Centrofacial Rejuvenation

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
F
E
H
G
Fig. 10-8, cont’d E,
from the anterior nasal spine to the tip. F,

thereby avoiding any major blood vessels. G and H, Finally the nasal shape is completed by adding
small boluses at either side of the radix to create a smooth nasoorbital aesthetic line.

• Aesthetic Contouring of the Upper and Central Third of the Face
This replicates exactly what a colum ellar strut graft would achieve. For extra

noticeable aesthetic accent.
To widen the root of the nose and allow the dorsal aesthetic lines of the nose to

laterally and then m olded to create a continuous nasoorbital curve (Fig. 10-9).
-
plications.
Fig. 10-9 A, A young Asian lady with a low nasal bridge and inadequate tip projection. B, An injec-

nasoorbital aesthetic line.
B
A
CONTOURING OF THE SUPRAORBITAL BROW AND FOREHEAD
As awareness increases for the need to rejuvenate the nose and familiarity grows
w ith the techniques of doing so, the natural progression is to also rejuvenate
and reshape the brow and forehead. This starts with an aesthetic sensibility to
visually connect the side of the nose with the medial brow and to see the brow

and aesthetically desirable shadows in the periorbital area.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
-
per and lower lids, giving the appearance of bulging “frog-like” eyes. A low nasal
radix accentuates this perception. Adding volum e and projection to the supra-
orbital rim creates an aesthetically more interesting periorbital region in which
the eyes look more recessed (Fig. 10-10).
Fig. 10-10 A,
bulgy eyes. B, -
soorbital curvature, anteriorly project the supraorbital ridge, and enhance the m alar highlights,
thereby m aking the eyes protrude less. Projection of the superolateral orbital rim also creates a
more aesthetic oblique view of the face.
B
A

• Aesthetic Contouring of the Upper and Central Third of the Face
-
ther above, behind, or below the level of the eyebrow can alter the perceived level
of the brow. In both Asian and patients of European descent a smooth, rounded
forehead is considered aesthetically desirable, and a growing trend, especially
in Asia, is for forehead contouring and smoothing (Fig. 10-11).
Fig. 10-11 A, B, She is shown 3 months

curve the forehead anteriorly.
B
A

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice

Shaping of the brow and forehead is very dependent on the desires of the patient
and the aesthetic judgment of the injector. Regardless of the aesthetic endpoint,
-

vessels that emerge through it. This is followed by slow, steady injection through
a 30-gauge needle placed perpendicularly directly onto the bone. Between 10
and 20 individual interrupted boluses or columns, depending on the size of each
bolus, are injected from the bone up to the overlying skin, creating a tent-pole
-
-

Fig. 10-12 -
ered as a bolus preperiosteally and subgaleally. This is the plane of least resistance. Disconnected
boluses of varying height and volume are molded together to achieve a smooth and harmonious
curved surface.

• Aesthetic Contouring of the Upper and Central Third of the Face

For m en who wish to have a stronger, m ore m asculine brow, direct injections
to the m edial half of the anterior surface of the supraorbital ridge behind the
eyebrow creates a more forward and purposeful appearance. A small amount of

Women typically desire smoothly arched eyebrows with the tail at a level higher

the lateral half of the supraorbital ridge, which creates m ore visual space be-
tween the tail of the eyebrow and the lash margin (Fig. 10-13).
Fig. 10-13

supraorbital notch at all times to reduce trauma to the vessels and nerves. If projection is required
in this region, boluses should be delivered on either side of the foramen and then molded toward it.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice


halfway between the supraorbital ridge and the anterior hairline. The size of the
bolus depends on the patient’s anatomy, the desired result, and the physician’s
clinical judgment. The patient is turned sideways to evaluate whether the apex

of Asians and persons of European descent foreheads exist: The apex of Asian
foreheads has a convexity at the junction of the upper third of the forehead with
the middle third. The foreheads of patients of European descent tend to peak at
the junction of the middle third with the lower third. Once this point has been
established, m ultiple boluses are placed adjacent to the central one, spreading
out in a radial fashion. After each injection the boluses are m olded to create a
smooth, harmonious result that blends in with the temporal region and obscures
the temporal crest (Fig. 10-14).
Fig. 10-14 A, This 29-year-old woman was concerned about a narrow, unaesthetic forehead. She
wished to have greater anterior and lateral convexity, creating a broader forehead. B, Larger boluses

starting centrally and then moving laterally according to the desired shape. C, Smaller boluses of

contour irregularities. All boluses were m olded together to form a sm ooth, continuous surface.
D,
B
A
D
C

• Aesthetic Contouring of the Upper and Central Third of the Face

-
pendicularly down to the bone of the temporal fossa from a point 1 cm above and

m uscle itself, its spread lim ited by the deep temporal fascia, which is attached
to the temporal crest. This also avoids the temporal arteries, which course at a
higher level and above the level of the deep temporal fascia. Severe temporal con-

or creating convex, bulging temples is aesthetically undesirable. Volumes of 0.5

into the lower part of the temporal fossa, the entry point of the needle should
be just behind (within 1 cm ) the posterior aspect of the lateral orbital rim and
above the zygomatic arch (Fig. 10-15).
Fig. 10-15 Injection technique for the temples. The surface m arkings are the temporal crest and
-
ral artery. Injections below this point and directly onto the bone of the temporal fossa encounter
few problem s.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
The only vessel in the temporal fossa at this point is the sentinel vein, which may
cause slight but inconsequential bruising if punctured (Fig. 10-16).
Fig. 10-16 Anatom ic dissection of the temporal region. A,
-
eral to the tail of the eyebrow. B,



fascia to the temporal crest.
B
A

Injection of the upper lids should be undertaken by advanced injectors who are
-
lying anatomy. Supraorbital nerve blocks with lidocaine mixed with adrenaline
are always used for pain relief and to create arterial vasoconstriction that m ay
reduce the risk of vascular embolism. Fillers in the upper eyelids are used to cre-
ate the aesthetic fullness of youth and eliminate supraorbital hollows or A-frame

• Aesthetic Contouring of the Upper and Central Third of the Face
-
dle angled upward is used to create a series of disconnected boluses directly onto

neurovascular structures that em erge from it. The boluses are then m assaged
together for a smooth result (Fig. 10-17).
-
dle or cannula is inserted via a small puncture at the lateral aspect of the eyelid.

lines that bulk up the eyelids and decrease supraorbital shadows. A 30-gauge
cannula creates less bruising and trauma in the upper lids.
Fig. 10-17 A, The injection technique for the undersurface of the supraorbital ridge follows the
same principles as contouring its anterior surface. The thumb should be placed on the supraorbital

B, This
maneuver should be used with great caution, because overinjection is easy and will create lump-
iness and unevenness. Injection into the soft tissue of the upper lids introduces a greater chance
of trauma to the blood vessels.
B
A

