Asian Facial Cosmetic Surgery

MANDIBULAR ANGLE OSTECTOMY
366
the osteotomy line, and gently tapped to widen the
osteotomy space. After the space becomes wide enough to
insert the periosteal elevator, the angle piece of the
mandible is lifted with the leverage of the inserted elevator
(Figure 39-10). The periosteum of the medial aspect of
the mandible is then elevated through this space (Figure
39-11). Elevation of the periosteum on the medial aspect
of the mandibular angle is somewhat difficult because of
the instability created by the osteotomy. It is often
necessary to cut with the scissors or even avulse a small
amount of tissue attachment at the angle and the posterior
border of the ramus. The angle piece is then extracted with
bone forceps (Figure 39-12). After the mandibular angle
ostectomy, a sharp angle will develop at the junction
between the ostectomy line and the inferior border.
B
Figure 39-9
A, Illustration of the intraoperative view of angle osteotomy. B, Angled oscillating
saw on the angle osteotomy line.
Figure 39-10
The mandibular angle is lifted by the periosteal elevator that is introduced through
the osteotomy slit.
A
B

PROCEDURE
367
Often the patient has requested a smooth, uninterrupted
curvilinear line at this transition area. The sharp angle is
corrected either by drilling the bumpy transition with a
large rotating cutting burr or performing a second,
shallow ostectomy along the inferior border of the
mandible (Figures 39-13 and 39-14). The second ostec-
tomy requires a removal of a flat triangular piece of bone
with a maximal height of 1 cm. In every step of the
ostectomy, the surgeon should be extremely conscious of
the need for symmetry.
Next, hemostasis is obtained with a bipolar cautery. At
times, a bleeding vessel can be difficult or impossible to
find. The best prevention is to stay on the bone with the
periosteal elevator and to avoid accidental slippage. Unless
a major arterial bleeder is available, additional hemostasis
for minor oozing vessels has to rely on postoperative
vacuum drainage and compression. The pocket is then
irrigated with copious amount of antibiotic solution.
Additional hemostasis is obtained before the wound is
closed. The exit point of the drain (Blake #10 French)
Figure 39-11
The periosteum on the medial aspect of the angle portion of the mandible is
elevated.
Figure 39-12
Removed pieces of the mandibular angles.
Figure 39-13
A sharp angle on the inferior border is smoothed with the use of a large cutting burr.
Figure 39-14
The inferior border angle is resected with an angled oscillating saw.

MANDIBULAR ANGLE OSTECTOMY
368
within the mandibular pocket is between the mental
foramen and the lower border of the mandible. This
narrow, open-lumen, small-suction drain exits through a
2-mm stab incision made in the midline submental crease
(Figure 39-15). To prevent an accidental penetration of the
mandibular branch of the facial nerve, a trocar should hug
the plane of the periosteum as it is aimed at the para-
symphysisial area. It should follow the curve of the anterior
mandibular contour to reach the submental crease
incision. The drain is secured to the submental skin with a
suture. The oral incision is closed in a watertight seal
fashion using 3-0 chromic catgut suture in a running
horizontal mattress fashion. The drain is then connected
to the reservoir under negative pressure. Compression
dressings are applied by placing layers of gauze over the
mandibular angle defect and then wrapping it with elastic
bandages. The patient is allowed to wake up after the
compression dressings are completed.
Postoperative Care
Close monitoring of the airway is crucial. Nausea should
be treated early and aggressively. The patient and the
caregiver should be thoroughly educated on ways to handle
vomiting. A pair of scissors should be available next to the
patient to remove the compression bandage. Evacuating
saliva with a Yankauer suction tip helps clear the airway.
The patient is advised to sleep in a semi-sitting position. A
caregiver is advised to stay next to the patient for at least
first 2 days. The use of steroids for swelling is controversial
and is reserved for acute airway obstruction. Development
of hematoma should be carefully observed and treated if
necessary. The drain is removed in 2 to 3 days depending
on the amount it drains (less than 5 to 10 mL in 24 hours).
A liquid or pureed diet is spoon-fed for 1 week and should
not be spilled into the gingivobuccal gutter. After each
meal, a gentle mouthwash of water/H2O2 is encouraged.
Recovery
A choking sensation caused by a tight compression
dressing is common. Drooling continues for several days.
Lip and cheek swelling may last 7 to 10 days. The patient
may resume strenuous physical activity after 3 weeks.
Biting and chewing are not limited after 1 week as long as
the patient can tolerate pain.
Complications
The risks and complications that are associated with the
surgery are as follows:
• Airway obstruction
• Facial nerve injury
• Bleeding
• Weakness of the mandible
Drain position
Mandibular angle osteotomies
To collection bags
Figure 39-15
The suction drain (Blake #10 French) exits through a submental stab incision.

CASE STUDIES
369
• Hematoma
• Iatrogenic mandibular fracture
• Masseteric space infection
• Malocclusion
• Osteomyelitis
• Temporomandibular joint injury
• Wound dehiscence
• Asymmetry
• Loss of teeth
• Failure to improve
• Toothache
• Numbness of the lip and the teeth
Case Studies
See Figures 39-16 and 39-17.
References
1. Baek SM, Kim SS, Bindiger A: The prominent mandibular
angle: preoperative management, operative technique, and
results in 42 patients, Plast Reconstr Surg 83:272-278, 1989.
2. Yang DB, Park CG: Mandibular contouring surgery for purely
aesthetic reasons, Aesth Plast Surg 15:53-60, 1991.
3. Kang J, Han K: Cosmetic contouring of the lower face:
masseteric hypertrophy and prominent mandibular angle,
Probl Plast Reconstr Surg 1:654-666, 1991.
4. Moore AP, Wood GD: The medical management of
masseteric hypertrophy with botulinum toxin type A,
Br J Oral Maxillofac Surg 32:26-28, 1994.
5. Smyth AG: Botulinum toxin treatment of bilateral masseteric
hypertrophy, Br J Oral Maxillofac Surg 32:29-33, 1994.
A
B
Figure 39-16
A, Preoperative view. B, Postoperative view.
Figure 39-17
A, Preoperative view. B, Postoperative view.
A
B

371
Patients who wish to undergo lower face–contouring
surgery are apt to focus their attention on the mandibular
angle, but the body and inferior margin of the mandible
also have a close bearing on the contour of the lower face.
Neglect of the shape of these regions may lead to excessive
resection of the mandibular angle and result in deformity
or undercorrection. Mandibular angle resection is effective
in correcting a mandibular angle that conspicuously juts
out laterally. Some patients have mandibular angles that
curve posteromedially and mandibular bodies with a
convex protrusion. In such cases, it is impossible to change
the shape of the mandible merely by shaving the lateral
Mandibular Angle Splitting
Ostectomy
Masami Deguchi
cortex. To reduce the width of the lower face, as much
excessive bone as possible must be removed on the sagittal
plane. Caution must be exercised to not injure the inferior
alveolar nerve in the process (Figure 40-1).
Angle-splitting ostectomy achieves the goal by resecting
the bone on the sagittal plane (Figure 40-2). A protuberant
mandibular angle and a convex mandibular body can be
treated alike. The same operative technique can apply
regardless of their shapes. This implies that the greater the
protrusion, the larger the excised bone fragment. Another
advantage of angle-splitting ostectomy is that the anterior
40
TYPE I
TYPE II
TYPE III
Figure 40-1
Classification of the shape of the mandible. Type I:The mandibular angle juts out conspicuously. Type II:The mandibular angle is curved posteromedially and the
mandibular body protrudes in convexity. Type III:Type II, with loss of the vertical height of the chin.

MANDIBULAR ANGLE SPLITTING OSTECTOMY
372
line of bone resection is always at the same level from the
midline. As a result, postoperative asymmetry is unlikely.
If asymmetry is present preoperatively, it can be readily
corrected. A smooth jaw line can be created through
careful trimming of the bony irregularities in the vicinity of
the mental foramen. It is important to obtain symmetry in
the frontal view and a smooth mandibular curve with a
desirable angle in the lateral or oblique view.
In patients with retrusive chins, genioplasty may enhance
the improvements of mandibular angle ostectomy
(Figure 40-3).
Consultation
The expectations of the patient should be carefully
evaluated. Frontal, lateral, and panoramic radiographs of
the patient should be taken and analyzed. A treatment
plan is discussed thoroughly. The anticipated postoperative
facial contour change and the limitations of the surgery
should be clearly explained. The informed consent is
obtained before surgery.
The surgery is not recommended in cases in which the width
of the lower face in the frontal view cannot be narrowed.
Preoperative Care
The surgeon should study the radiographs to determine
the feasibility and extent of the proposed mandibular angle
resection based on the position of the mandibular canal.
The position and course of the inferior alveolar nerve are
confirmed. The condition of the teeth and the occlusal
pattern should be evaluated and documented. The patient’s
ability to fully open the mouth must be checked.
Postoperative instructions on feeding and toothbrushing
are given during the preoperative period. A preoperative
history and general physical examination are obtained.
Figure 40-2
Case 1: Angle-splitting ostectomy was performed on a 22-year-old woman. Although masseter muscle hypertrophy was present,
resection was not done. Preoperative (A,B) and 1-month postoperative (C,D) views.
A
B
C
D

PROCEDURE
373
Anesthesia
General nasotracheal intubation is preferred. Supple-
mentary local anesthsia of lidocaine with epinephrine is
infiltrated in the periosteal plane to achieve a bloodless
dissection field.
Instruments
See Figure 40-4.
• Periosteal elevator
• Obwegeser mandibular inferior border stripper
• Obwegeser retractor
• Round burr (large and small)
• Drill burr
• Chisel (10 mm wide)
• Long shaft spoon
Procedure
A local anesthetic, which consists of 1% lidocaine with
1:100,000 epinephrine, is injected into the buccal mucosa
along the oblique line in the mandibular ramus and deep
under the masseter muscle around the mandibular angle.
An intraoral incision is made in the posterior buccal
mucous membrane along the oblique line of the ramus of
the mandible and running anterior to the level of the first
molar tooth in the mucous membrane on the labial side of
the buccal sulcus. Submucosal undermining is done; the
surgeon should take care to not expose the buccal fat.
Figure 40-3
Case 2: Angle-splitting ostectomy and anterior sliding genioplasty was performed on a 24-year-old woman. Preoperative (A,B) and
3-month postoperative (C,D) views.
A
B
C
D
Figure 40-4
Instruments used in the procedure.

MANDIBULAR ANGLE SPLITTING OSTECTOMY
374
The periosteum is raised with a sharp, curved periosteal
elevator. The subperiosteal dissection is continued until
the ostectomy site over the mandibular body, ramus, and
angle is exposed. The surgeon should be particularly
careful to prevent injurying the mental nerve. To provide
adequate exposure, the masseteric aponeurosis attached to
the angle must be separated from the bone.
The cheek is retracted laterally, and the lateral mandibular
angle is marked according to the preoperative plan. Angle-
splitting ostectomy is carried out in the area posterior and
inferior to the course of the inferior alveolar nerve that
runs through the mandible. The cortex anterior to the
estimated ostectomy line is shaved in advance with a round
cutting burr. To prevent an accidental fracture through
the sigmoid notch or condyle, a straight drill burr is used
to drill a groove deep along a line that extends from
the occlusal plane and leads to the posterior margin of the
mandible. This groove serves as the upper limit of the
splitting ostectomy (Figure 40-5, A). As the mandible is
B
A
C
D
Figure 40-5
Illustration of the angle-splitting ostectomy. A, The dotted area is shaved with a round burr, and a piercing burr is used to make a deep groove along the line extending from the
occlusal plane. This groove serves as the upper boundary of the splitting ostectomy. B, A drill burr is used to make tunnels at 2- to 3-mm intervals. Both lateral and medial
cortices are resected in case the posterior and inferior margin protrudes outward. C, The cortex is split with a 10-mm-wide chisel along the tunnels. D, Bone projections created
by the ostectomy are trimmed with a round burr at the inferior mandibular border near the mental foramen.

