Aesthetic Oculofacial Rejuvenation

EQUIPMENT
Almost all CDT machines are based on the same archi-
tecture. They contain the following parts (Fig. 14.2):
v CO2 tank
v pressure regulator
v 0.22 mm filter
v electromechanical valves
v embedded central processing unit board and
human/machine interface
v gas heater
v tubes/terminal, 0.22 mm filter, 30G needle
CO2 Tank
A CO2 tank is normally purchased or rented from
a medical gas supplier. It contains medical grade
CO2, which is the same as the gas used for abdomi-
nal surgery that is found in most hospitals. The tank’s
size varies from one country to another and there are
different sizes on the market. Care is required to
ensure that the CDT machine is compatible with
the tank. Most of the time an adaptor/regulator is
delivered with the machine when it is installed.
There are several precautions necessary when
manipulating gases. The tank should be delivered
with a safety sheet covering most of the points of
which practitioners should be aware.
v Keep oil and other lipids away from the tank as
pressure and fat may cause an explosion.
v Use the CDT machine in a ventilated room to
avoid accumulation of CO2, which could
potentially cause breathing difficulties.
v Control the temperature of the room where the
equipment is operated.
v Verify that tubes are properly attached and
locked in place to avoid leaks. A leak could
empty a tank in a few hours and could also lead
to unstable output pressure, compromising the
treatment.
Pressure Regulator
Almost all medical gases are stored in tanks at very
high pressure. CO2 tanks are usually at 50–60 bars.
For CDT, we lower the pressure to 2–3 bars. The
gas regulator should adjust the pressure and stabilize
it. Most of the time the output pressure can be
manually adjusted according to treatment needs. A
suggested output pressure is 3 bars. Most pressure
regulators have two manometers: one for input
pressure (typically 50 bars) and one for the output
pressure (treatment pressure) (Fig. 14.3). Although
it should only be necessary to adjust the pressure
when the tank is opened, it is not a bad idea to
check manometers from time to time during the
day as gas bottles can empty or need adjusting.
First Filter
The first filter, typically 0.22 mm, may be optional
in some machines. The filter (Fig. 14.4) is provided
in order to block viruses, bacteria and impurities
so that a pure, filtered gas enters the CDT machine.
Electro-mechanical
valves
CO2 tank
Pressure regulator
Drops from 50 bars to 2−3 bars
Gas heating system
20° to 30°
Gas filter
Gas output plug on the machine
Human–machine interface
Embedded CPU board
LCD screen
Fig. 14.2 Components of a CDT machine.
Fig. 14.3 Pressure regulator: most CO2 tanks are at 50 bar.
The regulator lowers the pressure to 2–3 bars (30–40 psi).
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Carbon Dioxide Therapy: Face and Body Rejuvenation

The filter should usually be changed every 3 months
to maintain its efficacy. After some time the mem-
brane could be affected and may allow dust, parti-
cles, bacteria and viruses to pass through. If this is
the case, the risk of bacterial colonization of the
inside of the machine is increased.
Electro-mechanical Valve Compartment
The heart of any CDT system is the electro-
mechanical valve compartment. Once the gas pres-
sure has been set to 3 bars, the total amount of
delivered CO2 has to be controlled at a constant
volume per minute (cc/min). To achieve this goal,
each machine has a set of electronically monitored
valves, which open or close to maintain a precise
flow and CO2 quantity.
Computerized Area
Valves should deliver a precise amount of CO2 at
a predetermined flow. For this reason, they are
driven by an embedded electronic computer. This
computer reads values from a flow meter and is
capable of controlling the positions of all the valves.
Timer functions are used by the computer to stop
the injection when a precise amount of gas has been
delivered to the skin.
In most machines, the CPU board also accepts
the operator’s commands through a digital touch
liquid crystal display interface (Fig. 14.5). The physi-
cian is able to select a flow and duration, and
sometimes a specific injection mode.
Gas Heater
It has been demonstrated that warm CO2 is better
than cold as it gives more vasodilation and an
increased Bohr effect with better oxygen release.
Frozen, decompressed gas also gives a higher level
of pain when it is injected into the dermis or into
subcutaneous skin layers. New generations of CDT
machines are all able to deliver heated gas.
Tubes, End Filter and Needles
Tubes, filter and needles are the consumables
attached to the CDT machine. They are sterile, for
obvious reasons, and are changed for each patient.
These parts are not much different from the tubes
used in traditional intravenous injections of drugs.
The plastic tube should resist the 3 bars pressure
and should be long enough to let the operator work
easily. A minimum length of 1 m is required.
The tube is attached to a bacteria/virus filter which
lets the CO2 gas pass through. It is a 0.22 mm mem-
brane. This filter receives a 30 G mesotherapy needle.
The shape of the filter is designed to let the operator
manipulate the needle with precision (Fig. 14.6).
INDICATIONS AND CONTRAINDICATIONS
CDT has various indications. Most publications
cover vascular disease and localized fat where proto-
cols and indications are relatively clear.
We can split indications into two groups: medical
vascular diseases and aesthetic procedures. The first
group is the best documented, with a large number
of publications since 1930.
Fig. 14.4 A 0.22 mm filter, which is inserted between CO2
tank and CO2 equipment in most machines. It prevents
contamination and dust from entering the system.
Fig. 14.5 Front liquid crystal display of a CO2 insufflation
machine. The most important parameters are flow value,
total amount of CO2 delivered, heated or non-heated
mode.
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Aesthetic Oculofacial Rejuvenation

CDT Indications
Vascular
v Raynaud’s phenomenon
v Lower limb arterial diseases and ischemia
v Erectile dysfunction with micro-
vascularization disorders
Aesthetic
v Localized fat
v Acne scars
v Surgical scars
v Traumatic scars
v Stretch marks
v Eye wrinkles, fat deposits and under-eye dark
circles
v Rejuvenation of the hands, de´colletage, neck
v Psoriasis
v Nasogenian folds and peri-oral wrinkles
It should be noted that some South American phy-
sicians, although not published, use CDT prior to sur-
gery to lower scarring complications. Some operators
also use CDT to treat skin grafts and burnt skin.
Vascular Indications
Raynaud’s Phenomenon
Raynaud’s phenomenon is a vasospastic disorder of
the extremities causing discoloration of fingers and
toes, and pain. It is an inappropriate vasomotor
response to cold and/or emotional stress, with sympa-
thetic system hyper-activation, which leads to strong
vasoconstriction of the peripheral blood vessels, caus-
ing tissue hypoxia. Chronic Raynaud’s phenomenon
may lead to skin atrophy.
CDT has blood flow increase properties, espe-
cially targeting microcirculation of the superficial
tissues. In addition, the Bohr effect has strong
anti-ischemic properties. CDT may therefore be a
complementary treatment for this condition.
Lower Limb Vascular Diseases
with Ischemic Symptoms
CDT has been widely used in France’s Royat Spa
since the beginning of the 20th century to treat
arterial diseases of the legs. There are now better
treatments available such as bypasses and vessel
grafts. CDT should only be seen as a complementary
procedure for lower limb ischemic arteriopathy.
Ulcers (Arterial and Venous)
Ulcers are related to venal or arterial insufficiency.
Consequently, the healing process may be improved
by intradermal CO2 injections. Although particu-
larly painful, CDT sessions to treat ulcers require
very low flows until complete re-epithelialization.
Aesthetic Indications
Localized Fat
Since its publication at the University of Siena, the
use of CDT for localized fat has been among the
best known indications for the technique.3
Direct pressure causes trauma to the adiposities
and, although this is unproven, seems to weaken
them. Blood flow increase and the Bohr effect bring
more oxygen to the adiposities leading to an opti-
mized physiological lipolysis.
CDT can be used alone for localized fat or com-
bined with liposuction for even better results. It
can also be used to improve the ‘wave effect’,
which may be seen after a liposuction, especially
in areas which were either not treated or not
treated effectively. Physicians should be aware that
liposuction may create septations, preventing the
gas from diffusing normally and requiring multiple
CO2 punctures.
Acne Scars
CDT works in various ways for acne scars. It has
been demonstrated that CO2 injections stimulate
the synthesis of collagen. This property is used to
improve atrophic scars by increasing the quantity of
collagen below the atrophy. Nd–YAG (1064 nm) or
Fig. 14.6 The CO2 end filter and 30 G mesotherapy
needle. The filter is held by the operator’s fingers. It is a
0.22 mm filter, which will prevent most bacterial or viral
infections.
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Carbon Dioxide Therapy: Face and Body Rejuvenation

erbium–glass (1320–1550 nm) lasers produce the
same effect. The use of CDT is adapted to imperfec-
tions and mild acne scarring.
Some CDT procedures may also be of use in a
way which can be compared to subcision. Some
physicians use high flows of CO2 to simulate the
effect of a needle. This technique aims to break
fibrous septae which pull the scar below the skin
surface. As yet, no stabilized protocol has been pub-
lished but before/after photographs show interest-
ing results.
Surgical Scars
CDT is also used to improve post-surgery scars.
CO2 may restore skin laxity and color, and speeds
up the wound-healing process. It is an interesting
procedure
for
white
thyroidectomy,
caesarean,
appendectomy scars and other scars in general.
Some physicians also use CDT in a presurgical
procedure to prepare the skin for the healing phase
before the surgical incision.
Traumatic Scars
Recent trauma may benefit from the healing prop-
erties of CO2. The improvement of oxygen concen-
tration and the neo-vascularization induced by
subcutaneous injections shortens skin restoration
times. CO2 may prevent hypocromic scars, espe-
cially with dark phototypes.
Stretch Marks
Stretch marks are very common among women and
are a good indication for CDT. While recent marks
may benefit from pulsed dye laser or potassium-
titanyl-phosphate (KTP) laser sessions, old white
marks still remain a problem for the physicians.
Some authors have stimulated pigmentation using
excimer lasers or UV-B narrow-band lamps. Others
are using collagen remodeling lasers such as with
Nd–YAG, erbium–glass and fractional lasers. All
these approaches have a non-negligible level of
patient dissatisfaction. CDT is a relatively new indi-
cation for old white stretch marks. It works in three
different ways:
v neo-angiogenesis below the mark, which adds a
pink color
v melanin stimulation caused by increased oxygen
in the tissues
v collagen synthesis, which reduces the creased
appearance.
Eye Wrinkles, Lower Lid Fat Deposits
and Under-eye Circles
Because it stimulates collagen synthesis and has a
local lipolytic action, CO2 injection may be an indi-
cation for eye rejuvenation and fat deposits. The pro-
cedure is easy, fast and produces virtually no pain.
There are several possible causes of dark under-
eye circles:
v Deposition of pigments and melanin after the
lower lid has been exposed to allergy and chronic
irritation/inflammation can be compared to post-
inflammatory hyperpigmentation. This is not a
good CDT indication. Physicians would probably
use peelings and/or lasers (KTP, Q-switched).
v Vascular pooling with congestion of the lower eye
lid capillary network results in a bluish
appearance that can be seen through the skin.
CDT is a good indication for this condition:
better oxygenation and higher flow will convert
the blue color to red, decreasing the dark circle
appearance.
v The depression beneath the lower eyelids
known as ‘tear trough deformity’ is not a good
indication for CDT. Patients need fillers to
restore volume.
v Fat accumulation in the lower part of the lower
lid, known as ‘fatty prolapse’ is a good indication
for CDT sessions as the procedure has lipolytic
properties. Extreme care should be taken in this
area because the skin is fragile and thin. Low flow
values should be used.
Rejuvenation of the Hands, De´colletage
and Neck
Carbon dioxide injections are also good for skin lax-
ity and therefore skin rejuvenation, in all the exposed
areas.
The dorsal side of the hands may be treated using
intradermal injections. The expected effect is skin
tightening after four or more sessions. CDT will
have no effects on lentigos, which will require other
treatment modalities such as nitrogen, KTP laser,
Alexandrite laser or Q-switched laser.
Neck and de´colletage rejevenation are very good
indications for CDT.
Psoriasis
Some physicians use CDT for psoriasis treatment.
There do not appear to be any protocols or pub-
lished studies about this indication, which should
be considered experimental.
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Aesthetic Oculofacial Rejuvenation

Nasogenian Folds and Peri-oral Wrinkles
CDT is an alternative to fillers in some cases.
Patients with contraindications to fillers or who do
not want filler injections may be treated with CO2
injections.
Physicians
and
patients
should
be
informed that several sessions are necessary with
CO2, with progressive improvement, whereas fillers
have immediate results.
CDT CONTRAINDICATIONS
CDT contraindications are limited and very similar
to those for mesotherapy. There are general contra-
indications, local skin contraindications and tempo-
rary ones.
General Contraindications
The general contraindications for CDT are:
v needle phobia
v stress, with history of vagal unconsciousness event
v severe heart failure, congestive heart disease
v recent heart infarction or instable angina pectoris
v restrictive pulmonary disease, chronic
obstructive lung diseases
v sleep apnea
v renal failure, dialysis
v recent cerebrovascular accident
v uncontrolled blood pressure
v epilepsy
v recent phlebitis or pulmonary embolism
v uncontrolled diabetes
v immunosuppression or deficiency
v chemotherapy, cancer (healing disorders)
v patients with impaired healing
v connective tissue disorders or diseases
v bleeding diseases: Willebrand’s disorder,
hemophilia.
Local Contraindications
There are also a series of local contraindications:
v bacterial infection: dermatitis, cellulitis
v foreign body in the area to be treated (jewellery
implants and so on)
v herpes simplex in acute phase and other acute
skin viral infection
v skin disease with abnormally increased local
circulation
v facial rosacea
v poikiloderma of Civatte
v red necks and red de´colletage.
Temporary Contraindications
Temporary contraindications include:
v pregnancy (precautionary principle)
v lactation (precautionary principle)
v anticoagulation, recent aspirin or
antiinflammatory drugs intake
v acute skin infection (wait until it is cured)
v other aesthetic procedure or skin traumatism less
than 15 days prior to CDT.
SKIN LAYERS AND CDT CONCERNS
CDT indications require different planes of injec-
tion, depending on the effect desired. We can
schematize two different injections: subcutaneous
and intradermal; each one giving different effects.
Skin Layers
Mesotherapy 30 G needles for CDT have an approx-
imate length of 11 mm. This size is ideal for targeting
the two different layers of the skin. Although the
subcutaneous layer is easy to inject, intradermal
injections may be hard for novices to administer
precisely, a problem similar to that encountered by
medical students trying to administer intradermal
reaction tests for tuberculosis vaccinations. Carboxy-
therapists should proceed in the same way in order
to target intradermal layers (Fig. 14.7).
Intradermal
Subcutaneous
Fig. 14.7 Different CO2 injection layers.
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Carbon Dioxide Therapy: Face and Body Rejuvenation

Subcutaneous Injections
Subcutaneous CDT injections are administered to
reach the localized fat area, activate lipolysis and
improve blood flow (Figs 14.8–14.11).
Subcutaneous injections require a 30 G meso-
therapy needle with a length of 11 mm mounted on
the 0.22 mm filter. The skin is disinfected at least
1 minute before injecting CO2.
The needle should point at an angle of 35–45 to
the skin. It is possible to pinch the skin to ease the
penetration of the needle. In traditional mesother-
apy, it is necessary to make multiple injections as
the liquid drug does not diffuse much. CDT, on
the other hand, injects a gas, which is able to diffuse,
sometimes very far from the puncture. Because the
gas diffuses both along the surface and to greater
depths, it is not necessary to place the needle too
deep to get a good effect. Moreover, placing the
needle too deep will prevent the operator seeing
and controling the end point. Making a superficial
subcutaneous injection will therefore let the operator
monitor the CO2 below the skin. Usually, a good
subcutaneous injection will produce a 15–18 cm red
circle on the skin surface. This circle has a granite-
like appearance. For an optimized session, it is neces-
sary to move the needle for each injection by
15–18 cm, with no overlapping, to cover the fat
areas. While pain is limited in thick areas of fat, it
may be higher in areas when the fat layer is thin.
In CDT, it is important to be aware that after the
first session the gas will not diffuse too far from the
injection point. In the subsequent sessions (around
five to eight), the CO2 gas will tend to diffuse great
distances from the needle. This phenomenon is nor-
mal and permits fewer injections/treatment sessions
to be required. Patients also report less pain from
one session to another as the skin layers get used
to be separated.
Fig. 14.9 Beginning of a subcutaneous injection.
Fig. 14.10 End of injection and skin appearance after
2 minutes.
Fig. 14.11 In the first sessions, the gas diffuses to create
a 10–15 cm circle where the skin appearance is modified.
Epidermis
Dermis
Subcutaneous
layer
Muscle
Connective tissue
Fat cells
Needle
45°
0.22µm filter
Fig. 14.8 Subcutaneous injections require a 45 angle
to target fat cell areas.
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Intradermal Injections
Intradermal injections (Fig. 14.12) are performed in
most CDT procedures. The goal is to stimulate
the dermis to collagen synthesis. As with deep-
penetration lasers, we are aiming to get a remodel-
ing effect.
The intradermal injection is made with a 30 G
mesotherapy needle mounted on the 0.22 mm filter.
The skin is disinfected at least one minute prior to
puncturing the skin.
The injection is made at an angle of less than 15,
needle bevel up or with an extremely small rotation
angle. The operator should not push the needle too
far. If properly positioned, there is a short skin
whitening appearance before immediate inflation.
The whitening indicates a good intradermal position.
Most
intradermal
injections
will
produce
a
1.5–2 cm red disk with a granite-like skin appear-
ance. In some cases, a very superficial skin detach-
ment may also be seen, producing the appearance
of fern leaves. To cover the full area, the needle
should be moved by 2 cm each time, with no over-
lapping. The endpoint of the treatment is when
redness (erythema) affects the skin.
If there are any remaining white areas, these
indicate untreated areas and should be injected
immediately.
Using intradermal injections for the de´colletage
(Figs 14.13 and 14.14) may be uncomfortable for
the operator as getting a proper injection angle –
lower than 15 – is sometimes hard with large sur-
faces. It is possible to bend the needle to maintain
a low puncture angle.
OPERATIVE APPROACH
This section of the chapter is intended to be a tool for
the operator or physician, therefore all the operative
approaches are presented as a practical checklist for
everyday use. These are tools act as aides-memoires
and are particularly useful for novices. Plastic-
wrapped photocopies attached to the machine are a
simple way of using these in practice.
RAYNAUD’S PHENOMENON
Principle
Improve micro-circulation of the fingers. Increase
blood flow and oxygen release in the superficial skin
layers of the fingers. Stimulate neovascularization.
Fig. 14.13 Example of a de´ colletage area, 3 minutes after
CO2 therapy.
Fig. 14.14 Example of a de´ colletage area, 3 minutes after
CO2 therapy with treated areas marked.
Epidermis
Dermis
Subcutaneous
layer
Muscle
Fat cells
Needle
15°
0.22µm filter
Fig. 14.12 Intradermal injections require very low needle
angle to treat the dermis.
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Carbon Dioxide Therapy: Face and Body Rejuvenation