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
RESULTS AND OUTCOMES
The 40-year-old m an in Fig. 10-18 who had previous upper lid blepharoplasty
and autologous fat transfer to the supraorbital ridge felt the upper lids were too
sunken and was concerned about contour irregularities of the brow ridge caused

through a 30-gauge needle on each side to improve the supraorbital hollowing
-
jected into the root of the nose, continuing onto the anterior aspect of the su-
praorbital ridge to smooth the irregularities and improve masculine projection.
Fig. 10-18 A, Before injection. B, At 1 year postoperatively.
B
A
The 47-year-old Asian woman in Fig. 10-19 complained of “tired-looking eyes”
with supraorbital hollowing and skeletonization of the supraorbital rim . A bo-

lower the lid crease.
Fig. 10-19 A, Before injection. B, Immediately after injection; the relative lack of trauma is evident.
B
A

• Aesthetic Contouring of the Upper and Central Third of the Face
CONCLUSION

bring about profound changes to overall facial aesthetics. Good results depend

anatomy, especially the blood vessels, and of the unique arrangem ent around
the eyes that connects the internal and external carotid system s is imperative.
-
drophilicity are also important in determining good and safe outcomes. A slow

and potential complications.
Technical Pearls
• Patients should be seated upright, with the head stable, under good lighting.
•
are safest.
•
•
Severe complications can occur very quickly.
• Thirty-gauge needles and cannulae create the least trauma and pain. They
allow the injector to focus on delivering slow, steady injections.
• The physician m ust be aware of the underlying anatom ic structures and
avoid bony foramina.
• Lidocaine and adrenaline should be used for local nerve blocks.
•
because it gives an unaesthetic sausage-like appearance.
REFERENCES

-

2002.
2. Wu W TL. Non surgical facial rejuvenation w ith the 4R principle: innovative uses of

Facial Mosaic. Berlin: Springer, 2006.


Rejuvenation With Fillers. Techniques in Aesthetic Plastic Surgery Series. Philadelphia:
WB Saunders, 2009.
4. Seghers M, Longacre J, Destefano G. The golden proportion and beauty. Plast Reconstr
Surg 34:382-386, 1964.

Plast Reconstr Surg 106:1090-1096, 2000.
6. Farkas LG, Katic MJ, Forrest CR, et al. International anthropometric study of facial mor-
phology in various ethnic groups/races. J Craniofac Surg 16:615-646, 2005.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
7. Naini FB, Gill DS. Facial aesthetics: 1. Concepts and canons. Dent Update 35:102-104,
2008.
8. Prokopakis EP, Vlastos IM, Picavet VA, et al. The golden ratio in facial symmetry. Rhinol-
ogy 51:18-21, 2013.


of Asian beauty. Aesthetic Plast Surg 40:193-201, 2015.

42:289-300, 2015.
-
lised hyaluronic acid-based gel of non-animal origin in facial tissue augmentation. Aesth
Plast Surg 34:88-95, 2010.


13. Lazzeri S, Figus M, Nardi M, et al. Iatrogenic retinal artery occlusion caused by cosmetic


review of cause and therapy. Plast Reconstr Surg 134:1197-1201, 2014.
-
lowing cosm etic hyaluronic acid injection. JAMA Ophthalmol 131:1234-1235, 2013.
16. Kim EG, Eom TK, Kang SJ. Severe visual loss and cerebral infarction after injection of hy-
aluronic acid gel. J Craniofac Surg 25:684-686, 2014.
17. Kim YJ, Kim SS, Song WK, et al. Ocular ischemia with hypotony after injection of hyal-
uronic acid gel. Ophthalmol Plast Reconstr Surg 27:152-155, 2011.
18. Lazzeri D, Agostini T, Figus M, et al. Blindness following cosmetic injections of the face.
Plast Reconstr Surg 129:995-1012, 2012.
19. Liu OG, Chunming L, Juanjuan W, et al. Central retinal artery occlusion and cerebral in-
farction following forehead injection with a corticosteroid suspension for vitiligo. Indian
J Dermatol Venereol Leprol 80:177-179, 2014.
20. Jiang X, Liu DL, Chen B. Middle temporal vein: a fatal hazard in injection cosmetic surgery
for temple augmentation. JAMA Facial Plast Surg 16:227-229, 2014.
21. Tansatit T, Apinuntrum P, Phetudom T. An anatomical study of the middle temporal vein
and the drainage vascular networks to assess the potential complications and the pre-
ventive maneuver during temporal augmentation using both anterograde and retrograde
injections. Aesth Plast Surg 39:791-799, 2015.
-
ers: a review of the world literature. Dermatol Surg 41:1097-1117, 2015.
23. Wu WTL. The Oriental nose: an anatomical basis for surgery. Ann Acad Med Singapore
21:176-189, 1992.
24. Nahai F. The Art of Aesthetic Surgery, ed 2. St Louis: CRC Press, 2010.


the Asian face. Aesthetic Plast Surg 40:202-212, 2015.
26. de Lacerda DA, Zancanaro P. Filler rhinoplasty. Dermatol Surg 33:S207-S212, 2007.

484, 2009.

year old Middle Eastern m an. Can J Plast Surg 19:156-158, 2011.
29. Redaelli A. Medical rhinoplasty with hyaluronic acid and botulinum toxin A: a very sim -

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
11
The Microbotox
Technique

Was this the face that launched a thousand ships,
and burnt the topless towers of Ilium?
Oh sweet Helen, make me immortal w ith a kiss!
CHRISTOPHER MARLOW E

(Trang không có chữ)

• The Microbotox Technique
I developed the Microbotox technique in 2001. In this procedure, tiny droplets


appearance of horizontal rhytids without compromising the lifting action of the

quality of the forehead skin.1-4
Since its inception, the Microbotox technique has evolved into a versatile che-
moresurfacing technique that alters the sheen and texture of skin by decreasing
sweat, oil, and sebum production; improving acne and rosacea; reducing the

m ovem ent; lifting and sculpting the jawline; sm oothing the neck and under-
eye areas; and generally giving a natural appearance to the face w ithout an
“over-Botoxed” look.1 It is also regularly used to treat hypertrophic and keloid
scars when used in conjunction with intralesional triamcinolone. It can also im -
prove the appearance of acute breast and abdominal striae as well as thigh and
buttock cellulite.
The key to the technique is the delivery of m ultiple, evenly distributed m icro-
droplets of Botox into the dermal and subdermal layer of the skin that then dif-




production of sweat (which is well documented) and sebaceous secretions and
bring about atrophy of the sweat and sebaceous glands, which in turn causes a
thinning and tightening of the skin envelope.5-7 Pores appear reduced in size as
a result, and the skin becom es sm ooth and unlined. Acne and rosacea are visi-
bly improved.

