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A
B
FIGURE 14-105.  This patient with severe photodamage and atrophy was treated with Botox, filler, and aggressive CO2 laser
resurfacing.
A
B
FIGURE 14-106.  Patient was treated with Botox and hyaluronic acid filler in the glabellar region.
A
B
FIGURE 14-107.  Patient was treated with half a syringe of hyaluronic acid filler in each nasojugal groove (tear trough).

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
FIGURE 14-108.  Male patient was treated with a single syringe of hyaluronic acid filler in each tear trough.
A
B
FIGURE 14-109.  Patient was treated with half a syringe of hyaluronic acid filler in each tear trough.
A
B
FIGURE 14-110.  Patient with lipoatrophy was treated with five syringes of hyaluronic acid filler for midfacial augmentation.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
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• Underfill
• Contour irregularities (lumpiness)
• Material visible through skin (injection too superficial)
• Herpes simplex activation
Most of these complications represent minor or transient
problems that self-correct or improve. Improper injection can
cause tissue necrosis. Necrosis can also be seen from vascular
congestion from injections that compromise the vascular plexus.
Tissue blanching can be seen while injecting (Figure 14-112)
and is usually transient, but in some cases, vascular refill does
injecting near the periorbita. The main complications seen with
fillers include:
• Intravascular injection
• Tissue necrosis
• Bruising
• Excessive swelling
• Hematoma
• Needle tracks
• Asymmetry
• Overfill
A
B
C
D
FIGURE 14-111.  A female patient was treated with half a syringe of hyaluronic acid filler in each earlobe for volumization.

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Hematoma and bruising are very disconcerting to the
patient and can effect the reputation of the surgeon. Even the
best injectors will experience patients with bruising, given
the extreme vascularity of the perioral region (Figures 14-114
and 14-115). Patients who take medications that affect platelet
function or herbal preparations such as gingko, garlic,
ginseng, or St. John’s wort may be more prone to bleeding
and bruising. Stopping elective supplements a week prior
to injection may assist. Patients must be advised to consult
their health care prescriber before stopping prescription
anticoagulants.
Actual intrainjection hematoma is very rare but can occur.
This is usually evident immediately but can be delayed. Although
very disconcerting to the patient (and surgeon) it generally
resolves rapidly with immediate icing followed by heat applica-
tion (Figure 14-116).
Swelling, like bruising, is the unknown variable from patient
to patient and generally resolves within 24 to 48 hours. The vast
majority of my filler patients go to work the following day.
Occasionally, excessive swelling is seen after filler injection, espe-
cially in the lips (Figure 14-117). These patients usually respond
well to ice for 48 hours followed by heat. Oral steroids can also
be used in severe cases. Hyaluronic acid is very hydrophilic, and
immediate swelling is often seen with these fillers.
As with any procedure, a sound preoperative informed
consent can mitigate potential posttreatment problems.34 The
consent should not only cover the main complications but also
address the need for follow-up treatments and specify how
touchup injections will be handled financially. Many patients
expect the surgeon to absorb the cost. To avoid miscommunica-
tion, this topic should specifically be addressed. I frequently
provide touchup injections at a significantly reduced rate, espe-
cially when the cause is something such as asymmetry. Of all
caveats, being a conservative injector and having the patient
return for follow-up evaluation is perhaps the most important.
It is also important to not overfill treated areas, because more
filler can always be added. A series of preoperative photographs
of the frontal, oblique, and lateral views of the area to be treated
are vital. This record can assist the surgeon and the patient in
many ways. Frequently, patients forget what their lips looked
like before injection and can be overly critical of the result.
Referring to the preoperative photographs can be helpful in this
circumstance. In addition, these images can be used for market-
ing or, more important, to show prospective patients anticipated
results.35
Patients with a significant history of herpetic lesions in the
perioral area are given antiviral medication prophylaxis. Her-
petic outbreaks can be triggered by filler injection, but this is
very rare in my experience (Figure 14-118).
Overtreatment is a complication that can occur. This can
be especially common when significant immediate swelling
occurs while injecting, and landmarks become obscured. It
can also occur from placing filler in the incorrect regions of
the lips (Figure 14-119). When excessive filler is encountered,
it is possible to massage small lumps or masses and redistribute
the bulk. In localized areas, it is possible to puncture the area
of excess with an 18-gauge needle and express the excess filler
(Figure 14-120).
not occur, and areas of tissue slough can result (Figure 14-113).
This situation can be prevented by paying attention to the plane
of injection and not overinjecting or injecting with excessive
pressure to produce blanching. If blanching is seen, the injection
should be halted and the needle repositioned.
A
B
FIGURE 14-112.  If blanching is seen during injection, the procedure should
be momentarily stopped, the tissue allowed to reperfuse, and the needle
repositioned. Blanching (A) quickly resolved (B) in this patient.
FIGURE 14-113.  This area of lip necrosis was seen several days after
prolonged blanching occurred during injection.

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A
B
FIGURE 14-114.  These patients sustained visible bruising after injection of nasolabial folds with hyaluronic acid fillers.
A
B
FIGURE 14-115.  These patients sustained significant bruising after lip injection with hyaluronic acid fillers.
A
B
FIGURE 14-116.  Both of these patients developed hematomas shortly after filler injection. Although rare, they are very bother-
some to the patient but usually resolve within 48 to 72 hours.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
or massaged, resulting in an irregular surface which is visible
upon animation.
Since Radiesse was originally developed as a soft-tissue radio-
logic marker, it makes sense that it is radiopaque and may show
up on x-ray. Figure 14-123 shows a dental x-ray of a patient
treated with Radiesse, which is quite visible on the radiograph
(arrows).
Although any soft-tissue filler can migrate along soft tissue
planes, I have personally seen this happen with Radiesse more
than any other filler. I have personal experience in a single case
and have seen two other cases from other offices, as well as heard
collegial discussion with similar reports. Figure 14-124 and 14-
125 illustrate two cases where the filler migrated remotely from
the point of injection and had to be surgically removed. This
patient presented to my office requesting high nasolabial fold
augmentation in the perialar region. About 0.5 mL of Radiesse
was injected high on the fold lateral to the alae. Normal light
tissue massage was performed immediately after injection. The
patient returned 14 days later with the chief complaint of a
“tumor” on the upper left lip. A firm, round swelling was visible
in the left upper lip and appeared to contain white granules
visible through the mucosa. The lesion was surgically removed,
and biopsy was consistent with calcific particles, with a foreign-
body giant cell reaction.
Distant migration can occur from overzealous surgeon or
patient injection-site massage but can probably also spontane-
ously occur from compression of the tissues with normal oral
function in the early postinjection period. Any activity that
produces excessive oral function should be avoided for at least
24 hours.
Silicone oil has also been known to migrate to distant tissues,
but with the relatively small amounts used with lip and fold
filling, need for its removal is most likely secondary to overfill.
Since silicone oil is a “permanent” filler, injudicious use can
produce deformities that are difficult to correct and can only be
improved with surgical excision (Figure 14-126).
The 2-week return visit after filler injection is a good exercise
for both the surgeon and the patient. On occasion, I will see a
patient at follow-up, and they are happy with the result, but I
am not. This return visit gives me the opportunity to fine tune
my work. Although most patients don’t need touchup, some-
times areas of undertreatment, overtreatment, or asymmetry are
recognized and treated (Figure 14-121).
The HA fillers are much more forgiving than longer-lasting
or permanent fillers. Figure 14-122 shows a patient injected
with a hydroxyapatite filler that was not injected homogeneously
FIGURE 14-117.  Patient received half a syringe of hyaluronic acid filler in
each lip and sustained excessive and sustained swelling requiring oral
steroids. She is shown 6 days post injection.
FIGURE 14-118.  Patient developed a herpetic outbreak after filler injection
to the upper lip. She was treated with antiviral medication.
FIGURE 14-119.  The patient was treated at another office and presented
with excessive filler placed too high in the lip.