Indication
Any form of Raynaud’s phenomenon, after diagnosis
has been established.
Protocol
Subcutaneous layer
1 injection per day for 15–20 days (Fig. 14.15).
Flow: 50–80 cc/min
Technique
Inject CO2 into the distal interphalanx spaces. Pull
up the skin to limit the risk of pinching vascular or
nerve structures. After each injection, remove the
needle and use the finger to apply a proximal to dis-
tal massage, which will push the gas into the fingers
(Fig. 14.16). As the strategy is to let the gas diffuse
down to the fingers, use the hand that is not inject-
ing to prevent the gas from going the wrong
direction. During the insufflation apply gentle pres-
sure to the dorsal side of the hand to stop the gas.
Injection Points
Interphalanx spaces
Endpoint
Subcutaneous spaces will inflate. The skin attains a
crepe paper appearance. Gas will climb up to the
dorsal side of the hand.
Post-treatment Care
No postinjection treatment is necessary.
Pain Management
To limit pain, start the first sessions with low flow
values and increase them from session to session.
Results
Reduction of the pain and duration of spastic phases.
Reinforcement Sessions
Each year, before winter.
General Advice
Patient should continue to protect hands against the
cold, wear gloves and so on.
LOCALIZED FAT
Refer to Figures 14.17 and 14.18.
Principle
Stimulate
blood
flow
and
activate
receptors
involved in the natural lipolysis of the body.
Fig. 14.16 Raynaud’s phenomenon: the CO2 gas is pushed
down to the fingers with massage.
Fig. 14.15 Subcutaneous injection (Raynaud’s phenomenon).
Fig. 14.17 Arm injection points.
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Aesthetic Oculofacial Rejuvenation

Indication
Any kind of localized fat or skin irregularity after
liposuction. Also a complementary treatment to
liposuction.
Protocol
Subcutaneous layer
1 session per day to 1 per week
Flow: 1–2 cc/kg/min (50–80 cc/min)
Approximately 2 minutes per injection
Punctures spaced 15–20 cm apart
Number of sessions: 10–20
Progressive flow (automatic mode) available with
some machines
Submentonian area: deep dermis (and/or
subcutaneous)
Flow: 1–2 cc/kg/min (50–80 cc/min)
Approximately 30–60 seconds (until onset of
erythema or pain)
Usually three punctures.
Technique
Pinch and pull the skin between thumb and index
finger and inject the pinched skin in its subcutane-
ous layers.
Injection Points
Injection points should be made in the area where
localized fat resides. There are variations between
men and women.
Men: abdomen, lumbar area, chest, submentonian
area
Women: hips, abdomen, thighs, buttocks,
submentonian area, back
Endpoint
Subcutaneous injection will let the gas diffuse and
create a 15–20 cm diameter disk. Skin has a granite-
like appearance and shows erythema. Move the needle
15–20 cm away from the previous injection point
(no overlapping) to treat the entire fat area. Note that
the 15–20 cm circle occurs only during the first
sessions. After several sessions, typically five to six,
the skin offers less resistance to the gas diffusion and
one or two injection points may then be enough to
treat all the cellulite area.
Post-treatment Care
None.
Pain Management
Pain can be reduced with a ‘piano’ massage during
the injection. Pain is more frequent during the first
sessions: CO2 flow can be reduced in the first ses-
sions and progressively increased from session to
session. If too much pain is reported, change the
injection point and reduce the treatment time, giv-
ing more, shorter injections. Some CDT machines
have a progressive flow mode, which starts the
injection at a low flow and increases it progressively
during the course of the injection.
Results
Most patients report improvement after six to eight
sessions. Treatment is usually delivered for up to a
maximum of 20 sessions.
Maximizing Results
CO2 procedures may benefit from combined treat-
ments
such
as
RF,
Cellu-M6®,
Velasmooth®,
manual lymphatic drainage massage and so on.
Some nutritional advice and the maintenance of a
steady body weight are recommended.
Fig. 14.18 Body injection points.
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Carbon Dioxide Therapy: Face and Body Rejuvenation

Reinforcement Sessions
Patients are usually advised to renew the treatment
at least once each year in order to maintain the
effect.
Remarks
After liposuction, fat areas may be compartmenta-
lized and this will require multiple punctures to be
made, as the gas will not diffuse evenly. Ultrasound
imaging with high frequency probes may help.
Submentonian Fat Tightening
Refer to Figure 14.19.
CELLULITE/ORANGE PEEL SKIN
Principle
Stimulate blood flow and activate receptors involved
in the natural lipolysis of the body. Improve skin
tightening to reduce orange peel skin. Fibrous cellu-
lite treatments will require mechanical disruption of
fibrous septae with high CO2 flows.
Indication
All types of cellulite from grade I–II to grade
III–IV. Subcutaneous irregularities after liposuc-
tion.
Complementary
treatment
to liposuction,
which does not have any efficacy on cellulite.
Protocol
There are various protocols derived from the Royat
Spa, the use of which depends on the patient’ avail-
ability for treatments. At least one session per week
up to one session daily.
Cellulite grade I or II
Combination of subcutaneous and intradermal
injection
One session per day to one per week
Flow: 1–2 cc/kg/min – approximately 2 minutes
per subcutaneous injection
Punctures: 15–20 cm spaced, no overlapping
Number of sessions: 10–20
Progressive flow (automatic mode) available with
some machines
Cellulite grade III or IV
Combination of subcutaneous and intradermal
injection
One session per day to one per week
1
1
Subcutaneous
80 cc/min
30 sec
+ deep dermis
80 cc/min
30 sec
Subcutaneous
and deep dermis
3
80 cc/min
30 sec
Subcutaneous (fat)
+ deep dermis
(skin tightening)
2
Lateral view
Front
Subcutaneous
80 cc/min
30 sec
+ deep dermis
2
80 cc/min
30 sec
Subcutaneous for fat
+ deep dermis for laxity
Fig. 14.19 Submentonian: areas and parameters.
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Aesthetic Oculofacial Rejuvenation

Flow: >2 cc/kg/min
Punctures: 15–20 cm spaced, no overlapping
Number of sessions: 10–20
Progressive flow (automatic mode) available with
some machines
Technique
The operator’s hand movement should target both
the subcutaneous layer and the intradermal layer
as both lipolysis and collagen synthesis for skin
toning need to be improved. Start by injecting the
dermis and, when done, push the needle further/
deeper to inject the subcutaneous layers. This
appears to be the easier approach, although injecting
the subcutaneous layers first still appears to work.
Injection Points
Injections points should be made in the area where
cellulite resides. It is almost always in the hips and
thighs (Fig. 14.20).
Endpoint
Subcutaneous injection will let the gas diffuse and
create a 15–20 cm diameter disk. The skin has a
granite-like appearance and shows erythema. Move
the needle 15–20 cm away from the previous injec-
tion point (no overlapping) to treat the entire cellu-
lite surface. Note that the 15–20 cm circle occurs
during the first sessions. After several sessions, typ-
ically five to six, the skin offers less resistance to the
gas diffusion, one or two injection points may then
be enough to treat the cellulite area.
Post-treatment Care
No post-injection care is necessary. Advise the
patient not to take long warm baths during the fol-
lowing 24 hours, nor to perform active sports for
24–48 hours and to avoid new skin trauma or
bleeding.
Pain Management
Pain can be reduced with a ‘piano’ massage during
the injection. Pain is more frequent in the first ses-
sions: CO2 can be reduced in the first sessions and
progressively increased from session to session. If
too much pain is reported, change the injection
point and reduce the treatment time, giving more,
shorter injections. Some machines have a progres-
sive flow mode which starts the injection at a low
flow and increases it progressively during the course
of the injection.
Results
Most patients report improvement after six to eight
sessions. Treatment is usually delivered for up to a
maximum of 20 sessions.
Maximizing Results
CDT may benefit from combination with such treat-
ments as RF, Cellu-M6®, Velasmooth® and manual
lymphatic massage. Dietetic advice should be given
to help the patient maintain a stable weight.
Reinforcement Sessions
Patients are usually advised to renew the treatment
at least once a year in order to maintain the effect.
ACNE AND SURGICAL SCARS
Principle
Same effect as needle subcision. Improve blood
flow, vascularization and collagen synthesis.
Fig. 14.20 Cellulite injection points.
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Carbon Dioxide Therapy: Face and Body Rejuvenation

Indications
Recent scars treated during the healing phase,
atrophic scars, white scars. Thyroidectomy scars,
caesarean scars, post-traumatic scars and postsurgical
scars. Narrow atrophic scars.
Protocol
It is important to evaluate the scar hardness. The
harder the scar is, the higher the required CO2 flow.
Depressed scars
Combined subcutaneous and intradermal
injection
One session per week
Flow: 80 cc/min
Punctures inside the scar
Number of sessions: four to six
Deeper injections are more painful for patients
with adhesions
Multiple injections in deep layers as CO2 does
not diffuse well
Narrow scars, non depressed scars
Intradermal injection only
One session per week
Flow: 30–40 cc/min for soft scars
Punctures inside the scar (as per stretch marks)
Number of sessions: four to six
Acne scars (face)
Combined subcutaneous and intradermal
injection
One session per week
Flow: 30–40 cc/min for minor scars (soft),
>80–90 cc/min (subcutaneous) to get a
subcision-like effect on retracted acne scars
and hard scars.
Punctures inside the scar
Number of sessions: four to six
Deeper injections are more painful for patients
with adhesions
If adhesions are suspected: multiple injections in
the deep layers as CO2 does not diffuse well
Technique
Hand movement should target both the subcutaneous
layer and the intradermal layer for depressed scars.
If adhesions are suspected, multiple subcutaneous
injections are required. The dermal plane is usually
injected first and then the needle is pushed further,
into the subcutaneous plane, in a second movement.
For small scars or scars that are not depressed, only
intradermal injections should be necessary.
Injection Points
Directly into the scar.
Endpoints
Erythema (subcutaneous injections); popcorn effect
or fast inflation (intradermal injections).
Post-treatment Care
No post-treatment care is required. If treatment is
to the face, a sun protection cream and a moistu-
rizer are usually provided.
Pain Management
Emla® if too painful (this cream may lower the
Bohr effect, because vasoconstriction may reduce
blood flow); lower flow will reduce pain (but may
reduce efficacy in breaking septae).
Note 1: A few physicians use CDT for the treat-
ment of keloids, applying higher flows (first session
around 50 cc/min, then usually 90–100 cc/min) as
scars are tough. Results are apparently very variable.
We have no personal experience of treating these
scars.
Note 2: Patients with acne and acne scars may
benefit from combined treatments:
v traditional acne drugs and carboxytherapy
v erbium–glass/Nd–YAG laser and CDT (not
during the same session but 15 days apart)
v fractional laser and CDT.
STRETCH MARKS
Refer to Figures 14.21–14.23.
Fig. 14.21 Stretch marks before injection.
168
Aesthetic Oculofacial Rejuvenation

Principle
Improve neovascularization and blood flow (red
color seen via skin transparency will appear pink,
close to the natural skin color), improve melanocyte
pigment production to darken white stretch marks.
Improve collagen synthesis to reduce the wave
appearance of old stretch marks.
Indications
Old white stretch marks, deep depressed stretch
marks, irregular old stretch marks are the main indi-
cations. For young pink/red stretch marks, laser
treatment is preferred: KTP or pulsed dye laser,
one to three sessions, 1 month apart.
Protocol
Combined intradermal and subcutaneous
injections
One session per month
Flow: 80–150 cc/min
Puncture inside the mark
Number of sessions: four to ten
Technique
It is preferable to start injecting the dermis and
when done push the needle further to inject the
subcutaneous layers. This appears to be the easiest
approach.
Endpoints
Popcorn appearance (inflated stretch marks) for
1 or 2 minutes then erythema.
Injection Points
Follow each stretch mark and inject each 1–2 cm.
Post-treatment Care
No post injection care is required. Sun protection is
advisable.
Pain Management
Injecting stretch marks is often painful. Patients
describe a burning sensation. Although flow greater
than 100 cc/min is recommended, it is sometimes
impossible to maintain these values because of the
pain. Lowering flows to 70–80 cc/min may make
the patient more comfortable.
EYE PROCEDURES
Principle
Increase blood flow, stimulate collagen production,
reduce fatty prolapse in some cases (lipolytic effect).
Indications
Fatty prolapse, eye wrinkles, under-eye dark circles.
Protocol
Eye wrinkles
Combined intradermal and subcutaneous
injections
One session per month
Fig. 14.22 Stretch marks 3 minutes post injection:
intradermal: 150 cc/min.
Fig. 14.23 Stretch marks 1 month after three sessions.
169
Carbon Dioxide Therapy: Face and Body Rejuvenation

Flow: 20–40 cc/min
Four to five punctures around the lower orbit
bones
Number of sessions: three to six
Under-eye dark circles
Intradermal injections
One session per month
Flow: 20–40 cc/min
Four to five punctures around the lower orbit
bones
Number of sessions: three to six
Fatty prolapse (see Fig. 14.24)
Subcutaneous and intradermal injections
(Fig. 14.25)
One session per month
Flow: 20–40 cc/min
Puncture in the fatty area
Number of sessions: three to six
Technique
Very few injections are required to treat the eye.
For eye wrinkles and fatty prolapse both intrader-
mal and subcutaneous injections can be used. The
needle’s angle is less than 15. Under-eye dark
circles will require superficial dermis intradermal
injections.
Injection Points
Refer to Figure 14.26. Fatty prolapse will receive
two to four quick punctures in the area where the
fat resides. Eye wrinkles and dark circles require
from four to six punctures, 1 or 2 cm spaced, 1 or
2 seconds each, made all along the external inferior
border of the eye orbit, next to the orbit bones
(zygomatic bone) (Fig. 14.27). The free hand may
Fig. 14.24 Eye treatment follows the bone’s border.
Fig. 14.25 After one session at 40 cc/min: subcutaneous
and intradermal injection.
Fig. 14.26 CDT rejuvenation of the eye: injection points.
Fig. 14.27 Before carboxytherapy treatment.
170
Aesthetic Oculofacial Rejuvenation

be used to gently maintain the patient’s head in
position that avoids any unwanted movement.
Endpoints
Eye lid becomes distended and inflated. Upper eye
lid distention may be important (Fig. 14.28). Fatty
prolapses are inflated and red. The eye returns to
normal appearance within 2 or 3 minutes.
Post-treatment Care
No post-treatment care is required. Sun protection
is advisable.
Pain Management
Emla® if treatment is too painful (this cream may
lower the Bohr effect, because vasoconstriction
may reduce blood flow); lower the flow and
increase the number of punctures to limit pain.
Caution
One of the major CO2 side effects and complica-
tions is pertinent to the eyelid procedure. It is
important to purge and remove any trace of oxy-
gen/air in the tubes and needle. O2 injection into
the eye lid leads to a strong inflammatory reaction
which lasts 4 or 5 days, with redness, edema, closed
eye and pain.
CDT Rejuvenation
See Figures 14.29–14.31.
Fig. 14.29 CDT rejuvenation of the eye: 1 year before CDT.
Fig. 14.30 CDT rejuvenation of the eye: after one session.
Fig. 14.28 End point after injection.
Fig. 14.31 CDT rejuvenation of the eye: after two sessions.
171
Carbon Dioxide Therapy: Face and Body Rejuvenation