COMPLICATIONS
375
held with a retractor, tunnels are made using a piercing
burr at 2- to 3-mm intervals running toward the medial
side of the mandible, staying as close as possible to the
posterior and inferior margins. In some cases, it may be
helpful to use a contraangle drill (see Figure 40-5, B). The
cortex of the mandibular angle is split between the tunnels
with a 10-mm wide chisel (see Figure 40-5, C). Gentle
hammering is applied to separate the cortical bone
from the cancellous bone. Chiseling should be done
carefully through the anterior two-thirds to avoid injuring
the inferior alveolar nerve. The bony projections on the
inferior border and at the anterior inferior end of
the ostectomy line near the mental foramen should be
trimmed scrupulously with a small round cutting burr.
A long shaft spoon (see Figure 40-4) is used to protect
the soft tissue. The masseter muscle is not resected (see
Figure 40-5, D).
Bleeding is minimal with the exception oozing from the
bone marrow, unless the masseteric muscle or facial artery
is avulsed during the periosteal elevation or drilling. A
suction drain through a submental incision is maintained
for 24 hours.
After hemostasis has been achieved, the wound is closed in
a watertight fashion with a single layer of absorbable
sutures (e.g., 4-0 chromic catgut).
Postoperative Care
A bulky pressure dressing with cotton padding is applied
and maintained for 2 to 3 days. Rehabilitation to relieve
trismus is started on the third or fourth postoperative day
and continued for several days until the patient is able to
fully open the mouth. The patient is fed a liquid or pureed
diet for 1 week. Gentle mouthwashing is encouraged after
each meal.
Recovery
Angle-splitting ostectomy causes virtually no damage
to the masseter muscle or any other soft tissues. The
operating time is short, and the outcome is satisfactory.
Considerable cheek swelling is present for 1 week. The final
contour becomes apparent within 1 or 2 months after the
operation. Numbness of the lower lip usually recovers
within 3 to 6 months.
Complications
The following complications may occur:
• Bleeding
• Hematoma
• Infection
• Osteomyelitis
• Wound dehiscence
• Iatrogenic mandibular fracture
• Numbness of the lower lip
References
1. Baek SM, Kim SS, Bindiger A: The prominent mandibular
angle: preoperative management, operative technique, and
results in 42 patients, Plast Reconstr Surg 83:272, 1989.
2. Deguchi M, Iio Y, Kobayashi K, et al: Angle-splitting
ostectomy for reducing the width of the lower face, Plast
Reconstr Surg 99:1831, 1997.
3. Yang DB, Park CG: Mandibular contouring surgery for purely
aesthetic reasons, Aesthetic Plast Surg 15:53, 1991.
4. Yang DB, Song HS, Park CG: Unfavorable results and their
resolution in mandibular contouring surgery, Aesthetic Plast
Surg 19:93, 1995.

377
Anatomy
The masseter muscle is a quadrangular muscle that covers
the mandibular ramus and coronoid process. It has both
superficial and deep heads. The superficial head originates
from the lower border of the zygomatic arch and inserts
into the angle and lower lateral aspect of the mandible.
Along with the mandible, this muscle has a significant
role in the contour of the lower facial frame. The deep
head originates from the posterior and medial side of the
zygomatic arch and inserts into the coronoid process and
upper lateral aspect of the ramus of the mandible. This
portion contributes to the contour of the posterior cheek.
Reduction of the superficial head of the masseteric muscle
improves the contour of the lower face while having a
minimal effect on masticator or temporomandibular joint
(TMJ) function.
Mechanism of Action
Injection of botulinum toxin type A into the masseteric
muscle results in a chemical denervation at the neuro-
muscular junction. The ensuing muscle atrophy reduces
the bulkiness of the lower lateral face and gives a soft round
contour to the lower face.
Botulinum Toxin Type A
Injection for Masseteric
Muscle Hypertrophy
Gyu Suk Hwang and Jung I. Park
Indications
Indications for the surgery are as follows:
• Small mandible and hypertrophic muscle: excellent
candidate
• Small mandible and average muscle: relative indication
• Large mandible and hypertrophic muscle: relative
indication
• Large mandible and small muscle: poor candidate
• The degree of muscle hypertrophy is determined by
placing the hands over the masseteric muscle while the
patient contracts and relaxes the muscle
Injection Technique
Principles
1. The volume of muscle reduction correlates with the
amount of the toxin injected.
2. Injection into the deep head of the muscle causes
posterior cheek depression.
3. Injection into the deep part of the superficial head in the
lower part of the mandible prevents accidental injection
into the parotid gland or the muscles of the facial
expression.
41

BOTULINUM TOXIN TYPE A INJECTION FOR MASSETERIC MUSCLE HYPERTROPHY
378
Dilution
The author uses a solution that is more diluted than that
used for the other facial muscles. Botulinum toxin type A,
Dysport® (Ipsen, Slough, U.K.), is diluted with 5 mL
normal saline to make 100 U/1.0 ml.
Dosage
The amount of Dysport solution used is 80 to 120 units
(average 100 units) for the average Korean female and 100
to 150 units (average 125 units) per side for the average
Korean male. As the size of the masseteric muscle in-
creases, the dosage should be increased. One case required
250 units of Dysport per side to achieve an optimal result.
The minimal dose to achieve any result is 50 units per side.
Design
With the patient in the supine position, a marking pen is
used to mark the boundary of the masseter muscle as the
patient contracts the muscle while the surgeon palpates
the boundary. Points A and B are then marked below the
line that connects the oral commissure and the lower
attachment of the ear lobe. At point A, the cheek protrudes
the most as the patient contracts the masseter muscle.
Point B is 1 cm superior and 1 cm anterior to the angle of
the mandible (Figure 41-1).
Injection
The toxin is delivered through a 3-mL syringe with a 1-inch
30-gauge needle or 1.5-inch 26-gauge needle. The needle
should be long enough so that the tip is able to reach
the deepest portion of the masseteric muscle without
extending into the parotid gland. First, the needle is
injected through point A until the tip of the needle touches
the bone. The needle is then withdrawn 2 mm, and half
of the entire amount is injected evenly by redirecting the
needle tip while the masseter muscle is fully relaxed. The
patient experiences less pain when the solution is injected
into a relaxed muscle. The remaining half of the solution
is injected in an identical manner through point B
(Figure 41-2).
Additional Injection
The patient is examined 2 weeks later to evaluate the
degree of volume reduction. After a discussion with the
patient, an additional dose (25% to 50% of the initial
dose) is injected into any muscle that remains actively
contracting.
Figure 41-1
Procedure design. A,The top point of maximal muscle contraction. B,The point 1 cm
anterior and 1 cm superior to the mandibular angle.
Figure 41-2
Injection. Half of the entire dose is injected through point A and half through
point B.

BOTOX
379
Sequential Changes
Sequential changes are as follows:
3 days: Patient shows evidence of weakening muscle
contraction
2 weeks: Complete disappearance of muscle contraction
4 weeks: Patient begins to show evidence of muscle volume
reduction
1 to 2 months: Maximal volume reduction period
3 months: End of muscle volume reduction
4 months: Patient begins to show evidence of muscle
contraction and volume increase
6 months: Visible volume increase
12 months: 50% to 60% of volume regained
18 to 24 months: 80% to 90% of volume regained
The maximal shrinkage of muscle occurs within 3 months
after the injection. Although the muscle volume begins to
increase in 4 months, clinically significant enlargement
becomes more evident in 6 months. At that time, a repeat
injection may be considered. The volume increase
continues gradually and correlates with the amount of
masseter muscle use. The desire of the patient becomes
strong enough to revisit for an additional injection when
the volume regained is about 50% to 60%, usually 12
months after the original injection (Table 41-1) (Figures
41-3 to 41-5).
Repeat Injection
There is no predetermined timetable for repeat injection
after the initial series of toxin doses. However, repeat
injection may be initiated when the muscle begins to
enlarge within 6 months. Most patients desire a repeat
injection in about 12 months, when the muscle mass has
increased by 50% to 60%. The dose for the second injection
is about two-thirds of the initial series because the volume
of the muscle mass is still smaller than the original mass
(Figure 41-6).
Complications
Cheek depression: This is caused by the injection of the
deep head of the masseter muscle high in the cheek. It
also could be due to an excessively large dose.
Loss of strength in mastication: This correlates with the
amount injected. Chewing is not severely restricted
except for the cracking of hard food. The temporalis and
medial pterygoid muscles supplement the loss of
function of the masseteric muscle.
Disturbance in facial expression: This is the result of an
excessively large dose or a too-superficial injection. It is
temporary and resolves within 3 to 4 weeks. It is rarely
due to a complete paralysis of the involved muscle.
Table 41-1. Changes in Masseter Muscle Volume
1 to 2 months: Rapid volume reduction.
3 months: Maximal volume reduction.
12 months: 50% to 60% of volume regained.
18 to 24 months: Plateau; 80% to 90% of original volume regained.
Black line, full dose; dotted line, half dose.
100%
50
0
1
2
3
4
5
6
12
18
24 mon.

BOTULINUM TOXIN TYPE A INJECTION FOR MASSETERIC MUSCLE HYPERTROPHY
380
Correction is aimed at regaining a balance between the
muscles on each side by injecting small incremental
doses of toxin into the healthy side. The usual dose is
5 units every 3 to 4 days until correction is achieved
(Figure 41-7).
Trismus: This almost always occurs after injection of an
excessively large dose during repeat injection. Although
a specific treatment is not available, the condition
resolves within 3 to 4 weeks.
Botox
Botulinum toxin A injection into the masseteric muscle
revolutionized the way to achieve softening and feminizing
A
B
C
Figure 41-3
A, Preoperative view. B, 1-month postoperative view.
C, 2-month postoperative view.

BOTOX
381
of the lower faces of Asian patients. Although it is not a
cure for the square, flared-out angle of the mandible, the
reduction of volume of the masseteric muscle narrowed
the indication for mandibular angle ostectomy. It also
eliminated the need for partial resection of the masseteric
muscle. Considering the magnitude of the mandibular
angle surgery and its long recovery and high complication
rate, a simple injection of botulinum toxin A is a truly
meaningful addition to the Asian cosmetic surgical
armamentarium. Botox (Botulinum toxin A, Allergan,
Inc., Irvine, CA) is available in the United States as a
purified crystallized toxin and is shipped in a sterile
vacuum bottle. The toxin is then dissolved by adding sterile
saline solution without preservation. Each bottle contains
A
B
C
Figure 41-4
A, Preoperative view. B, 3-month postoperative view.
C, 12-month postoperative view.