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A
B
FIGURE 14-120.  Patient returned after injection with several lumps of filler. The mucosa was punctured with an 18-gauge needle,
and the excess filler was expressed.
A
B
C
FIGURE 14-121.  Patient returned to the office for routine follow-up 2 weeks after lip injection. Although the patient was happy,
it was noticed that the left lateral lip was undertreated, and a touchup injection was performed. A, Patient immediately after
initial injection. B, Undertreated region at follow-up. C, Same area after the addition of a small amount of filler to the patient’s
left lateral lip.
FIGURE 14-122.  Patient was injected with a hydroxyapatite filler at another
office. The result is lumpy and unaesthetic. Controlled injection and
massage at the time of treatment would have made a difference. Highly
particulate fillers may be a poor choice for the superficial lip.
FIGURE 14-123.  Radiesse is a radiopaque filler and may be visible on dental
and other imaging studies. It is important that the patient and treating
doctors realize this so it is not mistaken for pathology.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
As already noted, an advantage of using HA fillers is that
they can be simply and quickly reversed by using hyaluroni-
dase. Hyaluronidase works quickly by hydrolyzing the injected
HA and splitting the glucosaminidic bond.36 This action is
visible in a matter of hours and can be very dramatic at 24 to
48 hours. Amphadase (Amphastar Pharmaceuticals, Rancho
Cucamonga, CA) is a preparation of hyaluronidase that is
shipped in 1-mL vials containing 150 units of hyaluronidase.
To treat excess HA filler, this solution must be injected in the
same tissue planes as the filler. Although hyaluronidase can be
injected directly from the vial, I usually reconstitute it with
1 mL of sterile saline or local anesthesia. This now produces
2 mL with 75 units of hyaluronidase in each mL (Figure
14-128). In cases where I want the entire amount of filler dis-
solved, I will inject the entire 75 units. In cases where I desire
only a reduction of the amount of filler, I will inject as little
as 5 to 15 units in that area. As stated, the HA filler is quickly
affected by the hyaluronidase, and the clinical effect is dramatic
(Figure 14-129). In many cases, the treated area will first
appear “overdissolved,” which I believe is a result of the exog-
enous hyaluronidase on the native hyaluronic acid in the skin.
This quickly replenishes over a matter of hours. Figures 14-128
and 14-129 show treatment of overfilled nasojugal folds with
diluted hyaluronidase.
Another filler complication frequently seen in the tear trough
region is the Tyndall effect, where light scatters from particles
The tear trough region is specifically prone to filler compli­
cations, owing to the extremely thin skin and vascularity of
the area (Figure 14-127). This is not an area to inject shortly
before a social function or important appointment; bruising is
common, and minor irregularities are unforgiving.
A
B
C
FIGURE 14-124.  A, Patient with a large mass in the upper left lip 14 days after Radiesse injection of the nasolabial folds.
B, Excised mass of migrated filler. C, Histologic slide confirming calcific particles and foreign-body giant cell reaction.
A
B
FIGURE 14-125.  A, This patient was injected in the oral commissures with Radiesse at another office and came to my office
with a 3-cm hard ball of migrated filler in the left lower lip. B, Excision of the filler mass from the soft tissues.
FIGURE 14-126.  Patient was treated in another state and was grossly
overinjected with silicone oil, causing grape-sized masses. She has
already undergone numerous surgical excisions, as evidenced by
scarring.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
691
performed well over a hundred lip implants over the past
decade,37,38 but this caseload has quickly tapered off with the
advent of filler advances and choices.
My experience with lip implants began with ePTFE cords
and strands. Although biocompatible, they frequently hardened
and impeded function and aesthetics (Figure 14-133). After
placing and removing a number of these implants (some remain
viable in happy patients), I became aware of the newly formu-
lated ePTFE biomaterial (Advanta Facial Implant, Surgiform
Technologies, Columbia, SC). This manufacturing process
created a dual-porosity implant that was much silkier, smoother,
and softer than previous ePTFE formulations (Figure 14-134).
I placed over 100 of these implants and reported my findings
positively.35 These implants were largely successful, and most
explantation resulted from operator error (placing a too-short
implant in the lip) or the patient deciding they no longer
wanted a palpable implant in the lips.
in suspension. Stirring household flour (which is white) in water
(which is clear) makes the suspension appear blue because blue
light scatters more than red light (Figure 14-130). The Tyndall
effect (or similar phenomenon) manifests when clear filler gel
shows through the thin eyelid skin as a blue tinge (Figure
14-131).
In the discussion of filler complications, infection is a rare
occurrence. In the thousands of filler injections I have per-
formed, I have only seen a single documented infection, which
occurred as a canine-space abscess several days after injection of
the nasolabial fold. The patient was anesthetized intraorally, so
it was difficult to determine whether the source of injection was
the mucosa or the skin (Figure 14-132).
Lip Implants
Lip implants occupy a small niche that seems to come in and
go out of popularity as new materials or devices emerge. I have
A
B
FIGURE 14-127.  The tear trough region is prone to bruising (A), and if contours are not smooth, they can be quite visible through
the thin lower-lid skin (B).
A
B
FIGURE 14-128.  A 1-mL vial of hyaluronidase is diluted with an equal amount of local anesthesia and is then injected into the
region of unwanted filler in the same plane as the filler.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
I became involved with a research project involving a new
implant prototype (VeraFil Facial Implant, Evera Medical,
Foster City, CA). This implant consists of an innovative design
with a silicone balloon that is ePTFE powder coated (Figure
14-135). The advantage of this implant is that it is placed in the
lip then inflated to the desired fill, and the fill tube is removed
from an ingenious self-sealing valve. Being flaccidly filled with
saline, this implant feels very natural and does not present the
hard or solid feeling other implants produced. The implant is
relatively technique sensitive and has undergone numerous
modifications for improvement and ease of placement. A
A
B
FIGURE 14-129.  Patient was injected with a hyaluronic acid filler to augment
the tear trough regions but was unhappy with the result. Patient immedi-
ately before (A) and 48 hours after (B) treatment with 75 units of hyal-
uronidase in each tear trough.
FIGURE 14-130.  The Tyndall effect is illustrated by placing a tablespoon of
flour in a glass of water. Even though the water is clear and the flour is
white, a blue hue is produced.
A
B
FIGURE 14-131.  Patient was successfully treated for augmentation of the tear trough. The superficial filler and thin lower eyelid
skin produced a bluish tinge (A). B, Impressive dissolution of the filler 24 hours after 75 units of hyaluronidase were injected
into the filler excess.
downside of this system is the possibility of deflation and the
difficulty of injecting fillers close to the implant. At the time of
this writing, these implants are not currently being marketed.
Most recently, I have placed another type of implant made
of soft, stretchable silicone rubber (PermaLip, SurgiSil LLP,
Plano, TX) (Figure 14-136). In the short term, this implant has
proven easy to place and/or remove and provides natural aug-
mentation and feeling and does not impede normal oral
function.
I have been quoted as saying, “Lip implants are okay when
they work.” That sounds like a joking remark, but it is true in

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693
FIGURE 14-132.  Patient 4 days after filler injection to the nasolabial folds.
She developed a left-sided infraorbital infection, manifested by cheek and
lower-lid swelling and erythema and was successfully treated with incision
and drainage and systemic antibiotics.
FIGURE 14-133.  Original ePTFE implants became contracted and hardened
after placement in some patients.
High porosity
(soft) 100 microns
Medium porosity
(smooth) 50 microns
Dual porosity design
FIGURE 14-134.  A new dual-porosity manufacturing process enabled the
fabrication of a softer, more supple ePTFE implant. (Courtesy Surgiform
Technology Ltd., Columbia, SC.)
FIGURE 14-135.  The VeraFil inflatable lip implant is a latex implant that is
ePTFE powder coated. The implant is adjustably inflated with saline at the
time of placement.
FIGURE 14-136.  The PermaLip implant is a very soft, supple, stretchable
silicone implant.
my experience. First of all, the concept of lip implants sounds
great. It is permanent, affordable, requires no repetitive needles,
and is available in multiple sizes. Because of these features, many
patients think this would be an optimum treatment and want
to “jump” into this procedure. These patients must be tempered
as to the advantages and disadvantages of lip implants. Although
they are easy to place and biocompatible, they can be very
technique sensitive. The most common problem I have encoun-
tered from my cases or other surgeons’ is placing either a too-
short implant or placing the implant too superficially. Both of
these situations can cause an unnatural looking lip where the
implant outline or ends can be seen with function (Figure
14-137). Also, regardless of the implant type, all lip implants
will be palpable. Most patients can tolerate a palpable implant
in the breasts, but the lips are different and can bother some
patients. In addition, due to the significant muscular function
in the perioral region, implants can migrate out of their original
position.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
FIGURE 14-137.  Lip implant tails can be visible when placed too superficially. This is seen on the inside of the lip (A) and the
outside of the lip (B).
Having said all of this, I presently have scores of lip implant
patients who have been happy for years with their original
implants. It seems that patients either love them or hate them.
Again, sometimes the problem is from the placement and other
times from the material or device. In any event, these nuances
must be explained to the patient prior to surgery as a lip implant
can sound like the greatest procedure. With the increased prog-
ress of injectable fillers, lip implants have become much less
requested in my practice. Lip implants should not be placed in
patients who rely on oral function, such as singers, speakers,
scuba divers, and woodwind musicians. Placing them in smokers
is also a poor idea, owing to the continual puckering, which
usually begins immediately post placement. All patients must
realize that the implants will be palpable and may be visible on
extreme animation. With the progress of injectable fillers, lip
implants have become much less requested in my practice.
Lip Implant Technique
Lip implants can easily be placed with local anesthesia by per-
forming the previously discussed miniblock technique, and then
after the lip is numb, further local anesthesia is injected in the
deep portions of the lip. Patients are placed on appropriate
antibiotics beginning 24 hours before surgery and continued for
5 days postoperatively.
Depending upon the type of implant used, the correct size
must be selected or custom cut from a larger piece of material.
Whether using prefabricated implants or custom cutting
implants, it is important to measure the proper length along
the lips. This must be done with the mouth open and not
closed—the measurements are very different (Figure 14-138).
Ideally, the implant should be long enough to lie just short of
the intended placement incisions.
Regardless of the type of implant to be placed, the currently
available choices are placed similarly. A stab incision is made in
the upper lip several millimeters medial to the oral commissure
(Figure 14-139). The incision is dissected for several millimeters
medially by spreading with iris scissors or a hemostat to the
center of the lip. The dissection will proceed directly in the
center of the lip, which is generally a safe plane and is far away
enough from the labial artery to prevent damage. The dissection
can be performed with a tendon passer, trocar cannula system,
sterile knitting needle, or any smooth, blunt instrument that
can be used to tunnel and dilate (Figure 14-140). The tunneling
instrument is inserted into the original stab incision, and the
dissection proceeds to the opposite commissure to exit the lip.
It is important that the dissection remain in the center of the
lip for several reasons. Number one, the labial artery is located
in the posterior lip, and dissecting in the central lip is a safe
plane (Figure 14-141). Number two, the implant needs to
occupy the center of the lip. Placing it higher creates an unnatu-
ral look.
Another caveat is to make sure the instrument is passed in a
single center plane and does not “porpoise” in a sinusoidal
pattern in and out of the center of the lip (Figure 14-142). If
the dissection tunnel is not straight, the implant will affect form
and function. Also important are the entry and exit incisions.
These should proceed immediately to the deep lip and not have
a long taper. The ends of the implants will lie just short of
the stab incisions, and if this entry is shallow, the end of the
implant can be visible, making an otherwise successful case
unsuccessful.
At this point, with the tendon passer protruding from the
exit incision, the implant is grasped and pulled back through
the dissection tunnel. Ideally, the ends of the implant will lie
just short of the stab entry and exit incision. It is important that
the implant tails do not lie directly under the incision, or they
can perforate. Some surgeons prefer to dissect lateral to the stab
incision so the implant tail will actually lie past the actual inci-
sion. I personally position the tails just short (medial) of the
stab incision. When the implant is pulled through the dissection
tunnel, it is not uncommon for the lip to “accordion” or bunch
up in the center. After the implant is passed, both ends are
secured with hemostats, and the implant is stretched from both
ends while the bunched-up lip is released by massaging the
bunched tissue laterally (Figure 14-143). At this point, the
implant and lip should lie passive. Sometimes several millime-
ters of implant tail will protrude out the end of the stab inci-
sions. By stretching the lip, they will usually fall perfectly into