NASOGENIAN FOLDS, PERI-ORAL
WRINKLES AND CROW’S FEET LINES
Refer to Figure 14.32. Nasogenian folds and peri-
oral wrinkles may be improved with carboxytherapy
too. Unlike fillers or Botox®, CO2 should be
injected close to the wrinkle line but not into the
line or the walls. Injecting into the walls may pro-
duce a deeper wrinkle.
Principle
Stimulate the synthesis of collagen.
Indication
Thin to mild wrinkles.
Protocol
Nasogenian folds
Intradermal injections
One session per month
Flow 20–40 cc/min
Punctures each 1 or 2 cm all along the nasogenian
fold (do not inject into the wrinkle or onto
its walls)
Number of sessions: three to six
Peri-oral wrinkles
Intradermal injections
One session per month
Flow at 20 cc/min. (These injections are usually
painful and may require numbing cream).
Punctures should be near the wrinkles (do not
inject into the wrinkle or onto its walls).
Punctures spaced 1 or 2 cm apart.
Number of sessions: three to six
Emla® is almost always required because this
treatment is painful.
Post-treatment Care
None required.
Pain Management
Peri-oral wrinkle injections are painful. Multiple
punctures with a low flow may lower the pain level.
Emla® may be necessary. Avoid cold chillers as they
give a vasoconstriction effect limiting the effect of
the CO2. Emla® may also cause a vasoconstriction
and therefore a limited Bohr effect.
HANDS, NECK AND DE´COLLETAGE
REJUVENATION
Principle
This rejuvenation procedure aims to stimulate colla-
gen synthesis and skin elasticity.
Indication
Neck skin laxity, neck laces, neck wrinkles, hand
rejuvenation, de´colletage skin laxity (lentigo and
other pigmented lesions are not good indications
for CDT).
Protocol
Intradermal injections
One session per month
Flow at 80 cc/min
Punctures spaced 1 or 2 cm until the full surface
is covered.
Number of sessions: three to six sessions
Technique and Injection Points
Refer to Figures 14.33–14.35.
Under eye dark circles
• 20–40 cc/min superficial dermis
• 4 to 5 punctures
• 4–6 sessions each month
Neck and décolleté
• 80 cc/min intradermal
• 2 cm spaced punctures
• 4–6 sessions each month
Nasogenian/peri-oral
• 20–40 cc/min intradermal
next to the wrinkles
• 4–6 sessions each month
Eye wrinkles
• 20–40 cc/min intradermal
• 3 to 5 punctures
• 4–6 sessions each month
Fig. 14.32 Strategy to rejuvenate the face with CDT.
172
Aesthetic Oculofacial Rejuvenation

Neck: cover the full surface with punctures
1–2 cm apart
Hands: cover the full surface with punctures
1–2 cm apart
De´colletage: cover the full surface with punctures
1–2 cm apart. The needle may be bent to ease the
tangential puncture of the de´colletage.
No overlapping should occur. A well-treated area
appears red. Any white disks remaining are untreated
zones, which the operator needs to correct. When
treating the hands, it is necessary to pinch the skin
and pull it so as to avoid nerves or blood vessels when
injecting.
Endpoint
A circle of skin 1–2 mm wide whitens momentarily
when the needle is intradermal. Then, almost immedi-
ately, the skin detaches, remaining detached for 1 or
2 minutes, after which there is redness for 15 minutes.
Post-treatment Care
No post-treatment care is necessary.
Pain Management
If pain is experienced, lower the flow or make
multiple punctures instead of a few.
Hand rejuvenation
• Intradermal injections
• 80 cc/min
• 2 cm spaced
• 1 or 2 sec/puncture
• 8 to 10 punctures per hand
• Dorsal side
Fig. 14.35 CDT rejuvenation of the hands.
Décolleté rejuvenation
• Triangular treatment area
• Intradermal injections
• 80 cc/min
• Punctures spaced
1 to 2 cm
• No overlapping
2 cm
2 cm
Fig. 14.34 CDT rejuvenation of the de´ colletage.
Platysmal Botox®
can help
Danger
area
Danger area
thyroid isthmus
(superficial)
Neck rejuvenation
Danger! Stay intradermal
• Intradermal
• 2 cm spaced punctures
• No overlapping
• 80 cc/min
• 1 or 2 sec/puncture
2 cm
2 cm
Fig. 14.33 CDT injection points for neck rejuvenation.
173
Carbon Dioxide Therapy: Face and Body Rejuvenation

OPTIMIZING OUTCOMES
Avoid cold compresses or topical gel application
since it could compromise vasodilation and the Bohr
effect.
Localized Fat Procedure
Sessions should be frequent: up to five per week, if
the patient can tolerate this many. It is medically
acceptable.
Manual massage during injections to lower pain
and optimize CO2 diffusion.
Combine with Endermology®, Velasmooth®,
Velashape®, Lipotron® or any RF device
available.
Rejuvenation
Combine with amino-acid mesotherapy or mesolift.
Combine with lasers and injectables (not in the
same session). Wait at least 15 days until the skin
recovers from the initial trauma.
Maximizing Results After a CDT Session
Do not use cold compresses or cold gel to lower
pain as this leads to vasoconstriction that lowers
the effect of CDT.
Advise patients not to take too long, hot baths or
saunas, or to take part in active sports in the hours
following CDT.
Massage during injection or immediately after
puncture may improve gas diffusion and lower the
number of punctures necessary. During subcutane-
ous injection this is a good way to lower the sensation
of pain. An efficient massage lowers ‘under-skin
pressure’ during injection. One useful technique is
a ‘piano’ CDT massage, the four fingers of a hand
pressing alternately, in the manner in which a pianist
would play the A, B, C and D keys (Fig. 14.36).
A Cellu-M6® session, between CDT sessions or
immediately after a CO2 injection, is known to
optimize results. Endermology® is also a non-surgical
approach that increases circulation, optimizing natu-
ral lipolysis. We assume CO2 and Endermology® to
have a synergistic effect.
A
B
C
D
Fig. 14.36 The piano technique to lower pressure and decrease pain.
174
Aesthetic Oculofacial Rejuvenation

Some authors are experimenting with combined
treatments including:
v CDT and monopolar or bipolar RF
v CDT and lipolysis laser
v CDT and remodeling laser
v CDT and mesotherapy.
These studies have yet to be published, however.
Combination therapy is likely to offer significant
improvements over single treatments.
Note: CDT is often used after liposuction. Where
compartmentalization occurs, CO2 will not diffuse
well and it will be necessary to make multiple
punctures.
COMPLICATIONS AND SIDE EFFECTS
Vagal Reaction, Vaso-vagal Syndrome
and Syncope
Vagal reactions may be seen in any procedure with the
use of needles and though rare may lead to syncope.
The occurrence can probably be limited with good
patient education and patients can be assured of the
low morbidity of the treatment. It may not be a good
idea to perform CDT immediately after a meal.
A vagal reaction can be dealt with in the same
way as with any other emergency. A scope is a plus
but blood pressure can be monitored manually and
heart frequency checked. Depending on the level
of the incident, the legs can be raised to move blood
into the general circulation system. Atropin 0.25 mg
subcutaneous may be used in severe vagal reactions.
Heavy Arm, Limbs and a Sensation
of Anesthesia
A majority of patients report a sensation of anesthe-
sia below the injection area (distal anesthesia). In
most cases this sensation occurs in the lower limbs
and arms. It seems to be more frequent in arm pro-
cedures (cellulite, skin laxity and localized fat pro-
cedures). Patients often report a ‘dead hand’. This
sensation is short and lasts around 2 to 3 minutes
maximum.
Heart or Respiratory Disease Unmasking
Because of blood flow increase and the modification
of gas exchange in the body, CDT might unmask an
unstable respiratory system or heart disease, although
this is rare. Precautions should be taken and CDT
procedures should be avoided for patients with severe
heart pathologies or respiratory insufficiency.
Epilepsy Triggering
There is very little information concerning CDT and
epilepsy. One article mentions the possibility but
with no clear explanation. It is not illogical to think
that a temporary hypoxemia may lead to a crisis.
Further studies are necessary.
Infection
Infection is most likely to be caused by poor skin dis-
infection measures. CDT is similar to mesotherapy,
sharing the same low level of risk. Disinfection of
the skin 1 or 2 minutes before injection is required.
It can be performed with alcohol or quaternary
ammonium, for instance, and a compress tissue.
Protocol for Disinfection
Hand wash with liquid soap and hydro-alcoholic
solution between each patient. If no handwash is
available, the minimum is hydroalcoholic handwash.
The operator should wear non-sterile hypoallergenic
gloves and these should be changed between
patients.
Skin disinfection with a compress and alcohol 70%
or quaternary ammonium at least 1 minute
before injection. Skin is cleaned in centrifugal
circles.
Leave 1 minute for the disinfectant to dry. During
this time, the operator may prepare needles,
apply machine settings and so on.
Care should be taken with periocular disinfection
since alcohol fumes may burn the cornea and
conjunctiva. Eyes should be kept closed until the
disinfectant evaporates from the skin.
Herpes Simplex Reactivation
Herpes simplex can be reactivated because of the
trauma to the skin. As with laser procedures, if
there is previous history a prophylactic treatment
with an antiviral drug a few days prior to the session
is recommended, maintained for 5 days after the
session. This pre-treatment is efficient in lowering
the risk of triggering.
Bruises and Bleeding
Patients with a history of bleeding should be treated
carefully. Bleeding and bruises are found in 20% of
patients, including those with no known history.
Anticoagulatory drugs, aspirin and antiinflammatory
drugs may also increase the risk.
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Carbon Dioxide Therapy: Face and Body Rejuvenation

Lower Lid Wound or Tear due to Movement
During Injections
Injecting the eye area with CO2 has the same risk
level as doing so with fillers or Botox. Some patients
may be nervous and might move their heads by acci-
dent or because of pain. A fast and unwanted move-
ment while the needle is in the dermis may lead to a
trauma and/or bleeding. Immobilizing the patient’s
head with the free hand can prevent the patient
from moving too much.
Corneal or Conjunctival Wound
During Injection
Eyelid injection points are usually far from the cor-
nea and therefore puncture of the cornea is rare.
Usually it is due to an unwanted movement by the
physician or the patient. The head of the patient
should be gently immobilized.
Persistent Eyelid Insufflation (Oxygen/Air
Injected by Accident)
Refer to Figure 14.37. It is extremely important to
properly purge the needle line/tubing before making
any injection into the eyelids. Only CO2 should be
injected. Oxygen or air injected by accident lead
to major inflammation, sometimes preventing the
patient from opening the eye. They experience major
lid edema and erythema. This reaction lasts approxi-
mately 3–5 days, but the healing process may be
shortened using antiinflammatory drugs or ice-packs.
Pain (Puncture of a Local Terminal Nerve)
Pain is frequently reported by patients during CDT
sessions. Some procedures may be painful while
some others are well tolerated.
Types of pain in CDT include:
v sensation of burn during the injection
v sensation of too much compressive pressure.
It is important to let patients understand the
difference between pain and gas spreading feelings,
which are:
v sensation of water spreading below the skin
v sensation of insects creeping below the skin.
Flow Rates and Pain
Logically, the higher the flow the higher the pain
risk. This is certainly true in the treatment of loca-
lized fat, especially during the first sessions when
the skin is not used to gas diffusion. It may be nec-
essary to start with lower flow values and increase
them from session to session. The operator nor-
mally stops and changes the point of injection when
the patient reports pain. The flow is lowered by
20–30% if the patient remains uncomfortable.
Note that some machines have an automatic mode.
This mode can begin the injection with a very low
flow and increase it progressively up to the optimal
level, leaving time for the skin to adapt.
It is also known that injecting around the periphery
of fat is more painful than injecting in the center,
especially in the thighs (external and internal sides).
The experience of pain during stretch mark pro-
cedures is known to be very sensitive to flow para-
meters. A normal 120–100 cc/min flow may be
uncomfortable for some patients, with a significant
burning sensation. Lowering the flow value to under
90 cc/min solves the problem.
For facial wrinkles, pain may also be related to
flow values. The strategy is to reduce the flow rate
until pain is no longer experienced, before making
further injections.
Skin Layers and Pain
Experience shows that subcutaneous injections are
less painful than intradermal injections. The depth of
subcutaneous injections does not seem to make a dif-
ference to pain levels. Superficial subcutaneous injec-
tions give visual control on how far the gas is diffusing.
Procedures and Pain
Some procedures are more painful than others.
A listing by level of pain is given in Figure 14.38.
A true evaluation of pain with using the Visual
Analogic Pain scale is currently being developed by
the authors.
Fig. 14.37 Complications caused by oxygen injection
during a CDT session.
176
Aesthetic Oculofacial Rejuvenation

Injection Areas and Pain
Patients may experience different levels of pain for
a given procedure, depending on the area treated.
Flow values may be lowered and/or the number of
injections increased.
v Localized fat: abdomen is usually painless.
Internal sides of thighs are usually more painful
than external sides. Peripheral injections of fat
area are usually more painful than in the center.
Lower ends of thighs and arms are usually more
painful than the proximal ends.
v Cellulite: pain levels are similar to localized fat.
v Stretch marks: although having a high level of
patient satisfaction, CDT for stretch marks is
almost always painful with a sensation of burning.
Intradermal injection with very high flow over
100 cc/min is used. Upper parts of the abdomen
are less sensitive than lower parts and pubis.
Concerning the thighs, the internal areas are
more painful than the external ones. Treatment
of marks on chests and arms are usually tolerated
with a low level of pain by most patients.
v Wrinkles: facial wrinkles are usually treated with
gentle flows (20–40 cc/min) and therefore with
low pain levels reported. Anesthesia is rarely
used for face and eye rejuvenation exception for
peri-oral wrinkles, for which the level of pain is
extremely high. We use Emla® or an equivalent
(one application 1 hour before treatment, a
second application 30 minutes before treatment).
v Ulcers: arterial and venous ulcers, although
treated with extremely low flows (20–40 cc/min)
are known to be very painful. The onset of pain is
the endpoint.
Lowering Pain
Cold packs and pulsed cryogenic sprays are very
good for lowering pain during laser sessions but
they may lead to vasoconstriction. Vasoconstriction
increases distal vascular resistance leading to a
slower blood flow, which is the opposite of the
effect sought. It is then illogical on one hand to opti-
mize blood flow with CDT and, on the other hand,
to reduce it with cryogen anesthesia.
Use of Emla® cream should be limited as much
as possible, since it may give vasoactive effects in
the superficial layers of the skin.
Accidental Thyroid Puncture (in Neck
Rejuvenation)
CDT is a technique with low risks. However, there is
an area where the procedure should be undertaken
with extreme care: the thyroid isthmus zone. Women
with long thin necks have a very superficial isthmus,
which could be injured if the needle goes deeper
than the dermal plane. To avoid such accidents, it is
necessary for the needle to remain intradermal.
Accidental Fragmentation of the Needle
Below the Skin
This is extremely rare, most incidences occurring
with intra-muscular injections.
Increased Telangiectasias or Rosacea
Telangiectasia and rosacea are capillary disorders
caused by a permanently high blood flow. Using
CDT on skin with signs of hyper-vascularization is
not a good indication as it can worsen the disease.
Sensation of Warmth in the Injected Area
This sensation is the most commonly reported
complication of CDT. Any CO2 injection will lead
to vasodilatation and blood flow increase. When
these reactions occur, the patient feels warmth.
This feeling is generally reported between the first
few
minutes
and
1
hour
after
the
start
of
treatment.
CONCLUSIONS
CDT is an old French technique for treatment of
vascular diseases. It has found new application in
the
rejuvenation
and
anti-aging
market
with
Pain level
Localized fat
Localized fat abdomen (subcutaneous)
Localized fat lower limbs (subcutaneous)
Localized fat arms (subcutaneous) and skin laxity arms
(mix subcutaneous, intradermal)
Localized fat submentonian area (subcutaneous)
Face rejuvenation
Décolleté (intradermal)
Eye lids and fat bag (intradermal)
Neck (intradermal)
Perioral wrinkles (needs Emla because of pain)
Stretch marks
Abdominal stretch marks
Thighs external side
Thighs internal side
Fig. 14.38 Listing of pain levels.
177
Carbon Dioxide Therapy: Face and Body Rejuvenation

interesting results, especially for face rejuvenation
around the eye and stretch marks. It is a simple
technique to learn, with very few known side
effects, all of which are well controlled.
The procedures involved in CDT are simple and
easy to implement in a medical practice, either sur-
gical or clinical, due to its many clinical applications.
In most countries, a nurse can legally make CO2
treatment under a physician’s supervision.
Among aesthetic CDT procedures, some are
more popular than the others because they are easy
to perform, with quick results in a few sessions, and
within a reasonable patient budget, for example:
v stretch marks
v scar revision
v eyelid rejuvenation.
Although often used on their own for aesthetic
purposes, we believe that CDT should be used
more often as part of combination therapies with,
for example, fillers, Botox®, lasers, peeling, surgery,
radiofrequency treatment and mesotherapy.
While this chapter has been based around our
own work with CO2 in rejuvenation indications,
CDT is also used by South American and Central
European doctors for reconstructive purposes with
promising results.
REFERENCES
1
Tavares Ferreira JC, Haddad A, Navarro Tavares SA. Increase in
collagen turnover induced by intradermal injection of carbon
dioxide in rats. J Drugs Dermatol. 2008;7(3):201–206.
2
Brandi C, D’Aniello C, Grimaldi L, et al. Carbon dioxide therapy in
the treatment of localized adiposities: clinical study and histopatho-
logical correlations. Aesthetic Plast Surg. 2001;25(3):170–174.
3
Komoto Y, Nakao T, Sunakawa M, et al. Elevation of tissue pO2
with improvement of tissue perfusion by topically applied CO2.
Adv Exp Med Biol. 1985;222:637–645.
4
Savin E, Bailliart O, Bonnin P, et al. Vasomotor effects of transcu-
taneous CO2 in stage II peripheral occlusive arterial disease.
Angiology. 1995;46:785–791.
5
Cadic P. Carboxytherapy. Available:
com; 6 March 2009.
6
Cadic P, Cantisano-Zilkha M. CO2 insufflation for stretch marks
– revamping an ancillary technique. 29th Annual Meeting of
the International Society for Dermatologic Surgery, October
2–5, 2008, Las Vegas/USA. Available:
com/watch?v=DID4EwXsEY4&feature=channel_page31; March
2009 and
pdf31; March 2009.
178
Aesthetic Oculofacial Rejuvenation