the droplet size small and delivering these at regular intervals of approximately
-
ery of the toxin to the target layers. The aim is not to paralyze the muscle totally
as in traditional Botox techniques.
HISTORICAL BACKGROUND



delivered so easily to selectively paralyze and weaken muscles. As an intramus-

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
cular injection it was a trem endous novelty to be able to render these m uscles
inactive, with the unintentional result of an era of “overenthusiastic, obsessive”
paralysis, which creates the undesired over-Botoxed or frozen look.



too much Botox into the forehead in the mistaken belief that a smooth forehead
was the only desired ideal for patients.

evident that patients did not want a smooth forehead at the expense of low set,
angry eyebrows. What was desired was a natural, smooth-looking forehead that
could still move and elevate the eyebrows. This appears to be a paradox, because
the muscles responsible for the forehead lines are the same muscles that are re-
sponsible for elevation of the eyebrows. It therefore became obvious that a tech-
nique of Botox administration was needed that decreased visible forehead lines
but still allowed the underlying muscles to move and the eyebrows to elevate.
A common observation was that when the Botox was injected intramuscularly
into the frontalis muscle, the overlying forehead skin would often become shiny,
smooth, and tight with few if any visible pores. Many patients liked this “resur-


because the droplet size recom m ended was too large and had a greater radius

Traditionally 100 units of Botox was reconstituted w ith 2.5 m l saline, and a
1 ml syringe would therefore contain 40 units. Thus 0.1 ml of this reconstituted
solution contained 4 units of Botox, which becam e the default recom m ended

of the crow’s-feet (24 units) injection patterns that are currently approved for
on-label use in many territories.
Another clinical problem encountered was in achieving a smooth lower eyelid.
After the conventionally placed Botox injections for the glabellar, crow’s-feet,
and forehead regions, patients often experienced pronounced “bunny lines” and

The adm inistration of traditional Botox to the infraorbital area and to the hy-
pertrophic muscle bundle of the lower lid may provide a pleasing result, with a

m akes the eye look bigger and m ore attractive. These are usually younger pa-

distressing complications with resulting bags under the eyes, a waterlogged ap-

• The Microbotox Technique
pearance, and an unwelcome inanimate response of the lower lid with smiling.
These patients feel they look worse than before the Botox administration. These
are invariably older patients with unrecognized eye bags or skin laxity in whom
relaxation of the infraorbital orbicularis oculi muscle allows the eye bags to bulge
and become more visible. The action of the muscles before Botox administration
helps to keep the skin tightened in a state of tension and push the eye bags in-
ward, thus rendering them less obvious. The issue is only unm asked when the
m uscles relax and are no longer able to provide any resistance to the eye bags
and they herniate outward.
A third problem area was the neck. Early techniques advocated adm inistering
traditional Botox (Botox diluted with 2 to 2.5 ml of saline) into the anterior and
lateral platysmal bands without injecting into the muscle between these bands,
over the horizontal neck creases, or above the jawline. Some patients had good
results with softening of the platysmal bands and improvement of the cervico-
m ental angle, but none experienced a lifting of the jawline, reduction of hori-
zontal lines, or improvement of neck skin quality.
In looking for a solution to these three problems, and drawing on my experience
with intradermal injections of Botox to the axilla to decrease hyperhidrosis and
odor, I developed the Microbotox technique.5-7
ORIGIN OF MICROBOTOX AND ITS NOMENCLATURE
This technique was originally termed Mesobotox.
-
nique; hence the term Microbotox was coined and adopted in 2002. It is essen-
tially an intradermal or subdermal injection of evenly spaced, very dilute Botox

facial muscles. It requires careful preparation of the solution and a sensitive and


total muscle paralysis, which is not desired.
PHYSIOLOGIC BASIS FOR ACTION
Botox is well known as a versatile drug that inhibits a variety of receptors, in-
cluding substance P. New uses of the toxin are constantly being discovered, such
as in the reduction of m asseteric m uscle and parotid gland hypertrophy.4,8-10
The principle action of Botox is to block cholinergic receptors, which inhibits
neuromuscular transmission. This relaxes muscles, which in turn decreases the
intensity of facial wrinkles. Sweating is also largely mediated through choliner-

muscular activity and alter the quality of the overlying skin of the injected area.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
CONCEPT OF MICROBOTOX
In traditional Botox administration, the objective is to bring about muscle weak-
ening or paralysis; in the case of Botox facial sculpting, the goal is atrophy of the
masseteric muscle bulk or reduction of iatrogenic parotid gland hypertrophy.4,8-10

11-1). This can sometimes lead to pain and bruising. Because the margin for er-
ror is higher when injecting into the muscle, surgeons may be more cavalier in
their injection technique in these traditional areas, often not ensuring that the
correct dose of Botox is being delivered in a precise fashion.
Fig. 11-1 Standard Botox technique. A, Botox is injected into the m uscles. B, The Botox spreads
C, The muscle begins to weaken. D,
E, Paralysis of the muscle is achieved.
B
Epidermis
Dermis

layer
Deep
layer
Bolus spreads radially 360 degress
Skin
Muscle
C
Epidermis
Dermis

layer
Deep
layer

Skin
Muscle
D
Epidermis
Dermis

layer
Deep
layer

Skin
Muscle
E
Epidermis
Dermis

layer
Deep
layer
Entire muscle paralyzed
Skin
Muscle
A
Epidermis
Dermis

layer
Deep
layer
Conventional Botox
Skin
Muscle
BTX droplet
Injected directly into muscle

• The Microbotox Technique
For Microbotox, the delivery technique is very important, because multiple tiny
boluses of Botox are injected into the derm is or into the junction between the


-
kles that patients dislike. In the skin, the sweat and sebaceous gland activity is
reduced (mediated through both cholinergic and noradrenergic receptors), and
they become atrophic. This causes the skin envelope to shrink, and patients feel
tighter and lifted. Reduction of sebaceous secretion also helps in the control of
acne but more importantly makes open pores appear smaller and fewer. As a re-

