Color Atlas of Cosmetic Oculofacial Surgery

Dissection and severance of the medial and lateral
extensions of the levator (the ‘horns’) are to be
avoided if possible since it is thought that this lessens
the lift per millimeter of levator resected. The appro-
priate amount of resection is usually between 16 and
18mm, and this is marked on the levator. Three dou-
ble-armed 6-0 Dexon or Vicryl sutures are placed along
the antero-superior edge of the upper tarsus, and then
each end is applied through the underside of the leva-
tor muscle at the marked sites. The levator muscle is
advanced and tied down. The muscle is resected. The
ends of the double-armed 6-0 Dexon sutures are then
applied along the upper and lower skin edges to facili-
tate formation or reformation of the lid crease (Fig.
12.13). The crease wound is closed with additional
6-0 nylon or absorbable sutures (Fig. 12.14).
206
Chapter 12: Ptosis (Blepharoptosis)
Figure 12.13 Three double-armed 6-0 Dexon sutures function as a
crease-forming suture.
Figure 12.14 Same child as in Figure 12.4, after levator resection.

Empirical tables correlating desired upper lid mar-
gin position intraoperatively to preoperative levator
function are often used. An example of such is shown
in Table 12.1.
Patients should be counseled preoperatively that
lagophthalmos may likely occur or be worsened fol-
lowing surgery. Artificial tears and ocular lubricant
nightly are helpful adjuncts. The upper lid usually
relaxes after 4–5 months and the globe will then be
adequately protected as long as there is a good Bell’s
eye protective mechanism (Fig. 12.15).
207
Surgical Repair
Table 12.1: Levator resection for patients with levator function 5–10mm
(under general anesthesia).
Levator function
Desired intraoperative lid margin
5–6mm
Place it 1.0–1.5mm above desired level
7–8mm
Place it at desired level plane
9–10mm
Place it 1 mm below desired level
Figure 12.15 Adult woman (A) before and (B) after levator resection.
The exception to use of this technique for patients
with moderate levator function of 5–10mm would be
patients with Marcus Gunn jaw winking ptosis.
These patients are better managed with extirpation of
their aberrant levator muscle, coupled with bilateral
frontalis suspension.
A
B

For patients with LF of 0–5mm: Frontalis
Suspension
For those with poor levator function, the classical
frontalis supension is really the only available option,
assuming that the patient has a functioning frontalis
muscle. Problems postoperatively include undercor-
rection, corneal exposure, lid margin contour abnor-
mality, asymmetry, and lagophthalmos. It is not a
very satisfactory solution and in some segments of
the oculoplastic community, it is not enthusiastically
endorsed.
Adjustable frontalis suspension using a 1mm
silastic rod
Indications include patients with myogenic ptosis
(myotrophic dystrophy, myasthenia gravis, chronic
progressive external ophthalmoplegia; congenital
ptosis where the patient is too young to yield suffi-
cient autogenous fascia lata) as well as neurogenic
ptosis (Marcus Gunn ptosis).
Under general anesthesia, the surgeon applies a
corneal protective shield over each eye. A No. 15 blade
is used to make a 10mm skin incision over the central
portion of the eyebrow, just above the hairline. Three
small subcutaneous incisions (3mm each) are made
over the pretarsal region of the upper lid, just below
the lid crease or superior tarsal border, medially, later-
ally, and centrally. A Keith needle may be bent into a
gentle curve and then passed from the supra-brow
incision, staying between the periorbital orbicularis
and the underlying levator muscle, to exit through the
small infra-crease incision medially. A length of 1mm
silastic rod is threaded through the eye of the Keith
needle and retrieved back towards the supra-brow
incision. A straight Keith needle is used to thread the
1mm silastic rod horizontally across the tarsus in an epi-
tarsal manner. In this maneuver, exiting through the
central infra-crease incision and then repassing it and the
1mm silastic rod to the lateral infra-crease incision
makes the passage more controlled.*
Sutures of 7-0 silk are used to tie down the silastic
rod along each of the three infra-crease incisions, tak-
ing an intratarsal bite, before any attempt is made to
lift the lid with the 1mm rod. The original curved Keith
needle is then repassed through the brow incision, exit-
ing through the lateral infra-crease incision to
redirect the silastic rod back towards the brow
incision. Over the supra-brow incision, a silastic
Watzke sleeve (retinal buckling synthetic element) is
expanded with a micro-hemostat and each end of the
silastic loop is passed through the sleeve, allowing the
sling to be tied down and adjusted to the proper
tension. Again, empirical tables are used, an example
of which is shown in Table 12.2.
208
Chapter 12: Ptosis (Blepharoptosis)
Table 12.2: Frontalis suspension for patients with levator function 5–10mm
(under general anesthesia).
Levator function
Desired intraoperative lid margin
0–2 mm
Place it 1mm above desired level
3–4 mm
Place it at desired level plane
5 mm
Place it 1mm below desired level
*Clinical point: If a patient does not have a crease, the tar-
sus is everted and the distance from the central lid margin
to the superior tarsal border is measured with a caliper;
this is where a physiologic upper crease ought to be placed
on the skin side. Full-thickness lid-crease-forming sutures
like Pang’s sutures are seldom necessary, as the sling will
crease a fold over the superior tarsal border, mimicking
an upper lid crease, providing the pretarsal portion of the
synthetic sling is adequately fixated.
12.2

The two ends of the silastic rod within the Watzke
sleeve are further tied on the outside with a 4-0
Polydek suture (ME-2 needle, by Deknatel), and then
it is secured to the upper cut edge of the deep frontalis
muscle. Upward movement of the frontalis will pull
the upper lid margin via the action of the sling. It is
important to check for this, even though the patient is
in a supine position, to make sure that the lid mar-
gin’s elevation is physiologic and not lifted away from
the surface of the globe. The brow incision is closed
in the deep layer with a 4-0 Vicryl suture and on the
skin side with a 5-0 nylon suture, in an interlocking
stitch. Each of the three infra-crease skin incisions is
closed with a single 6-0 absorbable stitch.
Advantages and disadvantages The use of 1mm
silastic rod instead of autogenous fascia lata allows
for subsequent access to the tract of the sling and
readjustment of the lid position, should there be
need for tightening (to reverse undercorrection) or
loosening (to reverse overcorrection). This is especially
advantageous for patients who have neurogenic or
myogenic ptosis, where postoperative results are often
unpredictable. It also obviates the need for harvesting
the patient’s own fascia lata.
There is a higher incidence of undercorrection or
loss of the sling’s effectiveness with time. Infection
has been reported, although this is easily managed
with antibiotics, and, when necessary, the silastic rod
can be easily removed.
Frontalis suspension using autogenous fascia lata
For adolescents and adults who have congenital pto-
sis with poor levator function in the absence of other
neurologic or muscular conditions, one may elect to
harvest fascia lata from the lateral thigh of the
patient. A Crawford fascial stripper is used to harvest
a 10cm ´10mm band of fascia in a young child, or a
15cm ´ 10mm band in an adult. The 10mm gives
enough width to then subdivide the band into four
strips, each 2.5mm wide. This is sufficient for those
surgeons who prefer to suspend the lid by two trian-
gles on each side rather than through a single, trape-
zoidal sling. The fascial strip is tunneled across the lid
and along the anterior tarsal surface using a pediatric
Crawford fascia needle.
The steps involved in the passage of these fascial
strips are as listed in the previous section on frontalis
suspension using a silastic rod. After the lid level has
been adjusted appropriately, the fascia lata strip is
tied at each end. The fascial knot is re-enforced with a
4-0 Polydek suture and then anchored to the underly-
ing frontalis muscle on the upper edge of the supra-
brow incision. It is important not to anchor it to the
underlying cranial periosteum as this will result in an
immobile eyebrow.
209
Surgical Repair

FURTHER READING
Anderson RL. Aponeurotic ptosis surgery. Arch
Ophthalmol 1979;97:1123–8.
Bedrossian EH. HIV and banked fascia lata. Ophthal
Plast Reconstr Surg 1991;7:284–8.
Callahan M, Beard C. Ptosis, 4th edn. Birmingham:
Aesculapius; 1990.
Collin JR, Beard C, Wood I. Experimental and
clinical data on the insertion of the levator
palpebrae superioris muscle. Am J Ophthalmol
1978;85:792–801.
Crawford JS. Repair of ptosis using frontalis muscle
and fascia lata. Trans Am Acad Ophthalmol
Otolaryngol 1956;60:672–8.
Crawford JS. Repair of ptosis using frontalis muscle
and fascia lata: a 20-year review. Ophthalmic
Surg 1977;8:31–40.
Dresner SC. Further modification of the Mueller’s
muscle–conjunctival resection procedure for
blepharoptosis. Ophthal Plast Reconstr Surg
1991;7:114–22.
Fasanella RM, Servat J. Levator resection for
minimal ptosis: another simplified operation.
Arch Ophthalmol 1961;65:493–496.
Frueh BR. The mechanistic classification of ptosis.
Ophthalmology 1980;87:1019–21.
Jones LT, Quickert MH, Wobig JL. The cure of
ptosis by aponeurotic repair. Arch Ophthalmol
1975;93:629–34.
Linberg JV, Vasquez RJ, Chao GM. Aponeurotic
ptosis repair under local anesthesia. Prediction
of results from operative lid height.
Ophthalmology 1988;95:1046–52.
McCord CD Jr. Eyelid surgery: principles and
techniques. Philadelphia: Lippincott-Raven;
1995.
Older JJ, Dunne PB. Silicone slings for the correction
of ptosis associated with progressive external
ophthalmoplegia. Ophthalmic Surg
1984;15:379–81.
Pang HG. Surgical formation of upper lid fold. Arch
Ophthalmol 1961;65:783–4.
Putterman AM, Urist MJ. Mueller muscle–
conjunctiva resection. Arch Ophthalmol
1975;93:619–23.
Schechter RJ. Ptosis with contralateral lid retraction
due to excessive innervation of the levator
palpebrae superioris. Ann Ophthalmol
1978;10:1324–8.
Shore JW, McCord CD. Anatomic changes in
involutional blepharoptosis. Am J Ophthalmol
1984;98:21–7.
Tillett CW, Tillett GM. Silicone sling in the correction
of ptosis. Am J Ophthalmol 1966;62:521–3.
Wagner RS, Mauriello JA Jr, Nelson LB, Calhoun
JH, Flanagan JC, Harley RD. Treatment of
congenital ptosis with frontalis suspension: a
comparison of suspensory materials.
Ophthalmology 1984;91:245–8.
210
Chapter 12: Ptosis (Blepharoptosis)