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695
61 mm
86 mm
A
B
C
D
FIGURE 14-138.  A–B, The lip is longer when opening than in repose. The planned implant must account for this discrepancy
when choosing proposed implant length, and this can be one advantage of uncut implant stock that allows the surgeon to
trim to desired length. C–D, Precut implants should be selected based on patient measurements.
A
B
FIGURE 14-139.  Local anesthesia is infiltrated throughout the lip (A), and a stab incision is made several millimeters medial to
the oral commissure (B).

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
FIGURE 14-140.  A tendon passer is directed from one lateral incision through the center of the lip and out the contralateral
incision (A). The implant is then grasped (B) and pulled back through the lip tunnel.
1
2
4
3
FIGURE 14-141.  The lip implant should lie in the center of either lip, under
the muscle and anterior to the labial artery. 1, Vermilion mucosa; 2, orbi-
cularis oris muscle; 3, labial artery; 4, intended implant position.
A
B
FIGURE 14-142.  The implant should be placed in a straight line through the
lip and not in a sinusoidal manner; otherwise form and function can be
affected.
FIGURE 14-143.  The lip can gather in the center after the implant is pulled
through the tunnel. The tissue must be stretched laterally to release the
bunched tissue for an accurate visualization of implant length and position,
as well as to heal with normal function.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
697
A
B
FIGURE 14-144.  After any gathering is released, the implants should lie passively, and the tails should lie 1 to 2 mm medial to
the stab incision entry and exit incisions.
FIGURE 14-145.  After the implant is passively positioned, incisions are
closed with 5-0 gut suture.
A
B
FIGURE 14-146.  Patient before (A) and 3 months after (B) upper and lower ePTFE dual-porosity lip implants.
place, several millimeters medial to the incision (Figure 14-144).
If they do not passively sink into the incision, they should be
trimmed with a taper, again to lie just short of the stab incision.
The taper is important because the blunt end of an implant can
be visible during function.
Finally, the stab incisions are closed with several 5-0 gut
sutures, and the same procedure is repeated in the lower lip
(Figure 14-145). Some surgeons make the entry incision close
to the commissure and place both lip implants through the same
incision for the upper and lower. I usually use four separate stab
incisions.
Postoperatively, ice is applied for 48 hours, and the patient
is asked to refrain from unnecessary oral function, especially
puckering. Swelling can be significant and sometimes postop-
erative steroids are useful. Patients will have some initial sensory
loss, which in my experience has always been temporary.
Lip Implant Case Presentations
Figures 14-146 to 14-148 illustrate several lip implant cases.

698
Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
C
D
E
F
FIGURE 14-147.  Patient before (A) and 3 months after (B) upper and lower Advanta ePTFE dual-porosity lip implants. C–D,
Lateral view. E–F, Frontal view.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
699
A
B
C
D
FIGURE 14-148.  Patient before (A) and 4 months after (B) placement of VeraFil inflatable saline-filled silicone implants in both
lips. C–D, Lateral view.
Continued

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
E
F
E–F, Normal animation when smiling and puckering
after implant placement.
FIGURE 14-148, cont’d
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Stroke 24:615–616, 1993.
16. Niamtu J: Local anesthetic blocks of the head and neck for cosmetic facial
surgery. Part I. A review of basic sensory neuroanatomy. Cosmet Dermatol
17: 515–522, 2004.
17. Niamtu J: Simple technique for lip and nasolabial fold anesthesia for inject-
able fillers. Dermatol Surg 31:1330–1332, 2005.
18. Niamtu J: Fat injection micro cannula instead of needles for filler injection.
Dermatol Surg; in press.
19. Niamtu J: Accurate and Anatomic Midface Filler Injection by Using Cheek
Implants as an Injection Template. Dermatol Surg 34:93–96, 2008.
20. Orentreich D: Liguid injectable silicone: techniques for soft tissue augmen-
tation. Clin Plast Surg 27:595–612, 2000.
21. Von Heimburg D, Hemmrich K, Haydarlioglu S, et al: Comparison of
viable cell yield from excised versus aspirated adipose tissue. Cells Tissues
Organs 178(2):87–92, 2004.
22. Donofrio LM: Structural lipoaugmentation: a pan-facial technique. Der-
matol Surg 26(12):1129–1134, 2000.
23. Glasgold RA, Lam SM, Glasgold MJ: Facial fat grafting: the new paradigm.
Arch Facial Plast Surg 10(6):417–418, 2008 Nov–Dec.
24. Hanke CW, Higley HR, Jolivette DM, et al: Abscess formation and local
necrosis after treatment with Zyderm or Zyplast collagen implant. J Am
Acad Dermatol 25:319–326, 1991.
25. Friedman PM, Mafong EA, Kauvar AN, et al: Safety data of injectable
nonanimal stabilized hyaluronic acid gel for soft tissue augmentation.
Dermatol Surg 28(6):491–494, 2002.
26. Lowe NJ, Maxwell CA, Lowe P, et al: Hyaluronic acid skin fillers: adverse
reactions and skin testing. J Am Acad Dermatol 45(6):930–933, 2001.
27. Lupton JR, Alster TS: Cutaneous hypersensitivity reaction to injectable
hyaluronic acid gel. Dermatol Surg 26:135–137, 2000.
28. Fernandez-Acenero MJ, Zamora E, Borbujo J: Granulomatous foreign
body reaction against hyaluronic acid: report of a case after lip augmenta-
tion. Dermatol Surg 29(12):1225–1226, 2003.
29. Honig JF, Brink U, Korabiowska M: Severe granulomatous allergic tissue
reaction after hyaluronic acid injection in the treatment of facial lines and
its surgical correction. J Craniofac Surg 14(2):197–200, 2003 Mar.
30. Andre P, Kaminer M: Soft tissue augmentation: an international perspec-
tive. Semin Cutan Med Surg 23:4, 2004.
31. Andre P, Lowe NJ, Parc A, Clerici TH, Zimmermann U: Adverse reactions
to dermal fillers: A review of the European experiences. J Cosmet Laser
Ther 7:171–176, 2005.
32. Niamtu J: The use of Restylane in cosmetic facial surgery. J Oral Maxillofac
Surg 64:317–325, 2006.
33. Niamtu J: Complications in fillers and Botox. Oral Maxillofac Surg Clin
North Am 21(1):13–21, v, 2009 Feb.
34. Niamtu J: New lip and wrinkle fillers in minimally invasive cosmetic
surgery. Oral Maxillofac Surg Clin North Am 17:17–27, 2005.
35. Niamtu J: Image is everything: Pearls and pitfalls of digital photography
and PowerPoint presentations for the cosmetic surgeon. Dermatol Surg
30:81–91, 2004.
36. Brody HJ: Use of hyaluronidase in the treatment of granulomatous hyal-
uronic acid reactions or unwanted hyaluronic acid misplacement. Dermatol
Surg 31:893–897, 2005 Aug.
37. Niamtu J: Advanta ePTFE facial implants in cosmetic facial surgery. J Oral
Maxillofac Surg 64:543–549, 2006.
38. Niamtu J: Who is still using lip implants? [letter]. Dermatol Surg
32(10):1302–1304, 2006 Oct.

