Aesthetic Oculofacial Rejuvenation

cheek for moderate-to-severe lipoatrophy. An assis-
tant massages the treated areas for 5 minutes imme-
diately after treatment. The patient is instructed
to self-massage the area for 5 minutes per day
for approximately 1 week. In addition, patients are
instructed to apply ice to the treated areas post
injection.
Complications and Contraindications
There are no absolute contraindications to injection
of PLLA. Relative contraindications include active
infection or inflammation in the area to be injected.
In addition, patients who are using anticoagulants
should be warned that they may experience an
increased risk of bruising or hematoma formation.
This warning should apply to any injectable. Com-
mon adverse effects following treatment include
inflammation, bruising and edema in approximately
5–10% of patients. Because PLLA is a synthetic,
non-animal-based polymer composed of the same
material that is commonly used in absorbable
sutures, there is minimal risk of an allergic reaction.
In some patients, dermal or subcutaneous papules
can occur months later (Fig. 9.9). This is thought
to be due to uneven subcutaneous placement or
inadvertent
dermal
injection
of
PLLA.
These
papules, however, are usually small and non-visible.
They can be minimized by ensuring even placement
of PLLA in the subcutaneous tissue and massaging
the treated areas following treatment.
SYNTHETIC CALCIUM HYDROXYLAPATITE
Synthetic calcium hydroxylapatite (CaHA; Radi-
ance® FN, Radiesse®; BioForm Inc., Franksville, WI)
is a high-density, low-solubility bioceramic compound
of microspheres in a water-based gel carrier. The FDA
originally approved it for such uses as treating vocal
cord insufficiency, augmenting the neck of the bladder
to treat urinary incontinence and treating periodontal
defects. It was also used as a radiological tissue marker.
In late 2006, the FDA approved Radiesse® for long-
lasting correction of moderate-to-severe facial wrin-
kles and folds, and correction of facial lipodistrophy
on HIV-positive patients. It acts as a scaffold for sti-
mulating collagen production. It is used most com-
monly for nasolabial folds26 (Figs 9.10 and 9.11) and
marionette lines, malar and jaw enhancement, tear
trough deformity, areas of bone depression or bone
erosion, depressed scars, and in areas requiring soft
tissue filling. Sklar and White reported treating 64
patients over a period of 6 months.27 All patients
showed clinical improvement, a high level of satisfac-
tion and minimal side effects (bruising, swelling, lip
nodules and tear through overcorrection). The authors
do not personally recommend Radiesse® for lip aug-
mentation due to visible nodular formation. When
treating tear trough correction Radiesse® has to be
placed deeply over the periorbital periosteum. When
this is not done correctly, the white color of the prod-
uct can be visible under the skin. Because Radiesse® is
completely biocompatible, no pretreatment allergy
testing is required (Table 9.3). Radiesse comes in pre-
sentation of prepacked 1.5 cc, 0.8 cc and 0.33 cc, for
big, moderate and touch up corrections, respectively.
The FDA justapproved its dilution on 0.2 cc lidocaine,
and the technique uses a female-to-female Luer lock
connector (Baxa®, Englewood, Co). It has decreased
patients’ discomfort during treatment and no topical
anesthesia or overcorrection is required.
NON-BIODEGRADABLE
AND COMBINATION FILLERS
Non-biodegradable fillers and combination fillers that
mix biodegradable and non-biodegradable substances
are the ‘permanent fillers.’ These injectables are made
from a variety of materials, ranging from polymethyl-
methacrylate (PMMA) to silicone. Most of these sub-
stances are designed to be encapsulated by one’s own
body collagen and remain as a permanent to semiper-
manent solution for tissue deficiencies and simple
cosmetic enhancement. Many are not yet available in
Fig. 9.9 Nodular formation 2 months post Sculptra®
injection on cheeks. Courtesy of Dr Alessandra Haddad.
107
Facial Fillers and Volumizers

the USA – at least not with FDA approval. The Amer-
ican Society for Aesthetic Plastic Surgery keeps track
of what injectables and dermal fillers are approved on
the FDA website ().
Silicone
The clinical use in humans of pure silicone (polymers
of dimethylsiloxane) preceded controlled studies
in animals. In the 1960s, Dow Corning produced
medical-grade silicone for lubricating and coating
containers, and for use in skin lotions. It was not
intended to be injected into human tissue. Very
quickly, liquid silicone for injection purposes became
very popular in Asia, Europe and Latin America. The
first significant injections of silicone was in Japan, but
it was, reportedly, adulterated with olive oil.28 In the
USA, Conway and Goulian reported injecting sili-
cone into the breast and face.29 In 1965, the FDA
declared that injectable silicone was a drug and
required Dow Corning to file an investigational new
drug application for injectable silicone. In spite of
its long history of use for soft tissue augmentation,
silicone was never approved by the FDA for that pur-
pose. There are two products available in the USA
that are FDA-approved for ophthalmic use. They
are Adatosit-5000® and Silikon®. To prescribe sili-
cone injections for soft tissue augmentation constitu-
tes an off-label use.
Despite many problems with product quality,
injectable silicone gained popularity throughout
the world, and the technique of injecting it into the
dermis and subcutaneous tissue in small amounts
(microdroplets) – with 1–2 mm of separation30 at
Midline
Piriform aperture
0.5cc 27g CaHA
Canine tooth
Canine eminence
Canine fossa
Digital massage
to contour
Nasolabial fold
NLF fills-in for a
contour microlift
A
B
C
Fig. 9.10 Fosa caninae technique.
A
B
Fig. 9.11 A, Before Radiesse®
injection on fossa caninae and
melomental areas. B, Immediately
after Radiesse® injection on fossa
caninae and melomental areas.
108
Aesthetic Oculofacial Rejuvenation

each treatment site – has become crucial for suc-
cessful treatment. A fibroplastic reaction to the
foreign material is responsible for the permanent
progressive result, and that is why we should make
an attempt to undercorrect the patients. The
technique should be repeated every 6 months until
the desired effect is obtained. The adverse effects
of silicone injected in humans are inflammation,
hardness, ulceration, migration, change in coloration
and granulomas. In the case of silicone injection for
Table 9.3
Biodegradable fillers FDA approved in the USA (non-collagen derived)
Product
Source
Approved indication
in U.S.
FDA
approval
Duration
Injection
needle
Restylane®
Bacterial fermentation
NASHA technology
For the correction of
moderate to severe facial
wrinkles and folds and lips
December
2003
6–8 months
30 gauge
Perlane®
Bacterial fermentation
NASHA technology
FDA approved; designed for
shaping facial contours
(such as in the cheeks and
chin), correcting deep folds
May 2007
9–12 months
27gauge
Captique™
Hyaluronan-
synthesized via
bacterial fermentation
For the correction of
moderate to severe facial
wrinkles and folds
December
2004
4–6 months
Juve´ derm 30
HV®
Produced by bacterial
fermentation
For the correction of
moderate to severe facial
wrinkles and folds
June 2006
9–12 months
27 gauge
Juve´ derm 24
HV®
Produced by bacterial
fermentation
For the correction of
moderate to severe facial
wrinkles and folds
June 2006
6–8 months
30 gauge
Juve´ derm
30®
Produced by bacterial
fermentation
For the correction of
moderate to severe facial
wrinkles and folds
June 2006
9–18 months
27 gauge
Hylaform®
Animal derived from
rooster combs
For the correction of
moderate to severe facial
wrinkles and folds
April 2004
4–6 months
30 gauge
Hylaform
Plus®
Animal derived from
rooster combs
Shaping facial contours
(such as in the cheeks and
chin), correcting deep folds
and for lip augmentation
October
2004
6–8 months
27 gauge
Elevess®
Produced by bacterial
fermentation
Correction of moderate to
severe facial wrinkles and folds
October
2004
6–8 months
30 gauge
Slowly biodegradable filters
Sculptra™
Poly-L-lactic acid
For the restoration and/or
the correction of lipoatrophy
in patients with HIV
August
2004
1–2 years
26 gauge
Radiesse™
Calcium
hydroxylapatite
microspheres
suspended in an
aqueous gel
Long-lasting correction of
moderate to severe facial
wrinkles and folds, such as
nasolabial folds. Radiesse also
received a second FDA
approval for the long-lasting
correction of facial fat loss
(lipoatrophy) in people with
human immunodeficiency
virus (HIV)
December
2006
1–2 years
27 gauge
109
Facial Fillers and Volumizers

breast augmentation, the migration of silicone parti-
cles in axillary lymph nodes has been reported.31,32
Artefill® (Artes Medical, USA) is the latest gener-
ation of Artecoll®, which is available in Europe. It is
a suspension of PMMA beads, 32–40 mm particles in
size, in 3.5 bovine collagen suspension. Artefill® has
been FDA-approved since 2005. Since it is the only
permanent filler with FDA approval for facial use,
proper patient selection is of utmost importance.
Like other bovine collagen preparations, Artefill®
has to be tested prior to injection to rule out an intol-
erance to bovine protein. To diminish their electro-
static force, the beads are polished. This has
decreased the frequency of granulomas, which was
relatively high with the old preparation (Artecoll®).
Pollack recommends a conservative approach with
small volume (undercorrection) and long interval
between injections.33 Artefill® is injected into the
immediate subdermis or at the deepest dermal level,
for deep rhytids and folds. Patients with thin skin,
defects that are not well defined or large pores are
not good candidates, since it can lead to lumpiness,
beading and rigging. In general, two or three treat-
ments are necessary, depending on the area cor-
rected. There is an immediate filling effect, due to
the collagen in the preparation, which is slowly
resorbed in 2–3 months and then substituted by
a
neosynthesis
of
collagen,
stimulated
by
the
microspheres of PMMA that are encapsulated by
the body’s own collagen. This process takes from
2 to 4 months.
The results are reported to be good and perma-
nent. However, when granulomas develop, they
should be carefully, and immediately, treated with
intralesional triamcinolone. According to Acalay
et al. they resolve well.34 Care should be taken to
prevent skin atrophy due to the steroid treatment.
Surgical removal of granulomas is difficult and can
be mutilating. Recently, granuloma formations asso-
ciated with Artecoll® and Artefill®, which occurred
many years after their injection, have been observed
following a laser skin resurfacing and during an
interferon treatment for viral hepatitis. It is there-
fore suggested that patients undergoing any immu-
nomodulating therapy should be asked if they have
had previous injection of long-lasting or permanent
fillers. For lip augmentation, where there seems to
be a higher incidence of beading, Carruthers and
Carruthers recommend pretreating the orbicularis
oris with botulinum toxin.5 In the opinion of the
authors, since we do not like to compromise safety
for longevity, better alternatives than Artefill® are
available today for lip enhancement.
OTHER NON-FDA-APPROVED
PERMANENT FILLERS
Artecoll® (RMI, The Netherlands) is approved in
Europe
and
Canada,
and
comprises
30–60 mm
PMMA beads, 3.5% bovine collagen and 0.3% lido-
caine. As mentioned previously, it is the precursor
of Artefill®, FDA-approved in 2005. Acalay and col-
leagues have reported late-onset granuloma forma-
tion34 (Fig. 9.12).
Bioalkamide®
(Polymekon,
Italy)
is
another
homogenous permanent gel preparation of polyalkyli-
mide. As with the other permanent gel preparations,
it gives good results when it is tolerated. However,
allergic reactions appear to be common and may come
with huge edematous swelling and/or granuloma for-
mation. Allergic reactions may be treated with steroid
injections. In addition, incision and expression works
remarkably well with this gel.2 Bioalkamide® has CE
Marking as a humanitarian-use device (HUD) for
treating severe lipodistrophy.
Aquamid® (Contura International A/S, Soeborg,
Denmark) is made of hydrophilic polyacrylamide,
which can absorb between 300 and 400 times its orig-
inal weight in water. It has also been used for over a
decade as a filler in cosmetic applications, nasolabial
folds, lip augmentation and facial irregularities.
Although the results are permanent, they are, report-
edly, reversible with dilution and aspiration. Nodular
formation and abnormal swelling have been reported
from 1 week to a year following its injection.35
Bioplastique® is injectable solid silicone micro-
spheres suspended in a polyvinylpyrrolidone carrier
that is used as a contouring injectable.36 It has CE
Marking.
Fig. 9.12 Granuloma formation on upper lip post Artecoll®
injection. Courtesy of Dr Alessandra Haddad.
110
Aesthetic Oculofacial Rejuvenation

Biopolimero®, also known as silicone oil, comes
in 350, 1000 and 5000 centistokes. The higher the
number, the more viscous the oil. This product is
permanent and difficult to remove.
Dermagen® is a mineral-based dermal filler that
comprises silica and oxygen.
DermaLive® or DermaDeep® is a French inject-
able implant manufactured by Derma Tech and,
reportedly, distributed in over 40 countries. It is a
HA-based dermal filler with added acrylic hydrogel
(a non-resorbable component). This product com-
prises positively charged, porous, polyvinyl micro-
spheres suspended in a polyacrylamide gel. The
microspheres are manufactured of the same suture
material already used very successfully in microsur-
gery. After injection, the hydrophilic acrylic hydro-
gel attracts a great amount of water and forms
minute particles that stimulate collagen synthesis,
thus sustaining a very long-lasting effect. It is not
degradable by the human body. If side effects occur,
they will remain as long as the material is in the skin.
There is a very high risk of granuloma formation,
which starts as small palpable nodules that most
patients can feel as hard nodules even before they
become obvious for other people (Figs 9.13 and
9.14). Surgical removal is the treatment, but once
the patient reacts with granulomas, they will con-
tinue to develop new nodules that have to be
removed. Histopathologically (Figs 9.15 and 9.16)
well-demarcated foreign-body granulomas are seen
with a fibrous pseudocapsule and polygonal foreign
bodies in a dense granulomatous and partly fibrous
tissue. Areas of necrosis develop, and fistula forma-
tion is not rare.2 Apparently, a bacterial biofilm may
Fig. 9.13 Well-demarcated foreign-body granulomas post
Dermalive® injection. Courtesy of Professor Eckart
Haneke.
Fig. 9.14 Postsurgical extirpation of granulomas. Courtesy
of Professor Eckart Haneke.
A
B
Fig. 9.15 Macroscopy of granulomas.
111
Facial Fillers and Volumizers

form on the surface of the acrylic particles. It is
thought that this phenomenon may be the reason
for late abscess formation following injection of
these fillers.
They should not be injected over other products;
if a temporary injectable has been given before, it
has to be fully dissipated before injecting the acrylic
hydrogel. Since complications such as infection and
local inflammation are rather common, the treat-
ment area should not be touched, and, if the area
has to be cleaned, it should be done with a sterile
gauze pad and rubbing alcohol. Cosmetic creams
or moisturizers should not be applied, and the
injection site should be kept free of cosmetics, oils,
etc. for at least 12 hours. Failure to do so can result
in infections and abscesses (Fig. 9.17). These pro-
ducts can be found in Australia, the UK and Africa,
and throughout Europe and Asia. It has CE Mark-
ing. DermaDeep® is intended for the deepest layers
of the skin to correct tissue deficiencies or for tissue
contouring;
DermaLive®
is
intended
for
more
superficial layers. Both products are not suitable
for superficial wrinkles.2
Evolution® consists of polyvinylhydroxide micro-
spheres suspended in acrylamide. The product is
generally well tolerated, but it can also induce a for-
eign body reaction. Results reportedly last 2–3 years
or more.
Metacrill®, made in Brazil by Metacril, comprises
PMMA microspheres suspended in a clear carrier
made from carboxymethylcellulose.
Outline®, manufactured in France, is made up of
positively charged hydrophilic polyacrylamide gel
with an unknown percentage of residual unpolymer-
ized acrylamide monomer. Its pH is 7.4. It comprises
only positively charged hydrophilic polyacrylamide
gel. The positive charge attracts the negatively charged
HA and other glucosaminoglycans. Outline is pre-
sented in three forms and can be injected into the
mid-dermis, deep dermis and just below the dermis.2
General Treatment Techniques
Regardless of which dermal filler is used, the choice
of the product and the correct depth of application
are critical for the optimum result.
Fig. 9.16 Microscopic aspect of fibrous pseudocapsule
and polygonal foreign bodies in a dense granulomatous
and partially fibrous tissue. Areas of necrosis develop and
fistula formation is not rare. Apparently, a bacterial biofilm
may form on the surface of the acrylic particles. Courtesy
of Professor Eckart Haneke.
A
B
Fig. 9.17 A, Patient at 6 months post injection with Dermalive® in Paris, as an attempt to elevate her eyebrows. Necrotic
and painful inflammatory granuloma formation secondary to the injection. Removing the necrotic material by surgery is the
only treatment indicated. Courtesy of Dr Marian Cantisano-Zilkha. B, Frontal view of same patient. Courtesy of Dr Marian
Cantisano-Zilkha.
112
Aesthetic Oculofacial Rejuvenation

