Video Atlas Phẫu Thuật Tạo Hình Thẩm Mỹ (Aesthetic Plastic Surgery Video Atlas)

Aesthetic
Plastic
Surgery
VIDEO
ATLAS

Commissioning Editor: Sue Hodgson
Development Editor: Emma Cole
Project Manager: Cheryl Brant
Design: Stewart Larking
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Illustrator: Antbits
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Aesthetic
Plastic Surgery
VIDEO ATLAS
Bahman Guyuron MD, FACS
Kiehn-DesPrez Professor and Chair
Department of Plastic Surgery
Case Western Reserve University/University Hospitals Case Medical Center
Cleveland, Ohio, USA
Brian M. Kinney MD, FACS, MSME
Clinical Assistant Professor of Plastic Surgery
University of Southern California
Private Practice
Plastic and Reconstructive Surgery
Los Angeles, CA, USA
For additional online content visit

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Saunders
British Library Cataloguing in Publication Data
Aesthetic plastic surgery video atlas.
1. Surgery, Plastic–Atlases.
I. Guyuron, Bahman.
617.9'52-dc22
9781455711833
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress.
Notice
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v
CONTENTS
User Guide
vii
Preface
ix
List of contributors
x
Dedication
xiii
Acknowledgements
xiv
Aesthetic Plastic Surgery Video Atlas

1 Patient Assessment
1

Bahman Guyuron

2 Skin Care Including Chemical Peeling
11

Zoe Diana Draelos

3 Non-surgical Facial Rejuvenation with Fillers
21

Brian M. Kinney, David J. Rowe and David Stepnick

Clip 3.1: Non-surgical Facial Rejuvenation with Fillers

Brian M. Kinney

4 Botulinum Toxin
35

Michael A. C. Kane

Clip 4.1: Botulinum Toxin

Bahman Guyuron

5 Laser Facial Resurfacing and Dermabrasion
43

Richard O. Gregory

Clip 5.1: Laser Resurfacing and Dermabrasion

Thomas E. Rohrer

6 Management of Alopecia
49

Jack Fisher

Clip 6.1: Hair Transplantation

Robin Unger and Walter Unger

7 Forehead Rejuvenation
67

Bahman Guyuron

Clip 7.1: Forehead Rejuvenation

Bahman Guyuron

8 Periorbital Rejuvenation
85

Bahman Guyuron and Donald T. Hudak

Clip 8.1: Periorbital Rejuvenation

Bahman Guyuron

9 Facelift with SMAS Flaps
103

Timothy J. Marten

Clip 9.1: High SMAS Face and Mid-face Lift

Brian M. Kinney

vi

10 Neck Rejuvenation
131

Patrick K. Sullivan and Erik A. Hoy

Clip 10.1: Neck Contouring

Bahman Guyuron

11 Primary Rhinoplasty
137

Rod J. Rohrich and Ronald E. Hoxworth

Clip 11.1: Primary Rhinoplasty

Rod J. Rohrich

12 Secondary Rhinoplasty
167

Bahman Guyuron and David Stepnick

13 Genioplasty
179

Bahman Guyuron and Adam Bryce Weinfeld

Clip 13.1: Genioplasty

Bahman Guyuron

14 Aesthetic Contouring of the Craniofacial Skeleton
199

Michael J. Yaremchuk

Clip 14.1: Chin Augmentation with Porous Implants

Michael J. Yaremchuk

Clip 14.2: Mandible Augmentation with Porous Implants

Michael J. Yaremchuk

15 Augmentation of Facial Structures with Autologous Fat
213

Sydney R. Coleman and Alesia P. Saboeiro

16 Breast Augmentation
219

Per Hedén

Clip 16.1: Breast Augmentation

Per Hedén

17 Breast Reduction
233

Elizabeth J. Hall-Findlay

Clip 17.1: Breast Reduction

Elizabeth J. Hall-Findlay

18 Mastopexy
249

G. Patrick Maxwell, Jeremy Waldman and Stephanie Stover

Clip 18.1: Mastopexy

Elizabeth J. Hall-Findlay

19 Liposculpture
259

Fabio X. Nahas, Marcus Vinicius Jardini Barbosa and Lydia Masako Ferreira

Clip 19.1: Liposculpture

Fabio X. Nahas

20 Abdominoplasty
267

Al S. Aly, Silvia Cristina Meneghetti Rotemberg and Albert E. Cram

Clip 20.1: Abdominoplasty

Al S. Aly

21 Bodylifts and Post-massive Weight Loss Body Contouring
285

J. Peter Rubin and Jeffrey Gusenoff

Clip 21.1: Post Bariatric Surgery Skin Tightening

J. Peter Rubin

22 Surgical Management of Migraine Headaches
313

Bahman Guyuron and Devra B. Becker

Index
325
CONTENTS

vii
USER GUIDE
Aesthetic Plastic Surgery Video Atlas
The supporting website for the book, which includes all of the book’s
content, including the video and image downloads, can be found at

This page intentionally left blank

ix
PREFACE
Implementing the knowledge attained from a book chapter in the
operating room, regardless of how detailed the description of the
procedure is in the text, often presents an enormous challenge since
some of the nuances would be commonly omitted. A combination
of proper description of the surgical technique and precise artistic
renderings along with clear videos provides the optimum source of
information for surgery, and overcomes this diffi culty in execution in
most instances. With that in mind, we have prepared this book to
give the readers a practical tool that can be used to augment the safety
of the contemplated procedures. This atlas with accompanying videos
will not only serve residents and new graduates, who can read the
text, review the illustrations and observe the video prior to the surgery,
it will also help seasoned surgeons who may wish to refi ne their
technique. Especially for the latter group who has experience with
these techniques, some of the points that are demonstrated by the
experts in the videos may serve to facilitate the surgery, add to the
safety and improve the outcomes. We have asked highly respected
authors in the fi eld to share their techniques with the readers using
as much detail as possible. The videos have been edited by our well-
regarded colleague Dr. Brian M. Kinney, who is highly recognized for
his quintessential talent in this area, and we are utterly grateful to
him for his contribution to this volume. We are very much hopeful
that the readers are going to enjoy the content, the illustrations and
the videos. Finally, we would like to acknowledge and thank the other
editors of Plastic Surgery, Indications and Practice for their unselfi sh
and persevering work, expertise and wisdom which made this spin
off possible.
Bahman Guyuron, MD

x
LIST OF CONTRIBUTORS
Al S. Aly MD
Assistant Professor of Surgery
University of Iowa College of Medicine
Coralville
IA
USA
Chapter 20 Abdominoplasty

Clip 122.1 Abdominoplasty
Marcus Vinicius Jardini Barbosa MD PhD
Collaborator Professor
Department of Surgery, Division of Plastic
Surgery
Federal University of São Paulo
São Paolo
SP
Brazil
Chapter 121 Liposculpture
Devra B. Becker MD
Assistant Professor
Department of Plastic Surgery
Case Western Reserve University/University
Hospitals
Cleveland
OH
USA
Chapter 22 Surgical Management of Migraine
Headaches
Sydney R. Coleman MD
Assistant Clinical Professor NYU School of
Medicine
Tribeca Plastic Surgery
New York
NY
USA
Chapter 15 Augmentation of Facial Structures
with Autologous Fat
Albert E. Cram MD FACS
Iowa City Plastic Surgery
Coralville
IA
USA
Chapter 20 Abdominoplasty
Zoe Diana Draelos MD
Primary Investigator
Dermatology Consulting Services
High Point
NC
USA
Chapter 2 Skin Care Including Chemical
Peeling
Lydia Masako Ferreira MD
Full Professor and Chairwoman
Plastic Surgery Division
Federal University of São Paulo
São Paulo
Brazil
Chapter 121 Liposculpture
Jack Fisher MD
Associate Clinical Professor
Department of Plastic Surgery
Vanderbilt University
Nashville
TN
USA
Chapter 6 Management of Alopecia
Richard O. Gregory MD
Director
Institute of Aesthetic Surgery
Celebration
FL
USA
Chapter 5 Laser Facial Resurfacing and
Dermabrasion
Jeffrey Gusenoff MD
Director, Life After Weight Loss
Division
of
Plastic
and
Reconstructive
Surgery
University of Rochester
Rochester
NY
USA
Chapter 21 Bodylifts and Post-massive Weight
Loss Body Contouring

Clip 21.1 Post Bariatric Skin Tightening
Bahman Guyuron MD FACS
Kiehn-DesPrez Professor and Chair
Department of Plastic Surgery
Case Western Reserve University/University
Hospitals Case Medical Center
Lyndhurst
OH
USA
Chapter 1 Patient Assessment
Chapter 7 Forehead Rejuvenation
Chapter 8 Periorbital Rejuvenation
Chapter 12 Secondary Rhinoplasty
Chapter 13 Genioplasty
Chapter 22 Surgical Management of Migraine
Headaches

Clip 4.1 Botulinum toxin

Clip 7.1 Forehead Rejuvenation

Clip 8.1 Periorbital Rejuvenation

Clip 10.1 Neck Rejuvenation

Clip 13.1 Genioplasty
Elizabeth J. Hall-Findlay MD FRCSC
Private Practice
Mineral Springs Hospital
Banff
AB
Canada
Chapter 17 Breast Reduction

Clip 17.1 Breast Reduction

Clip 18.1 Mastopexy
Per Hedén MD PhD
Associate Professor in Plastic Surgery
Akademikliniken
Stockholm
Sweden
Chapter 16 Breast Augmentation

Clip 16.1 Breast Augmentation
Ronald E. Hoxworth MD
Assistant Professor
Department of Plastic Surgery
University of Texas Southwestern Medical
Center
Dallas
TX
USA
Chapter 11 Rhinoplasty

Clip 11.1 Primary Rhinoplasty

xi
Erik A. Hoy MD
Resident
Department of Plastic Surgery
Brown University – Rhode Island Hospital
Providence
RI
USA
Chapter 10 Neck Rejuvenation
Donald T. Hudak MD
Assistant Professor of Plastic Surgery and
Ophthalmology
Case Medical Center
Cleveland
Assistant Professor of Ophthalmology
University of Cincinnati
Cincinnati Eye Institute
Cincinnati
OH
USA
Chapter 8 Periorbital Rejuvenation
Michael A. C. Kane MD
Attending Surgeon
Manhattan Eye, Ear and Throat Hospital
New York
NY
USA
Chapter 4 Botulinum Toxin
Brian M. Kinney MD FACS MSME
Clinical Assistant Professor of Plastic
Surgery
University of Southern California
Private Practice
Plastic and Reconstructive Surgery
Los Angeles
CA
USA
Chapter 3 Non-surgical Facial Rejuvenation
with Fillers

Clip 3.1 Non-surgical Facial
Rejuvenation with Fillers

Clip 9.1 High SMAS Face and
Midface Lift
Timothy J. Marten MD
Founder and Director
Marten Clinic of Plastic Surgery
San Francisco
CA
USA
Chapter 9 Facelift with SMAS Flaps
G. Patrick Maxwell MD FACS
Maxwell Aesthetics
Nashville
TN
USA
Chapter 18 Mastopexy
Fabio X. Nahas MD PhD
Associate Professor
Division of Plastic Surgery
Federal University of São Paulo
São Paulo
Brazil
Chapter 19 Liposculpture

Clip 19.1 Liposculpture
Thomas E. Rohrer MD
Director, Mohs Surgery
SkinCare Physicians of Chestnut Hill
Clinical Associate Professor
Department of Dermatology
Boston University
Boston
MA
USA

Clip 5.1 Laser Resurfacing and
Dermabrasion
Rod J. Rohrich MD
Professor and Chairman
Crystal Charity Ball Distinguished Chair
in Plastic Surgery
Betty and Warren Woodward Chair in Plastic
and Reconstructive Surgery
Department of Plastic Surgery
University of Texas Southwestern Medical
Center
Dallas
TX
USA
Chapter 11 Rhinoplasty

Clip 11.1 Primary Rhinoplasty
Silvia Cristina Meneghetti Rotemberg
MD
Associate Staff
Plastic Surgery
The Cleveland Clinic
Cleveland
OH
USA
Chapter 20 Abdominoplasty
David J. Rowe MD
Assistant Professor, Plastic Surgery
Department of Plastic Surgery
University Hospitals Case Medical Center
Lyndhurst
OH
USA
Chapter 3 Non-surgical Facial Rejuvenation
with Fillerss
J. Peter Rubin MD
Director of Body Contouring Program
Associate Professor of Surgery
Division of Plastic Surgery
University of Pittsburgh
Pittsburgh
PA
USA
Chapter 21 Bodylifts and Post-Massive
Weight Loss Body Contouring

Clip 21.1 Post Bariatric Skin Tightening
Alesia P. Saboeiro MD
Private Practice
Tribeca Plastic Surgery
New York
NY
USA
Chapter 15 Augmentation of Facial
Structures with Autologous Fat
David Stepnick MD FACS
Associate Professor, Facial Plastic Surgery
Department of Plastic Surgery
University Hospitals Case Medical Center
Case Western Reserve University
Lyndhurst
OH
USA
Chapter 3 Non-surgical Facial Rejuvenation
with Fillers
Chapter 12 Secondary Rhinoplasty
Stephanie Stover MD
Associate to Dr Maxwell
Nashville Plastic Surgery
Nashville
TN
USA
Chapter 18 Mastopexy
Patrick K. Sullivan MD
Associate Professor
Plastic Surgery
Brown University
Providence
RI
USA
Chapter 10 Neck Rejuvenation
Robin Unger MD
Assistant Clinical Professor
Department of Dermatology
Mount Sinai Medical School
New York City
NY
USA

Clip 6.1 Hair Transplantation
Walter Unger MD
Clinical Professor
Department of Dermatology
Mount Sinai School of Medicine
New York
NY
USA

Clip 6.1 Hair Transplantation
list of Contributors

xii
Jeremy Waldman MD
Plastic Surgeon
Private Practice
Plastic and Reconstructive Surgery
Waldman Plastic Surgery and Dermatology,
PLLC
Nashua
NH
USA
Chapter 18 Mastopexy
Adam Bryce Weinfeld MD
Attending Plastic Surgeon
University Medical Center
Brackenridge and Dell Children’s Medical
Center of Central Texas
Austin
TX
USA
Chapter 13 Genioplasty
Michael J. Yaremchuk MD
Clinical Professor of Surgery
Harvard Medical School
Chief of Craniofacial Surgery
Massachusetts General Hospital
Boston
MA
USA
Chapter 14 Aesthetic Contouring of the Cran-
iofacial Skeleton

Clip 14.1 Chin Augmentation with
Porous Implants

Clip 14.2 Mandible Augmentation with
Porous Im plants
list of Contributors

xiii
DEDICATION
To Bruce Achauer.

xiv
ACKNOWLEDGEMENTS
We would like to thank our families whose sacrifi ces and unselfi sh reduction
of demand on our family time makes our participation in endeavors like editing this book possible for us.
Bahman Guyuron: To Lora, Glen, Greg, and Grant
Brian M. Kinney: To my Mother and Father, and Pearl