701
15 
Lip Reduction (Reduction
Cheiloplasty)
L
ip augmentation was addressed in Chapter 14, and for
thoroughness I thought that lip reduction and shorten-
ing, though much rarer procedures, should also be dis-
cussed. Lip enhancement is the mainstay of the minimally
invasive portion of most cosmetic facial surgery practices, but
not all patients seeking cosmetic lip enhancement desire larger
lips. A few seek cosmetic consultation for lip reduction, and the
cosmetic facial surgeon should be versed in this treatment
option as well. In my personal experience, most patients pre-
senting for lip reduction are of African American heritage, but
I have performed this procedure on patients from other ethnic
groups, including Caucasians. Of interest is the fact that I am
now seeing Caucasian patients on a regular basis who have been
overtreated with fat or permanent lip fillers and are requesting
cosmetic lip reduction for iatrogenic macrocheilia.
Diagnosis and Consultation
Macrocheilia is defined as excessive lip size. Various ethnic
groups share the characteristic of larger lips, including African
American, Asian, and other groups (Figure 15-1), so for the
remainder of this chapter, racial lip differences with larger lip
anatomy will be referred to as ethnic lips. This would apply to
lips that are larger than the Caucasoid lip and more frequently
treated with cosmetic lip reduction, or reduction cheiloplasty.
In the Caucasian patient, the upper lip constitutes a third of
the total lip volume, and the lower lip constitutes about two-
thirds, with a ratio of about 1 : 1.61,2 (Figure 15-2). African
American lips are generally larger in all dimensions, and the
upper and lower lip volumes are frequently nearly the same in
many patients. Ethnic lips are also more protrusive, due in part
to more soft-tissue mass. On average, chin and lip soft-tissue
thickness is approximately 12 mm in Caucasians and 15 mm
in African Americans.3 Vermilion height norms vary in different
ethnicities: African American males have 13.3-mm upper lips
and 13.2-mm lower lips, and African American females have
13.6-mm upper lips and 13.8-mm lower lips. North American
Caucasian vermilion heights for upper and lower lips are
8.0 and 8.7 mm for males and 9.3 and 9.4 mm for females.4,5
Normally there is a 0 to 3-mm intralabial gap between the lips
in repose. Patients with a larger intralabial space may not be
good surgical candidates.
The importance of ruling out dentofacial deformities as
contributing factors to macrocheilia cannot be overstressed, and
orthodontic, oral, and maxillofacial consultation and a lateral
cephalogram may be of assistance. Many African Americans
exhibit a skeletal bimaxillary protrusion in which the angulation
of maxillary and mandibular alveolar bone and teeth protrude
anteriorly, influencing lip posture (Figure 15-3). If dentofacial
abnormalities are not recognized, lip reduction may be contra-
indicated and worsen the cosmetic deformity by overly reducing
lip size and exposing the dentofacial deformity. Microgenia can
frequently accompany a bimaxillary protrusive profile, and the
lack of chin prominence can make the lower lip appear larger.
Esthetically, unusually large lips (like any body part) can
make a person appear or feel unattractive. Adverse stereotypic
characterizations historically amplified this trait (especially a
“dangling” lower lip) and used it to demean those who possessed
it. Reasons for seeking lip reduction may be motivated by more
A
B
FIGURE 15-1.  Typical lip size of a patient seeking lip
reduction.

702
Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
than psychological discomfort, however. Function can also be
affected by very large lips, because they can make speaking and
eating difficult in some cases and promote drooling in the case
of abnormal orbicularis oris muscle tone.
Other ethnic patients presenting for lip reduction may not
have abnormally large lips for their race but want to look more
international. This is in the same vein as altering the eye shape,
straightening the hair, tanning the skin, or getting lip filler. I
refer to this as the cosmetic paradox in that people with small
features want big ones, and people with big features want small
ones. Beauty is truly in the eye of the beholder.
Differential Diagnosis
Macrocheilia can be due to ethnic variation, dentofacial defor-
mities (pseudomacrocheilia), pathology such as lymphatic dis-
orders or hemangiomas, and medical disorders. Medical causes
include Melkersson-Rosenthal syndrome, which is a rare neu-
rologic disorder characterized by recurring facial paralysis, swell-
ing of the face and lips (usually the upper lip), and development
1/3
2/3
FIGURE 15-2.  Individual lip volume relative to total lip mass in a Caucasian
female.
A
B
FIGURE 15-3.  A, Lateral cephalogram of a Caucasian male with a typical dentoskeletal relationship. B, Lateral cephalogram of
an African American male with bimaxillary protrusion. Note the differences in alveolar, tooth, and lip relationships.
of folds and furrows in the tongue.6 Ascher’s syndrome is a rare
disease first described in 1920 by an ophthalmologist by the
same name. The disease is characterized by a double upper lip,
blepharochalasis, and nontoxic thyroid enlargement.7 These two
medical entities oftentimes go undiagnosed, and the astute
surgeon should always consider systemic disease as a contribut-
ing factor. Additionally, some patients have lower-lip ptosis due
to orbicularis oris dysfunction or central nervous system prob-
lems; orbicularis oris function should always be evaluated.
Patients who cannot retract their lower lip or those with lip
incompetence from poor muscle tone or other causes are not
candidates for reduction cheiloplasty.
Lip Anatomy and Histology
The lips serve many functions: eating, drinking, speaking,
mimetic animation, kissing, and serving as a valve for the ter-
minal oral airway. Lips are among the most vascular structures
on the face and are supplied by the superior and inferior labial
branches of the facial artery as it branches from the external
carotid artery. The labial artery lies in the posterior third of the
lip at about the incisor level. The depth of this artery is an
important landmark to keep in mind, but fortunately it is deep
to most lip-reduction procedures.
The anatomy of the lip is very unique in that there is a triple
transition from hair-bearing skin to vermilion tissue to oral
mucosa. The hair-bearing skin terminates at the cutaneous/
vermilion junction. The vermilion tissue consists of a very thin
keratinized stratified squamous epithelium with extensive inter-
digitations with the underlying dermis (Figure 15-4). The ver-
milion is devoid of hair follicles, sweat glands, and sebaceous
glands (although they may be sparsely present). The lack of
sebaceous glands causes the vermilion to dry and crack, and
hence the lips must remain moistened with saliva. The vermilion
derives its color from the rich vascular plexus in the underlying
dermis. This area is also highly sensitive, owing to its rich
sensory innervation.
The thin, keratinized stratified squamous epithelium of the
exposed vermilion transitions into a thick, nonkeratinized

Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
703
Procedure
Reduction cheiloplasty has been described over the last 50 years
by numerous authors from multiple countries.8-18 Like any pro-
cedure, many nuances exist from surgeon to surgeon, but in
reviewing the literature, the basis of the described procedures
are very similar and involve removing a fusiform or elliptical-
shaped section of tissue and closing the defect to change the
posture of the lip.
D
E
FIGURE 15-4.  Vermilion portion of the lip consists of a thin, keratinized,
stratified squamous epithelium (E) that extensively interdigitates with
the underlying dermis (D). (From Applebaum E, Lamm A, Moss-Salentijn
L: Orofacial histology and embryology: a visual integration, Philadelphia,
1972, FA Davis.)
FIGURE 15-5.  Facial skin surrounding the lips contains hair follicles and
sweat and sebaceous glands (A). The vermilion portion of the lip consists
of thin, keratinized, stratified squamous epithelium (B) and transitions to
the thick, nonkeratinized, stratified squamous epithelium of the oral mucosa
(C). The submucosa of the intraoral mucosa contains numerous minor
salivary glands (D). The orbicularis oris muscle is seen underlying these
structures and constitutes the bulk of the lip (E). The vermilion is almost
in contact with the orbicularis oris muscle anteriorly. (From Applebaum E,
Lamm A, Moss-Salentijn L: Orofacial histology and embryology: a visual
integration, Philadelphia, 1972, FA Davis.)
D
F
V
OOM
M
FIGURE 15-6.  Transverse section through the lower lip shows the dermis
(D), fat (F), orbicularis oris muscle (OOM), vermilion (V), and oral mucosa
(M). Note the orbicularis muscle is situated closer to the oral surface of
the lip than the facial surface and also terminates as it curves around the
vermilion cutaneous junction.
stratified squamous epithelium and becomes the intraoral
mucosa (Figure 15-5). Under this thicker epithelium lies a sub-
mucosa containing numerous accessory salivary glands, includ-
ing serous, mucous, and mixed seromucous glands.
The bulk of the lip volume is made up of the circumoral
orbicularis oris muscle, which blends laterally into the complex
modiolus, a convergence of the perioral mimetic muscles. The
orbicularis muscle lies more to the posterior region of the lip,
curls over the vermilion surface, and ends at the vermilion/
cutaneous junction.(Figure 15-6).
Lip-Reduction Procedure
Preoperative Preparation
Preoperative evaluation involves discussing the procedure and
anesthesia and completing the informed consent process.
Patients must understand that the recovery process can be from
1 to 3 weeks, depending upon swelling. They must further
understand that sensation will be temporarily affected, as will
normal function. It is also imperative to explain the need for
conservative surgery in that more tissue can be removed, but it
is difficult to put it back—much the same as blepharoplasty.
Patients are given a prescription for cephalexin 500 mg to be
taken the day before surgery and for the first 5 days postop.
Those with a history of frequent herpetic perioral outbreaks
would also be placed on antivirals.
Anesthesia
Lip reduction can be effectively performed with local anesthesia
alone, but since it can be a bloody procedure with significant
manipulation, most patients and surgeons will fare better with
IV sedation.