Patients are treated while sitting in an upright
position. They are given three sublingual arnica
montana C5 pellets immediately before the injec-
tions and advised to continue taking them four
times daily for 3 days. The areas to be injected are
first cleansed to remove make-up, and a headband
is applied to keep the hair away. Photographs taken
before and after the injection are paramount for
future publications or for comparative purposes.
As mentioned previously, most collagen products
(except Evolence® and Sculptra® when reconsti-
tuted)
contain
lidocaine
in
their
formulations,
which reduces the discomfort associated with injec-
tion. In contrast, most HA products (except Ele-
vess®) do not contain anesthetic agent; therefore
we should apply either topical anesthetic or regional
blocks, or inject the area around the treatment site
with local anesthetic in a ‘field block’ fashion (such
as mini-dental blocks or ‘depression blocks’), taking
care not to create too much tumescence and distort
the defect. The peripheral nerve blocks (supra- and
infraorbital, and mental) will provide deeper anes-
thesia, but some degree of distortion.
If a topical anesthetic is used, Natragel™(Gel
Concepts LLC., Whippany, NJ) is applied, for a
deeper penetration of the material and some vaso-
constrictive effect. Ice may be applied before and
after injection.
Four different implantation techniques are gener-
ally used: linear threading, serial puncture, fanning
and cross-hatching. Regardless of the technique
being used, the injection should be administered
slowly to minimize discomfort, bruising and adverse
outcomes secondary to technique injection.
Serial puncture is technically the easiest method
because the needle tip does not move during injec-
tion. The needle enters the skin to the desired
depth, a small amount of filler is deposited, and
the needle is withdrawn. It is a favorite technique
for beginners. It can be a good technique for gla-
bella, distensible acne scars and lip augmentation,
right on the bulk of the mucosa, or to create defini-
tion, to the philtrum (Fig. 9.18). The injection sites
should be close together, to prevent gaps, and the
skin should be tightly pulled from the injection site.
After the injection, the area should be gently mas-
saged to create a smooth layer.
The linear threading is the most popular tech-
nique. It involves holding the needle parallel to the
length of the wrinkle on the dermal level or fold
that is being treated, piercing the skin, creating a
tunnel, advancing the needle and injecting the mate-
rial in either a retrograde or an anterograde fashion,
making sure to stop injecting before withdrawing
the needle. This technique is ideal for vermilion
border, nasolabial folds and tear trough deformi-
ties.22 We should also use the ‘Restylane push tech-
nique,’26 where we apply a certain amount of the
filler over the periosteum, in a retrograde fashion,
and
then
gently
massage
it
over
the
defect
(Fig. 9.19).
The fanning and cross-hatching techniques are
variations of linear threading. They can be used in
areas where a larger volume of filler is needed or
when a multicontoured area is being filled with a
product such as Sculptra®, which was previously
described (Fig. 9.20).
The puncture and linear threading techniques are
the most used techniques for soft tissue augmenta-
tion
(collagen,
HA,
L-polylactic
acid,
calcium
hydroxylapatite and the non-biodegradable pro-
ducts). The fanning and cross-hatching techniques
are also suitable for HA products and L-polylactic
acid therapies, and, often, when a broad area of
defect is covered. (This technique is described sep-
arately because of its uniqueness of reconstitution,
which is the key for success.)
COMPLICATIONS
Complications can be technique dependent, filler
dependent or both. Once you carefully and con-
sciously choose the best and safest filler for the
particular area to be injected, the most frequent
reasons for patient dissatisfaction are inappropriate
placement or superficial placement. To further
reduce the chance of problems, there are general
Techniques
Fig. 9.18 Serial and puncture techniques
for lip augmentation.
113
Facial Fillers and Volumizers

guidelines related to the injection technique, the
site of correction and volume techniques. You may
even combine chemically different fillers and still
be very safe. Due to the reversibility of HA, compli-
cations from these fillers can be easily corrected
(Fig. 9.21), with diluted intradermal or subcutaneous
injections of hyaluronidase (Hydase®, Vitrase®), on
the site to be corrected. Sensitivity to any of the
currently approved FDA products is quite rare and
can
usually
be
managed
with
antiinflammatory
agents. Infection is also quite uncommon and can
usually be managed with either antibiotics or anti-
virals, depending on the clinical features. The most
concerning
complication
of
fillers
is
cutaneous
necrosis.37,38
Patients reluctantly accept localized bruising and
puncture marks at the injection sites. They can be
minimized with the use of topical vasoconstricting
anesthetic agents, cutaneous pre- and postinjection
cooling with Natragel® masks and ice, and applying
postinjection pressure.
In areas such as the glabella, there is a danger of
creating local vascular occlusion with local develop-
ment of necrosis and retinal vascular obstruction,
therefore
some
practitioners
completely
avoid
injecting that area. The authors recommend soft
biodegradable fillers, low volumes, slow injection
technique and keeping injections on a very superfi-
cial dermal plane.
Hyaluronic Acid
Mild transient localized erythema is the exception
rather than the rule following HA implantation.
Local areas of hardening and gel aggregation at the
A
B
C
Anterior lacrimal
crest
Tear trough
deformity
Infraorbital
foramen
Bolus x2 each
0.5 cc of HA
Infraorbital
rim
Periosteum
Digital massage
to contour
Fig. 9.19 Treatment of tear trough deformities.
Linear threading
Serial puncture
Fanning
Cross-hatching
Fig. 9.20 Injection techniques.
Fig. 9.21 Superficial placement of HA on right lower lid.
This can be easily corrected with diluted injection of the
enzyme hyaluronidase. Courtesy of Dr Marian Zilkha.
114
Aesthetic Oculofacial Rejuvenation

injection sites can often be palpated for several
days. Although they are rarely visible, the patient
should be told that this is not unusual and will
become less apparent with time. Following lip aug-
mentation, superficial injections can leave more vis-
ible lumps. Because the product is very hydrophilic,
any localized irritation and increased secondary
edema will amplify their prominence. To avoid this,
patients should be instructed not to rub the areas
with their tongue. In areas of superficial implanta-
tion or translucent skin, the gel may be visualized
as a gray shadow through the skin. Most female
patients prefer the correction of the cutaneous
depression and do not object to the grayish shadow,
the Tyndall effect. However, they must be advised
of it before the treatment.
Localized edema following implantation is usually
not problematic and may even accentuate the cor-
rection (Fig. 9.22). The authors instruct patients
that if the correction is less evident in 5–7 days, this
is not because the gel has dissipated but because
they need more volume implanted. Patients are
asked to return in 7–10 days for a possible touch-
up. During 1996 and 1997, the authors saw two
cases of sterile, suppurating granulomas with onsets
10–14 days following the initial injections. One
required incision and drainage, the other was self-
limited, with complete resolution after 16 days.
No other similar reactions have been seen with
Restylane® or Perlane® since 1997.38–40 Delayed
reaction to Hylaform® or Hylaform Plus® may be
somewhat different because they are cross-linked
products of avian origin. In areas where there has
been an over-filling, or where the implantation of
HA has been too superficial, patients may not want
to wait for the naturally occurring breakdown.
These areas can be injected with diluted dose of
hyaluronidase (Hydase® or Vitrase®) and the defect
dissipates within 24 hours.
Collagen
Even the patients with two negative skin tests may
eventually exhibit an inflammatory response follow-
ing implantation and require corticosteroid injec-
tions; these patients may develop localized atrophy
at the injection sites or develop subcutaneous scar-
ring in the long term. This becomes evident when
other products are used for volume augmentation at
a later date. There has also been some controversy
regarding sequential collagen implantation and the
development or exacerbation of autoimmune and
collagen-vascular
diseases.40–42
Although
patients
with known inflammatory responses to collagen are
discouraged from undergoing further treatments
with human fibroblast-derived collagen, it is hoped
that these products will produce less inflammatory
responses in fewer patients (Table 9.4).
Non-biodegradable Fillers
An Internet search for fillers reveals a great number
of preparations, most of which have no FDA or EU
approval. Their production standards and quality
are sometimes questionable. However, because they
are usually sold at a much lower price, they are
tempting for some users and potential patients.
Fig. 9.22 Angioneurotic edema post hyaluronic lip
injection. Courtesy of Dr Alessandra Haddad.
Table 9.4
Adverse sequelae and complications
associated with collagen injections
Bovine and human:
Redness, edema, bruises
Infection, herpetic or acneiform eruption
Contour irregularity (wrong placement)
Intravascular injection, tissue necrosis, blindness
Bovine:
Hypersensitivity reaction: cyst, granuloma
115
Facial Fillers and Volumizers

The authors expressively warn against the use of
unapproved fillers even though they may come with
a ‘certificate of good production’ and claims of perfect
purity and good tolerability. The physician always
remains legally responsible for what he or she does.
Patients seeking, and paying for, aesthetic procedures
to improve their appearance will not hesitate to
litigate, and it will be the physician’s problem to
prove that approved, top-quality products were used.
Bacterial infections are late adverse events asso-
ciated with gels and particulate preparations that
may become clinically evident as soon as 1–2 weeks,
or as late as years after injection. The bacterial cul-
tures often remain negative or may grow so-called
non-pathogenic bacteria that are part of the normal
resident flora of the skin and/or oral mucosa. Histo-
logically, the lesions are similar to whatever prepa-
ration was used: foreign body granuloma containing
gel particles, macrophages, lymphocytes, often gran-
ulocytes, rarely bacteria, sometimes central necrosis
and fistula formation. An early clinical symptom
may be a deep-seated tingling followed by swelling.
Such an infection will disappear when a degradable
substance has been injected, but any infection
that develops after non-degradable filler injection
requires high-dose antibiotic treatment for at least
2 weeks without prior steroid injections. If non-
steroidal antiinflammatory drugs, steroids or low-
dose antibiotics were given before the antibiotic
treatment, these have to be extended over a month
or even longer. Although the material is highly bio-
compatible and does not move in the tissue, it is
an excellent growth medium for many kinds of bac-
teria. Microscopic examinations suggest that they
may form a biofilm on the surface of the polyacryl-
amide particles. Sometimes, one or more surgical
interventions may be necessary and sometimes they
can be mutilating (Figs 9.23 and 9.24).
Products containing PMMA microspheres should
not be used in the periorbital area because there are
the possibilities of a retrograde venous injection
and a central retinal vein occlusion with secondary
blindness. Although the exact percentage has not
been published, many of these patients develop
granulomas. Considerable granuloma formation has
also been observed many years after PMMA injec-
tion after the patient received interferon injections
for the treatment of chronic hepatitis C.42,43 The
authors have seen several patients, referred from
Europe, who have developed skin ulcerations. The
products using bovine collagen to suspend the
microspheres may also have complications second-
ary to bovine collagen use. Products containing HA
in suspension may also have complications second-
ary to the source of HA.
Poly-Lactic Acid
Poly-lactic acid has to be reconstituted and mixed
very well before use. If it is not mixed thoroughly
enough at least 24 hours prior to injection and not
sufficiently diluted, there may be an increased inci-
dence of granuloma formation. It is very important
to know how to differentiate granuloma formation
from the accumulation of too much material that
has not been totally reconstituted, creating clogs of
polylactic acid. In my (MCZ) 6 years of highly suc-
cessful clinical experience with the use of such a
material, I have learned that a practical way to know
if the suspension is well mixed is to carefully follow
the steps of reconstitution, and to make sure that
the suspension does not clog a 27-gauge needle,
Fig. 9.23 Metacril on cheeks, on facial lipodystrophy;
palpable nodular formation. Courtesy of Dr Alessandra
Haddad.
Fig. 9.24 Metacril on nasolabial folds – palpable and painful
nodular formation. Courtesy of Dr Alessandra Haddad.
116
Aesthetic Oculofacial Rejuvenation

which is the recommended size for the injection.
Clogging will require frequent changing of the needle
and increase the likelihood of irregular injection.
After the injection is finished, the authors often mas-
sage the area with an antibiotic ointment for 10 min-
utes
to
make
sure
that
the
product
is
well
distributed. If an inflammatory granuloma formation
occurs (Fig. 9.9), injection of diluted steroids is
recommended. If too much accumulation of material
is observed, the authors recommend injecting dis-
tilled water in the lesion to dilute and dissolve it.
Silicone
Using microdroplets of ultrapurified silicone in
properly selected patients may avoid the extreme,
and often unrepairable, complications associated
with its abuse. Large volumes of silicone that have
been injected will migrate. With time the spreading
of the product makes surgical excision difficult or
impossible. Because of the adjacent inflammatory
reaction, these masses of silicone will be difficult
or impossible to remove without leaving significant
soft tissue deformities. In case of siliconomas, a
TNF-a inhibitor may be tried.
THE FUTURE
New injectable tissue augmentation materials are
already in the pipeline. There is a growing interest
in products that are longer lasting, but that do not
sacrifice safety for longevity, as previously discussed.
The availability of products that have fibroplastic
properties, and offer great safety and patient satisfac-
tion, is a reality. There is also a great potential for
stem cell implantation in the near future. Products
containing a combination of HA and dextranomers
have already been tested for longer-lasting correc-
tions of facial surface and contour irregularities.
THE KEYS TO SUCCESS/OPTIMIZING
OUTCOMES
v Understanding the differences between fillers.
v Understanding differences between static
wrinkles and laxity.
v Correct evaluation of the defect.
v Proper choice of the filler.
v Patients with realistic expectations.
v Good technique for application.
CONCLUSIONS
In conclusion, dermal fillers are a true, real, good
option for minimally invasive rejuvenation. The
complications with dermal fillers can be well pre-
vented, as long as you select safer fillers, follow
low-volume and gentle techniques of injection, and
use easily-deployed strategies to minimize their
incidence and impact.43,44
REFERENCES
1 Terino OE. Three-Dimensional Facial Sculpting. New York:
Informa Healthcare; 2007.
2 Haneke E. Polymethyl methacrylate microspheres in collagen.
Semin Cutan Med Surg. 2004;23:227–232.
3 Goldberg DJ. Fillers in Cosmetic Dermatology. Informa Health-
care UK, Series in Cosmetic and Laser Therapy. 2006;1:4.
4 Panicacci RS, Grossman K. Facial rejuvenation with autologous
fat injections. In: Bosniak S, Antisano VCV, Zilkha M, eds. Mini-
mally Invasive Techniques in Oculoplastic, Orbital and Recon-
structive Surgery. New York: Theime; 1999.
5 Carruthers J, Carruthers A. Soft Tissue Augmentation. 2nd ed.,
vol. 7. Elsevier; 2008:83 (fillers working by Fibroplasia).
6 Goldberg DJ. Fillers in Cosmetic Dermatology. Informa Health-
care UK, Series in Cosmetic and Laser Therapy. 2006;1:6–10.
7 Goldberg DJ. Fillers in Cosmetic Dermatology. Informa Health-
care UK, Series in Cosmetic and Laser Therapy. 2006;6:137.
8 Matti BA, Nicolle FV. Clinical use of Zyplast in correction of age-
and disease-related contour deficiencies of the face. Aesthetic
Plast Surg. 1990;24:227–234.
9 Stegman SJ, Chu S, Bensch K, Armstrong R. A light and electron
microscopic evaluation of Zyderm collagen and Zyplast implants
in aging human facial skin: a pilot study. Arch Dermatol.
1987;123:1644–1649.
10 Lemperl G, Morhenn V, Charrier U. Human histology and persis-
tence of various injectable filler substances for soft tissue augmen-
tation. Aesthetic Plast Surg. 2003;27:354–367.
11 Narins RS, Brandt FS, Lorene ZP, Maas CS, Monheit GD,
Smith S. Twelve-month persistency of a novel ribose-cross-linked
collagen dermal filler. Dermatol Surg. 2009;34(suppl 1):S31–S39.
12 Braun M, Braun S. Nodule formation following lip augmentation
using porcine collagen-derived filler. J Drugs Dermatol. 2008;
7(6):579–581.
13 Instructions for use.
Available at Accessed
June 27, 2008.
14 Yoshiko M, Fumitaka T, Nobuyoshi Hideo S, et al. Atelocollagen-
mediated synthetic small interfering RNA delivery for effective
gene silencing in vitro and in vivo. Nucleic Acids Res. 2004;32:109.
15 Klein AW. Skin filling. Collagen and other injectables of the skin.
Dermatol Clin. 2001;19(3):491–508, ix.
16 Sclafani AP, Romo 3rd T, Jacono AA, et al. Evaluation of
acellular dermal graft sheet (alloderm) and injectable (micronized
Alloderm) forms for soft tissue augmentation. Clinical observa-
tions and histological analysis. Arch Facial Plast Surg. 2000;2
(2):130–136.
17 Fagien S. Facial soft tissue augmentation with injectable autolo-
gous and allogenic human tissue collagen matrix (atuologen and
dermalogen). Plast Reconstr Surg. 2000;105:362–373.
18 Isolagen and FDA Reach Agreement on Phase III Protocol Design.
Dermatology News. Oct. 14, 2006.
19 Agerup B, Wik O. NASHA: the Monograph. Uppsala, Sweden:
Q-Med; 2001.
117
Facial Fillers and Volumizers

20 Narins RS, Brandy F, Leyden J, et al. A randomized, double-blind,
multicenter comparison of the efficacy and tolerability of Resty-
lane versus Zyplast for the correction of nasolabial folds. Dermatol
Surg. 2003;29:588–595.
21 Bosniak S, Cantisano-Zilkha M, Glavas JP. Injectable fillers. In:
Bosniak S, Cantisano-Zilkha M, eds. Minimally Invasive Techni-
ques of Oculofacial Rejuvenation. New York: Theime; 2005.
22 Bosniak S, Sadick N, Cantisano-Zilkha M, Glavas Y, Roy D.
Definition of the tear trough and the tear trough rating scale.
J Cosmetic Dermatol. 2007;6(4):218–225.
23 Approvals FDA. Juve´derm. Available at Accessed
on February 6, 2007.
24 Official Site, (accessed October 2008).
25 Leonard AL, Hanke CW. J Am Acad Dermatol. 2006;55:511-512.
Surgical Pearl: the use of a laboratory vortex for poli-L-lactic acid
injection.
26 Ahn MS. Calcium hydroxylapatite: radiesse. Facial Plast Surg
Clin North Am. 2007;15(1):85–90, vii.
27 Sklar JA, White SM, Radiance FN. A new soft tissue filler.
Dermatol Surg. 2004;30:764.
28 Rees TD, Platt J, Ballantyne DL. An investigation of cutaneous
response to dimethylpolysiloxane (silicone liquid) in animals and
humans – a preliminary report. Plast Reconstr Surg. 1965;
35:131–139.
29 Conway H, Goulian Jr D. Experience with injectable Silastic RTV
as a subcutaneous prosthetic material. Plast Reconstr Surg. 1963;
32:294–302.
30 Spira M, Rosen T. Injectable soft tissue substitutes. Clin Plast
Surg. 1993;20:181–188.
31 Nosanchuck
JS.
Silicone
granuloma
in
breast.
Arch
Surg.
1968;97:583–585.
32 Symmers WstC. Silicone mastitis in ‘topless’ waitress and some
other varieties of foreign-body mastitis. BMJ. 1968;iii:19–22.
33 Pollack S. Some new injectable dermal filler materials. Hylaform,
Restylane and Artecoll. J Cutaneous Med Surg. 1999;3(suppl 4):
S27–S37.
34 Acalay J, Alkalay R, Gat A, Yorav S. Late onset granulomatous
reaction to Artecoll. Dermatol Surgery. 2003;29(8):859–862.
35 Christensen L, Breiting V, Vuust J, Hogdall E. Adverse reactions
following injection with permanent facial filler polyacrylamide
hydrogel (Aquamid): causes and treatment. Eur J Plast Surg.
2006;28(7):464–471.
36 Ellis DA, Segall L. Review of non-FDA-approved fillers. Facial
Plast Surg Clin North Am. 2007;15(2):239–246.
37 Hanke CW, Higley HR, Lolivette DM, et al. Abscess formation
and local necrosis after treatment with Zyderm or Zyplast colla-
gen implant. J Am Acad Dermatol. 1991;25(2 Pr 1):319–326.
38 Bosniak S, Cantisano-Zilkha M. Restylane hyaluronic acid gel for
facial rejuvenation: A 4-year experience. J Cosmet Laser Ther.
2001;3:192–193.
39 Bosniak S. Cantisano-Zilkha M. Glavas IP. Non-animal stabilized
hyaluronic acid gel for facial rhytids ablation: a six-year clinical
experience. In press.
40 Cukier J, Beauchamp RA, Spindler JS, et al. Association between
bovine collagen dermal implants and a dermatomyositis or
polymyositis-like syndrome. Ann Intern Med. 1993;118(12):
920–928.
41 Trautinger F, Kokoschka EM, Menzel EJ. Antibody formation
against human collagen and C1q in response to a bovine collagen
implant. Arch Dermatol Res. 1991;283(6):395–399.
42 Fischer J, Metzler G, Schaller M. Cosmetic permanent fillers for
soft tissue augmentation: a new contraindication for interferon
therapies. Arch Dermatol. 2007;143:507–510.
43 Glogau R, Kane M. Effect of injecting techniques on the rate of
adverse events in patients implanted with non-animal hyaluronic
acid dermal fillers. Dermatol Surg. 2008;34(1):S105–109.
44 Cantisano-Zilka M. Understanding the uses of injectable fillers
and volumizers. In: Zilka M, ed. Contemporary Guide to Aesthetic
Enhancement. Newtown, PA: Handbooks in Health Care; 2008.
118
Aesthetic Oculofacial Rejuvenation