1
CHAPTER 1
Patient Assessment
Bahman Guyuron
INTRODUCTION
A cosmetic surgery patient requires a different evaluation from the
patient who is seeking a reconstructive procedure. Since the former is
an elective surgery, decisions regarding the patient’s medical suitabi-
lity to undergo surgery, patient preparation and selection of a procedure
that will successfully fulfi ll the aesthetic objectives must be approached
with more scrutiny every step of the way.
The individual’s perception of the nature of the aesthetic dishar-
mony and his or her motivation for consultation may differ from those
of the surgeon. For this reason, the cardinal aim in the assessment of
a patient seeking aesthetic surgery is to delineate the patient’s percep-
tion of the existing problems. A circumspect facial analysis then guides
the surgeon in choosing the proper candidate and the optimal proce-
dure. Current, or previous, cigarette smoking may increase the risk of
complications from surgeries of any type, especially those requiring
elevation of skin fl aps. Cessation of smoking does not necessarily
eliminate this risk; it may only reduce the extent of complications.
Thus, in most incidences, those who have smoked cigarettes heavily
for a long period pose higher risk than non-smokers, due to compro-
mised skin circulation. Additionally, patients with cold intolerance, in
all likelihood, suffer from reduced skin circulation and any surgery
involving skin fl aps on this group of patients may ensue with delayed
healing or loss of a portion of the skin fl ap.
Careful listening to the patients’ statements, exploration of their
reasons for surgery and their expectations from the surgery, may lead
the surgeon to suspect that a patient may have, at least, unrealistic
expectations from the surgery or even perhaps body dysmorphic
disorder (BDD). Visits to numerous plastic surgeons’ offi ces, having
undergone multiple surgeries with resultant dissatisfaction and/or
disparaging remarks about the previous surgeon should alert the exam-
ining surgeon to the need for exercising more caution, analyzing the
patient’s emotional stability more in depth and, if deemed necessary,
seeking consultation from a psychiatrist or a psychologist, especially
when a depressive or dysmorphic type disorder is suspected. A morose,
tearful patient who sees only the negative aspect likely suffers from
a depression, while the patient with BDD either sees a deformity
that does not exist or sees a great deal more than is present
(Table 1.1).
The mean age of BDD onset is 16.4 ± 7 years, although most
patients don’t seek treatment until their late thirties.1,2 The course of
the disorder tends to be continuous rather than episodic and complete
remission of symptoms appears to be rare, even after treatment. The
disorder appears to affect men and women with equal frequency.2,3
Male patients may be more likely to be unmarried.
Clinical features of BDD include varying degrees of preoccupation
with perceived defects. Men may become preoccupied with their geni-
tals, height, hair and body build, whereas women typically report
concerns with their weight, hips, legs and breasts. Some patients may
present with highly specifi c concerns (e.g. perceived asymmetry of a
body part), whereas others may have vague complaints (e.g. concern
Summary
1. The fi rst step in achieving a successful surgery outcome is to
establish a clear understanding of the patient’s objectives and
to ensure that they match those of the surgeon’s.
2. Hypertension, diabetes, smoking, cold intolerance,
consumption of anti-infl ammatory medication and some of the
herbal medications, such as gingko biloba, may increase the
risk of aesthetic surgery or prolong the recovery.
3. Patients who have a history of multiple previous aesthetic
procedures and continue to be dissatisfi ed may be suffering
from body dysmorphic disorder (BDD) and should be assessed
with more scrutiny.
4. While patients with thin, light skin (Fitzpatrick I or II) may
demonstrate aging faster with fi ne lines, they respond to
chemical peel and laser resurfacing more favorably. On the
contrary, patients with thick and dark skin (Fitzpatrick V or VI)
are not ideal candidates for resurfacing.
5. Deep horizontal forehead lines are often the consequence of
blepharodermachalasia or blepharoptosis and compensation by
frontalis muscle. Steps should be taken to relax the frontalis
muscle prior to a fi nal judgment as to the position of the
eyebrow.
6. On a face with optimal balance, distance from the cephalic
border of the eyebrow to the mid point of the pupil on a
straight gaze is 2.5 cm.
7. Pre-existing lower lid lag, loss of lower lid tone or presence of
a negative vector where the malar soft tissue prominence is
positioned behind the cornea on profi le, and symptoms of dry
eyes mandate conservative surgery and canthopexy or
canthoplasty.
8. The intercanthal distance is about 31–33 mm wide and
matches the distance from the medial to the lateral canthus
{orbital fi ssure}. The orbital fi ssures should be more cephalad
laterally by 2º.
9. The upper incisor should be visible 2 mm caudal to the upper
lip with the lips gently parted on repose, with minimal or no
gingiva exposed on smiling.
10. An obtuse neck angle could be the consequence of varying
combinations of excess skin, excess supra-platysma fat,
excess sub-plastysma fat, prominent platysma bands,
hypertrophic anterior belly of the digastric muscles or
submaxillary gland and ptotic submaxillary gland.

1
PATIENT ASSESSMENT
2
that a body part just does not look right). Rhinoplasty, liposuction and
breast augmentation are among the most frequently sought surgical
procedures by the patients affl icted with BDD.4,5 Seven to fi fteen
percent of cosmetic surgery patients meet criteria for BDD.
MEDICAL HISTORY
Consumption of prescription, over-the-counter or herbal medications
should be investigated carefully (Table 1.2). These may have deleteri-
ous effects on surgery and recovery by causing intraoperative bleeding,
subsequent hematomas and delayed healing.
The condition and color of the skin is relevant to the successful
outcome of the fi nal surgery in pivotal ways. The patients with lighter
skin (Fitzpatrick I or II) generally heal better and are more suitable
candidates for laser resurfacing or chemical peel, although their
dynamic lines, which appear on animation, would not respond favor-
ably to resurfacing, while the static lines, which are present all the
time, improve notably with resurfacing. However, those with light
freckled skin and blue eyes, have a higher propensity to bleed exces-
sively and develop hypertrophic scars after surgery. The patients who
possess darker skin (Fitzpatrick V or VI) are not ideal candidates for
resurfacing and any resurfacing on this group of patients will require
additional consideration. This group of patients, on the other hand,
usually does not exhibit deep dynamic lines.
Table 1.1 Alarming clues suggestive of further patient
assessment or avoidance of surgery
You have an uncomfortable feeling about the patient
Patient exhibits clinical signs of emotional instability
Patient’s expectations seem unrealistic
Patient’s objectives are in confl ict with your aesthetic judgment
Patient provides you with deceitful information
Patient demands guarantees
Patient makes disparaging remarks about the previous surgeon
Patient asks you to take part in keeping the truth about surgery
from the spouse
Patient treats you or your staff disrespectfully
Patient appears to have diffi culty comprehending the
recommended course
Table 1.2 Medications and food products that have deleterious effects on surgery
Acutane
Advil
Aleve
Accutrim
Actifed
Adapin
Alka Seltzer
Anacin
Ansaid
Anaprox
Argesic
Arthralgen
Arthrits Pain Formula
Arthropan
Ascription
Aspercin
Aspergum
Ativan
Axotal
Bayer Aspirin
BC tab or Powder
Bufferin
Capron Capsules
Chlortrimetron
Cama
Compazine
Congesprin
Cope
CP-Z
Clinoril
Contact
Coricidin
Coumadin
Darvon
Dimetane
Dimetapp
Dolcin
Dristan
Duradyne
Duradyne Forte
Duragesic
Ecotringen
Emprin
Endep
Etiaron
Excedrin
Feldene
Fiorinal
Flagyl
4-Way Cold
Tablets
Goody’s Tablets
Ibuprofen
Indocin
Measurin
Milain
Minocin
Momentum
Motrin
Mysteclin-F
Naprosyn
Nicobid
Nuprin
Orafl ex
Pabirin
PAC
Pamelor
Parodyne Analgesic
Pepto Bismal
Percodan
Persantine
Persistin
Robaxisal
Ruffen
Ru-Tass
Sal-Payne Capsules
Seldane
S-A-C Tablets
Saieto
Salacol
Sineutab
Sinequan
Sk-65 Compound
Sanback
Stelazine
Stendin
Sine-Off
Sparine
Stanback Tabs/
Powder
St. Joseph’s Baby
Aspirin
Supac
Surmontil
Syalgos
Talwin
Telanil Tantab
Tenuate
Tepanil
Thorazine
Tofranil
Tolmetin
Toridol
Trilifon
Tenuate Dospan
Tetracycline
Tolectin
Trendar
Triaminicin
Trigesic
Ursinus
Uracel
Vanquish
Vibramycin
Vioxx
Warfarin
Zomax
Zorporin
Herbs: feverfew, ginko balboa, ginger and St. John’s wort.
Vitamins: E, fi sh oil, garlic tablets.
Cholesterol medications (should be stopped 2 weeks before surgery).
Foods containing salicylates (should be eaten in moderation): almonds, apples, apricots, berries (blackberry, boysenberry, raspberry, strawberry), cherries, Chinese black
beans, cucumbers, currants, grapes, pickles, prunes, tomatoes, wine and alcohol.

3
Facial Analysis
Patients in the age group of 50 years or older, and those with
known medical conditions that could potentially increase the risk
of surgery, should undergo a full medical check up, or an ophthalmol-
ogy examination within 1 year of surgery if eyelid surgery is being
considered.
Completion of a comprehensive health form is the most effective
way to record information regarding a patient’s medical history. Most
seasoned surgeons have designed their own questionnaires to lead
patients in disclosing medical problems that may have an adverse
effect on the surgical outcome.
The most common medical condition that may have deleterious
infl uence on an aesthetic surgery outcome is hypertension. Undoubt-
edly, controlling the hypertension plays a prodigious role in reducing
the risk of postoperative hematoma development. The patient’s blood
pressure must be normalized during the several weeks before surgery.
If the patient is consuming medications that may contract the blood
volume, the surgeon must exercise caution for any developing intra-
operative hypotension and, if it occurs, it should be corrected before
the incisions are closed. Otherwise, hypotension prevents visualization
of the transected blood vessels since they do not bleed, which can start
bleeding when the blood pressure rises to the normal level post opera-
tively. In other words, it is the relative hypertension that may cause
postoperative hematomas.6
Diabetes is another condition that may lead to postoperative com-
plications.7 Patients with a positive family history of diabetes may have
a weakened immune system without clinical or laboratory evidence of
diabetes, causing infectious complications that would not otherwise
occur under ordinary circumstances. A history of recurrent infection or
poor healing on a patient with a family history of this condition, may aid
in diagnosing previously undetected diabetes.7 When diabetes is sus-
pected and the fasting blood glucose levels are normal, a simple glucose
tolerance test can help uncover an unrecognized diabetes. History of
easy bruising or prolonged bleeding, if no pharmaceutical products
which can cause bleeding have been consumed, should raise the sus-
picion of some type of coagulopathy, such as Von Willebrand’s disease.7a
FACIAL ANALYSIS
In this chapter we will focus on facial analysis in detail. Analysis of
the other parts will be incorporated within the related chapters. To
analyze the face in an organized manner, the face is arbitrarily divided
into three anatomic zones by three imaginary horizontal lines. The
upper line lies at the hairline; the second is at eyebrow level; and the
lower line passes through the columella-labial junction (Fig. 1.1). In a
comely face these three horizontal lines divide the face into three equal
sections. The components of these three zones are appraised individu-
ally from frontal and profi le views, and likewise the relationships
between these units are examined.
Front view of the upper zone
The harmony of the upper aesthetic unit can be marred by a high-
positioned hairline, leading to an elongated forehead. This fi nding is
of particular signifi cance when planning the incision for forehead
rejuvenation on a patient with a senescent forehead (Fig. 1.2). When
the forehead is long, the surgeon may forego a coronal incision or an
endoscopic forehead rejuvenation and choose a pretracehial incision,
using either the subcutaneous or subgaleal dissection to reduce the
forehead height.8,9
Deep wrinkles in the forehead area are commonly the result of
compensation of the frontalis muscle to minimize the effects of
eyebrow or eyelid ptosis (Fig. 1.3). Thus, it is critical for the surgeon
to relax the forehead before selecting a forehead rejuvenation proce-
dure. This can often be accomplished by asking the patient to smile.
Usually a compensatory elevation of the eyebrow is eliminated while
smiling. The second approach is to ask the patient to close the eyes
tightly, and then gently start opening the eyes until the patient can
see the viewer. The compensation will become evident as soon as the
patient is asked to open the eyes at libre. Analyzing the type of exist-
ing wrinkles also aids in choosing a more effective forehead rhytidec-
tomy procedure. In general, deep forehead wrinkles do not respond as
favorably to a subgaleal forehead rhytidectomy or an endoscopic fore-
head rejuvenation. A subcutaneous approach may produce a more
successful result in patients with pronounced forehead wrinkling.10 A
combination of endoscopic forehead rejuvenation and laser resurfacing
is a logical choice for those who exhibit eyebrow ptosis and many fi ne
wrinkles.
Because of the role they play in the selection of suitable corrective
procedures, the function of the corrugator and procerus muscles and
their effect on the overlying skin deserve attention. Visible vertical
frown lines may require removal of the corrugator muscle and subcu-
taneous placement of fat. An overactive depressor supercilii muscle
results in oblique lines medial to the eyebrows.
Profi le view of the upper zone
Reviewing the lateral portion of the forehead helps the surgeon to
determine the position of the temple hair in relation to the lateral
canthus. If the hairline is receding at the temple area and the patient
is considering a facial rhytidectomy (Fig. 1.4), one may choose the
anterior hairline temple incision11,12 over the incision placed within
the hair-bearing temple.
The forehead profi le contour should be smooth and pleasing. Any
imperfections, such as frontal protrusion and recession, can be the
result of a variety of pathologic conditions. Most commonly, the fore-
head contour abnormality results from bony protrusion caused by
sinus hyperaeration (frontal bossing) (Fig. 1.5) and, less commonly, it
results from soft tissue excess.13 Not only do these fl aws reduce the
desirability of the forehead contour; they may infl uence the outcome
of other aesthetic procedures, such as rhinoplasty. A small ridge cranial
to the eyebrow is an acceptable masculine characteristic. Presence of
a ridge on a woman, or an exaggerated prominence on either gender,
may require aesthetic contouring of the frontal bone. Additionally, as
Fig. 1.1 Lines passing through eyebrows and subnasale divide face
into three equal zones.
Three equal zones of the face
2
1
3
Subnasal
Hairline
Glabella

1
PATIENT ASSESSMENT
4
Fig. 1.2 Frontal view of a patient with elongated forehead and
eyebrow ptosis who would be a better candidate for forehead
rejuvenation with pretrichial incision rather than endoscopic
forehead rejuvenation or coronal incision.
Fig. 1.3 Patient with iatrogenic receding temple hairline as a
consequence of rhytidectomy incision being placed at temple
hairline.
Fig. 1.4 Patient with signifi cant forehead wrinkles and eyelid ptosis;
note eyebrow compensation.
Fig. 1.5 Profi le view of patient with frontal bossing caused by
hyperaeration of frontal sinuses.
a consequence of aging, the round and slightly projected glabellar area
may appear fl at or even depressed to varying degrees. Correction of
this fl attening undoubtedly bestows a rejuvenated appearance to the
forehead.
Front view of the middle zone
Most imbalances involve the middle and lower areas of the face. The
upper border of the eyebrows should be located at least 2.5 cm above
the mid pupil level on a straight gaze.14 The medial end of a pleasing
eyebrow is caudal to the lateral extreme, and the highest portion of
the eyebrow arch is at the junction of the lateral third with the medial
two-thirds of the eyebrow, corresponding to the lateral limits of the
limbus in a straight gaze. Eyebrow ptosis results in crowding of the
orbital region and must be differentiated from blepharodermachalasia.
Any asymmetry in the level or the shape of the eyebrow arch may
require differential eyebrow ptosis correction.
The distance between the medial canthi (intercanthal distance)
that is normally approximately 31–33 mm, equals the distance between

5
Facial Analysis
Upper face
Fig. 1.6 Width of upper face is 5 times that of palpebral fi ssure. Of
fi ve equal segments, two are occupied by eyes, one by nose and
two by temples.
the medial and lateral canthi (orbital fi ssure width) (Fig. 1.6). This
relationship becomes particularly important when dealing with rhino-
plasty candidates who would benefi t from refi nement of the nasal
dorsum and adjustment of the alar bases. Adding to the radix creates
an illusion of reduced intercanthal distance, which is detrimental to
those patients who exhibit hypotelorism, whereas reduction of the
nasal dorsal projection produces the opposite effect.15 Even slight hypo-
telorism is undesirable and detracts signifi cantly from the patient’s
attractiveness. Narrowing the distance of the nasal bones spawns an
illusion of decreased intercanthal distance.8
The individual with a slight increase in the intercanthal distance
may still be considered attractive. Yet, when the distance extends
beyond 36 mm, it leads to a grossly abnormal and displeasing appear-
ance. Presence of hypertelorism or telecanthus is also consequential
when planning rhinoplasty because widening the distance between the
nasal bones literally or by virtue of an optical illusion, such as adding
a wide dorsal graft, will result in the appearance of more severe hyper-
telorism or telecanthus. While the surgeon must be conservative
when widening the nasal bridge of a patient with a wide intercanthal
distance, a wider bridge may prove salutary for the patient who has a
shorter intercanthal distance.
The upper portion of the midface can be divided into fi ve equal
segments, two are occupied by the eyes; one extends from one medial
canthus to another, containing the root of the nose; and two extend
from the lateral canthi to the lateral boundary of the ipsilateral temple
area (Fig. 1.6). Disharmony of this area has a signifi cantly ruinous
effect on the pulchritude of the face. Anteroposterior discrepancies of
the eyes cannot be fully noticed on a frontal view, but are more per-
ceptible on a basilar view. Detection of level and depth abnormalities
of the eye is important so that the patient can be informed of structural
abnormalities that may fail usual efforts at achieving balance in this
part of the face.
Edema around the eyes in a blepharoplasty candidate may indicate
abnormal thyroid dysfunction or renal failure (Fig. 1.7). Bilateral or
unilateral exophthalmus may be the consequence of hyperthyroidism
Fig. 1.7 Patient presenting for blepharoplasty exhibits periorbital
edema. Thyroid tests disclosed hypothyroidism.
(Fig. 1.8). On patients who are contemplating blepharoplasty, vision
and lacrimal function also should be assessed. A combination of slight
proptosis and dry eyes or borderline tear production is inauspicious
and can lead to a troublesome postoperative course.
The optimal vertical opening of one eye is approximately 10 mm,
placing the upper eyelid margin 1 mm below the upper limits of the
limbus. In the aesthetic surgery patient population, mild-to-moderate
upper eyelid ptosis is common, but can easily be missed. This condi-
tion is readily corrected using one of several available techniques. In
a harmonious face the lateral canthus is generally 2º higher than the
medial canthus, giving a slight slant to the eye fi ssure. The antipode
of this relationship gives the patient a tired and sad appearance (Fig.
1.9), typically seen in patients with craniofacial deformities, such as
Treacher-Collins syndrome, and in patients with lateral lid lag
following lower blepharoplasty (Fig. 1.10).
As stated, unilateral or bilateral proptosis is an important fi nding
that may present as only a slight asymmetry and excessive opening of
one eye or both eyes, or as a signifi cant prominence of the globes.
Often this fi nding is an indication of a thyroid dysfunction and, there-
fore, it necessitates a careful medical evaluation before blepharoplasty.
Generalized thickening of the upper and lower eyelids may be a refl ec-
tion of hypothyroidism, which should be investigated thoroughly
before any periorbital surgical endeavor. Occasionally the lacrimal
glands are ptotic and present as an excessive bulk along the lateral
Fig. 1.8 Patient seeking blepharoplasty to correct exophthalmus
was discovered to have hyperthyroidism.