704
Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
repeat this pursing maneuver to a point at which they would
optimally like the amount of vermilion show and posture. This
is marked by making a line at the retracted vermillion (blue lines,
Figure 15-7, B). To estimate the posterior extent of the incision,
the patient relaxes the pursed lips, and another line is made
posterior to the “retracted position line” (white line, Figure 15-7,
C). The distance between these two lines is measured and is a
general estimate of the minimum excess to be removed (Figure
15-8, A). If this distance was measured at 8 mm, then at
least 8 mm of tissue would be removed posterior to the wet/dry
line, although my experience has shown that 1.5 times the
amount measured can be safely removed (Figure 15-8, B-C).
Although experienced surgeons may excise 2 to 2.5 times the
normal amount of tissue, the novice surgeon should remain
conservative.
The configuration of the marked area to be excised is a
curved ellipse or “smiley face” that is larger in the center and
tapers sharply toward the commissure. The width of the curved
ellipse is commensurate with the amount of tissue excess to be
removed. The edges of the curved ellipse gently taper into the
commissure so as not to leave a “dog-ear” deformity. The inci-
sion does go into the corner of the mouth.
I personally sedate all lip-reduction patients and then
infiltrate the lips with several milliliters of 2% lidocaine
with 1 : 100,000 epinephrine (Figure 15-9). This is important
for hemostasis, pain control, and hydrodissection. A vagolytic
drug such as atropine or glycopyrrolate will aid in reducing
salivation.
When the patient arrives for surgery, all makeup is removed,
and a preoperative photographic series is taken, with a minimum
of frontal, three-quarter, and lateral views. Taking additional
images of smiling and puckering can also be helpful and
instructional.
Similar to blepharoplasty surgery, marking the patient is very
important. The lips should first be dried and wiped with alcohol
to allow better ink adherence and kept dry after marking with
gauze between the lips so saliva does not dilute the surgical
markings. If the markings are lost or obscured, the result can be
jeopardized. The patient should be marked in the upright posi-
tion and before local anesthetic injection; lying supine and
anesthetic engorgement distort the anatomy.
Marking the lips to discern the excess to be removed is
more art than science. The basic premise is to make markings
at or posterior to the wet/dry line. This will be the anterior
extent of the incision as well as the position of the suture
line and final scar. Placing the incision too far forward can
make a visible scar and remove excessive vermilion. Placing
the incision too far posteriorly can have less effect in “rolling”
the lip back.
My personal marking technique is as follows. I ask the
patient to lick their lips and relax them. Most patients will do
this without occluding their teeth, which places the jaw and
hence lip posture in a neutral position (Figure 15-7, A). Next,
I ask the patient to purse his or her lips (pulling the lips towards
the teeth), which will reduce the amount of protrusion and
vermilion show. The patient is given a mirror and asked to
A
B
C
FIGURE 15-7.  Preoperative patient is shown in repose (A) and with the lips pursed to a position the patient would like the final
result to simulate (B). C, Anterior incision markings that will be drawn in this “preview” position and will be the maximum anterior
extent of the excision. Generally, most of the excision should be posterior to the wet/dry line except in extreme cases. Finally,
a second line is drawn with the lips relaxed and this line will serve as the posterior incision extent and hence the minimal amount
of tissue to be removed.
8 mm
Desired reduction 8 mm
Actual reduction 8 mm x 1.5 = 12 mm
12 mm
12 mm
A
B
C
FIGURE 15-8.  A, The width difference from the pursed lip marking to the wet/dry line, which in this case is 8 mm. B, Actual
excision marking, which is 112 times the desired 8-mm distance. C, The total 12-mm proposed excision posterior to the
wet/dry line. The elasticity of the oral mucosa requires excising more tissue than the actual prediction.

Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
705
retract the lip back into a more retrusive position. For very large
reductions, it may be necessary to remove some of the deeper
tissue (e.g., submucosa, minor salivary glands, and rarely orbi-
cularis oris muscle) in a V or wedge-shaped excision to reduce
some of the lip volume (Figure 15-13). This also takes tension
off the incision. Every attempt is made to not disrupt the orbi-
cularis oris muscle so as not to affect its function. It is also
important that the elliptical excision does not alter the Cupid’s
bow or the central lip tubercle. The idea of this procedure is to
remove enough tissue to roll the lip posteriorly without altering
the normal anatomy. Figure 15-14 shows a typical excision
specimen removed from the lip.
FIGURE 15-9.  Several milliliters of local anesthetic with vasoconstrictor are
infiltrated into both lips.
A
B
FIGURE 15-10.  Initial lip incision being performed with radiofrequency
microneedle (A) and CO2 laser (B).
A
B
FIGURE 15-11.  A, Radiowave microneedle incision. B, Excision of the mucosa from the submucosal structures.
As the lips are so vascular, I do not use a scalpel or scissors
to dissect, I use the radiowave microneedle or CO2 laser (Figure
15-10). Both of these modalities provide simultaneous incision
and hemostasis. Less bleeding translates into better surgery, less
swelling, less pain and bruising, and faster recovery.
Dissecting the mucosa from the submucosa is very similar to
peeling a grape or dissecting the skin from the orbicularis oculi
muscle in blepharoplasty surgery (Figure 15-11). The layer
immediately under the mucosa consists of submucosa with
abundant minor salivary glands, and occasionally orbicularis
oris muscle may be visible (Figure 15-12).
An additional technique to control bleeding and simultane-
ously approximate a semblance of surgical result is to clamp the
marked mucosa with a curved hemostat and crush the tissue
together. This creates a ridge whose base is easily excised similar
to a “skin pinch” blepharoplasty. When the tissues are pinched,
the lip everts, and the surgeon can visualize the result.
No undermining of the wound edges is performed, or it
would defeat the process of pulling back the lip. For minor
reduction procedures, removing the mucosa only may suffice to

706
Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
Hemostasis is important from the onset of the first incision.
The lips are so vascular that the surgical field can be obstructed.
Final hemostasis is also important to prevent hematoma or
increased swelling. A small-tipped radiowave bipolar forceps is
convenient for this surgery (Figure 15-15).
After suitable tissue is removed, the wound margins can be
temporarily approximated with tissue forceps to grossly antici-
pate the surgical result. This is not entirely accurate, owing to
the effects of injected local anesthesia and surgical edema.
Although more tissue can be removed and the result adjusted,
it is always better to err on the conservative side, especially for
the novice surgeon.
The surgical site is again checked for hemostasis and then
closed. I prefer to begin closure with a series of “key” sutures.
First the midline is determined, and the first suture is placed.
The “rule of halves” is followed by placing another suture half
the distance to the end of the incision until five or six sutures
A
B
FIGURE 15-12.  A, Half of the mucosa excised. B, Surgical field after final mucosal excision.
A
B
FIGURE 15-13.  A V-shaped deeper tissue excision is performed in cases that require a greater degree of reduction; only so
much decrease in protrusion can be achieved by pulling skin alone. A, Example of a case in which a wedge reduction is
performed (frontal view). B, Similar case, lateral view.
FIGURE 15-14.  Typical excess skin excised from a lip-reduction procedure.
Specimen is actually larger but contracts after removal.

Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
707
Postoperative Care
No distinct dressing is used for lip-reduction cases, but I will
occasionally tape lips at the vermilion from cheek to cheek for
24 hours to restrict swelling. This may be effective, but unfor-
tunately the dressing is very cumbersome to the patient. Intra-
operative steroids are used, and the patient may be placed on
postoperative oral steroids. Ice is applied immediately postop-
eratively and used for the next 2 to 3 days, and patients are
asked to sleep with their head elevated. They are instructed to
follow a liquid or soft diet for the first 72 hours, refrain from
excessive animation, and use care while brushing the teeth.
Wound care includes hydrogen peroxide and anti­biotic oint-
ment. Sutures are removed 1 week after surgery (Figure 15-21).
Complications
Significant complications are rare with lip-reduction surgery
and can be subjective in the case of underresection. In this
case, a revision procedure may be necessary. Similar to ble­
pharoplasty, overresection is more problematic, and overly
aggressive resections should be avoided, especially by novice
surgeons. In the case of overresection, a mucosal graft maybe
required. In this situation, the incision is opened in the midline,
and the anterior and posterior tissue margins are undermined
to create a gap which should allow the lip to roll out anteriorly.
This defect is then grafted with a mucosal graft harvested from
the intraoral cheek mucosa.
are placed (Figure 15-16). I prefer 4-0 gut, silk, or braided nylon
for these sutures, which give strength to the wound. Finally a
smaller 5-0 suture is used to close the remaining tissue (Figure
15-17). If a continuous running suture is used, it should not
be placed too tightly and prevent drainage. In addition, post-
surgical edema can be significant, and tight sutures can cause
necrosis.
Initially the suture line will be visible due to edema, and the
patient must be made aware that as healing progresses and the
edema resolves, the lip will settle and the suture line will be
hidden.
Subtotal Lip Reduction
Although most lip-reduction cases involve removing a contigu-
ous band of excess mucosa, some cases do not. Specifically, some
patients present with a “double lip” deformity where excess
tissue is bilateral but not in the midline region (Figure 15-18).
These patients may show a significant amount of oral mucosa
in addition to increased vermilion.
The surgical procedure is the same as previously described
but the midline is not resected (Figure 15-19). In some cases,
the excision must encompass the entire length of the lip to
prevent “dog-ear” deformities or maintain symmetry of the
resection. Figure 15-20 shows a patient who presented for only
midline lip-excess reduction.
A
B
C
FIGURE 15-15.  A, Due to extreme vascularity, lip surgery produces generous bleeding. B, Areas of bleeding being cauterized
with small-tipped radiofrequency bipolar forceps. C, Surgical site after hemostasis.
FIGURE 15-16.  “Key” sutures using 4-0 gut are placed along the incision
line to stabilize the repair.
FIGURE 15-17.  The final closure with 5-0 gut suture.