BOTULINUM TOXIN TYPE A INJECTION FOR MASSETERIC MUSCLE HYPERTROPHY
382
100 units of Botox. The manufacturer recommends various
dilution formulae, mixing from 2 to 8 mL of sterile saline to
the contents of the vial. The solution is injected into the
masseteric muscle with a 1-inch 30-gauge needle. A
solution of 2% plain lidocaine, 10% of the volume of Botox,
is added just before the injection to dampen the stinging
pain during the injection. A 3-mL syringe is used for the
accurate control of volume distribution. The author uses
the 8-mL dilution formula. This dilution is effective in
paralyzing a rather bulky masseteric muscle. Only the
lower half of the masseteric muscle is injected. This
portion of the muscle is responsible for the bulkiness of the
lower face and mandibular angle area. Injection of Botox
into the upper half of the muscle creates an unsightly
A
B
C
Figure 41-5
A, Preoperative view. B, 3-month postoperative view.
C, 24-month postoperative view.

CASE STUDIES
383
depression of the midlateral cheek and causes a
prominence of the zygomatic arch. The needle tip may
reach a spot in the muscle by penetrating vertically at a
right angle to the skin. This method requires multiple
punctures to infiltrate the entire muscle. The author inserts
the needle obliquely across the entire belly of the muscle
(Figures 41-8 to 41-10). The solution is then injected in a
steady stream as the needle is withdrawn or advances. The
latter method is preferred because of the benefit of the
preceding anesthetic effect as the needle advances slowly.
The patient is asked to clench the jaw to tighten the
masseteric muscle. The boundary of the muscle is marked
with a marking pen. The inferior border of the zygomatic
arch is also marked for anatomic orientation. Two or three
lines are drawn horizontally to provide a mental image of
the needle passage as a guide. The needle entry could be
from the anterior aspect (see Figures 41-8 and 41-9) or the
posterior aspect (see Figure 41-10). Although it is only a
theoretical significance, the anterior approach is preferred
to avoid penetrating the proximal portion of the facial
Figure 41-6
A, 3-month postoperative view. B, 4 months after the second injection, which was 12 months after the first injection.
Figure 41-7
A,The lip deviates to the right side due to a weakness of the left platysma muscle. B, 5 units of Dysport were injected into the right platysma muscle at the lower anterior
border of the masseter muscle in the deep subcutaneous plane.
A
B
A
B

BOTULINUM TOXIN TYPE A INJECTION FOR MASSETERIC MUSCLE HYPERTROPHY
384
Figure 41-8
The left index finger holds the angle of mandible as a guide. The patient maintains
the contracted muscle by clenching the jaw. The anterior horizontal approach is
preferred.
Figure 41-9
The muscle is palpated to assist the needle passage at a proper depth.
Figure 41-10
The posterior approach. Notice the placement of left index finger against the anterior
border of the masseteric muscle as a guide.

CASE STUDIES
385
nerve branches. As the needle advances, the patient is
asked to continue clenching the muscle while the operator
palpates the muscle with the nondominant left fingers. The
needle is passed through the midlevel or slightly deeper
than midlevel of the muscle.
The lower needle passage is at the level that is 1 cm above
the inferior border of the mandible. The needle quickly
reaches the muscle depth when the surgeon palpates the
muscle. The needle then advances parallel to the inferior
border of the mandible. The next injection is approx-
imately 1 cm above the first needle passage. These two
injections cover a 3-cm area from the inferior border of
the mandible. A third injection may be needed in certain
patients to cover the necessary area. The average initial
amount of injection ranges between 40 and 60 units
for both sides. The patient is reexamined in 1 month. An
additional injection is given based on the result of the
initial injection. The horizontal/oblique injection method
is preferred to paralyze the muscle across the belly of the
muscle. This transverse approach paralyzes the muscle
in the center of the longitudinally oriented muscle fibers
without requiring an injection in the entire length of the
muscle. It also covers the larger numbers of the muscle
fibers with the same amount of solution. Passing the needle
through the middepth of the muscle allows an even
diffusion of the solution, both superficially and deeply, as
opposed to injecting the deepest portion of the muscle and
expecting the solution to diffuse over the entire muscle
thickness. Diluting with 8 ml of saline solution enhances
easier diffusion of the toxin in a larger area.
Case Studies
See Figures 41-11 and 41-12.
Figure 41-11
A, Preoperative frontal view. B, Postoperative frontal view. Softening of both mandibular angle is evident.
A
B

BOTULINUM TOXIN TYPE A INJECTION FOR MASSETERIC MUSCLE HYPERTROPHY
386
References
1. PRS 107:327-332, 2001.
2. BR J Plast Surg 54:197-200,2001.
3. Br J Oral Maxillofacial Surg 23:26-28, 1994.
4. Br J Oral Maxillofacial Surg 57:1017-1019, 1999.
5. J Clin Neuro Ophthalmol 12:121-127, 1992.
6. Neurology 46:1382-1386, 1996.
Figure 41-12
A, Preoperative oblique view. B, Postoperative view. A smooth curve around the angle has been achieved.
A
B

V
387
When chemical peels were originally introduced in Japan,
they used strong agents such as phenol and trichloroacetic
acid (TCA). However, because of the high incidence of
hyperpigmentation and scarring, their use was considered
unsuitable for Asian skin. The development of superficial
to very superficial chemical peels using alpha hydroxy acids
(AHAs) and Jessner’s solution has made chemical peels
in the Asian countries more promising. Since it has been
shown that glycolic acid is quite effective, with fewer
incidences of adverse reactions even in Asians, it has
become the most popular peeling agent in Japan. Jessner’s
solution and beta hydroxy acid (BHA) (e.g., salicylic acid)
are lipophilic and exert keratolytic actions. These
chemicals have been shown to be very effective, primarily
for the treatment of acne and the care of oily skin or skin
with open pores. Despite the problems associated with
TCA on the Asian skin, it can be used for skin rejuvenation
and antiaging when an appropriate pretreatment protocol
is followed and the optimal concentration is chosen. TCA
can also be used for spot application on senile pigments,
freckles, and acne. Skin peeling–induced adverse events
have been reduced by the use of a pre- and postchemical
peel skin care regimen. The skin peel’s rejuvenating effects
Skin Resurfacing
Chemical Skin Rejuvenation
in Asians
Rie Yamashita
have efficiently increased, resulting in long-lasting effects.
Chemical peels have now become one of the most
important treatments in the skin care armamentarium for
Asian patients. For chemical peels to be successful, it is
important to examine the skin condition of each patient
before peeling, understand the patient’s objectives and
purpose for seeking treatment, and choose the method
most suitable for each patient.
Classification of Chemical Peels by
Penetration Depth
Skin peels are classified according to their potency and
ability to penetrate and destroy the skin layers, as follows:
1. Superficial peel: to the papillary dermis
2. Medium-depth peel: to the upper reticular dermis
3. Deep peel: to the midreticular dermis
This classification was later expanded to the following four
levels1:
1. Very superficial (exfoliation)
2. Superficial (epidermal)
42

CHEMICAL SKIN REJUVENATION IN ASIANS
388
3. Medium depth (papillary dermal)
4. Deep (reticular dermal)
Based on the Rubin and the Harold Classification,1,2 major
peeling agents and methods that are applied to Asian skin
are summarized according to the penetration depths
(Table 42-1).
Characteristics of Chemical Peeling
Agents and Preparation of Peeling
Solutions
Although concentration is one of the factors that
determines the penetration depth of AHA agents, the
penetration depth of the agents is not dose dependent.
The ratio of the concentration of free AHAs, which can
penetrate through keratinocyte layers, to total AHA
concentrations is defined as a bioavailable concentration.
The value of this free acid concentration is an indicator of
AHA effectiveness on skin peeling, which is determined by
its pH value. Most commercially available chemical peeling
agents do not clearly describe their components and
content percentage in the insert. Thus when a commer-
cially available AHA agent is used, it is desirable to first
measure the pH of the solution. Next, the free acid value,
which is actually the effective concentration of the agent, is
calculated, and then the chemical peel is performed based
on the calculated values using the Henderson-Hasselbach
equation. The pKa value of glycolic acid is 3.83 at 25o C
(Table 42-2).3 For successful chemical peeling to occur, it is
recommended that the surgeon first examine one agent
and understand its chemical characteristic and properties,
and then use it until a comfort level with its optimal
condition has been achieved.
Glycolic Acid (Hydroxyacetic Acid)
Preparation
Two formulas are commercially available:
70% solution and crystal with 97% purity. The solution
can be diluted with distilled water alone or a mixture of
distilled water and propylene glycol. The author generally
prepares the solution by adding sodium hyaluronic acid,
glycerin, and hydroxycellulose into distilled water and then
titrating this solution to the optimal pH with a sodium
citrate buffer. However, it is also acceptable and easy to
prepare the solution simply by diluting it with distilled
water. Moreover, the gelatinlike semi-liquid solution can be
prepared using xanthene gum. Because the effectiveness of
glycolic acid is monitored by the changes in the peeled
skin, the author uses a solution with a transparent base.
Table 42-1. Classification of Various Chemical Peeling Agents According to Penetrating Depth
Type of Peel
Chemical Formula
Approximate Depth of Wound
Very superficial
Jessner’s solution
Stratum corneum
10% to 50% glycolic acid
10% trichloroacetic acid (TCA)
Salicylic acid
Azelaic acid
Retinoic acid
Superficial
10% to 25% TCA
Stratum granulosum to the basal cell layer
50% to 70% glycolic acid
Medium depth
35% TCA + Jessner’s solution
Papillary dermis
35% TCA + 70% glycolic acid
30% to 45% TCA
Deep
Baker-Gordon phenol formula
Upper reticular dermis
88% phenol
≥50% TCA
Table 42-2. Henderson-Hasselback Equation
pH = pKa + log [A–]
[HA]
or
HA =
1
× C
1 + antilog (pH – pKA)
where C = original concentration of acid
HA = free acid value
From Coleman WP, Lawrence N: Skin resurfacing, Philadelphia, PA, 1998,
Lippincott, pp 52-53.

