco-
pene), red berries and rose-hips.
Vitamin C
Vitamin C (L-ascorbic acid) is a very effective radical
scavenger and is essential for collagen and hyaluronic
acid synthesis and induction of production of other
intercellular substances. It exerts a mild UV protec-
tive action and has mild antiinflammatory effects.
Cosmetic preparations containing stabilized vitamin
C have a positive effect on skin quality.
Vitamin C cannot be synthesized by the human
body and has to be taken up with food. It is found
in green vegetables and potatoes, fruit (particularly
citrus fruit) and peppers. The molecule is unstable
in air, light and heat, and must be promptly
consumed.
24
Aesthetic Oculofacial Rejuvenation

Vitamin E
Vitamin E (a-tocopherol) increases the water-binding
capacity of the skin and is a natural moisturizer. Its
main biochemical function is to protect cell memb-
ranes against the damaging effects of UV-induced free
radicals. It also inhibits the formation of peroxides,
which are implicated in the aging process. It stimulates
cell renewal and supports biological skin stability. Skin
tension is increased, wound-healing stimulated and
the final quality of the skin scar is improved. It is a
strong antioxidant and after topical application for 6
to 24 hours it concentrates in the dermis, where it
can exert its positive effects (Fig. 3.3).
Vitamin E is a plant product and is found in many
plant oils, nuts and seeds. It stabilizes vitamin C.15
Together, topical vitamins C and E reduce harmful
UV effects (Fig. 3.4).
Some
users
have
developed allergic
contact
dermatitis from vitamin E soaps and lotions. This
appears to be unique to topical vitamin E prepara-
tions since systemic administration of vitamin E
virtually never produces allergic reactions.
Vitamin B3
Vitamin B3 (nicotinic acid or niacin) and its amide,
nicotinamide (or niacinamide), are similarly effective
since they are interconverted within the body. Niacin-
amide is a component of important coenzymes
involved in hydrogen transfer. It is the prosthetic
group of two codehydrogenases, nicotinamide ade-
nine dinucleotide (NAD) and nicotinamide adenine
dinucleotide phosphate (NADP). Topical application
of niacinamide has a stabilizing effect on epidermal
A
B
Fig. 3.3 Effect of a cream containing a-tocopherol 1%. A, Before treatment; B, after 4 weeks of daily application.
A
B
Fig. 3.4 Effect of a combined a-tocopherol 1% plus 5% vitamin C cream. A, Before treatment; B, after 8 weeks of twice-
daily application.
25
Skincare

barrier function, reducing transepidermal water loss
and improving the moisture content of the horny
layer. It increases protein synthesis, for instance of
keratin, stimulates ceramide synthesis, speeds up
the differentiation of keratinocytes and raises intra-
cellular NADP levels. In aging skin, topical application
of
niacinamide
improves
the
surface
structure,
smoothes out wrinkles and inhibits photocarcino-
genesis. It increases the protein content of the barrier
layer of the epidermis and the collagen mass in the
dermis. It has antiinflammatory effects in acne, rosa-
cea and nitrogen mustard-induced irritation. Its verifi-
able beneficial effects make niacinamide a suitable
component in cosmetic products for epidermal bar-
rier function disorders, for aging skin, for improving
pigmentary disorders and for use on skin prone to
acne and rosacea. It is well tolerated by most patients
complaining of ‘sensitive skin’.16
Vitamin K
Vitamin K (phylloquinone) has an antiedematous and
antiinflammatory effect through stabilization of vessel
walls, thus reducing actinic purpura and tissue iron
content. The negative effect of iron overload is dimin-
ished. Its main cosmetic use is in creams to alleviate
periorbital dark circles and restore facial skin color.17
Alpha-hydroxy Acids
Fruit acids (a-hydroxy acids (AHA)) are a group of
organic acids mainly, but not exclusively, contained
in fruits: glycolic, lactic, tannic, tartaric, citric, malic
acid, etc. They are all radical scavengers. In addition,
they are exfoliative, keratolytic, hydrating and bleach-
ing agents. AHAs modulate the maturation of the
epidermis to improve the quality of the horny layer.
Their effect is related to their chemical structure
and is proportional to acidity, concentration and dura-
tion of application: the lower the pH, the higher the
concentration, the longer the application, the more
intense the effect. In low concentrations between
2 and 10%, they can be used by the consumers them-
selves whereas high concentrations, which are used
for skin peels, should be used by experienced persons
only. Their main indications are mild acne, spotty
dyspigmentation, hyperkeratoses, skin refreshing and
pretreatment before chemical peeling.18
Beta-hydroxy Acids
Beta-hydroxy acids (b-butanoic acid, tropic acid) and
polyhydroxy acids have similar actions. The latter are
derived from sugars and other carbohydrates. For
instance, vitamin C (ascorbic acid) is the lactone
form of an AHA, but it has no effect on keratiniza-
tion comparable to other AHAs. Alpha-keto acids,
e.g. pyruvic acid, have similar effects, as lactic acid
can be oxidized to pyruvic acid by lactate dehydroge-
nase. Polyhydroxy acids are also antioxidants.19
Dimethylaminoethanol
Dimethylaminoethanol (DMAE) has become a new
‘miracle drug’ in the cosmetic skincare market.
Although it has been listed in the Cosmetic, Toiletries,
and Fragrance Association Dictionary for a long time,
the observation of its immediate tightening action on
skin has only recently been exploited for new anti-
aging creams. DMAE is currently marketed as an oral
nutritional supplement for memory improvement and
enhancement of physical performance, but this has
apparently to be separated from its action on the
epidermis. The mechanism of action is thought to
induce a vacuolar effect on cells of the upper skin
layers, causing cell expansion and thus giving the
appearance of an immediate antiwrinkle effect.20
Zinc
Zinc has an anti-free radical effect and is essential for
many immune functions, connective tissue regenera-
tion and wound healing. It is often used in the form
of a fine white powder of zinc oxide, particularly in
sunscreens. The whitish hue it gives to the skin
makes these preparations cosmetically unacceptable.
However, the white color can be diminished by add-
ing brown pigments, and recently the zinc has been
micronized, improving the final preparation texture.
Estrogens
Estrogens are female sex hormones that decrease
considerably with the menopause. The addition of
estrogen-active substances to skincare products may
improve stratum corneum hydration and alleviate
fine wrinkles.21
Soy
Soy has been known for many years to have positive
nutritional and health effects. Chinese women work-
ing in the tofu industry were famous for having the
most beautiful (fair, smooth, porcelain-like, fine)
skin. At least one part of soy’s positive action on
skin is due to its relatively high content of isoflavones,
26
Aesthetic Oculofacial Rejuvenation

phytoestrogenic substances with weak antioxidant
and antiinflammatory properties. Soy phytosterols
interfere with the arachidonic cascade and provide
mild antiinflammatory effects. Soy beans contain the
water-soluble
vitamins
thiamine
(B1),
riboflavin
(B2), niacin, and folic and pantothenic acids, and the
fat-soluble vitamins A and E. They are an important
source of zinc, manganese, magnesium and calcium.
Soy saponins provide active antioxidant and free-
radical scavenging effects. A preparation made of the
complete spectrum of soy components improved
the firmness and elasticity of the skin.22 Specific soy
bean proteins interfere with melanosome transfer,
resulting in more even pigmentation and pigment
reduction.22 Soy components are also used for skin
conditioners and emollients (soy-bean oil), emulsi-
fiers (soy protein hydrolysates), surfactants, emulsi-
fiers and stabilizers (soy lecithin and phospholipids),
as well as skin conditioners (soy sterol).
Green Tea
Green tea extracts improve UV-induced skin dam-
age. Green tea polyphenols reduce UV erythema.
The active substances are (
)-epigallocatechin-3-
gallate and (
)-epicatechin-3-gallate, which protect
against the deleterious effects of UV on immune
cells such as Langerhans cells.23 Black tea extracts,
both orally and topically applied, are also able to
protect against UV-induced skin damage. The active
substance is theaflavin.24
Spearmint
Spearmint (Mentha spicata) can reduce the oxidizing
potency of benzoyl peroxide and salvage the anti-
oxidant properties of a variety of reducing enzymes
that contain glutathione as their active component.25
Hamamelis
Hamamelis (witch hazel) may reduce UV-induced
erythema. However, this effect depends on the
way its active ingredients are distilled.26
Essential Fatty Acids
Essential fatty acids, particularly the n-3 type,
reduce the risk of squamous cell cancer develop-
ment.27 Evening primrose oil and borage oil improve
dry skin and its barrier function, especially in atopic
subjects.
Beta-lipohydroxyacid
Beta-lipohydroxyacid is able to improve features of
female aged skin by inducing epidermal thickening
and some recipients also develop a thicker filaggrin-
containing layer in the epidermis.28
Essential Oils
Essential oils have also been tested for their skincare
effect. Lavender oil has an antiinflammatory action.29
Other Cosmetics
Herbs, plant oils, unsaturated fatty acids, algae,
shark cartilage and so on have some – if barely
detectable – skincare effect.
New Products
There are two relatively new developments in the
cosmetic field: amino acids of sugar cane and kinetin.
Sugar Cane Amino Acids
Sugar cane amino acids occur in the sprouts of
young sugar cane plants. They are small molecules
that rapidly penetrate the skin and are the only
substances known that can increase skin moisture
threefold, thus improving skin tonicity. In combina-
tion with vitamin C they are highly active.
Indications of these promising new treatments
are photodamage, wrinkles, pigment spots, dry skin,
peeling pretreatment, acne and rosacea.
Kinetin
Kinetin (N6-furfuryl adenine) is a plant hormone
which stimulates growth. It is the substance that
keeps cut leaves green but it also prevents the skin
aging processes. In creams, it improves skin texture,
color, pigmentation, fine wrinkles and reduces trans-
epidermal water loss. It is non-irritative, non-allergenic
and may be combined with other cosmeceuticals. It
also alleviates reddening of facial skin.30–32
New Developments
There is presently a lot of research focusing on
cosmetics to prevent photoaging. Some will provide
modulation of DNA repair mechanisms using exog-
enously applied enzymes such as bacterial photo-
lyase,
while
others
stimulate
DNA
repair
by
exogenous UV-damaged DNA. Pretreatment with
27
Skincare