211
Chapter 13
Cosmetic Botulinum Neurotoxin
Application
Jemshed A Khan and Michael S McCracken
Introduction and History
One of the safest, simplest, and most satisfying meth-
ods of elective cosmetic reduction of facial rhytides is
by the injection of botulinum neurotoxin Type A
(BoNT-A, BOTOX® (Allergan, Irvine, CA) ). Dysport®
(Medicis, Scottsdale, AZ) is another formulaion of
BoNT-A which is nearing FDA approval. Doses in this
chapter are specific to BOTOX®, and Dysport® doses
are approximately 2.5–3 times those for BOTOX®.
BoNT-A is currently injected into selected superficial
musculo-aponeurotic system (SMAS)-type facial mus-
cles to temporarily reduce associated static and
dynamic wrinkles. BoNT-A relaxes muscles by pre-
venting the presynaptic release of the neurotransmit-
ter acetylcholine at the peripheral cholinergic motor
neuron endplate (Fig. 13.1A & B).
Figure 13.1 (A) Normal skeletal muscle contraction results when there is
presynaptic release of the neurotransmitter acetylcholine (ACh) at the
peripheral cholinergic motor neuron endplate or nerve ending. The ACh
molecules diffuse across the synapse in order to stimulate skeletal muscle
contraction. (Courtesy of Allergan, Inc.)
Figure 13.1 (B) ACh is stored in vesicles residing in the motor nerve
ending. Docking of ACh-containing vesicles with the nerve membrane is
a necessary step prior to release of Ach into the neuromuscular junction.
Docking is mediated by a number of molecules including SNAP-25A
attached to the nerve membrane (blue strands). (Courtesy of Allergan,
Inc.)
A
B

212
Chapter 13: Cosmetic Botulinum Neurotoxin Application
Acetylcholine (Ach) is stored in vesicles residing in
the motor nerve ending. Docking is a necessary step
prior to release of ACh into the neuromuscular junc-
tion. BoNT-A prevents the docking and exocytosis of
these acetylcholine vesicles to the nerve endplate. In
order for BoNT-A to exert this effect, it must first be
absorbed into the nerve ending by a process termed
receptor-mediated endocytosis. After BoNT-A is
internalized within a cytoplasmic vesicle, the light
chain is released into the cytoplasm. The light chain
cleaves a protein known as SNAP-25A which must
be functional in order for acetylcholine vesicles to
dock prior to release into the neuromuscular junc-
tion (Fig. 13.1C–F).
Figure 13.1 (D) After BoNT-A molecules bind to nerve endings, they are
absorbed into the nerve ending through a process termed ‘receptor-
mediated endocytosis.’ BoNT-A is then internalized into cytoplasmic
vesicles. (Courtesy of Allergan, Inc.)
Figure 13.1 (Continued) (C) Following botulinum neurotoxin type A
(BoNT-A) injection, molecules of BoNT-A (yellow and gold-colored
molecules) diffuse through the tissues and bind to the surface of the nerve
ending via specific surface receptors (red and blue structures). (Courtesy
of Allergan, Inc.)
Figure 13.1 (E) and (F) After BoNT-A is internalized within a cytoplasmic vesicle, the light chain of the molecule (yellow) is released into the cytoplasm.
The light chain cleaves a protein known as SNAP-25A (blue) which must be functional in order for acetylcholine vesicles to dock prior to release into the
neuromuscular junction. (Courtesy of Allergan, Inc.)
C
D
E
F

213
Introduction and History
Several distinct immunological BoNT serotypes exist
(A, B, C1, D, E, F, G) which vary from approximately
300 to 900kD size. All BoNT serotypes target one or
more specific intracellular proteins necessary for synap-
tic release of neurotransmitter. Proteins targeted by
different serotypes include SNAP-25, syntaxin, and vesi-
cle-associated membrane protein (VAMP, also known as
synaptobrevin). Over time, the nerve ending may sprout
additional axons, which establish new motor endplates
(Fig. 13.1G). This results in a gradual return of motor
function. Clinically, muscle function returns in 3–4
months. Skin testing for allergy to BoNT-A is not neces-
sary, although blocking antibodies may occur in patients
who receive high doses repeatedly.
History of botulinum toxin
■ In 1895, Emile Pierre van Ermengem, of Belgium
identified Bacillus botulinus
■ In the 1920s, botulinum toxin type A isolated in
purified form by Dr Herman Sommer at the University
of California, San Francisco, USA
■ In 1946, Edward J. Schantz and colleagues purified
botulinum toxin type A in crystalline form
■ In the 1960s and 1970s, Alan B. Scott tested
botulinum toxin type A in monkeys to determine if the
drug might be an effective therapy for strabismus
■ 1978, Dr Scott received permission from the Food
and Drug Administration (FDA) to test botulinum toxin
type A in human volunteers
■ 2002, FDA approval of BOTOX® for cosmetic
treatment of the glabella (Dysport® approved 2009)
Figure 13.1 (G) The muscle inactivity produced
by a BoNT-A injections is temporary because
peripheral nerve ending sprouts eventually
develop and re-enervate the skeletal muscle.
(Courtesy of Allergan, Inc.)
G

214
Chapter 13: Cosmetic Botulinum Neurotoxin Application
Anatomy
The facial mimetic muscles are specialized for several
functions including facial signaling and communica-
tion. Most of the muscles of facial expression are part
of a continuous interconnected layer of muscle and
connective tissue known as the SMAS layer (Fig. 13.2).
While these muscles are specialized for facial expres-
sion, there is also a decline with age in the accuracy
with which these muscles convey facial expression.
Hence, the age-related development of standing glabel-
lar furrows may create a mistaken expression of
disapproval. It is often the goal of BOTOX® injection
to reduce the facial ‘miscues’ through selective pharma-
cologic denervation of the offending muscles. The com-
mon target muscles are summarized in Table 13.1.
Figure 13.2 Muscles of facial expression.
Table 13.1: Target muscles for botulinum neurotoxin injection.
Muscle
Action
Clinical effect and


wrinkle(s) produced
Orbicularis oculi (orbital portion)
Forced eyelid closure,
Crow’s-feet, eyebrow depression

lateral eyebrow depression
Corrugator supercilii
Depresses and adducts medial
Glabellar frown Lines

half of eyebrow
Procerus
Depresses medial eyebrow
Horizontal nasal bridge lines
Depressor supercilii
Depresses head of eyebrow
Depresses head of eyebrow
Frontalis (occipitofrontalis)
Furrows forehead, elevates eyebrows
Horizontal forehead lines
Orbicularis oris
Purses and puckers lips
Vertical lip lines
Depressors of mouth: depressor
Depresses lateral angle of mouth
Ptosis of lateral commissure
labii inferioris depressor anguli oris
Platysma
Depresses lower jaw and lip
Vertical neck bands

215
Clinical Indications and Patient Selection
Clinical Indications and Patient
Selection
BoNT-A injection works well and reliably in the
crow’s-feet, glabella, and forehead (Fig 13.3). With
experience, the eyebrows may be repositioned through
treatment of the adjacent orbicularis oculi, procerus,
corrugator supercilii, and depressor supercilii. BoNT-A
may also be used with caution and experience to reduce
the perioral rhytides and to improve the lateral angle
of the mouth. However, the risk of perioral treatment
resides in the possibility of inducing a neurolytic
incompetence of the oral sphincter which may result in
temporary drooling, difficulty in pronouncing some
sounds (P or B), or inability to whistle, and difficulty
playing wind instruments. BoNT-A is not helpful in
the treatment of the nasolabial and marionette lines
because such treatment results in facial ptosis. Dose is
often individualized and may be related to muscle mass
such that relatively smaller doses are sometimes used
in females and Asians (Tables 13.2 & 13.3). BOTOX®
injection is contraindicated in the presence of infection
at the injection site or in patients with known hyper-
sensitivity to BOTOX® or any of its components.
Caution should be used in treating patients with
pre-existing neuromuscular disorders. BoNT-A treat-
ment is contraindicated in women who are pregnant or
nursing.
Figure 13.3 (A) Wrinkles indicated for BOTOX® treatment: green wrinkles
respond well; yellow wrinkles should be treated cautiously; red lines
should not be treated.
Figure 13.3 (B) Facial zones and underlying muscle groups. Green areas
respond predictably and well. Caution is used in yellow areas because of
unwanted effects such as adynamic and ptotic eyebrow. Red areas will
produce unwanted effects such as drooping cheek and mouth.
A
B