APPLICATION
389
Storage
Because glycolic acid is not light sensitive, it
can be stored in a regular clear bottle for 2 years.
Lactic Acid
Preparation
The original formula is a liquid with 85%
concentration, and it can be diluted with distilled water.
Lactic acid can be used alone or as a mixture with other
peeling agents.
Storage
Although lactic acid is not particularly light
sensitive, storage is recommended in a brown bottle for no
more than 2 years.
Jessner’s Solution
Preparation
The solution is prepared as follows:
Lesolucynol, 14 grams
Salicylic acid, 14 grams
Lactic acid, 14 grams
The solution is mixed in 95% ethanol to make a total
volume of 100 mL.
Storage
The Jessner’s solution is highly sensitive
to light and air. Therefore the recommended storage is
in an amber bottle at room temperature for no more than
2 years.
Salicylic Acid (BHA)
Preparation
Salicylic acid is a powder that can be
solubilized in ethanol.
Storage
Salicylic acid can be stored in an amber bottle
at room temperature for 2 years.
Trichloroacetic Acid (TCA)
Preparation
TCA is 100% crystal and is generally
dissolved in distilled water. Although TCA can be
dissolved in alcohols such as ethanol, TCA in alcohol
solutions cannot penetrate into the skin.
Storage
TCA can be stored in a transparent plastic
bottle at room temperature and remain stable for 2 years.
Phenol (Coal Acid)
Preparation
Phenol is available as an 88% solution.
Of the several formulas, the Baker-Gordon solution is the
most widely used. It contains the following preparation:
Phenol (88%), 3 mL
Croton oil, 3 drops
Detergent, 8 drops
Distilled water, 2 mL
Pharmacologic Actions of Peeling
Agent
Chemical peels remove aged skin and rejuvenate the skin
by using a natural healing process. Glycolic acid facilitates
the turnover of the epidermis by destroying the hemi-
desmosome in the lower keratinocyte layers and reducing
the attachment among the keratinocytes.4 This event can
be observed with an electron microscope.5 This effect is
very specific only to glycolic acid, unlike other peeling
agents whose main actions are liquefaction of the
superficial epidermal layer. In addition, glycolic acid can
stimulate the synthesis of dermal components such as
collagen, elastin, and glycosaminoglycan to thicken the
dermis.6,7 Furthermore, an inhibitory effect of glycolic acid
on the melanin production of melanocytes has also been
suggested.8 In addition, glycolic acid acts on sebaceous
glands to remove sebaceous material and penetrates into
enlarged skin pores to constrict them. Salicylic acid breaks
down and liquefies the keratinocytes. On the other hand,
TCA and phenol denature the proteins of the superficial
epidermis, resulting in dermonecrosis of the tissue. This
initiates the process of tissue regeneration, during which
collagen synthesis is stimulated and the papillary layer of
dermis is thickened. Phenol also causes depigmentation.
Application
In the United States and Europe, chemical peels have been
performed to rejuvenate aged skin. In Japan, however,
superficial to very superficial chemical peels are used for
the reduction of the oily component in oily skin, shrinkage
of enlarged skin pores, and treatment of dry skin. Chemical
peels are also used for the treatment of acne9,10 (Figures
42-1 to 42-3), photoaged skin (Figures 42-4 and 42-5),
chloasma (Figures 42-6 and 42-7), acne scars, and rough
skin induced by lichen planopilaris. It is important to
choose the peeling agents and methods most suitable to
each patient.
The lipophilic Jessner’s solution and salicylic acid are very
effective for the skin care of acne and oily skin. Because

CHEMICAL SKIN REJUVENATION IN ASIANS
390
Figure 42-1
A, Before the peel. The patient was a 28-year-old female with acne vulgaris that has been ineffectively treated with other methods. B, After the peel.
Figure 42-2
A, Before the peel. The patient was a 22-year-old female with acne vulgaris. B, 3 months after the peel. A total of four peels were performed with Jessner’s solution and glycolic
acid. TCA was locally applied twice by spot application onto the area of pustule.
A
B
A
B

APPLICATION
391
Figure 42-3
A, Before the peel. The patient was a 29-year-old female with acne vulgaris that has been ineffectively treated with other methods. B, After the peel.
Figure 42-4
A, Before the peel. The patient was a 72-year-old female with photoaged skin. B, After the peel.
A
B
A
B

CHEMICAL SKIN REJUVENATION IN ASIANS
392
A
B
A
B
A
B
Figure 42-5
A, Before the peel. The patient was a 47-year-old female with photoaged skin and scattered pigmentations. B, After the peel.
Figure 42-6
A, Before the peel. The patient was a 45-year-old female with chloasma. B, After the peel.
Figure 42-7
A, Before the peel. The patient was a 47-year-old female with chloasma. B, After the peel.

APPLICATION
393
these agents produce more desquamation than glycolic
acid, patients feel as though they have experienced
“peeling.” Patients may be concerned about interruptions
to their social lives because it usually takes 1 week for the
desquamation to settle.
Laser or light therapy is effective for patients with photo-
aged skin, specifically senile pigmentation and seborrheic
keratosis. Positive effects can be realized very quickly. Thus
the combined therapy of chemical peels with laser may
be recommended. In other cases, a glycolic acid peel for
the entire face with spot application of TCA may be
performed. The combination therapy of a glycolic acid11-13
or lactic acid peel, retinoic acid and hydroquinine
ointment, and oral medication with tranexiam acid and
vitamins C and E can be very effective for the treatment of
chloasma or age-induced stained skin (Figure 42-8). The
author pretreats the post-acne scars with Jessner’s solution
and then performs a glycolic acid peel for the entire
face. Then the author locally applies TCA to the area
surrounding the depression. Multiple sessions are required
for optimal results. For severe acne scars, the author often
performs various combination therapies of resurfacing
with the Erbium YAG laser, TCA peels, and nonablative
lasers such as the Cool Touch laser (Cool Touch, Inc.,
Roseville, CA) or the Cool Glide Xeo (Cutera, Inc.,
Brisbane, CA) (Figure 42-9).
TCA has been used as a primary agent for medium-depth
chemical peels. The peeled skin becomes white in
appearance. This phenomenon is called frosting. It induces
dermal injury by protein denaturing and aggregation. If this
phenomenon persists too long, cicatrization may occur.
The severity of frosting indicates the penetration depth of
TCA into the skin. This process is irreversible and cannot
be neutralized after the agent has been applied to the skin
and frosting has occurred.
Jessner’s solution and salicylic acid can produce a similar
whitening appearance not by frosting but by a coating with
residual degenerated alcohol remaining in the skin surface.
Although the Obagi Peel (OMP, Inc., Long Beach, CA)
(i.e., blue peeling) controls the penetration depth of the
TCA solution for safe application, it sometimes requires
anesthesia and causes long-lasting erythema. Thus this
method is not well accepted in Japan, where limitations to
daily life are not well tolerated. On the other hand, super-
ficial to very superficial peels using glycolic acid, lactic acid,
and salicylic acid have been the chemical peels of choice in
Japan because of their safety and low cost.
When a peeling agent is applied to the skin, the patient
generally feels itching and burning pain on the skin. If
the patient feels excessive pain, then the agent should be
immediately removed. Some conditions may cause deeper
penetration and excessive pain, such as facial shaving or
application of a facial pack before the peel, sunburn,
allergic or atopic dermatosis, or the presence of subtle
scars.
A
B
Figure 42-8
A, Before treatment. The patient was a 45-year-old female with chloasma. B, After treatment.

CHEMICAL SKIN REJUVENATION IN ASIANS
394
Chemical Peel
Consultation
The following issues should be thoroughly discussed with
the patient before the procedure.:
1. Effects of the chemical peel and other treatments
2. Actual method, frequency of treatments, interval
between treatments, and cost
3. Skin care before and after the treatment
4. Adverse reactions and possible remedies
5. Limitations of the treatment
Preparation and Pretreatment
The patient should follow several restrictions before the
chemical peel:
1. No facial shaving
2. No facial pack or face scrub for 1 day before peeling
3. No suntan or sunburn for 2 weeks before peeling
4. No other facial rejuvenation treatments (e.g., other
chemical peels, laser treatment, electric or wax removal
of hair) for 1 month before peeling
A medical history regarding allergies, infectious disease
(e.g., herpes labialis or contagious impetigo), autoimmune
diseases, or oral and topical medications (e.g., steroids) is
taken. These conditions may delay healing after the
chemical peel. Patients with hay fever–induced dermatitis
may suffer from excessive pain or develop deeper penetra-
tion of the peeling agents. The patient may have very small,
undetectable scars in the skin. The peeling agent can
penetrate deep into those scars, causing an unexpected
worsening of the scar. The skin should be thoroughly
examined to detect any scar. Petroleum jelly should be
applied on the scar and the area should be covered with
tape to avoid contact with the peeling agents.
A
B
Figure 42-9
A, Before treatment. The patient was a 29-year-old female with acne vulgaris. B, After the peel and laser treatment.

ADVERSE REACTIONS
395
The pretreatment for peeling, or so-called “priming,” is a
skincare regimen that can be done at home for 3 weeks
before the treatment. Although the use of priming is
controversial, it facilitates the absorption of the peeling
agent by the skin and improves facial rejuvenation when
administered properly. Certain lotions and gels containing
AHAs, retinoic acid, hydroquinone, and kojic acid have
been used. However, they all cause inflammatory reactions
at higher concentrations and may even cause problems for
the chemical peel. It is essential to properly educate the
patient regarding the use of various pretreatment agents.
Procedure
Removal of Oil
The author uses acetone. Because of
its strong, irritating smell, the patient is asked to breathe
through the mouth.
Application of the Peeling Agents
The author
applies 20% or 30% glycolic acid for 8 to 10 minutes.
Because the effect of glycolic acid is time dependent, a
timer is used. The optimal concentration and pH of
glycolic acid are determined before each peeling and is
based on the patient’s medical history and skin condition.
TCA or salicylic acid is applied locally to areas with
pustules or acne by spot peeling with a cotton swab, and
then the pus may be gently squeezed out after the skin has
cooled. A solution of 15% to 30% TCA is locally applied to
the area of senile pigmentation. Patients often complain of
a tingling, itchy feeling or pain. If the patient experiences
excessive pain, the peeling agents should be immediately
and completely removed by thoroughly washing the face.
Water and steroid-containing eye drops should be available
to rinse the eye in case the solution accidentally spills into
the eye.
Removal of the Peeling Agents
The peeling agents
should be removed from the skin with purified water
gauze. In the author’s hospital, application of the peeling
agents is performed only by the medical doctors, but
removal of the agents and cleaning can be performed by
the nurses.
Cooling
Currently, the author’s practice provides
relaxation with aromatherapy. The face is cooled with a
chilled lavender-water gauze (100% pure oil is mixed in the
purified water) for 5 minutes. It has an antiinflammatory
effect. If the redness of the skin is too strong, the author
adds another 5 minutes of cooling.
Application of Moisturizing Agents and Ultraviolet-
Shield Cream
The author uses moisturizing agents that
contain hyaluronic acid. In most cases, peels are performed
on a 4-week cycle.. The concentrations and pH of the gly-
colic acid are determined each time the peel is performed.
The skin-reaction response to the chemical peel may differ
among individuals and also according to the daily lifestyle
and habits of each patient. Many patients may have
expectations that are too high because of the influence
of mass media. Therefore it is necessary for medical
professionals to educate patients regarding the science of
chemical peels.
Adverse Reactions
The following adverse reactions have been reportedly
induced by chemical peels: hyperpigmentation or de-
pigmentation, erythema, herpes, bacterial or mycotic
infection, cicatrization, allergic reaction, and intoxication.
Erythema
In general, chemical peel–induced erythema disappears
within 3 hours to 3 days. However, it may last for 1 month
if a TCA peel has been performed. The patients should be
told that this reaction is a temporary phenomenon. It is
important to completely remove the peeling agents when
the peel is completed. In the event that some hot areas
remain, the face should be cooled with a cold water
compress until the heat sensation disappears. Figure 42-10
shows the facial condition of a 36-year-old female patient
who had a 10-minute glycolic acid peeling (30%, pH = 1.2)
followed by 5 minutes of cooling with a cold water
compress. The erythema shown in this figure disappeared
the next evening.
Hyperpigmentation and Depigmentation
Although both hyperpigmentation and depigmentation
may occur after a chemical peel, hyperpigmentation is the
most frequent adverse reaction in Japan. Hyperpigmenta-
tion occurs as a result of inflammation caused by deep
penetration of the peeling agent. The contributing factors
include: 1) poor selection of patients with a prior history of
hyperpigmentation; 2) the effect on the strength of the
chemical peeling agent (i.e., changes in the pH values);
3) poor choice of peeling agent and its application method

CHEMICAL SKIN REJUVENATION IN ASIANS
396
or duration; 4) insufficient skin preparation before the
application of the peeling agent; and 5) inadequate super-
vision during the skin changes after the application of
the peeling agents. To reduce the hyperpigmentation, the
following steps are recommended:
1. The patient’s skin condition should be examined before
the peel.
2. The pH of the peeling agents should be measured.
3. A timer should be used to precisely monitor the
duration of the application (Figure 42-11).
4. A standardized application method should be
established.
5. The chemical peel should be performed in a bright
room where the changes in the patient’s skin can be
easily observed, and the face should not be covered.
6. Transparent peeling agents should be selected.
7. The treating physician should engage in a regular
dialogue with the patient during the treatment to
monitor how the patient feels.
Extra caution is required when the peeling agent is applied
to the cheekbone, mouth angle, or nasolabial groove area
because the peeling agents may penetrate deeper in these
areas.
A
B
Figure 42-10
A, Erythema in a 36-year-old female immediately after treatment with a glycolic acid peel. B,The erythema disappeared within 2 days. The photo was taken 1 month after the
procedure.
Figure 42-11
A timer is used to measure the peeling time.