thymidine dinucleotide may interfere with the
harmful effect of high-energetic UV light.
CONCLUSION
Skincare appears to be something self-evidently
necessary for many women, but most men are un-
familiar with it. Two aspects of skincare have to be
differentiated: basic skincare with moisturizers and
treatment with cosmeceuticals. Both moisturizers
and cosmeceuticals can improve the skin quality,
prevent or at least diminish damage from environ-
mental hazards, and delay signs and symptoms of
aging. This is possible with minimal effort and
there are excellent long-term results. However,
sun protection is of paramount importance and can
be derived from both basic skincare and from
cosmeceuticals.
REFERENCES
1 Denda M, Koyama J, Hori J, et al. Age and sex-dependent change
in
stratum
corneum
sphingolipids.
Arch
Dermatol
Res.
1993;285:415–417.
2 Green A, Martin NG. Measurement and perception of skin colour
in a skin cancer survey. Br J Dermatol. 1990;123:77–84.
3 Seidenari S, Pagnoni A, Di Nardo A, Riannetti A. Echographic
evaluation with image analysis of normal skin: variations according
to age and sex. Skin Pharmacol. 1994;7:201–209.
4 Maheux R, Naud F, Rioux M, et al. A randomized double-blind,
placebo-controlled study on the effect of conjugated estrogens
on skin thickness. Am J Obstet Gynecol. 1994;170:642–649.
5 Fraser JK, Wulur I, Alfonso Z, Zhu M, Wheeler ES. Differences
in stem and progenitor cell yield in different subcutaneous
adipose tissue depots. Cytotherapy. 2007;9:459–467.
6 Hattori K. Okamotow. Skin fold compressibility in Japanese
university students. Okajima Folia Anat Jpn. 1993;70:69–78.
7 Querleux B, Cornillon C, Jolivet O, Bittoun J. Anatomy and
physiology of subcutaneous adipose tissue by in vivo magnetic
resonance imaging and spectroscopy: Relationships with sex and
presence of cellulite. Skin Res Technol. 2002;8:118–124.
8 McFarland RA, Kadish R. Sex differences in finger temperature
response to music. Int J Psychophysiol. 1991;11:295–298.
9 Gloor M, Hauth A, Gehring W. O/W emulsions compromise the
stratum corneum barrier and improve drug penetration. Pharma-
zie. 2003;58:709–715.
10 Gloor M, Fluhr J, Lehmann L, Gehring W, Thieroff-Ekerdt R.
Do urea/ammonium lactate combinations achieve better skin pro-
tection and hydration than either component alone? Skin Pharma-
col Appl Skin Physiol. 2002;15:35–43.
11 Gehring W, Gloor M. Effect of topically applied dexpanthenol on
epidermal barrier function and stratum corneum hydration.
Results
of
a
human
in
vivo
study.
Arzneimittelforschung.
2000;50:659–663.
12 Mu¨ller RH, Ma¨der K, Gohla S. Solid lipid nanoparticles: produc-
tions, characterization and applications. Adv Drug Deliv Rev.
2001;47:165–196.
13 Wilhelm KP, Maibach HI, Wilson D. Irritant reactivity in males
and females. Contact Dermatitis. 1987;17:276–280.
14 Jurkiewicz BA, Buettner GR. EPR detection of free radicals in
UV-irradiated skin: mouse versus human. Photochem Photobiol.
1996;64:918–922.
15 Rozman B, Gasperlin M. Stability of vitamins C and E in topical
microemulsions for combined antioxidant therapy. Drug Deliv.
2007;14:235–245.
16 Gehring W. Nicotinic acid/niacinamide and the skin. J Cosmet
Dermatol. 2004;3:88–93.
17 Iscan Y, Wissing SA, Hekimoglu S, Mu¨ller RH. Solid lipid nano-
particles (SLN) for topical drug delivery: incorporation of the
lipophilic drugs N,N-diethyl-m-toluamide and vitamin K. Phar-
mazie. 2005;60:905–909.
18 Ditre CM, Griffin TD, Murphy GF, et al. Effects of a-hydroxy
acids on photoaged skin: a pilot clinical, histological and ultra-
structural study. J Am Acad Dermatol. 1996;34:187–195.
19 Yu RJ, Van Scott EJ. a-Hydroxyacids, polyhadroxy acids, aldobio-
nic acids and their topical actions. In: Baran R, Maibach H, eds.
Textbook of Cosmetic Dermatology. 3rd ed. London: Taylor &
Francis; 2005:77–93.
20 Morissette G, Germain L, Marceau F. The antiwrinkle effect of
topical concentrated 2-dimethylaminoethanol involves a vacuolar
cytopathology. Br J Dermatol. 2007;156:433–439.
21 Schmidt JB, Binder M, Macheiner W, et al. Treatment of skin
ageing symptoms in perimenopausal females with estrogen com-
pounds. A pilot study. Maturitas. 1994;20:25–30.
22 Wallo W, Nebus J, Leyden JJ. Efficacy of a soy moisturizer in
photoaging: a double-blind, vehicle-controlled, 12-week study.
J Drugs Dermatol. 2007;6:917–922.
23 Elmets C, Singh D, Tubesing K, et al. Cutaneous photoprotection
from ultraviolet injury by green tea polyphenols. J Am Acad
Dermatol. 2001;44:425–432.
24 Nomura M, Ma W-Y, Huang C, et al. Inhibition of ultraviolet
B-induced AP-a activation by theaflavins from black tea. Mol
Carcinog. 2000;28:148–155.
25 Saleem M, Alam A, Sultana S. Attenuation of benzoyl peroxide-
mediated
cutaneous
oxidative
stress
and
hyperproliferative
response by the prophylactic treatment of mice with spearmint
(Mentha spicata). Food Chem Toxicol. 2000;38:939–948.
26 Hughes-Formella B, Filbry A, Gassmueller J, et al. Anti-
inflammatoryx efficacy of topical prepatations with 10% hama-
melis distillate in a UV erythema test. Skin Phamacol Appl Skin
Physiol. 2001;15:125–132.
27 Hakim I, Harris R, Ritenbaugh C. Fat intake and risk of squamous
cell carcinoma of the skin. Nutr Cancer. 2000;36:155–162.
28 Avila-Camacho M, Montastier C, Pie´rard GE. Histometric assess-
ment of the age-related skin response to 2-hydroxy-5-octanoyl
benzoic acid. Skin Pharmacol Appl Skin Physiol. 1998;11:52–56.
29 Kim H-M, Cho S-M. Lavender oil inhibits immediate-type allergic
reaction in mice and rats. J Pharm Pharmacol. 1999;51:221–226.
30 Rattan SJS, Clark BFC. Kinetin delays the onset of aging charac-
teristics in human fibroblasts. Biochem Biophys Res Commun.
1994;201:665–673.
31 McCullough J. Furfuryl adenine – a new antiaging topical: research
and clinical experience. Skin Allergy News. 1999;3–5.
32 Chiu PC, Chan CC, Lin HM, Chiu HC. The clinical anti-aging
effects of topical kinetin and niacinamide in Asians: a randomized,
double-blind, placebo-controlled, split-face comparative trial.
J Cosmet Dermatol. 2007;6:243–249.
28
Aesthetic Oculofacial Rejuvenation

Chemical Peels
Marina Landau, Richard H Bensimon
Included on DVD
INTRODUCTION
Chemical peeling is a procedure used for the cos-
metic improvement of skin or for the treatment of
some skin disorders. Chemical exfoliating agent is
applied to the skin to destruct portions of epidermis
and/or dermis with subsequent regeneration and
rejuvenation of the tissues. In the periorbital area, it
results in improvement of the skin quality, shrinkage
of redundant skin and lightening of the pigmentation.
The periorbital area is a barometer of facial aging,
since it is affected by intrinsic and extrinsic factors
of aging.1 In addition, the skin in this area is tightly
attached to the underlying orbicularis oculi muscle
and therefore is under constant muscular move-
ments, induced by mimetic expressions. Moreover,
the periorbital skin has the thinnest epidermis and
dermis. It has been shown that type I collagen con-
tent diminishes with aging in the eyelid skin due to
a decrease in its synthesis.2 All these factors con-
tribute to the fact that the periorbital area is the
first to show the signs of facial aging.
Chemical peels can be performed on the lower lid
exclusively or on the whole periorbital skin. They can
be a part of the full-face peeling procedure or can be
performed as isolated chemical blepharoplasty. Eye-
lid peeling can be combined with simultaneous surgi-
cal blepharoplasty or with non-surgical procedures,
such as botulinum toxin injection or tear trough
deformity correction by dermal fillers.
INDICATIONS AND CONTRAINDICATIONS
Lower eyelid wrinkles and redundant eyelid skin are
challenging for treatment. As long as the skin in this
area is tight and elastic, eyelid wrinkles can be
improved by infraorbital injection of small doses of
botulinum toxin. If flaccid, additional relaxation will
worsen the skin appearance and cause suborbital
swelling. Furthermore, the lower portion of the lateral
INDICATIONS
• Periorbital wrinkling
• Upper eyelid ptosis
• Periorbital pigmentation
CONTRAINDICATIONS
• Ectropion
• Lower lid laxity (moderate to severe)
• Severe eye dryness
• Claustrophobia
orbicularis oculi assists in elevation of the upper
cheek. When it is totally paralyzed in older patients,
an extra roll of skin becomes apparent at the junction
of the lower eyelid and cheek skin when smiling.3
Lateral crow’s feet in young patients are treated
successfully by botulinum toxin injection. Our
experience shows, however, that if these lines are
not significantly worsened during animation, as hap-
pens in older individuals, the effect of muscle paral-
ysis would not be sufficiently effective. The option
of botulinum toxin injection in sub- and periorbital
areas is therefore preserved for relatively young
patients with tight skin. Chemical peels significantly
improve this area.4 Periorbital skin rejuvenation
using medium and deep peels is achieved due to
stimulation of the production of new dermal colla-
gen and elastic tissues, with a desired overall
refreshed and tightened appearance, reduction of
fine wrinkles and skin tightening.5–8
Lower eyelid wrinkles are minimally helped
by standard surgical blepharoplasty, in particular
when a transconjunctival approach is used for fat
removal or fat transposition. They are therefore
commonly
neglected during
this
procedure.
A
combination of eyelid surgery with lower eyelid
peeling has been suggested as an effective and safe
4