216
Chapter 13: Cosmetic Botulinum Neurotoxin Application
Table 13.2: Glogau wrinkle classification scale.
Type I
No wrinkles
Type II
Wrinkles in motion
Type III
Wrinkles at rest
Type IV
Only wrinkles
Table 13.3: General guidelines for typical botulinum neurotoxin type A (BOTOX®) cosmetic doses.
Site
Dose
Number of
Total dose
Spacing of
Recommended initial

per site
injections
per side
ipsilateral
dose per side/


per side

injection
#injection sites per side/





distance between injections
Forehead
2.5–5 u
2–5
10–15 u
1–3 cm
2.5 u/ 2/3 cm
Glabella
5–10 u
1–2
10–20 u
1–2 cm
5 u/ 2/1+cm
Crow’s-feet
3–10 u
1–5
10–15 u
1–2.5 cm
5 u/ 2/1+cm
Upper lip
1–1.5 u
1–2
1–2 u
1.5 cm
1 u/ 1/ na
Lower lip
1–1.5 u
1–2
1–2 u
1.5 cm
1 u/ 1/ na
Lateral Commisure
5–10 u
1–2
5–10 u
1–1.5 cm
5 u/ 1/ na
Platysma
5 u
variable
15–50+
1–3 cm
5 u/ variable/ 1.5+cm

217
Preparation
Figure 13.4 Vacuum sealed vial + 2.2mL non-preserved saline = approx.
5 u/0.1mL.
Preparation
Botulinum Toxin A (BOTOX®) consists of lyophilized
albumin and neurotoxin cryoprecipitate. Preserved or
preserva tive-free saline is used for reconstitution. The
authors use 2.2 mL of saline as diluent because
approximately 0.1mL remains in the vial through cap-
illary attraction to the glass surface (Fig. 13.4; Table
13.4). The reconstituted drug should be used within 4
Table 13.4: Effect of diluent volume on final
BOTOX® concentration.
Saline diluent
Concentration
Concentration

per 0.1mL
per 1.0 mL
1.0 mL
10 u
100 u
2.0 mL
5 u
50 u
2.5 mL
4 u
40 u
4.0 mL
2.5 u
25 u
10 mL
1.0 u
10 u
hours according to manufacturer’s recommendation.
A fine 27- or 30-guauge needle is used for administra-
tion. Significant reconstituted volume of drug may be
wasted in the hub of a detachable 27- or 30-guauge
needle: the authors prefers the economy of an insulin
syringe with permanently attached needle.
The saline diluent should be dripped into the vial
slowly so as to avoid creating a streaming jet of fluid
that may inactivate the labile toxin.
Preparation
1. Store in freezer prior to use
2. (Optional step) Break seal and remove stopper
3. Drip in non-preserved saline slowly, 2.2mL
4. 2.2mL non-preserved saline = approx. 5 u/0.1mL
5. Roll gently to mix – do not shake or stir
6. Withdraw in a 0.5 or 1.0mL via insulin syringe without
dulling tip
7. Refrigerate unused portion and use within 4 hours

218
Chapter 13: Cosmetic Botulinum Neurotoxin Application
Injection Techniques
General principles
The purpose of injection is to deliver an appropri-
ate intramuscular or perimuscular drug dose while
minimizing the risks of bruising and pain. Because
of the thinness of the overlying skin, ecchymosis is
easily visible when it arises from the orbicularis
oculi muscle. Thus, it is better to inject subcutane-
ously over the orbicularis oculi muscle and thereby
avoid direct intramuscular injection and visible
ecchymosis. Ecchymosis may also result from
transection of fine subcutaneous vessels; therefore
it is important to look for and avoid such vessels
when injecting in the crow’s-feet area. Superficial
injection may be delivered by perpendicular or tan-
gential placement of subdermal BoNT-A to relax
the frontalis muscle. Application of pressure imme-
diately and directly to the injection site will mini-
mize bruising. In the areas of thicker dermis
overlying the orbicularis oris, mouth depressors,
and corrugator supercilii muscles, one may attempt
intramuscular injection since the thick overlying tis-
sue will obscure ecchymosis.
Gently pinching the skin overlying the procerus,
corrugator, and frontalis muscles may help reduce dis-
comfort and ensure superficial placement of drug
(Fig. 13.5). One may also reduce discomfort with top-
ical anesthesia techniques including ice, EMLA
(AstraZeneca LP, Wilmington, DE), Betacaine LA
(Theraderm, Tampa, FL), LMX4® (Ferndale Laboratoris
Inc, Ferndale, MI), etc.
Figure 13.5 (A) The pinch technique is used to ensure correct anatomic
placement of the needle tip over the corrugator supercilii and to reduce
discomfort.
Figure 13.5 (B) A similar technique is employed to treat the procerus
muscle. (Courtesy of Rick Anderson, MD)
A
B
13.1–
13.7

219
Injection Techniques
Crow’s-feet injection
Crow’s-feet injection is one of the simplest and most sat-
isfying applications of BoNT-A. The radiating dermal
crow’s-feet lines result from the concentric constriction
of the underlying orbital and preseptal orbicularis oculi
muscle (Fig. 13.6). The orbicularis oculi injections of
BoNT-A may result in diminution of both active and
static crow’s-feet rhytides, may prophylactically delay
the onset and progression of such wrinkles, and improve
final outcome following ablative periocular resurfacing.
The thin periocular skin is prone to visible bruising;
therefore injection should be delivered in the subdermal
plane while avoiding actual intramuscular injection.
The loose periocular subdermal plane in the area of
crow’s-feet rhytides should visibly balloon up when the
injection is delivered at the proper depth. Following
injection, the patient may apply pressure with facial
tissues for 1–2 minutes over the injection sites to
minimize bruising. Massage may be used to assist the
penetration of the BoNT-A into the orbicularis oculi.
Figure 13.6 (A) Crow’s-feet rhytides. (B) Typical injection sites for radiating crow’s-feet rhytides. (C) Location of underlying concentric orbicularis oculi
muscle fibers. (D) Improvement in rhytides following botulinum neurotoxin type A injection. (Courtesy of Joan Kaestner, MD)
Essentials
■ Consciously avoid visible vessels
■ Insulin syringe with integrated 30-gauge needle
■ Injection sites 1–2cm lateral to lateral canthal angle
■ 10–15u total dose per side divided into 2–5 injections
per side
■ Injections 1–5cm apart
■ Apply pressure after each injection
A
B
C
D

220
Chapter 13: Cosmetic Botulinum Neurotoxin Application
Corrugator and Procerus Rhytide
Treatment
Cosmetic injection of BOTOX® for glabellar rhytides
was approved by the FDA in April, 2002 (Fig 13.7).
To reduce pain and avoid blunting the needle tip dur-
ing injection, care should be taken to avoid injecting
too shallow or too deep: stay deep enough to be sub-
dermal, but not so deep as to engage the periosteum.
Pain may also be reduced by palpating the supraor-
bital notch and thereby avoiding the vertical course of
the supraorbital nerve. Stay 0.5cm superior to the eye-
brow to reduce the risk of eyelid ptosis.
The procerus muscle may be injected in the mid-
line or by pinching the nasal bridge and entering the
procerus tangentially. The drug is deposited in the
midline. Generally, a single procerus injection is
placed over the upper nasal bridge either at or up to
7mm higher than the level of the medial canthal
tendon.
Figure 13.7 (A) Glabellar and
horizontal procerus wrinkles.
Figure 13.7 (B) The corrugator
muscles are represented by red lines.
The procerus muscle location is
depicted by green lines. Note the
course of the supraorbital nerve (yellow)
located 2.5cm lateral to the midline and
often also located by palpating the
supraorbital notch. The inferior portion
of the nerve should be avoided
because of pain or ecchymosis due to
injection of the nerve or laceration of
the accompanying blood vessels.
A
B

221
Corrugator and Procerus Rhytide Treatment
Essentials of treatment for glabellar rhytides
■ Perpendicular or tangential injections
■ Insulin syringe with integrated 30-gauge needle
■ Avoid supraorbital neurovascular bundles
■ Avoid dulling the needle against the periosteum
■ Inject at subdermal or intramuscular depth
■ Deeper depth is more painful
■ Injection sites placed at least 0.5cm superior to the
upper eyebrow border
■ Injection sites placed at least 0.5cm medial and
lateral to the path of the supraorbital nerve
■ Two injections of 5u each delivered to each
corrugator muscle and 5u in to the procerus
■ Apply pressure after each injection
`
Essentials of treatment for procerus
■ Procerus muscle is midline structure
■ Procerus action creates horizontal furrows
■ Emotional signal created by procerus action is
aggression
■ Inject 5u into the midline procerus
Figure 13.7 (C) Typical injection sites.
Five injection sites of 5u each are
typically used. Note that the lateral site
is never placed directly superior to the
supraorbital notch.
Figure 13.7 (D) Improvement in
rhytides following BoNT-A injection.
Note the smoother appearance to the
glabellar area. (Courtesy of Joan
Kaestner, MD)
C
D