ADVERSE REACTIONS
397
The host factors for hyperpigmentation are as follows: 1)
the patient used an aggressive facial scrub; 2) the patient is
on medications with steroids; 3) the skin is dry; and 4) the
patient is menstruating or did not have enough sleep.
Figure 42-12 shows a 32-year-old female patient who was
treated with a 40% glycolic acid peel at a pH of 1.5 for 8
minutes. She developed crust formation in the lower jaw
area, which resulted in persistent hyperpigmentation. The
application of a mixture of kojic acid, hydroquinone, and
vitamin C may resolve the pigmentation. Unless the hyper-
pigmentation is very deep, the spots may disappear within
3 to 6 months in most cases. However, hyperpigmentation
causes tremendous anxiety for the patient.
Temporary Aggravation of Acne Vulgaris
Acne may become worse in 5 to 7 days after the chemical
peel. This is usually temporary and easily improved with
the use of antibiotics. When severe acne associated
with hormonal imbalance (e.g., irregular menstruation)
develops after the peel, then the patient should be
comforted with a thorough explanation.
Figure 42-13, A shows a 28-year-old female patient with
severe acne even after various treatments, including a
5-year regimen of antibiotics. The photograph shows a
worsening of the acne 10 days after a 5-minute salicylic
acid (20%) peel followed by a 10-minute glycolic acid peel
(20%, pH = 1.8). Her acne improved significantly within
1 week of antibiotic medication. Figure 42-13, B shows
an improvement after five sessions of chemical peeling
Figure 42-12
Hyperpigmentation in a 32-year-old female after treatment with a glycolic acid peel.
Figure 42-13
A,Temporary aggravation of acne induced by a peel. The photograph shows a
patient 10 days after the peel. A solution of 20% salicylic acid was first applied for
5 minutes, followed by a 10-minute treatment with 20% glycolic acid (pH = 1.8).
The patient’s acne improved after a 1-week course of antibiotics. B, After five peels.
A
B

CHEMICAL SKIN REJUVENATION IN ASIANS
398
(5 minutes of 20% salicylic acid + 10 minutes of 20%
glycolic acid [pH = 1.8]).
Herptic, Bacterial, and Mycotic Infections
Severe bacterial infection is rare after a chemical peel.
However, chemical peels are contraindicated in the patient
with a history of herpes simplex or herpes zoster.
Cicatrization
It is unlikely that superficial to very superficial peels cause
cicatrization. The deeper a chemical peeling agent gets into
the skin, the more effective it becomes. At the same time,
the risk of adverse events becomes higher as the agent
penetrates deeper. Therefore it is strongly recommended
that deep chemical peels be performed by well-trained
physicians or surgeons. Because deep peels using TCA or
phenol have a higher risk of cicatrization, extra caution
should be used for these treatments.
Allergy and Cardiac Toxicity
The cardiac toxicity of phenol may cause severe arrhyth-
mia or anaphylactic shock.14 Electrocardiograph monitor-
ing is necessary during the procedure.
Intoxication
Patients who use salicylic acid may exhibit symptoms of
intoxication called salicylism. It usually begins with tinni-
tus and vertigo and may progress to anaphylactic shock
when excessive doses are used. Lesolucynol, a component
of the Jessner’s solution, may cause hypothyroidism when
used as a long-term therapy. It also has hepatic toxicity and
may cause a methemoglobinnemia-induced jaundice.
Incrustation
Incrustation is always a strong concern among Japanese
patients. Salicylic acid is notorious for producing crust
formation. Therefore it is very important to educate
the patient well and choose the correct peeling agents.
Figure 42-14 shows a photo of a 22-year-old female patient
5 days after a 5-minute application of Jessner’s solution.
She experienced incrustation that resembled a sunburn. In
Figure 42-15, a 58-year-old female patient exhibited crust
formation 5 days after a 10-minute peeling treatment with
30% glycolic acid (pH = 1.2). In Figure 42-16, a 52-year-old
female patient exhibited crust formation 4 days after a 10-
minute peeling treatment with 40% glycolic acid (pH = 1.2).
Figure 42-14
Incrustation 5 days after a chemical peel. The 22-year-old female patient had been
treated with a 5-minute application of Jessner’s solution.
Figure 42-15
Incrustation 5 days after a chemical peel. The 58-year-old female patient had been
treated with a 10-minute application of 30% glycolic acid (pH = 1.2).

ADVERSE REACTIONS
399
References
1. Rubin MG: Manual of chemical peels, Philadelphia, 1995,
Lippincott.
2. Brody HJ: Chemical peeling, St Louis, 1992, Mosby, pp 1-5.
3. Yu RJ, Van Scott EJ: Biovailability of alpha-hydroxy-l acids
in topical formulations, Cosmet Dermatol 9(6), 1996.
4. Smith WP: Comparative effectiveness of alpha-hydroxy
acids on skin properties, Int J Cosmet Sci 18:75, 1996.
5. Fertash M, Teal J, Menon GK: Mode of action of glycolic
acid on human stratum corneum: ultrastructural and
functional evaluation of epidermal barrier, Arch Dermatol
Res 289:404, 1997.
6. Moy LS, Peace S, Moy RL: Comparison of the effect of
various chemical peeling agents in a mini-pig model,
Dermatol Surg 22:429-432, 1996.
7. Moy LS, Howe K, Moy RL: Glycolic acid modulation of
collagen production in human skin fibroblasts cultured in
vitro, Dermal Surg 22:439-441,1996.
8. Moy LS, Mulad H, Moy RL: Superficial chemical peels. In
Eheeland RG, ed: Cutaneous surgery, Philadelphia, 1994,
Saunders, pp 463-478.
9. Wang C-M, Huang C-L, Sindy C-T, et al: The effect of
glycolic acid on the treatment of acne in Asian skin,
Dermatol Surg 23:23-29, 1997.
10. Yamashita R: Chemical peeling in the treatment of acne,
Japan J Plast Reconstr Surg 46(3):271-278, 2003.
11. Yamashita R: Chemical peeling for photoaged skin
pigmentation, Clin Dermatol 44(11):1207-1211, 2002.
12. Daniel P, Mary D, Steven H, et al: Short-contact 70%
glycolic acid peels as a treatment for photodamaged skin,
Dermatol Surg 22:449-452, 1996.
13. Joyce TEL, Siew NT: Glycolic acid peels in the treatment of
melasma among asian women, Dermatol Surg 23:177-179,
1997.
14. Melvin S, Frank JG, Baron H: Complication of chemical
face peeling, Plast Reconstr Surg 54:397-403, 1974.
Figure 42-16
Incrustation 4 days after a chemical peel. The 52-year-old female patient had been
treated with a 10-minute application of 40% glycolic acid (pH = 1.2). The crust
peeled off spontaneously.

401
Skin rejuvenation in Asian patients differs in several
important respects from that in Caucasians. In Asian
patients, photoaging is associated with more pigmentation
problems but less wrinkling. However, Asian patients have
a higher epidermal melanin content and are more likely to
develop postinflammatory hyperpigmentation after laser
resurfacing. As a result, laser resurfacing is less warranted.
Nonablative skin rejuvenation is therefore more suitable
for Asian patients.
Before commencing treatment, it is important to clarify
patient expectations. The management protocol for those
who wish to improve skin pigmentation differs significantly
to the protocol for patients who want to improve skin
texture and reduce wrinkling.
Advantages and Disadvantages of
Lasers and Intense Pulsed Light Source
The advantages and disadvantages of laser versus intense
pulsed light source (IPL) are summarized in Table 43-1.
Lasers are monochromatic radiation and are therefore
highly specific. Different lasers are required to obtain a
desirable effect, thus the cost of setting up a comprehensive
laser center is high. The spot size of a laser is smaller than
that of IPL and therefore more time consuming for the
The Use of Laser, Intense
Pulsed Light Source, and
Radiofrequency for Skin
Rejuvenation in Asians
Henry H.L. Chan
operator. However, the short pulse width (nanosecond) is
advantageous, especially in the presence of dermal pigment
(e.g., tattoos and nevus of Ota), because it allows thermal
diffusion to be confined to the chromophobes. Because it
is more selective, higher fluence can be used and the
desirable clinical outcome achieved with fewer treatment
sessions. However, when it is used to treat epidermal
pigmentation, crusting can occur and patients may want to
restrict some of their daily activities (so-called “downtime”)
because they may look as though they have recently
undergone facial surgery.
Intense pulsed light source is polychromatic and therefore
less specific. It targets different chromophobes simultan-
eously and may be associated with a higher risk of compli-
43
Table 43-1. Pros and Cons of Laser and IPL
Laser
IPL
Monochromatic (fixed
Polychromatic (fixed spectrum
wavelengths)
of wavelengths)
Collimated (coherent)
Divergent (incoherent)
More specific
Less specific and act on several
Fewer treatment sessions
targets at the same time
Associated with downtime
Penetrate different depth
More expensive
More treatment sessions
Very short pulse width
necessary
is possible
No downtime
Less expensive
Larger spot size