Fat Transfer
Luiz Alexandre Lorico Tissiani
INTRODUCTION
Fat transplants have been used in the aesthetic and
reconstructive plastic surgery field for more than a
century. In 1893, when Neuber1 first reported on
using fat grafts to treat depressed scars, he con-
cluded that fat specimens could not be bigger than
an almond. Since that time, numerous surgeons
from different medical specialties have utilized fat
tissue in a great variety of pathologies.
Lexer2 used a block of fat tissue to correct a post-
traumatic facial deformity and obtained an initial
good result. In the long-term follow-up, he observed
high rates of contraction and this fact inspired him
to use bigger and bigger blocks of fat tissue. He
never analyzed his grafts under the microscope. To
improve
the
integration
of
fat
grafts,
May3
incorporated fascia to fat tissue grafts, and Peer4
chose to add the dermis to fat tissue. In 1957,
Schorcher5 treated patients with hypomastia using
multiple small fragments of fat tissue and observed
a 75% loss rate in a 9-month follow-up. Ellenbogen6
developed the so-called ‘fat pearls’ with an average
size of 8
5 mm. He used them in the eyelids
and tear troughs, and experienced a 50% loss.
Because so many plastic surgeons have published
unsatisfactory results with the use of fat grafts, this
technique fell into disgrace for many years until
Coleman’s first papers were published in the early
1990s.7,8 His results have given the plastic surgery
community a new look at fat grafts. He discovered
how to work with fat in a very systematic and repro-
ducible way, which is called ‘lipostructure’, and has
obtained much more favorable results.
In 1998, Lambros9 published some thoughts about
retaining ligaments of the midface as latticework, and
its relationship with skin and soft tissues, mainly the
fat tissue. There is often a deflation component when
the face ages, and this makes volume replacement
necessary when rejuvenating a patient’s face. The
zygomatic area and tear trough are anatomical sites
where grafted fat tissue presents very good to excel-
lent survival rates. Conversely, lips and nasolabial folds
are the areas with the least graft integration rates.10
Considering that fat tissue has been used as a
filler, it might be assumed that it has many charac-
teristics of an ideal filler (Table 10.1), and only
recently it has been adopted as the main source of
adult mesenchymal stem cells.11,12
INDICATIONS AND CONTRAINDICATIONS
Fat tissue transplantation can be used whenever the
main problem is soft tissue insufficiency caused by
surgery, trauma, aging or pathology. In cosmetic
surgeries, fat grafts can be used in post-liposuction
deformities (Fig. 10.1), in saucer deformity after
gynecomastia surgery, and to reestablish, or simply
add volume to, all facial areas such as zygomatic
(Fig. 10.2), mandibular, mental, temples, lips, naso-
labial folds, eyebrows, eyelids, neck, tear troughs,
face lifting deformities and acne scars. Cosmetic
breast augmentation with fat is possible, but it is a
very controversial issue. It deserves a closer evalua-
tion and requires a great knowledge of adipose-
derived stem cells (ADSCs) and their handling.
Fat transplants also have many applications in recon-
structive surgeries, the most common of which are the
Romberg’s syndrome (Fig. 10.3) and other pathologies
that present with lipodystrophy. Post-traumatic tissue
loss in different areas of the body, defects following
benign and malignant tumor resections, refinements
in breast reconstruction, sequelae of facial paralysis,
and sequelae of radiation therapy are all very common
reasons for undergoing plastic surgery.13
There are very few situations where fat tissue
cannot be used. Extreme thinness is the most com-
mon contraindication because thin people do not
have enough fat tissue to be harvested and grafted.
Patients with poor general health are also not candi-
dates for fat grafting.
10

PREOPERATIVE HISTORY
AND CONSIDERATIONS
When a patient asks for some facial improvement, it
is important to identify exactly what he/she is look-
ing for, what his/her lifestyle is and how long the
downtime period can be. Patients with high expec-
tations are tricky, and the surgeon must thoroughly
discuss the goals and limitations of the technique. It
is also very important to take as many photographs
Table 10.1
Advantages of fat tissue
Low-cost harvesting
Readily and easily obtainable
Possible repeated harvesting
No immune reactions (short or long term)
A source of adipose derived stem cells
Indirect stimulation of angiogenesis
A
B
C
Fig. 10.1 Post-liposuction deformity on the abdomen: preoperative, demarcation and postoperative result after 9 months
of structured fat grafting.
A
B
Fig. 10.2 One-year postoperative
period of fat grafting to the malar
areas and lips.
120
Aesthetic Oculofacial Rejuvenation

as possible, from different angles and views, dis-
cuss with the patient where the problems are
and demonstrate how they will be addressed by
making drawings on the photographs. It is a good
idea to ask patients to bring you old photographs.
This can help you understand how they are aging
and can give you clues about what a patient is
looking for.
A patient’s medical history is a fundamental
source of information about pathologies, blood
clotting problems, allergies, current medications,
previous surgeries and response to anesthesia. It is
important to ask about previous cosmetic treat-
ments: when, where, what product was injected,
and how often? These questions can give you some
information about the patient’s self-esteem and
may suggest potential problems during fat graft
delivery to the host tissue.
On physical examination, check skin quality and
sensitivity, mimic musculature work and palpate
the whole face in search for small nodules or
blurred subcutaneous areas. This can help to iden-
tify areas treated with fillers that were missed dur-
ing the clinical questionnaire.
Do not forget to prepare a good informed consent
document with as much information as possible,
including a note that a second procedure of fat
transfer could be necessary because some absorption
might occur. Fat grafts present some volumetric
reduction until the sixth month and stabilize by the
12th month. Horl et al.10 demonstrated this phenom-
enon very well using magnetic resonance imaging.
A
B
C
D
Fig. 10.3 Two years 1-month
postoperative two fat grafting
sessions for Romberg’s syndrome.
Patient has put on weight (20 kg)
between the first and second
procedures. Note the improvement
on the periorbital region (lid–cheek
junction and temporal fossa).
121
Fat Transfer

OPERATIVE APPROACH
Structured fat grafting involves three important
steps: harvesting, preparation and transfer. Fat tis-
sue is obtained through small cannulas (2.5 mm in
diameter
15 cm in length) with two sequenced
holes on the tip and under low negative pressure.
The plunger of a 10 cm3 Luer Lok syringe should
be pulled back in 2 cm3 increments. If general anes-
thesia is employed, a solution of ringer lactate and
epinephrine in a final concentration of 1:500 000 is
utilized and, if sedation is the option, a solution is
made with lidocaine, bupivacaine, sodium bicarbon-
ate, saline and epinephrine.
The abdomen is the preferred donor site. When
different areas of the body are compared, some stud-
ies show no difference in adipocyte viability and
survival rate after harvesting. Usually, the abdomen
presents some localized fat and incisions can be placed
inside the navel, leaving behind no stigma of surgery.
To optimize centrifugation, syringes full of fat are
briefly decanted in a tube rack (Kartell, Labware
Division, Noviglio, Italy) before they go into the
centrifuge. Plungers are removed and a plastic plug
seals the tip of the syringe while a silicone cork
closes the upper part. The whole process of centri-
fugation is completely sterile.
After centrifugation (3000 rpm for 3 min), three
well-separated layers are present. The top layer
(least dense) is full of oil and cell debris, and the
bottom layer is a mixture of blood and anesthetic
solution. Both these layers must be discarded by
aspirating the oil and draining the blood. The inter-
mediate layer primarily consists of viable fat cells.
To check the number of living cells, Boschert
et al.11 specifically subdivided this layer into three
parts and concluded that the part close to the bot-
tom layer contained more adipocytes (in number)
than the other two parts.
The middle layer is entirely transferred to 1 cm3
Luer Lok syringes, through a Luer-to-Luer transfer,
and grafting maneuvers are started. To do so, micro-
cannulas (which means ‘a blunt tip’) of 1.0, 1.2 and
1.4 mm in diameter
7 cm in length, with one hole
on the tip, are employed. Multiple layers are done
starting deep to the bone, passing through the mus-
cles and ending close to the skin. If necessary, cross-
ing tunnels can be made. The most important thing
is to deliver small amounts of fat cells during with-
drawal and, usually, to introduce a volume less than
0.1 cm3, in a radiating pattern during each pass.
Needles are never used to graft fat tissue, and
3 cm3 syringes are not used on the face.
To improve tear trough and lid–cheek junction,
two portals are done. The first is located lateral to
the orbit and approximately 1 cm below a horizon-
tal line that passes at the level of the lateral canthus
(Fig. 10.4). The second one is placed at the meeting
point of two lines – a vertical one that passes tan-
gential to the lateral limbus and a horizontal one
that passes at the level of the nostril sill. The latter
portal is also utilized to graft the malar area.
Because the portals are made with a 21G needle,
there is no need for sutures and there is no scarring
(Figs 10.5 and 10.6).
OPTIMIZING RESULTS
Table 10.2 summarizes areas we consider can opti-
mize the results of fat transplantation.
COMPLICATIONS AND SIDE EFFECTS
As in every surgical procedure, structured fat grafting
has complications; however, most of them are con-
sidered mild to moderate. As the consequence of
multiple passes, edema and ecchymosis are present
after all surgeries but are considered undesirable side
effects rather than complications (Fig. 10.7). Edema
and ecchymosis are really troublesome when so
much work is done to the eyelids and tear trough
because these structures are composed of easily dis-
tensible tissues. Corticoids are routinely used during
the induction of anesthesia to prevent formation of
severe edema.
Fig. 10.4 The portal to the orbit is being made with a needle
where the microcannula is inserted and positioned
under the orbicularis.
122
Aesthetic Oculofacial Rejuvenation

When working on the eyelids, irregularities are
more likely to happen due to the thin skin.
There are two ways to treat minor irregularities
and lumps. First, it is possible to aspirate fat by
employing the twist technique (Lambros) or by sim-
ply moving the cannula back and forth. Second, it is
possible to combine some removal (by suctioning)
with grafting to fade the lumps away.
Major asymmetries are rare but possible. Mild
ones are more frequent, and care should be taken
to avoid them. A meticulous physical examination
must be made at the office to detect constitutional
or acquired asymmetries and, once detected, they
should be rigorously discussed with the patient.
Photographs will help the surgeon to show these
anatomical differences to patients, and will allow
the preparation of an appropriate operative plan. The
photographs must be present in the operating room.
Muscle imbalance and nerve paresthesia are occa-
sional and transient symptoms. They indicate that
some work was done inside the muscle and that
cannula passes caused some trauma to the nerve.
Using blunt tip microcannulas eliminates the possi-
bility of causing trauma to a partial or complete sec-
tion of a nerve, vessel or latticework of the face.
Amaurosis is a very rare and disastrous complica-
tion in facial fat grafting. The great majority of cases
are related to fat injections in the glabellar area and
usually happen due to arterial occlusion. This author
discourages fat grafting into the glabella.
A
B
Fig. 10.5 Preoperative and 10-month
postoperative of superior and inferior
blepharoplasty, with fat grafting into
the lid–cheek junction and tear
trough.
A
B
Fig. 10.6 Pre- and postoperative of
10 months of fat grafting into the
midface, tear trough, and lid–cheek
junction.
123
Fat Transfer

POSTOPERATIVE CARE
As previously mentioned, edema and ecchymosis
will always be present in the immediate postopera-
tive period. Usually, ecchymosis subsides in 2–3
weeks, and gross edema subsides in 4 weeks. When
treating lips and eyelids, more intense edema and
ecchymosis are expected. In the first 2 weeks,
cooled devices (gel masks, ice packs and gauzes with
chilled saline), applied topically, should be used to
reduce edema in the treated area. As soon as the
edema subsides, the volume of the tissues reduces
dramatically. Antibiotic prophylaxis is employed
and painkillers are prescribed to be taken only if
necessary. Small dressings on the ports are changed
daily in the first week and discontinued after that.
Patients must be informed that the final result will
be reached within 1 year, but only minor changes
will occur after the sixth month. Direct sun expo-
sure must be avoided during the first 6 months.
It is very important that you do not omit any infor-
mation when assuring patients about the postopera-
tive course. The more you inform, the more
uneventful the recovery period will be.
CONCLUSIONS
There are hundreds of published papers in the litera-
ture in favor of and against fat tissue transfer, and with
both favorable and unfavorable results.14–19 As in all
surgical procedures, some techniques are better than
others and the best one may not exist. However, when
fat grafting is considered, it might be assumed that the
Table 10.2
Tips for structured fat grafting
Harvest
Use fine cannulas
Use low negative pressure
Use Luer Lok syringe system
Preparation
Provides an excellent cell separation
(centrifugation)
Is a very systematic way to handle
fat tissue
Optimizes volume placement
Grafting
Use microcannulas (blunt tip).
Use 1.0 cc Luer Lok syringes.
Take small parcels of fat in each pass
Make sure there are no lumps
Avoid external molding
Structure work with multiple passes
Use criss-cross only if necessary
Use needle ports instead of
incisions
Employ knowledge of topographic
facial anatomy
Become familiar with the resistance
of different tissues
Do not use an injector gun
A
B
Fig. 10.7 Observe edema and
ecchymosis after treating lips and
inferior eyelids in recent
postoperative periods.
124
Aesthetic Oculofacial Rejuvenation

‘structured way,’ with all its steps, is the gold-standard
method of grafting fat tissue. Structured fat grafting is
a reliable and reproducible technique.
In this systematized method, surgeons can con-
stantly work in the same manner, and the daily prac-
tice can teach them where mistakes were made and
where progress needs to be made. Moreover, surgeons
of different schools and countries can exchange
experiences as the methodology is standardized, and
improvements to the technique can be added.
Recently, Coleman12 published a paper where he
emphasized that fat tissue is more than a permanent
filler carrying some biological properties.
Fat tissue is currently the main source of adult
mesenchymal stem cells, the so-called ADSCs.
The presence of these cells in the grafted tissue
can answer some questions and issues that, in the
past, were obscure. Improvement of skin quality
(texture and color), acne scars and radiotherapy
damage are now attributed to the presence of these
multipotent cells in the fat transplants.
The main reason for making multiple passes while
grafting fat tissue is not to possibly enhance the
volume to be injected but to improve the contact of
fat cells with the host tissue to promote better nutri-
tion, respiration and adhesion of the transplanted
cells. Although meticulous and technical work is
done, inevitably some cells will die. According to
the ‘surviving theory’ (the most accepted theory to
explain how transplanted fat cells survive), trans-
planted adipocytes, in this stress-induced situation,
have the capacity to differentiate into preadipocytes,
which are more resilient to hypoxia and nutritional
deficiencies. Structured fat grafting provides a favor-
able microenvironment for mature adipocytes, pre-
adipocytes and ADSCs. That is the reason this
technique presents amazing results.20,21
To
isolate
ADSCs,
let
them
multiply
on
sequenced symmetric mitosis and enrich a regular
fat graft with them. Doing this can really improve
graft adherence rates. There are four possible ways
ADSCs can improve graft adherence:
v ADSCs can differentiate into adipocytes.
v ADSCs can differentiate into endothelial cells
promoting angiogenesis and graft survival.
v ADSCs secrete vascular endothelial growth
factor (VEGF), which stimulates angiogenesis.
v ADSCs survive as original multipotent cells.
The incorporation of this recent biotechnology to
fat grafts has brought a new understanding of fat
tissue usage and represents both the present and
the future of cosmetic and reconstructive plastic
surgery. Surgeons who have been working with fat
tissue, and those who intend to, must be open
minded to this new era of regenerative medicine.
REFERENCES
1 Neuber F. Fat transplantation. CHir Kongr Verhandl Dsch Gesellc
Chir. 1893;22:66.
2 Lexer E. Euber freie fettransplantation. Klin Ther Wehnschr.
1909;18:53.
3 May A, Knaysi G. On the use of basic dyes for the demonstration
of the hydrolysis of fat. J Bacteriol. 1941;42(5):587–589.
4 Peer LA. The neglected ‘free fat graft’: its behaviour and clinical
use. Am J Surg. 1956;92:40.
5 Schorcher F. Fettgewebsverpflanzung bei zu kleiner Brust. Munch
Med Wochenschr. 1957;99:489.
6 Ellenbogen R. Free autogenous pearl fat grafts in the face. A pre-
liminary report of a rediscovered technique. Ann Plast Surg.
1986;16:179–194.
7 Coleman SR. Long-term survival of fat transplants: controlled
demonstrations. Aesthet Plast Surg. 1995;19(5):421–425.
8 Coleman SR. Facial recontouring with lipostructure. Clin Plast
Surg. 1997;24(2):347–367.
9 Lambros V. Fat injection for the aging midface. Oper Techn Plast
Reconstr Surg. 1998;5(2):129–137.
10 Horl HW, Feller AM, Biemer E. Technique for liposuction
fat reimplantation and long-term volume evaluation by magnetic
resonance imaging. Ann Plast Surg. 1991;26:248–258.
11 Boschert MT, Beckert BW, Puckett CL, Concannon MJ. Analysis
of
lipocyte
viability
after
liposuction.
Plast
Reconst
Surg.
2002;109(2):761–765.
12 Coleman SR. Structural fat grafting: more than a permanent filler.
Plast Reconst Surg. 2006;118(3S):108S–120S.
13 Billings E, May Jr J. Historical review and present status of free
fat graft autotransplantation in plastic and reconstructive surgery.
Plast Reconstr Surg. 1989;83(2):368–381.
14 Chajchir A. Fat injection: long-term follow up. Aesthet Plast Surg.
1996;20:291–296.
15 Ciuci PM, Obagi S. Rejuvenation of the periorbital complex with
autologous fat transfer: current therapy. J Oral Maxillofac Surg.
2008;66(8):1686–1693.
16 Guerrrerosantos J. Long-term outcome of autologous fat trans-
plantation in aesthetic facial recontouring . 16 years of experience
with 1936 cases. Clin Plast Surg. 2000;27(4):515–543.
17 Jackson I. A successful long-term method of fat grafting: recon-
touring of a large subcutaneous postradiation thigh defect with
autologous
fat
transplantation.
Aesthet
Plast
Surg.
2001;
25:165–169.
18 Niechajev I, Sevcuk O. Long-term results of fat transplantation:
clinical and histologic studies. Plast Reconstr Surg. 1994;94
(3):496–506.
19 Pu LL, Cui X, Fink BF, Gao D, Vasconez HC. Adipose aspirates
as a source for human processed lipoaspirate cells after optimal
cryopreservation. Plast Reconstr Surg. 2006;117(6):1845–1850.
20 Rigotti G, Marchi A, Galie` M, et al. Clinical treatment of radio-
therapy tissue damage by lipoaspirate transplant: a healing process
mediated by adipose-derived adult stem cells. Plast Reconstr Surg.
2007;119(5):1409–1422.
21 Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat
transfer viability: a quantitative analysis of the role of centrifu-
gation and harvest site. Plast Reconst Surg. 2004;113(1):
391–395.
22 Sommer B, Sattler G. Current concepts of fat graft survival: his-
tology of aspirated adipose tissue and review of the literature.
Dermatol Surg. 2000;26(12):1159–1166.
125
Fat Transfer