708
Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
A
B
FIGURE 15-19.  Lateral lip excess can be unilateral or bilateral. Some of these cases can be treated singularly without crossing
the midline, whereas others require midline incision to prevent “dog-ear” deformities when closing. A, Radiowave microneedle
excision of excess lateral lip excess. B, The surgical site.
A
B
C
FIGURE 15-20.  A, A Caucasian patient whose chief complaint is midline upper-lip excess. B, Proposed surgical outline.
C, Excision site.
A
B
FIGURE 15-18.  A “double lip” deformity in repose and smiling. This condition can be present in either large or normal-sized lips;
the distinctive characteristic is pleated and pendulous oral mucosa that hangs down into view.
Due to the extreme vascularity of the lips, some patients may
experience alarming but harmless edema and should be fore-
warned (Figure 15-22). I have had several patients who took 4
to 6 weeks for this level of edema to resolve. Head elevation,
heat, and prednisone 60 mg/day for 5 days is used to control
postsurgical edema.
Because the lips are so vascular, infection after lip reduction
is extremely rare. I cover all these patients with cephalexin
500 mg every 6 hours beginning the day before surgery and for
the next 5 days.
As stated earlier, patients must be aware that sensation and
movement of the lips will be affected for the first several weeks;
these are sequelae, not complications.
Suture lines may be visible until the swelling resolves, and
patients should be advised that they will feel irregularities along
the suture line during the healing process. The extreme sensory

Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
709
Lip Shortening Procedure
(Subnasal Lift)
From time to time, patients come to the cosmetic surgery prac-
tice for lip enhancement but anatomically are not great filler
candidates. Lengthened upper lips present numerous cosmetic
problems. First and foremost, the elongated upper lip is unaes-
thetic; younger patients have short, curvaceous lips with ade-
quate volume. The aging lip becomes elongated, sustains volume
loss, and loses its curves (Figure 15-27). In addition, a long lip
can cover the upper teeth and give the patient a “denture”
appearance.
The “lip lift” procedure produces several aesthetic improve-
ments. It shortens the elongated senescent lip to a more youth-
ful, shorter lip and rolls out the vermilion border to provide a
more voluminous vermilion. It also allows several millimeters of
incisor show, which is considered a pleasing attribute.
The basis of the subnasal lift is to excise a mustache-shaped
or “bull horn”–shaped piece of skin and muscle from the naso-
labial junction. When the tissue is excised and the incision
closed, the lip is not only shortened, but the vermilion border
is rolled upward and forward. This procedure is only performed
on patients with a lip length of at least 18 mm from the colu-
mella to the bottom of the upper lip.19,20 This is important
because performing this procedure on a patient with a short lip
will expose excessive incisor show and may prevent the patient
from being able to put their lips together. A relative contrain-
dication to the lip lift procedure is a patient with significantly
downturned oral commissures. In this case, elevating and short-
ening the central lip can produce an unnatural appearance.19,20
The width of the excision is commensurate with the amount
of desired lift and can be overcorrected by 25% to accommo-
date for relapse.19 At least 6 mm of skin excision is required for
a noticeable result. Care is taken to not decrease the lip length
to less than 15 mm. When the excision is viewed in cross-
section, it is a wedge shape which includes the orbicularis oris
muscle. For patients who need true vertical lifting, the excision
should include more muscle, and for patients who need mostly
vermilion eversion, more skin is removed and less muscle.19,20
Incision closure is performed in layers, with the muscle and
subcutaneous planes closed with 5-0 gut suture and the skin
closed with 6-0 nylon suture. The scar remains well hidden in
the nasolabial crease and generally heals aesthetically. Makeup
can be applied at 7 to 10 days if necessary. In the case of a
visible scar, several passes of CO2 laser resurfacing is very
effective.
Procedure
This procedure can easily be performed with local anesthesia,
but operating literally under the patient’s nose may provide a
more relaxed patient with IV sedation.
The incision is marked just inferior to the nasal sill and
extends from one ala to the other. The incision should not
cross the curvature of the nostril sill into the nasal vestibule.19
Figure 15-28 illustrates the procedure. Figures 15-29 and 15-30
show before-and-after images of patients who underwent sub-
nasal lift.
sensitivity of the lips causes patients to take notice of small
irregularities more so than on other facial surfaces. Mucous
retention “cysts” can develop and are simply ablated, but this
has been a rare finding.
In my experience, most patients are happy after 4 to 8 weeks,
and the biggest complaint is usually “I really like the result, but
I wish a tiny bit more could have been removed.” Similar to
eyelid surgery, this “last little bit” can be the difference between
a successful case and an overtreated case.
Many African-American patients have a retrognathic profile
and a weak chin can accentuate the size of an already large
lower lip. For this reason, some lip-reduction patients will
benefit from simultaneous chin implant augmentation, which
not only enhances the profile, but gives support and balance to
the lower lip.
Figures 15-23 to 15-26 show before-and-after images of
reduction cheiloplasty patients.
FIGURE 15-21.  Typical patient 1 week after surgery, returning for suture
removal.
FIGURE 15-22.  Patient is an example of significant edema seen in some
patients after lip-reduction surgery.
Text continued on page 717.

710
Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
A
B
C
D
E
F
FIGURE 15-23.  A–B, Patient 10 weeks after upper and lower lip-reduction surgery. C–D, Oblique view. E–F, Lateral view.

Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
711
G
H
A
B
FIGURE 15-24.  Patient before (A) and after (B) bilateral lip-reduction surgery.
G–H, Lateral facial view. A chin implant was simultaneously performed with the lip-reduction surgery and
enhanced overall perioral aesthetics.
FIGURE 15-23, cont’d

A
B
C
D
FIGURE 15-26.  Patient in repose before (A) and after (B) upper-lip-only lateral excess reduction. Patient smiling before (C) and
after (D) upper lateral lip excess reduction.
A
C
D
B
FIGURE 15-25.  A–B, Patient after a conservative bilateral lip reduction. C–D, Lateral view.

Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
713
A
B
FIGURE 15-27.  A, Youthful lip. B, Elongated aging lip. As we age, the upper lip becomes atrophic, lengthened, and loses form
and volume.
A
B
C
D
FIGURE 15-28.  A, The “bull horn” outline incision is shown after scalpel incision. B, The surgical site after skin excision. C, The
incision after subcutaneous closure with 5-0 gut suture. D, Final closure with the excised “bull horn” overlying the surgical site.
Continued

714
Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
E
F
G
H
A patient before (E) and 1 week after lip lift (F). The same patient before (G) and 1 month after lip lift (H).
FIGURE 15-28, cont’d

Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
715
A
B
C
D
E
F
FIGURE 15-29.  A–B, Patient underwent a 7-mm subnasal excision. C–D, Lateral view. E–F Frontal view.

716
Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
A
B
E
F
C
D
FIGURE 15-30.  A–B, Patient had a subnasal lip lift. Notice the improved amount of incisor show. C, The area under the nose
before surgery. D, After surgery, illustrating an acceptable scar. E–F, Increased “incisor show” in the semi-open view.

Chapter 15  •  Lip Reduction (Reduction Cheiloplasty)
717
References
  1. Niamtu J: The use of Restylane in cosmetic facial surgery. J Oral Maxillofac
Surg 64:317–325, 2006
  2. Niamtu J: New lip and wrinkle fillers in minimally invasive cosmetic
surgery. Oral Maxillofac Surg Clin North Am 17:17–27, 2005.
  3. Epker BN, Wolford LM: Reduction cheiloplasty: its role in the correction
of dentofacial deformities. J Maxillofac Surg 5(2):1340–1341, 1977 Jun.
  4. Dev VR, Wang P: Lip reduction.
article/1288624-overview. Accessed June 15, 2009.
  5. Farkas LG: Anthropometry of the Head and Face in Medicine. NY, 1981,
Elsevier Science.
  6. El-Hakim M, Chauvin P: Orofacial granulomatosis presenting as persistent
lip swelling: review of 6 new cases. J Oral Maxillofac Surg 62(9):1114–
1117, 2004 Sep.
  7. Ali K: Ascher syndrome: a case report and review of the literature. Oral
Surg Oral Med Oral Pathol 103:e26–e28, 2007.
  8. Fanous N, Brousseau VJ, Yoskovitch A: The “bikini” lip reduction: an
approach to oversized lips. Plast Reconstr Surg 122(1):23e–25e, 2008 Jul.
  9. Hoffman S: A simple technique for mucosal irregularities of the lip. Plast
Reconstr Surg 103(1):328, 1999 Jan.
10. Manstein CH: Vermilionectomy and mucosal advancement. Plast Reconstr
Surg 100(5):1363, 1997 Oct.
11. O’Sullivan ST, O’Shaughnessy M: A simple technique for correction of
mucosal irregularities of the lip. Plast Reconstr Surg 101(4):1146–1147,
1998 Apr.
12. Cortés-Aroche S: [Double lip treated with “midmoon” incision. Report
of a case.] Rev Med Inst Mex Seguro Soc 45(3):277–280, 2007 May–Jun.
[Spanish]
13. Pinto Rdos S, Marzola C: [Double lips: surgical technic.] Rev Assoc Paul
Cir Dent 20(5):203–206, 1966 Sep–Oct. [Portuguese]
14. Kruse-Lösler B, Presser D, Metze D, Joos U: Surgical treatment of
persistent macrocheilia in patients with Melkersson-Rosenthal syndrome
and cheilitis granulomatosa. Arch Dermatol 141(9):1085–1091, 2005
Sep.
15. Rey R, Carreau JP, Gola R, Berbis P: [Melkersson-Rosenthal syndrome.
Value of reduction cheiloplasty.] Ann Dermatol Venereol 123(5):325–327,
1996. [French]
16. Stucker FJ: Reduction cheiloplasty. An adjunctive procedure in the black
rhinoplasty patient. Arch Otolaryngol Head Neck Surg 114(7):779–780,
1988 Jul.
17. Pierce HE: Cheiloplasty for redundant lips. J Natl Med Assoc 68(3):211–
212, 1976 May.
18. Calnan J: Congenital double lip: record of a case with a note on the
embryology. Br J Plast Surg 5(3):197–202, 1952 Oct.
19. Perenack JD, Biggerstaff T: Lip modification enhances aesthetic appear-
ance. Atlas Oral Maxillofac Surg Clin North Am 14(1):51–74, 2006
Mar.
20. Perenack J: Treatment options to optimize display of anterior dental esthet-
ics in the patient with the aged lip. J Oral Maxillofac Surg 63(11):1634–
1641, 2005 Nov.