THE USE OF LASER, INTENSE PULSED LIGHT SOURCE, AND RADIOFREQUENCY FOR SKIN REJUVENATION IN ASIANS
402
cations. To avoid adverse effects, lower fluence is used with
consequent less downtime, an advantage for some patients.
Because the device is less specific, more treatment sessions
are necessary and the financial costs to the patient are
higher. However, it is more cost effective for the operator
because one IPL can be used to treat different conditions.
IPL should not be used to treat problems of dermal
pigmentation because of the high risk of scarring due to
thermal diffusion. IPL should be used cautiously when
treating vascular lesions in Asian patients because the
higher amount of epidermal melanin reduces the safety
margin and increases the risk of adverse effects.
Laser and Intense Pulsed Light Source
for the Treatment of Pigmentation
Problems in Asians
A previous study1 that assessed cutaneous damage in
Korean patients between ages 30 and 92 confirmed the
belief that pigmentary changes are common features of
photoaging in Asians. Seborrhoeic keratosis is the major
pigmentary lesion in men, and lentigine is a prominent
feature in women.
For the last 20 years, Q-switched (QS) lasers have been
used to treat lentigines. Although QS lasers are effective,
postoperative postinflammatory hyperpigmentation (PIH)
occurs in 10% to 20% of Asian patients (Figure 43-1). It has
been suggested that this photomechanical effect (i.e., the
rapid change of thermal gradient associated with the use of
QS laser leads to generation of localized shockwave within
the target) is undesirable because most QS lasers are
absorbed by hemoglobin as well as by melanin, although to
a lesser degree. This can result in purpura and inflamma-
tion followed by PIH.2,3 Furthermore, the photothermal
and photomechanical effects of QS lasers with a longer
wavelength (i.e., alexandrite and ruby) can lead to sublethal
laser damage of the hair follicle melanocytes and cause
hyperpigmentation.
A recent study has revealed that use of a long-pulsed,
pigment-specific laser such as the 532-nm neodymium:
yttrium-aluminum-garnet (Nd:YAG)/KTP (2 millisecond
Figure 43-1
A, Before laser treatment. B, Postinflammatory hyperpigmentation after QS 532-nm Nd:YAG (fluence of 1.0 to 1.5 J/cm2, spot size of 3 to 4 mm).
A
B

LASER AND INTENSE PULSED LIGHT SOURCE FOR THE TREATMENT OF PIGMENTATION PROBLEMS IN ASIANS
403
[ms] pulse width) (Figure 43-2) or the long-pulsed
alexandrite laser (3 ms pulse width) and IPL compared
with QS lasers is associated with a lower risk of PIH. By
choosing pulse width (millisecond domain) that matches
the thermal relaxation time of the epidermis (10 mss), the
risk of thermal injury to the dermis is minimized.3
The author’s current treatment approach is to use a 532-
nm Nd:YAG laser (2-ms pulse width, 2-mm spot size, 6.5
to 8 J/cm2) with an ashen-gray appearance as the clinical
endpoint. Patients are warned that mild postoperative
crusting will occur for 5 to 7 days. For clinicians with QS
lasers, the intention is to use the lowest possible fluence
and the smallest spot size (and therefore spare the
surrounding normal epidermis) to obtain immediate
whitening. For example, for QS 532-nm Nd:YAG laser, a
2-mm spot size with 0.9 to 1 J/cm2 should be used. In some
devices (e.g., Versapulse, Lumenis), such an approach is not
possible because of mechanical reasons. It is then best to
use the lowest possible fluence. The author frequently first
tests the technique on a small skin area. This not only
enables assessment of clinical outcome but also helps
patients understand the procedure and the need for post-
operative downtime. In patients for whom downtime is a
problem, IPL can be used instead. IPL also has the
advantage of improving other skin qualities such as skin
texture and telangiectasia. The suggested parameters for
different IPL devices are listed in Table 43-2 (Figures 43-3
and 43-4). Newer generation IPL systems offer enhanced
selectivity by variation of fluence density with wavelength,
improvement in pulse width, and filtering technology.
These systems appear to improve both clinical efficacy and
safety (Figures 43-5 and 43-6).
In all cases, a moderate-potency steroid mixed with
antibiotic (e.g., mometasone furoate and fusidic acid) is
applied to the skin immediately postoperatively to reduce
the risk of PIH. Sun protection, sun avoidance, and the use
of bleaching agents 2 weeks before and after any laser/IPL
procedure also lower the risk of PIH.
Acquired bilateral nevus of Ota–like macules (ABNOM),
or Hori’s macules, is a common condition in Asia and
affects about 0.8% of the population. Clinically, it presents
A
B
Figure 43-2
A, Lentigines before laser surgery. B, Clear after treatment with long-pulse 532 Nd:YAG laser (fluence of 9 J/cm2, spot size of 2 mm, pulse width
2 ms).

THE USE OF LASER, INTENSE PULSED LIGHT SOURCE, AND RADIOFREQUENCY FOR SKIN REJUVENATION IN ASIANS
404
as bluish hyperpigmentation that usually affects the
bilateral malar regions. Other areas can also be involved,
including the temples, root of the nose, alae nasi, eyelids,
and the forehead. Unlike nevus of Ota, the pigmentation in
ABNOM occurs in a symmetrical bilateral fashion, has a
late onset in adulthood, and does not involve the mucosa.
Different QS lasers have been found to be effective in the
treatment of this condition including QS ruby, QS
alexandrite, and QS 1064-nm Nd:YAG.4-6 The suggested
treatment parameters and clinical endpoints are listed
in Table 43-3 (Figure 43-7). This condition appears to be
more resistant to laser treatment than nevus of Ota. The
risk of pigmentary disturbance is also high, with PIH
reported in 7% to 73% of cases. Several measures appear to
be important in improving the clinical outcome; these are
listed in Table 43-4.
Ablative, Nonablative Skin
Rejuvenation, and Fractional
Resurfacing
Asians tend to experience much less wrinkling. Further-
more the short-term adverse effects associated with laser
resurfacing, such as erythema and PIH, are such that this
procedure is not popular for the treatment of photoaging.
Although nonablative skin rejuvenation has been used to
treat acne scarring, the degree of improvement ranges
from mild to moderate at best. As a result, laser resurfacing
combined with other surgical procedures such as subcision
and punch biopsy remains the therapeutic option that
offers the optimal clinical outcome. Patients with acne who
have received isotretinoin in the previous 6 months should
not undergo laser resurfacing.
A
B
Figure 43-3
A, Lentigines before treatment. B, After seven treatments with IPL Vasculight (590- to 645-nm filter, energy of 45 to 60 J/cm2, duration of 2.5 to 4 for T1-T3, pulse delay
20 ms).
Table 43-2. Suggested Parameters for IPL Devices for Photorejuvenation in Asians
Energy
Filter Wavelength
Mean
Range
Palomar (Estelux, LuxG)
500 to 670 nm & 870 to1400 nm
Level 5 to 6 (28 J/cm2)
Button 1 to 6 (17 to 30 J/cm2)
Ellipse
400 to 720 nm
8 J/cm2
8 J/cm2
Aurora
580 nm
25 J/cm2, RF 20 J/cm2
20 to 28 J/cm2
Quantum
560 nm
23 J/cm2
19 to 29 J/cm2
640 nm
30 J/cm2
24 to 35 J/cm2
Vasculight
550 to 590 nm
36 J/cm2
33 to 55 J/cm2

ABLATIVE, NONABLATIVE SKIN REJUVENATION, AND FRACTIONAL RESURFACING
405
In the author’s practice, a 2-mm punch biopsy for deep,
punch-out acne scars is taken 2 weeks before laser
resurfacing. For laser resurfacing, patients are prescribed
a systemic antiviral (famciclovir 250 mg total dissolved
solids) and a systemic antibiotic (cefuroxime 250 total
dissolved solids) 48 hours before laser surgery and until
complete reepithelization. Patients receive diazepam
(10 mg) and two tablets of dologesic 1 hour before the laser
procedure, which is performed under regional nerve block
and local anaesthetic tumescent injection. Three passes of
Figure 43-4
A, Before treatment. B, After six treatments with IPL Quantum (560-nm filter, energy of 22 to 27 J/cm2, duration of 2.4 and 4.0 for T1 and T2, pulse delay 15 ms).
A
B
A
B
Figure 43-5
A, Before treatment. B, After six treatments with IPL Palomer Estelux (Lux G-6, 500- to-670-nm and 870- to 1400-nm filter, energy of 30 J/cm2, pulse delay 20 ms).

THE USE OF LASER, INTENSE PULSED LIGHT SOURCE, AND RADIOFREQUENCY FOR SKIN REJUVENATION IN ASIANS
406
CO2 laser are performed followed by one pass of Erbium
YAG (Figure 43-8). A closed dressing is applied for 48
hours, followed by an open dressing. Daily follow-up is
necessary to ensure that wound infection does not occur.
Nonablative rejuvenation, with its lower risk of adverse
effects and downtime, has generated much interest among
Table 43-3. Suggested Treatment Parameters for ABNOM
Laser
Wavelength
Fluence
Spot Size
QS ruby
694 nm
7 to 10 J/cm2
2 to 4 mm
QS alexandrite
755 nm
4 to 6 J/cm2
3 mm
QS Nd:YAG
1064 nm
4 to 6 J/cm2
3 mm
A
B
A
B
Figure 43-6
A, Before treatment. B, After one treatment with IPL DDD Ellipse (400-nm filter, pulse time of 2.5ms, delay of 10 ms, 8 J/cm2).
Figure 43-7
A, ABNOM before laser surgery. B, Complete clearing after QS alexandrite (fluence of 6 to 8 J/cm2).

ABLATIVE, NONABLATIVE SKIN REJUVENATION, AND FRACTIONAL RESURFACING
407
A
B
C
Figure 43-8
A, Before treatment. B, Immediately after treatment. C, 6 months after
ablative treatment for acne scarring (three passes with a CO2 laser
followed by one pass with a Er:YAG laser).