222
Chapter 13: Cosmetic Botulinum Neurotoxin Application
Frontalis Treatment
Frontalis injection is useful in treating horizontal fore-
head wrinkles. Injection sites are at least 1.0–2.0 cm
above the eyebrows to avoid a ptotic or adynamic and
expressionless eyebrow. Injection should be delivered
across the medial and lateral frontalis to avoid seg-
mental eyebrow elevation (see Complications below).
A series of two injections per ipsilateral forehead is
usually a good starting point, and may be increased to
10 sites depending upon patient response (Fig. 13.8).
Prior to injection, one should search for any under-
lying eyelid ptosis with compensatory eyebrow eleva-
tion. Forehead injection and the resulting eyebrow
depression may worsen an underlying eyelid ptosis
such patients.
Essentials
■ Frontalis is a paired muscle, connected to the
posteriorly located occipitalis muscle
■ Frontalis action raises the eyebrows and furrows the
forehead
■ The emotional signal created by frontalis action is
surprise
■ Usual injection dose is 1.5–4.0 u per site
■ Usually, there are between 4 and 10 injections sites
per patient, depending upon the size of the forehead
■ Use proper technique to avoid brow ptosis
■ Use proper technique to avoid adynamic eyebrows
Figure 13.8 (A) Note horizontal forehead furrows prior to injection.
Figure 13.8 (B) Red lines depict the location of the vertically oriented
frontalis muscle.
Figure 13.8 (C) Four injection sites of 1.5 to 4.0 units per site is a safe
beginning dose.
Figure 13.8 (D) Smooth forehead appearance 2 weeks following
injection.
A
B
C
D

223
Advanced Techniques
Advanced Techniques
Perioral
The perioral area responds less predictably than other
treatment areas because of the dynamic muscle actions
associated with eating, drinking, speaking, and smil-
ing may be impaired. Therefore a cautious approach
to this area is warranted (Figs 13.9–13.11). The men-
talis area may also be injected to treat a ‘popply chin’.
Figure 13.9 (A) Typical treatment sites for vertical lip lines. Minute doses,
i.e. 1.0–1.5 units per site, are delivered. The dose and number of injection
sites may be gradually increased if the response is inadequate. Only 50%
of patients are satisfied with perioral BOTOX® because of drooling,
difficulty puckering and whistling, and impaired enunciation.
Figure 13.9 (B) Patient with vertical lip lines demonstrating ability to
pucker prior to injection.
Figure 13.9 (C) Same patient following BOTOX® injection demonstrates
inability to pucker despite voluntary effort. (Courtesy of Rick Anderson, MD)
A
B
C

224
Chapter 13: Cosmetic Botulinum Neurotoxin Application
Figure 13.10 (A) Preoperative appearance of patient with depressed
lateral oral commissures. Note the slight downward angulation of the
lateral oral commissures prior to injection.
Figure 13.10 (B) Injection sites for treatment of depressed lateral oral
commissures. Generally, 2.5 to 5 units per site is delivered.
Figure 13.10 (C) Overlay of perioral muscles. Green lines represent
depressor anguli oris. Red lines represent depressor labii inferioris.
Caution must be exercised to avoid injecting the depressor labii inferioris.
Figure 13.10 (D) Note subtle improvement in wrinkles and slight elevation
of the lateral oral commissures 2 weeks following injection
A
B
C
D
Depressor Anguli Oris
The depressor anguli oris (DAO) is a paired muscle that
runs from the outer surface of the mandible to the angle
of the mouth. Its action is to depress the corner of the
mouth and draw it laterally. By injecting this muscle an
injector can counter its effect of turning down the cor-
ner of the mouth. The muscle can be palpated when the
patient is asked to keep their teeth together while low-
ering the lower lip to show their lower teeth. We rec-
ommend two injection sites of 2.5 units each per side,
for a total of 10 units. Caution must be exercised to
avoid injecting the depressor labii inferioris (DLI),
which is found medial to the DAO and depresses the
lip. Weakening of the DLI will cause lip asymmetry.

225
Advanced Techniques
Figure 13.11 (A) Patient with depressed corners of the mouth.
Figure 13.11 (B) Injection sites for BoNT-A treatment of the depressot
anguli oris (DAO).
A
B
Figure 13.11 (C) More aesthetic appearance of the mouth after DAO
treatment
C
Pitfalls
■ Avoid injecting medially to the DAO to prevent
injection of the DLI, which will cause lip asymmetry
■ Only 50% of patients are happy with perioral
injections

226
Chapter 13: Cosmetic Botulinum Neurotoxin Application
Figure 13.12 (A) Patient with two platysmal bands.
Figure 13.12 (B) Four injections of 5.0u each were administered to each
band. Injection points for the left band are indicated by arrows.
Figure 13.12 (C) Reduction in platysmal bands
A
B
C
Platysmal bands
The platysma is a paired muscle that runs from the ster-
nocleidomastoid to above the mandible. With aging,
vertical bands may develop in the muscle. When these
bands are accompanied by excessive skin laxity, the
neck is best treated with a facelift. However, patients
with prominent band and minimal excess skin may
respond well to BoNT-A treatment. Bands that become
more prominent when the patient is asked to push their
forehead forward against the examiner’s hand are
bands that are likely to respond well to BoNT-A treat-
ment. We recommend pinching each band and making
approximately three or four evenly spaced injections
several centimeters apart into each band. For an injec-
tor not experienced in this area, a total of 20 units for
both sides is a reasonable stating point. Complications
include bruising, weakness of neck flexion, and tran-
sient hoarseness or difficulty swallowing due to recur-
rent laryngeal nerve weakness. Fatalities have been
reported due to swallowing difficulties and aspiration
associated with high-dose injections in the neck region.

227
Complications
Complications
Systemic complications include flu-like symptoms, res-
piratory infection, nausea, headache, and hypersensi-
tivity reactions. There have been rare reports of death
following BOTOX® injection, most recently in chil-
dren who received large doses for lower limb spastic-
ity. However, it is important to note that although use
of cosmetic BoNT-A injections continues to rise (over
three million cosmetic treatments were administered in
2006), death has not been associated with cosmetic
injection of BoNT-A. An extensive list of possible com-
plications is found on the package insert.
Local complications of cosmetic BoNT-A injection
include bruising, blepharoptosis, brow ptosis, residual
temporal brow elevation (‘Spocking’), lagophthalmos,
dry eye, diplopia, ectropion, and transient loss of
orbicularis oris function.
Local complications may be minimized with
appropriate refinement and adjustment of injection
sites and doses on subsequent visits. For example,
the patient pictured in Figure 13.13 received supple-
mental injections to the lateral frontalis muscle to
correct the excess temporal eyebrow elevation. Figure
13.14 shows secondary ptosis following BoNT-A.
Figure 13.13 Patient complained of temporal eyebrow tenting following
forehead botulinum neurotoxin type A (BoNT-A) injections. Placement of
additional doses of 5u in to each lateral frontalis muscle corrected the
eyebrow contour deformity.
Figure 13.14 Temporary eyelid ptosis following BoNT-A treatment of
forehead and glabella.
Essentials
■ Complications may be reduced with appropriate
dosing
■ Complications may be reduced with appropriate
anatomic technique
■ Ptosis will resolve spontaneously
■ Eyelid ptosis may be treated with Iopidine drops or
Naphcon-A drops
■ Perioral complications include drooling, difficulty in
pronouncing some sounds (P or B), inability to whistle,
and difficulty playing wind instruments
■ Diplopia, dry eyes, exposure keratitis, and
lagophthalmos are unusual with cosmetic injections

228
Chapter 13: Cosmetic Botulinum Neurotoxin Application
Chapter 13: Cosmetic Botulinum Neurotoxin Application
Documentation of Treatment
Anatomic documentation of treatment sites creates a
historical record upon which further treatment modi-
fications may be individualized (Fig. 13.15). For
example, if a patient has inadequate lateral forehead
wrinkle reduction, one may refer to the previous treat-
ment diagram and use this as a basis for adding new
lateral treatment sites.
BOTOX® Treatment Record
Patient name:
Dx: BEB/Hemifacial spasm/Cosmetic/
Date
Pt comments:
U Given
Notes:
RTC
Signed:
Discard
Share
CC: Spasms returning
Cosmetic
Figure 13.15 BOTOX® treatment record.