718
16 
Cosmetic Removal of Nevi
and Lesions With 4-MHz
Radiowave Surgery
I
t is very common for patients to present to a cosmetic
surgery practice for the aesthetic removal of nevi and
various other lesions. Although there exist numerous ways
and means of treating benign lesions, liquid nitrogen cryo-
therapy, electrosurgery, and surgical excision remain the most
common. The main drawbacks of cryotherapy include hypo­
pigmentation and scar depression due to excessive lateral cryo-
damage, or in the case of electrosurgery, lateral thermal damage
can occur (Figure 16-1). Unaesthetic surgical scars remain the
common downside of surgical excision.
Radiowave surgery is a modality often mistakenly lumped
in with electrosurgery. Although both radiowave surgery
and electrosurgery both employ household current to energize
their respective systems, there are vast differences in the
technology.1-5
Common electrosurgery has changed little since its invention
in the 1920s. With electrosurgery, the electrode tip provides the
resistance and can produce intense heat. Anyone who has ever
used a hospital Bovie machine knows that the tip can get red
hot and even melt. This may not be a problem when incising
intestine, but for the face and neck is very uncontrolled. In
effect, electrosurgery is a sophisticated soldering iron. The
grounding pad required to complete the electrical circuit can
also cause severe burns to the patient and shock the operator.
The Ellman Surgitron Dual RF 4-MHz radiowave surgical
instrument (Ellman International, Oceanside, NY) is a patented
and extremely different technology. These units operate at a
higher frequency on the electromagnetic spectrum between AM
and FM radio frequencies (Figure 16-2). The radiowave elec-
trode does not provide the resistance, but rather the tissue
provides the resistance, and the tip does not become heated. The
actual tissue cutting works by a process known as intracellular
volatilization. As the radiowaves are channeled from the elec-
trode tip to the tissues, energy is created within the cell, causing
steam that bursts the cells (Figure 16-3). Much less lateral tissue
damage is produced (Figures 16-4 and 16-5).
All incision modalities, including scalpel incisions, produce
lateral tissue damage. A scalpel will produce 15 to 20 microns
of lateral tissue damage. Numerous studies have been performed
in multiple surgical disciplines showing that the Ellman Surgi-
tron 4.0 radiowave surgery system can produce tissue incisions
with as little as 20 microns of lateral tissue damage.6-10 There is
no grounding pad with radiowave surgery, but rather an antenna
that is Teflon coated and does not require skin contact—in fact,
it can be placed under the operating table padding. This antenna
serves to channel the radiowaves from the patient back to the
unit (Figure 16-6). There is no danger of burning the patient.
Another advantage of 4.0 MHz radiowave incision is that
when used at the proper settings, artifact is minimal and
does not affect pathology histologic diagnosis (as does electro-
surgery), making the radiowave system viable for tissue biopsy
(Figure 16-7).
A
B
FIGURE 16-1.  Uncontrolled ablation of moles and
lesions very often leads to hypopigmented and
depressed scars that can be worse than the original
mole.

Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
719
Household
current
Microwave
Faradic
effect
Surgitron
high RF
Electrosurgery/
low RF
AM radio
TV
Laser
X-ray
60
Hz
100
Hz
300
kHz
500
kHz
1.5
MHz
4.0
MHz
2500
MHz
Photon
energy
FIGURE 16-2.  The electromagnetic spectrum showing the wavelength of
4.0 MHz radiowave surgery.
1
2
3
4
5
FIGURE 16-3.  Intracellular volatilization is a process whereby radiowaves
are converted to energy that produces intracellular steam that bursts cells.
(Courtesy Ellman International Inc., Oceanside, NY.)
15
500
500
650
600
500
400
300
200
100
Depth of penetration
Absorption comparison of surgical energy sources
4.0 MHz
Ellman radio
frequency
10,600 nm
CO2 laser
2,100 nm
Holmium
laser
.5 MHz
Electrosurgery/
radiosurgery
FIGURE 16-4.  Amount of lateral tissue damage produced by various inci-
sional modalities.
Household
current
Household
current
Faradic
effect
Faradic
effect
360 KHz
360 KHz
1.7 MHz
4.0 MHz
1.7 MHz
4.0 MHz
60
Hz
100
Hz
300
KHz
500
KHz
550
KHz
1.5 3.0 3.5 4
MHz
54
60
Hz
100
Hz
300
KHz
500
KHz
550
KHz
1.5 3.0 3.5 4
MHz
54
A
B
FIGURE 16-5.  A, Lower-wavelength electrosurgery machines. B, The lower the wavelength, the more char produced at the
incision edges, hence more lateral tissue damage is produced. Note the absence of incision margin char with the 4.0 MHz
radiowave incision.
On a daily basis in the cosmetic facial surgery practice,
patients are seen for aesthetic concerns about nevi, verrucae,
fibromas, keratoses, lentigines, syringomas, sebaceous hyperpla-
sia, dermatosis papulosa nigra (DPN), and other benign lesions.
It is common for a patient to say, “My plastic surgeon [or der-
matologist] told me never to have this removed because the scar
will be worse than the lesion.” This advice is unfortunate. The
unaesthetic nature of the lesion to the patient, as well as the
delay in biopsy if it changes histologically to a more ominous
lesion, can make inaction unadvisable. Invariably, I am able to
perform extremely aesthetic lesion removal with 4.0 MHz
radiowave surgery, much to the relief of the patient who has
unnecessarily lived with the mole, wart, or other blemish for
years.
Obviously, it is impossible for any surgeon to guarantee a
patient that lesion removal will be scarless, but I can attest that
after removing thousands of garden-variety benign lesions over
the past 25 years that I have never had a patient who felt the
scar was worse than the mole.
Technique
The primary consideration with any lesion slated for ablation is
to rule out a malignant or premalignant state. For this reason,
any surgeon who removes apparently benign lesions should be

720
Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
can be used (Figure 16-10). Lesions are first photographed
then anesthetized with local anesthesia with epinephrine. The
radiowave generator is set between 7 and 12 watts, and the
“pure cutting” mode (90% cut/10% coagulation) is utilized.
This setting produces the least amount of lateral thermal
damage. After the underlying skin is blanched from the
local anesthesia, the electrode is bent to facilitate the most
ergonomic angle (Figure 16-11) and stabilized with a finger
rest. The finger rest involves stabilizing the handpiece in the
operating hand, using the fingers of the nonoperating hand
to make a stable base. This technique—used by dentists,
those who perform microsurgery, and watchmakers—allows
better stabilization and control of the electrode tip to make
familiar with the warning signs of malignant melanoma, dys-
plastic nevus syndrome, and similar conditions (Figure 16-8).
When appropriate warning signs or changes are present or if
there is ever a doubt, the lesion should be sent for histopatho-
logic diagnosis.
Most benign-appearing lesions can also be shave biopsied
just before ablation by using a scalpel to remove a representative
portion of the lesion (Figure 16-9). Multiple studies have shown
that when used with the correct energy parameters, loop biopsy
with 4.0 MHz radiowave surgery does not produce histologic
obstructing artifact.11
I prefer a #133 malleable electrode (Ellman International),
although ball electrodes, loop electrodes, or blade electrodes
A
B
FIGURE 16-6.  The Ellman Surgitron radiowave system (A) and the Teflon-coated antenna (B). This antenna does not contact
the skin, so there is no danger of burning the patient.
A
B
FIGURE 16-7.  A, Biopsy made with common electrosurgery; significant artifact can obscure the pathology diagnosis. B, Biopsy
made with the Ellman Surgitron 4.0 MHz radiowave system shows minimal artifact, which would not affect pathology
diagnosis.

Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
721
differentiation between lesion and normal skin. Since a smoke
plume is generated, a smoke evacuator must be used for safety
reasons (Figure 16-13).
As the base of the lesion is reached, remnant lesion is usually
chamois colored compared to the surrounding dermis (Figure
16-14). I recommend treating the lesion just below the flush
skin surface, with minimal saucerization (Figure 16-15). Novice
surgeons should halt the ablation flush with the skin. It must
be remembered that the actual ablation depth is slightly deeper
than the visual ablation depth, owing to lateral tissue damage.
Once the surgeon has enough experience in judging endpoints,
a more aggressive ablation can be performed. When this is
judged correctly, what first appears as a crater will actually heal
flush with the normal skin for an excellent result. Obviously, if
“paintbrush strokes” with the handpiece and electrode
(Figure 16-12).
The correct ablation technique is a light, almost pressureless
paintbrush stroke over the lesion. If the power setting and elec-
trode are correct, the tip should move through the lesion like
butter. Approximately 5-second bursts of treatment are made
at a time, then the lesion is firmly wiped with a dry gauze
to remove the char. The ablation is performed in a circular
motion, with the average mole-type lesion requiring 4 to 5
“burn-and-wipe” sequences until the lesion is treated to its
base. Wearing loupes and a headlight greatly facilitates the
Symmetrical
Nonsymmetrical
Even edges
Uneven edges
One shade
Two or more shades
Smaller than 1/4 inch
Larger than 1/4 inch
Benign
Malignant
Asymmetry
Border
Color
Diameter
FIGURE 16-8.  All lesions, especially pigmented lesions, must be scrutinized
for melanoma. This image shows the “A, B, C, D” danger signs of mela-
noma lesions. (Source: Skin Cancer Foundation.)
A
B
C
FIGURE 16-9.  Any suspicious lesion can be shave biopsied prior to radiowave ablation.
FIGURE 16-10.  The Ellman #133 electrode for mole and lesion ablation.