1
PATIENT ASSESSMENT
6
occur. To conduct the test for Bell’s phenomenon, the examiner asks
the patient to force the eyes closed while the examiner attempts to
open the eyelid by lifting the lid with a fi nger. With a positive Bell’s
phenomenon, the globe rolls cephalad, protecting the cornea under the
upper lid (Fig. 1.11). A negative Bell’s phenomenon may be indicative
of a potential for an increase in corneal exposure; hence, dryness
and ulceration of the cornea should a lid lag ensue post eyelid
surgery.
A pleasing lower eyelid is located at the caudal limits of the limbus
or minimally overlaps it. An increased distance between the lower lid
and the limbus, with excessive sclera visible through the lids, is an
indication of a lower lid lag, which should be evaluated carefully. The
lower lid support system weakness could be congenital. Whether it is
congenital, iatrogenic or due to senescence, this condition should alert
the aesthetic surgeon to undertake a conservative lower lid surgery or
to incorporate a procedure that fortifi es the lid support, such as can-
thoplasty or canthopexy. A lower lid lag should be differentiated from
an ectropion. The latter is characterized by outwards rotation of the
lid margin and the eyelashes. Checking the tone of the lower lid with
a pinch and traction test may aid the examiner in differentiating a
congenital caudal lower lid malposition from a weak lower lid support.
Swift return of the lid to its previous position, after it is pulled caudally
or pinched and released, indicates good muscle tone. Motility (cepha-
locaudal moveability) of the lateral canthus should be less than 7–
8 mm and the maximum distance from the globe while the lid is pulled
anteriorly should not exceed 7 mm.
The quality of the skin and the types of existing wrinkles guide the
surgeon in deciding between skin/muscle fl ap, conjunctive blepharo-
plasty, a lower lid laser resurfacing procedure, a chemical peel, or a
combination of these techniques. Generally, patients with thin skin
and fi ne wrinkles do not experience long-lasting results from laser
resurfacing, even though the initial improvement may be signifi cant.
On the other hand, patients with thicker skin usually experience a
lesser degree of improvement that is of longer duration.
Any depression in the nasojugal area or cephalad to the infraorbital
rim may necessitate soft tissue repositioning or fat grafting. Malar
bone hypoplasia, although better judged in the profi le view, may be
detected in the frontal view as well. When evaluating the nose, the
examiner must observe the width, direction and smoothness of the
dorsal contour. The cephalocaudal nose length, defi ned as the distance
from the nasion to the caudal border of the infra tip lobule, is twice
the distance from the columella-labial junction (subnasale) to the junc-
tion of the lips (stomion) and equals the distance from the stomion to
the menton (base of the chin) (Fig. 1.12). The nasal dorsum and the
tip should be in line with the midline of the other facial structures.
Any abnormalities can be easily ascertained by drawing an imaginary
vertical line starting from the glabella. The nose tip, the philtum
dimple and the center of the chin should all fall on the same line.
The quality of the nasal skin is a signifi cant factor in planning
surgery and achieving the intended objectives.10 Patients who have
thicker skin usually are not optimal candidates for rhinoplasty because
the tip would not be as well-defi ned post operatively. On the other
hand, patients who have very thin skin tend to reveal every imperfection
Fig. 1.9 Patient with antimongoloid slant of orbital fi ssure,
rendering sad and tired appearance.
Fig. 1.10 Patient with iatrogenic displacement of lateral portion of
lower eyelid and lateral canthus.
portions of the upper eyelids. In this case, lacrimal gland suspension
should be discussed with the patient. Neither this condition nor
suspension of the gland is of functional signifi cance.16
Ideally, the supratarsal fold is visible about 3–4 mm above the lid
margin on a straight gaze while this distance is about 10–11 mm when
the eyelids are closed. A levator dehiscence is suspected when the tarsal
show is increased in the cephalocaudal dimension with a more pro-
nounced supratarsal crease. If eyelid ptosis is diagnosed, levator func-
tion must be checked because it is a crucial factor in the selection of
a corrective approach. Presence of Bell’s phenomenon indicates a
reduced risk of exposure keratitis if complications, such as lid lag,
A
B
Fig. 1.11 A, Positive Bell’s phenomenon
demonstrated by cephalad rotation of globe
when examiner attempts to separate eyelids
against patient’s resistance. B, Negative
Bell’s phenomenon depicted by failure of
globe to rotate cephalad when examiner tries
to separate eyelid and patient attempts to
keep them closed.

7
Facial Analysis
in the nasal frame. Both extreme cases require a change in the surgical
planning, and the incidence of revisional surgery could be higher on
these patients because of these adverse conditions. A thorough expla-
nation of the reasons for potential revisional surgery may result in
lesser postoperative dissatisfaction in these patients.
The nasal bones should line up symmetrically, allowing a graceful
transition of shadow from the eyebrows to the nasal tip through a pair
of smooth and pleasing dorsal lines. Any excess or defi ciency of nasal
bone width, unilateral or bilateral may distort these lines.17
A portion of the nostril opening should be visible on the frontal
view. Inadequate nostril show may be an indication of a long nose or
caudally positioned ala, whereas excessive nostril show may denote a
short nose or retracted alar rims. Most rhinoplasty candidates have
wide and asymmetric nostrils. This becomes even more apparent when
the individual smiles. This imperfection has signifi cant surgical con-
notations and must be elicited by asking to the patient to smile. Tip
overlap on the upper lip becomes more noticeable on animation. Fur-
thermore, the form, symmetry and particularly the width of the lower
lateral cartilages can be judged easily on the front view.
The distance between the alar bases, as measured from the lateral
border of one alar base to its opposite counterparts, should be slightly
wider than the intercanthal distance. An imaginary line drawn verti-
cally from the medial canthi should pass 1–2 mm on the inside of the
alar base, providing that the intercanthal distance is normal (Fig. 1.13).
If the intercanthal distance is abnormal, the alar base distance should
be 2 mm wider than the orbital fi ssure width (from the medial to the
lateral canthus).18 The pleasing nasal tip has two highlights. The dis-
tance between these two points matches the width of optimal nasal
dorsal lines.
Profi le view of the middle zone
On the frontal view, the lateral boundaries of the ears are visible with
the helix slightly more projected lateral to the antihelix. The entire ear
contour creates a parallel vertical line relative to the face. Excess ear
projection results in greater visibility of the helix and disappearance of
the antihelical fold. The length of the ear equals that of the nose. A
horizontal line drawn from the subnasale touches the caudal border of
the earlobes. The ears are more precisely assessed on the lateral view.
The overall confi guration, helix size, development of antihelical folds,
earlobe size, and cephaloconchal angle are observed. The normal angle
between the patient’s body and long ear is approximately 30º, with the
cephalic portion of the ear tilting posteriorly.
On the profi le view, the supraorbital rims are about 10–15 mm
anterior to the globes. The nasion, the most depressed portion of the
nasal dorsum, is located at the level of the upper lid margin on a
straight gaze and is 4–6 mm deep in relation to the glabella. The nasal
dorsum creates a 34º angle with the vertical facial plane on a woman
and a 36º angle on a man. In both men and women there is a gentle
and gradual curve of the dorsum extending from the nasion to the tip;
the deepest portion is 0.5–1 mm for a man and 1–1.5 mm for a
woman. The nasolabial angle measures 105–108º for a woman and
95–100º for a man.19 A desirable tip defi nition includes a small supra-
tip break on the profi le view. The inferior border of the columella is
approximately 4 mm caudal to the alar rim on the lateral view and the
alar base is about 2 mm cephelad to the subnasale.20
The malar soft tissue is projected anterior to the most prominent
portion of the optical globe. Reversal of this relationship produces a
negative lower lid vector, potentiating the chance of lid retraction and
postoperative dry eye syndrome.21
Front view of the lower zone
In the frontal view of the lower facial zone, the upper lip length, as
measured from the base of the columella to the stomion, should be
half the distance from the stomion to the horizontal line, passing
through the most caudal portion of the chin. On a patient with a
normal underlying maxillary and mandibular frame, dentitions and
patent airway, the lips are sealed in repose. Lip incompetence, which
is habitual failure to close lips in repose, often is seen on patients with
a long face deformity on those who are mouth breathers due to nasal
blockage, patients with an open bite, or patients with iatrogenic or
muscular dystrophy related lower lip ptosis.
The upper lip is slightly thinner than the lower lip. The width of
the oral commissure equals the distance from one medial limbus to
the other side. On frontal view the lower jaw line is well defi ned in a
symmetric fashion, with the superfi cial musculoaponeurotic system
(SMAS) being tight and smooth. Ptosis of the SMAS and fat is an
integral part of gravity effects and the aging process, which causes jowls
to develop and the lower face to widen. A horizontal line connecting
the oral commissures runs parallel to the lines connecting the canthi.
The oral commissures are located horizontally on young patients,
whereas senescent patients demonstrate claudal tilt of the oral com-
missures. The philtrum dimple is bordered with a well-defi ned cupid’s
bow. Excess submental fat may obscure the chin defi nition and hide
Menton
Subnasale
Stomion
Middle to lower face
2:1
1:1
2:1
Fig. 1.12 Proportions of the middle to lower facial areas.
Eyes
2º
2–2.5cm
1–2mm
1/3 1/3 1/3
Fig. 1.13 Width of alar base is slightly wider than intercanthal
distance. Distance from eyelid to eyebrow and position of eyebrow
arch in relation to iris are shown.

1
PATIENT ASSESSMENT
8
enlarged or ptotic submaxillary glands and they can only be detected
by palpation.
A congruous tooth alignment is a material component of an attrac-
tive smile. When the lips are slightly apart, 2–3 mm of the upper
incisors should be visible between the lips. Any excess incisor show
may infer a long face deformity or a short upper lip. When the patient
is asked to smile, there is usually minimal gum show. Excess gum
show may indicate a long face deformity or a short upper lip. Normally
the central incisors and canines are slightly longer than the lateral
incisors. Crowding is an indication of discrepancy between the width
and number of teeth and the size of the dental arch. Patients with this
type of dental fl aw may require orthodontic correction or combined
orthodontic preparation and orthognathic surgery. Dental occlusion
should be examined to ensure the presence of a normal relationship
between the mandible and the maxilla. Abnormal jaw growth and
speech diffi culties can be the consequence of a large tongue, detection
of which is an integral part of a thorough facial evaluation.
Profi le view of the lower zone
On patients with a hypoplastic anterior maxillary region or a defi cient
nasal spine, cephalad portion of the upper lip is retruded on the profi le
view. Augmentation of the anterior maxilla, nasal spine and caudal
septum improves this relationship noticeably. In a harmonious face
either the upper and lower lips are lined up evenly in a vertical plane
or the lower lip is slightly posterior to the upper lip. The lips are sealed
in a relaxed position. Any substantial imbalance between the upper
and lower lips often indicates a skeletal abnormality.
The labiomental groove is often well defi ned and approximately
4 mm deep. This is one of the most underestimated features of the
face. An imaginary line touching the most projected portions of the
upper and lower lips should touch the most anterior portion of
the chin (Reidel’s plane) (Fig. 1.14).22 A defi cient or excessive chin may
be easily detected by this simple examination. Patients with receding
chins who already exhibit a deep labiomental groove often have ret-
rognathia and usually are not good candidates for genioplasty alone.
Commonly, mandibular advancement, with or without a genioplasty,
serves these patients best.
The cervical region
Ellenbogen has described the attributes of an aesthetically pleasing
neck whereby a 100 angle is created between the chin and the neck.23
This angle can be altered by a variety of neck fl aws. These could
include: excess skin, presence of platysmal muscle bands, excess sub-
platysmal and supraplatysmal fat, a malpositioned hyoid bone (Fig.
1.15),24 a receding chin, or a varying combination thereof. A ptotic or
enlarged submaxillary gland may also disturb the balance of the cer-
vicomental region.
The basilar view
Evaluation of the face on basilar view is crucial to a thorough facial
assessment. In this view, any asymmetry of the forehead can be
Mouth and chin
Fig. 1.14 Reidel’s plane of lip and chin line-up is straight line
connecting most prominent portion of upper lip to lower lip. In
pleasing profi les, line usually contacts most prominent portion of
soft tissue chin.
A
B
Fig. 1.15 Patient with poorly positioned hyoid bone. A, Patient profi le exhibits undesirable cervicomental defi nition.
B, Cephaloxerogram demonstrates low and anteriorly positioned hyoid bone.

9
References
detected easily. More importantly, the anteroposterior eye globe posi-
tion can be observed more precisely. The malar bones, their symmetry
and the overlying soft tissue prominence also can be evaluated clearly
in this view. The columella direction and nostril asymmetry also are
more detectable in this view. Additionally, the chin position and its
line-up with respect to the rest of the face are more clearly identifi ed
in this position. Also, the ear projection is assessed more readily with
the head tilted back.
The overhead view
Finally, if the examiner stands behind the patient’s chair, tilts the
patient’s head back and reviews the face from this perspective, several
abnormalities may become discernible more clearly. Gradually moving
from a standing to a sitting position, the examiner reviews the face
from different cephalic angles. The imperfections of the forehead and
eye position, enophthalmus and exophthalmus, malar asymmetry,
direction of the nasal bridge, and chin asymmetry can be easily
appraised in this particular type of examination.
Internal nose examination
Assessment of the nasal valves function is an integral part of the nasal
evaluation. This is done by asking the patient to breathe in and out
with, and without, a cotton tip or speculum lifting the ala and upper
lateral cartilages. Also, observation of the internal nose for septal
deviation, enlargement of the inferior turbinates, septal perforation,
synechia and polyps is essential for a successful septorhinoplasty.
VISUAL EXAMINATION
In preparation for aesthetic surgery the importance of a simple vision
test, using a vision chart cannot be overemphasized. Each eye must be
examined separately. A Schirmer’s test also may be helpful if the
patient has a history of dry eyes, although it is not a very reliable
test.
REFERENCES
1. Phillips KA, Diaz S. Gender differences in body dysmorphic disorder.
J Nerv Ment Dis 1997; 185:570.
2. Phillips KA, Menard W, Fay C et al. Demographic characteristics,
phenomenology, comorbidity, and family history in 200 individuals with
body dysmorphic disorder. Psychosomatics 2005; 46:317.
3. American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, 4th edn. Washington, DC: American Psychiatric
Association; 2000.
4. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and
cosmetic surgery. Plast Reconstr Surg 2006; 118:167E–180E.
5. Crerand CE, Phillips, KA, Menard W et al. Non-psychiatric medical
treatment of body dysmorphic disorder. Psychosomatics 2006; 46:549.
6. Beckenstein M, Guyuron B. Postrhytidectomy hematomas and “relative”
hypertension. Unpublished data, 1994.
7. Guyuron B, Rasqewski R: Undetected diabetes and the plastic surgeon,
Plast Reconstr Surg 86:471–474, 1990.
7a. Guyuron B, Zarandy S, Tirgan A. Von Willebrand’s disease and plastic
surgery, Ann Plast Surg 32:351–355, 1994.
8. Connell B: Brow ptosis: local reactions. Third International Symoseum
on Plastic and Reconstructive Surgery of the Eye and Adnexa, Baltimore,
1982, Williams and Wilkins.
9. Guyuron B, Davies B. Subcutaneous anterior hairline forehead
rhytidectomy. Aesthetic Plast Surg 1988; 12:77–83.
10. Guyuron B. Precision rhinoplasty. II. Prediction. Plast Reconstr Surg
1988; 81:500–505.
11. Guyuron B. Modifi ed temple incision of facial rhytidectomy. Ann Plast
Surg 1988; 21:439–443.
12. Lewis CM. Preservation of the female sideburn. Aesthetic Plast Surg
1984; 8:91.
13. Guyuron B. Soft-tissue frontal bossing. Plast Reconstr Surg 1987;
80:296–297.
14. McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift.
Aesthetic Plast Surg 1991; 15:141–147.
15. Guyuron B. Dynamics of rhinoplasty. Plast Reconstr Surg 1991;
80:970–978.
16. Guyuron B, DeLuca L. Aesthetic and functional outcomes of
dacryoadenopexy. Aesthetic Surgery Quarterly 1996; 16:138–141
17. Sheen J. Aesthetic rhinoplasty, 2nd edn, vol 2. St Louis: Mosby; 1987.
18. Guyuron B. Precision rhinoplasty. I. The role of life-size photographs and
soft-tissue cephalometric analysis. Plast Reconstr Surg 1988; 81:489–499.
19. Guyuron B, Davies B. Experience with the modifi ed Putterman
procedure. Plast Reconstr Surg 1980; 82:775–780.
20. Powell N, Humphreys B. Preparation of the aesthetic face. New York:
Theime; 1984.
21. Rees TD, Jelks GW. Blepharoplasty and the dry eye syndrome.
guidelines for surgery? Plast Reconstr Surg 1981; 68:249–252.
22. Reidel RA. An analysis of the dentofacial relationships. Am J Orthod
Dentofacial Orthop 1957; 43:103.
23. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the
youthful neck. Plast Reconstr Surg 1980; 80:823–837.
24. Guyuron B, Arons J. The chin, hyoid bone, and neck. World Plast 1995;
3:195–205.