Cosmetic Dentistry of the
Perioral Area — The Odontological
Point of View
Luiz Gustavo Nascimento de Melo,
Marcelo Pereira Nunes, Marcelo Wolff Fernandes,
Luciane Magalha˜es Antonini, Maria Beatriz RG de Oliveira
INTRODUCTION
‘The complete dental solution is a holistic approach
that recognizes as a significant factor the psychologi-
cal well-being of the patient and provides a healthy
appearance as well as functional restoration. Aes-
thetics is an inseparable part of today’s dental treat-
ment.’1 From a purely cosmetic standpoint, the
value of the appearance of one’s teeth has taken on
a greater importance in our society. The public places
an increasing priority on a healthy and attractive
smile. The dental profession’s traditional domain,
centered around the eradication of disease, now finds
itself on the threshold of uncharted territory: the
enhancement of appearance. Yet, foundations of
health, proper function, and sound scientific princi-
ples with consistency of results, reliability of treat-
ment modalities and long-term prognosis also must
prevail.2
The essentials of an aesthetic smile involve the
relationships between the teeth, the lip framework
and the gingival scaffold.3
THE LIPS
Garber and Salama3 stated that the lips form the
frame of a smile and, as such, define the aesthetic
zone. Liplines have classically been defined as
being high, medium or low. In the typical low
lipline, only a portion of the teeth is exposed
below the inferior border of the upper lip. The
high lipline shows a large expanse of gingiva
extending from the inferior border of the upper
lip to the free gingival margin. The medium lipline
shows a nominal exposure of 1–3 mm of gingiva
from the most apical extent of the free gingival
margin to the inferior border of the upper lip.
Thus, the teeth in their entirety are on display, as
well as the interdental gingival tissue and the
border of free gingiva around the cervical area of
the tooth (Fig. 15.1).
THE GINGIVAL CONTOUR
An irregular gingival arrangement, despite being
healthy, may strike a discordant note, and it may
become desirable to establish a certain harmony
and continuity of form to the gingival margin.3
One significant feature of gingival morphology is
the gingival line, which is defined as a line joining
the tangents of the gingival zeniths of the central
incisor and canine. The gingival zenith is the most
apical aspect of the free gingival margin.4 It is com-
monly accepted that the gingival zenith of the two
central incisors should be at the same level. The gin-
gival zenith of the lateral incisors, however, should
be slightly above (coronally) the central incisor’s
zenith (<1 mm). The canines, in turn, would have
the free gingival margin at the same level of the cen-
tral incisors and matching one another (Fig. 15.2,A).
Extending distally, the tissues on the premolars
would be somewhat coronally positioned.5 How-
ever, a recent study5 observed, on analyzing maxil-
lary casts of 103 young adults, that the gingival
zenith is, in fact, apical to the gingival zenith of
the incisors, and the gingival zenith of the lateral
incisors is below (81.1%) or on (15%) the gingival
line when the head is oriented in the axis orbital
plane. Periodontic plastic procedures, such as the
basic gingivectomy, soft tissue grafting or the api-
cally positioned flap, may be used to change the sil-
houette form of teeth and their relative proportion.
15

THE TEETH
The dentist is concerned with the color, position
and shape or silhouette form of teeth. The advent
of adhesive dentistry has allowed a literally instanta-
neous change in the color, shape and position of
teeth via bonding techniques such as porcelain-
laminated veneers and direct composite bonding.3
It is possible to establish the appropriate height of
the six maxillary anterior teeth, changing the aspect
ratio of teeth for an improved aesthetic appearance.
The tooth’s aspect ratio, or height-to-width con-
tour, for the six maxillary anterior teeth is generally
considered to be optimal when the tooth is 75% as
wide as it is tall6 (Fig. 15.2,B).
GEOMETRIC PARAMETERS OF HARMONY
Elements of the aesthetically pleasing, well-balanced
smile have been extensively reviewed.3,6–8 It is com-
monly accepted that the maxillary anterior teeth
should be completely displayed during a full smile,
with a maximum of 3 mm of gingiva revealed above
the
central
incisors.
According
to
Garber
and
Salama,3 within the confines of the lipline, the
remaining two components of the smile, the gingival
scaffold and teeth, need to be arranged in such a
way as to develop a certain continuity of form, har-
mony and balance. Classically, the level of the gingival
margins of the maxillary teeth parallels the form of
the upper lip. The incisal edges of these maxillary
teeth tend to follow the form of the lower lip. In a
transverse dimension, the teeth should extend pro-
gressively posteriorly and laterally to fill the vestibule,
extending to the corners of the smile (Fig. 15.3).
Continuity of linear horizontal form between the
gingival expanse, the teeth and the upper lip is criti-
cal. Any asymmetry in this parallelism disturbs the
sense of balance in the composition, disturbing the
flow, and results in an unaesthetic smile.3 By this
definition, a high lipline in itself may not be unaes-
thetic if these basic rules are followed. However, in
today’s mass media-influenced culture, many people
consider even the slightest excessive display of gin-
gival tissue, the ‘gummy smile,’ unattractive.3 The
A
B
C
Fig. 15.1 A, Low lipline, B, medium lipline, C, high lipline.
A
B
Fig. 15.2 A, The aesthetic gingival
contour: 1, midline of the teeth;
2, gingival zenith; 3, gingival line.
B, The tooth ideal height-to-width
contour.
1
2
3
4
5
Fig. 15.3 Smile with various components in harmony. The
gingival line (3) is in proximity with the inferior border of the
upper lip. The line joining the zeniths of the six anterior
teeth (2) follows the form of the upper lip (1). The teeth’s
incisal edge line (4) follows the form of the lower lip (5).
180
Aesthetic Oculofacial Rejuvenation

gummy smile or high lipline case with an expanse of
soft tissue can result from two problems: (1) altered
passive eruption and (2) vertical maxillary excess.
ALTERED PASSIVE ERUPTION
In a person with healthy dentition, each tooth and
its alveolus actively emerges from its crypt.9,10 The
teeth continue to erupt through the gingiva until
they make occlusal contact with the teeth in the
opposing arch. This stage is followed by passive erup-
tion or the exposure of the teeth by apical migration
of the gingiva. Altered or delayed passive eruption is
the failure of the gingival tissue to adequately recede
to the proper level to the tooth’s cementoenamel
junction (CEJ). The consequence of this is short
crowns and gingival excess.11 Coslet et al.12 classi-
fied altered passive eruption into two categories for
differential diagnosis and appropriate treatment.
In type I, there is typically an excessive amount
of gingiva, as measured from the free gingival mar-
gin to the mucogingival junction.
In type II, there is a normal dimension of gingiva
when measured from the free gingival margin to the
mucogingival junction. Although these might appear
to be clinically similar in that there is tissue
extended over the coronal portion of the tooth,
therapeutically the diagnosis between the two types
is essential to determine the appropriate treatment
modality.
Type I can further be subdivided on an anatomi-
cal histological basis into subcategories A and B.
This subclassification depends on the relationship
of the osseous crest to the CEJ of the tooth.
In subcategory A, the dimension between the
level of the CEJ and the osseous crest is greater
than 1 mm, which is sufficient for the insertion of
the connective tissue fibrous attachment compo-
nent of the biological width.
In subcategory B, detected by the process of
bone sounding via the sulcus, the osseous crest
occurs in close proximity to the CEJ, thereby
diminishing the space for the insertion of the con-
nective tissue of the biological width.
The term ‘biological width’ refers to a length that
includes:
v the epithelial attachment, known as the
junctional epithelium, which rests on the root’s
cemental surface
v the connective tissue fibers that insert on the
root’s cemental surface and which are located
below the junctional epithelium.13
Based on necropsy studies conducted by Gargiulo
et al.,14 the average dimensions of the biological width
were considered to be approximately 2.7 mm: about
1 mm for the junctional epithelium, 1 mm for the
connective tissue attachment and 1 mm for the sul-
cus. In clinical practice, the authors have found this
to be a more varied dimension, often exceeding the
3 mm average.
VERTICAL MAXILLARY EXCESS
According to Garber and Salama,3 the gummy smile
frequently results from a skeletal dysplasia such as a
hyperplastic growth of the maxillary skeletal base.
This results in the teeth being positioned farther
away from the skeletal maxillary base and a display
of gingiva below the inferior border of the upper lip.
Diagnosis in the high lipline case involving a verti-
cal maxillary excess requires ruling out the case due
to a superimposition of altered passive eruption in
combination with maxillary hyperplasia. Garber and
Salama proposed a classification for vertical maxillary
excess.3 The classification was developed to help
determine the most appropriate treatment modality.
The diagnosis relative to the degree of severity is pre-
dicted on first treating the altered gingival display
(removing the altered passive eruption component)
to develop a normal tooth form (crown form).
Degrees of severity I (2–4 mm of remaining gingival
display), II (4–8 mm of remaining gingival display)
and III (more than 8 mm of remaining gingival dis-
play) are then determined by the amount of gingival
display. The treatment modalities range from ortho-
dontic intrusion alone through complex treatments
involving orthognathic surgery, orthodontics, restor-
ative components and periodontal plastic procedures.
TREATMENTS FOR ALTERED PASSIVE
ERUPTION AND VERTICAL MAXILLARY
EXCESS: INDICATIONS AND
CONTRAINDICATIONS
Treatment of Type I A
Altered Passive Eruption
The typical case of altered passive eruption type I A
exhibits short, square-looking teeth and an expanse
of gingiva below the inferior border of the upper
lip. A gingivectomy using scalpel, electrosurgery or
carbon dioxide laser is indicated and will readily
remove this tissue. This procedure will result in a
revised silhouette form for the tooth that is more
181
Cosmetic Dentistry of the Perioral Area — The Odontological Point of View

elliptical and attractive, and will resolve the unwar-
ranted excessive display of gingiva apparent during
smiling3 (Table 15.1). When the amount of attached
gingiva is normal or minimum (¼ 1.5–2.0 mm of
attached gingiva), gingivectomy is contraindicated.
Treatment of Type I B Altered
Passive Eruption
The clinical appearance of Type I B altered is similar
to type I A altered passive eruption, with an exces-
sive amount of gingiva from the free gingival margin
to the mucogingival junction readily shown during
smiling. On bone sounding via the sulcus, however,
it would appear that the osseous crest is at the same
level as the CEJ. This would seem to be contrary to
the concept of the biological width, as the connective
tissue fibrous attachment cannot insert into the
enamel and yet must be present. The proximity of
the osseous crest to the CEJ requires surgical reloca-
tion of the soft tissue apically via reduction of the
osseous crest to allow for insertion of these fibers in
a more coronal position, followed by a concomitant
apical positioning of the junctional epithelium and
the sulcus. This ultimately results in the free gingival
margin being positioned right at the CEJ.3 When the
amount of attached gingiva is normal or minimum
(¼ 1.5–2.0 mm of attached gingiva), gingivectomy is
contraindicated (Table 15.1).
Treatment of Vertical Maxillary Excess
The combined case (altered passive eruption with ver-
tical maxillary excess) requires for optimal treatment
a multidisciplinary approach to treatment planning
involving an orthodontist, a periodontist, an ortho-
gnathic surgeon and a restorative dentist. Orthog-
nathic surgery for gummy smile treatment has been
described previously.15,16 Clinical examination and
radiographic interpretation of cephalograms generally
permit the clinician to correctly diagnose vertical
maxillary excess. Dolt and Robbins17 recommended
that, if the clinical crowns of the teeth are short as
a result of altered passive eruption, clinical crown
lengthening should be performed before orthognathic
surgery. However, Garber and Salama3 have sug-
gested a two-phase approach: initial gingival surgery
before the orthognathic procedure (to create an
attractive silhouette form for the teeth developing
normal anatomical form and give the surgeon a defin-
itive guideline as to the potential lip-to-tooth relation-
ships and the amount of impaction necessary), with a
second possible alteration of gingival display following
orthognathic surgery (Table 15.1).
Table 15.1
Treatments for altered passive eruption and vertical maxilary excess: indications and
contraindications
Condition
Indications
Contraindications
Altered passive eruption type I A
(>1.5–2.0 mm of attached gingiva)
Gingivectomy
Osseous resection
Altered passive eruption type I B
(> 1.5–2.0 mm of attached gingiva)
Gingivectomy
Apically positioned flap with osseous resection
–
Altered passive eruption type II A
( 1.5–2.0 mm of attached gingiva)
Apically positioned flap with osseous resection
Gingivectomy
Altered passive eruption type II B
( 1.5–2.0 mm of attached gingiva)
Apically positioned flap with osseous resection
Gingivectomy
Vertical maxillary excess – degree 1
Orthodontics
Orthodontics and periodontics
Periodontics
Periodontics and restorative dentistry
Lip repositioning
Orthognathic surgery
Vertical maxillary excess – degree 2
Periodontics and restorative dentistry
Orthognathic surgery
Lip repositioning
–
Vertical maxillary excess – degree 3
Orthognathic surgery plus
Periodontics and restorative dentistry where necessary
Lip repositioning
Adapted from reference 3
182
Aesthetic Oculofacial Rejuvenation