This page intentionally left blank

Dark Circles: A Combination
Approach
Doris M Hexsel, Taciana Dal’Forno, Alessandra
Haddad, Marian Cantisano-Zilkha
Included on DVD
INTRODUCTION
Dark circles are one of the most common dermatolo-
gical complaints. The condition is also called periorbi-
tal melanosis, periorbital skin hyperpigmentation and
infraorbital darkening. Dark circles are defined as
unaesthetic blemishes around the eyes, especially at
the lower eyelid. This condition is frequently seen in
both men and women of all ages.1 Despite occurring
in children and being more prevalent in certain ethnic
groups (Middle Eastern and Mediterranean back-
grounds), dark circles can be interpreted as an
age-related change, since smooth skin around the
eyes – the thinnest skin in the body – and skin color
uniformity are the main attributes related to per-
ceived age.2 The physiopathology of dark circles is
not yet completely understood.
Three different factors may contribute to the
clinical picture of this condition, alone or in
combination:
1. Shadows: shadowing is secondary to convexity of
the lower eyelid, which in turn is caused by the
bulge of the eye, lower lid fat prolapse or excess
depth of the nasojugal groove (known more
recently as tear trough deformity)(Fig. 11.1).3
2. Vessels: a bluish color is secondary to the
subcutaneous venous network (Fig. 11.2) while a
reddish color is secondary to the visible dermal
capillary network (Fig. 11.3).
3. Pigment: the brown color commonly seen in this
condition is secondary to superficial melanin
(Fig. 11.4) while a brown-blue color is secondary
to dermal melanin.4 These can be more easily
seen under a Wood’s lamp (Fig. 11.5).
Other etiologic factors are also reported for dark
circles, including postinflammatory hyperpigmenta-
tion secondary to atopic or allergic contact dermati-
tis and periorbital edema.5
The lower eyelid skin is very thin, and alterations in
the blood flow supplying this area can worsen dark
circles. Aging, expressed by changes in the pigmenta-
tion of the skin, loss of elasticity, worsening of the
nasojugal groove and more visible vessels under the
skin, can also aggravate the appearance of dark circles.
Very few studies have been published on dark
circles, one possible reason being the difficulty in
measuring the condition. Ohshima and Takiwaki
analyzed dark circles quantitatively using various
bioengineering techniques.6 Two kinds of reflec-
tance meters and image analysis were used to meas-
ure erythema index (EI), melanin index (MI) and
oxygenation index (OX) in subjects with and with-
out dark circles. Also, the thickness and echo den-
sity of the dermis were evaluated using ultrasound
echo images. Evaluation of EI and MI by image pro-
cessing methods also seems suitable for quantitative
evaluation of dark circles of the lower eyelid.
Dermal thickness of the eyelid skin may also be
involved in the appearance of dark circles.
There are also few published studies on the treat-
ment of dark circles in the indexed literature. Pro-
posed treatments usually involve a combination of
different techniques: topical therapy, dietary sup-
plements, peelings, fillers, autologous platelet-rich
plasma rejuvenation, lasers, carbon dioxide therapy
and surgery, and these should be directed to the
local skin alterations (blood vessels, pigments, naso-
jugal groove and surface irregularities). They can be
used alone or in combination, according to the
patient’s needs (Figs 11.1–11.5).
TOPICAL THERAPY
Many active ingredients of commercial products for
the treatment of dark circles have not yet been studied
to prove their real efficacy. These products generally
contain antioxidants, bleaching agents, moisturizers
and stimulants of new collagen formation.
A multicenter study investigated an eye cream con-
taining a proprietary mixture of human growth factors
11

and cytokines in combination with caffeine, bisabolol,
glycyrrhinic acid and sodium hyaluronate for peri-
orbital rejuvenation. The study revealed that some
clinical signs of aging, including dark circles, showed
Fig. 11.1 Shadowing secondary to the bulging contour
of the lower lid (nasojugal groove).
Fig. 11.2 Bluish color secondary to the subcutaneous
venous network.
Fig. 11.3 Reddish color secondary to the visible dermal
capillary network.
Fig. 11.4 Brown color secondary to hyperpigmentation
of the periorbital area.
A
B
Fig. 11.5 Patient with slight dark circles. A, Clinical
aspect of patient with slight dark circles. B, UV picture
of the same patient showing hyperpigmentation in the
periorbital area.
128
Aesthetic Oculofacial Rejuvenation

significant improvement after 6 weeks of twice-daily
application, with excellent tolerability.7
A study showed that the use of vitamin K com-
bined with retinol 0.15% for the treatment of peri-
orbital hyperpigmentation was effective in 93% of
patients.8 Another study evaluated a gel containing
2% phytonadione, 0.1% retinol and 0.1% vitamins
C and E, which was moderately effective in reducing
dark circles when applied twice daily to the lower
eyelid site for 8 weeks in healthy Japanese adults.9
Cosmetic camouflage, an opaque make-up, is
very helpful for patients, especially women, who
are familiar with these types of products. Camou-
flage make-up is usually creamy and comes in a
variety of shades to match the natural skin color.
Sometimes it is blended with color correctors to
achieve a good color match and conceal dark circles.
DIETARY SUPPLEMENT
One study has evaluated the effects of a dietary sup-
plement containing soy extract, fish protein polysac-
charides, extracts from white tea, grape seed and
tomato, vitamins C and E as well as zinc and
chamomile extract on the skin of post-menopausal
women.10 The evaluation after 3 and 6 months of
treatment showed significantly greater improvement
of skin conditions in the active group in a variety of
parameters, including dark circles. This was the first
study evaluating the effect of dietary supplements
on dark circles, but it may be the beginning of a
new research treatment field.
CHEMICAL PEELING
Despite little support in the literature, chemical
peeling can be helpful for dark circles. It acts
through exfoliation, abrasion and the shedding of
superficial skin cells and layers, reducing pigmenta-
tion and wrinkles of the skin (Fig. 11.6) around the
eyes, significantly improving some cases of dark
circles. The choice of the agent, concentration,
number of applications and other factors will depend
on each patient’s needs. The most frequently used
peels
for
dark
circles
are
trichloroacetic
acid
(TCA) and phenol peels.11 For further information
see Chapter 4.
FILLERS
Injectable fillers can be used alone or in combina-
tion with other facial procedures to improve the
appearance of dark circles. Addressing the hollow-
ness of the periorbital region by using a filler
requires a thorough understanding of the delicate
and vascular nature of these tissues. Injectable hya-
luronic acid is used to augment the nasojugal groove
to eliminate the shadowing that worsens dark
circles (Fig. 11.7).12–15
Airan and Born first described a technique using
injectable
non-animal-stabilized
hyaluronic
acid
(NASHA) placed in the subperiosteal plane of the
inferior orbital rim using a multiple puncture tech-
nique administered under local anesthetic.16 One
year later, Steinsapir and Steinsapir reported a
2-year experience of treating nasojugal grooves
with injectable hyaluronic acid. They demonstrated
the usefulness of these fillers for the treatment of
these grooves, with a low incidence of complications.
In
the
postoperative
period,
localized
swelling,
bruising and asymmetry were relatively common.
Cellulitis occurred in two cases and migraine in one
patient.12
Goldberg and Fiaschetti published their experi-
ence in periorbital augmentation with 244 hyaluro-
nic acid (HA) injections in 155 patients. One
hundred and eight out of 121 patients (89%) who
received follow-up visits were satisfied with the
cosmetic improvement. For maintenance, the inter-
val to a second injection averaged 6.5 months.
A
B
Fig. 11.6 TCA peeling for treatment of
photoaging and dark circles.
A, Before treatment with 30% TCA.
B, After treatment.
129
Dark Circles: A Combination Approach

The authors highlighted that patients with very
thin skin, preexisting color problems or preexisting
eyelid fluid may not be good candidates for perior-
bital filling with injectable hyaluronic acid gels,14
since the high hydrophilic properties of HA may
worsen the condition.
Bosniak, Zilkha et al introduced a modified tech-
nique using injectable HA gel for augmentation of
the lower eyelids in 12 female patients.17 The tech-
nique is applied in the supraperiosteal plane, punc-
turing the skin twice only with a 0.25 mL bolus of
HA, while under topical anesthesia. After the pro-
cedure, digital pressure was used when hemostasis
was needed and to minimize possible ecchymosis.
Ice compresses were applied for 5 minutes post
procedure to minimize localized swelling and ery-
thema. The authors called this technique ‘hyaluro-
nic acid push’ due to the use of digital pressure to
push the filler into the desired position to modify
the contour. The most common complications were
temporary
postinjection
erythema
and
edema.
These were treated with application of ice com-
presses and resolved completely over 72 hours.
One patient with slight overcorrection and anterior
placement of the filler over the anterior lacrimal
crest improved with administration of hyaluroni-
dase and massage.
According to Bucky and Kanchwala, autologous fat
and alternative fillers, including calcium hydroxyl-
apatite, can be considered as an additional option
for the treatment of dark circles, besides contribu-
ting significantly to overall facial rejuvenation.18
In the infraorbital region, intravascular injection
may occur, causing side effects of different degrees
of severity, from hematomas to vascular occlusion.
These can be avoided by the use of small and deli-
cate cannulas.
AUTOLOGOUS PLATELET-RICH
PLASMA REJUVENATION
Autologous platelet-rich plasma rejuvenation is a
novel treatment strategy that relies on the natural
healing capacity of the synergistic cascade of autolo-
gous growth factors.19 It has been used in clinical
practice since the 1990s and has an extremely broad
range of healing applications in oral and maxillo-
facial surgery, cosmetic surgery, cardiovascular sur-
gery, otolaryngology, burns and wound healing, and
lately in aesthetics, where it is used to address dam-
aged and aged skin. Platelets, when present in body
tissues outside the bloodstream, are activated by
various chemicals to release growth factors, which
attract stem cells to the site of injury. The growth
factors stimulate neo-vascularization and the pro-
duction of collagen, elastin and new extra-cellular
matrix. Platelet-rich plasma is a natural and power-
ful means of delaying as well as reversing cutaneous
aging and due to its importance it is thoroughly
discussed in Chapter 13. The significant increase in
skin thickness and elasticity as well as the moderate
volumetric effect achieved by both intradermal and
subdermal injection of platelets provides a safe,
natural and long-term solution for skin regeneration
and in particular peri-orbital rejuvenation.
LASERS
The ruby or Nd-Yag, the Q-switched alexandrite
laser, the carbon dioxide (CO2) laser and the
intense pulsed light (IPL) are the most commonly
used lasers in the treatment of dark circles.4,20 They
improve dark circles by acting on specific chromo-
phores, such as water, hemoglobin and melanin.
A
B
Fig. 11.7 Hyaluronic acid
augmentation of the nasojugal
groove. A, Before treatment. B, After
treatment.
130
Aesthetic Oculofacial Rejuvenation

By targeting
these chromophores, they induce
vascular
and
pigment
alterations.
Furthermore,
they stimulate collagen production, thus improving
the flaccidity that worsens dark circles. The num-
ber of sessions and the results may vary for each
patient, according to the type of laser or light
source used. The use of sunscreens during treat-
ment is highly recommended to prevent hyperpig-
mentation after the procedures.
Significant lightening of infraorbital hyperpig-
mentation was observed in one study, 9 weeks after
CO2 laser resurfacing.21 This was the first report of
the successful use of a non-pigment-specific laser
system
for
the
treatment
of
infraorbital
dark
circles. Manuskiatti et al. also showed in their
study that 75–100% of the patients demonstrated
improvement in periorbital hyperpigmentation with
a Q-switched alexandrite laser immediately follow-
ing the use of a pulsed CO2 laser.4
On the other hand, Lowe et al. evaluated the
clinical and histological appearance of infraorbital
skin pigment in 17 patients with dermal melanin
deposition treated with a Q-switched ruby laser.22
Of those patients treated with a single Q-switched
ruby session, 23.5% achieved greater than 50%
response. Of those treated twice, 88.9% achieved
greater than 50% response.
A total of 18 Japanese patients underwent com-
bined therapy using a Q-switched ruby laser to
eliminate dermal pigmentation and topical bleach-
ing treatment with tretinoin aqueous gel and hydro-
quinone ointment performed 6 weeks beforehand
to reduce epidermal melanin. Seven of 18 patients
(38.9%) showed excellent clearing after treatment
and eight patients (44.4%) were rated as good.
Only one patient (5.6%) was rated as fair and none
was rated as poor. Postinflammatory hyperpigmen-
tation was observed in only two patients (11.1%).
This new treatment was considered effective for
improvement of periorbital skin hyperpigmenta-
tion, with a low incidence of postinflammatory
hyperpigmentation.23
Alster and Hirsch evaluated the clinical efficacy
and side effect profile of single-pass CO2 laser skin
resurfacing in 52 consecutive patients with skin
phototypes I–VI presenting with infraorbital hyper-
pigmentation.24 The treatment improved, among
other parameters, the appearance of infraorbital
hyperpigmentation in all skin types. The severity
and duration of side effects and complications
are reduced with this technique (compared with
multiple-pass procedures with the same device)
and may offer a possible solution to the problem
of treating patients with darker complexions.
The new fractional devices (CO2, Erbium:Yag)
seem to offer similar results to CO2 ablative treat-
ments, with less downtime but more sessions
required. However, further studies are required to
determine the best treatment parameters.
CARBON DIOXIDE INSUFFLATION THERAPY
Carbon dioxide insufflation therapy is an ancient
technology that is gaining popularity in Europe and
South America for skin tightening and rejuvenation
(see Ch. 14). Carbon dioxide insufflation therapy
is the cutaneous and subcutaneous administration of
CO2 gas for therapeutic purposes. It originated in
the royal spas of France in 1932, where it was used
to treat patients affected by peripheral arterial
occlusive disease. Studies have demonstrated that
subcutaneous CO2 therapy positively affects local
parameters of cutaneous microcirculation, improves
cutaneous elasticity and induces localized adiposity
cytolysis. In South America, especially in Brazil,
and in Europe, CO2 therapy has been applied to
the treatment of stretch marks, hypertrophic scars
and cellulite with impressive results. Some other
additional medical applications for CO2 insufflation
therapy are:
v peripheral arteriopathies
v microangiopathies
v erectile dysfunction associated with
microangiopathy
v psoriasis
v varicose ulcers
v alopecia
v skin laxity
v dark undereye circles
v acute arthritis neuropathies
v sports medicine applications.
The possible positive effect of CO2 therapy on
microcirculation, skin elasticity and localized adipo-
sities leads us to believe that it may be a valuable
adjunct in the treatment of physiologic aging changes
of the periorbital area and dark circles, and that it
will enhance the effects of current non-invasive and
minimally invasive treatments. Several studies are
currently ongoing around the world to scientifi-
cally document the safety and effectiveness of this
adjunct therapy, which seems to be a very promising
addition
to
our
current
range
of
rejuvenation
procedures.
131
Dark Circles: A Combination Approach