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11
CHAPTER 2
Skin Care Including Chemical Peeling
Zoe Diana Draelos
● protein rich cells (corneocytes);
● skin lipids that hold the corneocytes together (Fig. 2.1).
Structural damage to the corneocytes or to the lipids results in a defec-
tive barrier. With the aid of an electron microscope, it is possible to
see the covalently bound lipid layer between the corneocytes forming
an organized watertight seal over the body (Fig. 2.2).
Barrier damage occurs when:
● the intercellular lipids are removed, typically by the chemical insult
of soaps;
● the corneocytes are physically removed, such as through aggressive
scrubbing or the use of chemical peels.
The health of the skin is therefore ultimately dependent on the non-
living stratum corneum. The underlying viable epidermis and dermis
form the cellular renewable layers of the skin, accounting for its
strength and distensible characteristics.
The most important role of the stratum corneum is to modulate the
water content of the skin, which should be approximately 30%. Too
much water creates maceration and too little water decreases the elastic
properties of the skin and creates skin surface wrinkles of dehydration.
Equilibrium between the external climate and internal environment
of the body occurs at about 70% humidity; however, the average humid-
ity of a conditioned environment is 20–30%. Therefore, there is a
constant net loss of water from the skin to the air (i.e. transepidermal
water loss). If this water loss becomes excessive, the skin recognizes
that a barrier defect has occurred, resulting in a rapid burst in the
synthesis of intercellular lipids (ceramides, sterols, and fatty acids).
Deliberate wounding of the skin, such as the insult induced by
chemical peeling, results in a profound, but controlled, damage to the
skin structures, requiring the proper selection of skin care products to
optimize the cosmetic result.
INDICATIONS
Fair complected patients:
●
dyspigmentation
●
poor skin texture
Relative contraindications
●
Patients with dark skin (Fitzpatrick types IV and higher)
●
History of consumption of oral retinoids within the past year
●
Radiated skin.
Contraindications
●
Hypersensitivity to chemical peels
●
Keloid formation within 6 months after cessation of oral retinoids
●
Evidence of poor healing.
Summary
1. Chemical peeling is the controlled removal of the stratum
corneum, epidermis, and/or superfi cial dermis to improve skin
texture and pigmentation.
2. Superfi cial chemical peeling with hydrophilic glycolic acid or
lipophilic salicylic acid is intended to produce mild exfoliation
of the stratum corneum.
3. Medium-depth chemical peeling with trichloroacetic acid
preceded by a superfi cial chemical peel is useful in improving
facial dyspigmentation.
4. Deep chemical peeling with phenol is useful in improving
superfi cial facial rhytids, but inevitably produces skin lightening.
5. Chemical peel is contraindicated in patients who have been
treated with systemic tretinoin within the previous 6 months
and as a treatment of keloids.
6. The skin barrier can be visualized as a brick wall consisting of
the protein-rich corneocytes functioning as the bricks held in
place by intercellular lipids as the mortar.
7. Cleansers are designed to remove environmental dirt, sebum,
bacteria, and fungal organisms from the face while leaving the
intercellular lipids and stratum corneum barrier intact. Modern
cleansers contain synthetic detergents (syndets), such as sodium
cocoyl isethionate and sodium laureth sulfate, which maintain
skin hygiene, but prevent damage to the intercellular lipids.
8. Moisturizers decrease transepidermal water loss, creating an
environmental optimal for barrier repair. They create an
occlusive barrier to evaporation (petrolatum, dimethicone,
mineral oil) or functioning as a humectant to attract water
from the dermis to the viable epidermis and stratum corneum
(glycerin, propylene glycol, sorbitol).
9. Estrogen replacement therapy and oral contraceptives predispose
the patient to hyperpigmentation following chemical peel.
10. Sunscreens can be added to moisturizers to prevent UVB- and
UVA-induced photodamage and photocarcinogenesis.
INTRODUCTION
Skin is the defi ning boundary of our personal space, a self-renewing
organ, the fi rst line of defense against systemic infection, and an indi-
cator to others of our chronologic age. It is a barrier that weathers with
advancing age and the insults of ultraviolet (UV) radiation to become
wrinkled, discolored, and uneven. Skin care includes cleansing, mois-
turizing, and photoprotection, while chemical peeling is a method for
improving the appearance and function of aging skin.
The skin is composed of three layers: the stratum corneum,
epidermis, and dermis.
The stratum corneum forms the skin barrier and is composed of
two distinct anatomic units:

2
SKIN CARE INCLUDING CHEMICAL PEELING
12
Skin peeling is a controlled removal and renewal of the various
layers of the skin, depending on the depth of the wound:
● superfi cial peels wound the stratum corneum and possibly the
upper layers of the epidermis;
● medium-depth peels wound the stratum corneum, epidermis, and
superfi cial dermis;
● deep chemical peels wound the stratum corneum, epidermis, and
mid-dermis.
The depth of the peel is controlled by the strength of the acid applied
to the skin surface and the length of time for which the acid is left in
contact with the skin.
Chemical peels are a carefully controlled wounding of the skin and
are designed to improve cosmetic appearance.
Any part of the body can be subjected to a chemical peel, but the
face produces the most dramatic and reliable results. This is because
the facial skin is thin and it heals with minimal scarring. The face is
the only body site where a deep chemical peel is performed.
Superfi cial chemical peels produce little effect on any area other
than the face where they are used to produce a mild exfoliation improv-
ing skin texture. This improved skin texture is appreciated by the
patient as increased facial shine (sometimes referred to as radiance)
and smoother facial cosmetic application.
Medium-depth chemical peels may be performed on the entire
body, but are most frequently used on the neck, chest, and arms.
Typically, higher concentration acids are used on the face with a
reduced concentration applied to any other body area.
Chemical peels produce the best results in fair complected indi-
viduals (Fitzpatrick type I and II) with predominantly pigmentary
photodamage. Darker skin types (Fitzpatrick type III and higher) are
more challenging to treat with chemical peeling because the infl am-
mation induced by the superfi cial or medium-depth peel may result in
unsightly post-procedure hyperpigmentation. Darker skin types also
more frequently exhibit hypertrophic scarring and keloid formation,
predisposing to an undesirable outcome.
Deep chemical peels are never performed on darker skinned indi-
viduals because the acid may damage the melanocytes, resulting in
permanent hypo- or depigmentation, unless hypopigmentation is part
of the aesthetic goal.
A chemical peel can be performed for a variety of indications:
Fig. 2.1 Stratum corneum. The stratum corneum is visually modeled
as a brick wall with the bricks representing the corneocytes and the
mortar representing the intercellular lipids.
Corneocyte (protein)
Lipid
Ordered epidermal lipids
Covalently bound lipid layer on corneocyte surface
The stratum corneum
HM
HORNY
TPM
BM
Granular
Skin lipid
Skin lipid
Spinous
Basal
MCG
ER
ER
AC
D
R
R
R
Kh
M
G
N
N
N
M
M
F
F
F
F
The intercellular lipids
Fig. 2.2 Intercellular lipids. The intercellular
lipids that surround the corneocytes provide
waterproof characteristics to the skin barrier.

Operative Approach
13
● superfi cial chemical peels can be used to enhance exfoliation,
improve skin texture, and minimize comedonal acne;
● superfi cial peels damage the skin barrier and may be used to
enhance the penetration of topical medications, such as hydro-
quinone skin lightening cream or tretinoin, and
● a superfi cial chemical peel is the fi rst step in performing a medium-
depth peel, allowing deeper penetration of the acid into the skin;
● medium-depth peels are used to improve defects in skin pigmenta-
tion (such as lentigenes and melasma), and fi ne lines around the
eyes and upper cheeks;
The best indication for chemical peeling is to improve facial
pigmentation.
A medium-depth peel will not improve deeper rhytids around the
mouth and folds on the face, such as the nasolabial and melolabial
folds. It is not possible to successfully improve facial folds with any
type of chemical peel, but deeper rhytids around the mouth and on
the lateral cheeks can be improved with a deep chemical peel, possibly
combined with a facelift procedure or the use of injectable fi llers.
In my opinion, the best indication for chemical peeling is in the
improvement of facial pigmentation. The precise ability to control the
depth of the peel by proper acid selection yields excellent pigment
removal without further dyspigmentation or scarring. Although laser
resurfacing is sometimes used for pigmentation improvement, the
laser does not afford the control of chemical peeling. Chemical peeling
is an art combining visual assessment of the peel depth produced by
the different types and strengths of acid left on the skin for varying
intervals. This allows clinicians to adapt the chemical peel to the
varying degrees of pigmentation in the treated area.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
A detailed history must be obtained prior to a chemical peeling
procedure to ensure an optimal outcome and result longevity.
Individuals who have been treated with systemic retinoids should
not undergo a chemical peeling procedure for at least 6 months to 1
year, depending on the depth of the chemical peel desired. This is
because systemic retinoids such as isotretinoin reduce the activity of
sebaceous glands and thereby increase susceptibility to hypertrophic
scarring, which can be disastrous in the case of a chemical peel where
the entire face is wounded.
A history of oral hormone supplementation is also important.
Estrogen replacement therapy and oral contraceptives predispose
the patient to facial hyperpigmentation. In some individuals, dyspig-
mentation may rapidly return following a facial peel if exogenous
estrogen is consumed. Discontinuation of the estrogen for at
least 3–6 months prior to the procedure and after the procedure is
advantageous, but not always feasible. Women who are not able
to discontinue their estrogen should be advised that the pigmenta-
tion may return and counseled on the proper use of photoprotection.
It is also worth inquiring about the patient’s skin care regimen.
Patients who are using prescription topical retinoids, such as tretinoin,
adapalene, or tazarotene, will experience much deeper and more rapid
penetration of the acid into the skin. Although retinoids are used prior
to medium and deep chemical peels to enhance penetration, they may
produce a much deeper peel than expected or desired in patients
wishing only a superfi cial chemical peel.
Patients may also be undergoing microdermabrasion, spa-admin-
istered chemical peels, or other aesthetician procedures that damage
the skin barrier, enhancing acid penetration and yielding unexpected
results.
OPERATIVE APPROACH
The peeling procedure for superfi cial, medium, and deep peels is
somewhat similar, each deeper peel building on a more superfi cial skin
wounding (Table 2.1).
Superfi cial peels
Superfi cial peels usually consist of either a glycolic or salicylic acid
solution applied to the face in three coats. Glycolic acid superfi cial
peels are water-soluble (hydrophilic) in contrast to salicylic acid
peels, which are oil soluble (lipophilic).
Table 2.1 Chemical peel technique comparisons.
Chemical peel properties
and suitability
Glycolic acid superfi cial peel
Salicylic acid superfi cial peel
Trichloroacetic acid medium-
depth peel
Sensitive skin patient
Stinging and burning due to
rapid dermal penetration
Primarily epidermal effect; best
tolerated by sensitive skin;
salicylate is anti-infl ammatory
Surgical procedure with
prolonged pain
Exfoliation benefi t
Minimal exfoliation at 10%,
mild exfoliation at 20–30%,
moderate exfoliation at 40–70%
Minimal exfoliation at 10%,
mild exfoliation at 20–30%
Aggressive exfoliation at 25–35%,
severe exfoliation at 50%
Rhytid reduction
No permanent rhytid reduction
beyond post procedure edema
No permanent rhytid reduction
beyond post procedure edema
Reduction of fi ne rhytids around
eyes, lateral cheeks
Dyspigmentation
Mild pigment reduction
Minimal pigment reduction
Excellent improvement in
epidermal pigmentation
Darker skin color
Must be used with care
Suitable
Not suitable
Acne treatment
Minimal improvement in open
comedones
Excellent improvement in open
comedones
Not appropriate
Recovery period
No recovery period
No recovery period
1 week
Procedural pain
Moderate
Minimal
Severe

2
SKIN CARE INCLUDING CHEMICAL PEELING
14
Glycolic acid peels
Glycolic acid peels in concentrations of 10% or less may be applied
by unsupervised aestheticians in a spa setting, but concentrations of
20% or higher should be applied by a physician or in a carefully
supervised setting.
Glycolic acid peels are formulated by diluting a 70% stock satu-
rated solution of glycolic acid in concentrations of 20, 30, 40, 50, and
60% with water. The most commonly used glycolic acid peels are:
● 20 and 30% for gentle skin exfoliation;
● 70% for mild dyspigmentation.
The peels can be administered in a weekly series with gradual 10%
increases in strength from 20 to 70% to achieve a cumulative effect
and enhanced improvement in photoaging. Glycolic acid peels
are water soluble and therefore only peel a skin surface devoid
of oil.
Salicylic acid peels
Salicylic acid peels are able to peel the skin surface as well as in the
oily milieu of the pore. Salicylic acid peels are therefore preferred for
patients wishing comedolysis as part of acne treatment or for patients
wishing to remove retained hairs and other debris from within the
pore.
Salicylic acid peels are formulated from salicylic acid powder,
which is dissolved in either benzyl alcohol or ethanol in concentrations
ranging from 10 to 50%. I prefer benzyl alcohol as solvent because it
is less pungent.
Glycolic acid peels are water soluble and only peel a skin surface
devoid of oil, whereas salicylic acid peels are lipophilic and peel
not only the skin surface but also in the oily milieu of the pore.
10–20% concentrations of salicylic acid peels are solutions,
whereas 30–50% peels are shake lotions and the salicylic acid must
be resuspended prior to application.
Salicylic acid is unique in that it does not penetrate into the dermis
making it an ideal superfi cial peel for patients with sensitive skin,
rosacea, or other infl ammatory skin diseases.
Peeling procedure
A superfi cial peel can be the desired treatment endpoint or it may be
followed by a medium-depth peel, which is actually a two-step peeling
procedure with a stratum corneum wounding procedure followed by
a deep epidermal or superfi cial dermal wounding procedure.
Superfi cial peel
● The fi rst step in peeling is to degrease the face and remove all skin
care products and cosmetics. If the skin is not clean, the superfi cial
peel will not penetrate and no skin improvement will be perceived.
I prefer to use a triclosan solution to clean the face with aggressive
gauze scrubbing, but any soap-based cleanser can be used.
● Following cleansing, the skin should be thoroughly dried and the
patient placed on the exam table with a bedside fan blowing a
gentle breeze across the face.
● Next, a rectal swab should be used to apply the 2 mL of superfi cial
peel solution poured into a small shot glass (Fig. 2.3A).
● The solution should be applied in three coats to the entire face. I
begin with broad strokes across the forehead, moving down to both
cheeks, then to the chin, upper lip, and lastly across the nose (Fig.
2.3B).
● It is important to avoid applying the solution to the corners of the
eye, nose, and mouth. Any junction between cornifi ed skin and
mucosa should be avoided because these areas tend to peel more
deeply and a painful erosion may result.
● At all times, an eye should be kept on the skin of the patient to
determine the degree of barrier damage. Superfi cial peels should
only wound the stratum corneum and uppermost epidermis. The
depth of the peel can be assessed by asking the patient about their
level of discomfort. I typically ask the patient to rate the stinging
and burning on a scale of 1–10 with 10 indicating extreme pain.
The application of the peel solution should cease when the patient
complains of discomfort at the 4–5 level, even if three coats have
not been applied.
● It is also important to watch for reddening and whitening of the
face. Reddening of the face indicates early wounding and vasodila-
tion whereas whitening (also known as frosting) indicates deeper
wounding and protein coagulation. The more confl uent the whiten-
ing of the skin, the deeper the peel (Fig. 2.3C). Very minimal scat-
tered whitening is all that should be achieved with a superfi cial
peel. The peel is immediately neutralized with cool water on dis-
posable washcloths wiped across the face until the stinging and
burning has resolved. Neutralization is extremely important in
glycolic acid peels because the acid will continue to wound the
skin until removed. However, salicylic acid peels are self-neutral-
izing because the acid crystallizes on the skin surface. Thorough
water rinsing is soothing to the skin surface. I usually completely
rinse the skin three times and follow this by an application of a
bland occlusive moisturizer, such as Cetaphil cream (Galderma,
Ft Worth, TX). Further skin care considerations are discussed in
the Skin care section.
A
B
C
Fig. 2.3 Superfi cial peeling procedure. A, 1–3 mL of the peel solution is decanted into a small glass crucible for application. B, A rectal swab
stroked over the face is used to apply the peel solution to the skin surface. C, The confl uence of the skin whitening is an indication of the
depth of the peel.