As orthognathic surgery is frequently associated
with significant morbidity and requires hospitaliza-
tion, an alternative method, called lip repositioning,
has been recently recommended for vertical maxillary
excess treatment.18 The lip-repositioning technique
is accomplished by removing a strip of mucosa from
the maxillary buccal vestibule, then suturing the
lip mucosa to the mucogingival line. This results in
a narrower vestibule and restricted muscle pull,
thereby reducing gingival display during smiling.18
CASE 1 – PREOPERATIVE HISTORY
AND CONSIDERATIONS
A 26-year-old female patient was referred from the
Division of Esthetic Dentistry of SchoolofProfessional
Improvement (EAPGOIA´S) with a complaint of an
excessive gingival display. The preoperative view of
the smile showed an excessive display of gingiva and a
significant alteration of the basic shape of the teeth
(Fig. 15.4). They appeared to be short and squat, mean-
ing that the vertical dimension appears too short com-
pared with the horizontal dimension. After clinical and
radiographic examination, a diagnosis of altered passive
eruption was determined (Fig. 15.5). Her treatment
goal was to minimize gingival display in her smile.
The treatment plan for this patient included the aes-
thetic anterior teeth crownlengthening associated with
the lip-repositioning technique to reduce the amount
of gingival display and raise the height of the anterior
teeth, along with raising the incisal length of the inci-
sors, canines and premolars with porcelain-laminated
veneers to follow the contours of the lower lips.
Operative Approach
Mucoperiosteal flap reflection from the buccal
aspect revealed alveolar bone to the level of the
CEJs. Osseous recontouring was performed on the
buccal aspect, from the right first molar to the left
first molar, to locate the alveolar crest 3 mm apical
to the CEJ (Fig. 15.6). This allowed the dentogingi-
val junction to heal with the gingival margin at the
level of the CEJ. A stable, aesthetic result was seen
at 3 months following the crown-lengthening proce-
dure, and the silhouette form of teeth became more
attractive (Fig. 15.7,A). After the crown-lengthening
procedure, the passive eruption component from
the case was removed, leaving only the vertical maxi-
llary excess evident (Fig. 15.7,B). A second surgical
Fig. 15.4 Preoperative smile.
Fig. 15.5 This condition was diagnosed as an altered
passive eruption.
A
B
Fig. 15.6 A, The crestal bone was at the level of the
cementoenamel junctions. B, This was subsequently
recontoured to permit healing of the dentogingival junction
with an optimum display of the clinical crowns.
183
Cosmetic Dentistry of the Perioral Area — The Odontological Point of View

procedure was therefore proposed to minimize the
residual excessive gingival display.
The technique proposed was the ‘lip-repositioning’
related by Rosenblatt and Simon.18 Local anesthetic
(mepivacaine 2% with epinephrine, 1:1 000 000)
was administered in the vestibular mucosa and lip
from maxillary right to left first molar. A partial-
thickness incision was made at the mucogingival junc-
tion from the mesial line angle of the first molar to the
mesial line angle of the left first molar. A second
partial-thickness incision, parallel to the first, was
made in the labial mucosa, 10–12 mm apical to the
mucogingival junction (Fig. 15.8). The incisions were
connected at each first molar, creating an elliptical
outline. The epithelium was removed within the out-
line of the incisions, leaving the underlying connective
tissue exposed (Fig. 15.9). The parallel incision lines
were approximated with interrupted stabilization
sutures (Vycril 6.0) at the midline and other locations
along the borders of the incision to ensure proper
A
B
Fig. 15.7 A, A stable, aesthetic result is seen intraorally, 3 months following the crown-lengthening procedure.
B, A residual excessive gingival display is still evident extraorally after the crown-lengthening procedure.
A
B
Fig. 15.8 A, First partial thickness incision made at the mucogingival junction. B, A second partial thickness incision.
A
B
Fig. 15.9 A, The epithelial layer is removed. B, A partial-thickness flap exposes the underlying connective tissue.
184
Aesthetic Oculofacial Rejuvenation

alignment of the lip midline with the midline of the
teeth. Then, a continuous interlocking suture was
used to approximate both flap ends (Fig. 15.10).
Sutures were removed 2 weeks later. A follow-up
examination 2 months later showed a reduction in
the patient’s excessive gingival display (Fig. 15.11).
The laminated porcelain veneers were placed 6 weeks
after the aesthetic crown lengthening.19 An image of
the patient’s smile line at the placement of the
veneers demonstrates that the contours of the gingival
margins, and the length and incisal plane of the teeth
are closer to ideal (Fig. 15.12).
Optimizing Outcomes
In aesthetic crown lengthening, neither palatal nor
interdental soft tissue should be reflected to ensure
maintenance of interdental papillae.
Complications and Side Effects
In the lip-repositioning technique, during the epi-
thelium removal, care must be taken to avoid dam-
age to any minor salivary glands in the submucosa.
Postoperative Care
The suture line healed in the form of a scar that was
not apparent when the patient smiled because it
was concealed in the upper lip mucosa. A follow-
up examination 2 months later showed a reduction
in the patient’s excessive gingival display (Fig. 15.11).
CASE 2 – PREOPERATIVE HISTORY
AND CONSIDERATIONS
A 25-year-old female patient was referred from
EAPGOIA´S with a complaint of a ‘gummy smile’
(Fig. 15.13). However, during the clinical examina-
tion, a hypertrophied, broad, thick labial frenum
A
B
Fig. 15.10 A, Initial interrupted suture at the midline is applied to stabilize the desired line of closure. B, The wound is
sutured continuously.
Fig. 15.11 Postoperative smile.
Fig. 15.12 Smile after 6 weeks with porcelain veneers
laminated.
Fig. 15.13 Preoperative smile.
185
Cosmetic Dentistry of the Perioral Area — The Odontological Point of View

was also observed (Fig. 15.14). Her treatment goal
was to minimize excessive gingival display in her
smile. The treatment plan for this patient included
aesthetic
anterior
teeth
crown
lengthening
to
reduce the amount of gingival display and raising
the anterior teeth, along with raising the incisal
length of the incisors, canines and premolars with
resin composite.
Operative Approach
A modern technique of frenectomy was planned
considering the patient’s concern for aesthetics and
the wide, thick hypertrophied frenum with abnor-
mal attachment, which can leave a wide defect after
excision by traditional techniques, leading to scar
formation.
The maxillary anterior region was anesthetized
(mepivacaine 2% with epinephrine, 1:1 000 000),
by local infiltration on the buccal and palatal aspects.
The frenum
was
immobilized
with
a
pair
of
hemostats. A V-shaped oblique partial incision was
placed at the gingival base of the frenal attachment
with an external bevel. Fibrous tissue attached to
the lip was dissected with scissors, and undermining
of the labial mucosa was done. In association with
frenectomy and for an improved surgical and cos-
metic result, a triangular-shaped gingival graft, har-
vested from palate, was sutured in place (Fig. 15.15).
In
addition,
an
aesthetic
crown-lengthening
including the molars to reduce the amount of gingival
display was proposed. To accomplish this, the initial
surgical incision was mapped out by measuring the
length of the maxillary teeth and using a periodontal
probe to create a bleeding point at the height of
contour before making the incision. After the initial
incision, a second intrasulcular incision was made
and the collar of gingiva was removed (Fig. 15.16).
After a healing period of 30 days, the incisal
length of the incisors, canines and premolars was
raised and widened with resin composite. A stable,
aesthetic result was seen following the cosmetic
A
B
C
Fig. 15.14 A, Preoperative smile, with a hypertrophied, broad, thick labial frenum from the right (B) and from the left (C).
A
B
C
Fig. 15.15 A, Frenum immobilized with a pair of hemostats. B, Partial thickness dissection of fibrous tissue attached
to the lip. C, Triangular-shaped free gingival graft sutured.
186
Aesthetic Oculofacial Rejuvenation

dentistry procedure, and the silhouette form of
teeth became more attractive (Fig. 15.17). After
the crown-lengthening and cosmetic dentistry pro-
cedures, the vertical maxillary excess was still evi-
dent (Fig. 15.18). A lip-repositioning procedure was
therefore proposed to minimize the residual exces-
sive gingival display (Fig. 15.19). A follow-up exami-
nation one month later showed a reduction in the
patient’s excessive gingival display (Fig. 15.20).
Optimizing Outcomes
In aesthetic crown lengthening, during the initial
incision, it is important to observe that the height
of the gingival contour is not a symmetrical arch
Fig. 15.16 Aesthetic crown lengthening performed with
gingivectomy.
A
B
Fig. 15.17 A, Stable aesthetic result following the cosmetic
dentistry with a more attractive silhouette form of teeth.
B, Negative view of the final restorations indicating the
harmony of gingival contour with the correct height and
localization of the central incisor’s zenith.
Fig. 15.18 A residual excessive gingival display is still
evident extraorally after the crown-lengthening procedure.
A
B
C
Fig. 15.19 The lip-repositioning procedure. A, First partial
thickness incision made at the mucogingival junction.
B, A second partial thickness incision. C, Initial interrupted
suture at the midline.
187
Cosmetic Dentistry of the Perioral Area — The Odontological Point of View

on the maxillary central incisors; it actually is at the
distal one-third of the tooth on the incisors and fol-
lows the natural distal inclination of the roots of the
incisors (Fig. 15.17).
Complications and Side Effects
In the lip-repositioning technique, according to
Simon,18 the sutures must be left in for a few months
(using maxon 6/0 sutures) to prevent relapse of the
lip position.
Postoperative Care
The suture line healed in the form of a scar that was
not apparent when the patient smiled because it was
concealed in the upper lip mucosa. A follow-up
examination 1 month later showed a reduction in
the patient’s excessive gingival display (Fig. 15.20).
CONCLUSIONS
As the public become increasingly concerned with
looking younger and healthier, aesthetic considera-
tions will become increasingly more relevant in
dental treatment planning. As such, dentists must
define the basic tenets of an aesthetic smile –
extending that vision beyond simply ‘pretty teeth’
to a concept whereby total dentofacial harmony is
developed. Aesthetics is not simply a matter for
restorative dentists; it uses restorative dentistry as
one of the disciplines, but it is about beauty. The
same rules that apply for a denture are, therefore,
pertinent for crown and bridge and/or implants,
and must be applied in all aesthetic endeavors.3
REFERENCES
1 Nowzari H. Aesthetic periodontal therapy: introduction. Period-
ontol 2000. 2001;27:8–28.
2 Morley J. The role of cosmetic dentistry in restoring a youthful
appearance. J Am Dent Assoc. 1999;130:1166–1172.
3 Garber DA, Salama MA. The aesthetic smile: diagnosis and treat-
ment. Periodontol 1996. 2000;11:18–28.
4 Charruel S, Perez C, Foti B, Camps J, Monnet-Corti V. Gingival
contour assessment: clinical parameters useful for esthetic diagno-
sis and treatment. J Periodontol. 2008;79(5):795–801.
5 Allen EP. Use of mucogingival surgical procedures to enhance
esthetics. Dent Clin North Am. 1988;32(2):307–330.
6 Chiche GJ, Pinault A. Esthetics of Anterior-Fixed Prosthodontics.
Chicago: Quintessence Publishing Company, Inc; 1994.
7 Cohen ES. Atlas of Cosmetic and Reconstructive Periodontal
Surgery. Lewiston, NY: BC Decker Inc; 2007.
8 Morley J, Eubank J. Macroesthetic elements of smile design. J Am
Dent Assoc. 2001;132:39–45.
9 Evian CI, Cutler SA, Rosenberg ES, Shah RK. Altered passive
eruption: the undiagnosed entity. J Am Dent Assoc. 1993;124
(10):107–110.
10 Wolffe GN, van der Weijden FA, Spanauf AJ, de Quincey GN.
Lengthening clinical crowns – a solution for specific periodontal,
restorative, and esthetic problems. Quintessence Int. 1994;25(2):
81–88.
11 Kao RT, Dault S, Frangadakis K, Salehieh JJ. Esthetic crown
lengthening: appropriate diagnosis for achieving gingival balance.
J Calif Dent Assoc. 2008;36(3):187–191.
12 Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and classification
of delayed passive eruption of the dentogingival junction in the
adult. Alpha Omegan. 1977;70(3):24–28.
13 Cohen DW. Periodontal preparation of the mouth for restorative
dentistry. Presented at the Walter Reed Army Medical Center,
Washington, June 1962.
14 Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of
the dentogingival junction in human. J Periodontol. 1961;32:
261–267.
15 Arnett GW, Kreashko RG, Jelic JS. Correcting vertically altered
faces: orthodontics and orthognathic surgery. Int J Adult Ortho-
don Orthognath Surg. 1998;13(4):267–276.
16 Sarver DM, Weissman SM. Long-term soft tissue response to
Lefort I maxillary superior repositioning. Angle Orthod. 1991;
61(4):267–276.
17 Dolt 3rd AH, Robbins JW. Altered passive eruption: an etiology
of short clinical crowns. Quintessence Int. 1997;28(6):363–372.
18 Rosenblatt A, Simon Z. Lip repositioning for reduction of exces-
sive gingival display: a clinical report. Int J Periodontics Restorative
Dent. 2006;26(5):433–437.
19 Kois JC. Altering gingival levels: The restorative connection. Part
I: Biologic variables. J Esthet Dent. 1994;6:3–9.
Fig. 15.20 Postoperative smile after 30 days of follow-up.
188
Aesthetic Oculofacial Rejuvenation

The Importance of the Aesthetician
in a Cosmetic Practice
Susanne S Warfield
INTRODUCTION
Cosmetic practices have a growing need to associate
additional specialized services, including those offered
by aestheticians. From the physician’s perspective, the
influx of managed care, reduced insurance reimburse-
ments and rising malpractice insurance premiums
have severely impacted on revenues and the costs of
doing business. Physicians have an unavoidable need
to adapt to this changing marketplace.
At the same time, baby boomers are becoming
more focused on achieving or maintaining a younger,
more vibrant appearance, and expectations have
opened the door for many professionals to enter the
aesthetic arena and for consumers to seek out their
services.
For the physician looking to develop an aesthetic
healthcare niche, there are a number of obstacles to
overcome, including lack of time to develop the
expertise and knowledge about the issues surround-
ing their new endeavor. Here is where the aestheti-
cian can step in to provide many services of benefit
to both the physician and the patient.
WHAT IS IN IT FOR YOU, THE PHYSICIAN?
‘How much time do you presently spend with your
patient?’ If the answer to this question has you paus-
ing for reflection, that is intended. The patients of
today have high expectations for medical care and,
with the high cost of their medical insurance pre-
miums, patients are demanding a right to quality time
with the physician and staff. The physician must offer
the cosmetic patient a complete informative consul-
tation, including a medical evaluation, treatment plan
and statement of costs involved. Once the physician
has completed the initial phase of a medical evalua-
tion, the aesthetician can work with the patient for a
skincare evaluation and treatment. The time allotted
for this session may vary depending on the procedure
and/or diagnosis, but by having the professionals
working to supplement one another’s roles, the
patient is generally the beneficiary.
The aesthetician is an integral member of the
healthcare team in a cosmetic medical practice. The
aesthetician helps both the physician and the con-
sumer by reinforcing the proper usage of pre- and post-
operative medications and home-care instructions.
Acting as a liaison between the patient and physi-
cian, the aesthetician is in a position to educate the
patient and reinforce compliance to pre- and post-
operative instructions and care.
Women, being social animals by nature, confide
and trust their aesthetician and like to discuss with
them anything and everything. It is only natural that
the physician’s aesthetician is privy to information
not heard by the doctor, including their dissatisfac-
tions and happiness with treatments and outcomes.
This becomes an extremely relevant tool, not only
in educating patients and preparing them for the
different treatments and possibilities and their
post-operative care, but also in guiding the physician
in changes of proposed plans and goals during the
patient’s treatment. It is important for the physician
to carefully assess patients seeking cosmetic surgery
to be sure that they are good candidates for the
procedures, both physically and psychologically. The
aesthetician can contribute to this assessment by
communicating with the physician about any addi-
tional information that may impact on the patient’s
care. When such communication between physician
and aesthetician is open and ongoing, the patient is
ultimately the beneficiary.
ARE THEY PATIENTS OR CLIENTS?
As some traditional medical practices strive to achieve
a more cosmetic practice environment, a new breed,
the medi-spa, emerges, offering all sorts of cosmetic
services. In such an environment, the line between
16