SURGERY (BLEPHAROPLASTY)
Successful outcomes have been obtained in the
improvement of the appearance of dark circles with
transconjunctival blepharoplasty associated with phe-
nol chemical peels in patients with Fitzpatrick photo-
types I–IV, with a low incidence of complications.25
CONCLUSION
Dark circles represent a common unaesthetic condi-
tion caused by multiple etiologic factors, which may
vary from patient to patient. The treatment of dark
circles should be directed to the factors responsible
for the clinical manifestations of each patient, such
as blood vessels, pigmentation and skin irregularities.
Thus, the treatment response can also vary from
patient to patient. Some treatments are very effective
for some patients, but not for all. Further studies are
needed to improve understanding of the causes of this
condition and to develop more effective therapeutic
options.
REFERENCES
1 Baumann L. Disorders of pigmentation. In: Baumann L, ed.
Cosmetic Dermatology. New York: McGraw-Hill; 2004:63–71.
2 Nkengne A, Bertin C, Stamatas G, et al. Influence of facial skin
attributes on the perceived age of Caucasian women. J Eur Acad
Dermatol Venereol. 2008. (Epub ahead of print).
3 Sadick NS, Bosniak SL, Cantisano-Zilkha M, Glavas IP, Roy D.
Definition of the tear trough and the tear trough rating scale.
J Cosmet Dermatol. 2007;6(4):218–222.
4 Manuskiatti W, Fitzpatrick RE, Goldman MP. Treatment of facial
skin using combinations of CO2, Q-switched alexandrite, flash-
lamp-pumped pulsed dye, and Er:YAG lasers in the same treat-
ment session. Dermatol Surg. 2000;26(2):114–120.
5 Freitag FM, Cestari TF. What causes dark circles under the eyes?
J Cosmet Dermatol. 2007;6(3):211–215.
6 Ohshima H, Takiwaki H. Evaluation of dark circles of the lower
eyelid: comparison between reflectance meters and image proces-
sing and involvement of dermal thickness in appearance. Skin Res
Technol. 2008;14(2):135–141.
7 Lupo ML, Cohen JL, Rendon MI. Novel eye cream containing a
mixture of human growth factors and cytokines for periorbital
skin rejuvenation. J Drugs Dermatol. 2007;6(7):725–729.
8 Elson M, Nacht S. Treatment of periorbital hyperpigmentation
with topical vitamin K/vitamin A. Cosmetic Dermatol. 1999;12
(12):32.
9 Mitsuishi T, Shimoda T, Mitsui Y, Kuriyama Y, Kawana S. The
effects of topical application of phytonadione, retinol and vita-
mins C and E on infraorbital dark circles and wrinkles of the
lower eyelids. J Cosmet Dermatol. 2004;3(2):73–75.
10 Skovgaard GR, Jensen AS, Sigler ML. Effect of a novel dietary
supplement on skin aging in post-menopausal women. Eur J Clin
Nutr. 2006;60(10):1201–1206.
11 Gatti JE. Eyelid phenol peel: an important adjunct to blepharo-
plasty. Ann Plast Surg. 2008;60(1):14–18 discussion 1920.
12 Steinsapir KD, Steinsapir SM. Deep-fill hyaluronic acid for the
temporary treatment of the naso-jugal groove: a report of 303
consecutive treatments. Ophthal Plast Reconstr Surg. 2006;22
(5):344–348.
13 Kane MAC. Treatment of tear trough deformity and lower lid
bowing
with
injectable
hyaluronic
acid.
Aesth
Plast
Surg.
2005;29(5):368–372.
14 Golberg R, Fiaschetti D. Filling the periorbital hollows with acid
hialuronic gel: initial experience with 244 injections. Ophthal
Plast Recontr Surg. 2006;22(5):335–341.
15 Stephen B, Neil S, Marian C, Ioannis PG, Deborshi R. The hya-
luronic acid push technique for the nasojugal groove. Dermatol
Surg. 2008;34(1):127–131.
16 Airan LE, Born TM. Nonsurgical lower eyelid lift. Plast Reconstr
Surg. 2005;116:1785–1792.
17 Bosniak S, Sadick NS, Cantisano-Zilkha M, Glavas IP, Roy D.
The hyaluronic acid push technique for the nasojugal groove.
Dermatol Surg. 2008;34(1):127–131.
18 Bucky LP, Kanchwala SK. The role of autologous fat and alterna-
tive fillers in the aging face. Plast Reconstr Surg. 2007;120
(6 suppl):89S–97S.
19 Kakudo N, Mitsui T, Kushida S, Notodihardjo FZ, Kusumoto K.
Proliferation-promoting effect of platelet-rich plasma on human
adipose-derived stem cells and human dermal fibroblasts. Plast
Reconstr Surg. 2008;122(5):1352–1360.
20 Fodor L, Ramon Y, Fodor A, Carmi N, Peled IJ, Ullmann Y.
A side-by-side prospective study of intense pulsed light and
Nd:YAG laser treatment for vascular lesions. Ann Plast Surg.
2006;56(2):164–170.
21 West TB, Alster TS. Improvement of infraorbital hyperpigmenta-
tion following carbon dioxide laser resurfacing. Dermatol Surg.
1998;24(6):615–616.
22 Lowe NJ, Wieder JM, Shorr N, Boxrud C, Saucer D, Chalet M.
Infraorbital pigmented skin. Preliminary observations of laser
therapy. Dermatol Surg. 1995;21(9):767–770.
23 Momosawa A, Kurita M, Ozaki M, et al. Combined therapy using
Q-switched ruby laser and bleaching treatment with tretinoin and
hydroquinone for periorbital skin hyperpigmentation in Asians.
Plast Reconstr Surg. 2008;121(1):282–288.
24 Alster T, Hirsch R. Single-pass CO2 laser skin resurfacing of light
and dark skin: extended experience with 52 patients. J Cosmet
Laser Ther. 2003;5(1):39–42.
25 Epstein JS. Management of infraorbital dark circles. A significant
cosmetic concern. Arch Facial Plast Surg. 1999;1(4):303–307.
132
Aesthetic Oculofacial Rejuvenation

Minimally Invasive Laser Lipolysis
for Facial and Neck Rejuvenation
Bruce E Katz, Jason C McBean
Included on DVD
INTRODUCTION
Laser lipolysis is a new minimally invasive method
for liquefying fat and tightening the skin. The Food
and Drug Administration approved the first laser
lipolysis device in October 2006 for the surgical inci-
sion, excision, vaporization, ablation and coagulation
of all soft tissues.1 Liposuction is an extremely com-
mon cosmetic surgical procedure with over 450 000
operations performed in 2007, according to the
American Society of Aesthetic Plastic Surgery.2 It
is also fast becoming a preferred method for facial
and neck rejuvenation, given the low operative risk,
absence of scarring and fast recovery times. The
drawbacks associated with traditional liposuction
include increased blood loss, ecchymosis, long recov-
ery time with increased postoperative discomfort,
skin laxity as well as pulmonary emboli, seromas
and visceral perforations.
Since the inception of a 1064 nm pulsed Nd:YAG
laser system (SmartLipo, manufactured by Deka,
distributed by Cynosure, Westford, MA) in 2006,
several additional devices have been introduced to
the market. At the time of this publication, these
include additional 1064 nm laser devices (Prolipo®
by Sciton, Palo Alto, CA, and Lipolite® by Syneron,
Irvine, CA), a 1320 nm laser (CoolLipo® by Cool-
touch, Roseville, CA), a 980 nm diode device
(Lipotherme® by Osyris, Helemmes, France), and
a new combination 1064 nm/1320 nm sequential
firing laser (Smartlipo Multiplex® by Cynosure,
Westford, MA).
These newer technologies are indicated for laser
lipolysis as well as improvement of flaccidity. Laser
lipolysis addresses the drawbacks mentioned above:
increased blood loss, ecchymosis, long recovery
time and skin laxity. It achieves these improve-
ments by creating lipolysis, coagulating small blood
vessels and inducing new collagen formation, the
end result being reduced adiposity, skin retraction
and decreased flaccidity.
EQUIPMENT AND LASER SPECIFICATIONS
The standard laser lipolysis device is a pulsed 1064 nm
Nd:YAG system. The pulse width is 150 ms and the
repetition rate 40 Hz. The power output goes as high
as 18 W. The key features of this technology include
the short pulse duration that creates a high peak power
and the high repetition rate (Fig. 12.1).
Laser lipolysis utilizes a gradient pulse delivering
high peak power. Other laser systems use a gated
or standard pulse delivery system that delivers
energy over a longer period of time, leading to
potential collateral tissue damage. The peak power
of laser lipolysis leads to adipocyte rupture without
charring of adjacent tissue.
In this procedure, energy is transmitted to the sub-
cutaneous tissue through a 300 or 600 mm fiber. The
300 mm fiber is used for machines with power wattage
up to 10 W, whereas the 600 mm fiber is used for
18 W and higher. The fiber is seated in a 1 mm dia-
meter stainless-steel microcannula of variable lengths,
depending on the treatment location. The fiber optic
is extended 2 mm beyond the end of the cannula and
cleaved cleanly prior to operating. A guiding red light,
referred to as the ‘He:Ne beam’ (helium and neon),
aids the surgeon in precisely visualizing the subcutane-
ous laser fiber location while operating. A 1.5 mm inci-
sion, #11 blade stab or 18-guage needle is enough to
introduce the cannula, which is then guided through
the fat at various depths, including the subdermal layer.
The exact mechanism of action of lipolysis and
collagen stimulation is still under investigation.
A proposed theory involves photothermal heating
and photomechanical effects that disrupt adipocyte
membranes, thereby breaking them into smaller par-
ticles that are then removed by suctioning or reab-
sorbed through the lymphatic system. The localized
heating induced by the laser also denatures existing
collagen, allowing for the stimulation of new collagen
and collagen retraction. In addition to lipolysis and
collagen stimulation, the laser also coagulates blood
12

vessels, which, when combined with the hemostatic
effects of tumescent anesthesia, leads to marked
improvement of ecchymoses, seromas and edema.
INDICATIONS AND CONTRAINDICATIONS
Indications and contraindications are shown in
Box 12.1.
Laser lipolysis is a body-contouring technique for
relatively healthy individuals. Laser lipolysis should
be limited to patients who fall into the American Sur-
gical Association class I, II or, rarely, III (Box 12.2).
Physicians should obtain a complete history and
physical evaluation, particularly regarding recent
pregnancy and weight patterns. The surgeon should
also verify baseline laboratory data to evaluate liver
function and to test for presence of hepatitis preg-
nancy, occult infection or blood discrasias.
BOX 12.1 INDICATIONS
• Small localized areas of unwanted adiposity
• Mild to moderate skin laxity
CONTRAINDICATIONS
• Impaired liver function, hepatitis C, chronic hepatitis B,
alcoholic liver disease
• Acute infections
• Current pregnancy or pregnancy within the 3 months
prior to surgery
• Allergy to lidocaine or epinephrine
• Thin areas with severe dermatoheliosis with little
subcutaneous adipose tissue
Prior to surgery, it is important to determine
whether the patient is an appropriate candidate for
laser lipolysis. The ideal candidate is one who has
small, localized areas of adipose tissue and mild-to-
moderate skin laxity. Patients who have severe skin
laxity with minimal adipose tissue, thin ‘crepy’ skin,
prominent submental salivary glands or retrognathia
are less ideal candidates with features that may hinder
optimal results. Those who demonstrate thin ‘crepy’
skin or severe laxity in the absence of subcutaneous
adipose tissue are at an increased risk of thermal
burns. These patients are candidates for skin-tighten-
ing devices (see Chapter 7).
The indications for laser lipolysis as it pertains to
facial and neck rejuvenation continue to evolve. His-
torically, liposculpture of the cervical and submen-
tal regions were reserved for younger patients with
good skin tone. Now, laser lipolysis alone or com-
bined
with
suction-assisted
lipoplasty
provides
excellent results for patients in their 50s, 60s and
even 70s. Generally, laser lipolysis is indicated for
patients who have small unwanted localized areas
of adipose tissue and mild-to-moderate skin laxity.
Cervical and submental regions are ideal locations
for laser lipolysis for several reasons. As highlighted
by Zins et al., numerous authors have noted that
neck skin, as opposed to facial skin or skin else-
where, has a unique ability to contract.3 This clinical
observation, while not entirely understood, has
prompted many surgeons to opt for more conserva-
tive neck rejuvenation, favoring liposculpture over
platysmaplasties and neck lifts.3 Due to the addi-
tional contractile effect produced by the laser, sur-
geons are now noting dramatic improvement in the
postoperative cervicomental angles of their patients.
Additionally, the cervical and submental areas are
small and therefore can be easily accessed via few,
4500
1000
150µs
180µs
10ms
Time
Power (mW)
Gated pulse
Standard pulse
Gradient pulse
Fig. 12.1 High peak power of laser-assisted lipolysis.
BOX 12.2
• Class I = normal healthy patients
• Class II = mild systemic disease that results in some
functional limitation
• Class III = moderate to severe disease, which results in
some functional limitation
• Class IV = systemic diseases that pose constant threats
to life and are functionally incapacitating
• Class V = moribund and not expected to survive
24 hours with or without surgery.
Lawrence N, Leonhardt J, Liposuction. In: Robinson JK, Hanke W,
Sengelmann R, Siegel. Surgery of the Skin: Procedural Dermatology
Spain: Elsevier Mosby; 2005. p. 517
134
Aesthetic Oculofacial Rejuvenation

inconspicuous incisions. Also, the risk of lidocaine
toxicity is reduced due to the smaller volumes
necessary to achieve adequate anesthesia.
There are no contraindications specific to laser
lipolysis when compared to traditional tumescent
liposuction. The same considerations with regard to
tumescent anesthesia and lidocaine toxicity apply.
PREOPERATIVE HISTORY
AND CONSIDERATIONS
The preoperative evaluation also involves obtaining
adequate history, physical examination, and labora-
tory data in order to ensure the suitability of the
liposuction candidate. Patients with a preexisting
cardiovascular or respiratory condition may require
medical clearance by their primary-care physicians,
cardiologist or pneumonologist. Naturally, patients
may downplay the severity of their health condi-
tions for an elective cosmetic procedure.
The physician should be particularly aware of
those patients with impaired liver function, hepatitis
C, chronic active hepatitis B and alcoholic liver dis-
ease because lidocaine is metabolized by the cyto-
chrome P450 enzymes of the liver. While patients
with liver disease are at an increased risk of develop-
ing lidocaine toxicity, treatment of small areas such
as the neck, submental areas and face inherently
limit toxicity risk due to the small volumes necessary
to achieve adequate anesthesia. Laboratory evalua-
tion should include complete blood count with plate-
lets, serum chemistries, partial thromboplastin time
(PTT), prothrombin time (PT), human immunodefi-
ciency virus (HIV), hepatitis B and C panel, and
pregnancy test.
A surgical history is also important. Patients with
prior surgeries or liposuction may have increased scar-
ring, making passage of the cannula difficult. In these
scenarios, one may discuss the prior case with the pre-
vious surgeon. The age of scars is also important infor-
mation to obtain from the patient. Older scars tend to
be softer and may be suctioned through, while newer
scars should be suctioned around.4
Onceinformedconsentisobtained,abaselinepatient
weight and vital signs are obtained. The weight is used to
determine the optimum, safe maximum volume and
concentration of tumescent anesthesia. The recom-
mended maximum dose of lidocaine for tumescent
anesthesia is 55 mg/kg as per the American Academy
of Dermatology. Cardiac monitoring with pulse oxime-
try and supplemental oxygen should be available and a
plan for medical emergencies should be established.5
The patient may be photographed using standard
lighting and positioning. The patient may be seated
or standing, and images should be taken from the
front, at 3/4 view and from the side (profile)
(Fig. 12.2). It is important to standardize images as
much as possible to ensure a correct comparison of
before and after images. Excellent clinical photo-
graphs are critical because many patients forget their
presurgery appearance and are impressed by the
change after seeing the before images. Patients are
informed that the images are confidential and sign a
release if used for research or publication purposes.
The images are also vital for medical–legal purposes.
Perioperative medications vary by clinician prefer-
ence and patient requirements. Some clinicians pro-
vide an anxiolytic such as lorazepam or midazolam
prior to the procedure. Clonidine, an alpha-2 adre-
nergic receptor, used as antihypertensive, may be
employed for its additional sedative effect and to
temper tachycardia resulting from epinephrine used
in the tumescent anesthesia. Intramuscular narcotics
such as meperidine may be employed to dampen the
discomfort of the infused tumescent anesthesia.
Finally, an antihistamine such as hydroxyzine is often
employed for additional sedation and to offset poten-
tial nausea or dermatitis produced by the above
medications.
OPERATIVE APPROACH
After the patients are photographed, they are
marked with a surgical marker. Meticulous marking
is paramount because once the anesthesia is admi-
nistered anatomical landmarks may be lost. Closely
follow the contours of the adipose areas when
marking to facilitate smooth transitions between
anatomic units. Mark the borders of the mandible,
being careful to include the fuller areas of the jowls
and submental fat pads. Stay medial to the anterior
border of the sternocleidomastoid muscles to avoid
vital vessels and nerves (Fig. 12.3).
Once the patient is marked and receives the peri-
operative medications, the nursing personnel prepares
the entire area with a surgical antimicrobial cleanser.
Small incisions are made with a 1.5 mm punch, an
18-gauge needle or a #11 blade. The incisions are
made in three locations: just inferior to the angle of
the mandible bilaterally and in the submental crease.
The authors’ preferred method is to use a 1.5 mm
punch (Fig. 12.4) due to ease of creating a uniform
hole, which relaxes in the direction of normal skin
tension lines. We do not suture these small incisions
to allow natural drainage of the infiltrated solution,
135
Minimally Invasive Laser Lipolysis for Facial and Neck Rejuvenation

A
B
C
D
E
Fig. 12.3 Preoperative surgical markings.
Fig. 12.4 1.5 mm punch for incision sites.
Fig. 12.2 Preoperative patient
photographs demonstrating front,
side and 3/4 views.
136
Aesthetic Oculofacial Rejuvenation

blood and the liquefied fat produced by the laser
action. Additionally, because they are so small and
are located on concave surfaces, they heal with less
noticeable scars than those closed with sutures.
It must be emphasized that virtually all cases of
laser lipolysis can be performed with tumescent
anesthesia. This is an advantage as multiple studies
have documented the superior safety record of
tumescent liposuction over liposuction performed
under general anesthesia or intravenous sedation.
In addition, data illustrate that tumescent liposuc-
tion performed in the outpatient setting is safer
than any liposuction performed in the hospital
inpatient setting.6
For the administration of the anesthesia, the
patient is positioned supine, with the neck gently
extended at the head of the surgical table. Note that
when the neck is extended and rotated laterally, the
marginal mandibular branch of the facial nerve
moves superficially, becoming more susceptible to
nerve injury.7 Extra care should therefore be taken
in this area. Local tumescent anesthesia can then
be administered via a powered or manual infusion
cannula. The authors’ preferred cannula size is a
6-inch sprinkler tipped infusion cannula attached
to a power infusion pump (Fig. 12.5).
It is prudent, when infusing tumescent anesthesia
of the face, submental area and neck, to infuse at a
slow rate not to over-infuse, risking potential oral
airway compression. The slower rate of infusion also
enhances patient comfort during administration.
Patient comfort may also be improved by using a
warm (40
C) buffered solution. The surgeon should
be careful that the liquid anesthesia does not inad-
vertently wash away the markings made prior to
infusing. This can be avoided by carefully placing a
4  4 cm gauze over the incision sites to prevent
leakage. Between 15 and 45 minutes is adequate
time for complete anesthesia. The small size of the
laser fiber cannula (1 mm) allows lasing to begin
sooner after the administration of anesthesia than
with traditional tumescent liposuction.
Patients and medical staff are equipped with
protective goggles. The encased laser fiber emitting
1064 nm (Nd:YAG laser system) (Fig. 12.6) is
inserted through the incisions and slowly manipu-
lated forward and backward in a criss-cross pattern.
As a rough guideline, ten passes per section are
made; however, it is important to recognize surgical
end points when utilizing laser lipolysis. These end
points can be determined by factors such as feel
and temperature.
There is a learning curve when becoming comfort-
able with palpation as an end point. The tissue is con-
tinually palpated during cannulation until it feels soft
and pliable, contrasting with the preoperative firm,
larger, indurated areas. Continue palpation until the
density of the treated area is uniform. Specialized
cutaneous infrared thermometers can accurately
record the surface temperature. In the authors’
experience, safe, optimal lipolysis and skin tighten-
ing occur at surface temperatures between 35 and
40
C. Finally, additional end points such as the
accumulated energy and change in resistance of fiber
passage can be employed.
Once lasing is complete, record the total energy
utilized. This will assist the surgeon in recognizing
the endpoints of future procedures. Continued
experience and documentation of previous cases
Fig. 12.5 Sprinkler tipped infusion cannula.
Fig. 12.6 Laser fiber in steel cannula extended 2 mm
beyond the tip.
137
Minimally Invasive Laser Lipolysis for Facial and Neck Rejuvenation