15
Complications and Side Effects
Medium-depth peel
● It is most important to remove all grease from the skin surface
when a superfi cial peel is preparation for a medium-depth peel. I
prefer to use acetone on a gauze vigorously rubbed across the face
following triclosan cleansing. This removes all traces of oil from
the skin surface ensuring even uptake of all the peel solutions in
both oily and dry facial areas.
● There is tremendous variability in the medium-depth prepeel. Some
clinicians prefer glycolic acid, whereas others use a carbon dioxide
slush peel or a mechanical microdermabrasion peel. My prefer-
ence is to use a combination prepeel with both lipophilic and
hydrophilic substances to prepare the skin surface and the pores
for the medium-depth peel procedure. This prepeel solution is
known as Jessner’s peel and is a combination of lactic acid, res-
orcinol, salicylic acid, and ethanol. It is applied in one to three
coats to the skin surface with a rectal swab until early whitening
of the skin is achieved.
● Once whitening has occurred with the prepeel, 25–35% trichloro-
acetic acid is quickly applied evenly to the entire face with a lightly
moistened rectal swab. The strength of acid selected depends on
the depth of the desired peel, which is determined by the degree
and confl uence of facial frosting (Fig. 2.4A).
● At this point, the fan should be blowing briskly across the patient’s
face and ice cold water compresses applied as soon at the desired
amount of frosting has occurred (Fig. 2.4B).
● After the burning has subsided, the face should be examined for
any skip areas that might need to be touched up.
● It is not necessary to neutralize either the Jessner’s prepeel or the
trichloroacetic peel because they are both self-neutralizing.
● A heavy layer of petroleum jelly is then applied over the entire
face, followed by petroleum impregnated gauze, Telfa, and netting,
if desired. The face should be rinsed with warm tap water at least
twice daily and covered with petroleum jelly until re-epithelializa-
tion is well underway by postprocedure day 4. At this time, cosmet-
ics can be worn and the patient is socially acceptable.
Deep chemical peels
Deep chemical peels:
● are not commonly performed because most patients who desire
the results of a deep peel prefer to undergo a laser resurfacing
procedure;
● are performed with phenol, which is cardiotoxic, requiring intra-
operative monitoring, and produces permanent pigment lightening.
Optimizing outcomes
●
Initiate nightly application of a retinoid 3 weeks prior to
chemical peel.
●
Remove all sebum and cosmetics from the face prior to
initiating the peel.
●
Apply the peel solution quickly and evenly to the entire face –
if areas of the face are skipped, reapplication is required,
which prolongs the procedure time and pain.
●
Do not drip the peel solution into the eyes or outside the
desired peel skin area.
●
Some patients may prefer to take a sedative prior to the
procedure, though reassuring conversation, careful fan
placement, and quick application of ice cold towels can
provide adequate pain relief for the short duration of
the procedure.
Optimizing a medium-depth peel result
●
Ensure even penetration of the acid over the entire face,
especially on the oily areas such as the nose – this is achieved
by having the patient use a retinoid nightly for 3 weeks prior
to the peeling procedure. My preferred retinoid is 0.025%
tretinoin cream, but other strengths of tretinoin (0.05 or 1%),
adapalene, or tazarotene cream may be used. The retinoid
should be discontinued for 1 month after the peel to allow
healing to occur and then restarted to maintain the cutaneous
peel effect for as long as possible. (Retinoids can also be used
with superfi cial peels, but the strength of the superfi cial peel
solution may need to be decreased).
COMPLICATIONS AND SIDE EFFECTS
Chemical peeling is a relatively safe procedure, but a few complications
should be avoided. Proper patient selection to avoid using the proce-
dure in dark complected patients and those with healing disorders is
A
B
Fig. 2.4 Medium-depth peel. A, Facial appearance immediately after a mild trichloroacetic acid peel. B, Ice-cold disposable towels are placed
over the face to decrease the warmth, stinging, and burning associated with facial peeling.

2
SKIN CARE INCLUDING CHEMICAL PEELING
16
key to avoiding complications of scarring, hyperpigmentation, and
hypopigmentation. In addition, patients who have a history of frequent
herpes simplex infections of the peeled body area should be treated
with preventive acyclovir, famciclovir, or valacyclovir on the day of the
procedure to prevent dissemination of the herpes simplex virus in the
wounded area.
POSTOPERATIVE CARE
The amount of postoperative care depends on the degree of the skin
wound. Superfi cial peels require no postoperative care, whereas medium
and deep chemical peels require application of petroleum jelly, to
prevent undesirable water loss from the wounded skin surface, at least
twice daily with warm tap water rinsing of the area for at least 4 days.
At day 4, most patients can begin wearing cosmetics and use a foaming
face cleanser accompanied by a simple oil-in-water moisturizer (Eucerin
cream, Beiersdorf, Germany). It is best to follow up the patient 1 week
after a medium or deep peel procedure to ensure that healing is pro-
gressing and there are no problems.
If the medium-depth peel is being performed to improve skin dys-
pigmentation, a hydroquinone-containing bleaching cream is recom-
mended 1 week after the peel. This prevents repigmentation from UV
exposure and hormonal infl uences. The use of a physical sun block,
containing zinc oxide or titanium dioxide, may also be helpful to
prevent UVA stimulation of the melanocytes.
Skin care
Postpeel skin care is important and includes the use of cleansers and
moisturizers.
Skin cleansing is the chemical interaction of surfactant with the
skin surface combined with physical rubbing. The physical rubbing
and the chemical interaction are equally as important.
Proper skin cleansing removes sebum, apocrine and eccrine secre-
tions, environmental dirt, bacteria, fungal elements, yeast, desquamat-
ing keratinocytes, medications, cosmetics, and skin care products
while not removing intercellular lipids or damaging the brick and
mortar structural organization of the stratum corneum.
Cleansers
There are a variety of skin cleansers,1–3 including soaps, syndets, and
combars (Table 2.2), which can be placed on a variety of cleansing
implements from the hands to a washcloth to a disposable face
cloth.
Synthetic detergents (syndets), particularly in the form of a foaming
face wash, are the best post-procedure cleansers. Combars are a
combination of soap and syndet and are useful post-surgically for
the patient who is at risk for cutaneous infection.
True soap is a specifi c type of cleanser with an alkaline pH of 9–10
created by chemically reacting a fat and an alkali to create a fatty acid
salt with detergent properties. Soap effi ciently removes both sebum
and intercellular lipids, making it an excellent general skin cleanser,
but a poor choice following any type of surgical procedure resulting in
a damaged barrier.
The need for good hygiene in a compromised barrier situation has
led to the development of synthetic detergents, known as syndets (Fig.
2.5). The most popular syndet cleansers contain sodium cocoyl isethi-
onate with a neutral pH of 5.5–7. This more neutral pH removes fewer
intercellular lipids, preventing further barrier damage during cleansing.
These products, particularly in the form of a foaming face wash, are
the best post-procedure cleansers.
The fi nal category of traditional cleansers is combars, which
combine soap and syndet cleansers in the same product with a pH of
7–9. Combars remove more sebum than a syndet cleanser, but less
than a soap cleanser. Most deodorant cleansers fall into this category
and contain triclosan as a topical antibacterial. Combars are useful
post-surgically for the patient who is at risk for cutaneous infection.
Moisturizers
Moisturizers (Fig. 2.6)4–7 are applied to the skin following cleansing in
the post-surgical patient to minimize transepidermal water loss, so
creating an environment that is optimal for skin healing.
The three categories of substances that can be combined to
enhance the water content of the skin are occlusives, humectants,
and hydro colloids:
Table 2.2 Skin cleanser categories and properties.
Type of cleanser (commercial examples)
Advantages
Disadvantages
Soap
Excellent cleansing thorough sebum removal
Can dry skin; not recommended for
sensitive, healing or diseased skin
Syndet (synthetic detergent)
More mild cleansing; recommended post-surgery;
may be used for sensitive or diseased skin
Not as thorough sebum removal
Combar
Good cleansing; commonly combined with
triclosan topical antibacterial; good choice for
high-risk wound infections or contaminated body
areas
Fig. 2.5 Cleansers. A variety of cleansers are illustrated, from left to
right, a syndet bar soap, a foaming facial cleanser, and a lipid free
cleanser.

Postoperative Care
17
Sunscreen ingredients can be classifi ed into two major categories.
● Chemical ingredients undergo a chemical transformation, known
as resonance delocalization, to absorb UV radiation and transform
it to heat. This reaction occurs within the phenol ring, which
contains an electron-releasing group in the ortho and/or para posi-
tion. This chemical reaction is irreversible, rendering the sunscreen
inactive once it has absorbed the UV radiation.
● Physical sunscreens, in contrast, are usually ground particulates
that refl ect or scatter UV radiation, absorbing relatively little of the
energy. For this reason they have longer activity on the skin
surface.
Sunscreen ingredients can be divided into the following three groups:
● UVA (320–360 nm) absorbers, such as oxybenzone, avobenzone,
menthyl anthranilate;
● UVB (290–320 nm) absorbers, such as PABA derivatives, salicy-
lates, cinnamates;
● UVB/UVA blocks that refl ect or scatter UVA and UVB, such as
titanium dioxide, zinc oxide.
Most modern sunscreen formulations are a blend of two to three dif-
ferent substances carefully selected to compliment one another and
enhance product performance (Fig. 2.7). However, raising the SPF
above 30 only confers an incremental increase in photoprotection
(Fig. 2.8).
UVA sunscreen ingredients
Proper UVA photoprotection is important because it is this spectrum
of radiation that results in photoaging, skin pigmentation, and photo-
carcinogenesis.
Oxybenzone is a widely used weak UVA (it absorbs at 320 nm)
absorber commonly used as a secondary sunscreen to increase the
broad-spectrum protection of the formulation. It is an oil-soluble ingre-
dient that can add to the sticky feel of a sunscreen if used in too
high a concentration. It has been used in combination with 2–6-
diethylhexylnaphthalate to stabilize avobenzone (also known as Parsol
1789), which is highly photounstable with 36% of the avobenzone
destroyed shortly after sun exposure.
Oxybenzone may also be combined with menthyl anthranilate (also
known as meradimate) to extend UVA photoprotection with a peak
● occlusives are oily substances such as petrolatum, lanolin, mineral
oil, vegetable oils, dimethicone, and cetyl alcohol that retard tran-
sepidermal water loss by placing an oil slick over the skin
surface;
● humectants are substances such as propylene glycol, hyaluronic
acid, glycerin, sorbitol, gelatin, urea, sodium lactate, vitamins and
proteins, that attract water to the skin, not from the environment,
unless the ambient humidity is 70%, but from the inner layers of
the skin – humectants draw water from the viable dermis into the
viable epidermis and then from the nonviable epidermis into the
stratum corneum;
● hydrocolloids are physically large substances, such as peptides and
colloidal oatmeal, that cover the skin, therefore retarding transepi-
dermal water loss.
A quality moisturizer will combine ingredients from all three catego-
ries to provide multiple mechanisms of moisturizing the skin.
A commonly marketed moisturizer formulation combines petrola-
tum (the most effective moisturizing ingredient presently known) with
dimethicone to minimize greasiness and effectively retard 99% of the
transepidermal water loss. The addition of glycerin to hold water in
the skin with a peptide to create an artifi cial barrier complete the
formulation. Incorporating vitamins, such as vitamin C or vitamin E,
or botanicals (such as aloe, green tea, or soy) add distinction among
products in the marketplace.
The biggest challenge in the delivery of anti-aging substances to
the skin is the stratum corneum. An intact stratum corneum is key
to the skin barrier and a necessary part of post-procedure healing,
but impedes the penetration of many substances into the skin. This
extremely important function means that the stratum corneum pre-
vents infection and the entry of toxic foreign substances and allergens
into the body. However, the barrier also prevents most large molecular
weight proteins and botanicals from entering the skin and functioning
as modulators of collagen production or topical antioxidants.
Probably one of the most effective moisturizer additives is sun-
screen, which has the ability to both prevent and reverse photoaging.
Sunscreens
Sunscreens8–19 are an important part of post-surgical skin care. Infl am-
mation resulting from a face peel or other skin wounding procedure
can cause hyperpigmentation, especially in the presence of UVA
radiation, which stimulates melanin production by melanocytes.
Photoprotective mechanisms may be endogenous (Table 2.3) or
externally applied (Table 2.4).
Fig. 2.6 Moisturizers. A variety of moisturizers are illustrated, from
left to right, a lotion, a cream, and an ointment.
Table 2.3 Natural cutaneous UV protective mechanisms.
Cutaneous structure
Sun protective mechanism
Compact horny layer
Absorbs and scatters UV
Keratinocyte melanin
1. UV absorbing fi lter
2. Free radical scavenger
3. Dissipates UV as heat
4. Undergoes oxidation in 300–360 nm
range to produce immediate
pigment darkening
Carotenoid pigments
1. Membrane stabilizers
2. Quench oxygen radicals
Urocanic acid
Oxidized to stabilize UV-induced
oxygen radicals
Superoxide dismutase
1. Oxygen radical scavenger
2. Protects cell membrane from
lipoprotein damage
Epidermal DNA
excision repair
Repairs UV-induced DNA damage

2
SKIN CARE INCLUDING CHEMICAL PEELING
18
Fig. 2.7 Sunscreen protection. Sunscreens are combined to provide the broadest coverage of absorption spectra yielding optimal
photoprotection in the UVB and UVA range.
Conc. (%)
Wavelength (nm)
UV Attenuation (nm)
Peak absorbance
Total (III)
UV filter
PBSA (2-phenylbenzimidazole-
5-sulfonic acid)
4
290
300
310
320
330
340
350
360
370
380
390
400
324
OSAL (octyl salicylate)
5
327
HSAL (homosalate)
15
328
OPABA (octyldimethyl PABA)
8
330
OMC (octyl methoxycinnamate)
7.5
339
OCTO (octocrylene)
10
356
OXY (oxybenzone)
6
361
MAN (metnthyl anthranilate)
5
363
TiO2 (titanium dioxide)
25
379
ZnO (zinc oxide)
25
382
AVO (avobenzone)
3
383
Sunscreen formulations
Table 2.4 Sunscreen ingredient comparison.
Sunscreen
ingredient
Maximum photoprotection
wavelength
Advantages
Disadvantages
Oxybenzone
320 nm
Used to stabilize avobenzone
Thick, greasy oil
Avobenzone
Broad UVA
Only broad-spectrum chemical
photoprotectant
Poor photostability, no photoprotection
after 5 hours’ sun exposure
Meradimate
336 nm
Excellent photostability
Thick, greasy oil
Octinoxate
305 nm
Excellent photostability, 4.5%
photodegradation
Small chance of allergenicity
Octisalate,
homosalate
300–310 nm
Minimal allergenicity
Used as a secondary sunscreen due to
weak photoprotection
Titanium dioxide
Broad-spectrum protection
due to UV refl ection
Long-lasting photoprotection,
good UV refl ection with larger
micronized particles
May whiten skin
Zinc oxide
Broad-spectrum protection
due to UV refl ection
Long-lasting photoprotection
enhanced by silicone-coated
particles
Not compatible with some other
sunscreens, such as avobenzone