229
Informed Consent
Informed Consent
While botulinum toxin A appears to be a safe and
effective drug, the very-long-term consequences of
neurotoxin
injection
are
unknown.
Therefore,
1. I,___________________ ___________________
(first name, last name), request that Dr ___________,
or whomever he designates, administer botulinum
toxin to me for either medical or cosmetic purposes.
BOTOX® is not FDA approved for headache
treatment, tarsorrhaphy, or muscle twitching.
Photos of me may be taken and used for
educational, scientific, or marketing purposes.
2. If botulinum is given for medical purposes, such as
involuntary muscle spasm, tarsorrhaphy,
blepharospasm, hemifacial spasm, muscle twitch or
tick, etc., I hereby acknowledge that I understand
that there may be alternative treatments for this
condition, including, but not limited to, medical
therapy including the administration of oral
medicines, muscle stripping or other operations,
removal of motor nerves, or procedures to release
pressure on involved nerves.
3. I acknowledge that I understand that BOTOX® A
includes human albumin. Albumin is a protein, similar
to the white of a chicken egg, that is derived from
human blood products. While it is not believed that
there has been any transmission of diseases from
BOTOX® A, I understand that this is very unlikely but
possible. I accept the risk of the possibility of acquiring
an infection, including viral or other types of infections
from BOTOX® administration and accept the risk of
unknown future complications from BOTOX® use.
I understand that botulinum B can also be used for my
condition and does not contain albumin.
4. Botulinum toxin usually works well in 95% of patients.
There is a 5% chance that it will not have an
adequate effect. It is not always possible to predict
the effect, and it may work too well or not well
enough. Some of the side effects may include flu
symptoms, headache, temporary droopiness of one
or both eyelids, or double vision. Permanent muscle
weakness is very unlikely. Rare reports of death have
been associated with botulinum toxin use.
5. By signing this document, I agree that it includes all
botulinum toxin injections already provided by
Dr ___________ or whomever he designates, as well
as all future BOTOX® treatments.
6. I understand that the effects of botulinum toxin use
with pregnancy or breast-feeding are not known and
that I should not take BOTOX® if the possibility of
pregnancy or nursing exists.
7. In summary, the risks, consequences, benefits, and
alternatives of treatment, including no treatment,
have been explained to me.
Signed (Patient) ____________________________
Date __/___/___
Witnessed By _____________________________
Date __/___/___
Lifetime consent for administration of BOTOX®
informed consent is important despite the relative
simplicity of the procedure. Informed consent discus-
sion should include both the known side effects as
well as discussion of unknown risks related to the use
of human albumin in botulinum toxin A.

231
Chapter 14
Ablative and Fractionated Laser
Skin Resurfacing
Jemshed A Khan
Introduction
Ablative erbium:YAG and ablative CO2 laser resur-
facing systems create a contiguous zone of controlled
depth, cutaneous ablation and an associated thermal
injury zone which is followed by a healing response
that produces the desired improvement. In order to
ablate skin without scarring, the laser must remove
the epidermis and some papillary dermis while mini-
mizing thermal injury. Since the ‘chromophore’ for the
10.6 μm CO2 and 2.94 μm erbium:YAG laser is water,
ablation occurs when the laser pulse is sufficient to
almost instantaneously raise the intracellular epider-
mal fluid to its boiling point, at which time a steam
plume is ejected out of the wound, quickly carrying
away with it the generated heat before significant col-
lateral tissue damage can occur. Subsequent passes
with the CO2 laser must induce thermal, conforma-
tional, and other changes in the dermal collagen to
induce shrinkage and wrinkle reduction (Figs 14.1 &
14.2). Because these thermal effects are thought to
prolong healing times, the Erbium:YAG lasers are
marketed as an alternative ‘cool’ method of epidermal
ablation and wrinkle improvement.
Figure 14.1 Patient prior to upper and lower eyelid blepharoplasty with
periocular ablative CO2 laser skin resurfacing.
Figure 14.2 Patient subsequent to upper and lower eyelid blepharoplasty
with periocular ablative CO2 laser skin resurfacing.
14.1

232
Chapter 14: Ablative and Fractionated Laser Skin Resurfacing
Fractionated CO2 laser systems deeply treat about
20% of the skin surface area during each treatment.
These small areas of treatment are known as micro
thermal zones (MZT). The remaining untreated area
promotes rapid healing in 2–3 days. Improvement
continues for an additional few months after the
procedure. Fractionated systems in other wavelengths
(1440 nm, 1540nm, 1550nm, 2940nm) are also
available.
10-4
.1
1
10
.1
1
10
10-3
10-2
10-1
100
101
102
103
104
105
Water
Hemoglobin
Laser absorption
Penetration depth (mm)
Wavelength (microns)
Ultra violet visible infrared
Scatter
Melanin
Protein
2.0
1.0
0.0
3.0
4.0
CO6
Ho
Er
Nd
KTP
Excimer
Figure 14.3 Absorption and tissue penetration curves for CO2 and erbium lasers.

233
Comparison of CO2 Ablation, Erbium Ablation, and Fractionated CO2
Comparison of CO2 Ablation, Erbium
Ablation, and Fractionated CO2
Although both CO2 and erbium wavelengths ablate
tissues, with CO2 more tissue is ablated per pulse and
the zone of associated thermal injury is greater. The
difference between erbium and CO2 effects is largely
related to the longer pulse duration of CO2 (approx.
1msec) and its greater tissue penetration (Fig. 14.3).
The greater thermal injury and ablation associated
with CO2 are advantageous insofar as the patient has
a greater improvement in wrinkling and one can
resurface further into the vascular dermis without the
encumbrance of significant bleeding (Fig. 14.4). On
the other hand, with erbium one can create a finer
degree of epidermal ablation and the patients
encounter proportionally quicker recovery times (Fig.
14.5). Since erbium wavelength is absorbed more
Figure 14.4 (A) Image: Schematic of CO2 ablation. (Khan JA. Laser skin
resurfacing. In: Chen WP. Oculoplastic surgery: the essentials. New York:
Thieme; 2001:180.)
Thermal
injury
Epithelium
removed
A
B
Figure 14.4 (B) Image: Schematic of fractionated CO2.
Thermal
injury
Epithelium
removed
Figure 14.5 Image: Schematic of erbium CO2 ablation. (Khan JA. Laser
skin resurfacing. In: Chen WP. Oculoplastic surgery: the essentials. New
York: Thieme; 2001:180.)

234
Chapter 14: Ablative and Fractionated Laser Skin Resurfacing
highly by water than is CO2, there is a corresponding
difference in the minimal fluences necessary for abla-
tion: for CO2 laser, ablation occurs at or above 4–5 J/
cm2, whereas for erbium laser ablation occurs at
>1.6 J/cm2 or higher (Table 14.1).
With fractionated CO2, only 20% of the skin sur-
face is treated, but the CO2 creates cylinders of vapor-
ized tissue that are 70–100 μm diameter and penetrate
the skin up to a depth of 1.5 mm or more. This results
in rapid healing depending upon the depth of treat-
ment, sometimes within 3–6 days. Patients generally
require three treatments 1 month apart.
Table 14.1: Comparison of CO2 and erbium lasers.
Laser
CO2 ablative
CO2 fractional
Er:YAG
Ablation fluence
>4–5 J/cm2
>4–5 J/cm2
>1.6 J/cm2
Wavelength
10.6 μm
10.6 μm
2.94 μm
Usual pulse
950 usec
Continuous or pulsed
250 msec
Thermal damage
75–150 μm

10–50 μm
Vaporization
20–70 μm
Variable, upto 1500 μm or greater depth
2–400 μm


column of ablated tissue
Tissue penetration
30 μm
See above
1 μm
Collagen Shrinkage
++++
+++
+

235
Tissue Response
Figure 14.6
Preoperative appearance
of age-related facial laxity.
Figure 14.7 Note the
improved intraoperative
facial appearance
resulting from thermal
collagen shrinkage and
vaporization of the aged
epidermis.
Tissue Response
The first ablative CO2 laser pass vaporizes the epider-
mis, leaving a residual desiccated debris which is
wiped away. By contrast, several passes with the
erbium:YAG laser are required to reach equivalent
depth. No more resurfacing passes are necessary
when the goals of treatment are limited to the epider-
mis. Subsequent laser passes may be applied to the
papillary dermis in order to create deeper ablation.
Because of the thermal effects associated with CO2,
there is also an immediately noticeable thermal
shrinkage and stimulation of a long-term healing
response characterized by deposition of new subepi-
dermal collagen (Grenz zone) and elastin fibers. This
tightening of the dermis creates the wrinkle reduction
(Figs 14-6–14.10).
Fractional CO2 is characterized by an immediate fine
microarray of treatment spots which develop micro-
crusting, as well as immediate erythema and swelling.
Figure 14.8 Epidermis
has healed and
regenerated by day 14
with residual erythema.