will provide the surgeon with appropriate bench-
marks when performing subsequent cases.
OPTIMIZING OUTCOMES
v Proper patient selection.
v Aspiration versus no aspiration.
v Stay deep and pinch skin away from vital
structures when operating over marginal
mandibular nerve, facial artery, and vein.
v Maximize skin tightening by creating criss-cross
tunnels with the laser fiber.
In a previous section, we note that the ideal laser
lipolysis patient is one who has localized areas of
adiposity and mild-to-moderate skin laxity. Selecting
the proper patient is the first step toward optimal out-
comes. Again, patients with severe dermatoheliosis or
sun damage, or thin skin without noticeable adipose
tissue are likely to have less than ideal outcomes and
may in fact increase the risk of adverse sequelae.
Controversy does exist surrounding the need for
suctioning after lasing. At a 2007 conference of the
American Society of Laser Medicine and Surgery,
Dr Douglas Key presented his experience using a
1320 nm device comparing lipolysis with aspiration,
lipolysis without aspiration and aspiration without
lipolysis. He found no clinical difference among the
three techniques, suggesting that lipolysis alone was
sufficient and safe to achieve optimum results.
Doerr also notes that in cases of small areas (usually
less than 50 cm3 of estimated fat) or in patients with
mild-to-moderate skin laxity, it is not necessary to
aspirate the treated tissue.8 In the authors’ experi-
ence, most submental and neck regions do not
require suctioning; however, the liquefied fat should
be squeezed out through the incisions. Note that
larger patients may benefit from minimal suction
assistance to optimize results.
Suctioning can be accomplished manually or with a
power-assisted device. The syringe method has been
evaluated. Some surgeons prefer using a manual suc-
tion technique because patients may experience dis-
comfort with the vibratory action associated with a
power-assisted device. The authors have not experi-
enced this phenomenon when using a power-assisted
device. In fact, they have found more uniform and
efficient removal of small, difficult areas with greater
ease using a power-assisted device.
To optimize the end results and safety of laser
lipolysis of the submental region, it is imperative that
the surgeon stays deep in the subcutaneous fat. If the
laser is fired too superficially, as with traditional
liposuction, irregularities may result. Additionally,
the energy from the laser can lead to superficial
burns if the operator is too superficial to the skin.
Finally, as mentioned earlier, the location of the mar-
ginal mandibular branch of the facial nerve is more
superficial when the neck of the patient is extended
and rotated laterally. Remaining in the proper plane
in this location is therefore imperative. These poten-
tial risks can best be avoided by continuously pinch-
ing the skin away from the underlying structures
and ensuring a position that is deep enough to avoid
irregularities and burns, but not so deep as to com-
promise the safety of the marginal mandibular
branch of the facial nerve.
An additional method to optimize the shrinking
and tightening effect of laser lipolysis is to manipu-
late the fiber in a series of criss-cross tunnels. As a
rough guideline, 10 passes per section are made.
This criss-crossing ensures the optimal surface area
coverage
while
preventing
overaccumulation
of
energy in any one particular location.
COMPLICATIONS AND SIDE EFFECTS
With any new technology it is important to under-
stand the associated potential complications and side
effects. The potential risks when employing new
lasers include burns, purpura, scarring, retinal and cor-
neal damage, hyperpigmentation or hypopigmenta-
tion, necrosis and nerve damage. When performing
liposuction, risks can be categorized as local or sys-
temic. Local risk factors for liposuction are skin or
subcutaneous infection, permanent skin irregularity
(dimpling, retraction), seroma, allergic contact derma-
titis to tape, skin ulceration or necrosis, permanent
sensory nerve damage, unacceptable scars and persis-
tent postoperative edema. The systemic complica-
tions include allergic reaction to oral or intramuscular
medication, fevers, systemic infection, arrhythmias,
anemia, fluid or blood loss requiring a transfusion, pul-
monary emboli, fat emboli, shock, bowel or thoracic
perforation, seizures, thrombophlebitis and death.
When combining lasers with liposuction, the list of
potential complications does indeed grow.
Despite these potential local and systemic risk
factors and complications, in the authors’ experience
with over 500 cases actual complications of laser
lipolysis have been rare. Out of 537 laser lipolysis
cases, one patient developed a localized infection
successfully treated with oral antibiotics and four
patients developed skin burns.9 The burns were trea-
ted with topical antibacterial ointments and were
138
Aesthetic Oculofacial Rejuvenation

probably secondary to a rapid accumulation of ther-
mal energy localized to one area. One way to prevent
burns is to avoid keeping the laser in one location for
too long. To address this complication, one company
has developed a built-in safety device referred to as
an ‘accelerometer.’ This device stops lasing when
the handpiece is slowed or when the handpiece
decelerates to change direction. Another way to pre-
vent inadvertent burns is to monitor the skin with a
thermal scanning device that measures cutaneous
temperature, being careful not to exceed 40
C.
An additional safety concern is the theoretical
possibility of nerve damage. In the 537 cases per-
formed at the authors’ center, there were no cases
of persistent neuropathy, paresthesias or numbness.
Studies by Goldman et al. demonstrated histo-
logically intact nerve fibers with surrounding dis-
integrated adipose tissue, suggesting a selective
thermolytic effect.10 Despite this histologic finding,
take special care when near the marginal mandibular
branch of the facial nerve by gently pinching the
skin away from the mandible when lasing in this
location. Another issue of concern is the possibility
of increased serum lipids as a result of lipolyzed
adipose tissue. Goldman and colleagues found no
significant change in triglycerides and lipid profiles
among patients treated with laser lipolysis 1 day,
1 week and 1 month post procedure.
In the authors’ experience, laser lipolyis also led
to fewer touch-up procedures compared to tradi-
tional liposuction. Only 19 touch-up procedures
were required in over 500 cases, using laser-assisted
lipolysis and the tumescent technique.7 These
19
patients
comprise
only
3.5%
of
the
total
liposuction cases completed at the center. In con-
trast, Lawrence and Butterwick studied the number
of touch-up procedures at a large liposuction prac-
tice and found that over 12% of 954 liposuction
cases required a touch-up.11 The lower touch-up rate
associated with laser lipolysis suggests enhanced
uniform removal of adipose tissue, thereby contri-
buting to improved physician control and precision
of body contouring.
POSTOPERATIVE CARE
Once the procedure is complete, patients are
cleaned, bandaged, and assisted into their compres-
sion garments. For treatment of the submental
region, the garment is worn 24 hours a day for
3 days. Patients should be informed that the day
after the procedure they may have minimal normal
blood-tinged drainage. Some surgeons have patients
return the second day after the procedure, at which
time ultrasound, lymphatic drainage, diode laser or
defocused Nd:YAG external laser treatment is
employed. These treatments, some authors believe,
may hasten the healing time.
In the authors’ practice, patients return to clinic
for reevaluation in 2 weeks, 6 weeks, 3 months
and 6 months after the procedure. Patients will note
the most rapid improvement 2–3 months after the
procedure and will continue to improve up to 6
months after the surgery. To manage patients’
expectations, it is important to inform them that
maximal skin tightening may take up to 6–8 months.
At the 6-month visit, postoperative images are
taken and shared with the patient (Fig. 12.7).
Ai
Aii
Fig. 12.7 Before and after images for laser-assisted lipolysis (left is preoperative, right is postoperative).
(Continued)
139
Minimally Invasive Laser Lipolysis for Facial and Neck Rejuvenation

CONCLUSIONS
Laser lipolysis is an exciting new development that
efficiently removes fat and tightens skin. The technol-
ogy continues to improve with various wavelengths
and combination systems that promise to improve
on original designs. Laser lipolysis of the submental
and neck regions is an ideal option for those with
small-to-moderate areas of adiposity combined with
mild-to-moderate skin laxity. Laser lipolysis is partic-
ularly suited to the neck and submental regions due to
the inherent contractile nature and, in some patients,
may replace neck lifts or platysmaplasties.
REFERENCES
1 US Food and Drug Administration.
htm 19 March 2009.
2 American Society for Cosmetic Plastic Surgery. 11.7m cosmetic
procedures in 2007.
trends/cosmetic_procedures_in_2007 19 March 2009.
3 Zins JE, Fardo D. The ‘anterior-only’ approach to neck rejuve-
nation: an alternative to face lift surgery. Plast Reconstr Surg.
2005;115(6):1761–1768.
4 Lawrence NL, Leonhardt J. Liposuction. In: Robinson JK,
Hanke R, Sengelmann R, Siegel DM, eds. Surgery of the skin:
procedural dermatology. St Louis: Mosby; 2005:13–14.
5 Coleman WP, Glogau RJ, Klein JA, et al. Guidelines of care for
liposuction. J Am Acad Dermatol. 2001;45:438–447.
6 Hanke WC, Sterling JB, Melton JL, Sattler G. Review of liposuc-
tion safety studies. In: Dover J, Hanke CW, Sattler G, eds. Proce-
dures in cosmetic dermatology: liposuction. London: Elsevier
Saunders; 2005:141.
7 Jacob CI, Berkes BH, Kaminer MS. Liposuction and surgical
recontouring of the neck: a retrospective analysis. Dermatol Surg.
2000;26:625–632.
8 Doerr TD. Lipoplasty of the face and neck. Curr Opin Otolaryn-
gol Head Neck Surg. 2007;15:228–232.
9 Katz BE, McBean JC. Laser assisted lipolysis: a report on compli-
cations. J Cosmet Laser Ther. 2008;10(4):231–233.
10 Goldman A, Shavelzon D, Blugerman G. Laser lipolysis: Liposuc-
tion using and Nd:YAG laser. Rev Soc Bras Cir Plast. Sao Paulo.
2002;17(1):17–26.
11 Lawrence L, Butterwick KJ. Immediate and long term post-
operative care and touch-ups. In: Narins RS, ed. Safe Liposuc-
tion and Fat Transfer. New York: Marcel Dekker; 2003:
329–341.
Bi
Bii
Fig. 12.7—Cont’d
140
Aesthetic Oculofacial Rejuvenation

Mesotherapy
Alexander Kulick
Included on DVD
INTRODUCTION
The term ‘mesotherapy’ was reputedly first coined by
journalists attending a lecture by Dr Michael Pistor, a
French physician, in 1958. They mistakenly believed
he was referring at the time to the mesoderm, an
embryonic layer, and one of the three primary germ
cell layers in the very early embryo, as opposed to
injections into the dermis, the middle layer of the
skin.1
Dr Pistor’s principles were first enumerated in
1958. His system was at the time primarily used
for medical and musculoskeletal disorders, and con-
sisted of the need for:
v correct diagnosis
v the localized application of medications near the
target organ
v the use of the smallest dose of pharmaceuticals
for effective and localized treatment.
v During his lecture, Dr Pistor used the expression :
“ I don’t know how, I don’t know why but it works.”
There are numerous theories that describe the
mechanism of action. Some practioners believe in the
reflexive theory, where the mechanism of action is
due to the direct mechanical puncture, and chemical
(or pharmacological) actions are a result of the action
of the injected drugs. An alternative theory is micro-
circulation stimulation by the local injections close to
the vessels damaged by the pathological process. In
this theory the applications are made close to arterial
paths with 1 or 2 cm in between the punctures. The
third theory is Kaplan’s interface where molecules
with low weight are absorbed by blood vessels and
the high molecular weight molecules are absorbed by
lymphatic vessels passing through lymphatic nodes.2
In 1958 the French Academy of Medicine,
endorsed mesotherapy as an integral part of tradi-
tional medical standards and in 1996 it was recognized
by the National Health Agency of Accreditation and
Evaluation in France.
The theory of mesotherapy is simple. The stratum
corneum of the skin acts as an effective barrier to
most large molecules, hence the paucity of pharma-
ceutical transdermal patches. In mesotherapy, the
integrity of the stratum corneum is pierced, allowing
the deposition of small amounts of pharmaceuticals.
Numerous studies have demonstrated that molecules
deposited in the epithelial dermal layer or the intra-
dermal layer will be found in venous return for up
to 8 hours, as opposed to 1 hour for subcutaneous
injections. This prolonged exposure at the site of
the target lesion leads to a more profound effect.2
MATERIALS, NEEDLES AND SYRINGES
Needles
The needles generally used in mesotherapy are 30 g
(29 mm) and 27 g (40 mm) with needle lengths
ranging from 4 to 13 mm for cosmetic purposes.
Generally a 5 cc syringe is used manually or with
an injection device.
Injection Devices and Mechanical Syringe
Support
In recent years, a large number of mechanical injec-
tion devices that can accurately control both the
depth and speed of injection have been developed.
The most common devices will be described below
along with some of the benefits and drawbacks of
these devices.3
The ideal pistols should fulfill the following criteria:
v All the parts that have direct contact with the
patient must be disposable
v The medication does not run inside the pistol but
inside the syringe
v Must have mechanisms to calibrate depth of the
needle and drug delivery
v Must have energy power or rechargeable battery
13

v Must be economic
v Must be ergonomic enough to allow injections
in deferent angles and positions
Types of devices:
Den-Hub is a simple mechanical pistol fitted with
a screw that determines the depth of injection
and is activated by a simple trigger. It is an
automatic device where a 10 mL syringe is
plugged in.
Mesopen – this pistol operates on a lithium battery
and both the depth and volume of substance to
be delivered can be adjusted.
Mesalyse I – the Mesalyse I is composed of three
components: a compressor, a control unit that
can be programmed for both speed and depth
of the injection and which can be set on a
continuous or single injection mode, and a pistol
with individual needles. The advantage of this
device is that the speed of the injection can be
modulated: increasing the speed decreases the
patient’s discomfort.
U225 – this device is very similar in form and
function to the Mesalyse I.
DHN 1, 2, 3 and 4 – offers various degrees of
complexity with the DHN 3 being the most
complete device. The injection is triggered by
pressure of the pistol on the skin and enables
injections in continuous mode or single shot.
Piso 4 – this is a battery-operated system that allows
the frequency and volume of injection to be
adjusted and has one unique feature –
mesoperfusion. Mesoperfusion allows two to six
needles to be fixed to tubing connecting to a
device that will perfuse the chosen medication at
a low pressure. This allows a large area to be
perfused at a low, comfortable pressure, e.g. for
cellulite. The disadvantage lies in the need to
purge the tubing before each usage and the
necessity of replacing the tubing each time,
together with a requirement for service and
cleaning by the manufacturer every 6 months.
In the hands of a skilled practitioner
mesotherapy can be performed manually with a
simple syringe and needle. For novices, or if an
assistant is to be taught, electronic pistols allow
more control since the depth, volume, speed and
frequency of the injection can be preset. Many of
the devices do not fully retract the needle after
penetration, causing superficial lacerations if the
injector is ‘dragged’ across the face or body for
continuous injection. This problem is found
primarily with the use of needles made in the
USA, which have less flexibility than many of the
needles manufactured in Europe.
TECHNIQUES AND DEPTHS OF INJECTION
Intraepidermal Injection
Intraepidermal injection involves use of a 13 mm
needle, which is is placed horizontally on the skin with
the bevel facing upward. A series of injections to 1 mm
depth is performed by a vertical flicking of the practi-
tioner’swrist on moving along the desired area. The nee-
dle must not be dragged between points of injection or
abrasions will result. The product is not injected into
the skin but the disruption of the stratum corneum
allows for quick localized absorption. The punctures
are placed 2–4 mm apart and the movement is some-
times described as a “parkinsonian” type of movement,
this technique is referred to in French as ‘nappage’.
Intradermal Superficial Injection
Intradermal superficial injection involves injection
with a 6 mm needle at a depth of 1–2 mm. At this
depth either point-by-point (PPP), which is a tradi-
tional injection technique, or nappage, with a total
of 0.1 mL injected approximately at 1–2 mm, can
be used. At this depth nappage is frequently
described as a ‘bouncing’ technique, with numerous
injections 2 cm apart. Pressure on the plunger is
applied when the needle is in contact with the skin.
Deep Intradermal Injections
Deep intradermal injections are administrated at
2–3 mm depth with a volume of 0.5 mL per injection.
Hypodermal Injection
These injections can vary between 4 and 13 mm
depending on the pathology being treated. For our
purposes, the techniques that will be described are:
v nappage at 1 mm for skin rejuvenation
(sometimes called mesoglow)
v nappage at 2–3 mm for cellulite
v point-by-point at 13 mm for localized fat
(lipodissolve injections usually consist of
phosphatidylcholine, and are meant for localized
fat elimination)
v ‘point by point’ technique, which may be used to
minimize scars.
142
Aesthetic Oculofacial Rejuvenation