procedure that improves the final result of lower
blepharoplasty.9,10
For upper eyelid blepharochalasis, surgical bleph-
aroplasty is indicated in most cases. The results are
generally good, natural and long lasting. Neverthe-
less, if a patient is reluctant to have surgical inter-
vention or if full-face chemabrasion is scheduled,
the periorbital procedure can be surprisingly effect-
ive on the upper eyelid as well (Fig. 4.1).11
Periorbital pigmentation is prevalent in 9–38% of
American women under the age of 30 years.12 This
manifestation worsens with age. Histological exam-
ination of infraorbital darkening suggests that it is
caused by multiple etiologic factors, including acquired
dermal melanocytosis, ethnic or age-related dermal
melanin deposition, postinflammatory hyperpigmenta-
tion secondary to atopic or allergic contact dermatitis,
periorbital edema, skin photoaging, superficial location
of the vasculature, and tear trough depression.13,14
Chemical peels are highly effective for the
removal of melanin depositions secondary to ethnic
dark circles and postinflammatory hyperpigmenta-
tion, and in skin photoaging.
Our experience shows that in ethnic dark circles,
deep peels create definitive results (Fig. 4.2).
A novel use of periorbital peels is to treat youn-
ger patients who show only textural changes and
who are not necessarily contemplating surgery. This
approach not only opens up treatment to a much
larger patient population but is also a means of
keeping up with aging. The inherent improvement
and tightening of the anterior lamella caused by
the peel may bring enough improvement in younger
patients with mild fat protrusion who may not be
ready to consider surgery (Figs 4.3 and 4.4).
There are no absolute contraindications for perior-
bital peeling. Ectropion secondary to chemical peeling
is a remote possibility and its existence is debat-
able.7,15 Nevertheless, pre-existing ectropion or
moderate-to-severe lower lid laxity is a relative con-
traindication for lower eyelid peeling, unless each is
corrected surgically prior to the chemical peel.
A
B
Fig. 4.1 Upper and lower eyelid:
A, before; B, after full-face deep
peeling.
A
B
Fig. 4.2 A 28-year-old woman with
periorbital pigmentation: A, before;
B, after periorbital deep peeling
combined with full-face medium-
depth peel.
30
Aesthetic Oculofacial Rejuvenation

PREOPERATIVE HISTORY
AND CONSIDERATIONS
When evaluating the patient before the peel, an
extensive history should be taken. The patient has
to be questioned about general health status, medi-
cations such as oral isotretinoin, smoking, previous
cosmetic procedures such as surgical lifts or fluid
silicone injections, recurrent herpetic outbreaks,
keloid formation, etc.
Skin type should be determined, based on Fitzpa-
trick’s skin type scale. Skin preparation with bleaching
creams and early reintroduction of these products
in the immediate post-peel period are crucial to
avoid postinflammatory hyperpigmentation in dark
phenotypes.
The message of ‘the deeper the peel, the more the
inconvenience, the more significant the results’ should
be clearly conveyed and discussed with the patient.
The patient should be aware of the need to regu-
larly apply sunscreen in the immediate post-peel
period and of the possibility of using makeup to con-
ceal post-peel redness, and advised to resume normal
daily activities immediately after the procedure.
A
B
Fig. 4.3 A young man with obvious
wrinkling of lower eyelid skin in sharp
contrast with the rest of the face:
A, before; B, after isolated deep
peel of lower eyelid skin.
A
B
Fig. 4.4 A 56-year-old patient with
evenly prematurely aged skin. Note
the periorbital area: A, before;
B, following full-face deep peeling.
31
Chemical Peels

Of paramount importance is to have the patients
photographed and sign the term of consent prior to
the procedure.
OPERATIVE APPROACH
Chemical peels are an extremely versatile tool and
are divided into three categories, depending on the
depth of the wound created. Superficial peels pene-
trate the epidermis only, medium-depth peels dam-
age the entire epidermis and papillary dermis, while
deep peels create a wound to the level of the mid-
reticular dermis.16
The depth of the peel is dictated by a number of
factors: the chemicals that have been applied, their
concentration and mode of application, and skin
type and its condition. In general, the depth of the
peel determines patient’s inconvenience during and
after the procedure, healing time, the rate of the
potential side effects and the results.
PRE-PEEL SKIN PREPARATION
Skin
can
be
pretreated
with
topical
tretinoin
0.025–0.05% for 2–6 weeks, but its efficacy in peri-
orbital skin priming is controversial.4,6,9 Immedi-
ately before applying the chemical, the skin is
thoroughly cleaned and degreased with acetone.
The treatment area, particularly in the lower eyelid,
is marked while the patient is in the sitting position.
If an occluded deep-peel procedure is scheduled,
the authors mark the area to be occluded and a
marginal area in which to perform a non-occluded
peel (Fig. 4.5).
To prevent any damage that might result from
chemical leaking into the eye itself, the patient
should be just slightly reclined, and sterile ophthal-
mic ointment is instilled to coat the eye globe
before the procedure starts. All the extra ointment
should be meticulously removed from the periorbi-
tal skin to avoid interference with the solution
penetration.
CHOICE OF CHEMICAL AGENT
Various peeling solutions may be used effectively to
perform periorbital peeling, including trichloroace-
tic acid (TCA) 35% and phenol–croton oil-based
solutions. Stronger chemicals will cause a deeper
wound with a greater effect on the skin.17 The fol-
lowing factors must be considered when choosing
chemicals: the amount of redundant skin, degree
of laxity of the lower eyelid, degree of actinic dam-
age, skin color and concomitant or previous surgical
intervention.
TCA 35% is effective to remove pigmentation
and fine wrinkles.4,6,7 Nevertheless, our experience
shows that for deep melanin deposits, deep peeling
creates more significant and long-lasting results. The
authors do not recommend higher concentrations of
TCA, since the results are less predictable and the
potential for scarring is higher. In order to increase
the depth and efficacy of TCA peel, without
increasing the concentration of the acid, the TCA
can be preceded by Jessner’s solution (Monheit
method).4
TCA solution is compounded in a weight-to-
volume preparation. To prepare a 35% solution,
the authors dissolve 35 g of TCA crystals in a small
amount of water and add water to make a total vol-
ume of 100 mL. TCA is stable in room temperature
and is not light sensitive.
When attempting to treat blepharochalasis, deep
peel is our first option. Deep-peeling solutions
penetrate the skin to the mid-reticular dermis and
create maximal effect for production of new colla-
gen.17 The solutions for deep peeling are composed
of a combination of croton oil and phenol in various
concentrations.18 Phenol is an aromatic hydrocarbon
derived originally from coal tar. Croton oil is an
extract of the seed of the plant Croton tiglium and
Fig. 4.5 Procedure plan: marking of the periorbital skin to
be occluded and the transitional area to be peeled
without occlusion.
32
Aesthetic Oculofacial Rejuvenation

has been commercially prepared as croton resin
since 1932. Its activity on the skin is related to
free hydroxyl groups, which cause skin vesiculation
even in low doses. Other chemicals in use in deep
chemical peel formulas include septisol, water and
vegetable oils (glycerin, olive and sesame).
The key to the peel is that the croton oil con-
centration is weak enough that the application
technique is a main determinant of the depth
reached.19 The experienced practitioner is able to
control the process in order to reach the desired
depth and go no further. A thin transparent frost
with a pink background denotes a peel to the papil-
lary dermis, and this is an appropriate depth for the
eyelids. Regardless of concentration used, it is
always imperative to judge the depth reached by
means of the visual guidelines outlined above.
A combination of different solutions can be used
by an experienced physician to comply with differ-
ences in each skin area.6 Periorbital deep peeling
can be combined with medium-depth peel on the
rest of the skin to prevent demarcation lines.
ANESTHESIA AND PATIENT MONITORING
The majority of patients do not require anesthesia
for the peel procedure. In some cases, a combina-
tion of an oral sedative, such as lorazepam or diaze-
pam, and an analgesic, such as tramadol, is used.
Another option to be considered, especially for
phenol peels, is regional block.
Periorbital TCA and phenol peels do not require
any monitoring. Full-face phenol-based peel is car-
ried out under full cardiopulmonary monitoring with
intravenous hydration throughout the procedure.20
PEELING TECHNIQUE
After skin defatting with acetone, a single cotton
tip is dipped in a small container containing the
peeling solution and squeezed over its side to avoid
dripping of the solution to other areas. The authors
use commercial cotton tips and roll an additional layer
of soft cotton on them to increase fluid absorption.
The upper eyelids are peeled while the eyes are
closed. For the lower eyelid procedure, a patient is
required to open the eyes wide and look up. At this
stage, uncontrollable tearing regularly appears. It is
therfore important that an assistant holds cotton tips
in the medial and lateral canthi to absorb the tears
and avoid spreading of the solution. For extra com-
fort, eyedrops of tetracaine solution can be recom-
mended, but administration of the eyedrops has to
be done very carefully since it can mask any inadver-
tent peel that may go into the eyes by capillarity.
As the acid encounters the skin, it coagulates and
precipitates the protein, resulting in varying shades
of white, called a frost (Fig. 4.6,A). With progressive
passes, the frost becomes denser, indicating deeper
penetration. Phenol peels induce immediate protein
coagulation. With TCA 35%, a patient observation
of the skin is needed, since this chemical creates
delayed skin frosting.
Another visual clue, which is useful with deep
peels on the eyelids, is epidermal sliding. This phe-
nomenon occurs when the peel reaches the papillary
dermis and the epidermis is separated from the
underlying reticular dermis and slides on a thin,
independent sheet. Epidermal sliding is an excellent
way to judge the depth of peel in the eyelids.
POSTOPERATIVE CARE
After a phenol-based peel, the lower eyelid can be
occluded for 24 hours or left unoccluded. The peri-
pheral treatment area is left unoccluded to create
a more even blending with untreated skin. If a water-
proof zinc oxide non-permeable tape or a plastic mask
(Neofarma® Compounding Pharmacy, Sao Paulo,
Brazil) is used, after the occlusion is removed, the skin
exudate is cleaned by sterile saline. The face is
covered with bismuth subgalate antiseptic powder
for 7 days. On the eighth day, wet soaking with tap
water is used to soften the powder mask and to
remove it.
If a non-occluded deep peel is employed, the skin
is covered with a thin layer of petroleum ointment
postoperatively. Although the recovery from a full-
face peel is somewhat difficult for the patient, an
isolated peel of the lower lids is easy to tolerate,
BOX 4.1
1. Meticulous defatting maximizes the results of the peel
2. To avoid eye injury an almost-dry Q-tip should be
employed
3. To avoid spreading of the peeling solution, an assistant
holds cotton tips in the medial and lateral canthi to
absorb the tears.
4. Upper eyelids are peeled while the eyes are closed.
5. For the lower eyelid procedure a patient opens the
eyes wide and looks upwards
6. To blend color and textural differences a more
superficial peel might be needed in the marginal area
33
Chemical Peels