722
Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
A
B
FIGURE 16-11.  A significant advantage of the malleable electrodes is that they can be bent to ergonomically accommodate
virtually any anatomic region.
FIGURE 16-12.  Using a “finger rest” by resting the handpiece on the non-
operating index finger allows very light and precise “brush strokes” to
precisely control tissue removal.
the surgeon errs on the aggressive side and creates too deep a
crater, it may heal with a depressed scar. When treating the last
remnant lesion base, precision can be improved by making a
finger rest with the nonsurgical hand and moving the probe in
a circular up-and-down “pecking” motion around the remnant
tissue until it is flat or gone (Figure 16-16).
For deeper lesions, the goal is to not create a “pothole” with
precipitous edges; these leave very obvious scars. If an ablation
is deeper, it is important to bevel the edges so the actual crater
will have tapering edges like a saucer instead of a deep pothole
(Figure 16-17). To blend the precipitous lesion rim, the lesion
edges are gently beveled inward with the same electrode to
establish a thin, tapering border (Figure 16-18). As the base of
the lesion is reached, the electrode is used in a pecking motion
circumferentially around the lesion base, with very light finger
pressure to accurately treat the last vestiges of the lesion. Even
though a small, visible remnant may remain, it must be kept
in mind that there is some (albeit it minimal) thermal
damage that extends beyond the visible lesion base. To better
identify the base of the lesion and elevate it, the lesion can
be pinched, which will bring the remnant tissue into view
(Figure 16-19).
I tell all patients that the reason for the excellent postablation
aesthetics is conservatism, and that there is a small chance the
lesion will need a second treatment. This is rare and happens in
less than 1% of cases, but keeping a conservative mindset pre-
vents overtreatment and associated hypopigmentation and scar
depression. It is far better to treat twice than to overtreat once
and leave an unsightly scar. Figures 16-20 and 16-21 show
typical treatment sequences.
Although I most commonly use the #133 electrode for mole
removal, other electrodes work well. The ball or loop electrode
can also be used for raised lesions (Figure 16-22). A loop is
convenient to first shave biopsy the mole, then use the side of
the loop to flatten the lesion. When using a loop electrode, the
operator needs to be careful to not crater the base of the lesion;
the geometry of the loop is such that it cuts with concavity.
Rhinophyma
Rhinophyma is a descriptive term for a large, bulbous, ruddy
appearance of the nose caused by granulomatous infiltration
and hypertrophy of the sebaceous glands, commonly due to
untreated rosacea.12 Alcohol abuse is mistakenly attributed as a
causative factor for this disease, although ethanol abuse aggra-
vates the condition, and consequently, rhinophyma is suffered
by many alcoholics. The classic presentation is the bulbous,
granular nose of the late actor, W.C. Fields.

Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
723
A
B
FIGURE 16-13.  A, Use of loupes and headlight to best visualize lesion removal. B, Use of a smoke evacuator, a necessity
during radiowave lesion removal or radiowave surgery.
FIGURE 16-14.  Ablation almost completed, with chamois-colored remnant nevus tissue at the base of the lesion. Although
experienced surgeons would further reduce this tissue, novice surgeons should stop at the lesion base. A revision treatment
is better than a permanent depression.
A
B
FIGURE 16-15.  A, Nevus treated to the lesion base. B, Lesion after the remnant nevus tissue is ablated slightly below the lesion
base.

724
Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
FIGURE 16-16.  To precisely ablate the base of the lesion below the level of the skin surface, a circular “pecking” up-and-down
motion is used.
A
B
FIGURE 16-17.  The purpose of correct technique is not to leave a “pot hole” or precipitous edge on the
skin (A). Beveling the circumference of the lesion will enable a smoother transition from nontreated to
treated skin (B).
FIGURE 16-18.  Beveling the lesion periphery ensures a smooth transition without a precipitous edge.

Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
725
A
B
FIGURE 16-19.  Pinching the base of the lesion will elevate the remnant base for better visualization.
A
B
C
D
FIGURE 16-20.  A nevus preoperatively (A) and immediately after radiowave ablation (B). C, Close-up of site immediately post
treatment. D, The site 10 weeks after removal.

726
Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
A
B
C
FIGURE 16-21.  Pigmented nevus before treatment (A), intraoperatively before base removal (B), and after beveling of the wound
edges to prevent a precipitous edge (C).
A
B
C
FIGURE 16-22.  A, Pedunculated lesions before removal with the loop electrode. B, Lesion elevated with forceps and severed
at the base with the loop. C, The area immediately after loop removal.
Many treatment modalities have been utilized, including
scalpel excision, CO2 laser ablation, and radiowave excision.
Specialized radiowave “cheese-cutter” wire electrodes (Ellman
International) are very convenient and efficient in reshaping
the rhinophymatous nasal tissue (Figure 16-23). These elec-
trodes enable precise tissue removal as they cut a predetermined
swath through the tissue. The procedure is performed by
removing contiguous strips of affected tissue from the hyper­
trophic regions (Figure 16-24, A and B). After the nasal
tissue is leveled, bleeding is controlled with a radiowave ball
electrode (see Figure 16-24, C). The surgeon must cautiously
gauge the depth of the removal to normalized tissue. It is
preferable to err on the safe side to prevent scarring. Again,
it is always better to treat twice than to overtreat once.
Figure 16-25 shows the treated area of a rhinophyma patient’s
nose. This condition can also be treated with CO2 laser
(Figure 16-26).
Keloids or other hypertrophic conditions can also be treated
by radiowave ablation (Figure 16-27). The surgeon should
understand that recurrence of ablated keloid tissue is common
and may require treatment with intralesional steroids or post-
excision radiation.
Postoperative Care After
Radiowave Excision
After radiowave ablation, the patient is told to keep petroleum
jelly or triple-antibiotic ointment on the lesion for 4 to 5 days
until it is reepithelialized (smooth, dry, and pink). The patient
is instructed that the lesion will remain pink, with gradual

Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
727
FIGURE 16-23.  Specialized radiowave electrodes are available to produce
precise and controlled removal of hypertrophic rhinophyma tissue.
A
B
C
FIGURE 16-24.  A–B, Ellman wire radiowave electrodes are used to shave strips of hypertrophic sebaceous tissue from the
nose. C, A radiowave ball electrode is used to control bleeding and further level hypertrophic nasal tissue when treating
rhinophyma.
FIGURE 16-25.  The nose of a rhinophyma patient after radiowave tissue
removal and ball cauterization.
fading over the ensuing weeks. Patients are scheduled for 8-week
follow-up, and often we have to revisit the preoperative picture
to see where the mole was, because neither surgeon nor patient
can see a scar. This is a positive marketing point that I have
experienced time and time again. In the event the lesion is still
visible at the 8-week follow-up, it is retreated at this visit. Very
light-skinned patients may experience extended erythema and
should be instructed that the scar can stay pink, in some cases
for months.
Figures 16-28 to 16-41 illustrate very aesthetic cases of radio-
wave lesion removal.
Complications
Complications have been very rare with this technology. Like
any ablative procedure, overtreatment is always possible, and the
novice surgeon should be aware of this and take a conservative
approach to any blemish excision. Suspicious lesions should be
biopsied. Deep, pigmented lesions may leave residual pigment
which will require revision.
Patients with older-style nonshielded pacemakers should
have a cardiology consult before treatment. Newer shielded
Text continued on page 733.

728
Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
FIGURE 16-26.  Rhinophyma patient being treated with the CO2 laser, which ablates the hypertrophic sebaceous tissue.
A
B
FIGURE 16-27.  An earlobe keloid ablated with radiowave surgery.
A
B
C
FIGURE 16-28.  Patient was treated with local anesthesia for the removal of 100 benign nevi with radiowave surgical ablation.
Patient before the procedure (A), immediately after ablation (B), and 10 weeks later (C).

Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
729
A
B
FIGURE 16-29.  Before (A) and after (B) radiowave removal of multiple keratoses.
A
B
FIGURE 16-30.  Before (A) and after (B) radiowave ablation of a benign nevus. A biopsy was performed on the lesion because
it had the pearly, telangiectatic appearance of a basal cell carcinoma. Biopsy was negative.
A
B
FIGURE 16-31.  Pedunculated scalp lesion before (A) and after (B) radiowave ablation.

730
Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
A
B
FIGURE 16-32.  Cheek lesion before (A) and after (B) radiowave ablation.
A
B
FIGURE 16-33.  Multiple nevi before (A) and after (B) radiowave ablation.
A
B
FIGURE 16-34.  Pigmented lesion before (A) and 3 months after (B) radiowave ablation.

Chapter 16  •  Cosmetic Removal of Nevi and Lesions With 4-MHz Radiowave Surgery
731
A
B
FIGURE 16-35.  Before (A) and 8 weeks after (B) radiowave ablation of a pigmented lesion (biopsy negative). Small areas of
pigmentation are evident and were retreated.
A
B
FIGURE 16-36.  Before (A) and after (B) radiowave ablation.
A
B
FIGURE 16-37.  Before (A) and after (B) radiowave ablation.