B
Epidermis
Dermis

layer
Deep
layer

Skin
Muscle
C
Epidermis
Dermis

layer
Deep
layer

Skin
Muscle
D
Epidermis
Dermis

layer
Deep
layer
Atrophy of sweat and sebaceous glands
Skin
Muscle
A
Epidermis
Dermis

layer
Deep
layer
Microbotox
Skin
Muscle
Microdroplets injected into dermis
or subcutaneously
E
Epidermis
Dermis

layer
Deep
layer
Contraction of skin envelope
Skin
Muscle
Fig. 11-2 Microbotox technique. A, Botox is injected as very tiny droplets into the dermis or into
B,
into the sweat and sebaceous glands, with a decrease in sweating and sebaceous activity. C, Paral-
D, Atrophy of sweat and sebaceous glands in the skin
occurs. E, Contraction of the skin envelope results from the gland atrophy.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
DILUTION AND INJECTION TECHNIQUE FOR MICROBOTOX
A 100-unit bottle of Botox is diluted with 2.5 ml of normal saline. This dilution
is used for all injections of standard Botox to the face or masseter muscles (Bo-
tox facial slim m ing); as m entioned previously, 0.1 m l of this solution contains
4 units of Botox, and 0.05 ml contains 2 units of Botox.6
For the Microbotox technique, depending on the region of the face or neck to be
injected, the required quantity is drawn up into a 1 m l syringe, which is then
topped up to 1 ml with normal saline or 0.5% lidocaine.
For example, if the combined forehead, glabellar, and crow’s-feet regions require
24 units of Botox, then 0.6 ml of the prepared standard Botox (2.5 ml dilution) is
drawn into a 1 ml syringe and an additional 0.4 ml of saline or 0.5% lidocaine is
added to create 1 ml of injectable solution. This equates to 24 units of Botox in
1 m l of solution. I prefer lidocaine for the additional diluent and have not ob-

-
pecially when treating patients solely for pore closure or smoothing of the skin
when disturbing the underlying muscle activity is not desirable. I use three stan-
dard dilutions:

1. 20 units in 1 ml solution for decreasing oily skin, visible pores, and rosa-
cea in the T zone and over the central third of the face, including the nose.


2. 24 units in 1 m l solution for treating the forehead, glabellar, and crow’s-
feet regions.

3. 28 units in 1 m l solution for treating one side of the jawline and neck to
smooth the appearance of vertical bands and horizontal creases, to elevate
the jowls, and to improve cervicomental contouring.11 Two syringes (2 ml,
or 56 units of Botox) are required to adequately cover both sides of the
upper two thirds of the lower face and neck. Occasionally in thick necks
with strong platysmal bands, as seen in heavyset patients, three syringes
(3 ml, or 74 units of Botox) may be required.

• The Microbotox Technique
Experience is required to develop proper injection technique; novice injec-

-
tive surface, such as a mirror. Physicians should practice this until they are adept
at delivering small or large droplets consistently. Most physicians attempting this
exercise are surprised to learn that they typically overinject the Botox and do not
deliver evenly sized boluses with each injection (Fig. 11-3).
In reality, a 0.1 ml droplet of solution is quite large; an inaccurately placed drop-
let near the eyebrow (when treating glabellar frown lines) can cause unwanted


A 0.05 m l droplet contains 2 units of Botox and is the volum e of each droplet I
use when doing standard intramuscular injections. Where muscles are thicker
or more dense (as in men), 0.1 ml droplets are used.
For Microbotox, a 0.05 m l droplet can be injected instead as m ultiple sm aller
droplets. Depending on the skill of the operator, 0.05 m l can easily be injected
in 10 to 14 drops (see Fig. 11-3). Clinically, if the operator can divide an injection

should deliver 100 to 120 droplets if performed correctly.
Fig. 11-3 Microdroplet training. Practice is required to enable the injector to release tiny drop-
lets of diluted Botox regularly and evenly. Standard injections of 0.1 m l and 0.05 m l droplets are
seen at the top left. In comparison, the cluster of droplets below are derived from a single 0.05 ml
droplet divided into m ultiple m icrodroplets. The cluster of droplets on the bottom right is very

on the left (0.05 ml divided into 12 microdroplets) is more practical.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
The sm all boluses of Botox should be injected slowly and evenly, with boluses
spaced about 1 cm apart in a gridlike fashion. Once the injections can be per-
form ed steadily and the boluses m ade even sm aller, the injection distance can
be reduced to less than 1 cm. All air bubbles must be carefully removed from the
syringe before injection, because they may compromise the injection accuracy.

The objective of Microbotox of the forehead is to retain as much muscular func-
tion and hence eyebrow elevation as possible while simultaneously smoothing
the skin, reducing pore size, improving the sheen, and reducing rhytids, espe-


the eight points of injection over the glabellar and eyebrow region to decrease
corrugator activity and the eight points over the crow’s-feet area. If traditional
Botox has already been given to the glabellar, eyebrow, and central forehead re-

the lateral forehead alone (Fig. 11-4). This treatment will typically last 4 months.
Fig. 11-4 -
droplets (white m arks). Each drop should raise a sm all whitish bleb. If this does not occur, the in-
jection was too deep. A volume of 0.05 ml (2 units) of standard Botox (2.5 ml dilution) is used for
the glabellar and central forehead region (brown marks). Patients may request Microbotox droplets
in each of the points marked (white and brown
and glabellar region.

• The Microbotox Technique
Fig. 11-5 A forehead that was treated with Microbotox. A, At rest. B, Upon elevation. The eyebrows
move freely and no forehead wrinkles are discernible.
B
A
B
A
Fig. 11-6 A forehead and glabella 4 m onths after adm inistration of 20 units Microbotox, with
minimal recurrence of forehead lines. A, At rest. B, On elevation.
On average the forehead will be covered with 40 to 50 injection points. To anes-
thetize the forehead, a supraorbital nerve block with a small bolus of 0.5% lido-
caine without adrenaline administered to the supraorbital nerves will provide
adequate numbness. In addition, 5% topical lidocaine can be used to supplement
the areas not covered by the nerve blocks. Patients seldom complain of pain even
if an anesthetic is not used because of the small volume of the injection. Under-
injecting the lateral forehead is preferable to avoid lowering of the eyebrow or
creating a sensation of heaviness. Patients should have a sm ooth forehead but
still be able to elevate their eyebrows and look natural (Figs. 11-5 and 11-6).

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice

-
ter Botox is administered to the crow’s-feet, glabella, and forehead regions, and
patients commonly request treatment to smooth them. The muscles around the

Botox is adm inistered (as in conventional Botox droplets), the entire preseptal
orbicularis oculi of the lower lid can become lax, causing complications such as
enhanced eye bags or m alar festooning; lid laxity; a swollen, waterlogged ap-
pearance; or an inanimate lower eyelid.
The controlled delivery of evenly spaced microdroplets by the Microbotox tech-
nique is extrem ely useful in this region. I typically use 8 to 12 units for the
infraorbital and nasal bunny line region. The results last approxim ately 3 to
4 months; patients are warned that this area may revert faster than other areas
simply because there is less Botox spread out over a wide area. For patients who
also desire an improvement of wrinkles over the lateral orbicularis (crow’s-feet
region), 24 to 28 units can cover all three areas. Many patients who used to re-
ceive traditional Botox in these areas now request Microbotox instead, because

An infraorbital nerve block with a small bolus of anesthetic (0.25 ml of 2% lido-
caine) m ay be used, although m ost patients can tolerate the infraorbital injec-
tions without any anesthesia. About 20 injection points are used for the undereye
and bunny line region (Fig. 11-7).
Patients are invariably enthusiastic to reduce the lines in this region, and very
sm all doses of Botox are needed to do so. Thus the surgeon should avoid over-
injecting this area.
Fig. 11-7 Microbotox of the infraorbital and bunny line region (9 to 10 microdroplets per side) to

visible pores and improve skin texture. The droplets should be evenly spaced to prevent overre-
laxation of the orbicularis m uscle and unwanted bulging of the eye bags.