19
References
absorption at 336 nm. Meradimate is commonly used as a secondary
UVA photoprotectant because it is a sticky oil and can decrease sun-
screen aesthetics.
UVB sunscreen ingredients
The sunscreen ingredients that contribute the sun protection factor
rating (known as the SPF), provide protection against UVB exposure,
which contributes to sunburn and photocarcinogenesis.
The salicylates, such as octisalate and homosalate, are important
UVB photoprotectants, with internal hydrogen bonding providing for
maximal UVB absorption at 300–310 nm. Approximately 56% of sun-
screens currently available use the salicylates as a secondary sunscreen
active because of their minimal allergenicity.
86% of products with an SPF rating of 15 or higher contain octyl
methoxycinnamate (also known as octinoxate), which has maximal
absorption at 305 nm. Octinoxate has excellent photostability with
only 4.5% degradation after UVB exposure and is commonly used in
sunscreen-containing moisturizers and facial foundations.
Physical UVA/UVB absorbers
The physical UVA/UVB absorbers are titanium dioxide and zinc
oxide.
● Titanium dioxide is usually micronized to contain particles of many
sizes to provide optimal UV scattering abilities. It leaves a white
fi lm on the skin and is used mainly for beachwear products.
● Zinc oxide is usually available in a microfi ne form (i.e. it contains
small particles of one size), making it appropriate for day wear in
persons of all skin colors. Zinc oxide-based sunscreens provide the
most complete post-procedure photoprotection, especially after
completion of a chemical peel.
CONCLUSION
Chemical peeling is a versatile method of improving skin texture, pig-
mentation, and fi ne lines, especially on the face, but also on other body
areas. It improves skin appearance by encouraging exfoliation while
removing dyspigmented skin. It is an acquired art that requires no special
equipment and can be performed for a relatively small investment.
Following a superfi cial, medium, or deep chemical peel, proper skin
care is important to ensure optimal healing and longevity of the result
and involves the use of mild cleansers to prevent barrier damage and
moisturizers to enhance the water holding capacity of the skin. Sun-
screens that provide both UVB and UVA photoprotection must also
be applied to prevent unnecessary photodamage.
The combination of proper skin care and a well-executed cosmetic
procedure will optimize skin appearance.
REFERENCES
1. Willcox MJ, Crichton WP. The soap market. Cosmet Toilet 1989;
104:61–63.
2. Wortzman MS. Evaluation of mild skin cleansers. Dermatol Clin 1991;
9:35–44.
3. Wortzman MS, Scott RA, Wong PS, et al. Soap and detergent bar
rinsability. J Soc Cosmet Chem 1986; 37:89–97.
4. Draelos ZD. Therapeutic moisturizers. Dermatol Clin 2000; 18:597–607.
5. Flynn TC, Petros J, Clark RE, et al. Dry skin and moisturizers. Clin
Dermatol 2001; 19:387–392.
6. Rawlings AV, Harding CR, Watkinson A, et al. Dry and xerotic skin
conditions. In: Leyden JJ, Rawlings AV, eds. Skin moisturization,
New York: Marcel Dekker; 2002:119–144.
7. Draelos ZD. Moisturizers. In: Draelos ZD, ed. Cosmetics in
dermatology. 2nd edn. New York: Churchill-Livingstone; 1995:83–95.
8. Ichihashi M, Ueda M, Budiyanto A, et al. UV-induced skin damage.
Toxicology 2003; 189:21–39.
9. Young AR. Cumulative effects of ultraviolet radiation on the skin:
cancer and photoaging. Semin Dermatol 1990; 9:25–31.
10. Gilchrest BA. A review of skin ageing and its medical therapy. Br J
Dermatol 1996; 135:867–875.
11. Matsumura Y, Ananthaswamy HN. Toxic effects of ultraviolet radiation
on the skin. Toxicol Appl Pharmacol 2004; 195:298–308.
12. Wulf HC, Sandby-Møller J, Kobayasi T, et al. Skin aging and natural
photoprotection. Micron 2004; 35:185–191.
13. Kawada A, Noda T, Hiruma M, et al. The relationship of sun
protection factor to minimal erythema dose, Japanese skin type, and
skin color. J Dermatol 1993; 20:514–516.
14. Roelandts R, Sohrabvand N, Garmyn M. Evaluating the UVA protection
of sunscreens. J Am Acad Dermatol 1989; 21:56–62.
15. Diffey BL. A method for broad spectrum classifi cation of sunscreens.
Int J Cosmet Sci 1994; 16:47–52.
16. Nash JF. Human safety and effi cacy of ultraviolet fi lters and sunscreen
products. Dermatol Clin 2006; 24:35–51.
17. Gasparro FP, Mitchnick M, Nash JF. A review of sunscreen safety and
effi cacy. Photochem Photobiol 1998; 68:243–256.
18. Moloney FJ, Collins S, Murphy GM. Sunscreens: safety, effi cacy and
appropriate use. Am J Clin Dermatol 2002; 3:185–191.
19. Tanner PR. Sunscreen product formulation. Dermatol Clin 2006;
24:53–62.
% UVB Protection
SPF Level
UVB Protection Correlated to SPF Level
SPF rating scale is not linear
20.0
2
4
6
8
10
12
15
30
50
100
0.0
40.0
60.0
80.0
100.0
SPF and photoprotection
Fig. 2.8 SPF and photoprotection. The relationship between SPF and
the degree of photoprotection is not linear. This means there is very
little increase in photoprotection beyond an SPF of 30.

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21
CHAPTER 3
Non-surgical Facial Rejuventation with Fillers
Brian M Kinney, David J Rowe and David Stepnick
the physiochemical properties of the fi ller types, but also must under-
stand the differences in injection levels and techniques for each of the
fi llers. A thorough aesthetic evaluation of the patient as well as a
complete discussion of the patient’s aesthetic goals and treatment
preferences must be performed in order to achieve a treatment plan
that is safe and realistic.
SOFT TISSUE LOSS IN THE
AGING PATIENT
Some of the features that a youthful face exhibits include smooth
contours, few wrinkles, except in dynamic expression, and full subcu-
taneous tissues with minimal or no soft-tissue atrophy (Fig. 3.1).
Nasolabial, glabellar and crow’s feet skin folds are almost uniformly
absent at rest, and minimally noticeable, even with muscular contrac-
tion. During aging of the normal, healthy adult, there is loss of soft-
tissue fullness in the face, often beginning in the nasolabial folds and
progressing inferiorly along the marionette lines. Lines in the upper
face may show years earlier during dynamic expression than at rest.
Lipoatrophy can distress the aging patient with resultant low self-
image and self-esteem, depression and social isolation.1,2 With the
severe rise in obesity in recent years, loss of facial fat due to aging may
be partially offset due to fatty accumulation after weight gain.
In the normal aging face there is gravitational pull on sagging skin,
fl attening of the youthful contours, accompanied by solar degenera-
tion, variation in pigmentation, an increase in rhytids, capillary break-
down, loss of muscle tonicity and progressive thinning of the skin and
subcutaneous tissues (Figs 3.2 and 3.3). One of the hallmarks of aging
skin – and one for which we have essentially no topical or minimally
invasive corrective solution – is poor elasticity, breakdown of elastic
fi bers and excess skin envelope. In essence, with an imbalance of soft
tissue volume to skin envelope, there are three basic approaches:
1) fi ll up the lost tissue volume, 2) chemically peel, laser, or mechan-
ical dermabrade or excise the excess skin, or 3) live with the difference.
Because few patients have one isolated contributing factor, the ideal
approach would often include volume restoration and treating the skin.
However, many patients do not desire more aggressive treatment.
Chemical peels and lasers chemically denude the superfi cial layers of
the skin, but do not reduce the surface area of the skin suffi ciently to
balance the loss of soft tissue volume in any but the mildest conditions
in the youngest patients. While they tighten the skin, in essence by
cross-linking collagen and other proteins, they do not restore the elastic-
ity of youth.
SOFT TISSUE LOSS IN DISEASE
CONDITIONS
While less common, certain disease conditions cause premature loss
of soft-tissue volume; some are genetic and some acquired. Congenital
generalized lipodystrophy (autosomally recessive) results in lack of
Summary
1. Facial aging is multi-factorial, and often due to a combination
of ptosis, loss of skin tone, elasticity, perfusion, hydration,
muscle function, and subcutaneous tissue volume.
2. Soft-tissue fi llers are rapidly increasing in use and
sophistication, but do not address all lost tissues.
3. Very few patients’ conditions are correctable by injection
alone; a thorough understanding of combination therapy,
including surgery, is essential.
4. Natural fi llers are safer and generally preferred to synthetic,
but do not last permanently.
5. Permanent fi llers are synthetic, have more serious
complications and require extremely careful injection
techniques.
6. As more fi llers become available, more understanding is
required by the surgeon and more confusion is likely by the
patients.
7. While minimally invasive in nature, injections must be guided
by an accurate understanding of the surgical anatomy.
8. Complications are rare, but excellent results are more elusive
than generally appreciated.
9. The nasolabial folds and the marionette lines are generally
easier to manage than other regions.
10. Injections in the hands and on the trunk are less common,
well-studied and effi cacious than in the face.
INTRODUCTION
The rising interest in cosmetic surgery among the general population
is so widespread that cosmetic procedures, surgical, and non-invasive,
have essentially entered the popular lexicon. With the purifi cation of
bovine collagen and its subsequent clearance for marketing by the US
Food and Drug Administration (FDA), soft-tissue fi lling fi rst became
practical in the 1980s. As minimally invasive cosmetic procedures
grew from an occasional medical novelty, the purview of the rich and
famous, their use became widespread in the 1990s, eventually to a
commonly sought means of cosmetic enhancement for millions of
people. In 1992 the American Society of Plastic Surgeons reported
41 623 collagen injections, the only type of exogenous fi ller generally
available in the USA. In 2006, 388 316 injections were reported by its
members and their use had been accepted in mainstream culture. If
data on botulinum toxin is included, the numbers go beyond 1 million
per year.
The choice of the appropriate fi ller, however, has become increas-
ingly diffi cult. With the ever-expanding number of fi llers and fi ller
types, the surgeon must, not only maintain an adequate knowledge of

3
NON-SURGICAL FACIAL REJUVENTATION WITH FILLERS
22
adipose tissue from birth. Familial partial lipodystrophy (autosomally
dominant) causes progressive peripheral fat loss beginning at puberty
and, typically, the facial fatty tissue will stay the same, or rarely gain
fat, while the body atrophies. Mandibulosacral dysplasia (autosomally
recessive) shows two forms: type A demonstrates peripheral fat loss
with normal or excess facial fat, while type B shows generalized fat
loss. Partial lipodystrophy (autoimmune mediated) presents during
childhood or adolescence and the upper body, including the face, pres-
ents with fat loss. Excess fat is found in the legs and hips. Generalized
lipodystrophy (immune mediated) presents during childhood or ado-
lescence and shows generalized fat loss, including the face.
Acquired lipodystrophies arise from multiple mechanisms, but
more commonly small localized areas of fat loss may occur from drug
injections, local trauma or crush injuries, immune-mediated mecha-
nisms, cancer or HIV, the most prevalent form. Highly active antiret-
roviral therapy (HAART) is associated with the condition, but its
actual mechanism is unknown. There appears to be some interaction
with protease inhibitors and nucleoside reverse transcriptase inhibi-
tors. The HIV patient shows rapid loss of peripheral fat and fat in the
face, occurring within 1 year of treatment.3 Fat paradoxically accumu-
lates in the abdomen, breast and dorsocervical spine. In the face, the
buccal and temporal fat pads are most locally affected; however, there
is loss of fat diffusely in the face. Fat loss may be rapid and progressive
and is often permanent, refractory to steroid administration and dietary
intervention. The prevalence has been reported as variable (18–83%)
due to differing defi nitions.4 Lipoatrophy in HIV patients can lead to
compliance issues, reducing the effect of HAART and accelerating
disease progression, fear of stigmatization and recognition.5,6
INDICATIONS
Indications
1.
Nasolabial fold prominence
2.
Marionette lines and secondary smile lines
3.
Perioral lines
4.
Paramental soft tissue atrophy
5.
Tear trough atrophy
6.
Temporal and buccal fat loss
7.
Generalized cheek atrophy
8.
Crow’s feet
9.
Glabellar lines
10. Combination therapy with laser, chemical peel or facelift.
Skin lines, wrinkles and folds
By far the most frequently injected area, the nasolabial fold (NL), may
be best evaluated by the standardized Lemperle scale of severity (Fig.
3.4). Natural folds in the face are created by attachment of the facial
muscles to the undersurface of the skin. No comparable scale is widely
used in the marionette lines, the crow’s feet and/or other skin folds
of the face. However, an appropriate approach would be to use the
commonly accepted Lemperle scale. The NL fold may begin to appear
in the early 20s and progresses with aging. While this scale is primarily
Forehead Lines
Facial Scars
Frown Lines
Vermilion Border
Vertical Lip
Lines
Marionette Lines
Smile Lines
Crow’s Feet
Fig. 3.1 Location of rhytids in the aging face.
Fig. 3.2 The aging face: presence of rhytids and soft tissue descent.
Skin lines, wrinkles and folds
Epidermis
(outer layer of skin)
Dermis
(inner layer of skin)
Fold
Wrinkle
Line
Subcutis
(beneath the skin)
Fig. 3.3 Architecture of rhytids.

Indications
23
A
B
C
D
E
F
Fig. 3.4 Lemperle scale of nasolabial fold severity. A, Grade 0 contains no wrinkles or lines, but may show some minimal contour
depression. B, Grade 1 shows just perceptible wrinkles. C, Grade 2 shows shallow wrinkles. D, Grade 3 shows moderately deep wrinkles.
E, Grade 4 shows deep wrinkles with well-defi ned edges. F, Grade 5 shows very deep wrinkles with a redundant fold.
focused on skin wrinkling, soft tissue loss is a contributing factor as
well.
Facial lipoatrophy scale
A four-point grading system is commonly used to measure facial lipoa-
trophy (Fig. 3.5). Grade 1 is characterized by small localized areas of
fat loss, especially in the nasolabial folds. Grade 2 includes mentolabial
folds (marionette lines) and may include concavity of the lips. Grade
3 progresses to malar fat atrophy, preauricular hollowing and shadow-
ing of the cheeks and mandibular ridge, while Grade 4 demonstrates
malar fat ptosis, temporal hollowing and protruding musculature and
bones.

3
NON-SURGICAL FACIAL REJUVENTATION WITH FILLERS
24
CONTRAINDICATIONS
Contraindications
1.
Positive skin allergy test (in injections containing collagen).
2.
Known sensitivity to injectate (e.g. collagen, hyaluronic acid,
calcium hydroxlyapatite, etc.).
3.
Severe skin disease e.g. psoriasis, eczema.
4.
Severe systemic disease.
5.
Active acne in the region of injection.
6.
History of connective tissue disease.
7.
Recent chemical peel or ablative laser treatment.
8.
Recent use of aspirin, non-steroidal anti-infl ammatories or
other blood-thinning medications.
9.
Previous lumps or nodules in the area of injection.
10. Dense scar tissue.
While there are many contraindications to surgical interventions, there
are very few for injectables. This, along with their relatively low inci-
dence of complications, is the factor contributing to their wide popular-
ity. They are very easy to inject, but much more diffi cult to inject well.
Careful attention to topical and deep anatomic detail is essential to
avoid distortion of facial anatomy, lumps and nodules. In addition,
even in patients with an undesirable outcome, effects rarely last longer
than the prospective duration of the injection. This ranges from about
3 months with collagen to about 2 years for calcium hydroxyapatite,
but may be permanent with polymethylmethacrylate synthetics.
Patients with mild connective tissue diseases may be eligible for injec-
tion after a careful history and physical exam, but should be considered
a relative contraindication. Active acne, psoriasis or eczema warrant
withholding the procedure. A patient who has an apparent large soft-
tissue volume loss may be corrected partially, but almost never should
be fully corrected, as a signifi cant portion of the defect may also be
due to ptosis of soft tissues. To the extent the soft tissues have fallen
they should be lifted; to the extent the soft tissues have atrophied, the
volume should be restored.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
Pre-procedure analysis
Paramount in the decision-making process as to the choice and loca-
tion of injectable fi llers are the patient’s physical characteristics and
aesthetic goals. A complete pre-procedure assessment includes pre-
procedure history and a site-directed physical/aesthetic examination,
as well as patient education and informed consent. First, an accurate
understanding of the patient’s aesthetic goals must be ascertained.
Perhaps the most important consideration in the busy cosmetic clinic
is an unreasonable expectation by the patient, e.g. viewing an injection
as a facelift in a syringe. Part of this misperception is due to unreason-
able promotion by some physicians and the titanic interest in the
procedure by the fashion, beauty industries and the public at large in
a youth-oriented culture.
It is therefore the surgeon’s obligation to include discussion of
possibly relevant surgical as well as non-surgical procedures that may
be needed to meet the patient’s expectations. If the patient is best
suited for a surgical procedure and opts for a fi ller-type correction, one
must carefully point out what will and what will not be corrected with
the fi ller.
Age is an important factor, as approximately 80% of all injections
are performed between the ages of 35 and 64.7 Increasing age leads to
the tendency of decreased immunogenicity, so, presumably, there
would be less of an infl ammatory response to a permanent or semi-
permanent fi ller. However, thinner skin and dermal atrophy make
superfi cial injection techniques risky, as lumpiness and color defor-
mity may occur more readily. Avoidance of aspirin, NSAIDs, gingko
biloba, St. John’s Wort, and high-dose vitamin E for 1–3 weeks prior
to the injection is encouraged.
A
B
C
D
Fig. 3.5 Facial lipoatrophy scale. A, Grade 1
facial lipoatrophy. B, Grade 2 facial
lipoatrophy. C, Grade 3 facial lipoatrophy.
D, Grade 4 facial lipoatrophy. (Photos
courtesy of Ute Bauer, MD, 2004.)