with epithelialization occurring in approximately
5–7 days (Fig. 4.6,B–F ). This is followed by about
6 weeks of redness, which is easy to camouflage
with make-up or glasses.
For TCA peels, wet soakings are used immedi-
ately postoperatively. In both cases, during the next
few days patients may expect to feel tightening and
swelling of the skin, together with gradual darkening
of the skin color. On day 3 or 5, the skin starts
to crack and desquamation begins. At this stage
moisturizing cream can be applied, although a few
authors choose to recommend bland moisturizers
(petrolatum, for instance) from day 1. Full re-epi-
thelization is completed after 5–7 days. At this stage,
the patient is advised to wear camouflage make-up
and resume normal daily activities. Blunt moisturizer
and high-level sun protection are recommended for
the next 2–3 weeks.
SPECIAL CONSIDERATIONS
FOR PERORBITAL PEELINGS
In the post-peeling period a crust is formed on the
eyelid skin. The eyelids therefore become less flex-
ible and the efficacy of the blinking mechanism,
responsible for the tears dispersion, is reduced. As
a result, some patients complain of ophthalmic irri-
tation during the healing period. The authors advise
all the patients to use artificial tears. Patients with
severe preoperative eye dryness should be especially
instructed and closely followed up.
Periorbital
peeling
causes
extensive
swelling
around the eyes. In some cases, complete closure
of the eyelids can occur. This possibility has to be
discussed with claustrophobic patients. Some of
them will benefit from antianxiety medications in
the first few days after the peeling.
A
B
C
D
E
F
Fig. 4.6 Unoccluded lower eyelid peeling: A, frost forms as the acid is progressively applied on the skin; B, day 1
after peel; C, day 5 post treatment; D, day 10 post treatment; E, 3 weeks post treatment; F, 7 months post treatment.
34
Aesthetic Oculofacial Rejuvenation

REPEATED PEELINGS
Repeated peelings of the lower eyelid improve the
results. Lower eyelid peel can be repeated and per-
formed in a graded fashion. If a patient desires a
quicker recovery, then a lighter peel can be done
and repeated in the future with an additive effect.
In this manner the lower lid skin can be peeled to
the patient’s satisfaction (Fig. 4.7).
Repeated sessions of TCA peel are performed 1
month apart, while phenol peels can be repeated
after 3–6 months.4,9
COMBINATION OF PEELING
WITH SURGERY
In the traditional transcutaneous lower lid blepharo-
plasty, the orbital fat is accessed by going through
the anterior lamella and traversing the orbital sep-
tum. Once the fat has been modified, surgeons can-
not seem to avoid temptation and try to improve
wrinkles by pulling up on the skin and removing
the excess. The contracture of the injured septum,
coupled with the removal of skin, cause a vertical
shortening and invariably result in rounding of the
outer canthus or, worse, frank ectropion.
The author’s (RHB) preference is to utilize the
bi-lamellar approach – that is, access the fat in
the posterior lamella through a transconjunctival
approach and then manipulate the anterior lamella
if necessary, be it suspension of the orbicularis oculi
muscle and lateral canthi tightening and/or removal
of excess skin, without invading the orbital septum.
Regardless of the technique used, the last, and often
very important, factor is dealing with the textural
changes of aging eyelid skin.
For many patients, the combination of trans-
conjunctival fat resection and croton oil peel is an
excellent choice. If there is true excess of skin or an
orbicularis oculi, and lateral canthi manipulation is
deemed necessary, these can be performed after the
elevation of a skin flap and a peel can be done at a later
time. In this manner, both the structural and the tex-
tural changes can be dealt with appropriately while
preserving the natural shape of the eye and avoiding
the all-too-common ‘operated’ look (Fig. 4.8).
COMPLICATIONS
The list of potential complications of chemical peels
includes pigmentary changes, infections, milia, acne-
form eruption, scarring and cardiotoxicity.
1. Pigmentary changes – Reactive
hyperpigmentation can occur after chemical
peels. Usually lighter complexions have lower
risk for hyperpigmentation. In regional peels,
especially in darker skin phenotypes or in
severely sun damaged skin, a demarcation line at
the margins of the peeled area can occur. If this is
the case, a full-face procedure or skin
camouflaging has to be considered.
Hypopigmentation after phenol peels is
proportional to the depth of the peel, the amount
of solution used, the number of drops of croton
oil in the solution, inherent skin color and post-
peel sun-related behavior.
2. Infection – Bacterial and fungal complications in
chemical peels are rare. Patients with a positive
history of herpes simplex infection are treated
prophylactically with acyclovir or valacyclovir
A
B
C
Fig. 4.7 Gradual peeling: A, wrinkled lower eyelid skin pretreatment; B, results after first peel of lower eyelid;
C, 1 year after second peel of lower eyelid.
BOX 4.2
Repeated peelings of the lower eyelid improve the results.
35
Chemical Peels

during medium and deep peel until full
re-epithelization is achieved.
3. Scarring – Scarring and cicatricial ectropion
remain the most dreadful potential complications
of periorbital peels. Delayed healing and
persistent redness are important alarm signs for
forthcoming scarring. Topical antibiotics and
potent steroid preparations should be introduced
as soon as this diagnosis is made. Nevertheless,
this complication is extremely rare.9,15
4. Cardiotoxicity, milia and acneiform eruption,
which can occur in full face peeling, have not
been seen by the authors during the procedure in
the periorbital area.
LONG-TERM RESULTS
In spite of the fact that the tightness of the eyelid skin
usually seen in the first 3–6 months is not permanent,
patients usually appreciated an overall improvement
in their eye appearance following the peel. To prevent
recurrence of mimetic periorbital wrinkles, the
authors advise all patients to start periorbital botuli-
num toxin injections about 4 weeks postoperatively.
As for patients peeled for dark circles, their satisfac-
tion does not reduce with time (Fig. 4.9).
REFERENCES
1 Landau M. Exogenous factors in skin aging. Curr Probl Dermatol.
2007;35:1–13.
2 DeBacker CM, Putterman AM, Zhou L, Holck DE, Dutton JJ.
Age-related changes in type-I collagen synthesis in human eyelid
skin. Ophthal Plast Reconstr Surg. 1998;14:13–16.
3 Kane MAC. Classification of crow’s feet patterns among Cauca-
sian women: the key to individualizing treatment. Plast Reconstr
Surg. 2003;112(suppl):33S–39S.
4 Kadhim KA, Al-Waiz M. Treatment of periorbital wrinkles by
repeated medium-depth chemical peels in dark-skinned individ-
uals. J Cosmet Dermatol. 2005;4:18–22.
5 Litton C, Trinidad G. Chemosurgery of the eyelids. In: Aston SJ,
Hornblass MA, Meltzer MA, Rees TD, eds. Third International
Symposium of Plastic and Reconstructive Surgery. Baltimore:
Williams and Wilkins; 1982:341–345.
A
B
Fig. 4.9 A 44-year-old patient: A, before; B, 3 years after periorbital peeling for periorbital pigmentation.
A
B
Fig. 4.8 Combination of transconjunctival blepharoplasty with lower eyelid peeling: A, prior to surgery; B, results
after combination procedure.
36
Aesthetic Oculofacial Rejuvenation

6 Morrow DM. Chemical peeling of the eyelids and periorbital area.
J Dermatol Surg Oncol. 1992;18:102–110.
7 Dailey RA, Gray JF, Rubin MG, et al. Histopathological changes
of the eyelid skin following trichloroacetic acid chemical peel.
Ophthalmic Plast Reconstruc Surg. 1998;14:9–12.
8 Nelson BR, Fader DJ, Gillard M, Majmudar G, Johnson TM.
Pilot histologic and ultrastructural study of the effects of
medium-depth chemical facial peels on dermal collagen in
patients with actinically damaged skin. J Am Acad Dermatol.
1995;32:472–478.
9 Gatti JE. Eyelid phenol peel. An important adjunct to blepharo-
plasty. Ann Plast Surg. 2008;60:14–18.
10 Zins JE. Invited discussion: Eyelid phenol peel. An important
adjunct to blepharoplasty. Ann Plast Surg. 2008;60:19–20.
11 Parada MB, Yarak S, Gouveˆa LG, Hassun KM, Talarico S,
Bagatin E. ‘Blepharopeeling’ in the upper eyelids: A nonincisional
procedure in periorbital rejuvenation – a pilot study. Dermatol
Surg. 2008. [Epub ahead of print].
12 Gupta MA, Gupta AK. Dissatisfaction with skin appearance
among patients with eating disorders and non-clinical controls.
Br J Dermatol. 2001;145:110–113.
13 Yoshimura K, Sato K, Aiba-Kojima E, et al. Repeated treatment
protocols
for melasma and acquired dermal melanocytosis.
Dermatol Surg. 2006;32:365–371.
14 Lowe NJ, Wieder JM, Shorr N. Infraorbital pigmented skin. Pre-
liminary observations of laser therapy. Dermatol Surg. 1995;21:
767–770.
15 Wojno T, Tenzel RR. Lower eyelid ectropion following chemical
face peeling. Ophthalmic Surg.. 1984;15:596–597.
16 Landau M. Chemical peels. Clin Dermatol. 2008;26:200–208.
17 Butler PE, Gonzalez S, Randolph MA, Kim J, Kollias N,
Yaremchuk M. Quantitative and qualitative effects of chemical
peeling on photo-aged skin: an experimental study. Plast Reconstr
Surg. 2001;107:222–228.
18 Hetter G. An examination of the phenol-croton oil peel:
Part I. Dissecting the formula. Plast Reconstr Surg. 2000;105:
239–248.
19 Hetter GP. An examination of the phenol-croton oil peel: part IV.
Face peel results with different concentrations of phenol and
croton oil. Plast Reconstr Surg. 2000;105:1061–1083.
20 Landau M. Cardiac complications in deep chemical peels. Derma-
tol Surg. 2007;33:190–193.
37
Chemical Peels