• The Microbotox Technique

Another common request is smoother facial skin with a reduced appearance of
large facial pores, rosacea, and acne. Although m any m edical and nonsurgical


duration of action is up to 4 m onths (Fig. 11-8). The surgeon m ust ensure that
small boluses of the Microbotox solution are accurately injected into the dermis
-
dle for these procedures is preferable.
Fig. 11-8 Left, Before Microbotox injection into the infraorbital region and anterior cheeks and
nose to treat greasy, rough-textured skin with large visible pores. Right, After adm inistration of

reduction of visible pores.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
The forehead, T zone of the central face, and the anterior cheeks and nose are
the areas m ost com m only treated; one syringe of Microbotox with 20 units in

Infraorbital and supraorbital nerve blocks using sm all am ounts of lidocaine
-
able during the injection process. It is also helpful to apply 5% topical lidocaine
to the area to be treated 20 minutes before the procedure.
Fig. 11-9 Left, This 43-year-old woman was concerned about open pores, oily skin, and rosacea.
Right, One week after adm inistration of 28 units of Microbotox to the T zone, nose, and anterior
cheeks. She has reduced pore visibility, smoother skin, and reduced rosacea.

There were previously very few techniques for consistently improving the tex-
ture and appearance of the neck and jawline. Microbotox has becom e a useful
nonsurgical tool to elevate the jowls, smooth the jawline, reduce the platysmal
bands, reduce horizontal creases, and decrease the crepey appearance of the neck
skin and allow it to drape the cervicomental angle more acutely.
The com bined action of Microbotox treatm ent in decreasing sweat and seba-
ceous gland activity of the neck to smooth and tighten the skin while weakening



be used in conjunction w ith other skin-tightening devices and therapies. Pa-

and that the procedure needs to be repeated periodically to maintain the result.

• The Microbotox Technique
Topical lidocaine can applied to the whole neck for 20 m inutes to increase pa-
tient comfort, but again it is not usually required and most patients can tolerate
the 200 to 240 injections of the entire neck because of the local anesthetic com -
ponent of the solution. Two to three syringes of the Botox solution are needed,
each containing 28 units in 1 ml saline.

The area of the lower face and neck to be injected corresponds to the entire ex-
tent of the platysm al m uscle as it sweeps up from the clavicle over the jawline

-
-
breadth posterior to the depressor anguli oris and over the anterior neck be-
tween the two sternocleidomastoids, and all the way down to the clavicle (Fig.
11 -10). Injections are only delivered outside of this area if there are horizontal
neck lines that extend laterally beyond the sternocleidom astoid or if there are
particularly strong lateral platysm al bands. Microbotox treatm ent in this area
not only improves neck skin texture, color, and sm oothness but also decreases


11
Fig. 11-10 Microbotox of the neck and jawline. The distribution of injections starts two to three
-

the m outh to avoid weakening the depressor angular oris. This corresponds to the distribution of
the platysm a m uscle.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
The entire neck and jawline area can usually be treated using two syringes of
1 ml solution, each containing 28 units of Botox. The injection points are spaced
approxim ately 1 cm apart. For heavyset patients, 3 m l of solution m ay be re-
quired, and the injection points can be closer together.
In all cases of neck and jawline Microbotox treatm ent, care should be taken to
not inject over the risorius or the depressor anguli oris, because this can lead to
an asymmetrical smile or the inability to produce a full, broad smile (Fig. 11-11).
Fig. 11-11 Microbotox treatment of the neck and jawline. A, This 60-year-old woman had hori-
zontal neck creases, platysmal banding, mild jowling, and crepey skin. Three syringes of Microbotox
solution (each containing 28 units of Botox in 1 ml of solution) were injected. A total of 84 units of
Botox were used. B, Three months later, she had reduction of the intensity of the horizontal lines
and improved skin texture. A further 56 units of Microbotox (two syringes of 28 units each) were
injected into the sam e distribution and over each horizontal line at this follow-up visit. C, Two
months after the second injection she has further improvement in the appearance of the horizon-
tal neck creases and the quality of her skin.
B
A

C

• The Microbotox Technique

When a m uscle contracts, it shortens, and the diam eter or girth of the m uscle
increases, creating a lateral force or bulging on either side of the m uscle (Fig.
11-12, A). If only one side of the m uscle surface is weakened, the contralateral
side will contract upon stim ulation and pull to its side. The entire muscle thus
pulls away from the weakened side (Fig. 11-12, B). In Microbotox treatm ent of
the neck, this principle is used to achieve better cervicomental contouring and
is called the
Fig. 11-12 A, Normal muscle contraction is linear, with shortening of muscle
B, If only one side of the muscle is weakened with Microbotox,
-
tralateral m ovem ent.
Diameter of
muscle at rest
equals diameter of
paralyzed muscle
Expansion of
unparalyzed muscle
with contraction
B
A
Expansion of muscle
with contraction
Diameter of
muscle when
contracted
The platysma muscle is a large sheet of subcutaneous muscle that envelops the
anterolateral neck and jawline. It belongs to a unique group of m uscles called
the panniculus carnosus. These muscles lie in a plane just under the panniculus
adiposus.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
The contraction of the platysma shortens the distance between the chin and the
clavicle and blunts the cervicomental angle. This can be easily seen by having the
patient actively contract the m uscle. When Microbotox injection weakens the

action and contract centripetally inward and upward, creating a more snug ap-
position of the platysm a to the underlying neck contour (Fig. 11-13). This cre-

and jawline (Fig. 11-14).
Fig. 11-13 The platysm al m uscle. A, At rest. B, Upon norm al contraction. C, After Microbotox
administration.
B
A

C
Fig. 11-14 A, This 65-year-old man had a heavy neck, obvious jowling, and
poor cervicomental contouring. Three syringes of Microbotox solution (each containing 28 units
of Botox in 1 m l of solution) were injected. A total of 84 units of Botox were used. B, One month
later he has visible improvement of the jowling, skin draping, and cervicomental contouring.
B
A