AESTHETIC MESOTHERAPY
Localized Fat
Adipose tissue has two types of receptors, a and b,
that normally interact with epinephrine norephi-
nephrine and glucagon. These receptors may be sti-
mulated by a number of medications that will in
turn stimulate or suppress lipolysis. It should be
noted that receptors are distributed differently in
men and women, but in general there is a higher
proportion of alpha receptors in the hip and buttock
areas and more beta in the mid and upper torso.4
Cellulite
Cellulite refers to dimpling of the skin and most
commonly affects the thighs and buttocks. Cellulite
is brought about by alternating depressions and pro-
trusions in the upper compartment systems of fatty
tissue.
There are three major components in cellulite:
hypertrophic adipocytes, thickening of connective
tissue and consequently, bad drainage of the inter-
cellular liquid.4
The pathophysiology may be attributed to a
number of factors:
v genetic, gender and hormone factors
v vascular factors, including venous stasis and
decreased lymphatic drainage
v lifestyle factors, such as tobacco, weight gain, and
lack of exercise.
On a clinical level (Figs 13.1–13.4) the states can
be identified as follows.
v Stage I can be elicited by compressing the skin
but is otherwise not visible (Fig. 13.1A & B).
v Stage II is visible only on standing (Fig. 13.2).
v Stage III is visible on standing or lying down
(Fig. 13.3).
v Stage IV is visible on both standing and lying
down with moderate to severe nodules or pitting
(Fig. 13.4).
Histologically, stages I and II are characterized by
venous stasis and edema, and stages III and IV by
fibrosis, with the eventual encapsulation of adipo-
cytes by collagen fibers, forming micronodules and
macronodules that are easily palpated.
Treatment
Treatment of cellulite can be very frustrating for both
physician and patient as it often requires a combina-
tion of different modalities and an understanding and
commitment from the patient to lifestyle changes.
In stages I and II the main purpose is to to
contract the veins, open the capillaries and decrease
the edema to avoid fibrosis in the future. After
preparation using an appropriate disinfectant it is
A
B
Fig. 13.1 Cellulite, stage I. Courtesy of Dr Eckart Haneke.
Fig. 13.2 Cellulite, stage II. Courtesy of Dr Eckart Haneke.
143
Mesotherapy

possible to use either point-by-point injections or
nappage if we wish to avoid bruising. Many combi-
nations are used but in general they include:
v pentoxyphylline (Trental®) and/or phentolamine
as a capillary dilator
v dihydroxyergotamine to cause vasoconstriction
and reduce edema
v a solution of sodium monomethyltrisilanol
orthohydroxybenzoate, associated with a
derivative of bioavailable organic silicon and
salicylic acid (Conjunctyl®) to increase collagen
v procaine, a potent vasodilator.
In Stages III and IV, phentolamine is always used for
dilation. For the fibrosis, Conjunctyl® (monometilsia-
notriol salicylate) and collagenase may be used spar-
ingly with subcision, to undermine the fibrotic bed of
large nodules. Treatments should be weekly for
8 weeks followed by biweekly sessions for 1 month,
and then monthly for 2–3 months. Depending on
the severity, several other classes of drugs and herbs
may be used but we should first briefly discuss the
physiology of lipolysis.
Lipolysis
If blood sugar is low or metabolic demands
increase, glucagon and epinephrine, respectively, are
released. These hormones increase cyclic AMP,
which in turn binds to protein kinase and stimulates
the lipases. It should be noted that beta-2 receptors
increase lipolysis, alpha-2 receptors inhibit it. It is
known that if phosphodiesterase is inhibited it will
interfere with this process, probably by interfering
with the binding of cyclic AMP to protein kinase.
Hence inhibiting phosphodiesterase and stimulating
the beta receptors (where epinephrine binds) and
inhibiting the alpha receptors will all increase lipoly-
sis. Many formulas use these principles.
Localized Fat
Two further treatments are used in the treatment of
both cellulite and localized fat. The first is a mixture
of phosphatidylcholine 50 mg/mL and deoxycholic
acid 4.75 mg/mL, known as PC/DC, which has been
used to facilitate lipolysis. Since the injections
involved, at 13 mm depth, are into the hypodermis
rather than the dermis, many consider this treatment
not to be a form of mesotherapy and hence refer to it
as ‘lipodissolve’. Many practitioners combine PC/DC
with the mixture of medication mentioned in the last
section for treatment of localized fat and cellulite in
Stages III and IV. The technique used is point-by-
point PPP, 2 cm apart in the area to be treated. The
use of PC/DC will inevitably lead to localized edema,
swelling and pain. The pain subsides within 1 day and
the swelling within 2–3 days. It is believed that the
inflammatory response evoked by the deoxycholic
Fig. 13.3 Cellulite, stage III. Courtesy of Dr Eckart Haneke.
Fig. 13.4 Cellulite, stage IV. Courtesy of Dr Eckart Haneke.
DRUG
ACTION
Aminophylline,
Forskolin, caffeine
Phosphodiesterase inhibitors
Isoproterenol
b2 agonists
Yohimbe and
phentolamine
Block a2 receptors
Acetyl-L-carnitine
Increases the transport of free
fatty acids into the
mitochondrion to be
metabolized
Artichoke, mellilotus/
rutina
Increase lymphatic drainage and
decrease venous stasis
144
Aesthetic Oculofacial Rejuvenation

acid causes retraction of the skin after lipolysis.
Where a ‘cocktail’ is used, careful monitoring of the
total doses of aminophylline, isoproteronal and
yohimbe is required because of the associated cardio-
vascular effect and aminophylline toxicity. Patients
with mitral valve prolapse, coronary artery disease
(CAD) or known cardiac arrhythmias should not be
injected with isoproterenol or yohimbe. According to
Patricia Rittes,5 the use of PC/DC in pure form, undi-
luted, has avoided many of the complications asso-
ciated with the use of the b-agonist, aminophylline,
and alpha-2 agonists.
Facial Lipodissolve
Patricia Rittes’ protocols involve the use of PC/DC
for other localized areas of fat:
v Double chin injections (Fig. 13.5): 0.5 mL of
PC/DC in three to four areas and for jowls
0.5–0.6 mL at two points bilaterally.
v Fat pockets in the lower eyelids are treated to a
depth of 6 mm with two to three injections of
0.1 mL of product per fat pad.6
Any area of the body can be treated with lipo-
dissolve: axillary folds, love handles, saddle bags and
abdomen.7 Generally the abdomen is divided into
four quadrants with either the lower or upper abdo-
men being treated with a maximum of 20 mL of
PC/DC in each session. The treatment per area is
every 2 weeks for four to six sessions. If results are
not achieved, the sessions can be repeated after
2 months, as the PC/DC continues to work for up
to 10 weeks.8 One study on love handles showed his-
tological changes that were primarily inflammatory,
with lipolysis and release of free fatty acids and
phagocytosis at 10 weeks.9
Loose Skin
Attempts have been made to treat loose skin with PC/
DC, achieving occasional success in the periumbilical
area. The fibrosis necrosis that follows injection into
small fatpockets around the umbilicus will occasionally
cause retraction and tightening of the lower abdomen.
For the face glutathione and DMAE (dimethyl-
ethanolamine) can be applied by nappage to a depth
of 2 mm to create a mild lifting of the face.
Mesotherapy has not been effective for the
tightening of loose skin on the posterior arms and
anterior thighs.
Mesoglow/Mesolift
This procedure, shown in Figure 13.6, is used for skin
rejuvenation and is not intended to replace Botox® or
the various injectables. It is meant to improve the qua-
lity of the skin, repair sun damage with antioxidants,
and to tighten skin and restore its hydration and shine.
In facial rejuvenation the structures are treated
with the following substances:10
Fibroblasts:
v DNA stimulates healing and has a profound
hydrating effect, as well as acting as a strong
antioxidant (Ikeda)
v Conjunctyl® inhibits destruction of
collage and elastin, and induces collagen
formation
v placental extract (Filatov) controls growth and
cellular rejuvenation
A
B
C
Fig. 13.5 Post-mesotherapy.
145
Mesotherapy

v retinoic acid stimulates turnover of the skin
v glycolic acid.
Interstitial components:
v vitamin C and copper stimulate new collage
formation
v copper–selenium (Cu-Se)
v pentoxyfilline
v hyaluronic acid.
Unlike traditional fillers, this procedure uses
non-cross-linked hyaluronic acid 4%, with the inten-
tion that it diffuses and supplements hyaluronic
acid (HLA) lost as part of the aging process. It thus
acts as a ‘super’ moisturizer that persists for 2–3
months prior to degradation.
DMAE can be added to tighten the skin and
decrease the viscosity of the HLA. Generally an ini-
tial layer of this mixture is applied with nappage at
1 mm depth. Once this application dries and the
HLA has been absorbed, a second layer of multi-
vitamin and coenzyme Q-10 is applied. Caution is
necessary with coenzyme Q-10. It can cause severe
irritation of the eye if the compound or its fumes
come in contact with the eye. While the coenzyme
Q-10 may produce substantial enhancement of the
skin’s appearance, beginners might wish to leave
this material out of their treatment.
Fabbi el al proposed a mixture of 1.5 mL of multi-
vitamins with 0.05ml of non-cross linked HLA, the
treatment being delivered in one session every 3–4
weeks for a total of four sessions. A few practitioners
use point-by-point injections on the cheeks and fore-
head with individual doses of 0.05 mL of HLA fol-
lowed by nappage, but there is a high percentage of
resultant hematomas.3 To avoid this complication
Le Coz2 prefers to inject only the nasalabial folds
with PPP, and the rest is administered by nappage.
Other protocols include 0.5 mL DMAE 25 mg/mL,
0.5 mL
silicium (Conjunctyl®), 0.5 mL
sodium
bicarbonate and 0.5 mL procaine. Mesoglow may
also be used for de´colletage and dorsum of the hands.
Alopecia
Alopecia (Fig. 13.7) is the loss of hair from the head
and/or body. Depending on certain variables, such
as age and gender, alopecia affects people differ-
ently. Causes of this disorder include hypothyroid-
ism, iron deficiency and stress. Due to the variety
of hair loss patterns associated with alopecia, it is
divided into subcategories.
Androgenic Alopecia
Androgenic alopecia is common in both men and
women. According to researchers, the hormones
responsible are called androgens, hence its name. In
men this condition is commonly known as male-
pattern baldness. The hairline starts to recede, begin-
ning above the temples and forming an ‘M’ shape,
along with hair loss at the crown of the head. Females
experience thinning of hair on the entire head.
The origins of androgen (testosterone) in men are
80% testicular and 20% adrenal. In women, 60% is
formed through peripheral conversion, primarily
by the skin, and 40% is adrenal and ovarian. In the
initial evaluation of alopecia the following tests
should be ordered:
v free and total testosterone
v thyroid stimulating hormone
v ferritin
v prolactin.
The patient should also be evaluated for emo-
tional stress. The pathophysiology is the conversion
of delta-4-androstenedone by 5-alpha reductase to
dihydrotestosterone. If the conversion is blocked
at the hair follicle by a 5-alpha reductase inhibitor
then hair loss can be minimized and hair growth will
exceed hair loss.
Frontal Traction Alopecia
The occurrence of frontal traction alopecia is due to
tightening of the hair for long periods of time,
which in turn damages the hair follicles. Young
women are most likely to be diagnosed due to their
adopting hairstyles which give rise to the condition.
Fig. 13.6 Post-mesoglow.
146
Aesthetic Oculofacial Rejuvenation

Alopecia Areata
Alopecia areata is commonly known as ‘spot bald-
ness’ and occurs mainly on the scalp. Areata has its
own set of subcategories:
v Alopecia totalis is the total loss of hair from the
head and even with mesotherapy hair regrowth
varies.
v Confined alopecia areata occurs when the hair
loss is limited to one specific area.
v Alopecia universalis is the most intense form of
alopecia areata, involving loss of all hair, including
the eyebrows.
v Post-partum alopecia occurs in women after they
have given birth.
Treatment
In female patients treatment is given once weekly
for 4 weeks, biweekly for 1 month and then once
every 4–6 weeks. The recommended protocol is a
mixture of 0.5 mL procaine, 0.5 mL biotin, 0.5 mL
D-pantethol and 0.5 mL vitamin C. In postmeno-
pausal women the addition of Dutesteride can be
beneficial.
The goal is to target the affected area by injecting
the desired medication directly onto the area to be
treated and to a depth of 1–3 mm. Due to the loca-
lity, the medication is generally well-tolerated;
there is very little blood loss or pain and hematomas
are rare. When treating diffuse or regional alopecia,
injection is by point or nappage on the frontal,
fronto-parieto-occipital or vertex of the head. On
the other hand, if treating circumscribed alopecia,
injections are performed on the patches of hair loss.
In order to achieve the best results and to maintain
hair regrowth, it is recommended that the patient
be treated once weekly for five sessions, then once
every 15 days for three sessions, followed by once
monthly for two sessions and finally once every
3 months.
CONTRAINDICATIONS
There are several important medical as well as psy-
chological conditions, which make patients unsuit-
able for mesotherapy.
v Mesotherapy is not a replacement for exercise
but a supplement, and patients who are not
A
B
C
D
Fig. 13.7 Alopecia. A and B, pre-treatment. C, 2 months post-treatment. D, 3 months post-treatment.
147
Mesotherapy

actively exercising should be discouraged from
having this procedure.
v Although at present there is no literature to
support the case, mesotherapy should not be
given to patients with history of diabetes type I
or type II.
v Patients with autoimmune conditions or
extensive skin conditions (such as eczema or
psoriasis) should not receive mesotherapy since
they may have an increased risk of skin infection
and abscess formation.
v Mesotherapy is not recommended in patients
with a history of body image distortions, such as
body dysmorphic syndrome.
COMPLICATIONS
Most of the undesirable effects are due to bad tech-
nique of application. It is important to know the
origin of the drugs used, the amount, the number
of sessions and the interval between them, and
specially avoid the use of more than 4 substances
at the same time.11
CONCLUSION
Mesotherapy is a non-invasive procedure and can be a
great adjuvant for weight loss, cellulite management,
hair growth, and for the delivery of nutrients and anti-
oxidants to achieve healthier skin. Even though most
people are potential candidates for mesotherapy,
their goals and expectations must be realistic –
mesotherapy is not a miracle. In the proper hands,
and with the right patient selection, mesotherapy
can be of assistance but there are no ‘typical results’.
At the moment, there are no double-blind pla-
cebo-controlled studies showing average response in
a given population group and for this reason the
experience of mesotherapy is, for the most part,
anecdotal. However, 50 years of mesotherapy treat-
ment, in particular in France, Italy, other European
countries and South America, have led to widespread
public support for its efficacy. Some doctors report
on their websites ‘miraculous’ results of up to 6 to
13 inches of waist loss. We believe that these types
of results will not be consistently achieved and may
not be typical; they may depend on the particular
treatment that is used by the practitioner. This may
contribute to the variability of results seen between
different facilities performing mesotherapy. More
studies are necessary and data are being collected
for future medical presentations. It is a field that is
growing rapidly due to the efforts of people like
Jorge Silva, Jaque Le Coz, Phillipe Petit and a host
of others around the world.
REFERENCES
1 Pistor M. Un de´fi Therapeutique: La mesotherapie en pratique
veterinaire. III Congreso Internazionale de Mesotherapia, Roma,
1982.
2 Le Coz J. Mesotherapie en Me´dicine Ge´nerale. Paris: Masson; 1993.
3 Rosenbaum R, Hellmer P, et al. An investigation of the morphol-
ogy and biochemistry of cellulite. Plast Recon Surg. 1998;101
(7):34–37.
4 Le Coz J, Fabbi P, Lopez-Barri A. Me´sotherapie et medicine
Estetique. Marseille: Solar Editeurs; 1994.
5 Rittes P. The use of phospatidylcholine for correction of Localized
fat deposits. Aesth Plast Surg. 2003;27:315–318.
6 Co AC, Abad-Casintahan MF, Espinoza-Thaebtharm A. Sub-
mental fat reduction by mesotherapy using phosphatidylcholine
alone vs. phosphatidylcholine and organic silicium: a pilot study.
J Cosmet Dermatol. 2007;6(4):250–257.
7 Duncan D, Rubin JP, Golitz L, et al. Refinement of technique in
injection lipolysis based on scientific studies and clinical evalua-
tion. Clin Plast Surg. 2009;36(2):195–209 v-vi; discussion 211.
8 Matarasso A, Pfeifer TM. Mesotherapy and injection lipolysis.
Clin Plast Surg. 2009;36(2):181–92, v; discussion 193.
9 Rose PT, Morgan M. Histological changes associated with mesother-
apy for fat dissolution. J Cosmet Laser Ther. 2005;7(1):17–19.
10 Iorizzo M, De Padova MP, Tosti A. Biorejuvenation: theory and
practice. Clin Dermatol. 2008;26(2):177–181.
11 Tennstedt D, Lachapelle JM. Cutaneous adverse effects of
mesotherapy. Ann Dermatol Venereol. 1997;124(2):192–196.
COMPLICATIONS
Pain
Erythema
Mechanical nerve lesion (particularly in superficial nerves)
Hematomas
Cutaneous necrosis
Infection
148
Aesthetic Oculofacial Rejuvenation

Skin rejuvenation with platelet-rich plasma
Maria Angelo-Khattar
INTRODUCTION
To date, the various options for skin rejuvenation
have included lasers and energy-based devices, such
as intense pulsed light and radio frequency, to
stimulate neocollagenesis and enhance the skin’s
microcirculation. Furthermore, restoration of facial
volume is currently accomplished by the use of
synthetic dermal fillers and autologous fat (Chs 9
and 10, respectively). The therapeutic value of such
treatment modalities, particularly with respect to
periorbital rejuvenation, including the management
of dark circles and under-eye depressions, is rather
limited.
The use of autologous platelet-rich plasma (PRP)
in cutaneous rejuvenation is a novel treatment
strategy that relies on the natural healing capacity
of the synergistic cascade of autologous growth
factors.
Autologous PRP has been used in clinical practice
since the 1990s and has an extremely broad range
of healing applications in oral and maxillofacial
surgery, cosmetic surgery, cardiovascular surgery,
otolaryngology, burns and wound healing.
The latest application of autologous PRP now
includes aesthetic treatments to address damaged
and aged skin. Platelets, when present in body tis-
sues outside the bloodstream, are activated by vari-
ous chemicals to release growth factors that attract
stem cells to the site of injury. The growth factors
stimulate further mitosis of stem cells and differen-
tiation into keratinocytes, fibroblasts and pre-adipo-
cytes. This ultimately results in neovascularization
and the production of collagen, elastin and new
extracellular matrix. Platelet-rich plasma is a natural
and powerful means of delaying as well as reversing
cutaneous aging. The significant increase in skin
thickness and elasticity, as well as the moderate
volumetric effect achieved by both intradermal
and subdermal injection of platelets, provides a safe,
natural and long-term solution for skin regeneration
and, in particular, periorbital rejuvenation. Further-
more, treatments with PRP are well accepted by
patients due to the inherent safety of the technique.
Because it is an autogenous preparation, PRP is free
from transmissible diseases such as HIV, hepatitis
and Creutzfeldt–Jacob disease.
PHYSIOLOGICAL ROLE OF PLATELETS
IN HEMOSTASIS
Platelets play a central role in the mechanism of
hemostasis.
The hemostatic response to injury includes the
release of endothelial factors that attract circulating
platelets and activate the coagulation process. The
platelets aggregate at, and adhere to, the site of
injury, where they release granules that contain
the various cytokines that initiate coagulation and
the formation of fibrin. Moreover, the release of
thrombin at the site of injury further enhances the
activation of platelets and the formation of a hemo-
static plug to arrest bleeding. Both thrombin and
the activated platelets are responsible for the initia-
tion of the wound-healing reaction, resulting in
tissue proliferation and angiogenesis.1
DEFINITION OF PLATELET-RICH PLASMA
Platelet-rich plasma is an autologous concentration
of platelets in a small volume of plasma. It is
derived from whole blood through the process of
gradient density centrifugation. Normal platelet
counts in blood average about 200 000 platelets/ml
whereas effective preparation of PRP yields concen-
trations of 1 000 000 platelets/ml. This concentra-
tion of platelets in a 5 ml volume of plasma is now
recognized as being the working definition of thera-
peutic enriched PRP.2
149
Mesotherapy