patient and client begins to get blurred. A patient, as
described in dictionary terms, is ‘. . . one who is
suffering an ailment, disease or is a victim’. The use
of the word ‘client’, on the other hand, is described
as ‘. . . a future customer, buyer, purchaser, service
user’. Based on dictionary definitions, the use of
the word ‘client’ better suits what today’s cosmetic
patient is all about. As the lines become blurred, the
dilemmas and ethical considerations seem to spawn.
Some physicians believe that those they treat are still
patients, as they come seeking sound advice from
a qualified physician who holds a medical degree.
Others think the changing face of medicine and infil-
tration of managed care have forced them into taking
a hard stand against the traditional views and have
adopted client terminology instead.
It is this author’s belief that they are still patients
even though we do market to them as future consu-
mers or clients of cosmetic services. The bottom
line is that, regardless of the approach to obtaining
each client (i.e. marketing), the care they receive
must be of equal quality, regardless of patient/client
terminology.
THE WORK OF AN AESTHETICIAN
IN A MEDICAL PRACTICE
This chapter is not a textbook of medical aesthetics,
but it is appropriate to outline in broad terms what
procedures the aesthetician working in a medical
practice is likely to carry out. The work can be
divided into two broad categories:
1. preparation of the skin for cosmetic or medical
procedures
2. postoperative care of the skin, for example
lymphatic drainage to assist in reduction of
bruising and swelling, camouflaging cosmetics
to cover scars postoperatively,
micropigmentation for reconstruction or
cosmetic purposes, electrolysis or laser light
sources for unwanted hair removal, and more.
SKINCARE SERVICES BENEFICIAL
IN A COSMETIC SURGICAL SETTING
Preoperative Care
The care given by the aesthetician 4–6 weeks prior
to cosmetic surgery may consist of a deep cleansing
facial, which may include a chemical exfoliation
using a variety of different products that essentially
exfoliate the skin. The surgeon prepares the skin by
prescribing to the patient a tretinoin or glycolic
preparation. The aesthetician performs treatments
that can optimize the surgical outcome through
procedures such as removal of comedones and
hydration of the skin.
One aspect of these treatment visits that is often
overlooked is the ability of the aesthetician to moni-
tor the state of the patient through the preoperative
phase. Patient compliance to the proper use of
topical medications and starting the prophylactics
phase of treatment with the antiviral or antifungal
medication can also be monitored. The patient
who may be experiencing second thoughts about
the procedure may express those concerns to the
aesthetician, and they can be immediately brought
to the physician’s attention.
Chemical Exfoliation
There are two purposes for the use of the word
‘exfoliation’ as opposed to ‘chemical peel’. The first
is to clarify the fact that aestheticians are not physi-
cians performing ‘peels’. The second purpose is to
ward off problems with proposed legislation by the
Food and Drug Administration concerning the use
of alpha-hydroxy acids (AHAs) by aestheticians
for professional use.
The National Coalition of Estheticians, Manufac-
turers/Distributors & Association ()
is a coalition of active skincare associations, compa-
nies and individuals who have united to establish
standards and best practices, and provide political
representation for the profession to state legislators
and licensing boards. They have taken the position
that appropriately trained aestheticians, who have
completed a mandated course including theoretical
and practical applications, be allowed to perform
chemical exfoliation procedures.
The NCEA recommends that aestheticians abide
by federal, state and local regulations. There are
risks involved with using higher percentages of
AHAs that require the skill of a properly trained
physician. There is not one state of which this
author is aware that allows the aesthetician to:
(a) use treatments that go below the stratum
corneum, or
(b) perform invasive procedures.
Tissue Hydration
The hydration of the skin is a primary focus of aes-
thetic treatments and is one of the considerations to
look for in a skincare evaluation.
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Comedone Extraction
The extraction of comedones has long been a part of
the ‘facial’ treatment process. Some state aestheti-
cian boards do not allow the invasive use of imple-
ments, therefore the aesthetician is taught to
‘prepare’ the skin for extractions using exfoliants
or preparation masks, galvanic desincrustation and
steaming (the most widely used procedure).
Lymphatic Drainage
Manual lymphatic drainage massage is a hands-on
technique that enhances the movement of lymph
and connective tissue fluids in the body and pro-
motes the normal, healthy functioning of the lym-
phatic system. A highly specialized set of massage
techniques designed to promote the movement of
lymphatic fluids was developed in the early 1930s
by Emil and Estrid Vodder. This technique came to
be known as Dr Vodders’ manual lymph drainage
(MLD). While there are several forms of lymphatic
drainage massage in the world today, all owe their
origins to the work of the Vodders. MLD has been
widely employed in Europe, where the technique is
practiced in hospitals and clinics. It is recognized by
the Austrian and German government health insur-
ance plans. Only recently has the technique become
more widely known and practiced in the USA.
Mechanical methods of lymph drainage work on
a similar premise of manual, but a machine with
either a pulsating suction or a constant flow is used
to accomplish similar goals. The Lymphobiology®
system developed by Catherine Atzen, San Jose,
CA, is one popular device among practitioners of
lymphatic drainage.
Cosmetic Camouflage Makeup
The use of cosmetics for camouflaging redness and
swelling has become a necessary part of the physi-
cian’s cosmetic practice. The patients of today require
a ‘quick-fix’ in order to return in a timely fashion to
their daily chores and routines. Also of importance
are the thousands of people who use this technique
on a daily basis to simply cover burn scars or other
injuries that require more opaque make-up coverage
than standard cosmetics offer.
Within the medical setting, this type of service is
essential, especially with the postlaser resurfacing
patient, who may have prolonged erythema. The
camouflage make-up manufacturers offer a wide
range of purchasing options for the physician and
aesthetician wanting to incorporate this service into
their practice and business. The dilemma, however,
is whether to charge the cosmetic surgery patient
for this ‘extra service.’ The response to this is ‘no.’
Another important point is to know that most aes-
thetic schools do not teach camouflage make-up as
part of the standard curriculum. Training can be
received at postgraduate facilities and from manu-
facturers of these products.
Dermal Micropigmentation/Permanent
Cosmetics
Implanting pigment into the upper dermis is also
known as permanent cosmetics, microstipling and
tattooing. The enhancement of eyeliner, lips lines
and brows are only a few of the cosmetic applica-
tions. Tattooing is an art form that many practi-
tioners and consumers aspire to. The procedure has
gained new importance within the medical practice
with greater application than just cosmetic tattooing.
The reconstruction of a nipple areola, treatment for
loss of pigment and filling in of ‘hair’ for alopecia
areata have presented the physician with better
options for those patients. The state laws vary as to
who can perform these procedures and under what
conditions, so be sure to check references or contact
a professional organization, such as the Society of
Permanent Cosmetics Professionals ().
Microdermabrasion
Microdermabrasion,
sometimes
referred
to
as
microabrasion, is one of the latest procedures for
skin exfoliation. Like a miniature sand blaster, the
moving handpiece impasses fine particles, known
as corundum, against the face. (Corundum is an alu-
minum oxide mineral from which the gemstones
ruby and sapphire and the abrasive material emery
are made.) Corundum is an inert substance, lacking
in any known active properties. Machine manufac-
turers make different models for use in the medical
office and the salon.
The NCEA regulates microdermabrasion practice
and licensing to include theoretical and practical
applications as part of their core curriculum or as
continuing education modules.
GENERAL CONSIDERATIONS
The NCEA recommends that aestheticians abide by
federal, state and local regulations.
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The Importance of the Aesthetician in a Cosmetic Practice

Presurgery Procedures
Aestheticians are the experts in cleansing and other
techniques that create the best possible conditions
for the skin. Every physician will have their own
protocol for preparing patients for surgery, but the
broad outline tends to be the same.
For facial cosmetic surgery, the regime commonly
begins 3–6 weeks prior to surgery with a thorough,
deep cleansing of the face and neck. If the treatment
is performed far enough in advance of the surgery,
exfoliation will be included as well. Lymphatic drain-
age has also been shown to have excellent outcomes
when used preoperatively on a patient. These treat-
ments may be performed manually or using a
machine. Depending on the experience of the aesthe-
tician, some physicians will allow treatment up until
the day of surgery. Other types of treatments may
be repeated at set intervals until about 2 days prior
to surgery. The aesthetician will also advise patients
about what skincare regime they should use during
the weeks and days before surgery. The object is to
keep the skin as healthy as possible.
The NCEA recognizes the following presurgery
procedure treatments as appropriate for incorpora-
tion by the aesthetician:
1. skin treatments to hydrate and clear skin of
blemishes – this may include microdermabrasion,
chemical exfoliation treatments and more
2. manual or mechanical lymphatic drainage to
improve circulation and lymphatic concerns
3. a product regimen that may include
incorporation of retinoids, tretinoin and
antipigmentation topicals
4. recommendation of antibruising herbal
supplements or other homeopathic nutraceuticals.
Postsurgery Procedures
Postoperative skincare begins after receiving the green
light from the surgeon. After surgery, the aesthetician
may perform various procedures designed to hasten
wound healing, such as hydration, and reduction of
bruising and swelling via lymphatic drainage. When
healing has progressed to the point where gentle
manipulation can be performed, the aesthetician will
give the patient new make-up and instruction on how
to apply it and how to keep the skin clean and healthy.
Here is where artistry becomes important. Cosmetic
techniques the patient relied on before surgery may
no longer be appropriate, either because a problem
the patient had tried to cover up no longer exists or
because the lines and contours of the face have
changed. Naturally, patients who have just had cos-
metic surgery have a strong interest in their new
appearance and will turn to the aesthetician for advice
about products and techniques that make the most of
it. The aesthetician will, in essence, be responsible for
putting the finishing touches to the whole experience.
For the reconstructive patient, the aesthetician’s
expertise will again serve to make the most of the
medical procedure. Special care may be needed to
promote healing and to minimize scarring, but the
most important aspect of the work is often in the
skilled use of make-up to camouflage scarring or dis-
coloration. Since the deepest scars for the trauma
patient or burn survivor may be the psychological
ones that persist long after healing is complete, the
aesthetician can play a very significant role in healing
and even eliminating those psychological scars.
The NCEA recognizes the following postproce-
dure treatments as appropriate for incorporation in
the work of the aesthetician:
1. skin treatments over intact skin, which could
include microdermabrasion, chemical exfoliation
treatments and more
2. manual or mechanical lymphatic drainage to
improve circulation and lymphatic concerns
3. a product regimen that may include
incorporation of retinoids, tretinoin,
antipigmentation topicals, etc.
4. specific postprocedure products that may contain
vitamins, essential oils, antioxidants, etc.
5. application of camouflage make-up to cover
postoperative bruising and wounds.
Depending on the procedure performed the heal-
ing time will vary, and the basic prescribed regimen
will also depend on the patient’s skin type, post-
operative complications (if any) and medications
(i.e. postoperative antibiotics, herbals or nutritional
supplements given by the physician or in some cases
by wellness centers).
LEGAL AND LIABILITY ISSUES
Some recent unfavorable situations at medical and
non-medical spas have caught the attention of state
boards that regulate aesthetician licenses, as have
some of the non-specialty physicians who start a
business and begin performing laser light proce-
dures, or what the dermatology community would
call ‘cutaneous medicine’. At the time of writing
this chapter, it is still pretty much any physician’s
legal right to do just about anything – training or
not!
The
American
Medical
Association
has
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Aesthetic Oculofacial Rejuvenation

introduced more restrictive rulings on in-office dis-
pensing and supervision requirements, including
the physician’s right to delegate procedures to staff
members. All these developments have added to
the burgeoning unrest of practicing physicians.
Ultimately, the first issue overlooked is simply
this: is the facility actually a medical spa or is the
word ‘spa’ being used to portray the sense of a
non-clinical surrounding to the consumer? Two
national organizations have issued position state-
ments defining a medical spa and a day spa to help
clarify the differences within this industry.
WHAT IS A MEDICAL SPA?
‘A medical spa is a facility that during all hours of
business operates under the on-site supervision of
a licensed healthcare professional operating within
their scope of practice, with a staff that operates
within their scope of practice as defined by their
individual licensing board, if licensure is required.
The facility may offer traditional, complementary,
and alternative health practices and treatments in
a spa-like setting’ (NCEA).
The proper licensing of your facility will ensure
that those individuals working in the facility with
you are working within their scope of practice. To
refer back to the NCEA’s definition, ‘. . . Practitioners
working within a medical spa will be governed by their
appropriate licensing board, if licensure is required.’
Proper licensing of the facility ensures that the
licensed individual is working within a licensed
facility, which then translates into liability insurance
coverage. If a licensee – an aesthetician – is not
working in a licensed facility (by the board issuing
his/her license) then the possibility exists that
should an ‘incident’ occur, the liability insurance
policy will become null and void. Simply put, the
licensee is in violation of a state licensing require-
ment that the licensee work in a licensed facility.
The insurance company will deny the claim because
the licensee was in violation of its license.
Perhaps more important than the industry defini-
tion of a spa is the connotation of ‘medical’ spa in
the mind of the patient. The word ‘medical’ implies
that there will be medical supervision or medical
interaction of some kind. Also, there could be a
belief that it is safer to have facials in this medical
spa environment rather than a regular spa. Such a
perception may or may not be true, depending on
the amount of specific staff training that a licensee
receives within the medical spa environment.
This would be a good time to mention that terms
such as ‘medical aesthetician’ or ‘clinical aestheti-
cian’ are meaningless and not recognized by state
licensing boards anywhere in the USA as of this
writing. NCEA’s position is that:
‘Estheticians should represent themselves according to
their licensed title, as designated by their state licensing
board or regulatory agency, and not promote themselves
or allow any employer to market them otherwise.’
MEDICAL TREATMENTS VERSUS
TRADITIONAL AESTHETIC SERVICES
What is the difference between a medical facial and
a traditional facial? There is a vast difference of
opinion on this subject, and it matters not only to
the patient but also to the physician, in terms of
liability. The laws on this matter vary considerably
from state to state and are still in the process of
being defined.
In over 28 states, the aesthetician license is not
even valid or recognized in a medical setting. The
important thing to remember is that an aestheti-
cian’s license to perform procedures varies accord-
ing to whether the facility is licensed as a medical
facility or spa/skincare (cosmetological) facility.
Insurance coverage for the aesthetician is often tied
to the Cosmetology State Board that governs the
aesthetician’s license. Some state boards stipulate that
the aesthetician must perform aesthetic skincare ser-
vices in a licensed cosmetological facility. This state-
ment precludes an aesthetician from practicing in a
medical setting. In fact, in one case in which I became
involved, the state board would not budge and insisted
that the physician become a licensed master cosmeto-
logist! Sometimes an ambiguous clause, stipulating
that the aesthetician practice ‘under the physician’s
supervision’ is included, but this is subject to interpre-
tation. What does supervision mean:
1. on the premises or in the building?
2. available by beeper/telephone?
3. physically in the room when the procedure is
being performed?
NATIONAL CERTIFICATION STANDARDS
FOR SKINCARE PROFESSIONALS
With so much ambiguity of terms, conflicting state
regulations and the introduction of increasingly
sophisticated technologies, the need for national
standards becomes increasingly essential.
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The Importance of the Aesthetician in a Cosmetic Practice

It is NCEA’s goal to have all state regulatory
boards recognize NCEA-certified professionals in
their state. NCEA’s certification goal is to raise the
educational requirements of a skincare professional
to a standardized 1200 hours across the country, in
contrast to the current average state requirement of
600 hours, to include both theoretical and practical
knowledge. The NCEA is also working toward inter-
national recognition of NCEA certification.
The NCEA Certification Program benefits the
patients by:
1. providing patients with assurance that they are
being treated by well-trained professionals with
personal competence
2. identifying and controlling consumer (patient)
risks
3. assuring the patient that the aesthetician is both
maintaining and updating skills, by receiving
training in new emerging technologies. (The NCEA
Continuing Education Program has a requirement
of 12 additional hours of credit every 3 years.)
THE ATTRIBUTES OF AN NCEA-CERTIFIED
PROFESSIONAL
The attributes of an NCEA-certified professional
include the following:
v serving the best interests of their clients at all
times and providing the highest quality service
possible
v maintaining client confidentiality, keeping
treatment documentation records and providing
clear, honest communication
v providing clients with clear and realistic goals and
outcomes, and not making false claims regarding
the potential benefits of the techniques rendered
or products recommended
v adhering to the scope of practice of their
profession and referring clients to the appropriate
qualified health practitioner when indicated
v offering services only within the scope of
their practice as defined by the state within
which they operate, if required, and in
adherence with appropriate federal laws and
regulations.
v understanding of new techniques or procedures
and obtaining adequate training before
performing a treatment on the client
v representing their state licensure, education,
training, qualifications and abilities honestly
v strictly adhering to all usage instructions and
guidelines provided by product and equipment
manufacturers, provided those guidelines and
instructions are within their scope of practice as
defined by the state, if required.
HOW TO FIND A QUALIFIED AESTHETICIAN
Look for professional attire. Aestheticians should
‘walk the walk and talk the talk’, i.e. have good skin,
and be well groomed and well styled.
Get recommendations from people you respect,
especially those who have obtained visibly good
results. Make a surprise visit to the facility prior to
making an appointment. Check to see their current
license. Ask if they are NCEA certified (if so, they
should have a valid certificate and certification
card).
CONCLUSIONS
The career of the aesthetician is the fastest growing
segment within the beauty industry. With the scien-
tific advances in cosmeceutical ingredients and new
device technologies, the state regulatory boards are
scrambling to catch up. The aestheticians you trust
to care for your patients’ skin should have a ‘never
stop learning’ attitude because the day they lose
that desire to learn is the day they should stop being
an aesthetician!
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From the Inside Out:
A Psychotherapist’s Views
on Aesthetic Enhancement
Michael Colberg
We have come to prefer a world where the
distractable take Ritalin, the depressed take Prozac,
and the unattractive get cosmetic surgery to a world
ruled, arbitrarily, by those fortunate few who were
born focused, happy, and beautiful. Cosmetic surgery
is not “earned” beauty, but then natural beauty isn’t
earned, either. One of the principal contributions of
the late twentieth century was the moral deregulation
of social competition—the insistence that advantages
derived from artificial and extraordinary intervention
are no less legitimate than the advantages of nature.
Malcolm Gladwell1
INTRODUCTION
Technology has enabled people to seek facial rejuve-
nation and other cosmetic procedures. It has also
helped to establish firmly the parameters of what it
is they are seeking. It has created the illusion that
they can become part of the ‘focused, happy and
beautiful’ group that Gladwell writes of. Fortunately,
or unfortunately, what they end up discovering, if
they are conscious enough to notice, is that there is
no group. There are other people whom the seeker
perceives as being members of the group, but the
quality of being safe and belonging is elusive. These
qualities exist and develop only as people establish
real relationships with themselves. We exist as indi-
viduals, and it is by developing what is special and
unique within ourselves that we become whole and
contributing members of society.
We happen to exist at a time when technology
has both enabled us to alter our appearance and
caused us to be connected in a much more immedi-
ate way than we have ever been connected before.
Ironically, this has taken from us many of the
tools we used to achieve intimacy. Television has
replaced conversation. Email has replaced letter
writing. Instant messages have replaced telephone
conversations, and, in many instances, cell phone
conversations have replaced time that was formerly
used to gather our thoughts and to connect with
ourselves. The internet has, arguably, removed the
need to actually interact directly with other human
beings. At the same time that we have gained the
freedom to alter our appearance, to become ‘who
we want to be,’ we have been isolated from having
real contact with ourselves and with others. We
are being inundated with images of those whose
lives are lived in the glow of the public eye and
those who will stop at nothing to get there. There
are reality shows that document a reality that does
not exist, there are talent shows featuring people
without talent and there are makeover shows that
highlight the degrees to which people will go to feel
like they fit in without connecting to themselves.
This has a numbing effect. The message is that, in
order to be happy, we should abandon what causes
us to be unique, thoughtful, creative and compas-
sionate, and do what we can to conform to current
trends. We are more in each other’s faces but less
in each other’s hearts. Many of those who choose
another path are banished to an invisible sideline.
Obviously, there are still many people for whom
appearance is not particularly important. There is
no body of information yet available that compares
people who seek out cosmetic intervention with
those who do not. In the end, it may be that the
majority of people who seek cosmetic procedures
simply place a higher emphasis on improving or
maintaining their appearance than those who do
not. It is possible that neither group represents the
majority of pathology present in the population as a
whole. We will need to wait for sound scientific data
before we can move forward with that discussion.
The discussion in this chapter has several parts:
a discussion of the psychological and emotional
17