• The Microbotox Technique


Microbotox of the neck and jawline is a useful complementary treatment to the
Botox facial slim m ing technique for m asseteric hypertrophy, in which the ini-
tial rapid shrinkage of the masseteric bulk can lead to a temporary laxity of the
jowl and upper neck skin. Microbotox treatm ent of the neck and jawline helps
to alleviate this by allowing the skin to redrape more closely to the jawline and
cervicomental angle.
COMPLICATIONS
Complications are uncom m on and usually result from a lack of understanding
of the underlying concepts of the m ethod and poor injection technique. Physi-
cians new to the technique m ay be unsure of how small a microdroplet should
be. Practice is required. The main complications of the Microbotox technique are

unintended areas, thereby causing unwanted m uscle weakness and undesired
facial movements or expression. This is always a result of injecting overly large
-
tions can be avoided by developing a sound and meticulous injection technique.
The forehead is variable from one individual to another and requires careful judg-
ment to determine how much Microbotox should be injected, not only in terms
of volume but in dosage as well. The forehead may be low, high, narrow, or wide

too m uch volum e, whereas in a person with a high, wide forehead, 0.5 m l m ay



the eyebrows and hooding of the lateral brow and loss of the upper eyelid crease.
Infraorbital complications, which include eye bags becoming more noticeable;
m alar festooning; lid laxity; a swollen, waterlogged appearance; and an inan-
im ate lower eyelid have already been discussed in detail. Again, great care is
necessary during the injection to ensure the boluses are sm all and uniform ly
delivered.
When Microbotox is used to treat the neck, patients som etim es complain of
weakness that is usually noticed on getting up from bed or in perform ing sit-
ups. Dancers of the waltz or tango may also notice neck weakness. This occurs if
too much Microbotox has been injected over the sternocleidomastoid muscles.
It can be avoided by either avoiding injecting over these m uscles or increasing
the spacing between the injection points to reduce the total load of Botox to that
area. Of course, the surgeon must always deliver small, consistent droplets. There
have been no complications regarding phonation or swallowing.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
At or above the jawline, if the injections are carried too far forward over the
depressor anguli oris or too close to the risorius, a weak or lopsided sm ile can
result. Som e patients complain that they cannot sm ile broadly. This m ay be of
concern and embarrassment to patients and may necessitate a small dose of Mi-
crobotox to the contralateral side to achieve symmetry. This same complication
can occur with injection into the cheeks for oil control and pore size reduction.

mouth.
DISCUSSION
As mentioned in the beginning of the chapter, the large droplet size of conven-


size (0.003 to 0.005 ml), Microbotox is able to target these areas more precisely



that insert into the subcutaneous layer. This preserves the m uscle function of

The use of Microbotox in the treatment of scars and keloids, whether on the body
or the face and neck, has been particularly rewarding. It arose from the simple
-
tant injections of intralesional steroid and has now becom e part of my clinical
practice in the m anagem ent of scars.3,12-17 It was subsequently noted that the
Microbotox m ay prom ote apoptosis of keloid cells through a process of down-
regulation; I now inject all fresh surgical scars with Microbotox on the 6th or
7th postoperative day just before the removal of stitches.18-20 If treating an es-
tablished keloid, com bination therapy with intralesional triam cinolone is ad-
ministered at intervals of 1 to 2 months until the keloid has resolved. This may
require several sessions.
CONCLUSION
Microbotox has m ultiple uses in the face, neck, and hands and body as well as

increased the versatility of an already fascinating drug.

• The Microbotox Technique
REFERENCES




-
gery of the Facial Mosaic. Berlin: Springer, 2006.
3. Wu WTL. Skin resurfacing with Microbotox and the treatment of keloids. In Benedetto
AV, ed. Botulinum Toxins in Clinical Aesthetic Practice, ed 2. Zug, Switzerland: Informa

4. Wu WTL. Botulinum toxin A injections for facial rejuvenation and reshaping. In Lee P,
Chen YR, Li QF, et al, eds. Aesthetic Plastic Surgery in Asians: Principles and Techniques.
Boca Raton, FL: CRC Press, 2015.
-
illary hyperhidrosis. Clin Exp Derm atol 21:276-278, 1996.
6. Glogau RG. Botulinum A neurotoxin for axillary hyperhidrosis: no sweat Botox. Dermatol
Surg 24:817-819, 1998.
7. Naumann M, Lowe NJ. Botulinum toxin type A in the treatment of bilateral primary axil-
lary hyperhidrosis: a randomized, parallel group, double blind, placebo controlled trial.
BMJ 323:596-599, 2001.
8. Wu WTL. Botox facial slimming/facial sculpting: the role of botulinum toxin-A in the
treatment of hypertrophic masseteric muscle and parotid gland enlargement to narrow
the lower facial width. Facial Plast Surg Clin N Am 18:133-140, 2010.
9. Wu WTL. Facial and lower limb contouring. In Benedetto AV, ed. Botulinum Toxins in

10. Wu WTL. Facial sculpting and facial slimming with neurotoxins. In Sundine M, Connell
B, eds. Aesthetic Rejuvenation of the Face. New York: Thieme, 2015.
11. Wu WTL. Microbotox of the lower face and neck: evolution of a personal technique and

12. Wu WTL. The role of Botox in keloid therapy. Annual Meeting of the Multi Specialty Foun-
dation, Las Vegas, NV, June 2007.

improves cosmetic outcom e in primates. Plast Reconstr Surg 105:1948-1953, 2000.

a prospective, blinded, placebo controlled study. Mayo Clin Proc 81:1023-1028, 2006.
15. Giebler FRG, Giebler EF. Creating invisible scars. Int J Cosmet Surg Aesth Derm 4:107-110,
2002.

of facial scars. Plast Reconstr Surg 112:1464-1466, 2003.

18:35-39, 2002.

epithelial components of the prostate gland. J Urol 175(3 Pt 1):1158-1163, 2006.
-

2001.
-
ripheral and central areas of keloid tissues. Plast Reconstr Surg 120:625-630, 2007.

(Trang không có chữ)

Part III
The Art
and Science of
Croton Oil Peeling

(Trang không có chữ)

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
12
Background to Facial
Aging and Facial
Resurfacing
Richard H. Bensim on

you still have to deal w ith the fabric!
FRITZ BARTON, MD

(Trang không có chữ)

• Background to Facial Aging and Facial Resurfacing
One of the greatest challenges in aesthetic m edicine is helping patients de-

quotes and clichés referencing the skin (for example, “thick skin”) and count-
less books on skin health and beauty regimens. Thousands of cosmetic and skin
care products, home recipes, diets, and supplements are available. The trend of
airbrushed images is imprinting the way society perceives skin and beauty. The
depiction of perfect skin can be disconcerting to a patient with substantial ag-
ing changes. This unattainable ideal has been a driving force in the beauty and
cosmetic industry, leading consumers to spend billions of dollars on treatments
and skin care products that are unproven and do not work.
The lack of integrity in the industry is further demonstrated through clever and
m isleading m arketing that can trick and confuse consum ers into purchasing

Achieving even skin color and tone are cosmetic priorities for most cultures but
especially for people with a higher degree of m elanin in their skin. Despite the
widespread availability of m akeup to help cover and blend uneven pigm enta-
tion of the skin and products to help suppress melanin and increase exfoliation
to improve tone, no product exists that can reproduce smooth, unwrinkled skin.
Smooth unwrinkled skin is young skin; smooth unwrinkled skin is healthy skin.

to achieve.
CAUSES OF FACIAL AGING
Cutaneous aging is a complex biological process that involves many cellular com -
ponents of the skin. The aging process is inevitable, but there are substantial dif-
ferences in the way people age depending on genetics and lifestyle. Two biolog-

internal and chronologic changes; and environm ental, or extrinsic, aging rep-

exaggerate the natural intrinsic aging process.
Both intrinsic and extrinsic aging lead to a progressive degradation of physio-
logical functioning and structural support, but histologically, they are very dif-
ferent. Intrinsic skin aging is characterized by the slow and inalterable internal



the third decade, are good markers of intrinsic aging.