THERAPEUTIC EFFECT OF PLATELET-RICH
PLASMA
The therapeutic effect of autologous PRP is due to
mediation of the wound-healing reaction, which is
initiated by formation of a fibrin clot and the
degranulation of the alpha granules within platelets
to release the full complex of growth factors. This
action begins within 10 minutes of clot formation.
The fibrin clot produced by the cell adhesion pro-
teins in PRP, namely fibrin, fibronectin and vitro-
nectin, serves as a scaffold for the platelets that
are entrapped within the fibrin strands. The plate-
lets release growth factors that act as a chemo-
attractant for stem cells and fibroblasts, which then
begin to proliferate. Fibroblasts generate additional
cytokines and produce collagen, elastin and glycos-
aminoglycans. This function of matrix remodelling,
initiated by fibroblasts, continues for a period of
approximately 300 days. However, the clinical
benefit of PRP should last well over a year due to
the profound neocollagenesis achieved.
The main fundamental protein growth factors
proven to be actively secreted by platelets include
the three isomers of platelet-derived growth factor
(PDGF aa, PDGF bb, and PDGF ab), two of the
numerous transforming growth factors b (TGF b1
and TGF b2), vascular endothelial growth factor,
insulin-like growth factor and epidermal growth
factor. All of these growth factors, with different
physiological functions (Table 13.1) have been docu-
mented as being present in platelets.3
Following the initial release of growth factors, the
platelets continue to synthesize and release addi-
tional growth factors for their remaining life span of
7 days. Once the platelet is depleted and apoptosis
occurs, macrophages invade the area and take over
the function of wound healing by further secreting
growth factors. An additional source of growth fac-
tors is the leucocytes, a high concentration of which
is obtained during the PRP preparation process. The
presence of the leucocytes also imparts an added
antimicrobial effect to the PRP.
The growth factors exert their action by binding
to the external surface of cell membranes within
the tissues. Studies have shown that adult mesen-
chymal stem cells, fibroblasts, endothelial cells,
osteoblasts and epidermal cells express cell mem-
brane receptors to growth factors in the PRP. These
transmembrane receptors in turn activate a protein
within the cell, which signals cellular proliferation,
matrix formation, osteoid production and collagen
synthesis. The significance of this information is to
highlight the fact that PRP is not mutagenic and
cannot induce tumour formation since it does not
enter the cell or its nucleus.4
CONTROVERSIES REGARDING
PLATELET-RICH PLASMA
There are several critical reports in the literature
regarding the clinical efficacy of PRP. Some of these
studies have used PRP from donor animals and it
must be stated that true PRP is always autologous
and not homologous. Furthermore, the success of
the procedure is highly contingent upon the PRP
preparation process. The centrifugation process
must be sterile and the system used must allow
for the sequestration of platelets in high concentra-
tion without damaging them in the process. Studies
suggesting that there is no benefit from PRP can
therefore be traced to poor quality PRP preparation
by inadequate devices.
A positive cellular response in terms of fibroblast
proliferation and type I collagen production may
only be achieved by optimal platelet concentrations
of four to five times baseline value.5 Investigators
using US Food and Drug Administration (FDA)
and Certification Europe (CE) approved kits that
allow for sufficient enrichment of plasma have
reported significant enhancement of bone and soft
tissue healing in face-lift surgeries6, cosmetic der-
mal fat grafts,7 mandibular bone grafts8 and a multi-
tude of other indications. However, to date there
Table 13.1
Growth factors in platelet-rich
plasma
Growth factor
Physiological function
Platelet derived
growth factor
Stimulates mitosis of connective
tissue and other cell types
Promotes synthesis of collagen
and structural proteins
Transforming
growth factor
Regulation of cell proliferation,
differentiation and apoptosis
Insulin-like growth
factor
Regulator of cell metabolism and
growth
Vascular endothelial
growth factor
Regulates angiogenesis
Epidermal growth
factor
Regulates cell proliferation,
differentiation and survival
150
Aesthetic Oculofacial Rejuvenation

have been no clinical studies published on the use of
PRP for cosmetic indications in skin rejuvenation.
PREPARATION OF PLATELET-RICH PLASMA
AND INJECTION TECHNIQUE
Several platelet enrichment kits are available but
the one used by the authors was the Regen PRP-
Kit® by ReGen Lab (Mollens, Switzerland). This
class IIa medical device, cleared by Certification
Europe (CE), is a quick in-office procedure that
requires less than 30 minutes of preparation time.
Preparation Procedure
v Blood (8.5 ml) is aspirated into a RegenTHT®
(thrombocytes harvesting tube) containing citrate
anticoagulant and a gel separator.
v The RegenTHT® tube is centrifuged for
8 minutes at 3100 rpm, which results in
fractionation of the blood, with the erythrocytes
being separated from the platelets, leucocytes
and plasma by the gel separator.
v This yields on average 5 ml of plasma. To further
enrich the preparation, 20% of the volume of the
plasma is aspirated prior to resuspension of the
platelets and leucocytes by tipping the tube
several times.
v The tube is allowed to stand for 10 minutes prior
to injection.
v The plasma is then aspirated into a 3 ml syringe
containing 0.3 ml of 10% calcium chloride, which
serves to activate the platelets.
Injection Technique
The activated platelets must be injected within
10 minutes of preparation; otherwise the fibrin clot
will form inside the syringe. The PRP must then be
injected very superficially, such that small blebs are
obtained on the surface of the skin. Multiple injec-
tions are performed at almost every centimeter of
the treatment area, akin to the ‘coup par coup’ tech-
nique of mesotherapy. Alternatively, for treatment of
fine lines and wrinkles, PRP may be injected into the
deep dermis and sub cutis, in the same manner as a
dermal filler. Typical average injection volumes are:
1.5 ml per eyelid, 5 ml per cheek, 4 ml for the fore-
head, 7 ml for the neck and 8 ml for the back of each
hand.
Pain management during injection may be achieved
with either topical anesthetic cream or infiltration
anesthesia, as required.
AESTHETIC INDICATIONS
AND CONTRAINDICATIONS OF
PLATELET-RICH PLASMA
Aesthetic indications
Skin aging, resulting from the progressive decrease in
dermal collagen and elastin, manifests as early as the
late 20s, due to both chronological and, most signifi-
cantly, environmental factors. PRP can therefore be
used for the prophylaxis of cutaneous aging, as of
the early 30s. In older individuals where there is a
need for rejuvenation and the reversal of the aging
process, PRP can be used to fill out fine lines and
wrinkles as well as to improve general skin tone and
elasticity. Figure 13.8 shows the results of two PRP
treatments on the full face of a 63-year-old patient.
Figure A is the baseline photo and Figure B was taken
two months after the second treatment. Typically
A
B
Fig. 13.8 A 63-year-old female patient before (A) and two
months after (B) two treatments of the whole face with
platelet-rich plasma.
151
Mesotherapy

PRP is injected in facial skin but is also beneficial
for the restoration of skin on the neck, de´collete´ and
back of the hands. Figure 13.9 shows the increase in
skin thickness and elasticity 2 months after two PRP
treatments on the left hand of a 57-year-old subject,
with the right hand serving as a control.
Platelet-rich plasma is also a very effective treat-
ment for saucerized acne scars, in particular when
performed subsequent to ablative fractional laser
resurfacing. In Figures 13.10 and 13.11 two patients
with atrophic acne scars were treated with PRP
alone. The figures exhibit a decrease in the depth
of the scars 1 month after a single treatment.
One of the most impressive outcomes of PRP is in
periorbital rejuvenation. Platelet-rich plasma results
in a decrease in fine lines and wrinkles as well as a
significant reduction in dark under-eye circles and
depression such as the tear trough and nasojugal
groove. Both the upper and lower eyelids of the
patient shown in Figure 13.12 were treated twice
with PRP at an interval of 6 weeks. There was a
significant reduction in both under-eye depressions
and skin laxity 1 month post treatment. Figure 13.13
shows the results obtained 1 month after a single
treatment of the lower eyelids.
Dark circles affect individuals of all ages, both gen-
ders and all races. They give the person a tired and sad
appearance. Although infraorbital darkening is attribu-
ted to multiple etiologic factors, the most commonly
implicated factor is the superficial location of the vas-
culature, which is further exacerbated by skin laxity.
The fact that infraorbital circles are seen in several
members of the same family suggests a hereditary
basis.9 The increase in skin thickness and elasticity
achieved with PRP yields a very natural and long-last-
ing solution to the rejuvenation of the lower eyelids.
Improvement in skin texture of the upper eyelids is
also achieved with PRP, in particular post-blepharo-
plasty since it is possible to increase skin thickness
and thus camouflage the telengiastasia often seen after
eyelid surgery.
The aesthetic indications for PRP can be sum-
marized as follows:
v reduction of fine lines and wrinkles on the face
and neck;
v improvement of skin elasticity on face, neck,
de´collete´ and hands;
v treatment of post-acne atrophic scars;
v treatment of infraorbital dark circles and hollows;
v treatment of upper eyelids.
Contraindications of platelet-rich plasma
The contraindications of PRP are few and basically
include clotting abnormalities and treatment with
anticoagulant drugs. The only minor complication of
PRP thus far encountered has been bruising due to
needle trauma. However, as with any dermal filler or
even autologous fat, there is a potential risk of intra-
vascular injection or nerve trauma. Post treatment,
patients are advised not to take any steroids or
Fig. 13.9 Hands of a 57-year-old female patient taken
2 months after two treatments of the back of the left hand,
with the right hand serving as a control.
A
B
Fig. 13.10 A 34-year-old male patient before (A) and 1 month after (B) a single treatment for acne scars.
152
Aesthetic Oculofacial Rejuvenation

non-steroidal anti-inflammatory drugs (NSAIDs), as
this would suppress the immune response, which is
integral to the wound healing reaction.
The contraindications to PRP can be summarized
as follows:
v platelet abnormalities such as low platelet count;
v infection in the area of proposed treatment;
v febrile illness;
v chronic liver disease;
v anticoagulation therapy (warfarin or heparin).
Post-treatment
The patient should be maintained on a daily regimen
of 3000 mg of Vitamin C orally for optimum
collagen synthesis as well as the use of topical
dermocosmeceutical products rich in vitamin C, vita-
min A, idebenone or alphalipoic acid. The patient
should also be cautioned against the ingestion of
non-steroidal anti inflammatory agents since these
might suppress the wound healing response, which
is integral to the success of the treatment.
A
B
Fig. 13.12 A 56-year-old female before (A) and 1 month after (B) two treatments of the lower and upper eyelids.
A
B
Fig. 13.13 A 45-year-old female before (A) and 1 month after (B) a single treatment of the lower eyelids.
A
B
Fig. 13.11 A 29-year-old female patient before (A) and 1 month after (B) a single treatment for acne scars.
153
Mesotherapy

The proposed frequency of treatment for the pre-
vention of aging in younger individuals is once a year.
For skin rejuvenation in older patients, more frequent
treatments are required, namely once every 4 to
6 weeks until optimal correction has been obtained
and thereafter either annually or biannually.
COMBINATION TREATMENTS
WITH PLATELET-RICH PLASMA
As with other non-surgical and minimally invasive
rejuvenation
techniques,
combination
therapies
complement and optimize the final outcome of
PRP treatments.
Carbon dioxide insufflation therapy (see Chapter
14) is an ideal adjunct post-PRP therapy, in particu-
lar for periorbital rejuvenation and dark under-eye
circles. The Rioblush™device (Rioblush, New
York, NY, USA) is used for dermal and subcutane-
ous administration of CO2 gas in a regular program
of six treatments every 3 to 4 weeks. Studies have
shown that CO2 therapy has a positive effect on
cutaneous
microcirculation,
localized
adiposities
and skin elasticity and hence provides a useful tool
against periorbital aging.10
Energy-based devices also provide an effective
adjunct to PRP treatments, in particular for the
management of saucerized post-acne scarring. Pre-
treatment and post-treatment with fractional Er:YAG,
fractional CO2 lasers or fractional radio frequency
(Alma lasers Ltd., Buffalo Grove, IL, USA) serve to
optimize the outcome.
Infiltration with vitamin C, which is integral to
the synthesis of collagen, potentiates the wound
healing reaction initiated by PRP. This contributes
to the restoration of skin radiance and elasticity as
part of an anti-aging program. Vitamin C may be
administered by mesotherapy or by use of the new
Isolaz device (Aesthera Corp., Pleasanton, CA,
USA). Isolaz is a photopneumatic therapy device,
whereby the optics of the skin are altered. The skin
is stretched, hence rendering it more permeable,
and the targets within the skin, such as the fibro-
blasts, are elevated. During the first treatment pass,
the stretched skin is irradiated with broadband light
to stimulate the fibroblasts. In a second pass, vita-
min C is infiltrated into the skin by use of a special
sponge tip impregnated with a 10% vitamin C solu-
tion. Isolaz treatments are administed bimonthly for
the first 2 months post PRP therapy. Finally, oral
ingestion of 3000 mg of vitamin C in divided doses
and the use of dermocosmeceutical skincare pro-
ducts with antioxidants provide a good adjunct to
PRP treatments.
CONCLUSION
Platelet-rich plasma provides an ideal treatment
strategy in the quest for natural aesthetic solutions.
This quick and effective in-office procedure with
relatively no downtime fulfils an essential need in
today’s time-strapped environment. Platelet-rich
plasma is ideal in prolonging the appearance of
youthful, radiant skin. It is effective in relatively
young individuals for the prevention of aging and
in the treatment of acne scars and dark under-eye
circles. In older individuals it can reverse cutaneous
aging and enhance the efficacy of any anti-aging
treatment program. The inherent safety and long-
lasting clinical benefits of PRP make this treatment
modality highly appealing to many patients.
REFERENCES
1 Knighton DR, Hunt TK, Thrakral KK, Goodson WH. Role of
platelets
and
fibrin
in
the
healing
sequence.
Ann
Surg.
1982;196:379–388.
2 Haynesworth SE, Kadiyala S, Liang LN, et al. Mitogenic Stimula-
tion of Human Mesenchymal Stem Cells by Platelet Release Sug-
gests a Mechanism of Enhancement of Bone Repair by Platelet
Concentrates. Boston, MA: Presented at the 48th Meeting of the
Orthopaedic Research Society; 2002.
3 Marx RE. Platelet-rich plasma: evidence to support its use. J Oral
Maxillofac Surg. 2004;62:489–496.
4 Schmitz JP, Hollinger JO. the biology of platelet-rich plasma.
J Oral Maxillofac Surg. 2001;59:1120.
5 Lui Y, Kalen A, Risto O, et al. Fibroblast proliferation due to
exposure to a platelet concentrate in vitro is pH dependent.
Wound Repair Regen. 2002;10:336.
6 Adler SC, Kent KJ. Enhancing healing with growth factors. Facial
Plast Surg Clin North Am. 2002;10:129.
7 Abuzeni P, Alexander RW. Enhancement of autologous fat trans-
plantation with platelet rich plasma. Am J Cosmetic Surg.
2001;18:59.
8 Marx RE, Carlson ER, Eichstaedt R, et al. Platelet rich plasma:
Growth factor enhancement for bone grafts. Oral Sug Oral Med
Oral Pathol Oral Radiol Endod. 1998;85:638.
9 Lowe NJ, Wieder JM, Shorr N. Infraorbital pigmented skin.
Preliminary
observations
of
laser
therapy.
Dermatol
Surg.
1998;21:767–770.
10 Brandi C, D’Aniello C, Grimaldi L, et al. Carbon dioxide therapy
in the treatment of localised adiposities: clinical studies and histo-
pathological correlations. Aesth Plas Surg. 2001;25:170–174.
154
Aesthetic Oculofacial Rejuvenation

Carbon Dioxide Therapy: Face and
Body Rejuvenation
Philippe Cadic
Included on DVD
Ήgήsasyai m
en to`n didaxanta me t
Zn tewnZn tautZn
Ysa genetZsin emoı˜si, kaì biou koinosasyai, kaì
wre~on wrZizonti metadosin poiήsasyai, kaì genoB to`
ex oU´ teou Odeljoı˜B Yson epikrineein ¼r
resi, kaì
didaxein t
Zn tewnZn tautZn, jn wrZizosi manyanein,
¼neu misyoU˜ kaì xuggraj~ZB, paraggeliZB te kaì
IkroZsioB kaì t~ZB loip~ZB ±pasZB mayZsioB
metadosin poiZsasyai uìoı˜si te emoı˜si, kaì toı˜si
toU˜ em
e didaxantoB, kaì mayZtaı˜si
suggegrammenoisi te kaì
orkismenoiB no´mo• ìZtrik~o
_
,
¼llo_ d
e oU´ deni.
To hold him who has taught me this art as equal to
my parents and to live my life in partnership with
him, and if he is in need of money to give him a share
of mine, and to regard his offspring as equal to my
brothers in male lineage and to teach them this art – if
they desire to learn it – without fee and covenant; to
give a share of precepts and oral instruction and all
the other learning to my sons and to the sons of him
who has instructed me and to pupils who have signed
the covenant and have taken an oath according to the
medical law, but no one else.
Hippocrates of cos II
INTRODUCTION
Carbon dioxide therapy (CDT) is a procedure
which is very similar to mesotherapy. It consists of
intradermal or subcutaneous injections of medical
grade CO2 using 30 G needles. With a few medical
applications published in the medical literature,
CO2 insufflation has been widely used in the last
8 years in South America and in particular in Brazil
for cosmetic purposes, such as stretch marks, cellu-
lite, localized adiposities and under-eye dark circles,
in combination with other minimally invasive aes-
thetic procedures. The low morbidity, high level
of patient tolerance and minimal side effects makes
it a very interesting technique in our battery of face
and body rejuvenation techniques, with a high level
of patient satisfaction.
CDT (also known as carboxitherapy, carboxy-
therapy, carbossitherapy or carbotherapy) was first
described in the central mountains of France in
the early 1930s, in the medical spa of Royat. Doc-
tors found that transdermal use of CO2 in enriched
warm baths improved vascular ischemia symptoms
because of a strong direct vasodilator effect, a neo-
angiogenesis effect and better oxygen release in
superficial tissues related to the Bohr effect (see
below). Authors soon tried subcutaneous injections
of the spa’s CO2 gas, looking to find optimized and
stronger effects.
There are numerous available PubMed and Med-
Line articles about vascular uses of injected CO2.
Many hundreds of thousands patients have now
been treated, with indications such as lower limb
ischemic arterial pathology, Raynaud’s phenomenon,
skin ulcers with arterial or venous cause, as well as
several vascular erection disorders.
The aesthetic use of CO2 insufflations is rela-
tively new, the first articles being published in
around 1990 by Belotti and De Bernardi and around
2000 in Italy. These articles concerned improve-
ment of localized adiposities with CDT, the treat-
ment sometimes being associated with liposuction.
The number of available articles on the subject is
limited to the two main studies of D’Aniello and
Brandi from the University of Siena.1
Despite the lack of any publication in other
indications, CDT is also commonly used in the
following procedures:
v cellulite skin appearance (orange peel)
v face wrinkles (alone or combined with
mesotherapy and/or Botox and/or fillers and/or
laser treatment or radiofrequency equipment
v eye wrinkles
v under-eye dark circles
v skin laxity (hands, neck, submentonian area,
de´colletage area)
14