context in which the profession is operating, a look
at cosmetic procedures from the physicians’ per-
spective, a perspective on clients and some tools to
help initiate some of the ideas presented. I want
to begin by touching upon some of the major events
that influenced how we have been thinking about
and approaching the practice of cosmetic and mini-
mally invasive plastic surgery.
A HISTORICAL PERSPECTIVE
Elizabeth Haiken did a particularly thorough job of
discussing the history of the profession in her book
Venus Envy: A History of Cosmetic Surgery.2 There
were attempts made to address disfigurement as
early as the 16th century, but the first concentrated
effort to address cosmetic reconstruction was made
in response to wounds suffered on the battlefields
of World War I. The medical community was both
able and highly motivated to develop new ways to
treat the disfiguring wounds suffered by soldiers dur-
ing World War I. Although many of these wounds
were not physically life threatening, they were psy-
chologically life altering. By the beginning of the
20th century, the work of Freud, Hall, Jung and
those who followed them began to explore what it
means to have an internal life – a meaningful relation-
ship with the self – and we entered the age of
psychological awareness. Against this background,
medicine’s urge to ‘make whole’ seriously wounded
World War I veterans takes on special meaning.
As society became aware of medicine’s ability to
alter appearance, other potential clients emerged. As
author Christine Rose wrote, ‘The greatest boon to
modern cosmetic surgery was not the development
of any particular technique or the creation of a miracle
product. It was an import from psychology: the inferi-
ority complex. Popularized by Viennese psychologist
Alfred Adler in the early twentieth century, it
reached an eager audience in the United States. The
inferiority complex provided a crucial link: it joined
individual mental health with physical appearance
and thus “psychologized cosmetic surgery”. People
suffering from an inferiority complex because their
breasts were small or their chins droopy were ill; they
required medical intervention to alleviate their psy-
chological suffering. As Haiken notes, by the 1920s
and 1930s, Americans had made this link between
physical appearance and mental health permanent;
as a result “their demands for surgical attention
became more insistent at the same time as the new
language of psychology made these demands more
persuasive”. By 1940, Good Housekeeping magazine
was asking, “why should anyone suffer under the
handicap of a conspicuously ugly feature? Why not
let modern science give him a normal face and an
equal chance with other people?”’3
Cosmetic procedures came to occupy an estab-
lished niche in the medical field, and people seeking
cosmetic intervention became patients. This secured
the fit between cosmetic procedures and the stan-
dard medical model. As the field of psychology has
matured, each generation of studies has shown there
to be less pathology among those seeking cosmetic
intervention than the early studies suggested.
According to Sarwer et al., early reports of the psy-
chological characteristics of rhinoplasty patients date
back to the 1940s and 1950s. Many of these reports,
as well as studies conducted into the 1960s, relied
heavily on clinical interviews and observations of
patients that suggested rhinoplasty patients were
highly psychopathological. One group of investigators
went so far as to state that all patients desiring
rhinoplasty were mentally ill and described their sam-
ple of patients as suffering from a variety of psychia-
tric issues, ranging from feelings of inferiority to
psychosis. In another study, 53% of patients received
preoperative diagnoses of personality disorders.4
More recent studies of patients who had rhytidec-
tomies and blepharoplasties indicate that these
patients are not as psychopathological as earlier stud-
ies suggested. In addition, results from body image
studies indicate that patients seeking anti-aging proce-
dures may place greater emphasis on their appearance
and report less dissatisfaction with their overall body
image than do patients who seek other procedures.4
Sarwer et al. concluded that, given the popularity
of other minimally invasive facial procedures, there
is a need for studies of the psychological character-
istics of patients who seek these treatments.4 I dis-
agree. It is time for us to discard the pathology
model, and for physicians who practice cosmetic
and plastic surgery to understand the increasingly
important role they have to play in helping their cli-
ents engage in self-care. This change in thinking can
be seen elsewhere in the practice of western medi-
cine. For example, the scientific community has
begun to accept that meditation, acupuncture and
other healing modalities contribute not just to heal-
ing but also to staying healthy. It is my belief that,
in the coming years, our understanding of the con-
nection between mind and body will change and
play a different and increasingly important role in
science and in the practice of medicine; the rela-
tionship between mind and body can be a source
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Aesthetic Oculofacial Rejuvenation

of health and well-being. People who feel good
about themselves are often healthier than people
who do not.
COSMETIC MEDICINE FROM
THE PHYSICIAN’S PERSPECTIVE
Noting that the nature of medical education has not
changed much in the last half century, Bloom
writes, ‘Until today . . . this general form has per-
sisted, producing an elite corps of highly trained
specialists who are prepared to practice a science-
based, technologically complex type of medicine’.5
It would at first appear that this group of physicians
is perfectly suited to enter a field where the use of
technology is rapidly changing and expanding the
very nature of cosmetic medicine. However, tech-
nological expertise is but one set of skills needed
to practice minimally invasive cosmetic medicine.
According to the American Society of Plastic
Surgeons (ASPS), over 13.5 million plastic surgical
procedures were performed in 2004. Most of them
were minimally invasive cosmetic procedures, many
of which did not exist in 1992 when ASPS started
tracking procedures.6 As technology plays an increas-
ingly important role in cosmetic practices, other pro-
fessions have sought out and acquired the knowledge
necessary to offer many of these procedures. The
ASPS
numbers
are
probably
an
underestimate
because they do not account for the increasing number
of non-plastic surgeon physicians, including cosmetic
dermatologists, and trained aestheticians, who are also
joining the pool of professionals offering minimally
invasive cosmetic procedures. It would appear that
the demand for these procedures is rapidly increasing,
the kinds of procedures available are increasing and
the number of practitioners is expanding.
Physicians practicing in the field of cosmetic sur-
gery will be well served by acquiring interpersonal
skills that are generally de-emphasized during their
medical training. Sarwer et al. wrote, ‘Plastic surgeons
typically have not been provided with adequate train-
ing in how to better understand the emotional and
interpersonal aspects of patient functioning’.4 They
go on to state, ‘to obtain such training and integrate
these skills into their everyday practice adds to the
already demanding burdens that all surgeons experi-
ence. However, compared to their investments in
developing their surgical skills, the amount of time
and effort needed to develop a deeper understanding
of the psychological functioning of their patients is
relatively small’.4
I think that this last statement touches upon the
very essence of what I hope to accomplish with this
discussion. I believe that, as with those seeking to
become surgeons, a certain amount of talent, and
perhaps intuition, is needed to become an artful
practitioner. Some people make gifted surgeons and
others are gifted at helping people better understand
themselves. Sometimes a person has both gifts and
other times not. When surgeons find that they are
not particularly skilled at client communication or
assessment there is absolutely nothing wrong with
reaching out and collaborating with someone who
has been trained in those areas. It is important for
surgeons to know and develop their strengths and
to both acknowledge and respect their limitations.
Robert M. Goldwyn, writing in Psychological
Aspects of Plastic and Cosmetic Surgery: Clinical,
Empirical and Ethical Perspectives,4 offers the fol-
lowing list of ‘potentially problematic patients from
a psychological perspective’:
v the VIP patient
v the patient who appeals to the surgeon’s ego
v the perfectionist patient
v the patient under psychiatric care
v the patient thought to be in need of
psychiatric care
v the dishonest patient
v the disheveled patient
v the patient whose personality clashes with that of
the surgeon.
I think the list suggests a problem associated with
trying to standardize human behavior. Most of the
judgments that need to be made when deciding
whether or not a client is potentially problematic
are subjective in nature. I personally feel that when
a person is using a checklist to assess someone sit-
ting across from them, they may be missing out on
the best assessment tool they possess – themselves.
The initial question for a surgeon to ask is: Am
I comfortable moving forward with this person?
If not, is there some conversation that can be had
that would clarify whether client and surgeon
could/should work together? Am I capable of having
that conversation and, if not, can I collaborate with
someone who is?
What are some of the things to look for and think
about when trying to understand clients desiring cos-
metic procedures? As Sarwer points out, ‘These pro-
cedures are no longer reserved for the wealthy and
elite; women and men across age, racial and socioeco-
nomic groups seek cosmetic surgery to improve their
appearance and ultimately their body image’.7 In
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From the Inside Out: A Psychotherapist’s Views on Aesthetic Enhancement

2007, nearly 10 million minimally invasive proce-
dures were performed in the USA, an increase of
81% from the number of procedures performed in
2000.8 According to the American Academy of Cos-
metic Surgery, between 1982 and 1992 the number
of people surveyed who said that they approved of
cosmetic surgery increased by 50% and the number
who disapproved declined by 66%. With this decline
in disapproval, consumer demand for surgery has
skyrocketed.3
FROM THE PATIENT’S PERSPECTIVE
In a review of psychosocial outcomes for patients
seeking cosmetic procedures, Honigman et al. found
that, ‘Most people seeking cosmetic surgery proce-
dures appear psychologically healthy; however, some
are not, and for these individuals, cosmetic procedures
may have a negative outcome, creating problems for
both patient and surgeon. The challenge that surgeons
face is how to identify, before surgical intervention,
those patients who may have a poor outcome in terms
of psychological adjustment and psychosocial func-
tioning despite a technically satisfactory result’.9
Although pathology does exist within the plastic and
cosmetic surgery seeking population, often in the form
of body dysmorphic disorder, newer studies have
shown that the majority of those undergoing proce-
dures are not seriously impaired. This discussion will
focus on that segment of the population.
My goal is to discuss cosmetic clients in a way that
helps physicians better understand how to assess and
guide clients, and to help them make intelligent deci-
sions about whether the physician–client match is
likely to be a good one. To do this, I am going to intro-
duce an alternative to the traditionally used medical
pathology model by borrowing from work originally
written to help social workers move away from using
this deficit-based lens. It introduces a ‘strengths-
based perspective’ for use in client assessment and
interaction. I find this approach to be useful for phy-
sicians seeking to improve their ability to assess and
communicate more effectively with clients.
Dennis Saleebey describes the frame of the
strengths-based perspective in three basic concepts:10
1. Given the difficulties they have, and the known
resources available to them, people are often
doing amazingly well, the best they can at the
time.
2. People have survived to this point ‘certainly not
without pain and struggle’ through employing
their will, their vision, their skills and, as they
have grappled with life, what they have learned
about themselves and their world. We must
understand these capacities and make alliance
with this knowledge in order to help.
3. Change can only come when you collaborate with
client’s aspirations, perceptions and strengths,
and when you firmly believe in them.
The strengths-based perspective embraces the
world view of the client. It is truly starting where
the client is, rather than starting where the theory is.
Viewed from a strengths-based perspective, we
can say that the majority of clients seeking cosmetic
consultations are functioning at a level that affords
them the ability to make active choices about how
they want to live. Stated simply, it is the physician’s
job to understand what their clients are hoping to
accomplish, to decide whether they are comfortable
helping their clients achieve that goal and, if the
answer is ‘yes’, to help them refine their expecta-
tions so that they are aligned with all possible out-
comes as they move forward together.
Although our ability to control extends only to
making decisions about how to respond to what is
actually happening, many people spend their time
seeking to control as much of what is happening as
possible. By definition, the thought of turning them-
selves over to a stranger who may alter their appear-
ance puts patients out of control and may cause
them to behave in ways that might appear pathologi-
cal when, in fact, they are merely ‘acting out’ because
they are feeling frightened. A question to ask is: Might
the patient be experiencing vulnerability that has the
appearance of instability? One way to check this out
is to help the client try to access and express fearful
feelings so that they can be addressed in a healthy
way. Making use of a strengths-based model would
help the client feel less out of control and powerless.
Dr Marian Cantisano-Zilkha wrote a manual enti-
tled Contemporary Guide to Aesthetic Enhancement,
which introduces and discusses minimally invasive
modalities of facial periocular rejuvenation in a way
that is intended to give a general education to doctors
and the cosmetic industry.11 Ultimately, it becomes a
valuable tool for patients as they become as informed
as possible and more able to take responsibility for,
and to commit to, a course of action. This creates a
sense of partnership, and working in this collaborative
way helps clients take responsibility for the choices
they make. The point I want to make is that having
the guide available empowers the client and demysti-
fies the procedures so that a more collaborative rela-
tionship can happen between the doctor and the client.
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Aesthetic Oculofacial Rejuvenation

USING THE STRENGTHS-BASED MODEL
I think it is important to make it absolutely certain
that patients are clear about the range of outcomes
that are possible. This includes both how their
appearance might and might not be changed by
the procedure and what the downtime may be,
and therefore be certain to be generous in your esti-
mate of how long it might take for them to be ready
to resume their lives. It is also important to explain
the range of outcomes that are possible with each of
the procedures under consideration and emphasize
that results may differ among diverse individuals.
If the client is following your lead and you are
making an educated guess as to which path seems
to be the best fit between their desire and what is
possible, make sure that they know that this is an
inexact science and that you cannot guarantee
exactly how their body will respond. The goal is to
form a collegial relationship. Remember, you are in
charge of the procedure and they are in charge of
the pre- and post-procedure care that may deter-
mine whether or not the procedure is a success.
As the technology becomes more sophisticated, it
is entirely possible that the strengths-based collabo-
rative approach will help physicians to work with
clients as their partners rather than experience
them as the objects of their ministrations.
It is important to try to understand how each
potential client looks at their aging process. It is
entirely possible to grow in an age-appropriate way
while seeking to avail oneself of the opportunities
currently available to remain attractive and vital.
As Sarwer pointed out, ‘Using cosmetic surgery to
bargain with the clock stirs deep emotions. Matur-
ing faces (and our bodies) also confront us with
our mortality, a reminder that no one lives forever.
Our time is limited. At times, the emotional impact
of these reminders is mistakenly experienced as a
reaction to the skin and body changes themselves.
Is the patient more upset about the wrinkles or
the unalterable realities of aging?’12 This is an
important difference because even a successful
surgical outcome will not address the fact that the
client is aging. It is not possible to stay young. For
those who are lucky enough to make it, being old
is a natural part of being alive.
If a surgeon suspects that clients are struggling
with the fact of aging, it may be useful to help them
work through some of the normal emotional chal-
lenges that accompany aging. A surgeon might ask
them if there is an age at which they imagine them-
selves putting a halt to cosmetic intervention. They
may also ask them about how their family and
friends negotiated, or are negotiating, the aging pro-
cess. These inquiries may help give a physician a
sense of whether the clients’ expectations are reali-
stic and, more importantly, whether these are the
expectations with which the physician is comfort-
able. There is a difference between people seeking
to look younger and people seeking to look good,
refreshed and revitalized. As Jonathan Van Meter
of New York Magazine observed, ‘Even the most
successful and beautiful result is entirely different
from what a woman looked like when she was 30.
Demi Moore, the gold standard of good plastic sur-
gery, does not look at all like she did when she made
Ghost. The new new face is a fantastic approxi-
mation! An uncanny resemblance! It is, at its best,
a close copy of youthful beauty, not youthful beauty
itself’.13
It can be difficult to distinguish between those
who seek to remain vital looking and those for
whom aging is so threatening as to pose the risk of
serious destabilization. Although it is always possi-
ble that a previously invisible underlying instability
may be triggered by a cosmetic procedure, the level
of engagement needed to move through a procedure
using a strengths-based collaborative gives both the
client and the physician a greater opportunity to
recognize and respond to any red flags before they
become problems. This could spell the difference
between a relationship ending in litigation or not.
When using a strengths-based perspective, clients
must be approached as individuals. They should be
respected as being the experts on who they are
and how they want to live. On the other hand, the
physician is the expert on how the body is respond-
ing to the aging process and how that process can be
adjusted to suit the client’s objectives. Special care
must be taken when dealing with adolescents or
young adults. There is now strong evidence that
the brain does not cease to mature until the early
20s, particularly in the areas that govern impulsi-
vity, judgment, planning for the future, foresight
of consequences and other characteristics that make
people morally responsible. In fact, the age of 21 or
22 years would be closer to the ‘biological’ age of
maturity.14 That being the case, extra thought
should be given when considering working on an
adolescent. Be thorough during the assessment pro-
cess to make certain that it is the adolescent who
wants the procedure and that the adolescent under-
stands the nature of the procedure, the possible
range of outcomes and the downtime involved.
Obviously, agreeing to help a depressed teenager
199
From the Inside Out: A Psychotherapist’s Views on Aesthetic Enhancement