• The Art and Science of Croton Oil Peeling
The natural decline of hormones and dermal and epidermal grow th factors also
play a role in chronological skin aging. A decrease in estrogen causes thinning
and drying of the dermis, and supplementation has been shown to improve and
reverse aging changes of the skin.
The end product of these processes is the deterioration of collagen, elastin, and

-
dermal ridges, which decreases the area of surface contact, leading to diminished
nutrition of the epidermis and a slowing of epidermal cell turnover. In the der-
mis, there is a generalized decrease in cells.

that include exposure to the sun, pollution, tobacco smoking, diet, alcohol intake,
and other lifestyle choices. The m ost com m on contributor to extrinsic aging is
sun exposure; therefore extrinsic aging is com monly referred to as photoaging.
In contrast to intrinsically aged skin, the clinical hallmarks of photoaging are the
appearance of leathery or inelastic skin, sallow coloring (yellow) with a loss of
translucency (the pink, radiant glow indicative of young, healthy skin), coarse
texture (deep wrinkles), blotchy irregular pigm entation (dark spots or lentigi-


distinguished by unique cellular changes. The histologic hallmark of photoaging
is solar elastosis, characterized by a m assive deposition of abnorm ally struc-


the dermal matrix. Solar elastosis is responsible for the “leathery” look and feel
of sun-damaged skin.

dam age to cell m em branes and increases m atrix m etalloproteinases (MMPs).
MMPs are enzym es that increase collagenase (catabolic proteins that “eat up”
and degrade collagen, “Pacm an”-style) and create an environm ent of chronic

telomeres interfere with DNA replication, leading to an irreversible and planned
arrest of cell function followed by cell death (apoptosis).
The abnorm alities in the structural protein of the extracellular m atrix are re-
sponsible for a dry appearance and wrinkling. This is a complex situation because
sun-dam aged skin has a paradoxical increase in water content. In undam aged
skin, water binds with proteins (collagen and elastin) and m ainly with glycos-
am inoglycans (GAGs) in the derm is, responsible for hydration of the skin. In
photoaged skin, the GAGs are abnormally attached to the aberrant proteins and
unavailable to bind with water. The unbound water binds to itself in a tetrahe-
dral form, resulting in a loss of turgor or buoyancy and clinically “drier” skin.

• Background to Facial Aging and Facial Resurfacing
Cumulative ultraviolet radiation from the sun further damages skin by causing
DNA mutations that interfere with the normal immune mechanisms that police
carcinogenic cells. Increased skin cancer rates have been seen in “baby boom-
ers,” a generation that has lived the longest with the most exposure to outdoor
recreational activities and long-term sun exposure.
The important clinical implication is that a vast population of patients, from
young to old, are seeking to improve the early signs of aging skin, to m inim ize
established wrinkles, and to improve the appearance of sun damage.

only improve the early signs of aging, wrinkles, and sun damage, but can reverse
extensive skin damage and deep wrinkling and perhaps even prevent skin cancer.
PROCESS OF FACIAL AGING
The process of facial aging, although complex, can be subdivided into three main
categories: (1) structural or gravitational changes, (2) correction of volume de-

Structural or gravitational changes are the m ost obvious and fam iliar changes
to surgeons and lay individuals, who may notice them when they pull the skin
back while looking in a mirror. A multitude of surgical procedures address these
structural changes, and m ost aesthetic surgeons are well within their com fort
zone in performing them. These operations understandably dominate meetings
and publications, because surgeons are familiar with them and are able to read
or hear about a new technique and successfully perform it.
In recent years, an important factor that has received increased attention is the



surgical practices. In the last decade, the enormous value of autologous fat trans-
fers has becom e recognized not only for generalized volum e replacem ent but
for the action of stem cells and grow th factors. The qualitative improvement to
be gained by harnessing the intangible power of these techniques is an exciting
new frontier discussed elsewhere in this book.
The treatment of well-established rhytids, creases, and textural changes is per-

aging-related changes. Surgeons are intim idated by this aspect of the specialty
-

The most common tactic is to simply ignore the issue. Regrettably, in doing so,
surgeons are m issing the opportunity to deliver a m ore complete rejuvenation

• The Art and Science of Croton Oil Peeling
and improve such a fundamental aspect of aging. Surgeons tend to concentrate

m ore notable to a patient than jowls or loose skin. If textural changes are un-
accounted for, the very best facelift, although a technical success, can paradox-
ically accentuate deep creases around the m outh or forehead and result in an
aesthetic failure.

-

are quite w illing to cut and sew skin, they seem ill-equipped to treat the skin
itself, whether because this seem s to lie m ore in the realm of aestheticians or
dermatologists or simply because plastic surgeons have not had the training or
exposure.
The m ain purpose of this chapter is to demystify and system atize the process
of modern chemical peeling so that practitioners may be motivated to try them

TECHNIQUES
To understand current treatm ent options, the historical perspective m ust be
considered, particularly as it applies to clinical reality. In this manner, each prac-
titioner can decide what best suits his or her practice.

Dermabrasion is a long-standing technique that is a viable option for the perioral
area. Derm atologists have used derm abrasion for acne scarring, and especially

a narrow range of safety. Plastic surgeons have tapped into this experience and

is of limited value around the eyes or on thin skin. Traditionally, plastic surgeons
have limited exposure to dermabrasion, and more recently, with fears of blood
splatter, it is becoming a lost art.


chemical peel. Chemical peels were introduced to the United States in the 1920s,

French surgeon who had treated victims of gas attacks after World War I and had
devised a particular peeling technique. The exact origin of the formula has been
lost to history, but several of these lay peelers, who clearly had contact with each
other, established practices in various parts of the United States. What is clear
is that they did quite good work and gained enough notoriety to arouse interest
and eventual animosity from the medical comm unity. Inevitable brushes with