Lasers and Intense Light Sources
Eckart Haneke
Included on DVD
INTRODUCTION
The laser is a technical miracle. It was Albert Einstein
who predicted the existence of laser light but it took
almost another half-century until the first laser
was developed. Initially, they were known as masers
(microwave amplification by stimulated emission of
radiation), but they were soon renamed lasers (light
amplification by stimulated emission of radiation).
Laser light is unique due to its three characteris-
tic properties. It is:
v monochromatic, which means it emits light of
one specific wavelength
v coherent, which means that all light waves are in
the same phase
v collimated, meaning that the light rays are all
parallel.
A typical laser device consists of an optical
medium, a source of excitation producing light or
energy, and a set of mirrors positioned to potentiate
the excitation light.
The use of lasers in selective photothermolysis
was heralded in a 1980 paper by Rox Anderson,
and since then lasers have found a wide range of
medical applications.
‘[Selective photothermolysis] relies on selective
absorption of a brief radiation pulse to generate and
confine heat at certain pigmented targets. An
absolute requirement is that the targets have greater
optical absorption at some wavelength than
surrounding tissues. . .’
(Anderson & Parrish)
CLASSIFICATION OF LASER DEVICES
(Tables 5.1–5.4)
Basic Concepts
Laser light is widely thought to penetrate the skin,
where it is specifically absorbed by the target.
However, this is only partially true. Firstly, the light
is reflected, not only by the skin surface but also by
optical grenz zones; secondly, it is transmitted through
the more-or-less transparent skin; thirdly, it is scat-
tered whenever it hits particles; fourthly, it is absorbed
and its relative energy transformed into heat (Fig. 5.1).
The tissue effect is caused by the absorption. The
deeper the target, the more energy will be non-
specifically lost by reflection and scattering, until a
threshold is reached at which no tissue effects will be
generated.
A laser for medical use is characterized by its
wavelength (in other words its color), its mode of
light emission as a continuous wave (CW) or pulsed,
by the pulse width (duration of a single light pulse),
by its power and by its fluence.
Wavelength
The wavelength is the color of the light used. It
determines the absorption of the light energy by
the pigmented target (chromophore). Many of the
intended targets for treatment are beneath the skin
surface and the wavelength also plays a role in deter-
mining the amount of scatter and hence the penetra-
tion depth of the light energy; penetration of visible
laser light is inversely related to wavelength.
Pulse Width
Pulse width is the time interval over which the
energy is delivered. For effective treatment, this
pulse width should be shorter than the thermal
relaxation time (TRT) of the intended target. The
TRT is a measure of the time it takes for 50% of
the energy absorbed by the target (i.e. heat) to
diffuse into the surrounding tissue.
Fluence
Fluence is the amount of light energy per area deliv-
ered to heat a target. Sufficient energy must be
provided to damage the tissues of the target. For a
5

Table 5.1
Laser classification by optical
medium
Lasing medium
Laser type
Gas
CO2, argon
Liquid
Dye lasers
Solid
Crystal, ruby, alexandrite,
NdYag-diode
Table 5.2
Laser classification by emitted wavelength
Laser type
Wavelength
Color
Indications
Xenon chloride excimer
308 nm CW
UV-B
Vitiligo, psoriasis
Argon
488 nm CW
514 nm CW
Blue
Green (secondary,
weak)
Vascular lesions
Vascular lesions
KTP (frequency doubled
Nd-YAG)
532 nm QS
Yellow
Telangiectasiae
Copper vapor
511 nm, 578 nm
pseudo-continuous
Yellow, orange
Pigment, blood vessels
Tunable dye (argon laser
pumped)
550–585 nm CW
Yellow, orange,
red
Blood vessels
Pulsed dye laser (flash-
lamp pumped)
585 nm pulse
Orange
Blood vessels
Q-switched ruby
694 nm QS
Red
Pigments
Alexandrite
755 nm QS, long-pulse
Near infrared
Pigments, tattoos
Diode
810 nm long-pulse
800 nm pulse
Near infrared
Hair removal
Nd-YAG
1060 nm CW, pulse,
long-pulse, QS
Infrared
Pigments, hair removal
Nd-YAG
1360 nm
Infrared
Pigment, tattoos, coagulation,
hair removal, etc.
Diode
1450 nm
Infrared
Photorejuvenation
Er-glass
1550 nm
Infrared
Photorejuvenation
Er-YAG
2940 nm pulse
Infrared
Laserablation, microablation,
fractional
Carbon dioxide
10 600 nm CW, pulsed
Infrared
Resurfacing, cutting, vaporizing,
fractional
Intense pulsed light
500–950 nm
600–950
580–980 nm
645–1200 nm
590–1200 nm
525–1200
Broad range
visible light
Photorejuvenation, pigment
lesions, telangiectasiae
CW, continuous wave; QS, Q-switch.
Table 5.3
Laser classification by emitted power
Low-level lasers
Medium-level lasers
Strong lasers
40
Aesthetic Oculofacial Rejuvenation

given laser energy a smaller spot size creates a
higher fluence. To calculate the fluence the equa-
tion below is used:
fluence ðJ=cm2Þ ¼ energy of the beam ðJÞ
=area of the beam ðcm2Þ
Spot Size
Spot size is the diameter of the beam at the skin
surface. This parameter affects the treatment area
and depth.
Repetition Rate
Repetition rate is the number of pulses per second
and determines the speed of the treatment.
Energy
Energy is measured in joules and is defined as force 
distance (N  m). Power is energy divided by time
(J/s). Irradiance is power density, i.e. power divided
by area (W/cm2), and fluence is power  time
divided by area (J/cm2). These variables are of the
utmost importance as they allow the laser parameters
to be accurately determined and measured, and
understanding of them makes the difference between
a physician and a beautician. Lasers can be classified
by power as low-level, medium-level or strong lasers.
While the specific wavelength of a laser defines
its absorption spectrum and thus its principal bio-
physical effects, the duration of the laser emission
also has a profound impact on the end result. CW
lasers can be used to coagulate, cut, carbonize or
vaporize tissue, or to stimulate certain cells. They
usually exert important thermal effects on the
tissues that absorb the energy, but there is also an
effect on neighboring tissue, due to heat convection.
The argon laser is a typical example of a CW laser
that is used to coagulate blood vessels (port-wine
stains, sun-burst vessels) and to heat up tissue
(xanthelasma,
small
fibromas,
small
seborrheic
keratoses).
Different techniques have been used to reduce
the undesirable effect of CW lasers on adjacent tis-
sue. The superpulse and ultrapulse techniques use
Table 5.4
Laser classification by delivery type
of energy
Continuous wave
Pseudo-continuous (Cu vapor laser generates a train of
15 000 pulses per second, thus acting as a quasi-
continuous laser)
Pulsed
Q-switched
1,000,000
100,000
10,000
1,000
100
10
Power (Watts)
ns
10–9
µs
10–6
ms
10–3
s
1
Time
QS
Pulse
Continuous
Reflection
Scatter
Target
Absorption
A
B
Fig. 5.1 A, Relationship of pulse duration and power of laser light. B, Light tissue interaction.
41
Lasers and Intense Light Sources

surgical carbon dioxide lasers with multiple inter-
ruptions, which give time for the tissue to cool
down between pulses. Another technique is to use
scanners, which reduce the possibility of inaccurate
application of the laser beam by the physician.
Pulsed lasers emit short bursts of high energy
light. This extreme power can lead to a number of
undesirable side effects: when treating port-wine
stains or telangiectasiae with a flash-lamp pumped
dye laser, the power of a single pulse can be so high
that the target tissues – the blood vessels and ery-
throcytes – explode and cause purpura, a reddish-
black discoloration, which is cosmetically embarras-
sing. On the other hand, short pulses are shorter than
the so-called thermal relaxation time, defined as half
the time needed for 50% of the heat to pass to neigh-
boring structures. When pulses remain below the
thermal relaxation time of a given target no heat
damage of the adjacent structures occurs.
To make a continuous wave laser into a pulsed
one, a quality switch (Q-switch; QS) is necessary.
This changes many of the laser properties, examples
being the CW neodymium-YAG and the QS
Nd-YAG lasers. Another way to modify a laser is
frequency doubling, which changes the biophysical
properties such as light absorption.
TYPES OF LASER
Continuous Wave Lasers for Aesthetic
Enhancement
CW lasers are now rarely used in aesthetic derma-
tology. The three main CW lasers still used are
argon, tunable dye and CO2 lasers, now seen by
many as ‘historical’. Three parameters can be set
by the operator: power, spot size and speed of
movement (or length of shutter).
The CO2 laser was the most important surgical
laser used for cutting, vaporizing, carbonizing and,
above all, for skin resurfacing. The latter procedure
gives excellent results that cannot be achieved with
modern non-invasive procedures. However, its main
disadvantage is the long downtime period and the
comparatively high risk of adverse side effects.
Because its use is invasive, it will not be dealt with
here. The Er-YAG laser, the light of which is
absorbed 10 times more specifically by water, leaves
much less thermal damage and healing is therefore
faster. It may be an alternative for the treatment
of prominent scars, mesh graft-like scars, excess
graft tissue, some burn scars and traumatic tattoos.1
The argon laser, with its strong blue and weaker
green emission, was the first vascular laser. Its emis-
sion wavelengths do not coincide with any of the oxy-
hemoglobin absorption maxima, and heat conduction
from the target to neighboring structures is an addi-
tional source of tissue damage. Furthermore, before
even reaching the vessels, melanin of the epidermis
absorbs much of its light energy.2 Depigmentation
and epidermal necrosis are the consequences, often
accompanied by scarring. Today’s indications are
mainly cherry angiomas, syringomas and xanthelas-
mata and other soft tissue lesions (Fig. 5.2 and 5.3).
The tunable dye laser, pumped by an argon laser,
could be adjusted to the 577 nm oxyhemoglobin
absorption maximum. It was better adapted for
vascular lesions but because of its CW nature and
relatively weak output its results were not really
superior.
Pulsed and Q-switched Lasers
Pulsed lasers with an emission peak at 577 nm, where
absorption by melanin is weaker, and with a pulse
duration below the thermal relaxation time should
be optimal to target superficial vessels without addi-
tional damage to surrounding structures. Q-switched
lasers used in conjunction with preferentially absorb-
ing pigments are optimal for melanotic lesions.
The flash-lamp pumped pulsed dye laser (PDL)
with rhodamin G as the lasing medium emits light
A
B
Fig. 5.2 Soft fibroma on the upper lip.
A, Before treatment; B, two months
after argon laser coagulation.
42
Aesthetic Oculofacial Rejuvenation