THE USE OF LASER, INTENSE PULSED LIGHT SOURCE, AND RADIOFREQUENCY FOR SKIN REJUVENATION IN ASIANS
408
Asian patients. Many lasers have been used. The vascular
type (pulse dye lasers and 532 Nd:YAG laser) affects the
papillary dermal vessels and in doing so leads to microvas-
cular damage. The subsequent healing process generates
new collagen. Because of the higher epidermal melanin
content of Asian skin, vascular lasers are more likely to
induce adverse effects. Furthermore, because epidermal
melanin acts as a competing target chromophore for
hemoglobin, the optimum parameters for nonablative skin
rejuvenation in Asians when a vascular laser is used are not
yet determined. The infrared lasers (1064 to 1540 nm)
target water, and their photothermal effect, produced as a
result of the laser-tissue interaction, causes a rise in the
dermal temperature. The consequences are collagen
tightening, increased fibroblastic activity, and increased
collagen production. These longer wavelength lasers are
better suited to nonablative skin rejuvenation in Asians
because the longer wavelength is associated with less
epidermal melanin interference.
A recent study showed that a 1064 Nd:YAG laser in the ms
domain plus long-pulsed 532-nm potassium titanyl
phosphate (KTP) laser can be used successfully for
nonablative skin rejuvenation in Asians.7 The fluences that
were used varied between 7 and 15 J/cm2 at 7- to 20-ms
pulse duration with a 2-mm handpiece, and 6 to 15 J/cm2
and 30- to 50-ms pulse duration with a 4-mm handpiece
for KTP. The Nd:YAG fluences were set at 24 to 30 J/cm2
for a 10-mm handpiece and 30 J/cm2 for a SmartScan Plus
scanner. These energies were delivered at 30- to 65-ms
pulse durations.
Another study8 concluded that use of a 1320-nm Nd:YAG
laser was well tolerated in Asians and produced a moderate
improvement that was both subjectively apparent to the
patient and objectively confirmed by histologic and
cutometer assessment. The parameters and the technique
used are listed in Table 43-5.
The 1450-nm diode laser tends to be associated with a
significant risk of PIH; therefore its use in Asian patients is
limited. It has been proposed that the total duration of
cryogen spray at 60 mss was responsible for the high rate of
PIH.9 However, even with a shorter cryogen spray duration
at 40 mss, a recent study of its use in the treatment of
atrophic acne scarring in Asian patients concluded that the
5% risk of PIH was too high for a cosmetic procedure.10
The 1540-nm Erbium glass laser is another long-
wavelength infrared system that has been used for
nonablative skin rejuvenation.11 Its advantage compared
with other lasers in the infrared spectrum is that it is
painless. However, the lack of a clinical end point is a
disadvantage. When using such a laser, the author uses five
stack pulses of 10 J/cm2 to treat most of the face except the
periorbital area, where three stack pulses of 10 J/cm2 are
used (Figure 43-9).
Fractional resurfacing is a new development in laser
technology that involves the use of a 1540-nm laser and a
computer scanning device to generate microscopic spots
of thermal injury surrounded by healthy skin tissue.12
Preliminary data derived from Asian patients suggest that
PIH is not a problem. Further large-scale study of its role in
the treatment of photoaging in Asians is required.
Table 43-4. Measures for Improving Clinical Outcomes
for Patients with ABNOM
Avoidance of sun exposure and application of sunblock at least
2 weeks before treatment and continued thereafter
Use of bleaching agents (4% hydroquinone mixed with 0.1%
mometasone furoate and 0.025% tretinoin cream) twice daily
at least 2 weeks before treatment and continued thereafter
Application of depigmentary agents from the second week
after each laser treatment, when the epidermis had
reepithelialized, until the next laser treatment (scheduled at
4- to 6-week intervals)
For resistant cases, immediate use of QS alexandrite after QS
1064-nm Nd:YAG laser
Patient education regarding the risks of hyperpigmentation
and hypopigmentation
Table 43-5. Parameters and Technique for Nonablative Skin
Rejuvenation Using 1320-nm Nd:YAG Laser
Perform three passes, two with precooling and one with a
postcooling cryogen spray of tetrafluoroethane.
Fluence used for the first and second precooling passes should
be in the range of 16 to 22 J/cm2.
Fluence for the first and second passes should be determined
by achieving a peak temperature of 42° to 45° C.
Third pass should be delivered with a fluence of 13 to 17 J/cm2;
aim to achieve a temperature of less than 40° C after laser
treatment.
Temperature should be rechecked after 10 treatment spots
because cutaneous temperature tends to increase.
Because the central facial area and pitted scars are more likely
to develop complications, careful temperature monitoring is
necessary in these regions.

CONCLUSION
409
Radiofrequency and Light-Emitting
Diode
Radiofrequency differs significantly from laser surgery:
Instead of targeting a particular chromophobe, it involves
the passage of an electrical current leading to volumetric
tissue heating. The degree to which tissue is heated depends
on its resistance to electron movement. To protect the
epidermis, simultaneous contact skin cooling is necessary.
The advantage of radiofrequency is that the operator can
control the depth and the amount of energy delivered by
alternating the size of the electrode, amount of electric
current, and degree of cooling. The thermal effect is inde-
pendent of the skin type, which is a major advantage for
Asian patients. Two types of radiofrequency device for non-
ablative skin rejuvenation are available. Unipolar radio-
frequency involves the application of one electrode to the
trunk with the other in a handpiece attached to a cooling
device. The thermal profile indicates that the depth of thermal
diffusion for such unipolar radiofrequency systems is as
deep as 7 mm below the skin surface. It can be effectively
used for the treatment of perioribital wrinkling, skin laxity
(Figure 43-10) and to obliterate the nasolabial groove.13,14
Bipolar radiofrequency implies that both electrodes are
located in the handpiece and therefore the depth of
thermal diffusion is much more superficial. To improve
clinical efficacy, bipolar radiofrequency is used in combi-
nation with IPL (Figure 43-11) or laser for nonablative skin
rejuvenation, hair removal and treatment of vascular
lesions.15 The intention of such a combination is to create
a synergic thermal effect and thus enhance efficacy.
Limited data comparing such combined devices with IPL
or laser alone are available, and further study is necessary
to define their role in Asian patients.
Photomodulation using a light-emitting diode (LED) laser
is a recent development. Data suggest that it works by
sending signals to the cells and in doing so, leads to alter-
nation in cellular function including increased collagen
production.16 Data on the effects of its use in Asians are not
available, but it appears to be effective when combined
with other nonablative techniques such as IPL.
Conclusion
Photoaging in Asian patients tends to present as a
pigmentation problem. Long pulse laser with IPL can
more effectively remove epidermal pigmentation with a
lower risk of postinflammatory hyperpigmentation when
compared with QS lasers. Dermal pigmentation such as
ABNOM should be treated with QS lasers.
A
B
Figure 43-9
A, Before treatment. B, Afterfour treatments with laser Aramis (1540 nm, 10 J/pulse × 5 pulses, periorbital: 30 J of 10 J/pulse × 3 pulses).

THE USE OF LASER, INTENSE PULSED LIGHT SOURCE, AND RADIOFREQUENCY FOR SKIN REJUVENATION IN ASIANS
410
A
B
A
B
Figure 43-10
A, Before treatment. B, 4 months after first treatment with RF (treatment level: 13.0 to 15.0, one pass).
Figure 43-11
A, Before treatment. B, After six treatments with IPL Aurora (580 nm, short pulse, RF = 20, energy of 20 to 28 J/cm2, 12% to 18% ISL).

CONCLUSION
411
Long-wavelength lasers should be used to improve
wrinkles and skin texture in Asian patients. Both the
1320-nm Nd:YAG and 1540-nm Erbium glass lasers appear
to be effective. The 1450-nm diode laser is associated with
a higher risk of postinflammatory hyperpigmentation and
should be avoided. IPL can be used to improve all aspects
of photoaging but is less specific and thus requires more
treatment sessions. Further advances including radio-
frequency, fractional resurfacing, and photomodulation
can improve the outcome for Asian patients who want to
undergo skin rejuvenation.
Bibliography
Chan HH, Alam M, Kono T, et al: Clinical application of lasers
in Asians, Dermatol Surg 28:556-563, 2002.
Chan HH: Treatment of photoaging in Asian skin. In Rigel DS,
Weiss RA, Lim HW, et al, eds: Photoaging, New York, 2002,
Marcel Dekker, pp 343-364.
Chan HH, Kono T: Laser treatment for ethnic skin. In Dover JS,
Alam M, Goldberg D, ed: Procedures in cosmetic
dermatology, vol 2: Laser skin surgery, New York, 2005,
Elsevier (in press).
References
1. Chung JH, Lee SH, Youn CS, et al: Cutaneous photodamage
in Koreans: influence of sex, sun exposure, smoking, and
skin color, Arch Dermatol 137:1043-1051, 2001.
2. Chan H: The use of lasers and intense pulsed light sources
for the treatment of acquired pigmentary lesions in Asians,
J Cosmet Laser Ther 5(3-4):198-200, 2003.
3. Chan HH, Fung WKK, Ying SY, et al: An in vivo trial
comparing the use of different types of 532-nm
neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers in
the treatment of facial lentigines in oriental patients,
Dermatol Surg 26:743-749, 2000.
4. Kunachak S, Leelaudomlipi P, Sirikulchayanonta V:
Q-switched ruby laser therapy of acquired bilateral nevus of
Ota–like macules, Dermatol Surg 25:938-941, 1999.
5. Polnikorn N, Tanrattanakorn S, Goldberg DJ: Treatment of
Hori’s nevus with the Q-switched Nd:YAG laser, Dermatol
Surg 26:477-480, 2000.
6. Lam AY, Wong DS, Lam LK, et al: A retrospective study on
the efficacy and complications of Q-switched Alexandrite
laser in the treatment of acquired bilateral nevus of
Ota–like macules, Dermatol Surg 27:937-941, 2001.
7. Lee MW: Combination visible and infrared lasers for skin
rejuvenation, Semin Cutan Med Surg :288-300, 2002.
8. Chan HH, Lam LK, Wong DS, et al: Use of 1320-nm
Nd:YAG laser for wrinkle reduction and the treatment of
atrophic acne scarring, Lasers Surg Med 34:98-103, 2004.
9. Tanzi EL, Williams CM, Alster TS: Treatment of facial
rhytides with a nonablative 1450-nm diode laser: a
controlled clinical and histologic study, Dermatol Surg
29:124-128, 2003.
10. Goh CL, Chua SH, Ang P, et al: Efficacy of smooth-beam,
1450-nm laser for treatment of acne scars in Asian skin,
Lasers Surg Med S16:76, 2004.
11. Fournier N, Dahan S, Barneon G, et al: Nonablative
remodeling: a 14-month clinical ultrasound imaging and
profilometric evaluation of a 1540-nm Er:Glass laser,
Dermatol Surg 28:926-931, 2002.
12. Herron GS, Tanner H, Sink RK, et al: Fractional resurfacing
treatment of periorbital wrinkles, Lasers Surg Med S16:72,
2004.
13. Ruiz-Esparza J, Gomez JB: The medical face lift: a
noninvasive, nonsurgical approach to tissue tightening in
facial skin using nonablative radiofrequency, Dermatol Surg
29:325-332, 2003.
14. Fitzpatrick R, Geronemus R, Goldberg D, et al: Multicenter
study of noninvasive radiofrequency for periorbital tissue
tightening, Lasers Surg Med 33:232-242, 2003.
15. Sadick NS, Makino Y: Selective electrothermolysis in
aesthetic medicine: a review, Lasers Surg Med :91-97, 2004.
16. Weiss RA, McDaniel DH, Geronemus RG, et al:
Nonablative, non-thermal light- emitting diode
phototherapy of photoaged skin, Lasers Surg Med S16:92,
2004.