Injectable Fillers
25
INJECTABLE FILLERS
We have truly entered the ‘fi ller revolution’ and the number of new
fi llers on the market is constantly increasing.8 The fi rst injectable fi ller
that was approved by the FDA was bovine collagen (Zyderm/Zyplast;
Inamed Aesthetics, Santa Barbara, CA). The need for skin testing and
its lack of longevity were key issues hindering its widespread use.9
Since this time, many classes of fi llers have been approved by the FDA,
with more likely in the future. Listed in this section is a brief descrip-
tion of each of the major injectable fi llers currently being utilized in
the USA.
Hyaluronic acid
Of the 9.2 million non-surgical cosmetic procedures performed in
2004, almost 900 000 included augmentation using injectable hyal-
uronic acid (HA) fi llers.10 Hyaluronic acid is a glycosaminoglycan that
is a naturally occurring polysaccharide. Hyaluronic acid is an essential
component of the extracellular matrix, essentially ubiquitous through-
out all animal species. Therefore, it has no species or tissue specifi city,
making HA ideal from an immunologic standpoint. In its native form,
catabolism of HA is rapid (hours to days), therefore stabilization via
crosslinking is essential for utility as an injectable fi ller. HA is hydro-
philic and able to retain 95% of volume with water.11 Unique to HA
is its ability to follow isovolemic degradation, a process by which the
remaining molecules of HA are able to bind an increasing amount of
water thus maintaining volume until the majority of product is
degraded.
Currently, there are several HA derivative products approved by the
FDA. All products are approved for mid-to-deep dermal implantation
for correction of moderate-to-severe facial wrinkles and folds:12–14
Restylane (Medicis, Scottsdale, AZ), Perlane (Medicis, Scottsdale, AZ),
Juvederm (Allergan, Irvine CA), Captique (Allergan, Irvine, CA), and
Hyalform (Allergan, Irvine, CA). Restylane was the fi rst of the HA
fi llers to be FDA approved (12/2003); in initial studies by Narins et al
it showed superiority to Zyplast with a smaller concentration of
product.15 Restylane has a HA concentration of 20 mg/ml, a gel par-
ticle size of 400 μm, and a 1% degree of crosslinking.16 It is distributed
in 0.4 ml and 1.0 ml disposable syringes. Wang et al17 recently reported
that, in addition to the physiochemical properties of Restylane, it may
augment dermal fi lling by stretching fi broblasts and thereby stimulat-
ing de novo collagen formation.
Other HA fi llers are similar to Restylane but differ in several key
categories: concentration, particle size, and degree of crosslinking.
Juvederm was FDA approved in June 2006 and has a slightly higher
concentration of HA (24 mg/ml), a higher percentage of crosslinking,
and has randomly shaped particles. In addition to Juvederm, two other
formulations of Juvederm have been FDA approved. Juvederm Ultra is
a thinner version of Juvederm. Juvederm Ultra Plus has a greater par-
ticle size and a larger degree of crosslinking, marketed to be utilized
as a volumizer injected deeper than its predecessor. Perlane is similar
in crosslinking to Restylane; however, like Juvederm Ultra Plus, it has
a larger particle size intended to be placed deeper in the dermis and/or
subdermis. Restylane, Juvederm, Juvederm Ultra, Juvederm Ultra Plus,
and Perlane are all derived from non-animal stabilized HA (NASHA).
NASHAs, coupled with the ubiquity of HA, render these injectables
as having a low potential for immunogenic reaction. In contrast, Hyla-
form is derived from rooster combs and does confer immunogenicity.
Puragen recently renamed as Prevelle Shape, has been approved in the
EU for two years and is double cross-linked with the aim to better resist
degradation (Figs 3.6, 3.7 and 3.8).
A
Fig. 3.6 Patient in her 50s 14 months after double cross-linked
hyaluronic acid in the nasolabial folds.
Table 3.1 Comparison of hyaluronic acid fi llers chemistry and impact on clinical outcomes

Prevelle
Puragen
Juvederm 30HV
Perlane
Restylane
Clinical Impact
Gel hardness, G′
modulus, Pa
230–260
865
105/1000
588
660
More loft, fi rmer feel, better for scar injection
Particle size, micron
350
180
150/1500
650
300
Smaller particles
More forgiving
Use superfi cially
Smoother injection
Hyaluronic acid (HA)
conc., mg/ml
5.5
20
24
20
20
Higher concentrations
More swelling
Longer duration
Gel/fl uid ratio
98/2
88/12
60/40
75/25
75/25
Lower ratio
More lubrication
Degree of HA
modifi cation (%)
23
∼3.5
7
3
3
More alteration
More control of response
Dilution durability/
%swelling
<25
∼25
300
50
50
Initial effect is late result
Less swelling
B

3
NON-SURGICAL FACIAL REJUVENTATION WITH FILLERS
26
Calcium hydroxylapatite
Synthetic calcium hydroxylapatite (CaHA) is a biocompatible sub-
stance with a similar mineral component to bones and teeth. The
CaHA scaffold theoretically allows for tissue ingrowth with no immu-
nogenic or infl ammatory response as well as no migration. Radiese
(BioForm Medical, San Mateo, CA) is a suspension of 30% CaHA
microspheres of 25–45 μm in diameter in a gel consisting of 1.3%
carboxymethyl cellulose, 6.4% glycerin, and 36.6% sterile water.
Radiesse was approved by the FDA in December 2006 for the correction
of soft-tissue wrinkles and folds; however, it was previously approved
for laryngeal augmentation, soft-tissue marking, and fi lling/augmenta-
tion of dental intraosseous defects and oral/maxillofacial defects.18 It
is also now approved for correction of HIV facial lipoatrophy.19
Histologically, by 3 months, there is some residual phagocytosis of
the gel substrate and a fi ne fi brous stroma between the CaHA micro-
spheres (Fig. 3.9). By 9 months, there is irregularity of the shape of
the CaHA microspheres, presumably from enzymatic degradation. No
foreign body granulomatous reactions have been identifi ed (Fig.
3.10).20–23 Radiesse has been reported to persist histologically from 2
to 7 years.24
B
Fig. 3.7 A, Patient in his 50 s 91/2 months after injection of double cross-linked hyaluronic acid. B, At 12 months the left nasolabial fold has
partially returned.
Fig. 3.8 A 57-year-old patient with double cross-linked hyaluronic
acid. Almost full correction at 101/2 months.
Fig. 3.9 Microspheres individually surrounded by delicate fi brous
encapsulation 12 months after implantation.
Fig. 3.10 Six months after injection of upper and lower lips,
nasolabial folds and the oral commissure. (Photo courtesy of Miles
Graivier, MD.)
A
A
B
A
B

Injectable Fillers
27
Poly-L-lactic acid
Poly-L-lactic acid (PLA) is a synthetically polymerized lactic acid
material fi rst synthesized from vegetable sources in 1954 and used in
multiple surgical devices, including suture materials (DEXON (Davis
& Geck, Manati, Puerto Rico), VICRYL (Ethicon, Inc., Somerville,
N.J.), and in resorbable plates and screws, as well as a vehicle for
sustained drug release. Sculptra (New-Fill in Europe) is manufactured
in Italy and distributed in the USA by Dermik Laboratories (Berwyn,
PA – Sanofi -Aventis, Bridgewater, NJ). Sculptra is formulated into PLA
microspheres (40–63 μm) suspended in a sodium carboxymethylcel-
lulose carrier and reconstituted with sterile water. Sculptra was FDA
approved in 2004 for correction of facial lipoatrophy in HIV patients
(Figs 3.11 and 3.12).
Following solubilization, the lactic acid degrades via the lactate/
pyruvate route, and is then eliminated as CO2 through the respiratory
system.25 Histologically, no polymer is detected after 9 months.21
Tissue fi lling is ultimately achieved by ingrowth of type I collagen
(neocollagenosis).26 Thus, the fi lling persists despite resorption of poly-
lactic acid microparticles. Investigations in HIV lipoatrophy have
revealed increased dermal thickness by threefold, as well as increasing
the quality of life in this group of patients.27,28
Polymethylmethracylate beads coated
in collagen
Polymethylmethracylate (PMMA) microspheres are insoluble, syn-
thetic and chemically related to Plexiglas. PMMA is commonly used
in orthopedics for permanent fi xation and support of bony tissues.
ArteFill (San Diego, CA) is composed of a 20% solution of PMMA
microspheres 30–42 μm in diameter and suspended in a solution of
partly denatured bovine collagen and 0.3% lidocaine. ArteFill received
FDA approval in January 2007 for correction of facial wrinkles, thus
making it the fi rst permanent injectable wrinkle fi ller in the USA.29
Patients must be skin tested for allergy to bovine collagen and possibly
tested for reactivity to collagen.30
Artecoll, the identical product with previous marketing nomencla-
ture, has been implemented throughout the world since 1994. Report-
edly 400 000 patients have been treated to date.31,32 The PMMA
microspheres are non-biodegradeable and are unable to be phagocy-
tosed by macrophages, due to their size and lack of electrical charge.
Thus, soft-tissue augmentation is thought to be permanent. By 1
month post-injection, each individual microsphere is encapsulated
by collagen, macrophages, and fi broblasts. Resorption of the bovine
collagen and replacement with native collagen occurs within 1–3
months. The size of the Artecoll microspheres is unchanged by 9
months.21,33
Injected in small amounts and corrected less than 1 : 1 in volume,
excellent results can be extremely pleasing clinically, as good as or
better than any others. The injectate is permanent and may not show
at all, or potentially after the normal soft-tissue atrophy of aging occurs
years later. Experience has not ranged over suffi cient years since intro-
duction about 10 years ago to be sure of the clinical signifi cance of this
possibility.34 If there is a complication, the results may respond to
triamcinolone injection, or may require excision, because the body
cannot resorb this synthetic polymer.
Polyacrylamide gel
Aquamid (manufactured by Ferrosan, Copenhagen, Denmark; distrib-
uted by Contura International, Soeberg, Denmark) consists of 2.5%
crosslinked polyacrylamide and 97.5% water. Polyacrylamide injected
into the subcutaneous tissues elicits a fi brous capsule that surrounds
the gel by 6–9 months.21 This material is currently not approved by
the FDA; however, it is in use throughout Europe, South America, and
the Middle East.
Other injectables
Silicone has a very small group of supporters, but it is not cleared by
the FDA and has a past history of an extremely high incidence of
complications, including severe scarring, distortion of anatomy and
the need for surgical excision of skin, fi brosis and even muscle. Autog-
enous fat, a highly successful technique, is not within the scope of this
chapter, but should always be considered when choosing a method of
soft-tissue restoration.
A
B
Fig. 3.11 A, Patient in her early 40s with
facial atrophy after more than 6 months of
seizure medications. B, Nine months after
three injection sessions 4–6 weeks apart with
poly-L-lactic acid injections in the temple and
cheek. Her weight did not change
appreciably.
A
B
Fig. 3.12 A, Septuagenarian patient prior to
poly-L-lactic acid (PLA) injections in the
hands. B, Eight months after three injections
of PLA about 6 weeks apart in the dorsal
hand, fi rst through fourth web spaces. There
is palpably increased soft tissue in the hands.

3
NON-SURGICAL FACIAL REJUVENTATION WITH FILLERS
28
OPERATIVE APPROACH
Anesthesia
While many patients are able to tolerate neurotoxin injections without
the use of anesthesia, most patients require an anesthetic to ensure
maximal comfort for the injection of fi llers such as the HAs. Especially
in extremely sensitive areas such as the lips, an otherwise good
experience can leave lasting memories of anxiety and pain, which may
curb a patient’s desire to have repetitive treatments. Areas such as the
region under the eyes may require a much lower level of anesthesia,
and, as such, choice of an anesthetic must be tailored to the patient,
the material being injected, and the area of treatment.
Applying ice to the area to be injected is probably the lowest cost
and easiest technique for decreasing the apparent pain. Many patients
prefer this technique rather than either waiting for the topicals to take
effect or experiencing the anesthesia which can be achieved with
regional blocks.
Topical anesthetics include EMLA cream (a eutectic mixture of
lidocaine 2.5% and prilocaine 2.5%), L-M-X (lidocaine 4%), and
Tetracaine cream. Compounding pharmacies may create other prod-
ucts utilizing these and various other available topical anesthetic
agents. When a topical anesthetic is used, maximal effect is achieved
if the product remains in place for 30–60 minutes after application.
Rare serious side effects, such as methemoglobinemia with EMLA,
may occur. The senior author (BK) has found that in over 90% of
patients with triple anesthetic cream and slow, low-pressure injection
technique, there is no need for local injection or regional block. Pain
Ease®, topical dichlortetrafl uoroethane and ethyl chloride (Gerbauer
Company, Cleveland, OH), and similar products are topical refriger-
ants which can be applied to the skin just prior to needle insertion.
The product is useful for the nasolabial folds and cheeks, and should
not be used on the oral mucosa.
Nerve blocks provide the most effective and profound anesthesia.
Local infi ltration of an anesthetic agent is to be discouraged, since the
volume of anesthetic changes the apparent volume of the area to be
corrected with the fi ller material. Very small volumes of an anesthetic
agent – 0.3–0.5 cc – properly deposited in the area where the nerves
exit their foramina provide anesthesia without altering the tissue
volume. Various choices are available, but lidocaine is the most
commonly used agent.
Anatomical considerations
Superfi cial layers
Low crosslink density, small particle size hyaluronic acids are best
close to the surface where the likelihood of lumpiness or nodularity is
low. Collagen preparations may be injected here with low risk. The
greater the crosslink density and the larger the particle size, the deeper
the injection should be placed.
Deeper layers
CaHA and PMMA should be injected in deeper layers, not close to the
surface due to their long duration and fi rmness. PLA, a volume
restorer, should be injected in deeper layers. These injections are in
large volumes and should not be placed close to the skin or targeted
at rhytids.
Nasolabial folds
Threading, fanning, and serial droplet techniques can be employed.
Of these, the threading technique provides good results and is an
optimal choice for the nasolabial crease. An eyeliner pencil is easily
visualized yet can be effortlessly removed. Patients then may lean back
and receive the injections in a relaxed, semi-recumbent position. The
needle is inserted to its hub in the deep dermal or immediate subder-
mal plane. HAs are injected into the deep dermis; CaHA is injected just
below the dermis. Inspection and feel guide proper needle placement:
dimpling of the skin with downward pressure on the needle signifi es that
the needle is, indeed, in the deep dermis. If the needle can be visualized
through the skin, it is too superfi cial. If there is little resistance to the
needle and the product, it is likely in the subcutaneous tissue.
Approximately three threads of product are placed, taking care to
deposit the material in the valley beneath the nasolabial crease. The
triangular area bounded by the nasal alar crease and the nasolabial
fold should be fi lled. If the cheek above the crease is injected, the
nasolabial fold will be accentuated rather than blunted. A key part of
the procedure is fi rmly massaging the deposited material, molding it
to fi ll the hollow, achieving a natural appearance without visible
lumpiness.
Following injection, the patient is given ice to hold on the areas
for 15 minutes to help minimize swelling and bruising. Results improve
over 1 week or 2 as infl ammation subsides. Especially with calcium
hydroxyapatite, which is much denser than the surrounding soft tissue,
the material is palpable for weeks to 2–3 months, at which point the
carrier vehicle absorbs and degrades, and the tissue consistency
resembles normal tissue. Patients should be so advised.
To achieve optimal results and longevity, the nasolabial folds must
be maximally corrected. Less than maximal correction often contrib-
utes to patient dissatisfaction. Studies examining longevity treated
patients to maximal correction and, as such, patients not receiving
maximal correction cannot be expected to have as long-lasting a
result. Indeed, complete correction and placement of the materials in
the proper plane appear to be key factors for success.17
HAs placed too superfi cially appear as a visible, raised blue line
along the fold. Calcium hydroxyapatite appears white. For the HAs,
the product can often be expressed by digital pressure or by nicking
the dermis with an 18 gauge needle and expressing it with applied
pressure. Hyaluronidase injections will break down the product if
needed. Patients with deep, hyperdynamic creases or those with heavy
cheeks may have a suboptimal result.
Marionette lines
The fanning technique is particularly useful in this region. Fanning
involves introducing the needle at a 30º angle to the level of the deep
dermis. The needle is passed back and forth medially and laterally to
the fold by about 2 mm in each direction. Unlike the linear threading
technique, the material is deposited both upon insertion and with-
drawal of the needle, and bevel position is irrelevant. As with the
nasolabial crease, if too much material is deposited superior/lateral
to the fold, it may be accentuated instead of being reduced.
Paramental crease
As with other areas of the face, the paramental crease and prejowl
sulcus results from a combination of descent of tissues, due to gravity
and loss of elasticity, together with defl ation and loss of volume in
particular areas of the face. While surgical correction is the only way
to lift and tighten the jowls themselves, fi llers can be used in the pre-
jowl sulcus to camoufl age the appearance of the jowls. As this is not
a discrete crease like the nasolabial creases and the marionette lines
previously discussed, the material deposited needs to be more diffuse
and slightly deeper. Subcutaneous placement is desired, whereas deep
dermal placement may produce a lumpy appearance.
Glabellar lines
In general, glabellar rhytids are best and most frequently treated with
botulinum toxin. However, for patients with particularly deep lines,
the neurotoxin may not provide suffi cient improvement to appropri-
ately eliminate these creases. In such patients, a synergistic effect can
be obtained by using a fi ller in combination with the neurotoxin.33
Others have reported that concurrent injection of Restylane® and
botulinum toxin increases the longevity of the former.35 The serial
puncture technique is used, staying in the mid-dermis. Injection occurs

Operative Approach
29
as the needle is being withdrawn. It may be useful to compress
the supratrochlear vessels to minimize likelihood of intravascular
injection.
Bruising is not uncommon in this region. Multiple cases of skin
necrosis and scarring have been reported in the literature, particularly
in this region.36,37 Immediate care of prolonged skin blanch after injec-
tion involves massage to stimulate blood fl ow into the region. If this
is not effective topical 2% nitroglycerine ointment can be applied.
Lower eyelids (nasojugal groove and tear
trough regions)
One of the more diffi cult areas to treat successfully is that area of the
lower eyelids. However, a good result is equated with high degrees
of patient satisfaction.38 Signifi cant hollowing occurs as a result of
pseudoherniation of orbital fat combined with descent of the buccal
fat. This may also result as a result of cosmetic lower blepharoplasty.
The thin, delicate nature of the skin makes this area a challenge. The
area bruises very easily, especially in patients with clotting abnor-
malities, those prone to bleeding, or in whom pharmaceuticals are
used that interfere with normal clotting. Fillers injected just beneath
the surface of the very thin skin can be visible, and are to be avoided.
For this reason, many clinicians are reluctant to inject the tear trough
region. Surgeons who have an excellent understanding of the orbital
and lid anatomy form having operated upon it in the past are well-
prepared to inject in an entirely different plane than discussed with
the other subsited thus far. The fi ller should be injected beneath the
orbicularis muscle, overlying the periosteum, serially along the orbital
rim. Surface irregularities can in this way be minimized. Undercor-
rection is preferred to overcorrection. As the HAs are hydrophilic and
attract water in the fi rst few weeks after the fi ller is placed, complete
correction can actually become overcorrection, and the eyes may take
Linear threading technique
A
B
B
Serial puncture technique
A
Fan technique
9
3
5
4
6
7
8
2
1
C
Cross-hatching technique
D
Fig. 3.13 Techniques of injection. A, Serial puncture technique: multiple injections are placed sequentially along the length of the wrinkle or
fold. Adjacent areas should join together into a continuous, smooth line without spaces. B, Linear threading technique: the full length of the
needle is inserted into the middle of the fold and material is injected while gently withdrawing the needle longitudinally. Each thread should
be as long as the needle inserted to the hub. C, Fan technique: the needle is inserted in the area as when using the linear threading
technique, and after injecting in one line, the needle is kept under the skin and reinserted in a new line, repeated in a fan-shaped pattern.
D, Cross-hatching technique or Lake technique: commonly used for poly-L-lactic acid and may be used for fi lling the cheeks with hyaluronic
acid.