between 577 and 585 nm at a pulse duration of
450 ms.3 This is below the thermal relaxation time
and thus no heat conduction occurs. Side effects are
therefore rare except for transitory purpura lasting
for about 2 weeks. These purpuras are due to the
impact of the power being confined to a short time
scale and can be prevented by using a long-pulse dye
laser.4 A comparative trial with fluence of 1 J/cm2
below and 0.5 J/cm2 above the purpura threshold
showed that clearance of telangiectasiae is possible
with both modes.5 However, a longer pulse requires
higher power densities, which are achieved with a
frequency doubled Nd-YAG laser. This allows pulse
widths of 1–30 ms and fluence rates of 15–20 J/cm2.
A novel approach is the combination of a pulsed
dye laser with a Nd-YAG laser. It has been shown
that blood changes its absorption characteristics
during subpurpuric photocoagulation, due to met-
hemoglobin generation6,7 increasing infrared absorp-
tion 3–5 fold.8 This allows the energy densities of
both lasers to be reduced, thus minimizing potential
side effects such as scars. A study using a device
with
one
hand-piece,
delivering
PDL
light
of
595 nm (10 J/cm2, 10 ms pulse width, 7 mm spot
size) and 100 ms later another pulse of 1064 nm
Nd-YAG (70 J/cm2, 15 ms, 7 mm) was significantly
more effective than either laser alone.9
Pigments, both endogenous melanin as well as
tattoo ink, are the main target for the so-called pig-
ment lasers such as ruby and alexandrite. Melanin
absorbs from 300–1064 nm, but minimizing inter-
ference with blood while still maintaining relatively
high absorption makes a wavelength of 510 nm
most suitable.10 Although not at precisely this
wavelength, the light from ruby and alexandrite
lasers is absorbed at a wavelength where absorption
by hemoglobin is virtually zero, allowing melanin
and tattoos to be effectively treated. Although ruby
laser light at 694 nm is maximally absorbed with
minimal absorption by hemoglobin and water, its
light pulses are too short to damage hair follicles
sufficiently for it to be useful in hair removal.11
The QS Nd-YAG laser penetrates deeper and it
therefore is now also widely used for hair removal12
as well as the removal of dermal melanin and black
tattoos.13
Non-ablative lasers minimize the risks of tempo-
rary and permanent scarring because they leave the
epidermis intact while delivering dermal irradiation
with concomitant surface cooling. The absence of
epidermal damage is associated with the absence of
a true wound-healing response and therefore non-
ablative lasers have minimal resurfacing efficacy.
Because of this, multiple treatment sessions are
required and there is variable and modest clinical
improvement.14–17
Fractional (Pixellated) Lasers
Fractional lasers are novel devices the use of which
is grounded in the theory of selective photothermo-
lysis. Their use involves creation of microscopic
treatment zones (MTZs) of controlled width, depth
and densities, which are surrounded by viable skin.
While ablative lasers produce excellent skin rejuve-
nation but with considerable downtime, non-ablative
photorejuvenation is much less efficacious but has
the advantage that there is no downtime. Ablative
and non-ablative lasers both create large macroscopic
zones of thermal damage, which are defined by the
A
B
Fig. 5.3 Syringomas of the upper eye lid. A, Before treatment; B, two weeks after argon laser treatment.
43
Lasers and Intense Light Sources

laser spot size. A new type of laser light delivery with
patterns of 100 to over 1500 microscopic treatment
zones/cm2 was developed both with non-ablative
lasers18,19 and with CO2 and Er-YAG lasers. Small
channels of controlled width, depth and densities of
connective tissue damage are produced that are less
than 200 mm wide. Within 1 hour of non-ablative laser
irradiation, well-defined columns of both epidermal
and dermal thermal damage are seen, with an intact
overlying stratum corneum. Within 24 hours, viable
cells migrate from the periphery toward the MTZs
and microscopic epidermal necrotic debris (MEND)
is formed. MEND comprises epidermal and dermal
thermally damaged cells as well as melanin and
elastin.20 It is extruded transepidermally within 3–7
days. Cellular markers of dermal wound healing and
neocollagenesis are expressed within the treatment
areas.
Fractional ablative lasers produce tiny holes
reaching into the epidermis and upper dermis which
are surrounded by normal skin. They increase in
depth and width with increasing pulse energies.21
Channels up to 1600 mm deep can be safely made
with the CO2 or Er-YAG fractional lasers. The
effect of ablative fractional lasers is much more
pronounced, but healing takes at least a week.
Hair Removal Lasers
Hair density and distribution are important factors
in psychosocial relations. Both too little and too
much hair can be extremely embarrassing.
Hair removal with lasers is one of the most
popular cosmetic treatment methods. Depending
on hair color – the darker the better – and skin com-
plexion – the lighter the better – long-lasting results
are usually achieved after 5–10 sessions.
Long-lasting to almost permanent removal of
unwanted hair has become possible with new laser
devices. They are mainly based on long-pulsed alex-
andrite, diode and Nd-YAG lasers or intense pulsed
light (IPL) sources, and by 2004 more than 22 dif-
ferent types of machine were available. It has been
shown that photoepilation is much more efficacious
than needle epilation, hurts less, is about 60 times
faster and the results are aesthetically better.22
However, skillful photoepilation requires a great
deal of experience.23,24
The basis of photoepilation is the interaction of
light and its target. About 5% of light is reflected by
the stratum corneum. Light scatter on tissue inhomo-
geneities is the most important cause of energy loss
because the laser beam loses its collimation and
coherence (see Fig. 5.1). This loss can be reduced by
choosing a greater spot size. Laser wavelength
is another important variable: the longer the wave-
length the deeper the penetration, up to about
1050 nm, when absorption by tissue water begins
to increase. Choosing the right wavelength allows
the target structure to be specifically heated without
damaging the neighboring structures; this phenome-
non is called selective photothermolysis. Follicular
melanosomes are believed to be the targets of laser
and IPL epilation,25 and dendritic melanocytes have
also been found in the bulge, the region of the follicu-
lar stem cells. In the hair bulb, most melanin is pres-
ent in anagen phases III–VI and this is the phase to be
chosen for the treatment. Since only about 50–70%
of facial hair is in anagen, multiple treatment sessions
are necessary for a good result.
Intense Pulsed Light Sources
IPL has a broad spectrum of wavelengths potentially
targeting several skin structures. It is used for vascu-
lar and pigment lesions as well as hair removal and
photorejuvenation.
While the first IPL device was a very complex
machine, demanding expert skills in order
to
achieve good results, the newer units are simpler
to operate. They usually have at least two different
treatment windows in order to either target hemo-
globin or melanin. For hair removal and induction
of collagen neosynthesis, longer wavelengths in the
near infrared are preferred. The light pulses are
commonly divided into two or three portions that
are temporally spaced so that the surrounding tissue
can cool down while the target remains hot, thus
adding heat to the target with each subpulse.
IPL has, until now, been associated with minor
and only transient side effects. Pain, erythema, hypo-
or hyperpigmentation, and superficial crust or vesicle
formation have been the most commonly reported
adverse effects in applications for both photorejuve-
nation and depilation.26 The potential for ocular side
effects has been alluded to, with previously reported
cases of facial treatments deliberately avoiding direct
application of IPL to the upper lids and protecting
them from exposure by small external plastic shields.
USE OF LASERS
Preoperative History and Considerations
As with all cosmetic procedures, patient selection
and
preparation
are
of
utmost
importance.
44
Aesthetic Oculofacial Rejuvenation

Skin type, according to Fitzpatrick, is an important
factor as it determines the risk of post-laser hyper-
and hypopigmentation. Light skin is easier to treat
and has far fewer complications. In many conditions
the laser light has to go through the epidermis and
its absorption by melanin is an unwanted effect,
not only reducing the energy that reaches the sub-
epidermal target but also causing the heating of
the epidermis, leading to necrosis, slough, pigment
disturbance and a risk of scarring. Tanning before
laser treatment is therefore strongly discouraged.
Lifestyle, current medications, supplementations
and skincare, previous cosmetic treatments includ-
ing surgery, and a good psychological status with
realistic expectations have to be considered. As all
laser treatments, ablative as well as non-ablative,
can reactivate herpes simplex, antiviral prophylaxis
is indicated when there is a previous history of this
condition. Special concern is necessary in patients
taking photosensitizing drugs or gold medications.
It is the laser physician’s task to explain that coop-
eration and compliance with the recommended
post-laser regimen ensures normal healing and helps
to avoid complications (Table 5.5). A patient who is
likely to be noncompliant or unable to avoid sun
exposure is not a good candidate for most laser pro-
cedures. Generally, men are better candidates for
ablative laser therapies because their skin is often
thicker. However, men are often negligent in using
sunblockers to prevent pigmentary disturbances.
The potential dangers accompanying laser and
IPL treatments have been well documented.27
Several major areas in which ‘professional error’
can occur are deficient training, incorrect operation
of the laser or light source, failure to perform test
treatments, and misdiagnosis. The training of staff
to suitable standards and ensuring that only clini-
cians who have been trained in dermatology are
allowed to operate lasers and other light sources
are important steps in minimizing this kind of error.
Test treatments, knowledge of appropriate laser and
light settings and probe handling, as well as use of
cooling media and appropriate shields/blocks are
important factors in minimizing skin damage and
further sequelae.
There are some absolute prerequisites for ratio-
nal laser treatment:
v correct diagnosis and indication
v patient history, including prior treatments with
lasers, light, peels, dermabrasion and other
cosmetic surgeries
v standardized informed consent; an informed
consent form should be available and explained
to the patient (Table 5.6).
v standardized clinical photography
v a suitable laser test field – it should be similar to
the treatment area but preferably less visible
v treatment
v adequate follow-up and control photography
v avoidance of treatment of unclear or suspicious
pigmented lesions.
Both the physician and the patient have to under-
stand these facts so that the most appropriate laser
can be chosen for the treatment based on the partic-
ular needs and desires of the patient. Non-ablative
photorejuvenation (subepidermal resurfacing) causes
almost no downtime but gives only weak-to-moderate
improvement; fractional lasers give better results but
with some days of redness and crusting, particularly
Table 5.5
Comparison of laser and intense pulsed light
Laser
IPL
Light
Monochromatic, coherent, collimated
Polychromatic, non-coherent,
non-collimated
Pulses
Usually one depending on wavelength
Multiple stacked
Target
Single
Several, depending on spectral
range used
Handpiece
Small, light
Large, bulky
Treatment
time
Longer
Shorter
Cooling
Various systems: direct contact, gel, cold air, cryogen
spray
Contact gel and cooling handpiece
45
Lasers and Intense Light Sources