• Background to Facial Aging and Facial Resurfacing

quietly “underground” to avoid attention.
Important insights can be gained by studying what is known from the experi-
ence of the early peelers. They used cumbersome “secret” formulas that involved
dissolving crystals to obtain liquid phenol and adding drops of the caustic acid
croton oil. Consistently, the lay form ulas had a relatively weak croton oil con-

mystery. The other known facts are that the results were excellent and as far as
it is known, the peels were perform ed w ithout any anesthesia (except for the
presumptive use of liquor).
Perhaps stirring crystals in a pot was too bizarre or too much like witchcraft for
physicians, because little interest was shown by the medical community other
than to persecute the peelers rather than to learn from them. Eventually plastic
surgeons took note, and in 1961 Thomas Baker1 from Miami published a formula
that was straightforward and easily reproduced. The form ula, presum ably ob-
tained from a lay peeler, contained liquid phenol, three drops of croton oil, water,
and the soap Septisol to act as a surfactant to allow the oil and water to mix. It
was believed that phenol was the peeling agent and the purpose of the croton oil
was unclear other than it was always present in all the original formulas.
In 1962 Dr. Baker2 altered the volum es of the form ula for convenience, while
keeping the three drops of croton oil unchanged. This seemingly small change ef-
fectively elevated the croton oil concentration to 2.1% and inadvertently changed
the history of chemical peeling. This formula was published nationally and be-
cam e the standard for decades. The Baker peel, as it becam e known, was very

of causing predictable and severe hypopigm entation. The peel gave dram atic
results but patients developed an unnatural porcelain or alabaster look that
doom ed them to perm anently wear m akeup. In older patients with extensive

the Baker peel was reserved for older, light-eyed individuals.

of having an “all-or-none” phenom enon that was out of the surgeon’s control.
The rationale was that phenol denatured the skin and created a barrier that pre-
vented deeper penetration. A weaker concentration was believed to be dangerous
because it would peel deeper. It took a great deal of faith and hope to paint the
solution on and hope for the best as the face densely frosted. Phenol also had the
reputation of being cardiotoxic, requiring a slow application under strict cardiac
monitoring. These beliefs became dogma, no matter how unsubstantiated, and
were passed on from generation to generation of plastic surgeons. To this day,
these presumptions are still mentioned in professional publications, and “phenol
peels” generally have a negative connotation in lay books on cosm etic surgery.
Although the results were quite rem arkable, the risks proved to be too intim i-

• The Art and Science of Croton Oil Peeling
dating and prevented this peel from gaining widespread acceptance. I witnessed
several Baker peels during plastic surgical training and was quite convinced I
would never try them.
Lasers
In the late 1980s carbon dioxide lasers were introduced for skin resurfacing. In
experienced hands this is a potential alternative, but problem s sim ilar to the
Baker peel, nam ely hypopigm entation and a prolonged recovery, soon becam e
evident. One notable advance was that the surgeon had some choice on the depth
-
ers m ounted costly m arketing campaigns establishing an “arm s race” between
practitioners and advertised directly to the public. The clinical advantage touted
was the precision of depth of damage, but over the years the disadvantages have
outweighed the advantages.
The Erbium laser was later introduced as an alternative, but although the recov-

match those of the carbon dioxide laser.

In an attempt to minimize recovery time, manufacturers have developed a mul-
titude of nonablative and fractionated machines that promise much, but deliver
dubious, short-lived results. Each year new machines are introduced that claim
good clinical results with no downtime. Clinically these treatments have proven
to provide very subtle improvements and a lack of long-term results at an astro-
nom ical price. The reality is that to improve deep wrinkles and etching of the
skin, wounding into the dermis is necessary, and this requires a notable recovery.

enough to warrant the recovery and inconvenience to the patient.

The next developm ent in skin resurfacing was the popularization of trichloro-
acetic acid (TCA) peels by dermatologist Zein Obagi. TCA peels have been around
for som e tim e, but Obagi’s work in the 1990s brought them to the attention of
plastic surgeons. Obagi’s role was controversial at the onset after unseemly com-
m ercialization w ith “secret form ulas” and very expensive training program s.
Nevertheless, his book, Obagi Skin Health Restoration and Rejuvenation, remains
an important contribution, especially for plastic surgeons who are less familiar
with peels and skin anatomy and physiology.3
-
tions to vary the depth of the peel, and application technique was a major deter-

• Background to Facial Aging and Facial Resurfacing
m inant of depth reached. Light to m edium peels were possible with a concen-
tration of up to 25%, but the general consensus was that medium to deep peels

more serious complications, namely scarring. Nonetheless, TCA peels have a role

EVOLUTION OF CHEMICAL PEELS
The advent of modern chemical peels can be traced to the pivotal contribution

resurfacing and serendipitously, Nevada was a state in which aestheticians could
legally perform weak phenol peels. In treating patients who had had these peels,
-
portant, they had not been harmed by the weaker phenol concentration, directly
contradicting what had been believed and taught about phenol peels for decades.

patients, now without the hypopigmentation that normally attended the older



-

concentrations led to deeper peels proportional to the concentration of the cro-

oil used. An analysis of the classic Baker form ula revealed that the croton oil
concentration was quite high at 2.1%, responsible for the results as well as the
-





alter the croton oil concentration as needed is a major advancement that allows

This versatility makes the peel applicable to all ages and skin types.

completely changes the nature of the peel. It is now possible to use croton oil
concentrations weak enough so that application technique becomes one of the
important factors in determining the depth reached. The entire process is slowed
down so that the surgeon can observe the skin changes and have the opportunity
to stop at whatever depth is deem ed appropriate. The “all-or-none” phenom e-
non seen with the Baker peel was simply that the croton oil concentration was
so high that it immediately resulted in dense frosting. This consistently resulted
in a peel deep enough to cause hypopigmentation.

• The Art and Science of Croton Oil Peeling
The depth of peel can now be customized depending on skin type, age, or clin-
ical need, and by choosing the appropriate concentration and how the peel is
applied, the surgeon is in precise control.
On a practical level, it is now feasible to peel to the desired clinical result with-


face depending on relative skin thickness. Many practitioners of the traditional
peel were reluctant to treat the eyelids because of fear of scarring, but now with
the choice of a weak concentration such as 0.1%, the delicate eyelid skin can be

REFERENCES
1. Baker TJ. The ablation of rhitides by chemical means: a preliminary report. J Fla Med Assoc
48:451-454, 1961.
2. Baker TJ. Chemical face peeling and rhytidectomy: a combined approach for facial rejuve-
nation. Plast Reconstr Surg 29:199-207, 1962.

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
13
The Technical Use of
Croton Oil Peels
Richard H. Bensim on
The only source of knowledge
is experience.
ALBERT EINSTEIN

Chapter Videos
13-1 Croton Oil Peel Without Anesthesia
13-2 Croton Oil Peel With Anesthesia
13-3 Removing the Zinc-Oxide Tape Mask and Applying Bismuth Paste
13-4 Lower Lid Peel Without Anesthesia
Additional procedural video and author discussion of technique can be
found on Media Center.