with severe acne scarring differs from enhancing
the bust line of a depressed 14-year-old. It is impor-
tant to make every effort to be alert to the whole
person because the solution to their distress may
not lie in changing their appearance, especially at
that age.
People who want to look different may seek
change for a variety of reasons. For example, a
mysterious spy or crime figure seeks anonymity by
changing his or her appearance, hoping to begin
anew in a new locale. Can we wipe the slate clean
by changing our wrapping or do we complicate mat-
ters when we do something to our outside without
addressing the corresponding internal changes that
need to be made? What about the person who goes
through a life-altering tragedy? How important is it
that they take time to reflect on the experience
before turning to cosmetic surgery? The answers to
these questions are complex and differ on a case-
by-case basis. I imagine that, as a clinician, I would
respond very differently to a client seeking to have
breast reconstruction immediately following a mas-
tectomy than I would to a person wanting complete
facial rejuvenation a week after losing a child in a car
accident.
Imagine persons who wish to have work done in
order to resemble a celebrity in the hope that their
lives may take on some of the ‘sparkle’ they attri-
bute to that person. Would you, as a physician, be
comfortable helping them to achieve their goal? Is
their goal to look like that celebrity or to feel like
they imagine that celebrity feels? Are you trained
to be able to elicit that kind of information from a
prospective client? Is one reason appropriate while
the other is not? What about a second person who
seeks the same goal for a completely different rea-
son? They may regularly be mistaken for a particular
celebrity and find that they can best support them-
selves and their families by building on this fluke of
nature and want to further conform their features
to and then find work impersonating the said celeb-
rity. While the former person’s motives may point
toward the need for further evaluation, is that
necessarily the case with the latter?
It is clear that looks do play an important role in
the marketplace. There are apparently real eco-
nomic harms and benefits tied to personal appear-
ance. A 1993 study conducted by economists
Daniel Hamermesh and Jeff Biddle, and published
by the National Bureau of Economic Research,
found that ‘holding constant demographic and
labor-market characteristics, plain people earn less
than people of average looks, who earn less than
the good-looking. The penalty for plainness is 5 to
10 percent, slightly larger than the premium for
beauty. The effects are slightly larger for men than
women; but unattractive women are less likely than
others to participate in the labor force and are more
likely to be married to men with unexpectedly low
human capital’.15
A question to consider is whether we have
arrived at a place where the presence of features
such as gap teeth, an overly prominent nose, or ele-
phant ears tends to identify someone as belonging to
a lower socioeconomic class or undesirable ethnic
group.
While some people seek to improve their body
image by altering a feature they do not like, some
may not really care that much about how they look
but choose, or are pressured, to alter their appear-
ance to make themselves more marketable. Others
may find that something about their looks detracts
from their ability to focus 100% on their job. Our
environment also dictates what is appropriate for
us. Traditionally, Europeans have been thought of
as allowing themselves to age more naturally than
those in the Americas.
CONCLUSION
What happens during an initial consultation is
remarkably circumscribed. The patient is there to
decide whether or not to receive care from the sur-
geon or to convince the surgeon to comply with his
or her desire to have surgery. In turn, the surgeon is
making a decision about whether or not to accept
that person as a patient. This evaluative process
puts the personality characteristics of both individ-
uals on display.4
Goldwyn states, the surgeon is “making a deci-
sion about whether or not to accept that person as
a patient.”4 The client is a patient from the moment
the consultation begins. This may seem like a trivial
point, but it undermines the creation of a collabora-
tive stance by creating a power inequity. I believe
that more is accomplished when the physician and
the client work holistically. The entire person in
their environment should be considered if neces-
sary. The extent of this inquiry depends upon how
comfortable the fit is between the client and the
physician. If there is trust and understanding
between them then the conversation can cover
more ground with fewer words. If there is no innate
connection, then it pays to take the time to cover all
of the bases that need to be covered.
200
Aesthetic Oculofacial Rejuvenation

Recognizing that not all physicians have the talent
to engage in these conversations and that some
among those who do have the skills lack the time,
I would like to make some suggestions. One possi-
bility is for prospective clients to fill out question-
naires that are designed to get them to think about
what they want to accomplish, why they are choos-
ing to do it now, what their expectations of the phy-
sician and the procedure are, and whether there is
any history that would contraindicate or complicate
moving
forward.
Some
sample
questions
are
included at the end of this chapter. It might also
be a good idea for physicians to form a relationship
with a trained mental health professional who can
offer input when needed.
Another idea borrowed from psychotherapy is
the idea of a peer support and supervision group.
It involves colleagues getting together to discuss
what does and does not work as they try to develop
their
interpersonal
skills
further.
A
secondary
benefit derived from forming a group of this type
is that colleagues begin to get a sense of what types
of clients are the best fit for them personally. This
gives them an option to refer to a member of the
group a client whose personality is not a good match
for them.
We have arrived at an important moment in
the practice of aesthetic enhancement and plastic
surgery. In its infancy, cosmetic practice made the
leap from addressing the needs of wounded veter-
ans of World War I to those in the general popula-
tion seeking to change their appearance. Now we
have made a more subtle leap. We have entered an
age
when
minimally
invasive
procedures
have
become available and highly sought after. In order
to address the population of clients seeking treat-
ment, physicians are best served by discarding the
traditional pathology model and adopting a model
more reflective of the times, one based on colla-
boration. Making use of a strengths-based model
respects the fact that both physicians and clients
have contributions to make to their interaction
that can make their relationship more efficient and
more satisfactory and, ultimately, optimizing the
results.
We are moving into a time of uncertainty. We
have many possibilities and few answers. I believe
that we will have the best possible outcome if we
learn to connect with each other and respect what
each of us can and cannot bring to the table. I hope
that
those
who
read
this
chapter
are
better
equipped and more motivated to connect, share
and learn from both clients and colleagues.
SUGGESTED QUESTIONS FOR ASSESSING
A PATIENT’S UNDERSTANDING AND
READINESS FOR COSMETIC PROCEDURES
1. What is the goal?
2. Why now? What makes now feel like the
right time for this procedure rather than a
month or a year ago, or a month or a year in the
future? (Do not stop with purely practical
answers, like I have a vacation coming up or
I just got a bonus check. Continue with
‘Okay, but is there anything else?’)
(Sarwer/Grossbart)12
3. What are three wishes you have about the
impact on your life from a successful outcome?
Please answer on a pure fantasy level, do not be
realistic. (Sarwer/Grossbart)
4. What are three realistic expectations you have
for the impact a successful procedure will have
on your life? Can you imagine any possible
disadvantages to a successful outcome?
(Sarwer/Grossbart)
5. How do you expect key people in your life will
respond differently to you after the procedure?
How about strangers? (Sarwer/Grossbart)
6. Does your target body part remind you of
anyone you know, you have met, or any of your
family members? Whose eyes or whose thighs
do you have? (Sarwer/Grossbart)
7. Have you noticed that your readiness to have
the procedure varies from day to day or from
week to week? Is the desire greater with certain
events, moods or the reactions of others?
(Sarwer/Grossbart)
8. Have you noticed any unexpected emotional
reactions to personnel, the doctor’s office
or talking about the procedure?
(Sarwer/Grossbart)
9. Have you ever had any indications that others
see you differently to how you see yourself?
(Sarwer/Grossbart)
10. Do you ever have trouble following health or
beauty guidelines that you agree with?
(Sarwer/Grossbart)
11. What percentage of people’s first impression of
you do you believe your target body part
accounts for? What percentage after they get to
know you? (Sarwer/Grossbart)
12. Why are you choosing this procedure over
another, more invasive surgical procedure?
13. Who are you telling about this procedure?
Why and why not?
201
From the Inside Out: A Psychotherapist’s Views on Aesthetic Enhancement

14. What about downtime?
15. How long do you expect this will it take to heal?
16. How long do you expect the desired effects of
this procedure will last?
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2 Haiken E. Venus envy. Baltimore: Johns Hopkins University
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4 Sarwer D, Pruzensky T, Cash T, et al., eds. Psychological aspects
of reconstructive and cosmetic plastic surgery: clinical, empirical,
and ethical perspectives. Philadelphia: Lippincott, Williams and
Wilkins; 2006.
5 Bloom S. Structure and ideology in medical education: an analysis
of resistance to change. JHSB. 1998;29(4):294–306.
6 Pruzensky T, Sarwer D, Cash T, et al. Multiple perspectives on
the psychology of plastic surgery. In: Sarwer D, Pruzensky T,
Cash T, et al., eds. Psychological Aspects of Reconstructive and
Cosmetic Plastic Surgery. Philadelphia: Lippincott, Williams and
Wilkins; 2006:13–22.
7 Sarwer D. Cosmetic surgery and changes in body image. In:
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research
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clinical
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8 American Society of Plastic Surgeons. 2008 Report of the 2007
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9 Honigman R, Phillips K, Castle DJ. A review of psychosocial out-
comes for patients seeking cosmetic surgery. Plast Reconstr Surg.
2004;113(4):1229–1237.
10 Saleebey D. The strengths approach to practice. In: Saleebey D,
ed. The strengths perspective in social work practice. Longman:
White Plains; 1997:49–58.
11 Zilka
M.
Contemporary
Guide
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Aesthetic
Enhancement.
Newton, PA: Handbooks in Health Care Company; 2008.
12 Grossbart T, Sarwer D. Cosmetic surgery: surgical tools – psycho-
social goals. Semin Cutan Med Sur. 1999;18(2):101–111.
13 Van Meter J. About face. New York Magazine. 2008;(August 11).
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202
Aesthetic Oculofacial Rejuvenation

The Future of Oculofacial
Rejuvenation: A Perspective
Sterling Baker, Erin L Holloman
‘Beauty is truth, truth beauty.’
Keats
This concept was studied by Keats while observing a
painting on a Grecian urn. Keats further suggested
that if we understand truth and beauty, we know
all we need to know. As with many abstract con-
cepts, we humans have a difficult time understand-
ing this relationship. Truth is a concept that seems
to defy definition. Yet, we seem to comprehend
beauty on an intuitive basis, even though that intui-
tion is greatly influenced by time and culture. To a
major extent, we have historically and collectively
equated beauty with youth. This youth portion of
the equation frequently becomes the pursuit of
vitality. With all of the hyperventilation we can
muster, we enshrine vitality as a basic urge, if not
a primal right, to live our allotted time as fully as
possible. Then the beauty portion of the equation
not so subtly suggests that the appearance of youth
is as important – if not more so – than the posses-
sion of vitality. Keats and indeed many others
remind us not to succumb to the myopic assertion
that this generation and this time have somehow
discovered a universal truth about beauty.
Even a cursory review of our history on the
planet shows that we have long assumed appear-
ance, which conceals chronologic progression, is a
desirable goal, therefore are we now providing some
new (and some not so new) methods that are
mainly extensions of ancient practices? Perhaps
lasers, which are arguably the newest set of our
tools, are no more than sophisticated, high-tech
ways to produce thermal damage to a graded depth
in the relatively superficial dermis. Even if the aes-
thetic practitioners of ancient societies who used
fire to singe the skin did not know the complexity
of the target organ, they did know that they had
to avoid full-thickness damage to prevent scarring.
Some might contend that all modern practitioners
should be so well informed.
Early efforts often were mechanical or thermal.
These methods share a commonality with their
modern equivalents. Energy is applied directly to
the surface. Outer layers of the dermis are dam-
aged. In a modern extension, these applications are
altered to preserve the surface, usually by dynamic
cooling delivered just prior to and immediately fol-
lowing the application of energy. Fractionated deli-
veries of energy leave areas of normal tissue between
‘islands’ of treated tissue to speed recovery. Rejuve-
nation is accomplished through regeneration of the
damaged collagen in the papillary and upper reticular
dermis. The efficacy of reepithelialization is a func-
tion in large part of the density of appendages in the
treated area. In both of these applications, the skill
of the practitioner is obvious to all. Knowledge of
the territory and cultivation of a light touch can be
summarized in the time-honored admonition to ‘first
do no (permanent) harm’.
Since early antiquity, rejuvenating lotions and
potions have been concocted from all manner of
secret ingredients. Early efforts involved cytotoxic
and lytic agents that produced partial-thickness
damage to the dermis. Understanding the target tis-
sue, predicting the penetration depth and knowing
the neutralization process were of critical import-
ance if scarring was to be avoided. Surely, the exag-
gerated claims for the many proprietary agents and
practices currently being promoted remind us of
Bob Dylan’s reference to his lost love in Tangled
Up in Blue: ‘The past is close behind.’ If the past
is indeed the recent prologue to our time, will the
future be a refined version of the present? Or will
it be unrecognizable?
So now we have arrived at the risky business of
predicting. And, dear reader, you might be tempted
to ask by what authority we represent our opinions
as having value? Well, the authors of this book asked
for our opinion and you acquired the book. In truth,
our ability to see past our own noses is probably no
better than yours. As you read this, do not take us
18

(or yourself) too seriously! Enough already. What is
out there?
Over the last two decades, we have learned that
surgical wounds heal without scarring when cleft
lips and palates are repaired intrauterine. The heal-
ing process occurs in an environment that lacks
inflammatory cell proliferation. Histological analysis
of these wounds shows increased deposition of
hyaluronic acid. Perhaps, altering the wound environ-
ment with substances such as hyaluronics during
surgery and postoperative recovery will decrease
the presence of scarring.
Surely, somewhere in the future we will abandon
the relatively gross insults to tissue that we now
offer as therapeutic interventions. Patient com-
plaints of prolonged side effects and lengthy recov-
eries do not now fit comfortably into our therapies
and that is not likely to change in the future. Geno-
mic studies may provide an early step in our under-
standing of how to arrest (or slow) the decline in
peak performance as a result of the aging process
by manipulating tissue to maintain maximum vita-
lity. Understanding genetic coding could lead to
ways to manipulate function at the cellular level.
Or perhaps new cells will be developed from an as
yet unknown source of stem cells. Given the ethical
debate over embryonic stem cell use and the diffi-
culty in obtaining those cells, an alternative source
of resident cells with either inherent or inducible
pluripotent potential may represent a more accept-
able early effort. In fact, our initial efforts with fat
autographs suggest that we may even now be at
an early stage of grafting undifferentiated cells that
will mature. At a more advanced cellular level, will
specific specialized cells be reengineered by the
insertion of new genetic information? For example,
recombinant genetic technology has been utilized
to ‘teach’ bacteria how to make human insulin.
Early efforts to treat some forms of Leber’s congen-
ital amaurosis, an autosomal-recessive group of
blinding retinal diseases, by inserting genetic mate-
rial attached to an adenoviral vector into the eye
have been encouraging.1
Our understanding of intercellular communication
is limited. Pathways and transmitting agents are not
clear. Some of the ‘cross-talk’ at the cellular level
can produce effects that can be either beneficial or
disastrous, depending on the tissue involved. Vascular
endothelial growth factors (VEGF) have recently
gained much interest, especially in the eye, because
the neoangiogenesis they promote in hypoxic tissue
can lead to new vessels that are not competent. In
advanced cases of diabetes and macular degeneration,
these new vessels tend to leak blood and serum that
can obscure the visual axis, leading to irreversible
damage of the retina. Anti-VEGF treatments are
employed for targeted therapy in these diseases.
However, VEGF has other modulating activities
in vivo that can be useful in other locations. It affects
a broad spectrum of neuronal and glial proliferation,
cell migration, cell survival and proteolysis. Might it
or other as yet unidentified modulating agents be use-
ful in promoting rejuvenation locally at specified tar-
gets? Human growth hormone supplementation has
been promoted rather vigorously as an antiaging agent.
But many are concerned because of the possible pro-
neoplastic potential of such activities. The goals of
beauty and sustained youth seem direct enough, but
what are the ‘trade-offs’? Product liability is an issue
that no one can ignore. Perhaps, viral stimulation will
become a way to alter intracellular activity. Produc-
tion of new collagen and elastin in the dermis is less
important than the amount produced. Certainly, our
early insights into modulators and receptor sites place
us at the brink of an exciting and as yet poorly under-
stood internal universe that seems to offer limitless
possibilities. Will the beauty industry in its exponen-
tial and escalating growth modulate or be modulated
by patient’s needs and expectations in the search for
the fountain of youth and vitality?
If the aging process is stopped or even reversed,
what will the goal be? Who will decide what our
allotted time is? Will we review the family album
with succeeding generations who all are chronologi-
cally arrested at the same time in life? Who decides
what are the optimal parameters for a prolonged
existence? Will there be an ideal attainable by all of
us? What sacrifice of individual phenotypic expres-
sion will we be willing to tolerate? A new organ
(you specify which one) for someone who suffers
with a failing one truly represents a medical miracle.
New skin, forever youthful, may not be far behind.
In his song With Every Wish Bruce Springsteen
reminds us that we ‘better think first, with every
wish there comes a curse’. We cannot all live forever
or even for a very long time – whatever that is.
REFERENCE
1
Bainbridge JW, Smith AJ, Barker SS, et al. Effect of gene therapy
on visual function in Leber’s congenital amaurosis. N Engl J Med.
2008;358(21):2231–2239.
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