with the ablative pixellated lasers; ablative lasers,
meanwhile, yield by far the best results but lead
to considerable patient downtime. Even a series of
non-ablative laser treatments will scarcely produce
the same results as a single CO2 or Er-YAG resurfa-
cing. On the other hand, a series of very superficial
Er-YAG peels may also be performed and these will
give the patient very limited downtime.28 These
options have to be discussed with the patient
beforehand.
Immediately before the laser treatment, the skin
is cleansed as small foreign particles may take up
laser energy, be heated and be ‘burned into’ the
skin. Hair should be shaved 2–3 days prior to hair
removal, and for other procedures immediately
before the start of treatment.
Table 5.6
Consent form for laser treatment (adapted from M Cantisano-Zilkha, Understanding
Chemical Peels)
A laser treatment is not a ‘cure all’ treatment. It can give marked improvement for appropriate conditions. It is important
that you have a thorough understanding of what the laser can and cannot do for your particular condition.
I, __________________________________________, give my consent for Dr___________________________to perform a
laser treatment on my face or other area of my body___________________________to treat the following conditions:
______________________________________________________________________________________________________
I understand that this is a program of treatments and that I may need several sessions to achieve my best results.
__________I understand that the degree of improvement I can expect to see depends on many variables and therefore
cannot be guaranteed. Additionally, I understand that strict adherence to the physician’s instructions is necessary to
ensure my best results.
__________I understand that Dr__________________________has the right to discontinue my treatment at any stage if he
or she thinks that I am not following instructions, or if he or she believes that no further improvement is possible.
__________I understand that the laser treatment is an outpatient procedure done in the office. I also understand that I can
expect to have some minutes of stinging or burning sensations during and after the procedure, but this will stop.
__________I understand that during healing from the laser therapy, my skin may look red and darker, depending on the
laser used and the condition treated and that I may be unable to work. My particular laser treatment and its relationship to
my ability to work have been discussed with me by Dr__________________________.
__________I consent to have my photographs taken before, during and after my treatment. These may be used for
educating future patients and in possible publications and promotions. My name will not be used.
__________Although complications are rare, they occur. Prompt recognition and treatment of any complication is
necessary to decrease its potential danger. It is extremely important that I follow doctor’s instructions exactly and that I
notify the office if I have any of the following complications:
□Skin infections, usually appearing as a red tender area, often with a scab
□Cold sore on my lips or face
□Allergic reaction to any medications I am using
□Any medication taken, including food supplements and ‘natural’ drugs
□Appearance of thick scars or keloids in the areas of my laser therapy
□Prolonged sensitivity to the sun and harsh climate
□Persistent areas of increased or decreased pigmentation
□Eye problems
Read and understood:
______________________________
_______________
Patient signature
Date
______________________________
_______________
Witness signature
Date
46
Aesthetic Oculofacial Rejuvenation

Treatment
It is wise to treat a test area before performing a full-
face treatment. This may also be treated as a test of
whether or not the patient will require anesthesia or
whether cooling will be sufficient. Preauricular skin
is the optimal laser test area. After the laser test,
the skin is cooled with a cool pad for about 30 min-
utes. Where there is good tolerance, light-skinned
persons may be treated immediately, while indivi-
duals with Fitzpatrick type III and above are better
treated the next day. Moles should not be included
in the treatment zone. Before each new session, the
clinician should discuss with the patient how well
the previous session was tolerated, in order to deter-
mine if the laser/IPL parameters should be adjusted.
Patients should be reminded to stay out of the
sun. Protective goggles must be worn and the eyes
must be shut during therapy. When treating the
eyelids
directly,
protective
shields
should
be
applied. Before starting the treatment a contact gel
is usually applied, which couples the handpiece to
the skin to minimize energy loss and also cools the
skin surface. Use of a gel depends on the particular
laser device, as some have built-in contact cooling.
In other types the epidermis can be given a short
spray of a cooling gas immediately before emission
of the light beam. Cooling reduces the discomfort
of the treatment and protects the epidermis from
undue heat.29 Each laser/IPL shot is felt like a sting
or short burn, and when working near the eyes the
patient will notice a light flash. Any swelling is trea-
ted by the cooling, but care has to be taken not to
freeze the skin as this again will damage the skin.
Depending
on
reaction
to
the
treatment,
the
appointment for the next treatment session should
be fixed before the departure of the patient to
ensure that they remember that non-ablative laser
treatments require a series of sessions.
Optimizing Outcomes
There are a number of areas that can be addressed in
order to optimize treatment outcomes. These are:
v select skin type
v select target chromophore
v assure sun avoidance between sessions
v offer herpes simplex prophylaxis if requested
v select the right wavelength
v use cooling (pre and/or post-treatment)
v train staff
v increase energy by 10–20% each session
v promise less than you can give.
Immediate Post-treatment Care
The laser/IPL causes a certain degree of irritation of
the skin, which is normal and usually lasts for about
24 to 48 hours. Blistering is – in most cases – a
sign that the fluence was too high or surface cooling
was not sufficient. The resulting scab must not be
removed by the patient, and he/she has to be advised
that this will result in temporary hypopigmentation,
sometimes followed by postinflammatory hyperpig-
mentation. In patients with a tendency to develop
melasma a consistent antimelasma treatment should
be started even before the first session and should
be continued until about 6 months after completion
of the laser/IPL treatment.
The skin reaction is more intense after a treatment
with a fractional laser, and crusting may last for
several days after an ablative fractional laser therapy.
Encouraging the use of mild moisturizers, soap-
free cleansers and sunscreen in the post-operative
period is of paramount importance.
Side Effects
Non-ablative treatments using the principle of selec-
tive photothermolysis are usually free of serious
adverse side effects. As mentioned above, local
swelling, which often becomes less intense in sub-
sequent sessions,30 responds to cooling, which also
reduces the development of blisters. A slight discol-
oration after treatment is common and resolves by
itself; hyperpigmented spots will look darker after
treatment, indicating that the target was actually
hit. Purpura may be seen when a PDL with short
pulses is used; these take about 2 weeks to disappear.
Pigmentary disturbances may develop when the
laser/IPL-treated skin is exposed to the sun too early.
Most recently, bilateral anterior uveitis with
permanent ocular damage has been reported. This
occurred in a beauty therapy salon after IPL treat-
ment for periocular dyspigmentation was given
without the use of eye shields.31
INDICATIONS
The main indications for laser and IPL treatment
are:
v port-wine stains
v telangiectasiae
v pigmentary disturbances
v photodamage
v hypertrichosis
v scars.
47
Lasers and Intense Light Sources

Port-wine Stains
Port-wine stains can be treated with a variety of lasers
and IPL sources. The ideal wavelength is 577 nm, but
because laser light is completely absorbed at this
wavelength the laser beam would not penetrate to
the undersurface of the vessel and complete oblitera-
tion of the vessels would therefore be hard to
achieve.32 This is why a wavelength of 585 nm with
a flash-lamp pulsed dye laser is usually chosen;
595 nm PDL are now also available.30,33,34 As outlined
above, very short pulses do not damage surrounding
cells but have the disadvantage of producing post-
treatment purpura. Long pulses in the millisecond
range are commonly used to avoid this complication.
Another possibility is the use of compression.35
Preparation of the skin for port-wine stain treat-
ment depends on the requirements of the particular
laser used. After preparation it is cooled. The pat-
tern with which a port-wine stain is treated depends
on the user, but as several sessions are almost always
required overlapping is commonly avoided. The full
therapeutic benefit of each session can be seen after
2–3 months, thus treatment for a large port-wine
stain may be a long procedure.
Argon, argon-pumped CW tunable dye and copper
vapor lasers are no longer recommended for the
treatment of port-wine stains. However, they are still
very useful for senile angiomas. The Nd-YAG laser,
with its deeper penetration, is sometimes used to
treat nodular angiomatous lesions.
The use of lasers in infantile hemangiomas is still
disputed although a proactive approach is gene-
rally recommended for large hemangiomas with
functional impairment, risk of ulceration and dra-
matic cosmetic disfigurement.36
Acquired Vascular Lesions
Acquired vascular lesions of the face are mainly tel-
angiectasiae, rosacea-associated erythema, spider
nevi, poikiloderma of Civatte, venous lakes and
cherry angiomas.
Telangiectasiae are usually treated in a tracking
mode37 (Fig. 5.4). Many lasers are suitable for their
treatment, the light of which is sufficiently absorbed
by blood. As described above for port-wine stains,
thin vessels can be effectively treated with the
flash-lamp pumped dye laser. Thicker vessels have
been shown to benefit from a combined treatment
with a PDL and Nd-YAG laser9 or with stacked
pulses (multiple pulses superimposed on one another
on the same area) of an IPL38 (Figs 5.4 and 5.5).
Where individual vessels cannot be seen, as in rosa-
cea-associated erythema and Civatte’s poikiloderma,
large spot-size devices, particularly IPLs, are advanta-
geous. They are used with a 25 to 35% overlap in
order to avoid visible treatment fields. However,
the bulky handpiece decreases its maneuverability
in concave areas such as around the nose. The treat-
ment area is not immediately visible due to direct
contact between the handpiece and the skin.
Pigmentary Disturbances
Pigmentary disturbances may be treated with a vari-
ety of lasers and IPL machines according to the spe-
cific wavelengths emitted. The thermal relaxation
A
B
Fig. 5.4 Large caliper telangiectasiae. A, Before laser treatment; B, immediately after treatment with the frequency-
doubled Nd-YAG laser with contact cooling, showing redness and edema.
48
Aesthetic Oculofacial Rejuvenation

time of the melanosomes, which are about 0.5 mm
in diameter, is about 250 ns. Laser light with suffi-
cient absorption by melanin and with very short
pulses should theoretically be optimal for treat-
ment. The QS ruby laser, with its wavelength of
694 nm and pulse duration of 25 to 40 ns, can selec-
tively target melanosomes without damaging the
surrounding tissue.39 However, there are many
other lasers targeting melanin because it has a very
broad spectrum of absorption. Both wavelengths
(488 and 514 nm, CW) of the argon laser, the
frequency doubled Nd-YAG (KTP) laser (532 nm,
5–10 ns, fluence 2–2.5 J/cm2 at 10 Hz, spot size
1–3 mm)
(Fig.
5.6),
QS
alexandrite
(755 nm,
50–100 ns, fluence 6–7 J/cm2) and the QS Nd-YAG
(1064 nm, 10 ns, fluence 8 J/cm2, spot size 3 mm
for nevus of Ota) all target melanin. Although the
longer wavelengths are not so well absorbed by the
melanin this light penetrates deeper and can thus also
remove dermal pigment.40
Dermatitis papulosa nigra, a frequent condition
in skin types V and VI in black Africans and Afro-
americans as well as Orientals, responds well to
the Nd-YAG laser.41
Tattoos
Tattoos are due to exogenous pigments like black
ink, but also exist in a variety of other colors. While
the removal of black tattoos does not usually pose
problems, colored tattoos are more difficult to tar-
get (Figs 5.7 to 5.9). Another problem is the depth
of the tattoo: lay tattoos are usually much deeper
and less regular than professional ones. Their
removal is therefore more difficult. Furthermore,
most lasers also target the overlying melanin, lead-
ing to (temporary) depigmentation. This is the
reason why tanned individuals should not be treated
with lasers that preferentially target melanin, but
with the QS 1064 Nd-YAG. Transient hyperpig-
mentation can also occur and prelaser hydroquinone
treatment may be advisable in those tending to
develop postinflammatory hyperpigmentation or
melasma. It is still not known exactly what happens
to the tattoo particles, particularly with multicol-
ored tattoos of organic permanent dyes. Some rela-
tively light colors, such as white, flesh-tone and red,
may undergo immediate darkening.42,43 The alexan-
drite laser is good for black, blue and most green
colored particles. The QS ruby laser is effective in
removing black, green and blue inks, but relatively
ineffective for red and yellow colors. The QS KTP
laser with its 532 nm wavelength is used to remove
red and orange tattoos. All treatments have to be
repeated until sufficient blanching or complete
removal is achieved. It is important to stress this
in
advance
as
many
patients
expect
a
single
treatment.
A
B
C
Fig. 5.5 Periocular vein. A, Before treatment; B, the vein is more visible upon stretching the overlying skin; C, after
three sessions with an IPL device.
Fig. 5.6 Pigment spots on the arms. Right, untreated; left,
after two sessions with the 532 nm QS Nd-YAG laser.
49
Lasers and Intense Light Sources