3
NON-SURGICAL FACIAL REJUVENTATION WITH FILLERS
30
on a puffy appearance. More than any other area, bruising can occur
and so patients need to account for this to ensure that whatever
bruising does occur does not interfere with their lifestyle.
Lips
Fillers can be useful when patients complain of lipstick ‘bleeding’ onto
the cutaneous lip, enhancing the lip border lessens or eliminates this
problem. Similarly, in smokers, the fi llers can re-infl ate the fi ne lines
that develop around the lips as a result of smoking. The lips are an
extremely sensitive area and nerve blocks are virtually a necessity.
Linear threading is essentially always used in place of serial puncture.
The risk of hematoma (in the labial artery) is quite high compared to
other areas of injection and careful observation is necessary. Immedi-
ate application of fi rm pressure is required, should it occur. In the
midst of injection it is possible to monitor the fl ow of injection. Some
prefer convexity of the mucosa surface and some prefer defi nition in
the vermillion border; needle placement should be adjusted accord-
ingly. The fi ller is injected carefully, as any irregular deposition will
be obvious as the swelling diminishes. Ice should be used to minimize
swelling, but even with ice, swelling may hide any lumpiness or irreg-
ularity. As such, the lips should be carefully palpated, and massaged
to properly contour the lips. For patients with thin lips, the needle is
reinserted and a second bead of fi ller is placed 1–2 mm inferior to the
vermillion border, parallel to the fi rst injection. This produces a favor-
able upwards roll to the lip.
Increased volume and lip body are achieved by injecting directly
into the lip. The body of the lip is injected in a manner similar to the
vermillion, in the area of the lip between the vermillion and the wet
lip. The wet lip should not be injected, because at this depth, the labial
artery is at risk of occlusion by the material and the theoretic risk of
ischemia of the lip needs to be considered. Typical volumes needed to
enhance the volume of the lip are 0.25–0.5 cc per lip. It is unusual to
use more than 1.0 cc per lip. Deep vertical rhytids can be individually
and directly injected, but should not be overcorrected.
Generally, HA, having supplanted the use of collagen in the last
3–4 years, is the injectate of choice in the lip (Fig. 3.14). CaHA,
PMMA and PLA are generally not indicated in the lips and should be
used with great caution except in the hands of the experienced injector
and the experienced patient who know the doctor well.
Patients with a history of cold sores should receive antiviral pro-
phylaxis, as injections can stimulate reactivation of latent herpes
infection. These patients should receive Valtrex 500 mg bid on the day
of treatment and for a total of 10 days of therapy.
Other important details
The patient should be in a position that best demonstrates the defect
– usually in a near upright position. The head should be stabilized
against a headrest. We like to have the patient examine closely the
areas of treatment in a handheld mirror while we highlight the method
of treatment prior to its start. After each injection the patient has an
opportunity to view the partial result within an individual area and
compare left to right.
Optimizing outcomes
●
Correction must be optimized based on product hydration and
swelling expected.
●
Overcorrection and swelling is permissible immediately after
underhydrated HA products.
●
Permanent fi llers should never be used to overcorrect volume.
●
Slow, gentle injection without excess pressure is essential.
●
During rapid, high-pressure injection the injectate will dissect
along the path of least resistance, which may even be
perpendicular to the long axis of the needle.
●
Intra-injection monitoring of tissues is required for optimal
contouring and volume restoration.
●
Calcium hydroxlyapatite must be injected deep and in several
sessions to avoid palpable or visible nodules.
●
Adequate local anesthesia prevents facial muscle contraction
and distortion during injection.
●
Compounding pharmacies make available a triple anesthetic
cream with 20% benzocaine, 8% lidocaine and 4% tetracaine,
which works within just a few minutes, much faster than the
standard topical anesthetics that may take up to 30–45
minutes to anesthetize adequately.
COMPLICATIONS AND SIDE EFFECTS
1. Pain
2. Erythema
3. Swelling
4. Bruising
5. Infl ammation
6. Asymmetry
7. Hematoma
8. Allergy
9. Early resorption
10. Nodularity and purulence.
The fi rst fi ve on the list are relative common adverse events, are almost
always transitory and responsive to palliative treatment. Asymmetry
is almost always present, but those cases leading to dissatisfaction are
relative uncommon. Hematoma, while relatively more uncommon, is
also short-lived and generally easy to treat. Allergy implies exposure
to protein, and in HA preparations it is residual from the production
process of bacterial fermentation. Protein loads in HA preparations is
in the order of 1 part per million. This is generally not a problem with
A
B
Fig. 3.14 Injection of double cross-linked
hyaluronic acid (HA) for lip augmentation.
A, Double cross-linked HA pre injection.
B, Double cross-linked injection at 4 months.
Lower lip eversion and decreased vertical
upper lip lines are still improved. Volume loss
has begun to occur.

31
Complications and Side Effects
CaHA and PLA, but PMMA has an outer coating of collagen and
carries the risk of allergy, just as traditional collagen injection does.
However, hypersensitivity reactions may occur many months after
treatment. In a study of 709 patients injected with Hylaform or Resyl-
ane followed-up for 12 months or more, six developed delayed skin
reactions 8 weeks after injections.39 In a 1999 study, localized hyper-
sensitivity reactions occurred in approximately 1 in 1400 patients, and
adverse events were reported in one in 650 patients (0.15%). In 2000,
when the amount of protein in the raw product decreased, those
numbers fell to one in 5000 for hypersensitivity reactions and one in
1800 for adverse events (0.06%). Andre performed a retrospective study
evaluating the incidence of adverse reactions after non-animal stabi-
lized hyaluronic acid injections and found an overall 0.8% global risk
of hypersensitivity reactions, of which 50% were immediate and
resolved in under 3 weeks.40
The incidence of purulence and nodularity amongst HA injec-
tions is not known, but may be between 1 : 1000 and 1 : 5000. This
can be a devastating complication and can lead to scarring, and
permanent contour alteration. Treatment includes various combina-
tions of antihistamines, oral or parenteral antibiotics, hyaluronidase
injection and triamcinolone injection depending on the clinical
presentation.
Clinical examples
Fig. 3.15 Hyaluronic acid injection with expected immediate
post-injection edema and erythema. Cold compresses immediately
after injection and over the counter analgesics are all that are
required.
Fig. 3.16 Asymmetry 14 months after double-cross-linked hyaluronic
acid (Puragen) due to irregular resorption and underlying anatomical
differences. This case is not a complication per se. Retreatment at
the patient’s or physician’s discretion is permitted. A greater than
40% correction remains in a 120 kg male, almost 2 meters tall, not a
typical patient. Early asymmetry may be due to missed diagnosis,
incomplete correction or other causes.
Fig. 3.17 Nodularity without purulence. Late nodule formation with
photos 9 months and 9 months and 1 day after injection. Nodularity
resolved within a few days. The patient had reported several
episodes between 3 and 9 months of temporary (1–2 day)
appearance and spontaneous resolution of infl amed nodularity.
Improvement was likely due to rapid resorption of hyaluronic acid
(HA) after episodic breakdown of the long-standing normal
connective tissue capsule. Connective tissue infl ammation may be
treated with triamcinolone injection and HA sequestrum may be
treated with hyaluronidase enzyme injection.
Fig. 3.18 Early resorption at 4 months in a 11/2 pack per day
cigarette smoker who has used indoor tanning booths twice a week
for many years. No other fi ndings were seen.
Fig. 3.19 Hyaluronic acid injection in the nasolabial fold with nodule
formation and infl ammatory response. Multimodal treatment may
include triamcinolone injection, hyaluronidase injection, oral
antibiotics and antihistamines. Ultrasound treatments or hypodermic
epidermoclysis may break down the connective tissue capsule.
A
B
A
B
A
B

3
NON-SURGICAL FACIAL REJUVENTATION WITH FILLERS
32
POSTOPERATIVE CARE
Immediate post-injection treatment is minimal, but varies with each
material. Generally, the patient is kept in the offi ce for 5–10 minutes
with cold compresses applied to monitor for hematoma, nodularity,
palpability or other problems. No dressings are required and makeup
may be applied before leaving the offi ce. Much discussion has occurred
about having patients refrain from vigorous physical activity for several
days, but this has no scientifi cally validated foundation. It is left to
the preference of the individual doctor and patient.
A 2-week appointment is essential to effectively evaluate the
results. Often patients will call with questions, and to answer most an
examination is required. With long-acting materials like CaHA and
PMMA excessive injection at the fi rst visit is likely to increase nodu-
larity, palpability and overcorrection. It is much safer to assess the
fi nal endpoint of injection at 2 weeks rather than at the fi rst injection.
With increasing experience on the part of the doctor and the patient,
the repeat visits may be canceled at the patients’ discretion. Pre- and
post-procedure photography is standard care in plastic surgery and is
essential for the precise recognition of contour changes.
Long-term care is minimal, but follow-up is essential. Appoint-
ments at 3, 6 and 9 months allow for the opportunity to perform
touch-up procedures, monitor for the inevitable asymmetric resorbtion
and consider complimentary procedures. The rare late complication
can be discovered on these visits.
CONCLUSION
Soft-tissue injectables are among the safest and most satisfying proce-
dures in plastic surgery. They go a long way to ameliorating the early
effects of aging; infectious, post-traumatic or acne scars; and soft-tissue
atrophy of many etiologies. Many patients who are not clinically ready
for more advanced or invasive procedures, are not willing to undergo
surgery, cannot afford the time or fi nancial impact, or are just new to
aesthetic procedures are ideal for this approach to rejuvenation. In an
ASPS survey 47% of patients who had a positive experience with injec-
tions would consider having surgery with the doctor with whom they
underwent injection procedures.
It is important to understand the different chemistry and variations
in technique among the various materials available. While it is easy
to perform injections, it is not easy to perform them excellently. Pres-
ervation of the tissues, careful attention to topical, subcutaneous and
muscular anatomy, precise correction and meticulous injection tech-
nique is required. The ideal approach would be to ‘tissue engineer’
cutaneous and subcutaneous tissues. In the future, our choices will
incorporate more advanced materials, with chemistry more closely
analogous to our natural tissues.
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A
B
Fig. 3.20 A, Nodularity following
polymethylmethracylate (PMMA) injection.
B, Biopsy of four sites after injection of
PMMA microspheres. (Photo courtesy of
Claudio DeLorenzi, MD.)

33
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35
CHAPTER 4
Botulinum Toxin
Michael AC Kane
fi rst publication concerning the injection of the toxin into humans was
published in 1980.3
For years, the toxin was an effective, though seldom used medica-
tion, limited to the fi eld of investigational ophthalmology. Its primary
uses were for blepharospasm and strabismus. There were rare anec-
dotal reports of its use for wrinkle reduction (Wyshynski PE, personal
communication).4 The fi rst comprehensive report detailing its cos-
metic usefulness was published by the Carruthers, an ophthalmolo-
gist/dermatologist team, in 1992.5
Most patients have an initial excellent response for the fi rst 3.5–4
months, with diminishing returns thereafter as the muscle regains its
strength. However, when carefully scrutinized, it typically takes 6–7
months for all of the clinical effects to fade. As patients continue to have
the toxin injected on a regular basis over 2 years, most begin to have an
increased duration of action.6 Initially, recovery appears to be facilitated
by neurite sprouting as early as 8 weeks after injection. It also appears
that the initially blocked nerve terminals recover their function.7
Typically, after years of regular repeated injections the results last
longer.
Anecdotally, and in one publication,8 it appears that reconstituted
toxin that has been allowed to sit unused for weeks may have the same
initial effect, but a possibly decreased duration of action.9
Botox is supplied as a freeze-dried crystalline complex in a vial
containing 100 units. Although the package insert says to dilute the
vial with 2.5 mL of non-preserved saline, I have used 4 mL of non-
preserved saline to reconstitute a vial of Botox since 1991.
I use 4 mL of non-preserved saline to reconstitute a vial containing
100 units freeze-dried crystalline Botox, though the package insert
says to dilute it with 2.5 mL of non-preserved saline.
INDICATIONS
●
Glabellar rhytids
●
Complications from aesthetic surgical procedures
●
Hyperhidrosis
Contraindications
●
Disorders of neuromuscular transmission, such as myasthenia
gravis and Lambert-Eaton syndrome
●
Aminoglycoside antibiotics may potentiate effects of the toxin
●
Pre-pregnancy, pregnancy and breastfeeding (though no
evidence to suggest potential harm)
Summary
1. The key to successful rejuvenation using botulinum toxin A is
an understanding of the functional anatomy.
2. Using the minimal effective dose minimizes a frozen, unnatural
appearance.
3. Brow elevation depends on the relative weakness of the brow
elevators vs brow depressors.
4. The dose must be based on estimated muscle mass, not rhytid
depth.
5. Avoidance of medications that reduce platelet function will
decrease ecchymosis.
6. The lower frontalis has the greatest effect on brow elevation.
7. Threading the injection through the lips gives a more natural
result than the more common point technique.
8. Cooling the skin before injection minimizes discomfort.
9. A general rule is that injecting depressors more strongly than
elevators will tend to give a gentle lift to the structure involved.
10. Overinjecting the mentalis can result in a ‘witch’s chin’
deformity and oral incompetence.
INTRODUCTION
Botulinum toxin type A injections are the most frequently performed
cosmetic procedure in the United States. Initially an ophthalmologic
drug, Botox (botulinum toxin type A) has become a cultural touch-
stone, a topic for sitcoms and even an issue in presidential elections
in just over a decade. Its importance in aesthetic plastic surgery simply
cannot be overstated. Nearly 4 million procedures were performed in
2005. That is more than all liposuction, breast augmentation, rhino-
plasty, facelift, and blepharoplasty procedures (essentially all of the
procedures in this book) combined.
Eight neurotoxins are secreted by Clostridium botulinum.1 Type A
is a fully sequenced 1295 amino acid chain surrounded by other hem-
agglutinin and nontoxic nonhemagglutinin proteins for stability.
All type A preparations have the exact same 1295 chain amino acid
as their active ingredient, but their different complexing proteins give
them different properties. All type A toxins, however, have the same
mechanism of action. The heavy chain binds to receptors on the cell
membrane of the nerve, which allows the light chain to enter the
cytoplasm where it cleaves synaptosomal associated protein 25 (SNAP
25). Because SNAP 25 is essential for the exocytosis of the acetylcho-
line-containing vesicle, this cleavage results in a presynaptic nerve
blockade.
Dr Alan Scott, an ophthalmologist, pioneered the use of botulinum
toxin type A in humans. His fi rst publication, detailing the toxin’s
effect on Rhesus monkeys, appeared in 1973.2 He fi rst injected the
toxin into humans in 1977 (Scott AB, personal communication). His