236
Chapter 14: Ablative and Fractionated Laser Skin Resurfacing
Figure 14.10 Thickened Grenz zone
following ablative CO2 laser skin
resurfacing.
Epidermis
Sub-epidermal Collagen
(Grenz Zone)
Elastotic Fibers (black)
in Superficial Dermis
Figure 14.9 Preoperative appearance
of thinned Grenz collagenous zone in
aged skin.
Epidermis
Sub-epidermal
Collagen
(Grenz Zone)
Elastoxic Fibers (black)
in Superficial Dermis

237
Wound Healing
Wound Healing
Healing after ablative resurfacing requires the re-estab-
lishment of the barrier function of the epidermis and
appropriate return of normal skin pigmentation. The new
epidermis results from the differentiation and surface
migration of a reservoir of basal-like keratinocytes resid-
ing deep to the epidermis in the pilar complexes. Hence,
re-epithelialization may be impaired when the pilar com-
plexes have been inactivated by isoretinoin (Accutane®)
use, heavy X-ray irradiation, or destroyed (i.e. very deep
resurfacing into the dermis). Hence, caution is prudent,
especially when resurfacing the very thin eyelid skin or
when attempting to erase very deep wrinkles whose bases
may lie at the same depth as the reticular dermis of the
adjacent tissue shoulder (Fig. 14.11; Table 14.2). Likewise,
hypopigmentation may result from deep resurfacing.
Scarring may also be more likely in keloid-prone patients
or over the edges of facelift flaps. Complete epithelializa-
tion is characterized by the cessation of weeping and ooz-
ing and a smooth, pink, dry skin surface. In general,
re-epithelialization is completed within 7 days for
erbium:YAG and 10–14 days for CO2 resurfacing.
Erythema typically takes a few weeks to resolve after
erbium:YAG, but lasts around 12 weeks for CO2 laser.
By comparison, wound healing is rapid and pain is
minimal with fractional CO2. Erythema and edema
generally resolve within 2–3 days. Overall downtime
is generally 4–6 days.
Figure 14.11 Danger zones for resurfacing. Note that the dermis of the
neck, mandibular border, and eyelids are especially thin. White areas are
usually not treated with CO2 laser, e.g., pretarsal upper eyelid skin,
eyebrows, lips, ears. Orange areas are treated with extreme caution, i.e.,
usually a single light pass. Yellow areas are treated lightly with one or
sometimes two passes. Light-beige areas are treated moderately. (Khan
JA. Laser skin resurfacing. In: Chen WP. Oculoplastic surgery: the
essentials. New York: Thieme; 2001:188.)
Table 14.2: Average thickness of facial skin in microns at various locations and ranked
by dermal thickness (in microns).
Zone location
Epidermis
Dermis
Hypodermis
Total
Neck
115
138
544
797
Eyelids
130
215
248
593
Root of nose
144
324
223
691
Cheek
141
909
459
1509
Lobule of nose
111
918
735
1764
Forehead
202
969
1210
2381
Lower lip
113
973
829
1915
Upper lip
156
1061
931
2148
Mental region
149
1375
1020
2544
Gonzalez-Ulloa M et al. Preliminary study of the total restoration of the facial skin. Plast Reconst Surg 1954; 13:151–161 (Copyright
expired).

238
Chapter 14: Ablative and Fractionated Laser Skin Resurfacing
Preoperative Evaluation
The preoperative evaluation screens for patients who are
at a higher risk of complications. Specific features to elicit
in the history include immune system compromise, racial
origins of African, Far-East Asian, or Native American
background. A personal or family history of keloid for-
mation may increase the likelihood of keloid formation or
hypertrophic scarring after resurfacing. Fitzpatrick class
IV or darker skin is prone to hypertrophic scarring or pig-
mentary problems (Table 14.3). Isoretinoin (Acutane®)
treatment or past facial X-ray treatments may impair fol-
licle and sweat gland activity, thus resulting in delayed or
absent re-epithelialization after resurfacing. Active acne
may be accelerated by the intense healing response and
trigger further scarring (Fig. 14.12). Patients with acne
Table 14.3: Fitzpatrick’s skin type classification
system.
Type
Color
Reaction to First Sun


Exposure Yearly
I
White
Always burn/never tan
II
White
Usually burn/tan with


difficulty
III
White
Sometimes mild burn/tan


average
IV
Medium brown Rarely burn/tan


with ease
V
Dark brown
Rarely burn/tan


very easily
VI
Black
Never burn/tan


very easily
Data from Fitzpatrick RE, Goldman MP, Satur NM, Tope WD.
Pulsed carbon dioxide laser resurfacing of photoaged facial
skin. Arch Dermatol 1996; 132:395–402.
Figure 14.12 (A) Unusally severe acne eruption subsequent to ablative CO2
laser skin resurfacing. (Image courtesy of Bhupie Patel, MD) (B) Preoperative
appearance of an Asian patient in whom ablative CO2 treatment would be
risky, but fractionated CO2 would be better tolerated. (Image courtesy of
Mark N Berkowitz, MD) (C) Asian patient following fractionated CO2 laser
treatment to forehead. Note even postoperative skin pigmentation and
reduction if horizontal rhytides. (Image courtesy of Mark N Berkowitz, MD)
A
B
C

239
Preoperative Evaluation
Table 14.4: Risk factors and relative contraindications to laser skin resurfacing.
Condition
Possible outcome
Relative risk
Active acne
Exacerbation, scarring
High
Keloid history
Hypertrophic scarring
High

Fitzspatrick IV–VI skin
Hyperpigmentation
Moderate to high


X-ray facial irradiation
Poor
Moderate to high

re-epithelialization
Accutane use in past
Poor
High

re-epithelialization
Vitiligo
Dyschromia
High
Phenol peel
Dyschromia
Moderate
Deep dermabrasion
Dyschromia
Moderate
Herpes simplex
Herpetic outbreak
Low with prophylaxis
Immunosuppression
Infection
Moderate to high
Lower eyelid laxity
Ectropion
Moderate
rosacea or telangiectasia may have more noticeable ves-
sels after resurfacing. Lower eyelid laxity may predispose
to ectropion (Table 14.4). Because fractional CO2 is less
disruptive, the risks of treatment should be less than with
ablative CO2. Fractional CO2 carries a lower risk in pig-
mented skin types.

240
Chapter 14: Ablative and Fractionated Laser Skin Resurfacing
Prophylaxis
The large raw exposed facial areas following resur-
facing may invite devastating bacterial cellulitis
(Staphylococcus aureus, Streptococcus pyogenes, and
Pseudomonas aeruginosa), primary Herpes simplex,
or reactivation of latent Herpes simplex with dissemi-
nated facial scarring. Therefore, physicians may
prescribe prophylactic antibiotic and antiviral medi-
cations prior to resurfacing (Fig. 14.13) in order to
achieve therapeutic levels at the time of treatment
(Table. 14.5). Medications are continued for 12 days
thereafter or until re-epithelialization is well estab-
lished. All resurfacing patients, except those undergo-
ing very small treatment areas, receive a preoperative
oral antibiotic, usually ciprofloxacin hydrochloride
(Cipro®) 500mg orally b.i.d. for 14 days, begun 48
hours prior to surgery. Acyclovir (Zovirax®) a thymi-
dine kinase inhibitor that is active against human
herpes viruses, may be prescribed as 400mg orally
every 8 hours for 14 days, begun at least 2 days prior
to surgery. While the risks of infection should be
lower with fractional CO2, there are still multiple
pinpoint breaches of the epidermal barrier; therefore,
we recommend antibiotic coverage as with ablative
CO2 laser treatments.
Figure 14.13 Preoperative appearance of herpetic
‘cold sore.’ Procedure was cancelled.
Table 14.5: Resurfacing prophylactic preoperative care.
Indication/class
Generic name
Brand name
Recommended
Antibiotic
Ciprofloxacillin
Cipro
Most cases
Antiviral
Acyclovir
Zovirax
Most cases
Antifungal
Fluconazole
Diflucan
Not recommended
Bleaching agent
Hydroquinone
Various
Fitzpatrick IV,V,VI
Bleaching agent
Kojic acid
Generic
Fitzpatrick IV,V,VI
Anticomedogenic
Tretinsin
Retin A
Neutral
Steroid
Hydrocortisone
Various
Use with Retin A
Sunscreen
Various
Various
Neutral

241
Laser Safety and Anesthesia
Laser Safety and Anesthesia
Both CO2 and erbium:YAG wavelengths are invisible
to the human eye and hazardous to ocular tissues.
Therefore, wavelength-specific protective goggles
should be worn by the surgical team, and the patient’s
eyes should be protected by laser-impenetrable shields
(Fig. 14.14). In addition, there is a combustion hazard
and non-flammable or wet drapes are used. Any tub-
ing carrying oxygen should be non-flammable or
wrapped in non-flammable material. The laser plume
may contain viral particles: laser safety masks which
filter out smaller-sized particles should be worn.
Ablative CO2 and erbium:YAG resurfacing may be
performed with topical, local, regional, or general
anesthesia. Topical anesthesia alone is generally unre-
liable and is often supplemented with intravenous or
oral administration of analgesics and sedatives.
14.2
Figure 14.14 (A) A special-finish laser blepharoplasty instrument designed to reduce laser energy reflection: Khan laser eye shield with unique
antirotational posts and eyelash traction bar for laser-impenetrable globe protection during CO2 and erbium:YAG laser skin resurfacing. (Bausch and
Lomb Surgical/Storz Instrument Co., St. Louis, MO.) (B) Ambidextrous matte-finish titanium Khan–Sutcliffe ‘propeller’ laser shield used as a backstop
during incisional blepharoplasty and to mask off areas during resurfacing. (Bausch and Lomb Surgical/Storz Instrument Co., St. Louis, MO.)
A
B

242
Chapter 14: Ablative and Fractionated Laser Skin Resurfacing
Topical Betacaine seems to provide more effect than
EMLA (Figs 14.15 & 14.16). Local infiltrative
anesthesia usually consists of lidocaine with epineph-
rine. Regional nerve blocks are usually to the supraor-
bital, supratrochlear, infraorbital, and mental branches
of the trigeminal nerve. With general anesthesia or
deep intravenous sedation with Propofol, local anes-
thetics are unnecessary.
Fractional CO2 laser may be performed with topi-
cal anesthesia, but still creates moderate discomfort.
Figure 14.15 Preoperative appearance of periocular
rhytides.
Figure 14.16 The treatment area is outlined with a
surgical marking pen and EMLA cream is applied for
topical anesthetic effect.