Photorejuvenation
Photorejuvenation, also called subepidermal resur-
facing, is a non-ablative or fractional laser treatment
which removes telangiectasiae, pigment spots, other
skin irregularities, solar elastosis and superficial
wrinkles, improves skin texture and reduces skin
laxity. A wide variety of lasers and IPL devices can
be used, which not only vary in wavelength emitted,
but also in pulse width, spot size, repetition rate,
pulse stacking, compression and cooling systems.
Cooling systems have a profound influence on the
fluence to be administered to achieve the result
required.
General
treatment
recommendations
concerning most of the parameters mentioned
therefore cannot be given here but depend on the
particular device being used. As mentioned above,
a test treatment in a relatively inconspicuous area
is always recommended, although with experience
and familiarity with the particular laser used the
need for tests prior to full-face treatments will
diminish. Moreover, the parameters used will also
depend on the particular treatment plan, i.e. when
A
B
C
Fig. 5.8 Tattoo in shape of a ring. A, After two sessions with a QS Nd-YAG laser; B, 2 weeks after a final alexandrite
laser session; C, 3 months after the last laser treatment.
A
B
C
Fig. 5.9 Ornamental black tattoo. A, Before treatment; B, 3 weeks after QS alexandrite laser; C, laser treatment also
reduced normal melanin pigment.
A
B
C
Fig. 5.7 Mainly black tattoo with small red portion. A, Before treatment; B, 4 months after first QS alexandrite laser
session; C, 2 months after third treatment session showing residual bluish-black pigment.
50
Aesthetic Oculofacial Rejuvenation

pigment lesions are more important they will be
treated first and either another laser or different
treatment parameters will be chosen for consecu-
tive sessions. Skin type is important too, as types I
and II are best suited to treatment with shorter
wavelengths than types III and IV. Asian skin reacts
differently and requires extra experience. Most
devices are used with two to three passes per ses-
sion and several sessions some 3 to 6 weeks apart.
The combination with botulinum toxin A injections
was reported to give significantly better results on
fine lines and small wrinkles.44
Hair Removal
Hair removal has become a very popular cosmetic
procedure in the last decade.45 Since its introduc-
tion, the technology has changed considerably: from
waxing to thermolysis, electrolysis and now laser-
assisted techniques based on selective photother-
molysis. In order to have a long-term effect on hair
growth both the bulb (hair matrix) as well as the
bulge (stem cell region) have to be damaged with
the laser. Hitting the hair bulb requires the hair to
be in the growth (anagen) phase. The hair bulb is
located deep in the dermis, or even in the superfi-
cial hypodermis, requiring relatively long wave-
lengths, which are able to penetrate that deep.
The laser pulses have to be of sufficient duration
to bring enough energy to the required depth, but
need to do so without damaging the overlying epi-
dermis. The thermal relaxation time of the follicle
is roughly 10 times that of the epidermis. Optimal
pulse width would therefore be 40–100 ms.45 To
make the laser light penetrate deeper a larger spot
size is used.
Nd-YAG light of 1064 nm penetrates deeply,
but is poorly absorbed by melanin. To overcome
this disadvantage a mineral oil–carbon solution is
used.46,47 It is applied to the shaved or waxed skin
surface and massaged into the follicular openings.
Excess material is wiped away about 10 minutes
prior to starting treatment. The laser treatment is
delivered at a fluence of 2–3 J/cm2, pulse width
10–20 ns, repetition rate of 10 Hz and spot size of
7 mm. It is thought that the effect is produced both
by the thermal effect of the carbon particles being
heated by absorption of the laser light and by the
kinetic energy of the carbon particles which are hit
by the light and propelled into the surrounding
follicular cells. Treatment is performed in scanning
movement until all carbon particles have disap-
peared. This procedure achieves a subjective and
objective reduction of hair density, which was
apparently not permanent.
A long-pulsed Nd-YAG laser was able to remove
between 20 and 40% of the unwanted hair per ses-
sion with almost complete hair removal after 4–6
sessions.48
The ruby laser emits light at a wavelength of
694 nm, which can be used to specifically target
melanin. There is apparently enough melanin in
the follicle to act as a chromophore for hair
removal,
although
the
epidermis
also
contains
melanin that absorbs ruby laser light. It has been
observed that the pulse width of the QS ruby laser
beam is too short to damage the hair follicle suffi-
ciently and because of this a 3 ms, 10–75 J/cm2
normal mode ruby laser with a repetition rate of
0.5 Hz, a 10–12 mm spot size and a cooling hand-
piece was developed (Epilaser®). Fifteen to twenty
per cent of its energy penetrates through the entire
dermis to damage the hair follicle.49 The handpiece
is firmly pressed against the epidermis to minimize
epidermal damage and to allow for deeper light pen-
etration. Topical hydroquinone treatment is advised
in darkly pigmented or tanned patients prior to laser
treatment. The fluence in skin types III and IV is
around 10 J/cm2, and in fair skinned people up to
75 J/cm2. However, the ideal treatment parameters
have to be adapted to each single patient and ses-
sion. This procedure gives longer-lasting hair reduc-
tion than the Nd-YAG carbon particle method.
When the hair regrows it is usually thinner and ligh-
ter in color. Staged multiple retreatments are now
generally recommended. Another ruby laser, with
a 0.8 ms pulse width, 1.2 Hz and 4–6 mm spot size,
has also been used.
Alexandrite lasers that are used in QS mode for
pigmented lesions and tattoos are now also available
in a long pulse mode with pulse widths between
2 and 20 ms.50 Alexandrite laser light is less well
absorbed by epidermal melanin than that of the
ruby laser, and hence more darkly pigmented skin
types may be treated with alexandrite lasers. Skin
cooling is, however, a prerequisite to reduce poten-
tial epidermal damage from the high energy and rel-
atively long pulses. Its large spot size and repetition
rate of 1–5 Hz allow large skin areas to be treated in
a reasonable time. Clearance rates observed are
between 33 and 80%.22,51–54 A pneumatic skin flat-
tening device has been shown to considerably
reduce the pain felt during laser treatment as com-
pared to a dynamic cooling device.55
Diode lasers emitting light at either 800 or
810 nm have a pulse width of 5–100 ms. This allows
51
Lasers and Intense Light Sources

skin types up to III to be treated with fluences of up
to 60 J/cm2; darker skin requires lower levels. A
rectangular tip of 9  9 mm and a repetition rate
of 2 Hz permits the treatment of large hairy areas
in a relatively short time. Clearance rates are
between 25 and 60%, depending on the time of fol-
low-up and the number of sessions.56–58 Skin cool-
ing is necessary and usually achieved with a chilled
tip built into the handpiece. However, the sapphire
lens has to be cleaned after every few laser shots in
order to remove burnt hair remnants that may
reduce the laser intensity but also heat the epider-
mis when heated by the laser beam.
IPL systems have a broad spectrum of incoherent
light with wavelengths from 500 nm to 1200 nm.
These systems allow not only hypertrichosis to be
treated but also benign pigmented and vascular
lesions.59 IPL devices have a range of selection para-
meters for the laser physician to choose from and
these usually make IPL treatment more demanding
than when using lasers. Wavelength range and flu-
ence are chosen according to skin type – the darker
the skin, the longer the wavelength. The pulses can
be stacked and applied as a single, double or up to a
7-fold pulse, with intervals between 1 and 300 ms.
These variables can be chosen individually or pro-
grams pre-defined by the manufacturer of the
device can be used. The spot size is usually rectan-
gular and very large compared to that of most lasers,
which makes up for one of their major disadvan-
tages: the slow repetition rate of approximately
0.3 Hz. Apparently, actual fluences are often not
precisely what is indicated by the manufacturers.60
Clearance rates range from 60% to over 80%.61–64
Scars
Scars can be treated with a variety of lasers. The
rationale behind their use is either to inhibit deposi-
tion of excess collagen to avoid hypertrophic scars
and keloids, or to reduce scar vascularization and
redness and to debulk scars.65,66 Observation has
shown that the microvasculature is not the sole tar-
get of the pulsed dye laser: it also makes scars more
pliable as well as less erythematous, hypertrophic
and itchy (Figs 5.10 and 5.11).
Microscopic examination of scars after laser
treatment showed finer and more fibrillar collagen.
For hypertrophic scars, two to four treatments with
the PDL, 585 nm, at fluences of 6–7 J/cm2, a 5 or
7 mm spot size and adjacent, non-overlapping
pulses were used whereas keloids required two to
six treatments.
Fractional photothermolysis has intensively been
studied in acne, surgical and traumatic scars. Even
though CO2 and Er-YAG ablative resurfacing remain
unsurpassed for the treatment of facial rhytides,
both methods have yielded lesser improvements for
scarring, with keloids usually recurring soon after
treatment. This is probably due to the fact that
the depth of tissue ablation is limited. Fractional
lasers achieve significant depth of penetration,
leading to improvements in scars similar to those-
achieved with the ablative lasers. Another advantage
of fractional lasers is that the risk of pigmentary
disturbance,
even
in
higher
skin
pigmentation
types, is greatly reduced. High energies, with deep
tissue coagulation, are apparently associated with
the best clinical improvement. In a large series of
A
B
Fig. 5.10 Scar from car accident. A, before treatment; B, after three laser sessions.
52
Aesthetic Oculofacial Rejuvenation