VI
413
Hair transplantation in Asians differs from that in
Caucasians, as follows:
1. The scalp of the Asians appears round and wide com-
pared with the long and narrow scalp of Caucasians.
Also, Asians tend to form keloids or hypertrophic scars.
Therefore the scar may become visibly wide when scalp
reduction surgery is performed in Asians.
2. Most Asian hair is black, coarse, and straight. Hair
transplantation is difficult, especially when the skin is
light. Many Koreans with thick hair have a visibly high
contrast between the hair and skin color, which requires
very small grafts (usually fewer than two hairs per graft)
to produce a natural look. The occipital scalp hairs
of Koreans consist of 45% 1-hair follicular units, 42%
2-hair follicular units, and 7% 3-hair follicular units.1
Follicular unit transplantation uses hair from their
natural groupings.2 A great advantage of follicular unit
transplantation is that a single session can stand
completely on its own and look extraordinarily natural.
Subsequent procedures are simply the decision of
the patient to add additional density. However, this
technique involves a long operating time, reliance on a
large surgical team, and the use of more delicate grafts.
Hair transplantation
Hair Transplantation
in Asians
Jung-Chul Kim
These factors introduce a new set of problems, which
can potentially manifest itself as poor hair growth. This
technique involves the joint efforts of highly trained and
experienced assistants as well as the physician.
3. Asians often have low, wide, and flat hairlines with a
wider and gentler curve. These characteristics create
difficulties in hairline design. The physician must
negotiate with the patients and modify the desired
hairline to produce good cosmetic results.
4. Asians have a lower hair density than Caucasians.
Korean hairs have a density of approximately 120 hairs
per cm2 in the occipital zone and about 100 hairs per
cm2 in the temple area.1 Therefore a larger donor area is
required and the available donor hair is limited.
5. Asians generally want a full head of hair. Asians have high
expectations and reluctantly accept alopecia on the vertex.
The patient must be well informed about future hair loss.
Planning
Male pattern baldness is a progressive disorder. Planning
should ideally take into consideration the present as well as
44

HAIR TRANSPLANTATION IN ASIANS
414
future areas of involvement. The surgeon should therefore
transplant into areas that are still hair bearing but can be
expected to become alopecic in the future. The vertex is
not a good candidate for transplantation, especially in
younger patients, because of the difficulty in accurately
estimating future hair loss. It is wise to maintain a donor
area “reserve” of hair that is expected to be permanent.
Younger patients are recommended to begin medical
therapy. Finasteride with or without minoxidil has the
potential to significantly reduce future hair loss and may
also promote growth, particularly in the vertex. The new
5-year data on finasteride shows that 66% of treated
patients have significantly more hair in the vertex than
when they started the drug therapy.3 The effectiveness of
both drugs in the vertex is another reason to delay
transplanting in this area. By preventing or reducing the
potential for further hair loss, the surgeon has a much
greater margin of safety.
The transplanted hairline should not be too low or cause
excessive blunting of the frontotemporal recessions. The
natural hairline is a feather zone of sparse, fine, and irregu-
larly placed hair with increasing density from the bald
forehead to the denser, coarser hair found on top of the
head. Its placement is important because it frames the face
and improves the aesthetic appearance lost through baldness.
Preoperative Instructions
and Anesthesia
The hair is shampooed the night before and the morning
of the transplant. A complete blood count, a routine
urinalysis, tests for human immunodeficiency virus (HIV)
and hepatitis B and C antigen, and a thorough patient
history and physical examination should be performed in
all patients before surgery commences. When the patient
arrives for surgery, the author begins by taking presurgical
photographs. Diazepam 10 mg is given orally 30 minutes
before surgery to minimize anxiety and decrease the
possibility of anesthetic toxicity.
A careful assessment of the donor site is performed with a
densitometer to gauge the number of 1-, 2-, and 3-haired
groupings that might be obtained from the donor strip.
Hair in the donor area is clipped to a length of 1.0 to 1.5 cm
(Figure 44-1). The patient is placed in a prone position and
draped; paper tape should be used to hold the hair clear
of the operative field. A buffered solution of 1% lidocaine
with 1:100,000 epinephrine is injected slowly through a
30-gauge needle into the deeper tissues to raise the scalp
and harden the donor tissues. A pulse oximeter is used
throughout the surgery.
Donor Harvesting and Closure
Because of the relative sparseness of the donor hair and
the propensity of Asians to form thick scars, wide donor
area scars are seen more often in Asians. Cosmetically
acceptable scarring is best achieved by careful patient
selection, reduction of risk factors, and meticulous surgical
technique. Despite these precautions, a small percentage of
patients will develop significant scarring.
The author prefers the lateral donor harvesting technique.4
This technique uses the hair of the parietal area from the
onset. The donor area extends from the midline of the
occipital area into the parietal and posterior temporal area.
The typical donor width is 1.2 to 1.5 cm, and the length is
10 to 14 cm. The author usually obtains approximately
2000 hairs per session. The contralateral area is used in the
second session (Figure 44-2).
Moreover, the author prefers a simple elliptical harvesting
technique5 using a single-bladed knife with a #20 blade,
rather than the multiblade knife technique (Figure 44-3).
Because the hair follicles of Asians are longer than those
of Caucasians, the probability of transection is very high in
Asians.
Figure 44-1
Hair in the donor area is clipped to a length of 1 cm.

DONOR HARVESTING AND CLOSURE
415
The scalp surface is gently scored with the #20 blade, and
then a deeper incision is made. A donor strip is excised at
the level of the subcutaneous adipose tissue (Figure 44-4).
The undersurface of the donor strip should not be stained
with blood. Bloodstaining of the adipose tissue greatly
complicates the graft dissection. The surgeon should
stay above the galea at all times and encounter only mild
bleeding. Very little cautery is required.
Wide scars tend to occur more readily in younger patients.
Younger skin is more elastic. The rate of collagen synthesis
is also greater in younger persons. The author prefers long,
skinny strips for younger patients. The wound is usually
closed with a running single-layer suture technique using a
3-0 nonabsorbable monofilament suture. Generally, short
and wide strips can be used for older patients because they
have a lowered inflammatory response and less scar tissue
than younger people. In this case, the donor closure is
often complicated by moderate tension on the wound
edges. The wound closure is achieved with a Pulley suture6
at three points, with the first in the middle of the wound
and the other two placed laterally (Figure 44-5). Simple
interrupted sutures are used to complete the wound edge
approximation. The pulley suture is useful in closure of
First session
Second session
Figure 44-2
Lateral donor harvesting.
Figure 44-3
A single-bladed knife is used to obtain the strip.
Figure 44-4
Strip removal is accomplished with a #20 blade.

HAIR TRANSPLANTATION IN ASIANS
416
wounds under tension without the complications asso-
ciated with excessive undermining. The sutures are usually
removed at the 10th postoperative day. The length and
width of the donor strips, the closing tension, and the
number of grafts obtained are noted on the operative
record and serve as a guide to the amount of donor tissue
that should be excised in future sessions.
Graft Preparation
The excised strip is placed on a block of birchwood and
sectioned into smaller segments using a #20 scalpel blade,
with careful positioning of the blade between and at the
same angle as the visible hair follicles (Figure 44-6). With
the same blade, each segment is then cut again into
follicular units. Grafts are closely trimmed to eliminate all
unnecessary dermis and subcutaneous tissue, thereby pro-
viding very clean and neatly trimmed grafts (Figure 44-7).
Clean and closely trimmed grafts allow for implantation in
a greater density than grafts that are allowed to carry with
them all the surrounding dermis. Drying of the grafts
should be avoided during the graft preparation.7
A transection cannot be avoided during the dissection
process. However, the author will implant the transected
grafts. Upper follicle implants can regenerate thin hairs,
and lower follicle implants can also reconstitute the
complete hair follicle.8
The grafts should be placed in a petri dish with gauze or
Telfa pads (Kendall Co., Mansfield, MA) that has been at
least half filled with cold saline (Figure 44-8). Preserved
Figure 44-5
Donor site closure with Pulley suture and simple interrupted suture.
Figure 44-6
The excised strip is sectioned into smaller segments using a #20 blade.
Figure 44-7
The grafts are neatly trimmed.
Figure 44-8
The grafts are placed in a petri dish with gauze.

IMPLANTATION
417
hair grafts have a greater survival rate at 4° C compared
with room temperature.7 Storage of prepared grafts on
gauze or Telfa pads (in air-fluid interface) can increase the
integrity of hair grafts as compared with floating (i.e.,
submerged preservation). If the grafts are immersed, the
grafts absorb excess solution, which causes greater diffi-
culty during placement into the needle of the implanter.
Even though chilled normal saline is used, it is best to
implant the grafts within a 6-hour period.
Implantation
A solution of 2% lidocaine with 1:100,000 epinephrine is
used to produce a ring block along the hairline and a field
block in the recipient area. The author does not infiltrate
the entire recipient area at once but instead infiltrates a
small planting area.
A follicular unit is placed onto the needle of the KNU
implanter9 using jeweler’s forceps (Figure 44-9). The
operator should now insert the needle into the skin at
the desired angle and push the plunger. The needle is
automatically withdrawn, leaving the hair graft neatly
tucked under the skin. It should be noted that the small
guide hook on the housing holds the hair graft in place as
the needle is withdrawn (Figure 44-10).
Therefore the KNU implanter requires less graft handling
and eliminates crushing, squeezing, and bending of the
grafts. Three types of KNU implanters are available: 1) type
L (equipped with an 18-gauge needle) for implanting 3-hair
follicular units; 2) type M (20-gauge needle) for 2-hair
follicular units or single-hair grafts; and 3) type S (22-gauge
needle) for fine single-hair grafts (Figure 44-11). The guide
Figure 44-9
A follicular unit is placed into the needle of the KNU implanter.
Figure 44-10
Graft implantation using the KNU implanter.
Figure 44-11
Three types of KNU implanters.

HAIR TRANSPLANTATION IN ASIANS
418
hook on the implanter can make the epidermis level the
same between the grafts and the recipient skin so that
the exit point of each hair looks very natural. It is very
important to avoid burying the grafts beneath the level of
the surrounding skin. It is far better to leave a graft
protruding slightly above the level of the skin than to leave
it below the skin because pitting or epidermal cysts may
result from the latter. The KNU implanter helps ensure
the proper direction and acute angle of the grafts (Figure
44-12). An acute angle of insertion can reduce bleeding
and the “popping-up” phenomenon.
The hairline is made with single hair grafts at first.
Follicular units are inserted randomly to conserve their
original architecture posterior to the hairline.
For most patients, limited transplantion to the anterior
two-thirds of a potential balding area is a more reasonable
and cosmetically acceptable goal. When the patient wants
to attempt to treat the entire area, the grafts are implanted
in a very low density in the posterior third.
Popping can be very frustrating and can prolong surgery.
Popping refers to previously transplanted grafts “popping”
out of the skin during the transplantation of a new graft.
To reduce graft popping, follicular units are usually
transplanted from posterior to anterior and left to right.
This reduces the amount of compression force on the
previously planted left and posterior graft.
Periodic additional infiltration of small amounts of
1:50,000 epinephrine is used whenever the bleeding
becomes problematic during graft implantation.
Dense packing with more than 40 follicular units/cm2
results in poorer growth. The placement of 30 to 40
follicular units/cm2 with the KNU implanter does not
decrease hair survival.
With follicular units weighted to the front and on the
parted side, combing the hair from the part and front
produces a “layering” effect that makes the hair appear
fuller and thicker. Layering is a critical element in the
aesthetics of the hair restoration process in Asians. The
density that can be achieved is less than that which was
originally present. By layering the hair, the light does not
easily penetrate the scalp and the lower density becomes
less obvious.
Many surgeons have used hydrogen peroxide to remove
blood during and after surgery. Hair growth is adversely
affected even at 1 minute with the standard, commercially
available 3% solution of hydrogen peroxide. The author
uses normal saline or 1.5% hydrogen peroxide for scalp
cleansing during hair transplantation.
Follicular unit transplantation using the KNU implanter is
especially suited to young patients or women who have
generalized thinning because it allows for the placement of
grafts between areas of thinning without removing a
potentially long-lasting hair (Figure 44-13).
The author routinely performs hair restoration sessions of
approximately 2000 hair follicles (Figures 44-14 and 44-15).
The operating time is about 3 hours. A six-person team is
generally used, which includes one doctor who implants
follicular units, one assistant who inserts grafts into the
needle of the KNU implanter, and four assistants who
prepare the grafts.
Postoperative Care
The patients require no bandages. The recipient area is
always left open. This enables the transplanted area to be
exposed to the air for drying. Oral steroids, analgesics, and
Figure 44-12
The KNU implanter helps ensure the proper direction and acute angle of the grafts.