243
Laser Treatment
Laser Treatment
With ablative CO2, laser treatment generally consists
of a first pass which addresses epidermal changes by
removing the epidermis. Debris must be wiped away
prior to each subsequent pass to reduce unwanted
thermal injury (Figs 14.17 & 14.18). After first pass,
subsequent passes may be applied to the exposed der-
mis depending upon the severity of wrinkles as well as
individual and regional facial tolerances for dermal
ablation. Generally speaking, a single pass is applied
to the thin eyelid skin while two or three passes may
be tolerated over the crow’s feet, glabella, or upper
lip. Only a single pass is prudent as one approaches
the thinner skin at the transition from facial to neck
skin that occurs over the rim of the mandible. Debris
may be left unwiped after the final pass in order to
promote more rapid healing.
Figure 14.17 White anhydrous carbon-rich epidermal debris
corresponding to each individual ablative CO2 laser spot is
evident following the first pass.
Figure 14.18 The epidermal debris is wiped away prior to
subsequent passes in order to avoid a ‘heat sink’ effect that
can create unintended deeper thermal damage. Note the
smooth avascular plane of the exposed dermis subsequent to
the first pass.
14.3
14.4
14.5
14.6

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Chapter 14: Ablative and Fractionated Laser Skin Resurfacing
Multiple ablative CO2 laser passes are applied over
the thicker skin of the crow’s feet, forehead, glabella,
nose, circumoral areas and cheeks when the goal is to
induce significant dermal remodeling so as to reduce
moderate to deep wrinkles. In order to prevent excess
thermal damage, debris must be wiped from the der-
mal surface between passes.
With each subsequent pass, one ablates and induces
deeper thermal damage to the dermis. Although this
results in greater final wrinkle reduction, one also runs a
commensurately increased risk of postoperative scar-
ring, a delayed or prolonged healing phase, and dyspig-
mentation. With each pass, one sees a progressive
tightening and yellowing of the dermis (Figs 14.19 &
14.20). There are two end points for multiple-pass
ablative CO2 resurfacing. Ablative CO2 resurfacing is
stopped as soon as any one end point is reached. The
end points consist of (1) an arbitrary number of passes
(usually 1–3 passes depending on the exact area treated)
and (2) a smooth and wrinkle-free dermal surface.
Figure 14.19 Note the scant debris, contracted
surface appearance, and slight yellowish coloring
(‘chamois effect’) following the second pass.
Figure 14.20 Final appearance following ablative CO2
periocular resurfacing with marked reduction of
rhytides.

245
Laser Treatment
With fractional CO2 laser (Figs 14.21 & 14.22),
generally a single-pass treatment is performed. The
Figure 14.21 Preoperative appearance of lower face
prior to fractional CO2 resurfacing. (Image courtesy of
Mark N Berkowitz, MD)
Figure 14.22 Postoperative appearance of lower
face following fractional CO2 resurfacing. Note that
the final result is comparable to traditional ablative
CO2 resurfacing. (Image courtesy of Mark N
Berkowitz, MD)
depth of tissue fractional ablation can be varied as can
the relative area treated (20% to 100%).

246
Chapter 14: Ablative and Fractionated Laser Skin Resurfacing
Erbium Laser Treatment
With erbium:YAG resurfacing, each pass generally
ablates one-fifth to one-third of the epidermis. Therefore,
depending upon the depth of treatment, patients may
have little or no significant healing time. One may titrate
the desired effect from partial to full epidermal ablation
and may ablate in to the dermis, although this is limited
somewhat by bleeding (Fig. 14.23).
Figure 14.23 (a) Preoperative appearance of mild to moderate periocular
rhytides. (b) Intraoperative appearance following erbium laser treatment of
the epidermis. Following 3–5 passes with erbium:Yag laser, the epidermis
has been mostly vaporized. Absence of bleeding indicates that the
treatment has not extended significantly into the superficial papillary dermis.
(c) Final appearance approximately 2 weeks following erbium:YAG
resurfacing. Note the improvement in rhytides and minimal erythema.
C
B
A

247
Early Postoperative Wound Care
Early Postoperative Wound Care
Prior to re-epithelialization, the barrier function of the
skin is disturbed and there is leakage and oozing of
serum and protein onto the raw dermal surface (Figs
14.24 & 14.25; Table 14.6). Unsightly crusting, scab-
bing, and exudate often accumulate on the skin
surface. This presents a risk for viral, fungal, or bacte-
rial infection or colonization. Therefore, the goal of
postoperative wound care is to promote rapid re-epi-
thelialization. This is accomplished by maintaining a
moist surface and avoiding infection.
Table 14.6: Resurfacing immediate postoperative care – prior
to complete epithelialization.
Indication/class
Generic name
Brand name
Recommended
Antibiotic
Ciprofloxacillin
Cipro
Most cases
Antiviral
Acyclovir
Zovirax
Most cases
Antifungal
Fluconazole
Diflucan
As needed
Occlusive dressing
Various
Various
Not recommended
Occlusive topical
Petroleum jelly
Vaseline
Recommended
Occlusive topical
Various
Aquaphor
Recommended
Steroid cream
2.5% hydrocortisone
Various
Recommended
Wound care
Acetic acid
na
Recommended
Figure 14.24 At the completion of ablative CO2 laser resurfacing, the
de-epithelialized skin is smooth and moist.
Figure 14.25 By postoperative day 6, the disturbed epidermal barrier
allows exudate to dry on the skin surface, resulting in dried debris,
crusting, and weeping.

248
Chapter 14: Ablative and Fractionated Laser Skin Resurfacing
A moist surface is maintained by the application of
hydrocortisone cream 1% and Aquaphor q.i.d. or
application of an occlusive dressing. Occlusive dress-
ings are associated with a higher rate of infection, but
also benefit the patient in terms of faster epithelializa-
tion and lessened erythema and postoperative discom-
fort. Diluted white vinegar and water soaks are applied
q.i.d. in order to loosen exudative crusts, and because
of their antifungal and antibacterial effects. Oral anti-
biotics and antiviral agents (and sometimes antifungals)
are also helpful. The completion of re-epithelialization
is characterized by the appearance of a dry, smooth,
pink skin surface (Fig. 14.26). Patients should be
warned to avoid social and public contact (for up to 2
weeks with ablative CO2, and up to 6 days with
fractional CO2) because of the unsightly appearance.
Figure 14.26 By postoperative day 12, the skin has re-epithelialized.
The epidermal barrier is re-established, and the skin has a dry, smooth,
and pink surface.

249
Late Postoperative Wound Care
Late Postoperative Wound Care
Subsequent to re-epithelialization, wound care is
designed to hasten the resolution of erythema and mini-
mize postinflammatory hyperpigmentation (Figs 14.27
& 14.28). Both conditions are minimized by the topical
application of hydrocortisone cream 1% h.s. for up to
6 weeks after surgery. Postinflammatory hyperpigmen-
tation is also reduced by the prophylactic use of sun-
screen SPF 30 or greater for 12 weeks after surgery.
Topical hydroquinone cream 4% may be applied h.s.
to hasten the resolution of hyperpigmentation (Figs
14.29 & 14.30; Table 14.7). With fractional CO2 laser,
less-aggressive postoperative therapy is the norm.
Figure 14.27 Preoperative appearance of a patient of Mediterranean
ancestry.
Figure 14.28 Hyperpigmentation present in resurfaced areas about 4–6
weeks after ablative CO2 laser skin resurfacing.

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Chapter 14: Ablative and Fractionated Laser Skin Resurfacing
Table 14.7: Products used in resurfacing wound care; late postoperative care – after complete epithelialization.
Indication/class
Generic name
Brand name
Recommended
Steroid cream
Hydrocortisone 2.5%
Various
Recommended
Sunscreen SPF >25
Various
Various
Recommended
Concealer
Various
Various
Recommended
Bleaching agent
Hydroquinone
Various
If pigmenting
Bleaching agent
Kojic acid
Generic
If pigmenting
High potency steroid
Clobetasol propionate
Temovate-E
If prolonged erythema –



caution: use 1 week only
Figure 14.29 Hyperpigmentation has resolved following several weeks’
application of topical hydroquinone.
Figure 14.30 Prolonged erythema lasting several months after ablative
CO2 laser skin resurfacing. Erythema resolved with time and topical
steroid therapy.

251
Chapter 15
The ability to control the location and placement of a
crease, as well as the finer quality of a crease, includ-
ing shape, height, depth, softness, etc., should be a
basic skill for any cosmetic facial surgeon. Whether
to reset a crease higher or lower, or to create or oblit-
erate a crease, the Asian eyelid surgery model is ideal
to study the interplay between the different factors, as
the margin or tolerance for errors is quite small.
A firm grasp of these concepts will allow one to apply
them further onto reconstructive as well as aesthetic
cases in all ethnic groups, whether Asians or not.
(One can view it in the reverse way – a firm grasp of
these factors as practiced in non-Asian patients will
allow one to critically apply the skills towards Asian
eyelid surgery, where the adverse margin is higher due
to the relative lack of redundant skin and intrinsic
reactivity of the tissues.)
I will start first by elaborating on some of the para-
meters controlling an upper lid crease in Asians, then
go through some of the suboptimal results encoun-
tered, followed by the various surgical solutions. The
chapter will conclude with a series of complex revi-
sions to illustrate some of the interplay that goes
through my mind as I tackle these cases, in an attempt
to lead to an improved outcome and, most of all, a
happier patient.
One of the often neglected aspects of preoperative
interaction with the patients is a failure to realize
that different patients, young or old, whether from
Western countries or elsewhere, may have a different
concept of what constitutes a beautiful eye accentu-
ated by an aesthetically placed upper lid crease.
Some will consider a low-set nasally tapered crease
as ‘natural’ and ‘beautiful’. Some like the crease to be
shielded somewhat, to give a ‘natural look’. Some like
a prominent crease, to make the eyelid fissure appear
larger, while others like their crease to be relatively
shallow or ‘soft’. Some want to add constancy to
their intermittent and unpredictable crease line; and
almost none like it rounded, half-moon shaped, or as
high as the supratarsal sulcus. To achieve their chosen
aim, patients have been known to try surgeries, and
non-invasive means including adhesive eye tapes,
surgical glues, and cosmetic glues available in Asia
(Fig. 15.1), or even manual manipu lation with vari-
ous fine tools, sometimes taking 30 minutes to 2
hours every morning.
Management of the Eyelid Crease:
Advanced Techniques
William PD Chen
Figure 15.1 One
form of glue for
non-surgical
self-administered
formation of eyelid
crease: ‘Eye Putti’
from Japan.

In deciding on the width or height of an Asian
crease from the superior lash line, one must be aware
that a lower-than-average crease should be no more
than 0.5mm (500μm) below that patient’s measured
tarsal height. Likewise, the upper limit is no more
than 0.5mm above the measured height of the upper
tarsus, as measured centrally over the middle one-
third of the lid margin. Any significant deviation from
these values may result in pseudo-ptosis, static crease
formation, secondary lagophthalmos, a prominent
pretarsal skin zone from chronic edema, and exagger-
ation of sulcus. The use of buried non-absorbable
crease-fixation sutures along the levator aponeurosis
over the superior tarsal border may lead to persistent
foreign body sensation, upper lid retraction, and
scleral show above the superior corneal limbus.
For Asians who request placement of a conservative
upper lid crease, removal of preaponeurotic fat is often
unnecessary and should be avoided, due to concern
that it may lead to a prominent supratarsal sulcus.
Often, physicians are coaxed by the patients into
creating a high crease. Asians, in general, have a
smaller physique, not only in terms of weight and
height but also with respect to the size of their tarsus,
their eyelid width, the distance from upper lid margin
to the lower border of the brow, etc. Since Western
physicians often consider 10–11mm as the average
upper eyelid crease height, a crease that they would
consider as ‘high’ will therefore be greater than
9–10mm and much higher than the superior border of
the upper tarsus in an Asian. When a ‘high crease’ as
requested by an Asian patient is then constructed by
such a physician, it is anatomically inappropriate and
aesthetically undesirable, as it tends to lead to lagoph-
thalmos from any placement of ‘skin–levator–skin’
fixation sutures or ‘inferior subcutaneous orbicularis
oculi muscle-to-levator aponeurosis’ sutures. It is
almost always undesirable to create a high crease in
Asians: the visual impact is an image of a crease
bisecting the zone between the eyebrow and the upper
eyelid margin.
Some surgeons advocate that in order to reduce
fullness in the pretarsal space, aggressive excision of
pretarsal fat and some pretarsal orbicularis oculi
should be carried out to ensure that the pretarsal skin
lies flat against the tarsus postoperatively. In my prac-
tice, I have found that slight fullness in the pretarsal
area is not always undesirable. When the pretarsal
area appears expanded and swollen, it is usually the
result of a crease that is placed too high to start with,
leaving more tissue in between this high crease and
the lid margin. Aggressive dissection or excision of
pretarsal tissues tends to lead to persistent lymphe-
dema and risks formation of multiple pseudo-creases
in the pretarsal region. It is more effective, in my
experience, to create a crease fit for that individual
that is based on the vertical height of his or her tarsus
(measuring 6.5 to 8.0mm), and to excise no more
than 2–3mm of the pretarsal orbicularis oculi muscle
along the inferior cut edge of the skin incision.
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Chapter 15: Management of the Eyelid Crease: Advanced Techniques

Clinical pearls
■ Removal of preaponeurotic fat pads in Asian
blepharoplasty should be avoided, especially in older
patients, to reduce the possibility of enhancing the
supratarsal sulcus, a feature that is aesthetically
undesirable in Asians.

Pitfalls
■ It is always undesirable to create a high crease in
Asians.

Almost all suboptimal results and complications
arise from failure to observe the following points. In
patients who do not have a crease and desire Asian
blepharoplasty, the only thing that matters to those
patients is the new crease line that you will create for
them on the upper eyelids. A line can be described by
several parameters in mathematics and geometry: it
can be described by its length (the horizontal extent
or width along the superior tarsal border), its geo-
metric configuration (shape), its relative separation
from the eyelash margin (height), and its spatial rela-
tionship to the medial and lateral canthi; whether the
crease is continuous or broken apart (continuity) and
whether it stays permanent in appearance (perma-
nency) (Fig. 15.2). Symmetry between the two lids
can occur only if all of the above parameters are accu-
rate, correct, and equally well executed on both sides.
By now, one understands that aesthetic Asian eye-
lid surgery is not as easy as it seems. The surgery
demands nothing short of perfection in performing
these points. To take the simplest: if the shape is not
properly chosen (either as a parallel crease or a
nasally tapered crease), one can end up with a semi-
lunar crease and a ‘westernized’ look, which is not
what an Asian wants. The Asian patients want to
look like their Asian friends who were born with
natural, Asian-looking creases. One can also get a
bifid crease medially, or one with an exaggerated
upward flare laterally. Asymmetry may occur between
the two creases simply because they are different in
shape (Fig. 15.3).
253
Management of the Eyelid Crease: Advanced Techniques
Figure 15.2 Critical parameters for
formation of an eyelid crease. (Reproduced
with permission from Chen WPD. Asian blepharoplasty
and the eyelid crease. Philadelphia: Elsevier; 2006.)
Height
Permanency
Continuity
Shape

254
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.3 Circle of complications in crease formation. Failure to reach each of these parameters or in combination often leads to the findings
deviating from this circle of interconnected factors. (Reproduced with permission from Chen WPD. Asian blepharoplasty and the eyelid crease.
Philadelphia: Elsevier; 2006.)
Shape
Permanency
Continuity
Too high (incorrect incision
marking, suture placement, edema)
Excessive fat removal
(high sulcus ‘famined look’)
Fragmented crease
(discontinuous)
Multiple
creases*
Shallow crease
Partial or complete
obliteration
Fading of
medial 1/3 crease
* Excessive dissection in pretarsal, and pre-aponeurotic space;
Excessive removal of pretarsal, and pre-aponeurotic space, tissues.
Downward shifting
Too low
Semilunar crease
Bifid
Exaggerated lateral flare
Asymmetry
Height

If the height is not properly executed based on the
central tarsal height, one can get an excessively high
crease (Fig. 15.4). It can occur from incorrect place-
ment of the incision line, poor suture placement (onto
tarsus, orbital septum, levator aponeurosis, or orbi-
cularis oculi), or persistent edema. A low crease may
occur, although it is rare. Excessive fat removal will
lead to a ‘famined’ look with an exaggerated and
hollowed supratarsal sulcus (Fig. 15.5), which is a
suboptimal feature on an Asian face. Multiple creases
(Fig. 15.6) are more prone to occur if the incision
is too high above the superior tarsal border, or if
255
Management of the Eyelid Crease: Advanced Techniques
excessive dissection has been carried out along the
pretarsal plane or within the preaponeurotic (post-
septal) space.
Problems with continuity can give rise to a frag-
mented (discontinuous) crease, a rudimentary shal-
low but complete crease, or a partially (Fig. 15.7) or
completely obliterated crease. An otherwise properly
formed crease may look obliterated due to inade-
quate removal of skin and soft tissue above it. This
results in hooding of eyelid tissue above the crease, in
essence shielding the real crease when the individual
is viewed face on, looking straight ahead.
Figure 15.4 A relatively high crease for this Asian lady. Note the
dysjunction of the medial end of the right upper lid crease with the medial
canthal fold.
Figure 15.5 Excessive fat removal has resulted in a ‘famined’ look with a
sunken supratarsal sulcus.
Figure 15.6 Multiple creases are seen over the left upper lid. The right
upper lid shows bifid medial crease.
Figure 15.7 The right upper lid has a partial crease as it is incomplete
medially. The left crease has disappeared after surgery.